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 Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 410, 416, 419, 421, 485, and 488
[CMS-1506-FC; CMS-4125-F]
RIN 0938-AO15
 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
 ACTION: Final rule with comment period and final rule.
 SUMMARY: This final rule with comment period revises 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. In this final rule with comment period, we describe 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 are applicable to services furnished on or after January 1, 2007. In addition, this final rule with comment period implements future CY 2009 required reporting on quality measures for hospital outpatient services paid under the prospective payment system. This final rule with comment period revises the current list of procedures that are covered when furnished in a Medicare-approved ambulatory surgical center (ASC), which are applicable to services furnished on or after January 1, 2007. This final rule with comment period revises the emergency medical screening requirements for critical access hospitals (CAHs). This final rule with comment period supports 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 final rule continues 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. In this rule, we are finalizing additional quality measures for 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: *Effective Date:*
                             The provisions of these final rules are effective on January 1, 2007. *Comment Period:*
                             We will consider comments on the payment classification assigned to HCPCS codes identified in Addendum B with the NI comment code, and other areas specified throughout the preamble, at the appropriate address, as provided below, no later than 5 p.m. January 23, 2007. *Application Deadline*
                            —New Class of New Technology Intraocular Lens: Requests for review of applications for a new class of new technology intraocular lenses must be received by close of business April 1, 2007.
 ADDRESSES: In commenting, please refer to file code CMS-1506-FC. 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-FC, 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-FC, 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. For information on viewing public comments, see the beginning of the 
                            **SUPPLEMENTARY INFORMATION**
                             section. *Applications for a new class of new technology intraocular lenses:*
                             Requests for review of applications for a new class of new technology intraocular lenses must be sent by regular mail to: ASC/NTIOL, Division of Outpatient Care, Mailstop C4-05-17, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.
 FOR FURTHER INFORMATION CONTACT: 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. 
                            ( print page 67961) 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: *Submitting Comments:*
                         We welcome comments from the public on the payment classification and status indicator assigned to HCPCS codes identified in Addendum B of this final rule with comment period with comment indicator NI and on the ambulatory surgical center procedures that were not proposed for addition to the ambulatory surgical center list in the CY 2007 OPPS proposed rule to assist us in fully considering issues and developing policies. You can assist us by referencing filed code CMS-1506-FC. *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 4:00 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 log in as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then log in as guest (no password required). Alphabetical List of Acronyms Appearing in the Final 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 IOL Intraocular lens 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 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., XIX., XXIII., XXIV., XXV., and XXVI. of the preamble and in Addenda A, B, C (Addendum C is available on the Internet only; see section XXIII. of the preamble of this final rule with comment period), D1, D2, and E of this final rule with comment period. The provisions related to the IPPS are included in sections XXII. and XXVI.E. of the preamble. The provisions related to ASCs are included in sections XVII. and XXV., and XXVI.C. of the preamble and in Addenda AA of this final rule with comment period. In addition, in this document, we address our 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 XVIII. and XXV.D. 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 (DRA) of 2005 1. 3-Year Transition of Hold Harmless Payments 2. Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms 3. Colorectal Cancer Screening G. Summary of the Provisions of the CY 2007 OPPS Proposed Rule 1. Updates to the OPPS Payments for CY 2007 2. Ambulatory Payment Classification (APC) Group Policies 3. Payment Changes for Devices 4. Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 5. Estimate of Transitional Pass-Through Spending in CY 2007 for Drugs, Biologicals, and Devices 6. Brachytherapy Payment Changes 7. Coding and Payment for Drugs Administration 8. Hospital Coding and Payments for Visits 9. Payment for Blood and Blood Products 10. Payment for Observation Services 11. Procedures That Will Be Paid Only as Inpatient Services 12. Nonrecurring Policy Changes 13. Emergency Medical Screening in Critical Access Hospitals (CAHs) 14. Payment Status and Comment Indicator Assignments 15. OPPS Policy and Payment Recommendations 16. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 2007 17. Revised ASC Payment System for Implementation January 1, 2008 18. Medicare Contracting 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. Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for FY 2008 IPPS Annual Payment Update 23. Impact Analysis H. Public Comments Received in Response to the CY 2007 OPPS and Reporting Hospital Quality Data for FY 2008 IPPS Annual Payment Update Program—HCAHPS Survey, SCIP, and Mortality Proposed Rules I. Public Comments Received on the November 10, 2005 OPPS Final Rule with Comment Period II. Updates Affecting OPPS Payments for CY 2007 A. Recalibration of APC Relative Weights for CY 2007 1. Database Construction a. Database Source and Methodology b. Use of Single and Multiple Procedure Claims c. Revised Overall Cost-to-Charge Ratio (CCR) Calculation 2. Calculation of Median Costs for CY 2007 3. Calculation of Scaled OPPS Payment Weights 4. Changes to Packaged Services B. Payment for Partial Hospitalization 1. Background 2. PHP APC Update for CY 2007 3. Separate Threshold for Outlier Payments to CMHCs C. Conversion Factor Update for CY 2007 D. Wage Index Changes for CY 2007 E. 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. Adjustment for Rural SCHs Implemented in CY 2006 Related to Pub. L. 108-173 (MMA) G. CY 2007 Hospital Outpatient Outlier Payments 1. CY 2007 Proposal 2. CY 2007 Final Rule Outlier Calculation H. Calculation of the OPPS National Unadjusted Medicare Payment I. Beneficiary Copayments for CY 2007 1. Background 2. Copayment for CY 2007 3. Calculation of an Adjusted Copayment Amount for an APC Group for CY 2007 III. OPPS Ambulatory Payment Classification (APC) Group Policies A. Treatment of New HCPCS and CPT Codes 1. Treatment of New HCPCS Codes Included in the Second and Third Quarterly OPPS Updates for CY 2006 2. Treatment of New CY 2007 Category I and III CPT Codes and Level II HCPCS Codes 3. Treatment of New Mid-Year CPT Codes B. 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. Movement of Procedures from New Technology APCs to Clinical APCs a. Nonmyocardial Positron Emission Tomography (PET) Scans (APC 0308) b. PET/Computed Tomography (CT) Scans (APC 0308) c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 0065, 0066, and 0067) d. Magnetoencephalography (MEG) Services (APCs 0038 and 0209) e. Other Services in New Technology APCs (1) Breast Brachytherapy (APCs 0029 and 0030) (2) Radiofrequency Ablation (APCs 0050 and 0423) (3) Extracorporeal Shock Wave Treatment (APC 0050) (4) Insertion of Venuous Access Device with Two Ports (APC 0623) (5) Stereoscopic X-Ray Guidance (APC 0257) (6) Whole Body Tumor Imaging (APC 0408) (7) Gastroesophageal Reflux Test With pH Electrode (APC 0361) (8) Home International Normalized Ratio (INR) Monitoring (APC 0604) (9) Tositumomab Administration and Supply (APC 0442) (10) Summary of Other New Technology Procedures Assigned to Clinical APCs for CY 2007 D. APC-Specific Policies 1. Radiology Procedures a. Radiology Procedures (APCs 0333, 0662, and Other Imaging APCs) b. Computerized Reconstruction (APC 0417) c. Cardiac Computed Tomography and Computed Tomographic Angiography (APCs 0282, 0376, 0377, and 0398) d. Radiologic Evaluation of Central Venous Access Device (APC 0340) 2. Nuclear Medicine and Radiation Oncology Procedures a. Myocardial Positron Emission Tomography (PET) Scans (APC 0307) b. Complex Interstitial Radiation Source Application (APC 0651) c. Proton Beam Therapy (APCs 0664 and 0667) 
                            ( print page 67963) d. Urinary Bladder Residual Study (APC 0340) e. Hyperthermia Treatment (APC 0314) f. Unlisted Procedure for Clinical Brachytherpy (APC 0312) 3. Cardiac and Vascular Procedures a. Electrophysiologic Recording/Mapping (APC 0087) b. Endovenous Laser Ablation Procedures (APC 0092) c. Repair/Repositioning of Defibrillator Leads (APC 0106) d. Thrombectomy Procedures (APCs 0103 and 0653) 4. Gastrointestinal and Genitourinary Procedures a. Insertion of Mesh or Other Prosthesis (APC 0195) b. Percutaneous Renal Cryoablation (APC 0423) c. Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance Guidance (MRgFUS) (APCs 0195 and 0202) d. Laser Vaporization of Prostate (APC 0429) e. Gastrointestinal Procedures with Stents (APC 0384) f. Endoscopy with Thermal Energy to Sphincter (APC 0422) 5. Ocular Procedures a. Keratoprosthesis (APC 0293) b. Eye Procedures (APCs 0232, 0235, and 0241) c. Amniotic Membrane for Ocular Surface Reconstruction 6. Other Procedures a. Skin Replacement Surgery and Skin Substitutes (APC 0025) b. Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064) c. Complex Skin Repair (APC 0024) d. Insertion of Posterior Spinous Process Distraction Device 7. Medical Services a. Medication Therapy Management Services b. Single Allergy Tests (APC 0381) c. Hyperbaric Oxygen Therapy (APC 0659) d. Guidance for Chemodenervation (APC 0215) e. Pathology Services (APC 0344) IV. OPPS Payment Changes for Devices A. Treatment of Device-Dependent APCs 1. Background 2. CY 2007 Payment Policy 3. Devices Billed in the Absence of an Appropriate Procedure Code 4. Payment Policy When Devices are Replaced Without Cost or Where Credit for a Replaced Device is Furnished to the Hospital B. Pass-Through Payments for Devices 1. Expiration of Transitional Pass-Through Payments for Certain Devices a. Background b. Policy for CY 2007 2. Provisions for Reducing Transitional Pass-Through Payments to Offset Costs Packaged into APC Groups a. Background b. Policies for CY 2007 V. OPPS Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals A. Transitional Pass-Through Payment for Additional Costs of Drugs and Biologicals 1. Background 2. Drugs and Biologicals With Expiring Pass-Through Status in CY 2006 3. Drugs and Biologicals With Pass-Through Status in CY 2007 B. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Status 1. Background 2. Criteria for Packaging Payment for Drugs, Biologicals, and Radiopharmaceuticals 3. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Status That Are Not Packaged a. Payment for Specified Covered Outpatient Drugs (1) Background (2) Payment Policy for CY 2007 (3) CY 2007 Payment Policy for Radiopharmaceuticals (a) Background and Proposed CY 2007 Radiopharmaceutical Payment Policy (b) CY 2007 Final Radiopharmaceutical Payment Policy b. CY 2007 Payment for Nonpass-Through Drugs, Biologicals, Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data (1) Background (2) CY 2007 Proposed and Final Payment Policy for Radiopharmaceuticals With HCPCS Codes, But Without Hospital Claims Data (3) CY 2007 Proposed and Final Payment Policy for Drugs and Biologicals With HCPCS Codes, But Without OPPS Hospital Claims Data (4) CY 2007 Proposed and Final Payment Policy for Drugs, Biologicals, and Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data and Without ASP-Related Data VI. Estimate of OPPS Transitional Pass-Through Spending in CY 2007 for Drugs, Biologicals, Radiopharmaceuticals, and Devices A. Total Allowed Pass-Through Spending B. Estimate of Pass-Through Spending for CY 2007 VII. Brachytherapy Source Payment Changes A. Background B. Government Accountability Office's Final Report on Devices of Brachytherapy C. Payments for Brachytherapy Sources in CY 2007 VIII. Changes to OPPS Drug Administration Coding and Payment for CY 2007 A. Background B. CY 2007 Drug Administration Coding Changes C. CY 2007 Drug Administration Payment Changes IX. 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 and Final Coding Policies 1. Clinic Visits 2. Emergency Department Visits 3. Critical Care Services C. CY 2007 Payment Policy D. CY 2007 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. Payment for Blood and Blood Products A. Background B. Policy Changes for CY 2007 XI. OPPS Payment for Observation Services XII. Procedures That Will be Paid Only as Inpatient Procedures A. Background B. Changes to the Inpatient List C. CY 2007 Payment for Ancillary Outpatient Services When Patient Expires (-CA Modifier) 1. Background 2. Policy for CY 2007 XIII. 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. Assignment of New HCPCS Code and Payment for Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) XIV. Emergency Medical Screening in Critical Access Hospitals (CAHs) A. Background B. Proposed Policy Change C. Public Comments Received on the Proposal D. Final Policy XV. OPPS Payment Status and Comment Indicators A. CY 2007 Status Indicator Definitions 1. Payment Status Indicators to Designate Services That Are Paid under the OPPS 2. Payment Status Indicators to Designate Services That Are Paid under a Payment System Other Than the OPPS 3. Payment Status Indicators to Designate Services That Are Not Recognized under the OPPS But That May Be Recognized by Other Institutional Providers 4. Payment Status Indicators to Designate Services That Are Not Payable by Medicare B. CY 2007 Comment Indicator Definitions XVI. OPPS Policy and Payment Recommendations A. MedPAC Recommendations B. APC Panel Recommendations C. GAO Recommendations XVII. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 2007 
                            ( print page 67964) A. ASC Background 1. Legislative History 2. Current Payment Method 3. Published Changes to the ASC List B. 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. Rationale for Payment Assignment 3. Response to Comments to the May 4, 2005 Interim Final Rule for the ASC Update 4. Procedures Proposed for Additions to the ASC List 5. Specific Requests for Payment Group Changes 6. Requests for Additions to the ASC List from Comments to the August 23, 2006 Proposed Rule a. Requests Accepted for Additions to the ASC List for CY 2007 b. Requests Not Accepted for Additions to the ASC List for CY 2007 7. Requests for Payment Increases for Procedures on the Current ASC List 8. Other Comments on the May 4, 2005 Interim Final Rule C. Regulatory Changes for CY 2007 D. Implementation of Section 1834(d) of the Act E. Implementation of Section 5103 of Pub. L. 109-171 (DRA) F. Modification of 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 and Final 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 an Adjustment of Payment for Insertion of a New Class of NTIOL is Appropriate d. Revision of the Content of a Request to Review e. Notice of CMS Determination f. Payment Adjustment G. Announcement of CY 2007 Deadline for Submitting Requests for CMS Review of Appropriateness of ASC Payment for Insertion Following Cataract Surgery of an NTIOL XVIII. Medicare Contracting Reform Mandate A. Background B. CMS's Vision for Medicare Fee-for-Service and Medicare Administrative Contractors (MAC) C. Provider Nomination and the Former Medicare Acquisition Authorities D. Summary of Changes Made to Section 1816 of the Act E. Provisions of the Proposed and Final Regulations 1. Definitions 2. Assignments of Providers and Suppliers to MACs 3. Other 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 Direct 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 XIX. Reporting Quality Data for Improved Quality and Costs under the OPPS XX. Promoting Effective Use of Health Information Technology XXI. Health Care Information Transparency Initiative XXII. Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update A. Background B. 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. Additional Steps for HCAHPS Participation 7. HCAHPS Survey Completion Requirements 8. HCAHPS Public Reporting 9. Reporting HCAHPS Results for Multi-Campus Hospitals E. SCIP & Mortality Measure Requirements for the FY 2008 RHQDAPU Program F. Conclusion XXIII. Files Available to the Public Via the Internet XXIV. Collection of Information Requirements XXV. Response to Comments XXVI. 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 OPPS Changes in This Final Rule with Comment Period 1. Alternatives Considered a. Alternatives Considered for Coding and Payment Policy for Visits b. Alternatives Considered for Brachytherapy Source Payments c. Alternatives Considered for Payment of Radiopharmaceuticals 2. Limitation of Our Analysis 3. Estimated Impact of This Final Rule with Comment Period on Hospitals 4. Estimated Effect of This Final Rule with Comment Period on Beneficiaries 5. Conclusion 6. Accounting Statement C. Effects of Changes to the ASC Payment System for CY 2007 1. Alternatives Considered 2. Limitations on Our Analysis 3. Estimated Effects of This Final Rule with Comment Period on ASCs 4. Estimated Effects of This Final Rule with Comment Period on Beneficiaries 5. Conclusion 6. Accounting Statement D. Effects of the Medicare Contracting Reform Mandate E. Effects of Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for IPPS FY 2008 1. Alternatives Considered 2. Estimated Effects of This Final Rule with Comment Period a. Effects on Hospitals b. Effects on Other Providers c. Effects on the Medicare and Medicaid Program F. Executive Order 12866 Regulation Text Addenda Addendum A—OPPS List of Ambulatory Payment Classification (APCs) with Status Indicators (SI), Relative Weights, Payment Rates, and Copayment Amounts—CY 2007 Addendum AA—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 Payment Status By HCPCS Code and Related Information CY 2007 Addendum D1—Payment Status Indicators Addendum D2—Comment Indicators Addendum E—CPT Codes That Are Paid Only As Inpatient Procedures Addendum L—Out-Migration Adjustment 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 cost-based payment methodology with a prospective payment system (PPS). The Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33), added section 1833(t) 
                        ( print page 67965)
                        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 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 labor-related 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 speech-language 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 
                        ( print page 67966)
                        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 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://www.cms.hhs.gov/​FACA/​ 05AdvisoryPanelonAmbulatory PaymentClassification Groups.as#TopOFPage.* 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 10 subsequent meetings, with the last meeting taking place on August 23 and 24, 2006. (The APC Panel did not meet on August 25, 2006, as announced in the meeting notice published on June 23, 2006 (71 FR 36118).) 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 and their continuation as subcommittees was approved at the August 2006 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 and August 2006 meetings 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 provision 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 threshold of $50 per administration 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 in section V. of this preamble a discussion of the methodology that we will use to determine a threshold for establishing separate APCs for drugs and biologicals for CY 2007. 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 methodology for payment for brachytherapy devices for CY 2007 in section VII.B. of this preamble. F. Provisions of the Deficit Reduction Act (DRA) 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 
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                        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. This provision is discussed in section II.F.1. of the preamble. 2. Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms (AAAs) 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 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. See section XIII.B. of this preamble for a detailed discussion of this provision. 3. Colorectal Cancer Screening Section 5113 of Pub. L. 109-171 amended section 1833(b) of the Act to add colorectal cancer screening to the list of services for which the beneficiary deductible does not apply. This provision applies to services furnished on or after January 1, 2007. See the Medicare Physician Fee Schedule (MPFS) CY 2007 final rule for a detailed discussion of this provision. G. Summary of the Provisions of the CY 2007 OPPS Proposed Rule On August 23, 2006, we published a proposed rule in the 
                        **Federal Register**
                         (71 FR 49506) that set forth proposed changes to the Medicare hospital OPPS for CY 2007 to implement statutory requirements and changes arising from our continuing experience with the system and to implement certain provisions of Pub. L. 109-171 specified in sections II.F.1. and XIII.B. of this preamble. We also proposed to revise the standard for critical access hospital personnel that are allowed to perform emergency medical screenings. In addition, we proposed changes to the Medicare ASC payment system for CY 2007 and CY 2008 and to the way we process fee-for-service (FFS) claims under Medicare Part A and Part B. Finally, we set forth a proposed rule seeking comments on the RHQDAPU program under the Medicare hospital IPPS for FY 2008. These changes will be effective for payments beginning with FY 2008. The following is a summary of the major changes included in the CY 2007 OPPS proposed rule: 1. Updates to the OPPS' Payments for CY 2007 In the proposed rule, we set forth— The methodology used to recalibrate the proposed APC relative payment weights and the proposed median costs 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 hold harmless payment provision and § 419.70(d).
                    Proposed changes relating to payment for rural SCHs, including Essential Access Community Hospitals (EACHs) for CY 2007.
                    The proposed retention of our current policy for calculating 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. Ambulatory Payment Classification (APC) Group Policies In the proposed rule, we discussed establishing a number of new APCs and making 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 discussed the application of the 2 times rule and proposed exceptions to it; proposed changes for specific APCs; proposed movement of procedures from the New Technology APCs; and the proposed additions of new procedure codes to the APC groups. 3. Payment Changes for Devices In the proposed rule, we discussed proposed changes to the device-dependent APCs and to payment for pass-through devices. We also discussed the proposed payment policy for devices that are replaced without cost or credit to the hospital for a replaced device and the proposed related regulation under § 419.45. 4. Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals In the proposed rule, we discussed proposed payment changes for drugs, biologicals, and radiopharmaceuticals. 5. Estimate of Transitional Pass-Through Spending in CY 2007 for Drugs, Biologicals, and Devices In the proposed rule, we discussed 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. Brachytherapy Payment Changes In the proposed rule, we included a discussion of our proposal concerning coding and payment for the sources of brachytherapy. 7. Coding and Payment for Drugs Administration In the proposed rule, we discussed our proposed coding and payment changes for drug administration services. 8. Hospital Coding and Payments for Visits In the proposed rule, we discussed our analyses of various guidelines for coding hospital visits and the proposed HCPCS codes and payment policy for those visits. 
                        ( print page 67968) 9. Payment for Blood and Blood Products In the proposed rule, we discussed our proposed criteria and coding changes for the blood and blood products. 10. Payment for Observation Services In the proposed rule, we discussed our proposed continuation of applying the criteria for separate payment for observation services and the coding methodology for observation services implemented in CY 2006. 11. Procedures That Will Be Paid Only as Inpatient Services In the proposed rule, we discussed the procedures that we proposed to remove from the inpatient list and assign to APCs. 12. Nonrecurring Policy Changes In the proposed rule, we discussed a proposed technical change to § 419.21(d) of the regulations related to Comprehensive Outpatient Rehabilitation Facility (CORF) services and proposed coding and payment for ultrasound screening for abdominal aortic aneurysms (AAAs) as a new service paid under the OPPS in CY 2007. 13. Emergency Medical Screening in Critical Access Hospitals (CAHs) In the proposed rule, we discussed our proposal to revise § 485.618(d) of the regulations pertaining to the standards for critical access hospital personnel available to perform emergency medical screening services. 14. Payment Status and Comment Indicator Assignments In the proposed rule, we discussed our list of status indicators assigned to APCs and presented our comment indicators that we proposed to use in this final rule with comment period. 15. OPPS Policy and Payment Recommendations In the proposed rule, we addressed recommendations made by MedPAC, the APC Panel, and the GAO regarding the OPPS for CY 2007. 16. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 2007 In the proposed rule, we discussed changes to the ASC list of covered procedures for CY 2007; implementation of section 5103 of Pub. L. 108-173; our proposal for modifying the current ASC process for adjusting payment for new technology intraocular lenses; and related regulatory changes. 17. Revised ASC Payment System for Implementation January 1, 2008 In the proposed rule, we set forth our proposal to revise the current ASC payment system in accordance with Pub. L. 108-173, effective January 1, 2008. We note that we are not finalizing this proposal in this final rule with comment period. Rather, we will issue a separate document in the 
                        **Federal Register**
                         that will address public comments received and finalize the ASC payment system effective January 1, 2008. 18. Medicare Contracting Reform Mandate In the proposed rule, we set forth changes to the way we process FFS claims under Medicare Part A and Part B. 19. Reporting Quality Data for Improved Quality and Costs Under the OPPS In the proposed rule, we proposed to adapt the quality improvement mechanism provided by the IPPS RHQDAPU program for use under the OPPS. 20. Promoting Effective Use of Health Information Technology In the proposed rule, we discussed our plans to promote and adopt effective use of health information technology to improve the quality of care for Medicare beneficiaries. 21. Health Care Information Transparency Initiative In the proposed rule, we announced our plans to launch a major health care transparency initiative in 2006. 22. Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for FY 2008 IPPS Annual Payment Update In the proposed rule, we discussed our proposal to expand the IPPS Reporting Hospital Quality Data for Annual Payment program measurement set for FY 2008 beyond the measures adopted for the FY 2007 IPPS update. 23. Impact Analysis In the proposed rule, we set forth an analysis of the impact that the proposed changes will have on affected entities and beneficiaries. H. Public Comments Received in Response to the CY 2007 OPPS Proposal Rule and on the Reporting Hospital Quality Data for FY 2008 IPPS Annual Payment Update Program—HCAHPS Survey, SCIP, and Mortality Proposed Rule We received approximately 1,100 timely items of correspondence containing multiple comments on the CY 2007 OPPS proposed rule. We note that we received some comments that were outside of the scope of the CY 2007 OPPS proposed rule. These comments are not addressed in the CY 2007 final rule. We also received approximately 20 timely items of correspondence on Reporting Hospital Quality Data for FY 2008 Inpatient Prospective Payment System Annual Payment Update Program—HCAHPS Survey, SCIP, and Mortality proposed rule. Summaries of the public comments and our responses to those comments are set forth under the appropriate headings. I. Public Comments Received on the November 10, 2005 OPPS Final Rule with Comment Period We received approximately 41 timely items of correspondence on the November 10, 2005 OPPS final rule with comment period, some of which contained multiple comments on the APC assignment of HCPCS codes identified with the NI comment indicator in Addendum B of that final rule with comment period. Summaries of those public comments and our responses to those comments are set forth in the various sections under the appropriate headings. II. Updates Affecting OPPS Payments for CY 2007 A. Recalibration of APC Relative Weights for CY 2007 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). 
                        ( print page 67969) In the CY 2007 OPPS proposed rule, we proposed 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 proposed to use the most recent available data to construct the database for calculating APC group weights. For the purpose of recalibrating the APC relative payment weights for CY 2007, we used approximately 142.5 million final action claims for hospital OPD services furnished on or after January 1, 2005, and before January 1, 2006. Of the 142.5 million final action claims for services provided in hospital outpatient settings, 110.2 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 110.2 million claims, approximately 51.7 million were not for services paid under the OPPS or were excluded as not appropriate for use (for example, erroneous cost-to-charge ratios or no HCPCS codes reported on the claim). We were able to use 54.1 million whole claims of the remaining 58.5 million claims to set the OPPS APC relative weights for CY 2007 OPPS. From the 54.1 million whole claims, we created 98.5 million single records, of which 68.5 million were “pseudo” single claims (created from multiple procedure claims using the process we discuss in this section). As proposed, the final APC relative weights and payments for CY 2007 in Addenda A and B to this final rule with comment period were calculated using claims from this period that had been processed before June 30, 2006, and continue to be based on the median hospital costs for services in the APC groups. 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. *Comment:*
                         Several commenters supported the use of the most recent claims and cost report data to calculate the median costs for use in the CY 2007 OPPS. *Response:*
                         We appreciate the commenters' support and have used the claims for services paid under the CY 2005 OPPS as processed through the common working file as of June 30, 2006, in the calculation of the median costs on which the CY 2007 OPPS rates are based. In addition, we have used the most recently submitted cost report data as reported to the HCRIS system as of June 30, 2006, to calculate the cost-to-charge ratios (CCRs) used to reduce the billed charges to costs for purposes of calculating the median costs on which the CY 2007 OPPS rates are based. After carefully considering all comments received, we are finalizing our data source and methodology for the recalibration of CY 2007 APC relative payment weights as proposed without modification, as described in this section. b. Use of Single and Multiple Procedure Claims For CY 2007, we proposed 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 multiple separately paid procedures on the same claim. For the CY 2007 OPPS, we proposed 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 
                        ( print page 67970)
                        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 the 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 proposed 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 proposed for the CY 2007 OPPS resulted in our being able to use some part of 92.6 percent of the total claims that are eligible for use in the OPPS ratesetting and modeling in developing this final rule with comment period. This process enabled us to use, for CY 2007, 68.5 million “pseudo” singles and 31.6 million “natural” single bills. We proposed to bypass the 454 codes identified in Table 1 of the proposed rule (71 FR 49517) 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 proposed 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). (Bypass codes shown in Table 1 with an asterisk indicated the HCPCS codes we proposed to add to the CY 2006 OPPS listed codes for bypass in CY 2007.) 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. As proposed, the following empirical criteria that we used to determine the additional codes to add to the CY 2006 OPPS bypass list to create the bypass list for the CY 2007 OPPS 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.
                    The median cost of packaging observed in the single claims 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 proposed to add to the bypass list codes that our clinicians believe contain minimal packaging and codes for specified drug administration services 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 payment changes in section VIII.C. of this preamble. In the CY 2007 OPPS proposed rule, we specifically invited public comment on the “pseudo” single process, including the bypass list and the criteria. *Comment:*
                         The commenters urged CMS to continue to find ways to use all data from multiple procedure claims to set the median costs on which the payment rates are based. Many commenters supported the bypass list as a vehicle to enable use of all claims data. However, some commenters were concerned that placing HCPCS codes on the bypass list would lead to those codes being undervalued because no packaging from the multiple procedure bill is attributed to them. These commenters urged CMS to validate that these services were not being systematically undervalued by being bypassed and thus having many units of the service used for median setting with no attribution of packaging to the code. In many cases, the commenters did not offer specific discussion of what packaging they believe would be appropriately attached to the codes on the bypass list. One commenter suggested that CMS add CPT code 77421 (Steroscopic X-ray guidance for localization of target volume for the delivery of radiation therapy) to secure more single procedure claims data for median setting. Another commenter asked that CMS add CPT code 88307 (Level V-Surgical pathology, gross and microscopic examination) to the bypass list because it would be consistent with the inclusion of CPT codes 88304 (Level III-Surgical pathology, gross and microscopic examination) and 88305 (Level IV-Surgical pathology, gross and microscopic examination) on the bypass list. *Response:*
                         We agree that the bypass list has been very useful in enabling us to use data from multiple procedure claims to set median costs for many services. The use of date of service stratification and the bypass list enabled us to create 68.5 million “pseudo” single claims that would not otherwise have been used to set median costs for the CY 2007 OPPS. However, we recognize that it is necessary to be cautious in this approach to minimize the possibility that we could mistakenly apply packaging on the claim to the wrong service. For that reason, each year we investigate the amount of packaging on natural single bills and consider whether changes should be made to the bypass list. However, in some cases, we know that the natural single bills are incorrect, and it is not 
                        ( print page 67971)
                        reasonable to base a decision on their level of packaging from what we believe are incorrectly coded claims. In these cases, we use clinical judgment to determine whether, on a correctly coded claim, the packaging would be associated with the code as defined or whether the packaging would more appropriately be associated with other procedures. For example, a single procedure bill for an ultrasound guidance service which is used only for guidance during an associated surgical procedure would not be correctly coded and therefore, clinically, we would not expect the packaged costs observed on these single claims to be correctly attributed to the guidance procedure. We believe that the ultrasound guidance procedure itself could not be the service that required the drugs, devices, or operating room use that would usually also be billed on a correctly coded claim. In these cases, we would place the ultrasound guidance procedure on the bypass list and attribute the packaged costs that appear on the same claim to the surgical procedure on the claim. We have been actively investigating options for using all claims data in the establishment of median costs, and we intend to be ready to discuss our findings in the CY 2008 OPPS proposed rule. With respect to the suggestions for additions to the bypass list, we will evaluate the potential for adding CPT codes 77421 and 88307 to the bypass list for purposes of the CY 2008 OPPS ratesetting. *Comment:*
                         One commenter asked that CMS use all claims data on multiple procedure claims by allocating the packaging on a claim with multiple surgical procedures based on the currently existing relative weights to create “pseudo” single claims from all multiple procedure claims. The commenter suggested that if CMS is concerned about that process causing the weights being calculated to not reflect changes in cost, CMS might use this process only in cases in which the number of units for HCPCS codes on natural single bills are below some tolerance so that these claims would be used only on low volume procedures. *Response:*
                         We are concerned that use of the current relative weights to allocate the packaging on multiple procedure claims may cause packaging to be allocated inappropriately in some cases. As we indicate above, we are continuing to explore ways that packaging could be allocated on multiple procedure claims in such a way that we would have confidence in the allocation. *Comment:*
                         One commenter requested that CMS remove CPT code 76942 (Ultrasonic guidance for needle placement (eg biopsy, aspiration, injection, localization device), imaging supervision and interpretation) from the bypass list, because the commenter believed it would raise the median cost for APC 0268, the APC where CPT code 76942 is assigned for CY 2007. According to the commenter, the natural single claims for CPT code 76942 have a higher median cost than the “pseudo” single claims. The commenter indicated that when all packaged costs are removed from the natural singles, their median is close to the median for the “pseudo” single claims. If removing this code from the bypass list altogether results in too few “pseudo” single claims, the commenter requested that CMS calculate the median cost for APC 0268 using only natural single claims. *Response:*
                         We agree with the commenter that the median of APC 0268 is higher with the exclusion of “pseudo” singles that are created from claims that include CPT code 76942 than it would be if we only used true single claims that include CPT code 76942. However, we believe that the single bills for CPT code 76942 are miscoded and, therefore, inappropriately attribute the procedural costs (for example, the needle placement for biopsy and injection) to ultrasound guidance rather than the biopsy or aspiration procedures. We note that CPT code 76942 is the code with the highest frequency in APC 0268 and, therefore, contributes greatly to the median cost of the APC. The commenter provided no information regarding the specific packaging associated with CPT code 76942; therefore, we continue to believe that its inclusion on the bypass list, and the resulting calculation of the APC median cost for APC 0268, is appropriate. After carefully considering all public comments received on our proposal, we are adopting as final the proposed “pseudo” single process and the bypass codes listed in Table 1. 
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  c. Revised 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 the CY 2007 OPPS, we proposed 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. As stated in the CY 2007 OPPS proposed rule (71 FR 49528), we have discovered that the calculation of the overall CCR that the fiscal intermediaries are using to determine outlier payments and payments 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-to-Charge 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 latter. We exclude selected ancillary cost centers from our overall CCR calculation, such as 5700 Renal Dialysis, because we believe that the costs and 
                        ( print page 67984)
                        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, Part V (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, Part V (Columns 2, 3, 4, and 5 and subscripts thereof). The elimination of the reference to Part VI in this final rule with comment period is not a change from the proposed methodology. We used only data from Worksheet D, Part V of the HCRIS electronic cost report to calculate the overall CCRs for both the proposed rule and final rule with comment period. We previously referenced both Part V and Part VI in the proposed rule and in prior rules because both Part V and Part VI appear on the same page in Worksheet D on the paper cost report, although no data from Part VI on the electronic cost report were used in the calculation. 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 intermediaries 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, Part V, makes the overall CCR calculation more specific to OPPS. Therefore, we proposed 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, Part V, 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. As we indicated in the proposed rule (71 FR 49528), using the same cost report data in this study, 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. As stated in the CY 2007 OPPS proposed rule (71 FR 49528), 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. Using updated cost report data for the calculations in this final rule with comment period, we estimate a median overall CCR across all hospitals of 0.3015 using the new overall CCR calculation. We believe that a single overall CCR calculation should be used for all components of the OPPS for both modeling and payment. Therefore, we proposed 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. *Comment:*
                         Several commenters supported the proposed change to the calculation of the overall CCR to be weighted by Part B charges and to exclude the costs of nursing and allied health professional education programs. One commenter asked that CMS provide examples at the line level of how the revenue code to cost center crosswalk is applied to sample claims to illustrate to hospitals how selection of the revenue code for any particular item or service controls the resulting cost that is used in median calculation. The commenter also asked that CMS instruct fiscal intermediaries to allow hospitals to reclassify expense and revenue whenever the hospital believes it is appropriate, to ensure that the charges on the claim result in appropriate costs for median setting and order the fiscal intermediaries not to reverse reclassification of costs in audit adjustments. The commenter also suggested that CMS should have fiscal intermediaries conduct a survey of their audit staff with regard to the validity of the revenue code to cost center crosswalk. *Response:*
                         We continue to believe that the proposed change to the CCR calculation is appropriate, and we have used the revised formula to calculate the 
                        ( print page 67985)
                        overall CCRs used to set the medians on which the CY 2007 payment rates are based. With respect to the request for detailed examples to illustrate how selection of a revenue code will control the cost that is used in the median calculation, we believe that hospitals, like any business, are responsible for performing their own analysis regarding issues that affect their revenue stream. We have gone to great lengths in the preamble of our proposed and final rules to discuss how we derive costs from charges and how we crosswalk the charge from the revenue code reported for the charge to the cost center on the cost report. Moreover, the revenue code to cost center crosswalk has been on the CMS Web site for several years, open continuously to public comment. We do not believe it is necessary to create and publish examples at the claim-line level to further elaborate on how we convert charges to costs for purposes of establishing median costs. Hospitals that are interested should have sufficient information available already on this topic. Moreover, Medicare auditing rules have been well-established and standardized over many years, and we rely on our contractors to enforce them appropriately. *Comment:*
                         One commenter suggested that CMS study the crosswalk that is used in the completion of the Provider Statistical and Reimbursement Report (PS&R) to determine whether changes to the CMS crosswalk of revenue codes to cost centers might be appropriate. Specifically, the commenter suggested the following revisions: Revenue code 0413 (hyperbaric oxygen therapy) should be crosswalked to the hospital overall CCR; Revenue code 026X (IV therapy) could have cost center 5600 (Drugs charges to patients) as the secondary default CCR before defaulting to the overall CCR; Revenue code 046X (Pulmondary therapy) should have cost center 4600 (respiratory therapy) as secondary and cost center 3160 as tertiary; and Revenue code 074X (EEG) should have cost center 5400 (EEG) as primary and cost center 3280 (EKG and EEG) as secondary. *Response:*
                         We have not made any changes in response to the commenter's suggestions for CY 2007. However, we will carefully examine the commenter's suggestions with regard to the calculation of CCRs for the CY 2008 OPPS. After carefully considering all the public comments received, we are adopting our proposal for CY 2007 without modification. As stated in the CY 2007 proposed rule (71 FR 49529), we will issue a Medicare program instruction to fiscal intermediaries that will instruct them to recalculate and use the hospital-specific overall CCR as we have finalized for the above stated purposes. 2. 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 final rule with comment period is posted provides an accounting of claims used in the development of the final rates: 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS.*
                         The accounting of claims used in the development of this final rule with comment period is included on the Web site under supplemental materials for the CY 2007 final rule with comment period. 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.” As proposed, we used the following methodology to establish the relative weights to be used in calculating the OPPS payment rates for CY 2007 shown in Addenda A and B to this final rule with comment period. This methodology is as follows: We used outpatient claims for the full CY 2005, processed before June 30, 2006, to set the relative weights 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, American Samoa, and the Northern Marianas 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 110 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. As proposed, for this final rule with comment period, we used the most recently submitted cost report to calculate the CCRs to be used to calculate median costs for the CY 2007 OPPS. 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 calculated both an overall CCR and cost center-specific CCRs for each hospital. We used the final overall CCR calculation discussed in II.A.1.c. of this preamble for all purposes that require use of an overall CCR. 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 
                        ( print page 67986)
                        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 proposed 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, if a visit was reported under the clinic revenue code, but the hospital did not have a clinic cost center, we mapped the hospital-specific 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 of the proposed rule (71 FR 49532) contained a list of the allowed revenue codes. Revenue codes not included in Table 2 are those 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, American Samoa, and the Northern Marianas 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 influenza 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 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 day 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 the CY 2007 OPPS, we proposed to use status indicators, as described above, to sort the claims into these groups. We believed that using status indicators was an appropriate way to sort the claims into these groups and also to make our process more transparent to the public. We further believed that this proposed method of sorting claims would enhance the public's ability to derive useful information and become a more informed commenter on the 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 non-OPPS claims (numbers 3, 4, and 5 above) because we did not use these claims in calculating median costs. 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 the proposed rule (71 FR 49517) and discussed in section II.A.1.b. of this preamble 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 
                        ( print page 67987)
                        from that residual claim record, which retained the costs of packaged revenue codes and packaged HCPCS codes. This enabled 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 was shown in Table 2 of the CY 2007 OPPS proposed rule (71 FR 49532) and below. 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, 58.4 million claims were left. Of these 58.4 million claims, we were able to use some portion of 54.1 million whole claims (92.6 percent of the 58.4 million potentially usable claims) to create the 98.5 million single and “pseudo” single claims for use in the CY 2007 median development and for ratesetting. We also excluded (1) claims that had zero costs after summing all costs on the claim and (2) claims containing packaging flag 3. Effective for services furnished on or after July 1, 2004, the Outpatient Code Editor (OCE) assigns packaging 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 hospital, are valid reflections of hospital resources. Therefore, we deleted these claims. In the proposed rule, we deleted claims with payment flag 3 (not packaging flag 3) because we believed that payment flag 3 identified claims for which the charges were not as submitted by the provider as described above. As we were processing claims for this final rule with comment period, we realized that this was not the case and corrected the process to eliminate claims which, as described above, have charges that are not as submitted by the provider. See the CY 2007 final rule claims accounting under supporting documentation posted on our Web site, 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS*, for this final rule with comment period for further explanation. We note that in this final rule with comment period, as stated in both the proposed rule and here, we have excluded those claims that we believed were not valid reflections of hospital resources. 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 proposed to use the pre-reclassified wage indices for standardization because we believed that they better reflect the true costs of items and services in the area in which the hospital is located than the post-reclassification 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 438,440 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 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 medians for blood and blood products is included in section X. of this preamble. A discussion of the 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 median for observation services is included in section XI. of this preamble, and a discussion of the median for partial hospitalization is included below in section II.B. of this preamble. We specifically invited public comment on the relative benefits of deleting claims reported with modifier 50 signifying two procedures were performed versus dividing the costs for the two procedures by two to create two “pseudo” single claims. We received one comment on this issue. *Comment:*
                         One commenter supported deletion of the conditional or independent bilateral service claims because the commenter believes that the total cost of a bilateral procedure (including packaged costs) is generally less than 2 times the total cost of a unilateral procedure, and such cost savings are already reflected in each hospital's CCR. The commenter stated that to divide the cost of the bilateral procedure by two would result in “pseudo” singles that would underrepresent the full cost of a single procedure. *Response:*
                         We have excluded claims for conditional and independent bilateral procedures from the claims we used to calculate the median costs for the CY 2007 OPPS. We will carefully consider how to treat these claims for future years. 
                        ( print page 67988) For the final CY 2007 OPPS ratesetting process, we deleted these claims, as we did for the proposed rule. We received many comments on our proposed CY OPPS data process. A summary of the comments and our responses follows: *Comment:*
                         The commenters objected to what they view as wide fluctuations in the APC payment rates from CY 2006 to CY 2007, because such variability makes it difficult to plan and budget for the services that the hospital will provide in the upcoming year. The commenters objected to changes in proposed OPPS rates that are greater than 5 percent from the prior year's rates and urged CMS to adjust rates so that no payment rate in CY 2007 declined by more than 5 percent compared to its payment in CY 2006. The commenters stated that more than 250 APC rates declined compared to their CY 2006 rates, some by 10 to 20 percent or more. In contrast, they noted that over 300 APC rates increased, many substantially and by up to 30 percent compared to their CY 2006 rates. The commenters stated that they did not believe that the changes in the median costs were reflective of changes in hospital costs, because hospital costs do not vary so widely from year to year. The commenters indicated that they expected that after more than 5 years of experience, the rates would no longer show such significant volatility and urged CMS to use more multiple claims data to set the median costs. *Response:*
                         There are a number of factors pertinent to the OPPS that cause median costs to change from one year to the next. These include reassignment of HCPCS codes to APCs to rectify 2 times violations and to respond to public comments; the need to split costs derived from claims data among the many different HCPCS codes, which results in very few usable claims for some services; and annual changes in reported hospital charges and costs that provide the source of the cost data on which the system is based. Although the APC number and title may remain the same from year to year, we routinely reassign HCPCS codes to different APCs to resolve violations of the 2 times rule as required by law or reconfigure APCs to create more levels in a series. We also reassign codes in response to public comments when we believe that the requested reassignment will result in improved clinical homogeneity and more similar resource use for a particular service or group of services. To the extent that there has been a reassignment either into or out of an APC or a reconfiguration of an APC into multiple levels, a comparison of the APC median from 1 year to the next is often not a valid comparison of the costs for the same services. In addition, every year new HCPCS codes that were initially assigned to clinical APCs for payment purposes may begin to contribute claims data to those APC median costs, also leading to ill-founded comparisons across years. Moreover, many of the claims we receive for OPPS services are multiple procedure claims that must be fragmented for use in establishing the median costs for single procedures. Unlike other prospective payment systems in which the costs of multiple services are aggregated into a single payment for a defined encounter (for example, inpatient stay and home health episode of care), under the OPPS the costs that reflect the charges on Medicare claims that contain more than a single service on the same date must be fragmented into pieces to provide costs at a unit level, rather than being aggregated to provide the total cost for a set of services furnished in a single encounter. The more the costs on claims are split to accommodate payment for individual items and services described by HCPCS codes, and the fewer single bills that are available for ratesetting because the costs cannot be fragmented into unique services, the more variability is introduced into the cost. Because of the difficulty in assigning the revenue code charge data that hospitals submit on multiple procedure claims to the separately payable HCPCS codes that form the basis of payment in the OPPS, we must often use small numbers of claims to set the median costs for some services. We believe that the small numbers of single claims are the source of much of the volatility in the payment system. When we examine claims data for APCs like the Visit APCs, for which we have large and stable numbers of services, we do not see the median cost fluctuations that typically occur in those APCs for which we regularly have small numbers of single bills. However, we are rarely asked for larger APCs that contain more codes or for more packaging of payment for HCPCS codes into the APC rates, both of which would enable us to use more claims and, we believe, provide more stable payment rates. Indeed, payment in the OPPS has become more specific each year, largely in response to our willingness to accommodate the requests of stakeholders when we believe they are justified and supported by the data. Each year, we are asked for increasingly more APCs that contain fewer HCPCS codes, as well as more precise costing of particular services. Generally, the comments received in response to our proposed rule asked for more separate payment, less packaging, and greater service-specific precision in the calculation of median costs for specifically identified services in the OPPS. We are also often asked to specifically recalculate median costs by using subsets of claims that meet specific criteria or by applying alternative methodologies for identified services. While these special approaches are generally intended to increase payments for their particular services of interest, they likely contribute to less stability in the system in general. Inevitably, such specificity would lead to more, not less, volatility as it would reduce the number of claims that can be used to set median costs. Lastly, hospital charges and costs are the foundation of the payment weights, but hospitals change the mix of services they furnish and thereby also change their cost structure to some extent each year. Moreover, hospitals increase, sometimes decrease, or hold steady their charges each year based on a variety of business reasons, but these changes to charges often vary across the different services they furnish. Thus, hospital decisions to change their mix of services or to change their charges for some services differentially also contribute to the volatility in payment rates. We recognize that it could be desirable for a payment system's rates to not vary by a certain percentage from the prior year's payment rates, but there is no reason to believe that limiting the changes in payment rates to prevent a decline by any percentage each year would be accurately reflective of changes in relative costs. Although the commenters asked that no payment for any service decline by more than 5 percent, none addressed a limitation for a payment increase. We do not believe that it is appropriate to artificially impose limits on a payment rate's increase or decrease from one year to the next, because, as noted above, comparisons between APC payment rates from year to year have little meaning for the many APCs that have experienced HCPCS migration. Moreover, to limit the increases or decreases in payment to a set amount for all services would conflict with the statutory requirement that at least annually we revise APCs and other components of the OPPS using new cost data and other relevant information. Therefore, we are not adjusting the rates as requested to account for a decline of more than 5 percent from CY 2006 in the final CY 2007 OPPS payment rates. We will continue to explore ways to use the data from multiple procedure claims because we agree that a high level of 
                        ( print page 67989)
                        volatility is not desirable in the OPPS, and we also believe that the most viable long term solution to instability is the use of all the claims data. However, we also believe that changes in median costs from one year to the next are unavoidable in a relative weight payment system which also depends on hospital charges and costs and in which reassignment of HCPCS codes from one APC to another is required by law in cases of 2 times violations. As the commenters noted, some CY 2007 APC payment rates decrease but others increase in comparison with the CY 2006 rates, consistent with expectations for a budget neutral payment system like the OPPS. *Comment:*
                         One commenter objected to the inclusion of charges from the following revenue codes as packaged services under the OPPS: (1) Revenue code 274 (Prosthetic/orthotic devices) on the basis that the revenue code is for nonimplanted devices that require a HCPCS code, are paid under the MPFS, and have a status indicator of “A” under the OPPS; (2) Revenue code 280 (Oncology) on the basis that there is no oncology service that would not be coded by a HCPCS code, and, therefore, any charge without a HCPCS code should not be packaged; (3) Revenue code 290 (Durable Medical Equipment (DME)) on the basis that DME is for use in the home and not in the outpatient setting; (4) Revenue codes 343 and 344 (Diagnostic radiopharmaceuticals and therapeutic radiopharmaceuticals) on the basis that they are required to be billed with a HCPCS code, and, therefore, charges without a HCPCS code should not be packaged; and (5) Revenue code 560 (Medical Social Services) on the basis that they are separately billable only by home health agencies and are, therefore, suspect and should not be packaged. *Response:*
                         With a few limited exceptions, CMS does not specify the revenue codes hospitals must use to report their charges. Therefore, we selected a generous set of revenue codes to maximize the likelihood that we would capture all of the costs of a particular service for purposes of calculating the median costs on which the OPPS payment rates are based. To cease packaging costs under these revenue codes where there is no HCPCS code reported on the line may result in erroneous reductions in median costs and, therefore, in the related OPPS payment rates. With regard to the specific concerns of the commenter, our responses regarding the rationale for packaging the revenue code charges for each revenue code of interest follow: (1) Revenue code 274 is one of the revenue codes we previously instructed hospitals to use to report devices that had been paid as pass-through devices; (2) Revenue code 280 is packaged because we believe that it is possible that a hospital could have costs related to packaged OPPS services for which it would choose not to bill a HCPCS code, and we want to ensure that those costs are not lost in median calculation; (3) Revenue code 290 (DME) is governed by the statute which explicitly states that implantable DME provided in hospitals is paid under the OPPS, and we believe that it is possible that hospitals may charge for implantable DME but not bill a HCPCS code for the items; (4) Revenue codes 343 and 344 (diagnostic and therapeutic radiopharmaceuticals) are included as hospitals may charge for these items without placing a HCPCS code on the line; (5) Revenue code 560 (Medical Social Services) is included because hospitals may charge without billing a HCPCS code for the services of a medical social worker that are related to a visit service and thus would otherwise not be packaged into the median cost for the visit. We note that National Uniform Billing Committee guidelines on use of revenue code 560 recognize that it may be reported by hospitals in some circumstances. *Comment:*
                         One commenter asked that CMS implement an indirect medical education adjustment under the CY 2007 OPPS to address what the commenter states is a 23-percent shortfall to the market basket for OPPS services. The commenter indicated that this adjustment was needed to reimburse hospitals for the higher costs incurred by major teaching hospitals to provide outpatient care to Medicare beneficiaries. *Response:*
                         We do not believe an indirect medical education add-on payment is appropriate in a budget neutral payment system where such changes would result in reduced payments to all other hospitals. Moreover, in this final rule with comment period, we have developed payment weights that we believe resolve many of the public concerns regarding appropriate payments for new technology services and device-dependent procedures that we believe are furnished largely by teaching hospitals. We believe this and other payment changes should help ensure adequate and appropriate payment for teaching hospitals. *Comment:*
                         One commenter supported CMS' proposal to discard claims that contain token charges for packaged devices but opposed discarding claims when there is only one separately paid procedure on the claim, although there are other packaged services billed with token charges on other lines of the claim. *Response:*
                         We have not discarded claims that contain token charges where there is only one separately paid procedure on the claim if there are other packaged services billed with token charges on other lines of the claim. We discarded claims with token charges only when such claims included token charges for devices with procedure codes that are assigned to device-dependent APCs, because we instructed hospitals to bill token charges for devices that were replaced without cost to the provider due for example, to warranty, field action or recall. We also discarded claims that, as submitted, contained token charges for separately paid (not packaged) procedure codes, which during claims processing were converted to imputed charges for purposes of applying the outlier policy and which came to us through the national claims history with the imputed charges. These claims are identified with a packaging flag 3 and are excluded because the charges shown on the claim we receive were not the charges submitted by the provider. We discuss this in more detail in the CY 2007 final rule claims accounting on the CMS OPPS Web page at 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​*. After carefully considering all public comments received, we are finalizing the list of packaged services by revenue code shown in Table 2 and our data process for calculating the median costs for OPPS services furnished on or after January 1, 2007, without modification. Table 2 below contains the list of packaged services by revenue code that we used in developing the APC relative weights listed in Addenda A and B of this final rule with comment period. Table 2.—CY 2007 Packaged Services by Revenue Code
Revenue code
Description250
PHARMACY.( print page 67990)251
GENERIC.252
NONGENERIC.254
PHARMACY INCIDENT TO OTHER DIAGNOSTIC.255
PHARMACY INCIDENT TO RADIOLOGY.257
NONPRESCRIPTION DRUGS.258
IV SOLUTIONS.259
OTHER PHARMACY.260
IV THERAPY, GENERAL CLASS.262
IV THERAPY/PHARMACY SERVICES.263
SUPPLY/DELIVERY.264
IV THERAPY/SUPPLIES.269
OTHER IV THERAPY.270
M&S SUPPLIES.271
NONSTERILE SUPPLIES.272
STERILE SUPPLIES.274
PROSTHETIC/ORTHOTIC DEVICES.275
PACEMAKER DRUG.276
INTRAOCULAR LENS SOURCE DRUG.278
OTHER IMPLANTS.279
OTHER M&S SUPPLIES.280
ONCOLOGY.289
OTHER ONCOLOGY.290
DURABLE MEDICAL EQUIPMENT.343
DIAGNOSTIC RADIOPHARMS.344
THERAPEUTIC RADIOPHARMS.370
ANESTHESIA.371
ANESTHESIA INCIDENT TO RADIOLOGY.372
ANESTHESIA INCIDENT TO OTHER DIAGNOSTIC.379
OTHER ANESTHESIA.390
BLOOD STORAGE AND PROCESSING.399
OTHER BLOOD STORAGE AND PROCESSING.560
MEDICAL SOCIAL SERVICES.569
OTHER MEDICAL SOCIAL SERVICES.621
SUPPLIES INCIDENT TO RADIOLOGY.622
SUPPLIES INCIDENT TO OTHER DIAGNOSTIC.624
INVESTIGATIONAL DEVICE (IDE).630
DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS.631
SINGLE SOURCE.632
MULTIPLE.633
RESTRICTIVE PRESCRIPTION.681
TRAUMA RESPONSE, LEVEL I.682
TRAUMA RESPONSE, LEVEL II.683
TRAUMA RESPONSE, LEVEL III.684
TRAUMA RESPONSE, LEVEL IV.689
TRAUMA RESPONSE, OTHER.700
CAST ROOM.709
OTHER CAST ROOM.710
RECOVERY ROOM.719
OTHER RECOVERY ROOM.720
LABOR ROOM.721
LABOR.762
OBSERVATION ROOM.810
ORGAN ACQUISITION.819
OTHER ORGAN ACQUISITION.942
EDUCATION/TRAINING.
 3. Calculation of Scaled OPPS Payment Weights Using the median APC costs discussed previously, we calculated the final relative payment weights for each APC for CY 2007 shown in Addenda A and B of this final rule with comment period. 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. As proposed, for the CY 2007 OPPS, we scaled all of the relative payment weights to APC 0606 (Level 3 Clinic Visits) because we deleted 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 3 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 a median 
                        ( print page 67991)
                        for calculating unscaled weights representing the median cost of some of the most frequently provided services, we proposed to continue to use the median cost of the middle level clinic APC, proposed APC 0606, to calculate unscaled weights. Following our standard methodology, but using the 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 final 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 1.364598352 for budget neutrality. We recognize the scaler, or weight scaling factor, for budget neutrality that we proposed 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 use of the median cost for APC 0606 of $83.39 based on final rule with comment period data causes the unscaled weights to be lower than they would have been if we had chosen APC 0605 (Level 2 Clinic Visits; median $60.13 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 1.364598352 for this final rule with comment period, 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 final relative payment weights listed in Addenda A and B of this final rule with comment period 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. As proposed, for CY 2007, we calculated specific payment rates for brachytherapy sources, which were subjected to scaling for budget neutrality. (We provide a discussion of brachytherapy payment issues, including their CY 2007 treatment with respect to outlier payments, under section VII. of this preamble.) Therefore, the costs of brachytherapy sources are accounted for in the scaler of 1.364598352. 4. Changes to Packaged Services 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 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; acoustic heart sound 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)).( print page 67992)
                    CMS maintain the packaged status of CPT code 36500 (Venous catheterization for selective blood organ sampling).
                    CMS pay separately for CPT code 36540 (Collection of blood specimen from a completely implantable 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 (Injection procedure for identification of sentinel node) 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 (eg, for parathyroid hormone, rennin), 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 (separate procedures), up to one hour physician time, other than 71023 or 71024 (eg, cardiac fluoroscopy)).
                    CMS maintain the packaged status of CPT codes 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)), 76003 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)), and 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral fact joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction).
                    CMS maintain the packaged status of CPT codes 76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting) and 75998 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position)).
                    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 for drug delivery systems) 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. At its August 2006 meeting, the Packaging Subcommittee further discussed the packaging status of several of the HCPCS codes described above and reported its findings to the APC Panel. The APC Panel accepted the report of the Packaging Subcommittee, heard one presentation, reviewed one written comment, and discussed the deliberations of the Packaging Subcommittee. The APC Panel made the following recommendations for CY 2007: + That CMS package new CPT codes 0174T, Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure), and 0175T, Computer aided detection (CAD ) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation). + That CMS continue to package revised CPT code 0069T (Acoustic heart sound recording and computer analysis; acoustic heart sound recording and computer analysis only). + That CMS assign CPT code 96523 (Irrigation of implanted venous access device for drug delivery systems) status indicator “Q” as a “special” packaged code. For CY 2007, we proposed to maintain CPT code 0069T as a packaged service and not adopt the APC Panel's March 2006 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 with comment period. 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. CPT code 0069T is an add-on code to an electrocardiography (ECG) service for CYs 2005 and 2006. However on July 1, 2006, the AMA released to the public a code descriptor change to remove the add-on code designation for CPT code 0069T. The effective date of this change is January 1, 2007, at which point the descriptor will be “Acoustic heart sound recording and computer analysis; acoustic heart sound recording and computer analysis only.” We do not include Category III CPT codes that are released in July of a given year in the OPPS proposed rule for the following calendar year because of timing restraints. We include these codes in the OPPS final rule where they are assigned interim comment indicator “NI” to denote that they are open for public comment. In its March 2006 presentation to the APC Panel, a 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. The manufacturer stated 
                        ( print page 67993)
                        that the acoustic heart sound 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. During the August 2006 meeting, the Packaging Subcommittee further discussed CMS's proposal to package CPT 0069T for CY 2007 and the CY 2007 code descriptor change, and ultimately recommended to the APC Panel that CMS continue to package this code for CY 2007. The APC Panel accepted this recommendation. *Comment:*
                         One commenter requested that CMS pay separately for CPT code 0069T for CY 2007, mapping the code to an APC paying between $63 and $97. The commenter clarified that this service is sometimes provided with an ECG and sometimes provided without an ECG, according to its revised descriptor for CY 2007. The commenter could not explain the low median cost that was calculated from the claims data, but suggested that the nine claims used to calculate the median were miscoded. The commenter estimated the cost of the service to be approximately $80 per procedure, significantly higher than the median cost for APC 0099 (Electrocardiograms), which was $23.60 based on the CY 2005 data that were used to calculate the CY 2007 proposed median costs. Though the commenter agreed that it would be rare for the acoustic heart sound procedure to be performed alone without any other OPPS services, the commenter disagreed that the procedure would be “associated” with other services. Instead, the commenter clarified that it could be provided with a broad range of services, such as an emergency department visit, clinic visit, chest x-ray, or ECG. In addition, the commenter did not expect this service to have a meaningful impact on the median costs of those services because acoustic heart services are expected to be provided infrequently, compared to the total number of emergency department and clinic visits, chest x-rays, and ECGs. *Response:*
                         Despite the change in add-on status for CPT code 0069T for CY 2007, based on the clinical uses that were described during the March 2006 APC Panel meeting and in the public comments, we believe that it is highly unlikely that CPT code 0069T would be performed in the hospital outpatient department as a sole service without other separately payable OPPS services. 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 would usually be closely linked to the performance of an ECG, and would rarely, if ever, be the only OPPS service provided to a patient. We understand that the commenter is clarifying that this service is not required to be provided in conjunction with an ECG. However, we continue to believe that it is likely that an ECG or other separately payable service would be performed on the patient in conjunction with the acoustic heart sound service. Therefore, we believe that it is appropriate to continue packaging CPT code 0069T for CY 2007. In addition, this service is estimated to require only minimal hospital resources. Using CY 2005 claims that have been updated with more recent CCRs, we had only nine single claims for CPT code 0069T, with a median line-item cost of $2.45, 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. After carefully considering all comments received, we are adopting the APC Panel's August 2006 recommendation to continue to package this code for CY 2007. Therefore we are finalizing our proposal without modification to maintain CPT code 0069T as a packaged service for CY 2007. For CY 2007, we proposed 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 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 “NI” in the CY 2006 OPPS final rule with comment period. For CY 2006, the code is indicated as an add-on code to chest x-ray CPT codes, according to the AMA's CY 2006 CPT book. However, on July 1, 2006, the AMA released to the public an update that deletes code 0152T for CY 2007 and replaces it with two new Category III CPT codes, 0174T and 0175T. Effective January 1, 2007, the descriptor for CPT code 0174T will be “Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) and the descriptor for 0175T will be “Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation.” As indicated above, we do not include Category III CPT codes that are released in July of a given year in the OPPS proposed rule for the following calendar year because of timing restraints. We include these codes in the OPPS final rule, where they are assigned new interim comment indicator “NI” to denote that they are open to comment. In its March 2006 presentation to the APC Panel, before the AMA had released the CY 2007 changes to this code, 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 post-processing services that are paid separately. We proposed to accept the APC Panel's recommendation to package CPT code 0152T for CY 2007. In its August 2006 presentation to the APC Panel, after the AMA had released the CY 2007 code changes, the manufacturer requested that we assign both of these two new codes to a New Technology APC with a payment rate of $15. The APC Panel members discussed these codes extensively. They considered the possibility of treating CPT code 0175T as a “special” packaged code, thereby assigning payment to the code only when it was performed by a hospital without any other separately payable OPPS service also provided on the same day. They questioned the meaning of the word “remote” in the code descriptor for CPT code 0175T, noting that is was unclear as to whether “remote” referred to time, geography, or a specific provider. They thought it was likely that a hospital without a CAD system that performed a chest x-ray and sent the x-ray to another hospital for performance of the CAD would be providing the CAD service under arrangement and, therefore, would be providing at least one other 
                        ( print page 67994)
                        service (chest x-ray) that would be separately paid. Thus, even in these cases, payment for the CAD service could be appropriately packaged. After significant deliberation, the Panel recommended that we package both of the new CPT codes, 0174T and 0175T, for CY 2007. *Comment:*
                         One commenter requested that CMS pay separately for CPT codes 0174T and 0175T, mapping them to New Technology APC 1492, with a payment rate of $15. The commenter indicated that there is no basis for believing that chest x-ray computer-aided detection (CAD) will increase the number of chest x-rays performed in the outpatient setting, because chest x-ray CAD is not a screening tool and should only be applied to chest x-rays that are suspicious for lung cancer. The commenter also indicated that separate resources are required for chest x-ray CAD that are not required for a standard chest x-ray. In addition, the commenter stated that chest x-ray CAD can be performed at a different time or location or by a different provider than the chest x-ray. In these cases, the commenter believed that separate payment would be appropriate. The commenter was concerned that if hospitals are not paid separately for this technology, they will not be able to provide it, thereby limiting beneficiary access to chest x-ray CAD. *Response:*
                         We agree with the APC Panel that packaged payment for chest x-ray 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. We do not believe that CPT code 0174T would ever be performed as a sole service without other separately payable OPPS services, based on the code definition as an add-on service performed concurrent with the primary interpretation of a chest x-ray. We believe that payment for CPT code 0174T is appropriately packaged into payment for the chest x-ray services it accompanies. Payment for chest x-rays is provided through APC 0260 (Level I Plain Film Except Teeth), with a CY 2007 median cost of $43.35. The median costs for the individual x-ray services that can be reported with the CAD technology range from $36.00 to $56.11, easily overlapping the modest additional costs of providing chest x-ray CAD services. Although CPT code 0175T applies to chest x-ray CAD that is “remote” from the primary interpretation, the definition of “remote” as used in the code descriptor is vague, with respect to time, geography, or a specific provider, so the circumstances in which it would be the only service provided by a hospital are also unclear. As discussed by the APC Panel if an x-ray were sent to another hospital for performance of the CAD, the CAD service would likely be provided under arrangement, in which case the hospital that performed the x-ray would bill for both the x-ray and the CAD service. It is unnecessary to treat CPT code 0175T as a “special” packaged code because generally the payment for the x-ray CAD would be bundled into the payment for the chest x-ray. While we have no costs from claims data because 0152T was a new CPT code for CY 2006, and 0174T and 0175T are new codes for CY 2007, we estimate that the CAD service requires only modest resources. We expect that a hospital's cost per chest x-ray CAD service would largely depend on the volume of CAD services provided. 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. After carefully considering all public comments received on this proposal, we are accepting the APC Panel's August 2006 recommendation to package new CPT codes 0174T and 0175T for CY 2007 on an interim final basis. For CY 2007, we proposed to accept the recommendation of the APC Panel and maintain the packaged status of CPT code 36500. As noted in the CY 2007 OPPS proposed rule (71 FR 49535) we have heard 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. Using CY 2005 claims, we have approximately 200 single claims for CPT code 75893, with a median cost of $269.13. As proposed for CY 2007 and described below for “special” packaged codes, 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. We received no public comments on our proposal. Therefore, we are finalizing our proposal to accept the APC Panel's recommendation to maintain the packaged status of CPT code 36500 without modification. For CY 2007, we proposed 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 proposed 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). During the August 2006 APC Panel meeting, the APC Panel reviewed a request from the public to assign payment to CPT code 96523 when it appears on a claim with no separately payable OPPS services also reported for the same date of service. The Panel 
                        ( print page 67995)
                        recommended that we treat CPT code 96523 as a “special” packaged code for CY 2007. 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 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 included in the CY 2007 OPPS proposed rule (71 FR 49536) and shown below listed 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. 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. *Comment:*
                         Many commenters complimented the Packaging Subcommittee for their efforts to improve payment under the OPPS. In addition, the commenters further commended the Packaging Subcommittee and CMS for proposing to provide payment for “special” packaged codes under certain circumstances. One commenter stated that “special” packaged codes further complicate an already complicated system and requested that CMS consistently either package a code or pay separately for a code, but not both. *Response:*
                         We appreciate the commenters' support and plan to continue working with the Packaging Subcommittee to review other packaged codes that are brought to our attention by the public. While we acknowledge that “special” packaged codes add a layer of complexity to a complicated payment system, we continue to believe that it is appropriate to assign payment to “special” codes under certain circumstances. We note the “special” packaged code policy should impose no additional reporting burden on hospital billing staff because the OCE is automatically programmed to assign payment when appropriate. *Comment:*
                         One commenter appreciated that CMS clarified that a hospital cannot bill a CPT E/M code simply because the hospital would like to receive payment for the packaged service that was provided. The commenter asked that CMS also clarify whether this applies only to packaged services, or if it also applies to a service for which there is no applicable HCPCS code. Another commenter noted that CMS is now contradicting Transmittal A-02-129, which states that hospitals can bill a low level clinic visit with CPT code 97602 (Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session) to receive payment. *Response:*
                         Providers should bill a low-level visit code only if the hospital provides a significant, separately identifiable visit from any other service provided. This general rule applies to any service provided by a hospital. As discussed below in section IX.A, we would expect that the hospital resources associated with a visit would be reflected in the hospital's internal guidelines used to select the level of reporting for the visit. The hospital should bill the clinic visit code that most appropriately describes the service provided. We acknowledge that Transmittal A-02-129 is based upon our past policy that a hospital could bill a low level visit code in addition to CPT code 97602, which was then packaged in CY 2003, at the time of the instruction. However, beginning in CY 2006 we have provided separate payment for CPT 97602 when it is performed as a nontherapy service in the hospital outpatient setting. Therefore, the instruction is no longer relevant and will be revised, because hospitals are now able to report and be paid for this wound care service with the most specific CPT code available. This OPPS payment policy for nontherapy, nonselective wound care services will continue for CY 2007. In circumstances where there is no applicable HCPCS code to describe a distinct service, hospitals should continue to report the most appropriate unlisted procedure or unlisted services CPT code. In summary, with respect to the billing of low level visit CPT codes, as described above, our current policy dictates that hospitals may only bill a low-level visit code if the hospital provides a significant, separately identifiable visit from any other service provided. *Comment:*
                         One commenter thanked CMS for clarifying that CMS receives claims with only packaged codes that may be used for data analysis. The commenter also stated that it hoped that the “special” packaged codes policy would convince its hospital billing department to submit claims with only packaged services on them, so that CMS would have cost data for these codes. Other commenters asked that CMS clarify that it receives claims with only packaged codes and no separately payable codes. *Response:*
                         We will clarify again that claims with only packaged codes are received and processed by the OCE. We can access cost data for all of the packaged codes on the claim. We encourage hospitals to continue to submit claims to CMS with only packaged codes because these submissions will allow us to continue to gather cost data for these codes, and help us determine whether it would be appropriate to add additional packaged codes to the “special” packaged codes list. 
                        ( print page 67996) After carefully considering the public comments received, we are adopting without modification, our proposal to accept the APC Panel's March 2006 recommendation to treat CPT codes 36540, 36600, 38792, 75893, 94762, and 96523 as “special” packaged codes. We note that we also are adopting the APC Panel's August 2006 recommendation to treat CPT code 96523 as a “special” packaged code. The APC assignments for these codes are shown in Table 3 below. These codes are assigned status indicator “Q” in Addendum B to this final rule with comment period. Table 3.—Status Indicators and APC Assignments for “Special” Packaged CPT Codes
CPT code
Descriptor
CY 2007 APC
Status 
                                 indicator
CY 2007 APC median36540
Collect blood, venous access device
0624
S
$31.4436600
Arterial puncture; withdrawal of blood for diagnosis
0035
T
12.2238792
Sentinel node identification
0389
S
84.0575893
Venous sampling through catheter, with or without angiography, radiological supervision and interpretation
0668
S
381.7194762
Noninvasive ear or pulse oximetry for oxygen saturation by continuous overnight monitoring
0443
X
63.6196523
Irrigation of implanted venous access device
0624
S
31.44
 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 and separately paid. 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 proposed 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 CPT 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. We received no public comments on our proposal. Therefore, we are adopting our proposal to accept the APC Panel's recommendation and maintain the packaged status of CPT codes 74328, 74329, and 74330 for CY 2007. For CY 2007, we proposed 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. As noted in the CY 2007 proposed rule (71 FR 49536), we received a comment which stated that it was inconsistent to pay separately for CPT code 76000 but to package CPT code 76001, 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 procedure-specific 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. We received no public comments that objected to our proposal. Therefore, we are adopting our proposal, without modification, 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 for OPPS services furnished on or after January 1, 2007. For CY 2007, we proposed 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. We found that 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 proposed to continue to package both CPT codes 76937 and 75998 for CY 2007. CPT code 75998 will be replaced with CPT code 77001, effective January 1, 2007. The code descriptor will remain the same. *Comment:*
                         Several commenters requested that CMS pay separately for CPT code 76937 because they believe that packaged payment creates a disincentive for use of this technology. Three commenters cited a June 2001 report published by the Agency for Healthcare Research and Quality that claims that use of ultrasound guidance reduced the relative risk for complications during a central venous 
                        ( print page 67997)
                        catheter insertion. In addition, two commenters submitted claims data analyses that suggested that for those vascular access procedures that CPT code 76937 could be reported with, CPT code 76937 was reported, on average, only 14 percent of the time, with the greatest utilization rate no more than 25 percent. The commenters stated that these analyses confirmed that ultrasound guidance is not standard practice while performing vascular access procedures. *Response:*
                         We appreciate the data analyses submitted by the commenters. In fact, we published the results of our similar analysis in the CY 2006 final rule with comment period (70 FR 68544). To summarize our previous analysis, using CY 2004 single claims data, we determined that for the four most commonly billed venous access device insertion codes (CPT codes 36556, 36558, 36561, and 36569), one or more forms of guidance (fluoroscopic and/or ultrasound) were reported on 41 to 64 percent of the single claims utilized for ratesetting. Specifically, ultrasound guidance was reported from 16 to 34 percent of the time and fluoroscopic guidance was billed from 29 to 52 percent of the time. Thus, overall for these vascular access device insertion services, guidance was used in at least 41 percent of the single claim cases, a very significant portion of the time. We note that all of the commenters are specifically concerned about unpackaging CPT code 76937 and do not appear to be concerned with the packaged status of CPT 75998. In fact, the commenters' analyses only included ultrasound guidance and did not specify the number of venous access device insertions that involved fluoroscopic guidance. We believe that hospital staff choose whether to use no guidance or fluoroscopic guidance or ultrasound guidance on an individual basis, depending on the clinical circumstances of the vascular access device insertion procedure. We also note that the two commenters studied the frequency of CPT code 76937 when billed with CPT codes 36555-36585, which includes central venous access device insertions, repairs, and replacements. In fact, the study that the commenters reference indicates that ultrasound guidance is appropriate for central venous access device insertions. Interestingly, the data now show that 16 percent of all central venous access device insertions are billed with ultrasound guidance while only 2 percent of repairs and replacements are billed with ultrasound guidance. We believe that this indicates that it may be less useful to use ultrasound guidance in conjunction with central venous access device repairs and replacements. Our hospital claims data demonstrate that in CY 2004 guidance services were used frequently for the insertion of vascular access devices, and we have no evidence that patients lacked appropriate access to guidance services necessary for the safe insertion of vascular access devices in the hospital outpatient setting. To the extent that ultrasound guidance may be more frequently provided in the future in association with the insertions of venous access devices or other OPPS services, we expect that its cost would also be increasingly reflected in the median costs for those services. Also in the CY 2006 final rule (FR 70 68544), we reported our analysis of claims data related to ultrasound guidance for vascular access device insertion procedures from another perspective. Rather than determining how often central venous access device insertions were billed with ultrasound guidance, we determined how often ultrasound guidance was billed with central venous access device insertions. The OPPS hospital claims data reviewed at that time revealed that out of the total instances of CPT code 76937 appearing on the claims used for setting payment rates for CY 2006, CPT code 76937 was billed with four separately payable codes for insertion of central venous access devices 84 percent of the time. This indicated, as might have been expected, that the costs for CPT code 76937 were typically packaged into payment for four CPT codes, 36566, 36558, 36561, and 36569, the most commonly billed codes under the OPPS for vascular access device insertion. Because we believe that ultrasound guidance would always be provided with another separately payable procedure, its costs would be appropriately bundled with the handful of vascular access device insertion procedures with which it is most commonly performed. In addition, packaging is also appropriate because the cost of ultrasound guidance is relatively low compared to the CY 2007 payment rates for the separately payable services it most frequently accompanies. After carefully considering the public comments received, we are adopting our proposal without modification to accept the APC Panel's March 2006 recommendation to continue to package CPT codes 76937 and 77001, which replaces CPT code 75998. For CY 2007, we proposed 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 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) or 93526 (Combined right heart catheterization and retrograde left heart catheterization). In addition, the median cost of G0269 is low compared to the costs of the procedures with which it is typically associated. We received no public comments on our proposal. Therefore, we are finalizing our proposal, without modification, to package HCPCS code G0269 for CY 2007. For CY 2007, we proposed to continue packaging CPT codes 94760 and 94761 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 1.18 million claims in CY 2005 for the single pulse oximetry determination service and over 485,000 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 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 final rule with comment period, 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 
                        ( print page 67998)
                        appropriate provision as single services should be very rare. Therefore, for CY 2007 we proposed not to include these codes on the list of “special” packaged codes, so their payment would remain packaged in all circumstances. We received no public comments on our proposal. Therefore, we are adopting our proposal to continue packaging CPT codes 94760 and 94761 and are not adopting the APC Panel's March 2006 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. For CY 2007, we proposed 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. We received no public comments on our proposal. Therefore, we are adopting our proposal without modification 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. For CY 2007, we proposed to assign status indicator “N” to CPT code 0126T (Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor). We received one public comment on this proposal. *Comment:*
                         One commenter disagreed with our status indicator assignment of “N” for CPT code 0126T and stated that CMS should pay separately for the common carotid IMT procedure because this is often the sole service that is performed in the hospital outpatient setting. As clarified by the commenter, common carotid IMT is a standardized ultrasound procedure that enables physicians to safely and accurately measure and monitor atherosclerosis, which is the underlying cause of heart attacks and stroke. The commenter reported that this code became effective on January 1, 2006. According to the commenter, unlike certain other ultrasound procedures that must be provided with other services, common carotid IMT is a stand-alone diagnostic test because it requires special imaging of the arterial wall and quantitative analysis. The commenter further added that based on the CPT code book instruction for other carotid procedures (that is, CPT codes 93880 and 93882), CPT coding does not permit bundling of 0126T with other procedure codes. The commenter urged CMS to pay separately for common carotid IMT and assign this code to New Technology APC 1504—Level IV ($200-$300), with a payment rate of $250. *Response:*
                         We continue to believe that it would be unlikely for this code to be provided without any other separately payable services on the same day. However, we also think that the commenter's suggestion bears closer examination. Therefore, we will review this code with the Packaging Subcommittee of the APC Panel, as is our standard procedure for codes that we are asked to review during the comment period, and as we have previously done for the other services discussed above. We will discuss with the Packaging Subcommittee, on an ongoing basis, packaged procedures for which status indicator changes have been suggested by the public. We note that 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. Payment for Partial Hospitalization 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 final rule with comment period 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 
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                        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 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. PHP APC Update for CY 2007 For CY 2007, we proposed to calculate the CY 2007 PHP per diem payment rate using the same update methodology that we adopted in CY 2006. That is, we proposed 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. As discussed in the CY 2007 OPPS proposed rule (71 FR 49538), we analyzed 12 months of data for hospital and CMHC PHP claims for services furnished between January 1, 2005, and December 31, 2005. We 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 hospital-based PHPs was $209. Following the methodology used for the CY 2005 update, the CY 2007 combined hospital-based 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. As a result, we proposed the same policy we adopted for CY 2006—a 15-percent reduction applied to the current median cost. Therefore, to calculate the proposed PHP per diem rate for CY 2007, we applied an additional 15-percent reduction to the 
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                        combined hospital-based and CMHC median per diem cost. To calculate the proposed 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 proposed combined median per diem cost of $208.80. We received numerous public comments in response to our proposal. A summary of the comments received and responses follow: *Comment:*
                         A number of commenters expressed concern about the magnitude of the reduction, particularly in light of last year's 15 percent reduction. The majority of commenters requested that CMS freeze the PHP rate at the CY 2006 level. Representatives of CMHCs argued that their costs are higher than those of hospitals, with most in the $300 to $400 range. Another commenter indicated that a per-day rate of $325 to $375 was more appropriate than the proposed amount. The commenters also suggested alternatives to calculating the PHP rate, such as including prior years' CMHC data trended forward based on medical inflation or market basket update. In addition, several patients were concerned that a 15-percent reduction in payment would negatively impact their ability to continue therapy. *Response:*
                         For this CY 2007 final rule with comment period, we analyzed 12 months of more current data for hospital and CMHC PHP claims for services furnished between January 1, 2005 and December 31, 2005. These claims data are more current because the data include claims paid through June 30, 2006. We also used the most currently available CCRs to estimate costs. Using these updated data, we recreated the analysis performed for the CY 2007 proposed rule to determine if the significant factors we used in determining the proposed PHP rate had changed. The median per diem cost for CMHCs increased $8 to $173, while the median per diem cost for hospital-based PHPs decreased $19 to $190. The CY 2005 average charge per day for CMHCs was $675 similar to the figure noted in the CY 2007 proposed rule ($673) but still significantly lower than what is noted for CY 2003 ($1,184). Following the 15-percent reduction methodology used for the CY 2005 update, the combined hospital-based and CMHC median per diem cost would be $175, only slightly more than the figure noted in the CY 2007 proposed rule ($172). We continue to believe this amount is too low to cover the cost of PHPs. However, we believe that freezing the current rate would not reflect the downward trend in data. Although the data continue to show a low per diem cost for PHP, we believe that a transition to the reduced amount may be more appropriate to ensure access for the vulnerable population served in PHPs. We recognize that many CMHCs are located in areas affected by Hurricanes Katrina and Rita where access to intensive mental health treatment is now limited. We note that the median per diem cost for hospital-based PHPs, which has been in the $200 to $225 range since the OPPS was implemented, went from $201 in CY 2004 to $190 in CY 2005, a decrease of 5 percent. We believe this percentage decrease provides a valid transitional percentage measure reflecting the downward trend in PHP cost. Therefore, for CY 2007, we are making a 5-percent reduction to the CY 2006 median per diem rate. This amount accounts for the downward direction of the data and addresses concerns about the magnitude of a 15-percent reduction in 1 year. 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 5 percent, which resulted in a combined per diem cost of $233.37. If the PHP per diem cost continues to be low in CY 2008, we expect to continue the transition of decreasing the PHP median per diem cost to an amount that is reflective of the PHP data. *Comment:*
                         The commenters requested that CMS better define how it is monitoring and working with CMHCs to improve their reporting. *Response:*
                         CMS has provided guidance to all providers, through transmittals and manuals. In addition, when necessary, CMS has worked closely with fiscal intermediaries to provide guidance to targeted PHP providers to improve reporting. *Comment:*
                         Several commenters stated that CMS has applied its own assumptions and methodology on a different basis to compute the PHP rate each year from CY 2003 to CY 2006. The commenters also stated that the only years CMS used the same method was CY 2006 and CY 2007, when CMS made a simple 15-percent reduction from the previous year's rate. *Response:*
                         We do not agree with the commenters' assessment of our methodology for computing the PHP median per diem cost. Although a 0.583 adjustment factor was applied to CMHC costs in the CY 2003 update, all other aspects of the methodology that the commenter referenced have been the same each year until CY 2006. We have consistently calculated the PHP median per diem cost by using combined hospital-based and CMHC median cost data and scaled the figure relative to the cost of a mid-level office visit and then applied the conversion factor. However, in CY 2006, the combined hospital-based and CMHC median cost data produced an amount we believed was so low that it would result in too large of a single year rate reduction that we modified our methodology by limiting this decrease to 15 percent. *Comment:*
                         One commenter replicated the CMS methodology and computed rates very close to the CY 2007 proposed per diem rate, as well as the separate median per diem costs for CMHCs and hospital-based PHPs. The commenter also created a 3-year rolling median cost that also resulted in a rate similar to the proposed PHP rate. However, the commenter recommended that CMS use the hospital-specific cost center CCR for partial hospitalization instead of the overall outpatient CCR to calculate PHP median costs. The commenter believed that CMS has understated the PHP median costs by not using the hospital-specific CCRs for partial hospitalization. *Response:*
                         We note that most hospitals do not have a cost center for partial hospitalization; therefore, we have used the CCR as specific to PHP as possible.  The following link contains the Revenue Cost to Cost Center Crosswalk: 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​03_​crosswalk.asp#TopOfPage*. This crosswalk indicates how (and if) charges on a claim are mapped to a cost center for the purpose of converting charges to cost. One or more cost centers are listed for every revenue code that is used in the OPPS median calculations, starting with most specific, and ending with most general. CMS maps the revenue code to the most specific cost center with a provider-specific CCR. If the hospital does not have a CCR for any of the listed cost centers, the overall hospital CCR is the default. The PHP revenue centers are mapped to a Primary Cost Center 3550 “Psychiatric/Psychological Services.” If that cost center is not available, then the Secondary Cost Center is 6000 “Clinic.” We use the overall facility CCR for CMHCs because PHP is the CMHCs’ only Medicare cost and CMHCs do not have the same cost centers as hospitals. Therefore, for CMHCs, we use the CCR from the outpatient provider-specific file. *Comment:*
                         One commenter stated that its internal computations reflect PHP per diem costs of $262.82 for its facility. The commenter urged CMS to increase the CY 2006 PHP rate of $245.65 by 6.8 percent so that the commenter's 
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                        program would break even. Another commenter questioned why CMS did not use actual cost report data to obtain true costs instead of estimating cost using CCRs applied to charges. A third commenter stated that CMS is required to include average costs for all providers and that CMS claims to utilize data representative of the mean of actual operating costs. *Response:*
                         We appreciate the commenter sharing its facility's per diem costs for its facility. However, PHP providers are paid under the OPPS. Under the OPPS, we generally determine rates based on median cost using charges from bill data and then estimate costs using CCRs. The OPPS is a PPS and will reflect generally the cost of providing services. A PPS may pay more or less than a provider's costs and is not a reasonable cost reimbursement system. *Comment:*
                         One commenter observed a decline of 19 percent in the number of hospital-based PHPs from CY 2003 to CY 2005 and a decline of 21 percent in the number of hospital-based PHP claims. The commenter expected further reductions in the number of hospital-based PHPs if CMS implements the proposed 15-percent rate cut in CY 2007. *Response:*
                         We do not believe this is an appropriate comparison because the commenter did not use the complete year of CY 2005 claims data. Rather, the commenter used CY 2005 claims processed through December 31, 2005. Using comparable CYs 2003 and 2005 data, (both CY 2003 and CY 2005 claims processed through June 30, 2004 and June 30, 2006, respectively), the declines are 11 percent and 5 percent, respectively. During the same time period, the number of CMHCs increased 13 percent and the number of CMHC PHP claims increased 36 percent. While there may have been fewer hospital-based PHPs, the number of CMHCs increased from 136 in CY 2003 to 179 in CY 2005. In CY 2005, CMHC and hospital-based PHPs combined provided 1.2 million days of PHP care, compared to approximately 0.8 million days of PHP care in CY 2003. We believe our payment rates continue to ensure adequate access to PHP care. *Comment:*
                         Several commenters suggested establishing a task force to develop a new rate methodology that captures all relevant data and reflects the actual costs to providers to deliver PHP services. The commenters recommended that the new ratesetting task force be composed of CMS staff and a diverse group of stakeholders that include front-line providers of PHP services and representatives from national industry organizations. *Response:*
                         We agree that the payment rate for PHP needs to be accurate and appropriate to sustain access to care. As we consider changes to the current methodology, we believe input from the industry is an important part of that process. Therefore, we welcome any input and information that the industry can provide about the costs of their programs and encourage providers to submit information on their costs. We note that any significant change in payment methodology would require a statutory change. *Comment:*
                         A few commenters stated that wage index adjustment does not accurately reflect the cost of labor in areas affected by Hurricanes Katrina and Rita. *Response:*
                         The hospital wage data used to compute the FY 2007 hospital wage index is from the FY 2003 hospital cost reports for all hospitals. This is the standard lag timeframe in determining the hospital wage index. It will be another 2 years before the FY 2005 data will be reflected in the FY 2009 hospital wage index. The wage index is a relative measure of differences in area hourly wage levels. It compares a labor market's average hourly wage to the national average hourly wage. To the extent that post-hurricane hospital labor costs are higher relative to the national average, the wage index will reflect the higher relative labor cost beginning when the FY 2005 data will be used in the FY 2009 IPPS hospital wage index (which will be applied to the CY 2009 OPPS rate year). In addition, the statutory authority for the OPPS wage index policy in section 1833(t)(2)(D) of the Act requires that wage adjustments be made in a budget neutral manner. Therefore, we cannot raise one wage area and still maintain budget neutrality. *Comment:*
                         A few commenters disagreed with the CMS approach to establishing the median per diem cost by summarizing the line-item costs on each bill and dividing by the number of days on the bills. The commenters indicated that this calculation can severely dilute the rate and penalize providers. The commenters stated that all programs are strongly encouraged by the fiscal intermediaries to submit all PHP service days on claims, even when the patient receives less than three services. They further stated that programs must report these days to be able to meet the 57 percent attendance threshold and avoid potential delays in the claim payment. The commenters were concerned that programs are only paid their per diem when three or more qualified services are presented for a day of service. The commenters stated that if only one or two services are assigned a cost and the day is divided into the aggregate data, the cost per day is significantly compromised and diluted. They claimed that even days that are paid but only have three services dilute the cost factors on the calculations. *Response:*
                         If a provider has charges on a bill for which they do not receive payment, this will be reflected in that provider's CCRs. This lower CCR will be applied to the larger charges and will result in the appropriate cost per diem. To gauge the effect that days with one or two services had on the per diem cost, we trimmed all days with less than three services, and the recalculated median per diem cost only increased by $4.00. As such, we do not believe the calculations are adversely affected by the inclusion of these days. *Comment:*
                         A few commenters expressed concern that their financial status is affected where States limit payment of beneficiary coinsurance if the amount of Medicare payment made to a provider exceeds the State's payment rate for PHP. *Response:*
                         This is a Medicaid issue and beyond the scope of this final rule. *Comment:*
                         With respect to the methodology used to establish the PHP APC amount, commenters were concerned that data from settled cost reports fails to include costs reversed on appeal. The commenters stated that there are inherent problems in using claims data from a different time period than the CCRs from settled cost reports. The commenters indicated this would artificially lower the computed median costs, even though when cost reports are settled, generally 2 years or more after the actual year of services, as the providers have operated on actual revenues of 80 percent of the per diem. *Response:*
                         We use the best available data in computing the APCs. We issued a Program Memorandum on January 17, 2003 directing fiscal intermediaries to update the CCRs on an on-going basis whenever a more recent full year cost report is available. In this way, we minimize the time lag between the CCRs and claims data and continue to use the best available data. *Comment:*
                         One commenter stated that administrative costs for CMHCs continue to be a major impediment to operating PHPs for Medicare beneficiaries. The commenter was concerned that Medicare does not cover transportation to and from programs and does not cover meals. The commenter stated that almost all programs offer transportation because in most cases 
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                        Medicare beneficiaries with serious mental illnesses would not be able to access these programs without the transportation. *Response:*
                         The services that are covered as part of a PHP are specified in section 1861(ff) of the Act. Meals and transportation are specifically excluded under section 1861(ff)(2)(I) of the Act. *Comment:*
                         Several commenters summed the payment rate for four Group Therapy sessions (APC 0325) and requested that amount as the minimum for a day of PHP (that is, 4 × $66.40=$265.60). Another commenter presented two different typical days using proposed CY 2007 rates. Typical Day 1 had three Group Therapy sessions (CPT code 90853, APC 0325, 3  ×  $66.40) and one Individual Psychotherapy session (CPT code 90818, APC 0325, $105.68). The commenter priced Typical Day 1 at $304.88. Typical Day 2 had one Group Therapy session (CPT code 90853, APC 0325, $66.40), one Individual Psychotherapy session (CPT code 90818, APC 0323, $105.68), and one Family Therapy session (CPT code 90847, APC 0324, $135.95). The commenter priced Typical Day 2 at $308.03. Based on the commenter's presented material, the commenter stated that the typical days yield an average componentized rate of $306. The commenters questioned how CMS can set rates for APCs 0322 through 0325, yet are unable to determine a payment rate for a day that is comprised of a minimum of three to four of those services. Another commenter stated that CMS requires a minimum of four treatments per day to qualify for a day of PHP and the proposed per diem rate of $208.27 for PHP that is less than what CMS would pay for four Group Therapy sessions (4  ×  $66.40=$265.60). *Response:*
                         We do not believe this is an appropriate comparison. The commenter does not use the PHP APC, APC 0033. The payment rates for APC services cited by the commenter (APC 0323, APC 0324 and APC 0325) are not computed from PHP bills. As stated earlier, we used data from PHP programs (both hospitals and CMHCs) to determine the median cost of a day of PHP. PHP is a program of services where savings can be realized by hospitals and CMHCs over delivering individual psychotherapy services. We structured the PHP APC (0033) as a per diem methodology in which the day of care is the unit that reflects the structure and scheduling of PHPs and the composition of the PHP APC consists of the cost of all services provided each day. Although we require that each PHP day include a psychotherapy service, we do not specify the specific mix of other services provided and our payment methodology reflects the cost per day rather than the cost of each service furnished within the day. We note that CMS does not require a minimum of four services. *Comment:*
                         One commenter requested that the same provisions given to rural hospital outpatient departments also be given to rural CMHCs. *Response:*
                         We believe the commenter may be referring to the statutory hold harmless provisions. Section 1833(t)(7)(D) of the Act authorizes such payments, on a permanent basis, for children's hospitals and cancer hospitals and, through CY 2005, for rural hospitals having 100 or fewer beds and SCHs in rural areas. Section 1866(t)(7)(D) of the Act does not authorize hold harmless payments to CMHC providers. Section 411 of Pub. L. 108-173 required CMS to determine the appropriateness of additional payments for certain rural hospitals. That authority also does not extend to CMHCs. *Comment:*
                         Representatives of several CMHCs claimed that their costs are higher because “hospitals can share and spread their costs to other departments.” The commenters believed that the CMHC patient acuity level is more intense than that for hospital patients because hospital outpatient departments need only provide one or two therapies, yet still receive the full PHP per diem. *Response:*
                         CMHCs are required to furnish an array of outpatient services including specialized outpatient services for children, the elderly, individuals with a serious mental illness, and residents of its service area who have been discharged from inpatient treatment. Accordingly, CMHCs have the same ability to share costs among its programs as needed. Further, we believe hospital costs in some areas, for example, capital and 24-hour maintenance costs, likely exceed CMHC costs. *Comment:*
                         A few commenters stated that hospitals that offer partial hospitalization services should not be penalized for the instability in data reporting of CMHCs. Another commenter requested that CMS require that CMHCs improve their reporting or have that provider group face economic consequences. *Response:*
                         We believe that hospital-based programs may have benefited from the inclusion of CMHC data, as generally the median calculated from hospital outpatient department PHPs was consistently far less then the median amount that is computed for CMHCs. We have also taken steps to better educate the CMHCs in the cost reporting requirements. *Comment:*
                         One commenter asked why there are no CMHCs shown in the impact statement. The commenter asked if this is required by regulation. *Response:*
                         CMHCs do not share the same characteristics as hospitals and do not fit into the traditional impact categories (like bed size). Therefore, we have not included them in the impact chart. As PHP is the only Medicare service CMHCs provide, the impact is the percentage change in the APC amount from year to year. Assuming that the number days of PHP provided by CMHCs stays the same as it was in CY 2005, the estimated impact on CMHCs as a result of the CY 2007 PHP payment rate compared to the CY 2006 PHP payment rate is a 5-percent decrease. 3. 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 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 
                        ( print page 68003)
                        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, we believe the CY 2005 CMHC data produce median per diem cost too low to use for the CY 2007 partial hospitalization payment rate. Due to the continued volatility of the CMHC charge data, we proposed 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 proposed to continue our policy of setting aside 1.0 percent of the aggregate total payments under the OPPS for outlier payments. We proposed 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 proposed 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 did not propose to set a dollar threshold for CMHC outliers. As noted above, we proposed 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. We received no public comments on our proposal. As discussed in section II.G. of this preamble, using more recent data for this final rule with comment period, we set the target for hospital outpatient outlier payments at 1.0 of total OPPS payments. We allocate a portion of that 1.0 percent, an amount equal to 0.15 percent of outlier payments and 0.0015 percent of total OPPS payments to CMHCs for PHP service outliers. For CY 2007, we set the outlier threshold for CMHCs for CY 2007 at 3.40 percent times the APC payment amount and the CY 2007 outlier percentage applicable to costs in excess of the threshold at 50 percent. C. Conversion Factor Update for CY 2007 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 hospital market basket increase for FY 2007 published in the IPPS final rule on August 18, 2006 is 3.4 percent (71 FR 48146), the same as the forecast published in the FY 2007 IPPS proposed rule on April 25, 2006 (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 0.999331979 for wage index changes by comparing total payments from our simulation model using the FY 2007 IPPS final wage index values as finalized 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 0.999975941 for the rural adjustment, including EACHs. For CY 2007, we estimate that allowed pass-through spending would equal approximately $65.6 million, which represents 0.21 percent of total OPPS projected spending for CY 2007. The final conversion factor also is adjusted by the difference between the 0.17 percent pass-through dollars set-aside in CY 2006 and the 0.21 percent estimate for CY 2007 pass-through spending. Finally, payments for outliers remain at 1.0 percent of total payments for CY 2007. The market basket increase update factor of 3.4 percent for CY 2007, the required wage index budget neutrality adjustment of approximately 0.999331979, the adjustment of 0.04 percent for the difference in the pass-through set-aside, and the adjustment for the rural payment adjustment for rural SCHs, including rural EACHs, of 0.999975941 result in a standard conversion factor for CY 2007 of $61.468. We received many public comments on the calculation of the proposed conversion factor updates for CY 2007 with regard to the proposal to reduce the CY 2007 conversion factor for failure to report the IPPS RHQDAPU data. These comments are addressed in section XIX. of this preamble. We received no other comments on the proposed conversion factor update for CY 2007. D. Wage Index Changes for CY 2007 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. Since the inception of the OPPS, CMS policy has been to wage adjust 60 percent of the OPPS payment, based on a regression analysis that determined that approximately 60 percent of the costs of services paid under OPPS were attributable to wage costs. We did not propose to revise this policy for CY 2007 OPPS. See section II.H. of this final rule with comment period for a description and example of how the wage index for a particular hospital is used to determine the payment for the hospital. This adjustment must be made in a budget neutral manner. As we have done in prior years, we proposed 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 “non-IPPS” 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 
                        ( print page 68004)
                        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 the CY 2007 OPPS proposed rule, in accordance with our established policy, we proposed 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 would be published in our final rule with comment period for CY 2007 which will include the finalized wage indices in effect through March 31, 2007, and those 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 copayment standardized amount. 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 published 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). On October 11, 2006 (71 FR 59886), we published an IPPS notice in the 
                        **Federal Register**
                         that, in part, finalized the adjusted occupational mix wage indices published in the FY 2007 IPPS final rule. Readers are directed to refer to the wage index tables that were published on the CMS Web site before October 1, 2006. 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 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 final rule (71 FR 48005 through 48028) for a detailed discussion of the changes to the wage indices. Readers should refer also to our IPPS notice published in the 
                        **Federal Register**
                         on October 11, 2006, for finalized changes to the adjusted occupational mix wage indices and related issues (71 FR 59886). In this final rule with comment period, we are not reprinting the FY 2007 IPPS wage indices referenced in the discussion below, with the exception of the out-migration wage adjustment table (Addendum L of this final rule with comment period). 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 finalized FY 2007 IPPS wage indices tables. 1. 
                        *The 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 final 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-to-rural 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 the FY 2007 IPPS final rule and the October 11, 2006 IPPS notice discussed above. Under that final rule, the wage indices are adjusted 100 percent for occupational mix. In addition, as stated above, the finalized version of the FY 2007 IPPS wage index tables and other adjustment factors were published in the October 11, 2006 IPPS notice and are applicable to discharges occurring on or after 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 final rule with comment period, we have used the finalized FY 2007 IPPS wage indices identified in the October 11, 2006 IPPS notice that are fully adjusted for differences in occupational mix using the new survey data, effective October 1, 2006. As proposed, in all cases, we are using the finalized 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 proposed 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 final rule (71 FR 48024 and 48025), we finalized the 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 will calculate 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 out-migration wage adjustment, discussed 
                        ( print page 68005)
                        in greater detail in section III.I. of the FY 2007 IPPS final rule (71 FR 48026) 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 out-migration wage adjustment if they are located in an adjustment county. We note that 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 final rule (71 FR 48026), 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 “out-migration” counties receive a wage index increase unless they have already been otherwise reclassified. (See the IPPS FY 2007 final rule for further information on out-migration.) For OPPS purposes, we proposed to continue our policy from CY 2006 to allow non-IPPS hospitals paid under the OPPS to qualify for out-migration adjustment if they are located in a section 505 out-migration 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 were published after the FY 2007 IPPS final rule on October 11, 2006 (71 FR 59886). These tables reflect updated county listing to reflect changes to the occupation mix adjustment made in response to 
                        *Bellevue*
                         court case discussed above. Because we proposed to adopt the final FY 2007 IPPS wage index, we are adopting any changes in a hospital's classification status that will make them either eligible or ineligible for the out-migration 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 final rule with comment period, 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 final 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 one-time appeal process. Because the increased OPPS payments already count against the $900 million limit, we did not consider these reclassifications when we calculated the OPPS budget neutrality adjustment. Under the procedural rules described under section II.D.3. of this final rule with comment period and in section III.H.6. of the FY 2007 IPPS final rule (71 FR 48024) 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 proposed 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 final rule (71 FR 48026). We received several comments on the proposed wage index policy for the CY 2007 OPPS. *Comment:*
                         One commenter urged CMS to use the IPPS labor-related adjustment to determine reimbursements for outpatient services. Specifically, the commenter requested that the labor-related percentage for the OPPS be revised from the 60 percent currently proposed to 69.7 percent, consistent with what is stated in the FY 2007 IPPS rule. The commenter further requested that, at a minimum, CMS update the OPPS labor-related share in effect for CY 2007 from 60 percent to 63 percent, the labor-related percentage referenced by CMS in the CY 2006 OPPS final rule. *Response:*
                         We did not propose a change to the labor share, but we do not believe that such a change is appropriate. The determination to wage adjust 60 percent of the payment of each APC was made based on a regression analysis at the beginning of the OPPS. We repeated this analysis as part of the rural adjustment study we performed for the CY 2006 OPPS based on CY 2004 claims data. This study examined the extent to which the body of costs for services furnished in the outpatient department was split between wage and nonwage costs and, based on our most recent findings, we believe that it remains appropriate to wage adjust 60 percent of the APC payment (70 FR 68533). *Comment:*
                         One commenter urged CMS to postpone the implementation of 100 percent of the occupational mix survey adjustment until the DRG severity refinements can be fully implemented and their possible unrecognized adverse effects on quality of care and outcomes can be resolved. Another commenter expressed concern about the application of the 100-percent occupational mix adjustment for CY 2007. The commenter encouraged CMS to approach Congress for authority to transition the occupational mix and to repeal the mandate that CMS apply an occupational mix adjustment to wage indices. *Response:*
                         We appreciate the comments concerning this issue and refer readers to the CMS final rule for the CY 2007 IPPS ( 71 FR 48006) for a discussion of the reasons that CMS adopted a 100 percent occupational mix adjusted wage index for hospitals receiving payments under the IPPS. As first published in the original OPPS final rule on April 7, 2000 (65 FR 18545), the OPPS has consistently adopted the final IPPS wage indices as the wage indices for adjusting the OPPS standard payment amounts for labor market differences. We continue to believe that using the IPPS wage index as the source of an adjustment factor for the OPPS is reasonable and logical given the inseparable, subordinate status of the hospital outpatient department within the hospital overall. Therefore, given that a 100 percent occupational mix adjusted wage index was adopted in the IPPS, we will also adopt the same index for the OPPS. After carefully considering all public comments received, we are finalizing our wage index adjustment policy for the CY 2007 OPPS as proposed without modification. 
                        ( print page 68006) E. Statewide Average Default CCRs 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 with comment period published on November 10, 2005 (70 FR 68553 through 68555). As we proposed, in this final rule with comment period, we have updated 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. Refer to section II.A.1.c. of this preamble for a discussion of our revision to the overall CCR calculation. Table 4 published in the CY 2007 OPPS proposed rule listed the proposed CY 2007 default urban and rural CCRs by State and compared them to last year's default CCRs (71 FR 49542 through 49545). 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 the proposed rule, 81.79 percent of the submitted cost reports represented data for CY 2004. We have since updated the cost report data we use to calculate CCRs with additional submitted cost reports for CY 2005. For this final rule with comment period, 66.41 percent of the submitted cost reports utilized in the default ratio calculation were for CY 2004, whereas 34.95 percent were for CY 2005. 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. 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 CY 2007 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. 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 proposed 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 § 489.18, and that has not yet submitted its first Medicare cost report. We proposed that this policy be effective for hospitals experiencing a change of ownership on or after January 1, 2007. We believed 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 believed that the hospital that has chosen not to accept assignment may have different costs and charges than the existing hospital. Furthermore, we believed that the hospital should be provided time to establish its own costs and charges. Therefore, we proposed to use the default statewide CCR to determine cost-based payments until the hospital has submitted its first Medicare cost report. We did not receive any public comments concerning the proposed statewide average default CCR. Therefore, we are finalizing the statewide average default CCRs shown in Table 4 below for OPPS services furnished on or after January 1, 2007 without modification. 
 
  
 
  
 
  F. OPPS Payments to Certain Rural Hospitals 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 
                        ( print page 68010)
                        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 5105 of Pub. L. 109-171 through Transmittal 877, issued on February 24, 2006. We did not specifically address whether TOPs payments apply to essential access community hospitals (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. In the CY 2007 OPPS proposed rule, we proposed to update § 419.70(d) to reflect the requirements of Pub. L. 109-171. 2. Adjustment for Rural SCHs Implemented in CY 2006 Related to Pub. L. 108-173 (MMA) 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. As indicated in the CY 2007 OPPS proposed rule (71 FR 49547), we recently became aware that we did not specifically address whether the adjustment applies to EACHs, which are considered to be SCHs under 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 proposed to continue our current policy of a budget neutral 7.1 percent payment increase for rural SCHs for specified services. *Comment:*
                         Many commenters expressed concern that small rural hospitals will suffer financially if TOPs payments continue to decrease each year, as specified in section 5105 of Pub. L. 109-171. The commenters noted that patient access to small rural hospitals could be at risk. One commenter supported permanent TOPs for rural SCHs, which currently do not receive any TOPs payments. Several commenters noted their support for a Senate bill, S.3606, which is known as the “Save our Safety Net Act of 2005.” *Response:*
                         We share the concerns of rural hospitals and do not intend to limit access to health care for Medicare beneficiaries in rural areas. However, we note that the statute is very specific and does not provide TOPs payments for entities other than those listed in the statute. The statute also requires TOPs payments to gradually decrease through CY 2008. *Comment:*
                         Several commenters requested that CMS clarify that the 7.1 percent rural SCH adjustment applies to EACHs retroactive to January 1, 2006. *Response:*
                         As stated above, we are clarifying that EACHs are treated as SCHs for purposes of receiving this adjustment, assuming these entities otherwise meet the rural adjustment criteria. EACHs are eligible for this adjustment effective January 1, 2006, as are all rural SCHs. As stated above, we agree with the commenters and are revising § 419.43(g) to specifically reflect this clarification. In addition, we will ensure that a retroactive payment adjustment occurs. *Comment:*
                         Several commenters supported the 7.1 percent adjustment for rural SCHs for CY 2007, but requested that CMS rerun the analyses to possibly provide for an adjustment for other rural hospitals during CY 2008 and CY 2009, when TOPs payments will be further reduced. *Response:*
                         As stated above, while we will not reestablish the adjustment amount nor determine whether other rural hospitals are eligible for the adjustment on an annual basis, we may review the adjustment in the future and, if appropriate, would revise the adjustment. After carefully considering the comments received, we are finalizing our policy by continuing a payment adjustment for rural SCHs, including EACHs, of 7.1 percent and finalizing the regulation text at § 419.70(d) without modification. We are also revising § 419.43(g) to clarify that EACHs are also eligible for the rural SCH OPPS adjustment. G. CY 2007 Hospital Outpatient Outlier Payments 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 final rule with comment period. As explained in the 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. The 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 the 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. However, when we published the CY 2007 OPPS proposed rule, we did not have a complete set of CY 2005 claims data to produce this number for CY 2005 and stated that we would report on CY 2005 outlier payments in this CY 2007 OPPS final rule with comment period. In the final set of CY 2005 OPPS claims, aggregated outlier payments were 2.39 percent of aggregated total OPPS payments. For CY 2005, the estimated outlier payments were set at 2 percent of the total aggregated OPPS payments. Therefore, for CY 2005, we paid 0.39 percent in excess of the CY 2005 outlier target of 2 percent of total aggregated OPPS payments. 1. CY 2007 Proposal For CY 2007, we proposed to continue our policy of setting aside 1.0 percent of 
                        ( print page 68011)
                        aggregate total payments under the OPPS for outlier payments. We proposed that a portion of that 1.0 percent would be allocated to CMHCs for partial hospitalization program service outliers. We proposed that the portion allocated to CMHCs would be determined by the amount of estimated outlier payments resulting from the CMHC outlier threshold. 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 proposed that the outlier threshold be set so that outlier payments would be 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 the CY 2007 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 the CY 2006 OPPS final rule with comment period, and we indicated in our preamble discussion for that rule, that we might revisit the threshold estimate methodology 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 calculated for the CY 2006 OPPS final rule with comment period is too low. The OPPS impact table in section XXVII. of the CY 2007 proposed rule (Table 49; 71 FR 49687) demonstrated 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 proposed 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. 2. CY 2007 Final Rule Outlier Calculation The claims that we use to model each OPPS update lag by 2 years. For this final rule with comment period, we used CY 2005 claims to model the CY 2007 OPPS. In order to estimate CY 2007 outlier payments for this final rule with comment period, we inflated the charges on the CY 2005 claims using the same inflation factor of 1.1642 that we used to estimate the IPPS fixed-dollar outlier threshold for the FY 2007 IPPS final rule. For 1 year, the inflation factor is 1.079. The methodology for determining this charge inflation factor was discussed in the FY 2007 IPPS final rule (71 FR 48150). As we stated in the CY 2005 OPPS final rule with comment period, we believe that the use of this charge inflation factor is appropriate for the 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). 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 actual outlier payments are made and calculated (70 FR 47495). 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 are projecting that 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. In the CY 2007 OPPS proposed rule, we proposed 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. of the preamble to this final rule with comment period. We received many comments on our proposed outlier policy for CY 2007. *Comment:*
                         Some commenters were concerned that the outlier threshold that CMS proposed is set too high and will result in CMS not spending all of the money in the projected 1.0 percent outlier target. The commenters stated that the estimated outlier target amount has historically been greater than the actual need, and they asked that CMS either reduce the set aside amount and retain that money in the OPPS rates or reduce the threshold for qualification so that the outlier expenditures are at a zero balance at the end of each year. One commenter asked that CMS limit the increase in the outlier threshold to the amount of the market basket update each year, which would mean, for CY 2007, that the CY 2006 threshold would be increased by only 3.4 percent. *Response:*
                         We believe that the threshold of $1,825 will result in paying 1.0 percent of the OPPS expenditures in outliers. As we indicated in the CY 2006 OPPS final rule, in the final set of CY 2004 OPPS claims, aggregated outlier payments were 2.5 percent of aggregated total OPPS payments. Similarly, using the final set of CY 2003 OPPS claims, aggregated outlier payments were 3.1 percent of total OPPS payments. As stated earlier, in the final set of CY 2005 claims, aggregated outlier payments were 2.39 percent of the aggregated total OPPS payments. For all three years, the estimated outlier payments were set at 2.0 percent of the total aggregated OPPS payments. Hence, our historic estimation of outlier payments has resulted in outlier payments that exceeded our target, and we believe that our proposed methodology will provide an outlier threshold that will result in more accurate aggregate program outlier payments. As discussed above, for the proposed rule, we used a charge inflation factor of 1.1515 to inflate the charges for CY 2005 claims to CY 2007 dollars. We then applied the provider's overall CCR that we calculate as part of our APC median estimation process to those inflated charges to estimate costs. We compared these estimated costs to 1.75 times the proposed APC payment amount and to the APC payment amount plus a number of fixed-dollar thresholds until we identified a threshold that produced an estimate of total outlier payments equal to 1.0 percent of total aggregated OPPS payments. We used the same estimation process for this final rule with comment period. We used a complete set of CY 2005 claims, and the updated charge inflation 
                        ( print page 68012)
                        estimate of 1.1642 percent from the FY 2007 IPPS final rule and each hospital's overall CCR, as calculated for our APC median setting process. Using this methodology, the final fixed-dollar threshold for the CY 2007 OPPS is $1,825, and the final multiple threshold is 1.75 times the APC payment rate. We did not increase the CY 2007 outlier threshold by the market basket update of 3.4 percent because our calculations are intended to best approximate the outlier target of 1.0 percent of CY 2007 OPPS expenditures. As we stated in the CY 2006 OPPS final rule, we established the projected target for aggregate outlier payments at 1.0 percent because we believed, consistent with MedPAC's recommendations, that the fairly narrow definitions of APC groups make outlier payment less necessary for the OPPS, that multiple service payments are common for any given claim, and that the susceptibility to “gaming” through charge inflation continues (70 FR 68563). Because OPPS outlier payments are targeted to services, rather than clinical cases, we believe it is unlikely that any specific service would be excessively costly, and reducing the outlier threshold to 1.0 percent of total OPPS payment effectively raises the payment for all other services. We continue to believe that an outlier target of 1.0 percent of total OPPS payment is appropriate for the OPPS. *Comment:*
                         One commenter asked that CMS modify the charge methodology used to set the OPPS outlier threshold to account for the change in CCRs over time in a manner similar to that used for the FY 2007 IPPS. The commenter believed that it is appropriate to apply an adjustment factor to the CCRs, so that the CCRs CMS would use in simulations of outlier payments would more closely reflect the CCRs that would be used in CY 2007. *Response:*
                         Given the potential difference in cost increases between inpatient and outpatient hospital departments, we do not believe it would be appropriate to apply the exact same CCR adjustment used under the IPPS without an OPPS-specific analysis. However, it is possible that a similar analysis specific to the OPPS could indicate that it would be appropriate to apply an OPPS CCR adjustment. We expect to study this issue further and would address any changes to the outlier methodology through future rulemaking. *Comment:*
                         Some commenters objected to the lack of analysis to support the statement that the proposed outlier threshold would result in full payment of the outlier pool and urged CMS to publish the estimated outlier payments in the proposed rule, based on available data, to permit the public to better comment on the proposed outlier policy. *Response:*
                         The proposed rule contained considerable discussion of the methodology we use to create the proposed outlier threshold, as well as the projected program expenditure amount that we use to determine the amount of the outlier set aside. Moreover, the claims we used for the simulation are available to the public. Indeed, the commenters perform many different types of analyses and often comment in extreme detail based on their analyses of the claims data and our description of the methodology we use to calculate the median costs on which the payment rates are based. Therefore, the public has every opportunity to perform a full and complete analysis of our outlier projections in preparation for commenting on the proposed outlier policy. *Comment:*
                         One commenter objected to the payment of 50 percent of the cost that exceeds the threshold and believed that CMS should pay 80 percent of the cost rather than 50 percent to ameliorate the level of losses that major teaching hospitals incur to provide complex outpatient services and to make outlier payment under the OPPS consistent with IPPS outlier payment. *Response:*
                         We disagree with the commenter that we should pay 80 percent of the cost that exceeds the threshold to ameliorate the level of losses that major teaching hospitals incur and to make outlier payment under the OPPS consistent with outlier payment under the IPPS. As we have explained, if we increase the percent of the excess over cost, in particular by 30 percent more than our proposed level of 50 percent, the threshold would need to be greatly increased to avoid paying more than the 1.0 percent we have allowed for outlier payments. Moreover, we do not believe that it is appropriate to have the same policy governing outlier payment under both the IPPS and the OPPS because of the inherent differences in the clinical cases and payment methodologies that characterize the two systems. The circumstances giving rise to outlier payments under each system are not found in the other system, and therefore applying the same outlier policies would likely be contrary to the reasons behind each policy. After carefully considering the public comments received, we are finalizing our proposed policy for CY 2007 outlier payments. Recalculation of the fixed outlier threshold using this methodology results in a fixed-dollar outlier threshold of $1,825 and a multiple threshold of 1.75, based on an outlier estimate of 1.0 percent of payments projected to be made under the CY 2007 OPPS and outlier payments to be made at 50 percent of the amount by which the cost of furnishing the service exceeds 1.75 times the APC rate. The following is an example of an outlier calculation for CY 2007 under our final policy with this modification. A hospital charges $26,000 for a procedure. The wage adjusted, and rural adjusted, if applicable, APC payment for the procedure is $3,000. The provider's overall CCR is 0.30. The estimated cost to the hospital is $7,800 (0.30 × $26,000). 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) $7,800 exceeds $5,250 (1.75 × $3,000). (2) $7,800 exceeds $4,825 ($3,000 + $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 $5,250 (1.75 × $3,000) from $7,800 (resulting in $2,550). The provider is eligible for 50 percent of the difference, in this case $1,275 ($2,550/2). The formula is (cost − (1.75 × APC payment rate))/2. H. Calculation of the OPPS National Unadjusted Medicare Payment 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 final rule with comment period and the relative weight determined under section II.A. of this final rule with comment period. Therefore, the national unadjusted payment rate for each APC contained in Addendum A to this final rule with comment period and for HCPCS codes to which payment under the OPPS has been assigned in Addendum B to this final rule with comment period (Addendum B is provided as a convenience for readers) was calculated by multiplying the final CY 2007 scaled 
                        ( print page 68013)
                        weight for the APC by the final 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 that has a status indicator of “S,” “T,” “V,” or “X” 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 final rule with comment period that was developed for the final FY 2007 IPPS payment rates and finalized in the IPPS notice published in the 
                        **Federal Register**
                         on October 11, 2006 (71 FR 59886). These finalized FY 2007 IPPS wage indices, which are effective October 1, 2007, have been adjusted 100 percent for differences in occupational mix. As is our practice, we 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 finalized wage index increase developed for the FY 2007 IPPS (71 FR 59886). 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 § 412.92, 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. We did not receive any public comments on our proposed methodology for calculating the national unadjusted Medicare payment amount for CY 2007. Therefore, we are finalizing our proposed methodology for CY 2007 without modification. I. Beneficiary Copayments for CY 2007 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 (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. Sections 1834(d) (2) and (d)(3) of the Act further require Medicare to pay the lesser of the ASC or OPPS payment rate for screening flexible sigmoidoscopies and screening colonoscopies, with coinsurance equal to 25 percent of the payment amount. We have applied the 25-percent coinsurance to all of these services since the beginning of the OPPS. Medicare does not make payment to ASCs for screening sigmoidoscopies so there is no payment comparison to be made for those services. However, for CY 2007, the OPPS payment for screening colonoscopies, HCPCS codes G0105 (Colorectal cancer screening; colonoscopy on individual at risk) and G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), developed in accordance with our standard OPPS ratesetting methodology, would exceed the ASC payment of $446 for these procedures. Therefore, for CY 2007, the OPPS payment rates for HCPCS codes G0105 and G0121 that describe screening colonoscopies will be set to equal the CY 2007 ASC rate of $446 for these services. 2. Copayment for CY 2007 For CY 2007, we proposed 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.) These unadjusted copayment amounts for services payable under the OPPS that will be effective January 1, 2007, are shown in Addendum A and Addendum B of this final rule with comment period. 3. Calculation of an 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 $30.21. *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 I.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. The unadjusted copayments for services payable under the OPPS that will be effective January 1, 2007, are shown in Addendum A and Addendum B of this final rule with comment period. We did not receive any public comments concerning our methodology for calculating the beneficiary unadjusted copayment amount. Therefore, we are finalizing our proposed methodology for CY 2007 without modification. 
                        ( print page 68014) III. OPPS Ambulatory Payment Classification (APC) Group Policies A. Treatment of New HCPCS and CPT Codes 1. 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, specifically C9227, C9228, C9229, and C9230 that were not addressed in the November 10, 2005 final rule with comment period that updated the CY 2006 OPPS. We designated the payment status of these 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 the CY 2007 OPPS proposed rule, we also solicited public comments on the status indicators and APC assignments of these codes, which were listed in Table 5 of that proposed rule (71 FR 49548), and now appear in Table 5 of this final rule with comment period. Because of the timing of the proposed rule, the codes implemented in the July 2006 OPPS update were not included in Addendum B of that proposed rule, while those codes based upon the April 2006 OPPS update were included in Addendum B. In the CY 2007 OPPS proposed rule, we proposed to assign the new HCPCS codes for CY 2007 to the appropriate APCs and incorporate them into our final rule with comment period for CY 2007, which is consistent with our annual APC updating policy. We did not receive any public comments on the APC assignments and status indicators designated for C9227, C9228, C9229, or C9230 that were implemented in either April 2006 or July 2006. However, for CY 2007, the National HCPCS Panel created permanent J-codes for each of these drugs. Consistent with our general policy of using permanent HCPCS codes if appropriate rather than C-codes for the reporting of drugs under the OPPS in order to streamline coding, we are showing the J-codes in Table 5 that replaced the C-codes, effective January 1, 2007. C9227 is replaced with J2248 (Injection, micafungin sodium, 1 mg); C9228 with J3243 (Injection, tigecycline, 1 mg); C9229 with J1740 (Injection, ibandronate sodium, 1 mg); and C9230 with J0129 (Injection, abatacept, 10 mg). The J-codes describe the same drugs and the same dosages as the C-codes that will be deleted December 31, 2006. We note that C-codes are temporary national HCPCS codes. To avoid duplication, temporary national HCPCS codes, such as C, G, K, and Q codes, are generally deleted once permanent national HCPCS codes are created that describe the same item, service, or procedure. Because the four new J-codes describe the same drugs and the same dosages that are currently designated by C9227, C9228, C9229, and C9230 and all four of these drugs will continue with pass-through status in CY 2007, we are assigning the J-codes to the same APCs and status indicators as their predecessor C-codes, as shown in Table 5. That is, J2248 will be assigned to the same APC and status indicator as C9227; J3243 to APC 9228; J1740 to APC 9229; and J0129 to APC 9230. Because we received no public comments on the APC and status indicator assignments for the new HCPCS codes that were implemented in April or July 2006, we are adopting as final without modification, our proposal to assign their replacement HCPCS J-codes to the appropriate APCs, as shown in Addendum B of this final rule with comment period. Table 5.—New HCPCS Codes Implemented in April or July 2006
New HCPCS J-Code effective January 1, 2007
HCPCS C-Code
Description
Assigned status indicator
Assigned APCJ2248
C9227
Injection, micafungin sodium, per 1 mg
G
9227J3243
C9228
Injection, tigecycline, per 1 mg
G
9228J1740
C9229
Injection, ibandronate sodium, per 1 mg
G
9229J0129
C9230
Injection, abatacept, per 10 mg
G
9230
 2. 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 summer through 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.) In our CY 2007 OPPS proposed rule, we proposed to continue this recognition and process for CY 2007. Therefore, new Category I and III CPT codes and new Level II HCPCS codes, effective January 1, 2007, are listed in Addendum B of this final rule with comment period and designated using comment indicator “NI.” The status indicator, the APC assignment, or both, for all such codes flagged with Comment Indicator “NI” are open to public comment. As indicated in the CY 2007 OPPS proposed rule, we will respond to all comments received concerning these codes in a subsequent final rule for the next calendar year's OPPS update. We received some comments to the CY 2007 proposed rule regarding individual new HCPCS codes that commenters expected to be implemented for the first time in the CY 2007 OPPS. We could not discuss APC and/or status indictor assignments for new CY 2007 HCPCS codes in the proposed rule because the codes were not available when we developed and issued the proposed rule. For those new Category I CPT codes whose descriptors were not officially available during the comment period and development of the CY 2007 final rule with comment period, we do not specifically respond to those comments in this final rule with comment period. For those new Category III CPT codes that were released on July 1, 2006, for implementation January 1, 2007, we respond to those comments in this final rule with comment period because those codes were publicly available during the comment period to the proposed rule and the development of this final rule with comment period. Both of these groups of codes are flagged with comment indicator “NI” in this final rule with comment period, as discussed above, to signal that they are open to public comment. 
                        ( print page 68015) Two new G-codes for CY 2007 that are assigned comment indicator “NI” in this final rule with comment period were developed to enable clinicians and facilities to specifically report transluminal balloon angioplasty to existing arteriovenous fistulas or prosthetic grafts for hemodialysis access. Currently, there are no CPT or alphanumeric HCPCS codes on the ASC list that would provide payment to ASCs for providing this service to Medicare patients with failing or stenotic hemodialysis access fistulas or grafts. There are no CPT codes that are specific to this particular service. Therefore, we are creating two Level II HCPCS G-codes for implementation in CY 2007: (1) G0392 (Transluminal balloon angioplasty, percutaneous, hemodialysis access fistula or graft; arterial) and (2) G0393 (Transluminal balloon angioplasty, percutaneous, hemodialysis access fistula or graft; venous). We will provide payment for these G-codes at the same OPPS rates as for CPT codes 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel) and 35476 (Transluminal balloon angioplasty, percutaneous; venous) through APC 0081 (Non-Coronary Angioplasty or Atherectomy), with a CY 2007 final median cost of $2,450.64. We will also assign both G-codes to payment group 9 for ASC payment in CY 2007. The G-codes will be used by hospital outpatient departments and ASCs to report transluminal balloon angioplasty of hemodialysis access fistulas or grafts in these settings. Beginning in CY 2007, CPT codes 35475 and 35476 should not be reported for patients undergoing percutaneous transluminal balloon angioplasty of hemodialysis access fistulas or grafts. Both CPT codes will remain active to report all other clinical services that would be described by these codes. We did not receive any public comments on our proposal to assign a comment indicator of “NI” in Addendum B of the OPPS final rule to the new codes that are open to public comment. Therefore, we are finalizing our proposed treatment of new CY 2007 Category I and III CPT codes, as well as the Level II HCPCS codes, without modification. 3. 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, the 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 or 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 assigned them an interim payment status which was subject to public comment following publication of the final rule that implemented the annual OPPS update. As discussed 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 that are payable under the OPPS and were 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. These codes were shown in Table 6 of the CY 2007 OPPS proposed rule (71 FR 49549). They were not included in Addendum B of that rule, which was based upon the April 2006 OPPS update. In the CY 2007 OPPS proposed rule, we solicited public comments on the status indicators and, if applicable, the APC assignments of these services. We proposed in the CY 2007 OPPS proposed rule to finalize the assignments of these Category III CPT codes implemented in July 2006 in this final rule with comment period. As indicated in the CY 2007 OPPS proposed rule (71 FR 49549), 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 to 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 proposed to include in Addendum B of this final rule with comment period, 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 CPT codes and the new vaccine codes implemented effective January 1, 2007, are flagged with comment indicator “NI” in Addendum B of this final rule with comment period to indicate that we have assigned them an interim payment status which is subject to public comment. As discussed earlier, Category III CPT codes implemented in July 2006, which appear in Table 6, were subject to comment through the CY 2007 OPPS proposed rule and their statuses are finalized in this final rule with comment period. 
                        ( print page 68016) Table 6.—Category III CPT Codes Implemented in July 2006
CPT code
Long descriptor
Proposed CY 2007 status indicator
Proposed CY 2007 APC
Final CY 2007 status indicator
Final CY 2007 APC0155T
Laparoscopy, surgical,  implantation or   replacement of   gastric stimulation  electrodes, lesser   curvature (ie,   morbid obesity)
T
0130
T
01300156T
Laparoscopy, surgical, revision   or removal of   gastric stimulation  electrodes, lesser  curvature (ie,   morbid obesity)
T
0130
T
01300157T
Laparotomy, implantation or   replacement of   gastric stimulation  electrodes, lesser   curvature (ie,   morbid obesity)
C0158T
Laparotomy, revision or removal  of gastric   stimulation   electrodes, lesser   curvature (ie,   morbid obesity)
C0159T
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
N0160T
Therapeutic repetitive   transcranial   magnetic   stimulation   treatment planning
X
0340
S
02160161T
Therapeutic repetitive   transcranial   magnetic   stimulation treatment delivery   and management, per  session
X
0340
S
0216
 We received several public comments on the proposed APC assignments for Category III CPT codes 0159T, 0160T, and 0161T. A summary of the comments and our responses follows: *Comment:*
                         One commenter requested that CMS assign CPT code 0159T to an APC that is separately payable under the OPPS because there are additional resources associated with performing a breast MRI with computer-aided detection (CAD), which is a significant advancement in early detection and treatment for possible breast cancers. The commenter indicated that the procedure described by CPT code 0159T is similar to the CAD procedures that are associated with mammography, which CMS previously recognized and allowed separate payment. The commenter urged CMS to pay separately for CPT code 0159T, if not through the hospital OPPS, then by a separate payment under the MFPS, similar to other hospital-based mammography services. *Response:*
                         The CAD procedures that the commenter makes reference to are described by CPT codes 77051 (Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography) and 77052 (Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography). These are both paid off the MPFS, according to specific provisions in the law for screening and diagnostic mammography that specify that such services, when performed in the hospital outpatient setting, are paid according to the MPFS. Other hospital outpatient imaging services, such as CPT code 0159T, are paid under the OPPS. We have assigned this service packaged payment status under the OPPS for CY 2007, because we believe that it is a minor ancillary service that would always be provided in association with another separately payable service (mostly likely an MRI), into which its payment would be appropriately packaged. As a prospective payment system, the OPPS makes payment for groups of services that are clinically coherent with similar resource utilization and packages payment for many items, supplies, and minor associated services into the payment for the primary service. Our final CY 2007 treatment of CPT code 0159T is the same as our final CY 2007 packaged status for two chest x-ray CAD services, CPT code 0174T (Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation) and CPT code 0175T (Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation) that is discussed further in section II.A.4. of this final rule with comment period. *Comment:*
                         One commenter requested that CMS not map Category III CPT codes 0160T and 0161T to APC 0340 (Minor Ancillary Procedures) because the technology associated with these procedures is currently under review by the FDA and approval is not expected until January 2007. The commenter indicated that these codes describe therapeutic transcranial magnetic stimulation (TMS) therapy, which is used for the treatment of major depression. The commenter further indicated that TMS therapy represents a procedure that involves a complex brain mapping and stimulation treatment process and requires the use of specific equipment and a specialized operator skill set. As such, the commenter concluded that TMS therapy represents a procedure whose hospital resources are significantly greater than reflected by the proposed payment rate for APC 0340 of about $38. The commenter believed that mapping Category III CPT codes 0160T and 0161T to APC 0340, or to any other APCs, is inappropriate at this time because the costs of these services are currently not known. The commenter cautioned that assigning these codes to specific APCs would be arbitrary and could significantly overcompensate or undercompensate providers because there are no cost data available to appropriately map codes 0160T and 0161T at this time. The commenter acknowledged that not assigning the two codes to specific APCs may result in no payment for TMS therapy performed in hospital outpatient settings for CY 2007 and likely limit access for some patients. However, the commenter indicated that it plans to work with the APC Panel in CY 2007 to determine the appropriate mapping for the two codes to ensure access for appropriate patients. Other commenters noted that there was a related Category III code, CPT code 0018T (Delivery of high power, 
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                        focal magnetic pulses for direct stimulation to cortical neurons) that was created prior to the full maturation of the therapeutic TMS procedure and related technology. The commenters noted differences between CPT code 0018T and the two new Category III CPT codes, including its lack of incorporation of the treatment planning function, its failure to specify repetitive in the descriptor, and its lack of description of therapeutic treatment delivery. They believed that the historical APC assignment of code 0018T to APC 0215 (Level I Nerve and Muscle Tests) was inappropriate, although one commenter stated that it was not involved in determining that mapping. The commenters pointed out that there are also two Category I CPT codes that incorporate TMS for diagnostic purposes, including CPT code 95928 (Central motor evoked potential study (transcranial motor stimulation); upper limbs) and CPT code 95929 (Central motor evoked potential study (transcranial motor simulation); lower limbs). The commenters added that both of these codes were proposed for assignment to APC 0218 (Level II Nerve and Muscle Tests) for CY 2007 with a payment rate of about $74. *Response:*
                         We appreciate the commenters' suggestion and background information. However, because the CPT code descriptors are general in nature and not specific to a particular product, our policy has been to assign an APC to each Category III CPT code if we believe that the procedure, if covered, would be appropriate for separate payment in the OPPS. In addition, as indicated in the CY 2006 OPPS final rule (70 FR 68567), some of the new Category III CPT codes may describe services that our medical advisors determine to be similar in clinical characteristics and resource use to HCPCS codes in an existing APC. In such instances, we may assign the Category III CPT code to the appropriate clinical APC. Other Category III CPT codes may describe services that our medical advisors determine 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 the case of CPT codes 0160T and 0161T, we believe the services described by these active CPT codes would be appropriately separately paid under the OPPS if they are covered. We do not believe the technology used to provide these services is so new that their assignment to New Technology APCs would be appropriate. Although our final determination regarding these two codes is to provide assignments to specific APCs with payment rates for CY 2007 as described below, this decision does not represent a determination that the services described by Category III CPT codes 0160T and 0161T are reasonable and necessary. Medicare contractors determine whether the services described by all HCPCS codes with status indicators reflecting their potential for payment under the OPPS, including Category III CPT codes, meet all the program requirements for coverage in different clinical circumstances. The Internet listing of Category III code changes on the AMA Web site includes a parenthetical note that CPT Code 0018T has been deleted as of July 1, 2006, the same date new CPT codes 0160T and 0161T were first implemented. The note also indicates that, to report the procedure previously described by 0018T, one should see CPT codes 0160T and 0161T. CPT Changes, an Insider's View for CY 2002 when 0018T was created, describes the use of CPT code 0018T for treatment of a patient with a long history of depression, incorporating planning and therapeutic treatment delivery in the description of the procedure. In general, that outline of the service described by CPT code 0018T closely parallels the clinical vignettes for CPT codes 0160T and 0161T that were provided to us in a public comment. Therefore, we do not agree with the commenters that our historical claims for 0018T must be instances of miscoding or the use of TMS for diagnostic purposes. While we had no claims for CPT code 0018T for CY 2005, we do have claims data for this service from CYs 2002 through 2004, although there were fewer than 15 total claims for each of those years. The procedure was assigned to APC 0215 (Level I Nerve and Muscle Tests) with a payment rate of about $35 throughout that time period, with no specific comments from the public on this assignment during the OPPS proposed updates for those years. We understand that the hospital resource costs of specific technologies may change over time as those technologies evolve. In reviewing the clinical aspects of CPT codes 0160T and 0161T, in the context of related codes and our historical OPPS claims data for CPT code 0018T and other services, we agree with the commenter that APC 0340 is not the most appropriate assignment for CPT codes 0160T and 0161T for CY 2007. The commenter provided no specific suggestions regarding the APC assignments for these codes. As discussed earlier, CPT codes describe general services that are not specific to one product, and we believe it is most appropriate to provide APC assignments for all new HCPCS codes that would be appropriately separately paid under the OPPS if they were covered. This approach helps ensure access to services described by these codes for Medicare beneficiaries in the hospital outpatient department and allows us to initiate collection of hospital cost information as soon as possible. The commenter indicated that TMS may be safely performed in the hospital outpatient setting. We do not see any reason to provide the Category III CPT codes for TMS nonpayable status indicators in the OPPS for CY 2007, when the codes were implemented in July 2006 and there are no alternative HCPCS codes to describe the services. However, we believe that APC 0216 (Level III Nerve and Muscle Tests) best represents both the clinical and resource homogeneity of CPT codes 0160T and 0161T for CY 2007, considering all of the information available to us. We note that this APC has a status indicator of “S,” so that under the occasional circumstance of two treatments in one day for a single patient as described by a commenter, payment would not be reduced for the second service. We will reevaluate these assignments for future OPPS updates as additional information becomes available to us, including updated claims data. After carefully considering the comments received, we are finalizing our general proposal for the treatment of new mid-year CPT codes, with modification only to the CY 2007 APC assignments for Category III CPT codes 0160T and 0161T as described above and indicated in Table 6. B. Variations Within APCs 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 
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                        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 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 proposed packaging methodology is discussed in section II.A. of this preamble. 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 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 the relevant specific sections throughout 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 low-volume items and services. During the APC Panel's March 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 most service-specific issues, the APC Panel recommendations, if any, and our proposals for CY 2007 are contained principally in sections III.C. and 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 proposed changes to their HCPCS codes' APC assignments in Addendum B of the CY 2007 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 proposed changes to the status indicators for some codes that were not specifically and separately discussed in the proposed rule. In these cases, we changed the status indicators for some codes because we believed that another status indicator more accurately described their payment status from an OPPS perspective based on our CY 2007 proposed policies. Addendum B of the CY 2007 OPPS proposed rule identified with a comment indicator “CH” those HCPCS codes for which we proposed a change to the APC assignment or status indicator as assigned in the April 2006 Addendum B update. Addendum B of this final rule with comment period identifies with the “CH” comment indicator the final CY 2007 changes compared to the codes” status as reflected in the October 2006 Addendum B update. We received many public comments regarding the proposed APC and status indicator assignments for CY 2007 for specific HCPCS codes. These are discussed mainly in sections III.C. and III.D. of this final rule with comment period, and the final action for CY 2007 related to each HCPCS code is noted in those sections. 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 low-volume items and services. At the time of the proposed rule, taking into account the APC changes that we proposed for CY 2007 based on the APC Panel recommendations discussed mainly in sections III.C. and III.D. of the preamble, the proposed changes to status indicators and APC assignments as identified in Addendum B of the CY 2007 OPPS proposed rule, 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 published in the CY 2007 OPPS proposed rule (71 FR 49551) 
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                        listed the APCs that we proposed 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 proposed for CY 2007. The median costs for hospital outpatient services for these and all other APCs which were used in development of the proposed rule can be found on the CMS Web site: 
                        *http://www.cms.hhs.gov*. We did not receive any general public comments related to the list of proposed exceptions to the 2 times rule. We received a number of specific comments about some of the procedures assigned to APCs that we proposed to make exempt from the 2 times rule for CY 2007. Those discussions are elsewhere in the preamble, in sections related to the types of procedures that were the subjects of the comments. For the proposed rule, the listed exceptions to the 2 times rule were based on data from January 1, 2005, through September 30, 2005. For this final rule with comment period, we used data from January 1, 2005 through December 1, 2005. Thus, after responding to all of the comments on the proposed rule and making changes to APC assignments based on those comments, we analyzed the full CY 2005 data to identify APCs with 2 times rule violations. Based on those final data, we found that there were 37 APCs with 2 times rule violations. We applied the criteria as described earlier to finalize the APCs that are exceptions to the 2 times rule for CY 2007. The final revised list of APCs that are exceptions to the 2 times rule for CY 2007 is displayed in Table 7 below. After careful review of all public comments on the proposed rule and the claims data for the full year, CY 2005, available to us for this final rule with comment period, we are finalizing the list of APCs exempted from the two times rule as displayed in Table 7 below. Table 7.—APC Exceptions to the 2 Times Rule for CY 2007
APC
APC description0007
Level II Incision & Drainage.0010
Level I Destruction of Lesion.0019
Level I Excision/ Biopsy.0024
Level I Skin Repair.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.0093
Vascular Reconstruction/Fistula Repair without Device.0105
Revision/Removal of Pacemakers, AICD, or Vascular.0111
Blood Product Exchange.0112
Apheresis, Photopheresis, and Plasmapheresis.0203
Level IV Nerve Injections.0204
Level I Nerve Injections.0215
Level I Nerve and Muscle Tests.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.0340
Minor Ancillary Procedures.0367
Level I Pulmonary Test.0381
Single Allergy Tests.0397
Vascular Imaging.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.0621
Level I Vascular Access Procedures.0664
Level I Proton Beam Radiation Therapy.0676
Thrombolysis and Thrombectomy.
 C. New Technology APCs 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. More recently, at its August 2006 meeting the APC Panel recommended that when CMS assigns a new service to a New Technology APC, the service should remain there for at 
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                        least 2 years until sufficient claims data are collected. In general, services remain in New Technology APCs for at least 2 years consistent with the APC Panel's recommendation. However, we do not fully accept the APC Panel's recommendation. While we agree with the APC Panel that we need sufficient claims data to move services from New Technology APCs to clinical APCs, we also continue to believe that it occasionally may be appropriate to move a service from a New Technology APC to a clinical APC in less than 2 years if the data are robust and there is an appropriate clinical APC for its assignment. We note that the cost bands for New Technology APCs range from $0 to $50 in increments of $10, from $50 to $100 in increments 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 the 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 cost-efficient 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 informed business decisions regarding the 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 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. 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 at the time of developing the proposed rule we believed we had sufficient data to reassign them to clinically appropriate APCs for CY 2007. a.  Nonmyocardial Positron Emission Tomography (PET) Scans (APC 0308) 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 of hospital claims data, in the CY 2007 proposed rule (71 FR 49566 through 49567) we indicated that we believed that we had sufficient data to assign nonmyocardial PET scans to a clinically appropriate APC for CY 2007. 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 costs of the procedures. 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. As noted in the CY 2007 proposed rule, in the case of nonmyocardial PET services, we believed that we had sufficient data to assign them to a clinically appropriate APC. For CY 2006, we maintained the APC payment methodologies from CY 2005 for nonmyocardial PET services. According to that methodology, payment was 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 XIII ($1100-$1200)) for a blended payment rate of $1,150. For CY 2007, we proposed the assignment of nonmyocardial PET procedures to a clinically appropriate APC as we now have several years of robust and stable claims data upon which to determine the median cost of 
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                        performing these procedures. Based on analysis of the Medicare 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. However, 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 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 OPPS proposed rule, we had 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 were not complete when we published the CY 2007 OPPS proposed rule, we noted that the apparent decline in numbers of claims for nonmyocardial PET scans alone in the CY 2005 claims data was likely related to the large number of claims for PET/CT scans 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 the proposed rule, in comparison to final claims for CY 2004 of approximately 121,000 for PET scans. Therefore, we proposed to assign nonmyocardial PET scans, in particular, CPT codes 78608, 78811, 78812, and 78813, to new APC 0308 (Nonmyocardial Positron Emission Tomography (PET) Imaging) with a median cost of $865.30 for CY 2007. We noted we were confident that in the face of our stable median costs for nonmyocardial PET scans over the past 4 years, 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 would ensure continued availability of this technology now that its services would be paid through a clinical APC in CY 2007, like most other OPPS services. *Comment:*
                         A few commenters representing rural providers stated that they would no longer be able to provide PET scans to their patients who are Medicare beneficiaries if Medicare lowered its payment for the services. They stated that, because they relied on more costly, mobile units, the proposed payment amount would not be adequate for them to be able to continue to provide the service in their communities. A number of other commenters opposed proposed payment reductions for PET imaging services that they believed were essential to ensuring appropriate treatment of patients with cancer and providing necessary patient access. *Response:*
                         We are sensitive to the obstacles that rural providers face in trying to provide some services to Medicare beneficiaries. However, we have years of stable and consistent data that indicate that Medicare will now be paying more accurately for the scans at the proposed clinical APC rate. We believe this rate will ensure the necessary patient access to PET services. *Comment:*
                         Several commenters requested that, instead of assigning CPT code 78608 (Brain imaging, positron emission tomography (PET); metabolic evaluation), to APC 0308 with the CPT codes for tumor PET scans, CMS should assign this single code to a separate clinical APC. The commenters had no objections to assignment of PET services to clinical APCs, with payment rates based on the APCs' median costs. The commenters believed that assignment of the CPT code for brain PET scans to its own APC would be more appropriate because the brain PET scans are not clinically homogenous with the other tumor PET scans assigned to APC 0308. *Response:*
                         The brain PET scan services have been assigned to the same New Technology APC with the same payment rate as the other nonmyocardial PET services for a number of years. The CY 2005 median cost for the brain PET CPT code of $886 is very similar to the median costs for the two tumor PET CPT codes of $873 and $762, indicating that all three of these related PET services require comparable hospital resources. We are not convinced that separating nonmyocardial PET scans according to the body site being examined is necessary for clinical homogeneity, and the result of such a distinction would be a single CPT code in one APC and two CPT codes in another APC. The OPPS is a prospective payment system that provides payment for groups of services that share clinical and resource use characteristics. We believe that PET scans for tumor imaging and brain imaging are similar in both respects and are appropriately assigned to the same clinical APC. Therefore, we are finalizing our proposal to assign CPT code 78608 to APC 0308, along with CPT codes 78811, 78812, and 78813. After carefully considering the comments, we are adopting our proposal for CY 2007 without modification to provide payment for nonmyocardial PET scans through APC 0308. b. PET/Computed Tomography (CT) Scans (APC 0308) 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 G-codes for billing to Medicare. Several commenters on the November 15, 2004 final rule with comment period (69 FR 65682) urged us to replace the G-codes 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 that were 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 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 proposed the assignment of concurrent PET/CT scans, specifically CPT codes 78814, 78815, and 78816, to a clinically appropriate APC because we believed that we had adequate claims data from CY 2005 upon which to determine the median cost of performing these procedures. At the time of the proposed rule, based on our analysis of CY 2005 single claims, the median cost of PET/CT scans was $865 from almost 70,000 single claims. Comparison of the median cost of nonmyocardial PET procedures of $867 with the median cost of concurrent PET/CT scans demonstrated that the median costs of PET scans with or without 
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                        concurrent CT scans for attenuation correction and anatomical localization were about the same. This result was not unexpected because many newer PET scanners also had 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 that 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 the proposed rule for these scans. We believed that our claims data accurately reflected the comparable hospital resources required to provide PET and PET/CT procedures, and the scans had obvious clinical similarity as well. Therefore, for CY 2007 we proposed to assign the CPT codes for PET/CT scans, along with the CPT codes for PET scans, to the same new APC 0308 (Nonmyocardial Positron Emission Tomography (PET) Imaging) with a proposed median cost of $865.30. At its August 2006 meeting, the APC Panel recommended that CMS retain PET/CT scans in New Technology APC 1514 with a payment rate of $1,250 for CY 2007. We note that we have been paying separately for fluorodeoxyglucose (FDG), the radiopharmaceutical described by HCPCS code A9552 (Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries) that is commonly administered during nonmyocardial PET and PET/CT procedures. For CY 2007, we proposed to continue paying separately for FDG, according to the methodology described in section V. of the preamble of the CY 2007 proposed rule. *Comment:*
                         A number of commenters disagreed with the proposal to assign PET/CT services to APC 0308. Among the reasons provided by commenters that PET/CT services should not be assigned to APC 0308 were that: payment at the proposed level would not cover the costs of providing the services; the APC Panel recommended during its August 2006 meeting that CMS retain PET/CT services in New Technology APC 1514 for another year so that more CPT-coded claims upon which to base a decision about the appropriate APC assignment for the services would be available; PET/CT services are a clinically distinct technology from conventional PET procedures and should not be assigned to the same APC; PET/CT services are more costly to provide than are other nonmyocardial PET services and there must be a payment differential to recognize that; and a 30-percent payment decrease would result in decreased Medicare beneficiary access to the services. The commenters reported that the higher costs associated with PET/CT were due to requirements for specially-trained, licensed technicians, more costly capital equipment, and higher equipment maintenance costs. Most commenters recommended that PET/CT should remain in its current New Technology APC 1514 with a payment rate of $1,250 for CY 2007. Some of the commenters believed that CMS' proposal to assign PET/CT scans to a clinical APC was premature because CMS did not have a full year of reliable cost data for PET/CT. They made that assertion because the CPT codes used to report the services were newly recognized by the OPPS in April 2005 and, therefore, only 9 months of claims data were available for the CY 2007 OPPS update. The commenters observed that if PET/CT scans were moved to a clinical APC for CY 2007, they would have been assigned to a New Technology APC for only 21 months, while the APC Panel recommended at its August 2006 meeting that services assigned to New Technology APCs should remain there for at least 2 years. Further, because hospitals often do not update their chargemasters more than once per year, the commenters believed that true hospital costs were not reflected in the CY 2005 data that CMS considered when developing its proposal for CY 2007. One of the commenters provided limited hospital-level average cost data for PET and PET/CT scans, as well as a cost analysis model for PET/CT services. Those data covered the 6-month period of July through December and display average cost and charge data for two sets of hospitals, separated according to two different methods of reducing their charges to costs. *Response:*
                         We have carefully considered the APC Panel recommendation and all of the information provided in the comments received regarding the proposed APC assignment and payment amount for PET/CT scans for CY 2007. We remain confident that our CY 2005 data for conventional nonmyocardial PET services are accurate reflections of hospital costs for those services, in spite of the CY 2005 coding changes. Similarly, our review of the hospital data provided in one of the public comments shows that the average cost per hospital for PET/CT for one set of hospitals was $829 and for the other group was $912. We are encouraged that these mean costs are so similar to our median cost for the services, and these data serve to increase our confidence in the CY 2005 claims data. However, we recognize that there are other factors to consider related to hospital charging practices for PET/CT services. For instance, prior to institution of the specific CPT codes for PET/CT scans, hospitals were reporting a diagnostic CT scan charge in addition to the appropriate G-code charge for the PET scan. Therefore, the transition to the new CPT codes was not a simple coding crosswalk for the PET/CT services because it required the hospital to change from reporting two charges for the service to only one charge that was to include the costs of the entire service. We are aware that making that adjustment may have been difficult for some hospitals. After considering the information and opinions provided to us in the comments, particularly with respect to our data that are limited to 9 months of claims (although there are over 76,000 single claims from that time period), we are persuaded that there are valid reasons to assign PET/CT services to a different APC than the conventional PET services for CY 2007. We are convinced that, in this instance, we should wait for a full year of CPT-coded claims data prior to assigning the PET/CT services to a clinical APC and that maintaining a modest payment differential between PET and PET/CT procedures is warranted for CY 2007. For these reasons, we are assigning PET/CT to a different APC than conventional PET services for CY 2007, based on our continued expectation of the appropriate relative cost difference between the two types of services. When we first recognized PET/CT CPT codes for payment in CY 2005, we established their payment rate at $100 more than the payment rate for PET scans. Although the commenters to the CY 2007 proposed rule did not provide specific information regarding an appropriate differential between 
                        ( print page 68023)
                        payments for PET and PET/CT scans, the commenters generally did not oppose our proposed payment for PET scans through a clinical APC with a payment rate of about $850. Historically, when both PET and PET/CT scans were assigned to New Technology APCs with a $100 payment difference for CYs 2005 and 2006, we received few public comments indicating that payment difference was inappropriate. Therefore, we are assigning PET/CT scans to New Technology APC 1511 (New Technology—Level XI ($900-$1,000)) with a payment of $950 for CY 2007 to maintain the approximately $100 difference between payments these services and nonmyocardial PET scans, which will be assigned to APC 0308 with a median cost of about $850 for CY 2007. In this way, the differential payment between conventional PET and PET/CT scans will be preserved at an appropriate level, the payment decrease for PET/CT procedures will be moderated as the services transition to payment based on their costs in a clinical APC, and CMS will be able to consider a full 12 months of CPT-coded claims prior to making the assignment of PET/CT scans to a clinical APC. c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 0065, 0066, and 0067) 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 G-codes (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 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 deliberations about the possible need for CMS to separately track planning for SRS, the APC Panel eventually recommended that CMS create a single HCPCS code to encompass both Cobalt 60-based and linear accelerator-based 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 CMS 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 CMS wait for the outcome of these deliberations before making any significant changes to SRS delivery coding or payment rates. As indicated in the CY 2007 OPPS proposed rule, we did not receive a report from participating professional societies as to the outcome of such deliberations prior to publishing that rule (71 FR 49554). 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 HCPCS code 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 our proposed rule 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 our proposed rule CY 2005 claims, based upon hundreds of single claims from each year. For HCPCS code G0251, fractionated non-image 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 
                        ( print page 68024)
                        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 revealed highly stable median costs from year to year based on significant claims volume. Based on the above findings, in the CY 2007 proposed rule we indicated that we believed that we had adequate claims data to assign the SRS treatment delivery procedures to clinically appropriate APCs, and we believed that such movement was appropriate. For CY 2007, we proposed 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 proposed to assign HCPCS codes G0339 and G0173 to the same Level III SRS APC, because we believed that these codes that describe the complete or first fraction of all types of linear accelerator-based SRS treatments had 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, non-robotic linear accelerator-based SRS treatments were each assigned to their own clinical APCs in our proposal, as they demonstrated significant differences in resource utilization as reflected in their median costs. Their previous assignments to different New Technology APCs anticipated these resource distinctions. We proposed 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 were listed in Table 8 of the CY 2007 OPPS proposed rule (71 FR 49554), which has been reproduced as Table 8 below, amended with the final status indicators, APC assignments, and median costs for these services. We received many comments on our proposal from hospitals, health professionals, and various healthcare associations. A summary of the comments and our responses follow: *Comment:*
                         Several commenters objected to our use of the CY 2005 claims data in setting the CY 2007 payment rates, specifically with regards to the image-guided robotic SRS services, as described by HCPCS codes G0339 and G0340. They indicated that the claims data used to set the proposed payment rates for HCPCS codes G0339 and G0340 were based on a flawed methodology because several centers providing these services submitted claims to CMS for less than a full year during CY 2004 and CY 2005. Because centers that provided image-guided SRS grew in number significantly over the past 2 years, the commenters believed that CMS did not have meaningful data over 2 years from a large number of institutions providing the services upon which to base the proposed changes. They believed that new technology services should have a minimum of 2 years of claims data before moving them to clinical APCs. These commenters urged CMS to maintain HCPCS code G0339 in its current New Technology APC 1528 with a payment rate of $5,250, and to also maintain HCPCS G0340 in its current New Technology APC 1525 with a payment rate of $3,750. *Response:*
                         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 noted that we would retain services within New Technology APC groups until we gathered sufficient claims data to enable us to assign the service to a clinically appropriate APC. There is no requirement for a minimum number of claims or years of claims data before services may be moved from New Technology APCs to clinical APCs. In the case of the image-guided robotic SRS services, specifically G0339 and G0340, we continue to believe that we have adequate claims data from CY 2005 upon which to base our payments for CY 2007. Both HCPCS codes G0339 and G0340 were effective for reporting beginning January 1, 2004, under the OPPS, and consequently, we have 2 full years worth of hospital claims data for these services. As we noted earlier, the median costs for both procedures have been reasonably stable over the past 2 years based upon substantial numbers of single claims, and there was similar growth in both services from CY 2004 to CY 2005. The fact that image-guided robotic SRS centers have grown in number and service volume over the most recent 2 years of claims submissions is expected for new technology and other OPPS services. Many OPPS services are only provided in a small subset of hospitals paid under the OPPS, and we routinely establish APC median costs based on Medicare OPPS claims from the hospitals that were providing the services 2 years prior to the OPPS update year. We recognize that our claims data evolve over time, in part because the pool of hospitals providing certain procedures may change significantly. The information provided in the comments did not convince us that the proposed payment rates for HCPCS code G0339 and G0340 were based on inadequate claims data that did not represent the costs of the procedures for the hospitals providing the services in CY 2005. Based on our final CY 2005 claims data, we found 1,535 single (of 1,655 total) claims for HCPCS code G0339 and 2,716 single (of 2,798 total) claims for HCPCS code G0340. We believe that the single claims data for both procedures are sufficiently robust for ratesetting purposes. *Comment:*
                         Several commenters agreed with CMS that the hospital claims data from the past 2 years for the SRS services have been relatively stable and based on at least several hundreds of claims both years. However, these commenters expressed concern about our proposal to assign HCPCS codes G0173 and G0339 to the same APC, specifically APC 0067 (Level III Stereotactic Radiosurgery). The commenters opposed assignment of the two procedures to the same APC because they believed that our claims data clearly showed that the median cost of G0339 has been significantly higher than the median cost of G0173 for both CY 2004 and CY 2005. *Response:*
                         Both services have been assigned to the same New Technology APC 1528 for the past 3 years because of our initial expectation that the costs of the first or complete session of linear accelerator-based SRS would be similar, regardless of whether or not the SRS procedure was an image-guided robotic service. While we have observed that their costs are somewhat different, we believe that they are sufficiently comparable to warrant placement of the SRS services in the same clinical APC, given the comparable clinical characteristics of the services. The OPPS provides payments based on APC groups of services that share clinical and resource characteristics, and the median of the highest cost service 
                        ( print page 68025)
                        within an APC group should not be more than 2 times greater than the median cost of the lowest cost service within that same group. The final CY 2005 median cost of G0173 is $3,407.53, and the final CY 2005 median cost of G0339 is $4,126.46. These median costs are quite comparable, and APC 0067, configured as proposed, does not violate the 2 times limit on the variation of costs within the APC. Therefore, for CY 2007, both HCPCS codes G0339 and G0173 are reassigned to clinical APC 0067 with a median cost of $3,872.87, and HCPCS code G0340 is reassigned to clinical APC 0066, with a median cost of $2,629.53. *Comment:*
                         Several organizations supported our proposed clinical APC assignments but were concerned by the extent of the payment reductions for certain services. The commenters expressed concern regarding the 23-percent reduction in payment for HCPCS codes G0173 and G0339. They urged CMS to review the cost calculations for all SRS services and use the most current claims data available for the CY 2007 OPPS final rule. *Response:*
                         We thank the commenters for their suggestion. The payment rates reflected in Table 8 are based on the latest and most complete CY 2005 claims data, with CY 2007 payment rates based upon APC median costs calculated according to the standard OPPS methodology. Almost all of the claims are single claims; therefore, we are confident that the observed costs in the claims data are representative of the costs of the SRS services provided in CY 2005. *Comment:*
                         Several commenters requested that CMS modify the descriptors for HCPCS codes G0339 and G0340 to be more precise and reflect the technology accurately. The commenters provided their proposed language, and indicated that not refining the descriptors would make it virtually impossible to determine appropriate APC payment rates for image-guided robotic SRS services in the future. They also urged CMS to work with the centers providing these specialized services to establish accurate and appropriate payments for image-guided robotic SRS. *Response:*
                         The recommended language provided by the commenters is very specific and may cause more confusion for hospitals and coders. Long descriptors of HCPCS codes that describe services and procedures are usually more general and not specific to a particular specialty or product. We do not establish HCPCS codes that are specific to certain technologies. Instead, we rely on hospitals to select the most specific HCPCS codes that accurately describe the services they provide. We believe that the current HCPCS code descriptors adequately distinguish image-guided robotic linear accelerator-based SRS from other types of SRS. We observe significant difference in the costs of G0251 and G0340 that describe the later fractions of non-image-guided and image-guided SRS respectively, so that they require assignment to two separate clinical APCs. We have no evidence that hospitals are not accurately reporting these services based on the technology utilized to provide SRS in their institutions. For CY 2007, the CPT Editorial Panel created four new SRS Category I CPT codes in the Radiation Therapy section of the 2007 CPT manual. Specifically, the CPT Editorial Panel created CPT codes 77371 (Radiation treatment delivery, stereotactic radiosurgery (SRS) (complete course of treatment of cerebral lesion[s] consisting of 1 session); multi-source Cobalt 60 based)), 77372 (Radiation treatment delivery, stereotactic radiosurgery (SRS) (complete course of treatment of cerebral lesion[s] consisting of 1 session); linear accelerator based)), 77373 (Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions), and 77435 (Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions). For CY 2007, we will continue our recent practice of not recognizing established CPT code 61793 (Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator), one or more sessions) under the OPPS because the OPPS will utilize more specific SRS codes to provide appropriate payment for the facility resources associated with specific types of SRS treatment delivery. Below is our discussion of the new SRS CPT codes, and our assignments for the codes under the OPPS. CPT code 77371 describes a cobalt-based SRS procedure for a single, complete treatment session of one or more cerebral lesions. Under the OPPS, this procedure has been separately payable under HCPCS code G0243 (Multi-source photon stereotactic radiosurgery, delivery including collimator changes and custom plugging, complete course of treatment, all lesions) since January 1, 2002. We believe this single CPT code may be appropriately reported in all clinical situations of cobalt-based SRS treatment. For CY 2007, HCPCS G0243 will no longer be reportable under the hospital OPPS because the code will be deleted and replaced with CPT code 77371, effective January 1, 2007. CPT code 77371 is assigned to the same APC and status indicator as its predecessor code (G0243). That is, for CY 2007, CPT code 77371 is assigned to APC 0127 (Level IV Stereotactic Radiosurgery) with a status indicator of “S”.
                    CPT code 77372 describes a single session, complete course of treatment, linear accelerator-based procedure. During CY 2006, this procedure was reported under one of two HCPCS codes, depending on the technology used, specifically, G0173 (Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session) and G0339 (Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment). Because HCPCS codes G0173 and G0339 are more specific in their descriptors than CPT code 77372, we have decided to continue using G0173 and G0339 under the OPPS for CY 2007. Therefore, for CY 2007, we have assigned CPT code 77372 to status indicator “B” under the OPPS.
                    CPT code 77373 describes a fractionated session linear accelerator-based procedure. During CY 2006, CPT code 77373 was reported under one of three HCPCS codes depending on the circumstances and technology used, specifically, G0251 (Linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment), G0339 (Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment), and G0340 (Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment). Because HCPCS codes G0251, G0339, and G0340 are more specific in their descriptors than CPT code 77373 and these HCPCS codes are assigned to different clinical APCs for CY 2007, we have decided to continue using G0251, G0339, and G0340 under the OPPS for CY 2007. Therefore, for CY 2007, we have assigned CPT code 77373 to status indicator “B” the hospital OPPS.
                    CPT code 77435 also describes treatment management for a full treatment course of linear accelerator-based SRS. During CY 2006, CPT code( print page 68026)
                        77435 was described under CPT code 0083T (Stereotactic body radiation therapy, treatment management, per day), which was assigned to status indicator “N” in the OPPS. The CPT Editorial Panel has decided to delete CPT code 0083T on December 31, 2006, and replaced it with CPT code 77435. Because the costs of SRS treatment management are already packaged into the OPPS payment rates for SRS treatment delivery, for CY2007 we have assigned CPT code 77435 to status indicator “N”, which is the same status indicator that was assigned to its predecessor Category III CPT code. After carefully considering all the comments and concerns raised by the commenters, we are finalizing our proposal as shown in Table 8 without modification. Given the ample cost information reflected in the CY 2005 claims data for the SRS services and given the fact that these services have been in New Technology APCs for 3 full years, since they were first assigned to New Technology APCs beginning January 1, 2004, we believe our claims data are sufficient for us to move these services to clinical APCs. Therefore, for CY 2007, HCPCS codes G0173 and G0339 are assigned to clinical APC 0067, with a median cost of $3,872.87, HCPCS code G0251 to clinical APC 0065, with a median cost of $1,241.89, and HCPCS code G0340 to clinical APC 0066 with a median cost of $2,629.53. As described above, despite new CPT codes for SRS treatment delivery in CY 2007, coding for linear accelerator-based SRS treatment delivery services will not change in the CY 2007 OPPS. Table 8.—Final APC Assignments for SRS Treatment Delivery Services for CY 2007
HCPCS code
Short descriptor
CY 2006 SI
CY 2006 APC
CY 2006 payment rate
Final CY 2007 SI
Final CY 2007 APC
Final CY 2007 APC median costG0173
Linear acc stereo radsur com
S
1528
$5,250.00
S
0067
$3,872.87G0251
Linear acc based stero radio
S
1513
1,150.00
S
0065
1,241.89G0339
Robot lin-radsurg com, first
S
1528
5,250.00
S
0067
3,872.87G0340
Robt lin-radsurg fractx 2-5
S
1525
3,750.00
S
0066
2,629.53
 d. Magnetoencephalography (MEG) Services (APCs 0038 and 0209) Magnetoencephalography (MEG) is a noninvasive diagnostic tool that assists surgeons in the presurgical period 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 (Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization)), 95966 (Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization)), and 95967 (Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (e.g., sensory, motor, language, or visual cortex localization)) have been assigned to New Technology APCs. In the CY 2006 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.” The commenters on the CY 2006 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 indicated that these procedures are rarely performed on Medicare beneficiaries. For claims submitted from CY 2002 through CY 2005, our single claims data showed that there were annually only between 2 and 23 claims submitted for CPT code 95965, between 3 and 7 claims for CPT code 95966, and only 1 claim for CPT code 95967. In addition, 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 was $217. As noted in our CY 2007 OPPS proposed rule (71 FR 49555), we had 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 payment 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 provided us with CY 2005 charge and cost information from six hospitals that provided MEG services. These external data showed wide variation in hospitals' costs and charges for MEG procedures, with 
                        ( print page 68027)
                        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 were 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 demonstrated 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 was 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 cost-efficient 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. In the CY 2007 OPPS proposed rule, we indicated that since we now had 4 years of hospital claims data for MEG procedures and because MEG was no longer a new technology, we did not believe these external data from six hospitals that performed MEG services in CY 2005 provided 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 agreed with the APC Panel and proposed 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 proposed 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 believed that the assignment of CPT codes 95966 and 95967 to APC 0209 was appropriate because MEG studies were similar to EEGs and sleep studies in measuring activity of the brain over a significant time period, and our hospital claims data showed that their hospital resources were also relatively comparable. MEG procedures and their CY 2007 proposed APC assignments were displayed in Table 9 published in the CY 2007 OPPS proposed rule (71 FR 49556), which has been reproduced in Table 9 of this final rule with comment period and updated to include the final status indicators, APC assignments, and APC median costs for CY 2007. *Comment:*
                         Most of the commenters agreed with the APC assignments for both CPT codes 95965 and 95967 but requested that CMS reconsider the APC assignment for CPT code 95966. The commenters supported the establishment of a separate APC for CPT code 95965 and its proposed payment rate. They also agreed that CPT code 95967 is an add-on code that is always used in conjunction with CPT codes 95965 or 95966 and is less costly to perform. They generally agreed with the proposed APC assignment and payment rate for CPT code 95967, despite the very low volume of OPPS claims for the procedure. The commenters disagreed with the proposed APC and payment rate for CPT code 95966. They indicated that MEG is a highly specialized service performed in a limited number of hospitals in the U.S. Because the service is not commonly performed, the commenters acknowledged that Medicare beneficiaries represent only a small number of patients who receive MEG services because epilepsy surgery is rarely performed on elderly patients, which further explains the very low volume of these services in the Medicare claims data. While the commenters agreed with the proposed APC assignments for CPT codes 95965 and 95967, they believed that the resources required to perform 95966 were significantly higher than the payment rate reflected in APC 0209, its proposed assignment for CY 2007. The commenters indicated that the costs of MEG services were substantially higher than the EEG or sleep study services that are also assigned to APC 0209. As such, the commenters believed that CPT code 95966 should be assigned to its own APC at a rate equal to 50 percent of the payment rate for CPT code 95965, or approximately $1,550. They believed that this payment rate was supported by the hospital cost data for the six hospitals providing a high volume of MEG services, which were provided to CMS and discussed in the CY 2007 OPPS proposed rule. *Response:*
                         We appreciate the commenters' input and suggestions. However, given that we have 4 years of hospital claims data for MEG procedures and because MEG is no longer a new technology, we believe that the proposed APC assignment for CPT code 95966 is appropriate. If we were to assign CPT code 95966 to its own clinical APC, the median cost of that APC would be the median cost of CPT code 95966 of $709 from CY 2005 claims data, quite consistent with the median cost of APC 0209. We do not assign payment rates for clinical APCs based upon speculative relationships of the costs of its services to payments for other services. Instead, the standard OPPS methodology to develop the median cost of a clinical APC upon which a specific procedure's payment is based is to establish the APC median from claims data for all of the services assigned to the APC. As we have indicated above, while the volumes of 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. Taking into consideration our hospital claims data for CPT code 95966 from the last several years, we continue to believe that its assignment to APC 0209 is appropriate, and that the service is sufficiently similar to other diagnostic procedures also residing in the APC. Therefore, for CY 2007, we are assigning CPT code 95965 to APC 0038, with a final CY 2007 median cost of $3,270, and CPT codes 95966 and 95967 to APC 0209, with a final CY 2007 median cost of $687. *Comment:*
                         One commenter indicated that the claims data cited in the CY 2007 OPPS proposed rule for CPT codes 95965, 95966, and 95967 were based both on incomplete and inaccurate claims data. The commenter submitted copies of paid Medicare claims from CY 2005 for CPT code 95965, which included nine claims that reflected 5 months of data, each representing total charges greater than the CY 2007 proposed payment rate for CPT code 95965. The commenter requested that CMS consider these claims in determining the appropriate APC assignments for the MEG services. *Response:*
                         We confirmed that the claims data submitted to us are accurately reflected in the CY 2005 claims data used for the CY 2007 OPPS update. Consequently, we believe that our claims data adequately reflect the costs associated with providing the MEG service identified by CPT code 95965. In determining a hospital's cost for a service, we take the individual hospital's departmental CCR and multiply this by the total charge on a 
                        ( print page 68028)
                        single claim for that service. In the event there is no applicable departmental CCR, we use the overall hospital-specific CCR. For this CY 2007 OPPS update, the average overall hospital CCR is 0.30142. Multiplying this average CCR by the typical MEG procedure charge of about $10,500 on the claims provided to us yields a cost for CPT code 95965 of about $3,165, consistent with the final CY 2007 median cost of APC 0038 of about $3,270. This median cost provides the basis for establishing the procedure's payment rate. Overall, we believe the claims provided by the commenter help to validate our final CY 2007 APC 0038 assignment of CPT code 95965, with its payment rate calculated according to our standard OPPS methodology. After carefully reviewing the data and considering the public comments received, we are finalizing our proposal for APC assignment for MEG as shown in Table 9 without modification. Table 9.—CY 2007 APC Assignment for MEG
HCPCS code
Short descriptor
CY 2006 SI
CY 2006 APC
CY 2006 payment rate
CY 2007 SI
Final CY 2007 APC
Final CY 2007 APC median cost95965
Meg, spontaneous
S
1523
$2,750.00
S
0038
$3,270.3595966
Meg, evoked, single
S
1514
1,250.00
S
0209
687.2695967
Meg, evoked, each additional
S
1510
850.00
S
0209
687.26
 e. Other Services in New Technology APCs Other than the PET, PET/CT, SRS, and MEG new technology services discussed in section III.C.2.a. through d. of this preamble, there are 23 procedures currently assigned to New Technology APCs for CY 2007 for which we believed we also had data that were adequate to support their assignment to clinical APCs. For CY 2007, we proposed to reassign these procedures to clinically appropriate APCs, applying their CY 2005 claims data to develop their clinical APC median costs upon which payments would be based. These procedures and their proposed APC assignments were displayed in Table 10 of the CY 2007 OPPS proposed rule. This table has been reproduced as Table 10 at the end of this section and updated with the final status indicators, APC assignments, and median costs. We received many comments concerning the proposed reassignment of other new technology procedures listed in Table 10 to clinical APCs for CY 2007. A summary of the comments and our responses follow: (1) Breast Brachytherapy (APCs 0029 and 0030) For CY 2007, we proposed to reassign CPT code 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) from New Technology APC 1524 (New Technology Level XIV—($3000-$3500)) to clinical APC 0030 (Level III Breast Surgery) with a proposed median cost of $2,516.94. We also proposed to reassign CPT code 19297 (Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy) from New Technology APC 1523 (New Technology Level XXIII—($2500-$3000)) to clinical APC 0029 (Level II Breast Surgery), with a proposed median cost of $1,738.75. *Comment:*
                         Numerous commenters requested that CMS maintain CPT code 19296 and CPT code 19297 in New Technology APCs 1524 and 1523, respectively, for another year so that more claims data could be collected for both services. They were concerned about the proposed significant payment decreases for CPT codes 19296 and 19297 that ranged from -23 percent to -37 percent. The commenters also indicated that the number of hospital outpatient claims for both codes were low and thus inadequate to support their assignment to appropriate clinical APCs. The commenters indicated that in developing the proposed rule, CPT code 19296 had a total of 491 single claims for CY 2005, and only 36 single claims were available for CPT code 19297. One commenter was surprised that CMS would consider moving CPT code 19297 to a clinical APC with only 36 single claims, while CPT code 19298 (Place breast rad tube/caths), with 49 single claims for CY 2005, would continue to be assigned to New Technology APC 1524. The commenters generally urged CMS to reevaluate the proposed clinical APCs for these procedures, and, if necessary, place them in more appropriate APCs that accurately reflected the costs and clinical characteristics of these services. Many commenters requested that CMS either continue to assign CPT codes 19296 and 19297 to their current CY 2006 New Technology APCs for CY 2007, or place them in APC 0648, retitled “Level IV Breast Surgery,” which had a proposed median cost of $3,012.92 and a CY 2006 title of “Breast Reconstruction with Prosthesis.” As to our proposed CY 2007 APC assignments, for these codes, the commenters indicated that the other procedures in APCs 0030 and 0029 did not use high cost devices, and the median costs of the various procedures assigned to these APCs violated the 2 times rule when the device-dependent median costs of CPT codes 19296 and 19297 were considered. The commenters further added that the procedures within these APCs were not clinically homogeneous and recommended that we reassign CPT codes 19296 and 19297 to APC 0648 (Breast Reconstruction with Prosthesis), which contained procedures that were more similar to the brachytherapy catheter insertion procedures in terms of their clinical characteristics and use of costly devices. *Response:*
                         As we have stated previously, we retain services within New Technology APC groups until we gather sufficient claims data to enable us to assign the services to clinically appropriate APCs. This policy allows us to move services from New Technology APCs in less than 2 years if sufficient data are available. It also permits us to retain services in New Technology APCs for more than 3 years if sufficient data upon which to base a decision for reassignment have not been collected. In the case of CPT codes 19296 and 19297, the predecessor codes for these services were created in April 2004. CPT code 19296 was previously described by HCPCS code C9715 (Placement of balloon catheter into the breast for interstitial radiation therapy following a partial mastectomy; delayed), and CPT code 19297 was described by HCPCS code C9714 (Placement of balloon catheter into the breast for interstitial 
                        ( print page 68029)
                        radiation therapy following a partial mastectomy; concurrent/immediate). Both predecessor codes were assigned to New Technology APCs when the codes were announced in the April update of the CY 2004 OPPS (Transmittal 132, dated March 30, 2004). Specifically, HCPCS code C9715 was assigned to New Technology APC 1524 and HCPCS code C9714 was assigned to New Technology APC 1523. Consequently, we believe we have sufficient data from almost 3 years of hospital claims to assign both CPT codes 19296 and 19297 to clinically appropriate APCs. We recognize that, in the case of CPT code 19297 which is an add-on code to a partial mastectomy service, single bills would likely always be miscoded and available in only small numbers, because the correctly coded claims would be multiple procedure claims that we could not use for ratesetting. However, in light of the comments received and our review of all the information provided by the commenters, we reconsidered the proposed APC assignments for CPT codes 19296 and 19297. We agree with the commenters that the clinical APC assignments for CPT codes 19296 and 19297 should accurately reflect the costs of the procedures, as well as their clinical features. We note that the final CY 2005 median cost for CPT code 19296 is $3,041.58 based on 537 (of 860 total) single claims, and the final CY 2005 median cost for CPT code 19297 is $1,322.03 based on 36 single claims (of 443 total claims). As noted previously, we do not believe the median cost of CPT code 19297 is calculated based upon correctly coded claims. Therefore, after full consideration of the public comments received, we believe it is appropriate for CY 2007 to assign both services to clinical APC 0648 with an APC title of “Level IV Breast Surgery” and a final median cost of $3,130.45. We believe this is the most appropriate assignment for both procedures, when we consider their clinical and resource characteristics in the context of other procedures also assigned to APC 0648. APC 0648 is assigned status indicator “T,” which means that when a service assigned to it is reported with a lower priced service (for example, a mastectomy procedure) that is also assigned status indicator “T,” payment for the lower priced service would be reduced by 50 percent. This reduction in payment reflects the efficiencies that occur when a lower paid service is performed during the same operative session as a higher paid surgical procedure. We believe this reduction is appropriate due to efficiencies that may be gained when both services are performed in a single session. As for CPT code 19298, because there was no predecessor code to describe this procedure, which was new in CY 2005, we only have 1 year of claims data. Therefore, we are continuing to assign this code to New Technology APC 1524 for CY 2007 to enable us to collect additional data for appropriate ratesetting in the future. *Comment:*
                         Several commenters indicated that the procedure associated with CPT codes 19296 and 19297 requires the use of a specialized catheter that has a list price of $2,750, which is more costly than the proposed payment rate for APC 0030 or APC 0029. One commenter added that hospitals do not receive discounts or rebates on the unique catheters, and that regardless of whether the procedure is performed at the time of lumpectomy or during future surgery, the cost of the catheter is still the same in both cases. *Response:*
                         As noted above, after carefully considering all the public comments received, we have reassigned CPT codes 19296 and 19297 to APC 0648, a device-dependent APC, for CY 2007. The final median cost for this device-dependent APC was calculated using only claims that contained appropriate device HCPCS codes for all the procedures assigned to it with nontoken charges for the devices as discussed in section IV.A.2 of this preamble. The median cost from the subset of claims reporting a device HCPCS code for the brachytherapy catheter was $3,469.85 for CPT code 19296 and $3,379.97 for CPT code 19297. We believe that payment for APC 0648 accurately reflects the resources and costs associated with performing these device-dependent brachytherapy catheter insertion procedures. To ensure that their future claims include charges for the necessary devices to assist in ratesetting, we will implement procedure-to-device edits for both of these services in CY 2007. In order to receive payment for the two procedures to insert brachytherapy balloon catheters, hospitals will be required to report the appropriate device HCPCS code or their claims will be returned to them for correction. *Comment:*
                         Several commenters were concerned about the proposed assignment of status indicator “T” to both CPT codes 19296 and 19297. They observed that the indicator would always reduce the payment for CPT code 19297 by 50 percent. *Response:*
                         Based on the final CY 2007 assignment of CPT code 19297 to APC 0648, we believe this reduction is appropriate due to efficiencies that may be gained when both the partial mastectomy and placement of brachytherapy catheter procedures are performed in a single operative session. According to the CPT manual, CPT code 19297 would be reported with CPT code 19160 (Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)) or 19162 (Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy). These codes are assigned to APCs 0028 (Level I Breast Surgery), with a final CY 2007 median cost of $1,178.12, and 0693 (Breast Reconstruction), with a final CY 2007 median cost of $2,260.98, respectively. In cases where the partial mastectomy is performed with concurrent placement of a brachytherapy balloon catheter into the breast, payment for the nondevice-dependent partial mastectomy procedure would be appropriately reduced by 50 percent, while full payment would be provided for the device-dependent procedure described by CPT code 19297, consistent with the expected resource efficiencies when these procedures are performed in a single session. After carefully considering all public comments received, we are finalizing our CY 2007 proposal with modification to reassign CPT codes 19296 and 19297 from New Technology APCs to clinical APC 0648, retitled “Level IV Breast Procedures,” with a final CY 2007 median cost of $3,130.45. We also are implementing appropriate procedure-to-device edits for both of these procedures. (2) Radiofrequency Ablation (APCs 0050 and 0423) For CY 2007, we proposed to reassign CPT code 20982 (Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis), radiofrequency, percutaneous, included computed tomographic guidance) from New Technology APC 1557 (New Technology—Level XX ($1800-$1900)) to APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot), with a proposed median cost of $1,535.66. We also proposed that CPT code 50592 (Ablation, one or more renal tumor(s), percutaneous, unilateral radiofrequency), which was a new CPT code for CY 2006, and CPT code 47382 (Ablation, one or more liver tumor(s), percutaneous, radiofrequency) continue to be assigned to APC 0423 (Level II Percutaneous Abdominal and Biliary Procedures), with a proposed median cost of $2,410.33. *Comment:*
                         One commenter objected to the proposed payment for APC 0423 and 
                        ( print page 68030)
                        the placement of CPT codes 47382 and 50592 in APC 0423 because the commenter believed that the proposed payment was too low to adequately compensate hospitals for the required radiofrequency electrode and the necessary services. One commenter also asked that CPT code 20982 be reassigned to APC 0051 (Level III Musculoskeletal Procedures Except Hand and Foot) to pay a more appropriate amount. The commenter provided a comparison to the MPFS practice expense inputs that showed that the supply, clinical time, and capital expense for performing CPT code 20982 was about $2,100. Moreover, the commenter asked that CMS ensure that a forthcoming CPT code for ablation of a lung tumor be assigned to an APC that would make appropriate payment for both the electrode and the services. The commenter stated that the electrodes used in these services typically cost from $900 to $2,500, with an approximate average of $1,500. The commenter asked that CMS grant its pass-through device category application, establish a new device category code for radiofrequency electrodes for pass-through payment, and designate APCs 0423, 0132 (Level III Laparoscopy), and 0050 as device-dependent APCs and implement appropriate procedure-to-device edits. *Response:*
                         The MPFS is a different payment system that establishes payment rates based on a methodology that is wholly unrelated to the OPPS setting of relative weights, so its practice expense costs are not applicable to the OPPS. However, in this final rule with comment period, we are reassigning CPT code 20982 to APC 0051 for CY 2007 because we agree, based on review of our historical claims data and final CY 2005 claims, that CPT code 20982 is more appropriately assigned to APC 0051 than to APC 0050 from hospital resource and clinical perspectives. However, we are retaining CPT codes 47382 and 50592 in APC 0423, with a median cost established based upon our standard OPPS methodology, because we believe that we have sufficient claims data for CPT code 47382, which was created in CY 2002. We have 4 years of claims data for this procedure, with hundreds of single claims from CY 2005 that reflect a stable code-specific median cost in comparison with CY 2004 claims. For CY 2007, CPT code 47382 is the only code assigned to APC 0423 that contributes claims data to the median cost calculation for the APC. We also believe that CPT code 50592, which has no CY 2005 claims data because it was new for CY 2006, is similar to CPT code 47382 based on clinical and resource considerations. Therefore, it is most appropriately assigned to the same clinical APC. Moreover, because CPT code 47382 uses devices that never had pass-through status, we have not placed any of the CPT codes for radiofrequency ablation procedures in specialized APCs, nor do we consider their APCs to be device-dependent. Because the device is well-established in its use for radiofrequency ablation of liver tumors, we believe that hospital charges for the procedure contain the charges the hospital considers are appropriate for the electrode and other required supplies. This is similar to our treatment of CPT code 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)). This is a well-established service that predates the OPPS and that uses a device that was never a pass-through device. We also do not consider its APC to be device-dependent. We also are assigning new CPT code 32998 (Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral) to APC 0423 because we have no reason to believe that the resources required for the newly coded service differ in any substantive way from the resources required for longstanding CPT code 49382. This new CPT code's assignment is open to comment in this final rule with comment period. We do not make pass-through device category determinations through rulemaking, nor do we create new device category codes outside of the pass-through process. Because there is no specific device code to describe the radiofrequency ablation electrode, we are unable to implement procedure-to-device edits for any of these procedures. After carefully considering the public comments received, we are finalizing our proposal with modification. CPT code 20982 is reassigned to APC 0051 for CY 2007, with a median cost of $2,510.95. CPT codes 47382 and 50592 continue to be assigned to APC 0423 for CY 2007, with a median cost of $2,283.08. New CPT code 32998 is also assigned to APC 0423 for CY 2007, and this assignment is open to comment in this final rule with comment period. (3) Extracorporeal Shock Wave Treatment (APC 0050) For CY 2007, we proposed to reassign CPT code 28890 (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia) and CPT code 0102T (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle) from New Technology APC 1547 (New Technology—Level X ($800-$900)) to clinical APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot), which had a proposed payment rate of $1,542.47. *Comment:*
                         One commenter on our CY 2006 final rule with comment period was concerned that our assignment of new CPT code 28890 to APC 1547 may be insufficient to appropriately pay for the costs associated with its performance and facility costs in the outpatient setting. The commenter admitted that it did not have actual cost data for supplies and equipment used in the hospital outpatient setting. Nevertheless the commenter was concerned that the $850 payment rate for services assigned to APC 1547 may be insufficient for this service the OPD. The commenters on our CY 2007 OPPS proposed rule believed that our proposed reassignment of CPT codes 28890 and 0102T to APC 0050 was appropriate for CY 2007 until the Medicare hospital claims data become more robust. Several commenters supported our proposal to reassign CPT code 28890 and CPT code 0102T from New Technology APC 1547 to clinical APC 0050. The commenters believed that APC 0050 appropriately reflects the true costs and clinical resources associated with CPT code 0102T. One commenter indicated that the costs of the procedures currently classified under clinical APC 0050 are not dissimilar to the median cost of its predecessor code, specifically, HCPCS code C9720 (High-energy (greater than 0.22mj/mm2) extracorporeal shock wave (ESW) treatment for chronic lateral epicondylitis (tennis elbow)), and therefore, agreed with our proposed assignment. However, one commenter believed that the true resource costs of CPT codes 28890 and 0102T are not fully reflected in the CY 2005 claims data upon which CY 2007 payment rates are based. Therefore, the commenter recommended that CMS adopt the proposed assignments of these CPT codes to APC 0050, but that CMS continue to track and evaluate its claims data as additional claims data become available. However, the commenter questioned our assignment of CPT code 0101T (Extracorporeal shock wave involving musculoskeletal system, not otherwise 
                        ( print page 68031)
                        specified, high energy) to APC 0050, stating that this code describes a variety of unspecified procedures for which we have no CY 2005 claims data. The commenter recommended that we not assign CPT code 0101T to APC 0050 or to any inappropriately low-priced New Technology APC. *Response:*
                         Concerning the comment to our CY 2006 assignment of CPT code 28890, we note that the OPPS payment is for the technical or facility portion of the payment only. The physician performing the procedure would also bill CMS for the professional services in providing the procedure. Therefore, the CY 2006 OPPS payment for APC 1547 was not for both the performance and facility fee as suggested by the commenter. Nevertheless, in our proposed rule for CY 2007, we proposed reassigning CPT code 28890 to APC 0050, Level II Musculoskeletal Procedures Except Hand and Foot, with a proposed payment rate of $1,542.47. Prior to the introduction of this CPT code in CY 2006, hospitals reported HPCPS code C9721 (High-energy (greater than 0.22mj/mm2) extracorporeal shock wave (ESW) treatment for chronic plantar fasciitis), to describe the service. This C-code had a median cost of about $1,794 based on CY 2005 claims, consistent with the proposed payment rate for APC 0050. We appreciate the support for our proposed reassignment of ESWT CPT codes 28890 and 0102T to APC 0050 for CY 2007. Concerning the objection to assigning CPT code 0101T to APC 0050 due to the lack of claims data, we believe that the clinical characteristics and expected resource use for CPT code 0101T will be similar to other ESWT treatments such as those described by CPT codes 28890 and CPT 0102T. As indicated in our CY 2007 OPPS proposed rule (71 FR 49549), 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. In the case of CPT code 0101T, we believe this procedure is similar in clinical characteristics and resource use to CPT code 28890 and CPT code 0102T. After carefully considering the public comments received, we are finalizing our proposal without modification to assign CPT codes 28890, 0102T, and 0101T to APC 0050 for CY 2007. (4) Insertion of Venous Access Device With Two Ports (APC 0623) For CY 2007, we proposed to reassign CPT code 36566 (Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separately venous access sites: with subcutaneous port(s)) from New Technology APC 1564 (New Technology—Level XXVII ($4500-$5000)), to APC 0623 (Level III Vascular Access Procedures), with a proposed median cost of $1,703.94. At its August 2006 meeting, the APC Panel recommended that this procedure be moved to an APC with a payment rate no less than that of New Technology APC 1524 (New Technology—Level XXIV ($3000-$3500)) and more than that of New Technology APC 1564 (New Technology—Level XXVII ($4500-$5000)). The APC Panel also recommended that CMS establish a procedure-to-device edit for the service. *Comment:*
                         Some commenters objected to the proposed payment rate for CPT code 36566. The commenters asked that CMS establish the median cost for this code based only on claims that contain HCPCS code C1881 (Dialysis access system, implantable) and that we add a device edit that requires that hospitals must bill for HCPCS code C1881 as a condition of being paid for CPT code 36566. They indicated that two devices, totaling $3,500, are required for the procedures. *Response:*
                         We agree that CPT code 36566, created in CY 2004, should be assigned to a device-dependent APC, and we calculated median costs for device-dependent APCs in CY 2007 based upon claims that passed the device edits and contained nontoken device charges as described in section IV.A.2 of this preamble. When we calculated the median cost of CPT 36566 based only on that subset of claims with HCPCS code C1881, its median cost was $5,100.26. We are generally accepting the APC Panel's recommendation to assign CPT code 36566 to an APC with an appropriate payment rate and to establish a procedure-to-device edit for CY 2007. For CY 2007, we have placed CPT code 36566 in new APC 0625 (Level IV Vascular Access Procedures) because there is no currently existing clinical APC where CPT code 36566 could appropriately be reassigned based on clinical and resource considerations. We have established APC 0625 as a device-dependent APC because the APCs for the vascular access device services that require devices of significant cost generally have been considered device-dependent since the inception of the OPPS. We have established a device edit, effective for services on or after January 1, 2007, that will not provide payment for CPT code 36566 unless an appropriate device HCPCS code is also reported on the claim. We have calculated the median cost of APC 0625 for CY 2007 using only claims that contain nontoken charges for HCPCS code C1881. After carefully considering the public comments received, we are finalizing our CY 2007 proposal with modification. We are assigning CPT code 36566 to APC 0625, with a median cost of $5,100.26, and establishing an appropriate procedure-to-device edit for CY 2007. (5) Stereotactic X-ray Guidance (APC 0257) For CY 2007, we proposed to reassign CPT code 77421 (Stereoscopic x-ray guidance) from New Technology APC 1502 (New Technology—Level II ($50-$100)) to clinical APC 0257 (Level I Therapeutic Radiologic Procedures), with a proposed median cost of $60. *Comment:*
                         Some commenters expressed concern about our proposal to reassign CPT code 77421 from New Technology APC 1502 to clinical APC 0257. The commenters indicated that the proposed payment rate of $60.14 for APC 0257 was insufficient and did not adequately cover the actual costs associated with providing the guidance service described by CPT code 77421. In addition, the commenters believed that the other services currently assigned to APC 0257 were significantly different from CPT code 77421. The commenters stated that the stereotactic x-ray guidance procedure is considerately more sophisticated and technologically more complex, and thus, more resource intensive, than the procedures in APC 0257. Furthermore, the commenters cited the global payment rate of $151.59 for CPT code 77421 under the MPFS, and requested that we take into consideration the MPFS practice expense information for ratesetting rather than relying on very limited hospital claims data. Some commenters requested that CMS reassign CPT code 77421 to APC 0296 (Level II Therapeutic Radiologic Procedures), which had a proposed median cost of $167, to more accurately reflect the true costs associated with providing this service. The commenters further indicated that the other services assigned to APC 0296 were similar clinically and resource-wise to the stereotactic x-ray guidance procedure. Other commenters requested that CMS maintain CPT code 77421 in New Technology APC 1502 with a payment rate of $75 for CY 2007, until CMS has more experience with the CPT code. Some commenters noted that CMS may have mistakenly cross-walked CY 2005 claims data for C9722 (Stereoscopic kilovolt x-ray imaging 
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                        with infrared tracking for localization of target volume) to CPT code 77421, based on the belief that both codes described the same services. *Response:*
                         While CPT code 77421 was made effective on January 1, 2006, under the OPPS stereoscopic kV x-ray guidance was previously reported with HCPCS code C9722, which was made effective January 1, 2005, and deleted on December 31, 2005, according to our usual practice when services previously described by a C-code can be reported with a CPT code. Based on our claims data, we found 14,794 single claims (out of 15,367 total claims) for HCPCS code C9722 in the CY 2005 data upon which we are basing the CY 2007 relative weights. We believe that services previously reported with HCPCS code C9722 may now be reported with CPT code 77421, although CPT code 77421 may allow reporting of a broader set of technologies. We also believe this CY 2005 volume of services is sufficient to justify setting a relative weight based on claims-based cost information rather than keeping the service in a New Technology APC for another year. In addition, our claims information is not consistent with a payment for the service through clinical APC 0296, which has a final median cost of about $164. We note that, of the claims available for ratesetting for APC 0257, almost 90 percent of them were for HCPCS code C9722; therefore, we are confident that the median cost of APC 0257 appropriately reflects the costs of stereoscopic x-ray imaging. We also believe the other imaging services assigned to APC 0257 share sufficient clinical and resource similarity with CPT code 77421 to support their assignment to the same clinical APC. Moreover, we again note that the MPFS practice expense information for this service is not relevant to the setting of relative weights under OPPS. After considering all the public comments received, for CY 2007, we are adopting as final without modification our proposal to reassign CPT code 77421 from New Technology APC 1502 to clinical APC 0257, which has a final CY 2007 median cost of $67.06. (6) Whole Body Tumor Imaging (APC 0408) For CY 2007, we proposed to reassign CPT code 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days imaging) from New Technology APC 1508 (New Technology—Level VIII ($600-$700)) to clinical APC 0408 (Level II Tumor/Infection Imaging) with a proposed median cost of $309. *Comment:*
                         Several commenters disagreed with the proposed reassignment of CPT code 78804, which describes a whole body study that requires multiple days of imaging, from New Technology APC 1508 to the same new clinical APC 0408 as the assignment of CPT code 78806 (Radiopharmaceutical localization of inflammatory process; whole body), which describes a single day whole body imaging study. While the commenters acknowledged that the two procedures use similar resources for a day of imaging, they stated that the clinical time and work involved in performing a multiple day imaging study is significantly more intensive than a single day study; therefore, hospitals incur additional costs. As such, the commenters disagreed with our proposal to assign the single and multiple day study CPT codes to the same clinical APC because the hospital resources are not homogeneous for these clinically similar studies. The commenters urged CMS to maintain the single day study as described by CPT code 78806 in its current APC assignment, specifically APC 0406 (Level I Tumor/Infection Imaging), and to create a new APC for CPT code 78804 for assignment of the multiple day study. Furthermore, the commenters recommended that the payment rate for CPT code 78804 be based on the current claims data for the procedure. *Response:*
                         After further review of our CY 2005 claims data and consideration of the clinical characteristics of CPT code 78804, we agree with the commenters' recommendation to maintain the single day study, which is described by CPT code 78806, in its current CY 2006 APC 0406. We further agree with the commenters' assignment of CPT code 78804 to a separate APC established as Level II Tumor/Infection Imaging, and therefore, have decided to keep this code as the only code assigned to APC 0408 for CY 2007. Based on our final revised policy, the CY 2007 median cost of APC 0408 is $362.05. The separate APC assignments for the single and multiple day tumor/infection imaging studies adequately achieve both clinical and resource coherence for the services in both APCs. Therefore, we are finalizing our proposed CY 2007 APC assignment of CPT code 78804 to new clinical APC 0408 for CY 2007, with modification to the proposal through reconfiguration of APC 0408 as described above. (7) Gastroesophageal Reflux Test With pH Electrode (APC 0361) For CY 2007, we proposed to reassign CPT code 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry ph electrode placement, recording, analysis and interpretation) from New Technology APC 1506 (New Technology—Level VI ($400-$500)) to clinical APC 0361 (Level II Alimentary Tests) with a proposed payment of $242. *Comment:*
                         One commenter disagreed with our proposal to reassign CPT code 91035 from New Technology APC 1506 to clinical APC 0361. The commenter believed that the proposed payment level of $242 for APC 0361 did not adequately reflect the cost of providing the service and that it did not appropriately differentiate between the two types of pH monitoring for detection of gastroesophageal reflux disease (GERD): capsule-based and catheter-based. (CPT code 91035 describes the capsule-based pH monitoring service while CPT code 91034 describes the catheter-based pH monitoring procedure.) The commenter believed that the resource costs for the two procedures are significantly different, and as such, each procedure should be placed in a separate APC to accurately reflect the costs of providing the services. The commenter indicated that the average cost of the capsule is about $184, which is significantly higher than the cost of the catheter used for pH monitoring that is priced at about $45. In addition, the commenter requested that CPT code 91035 be designated as a device-dependent procedure, and also requested that CMS establish a C-code for the capsule to appropriately track its cost. The commenter also requested that CMS compare the costs of single claims with claims that include an endoscopy procedure, with which the pH capsule procedure is very commonly performed, to ensure that all costs were captured and based on the most likely clinical scenario when determining the appropriate payment rate for CPT code 91035. *Response:*
                         Since April 2004, the procedure described by CPT code 91035 has been designated as a new technology service under the OPPS. While CPT code 91035 was not effective for reporting until January 1, 2005, its predecessor code, specifically HCPCS code C9712 (Insertion of a pH capsule for measurement and monitoring of gastroesophageal reflux disease, includes data collection and interpretation) was designated as a new technology service and assigned to New Technology APC 1506 from April 2004 until December 31, 2004, when the code was deleted and replaced with CPT code 91035. CPT code 91035 was then assigned to the same New Technology 
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                        APC for CY 2005, with a payment rate of $450. As usual, in determining the initial payment level for this service, we took into consideration the costs associated with the procedure, including the necessary capsule device. We do not believe that our claims data from CYs 2004 and 2005 demonstrate that the resources associated with a capsule-based pH monitoring procedure are significantly greater than those required for a catheter-based pH monitoring procedure, leading to their inappropriate assignments to the same clinical APC. Based on our CY 2005 claims data, the median costs for each procedure are relatively comparable: $260 for CPT code 91034 (based on 2,982 single claims) and $300 for CPT code 91035 (based on 1,160 single claims). We believe that both procedures are fairly similar in terms of device cost, clinical staff time, and other facility resources required for performing the procedures. We note that the median cost for CPT code 91035 was based upon 1,160 single claims out of 4,777 total claims for the procedure. While we understand that capsule-based pH monitoring is often initiated in association with an endoscopy procedure, we have no reason to believe that our median cost from single claims calculated according to our standard OPPS methodology understates the cost of the procedure. Indeed, we would expect that the resources could be less if the service were performed in association with another surgical procedure because of efficiencies, although there would be no payment reduction because APC 0361 has a status indicator of “X.” With respect to designation of the procedure as device-dependent, we typically have only designated APCs as device-dependent in the context of historical payment adjustments provided for these APCs. Many device-intensive procedures appropriately reside in clinical APCs along with procedures that do not require expensive devices. Currently device HCPCS codes are only established when new pass-through device categories are approved. Therefore, we will not create a new device code to track charges for this particular device that has not had pass-through status. We expect that hospitals will include their charges for the cost of the capsule either in the line-item charge for the pH monitoring procedure or under a separate revenue code line on their claims. Because we believe that the median cost of APC 0361 appropriately represents the costs and resources involved in performing both capsule-based and catheter-based pH monitoring procedures, and these services are clinically similar, we are finalizing our assignment of CPT code 91035 to APC 0361 for CY 2007 without modification. (8) Home International Normalized Ratio (INR) Monitoring (APC 0604) Since CY 2002, home INR monitoring services have been described by two G-codes, specifically G0248 and G0249, and have been assigned to New Technology APCs. These codes were created effective July 2002 in the context of a National Coverage Determination (NCD) that covers home INR monitoring for patients with mechanical heart valves on warfarin that have been anticoagulated for at least 3 months, who undergo an educational program on anticoagulation management and use of the device prior to its use in the home, and who perform self-testing no more than once a week. The G-codes have been assigned to New Technology APCs for 5 years. Generally, codes remain in New Technology APCs until we can determine an appropriate clinical APC, based on the median cost and clinical characteristics of the services described by the code. This usually ranges from approximately 2 to 3 years. In CY 2002, G0248 and G0249 were assigned to a New Technology APC with a payment rate of $75. In CY 2003, these codes were reassigned to a New Technology APC with a payment rate of $150, and they have remained there since that time. Our analysis of hospital data for Medicare single and multiple claims submitted from CY 2002 through CY 2005 indicates that these procedures are rarely performed by hospital outpatient facilities. For claims submitted from CY 2002 through CY 2005, our single claims data show that there were zero claims submitted during CYs 2002, 2003, and 2004, and in CY 2005, only nine single claims for G0248 and only seven for G0249 are available for ratesetting. Looking at total claims, from 2002 through 2004, we had fewer than 20 claims for each of the specific services. In addition, the median costs for these codes are $95 for G0248 and $128 for G0249 based on CY 2005 claims. Because we received no single claims between CY 2002 and CY 2004 for these codes, we have no prior median cost data. In the CY 2007 OPPS proposed rule (71 FR 49556), we proposed to assign both G0248 and G0249 to clinical APC 0604 (Level I Clinic Visits), with a proposed median cost of $49.93. We believe these assignments were appropriate based on both clinical and resource considerations, in the context of other services also proposed for assignment to APC 0604. During the August 2006 APC Panel meeting, one presenter recommended that we either continue to assign G0248 and G0249 to a New Technology APC or move them to an appropriate clinical APC consistent with the clinical and resource cost characteristics of providing these services. This technology is used in monitoring the adequacy of anticoagulation in patients taking warfarin to prevent major thromboembolic events. The presenter indicated that providers have been slow to adopt the technology because they must purchase the monitors and materials. The presenter requested that the codes remain in New Technology APCs or be reassigned to clinical APCs that appropriately make payments for the costs of providing the services, so that use of this technology increases and more data can be collected. The Panel agreed that providing payment at an appropriate rate would encourage more use of home INR monitoring, which would actively engage patients in their own care. The Panel recommended that we assign G0248 and G0249 to APC 0421 (Prolonged Physiologic Monitoring) for CY 2007. *Comment:*
                         One commenter expressed concern regarding our proposal to move home INR monitoring from New Technology APC 1503 (New Technology—Level III ($100-$200)) to clinical APC 0604. The commenter was particularly concerned that the proposed clinical APC 0604, which has a payment rate of $49.75, would not compensate for the costs incurred in delivering this service. While the commenter understood the reason for assigning these codes to a clinical APC because these codes have been assigned to a New Technology APC since July 2002 (these codes were made effective in July 2002 and announced through the OPPS July 2002 update, specifically Transmittal A-02-050, dated June 17, 2002), the commenter stated that the technology is fairly new with only a small number of hospital claims, which could therefore warrant its continued assignment to the current New Technology APC 1503. The commenter also indicated that the assignments of HCPCS codes G0248 and G0249 to clinical APC 0604 were neither economically nor clinically coherent because none of the other procedures also proposed for assignment to APC 0604 involved the furnishing of equipment and supplies to patients for use in their homes or involved care extended over a 4-week period. Therefore, the commenter urged CMS to maintain home INR monitoring services 
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                        in New Technology APC 1503 with a payment rate of $150 for at least one more year. Alternatively, the commenter requested that CMS assign these codes to clinical APC 0421, which had a proposed payment rate of $101.47, because the reimbursement rate more closely corresponded with the costs of providing the services, and also with the clinical characteristics of the other procedure already assigned to this same APC. *Response:*
                         As we indicated above, the APC Panel also recommended that these two HCPS codes be assigned to APC 0421 for CY 2007. We agree with both the commenter and the APC Panel's recommendation to assign these codes to APC 0421. Therefore, we are finalizing our proposed movement of HCPCS codes G0248 and G0249 from New Technology APC 1503 to a clinical APC for CY 2007 with modification. Effective January 1, 2007, HCPCS codes G0248 and G0249 will be assigned to APC 0421, with a final median cost of $99.43. (9) Tositumomab Administration and Supply (APC 0442) For CY 2007, we proposed to assign HCPCS code G3001 (Administration and supply of tositumomab, 450 mg) from New Technology APC 1522 (New Technology—Level XXII ($2000-$2500)) to clinical APC 0442 (Dosimetric Drug Administration), which had a proposed median cost of $1,515.80. *Comment:*
                         Several commenters, including a pharmaceutical company, expressed concern with the CMS proposal to assign HCPCS code G3001 from New Technology APC 1522 with a payment rate of $2,250 to clinical APC 0442. The commenters were concerned that the payment rate of $1,510.52 that was proposed for APC 0442 would not adequately cover both the cost of the product and the administration of the product itself since the WAC for the tositumomab product was approximately $2,189. They requested that CMS maintain the current payment rate for G3001 of $2,250 for CY 2007. Furthermore, one commenter recommended that HCPCS code G3001, currently applicable to both doses of the non-radioactive component of therapy and its administration, be amended to apply only to the unlabeled tositumomab product. The commenter urged CMS to assign a specific code that describes the unlabeled tositumomab to enable appropriate payment for the product. The commenter added that unlabeled tositumomab alone is only FDA approved as part of the overall BEXXAR therapeutic regimen, and therefore cannot be used other than as part of BEXXAR therapy. The commenter also recommended CMS permit hospitals to use a CPT code for the 1-hour administration of the nonradioactive component of BEXXAR. *Response:*
                         We first established G3001 in CY 2003. As we stated in the CY 2004 OPPS final rule with comment period (68 FR 63443), unlabeled tositumomab is not approved as either a drug or a radiopharmaceutical, but it is a supply that is required as part of the BEXXAR treatment regimen. We do not make separate payment for supplies used in services provided under the OPPS. Payments for necessary supplies are packaged into payments for the separately payable services provided by the hospital. Administration of unlabeled tositumomab is a complete service that qualifies for separate payment under its own APC. This complete service is currently described by HCPCS code G3001. Therefore, we do not agree with the commenter's recommendation that we assign a separate code to the supply of unlabeled tositumomab, which would not then receive separate payment. Rather, we will continue to make separate payment for the administration of tositumomab through G3001, and payment for the supply of unlabeled tositumomab is packaged into the administration payment. Based on our CY 2005 claims data that show a final median cost of $1,367 for APC 0442, which contains only the service described by G3001, we had 148 single claims for the service. The median cost of G3001 from CY 2004 claims is $1,210 based on 69 single claims. We expect the annual volume of this service to Medicare beneficiaries to remain modest. By CY 2007, G3001 service will have been assigned to a New Technology APC for 3 years, providing two full years of claims data for our analysis. We believe that the final CY 2007 median cost of APC 0442 accurately reflects the hospital resources required to perform the administration and supply of tositumomab service, and that our data are sufficient at this point to support movement of G3001 out of a New Technology APC and into an appropriate clinical APC for CY 2007. Consequently, we are finalizing the proposed CY 2007 reassignment of HCPCS code G3001 from New Technology APC 1522 to clinical APC 0442, without modification. (10) Summary of Other New Technology Procedures Assigned to Clinical APCs for CY 2007 After carefully considering all of the public comments received, we are adopting our proposal to reassign the new technology procedures to clinically appropriate APCs with modification to the final APC assignments for CPT codes 19296, 19297, 20982, 36566, and 78804 as shown in Table 10 below. 
 
  D. APC-Specific Policies 1. Radiology Procedures a. Radiology Procedures (APCs 0333, 0662, and Other Imaging APCs) At its March 2006 meeting, the APC Panel made three recommendations regarding radiology services. These included the following: Reaffirmed 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 the OPPS payment rates for imaging services.
                    Recommended 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.
                    Recommended 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, in their CCRs and the median costs for the procedures. As noted in the CY 2007 OPPS proposed rule (71 FR 49567), 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 support continued deferral for CY 2007 of implementation of a multiple imaging procedure payment reduction policy in the OPPS. Therefore, we accepted 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 rates to further refine these rates in the context of additional study findings. We received numerous public comments concerning our proposal. A summary of the comments and responses follow: *Comment:*
                         Numerous commenters supported the CMS proposal to defer implementing a multiple imaging 
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                        procedure payment reduction policy in the OPPS for CY 2007. A number of commenters reiterated that CMS should never implement such a policy in the OPPS, based on the inherent characteristics of the standard methodology that is used to establish OPPS payment rates that already captures the efficiencies of these multiple services in the CCRs used to convert charges to costs on hospital claims. They argued that such discounting is not needed and unwarranted, because discounting has already been considered in setting the APC weights. *Response:*
                         We continue to be concerned about making appropriate payments for imaging services in the common circumstances where multiple procedures using the same imaging modality are provided in the same encounter. We will continue to study our single and multiple outpatient hospital claims for diagnostic imaging procedures and consider refinements to our payment rates for these services if results from the analyses suggest that changes to our payment policies would provide more accurate payments for these services. After carefully considering the public comments received, we are adopting our proposal to defer implementation of a multiple imaging procedure payment reduction for CY 2007, without modification. As indicated in the CY 2007 OPPS proposed rule (71 FR 49568), we also accepted the APC Panel's recommendation to review the CY 2007 proposed payment rates for CT and CTA procedures to ensure that their rates were 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 were similar to those for CT procedures that included scans without contrast followed by scans with contrast, but additional resources were required for the 3-dimensional reconstruction that was part of the CTA procedures. As a result of this image postprocessing, CTA scans displayed the vasculature in a 3-dimensional format rather than in the 2-dimensional cross-sectional images of conventional CT scans. As indicated in our CY 2007 proposed rule (71 FR 49568), based upon CY 2005 claims data, the CY 2007 proposed median cost for APC 0333 for CT procedures that included scans without contrast material, followed by contrast scans to complete the studies was $309, and the CY 2007 proposed median cost for APC 0662 for CTA procedures was $304. As has been the case for the past several years, the proposed median costs associated with these two APCs were virtually identical to one another and were also quite consistent with their historical costs from prior years of claims data. The CY 2007 proposed median costs for APCs 0333 and 0662 were 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, was consistent with our belief that the median costs of these APCs accurately reflected 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 provided no evidence that Medicare beneficiaries were experiencing difficulty accessing these services in the hospital outpatient setting. CTA procedures were 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 were very similar to the hospital costs of the more involved and resource-intensive complex CT services that, like CTA procedures, included scans without contrast material, followed by scans with contrast. Thus, we indicated in the CY 2007 proposed rule that we believed that our CY 2007 proposed payment rates for CT and CTA procedures were generally consistent with one another and accurately reflective of hospitals' resource costs. We received several comments concerning our proposal. A summary of the comments and our responses follows: *Comment:*
                         Several comments on our proposed payment rate of $302.85 for the CTA procedures placed in APC 0662 (CT Angiography) indicated that the CTA procedures were reimbursed at a lower rate than conventional CT procedures, although the utilization costs of CTA exceeded conventional CT. The commenters urged CMS to set the payment for APC 0662 at a rate equal to the sum of APC 0333 (Computerized Axial Tomography and Computerized Angiography without Contrast followed by Contrast), which had a proposed payment rate of $307.88, and the postprocessing APC, specifically, APC 0282 (Miscellaneous Computerized Axial Tomography), which had a proposed payment rate of $95.72. Alternatively, the commenters suggested that CMS reassign the CTA procedures from APC 0662 to an existing APC that more closely reflected the resource costs of performing the procedures. *Response:*
                         While we acknowledge the commenters' concerns, we believe that our claims data accurately reflect the resource costs associated with providing the CTA services. As we stated in the November 15, 2004 final rule with comment period (69 FR 65722) and further reiterated in the November 10, 2005 final rule with comment period (70 FR 68597), accurate cost information about the costs of image reconstruction for CTA specifically, and for CT alone as utilized with CTA, would be required in order to implement one commenter's suggestion that we make the payment rate for CTA (APC 0662) equal to the sum of the rates for CT alone (APC 0333) plus image reconstruction (APC 0282). However, such cost information is still not available. We have had several years of robust claims data for CTA procedures, whose code descriptors by definition include the required CT scans and image postprocessing, and have no reason to doubt these data. Based on the full year of CY 2005 data, we note that the median cost of $295.80 for APC 0333 (CT) is almost equal to the median cost of $296.70 for APC 0662 (CTA). Moreover, for specific reasons cited in the CY 2006 OPPS final rule (70 FR 68599), we are not reassigning the CTA procedures to any other clinical APC(s) for CY 2007. We believe that APC 0662 is quite homogeneous and see no other clinical APC where these services could be appropriately assigned based on clinical and resource considerations. We will apply the same standard OPPS ratesetting methodology for CY 2007 that we used for CY 2006 in establishing the payment rate for CTA procedures residing in APC 0662. After carefully considering the public comments received, we are finalizing our proposal for payment of APCs 0333 and 0662 based on their median costs established according to the standard OPPS methodology, without modification. With respect to the APC Panel's recommendation regarding the reporting of costs and charges for radiology services, as we noted in the proposed rule, 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 
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                        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, in the CY 2007 proposed rule, we indicated that we believed 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 was not clear that the marginal improvement in precision created by such a requirement would justify the additional administrative burden. We believed that the current hospital practice of matching costs to the general intended meaning of a cost center ensures that most services in the cost center would be comparable across providers, even if the precise composition of a cost center among hospitals differed. 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 CCRs 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 accepted the APC Panel's recommendation and specifically invited 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. We received a number of public comments concerning this APC Panel recommendation. A summary of the comments and our responses follows: *Comment:*
                         Several commenters agreed that any steps taken to ensure greater uniformity in the reporting of costs and charges would have to carefully balance the additional administrative burden and loss of flexibility in hospitals' accounting practices. They noted that the difficulty in applying CCRs to arrive at hospital costs is that this requires assumptions of consistency in the relationship of HCPCS codes and revenue codes to revenue center service categories on the cost report. However, the cost report recognizes service categories that reflect the general descriptions of a hospital's service categories, but services that were at one time performed in a specific department of the hospital may now be performed in many departments of hospitals. The commenters noted that inconsistencies occur when determining the cost of a service if the CCR utilized in the calculation is from a different cost report service category than where the service was actually performed. The commenters also urged CMS to recognize the limitations and inconsistencies in the preparation of hospital cost reports, attributable to both hospital and fiscal intermediary behavior. They urged CMS to proceed with care in instructing hospitals because hospitals need the flexibility to set charges and allocate costs in a manner that makes the most sense for the particular hospital based on the mix of services it provides. The commenters noted that even small changes in practice and procedures require significant systems changes, and that CMS should allow time for dissemination of any such changes, coupled with significant provider education. *Response:*
                         We appreciate the commenters' observations. We will continue to reflect on the delicate balance between greater accuracy in developing CCRs to convert charges to costs under the OPPS and the needs of hospitals for flexibility in their accounting practices. After carefully considering the public comments received, we will continue to seek input on this balance as we work on refining the OPPS payment system to pay more accurately for outpatient hospital services. For CY 2007, we did not propose to make any changes from CY 2006 in our proposed APC assignments of CT, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) services, preserving the longstanding APC groupings of these services. In particular, CT services were assigned to APCs 0332 (Computed Tomography without Contrast), 0283 (Computed Tomography with Contrast Material), and 0333 (Computed Tomography without contrast followed by Contrast) based upon their nature as studies without contrast, with contrast, and without contrast followed by contrast, respectively. MRI and MRA procedures were assigned to APCs 0336 (Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast), 0284 (Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast), and 0337 (Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast) based upon their characteristics as studies without contrast, with contrast, and without contrast followed by contrast, respectively. *Comment:*
                         One commenter requested that CMS revise the established CT, MRI, and MRA APC groupings to create greater internal clinical and resource consistency. The commenter believed that diagnostic services performed in the same anatomical region have similar resource utilization and should, therefore, be assigned to the same APC grouping. The commenter recommended that CMS differentiate among these services based on two body regions, the core (including the head, neck, thorax, spine, chest, abdomen, and pelvis) and the extremities (including the orbit/ear/fossa, maxillofacial region, upper extremity, and lower extremity). The commenter argued that because the OPPS was being used as the benchmark established by the DRA to limit payment for imaging services under the MPFS, this refinement would assist in ensuring even greater resource similarity of procedures within imaging APCs to establish more accurate payment rates under both the OPPS and the MPFS. *Response:*
                         We examined the current APC structure for CT, MRI, and MRA services and observed that there were no violations of the 2 times rule in any of the APCs. The median costs of the services assigned to each APC were relatively close, and we did not identify any code-specific patterns of significantly increased or decreased 
                        ( print page 68038)
                        costs based on the specific anatomical region of the body imaged. We believe these APCs as currently structured contain services that are quite homogeneous with respect to their clinical and resource characteristics. The OPPS provides payments for APC groups of closely related procedures, and the current imaging groups provide appropriate payments for these services in a manner that is consistent with the payment policies of the OPPS. Accordingly, we see no reason to further distinguish CT, MRI, and MRA procedures into even smaller, more refined groupings. We also do not believe it would be appropriate to adjust these APC groups in order to affect the payments for CT, MRI, and MRA procedures under the MPFS. After carefully considering the public comment received, we are finalizing our CY 2007 proposal for payment of CT, MRI, and MRA procedures, without modification. b. Computerized Reconstruction (APC 0417) We proposed to assign HCPCS code G0288 (Reconstruction, computed tomographic angiography of aorta for surgical planning for vascular surgery) to APC 0417 (Computerized Reconstruction) for CY 2007, with a proposed median cost of $192.34. This was the same APC assignment as CY 2006, and this service is the only service assigned to the APC. *Comment:*
                         One commenter strongly opposed the proposed payment amount for CY 2007 for HCPCS code G0288. The commenter stated that the OPPS proposed payment amount was not nearly enough to cover the hospital's costs for providing this important service. The commenter believed that implementation of the proposed payment would jeopardize the quality of the HCPCS code G0288 procedures that are performed, limit beneficiary access to the services, and result in postoperative complications due to implantation of poorly fitting stents. *Response:*
                         The payment amount proposed for the APC 0417, to which HCPCS code G0288 is the only service assigned, is based on the median cost from 6,028 single claims for this one service. We are confident that these data provide an accurate representation of hospital costs for providing the service. We note that despite reductions in payment rates over the last several years, the number of total procedures billed under the OPPS for HCPCS code G0288 has risen steadily from 2,065 in CY 2002, to 4,733 in CY 2003, to 8,421 in CY 2004, and most recently to 9,395 in CY 2005. We have no evidence that Medicare beneficiaries are having trouble accessing this service based on our hospital claims information. We believe that it is appropriate for us to use our historical hospital cost data as the basis for the CY 2007 payment amount. Therefore, we are finalizing our CY 2007 payment rate for APC 0417 based on a median cost of $197.95. c. Cardiac Computed Tomography and Computed Tomographic Angiography (APCs 0282, 0376, 0377, and 0398) In Addendum B of the CY 2007 proposed rule (71 FR 49832), we proposed to assign the eight cardiac computed tomography (CCT) and computed tomographic angiography (CCTA) Category III CPT codes to the APCs as shown in Table 11 below. These services were new for CY 2006, and we did not propose any changes to their APC assignments for CY 2007. Table 11.—Proposed CY 2007 APC Assignments for CCT and CCTA Category III CPT Codes
CPT code
Descriptor
Proposed CY 2007 APC assignment
Proposed CY 2007 APC assignment payment rate0144T
CT heart wo dye; qual calc
0398
$261.660145T
CT heart w/wo dye funct
0376
306.340146T
CCTA w/wo dye
0376
306.640147T
CCTA w/wo, quan calcium
0376
306.340148T
CCTA w/wo, strxr
0377
415.120149T
CCTA w/wo, strxr quan calcium
0377
415.120150T
CCTA w/wo, disease strxr
0398
261.660151T
CT heart funct add-on
0282
95.72
 *Comment:*
                         Several commenters requested that CMS remove the APC assignments for the eight CCT and CCTA procedures because these codes fall within the Category III CPT code section, and because they are carrier-priced and not assigned any relative value units under the MPFS. The commenters believed that the Deficit Reduction Act MPFS provisions should not apply to these procedures. *Response:*
                         As we stated in a section III.A.2. of this CY 2007 OPPS final rule with comment period, we implement Category III codes that are released by the AMA in July of a given year for implementation in January of the next year by providing them with new interim assignments in the OPPS final rule for the next update year. These CCT and CCTA codes were released in July 2005 for implementation in January 2006. We received no public comments on their interim final APC assignments published in Addendum B of the CY 2006 OPPS final rule with comment period. As we indicated in our CY 2007 OPPS proposed rule (71 FR 49549), some 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 to one of several nonseparately payable status indicators, including “N,” “C,” “B,” or “E,” which we believe is appropriate for the specific code. We believe that CCT and CCTA procedures are appropriate for separate payment under the OPPS should local contractors provide coverage for these procedures, and, therefore, they warrant status indicator and APC assignments that would provide separate payment under the OPPS. MPFS concerns regarding payment limitations for these procedures are outside the scope of this final rule with comment period. *Comment:*
                         Many commenters expressed their appreciation of our recognition of the CPT codes as separately payable services under the OPPS; however, they believed that the CCTA Category III CPT codes (0144T 
                        ( print page 68039)
                        through 0151T) should be moved from APCs 0282, 0376, 0377, and 0398, to appropriate New Technology APCs so that adequate hospital claims data could be gathered. They provided specific recommendations for the New Technology APC assignments of these services. These same commenters added that once CMS has acquired adequate claims data, pricing information could be used to separate and incorporate the various Category III CCTA CPT codes into clinical APCs. Some commenters were also concerned that CCT and CCTA procedures were not clinically homogeneous with other procedures currently assigned to APCs 0282, 0376, 0377, and 0398, noting that the last three APCs previously contained only nuclear medicine cardiac imaging procedures. *Response:*
                         We appreciate the suggestions submitted by the commenters. However, as we indicated above, 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. In the case of these eight CCT and CCTA procedures, we believe that their clinical characteristics and resource use are similar to the other procedures assigned to APCs 0282, 0376, 0377, and 0398. We have not limited APCs 0376, 0377, and 0398 solely to nuclear medicine cardiac imaging services. We believe that cardiac imaging services using different modalities may be appropriate for assignment to the same clinical APCs, based on their clinical and resource characteristics. The OPPS is a prospective payment system that provides payment for services based on their assignment to APC groups, and, as such, we think the proposed APC assignments for these CCT and CCTA services, which are the same as their CY 2006 interim final assignments, are appropriate. While we understand that use of CCT and CCTA to image the heart are relatively new applications of specifically refined technology, cardiac imaging using other modalities is already well-established, as is the noncardiac use of CT and CTA. Therefore, for CY 2007, we are continuing with our proposal to assign Category III CPT codes 0144T through 0151T to clinical APCs 0282, 0376, 0377, and 0398. We expect to have claims data for these procedures available for the CY 2008 OPPS update. After carefully considering the public comments received, we are finalizing our proposal without modification to assign CPT codes 0144T through 0151T to APCs 0282, 0376, 0377, and 0398, all with status indicator “S.” d. Radiologic Evaluation of Central Venous Access Device (APC 0340) For CY 2006, new CPT code 36598 (Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopic guidance) was assigned to APC 0340 (Minor Ancillary Procedures) on an interim final basis. The proposed assignment of the code for CY 2007 was unchanged. *Comment:*
                         One commenter requested that CMS assign new CPT code 36598 to APC 0263 (Level I Miscellaneous Radiology Procedures) for CY 2007. The commenter stated that the procedure reported by CPT code 36598 is very similar to that which is coded using CPT code 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation), which is assigned to APC 0263 for CY 2006. Further, the commenter stated that the use of contrast and fluoroscopy makes CPT code 36598 more resource intensive than the other procedures assigned to APC 0340, where CMS assigned it with an interim final status for CY 2006. *Response:*
                         We will not have data upon which to base our decisions about the APC assignment for this procedure until next year. However, based on our data for many procedures that we believe are similar to that coded by CPT code 36598, we believe that assignment to APC 0340 is appropriate and do not believe that it is appropriate to reassign it to another APC at this time. We are maintaining the assignment of CPT code 36598 to APC 0340 for CY 2007 and will reevaluate that assignment when data become available. 2. Nuclear Medicine and Radiation Oncology Procedures a. Myocardial Positron Emission Tomography (PET) Scans (APC 0307) 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 78492 (Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress), 78459 (Myocardial imaging, positron emission tomography (PET), metabolic evaluation), and 78491 (Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress) under the OPPS. Public comments on 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 (Myocardial Positron Emission Tomography (PET) Imaging) with a payment rate of $2,484.88. Analysis of the CY 2005 claims data for myocardial PET scans for the CY 2007 proposed rule revealed that the APC median costs for the single and multiple myocardial PET codes were $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 of a single CPT code for multiple studies (CPT code 78492), 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 
                        ( print page 68040)
                        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 suggested that the median appropriately captured the greater variability in relative hospital costs for multiple myocardial PET studies in the CY 2005 claims data. Based on these claims data, we believe that it is apparent that the use of myocardial PET scan technology had become more widely prevalent in hospitals, and as a result, we had more data to support our proposed payment rates. We believed 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 1,600 single claims, for both the single and multiple scans, were reflective of the hospital resources required to provide the services to Medicare beneficiaries in the outpatient hospital setting. Based on those data, we concluded in the CY 2007 proposed rule that the differential median costs of the single and multiple study procedures did not support the two-level APC payment structure. Although we acknowledged that some individuals 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, we noted that our data did 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, we believed that it was possible that most hospitals performing multiple PET scans were particularly efficient in their delivery of higher volumes of these services and, therefore, incurred hospital costs that were similar to those of single scans, which were provided less commonly. In fact, the CPT code for multiple scans had a lower median cost than either of the CPT codes for single procedures. When all myocardial PET scan procedure codes were combined into a single clinical APC, as they were prior to CY 2006, the CY 2007 proposed rule APC median cost for myocardial PET services was about $727, very similar to the $703 median cost of their single CY 2005 clinical APC. Therefore, for CY 2007, we proposed to assign CPT codes 78459, 78491, and 78492 to a single APC, specifically, APC 0307. We believed that the assignment of these three CPT codes to APC 0307 was appropriate, as the CY 2005 claims data revealed that more hospitals were providing multiple myocardial PET scan services, most myocardial PET scans were multiple studies, and the hospital resource costs of single and multiple studies were similar. We believed that the proposed median cost appropriately reflected the hospital resources associated with providing myocardial PET scans to Medicare beneficiaries in cost-efficient settings. Further, we believed that the proposed rates were adequate to ensure appropriate access to these services for Medicare beneficiaries. We specifically invited 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 were displayed in Table 17 of the CY 2007 OPPS proposed rule (71 FR 49567). *Comment:*
                         A number of commenters requested that CMS not finalize our proposed APC assignments for CPT codes 78492, 78459, and 78491. The commenters stated that it is inappropriate to assign multiple scan procedures to the same APC with single scan procedures as we proposed, because CPT code 78492 requires more hospital resources than do CPT codes 78459 and 78491. The commenters stated that multiple scans require significantly greater hospital resources due to much longer scan times, and believed that our median cost data were seriously flawed. The commenters objected to the proposal to assign the multiple scan procedures to the same APC as the single scans because they believed the APC assignment creates a 2 times violation for APC 0306; the proposed payment for the multiple scan procedures decreases by 71 percent between CYs 2006 and 2007; if payment is allowed to decrease to the level proposed by CMS, beneficiary access to these important diagnostic procedures (CPT code 78492) will be seriously restricted; the Medicare program will have to spend more for diagnostic procedures such as cardiac catheterizations if hospitals cannot afford to offer the multiple scan myocardial PET procedures; and CMS does assign other cardiac nuclear medicine studies to separate APCs based on whether they are single or multiple. The commenters recommended that CMS retain the multiple scan procedures in a separate APC as in CY 2006, and that the payment rate decrease be dampened to mitigate the potential for underpayment, as we have in the past for device-dependent and blood product APCs. One commenter suggested that CMS dampen payment for the multiple scans APC by 15 percent each year for the next 2 to 3 years to moderate the large payment decrease for the multiple myocardial PET scans. *Response:*
                         We understand the commenters' objections to the median cost for the multiple myocardial PET scans, but see no reason to modify our proposal to assign them to the same APC with the single scans. We do not believe that our data are erroneous. Myocardial PET scans are not new procedures and the data across years, except for the CY 2004 claims data, have been relatively consistent with regard to median costs, while the frequency of multiple scans has been growing consistently. As described above, we explored many aspects of the CY 2005 claims data in an attempt to explain the decreased costs reported for the multiple scans and to assure ourselves and the public that the data were reliable. Our additional investigations included analyses of claims to determine whether they were submitted by only a few hospitals and whether any of the hospitals accounted for an unusually high number of the multiple scan claims or for unusually low costs. We also examined the claims in an attempt to detect whether there were differences in billing practices for the CPT code compared to the predecessor G-codes for multiple myocardial PET scans. There was no indication that the data are erroneous in any regard. Claims were submitted by at least 25 hospitals (compared to 17 in the CY 2004 claims data), and no hospital was responsible for a disproportionate number of claims (in contrast to what was found in the CY 2004 claims) or for unusually low costs. No systematic hospital coding irregularities were discovered. Further, the number of single claims for the multiple scan procedures increased from 872 in the proposed rule data to 983 in the final rule data and the median cost remained stable, increasing by only $5.00, still lower than the median cost for single scans. Our data do not support a resource differential that warrants assignment of the multiple myocardial scan procedures to an APC separate from the single scans. Single and multiple scan 
                        ( print page 68041)
                        procedures are closely related from a clinical perspective, and their hospital resources required, as reflected in our claims data, appear comparable in terms of cost. The 2 times violation for CY 2007 in APC 0307 results from the inclusion of limited data from one G-code for multiple scan procedures that was reported for the first 3 months of CY 2005. The median cost for that G-code is $1,840, based on 129 single claims. However, the code was deleted in CY 2005, and the median cost for the CPT code that replaced it is only $665, based on 983 single claims. We utilized the data from the predecessor G-code in developing the median cost for APC 0307 (where it would be likely to affect the APC median cost by raising it). The fact that data from a deleted code are responsible for the violation leads us to conclude that the violation is not significant. Therefore, based on clinical and resource homogeneity, we are excepting APC 0307 from the 2 times rule for CY 2007. By assigning the multiple and single scans to the same clinical APC for myocardial PET scans, we are maintaining the clinical and resource use homogeneity in APC 0307, where the APC payment will be slightly higher for the multiple scans than it would have been if we retained the multiple scans in a separate APC. Similarly, we do not believe that there is a basis for dampening the payment decrease for a separate multiple myocardial PET scan APC. Although we have adjusted payment amounts for device-dependent and blood product APCs in the past, as noted by the commenters, we generally have done so to moderate the effects on payment resulting from inaccurate claims data that failed to fully capture the costs associated with the procedures in ways that we could partially identify. In some of these situations, we had very few single claims, contributing to the problem of unstable payment rates, but myocardial PET scans have significant numbers of single claims. We have examined the claims data thoroughly and found nothing to indicate inaccuracy for myocardial PET scans. To the contrary, with the exception of the CY 2004 claims data, we found that costs from the CY 2005 claims are relatively consistent with costs calculated from claims for myocardial PET scans provided in years before CY 2004. We believe that our CY 2006 APC assignments for multiple and single myocardial PET scans to separate APCs were based on data that were unduly affected by one hospital's unusually high charges for multiple scans. Without evidence that the claims data for CPT codes 78459, 78491, and 78492 are too flawed to use as a basis for setting weights, we believe it is prudent to establish the CY 2007 payment rate for APC 0307 using the standard OPPS methodology for developing payment rates. After carefully considering the public comments received, we are finalizing the APC assignments for the myocardial PET procedures as shown in Table 12 below without modification. Table 12.—CY 2007 APC Assignment for Myocardial PET
HCPCS code
Short descriptor
CY 2007 
                                 SI
CY 2007 APC
CY 2007 
                                 median cost
CY 2007 
                                 Final APC  
                                 307 median cost78459
Heart muscle imaging (PET)
S
0307
$784.42
$726.9878491
Heart image (pet), single
S
0307
1,014.61
726.9878492
Heart image (pet), multiple
S
0307
665.42
726.98
 b. Complex Interstitial Radiation Source Application (APC 0651) 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 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) were displayed in Table 14 of the CY 2007 OPPS proposed rule (71 FR 49564), and are reproduced below in Table 13. 
 
  We have frequently been informed 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 informed 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 have been advised 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 have been 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 contained 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. The presenters also urged CMS to provide hospitals with 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's resources required for the interstitial source application procedure. The presenters believed that these claims should be excluded from use in establishing the median cost for APC 0651. They believed that hospitals that reported the brachytherapy sources on their claims were more likely to report complete charges for the associated brachytherapy procedure than hospitals that did 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, the 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 explicitly analyzed the standard OPPS methodology that we used in determining our CY 2007 proposed payment rate for APC 0651 in the context of alternative multiple bill methodologies. 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. As stated in the CY 2007 OPPS proposed rule, we will consider the input of any individual or organization to the extent allowed by Federal law, including the Administrative Procedure Act (APA) 
                        ( print page 68043)
                        and the Federal Advisory Committee Act (FACA) (71 FR 49564). 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 the CY 2007 OPPS proposed rule, we developed a median cost for APC 0651 using single procedure claims and the general OPPS methodology, but we also looked at multiple procedure claims that contained the most common combinations of codes used with APC 0651. In the proposed rule, our single procedure claims process using CY 2005 data resulted in using 1,123 claims to calculate a proposed median cost of $1,028.93 for APC 0651. We added CPT code 76965, a CPT code for ultrasound guidance that commonly appeared on claims for complex interstitial brachytherapy, to the bypass list for CY 2007 after close clinical review because we believed that it would typically have little associated packaging. We believed that this change, along with maintenance of CPT code 77290 for complex therapeutic radiology simulation-aided field setting on the bypass list, was responsible for the growth in single procedure claims from the 381 single bills upon which the final APC 0651 median cost was calculated for CY 2006. However, only 6 of these 1,123 single and “pseudo” single claims data used in calculating the proposed median cost also included brachytherapy sources used in complex interstitial brachytherapy source application, and the median cost for these 6 claims at $600.68 was significantly less than the median cost for all single claims. It was unclear why so many of these claims did not contain brachytherapy sources, which were separately paid at cost in CY 2005. Because we proposed to pay separately for brachytherapy sources again for CY 2007, we saw no reason to believe that these few claims for brachytherapy services that included sources, which also did not report CPT code 55859 for placement of needles or catheters into the prostate, were more correctly coded than those claims that did not separately report brachytherapy sources. We believed it was 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 55859 and 77778 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 published in the CY 2007 OPPS proposed rule (71 FR 49565) and shown below as Table 14-A and Table 14-B for the results of this investigation. In the proposed rule, 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 in the proposed rule's data contained any combination of the three ancillary codes (76000, 76965, or 77290). Table 14-A shows the results of bypassing and packaging the line-item costs of the three ancillary procedures based on the data used to construct the proposed rule. Table 14-A.—Multiple Procedure Claims Including CPT Codes 55859 and 77778 Proposed Rule Data
Frequency
Minimum cost
Maximum cost
Mean cost
Median costAncillary Codes Packaged
7180 (1 lost to trimming)
$828.46
$11,202.81
$3,326.50
$3,062.99Ancillary Codes Bypassed
7181
811.95
11,203.81
3,300.16
3,030.01
 We found 9,791 multiple procedure claims in the proposed rule's data 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 three ancillary codes. Table 14-B shows the results of bypassing and packaging the line-item costs of the three ancillary procedures, using the proposed rule's data. Table 14-B.—Multiple Procedure Claims Including CPT codes 55859 and 77778 and One or More Brachytherapy Sources—Proposed Rule Data
Frequency
Minimum 
                                 cost
Maximum 
                                 cost
Mean 
                                 cost
Median 
                                 costAncillary Codes Packaged
6,748
$890.56
$10,224.17
$3,240.13
$3,026.62Ancillary Codes Bypassed
6,748
$912.81
$10,307.37
$3,215.75
$2,992.60
 We found that the claims containing CPT codes 55859 and 77778 and any combination of the three identified ancillary codes had mean and median costs that were 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 led us to conclude that the presence of sources on the claim did not make a significant difference in the median cost of the combined service. Moreover, when we calculated the total median cost from single bills for the APCs for the two major procedures codes from the proposed rule's data 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 
                        ( print page 68044)
                        0651 and APC 0163 was $3,197.07, which was greater than the combination medians, even when the three ancillary services were 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, as indicated in the CY 2007 OPPS proposed rule (71 FR 49565), we believed 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 proposed 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 recognized that prostate brachytherapy was not the sole use of CPT code 77778, although it was 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. As we noted in the proposed rule, this clinically driven variability in the claims data was difficult to assess without adding additional levels of complexity to the issue by considering diagnoses in establishing payments rates. However, recognizing that a prospective payment system is a system based on averages and, to the extent that claims for all types of complex interstitial brachytherapy source application were included in the body of claims used to set the median cost for APC 0651, we believed that the payment for these services as proposed for CY 2007 was appropriate. We received several public comments concerning our proposal. A summary of the comments and our responses follow: *Comment:*
                         The commenters generally supported the proposed median cost for APC 0651. One commenter encouraged CMS to consider calculating a packaged combination median cost for both CPT codes 55859 and 77778 and splitting the cost between the two codes, should the median cost for APC 0651 drop by a significant percent in future years as it has sometimes done in the past. *Response:*
                         The median cost for APC 0651 calculated using CY 2005 claims data as updated for this final rule with comment period is $1,029.47, virtually the same as the proposed rule median cost of $1,028.93. Together with the median cost for APC 0163 of $2,134.32, and separate payment for each source applied (section VII. of this preamble), we believe that the OPPS will make appropriate payment for brachytherapy services in CY 2007. After carefully considering the public comments received, we are finalizing our proposal to develop a median cost for APC 0651 using single procedure claims and the general OPPS methodology as discussed above without modification. c. Proton Beam Therapy (APCs 0664 and 0667) For CY 2007, we proposed to pay for the following four CPT codes that describe proton beam therapy: 77520 (Proton treatment delivery; simple, without compensation), 77522 (Proton treatment delivery; simple, with compensation), 77523 (Proton treatment delivery; intermediate), and 77525 (Proton treatment delivery; complex). We proposed to assign the simple proton beam therapy procedures to APC 0664 (Level I Proton Beam Radiation Therapy), with a proposed median cost of $1,141, and the intermediate and complex proton beam therapy procedures to APC 0667 (Level II Proton Beam Radiation Therapy), with a proposed median cost of $1,365. These proposed assignments were unchanged from CY 2006. The proposed payment rates for proton beam therapy were based on CY 2005 claims data and showed an increase of about 20 percent over the CY 2006 payment rates. *Comment:*
                         Several commenters supported our CY 2007 proposed APC assignments and payment rates for proton beam therapy. The commenters also supported our proposing APC 0664 as an exception to the 2 times rule for CY 2007. They were generally concerned about the payment for the same services furnished in freestanding proton therapy centers located in several States because the OPPS payment rates were very different from the carrier-priced payments for these services. The commenters requested that CMS establish consistent payments for these services under the OPPS and the MPFS because the significant capital costs required to provide proton beam therapy treatments do not vary across delivery settings. *Response:*
                         We appreciate the commenters' support for our CY 2007 OPPS proposed payment rates for proton therapy. We note that the OPPS payment rates for these services have increased significantly over the past several years, although we understand that there are only a small number of active hospital-based centers providing proton therapy. In addition, this is the second year in which we have exempted APC 0664 from its violation of the 2 times rule. We also observe that the payment rates for the two proton therapy APCs are quite close for CY 2007, with only a small differential between Levels I and II of therapy. As such, we will continue to monitor our claims data for proton beam therapy in the future to assess the appropriateness of the current APC structure. We are generally concerned about APCs that chronically violate the 2 times rule, especially when those APCs contain few services and we have no specific data concerns regarding the services assigned to them. With respect to the commenters' request regarding consistent payment for proton therapy under the MPFS and the OPPS, we note the MPFS and the OPPS are completely separate payment systems, whose rates are established based on different methodologies. After careful consideration of the public comments received, we are finalizing without modification our CY 2007 proposal to provide payment for proton beam therapy through APCs 0664 and 0667, with their payment rates based on the final APC median costs of $1,154 and $1,381, respectively. d. Urinary Bladder Residual Study (APC 0340) At its February 2005 meeting, the APC Panel recommended that we move CPT code 78730 (Urinary bladder residual study) from APC 0340 (Minor Ancillary Procedures) to APC 0404 (Level I Renal and Genitourinary Studies) for CY 2006, because the Panel believed that the CY 2003 data for CPT code 78730 may have been derived from incorrectly coded hospital claims. Based on reasons discussed in detail in the CY 2006 OPPS final rule with comment period (70 FR 68602), we maintained the assignment of CPT code 78730 in APC 0340 for CY 2006. For CY 2007, we proposed assignment of CPT code 78370 to APC 0340 once again. *Comment:*
                         Several commenters requested that CMS move CPT code 78730 from APC 0340 to APC 0399 (Nuclear Medicine Add-on Imaging). Some commenters indicated that in CY 2005 they disagreed with our APC assignment of APC 0340 for CPT code 78730. One commenter added that the data for CPT code 78730 may have been derived from incorrectly coded hospital claims. The commenters indicated that the CPT Editorial Panel would be revising the service's code descriptor for CY 2007 to more specifically indicate the performance of a nuclear medicine procedure. 
                        ( print page 68045) *Response:*
                         In the November 15, 2004 final rule with comment period (69 FR 65705), we stated that CPT code 78730 was originally created and valued for the MPFS as a procedure requiring the services of a nuclear medicine technician, but that the use of the code subsequently had changed to be used primarily by urologists rather than by nuclear medicine physicians. While we reassigned CPT code 78730 to APC 0340 for CY 2005 based on robust CY 2003 claims data, we solicited other physician specialties to submit resource data for us to review in the context of our hospital claims data so that we could reexamine the appropriate APC placement of CPT code 78730 for CY 2006. While we acknowledge the commenters' repeated concern that the median cost for CPT code 78730 may reflect miscoded claims, commenters again provided no supporting evidence for either CY 2006 or CY 2007 of what they believe to be the true resource costs associated with CPT code 78730. In fact, a relatively stable number of single procedure claims has generated a consistent median cost for CPT code 78730 over the past 5 years (that is, ranging from $39 based on the CY 2001 claims data to $42 based on the CY 2005 claims data) and supports our assignment of CPT code 78730 to APC 0340 with an APC median cost of $37, as opposed to APC 0399 with an APC median cost of $92. We are aware that the code descriptor and parenthetical language in the CPT manual for CPT code 78730 indicating other CPT codes to be reported for certain bladder studies will be modified for CY 2007. However, we do not know if these additional instructions will lead to differences in hospital reporting that result in a significant change in the procedure's cost. Therefore, we are maintaining CPT code 78730 in APC 0340 for CY 2007. After carefully considering the public comments received, we are finalizing our proposal to assign CPT code 78730 to APC 0340 for CY 2007, with a median cost of $37.29. e. Hyperthermia Treatment (APC 0314) We did not propose any APC assignment changes for CY 2007 for the CPT codes used to report hyperthermia treatments. The following five hyperthermia treatment CPT codes are the only codes that we proposed to assign to APC 0314 (Hyperthermic Therapies) for CY 2007: 77600 (Hyperthermia, externally generated; superficial); 77605 (Hyperthermia, externally generated; deep); 77610 (Hyperthermia, generated by interstitial probe(s); 5 or fewer interstitial applicators); 77615 (Hyperthermia, generated by interstitial probe(s) more than 5 interstitial applicators); and 77620 (Hyperthermia generated by intracavitary probe(s)). The CY 2007 proposed median cost for APC 0314 was $225.96. *Comment:*
                         Several commenters reported that the proposed APC 0314 CY 2007 payment rate was 32 percent less than the CY 2006 payment rate of $332.31 and suggested that the decrease was due to the use of inaccurate CMS claims data. The commenters believed that the flaws in the CMS claims data were due to a few factors: The variation in hospitals' cost allocation methodologies; CMS' use of hospital CCRs derived from those varying hospital allocation practices and which they reported varied dramatically (from 15 to 50 percent) across hospitals that provided hyperthermia therapies; and low utilization among the few hospitals that reported the services. Further, the commenters expressed an additional concern for one of the procedures, CPT code 77605, for which there were no claims in the CY 2005 data that CMS used for the CY 2007 median calculation proposal. The commenters added that in past years, the procedure had been one of the more frequently reported therapies, and they believed that having no cases in the claims data used to calculate the medians for APC 0314 was indicative of inaccurate data and also contributed to the inappropriately low proposed median cost. The commenters submitted some estimated hospital costs of hyperthermia treatment for five hospitals, and recommended three options that CMS could use to moderate the proposed CY 2007 payment decrease for APC 0314. The three options are as follows: That CMS could use external hospital survey data to establish a payment rate of $1,005 for APC 0314; that CMS could apply an average cost for CPT code 77605 using the medians calculated for CY 2004 through CY 2006 to establish a more appropriate payment amount for CY 2007; or that CMS could maintain the CY 2006 payment rate for CY 2007. *Response:*
                         In our analysis, we found that there were 55 claims reported for CPT code 77605 in the CY 2005 data, but that all were excluded from the data because they did not meet the criteria for use in calculating the median costs due to any number of factors. Included among the reasons for removing the claims for CPT 77605 from the CY 2005 data that were used to calculate median costs were that the reporting hospitals' claims were excluded because their CCRs were outside of the allowed range, or the reporting hospital was a CAH or an otherwise excluded hospital (as explained in section II. of this final rule with comment period). We exclude claims from the data to be used for calculation of median costs every year to ensure that the claims we use are accurate and valid representations of claims for the services. The method for identifying claims that meet the criteria for inclusion in the median cost development process for CY 2007 was performed similarly to the methodology applied for past OPPS updates and should not have had a disproportionate effect on hyperthermia procedures. As noted by the commenters, median costs for the hyperthermia procedures have been somewhat unstable across the years due to low volume and the small number of facilities reporting the procedures. For CY 2007, the decrease is more pronounced than changes in past years and we appreciate the providers' concerns. We note that these historical changes have served both to increase and decrease payments for the treatments over time. We agree with the commenters' observation about the relative median cost instability for these procedures and the probable reasons for that, but given that we do not observe specific inaccuracies in our claims data that are used in the standard OPPS methodology, it appears these fluctuations are in keeping with the historical charges. The median costs for the individual procedures assigned to APC 0314 vary from approximately $194 to $431. The median for the APC overall is significantly lower than the highest service-specific median because 195 of the 225 single claims for the APC are for CPT code 77600, which has a median cost of $194. In the past, CPT code 77605 has contributed a significant number of claims to the number of single claims in the APC and has also had a higher median than CPT 77600. Thus, the lack of claims for that procedure may have contributed to the lower APC median for CY 2007, but the median cost calculated for the APC is accurate and reflects costs for those services based upon the CY 2005 claims data that meet our criteria for use in calculating APC medians. We have no reason to doubt the accuracy of those data and, therefore, have no basis for diverging from the established method of calculating the median cost for APC 0314. For these reasons, we will not accept any of the options recommended to us by the commenters and are finalizing the CY 2007 payment rate for APC 0314 
                        ( print page 68046)
                        based on its median cost of $204, calculated using our CY 2005 claims data as proposed. f. Unlisted Procedure for Clinical Brachytherapy (APC 0312) For CY 2007, we proposed to move CPT code 77799 (Unlisted procedure, clinical brachytherapy) from APC 0313 (Brachytherapy) to APC 0312 (Radioelement Applications) for the CY 2007 OPPS. *Comment:*
                         Several commenters objected to the proposal to reassign CPT code 77799 from APC 0313 to APC 0312 for CY 2007. The commenters stated that APC 0312 is titled “Radioelement Applications,” while APC 0313 is titled “Brachytherapy,” and that it is in keeping with the intent of APC classification to group procedures that are similar in clinical characteristics and resource use. Therefore, the commenters believed that because APC 0313 was the lowest payment level brachytherapy APC, it would be most appropriate to continue to assign CPT code 77799 to APC 0313 with other brachytherapy procedures. *Response:*
                         We disagree. CPT code 77799 has no meaningful definition that would enable us to place it accurately in one brachytherapy APC versus another APC based on clinical homogeneity or resource considerations. While the APC title for APC 0312 does not contain the term brachytherapy explicitly, all of the procedures assigned to APC 0312 are from the section of the CPT manual called “Clinical Brachytherapy.” Furthermore, APC 0312, not APC 0313, is the lowest payment level brachytherapy procedure APC. In CY 2005, we finalized the OPPS policy of assigning all unlisted or “not otherwise classified” HCPCS codes to the lowest level APC that is appropriate to the clinical nature of the service (69 FR 65725). Therefore, we believe that our reassignment of CPT code 77799 to APC 0312 is appropriate. After carefully considering the public comments received, we are finalizing our CY 2007 proposal for the assignment of CPT code 77799 to APC 0312, without modification. 3. Cardiac and Vascular Procedures a. Electrophysiologic Recording/Mapping (APC 0087) 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 and 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 (Ablate Heart Dysrhythm Focus) 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 rule 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 agreed with the APC Panel's assessment and accepted this APC Panel recommendation. Therefore, we proposed that CPT codes 93609, 93613, and 93631 remain assigned to APC 0087 for CY 2007. We did not receive any public comments concerning our proposal. Therefore, we are adopting our CY 2007 proposal as final without modification. b. Endovenous Laser Ablation Procedures (APC 0092) We proposed to reassign CPT codes 36478 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous laser; first vein treated;) 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) from APC 0091 (Level II Vascular Ligation) for CY 2007 to APC 0092 (Level I Vascular Ligation), with a proposed median cost of $1,518.22 for CY 2007. *Comment:*
                         A few commenters requested that CMS retain CPT codes 36478 and 36479 in APC 0091 for CY 2007 instead of assigning them to APC 0092, as we proposed. The commenters believed that the percutaneous laser procedures should be assigned to the same APC as CPT codes 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated); and 36476 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites), because the hospital costs for both types of procedures are very similar. The proposed APC assignment for CPT codes 36475 and 36476 was to APC 0091. *Response:*
                         In our review of APCs for the CY 2007 proposed rule, we found that the procedures assigned to APCs 0091 and 0092 were appropriate clinically, but that the median costs within both of the APCs had become heterogeneous so there was not significant differentiation between the medians for the two levels of vascular APCs. In addition, CPT codes 36475 through 36479 were new in CY 2005 and, as such, their median costs were available to us for the first time in our development of the CY 2007 proposed rule. In order to remedy the heterogeneity within APCs 0091 and 0092, we reconfigured them to achieve greater differentiation between the median costs of the two APCs and to improve internal homogeneity. In that reconfiguration, CPT codes 36478 and 36479 were assigned to APC 0092, with other procedures with similar resource requirements. The median costs for CPT codes 36478 and 36479 are $1,521 and $1,241, respectively, and the median cost for APC 0092 is $1,520. There are more than 800 single claims for CPT code 36478, and we are confident that the data reflect hospital costs for the procedure. We believe that these procedures fit appropriately into the APC 0092. In contrast, CPT codes 36475 and 36476 were assigned to APC 0091, which has a median cost of $2,122. The median costs for those procedures are $2,295 and $3,017, respectively, and there are more than 900 single claims for CPT code 36475. Although the endovenous ablation procedures described by CPT codes 34675 through 36479 are clinically related, we do not believe that they belong in the same 
                        ( print page 68047)
                        APC. In this case, there exist separate APCs into which each procedure type is appropriately assigned to reflect more similar usage. The reconfiguration resulted in improved differentiation between the two APCs. For CY 2006, the difference between the APC median costs was only about $140. For CY 2007, that difference is about $600, and the internal homogeneity in each APC is improved. For these reasons we are finalizing our proposal to assign CPT codes 36478 and 36479 to APC 0092 for CY 2007. c. Repair/Repositioning of Defibrillator Leads (APC 0106) For CY 2007, we proposed to assign CPT code 33218 (Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator), and CPT code 33220 (Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator) to APC 0106 (Insertion/Replacement/Repair of Pacemaker and/or Electrodes), with a proposed median cost of $2,754.86. These procedures were both assigned to APC 0106 for CY 2006. *Comment:*
                         Several commenters asked CMS to reassign CPT codes 33218 and 33220 from APC 0106 to APC 0105 (Revision/Removal of Pacemakers, AICD, or Vascular Devices) because these two codes do not require a device like other codes in APC 0106 and their median costs are closer to the proposed median cost of APC 0105 of $1,449.44. *Response:*
                         We agree and have moved CPT codes 33218 and 33220 out of APC 0106 and into APC 0105 for CY 2007. The final rule median cost for APC 0106 is $3,596.86. After carefully considering the public comments received, we are finalizing our CY 2007 proposal with modification to reassign CPT codes 33218 and 33220 from APC 0106 to APC 0105. We also are modifying the titles of these APCs to reflect their new composition. APC 0106 is retitled “Insertion/Replacement of Pacemaker Leads and/or Electrodes.” APC 0105 is retitled “Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices.” The final median cost of APC 0106 is $3,596.87, and the final median cost of APC 0105 is $1,565.27. d. Thrombectomy Procedures (APCs 0103 and 0653) For CY 2006, new CPT codes 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel); 37187 (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injection(s) and fluoroscopic guidance); and 37188 (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injection(s) and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy) were provided interim final assignments to APC 0653 (Vascular Reconstruction/Fistula Repair with Device). New CPT codes 37185 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family) and 37186 (Secondary percutaneous transluminal thrombectomy (e.g., nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy) were provided interim final assignments to APC 0103 (Miscellaneous Vascular Procedures). The proposed assignments of these codes for CY 2007 were unchanged. *Comment:*
                         One commenter who addressed our CY 2006 APC assignments for CPT codes 37184, 37187, and 37188 believed that all of the new codes should have been assigned to APC 0088 (Thrombectomy). The commenter stated that the procedures reported by the new CPT codes were very similar to the procedures reported by CPT code 92973 (Percutaneous transluminal coronary thrombectomy), that was assigned to APC 0088 because they required the use of a costly mechanical thrombectomy catheter. The commenter stated that the procedures coded with CPT codes 37184 through 37188 also required the use of costly catheters and were clinically more similar to the other procedures assigned to APC 0088 than to those assigned to either APC 0103 or APC 0653. *Response:*
                         Although we will not have data for these procedures until next year, based on the information in the comment and our further review, we agree with the commenter that a more appropriate assignment for the procedures is APC 0088 for CY 2007. We believe the reassignments provide more accurate payment for these thrombectomy procedures. After careful consideration of the public comment received, we are finalizing our proposal for the APC assignments of CPT codes 37184, 37185, 37186, 37187, and 37188 with modification. All five procedures are assigned to APC 0088 for CY 2007. 4. Gastrointestinal and Genitourinary Procedures a. Insertion of Mesh or Other Prosthesis (APC 0195) During the March 2006 APC Panel meeting, a presenter requested that we 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 was 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 was subject to the multiple procedure discount because it was always a secondary procedure, and the discounted payment amount was 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. As stated in the CY 2007 OPPS proposed rule, in the CY 2005 claims data, the median cost for CPT code 57267 was $529.14, the lowest by far for procedures in APC 0154, which had a proposed APC median cost of $1,821 for CY 2007 (71 FR 49562). However, the proposed median cost of CPT code 57267 was based on only 6 single claims of the total 1,038 claims submitted for the service. Because the procedure always was performed in addition to other related procedures, we expected that claims for this service would be multiple claims. Therefore, we were not confident that the procedure's median 
                        ( print page 68048)
                        cost based upon the six single claims was accurate. Therefore, at the time of the proposed rule, 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 was a high volume procedure that also used 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 published in the CY 2007 OPPS proposed rule displayed the median costs from those claims (71 FR 49562). The costs shown in the column titled “Line-item Median Cost” of Table 13 were those we obtained by looking at all CY 2005 OPPS claims upon 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” were 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 supported the APC Panel presenter's assertion that the cost of the mesh was greater than 50 percent of the total cost of CPT code 57267, but it also indicated that the mesh cost was far less than 50 percent of the payment amount for APC 0154. In CY 2006, the payment rate for APC 0154 was $1,704.59, and the payment when the multiple procedure discount was taken was $852.30, which was much greater than both the line-item median cost of the mesh and the median single claims cost of CPT code 57267 (which explicitly included the implantable mesh) reflected in our claims data. We agreed with the APC Panel that the procedure should be assigned to a more clinically appropriate APC, and therefore, we proposed 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 was $1,777 for CY 2007, very comparable to the CY 2006 median cost of APC 0154, where CPT code 57267 was assigned for CY 2006. The median cost for the procedure remained very low in comparison with other procedures assigned to APC 0195; therefore, we believe that payment for the service when the multiple procedure reduction was applied would be appropriate. While not affecting the procedure's payment significantly, this reassignment improved the clinical homogeneity of APCs 0154 and 0195. *Comment:*
                         The commenters generally believed that CPT code 57267 should be assigned to APC 0202 (Level X Female Reproductive Procedures), which is a device-dependent APC and for which the proposed CY 2007 median cost is $2,534.46. They stated that the analyses that CMS performed for the proposed rule to identify costs for the procedure described by CPT code 57267 when billed with the HCPCS code C1781 for the mesh implant were incorrect because the mesh devices that are used in pelvic floor repair are best described by HCPCS codes C1762 (Connective tissue, human (includes fascia lata)) and C1763 (Connective tissue, non-human (includes synthetic)). One commenter provided data showing the costs of four procedures, including CPT codes 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele) and 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), when performed with and without the graft insertion procedure, CPT code 57267. Their data indicated that the median cost for CPT code 57267, including the device (C1762 or C1763), ranged from $946 to $1,465, and that, on average, the cost was $1,254. *Response:*
                         In response to the comments, we performed additional analyses of claims for CPT code 57267 that included the two types of mesh/connective tissues devices coded with HCPCS codes C1762 and C1763, as well as those with device code C1781 that we presented in the proposed rule. We analyzed all single and “pseudo” single claims and multiple claims for CPT code 57267 reported with one of the 3 device codes (C1762, C1763, and C1781) and examined the line-item cost for each of the three devices, based upon our belief that the cost of the add-on repair procedure was principally due to the device cost. The results of our study showed that the median line-item costs for device codes C1762 and C1763 on claims for the pelvic floor repair procedure were $810.72 and $503.71, respectively, compared to $352.20 for device code C1781. Although the commenters stated that the graft insertion procedure to repair the pelvic floor was performed using only the connective tissue products coded by device codes C1762 and C1763, there is no guidance with regard to use of the CPT code 57267 that specifically restricts the type of device that may be reported with that code. In the list of device category codes and their definitions posted on the CMS Web site, we indicate that device code C1781 is defined as, “A mesh implant or synthetic patch composed of absorbable or non-absorbable material that is used to repair hernias, support weakened or attenuated tissue, cover tissue defects, etc.” We also note in the definition that other device codes should be used for reporting connective tissue when used to treat urinary incontinence. There are far more CY 2005 claims for CPT code 57267 with device code C1781 than with either of the device codes presented by the commenters. Therefore, the CY 2005 claims data for the procedure are more reflective of the use of the mesh reported with device code C1718 than of the mesh the commenters believed was most often used. Table 15 displays the numbers of claims and the median costs found in our analyses. We continue to believe that assignment of CPT code 57267 to APC 0195 is appropriate and ensures adequate payment for the procedure, even when the multiple procedure discount is taken. Based on the typical cost of any one of the mesh/connective tissue devices that are used in the service, 50 percent of the payment for APC 0195, based on its CY 2007 median cost of $1742.20, should be appropriate. Assignment to APC 0202, with a median cost of $2,534.46, would result in overpayment for the procedures. 
                        ( print page 68049) Table 15.—Median Costs of HCPCS Codes C1762, C1763 and C1781 and 57267
HCPCS code
Short descriptor
CY 2005 
                                 frequency of total claims
CY 2005 
                                 line-item median costC1762 (billed with 57267)
Conn tiss, human (inc fascia)
22
$810.72C1763 (billed with 57267)
Conn tissue, non-human
55
503.71C1781 (billed with 49568)
Mesh (implantable)
175
352.20
 After carefully considering the public comments received, we are finalizing our proposal to reassign CPT code 57267 to APC 0195 without modification. b. Percutaneous Renal Cryoablation (APC 0423) During the March 2006 APC Panel meeting, a presenter requested that we reassign CPT code 0135T (Ablation renal tumor(s), unilateral, percutaneous, cryotherapy) from APC 0163 (Level IV Cystourethroscopy and other Genitourinary Procedures) 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 was where CPT code 47382 was assigned, and stated that the costs of the two procedures were very similar. Based on the information presented, the APC Panel recommended that we reassign CPT code 0135T from APC 0163 to APC 0423 for CY 2007. CPT code 0135T is new for CY 2006 and, therefore, we had no claims data upon which to base our APC assignment decision. The procedure currently has an interim assignment to APC 0163, with a CY 2006 payment amount of $1,999.35. In the CY 2007 OPPS proposed rule, we proposed to accept the APC Panel's recommendation to reassign CPT code 0135T to APC 0423 for CY 2007. We believed that assignment of CPT code 0135T to APC 0423 was clinically appropriate, and the CY 2007 proposed median cost of APC 0423 of $2,410.33 was reasonably close to our expectations regarding the resource requirements for the renal cryoablation procedure. The APC Panel did not discuss this procedure again at its August 2006 meeting, nor were there any public presentations on this issue at that meeting. *Comment:*
                         Several commenters approved of the proposed reassignment of CPT code 0135T from APC 0163 to APC 0423 for CY 2007 because this move placed the percutaneous cryoablation procedure with other similar procedures. However, the commenters were concerned that the payment rate for CPT code 0135T was inadequate and did not reflect the total cost incurred by hospitals in providing this service. The commenters also indicated that the payment rate for CPT code 0135T was not based on timely data or accurate hospital claims. The commenters believed that the proposed payment rate would not cover the costs of the expensive cryoablation probes used in performing the procedures. One commenter indicated that the average cost of one probe was about $1,000, and the average procedure used between 2.3 and 2.5 probes. Another commenter submitted copies of invoices showing the costs of the probes. The commenter urged CMS to reevaluate the payment for APC 0423, because an underpayment could result in hospitals not offering this procedure, thereby creating an access barrier for Medicare patients. Several commenters requested that CMS use all available data, including external data, to determine the appropriate payment rate for APC 0423. *Response:*
                         We reviewed the data for APC 0423, considered the comments, and examined all available information regarding the procedure described by CPT code 0135T, as well as other procedures that are separately payable under the OPPS and for which we have claims data. In addition, we reviewed the recommendation of the APC Panel from its March 2006 meeting that was based upon the request of a presenter. Based on our evaluation, we believe that we have appropriately assigned CPT code 0135T to APC 0423 for CY 2007 based on clinical and resource homogeneity considerations. Under the standard OPPS methodology, the APC payment rate is established based on CY 2005 claims data for those services for which there are data. One service also assigned to APC 0423 has significant claims volume, and its median costs have been stable over the past several years. The final median cost of APC 0423 upon which the payment rate for CPT code 0135T is based is $2,283.08. We believe that this payment will be sufficient to ensure access to this service for Medicare beneficiaries. *Comment:*
                         Several commenters acknowledged that cryoablation and radiofrequency percutaneous ablation procedures for renal tumors were clinically similar; however, there were major resource differences in the required equipment and the technology-specific probes. One commenter indicated that the radiofrequency ablation procedure involves the use of only one probe, while the cryoablation procedure requires, on average, 2.5 probes. *Response:*
                         We believe that CPT code 0135T is appropriately assigned to APC 0423 because it is placed with other procedures that share clinical and resource homogeneity. If hospitals use more than one probe in performing the renal cryoablation procedure, we expect hospitals to report this information on the claim and adjust their charges accordingly. Hospitals should report the number of cyroablation probes used to perform CPT code 0135T as the units of HCPCS code C2618 (Probe, cryoablation), which describes these devices, with their charges for the probes. Since CY 2005, we have required hospitals to report device HCPCS codes for all devices used in procedures if there are appropriate HCPCS codes available. In this way, we can be confident that hospitals have included charges on their claims for costly devices used in procedures when they submit claims for those procedures. *Comment:*
                         Several commenters indicated that in the CY 2007 OPPS proposed rule we acknowledged the lack of claims data to set the payment rate for the renal cryoablation procedure reported with CPT code 0135T. They believed that CMS should assign CPT code 0135T to a New Technology APC and base its payment on the actual cost of performing the procedure. One commenter reported that the renal cryoablation procedure was a relatively new procedure that had only rarely been performed in the outpatient setting. The commenter also noted that assigning CPT code 0135T to a New Technology 
                        ( print page 68050)
                        APC would allow CMS time to obtain meaningful outpatient cost information for the procedure, so that CMS could eventually place the procedure in an appropriate clinical APC. The commenter added that prior to January 1, 2006, there was no specific HCPCS code that accurately described the renal cryoablation procedure, and, as a result, the service was reported by those hospitals performing the procedure under the general unlisted CPT code 53899. Because of the use of the unlisted CPT code, the commenter indicated that it would be impossible to identify the historical hospital outpatient claims that were related to percutaneous renal cryotherapy. *Response:*
                         While we previously acknowledged the lack of claims data in setting the payment rate for CPT code 0135T, we have commonly assigned a new service or procedure without claims data to a clinical APC that we believed appropriately reflected the cost and clinical features of the procedure. We often have relevant information available to us based on claims data for other services historically paid under the OPPS, as well as data provided to us by the public. In the case of CPT code 0135T specifically, the APC Panel at its March 2006 meeting recommended that we reassign this code from APC 0163 to APC 0423 for CY 2007. Based on this recommendation and our comprehensive review of the procedures assigned to APC 0423, we believe that we have assigned the renal cryoablation procedure to an appropriate clinical APC, specifically APC 0423, which reflects clinical homogeneity and comparable resource costs among the procedures assigned to the APC for CY 2007. We note that we expect to have claims data for CPT code 0135T available for the CY 2008 OPPS update. After carefully considering all the public comments received, we are reassigning CPT code 0135T to APC 0423, as proposed, without modification. The final APC 0423 median cost is $2,283.08. c. Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance Guidance (MRgFUS) (APCs 0195 and 0202) We received many public comments concerning the APC assignments for HCPCS codes 0071T and 0072T. In the CY 2006 final rule we assigned magnetic resonance guided focused ultrasound ablation of uterine fibroids (MRgFUS) procedures, CPT codes 0071T and 0072T, to APCs 0195 (Level IX Female Reproductive Procedures) and 0202 (Level X Female Reproductive Procedures), respectively, for CY 2006. We made those reassignments in response to public comments to our proposed rule of July 25, 2005, in which we had proposed to assign the procedures to APC 0193 (Level V Female Reproductive Procedures) for CY 2006. These services had been assigned to APC 0193 since their implementation in the OPPS in CY 2005. We proposed no changes to their final CY 2006 assignments for CY 2007. *Comment:*
                         Although our assignments of the procedures were to separate, higher paying APCs for CY 2006 than their assignments for CY 2005, commenters on the CY 2007 proposed rule believed that the procedures' assignments still resulted in significant underpayment. The commenters asserted that while MRgFUS treats anatomical sites that are similar to other procedures assigned to APCs 0195 and 0202, the resources utilized differ dramatically. Further, they stated that treatment of uterine fibroids using the MRgFUS procedure is more cost effective for the Medicare program and for beneficiaries because the recovery time is shorter, and beneficiaries would be spared the need for hysterectomies. The commenters indicated that the most appropriate assignment for the MRgFUS procedures would be APC 0127 (Level IV Stereotactic Radiosurgery) based on their analyses of the procedures' resource use and clinical characteristics. The similarities between the two technologies that were presented by the commenters included their clinical indication to treat non-invasive tumors by using focused ionizing radiation (stereotactic radiosurgery) or acoustic waves (MRgFUS) to destroy the tumor tissue. Further, the commenters argued that the procedures require similar hospital resources: planning prior to treatment; specialized equipment housed in treatment rooms; continuous monitoring during treatment; and 120 to 300 minutes to perform the treatment. One commenter sent data that compared the hospital charges for three MRgFUS cases to those for five stereotactic radiosurgery (SRS) procedures. Those data showed charges for CPT code 0071T of $18,215 and for 0072T, $22,122 and $23,463, and for SRS, charges ranging from $21,360 to $28,790. In addition, many of the commenters reported that their hospitals charge between $18,000 and $24,000 for each MRgFUS treatment. *Response:*
                         As we stated in the November 10, 2005 final rule, we believe that MRgFUS treatment bears a significant relationship to technologies already in widespread use in hospitals, in particular magnetic resonance imaging (MRI) and ultrasound services. The use of focused ultrasound for thermal tissue ablation has been in development for decades, and the recent application of MRI to focused ultrasound therapy provides monitoring capabilities that may make the therapy more clinically useful. We believe that MRgFUS therapy is a new and integrated application of existing technologies (MRI and ultrasound) and that the technology used in this service fits as well into existing clinical APCs for female reproductive services, as do many other modalities that are currently assigned to those clinical groups. Retaining them in clinical APCs with other female reproductive procedures will enable us both to set accurate payment amounts and to maintain appropriate clinical homogeneity of the APCs. The similarity of the charges for MRgFUS and SRS as reflected in the examples provided by one commenter does not convince us that the level of hospital resources used to provide MRgFUS is the same as for SRS. APC assignments are made based on consideration of both hospital resources and clinical homogeneity. There are many OPPS claims with similar charges, but where the reported procedures have nothing in common with one another clinically. We do not assign those procedures to the same clinical APC. In our CY 2005 claims data, there are two claims for CPT code 0071T but none for CPT code 0072T and 3,346 claims for the single SRS service assigned to APC 0127. Those data show the median cost for SRS is $8,461 and the median cost for the two MRgFUS claims is $1,026. We realize the limited nature of the data from which to draw any conclusions about cost, but because treatment of uterine fibroids is most common among women younger than 65 years of age, we do not expect that there ever will be many Medicare claims for those procedures. Nevertheless, we do not see a compelling reason to except MRgFUS from our established policy to rely on our claims as the basis for weight-setting under the OPPS. Further, and in contrast with SRS, the MRI equipment used to provide the MRgFUS therapy can also be used to perform conventional MRI procedures and does not necessarily represent an additional capital expense for the hospital. Those costs should be allocated accordingly so that amortization will be shared by those other tests. In addition, we remind commenters that the OPPS was originally set up to be budget neutral to the prior system, which under several provisions of the statute, paid 
                        ( print page 68051)
                        approximately 82 percent of reported hospital outpatient department costs as shown on the cost reports. Therefore, payment rates for individual services are set, in effect, to reflect relative resource use within a payment system that pays, on average, at what was a discount of approximately 18 percent. Because the OPPS is a prospective payment system as well, payment may be more or less than a provider's costs in any specific case. We expect that our payment rates generally will reflect the costs that are associated with providing care to Medicare beneficiaries in cost-efficient settings. Prior to assigning CPT codes 0071T and 0072T to APCs 0195 and 0202 respectively, we compared the necessary hospital resources for the MRgFUS procedures, including specialized equipment, MRI/procedure room time, personnel, anesthesia and other required resources, to various other procedures for which we have historical hospital claims data. In addition, we took into consideration projected costs for the MRgFUS procedures submitted to us, and other available information regarding the clinical characteristics and costs of those services. We do not believe that there are significant clinical similarities between MRgFUS and the multi-source photon SRS procedure assigned to APC 0127. This SRS procedure is generally performed on intracranial lesions, and requires immobilization of the patient's head in a frame that is screwed into the skull. Several hundred converging beams of gamma radiation are applied to the target lesion, requiring their accurate placement to the fraction of a millimeter. In contrast, during MRgFUS, MRI guidance is utilized to confirm tissue heating, while multiple sonications at various points in the fibroid treatment area are executed until the entire target volume has been treated. Therefore, we do not think these two types of procedures are clinically similar, nor do we believe they require comparable hospital resources based on the considerations described previously that went into our CY 2006 APC assignments for MRgFUS and SRS procedures. We continue to believe that the assignments of CPT codes 071T and 072T for MRgFUS procedures to APCs 0195 and 0202 respectively for CY 2007 will make appropriate OPPS payments for MRgFUS services, thereby ensuring access for Medicare beneficiaries who need them. After careful consideration of the public comments received, we are finalizing our proposed CY 2007 APC assignments of CPT codes 071T and 072T, without modification. d. Laser Vaporization of Prostate (APC 0429) For CY 2007, we proposed to assign CPT code 52648 (Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)) to APC 0429 (Level V Cystourethroscopy and other Genitourinary Procedures), with a proposed median cost of $2,651.79. The procedure was assigned to APC 0429 for CY 2006. *Comment:*
                         One commenter indicated that the proposed assignment of CPT code 52648 to APC 0429 seemed appropriate but asked CMS to use only claims for CPT code 52648 that also contained HCPCS code C9713 (Noncontact laser vaporization of prostate, including coagulation control of intraoperative and postoperative bleeding) to calculate the median cost for APC 0429. The commenter believed that by using single bills that did not also contain HCPCS code C9713, CMS may have excluded the correctly coded claims. *Response:*
                         We agree that assignment of CPT code 52648 to APC 0429 is appropriate, but we disagree that we should require HCPCS code C9713 to be on all claims for CPT code 52648 as either a condition of payment for CPT code 52648 or to calculate the median cost of APC 0429. HCPCS code C9713 was created to describe the service for laser vaporization of the prostate because we did not believe that CPT code 52648, as defined before January 1, 2006, described the same service, and HCPCS code C9713 should not have been included on any claims with CPT code 52648. HCPCS code C9713 was deleted effective December 31, 2005, as a result of the change to the descriptor of CPT code 52648. Hospitals that billed both codes on the same claim in CY 2005 were billing incorrectly, as HCPCS code C9713 did not describe the device used to furnish the service. After carefully considering the public comment received, we are finalizing our CY 2007 proposal to assign CPT code 52648 to APC 0429 for CY 2007. The CY 2007 final median cost of APC 0429 is $2,633.85. e. Gastrointestinal Procedures with Stents (APC 0384) For CY 2007, we proposed to calculate the median cost of APC 0384 (GI Procedures with Stents) using only claims that pass the device edits and which do not contain token charges for the device HCPCS codes on the claims. The proposed rule median cost of APC 0384 was $1,400.71. *Comment:*
                         The commenters asked that CMS calculate the median by applying the same device edits for CPT codes 43268 (Endoscopic retrograde cholangiopancreatography (ECRP); with retrograde insertion of tube or stent into bile or pancreatic duct); 43269 (Endoscopic retrograde cholangiopancreatography (ECRP); with retrograde removal of foreign body and/or change of tube or stent); and 43219 (Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent) that were applied to calculate the CY 2006 OPPS median cost. The commenters stated that CMS used only claims containing stent device codes to calculate the median cost for APC 0384 for CY 2006 OPPS. They believed that the CY 2007 OPPS median cost for APC 0384 would be significantly higher if only claims that contained the stent device codes were used in the calculation. *Response:*
                         We have not calculated the CY 2007 median cost for APC 0384 using only claims that contain the HCPCS codes for stents for the procedures reported under CPT codes 43268 and 43219, because the procedures may be performed with tubes rather than stents. There are no device HCPCS codes for the tubes that may be used. Similarly, the procedure identified by CPT code 43269 may or may not use either a stent or a tube, and, therefore, it would be erroneous to require that a stent be reported on the claim. We assume that where a stent HCPCS code is not reported on the claim, the charge for the procedure incorporates the charge for the tube if one was used in the case of CPT codes 43268 and 43219, or in the case of CPT code 43269, we assume that no stent or tube was used at all. It is also possible that if the hospital inserted a tube, the hospital provided a charge for the tube under a revenue code with no HCPCS code. The other CPT codes in the APC require the use of a stent (and make no provision for substitution of a tube) and, therefore, we require that a stent HCPCS C-code be reported on the claims for those services. This is the same methodology and the same set of device edits for these procedures that were applied to calculate the median cost of APC 0384 to establish its CY 2006 OPPS payment rate. Our discussion of our final policy for setting the payment rates for device-dependent APCs, including APC 0384, is included in section IV.A.2. of this final rule with comment period. 
                        ( print page 68052)
                        See the OPPS device edits at 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​*
                         under “downloads” for the device edits in place for this APC for each calendar quarter since October 2005. After carefully considering the public comments received, we are finalizing our CY 2007 proposal for APC 0384 without modification. The final median cost for APC 0384 is $1,402.31. f. Endoscopy With Thermal Energy to Sphincter (APC 0422) CPT code 43257 (Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease), effective January 1, 2005, is used for esophagoscopy with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia for the treatment of gastresophageal reflux disease. This code describes the Stretta procedure, including use of the Stretta System and all endoscopies associated with the Stretta procedure. Prior to CY 2005, the Stretta procedure was recognized under HCPCS code C9701 from January 1, 2004, through December 31, 2004, in the OPPS. For the CY 2005 OPPS, HCPCS code C9701 was deleted and CPT code 43257 was utilized for the Stretta procedure. In CY 2005, the Stretta procedure was transitioned from a New Technology APC to clinical APC 0422 (Level II Upper GI Procedures) based on several years of hospital cost data. Procedures within APC 0422 were similar to the Stretta procedure in terms of clinical characteristics and resource use. For both CYs 2005 and 2006, we specifically calculated the median cost for the Stretta procedure reported with CPT code 43257 taking into account the codes that hospitals billed for the service in CYs 2003 and 2004, which included HCPCS code C9701 and one unit of endoscopy service. For CY 2007, we proposed to continue with the current APC assignment for the Stretta procedure, with no need for a special median cost calculation. We received several public comments in response to the CY 2007 proposed payment rate for the Stretta procedure, in particular with a focus on the median cost methodology. *Comment:*
                         Some commenters objected to the APC assignment of the Stretta procedure to APC 0422 and cited the use of the CY 2004 claims data in determining its median cost for CY 2007. The commenters indicated that CMS should recalculate the median cost for CPT code 43257 to ensure that all claims contributing to the median reflect the resources of the endoscopic procedures that are part of this procedure. *Response:*
                         The commenters cited the CY 2004 claims as part of their objection. However, we used claims data from CY 2005 for all services, including CPT code 43257, in determining the payment rates for CY 2007. As we stated in the CY 2007 OPPS proposed rule, median costs for the CY 2007 OPPS update were based on the CY 2005 hospital claims data. APC assignments are based on clinical homogeneity and comparable resource utilization for all CPT and HCPCS codes within an APC. In the case of APC 0422, we believe that the procedures assigned to this APC are similar in costs and resource consumption, with median costs for the significant procedures assigned to the APC of $1,475 to $2,084, well within the 2 times rule limits. *Comment:*
                         Several commenters requested that CMS create a new APC that includes both CPT codes 43257 and 0008T (Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with suturing of the esophagogastric junction) to appropriately cover the costs associated with performing these procedures. One commenter requested that CMS create a new APC to which CMS would assign CPT codes 43257 and 0008T, and that CMS use a different methodology to calculate the median cost. The commenter indicated that because CPT codes 43228 and 43830 have higher volumes but lower costs, the inclusion of them in the same APC as CPT code 43257 does not lead to payment of CPT code 43257 at a level that is appropriate to pay the costs of the service. The same commenter indicated that the continued inclusion of CPT codes 43228 and 43830 decrease the payment rate for many of the procedures placed in APC 0422. The commenter believed that creating the new APC was analogous to what CMS proposed to do for vascular access devices in the proposed rule. *Response:*
                         We disagree with the commenters. We believe that the procedures in APC 0422 contain similar procedures for the treatment of gastroesophageal reflux disease, and these services are, therefore, appropriately assigned based on clinical homogeneity and resource use. Thus, for CY 2007, CPT code 43257 will remain in APC 0422. CPT code 0008T will be deleted as of January 1, 2007. For the CY 2007 OPPS, the payment for APC 0422 is based on the final median cost of $1,573.89. Furthermore, with regard to the commenter's analogy to a new APC for vascular access devices, such a comparison was misplaced as we did not propose to create a new APC for vascular access devices in the CY 2007 OPPS proposed rule. *Comment:*
                         One commenter requested that CMS recompute the median cost for CPT code 43257, and suggested two specific options for determining a revised median cost. One option suggested by the commenter was that CMS add the median cost for CPT code 43235 to the cost of all claims for HCPCS code C9701 (CPT code 43257 in CY 2005) that did not also contain at least one unit of an endoscopy code on the claim. The commenter indicated that these inflated claims costs would then be combined with all claims for HCPCS code C9701 that also contain at least one unit of an endoscopy code and with the claims for CPT code 0008T to set the median cost for the APC they wanted CMS to create. The commenter suggested that another option would be to use only claims that contained both HCPCS code C9701 and CPT codes 43234, 42235, or any other endoscopy code to calculate the median cost, which the commenter admitted would not yield as robust a set of claims for setting medians. *Response:*
                         We no longer have a need for special calculations to develop the median cost of CPT code 43257 because the code itself was reported by hospitals in CY 2005 and includes all endoscopies. In addition, HCPCS code C9701 was deleted for CY 2005 so we have no claims for the service from that year. Further, as we indicated in the CY 2006 OPPS final rule with comment period that addressed this same issue and similar comment (70 FR 68606), we see no reason to create a new APC for CPT codes 43257 and 0008T. We believe that the procedures in APC 0422 contain similar procedures for the treatment of gastroesophageal reflux disease, and therefore, the APC is appropriately structured based on clinical homogeneity and resource use. After carefully considering the public comments received, we are finalizing our proposal for assignment of CPT code 43257 to APC 0422 for CY 2007, with a median cost of $1,573.89. 5. Ocular Procedures a. Keratoprosthesis (APC 0293) CPT code 65770 (Keratoprosthesis) is a surgical procedure for implantation of a keratoprosthesis, an artificial cornea. In the CY 2007 proposed rule, we indicated that we believed that the keratoprosthesis device that is required 
                        ( print page 68053)
                        for the implantation is described by HCPCS code C1818 (Integrated keratoprosthesis), a device category that received transitional pass-through payment under the OPPS from July 2003 through December 2005. When the pass-through status for the device expired for CY 2006 and the costs of the device 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 agreed with the recommendation of the APC Panel. At the time of the proposed rule, claims data from CY 2005 demonstrated that the median cost for implantation of a keratoprosthesis of $3,127.51 remained significantly higher than the median costs of other procedures assigned to APC 0244, although there was no 2 times violation. In addition, CPT code 65770 contributed less than 1 percent of the single claims in the APC available for ratesetting, and it was 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 proposed 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. CPT code 65770 was the only code proposed for assignment to that APC. *Comment:*
                         One commenter and a presenter to the APC Panel during its August 2006 meeting requested that the procedure be paid at a higher rate than the proposed payment rate. They believed that our cost data were inaccurate and understated the cost of the implantable device, HCPCS code C1818. The commenters reported that the device, a biointegratable artificial cornea, costs approximately $7,000, far more than the proposed $3,116.62 OPPS payment rate for the procedure to implant the device. At its August 2006 meeting, the APC Panel recommended that CMS consider external data for these procedures to validate whether the claims used for ratesetting were properly coded and make appropriate adjustments to the OPPS payment rate if necessary. Further, the Panel recommended that CMS implement a device edit that would ensure that the device code (HCPCS code C1818) is included on claims for the keratoprosthesis procedure. The commenters provided hospital data that showed that many hospitals that performed the procedure which may be reported for implantation of the costly biointegratable artificial cornea described by HCPCS code C1818 did not report charges for the device on their bills to Medicare. Further, one commenter performed analyses of Medicare hospital outpatient claims data and found that if CMS used only single procedure claims that included HCPCS code C1818 and CPT code 65770 to establish the median cost for APC 0293, it would be more than $10,000 and would result in a payment rate that would be adequate to cover the costs of implantation of the integrated keratoprosthesis device. *Response:*
                         In response to the comments and the APC Panel's recommendations, we performed additional analyses of our claims data. We noted that a new alphanumeric HCPCS code L8609 (Artificial cornea) was established in CY 2006, but there would not have been any claims reported for this code in the CY 2005 claims data used for this CY 2007 OPPS update. We found that only 8 of the 47 single claims for CPT code 65770 included the HCPCS device code C1818. The median cost for those few claims was $10,715.30, consistent with the commenter's data analyses. Upon further exploration of the background of HCPCS device code C1818, we noted that we had provided specific guidance concerning the device code in the June 2003 Transmittal A-03-051, explaining, “The device is composed of a flexible, one-piece biocompatible polymer * * *.” We are aware of at least one other device that may be inserted during the procedure described by CPT code 65770, and that keratoprosthesis is a two-part device that would not be appropriately described by HCPCS code C1818. We have been told that the device is significantly less costly than the device described by HCPCS code C1818, the one-piece biointegratable keratoprosthesis. Because there are at least two devices with different costs that could have been used in CY 2005 to perform CPT code 65770, but there was no HCPCS code in CY 2005 for the two-part keratoprosthesis not described by HCPCS code C1818, it would not be appropriate for us to use only claims reporting HCPCS code C1818 to calculate the median cost for CPT code 65770. If we were to follow the recommendation of the commenter, we could be systematically and incorrectly excluding claims for CPT code 65770 that may have been correctly coded at the time by hospitals implanting a two-part keratoprosthesis with a lower device cost than the cost of the one-piece device coded by CPCS code C1818. The OPPS is a prospective payment system that pays based on the median cost of procedures assigned to APC groups, and to the extent that various devices with dissimilar costs may be used to provide the same procedure, those different device costs are packaged into the procedural payment in relationship to their utilization in the procedure. Therefore, we do not believe the 47 single claims from CY 2005 used for ratesetting for APC 0293 were miscoded, and we do not believe adjustments to the payment rate for APC 0293 established based on the standard OPPS methodology are needed for CY 2007. Where there are device HCPCS codes for all possible devices that could be used to perform a procedure that always requires a device and the APC is designated a device-dependent APC, we have commonly instituted device edits that prevent payment of claims that do not include both the procedure and an acceptable device code. In that way, hospitals become aware of the proper coding requirements, and we can be confident that our procedure claims include charges for the necessary devices so we can establish appropriate payment rates for those procedures. Because there was a new, more general HCPCS L-code (L8609) created for the artificial cornea in CY 2006 that may be used to report all keratoprostheses not already described by HCPCS code C1818, we are accepting the APC Panel's recommendation regarding the establishment of device edits for CPT code 65770. We will establish a device edit in CY 2007 for CPT code 65770 that requires reporting of an appropriate device HCPCS code to ensure that all claims for CPT code 65770 in CY 2007 and future years include charges for a required device. However, to the extent that devices with different costs are used to provide the keratoprosthesis procedure, unless the CPT code descriptor for the service is revised or more specific CPT codes are developed, our claims data will continue to reflect highly variable costs 
                        ( print page 68054)
                        for the services that are provided using the full spectrum of keratoprosthesis devices. After carefully considering the comments received, we are adopting our proposal without modification to assign CPT code 65770 to APC 0293, with a median cost of $3,177.05 for CY 2007. We are also assigning a procedure-to-device edit for CPT code 65770 with APC 0293. b. Eye Procedures (APCs 0232, 0235, and 0241) In Addendum B of the CY 2007 proposed rule (71 FR 49702), we proposed to assign a payment rate of $368.07 for APC 0232 (Level I Anterior Segment Eye Procedures), a payment rate of $250.82 for APC 0235 (Level I Posterior Segment Eye Procedures), and a payment rate of $1,529.55 for APC 0241 (Level IV Repair and Plastic Eye Procedures). *Comment:*
                         Several commenters questioned the reasoning behind the payment reductions for APCs 0232, 0235, and 0241 when their facilities experienced increased costs for the procedures assigned to these APCs. Specifically, the commenters questioned why the payment rate for APC 0232 declined from $411.84 for CY 2006 to the proposed payment rate of $368.07 for CY 2007; why the payment rate for APC 0235 declined from $285.21 for CY 2006 to the proposed payment rate of $250.82 for CY 2007; and why the payment rate for APC 0241 declined from $1,806.03 for CY 2006 to the proposed payment rate of $1,529.55 for CY 2007. At the same time, several commenters supported the proposed payment increases for APCs 0242 (Level V Repair and Plastic Eye Procedures), 0245 (Level I Cataract Procedures without IOL Insert), 0247 (Laser Eye Procedures Except Retinal), 0248 (Laser Retinal Procedures), 0673 (Level IV Anterior Segment Eye Procedures), and 0699 (Level IV Eye Tests and Treatment). The commenters requested that CMS reexamine the proposed payments for APCs 0232, 0235, and 0241. *Response:*
                         Each year, we reevaluate APC assignments for procedures, services, and items paid under the hospital OPPS based on claims data paid by Medicare to set annual payment rates. Based on our analyses, we make changes to the APC assignments when necessary. As we stated in the CY 2007 OPPS proposed rule (71 FR 49514), we used approximately 50.7 million whole claims that reflected services furnished on or after January 1, 2005, and before January 1, 2006, to recalibrate the APC relative payment weights for CY 2007. While the payment rates for many APCs remain stable over time, in the absence of APC reconfiguration, it is not unusual for the payment rates for certain APCs to vary modestly from year to year, similar to the approximately 10-percent decrease in median costs observed for APCs 0232 and 0235 for CY 2007. However, as the commenters noted, other eye procedure APCs also had proposed increases for CY 2007. The CY 2007 median costs for APCs 0232 and 0235 have been calculated based upon CY 2005 claims using the standard OPPS methodology. In the case of APC 0241, the commenter is mistaken to believe that the CY 2006 OPPS payment rate for the APC was $1,806.03. The CY 2006 OPPS payment rate for APC 0241 was $1,378.76. Therefore, the proposed payment rate of $1,529.55 for APC 0241 was a proposed payment rate increase for CY 2007. After carefully considering the public comments received, we are finalizing our CY 2007 proposal for APCs 0232, 0235, and 0241 without modification, with final median costs of $370.77, $240.36, and $1,543.32, respectively. c. Amniotic Membrane for Ocular Surface Reconstruction In Addendum B of the CY 2007 proposed rule (71 FR 49845), we proposed to assign HCPCS code V2790 (Amniotic membrane for surgical reconstruction, per procedure) to status indicator “N” (packaged). *Comment:*
                         Several commenters requested that CMS consider assigning status indicator “F” (paid at reasonable cost) to HCPCS code V2790 rather than status indicator “N”. One commenter indicated a discrepancy in payment policy and status indicator assignment for two types of tissues currently used for ocular surface transplants; that is, HCPCS code V2785 (Processing, preserving and transporting corneal tissue), which is assigned to status indicator “F” and HCPCS code V2790, which is assigned to status indicator “N,” are not treated similarly with regard to status indicator assignments and OPPS payment policy. The commenters added that payment for items and services assigned to status indicator “N” is packaged into payment for the associated procedures, while payment for items and services assigned to status indicator “F” is made at reasonable cost, not under the OPPS. The commenters believed this discrepancy could create a competitive disadvantage and financial disincentive for hospitals to promote the treatment of ocular surface diseases using amniotic membrane tissue, and ultimately impede beneficiary access to this unique ocular reconstructive procedure. The commenters requested that CMS reassign HCPCS code V2790 from status indicator “N” to status indicator “F” for CY 2007. *Response:*
                         We appreciate the commenters” interest in payment for tissues used in ocular treatments. The OPPS has provided separate payment for corneal tissue acquisition at reasonable cost since the beginning of the OPPS, due to the highly variable corneal tissue processing fees required for eye banks to provide safe corneal tissue from donors as needed for transplant, through special distribution channels. These costs may vary substantially and unpredictably, depending on philanthropic and in-kind service contributions to eye banks that vary from community to community and from year to year. Our understanding is that amniotic membrane retrieved from donated placental tissues is a processed, cryopreserved, and commercially marketed product used for ocular reconstruction that may be stocked and stored by hospitals. Therefore, there is no need for HCPCS code V2790 to be paid based on reasonable cost outside of the OPPS. Instead, like many items under the OPPS used in surgical procedures, its prospective payment is appropriately packaged into payment for the procedures in which it is used. After consideration of the public comments received, we are finalizing our proposed CY 2007 payment policies without modification for HCPCS codes V2785 and V2790 as reflected in their assigned status indicators. 6. Other Procedures a. Skin Replacement Surgery and Skin Substitutes (APC 0025) For CY 2006, the 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, 
                        ( print page 68055)
                        Allograft/Tissue Cultured Allogeneic Skin Substitute, and Xenograft. 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 code 15342 (Application of bilaminate skin substitute/ neodermis; 25 sq cm), CPT code 15343 (Application of bilaminate skin substitute/neodermis; each additional 25 sq cm), CPT code 15350 (Application of allograft, skin; 100 sq cm or less), and CPT code15351 (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 code 15170 (Acellular dermal replacement, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children)
                    CPT code 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 code 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 code 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 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)
                    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)
                    CPT code 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 code 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 code 15340 (Tissue cultured allogeneic skin substitute; first 25 sq cm or less)
                    CPT code 15341 (Tissue cultured allogeneic skin substitute; each additional 25 sq cm)
                    CPT code 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 code 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 code 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 code 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 code 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 code 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 code 15430 (Acellular xenograft implant; first 100 sq cm or less, or one percent of body area of infants and children)
                    CPT code 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 were listed in Table 11 of the CY 2007 OPPS proposed rule (71 FR 49557). As noted in the proposed rule, in general, biological skin substitutes and replacements used in procedures described by these CPT codes were proposed for separate payment under the OPPS for CY 2007, according to the methodology outlined in section V. of the preamble of the proposed rule (71 FR 49557) and discussed in this preamble. As we indicated in the proposed rule (71 FR 49558), 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 agreed 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 disagreed that these procedures should be placed in APC 0027 (Level IV Skin Repair). The APC Panel presenters reasoned that some of the codes (CPT codes 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 asserted in the proposed rule that this procedure was not appropriately placed in APC 0027. Split-thickness and full thickness skin autograft procedures currently assigned to APC 0027 were 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 proposed to reassign CPT code 15300 to APC 0025 (Level II Skin Repair), with an APC median cost of $314.58. We agreed, in principle, that other CPT codes for the first increment of body surface area treated with a skin replacement or skin substitute were similar clinically and from a hospital resource perspective to CPT code 15300 and, therefore, we 
                        ( print page 68056)
                        proposed to assign these procedures to APC 0025 as well for CY 2007. Similarly, presenters reasoned that the related add-on codes (CPT codes 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 proposed 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 would 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 asserted in the proposed rule that this reduction in payment for the procedural resources associated with the add-on services was appropriate. (71 FR 49558). The APC Panel did not hear any presentations or make any recommendations regarding skin substitutes or skin replacement codes and APCs at its August 2006 meeting. *Comment:*
                         One commenter on the CY 2006 final rule requested that we reassign CPT codes 15340 and 15341 to APC 0025, where the services would be grouped with clinically related services that require comparable hospital resources. In particular, the commenter noted that APC 0024 did not provide appropriate payment for the costs of surgical debridement of the wound to prepare it properly for application of the allogeneic skin substitute. Several commenters on the CY 2007 proposed rule supported our proposal to assign new CPT codes 15340 and 15341 to APC 0025. One commenter noted that the proposed assignments of these CPT codes for tissue cultured allogeneic skin substitutes to APC 0025 for CY 2007 would correct substantial reductions in payment for application of one product that occurred with the assignment of these CPT codes to APC 0024 for CY 2006. The commenter believed that our proposal represented a significant step toward the appropriate payment for these services. The commenter further claimed that its external analyses of Medicare claims data supported the change, with a median cost for new CPT code 15340 that was higher than the median cost of APC 0025 but lower than the median cost of APC 0027. *Response:*
                         We appreciate the recognition from the commenter that the proposed assignments of CPT codes 15340 and 15341 to APC 0025 provides more appropriate payment for these services. *Comment:*
                         A commenter supported our CY 2007 proposed assignments of CPT codes 15170 through 15176, 15300-15321, 15340-15366, and 15420-15431 to APC 0025. One commenter agreed that skin substitute or replacement add-on codes (CPT codes 15171, 15176, 15301, 15321, 15341, 15361, 16366, 15421, and 15431) should be placed in APC 0025. Another commenter provided significant clinical detail about dermal replacement services, described by CPT codes 15170 through 15176, and about temporary wound closure by allograft services, described by CPT codes 15300 through 15321. In contrast to our proposal, the commenters believed that, based on the clinical characteristics and expected costs including anesthesia, procedure room time, supplies, and preparation of the products for application, these services would be most appropriately assigned to APC 0686 (Level III Skin Repair). They believed that CMS had underestimated the resources required to perform these procedures. *Response:*
                         While the commenters provided comparisons among the expected relative costs of various procedures, the commenter provided no specific cost analyses to persuade us to assign CPT codes 15170 through 15176 and 15300 through 15321 to a skin repair APC that would provide payment at two and a half times the proposed payment rate for these services. We do not agree that the clinical and resource distinctions between these procedures and other services also assigned to APC 0025 would warrant their reassignment to APC 0686, with its significantly higher payment rate than their CY 2007 proposed payment rate. We note that we will have claims data for all of these CPT codes available for the CY 2008 OPPS update. After carefully considering the public comments received, we are finalizing our proposed assignments of skin substitute and skin replacement procedures as shown in Table 16 below without modification. 
 
  b. Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064) APC 0046 (Open/Percutaneous Treatment Fracture or Dislocation) was 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 
                        ( print page 68058)
                        them. The APC Panel recommended that CMS continue to evaluate the refinement of APC 0046 into at least three APC levels, with consideration of a fourth level should data support this additional level. We accepted the APC Panel's recommendation and proposed 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 were 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 eliminated 2 times rule violations in the Fracture/Dislocation series. The APC Panel did not hear any presentations or make any recommendations regarding APC 0046 or our proposed APCs 0062, 0063, and 0064 at its August 2006 meeting. We did not propose a fourth APC level in the Fracture/Dislocation series because we did not believe our claims data were 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), was not clinically coherent with the other procedures in APC 0046, and we proposed to reassign this procedure outside of the Fracture/Dislocation series to APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot) for CY 2007. We received two supportive comments on our proposed reconfiguration of APC 0046. A summary of the comments and our response follow: *Comment:*
                         A few commenters supported our proposal to move from one APC (0046) to three APCs (0062, 0063, and 0064) for services that treat fractures and dislocations. The commenters noted that three APCs better recognize the differences in hospital resource utilization. The commenters noted that OPPS payments would increase significantly for the highest level of fracture and dislocation treatment, decrease for the lowest level, and remain relatively stable for the medium treatment level. *Response:*
                         We appreciate the acknowledgement that we are attempting to better recognize the differences in hospital resource utilization for fracture and dislocation procedures. We note that AMA's CPT Editorial Panel has deleted CPT 25611 (Percutaneous skeletal fixation of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, requiring manipulation, with or without external fixation) for CY 2007, replacing it with CPT code 25606 (Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation). AMA's CPT Editorial Panel has also deleted CPT code 25620 (Open treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, with or without internal or external fixation) for CY 2007, replacing it with three CPT codes as refinements: CPT code 25607 (Open treatment of distal radial extraarticular fracture or epiphyseal separation, with internal fixation); CPT code 25608 (Open treatment of distal radial intraarticular fracture or epiphyseal separation; with internal fixation of two fragments); and CPT code 25609 (Open treatment of distal radial intraarticular fracture or epiphyseal separation; with internal fixation of three or more fragments). These changes are effective January 1, 2007. The interim final APC assignments of the new CY 2007 CPT codes for fracture treatments are included in Table 17 below. After carefully considering the comments received, we are finalizing our proposal without modification to reconfigure CY 2006 APC 0046 for fracture and dislocation procedures into three new APCs for CY 2007, APCs 0062, 0063, and 0064, as displayed in Table 17, and to reassign CPT code 27615 to APC 0050. Table 17.—Reconfiguration of APC 0046
HCPCS 
                                 code
Description
CY 2007 
                                 APC21336
Treat nasal septal fracture
006321805
Treatment of rib fracture
006223515
Treat clavicle fracture
006423530
Treat clavicle dislocation
006323532
Treat clavicle dislocation
006223550
Treat clavicle dislocation
006323552
Treat clavicle dislocation
006323585
Treat scapula fracture
006423615
Treat humerus fracture
006423616
Treat humerus fracture
006423630
Treat humerus fracture
006423660
Treat shoulder dislocation
006323670
Treat dislocation/fracture
006423680
Treat dislocation/fracture
006324515
Treat humerus fracture
006424516
Treat humerus fracture
006424538
Treat humerus fracture
006224545
Treat humerus fracture
006424546
Treat humerus fracture
006424566
Treat humerus fracture
006224575
Treat humerus fracture
006424579
Treat humerus fracture
006424582
Treat humerus fracture
006224586
Treat elbow fracture
006424587
Treat elbow fracture
006424615
Treat elbow dislocation
006424635
Treat elbow fracture
006424665
Treat radius fracture
0063( print page 68059)24666
Treat radius fracture
006424685
Treat ulnar fracture
006325515
Treat fracture of radius
006325525
Treat fracture of radius
006325526
Treat fracture of radius
006325545
Treat fracture of ulna
006325574
Treat fracture radius & ulna
006425575
Treat fracture radius/ulna
006425606 (25611 deleted)
Treat fx distal radial
006225607 (25620 deleted)
Treat fx rad extra-articul
006425608 (25620 deleted)
Treat fx rad intra-articul
006425609 (25620 deleted)
Treat fx radial 3+ frag
006425628
Treat wrist bone fracture
006325645
Treat wrist bone fracture
006325651
Pin ulnar styloid fracture
006225652
Treat fracture ulnar styloid
006325670
Treat wrist dislocation
006225671
Pin radioulnar dislocation
006225676
Treat wrist dislocation
006225685
Treat wrist fracture
006225695
Treat wrist dislocation
006226608
Treat metacarpal fracture
006226615
Treat metacarpal fracture
006326650
Treat thumb fracture
006226665
Treat thumb fracture
006326676
Pin hand dislocation
006226685
Treat hand dislocation
006326686
Treat hand dislocation
006426715
Treat knuckle dislocation
006326727
Treat finger fracture, each
006226735
Treat finger fracture, each
006326746
Treat finger fracture, each
006326756
Pin finger fracture, each
006226765
Treat finger fracture, each
006326776
Pin finger dislocation
006226785
Treat finger dislocation
006227202
Treat tail bone fracture
006327509
Treatment of thigh fracture
006227524
Treat kneecap fracture
006327566
Treat kneecap dislocation
006327615
Remove tumor, lower leg
005027756
Treatment of tibia fracture
006227758
Treatment of tibia fracture
006327759
Treatment of tibia fracture
006427766
Treatment of ankle fracture
006327784
Treatment of fibula fracture
006327792
Treatment of ankle fracture
006327814
Treatment of ankle fracture
006327822
Treatment of ankle fracture
006327823
Treatment of ankle fracture
006427826
Treat lower leg fracture
006327827
Treat lower leg fracture
006427828
Treat lower leg fracture
006427829
Treat lower leg joint
006327832
Treat lower leg dislocation
006327846
Treat ankle dislocation
006327848
Treat ankle dislocation
006328406
Treatment of heel fracture
006228415
Treat heel fracture
006328420
Treat/graft heel fracture
006328436
Treatment of ankle fracture
006228445
Treat ankle fracture
006328456
Treat midfoot fracture
006228465
Treat midfoot fracture, each
006328476
Treat metatarsal fracture
006228485
Treat metatarsal fracture
006328496
Treat big toe fracture
006228505
Treat big toe fracture
006328525
Treat toe fracture
006328531
Treat sesamoid bone fracture
006328545
Treat foot dislocation
0062( print page 68060)28546
Treat foot dislocation
006228555
Repair foot dislocation
006328576
Treat foot dislocation
006228585
Repair foot dislocation
006328606
Treat foot dislocation
006228615
Repair foot dislocation
006328636
Treat toe dislocation
006228645
Repair toe dislocation
006328666
Treat toe dislocation
006228675
Repair of toe dislocation
0063
 c. Complex Skin Repair (APC 0024) In the CY 2007 OPPS proposed rule, we proposed to assign CPT code 13151 (Repair, complex, eyelids, nose, ears and/or lip, 1.1 cm to 2.5 cm, to APC 0024 (Level I Skin Repair) with a payment rate of $91.86. *Comment:*
                         One commenter asked why CPT code 13151 (Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm) was assigned to APC 0024, rather than to APC 0025 (Level II Skin Repair). The commenter pointed out that the smaller skin repair represented by CPT code 13150 was assigned to APC 0025 with other more complex skin repair procedures. *Response:*
                         We agree with the commenter that CPT code 13151 would be more appropriated assigned to APC 0025 and are making that reassignment effective January 1, 2007. d. Insertion of Posterior Spinous Process Distraction Device The AMA released two new Category III codes on July 1, 2006, for insertion of a posterior spinous process distraction device, namely: 0171T (Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level); and 0172T (Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure)). These two new codes are effective January 1, 2007. Moreover, we have created a new device category for transitional pass-through payment, effective January 1, 2007, C1821 (Interspinous process distraction device (implantable)), which we expect to be reported with these procedures. At its August 2006 meeting, the APC Panel recommended that CMS review the resources required for these new CPT codes and recommend appropriate APC assignments for them for CY 2007. *Comment:*
                         Some commenters indicated that CMS should place new procedure codes 0171T and 0172T into clinical APC 0051 (Level III Musculoskeletal Procedures Except Hand and Foot). Although the level of resources used in performing CPT code 0172T (second and subsequent level implants) is less than those used for CPT code 0171T (the single level implant of the device), the commenters believed that APC 0051 is also appropriate for 0172T because APC 0051 is subject to the multiple procedure discount. CPT code 0172T is an add-on code to the primary procedure reported with CPT code 0171T; therefore, payment for 0172T would always be reduced by 50 percent. One commenter stated that the resource elements they outlined specifically for CPT code 0172T are all costs incurred separately and in addition to the costs of the single level procedure, CPT code 0171T. The commenter believed it would be inappropriate to place CPT code 0172T into an APC based on the claimed resources, and then reduce the payment rate by 50 percent when a multiple procedure discount applies to every case that is correctly coded. The commenter provided charge data from seven claims for six different facilities that performed the single level procedure (CPT code 0171T). The commenter calculated a “median” of these charges reduced to cost of $2,727, which the commenter asserted was within the range of median costs of other procedures assigned to APC 0051. The commenter stated that it was unable to obtain any facility charge or cost data for CPT code 0172T. The commenter acknowledged that CMS had also granted transitional pass-through payment status for spinous process distraction devices effective January 1, 2007. One commenter indicated that it expected the spinous process distraction device to remain on pass-through status through CY 2008 and, therefore, be paid separately through that time. However, the commenter expressed concern that once the device is no longer paid separately under pass-through payment, the device costs, which would be a substantial percentage of total procedural costs, would be packaged into payment for the procedural APC and adjusted by the wage index that is applied to 60 percent of the payment rate. The commenter requested that CMS address this issue, so that once payment for the spinous process distraction device is packaged into the procedural APC payment, hospitals with wage indices below 1.0 would be able to continue offering the procedure to patients. Another commenter stated that it had performed four spinous process distraction device cases over the past year. All four cases had similar utilization patterns and outcomes. The commenter claimed to have evaluated the time and resources needed to complete the procedure, and compared the costs to other procedures, for example, laminectomies and diskectomies, performed at the hospital, and also extracted single procedure costs for all cases performed in APCs 0049 through 0052. The commenter determined that the costs of the four spinous process distraction device cases were most consistent with the costs of other services assigned to APC 0051. *Response:*
                         The commenters provided their recommendation based on their limited cost studies that relied on information from a few hospitals with experience implanting spinous process distraction devices. This is not unusual for new procedures, such as CPT Category III codes. We examined the procedural resource information provided by commenters as well as considered CY 2005 claims data for other musculoskeletal procedures in the OPPS. We believe that both of the procedures describe by CPT codes 
                        ( print page 68061)
                        0171T and 0172T would be most appropriately assigned to APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot), based on both clinical and expected resource considerations. Their assignment to the same clinical APC for CY 2007 will ensure appropriate payment for CPT code 0172T when the multiple procedure payment reduction is applied. We note that the device cost of HCPCS code C1821 (Interspinous process distraction device (implantable)), will be paid separately under the OPPS for at least 2 and not more than 3 years of pass-through payment. After that period, payment for the cost of the device would be packaged into the procedural APC payments for its implantation, most likely CPT codes 0171T and 0172T. At that time, we will further evaluate the most appropriate APC assignments for these procedures, as we will each year. For a discussion about application of the wage index to payments for APCs that have significant device costs, see section IV.A.2 of this final rule with comment period. After carefully considering the public comments received, we are accepting the APC Panel's recommendation and assigning CPT codes 0171T and 0172T to APC 0050 with status indicator “T” for CY 2007. These assignments are interim final, and, therefore, open to comment in this final rule with comment period. 7. Medical Services a. Medication Therapy Management Services 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 CMS 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. As indicated in the CY 2007 OPPS proposed rule (71 FR 49563), we did not accept the APC Panel's recommendations. Rather, we proposed 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, in the CY 2007 proposed rule, we noted that we believe their associated hospital resource costs were 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 indicated that we had 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 the CY 2007 proposed rule, we explained that 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 for which 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 that are unrepresented in historical hospital claims data. As stated earlier, because we believe the costs of medication therapy management services were imbedded as a component within our claims data, we were confident that our CY 2005 claims data reflected the costs of pharmacist medication management services provided to hospital outpatients who were receiving hospital services. We received a large number of public comments concerning our proposal for CPT codes 0115T, 0116T, and 0117. A summary of the comments and our responses follows: *Comment:*
                         Most commenters requested that Medicare pay separately for medication therapy management because it is difficult for the hospital to provide this service without receiving any payment. One commenter elaborated on the emerging role of a pharmacist and the increasing scope of services provided by the pharmacist to the patient, including proactive assessments rather than simply reactive responses. This commenter stated that although the historical resource costs of the pharmacist's services may be captured in the claims data, it was unlikely that the resource costs of the new responsibilities are represented in the data. Another commenter quoted statistics that estimated that, in 2004, only 30 percent of hospitals had pharmacists who were involved in ambulatory care. Of those who were involved, only 50 percent had involvement in medication therapy management services. Therefore, although there may be cost data embedded in the claims, the fact that these services have historically been provided infrequently means that the costs of these services have minimal impact on our median cost data. Many commenters noted that these pharmacist services reduce costs in the long run by improving the health of patients. One commenter agreed that these services are already accounted for in the claims data and further agreed that there is no need to distinguish between services provided by pharmacists and other providers. One commenter suggested that medication therapy management could be provided to a patient on the same day as a laboratory test and requested that CMS clarify the appropriate billing technique under such circumstances. Another commenter specifically asked if it was appropriate to bill CPT code 99211, the lowest level clinic visit, if the only service provided to a patient is medication therapy management by a pharmacist. One commenter agreed that these services are not technically new, but suggested that CMS map them to New Technology APCs because they are new in the sense that they are now more 
                        ( print page 68062)
                        readily available independent of a physician's service or clinic procedure. One pharmacy association objected to our statement that these services can be provided by staff other than pharmacists. The association notes that pharmacists have distinct training, skills, and abilities to perform these services, which are reflected in the new Category III codes. *Response:*
                         We agree with the commenters that medication therapy management services are important services provided to patients and that providers should receive payments for these services. We would expect the hospital charges for the services provided to the patient to include charges for all hospital resource costs associated with the patient's care, including medication therapy management services, if appropriate. As we stated above, medication therapy management services are not new services, and they have been provided in the past as components of a wide variety of services provided by hospitals, including clinic and emergency room visits, procedures, and diagnostic tests. Although we do not make separate payment for medication therapy management provided by a pharmacist, the costs for this service are included in the costs of other services furnished by the hospital on the same day. Therefore, we continue to believe that the costs for these services are embedded in our claims data, and are reflected in our payment rates, thereby providing payments for these important services. While we acknowledge commenters' concerns that hospitals are providing medication therapy management services more frequently than in the past, we continue to disagree that they are new and should be assigned to a New Technology APC. To the extent that medical management services evolve over time to require more facility resources due to their greater complexity, we expect those higher costs to be reflected in hospitals' charges for the associated services, which will then provide the basis for future ratesetting under the OPPS. To clarify our billing requirements, if the only service provided to a patient is a laboratory test to determine medication levels, the laboratory test is all that should be billed. If a hospital provides a distinct, separately identifiable service in addition to the test, the hospital is responsible for billing the HCPCS code that most closely describes the service provided. Billing a visit code in addition to another service merely because the patient interacted with hospital staff or spent time in a room for that service is inappropriate. A hospital may bill a visit code, based on the hospital's own coding guidelines which must reasonably relate the intensity of hospital resources to the different levels of HCPCS codes. Services furnished must be medically necessary and documented. After carefully considering the comments received, we are continuing to assign status indicator “B” to CPT codes 0115T, 0116T, and 0117T for CY 2007 and finalizing our proposed policy without modification. b. Single Allergy Tests (APC 0381) We proposed 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 (Allergy Tests) 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 did 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 appeared to provide charges that represented a “per visit” charge, rather than a “per test” charge. Therefore, consistent with our payment policy for CY 2006, we proposed 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 was allocated equally to each unit of the CPT code. Using this methodology, we calculated a median cost of $13.29 for APC 0381 for CY 2007. As indicated in the CY 2007 OPPS proposed rule (71 FR 49566), we were hopeful that the better and more accurate hospital reporting and charging practices for these single allergy test CPT codes beginning in CY 2006 would allow us to calculate the median cost of APC 0381 using the standard OPPS process in future OPPS updates. We did not receive any public comments concerning our proposed methodology for differentiating single allergy tests from multiple allergy tests for OPPS payment in CY 2007. The final CY 2007 APC 0381 median cost calculated based upon 382 single claims, using the methodology as proposed, is $16.43. c. Hyperbaric Oxygen Therapy (APC 0659) 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 APC 0659 (Hyperbaric Oxygen) 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 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 proposed 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 estimated a median cost of $98.36 for CY 2007. *Comment:*
                         One commenter agreed with CMS' approach to determining the median costs for HCPCS code C1300 
                        ( print page 68063)
                        (HBOT) to the extent that it eliminated services that were obviously billed incorrectly. The commenter believed that use of the hospital's overall CCR appeared to be the best option at this time. However, the commenter asked that hospitals be allowed to bill these services with multiple revenue codes (not just respiratory therapy), so that hospitals could bill the services under the revenue code that was most closely linked to the cost center where the services were furnished. The commenter also requested that the revenue code to cost center crosswalk be revised to reflect the use of the hospital's overall CCR for HBOT. In contrast, another commenter was concerned that CMS' claims data do not accurately reflect the costs of this therapy because of potential hospital miscoding. The commenter believed that the use of hospitals' overall CCRs did not reflect the relationship between costs and charges specific to HBOT. The commenter believed that the payment rate for HCPCS code C1300 continued to be inadequate as proposed for CY 2007 and asked that the rate be increased based on the external data provided by an association to the APC Panel. Another commenter objected to erratic payment rates for HBOT over a period of years, particularly a drop in payment between CYs 2004 and 2005. The commenter attributed this instability both to the confusion of hospitals regarding proper coding of treatment units and to CMS' inability to determine an appropriate CCR for HBOT because hospitals reported their costs under many cost centers. The commenter recommended that CMS use an external analysis that it indicated reproduces an accurate CCR for HBOT, calculated using a consistent and transparent methodology. *Response:*
                         We believe that the final median cost for APC 0659 ($97.20 per unit) is an appropriate relative cost to be used to set the weights upon which the HBOT payment will be based. CY 2007 is the third year in which we have used a special methodology to develop the median cost for HBOT services that removed obviously erroneous claims and deviated from our standard methodology of using departmental CCRs, when available, to convert hospitals' charges to costs. Prior to CY 2005, our inclusion of significant numbers of miscoded claims in the median calculation for HBOT and our exclusion of the claims for multiple units of treatment, the typical scenario, resulted in payment rates that were artificially elevated. As explained earlier, beginning in CY 2005 and continuing through the present, we have adjusted the CCR used in the conversion of charges to costs for these services so that claims data would more accurately reflect the relative costs of the services. The median costs of HBOT calculated using this methodology have been reasonably stable for the last 3 years. We believe that this adjustment through use of the hospitals' overall CCRs is all that is necessary to yield a valid median cost for establishing a scaled weight for HBOT services. After carefully considering the public comments received, we are finalizing our proposed methodology for estimating a “per unit” median cost for HCPCS code C1300, assigned to APC 0659, without modification for CY 2007. d. Guidance for Chemodenervation (APC 0215) For CY 2006, new CPT codes 95873 (Electrical stimulation for guidance in conjunction with chemodenervation) and 95874 (Needle electromyography for guidance in conjunction with chemodenervation) were provided interim final assignments to APC 0215 (Level I Nerve and Muscle Tests). The proposed APC assignments of the codes for CY 2007 were unchanged. *Comment:*
                         One commenter requested that CMS reevaluate the APC assignments for CPT codes 95873 and 95874 when data become available. The commenter believed that it would be appropriate to assign the codes to two different payment levels based on their different resource requirements, but the commenter understood the CMS decision to assign them both to one APC pending data development. *Response:*
                         We appreciate the commenter's request, and we will reevaluate the assignment for both of the new codes for the CY 2008 update to the OPPS. After carefully considering the public comment received, we are finalizing our proposal to assign CPT codes 95873 and 95874 to APC 0215 for CY 2007, without modification. e. Pathology Services (APC 0344) In Addendum B of the CY 2007 proposed rule (71 FR 49709), we proposed to assign a payment rate of $49.90 to APC 0344 (Level IV Pathology Services). *Comment:*
                         Many commenters considered the proposed payment rate for APC 0344 to be low, especially when compared with the MPFS payment for these same laboratory CPT codes that are assigned to APC 0344. Several commenters indicated that the payment rate of $49.90 was far below the level of payment necessary for performing these tests in the hospital outpatient settings. One commenter cautioned that the cost differential between the hospital OPPS and the MPFS would result in a site-of-service differential. The commenter submitted a table showing differences in payments between the OPPS and the MPFS. The commenter believed that the payment levels for these laboratory services should be the same as or equal under both Medicare payment systems. The commenter asked that CMS establish payment equity for the same service furnished in these respective settings. Several commenters urged CMS to review the payment rate for APC 0344, and assign a payment rate that reflects the complexity and resource costs associated with providing these services. *Response:*
                         The statutory method for calculating payment for physicians' practice expenses under the MPFS differs from the general statutory method we use for establishing payment rates in the hospital outpatient setting. Consequently, the application of the different methodologies results in different payment amounts in the two settings. Payment for services assigned to APC 0344 for CY 2007 will be made based upon the median cost of the APC, established according to the standard OPPS methodology from CY 2005 hospital outpatient claims. The median costs of individual services assigned to APC 0344 do not violate the 2 times rule. The claims data used to establish the APC median cost are stable and robust, and the APC is appropriately structured to include only those procedures with common clinical and resource features. After carefully considering the public comments received, we are finalizing the APC 0344 structure as proposed without modification. The final CY 2007 median cost of APC 0344 is $48.44, upon which its payment rate is based. IV. OPPS Payment Changes for Devices A. Treatment of Device-Dependent APCs 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 pass-through 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 
                        ( print page 68064)
                        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 pass-through 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 pass-through 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 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 because we believed 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 device-coded claims in median calculations as a proxy for completeness of the coding and charges on the claims. For the CY 2005 OPPS, we adjusted device-dependent 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. In addition, we 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 of commenters 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. CY 2007 Payment Policy For CY 2007, we proposed 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 device-dependent APCs. In the case of some procedures assigned to other device-dependent 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. At its February 2006 meeting, the APC Panel recommended that CMS consider calculating the median costs for APCs 0107 (Insertion of Cardioverter Defibrillator) and 0108 (Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads) by bypassing the line-item costs of CPT code 33241 (Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator 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 
                        ( print page 68065)
                        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 APC 0108, the packaging on the claim is appropriately assigned to the procedure code in APC 0107 or APC 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 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 passed the device edits and contained no token charges for devices were shown in Table 19 of the CY 2007 OPPS proposed rule (71 FR 49573) and 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 of 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 of 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, we believed that 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. As we noted in the CY 2007 proposed rule, packaging the costs of intraoperative electrophysiologic testing of the ICD leads yielded many more single bills on which to set median costs and also increased the median costs for APCs 0106, 0107, 0108, and 0418. Therefore, we proposed to package CPT codes 93640 and 93641 for CY 2007. Furthermore, the APC Panel, at its August 2006 meeting, recommended that CMS use readily available external data to validate the costs derived from claims data. While CMS reviews all information that comes to our attention, we have not systematically used external data to validate the median costs derived from our claims data, because external data are typically furnished by parties with special interest in a particular item or service. Therefore, it is of limited usefulness in determining the relative cost of all items and services paid under the OPPS. In a system of relative weights, it is the relativity of the costs of services to one another, as derived from a standardized system that uses standardized inputs and a consistent methodology, that is the foundation of the system. The relationship between the actual acquisition cost of a particular item or service compared to the relative cost derived from the standard system for a single item or service is of little value. For the proposed rule, 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 were 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 lacked appropriate device codes (where there are edits) and bills with token charges for devices, were in many cases less than the medians calculated using only claims that contained appropriate device codes without token charges for the devices. In some cases, the medians were significantly different when claims either without device codes or which had only token device charges were removed. In the CY 2007 proposed rule, we noted that we believed that the claims that reflected the best estimated costs for these APCs, including the costs of the devices, were those claims that contain appropriate device codes without 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.) Therefore, we proposed to base the payment rates for CY 2007 for these device-dependent APCs on median costs calculated using claims with appropriate device codes with no token charges for devices reported on the claim. We did not believe that adjustment of these median costs was necessary to provide adequate payment for these services, and, therefore, we did not propose to adjust the median costs for these APCs to moderate any decreases in medians from CY 2006 to CY 2007. However, we noted in the proposed rule 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, we noted that 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. Therefore, we proposed that use of claims that met the device edits and that 
                        ( print page 68066)
                        did not contain token charges for devices were the appropriate claims to use to set the median costs for the device-dependent APCs, ensuring that the costs of the principal devices were included in the APC medians. In addition, we proposed that, with our proposed changes to the OPPS packaging status of two codes for electrophysiologic evaluation of ICD leads, no special payment policies would be needed to establish payment rates that correctly reflect the relative costs of these procedures to other procedures paid under the OPPS. We received a number of public comments concerning our CY 2007 proposed payment policies for device-dependent APCs. *Comment:*
                         The commenters supported limiting the set of claims used to calculate median costs for device-dependent APCs to claims that passed the device edits and did not contain device charges less than $1.01 to calculate median costs. In addition, some commenters asked CMS to remove claims with residual charges in cases in which recalled devices were replaced by upgraded devices or a different type of device, as was done when we removed token charge claims, so that the full cost of the device would be wholly represented in the procedure claims used for ratesetting. Several commenters objected to the proposed payment rates on the basis that hospitals report the units and charges for devices incorrectly, leading to incomplete and inaccurate claims data. They also believed that the CMS methodology of applying CCRs to charges for device-intensive services results in median costs that do not reflect the true relative costs of those services. They believed that hospitals do not mark up their charges for high cost items sufficiently to result in the actual cost of the item, a phenomenon generally known as “charge compression.” The commenters stated that hospitals are inhibited by market and other forces from charging at a level necessary for the application of the CCR to result in an accurate estimate of the cost of the device. Some commenters offered specific statistical strategies for calculation of adjustment factors that could be applied to the charges for devices to overcome the effects of charge compression. The commenters urged CMS to examine these strategies for their potential application to calculation of median costs and to use the charge compression analysis currently underway for Medicare inpatient billings to initiate a similar analysis for Medicare outpatient hospital payments. They indicated that the proposed payment rates for device-dependent APCs would set payments at such a low level that hospitals were likely to cease furnishing these services so that beneficiaries would no longer have access to needed care. The commenters urged CMS to use external data in place of median costs derived from claims data and to protect all such external data used for ratesetting from public disclosure. *Response:*
                         We continue to believe that it is appropriate to calculate the median costs to be used for establishing the payment rates in CY 2007 for device-dependent APCs using only claims that do not contain token charges for devices and that contain the devices that are appropriate for the procedure code, where there are HCPCS codes for such devices. We proposed to exclude all claims containing token charges because there were a number of actions in CY 2005 (the year of claims being used for the CY 2007 OPPS update) that caused hospitals to replace devices that they received without cost from manufacturers, and we advised hospitals to report a token charge for these devices. We will reassess whether exclusion of token charges is necessary for future years because, effective January 1, 2006, devices furnished without cost to the provider will be identified with modifier “FB” and exclusion of claims with token charges may no longer be necessary. We proposed to exclude claims that did not contain appropriate devices, as defined by the device edits on the CMS Web site, to maximize the likelihood that we would be basing the median costs for device-dependent APCs on claims that contained the full charge for the service, including the device. However, we did not exclude claims that contained residual charges for upgrades of replaced devices for which hospitals received credits from manufacturers because it was not possible to identify them systematically. Moreover, because we are calculating a median cost and commenters inform us that upgraded devices represent only 10 to 15 percent of cases in which devices are replaced without cost or with credit for the replaced device, we believe that those claims would have minimal influence on the calculation of the device-dependent APC median cost used for ratesetting. By basing weights on the median cost where the median is the 50th percentile of the array, a relatively small number of unusually low values (as would likely be represented by 10 to 15 percent of a relatively small number of devices replaced without any or full cost) is not likely to significantly affect the median cost. We recognize that the use of the hospital's CCR, even at the departmental level, results in computed costs and relative weights that may be more or less than the actual costs for items in specific cases. We believe that this average is appropriate and inherent in PPS. One of the principles behind the use of median costs for weight setting in a budget neutral payment system like the OPPS is to determine the appropriate relativity in resource use among services, thus allowing fair and equitable distribution of payment among hospitals based on their mix of services provided to Medicare beneficiaries. The median costs are not intended to represent the actual acquisition costs of the services being furnished. They are estimated relative costs that are converted to relative weights, scaled for budget neutrality and then multiplied by a conversion factor to derive a payment under a PPS and are not intended to pay reasonable costs. For this reason, we believe that it is not appropriate to use external pricing information in place of the costs derived from the claims and Medicare cost report data, because we believe that to do so would distort the relativity that is so important to the system's integrity. Similarly, we do not believe that it is appropriate to remove specific claims from contributing to ratesetting if the hospital charge for a particular item does not exceed an established threshold. However, we recognize that there may be value in exploring the extent to which the estimated relative costs derived from claims and cost report data deviate so substantially from acquisition costs that payment adjustments may be appropriate. Therefore, we are interested in further studying the analytic technique suggested in the comments that would involve the use of a regression analysis to identify adjustments that could be made to the CCRs to account for charge compression. We note that the regression model furnished with some comments was only applied to expensive medical supplies and devices. It was not applied uniformly to develop potential adjustments that could be made to costs and charges across all revenue codes and cost centers that could potentially be subject to charge compression. If such a model were to be applied in the OPPS, we believe further analysis would have to be undertaken to determine whether it should apply to all costs and cost centers. At this time, we intend to study whether a rigorous model could provide a payment adjustment for charge compression to the extent it exists. 
                        ( print page 68067) We recognize that the issues the commenters raise regarding charge compression apply both to the OPPS weight setting and to the setting of the DRG weights that are an important determinant of payment under the IPPS for inpatient hospital services. Accordingly, CMS has awarded a 1-year contract to RTI International to study methods of improving estimates of the cost of Medicare inpatient hospital discharges used in constructing the DRG relative weights. The RTI contract will focus on methods of improving the accuracy of the adjustment of charges to cost to account for the fact that hospitals tend to mark up high cost items to a lesser extent than they mark up low cost items, the phenomenon known as charge compression. The study will also examine how charge compression interacts with other variables in the construction of the DRG relative weights, such as the number of cost centers included and whether hospital-specific relative values are used. To the extent that we find charge compression exists, we will further study potential models that could adjust for it so we might develop a more accurate system of cost-based weights to better reflect the relative costs of the different types of services provided under the OPPS. We plan to fully involve appropriate stakeholders in future analysis of this issue to the extent feasible. Before implementing such an adjustment, we would thoroughly describe our analysis and a potential proposed adjustment as part of the OPPS rulemaking process. Further, we intend to use the charge compression study that we will conduct over the next year as an opportunity to better understand the costs of medical devices. With regard to the comment that providers are ceasing to provide services that require devices, we have no data that causes us to believe that there is a problem with access to care. In fact, the volume and intensity of OPPS services are growing significantly each year. As we indicated in section XIX. of this final rule with comment period, Medicare program payment under the OPPS is expected to reach $32.54 billion in CY 2007, an increase of approximately 9 percent from the projected program payment of $29.809 billion in CY 2006. *Comment:*
                         A number of commenters urged CMS to make adjustments to the CY 2007 payment rates for device-dependent APCs to account for charge compression. Specifically, some commenters recommended that CMS set the APC payment rates based on the higher of the median cost calculated using only claims that contain appropriate devices and do not contain token charges for devices or 90 percent of the CY 2006 payment median because to do otherwise would result in discontinuation of some services that require high cost devices. Other commenters urged CMS to set the median cost at no less than 100 percent of the CY 2006 median cost plus the market basket update for CY 2007. Some commenters believed CMS should use only claims on which the charges for their devices equaled or exceeded minimum thresholds that would be set based on amounts they specified. In several cases, the commenters asked that CMS do this due to the billing of residual charges for upgraded devices that replaced recalled devices. In other cases, they recommended thresholds because they believed that hospital charges for devices were too low, thereby resulting in inadequate APC median costs for establishing the CY 2007 payment rates for device-dependent procedures and their packaged devices. *Response:*
                         We do not believe that it is necessary or appropriate to set the median cost for these device-dependent APCs at 100 percent of the CY 2006 payment median plus the update factor or at 90 percent of the CY 2006 payment median, or to otherwise override the estimated median costs derived from the claims process proposed, using only claims that contained device codes where appropriate and that did not contain token charges. Because the devices that are required for many of these services came off pass-through payment in CY 2003, we have implemented device edits to maximize the likelihood that the charges for the devices are included on the claim. Over the past several years, we provided for adjustments to the median costs of device-dependent APCs where the cost data for the OPPS update resulted in a decline in the median from one year to the next. We indicated in the CY 2006 final rule (70 FR 68620) that we fully expected to be able to transition to full use of the claims data without adjustment for CY 2007. We see no reason why we should limit the decrease in CY 2007 median cost for those APCs for which the median cost declines compared to the adjusted CY 2006 payment median cost. The nature of a payment system that is based on relative weights is that the weights vary from year to year. Any change in the median cost for an APC, whether one with a high device cost or not, is a function of many complex factors, including, but not limited to, the extent to which hospitals increase charges for some items and services at a different rate than charges for other items and services. As such, the median cost of any particular item or service is largely a function of both its costs and the various charging practices of the hospitals that bill the services. Hospitals have now had 6 years experience with the OPPS, 4 of which were after the expiration of pass-through payments for most devices. We believe that hospitals make thoughtful decisions regarding how they want to report and charge for device-dependent procedures in the context of the effects of those decisions on their payments by Medicare and other payers. *Comment:*
                         Some commenters objected to the application of the wage index to the payment for device-dependent APCs. They argued that it creates inequities for hospitals that have low wage indices, due to the application of the wage adjustment to 60 percent of the APC rate, even though the cost of the device is often much more than 60 percent of the APC payment and the device costs are the same regardless of the location of the facility. The commenters objected to hospitals in high cost areas receiving a premium for providing these service, and hospitals in low cost areas receiving what they viewed as a payment penalty for furnishing these services. The commenters asked that the wage index be applied only to 20 percent, rather than the current 60 percent, of the payment for certain device-dependent APCs, specifically 0039, 0107, 0108, 0222, 0224, 0225, 0226, 0227, 0315, 0418, 0654, 0655, and 0656. *Response:*
                         The immediate effect of changing the application of the wage index from 60 percent to 20 percent for these APCs is likely to lower payments to hospitals in high cost areas, which we believe likely provide the higher volumes of these services, and to raise payments in low cost areas that likely furnish fewer services. Therefore, we believe that such a change would actually result in lower overall OPPS payment for the procedures. Moreover, any such suggested change could not be done in isolation. At the beginning of the OPPS, we performed a regression analysis resulting in a determination to wage adjust 60 percent of the payment for each APC. This analysis examined the extent to which the body of costs for services furnished in the outpatient department was split between wage and nonwage costs. We determined that 60 percent is an average across all service types, many of which have significant labor costs (for example, visits, drug administration services, and diagnostic tests). We reaffirmed the appropriateness of applying the wage 
                        ( print page 68068)
                        index to 60 percent of the APC payment during our development of the CY 2006 OPPS (70 FR 68533). By definition, as an average across all services, a standard wage adjustment could not be linked to specific services, particularly the least expensive and most expensive services. To change the application of the wage index for certain device-dependent APCs as commenters request would require reassessing the application of the wage index to all services. In the CY 2006 OPPS final rule, we committed to assessing the effects of the wage index on the device-dependent APCs. We are continuing our efforts in this area. *Comment:*
                         Some commenters fully supported packaging CPT codes 93640 (Electrophysiological evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation) and 93641 (Electrophysiological evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation; with testing of single or dual chamber cardioverter defibrillator) because this approach greatly increased the number of single bills that were available for calculating the median costs of APCs 0107 and 0108. Other commenters objected to the packaging of these CPT codes where they appeared on a claim unless the claim also contained a HCPCS code assigned to APCs 0107, 0108, and 0106. Some commenters also objected to packaging 93640 and 93641 into services assigned to APC 0418 because they believed that the packaged services were not performed at the time that procedures in APC 0418 were performed. They were concerned that packaging these testing codes inappropriately raised the median cost of APC 0418. *Response:*
                         We continue to believe that the costs of CPT codes 93640 and 93641 are appropriately packaged because they are performed only during the course of identifiable surgical procedures. Under the OPPS data development process, the cost of a packaged HCPCS code on a claim is added to the cost of the single major procedure code that is reported on the same claim, along with other packaged costs also on the claim. In that manner, separate payment for the procedure provides payment for the packaged HCPCS code as well. Because of the enormous number of HCPCS codes, it is not practical to include logic that specifies that a particular HCPCS code is packaged with specified services but not with others. We rely upon hospitals to correctly code the claims they report to Medicare because they have significant incentives to do so (such as, payment and audit concerns). After carefully considering the public comments received, we are finalizing our proposed payment policies for device-dependent APCs for CY 2007. The CY 2007 payment rates for device-dependent APCs are based on their median costs calculated from CY 2005 nontoken claims that passed the device edits, without application of a maximum payment reduction floor in comparison with CY 2006 payment medians. Discussions of HCPCS code and APC-specific issues for device-dependent APCs are found in section III.D of this preamble, where other APC-specific policies are also discussed. 
 
  
 
  3. Devices Billed in the Absence of an Appropriate Procedure Code As we discussed in the proposed rule (71 FR 49573), in the course of examining claims data for creation of the payment rates for the CY 2007 OPPS 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 have led to the costs of the device being packaged with an incorrect procedure code and also have caused 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. 
                        ( print page 68071) As we stated in the proposed rule, we examined our CY 2005 claims data and found that incorrect billing occurred more often with some devices than with others. As noted in the CY 2007 OPPS proposed rule (71 FR 49573), we expected to implement device to procedure code edits for the specified devices and their associated procedures, that we believed 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 were used. The devices for which we expected to implement edits are shown below in Table 19, as well as in Table 20 of the proposed rule (71 FR 49573 and 49574), 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. As noted in the proposed rule (71 FR 49573), we believed that the establishment of claims edits reflected merely standard operational and administrative practice. However, as the public may assist in establishing appropriate edits, we, therefore, asked that comments regarding the specific associations of device codes and procedure codes be provided to the following email address: 
                        *OutpatientPPS@cms.hhs.gov.*
                         This is the same email address to which comments on the existing procedure to device edits should be directed. Comments submitted on this issue to this mail box were not comments on the proposed rule and as stated in our proposed rule (71 FR 49573), we are not responding to them in this CY 2007 OPPS final rule. However, we are taking this opportunity to advise the public that we will implement these edits effective with the January 2007 OCE. The edits will be posted on the OPPS Web site at 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​,*
                         and as with the device edits currently in place, we will continue to accept comments on them indefinitely at the email address identified above. Table 19.—Devices Which Must Be Billed With Associated Procedure Codes
Device
DescriptionC1721
AICD, dual chamber.C1722
AICD, single chamber.C1767
Generator, neuro non-recharg.C1777
Lead, AICD, endo single coil.C1778
Lead, neurostimulator.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 rate-resp.C2620
Pmkr, single, non rate-resp.C2621
Pmkr, other than sing/dual.
 4. 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 noted in the proposed rule that we believed that incidental device failures that are covered by manufacturer warranties occur routinely. While we understood that some device malfunctions might be inevitable as medical technology grows increasingly sophisticated, we believed that early recognition of problems would reduce the number of people with the potential to be adversely affected by these device problems. We indicated our belief that 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. As indicated in the CY 2007 OPPS proposed rule (71 FR 49574), 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) in partnership with the Heart Rhythm Society 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. As we indicated in the proposed rule, we encouraged 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 
                        ( print page 68072)
                        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, in the proposed rule we stated that we believed 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 noted that we have a fiduciary responsibility to the Medicare trust fund to ensure that Medicare pays only for covered services. Therefore, we proposed, 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 device is replaced without cost to the hospital or with full credit for the removed device. Specifically, we proposed to revise the existing regulations by adding new § 419.45, Payment and copayment reduction for replaced devices. This proposed regulation was 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. As proposed, 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. We proposed that 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. We also proposed that the beneficiary's copayment amount would be calculated based on the reduced APC payment rate. We indicated that we believed that this would be appropriate because in these cases the full cost of the replaced device would not be incurred and, therefore, we believed that an adjustment to the APC payment would be necessary to remove the cost of the device. We also indicated that we believe that the averaging nature of the calculation of the amount of the adjustment would cause 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. Moreover, we stated that we also believe that the proposed adjustment was 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 proposed 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. As we indicated in the proposed rule, we recognized 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 believed 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 for the service. As we discuss above, we proposed 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. 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 
                        ( print page 68073)
                        excessive payments in these circumstances, as noted previously we proposed 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 was of greater cost than the originally implanted device. We proposed that the adjustment would be limited to the APCs listed in Table 21, of the CY 2007 OPPS proposed rule (71 FR 49577) but only when the purpose of the procedure was to replace a device that was reported by a HCPCS code in Table 22 of that rule (71 FR 71 FR 49578), which was furnished without cost or at full credit by the manufacturer. We proposed 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 of the proposed rule on the basis of these three criteria. The first criterion we proposed was 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 was not needed or where it might or might not be needed to perform a procedure, we did not believe that reducing the payment for the APCs would be appropriate because the charges for the devices were unlikely to be a significant factor in establishing the rates for the APCs. The second criterion we proposed was 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 believed this was necessary to establish that the replacement device was a direct replacement for the device being removed. In cases of failures of devices that were surgically inserted or implanted but did not remain in the patient's body after the conclusion of procedures, we believe that it was highly likely that the replacement device was 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 was used, there was no savings to the hospital. For example, if a vascular catheter failed during a procedure, we believed that the physician would probably 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 believed that if a replacement catheter was 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 expected 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 we proposed was 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 defined a significant offset percent as exceeding 40 percent. We believed that this percent was appropriate because our studies have shown that approximately 60 percent of the cost of OPPS services is wage-related, 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 believed that once the device share of an APC exceeded 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 proposed to define the device costs as “significant” for purposes of this proposed policy. We recognized in the proposed rule that it might 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 indicated that 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 proposed to 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 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 (Implantation of Neurological Device) when current pass-through device C1820 (Generator, neuro rechg bat sys) is billed on the same claim. We indicated in the proposed rule that we believed that it was appropriate to apply this same methodology in circumstances when we needed to remove the cost of the device from the APC payment, not because the device was being paid under pass-through but because the hospital was either not incurring the cost for the replaced device or had been given full credit for the replaced device (71 FR 49576). In both cases, the intent was to remove the cost of the device from the APC payment rate. Using this methodology, we calculated the proposed offset amounts by first calculating an APC median cost including device costs and then calculating a median cost excluding device costs, using only single bills that met our device edits and did 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 we proposed 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, based upon CY 2007 
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                        proposed rule data 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 (Table 21 of the proposed rule at 71 FR 49577) 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 would be 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 pass-through status (no ICD currently has pass-through status) and if the reduction amount in Table 21 of the proposed rule were the appropriate reduction amount. We proposed 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 proposed that when a device was replaced without cost to the hospital under warranty or recall or a credit was 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 would apply to the unadjusted APC payment if the inpatient deductible were not exceeded. We proposed this because we believed that it was appropriate to reduce the beneficiary copayment in these cases because the device was being furnished or credited by the manufacturer without obligation on the part of the beneficiary. We noted, however, that in the case of some high cost APCs, making the payment adjustment in a recall or warranty situation might not result in reduction of the copayment because the copayment, although based on the reduced payment rate, might continue to exceed the inpatient deductible and, therefore, would continue to be set at the inpatient deductible. As we discussed in the proposed rule, this contrasted with the case of pass-through devices, where the beneficiary was liable for the copayment on the full APC amount (which, in the case of high cost APCs, was limited to the Medicare inpatient deductible) but paid no copayment for the incremental cost of the pass-through device. We stated that this was appropriate in the case of payment for pass-through devices because the hospital incurred costs for both the service and the device, and Medicare paid for both the service through the full APC 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 was 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 proposed 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. We proposed that 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 was that the procedure was assigned to one of the APCs in Table 21 of the proposed rule. We have discussed above the criteria that we employed for selecting the APCs to which we proposed that this policy would apply. We proposed that the second condition would be that the device for which the manufacturer furnished a replacement device (or provided credit for the device being replaced) would be one of the devices included in Table 22 of the proposed rule. We proposed to restrict the devices to which the adjustment would apply to those included in Table 22 of the proposed rule in order to ensure that the adjustment would not be triggered by the replacement of an inexpensive device whose cost would not constitute a significant proportion of the total payment rate for an APC. We also proposed that the presence of the modifier would trigger the adjustment in payment for the APCs in Table 21 of the proposed rule. While we recognized that this would create a reporting burden for hospitals, we indicated that we believed that the reporting requirement would be unavoidable. Only hospitals could report whether the circumstances for reduced payment as described above were met and, therefore, we saw no option other than to have hospitals report this information to us. We recognized that the current FB modifier (“Item furnished without cost to provider, supplier or practitioner”) might not be appropriate in cases in which the replacement device was a more expensive device than the device being removed and that it might need to be changed to expand its use for all potential APC payment adjustment scenarios. We noted in the proposed rule that we believed that 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 could explore them to see if there are systemic problems with certain devices. We believed that 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. We also stated that we believed that 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, we explained that we believed that 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, we noted that we believed that it would also identify those claims that contained reduced device charges due to the full credit provided by the manufacturer for a replaced device so that in the future we could assess the impact of these claims on median costs for the services into which the device costs are packaged. We proposed that the policy would be effective for services furnished on or after January 1, 2007. We believed that this proposed policy was necessary to enable us to secure claims data that might be used to identify trends in device problems that led to device replacements, and that it would also be necessary to fulfill our fiduciary responsibility to the Medicare program by not providing payments for items that were excluded from coverage under Medicare law because neither the beneficiary nor any party on his or her behalf had an obligation to pay. At its August 2006 meeting, the APC Panel recommended that CMS evaluate the proposed percentage adjustments in cases in which the device is furnished without cost or with credit for the replaced device to ensure that they have taken into account the administrative 
                        ( print page 68075)
                        resources required for hospitals to provide the replacement devices. In reviewing this recommendation, we have carefully considered the issue of administrative costs involved in furnishing the replacement devices and have concluded that the residual payment for the procedure should adequately compensate the provider for all administrative costs of furnishing the services, whether the device is furnished with or without cost to the provider. We elaborate on our responses to this recommendation in the discussion below. We received a number of comments on our discussion of data collection and the potential use of that data from a public health perspective. We agree with commenters that only data elements required to answer predefined questions should be collected. In addition to serving a public health role, we agree that data collection in registries may offer transparency once devices are on the market. We also agree with commenters that registry data may not be sufficient to develop clinical practice guidelines, and we believe that the process in place by many medical professional societies appropriately establishes guidelines based on the strength of evidence in which evidence from controlled clinical trials would be stronger than registry data. We received a number of public comments regarding Coverage with Evidence Development (CED) and registry funding that are outside the scope of this rule; therefore, we are not responding to them in this final rule with comment period. We received several public comments concerning our proposal for CY 2007. A summary of the comments and our responses follow. *Comment:*
                         Some commenters supported the proposed policy in cases in which the hospital incurs no cost for the device being replaced under warranty or otherwise without cost by the manufacturer. However, other commenters stated that the proposal to remove 100 percent of the cost of the devices is not appropriate because of the acquisition, handling, and administrative costs associated with the acquisition of the replacement device. The commenters indicated that although the hospital does not pay for the device, the hospital must record the special “no charge” status of the device, advise the finance and patient accounts departments how to charge for it, and report to Medicare that the procedure involves replacement of a defective device. They pointed out that although the device may be acquired without cost to the hospital, the hospital nevertheless incurs costs due to the special handling of the billing and accounting for the device. One commenter proposed that CMS reduce the APC payment by 70 to 80 percent of the offset amount rather than by the entire offset amount. Another commenter agreed with the proposed policy, provided that CMS excludes claims for these APCs that are reported with condition code 50 from the median cost calculation because including them would understate the device costs that should be packaged. Some commenters objected to the application of the policy in the case of upgraded devices in which the hospital is given a credit for the device that is covered under warranty but the hospital must pay the difference between the manufacturer's charge for the replaced device and the upgraded device being inserted and in the case of replacement under warranty in which there is a partial credit because the warranty does not cover the full replacement cost of the device. The commenters indicated that the same issue arises when one type of device is replaced with a different type of device (for example, a pacemaker being replaced under warranty by an ICD), whose procedural payment may be provided through a different APC than the procedural APC associated with the device being replaced. The commenters argued that these cases should be exempt from any reduction, notwithstanding that the hospital receives a credit for the device being replaced. Other commenters urged CMS to reduce the amount of the adjustment to the APC payment rate in these cases. They offered to work with CMS to develop the amount of the reduction that would apply in such situations. *Response:*
                         We continue to believe that it is appropriate to reduce the amount of the APC payment by the full estimated percentage of device cost, both in cases in which the hospital receives the device without cost and in cases in which the hospital receives a credit toward an upgrade for the device that is being replaced. We are concerned about a payment policy that would apply a smaller APC payment percentage reduction in upgrade cases, because we have no way of estimating an appropriate offset amount based on the CY 2005 claims data. We are unable to identify upgrade cases in our CY 2005 claims data, and we will not be able to identify such claims until our CY 2007 data are available for the CY 2009 OPPS update. In the meantime, we believe that our two alternatives would be either to provide the full APC payment or reduce the APC payment by the relevant full offset amount. We believe that making the full APC payment would result in significant overpayment because we are specifically establishing our CY 2007 payment rates based on claims where hospitals incur device costs, and in most cases those claims would include the full device costs. If we were to take no APC payment reduction in upgrade cases, such an approach would favor device upgrades, rather than replacement with a comparable device, in warranty or recall cases where the surgical procedure to replace the device with an upgraded device is only medically necessary because of the original defective device, for which the manufacturer bears responsibility. As discussed above, we calculated the CY 2007 payment rates for the APCs subject to the reduction policy using only claims which contained appropriate devices and for which there were no token charges for the devices. We used this methodology to maximize the probability that we captured all of the costs of the devices in these APCs in all situations where hospitals incurred costs to provide the devices. Therefore, in our median cost calculations for these device-dependent APCs, we used both claims where the hospital bore the full cost of the device and those where the hospital bore a partial device cost due to a manufacturer credit in an upgrade situation. The amounts by which we will reduce the payment for these APCs are calculated using the device costs that are found in the very same set of claims on which we calculated the median costs for the device-dependent APCs. As such, we believe that the percentages represent the best estimate of costs attributable to the devices, for which in most cases the hospital incurs no cost or, in the case of upgraded devices or partial credits, a reduced cost, and those costs are packaged into the APC payments. Moreover, commenters told us that upgrades account for only 10 to 15 percent of the cases where devices are replaced under warranty or recall. Thus, we believe it is appropriate to use the same device percentage for the APC payment reduction in both cases of device replacement without cost to the hospital and device upgrade with a manufacturer credit. We recognize that in some cases the estimated amount of device cost, and therefore the amount of the payment reduction, will be more or less than the hospital cost of the device in a specific clinical circumstance, but as averaging is inherent in a prospective 
                        ( print page 68076)
                        payment system, we do not believe that it is inappropriate. As described below in reference to the use of modifier FB in CY 2007, once we have CY 2007 claims data we expect that we would be able to examine the costs of device upgrades in recall or warranty replacement cases to see if they are typically significantly greater than the costs of replacement of a device without cost to the hospital. However, until we have data available that permit examination of the differential average costs in these two situations, we intend to provide payment of procedures where a manufacturer credit is provided toward an upgraded device at the same rate we would pay if a replacement device were provided by the manufacturer at no cost, by applying the same APC payment reduction in both situations. In this way, we will avoid significant overpayments while we collect claims data for future examination to see if an alternative payment policy could be warranted. Moreover, we do not believe that it is necessary to reduce the amount of the adjustment for administrative costs in these cases, as we believe that these costs are part of the payment that remains for the services furnished. Administrative costs vary significantly, with more resource-intensive administrative actions occasionally required even for the simplest services at times. Hence, we believe that the averaging nature of the payment that remains for the hospital procedural services should provide fair and adequate payment for these routine costs. With regard to the comment that we should exclude claims reported with condition code 50 from the median cost calculation because including them would understate the device costs that should be packaged, we do not agree. Condition code 50, “Product replacement for known recall of a product—Manufacturer or FDA has identified the product for recall and therefore replacement,” is placed on the claim at a claim level, not at a line level, and thus does not provide the level of specificity that the FB modifier provides. We expect to use the presence of the FB modifier on the line with the procedure code, as discussed below, to determine which claims should be removed from the set of claims used for calculation of the median cost. *Comment:*
                         Several commenters asked how the FB modifier would apply in cases of a credit for an upgrade in a warranty or recall situation. The commenters asked CMS to create a second modifier for use when there is a device upgrade or change in device type so that CMS could exclude those claims from the calculation of the median cost for the devices and more accurately apply an appropriate reduction in these cases. The commenters also questioned how the multiple procedure discount would apply when the procedure is reported with an FB modifier, signifying that the device was replaced or credited under warranty. Specifically, commenters indicated that all of the APCs for which we proposed this policy have status indicator “T” and that, therefore, their payment would be reduced by 50 percent if there was a higher paid service on the same date of service. The commenters objected to a policy that would first reduce the payment for the APC due to a recall and then also reduce the payment rate if there was a more costly procedure on the claim with a status indicator of “T.” *Response:*
                         Effective January 1, 2007, the definition of the FB modifier will read: “Item Provided Without Cost to Provider, Supplier, or Practitioner or credit received for replaced device (Examples, but not limited to: Covered under warranty, replaced due to defect, free sample).” Hospitals will be instructed to append the modifier to the HCPCS code for the procedure in which the device was inserted on claims when the device that was replaced under warranty, recall or field action is one of the devices in Table 21 below. Claims containing the FB modifier will not be accepted unless the modifier is on a procedure code with status indicator “S,” “T,” “V” or “X.” In cases in which the device being replaced is replaced without cost, the provider will report a token device charge. In cases in which the device being inserted is an upgrade (either of the same type of device or to a different type of device), the provider will report as the device charge the difference between its usual charge for the device being replaced and the credit for the replacement device. CMS will be able to identify whether the device was replaced without cost by the presence of the token charge. Where there is not a token charge for the device but there is an FB modifier on a HCPCS code, CMS will assume that an upgrade occurred. Therefore, we believe that with the change in the definition of the FB modifier as of January 2007, we have no need to establish a second modifier for device replacement situations where a manufacturer provides a credit toward an upgraded device. If the APC to which the procedure code is assigned is one of the APCs listed in Table 20 below, the fiscal intermediary will reduce the unadjusted payment rate for the procedure by an amount equal to the percent in Table 20 times the unadjusted payment rate. We intend to publish the actual adjustment amounts on the CMS website after publication of this final rule with comment period. If the FB modifier is assigned to a procedure code that is not on Table 21, then no adjustment will be taken. The adjustment will occur before wage adjustment and before the assessment to determine if a multiple procedure reduction applies. There may be cases where, after removal of the device cost, the remaining payment for the service is less than the payment for another procedure with a status indicator of “T,” and the multiple procedure reduction would apply. We believe this multiple procedure reduction continues to be appropriate even after the APC payment adjustment to remove payment for the device costs, because there would still be the expected efficiencies in performing the procedure if it were provided in the same operative session as another surgical procedure. Thus, it would be appropriate for the remaining procedural payment to be reduced by 50 percent, consistent with our well-established multiple surgical procedure reduction policy. Similarly, if the procedure is interrupted before administration of anesthesia and appended with modifier 73 or if the reduced services modifier 52 appears on the line with the procedure code, the 50 percent reduction will be taken from the adjusted payment amount as well. We believe that it is appropriate to treat the service subject to the APC payment reduction in cases of devices replaced without cost or with a full credit received like any other service and to apply the standard reduction policies. *Comment:*
                         One commenter objected to the application of a different offset percentage to APC 0385 (Level I Prosthetic Urology) than for APC 0386 (Level II Prosthetic Urology) for purposes of the adjustment when a device is replaced without cost or with credit for the device being replaced. The commenter stated that the ratio of device costs to overall procedure costs is basically identical for both ,and, therefore, the offset percent should be 60 percent for both. *Response:*
                         We disagree. The APC 0385 device percentage is 46.86 percent and the APC 0386 percentage is 61.16 percent. Therefore, we conclude that the device cost in APC 0386 is significantly higher than the device code in APC 385, and it would not be appropriate to assign the same percentage to both. After carefully considering the public comments received, we are finalizing our proposed CY 2007 policy for reduction of APC payments in cases of 
                        ( print page 68077)
                        device replacement without cost or when a full credit is received without modification. We are also making a technical change to the title of the regulation at new section 419.45 to better reflect our policy to reduce the APC payment in cases of devices replaced without cost or where full credit is received. The title of the proposed regulation does not reflect the entire policy as proposed or finalized as it references only devices replaced under warranty or as a result of recall. The revised title to section 419.45 is “Payment and copayment reduction for devices replaced without cost or full credit is received.” Table 20.—Adjustments to APCs in Cases of Devices Reported Without Cost or for Which Full Credit Is Received
APC
SI
APC group title
CY 2007 
                                 offset  
                                 percent0039
S
Level I Implantation of Neurostimulator
78.850040
S
Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve
54.060061
S
Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excludin
60.060089
T
Insertion/Replacement of Permanent Pacemaker and Electrodes
77.110090
T
Insertion/Replacement of Pacemaker Pulse Generator
74.740106
T
Insertion/Replacement/Repair of Pacemaker and/or Electrodes
41.880107
T
Insertion of Cardioverter-Defibrillator
90.440108
T
Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads
89.400222
T
Implantation of Neurological Device
77.650225
S
Implantation of Neurostimulator Electrodes, Cranial Nerve
79.040227
T
Implantation of Drug Infusion Device
80.270229
T
Transcatherter Placement of Intravascular Shunts
46.170259
T
Level VI ENT Procedures
84.610315
T
Level II Implantation of Neurostimulator
76.030385
S
Level I Prosthetic Urological Procedures
83.190386
S
Level II Prosthetic Urological Procedures
61.160418
T
Insertion of Left Ventricular Pacing Elect.
87.320654
T
Insertion/Replacement of a permanent dual chamber pacemaker
77.350655
T
Insertion/Replacement/Conversion of a permanent dual chamber pacemaker
76.590680
S
Insertion of Patient Activated Event Recorders
76.400681
T
Knee Arthroplasty
73.37
 Table 21.—Devices for Which the FB Modifier Must Be Reported With the Procedure Code When Furnished Without Cost or at Full Credit for a Replaced Device
Device
DescriptionC1721
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. Pass-Through Payments for Devices 1. Expiration of Transitional Pass-Through 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 pass-through 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 proposed 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 
                        ( print page 68078)
                        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 pass-through 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 pass-through 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. 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. For CY 2007, we proposed to continue to make payment under the pass-through provisions for category C1820. We proposed that this category would expire from pass-through payment after December 31, 2007 (71 FR 49578). 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. We did not receive any public comments concerning this proposal. Therefore, we are finalizing our proposal to expire category C1820, Generator, neurostimulator (implantable), with rechargeable battery and charging system, from pass-through payment after December 31, 2007 without modification. 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 based on single claims with device codes but 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 based on single claims 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, developed from the claims with device codes also reported enabled us to determine the percentage of the median APC cost that was attributable to the associated pass-through 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 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 pass-through 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 (generally C-codes) 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 were 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 were 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 C-codes 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 device HCPCS codes represented the typical costs of all hospitals providing the services. Therefore, we did not use CY 2004 claims with device codes 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 
                        ( print page 68079)
                        contributions of device costs to total procedural costs in the outpatient hospital environment of CY 2006. 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 were packaged into the existing APC structure based on partial CY 2005 claims data. 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 cost for the applicable APC 0222 contained costs for neurostimulators that were similar to neurostimulators described by 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 HCPCS codes and their charges when hospitals bill for services that utilize devices described by the existing device codes. In addition, during CY 2005, we implemented device edits for many services that require devices and for which appropriate device HCPCS codes exist. Therefore, we expected that the number of claims that included 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 proposed 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 proposed 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 proposed 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 HCPCS code reporting was required. b. Policies for CY 2007 For CY 2007, we proposed 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 proposed 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 will continue for pass-through 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 proposed 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 OPPS update. Based on full year CY 2005 claims data used for this final rule with comment period, the offset amount for C1820 is 77.65 percent of the final CY 2007 payment rate for APC 0222. (See Addendum A of this CY 2007 OPPS final rule with comment period for a listing of the final CY 2007 APC payment rates.) We proposed to continue our existing policy of establishing new 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 CY 2005 claims data contain a sufficient number of claims with identifiable costs associated with the new category of devices in any APC, we proposed to reduce the transitional pass-through payment for the device by the related procedural APC offset amount 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 proposed to announce the offset amount in the program transmittal that announces the new category. In summary, for CY 2007, we proposed to use CY 2005 hospital claims data to calculate device percentages and potential offsets for CY 2007 applications for new device categories. We proposed to publish, through quarterly program transmittals, any new or updated offsets that we calculate for CY 2007, corresponding to newly created categories or existing categories, respectively. After the CY 2007 proposed OPPS rule was published and prior to the publication of this final rule with comment period, we determined that we would establish two new device categories for transitional pass-through payment. Therefore, we are announcing our offset policy for these two device categories, whose coding and payment information is found in Addenda A and B. We have established device categories L8690 (Auditory osseointegrated device, external sound processor, replacement) and C1821 (Interspinous process distraction device (implantable)) for pass-through payment, effective January 1, 2007. As stated earlier, beginning in CY 2004 and now continuing through CY 2007, we apply an offset to a new device category only when we determine that an APC contains costs associated with a related device. We have determined that we cannot identify device-related costs in the procedural APCs we expect will be billed with either of the new categories L8690 or C1821, that is, in APC 0256 or APC 0050, respectively. Therefore, we are setting the offset amount to $0 for device categories L8690 and C1821 for CY 2007. We did not receive any public comments concerning our CY 2007 proposals for calculating device percentages and potential offset amounts. Therefore, we are finalizing our proposals without modification, and specifically applying them to device categories C1820, L8690, and C1821, as discussed above. V. OPPS Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals A Transitional Pass-Through Payment for Additional Costs of Drugs and Biologicals 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, 
                        ( print page 68080)
                        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. Proposed pass-through drugs and biologicals are assigned status indicator “G” in Addenda A and B of the CY 2007 OPPS proposed rule. The pass-through application and review process is explained on the CMS Web site at 
                        *http://www.cms.hhs.gov*. 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. This payment methodology is set forth in § 419.64 of the regulations. 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 for drugs and biologicals described in section 1842(o)(1)(C) of the Act that are furnished on or after January 1, 2005. The ASP methodology uses several sources of data as a basis for payment, including ASP, wholesale acquisition cost (WAC), and average wholesale price (AWP). In this final rule with comment period, the terms “ASP methodology” and “ASP-based” are inclusive of all data sources and methodologies described therein. Additional information on the ASP methodology can be found at 
                        *http://www.cms.hhs.gov/​McrPartBDrugAvgSalesPrice/​01_​overview.asp#TopOfPage*. Section 1833(t)(6)(D)(i) 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 1847B of the Act, as added by section 303(d) of Pub. L. 108-173, establishes the payment methodology for Medicare Part B drugs and biologicals under the competitive acquisition program (CAP). The Part B drug CAP was implemented July 1, 2006, and includes approximately 180 of the most common Part B drugs provided in the physician office setting. The list of drugs and biologicals covered under the Part B drug CAP, their associated payment rates and the Part B drug CAP pricing methodology can be found at 
                        *http://www.cms.hhs.gov/​CompetitiveAcquisforBios*. For CY 2007, we proposed to pay for drugs and biologicals that are granted pass-through status under the OPPS and that are included in the Part B drug CAP at a payment rate equal to the rate these drugs would be paid under the Part B drug CAP. We had several comments about this proposal. *Comment:*
                         Commenters expressed concern that Part B drug CAP rates are insufficient to cover the costs hospitals incur for drugs, as the CAP rate is an average of eligible approved CAP vendor bids, and hospitals are not able to obtain drugs at the CAP rates because they are statutorily excluded from the CAP program. The commenters suggested that the rate for all pass-through drugs should, therefore, be set to the ASP methodology, regardless of the drug's inclusion in the Part B drug CAP. *Response:*
                         As discussed above, our proposed methodology for setting payment rates for pass-through drugs that are also a part of the Part B drug CAP program is mandated by section 1833(t)(6)(D)(i) of the Act. In addition, we note that, for the two pass-through drugs that we proposed to pay at the Part B drug CAP rate in CY 2007, the Part B drug CAP rate exceeds the rate resulting from the October update of the ASP methodology for both drugs. Therefore, we disagree that the Part B drug CAP rate undermines hospitals' ability to procure drugs that are paid at this rate while on pass-through. *Comment:*
                         Commenters requested that CMS clarify the amount that we would pay for pass-through drugs and biologicals that are also included as part of the Part B drug CAP. Specifically, the commenters asked for clarification of how CMS determines the Part B drug CAP rate. *Response:*
                         As discussed above, the statutory language requires that if a drug or biological is covered under a competitive acquisition contract under section 1847B of the Act, the OPPS pass-through 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. As of the time of this final rule with comment period, the Part B drug CAP includes one national competitive acquisition area and one national vendor. Therefore, the average payment across all competitive acquisition areas at this time is also equal to the rate paid to the national vendor. We refer the public to the CY 2006 MPFS final rule (70 FR 70236) for a full description of the Part B CAP. *Comment:*
                         Commenters stated that pass-through payments were required by law to be paid on a drug-by-drug basis, and therefore a payment based on the Part B drug CAP process that incorporates many drugs across several vendors would violate this drug-specific requirement. *Response:*
                         We disagree that these statutory requirements pose a conflict. The Part B drug CAP program payment determination is performed on a drug-by-drug basis and complements the provisions of the pass-through concept. (For more information on the Part B drug CAP payment rate methodology, see section II.C.3. of the Interim Rule entitled “Competitive Acquisition of Outpatient Drugs and Biologicals Under Part B” which was published at the 
                        **Federal Register**
                         on July 6, 2005 (70 FR 39069) and section II.H.6. of the final rule entitled “Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2006 and Certain Provisions Related to the Competitive Acquisition Program of Outpatient Drugs and Biologicals Under Part B” which was published in the 
                        **Federal Register**
                         on November 21, 2005 (70 FR 70236).) For the reasons set forth in the section above, we are finalizing our proposed policy to pay for drugs and biologicals with pass-through status in CY 2007 that are also covered under the Part B drug CAP at the rate each drug would be paid under the Part B drug CAP. 2. Drugs and Biologicals With Expiring Pass-Through Status in CY 2006 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. 
                        ( print page 68081)
                        In Table 23 of the CY 2007 OPPS proposed rule (71 FR 49580), we proposed to allow the expiration of the pass-through status for 12 drugs and biologicals on December 31, 2006. We also proposed to delete temporary CY 2006 C-codes if an alternate permanent HCPCS code was available for purposes of OPPS billing and payment in CY 2007. There are seven pass-through drugs, identified with an asterisk (*) in Table22 below, that are paid under the OPPS for CY 2006 at the rate established by the Part B drug CAP. In CY 2007, these drugs, in accordance with OPPS policy for all non-pass through drugs, biologicals, and radiopharmaceuticals, are subject to the established OPPS payment methodologies discussed in section V.B of this final rule with comment period. Based on our review of the existing permanent HCPCS codes available at the time of the CY 2007 OPPS proposed rule, we determined that HCPCS code J7344 (Nonmetabolic active tissue) appropriately described the product reported under HCPCS code C9221 in the CY 2006 OPPS. We proposed to delete HCPCS code C9221 and instruct hospitals to use HCPCS code J7344 for services furnished on or after January 1, 2007. We did not receive any comments on this proposal. Therefore, we are finalizing our proposal without modification. Since the publication of the proposed rule, we have determined that HCPCS code J7319 (Sodium hyaluronate injection) appropriately describes the product reported under HCPCS code C9220, and that HCPCS code J7346 (Injectable human tissue) appropriately describes the product reported under HCPCS code C9222 as shown in Table 23 of the CY 2007 OPPS proposed rule. Therefore, in accordance with the policy described above, we are deleting HCPCS codes C9220 and C9222, and instructing hospitals to use HCPCS codes J7319 and J7346, respectively, for services furnished on or after January 1, 2007. We did not receive any public comments concerning our proposed policy for CY 2007. Therefore, we are finalizing our proposal to discontinue pass-through status as of December 31, 2006, for the 12 drugs and biologicals shown in Table 22 below. In addition, Table 22 indicates the final CY 2007 coding changes for these drugs and biologicals. Table 22.—List of Drugs and Biologicals for Which Pass-Through Status Expires December 31, 2006
CY 2007 
                                 HCPCS
CY 2006 
                                 HCPCS
CY 2007 
                                 APC
CY 2007 short descriptorJ7319
C9220
0896
Sodium hyaluronate injectionJ7344
C9221
9156
Nonmetabolic active tissueJ7346
C9222
9222
Injectable human tissueJ0128*

9216
Abarelix injectionJ0878*

9124
Daptomycin injectionJ2357*

9300
Omalizumab injectionJ2783

0738
RasburicaseJ2794*

9125
Risperidone, long actingJ7518

9219
Mycophenolic acidJ9035*

9214
Bevacizumab injectionJ9055*

9215
Cetuximab injectionJ9305*

9213
Pemetrexed injection* Indicates that the drug was paid at a rate determined by the Part B drug CAP methodology while identified as pass-through under the OPPS.
 3. Drugs and Biologicals With Pass-Through Status in CY 2007 In the CY 2007 OPPS proposed rule, we proposed to continue pass-through status in CY 2007 for the nine drugs and biologicals listed in Table 24 (71 FR 49582) that had received pass-through status as of April 1, 2006. We also assigned these APCs and HCPCS codes status indicator “G” in Addenda A and B of the CY 2007 proposed rule. We proposed to pay for drugs and biologicals that are not included in the Part B drug CAP at a rate equal 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 § 414.904 and generally be equal to ASP+6 percent. We received several comments on our proposal to pay for pass-through drugs and biologicals that are not included in the Part B drug CAP at the rate these drugs would receive in the physician office setting. *Comment:*
                         Many commenters supported our proposal to provide payment in CY 2007 for drugs and biologicals with pass-through status at the rate these drugs and biologicals would receive in the physician office setting. However, one commenter stated that the purpose of pass-through payments is to recognize additional costs that hospitals incur when providing new and expensive drugs and biologicals that are not yet reflected in the OPPS APC payment rates. Therefore, the commenter added, pass-through drugs and biologicals should be subject to a methodology that provides an additional payment, above the payment methodology provided to non-pass through drugs and biologicals. *Response:*
                         We appreciate the commenters' support for our proposed policy. In addition, we agree that the purpose of pass-through payments is to recognize and support hospitals that provide innovative and expensive therapies before these costs are reflected in the OPPS APC payment amounts. However, drugs are paid through their own drug specific APCs, typically at a rate that is based on the ASP methodology that reflects recent market prices. Payment rates for separately payable drugs are updated quarterly and do not rely on the most recent set of OPPS hospital claims data that results in the 2-year difference between hospital claims and OPPS payment rates experienced by other APCs. Therefore, we do not believe that pass-through drugs require a separate methodology or payments above the methodology used to set payment rates for other drugs. As discussed in section V.A.1. of this preamble, pass-through payments for CY 2007 are made under the OPPS for drugs and biologicals that are also included in the Part B drug CAP at the rate established by the Part B drug CAP. At the time of the proposed rule, two drugs (HCPCS codes J2503 (Pegaptanib sodium injection) and J9264 (Paclitaxel protein bound)) were approved for pass-through payments in CY 2007 that were also covered under the Part B drug CAP. 
                        ( print page 68082)
                        As we have established above, payment for these drugs will be amounts determined under the Part B drug CAP, which will be at a rate slightly different than the rate determined under the ASP methodology. Pass-through rates for all other CY 2007 pass-through drugs will be at a rate equal to the rate paid in the physician office setting, as determined by the ASP methodology. This information is updated quarterly as part of the ASP methodology process, and OPPS payment rates are adjusted accordingly. Additional information on this ASP methodology is available at 
                        *http://www.cms.hhs.gov/​McrPartBDrugAvgSalesPrice/​.* 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 proposed to base its payment on the WAC for the product as ASP data for radiopharmaceuticals are not available. In addition, we proposed to calculate payment for the radiopharmaceutical at 95 percent of its most recent AWP if WAC information was also not available. We proposed 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 received several comments on this proposal. *Comment:*
                         Several commenters requested that CMS pay separately for all radiopharmaceuticals at hospital charges reduced to cost using the hospital specific overall CCR. *Response:*
                         Comments received relating to nonpass-through radiopharmaceuticals are addressed in section V.B.3. of this preamble, and comments received regarding our proposed payment methodology for nonpass-through drugs, biologicals and radiopharmaceuticals without claims data are discussed in section V.B.3.b. of this preamble. Our CY 2007 proposal to pay for pass-through radiopharmaceuticals at WAC was closely aligned with our proposal to pay for separately payable nonpass-through radiopharmaceuticals based on mean unit costs calculated from CY 2005 hospital claims data. As we discuss in section V.B.3. of this preamble, after careful consideration of all comments received, we are not finalizing this proposal for separately payable nonpass-through radiopharmaceuticals. Therefore, we are also not finalizing our proposal to use a prospective WAC-based payment methodology for pass-through radiopharmaceuticals in CY 2007. We believe it is appropriate to align our payment methodologies, whenever possible, within the OPPS. Therefore, for CY 2007, we are finalizing our payment policy for pass-through radiopharmaceuticals as follows: For CY 2007, hospitals will receive payment for radiopharmaceuticals that are granted pass-through status in CY 2007 at the hospital's charge for the radiopharmaceutical adjusted to the cost, using the hospital's overall CCR. This methodology will provide payment for radiopharmaceuticals granted pass-through status in CY 2007 based on the same payment methodology that will be used to provide payment for separately payable nonpass-through radiopharmaceuticals in CY 2007 in the OPPS. We discuss in section V.B.3.b. of this final rule with comment period that we are making 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 pass-through application for the item. Accordingly, in CY 2007 the pass-through 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. In the proposed rule, we used payment rates based on the ASP data from the fourth quarter of CY 2005 for budget neutrality estimates, impact analyses, and completion of Addenda A and B of the proposed rule because these were the most recent data available to us during the development of the proposed rule. We proposed to update this data with the most recent data available for purposes of the final rule with comment period. We received no comments on this proposal. Therefore, we have updated the payment rates for budget neutrality estimates, impact analyses, and completion of Addenda A and B of this final rule with comment period to reflect payment rates based on ASP data effective October 1, 2006, as this is the most recent data available at the time of this final rule with comment period. In addition, to be consistent with the ASP-based payments that would be made when these drugs and biologicals are furnished in physician offices, we proposed to make any appropriate adjustments to the amounts shown in Addenda A and B on a quarterly basis on the CMS Web site during CY 2007 if later quarter ASP methodology calculations indicate that adjustments to the payment rates for these pass-through drugs and biologicals are necessary, or in the event that they become covered under the competitive acquisition program. The payment rate for a radiopharmaceutical with pass-through status would also be adjusted accordingly. In Table 24 of the proposed rule, we listed the drugs and biologicals for which we proposed that pass-through status continue in CY 2007 (71 FR 49581). We assigned pass-through status to these drugs and biologicals as of April 1, 2006 and identified them in Addenda A and B of the proposed rule with status indicator “G.” *Comment:*
                         One commenter supported our pass-through determination for C9228 (Injection, tigecycline), and one commenter supported our pass-through determination for Q4079 (Natalizumab injection) for CY 2007. *Response:*
                         We appreciate the commenters' support of our pass-through decisions for these drugs. Since the time of the proposed rule, we have granted pass-through status in CY 2007 to an additional nine drugs and biologicals. In addition, in accordance with the established policy discussed above, we are deleting six temporary CY 2006 C-codes because we have identified an alternate permanent HCPCS code that is available for purposes of OPPS billing and payment in CY 2007. These temporary codes, and their permanent HCPCS replacement codes, are listed in Table 23 along with all drugs and biologicals that we are finalizing for pass-through payments in CY 2007 under the OPPS. In addition, we have identified with an asterisk (*) those pass-through drugs for CY 2007 OPPS that are also included in the Part B drug CAP. 
                        ( print page 68083) Table 23.—List of Drugs and Biologicals With Pass-Through Status in CY 2007
CY 2007 
                                 final  
                                 HCPCS
CY 2007 proposed rule HCPCS
APC
Short descriptorC9232
**
9232
Injection,  idursulfase.C9233
**
9233
Injection, ranibizumab.C9350
**
9350
Porous collagen tube per cm.C9351
**
9351
Acellular derm tissue percm2.J0129
C9230**
9230
Abatacept injection.J0348
**
0760
Anadulafungin injection.J0894
C9231**
9231
Decitabine injection.J1740
C9229**
9229
Injection ibandronate sodium.J2248
C9227
9227
Micafungin sodium injection.J2278
J2278
1694
Ziconotide injection.J2503*
J2503
1697
Pegaptanib sodium injection.J3243
C9228
9228
Tigecycline injection.J3473
**
0806
Hyaluronidase recombinant.J7311
C9225
9225
Fluocinolone acetonide implt.J8501
J8501
0868
Oral aprepitant.J9027
J9027
1710
Clofarabine injection.J9264*
J9264
1712
Paclitaxel protein bound.Q4079
Q4079
9126
Natalizumab injection.* Indicates that the drug is included in the Part B drug CAP and will be paid at this methodology in 2007.** Pass-through status was granted after publication of the CY 2007 OPPS proposed rule.
 B. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Status 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, set the threshold for establishing separate APCs for drugs and biologicals at $50 per administration for CYs 2005 and 2006. Therefore, for CY 2006, we paid 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. In addition, we extended an exception to this packaging policy for oral and injectable 5HT3 forms of anti-emetic treatments (70 FR 68635 through 68638) for CY 2006. At the August 2006 APC Panel meeting, the Panel recommended that CMS allow providers to use all available HCPCS codes for reporting drugs in the OPPS to reduce the administrative burden associated with reporting drugs using only HCPCS codes with the lowest increments in their code descriptors. We include our response to this recommendation in the discussion below. *Comment:*
                         Several commenters recommended that CMS allow all drug, biological, and radiopharmaceutical HCPCS codes to be recognized under the OPPS, as opposed to our current policy that does not recognize some codes because they are not the lowest dosage unit HCPCS code available for an item. *Response:*
                         We appreciate these comments, as well as the efforts of the commenters to identify specific drugs where the OPPS currently recognizes only one of several HCPS codes. As is our longstanding interest, we are considerate of situations where hospitals may experience an administrative burden that could possibly be reduced with a change in OPPS policy. In general, the current practice of the HCPCS National Panel is to establish only one HCPCS code for a particular drug with a single appropriate dose descriptor for reporting all doses, whereas historically more than one HCPCS code may have been created with different dose descriptors for the same drug. Typically, under the OPPS, we have only recognized a single HCPCS code with the lowest dose descriptor, as this approach assists us in data collection for OPPS ratesetting purposes and allows hospitals to accurately reflect all doses administered by billing a variety of units in relation to the drug's dose descriptor. Our current practice is to make a packaging determination based on historical hospital claims data for each drug, biological, and radiopharmaceutical HCPCS code that we recognize under the OPPS. Therefore, we generally determine the packaging status for the lowest dose descriptor that exists for a particular 
                        ( print page 68084)
                        drug, as other doses are typically assigned status indictor “B” (Not recognized under OPPS; alternate code may be available). If we were to recognize all the HCPCS codes that may exist for a single drug, we would need to consider the ramifications of such a substantial change on our ratesetting methodology. For example, we would need to consider whether to adjust our methodology to provide packaging decisions based upon a particular drug, rather than making a determination for each HCPCS code. If we did not adjust our methodology, we could have variable packaging determinations for multiple HCPCS codes that described the same drug, and it is not clear whether this would be appropriate. Therefore, we are not accepting the recommendation of the APC Panel and the commenters to recognize all available HCPCS codes in the CY 2007 OPPS. However, we will further explore the issues surrounding such an approach for the future, to further develop our understanding of the implications of such a change. We continue to believe that the current HCPCS codes recognized under the OPPS allow hospitals to accurately report all doses of the drugs, biologicals, and radiopharmaceuticals they administer. 2. Criteria for Packaging Payment for Drugs, Biologicals, and Radiopharmaceuticals 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. As this provision expires at the end of CY 2006, we provided a discussion in the proposed rule of four packaging level options that were considered 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. We determined that this would be a straightforward policy that would speed the creation of procedural APC medians; however, we expressed concern that this policy would be inconsistent with OPPS packaging principles, would reduce hospitals' incentives for economy and efficiency, and would increase hospitals' administrative burden related to separate billing for more drugs, biologicals, and radiopharmaceuticals. During the August 2006 meeting of the APC Panel, the Panel endorsed this option and recommended that CMS eliminate the drug packaging threshold for all drugs and radiopharmaceuticals with HCPCS codes. We include our response to the Panel's recommendation in our discussion below. In addition to the APC Panel's recommendation, we received several comments requesting that we pay separately for all drugs, biologicals and radiopharmaceuticals (or combination thereof) with HCPCS codes that are provided in the hospital outpatient department and payable under the OPPS. *Comment:*
                         Two commenters acknowledged that unpackaging all drugs, biologicals and radiopharmaceuticals is inconsistent with the concept of a prospective payment system. However, one of these commenters contended that packaged items may not be fully accounted for in the OPPS ratesetting process, and these costs therefore may not appear in the final payment rates established for the primary service. For this reason, the commenter believed that the OPPS should pay separately for all drugs, biologicals, and radiopharmaceuticals. The commenter further asserted that the OPPS’ inability to use multiple procedure bills exacerbates the problem because multiple procedure claims are more likely to include packaged drugs, biologicals, and radiopharmaceuticals. *Response:*
                         We agree that unpackaging all drugs, biologicals and radiopharmaceuticals is inconsistent with the concept of a prospective payment system. We have not been presented with any data that support the commenter's assertion that multiple procedure claims would be more likely to include packaged drugs, biologicals, and radiopharmaceuticals. Multiple procedure claims contain a variety of services, including surgical procedures, diagnostic imaging tests, visits, and laboratory procedures that also could have significant associated packaging in addition to drugs, biologicals, and radiopharmaceuticals, such as devices, minor ancillary procedures, anesthesia, operating room time, and recovery room time. As we have previously indicated, we are unable to use these claims for ratesetting because we cannot attribute the packaging appropriately to the individual services on the claims. However, we would not expect the amount of drug, biological, and radiopharmaceutical packaging to be proportionately higher for these multiple procedure claims compared to the amount of drug packaging contained on the single drug administration claims we use for ratesetting. In fact, we might expect that the percentage of total costs related to packaged drugs on these multiple claims to be significantly less than the comparable percentage for single claims for drug administration services. In addition, much of the packaged drug costs on multiple procedure claims might be more accurately associated with services other than drug administration services. Thus, we are unsure about the appropriate methodology and the ultimate utility of studies to examine drug, biological, and radiopharmaceutical packaging on multiple claims. In section VIII.C. of this preamble, we provide a preliminary analysis of a study we performed in response to the APC Panel's March 2006 recommendation to further explore how packaged drug, biological, and radiopharmaceutical costs are accounted for within the OPPS ratesetting methodology so that their costs are incorporated into payment rates for associated drug administration procedures. The same analysis provides a preliminary response to the APC Panel's August 2006 recommendation that CMS provide claims analysis of the contributions of packaged costs (considering packaged drugs and other packaging) to the median cost of each drug administration service. *Comment:*
                         Several commenters asserted that separate payment for all drugs and biologicals under the OPPS was appropriate in the light of CMS's efforts to align payments across the physician office and hospital outpatient settings, for example, by adopting the ASP methodology in both settings. The commenters stated that continuing a policy of packaging certain items in the hospital outpatient setting would continue an inequality in payment between these settings. We also received several comments specifically against our proposal to set the packaging threshold for radiopharmaceuticals at $55. These commenters requested that we pay separately for all radiopharmaceuticals. *Response:*
                         While we believe that payment parity is appropriate for certain items in order to provide appropriate access to care without undesirable site of service shifts, the OPPS and MPFS are fundamentally different payment systems with essential differences in their payment policies. Specifically, the OPPS is a prospective payment system, based on the concept of paying for groups of services that share clinical and resource characteristics. Payment is made in the OPPS according to prospectively established payment rates that are related to the relative costs of hospital resources for services. The MPFS is a fee schedule that generally provides payment for each individual 
                        ( print page 68085)
                        component of a service. Differences in the degrees of packaged payment and separate payment between these two systems are only to be expected. In general, we do not believe that our packaging methodology under the OPPS creates issues that result in limiting beneficiary access to care. In those rare circumstances where we believe a situation may cause problems with beneficiary access or where our packaging methodology may unduly influence physicians' treatment decisions, in the best interest of Medicare beneficiaries, we have modified our packaging methodology, as is the case for 5HT3 anti-emetics. At this time there is neither sufficient reason, nor have we been presented with information, that leads us to consider modifying our packaging policy for radiopharmaceuticals. *Comment:*
                         Several commenters disagreed with our assertion that unpackaging all drugs and biologicals with HCPCS codes would increase the burden on hospitals, as many hospitals are following CMS' request to report charges for all drugs, biologicals, and radiopharmaceuticals with HCPCS codes, regardless of the packaging status of the particular item. However, another commenter agreed with our statement and explained that eliminating the packaging threshold for drugs, biologicals and radiopharmaceuticals would not only increase the administrative burden of hospitals, but that this change would lead to unexpected payment decreases for other services payable under the OPPS, because the OPPS is a budget neutral payment system. *Response:*
                         We appreciate these comments. We understand that the impact of increased coding responsibilities that would accompany a change in our packaging policy would likely vary from hospital to hospital. We appreciate the efforts of hospitals to include data for packaged services on their claims as it continues to provide us with a robust data set which we can use for both future ratesetting and development of OPPS payment policies. We note that in CYs 2005 and 2006, the statutorily mandated drug packaging threshold was set at $50, and we believe it is appropriate to continue a modest drug packaging threshold for the CY 2007 OPPS, consistent with the framework provided in the law. Therefore, because of our continued belief that packaging is a fundamental component of a prospective payment system that contributes to important flexibility and efficiency in the delivery of high quality outpatient hospital services, we are not adopting the option of paying separately for all drugs, biologicals, and radiopharmaceuticals for CY 2007. Accordingly, we also are not adopting the August 2006 APC Panel recommendation presented above. The second option we presented in the CY 2007 proposed rule was to increase the packaging threshold to a level much higher than the current $50 threshold. As we discussed, we believed that this option would be more consistent with OPPS packaging principles by packaging more drugs, biologicals, and radiopharmaceuticals. In addition, we stated that we believed this option would also provide greater administrative simplicity for hospitals. However, we expressed concern that implementation of this option might result in circumstances where drug administration payments could be less than the cost of the packaged drugs, as relatively expensive drugs, biologicals, and radiopharmaceuticals could become packaged under this option. We received no comments on this option and we are not adopting this methodology for CY 2007. The third option we presented in the CY 2007 proposed rule was to maintain the packaging threshold at $50. We discussed that maintaining the threshold would provide stability to the payment system, as the packaging threshold has been set at $50 since CY 2004. We also noted that this policy option would be consistent with the March 2006 APC Panel recommendation to maintain the packaging threshold at $50 in CY 2007. However we discussed our concern that this policy would not take into account price inflation and would, therefore, not be representative of real dollars in future years. We received one comment specifically on this option and a number of comments requesting this option if we decided to continue with a packaging methodology for the OPPS for CY 2007. *Comment:*
                         One commenter supported the March 2006 APC Panel recommendation to retain the $50 packaging threshold because it would help ensure adequate payments for hospitals, preserve stability in the payment policy, and continue to provide beneficiary access to care. *Response:*
                         We appreciate the commenter's support of the adequacy of the $50 threshold for drugs, biologicals, and radiopharmaceuticals. However, we have chosen to not to adopt this option, for the reasons discussed below. The final option discussed in the CY 2007 proposed rule was a variation of the previous option, where we proposed an annual update of the packaging threshold for inflation using an inflation adjustment factor based on the Producer Price Index (PPI) for prescription preparations. As described in the proposed rule, we calculated an adjusted packaging threshold for CY 2007 by using 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 proposed to apply an annual inflation adjustment factor that would be consistent with the practices of many health care payment policy areas, and many other areas of government policy, that acknowledge real costs by using an inflation adjustment factor instead of static dollar values. We discussed our concern that in the absence of a mechanism to update the threshold, we believed 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 the average sales price (ASP) data that are reported by their manufacturers, in the proposed rule we indicated that we believed that the PPI for prescription preparations would be an appropriate price index to use to update the packaging threshold for CY 2007 and beyond. Specifically, we proposed to adjust the packaging threshold by the PPI for prescription drugs each year, and round the adjusted dollar amount to the nearest $5 increment to identify the updated packaging threshold. We calculated the adjusted amount for CY 2007 at $55.99, rounded to $55. Therefore, for CY 2007 and beyond, we proposed to package all drugs, biologicals, and radiopharmaceuticals whose per day cost is less than or equal to $55 into the procedures with which they are billed. We explained that we believed that this proposal was consistent with the APC Panel's March 2006 recommendation to continue the $50 packaging threshold in CY 2007, because the real dollar value would be held constant during the calendar year in which it would be in effect. Our response to this recommendation is included in the discussion presented below. We received several comments on our proposal to provide an annual update of the packaging threshold using the four-quarter moving average PPI. *Comment:*
                         Most commenters, in general, disagreed with an increase to the packaging threshold. However, one commenter disagreed with our use of 
                        ( print page 68086)
                        the PPI as a basis for our annual packaging threshold update. The commenter explained that as the PPI includes information for all prescription medications, it includes information for drugs that are not covered under Part B benefits and may inaccurately represent the amount of inflation for Part B drugs. The commenter recommended that CMS calculate an inflation index using manufacturers' quarterly ASP data submissions. *Response:*
                         We appreciate the commenter's analysis of the applicability of the PPI and their proposed alternative methodology. There are a wide array of drugs that are covered under Part B of Medicare, and these drugs are used to treat a broad spectrum of clinical conditions in the hospital outpatient setting. These drugs range from monoclonal antibody agents, to complex chemotherapeutic agents, to antiemetics, to antibiotics, to narcotics, and to analgesics. The ASP system is relatively new, and we have only limited experience in following changes in manufacturers' data submissions over time. While we understand that the PPI includes drugs that may not be payable as a Part B benefit, we continue to believe that the PPI is a mature, well-established, and widely available index already used by Medicare that provides the most accurate estimate of Part B drug inflation for purposes of updating the OPPS drug packaging threshold each year. We intend to evaluate the applicability of the PPI as the drug packaging inflation adjustment factor as needed. Because we believe that packaging certain items is a fundamental component of a prospective payment system, that packaging these items does not lead to beneficiary access issues and does not create a problematic site of service differential, that a minimum $50 packaging threshold is reasonable based on its initial establishment in law for the CY 2005 OPPS, that updating the $50 threshold is consistent with industry and government practices, and that the PPI is an appropriate mechanism to gauge Part B drug inflation, we are finalizing our proposal to calculate an annual update to the OPPS packaging threshold using the proposed methodology without modification. Therefore, for CY 2007 and beyond, drugs, biologicals and radiopharmaceuticals that are not new and do not have pass-through status will be packaged if their calculated per day cost is equal to or less than $55 for CY 2007 or equal to or less than the updated threshold established, rounded to the nearest $5 increment, for the relevant update year. 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 proposed 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). In our calculation of per day costs for the CY 2007 OPPS proposed rule we used the manufacturer-submitted ASP data from the fourth quarter of CY 2005 (rates that were used for payment purposes in the physician office setting effective April 1, 2006) and a payment rate of ASP+5 percent, as our proposal was to pay for drugs and biologicals at ASP+5 percent for CY 2007. 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. For the proposed rule, we identified the items with per day cost less than or equal to $55 as packaged and identified items with per day cost greater than $55 as separately payable. Our policy during previous cycles of the OPPS has been to use updated data to establish final determinations of the packaging status of drugs, biologicals, and radiopharmaceuticals. We note it is also our policy to make an annual packaging determination at the time of the final rule. Only items that are identified as separately payable will be subject to quarterly updates as discussed in section V.B.3. of this preamble. Items that are finalized as packaged will be eligible for consideration of separate payment only for the next update of the OPPS. We proposed to use the ASP data from the first quarter of CY 2006 (reflected in payment rates in the physician office setting effective July 1, 2006) as a basis for our annual packaging determination for CY 2007, 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. As discussed in section V.B.3. of this preamble, for this CY 2007 final rule determination of packaging status we are also altering the payment rate used for the determination to reflect a payment rate of ASP+6 percent, based on our final CY 2007 policy, rather than the proposed rate of ASP+5 percent. Because the data we used in the proposed rule to calculate per day costs, and the payment rates applied to that data, have been updated for the final rule packaging status determination, the packaging status of certain drugs, biologicals, and radiopharmaceuticals may have changed. Under such circumstances, we proposed to apply the following policies to these drugs, biologicals, and radiopharmaceuticals whose relationship to the $55 threshold changed based on the final updated data: Drugs, biologicals, and radiopharmaceuticals that were paid separately in CY 2006 (which were 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 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 were 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 used for the CY 2007 final rule with comment period, would remain packaged in CY 2007.
                    Drugs, biologicals, and radiopharmaceuticals for which we proposed packaged payment in CY 2007 but then had per day costs greater than $55 based on the updated ASPs and hospital claims data used for the CY 2007 final rule with comment period, would receive separate payment in CY 2007. We received no comments on the methodology we proposed to use in the event that the packaging status of a drug had changed due to the data update between the proposed and final rules. Therefore, we are finalizing this proposal without modification. Table 24 below indicates those drugs, biologicals and radiopharmaceuticals that have changed packaging status between the proposed rule and the final rule, and indicates their final CY 2007 packaging status. 
                        ( print page 68087) Table 24.—Drugs, Biologicals and Radiopharmaceuticals That Experienced A Status Change Between the Proposed and Final CY 2007 OPPS Rules
CY 2007 
                                 HCPCS
Short description
CY 2007 
                                 proposed SI
CY 2007 
                                 final SI
CY 2007 
                                 final APCJ0580
Penicillin g benzathine inj
K
NJ1205
Chlorothiazide sodium inj
N
K
0747J2354
Octreotide inj, non-depot
K
NJ3320
Spectinomycn di-hcl inj
N
K
0753J8600
Melphalan oral 2 MG
K
NJ9040
Bleomycin sulfate injection
N
K
0748J9120
Dactinomycin actinomycin d
N
K
0752J9130
Dacarbazine 100 mg inj
N
K
0746J9230
Mechlorethamine hcl inj
N
K
0751
 For CY 2007, we also included a proposal to continue exempting the oral and injectable 5HT3 anti-emetic products from packaging, 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), it is our understanding that 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. In the proposed rule, we stated that we believed 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 received several supportive comments on this proposed policy for CY 2007. *Comment:*
                         Commenters commended CMS on the CY 2007 proposal to continue to pay separately for all 5HT3 antiemetics. *Response:*
                         We appreciate the support for our proposal, and we continue to believe that separate payment for these items is warranted for the reasons discussed above. Therefore, we are finalizing our proposal to exempt the 5HT3 antiemetics from the packaging threshold. As a result, the anti-emetics listed in Table 25 will receive separate payment status under the OPPS for CY 2007. Table 25.—Anti-Emetics Exempted from $55 Packaging Requirement
HCPCS code
Short descriptionJ1260
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.
 3. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Status That Are Not Packaged a. Payment for Specified Covered Outpatient Drugs (1) Background Section 1833(t)(14) of the Act, as added by section 621(a)(1) of Pub. L. 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. 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. In our data analysis for the CY 2006 OPPS final rule with comment period, we compared the payment rates for 
                        ( print page 68088)
                        drugs and biologicals using data from all three sources described above. We estimated aggregate expenditures for all drugs and biologicals 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. We excluded radiopharmaceuticals in our analysis because they were paid at hospital charges reduced to cost during CY 2006. 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 we 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. In consideration of this information, we stated in the CY 2006 OPPS final rule that payment rates derived from hospital claims data also included acquisition and pharmacy handling costs because they are derived directly from hospital charges. Therefore, in CY 2006, we finalized a policy of providing payment to hospital outpatient departments for drugs, biologicals and associated pharmacy handling costs at a rate of ASP+6 percent. (2) 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. 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 OPPS proposed rule, we evaluated the two data sources that were available to us for ratesetting purposes for drugs and biologicals in CY 2007. The first source presented in the proposed rule was based on the ASP methodology and included data from the fourth quarter of CY 2005, which were also the data used for payments in the physician office setting effective April 1, 2006. We stated that we have prices for approximately 500 drugs and biologicals (including contrast agents) payable under the OPPS using the ASP methodology (ASP+6 percent in most cases); however, we did not have any data from this source for radiopharmaceutical products. The second source of cost data for drugs, biologicals, and radiopharmaceuticals discussed in the OPPS proposed rule available for ratesetting purposes was CY 2005 hospital claims data, used to calculate mean and median costs for these items. 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. To determine our proposed payment rates for drugs and biologicals for CY 2007, we compared estimated aggregate expenditures for all drugs and biologicals (excluding radiopharmaceuticals) that would be separately payable in CY 2007 using data from both sources described above. We then used the OPPS proposed conversion factor to calculate weights for each separately payable drug and biological HCPCS code and developed an equivalent average ASP-based payment rate under both payment methodologies. The result of this analysis indicated 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 payment rates for these drugs and biologicals, on average, at ASP+5 percent. We again stated that this payment rate was representative of both hospital acquisition costs and pharmacy handling costs, as this ASP-based rate was calculated using hospital charge data, and hospital charges are inclusive of both acquisition costs and pharmacy handling costs for the particular drug. Therefore, for CY 2007, we proposed a policy of paying for the acquisition and overhead costs of separately paid drugs and biologicals at a combined rate of ASP+5 percent. We received several comments on our proposal to use these two data sources to calculate an average ASP-based payment rate for separately payable drugs and biologicals in the hospital outpatient department for CY 2007. *Comment:*
                         We received mixed comments about our proposal to continue to base OPPS payment rates for drugs and biologicals relative to the ASP methodology. A few commenters expressed their dissatisfaction with certain aspects of the ASP system, and as a result, our use of a payment rate relative to ASP. These commenters expressed concern that ASP rates reflect prompt pay discounts that hospitals do not experience, that the data represented by ASP reporting do not indicate hospital-specific prices, and that the inclusion of 340B prices skews ASP data because only a limited number of hospitals are eligible to receive these reduced prices. Other commenters who disagreed with our proposal to use the ASP methodology suggested that we conduct a survey to collect data on hospital acquisition costs and include factors such as size and type of hospital. However, other commenters expressed support of our continued use of the ASP-based methodology in the OPPS. *Response:*
                         We note that the ASP methodology has been established through rulemaking, and specific requests regarding methodological changes to this established system are outside the scope of this final rule with comment period. In addition, we note that we received numerous supportive comments regarding our proposal to use ASP as the basis for hospital payments in the OPPS for CY 2006. At that time, commenters generally supported the use of ASP as a payment methodology because these rates are updated quarterly and are therefore more reflective of current market conditions that influence hospital purchasing prices than hospital claims data, and payment equity across the hospital and physician office settings offers administrative benefits and does not create a site-of-service difference. Furthermore, comparison of the ASP data to our hospital claims data serves to ensure that we are paying for drugs in the OPPS in general at rates that are reflective of hospitals costs for acquisition and overhead. For these reasons, we continue to believe that ASP is an appropriate proxy of the 
                        ( print page 68089)
                        average acquisition and pharmacy overhead costs for drug and biologicals administered in the hospital outpatient setting. *Comment:*
                         Several commenters also addressed our methodology for determining the specific ASP-based payment rate including acquisition costs and pharmacy handling costs for separately payable drugs and biologicals that would equate to payment of drugs and biologicals based on their mean costs from claims data. Some commenters were confused about how our methodology resulted in a proposed payment at ASP+5 percent for CY 2007, while others disagreed with our methodology to only include separately payable drugs and biologicals in our calculations. The commenters theorized that due to hospital charge compression, pharmacy overhead costs for inexpensive drugs that are typically packaged under the OPPS exhibit a higher pharmacy handling cost relative to their acquisition cost because hospitals disproportionately load their pharmacy overhead costs in their charges for less costly drugs. Therefore, while hospitals may attribute costs associated with pharmacy services across all drugs, the costs associated with a particular drug do not necessarily encompass that drug's total pharmacy handling costs. The commenters believed that this results in an inaccurate ASP-based estimate for drugs and biologicals in the OPPS, because these lower cost packaged drugs that have proportionately greater pharmacy overhead costs in their charges are not used in our calculation, which is based only on those drugs with per day costs greater than the $55 packaging threshold. *Response:*
                         We included a detailed explanation of the methodology we used to determine our proposed average CY 2007 ASP-based payment inclusive of acquisition and pharmacy handling costs in the proposed rule (71 FR 49584), and we again discussed this methodology relative to the CY 2007 final ratesetting process above. We began our analysis by identifying those drugs and biologicals that we have determined will receive separate payment in CY 2007. (See section V.B.2. of this final rule with comment period for a discussion of the methodology we used to determine the packaging status for drugs, biologicals, and radiopharmaceuticals for CY 2007.) We do not include packaged drugs and biologicals in this analysis because cost data for these items are already accounted for within the APC rates setting process through the methodology discussed in section II.A. of this preamble. To include the costs of packaged drugs in both our APC ratesetting process (for associated procedures present on the same claim) and during our ratesetting process to establish a relative ASP-based payment amount for drugs and biologicals would give this data disproportionate emphasis in the OPPS system by skewing our analyses, as the costs of these packaged items would be, in effect, counted twice. Once we determined our final CY 2007 packaging policy for drugs, biologicals, and radiopharmaceuticals at a packaging threshold of $55 or less per day, we included the costs of these packaged drugs and biologicals in the standard OPPS calculation of procedural APC median costs. Accordingly, we are not implementing the suggestion from commenters that we include all packaged and separately payable drugs and biologicals when establishing an average ASP-based rate to provide payment for the hospital acquisition and pharmacy handling costs of drugs and biologicals. However, we remind commenters that because the costs of packaged drugs, including their pharmacy overhead costs, are packaged into the payments for the procedures in which they are administered, the OPPS provides payment for both the drugs and the associated pharmacy overhead costs through the applicable procedural APC payments. We noted that ASP data were unavailable for some drugs and biologicals at the time of the proposed rule, and some remain unavailable at the time of this final rule. For these drugs and biologicals, we proposed to use their mean unit costs from the CY 2005 hospital claims data to determine their packaging status for ratesetting. In addition, we proposed to base payment for these drugs and biologicals on their mean cost calculated from CY 2005 hospital claims data until ASP-based rates become available for these items. *Comment:*
                         One commenter requested that CMS use a drug's WAC or AWP data in order to determine an item's packaging status when ASP data are unavailable. *Response:*
                         We follow the established ASP methodology, and the ASP methodology incorporates several sources, such as WAC and AWP, as well as ASP data submitted by manufacturers. Additional information on the ASP methodology can be found at: 
                        *http://www.cms.hhs.gov/​McrPartBDrugAvgSalesPrice/​01_​overview.asp#TopOfPage.* We noted in the proposed rule that we determine the packaging status of each drug or biological for the following year only once during the annual update process; however, those drugs and biologicals that we determine will be separately payable during the next calendar year will receive quarterly updates to their ASP-based payment rates, as is the current process in both the OPPS and physician office setting. We indicated that in CY 2007, we will continue to post these quarterly payment rate changes on our Web site. 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 the proposed rule, we responded to these recommendations by stating that we would continue to work on issues related to pharmacy overhead costs, and we specifically requested public comments on methodologies that could be used when considering pharmacy overhead cost issues in future years. We again note that we regularly accept requests from interested organizations to discuss their views about OPPS payment policy issues, including pharmacy handling issues. As stated in our CY 2007 OPPS proposed rule (71 FR 49585), we 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). In addition, we establish the OPPS rates through regulations, and as such 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. The APC Panel recommended at its August 2006 meeting that CMS work with stakeholders to better understand the costs involved in the preparation of pharmaceutical agents for chemotherapy, and that CMS work to develop a new payment methodology that acknowledges and provides appropriate payment for those costs. The Panel requested a report on our findings at their next meeting. We will provide an update to the Panel on all the information that has been shared with us at their next meeting. We received many comments in response to our request for information related to hospital outpatient department pharmacy overhead costs. *Comment:*
                         A number of commenters expressed dissatisfaction with the 
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                        amount of pharmacy handling costs represented in the methodology that resulted in an aggregate payment for drug acquisition and pharmacy handling costs at ASP+6 percent in CY 2006. The commenters noted increased pharmacy costs, such as unfunded mandates, increased staff training in order to handle complex drugs, and multiple demands on the time of pharmacists, including quality verification requirements and patient or physician consultations, that contribute to pharmacy handling costs that are above the amount represented by the ASP+6 methodology after subtracting drug acquisition costs. Several of these commenters expressed disappointment that CMS had not implemented an administratively simple methodology for collecting hospital pharmacy overhead cost data that could be used as the basis for providing additional payments for pharmacy handling costs. Several commenters also expressed concern that the proposed payment of ASP+5 percent for CY 2007 would not be adequate to cover both the acquisition costs and pharmacy handling costs associated with drug services provided in a hospital outpatient department setting. One commenter suggested that CMS should, at a minimum, implement the two percent add-on payment that was discussed in the CY 2006 OPPS proposed rule. Others suggested various add-on payments, with amounts ranging from $10 for every billed drug, to inflating OPPS payment rates for separately payable drugs and biologicals to ASP+39 percent. MedPAC expressed concern that our proposal to pay for drugs and biologicals at ASP+5 percent, a proportional payment methodology, could result in inaccurate payments for individual drugs because it does not effectively account for large differences in pharmacy overhead costs among drugs. MedPAC recommended that payment for pharmacy overhead costs should reflect methods recommended in their June 2005 Report to Congress to collect drugs into APC groups based on attributes that affect overhead costs and establish payment rates for the APCs based on hospital claims data. MedPAC encouraged us to revisit this issue and develop a method that recognizes and pays more specifically for the pharmacy overhead costs of different classes of drugs. *Response:*
                         We appreciate these comments and recognize the concerns that were expressed related to identifying and providing accurate payments for hospital outpatient department costs for pharmacy handling services. We understand that not every hospital will be able to acquire all drugs for the same price, and to that end, we use aggregate amounts when determining the average ASP-based amount that applies across all drugs. We also acknowledge that different types of drugs likely have very disparate pharmacy handling costs. In the CY 2006 proposed rule, we proposed creating a set of HCPCS codes that hospitals would be able to use to indicate the relative resource levels of pharmacy handling involved in preparing a reported drug, biological, or radiopharmaceutical for administration. This methodology would have allowed us to begin collecting data on pharmacy overhead costs for possible use in future ratesetting calculations. We did not finalize this proposal for CY 2006 due to the overwhelming response from the hospital community citing the tremendous administrative burden reporting these pharmacy handling codes would have placed on hospital resources. Hospitals have now had 1 year to fully consider this proposal and it appears that there may be greater support for the creation of these pharmacy HCPCS codes, or another methodology to collect this data. We are reluctant to proceed with the implementation of our CY 2006 proposal until we are confident that there is not another feasible, less burdensome alternative or there is much broader support in the hospital community for this proposal. Therefore, we are not adopting this methodology for CY 2007. However, we again specifically request comments regarding hospital outpatient department pharmacy costs and request ideas and methodologies that we may consider for future data collection purposes under the OPPS. As we stated in our discussion of the average ASP-based methodology in CY 2006, and as we have reiterated above, it is our understanding that pharmacy handling costs are included in hospital charges for drugs and biologicals. Therefore, we continue to believe that without more information regarding the specific required resources and their associated costs for providing hospital outpatient department pharmacy handling services associated with particular groups of drugs, it is not reasonable to provide differential, identifiable payments for pharmacy handling services that are separate from our payments for the average acquisition costs of drugs. We believe that generally our methodology of providing a single payment level for drug acquisition and pharmacy overhead costs provides, in aggregate, appropriate payment to hospitals for both types of costs. This averaging methodology is fully consistent with the principles of a prospective payment system like the OPPS. *Comment:*
                         One commenter suggested that CMS develop a survey for hospitals and instruct fiscal intermediaries to administer, collate, and transmit this data back to CMS where this information could then be used as the basis for an additional pharmacy add-on or separate APC payments for pharmacy services. *Response:*
                         We appreciate the commenter's suggestions for gathering information regarding pharmacy overhead costs. We are not sure, however, that it would be administratively feasible and reasonable from a resource perspective to develop and update information regarding pharmacy overhead costs through a hospital survey administered by fiscal intermediaries. We are also concerned that such a survey could be quite burdensome for hospitals. We will continue to work with the hospital industry to better understand the costs associated with pharmacy overhead and drug handling, and we welcome additional suggestions for alternative approaches to gathering cost information to inform our policy development. *Comment:*
                         One commenter requested that CMS convene an APC Panel meeting specific to the topics of pharmacy handling issues and charge compression. *Response:*
                         We appreciate the commenter's suggestion. However, at this time, we do not believe that a special meeting of the APC panel on pharmacy overhead costs is necessary, since the topic has been included on the agenda of several recent Panel meetings, and has been the subject of extended discussions in the course of these meetings. Furthermore, the APC Panel's 2004 charter specifically states that the issue of cost compression is outside of the scope of the Panel. Additional information on the purpose and scope of the APC Panel is available at: 
                        *http://www.cms.hhs.gov/​FACA/​05_​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp.* In its final report on the hospital acquisition cost survey of specified covered outpatient drugs entitled “Medicare Hospital Pharmaceuticals: Survey Shows Price Variation and Highlights Data Collection Lessons and Outpatient Rate-Setting Challenges for CMS,” the GAO recommended that the Secretary validate, on an occasional basis, manufacturers' reported drug ASPs as a measure of hospitals' 
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                        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 would continue to analyze the adequacy of ASP-based pricing in light of our hospital claims data. In its October 31, 2005 letter of comment on proposed 2006 SCOD rates titled “Comments on Proposed 2006 SCOD Rates,” the GAO recommended that in order to approximate hospitals' acquisition costs of SCODs better, the Secretary should 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. For the CY 2006 OPPS final rule with comment period, 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 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. During the August meeting of the APC Panel, the Panel recommended that CMS maintain the payment rate for drugs and biologicals at ASP+6 percent in the hospital outpatient setting for CY 2007. We discuss our responses to these recommendations below. We received a number of comments on our proposal to set the ASP-based payment for separately payable drugs and biologicals provided in CY 2007 in the hospital outpatient setting at ASP+5 percent. *Comment:*
                         The majority of comments we received regarding our CY 2007 OPPS payment policy for drugs and biologicals expressed concern over the proposed rate of ASP+5 percent. Most commenters requested that we continue the ASP+6 percent methodology, or increase the ASP-based payment amount for separately payable drugs and biologicals under the OPPS for CY 2007. The commenters stated that the proposed ASP-based rate of ASP+5 percent was inadequate, citing difficulties obtaining drugs at this price and challenges identifying the portion of payment that was to account for pharmacy handling costs associated with these items. In addition, several commenters expressed that a difference in payment rates for drugs and biologicals across the hospital outpatient and physician office settings may result in an unexpected site of service shift that may be problematic for beneficiaries. The vast majority of commenters recommended that CMS retain the CY 2006 rate of ASP+6 percent for drugs, biologicals and their associated pharmacy handling costs for CY 2007. *Response:*
                         We appreciate these comments. In analyzing data for the CY 2007 final rule, we again performed the analysis described in the CY 2007 proposed rule comparing aggregate expenditures for separately payable drugs and biologicals to the ASP-based payment rates, weighting these HCPCS codes by their OPPS volumes, and calculating an ASP-based average payment rate for drugs and biologicals provided in hospital outpatient departments for CY 2007. As we did for our final rule analysis to determine the final packaging status for each drug, we used updated CY 2005 hospital claims data, including updated CCRs and complete year CY 2005 mean unit costs and drug volumes. The result of our final analysis using updated hospital claims data for the full CY 2005 year and updated CCRs indicates that the ASP-based average payment rate for separately payable drugs and biologicals, including pharmacy handling costs, would be the equivalent of ASP+4 percent for CY 2007. Thus, if we were to follow the methodology that we employed for establishing the payment rate for drugs and biologicals under the OPPS in the CY 2006 final rule and the CY 2007 proposed rule, we would set the CY 2007 payment rate for these items at ASP+4 percent. However, we have decided to accept the recommendation of the APC Panel and the recommendation of many commenters to continue to pay for the acquisition costs of separately payable drugs and biologicals and their associated pharmacy handling costs in the hospital outpatient department at a combined rate of ASP+6 percent for CY 2007. In addition, we are also finalizing our proposal to pay for separately payable drugs and biologicals without ASP-based data at their mean cost calculated from CY 2005 hospital claims data. We have adopted this final policy for CY 2007 for the reasons noted below. We continue to believe the MedPAC finding that pharmacy overhead costs are included in the hospital's charge for a drug, whether we treat the payment for the drug and its handling as packaged or separately payable. While our final rule analysis indicated an average ASP-based payment of ASP+4 percent, we note that this is the same relative ASP-based amount that was comparable to the GAO purchase price data for a subset of drugs reviewed in our CY 2006 final rule with comment period, which did not include pharmacy overhead costs. This factor furthered our conclusion that a final payment determination of ASP+6 percent was a reasonable level of payment for both the hospital acquisition and pharmacy overhead costs of drugs and biologicals in CY 2007. We further believe maintaining stability in the payment levels for drug and biologicals should be considered in light of the inherent complexity in determining how to best account for pharmacy overhead costs. We also understand the commenters' concerns about providing appropriate OPPS payment for the costs of pharmacy overhead and drug handling, but believe a better understanding of the full nature and magnitude of hospitals costs related to these important activities is needed. Therefore, we will continue to work with the hospital industry to examine the difficult and complex issues concerning pharmacy overhead in the hospital outpatient department. Therefore, for these reasons, we are not finalizing our proposal to pay for drugs and biologicals at ASP+5 percent. Instead, after carefully considering all comments and the recommendations of the APC Panel, we are accepting the Panel's recommendation to continue to pay for separately payable drugs, biologicals and their associated pharmacy handling in the hospital outpatient department for CY 2007 at a combined rate of ASP+6 percent to maintain the stability of our payments. We believe that this rate will ensure suitable payment for the hospital pharmacy overhead costs associated with drugs and biologicals, while we continue to work with the hospital industry to understand the complex 
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                        issues related to capturing and evaluating these overhead costs. Full consideration of the potential benefits and challenges associated with alternative OPPS payment methodologies for hospitals' pharmacy overhead and drug handling costs that are associated with administering drugs and biologicals in the hospital outpatient department is an important part of this ongoing work. During the March 2006 meeting of the APC Panel, the Panel included several recommendations regarding intravenous immune globulin (IVIG) including: that CMS work with the Plasma Protein Therapeutics Association and other stakeholders to develop appropriate payments for IVIG; that CMS maintain separate payment for IVIG preadministration-related services as long as it remains appropriate, and that CMS reevaluate payments for IVIG administration, especially considering the resource intensity of IVIG infusions. Our responses to these recommendations are included in our discussion below. *Comment:*
                         Several commenters urged the continuation of the one-year temporary preadministration-related services fee for IVIG that we established for CY 2006. The commenters stated that there continue to be concerns with IVIG access and availability and that eliminating the fee will have an adverse impact on beneficiary access to care. Furthermore, some indicated that CMS provided little rationale in the proposed rule for why the fee was no longer needed. A number of commenters expressed concerns about the adequacy of Medicare's drug and drug administration payment rates for IVIG, and made some suggestions for changes to these payment rates that they have previously expressed to us. For example, some urged CMS to take actions such as establishing separate HCPCS codes for each IVIG product, increasing payment for IVIG administration and instituting a payment adjustment to the ASP-based payment rates for IVIG. One commenter provided information from a survey conducted of 800 patients with primary immune deficiency syndrome. The commenter, a patient advocacy group, stated that since the beginning of 2005, Medicare patients receiving IVIG have been more likely than patients with other types of insurance to report a shift in site of care, increased intervals between infusions, reduced IVIG dosages, and adverse health effects, and they believe that this is the result of Medicare reimbursement issues. *Response:*
                         We recognize the importance of IVIG to patients who need it, and we are concerned about reports of problems with IVIG access and availability. Since 2005, CMS has taken several specific actions that are within our statutory authority in response to the IVIG concerns that have been raised, including creating separate HCPCS codes to report lyophilized and non-lyophilized IVIG in April 2005, having discussions with manufacturers about their ASP data to confirm that their ASPs have been developed in accordance with applicable guidance, and for CY 2006 establishing a temporary additional payment for IVIG preadministration-related services to compensate physicians and hospital outpatient departments for extra resources expended on locating and obtaining appropriate IVIG products and on scheduling patients' infusions during a period where there may be temporary market instability. In addition, we continue to work with manufacturers, patient groups, and stakeholders to understand the present situation and to assess potential actions that could help ensure an adequate supply of IVIG and patients receiving appropriate, high quality care. We believe that these ongoing efforts will continue to assist us in developing future payment policies that continue to adapt to the IVIG marketplace. Therefore, we accept the Panel's recommendation to work with external stakeholders to develop appropriate payments for IVIG and related services. As these efforts are ongoing, we do not believe that specific adjustments to the ASP-based payment rates for IVIG are appropriate or necessary at this time. We remain confident that our ASP data reflect current market pricing for all of the brands of IVIG, and that our CY 2007 final payment rates are appropriate for these therapies. Furthermore, there are currently two studies underway in the Department of Health and Human Services (HHS) concerning IVIG. The HHS Assistant Secretary for Planning and Evaluation has commissioned a study to better understand the market for IVIG and evaluate the demand, supply, and access to IVIG. The HHS Office of Inspector General is also conducting a study on availability and pricing of IVIG. We anticipate that these studies will provide more information on IVIG supply, demand, and pricing. With several studies on IVIG not yet completed and with comments from stakeholders suggesting that some beneficiaries are experiencing IVIG access issues such as delayed treatments and site of service shifts, we believe it is appropriate to continue the temporary IVIG preadministration-related services payment into CY 2007 to help ensure continued patient access to IVIG. We will continue to review IVIG access during CY 2007 as additional information becomes available, and we will discontinue this temporary preadministration-related services payment during CY 2007 through rulemaking if we determine it is no longer warranted. Therefore, after our assessment of the comments, we are also accepting the March 2006 recommendation of the APC Panel and the suggestion of several commenters to continue the IVIG preadministration-related services payment as long as it remains appropriate in CY 2007. Consequently, Medicare will temporarily allow a separate payment in CY 2007 for each day of IVIG administration to physicians and hospital outpatient departments that administer IVIG to Medicare beneficiaries. This payment is for the extra resources expended on locating and obtaining appropriate IVIG products and on scheduling patients' infusions during this time when there may continue to be transient disruptions in the marketplace. This preadministration-related service payment will continue to be billed under the same HCPCS code as CY 2006: G0332 (Preadministration-related services for intravenous infusion of immunoglobulin, per infusion encounter). We are continuing our CY 2006 placement of HCPCS code G0332 in New Technology APC 1502 (status indicator “S”) with a payment rate of $75 at this time. The payment for preadministration-related services is in addition to the separate payments Medicare makes for the IVIG product itself and its administration. We believe that continuation of this temporary separate payment provided through G0332 for the physician office and hospital outpatient resources associated with additional IVIG preadministration-related services will help facilitate beneficiary access to care in this current period where there may be continuing market fluctuations for IVIG products. At the same time, we will continue to work with the IVIG community, manufacturers, providers, and other stakeholders, and will be monitoring IVIG market developments and access to care closely. Additionally, regarding comments requesting the establishment of brand-specific HCPCS codes for IVIG products, we again remind the commenters that Level II HCPCS codes describe categories of similar items. The code set is not intended to be an exhaustive listing of all brands on the market. In CY 
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                        2006, we stated that we do not see a compelling reason to override that standard; this conclusion also holds true for CY 2007. (For further discussion of HCPCS coding procedures, see 
                        *http://www.cms.hhs.gov/​medicare/​hcpcs/​codpayproc.asp.*) Commenters expressed concern regarding OPPS payment for both IVIG drugs and their administration. Typically, IVIG administration requires a multiple hour infusion and frequent monitoring by qualified hospital staff. As discussed above, the APC Panel recommended that we reevaluate IVIG administration payments, taking into consideration the additional resources associated with this type of therapy. We accepted this APC Panel recommendation and reevaluated the IVIG administration payments, along with our general review of drug administration methodology. We believe that our final drug administration payment policy for CY 2007, as discussed in section VIII. of this final rule with comment period, will provide more accurate payments for extended infusions, including IVIG infusions. Finally, we received several comments requesting that we classify IVIG therapy as a biological response modifier. We note that the term “biological response modifier” is used in the text preceding CY 2006 CPT codes, and as such, we refer commenters to the AMA CPT Editorial Panel, as they are the creators and maintainers of CPT codes and CPT code instructions. In CY 2005, we applied an equitable adjustment to determine the payment rate for darbepoetin alfa (HCPCS code Q0137) pursuant to section 1833(t)(2)(E) of the Act. However, for CY 2006 we transitioned to ASP-based payment rates for OPPS drugs and biologicals and stated that it was our intent to permit market forces to determine the appropriate payment rate for this biological. We received a few comments on our proposal to continue with an ASP-based payment rate for this biological. *Comment:*
                         Commenters commended CMS on our decision to not exercise our equitable adjustment authority for any drug or biological in CY 2007. *Response:*
                         We appreciate the support of these commenters. As we discussed in CY 2006, we believe that as long as the market price for darbepoetin alfa is consistent with a payment rate derived using a clinically appropriate conversion ratio, invoking our equitable adjustment authority would not lead to a different result. During CY 2006, we provided payment for blood clotting factors under the OPPS at ASP+6 percent and included 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. In the CY 2006 OPPS final rule with comment period (70 FR 68661), we indicated that we would update the furnishing fee (based on the consumer price index) and the payment amount for this furnishing fee each calendar year so that the furnishing fee is equal to the amount noted in the MPFS final rule. *Comment:*
                         One commenter requested that CMS establish brand-specific HCPCS codes for each available sodium hyaluronate product. In addition, they requested that each brand-specific HCPCS code be assigned to an individual APC, with assigned APC payment rates based on product-specific ASP data. The commenter concluded that they believe that there is no scientific justification for the current three HCPCS code structure that assigns two products to individual HCPCS codes while other products are grouped together in a single HCPCS code. *Response:*
                         We appreciate this comment, and the National HCPCS Panel agreed that a reconfiguration of these codes was warranted. The National HCPCS Panel has examined the sodium hyaluronate codes referenced by this comment and has concluded that all sodium hyaluronate products will be reported in CY 2007 with the single HCPCS code J7319 (Hyaluronan (Sodium hyaluronate) or derivative, intra-articular injection, per injection). As we discuss in reference to pass-through drugs and biologicals in section V.A.3. of this final rule with comment period, it is our practice to adopt a national HCPCS code for reporting drugs when available, with the exception of certain pass-through drug situations. Therefore, for services furnished on or after January 1, 2007, hospitals are to use the single HCPCS code for sodium hyaluronate products, J7319, status indicator “K,” to report all sodium hyaluronate intra-articular injections provided in hospital outpatient departments. As there is a single national HCPCS code, and there are no sodium hyaluronate products with pass-through status in CY 2007, this single HCPCS code will be assigned to a single APC for OPPS payment purposes. Therefore, for CY 2007, HCPCS code J7319 is assigned to APC 0896 (Sodium Hyaluronate Injection). We have calculated a reference October 2006 ASP-based payment rate for this single code at $124.68, as shown in Addenda A and B of this final rule with comment period. In the CY 2007 OPPS, we proposed to continue our CY 2006 policy of providing payment for blood clotting factors at a rate of ASP+5 percent plus an additional furnishing fee. We received four comments on our proposal regarding blood clotting factors. *Comment:*
                         All commenters commended us on proposing to continue to pay the furnishing fee and urged us to continue providing payment for blood clotting factors under the OPPS at a rate equal to ASP+6 in CY 2007. Three of these commenters additionally expressed concern that the proposed ASP-based rate for blood clotting factors would also be applied to the inpatient hospital setting. These commenters requested that if payment rates were adjusted in the outpatient setting that we not apply these rates to the inpatient hospital setting as well. *Response:*
                         We appreciate these comments. As we proposed an ASP-based payment rate for CY 2007 of ASP+5 percent for separately payable drugs, biologicals and blood clotting factors in CY 2007, and we have since finalized a payment rate of ASP+6 percent for separately payable drugs and biologicals in this final rule, we are taking this opportunity to finalize a payment rate for separately payable blood clotting factors in the outpatient setting at ASP+6 percent plus the updated CY 2007 furnishing fee of $0.15. Issues concerning inpatient hospital rates are outside the scope of this final rule with comment period, and we refer the commenters to the annual IPPS rulemaking process to note these concerns. (3) CY 2007 Payment Policy for Radiopharmaceuticals (a) Background and Proposed CY 2007 Radiopharmaceutical Payment Policy Section 303(h) of Public Law 108-173 exempted radiopharmaceuticals from ASP pricing in the physician office setting. In both the CY 2005 and CY 2006 OPPS final rules with comment period, the OPPS exempted radiopharmaceutical manufacturers from reporting ASP data for payment purposes under the OPPS for reasons discussed in those rules (69 FR 65811 and 70 FR 68655, respectively). Consequently, we did not have ASP data for radiopharmaceuticals for consideration for CY 2007 ratesetting in the OPPS. Pursuant to section 1833(t)(14)(B)(i)(I) of the Act, radiopharmaceuticals are classified under the OPPS as specified covered outpatient drugs (SCODs). 
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                        Accordingly, payments for radiopharmaceuticals are to be made at average acquisition cost as determined by the Secretary and subject to any adjustment for overhead costs. Radiopharmaceuticals are also subject to the policies affecting all similarly classified OPPS drugs and biologicals, such as pass-through payments and packaging determinations, as discussed earlier in this final rule with comment period. For CY 2006, we used CY 2004 mean unit cost data from hospital claims to determine each items' packaging status, and 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 using the hospital's overall cost-to-charge ratio. This temporary methodology was finalized as an interim proxy for average acquisition cost because of the unique circumstances associated with providing radiopharmaceutical products to Medicare beneficiaries. We clearly stated in the 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. In the CY 2006 final rule, we also discussed the various data sources available to us, as well as the challenges associated with developing an acceptable mechanism to identify average costs for radiopharmaceutical products. In addition, we stated that we agreed with MedPAC's assessment that hospitals include associated preparation and handling costs in their charges for the radiopharmaceutical. We strongly encouraged hospitals and the radiopharmaceutical community to assist us as we began developing a viable long-term prospective payment methodology for these products under OPPS. 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. While Federal law, including the Administrative Procedure Act (APA) and the Federal Advisory Committee Act (FACA), govern the forum by which we receive input of stakeholders, we have met with interested organizations to discuss the numerous complexities associated with developing radiopharmaceutical payments under the OPPS, and in the CY 2007 OPPS proposed rule, we again invited comment and feedback on how we may be able to improve on our methodology in future years. We note that we received relatively little feedback in response to our CY 2006 requests for comments on methodologies we could consider during the development of a methodology for radiopharmaceutical payments in the hospital outpatient setting in preparation for the CY 2007 proposed rule. We again specifically invite feedback on this issue and request comments for our consideration during the development of our proposal for CY 2008 radiopharmaceutical payments. We considered a number of alternative methodologies for radiopharmaceutical payment policy under the OPPS in CY 2007. One of the options we considered for CY 2007 (71 FR 49587) was to package additional radiopharmaceuticals, either through increasing the packaging threshold for radiopharmaceuticals from a cost of $55 per day to a higher amount or through a policy that would package payments for all radiopharmaceuticals with payments for the services with which they are reported. All nuclear medicine procedures require the use of at least one radiopharmaceutical, and while many separately payable drugs may share the same drug administration HCPCS code, there are only a few radiopharmaceuticals that may be appropriately billed with the same nuclear medicine procedure. A policy to package additional radiopharmaceuticals would be consistent with OPPS packaging principles and would provide greater administrative simplicity for hospitals. We noted that while examining CY 2005 hospital claims data, we identified a significant number of nuclear medicine procedure claims that were missing HCPCS codes for the associated radiopharmaceutical. We believed that there could be two reasons for the presence of these claims in the data. One reason could be that the radiopharmaceutical used for the procedure was packaged under the OPPS and therefore would not be billed on the claim with a HCPCS code and an associated charge. The second reason could be that the hospitals may have incorporated the costs of the radiopharmaceutical into their charges for these nuclear medicine procedures. We did not propose this methodology for CY 2007 because we were concerned that payments for certain nuclear medicine procedures could potentially be less than the costs of some of the packaged radiopharmaceuticals, and that relatively expensive and high volume radiopharmaceuticals could become packaged. At the same time, we also note the GAO's comment in reference to the CY 2006 OPPS proposed rule that a methodology that includes packaging all radiopharmaceutical costs into the payments for the nuclear medicine procedures may result in payments that exceed hospitals' acquisition costs for certain radiopharmaceuticals as there may be more than one radiopharmaceutical that may be used for one particular procedure. We were also concerned that with such divergent outcomes, this payment policy could provoke a treatment decision that may not reflect the most clinically appropriate radiopharmaceutical for a particular nuclear medicine procedure. We also considered maintaining the CY 2006 policy of paying for radiopharmaceuticals at charges converted to cost. For CY 2007, our proposed methodology included a packaging threshold equal to that of other drugs and biologicals proposed for CY 2007 and established prospective payment rates for separately payable radiopharmaceuticals using mean costs derived from the CY 2005 claims data, where the costs were 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 were unavailable. This proposed payment methodology included both the acquisition and pharmacy handling costs of radiopharmaceuticals determined to be separately payable for CY 2007. As we have noted previously, we agree with the MedPAC finding that hospitals include overhead costs in their charges for the associated radiopharmaceutical. We believe this methodology provides for an appropriate proxy for the average acquisition cost of the radiopharmaceutical along with its handling cost. We noted that this proposed methodology would 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. We also proposed to update the packaging threshold consistent with the methodology discussed above. We noted in the proposed rule that the National HCPCS Panel implemented changes to many radiopharmaceutical codes and their descriptors effective January 1, 2006. In some instances, these changes were relatively minor; in 
                        ( print page 68095)
                        others, code descriptors changed from “per unit” to “per study dose.” The hospital claims data used for our proposed rule included 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 required us to propose a crosswalk to map the CY 2005 hospital claims data to updated CY 2006 codes that we expected to be in effect during CY 2007. Out of the 39 radiopharmaceutical HCPCS codes that we proposed to pay separately for in CY 2007, we were 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 proposed 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. (We refer readers to the CY 2007 proposed rule for a more detailed description of our proposed crosswalk methodology.) We also noted in the proposed rule that there were three cases where two CY 2005 HCPCS codes were mapped to the same new CY 2006 HCPCS code that would be reported in CY 2007. These three CY 2006 HCPCS codes were A9550 (Tc99m gluceptate), A9553 (Cr51 chromate), and A9559 (Co57 cyano). 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 proposed 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 used for CY 2007 ratesetting purposes. Table 26 of the CY 2007 proposed rule (71 FR 49589) listed 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 noted the crosswalk methodology used for the proposed rates. (b) CY 2007 Final Radiopharmaceutical Payment Policy During the August 2006 meeting of the APC Panel, the Panel recommended that CMS continue the 1-year temporary policy of paying for radiopharmaceuticals at charges reduced to cost, using the overall hospital CCR. In addition, the Panel recommended that we consider using external data to evaluate the proposed payment rate for HCPCS code A9600 (Sr89 strontium) because of concerns about hospital miscoding of this radiopharmaceutical. We include our responses to these Panel recommendations in the discussion presented below. In addition to these Panel recommendations, we received many comments on our proposed payment methodology for radiopharmaceuticals in CY 2007. *Comment:*
                         Several commenters supported our proposal to establish a prospective payment methodology for radiopharmaceuticals, but noted that, prior to the CY 2006 final rule with comment period, many hospitals were unaware that charges for the preparation and handling should be included in the charge for the associated radiopharmaceutical. Therefore, these commenters claimed that the CY 2005 data used to establish proposed mean-based payment rates for CY 2007 are inaccurate. In addition, commenters noted that several radiopharmaceutical HCPCS codes were updated in CY 2006 to standardize hospital coding for radiopharmaceuticals, and that CY 2005 data are unreliable because hospitals were not using the CY 2005 radiopharmaceutical HCPCS codes uniformly. Other commenters noted that using a methodology that incorporates a departmental CCR is not appropriate for radiopharmaceuticals because the unique costs associated with radiopharmaceuticals are not properly accounted for within any department. For these reasons, commenters requested that CMS extend the temporary CY 2006 methodology of paying for separately payable radiopharmaceuticals at charges reduced to cost, where payment is determined using each hospital's overall CCR. *Response:*
                         We understand the commenters' concerns regarding the data that are represented in the CY 2005 hospital claims, especially in light of the reports of confusion resulting from coding changes. We also acknowledge that the preparation and handling costs associated with administering radiopharmaceuticals are significant and should be fully captured in claims data used to establish prospective payments rates. At this time, we believe that there is sufficient reason to extend the temporary policy of paying for radiopharmaceuticals at charges reduced to cost for one additional year as the best proxy for radiopharmaceutical acquisition and overhead costs, consistent with the August 2006 recommendation of the APC Panel. Although we do believe that the costs unique to radiopharmaceuticals are recognized in several departmental cost-to-charge ratios, similar to the costs of many other items and services paid prospectively under the OPPS, consistent with the CY 2006 methodology, we will again calculate payment using each hospital's overall cost-to-charge ratio in CY 2007. As stated in the CY 2006 final rule, we believe that using hospitals' overall CCRs to determine payments could result 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. We note that it is still our intention to move toward a prospective payment methodology for radiopharmaceuticals in the OPPS, and that we generally employ departmental CCRs in setting payment rates for most items and services that are paid separately in the OPPS. We expect that for the CY 2008 OPPS update, hospitals will have adapted to the CY 2006 coding changes and responded to our instructions to include their charges for radiopharmaceutical handling in their charges for the radiopharmaceutical products. We anticipate, as do our commenters, that our CY 2006 claims data should be much more comprehensive and accurate in reflecting the full hospital costs for radiopharmaceutical products and their overhead. Because of the coding changes for CY 2006 to simplify radiopharmaceutical reporting, hospital data from that time should also reflect more consistent and correct coding because the HCPCS code units for reporting have been aligned with the clinical uses of the radiopharmaceuticals. *Comment:*
                         One commenter suggested that CMS require ASP reporting for radioimmunotherapy radiopharmaceutical manufacturers. The commenter suggested that this data could be used in conjunction with a new HCPCS code for compounding services related to these radiopharmaceuticals. The commenter suggested that CMS assign the compounding HCPCS code to its own APC and set the payment rate between $2,000 and $3,000. *Response:*
                         We appreciate these comments, but we do not believe that the complex issues relating to the collection of ASP data for radiopharmaceuticals, as discussed at length in the CY 2006 OPPS final rule with comment period (70 FR 68655), 
                        ( print page 68096)
                        have been resolved. Therefore, we believe that implementation of the collection of ASP data for these products remains premature. However, we will consider this comment during the development of future updates to the OPPS. *Comment:*
                         One commenter requested that CMS instruct hospitals to include radiopharmaceutical handling costs in the charge for the associated nuclear medicine procedure. *Response:*
                         We appreciate this comment. However, we believe that hospitals appropriately include these handling charges in their charges for drugs, biologicals, and radiopharmaceuticals. As such, we believe that these costs are already being captured through hospital charges for these items, which require preparation and handling for their administration. In addition, for hospitals that were not clear where these handling costs should be represented on a claim, we provided specific instructions in the CY 2006 final rule with comment period (70 FR 68654). As we stated for CY 2006, and reiterate here for CY 2007, it is appropriate for hospitals to set charges for radiopharmaceuticals based on all costs associated with the acquisition, preparation, and handling of these products so that their payments under the OPPS can accurately reflect all of the actual costs associated with providing these products to hospital outpatients. If necessary, we believe that hospitals can appropriately adjust their charges for radiopharmaceuticals so that the calculated costs from applying hospitals' overall CCRs to radiopharmaceutical charges on claims properly reflect their actual costs. We do not believe it is appropriate to provide different instructions in this final rule with comment period, when we have many comments reflecting hospitals' efforts to respond to our CY 2006 instruction. We received a few comments that included specific suggestions for consideration during the future development of our proposed CY 2008 radiopharmaceutical payment policy. *Comment:*
                         Commenters suggested that CMS consider establishing a buffering mechanism when radiopharmaceuticals are transitioned to a prospective payment methodology; that we continue to use the overall hospital CCR to calculate costs, regardless of any future radiopharmaceutical payment methodology; that we consider a unique data trimming methodology for radiopharmaceuticals; and that we consider using the PPI as a basis for annual radiopharmaceutical payment updates. *Response:*
                         We appreciate these comments, and we continue to encourage comments and suggestions on methodologies we may consider during the development of our CY 2008 proposed radiopharmaceutical payment policy. We also received several comments on the amount of pharmacy handling involved with compounding radiopharmaceuticals and preparing them for administration. *Comment:*
                         Commenters proposed several methodologies for implementation in the OPPS to provide additional payment for radiopharmaceutical pharmacy handling costs. Additional payments are warranted, commenters noted, because radiopharmaceutical products require substantial preparation and handling prior to administration, and these services are unique to radiopharmaceuticals. In addition, commenters cite concerns regarding the effects of charge compression for these high cost items with substantially higher pharmacy handling costs (see section V.B.III.a.2. of this preamble for additional discussion on the issue of charge compression). Commenters included suggestions ranging from inflating proposed payment amounts to providing a fixed add-on payment amount. *Response:*
                         As we noted in the CY 2006 final rule with comment period (70 FR 68654), we believe that hospitals have the ability to set charges for items properly so that charges converted to costs can appropriately account fully for their acquisition and overhead costs. As noted previously, commenters urged us to delay implementation of our proposed CY 2007 radiopharmaceutical payment methodology based on CY 2005 mean unit costs calculated from hospital claims data because, they claimed, hospitals had only begun including associated overhead charges in response to our CY 2006 final rule, and these preparation and handling costs were not included in the CY 2005 claims data. As we are continuing our CY 2006 methodology of paying for radiopharmaceuticals at a hospital's charges for the radiopharmaceutical reduced to costs, based upon the hospital's overall CCR, we do not believe that an additional payment specific to overhead costs for radiopharmaceutical products is warranted at this time. Therefore, for CY 2007, we have concluded that our final payment methodology provides an acceptable proxy for the average acquisition cost of the radiopharmaceutical along with its handling cost. In addition, we believe that this final payment policy addresses the concerns of the APC Panel regarding HCPCS code A9500. Therefore, we are accepting this Panel recommendation and we have applied the packaging methodology for radiopharmaceuticals, as described above, and determined that HCPCS code A9500 will be separately payable in the OPPS in CY 2007. As such, payment will be at a hospital's charge for the radiopharmaceutical reduced to cost, using the overall hospital CCR. We again reiterate our intent to develop a suitable prospective payment methodology for radiopharmaceutical products paid under the OPPS in future years, beginning in CY 2008. We generally do not make payments under the OPPS for items and services at cost, particularly if we do not expect the costs of the 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. However, we are encouraged by recent reports of ongoing discussions within the radiopharmaceutical community to develop a viable, ongoing methodology for OPPS radiopharmaceutical ratesetting and recent meetings with members of the radiopharmaceutical community. We again specifically solicit comments on alternative methodologies and data sources that may be used to set radiopharmaceutical payment rates in the OPPS. While payments for drugs, biologicals and radiopharmaceuticals are taken into account when calculating budget neutrality, we proposed to make payments for drugs, biologicals, and radiopharmaceuticals without scaling these payment amounts. 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 
                        ( print page 68097)
                        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. *Comment:*
                         A few commenters requested the implementation of edits similar to procedure to device edits that would require hospitals to include a radiopharmaceutical HCPCS code whenever a nuclear medicine procedure is billed. *Response:*
                         We understand that coding accurately for the variety of services provided across a hospital setting can be challenging, as can be keeping current on changes to codes, modifiers and updated billing instructions. However, we do not believe that the appropriate solution to complex billing is the implementation of edits for a large number of services. As discussed above, during our review of claims for the CY 2007 ratesetting process we identified a large number of claims without associated radiopharmaceuticals reported with nuclear medicine procedures. We believe that this may be due to hospitals using packaged radiopharmaceuticals, or because hospitals have already packaged the costs of the associated radiopharmaceutical into the cost of the nuclear medicine procedure. If this is the case, we do not believe that implementing procedure to radiopharmaceutical edits would be an appropriate mechanism for us to use in order to get additional data for radiopharmaceutical products. We do not mandate hospital charging practices for specific items, and implementing edits would be contrary to our general concept of encouraging hospitals to develop their charges, revenue centers and internal practices as they find appropriate. In addition, edits do not necessarily ensure quality data. Most importantly, we generally implement edits to ensure that high cost items with packaged payment are reported on appropriate claims, so that the procedural payment rates fully incorporate the costs of these items that are required for the procedures. We have no need to edit for the presence of radiopharmaceutical HCPCS codes on claims for nuclear medicine procedures when we will be paying separately in CY 2007 for all radiopharmaceuticals with per day costs greater than $55. Therefore, we are not accepting this commenter's proposal to implement procedure to radiopharmaceutical edits at this time. *Comment:*
                         The manufacturer of a radiopharmaceutical product stated that HCPCS codes A9500 (Tc99m sestamibi) and A9502 (Tc99m tetrofosmin) are comparable in terms of safety and efficacy, and as such, there should be no difference in OPPS payment rates. It suggested that factors such as manufacturer rebates and incomplete hospital reporting may have contributed to inaccurate CY 2005 claims data. It suggested that the payment rates for these products be averaged and that the resulting rate be used for both products. *Response:*
                         We believe the concerns expressed by this commenter are no longer applicable in light of the finalized payment methodology for radiopharmaceutical products in CY 2007 discussed above. b. CY 2007 Payment for Nonpass-Through Drugs, Biologicals, and Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data (1) Background 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 our policy to provide separate payment for new drugs, biologicals, and radiopharmaceuticals with HCPCS codes, but which did not have pass-through status at a rate that was equivalent to the payment they received in the physician office setting, established in accordance with the ASP methodology. 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. Therefore, we developed our proposed CY 2007 payment methodologies for drugs, biologicals, and radiopharmaceuticals with HCPCS codes but without OPPS hospital claims data in line with our payment methodologies for newly established HCPCS codes that are granted pass-through status under the OPPS. (Section V.A. of this final rule with comment period provides additional details on our final policies for CY 2007 pass-through drugs, biologicals, and radiopharmaceuticals.) In Addendum B of the CY 2007 proposed rule, we assigned status indicator “K” to these new CY 2007 HCPCS codes for drug, biological, and radiopharmaceutical items without pass-through status. (2) CY 2007 Proposed and Final Payment Policy for Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data In section V.B.3.a.(3) of this final rule with comment period, we discuss our proposed methodology to base payment rates for radiopharmaceuticals with CY 2005 hospital claims data at their mean costs for CY 2007. We also proposed to use WAC as a basis for ratesetting for new radiopharmaceuticals without hospital claims data that have been assigned HCPCS codes as of January 1, 2007, without regard to their pass-through status. If WAC data were unavailable, we proposed to use 95 percent of the most recent AWP, and to implement payment rate adjustments resulting from the quarterly update process accordingly. We received numerous comments on our proposed payment methodologies for radiopharmaceutical products, and one comment specific to HCPCS code A9567 (Technetium TC-99m aerosol). *Comment:*
                         One commenter objected to our proposed packaged status for HCPCS code A9567. The commenter recommended that in the absence of data providing payment information, we assign HCPCS code A9567 status indicator “H” and provide payment in CY 2007 at charges reduced to cost. In addition, other commenters remarking on our proposed radiopharmaceutical policies requested that we continue our CY 2006 payment methodology for separately payable radiopharmaceuticals (see section V.B.3.a.(3) of this preamble). That is, commenters requested that we continue to pay for radiopharmaceuticals at the hospital's charge for the radiopharmaceutical adjusted to the cost, using the hospital's overall CCR. *Response:*
                         We believe it is appropriate to align our payment methodologies, whenever possible, within the OPPS. Therefore, for CY 2007, we are finalizing our payment policy for nonpass-through radiopharmaceuticals without hospital claims data that have been assigned 
                        ( print page 68098)
                        HCPCS codes as of January 1, 2007, as follows: For CY 2007, hospitals will receive payment for nonpass-through radiopharmaceuticals without hospital claims data that have been assigned HCPCS codes as of January 1, 2007, at the hospital's charge for the radiopharmaceutical adjusted to cost, using the hospital's overall cost-to-charge ratio. This methodology will provide payment for nonpass-through radiopharmaceuticals using the same payment methodology that we have finalized for pass-through radiopharmaceuticals in CY 2007, as discussed in section V.B.3.a.(3) of this final rule with comment period. As we discuss above, we are aware that due to the additional costs associated with new radiopharmaceuticals that a decision to package these items may affect beneficiary access. Therefore, when we are unable to determine the appropriate packaging status (as outlined in section V.B.2. of this preamble) for a radiopharmaceutical in CY 2007 due to the lack of hospital claims data, we are finalizing a policy to provide payment for these items at the hospital's charge for the radiopharmaceutical adjusted to cost, using the hospital's overall CCR. (3) CY 2007 Proposed and Final Payment Policy for Drugs and Biologicals With HCPCS Codes, But Without OPPS Hospital Claims Data (a) New Drugs Without Hospital Claims Data For CY 2007, we proposed to continue payment for new drugs and biologicals with HCPCS codes as of January 1, 2007, but without pass-through status, at a rate that is equivalent to the payment they would receive in the physician office setting, unless the drug or biological was also covered under the Part B drug CAP. If the drug or biological was covered under the Part B drug CAP, then we proposed to set the OPPS rate equal to the Part B drug CAP rate. If not, then we proposed to set the OPPS payment rate at a rate equal to the payment rate established in accordance with the ASP methodology described in the CY 2006 MPFS final rule, where payment will generally be equal to ASP+6 percent. Additional information on the ASP methodology can be found at 
                        *http://www.cms.hhs.gov/​McrPartBDrugAvgSalesPrice/​01_​overview.asp#TopOfPage.* In the rare circumstance that a drug does not have a Part B drug CAP rate or data available for use for the ASP methodology, we proposed to make payment at 95 percent of the product's most recent AWP 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 noted in our proposal that it was our intent to adjust payment rates through the quarterly update process for items paid under a methodology other than ASP once ASP data became available and to make appropriate adjustments to the payment rates for new drugs and biologicals in the event that they become covered under the Part B drug CAP in the future. Table 26 below lists the new CY 2007 HCPCS codes for drugs, biologicals, and radiopharmaceuticals that were not available during development of the proposed rule. In addition, we note that these codes are included in Addendum B this final rule with comment period and are identified with comment indicator “NI.”. Table 26.—CY 2007 HCPCS Codes Without OPPS Claims Data and Without Pass-Through Status
HCPCS code
Short description
CY 2007 SI
CY 2007 APCC9234
Inj, alglucosidase alfa
K
9234C9235
Injection, panitumumab
K
9235J0364
Apomorphine hydrochloride
K
0766J1324
Enfuvirtide injection
K
0767J1562
Immune globulin subcutaneous
K
0804J2170
Mecasermin injection
K
0805J2315
Naltrexone, depot form
K
0759J8650
Nabilone oral
K
0808J9261
Nelarabine injection
K
0825
 (b) Established Drugs Without Hospital Claims Data As we discussed in the CY 2007 proposed rule, there are several drugs, biologicals, and radiopharmaceuticals which are not new for CY 2007, but for which we do not have CY 2005 hospital claims data. In order to determine the packaging status of these items for the CY 2007 proposed rule, we estimated the per day cost of each item by multiplying the proposed payment rate of ASP+5 for each product by an estimated average number of units typically furnished to a patient during one administration in the hospital outpatient setting. We included our estimated average number of units in Table 27 of the CY 2007 OPPS proposed rule (71 FR 49595). We proposed to use the same CY 2007 packaging methodology as was proposed for other drugs, biologicals, and radiopharmaceuticals. Specifically, we proposed that items with a per administration cost of less than or equal to $55 would be packaged and items with an estimated per administration cost greater than $55 would receive separate payment at a proposed rate of ASP+5 percent, using the ASP methodology, subject to adjustments as updates became available through the quarterly process. As we discussed in the proposed rule, we used the most recent data available at the time of the proposed rule to determine both the packaging status and payment rates for these drugs. We update these rates and reevaluate our proposed status indicators and payment rates for the final rule, as is the process for all other drugs, biologicals, and radiopharmaceuticals. We specifically requested comments on our proposed payment policies for drugs and biologicals with HCPCS codes but without hospital claims data that do not have pass-through status as of January 1, 2007. We received one comment specific to our packaging determination for HCPCS code J2805 (Sincalide injection) as a result of our proposal. *Comment:*
                         One commenter objected to our proposed packaging determination for HCPCS code J2805. This commenter stated that in absence of data, codes should not automatically be packaged; rather, J2805 should be assigned status indicator “K” with a payment rate at ASP+6 percent for CY 2007.
                        ( print page 68099) *Response:*
                         As we noted in the CY 2007 proposed rule, we have an ASP-based amount for HCPCS code J2805, however we do not have CY 2005 hospital claims data available. Therefore, in absence of aggregate totals for the number of units and the number of days this code was billed on hospital claims in CY 2005, we estimated an average number of units that would be clinically appropriate for one administration of this drug to a typical hospital outpatient. Our estimate was included in Table 27 of the OPPS proposed rule (70 FR 49595). In order to determine the packaging status of this drug, we multiplied the ASP-based payment rate by our estimated number of units per administration. We proposed to package HCPCS code J2805 because its cost per administration was below our proposed packaging threshold. The final packaging determination for CY 2007 for this code can be found in Table 27. In addition to this code-specific comment, we believe that the general comments received regarding our proposed packaging methodology and the comments received regarding our proposed payment rate of ASP+5 for nonpass-through drugs and biologicals also apply to this group of drugs with HCPCS codes but without CY 2005 hospital claims data and without pass-through status. (For a discussion of the comments and our responses to these issues, see sections V.B.2. and V.B.3. of this final rule with comment period.) For the reasons cited in sections V.B.2. and V.B.3. of this final rule with comment period, and because we believe it is appropriate to align our payment methodologies whenever possible within the OPPS, we are finalizing our policy for drugs and biologicals that have HCPCS codes but do not have pass-through status, and those that also do not have CY 2005 hospital claims data as follows: Packaging status will be determined using the threshold finalized in section V.B.2. of this final rule with comment period. That is, for CY 2007, items with a per administration cost of less than or equal to $55 would be packaged and items with an estimated per administration cost greater than $55 would receive separate payment. Estimating the per day costs for each item will be determined by multiplying the final payment rate (described in section V.B.3. of this final rule with comment period) for each product by the estimated average number of units typically furnished to a patient during one administration in the hospital outpatient setting as published in Table 27 of the proposed rule (71 FR 49595). For those drugs and biologicals that have been classified as separately payable using this final methodology, payment will be determined using the methodology finalized in section V.B.3. of this final rule with comment period. Therefore, drugs that have been identified as separately payable in CY 2007 will be paid under the ASP-based methodology at a rate of ASP+6 percent, and will be subject to adjustments through the quarterly update process. Table 27 below shows our final determinations using the methodology finalized above for drugs and biologicals that do not have CY 2005 hospital claims data and are not new for CY 2007. We note that since the time of the proposed rule, we have received claims data for two codes that were previously listed in Table 27 of the proposed rule. These codes are J0200 (Alatrofloxacin mesylate) and J0288 (Ampho b cholesteryl sulfate). Accordingly, these codes have been removed from the table and their packaging and payment rates determined under our final OPPS policy as noted in section V.B.1. of this final rule with comment period. 
 
  In addition, we note that HCPCS codes Q9945-Q9954 for low osmolar contrast material of various iodine concentrations were activated in the OPPS in CY 2006 and replaced several CY 2005 HCPCS A-codes that defined different sets of units in their descriptors. As we have no CY 2005 hospital claims data for the Q-codes, we used the CY 2005 data from the HCPCS A-codes (HCPCS mean, number of units, and days) to determine the packaging status of the corresponding set of HCPCS Q-codes for CY 2007. All of our estimated per-day administration rate determinations for the HCPCS A-codes were above the final OPPS CY 2007 packaging threshold of $55, as discussed in section V.B.2. of this final rule with comment period. Therefore, we are determining that the corresponding set of CY 2007 HCPCS Q-codes will be paid separately in CY 2007. As there are ASP data available for these HCPCS Q-codes, they will be paid at the same rate as other separately payable drugs and biologicals in the OPPS for CY 2007, which in general will be equal to ASP+6 percent, subject to adjustments based on the quarterly update process. This final CY 2007 methodology for separately payable drugs and biologicals is discussed further in section V.B.3 of this final rule with comment period. (4) CY 2007 Proposed and Final Payment Policy for Drugs, Biologicals, and Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data and Without ASP-Related Data In addition to the drugs, biologicals, and radiopharmaceuticals without CY 2005 claims data identified in Table 27 of the proposed rule (71 FR 49595), we identified three HCPCS codes for which there were no available data to support the ASP methodology and no available hospital claims data from CY 2005. As we were unable to estimate the per administration cost of these three HCPCS codes (90393,Vaccina ig, im; 90693, Typhoid vaccine, akd, sc; A9567, Technetium TC-99m aerosol), we proposed to package them in CY 2007. We specifically invited 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. We received a few public comments concerning our proposed CY 2007 policies for drugs, biologicals, and radiopharmaceuticals with HCPCS codes, but without OPPS hospital claims data and without ASP-related data. *Comment:*
                         Commenters suggested that ASP pricing data are available for one or more of these items. Another commenter requested that we use alternative data sources, such as WAC or AWP, to determine the CY 2007 packaging status of the three items listed above as ASP information is not available. *Response:*
                         We appreciate these comments. During the data update process we perform between the CY 
                        ( print page 68101)
                        2007 proposed and final rules, we again queried for ASP-related data for these three items, including other sources such as WAC and AWP. Again, we were unsuccessful in identifying this information. However, in the course of our research for updated pricing data, we discovered that HCPCS code 90693 (Typhoid vaccine, akd, sc) is not available for purchase by hospitals. Therefore, we are assigning status indicator “B” (Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x)). After carefully considering the comments received, we are finalizing our CY 2007 proposed policy to package HCPCS code 90393 (Vaccina ig, im), as we remain unable to determine pricing information for this item. Finally, HCPCS code A9567 (Technitium TC-99m aerosol) is a radiopharmaceutical, and as such, we are finalizing a policy to pay for this item in CY 2007 as we will pay for all new radiopharmaceuticals without claims data, regardless of pass-through status. Therefore, for CY 2007, we will pay for HCPCS code A9567 at the hospital's charge for the radiopharmaceutical adjusted to cost, using the hospital's overall CCR. In addition, HCPCS code J0190 (Inj biperiden lactate/5 mg) was packaged for CYs 2005 and 2006. As discussed in section V.B.2. of this final rule with comment period, to determine the CY 2007 final packaging status of drugs, biologicals, and radiopharmaceuticals we used ASP data from the first quarter of CY 2006 (reflected in payment rates in the physician office setting effective July 1, 2006), along with updated hospital claims data from CY 2005. Under this methodology, we determined that for CY 2007, HCPCS code J0190 will be separately payable. We note that for impact estimates and for purposes of publication of Addenda A and B of this final rule with comment period, we use payment rates for drugs, biologicals, and radiopharmaceuticals that are effective in the OPPS for October 2006. These rates are developed through the methodologies discussed in the CY 2006 final rule with comment period (70 FR 68631), and generally reflect ASP data from the second quarter of CY 2006, hospital claims data from CY 2004, or rates paid under the Part B drug CAP. This methodology essentially provides comparable payment rates across HCPCS codes at a specific point in time, and therefore enables consistency when calculating impact estimates. Under this methodology, we do not have ASP based data or CY 2004 claims-based mean unit cost data for HCPCS code J0190. Therefore, for purposes of impact estimates and for publication of Addenda A and B of this final rule with comment period, we have used the CY 2005 mean as it is the only pricing source available to us at this time. Also, based upon CY 2005 hospital claims mean unit cost data and the methodology described in section V.B.2. of this final rule with comment period, we have determined that HCPCS code A9566 (Tc99m fanolesomab) is separately payable in CY 2007. However, we do not have CY 2004 hospital claims data available for this code as its predecessor code, C1093, was not reported under the OPPS until January 1, 2005. Therefore, similar to HCPCS code J0190 described above, we are using the CY 2005 mean unit cost for this code for purposes of impact estimates. We note that there will be no payment rate information for this code included in Addenda A or B of this final rule with comment period because this code is a radiopharmaceutical and will be paid according to the methodology described in section V.B.3.a.(3) of the preamble of this final rule with comment period. VI. Estimate of OPPS Transitional Pass-Through Spending in CY 2007 for Drugs, Biologicals, Radiopharmaceuticals, and Devices 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 pass-through 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 payments exceed the applicable percentage, but also to determine the appropriate reduction to the conversion factor for the projected level of pass-through spending in the following year. For devices, developing 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 devices that were eligible for pass-through payment in CY 2005 and/or CY 2006 and that would continue to be eligible for pass-through payment in CY 2007. The second group contains items that we know are newly eligible, or project would be newly eligible, for pass-through payment beginning in CY 2007. B. Estimate of Pass-Through Spending for CY 2007 As we proposed, in this final rule with comment period, we are setting 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. In cases where we have relevant claims data for the procedures associated with a device category, we often project these data forward using inflation and utilization factors based on total growth in OPPS services as projected by CMS’ Office of the Actuary (OACT) to estimate the upcoming year's pass-through spending for this first group of device categories. As we stated in the CY 2007 OPPS proposed rule (71 FR 49596), we may use an alternate growth factor for any specific device category based on our claims data or the device's clinical characteristics, or both. Based on our historical claims data for the procedures associated with the current device category continuing for pass-through payment into CY 2007 and the device's clinical characteristics, we estimate pass-through spending attributable to the first group (that is, one category for CY 2007) described above to be $44.0 million for CY 2007. To estimate CY 2007 pass-through spending for device categories in the second group, that is, items that we know at the time of development of this final rule with comment period would be newly eligible for pass-through payment in CY 2007 or contingent projections for new categories in the second through fourth quarters of CY 2007, we used the following approach. In general, as described for the first group of device categories above, if we have relevant claims data we may project these data forward using OACT inflation and utilization factors based on total growth in OPPS services, or 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. As we indicated in the proposed rule (71 FR 49596), we anticipated that any new 
                        ( print page 68102)
                        categories for January 1, 2007 would be determined after the publication of the proposed rule, but before publication of this final rule with comment period. For the two additional device categories that have now been approved for pass-through status as of January 1, 2007, we used price information and utilization estimates from manufacturers, because we did not have any relevant CY 2005 claims data upon which to base a spending estimate for CY 2007. To account for the contingency of new device categories that we project could become eligible for pass-through status in the second, third, or fourth quarters of CY 2007, we used the general methodology as described above, while also considering the most recent OPPS experience in approving new pass-through device categories. Therefore, as indicated in our proposed rule (71 FR 49596), the estimate of pass-through spending in this CY 2007 OPPS final rule with comment period incorporates both CY 2007 estimates of pass-through spending for device categories made effective January 1, 2007, and estimates for those projected to be approved during subsequent quarters of CY 2007. With respect to CY 2007 pass-through spending for drugs and biologicals, as noted in the proposed rule (71 FR 49596) and explained in section V.A.3. of this final rule with comment period, the pass-through payment amount for new drugs and biologicals that we determine to have pass-through status will equal zero. Therefore, in this final rule with comment period, 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 pass-through 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 pass-through status.) There are no radiopharmaceuticals that were eligible for pass-through payment in CY 2005 or at the time of publication of this final rule with comment period in CY 2006. In addition, we 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 final estimate of pass-through spending for CY 2007. We discuss the methodology for determining the 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 those that first become eligible for pass-through status during CY 2007 will equal approximately $65.6 million, which represents 0.21 percent of total OPPS projected payments for CY 2007. This figure includes an estimate for the current device category continuing into CY 2007, which equals approximately $44.0 million, in addition to projections for both categories that were approved after publication of the OPPS proposed rule effective January 1, 2007, and discussed in section IV.B. of the preamble of this final rule with comment period, and new categories that may become eligible during the subsequent quarters of CY 2007. Table 28.—Estimate of CY 2007 Transitional Pass-Through Spending for Current Pass-Through Category Continuing into CY 2007
HCPCS
APC
Existing pass-through device category
CY 2007 estimated utilization
CY 2007 estimated pass-through paymentsC1820
1820
Generator, neurostimulator (implantable), with rechargeable battery and charging system
5,483
$43,974,519
 Because we estimate that pass-through spending in CY 2007 will not amount to 2.0 percent of total projected OPPS CY 2007 spending, we will return 1.79 percent of the pass-through pool to adjust the conversion factor, as we discuss in section II.C. of this preamble. Accordingly, we are finalizing our proposed methodology for estimating CY 2007 OPPS pass-through spending for drugs, biologicals, and categories of devices. Our final total pass-through estimate for CY 2007 is $65.6 million. VII. Brachytherapy Source Payment Changes 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 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 
                        ( print page 68103)
                        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. B. Government Accountability Office's Final Report on Devices of Brachytherapy Section 621(b)(3) of Pub. L. 108-173 required 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. This report was due to Congress and to the Secretary no later than January 1, 2005. The GAO's final report, “Medicare Outpatient Payments: Rates for Certain Radioactive Sources Used in Brachytherapy Could Be Set Prospectively” (GAO-06-635), which was published on July 24, 2006, was not available in time for review and discussion in the CY 2007 OPPS proposed rule. Therefore, we are summarizing and discussing the report's findings and recommendations in this final rule with comment period. The GAO report principally recommends that we use OPPS historical claims data to determine prospective payment rates for two of the most frequently used brachytherapy sources, iodine-125 and palladium-103, and also recommends that we consider using claims data for the third source studied, high dose rate (HDR) iridium-192. During the GAO hospital purchase price study period, separate device codes were not available to specifically distinguish high activity and low activity iodine and palladium sources. Therefore, in addition to establishing prospective payment rates for iodine-125 (C1718) and palladium-103 (C1720) based on claims data, the GAO states that it expects CMS to have data available to set prospective payment rates for high activity iodine-125 (C2634) and palladium-103 (C2635) sources in CY 2007 as well. These two codes were created in CY 2005 as a result of the Medicare Modernization Act (MMA) requirement that the OPPS establish brachytherapy device payments that account for the radioactive intensity of the sources. The GAO studied 3 of the 12 specific sources currently paid separately under the OPPS: palladium-103, iodine-125, and HDR iridium-192. The GAO conducted a survey of purchase prices paid by 121 hospitals, from July 1, 2003, through June 30, 2004. These hospitals were carefully selected to be representative of all hospitals providing these sources in CY 2002. The GAO used a regression model to identify stratification factors that would maximize the difference in mean purchase price among strata of the sample. It grouped hospitals into major teaching hospitals, nonmajor teaching hospitals, urban nonteaching hospitals, and rural nonteaching hospitals. The GAO placed small hospitals into a separate stratum to ensure that they were appropriately represented. For iodine and palladium sources, the survey requested reporting of the name of the manufacturer, the number of sources, the price per source, and certain characteristics of the sources purchased, such as radioactivity level and configuration. For iridium, it requested reporting of the name of the manufacturer, the number of treatments delivered, the source price, and its rebate eligibility. The GAO survey had an overall response rate of 51 percent, and the GAO was able to calculate the mean and median purchase prices for iodine and palladium. Few hospitals reported receiving rebates. To estimate the hospitals' mean and median purchase prices for iodine and palladium sources, the sample hospitals' purchase price data were weighted to make them representative of the sample frame of hospitals from which the sample was drawn. The GAO used standard statistical trimming principles, which resulted in the exclusion of only 2 percent of the reported purchase prices of iodine and exclusion of none of the reported purchase prices of palladium. It estimated the mean price per source as $29.54 (median $25.37) for iodine from data submitted by 52 hospitals and $45.35 (median $45.46) for palladium from data submitted by 40 hospitals, with very low price variability across hospitals. Specifically, the coefficients of variation for the mean estimates were 1.59 percent for the iodine purchase price data and 0.68 percent for the palladium purchase price data. This shows a remarkably low degree of variability within the data for the purchase prices of iodine and palladium brachytherapy sources during the survey period. The GAO found this price information to be reasonably consistent with cost data calculated from historical OPPS claims for the sources. It speculated that, to the extent that price variation in the survey data existed across either palladium or iodine sources, this variation could be attributed to differential pricing by source characteristics, such as configuration or radioactivity level. While the GAO stated that its survey data were insufficient to reliably identify any price differences by source characteristics, it concluded that any price variation should be reflected in its survey data because hospitals were to report all their purchases during the survey period. The GAO indicated that its results could be appropriately generalized to the approximately 950 hospitals providing these sources in the outpatient department that met the sampling criteria, and stated that the sampling frame contained 98 percent of the hospitals submitting OPPS claims for the three brachytherapy sources in CY 2002. Only 19 hospitals responded to the survey with iridium information, but 11 did not provide the number of treatments and/or reported questionable source prices, resulting in the GAO's inability to estimate the cost per treatment in these cases. For the other eight hospitals, there were also data inconsistencies. Because the GAO could not establish a unit cost for iridium, it could not assess if the unit cost of iridium varied substantially and unpredictably over time in a way that would make establishing a prospective payment rate inappropriate. The GAO report concluded that CMS could set prospective payment rates based on claims data for iodine and palladium sources, because the sources' unit costs are generally stable, both sources have identifiable unit costs that do not vary substantially and unpredictably over time, and reasonably accurate claims data are available. On the other hand, the GAO report explained that it was not able to determine a suitable methodology for paying separately for HDR iridium. The report noted that iridium is reused across multiple patients, making its unit cost more difficult to determine. However, the report also indicated that CMS has outpatient claims data from all hospitals that have used iridium and that in order to identify a suitable methodology for separate payment, CMS would be able to use these data to establish an average cost and evaluate whether that cost varies substantially and unpredictably. C. 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, 
                        ( print page 68104)
                        CMS is 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. In the CY 2007 OPPS proposed rule, we proposed to pay separately for each of the sources listed in Table 29 of that rule (71 FR 49597) on a prospective basis for CY 2007, with payment rates to be determined using the CY 2005 claims-based median unit cost per source for each brachytherapy device (with the exception of Ytterbium-169, as discussed below). Consistent with our policy regarding APC payments made on a prospective basis, we proposed 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 this preamble, for CY 2007 we proposed specific payment rates for brachytherapy sources, which would be subject to scaling for budget neutrality. Table 29 of the proposed rule included 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 proposed to use for CY 2007. The brachytherapy sources and related information in Table 29 were 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. As indicated in the CY 2007 OPPS proposed rule (71 FR 49597), we believed there were 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. Under our proposal, brachytherapy sources would be paid using the same basic median cost methodology as the overall OPPS. We believed that the payment of sources based on this approach would thus be an integral part of the OPPS, rather than a separate cost-based payment methodology within the OPPS. In addition, we proposed this option because we believed that consistent and predictable prospectively established payment rates under the OPPS for brachytherapy sources would be appropriate. We doubted that the hospital resource costs associated with specific brachytherapy sources would vary greatly across hospitals or clinical conditions under treatment, other than through differences in the numbers of sources utilized, which would be accounted for in our proposed per source payment methodology. We also believed that the proposed 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 the proposal 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 received numerous comments regarding our CY 2007 proposed payment methodology for brachytherapy sources. *Comment:*
                         A number of commenters objected to CMS’ proposal to set prospective payment rates based on median unit costs of sources because they believed that there was no valid, useful source of data for brachytherapy sources upon which to base prospective payment rates for CY 2007. The commenters stated that the GAO survey data were fundamentally flawed and should be disregarded by CMS, and that CMS’ claims data also did not reflect the true hospital costs of brachytherapy sources. Specifically with regard to the GAO survey, they believed that the data collected by the GAO were outdated, and that the survey response rate was inadequate as the basis for conclusions regarding the costs of sources. They stated that the GAO survey failed to provide data sufficient for analyses by source configuration (specifically, loose sources versus stranded sources) and type of hospital (specifically, rural versus urban), both of which they believed should be taken into account in setting prospective payment rates for brachytherapy sources. The commenters also stated that the CMS claims data were not valid because they were not available by source configuration (that is, loose sources versus stranded sources), which commenters viewed as an important distinction with respect to clinically meaningful characteristics and costs. They observed that the CMS cost data showed significant variation in unit costs across hospitals, and that the number of claims containing source charges was inadequate. They objected to reliance on CMS’ cost data because they stated that two-thirds of the source APCs have fewer than 50 hospitals reporting cost data for sources. They concluded that the CMS data must be erroneous, because it showed the costs of low activity iodine and palladium sources to be higher than the costs of high activity sources of iodine and palladium, a result that contradicted their expectations. The commenters believed that the use of median costs was not valid because median costs can result in a single claim or hospital being the determinant of the median cost. Therefore, they concluded that basing brachytherapy source payment on a median cost did not fully represent the costs of all hospitals. *Response:*
                         In contrast to the commenters' opinions, we believe that both the GAO survey information and CMS' claims data provide sufficient valid information on which to base prospectively established payment rates for brachytherapy sources. The findings of the GAO survey and CMS' claims data are sufficiently similar and stable to justify the use of claims data in setting prospective payment rates for brachytherapy sources. We do not view the delay in the publication of the GAO report as causing its contents to be outdated. In fact, the law that required the survey was passed on December 23, 2003. Instead of choosing to survey hospital costs only from CY 2003 or before, GAO, after seeking the views of stakeholders, chose to survey for the period, July 1, 2003, through June 30, 2004, in order to acquire the most current information available at the time that the survey was performed. We found the GAO survey to provide credible information based on a stratified sample of all relevant categories of hospitals furnishing brachytherapy sources. We noted that there was remarkably little variation within the cost data elements for the iodine and palladium sources, the two most commonly billed sources under the OPPS. The GAO survey was performed using standard survey techniques, and the statistics were calculated using standard statistical methods. The coefficients of variation demonstrated a remarkable amount of stability for the data which were gathered from a wide range of provider types. We agree with the GAO that the response to the survey, while not sufficiently robust to provide information by source configuration or other characteristics of sources, is sufficient to provide a valid measure of the purchase price for iodine and palladium sources. We do not believe that the information from the survey was insufficient to yield valid estimates of hospital costs. Moreover, the median costs provided by the GAO survey are remarkably consistent with the median costs derived from Medicare claims data 
                        ( print page 68105)
                        over the years as discussed below and shown in Table 29. The GAO report recommended that we use OPPS claims data to determine prospective payment rates for two of the most frequently utilized brachytherapy sources, iodine-125 and palladium-103. In addition, the GAO report stated that it was unable to determine a suitable methodology for paying separately for HDR iridium because the survey provided insufficient data to identify and evaluate iridium's average unit cost across hospitals. However, the GAO observed that CMS has historical outpatient claims data from all hospitals that have provided iridium sources. The GAO concluded that CMS should be able to use its data to establish an average unit cost for HDR iridium, which could then be evaluated for suitability as the basis for separate payment, specifically considering whether the source cost varies substantially and unpredictably. We do not believe the absence of data by configuration or type of hospital is relevant to the validity of the median costs of iodine and palladium sources that resulted from the survey. We discuss the issue of changes in source configuration in more detail below in the context of the CMS data. With respect to the absence of statistics by type of facility, we believe that the consistency between the GAO survey purchase prices and the CMS data (which are based on billing by all hospitals regardless of type) shows that the lack of response by rural hospitals to the GAO survey is not meaningful. We believe that there are sufficient and valid CMS claims data upon which to base prospective payment rates per source for each of the brachytherapy sources with available historical claims information. Sources of brachytherapy have been separately paid for virtually all of the history of the OPPS, with packaging of iodine and palladium sources only for prostate brachytherapy in CY 2003, when there was separate payment in that year for these sources for other uses. Moreover, before CY 2003 the sources were paid separately under the transitional pass-through payment methodology as pass-through devices. Therefore, hospitals have now had 6 years of experience in billing the sources separately to receive payment for these relatively costly items. Due to their pass-through payments in CYs 2000 through 2002 and payments at charges reduced to costs for CYs 2004 through 2006, hospitals have historically had a strong incentive to bill for sources at charges that reflected the costs of the sources. Therefore, to the extent that the commenters believed that our data show rank order anomalies or inadequate charges or wide variations in charges, we must assume that the charges reflect the hospitals' perceptions of the relative costs of the sources, and hospitals alone choose the charges they submit to Medicare and to all other payers. With regard to the use of the median cost, we note that the use of median costs for sources of brachytherapy is identical to the basis of payments for all services paid under the OPPS, other than drugs and biologicals, pass-through devices, and some new technology services. The nature of basing weights on median costs is that the volume of services, by definition, controls the median cost because the median is the 50th percentile of the array of data. However, use of the median cost also simultaneously eliminates the influence of not only the highest but also the lowest values in the array. Moreover, as the OPPS is a budget neutral relative weight system, it is the relativity of the medians that is important and not the specific median itself. Therefore, it is important that the same measure of central tendency (in this case the median cost) be used to establish the weights for all OPPS services to which the conversion factor applies to calculate their payment rates. We also do not consider the absence of data specific to loose versus stranded brachytherapy sources to be relevant to the calculation of sources' median costs. We have, as the law specified, established source codes for purposes of separate payments that take into account the number, isotope, and radioactive intensity of the sources. As with other medical devices, there will always be incremental improvements in the technology. We consider the configuration of sources as loose or stranded to be an incremental change, whose potential differential costs would be reflected in source cost data as the change penetrates the market for the product. As such, the impact of differing configurations would become apparent in hospital claims data over time as a matter of natural course. Based on the historical technological evolution in stranded brachytherapy sources, we expect that our CY 2005 median costs for sources already reflect their partial market penetration, as indicated in the comments and discussed later in this section. Moreover, we do not agree that special action is necessary to prevent disincentives to the use of improved products. We believe that hospitals and physicians balance the additional benefit to patients of improved products with the additional costs, if any, of those products. One of the functions of a prospective payment system is to encourage wise purchasing while simultaneously making appropriate payments for the services being furnished. We believe that payments based on the median unit costs of brachytherapy sources support this goal. Our review of the GAO findings and examination of OPPS claims data support use of the median costs from CMS” claims data as the basis for the CY 2007 payment rates for brachytherapy sources. In Table 29 below, we have summarized available historical OPPS information for the iodine and palladium sources studied by the GAO, in the context of our CY 2007 final rule median unit costs. Table 29.—Median Costs, Payment Rates, and GAO Study Findings for Iodine and Palladium Brachytherapy Sources
Source
CY 2003 payment
                                 rate*
CY 2004 proposed
                                 rate**
GAO survey median
                                 price @
Estimated CY 2006 median 
                                 payment #
CY 2007 final rule median
                                 unit costIodine-125
$31.33
$36.35
$25.37
$32.63
$36.12Palladium-103
43.96
44.00
45.46
48.92
48.53* Based on median from CY 2001 claims.** Based on median from CY 2002 claims.@ Purchase price between July 2003 and June 2004.# Based on charges reduced to cost method.
 
 
 While the CY 2007 final rule median costs are established as median unit costs calculated using the standard OPPS methodology of applying specific departmental CCRs, if available, to claims' charges, and defaulting to overall hospital CCRs only if departmental CCRs are unavailable, estimated CY 2006 payments are calculated according to the cost-based payment methodology in effect during CY 2006, which reduces charges to costs using overall hospital-specific CCRs. The table shows great consistency of OPPS claims data for these sources over the past 5 years, yielding reasonably stable median costs, with their associated payment rates, as either proposed or finalized over time. The CY 2007 final rule median costs for iodine, although based on claims for services provided approximately 1 to 2 years later than the dates of service for the survey data collected by the GAO regarding hospital purchase prices, are significantly higher than the median GAO purchase prices. For palladium, the final rule median cost is about 8 percent higher. On average, the CY 2007 median cost for iodine sources would be about 11 percent greater than the median payment under the CY 2006 cost-based methodology, while for palladium sources it would be about the same. Thus, we are relatively confident that the CY 2007 final rule brachytherapy source median unit costs from CY 2005 claims that are the basis of the CY 2007 payment rates for sources are reasonably accurate and should ensure continued access by Medicare beneficiaries to brachytherapy services delivered with these commonly used iodine and palladium sources. We also found that, for the eight other brachytherapy sources for which we have hospital claims data from CY 2005, hospital costs for these sources do not vary more significantly than for the two sources previously discussed. Of these eight sources, gold-198 (C1716), non-HDR iridium-192 (C1719), and yttrium-90 (C2616) were established sources in CY 2003, the only previous year where the OPPS provided separate payments for some brachytherapy sources (other than pass-through payments in years prior to CY 2003). Their CY 2003 payment rates were $22.74, $27.29, and $6,485.37, respectively, relatively consistent with our CY 2007 final rule median costs of $36.61, $23.01, and $10,525.13, respectively, based on CY 2005 claims data. Iodine-125 brachytherapy solution (C2632) was paid in CY 2003 as a pass-through device, without a prospective payment rate. In CY 2003, the OPPS did not pay for cesium-131, ytterbium-169, and linear palladium-102, and had not yet distinguished high activity iodine-125 and palladium-103 sources. While we have relatively low CY 2005 days and units for several of these 8 sources, we have at least 320 units for each one. We estimate that half of these devices would experience an increase in payment of 4 percent to 38 percent under the CY 2007 final rule methodology compared with their median payments under the CY 2006 cost-based methodology, while the others would experience decreases of 17 percent to 38 percent. This variation reflects the numerous different departmental CCRs that are used to calculate costs for brachytherapy from the relatively small number of hospitals reporting charges for many of the sources, in comparison with their overall hospital CCRs. We can identify no specific problems with the data for these eight sources that would cause us to question the accuracy of the CY 2007 final rule payment rates based on the sources' median costs from CY 2005 claims data. Therefore, we believe that the median cost per source from CY 2005 Medicare claims data provides a sufficient and valid basis to establish a prospective payment rate for each brachytherapy source with available CY 2005 claims data. *Comment:*
                         A few commenters questioned our median costs published in the CY 2007 OPPS proposed rule for high activity iodine-125 source (C2634), pointing out the proposed payment rate for C2634 was $25.68, which is lower than the proposed payment rate for the iodine-125 source (C1718) at $35.42. One commenter indicated that this reflected a rank order anomaly in proposed payments for high activity brachytherapy sources, and added that high activity iodine-125 sources always cost more, and typically may be many times more expensive than the corresponding low activity sources. The commenter stated that this error in the payment for high activity sources must be corrected for the sources to be clinically available. *Response:*
                         While the median cost of C2634 for this CY 2007 final rule with comment period, $32.49, is still lower than the median cost for C1718, at $36.12, the median cost for the high activity source is somewhat higher than proposed, and the gap between the median costs of the two sources has narrowed. The commenters did not provide data supporting their assertion that the cost of the high activity iodine-125 source is typically many times greater than the cost of the traditional low activity iodine-125 source. We acknowledge that the relatively low volume of claims from a small number of hospitals for the high activity iodine source from CY 2005 may contribute to the variability in its median cost, but we see no reason to believe that its median cost would not be appropriately reflective of the costs to hospitals providing the source in CY 2005. The GAO also noted that it expected us to have claims data from CY 2005 that could be used to establish a prospective payment rate for the high activity iodine-25 source. *Comment:*
                         Two commenters objected to our proposal to pay for sources of brachytherapy based on the median cost and asked that CMS set a prospective per source payment rate base on the mean cost derived from our claims data. One commenter believed that sources of brachytherapy should be paid based on prospectively set mean costs because they should be paid on the same basis as radiopharmaceuticals, for which we proposed to pay based on mean cost because both brachytherapy sources and radiopharmaceuticals contain radioactive material, are regulated by the Nuclear Regulatory Commission, and have the same storage, handling, and disposal requirements. *Response:*
                         We disagree that sources of brachytherapy should be paid identically to radiopharmaceuticals. Radiopharmaceuticals are defined by MMA as drugs and drugs are, by law, paid based on hospital average acquisition cost. Sources of brachytherapy are not required by law to be paid at average acquisition cost, and therefore we are setting the CY 2007 payment for these items based on median costs derived from our claims data, like most other OPPS services that are not drugs. We refer readers to the discussion below, in response to a comment, concerning our policy for payment of the handling and storage costs of brachytherapy sources. *Comment:*
                         A few commenters asserted that CMS did not provide an estimate of the effect on payments for brachytherapy sources due to the proposed change from a payment methodology of charges reduced to cost to a median cost methodology. They recommended that CMS evaluate the impact of any proposed changes in payment methodologies for brachytherapy sources and radiopharmaceuticals. *Response:*
                         In fact, we did consider the impact of the proposed brachytherapy source payment methodology and alternatives as discussed in section XXVII.B.1.b. of the CY 2007 proposed rule (71 FR 49681). 
                        ( print page 68107) *Comment:*
                         One commenter disagreed with our proposal that the cost of brachytherapy sources should be subject to the outlier provisions of the OPPS, indicating that historically brachytherapy sources have not been subject to additional outlier payments. The commenter also stated that services assigned to status indicator “K” status have not been eligible for outlier payments for the past 2 years. The commenter indicated that these types of changes are burdensome on hospitals and believed that brachytherapy sources should be excluded from outlier calculations, like separately paid drugs and devices receiving pass-through payments. *Response:*
                         Unlike separately paid drugs and devices eligible for pass-through payments, our proposal for brachytherapy sources is to pay for them based on median costs, which the commenter supports. Therefore, we are merely making our policy for brachytherapy sources consistent with our policy regarding other APC payments based on median costs, including that they be subject to the outlier provisions of section 1833(t)(5) of the Act. We are finalizing our proposal to make prospectively paid brachytherapy sources subject to the outlier provisions of section 1833(t)(5) of the Act. We note that we inadvertently did not show the necessary conforming regulation text in the proposed rule. Accordingly, we are making a conforming technical change to the regulation text at § 419.43(f) to delete brachytherapy sources from the services and groups excluded from outlier payments. We noted in the proposed rule that HDR iridium-192 (code C1717) is a reusable source across treatment sessions and across patients. We believed that it was unclear whether hospitals had been reporting the number of units provided accurately, in accordance with our instructions to report one unit per treatment. Thus, while we proposed that HDR iridium be paid separately on the basis of the median cost per source as we proposed to pay for the other brachytherapy sources, we invited comments on alternatives to using this methodology for this source in particular, such as on the basis of median cost per treatment day from hospital claims. We received a large number of comments specifically addressing the CY 2007 OPPS proposal for payment of HDR iridium, including suggestions for alternatives to payment based on the median unit cost of the source. *Comment:*
                         A number of commenters noted that the unit cost of HDR iridium is particularly variable, depending on the number of treatments provided by a hospital in a given calendar quarter before the source must be renewed. They believed that HDR iridium was, therefore, unlike most other OPPS services, for which hospital costs did not typically vary as greatly in relationship to service volume. They argued that providing payment at charges reduced to costs for this source, in particular, was important to ensuring patient access to HDR iridium treatment in their communities where the service volume may be low, such as at rural hospitals. Partial breast irradiation, with closely spaced treatments provided over a short time period in comparison with traditional treatment with external beam radiation therapy over many weeks, was cited as an important example of the value of HDR iridium in improving the care and quality of life for patients undergoing treatment for breast cancer. The commenters expressed concern that the proposed payment of $134.93 per fraction may provide inadequate payment, particularly to hospitals that do not provide a high volume of HDR brachytherapy, notably smaller and mid-sized hospitals. Some of the commenters agreed with our concern that hospitals may not be reporting accurate units and charges for this reusable source. The commenters recommended that HDR iridium should continue to be paid on a per treatment or per fraction basis, and not be paid per treatment day, due to the significant variations among different treatment protocols. Therefore, the commenters concluded that CMS should continue to pay for HDR iridium per fraction. A few commenters indicated that there is great variability in the cost of HDR iridium treatments, with such variations occurring because of the treatment site (for example, breast, uterus, prostate). These treatment variations result in differences in the resources needed, such as the number of source runs for each case. The commenters also indicated that our claims data for HDR iridium-192 presented huge variations in cost per unit source on claims and across hospitals, with costs ranging from $0 to $4,746. In addition, the commenters pointed out that the GAO report made no definitive recommendations regarding payment for the HDR iridium source. A number of commenters stated that CMS should continue to pay for HDR iridium based on the charges reduced to cost payment methodology. *Response:*
                         Our proposal to pay for HDR iridium-192 on a per source basis, which is equivalent to a per treatment or per fraction payment for this brachytherapy source, factors in the clinical variability in the number of treatments per day with this source. HDR iridium is a radioactive source with a 90-day life span that is purchased and used multiple times in numerous patients over its life. During a treatment with HDR iridium, the radioactive source is briefly inserted into each temporary treatment catheter that has been placed into a patient's treatment area and then removed. It never comes in direct contact with the patient so it may be used for multiple patients. We believe that the cost of the radioactive source per treatment procedure is the same, irrespective of how many dwell positions or source runs are provided in the variable numbers of catheters placed in patients. However, we also understand that a per day payment methodology that does not take into consideration the number of treatments per day could be problematic, because the total day's source cost when more than one treatment is provided on a day for the same Medicare beneficiary would be significantly greater than if only one treatment was performed on that day. We believe that a per source payment, which equates to a per treatment payment, for HDR iridium as proposed is appropriate, given these considerations. Because HDR iridium has a fixed active life and must be replaced every 90 days, we agree with commenters that hospitals' costs for the source will be highly dependent on the number of treatments provided by a hospital during that time period. The source cost must be amortized over the life of the sources so, in establishing their charges for the HDR iridium source, we expect that hospitals would project the number of treatments that would be provided over the life of the source and establish their charges accordingly. In this respect, HDR iridium is similar to capital equipment that hospitals buy to perform procedures and that has a limited lifespan. Hospitals' costs for such equipment must be spread over their charges for the procedures performed, so the cost per procedure would vary significantly depending on the number of services provided. For most such OPPS services, our practice is to establish prospective payment rates based on the median hospital costs as calculated from claims data, to provide incentives for efficient and cost-effective delivery of these hospital services. We examined our full year CY 2005 claims data for HDR iridium, as suggested by the GAO, and found the hospital costs for this source did not vary much more than for the other brachytherapy sources, including 
                        ( print page 68108)
                        iodine and palladium. We note that, based on our analysis, on average the CY 2007 final rule median cost for HDR of $141.75 based on the source's median unit cost from CY 2005 claims would be about 7 percent higher than under the CY 2006 cost-based methodology, which yields an estimated median payment of $132.30, similar to the pattern observed for iodine and palladium sources. While we recognize that the average unit cost of an iridium source purchased by a hospital would be related to the number of treatments provided with the source and that hospitals must bill Medicare based on projections of their unit cost, we have no reason to believe that our CY 2007 final rule payment rate based on the median unit cost for HDR iridium would place continued access to this source at risk. Like many services under the OPPS for which hospitals purchase reusable equipment and supplies, hospitals' unit costs for iridium sources would vary based on the number of treatments a hospital provides before the source must be renewed, thus incurring additional costs. Again, under a PPS methodology, payments generally account for the average costs of services, and do not specifically account for varying circumstances. We believe that hospitals understand this prospective payment methodology and should recognize that a PPS could pay more or less than the cost of delivering a specific service in an individual case. Regarding the comment that the GAO report made no definitive recommendations regarding payment for the HDR iridium source, this recommendation was based on the lack of data produced by the GAO's own survey, and the report indicated that it was the GAO's opinion that CMS has outpatient claims data from all hospitals that have used iridium. The GAO recommended that, in order to identify a suitable methodology for separate payment for HDR iridium, CMS would be able to establish an average cost and evaluate whether that cost varies substantially and unpredictably. In the efficient delivery of high dose rate brachytherapy services, our claims data provide no evidence that the hospital costs associated with HDR iridium vary greatly and unpredictably, so we believe that our CY 2005 claims provide an appropriate basis upon which to establish the CY 2007 prospective payment rate for HDR iridium for each treatment. This rate should help ensure that hospitals continue to operate efficiently in providing HDR brachytherapy treatments to Medicare beneficiaries. *Comment:*
                         One commenter recommended that CMS continue paying hospitals “based on use of the HDR Iridium-192 source,” but that CMS establish a maximum charge for HDR Iridium, that is, $700 per fraction. The commenter also suggested that each provider continue to establish a charge based upon the source costs per year divided by the number of fractions, thus allowing low volume HDR facilities to offer the service, while not overpaying high volume facilities. *Response:*
                         We do not instruct hospitals on establishing charges or restrict hospital charges for items billed to Medicare. Hospitals establish charges based on many factors, including, but not limited to, the costs of items and services and the market conditions in the communities that they serve. Moreover, the OPPS is not a system that pays hospital charges. The OPPS rates generally are based upon relative weights calculated from Medicare claims data and converted to payment rates by a conversion factor. Prospective payment rates under the OPPS are based on the median cost for each APC from historical hospital claims, with trimming of claims data only at the extremes to eliminate those claims of exceptionally high or low cost from contributing to APC median cost development. The commenter did not indicate how a maximum charge would alleviate problems associated with making appropriate payments for HDR iridium to hospitals, or any goals such a policy would accomplish. Additionally, the commenter did not provide the basis of its recommendation that the maximum charge should be capped at $700 per fraction. *Comments:*
                         A large number of commenters requested that iodine-125 liquid brachytherapy solution, C2632 (which will be paid under A9527, effective January 1, 2007, as stated elsewhere in this section), which is used in patients with brain cancer, continue to be paid on the basis of charges reduced to cost. The commenters claimed that the proposed payment is insufficient to meet the cost of the iodine-125 (I-125) solution, along with handling and other administrative costs associated with the source. The commenters stated that hospitals must continue to be able to offer this vital brain cancer radiotherapy option. Several commenters believed that the proposed payment of $19.32 is not sufficient to cover the cost of one mCi, the 150-200 mCi in a 1 mL vial of I-125 solution, or the usual 150-450 mCi required for a typical case. One commenter noted that while appropriate coding requires reporting one unit per mCi, or 150 units per 1 mL vial, hospitals are confused regarding the correct unit of billing, which undermines the accuracy of data on which CMS relies. One commenter stated that the “actual hospital charge” of a 1 mL vial of I-125 solution is $5,900, which at the rate of 150 mCi per vial is $39.33 per mCi, while our proposed payment rate was $19.32 per mCi. This commenter also mentioned that the APC Panel report from the March 2006 Panel meeting noted that some brachytherapy sources, including C2632, “demonstrate relatively inconsistent mean and median numbers of sources used,” and that CMS staff pointed out concerns about variability of the mean and median statistics. The commenter contracted an outside consultant to analyze CY 2005 OPPS claims data for C2632. The contractor concluded that there are wide variations in how hospitals billed for units of I-125 solution, which points to unreliable cost data on which to base payments for CY 2007. *Response:*
                         The commenters did not establish why payment based on the median unit cost for the I-125 liquid brachytherapy solution is insufficient. Most commenters did not provide any information on the cost of a one mL vial of I-125 solution or sufficient further information supporting their claim that the proposed payment rate is insufficient. The commenter who stated that the “actual hospital charge” for a 1 mL vial of I-125 solution is $5,900 is a manufacturer of equipment that uses the I-125 solution for its brain cancer treatments and was the only commenter to provide some information on the cost of the I-125 solution. We note that we proposed to pay for the I-125 solution on a per mCi basis. This per source payment methodology is designed to capture the variability in costs per treatment, depending on the radiation dose. We also observe that the typical treatment of 150-450 mCi cited would receive payments between $2,898 and $8,694 per treatment, at the proposed payment rate of $19.32 per mCi. We have issued instructions on the correct OPPS billing for the brachytherapy solution. Transmittal 132, Change Request 3154, dated March 30, 2004, notes how to account for the cost of handling and supervision related to radiation sources. The commenters claimed that hospitals are confused regarding the number of units of I-125 solution per vial. Our payment has historically been made on a per mCi basis, and this approach will continue for CY 2007, consistent with the predecessor C-code unit (C2632) and, for CY 2007, the permanent A-code unit (A9527). Therefore, when a vial of I-125 
                        ( print page 68109)
                        solution contains 150 mCi, there are 150 billing units of I-125 solution per vial, resulting in an OPPS payment, if all billing units are used, of $2,898 based on the CY 2007 proposed payment rate. CMS staff did point out to the APC Panel at the March 2006 meeting our concerns about variability in statistics for numbers of sources used and wondered whether significant differences between the median and mean mCi reported per day could point to coding confusion regarding the correct billing of units for individual cases. We asked the Panel members to respond and provide any recommendations. Individual Panel members familiar with brachytherapy source costs, as well as the Data Subcommittee in general, believed that the median costs per unit appeared to generally be reasonable for the most commonly furnished sources, but that erroneous billing of the units of sources could affect the median unit costs of some sources, including C2632. We are continuing to study the variability of brachytherapy source data, and note that there are significantly greater units for some sources, such as C2632, based on full year CY 2005 data, than were included in the partial CY 2005 data the Panel reviewed in March 2006. We believe it is appropriate to treat I-125 solution like all other brachytherapy sources for CY 2007 and establish its payment rate based on its median unit cost from CY 2005 claims data. *Comment:*
                         One commenter did not believe we had factored into the cost of brachytherapy the need for special handling of sources by nuclear physicists and sought payment consideration for these handling costs. *Response:*
                         We explicitly consider the special handling of brachytherapy sources by nuclear physicists in our ratesetting policies. We instructed providers, in Transmittal 132, Change Request 3154, dated March 30, 2004, to report charges for the supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways: report the charge separately using CPT 77790, in addition to reporting the associated HCPCS procedure code(s) for application of the radiation source; or include the charge as part of the charge reported with the HCPCS procedure code(s) for application of the radiation source. (We further noted in that transmittal that providers should not bill a separate charge for brachytherapy source storage costs, which are treated as part of the department's overhead costs.) Reporting in either of these ways results in the costs of special handling being packaged into payments for brachytherapy procedures. *Comment:*
                         Some commenters asked that CMS continue to pay for brachytherapy sources on the basis of charges reduced to cost because the APC Panel and Practicing Physicians Advisory Council (PPAC) recommended it. They also stated that continuation of payment based on charges reduced to cost would ensure that there are no barriers to access and would avoid their concerns with CMS data. The commenters stated that payment based on this methodology has worked well for the past 2 years and should be continued for at least CY 2007 and CY 2008. Noting the GAO report was due no later than January 1, 2005, the commenters believed that the intent of Congress in section 621(b) of the MMA was to provide 2 years of payments for brachytherapy sources based on charges reduced to cost after the publication of the GAO study to allow no less than 2 years for Congress, CMS, and the public to further analyze brachytherapy device cost and payment information, and the findings of the GAO survey in particular, before payment based on charges reduced to cost would cease. They believed that CMS should continue payment based on charges reduced to cost for CY 2007 and CY 2008 to comply with what they viewed as the intent of Congress, because the GAO report was not released until July 2006, about 18 months after its due date of January 1, 2005, for publication. One commenter supported the concept of prospective payment for brachytherapy sources when the payment rates can be based on data that are stable over time and reasonably accurate. The commenter believed that the GAO report was sound, and it supported the GAO's recommendations regarding payment of C1718, iodine-125, per source and C1720, palladium-103, per source. For other sources, the commenter recommended that CMS continue to pay on the basis of charges reduced to cost. The commenter believed this was especially important for HDR iridium, which entails particular data challenges in developing an accurate per treatment or per fraction median cost. *Response:*
                         We recognize that at its August 2006 APC Panel meeting, the Panel recommended that CMS continue the current methodology of charges reduced to cost using the overall hospital CCR for payment of brachytherapy sources for 1 year (see recommendations of the APC Panel at 
                        *http://www.cms.hhs.gov/​FACA/​).*
                         The Panel reviewed a letter of comment on this issue requesting continuation of the CY 2006 cost-based payment methodology for CY 2007, but no public presentation was heard. While we acknowledge the Panel's recommendation, we note that the Panel did not provide specific rationale for its recommendation, nor did it provide an explanation of what it perceived to be the problem with the proposed median costs. Accordingly, we do not choose to adopt the Panel's recommendation. We also acknowledge that the PPAC recommended that CMS abandon the proposal to pay for brachytherapy sources based on median unit costs calculated from claims data and reexamine its claims data for sources (see recommendation 57 H.1 in the summary of the August 2006 PPAC meeting at 
                        *http://www.cms.hhs.gov/​FACA/​*). The Panel's discussion of the issue at its August 2006 meeting centered on its belief that hospitals incorrectly reported HCPCS codes and charges for brachytherapy sources. However, as discussed in detail previously, we observe significant stability of claims-based costs for the most commonly used sources over time, and hospitals have generally had 6 years of experience with reporting the codes and charges for brachytherapy sources, upon which their specific source payments were based throughout that time period. Therefore, as we do not agree with the underlying rationale behind PPAC's recommendation, we are likewise not accepting its recommendation. We also note that the statute requires payment based on charges reduced to cost for sources furnished between January 1, 2004, and December 31, 2006. The law is clear as to the timeframe for this payment approach and is not linked to the issuance of the GAO report, as commenters suggested was the intent of Congress. Moreover, we have considered the GAO's findings in setting prospective payment rates for sources of brachytherapy, which we believe is fully consistent with the provisions of the MMA. *Comment:*
                         A few commenters recommended that CMS institute mandatory device code edits for brachytherapy procedures assigned to APCs 0312, 0313, and 0651, requiring the reporting of alphanumeric HCPCS codes for brachytherapy sources, which are always required for the delivery of brachytherapy. More generally, the commenters stated that they support expanding the CY 2007 device edit policy to all device-related APCs. They also remarked that the CMS source data were insufficiently representative of actual source costs because many hospitals that charged for brachytherapy 
                        ( print page 68110)
                        procedures did not include codes and charges for sources on the claims for these procedures, which could not have been performed without the use of brachytherapy sources. The commenters asked that CMS require hospitals to bill the alphanumeric HCPCS codes for sources as a condition of being paid for the brachytherapy procedures that cannot be performed without sources, in order to promote correct coding and to improve the quality of the claims data. The commenter also believed that hospitals should be educated regarding how to report charges for brachytherapy sources used in the outpatient department. *Response:*
                         Device edits are appropriate for APCs that have the costs of the relevant devices packaged into the costs of the procedural APCs. We require device edits for certain APCs in order to ensure that charges for the required devices are included on the claims, so that payments for device costs are appropriately packaged into the payments for the procedures that use the devices. Moreover, we impose device edits in association with specific procedures only when an item is of significant cost whose payment is packaged into the APC payment for the procedure. We do not impose claims edits for items, such as brachytherapy sources, that are separately paid and for which hospitals have a very strong incentive to bill Medicare. Specifically, APCs 0312, 0313, and 0651 do not have payment for the costs of brachytherapy sources packaged into the procedural APC payments. We believe that hospitals that furnish brachytherapy services either bill us for the sources separately using their alphanumeric HCPCS codes or apparently choose to package the charges for the sources into charges for the services in which they are applied and not seek separate payment for the sources. The latter reporting practice would lead to our overestimation of the costs of brachytherapy procedures. In addition, if hospitals include the charges for the sources in the charges for the procedures in which they are applied, a requirement for reporting of codes for the sources could result in these hospitals billing token charges, thus undermining the correct determination of the unit cost per source. As required by the law, we currently are paying separately for brachytherapy sources, as we have been for most sources every year since the beginning of the OPPS in CY 2000. We will be paying for sources separately in CY 2007 as well. Because payments are provided separately for brachytherapy sources reported with specific HCPCS codes, device edits are not needed to ensure appropriate payments for brachytherapy procedures. The reporting of brachytherapy source HCPCS codes is required for hospitals to receive payment for brachytherapy sources, and this should be sufficient incentive for providers to report brachytherapy source codes. After consideration of the comments received, as well as the recommendations of the APC Panel, the PPAC, and the GAO, we have decided to base payment for all sources of brachytherapy for which we have CY 2005 claims on their median unit costs derived from CY 2005 OPPS claims data. We refer readers to Addendum B of this final rule with comment period for the CY 2007 national payment rates and copayments for the sources of brachytherapy. We note that there is a new permanent Level II alphanumeric HCPCS codes for iodine-125 brachytherapy solution for CY 2007. The new code, A9527, has a long descriptor, Iodine I-125, sodium iodide solution, therapeutic, per millicurie, that describes the same brachytherapy source as the predecessor C-code, C2632, Brachytherapy solution, iodine 125, per mci, for which we are currently making separate payment under the OPPS. As of January 1, 2007, with the effective date of HCPCS code A9527, we will delete C2632. We will crosswalk claims data and establish the prospective payment rate for A9527 based on our CY 2005 claims for C2632. Table 30 in this final rule with comment period contains the median costs of brachytherapy sources from CY 2005 claims data and the HCPCS codes to be used in CY 2007 to report these devices. Therefore, we are finalizing our proposed payment methodology for brachytherapy sources based upon their median unit costs from CY 2005 claims data for CY 2007 without modification. While this methodology is fully consistent with the statutory requirement of separate payment for brachytherapy sources based on their number, isotope, and radioactive intensity, it will also provide hospitals with an incentive to operate efficiently in providing brachytherapy services to Medicare beneficiaries. Because brachytherapy sources will no longer be paid on the basis of their charges reduced to cost, we proposed to discontinue our use of payment status indicator “H” for APCs assigned to brachytherapy sources. We proposed to use status indicator “K” for all brachytherapy source APCs for CY 2007. We also proposed 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 the preamble of this final rule with comment period. We did not receive any public comments specific to the proposal to change the status indicator definitions for brachytherapy sources. Therefore, we are adopting as final for CY 2007, without modification our proposed changes to the definitions of status indicators “H” and “K” to address CY 2007 brachytherapy source payment. Table 30 below provides a complete listing of the HCPCS codes, long descriptors, APC assignments, median costs, and status indicators that we will use for brachytherapy sources paid separately under the OPPS in CY 2007. Table 30.—Separately Payable Brachytherapy Sources for CY 2007
HCPCS code
Long descriptor
CY 2007 APC
CY 2005
                                 median cost
CY 2007 status
                                 indicatorC1716
Brachytherapy source, Gold 198, per source
1716
$36.61
KC1717
Brachytherapy source, High Dose Rate Iridium 192, per source
1717
141.75
KC1718
Brachytherapy source, Iodine 125, per source
1718
36.12
KC1719
Brachytherapy source, Non-High Dose Rate Iridium 192, per source
1719
23.01
KC1720
Brachytherapy source, Palladium 103, per source
1720
48.53
KC2616
Brachytherapy source, Yttrium-90, per source
2616
10,525.13
KA9527 (C2632 deleted)
Iodine I-125, sodium iodide solution, therapeutic, per millicurie
2632
20.30
KC2633
Brachytherapy source, Cesium-131, per source
2633
90.31
K( print page 68111)C2634
Brachytherapy source, High Activity, Iodine-125,  greater than 1.01 mCi (NIST), per source
2634
32.49
KC2635
Brachytherapy source, High Activity, Palladium-103,  greater than 2.2 mCi (NIST), per source
2635
54.25
KC2636
Brachytherapy linear source, Palladium-103, per 1MM
2636
39.28
K
 As indicated in our CY 2007 OPPS proposed rule (71 FR 49598), there was one source for which we had no claims data or payment information from the CY 2005 claims data available for the development of the proposed rule, and this statement remains true based on our recent analysis of complete CY 2005 claims data for this final rule with comment period. 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 was our understanding at the time of development of the proposed rule that this source, which is for use in HDR brachytherapy, was not yet marketed by the manufacturer, although it had been approved by the Food and Drug Administration (FDA). Therefore, we had no claims data for this brachytherapy source in order to develop a prospective payment rate, as we did for the other brachytherapy sources for CY 2007. In addition, it was our understanding that no price for the product existed, as it had not yet been marketed. Thus, we also had no external information regarding the cost of this source to hospitals. We weighed our payment options for CY 2007 for brachytherapy sources for which we had no payment or claims information, such as the present case with Ytterbium-169. This included 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. We discussed these payment options in our CY 2007 OPPS proposed rule (71 FR 49598 and 49599), and they are reviewed below. One option for CY 2007 was to pay for the currently existing HCPCS code C2637 for Ytterbium-169 at charges converted to cost. However, this would be inconsistent with our final policy with regard to payment for brachytherapy sources under prospectively established payment rates. The law specifically required us to pay for all brachytherapy sources based upon charges converted to cost for CYs 2004 through 2006. 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 was to assign the code to its own APC or to a New Technology APC with a payment rate set at or near the lowest CY 2007 payment rate for any source of brachytherapy paid on a per source basis (as opposed, for example, to per mci), for CY 2007. However, we had 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 and radioactive intensities, that are relevant to their clinical uses in low dose rate (LDR) versus HDR brachytherapy. The solid brachytherapy source with the lowest final median cost for CY 2007 is HCPCS code C1719, for non-HDR Iridium-192, with a median cost of $23.01 per source, which is implanted in LDR brachytherapy. A third option was 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 was 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. We 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 recognize a 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 proposed 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 source of brachytherapy paid on a per source basis. This option resembled our policy regarding the APC assignment of not otherwise classified codes, in the absence of any data currently available. Once we had claims data, or obtain external data, we could consider movement to another APC, if warranted. We specifically invited comments on how we should establish the CY 2007 payment amount for Ytterbium-169 (HCPCS code C2637), especially with consideration of the four options discussed above, and on how we should generally proceed in the future to set 
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                        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. We received a number of public comments concerning our four proposed CY 2007 payment options for Ytterbium-169 and/or other new brachytherapy sources without hospital costs from claims data. A summary of the comments and our responses follow. *Comment:*
                         A few commenters recommended that we pay for ytterbium, and other new or established brachytherapy sources when no hospital claims data are available, at charges reduced to cost, which was generally the commenters' recommendation on payment for all sources. Several commenters claimed that ytterbium would be available to hospitals in CY 2007. The commenters noted that ytterbium is an HDR source with unique characteristics and that, as described in its original request to CMS for a HCPCS code, ytterbium has a shorter half-life than HDR Iridium-192, requiring replacement every 32 days versus 90 days for HDR iridium. The commenters also noted different shielding and target activity for ytterbium in comparison with HDR iridium. Because there are no other sources comparable to ytterbium, some commenters believed the most appropriate payment methodology was charges reduced to cost for a minimum of 2 years, while CMS collects claims data. The commenters believed that CMS should similarly employ the payment methodology of charges reduced to cost for other new sources when there are no hospital claims data available. A number of commenters recommended that CMS pay for new sources on the basis of charges reduced to cost for a period of 3 years. *Reponse:*
                         The commenters presented no compelling arguments that new sources for which there are no claims data need to be paid at charges reduced to cost. Such an approach is contrary to the way we generally pay for other new nonpass-through items and services based on prospective payment rates through their APCs in the OPPS. We note that none of the commenters, including the manufacturer of ytterbium, provided the cost of that source when it reportedly will be marketed in CY 2007. However, we agree with the commenters that we need to pay appropriately for new brachytherapy sources in order to ensure continued developments in the technology. We have determined that our proposed option, to pay for new brachytherapy sources based upon the lowest per source payment rate of currently available sources, could provide payments for new sources that were too low to permit continued new developments in brachytherapy technology. Therefore, after weighing the comments and the four options, we are adopting as final the fourth option discussed for CY 2007. That is, we would assign future new HCPCS codes for new brachytherapy sources to their own APCs, with prospective payment rates set based on our consideration of external data and other relevant information regarding the expected costs of the sources to hospitals. This approach is consistent with our usual treatment of new technologies under the OPPS. We do not pay for new technologies, other than pass-through devices, under the OPPS at charges adjusted to cost. Instead, for new technology services we utilize external data and other information available to us, including claims data on related services, to establish appropriate New Technology APC assignments for new services until we have costs from claims data specific to the new services. We would not assign a brachytherapy source to a New Technology APC because such APCs contain only services, and, according to the statute, we are to establish separate groups for payment of brachytherapy sources reflecting their number, isotope, and radioactive intensity. Therefore, when we establish HCPCS codes for new brachytherapy sources, we will utilize external data and other information available to us to establish a prospective payment rate specific to the source, for use until we have hospital costs from claims data. Consistent with this practice, although we solicited specific comments on payment for the ytterbium source in the CY 2007 proposed rule, to date we have received no cost data and have no other information that we could use to establish an informed prospective payment rate for the source. Therefore, we are assigning C2637 the nonpayable status indicator “B” for January 1, 2007, because we have no claims information or external cost data that would allow us to assign C2637 to its own APC with a prospective payment rate. Should we later receive relevant information, we could establish a payable status indicator and appropriate payment rate for the ytterbium source in a future OPPS quarterly update. In our CY 2007 OPPS proposed rule, we again invited the public to submit recommendations for new HCPCS codes to describe new brachytherapy sources in a manner reflecting the number, isotope, and radioactive intensity of the sources (71 FR 49599). We requested that commenters provide a detailed rationale to support recommended new sources and send recommendations to us. We noted that we would continue our endeavor to add new brachytherapy source codes and descriptors to our systems for payment on a quarterly basis (71 FR 49599). We specified that 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. As indicated in the CY 2007 OPPS proposed rule (71 FR 49599), we had 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 proposed 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 proposed that we would not consider specific devices that did not utilize radioactive isotopes to deliver radiation to be radioactive sources as envisioned by the statute. We received numerous public comments in response to our request for new brachytherapy source recommendations and our proposed definition of the term “brachytherapy sources.” A summary of the comments and our responses follow. *Comment:*
                         A large number of commenters disagreed with our proposed definition of brachytherapy sources for separate payment for a variety of reasons. Several commenters stated that our definition based on section 1833(t)(2)(H) of the Act was too narrow, and should be broadened to include new and innovative nonradioactive sources, such as “electronic” brachytherapy sources. The commenters indicated that brachytherapy sources do not need to be radioactive to deliver therapeutic doses of brachytherapy. They recommended that CMS consider all new technologies now FDA-cleared for brachytherapy and broaden our definition for separate payment to include innovative radioactive and nonradioactive sources. Many commenters believed that adopting the proposed definition of brachytherapy sources for separate payment would prevent Medicare beneficiary access to care and hamper the development of new cancer therapies, such as “electronic” brachytherapy. Some commenters indicated that brachytherapy is not 
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                        defined by the type of source used to treat the cancer, but by the treatment that is delivered to the patient. A few commenters stated that, through discussions with legislators, it was their understanding that the intent of the legislation was to provide separate payment for all devices of brachytherapy and not to exclude any devices. *Reponse:*
                         As indicated in the CY 2007 OPPS proposed rule (71 FR 49599) and reiterated in this preamble above, we considered the definition of “brachytherapy source” in the context of current medical practice and in regard to the language in section 1833(t)(2)(H) of the Act, which refers to brachytherapy sources as “a seed or seeds (or radioactive source).” We continue to believe that this provision of the Act mandating separate payment refers to sources that are themselves radioactive, meaning that the source contains a radioactive isotope. Furthermore, the statutory language is likewise clear that devices of brachytherapy paid for separately must reflect “the number, isotope, and radioactive intensity of such devices furnished'.” Accordingly, we further believe that section 1833(t)(2)(H) of the Act applies only to radioactive devices of brachytherapy. We point out that forms of radiation delivery such as nonradioactive brachytherapy, which was used by commenters as the principal example of other forms of brachytherapy, do not constitute a brachytherapy source as contemplated by the statute. In addition to not containing a radioactive isotope, these forms of radiation delivery are dependent on external equipment to deliver therapeutic radiation to the treatment sites within the body. Therefore, we will not consider specific devices, beams of radiation, or equipment that do not constitute separate sources that utilize radioactive isotopes to deliver radiation to be brachytherapy sources for separate payment, as such items do not meet the statutory requirements provided in section 1833(t)(2)(H) of the Act. *Comment:*
                         A few commenters claimed that section 1833(t)(2)(H) of the statute does not limit CMS to consider as new brachytherapy sources seeds or radioactive sources that are themselves radioactive. Some commenters cited section 1833(t)(2)(H) of the Act, while others defined current cancer therapies as “a drug or biological that is used in cancer therapy, including (but not limited to) a chemotherapeutic agent, an antiemetic, a hematopoietic growth factor, a colony stimulating factor, a biological response modifier, a bisphosphonate, and a device of brachytherapy * * *” and cited section 1833(t)(6) of the Act as authority for that definition. The commenters then stated that this definition did not require that a device of brachytherapy consist of a seed or seeds or radioactive sources, as we proposed, and that section 1833(t)(6) of the Act allegedly clearly indicated “but not limited to,” such that this list was not exclusionary. Another advocate of creating a new source code for “electronic” brachytherapy, cited section 1833(t)(2)(B) of the Act, which generally indicated that the Secretary may establish groups of services within the classification system that are comparable clinically and with respect to resources. Therefore, the commenters believed CMS should be able to group “electronic” brachytherapy with other sources, if they are comparable. *Reponse:*
                         The commenters miscite the statute, erroneously implying it is part of section 1833(t)(2)(H) of the Act. Section 1833(t)(6)(A)(ii) of the Act is the source of the commenters' quote and does not deal with separate payment of brachytherapy sources. Rather, the context of the quote is pass-through treatment of cancer therapies current when the Balanced Budget Refinement Act (Pub. L. 106-113) was enacted. The statutory authority mandating separate groups for payment discussed above is based on section 1833(t)(2)(H) of the Act. Specifically, section 1833(t)(2)(H) of the Act clearly states: “With respect to devices of brachytherapy consisting of a seed or seeds (or radioactive source), the Secretary shall create additional groups of covered OPD services that classify such [brachytherapy] devices separately from the other services * * * in a manner reflecting the number, isotope, and radioactive intensity of such devices furnished * * *.” We believe that Congress clearly limited any requirement for separate payment of brachytherapy sources to those which reflect the number, isotope, and radioactive intensity of the sources and to a “seed or seeds (or radioactive source)” as stated in section 1833(t)(2)(H) of the Act. Furthermore, while section 1833(t)(2)(B) of the Act provides the authority to create new APCs to group similar services together or distinguish new and/or different services to group together in terms of clinical characteristics and resource costs, it must be read in conjunction with the requirements given in section 1833(t)(2)(H) of the Act. We do not believe that nonradioactive devices that deliver radiation are appropriately grouped with brachytherapy sources for separate payment, given that the statute also requires separate payment groups for brachytherapy sources to reflect the number, isotope, and radioactive intensity of the sources. We also remind the commenters that payment for devices under the OPPS, other than brachytherapy devices and those devices described by categories with active pass-through status, is packaged into the procedural APC payments for those services in which they are used. *Comment:*
                         A few commenters supported our definition of brachytherapy source. *Reponse:*
                         We appreciate the support for our proposal. *Comment:*
                         Another commenter requested a clarification regarding the definition of “source,” claiming that the word source leaves unclear whether multiple brachytherapy seeds would constitute multiple sources, or, because they are all implanted at one time, they would constitute a single source. *Reponse:*
                         Multiple brachytherapy seeds implanted during a single treatment session constitute multiple sources for billing on the claim to Medicare. For example, if 50 brachytherapy seeds are implanted, a hospital should report on its claim to CMS that it used 50 units of the source. *Comment:*
                         Several commenters recommended that CMS establish new HCPCS codes and descriptors for separate payment of additional brachytherapy sources. Specifically, several commenters recommended that CMS establish new codes for stranded sources, namely Iodine-125, Palladium-103, RAPID Strand Iodine-125 (a brand of iodine-125), and cesium-131 sources in CY 2007. Possible new codes and descriptors suggested for two of the stranded sources were: C26xx, Brachytherapy device, Stranded Iodine-125, per source; and C26xx, Brachytherapy device, Stranded Palladium-103, per source. One commenter recommended that CMS create a new source code for separate payment based on its product name: C26xx, Brachytherapy device, RAPID Strand Iodine-125, per source. A few commenters recommended that CMS establish a new source code for separate payment as follows: Brachytherapy device, Stranded Cesium-131, per source. The commenters described stranded brachytherapy sources as embedded into the stranded suture material and separated within the strand by material of an absorbable nature at specified intervals. They claimed that this approach ensured the initial and long-term position of each source when implanted in and around tumors. The 
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                        commenters claimed that stranded sources were different from “traditional” sources in a number of ways, such as improved patient safety and clinical outcomes in the treatment of prostate cancer; increased production costs; requirements for separate FDA clearances; and potential for permitting greater radioactive intensity for treatment of specific patients because of their more precise positioning. The commenters further claimed that stranded sources could be placed at the periphery of the prostate or outside the prostate gland, permitting treatment of extra-prostatic extension of cancer without the potential for migration into another body organ. The commenters also pointed out that CMS has separately coded differences in configurations of previously established isotopes among brachytherapy source codes (that is, linear palladium-103 is separately coded as C2636). Some commenters claimed that thousands of Medicare patients received stranded iodine and palladium in CY 2006, whose specific costs would not have been reflected through separate codes for these source variants. Some commenters asserted that the lack of separate coding results in no separate data on the clinical practice for stranded sources. They claimed that CMS’ CY 2005 data do not reflect important new clinical protocols that have emerged over the past few years, which have resulted in increased clinical use of stranded and “custom-stranded” sources for the treatment of prostate cancer. The commenters indicated that absence of data concerning stranded brachytherapy sources was a significant flaw in CMS’ current data because stranded sources were distinct from traditional brachytherapy sources. *Reponse:*
                         Section 1833(t)(2)(H) of the Act requires the creation of separate APC groups for brachytherapy sources that reflect the number, isotope, and radioactive intensity of the brachytherapy devices (sources) furnished. Stranding of existing sources of a certain isotope, such as iodine or palladium, is a specific clinical configuration that does not affect the number, isotope, and radioactive intensity of the brachytherapy sources, and thus would not lead to a separate APC grouping. While we created a new source code, C2636, linear palladium-103, per 1 mm, even though a code already existed for palladium-103 (C1720), we determined that the linear palladium source led to a change in the number of sources used, because it required a different, and therefore separate, measurement, per millimeter, as opposed to per source (that is, seed). We agree that it is probable that thousands of Medicare patients received stranded iodine and palladium in CY 2006, and further agree that stranded iodine and palladium are likely well-represented in our historical claims data, such that stranded source costs and utilization are reflected in the source codes for iodine and palladium, C1718 and C1720, respectively. Therefore, their use should be well-represented in the respective median costs for these C-codes in our CY 2005 data used to establish CY 2007 payment rates. The GAO drew similar conclusions in its study of brachytherapy source purchase prices, where they believed that their purchase price data reflected information across the full spectrum of brachytherapy source configurations provided by hospitals during the study period. Neither the GAO data nor the CY 2005 Medicare claims data reflect significant variation in the hospital costs of iodine and palladium sources. Our preferred treatment of iodine, palladium, and cesium sources is consistent with our general expectation that, as technology evolves and grows in utilization, the costs of the newer technologies will increasingly be reflected in the claims data used to establish prospective payment rates for future services. Accordingly, we are not creating new brachytherapy source codes for separate payment for stranded iodine-125, stranded palladium-103, RAPID Strand Iodine-125, or stranded cesium-131 sources. *Comment:*
                         A number of commenters recommended that CMS establish a new brachytherapy source code and descriptor for “electronic” brachytherapy, effective January 1, 2007, with the following recommended code descriptor: C26xx, Brachytherapy device, High Dose Rate X-ray radiation, per source. The commenters made no recommendation on how to define “per source.” The commenters stated that technological advances demonstrate that nonradioactive sources can deliver a therapeutic radiation dose similar to a radioactive source or seed. They claimed that brachytherapy treatment does not define the type of source; instead, it defines a type of treatment and there may be many kinds of sources used in such treatments. *Response:*
                         We agree that nonradioactive sources may be capable of delivering a therapeutic radiation dose similar to a radioactive source or seed. However, we believe that nonradioactive sources do not meet the definition of brachytherapy sources for separate payment under section 1833(t)(2)(H) of the Act as previously indicated in our discussion of the definition of brachytherapy sources eligible for separate payment. Consistent with our discussion of the definition of a brachytherapy source, we are not creating a new brachytherapy source code for separate payment for “electronic” brachytherapy. *Comment:*
                         One commenter, the manufacturer of the Intrabeam system, recommended that CMS designate the radiation source used in the Intrabeam procedure as a brachytherapy device and provide separate payment for the source. The commenter claimed the radiation from the Intrabeam system is delivered directly into a tumor cavity, and therefore, by definition, is a form of brachytherapy. The commenter also claimed that the Intrabeam radiation source is a point source that is similar to other brachytherapy sources, such as seeds or pellets. The commenter stated that the wording of section 1833(t)(2)(H) of the Act, “with respect to devices of brachytherapy consisting of a seed or seeds (or radioactive source), the Secretary shall create additional groups of services * * *” to establish separate brachytherapy source payment would include the Intrabeam brachytherapy source within that definition of a source. The commenter argued that the temporarily activated gold of the Intrabeam system is a radioactive source as described in the statute. The commenter claimed that the statutory language does not limit brachytherapy sources to only radioactive isotopes, as is evidenced by the more general language “or radioactive source.” *Response:*
                         Based on the commenter's description, the Intrabeam system relies upon a miniature x-ray source, where electron beams travel to strike a gold target and x-rays are then emitted to treat the tissue surrounding a tumor cavity. The Intrabeam procedure uses external equipment to generate the electron beam, and the gold target is not itself a radioactive isotope used to provide radiation treatment. As noted previously, such forms of brachytherapy do not constitute a brachytherapy source as contemplated by the statute. In addition to not containing a radioactive isotope, such forms of radiation delivery are dependent on external equipment to deliver therapeutic radiation to the treatment sites within the body. The statute requires us to establish separate payment groups for brachytherapy sources that classify them separately based on their number, isotope, and radioactive intensity. We do not believe the concept of an isotope applies to the 
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                        Intrabeam system. Therefore, we are not creating a new brachytherapy source code for separate payment for the radiation source used in the Intrabeam system. After carefully considering the public comments received, we are not accepting any of the recommendations provided above by commenters for the establishment of new HCPCS codes to describe new brachytherapy sources for CY 2007. However, consistent with our general practice, we will consider recommendations submitted by the public for new brachytherapy sources during CY 2007, as discussed earlier. In addition, we are adopting as final our proposed definition of the term “brachytherapy source” without modification. VIII. Changes to OPPS Drug Administration Coding and Payment for CY 2007 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 per-visit 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 MPFS 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 introduced CPT concepts of initial, sequential, and concurrent services. Upon review of the completed revisions to our proposed CY 2006 methodology, and following a 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 six 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. CY 2007 Drug Administration Coding Changes In the CY 2007 OPPS proposed rule, we proposed to continue the CY 2006 OPPS drug administration coding structure, which combined CPT codes with several alphanumeric HCPCS C-codes. However, we solicited comments from hospitals regarding their experiences in implementing, for purposes of reporting to other payers, the CY 2006 CPT codes reflecting the concepts of initial, sequential, and concurrent services. Due to the discrepancies between APC payments (based on per-visit hospital claims data) and per-service CPT/HCPCS coding in CY 2005 and CY 2006, we provided special instructions to hospitals regarding the appropriate use of modifier 59 in relation to OPPS drug administration services in order to 
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                        ensure proper OPPS payments consistent with our claims processing logic. As the need no longer existed, for CY 2007 we proposed to instruct hospitals to apply modifier 59 to drug administration services using the same correct coding principles that they generally use for other OPPS services. At its August 2006 meeting, the APC Panel recommended that CMS recognize only the AMA's CPT codes for outpatient hospital reporting of drug administration services in CY 2007. We discuss our response to this recommendation along with our response to comments presented below. We received numerous comments from individual hospitals, health systems, university medical centers, physicians, community cancer centers, pharmaceutical companies, specialty societies, and various healthcare associations, on our proposal to continue with the existing CY 2006 OPPS drug administration coding structure for CY 2007, which combined CPT codes with several C-codes, as well as comments on the use of the CPT codes. *Comment:*
                         A few commenters requested that CMS continue with the current CY 2006 coding scheme of using CPT and C-codes for CY 2007, while many others requested that CMS use the CPT codes. The commenters supportive of our CY 2007 proposal indicated that the CY 2006 CPT drug administration codes were not applicable in the hospital setting because these codes were created specifically for physician use. Several commenters urged CMS to work with the CPT Editorial Panel and others to make revisions to the existing CPT codes so they are more reflective of hospital services. Overall, the vast majority of commenters requested that CMS adopt the full set of CPT codes for drug administration services in CY 2007, as many hospitals have been using these codes for non-Medicare payers for the past year. Several commenters indicated that the use of the CPT codes would reduce hospital's current operational burden related to charging different payers with different code sets, including the burden of maintaining two very different sets of codes for essentially the same services. They added that OPPS use of the full set of CPT codes would also promote consistency and transparency across sites of service and payment systems. The commenters also noted that, contrary to last year's substantial concerns regarding the operational aspects of implementing these codes, they have now adopted the full CPT code set, including full code descriptors and applicable CPT guidelines. However, even those commenters favoring adoption of the full set of drug administration CPT codes acknowledged that some outstanding questions remain regarding billing scenarios using the CPT codes, and they requested additional guidance from CMS on these issues. Nevertheless, commenters were overwhelmingly in favor of reporting the same codes to all payers. *Response:*
                         In the CY 2006 OPPS final rule with comment period (70 FR 68679), we indicated that we decided not to recognize 13 of the 33 CPT drug administration codes in an effort to minimize the administrative and operational burden hospitals would have reportedly faced if we had adopted all 33 of the CY 2006 drug administration CPT codes. In particular, many hospitals expressed concern regarding significant administrative problems in implementing the subset of CY 2006 CPT drug administration codes that incorporated the concepts of initial, sequential, and concurrent. At that time, a substantial number of commenters requested that, if CMS were to implement the full set of CY 2006 CPT codes in the hospital outpatient setting, in order for the codes to be applicable to the hospital setting, CMS would need to direct hospitals to disregard elements of the code descriptors. As it is not our practice to alter CPT codes in order to apply them to a particular site of service, we decided not to implement the full set of CPT codes at that time. Instead, we developed alphanumeric HCPCS C-codes for the hospital setting to replace those CY 2006 CPT drug administration codes with the problematic concepts of initial, sequential, and concurrent. During CY 2006, we received anecdotal information related to hospitals' experience implementing the full set of CY 2006 CPT codes for non-Medicare payers. While yet another transition to new drug administration codes was frustrating, these commenters, like commenters responding to our CY 2007 proposed rule request for information, noted that the operational issues were no longer a primary concern with drug administration coding, and they had gained valuable experience over the past year reporting these codes to non-Medicare payers. Instead, their concern was the time, effort, and administrative costs associated with maintaining two code sets for one group of services. After considering the recommendation of the APC Panel discussed above, and after carefully considering all the public comments received on the CY 2007 OPPS proposed rule, we have decided to adopt the full set of CPT codes for CY 2007 for use under OPPS. Therefore, we are accepting the August 2006 recommendation of the APC Panel to use only CPT codes for the reporting of drug administration services in the CY 2007 OPPS. Table 31 lists the alphanumeric HCPCS codes that were created to replace the CPT codes reflecting the concepts of initial, sequential, and concurrent, that are deleted effective December 31, 2006. Table 31.—Drug Administration C-codes That Will No Longer Be Reportable Under the OPPS in CY 2007
HCPCS 
                                 Code
Long descriptionC8950
Intravenous infusion for therapy/diagnosis; up to 1 hour.C8951
Intravenous infusion for therapy/diagnosis; each additional hour (List separately in addition to C8950).C8952
Therapeutic, prophylactic or diagnostic injection; intravenous push of each new substance/drug.C8953
Chemotherapy administration, intravenous; push technique.C8954
Chemotherapy administration, intravenous; infusion technique, up to one hour.C8955
Chemotherapy administration, intravenous; infusion technique, each additional hour (List separately in addition to C8954).
 *Comment:*
                         We received a few comments requesting that we retain HCPCS code C8957 (Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring the use of portable or implantable pump), if we finalize a policy to transition to the full set of CPT codes for CY 2007. These commenters expressed appreciation for CMS’ development of the Level II HCPCS code, as there is currently no CPT code that describes this service. *Response:*
                         We appreciate the support of commenters in the development of this code, and we agree that there is no comparable CPT code for this service. As such, we are retaining HCPCS code C8957 for use in the CY 2007 OPPS because there is no comparable CPT code available to report this service. Table 32 lists drug administration HCPCS codes, associated status indicators, and CY 2007 APC assignments, where applicable, for CPT codes that will be newly recognized under the OPPS for reporting drug 
                        ( print page 68117)
                        administration services provided in hospital outpatient departments on or after January 1, 2007. Table 32.—CY 2007 Newly Recognized Drug Administration CPT Codes*
2007 CPT code
2007 description
2007 APC
CY 07 SI90760
Intravenous Infusion, hydration; initial, up to one hour
0440
S90761
Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary procedure)
0437
S90765
Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); initial, up to one hour
0440
S90766
Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
0437
S90767
Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)
0437
S90768
Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
—
N90774
Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
0438
S90775
Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)
0438
S96409
Chemotherapy administration; intravenous, push technique, single or initial substance/drug
0439
S96411
Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)
0439
S96413
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
0441
S96415
Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
0438
S96417
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour
0438
S* Current Procedural Terminology (CPT) codes and descriptors are copyrighted by the American Medical Association (AMA).
 For CY 2007, we reiterate our CY 2006 final rule statement reminding hospitals that they are expected to report all drug administration CPT codes in a manner consistent with their descriptors, CPT instructions, and correct coding principles. As we have done in the past, we will release instructions separately from this final rule with comment period that will provide additional OPPS-specific guidance for hospital outpatient departments providing drug administration services in CY 2007. *Comment:*
                         A few commenters requested that, if CMS implement the full set of CPT codes, CMS should also provide hospitals with specific instructions on how to bill for CPT codes 90761, 90766, and 96415, as their CY 2006 code descriptors included a statement that they were to be billed for each hour “up to 8 hours” or “1 to 8 hours.” The commenters requested OPPS billing instructions in the event that infusions reported with these codes lasted longer than 8 hours. *Response:*
                         As indicated in Table 32, the CPT Editorial Panel has removed the reference to “up to 8 hours” and “1 to 8 hour” in the code descriptors for these three infusion service for CY 2007. Therefore, we do not believe any additional guidance is required for hospitals at this time. *Comment:*
                         Several commenters requested additional instructions regarding the administration of IVIG, hyperimmune IVIG, and DNA- or RNA-based therapies. Specifically, the commenters requested that CMS identify these items as biological response modifiers and instruct hospitals to report chemotherapy administration codes for these services in recognition of the significant resources incurred by hospitals that provide them. *Response:*
                         CPT instructions for the CY 2006 CPT code set included a statement that chemotherapy administration codes are appropriate for chemotherapy services but also apply to “parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (for example, cyclophosphamide for auto-immune conditions) or to substances such as monocolonal antibody agents, and other biologic response modifiers.” As is our longstanding practice, we defer questions about CPT code definitions to the AMA CPT Editorial Panel as they are the creators and maintainers of the CPT code set. *Comment:*
                         Several commenters requested that CMS remove various National Correct Coding Initiative (CCI) edits related to drug administration codes. These commenters expressed frustration about the increased administrative burden associated with identifying separate instances of drug administration services provided on the same day as a procedure that includes a drug administration service. *Response:*
                         We continue to believe that CCI edits for drug administration services are appropriate for the hospital outpatient department setting. We refer commenters with questions and concerns related to particular CCI edits to the National Correct Coding Initiative Policy Manual for Medicare Services at 
                        *http://www.cms.hhs.gov/​NationalCorrectCodInitEd/​.* C. CY 2007 Drug Administration Payment Changes Prior to CY 2005, hospitals were reporting per-day drug administration codes under the OPPS. These codes did not distinguish between the number of services, types of service, or duration of services provided. Hospitals received per-day APC payments for chemotherapy infusions, non-chemotherapy infusions, and chemotherapy other than infusion. With the implementation of CPT codes in CY 2005, hospitals began reporting separate codes and associated charges for many drug administration services for purposes of the OPPS. The CY 2007 update process offered us the first opportunity to consider this data for purposes of ratesetting. For the CY 2007 proposed rule, we explained that we expected codes for additional hours of infusion to be reported with codes for the first hour of 
                        ( print page 68118)
                        infusion. This would result in a substantial set of claims that were unusable for ratesetting purposes because multiple services would be present on the same bill. (See section II.A. of this preamble for a further discussion of multiple bills and our ratesetting methodology). In order to use these claims, we explained our process of adding three CY 2005 drug administration 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) to the bypass list in the CY 2007 proposed rule in order to create “pseudo” single claims that would be useable for OPPS ratesetting purposes. After creation of these “pseudo” single claims, we applied the standard OPPS methodology to calculate HCPCS median costs for these three drug administration codes and mapped their respective data to the APCs to which we assigned CY 2005 drug administration claims data for purposes of calculating these proposed APC median costs. As we explained in the CY 2007 proposed rule, bypassing these three CPT codes and developing additional “per unit” claims provided 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. However, 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 were always reported with other drug administration services, we expected that the packaging related to additional hours of infusion would be appropriately assigned to the drug administration services on the same claim. While we stated our belief that there are some packaged costs that are clinically related to the second and subsequent hours of infusion, especially for infusions of packaged drugs spanning several hours, we were not able for purposes of the CY 2007 proposed rule to accurately assign representative portions of packaged costs to multiple different services due to the limitations of our claims data. In the proposed rule, we indicated that we believed this proposed methodology took into account all of the packaging on claims for drug administration services and provided a reasonable framework for developing median costs for drug administration services that were often provided in combination with one another. After calculating HCPCS code 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 and based our assignments upon hospital resources utilized as reflected in HCPCS code median costs and clinical coherence. The result of this analysis was the development of six proposed drug administration APC levels based on CY 2005 claims data for the CY 2007 OPPS. The proposed structure was displayed in Table 30-1 of the CY 2007 OPPS proposed rule, and a refined table, reflective of the complete updated CY 2005 hospital claims data, is shown below in Table 33. 
 
  In the proposed rule, we noted that proposed placement of the CY 2005 drug administration HCPCS codes into the six APC levels followed logical, 
                        ( print page 68120)
                        clinically coherent principles, and was consistent with both expected and observed differences in hospital resource costs, both across levels and within each level. For example, the first hour of chemotherapy infusion was assigned to Level VI, while additional hours of chemotherapy infusion were assigned to Level III. This structure was mirrored by the nonchemotherapy codes that showed the first hour of nonchemotherapy infusion assigned to Level V, while additional hours of nonchemotherapy infusion were assigned to Level II. Using this structure as a base, we assigned the CY 2006 OPPS drug administration codes to the six-level APC structure based on their clinical and expected hospital resource characteristics. This general structure was presented to the APC Panel during the March 2006 meeting and was our proposed structure for CY 2007. 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. In the proposed rule, we accepted the APC Panel's recommendation for CY 2007 to use the proposed structure with the bypass and “per unit” methodology as described above as it established a drug administration payment structure that included a methodology to pay for infusion services by the hour. Hospitals' cooperation during CY 2005 in reporting all drug administration services, whether or not separate payments were made for all such services, allowed us to develop robust median costs for individual services so that we had sufficient information to propose this more specific APC payment structure for drug administration services for CY 2007. In the proposed rule, we indicated that we believed that this structure would make appropriate payments for the hospital resources required to provide drug administration services, as we had large numbers of claims for many specific drug administration services that revealed significant and differential costs. In particular, we noted that using the six-level 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 were provided alone. The APC Panel made a number of additional recommendations regarding payment for CY 2007 OPPS drug administration services at its August 2006 meeting in addition to the recommendation, discussed above, that CMS adopt the full set of CPT drug administration codes for CY 2007 OPPS purposes. First, the Panel recommended that if CMS does not recognize only the AMA CPT codes for drug administration services for CY 2007, CMS should allow hospitals to separately bill and receive payments for therapeutic infusions and hydration infusions provided in the same encounter. We do not believe that a response to this recommendation is required, as we have adopted the full set of CPT codes for CY 2007, as discussed above. Second, the Panel recommended that CMS make payment for a second or subsequent intravenous push of the same drug by instituting a modifier, developing a new HCPCS code for the procedure, or implementing another methodology in CY 2007. We discuss this recommendation along with comments on this issue in further detail below. Third, the Panel recommended that CMS provide payment for all intravenous pushes and therapeutic injections for pain management and other clinical conditions, regardless of the setting (for example, post-operative anesthesia care unit, cardiac catheterization laboratory). Again, we discuss this issue in greater detail below. Finally, the Panel recommended that CMS provide claims analyses of the contribution of packaged costs (considering packaged drugs and other packaging) to the median cost of each drug administration service. During the March and August 2006 meetings of the APC Panel, the Panel recommended that we provide additional information specific to the costs of packaged items that are represented in drug administration APC rates. Specifically, the Panel recommended that: CMS provide the Panel with data that indicate the costs of packaged drugs that are incorporated into drug administration payment rates (March 2006).
                    CMS provide claims analysis of the contributions of packaged costs (considering packaged drugs and other packaging) to the median cost of each drug administration service (August 2006). We have performed a preliminary analysis on a subset of CY 2005 claims data (the data that was used in preparation for the CY 2007 proposed rule). We intend to provide a more complete analysis based on CY 2005 final rule data to the APC Panel during its next meeting; this preliminary analysis only serves as a brief summary of our initial findings. We identified CY 2005 single claims (including “pseudo” single claims derived from the process detailed in section II.A.1. of this preamble) for drug administration services. We used all active CY 2005 drug administration codes, but excluded the additional hour infusion codes (as these hours were not separately payable in CY 2005). In addition, their treatment as codes on the bypass list results in no packaging being attributed to their “pseudo” single claims. Correct coding results in their claims always being multiple claims, so we have no correctly coded natural single claims for these procedures. We identified 16 separate revenue codes where we expected hospitals would associate packaged drugs—namely, those revenue codes that are in the 250 series (Pharmacy), 260 series (IV Therapy) and 630 series (Drugs Require Specific ID). We assumed that, for purposes of this analysis, packaged drug costs were included on claims with revenue codes listed above or with a drug HCPCS code that in CY 2005 was assigned status indicator “N.” We also assumed that hospitals reported the charges for the packaged drugs on the same claim on which they reported the drug administration code, with the same date of service. We calculated both the median and mean percentages on these single and “pseudo” single claims for: (1) All packaged costs (drug or not); and (2) the subset of packaged drug/pharmacy costs (defined as a code for either a drug revenue code cost or a packaged drug HCPCS code). We calculated the median costs by calculating the percentages for each single bill (including “pseudo” singles), arraying them, and calculating the 50th percentile of the array. We calculated the mean costs by summing the packaged costs of each type for the code and dividing each by the sum of all total costs for the code. Our initial analysis indicates that, for the highest volume drug administration codes, there is a significant amount of drug packaging costs on their claims that are used for ratesetting. For example, CPT code 90780 for the first hour of nonchemotherapy intravenous infusion has a median of 27 percent of packaging of any type and a median of 15 percent of drug/pharmacy packaging, showing clearly that the cost of packaged drugs is reflected in the median for the code. Its respective mean amounts are 30 percent and 22 percent. Similarly, for CPT code 6410, used to report the first hour of chemotherapy intravenous infusion, the median amount of packaging of any type is 21 percent, and the median amount of drug/pharmacy packaging is 13 percent. 
                        ( print page 68121)
                        Its mean amounts are 27 percent and 20 percent respectively. The findings are also similar for CPT code 96422 for the first hour of an intra-arterial chemotherapy infusion. Its median amount of packaging is 51 percent, and the median amount of drug/pharmacy packaging is 34 percent. We expect to replicate this study using final rule data for presentation to the APC Panel at its first meeting in CY 2007 and to present our results in more detail. However, we believe that these findings demonstrate that the costs of packaged drugs are reflected in the payment for the services with which they are furnished, contributing significant costs to establishment of the ultimate drug administration services payment rates. We note that in many cases in which drug administration codes are billed, Medicare also pays for separately paid drugs at ASP+6 percent. Therefore, the total payment for the drugs administered in an encounter is the sum of payment for separately paid drugs and the portion of the APC payment for drug administration services that reflects the packaged costs of drugs/pharmacy. As mentioned above, we intend to present this study, with updated data, to the APC Panel at the next Panel meeting. Therefore, we are specifically requesting feedback regarding the usefulness of this information to the hospital community. We received numerous comments on our payment proposal for drug administration services in the CY 2007 OPPS proposed rule. *Comment:*
                         A number of commenters believed that the assignments of CY 2005 cost data to the six APCs to develop their proposed median costs were appropriate. Many commenters were extremely supportive of the CY 2007 proposal to pay separately for each hour of drug infusion, indicating that this payment methodology would provide appropriate payment for infusions whose resources varied depending on the length of the infusions. Several commenters noted that the current CY 2006 methodology of paying for drug administration services does not pay separately for the second and subsequent hours of drug administration, and instead, packages them into payment for the first hour of drug administration. One commenter suggested that the packaging of the second and subsequent hours for drug administration resulted in inadequate reimbursement to hospitals because the payment did not reflect the true cost of providing the service, particularly in those instances that involved patients who received chemotherapy infusions that last 2 or more hours. *Response:*
                         We appreciate the commenters' support for our proposal to pay for drug administration services through a six-level APC structure for CY 2007, with separate payment to be provided for each hour of drug infusion. We remind commenters that our APC rates are based upon median costs calculated from historical hospital claims, and hospitals reporting multiple hours of infusion service were instructed to report the costs for these hours beginning in CY 2005. *Comment:*
                         Several commenters expressed their concerns regarding the low proposed payment rates for three chemotherapy administration codes described by CPT codes 96440 (Chemotherapy administration into pleural cavity, requiring and including thoracentesis); 96445 (Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis); and 96450 (Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture). In particular, commenters disagreed with our proposed APC assignments for CPT codes 96440 and 96445 to APC 0439 (Level IV Drug Administration), which had a proposed payment rate of $97.50, and CPT code 96450 to APC 0441 (Level VI Drug Administration), which had a proposed payment rate of $154.31. These commenters reported that the chemotherapy administration services described by these three CPT codes are far more intensive and require more facility resources than the other drug administration services currently assigned to the same APCs. The commenters further illustrated that when CPT code 96440 or CPT code 96445 is reported, hospitals cannot report separately the surgical procedure that is required for the drug administration service, such as CPT code 32000 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) or CPT code 49080 (Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial). They observed that the proposed payments for both surgical procedures were $224.20, and they believed that payments for the more extensive drug administration services should, therefore, be significantly higher than $224.20. The commenters strongly urged CMS to reevaluate the APC assignments for these chemotherapy administration codes. One commenter proposed three options for how CMS could make changes to the APC assignments for the three CPT codes. Specifically, they requested that CMS reassign CPT codes 96440, 96445, and 96450 to higher paying APCs, create a new APC group with a significantly higher payment rate for them, or instruct providers to report both the surgical procedures and the related drug administration codes as separate line items for the single service. *Response:*
                         We will not instruct hospitals to report CPT codes in a manner that is inconsistent with their code descriptors, such as would be the case if we asked hospitals to separately report the minor surgical procedures required to administer the chemotherapy services, when those puncture procedures are included in these drug administration code descriptors. We also note that the final median costs for these procedures are $160.03 for CPT code 96450 based on 394 single claims, $37.12 for CPT code 96440 based upon 38 single claims, and $61.98 for CPT code 96445 based upon 43 single claims are related to the median costs of their proposed APCs. We carefully reviewed all the comments received and our CY 2005 claims data, in the context of the clinical characteristics of these three services, as well as considered the low volume of claims for their single year of hospital cost data. As we proposed, we continue to believe these services should be assigned to drug administration APCs because they are best characterized as chemotherapy administration services, albeit with special methods of delivery. However, we are reassigning CPT codes 96440 and 96445 from APC 0439 to APC 0441 (Level VI Drug Administration), which has a final median cost of $151.86 as the highest paying CY 2007 drug administration APC. If we were to create another drug administration APC specifically for these three services, its median cost from CY 2005 claims for the special chemotherapy administration services would be less than the median cost of APC 0441 for CY 2007. In addition, based on our CY 2005 claims data from almost 400 single claims, we believe that the proposed APC assignment for CPT code 96450 is accurate and reflects the resource costs associated with performing the procedure. We will monitor our claims data in the future to see if additional changes are warranted to the APC assignments of these chemotherapy services. Therefore, for CY 2007, we are assigning CPT codes 96440 and 96445 from APC 0439 to APC 0441, which has a final median cost of $151.86, and we are finalizing our proposal without modification to assign CPT code 96450 to APC 0441. *Comment:*
                         Several commenters expressed concern about the decrease in 
                        ( print page 68122)
                        payment for the “first hour of infusion” codes from CY 2006 to their proposed CY 2007 rates. They asked that CMS verify that our calculations were correct and that the proposed rates were appropriate. *Response:*
                         Based on our CY 2006 payment methodology, we made one payment per day for administration of a particular type of infusion, regardless of its length, and packaged payment for additional hours of infusion of the same type. For example, the CY 2006 payment of $189.04 for CPT code 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour), reflected a payment for the median chemotherapy infusion, regardless of the number of hours of infusion. In contrast, for CY 2007 we proposed to pay separately for each hour of infusion. In the case of chemotherapy infusions, we proposed to pay $154.31 for the first hour, CPT code 96413, and $48.58 for each additional hour of infusion, CPT code 96415. We have confirmed that our calculations were correct for both the proposed rule and this final rule with comment period. The apparent decrease in payment for the first hour of infusion is a direct result of our proposal to unpackage payment for the additional hours of infusion and provide separate payment for each hour as opposed to a per-day payment. Because many chemotherapy infusions take place over more than one hour, the payment for the first hour appeared to decrease. As discussed earlier in this section, in our methodology we also assigned all packaging on the drug administration claims to the first hour of infusion codes to allow us to use multiple claims for ratesetting. We believe this payment methodology will provide more accurate payment to hospitals for the specific drug administration services they provide in CY 2007. *Comment:*
                         One commenter expressed concern over the methodology used in calculating the CY 2005 median cost for the non-chemotherapy intravenous (IV) push injection services, specifically CPT code 90784 (Therapeutic, prophylactic diagnostic or diagnostic injection (specify material injected); intravenous), and requested clarification on our methodology. The commenter indicated that providers reported CPT code 90784 in CY 2005 with multiple units when more than one IV push injection was provided, along with a dollar charge reflecting each injection. The commenter requested clarification as to whether CMS factored the multiple units into its payment rate calculation, and whether CMS discarded these claims from the ratesetting process because they may have been considered as multiple procedure claims. *Response:*
                         We were unable to use claims reporting multiple units of CPT code 90784 on the same date of service for ratesetting, because we had no way to attribute the packaging on the claims to the appropriate unit of the code. We also had no way of discerning from the CY 2005 claims whether multiple units of CPT code 90784 were reported for more than one intravenous push of the same drug, or multiple pushes of different drugs were provided. CPT code 90784 was deleted for CY 2006, and replaced by CPT codes 90774 (Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug) and 90775 (Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)). The situations discussed by the commenter would be reported and paid differently in the CY 2007 OPPS based upon the CY 2007 CPT code descriptors for IV push injections. According to our standard OPPS methodology as proposed based on median costs from single claims, we used only single claims for CPT code 90784 for ratesetting for APC 0438 as shown in Table 33 above. However, we examined our claims data and found that in over two-thirds of the cases, hospitals billed only a single unit of CPT code 90784 per day for an IV push injection. Therefore, we believe that our payment rate for the CY 2007 intravenous push injection CPT codes 90774 (Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug) and 90775 (Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug) through APC 0438 (Level III Drug Administration) is appropriate. After carefully considering the public comments related to our proposed six-level APC structure for drug administration services, we are finalizing our proposal with modification to assign all CY 2007 HCPCS codes for drug administration services to six new drug administration APCs, as listed in Table 34, with payment rates based on median costs for the APCs as calculated from CY 2005 claims data. We note that because our CY 2007 proposal reflected our assignment of CPT codes and C-codes to these APCs consistent with our drug administration coding proposal for CY 2007, we are finalizing our assignment of the newly recognized CPT codes to the APCs where their related C-codes were proposed for assignment. In the case of CPT code 90768 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion), we are packaging its payment for CY 2007 to maintain consistency, because concurrent infusions were not previously separately reported in the OPPS and their costs are already packaged into our CY 2007 payments. We believe that this approach provides consistency and will allow us to collect hospital claims data over the next two years to assess whether changes to the APC assignments for these newly recognized CPT codes should be considered. Because the newly recognized CPT codes discriminate among services more specifically than the CY 2006 C-codes, as was the case when the OPPS transitioned from more general Q-codes to more specific CPT codes for the reporting of drug administration services in CY 2005, for a period of 2 years drug administration services will be paid based on the costs of their predecessor HCPCS codes until updated data are available for review. 
 
  
 
 *Comment:*
                         In addition to the APC Panel recommendation introduced above, a number of commenters requested that CMS pay separately for multiple pushes of the same drugs, specifically for a second or subsequent IV push performed during the same episode of care, to cover the resource costs associated with providing the additional injections and drugs. Similar to the recommendation of the APC Panel, commenters suggested several options on how CMS could implement such a policy. *Response:*
                         We thank the commenters for their suggestions. However, consistent with our policy for reporting intravenous pushes of the same drug only once in CY 2006 and consistent with the definition of the CPT codes that will be used in CY 2007 to report these services, we will continue to provide payment for an intravenous push of each drug only once during a hospital encounter in CY 2007. In addition, we do not believe it would be appropriate to unbundle procedures by creating a new HCPCS code for an element of a service that should be reported with existing CPT codes when they are used in the CY 2007 OPPS. We also see no need to develop a modifier to identify these situations. We expect that hospitals will adjust their charges for the CPT codes used to report IV push injections accordingly, based on their experiences with providing intravenous injections of drugs in the outpatient setting. Therefore, we are not accepting the recommendation of the APC Panel to make payment for multiple pushes of the same drug in a single hospital encounter. *Comment:*
                         In addition to the APC Panel recommendation introduced above, several commenters advised CMS to provide payments for all intravenous pushes and therapeutic injections for pain management and other clinical conditions, regardless of the setting in which they are administered. *Response:*
                         The OPPS is a prospective payment system that provides payment for groups of services that are similar both clinically and in terms of resource use. We package into payment for each procedure or service within an APC group the costs associated with items or services that are directly related to performing a procedure or furnishing a service. Drug administration services are only paid separately in conjunction with many other procedures performed on the same day if they are distinct procedural services that are reported in a manner consistent with the principles of correct coding. We apply National Correct Coding Initiative edits as appropriate to services performed under the OPPS. More information regarding these edits may be found in the National Correct Coding Initiative Policy Manual for Medicare Services as referenced earlier in this section. Therefore, we are not accepting the recommendation of the APC Panel to pay separately for all intravenous pushes and injections for pain management and other clinical conditions. Consistent with our current payment policy, in some cases their payment is packaged into payment for the associated procedures. *Comment:*
                         Several commenters requested that CMS allow hospitals to bill separately and receive payments for the first hour of therapeutic infusions and hydration infusions when provided in the same encounter. *Response:*
                         With the use of CPT codes for the reporting of drug administration services under the CY 2007 OPPS, hospitals may bill for therapeutic drug administration and hydration services provided in the same encounter. However, as mentioned above, we expect hospitals to adhere to CPT coding instructions and instructions for the use of these codes. We do not believe that allowing hospitals to submit claims for, and receive separate payment for, the first hour of a therapeutic infusion and the first hour of a hydration infusion provided in one encounter through a single vascular access site would be consistent with CPT coding principles. Therefore, we are not adopting the commenters' proposal. We note that in the CY 2007 OPPS proposed rule we discussed HCPCS code G0332 (Preadministration-related services for intravenous infusion of immunoglobulin, per infusion encounter (This service is to be billed in conjunction with administration of immunoglobulin)) in this section of the preamble. However, for the CY 2007 OPPS final rule with comment period, we discuss this code and other issues relating to IVIG in section V.B.III. of this preamble. IX. Hospital Coding and Payments for Visits A. Background Currently, CMS instructs hospitals to use the CY 2006 CPT codes used by physicians and listed in Table 35 to report clinic and emergency department (ED) visits and critical care services on claims paid under the OPPS. Table 35.—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).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).( print page 68125)**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) 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 department 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 department 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 examination 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 on 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 
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                        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 on the August 9, 2002 proposed rule, including assignment of 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 laboratory 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. In the CY 2007 proposed rule, we indicated that we were reconsidering this perspective. We discuss this issue further below. 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 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 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 make recommendations to CMS. The AHA and AHIMA originally supported the ACEP model for emergency department 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 department 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 field-tested 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 department 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 department 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 
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                        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 department 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 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 were 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 and Final Coding Policies 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 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. 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 visits and to report critical care services, we have made significant progress in developing potential guidelines. Therefore, in the CY 2007 OPPS proposed rule (71 FR 49604-49618), we proposed 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 proposed that hospitals might continue to use their existing internal guidelines to determine the visit levels to be reported with these codes. We anticipated that many providers would choose to use their existing guidelines for reporting visits with CPT codes. We did not expect a substantial workload for a provider that chose to adjust its guidelines to reflect our policies. We acknowledged that it could be burdensome for providers to bill G-codes rather than CPT codes. In this case, because current CPT E/M codes do not describe hospital visit resources, we saw 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 proposed to establish 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 35. Providers have been reporting five levels of CPT codes through CY 2006, and we believed that it would be fairly easy to crosswalk current internal hospital guidelines to these five 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 proposed codes are listed in Table 36 below. Table 36.—CY 2007 Proposed HCPCS Codes To Be Used To Report Clinic Visits
HCPCS code
Short descriptor
Long descriptorGxxx1
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.
 *Comment:*
                         Although a few commenters were in favor of creating G-codes for CY 2007, numerous commenters requested that CMS postpone creation of G-codes until national guidelines are implemented. Almost all of these commenters stated that it would be extremely time consuming to train staff in the new coding system, only to retrain them 1 to 2 years later, when national guidelines were implemented. They believed that if national guidelines were established for CY 2007, hospitals could justify the time commitment and training expense. They added that prior to the establishment of national guidelines, however, there is little incentive for hospitals to transition to G-codes. Several commenters noted that there would be no benefit of improved data if hospitals transitioned to G-codes without guidelines because the median cost data captured from the G-codes would parallel current data because hospitals would still be using their own internal guidelines. It was implicit in many comments that once national guidelines are established, hospitals would agree to transition to G-codes. However, other commenters objected to the G-codes because other payors either fail to accept them or do not assign proper payment to them. Several commenters suggested that a proposal be submitted to the AMA requesting hospital-specific Category I visit codes. *Response:*
                         In response to the numerous comments related to creation of G-codes, we are postponing finalizing G-codes for clinic visits until national guidelines have been established, when we will again consider their possible utility. We are responding to the requests of many commenters who stated that it would be too difficult for them to first transition to G-codes and then to transition to national guidelines 
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                        shortly thereafter. Most commenters indicated a preference for training their staff once, for both coding and guidelines, even if it means that the training would be significant. In the meantime, as discussed further below, we will to continue work to develop national guidelines. For CY 2007, providers should continue to use CPT codes to bill for clinic visits. *Comment:*
                         Several commenters compared hospital resource cost differences between new and established patient visits and discussed whether it was necessary to distinguish between the two types of visits. The commenters were divided as to whether this distinction was necessary or useful. While some commenters stated that it would be appropriate to continue using different codes for new and established patients because of the observed median cost differences, other commenters found it cumbersome to bill a different code for each type of visit. One commenter speculated that hospitals often choose a new versus an established visit code based upon which code the physician bills, instead of choosing a code based on whether the patient is new or established at that particular hospital. One commenter suggested that the additional resources for new patients be reflected in the guidelines, rather than in the coding. Yet another commenter indicated that new patients did not necessarily use more hospital resources than established patients, and questioned whether both types of codes were necessary. *Response:*
                         We initially solicited comment as to whether a distinction between new and established visits was necessary because we were planning to transition to G-codes and did not want to unnecessarily create codes for both new and established visits. However, because hospitals will continue to bill CPT codes for CY 2007, they must continue to distinguish between new and established patients, according to the CPT code descriptor. Therefore, these codes will continue to be payable under the OPPS for CY 2007. The AMA defines an established patient as “one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.” To apply this definition to hospital visits, we stated in the April 7, 2000 final rule with comment period that the meanings of “new” and “established” pertain to whether or not the patient already has a hospital medical record number. If the patient has a hospital medical record that was created within the past 3 years, that patient is considered an established patient to the hospital. The same patient could be “new” to the physician, but an “established” patient to the hospital. The opposite could be true if the physician has a longstanding relationship with the patient, in which case the patient would be an “established” patient with respect to the physician and a “new” patient to the hospital. Because hospitals will be reporting CPT codes for CY 2007, they must continue to distinguish between new and established patients, according to the CPT code descriptor. However, it may be unnecessary for hospitals to report consultation CPT codes if either the new or established patient visit code accurately describes the service provided. To simplify billing, as many commenters requested, we are now considering whether consultation codes are necessary, or if hospitals could bill either a new patient visit or an established patient visit, instead of a consultation, as appropriate in these cases. We could assign status indicator “B” to the consultation codes and instruct hospitals to bill a new or established visit code. While developing the proposal to create G-codes in place of the clinic visit CPT E/M codes for CY 2007, we determined that hospitals could report G-code levels that reflect their resources used, by applying their guidelines, without the need for codes that differentiate among new, established, or consultation visits. However, because hospitals will continue to use CPT E/M codes for CY 2007, which distinguish between new, established, and consultation visits, we invite further input on this issue, specifically as to whether the consultation codes are necessary for hospitals to report, or whether it would be simpler for hospitals to report either a new patient visit or established patient visit, as appropriate in each circumstance. We are particularly interested to know whether consultation codes are a useful measure of hospital resource use under the OPPS, and how they are different, from a hospital resource perspective, from new patient visits and established patient visits. In summary, for CY 2007, providers should continue to use CPT codes to bill for clinic visits. The CPT codes for new and established visits and consultations will continue to be payable under the OPPS. Prior to implementation of national guidelines, we are considering whether it would be appropriate for hospitals to bill a new or established E/M visit code instead of a consultation code. In the national guidelines, we still need to determine whether there should be a distinction between new and established visits and consultations. We continue to be interested in the opinions of hospital staff and others who are familiar with these codes. Further discussion of these codes appears in section IX.C. of this preamble. *Comment:*
                         A few commenters requested that CMS clarify whether a hospital can bill several clinic visits for services provided to a patient who is seen in one clinic by several clinicians on the same day, although not at the same time. The commenters stated that, in oncology clinics, it is common for patients to have several scheduled visits on one day, provided by an oncologist, physicians trained in other specialties, therapists, or others, depending on the patients' needs. They added that, in some instances, the oncology clinic allows the patient to remain in one clinic room, while asking the various clinicians to meet the patient in the oncology clinic. One commenter noted that the patient usually consumes few hospital resources other than use of the clinic room. These commenters also indicated that HCPCS code G0175 (Scheduled interdisciplinary team conference (minimum of three exclusive of patient care nursing staff) with patient present) would only apply if the patient was seen by all the clinicians at the same time. According to the commenters, the hospital could bill multiple clinic visits if the patient was seen in several different clinics on the same day. They believed that the current policy penalizes oncology clinics for offering services in an efficient manner. One of the commenters requested that CMS change the descriptor of G0175 so that it would apply when a patient was treated by several clinicians on one day, in one clinic, but not necessarily at the same time. The commenter noted that an appropriate payment for the service would be at a rate comparable to the critical care payment rate. *Response:*
                         We expect the hospital resources associated with an extended clinic visit involving multiple clinicians to be reflected in the hospital's internal guidelines used to select the level for reporting of the visit. The hospital should bill the clinic visit code that most appropriately describes the service provided. We will maintain the same code descriptor for G0175 for CY 2007 because we believe it is appropriate to pay specifically for interdisciplinary team conferences that contribute to well-coordinated, high quality care, particularly for patients with severe or complex medical conditions. We note that payment for G0175 will be made through APC 0608 (Level V Clinic 
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                        Visits) at the highest payment level for clinic visits in CY 2007. 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 CAHs 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, Public Law 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 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 the regulations 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 DED 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 department visit codes under the OPPS for services furnished in a facility that meets the CPT definition for reporting emergency department 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 department 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, we proposed in the CY 2007 OPPS proposed rule (71 FR 49608) to establish 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 of the proposed rule and as finalized as Table 37 below in this final rule with comment period. These codes are called “Type B emergency department visit codes.”
                        ( print page 68130) Table 37.—CY 2007 Final HCPCS Codes To Be Used To Report Emergency Department Visits Provided in Type B Emergency Departments
HCPCS code
Short descriptor
Long descriptorG0380
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).G0381
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).G0382
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).G0384
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).G0385
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 proposed 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 are called “Type A emergency visit codes” and were proposed to replace hospitals' current reporting of the CPT emergency department visit E/M codes listed in Table 35. Our intention was 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 department visit codes. We believed that this definition of Type A emergency departments would neither narrow nor broaden the group of emergency departments or facilities that may bill the Type A emergency department visit codes in comparison with those that are currently correctly billing CPT emergency department visit E/M codes. Rather, our proposal refined and clarified the definition for use in the hospital context. We believed that because the concepts employed in the definition of a DED for EMTALA purposes are already familiar to 
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                        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 believed that these new codes for reporting emergency department 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 proposed for CY 2007 are listed in Table 38 below. Table 38.—CY 2007 Proposed HCPCS Codes To Be Used To Report Emergency Department Visits Provided in Type A Emergency Departments
HCPCS code
Short descriptor
Long descriptorGyyy1
Lev 1 hosp type A ED visit
Level 1 hospital emergency department visit provided in a Type A hospital-based facility or visit department. (The facility or department must be open 24 hours a day, 7 days a week and 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; 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 department visit provided in a Type A hospital-based facility or visit department. (The facility or department must be open 24 hours a day, 7 days a week and 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; 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 department visit provided in a Type A hospital-based facility or visit department. (The facility or department must be open 24 hours a day, 7 days a week and 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; 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 department visit provided in a Type A hospital-based facility or visit department. (The facility or department must be open 24 hours a day, 7 days a week and 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; 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 department visit type provided in a Type A hospital-based facility or visit department. (The facility or department must be open 24 hours a day, 7 days a week and 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; 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).
 *Comment:*
                         As discussed above in section IX.B.1. of this preamble describing coding for clinic visits, numerous commenters requested that CMS postpone adoption of G-codes until CMS has established national guidelines. We will not re-summarize or re-respond to those comments in this section. As to our proposed coding for emergency department visits, the majority of commenters agreed with our general distinction between Type A and Type B emergency departments. One commenter believed that our definition for Type B emergency departments was too broad because many urgent care centers would meet the definition of Type B emergency department based on the EMTALA criterion that “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.” This commenter suggested that urgent care centers that operated primarily with scheduled appointments be required to bill clinic visit codes. Many other commenters stated that our Type B emergency department definition was too narrow and would apply to only a few emergency departments. One commenter requested that CMS add two additional requirements for dedicated Type B emergency departments: (1) They must have transfer agreements with local and/or regional full service hospitals; and (2) they must have the presence of a “qualified medical person” (as defined in the EMTALA regulations) during operating hours. One commenter requested that CMS revise the description of an emergency department by replacing the words “licensed by the State” with “authorized or permitted by the State” to allow for States that do not license emergency departments. Several providers were concerned that CMS has used and is continuing to piggyback on the AMA's requirement that an emergency department must be open 24 hours a day in order to bill emergency department codes. They believed that if CPT codes do not describe hospital resources, CMS should not follow the CPT rules when billing these CPT codes. One commenter stated that the operating hours of an emergency department was irrelevant, and that the resource costs of the services provided should instead 
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                        determine selection of the appropriate code. In other words, the commenter indicated, if a Type B emergency department that was available less than 24 hours a day provided a highly resource-intensive service, that Type B emergency department should bill a Type A emergency department code and be paid at the Type A emergency department rate. Several commenters requested that CMS distinguish between Type A and Type B emergency departments using a method other than coding, as it would be burdensome for providers to choose the correct code. In addition, one commenter that specializes in coding indicated that it is more appropriate for a code to describe services provided rather than the facility type. Several commenters suggested that providers instead bill Type B emergency department services under a different revenue code than Type A emergency department services. *Response:*
                         In response to the numerous public comments received, and as discussed in detail in section IX.B.1. of this preamble on clinic visit coding, we are postponing finalizing G-codes for Type A emergency department visits until national guidelines have been established, when we will again consider their possible utility. For CY 2007, providers should continue to use CPT codes to bill for Type A emergency department visits. However, we are finalizing the definition of Type A emergency departments to distinguish it from Type B emergency departments. As stated above, we believe that this 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 department visit codes in comparison to 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. A Type A emergency department is a hospital-based facility or department that must be open 24 hours a day, 7 days a week and 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; 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). We were pleased that most commenters agreed with our distinction between the two types of emergency departments. While we acknowledge the comments that requested that we amend the definition of a Type B emergency department, we will continue to use the EMTALA definition of a dedicated emergency department as defined in 42 CFR 489.24 because, as stated above, we believed that because the concepts employed in the definition of a DED for EMTALA purposes are already familiar to hospitals. While we understand the reservations expressed by the commenters about the use of G-codes, we believe the creation of G-codes for Type B emergency departments is necessary because there currently are no CPT codes that fully describe this type of facility. If we were to continue instructing Type B emergency departments to bill clinic visit codes, we would have no way to track resource costs for Type B emergency department visits as distinct from clinic visits. These new G-codes will serve as a vehicle to capture median cost and resource differences among visits provided by Type A emergency departments, Type B emergency departments, and clinics. Further, we acknowledge that some providers prefer that we not distinguish between providers that are open 24 hours a day and those that are not. However, we continue to believe that hours of operation significantly impact hospital resource costs. It is necessarily more costly to operate a department with full capabilities 24 hours a day than to operate with full capabilities 12 hours a day. Emergency departments that are open 24 hours a day serve as a crucial safety net of our health care system, and we are concerned with ensuring that necessary emergency department services are available to Medicare beneficiaries. We are concerned that if we allow emergency departments that are open less than 24 hours a day to bill Type A emergency department codes, the result would be to dilute the median costs associated with the provision of services by emergency departments that are open 24 hours a day, 7 days a week. We note the commenters' concerns that G-codes may not allow accurate data collection because services for both Type A and Type B emergency department services may be reported under one revenue code. However, we expect hospitals to adjust their charges appropriately to reflect differences in Type A and Type B emergency departments. The current revenue codes do not distinguish between Type A and Type B emergency departments. Therefore, to track the resource costs differences between clinics, Type A emergency departments, and Type B emergency departments, it is necessary to create a new set of codes to be billed by Type B emergency departments. We will consider whether further instructions are necessary in the future to enhance our data collection. *Comment:*
                         Several commenters requested that CMS clarify whether Type A emergency department codes, Type B emergency department codes, or clinic visit codes apply in specific situations. One questioned whether a Type A emergency department that has a separate adjacent space that is organizationally part of the Type A emergency department, but treats less severe patients and is often closed at night, would be eligible to bill the Type A emergency department visit codes. The commenter clarified that the primary emergency area is fully staffed 24 hours a day. Several commenters questioned whether services provided at a satellite emergency department that is open less than 24 hours a day, located at a different location than the main campus, could bill the Type A emergency department visit codes. Again the commenter clarified that the primary emergency department was available 24 hours a day. Yet another commenter requested clarification about a Type A emergency department that operated subunits or locations within a Type A emergency department, that are closed part of the day or night, based on fluctuations in patient loads. This commenter noted that these subunits are sometimes referred to as “Fast Track areas.” *Response:*
                         We are aware that hospitals operate many types of facilities which they view in aggregate as an integrated healthcare system. For purposes of determining EMTALA obligations, under § 489.24(b) of the regulations, each hospital is evaluated individually to determine its own particular obligations. As we have discussed previously, hospital facilities or departments of the hospital that meet the definition of a dedicated emergency department consistent with the EMTALA regulations may bill Type A emergency department codes (CPT emergency department visit codes) or Type B emergency department codes (HCPCS G-codes), depending on whether or not the dedicated emergency department meets the definition of a Type A emergency department, which includes operating 24 hours per day, 7 days a week. For purposes of determining whether to bill Type A or Type B emergency department codes, each hospital must be evaluated individually and should make a decision specific to each area of the hospital to determine which codes 
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                        would be appropriate. Where a hospital maintains a separately identifiable area or part of a facility which does not operate on the same schedule (that is, 24 hours per day, 7 days a week) as its emergency department, that area or facility would not be considered an integral part of the emergency department that operates 24 hours per day, 7 days a week for purposes of determining its emergency department type for reporting emergency visit services. Instead, the facility or area would be evaluated separately to determine whether it is a Type A emergency department, Type B emergency department, or clinic. We would expect the hospital providing services in such facilities or areas to evaluate the status of those areas and bill accordingly. In general, it is not appropriate to consider a satellite emergency department or an area of the emergency department as if it were available 24 hours a day simply because the main emergency department is available 24 hours a day. It may be appropriate for a Type A emergency department to “carve out” portions of the emergency department that are not available 24 hours a day, where visits would be more appropriately billed with Type B emergency department codes. For CY 2007, we are finalizing our proposal with modification. We are not adopting the G-codes in Table 38 for Type A emergency departments, but we are adopting the G-codes in Table 37 for Type B emergency departments. 3. Critical Care Services For critical care services, we proposed in the CY 2007 OPPS proposed rule (71 FR 49610) to create two new codes to replace hospitals' reporting of the CPT E/M critical care codes listed in Table 35 above. Providers have been reporting two CPT codes through CY 2006, and we believed that it would be fairly easy to crosswalk current internal hospital guidelines to these two new codes. The proposed new codes are listed in Table 39 below. Table 39.—CY 2007 Proposed HCPCS Codes To Be Used To Report Critical Care Services
HCPCS code
Short descriptor
Long descriptorGccc1
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.
 *Comment:*
                         In addition to the many comments we received about G-codes in general, we received many comments on the proposed G-codes specific to critical care. Most comments fell under one of two categories: (1) Remove the minimum time requirement for critical care services; or (2) create one G-code for critical care without trauma activation and one G-code for critical care with trauma activation. Many commenters requested that CMS allow hospitals to bill critical care without a minimum time requirement. The commenters indicated that it was extremely difficult to measure time while providing critical care services because of the intensity of the services provided. These commenters also indicated that it is easier and more appropriate to use time when measuring physician resources rather than facility resources. They did not believe that time is an appropriate proxy for measuring hospital resource utilization when providing hospital critical care services because the hospital may have its highest resource use in the first 10 minutes of critical care, much earlier than the 30-minute minimum required in the code descriptor. However, because the proposed G-code indicates a minimum of 30 minutes of critical care services before the critical care code can be billed, the commenters indicated that the hospital would not be able to bill for the critical care services it provided. In case we still continued to require a 30-minute minimum, the commenters asked us to clarify how a hospital should count time. They asked: Does it start when the patient is admitted? Should each provider of care measure his own minutes, after which the hospital would add together all the minutes from all the providers involved? In addition, several commenters referenced page 18452 of the April 7, 2000 final rule preamble language, which has been interpreted by commenters to mean that the 30-minute minimum for critical care does not apply under the OPPS. One commenter requested that CMS remove the 30-minute minimum requirement because it creates a disincentive to provide critical care services in an efficient manner. Several commenters indicated that critical care should be the highest level visit code, regardless of time. One commenter suggested that critical care be paid at a flat rate, rather than involving time. Another commenter indicated that its State Medicaid agency did not accept critical care as a payable service and would only pay for the highest level emergency department visit code. Many commenters requested CMS to finalize the proposal to create G-codes for critical care, but that, in doing so, CMS create one G-code for critical care without trauma activation and one G-code for critical care associated with trauma activation. They also requested that CMS pay differentially for critical care provided with and without trauma activation. The commenters suggested that critical care services with trauma activation require a significantly higher level of hospital resources than critical care services alone. In particular, one commenter who made a presentation during the August 2006 APC Panel meeting suggested that CMS use revenue codes in the 68x series reported on the same date as a critical care service to determine whether a trauma response was activated in association with critical care services in order to facilitate selection of appropriate claims to establish differential payment rates for critical care services with and without trauma activation. The APC Panel recommended that CMS analyze cost data to determine if additional payment for trauma response was appropriate. *Response:*
                         We responded to the general comments regarding the use of G-codes in section IX.B.1. of this preamble on clinic visit coding. Under this response, we address the comments specific to critical care coding. First, we would like to respond to the apparent confusion concerning the April 7, 2000 response to a comment that we pay separately instead of packaging CPT code 99292 (each additional 30 minutes of critical care time). Apparently, many commenters misinterpreted the preamble language in that final rule and believed that it was not necessary to apply a 30-minute minimum before billing a critical care code. However, in response to a request to pay separately for CPT code 99292, 
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                        we responded that “We do not believe that paying hospitals for incremental time as critical care would better reflect facility resources. The most resource-intensive period for the hospital is generally the first hour of critical care. In addition, we believe it would be burdensome for hospitals to keep track of minutes for billing purposes. Therefore, we will pay for critical care as the most resource-intensive visit possible as defined by CPT code 99291.” In this context, it is clear that our response did not deal with the application of a 30-minute minimum time in the OPPS. Rather, our response dealt only with the issue involved; the packaging of payment for CPT code 99292. Specifically, we indicated that we package CPT code 99292 because it is burdensome for hospitals to track each additional 30-minute increment of time. Instead of requiring this tracking of all minutes of critical care services, we package payment for CPT code 99292 into the payment for CPT code 99291. Our response did not indicate that the 30-minute minimum requirement does not apply to CPT code 99291. In fact, the 30-minute minimum requirement has always applied and will continue to apply for CY 2007 and beyond. As is currently the case, the hospital can bill the appropriate clinic or emergency department visit code if fewer than 30 minutes of critical care is provided. We may provide more specific billing guidance at a later point in time. As described below, for CY 2007, clinic and emergency department visits will be paid at five levels, rather than three levels, which will ensure more accurate payments for these visits. Five payment levels will increase the payment rates for the highest level clinic and emergency department visits, which should benefit hospitals that provide these high-level services. In response to the commenters who requested that we pay differentially for critical care associated with trauma response, as well as the recommendation of the APC Panel, we performed several studies to determine whether critical care associated with trauma response was costlier than critical care without trauma response. As suggested by the commenter, we used revenue codes in the 68x series reported on the same date as a critical care service to determine whether a trauma response was activated in association with critical care services in order to facilitate selection of appropriate claims. There are specific National Uniform Billing Committee guidelines related to the reporting of trauma revenue codes in the 68x series, first implemented in October 2002. The revenue codes series 68x can only be used by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons. Different subcategory codes are reported by the designated Level 1-4 hospital trauma centers. Only patients for whom there has been prehospital notification based on triage information by prehospital caregivers, who meet either local, state, or American College of Surgeons field triage criteria, or are delivered by interhospital transfers, and are given the appropriate team response can be billed a trauma activation charge. We analyzed CY 2005 claims for critical care services, dividing claims into two groups: Those with trauma revenue code 68x on the same date of service as CPT code 99291 for the first period of critical care and those without trauma revenue code 68x on the same date of service as the critical care code. The median cost for critical care with a trauma revenue code charge is approximately $894, and the median cost for claims for critical care without a trauma revenue code charge is approximately $403. The proposed CY 2007 median cost for critical care was $495. We further reviewed the list of providers who billed critical care with a trauma revenue code. We noted that of all the 2,200 hospitals that billed a critical care code during CY 2005, less than 2 percent of these hospitals billed a trauma revenue code on the same date of service as CPT code 99291 one or more times on an OPPS claim. In addition, many of the hospitals that billed critical care with a trauma revenue code also billed critical care without a trauma revenue code. We further investigated whether providers that billed critical care with a trauma revenue code on the same date of service had higher median costs in general than providers that billed critical care without a trauma revenue code. We re-ran the median cost of critical care without a trauma revenue code on the same date of service using only claims from the subset of providers that had billed critical care with revenue code 68x to determine if it was different than the $403 median cost that was calculated using all providers. Our results showed that providers that billed critical care with revenue code 68x had very similar critical care resource costs to other hospitals. Therefore, for CY 2007, because we see meaningful cost differences between critical care when billed with and without trauma activation, we will pay differentially for critical care when there is trauma activation associated with the critical care and when there is no trauma activation. This will improve the accuracy of payments as related to resource use. Trauma centers provide important local and regional health services and serve valuable roles in their communities through their well-developed emergency capabilities. In response to commenters' concern about G-codes, we will continue to instruct providers to bill CPT codes 99291 and 99292 for critical care. In addition, we are creating one new G-code, G0390 (Trauma response team activation associated with hospital critical care service), effective January 1, 2007, which is assigned to APC 0618 (Critical Care with Trauma Response), with a median cost of $491.66. When critical care is provided without trauma activation, the hospital will bill CPT code 99291 (and 99292, if appropriate) as usual, and receive payment for APC 0617 (Critical Care), which has a median cost of $402.67, calculated from that subset of single claims for CPT code 99291 without revenue code 68x reported on the same day. If trauma activation occurs under the circumstances described by the National Uniform Billing Committee guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of G-code G0390, reported with revenue code 68x on the same date of service, thereby paying the hospital $491.66 under APC 0618. The CY 2007 median cost for APC 0618 was established based on the difference in median costs from the two subsets of single claims for CPT code 99291 representing the reporting of critical care services with and without revenue code 68x reported on the same day. The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed. We believe that trauma activation is a one-time occurrence in association with critical care services, and therefore, we will only pay for one unit of G0390 per day. CPT code 99292 remains packaged for CY 2007. We will monitor usage of the CPT codes for critical care services and the new G-code to ensure that their utilization remains at anticipated levels. For CY 2007, we are not adopting the proposed HCPCS G-codes in Table 39 for critical care services but we are adopting one new G-code (G0390) for trauma activation and response in association with critical care services. C. CY 2007 Payment Policy Since the implementation of the OPPS, outpatient visits provided by 
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                        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, it is to be billed as either a clinic visit or an emergency department 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 40, in general the two lowest levels of CPT codes (1 and 2) have been assigned to the low-level visit APC and the two highest levels of CPT codes (4 and 5) have been assigned to the high-level visit APC, with the single middle CPT level CPT code (3) assigned to the mid-level visit APC. Hospital claims data indicate that the cost of providing a visit of the same level is generally significantly higher for emergency department 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 department visit, and critical care APCs as configured for CY 2006 are listed below. Table 40.—Median Costs of Clinic and Emergency Department 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
$53.14
Level 1 Clinic Visit, Level 2 Clinic Visit.Mid Level Clinic Visits
61.89
Level 3 Clinic Clinic Visit.High Level Clinic Visits
89.09
Level 4 Clinic Visit, Level 5 Clinic Visit.**Emergency Department Visits**Low Level Emergency Visits
$74.44
Level 1 ED Visit, Level 2 ED Visit.Mid Level Emergency Visits
129.25
Level 3 ED Visit.High Level Emergency Vists
230.52
Level 4 ED Visit, Level 5 ED Visit.**Critical Care Services**Critical Care
$478.04
Critical care, first hour.
 However, historical hospitals claims data 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 proposed to create five payment levels for clinic and emergency department visits and one payment level for critical care services. As discussed in section IX.B. of this preamble, we are not adopting our proposal to replace all visit and critical care E/M CPT codes with G-codes, but we are creating five new G-codes to describe Type B emergency department visits and one new G-code to describe critical care services associated with trauma activation and response in association with critical care services. In the proposed rule, to determine appropriate payment rates for the proposed new G-codes, we mapped 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 department visits, and 1 for critical care services as shown in Table 41 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. The table, which is reprinted below, is relevant for calculating median costs at five payment levels, regardless of whether hospitals use CPT codes or G-codes. 
 
  In the case of the CPT E/M codes for emergency department visits, the assignment of data for the proposed rule from five levels of coding to five levels 
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                        of payment was straightforward. However, in some cases of the data for CPT clinic visit E/M codes, we assigned a code to 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 $60.70, it maps more appropriately to the Level 2 Clinic Visit APC, which has an overall median cost of $60.13. 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 was reflected in their respective proposed APC data assignments for CY 2007. For CY 2007, we proposed to assign the five new Type A emergency department visit codes for services provided in a Type A emergency department to the five new Emergency Visit APCs, 0609, 0613, 0614, 0615, and 0616. For CY 2007, we proposed to assign the five new Type B emergency department 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 department 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 and CMS require 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 department 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. 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. 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 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 final CY 2007 policy for drug administration services as described in section VIII. of the preamble of this final rule with comment period. In the proposed rule, we noted that we were 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 present for emergency care. We believe that our OPPS payment policies for Type A and Type B emergency department 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. *Comment:*
                         The commenters were divided as to whether to continue with three payment levels or to move to five payment levels for clinic and emergency department visits. Several commenters noted that five payment levels is better because it is similar to the payment structure of other payors, while others noted that three levels was more appropriate because it is difficult to distinguish among four or five levels. Another commenter opposed creation of five levels because its experience has shown that providers tend to choose the middle level automatically. One commenter preferred three levels to five levels to distinguish it from physician coding. Several commenters requested that CMS continue paying at three payment levels until CMS established national guidelines. These commenters also requested that CMS not transition to G-codes until national guidelines were established. They preferred to maintain the status quo until national guidelines were established, at which point they believed it would be more appropriate to also revise the coding and payment structure. The commenters believed that it would be simpler to make the changes all at once, rather than making incremental changes, leading up to the establishment of national guidelines. Several commenters favored moving to five payment levels before national guidelines were established, and encouraged CMS to finalize the number of payment levels before continuing work on national guidelines. The commenters believed that, if the cost data showed that five payment levels would lead to a more accurate distribution of payment, they were in favor of the change. While most comments favored the distinction between Type A and Type B emergency departments, several commenters believed that Type B emergency department visits should be paid at Type A emergency department rates, rather than clinic visit rates. The commenters believed that, although these facilities were open less than 24 hours a day, the services provided more closely resemble emergency department services than clinic services, and therefore, their resource costs were higher than clinics. Other commenters believed it was appropriate and reasonable to pay for Type B emergency departments at clinic visit rates until cost data was collected. One commenter was concerned that “unfettered proliferation of less than full-service emergency departments could reduce access for many individuals who need emergency care after hours when Type B emergency departments are closed. We do not want these facilities to have financial incentives to locate in areas where the population is more affluent and largely insured, leaving full-service hospital emergency departments with an even larger financial burden to care for the uninsured and underinsured after hours.” The commenter favored the distinction between the two types of emergency departments, but believed the costs of Type B emergency departments is closer to the cost of Type 
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                        A emergency department visits than clinic visits. The commenter was unsure of the direct impact this payment policy will have on Type B emergency departments, recognizing that these facilities improve patient access to emergency care. In particular, the commenter wondered how many hospital-based Type B emergency departments exist and how many of them are currently billing at emergency department rates. One commenter noted that emergency departments are suffering financially, and that CMS should pay them at higher rates to ensure continued access. Several commenters suggested that CMS pay Type B emergency departments at a rate somewhere in between the Type A emergency department rates and clinic visit rates until complete cost data are collected. Several commenters responded to our concern that rural hospitals may be disproportionately likely to offer essential emergency department services less than 24 hours per day, 7 days a week. Specifically, one commenter confirmed through conversations with State associations and hospitals that few emergency departments are open less than 24 hours a day. In particular, the commenter indicated many rural hospitals are designated as CAHs, for which the Medicare CAH conditions of participation require that emergency services are available 24 hours a day. While the commenter had heard of a few emergency departments that were open less than 24 hours a day, it did not believe that any rural emergency departments were open less than 24 hours a day. One commenter suggested that CMS adjust the copayments so that the Level 1 clinic copayment becomes significantly less than the Level 1 emergency department visit, to provide an incentive for Medicare beneficiaries to receive care in the most cost-efficient setting. As discussed in section IX.B.3. of this preamble on coding, we received a significant number of comments regarding payment for critical care services associated with trauma activation. We summarized and responded to those comments in that section. *Response:*
                         While we acknowledge the concern of several commenters that it is best to remain at status quo until national guidelines are developed, we continue to believe that five payment levels are now appropriate for both clinic and emergency department visits based on median cost data. This will allow us to more accurately distribute clinic and emergency department payments, as also noted by several commenters. Five payment levels will increase the payment rates for the highest level clinic and emergency department visits, which will benefit hospitals that provide these high-level services. In addition, we do not anticipate that hospitals will need to update their internal guidelines to reflect this change, as it affects payment, not coding. While we have heard anecdotally that some hospitals only bill level 1, level 3, and level 5 clinic and emergency department visit CPT codes to simplify their internal coding, our data indicates a fairly normal distribution, suggesting that overall, providers are billing all five levels of codes. In any case, general coding rules dictate that providers should bill the code that most appropriately describes the service provided. Therefore, for CY 2007, we will finalize our proposal to pay clinic and emergency department visits at five levels, rather than three levels. We will pay for critical care services at two payment rates as well, as described in section IX.B.3. of this preamble on coding. We re-assessed the APC assignments for the HCPCS codes in Table 41 using updated final rule data. Because hospitals will be reporting CPT codes for clinic visits for CY 2007, they must continue to distinguish between new and established patients and consultations according to the CPT code descriptor. However, it may be unnecessary for hospitals to report consultation CPT codes if either the new or established patient visit code accurately describes the service provided. We do not want to create an incentive for hospitals to bill a consultation code instead of a new or established patient code because we do not believe that consultation codes necessarily reflect different resource utilization than either new or established patient codes. Therefore, because consultation codes may be reported by hospitals during CY 2007, we re-reviewed the resource costs for the consultation codes, as well as the clinical homogeneity of the APCs to which we proposed to map them. As a result of this review, we have moved the consultation codes to the same APC as the established patient code, for each level of service. For example, CPT code 99242, the level 2 consultation code is mapped to APC 0605 (Level 2 Clinic Visits), which is where CPT code 99212, the level 2 established patient code, is mapped. In addition, we mapped the data for the deleted confirmatory consultation CPT codes, 99271-99275, to the same APC as the corresponding consultation code. Moving the consultation codes to the same APC as the corresponding established patient visit code eliminates the incentive for hospitals to bill a consultation code instead of a new or established patient code. Table 42 shows the assignment of claims data from the CY 2005 CPT E/M codes and other codes in the Visit APCs to the new Visit APCs for CY 2007. 
 
  
 
  We have reviewed all of the public comments carefully and continue to believe that it is appropriate to pay Type B emergency department visits at clinic visit rates, until we collect enough data to better determine their resource costs. We have no hospital resource data that would support how to establish appropriate payment rates for Type B emergency department visits at rates between clinic and Type A emergency department rates. The fact that they do not operate with all capabilities full-time suggests that hospital resources associated with visits to DEDs may not be as great as those for full-time hospital emergency departments. Paying clinic rates for visits to Type B emergency departments would be consistent with current OPPS policy and CPT guidelines that a facility that does not meet the CPT definition of emergency department cannot bill emergency department CPT codes and, therefore, cannot receive emergency department visit payments. We agree with the commenter that was concerned about creating incentives for emergency departments to be open less than 24 hours a day, which could thereby place additional burden on the emergency health care system. We do not have precise data on how many Type B emergency departments currently exist, but we believe that they are currently billing the clinic visit CPT codes, as required under the OPPS, and thus this policy would have little impact on current billing practices and payments. Therefore, for CY 2007, we are finalizing our proposal to pay Type B emergency departments at clinic visit rates. We appreciate the efforts of the commenters that responded to our concern about access to rural emergency departments. As most rural emergency departments are open 24 hours a day, we believe Medicare beneficiaries in rural areas should continue to have access to emergency care. In response to the commenter that suggested that the copayment for emergency department visits be set at a higher rate than the copayment for clinic visits, we note that the statute and regulation set a general formula that we use to calculate copayments. As stated in 42 CFR 419.41, for CY 2007, a copayment cannot be lower than 20 percent of the payment rate or greater than 40 percent of the payment rate. In addition, we have established through rulemaking a detailed formula that we use to calculate copayments. We do not artificially adjust copayments for any APC unless a statutory provision states that the standard formula does not apply. Because there is no statutory provision that excludes these visit APCs from the standard formula, we cannot ensure a specific relationship between the clinic and emergency department visit copayments. For CY 2007, we are finalizing without modification our proposal to create five payment levels for clinic and emergency department visits. We are finalizing with modification our proposal to create one payment level for critical care, by providing an additional payment when critical care is associated with trauma activation and response. D. CY 2007 Treatment of Guidelines 1. Background As described in section IX.A. of the preamble of this final rule with comment period, 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 (67 FR 66792), we noted that an independent panel of experts would be an 
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                        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 department 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 believe 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 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. In the CY 2007 OPPS proposed rule (71 FR 49616), we sought 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 department visits, rather than the five levels of codes that currently exist for clinic and emergency department visits. We believe that it is difficult to pay at five levels using these guidelines, unless the guidelines were revised, because hospitals would not have guidelines that applied to the Level 2 and Level 4 visits. As discussed above, our claims data indicate that five payment levels are justified for both clinic and Type A emergency department visits, and, therefore, we are finalizing five levels of clinic and emergency department visit payments 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 will now pay at five payment levels for CY 2007 and believe 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 setup, patient use of room, room cleaning” and assigned in the AHA/AHIMA guidelines to a low-level 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 department 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 
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                        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, in the proposed rule, we indicated that 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, provided certain conditions were met. If the guidelines strictly excluded all separately payable services, 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. In the proposed rule, we indicated that we are open to further discussion and welcomed 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 interventions, depending upon the numbers and types of different specimens collected. In the proposed rule, we encouraged 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. In the proposed rule, we expressed interest in receiving 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 
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                        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 G-codes 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, but similar in terms of resources to new patient visits. For example, based upon the final 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 $60.70. CPT code 99203, the level 3 clinic visit code for new patients, has a median cost of $72.33. CPT code 99243, the level 3 consultation visit code, has a median cost of $72.89. Finally, CPT code 99273, the level 3 confirmatory consultation visit code that was deleted for CY 2006 had a median cost of $98.24. In the proposed rule, we encouraged 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 CPT 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. For the new G-codes that we created in this final rule with comment period 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 department visit reporting. The AHA and AHIMA have not yet had the opportunity to consider the issue of Type B emergency department visit reporting in their guidelines, and in the proposed rule we welcomed public comments to provide additional perspectives on the appropriate guidelines for reporting visit levels in these Type B emergency departments. We received a large number of comments related to national guidelines for clinic and emergency department visits and critical care services, some of which described general questions and concerns about using a national model and others with specific suggestions for improving the AHA/AHIMA model. As noted in the CY 2007 proposed rule, we sought broad public input regarding our discussion of national guidelines to inform our guidelines development efforts at this point in time, but we made no specific proposal for CY 2007. Therefore, the comments below are summarized to reflect the breadth and depth of thoughtful input provided by the public, and we will continue to consider these comments and additional public input as we work to develop national guidelines for future implementation. *Comment:*
                         Most commenters strongly supported creation of national guidelines, but a few commenters preferred to continue using the internal guidelines that they had been using for several years. Some hospitals had successfully implemented the original AHA/AHIMA model, while others had success with diagnosis-related models and resource intensity point scoring models. One commenter indicated that a diagnosis-based model is not as complicated as we described. The commenter's hospital had great success training its staff and now has little coding variability among its coders. One developer of national guidelines noted that many hospitals had success with problem-based guidelines that it had created. The developer noted that its system was easy to use, produced consistent coding decisions with a normal distribution of visits, and even served as a tool to track effectiveness and efficiency. One hospital asked if it was permitted to continue using its own internal guidelines if CMS had indicated some concerns with that particular type of guidelines. Several hospitals asked us to clarify whether a normal distribution would be expected nationally, across all hospitals, or for an individual hospital. The commenter suggested that it would be appropriate for a trauma center to have a curve that was skewed to the right, toward higher level visit codes. Another commenter suggested that hospitals be instructed to bill the same level code that is billed on the physician side, to simplify coding and reduce excess documentation. The commenter noted that then there would be no concern about redistributive impact because we could simply study the physician E/M code distribution. One commenter requested that the final guidelines use criteria and/or interventions that would be available in electronic medical records, to ease guideline implementation for hospitals with this technology. The same commenter suggested that the guidelines should be very specific and serve as detailed coding instructions rather than just “guidelines,” which would make training easier and reduce the number of questions directed at the fiscal intermediaries. The commenter suggested that the guidelines include details, with regulation citations such as “the patient must be a registered outpatient of the hospital” as defined in a particular regulation. Several commenters requested that we clarify that the clinic guidelines are intended to be used by any outpatient area that is not an emergency department, even if that outpatient area is not a true clinic and suggested that the guidelines should be titled “Outpatient visit 
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                        guidelines” instead of “Clinic visit guidelines.” One commenter gave examples of outpatient areas that are not clinics, which included outpatient infusion centers, outpatient oncology centers, wound care centers, and outpatient maternity services. We received many specific comments about the AHA/AHIMA model. The AHA and AHIMA were pleased that we are working on their model and look forward to reconvening the expert panel to continue work on this project. They noted that the model was an initial attempt with a short turnaround time, and that it was never intended to be used as a stand-alone document. They anticipated creating educational supplemental materials that would accompany the guidelines. Several organizations expressed interest in working with CMS as well as the AHA/AHIMA expert panel in the development of national guidelines, including the American College of Emergency Physicians and Lynx Medical Systems. Several commenters agreed that it was appropriate to continue with five levels of coding to achieve consistency with other payors. Other commenters agreed that retaining five coding levels was appropriate if five payment rates existed. One commenter believed that three levels was simpler and distinguished hospital coding from physician coding, which has five coding levels. The AHA and AHIMA noted that the guidelines originally used three levels because the expert panel found it hard to distinguish between five levels when separately payable services were excluded. However, if separately payable services or other factors such as time could be included, the model could be modified to account for five levels. They requested clear guidance from CMS before proceeding. Many commenters agreed that multiple interventions were unclear and could be interpreted in several ways. Other commenters asked CMS to clarify exactly which interventions were unclear. One commenter noted that over time, after the guidelines are implemented, the ambiguities will decrease as staff becomes familiar with the model. Several commenters suggested that specific examples of patient acuity or symptoms would be useful. (We noted above that the AHA and AHIMA anticipated that they would provide significant supplemental materials.) Several commenters asked that we clarify the difference between “triage” and the medical screening exam required under EMTALA provisions. One commenter suggested that CMS only use interventions that measure quantitative items such as blood pressure, heart rate, and pain threshold scoring, and like items. Most commenters believed that separately payable interventions should be included in the guidelines because they serve as a proxy for resource use. One commenter noted that the American College of Emergency Physicians' guidelines have an excellent list of interventions, some of which are separately payable. One commenter suggested that we assign a modifier to a code that is separately paid so that it would not be counted toward calculating a visit level. The AHA and AHIMA aptly noted that not all separately payable services reflect patient acuity, so it would be necessary for the Panel to determine which services are appropriate for inclusion. One commenter asked that we continue to exclude separately payable services to avoid double billing and confusion. Some commenters indicated that most interventions in the original AHA/AHIMA model were appropriately placed, with some interventions that were valued too low and a few that were valued too high. Other commenters disagreed with several CMS-suggested revisions. For example, in the revised model, if emergency department staff performed a body assessment, pain measurement, vitals, and an x-ray, that service would no longer reach a level 1 visit, while under the original AHA/AHIMA guidelines, the service would be coded as a Level 1 visit. Several commenters argued that oxygen administration should not be moved to a low level because it is resource-intensive in terms of staff time and resource use. One commenter stated that specimen collection was appropriately assigned as a Level 1 intervention in a clinic setting but should be higher in the emergency department because staff often need to assist patients who are anxious and having trouble concentrating. Another commenter suggested Level 1 assignment for one to two specimen collections and Level 3 for three or more collections. Two hospitals speculated that their emergency department payment would decrease by 30 to 40 percent as a result of transitioning to the AHA/AHIMA guidelines. There were additional suggestions that specific interventions move from one level to another. Several commenters suggested additional interventions that should be included, such as restroom assistance, memory testing, reviewing medications, obtaining insurance authorization, psychological and spiritual counseling, emotional support, time with the family, discharge instructions, seizure precautions, drug/alcohol influence, prepping for surgery, postmortem care, dietary planning, pain management, and others. Although pre-authorization is not required for Medicare beneficiaries, some commenters noted that hospitals will use these guidelines for all payors, so it may be appropriate to include this intervention. One commenter agreed that continuous irrigation of the eye should not be a Level 5 visit. The AHA and AHIMA stated that its expert Panel looked carefully at each intervention. They noted that their criteria for placement included hospital staff time involved, complexity of intervention, number of hospital staff members required to perform the intervention, and the skill level, qualifications, or credentialing needed to perform the intervention. Other commenters noted that the interventions were focused on interventions performed by nurses, rather than by assorted clinicians and technicians. One hospital expressed interest in submitting further suggestions after the comment period ended. We received a few comments about applying one set of guidelines to all clinics, including specialty clinics, suggesting that it was unnecessary to create multiple guidelines. Several commenters suggested that any differences could be addressed with time as an element, which is the single biggest resource that varies among clinics. For example, a diabetic patient with limited eyesight requires additional training time to learn to read glucose levels and give the proper amount of insulin. A cancer association submitted an additional example, explaining that a simple blood draw can be time consuming when performed on an oncology patient, whose veins may be damaged from the effects of chemotherapy. One commenter suggested that if more than 50 percent of a visit is used for counseling and care coordination, the visit level should be increased by one level. Several associations stated that it is unlikely that one set of guidelines could apply to all specialty clinics. Specifically, one wound care association recommended that all wound care clinics use the guidelines developed by that particular association. Another wound care association developed an acuity scoring system that has been successfully implemented by wound care clinics. One commenter suggested that in a time-based model, there would be no American with Disabilities Act (ADA) violation. Another commenter suggested setting a flat copayment rate for all clinic and all emergency department visits to avoid an ADA violation. The 
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                        AHA and AHIMA clarified that their intention was not to increase the beneficiary copayment but was intended to reflect resource utilization. We discuss in sections IX.B. and C. of this preamble the comments that we received about the distinction among “new” and “established” visits and “consultations.” A few commenters suggested that a new patient could be a contributing factor in the guidelines. We also discuss in sections IX.B of this preamble the comments that we received about Type A versus Type B emergency departments. We received no comments on this topic that were specific to the AHA/AHIMA guidelines. One organization noted that some revisions may have been necessary due to changes in clinical practice since the guidelines were developed 3 years ago. Another commenter noted that several Level 1 emergency department interventions, such as first aid, are Level 3 clinic interventions, which leads to emergency departments receiving less payment for the same service, even though emergency departments are costlier. The AHA and AHIMA requested that CMS release the detailed analysis of the Iowa Foundation for Medical Care review of the AHA/AHIMA model so that they can review all concerns. They also requested that CMS clarify the rationale for the other modifications. For example, it sometimes appeared to them as if CMS measured physician time rather than facility resources or hospital staff time. For example, patient education by hospital staff was removed but physician counseling of more than 60 minutes was added. *Response:*
                         We appreciate all the comments we received from the public, and we encourage continued submission of comments at any time that will assist us, the AHA/AHIMA expert panel, and other stakeholders interested in the development of national guidelines. Until national guidelines are established, hospitals should continue using their own internal guidelines, even if we have expressed reservations about the type of guidelines that a hospital is currently using. As commenters stated, we would not expect individual hospitals to experience a normal distribution of visit levels, although we would expect a normal distribution across all hospitals after national guidelines are established. We would expect that a small community hospital may provide more low-level services than high-level services, while an academic medical center or trauma center may provide more high-level services than low-level services. The commenters are correct that we intend for these national guidelines to be used by any outpatient hospital department, even if it is not called a clinic. We would expect these national guidelines to provide for five levels of coding, to parallel the five payment levels that are finalized in this final rule with comment period. It would be impossible to code at three levels and pay at five levels. As described above, we believe that paying at five levels will allow a more accurate payment for clinic and emergency department visits. We agree with commenters that there may be advantages to including separately payable interventions in the guidelines as examples, because a measure of acuity may be lost in the absence of recognition of these procedures. We also agree with the AHA and AHIMA that it might be easier to distinguish among five levels of coding if separately payable interventions are included as examples. We appreciate all of the specific comments about interventions that may not be appropriately assigned to levels in the guidelines. We acknowledge that the guidelines are still being developed and require additional testing. While it would be impossible for every single hospital to agree about the placement of every single intervention in the guidelines, we anticipate that the interventions will be assigned in a way that best reflects the resource use of the services provided such that few providers will have objections. We remind providers that under a relative system, if a service is listed as a Level 1 intervention, it does not mean that very few hospital resources are involved. Instead, it means that the resources used in that service must be considered relative to the other interventions in the model. While most commenters believed that one set of guidelines could apply to all specialty clinics, it may be necessary to incorporate time into the guidelines as well. The AHA and AHIMA expert panel has considered this issue as well. We will determine whether the Iowa Foundation for Medical Care study of the modified AHA/AHIMA model can be released to the public. The public comments that we received on this guidelines section of the proposed rule are publicly available to the AHA and AHIMA and their expert panel, as well as other interested parties, along with comments that we received on the two versions of the guidelines posted on the CMS Web site at: 
                        *http://www.cms.hhs.gov*. We hope to receive additional input from the AHA and AHIMA and other stakeholders over the upcoming months to address the eight areas of concern that are discussed above, as well as the other issues reviewed above that have been brought to our attention by the public. We plan to communicate progress on the development of OPPS visit guidelines through updates to the OPPS Web site at: 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​*
                         and we may post other versions of draft guidelines in order to solicit additional public input during CY 2007. When we post additional materials to the Web site 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, and other broad-based communication forums. While we understand the interest of some hospitals in our moving quickly to promulgate national guidelines that will ensure 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 would 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 and evolving 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.
                        ( print page 68146) X. Payment for Blood and Blood Products A. Background 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 CY 2005 OPPS) to CY 2004 (used for the CY 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 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. Policy Changes for CY 2007 In the CY 2007 OPPS proposed rule, we proposed to base CY 2007 payment rates for blood and blood products on their median costs from CY 2005 claims data, calculated using a special methodology to simulate blood-specific CCRs if hospitals did not have such specific CCRs. After hearing several public presentations at the August 2006 APC Panel meeting, the Panel engaged in considerable deliberation and recommended that CMS reconsider its methodology to develop payment rates for blood and blood products to more accurately reflect the true costs of blood and blood products to hospitals, including using external data. We include our response to this recommendation in the discussion below. We received a number of public comments regarding this proposal. A summary of the comments and our responses follows: *Comment:*
                         A number of commenters objected to our proposal to base payments for blood and blood products on their simulated median unit costs. They stated that the proposed payments are inadequate to compensate hospitals for the full acquisition costs of blood and blood products. Some commenters said that they appreciated CMS' work to calculate more appropriate payment rates for blood and blood products, but urged CMS to use external data, rather than claims-based data, as a measure of the appropriateness of the median costs derived from the claims process. Specifically, the commenters asked CMS to set the payments for four blood products at 110 percent of the average hospital purchase price for four blood products, specifically, P9016, RBC Leukocytes reduced; P9017, Plasma 1 
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                        donor frz w/in 8 hr; P9019, and Platelets; P9035, Platelet pheresis leukoreduced as determined from data submitted by 1600 hospitals in response to a survey of 2004 blood costs that was conducted by the Department of Health and Human Services under a contract with the American Association of Blood Banks (AABB). The commenters believed that the 10 percent increase over the survey purchase price findings was necessary to update the amounts to reflect what they thought would be the costs to hospitals for these blood products in CY 2007. They stated that the amounts that resulted were very conservative because they reflected only the cost of the blood and its processing, without including a hospital allowance for the costs of overhead, storage, handling, and waste due to shelf-life limitations. Other commenters asked CMS to set the blood median costs for CY 2007 at 12 percent higher than the proposed rule median costs, because such an increase would result in a significant improvement in reimbursement for products for which the OPPS claims data understated true acquisition costs and would help to ensure continued beneficiary access to the nation's blood supply. Some commenters asked that CMS set the payment for blood at the charge established by large suppliers of blood products. Several commenters requested that CMS calculate the median costs for blood and blood products using only claims with dates of service after July 1, 2005, so that the only claims used in median calculation for these products would be claims that were submitted after the billing guidance and coding edits of CMS Program Transmittal 496 went into effect on July 1, 2005. Other commenters suggested that we establish median costs for basic blood products and, separately, for different types of additional blood processing (for example, irradiation and leukoreduction) to ensure that there would be no rank order anomalies in the medians derived from claims data. *Response:*
                         In developing this CY 2007 final rule with comment period, we are accepting the APC Panel's recommendation to review our methodology for developing payment rates for blood and blood products. We have also considered the only recent external data of which we are aware that was mentioned by several commenters. The recent survey by the AABB included reporting of the hospital purchase prices related to providing 4 of the 34 blood and blood products for which we have specific HCPCS codes. An abstract of the resulting report, including the average amounts hospitals paid for the four blood products in CY 2004, is available in the journal “
                        *Transfusion,*
                        ” 2006 volume 46 Supplement (page 188A). We reviewed the limited information that is currently available from the survey for these four blood products. However, we are unable to determine the extent to which the survey findings could be useful in evaluating the methodology and resulting median costs that were the basis for our CY 2007 proposal of payment rates for all blood and blood products. Our payment methodology for blood and blood products has historically been based upon median hospital costs (consistent with the standard OPPS claims-based methodology for establishing payment rates), and the survey reported average hospital purchase prices, rather than median costs. Moreover, this information was not available to the public at the beginning of the comment period of the CY 2007 OPPS proposed rule, and hence we were not able to request and consider public comments on it. The OPPS methodology to establish relative weights requires standardized cost finding applied to a standardized source of data to ensure that the relative weights for the items and services paid under the system are in the correct relationship to one another. To select four blood products for treatment outside of the standard methodology, substituting external data for claims data, may not result in weights that are appropriately relative to one another. Accordingly, we are not using the AABB survey data in determining the payment rates for blood and blood products for the CY 2007 OPPS. We also are not adopting one suggestion of the commenters to establish rates based upon the amounts charged by the largest suppliers of blood, because as described earlier regarding use of the AABB survey data, to do so would be contrary to the methodology of the OPPS that is based on a system of relative weights. Similarly, we do not believe it would be appropriate to increase the final median costs of blood and blood products by 12 percent over their proposed CY 2007 median costs because little justification was provided by the commenters for the increase. Lastly, we do not believe we should calculate median costs for this final rule using only claims submitted on or after the July 1, 2005, effective date of the blood instructions in Transmittal 496, because to do so would greatly reduce the number of claims for the low volume blood products. The rates for these products tend to volatile even with an entire year of claims data, because they are furnished in very low volume in outpatient hospital settings. We also are not setting median costs for the product without processing and establishing separate median costs for each different type of processing. Hospitals generally acquire the product processed as specified in the definition of the product they report, and we do not believe that they would be able to charge separately for the unprocessed product (for example, red blood cells) and also charge separately for the processing that occurred before they acquired the already processed product. Instead, for the CY 2007 OPPS, we are finalizing our proposal 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 utilizes 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 blood-specific 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. However, for CY 2007 we are providing a payment transition for those blood products for which the difference between their CY 2006 adjusted median cost and their CY 2007 simulated median cost is greater than 25 percent. Specifically, we are setting the CY 2007 median costs upon which payments for blood and blood products are based at the higher of the CY 2007 unadjusted simulated median cost or 75 percent of the CY 2006 adjusted median cost on which the CY 2006 payment is based. This results in adjustment to the simulated median costs for CY 2007 for 7 of the 34 blood products. See Table 43 below. The median costs for blood and blood products in this final rule with comment period 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, dated 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. The instruction went into effect for services furnished on or after July 1, 2005, and therefore, was in effect for the last 6 months of CY 2005. Thus, we expect 
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                        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 HCPCS 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-specific CCR methodology) for CY 2007 rise for 23 of them compared to their CY 2006 unadjusted simulated median unit costs. These 23 products account for about 82 percent of all units of blood products furnished to Medicare beneficiaries in the hospital outpatient department in our CY 2005 claims data. As has been the case in the past, the low volume products (which we have historically defined as fewer than 1,000 units per year) show the most volatility. Of the 11 low volume products, 6 products show increases in their unit costs compared to their CY 2006 unadjusted simulated median unit costs, and 5 products show decreases in their median unit costs compared to their CY 2006 unadjusted simulated median unit costs. The low volume products for which the median costs decline compared to their unadjusted simulated median costs in CY 2006 represent only 0.48 percent of the total units of blood products furnished in the CY 2005 OPPS claims data. However, we recognize that for some blood products, including one product that is not of low volume, the difference between the CY 2006 adjusted simulated median cost on which CY 2006 payment is based is greater than 25 percent. Therefore, we are providing a transitional payment for CY 2007 by limiting the amount of the decrease for CY 2007 compared to CY 2006 to no more than 25 percent. We believe that this is a necessary and appropriate step in the transition to payments for blood and blood products based fully on claims data. Fewer blood products actually experience increases in their median costs from CY 2006 to their final CY 2007 median costs because we adjusted the CY 2006 median costs for blood and blood products. Of the 34 blood products, median costs rise for 18 of them compared to the CY 2006 OPPS adjusted simulated median costs on which the CY 2006 payments are based (and which were adjusted to no less than 95 percent of the CY 2005 payment medians). These 18 products account for 81 percent of all units of blood products furnished in our CY 2005 claims data. Of the 11 low volume products, 3 show increases in their median unit costs compared to the CY 2006 OPPS adjusted simulated median unit costs, and 8 show decreases compared to their CY 2006 OPPS adjusted simulated median unit costs. The low volume products that show a decline in medians compared to their CY 2006 adjusted simulated median costs represent only 0.37 percent of the total units of blood products reflected in the CY 2005 claims data. In summary, we are setting the final payment rates for blood and blood products for CY 2007 based on the unadjusted simulated median costs for blood and blood products that are derived from CY 2005 claims data as we have described, with the exception of the seven products for which we are providing a payment adjustment to smooth their transition to full claims-based payment in the future. We believe that, in most cases, the unadjusted median 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 policy, based on the CY 2005 claims data, the projected payments will rise for approximately 81 percent of the blood product units paid under the OPPS if patterns of furnishing blood products in CY 2007 remain similar to those in CY 2005. The low volume products whose simulated median costs decline compared to their CY 2006 adjusted simulated 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. In addition, the median costs of several low volume blood products show a significant increase for CY 2007. 
 
  
 
 XI. OPPS Payment for Observation Services 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. In the CY 2007 proposed rule, we proposed a CY 2007 median cost for APC 0339 of $442.16. This reflected relative stability in hospital costs for separately payable observation care. Direct admission to observation (HCPCS code 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 proposed to assign direct admission to observation, when separately payable, to APC 0604 (Low Level Clinic Visit). The proposed CY 2007 median cost for APC 0604 was $49.93. As we stated in the CY 2006 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. During the APC Panel's August 2006 meeting, the Observation Subcommittee made several recommendations regarding observation services. The first of these was that CMS should consider adding syncope and dehydration as diagnoses for which observation services would qualify for separate payment. Second, the Observation Subcommittee recommended that CMS perform claims analyses and present data that would allow it to consider revising criteria for separately payable observation services when certain procedures that are assigned status indicator “T,” for example, insertion of a bladder catheter or laceration repair, are reported on the same claim with an emergency department visit and observation services, and all other criteria for separate observation payment (for example, qualifying diagnosis code, number of hours) are met. *Comment:*
                         A few commenters expressed ongoing support for the improved processing of observation claims through use of the OCE to assign separate or packaged status to observation services depending on whether the criteria for separate payment were met, an approach that CMS implemented for CY 2006. The commenters suggested that now that CMS has simplified the process for ensuring separate payment for covered outpatient observation services in specific circumstances, CMS should consider adding syncope and dehydration as diagnoses that qualify for separate observation payment. The commenters did not request CY 2007 implementation, but, rather, their suggestions were consistent with the APC Panel recommendation that CMS should explore this expansion to the list of diagnoses for which observation may be separately paid. Also related to the APC Panel recommendations, one commenter recommended that CMS perform claims and data analysis that would enable CMS to consider revising the criteria for separately payable observation services when certain procedures that are assigned status indicator “T” are reported on the same claim with an emergency department visit and observation services, and all other criteria for separate observation payment are met. *Response:*
                         We intend to perform a series of analyses over the upcoming year to explore the potential effects of adding syncope and dehydration as qualifying diagnoses for separately payable observation services, as well as the possibility of allowing separate observation payment for claims for observation services that also include specific minor or routine procedures that have “T” status indicators. We will continue to work with the APC Panel Observation Subcommittee over the coming months in response to these recommendations. We expect to have preliminary results of the analyses in time for discussion with the full Panel at the next APC Panel meeting in the winter of 2007. For CY 2007, as we proposed, we are continuing to apply 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 making final changes in APC assignments and payments for clinic and emergency department visits. As part of those changes, low level clinic visits are being moved from APC 0600 (Low Level Clinic Visits) to APC 0604 (Level 1 Clinic Visits), with a final CY 2007 median cost of $50.37. Under the circumstances where direct admission to observation is separately payable, we are finalizing our assignment of HCPCS code G0379 to APC 0604, consistent with its CY 2006 placement in the APC for Low Level Clinic Visits. *Comment:*
                         One commenter suggested that CMS adopt “midnight” as a defining measure of an overnight stay in hospital outpatient departments. The commenter believed that CMS proposed to apply that definition of an overnight stay in ASCs so beneficiaries in ASCs at midnight would be transferred at that time to hospital outpatient departments for continuing care. The commenter stated that those patients would be unlikely to meet acuity and severity requirements for inpatient admission and would be admitted to observation and that the hospital would be able to bill for the initial care with G0379 because the patient was a direct admission. The commenter expressed concern about the payment inequity between the situation in which a patient is transferred to observation from the 
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                        ASC (and the hospital can bill for direct admission to observation) compared to that for patients who are transferred from the hospital's own outpatient department into observation (and the hospital cannot bill). The commenter suggested that CMS consider a new source of admission code for “transfer from ASC” to be used by hospitals. The commenter believed that CMS would benefit from collection of that data. *Response:*
                         We believe the commenter has misinterpreted our proposed use of midnight to define an overnight stay in ASCs for CY 2008. There is no requirement for an ASC to transfer a patient who continues to require care at and beyond midnight. For implementation in CY 2008, we proposed to include on the list of procedures for which an ASC facility fee would be allowed any procedure that may be safely performed in the ASC and that does not require an overnight stay. We proposed to exclude from payment of an ASC facility fee any procedure for which prevailing medical practice dictates that the beneficiary would typically be expected to require active medical monitoring at midnight following the procedure (71 FR 49638). Therefore, midnight with respect to an overnight stay is used solely for determining which procedures are eligible to be included on the Medicare ASC list and, thus, payment of an ASC facility fee would be allowed. There is no requirement to transfer patients out of the ASC at midnight. Our proposed use of midnight to define overnight stay for purposes of evaluating procedures for inclusion on the Medicare ASC list has no payment implications for the hospital outpatient department. The proposal is still open for comment and, therefore, we will make no final decision about the proposal at this time. As the commenter pointed out, in the circumstances where a patient is transferred from an ASC to a hospital for observation, the hospital may report HCPCS code G0379 (Direct admission of patient for hospital observation care) for the direct admission to observation service, along with HCPCS code G0378 for the hours of observation care. However, unless the observation services meet our criteria for separate payment, the hospital would only receive separate payment for HCPCS code G0379 through APC 0604 (Level 1 Clinic Visits), with a CY 2007 median cost of about $50. Similarly, if a patient has an outpatient surgical procedure performed in a hospital and requires outpatient observation care after the recovery period, the hospital may report the hours of observation using HCPCS code G0379, with payment for the observation care packaged into payment for the surgical procedure. We believe that the current policy is reasonable because, in both cases, hospitals will receive a separate payment for their services, into which payment for the hours of observation care is packaged. *Comment:*
                         One commenter sought clarification on whether the CY 2007 median cost calculation for APC 0339 included claims with more than 48 hours of observation. The commenter also sought clarification about whether all hours of observation care beyond 48 hours are noncovered. *Response:*
                         As we have stated before in reference to the appropriate duration of observation services, we believe that in the overwhelming majority of cases, decisions can be and are routinely made in less than 24 hours, regarding whether to release a beneficiary from the hospital following resolution of the reason for the outpatient visit or whether to admit the beneficiary as an inpatient. Again, as we have stated repeatedly, all hospital observation services, regardless of the duration of the observation care, that are medically reasonable and necessary are covered by Medicare, and hospitals receive either packaged or separate OPPS payment for these covered observation services. Similar to CY 2006, in calculation of the CY 2007 median cost for APC 0339, we used all claims for G0244 (Observation care provided by a facility to a patient with CHF, chest pain, or asthma, minimum eight hours), the HCPCS code that hospitals used in CY 2005 to report hour of separately payable observation under the circumstances described by the code. Because this code was only to be reported for observation care that spanned a minimum of 8 hours, we used all claims for G0244 in our median cost calculation for APC 0339 for CY 2007, regardless of the number of units of G0244 reported. As we stated in Program Transmittal A-02-129 released in January 2003, we 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 applicable ICD-9-CM codes for separate payment for observation services under the CY 2007 OPPS are listed in Table 44 below. 
 
  
 
  
 
 XII. 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. Changes to the Inpatient List For the 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. Prior to publishing the CY 2007 OPPS proposed rule, we had not received any 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 six procedures. For CY 2007, we ultimately proposed to remove a total of eight procedures from the inpatient list. 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), in the CY 2007 proposed rule we solicited comments from all interested parties consistent with meeting our obligation to the public regarding outpatient services provided by hospitals. During the APC Panel meeting in August 2006, a presenter requested that the Panel recommend to CMS removal of 10 procedures from the inpatient list for CY 2007, in addition to those presented in the proposed rule. The 10 procedure codes and their descriptors are displayed in Table 45 below. The APC Panel recommended that CMS remove the procedures from the inpatient list and assign them to appropriate clinical APCs for payment beginning in CY 2007, including considering their assignment to APCs for female reproductive procedures such as APCs 0194 (Level VIII Female Reproductive Proc), 0195 (Level IX Female Reproductive Proc), and 0202 (Level X Female Reproductive Proc). Table 45.—Additional Procedures Recommended by the APC Panel for Removal From the Inpatient List for CY 2007
HCPCS 
                                 Code
Long Descriptor57282
Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus).57283
Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy).58260
Vaginal hysterectromy, for uterus 250 grams or less.58262
Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s).58263
Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of enterocele.58270
Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele.58290
Vaginal hysterectomy, for uterus greater than 250 grams.58291
Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s).58292
Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s), with repair of enterocele.( print page 68155)58294
Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele.
 We received numerous comments on our inpatient list proposal for the CY 2007 OPPS. A summary of the public comments and our responses follow: *Comment:*
                         Several commenters supported the APC Panel's recommendation made during its August 2006 meeting to remove the 10 procedures listed in Table 45 above. *Response:*
                         Although the most recent physician utilization data indicate that the procedures are performed on an inpatient basis 80 to 95 percent of the time, most of them have low volumes. We agree with the presenter and the APC Panel that they are performed predominantly for the younger women in our beneficiary population and, therefore, we believe they may be safely performed in the outpatient department. Therefore, we are removing the procedures as listed in Table 45 above from the OPPS inpatient list and assigning them to appropriate clinical APCs for CY 2007 as noted in Table 46 of this final rule with comment period. *Comment:*
                         Many commenters recommended elimination of the inpatient list altogether. Some of the commenters suggested that CMS rely on the Quality Improvement Organizations (QIOs) to handle issues related to care provided in inappropriate settings instead of maintaining the inpatient list, and all of the commenters believed that the decision to admit a beneficiary to the hospital should be left to the physician. They explained that the inpatient list causes confusion for hospitals when they are trying to make decisions about the medical necessity of admission for beneficiaries. In addition, the commenters suggested that, if CMS does not eliminate the list, CMS should post the inpatient list and an explanation of its purpose on CMS' Web page for physicians and carriers, and that CMS present that same educational information during the Physician Open Door Forum. Further, a number of the commenters suggested that CMS consider implementing an appeals process to allow providers to submit documentation about physician intent, patient clinical condition, and the circumstances that allowed the patient to be sent home safely without an inpatient admission after payment has been denied because the procedure performed in the outpatient department was on the inpatient list. *Response:*
                         We appreciate these comments and thoughtful suggestions. We continue to believe that the inpatient list is a valuable tool that is appropriate for the OPPS, and we will not eliminate it at this time. We believe there are many surgical procedures that are never safely performed for typical Medicare beneficiaries in the hospital outpatient setting, so that it would be inappropriate for us to assign them separately payable status indicators and establish payment rates in the OPPS. However, we welcome the commenters' suggestions to provide more education to physicians about the list and its purpose. We intend to put those suggestions into practice. However, we will not implement an appeals process at this time. *Comment:*
                         One commenter recommended that CMS not remove CPT code 22851 (Application of intervertebral biomechanical device(s)(eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace), 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar), or 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment) from the inpatient list. The commenter stated that CPT code 22851 should not be removed as CMS proposed because the primary procedures with which it is performed (CPT codes 22325 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; lumbar); 22326 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; cervical); and 22327 (Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; thoracic) are still on the inpatient list. The commenters believed that, even though CPT codes 22612 and 22614 were removed from the list in 2003, they should be put back on the inpatient list because the autologous and allograft bone graft procedures with which they are provided are still on the inpatient list. *Response:*
                         We proposed to remove CPT code 22851 because we believed that it was being performed safely in the outpatient setting. CPT code 22851 is not used exclusively with the CPT codes cited by the commenter. In fact, in our consultation with physician experts, we found that it is being performed safely in the outpatient setting, but not with the procedures that are on the inpatient list. We are confident after our additional medical consultation that proposing to remove CPT code 22851 from the inpatient list was appropriate. Therefore, we are finalizing our proposal, without modification, to remove CPT code 22851 from the inpatient list for CY 2007. We have received no comments prior to this year requesting that we put CPT codes 22612 and 22614 back on the inpatient list. Both of the procedures are performed 99 percent of the time in the inpatient setting, even though they are no longer on the inpatient list. We have a small number of outpatient hospital claims for both CPT codes from CY 2005. We have not seen significant growth in the outpatient performance of these procedures since they were removed the inpatient list several years ago. This is consistent with our belief that these procedures are being performed in the most appropriate setting, and we see no reason to reassign them to the inpatient list. Therefore, we are finalizing our proposal without modification and are not adding CPT codes 22612 and 22614 to the inpatient list for CY 2007. *Comment:*
                         One commenter requested that CMS not finalize the proposal to remove CPT code 61720 (Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus). The commenter stated that they have received feedback from physicians that it would not be clinically appropriate to perform the procedure in an outpatient setting. The commenter stated that requiring at least an overnight stay is the standard of care for the procedure. The commenter noted that the APC Panel recommended that CMS consult with the relevant specialty society to confirm 
                        ( print page 68156)
                        the appropriateness of removing the code from the inpatient list and stated that it was not clear in the proposed rule whether that confirmation was made. *Response:*
                         In our proposed rule, we clearly stated that we were interested in comments from the public on our proposals to remove codes from the inpatient list. We also stated that our solicitation of comments from the public includes physician specialty societies. Further, we explained that rather than solicit approval from a select group (physician specialty societies), we believed that solicitation of comments from interested parties was more consistent with meeting our obligation to the public. We note that aside from this one comment, we received no other responses to our proposal. We would have expected that the physicians who were concerned enough about our proposed removal of CPT code 61720 from the inpatient list that they discussed it with the commenter would have conveyed their concerns directly to us as well. Thus, we have no other information outside of the commenter's assertion to confirm this procedure requires an inpatient stay. The procedure coded as CPT code 61720 is performed only 26 percent of the time in the inpatient setting. We continue to believe that removing the procedure from the inpatient list is appropriate, and we are finalizing our proposal to do so, without modification. *Comment:*
                         One commenter requested that CMS remove three additional procedures, CPT code 37182 (Insertion of transvenous intrahepatic portosystemic shunt(s)(TIPS)(includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation)); 45563 (Exploration, repair, and presacral drainage for rectal injury; with colostomy); and 61624 (Transcatheter permanent occlusion or embolization (eg, tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord)) from the inpatient list. The commenter provided no rationale for requesting the removal of those procedures. *Response:*
                         The utilization data for these codes show that all of them are performed more than 80 percent of the time on an inpatient basis. While we first removed the CPT code for the revision TIPS procedure (CPT code 37183) from the inpatient list for CY 2006, our decision was based, in part, on a recommendation of the APC Panel to do so. We will be following OPPS claims data for that procedure based upon its newly payable status under the OPPS. However, without specific clinical evidence that the initial TIPS procedure and the other procedures recommended by the commenter may be safely performed in the hospital outpatient setting, we believe that it is appropriate to retain those procedures on the inpatient list. Therefore, we are finalizing our CY 2007 proposal, without modification, to retain these three services on the inpatient list. *Comment:*
                         One commenter requested that CMS remove two procedures, CPT codes 60502 ( Parathyroidectomy or exploration of thyroid(s); re-exploration) and 60520 (Thymectomy, partial or total; transcervical approach), from the OPPS inpatient list. The commenter stated that those procedures are often performed in the same operative session with CPT code 60500 (Parathyroidectomy or exploration of thyroid(s)), which is not included on the inpatient list. The commenter believed that the two procedures (CPT codes 60502 and 60520) may be safely performed in the hospital outpatient department and should be removed from the inpatient list. *Response:*
                         We reviewed the outpatient hospital claims data and Part B physician bill data for CPT codes 60502 and 60520. According to the Part B bill data, CPT code 60502 was performed 43 percent of the time in the hospital outpatient setting in CY 2005, and CPT code 65020 was performed 27 percent of the time in that setting. Although there were very few single procedure claims in the OPPS data for these two procedure codes, we did find 12 single procedure claims for CPT code 60502 with a median cost of approximately $2,715. Taking into account the utilization information, hospital data, cost data, and the advice of our medical advisors, we believe that it is appropriate to remove the two procedures from the inpatient list. Therefore, for CY 2007 we will assign CPT codes 60502 and 60520 to APC 0256 (Level V ENT Procedures), the same APC to which CPT code 60500 is assigned. We will monitor utilization and evaluate the assignments of these codes to APC 0256 as data become available to us (in time for the CY 2009 proposed rule) and as we do for all procedures after making changes in their APC assignments. Consistent with our CY 2007 proposal, the utilization data and clinical review findings for the eight procedures support our removal of them from the inpatient list. We also are accepting the APC Panel's recommendation regarding the removal of 10 additional procedures from the inpatient list for CY 2007 and the public comment requests that we remove 2 other procedures. Therefore, we are removing a total of 20 procedures from the inpatient list and assigning them to clinically appropriate APCs, as shown in Table 46. The changes to the inpatient list will be effective for services furnished on or after January 1, 2007. Table 46.—Procedure Codes Removed From Inpatient List and New APC Assignments, Effective January 1, 2007
HCPCS 
                                 code
Long Descriptor
CY 2007 
                                 APC  
                                 Assignment
CY 2007 
                                 Status 
                                 Indicator16035
Escharotomy; initial incision
0016
T21181
Reconstruction by contouring of benign tumor of cranial bones, extracranial
0254
T22851
Apply spine prosth device
0049
T57282
Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
0202
T57283
Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
0202
T57292
Construction of artificial vagina; with graft
0195
T57335
Vaginoplasty for intersex state
0195
T58260
Vaginal hysterectromy, for uterus 250 grams or less
0195
T( print page 68157)58262
Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)
0195
T58263
Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
0195
T58270
Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele
0195
T58290
Vaginal hysterectomy, for uterus greater than 250 grams
0202
T58291
Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)
0202
T58292
Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s), with repair of enterocele
0202
T58294
Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele.
0202
T60502
Parathyroidectomy or exploration of thyroid(s); re-exploration
0256
T60520
Thymectomy, partial or total; transcervical approach
0256
T61720
Creation of lesion by stereotactic method, including burr holes and localizing and recording techniques, single of multiple stages; globus pallidus or thalamus
0221
T62000
Elevation of depressed skull fracture; simple extradural
0254
T64804
Sympathectomy, cervicothoracic
0220
T
 C. CY 2007 Payment for Ancillary Outpatient Services When Patient Expires (-CA Modifier) 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 available for the CY 2007 proposed rule revealed a decrease in the use of modifier -CA in comparison with CY 2004 claims. In the final CY 2005 data available for this final rule with comment period, there were 260 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 
                        ( print page 68158)
                        in the number of OPPS claims reporting the modifier and in light of the growth in outpatient claims overall, it is encouraging that the level of claims with -CA modifier decreased compared to CY 2004. 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 note that not only was there no increase in the number of claims reporting modifier -CA in CY 2005, but there were also 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. Policy for CY 2007 In the CY 2007 OPPS proposed rule (71 FR 49622), we did 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, as we proposed, we are specifying 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 will 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 was $3,539, significantly increased from the $2,527 median cost in the CY 2006 proposed rule and the CY 2006 final median cost of $2,717. The CY 2007 final APC 0375 median cost is $3,549. This variation in median costs 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. Such cost variation for APC 0375 from year to year is generally anticipated and accepted because APC 0375 is unique in the OPPS and, by its definition, should always be limited in its use. We did not receive any public comments on our proposed payment policy for ancillary outpatient services when a patient expires. Therefore, we are finalizing our proposal without modification for CY 2007. XIII. Nonrecurring Policy Changes A. Removal of Comprehensive Outpatient Rehabilitation Facility (CORF) Services From the List of Services Paid Under the OPPS In the CY 2007 OPPS proposed rule (71 FR 49623), we proposed 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 Public Law 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 MPFS for payments to CORFs. We have not required CORF cost reports, or paid CORFs under the OPPS, since 2001. The 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. We did not receive any public comments on this issue. Therefore, we are adopting as final, without modification, the technical change to § 419.21(d) to remove from the list of services paid under the OPPS certain services furnished by a CORF when they are provided outside the patient's plan of care (for example, hepatitis B vaccine). B. Addition of Ultrasound Screening for Abdominal Aortic Aneurysms (AAAs) (Section 5112 of Public Law 109-171 (DRA)) 1. Background Section 5112 of the Deficit Reduction Act of 2005, Public Law 109-171 (DRA), amended section 1861 and related provisions of the Act to provide for coverage under Medicare 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 final rule governing this new Part B coverage is being established through a separate document, specifically the CY 2007 Medicare Physician Fee Schedule final rule. We refer readers to that document for a full and complete explanation of this coverage provision. 2. Assignment of New HCPCS Code and Payment for Ultrasound Screening for AAAs When we published the CY 2007 OPPS proposed rule, there was no current CPT code that specifically described an ultrasound screening for AAA. In that same rule, we proposed to establish the following 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. In this final rule with comment period, we are assigning HCPCS code G0389 (Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening) to be reported on or after January 1, 2007, to describe an ultrasound screening test for AAA. 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 noted previously that ultrasound screening for AAA is also addressed in detail in our final rule to update the MPFS for CY 2007. We are responding to all comments regarding the 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 CY 2007 MPFS final rule. In the CY 2007 OPPS proposed rule, we proposed that payment for this service be made at the same level as CPT code 76775 (Ultrasound, retroperitoneal (eg, renal aorta modes), B-scan and/or real time with image documentation; limited). We received several comments on this payment proposal. In particular, the commenters supported the payment assignment of HCPCS code G0389. The commenters agreed that the hospital costs associated with the screening study described by HCPCS code G0389 are very similar to those of the limited retroperitoneal ultrasound diagnostic 
                        ( print page 68159)
                        examination, which is described by CPT code 76775. Therefore, in this final rule with comment period, we are finalizing this assignment for CY 2007. That is, we are basing the CY 2007 payment for HCPCS code G0389 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, the screening and diagnostic studies should be assigned to the same clinical APC for reasons of clinical and resource homogeneity. Thus, we are assigning G0389 to APC 0266 with a median cost of $95.37 for CY 2007. Consistent with the statute, no Medicare beneficiary deductible will be applied to payment for this AAA screening service. XIV. Emergency Medical Screening in Critical Access Hospitals (CAHs) 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 
                        **Federal Register**
                         on September 9, 2003 (68 FR 53262). In response to this request, in the proposed rule published in the 
                        **Federal Register**
                         on August 23, 2006 (71 FR 49623), we proposed to revise the current CAH CoPs to align the emergency medical screening requirements in CAHs with those applicable to acute care hospitals. We proposed to 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 nonphysician 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 nonemergent 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 a 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. Therefore, under this CAH CoP, these are the only CAH personnel who are currently permitted to conduct an appropriate medical screening to determine that an individual, who presents in the manner described above, does not have an emergency medical condition (as required 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 and that there must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. 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 proposed 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 for medical care is within the registered nurse's scope of practice and is consistent with applicable State laws. 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 
                        ( print page 68160)
                        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 wished to provide flexibility to CAHs and to be consistent with existing EMTALA policy, we proposed the revision to the regulation at § 485.618(d). C. Public Comments Received on the Proposal We received 12 comments on our proposal. Our response follows each comment summary. *Comment:*
                         All of the commenters supported the proposed revision of the current CoP to allow registered nurses with training and experience in emergency care to conduct specific medical screening examinations under certain provisions. Several of the commenters commended CMS for proposing a rule change that would afford CAHs the staffing flexibility needed to maintain access and to provide efficient emergency and urgent care services for their patients. *Response:*
                         We appreciate the support of the provider community and believe that this revision to the current CoP will most likely decrease the regulatory burden for CAHs by allowing them greater staffing flexibility. *Comment:*
                         Several commenters pointed out an inconsistency between the preamble language in the proposed rule, which notes that medical screening examinations by a registered nurse would be allowed only if such screenings were permitted by the CAH's bylaws, and the proposed regulation text, which does not mention the bylaws. *Response:*
                         We appreciate the commenters bringing this inadvertent omission to our attention. We are revising the regulatory text at § 485.618(d)(2)(ii) in this final rule to indicate that the nature of a patient's request for medical care must be within the scope of practice and consistent with applicable State laws and the CAH's bylaws or rules and regulations in order for a registered nurse to conduct a medical screening examination. This revision to the language is also consistent with the EMTALA regulations at § 489.24(a)(1)(i), which refer to hospital “bylaws or rules and regulations.” *Comment:*
                         One commenter questioned the impact that this change may have on payment and encouraged CMS to ensure that it does not adversely affect the payment that CAHs receive for screening services. *Response:*
                         The change being made affects only the CAH CoPs and does not revise the CAH payment regulations, which are codifed at 42 CFR 413.70. *Comment:*
                         One commenter noted that, in the FY 2007 IPPS proposed rule for EMTALA false labor certifications, care roles and responsibilities were to be documented in the “the medical staff bylaws or rules and regulations,” while under the FY 2007 IPPS final rule, these roles and responsibilities are to be documented in “medical staff bylaws.” The commenter requested a clarification on this issue due to concern that the final rule imposed a more restrictive requirement than was proposed by limiting documentation to the bylaws only. *Response:*
                         The FY 2007 final IPPS rule is outside the scope of this rule and cannot be addressed here. We will address this comment in a future document. D. Final Policy After consideration of the public comments received on the proposed rule, we are adopting the proposed change to § 485.618(d), with minor modifications, to allow a CAH, if applicable, the flexibility of utilizing a registered nurse, with training and experience in emergency care, to conduct specific medical screening examinations only if the registered nurse is on site and immediately available at the CAH when a patient requests medical care and if the nature of the individual's request is within the registered nurse's scope of practice and consistent with applicable State laws and the CAH's bylaws or rules and regulations. As noted above, we have revised the regulatory text to include language regarding the CAH's bylaws, rules, and regulations. The revised regulatory text is now consistent with the preamble language contained in both the proposed rule and this final rule, and with the language in the EMTALA regulations at § 489.24(a). XV. OPPS Payment Status and Comment Indicators A. CY 2007 Status Indicator Definitions 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 CY 2007 final status indicator assignments for APCs and HCPCS codes are shown in Addendum A and Addendum B, respectively. We are using the status indicators and definitions that are listed in Addendum D1, which we discuss below in greater detail. 1. Payment Status Indicators To Designate Services That Are Paid Under the OPPS The table of proposed status indicators in section XV. of the proposed rule (71 FR 49625) inadvertently listed radiopharmaceuticals under status indicator “H” rather than under status indicator “K.” Consistent with our CY 2007 proposed payment policy for radiopharmaceuticals (as discussed in section V.B.3.a.(3) of this preamble) and their associated status indicators as correctly listed in Addenda A and B of the CY 2007 proposed rule, the list of status indicators, the items, and their OPPS payment status descriptions are noted in the corrected table below. 
                        ( print page 68161) CY 2007 Proposed Payment Status Indicators (Corrected)
Indicator
Item/code/service
OPPS payment statusG
Pass-Through Drugs and Biologicals
Paid under OPPS; Separate APC payment includes pass-through amount.H
Pass-Through Device Categories
Separate cost-based pass-through payment; Not subject to coinsurance.K
(1) Non-Pass-Through Drugs, 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.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. Payment Status Indicators To Designate Services That Are Paid Under a Payment System Other Than the OPPS Indicator
Item/code/service
OPPS payment statusA
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 
                                 • 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
Not paid under OPPS. Paid by fiscal intermediaries under a fee schedule or payment system other than OPPS.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. Payment Status Indicators To Designate Services That Are Not Recognized Under the OPPS But That May Be Recognized by Other Institutional Providers 
                        ( print page 68162) Indicator
Item/code/service
OPPS payment statusB
Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and13x).
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 and13x) may be available.
 4. Payment Status Indicators To Designate Services That Are Not Payable by Medicare Indicator
Item/code/service
OPPS payment statusD
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 
                                 •  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
Not paid under OPPS or any other Medicare payment system.
 We received several public comments regarding our general use of status indicators. *Comment:*
                         Some commenters suggested that each status indicator definition should be “pure” and have only one meaning. Specifically, they recommended that the current OPPS status indicator “B” be split into two different status indicators, with descriptions that uniquely reflect the two situations in which “B” is currently assigned. In CY 2006, the assignment of status indicator “B,” which identifies codes that are not recognized by the OPPS when submitted on an outpatient hospital Part B bill type (12X and 13X), reflects two possible reasons for its assignment to any specific HCPCS code: (1) Not paid under OPPS but may be paid by intermediaries when submitted on a different bill type, for example 75X (CORF); or (2) Not paid under OPPS but an alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12X and 13X) may be available. The commenters recommended that CMS continue to assign status indicator “B” to codes not paid under the OPPS for the first reason and develop new status indicator “Z” for assignment to codes not recognized for the second reason. The commenters also recommended that CMS publish a separate addendum as part of the OPPS rule that lists the alternative HCPCS Level II codes for the OPPS that should be used for all codes that were assigned the suggested new status indicator “Z.” *Response:*
                         The OPPS has no operational need to split the definition of status indicator “B” and to establish a new status indicator “Z” as suggested by the commenters. As discussed previously, our status indicators exist for purposes of assisting in determining payment, and a single status indicator “B” is sufficient for both circumstances when codes may be paid by intermediaries when submitted on a different bill type but would not be paid under the OPPS or an alternate code might be recognized under the OPPS. In either situation, there is no payment effect that would require the differential use of two separate status indicators. There are currently 19 different status indicators in Addendum B that are used to indicate whether a service described by a HCPCS code is payable under the OPPS or another payment system and whether particular OPPS payment policies apply to the code. Two new status indicators, “M” and “Q,” were established in CY 2006 for purposes of identifying the OPPS payment status of certain HCPCS codes. We believe that only a limited number of status indicators in the OPPS are needed to convey the necessary payment-related information, and that additional indicators should only be created at this point when policy necessitates further refinements in this area. We also believe that with 19 status indicators for CY 2007, the set of indicators is appropriately specific, while maintaining the administrative simplicity associated with a modest number of status indicators. We are unable to develop and publish an addendum that lists the alternative codes that should be used for payment under the OPPS when a HCPCS code is not recognized under the OPPS because an alternate code may be available. Although the commenters suggested that alternative codes are Level II HCPCS codes, in some cases alternate codes are CPT codes that describe specific portions of a service. In other cases, there may be multiple alternative codes that could be used to report complete services or portions of services that were provided, and we have no way to determine in any given situation the specific services a hospital provided for which an alternative code or codes might be available. Therefore, we believe that it is appropriate for hospitals that provide a specific service to determine, in situations where they believe a HCPCS code with a status indicator of “B” would be their choice for reporting, whether that code could be reported on a different bill type and be paid, and, if not, determine if the service provided may be correctly reported with one or more other HCPCS codes that are recognized for payment under the OPPS. For some HCPCS codes not recognized under the OPPS, the determination of an appropriate alternate code or codes is straightforward, and we believe 
                        ( print page 68163)
                        hospitals have already developed such crosswalks for their own use based on the services they provide. *Comment:*
                         One commenter stated that the community supported the CMS proposal to continue paying for the acquisition of corneal tissue as status indicator “F” as an item or service not paid under OPPS and paid at reasonable cost. The commenter believed that the adoption and implementation of an appropriate payment policy for the acquisition of corneal tissue for procedures provided in a hospital outpatient department setting was absolutely vital to the eye banking system, a network that was established for the single purpose of procuring and providing donated human eye tissue for sight restoring transplantation procedures. *Response:*
                         We appreciate the commenter's support. We are finalizing our status indicator definitions to be consistent with the final CY 2007 OPPS payment policies. Because separately payable radiopharmaceuticals will continue to be paid on a cost-based methodology in CY 2007 as discussed in section V.B.3.a.(3) of this preamble, we will continue to assign them to status indicator “H” as indicated in the table set forth below and in Addendum D1 of this final rule with comment period, rather than to status indicator “K” as proposed. We also note we are finalizing our proposed description of status indicator “K” to include brachytherapy sources because, as discussed in section VII.B. of this final rule with comment period, these sources will be paid based on payment rates through brachytherapy source-specific APCs in CY 2007. CY 2007 Final Payment Status Indicators To Designate Services That Are Paid Under the OPPS
Indicator
Item/code/service
OPPS payment statusG
Pass-Through Drugs and Bio­log­icals
Paid under OPPS; Separate APC payment includes pass-through 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.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.(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.
 To make the published Addendum B more relevant to the update of the OPPS, we are displaying in Addendum B of this final rule with comment period those HCPCS codes that describe items or services that are payable under the OPPS, as well as nonpayable codes for which we are making a final change in status for CY 2007. The final status indicators for items and services that are paid under the OPPS are listed in the table above. A complete listing of HCPCS codes with final OPPS payment status indicators and APC assignments for CY 2007 is available electronically on the CMS Web site 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​HORD/​list.asp#TopOfPage.* B. CY 2007 Comment Indicator Definitions In the November 15, 2004 final rule with comment period (69 FR 65827 and 65828), we made final our policy to use two 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 would be accepted. These two comment indicators are listed below. “NF”—New code, final APC assignment; comments were accepted on a proposed APC assignment in the proposed pule; 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, with the final CY 2007 definition as listed below: “CH”—Active HCPCS code in current and next calendar year; status indicator and/or APC assignment has changed; or active HCPCS code that is discontinued at the end of the current calendar year. 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 generally were previously subject to comment during the proposed rule comment period. As we proposed, we are continuing that policy in this CY 2007 OPPS final rule with comment period. 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 using the “CH” indicator in this CY 2007 final rule with comment period to indicate HCPCS codes for which the status indicator and/or APC assignment will change in CY 2007 and to indicate HCPCS codes that are discontinued at the end of the current calendar year. However, only HCPCS codes with 
                        ( print page 68164)
                        comment indicator “NI” in this CY 2007 OPPS final rule with comment period will be subject to comment during the comment period for this final rule with comment period. In the proposed rule, we used the “CH” indicator to call attention to changes in payment status indicators and/or APC assignments in the proposed rule to update the OPPS for CY 2007. We believed that using the “CH” indicator in the proposed rule facilitated the public's review of the changes that we proposed to make final in CY 2007. Use of the “CH” indicator in the proposed rule was significant because it highlighted changes that were subject to comment during the proposed rule comment period. The three comment indicators that we are implementing in CY 2007 and their definitions are listed in Addendum D2 of this final rule with comment period. We received several public comments regarding the use of the proposed CY 2007 comment indicators. *Comment:*
                         Several commenters recommended that the comment indicator “CH” be limited to only a single change. Currently, “CH” is assigned to indicate one of two possible changes. It can signify that the HCPCS code has had a status indicator change, and it can also indicate that the HCPCS code has had an APC reassignment. The commenters argued that limiting “CH” to a single change would readily facilitate the identification of the HCPCS code changes and would minimize the need for visual comparison of two separate Addendum B files to determine what has actually changed. *Response:*
                         The designation of HCPCS codes with comment indicator “CH” is a new process that we initiated in the CY 2006 OPPS final rule to facilitate the public's review of changes that were proposed or finalized from one calendar year to another. We believe the specific reasoning behind the change is not necessary, as our intent is to merely flag the changes from our proposed rule to our final rule. We appreciate the comment and will consider possible refinements to comment indicators in the future that could assist the public in recognizing and identifying proposed and final changes to OPPS payment policies regarding specific items and services of interest. *Comment:*
                         Several commenters asked CMS to clarify the use of status indicator “NI” and the length of time allowed for public comment regarding HCPCS codes with comment indicator “NI.” They also asked at exactly what point in time the “NI” designation would be removed. *Response:*
                         Comment indicator “NI” flags HCPCS codes that are new for the CY 2007 OPPS final rule with comment period and that did not appear in the CY 2007 OPPS proposed rule. Codes with comment indicator “NI” in Addendum B are open to comment in this CY 2007 final rule with comment period. The comment period for the OPPS final rule for a specific calendar year is specified as noted in the final rule. After the close of the final rule comment period, “NI” has no relevance, and it would not be applied to the same HCPCS codes for the next OPPS update year. The “NI” comment indicator is not used in the OPPS proposed rule because the status indicators and APC assignments of all HCPCS codes that appear in the proposed rule are open for public comment. After carefully considering the public comments received, we are implementing the comment indicators as proposed for CY 2007, with modification to the definition of comment indicator “CH” to include active HCPCS codes that are discontinued at the end of the current calendar year. XVI. OPPS Policy and Payment Recommendations 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 of the MedPAC recommendation regarding updates to the market basket was included in section II.C. (“OPPS Conversion Factor Update for 2007”) of the proposed rule (71 FR 49539). There have been no subsequent MedPAC recommendations with regard to Medicare payment under the OPPS. B. APC Panel Recommendations Recommendations made by the APC Panel at its March and August 2006 meetings 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_​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp*. The APC Panel met on August 23-24, 2006 to discuss the CY 2007 OPPS proposed rule and to hear testimony from concerned members of the public. The minutes of the meeting are available at: 
                        *http://www.cms.hhs.gov/​FACA/​05_​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage*. 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”) was contained in section V.3.B.a. of the CY 2007 OPPS proposed rule (71 FR 49584). The letter is referenced in section V.B. of this final rule with comment. 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) was contained in section V.3.B.a. of the CY 2007 OPPS proposed rule (71 FR 49584). The report is referenced in section V.B. of this final rule with comment period. A discussion of the July 26, 2006 GAO report entitled “Medicare Outpatient Payments: Rates for Certain Radioactive Sources Used in Brachytherapy Could be Set Prospectively” (GAO 06-635) is contained in section VII.B. of this final rule with comment period. These GAO reports are available for review in their entirety at: 
                        *http://www.GAO.gov*. XVII. 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 that are performed in an ambulatory surgical center (ASC). To participate in the Medicare program as an ASC, a 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. 
                        ( print page 68165) 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 Public Law 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. In section XVIII. of the CY 2007 OPPS proposed rule (71 FR 49635), we set forth our proposal for a revised ASC payment system that would be implemented on January 1, 2008. We are in the process of receiving and analyzing public comments on this proposal and we expect to issue a separate final rule for the revised ASC payment system sometime in the spring of 2007 to be effective January 1, 2008. Section 5103 of Public Law 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.B. of this preamble additions to and deletions from the list of Medicare-approved ASC procedures to be implemented January 1, 2007, prior to implementation of the revised ASC payment system. In section XVII.C. of this preamble, we discuss the regulatory changes that we are making for our current ASC payment system. In section XVII.D. of this preamble, we address the provisions of sections 1834(d)(2) and (d)(3) of the Act regarding payment amounts and beneficiary coinsurance amounts for screening flexible sigmoidoscopy and screening colonoscopy. In section XVII.E. of this preamble, we address the changes in payment to ASCs mandated by section 5103 of Public Law 109-171. In addition, in section XVII.F. of this preamble, we are making changes in the process to review payment adjustments for insertion of new technology intraocular lenses (NTIOLs). In section XVII.G. of this preamble, we announce the CY 2007 deadline for submitting requests for CMS review of appropriateness of ASC payment for insertion following cataract surgery of an NTIOL. In section XVIII. of the preamble of the CY 2007 OPPS proposed rule (71 FR 49635), we proposed 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 will be addressing the public comments received and implementing the revised ASC payment system in a separate final rule that we expect to be published separately in 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 MPFS. In the proposed rule and in this final rule with comment period, we address the second element, the payment of facility fees for ASC services. We also address the coverage of ASC services in the proposed rule and in this final rule with comment period. 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), Public Law 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 Public Law 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. Except for screening flexible sigmoidoscopy and screening colonoscopy services, 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, Public Law 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 new technology IOLs (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 the preamble of this final rule with comment period, we discuss the changes that we are making 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), Public Law 106-113, and the Medicare, Medicaid, and SCHIP Benefits Improvement and 
                        ( print page 68166)
                        Protection Act of 2000 (BIPA), Public Law 106-554. Readers may refer to the March 28, 2003 ASC List Update final rule (68 FR 15268-69) 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 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 to CPT and HCPCS coding changes was published in Transmittal R-720-CP, Change Request 4082, on October 21, 2005. The transmittal may be found on our Web site at: 
                        *http://www.cms.hhs.gov/​Transmittals/​*. B. 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. Our medical staff reviewed the recommended additions to the list, in consultation with other specialist physicians and medical organizations, as appropriate, 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 hospital inpatient, hospital outpatient, and ASC site-of-service 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. In the CY 2007 OPPS proposed rule, we did not propose changes to the criteria for adding or deleting items from the ASC list effective January 1, 2007. However, in section XVIII.B. of the proposed rule, we did discuss 
                        ( print page 68167)
                        proposed changes in the context of developing a revised ASC payment system to be effective January 1, 2008. The proposed changes to the criteria would result in the addition for CY 2008 of many procedures that do not meet the current criteria for addition to the list. As we indicated earlier, we expect the final rule that will implement the revised ASC payment system effective January 1, 2008 to be published as a separate document in the spring of 2007. 2. 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. In the CY 2007 OPPS proposed rule, we did not propose any changes to those nine payment groups; and we proposed to assign the procedures to be added to the ASC list to one of those existing payment groups. The payment group to which we assign each addition to the ASC list is judged by our medical advisors to be most appropriate in terms of facility resource inputs. The list of procedures eligible for Medicare payment of a facility fee and the rates for CY 2007 are displayed in Addendum AA of this final rule with comment period. The procedures that are affected by the payment limit required by section 5103 of Public Law 109-171 are identified in that addendum along with their payment rates. 3. Response to Comments to May 4, 2005 Interim Final Rule for the ASC Update In accordance with section 1833(i)(1) of the Act, as we proposed in the CY 2007 OPPS proposed rule, we are updating the list of procedures that are covered when furnished in an ASC, effective January 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. 4. Procedures Proposed for Additions to the ASC List Using the current criteria as described in section XVII.B.1. of this preamble, we identified 14 procedures to propose for addition to the ASC list effective January 1, 2007. The procedures were assigned to one of the nine existing ASC payment groups as indicated in Table 41 of the 2007 OPPS proposed rule (71 FR 49629), set out below as Table 47-A. Table 47-A.—Procedures Proposed for Addition to the ASC List Effective January 1, 2007
CPT
Short descriptor
ASC payment group13102
Repair wound/lesion add-on
113122
Repair wound/lesion add-on
113133
Repair wound/lesion add-on
119297
Place breast cath for rad
921356
Treat cheek bone fracture
322520
Percutaneous vertebroplasty, thor
922521
Percutaneous vertebroplasty, lumb
922522
Percutaneous vertebroplasty, add'l
135476
Repair venous blockage
936818
AV fuse, upper arm, cephalic
337205
Transcath IV stent, percutaneous
937206
Transcath IV stent/perc, add'l
143761
Reposition gastrostomy tube
146946
Ligation of hemorrhoids
1
 We received many comments in support of our proposal to add the procedures displayed in Table 47-A. In addition, some commenters requested that we add other procedures, that we assign specific procedures to higher payment groups, and that we not add several of the proposed procedures to the list. 5. Specific Requests for Payment Group Changes to the Proposed ASC List of Additions *Comment:*
                         One commenter supported the proposal to add CPT code 21356 (Open treatment of depressed zygomatic arch fracture (eg, Gillies approach)) but requested that CMS assign the procedure to payment group 9 rather than group 3, as proposed. The commenter stated that the ASC costs for the procedure are $1,365, and that the group 3 payment of $510 would not nearly cover those costs. *Response:*
                         We assigned the procedure to the same payment groups as CPT code 21355 (Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation) because we believe that facility costs are similar for the two procedures. We re-examined the facility resource requirements and clinical characteristics of CPT code 21356 and remain convinced that our proposed assignment of CPT code 21356 to payment group 3 is appropriate. Therefore, we are finalizing the assignment for this procedure in payment group 3, as proposed. *Comment:*
                         A few commenters supported the proposed addition of CPT codes 22520 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic); 22521 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar); and 22522 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body) to the ASC list for CY 2007. The commenters requested that CMS assign CPT code 22522 to payment group 9 as CMS did CPT codes 22520 and 22521. They stated that, although CPT code 22522 represents an add-on procedure, it nonetheless requires a kit that costs in the range of $700 to $1,400. They stated that the facility payment for the procedure is always subject to the multiple procedure discount because it is an add-on procedure, and even the full group 1 payment would not cover those costs. *Response:*
                         We agree with the commenters' assertion that when additional kit(s) are required for performing CPT code 22522, those extra costs would not be adequately recognized by payment at the group 1 level, especially because the procedure can only be billed secondarily to another procedure, and payment will always be discounted by half due to multiple procedure discounting. For these reasons, we believe that CPT code 22522 would be more appropriately assigned to payment group 9 than to group 1 as we proposed. We are finalizing the assignment of CPT code 22522 to ASC payment group 9 for CY 2007. *Comment:*
                         Some commenters supported the proposal to add CPT code 36818 (Arteriovenous anastomosis, open; by upper arm cephalic vein transposition) to the ASC list for CY 2007 and requested that CMS assign the procedure to a higher ASC payment group than group 3 as we proposed. *Response:*
                         We proposed to assign the procedure to group 3 because that is the payment level for CPT code 36819 (Arteriovenous anastomosis, open; by upper arm basilica vein transposition). The commenter provided no evidence to 
                        ( print page 68168)
                        support assignment to a higher payment group, and we found nothing in our data to suggest that payment for CPT code 36818 should be higher than what we proposed. We believe that assignment to the same level as CPT code 36819 is appropriate and that payment at the group 3 level appropriately recognizes facility costs for the procedure. Therefore, we are finalizing our assignment of CPT code 36818 to ASC payment group 3 as proposed. *Comment:*
                         Many commenters supported the proposal to add CPT codes 37205 (Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel) and 37206 (Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; each additional vessel) to the ASC list. However, a number of commenters requested that CMS not add these CPT codes to the ASC list. These commenters stated that the procedures do not satisfy the criteria for inclusion on the ASC list because they involve major blood vessels, would exceed the 90-minute limit on operating room time, and may be associated with complications that are threatening to patient safety. *Response:*
                         We found the divergence of responses among the public comments troubling and reexamined our proposal to add these procedures to the ASC list. Although the procedures are being performed about half of the time in hospital outpatient departments (HOPDs), the other half are being performed on an inpatient basis and they virtually are never done in a physician office. As we have stated in the past, there are many procedures that may be safely performed in a hospital outpatient department that may not be safely provided in an ASC, because only the hospital outpatient department has immediate access to the full spectrum of emergency and acute care facilities of the hospital. Our medical advisors reconsidered our proposal to add CPT codes 37205 and 37206 to the ASC list and determined that it would be in the best interests of Medicare beneficiaries to continue to deny payment for them in ASC facilities. Our medical advisors believe that the procedures would require more than 4 hours of recovery time and would most often require an overnight stay in the facility. For these reasons, we are not finalizing our proposal to add CPT codes 37205 and 37206 to the ASC list for CY 2007. *Comment:*
                         Many commenters supported the proposed addition of CPT code 35476 (Transluminal balloon angioplasty, percutaneous; venous) to the ASC list for CY 2007. In general, the commenters stated that providing access to the procedure in ASCs would be a great benefit to dialysis patients who are often in need of angioplasty procedures. One commenter objected to its addition to the list on the grounds that it was a significant safety risk because the procedures described by CPT code 35476 may involve large veins, with the potential for serious complications that should be handled in the hospital setting. Some commenters were disappointed that CMS did not also propose to add CPT code 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel). They stressed the importance of our support of the Fistula First ESRD quality initiative and stated that including CPT code 35475 would provide patients with a more efficient, but equally effective, option for ensuring the maintenance of their AV fistulas for vascular access. They also stated that inclusion of both CPT codes 35475 and 35476 on the ASC list would save lives, as well as reduce Medicare expenditures because rates of patient complications and hospitalizations would be decreased. *Response:*
                         We are sympathetic to the commenters' request for the arterial code, CPT 35475, to be added to the ASC list. We did not propose to add CPT code 35475 because use of the code is not limited to procedures involving arteries in the anatomic sites used for vascular access for hemodialysis or to procedures normally performed to maintain arteriovenous (AV) fistulas. Procedures involving more proximal major arteries, and therefore that present safety concerns for performance in ASCs, are also reported by CPT code 35475, and so the code does not meet the clinical criteria for inclusion on the ASC list. Additionally, on further review, we also believe it is most clinically appropriate to not finalize our proposal to add CPT code 35476 to the ASC list. Although CPT code 35476 is used to report venous rather than arterial procedures, it is appropriately used to report many different procedures, some of which may involve major veins and that are potentially too unsafe for performance in ASCs. However, we are committed to the Fistula First end-stage renal disease quality initiative and want to improve access to needed procedural services for dialysis patients if at all possible. We believe that in order to maintain healthy vascular access sites for dialysis patients, physicians may need to perform both venous and arterial angioplasty procedures concurrently. As discussed above, we will not be adding CPT code 35475 for arterial angioplasties to the ASC list, and we are not finalizing our proposal to add CPT code 35476 for venous angioplasties to the ASC list because of safety concerns due to the broad array of vessel angioplasties that could be reported with the two codes. Instead, in order to make those angioplasty procedures for AV fistula maintenance, which could otherwise be appropriately reported with CPT codes 35475 and 35476, available for Medicare payment in ASCs, we are implementing two new HCPCS G-codes to specifically describe the arterial and venous angioplasty procedures to maintain hemodialysis access through arteriovenous fistula or grafts for dialysis patients. These codes are G0392 (Transluminal balloon angioplasty, percutaneous; hemodialysis access fistula or graft; arterial) and G0393 (Transluminal balloon angioplasty, percutaneous; hemodialysis access fistula or graft; venous). We are adding both HCPCS codes G0392 and G0393 to the ASC list for CY 2007 and are assigning them to ASC payment group 9. Table 47-B displays final decisions regarding the procedures we proposed to add to the ASC list for CY 2007. Table 47-B.—Final Additions from the Proposed Additions to the ASC List Effective January 1, 2007
CPT
Short descriptor
ASC payment group13102
Repair wound/lesion add-on
113122
Repair wound/lesion add-on
113133
Repair wound/lesion add-on
119297
Place breast cath for rad
921356
Treat cheek bone fracture
322520
Percutaneous vertebroplasty, thor
922521
Percutaneous vertebroplasty, lumb
922522
Percutaneous vertebroplasty, add'l
936818
AV fuse, upper arm, cephalic
343761
Reposition gastrostomy tube
146946
Ligation of hemorrhoids
1
 
 
 The G-codes and other additions to the list that are being made in response to comments on the proposed rule are displayed in Table 48, Additional Procedures for Addition to the ASC List for CY 2007. 6. Requests for Additions to the ASC List from Comments to the August 23, 2006 Proposed Rule a. Requests Accepted for Additions to the ASC List for CY 2007 *Comment:*
                         Many comments requested that CMS add CPT code 13153 (Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less) to the ASC list for CY 2007. The commenters supported our proposal to add CPT codes 13102 (Repair, complex, trunk; 1.1 cm to 2.5 cm); 13122 (Repair, complex, trunk; 2.6 cm to 7.5 cm); and 13133 (Repair, complex, trunk; each additional 5 cm or less) to the list, but stated that CMS also should have proposed to add CPT code 13153, which is the only code in this series of CPT codes that was not proposed to be added. They stated that CPT code 13153 is comparable to the other codes already on the list and should be assigned to group 3 with the other codes in its series, CPT codes 13150 (Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less), 13151 (Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm) and 13152 (Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm). *Response:*
                         We agree with the commenters. We examined the series of codes and found that CPT code 13153 is the only one not proposed to be on the CY 2007 list. The base code to which CPT code 13153 is an add-on code is 13150 (Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less) and is assigned to payment group 3. We agree that it is appropriate to assign CPT code 13153 to the same payment group as CPT code 13150 because the procedure can only be billed secondarily to another procedure, so payment will always be discounted by half due to multiple procedure discounting. Therefore, we are adding CPT code 13153 to the ASC list in group 3 for CY 2007. *Comment:*
                         Several commenters requested that CMS add CPT code 19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy) to the ASC list. The commenters stated that this add-on procedure is performed in conjunction with breast biopsies that are on the ASC list. They stated that it is appropriate to allow payment for this service as well. *Response:*
                         We agree with the commenters that the addition of CPT code 19295 to the list is appropriate for CY 2007. We are adding it to the list and assigning it to ASC payment group 1. We believe this procedure is important to providing high quality health care for women undergoing evaluation for possible breast cancer, often as a result of the findings from screening mammography. *Comment:*
                         One commenter requested the addition of CPT code 31620 (Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s)) to the ASC list. The commenters explained that it is an add-on procedure that is performed in conjunction with bronchoscopies that are on the ASC list, and the procedure meets all of the criteria for inclusion on the list for CY 2007. *Response:*
                         We agree with the commenter that CPT code 31620 is an appropriate procedure for payment in the ASC and are adding it to the ASC list for CY 2007 in group 1, where CPT code 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing) and other procedures with similar resource requirements are assigned. *Comment:*
                         Several commenters requested that CMS add CPT code 43257 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease) to the ASC list for CY 2007. The commenters stated that they believed that this treatment for gastroesophageal reflux disease met all the current clinical criteria for inclusion on the ASC list. *Response:*
                         We agree with the commenters that this procedure satisfies our clinical criteria for addition to the list. The utilization data indicate that the procedure is performed 95 percent of the time in the hospital outpatient department. Based on the utilization data that indicate the safety of performing the procedure in outpatient settings in addition to our medical advisors' clinical judgment that it is an appropriate procedure for performance in the ASC, we are adding CPT code 43257 to the list for CY 2007 and assigning it to payment group 3. *Comment:*
                         Several commenters requested that CMS add CPT code 57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach) to the ASC list for CY 2007 and assign it to payment group 7. The commenters stated that the procedure costs were very similar to those for CPT code 49568 (Implantation of mesh or other prosthesis for incisional or ventral hernia repair) and, because that procedure is assigned to payment group 7, CPT code 57267 should also be assigned to group 7. *Response:*
                         We agree with the commenters. Our analysis shows that this procedure may be safely performed in the outpatient setting, and that the costs are similar to those for CPT code 49568. Therefore, we are adding CPT code 57267 to the ASC list in payment group 7 for CY 2007. *Comment:*
                         One commenter requested that CMS add CPT code 61795 (Stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal) to the ASC list for CT 2007. The commenter stated that addition of this procedure to the ASC list would provide improved quality of care by providing a method that would minimize trauma and risk for secondary damage to patients during certain procedures. *Response:*
                         We agree with the commenters that this procedure is appropriate for inclusion on the ASC list. It satisfies our clinical criteria so we are adding CPT code 61795 to the list and assigning it to payment group 1 with other procedures requiring similar levels of facility resources for CY 2007. *Comment:*
                         Several commenters requested that CPT codes 0176T (Transluminal dilation of aqueous outflow canal; without retention of device or stent) and 0177T (Transluminal dilation of aqueous outflow canal; with retention of device or stent) be added to the ASC list for CY 2007 because they are similar to other surgical procedures on the eye that are frequently provided in ASCs. Commenters pointed out that much of the clinical investigation for these canaloplasty procedures was performed by surgeons in ASC settings. *Response:*
                         These CPT codes were released by the AMA on July 1, 2006 for implementation on January 1, 2007. We agree with the commenters that they are appropriate for addition to the ASC list and, based on the expected facility costs of the procedures and the associated single use devices, appropriately assigned to payment group 9 for CY 2007. Therefore, we will add these two procedures to the ASC list for CY 2007. As discussed above, we determined that there are 10 procedures about which we received comments that met the criteria for inclusion on the ASC list for CY 2007 but that we did not propose 
                        ( print page 68170)
                        to add to the ASC list. We are adding those procedures and assigning them to ASC payment groups as indicated in Table 48. Table 48.—Additional Procedures for Addition to the ASC List for CY 2007
HCPCS
Short descriptor
Payment group13153
Repair wound/lesion add-on
319295
Place breast clip, percut
131620
Endobronchial us add-on
143257
Upper gi scope w/thrml txmnt
357267
Insert mesh/pelvic flr add-on
761795
Brain surgery using computer
1G0392
AV fistula or graft arterial
9G0393
AV fistula or graft venous
90176T
Aqu canal dilat w/o retent
90177T
Acq canal dilat w retent
9
 b. Requests Not Accepted for Additions to the ASC List for CY 2007 There were a number of procedures for which we received requests for addition to the ASC list that we are not adding to the ASC list because they do not meet the criteria set forth in the regulations as § 416.65. Those procedures are listed in Tables 50 and 51 below. Our data indicate that the procedures listed in Table 49 are performed predominantly in physician offices and are therefore, not eligible for inclusion on the ASC list for CY 2007. Table 49 includes 13 of the procedures we proposed not to add to the ASC list because they are furnished predominantly in the physician office setting, as well as an additional 22 procedures that are performed predominantly in physician offices that commenters to the proposed rule requested we add for CY 2007. One of the procedures on the list in the proposed rule, CPT code 31040 (Exploration behind jaw) is also not being added to the list for CY 2007. It is included in Table 50 rather than in Table 49 below, because it is excluded for not meeting our clinical criteria. Table 49.—Procedures Not Added to CY 2007 ASC List Because They Are Predominantly Performed in the Physician's Office
CPT
Short descriptor11603
Exc tr-ext mlg+marg 2.1-3 cm.20610
Drain/inject, joint/bursa.28124
Partial removal of toe.40812
Excise/repair mouth lesion.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.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.64505
N block, spenopalatine gangl.64508
N block, carotid sinus s/p.64555
Implant neuroelectrodes.64612
Destroy nerve, face muscle.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.
 *Comment:*
                         Many commenters indicated that CMS should remove the criterion that procedures performed predominantly in the physician's office are not eligible for inclusion on the ASC list for CY 2007 and, specifically, that CMS add CPT code 45330 (Diagnostic sigmoidoscopy) to the ASC list for CY 2007. *Response:*
                         The current criteria were used to make decisions regarding inclusion on the CY 2007 ASC list. We did not propose to alter these criteria prior to implementation of the revised payment system, as proposed for CY 2008. Although we proposed to allow procedures predominantly performed in physician offices to be paid under the revised ASC payment system, we will not make final any proposed changes to the criteria for the revised system until we have considered the public comments to that proposal. The comment period will not close for that proposal until after this final rule with comment period has been published. Therefore, for CY 2007, we will continue to adhere to the current criteria for inclusion on the list and will not add procedures that are provided predominantly in the physician office setting to the list. Procedures that are displayed in Table 49 above include office-based procedures recommended for addition to the ASC list by commenters to the CY 2007 OPPS proposed rule. Procedures that are predominately office-based do not meet our criteria for inclusion on the ASC list. Thus, we are finalizing our proposal to not include on the ASC list any of the services performed predominantly in physician offices as displayed in Table 49. In the CY 2007 OPPS proposed rule, we indicated that we were not proposing to add to the ASC list 14 procedures for which we received requests for addition because our medical advisors believe that those procedures do not meet the clinical criteria (§ 416.65) for addition. Our medical advisors believed that the procedures listed in Table 43 of the CY 2007 OPPS proposed rule (71 FR 49629) are of a type that: 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 life-threatening; or
                    Are of a type that result in extensive blood loss. These characteristics make procedures ineligible for addition to the list of ASC procedures. The 14 procedures that we proposed to not be added to the list based on clinical criteria, as well as additional procedures for which we received requests in comments to the August 23, 2006 proposed rule that did not meet the criteria, are displayed below in Table 50. Table 50.—Procedures Not Added to the CY 2007 ASC List Because They Do Not Meet Current Clinical Criteria for Addition to the ASC List
CPT
Short descriptor21390
Treat eye socket fracture.21406
Treat eye socket fracture.21407
Treat eye socket fracture.27412
Autochondrocyte implant knee.27415
Osteochondral knee allograft.( print page 68171)29866
Autgrft implnt, knee w/scope.29867
Allgrft implnt, knee w/scope.29868
Meniscal trnspl, knee w/scpe.31040
Exploration behind jaw.35470
Repair arterial blockage.35471
Repair arterial blockage.35475
Repair arterial blockage.35476
Repair venous blockage.35490
Atherectomy, percutaneous.35492
Atherectomy, percutaneous.35493
Atherectomy, percutaneous.35494
Atherectomy, percutaneous.35495
Atherectomy, percutaneous.37205
Transcath IV stent, percutaneous.37206
Transcath IV stent/perc, add'l.42844
Extensive surgery throat.47562
Laparoscopic cholecystectomy.47563
Laparo cholecystectomy/graph.47564
Laparo cholecystectomy/explr.60210
Partial thyroid excision.63001
Removal of spinal lamina.63003
Removal of spinal lamina.63005
Removal of spinal lamina.63011
Removal of spinal lamina.63020
Neck spine disk surgery.63030
Low back disk surgery.63035
Spinal disk surgery add-on.63040
Laminotomy single, cervical.63042
Laminotomy, single lumbar.63047
Removal of spinal lamina.63048
Remove spinal lamina add-on.63655
Implant neuroelectrodes.64448
N block inj fem, cont inf.64449
N block inj, lumbar plexus.
 *Comment:*
                         Some commenters addressed many of the codes that we did not propose to add because we believed that they did not meet the clinical criteria for inclusion on the ASC list for CY 2007. The commenters disagreed with some of our clinical determinations and stated that the procedures were safe for performance on an outpatient basis, satisfy our clinical criteria and should be included on the ASC list. Further, a few commenters noted that, although we proposed to exclude those 14 procedures from the list for CY 2007, we also proposed to add some of them to the list for payment under the CY 2008 revised payment system. They believed that we should add those procedures now rather than wait until CY 2008. *Response:*
                         Our medical advisors reviewed all of the procedures requested for addition in the comments. They did not find reason to change their determinations for any of the procedures included in Table 50. At the least, all of those procedures require longer than 4 hours of recovery time and some of them require overnight stays or involve major blood vessels. As noted by several of the commenters, we did propose to allow Medicare payment for some of the procedures under the revised ASC payment system for CY 2008. Integral to the proposal for CY 2008 is a revision of the criteria used to determine for which procedures Medicare would provide ASC facility payment. We did not propose any revision of the criteria for CY 2007 and clearly indicated in the proposed rule that all decisions regarding the ASC list for CY 2007 would be made according to the current criteria. We are finalizing our proposal not to include any of the services that do not meet current clinical criteria for addition to the ASC list that are displayed in Table 50 above for CY 2007, with modification to also not include procedures recommended by commenters to the CY 2007 proposed rule that do meet current clinical criteria for addition to the ASC list. For these reasons, we are making final our decisions not to add any of the procedures included in Table 50 to the ASC list for CY 2007. *Comment:*
                         A number of commenters requested that CMS add to the ASC list certain procedures that have very low facility costs and for which payment is included in that for other procedures. The requested procedures are currently assigned the following HCPCS codes: 36100-(Establish access to artery)
                    36120-(Establish access to artery)
                    36140-(Establish access to artery)
                    6145-(Artery to vein shunt)
                    6200-(Place catheter in aorta)
                    6215-(Place catheter in artery)
                    6216-(Place catheter in artery)
                    36217-(Place catheter in artery)
                    36218-(Place catheter in artery)
                    36245-(Place catheter in artery)
                    36246-(Place catheter in artery)
                    36247-(Place catheter in artery)
                    36248-(Place catheter in artery)
                    38792-(Identify sentinel node)
                    62290-(Inject spine disk x-ray)
                    62291-(Inject spine disk x-ray)
                    66990-(Ophthalmic endoscope add-on)
                    G0289-(Arthro, loose body + chondo) The commenters believed that these procedures were appropriate for addition to the ASC list so that the facilities could receive separate payment for them. *Response:*
                         Many of the requested procedures for addition to the list are procedures that are typically performed as minor services that are integrally related to the provision of the primary surgical procedure. Our policy in the ASC payment system is not necessarily to pay separately for each associated component of procedures, even if it is described by a separate HCPCS code, but rather to bundle payment for those components together into the payment for the primary surgical procedure. Many of those minor procedures that commenters requested we add to the ASC list are paid as part of the payment for the primary surgical service. For instance, Medicare does not make a separate facility payment for CPT code 36145, Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (cannula, fistula, or graft). The introduction of the needle or intracatheter described here is performed as an integral step that is part of the primary procedure, and it is not associated with any particular procedure but may be used in many different ones. Presumably, the primary procedure could not be performed unless the needle or intracatheter were first placed to provide access to the site for treatment. Therefore, we are not adding to the ASC list for CY 2007 any procedure that we have identified as a minor service that is integrally related to the provision of the primary surgical procedure. 7. Requests for Payment Increases for Procedures on the Current ASC List *Comment:*
                         A few commenters requested that we assign CPT code 57288 (Sling operation for stress incontinence (eg, fascia or synthetic)) to a higher ASC payment level. The commenters stated that because 
                        ( print page 68172)
                        Medicare does not allow separate payment for the synthetic mesh required for performing the procedure, payment at the current level is inadequate to cover the cost of the service. They reported that the costs for the synthetic mesh are between $700 and $850 and that the $717 payment made to the ASC does not cover the costs of providing the service. They stated that if CMS considers the sling material to be bundled into the ASC facility fee, then CPT code 57288 should be assigned to payment group 9. *Response:*
                         As we explained in our response to comments in the proposed rule related to CPT code 51992 (Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic)) (71 FR 49630), 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 in any other setting. Further, CPT code 57288, like 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 therefore, as we proposed, we are not changing that assignment. *Comment:*
                         One commenter requested that CMS assign CPT codes 58353 (Endometrial ablation, thermal; without hysteroscopic guidance) and 58563 (Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)) to payment group 9 instead of to group 4 to which they are currently assigned. They stated that because CMS assigned CPT code 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) to payment group 9 because we believed that it was more resource-intensive than other procedures assigned to group 4, that CPT codes 58353 and 58563 should also be assigned to group 9. The commenters indicated that those two procedures use transcervical, single use devices and have similar resource intensity to CPT code 58565. The commenters did not provide any cost information for either of the procedures. *Response:*
                         We examined cost data available to us regarding the facility or office costs associated with performing those procedures in other outpatient settings (physician offices and hospital outpatient departments). These are the best data available to us because we have no cost data for those procedures in ASCs. We agree with the commenters that payment in group 4 may not be adequate for either of the procedures, and we believe that the costs for CPT code 58563 are higher than those for CPT code 58353 due to the expensive guidance equipment used in the procedure. Therefore, we are assigning CPT code 58353 to payment group 7 for CY 2007 and CPT code 58563 to payment group 9 for CY 2007. 8. Other Comments on the May 4, 2005 Interim Final Rule In the May 4, 2005 interim final rule (70 FR 23690), we 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 treatment of them for CY 2007 is discussed below. *Comment:*
                         Several commenters 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. *Response:*
                         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 continued to believe that the procedures were appropriate for performance in the ASC and saw no reason to remove them from the list at this time. We proposed in the CY 2007 OPPS proposed rule to retain CPT codes 33212, 33214, and 33233 on the ASC list, with their current payment level assignments. We received no further comments on this proposal and, therefore, as we proposed, in this final rule with comment period, we are not making any changes to the ASC assignments for CPT codes 33212, 33213, and 33233. *Comment:*
                         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 believed that payment at a higher level was necessary in order to cover the costs of the equipment and supplies used in performing the procedures. *Response:*
                         We reviewed the OPPS cost data for the procedures as the best indicator available to us of facility costs and found that the median costs for CPT codes 57155 and 58346 when furnished in the hospital outpatient department were $506 and $364, respectively. 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 procedures' median costs in the generally more costly hospital outpatient setting. This led us to believe that the $446 payment in the ASC is quite adequate. We proposed in the CY 2007 OPPS proposed rule to retain CPT codes 57155 and 58346 in ASC payment group 2. We received no comments on this proposal and, therefore, as we proposed, in this final rule with comment period, we are not assigning the procedures to higher ASC payment groups. *Comment:*
                         Several commenters requested that CMS remove from the list 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 suggested that if we were unwilling to remove them from the list, that we assign the procedures to a higher payment group. They believed that the procedures required 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 MPFS for the required resources. 
                        ( print page 68173) *Response:*
                         We added these procedures to the list in response to public comments, because we believe they met all the criteria for addition to the ASC list. We initially assigned the codes to ASC payment group 3, consistent with other procedures with similar clinical indications. We continued to believe that these procedures were appropriate for performance in the ASC setting and did not propose to remove them from the list. However, we agreed with the commenters' point that the procedures require significantly more facility resources than traditional vein removal procedures, and proposed to assign them for CY 2007 to payment group 9 in the preamble of the CY 2007 OPPS proposed rule. We note that these codes mistakenly were published in Addendum AA of the proposed rule with assignment to payment group 8, and in the supporting public data files for the CY 2007 proposed rule as assigned to payment group 8. *Comment:*
                         Many commenters also expressed their concerns about the lack of clarity of the proposed payment group assignments for CPT codes 36475, 36476, 36478, and 36479 for CY 2007. Commenters noted the high cost of the procedures, which were assigned to payment group 3, and stated their belief that payment at level three is so low that that ASCs could not afford to provide the services at that rate. Commenters requested that CMS confirm that these CPT codes were assigned to payment group 9, and finalize our proposal for their CY 2007 treatment. *Response:*
                         We proposed that all four of these procedures be assigned to payment group 9 for CY 2007. We recognize that our data files caused confusion, and we appreciate the commenters bringing the inconsistencies to our attention. We continue to believe that these services should be assigned to payment group 9 for CY 2007. Therefore, we are finalizing our proposal to retain these procedures on the ASC list and assigning them to ASC payment group 9 for CY 2007. *Comment:*
                         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. *Response:*
                         We agreed with the commenters and proposed in the CY 2007 proposed rule to assign the procedure to ASC payment group 7 for CY 2007. We received no comments on this proposal and, therefore, are finalizing our assignment of CPT code 46947 to ASC payment group 7 for CY 2007. *Comment:*
                         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. *Response:*
                         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. As discussed previously, 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 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 therefore, as we proposed, we are not changing that assignment. *Comment:*
                         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). The commenter stated that there is no specific HCPCS Level II code to describe the microinserts and, thus, separate billing for them currently is not possible. *Response:*
                         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 were convinced that the procedure described by CPT code 58565 was significantly more resource-intensive than the other procedures in ASC payment group 4 and, therefore, proposed to reassign the procedure to ASC payment group 9 for CY 2007. We received no comments to this proposal and therefore are making final our proposal to assign CPT code 58565 to ASC payment group 9 for CY 2007. *Comment:*
                         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 after loading 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 after loading brachytherapy catheters into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance). One commenter supported our inclusion of CPT code 19296 on the ASC list in 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. *Response:*
                         In the CY 2007 proposed rule, we noted that 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 were persuaded that reassignment to a higher ASC payment group was warranted and proposed to reassign the CPT code 19298 to ASC payment group 9 for CY 2007. We received no comments about this proposal and, therefore, as we proposed, we are reassigning CPT code 19298 to ASC payment group 9 and will retain 
                        ( print page 68174)
                        CPT code 19296 in payment group 9 and payment for the balloon catheter will continue to be included in that rate. C. Regulatory Changes for CY 2007 As stated earlier, in the CY 2007 proposed rule, we proposed 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 would 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 will apply to the revised system beginning January 1, 2008. Therefore, as we proposed, we are revising Subparts D and E of Part 416 of the regulations to reflect that these are the rules governing the APC payment system prior to January 1, 2008, and redesignating 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 revising existing— § 416.1 (a)(2) and (a)(3) (under Basis and scope) and the definition of “Facility” under § 416.2 to remove the obsolete reference to “a hospital outpatient department,” to add provisions of section 5103 ofPublic Law 109-171, and applicable provisions of Public Law 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 removing the obsolete cross-reference in paragraph (a)(4) to § 405.310 and replacing 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 ofPublic Law 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 revising the headings of Subparts D and E and adding 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. In addition, we are making two technical changes: revising § 416.120 to replace the incorrect cross-reference to “Part 413” with the correct cross-reference to “Part 419”; and deleting § 416.150 (Beneficiary appeals) because it does not conform with the appeals process provisions of 42 CFR Part 405, subparts H and I. We received no comments on these proposed revisions and are finalizing them as proposed without modification. D. Implementation of Section 1834(d) of the Act Sections 1834(d)(2) and (3) of the Act require that the computed beneficiary coinsurance amount for screening flexible sigmoidoscopy and screening colonoscopy services provided in hospital outpatient departments and ASCs be equal to 25 percent of the payment amount. They also require Medicare to pay the lesser of the ASC or OPPS payment amount for those screening services in each geographic area. For CY 2007, the OPPS payment amount will be limited to the lesser ASC payment amount for screening colonoscopies. Medicare payment for screening flexible sigmoidoscopies will not be affected in CY 2007 because those services are not currently paid for in ASCs. There will be no effect on the payment amount to ASCs for screening colonoscopies. However, beginning in CY 2007, beneficiaries will be responsible for paying a 25-percent coinsurance for screening colonoscopies when provided in ASCs. Beneficiaries have been paying a 25-percent coinsurance for such services when provided in hospital outpatient departments. Although the provision is not new, it has not been implemented for ASCs due to ongoing instability in that payment system and uncertainty regarding plans for a revised payment system. There was uncertainty for several years about whether data gathered in a 1994 CMS-sponsored survey of ASC costs would be used to develop new rates for ASCs and, if so, how best to configure the payment methodology. The MMA requires the implementation of a revised system no later than January 1, 2008. However, section 5103 of the Deficit Reduction Act of 2005 (DRA) requires CMS to make some substantial payment rate changes for ASCs in CY 2007. Implementation of section 5103 of the DRA requires that carriers and ASCs make significant claims processing system changes. Since passage of the MMA, we have generally followed a policy of making as few changes to the current ASC payment system as possible prior to implementation of the MMA-mandated revised payment system, in order to minimize the administrative burden on ASCs. However, because changes to the system are being made for CY 2007 to comply with the DRA, we believe that we should also implement the requirements of section 1834(d) of the Act at the same time. We are confident that implementation of the coinsurance change required by section 1834(d) of the Act, in addition to changes required to comply with the DRA, will not interfere with ASCs' ability to provide services as usual. Currently, Medicare provides an ASC facility payment for two screening colonoscopy procedures reported by HCPCS codes G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), and not for any screening flexible sigmoidoscopies. Those are the only procedures that will be affected by the higher coinsurance amounts in ASCs in CY 2007. Beginning January 1, 2007, beneficiaries receiving services described by G0105 or G0121 in ASCs are responsible for a 25-percent coinsurance rather than the current 20 percent. Sections 1834(d)(2) and (d)(3) of the Act also require Medicare to pay the lesser of the ASC or OPPS payment amount for screening flexible sigmoidoscopies and screening colonoscopies. Medicare will not make payment to ASCs for screening sigmoidoscopies in CY 2007, so there is no payment comparison to be made for those services. This requirement will not impact ASC payments for the above listed screening colonoscopies in CY 2007, because the ASC amount will be lower than the OPPS payment calculated according to the standard OPPS methodology, prior to application of this requirement. E. Implementation of Section 5103 of Public Law 109-171 (DRA) As noted in section XVII.A.1. of this preamble, section 5103 of Public Law 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 final rule with comment period, we identify the HCPCS codes that we 
                        ( print page 68175)
                        believe will be subject to section 5103 based on a comparison of the final CY 2007 OPPS payment rates and the ASC standard overhead amounts that are effective in CY 2007. In addition, as we proposed, we are adding paragraph (c) to § 416.125 to reflect this change. *Comment:*
                         A few commenters asked that CMS not implement the payment limits because, in some cases, those payment decreases would result in payments that would be inadequate to cover the costs of the procedures. *Response:*
                         Implementation of the payment limitations required by the DRA is a statutory requirement. Therefore, we are finalizing the payment limits as required and as presented in our proposed rule without modification. F. Modification of the Current ASC Process for Adjusting Payment for New Technology Intraocular Lenses (NTIOLs) 1. Background 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 (47 FR 34082, August 5, 1982). Section 4063(b) of OBRA 1987, Public Law 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 (OBRA 1990), Public Law 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), Public Law 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), Public Law 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 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 at §§ 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 Table 51 below: Table 51.—Classes of NTIOLs Approved for Payment Adjustment
NTIOL category
HCPCS code
$50 Approved for services 
                                 furnished on or after
NTIOL characteristic
IOLs eligible for adjustment1
Q1001
May 18, 2000, through May 18, 2005
Multifocal
Allergan AMO Array Multifocal lens, model SA40N.( print page 68176)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 and Final 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. As we proposed in the CY 2007 OPPS proposed rule, we are continuing this established process and updating and streamlining 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.C. of this preamble, we are redesignating existing Subpart F of Part 416 as Subpart G, which will include the regulations pertaining to the ASC payment adjustment for NTIOLs. In addition, we are revising redesignated Subpart G to include revisions to existing § 416.180, § 416.185, § 416.190, § 416.195, and § 416.200 to reflect the changes that we are making to this process. One of the regulatory changes that we are making is to revise existing § 416.180 to establish the basis and scope for this ASC payment adjustment. This revision eliminates 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 making to the regulations at Part 416 will 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).” We received no comments on the changes we proposed to § 416.180. Accordingly, we are revising § 416.180 as we proposed, to reflect the Basis and Scope of Subpart G of Part 416. The other changes that we are making to Part 416, pertaining to the ASC payment adjustment for NTIOLs, are discussed below. b. Public Notice and Comment Regarding Adjustments of NTIOL Payment Amounts As we proposed, we are updating and streamlining 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 modifying 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 specifying that these NTIOL-related notifications will 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 our 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 will promote coordination and efficiency, thereby streamlining and expediting the NTIOL notification, comment, and review process. Specifically, we are establishing the following process: We will 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 for receipt of public comments will 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 will— + 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 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. *Comment:*
                         Most commenters supported in principle our proposal to incorporate NTIOL requests and approvals within the annual ASC notice and comment rulemaking cycle to promote greater coordination and efficiency. However, several commenters urged CMS to review NTIOLs on a quarterly rather than an annual basis. These commenters expressed concern about delays in beneficiary access to NTIOLs that could be avoided by quarterly reviews, which, the commenters noted, would also be more consistent with the CMS review cycle for OPPS pass-through device categories and new technology services. One commenter urged quarterly reviews so that lenses that belong to an active NTIOL class would not be competitively disadvantaged by having to wait for months or nearly a year to be recognized. Another commenter 
                        ( print page 68177)
                        recommended a 60-day comment period following issuance of the list of requests for NTIOL status rather than the 30-day comment period that we proposed. *Response:*
                         We appreciate the commenters' support for our proposal to coordinate the public notice and comment process regarding requests to establish new NTIOL classes with the update of ASC payment rates. We understand and share the commenters' concerns about facilitating beneficiary access to technology with demonstrated clinical improvement over existing technology. However, section 141(b)(3) of the Social Security Act Amendments of 1994 (SSAA 1994), Public Law 103-432, requires us both to implement the payment adjustment for new classes of NTIOLs through notice and comment rulemaking in the 
                        **Federal Register**
                         and to provide for a 30-day comment period on the lenses that are the subjects of the requests contained in the notice. We are not bound by the same prescriptive statutory requirements with regard to approval of applications for pass-through and new technology status under the OPPS, which is why we are able to implement updates of those provisions as part of the quarterly updates of the OPPS OCE and PRICER. However, we have issued a guidance document entitled “Revised Process for Recognizing Intraocular Lenses Furnished by Ambulatory Surgery Centers (ASCs) as Belonging to an Active Subset of New Technology Intraocular Lenses (NTIOLs).” This guidance document can be accessed on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​ASCPayment/​05_​NTIOLs.asp.* The guidance document provides details regarding requests for recognition of IOLs as belonging to an existing, active NTIOL category or subset, the review process, and information required for a request to review. Currently, there is one active NTIOL subset whose defining characteristic is the reduction of spherical aberration. CMS accepts requests throughout the year to review the appropriateness of recognizing an IOL as a member of an active subset of NTIOLs. That is, review of candidate lenses for an existing, active NTIOL subset is ongoing and not limited to the annual review process that applies to new NTIOL classes. We ordinarily would complete the review of a request within 90 days of receipt, and upon completion of our review, we would notify the requestor of our determination and post on the CMS Web site notification of a lens newly approved for a payment adjustment as an NTIOL belonging to an active NTIOL class when furnished at an ASC. We believe that consolidating the request, review, and approval process for new classes of NTIOLs as part of the annual ASC payment update cycle and accepting and reviewing requests for addition to an active NTIOL class on an ongoing basis will result in more timely access to improved health technologies for Medicare beneficiaries. Accordingly, we are revising § 416.185 to reflect the changes that we proposed to the current process for publishing separate 
                        **Federal Register**
                         notices specific to NTIOLs. 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 and whether the ASC payment amount for insertion of that lens 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 were identified for each class. We proposed 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, class-defining characteristic associated with improved clinical outcomes with designated members of an active or expired NTIOL class.
                    Evidence demonstrates 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. *Comment:*
                         Most commenters expressed general agreement with the criteria that we proposed as the factors we would consider in determining whether an adjustment of payment is appropriate for insertion of a new class of NTIOL. One commenter suggested amending § 416.195(a)(4) to make it clear that the list of superior outcomes are examples and not an all-inclusive list. *Response:*
                         We appreciate the commenter's concern that we not be overly prescriptive in what constitutes “superior outcomes.” However, we believe that § 416.195(a)(4)(vi), “Other comparable clinical advantages,” has the same effect as the revision suggested by the commenter. In other words, the superior outcomes cited in §§ 416.195(a)(4)(i)-(v) are not all-inclusive, and extend to other comparable (but unspecified) clinical advantages. In the preamble of the proposed rule (71 FR 49633), we suggest several “comparable clinical advantages” for the purpose of illustration. These suggestions were intended to be examples but not an all-inclusive list. *Comment:*
                         One commenter recommended removing “Reduced dependence on other eyewear (for example, spectacles, contact lenses, and reading glasses)” from the list of factors (71 FR 49633) because there should not be an NTIOL class for which the class-defining clinical advantage falls outside the scope of Medicare benefits. *Response:*
                         We appreciate the comment. To avoid unnecessary confusion, we will remove “reduced dependence on other eyewear” from the list of illustrative improved clinical outcomes. 
                        ( print page 68178) *Comment:*
                         The same commenter recommended that CMS clarify that when a requestor seeks to establish a new NTIOL category for a candidate IOL that bears the class-defining characteristic of an existing or expired NTIOL category but also offers an additional, new technological characteristic for which a new category is being sought that is distinguishable from the class-defining characteristic of an active or expired class, the lens should be eligible for consideration for NTIOL status as long as the characteristic and associated benefit of the active or expired class is not the basis of the request for a new class. *Response:*
                         The commenter makes an excellent point. Revised § 416.195(a)(3) does not preclude from consideration as a member of a new class of NTIOL a lens that includes as one of its characteristics a class-defining characteristic associated with members of an active or expired class. Only if that shared characteristic were the predominant characteristic of the lens would it be precluded from approval as a new class of NTIOL. However, if the lens featured other characteristics, one or more of which predominated, that were clearly tied with improved clinical outcomes, the lens would not be disqualified from consideration as an NTIOL just because it also shared a characteristic with members of an active or expired class. *Comment:*
                         One commenter recommended that if an IOL's label includes a claim of superiority, that CMS take that into account, but not require having the claim of superiority in FDA-approved labeling. The same commenter disagrees that FDA-approved labeling must include a statement of specific clinical benefits that would be the basis of an NTIOL request. A second commenter took the opposite position and commended CMS for requiring a copy of the labeling claims approved by the FDA for the IOL. The second commenter believed that this requirement (§ 416.195(a)(2)) is at the heart of an NTIOL application and that the FDA claims are of paramount importance in determining whether a lens is worthy of NTIOL status. *Response:*
                         We appreciate both commenters points of view. However, we are not persuaded by the first commenter's arguments that FDA approval of claims made in the labeling for the IOL is of incidental significance. Therefore, we are not modifying § 416.195(a)(2) as one of the factors that CMS will use to determine whether an IOL qualifies for a payment adjustment as a member of a new class of NTIOL when furnished at an ASC. In the proposed rule, we sought 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 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. *Comment:*
                         Several commenters presented thoughtful, illuminating discussions of what might constitute the “currently available lenses” with which a candidate NTIOL would be compared. A couple of commenters suggested establishing a threshold of sales in the market to delineate currently available lenses. Other suggestions for ascertaining benchmark lenses included solicitation of comments from the ophthalmic medical community and IOL industry, and consideration of whether the class-defining characteristic of IOLs in an active or expired NTIOL class has become a medically-accepted baseline technology upon which future technologies will be added. One commenter suggested that the best approach to addressing the questions we posed in the proposed rule would be through a Town Hall meeting or other forum that would bring stakeholders and CMS staff together to further deliberate on the process of how to determine whether a lens qualifies for NTIOL status and the appropriateness of a payment adjustment for such lenses. Most commenters who addressed this issue recommended that CMS not attempt to define “currently available lenses” with too much specificity. These commenters stressed that it was important for CMS to maintain sufficient flexibility to account for evolving IOL standards and to allow a variety of appropriate lenses to serve as relevant benchmarks. One commenter noted that while foldable spherical monofocal IOLs represent the current state-of-the-art against which candidate NTIOLs ought to be compared at this time, future advances would create new standards and require flexibility on the part of CMS. Another commenter asserted that, in general, the next IOL technological advancement worthy of NTIOL status should build upon the state of technology that is current at the time. The same commenter further recommended that CMS, in addition to being flexible, consider each request for NTIOL review on an individual, case-by-case basis. *Response:*
                         We appreciate commenters taking the time to formulate and communicate their views regarding the notion of “currently available lenses.” A number of thought-provoking suggestions were advanced. We agree with commenters that flexibility is critical, and that too much specificity would quickly become outdated by advancing technology. The commenters have presented a number of options for establishing baseline technology that we will carefully consider and evaluate during the course of future review of NTIOL applications. We look forward to continuing to work with stakeholders to ensure that our criteria and the NTIOL process generally are reasonable, are supportive of ongoing development of new IOL technology, and are geared to improved clinical outcomes for Medicare beneficiaries. In summary, after carefully considering the comments we received regarding the criteria we proposed as factors to be considered to determine whether an IOL qualifies for a payment adjustment as a member of a new class of NTIOL when furnished at an ASC, we are adopting as final, without modification, our proposed revision of § 416.195. d. Revision of 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 proposed to require that a request include certain specific information, which is listed below. We made this proposal to revise the content of a request, which is currently set forth in § 416.195(a), on the basis of 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 
                        ( print page 68179)
                        also have found that such information must be updated in a timely manner to ensure its relevancy to advancing technologies. Therefore, we also proposed to post the information that we require on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​center/​asc/​asp*
                         to provide quick and easy access for updating rather than codifying the items required in the application. In addition, we proposed to require a separate request for each NTIOL for which a payment review as member of a new class is sought. We also proposed to consider a request that does not include all of the following information as incomplete and we proposed not to accept an incomplete request for review until all information is furnished. We proposed to require the following information: 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 stated in the proposed rule that 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. In our proposed § 416.190(d), we provided 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. *Comment:*
                         Several commenters objected to our proposal to post on the CMS Web site the information required in a request for review of a potential new class of NTIOL rather than codifying it. Several commenters expressed concern that lags in Web site updates may compromise an NTIOL sponsor's ability to design and implement requisite studies and generate data that will adequately support timely consideration and approval of an application. Another commenter urged that there be sufficient stability in the requirements so that a manufacturer does not invest several months or years in conducting a comparative clinical study, only to learn when it is ready to submit an NTIOL request that the criteria have changed. Several commenters suggested that requestors have the opportunity to meet with CMS to discuss the study design and application processes to ensure that the agency's demands for documentation of an IOL's benefits are fully understood by applicants and are met upon submission of the application. *Response:*
                         We have received hundreds of applications for pass-through payment for devices and drugs and payment for new technology services under the OPPS using a format and process similar to that proposed for NTIOLs. The format for pass-through and new technology requests under the OPPS as well as the details of the application process are posted on the CMS Web site, but they are not codified. As a matter of policy and practice, we are available to meet with anyone with an interest in developing a request for consideration of a new class of NTIOLs at any time, to ensure that our requirements are clear and thoroughly understood by the requestor, and also to give CMS an opportunity to preview a potential applicant for NTIOL status. The application process is an interactive collaboration between CMS and the requestor that continues until CMS has all of the information it needs to be able to make a determination. We are concerned that commenters may also be confusing the factors that we are implementing in revised § 416.195, which are the criteria that CMS will consider to determine whether an IOL qualifies for a payment adjustment as a member of a new NTIOL class, with the items of information listed in the proposed rule in section XVII.E.2.d of the preamble, which comprise a list of the information that CMS needs in order to determine whether a lens meets the criteria in § 416.195. 
                        ( print page 68180) Finally, we are confused about commenters' apprehension regarding the potential for research studies being undermined in some manner if the information required for a request for NTIOL eligibility is not codified. The information required for a request for NTIOL eligibility is mostly descriptive and explanatory; it is not information required for a research study. *Comment:*
                         One commenter recommended that any information concerning NTIOLs be made available for public review and comment. Another commenter contended that the APA requires that the content requirements for an NTIOL payment request be subject to notice and comment rulemaking and subsequently published in the Code of Federal Regulations and also that any future revisions be subject to notice and comment rulemaking. *Response:*
                         We disagree with the commenters' contention that the points of information we proposed to require in a request to review a lens must be enumerated in the Code of Federal Regulations. We note that the information listed in current § 416.195(a)(1) through (5) is included in the list of information in section XVII.E.2.d. of the proposed rule (71 FR 49634). The additional points of information that we proposed to require in section XVII.E.2.d. of the preamble are simply an explicit itemization of “other information that CMS finds necessary for identification of the IOL” (see § 416.195(a)(6) of the current regulations). Instead of requiring requestors to use a pre-printed, prescribed application form, we simply list the individual items of information that have to be supplied, which we accept in whatever format the requestor finds most convenient. Moreover, the CY 2007 OPPS proposed rule has provided an opportunity for public comment on the information required in a request for NTIOL consideration. The few comments that we received are addressed below. The criteria for determining whether or not a lens qualifies as belonging to a new class of NTIOL are what require public comment, not the list of information needed to apply the criteria. *Comment:*
                         One commenter believed that the mere fact that scientific evidence has been published in a peer-reviewed journal should not impact whether CMS determines the evidence is credible. The commenter further believed that a study that has been accepted or published in a peer-reviewed journal should not be given greater weight simply because it has been published. *Response:*
                         We agree with the commenter's assertion that there are a variety of forms in which credible evidence can be presented, in addition to publication in a peer-reviewed journal. We encourage the submission of all credible evidence, published or not. However, we believe that published, peer-reviewed literature has particular value in that it is the product of a rigorous process of thorough scrutiny and standards that are acknowledged and recognized throughout the academic and scientific community. For reasons stated above, as we proposed, we are revising § 416.190 to reflect the specified 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 incorporating the list of information required with each request in the regulations, but are posting 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 revising § 416.190 to require that the content of each request for an IOL review must include all information as specified on the CMS Web site for the request to be considered complete. e. Notice of CMS Determination In the CY 2007 OPPS proposed rule, we proposed 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 proposed 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 proposed 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. We received no comments on these proposals. Therefore, we are making final, without modification, the process and timelines that we proposed. f. Payment Adjustment The current payment adjustment for a 5-year period from the implementation date of a new NTIOL class is $50. In the CY 2007 OPPS proposed rule, we did not propose to revise this payment adjustment for CY 2007. For CY 2007, we proposed to revise § 416.200(a) through (c) to clarify how the IOL payment adjustment would be made and how a NTIOL would be paid after expiration of the payment adjustment. We also proposed minor editorial changes to § 416.200(d). *Comment:*
                         Several commenters expressed concern that the $50 payment adjustment for a new NTIOL class is inadequate, has not been adjusted for inflation since it was initially implemented, and is out of step with the rising costs of innovative research. One commenter objected to a flat $50 adjustment for all NTIOLs on the grounds that research, development and production costs vary from lens to lens. Several commenters recommended that manufacturers be given the opportunity to present a request, supported by appropriate documentation, for a higher payment adjustment for NTIOLs for which it is warranted. *Response:*
                         In January 2008, as discussed elsewhere in this final rule with comment period, we plan to implement a significantly revised payment system for ASC facility services, which will affect payment for all ASC services, including payment for IOLs and their insertion and payment for cataract surgery. Only after we have implemented the revised ASC payment system in CY 2008 will we be able to evaluate whether or not the ASC facility fee established for cataract surgery with IOL insertion is appropriate when a lens determined to be an NTIOL is furnished. Therefore, we are retaining for now the current $50 payment adjustment for a new NTIOL class. In addition, we are 
                        ( print page 68181)
                        adopting as final without modification our proposal to revise § 416.200(a) through (c) to clarify how the IOL payment adjustment will be made and how a NTIOL will be paid after expiration of the payment adjustment; and to make minor editorial changes to § 416.200(d). In summary, after careful consideration of the public comments we received timely regarding our proposed changes, we are adopting as final without modification, with the exception of a few technical edits, the provisions of proposed new Subpart G under Part 416 to codify the rules governing the ASC payment adjustment for NTIOLs. G. Announcement of CY 2007 Deadline for Submitting Requests for CMS Review of Appropriateness of ASC Payment for Insertion Following Cataract Surgery of an NTIOL In accordance with § 416.185(a) of our regulations, as revised by this final rule with comment period, CMS announces that, in order to be considered for payment effective January 1, 2008, requests for a review of an application for a new class of new technology IOLs must be received at CMS by COB, April 1, 2007. Send requests to: ASC/NTIOL, Division of Outpatient Care, Mailstop C4-05-17, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850. To be considered, requests for NTIOL reviews must include the information posted on the CMS Web site at 
                        *http://cms.hhs.gov/​ASCPayment/​05_​NTIOLs.asp#TopOfPage.* XVIII. Medicare Contracting Reform Mandate A. Background Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Public Law 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) at 48 CFR chapter 3. Using competitive procedures, CMS will replace its current claims payment contractors (intermediaries and carriers) with new contract entities, MACs. Section 911(d)(1)(C) of Public Law 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 Public Law 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 final rule with comment period 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 final rule with comment period 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-for-Service and Medicare Administrative Contractors (MAC) CMS'  vision for the Medicare fee-for-service (FFS) program is that of a premier health plan that allows for comprehensive, quality care and world-class beneficiary and provider services. 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/​*. As of November 1, 2006, there are 20 intermediaries and 18 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. Four 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.) Four Durable Medical Equipment Regional Carriers (DMERCs) process claims for durable medical equipment, prosthetics, and orthotics. 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 Public Law 108-173. Prior to passage of Public Law 108-173, intermediary and carrier acquisition authorities did not require full and open competition or unified processing of Medicare Part A and Part B claims. Medicare contracting was significantly hampered by absence of competition 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 
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                        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 Public Law 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 Public Law 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) of the Act, 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. Section 911(d) of Public Law 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 contracts 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 Public Law 108-173 took effect on October 1, 2005. The changes that we proposed and are finalizing in this final rule with comment period to the regulations under 42 CFR Part 421, Subpart B (discussed under section XVIII.E. of this preamble) are intended to conform the regulations to these statutory changes. Prior to the statutory developments directed by Public Law 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, CAHs, SNFs, 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 will continue to exist until full implementation of MACs. Moreover, prior to the enactment of Public Law 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 the 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 
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                        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 Public Law 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 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 cost-reimbursement basis only;
                    Section 1816(f) of the Act required the Secretary to publish the 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 an agreement; in particular, no provision was made for the normal right of the government to terminate for convenience. In section 911(b) of Public Law 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 Public Law 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 HHAs and hospice providers. While section 911(d)(1)(B) of Public Law 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 Public Law 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 Public Law 108-173 (December 8, 2003). Therefore, while Congress specified that the Secretary should submit a 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 the report to Congress. This analysis requires that similar, conforming changes be made in our regulations as set forth in the proposed rule and as finalized in this final rule with comment period. E. Provisions of the Proposed and Final Regulations As discussed under section XVIII.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 Public Law 108-173, we are finalizing our proposed rules 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 Public Law 108-173, we also are making a number of changes to Subparts A and B of 42 CFR Part 421. In addition, we are changing the title of Part 421 from “Intermediaries and Carriers” to “Medicare Contracting” and making conforming revisions to Subpart B of Part 421. As discussed earlier, section 911(b) of Public Law 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 Public Law 108-173 gave the Secretary authority to disregard the provider nomination provisions in this contracting, even prior to October 1, 2005. In accordance with these statutory changes, we are finalizing our proposal to substantially modify or delete §§ 421.1(c), 421.3, 421.103, 421.104, 
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                        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 adding regulations pertaining to MAC contracts in a new subpart E (Medicare Administrative Contractors) under Part 421 as follows: § 421.400 (Basis and scope), § 421.401 (Definitions), and § 421.404 (Assignment of providers and suppliers to MACs). 1. Definitions As we proposed under proposed § 421.401, in this final rule with comment period, we are defining 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, or a specific provider of services or supplier (or class of such providers of services or suppliers), we are defining 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 a particular class of providers. 2. Assignment of Providers and Suppliers to MACs As we proposed, in this final rule with comment period, we are establishing 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. These suppliers will bill the MAC covering the area where the beneficiary resides—a continuation of existing policy. In the past, under the provider nomination provisions that were repealed by section 911 of Public Law 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 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 removing in accordance with the changes effectuated by section 911(b) of Public Law 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 Public Law 108-173 to authorize the Secretary to assign all providers and suppliers, even the members of multi-State entities, to the geographically based 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 section 911(d)(1)(C) of Public Law 108-
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                        173 abolished the former provider nomination framework, we believe that allowing the practice of consolidated billing by large chains is within the discretion of the Secretary under section 911 of Public Law 108-173. Accordingly, in this final rule with comment period, we are finalizing our proposal under § 421.404 that— Providers (as defined in42 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.
                    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 incorporating a definition of “qualified chain provider.” The criteria that constitute the 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 final rule with comment period) 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 section 911(d)(1)(C) of Public Law 108-173 abolished the provider nomination framework and 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 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 assigning suppliers (including physicians and nonphysician 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 DMEPOS suppliers in § 421.210 and § 421.212. We indicated in the proposed rule that as we move forward to implement MAC contracting in keeping with the statutory mandate of section 911 of Public Law 108-173 and the Secretary's Report to Congress, we were inviting public comments on these specified issues, including our proposed definitions and criteria. (Once the MACs are initially implemented, we indicated that we may propose more stringent criteria for consolidated billing status, in keeping with the overall thrust of section 911 of Public Law 108-173.) *Comment:*
                         One commenter supported the approach CMS is taking to consolidate the Medicare Part A and Part B claims processing functions into one MAC covering several States. The commenter was encouraged that this consolidation will promote greater consistency across geographic regions. The commenter requested that CMS instruct MACs to review local coverage determinations (LCDs) and other policies to ensure consistency in coverage between settings of care and to align payment policy and incentives between physicians and hospitals. *Response:*
                         As is our current practice, MACs will be required to develop LCDs in accordance with Chapter 13 of the CMS Program Integrity Manual. As the MACs commence operations in their jurisdictions, each MAC will consolidate all of the LCDs for its jurisdiction. CMS will continue to issue national coverage determinations (NCDs). *Comment:*
                         Several commenters share the commitment of CMS to implement the Medicare contracting reform provisions that are mandated by section 911 of the MMA. They requested that CMS grant exceptions to the general rule to permit large chain providers to choose an appropriate MAC. They believed that allowing providers to choose their MAC will ensure maximum efficiency. Another commenter asked if a “large chain” with “multiple national offices” could request that a specific “chain office” be used for consolidation to one MAC geographic locale. *Response:*
                         As specified in proposed new § 421.404(b)(3), a qualified chain provider approved by CMS to bill a single intermediary on behalf of its member providers prior to October 1, 2005, would be assigned at an appropriate time to the MAC contracted by CMS to administer claims 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 would not need to request an exception to § 421.404(b)(1). Accordingly, if the commenter's reference is to one “large,” previously approved, qualified chain organization, the qualified chain organization would be assigned to the MAC serving the geographic area where the qualified chain organization's home office is located. If the commenter's reference is to several distinct, previously approved, qualified chain organizations that have recently merged, the several distinct legacy chains would have to request status as a single qualified chain organization in accordance with § 421.404(b)(1); and as part of this process, the newly emerged chain organization will be required to establish the location of its home office. If CMS approves the request, the new qualified chain organization will bill and receive Medicare payment from the MAC that covers the geographic locale in which the qualified chain organization's home office is located. *Comment:*
                         Several commenters requested that CMS maintain maximum flexibility for all parties involved in Medicare contracting reform (that is, providers and contractors) during the transitional phases to the MACs. They suggested that CMS allow large chain providers the ability to maintain their existing relationships with 
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                        intermediaries until all MAC transitions are complete. *Response:*
                         We cannot allow large chain providers to maintain their existing relationships with intermediaries until all MAC transitions are complete because as intermediary functions are transitioned over time to MACs, those intermediaries will no longer be processing claims. Those claims will be processed by the “replacement” MAC. *Comment:*
                         One commenter requested that CMS provide a mechanism for a chain provider that has facilities in many Medicare Part A and Part B MAC jurisdictions to consolidate into a smaller number of MACs instead of a single MAC in the chain provider's home office jurisdiction. *Response:*
                         The policy announced in proposed § 421.404 allows chain providers that meet the requirements for qualified chain organization status to request single MAC billing status on behalf of its member providers. The process for submitting the request, together with the types of documentation the qualified chain organization must submit in support of its request, will be set forth in detail in a future CMS program manual. A chain provider may make the business decision to identify a segment of its organization as a distinct qualified chain organization with a regional management office that will fall appropriately within one MAC jurisdiction. Our current policy does not require that all member providers within the qualified chain organization bill through the chain provider's home office MAC. However, the future CMS program manual may require that a qualified chain organization make clear, in its centralized MAC billing request, the identity of each member provider, and which member providers are included within the request for centralized billing through the home office MAC. The future CMS program manual may require each such requesting qualified chain organization, if approved, to maintain that centralized billing configuration until a request for another change is approved by CMS. *Comment:*
                         Several commenters asked if an existing chain hospital that is in a jurisdiction that is transitioning to a MAC, but the existing chain provider's home office is not in that jurisdiction, will be allowed to continue to bill the intermediary it has been using, or must it transition to the contracted MAC in its jurisdiction. The commenters also wanted to know whether a chain organization may convert to a single MAC to avoid the need for multiple transitions. *Response:*
                         Up until the date a MAC commences operations in the jurisdiction where the existing chain provider's home office is located, the existing chain provider will be served by the current intermediary serving the State in which the existing chain provider's home office is located, provided the current intermediary does not end its contract prior to the time that the new MAC commences operations. Current intermediaries and carriers will complete their contract obligations, including serving the existing chain provider's home offices. In the event that the servicing intermediary does choose to end its contract, CMS will apply § 421.104 in reassigning the existing chain provider to another CMS contractor. Our overriding goal is to ensure continuity of operations during the period of time current contractors are transitioning to MACs. *Comment:*
                         One commenter asked CMS to allow a qualified chain organization to select either the MAC that covers the jurisdiction where its home office is located, or another MAC that covers the jurisdiction where the chain's billing office is located (if different), when deciding to consolidate Medicare billing activities. *Response:*
                         For the reasons set forth in the preamble to the proposed rule, it is CMS' policy that each qualified chain organization may request permission from CMS to bill centrally to one MAC. Further, our requirement is that the qualified chain organization must bill the MAC responsible for the geographic area where the qualified chain provider's home office is located. At this time, we will not allow the qualified chain organization to bill based on the location of its billing office (if different). Our policy protects the Medicare program against chain providers that might seek less restrictive MACs by relocating their billing offices. The process for submitting the request, together with the types of documentation the qualified chain organization must submit in support of its request, will be set forth in detail in a future CMS program manual. As we gain experience with the MAC environment, we may broaden the centralized billing alternatives to support options suggested by the commenter. *Comment:*
                         Several commenters requested that CMS have a clear notification and a transition process for notifying providers of potential reassignments deemed necessary by the Agency. They requested that a full explanation be given for the reasons for determining that the change would result in a more efficient and effective administration of services. *Response:*
                         We will ensure that providers affected by a transition from a legacy Medicare contractor to a MAC are notified in advance of the transition. This will be a significant activity within the implementation plan for each MAC as the MAC and the provider will need to work together on a number of issues (for example, test electronic billing arrangements). We have substantial experience in overseeing Medicare claims transitions and have refined these processes over many years. The reasons for the transition to MACs were set forth in the preamble to the rule. *Comment:*
                         Several commenters requested that CMS consider the potential impact on providers of delayed claims processing during the implementation of the Medicare contracting reform provisions under section 911 of the MMA. *Response:*
                         We note that Medicare claims processing timeframes are set elsewhere in statute and CMS' program requirements will not be affected by the transition to MACs. We will review all MAC contract proposals to verify that companies desiring to serve as MACs can meet these requirements, and we will closely monitor all transitions to ensure that strong program performance is maintained. *Comment:*
                         One commenter commended CMS for requiring MACs to pay claims timely. However, the commenter strongly requested that CMS not allow a MAC to move to a less frequent payment schedule, believing that Medicare claims volumes continue to warrant the most frequent payment schedule. The commenter also urged CMS to consider the ability and availability of the MAC to meet the needs of the providers assigned to the MAC. The commenter believed the MAC should be available during a provider's normal business hours, regardless of the provider's location within the MAC jurisdiction. *Response:*
                         The commenter raised issues that are outside the scope of the proposed rule. In this final rule with comment period, we are not responding to those comments. We note that Medicare claims processing timeframes are set elsewhere in statute and will not be affected by the transition to MACs. We will review the other comments and consider whether to take other actions, such as revising or clarifying the MAC contracts or CMS' operating instructions or procedures, based on the information or recommendations provided in the comments. *Comment:*
                         Several commenters had concerns that newly appointed MACs 
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                        may not have the expertise or familiarity needed to process specialized claims such as those for end stage renal disease (ESRD). *Response:*
                         These commenters raised issues that are outside the scope of the proposed rule. In this final rule with comment period, we are not responding to those comments. We note that we are requiring MACs that will administer specialized workloads to demonstrate their capability to do so in their contract proposals. *Comment:*
                         Several commenters requested that CMS allow ESRD providers the option of having their claims handled by multi-state, regional MACs. *Response:*
                         All of the MACs will serve multi-state areas, for example one will serve New York and Connecticut. ESRD suppliers will generally be assigned to MACs based on § 421.404(c)(1). However, a group of ESRD suppliers under common control and common ownership may obtain a § 421.404(c)(3) exception if CMS finds the request for centralized billing through the home office MAC will support the implementation of MACs or will serve some other compelling interest of the Medicare program, or both. *Comment:*
                         One commenter cautioned that if a chain were to consolidate to just one MAC, there is the potential for an excessive workload for a MAC that may have in its jurisdiction many home offices for large chain organizations. *Response:*
                         We believe that the MACs will be fully capable of administering their chains' workload, but we will monitor the concentration of qualified chain organization claims across the 15 Medicare Part A and Part B MACs. *Comment:*
                         One commenter recommended that CMS permit all of a qualified chain organization's member providers within a particular area to bill their local, geographically assigned MACs, even if the remainder of the qualified chain organization has requested and been approved for centralized, home office MAC billing. The commenter believed that some local MACs may be better suited to serve a chain's providers because LCDs vary across jurisdictions. Specifically, the commenter was concerned about a scenario where the home office MAC's LCD policy might not cover a hospitalization, even were the local MAC's policies might allow a physician to bill under the same clinical circumstances. The commenter stated that the typical chain often operates a variety of providers and suppliers such as hospitals, freestanding imaging centers, and physician offices. *Response:*
                         During the post-award/pre-commencement period, as an intermediary or carrier transitions to the selected MAC, the selected MAC's medical director will consolidate all the LCDs for the States in the MAC's jurisdiction by identifying and implementing the least restrictive LCD. This process will alleviate a certain percentage of LCD conflict across States. However, a given MAC will apply only the LCDs in force in its own jurisdiction. MACs will not be required to apply the LCDs of other MACs. The choice to request centralized, home office billing is a business decision for each qualified chain provider to weigh. We are providing this option under § 421.404(b)(2) of the regulations, but are not mandating that chains avail themselves of it. We will not routinely provide alternatives (other than the general alternative provided by § 421.404(b)(1)) because doing so is not generally in CMS' administrative interest and could devolve to the former “provider nomination” environment. We note that moving from 20 intermediaries and 18 carriers to 15 Medicare Part A and Part B MACs has been widely received as a step in the right direction by most segments of the Medicare provider community and a substantial accomplishment to support the contracting reform goal of improving the efficiency and effectiveness of delivering services to Medicare beneficiaries and providers. *Comment:*
                         One commenter requested clarification of CMS policy on how often qualified chain organization member providers can move in and out of centralized billing status. The commenter stated that chains frequently change in size and scope of operations, such as the establishment of a regional central billing office, and determine that it is more efficient to change the billing status for all or some member providers. The commenter suggested the status change be permitted each fiscal year with a minimum required notice of 120 days before the start of the next home office cost reporting period. *Response:*
                         We appreciate the industry's input on workable notice requirements. This is a policy detail we will address in the future CMS program manual. However, we wish to point out that no provider will be allowed to centralize (or decentralize) its billing without CMS approval, and we do not anticipate allowing chains to change their process frequently. There is a cost to the Medicare Program associated with moving providers from one contractor to another, and the lead time required will be more than 120 days in many cases. *Comment:*
                         Several commenters recommended that CMS allow companies with more than one legal entity, and currently assigned to a single intermediary, to continue to bill centrally. They also recommended that CMS allow companies with more than one legal entity to apply for single MAC status. *Response:*
                         Existing chain providers, including those with more than one legal entity, assigned to a single intermediary prior to October 1, 2005, will be assigned to a single MAC at an appropriate time in accordance with § 421.404(b)(3). If a chain provider with more than one legal entity, that is assigned to a single MAC, subsequently comes to CMS with a request to change the MAC assignment for one of the legal entities because of a change in the corporate structure of the overall chain, such as spinning off a downstream affiliate, then CMS may require the entire chain to reapply for single MAC status, applying the then-current CMS qualified chain organization program manual. *Comment:*
                         One commenter recommended that CMS expand the field of § 421.404(a) “eligible providers” that are entitled to be counted among the qualified chain provider's members. The commenter argued that allowing otherwise ineligible providers to join in centralized billing status would facilitate integration of important functions such as coverage rules, provider education, and support for beneficiaries. *Response:*
                         The group of “eligible providers” under § 421.404(a) was established by reference to the provider types that have traditionally been eligible to consolidate their billing. At this time, we do not intend to extend centralized billing beyond these provider types. However, we believe that § 421.404(b)(4) provides CMS the discretion to make exceptions if circumstances warrant. *Comment:*
                         Several commenters requested that CMS clarify what is meant by the term “best interest of the program”. *Response:*
                         “Best interest of the program” means that which the responsible CMS personnel (acting in their official capacity, or capacities) determine on a nonarbitrary and noncapricious basis, using reasonable judgment and information known to them, to be most advantageous to the Medicare program. In making such a determination, CMS personnel may balance competing factors and options. The factors considered may change over time; for instance, as the Medicare program's requirements change, 
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                        technology evolves, and the MACs are implemented. *Comment:*
                         One commenter offered input on the MAC procurement process and asked CMS to consider certain performance-related information in the awarding of a future MAC contract. Several commenters requested that CMS include providers in the contractor selection and renewal process. They requested CMS to allow providers to give mid-contract reviews of the MACs' performance. One commenter requested that CMS ensure that MACs are required to maintain a significant local presence inasmuch as each jurisdiction includes several States. *Response:*
                         These commenters raised issues that are outside the scope of the provisions of the proposed rule. In this final rule with comment period, we are not responding to those comments. However, we will review the comments and consider whether to take other actions, such as revising or clarifying the MAC contracts or the CMS operating instructions or procedures that are issued, based on the information or recommendations provided in the comments. We note that the Medicare contracting reform statute requires us to measure providers' satisfaction with the MACs, and that we will be periodically surveying providers for this information. *Comment:*
                         One commenter made an individual-case-specific request. One of its “health care systems” supposedly was granted centralized billing privileges by CMS but the transition to a single intermediary was never completed for various reasons. The commenter asked CMS to complete the centralized billing transition through the finalization of this rule. *Response:*
                         Through a series of “Medlearn Matters” articles published on the CMS Web site at 
                        *http://www.cms.hhs.gov/​MLNMattersArticles/​2005MMA/​List.asp#TopOfPage*
                         and distributed via Listserves and communications with CMS components and affiliated contractors in September and October of 2005, CMS notified the Medicare community that no requests for provider nomination would be accepted beyond October 1, 2005. The public comment and response process connected with a notice of proposed rulemaking is not the forum in which the Agency treats case-specific requests for qualified chain provider or centralized billing status. Chain organizations that have experienced a delay in conversion to centralized billing in connection with a pre-October 1, 2005 CMS decision to authorize centralized billing should contact the CMS component where the original request was made and provide documentation of CMS authorization for centralized billing. Without the proper documentation, a qualified chain organization must wait for CMS to open the period for single-MAC billing status. A forthcoming program manual that outlines the process for such requests will provide the appropriate instructions. After considering the public comments received, we are adopting as final, without modification, the proposed provisions of Subpart E of 42 CFR Part 421 (§§ 421.400, 421.401, and 421.404) governing MACs. 3. Other Technical and Conforming Changes a. Definition of “Intermediary” (§ 421.3) We did not receive any public comments on our proposal to revise the definition of the term “intermediary” under existing § 421.3 to delete reference to “alternative regional intermediaries,” and, therefore, are finalizing it in this final rule with comment period. 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 Public Law 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. In the proposed rule, we proposed to amend § 421.100, concerning functions to be included in intermediary agreements, to address the dual intermediary responsibilities. We also proposed 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 Public Law 108-173. We did not receive any public comments on these proposed technical and conforming changes and, therefore, are finalizing them in this final rule with comment period without modification. c. Options Available to Providers and CMS (§ 421.103) As we proposed, we are finalizing our change of the title of § 421.103 to “Payment to Providers” and revising 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 specifying that this function must remain with the intermediaries. We will no longer allow providers to receive payments directly from CMS, nor will 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. We did not receive any public comments on our proposed technical changes. d. Nomination for Intermediary (§ 421.104) As we proposed, we are finalizing our change of the title of § 421.104 to “Assignment of Providers of Services to Intermediaries During Transition to Medicare Administrative Contractors (MACs)” and revising 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 did not receive any public comments on the proposed technical change. 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 did not receive any public comments on our proposal to remove 
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                        § 421.105 and § 421.106 from the regulations; the sections will no longer be applicable with implementation of the new Subpart E of Part 421. Therefore, we are finalizing the removal in this final rule with comment period. f. Considerations Relating to the Effective and Efficient Administration of the Medicare Program (§ 421.112) We are finalizing our proposal to revise § 421.112 (a). As stated previously in this final rule with comment period, 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. We did not receive any specific public comments on this technical change. g. Assignment and Reassignment of Providers by CMS (§ 421.114) We are finalizing our proposal 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. We did not receive any specific public comments on this proposed technical change. 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 finalizing our proposal to delete § 421.116, Designation of national or regional intermediaries, and § 421.117, Designation of regional and alternative designated regional intermediaries for HHAs and hospices. The statutory provisions that made these regulations necessary were repealed by Public Law 108-173. Therefore, we no longer need these regulations. All providers will receive payment for covered services as described in § 421.103. We did not receive any public comments on this proposed technical change. i. Awarding of Experimental Contracts (§ 421.118) We are finalizing our proposal 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 Public Law 108-173. We did not receive any public comments on this proposed technical change. XIX. Reporting Quality Data for Improved Quality and Costs Under the OPPS 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 52.—Growth in Expenditures Under OPPS from CY 2001 through CY 2007 (Projected Expenditures for CY 2006 and CY 2007) in Billions
OPPS Growth
CY 2001
CY 2002
CY 2003
CY 2004
CY 2005
CY 2006
CY 2007Incurred Cost
17.702
19.158
20.8102
23.702
26.518
29.809
32.540Percent Increase

8.2
8.6
13.9
11.9
12.4
9.2Source: FY 2007 Mid-Session Review, Budget of the U.S. Government.
 As we indicated in the CY 2007 OPPS proposed rule, 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 53.—Percent Increase in Volume/Intensity of Hospital Outpatient Services
CY 2002
CY 2003
CY 2004
CY 2005
                                 (Est.)
CY 2006
                                 (Est.)Percent Increase
3.5
2.4
7.8
7.8
9.7Source: FY 2007 Mid-Session Review, Budget of the U.S. Government
 For outpatient hospital services, the volume and intensity of services for CY 2005 are estimated to continue to increase significantly at a rate of 7.8 percent, in excess of the long-term trend. This increase follows the 7.8 percent increase in CY 2004, and the growth is projected to be 9.7 percent in CY 2006. As we have stated repeatedly, this rapid growth in utilization of services in 
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                        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 the CY 2007 OPPS proposed rule, we sought public comment on value-based purchasing as related specifically to hospital outpatient departments. As part of our overall goal of promoting value-based purchasing in outpatient payment, we also made one specific proposal for the CY 2007 OPPS. 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 may 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 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 five 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 two percent bonus payment in addition to the regular Medicare DRG payment for the measured condition. Hospitals in the second highest 10 percent receive a one percent bonus payment. In the third year of the demonstration, if hospitals do not achieve absolute improvements above the demonstration's first year composite score baseline (the lowest 20 percent) for that condition, 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 Public Law 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?( print page 68191)
                    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 Public Law 109-171 amended section 1886(b)(3)(B) of the Act and made changes to the program established under section 501(b) of Public Law 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. The expanded set of 21 quality measures for the FY 2007 update that was included in the FY 2007 IPPS final rule (71 FR 48033) 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
                    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. In the CY 2007 OPPS proposed rule, we proposed 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 the proposed rule, we proposed 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 proposed 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. In the proposed rule, we indicated that, for this initial phase of implementing an OPPS RHQDAPU program in CY 2007, it would 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 50 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 would continue to receive the full update to the OPPS conversion factor. However, as we explained in the proposed rule, our intention was 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. In the proposed rule, we explained that 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 
                        ( print page 68192)
                        under our equitable adjustment authority. We believe 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 well-developed 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 proposed 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 seven 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. As we noted in the proposed rule, 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 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 seven 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 seven 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 seven 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 four 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 that ultimately depends on clinical considerations, including their response to treatment. Thus, we believe that all four 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, in the CY 2007 OPPS proposed rule we concluded that 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 
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                        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 step while specific quality measures are being developed and refined for reporting on the quality of care to hospital outpatients, we proposed that the initial CY 2007 OPPS RHQDAPU incorporate all of the quality measures that are applicable to the IPPS during FY 2007. In the proposed rule, we welcomed 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. In the proposed rule, we also discussed our proposed additional quality measures for hospital reporting of quality data for the FY 2008 IPPS. The proposed areas of expansion for the FY 2008 IPPS include the HCAHPS survey, which incorporates questions measuring patients' perspectives of 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 risk-adjusted 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, in the proposed rule we explained that 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 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 three 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 office visits, and reflect outcomes of care specifically for Medicare patients. Because we proposed 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, in the CY 2007 OPPS proposed rule we stated our intention 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. In the CY 2007 OPPS proposed rule, we welcomed public comments on the applicability of the FY 2008 IPPS additional quality measures that we proposed to the care of hospital outpatients. We also welcomed 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 indicated that we would 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, we proposed 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 proposed conversion factor of $60.36, reflecting an update of 1.4 percent, in place of the proposed conversion factor of $61.551 reflecting the full update of 3.4 percent. We proposed to add a new § 419.43(h) to incorporate our proposal. 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 (
                        *http://www.qnetexchange.org*). For purposes of determining which hospitals have not qualified to receive the full update under the OPPS for CY 2007, we indicated in the proposed rule that we would follow the determination for FY 2007 full IPPS payment update eligibility under the IPPS RHQDAPU program. Since publication of the CY 2007 OPPS proposed rule, CMS has determined that 171 hospitals are not eligible to receive the full FY 2007 IPPS payment update. As we noted above, we proposed 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) provided 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 would 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 would also 
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                        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 failed to meet the requirements for receiving the full update to the OPPS conversion factor in CY 2007 were available in September 2006. During the development of the proposed rule, we were unable to determine how many hospitals would receive a reduced update in CY 2007, or to determine the budget neutrality adjustment factor that would be necessary to ensure that estimated aggregate payments under the OPPS for CY 2007 did not change as a result of implementing the proposed OPPS RHQDAPU program. However, we noted that very few hospitals had previously failed to qualify for the full annual updates under the IPPS RHQDAPU program. Therefore, we anticipated 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 would be negligible. Our projections were correct, as only a few hospitals were not eligible to receive the full FY 2007 IPPS update. We explained in the proposed rule that it was 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 would 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 indicated in the proposed rule that 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 said that 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, outpatient-specific 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 explained that we would 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 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, in the proposed rule we welcomed comments on this issue. Specifically, in the CY 2007 OPPS proposed rule, we invited 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 and we proposed 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 would 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 proposed to all hospital outpatient departments paid under the OPPS. Therefore, we indicated that we would 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 explained that we would also begin development of mechanisms by which these hospitals could report the requisite quality data in a timely and effective manner. In the proposed rule, we welcomed comments on ways in which we could 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. In the proposed rule, we explained that 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 noted that we would 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 value-based purchasing by FY 2009. We explained that 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 would provide more comprehensive information about the quality of services provided by hospitals. In the proposed rule, we requested 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, in the CY 2007 OPPS proposed rule, we requested 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, we indicated that 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 
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                        authorities available to CMS under the Act to promote higher quality, more equitable care. We stressed that we did not believe that the status quo, with rapid and uneven growth in spending and limited evidence of its value, was consistent with an efficient hospital outpatient payment program and value-driven health care for Medicare beneficiaries, and we expect to take further steps to address this important concern. In addition, we sought 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. *Comment:*
                         Some commenters generally supported the proposal to reduce the update to the OPPS conversion factor for 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. One commenter characterized the proposal as “an important and laudable project.” However, this commenter also expressed concern that the projected expansion of reporting to additional, outpatient-specific measures would require significant increases in hospital resources, including additional staff and increased vendor workload. Another commenter agreed with the agency's goals of adopting value-based purchasing and promoting higher quality services. This commenter expressed concern, however, that the adoption of the IPPS standards might delay development of standards that are appropriate to outpatient care. Another commenter supported the proposal as an interim step toward development and reporting of quality measures that are most appropriate to the hospital outpatient department setting. This commenter noted that the proposed reduction to a hospital's outpatient payment update would provide an additional incentive to spur the submission of the inpatient quality data. Commenters also recommended that CMS evaluate the effectiveness of reporting quality data and consider increasing the reduction or shifting the application of the reduction to reflect actual performance rather than mere reporting. Another commenter supported the effort to improve the quality of care in hospital outpatient departments. This commenter offered specific suggestions for revising the proposed list of quality measures for use in the hospital outpatient department setting. For example, the commenter recommender that the heart attack (Acute Myocardial Infarction/AMI) measures be expanded to reflect current standards of care, which include provision of both aspirin and clopidogrel bisulfate to patients with Acute Coronary Syndrome on discharge. One commenter said that it was not clear whether CMS was proposing: (1) That hospitals must report the IPPS measures for outpatient services to prevent a 2.0 percent reduction on their FY 2007 conversion factor update, or (2) that hospitals that report all of the IPPS measures will automatically receive the full OPPS update. The commenter strongly objected to the application of the IPPS measures to outpatient hospital services and said that CMS should consolidate the various silos of measures into a single set of quality measures that promote patient-centeredness, episodes of care, the continuum of care, and disease management. The commenter also stated that there needs to be a national measurement framework for establishing the priorities for outpatient measures and that when outpatient measures are constructed, there should be testing prior to public reporting of the findings. However, the commenter also expressed support for a policy that CMS “use the evidence of IPPS reporting to influence the OPPS conversion factor update for CY 2007 * * *.” This commenter supported this “extra incentive for hospital quality reporting,” on the grounds that it “is imperative that all hospitals participate in this avenue for accountability and quality improvement. Thus, basing a portion of OPPS payment on whether hospitals report their IPPS measures is warranted.” One commenter noted that some hospitals are still attempting to master the original inpatient measures. The commenter suggested the most appropriate time to add outpatient quality indicators would be that when this task has been mastered. The commenter also suggested the non-inpatient indicators should be added for all entities at the same time, noting that the CMS proposal under the OPPS does not apply to ambulatory surgical centers. Finally, one commenter agreed that there is some correlation between outpatient and inpatient care for the specific diagnoses included in the current IPPS reporting measures, but expressed some concern about the use of the IPPS measures as a proxy for the quality of hospital outpatient services. The commenter suggested that modification of some current inpatient measures to include outpatients could provide an interim methodology. However, the commenter also stated that there should not be a rush to put outpatient measures into place without prior review of such modifications by all stakeholders. A number of other commenters strongly opposed our proposal. Several commenters objected that the proposal was unfair because it would take into account reporting that hospitals had already performed before they became aware of the additional payment reduction proposed under the OPPS for failure to report the measures. Some of these commenters expressed the view that, in this respect, the proposal amounted to retroactive rulemaking, since hospitals could now take no action to avoid a potential reduction to their CY 2007 payments if the proposal is adopted. Other commenters objected that the proposal exceeds CMS’ statutory authority. Some of these commenters argued that the congressional mandate of quality reporting in the hospital inpatient and home health settings precludes CMS from extending reporting into the hospital outpatient setting without such specific statutory authority. These and other commenters also objected that section 1833(t)(2)(E) of the Act, which allows the Secretary to establish “other adjustments as determined to be necessary to ensure equitable payments,” does not provide adequate statutory authority to tie hospital outpatient payments to quality reporting. In addition, some commenters noted that unlike other adjustments proposed for the CY 2007 OPPS, there appeared to be no provision for the amounts not spent in the full update for hospitals that did not meet the IPPS quality reporting standards to be returned to other providers through increases in payment. They believe that this proposal appeared to be a penalty, rather than an equitable adjustment. Some commenters also objected to the proposed linkage of outpatient payment to inpatient measures of quality. Several commenters stated that the IPPS quality measures have no documented validity for outpatient care and services. Other commenters stated that the inpatient measures are not appropriate proxies for hospital outpatient care measures, for a variety of reasons. For example, one commenter pointed out that there is evidence that patients diagnosed with AMI, and who have no contraindications for receiving particular medications, have a better outcome if they receive aspirin and beta blockers within a short time of presenting to the hospital. However, there is no evidence of better outcomes 
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                        for patients who receive aspirin when they present in an emergency department with chest pain, but are diagnosed with some condition other than heart attack and are sent home. Therefore, these commenters believe that CMS should proceed with care in taking these measures into account in the outpatient setting only after a thorough, scientific review to establish the application of the measures to outpatient care. One commenter specifically recommended that CMS should not proceed with expanding quality reporting into the hospital outpatient setting in any manner without a thorough scientific review conducted by such organizations as the National Quality Forum (NQF). The commenter noted that the NQF has endorsed the 21 hospital-based inpatient quality measures only for assessing quality of care in the inpatient setting, not for use in the hospital outpatient setting. Some commenters were concerned that additional outpatient hospital-specific measures could result in a greatly increased administrative burden, due to the volume of services in the outpatient setting that is much greater than the inpatient setting. Other commenters asked that outpatient quality and cost of care measures conform to standards of clinically appropriate care as established by peer-reviewed literature or professional consensus, be sufficiently flexible to allow access to new technology and devices, and be reviewed and updated periodically. They thought that when providers met a particular measure, it should be removed to reduce the reporting burden. MedPAC agreed that certain of the IPPS measures, such as provision of aspirin on arrival to a patient with AMI, could conceptually be employed for evaluating outpatient quality. However, MedPAC also advised that additional analysis may be necessary in order to ensure that these measures apply in the outpatient hospital setting. MedPAC also expressed a preference that CMS seek the authority to move beyond pay-for-reporting toward pay-for-performance, so that payment updates depend on empirical evidence of outcomes from the quality data, not merely on whether the data are submitted. *Response:*
                         We appreciate the many thoughtful comments that we received on our proposal. We continue to believe that the statute permits us to provide a differential payment adjustment under the OPPS for quality reporting, consistent with our broad authority under section 1833(t)(2)(E) of the Act to provide an adjustment to ensure that payments are equitable. As we explained in the proposed rule, it is inequitable for hospitals providing poorer quality care that may result in the provision of more health services to Medicare beneficiaries in the hospital outpatient department to be in a position to receive higher payments from the OPPS for that episode of care, a result more in keeping with a fee-for-service payment system that provides payments for services without a focus on quality. The rapid spending growth in the OPPS is primarily due to brisk growth in the intensity and utilization of services, rather than general price or enrollment changes. This growth has occurred in an OPPS payment environment that has not yet focused on accounting for high quality care that improves the health of Medicare beneficiaries. We believe that the OPPS must look forward, and that future OPPS spending should be directed in the most efficient manner possible toward higher quality services. A continued lack of focus on the quality and value is not desirable for the program over the upcoming years. Specifically, we believe we have the statutory authority to provide a differential update based on quality reporting in the OPPS as we proposed. While we acknowledge that the IPPS RHQDAPU program is based in part on a DRA provision, the law does not preclude the Secretary from using his other statutory authorities to ensure that other services paid by Medicare, such as the outpatient hospital services paid under the OPPS, are of appropriately high quality. CMS’ shift across payment systems to quality-based payment reform is an evolutionary process. On the hospital inpatient side, we began with linking the IPPS annual payment update to reporting on 10 quality measures, and we now have expanded the measure set for inpatient hospital reporting in FY 2007. In the DRA, Congress mandated that DHHS develop a plan for implementation of hospital value-based purchasing beginning with FY 2009. While the plan specifically focuses on the inpatient setting, moving toward pay for reporting in the hospital outpatient setting as we proposed is a logical next step. We believe it is very valuable for hospitals and CMS to gain as much experience as possible with all aspects of quality reporting with a focus on ultimately enhancing value for Medicare. As we discussed in detail in our proposal, we proposed as an initial step in the program's movement toward value-based purchasing to reduce the update to the CY 2007 OPPS conversion factor by 2.0 percentage points for those hospitals that are required to report quality data under the IPPS RHQDAPU quality reporting program and fail to meet the requirements for receiving the full FY 2007 IPPS payment update. We appreciate the perspective of the commenters who acknowledged that this initial step was a sensible progression and agreed that the proposal would provide an extra incentive for hospital quality reporting that is an effective avenue to hospital accountability and quality improvement. We also explained that this proposal was only the first phase of implementing a quality reporting program in the OPPS, which would eventually expand to encompass reporting by all hospitals paid under the OPPS and refinement of quality measures to include those specific to hospital outpatient services. In contrast, however, we acknowledge that many commenters expressed their belief that quality performance in the outpatient setting could only be fairly and accurately assessed through the reporting of quality measures that are specific to outpatient hospital care by all hospitals paid under the OPPS. We agree that the current inpatient quality measures have some limitations as proxies for the quality of outpatient hospital care, in particular, their use to assess what constitutes effective treatment for different patient populations. The inpatient measures have been developed and refined for those patients who are admitted as hospital inpatients, and those patients may differ in several ways, including the severity of their illnesses, from hospital outpatients. We agree with commenters who believe that hospitals should be held accountable for the quality of their outpatient hospital services through measures that are specific to that care. Throughout the development of the IPPS quality measures, we have highly valued stakeholder input in the measure selection and refinement processes. We hope they continue to contribute vital input into the OPPS RHQDAPU quality reporting program, as we seek to create a bridge based on quality in the OPPS between the care setting and the payment setting. We do not intend to implement a quality reporting program linked to the OPPS annual update that is based on quality reporting that does not conceptually and practically reflect this vital link. While the DRA-mandated hospital value-based purchasing plan only requires CMS to design a plan for the inpatient hospital setting, as part of that work we are also considering issues 
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                        related to the implementation of quality reporting in the hospital outpatient setting. We see extension of the focus on quality to outpatient hospital services, many of which were inpatient services until recently, as a logical progression. Most importantly, we believe that implementing a payment adjustment would serve as an important milestone to signal the program's emerging focus on quality services that provide significant benefits to the health of Medicare beneficiaries. We agree with the commenters that assessment of hospital outpatient performance would ultimately be most appropriately based on reporting of hospital outpatient measures developed specifically for this purpose. Public reporting of specific outpatient hospital quality measures requires not only having developed, accepted measures, but also having in place the infrastructure for data collection and reporting. To reach the point where an outpatient hospital measure is collected and reported, based on our experience with developing the IPPS measures, multiple steps are involved. For a single measure, these steps include developing the measure, obtaining stakeholder endorsement, vetting the measure with appropriate organizations, engaging vendors and providing a vehicle for chart reviews to support reporting, testing of the Web site display, and then beginning data collection. From the start of actual data collection, given the time period allowed for submission of data and the time it takes to preview and ultimately generate a usable report, it would take at least one year before the measure could be reported. CMS has built strong and productive working relationships with many organizations, including the Joint Commission on Accreditation of Healthcare Organizations, the NQF, Hospital Quality Alliance, and others through our IPPS measure development experience. We would hope these relationships continue in our move to develop outpatient hospital quality measures for reporting. We also would seek to minimize the reporting burden on hospitals through close collaboration with the hospital industry to develop appropriate measures and an efficient data collection methodology. Some commenters recommended that some of the current inpatient hospital measures could be adapted to provide information specifically regarding outpatient hospital care. However, whether we adapt existing measures or develop new ones, we would need to engage in the same development and infrastructure activities. We have already begun to take a more systematic approach to the development of hospital outpatient measures, and we plan to accelerate our timetable significantly during CY 2007. We appreciate the specific suggestions of commenters regarding measure development for hospital outpatient care, and we welcome ongoing public input in this area. We have concluded that the most appropriate course at this point is to implement the OPPS quality update reporting program based on measures specifically developed to characterize the quality of hospital outpatient care. We believe the process will require 2 years before quality measure data are available. Given our concerns about the increasing growth in OPPS spending without concern for the value of the services, we do not believe it would be appropriate to delay focusing on the quality of hospital outpatient services beyond the minimum of 2 years required for the development and implementation of these measures. We agree with those commenters who pointed out that implementation of the OPPS RHQDAPU program as proposed for CY 2007 would mean that hospitals could not have made decisions regarding their participation in the IPPS quality reporting program with full knowledge of the effects of their participation on their OPPS update. While implementation of the OPPS RHQDAPU program in CY 2008 based on hospitals' participation in the IPPS RHQDAPU would be possible because hospitals would have the opportunity to make decisions knowing the consequences of their participation, we believe that the quality of hospital outpatient services would be most appropriately and fairly rewarded through the reporting of quality measures developed specifically for application in the hospital outpatient setting. Therefore, we are delaying implementation of the OPPS RHQDAPU program until CY 2009, when we will implement a 2.0 point reduction to the OPPS conversion factor update for those hospitals that do not meet the specific requirements of the CY 2009 OPPS RHQDAPU program. The CY 2009 program will be based upon CY 2008 hospital reporting of effective measures of the quality of hospital outpatient care that have been carefully developed and evaluated, and endorsed as appropriate, with significant input from stakeholders. We have revised proposed § 419.43(h) to reflect this new effective date and we are adopting it as revised in this final rule with comment period. We also note that in the CY 2008 OPPS proposed rule, we may further refine our approach under the OPPS RHQDAPU program. We continue to believe that it is not only appropriate but necessary to require that hospitals must fully comply with the OPPS RHQDAPU program requirements to receive OPPS payment that reflects the full CY 2009 update to the conversion factor. We believe that ensuring that Medicare beneficiaries receive the care they need and that such services are of appropriately high quality are the necessary initial steps to incorporating value-based purchasing into the OPPS. We seek to encourage care that is both efficient and of high quality in the hospital outpatient department. We plan to work quickly and collaboratively with the hospital community to develop and implement quality measures for the OPPS that are fully and specifically reflective of the quality of hospital outpatient services. XX. Promoting Effective Use of Health Information Technology 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 evidence-based 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 portion of the total savings. 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 
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                        of participation in disease management programs and following medical advice. For these reasons, extreme caution should be used in interpreting these results. 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. In the proposed rule, we sought comments on our statutory authority to encourage the adoption and use of HIT. We also sought 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 the proposed rule, we did not propose adding adoption of HIT to the Medicare hospital conditions of participation. However, we solicited 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. We received 13 responses to the proposed rule on this section. Below is a summary of the comments within each response addressing: (1) CMS’ statutory authority and use of our conditions of participation to encourage adoption of effective HIT; (2) the role that HIT should play in value-based purchasing; and (3) the importance of interoperability standards in promoting the adoption of HIT. In addition to these areas in which we sought comments, we also received several comments on the challenges of implementing HIT, which were particularly focused on barriers such as the high cost of implementation. *Comments:*
                         Some commenters addressed CMS’ statutory authority to encourage adoption of effective HIT. One commenter referenced CMS’ previous use of statutory authority to promulgate exceptions under the physician self-referral law as an example of the agency's authority to promote the adoption of HIT. Another commenter stated that CMS does not have the statutory authority to promote adoption of HIT and, therefore, should concentrate on other mechanisms, such CMS’ demonstrations authority to encourage HIT adoption. Several commenters addressed CMS’ idea of promoting the adoption of HIT through CMS conditions of participation. Some of the commenters were in favor of including adoption of HIT in conditions of participation. One commenter suggested making modifications to existing conditions of participation in lieu of creating new conditions of participation to accommodate adoption of HIT. Many commenters opposed including the adoption of HIT in the conditions of participation. Commenters opposed to including HIT implementation within conditions of participation characterized the proposal as creating an “unfunded mandate.” Many commenters provided feedback on the proper role of HIT within a value-based purchasing system. The majority of commenters noted that adoption of HIT can lead to improved quality, enhanced patient safety, and increased efficiency. Many commenters emphasized that HIT can reduce the burden associated with quality reporting. One commenter stated that the foundation of HIT adoption should support the aims outlined within the IOM's “Crossing the Quality Chasm Report”: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Another commenter suggested that CMS could advance its quality agenda by investing in the development of algorithms for the calculation of quality measure scores. Most commenters stated that a value-based purchasing system should emphasize process and outcomes measures, rather than structural measures such as the use of HIT tools like computerized physician order entry. However, two commenters stated that use of HIT should be included as a structural measure for any value-based purchasing system. Several commenters addressed the costs associated with HIT implementation. Several commenters stated that HIT is very costly to implement and felt strongly that implementation of HIT should be a shared expense between providers, purchasers, and payers. Some commenters felt that incentives could aid providers by reducing the cost burden and suggested that direct Medicare payment for HIT would most effectively encourage its adoption. Several commenters addressed the importance of interoperability standards for HIT. Many commenters noted that interoperability standards are a critical component of any HIT system and must include a standard set of policies, procedures, and standards for data collection and documentation. The commenters also noted the importance of having interoperability standards that are publicly available and non-proprietary. One commenter suggested that HHS and AHIC should provide modern terminology to guide the adoption of interoperability standards, such as those identified in the Consolidated Health Informatics (CHI) and the SNOMED-CT®, adopted by CHI and approved by the National Committee on Vital and Health Statistics. In addition to interoperability standards, one commenter stated that a rigorous quality assurance process that addresses strict adherence to interoperability standards should be required by third party certification. 
                        ( print page 68199) One commenter strongly supported the role of both AHIC and the Ambulatory Quality Alliance-Hospital Quality Alliance Steering Committee in promoting the adoption of HIT. Another commenter commended CMS on promoting adoption of HIT by “promulgating regulatory protections under the physician self-referral and Anti-Kickback Statutes for donations related to electronic medical records.” *Response:*
                         We thank all commenters for their thoughtful and valuable discussion of the issues. In the HIT section of the preamble to the proposed rule, we recognized the potential for effective HIT to facilitate improvements in the quality and efficiency of health care services. We also pointed out CMS’ promotion of the adoption and effective use of HIT in coordination with other Federal agencies and the Office of the National Coordinator for Health Information Technology. Here, we will discuss three initiatives that we are emphasizing to promote the effective use of HIT, in light of the comments we received: (1) Value-based purchasing, (2) the recent CMS and OIG final rules regarding the donation of certain HIT, and (3) infrastructure and interoperability standards. We continue to explore the implementation of value-based purchasing payment system reforms because we believe that, among other advantages, value-based purchasing can encourage hospitals to invest in activities, such as effective HIT, that have the potential to improve quality and decrease unnecessary costs. However, linking a portion of Medicare payments to valid measures of quality and effective use of resources could give hospitals more direct incentives to implement innovative ideas and approaches that may result in improved value of care. We agree with the commenters that noted that the use of effective HIT could increase quality, efficiency, and patient safety. We also agree with the commenters that noted that effective use of HIT can be used to decrease the burden of reporting to value-based purchasing programs. However, we disagree with the commenters that recommended direct government funding of HIT. As stated in the President's 2007 Budget, “the Administration supports the adoption of [HIT] as a normal cost of doing business to ensure patients receive high quality care.” Commenters noted that multiple stakeholders in the health care system, including purchasers and payers, benefit from provider adoption and use of effective HIT and should share in the cost. CMS and OIG have recently issued final rules to allow hospitals and other health care providers under some circumstances to donate electronic prescribing and electronic health records technology to physicians and others without running afoul of the Stark (physician self-referral) and anti-kickback statutes. We believe that these rules facilitate the adoption of HIT by physicians and other health care providers who might otherwise have been unable or unwilling to invest in the technology. We also believe that these regulatory changes help to stimulate the adoption of effective HIT, and that, as HIT use spreads, the benefits relative to the costs of implementation may increase for all stakeholders. The majority of commenters pointed out that the current lack of HIT infrastructure, including lack of interoperability standards, is a major obstacle to adoption and effective use of HIT. To address the lack of infrastructure, the Secretary has undertaken a national strategy that calls for Federal agencies to collaborate with private stakeholders in the development of architecture, standards, certification processes, and methods of governance to facilitate the adoption of effective HIT. In September 2005, the Secretary selected 16 commissioners to serve on the American Health Information Community (AHIC or Community), which is a federally chartered collaborative forum of private and public interests charged with advising the Secretary on how to make health information digital and interoperable. The goals of the Community include immediate access to vital medical information at the point of care, privacy protection, better data for research, and overall cost savings. The work of the Community has been divided among six workgroups: (1) The Electronic Health Records Workgroup, (2) the Chronic Care Workgroup, (3) the Consumer Empowerment Workgroup, (4) the Biosurveillance Workgroup, (5) the Confidentiality, Privacy, and Security Workgroup, and (6) the Quality Workgroup. The AHIC Workgroups have made recommendations, as their initial “breakthroughs,” pertaining to: an electronic medication summary and registration history; secure messaging capabilities for individuals with chronic disease; biosurveillance monitoring; and, through secure means, broadening the availability and access to current and historical laboratory results and interpretations. More information about the Community is available at: 
                        *http://www.hhs.gov/​healthit/​ahic.html*. In conclusion, we are not at this time requiring adoption of certified, interoperable HIT as a part of the Medicare conditions of participation. Rather, we are reserving judgment on the imposition of such a requirement and will continue to research the feasibility of doing so. We may revisit this issue in the CY 2008 OPPS proposed rule or in another rulemaking proceeding. XXI. Health Care Information Transparency Initiative 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. 
                        ( print page 68200) 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 also recently posted geographically-based Medicare payment information for common elective procedures for ambulatory surgery centers on our Web site at 
                        *http://www.cms.hhs.gov/​HealthCareConInit/​03_​ASC.asp*. We will post similar information 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. The comments we received on our transparency initiative and our responses are summarized below. *Comment:*
                         All commenters supported the concept of providing useful information for consumers and patients on the price and quality of care delivered in the outpatient setting. However, many commenters also noted the complexity of such information, particularly price and cost data, and identified issues that would need to be addressed when determining what information is most helpful and the manner in which it should be given to consumers. In particular, commenters noted that (1) the price of services varies by patient needs and services, (2) hospital costs also include their public service role, (3) physician services are not included in the hospital bill, and (4) hospital prices would vary based on the insurance status of the patient. The commenters suggested that price information should be easy to understand and use, easy to access, use common definitions and language, and explain the factors that affect prices. Several commenters also described their proposals for making such information more readily available through state and insurer mandates and hospital and Federal research efforts to identify the most useful price information. Several commenters also noted that price and quality information should be released together. *Response:*
                         We agree that price information is complex and that the factors that affect price noted by the commenters should be considered when determining what information to release and the manner in which it is provided. For inpatient services, we released Medicare payment information for common conditions, and we plan to do so for outpatient services later this fall. This type of information provides beneficiaries and their families with information on their potential out-of-pocket costs. Another useful way to describe costs may be to provide information on the total costs for a course of treatment (beyond just the inpatient stay) for an episode of care (potentially encompassing all providers and over time for a specific condition). Consumers may also want information about the quality of care across the episode. Because some services delivered in the outpatient setting are also delivered in ambulatory surgical centers and physicians' offices, we also may consider comparisons across settings in the future. We also agree that information on price should be easy to use and access, and that it is important to continue research on the best way to provide such information to consumers. We have been posting information on the quality of care for several settings, including hospitals, nursing homes, dialysis facilities, Medicare Advantage plans, and Part D plans. Regarding the Part D information, we have created an interactive tool which provides beneficiaries an unprecedented level of detail on the availability of their drugs and potential cost liability for plans in their region. We anticipate using our experience with these tools and working with others to develop useful tools for displaying information on outpatient services. We are grateful for the support for our efforts and will welcome proposals for providing consumers and patients useful information on price and quality. *Comment:*
                         Several commenters suggested that CMS work through the AQA and Hospital Quality Alliance efforts, along with the joint steering committee charged with harmonizing hospital and physician measurement—the Quality Alliance Steering Committee—to identify the most useful price and quality measures for the outpatient settings. *Response:*
                         We strongly support the AQA and HQA efforts, and believe that such collaboration is critical to the success of transparency. To the extent these organizations, as well as others, such as the National Quality Forum, reach consensus regarding price or quality measures for outpatient settings we would look to their efforts to inform ours. *Comment:*
                         One commenter stated that in addition to making sure the measures and the process are useful, it is critical to make sure the data, particularly claims, are consistent across settings. The commenter noted the need to update data standards to reflect the contents of 21st century health records, including moving to ICD-10-CM and using other standards endorsed by the National Committee on Vital and Health Statistics (NCVHS). *Response:*
                         We agree that it is critically important for the information underlying these price and quality measures to be as uniform and accurate as possible. As directed by the President's Executive Order, we are currently engaged in numerous department initiatives to identify and endorse terminology and messaging standards and to support a certification process for electronic health records. We also support movement towards the ICD-10-CM coding system. As consumers, patients, and providers become increasingly engaged in the use of health care price and quality information this will become ever more important. *Comment:*
                         One commenter noted that the length of time used to calculate costs and quality is critical. The commenter stated that the outcome of a service may take a long time to manifest, sometimes even longer than a year, so that the 
                        ( print page 68201)
                        length of time used should be considered. *Response:*
                         We recognize that the length of time in which patient outcomes manifest may vary. We believe it will be important, particularly when assessing the cost and quality of broad episodes of care to vary the episode length depending on the patterns of care specific to the condition. XXII. Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update 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 Public Law 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 1886(b)(3)(B)(viii)(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 1886(b)(3)(B)(viii) (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 Consumer-Purchaser Disclosure Project, the AARP, the American Federation of Labor-Congress of Industrial Organizations (AFL-CIO), the Agency for Healthcare Research and Quality (AHRQ), as well as CMS, Quality Improvement Organizations (QIOs), 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. The RHQDAPU program, however, is distinct from the HQA (formerly known as the National Voluntary Hospital Reporting Initiative). Hospitals participate in the HQA on an entirely voluntary basis. Participation in HQA has no bearing on payment under Medicare or any other Federal program. The RHQDAPU program is a CMS program that ties quality data reporting to payment under the IPPS. In some ways, the HQA can be seen as a testing ground for a quality measure before CMS adopts it for purposes of the RHQDAPU program. To date, all of the quality measures CMS has adopted for purposes of the RHQDAPU had previously been for HQA reporting. We note, however, that HQA adoption is not a legal prerequisite for CMS to adopt a measure for purposes of the RHQDAPU program. In the FY 2007 IPPS final rule, we began to implement the new IPPS RHQDAPU program requirements by adding 11 HQA-approved measures to our 10-measure “starter set” of quality measures, for purposes of the FY 2007 update (71 FR 48031 through 48037). 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, we 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 in order 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 so 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, in the CY 2007 OPPS proposed rule, we sought comments on this proposal to expand, for FY 2008, the measurement set beyond those measures we adopted 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. We received a number of comments in response to our proposal. These comments are discussed below. *Comment:*
                         A majority of the commenters appreciated that CMS has proposed measures for FY 2008 that have already been adopted as part of the HQA's effort to promote public reporting of hospital data. Also, commenters recommended that CMS continue to work with HQA and that CMS align its choices of measures and link payment with the measures chosen by HQA to provide a public accountability for quality. The commenters suggested that this alignment will also reinforce the importance of public transparency on quality to help to focus quality improvement efforts on identified high priority care areas. *Response:*
                         We strongly value our association with the HQA, which was established as a public-private collaboration to promote voluntary hospital public reporting on quality of care. We plan to continue to work closely with HQA on the choice of measures publicly reported on Hospital Compare. Additionally, we will 
                        ( print page 68202)
                        continue to focus efforts on measures adopted by the HQA. *Comment:*
                         A majority of the commenters applauded and expressed support for CMS efforts to establish the measures hospitals will be expected to report under the IPPS RHQDAPU program early enough for hospitals to put the proper data collection processes in place. *Response:*
                         We appreciate these comments as we recognize the importance of communications to hospitals. CMS will continue to provide information as early as possible on the measures hospitals that will be used for the IPPS RHQDAPU program. We also look forward to commenters' continued support as we expand the set of measures for the program. *Comment:*
                         One commenter supported the expanded FY 2008 measurement set, but urged CMS to also add the structural measures that were included in the 2005 IOM report “Performance Measurement: Accelerating Improvement.” *Response:*
                         At this time we are not adopting the three structural measures recommended by the Leapfrog Group. As we continue to expand the set of measures under the IPPS RHQDAPU program, we will further evaluate and consider these structural measures. *Comment:*
                         One commenter supported the HQA and its work to implement NQF-endorsed measures through a collaborative, public-private partnership. However, although the commenter believed that the HQA has been instrumental in advancing hospital performance reporting via the Hospital Compare Web site, the commenter did not believe that the HQA adhered to the same consensus-building process used by the NQF. The commenter viewed the roles of these two entities as distinct, though complementary. *Response:*
                         We agree that the roles of the HQA and NQF are distinct. However, the NQF is represented on the HQA and the HQA has in principle and in practice agreed to only employ NQF-endorsed measures for public reporting. Therefore, all measures advanced by the HQA for public reporting have gone through the NQF consensus building process. *Comment:*
                         One commenter suggested that there was a need to develop an infrastructure that would facilitate the efficient transmission and storage of data and to designate an oversight entity that is responsible for the infrastructure. The commenter recommended that CMS consult with healthcare stakeholders before determining where the quality data are housed. *Response:*
                         We have a centralized information technology infrastructure in place for the transmission and storage of clinical data in support of our quality improvement initiatives. Clinical data are transmitted to the QIO Clinical Warehouse via QualityNet Exchange, a secure Web site. Access to data stored in the QIO Clinical Warehouse is limited to authorized parties. We solicit input from other healthcare stakeholders to facilitate the design and enhancements to this system. *Comment:*
                         One commenter stated the current reporting of quality data is costly, the data definitions change quarterly, and it is difficult to use the validation process. The commenter recommended that because payments are based on the validation of the measures, CMS must absolutely ensure that the CDAC and QIOs interpret the data the same way. *Response:*
                         The validation and appeal processes are posted on the QualityNet Web site under the Hospital/Data Validation tab. The Specifications Manual for National Hospital Quality Measures is updated routinely to stay with current medical practices. Hospitals should continue working with their QIOs in order to keep up with the most recent updates. The CDAC utilizes this same manual during validation for the re-abstraction of medical records. Modifications or clarifications in the manual are shared with hospitals, QIOs, and the CDAC concurrently in order to maintain a common abstraction knowledge base. We have devoted substantial resources to ensuring that the CDAC process is consistent, reliable and accurate. *Comment:*
                         Two commenters suggested that CMS create a private-sector mechanism to leverage the reporting benefit the JCAHO is providing through its vendors, especially with respect to attention to the quality of the data. *Response:*
                         CMS strongly values its collaborative relationship with the JCAHO and agrees the vendor community input is important. CMS is currently considering whether to form an advisory work group of vendors to work with our staff. *Comment:*
                         One commenter did not oppose collecting of data on the proposed measures and publishing the measures for the public. However, the commenter opposed tying payment to the quality of the data during the initial phases of data collection of new measures sets. Also, the commenter opposed the proposed implementation of the new measure set because it does not give hospitals a transition period to collect data that will affect payments. *Response:*
                         We thoroughly evaluate all measures before linking them to payment. We are using this rulemaking in addition to the IPPS rulemaking to establish additional measures in order to give hospitals advance notice and lead time to learn about the collection requirements of the new measures before linking them to payment. We note that the HQA will be collecting and reporting these new measures sets before hospitals begin reporting these measures for RHQDAPU purposes. For example, the HQA began collecting the SCIP-VTE 1 and SCIP-VTE 2 measures in fourth quarter 2006, when they were first published in the HQA Specifications Manual for National Hospital Quality Measures. This allows hospitals three months to abstract and submit these measures before the first quarter of 2007, when they become IPPS RHQDAPU measures for purposes of the FY 2008 IPPS market basket update. Collection of SCIP Infection 1 and SCIP Infection 3 as RHQDAPU program measures for FY 2008 began third quarter of 2006. CMS believes the addition of SCIP-VTE 1, SCIP-VTE 2, and SCIP Infection 2 measures to the RHQDAPU measures beginning first quarter 2007 provides reasonable advance notice for hospitals. B. Additional Quality Measures for FY 2008 1. Introduction In the CY 2007 OPPS proposed rule, we proposed to add the following categories to the FY 2008 IPPS RHQDAPU program 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 (VTE) prophylaxis ordered for surgery patient 
                        ( print page 68203) + SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery + SCIP Infection 2: Prophylactic antibiotic selection for surgical patients *Mortality* + Acute Myocardial Infarction 30-day mortality—Medicare patients + Heart Failure 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 another HHS agency, AHRQ, 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 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 hospitals' internal customer services and quality related initiatives. Three broad goals have shaped HCAHPS. The survey is designed to produce data on the patients' perspective of care that allows objective and meaningful comparisons among 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 for its review and endorsement through its consensus development process. The NQF is a voluntary consensus standard-setting organization established to standardize health care quality measurement and reporting. 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 HCAHPS 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. 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, before we collected 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 began in October 2006 for this first set of hospitals and survey vendors that are participating in the HCAHPS voluntary initiative. The initial data collection covers 9 months of patient discharges (October 2006 through June 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 are 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 January 2007. Hospitals may choose to self-administer 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 XXII.C. and XXII.D. of this preamble. *Comment:*
                         Commenters expressed appreciation for the iterative process that CMS engaged in with the hospital field and other Federal agencies such as AHRQ in the development and then implementation of HCAHPS. *Response:*
                         We appreciate the comments and the input we received from stakeholders during the development process. *Comment:*
                         Because HCAHPS is a new measure set for hospital data collection, one commenter opposed using HCAHPS as part of the IPPS RHQDAPU program 
                        ( print page 68204)
                        until at least 12 months of data have been abstracted, submitted, and validated. *Response:*
                         For FY 2008, the IPPS annual payment update under the program is tied to reporting, not performance. This gives hospitals the opportunity to use HCAHPS without tying their scores to performance. HCAHPS has been rigorously tested and validated in collaboration with a public-private partnership (HQA) on hospital quality reporting. In addition, the National Quality Forum endorsed HCAHPS in May 2005 (see final report at 
                        *http://www.qualityforum.org*) and it has received final approval from the Federal OMB (December 2005). In order to submit HCAHPS data, each hospital, either self-administering or through use of a vendor, must participate in at least a one month dry run. The dry run mirrors all aspects of the data collection process: Sampling, survey administration, and data submission. The dry run allows participating providers to submit data without having it publicly reported. Hospitals that did not participate in the Spring 2006 dry runs will be required to carry out a dry run in March 2007 following training. Approximately 2,500 hospitals participated in the Spring 2006 dry run. These hospitals will have used HCAHPS for at least one year by July 2007. Unlike the clinical measures, hospitals cannot validate survey data. Therefore, our oversight focuses on ensuring vendors and hospitals are following the HCAHPS protocols. During this initial implementation prior to July 2007, CMS will begin conducting oversight activities to provide feedback to hospitals and survey vendors. We are also currently providing feedback based on the April, May and June 2006 dry run submissions and will conduct a similar process for the March 2007 dry run. After careful consideration of the public comments received, we are adopting as final the HCAHPS measure requirements we proposed. 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 Department of Veterans Affairs (VA), the AHRQ, the Centers for Disease Control and Prevention (CDC) and CMS. SCIP is a comprehensive program, integrated into the quality improvement agenda of the CMS, JCAHO, the CDC, the American College of Surgeons, the VA's 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. Hospital participation in the SCIP program is voluntary. We received a number of comments on the SCIP measures. *Comment:*
                         One commenter applauded CMS' proposal to add SCIP-VTE 1 and SCIP-VTE 2 to the IPPS RHQDAPU program. The commenter stated that adding these measures for hospitals reporting quality data under this program will help to improve quality of care for Medicare beneficiaries, and reduce the risk of post-operative complications associated with VTE. *Response:*
                         We appreciate the comment as we recognize the importance of these measures in improving the quality of care provided to Medicare beneficiaries. We plan to continue to focus efforts on measures that will decrease the risk of surgical complications. We also look forward to the commenter's continued support as we expand the set of measures for the RHQDAPU program. *Comment:*
                         One commenter expressed concern that the CMS Medicare Quality Improvement Community (MedQIC) has delineated inappropriate cost effectiveness factors for the SCIP target areas. MedQIC's SCIP target area of “Deep vein thrombosis” includes a discussion of the cost of low-dose unfractionated heparin (LDUH) versus the cost of low-molecular-weight heparin (LMWH). *Response:*
                         We have reviewed the information currently posted on MedQIC and the information pertaining to cost effectiveness factors for SCIP target areas is accurate. The statement from the SCIP Education Module (developed by the Florida QIO) about the cost of low-dose unfractionated heparin (LDUH) versus the cost of low-molecular weight heparin (LMWH) is not meant to be an endorsement of the lower cost thromboprophylaxis. As evident in the VTE prophylaxis recommendation table located in the Measure Information Form for SCIP-VTE-1 (found at 
                        *http://www.QualityNet.com*, select Hospitals, then Specifications Manual from the drop-down menu), both forms of thromboprophylaxis are listed, where appropriate. *Comment:*
                         One commenter urged CMS to take the lead in developing a new VTE measure for prophylaxis of medical patients at risk for VTE. The commenter believed that this is consistent with NQF-endorsed safe practices. The commenter noted that the IPPS RHQDAPU program currently only includes measures for VTE prophylaxis in surgery patients and recommended that CMS expand the measure to include a measure for prophylactic treatment of medical patients at risk for VTE. *Response:*
                         Currently, we are supportive of JCAHO's efforts to create VTE measures for the medical community and have provided technical support to that activity in conjunction with the alignment of other measures. We will continue to take an active part in making recommendations for additional measure development. *Comment:*
                         One commenter commended CMS for the steps it has taken through the SCIP pilot to increase VTE prophylaxis in acute care hospitals. The commenter believed that the addition of the SCIP-VTE 1 and 2 to the Hospital Compare Web site is an important step to improving prophylaxis and reducing complications in surgical patients. However, the commenter believed that there are a significant number of hospitalized nonsurgical patients who are at risk for VTE. The commenter stated VTE is a hospital-wide preventable condition; while addressing prophylaxis for surgical patients in the hospital setting is a necessary step, alone it is not sufficient to reduce the overall rate of VTE across the continuum of care. The commenter encouraged CMS to go beyond the silos of hospital setting and need based on surgery and address three critical areas: Continuity of prophylaxis into other treatment setting after surgery;
                    Prophylaxis for the medical patients in the hospital who are high risk of VTE;( print page 68205)
                    Outcome measures for all hospitalized patients, at 90 days for re-hospitalization for symptomatic VTE and mortality. *Response:*
                         We believe that the clinical situation for non-surgical patients is very different. The NQF has endorsed surgical VTE prophylaxis measures, but has not endorsed any VTE prophylaxis measures for the non-surgical patient. We are working closely with JCAHO in its work regarding VTE prophylaxis in the non-surgical patient. That work is very time consuming and final measures will take a significant amount of time to create and then test. In the interim CMS will move ahead with those measures for surgical patients. After careful consideration of the public comments received, we are adopting as final the SCIP requirements we proposed. 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 the QualityNet Exchange Web site (
                        *http://www.qnetexchange.org*). We proposed 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. Under the proposal, rates for the 30-day pneumonia mortality measure would be posted as soon as possible after we receive NQF endorsement. As is currently the case for the other measures, hospitals would be provided a 30-day period in which they would be permitted to preview their rates before publication. As is currently the case for the “starter set” measures, hospitals that pledged to submit data for full annual payment update for FY 2008 would not be permitted to suppress or withhold publication of the rates on the Hospital Compare Web site, except under highly limited circumstances. *Comment:*
                         Three commenters believed that use of the 30-day risk adjusted mortality measures for acute myocardial infarction and heart failure patients did not represent the best outcome measures that could be selected by Medicare to represent the quality of care delivered to patients in hospitals. The commenters recommended that CMS identify outcome measures that better reflect the quality of hospital care. *Response:*
                         We are interested in identifying other outcome measures that reflect quality hospital care that are of importance to consumers. However, the 30-day risk adjusted mortality measures for acute myocardial infarction and heart failure complement the other AMI and HF measures already reported on Hospital Compare and will provide additional information to consumers regarding the quality of care for these two important conditions. The evidence underlying the process measures for the cardiac conditions is based on outcomes of care (usually mortality) measured at a specified time interval (most frequently 30 days). Also, length of stay varies by hospital due to local custom, efficiency and transfer policies. For these reasons we believe that 30 day risk-adjusted mortality is a better outcome measure to measure the quality of care delivered to patients in hospitals than in-patient mortality. In addition, these measures were unanimously recommended by the NQF Scientific Committee as the sole claims-based 30-day mortality measures that met the NQF's stringent scientific criteria. The measures were subsequently NQF-endorsed through its consensus development process. *Comment:*
                         One commenter believed that the use of the 30-day risk adjusted mortality for acute myocardial infarction is not congruent with the in-hospital mortality measures that are part of the JCAHO core measures for acute myocardial infarction and an outcome measure that is being used in the Premier Hospital Quality Incentive Demonstration project. *Response:*
                         It is our understanding that the once CMS begins publicly reporting these 30-day mortality measures on Hospital Compare, JCAHO will no longer independently report inpatient mortality. The 30-day mortality measures include both patients who expire while in the hospital and patients who expire after discharge. We believe that the 30-day measure is a better measure to assess hospital performance because a standardized period of time over which performance is assessed is particularly important because (1) length of stay varies by hospital due to local custom, efficiency and transfer policies, and (2) limiting reporting to in-hospital mortality would provide a strong incentive for hospitals to adopt strategies to transfer people who are dying to other facilities (other acute care hospitals or SNFs or home). *Comment:*
                         One commenter recommended that CMS publicly recognize the limitations associated with the use of the mortality measures, as every risk-adjustment methodology has limitations based on its underlying assumptions that the data is available and used in those calculations. Additionally, the commenter recommended that CMS to be open to refining the risk adjustment methodology and/or selection of alternate outcome measures based on hospital and health system recommendations. *Response:*
                         We will make the mortality measures methodology transparent to the public by posting the report on the risk adjustment methodology and measure specifications on the CMS website at 
                        *http://www.cms.hhs.gov*
                         or 
                        *http://www.cms.hhs.gov/​HospitalQualityInits/​.*
                         The limitations of the measures will be a part of the report. Furthermore, hospitals and health systems will have the opportunity to examine the methodology, review their own data, and provide feedback to CMS in a national “dry run” of the measures 
                        ( print page 68206)
                        prior to public reporting. We also plan to continue refining and updating the mortality measures in order to ensure the scientific soundness of the measure methodology. *Comment:*
                         One commenter supported the use of outcome quality measures such as the 3 mortality measures. However, the commenter believed that CMS must make its risk adjustment method completely transparent to all stakeholders prior to using these measures of quality and noted that the propose rule does not contain a transparent explanation of how risk adjustments will be made. *Response:*
                         We will make the risk adjustment methodologies and measure specifications available to the public. Furthermore, prior to publicly reporting these mortality measures on Hospital Compare, CMS will conduct a dry run with all the hospitals in the nation. CMS will not post the hospital mortality rates on the Hospital Compare Web site during the dry run. The dry run is intended to give hospitals an opportunity to have experience with the measures and the risk adjustment methodology and review their mortality rates prior to public reporting. Hospitals will also have an opportunity to send their feedback to CMS during the dry run. After careful consideration of the public comments received, we are therefore adopting as final the AMI and heart failure mortality measure requirements we proposed. When we proposed adding the pneumonia mortality measure for the FY 2008 IPPS RHQDAPU program, we believed that it would soon be endorsed by the NQF. However, the NQF has not yet endorsed the pneumonia mortality measure. Therefore, we are not adopting the pneumonia mortality measure in this final rule. We intend to adopt this measure after the NQF endorses it. At the time we determine to adopt the measure, we would finalize our proposal to adopt the pneumonia mortality measure in a notice published in the 
                        **Federal Register**
                        . 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, as we proposed, we are requiring 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. For HCAHPS, the submission needs to be in the required XML formats or through the online data submission tool. 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 in42 CFR Part 480. In addition, for purposes of the annual payment update, we will continue to require hospitals to pass our validation requirements for the clinical quality measures. 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 additional measures. D. HCAHPS Procedures and Participation Requirements for the FY 2008 IPPS RHQDAPU Program 1. Introduction Under sections 1886(b)(3)(viii)(III) and 1886(b)(3)(B)(viii)(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 Public Law 108-173, effective for payments beginning with FY 2007. CMS is expanding the set of IOM measures that hospitals will be required to report to receive the full IPPS market basket update for FY 2008. In accordance with the recommendation of the 2005 IOM report, CMS is expanding the “starter” measures by including the HCAHPS patient perspective survey. In accordance with section 1886(b)(3)(B)(viii)(V) of the Act, CMS is also adding “other measures that reflect consensus among affected parties and, to the extent feasible and practicable,” and include “measures set forth by one or more national consensus building entities.” Accordingly, CMS will add additional SCIP quality measures and two 30-day mortality measures, as discussed in section XXII.E. of this preamble. 2. HCAHPS Hospital Pledge and Beginning Date for Data Collection We proposed 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 be eligible for the full FY 2008 IPPS market basket update. In order to meet HCAHPS requirements for the RHQDAPU program, we proposed 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 with July 2007 discharges. We proposed that to meet HCAHPS requirements for the RHQDAPU program for FY 2008, all hospitals must submit this pledge to CMS. *Comment:*
                         One commenter wanted clarification as to whether all hospitals need to submit the pledge or just hospitals eligible for the RHQDAPU program. *Response:*
                         The pledge form referenced in the rule is for participation in the RHQDAPU program, so only hospitals eligible for the RHQDAPU program need to submit it. *Comment:*
                         One commenter recommended that CMS include HCAHPS in the annual formal pledge form for participation in the RHQDAPU program. *Response:*
                         We agree that it will be less confusing to hospitals to have one pledge form for both the clinical measures and HCAHPS. We will be combining all of the measures, including HCAHPS, into the RHQDAPU Notice of Participation form that hospitals fill out and submit to their QIO each summer. *Comment:*
                         One commenter requested that the RHQDAPU participation form be made available to submit electronically. *Response:*
                         The RHQDAPU Notice of Participation form is available electronically on 
                        *http://www.qualitynet.org*. Submitters must mail or fax their signed forms to the 
                        ( print page 68207)
                        QIOs. The QIOs then enter the information into the Program Resource System (PRS). We are finalizing our proposal to require that, in order to be eligible for the full FY 2008 IPPS market basket update, hospitals must submit a pledge stating that they will collect and submit HCAHPS data to the QIO Clinical Warehouse starting with July 2007 discharges. This pledge will be part of the RHQDAPU Notice of Participation form for FY 2008 that will include the clinical measures, HCAHPS, and the mortality measures. We will announce the deadline for the RHQDAPU Notice of Participation form at a future date. 3. HCAHPS Dry Run We are finalizing our proposal to require 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 proposed 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. We received no comments on this proposal. 4. HCAHPS Data Collection Requirements We also are finalizing our proposal that, to collect HCAHPS data, 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*. We received no comments on this proposal. 5. HCAHPS Registration Requirements We are adopting as final our proposal that HCAHPS registration requirements for the IPPS RHQDAPU program will include the following: 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*. We received no comments on this proposal. 6. Additional Steps for HCAHPS Participation We are finalizing our proposal that, in order to participate in HCAHPS, hospitals that self-administer 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 self-administering 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. The Guidelines provide details regarding the protocol for sampling, which is based on 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 handling all data, including 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, 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.HCAHPSonline.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 + Confidentiality/Privacy and Security procedures in accordance with 
                        ( print page 68208)
                        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.
                    *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 self-administering 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. *Comment:*
                         One commenter asked how the integrity of HCAHPS survey will be protected if it is sent to a prisoner or mentally incapacitated patient. The commenter also asked how CMS will validate that the survey was actually completed by the patient. *Response:*
                         Hospitals participating in the HCAHPS survey are instructed to exclude certain categories of patients from the universe of patients to whom the survey may be administered. These excluded categories encompass, among others, both prisoners and patients admitted to hospital for psychiatric treatment. In addition, psychiatric hospitals, as defined under section 1861(f) of the Act, do not participate in the RHQDAPU program because they are excluded from the IPPS. To ensure that the patient completes the survey, hospitals participating in HCAHPS and the survey vendors that administer the survey on their behalf must notify all patients they survey that only the patient himself or herself should complete the survey. Survey vendors conducting telephone surveys may only speak directly to the patient. If they reach a family member or someone other than the patient, that person cannot complete the survey. There are instructions on all mail surveys that only the patient may complete the survey. *Comment:*
                         Some commenters expressed concern about having yet another entity that hospitals and health systems need to be familiar with, especially since they deal primarily with the QIO regarding issues around quality measurement, submission of data to the QIO Clinical Warehouse, annual payment update, and appeals related to chart validation. These commenters asked whether the QIOs have any involvement with HCAHPS. *Response:*
                         The submission of HCAHPS data is similar to the data submission for the clinical measures. We have contracted with the Iowa Foundation of Medical Care (IFMC) for the data submission through QualityNet Exchange and the QIO Clinical Warehouse, and with the Health Services Advisory Group, Inc. (HSAG) of Arizona for all technical assistance and support for HCAHPS. HSAG is fully available to accommodate assistance needs on a national basis for HCAHPS. We believe that this carefully coordinated effort will ensure a high level of reliability of data collection, data submission and data oversight since consistency of protocols is essential to the success of this survey and to assuring quality data reporting to the public. In addition to these two QIOs (IFMC and HSAG), we anticipate that all QIOs will be involved in the preview process prior to public reporting. 7. HCAHPS Survey Completion Requirements We also are finalizing our proposal to require hospitals to 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 (October 2006 through June 2007) due to broad interest in making HCAHPS results publicly available as quickly as possible. As discussed above, participation in this initial 9 month reporting period is not a requirement under the RHQDAPU program and hospitals do not need to participate in this initial reporting period in order to receive the full FY 2008 IPPS market basket update. After this initial implementation, reporting of HCAHPS data will be required under the RHQDAPU program. 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. 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 hospitals that cannot collect 300 completed HCAHPS surveys, we plan to note on 
                        *http://www.hospitalcompare.hhs.gov*
                         that the results for these hospitals are based on less than 100 completed HCAHPS surveys, or between 100 and 299 completed HCAHPS surveys. 8. HCAHPS Public Reporting We are finalizing our proposal 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 of 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 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. The survey 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 or items from within these domains and 
                        ( print page 68209)
                        two overall ratings will be displayed. There will be both national and state comparisons for each of the 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. *Comment:*
                         A commenter noted that the proposed rule does not contain a transparent explanation of how risk adjustments will be made. *Response:*
                         We will adjust HCAHPS data for mode and patient-mix effects prior to public reporting. We will adjust hospital results to “level the playing field” by adjusting for factors not directly related to hospital performance: mode of survey administration, patient-mix, and non-response tendencies. An HCAHPS Mode Experiment was conducted for several months in 2006, and the data analyses are now underway. The adjustment algorithm will be made available prior to the public reporting of HCAHPS results. The mode experiment results, including the adjustments to be made, will be available in late 2006 on 
                        *http://www.HCAHPSonline.org*. Several questions on the HCAHPS survey, as well as some items from hospital administrative data, will be used for patient mix adjustment. *Comment:*
                         A commenter supported publicly reporting HCAHPS survey data in seven composites and two overall ratings displayed on the Hospital Compare Web site. However, the commenter suggested that CMS consider retaining the ability for consumers to drill down so that they may assess the hospital's performance related to a single question. *Response:*
                         We appreciate this sensitivity to consumers' need to assess specific information. We are currently testing and assessing various data displays for use on the Hospital Compare Web site. We will be testing drill-downs with consumers and after the testing is completed will determine the best way to display HCAHPS data. We are also testing the seven composites to ensure that they work well for the displays and are consumer friendly. *Comment:*
                         A commenter asked CMS to continue to allow private sector organizations to have full access to provider performance information from the CMS Compare Web site and that the performance information for each question (rather than just the composite scores) on the HCAHPS survey be available for download. *Response:*
                         We are considering different options for the downloadable database and will take this request into consideration as this database is developed. 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. We proposed to combine HCAHPS data 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. In the CY 2007 OPPPS proposed rule, we encouraged comments regarding this issue. *Comment:*
                         One commenter recommended that all hospital data be treated consistently by reporting both clinical quality and HCAHPS data by Medicare provider number or by individual hospital. *Response:*
                         We agree that data should be reported consistently for both clinical quality and HCAHPS data, either by Medicare provider number or by individual hospital. *Comment:*
                         A commenter applauded CMS’ interest in determining a way to identify those hospitals that share a Medicare provider number and move toward displaying performance information by campus rather than by hospital system as it provides consumers with more information to assist in decisions about where to obtain services. *Response:*
                         We appreciate the comment and will continue to explore ways to obtain and report information at the campus level. Currently, hospitals that share Medicare provider numbers combine their clinical data across campuses for submission and publication of their data. For purposes of the FY 2008 RHQDAPU program, we are adopting our proposal to require hospitals to combine their HCAHPS data for all campuses of a multi-campus provider. For each reporting period, which is 12 months starting in July 2007, hospitals that share a Medicare provider number need to obtain 300 survey completes across their multiple campuses. CMS will continue to explore ways to collect and report the data by campus in the future. E. SCIP & Mortality Measure Requirements for the FY 2008 RHQDAPU Program We proposed 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 proposed 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 proposed 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 proposed 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 proposed 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. *Comment:*
                         One commenter stated that, for the SCIP-VTE 1, SCIP-VTE 2, and SCIP Infection 2 measures, the proposed time frame to report these measures do not allow for hospitals to have sufficient staff on board and to make sure they are properly educated and trained to ensure a high degree of accuracy in the data abstraction. The commenter recommends that CMS require hospitals submit data for these measures 
                        ( print page 68210)
                        beginning with discharges in the third quarter 2007 (July through September 2007). *Response:*
                         Collection of SCIP-Infection 1 and SCIP-Infection 3 as RHQDAPU measures for FY 2008 (which we adopted for purposes of the RHQDAPU program in the FY 2007 IPPS final rule) began third calendar quarter of 2006. The data submission deadline for third calendar quarter of 2006 is February 15, 2007. For those hospitals that are already collecting and submitting data for SCIP-Inf-1 and SCIP-Inf-3, the addition of SCIP-Inf-2 would require collection of only two additional data elements (questions). These two additional data elements include Antibiotic Allergy and Vancomycin. We believe the addition of these measures to the RHQDAPU measures beginning first quarter 2007 is a reasonable expectation for hospitals. Collection of the SCIP-VTE 1 and SCIP-VTE 2 measures began as a voluntary submission in fourth calendar quarter of 2006 (October through December discharges) under the Surgical Care Improvement Project (SCIP) discussed in section XXII.B.3. of this final rule with comment period. These measures were first published in the Specifications Manual for National Hospital Quality Measures in the October 2006 release of the manual, which was available June 9, 2006. This provided hospitals with an opportunity to abstract and submit these measures three months before the first calendar quarter of 2007, when they become RHQDAPU measures for FY2008. SCIP-VTE-1, SCIP-VTE-2, and SCIP-Inf-2 measures can be found in the Specifications Manual for National Hospital Quality Measures that was released in June 2006. This version of the manual pertains to fourth calendar quarter of 2006 and forward (October through December discharges). *Comment:*
                         One commenter noted that, for the SCIP-VTE 1, SCIP-VTE 2, and SCIP Infection 2 measures, hospitals and health systems require time to work with their respective performance vendors to make sure that all tools are available to allow them to do the chart abstraction. *Response:*
                         The above SCIP-Inf-2 has been collected since first calendar quarter of 2005 as part of the HQA. The Specifications Manual for National Hospital Quality Measures for fourth quarter 2006 discharges has been available to Vendors since June 9, 2006. SCIP-VTE 1 and SCIP-VTE 2 have been collected since fourth quarter 2006 under SCIP. Based on their inclusion in the SCIP or HQA efforts, these measures have been incorporated in the August and October releases of the CART and ORYX® tools so there should be no concern regarding the availability of data collection tools. Hospitals may use these tools immediately. As discussed above, after careful consideration of the public comments received, we are adopting as final the SCIP requirements we proposed. F. Conclusion We believe that our decision to include HCAHPS, SCIP and mortality measures as part of the FY 2008 IPPS RHQDAPU program's reporting requirements meets the requirements of 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 adopting additional measures, including several measures from this report. HCAHPS and the SCIP Infection 2 measures are measures set forth in the 2005 IOM report. Thus, we believe our decision 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,” and include “measures set forth by one or more national consensus building entities.” In addition to adding additional measures from the baseline measures found in the 2005 IOM report, we are adding additional SCIP quality measures and two 30-day mortality measures. In selecting these measures to adopt consistent with this section for the FY 2008 payment update and thereafter, CMS is adding 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 Public Law 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. Therefore, as discussed above, we have decided not to adopt the 30-day Pneumonia mortality measure in this final rule with comment period. The HQA is another such consensus building entity. The HQA is a public-private 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. XXIII. Files Available to the Public Via the Internet Addenda A and B to this final rule with comment period provide various data pertaining to the CY 2007 payments for services under the OPPS. Addendum AA to this final rule with comment period include various data pertaining to the ASC list of covered procedures and payment rates for procedures furnished in ASCs in CY 2007. To conserve resources and to make Addendum B more relevant to the OPPS, we are including in Addendum 
                        ( print page 68211)
                        B of this final rule with comment period HCPCS codes (including CPT codes) for services that are assigned a payable status indicator under the OPPS and HCPCS codes for which we are making a change in status indicator and/or APC assignment for CY 2007. A list of all active HCPCS codes and those codes discontinued as of December 31, 2006, regardless of their assigned payment status or comment indicators under the OPPS, is available to the public by clicking “Addendum A and Addendum B Updates” on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​.* For the convenience of the public, we are also including on the CMS Web site a table that displays the HCPCS data in Addendum B sorted by APC assignment, identified as Addendum C. To access Addendum C and other supporting data files related to the CY 2007 update of the OPPS, go to 
                        *http://www.cms.hhs.gov/​HospitalOutpatientPPS/​HORD/​list.asp#TopOfPage,*
                         and select regulation number “CMS-1506-FC”. At this same Web site is a link to all of the FY 2007 IPPS wage index related tables from the FY 2007 IPPS final notice (71 FR 59886 through 60043), as they would be used for the CY 2007 OPPS. Similarly, we are including Addendum AA on the CMS Web site at: 
                        *http://www.cms.hhs.gov/​center/​asc.asp.* For additional assistance, contact Chuck Braver, (410) 786-6719. XXIV. Collection of Information Requirements Under the Paperwork Reduction Act (PRA) of 1995, we are required to provide 30-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 PRA 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 are included in this final rule with comment period and their associated burdens are subject to the PRA. Additional Quality Measures for FY 2008: Surgical Care Improvement Project (SCIP) Section 5001(a) of the Deficit Reduction Act (DRA) of 2005 (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 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 final rule with comment period, we are setting out the additional measures that we 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 SCIP, we estimate that there will be approximately 3,700 respondents per year. All of these hospitals already were required to submit SCIP Infection 1 and 3 to be eligible to receive the full IPPS market basket update for FY 2007. Additional surgical procedures covering approximately 6,000,000 discharges annually will be sampled at a 10-percent rate per hospital; therefore, 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 final rule with comment period to the OMB for its review of the aforementioned information collection requirements. This final rule with comment period 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 XXII. 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 outlined in this final rule with comment period to OMB. Further, as discussed in section XXII. of this preamble, for FY 2008, we are expanding 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); 4 questions to skip patients to appropriate questions; 3 questions to adjust for the mix of patients across hospitals; and 2 questions to support congressionally mandated reports. As explained in section XXII. of this preamble, CMS published a 
                        **Federal Register**
                         notice soliciting comments on the draft 27-item 
                        ( print page 68212)
                        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. 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. 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 this final rule with comment period 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 final rule with comment period need not be reviewed by the OMB under the authority of the PRA. If you comment on any of these information collection and recordkeeping 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-FC, 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-FC), 
                        *carolyn_lovett@omb.eop.gov.*
                         Fax (202) 395-6974. XXV. 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). XXVI. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this final rule with comment period 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. 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 will be implemented by this final rule with comment period will result in expenditures exceeding $100 million in any 1 year. We estimate that adding 19 procedures to the ASC list and implementing section 5103 of Public Law 109-171 in CY 2007 will result in savings to the Medicare program of approximately $15 million. A more detailed discussion of the effects of the changes to the ASC list of procedures for CY 2007 is provided in section XXVI.C. below. In addition, we estimate that the changes that we are making in section XVIII. of this preamble to implement Medicare contracting reform mandated by section 911 of Public Law 108-173 have no economic effect on current Medicare payments in CY 2007. This aspect of our rule amends our current Medicare contractor regulations to conform them to the statutory changes mandated by Public Law 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 making in section XXII. 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 1886(b)(3)(B)(viii)(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 provision is included in section XXII. of this preamble and section XXVI.E. below. However, we estimate the total increase (from changes in this final rule with comment period as well as enrollment, utilization, and case-mix changes) in expenditures under the OPPS for CY 2007 compared to CY 2006 to be approximately $2.24 billion. Therefore, this final rule with comment period 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 2,167 voluntary hospitals that we consider to be not for-profit organizations to which this final rule with comment period 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 
                        ( print page 68213)
                        significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. 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 CY 2005 final rule with comment period (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 final rule with comment period will 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 changes to the ASC payment system for CY 2007 will have no effect on small rural hospitals. Therefore, we conclude that this final rule with comment period will have a significant impact on a substantial number of small rural hospitals. 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 noncapital costs for SCIP, and no cost for mortality measures. This final rule with comment period 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, or otherwise has Federalism implications. We have examined this final rule with comment period in accordance with Executive Order 13132, Federalism, and have determined that it will not have an impact on the rights, roles, and responsibilities of State, local or tribal governments. As reflected in Table 54, we estimate that OPPS payments to governmental hospitals (including State, local, and tribal governmental hospitals) will increase by 2.7 percent under this final rule with comment period. The provisions related to payments to ASCs in CY 2007 will not affect payments to government hospitals. In addition, the provisions related to MACs and HCAHPS will not affect payments to government hospitals. B. Effects of OPPS Changes in This Final Rule With Comment Period We are making 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 final rule with comment period, we are updating 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. We also are revising 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 Public Law 108-173 that we analyze the cost of outpatient services in rural hospitals relative to urban hospitals, we are continuing increased payments to rural SCHs, including EACHs. Section II.F. of this preamble provides greater detail on this rural adjustment. Finally, we are not removing any device categories from pass-through payment status in CY 2007. Under this final rule with comment period, the update change to the conversion factor as provided by statute will increase total OPPS payments by 3.4 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 fixed-dollar outlier threshold to account for the underestimation of outlier payments in CY 2006, results in a net increase of 3.0 percent. The changes to the APC weights, changes to the wage indices, the continuation of a payment adjustment for rural SCHs, and the expansion of the rural adjustment to EACHs will 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 54 and described in more detail in this section. 1. Alternatives Considered Alternatives to the changes we are making and the reasons that we have chosen these options are discussed throughout this final rule with comment period. Some of the major issues discussed in this final rule with comment period and the options considered are discussed below. a. Alternatives Considered for Coding and Payment Policy for Visits. In section IX. of this preamble, we are creating five new G-codes for emergency department visits provided in Type B emergency departments and one new G-code for critical care associated with trauma response. Hospitals will continue using CPT codes to describe clinic visits and emergency department visits provided in Type A emergency departments. 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. One alternative considered was to create G-codes to be used by hospitals to report clinic visits, Type A and Type B emergency department visits, and critical care services, which would describe hospital resource use. However, many commenters objected to creating G-codes before national guidelines were implemented. In response to this concern, we are finalizing new G-codes for visits provided in Type B emergency departments because there currently are no CPT codes that describe services in these facilities. In addition, we are creating one new G-code for critical care associated with trauma response, in response to commenters' requests that we pay differentially for critical care provided with and without trauma response. Some hospitals have requested that they be permitted to bill emergency department visit codes under the OPPS for services furnished in a facility that meets the CPT definition for reporting 
                        ( print page 68214)
                        emergency department visit E/M codes, except that these hospitals are not available 24 hours a day. For CY 2007, we are establishing a set of codes for visits provided in dedicated emergency departments that have an EMTALA obligation. These codes will be billed by Type B emergency departments, specifically those that do not meet the Type A requirements. We are instructing hospitals to use current emergency department CPT codes to report 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 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 visit codes and require Type B emergency departments to bill clinic visit 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 are creating one new G-code for critical care associated with trauma response, in response to commenters' requests that we distinguish between critical care provided with and without trauma response. An alternative to this policy is to continue to uphold past policy and instruct hospitals to bill one CPT code for critical care services, regardless of whether the critical services were associated with trauma response. However, if hospitals only billed one code for critical care services with and without trauma activation, it would be difficult to pay differentially for the two services, as our claims data indicate is appropriate. We must also establish payment rates for clinic and emergency department visits and critical care services. For CY 2007, we are making payments at five payment levels for both clinic and emergency department visits and at two payment levels for critical care services. We see meaningful differences among the median costs of five levels of clinic and emergency department codes that 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. For critical care, our claims data indicate that critical care services associated with trauma response are costlier than critical care services that are not associated with trauma response. Paying for critical care services that are associated with trauma response at a higher rate will lead to a more accurate distribution of payments. 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 making payment at five levels for clinic and emergency department visits and two levels for critical care services for CY 2007 to ensure that payments more accurately reflect the median costs of the services provided. For CY 2007, we are making payment for 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 department visits provided in Type B dedicated emergency departments will 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 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 consistent payment policies while gathering more detailed cost data, we are continuing 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. Alternatives 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 making payment for brachytherapy sources at a prospectively determined rate for each source for which we have claims data, and each source is assigned to its own APC. We are converting the median cost to a relative weight by dividing it by the median for APC 0606, scaling the unscaled weight for budget neutrality, and multiplying 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. The first alternative we considered was to establish 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 specifically addressed to the hospital resources used under the unique clinical circumstances of each individual treatment because of the variation in the number of sources required to treat patients under different clinical conditions. 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 
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                        number of sources used may not as accurately reflect the resources used for an individual Medicare beneficiary's treatment as the per source payment methodology. Therefore, we are not setting payments on a per day basis. The second alternative we considered was to continue 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. The third alternative we considered and are accepting for CY 2007 is to make payment for each brachytherapy source on a per source rate that is calculated using our standard OPPS methodology. This is consistent with our methodology for setting payment rates for other services and is consistent with the expiration of the Public Law 108-173 requirement that payment for sources of brachytherapy be made at charges reduced to cost for dates of service on and after January 1, 2004, through December 31, 2006. Moreover, for the reasons we discuss in detail in section VII. of this final rule with comment period, we believe that this option will provide the most appropriate payment for brachytherapy sources. c. Alternatives Considered for Payment of Radiopharmaceuticals In developing the payment policy for separately payable radiopharmaceuticals for this CY 2007 final rule with comment period, we considered three policy options. The first alternative we considered was to package additional radiopharmaceuticals, either through packaging payments for all radiopharmaceuticals with payments for the services with which they are billed or setting a packaging threshold established specifically for radiopharmaceuticals that was much higher than the $55 threshold proposed for other drugs and biologicals. 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 would result in some increases in the associated nuclear medicine procedure APC payment rates. A policy to package additional radiopharmaceuticals would be 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, packaging the costs of all radiopharmaceuticals into the procedures in which they are used could result in inadequate payment for the highest cost products. The second alternative that we considered for CY 2007 would have established 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 policy would have established our packaging threshold for radiopharmaceuticals at $55, the same as the packaging threshold for drugs and biologicals under the CY 2007 OPPS. We did not select this option because commenters indicated that changes to many radiopharmaceutical HCPCS codes in CY 2006 were made because hospitals were having difficulty with the CY 2005 codes, and, therefore, the CY 2005 hospital claims data were not accurate and not applicable to the CY 2006 codes. The third alternative that we considered and have selected for CY 2007 is 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 doing for other drugs for the CY 2007 OPPS. This policy provides stability to the payment methodology for radiopharmaceuticals from CY 2006 to CY 2007. As we indicated for CY 2006, this payment methodology provides an acceptable proxy for the average acquisition of the radiopharmaceutical along with its handling cost. We intend this methodology to be a temporary measure until we have confidence in the coding and charging practices of hospitals under the HCPCS codes that were new for CY 2006. 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 will 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 rules, we solicited comments and information about the anticipated effect of the proposed changes on hospitals and our methodology for estimating them. Comments on the impact of the proposed changes for CY 2007 are included in the discussion of the applicable topics in the preamble of this final rule with comment period. There were no comments on the methodology we proposed to use to evaluate the impact of the proposed changes other than those discussed under applicable issues. 3. Estimated Impacts of This Final Rule With Comment Period 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 Public Law 108-173 on December 8, 2003, provided for the additional payment outside of the budget neutrality requirement for wage indices for specific hospitals reclassified under section 508 through CY 2007. Table 54 shows the estimated redistribution of hospital payments among providers as a result of a new APC structure, wage indices, and adjustment for rural SCHs (which includes EACHs), which are budget neutral; the estimated distribution of increased payments in CY 2007 resulting from the combined impact of the APC recalibration, wage effects, the rural SCH adjustment, and the market basket update to the conversion factor; and, finally, estimated payments considering all 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 
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                        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 depend 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 final rule with comment period will redistribute money during implementation also will 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 final OPPS rates for CY 2007 will have a positive effect for all hospitals paid under the OPPS. Changes will 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 pre-BBA ratio between payment and cost suggests that changes will result in a 3.0 percent increase in Medicare payments to all other hospitals. To illustrate the impact of the final 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 54 reflects the independent effects of the APC reclassification and recalibration changes. Column 3 reflects the effects of updated wage indices, including the new occupational mix data described in the FY 2007 IPPS final rule, 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 reclassification of services codes among APC groups and the 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 final 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 FY 2007 IPPS wage index, combined with the impact of the 7.1 percent rural adjustment for SCHs and EACHs for services other than drugs, biologicals, brachytherapy sources, and those receiving pass-through payments. The OPPS wage index used in Column 3 does not include changes to the wage index for hospitals reclassified under section 508 of Public Law 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 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 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 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 final CY 2007 policy on each hospital group by including the effect of all the changes for CY 2007 and comparing them to all estimated payments in CY 2006, including those required by Public Law 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 intermediaries for payment, the impact of changing the percentage of total payments dedicated to transitional pass-through payments to 0.21 percent, and the expiration of payment for wage index increases for hospitals reclassified under section 508 of Public Law 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 final weights for CY 2007. The wage indices in each year include wage index increases for hospitals eligible for reclassification under section 508 of Public Law 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 final CY 2007 conversion factor of $61.468. Column 5 also contains simulated outlier payments for each year. We used the charge inflation factor used in the 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 threshold of 1.75 and a fixed-dollar threshold of $1,825. Column 1: Total Number of Hospitals Column 1 in Table 54 shows the total number of hospital providers (3,992) 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 
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                        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 final rule with comment period will not impact these hospitals negatively, we removed them from our impact analyses. We show the total number (3,928) 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 effects of the APC reclassification and recalibration, in Column 2 are typical for APC recalibration. Overall, these changes increase payments to urban hospitals by 0.1 percent, 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. We estimate that large urban hospitals would see a 0.1 percent decrease, while “other” urban hospitals experience an increase of 0.2 percent. Overall, rural hospitals show a modest 0.3 percent decrease as a result of changes to the APC structure. Notwithstanding a modest overall increase in payments, there is substantial variation among classes of rural hospitals. The lowest volume hospitals experience the largest decrease of 3.0 percent. Rural hospitals with greater than 5,000 lines of volume demonstrate no change or decreases of no more than 0.4 percent as a result of APC recalibration. Among other classes of hospitals, the largest observed impacts resulting from APC recalibration include an increase of 0.2 percent for minor teaching 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 an increase 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, will experience decreases in payments of 7.2 percent, and for the urban subset, 7.4 percent. Classifying hospitals by type of ownership suggests that proprietary hospitals would gain 0.2 percent, governmental hospitals would experience losses of 0.1 percent, and voluntary hospitals would experience no change. Column 3: New Wage Indices and the Effect of the Rural Adjustment Changes introduced by the FY 2007 IPPS wage indices together with the effect of including EACHs in the rural adjustment would have a modest impact in CY 2007, with no changes to payments to rural hospitals other than SCHs, a decrease of 0.1 percent for large urban hospitals, and an increase to other urban hospitals of 0.1 percent. We estimate that rural SCHs will experience an increase in payments of 0.1 percent, while all other rural hospitals experience no change. With respect to volume, rural hospitals with fewer than 11,000 lines and 21,000-42,999 lines experience increases of 0.1 to 0.9 percent. For both facility size and volume, no category of rural hospitals experiences an increase greater than 0.9 percent. Overall, urban hospitals experience no change in payments as a result of the new wage indices and the rural adjustment. However, large urban hospitals experience a decrease of 0.1 percent and other urban hospitals experience an 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 volumes less than 42,999 lines experience decreases in payment from 0.1 percent to 0.7 percent. Looking across other categories of hospitals, we estimate that updating the wage index and continuing the rural adjustment will lead major teaching hospitals to gain 0.1 percent, and hospitals with minor graduate medical education programs are estimated to experience no change. Hospitals serving more than 35 percent low-income patients are estimated to experience a decrease of 0.1 percent. Hospitals serving no low-income patients are expected to see an increase of 0.2 percent, while hospitals for which the percent of low-income patients cannot be determined are expected to lose 0.4 percent. Voluntary hospitals as classes would experience an increase of 0.1 percent change in payment due to wage changes and the effect of the rural adjustment. Governmental and proprietary hospitals will lose 0.1 and 0.3 percent, respectively. 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 the IPPS, including psychiatric hospitals, rehabilitation hospitals, and LTCHs (DSH not available). In many instances, the redistribution of payments created by APC recalibration offsets 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 3.5 percent, which is 0.1 percent higher than the market basket update of 3.4 percent. Large urban hospitals will experience an increase of 3.2 percent and other urban hospitals will experience an increase of 3.8 percent. Urban hospitals with the lowest volume experience a negative market basket update of 1.4 percent. Urban hospitals with volumes greater than 5,000 lines have increases from 1.8 percent to 3.5 percent. We estimate that the cumulative impact of budget neutrality adjustments and the market basket update will result in an overall increase for rural hospitals of 3.2 percent, with rural SCHs experiencing an update of 3.3 percent and other rural hospitals also experiencing an update of 3.1 percent. In general, rural hospitals with more than 5,000 lines of volume experience increases equal to or greater than 3.1 percent. We estimate that low-volume rural hospitals would experience an increase of 0.9 percent. 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, which show negative payment updates. Voluntary and proprietary hospitals also show an increase equal to or greater than the market basket. Governmental hospitals show an increase of 3.2 percent. Column 5: All Changes for CY 2007 Column 5 compares all changes for CY 2007 to final payment for CY 2006 and includes any additional dollars resulting from provisions in Public Law 108-173 in both years, changes in outlier payment percentages and thresholds, and the difference in pass-through estimates. Overall, we estimate that hospitals will gain 3.0 percent under this final rule with comment period in CY 2007 relative to total spending in CY 2006. When we 
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                        excluded cancer and children's hospitals, which are held harmless, the gain remains 3.0 percent. Hospitals will receive the 3.4 percent increase due to the market basket update appearing in Column 4. However, they lose 0.04 percent due to the increase in the pass-through estimate between CY 2006 and CY 2007. Moreover, 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 gains from the combined effects of these factors. We estimate that, overall, urban hospitals will gain 3.1 percent. We estimate that hospitals in large urban areas will gain 2.9 percent in CY 2007, and hospitals in other urban areas will gain 3.2 percent. We estimate that low-volume urban hospitals will experience a decrease in total payments of 1.2 percent between CY 2006 and CY 2007. Overall, rural hospitals experience increases that are lower than those observed for urban hospitals. Overall, we estimate that rural hospitals will experience an increase in payments of 2.7 percent. We also estimate that rural SCHs and other rural hospitals will experience an increase of 2.6 percent and 2.8 percent, respectively. Rural hospitals with volumes greater than 4,999 lines experience increases of at least 2.7 percent. We project that low-volume rural hospitals will experience the greatest decrease in overall payment of 0.9 percent. Among other classes of hospitals, we estimate that hospitals not paid under the IPPS (DSH Not Available) will experience decreases in payments between CY 2006 and CY 2007 of 4.0 percent. We estimate that major teaching hospitals will experience an increase of 2.8 percent and that nonteaching hospitals will experience an increase of 3.0 percent. 
 
  
 
  
 
  4. Estimated Effect of This Final Rule With Comment Period 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 will 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 final rule with comment period, the minimum unadjusted copayment for APC 0099 is $4.66 because the OPPS payment for the service will increase under this final rule with comment period. In another example, for a Level IV Needle Biopsy (APC 0037), in the CY 2006 OPPS, the national unadjusted copayment was $228.76, and the minimum unadjusted copayment was $114.38. In this final rule with comment period, the national unadjusted copayment for APC 0037 is $228.76. The minimum unadjusted copayment for APC 0037 is $126.20, or 20 percent of the 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 CY 2007, the inpatient deductible is $992. 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 3,992 hospitals on which our modeling is based, that total beneficiary liability for copayments will decline as an overall percentage of total payments from 27.5 percent in CY 2006 (revised from the 29 percent that we estimated for CY 2006 in the CY 2006 OPPS final rule with comment period 70 FR 68727) to 26.6 percent in CY 2007. This estimated decline in beneficiary liability is a consequence of the APC recalibration and reconfiguration we are making for CY 2007. 5. Conclusion The changes in this final rule with comment period will affect all classes of hospitals. Some hospitals experience significant gains and others less significant gains, but almost all hospitals will experience positive updates in OPPS payments in CY 2007. Table 54 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 market basket increase, the cost of outliers, changes to the pass-through estimate and the elimination of the section 508 adjustment of Public Law 108-173. The accompanying discussion, in combination with the rest of this final rule with comment period constitutes a regulatory impact analysis. 6. Accounting Statement As required by OMB Circular A-4 (available at 
                        *http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf*, in Table 55 below, we have prepared an accounting statement showing the classification of the expenditures associated with the CY 2007 OPPS provisions of this final rule with comment period. This table provides our best estimate of the increase in Medicare payments under the OPPS as a result of the provisions presented in this final rule with 
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                        comment period for CY 2007. All expenditures are classified as transfers. Table 55.—Accounting Statement: Classification of Estimated CY 2007 OPPS Expenditures Associated With CY 2007 Final Rule Provisions
Category
TransfersAnnualized Monetized Transfers
$620 Million.From Whom to Whom
Federal Government to OPPS Medicare Providers.Annualized Monetized Transfer
$150 Million.From Whom to Whom
Premium Payments from Beneficiaries to Federal Government.Total
$470 Million.
 C. Effects of Changes to the ASC Payment System for CY 2007 We are adding 19 surgical procedures to the ASC list of Medicare payable procedures for CY 2007. We are also implementing section 5103 of Public Law 109-171 and sections 1834(d)(2) and (d)(3) of the Act. Section 5103 of Public Law 109-171 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. The OPPS cap on ASC payment rates 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 Public Law 109-171, we are not making any changes in CY 2007 to the ASC payment rates that are currently in effect. Sections 1834(d)(2) and (d)(3) of the Act require that the computed beneficiary coinsurance amount for screening flexible sigmoidoscopy and screening colonoscopy services provided in hospital outpatient departments and ASCs be equal to 25 percent of the payment amount. They also require Medicare to pay the lesser of the ASC or OPPS rate for those screening services in each geographic area. For CY 2007, the OPPS rate will be limited to the lesser ASC rate for screening colonoscopies. Medicare payment for screening sigmoidoscopies will not be affected in CY 2007 because those services are not currently provided in ASCs. There will be no effect on the fee paid to ASCs for screening colonoscopies. However, beginning in CY 2007, beneficiaries will be responsible for a 25 percent coinsurance for screening colonoscopies when provided in ASCs, as they have been for the services provided in hospital outpatient departments. Except for the payment changes required under section 5103 of Public Law 109-171 and sections 1834(d)(2) and (d)(3) of the Act, we are not making any changes in CY 2007 to the ASC payment rates that are currently in effect. CMS estimates that adding the 19 procedures discussed in section XVII. of this preamble and implementing the Public Law 109-171 mandate will result in a savings to the Medicare program of approximately $15 million in CY 2007. 1. Alternatives Considered We are issuing this final rule with comment period to meet a statutory requirement that we update the list of approved ASC procedures at least every 2 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 provider-specific files for hospitals, we cannot model distributional impacts of the CY 2007 changes in the ASC list and ASC payments similar to those we prepare for our OPPS impact analysis (see Table 54). The actuarial estimate of Medicare program costs or savings resulting from the update of the ASC list and implementation of section 5103 of Public Law 109-171 and sections 1834(d)(2) and (d)(3) of the Act in CY 2007 is based on estimated CY 2007 utilization. As we have done in previous rules, we solicited comments and information about the anticipated effect of these changes that we proposed for CY 2007 to gauge their impact on individual ASCs, but we received no comments on the subject. 3. Estimated Effects of This Final Rule With Comment Period on ASCs CMS estimates that approximately 25 percent of the cases currently reported by hospitals for each of the 19 codes we are adding to the ASC list will shift to the ASC setting in CY 2007. We estimate that the shift of these procedures to the less costly ASC setting will result in modest savings for the Medicare program. Savings will also be realized because section 5103 of the Public Law 109-171 will impose a payment limit for 275 procedures on the CY 2007 ASC list. The Office of the Actuary estimates that adding 19 surgical procedures to the ASC list and capping payment for 275 procedures on the current ASC list will result in a combined savings to the Medicare program of approximately $15 million in CY 2007. We have not estimated the impact of our changes for CY 2007 on Medicare expenditures in subsequent years because we have proposed to implement an entirely revised payment system in CY 2008. Currently, Medicare pays a facility fee to ASCs only for those procedures that have been approved for the ASC list. The addition of 19 surgical procedures to the ASC list will 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 19 procedures added to the ASC list will 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 will realize a savings because the ASC standard overhead amount for all procedures, including the proposed additions to the ASC list, will 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 
                        ( print page 68223)
                        surgeries overall than are performed in ASCs, we do not expect significant hospital revenue losses to result from migration of procedures that we are adding to the ASC list to the ASC setting. 4. Estimated Effects of This Final Rule With Comment Period on Beneficiaries The changes for CY 2007 will be positive for beneficiaries in at least two respects. First, with the exception of screening colonoscopies, beneficiary coinsurance for ASC facility services is set at 20 percent, which is generally lower than the OPPS coinsurance rate, which can range from 20 percent to 40 percent. In addition, in accordance with section 5103 of Public Law 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 Public Law 109-171, beneficiaries will be assured a lower ASC coinsurance amount for more procedures in CY 2007 than in previous years. Second, beneficiary access to services will be expanded by the addition of 19 surgical procedures to the ASC list. Beneficiaries will have an additional setting from which to choose were it necessary for them to undergo one of the surgical procedures that we are adding to the ASC list in CY 2007. Beneficiary coinsurance for screening colonoscopies performed in an ASC will increase from 20 percent to 25 percent beginning in CY 2007, which is the same coinsurance rate applicable to screening colonoscopies under the OPPS. This coinsurance rate is legislated. However, we do not believe that this coinsurance increase will materially affect access to screening colonoscopies performed in ASCs. 5. Conclusion The impact on ASCs of changes to the ASC payment system for CY 2007 will 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 added 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 Public Law 109-171. Overall, the Office of the Actuary estimates that the Medicare program will realize a $15 million savings as a result of implementing the changes for CY 2007. 6. Accounting Statement As required by OMB Circular A-4 (available at 
                        *http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf)*, in Table 56 below, we have prepared an accounting statement showing the classification of the expenditures associated with the CY 2007 ASC provisions of this final rule with comment period. This table provides our best estimate of the reduction in Medicare payments under the ASC payment system as a result of the provisions presented in this final rule with comment period for CY 2007. All expenditures are classified as transfers. Table 56.—Accounting Statement: Classification of Estimated CY 2007 ASC Expenditures Associated With CY 2007 Final Rule Provisions
Category
TransfersAnnualized Monetized Transfers
−$15 Million.From Whom to Whom
Federal Government to ASC Medicare Providers.Annualized Monetized Transfer
−$4 Million.From Whom to Whom
Premium Payments from Beneficiaries to Federal Government.Total
−$11 Million.
 D. Effects of the Medicare Contracting Reform Mandate In section XVIII. of this preamble, we discuss our revision of 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 Public Law 108-173, which took effect on October 1, 2005. As discussed in section XVIII. 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. E. Effects of 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 costs 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/​HCAHPSCostsBenefits200512.pdf)*. Hospitals that are self-administering 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. 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 
                        ( print page 68224)
                        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 will 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/​HospitalQualityInits/​downloads/​HCAHPSCostsBenefits200512.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 well-designed 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 of care that allow 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 HCAHPS is to provide one standardized instrument and accompanying data collection methodology that is in the public domain for measuring patients' perspectives of 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 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 and HF 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 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 hospitals' 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 of 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 
                        ( print page 68225)
                        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 National Quality Forum. Implementing this survey fulfills the requirements of sections 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 Public Law 108-173, effective for payments beginning with FY 2007. The IOM measures include the Hospital Quality Alliance (HQA) measures, the HCAHPS patient perspective survey, and three structural measures. No alternatives were discussed for the SCIP and mortality measures. 2. Estimated Effects of This Final Rule With Comment Period 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. F. Executive Order 12866 In accordance with the provisions of Executive Order 12866, this final rule with comment period was reviewed by the OMB. List of Subjects 42 CFR Part 410 Health facilities
Health professions
Laboratories
Medicare
Rural areas
X-rays 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 final rule with comment period, the Centers for Medicare & Medicaid Services is amending 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) and removing footnote 1 to read as follows: § 410.152
  
 (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, except that, 
                                ( print page 68226)
                                for screening flexible sigmoidoscopies and screening colonoscopies, Part B coinsurance is 25 percent of the standard overhead amount and Medicare Part B pays 75 percent of the standard overhead amount. (2) [Reserved]
 PART 416—AMBULATORY SURGICAL SERVICES
 3.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). 4.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
  (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) of the Act. The lesser payment amount shall be determined prior to application of any geographic adjustment.
 5.Section 416.2 is amended by revising the definitions of “Covered surgical procedures” and “Facility services” to read as follows: § 416.2
  
 *Covered surgical procedures*
                                 means those surgical procedures that meet the criteria specified in § 416.65 and are published in the 
                                **Federal Register**
                                . *Facility services*
                                 means services that are furnished in connection with covered surgical procedures performed in an ASC.
 6.The heading for Subpart D is revised to read as follows: Subpart D—Scope of Benefits for Services Furnished Before January 1, 2008
 7.Section 416.65 is amended by— a.Revising the introductory text. b.Revising paragraph (a)(4). The revisions read as follows: § 416.65
  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.
 8.A new § 416.76 is added to Subpart D to read as follows: § 416.76
  The provisions of this subpart apply to facility services furnished before January 1, 2008.
 9.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
 10.In paragraph (a) of § 416.120, the cross-reference “Part 413” is removed and the cross-reference “Part 419” added in its place. 11.A new § 416.121 is added to read as follows: § 416.121
  The provisions of this subpart apply to facility services furnished before January 1, 2008.
 12.Section 416.125 is amended by adding a new paragraph (c) to read as follows: § 416.125
  
 (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 is the lesser of the ASC payment rate established under paragraph (a) of this section or the prospective payment rate for the procedure established under § 419.32 of this chapter. The lesser payment amount is determined prior to application of any geographic adjustment.
 § 416.150
 13.Section 416.150 is removed. Subpart F [Redesignated]
 14.Subpart F is redesignated as Subpart G. New Subpart F [Added and Reserved]
 15.A new Subpart F is added and reserved. 16.Newly designated Subpart G is revised to read as follows: Subpart G—Adjustment in Payment Amounts for New Technology Intraocular Lenses Furnished by Ambulatory Service Centers
 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
  (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; (2) Factors that CMS considers for determination of a new class of new technology IOLs; and 
                                ( print page 68227) (3) Application of the payment adjustment.
 § 416.185
  (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
  (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
  (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 demonstrates 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
  (a) CMS establishes the amount of the payment adjustment for classes of new technology IOLs through proposed and final rulemaking in connection with ASC facility 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
 17.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). 18.Section 419.21 is amended by revising the introductory text of paragraph (d) to read as follows: § 419.21
  
 (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:
 19.Section 419.43 is amended by— a.Revising paragraph (f). b.Revising paragraph (g)(1)(i). c.Adding a new paragraph (h). The revision and addition read as follows: § 419.43
  
 (f) 
                                *Excluded services and groups*. Drugs and biologicals that are paid under a separate APC are excluded from qualification for outlier payments. (g) * * * (1) * * * (i) Is a sole community hospital under § 412.92 of this chapter or is an essential access community hospital under § 412.109 of this chapter; and 
 (h) 
                                *Applicable adjustments to conversion factor for CY 2009 and for subsequent calendar years*
                                —(1) 
                                *General 
                                    ( print page 68228)
                                    rule*. For CY 2009 and for subsequent calendar years, the applicable adjustment to the conversion factor specified in § 419.32(b)(1)(iv) is reduced by 2.0 percentage points for any hospital that fails to meet the standards for reporting of hospital outpatient quality measures as established by the Secretary for the corresponding calendar year. (2) 
                                *Limitation*. Any reduction to a hospital's adjustment to its conversion factor specified in § 419.32(b)(1)(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 2009 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,
 20.A new § 419.45 is added to Subpart D to read as follows: § 419.45
  (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.
 21.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
  
 (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
 22.The heading of Part 421 is revised to read as set out above. 23.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). 24.Section 421.3 is revised to read as follows: § 421.3
  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.
 25.Section 421.100 is amended by revising paragraph (i) to read as follows: § 421.100
  
 (i) 
                                *Dual intermediary responsibilities.*
                                 Regarding the responsibility for service to provider-based HHAs and provider-based 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.
 26.Section 421.103 is revised to read as follows: § 421.103
  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 of this chapter.
 27.Section 421.104 is revised to read as follows: § 421.104
  (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 
                                ( print page 68229)
                                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 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
 28.Section 421.105 is removed. § 421.106
 29.Section 421.106 is removed. 30.Section 421.112 is amended by— a.Revising paragraph (a). b.Revising paragraph (b). The revisions read as follows: § 421.112
  (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 § 421.122.
 31.Section 421.114 is revised to read as follows: § 421.114
  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
 32.Section 421.116 is removed. § 421.117
 33.Section 421.117 is removed. § 421.118
 34.Section 421.118 is removed. Subpart D [Added and Reserved]
 35.Subpart D is added to Part 421 and reserved. 36.A new Subpart E is added to Part 421 to read as follows: Subpart E—Medicare Administrative Contractors (MACs)
 421.400
                            Statutory basis and scope.
                            421.401
                            Definitions.
                            421.404
                            Assignment of providers and suppliers to MACs.
 § 421.400
  (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
  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
  (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 contiguous 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 
                                ( print page 68230)
                                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 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
 37.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). 38.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 cross-reference “paragraph (d)(3)(iii)” in its place. The revisions and additions read as follows: § 485.618
  
 (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 on site 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 and the CAH's bylaws or rules and regulations.
 PART 488—SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES
 39.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
  
 *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. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: October 27, 2006. Leslie Norwalk, Acting Administrator, Centers for Medicare & Medicaid Services. Dated: October 31, 2006. Michael O. Leavitt, Secretary.
 
 
 Addendum A.—OPPS List of Ambulatory Payment Classifications (APCs) With Status Indicators (SI), Relative Weights, and Copayment Amounts Calendar Year 2007
APC
Group title
SI
Relative Weight
Payment Rate
National Unadjusted Copayment
Minimum Unadjusted Copayment0001
Level I Photochemotherapy
S
0.4914
30.21
7.00
6.040002
Level I Fine Needle Biopsy/Aspiration
T
1.0995
67.58

13.520003
Bone Marrow Biopsy/Aspiration
T
2.4011
147.59

29.520004
Level I Needle Biopsy/Aspiration Except Bone Marrow
T
2.0687
127.16

25.430005
Level II Needle Biopsy/Aspiration Except Bone Marrow
T
3.9045
240.00
71.59
48.000006
Level I Incision & Drainage
T
1.4392
88.46

17.690007
Level II Incision & Drainage
T
11.1535
685.58

137.120008
Level III Incision and Drainage
T
17.5086
1,076.22

215.240009
Nail Procedures
T
0.7744
47.60

9.520010
Level I Destruction of Lesion
T
0.4760
29.26
8.02
5.850011
Level II Destruction of Lesion
T
2.5665
157.76

31.550012
Level I Debridement & Destruction
T
0.8432
51.83
11.18
10.370013
Level II Debridement & Destruction
T
1.0918
67.11

13.420015
Level III Debridement & Destruction
T
1.6241
99.83
20.13
19.970016
Level IV Debridement & Destruction
T
2.6749
164.42

32.880017
Level VI Debridement & Destruction
T
17.4423
1,072.14
227.84
214.430018
Biopsy of Skin/Puncture of Lesion
T
1.0259
63.06
15.44
12.610019
Level I Excision/ Biopsy
T
4.0919
251.52
71.87
50.300020
Level II Excision/ Biopsy
T
6.8083
418.49
107.67
83.700021
Level III Excision/ Biopsy
T
15.1024
928.31
219.48
185.660022
Level IV Excision/ Biopsy
T
20.0656
1,233.39
354.45
246.680023
Exploration Penetrating Wound
T
4.2212
259.47

51.890024
Level I Skin Repair
T
1.4843
91.24
29.88
18.250025
Level II Skin Repair
T
5.2594
323.28
101.85
64.660027
Level IV Skin Repair
T
21.4302
1,317.27
329.72
263.450028
Level I Breast Surgery
T
19.2788
1,185.03
303.74
237.010029
Level II Breast Surgery
T
28.0166
1,722.12
581.52
344.420030
Level III Breast Surgery
T
37.8692
2,327.74
747.07
465.550031
Smoking Cessation Services
X
0.1766
10.86

2.170033
Partial Hospitalization
P
3.8188
234.73

46.950035
Arterial/Venous Puncture
T
0.1999
12.29

2.460036
Level II Fine Needle Biopsy/Aspiration
T
2.0738
127.47

25.490037
Level IV Needle Biopsy/Aspiration Except Bone Marrow
T
10.2655
631.00
228.76
126.200038
Spontaneous MEG
S
53.5161
3,289.53

657.910039
Level I Implantation of Neurostimulator
S
187.3821
11,518.00

2,303.600040
Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve
S
56.5705
3,477.28

695.460041
Level I Arthroscopy
T
28.6245
1,759.49

351.900042
Level II Arthroscopy
T
45.5027
2,796.96
804.74
559.390043
Closed Treatment Fracture Finger/Toe/Trunk
T
1.6857
103.62

20.720045
Bone/Joint Manipulation Under Anesthesia
T
14.5947
897.11
268.47
179.420047
Arthroplasty without Prosthesis
T
33.4505
2,056.14
537.03
411.230048
Level I Arthroplasty with Prosthesis
T
47.4378
2,915.91

583.180049
Level I Musculoskeletal Procedures Except Hand and Foot
T
20.8706
1,282.87

256.570050
Level II Musculoskeletal Procedures Except Hand and Foot
T
25.1296
1,544.67

308.930051
Level III Musculoskeletal Procedures Except Hand and Foot
T
41.0893
2,525.68

505.140052
Level IV Musculoskeletal Procedures Except Hand and Foot
T
66.5800
4,092.54

818.510053
Level I Hand Musculoskeletal Procedures
T
16.1540
992.95
253.49
198.590054
Level II Hand Musculoskeletal Procedures
T
25.8758
1,590.53

318.110055
Level I Foot Musculoskeletal Procedures
T
20.4263
1,255.56
355.34
251.110056
Level II Foot Musculoskeletal Procedures
T
40.8559
2,511.33

502.270057
Bunion Procedures
T
28.2349
1,735.54
475.91
347.110058
Level I Strapping and Cast Application
S
1.0607
65.20

13.040060
Manipulation Therapy
S
0.4657
28.63

5.730061
Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve
S
84.1967
5,175.40

1,035.080062
Level I Treatment Fracture/Dislocation
T
25.5264
1,569.06
372.87
313.810063
Level II Treatment Fracture/Dislocation
T
37.5382
2,307.40
548.33
461.480064
Level III Treatment Fracture/Dislocation
T
57.2172
3,517.03
835.79
703.410065
Level I Stereotactic Radiosurgery
S
20.3224
1,249.18

249.840066
Level II Stereotactic Radiosurgery
S
43.0297
2,644.95

528.990067
Level III Stereotactic Radiosurgery
S
63.3759
3,895.59

779.120068
CPAP Initiation
S
1.5353
94.37
29.48
18.870069
Thoracoscopy
T
31.9442
1,963.55
591.64
392.710070
Thoracentesis/Lavage Procedures
T
3.6244
222.78

44.560071
Level I Endoscopy Upper Airway
T
0.7698
47.32
11.20
9.460072
Level II Endoscopy Upper Airway
T
1.4054
86.39
21.27
17.280073
Level III Endoscopy Upper Airway
T
3.8463
236.42
69.15
47.280074
Level IV Endoscopy Upper Airway
T
14.7928
909.28
292.25
181.86( print page 68232)0075
Level V Endoscopy Upper Airway
T
21.9512
1,349.30
445.92
269.860076
Level I Endoscopy Lower Airway
T
9.5228
585.35
189.82
117.070077
Level I Pulmonary Treatment
S
0.3527
21.68
7.74
4.340078
Level II Pulmonary Treatment
S
1.1206
68.88
14.55
13.780079
Ventilation Initiation and Management
S
2.6116
160.53

32.110080
Diagnostic Cardiac Catheterization
T
37.0615
2,278.10
838.92
455.620081
Non-Coronary Angioplasty or Atherectomy
T
42.9360
2,639.19

527.840082
Coronary Atherectomy
T
72.1982
4,437.88
954.62
887.580083
Coronary Angioplasty and Percutaneous Valvuloplasty
T
58.7904
3,613.73

722.750084
Level I Electrophysiologic Evaluation
S
9.8924
608.07

121.610085
Level II Electrophysiologic Evaluation
T
34.2808
2,107.17
426.25
421.430086
Ablate Heart Dysrhythm Focus
T
47.4931
2,919.31
812.36
583.860087
Cardiac Electrophysiologic Recording/Mapping
T
32.8988
2,022.22

404.440088
Thrombectomy
T
37.7391
2,319.75
655.22
463.950089
Insertion/Replacement of Permanent Pacemaker and Electrodes
T
123.6693
7,601.70
1,682.28
1,520.340090
Insertion/Replacement of Pacemaker Pulse Generator
T
98.3023
6,042.45
1,612.80
1,208.490091
Level II Vascular Ligation
T
34.7288
2,134.71

426.940092
Level I Vascular Ligation
T
24.8809
1,529.38
309.87
305.880093
Vascular Reconstruction/Fistula Repair without Device
T
22.8653
1,405.48

281.100094
Level I Resuscitation and Cardioversion
S
2.4233
148.96
46.29
29.790095
Cardiac Rehabilitation
S
0.5748
35.33
13.86
7.070096
Non-Invasive Vascular Studies
S
1.5303
94.06
37.62
18.810097
Cardiac and Ambulatory Blood Pressure Monitoring
X
1.0225
62.85
23.79
12.570098
Injection of Sclerosing Solution
T
1.0798
66.37

13.270099
Electrocardiograms
S
0.3789
23.29

4.660100
Cardiac Stress Tests
X
2.5336
155.74
41.44
31.150101
Tilt Table Evaluation
S
4.2769
262.89
100.24
52.580103
Miscellaneous Vascular Procedures
T
16.2375
998.09
223.63
199.620104
Transcatheter Placement of Intracoronary Stents
T
87.7183
5,391.87

1,078.370105
Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices
T
25.6142
1,574.45
370.40
314.890106
Insertion/Replacement of Pacemaker Leads and/or Electrodes
T
58.8594
3,617.97

723.590107
Insertion of Cardioverter-Defibrillator
T
304.4894
18,716.35

3,743.270108
Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads
T
379.7339
23,341.48

4,668.300109
Removal of Implanted Devices
T
10.9918
675.64

135.130110
Transfusion
S
3.4584
212.58

42.520111
Blood Product Exchange
S
11.7134
720.00
198.40
144.000112
Apheresis, Photopheresis, and Plasmapheresis
S
30.2231
1,857.75
433.29
371.550113
Excision Lymphatic System
T
21.2621
1,306.94

261.390114
Thyroid/Lymphadenectomy Procedures
T
37.7224
2,318.72
467.95
463.740115
Cannula/Access Device Procedures
T
29.2133
1,795.68
374.81
359.140121
Level I Tube changes and Repositioning
T
2.3587
144.98
43.80
29.000122
Level II Tube changes and Repositioning
T
7.4800
459.78

91.960123
Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant
S
20.3582
1,251.38

250.280125
Refilling of Infusion Pump
T
2.2041
135.48

27.100126
Level I Urinary and Anal Procedures
T
1.0887
66.92
16.45
13.380127
Level IV Stereotactic Radiosurgery
S
138.4486
8,510.16

1,702.030130
Level I Laparoscopy
T
32.1241
1,974.60
659.53
394.920131
Level II Laparoscopy
T
43.5488
2,676.86
1,001.89
535.370132
Level III Laparoscopy
T
70.5066
4,333.90
1,239.22
866.780140
Esophageal Dilation without Endoscopy
T
5.4566
335.41
91.40
67.080141
Level I Upper GI Procedures
T
8.3175
511.26
143.38
102.250142
Small Intestine Endoscopy
T
9.4946
583.61
152.78
116.720143
Lower GI Endoscopy
T
8.7686
538.99
186.06
107.800146
Level I Sigmoidoscopy and Anoscopy
T
4.8683
299.24
64.40
59.850147
Level II Sigmoidoscopy and Anoscopy
T
8.5477
525.41

105.080148
Level I Anal/Rectal Procedures
T
5.0770
312.07

62.410149
Level III Anal/Rectal Procedures
T
22.2682
1,368.78
293.06
273.760150
Level IV Anal/Rectal Procedures
T
29.6189
1,820.61
437.12
364.120151
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
T
19.8381
1,219.41
245.46
243.880152
Level I Percutaneous Abdominal and Biliary Procedures
T
20.2682
1,245.85

249.170153
Peritoneal and Abdominal Procedures
T
22.0832
1,357.41
397.95
271.480154
Hernia/Hydrocele Procedures
T
29.2182
1,795.98
464.85
359.200155
Level II Anal/Rectal Procedures
T
12.7389
783.03

156.610156
Level III Urinary and Anal Procedures
T
3.4079
209.48

41.900157
Colorectal Cancer Screening: Barium Enema
S
2.1149
130.00

26.000158
Colorectal Cancer Screening: Colonoscopy
T
7.8492
446.00

111.50( print page 68233)0159
Colorectal Cancer Screening: Flexible Sigmoidoscopy
S
3.6592
224.92

56.230160
Level I Cystourethroscopy and other Genitourinary Procedures
T
6.4951
399.24
101.58
79.850161
Level II Cystourethroscopy and other Genitourinary Procedures
T
19.2251
1,181.73
249.36
236.350162
Level III Cystourethroscopy and other Genitourinary Procedures
T
23.8700
1,467.24

293.450163
Level IV Cystourethroscopy and other Genitourinary Procedures
T
34.9261
2,146.84

429.370164
Level II Urinary and Anal Procedures
T
2.1393
131.50

26.300165
Level IV Urinary and Anal Procedures
T
18.1679
1,116.74

223.350166
Level I Urethral Procedures
T
18.3960
1,130.77

226.150168
Level II Urethral Procedures
T
29.0253
1,784.13
388.16
356.830169
Lithotripsy
T
43.5398
2,676.30
1,009.47
535.260170
Dialysis
S
6.6089
406.24

81.250171
Level V Anal/Rectal Procedures
T
37.8991
2,329.58
716.76
465.920180
Circumcision
T
20.5513
1,263.25
304.87
252.650181
Penile Procedures
T
32.9873
2,027.66
621.82
405.530183
Testes/Epididymis Procedures
T
23.5310
1,446.40

289.280184
Prostate Biopsy
T
5.6262
345.83
96.27
69.170188
Level II Female Reproductive Proc
T
1.2900
79.29

15.860189
Level III Female Reproductive Proc
T
2.8966
178.05

35.610190
Level I Hysteroscopy
T
21.3586
1,312.87
424.28
262.570191
Level I Female Reproductive Proc
T
0.1468
9.02
2.55
1.800192
Level IV Female Reproductive Proc
T
6.6592
409.33

81.870193
Level V Female Reproductive Proc
T
14.8489
912.73

182.550194
Level VIII Female Reproductive Proc
T
20.5081
1,260.59
397.84
252.120195
Level IX Female Reproductive Proc
T
28.5095
1,752.42
483.80
350.480196
Dilation and Curettage
T
17.7499
1,091.05
338.23
218.210197
Infertility Procedures
T
4.0007
245.92

49.180198
Pregnancy and Neonatal Care Procedures
T
1.4222
87.42
32.19
17.480200
Level VII Female Reproductive Proc
T
16.9328
1,040.83
243.36
208.170201
Level VI Female Reproductive Proc
T
18.5201
1,138.39
329.65
227.680202
Level X Female Reproductive Proc
T
42.9896
2,642.48
981.50
528.500203
Level IV Nerve Injections
T
12.1702
748.08
240.33
149.620204
Level I Nerve Injections
T
2.2614
139.00
40.13
27.800206
Level II Nerve Injections
T
5.7253
351.92
75.55
70.380207
Level III Nerve Injections
T
6.3603
390.95
86.92
78.190208
Laminotomies and Laminectomies
T
44.1489
2,713.74

542.750209
Level II MEG, Extended EEG Studies and Sleep Studies
S
11.2463
691.29
268.73
138.260212
Nervous System Injections
T
2.9907
183.83
65.96
36.770213
Level I MEG, Extended EEG Studies and Sleep Studies
S
2.2755
139.87
53.58
27.970214
Electroencephalogram
S
1.1968
73.56
28.24
14.710215
Level I Nerve and Muscle Tests
S
0.5741
35.29

7.060216
Level III Nerve and Muscle Tests
S
2.7199
167.19

33.440218
Level II Nerve and Muscle Tests
S
1.1872
72.97

14.590220
Level I Nerve Procedures
T
17.8499
1,097.20

219.440221
Level II Nerve Procedures
T
33.1520
2,037.79
463.62
407.560222
Implantation of Neurological Device
T
181.6249
11,164.12

2,232.820223
Implantation or Revision of Pain Management Catheter
T
30.8394
1,895.64

379.130224
Implantation of Reservoir/Pump/Shunt
T
47.0342
2,891.10

578.220225
Implantation of Neurostimulator Electrodes, Cranial Nerve
S
221.1512
13,593.72

2,718.740226
Implantation of Drug Infusion Reservoir
T
112.6322
6,923.28

1,384.660227
Implantation of Drug Infusion Device
T
174.4056
10,720.36

2,144.070228
Creation of Lumbar Subarachnoid Shunt
T
39.2633
2,413.44

482.690229
Transcatherter Placement of Intravascular Shunts
T
68.4697
4,208.70

841.740230
Level I Eye Tests & Treatments
S
0.7898
48.55
14.97
9.710231
Level III Eye Tests & Treatments
S
2.1451
131.86

26.370232
Level I Anterior Segment Eye Procedures
T
6.0673
372.94
93.43
74.590233
Level II Anterior Segment Eye Procedures
T
15.2259
935.91
266.33
187.180234
Level III Anterior Segment Eye Procedures
T
22.9970
1,413.58
511.31
282.720235
Level I Posterior Segment Eye Procedures
T
3.9333
241.77
58.93
48.350236
Level II Posterior Segment Eye Procedures
T
16.5239
1,015.69

203.140237
Level III Posterior Segment Eye Procedures
T
27.6020
1,696.64

339.330238
Level I Repair and Plastic Eye Procedures
T
2.8954
177.97

35.590239
Level II Repair and Plastic Eye Procedures
T
7.2819
447.60

89.520240
Level III Repair and Plastic Eye Procedures
T
17.1243
1,052.60
309.52
210.520241
Level IV Repair and Plastic Eye Procedures
T
25.2550
1,552.37
384.47
310.470242
Level V Repair and Plastic Eye Procedures
T
35.2292
2,165.47
597.36
433.090243
Strabismus/Muscle Procedures
T
21.2801
1,308.05
430.35
261.610244
Corneal Transplant
T
38.2707
2,352.42
803.26
470.480245
Level I Cataract Procedures without IOL Insert
T
14.8702
914.04
217.05
182.810246
Cataract Procedures with IOL Insert
T
23.6313
1,452.57
495.96
290.51( print page 68234)0247
Laser Eye Procedures Except Retinal
T
5.0839
312.50
104.31
62.500248
Laser Retinal Procedures
T
5.0841
312.51
95.08
62.500249
Level II Cataract Procedures without IOL Insert
T
29.2281
1,796.59
524.67
359.320250
Nasal Cauterization/Packing
T
1.1791
72.48
25.39
14.500251
Level I ENT Procedures
T
2.4520
150.72

30.140252
Level II ENT Procedures
T
7.5511
464.15
109.16
92.830253
Level III ENT Procedures
T
16.4266
1,009.71
282.29
201.940254
Level IV ENT Procedures
T
23.3299
1,434.04
321.35
286.810256
Level V ENT Procedures
T
38.1991
2,348.02

469.600257
Level I Therapeutic Radiologic Procedures
S
1.0974
67.45

13.490258
Tonsil and Adenoid Procedures
T
22.1165
1,359.46
437.25
271.890259
Level VI ENT Procedures
T
414.8455
25,499.72
8,698.43
5,099.940260
Level I Plain Film Except Teeth
X
0.7093
43.60

8.720261
Level II Plain Film Except Teeth Including Bone Density Measurement
X
1.2224
75.14

15.030262
Plain Film of Teeth
X
0.6550
40.26

8.050263
Level I Miscellaneous Radiology Procedures
X
1.6956
104.23
23.77
20.850264
Level II Miscellaneous Radiology Procedures
X
2.9586
181.86
70.27
36.370265
Level I Diagnostic and Screening Ultrasound
S
0.9923
60.99
23.63
12.200266
Level II Diagnostic and Screening Ultrasound
S
1.5607
95.93
37.80
19.190267
Level III Diagnostic and Screening Ultrasound
S
2.4606
151.25
60.50
30.250268
Level I Ultrasound Guidance Procedures
S
1.1882
73.04

14.610269
Level II Echocardiogram Except Transesophageal
S
3.2154
197.64
75.60
39.530270
Transesophageal Echocardiogram
S
6.2505
384.21
141.32
76.840272
Fluoroscopy
X
1.2908
79.34
31.64
15.870274
Myelography
S
2.5544
157.01
62.80
31.400275
Arthrography
S
3.6915
226.91
69.09
45.380276
Level I Digestive Radiology
S
1.4294
87.86
34.97
17.570277
Level II Digestive Radiology
S
2.2176
136.31
54.52
27.260278
Diagnostic Urography
S
2.4159
148.50
59.40
29.700279
Level II Angiography and Venography
S
9.5061
584.32
150.03
116.860280
Level III Angiography and Venography
S
20.8225
1,279.92
353.85
255.980282
Miscellaneous Computerized Axial Tomography
S
1.5379
94.53
37.81
18.910283
Computed Tomography with Contrast
S
4.0825
250.94
100.37
50.190284
Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast
S
6.1231
376.37
148.40
75.270288
Bone Density:Axial Skeleton
S
1.1755
72.26
28.90
14.450293
Level V Anterior Segment Eye Procedures
T
51.9894
3,195.68
1,128.29
639.140296
Level II Therapeutic Radiologic Procedures
S
2.6802
164.75
53.99
32.950297
Level III Therapeutic Radiologic Procedures
S
3.6392
223.69
89.47
44.740298
Level IV Therapeutic Radiologic Procedures
S
8.3906
515.75
206.30
103.150299
Miscellaneous Radiation Treatment
S
5.8839
361.67

72.330300
Level I Radiation Therapy
S
1.4826
91.13

18.230301
Level II Radiation Therapy
S
2.2295
137.04

27.410302
Computer Assisted Navigational Procedures
S
4.9138
302.04
105.94
60.410303
Treatment Device Construction
X
2.9430
180.90
66.95
36.180304
Level I Therapeutic Radiation Treatment Preparation
X
1.5735
96.72
38.68
19.340305
Level II Therapeutic Radiation Treatment Preparation
X
3.9723
244.17
91.38
48.830307
Myocardial Positron Emission Tomography (PET) imaging
S
11.8963
731.24
292.49
146.250308
Non-Myocardial Positron Emission Tomography (PET) imaging
S
13.9166
855.43

171.090309
Level II Ultrasound Guidance Procedures
S
2.1012
129.16

25.830310
Level III Therapeutic Radiation Treatment Preparation
X
13.8081
848.76
325.27
169.750312
Radioelement Applications
S
4.8569
298.54

59.710313
Brachytherapy
S
12.8473
789.70

157.940314
Hyperthermic Therapies
S
3.3461
205.68
60.88
41.140315
Level II Implantation of Neurostimulator
T
242.9363
14,932.81

2,986.560320
Electroconvulsive Therapy
S
5.5676
342.23
80.06
68.450321
Biofeedback and Other Training
S
1.3384
82.27
21.72
16.450322
Brief Individual Psychotherapy
S
1.1798
72.52

14.500323
Extended Individual Psychotherapy
S
1.7066
104.90

20.980324
Family Psychotherapy
S
2.1633
132.97

26.590325
Group Psychotherapy
S
1.0765
66.17
14.47
13.230330
Dental Procedures
S
7.0550
433.66

86.730332
Computed Tomography without Contrast
S
3.0908
189.99
75.24
38.000333
Computed Tomography without Contrast followed by Contrast)
S
4.8405
297.54
119.01
59.510335
Magnetic Resonance Imaging, Miscellaneous
S
4.5523
279.82
111.92
55.960336
Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast
S
5.6745
348.80
139.51
69.76( print page 68235)0337
Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast
S
8.1155
498.84
199.53
99.770339
Observation
S
7.2039
442.81

88.560340
Minor Ancillary Procedures
X
0.6102
37.51

7.500341
Skin Tests
X
0.0914
5.62
2.24
1.120342
Level I Pathology
X
0.0824
5.06
2.02
1.010343
Level III Pathology
X
0.5211
32.03
10.84
6.410344
Level IV Pathology
X
0.7927
48.73
15.66
9.750345
Level I Transfusion Laboratory Procedures
X
0.2178
13.39
2.87
2.680346
Level II Transfusion Laboratory Procedures
X
0.3484
21.42
4.39
4.280347
Level III Transfusion Laboratory Procedures
X
0.7423
45.63
11.28
9.130348
Fertility Laboratory Procedures
X
0.8321
51.15

10.230350
Administration of flu and PPV vaccine
S
0.3945
24.25

0.000360
Level I Alimentary Tests
X
1.4154
87.00
33.88
17.400361
Level II Alimentary Tests
X
3.8887
239.03
83.23
47.810362
Contact Lens and Spectacle Services
X
0.5865
36.05

7.210363
Level I Otorhinolaryngologic Function Tests
X
0.8525
52.40
17.44
10.480364
Level I Audiometry
X
0.4627
28.44
7.06
5.690365
Level II Audiometry
X
1.2419
76.34
18.52
15.270366
Level III Audiometry
X
1.8511
113.78
26.14
22.760367
Level I Pulmonary Test
X
0.6277
38.58
14.68
7.720368
Level II Pulmonary Tests
X
0.9454
58.11
22.77
11.620369
Level III Pulmonary Tests
X
2.7669
170.08
44.18
34.020370
Allergy Tests
X
1.0270
63.13

12.630372
Therapeutic Phlebotomy
X
0.5723
35.18
10.09
7.040373
Level I Neuropsychological Testing
X
1.7682
108.69

21.740374
Monitoring Psychiatric Drugs
X
1.1418
70.18

14.040375
Ancillary Outpatient Services When Patient Expires
S
58.0781
3,569.94

713.990376
Level II Cardiac Imaging
S
4.9832
306.31
119.77
61.260377
Level III Cardiac Imaging
S
6.5012
399.62
158.84
79.920378
Level II Pulmonary Imaging
S
5.0975
313.33
125.33
62.670379
Injection adenosine 6 MG
K

30.49

6.100381
Single Allergy Tests
X
0.2688
16.52

3.300382
Level II Neuropsychological Testing
X
2.8460
174.94
69.97
34.990384
GI Procedures with Stents
T
22.9475
1,410.54
295.41
282.110385
Level I Prosthetic Urological Procedures
S
79.2092
4,868.83

973.770386
Level II Prosthetic Urological Procedures
S
137.3897
8,445.07

1,689.010387
Level II Hysteroscopy
T
34.0155
2,090.86
655.55
418.170388
Discography
S
15.9758
982.00
289.72
196.400389
Level I Non-imaging Nuclear Medicine
S
1.3754
84.54
33.81
16.910390
Level I Endocrine Imaging
S
2.3432
144.03
57.61
28.810391
Level II Endocrine Imaging
S
2.7146
166.86
66.18
33.370392
Level II Non-imaging Nuclear Medicine
S
2.0057
123.29
49.31
24.660393
Red Cell/Plasma Studies
S
3.7562
230.89
82.04
46.180394
Hepatobiliary Imaging
S
4.3774
269.07
102.61
53.810395
GI Tract Imaging
S
3.6526
224.52
89.73
44.900396
Bone Imaging
S
3.9174
240.79
95.02
48.160397
Vascular Imaging
S
2.4204
148.78
49.58
29.760398
Level I Cardiac Imaging
S
4.1265
253.65
100.06
50.730399
Nuclear Medicine Add-on Imaging
S
1.5054
92.53
35.80
18.510400
Hematopoietic Imaging
S
3.9073
240.17
93.22
48.030401
Level I Pulmonary Imaging
S
3.1802
195.48
78.19
39.100402
Brain Imaging
S
4.6418
285.32
114.12
57.060403
CSF Imaging
S
3.4923
214.66
83.35
42.930404
Renal and Genitourinary Studies Level I
S
3.4209
210.28
84.11
42.060405
Renal and Genitourinary Studies Level II
S
4.0378
248.20
98.77
49.640406
Level I Tumor/Infection Imaging
S
3.9934
245.47
98.18
49.090407
Level I Radionuclide Therapy
S
3.1779
195.34
78.13
39.070408
Level II Tumor/Infection Imaging
S
5.9245
364.17

72.830409
Red Blood Cell Tests
X
0.1227
7.54
2.20
1.510411
Respiratory Procedures
S
0.3848
23.65

4.730412
IMRT Treatment Delivery
S
5.4731
336.42

67.280413
Level II Radionuclide Therapy
S
5.2957
325.52

65.100415
Level II Endoscopy Lower Airway
T
22.0099
1,352.90
459.92
270.580416
Level I Intravascular and Intracardiac Ultrasound and Flow Reserve
S
32.5472
2,000.61

400.120417
Computerized Reconstruction
S
3.2393
199.11

39.820418
Insertion of Left Ventricular Pacing Elect.
T
307.2828
18,888.06

3,777.610421
Prolonged Physiologic Monitoring
X
1.6270
100.01

20.00( print page 68236)0422
Level II Upper GI Procedures
T
25.7552
1,583.12
448.81
316.620423
Level II Percutaneous Abdominal and Biliary Procedures
T
37.3604
2,296.47

459.290425
Level II Arthroplasty with Prosthesis
T
107.1942
6,589.01
1,378.01
1,317.800426
Level II Strapping and Cast Application
S
2.2777
140.01

28.000427
Level III Tube Changes and Repositioning
T
11.6575
716.56

143.310428
Level III Sigmoidoscopy and Anoscopy
T
20.6375
1,268.55

253.710429
Level V Cystourethroscopy and other Genitourinary Procedures
T
43.1004
2,649.30

529.860432
Health and Behavior Services
S
0.6072
37.32

7.460433
Level II Pathology
X
0.2557
15.72
5.93
3.140434
Cardiac Defect Repair
T
88.0728
5,413.66

1,082.730436
Level I Drug Administration
S
0.1809
11.12

2.220437
Level II Drug Administration
S
0.3945
24.25

4.850438
Level III Drug Administration
S
0.7942
48.82

9.760439
Level IV Drug Administration
S
1.5848
97.41

19.480440
Level V Drug Administration
S
1.8090
111.20

22.240441
Level VI Drug Administration
S
2.4851
152.75

30.550442
Dosimetric Drug Administration
S
22.3666
1,374.83

274.970443
Overnight Pulse Oximetry
X
1.0409
63.98
25.59
12.800604
Level 1 Hospital Clinic Visits
V
0.8242
50.66

10.130605
Level 2 Hospital Clinic Visits
V
0.9840
60.48

12.100606
Level 3 Hospital Clinic Visits
V
1.3646
83.88

16.780607
Level 4 Hospital Clinic Visits
V
1.7096
105.09

21.020608
Level 5 Hospital Clinic Visits
V
2.1794
133.96

26.790609
Level 1 Emergency Visits
V
0.8136
50.01
12.70
10.000613
Level 2 Emergency Visits
V
1.3497
82.96
21.06
16.590614
Level 3 Emergency Visits
V
2.1150
130.00
34.50
26.000615
Level 4 Emergency Visits
V
3.4163
209.99
48.49
42.000616
Level 5 Emergency Visits
V
5.2915
325.26
75.11
65.050617
Critical Care
S
6.5894
405.04
111.59
81.010618
Trauma Response with Critical Care
S
8.0455
494.54
197.81
98.910621
Level I Vascular Access Procedures
T
8.7846
539.97

107.990622
Level II Vascular Access Procedures
T
22.6665
1,393.26

278.650623
Level III Vascular Access Procedures
T
28.5032
1,752.03

350.410624
Minor Vascular Access Device Procedures
X
0.5145
31.63
12.65
6.330625
Level IV Vascular Access Procedures
T
83.4609
5,130.17

1,026.030648
Level IV Breast Surgery
T
51.2269
3,148.82

629.760651
Complex Interstitial Radiation Source Application
S
16.8462
1,035.50

207.100652
Insertion of Intraperitoneal and Pleural Catheters
T
29.5416
1,815.86

363.170653
Vascular Reconstruction/Fistula Repair with Device
T
32.3818
1,990.44

398.090654
Insertion/Replacement of a permanent dual chamber pacemaker
T
112.7719
6,931.86

1,386.370655
Insertion/Replacement/Conversion of a permanent dual chamber pacemaker
T
152.6392
9,382.43

1,876.490656
Transcatheter Placement of Intracoronary Drug-Eluting Stents
T
108.3003
6,657.00

1,331.400657
Placement of Tissue Clips
S
1.7369
106.76

21.350658
Percutaneous Breast Biopsies
T
6.4387
395.77

79.150659
Hyperbaric Oxygen
S
1.5906
97.77

19.550660
Level II Otorhinolaryngologic Function Tests
X
1.4461
88.89
28.06
17.780661
Level V Pathology
X
2.5255
155.24
62.09
31.050662
CT Angiography
S
4.8552
298.44
118.88
59.690663
Level I Electronic Analysis of Neurostimulator Pulse Generators
S
1.1067
68.03
17.45
13.610664
Level I Proton Beam Radiation Therapy
S
18.8926
1,161.29

232.260665
Bone Density:AppendicularSkeleton
S
0.5497
33.79
13.51
6.760667
Level II Proton Beam Radiation Therapy
S
22.6031
1,389.37

277.870668
Level I Angiography and Venography
S
6.2463
383.95
88.26
76.790670
Level II Intravascular and Intracardiac Ultrasound and Flow Reserve
S
32.2854
1,984.52
536.10
396.900672
Level IV Posterior Segment Eye Procedures
T
37.4290
2,300.69

460.140673
Level IV Anterior Segment Eye Procedures
T
37.8967
2,329.43
649.56
465.890674
Prostate Cryoablation
T
108.7566
6,685.05

1,337.010675
Prostatic Thermotherapy
T
41.1375
2,528.64

505.730676
Thrombolysis and Thrombectomy
T
2.0726
127.40

25.480678
External Counterpulsation
T
1.7418
107.06

21.410679
Level II Resuscitation and Cardioversion
S
5.5233
339.51
95.30
67.900680
Insertion of Patient Activated Event Recorders
S
72.6022
4,462.71

892.540681
Knee Arthroplasty
T
205.6815
12,642.83

2,528.570682
Level V Debridement & Destruction
T
6.8832
423.10
158.65
84.620683
Level II Photochemotherapy
S
2.6734
164.33

32.870685
Level III Needle Biopsy/Aspiration Except Bone Marrow
T
6.1384
377.32
115.47
75.46( print page 68237)0686
Level III Skin Repair
T
14.0346
862.68

172.540687
Revision/Removal of Neurostimulator Electrodes
T
17.8334
1,096.18
438.47
219.240688
Revision/Removal of Neurostimulator Pulse Generator Receiver
T
35.5702
2,186.43
874.57
437.290689
Electronic Analysis of Cardioverter-defibrillators
S
0.6003
36.90

7.380690
Electronic Analysis of Pacemakers and other Cardiac Devices
S
0.3613
22.21
8.67
4.440691
Electronic Analysis of Programmable Shunts/Pumps
S
2.8942
177.90
60.61
35.580692
Level II Electronic Analysis of Neurostimulator Pulse Generators
S
1.9323
118.77
30.16
23.750693
Breast Reconstruction
T
36.9988
2,274.24
721.30
454.850694
Mohs Surgery
T
3.7292
229.23
91.69
45.850695
Level VII Debridement & Destruction
T
20.4276
1,255.64
266.59
251.130697
Level I Echocardiogram Except Transesophageal
S
1.5973
98.18
35.99
19.640698
Level II Eye Tests & Treatments
S
1.1607
71.35

14.270699
Level IV Eye Tests & Treatments
T
14.3845
884.19

176.840700
Antepartum Manipulation
T
2.3864
146.69

29.340701
Sr89 strontium
H0702
Sm 153 lexidronm
H0704
In111 satumomab
H0705
Tc99m tetrofosmin
H0722
Tc99m pentetate
H0723
Co57/58
H0724
Co57 cyano
H0726
Dexrazoxane HCl injection
K

180.13

36.030728
Filgrastim 300 mcg injection
K

188.07

37.610730
Pamidronate disodium /30 MG
K

34.80

6.960731
Sargramostim injection
K

25.55

5.110732
Mesna injection
K

10.10

2.020735
Ampho b cholesteryl sulfate
K

12.00

2.400736
Amphotericin b liposome inj
K

21.25

4.250737
Nitrogen N-13 ammonia
H0738
Rasburicase
K

121.26

24.250739
Tc99m depreotide
H0740
Tc99m gluceptate
H0741
Cr51 chromate
H0742
Tc99m labeled rbc
H0743
Tc99m mertiatide
H0744
Plague vaccine, im
K

150.00

30.000746
Dacarbazine 100 mg inj
K

4.90

0.980747
Chlorothiazide sodium inj
K

123.84

24.770748
Bleomycin sulfate injection
K

37.62

7.520750
Dolasetron mesylate
K

6.89

1.380751
Mechlorethamine hcl inj
K

141.61

28.320752
Dactinomycin actinomycin d
K

493.43

98.690753
Spectinomycn di-hcl inj
K

30.08

6.020759
Naltrexone, depot form
K

1.94

0.390760
Anadulafungin injection
G

1.91

0.380763
Dolasetron mesylate oral
K

48.91

9.780764
Granisetron HCl injection
K

7.21

1.440765
Granisetron HCl 1 mg oral
K

41.18

8.240766
Apomorphine hydrochloride
K

2.92

0.580767
Enfuvirtide injection
K

21.82

4.360768
Ondansetron hcl injection
K

3.72

0.740769
Ondansetron HCl 8mg oral
K

36.06

7.210800
Leuprolide acetate /3.75 MG
K

437.58

87.520802
Etoposide oral 50 MG
K

32.01

6.400804
Immune globulin subcutaneous
K

7.08

1.420805
Mecasermin injection
K

11.93

2.390806
Hyaluronidase recombinant
G

0.40

0.080807
Aldesleukin/single use vial
K

726.69

145.340808
Nabilone oral
K

16.96

3.390809
Bcg live intravesical vac
K

113.44

22.690810
Goserelin acetate implant
K

199.12

39.820811
Carboplatin injection
K

10.12

2.020812
Carmus bischl nitro inj
K

139.84

27.970814
Asparaginase injection
K

54.46

10.890820
Daunorubicin
K

24.56

4.910821
Daunorubicin citrate liposom
K
56.21

11.240823
Docetaxel
K

302.68

60.540825
Nelarabine injection
K

83.10

16.620827
Floxuridine injection
K

64.17

12.83( print page 68238)0828
Gemcitabine HCl
K

121.30

24.260829
Technetium TC-99m aerosol
H0830
Irinotecan injection
K

126.88

25.380831
Ifosfomide injection
K

52.39

10.480832
Idarubicin hcl injection
K

308.97

61.790834
Interferon alfa-2a inj
K

37.56

7.510835
Inj cosyntropin per 0.25 MG
K

62.91

12.580836
Interferon alfa-2b inj
K

13.75

2.750838
Interferon gamma 1-b inj
K

289.87

57.970840
Inj melphalan hydrochl 50 MG
K

1,194.15

238.830842
Fludarabine phosphate inj
K

243.82

48.760843
Pegaspargase/singl dose vial
K

1,687.04

337.410844
Pentostatin injection
K

2,034.63

406.930849
Rituximab cancer treatment
K

481.69

96.340850
Streptozocin injection
K

152.92

30.580851
Thiotepa injection
K

44.58

8.920852
Topotecan
K

813.08

162.620855
Vinorelbine tartrate/10 mg
K

22.82

4.560856
Porfimer sodium
K

2,505.40

501.080858
Inj cladribine per 1 MG
K

37.87

7.570860
Plicamycin (mithramycin) inj
K

61.36

12.270861
Leuprolide acetate injeciton
K

11.10

2.220862
Mitomycin 5 MG inj
K

18.31

3.660863
Paclitaxel injection
K

14.35

2.870864
Mitoxantrone hydrochl / 5 MG
K

223.27

44.650865
Interferon alfa-n3 inj
K

39.48

7.900868
Oral aprepitant
G

4.85

0.970876
Caffeine citrate injection
K

3.54

0.710884
Rho d immune globulin inj
K

80.52

16.100887
Azathioprine parenteral
K

49.17

9.830888
Cyclosporine oral 100 mg
K

3.66

0.730890
Lymphocyte immune globulin
K

315.76

63.150891
Tacrolimus oral per 1 MG
K

3.55

0.710892
Edetate calcium disodium inj
K

40.19

8.040895
Deferoxamine mesylate inj
K

14.84

2.970896
Sodium Hyaluronate Injection
K

124.68

24.940900
Alglucerase injection
K

39.22

7.840901
Alpha 1 proteinase inhibitor
K

3.31

0.660902
Botulinum toxin a per unit
K

5.04

1.010903
Cytomegalovirus imm IV /vial
K

853.18

170.640906
RSV-ivig
K

16.18

3.240910
Interferon beta-1b / .25 MG
K

90.00

18.000911
Inj streptokinase /250000 IU
K

79.50

15.900912
Interferon alfacon-1
K

4.65

0.930913
Ganciclovir long act implant
K

4,766.14

953.230916
Injection imiglucerase /unit
K

3.91

0.780917
Adenosine injection
K

30.49

6.100925
Factor viii
K

0.69

0.140926
Factor VIII (porcine)
K

1.33

0.270927
Factor viii recombinant
K

1.06

0.210928
Factor ix complex
K

0.72

0.140929
Anti-inhibitor
K

1.36

0.270930
Antithrombin iii injection
K

1.62

0.320931
Factor IX non-recombinant
K

0.90

0.180932
Factor IX recombinant
K

0.99

0.200935
Clonidine hydrochloride
K

66.04

13.210949
Frozen plasma, pooled, sd
K
0.9346
57.45

11.490950
Whole blood for transfusion
K
2.1472
131.98

26.400952
Cryoprecipitate each unit
K
0.7905
48.59

9.720954
RBC leukocytes reduced
K
2.8590
175.74

35.150955
Plasma, frz between 8-24hour
K
1.2489
76.77

15.350956
Plasma protein fract,5%,50ml
K
0.8339
51.26

10.250957
Platelets, each unit
K
0.9590
58.95

11.790958
Plaelet rich plasma unit
K
3.4048
209.29

41.860959
Red blood cells unit
K
2.1073
129.53

25.910960
Washed red blood cells unit
K
3.4331
211.03

42.210961
Albumin (human), 5%, 50ml
K

29.68

5.940963
Albumin (human), 5%, 250 ml
K

76.81

15.360964
Albumin (human), 25%, 20 ml
K

28.80

5.76( print page 68239)0965
Albumin (human), 25%, 50ml
K

65.26

13.050966
Plasmaprotein fract, 5%,250ml
K
3.8746
238.16

47.630967
Blood split unit
K
2.2323
137.22

27.440968
Platelets leukoreduced irrad
K
2.0390
125.33

25.070969
RBC leukoreduced irradiated
K
3.5394
217.56

43.511009
Cryoprecipitatereducedplasma
K
1.3404
82.39

16.481010
Blood, l/r, cmv-neg
K
2.5493
156.70

31.341011
Platelets, hla-m, l/r, unit
K
10.9263
671.62

134.321013
Platelets leukocytes reduced
K
1.5469
95.08

19.021016
Blood, l/r, froz/degly/wash
K
3.4335
211.05

42.211017
Plt, aph/pher, l/r, cmv-neg
K
6.4556
396.81

79.361018
Blood, l/r, irradiated
K
2.3472
144.28

28.861019
Plate pheres leukoredu irrad
K
10.0443
617.40

123.481020
Plt, pher, l/r cmv-neg, irr
K
11.4755
705.38

141.081021
RBC, frz/deg/wsh, l/r, irrad
K
8.0727
496.21

99.241022
RBC, l/r, cmv-neg, irrad
K
4.2653
262.18

52.441032
Aud osseo dev, int/ext comp
H1045
I131 iodobenguate, dx
H1052
Injection, voriconazole
K

4.66

0.931064
I131 iodide cap, rx
H1083
Adalimumab injection
K

308.33

61.671084
Denileukin diftitox, 300 mcg
K

1,403.23

280.651086
Temozolomide
K

7.30

1.461088
Iodine I-131 iodide cap, dx
H1096
Tc99m exametazime
H1150
I131 iodide sol, rx
H1166
Cytarabine liposome
K

396.66

79.331167
Inj, epirubicin hcl, 2 mg
K

24.67

4.931178
Busulfan injection
K

8.89

1.781203
Verteporfin injection
K

8.91

1.781207
Octreotide injection, depot
K

93.35

18.671280
Corticotropin injection
K

116.60

23.321330
Ergonovine maleate injection
K

33.11

6.621436
Etidronate disodium inj
K

71.41

14.281491
New Technology—Level IA ($0-$10)
S

5.00

1.001492
New Technology—Level IB ($10-$20)
S

15.00

3.001493
New Technology—Level IC ($20-$30)
S

25.00

5.001494
New Technology—Level ID ($30-$40)
S

35.00

7.001495
New Technology—Level IE ($40-$50)
S

45.00

9.001496
New Technology—Level IA ($0-$10)
T

5.00

1.001497
New Technology—Level IB($10-$20)
T

15.00

3.001498
New Technology—Level IC ($20-$30)
T

25.00

5.001499
New Technology—Level ID($30-$40)
T

35.00

7.001500
New Technology—Level IE ($40-$50)
T

45.00

9.001502
New Technology—Level II   ($50-$100)
S

75.00

15.001503
New Technology—Level III   ($100-$200)
S

150.00

30.001504
New Technology—Level IV  ($200-$300)
S

250.00

50.001505
New Technology—Level V   ($300-$400)
S

350.00

70.001506
New Technology—Level VI  ($400-$500)
S

450.00

90.001507
New Technology—Level VII  ($500-$600)
S

550.00

110.001508
New Technology—Level VIII ($600-$700)
S

650.00

130.001509
New Technology—Level IX   ($700-$800)
S

750.00

150.001510
New Technology—Level X    ($800-$900)
S

850.00

170.001511
New Technology—Level XI   ($900-$1000)
S

950.00

190.001512
New Technology—Level XII  ($1000-$1100)
S

1,050.00

210.001513
New Technology—Level XIII  ($1100-$1200)
S

1,150.00

230.001514
New Technology—Level XIV ($1200-$1300)
S

1,250.00

250.001515
New Technology—Level XV ($1300-$1400)
S

1,350.00

270.001516
New Technology—Level XVI  ($1400-$1500)
S

1,450.00

290.001517
New Technology—Level XVII ($1500-$1600)
S

1,550.00

310.001518
New Technology—Level XVIII ($1600-$1700)
S

1,650.00

330.001519
New Technology—Level IXX ($1700-$1800)
S

1,750.00

350.001520
New Technology—Level XX ($1800-$1900)
S

1,850.00

370.001521
New Technology—Level XXI ($1900-$2000)
S

1,950.00

390.001522
New Technology—Level XXII ($2000-$2500)
S

2,250.00

450.001523
New Technology—Level XXIII ($2500-$3000)
S

2,750.00

550.001524
New Technology—Level XXIV ($3000-$3500)
S

3,250.00

650.001525
New Technology—Level XXV ($3500-$4000)
S

3,750.00

750.001526
New Technology—Level XXVI ($4000-$4500)
S

4,250.00

850.00( print page 68240)1527
New Technology—Level XXVII ($4500-$5000)
S

4,750.00

950.001528
New Technology—Level XXVIII ($5000-$5500)
S

5,250.00

1,050.001529
New Technology—Level XXIX ($5500-$6000)
S

5,750.00

1,150.001530
New Technology—Level XXX ($6000-$6500)
S

6,250.00

1,250.001531
New Technology—Level XXXI ($6500-$7000)
S

6,750.00

1,350.001532
New Technology—Level XXXII ($7000-$7500)
S

7,250.00

1,450.001533
New Technology—Level XXXIII ($7500-$8000)
S

7,750.00

1,550.001534
New Technology—Level XXXIV ($8000-$8500)
S

8,250.00

1,650.001535
New Technology—Level XXXV ($8500-$9000)
S

8,750.00

1,750.001536
New Technology—Level XXXVI ($9000-$9500)
S

9,250.00

1,850.001537
New Technology—Level XXXVII ($9500-$10000)
S

9,750.00

1,950.001539
New Technology—Level II   ($50-$100)
T

75.00

15.001540
New Technology—Level III   ($100-$200)
T

150.00

30.001541
New Technology—Level IV  ($200-$300)
T

250.00

50.001542
New Technology—Level V   ($300-$400)
T

350.00

70.001543
New Technology—Level VI  ($400-$500)
T

450.00

90.001544
New Technology—Level VII  ($500-$600)
T

550.00

110.001545
New Technology—Level VIII ($600-$700)
T

650.00

130.001546
New Technology—Level IX   ($700-$800)
T

750.00

150.001547
New Technology—Level X    ($800-$900)
T

850.00

170.001548
New Technology—Level XI   ($900-$1000)
T

950.00

190.001549
New Technology—Level XII  ($1000-$1100)
T

1,050.00

210.001550
New Technology—Level XIII  ($1100-$1200)
T

1,150.00

230.001551
New Technology—Level XIV ($1200-$1300)
T

1,250.00

250.001552
New Technology—Level XV ($1300-$1400)
T

1,350.00

270.001553
New Technology—Level XVI  ($1400-$1500)
T

1,450.00

290.001554
New Technology—Level XVII ($1500-$1600)
T

1,550.00

310.001555
New Technology—Level XVIII ($1600-$1700)
T

1,650.00

330.001556
New Technology—Level XIX ($1700-$1800)
T

1,750.00

350.001557
New Technology—Level XX ($1800-$1900)
T

1,850.00

370.001558
New Technology—Level XXI ($1900-$2000)
T

1,950.00

390.001559
New Technology—Level XXII ($2000-$2500)
T

2,250.00

450.001560
New Technology—Level XXIII ($2500-$3000)
T

2,750.00

550.001561
New Technology—Level XXIV ($3000-$3500)
T

3,250.00

650.001562
New Technology—Level XXV ($3500-$4000)
T

3,750.00

750.001563
New Technology—Level XXVI ($4000-$4500)
T

4,250.00

850.001564
New Technology—Level XXVII ($4500-$5000)
T

4,750.00

950.001565
New Technology—Level XXVIII ($5000-$5500)
T

5,250.00

1,050.001566
New Technology—Level XXIX ($5500-$6000)
T

5,750.00

1,150.001567
New Technology—Level XXX ($6000-$6500)
T

6,250.00

1,250.001568
New Technology—Level XXXI ($6500-$7000)
T

6,750.00

1,350.001569
New Technology—Level XXXII ($7000-$7500)
T

7,250.00

1,450.001570
New Technology—Level XXXIII ($7500-$8000)
T

7,750.00

1,550.001571
New Technology—Level XXXIV ($8000-$8500)
T

8,250.00

1,650.001572
New Technology—Level XXXV ($8500-$9000)
T

8,750.00

1,750.001573
New Technology—Level XXXVI ($9000-$9500)
T

9,250.00

1,850.001574
New Technology—Level XXXVII ($9500-$10000)
T

9,750.00

1,950.001600
Tc99m sestamibi
H1603
TL201 thallium
H1604
In111 capromab
H1605
Abciximab injection
K

416.27

83.251606
Injection anistreplase 30 u
K

2,268.46

453.691607
Eptifibatide injection
K

15.37

3.071608
Etanercept injection
K

160.39

32.081609
Rho(D) immune globulin h, sd
K

14.30

2.861612
Daclizumab, parenteral
K

328.83

65.771613
Trastuzumab
K

56.17

11.231629
Nonmetabolic act d/e tissue
K

18.49

3.701630
Hep b ig, im
K

119.06

23.811631
Baclofen intrathecal trial
K

69.63

13.931632
Metabolic active D/E tissue
K

27.89

5.581633
Alefacept
K

26.31

5.261642
In111 ibritumomab, dx
H1643
Y90 ibritumomab, rx
H1644
I131 tositumomab, dx
H1645
1131 tositumomab, rx
H1646
In111 oxyquinoline
H1647
In111 pentetate
H1648
Technetium tc99m arcitumomab
H( print page 68241)1650
Tc99m succimer
H1651
F18 fdg
H1654
Rb82 rubidium
H1655
Tinzaparin sodium injection
K

2.48

0.501670
Tetanus immune globulin inj
K

87.77

17.551671
Ga67 gallium
H1672
Tc99m bicisate
H1675
P32 Na phosphate
H1676
P32 chromic phosphate
H1677
In111 pentetreotide
H1678
Tc99m fanolesomab
H1680
Acetylcysteine injection
K

1.94

0.391682
Aprotonin, 10,000 kiu
K

2.52

0.501683
Basiliximab
K

1,385.86

277.171684
Corticorelin ovine triflutal
K

4.17

0.831685
Darbepoetin alfa, non-esrd
K

2.99

0.601686
Epoetin alfa, non-esrd
K

9.36

1.871687
Digoxin immune fab (ovine)
K

533.72

106.741688
Ethanolamine oleate 100 mg
K

69.60

13.921689
Fomepizole, 15 mg
K

12.33

2.471690
Hemin, 1 mg
K

6.80

1.361691
Iron dextran 165 injection
K

11.78

2.361692
Iron dextran 267 injection
K

10.38

2.081693
Lepirudin
K

153.54

30.711694
Ziconotide injection
G

6.34

1.271695
Nesiritide injection
K

30.13

6.031696
Palifermin injection
K

11.43

2.291697
Pegaptanib sodium injection
G

1,107.54

221.511700
Inj secretin synthetic human
K

20.31

4.061701
Treprostinil injection
K

54.02

10.801703
Ovine, 1000 USP units
K

137.43

27.491704
Inj Vonwillebrand factor IU
K

0.88

0.181705
Factor viia
K

1.10

0.221707
Non-human, metabolic tissue
K

1.78

0.361709
Azacitidine injection
K

4.22

0.841710
Clofarabine injection
G

116.62

23.321711
Histrelin implant
K

1,741.71

348.341712
Paclitaxel protein bound
G

8.73

1.751713
Inj Fe-based MR contrast,1ml
K

30.41

6.081716
Brachytx source, Gold 198
K
0.5991
36.83

7.371717
Brachytx source, HDR Ir-192
K
2.3195
142.58

28.521718
Brachytx source, Iodine 125
K
0.5910
36.33

7.271719
Brachytx sour,Non-HDR Ir-192
K
0.3765
23.14

4.631720
Brachytx sour, Palladium 103
K
0.7942
48.82

9.761738
Oxaliplatin
K

8.77

1.751739
Pegademase bovine, 25 iu
K

177.83

35.571740
Diazoxide injection
K

111.89

22.381741
Urofollitropin, 75 iu
K

49.35

9.871820
Generator neuro rechg bat sys
H1821
Interspinous implant
H2210
Methyldopate hcl injection
K

10.01

2.002616
Brachytx source, Yttrium-90
K
172.2337
10,586.86

2,117.372632
Iodine I-125 sodium iodide
K
0.3321
20.41

4.082633
Brachytx source, Cesium-131
K
1.4779
90.84

18.172634
Brachytx source, HA, I-125
K
0.5316
32.68

6.542635
Brachytx source, HA, P-103
K
0.8878
54.57

10.912636
Brachytx linear source,P-103
K
0.6427
39.51

7.902731
Immune globulin, powder
K

25.27

5.052732
Immune globulin, liquid
K

30.33

6.072770
Quinupristin/dalfopristin
K

114.49

22.902940
Somatrem injection
K

35.60

7.123030
Sumatriptan succinate / 6 MG
K

57.40

11.483032
Dtp/hib vaccine, im
K

45.01

9.003038
Inj biperiden lactate/5 mg
K

88.15

17.633039
Inj metaraminol bitartrate
K

2.62

0.523041
Bivalirudin
K

1.75

0.353042
Foscarnet sodium injection
K

10.49

2.103043
Gamma globulin 1 CC inj
K

10.34

2.073045
Meropenem
K

3.68

0.74( print page 68242)3048
Doxorubic hcl 10 MG vl chemo
K

6.00

1.203049
Cyclophosphamide lyophilized
K

5.72

1.143050
Sermorelin acetate injection
K

1.75

0.357000
Amifostine
K

463.27

92.657005
Gonadorelin hydroch/ 100 mcg
K

189.84

37.977011
Oprelvekin injection
K

245.98

49.207015
Oral busulfan
K

2.14

0.437028
Fosphenytoin, 50 mg
K

5.59

1.127034
Somatropin injection
K

46.80

9.367035
Teniposide, 50 mg
K

264.88

52.987036
Urokinase 250,000 IU inj
K

457.73

91.557038
Monoclonal antibodies
K

856.05

171.217041
Tirofiban HCl
K

8.74

1.757042
Capecitabine, oral, 150 mg
K

3.83

0.777043
Infliximab injection
K

53.74

10.757045
Inj trimetrexate glucoronate
K

145.17

29.037046
Doxorubicin hcl liposome inj
K

379.21

75.847048
Alteplase recombinant
K

32.07

6.417049
Filgrastim 480 mcg injection
K

298.70

59.747051
Leuprolide acetate implant
K

2,208.90

441.787308
Aminolevulinic acid hcl top
K

107.72

21.549001
Linezolid injection
K

24.16

4.839002
Tenecteplase injection
K

2,036.66

407.339003
Palivizumab, per 50 mg
K

609.62

121.929004
Gemtuzumab ozogamicin
K

2,317.16

463.439005
Reteplase injection
K

902.72

180.549006
Tacrolimus injection
K

140.72

28.149012
Arsenic trioxide
K

33.36

6.679015
Mycophenolate mofetil oral
K

2.50

0.509018
Botulinum toxin type B
K

8.16

1.639019
Caspofungin acetate
K

32.25

6.459020
Sirolimus, oral
K

7.25

1.459022
IM inj interferon beta 1-a
K

108.04

21.619023
Rho d immune globulin 50 mcg
K

27.70

5.549024
Amphotericin b lipid complex
K

11.11

2.229031
Arbutamine HCl injection
K

160.00

32.009032
Baclofen 10 MG injection
K

198.54

39.719033
Cidofovir injection
K

763.15

152.639038
Inj estrogen conjugate 25 MG
K

58.05

11.619040
Intraocular Fomivirsen na
K

212.00

42.409042
Glucagon hydrochloride/1 MG
K

70.23

14.059044
Ibutilide fumarate injection
K

265.75

53.159046
Iron sucrose injection
K

0.36

0.079047
Itraconazole injection
K

36.45

7.299051
Urea injection
K

37.81

7.569054
Metabolically active tissue
K

13.87

2.779100
I131 serum albumin, dx
H9104
Antithymocyte globuln rabbit
K

329.62

65.929108
Thyrotropin injection
K

765.76

153.159110
Alemtuzumab injection
K

531.24

106.259112
Inj perflutren lip micros,ml
K

61.64

12.339115
Zoledronic acid
K

204.03

40.819119
Injection, pegfilgrastim 6mg
K

2,163.61

432.729120
Injection, Fulvestrant
K

80.66

16.139121
Injection, argatroban
K

17.48

3.509122
Triptorelin pamoate
K

218.53

43.719124
Daptomycin injection
K

0.33

0.079125
Risperidone, long acting
K

4.80

0.969126
Natalizumab injection
G

7.72

1.549133
Rabies ig, im/sc
K

64.53

12.919134
Rabies ig, heat treated
K

68.24

13.659135
Varicella-zoster ig, im
K

140.92

28.189137
Bcg vaccine, percut
K

117.39

23.489139
Rabies vaccine, im
K

157.74

31.559140
Rabies vaccine, id
K

166.16

33.239141
Measles-rubella vaccine, sc
K

60.82

12.169143
Meningococcal vaccine, sc
K

84.46

16.899144
Encephalitis vaccine, sc
K

96.22

19.249145
Meningococcal vaccine, im
K

53.71

10.74( print page 68243)9148
I123 iodide cap, dx
H9156
Nonmetabolic active tissue
K

45.02

9.009157
LOCM <=149 mg/ml iodine, 1ml
K

0.29

0.069158
LOCM 150-199mg/ml iodine,1ml
K

1.96

0.399159
LOCM 200-249mg/ml iodine,1ml
K

1.42

0.289160
LOCM 250-299mg/ml iodine,1ml
K

0.27

0.059161
LOCM 300-349mg/ml iodine,1ml
K

0.35

0.079162
LOCM 350-399mg/ml iodine,1ml
K

0.21

0.049163
LOCM >= 400 mg/ml iodine,1ml
K

0.30

0.069164
Inj Gad-base MR contrast,1ml
K

2.87

0.579165
Oral MR contrast, 100 ml
K

8.90

1.789167
Valrubicin, 200 mg
K

369.60

73.929202
Inj octafluoropropane mic,ml
K

49.61

9.929203
Inj perflexane lip micros,ml
K

7.05

1.419207
Bortezomib injection
K

31.87

6.379208
Agalsidase beta injection
K

127.20

25.449209
Laronidase injection
K

23.87

4.779210
Palonosetron HCl
K

18.08

3.629213
Pemetrexed injection
K

42.49

8.509214
Bevacizumab injection
K

56.88

11.389215
Cetuximab injection
K

49.86

9.979216
Abarelix injection
K

71.18

14.249217
Leuprolide acetate suspnsion
K

227.63

45.539219
Mycophenolic acid
K

2.15

0.439222
Injectable human tissue
K

743.96

148.799224
Galsulfase injection
K

1,516.12

303.229225
Fluocinolone acetonide implt
G

18,250.00

3,650.009227
Micafungin sodium injection
G

1.87

0.379228
Tigecycline injection
G

0.91

0.189229
Ibandronate sodium injection
G

139.12

27.829230
Abatacept injection
G

18.70

3.749231
Decitabine injection
G

26.50

5.309232
Injection, idursulfase
G

464.32

92.869233
Injection, ranibizumab
G

2,067.00

413.409234
Inj, alglucosidase alfa
K

127.20

25.449235
Injection, panitumumab
K

84.80

16.969300
Omalizumab injection
K

16.61

3.329350
Porous collagen tube per cm
G

494.53

98.919351
Acellular derm tissue percm2
G

44.01

8.809500
Platelets, irradiated
K
2.1079
129.57

25.919501
Platelet pheres leukoreduced
K
7.9511
488.74

97.759502
Platelet pheresis irradiated
K
6.8088
418.52

83.709503
Fr frz plasma donor retested
K
1.2119
74.49

14.909504
RBC deglycerolized
K
5.8292
358.31

71.669505
RBC irradiated
K
3.2049
197.00

39.409506
Granulocytes, pheresis unit
K
12.2073
750.36

150.079507
Platelets, pheresis
K
7.3686
452.93

90.599508
Plasma 1 donor frz w/in 8 hr
K
1.1422
70.21

14.04
 Addendum AA.—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 Deficit Reduction Act of 2005
HCPCS
Short descriptor
A*=new to list; 2007 CPT Changes: 
                                 A=Add  
                                 D=Delete
OPPS 
                                 payment  
                                 rate 
                                 ($)
ASC 
                                 payment  
                                 group
ASC 
                                 payment  
                                 rate 
                                 ($)
DRA cap
ASC 
                                 copayment  
                                 amount 
                                 ($)10121
Remove foreign body

928.31
2
446.00

89.2010180
Complex drainage, wound

1,076.22
2
446.00

89.2011010
Debride skin, fx

251.52
2
251.52
Y
50.3011011
Debride skin/muscle, fx

251.52
2
251.52
Y
50.3011012
Debride skin/muscle/bone, fx

251.52
2
251.52
Y
50.3011042
Debride skin/tissue

164.42
2
164.42
Y
32.8811043
Debride tissue/muscle

164.42
2
164.42
Y
32.8811044
Debride tissue/muscle/bone

423.10
2
423.10
Y
84.62( print page 68244)11404
Exc tr-ext b9+marg 3.1-4 cm

928.31
1
333.00

66.6011406
Exc tr-ext b9+marg > 4.0 cm

928.31
2
446.00

89.2011424
Exc h-f-nk-sp b9+marg 3.1-4

928.31
2
446.00

89.2011426
Exc h-f-nk-sp b9+marg > 4 cm

1,233.39
2
446.00

89.2011444
Exc face-mm b9+marg 3.1-4 cm

418.49
1
333.00

66.6011446
Exc face-mm b9+marg > 4 cm

1,233.39
2
446.00

89.2011450
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011451
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011462
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011463
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011470
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011471
Removal, sweat gland lesion

1,233.39
2
446.00

89.2011604
Exc tr-ext mlg+marg 3.1-4 cm

418.49
2
418.49
Y
83.7011606
Exc tr-ext mlg+marg > 4 cm

928.31
2
446.00

89.2011624
Exc h-f-nk-sp mlg+marg 3.1-4

928.31
2
446.00

89.2011626
Exc h-f-nk-sp mlg+mar > 4 cm

1,233.39
2
446.00

89.2011644
Exc face-mm malig+marg 3.1-4

928.31
2
446.00

89.2011646
Exc face-mm mlg+marg > 4 cm

1,233.39
2
446.00

89.2011770
Removal of pilonidal lesion

1,233.39
3
510.00

102.0011771
Removal of pilonidal lesion

1,233.39
3
510.00

102.0011772
Removal of pilonidal lesion

1,233.39
3
510.00

102.0011960
Insert tissue expander(s)

1,317.27
2
446.00

89.2011970
Replace tissue expander

2,525.68
3
510.00

102.0011971
Remove tissue expander(s)

1,233.39
1
333.00

66.6012005
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512006
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512007
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512016
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512017
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512018
Repair superficial wound(s)

91.24
2
91.24
Y
18.2512020
Closure of split wound

91.24
1
91.24
Y
18.2512021
Closure of split wound

91.24
1
91.24
Y
18.2512034
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512035
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512036
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512037
Layer closure of wound(s)

323.28
2
323.28
Y
64.6612044
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512045
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512046
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512047
Layer closure of wound(s)

323.28
2
323.28
Y
64.6612054
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512055
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512056
Layer closure of wound(s)

91.24
2
91.24
Y
18.2512057
Layer closure of wound(s)

323.28
2
323.28
Y
64.6613100
Repair of wound or lesion

323.28
2
323.28
Y
64.6613101
Repair of wound or lesion

323.28
3
323.28
Y
64.6613102
Repair wound/lesion add-on
A*
91.24
1
91.24
Y
18.2513120
Repair of wound or lesion

91.24
2
91.24
Y
18.2513121
Repair of wound or lesion

91.24
3
91.24
Y
18.2513122
Repair wound/lesion add-on
A*
91.24
1
91.24
Y
18.2513131
Repair of wound or lesion

91.24
2
91.24
Y
18.2513132
Repair of wound or lesion

91.24
3
91.24
Y
18.2513133
Repair wound/lesion add-on
A*
91.24
1
91.24
Y
18.2513150
Repair of wound or lesion

323.28
3
323.28
Y
64.6613151
Repair of wound or lesion

323.28
3
323.28
Y
64.6613152
Repair of wound or lesion

323.28
3
323.28
Y
64.6613153
Repair wound/lesion add-on
A*
91.24
3
91.24
Y
18.2513160
Late closure of wound

1,317.27
2
446.00

89.2014000
Skin tissue rearrangement

862.68
2
446.00

89.2014001
Skin tissue rearrangement

1,317.27
3
510.00

102.0014020
Skin tissue rearrangement

862.68
3
510.00

102.0014021
Skin tissue rearrangement

862.68
3
510.00

102.0014040
Skin tissue rearrangement

862.68
2
446.00

89.2014041
Skin tissue rearrangement

862.68
3
510.00

102.0014060
Skin tissue rearrangement

862.68
3
510.00

102.00( print page 68245)14061
Skin tissue rearrangement

862.68
3
510.00

102.0014300
Skin tissue rearrangement

1,317.27
4
630.00

126.0014350
Skin tissue rearrangement

1,317.27
3
510.00

102.0015000
Wound prep, 1st 100 sq cm
D

2
446.0015001
Wound prep, addl 100 sq cm
D

1
333.0015002
Wnd prep, ch/inf, trk/arm/lg
A
323.28
2
323.28
Y
64.6615003
Wnd prep, ch/inf addl 100 cm
A
323.28
1
323.28
Y
64.6615004
Wnd prep ch/inf, f/n/hf/g
A
323.28
2
323.28
Y
64.6615005
Wnd prep, f/n/hf/g, addl cm
A
323.28
1
323.28
Y
64.6615040
Harvest cultured skin graft

91.24
2
91.24
Y
18.2515050
Skin pinch graft

323.28
2
323.28
Y
64.6615100
Skin splt grft, trnk/arm/leg

1,317.27
2
446.00

89.2015101
Skin splt grft t/a/l, add-on

1,317.27
3
510.00

102.0015110
Epidrm autogrft trnk/arm/leg

1,317.27
2
446.00

89.2015111
Epidrm autogrft t/a/l add-on

1,317.27
1
333.00

66.6015115
Epidrm a-grft face/nck/hf/g

1,317.27
2
446.00

89.2015116
Epidrm a-grft f/n/hf/g addl

1,317.27
1
333.00

66.6015120
Skn splt a-grft fac/nck/hf/g

1,317.27
2
446.00

89.2015121
Skn splt a-grft f/n/hf/g add

1,317.27
3
510.00

102.0015130
Derm autograft, trnk/arm/leg

1,317.27
2
446.00

89.2015131
Derm autograft t/a/l add-on

1,317.27
1
333.00

66.6015135
Derm autograft face/nck/hf/g

1,317.27
2
446.00

89.2015136
Derm autograft, f/n/hf/g add

1,317.27
1
333.00

66.6015150
Cult epiderm grft t/arm/leg

1,317.27
2
446.00

89.2015151
Cult epiderm grft t/a/l addl

1,317.27
1
333.00

66.6015152
Cult epiderm graft t/a/l +%

1,317.27
1
333.00

66.6015155
Cult epiderm graft, f/n/hf/g

1,317.27
2
446.00

89.2015156
Cult epidrm grft f/n/hfg add

1,317.27
1
333.00

66.6015157
Cult epiderm grft f/n/hfg +%

1,317.27
1
333.00

66.6015200
Skin full graft, trunk

862.68
3
510.00

102.0015201
Skin full graft trunk add-on

323.28
2
323.28
Y
64.6615220
Skin full graft sclp/arm/leg

862.68
2
446.00

89.2015221
Skin full graft add-on

323.28
2
323.28
Y
64.6615240
Skin full grft face/genit/hf

862.68
3
510.00

102.0015241
Skin full graft add-on

323.28
3
323.28
Y
64.6615260
Skin full graft een & lips

862.68
2
446.00

89.2015261
Skin full graft add-on

323.28
2
323.28
Y
64.6615300
Apply skinallogrft, t/arm/lg

323.28
2
323.28
Y
64.6615301
Apply sknallogrft t/a/l addl

323.28
1
323.28
Y
64.6615320
Apply skin allogrft f/n/hf/g

323.28
2
323.28
Y
64.6615321
Aply sknallogrft f/n/hfg add

323.28
1
323.28
Y
64.6615330
Aply acell alogrft t/arm/leg

323.28
2
323.28
Y
64.6615331
Aply acell grft t/a/l add-on

323.28
1
323.28
Y
64.6615335
Apply acell graft, f/n/hf/g

323.28
2
323.28
Y
64.6615336
Aply acell grft f/n/hf/g add

323.28
1
323.28
Y
64.6615400
Apply skin xenograft, t/a/l

323.28
2
323.28
Y
64.6615401
Apply skn xenogrft t/a/l add

323.28
2
323.28
Y
64.6615420
Apply skin xgraft, f/n/hf/g

323.28
2
323.28
Y
64.6615421
Apply skn xgrft f/n/hf/g add

323.28
1
323.28
Y
64.6615430
Apply acellular xenograft

323.28
2
323.28
Y
64.6615431
Apply acellular xgraft add

323.28
1
323.28
Y
64.6615570
Form skin pedicle flap

1,317.27
3
510.00

102.0015572
Form skin pedicle flap

1,317.27
3
510.00

102.0015574
Form skin pedicle flap

1,317.27
3
510.00

102.0015576
Form skin pedicle flap

862.68
3
510.00

102.0015600
Skin graft

1,317.27
3
510.00

102.0015610
Skin graft

1,317.27
3
510.00

102.0015620
Skin graft

1,317.27
4
630.00

126.0015630
Skin graft

1,317.27
3
510.00

102.0015650
Transfer skin pedicle flap

1,317.27
5
717.00

143.4015731
Forehead flap w/vasc pedicle
A
862.68
3
510.00

102.0015732
Muscle-skin graft, head/neck

1,317.27
3
510.00

102.0015734
Muscle-skin graft, trunk

1,317.27
3
510.00

102.0015736
Muscle-skin graft, arm

1,317.27
3
510.00

102.0015738
Muscle-skin graft, leg

1,317.27
3
510.00

102.00( print page 68246)15740
Island pedicle flap graft

862.68
2
446.00

89.2015750
Neurovascular pedicle graft

1,317.27
2
446.00

89.2015760
Composite skin graft

1,317.27
2
446.00

89.2015770
Derma-fat-fascia graft

1,317.27
3
510.00

102.0015775
Hair transplant punch grafts

323.28
3
323.28
Y
64.6615776
Hair transplant punch grafts

323.28
3
323.28
Y
64.6615820
Revision of lower eyelid

1,317.27
3
510.00

102.0015821
Revision of lower eyelid

1,317.27
3
510.00

102.0015822
Revision of upper eyelid

1,317.27
3
510.00

102.0015823
Revision of upper eyelid

862.68
5
717.00

143.4015824
Removal of forehead wrinkles

1,317.27
3
510.00

102.0015825
Removal of neck wrinkles

1,317.27
3
510.00

102.0015826
Removal of brow wrinkles

1,317.27
3
510.00

102.0015828
Removal of face wrinkles

1,317.27
3
510.00

102.0015829
Removal of skin wrinkles

1,317.27
5
717.00

143.4015830
Exc skin abd
A
1,233.39
3
510.00

102.0015831
Excise excessive skin tissue
D

3
510.0015832
Excise excessive skin tissue

1,233.39
3
510.00

102.0015833
Excise excessive skin tissue

1,233.39
3
510.00

102.0015834
Excise excessive skin tissue

1,233.39
3
510.00

102.0015835
Excise excessive skin tissue

323.28
3
323.28
Y
64.6615836
Excise excessive skin tissue

928.31
3
510.00

102.0015839
Excise excessive skin tissue

928.31
3
510.00

102.0015840
Graft for face nerve palsy

1,317.27
4
630.00

126.0015841
Graft for face nerve palsy

1,317.27
4
630.00

126.0015845
Skin and muscle repair, face

1,317.27
4
630.00

126.0015847
Exc skin abd add-on
A
1,233.39
3
510.00

102.0015876
Suction assisted lipectomy

1,317.27
3
510.00

102.0015877
Suction assisted lipectomy

1,317.27
3
510.00

102.0015878
Suction assisted lipectomy

862.68
3
510.00

102.0015879
Suction assisted lipectomy

1,317.27
3
510.00

102.0015920
Removal of tail bone ulcer

251.52
3
251.52
Y
50.3015922
Removal of tail bone ulcer

1,317.27
4
630.00

126.0015931
Remove sacrum pressure sore

1,233.39
3
510.00

102.0015933
Remove sacrum pressure sore

1,233.39
3
510.00

102.0015934
Remove sacrum pressure sore

1,317.27
3
510.00

102.0015935
Remove sacrum pressure sore

1,317.27
4
630.00

126.0015936
Remove sacrum pressure sore

1,317.27
4
630.00

126.0015937
Remove sacrum pressure sore

1,317.27
4
630.00

126.0015940
Remove hip pressure sore

1,233.39
3
510.00

102.0015941
Remove hip pressure sore

1,233.39
3
510.00

102.0015944
Remove hip pressure sore

1,317.27
3
510.00

102.0015945
Remove hip pressure sore

1,317.27
4
630.00

126.0015946
Remove hip pressure sore

1,317.27
4
630.00

126.0015950
Remove thigh pressure sore

1,233.39
3
510.00

102.0015951
Remove thigh pressure sore

1,233.39
4
630.00

126.0015952
Remove thigh pressure sore

1,317.27
3
510.00

102.0015953
Remove thigh pressure sore

1,317.27
4
630.00

126.0015956
Remove thigh pressure sore

1,317.27
3
510.00

102.0015958
Remove thigh pressure sore

1,317.27
4
630.00

126.0016025
Dress/debrid p-thick burn, m

67.11
2
67.11
Y
13.4216030
Dress/debrid p-thick burn, l

99.83
2
99.83
Y
19.9719020
Incision of breast lesion

1,076.22
2
446.00

89.2019100
Bx breast percut w/o image

240.00
1
240.00
Y
48.0019101
Biopsy of breast, open

1,185.03
2
446.00

89.2019102
Bx breast percut w/image

240.00
2
240.00
Y
48.0019103
Bx breast percut w/device

395.77
2
395.77
Y
79.1519110
Nipple exploration

1,185.03
2
446.00

89.2019112
Excise breast duct fistula

1,185.03
3
510.00

102.0019120
Removal of breast lesion

1,185.03
3
510.00

102.0019125
Excision, breast lesion

1,185.03
3
510.00

102.0019126
Excision, addl breast lesion

1,185.03
3
510.00

102.0019140
Removal of breast tissue
D

4
630.0019160
Partial mastectomy
D

3
510.0019162
P-mastectomy w/ln removal
D

7
995.00( print page 68247)19180
Removal of breast
D

4
630.0019182
Removal of breast
D

4
630.0019290
Place needle wire, breast


1
333.00

66.6019291
Place needle wire, breast


1
333.00

66.6019295
Place breast clip, percut
A*
106.76
1
106.76
Y
21.3519296
Place po breast cath for rad

3,148.82
9
1,339.00

267.8019297
Place breast cath for rad
A*
3,148.82
9
1,339.00

267.8019298
Place breast rad tube/caths

3,250.00
9
1,339.00

267.8019300
Removal of breast tissue
A
1,185.03
4
630.00

126.0019301
Partical mastectomy
A
1,185.03
3
510.00

102.0019302
P-mastectomy w/ln removal
A
2,274.24
7
995.00

199.0019303
Mast, simple, complete
A
1,722.12
4
630.00

126.0019304
Mast, subq
A
1,722.12
4
630.00

126.0019316
Suspension of breast

1,722.12
4
630.00

126.0019318
Reduction of large breast

2,274.24
4
630.00

126.0019324
Enlarge breast

2,274.24
4
630.00

126.0019325
Enlarge breast with implant

3,148.82
9
1,339.00

267.8019328
Removal of breast implant

1,722.12
1
333.00

66.6019330
Removal of implant material

1,722.12
1
333.00

66.6019340
Immediate breast prosthesis

2,327.74
2
446.00

89.2019342
Delayed breast prosthesis

3,148.82
3
510.00

102.0019350
Breast reconstruction

1,185.03
4
630.00

126.0019355
Correct inverted nipple(s)

1,722.12
4
630.00

126.0019357
Breast reconstruction

3,148.82
5
717.00

143.4019366
Breast reconstruction

1,722.12
5
717.00

143.4019370
Surgery of breast capsule

1,722.12
4
630.00

126.0019371
Removal of breast capsule

1,722.12
4
630.00

126.0019380
Revise breast reconstruction

2,327.74
5
717.00

143.4020005
Incision of deep abscess

1,282.87
2
446.00

89.2020200
Muscle biopsy

928.31
2
446.00

89.2020205
Deep muscle biopsy

928.31
3
510.00

102.0020206
Needle biopsy, muscle

240.00
1
240.00
Y
48.0020220
Bone biopsy, trocar/needle

251.52
1
251.52
Y
50.3020225
Bone biopsy, trocar/needle

418.49
2
418.49
Y
83.7020240
Bone biopsy, excisional

1,233.39
2
446.00

89.2020245
Bone biopsy, excisional

1,233.39
3
510.00

102.0020250
Open bone biopsy

1,282.87
3
510.00

102.0020251
Open bone biopsy

1,282.87
3
510.00

102.0020525
Removal of foreign body

1,233.39
3
510.00

102.0020650
Insert and remove bone pin

1,282.87
3
510.00

102.0020670
Removal of support implant

928.31
1
333.00

66.6020680
Removal of support implant

1,233.39
3
510.00

102.0020690
Apply bone fixation device

1,544.67
2
446.00

89.2020692
Apply bone fixation device

1,544.67
3
510.00

102.0020693
Adjust bone fixation device

1,282.87
3
510.00

102.0020694
Remove bone fixation device

1,282.87
1
333.00

66.6020900
Removal of bone for graft

1,544.67
3
510.00

102.0020902
Removal of bone for graft

1,544.67
4
630.00

126.0020910
Remove cartilage for graft

1,317.27
3
510.00

102.0020912
Remove cartilage for graft

1,317.27
3
510.00

102.0020920
Removal of fascia for graft

862.68
4
630.00

126.0020922
Removal of fascia for graft

1,317.27
3
510.00

102.0020924
Removal of tendon for graft

1,544.67
4
630.00

126.0020926
Removal of tissue for graft

862.68
4
630.00

126.0020975
Electrical bone stimulation

37.51
2
37.51
Y
7.5021010
Incision of jaw joint

1,434.04
2
446.00

89.2021015
Resection of facial tumor

1,009.71
3
510.00

102.0021025
Excision of bone, lower jaw

2,348.02
2
446.00

89.2021026
Excision of facial bone(s)

2,348.02
2
446.00

89.2021029
Contour of face bone lesion

2,348.02
2
446.00

89.2021034
Excise max/zygoma mlg tumor

2,348.02
3
510.00

102.0021040
Excise mandible lesion

1,434.04
2
446.00

89.2021044
Removal of jaw bone lesion

2,348.02
2
446.00

89.2021046
Remove mandible cyst complex

2,348.02
2
446.00

89.2021047
Excise lwr jaw cyst w/repair

2,348.02
2
446.00

89.20( print page 68248)21050
Removal of jaw joint

2,348.02
3
510.00

102.0021060
Remove jaw joint cartilage

2,348.02
2
446.00

89.2021070
Remove coronoid process

2,348.02
3
510.00

102.0021100
Maxillofacial fixation

2,348.02
2
446.00

89.2021120
Reconstruction of chin

1,434.04
7
995.00

199.0021121
Reconstruction of chin

1,434.04
7
995.00

199.0021122
Reconstruction of chin

1,434.04
7
995.00

199.0021123
Reconstruction of chin

1,434.04
7
995.00

199.0021125
Augmentation, lower jaw bone

1,434.04
7
995.00

199.0021127
Augmentation, lower jaw bone

2,348.02
9
1,339.00

267.8021181
Contour cranial bone lesion

1,434.04
7
995.00

199.0021206
Reconstruct upper jaw bone

2,348.02
5
717.00

143.4021208
Augmentation of facial bones

2,348.02
7
995.00

199.0021209
Reduction of facial bones

2,348.02
5
717.00

143.4021210
Face bone graft

2,348.02
7
995.00

199.0021215
Lower jaw bone graft

2,348.02
7
995.00

199.0021230
Rib cartilage graft

2,348.02
7
995.00

199.0021235
Ear cartilage graft

1,434.04
7
995.00

199.0021240
Reconstruction of jaw joint

2,348.02
4
630.00

126.0021242
Reconstruction of jaw joint

2,348.02
5
717.00

143.4021243
Reconstruction of jaw joint

2,348.02
5
717.00

143.4021244
Reconstruction of lower jaw

2,348.02
7
995.00

199.0021245
Reconstruction of jaw

2,348.02
7
995.00

199.0021246
Reconstruction of jaw

2,348.02
7
995.00

199.0021248
Reconstruction of jaw

2,348.02
7
995.00

199.0021249
Reconstruction of jaw

2,348.02
7
995.00

199.0021267
Revise eye sockets

2,348.02
7
995.00

199.0021270
Augmentation, cheek bone

2,348.02
5
717.00

143.4021275
Revision, orbitofacial bones

2,348.02
7
995.00

199.0021280
Revision of eyelid

2,348.02
5
717.00

143.4021282
Revision of eyelid

1,009.71
5
717.00

143.4021295
Revision of jaw muscle/bone

464.15
1
333.00

66.6021296
Revision of jaw muscle/bone

1,434.04
1
333.00

66.6021300
Treatment of skull fracture
D

2
446.0021310
Treatment of nose fracture

150.72
2
150.72
Y
30.1421315
Treatment of nose fracture

150.72
2
150.72
Y
30.1421320
Treatment of nose fracture

464.15
2
446.00

89.2021325
Treatment of nose fracture

1,434.04
4
630.00

126.0021330
Treatment of nose fracture

1,434.04
5
717.00

143.4021335
Treatment of nose fracture

1,434.04
7
995.00

199.0021336
Treat nasal septal fracture

2,307.40
4
630.00

126.0021337
Treat nasal septal fracture

1,009.71
2
446.00

89.2021338
Treat nasoethmoid fracture

1,434.04
4
630.00

126.0021339
Treat nasoethmoid fracture

1,434.04
5
717.00

143.4021340
Treatment of nose fracture

2,348.02
4
630.00

126.0021345
Treat nose/jaw fracture

1,434.04
7
995.00

199.0021355
Treat cheek bone fracture

2,348.02
3
510.00

102.0021356
Treat cheek bone fracture
A*
1,434.04
3
510.00

102.0021400
Treat eye socket fracture

464.15
2
446.00

89.2021401
Treat eye socket fracture

1,009.71
3
510.00

102.0021421
Treat mouth roof fracture

1,434.04
4
630.00

126.0021445
Treat dental ridge fracture

1,434.04
4
630.00

126.0021450
Treat lower jaw fracture

150.72
3
150.72
Y
30.1421451
Treat lower jaw fracture

464.15
4
464.15
Y
92.8321452
Treat lower jaw fracture

1,009.71
2
446.00

89.2021453
Treat lower jaw fracture

2,348.02
3
510.00

102.0021454
Treat lower jaw fracture

1,434.04
5
717.00

143.4021461
Treat lower jaw fracture

2,348.02
4
630.00

126.0021462
Treat lower jaw fracture

2,348.02
5
717.00

143.4021465
Treat lower jaw fracture

2,348.02
4
630.00

126.0021480
Reset dislocated jaw

150.72
1
150.72
Y
30.1421485
Reset dislocated jaw

1,009.71
2
446.00

89.2021490
Repair dislocated jaw

2,348.02
3
510.00

102.0021497
Interdental wiring

1,009.71
2
446.00

89.2021501
Drain neck/chest lesion

1,076.22
2
446.00

89.20( print page 68249)21502
Drain chest lesion

1,282.87
2
446.00

89.2021555
Remove lesion, neck/chest

1,233.39
2
446.00

89.2021556
Remove lesion, neck/chest

1,233.39
2
446.00

89.2021600
Partial removal of rib

1,544.67
2
446.00

89.2021610
Partial removal of rib

1,544.67
2
446.00

89.2021700
Revision of neck muscle

1,282.87
2
446.00

89.2021720
Revision of neck muscle

1,282.87
3
510.00

102.0021725
Revision of neck muscle

88.46
3
88.46
Y
17.6921800
Treatment of rib fracture

103.62
1
103.62
Y
20.7221805
Treatment of rib fracture

1,569.06
2
446.00

89.2021820
Treat sternum fracture

103.62
1
103.62
Y
20.7221925
Biopsy soft tissue of back

1,233.39
2
446.00

89.2021930
Remove lesion, back or flank

1,233.39
2
446.00

89.2021935
Remove tumor, back

1,233.39
3
510.00

102.0022305
Treat spine process fracture

103.62
1
103.62
Y
20.7222310
Treat spine fracture

103.62
1
103.62
Y
20.7222315
Treat spine fracture

103.62
2
103.62
Y
20.7222505
Manipulation of spine

897.11
2
446.00

89.2022520
Percut vertebroplasty thor
A*
1,544.67
9
1,339.00

267.8022521
Percut vertebroplasty lumb
A*
1,544.67
9
1,339.00

267.8022522
Percut vertebroplasty addÆ
A*
1,544.67
9
1,339.00

267.8022900
Remove abdominal wall lesion

1,233.39
4
630.00

126.0023000
Removal of calcium deposits

928.31
2
446.00

89.2023020
Release shoulder joint

2,525.68
2
446.00

89.2023030
Drain shoulder lesion

1,076.22
1
333.00

66.6023031
Drain shoulder bursa

1,076.22
3
510.00

102.0023035
Drain shoulder bone lesion

1,282.87
3
510.00

102.0023040
Exploratory shoulder surgery

1,544.67
3
510.00

102.0023044
Exploratory shoulder surgery

1,544.67
4
630.00

126.0023066
Biopsy shoulder tissues

1,233.39
2
446.00

89.2023075
Removal of shoulder lesion

928.31
2
446.00

89.2023076
Removal of shoulder lesion

1,233.39
2
446.00

89.2023077
Remove tumor of shoulder

1,233.39
3
510.00

102.0023100
Biopsy of shoulder joint

1,282.87
2
446.00

89.2023101
Shoulder joint surgery

1,544.67
7
995.00

199.0023105
Remove shoulder joint lining

1,544.67
4
630.00

126.0023106
Incision of collarbone joint

1,544.67
4
630.00

126.0023107
Explore treat shoulder joint

1,544.67
4
630.00

126.0023120
Partial removal, collar bone

2,525.68
5
717.00

143.4023125
Removal of collar bone

2,525.68
5
717.00

143.4023130
Remove shoulder bone, part

2,525.68
5
717.00

143.4023140
Removal of bone lesion

1,282.87
4
630.00

126.0023145
Removal of bone lesion

1,544.67
5
717.00

143.4023146
Removal of bone lesion

1,544.67
5
717.00

143.4023150
Removal of humerus lesion

1,544.67
4
630.00

126.0023155
Removal of humerus lesion

1,544.67
5
717.00

143.4023156
Removal of humerus lesion

1,544.67
5
717.00

143.4023170
Remove collar bone lesion

1,544.67
2
446.00

89.2023172
Remove shoulder blade lesion

1,544.67
2
446.00

89.2023174
Remove humerus lesion

1,544.67
2
446.00

89.2023180
Remove collar bone lesion

1,544.67
4
630.00

126.0023182
Remove shoulder blade lesion

1,544.67
4
630.00

126.0023184
Remove humerus lesion

1,544.67
4
630.00

126.0023190
Partial removal of scapula

1,544.67
4
630.00

126.0023195
Removal of head of humerus

1,544.67
5
717.00

143.4023330
Remove shoulder foreign body

418.49
1
333.00

66.6023331
Remove shoulder foreign body

1,233.39
1
333.00

66.6023395
Muscle transfer,shoulder/arm

2,525.68
5
717.00

143.4023397
Muscle transfers

4,092.54
7
995.00

199.0023400
Fixation of shoulder blade

1,544.67
7
995.00

199.0023405
Incision of tendon & muscle

1,544.67
2
446.00

89.2023406
Incise tendon(s) & muscle(s)

1,544.67
2
446.00

89.2023410
Repair rotator cuff, acute

2,525.68
5
717.00

143.4023412
Repair rotator cuff, chronic

2,525.68
7
995.00

199.0023415
Release of shoulder ligament

2,525.68
5
717.00

143.40( print page 68250)23420
Repair of shoulder

2,525.68
7
995.00

199.0023430
Repair biceps tendon

2,525.68
4
630.00

126.0023440
Remove/transplant tendon

2,525.68
4
630.00

126.0023450
Repair shoulder capsule

4,092.54
5
717.00

143.4023455
Repair shoulder capsule

4,092.54
7
995.00

199.0023460
Repair shoulder capsule

4,092.54
5
717.00

143.4023462
Repair shoulder capsule

2,525.68
7
995.00

199.0023465
Repair shoulder capsule

4,092.54
5
717.00

143.4023466
Repair shoulder capsule

2,525.68
7
995.00

199.0023480
Revision of collar bone

2,525.68
4
630.00

126.0023485
Revision of collar bone

4,092.54
7
995.00

199.0023490
Reinforce clavicle

2,525.68
3
510.00

102.0023491
Reinforce shoulder bones

4,092.54
3
510.00

102.0023500
Treat clavicle fracture

103.62
1
103.62
Y
20.7223505
Treat clavicle fracture

103.62
1
103.62
Y
20.7223515
Treat clavicle fracture

3,517.03
3
510.00

102.0023520
Treat clavicle dislocation

103.62
1
103.62
Y
20.7223525
Treat clavicle dislocation

103.62
1
103.62
Y
20.7223530
Treat clavicle dislocation

2,307.40
3
510.00

102.0023532
Treat clavicle dislocation

1,569.06
4
630.00

126.0023540
Treat clavicle dislocation

103.62
1
103.62
Y
20.7223545
Treat clavicle dislocation

103.62
1
103.62
Y
20.7223550
Treat clavicle dislocation

2,307.40
3
510.00

102.0023552
Treat clavicle dislocation

2,307.40
4
630.00

126.0023570
Treat shoulder blade fx

103.62
1
103.62
Y
20.7223575
Treat shoulder blade fx

103.62
1
103.62
Y
20.7223585
Treat scapula fracture

3,517.03
3
510.00

102.0023605
Treat humerus fracture

103.62
2
103.62
Y
20.7223615
Treat humerus fracture

3,517.03
4
630.00

126.0023616
Treat humerus fracture

3,517.03
4
630.00

126.0023625
Treat humerus fracture

103.62
2
103.62
Y
20.7223630
Treat humerus fracture

3,517.03
5
717.00

143.4023650
Treat shoulder dislocation

103.62
1
103.62
Y
20.7223655
Treat shoulder dislocation

897.11
1
333.00

66.6023660
Treat shoulder dislocation

2,307.40
3
510.00

102.0023665
Treat dislocation/fracture

103.62
2
103.62
Y
20.7223670
Treat dislocation/fracture

3,517.03
3
510.00

102.0023675
Treat dislocation/fracture

103.62
2
103.62
Y
20.7223680
Treat dislocation/fracture

2,307.40
3
510.00

102.0023700
Fixation of shoulder

897.11
1
333.00

66.6023800
Fusion of shoulder joint

4,092.54
4
630.00

126.0023802
Fusion of shoulder joint

2,525.68
7
995.00

199.0023921
Amputation follow-up surgery

323.28
3
323.28
Y
64.6623930
Drainage of arm lesion

1,076.22
1
333.00

66.6023931
Drainage of arm bursa

1,076.22
2
446.00

89.2023935
Drain arm/elbow bone lesion

1,282.87
2
446.00

89.2024000
Exploratory elbow surgery

1,544.67
4
630.00

126.0024006
Release elbow joint

1,544.67
4
630.00

126.0024066
Biopsy arm/elbow soft tissue

928.31
2
446.00

89.2024075
Remove arm/elbow lesion

928.31
2
446.00

89.2024076
Remove arm/elbow lesion

1,233.39
2
446.00

89.2024077
Remove tumor of arm/elbow

1,233.39
3
510.00

102.0024100
Biopsy elbow joint lining

1,282.87
1
333.00

66.6024101
Explore/treat elbow joint

1,544.67
4
630.00

126.0024102
Remove elbow joint lining

1,544.67
4
630.00

126.0024105
Removal of elbow bursa

1,282.87
3
510.00

102.0024110
Remove humerus lesion

1,282.87
2
446.00

89.2024115
Remove/graft bone lesion

1,544.67
3
510.00

102.0024116
Remove/graft bone lesion

1,544.67
3
510.00

102.0024120
Remove elbow lesion

1,282.87
3
510.00

102.0024125
Remove/graft bone lesion

1,544.67
3
510.00

102.0024126
Remove/graft bone lesion

1,544.67
3
510.00

102.0024130
Removal of head of radius

1,544.67
3
510.00

102.0024134
Removal of arm bone lesion

1,544.67
2
446.00

89.2024136
Remove radius bone lesion

1,544.67
2
446.00

89.20( print page 68251)24138
Remove elbow bone lesion

1,544.67
2
446.00

89.2024140
Partial removal of arm bone

1,544.67
3
510.00

102.0024145
Partial removal of radius

1,544.67
3
510.00

102.0024147
Partial removal of elbow

1,544.67
2
446.00

89.2024155
Removal of elbow joint

2,525.68
3
510.00

102.0024160
Remove elbow joint implant

1,544.67
2
446.00

89.2024164
Remove radius head implant

1,544.67
3
510.00

102.0024201
Removal of arm foreign body

928.31
2
446.00

89.2024301
Muscle/tendon transfer

1,544.67
4
630.00

126.0024305
Arm tendon lengthening

1,544.67
4
630.00

126.0024310
Revision of arm tendon

1,282.87
3
510.00

102.0024320
Repair of arm tendon

2,525.68
3
510.00

102.0024330
Revision of arm muscles

4,092.54
3
510.00

102.0024331
Revision of arm muscles

2,525.68
3
510.00

102.0024340
Repair of biceps tendon

2,525.68
3
510.00

102.0024341
Repair arm tendon/muscle

2,525.68
3
510.00

102.0024342
Repair of ruptured tendon

2,525.68
3
510.00

102.0024345
Repr elbw med ligmnt w/tissu

1,544.67
2
446.00

89.2024350
Repair of tennis elbow

1,544.67
3
510.00

102.0024351
Repair of tennis elbow

1,544.67
3
510.00

102.0024352
Repair of tennis elbow

1,544.67
3
510.00

102.0024354
Repair of tennis elbow

1,544.67
3
510.00

102.0024356
Revision of tennis elbow

1,544.67
3
510.00

102.0024360
Reconstruct elbow joint

2,056.14
5
717.00

143.4024361
Reconstruct elbow joint

6,589.01
5
717.00

143.4024362
Reconstruct elbow joint

2,915.91
5
717.00

143.4024363
Replace elbow joint

6,589.01
7
995.00

199.0024365
Reconstruct head of radius

2,056.14
5
717.00

143.4024366
Reconstruct head of radius

6,589.01
5
717.00

143.4024400
Revision of humerus

1,544.67
4
630.00

126.0024410
Revision of humerus

1,544.67
4
630.00

126.0024420
Revision of humerus

2,525.68
3
510.00

102.0024430
Repair of humerus

4,092.54
3
510.00

102.0024435
Repair humerus with graft

4,092.54
4
630.00

126.0024470
Revision of elbow joint

2,525.68
3
510.00

102.0024495
Decompression of forearm

1,544.67
2
446.00

89.2024498
Reinforce humerus

4,092.54
3
510.00

102.0024500
Treat humerus fracture

103.62
1
103.62
Y
20.7224505
Treat humerus fracture

103.62
1
103.62
Y
20.7224515
Treat humerus fracture

3,517.03
4
630.00

126.0024516
Treat humerus fracture

3,517.03
4
630.00

126.0024530
Treat humerus fracture

103.62
1
103.62
Y
20.7224535
Treat humerus fracture

103.62
1
103.62
Y
20.7224538
Treat humerus fracture

1,569.06
2
446.00

89.2024545
Treat humerus fracture

3,517.03
4
630.00

126.0024546
Treat humerus fracture

3,517.03
5
717.00

143.4024560
Treat humerus fracture

103.62
1
103.62
Y
20.7224565
Treat humerus fracture

103.62
2
103.62
Y
20.7224566
Treat humerus fracture

1,569.06
2
446.00

89.2024575
Treat humerus fracture

3,517.03
3
510.00

102.0024576
Treat humerus fracture

103.62
1
103.62
Y
20.7224577
Treat humerus fracture

103.62
1
103.62
Y
20.7224579
Treat humerus fracture

3,517.03
3
510.00

102.0024582
Treat humerus fracture

1,569.06
2
446.00

89.2024586
Treat elbow fracture

3,517.03
4
630.00

126.0024587
Treat elbow fracture

3,517.03
5
717.00

143.4024600
Treat elbow dislocation

103.62
1
103.62
Y
20.7224605
Treat elbow dislocation

897.11
2
446.00

89.2024615
Treat elbow dislocation

3,517.03
3
510.00

102.0024620
Treat elbow fracture

103.62
2
103.62
Y
20.7224635
Treat elbow fracture

3,517.03
3
510.00

102.0024655
Treat radius fracture

103.62
1
103.62
Y
20.7224665
Treat radius fracture

2,307.40
4
630.00

126.0024666
Treat radius fracture

3,517.03
4
630.00

126.0024670
Treat ulnar fracture

103.62
1
103.62
Y
20.72( print page 68252)24675
Treat ulnar fracture

103.62
1
103.62
Y
20.7224685
Treat ulnar fracture

2,307.40
3
510.00

102.0024800
Fusion of elbow joint

2,525.68
4
630.00

126.0024802
Fusion/graft of elbow joint

2,525.68
5
717.00

143.4024925
Amputation follow-up surgery

1,282.87
3
510.00

102.0025000
Incision of tendon sheath

1,282.87
3
510.00

102.0025020
Decompress forearm 1 space

1,282.87
3
510.00

102.0025023
Decompress forearm 1 space

1,544.67
3
510.00

102.0025024
Decompress forearm 2 spaces

1,544.67
3
510.00

102.0025025
Decompress forearm 2 spaces

1,544.67
3
510.00

102.0025028
Drainage of forearm lesion

1,282.87
1
333.00

66.6025031
Drainage of forearm bursa

1,282.87
2
446.00

89.2025035
Treat forearm bone lesion

1,282.87
2
446.00

89.2025040
Explore/treat wrist joint

1,544.67
5
717.00

143.4025066
Biopsy forearm soft tissues

1,233.39
2
446.00

89.2025075
Removal forearm lesion subcu

928.31
2
446.00

89.2025076
Removal forearm lesion deep

1,233.39
3
510.00

102.0025077
Remove tumor, forearm/wrist

1,233.39
3
510.00

102.0025085
Incision of wrist capsule

1,282.87
3
510.00

102.0025100
Biopsy of wrist joint

1,282.87
2
446.00

89.2025101
Explore/treat wrist joint

1,544.67
3
510.00

102.0025105
Remove wrist joint lining

1,544.67
4
630.00

126.0025107
Remove wrist joint cartilage

1,544.67
3
510.00

102.0025110
Remove wrist tendon lesion

1,282.87
3
510.00

102.0025111
Remove wrist tendon lesion

992.95
3
510.00

102.0025112
Remove wrist tendon lesion

992.95
4
630.00

126.0025115
Remove wrist/forearm lesion

1,282.87
4
630.00

126.0025116
Remove wrist/forearm lesion

1,282.87
4
630.00

126.0025118
Excise wrist tendon sheath

1,544.67
2
446.00

89.2025119
Partial removal of ulna

1,544.67
3
510.00

102.0025120
Removal of forearm lesion

1,544.67
3
510.00

102.0025125
Remove/graft forearm lesion

1,544.67
3
510.00

102.0025126
Remove/graft forearm lesion

1,544.67
3
510.00

102.0025130
Removal of wrist lesion

1,544.67
3
510.00

102.0025135
Remove & graft wrist lesion

1,544.67
3
510.00

102.0025136
Remove & graft wrist lesion

1,544.67
3
510.00

102.0025145
Remove forearm bone lesion

1,544.67
2
446.00

89.2025150
Partial removal of ulna

1,544.67
2
446.00

89.2025151
Partial removal of radius

1,544.67
2
446.00

89.2025210
Removal of wrist bone

1,590.53
3
510.00

102.0025215
Removal of wrist bones

1,590.53
4
630.00

126.0025230
Partial removal of radius

1,544.67
4
630.00

126.0025240
Partial removal of ulna

1,544.67
4
630.00

126.0025248
Remove forearm foreign body

1,282.87
2
446.00

89.2025250
Removal of wrist prosthesis

1,544.67
1
333.00

66.6025251
Removal of wrist prosthesis

1,544.67
1
333.00

66.6025260
Repair forearm tendon/muscle

1,544.67
4
630.00

126.0025263
Repair forearm tendon/muscle

1,544.67
2
446.00

89.2025265
Repair forearm tendon/muscle

1,544.67
3
510.00

102.0025270
Repair forearm tendon/muscle

1,544.67
4
630.00

126.0025272
Repair forearm tendon/muscle

1,544.67
3
510.00

102.0025274
Repair forearm tendon/muscle

1,544.67
4
630.00

126.0025275
Repair forearm tendon sheath

1,544.67
4
630.00

126.0025280
Revise wrist/forearm tendon

1,544.67
4
630.00

126.0025290
Incise wrist/forearm tendon

1,544.67
3
510.00

102.0025295
Release wrist/forearm tendon

1,282.87
3
510.00

102.0025300
Fusion of tendons at wrist

1,544.67
3
510.00

102.0025301
Fusion of tendons at wrist

1,544.67
3
510.00

102.0025310
Transplant forearm tendon

2,525.68
3
510.00

102.0025312
Transplant forearm tendon

2,525.68
4
630.00

126.0025315
Revise palsy hand tendon(s)

2,525.68
3
510.00

102.0025316
Revise palsy hand tendon(s)

4,092.54
3
510.00

102.0025320
Repair/revise wrist joint

2,525.68
3
510.00

102.0025332
Revise wrist joint

2,056.14
5
717.00

143.4025335
Realignment of hand

2,525.68
3
510.00

102.00( print page 68253)25337
Reconstruct ulna/radioulnar

2,525.68
5
717.00

143.4025350
Revision of radius

4,092.54
3
510.00

102.0025355
Revision of radius

2,525.68
3
510.00

102.0025360
Revision of ulna

1,544.67
3
510.00

102.0025365
Revise radius & ulna

1,544.67
3
510.00

102.0025370
Revise radius or ulna

2,525.68
3
510.00

102.0025375
Revise radius & ulna

2,525.68
4
630.00

126.0025390
Shorten radius or ulna

1,544.67
3
510.00

102.0025391
Lengthen radius or ulna

2,525.68
4
630.00

126.0025392
Shorten radius & ulna

1,544.67
3
510.00

102.0025393
Lengthen radius & ulna

2,525.68
4
630.00

126.0025400
Repair radius or ulna

1,544.67
3
510.00

102.0025405
Repair/graft radius or ulna

1,544.67
4
630.00

126.0025415
Repair radius & ulna

1,544.67
3
510.00

102.0025420
Repair/graft radius & ulna

4,092.54
4
630.00

126.0025425
Repair/graft radius or ulna

2,525.68
3
510.00

102.0025426
Repair/graft radius & ulna

2,525.68
4
630.00

126.0025440
Repair/graft wrist bone

4,092.54
4
630.00

126.0025441
Reconstruct wrist joint

6,589.01
5
717.00

143.4025442
Reconstruct wrist joint

6,589.01
5
717.00

143.4025443
Reconstruct wrist joint

2,915.91
5
717.00

143.4025444
Reconstruct wrist joint

2,915.91
5
717.00

143.4025445
Reconstruct wrist joint

2,915.91
5
717.00

143.4025446
Wrist replacement

6,589.01
7
995.00

199.0025447
Repair wrist joint(s)

2,056.14
5
717.00

143.4025449
Remove wrist joint implant

2,056.14
5
717.00

143.4025450
Revision of wrist joint

2,525.68
3
510.00

102.0025455
Revision of wrist joint

2,525.68
3
510.00

102.0025490
Reinforce radius

2,525.68
3
510.00

102.0025491
Reinforce ulna

2,525.68
3
510.00

102.0025492
Reinforce radius and ulna

2,525.68
3
510.00

102.0025505
Treat fracture of radius

103.62
1
103.62
Y
20.7225515
Treat fracture of radius

2,307.40
3
510.00

102.0025520
Treat fracture of radius

103.62
1
103.62
Y
20.7225525
Treat fracture of radius

2,307.40
4
630.00

126.0025526
Treat fracture of radius

2,307.40
5
717.00

143.4025535
Treat fracture of ulna

103.62
1
103.62
Y
20.7225545
Treat fracture of ulna

2,307.40
3
510.00

102.0025565
Treat fracture radius & ulna

103.62
2
103.62
Y
20.7225574
Treat fracture radius & ulna

3,517.03
3
510.00

102.0025575
Treat fracture radius/ulna

3,517.03
3
510.00

102.0025605
Treat fracture radius/ulna

103.62
3
103.62
Y
20.7225606
Treat fx distal radial
A
1,569.06
3
510.00

102.0025607
Treat fx rad extra-articul
A
3,517.03
5
717.00

143.4025608
Treat fx rad intra-articul
A
3,517.03
5
717.00

143.4025609
Treat fx radial 3+ frag
A
3,517.03
5
717.00

143.4025611
Treat fracture radius/ulna
D

3
510.0025620
Treat fracture radius/ulna
D

5
717.0025624
Treat wrist bone fracture

103.62
2
103.62
Y
20.7225628
Treat wrist bone fracture

2,307.40
3
510.00

102.0025635
Treat wrist bone fracture

103.62
1
103.62
Y
20.7225645
Treat wrist bone fracture

2,307.40
3
510.00

102.0025660
Treat wrist dislocation

103.62
1
103.62
Y
20.7225670
Treat wrist dislocation

1,569.06
3
510.00

102.0025671
Pin radioulnar dislocation

1,569.06
1
333.00

66.6025675
Treat wrist dislocation

103.62
1
103.62
Y
20.7225676
Treat wrist dislocation

1,569.06
2
446.00

89.2025680
Treat wrist fracture

103.62
2
103.62
Y
20.7225685
Treat wrist fracture

1,569.06
3
510.00

102.0025690
Treat wrist dislocation

103.62
1
103.62
Y
20.7225695
Treat wrist dislocation

1,569.06
2
446.00

89.2025800
Fusion of wrist joint

4,092.54
4
630.00

126.0025805
Fusion/graft of wrist joint

2,525.68
5
717.00

143.4025810
Fusion/graft of wrist joint

4,092.54
5
717.00

143.4025820
Fusion of hand bones

992.95
4
630.00

126.00( print page 68254)25825
Fuse hand bones with graft

1,590.53
5
717.00

143.4025830
Fusion, radioulnar jnt/ulna

4,092.54
5
717.00

143.4025907
Amputation follow-up surgery

1,282.87
3
510.00

102.0025922
Amputate hand at wrist

1,282.87
3
510.00

102.0025929
Amputation follow-up surgery

862.68
3
510.00

102.0026011
Drainage of finger abscess

685.58
1
333.00

66.6026020
Drain hand tendon sheath

992.95
2
446.00

89.2026025
Drainage of palm bursa

992.95
1
333.00

66.6026030
Drainage of palm bursa(s)

992.95
2
446.00

89.2026034
Treat hand bone lesion

992.95
2
446.00

89.2026040
Release palm contracture

1,590.53
4
630.00

126.0026045
Release palm contracture

1,590.53
3
510.00

102.0026055
Incise finger tendon sheath

992.95
2
446.00

89.2026060
Incision of finger tendon

992.95
2
446.00

89.2026070
Explore/treat hand joint

992.95
2
446.00

89.2026075
Explore/treat finger joint

992.95
4
630.00

126.0026080
Explore/treat finger joint

992.95
4
630.00

126.0026100
Biopsy hand joint lining

992.95
2
446.00

89.2026105
Biopsy finger joint lining

992.95
1
333.00

66.6026110
Biopsy finger joint lining

992.95
1
333.00

66.6026115
Removal hand lesion subcut

1,233.39
2
446.00

89.2026116
Removal hand lesion, deep

1,233.39
2
446.00

89.2026117
Remove tumor, hand/finger

1,233.39
3
510.00

102.0026121
Release palm contracture

1,590.53
4
630.00

126.0026123
Release palm contracture

1,590.53
4
630.00

126.0026125
Release palm contracture

992.95
4
630.00

126.0026130
Remove wrist joint lining

992.95
3
510.00

102.0026135
Revise finger joint, each

1,590.53
4
630.00

126.0026140
Revise finger joint, each

992.95
2
446.00

89.2026145
Tendon excision, palm/finger

992.95
3
510.00

102.0026160
Remove tendon sheath lesion

992.95
3
510.00

102.0026170
Removal of palm tendon, each

992.95
3
510.00

102.0026180
Removal of finger tendon

992.95
3
510.00

102.0026185
Remove finger bone

992.95
4
630.00

126.0026200
Remove hand bone lesion

992.95
2
446.00

89.2026205
Remove/graft bone lesion

1,590.53
3
510.00

102.0026210
Removal of finger lesion

992.95
2
446.00

89.2026215
Remove/graft finger lesion

992.95
3
510.00

102.0026230
Partial removal of hand bone

992.95
7
992.95
Y
198.5926235
Partial removal, finger bone

992.95
3
510.00

102.0026236
Partial removal, finger bone

992.95
3
510.00

102.0026250
Extensive hand surgery

992.95
3
510.00

102.0026255
Extensive hand surgery

1,590.53
3
510.00

102.0026260
Extensive finger surgery

992.95
3
510.00

102.0026261
Extensive finger surgery

992.95
3
510.00

102.0026262
Partial removal of finger

992.95
2
446.00

89.2026320
Removal of implant from hand

928.31
2
446.00

89.2026350
Repair finger/hand tendon

1,590.53
1
333.00

66.6026352
Repair/graft hand tendon

1,590.53
4
630.00

126.0026356
Repair finger/hand tendon

1,590.53
4
630.00

126.0026357
Repair finger/hand tendon

1,590.53
4
630.00

126.0026358
Repair/graft hand tendon

1,590.53
4
630.00

126.0026370
Repair finger/hand tendon

1,590.53
4
630.00

126.0026372
Repair/graft hand tendon

1,590.53
4
630.00

126.0026373
Repair finger/hand tendon

1,590.53
3
510.00

102.0026390
Revise hand/finger tendon

1,590.53
4
630.00

126.0026392
Repair/graft hand tendon

1,590.53
3
510.00

102.0026410
Repair hand tendon

992.95
3
510.00

102.0026412
Repair/graft hand tendon

1,590.53
3
510.00

102.0026415
Excision, hand/finger tendon

1,590.53
4
630.00

126.0026416
Graft hand or finger tendon

1,590.53
3
510.00

102.0026418
Repair finger tendon

992.95
4
630.00

126.0026420
Repair/graft finger tendon

1,590.53
4
630.00

126.0026426
Repair finger/hand tendon

1,590.53
3
510.00

102.0026428
Repair/graft finger tendon

1,590.53
3
510.00

102.00( print page 68255)26432
Repair finger tendon

992.95
3
510.00

102.0026433
Repair finger tendon

992.95
3
510.00

102.0026434
Repair/graft finger tendon

1,590.53
3
510.00

102.0026437
Realignment of tendons

992.95
3
510.00

102.0026440
Release palm/finger tendon

992.95
3
510.00

102.0026442
Release palm & finger tendon

1,590.53
3
510.00

102.0026445
Release hand/finger tendon

992.95
3
510.00

102.0026449
Release forearm/hand tendon

1,590.53
3
510.00

102.0026450
Incision of palm tendon

992.95
3
510.00

102.0026455
Incision of finger tendon

992.95
3
510.00

102.0026460
Incise hand/finger tendon

992.95
3
510.00

102.0026471
Fusion of finger tendons

992.95
2
446.00

89.2026474
Fusion of finger tendons

992.95
2
446.00

89.2026476
Tendon lengthening

992.95
1
333.00

66.6026477
Tendon shortening

992.95
1
333.00

66.6026478
Lengthening of hand tendon

992.95
1
333.00

66.6026479
Shortening of hand tendon

992.95
1
333.00

66.6026480
Transplant hand tendon

1,590.53
3
510.00

102.0026483
Transplant/graft hand tendon

1,590.53
3
510.00

102.0026485
Transplant palm tendon

1,590.53
2
446.00

89.2026489
Transplant/graft palm tendon

1,590.53
3
510.00

102.0026490
Revise thumb tendon

1,590.53
3
510.00

102.0026492
Tendon transfer with graft

1,590.53
3
510.00

102.0026494
Hand tendon/muscle transfer

1,590.53
3
510.00

102.0026496
Revise thumb tendon

1,590.53
3
510.00

102.0026497
Finger tendon transfer

1,590.53
3
510.00

102.0026498
Finger tendon transfer

1,590.53
4
630.00

126.0026499
Revision of finger

1,590.53
3
510.00

102.0026500
Hand tendon reconstruction

992.95
4
630.00

126.0026502
Hand tendon reconstruction

1,590.53
4
630.00

126.0026504
Hand tendon reconstruction
D

4
630.0026508
Release thumb contracture

992.95
3
510.00

102.0026510
Thumb tendon transfer

1,590.53
3
510.00

102.0026516
Fusion of knuckle joint

1,590.53
1
333.00

66.6026517
Fusion of knuckle joints

1,590.53
3
510.00

102.0026518
Fusion of knuckle joints

1,590.53
3
510.00

102.0026520
Release knuckle contracture

992.95
3
510.00

102.0026525
Release finger contracture

992.95
3
510.00

102.0026530
Revise knuckle joint

2,056.14
3
510.00

102.0026531
Revise knuckle with implant

2,915.91
7
995.00

199.0026535
Revise finger joint

2,056.14
5
717.00

143.4026536
Revise/implant finger joint

2,915.91
5
717.00

143.4026540
Repair hand joint

992.95
4
630.00

126.0026541
Repair hand joint with graft

1,590.53
7
995.00

199.0026542
Repair hand joint with graft

992.95
4
630.00

126.0026545
Reconstruct finger joint

1,590.53
4
630.00

126.0026546
Repair nonunion hand

1,590.53
4
630.00

126.0026548
Reconstruct finger joint

1,590.53
4
630.00

126.0026550
Construct thumb replacement

1,590.53
2
446.00

89.2026555
Positional change of finger

1,590.53
3
510.00

102.0026560
Repair of web finger

992.95
2
446.00

89.2026561
Repair of web finger

1,590.53
3
510.00

102.0026562
Repair of web finger

1,590.53
4
630.00

126.0026565
Correct metacarpal flaw

1,590.53
5
717.00

143.4026567
Correct finger deformity

1,590.53
5
717.00

143.4026568
Lengthen metacarpal/finger

1,590.53
3
510.00

102.0026580
Repair hand deformity

992.95
5
717.00

143.4026587
Reconstruct extra finger

992.95
5
717.00

143.4026590
Repair finger deformity

992.95
5
717.00

143.4026591
Repair muscles of hand

1,590.53
3
510.00

102.0026593
Release muscles of hand

992.95
3
510.00

102.0026596
Excision constricting tissue

992.95
2
446.00

89.2026605
Treat metacarpal fracture

103.62
2
103.62
Y
20.7226607
Treat metacarpal fracture

103.62
2
103.62
Y
20.7226608
Treat metacarpal fracture

1,569.06
4
630.00

126.00( print page 68256)26615
Treat metacarpal fracture

2,307.40
4
630.00

126.0026645
Treat thumb fracture

103.62
1
103.62
Y
20.7226650
Treat thumb fracture

1,569.06
2
446.00

89.2026665
Treat thumb fracture

2,307.40
4
630.00

126.0026675
Treat hand dislocation

103.62
2
103.62
Y
20.7226676
Pin hand dislocation

1,569.06
2
446.00

89.2026685
Treat hand dislocation

2,307.40
3
510.00

102.0026686
Treat hand dislocation

3,517.03
3
510.00

102.0026705
Treat knuckle dislocation

103.62
2
103.62
Y
20.7226706
Pin knuckle dislocation

103.62
2
103.62
Y
20.7226715
Treat knuckle dislocation

2,307.40
4
630.00

126.0026727
Treat finger fracture, each

1,569.06
7
995.00

199.0026735
Treat finger fracture, each

2,307.40
4
630.00

126.0026742
Treat finger fracture, each

103.62
2
103.62
Y
20.7226746
Treat finger fracture, each

2,307.40
5
717.00

143.4026756
Pin finger fracture, each

1,569.06
2
446.00

89.2026765
Treat finger fracture, each

2,307.40
4
630.00

126.0026776
Pin finger dislocation

1,569.06
2
446.00

89.2026785
Treat finger dislocation

1,569.06
2
446.00

89.2026820
Thumb fusion with graft

1,590.53
5
717.00

143.4026841
Fusion of thumb

1,590.53
4
630.00

126.0026842
Thumb fusion with graft

1,590.53
4
630.00

126.0026843
Fusion of hand joint

1,590.53
3
510.00

102.0026844
Fusion/graft of hand joint

1,590.53
3
510.00

102.0026850
Fusion of knuckle

1,590.53
4
630.00

126.0026852
Fusion of knuckle with graft

1,590.53
4
630.00

126.0026860
Fusion of finger joint

1,590.53
3
510.00

102.0026861
Fusion of finger jnt, add-on

1,590.53
2
446.00

89.2026862
Fusion/graft of finger joint

1,590.53
4
630.00

126.0026863
Fuse/graft added joint

1,590.53
3
510.00

102.0026910
Amputate metacarpal bone

1,590.53
3
510.00

102.0026951
Amputation of finger/thumb

992.95
2
446.00

89.2026952
Amputation of finger/thumb

992.95
4
630.00

126.0026990
Drainage of pelvis lesion

1,282.87
1
333.00

66.6026991
Drainage of pelvis bursa

1,282.87
1
333.00

66.6027000
Incision of hip tendon

1,282.87
2
446.00

89.2027001
Incision of hip tendon

1,544.67
3
510.00

102.0027003
Incision of hip tendon

1,544.67
3
510.00

102.0027033
Exploration of hip joint

2,525.68
3
510.00

102.0027035
Denervation of hip joint

2,525.68
4
630.00

126.0027040
Biopsy of soft tissues

418.49
1
333.00

66.6027041
Biopsy of soft tissues

418.49
2
418.49
Y
83.7027047
Remove hip/pelvis lesion

1,233.39
2
446.00

89.2027048
Remove hip/pelvis lesion

1,233.39
3
510.00

102.0027049
Remove tumor, hip/pelvis

1,233.39
3
510.00

102.0027050
Biopsy of sacroiliac joint

1,282.87
3
510.00

102.0027052
Biopsy of hip joint

1,282.87
3
510.00

102.0027060
Removal of ischial bursa

1,282.87
5
717.00

143.4027062
Remove femur lesion/bursa

1,282.87
5
717.00

143.4027065
Removal of hip bone lesion

1,282.87
5
717.00

143.4027066
Removal of hip bone lesion

1,544.67
5
717.00

143.4027067
Remove/graft hip bone lesion

1,544.67
5
717.00

143.4027080
Removal of tail bone

1,544.67
2
446.00

89.2027086
Remove hip foreign body

418.49
1
333.00

66.6027087
Remove hip foreign body

1,282.87
3
510.00

102.0027097
Revision of hip tendon

1,544.67
3
510.00

102.0027098
Transfer tendon to pelvis

1,544.67
3
510.00

102.0027100
Transfer of abdominal muscle

2,525.68
4
630.00

126.0027105
Transfer of spinal muscle

2,525.68
4
630.00

126.0027110
Transfer of iliopsoas muscle

2,525.68
4
630.00

126.0027111
Transfer of iliopsoas muscle

2,525.68
4
630.00

126.0027193
Treat pelvic ring fracture

103.62
1
103.62
Y
20.7227194
Treat pelvic ring fracture

897.11
2
446.00

89.2027202
Treat tail bone fracture

2,307.40
2
446.00

89.2027230
Treat thigh fracture

103.62
1
103.62
Y
20.72( print page 68257)27238
Treat thigh fracture

103.62
1
103.62
Y
20.7227246
Treat thigh fracture

103.62
1
103.62
Y
20.7227250
Treat hip dislocation

103.62
1
103.62
Y
20.7227252
Treat hip dislocation

897.11
2
446.00

89.2027257
Treat hip dislocation

897.11
3
510.00

102.0027265
Treat hip dislocation

103.62
1
103.62
Y
20.7227266
Treat hip dislocation

897.11
2
446.00

89.2027275
Manipulation of hip joint

897.11
2
446.00

89.2027301
Drain thigh/knee lesion

1,076.22
3
510.00

102.0027305
Incise thigh tendon & fascia

1,282.87
2
446.00

89.2027306
Incision of thigh tendon

1,282.87
3
510.00

102.0027307
Incision of thigh tendons

1,282.87
3
510.00

102.0027310
Exploration of knee joint

1,544.67
4
630.00

126.0027315
Partial removal, thigh nerve
D

2
446.0027320
Partial removal, thigh nerve
D

2
446.0027323
Biopsy, thigh soft tissues

418.49
1
333.00

66.6027324
Biopsy, thigh soft tissues

1,233.39
1
333.00

66.6027325
Neurectomy, hamstring
A
1,097.20
2
446.00

89.2027326
Neurectomy, popliteal
A
1,097.20
2
446.00

89.2027327
Removal of thigh lesion

1,233.39
2
446.00

89.2027328
Removal of thigh lesion

1,233.39
3
510.00

102.0027329
Remove tumor, thigh/knee

1,233.39
4
630.00

126.0027330
Biopsy, knee joint lining

1,544.67
4
630.00

126.0027331
Explore/treat knee joint

1,544.67
4
630.00

126.0027332
Removal of knee cartilage

1,544.67
4
630.00

126.0027333
Removal of knee cartilage

1,544.67
4
630.00

126.0027334
Remove knee joint lining

1,544.67
4
630.00

126.0027335
Remove knee joint lining

1,544.67
4
630.00

126.0027340
Removal of kneecap bursa

1,282.87
3
510.00

102.0027345
Removal of knee cyst

1,282.87
4
630.00

126.0027347
Remove knee cyst

1,282.87
4
630.00

126.0027350
Removal of kneecap

1,544.67
4
630.00

126.0027355
Remove femur lesion

1,544.67
3
510.00

102.0027356
Remove femur lesion/graft

1,544.67
4
630.00

126.0027357
Remove femur lesion/graft

1,544.67
5
717.00

143.4027358
Remove femur lesion/fixation

1,544.67
5
717.00

143.4027360
Partial removal, leg bone(s)

1,544.67
5
717.00

143.4027372
Removal of foreign body

1,233.39
7
995.00

199.0027380
Repair of kneecap tendon

1,282.87
1
333.00

66.6027381
Repair/graft kneecap tendon

1,282.87
3
510.00

102.0027385
Repair of thigh muscle

1,282.87
3
510.00

102.0027386
Repair/graft of thigh muscle

1,282.87
3
510.00

102.0027390
Incision of thigh tendon

1,282.87
1
333.00

66.6027391
Incision of thigh tendons

1,282.87
2
446.00

89.2027392
Incision of thigh tendons

1,282.87
3
510.00

102.0027393
Lengthening of thigh tendon

1,544.67
2
446.00

89.2027394
Lengthening of thigh tendons

1,544.67
3
510.00

102.0027395
Lengthening of thigh tendons

2,525.68
3
510.00

102.0027396
Transplant of thigh tendon

1,544.67
3
510.00

102.0027397
Transplants of thigh tendons

2,525.68
3
510.00

102.0027400
Revise thigh muscles/tendons

2,525.68
3
510.00

102.0027403
Repair of knee cartilage

1,544.67
4
630.00

126.0027405
Repair of knee ligament

2,525.68
4
630.00

126.0027407
Repair of knee ligament

4,092.54
4
630.00

126.0027409
Repair of knee ligaments

2,525.68
4
630.00

126.0027418
Repair degenerated kneecap

2,525.68
3
510.00

102.0027420
Revision of unstable kneecap

2,525.68
3
510.00

102.0027422
Revision of unstable kneecap

2,525.68
7
995.00

199.0027424
Revision/removal of kneecap

2,525.68
3
510.00

102.0027425
Lat retinacular release open

1,544.67
7
995.00

199.0027427
Reconstruction, knee

2,525.68
3
510.00

102.0027428
Reconstruction, knee

4,092.54
4
630.00

126.0027429
Reconstruction, knee

4,092.54
4
630.00

126.0027430
Revision of thigh muscles

2,525.68
4
630.00

126.0027435
Incision of knee joint

2,525.68
4
630.00

126.00( print page 68258)27437
Revise kneecap

2,056.14
4
630.00

126.0027438
Revise kneecap with implant

2,915.91
5
717.00

143.4027441
Revision of knee joint

2,056.14
5
717.00

143.4027442
Revision of knee joint

2,056.14
5
717.00

143.4027443
Revision of knee joint

2,056.14
5
717.00

143.4027496
Decompression of thigh/knee

1,282.87
5
717.00

143.4027497
Decompression of thigh/knee

1,282.87
3
510.00

102.0027498
Decompression of thigh/knee

1,282.87
3
510.00

102.0027499
Decompression of thigh/knee

1,282.87
3
510.00

102.0027500
Treatment of thigh fracture

103.62
1
103.62
Y
20.7227501
Treatment of thigh fracture

103.62
2
103.62
Y
20.7227502
Treatment of thigh fracture

103.62
2
103.62
Y
20.7227503
Treatment of thigh fracture

103.62
3
103.62
Y
20.7227508
Treatment of thigh fracture

103.62
1
103.62
Y
20.7227509
Treatment of thigh fracture

1,569.06
3
510.00

102.0027510
Treatment of thigh fracture

103.62
1
103.62
Y
20.7227516
Treat thigh fx growth plate

103.62
1
103.62
Y
20.7227517
Treat thigh fx growth plate

103.62
1
103.62
Y
20.7227520
Treat kneecap fracture

103.62
1
103.62
Y
20.7227530
Treat knee fracture

103.62
1
103.62
Y
20.7227532
Treat knee fracture

103.62
1
103.62
Y
20.7227538
Treat knee fracture(s)

103.62
1
103.62
Y
20.7227550
Treat knee dislocation

103.62
1
103.62
Y
20.7227552
Treat knee dislocation

897.11
1
333.00

66.6027560
Treat kneecap dislocation

103.62
1
103.62
Y
20.7227562
Treat kneecap dislocation

897.11
1
333.00

66.6027566
Treat kneecap dislocation

2,307.40
2
446.00

89.2027570
Fixation of knee joint

897.11
1
333.00

66.6027594
Amputation follow-up surgery

1,282.87
3
510.00

102.0027600
Decompression of lower leg

1,282.87
3
510.00

102.0027601
Decompression of lower leg

1,282.87
3
510.00

102.0027602
Decompression of lower leg

1,282.87
3
510.00

102.0027603
Drain lower leg lesion

1,076.22
2
446.00

89.2027604
Drain lower leg bursa

1,282.87
2
446.00

89.2027605
Incision of achilles tendon

1,255.56
1
333.00

66.6027606
Incision of achilles tendon

1,282.87
1
333.00

66.6027607
Treat lower leg bone lesion

1,282.87
2
446.00

89.2027610
Explore/treat ankle joint

1,544.67
2
446.00

89.2027612
Exploration of ankle joint

1,544.67
3
510.00

102.0027614
Biopsy lower leg soft tissue

1,233.39
2
446.00

89.2027615
Remove tumor, lower leg

1,544.67
3
510.00

102.0027618
Remove lower leg lesion

928.31
2
446.00

89.2027619
Remove lower leg lesion

1,233.39
3
510.00

102.0027620
Explore/treat ankle joint

1,544.67
4
630.00

126.0027625
Remove ankle joint lining

1,544.67
4
630.00

126.0027626
Remove ankle joint lining

1,544.67
4
630.00

126.0027630
Removal of tendon lesion

1,282.87
3
510.00

102.0027635
Remove lower leg bone lesion

1,544.67
3
510.00

102.0027637
Remove/graft leg bone lesion

1,544.67
3
510.00

102.0027638
Remove/graft leg bone lesion

1,544.67
3
510.00

102.0027640
Partial removal of tibia

2,525.68
2
446.00

89.2027641
Partial removal of fibula

1,544.67
2
446.00

89.2027647
Extensive ankle/heel surgery

2,525.68
3
510.00

102.0027650
Repair achilles tendon

2,525.68
3
510.00

102.0027652
Repair/graft achilles tendon

4,092.54
3
510.00

102.0027654
Repair of achilles tendon

2,525.68
3
510.00

102.0027656
Repair leg fascia defect

1,282.87
2
446.00

89.2027658
Repair of leg tendon, each

1,282.87
1
333.00

66.6027659
Repair of leg tendon, each

1,282.87
2
446.00

89.2027664
Repair of leg tendon, each

1,282.87
2
446.00

89.2027665
Repair of leg tendon, each

1,544.67
2
446.00

89.2027675
Repair lower leg tendons

1,282.87
2
446.00

89.2027676
Repair lower leg tendons

1,544.67
3
510.00

102.0027680
Release of lower leg tendon

1,544.67
3
510.00

102.0027681
Release of lower leg tendons

1,544.67
2
446.00

89.20( print page 68259)27685
Revision of lower leg tendon

1,544.67
3
510.00

102.0027686
Revise lower leg tendons

1,544.67
3
510.00

102.0027687
Revision of calf tendon

1,544.67
3
510.00

102.0027690
Revise lower leg tendon

2,525.68
4
630.00

126.0027691
Revise lower leg tendon

2,525.68
4
630.00

126.0027692
Revise additional leg tendon

2,525.68
3
510.00

102.0027695
Repair of ankle ligament

1,544.67
2
446.00

89.2027696
Repair of ankle ligaments

1,544.67
2
446.00

89.2027698
Repair of ankle ligament

1,544.67
2
446.00

89.2027700
Revision of ankle joint

2,056.14
5
717.00

143.4027704
Removal of ankle implant

1,282.87
2
446.00

89.2027705
Incision of tibia

2,525.68
2
446.00

89.2027707
Incision of fibula

1,282.87
2
446.00

89.2027709
Incision of tibia & fibula

1,544.67
2
446.00

89.2027730
Repair of tibia epiphysis

1,544.67
2
446.00

89.2027732
Repair of fibula epiphysis

1,544.67
2
446.00

89.2027734
Repair lower leg epiphyses

1,544.67
2
446.00

89.2027740
Repair of leg epiphyses

1,544.67
2
446.00

89.2027742
Repair of leg epiphyses

2,525.68
2
446.00

89.2027745
Reinforce tibia

4,092.54
3
510.00

102.0027750
Treatment of tibia fracture

103.62
1
103.62
Y
20.7227752
Treatment of tibia fracture

103.62
1
103.62
Y
20.7227756
Treatment of tibia fracture

1,569.06
3
510.00

102.0027758
Treatment of tibia fracture

2,307.40
4
630.00

126.0027759
Treatment of tibia fracture

3,517.03
4
630.00

126.0027760
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227762
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227766
Treatment of ankle fracture

2,307.40
3
510.00

102.0027780
Treatment of fibula fracture

103.62
1
103.62
Y
20.7227781
Treatment of fibula fracture

103.62
1
103.62
Y
20.7227784
Treatment of fibula fracture

2,307.40
3
510.00

102.0027786
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227788
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227792
Treatment of ankle fracture

2,307.40
3
510.00

102.0027808
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227810
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227814
Treatment of ankle fracture

2,307.40
3
510.00

102.0027816
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227818
Treatment of ankle fracture

103.62
1
103.62
Y
20.7227822
Treatment of ankle fracture

2,307.40
3
510.00

102.0027823
Treatment of ankle fracture

3,517.03
3
510.00

102.0027824
Treat lower leg fracture

103.62
1
103.62
Y
20.7227825
Treat lower leg fracture

103.62
2
103.62
Y
20.7227826
Treat lower leg fracture

2,307.40
3
510.00

102.0027827
Treat lower leg fracture

3,517.03
3
510.00

102.0027828
Treat lower leg fracture

3,517.03
4
630.00

126.0027829
Treat lower leg joint

2,307.40
2
446.00

89.2027830
Treat lower leg dislocation

103.62
1
103.62
Y
20.7227831
Treat lower leg dislocation

103.62
1
103.62
Y
20.7227832
Treat lower leg dislocation

2,307.40
2
446.00

89.2027840
Treat ankle dislocation

103.62
1
103.62
Y
20.7227842
Treat ankle dislocation

897.11
1
333.00

66.6027846
Treat ankle dislocation

2,307.40
3
510.00

102.0027848
Treat ankle dislocation

2,307.40
3
510.00

102.0027860
Fixation of ankle joint

897.11
1
333.00

66.6027870
Fusion of ankle joint, open

4,092.54
4
630.00

126.0027871
Fusion of tibiofibular joint

4,092.54
4
630.00

126.0027884
Amputation follow-up surgery

1,282.87
3
510.00

102.0027889
Amputation of foot at ankle

1,544.67
3
510.00

102.0027892
Decompression of leg

1,282.87
3
510.00

102.0027893
Decompression of leg

1,282.87
3
510.00

102.0027894
Decompression of leg

1,282.87
3
510.00

102.0028002
Treatment of foot infection

1,282.87
3
510.00

102.0028003
Treatment of foot infection

1,282.87
3
510.00

102.0028005
Treat foot bone lesion

1,255.56
3
510.00

102.00( print page 68260)28008
Incision of foot fascia

1,255.56
3
510.00

102.0028011
Incision of toe tendons

1,255.56
3
510.00

102.0028020
Exploration of foot joint

1,255.56
2
446.00

89.2028022
Exploration of foot joint

1,255.56
2
446.00

89.2028024
Exploration of toe joint

1,255.56
2
446.00

89.2028030
Removal of foot nerve
D

4
630.0028035
Decompression of tibia nerve

1,097.20
4
630.00

126.0028043
Excision of foot lesion

1,233.39
2
446.00

89.2028045
Excision of foot lesion

1,255.56
3
510.00

102.0028046
Resection of tumor, foot

1,255.56
3
510.00

102.0028050
Biopsy of foot joint lining

1,255.56
2
446.00

89.2028052
Biopsy of foot joint lining

1,255.56
2
446.00

89.2028054
Biopsy of toe joint lining

1,255.56
2
446.00

89.2028055
Neurectomy, foot
A
1,097.20
4
630.00

126.0028060
Partial removal, foot fascia

1,255.56
2
446.00

89.2028062
Removal of foot fascia

1,255.56
3
510.00

102.0028070
Removal of foot joint lining

1,255.56
3
510.00

102.0028072
Removal of foot joint lining

1,255.56
3
510.00

102.0028080
Removal of foot lesion

1,255.56
3
510.00

102.0028086
Excise foot tendon sheath

1,255.56
2
446.00

89.2028088
Excise foot tendon sheath

1,255.56
2
446.00

89.2028090
Removal of foot lesion

1,255.56
3
510.00

102.0028092
Removal of toe lesions

1,255.56
3
510.00

102.0028100
Removal of ankle/heel lesion

1,255.56
2
446.00

89.2028102
Remove/graft foot lesion

2,511.33
3
510.00

102.0028103
Remove/graft foot lesion

2,511.33
3
510.00

102.0028104
Removal of foot lesion

1,255.56
2
446.00

89.2028106
Remove/graft foot lesion

2,511.33
3
510.00

102.0028107
Remove/graft foot lesion

2,511.33
3
510.00

102.0028108
Removal of toe lesions

1,255.56
2
446.00

89.2028110
Part removal of metatarsal

1,255.56
3
510.00

102.0028111
Part removal of metatarsal

1,255.56
3
510.00

102.0028112
Part removal of metatarsal

1,255.56
3
510.00

102.0028113
Part removal of metatarsal

1,255.56
3
510.00

102.0028114
Removal of metatarsal heads

1,255.56
3
510.00

102.0028116
Revision of foot

1,255.56
3
510.00

102.0028118
Removal of heel bone

1,255.56
4
630.00

126.0028119
Removal of heel spur

1,255.56
4
630.00

126.0028120
Part removal of ankle/heel

1,255.56
7
995.00

199.0028122
Partial removal of foot bone

1,255.56
3
510.00

102.0028126
Partial removal of toe

1,255.56
3
510.00

102.0028130
Removal of ankle bone

1,255.56
3
510.00

102.0028140
Removal of metatarsal

1,255.56
3
510.00

102.0028150
Removal of toe

1,255.56
3
510.00

102.0028153
Partial removal of toe

1,255.56
3
510.00

102.0028160
Partial removal of toe

1,255.56
3
510.00

102.0028171
Extensive foot surgery

1,255.56
3
510.00

102.0028173
Extensive foot surgery

1,255.56
3
510.00

102.0028175
Extensive foot surgery

1,255.56
3
510.00

102.0028192
Removal of foot foreign body

928.31
2
446.00

89.2028193
Removal of foot foreign body

418.49
4
418.49
Y
83.7028200
Repair of foot tendon

1,255.56
3
510.00

102.0028202
Repair/graft of foot tendon

1,255.56
3
510.00

102.0028208
Repair of foot tendon

1,255.56
3
510.00

102.0028210
Repair/graft of foot tendon

2,511.33
3
510.00

102.0028222
Release of foot tendons

1,255.56
1
333.00

66.6028225
Release of foot tendon

1,255.56
1
333.00

66.6028226
Release of foot tendons

1,255.56
1
333.00

66.6028234
Incision of foot tendon

1,255.56
2
446.00

89.2028238
Revision of foot tendon

2,511.33
3
510.00

102.0028240
Release of big toe

1,255.56
2
446.00

89.2028250
Revision of foot fascia

1,255.56
3
510.00

102.0028260
Release of midfoot joint

1,255.56
3
510.00

102.0028261
Revision of foot tendon

1,255.56
3
510.00

102.0028262
Revision of foot and ankle

1,255.56
4
630.00

126.00( print page 68261)28264
Release of midfoot joint

2,511.33
1
333.00

66.6028270
Release of foot contracture

1,255.56
3
510.00

102.0028280
Fusion of toes

1,255.56
2
446.00

89.2028285
Repair of hammertoe

1,255.56
3
510.00

102.0028286
Repair of hammertoe

1,255.56
4
630.00

126.0028288
Partial removal of foot bone

1,255.56
3
510.00

102.0028289
Repair hallux rigidus

1,255.56
3
510.00

102.0028290
Correction of bunion

1,735.54
2
446.00

89.2028292
Correction of bunion

1,735.54
2
446.00

89.2028293
Correction of bunion

1,735.54
3
510.00

102.0028294
Correction of bunion

1,735.54
3
510.00

102.0028296
Correction of bunion

1,735.54
3
510.00

102.0028297
Correction of bunion

1,735.54
3
510.00

102.0028298
Correction of bunion

1,735.54
3
510.00

102.0028299
Correction of bunion

1,735.54
5
717.00

143.4028300
Incision of heel bone

2,511.33
2
446.00

89.2028302
Incision of ankle bone

1,255.56
2
446.00

89.2028304
Incision of midfoot bones

2,511.33
2
446.00

89.2028305
Incise/graft midfoot bones

2,511.33
3
510.00

102.0028306
Incision of metatarsal

1,255.56
4
630.00

126.0028307
Incision of metatarsal

1,255.56
4
630.00

126.0028308
Incision of metatarsal

1,255.56
2
446.00

89.2028309
Incision of metatarsals

2,511.33
4
630.00

126.0028310
Revision of big toe

1,255.56
3
510.00

102.0028312
Revision of toe

1,255.56
3
510.00

102.0028313
Repair deformity of toe

1,255.56
2
446.00

89.2028315
Removal of sesamoid bone

1,255.56
4
630.00

126.0028320
Repair of foot bones

2,511.33
4
630.00

126.0028322
Repair of metatarsals

2,511.33
4
630.00

126.0028340
Resect enlarged toe tissue

1,255.56
4
630.00

126.0028341
Resect enlarged toe

1,255.56
4
630.00

126.0028344
Repair extra toe(s)

1,255.56
4
630.00

126.0028345
Repair webbed toe(s)

1,255.56
4
630.00

126.0028400
Treatment of heel fracture

103.62
1
103.62
Y
20.7228405
Treatment of heel fracture

103.62
2
103.62
Y
20.7228406
Treatment of heel fracture

1,569.06
2
446.00

89.2028415
Treat heel fracture

2,307.40
3
510.00

102.0028420
Treat/graft heel fracture

2,307.40
4
630.00

126.0028435
Treatment of ankle fracture

103.62
2
103.62
Y
20.7228436
Treatment of ankle fracture

1,569.06
2
446.00

89.2028445
Treat ankle fracture

2,307.40
3
510.00

102.0028456
Treat midfoot fracture

1,569.06
2
446.00

89.2028465
Treat midfoot fracture, each

2,307.40
3
510.00

102.0028476
Treat metatarsal fracture

1,569.06
2
446.00

89.2028485
Treat metatarsal fracture

2,307.40
4
630.00

126.0028496
Treat big toe fracture

1,569.06
2
446.00

89.2028505
Treat big toe fracture

2,307.40
3
510.00

102.0028525
Treat toe fracture

2,307.40
3
510.00

102.0028531
Treat sesamoid bone fracture

2,307.40
3
510.00

102.0028545
Treat foot dislocation

1,569.06
1
333.00

66.6028546
Treat foot dislocation

1,569.06
2
446.00

89.2028555
Repair foot dislocation

2,307.40
2
446.00

89.2028575
Treat foot dislocation

103.62
1
103.62
Y
20.7228576
Treat foot dislocation

1,569.06
3
510.00

102.0028585
Repair foot dislocation

2,307.40
3
510.00

102.0028605
Treat foot dislocation

103.62
1
103.62
Y
20.7228606
Treat foot dislocation

1,569.06
2
446.00

89.2028615
Repair foot dislocation

2,307.40
3
510.00

102.0028635
Treat toe dislocation

897.11
1
333.00

66.6028636
Treat toe dislocation

1,569.06
3
510.00

102.0028645
Repair toe dislocation

2,307.40
3
510.00

102.0028665
Treat toe dislocation

897.11
1
333.00

66.6028666
Treat toe dislocation

1,569.06
3
510.00

102.0028675
Repair of toe dislocation

2,307.40
3
510.00

102.0028705
Fusion of foot bones

2,511.33
4
630.00

126.00( print page 68262)28715
Fusion of foot bones

2,511.33
4
630.00

126.0028725
Fusion of foot bones

2,511.33
4
630.00

126.0028730
Fusion of foot bones

2,511.33
4
630.00

126.0028735
Fusion of foot bones

2,511.33
4
630.00

126.0028737
Revision of foot bones

2,511.33
5
717.00

143.4028740
Fusion of foot bones

2,511.33
4
630.00

126.0028750
Fusion of big toe joint

2,511.33
4
630.00

126.0028755
Fusion of big toe joint

1,255.56
4
630.00

126.0028760
Fusion of big toe joint

2,511.33
4
630.00

126.0028810
Amputation toe & metatarsal

1,255.56
2
446.00

89.2028820
Amputation of toe

1,255.56
2
446.00

89.2028825
Partial amputation of toe

1,255.56
2
446.00

89.2029800
Jaw arthroscopy/surgery

1,759.49
3
510.00

102.0029804
Jaw arthroscopy/surgery

1,759.49
3
510.00

102.0029805
Shoulder arthroscopy, dx

1,759.49
3
510.00

102.0029806
Shoulder arthroscopy/surgery

2,796.96
3
510.00

102.0029807
Shoulder arthroscopy/surgery

2,796.96
3
510.00

102.0029819
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029820
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029821
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029822
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029823
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029824
Shoulder arthroscopy/surgery

1,759.49
5
717.00

143.4029825
Shoulder arthroscopy/surgery

1,759.49
3
510.00

102.0029826
Shoulder arthroscopy/surgery

2,796.96
3
510.00

102.0029827
Arthroscop rotator cuff repr

2,796.96
5
717.00

143.4029830
Elbow arthroscopy

1,759.49
3
510.00

102.0029834
Elbow arthroscopy/surgery

1,759.49
3
510.00

102.0029835
Elbow arthroscopy/surgery

1,759.49
3
510.00

102.0029836
Elbow arthroscopy/surgery

1,759.49
3
510.00

102.0029837
Elbow arthroscopy/surgery

1,759.49
3
510.00

102.0029838
Elbow arthroscopy/surgery

1,759.49
3
510.00

102.0029840
Wrist arthroscopy

1,759.49
3
510.00

102.0029843
Wrist arthroscopy/surgery

1,759.49
3
510.00

102.0029844
Wrist arthroscopy/surgery

1,759.49
3
510.00

102.0029845
Wrist arthroscopy/surgery

1,759.49
3
510.00

102.0029846
Wrist arthroscopy/surgery

1,759.49
3
510.00

102.0029847
Wrist arthroscopy/surgery

1,759.49
3
510.00

102.0029848
Wrist endoscopy/surgery

1,759.49
9
1,339.00

267.8029850
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029851
Knee arthroscopy/surgery

2,796.96
4
630.00

126.0029855
Tibial arthroscopy/surgery

2,796.96
4
630.00

126.0029856
Tibial arthroscopy/surgery

1,759.49
4
630.00

126.0029860
Hip arthroscopy, dx

1,759.49
4
630.00

126.0029861
Hip arthroscopy/surgery

1,759.49
4
630.00

126.0029862
Hip arthroscopy/surgery

2,796.96
9
1,339.00

267.8029863
Hip arthroscopy/surgery

2,796.96
4
630.00

126.0029870
Knee arthroscopy, dx

1,759.49
3
510.00

102.0029871
Knee arthroscopy/drainage

1,759.49
3
510.00

102.0029873
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029874
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029875
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029876
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029877
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029879
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029880
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029881
Knee arthroscopy/surgery

1,759.49
4
630.00

126.0029882
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029883
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029884
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029885
Knee arthroscopy/surgery

2,796.96
3
510.00

102.0029886
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029887
Knee arthroscopy/surgery

1,759.49
3
510.00

102.0029888
Knee arthroscopy/surgery

2,796.96
3
510.00

102.0029889
Knee arthroscopy/surgery

2,796.96
3
510.00

102.00( print page 68263)29891
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029892
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029893
Scope, plantar fasciotomy

1,255.56
9
1,255.56
Y
251.1129894
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029895
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029897
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029898
Ankle arthroscopy/surgery

1,759.49
3
510.00

102.0029899
Ankle arthroscopy/surgery

2,796.96
3
510.00

102.0029900
Mcp joint arthroscopy, dx

992.95
3
510.00

102.0029901
Mcp joint arthroscopy, surg

992.95
3
510.00

102.0029902
Mcp joint arthroscopy, surg

992.95
3
510.00

102.0030115
Removal of nose polyp(s)

1,009.71
2
446.00

89.2030117
Removal of intranasal lesion

1,009.71
3
510.00

102.0030118
Removal of intranasal lesion

1,434.04
3
510.00

102.0030120
Revision of nose

1,009.71
1
333.00

66.6030125
Removal of nose lesion

2,348.02
2
446.00

89.2030130
Excise inferior turbinate

1,009.71
3
510.00

102.0030140
Resect inferior turbinate

1,434.04
2
446.00

89.2030150
Partial removal of nose

2,348.02
3
510.00

102.0030160
Removal of nose

2,348.02
4
630.00

126.0030220
Insert nasal septal button

464.15
3
464.15
Y
92.8330310
Remove nasal foreign body

1,009.71
1
333.00

66.6030320
Remove nasal foreign body

1,009.71
2
446.00

89.2030400
Reconstruction of nose

2,348.02
4
630.00

126.0030410
Reconstruction of nose

2,348.02
5
717.00

143.4030420
Reconstruction of nose

2,348.02
5
717.00

143.4030430
Revision of nose

1,434.04
3
510.00

102.0030435
Revision of nose

2,348.02
5
717.00

143.4030450
Revision of nose

2,348.02
7
995.00

199.0030460
Revision of nose

2,348.02
7
995.00

199.0030462
Revision of nose

2,348.02
9
1,339.00

267.8030465
Repair nasal stenosis

2,348.02
9
1,339.00

267.8030520
Repair of nasal septum

1,434.04
4
630.00

126.0030540
Repair nasal defect

2,348.02
5
717.00

143.4030545
Repair nasal defect

2,348.02
5
717.00

143.4030560
Release of nasal adhesions

150.72
2
150.72
Y
30.1430580
Repair upper jaw fistula

2,348.02
4
630.00

126.0030600
Repair mouth/nose fistula

2,348.02
4
630.00

126.0030620
Intranasal reconstruction

2,348.02
7
995.00

199.0030630
Repair nasal septum defect

1,434.04
7
995.00

199.0030801
Ablate inf turbinate, superf

464.15
1
333.00

66.6030802
Cauterization, inner nose

464.15
1
333.00

66.6030903
Control of nosebleed

72.48
1
72.48
Y
14.5030905
Control of nosebleed

72.48
1
72.48
Y
14.5030906
Repeat control of nosebleed

72.48
1
72.48
Y
14.5030915
Ligation, nasal sinus artery

1,529.38
2
446.00

89.2030920
Ligation, upper jaw artery

1,529.38
3
510.00

102.0030930
Ther fx, nasal inf turbinate

1,009.71
4
630.00

126.0031020
Exploration, maxillary sinus

1,434.04
2
446.00

89.2031030
Exploration, maxillary sinus

2,348.02
3
510.00

102.0031032
Explore sinus, remove polyps

2,348.02
4
630.00

126.0031050
Exploration, sphenoid sinus

2,348.02
2
446.00

89.2031051
Sphenoid sinus surgery

2,348.02
4
630.00

126.0031070
Exploration of frontal sinus

1,434.04
2
446.00

89.2031075
Exploration of frontal sinus

2,348.02
4
630.00

126.0031080
Removal of frontal sinus

2,348.02
4
630.00

126.0031081
Removal of frontal sinus

2,348.02
4
630.00

126.0031084
Removal of frontal sinus

2,348.02
4
630.00

126.0031085
Removal of frontal sinus

2,348.02
4
630.00

126.0031086
Removal of frontal sinus

2,348.02
4
630.00

126.0031087
Removal of frontal sinus

2,348.02
4
630.00

126.0031090
Exploration of sinuses

2,348.02
5
717.00

143.4031200
Removal of ethmoid sinus

2,348.02
2
446.00

89.2031201
Removal of ethmoid sinus

2,348.02
5
717.00

143.4031205
Removal of ethmoid sinus

2,348.02
3
510.00

102.00( print page 68264)31233
Nasal/sinus endoscopy, dx

86.39
2
86.39
Y
17.2831235
Nasal/sinus endoscopy, dx

909.28
1
333.00

66.6031237
Nasal/sinus endoscopy, surg

909.28
2
446.00

89.2031238
Nasal/sinus endoscopy, surg

909.28
1
333.00

66.6031239
Nasal/sinus endoscopy, surg

1,349.30
4
630.00

126.0031240
Nasal/sinus endoscopy, surg

909.28
2
446.00

89.2031254
Revision of ethmoid sinus

1,349.30
3
510.00

102.0031255
Removal of ethmoid sinus

1,349.30
5
717.00

143.4031256
Exploration maxillary sinus

1,349.30
3
510.00

102.0031267
Endoscopy, maxillary sinus

1,349.30
3
510.00

102.0031276
Sinus endoscopy, surgical

1,349.30
3
510.00

102.0031287
Nasal/sinus endoscopy, surg

1,349.30
3
510.00

102.0031288
Nasal/sinus endoscopy, surg

1,349.30
3
510.00

102.0031300
Removal of larynx lesion

1,434.04
5
717.00

143.4031320
Diagnostic incision, larynx

2,348.02
2
446.00

89.2031400
Revision of larynx

2,348.02
2
446.00

89.2031420
Removal of epiglottis

2,348.02
2
446.00

89.2031510
Laryngoscopy with biopsy

909.28
2
446.00

89.2031511
Remove foreign body, larynx

86.39
2
86.39
Y
17.2831512
Removal of larynx lesion

909.28
2
446.00

89.2031513
Injection into vocal cord

86.39
2
86.39
Y
17.2831515
Laryngoscopy for aspiration

909.28
1
333.00

66.6031525
Dx laryngoscopy excl nb

909.28
1
333.00

66.6031526
Dx laryngoscopy w/oper scope

1,349.30
2
446.00

89.2031527
Laryngoscopy for treatment

1,349.30
1
333.00

66.6031528
Laryngoscopy and dilation

909.28
2
446.00

89.2031529
Laryngoscopy and dilation

909.28
2
446.00

89.2031530
Laryngoscopy w/fb removal

1,349.30
2
446.00

89.2031531
Laryngoscopy w/fb & op scope

1,349.30
3
510.00

102.0031535
Laryngoscopy w/biopsy

1,349.30
2
446.00

89.2031536
Laryngoscopy w/bx & op scope

1,349.30
3
510.00

102.0031540
Laryngoscopy w/exc of tumor

1,349.30
3
510.00

102.0031541
Larynscop w/tumr exc + scope

1,349.30
4
630.00

126.0031545
Remove vc lesion w/scope

1,349.30
4
630.00

126.0031546
Remove vc lesion scope/graft

1,349.30
4
630.00

126.0031560
Laryngoscop w/arytenoidectom

1,349.30
5
717.00

143.4031561
Larynscop, remve cart + scop

1,349.30
5
717.00

143.4031570
Laryngoscope w/vc inj

909.28
2
446.00

89.2031571
Laryngoscop w/vc inj + scope

1,349.30
2
446.00

89.2031576
Laryngoscopy with biopsy

1,349.30
2
446.00

89.2031577
Remove foreign body, larynx

236.42
2
236.42
Y
47.2831578
Removal of larynx lesion

1,349.30
2
446.00

89.2031580
Revision of larynx

2,348.02
5
717.00

143.4031582
Revision of larynx

2,348.02
5
717.00

143.4031588
Revision of larynx

2,348.02
5
717.00

143.4031590
Reinnervate larynx

2,348.02
5
717.00

143.4031595
Larynx nerve surgery

2,348.02
2
446.00

89.2031603
Incision of windpipe

464.15
1
333.00

66.6031611
Surgery/speech prosthesis

1,434.04
3
510.00

102.0031612
Puncture/clear windpipe

1,434.04
1
333.00

66.6031613
Repair windpipe opening

1,434.04
2
446.00

89.2031614
Repair windpipe opening

2,348.02
2
446.00

89.2031615
Visualization of windpipe

585.35
1
333.00

66.6031620
Endobronchial us add-on
A*
1,984.52
1
333.00

66.6031622
Dx bronchoscope/wash

585.35
1
333.00

66.6031623
Dx bronchoscope/brush

585.35
2
446.00

89.2031624
Dx bronchoscope/lavage

585.35
2
446.00

89.2031625
Bronchoscopy w/biopsy(s)

585.35
2
446.00

89.2031628
Bronchoscopy/lung bx, each

585.35
2
446.00

89.2031629
Bronchoscopy/needle bx, each

585.35
2
446.00

89.2031630
Bronchoscopy dilate/fx repr

1,352.90
2
446.00

89.2031631
Bronchoscopy, dilate w/stent

1,352.90
2
446.00

89.2031635
Bronchoscopy w/fb removal

585.35
2
446.00

89.2031636
Bronchoscopy, bronch stents

1,352.90
2
446.00

89.2031637
Bronchoscopy, stent add-on

585.35
1
333.00

66.60( print page 68265)31638
Bronchoscopy, revise stent

1,352.90
2
446.00

89.2031640
Bronchoscopy w/tumor excise

1,352.90
2
446.00

89.2031641
Bronchoscopy, treat blockage

1,352.90
2
446.00

89.2031643
Diag bronchoscope/catheter

585.35
2
446.00

89.2031645
Bronchoscopy, clear airways

585.35
1
333.00

66.6031646
Bronchoscopy, reclear airway

585.35
1
333.00

66.6031656
Bronchoscopy, inj for x-ray

585.35
1
333.00

66.6031700
Insertion of airway catheter
D

1
333.0031717
Bronchial brush biopsy

236.42
1
236.42
Y
47.2831720
Clearance of airways

47.32
1
47.32
Y
9.4631730
Intro, windpipe wire/tube

236.42
1
236.42
Y
47.2831750
Repair of windpipe

2,348.02
5
717.00

143.4031755
Repair of windpipe

2,348.02
2
446.00

89.2031820
Closure of windpipe lesion

1,009.71
1
333.00

66.6031825
Repair of windpipe defect

1,434.04
2
446.00

89.2031830
Revise windpipe scar

1,434.04
2
446.00

89.2032000
Drainage of chest

222.78
1
222.78
Y
44.5632400
Needle biopsy chest lining

377.32
1
333.00

66.6032405
Biopsy, lung or mediastinum

377.32
1
333.00

66.6032420
Puncture/clear lung

222.78
1
222.78
Y
44.5633010
Drainage of heart sac

222.78
2
222.78
Y
44.5633011
Repeat drainage of heart sac

222.78
2
222.78
Y
44.5633212
Insertion of pulse generator

6,042.45
3
510.00

102.0033213
Insertion of pulse generator

6,931.86
3
510.00

102.0033222
Revise pocket, pacemaker

1,317.27
2
446.00

89.2033223
Revise pocket, pacing-defib

1,317.27
2
446.00

89.2033233
Removal of pacemaker system

1,574.45
2
446.00

89.2035188
Repair blood vessel lesion

2,319.75
4
630.00

126.0035207
Repair blood vessel lesion

2,319.75
4
630.00

126.0035875
Removal of clot in graft

2,319.75
9
1,339.00

267.8035876
Removal of clot in graft

2,319.75
9
1,339.00

267.8036260
Insertion of infusion pump

1,752.03
3
510.00

102.0036261
Revision of infusion pump

1,752.03
2
446.00

89.2036262
Removal of infusion pump

1,393.26
1
333.00

66.6036475
Endovenous rf, 1st vein

2,134.71
9
1,339.00

267.8036476
Endovenous rf, vein add-on

2,134.71
9
1,339.00

267.8036478
Endovenous laser, 1st vein

1,529.38
9
1,339.00

267.8036479
Endovenous laser vein addon

1,529.38
9
1,339.00

267.8036555
Insert non-tunnel cv cath

539.97
1
333.00

66.6036556
Insert non-tunnel cv cath

539.97
1
333.00

66.6036557
Insert tunneled cv cath

1,393.26
2
446.00

89.2036558
Insert tunneled cv cath

1,393.26
2
446.00

89.2036560
Insert tunneled cv cath

1,752.03
3
510.00

102.0036561
Insert tunneled cv cath

1,752.03
3
510.00

102.0036563
Insert tunneled cv cath

1,752.03
3
510.00

102.0036565
Insert tunneled cv cath

1,752.03
3
510.00

102.0036566
Insert tunneled cv cath

5,130.17
3
510.00

102.0036568
Insert picc cath

539.97
1
333.00

66.6036569
Insert picc cath

539.97
1
333.00

66.6036570
Insert picvad cath

1,393.26
3
510.00

102.0036571
Insert picvad cath

1,393.26
3
510.00

102.0036575
Repair tunneled cv cath

539.97
2
446.00

89.2036576
Repair tunneled cv cath

539.97
2
446.00

89.2036578
Replace tunneled cv cath

1,393.26
2
446.00

89.2036580
Replace cvad cath

539.97
1
333.00

66.6036581
Replace tunneled cv cath

1,393.26
2
446.00

89.2036582
Replace tunneled cv cath

1,752.03
3
510.00

102.0036583
Replace tunneled cv cath

1,752.03
3
510.00

102.0036584
Replace picc cath

539.97
1
333.00

66.6036585
Replace picvad cath

1,393.26
3
510.00

102.0036589
Removal tunneled cv cath

539.97
1
333.00

66.6036590
Removal tunneled cv cath

539.97
1
333.00

66.6036640
Insertion catheter, artery

1,752.03
1
333.00

66.6036800
Insertion of cannula

1,795.68
3
510.00

102.0036810
Insertion of cannula

1,795.68
3
510.00

102.00( print page 68266)36815
Insertion of cannula

1,795.68
3
510.00

102.0036818
Av fuse, uppr arm, cephalic
A*
2,319.75
3
510.00

102.0036819
Av fuse, uppr arm, basilic

2,319.75
3
510.00

102.0036820
Av fusion/forearm vein

2,319.75
3
510.00

102.0036821
Av fusion direct any site

2,319.75
3
510.00

102.0036825
Artery-vein autograft

2,319.75
4
630.00

126.0036830
Artery-vein nonautograft

2,319.75
4
630.00

126.0036831
Open thrombect av fistula

2,319.75
9
1,339.00

267.8036832
Av fistula revision, open

2,319.75
4
630.00

126.0036833
Av fistula revision

2,319.75
4
630.00

126.0036834
Repair A-V aneurysm

2,319.75
3
510.00

102.0036835
Artery to vein shunt

1,795.68
4
630.00

126.0036860
External cannula declotting

127.40
2
127.40
Y
25.4836861
Cannula declotting

1,795.68
3
510.00

102.0036870
Percut thrombect av fistula

1,990.44
9
1,339.00

267.8037500
Endoscopy ligate perf veins

2,134.71
3
510.00

102.0037607
Ligation of a-v fistula

1,529.38
3
510.00

102.0037609
Temporal artery procedure

928.31
2
446.00

89.2037650
Revision of major vein

1,529.38
2
446.00

89.2037700
Revise leg vein

2,134.71
2
446.00

89.2037718
Ligate/strip short leg vein

2,134.71
3
510.00

102.0037722
Ligate/strip long leg vein

2,134.71
3
510.00

102.0037735
Removal of leg veins/lesion

2,134.71
3
510.00

102.0037760
Ligation, leg veins, open

1,529.38
3
510.00

102.0037780
Revision of leg vein

1,529.38
3
510.00

102.0037785
Ligate/divide/excise vein

1,529.38
3
510.00

102.0037790
Penile venous occlusion

2,027.66
3
510.00

102.0038300
Drainage, lymph node lesion

685.58
1
333.00

66.6038305
Drainage, lymph node lesion

1,076.22
2
446.00

89.2038308
Incision of lymph channels

1,306.94
2
446.00

89.2038500
Biopsy/removal, lymph nodes

1,306.94
2
446.00

89.2038505
Needle biopsy, lymph nodes

240.00
1
240.00
Y
48.0038510
Biopsy/removal, lymph nodes

1,306.94
2
446.00

89.2038520
Biopsy/removal, lymph nodes

1,306.94
2
446.00

89.2038525
Biopsy/removal, lymph nodes

1,306.94
2
446.00

89.2038530
Biopsy/removal, lymph nodes

1,306.94
2
446.00

89.2038542
Explore deep node(s), neck

2,318.72
2
446.00

89.2038550
Removal, neck/armpit lesion

1,306.94
3
510.00

102.0038555
Removal, neck/armpit lesion

1,306.94
4
630.00

126.0038570
Laparoscopy, lymph node biop

2,676.86
9
1,339.00

267.8038571
Laparoscopy, lymphadenectomy

4,333.90
9
1,339.00

267.8038572
Laparoscopy, lymphadenectomy

2,676.86
9
1,339.00

267.8038740
Remove armpit lymph nodes

2,318.72
2
446.00

89.2038745
Remove armpit lymph nodes

2,318.72
4
630.00

126.0038760
Remove groin lymph nodes

1,306.94
2
446.00

89.2040500
Partial excision of lip

1,009.71
2
446.00

89.2040510
Partial excision of lip

1,434.04
2
446.00

89.2040520
Partial excision of lip

1,009.71
2
446.00

89.2040525
Reconstruct lip with flap

1,434.04
2
446.00

89.2040527
Reconstruct lip with flap

1,434.04
2
446.00

89.2040530
Partial removal of lip

1,434.04
2
446.00

89.2040650
Repair lip

464.15
3
464.15
Y
92.8340652
Repair lip

464.15
3
464.15
Y
92.8340654
Repair lip

464.15
3
464.15
Y
92.8340700
Repair cleft lip/nasal

2,348.02
7
995.00

199.0040701
Repair cleft lip/nasal

2,348.02
7
995.00

199.0040720
Repair cleft lip/nasal

2,348.02
7
995.00

199.0040761
Repair cleft lip/nasal

2,348.02
3
510.00

102.0040801
Drainage of mouth lesion

464.15
2
446.00

89.2040814
Excise/repair mouth lesion

1,009.71
2
446.00

89.2040816
Excision of mouth lesion

1,434.04
2
446.00

89.2040818
Excise oral mucosa for graft

150.72
1
150.72
Y
30.1440819
Excise lip or cheek fold

464.15
1
333.00

66.6040831
Repair mouth laceration

464.15
1
333.00

66.6040840
Reconstruction of mouth

1,434.04
2
446.00

89.20( print page 68267)40842
Reconstruction of mouth

1,434.04
3
510.00

102.0040843
Reconstruction of mouth

1,434.04
3
510.00

102.0040844
Reconstruction of mouth

2,348.02
5
717.00

143.4040845
Reconstruction of mouth

2,348.02
5
717.00

143.4041005
Drainage of mouth lesion

150.72
1
150.72
Y
30.1441006
Drainage of mouth lesion

1,434.04
1
333.00

66.6041007
Drainage of mouth lesion

1,009.71
1
333.00

66.6041008
Drainage of mouth lesion

1,009.71
1
333.00

66.6041009
Drainage of mouth lesion

150.72
1
150.72
Y
30.1441010
Incision of tongue fold

464.15
1
333.00

66.6041015
Drainage of mouth lesion

150.72
1
150.72
Y
30.1441016
Drainage of mouth lesion

464.15
1
333.00

66.6041017
Drainage of mouth lesion

464.15
1
333.00

66.6041018
Drainage of mouth lesion

464.15
1
333.00

66.6041112
Excision of tongue lesion

1,009.71
2
446.00

89.2041113
Excision of tongue lesion

1,009.71
2
446.00

89.2041114
Excision of tongue lesion

1,434.04
2
446.00

89.2041116
Excision of mouth lesion

1,009.71
1
333.00

66.6041120
Partial removal of tongue

1,434.04
5
717.00

143.4041250
Repair tongue laceration

150.72
2
150.72
Y
30.1441251
Repair tongue laceration

150.72
2
150.72
Y
30.1441252
Repair tongue laceration

464.15
2
446.00

89.2041500
Fixation of tongue

1,434.04
1
333.00

66.6041510
Tongue to lip surgery

1,009.71
1
333.00

66.6041520
Reconstruction, tongue fold

464.15
2
446.00

89.2041800
Drainage of gum lesion

88.46
1
88.46
Y
17.6941827
Excision of gum lesion

1,434.04
2
446.00

89.2042000
Drainage mouth roof lesion

150.72
2
150.72
Y
30.1442107
Excision lesion, mouth roof

1,434.04
2
446.00

89.2042120
Remove palate/lesion

2,348.02
4
630.00

126.0042140
Excision of uvula

464.15
2
446.00

89.2042145
Repair palate, pharynx/uvula

1,434.04
5
717.00

143.4042180
Repair palate

150.72
1
150.72
Y
30.1442182
Repair palate

2,348.02
2
446.00

89.2042200
Reconstruct cleft palate

2,348.02
5
717.00

143.4042205
Reconstruct cleft palate

2,348.02
5
717.00

143.4042210
Reconstruct cleft palate

2,348.02
5
717.00

143.4042215
Reconstruct cleft palate

2,348.02
7
995.00

199.0042220
Reconstruct cleft palate

2,348.02
5
717.00

143.4042226
Lengthening of palate

2,348.02
5
717.00

143.4042235
Repair palate

1,009.71
5
717.00

143.4042260
Repair nose to lip fistula

1,434.04
4
630.00

126.0042300
Drainage of salivary gland

1,009.71
1
333.00

66.6042305
Drainage of salivary gland

1,009.71
2
446.00

89.2042310
Drainage of salivary gland

150.72
1
150.72
Y
30.1442320
Drainage of salivary gland

150.72
1
150.72
Y
30.1442340
Removal of salivary stone

1,009.71
2
446.00

89.2042405
Biopsy of salivary gland

1,009.71
2
446.00

89.2042408
Excision of salivary cyst

1,009.71
3
510.00

102.0042409
Drainage of salivary cyst

1,009.71
3
510.00

102.0042410
Excise parotid gland/lesion

2,348.02
3
510.00

102.0042415
Excise parotid gland/lesion

2,348.02
7
995.00

199.0042420
Excise parotid gland/lesion

2,348.02
7
995.00

199.0042425
Excise parotid gland/lesion

2,348.02
7
995.00

199.0042440
Excise submaxillary gland

2,348.02
3
510.00

102.0042450
Excise sublingual gland

1,434.04
2
446.00

89.2042500
Repair salivary duct

1,434.04
3
510.00

102.0042505
Repair salivary duct

2,348.02
4
630.00

126.0042507
Parotid duct diversion

2,348.02
3
510.00

102.0042508
Parotid duct diversion

2,348.02
4
630.00

126.0042509
Parotid duct diversion

2,348.02
4
630.00

126.0042510
Parotid duct diversion

2,348.02
4
630.00

126.0042600
Closure of salivary fistula

1,009.71
1
333.00

66.6042665
Ligation of salivary duct

1,434.04
7
995.00

199.0042700
Drainage of tonsil abscess

150.72
1
150.72
Y
30.14( print page 68268)42720
Drainage of throat abscess

1,009.71
1
333.00

66.6042725
Drainage of throat abscess

2,348.02
2
446.00

89.2042802
Biopsy of throat

1,009.71
1
333.00

66.6042804
Biopsy of upper nose/throat

1,009.71
1
333.00

66.6042806
Biopsy of upper nose/throat

1,434.04
2
446.00

89.2042808
Excise pharynx lesion

1,009.71
2
446.00

89.2042810
Excision of neck cyst

1,434.04
3
510.00

102.0042815
Excision of neck cyst

2,348.02
5
717.00

143.4042820
Remove tonsils and adenoids

1,359.46
3
510.00

102.0042821
Remove tonsils and adenoids

1,359.46
5
717.00

143.4042825
Removal of tonsils

1,359.46
4
630.00

126.0042826
Removal of tonsils

1,359.46
4
630.00

126.0042830
Removal of adenoids

1,359.46
4
630.00

126.0042831
Removal of adenoids

1,359.46
4
630.00

126.0042835
Removal of adenoids

1,359.46
4
630.00

126.0042836
Removal of adenoids

1,359.46
4
630.00

126.0042860
Excision of tonsil tags

1,359.46
3
510.00

102.0042870
Excision of lingual tonsil

1,359.46
3
510.00

102.0042890
Partial removal of pharynx

2,348.02
7
995.00

199.0042892
Revision of pharyngeal walls

2,348.02
7
995.00

199.0042900
Repair throat wound

464.15
1
333.00

66.6042950
Reconstruction of throat

1,434.04
2
446.00

89.2042955
Surgical opening of throat

1,434.04
2
446.00

89.2042960
Control throat bleeding

72.48
1
72.48
Y
14.5042962
Control throat bleeding

2,348.02
2
446.00

89.2042972
Control nose/throat bleeding

1,009.71
3
510.00

102.0043200
Esophagus endoscopy

511.26
1
333.00

66.6043201
Esoph scope w/submucous inj

511.26
1
333.00

66.6043202
Esophagus endoscopy, biopsy

511.26
1
333.00

66.6043204
Esoph scope w/sclerosis inj

511.26
1
333.00

66.6043205
Esophagus endoscopy/ligation

511.26
1
333.00

66.6043215
Esophagus endoscopy

511.26
1
333.00

66.6043216
Esophagus endoscopy/lesion

511.26
1
333.00

66.6043217
Esophagus endoscopy

511.26
1
333.00

66.6043219
Esophagus endoscopy

1,410.54
1
333.00

66.6043220
Esoph endoscopy, dilation

511.26
1
333.00

66.6043226
Esoph endoscopy, dilation

511.26
1
333.00

66.6043227
Esoph endoscopy, repair

511.26
2
446.00

89.2043228
Esoph endoscopy, ablation

1,583.12
2
446.00

89.2043231
Esoph endoscopy w/us exam

511.26
2
446.00

89.2043232
Esoph endoscopy w/us fn bx

511.26
2
446.00

89.2043234
Upper GI endoscopy, exam

511.26
1
333.00

66.6043235
Uppr gi endoscopy, diagnosis

511.26
1
333.00

66.6043236
Uppr gi scope w/submuc inj

511.26
2
446.00

89.2043237
Endoscopic us exam, esoph

511.26
2
446.00

89.2043238
Uppr gi endoscopy w/us fn bx

511.26
2
446.00

89.2043239
Upper GI endoscopy, biopsy

511.26
2
446.00

89.2043240
Esoph endoscope w/drain cyst

511.26
2
446.00

89.2043241
Upper GI endoscopy with tube

511.26
2
446.00

89.2043242
Uppr gi endoscopy w/us fn bx

511.26
2
446.00

89.2043243
Upper gi endoscopy & inject

511.26
2
446.00

89.2043244
Upper GI endoscopy/ligation

511.26
2
446.00

89.2043245
Uppr gi scope dilate strictr

511.26
2
446.00

89.2043246
Place gastrostomy tube

511.26
2
446.00

89.2043247
Operative upper GI endoscopy

511.26
2
446.00

89.2043248
Uppr gi endoscopy/guide wire

511.26
2
446.00

89.2043249
Esoph endoscopy, dilation

511.26
2
446.00

89.2043250
Upper GI endoscopy/tumor

511.26
2
446.00

89.2043251
Operative upper GI endoscopy

511.26
2
446.00

89.2043255
Operative upper GI endoscopy

511.26
2
446.00

89.2043256
Uppr gi endoscopy w/stent

1,410.54
3
510.00

102.0043257
Uppr gi scope w/thrml txmnt
A*
1,583.12
3
510.00

102.0043258
Operative upper GI endoscopy

511.26
3
510.00

102.0043259
Endoscopic ultrasound exam

511.26
3
510.00

102.0043260
Endo cholangiopancreatograph

1,219.41
2
446.00

89.20( print page 68269)43261
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043262
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043263
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043264
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043265
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043267
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043268
Endo cholangiopancreatograph

1,410.54
2
446.00

89.2043269
Endo cholangiopancreatograph

1,410.54
2
446.00

89.2043271
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043272
Endo cholangiopancreatograph

1,219.41
2
446.00

89.2043450
Dilate esophagus

335.41
1
333.00

66.6043453
Dilate esophagus

335.41
1
333.00

66.6043456
Dilate esophagus

335.41
2
335.41
Y
67.0843458
Dilate esophagus

335.41
2
335.41
Y
67.0843600
Biopsy of stomach

511.26
1
333.00

66.6043653
Laparoscopy, gastrostomy

2,676.86
9
1,339.00

267.8043750
Place gastrostomy tube

511.26
2
446.00

89.2043760
Change gastrostomy tube

144.98
1
144.98
Y
29.0043761
Reposition gastrostomy tube
A*
459.78
1
333.00

66.6043870
Repair stomach opening

511.26
1
333.00

66.6044100
Biopsy of bowel

511.26
1
333.00

66.6044312
Revision of ileostomy

1,317.27
1
333.00

66.6044340
Revision of colostomy

1,317.27
3
510.00

102.0044360
Small bowel endoscopy

583.61
2
446.00

89.2044361
Small bowel endoscopy/biopsy

583.61
2
446.00

89.2044363
Small bowel endoscopy

583.61
2
446.00

89.2044364
Small bowel endoscopy

583.61
2
446.00

89.2044365
Small bowel endoscopy

583.61
2
446.00

89.2044366
Small bowel endoscopy

583.61
2
446.00

89.2044369
Small bowel endoscopy

583.61
2
446.00

89.2044370
Small bowel endoscopy/stent

1,410.54
9
1,339.00

267.8044372
Small bowel endoscopy

583.61
2
446.00

89.2044373
Small bowel endoscopy

583.61
2
446.00

89.2044376
Small bowel endoscopy

583.61
2
446.00

89.2044377
Small bowel endoscopy/biopsy

583.61
2
446.00

89.2044378
Small bowel endoscopy

583.61
2
446.00

89.2044379
Sbowel endoscope w/stent

1,410.54
9
1,339.00

267.8044380
Small bowel endoscopy

583.61
1
333.00

66.6044382
Small bowel endoscopy

583.61
1
333.00

66.6044383
Ileoscopy w/stent

1,410.54
9
1,339.00

267.8044385
Endoscopy of bowel pouch

538.99
1
333.00

66.6044386
Endoscopy, bowel pouch/biop

538.99
1
333.00

66.6044388
Colonoscopy

538.99
1
333.00

66.6044389
Colonoscopy with biopsy

538.99
1
333.00

66.6044390
Colonoscopy for foreign body

538.99
1
333.00

66.6044391
Colonoscopy for bleeding

538.99
1
333.00

66.6044392
Colonoscopy & polypectomy

538.99
1
333.00

66.6044393
Colonoscopy, lesion removal

538.99
1
333.00

66.6044394
Colonoscopy w/snare

538.99
1
333.00

66.6044397
Colonoscopy w/stent

1,410.54
1
333.00

66.6045000
Drainage of pelvic abscess

312.07
1
312.07
Y
62.4145005
Drainage of rectal abscess

783.03
2
446.00

89.2045020
Drainage of rectal abscess

783.03
2
446.00

89.2045100
Biopsy of rectum

1,368.78
1
333.00

66.6045108
Removal of anorectal lesion

1,368.78
2
446.00

89.2045150
Excision of rectal stricture

1,368.78
2
446.00

89.2045160
Excision of rectal lesion

1,368.78
2
446.00

89.2045170
Excision of rectal lesion

1,368.78
2
446.00

89.2045190
Destruction, rectal tumor

1,368.78
9
1,339.00

267.8045305
Proctosigmoidoscopy w/bx

525.41
1
333.00

66.6045307
Proctosigmoidoscopy fb

1,268.55
1
333.00

66.6045308
Proctosigmoidoscopy removal

525.41
1
333.00

66.6045309
Proctosigmoidoscopy removal

525.41
1
333.00

66.6045315
Proctosigmoidoscopy removal

525.41
1
333.00

66.6045317
Proctosigmoidoscopy bleed

525.41
1
333.00

66.60( print page 68270)45320
Proctosigmoidoscopy ablate

1,268.55
1
333.00

66.6045321
Proctosigmoidoscopy volvul

1,268.55
1
333.00

66.6045327
Proctosigmoidoscopy w/stent

1,410.54
1
333.00

66.6045331
Sigmoidoscopy and biopsy

299.24
1
299.24
Y
59.8545332
Sigmoidoscopy w/fb removal

299.24
1
299.24
Y
59.8545333
Sigmoidoscopy & polypectomy

525.41
1
333.00

66.6045334
Sigmoidoscopy for bleeding

525.41
1
333.00

66.6045335
Sigmoidoscopy w/submuc inj

299.24
1
299.24
Y
59.8545337
Sigmoidoscopy & decompress

299.24
1
299.24
Y
59.8545338
Sigmoidoscopy w/tumr remove

525.41
1
333.00

66.6045339
Sigmoidoscopy w/ablate tumr

525.41
1
333.00

66.6045340
Sig w/balloon dilation

525.41
1
333.00

66.6045341
Sigmoidoscopy w/ultrasound

525.41
1
333.00

66.6045342
Sigmoidoscopy w/us guide bx

525.41
1
333.00

66.6045345
Sigmoidoscopy w/stent

1,410.54
1
333.00

66.6045355
Surgical colonoscopy

538.99
1
333.00

66.6045378
Diagnostic colonoscopy

538.99
2
446.00

89.2045379
Colonoscopy w/fb removal

538.99
2
446.00

89.2045380
Colonoscopy and biopsy

538.99
2
446.00

89.2045381
Colonoscopy, submucous inj

538.99
2
446.00

89.2045382
Colonoscopy/control bleeding

538.99
2
446.00

89.2045383
Lesion removal colonoscopy

538.99
2
446.00

89.2045384
Lesion remove colonoscopy

538.99
2
446.00

89.2045385
Lesion removal colonoscopy

538.99
2
446.00

89.2045386
Colonoscopy dilate stricture

538.99
2
446.00

89.2045387
Colonoscopy w/stent

1,410.54
1
333.00

66.6045391
Colonoscopy w/endoscope us

538.99
2
446.00

89.2045392
Colonoscopy w/endoscopic fnb

538.99
2
446.00

89.2045500
Repair of rectum

1,368.78
2
446.00

89.2045505
Repair of rectum

1,820.61
2
446.00

89.2045560
Repair of rectocele

1,820.61
2
446.00

89.2045900
Reduction of rectal prolapse

312.07
1
312.07
Y
62.4145905
Dilation of anal sphincter

1,368.78
1
333.00

66.6045910
Dilation of rectal narrowing

1,368.78
1
333.00

66.6045915
Remove rectal obstruction

312.07
1
312.07
Y
62.4145990
Surg dx exam, anorectal

312.07
2
312.07
Y
62.4146020
Placement of seton

1,368.78
3
510.00

102.0046030
Removal of rectal marker

312.07
1
312.07
Y
62.4146040
Incision of rectal abscess

1,368.78
3
510.00

102.0046045
Incision of rectal abscess

1,368.78
2
446.00

89.2046050
Incision of anal abscess

312.07
1
312.07
Y
62.4146060
Incision of rectal abscess

1,368.78
2
446.00

89.2046080
Incision of anal sphincter

1,368.78
3
510.00

102.0046200
Removal of anal fissure

1,368.78
2
446.00

89.2046210
Removal of anal crypt

1,368.78
2
446.00

89.2046211
Removal of anal crypts

1,368.78
2
446.00

89.2046220
Removal of anal tag

1,368.78
1
333.00

66.6046230
Removal of anal tags

1,368.78
1
333.00

66.6046250
Hemorrhoidectomy

1,368.78
3
510.00

102.0046255
Hemorrhoidectomy

1,368.78
3
510.00

102.0046257
Remove hemorrhoids & fissure

1,368.78
3
510.00

102.0046258
Remove hemorrhoids & fistula

1,368.78
3
510.00

102.0046260
Hemorrhoidectomy

1,368.78
3
510.00

102.0046261
Remove hemorrhoids & fissure

1,368.78
4
630.00

126.0046262
Remove hemorrhoids & fistula

1,368.78
4
630.00

126.0046270
Removal of anal fistula

1,368.78
3
510.00

102.0046275
Removal of anal fistula

1,368.78
3
510.00

102.0046280
Removal of anal fistula

1,368.78
4
630.00

126.0046285
Removal of anal fistula

1,368.78
1
333.00

66.6046288
Repair anal fistula

1,368.78
4
630.00

126.0046608
Anoscopy, remove for body

525.41
1
333.00

66.6046610
Anoscopy, remove lesion

1,268.55
1
333.00

66.6046611
Anoscopy

525.41
1
333.00

66.6046612
Anoscopy, remove lesions

1,268.55
1
333.00

66.6046615
Anoscopy

1,268.55
2
446.00

89.20( print page 68271)46700
Repair of anal stricture

1,368.78
3
510.00

102.0046706
Repr of anal fistula w/glue

1,820.61
1
333.00

66.6046750
Repair of anal sphincter

2,329.58
3
510.00

102.0046753
Reconstruction of anus

1,368.78
3
510.00

102.0046754
Removal of suture from anus

1,368.78
2
446.00

89.2046760
Repair of anal sphincter

2,329.58
2
446.00

89.2046761
Repair of anal sphincter

2,329.58
3
510.00

102.0046762
Implant artificial sphincter

2,329.58
7
995.00

199.0046917
Laser surgery, anal lesions

1,255.64
1
333.00

66.6046922
Excision of anal lesion(s)

1,255.64
1
333.00

66.6046924
Destruction, anal lesion(s)

1,255.64
1
333.00

66.6046937
Cryotherapy of rectal lesion

1,368.78
2
446.00

89.2046938
Cryotherapy of rectal lesion

1,820.61
2
446.00

89.2046946
Ligation of hemorrhoids
A*
783.03
1
333.00

66.6046947
Hemorrhoidopexy by stapling

1,820.61
7
995.00

199.0047000
Needle biopsy of liver

377.32
1
333.00

66.6047510
Insert catheter, bile duct

1,245.85
2
446.00

89.2047511
Insert bile duct drain

1,245.85
9
1,245.85
Y
249.1747525
Change bile duct catheter

716.56
1
333.00

66.6047530
Revise/reinsert bile tube

716.56
1
333.00

66.6047552
Biliary endoscopy thru skin

1,245.85
2
446.00

89.2047553
Biliary endoscopy thru skin

1,245.85
3
510.00

102.0047554
Biliary endoscopy thru skin

1,245.85
3
510.00

102.0047555
Biliary endoscopy thru skin

1,245.85
3
510.00

102.0047556
Biliary endoscopy thru skin

1,245.85
9
1,245.85
Y
249.1747560
Laparoscopy w/cholangio

1,974.60
3
510.00

102.0047561
Laparo w/cholangio/biopsy

1,974.60
3
510.00

102.0047630
Remove bile duct stone

1,245.85
3
510.00

102.0048102
Needle biopsy, pancreas

377.32
1
333.00

66.6049080
Puncture, peritoneal cavity

222.78
2
222.78
Y
44.5649081
Removal of abdominal fluid

222.78
2
222.78
Y
44.5649085
Remove abdomen foreign body
D

2
446.0049180
Biopsy, abdominal mass

377.32
1
333.00

66.6049250
Excision of umbilicus

1,357.41
4
630.00

126.0049320
Diag laparo separate proc

1,974.60
3
510.00

102.0049321
Laparoscopy, biopsy

1,974.60
4
630.00

126.0049322
Laparoscopy, aspiration

1,974.60
4
630.00

126.0049402
Remove foreign body, adbomen
A
1,357.41
2
446.00

89.2049419
Insrt abdom cath for chemotx

1,795.68
1
333.00

66.6049420
Insert abdom drain, temp

1,815.86
1
333.00

66.6049421
Insert abdom drain, perm

1,815.86
1
333.00

66.6049422
Remove perm cannula/catheter

1,574.45
1
333.00

66.6049426
Revise abdomen-venous shunt

1,357.41
2
446.00

89.2049495
Rpr ing hernia baby, reduc

1,795.98
4
630.00

126.0049496
Rpr ing hernia baby, blocked

1,795.98
4
630.00

126.0049500
Rpr ing hernia, init, reduce

1,795.98
4
630.00

126.0049501
Rpr ing hernia, init blocked

1,795.98
9
1,339.00

267.8049505
Prp i/hern init reduc >5 yr

1,795.98
4
630.00

126.0049507
Prp i/hern init block >5 yr

1,795.98
9
1,339.00

267.8049520
Rerepair ing hernia, reduce

1,795.98
7
995.00

199.0049521
Rerepair ing hernia, blocked

1,795.98
9
1,339.00

267.8049525
Repair ing hernia, sliding

1,795.98
4
630.00

126.0049540
Repair lumbar hernia

1,795.98
2
446.00

89.2049550
Rpr rem hernia, init, reduce

1,795.98
5
717.00

143.4049553
Rpr fem hernia, init blocked

1,795.98
9
1,339.00

267.8049555
Rerepair fem hernia, reduce

1,795.98
5
717.00

143.4049557
Rerepair fem hernia, blocked

1,795.98
9
1,339.00

267.8049560
Rpr ventral hern init, reduc

1,795.98
4
630.00

126.0049561
Rpr ventral hern init, block

1,795.98
9
1,339.00

267.8049565
Rerepair ventrl hern, reduce

1,795.98
4
630.00

126.0049566
Rerepair ventrl hern, block

1,795.98
9
1,339.00

267.8049568
Hernia repair w/mesh

1,795.98
7
995.00

199.0049570
Rpr epigastric hern, reduce

1,795.98
4
630.00

126.0049572
Rpr epigastric hern, blocked

1,795.98
9
1,339.00

267.8049580
Rpr umbil hern, reduc < 5 yr

1,795.98
4
630.00

126.00( print page 68272)49582
Rpr umbil hern, block < 5 yr

1,795.98
9
1,339.00

267.8049585
Rpr umbil hern, reduc > 5 yr

1,795.98
4
630.00

126.0049587
Rpr umbil hern, block > 5 yr

1,795.98
9
1,339.00

267.8049590
Repair spigelian hernia

1,795.98
3
510.00

102.0049600
Repair umbilical lesion

1,795.98
4
630.00

126.0049650
Laparo hernia repair initial

2,676.86
4
630.00

126.0049651
Laparo hernia repair recur

2,676.86
7
995.00

199.0050200
Biopsy of kidney

377.32
1
333.00

66.6050390
Drainage of kidney lesion

377.32
1
333.00

66.6050392
Insert kidney drain

1,181.73
1
333.00

66.6050393
Insert ureteral tube

1,181.73
1
333.00

66.6050395
Create passage to kidney

1,181.73
1
333.00

66.6050396
Measure kidney pressure

131.50
1
131.50
Y
26.3050398
Change kidney tube

459.78
1
333.00

66.6050551
Kidney endoscopy

399.24
1
333.00

66.6050553
Kidney endoscopy

1,181.73
1
333.00

66.6050555
Kidney endoscopy & biopsy

399.24
1
333.00

66.6050557
Kidney endoscopy & treatment

1,467.24
1
333.00

66.6050561
Kidney endoscopy & treatment

1,181.73
1
333.00

66.6050688
Change of ureter tube/stent

459.78
1
333.00

66.6050947
Laparo new ureter/bladder

2,676.86
9
1,339.00

267.8050948
Laparo new ureter/bladder

2,676.86
9
1,339.00

267.8050951
Endoscopy of ureter

399.24
1
333.00

66.6050953
Endoscopy of ureter

399.24
1
333.00

66.6050955
Ureter endoscopy & biopsy

1,181.73
1
333.00

66.6050957
Ureter endoscopy & treatment

1,181.73
1
333.00

66.6050961
Ureter endoscopy & treatment

1,181.73
1
333.00

66.6050970
Ureter endoscopy

399.24
1
333.00

66.6050972
Ureter endoscopy & catheter

399.24
1
333.00

66.6050974
Ureter endoscopy & biopsy

1,181.73
1
333.00

66.6050976
Ureter endoscopy & treatment

1,181.73
1
333.00

66.6050980
Ureter endoscopy & treatment

1,181.73
1
333.00

66.6051010
Drainage of bladder

1,116.74
1
333.00

66.6051020
Incise & treat bladder

1,467.24
4
630.00

126.0051030
Incise & treat bladder

1,467.24
4
630.00

126.0051040
Incise & drain bladder

1,467.24
4
630.00

126.0051045
Incise bladder/drain ureter

399.24
4
399.24
Y
79.8551050
Removal of bladder stone

1,467.24
4
630.00

126.0051065
Remove ureter calculus

1,467.24
4
630.00

126.0051080
Drainage of bladder abscess

1,076.22
1
333.00

66.6051500
Removal of bladder cyst

1,795.98
4
630.00

126.0051520
Removal of bladder lesion

1,467.24
4
630.00

126.0051710
Change of bladder tube

459.78
1
333.00

66.6051715
Endoscopic injection/implant

1,784.13
3
510.00

102.0051726
Complex cystometrogram

209.48
1
209.48
Y
41.9051772
Urethra pressure profile

131.50
1
131.50
Y
26.3051785
Anal/urinary muscle study

66.92
1
66.92
Y
13.3851880
Repair of bladder opening

1,467.24
1
333.00

66.6051992
Laparo sling operation

2,676.86
5
717.00

143.4052000
Cystoscopy

399.24
1
333.00

66.6052001
Cystoscopy, removal of clots

399.24
2
399.24
Y
79.8552005
Cystoscopy & ureter catheter

1,181.73
2
446.00

89.2052007
Cystoscopy and biopsy

1,181.73
2
446.00

89.2052010
Cystoscopy & duct catheter

399.24
2
399.24
Y
79.8552204
Cystoscopy w/biopsy(s)

1,181.73
2
446.00

89.2052214
Cystoscopy and treatment

1,467.24
2
446.00

89.2052224
Cystoscopy and treatment

1,467.24
2
446.00

89.2052234
Cystoscopy and treatment

1,467.24
2
446.00

89.2052235
Cystoscopy and treatment

1,467.24
3
510.00

102.0052240
Cystoscopy and treatment

1,467.24
3
510.00

102.0052250
Cystoscopy and radiotracer

1,467.24
4
630.00

126.0052260
Cystoscopy and treatment

1,181.73
2
446.00

89.2052270
Cystoscopy & revise urethra

1,181.73
2
446.00

89.2052275
Cystoscopy & revise urethra

1,181.73
2
446.00

89.2052276
Cystoscopy and treatment

1,181.73
3
510.00

102.00( print page 68273)52277
Cystoscopy and treatment

1,467.24
2
446.00

89.2052281
Cystoscopy and treatment

1,181.73
2
446.00

89.2052282
Cystoscopy, implant stent

2,146.84
9
1,339.00

267.8052283
Cystoscopy and treatment

1,181.73
2
446.00

89.2052285
Cystoscopy and treatment

1,181.73
2
446.00

89.2052290
Cystoscopy and treatment

1,181.73
2
446.00

89.2052300
Cystoscopy and treatment

1,181.73
2
446.00

89.2052301
Cystoscopy and treatment

1,181.73
3
510.00

102.0052305
Cystoscopy and treatment

1,181.73
2
446.00

89.2052310
Cystoscopy and treatment

399.24
2
399.24
Y
79.8552315
Cystoscopy and treatment

1,181.73
2
446.00

89.2052317
Remove bladder stone

1,467.24
1
333.00

66.6052318
Remove bladder stone

1,467.24
2
446.00

89.2052320
Cystoscopy and treatment

1,467.24
5
717.00

143.4052325
Cystoscopy, stone removal

1,467.24
4
630.00

126.0052327
Cystoscopy, inject material

1,467.24
2
446.00

89.2052330
Cystoscopy and treatment

1,467.24
2
446.00

89.2052332
Cystoscopy and treatment

1,467.24
2
446.00

89.2052334
Create passage to kidney

1,467.24
3
510.00

102.0052341
Cysto w/ureter stricture tx

1,467.24
3
510.00

102.0052342
Cysto w/up stricture tx

1,467.24
3
510.00

102.0052343
Cysto w/renal stricture tx

1,467.24
3
510.00

102.0052344
Cysto/uretero, stricture tx

1,467.24
3
510.00

102.0052345
Cysto/uretero w/up stricture

1,467.24
3
510.00

102.0052346
Cystouretero w/renal strict

1,467.24
3
510.00

102.0052351
Cystouretero & or pyeloscope

1,181.73
3
510.00

102.0052352
Cystouretero w/stone remove

1,467.24
4
630.00

126.0052353
Cystouretero w/lithotripsy

2,146.84
4
630.00

126.0052354
Cystouretero w/biopsy

1,467.24
4
630.00

126.0052355
Cystouretero w/excise tumor

1,467.24
4
630.00

126.0052400
Cystouretero w/congen repr

1,467.24
3
510.00

102.0052402
Cystourethro cut ejacul duct

1,467.24
3
510.00

102.0052450
Incision of prostate

1,467.24
3
510.00

102.0052500
Revision of bladder neck

1,467.24
3
510.00

102.0052510
Dilation prostatic urethra

1,181.73
3
510.00

102.0052601
Prostatectomy (TURP)

2,146.84
4
630.00

126.0052606
Control postop bleeding

1,467.24
1
333.00

66.6052612
Prostatectomy, first stage

2,146.84
2
446.00

89.2052614
Prostatectomy, second stage

2,146.84
1
333.00

66.6052620
Remove residual prostate

2,146.84
1
333.00

66.6052630
Remove prostate regrowth

2,146.84
2
446.00

89.2052640
Relieve bladder contracture

1,467.24
2
446.00

89.2052647
Laser surgery of prostate

2,649.30
9
1,339.00

267.8052648
Laser surgery of prostate

2,649.30
9
1,339.00

267.8052700
Drainage of prostate abscess

1,467.24
2
446.00

89.2053000
Incision of urethra

1,130.77
1
333.00

66.6053010
Incision of urethra

1,130.77
1
333.00

66.6053020
Incision of urethra

1,130.77
1
333.00

66.6053040
Drainage of urethra abscess

1,130.77
2
446.00

89.2053080
Drainage of urinary leakage

1,130.77
3
510.00

102.0053200
Biopsy of urethra

1,130.77
1
333.00

66.6053210
Removal of urethra

1,784.13
5
717.00

143.4053215
Removal of urethra

1,130.77
5
717.00

143.4053220
Treatment of urethra lesion

1,784.13
2
446.00

89.2053230
Removal of urethra lesion

1,784.13
2
446.00

89.2053235
Removal of urethra lesion

1,130.77
3
510.00

102.0053240
Surgery for urethra pouch

1,784.13
2
446.00

89.2053250
Removal of urethra gland

1,130.77
2
446.00

89.2053260
Treatment of urethra lesion

1,130.77
2
446.00

89.2053265
Treatment of urethra lesion

1,130.77
2
446.00

89.2053270
Removal of urethra gland

1,130.77
2
446.00

89.2053275
Repair of urethra defect

1,130.77
2
446.00

89.2053400
Revise urethra, stage 1

1,784.13
3
510.00

102.0053405
Revise urethra, stage 2

1,784.13
2
446.00

89.2053410
Reconstruction of urethra

1,784.13
2
446.00

89.20( print page 68274)53420
Reconstruct urethra, stage 1

1,784.13
3
510.00

102.0053425
Reconstruct urethra, stage 2

1,784.13
2
446.00

89.2053430
Reconstruction of urethra

1,784.13
2
446.00

89.2053431
Reconstruct urethra/bladder

1,784.13
2
446.00

89.2053440
Male sling procedure

4,868.83
2
446.00

89.2053442
Remove/revise male sling

1,784.13
1
333.00

66.6053444
Insert tandem cuff

4,868.83
2
446.00

89.2053445
Insert uro/ves nck sphincter

8,445.07
1
333.00

66.6053446
Remove uro sphincter

1,784.13
1
333.00

66.6053447
Remove/replace ur sphincter

8,445.07
1
333.00

66.6053449
Repair uro sphincter

1,784.13
1
333.00

66.6053450
Revision of urethra

1,784.13
1
333.00

66.6053460
Revision of urethra

1,130.77
1
333.00

66.6053502
Repair of urethra injury

1,130.77
2
446.00

89.2053505
Repair of urethra injury

1,784.13
2
446.00

89.2053510
Repair of urethra injury

1,130.77
2
446.00

89.2053515
Repair of urethra injury

1,784.13
2
446.00

89.2053520
Repair of urethra defect

1,784.13
2
446.00

89.2053605
Dilate urethra stricture

1,181.73
2
446.00

89.2053665
Dilation of urethra

1,130.77
1
333.00

66.6054000
Slitting of prepuce

1,130.77
2
446.00

89.2054001
Slitting of prepuce

1,130.77
2
446.00

89.2054015
Drain penis lesion

1,076.22
4
630.00

126.0054057
Laser surg, penis lesion(s)

1,072.14
1
333.00

66.6054060
Excision of penis lesion(s)

1,072.14
1
333.00

66.6054065
Destruction, penis lesion(s)

1,255.64
1
333.00

66.6054100
Biopsy of penis

928.31
1
333.00

66.6054105
Biopsy of penis

1,233.39
1
333.00

66.6054110
Treatment of penis lesion

2,027.66
2
446.00

89.2054111
Treat penis lesion, graft

2,027.66
2
446.00

89.2054112
Treat penis lesion, graft

2,027.66
2
446.00

89.2054115
Treatment of penis lesion

1,076.22
1
333.00

66.6054120
Partial removal of penis

2,027.66
2
446.00

89.2054150
Circumcision w/regionl block

1,263.25
1
333.00

66.6054152
Circumcision

1,263.25
1
333.00

66.6054160
Circumcision, neonate

1,263.25
2
446.00

89.2054161
Circum 28 days or older

1,263.25
2
446.00

89.2054162
Lysis penil circumic lesion

1,263.25
2
446.00

89.2054163
Repair of circumcision

1,263.25
2
446.00

89.2054164
Frenulotomy of penis

1,263.25
2
446.00

89.2054205
Treatment of penis lesion

2,027.66
4
630.00

126.0054220
Treatment of penis lesion

131.50
1
131.50
Y
26.3054300
Revision of penis

2,027.66
3
510.00

102.0054304
Revision of penis

2,027.66
3
510.00

102.0054308
Reconstruction of urethra

2,027.66
3
510.00

102.0054312
Reconstruction of urethra

2,027.66
3
510.00

102.0054316
Reconstruction of urethra

2,027.66
3
510.00

102.0054318
Reconstruction of urethra

2,027.66
3
510.00

102.0054322
Reconstruction of urethra

2,027.66
3
510.00

102.0054324
Reconstruction of urethra

2,027.66
3
510.00

102.0054326
Reconstruction of urethra

2,027.66
3
510.00

102.0054328
Revise penis/urethra

2,027.66
3
510.00

102.0054340
Secondary urethral surgery

2,027.66
3
510.00

102.0054344
Secondary urethral surgery

2,027.66
3
510.00

102.0054348
Secondary urethral surgery

2,027.66
3
510.00

102.0054352
Reconstruct urethra/penis

2,027.66
3
510.00

102.0054360
Penis plastic surgery

2,027.66
3
510.00

102.0054380
Repair penis

2,027.66
3
510.00

102.0054385
Repair penis

2,027.66
3
510.00

102.0054400
Insert semi-rigid prosthesis

4,868.83
3
510.00

102.0054401
Insert self-contd prosthesis

8,445.07
3
510.00

102.0054405
Insert multi-comp penis pros

8,445.07
3
510.00

102.0054406
Remove muti-comp penis pros

2,027.66
3
510.00

102.0054408
Repair multi-comp penis pros

2,027.66
3
510.00

102.0054410
Remove/replace penis prosth

8,445.07
3
510.00

102.00( print page 68275)54415
Remove self-contd penis pros

2,027.66
3
510.00

102.0054416
Remv/repl penis contain pros

8,445.07
3
510.00

102.0054420
Revision of penis

2,027.66
4
630.00

126.0054435
Revision of penis

2,027.66
4
630.00

126.0054440
Repair of penis

2,027.66
4
630.00

126.0054450
Preputial stretching

209.48
1
209.48
Y
41.9054500
Biopsy of testis

631.00
1
333.00

66.6054505
Biopsy of testis

1,446.40
1
333.00

66.6054512
Excise lesion testis

1,446.40
2
446.00

89.2054520
Removal of testis

1,446.40
3
510.00

102.0054522
Orchiectomy, partial

1,446.40
3
510.00

102.0054530
Removal of testis

1,795.98
4
630.00

126.0054550
Exploration for testis

1,795.98
4
630.00

126.0054600
Reduce testis torsion

1,446.40
4
630.00

126.0054620
Suspension of testis

1,446.40
3
510.00

102.0054640
Suspension of testis

1,795.98
4
630.00

126.0054660
Revision of testis

1,446.40
2
446.00

89.2054670
Repair testis injury

1,446.40
3
510.00

102.0054680
Relocation of testis(es)

1,446.40
3
510.00

102.0054690
Laparoscopy, orchiectomy

2,676.86
9
1,339.00

267.8054700
Drainage of scrotum

1,446.40
2
446.00

89.2054800
Biopsy of epididymis

127.16
1
127.16
Y
25.4354820
Exploration of epididymis
D

1
333.0054830
Remove epididymis lesion

1,446.40
3
510.00

102.0054840
Remove epididymis lesion

1,446.40
4
630.00

126.0054860
Removal of epididymis

1,446.40
3
510.00

102.0054861
Removal of epididymis

1,446.40
4
630.00

126.0054865
Explore epididymis
A
1,446.40
1
333.00

66.6054900
Fusion of spermatic ducts

1,446.40
4
630.00

126.0054901
Fusion of spermatic ducts

1,446.40
4
630.00

126.0055040
Removal of hydrocele

1,795.98
3
510.00

102.0055041
Removal of hydroceles

1,795.98
5
717.00

143.4055060
Repair of hydrocele

1,446.40
4
630.00

126.0055100
Drainage of scrotum abscess

685.58
1
333.00

66.6055110
Explore scrotum

1,446.40
2
446.00

89.2055120
Removal of scrotum lesion

1,446.40
2
446.00

89.2055150
Removal of scrotum

1,446.40
1
333.00

66.6055175
Revision of scrotum

1,446.40
1
333.00

66.6055180
Revision of scrotum

1,446.40
2
446.00

89.2055200
Incision of sperm duct

1,446.40
2
446.00

89.2055250
Removal of sperm duct(s)

1,446.40
2
446.00

89.2055400
Repair of sperm duct

1,446.40
1
333.00

66.6055500
Removal of hydrocele

1,446.40
3
510.00

102.0055520
Removal of sperm cord lesion

1,446.40
4
630.00

126.0055530
Revise spermatic cord veins

1,446.40
4
630.00

126.0055535
Revise spermatic cord veins

1,795.98
4
630.00

126.0055540
Revise hernia & sperm veins

1,795.98
5
717.00

143.4055550
Laparo ligate spermatic vein

2,676.86
9
1,339.00

267.8055680
Remove sperm pouch lesion

1,446.40
1
333.00

66.6055700
Biopsy of prostate

345.83
2
345.83
Y
69.1755705
Biopsy of prostate

345.83
2
345.83
Y
69.1755720
Drainage of prostate abscess

1,467.24
1
333.00

66.6055725
Drainage of prostate abscess

1,467.24
2
446.00

89.2055859
Percut/needle insert, pros
D

9
1,339.0055873
Cryoablate prostate

6,685.05
9
1,339.00

267.8055875
Transperi needle place, pros
A
2,146.84
9
1,339.00

267.8056440
Surgery for vulva lesion

1,260.59
2
446.00

89.2056441
Lysis of labial lesion(s)

912.73
1
333.00

66.6056442
Hymenotomy
A
912.73
1
333.00

66.6056515
Destroy vulva lesion/s compl

1,255.64
3
510.00

102.0056620
Partial removal of vulva

1,752.42
5
717.00

143.4056625
Complete removal of vulva

1,752.42
7
995.00

199.0056700
Partial removal of hymen

1,260.59
1
333.00

66.6056720
Incision of hymen
D

1
333.0056740
Remove vagina gland lesion

1,260.59
3
510.00

102.00( print page 68276)56800
Repair of vagina

1,260.59
3
510.00

102.0056810
Repair of perineum

1,260.59
5
717.00

143.4057000
Exploration of vagina

912.73
1
333.00

66.6057010
Drainage of pelvic abscess

912.73
2
446.00

89.2057020
Drainage of pelvic fluid

409.33
2
409.33
Y
81.8757023
I & d vag hematoma, non-ob

1,076.22
1
333.00

66.6057065
Destroy vag lesions, complex

1,260.59
1
333.00

66.6057105
Biopsy of vagina

1,260.59
2
446.00

89.2057130
Remove vagina lesion

1,260.59
2
446.00

89.2057135
Remove vagina lesion

1,260.59
2
446.00

89.2057155
Insert uteri tandems/ovoids

409.33
2
409.33
Y
81.8757180
Treat vaginal bleeding

178.05
1
178.05
Y
35.6157200
Repair of vagina

1,260.59
1
333.00

66.6057210
Repair vagina/perineum

1,260.59
2
446.00

89.2057220
Revision of urethra

2,642.48
3
510.00

102.0057230
Repair of urethral lesion

1,752.42
3
510.00

102.0057240
Repair bladder & vagina

1,752.42
5
717.00

143.4057250
Repair rectum & vagina

1,752.42
5
717.00

143.4057260
Repair of vagina

1,752.42
5
717.00

143.4057265
Extensive repair of vagina

2,642.48
7
995.00

199.0057267
Insert mesh/pelvic flr addon
A*
1,752.42
7
995.00

199.0057268
Repair of bowel bulge

1,752.42
3
510.00

102.0057288
Repair bladder defect

2,642.48
5
717.00

143.4057289
Repair bladder & vagina

1,752.42
5
717.00

143.4057291
Construction of vagina

1,752.42
5
717.00

143.4057300
Repair rectum-vagina fistula

1,752.42
3
510.00

102.0057400
Dilation of vagina

1,260.59
2
446.00

89.2057410
Pelvic examination

912.73
2
446.00

89.2057415
Remove vaginal foreign body

1,260.59
2
446.00

89.2057513
Laser surgery of cervix

912.73
2
446.00

89.2057520
Conization of cervix

1,260.59
2
446.00

89.2057522
Conization of cervix

1,752.42
2
446.00

89.2057530
Removal of cervix

1,752.42
3
510.00

102.0057550
Removal of residual cervix

1,752.42
3
510.00

102.0057556
Remove cervix, repair bowel

2,642.48
5
717.00

143.4057558
D&c of cervical stump
A
1,091.05
3
510.00

102.0057700
Revision of cervix

1,260.59
1
333.00

66.6057720
Revision of cervix

1,260.59
3
510.00

102.0057820
D & c of residual cervix
D

3
510.0058120
Dilation and curettage

1,091.05
2
446.00

89.2058145
Myomectomy vag method

1,752.42
5
717.00

143.4058346
Insert heyman uteri capsule

912.73
2
446.00

89.2058350
Reopen fallopian tube

1,752.42
3
510.00

102.0058353
Endometr ablate, thermal

1,752.42
7
995.00

199.0058545
Laparoscopic myomectomy

1,974.60
9
1,339.00

267.8058546
Laparo-myomectomy, complex

2,676.86
9
1,339.00

267.8058550
Laparo-asst vag hysterectomy

4,333.90
9
1,339.00

267.8058555
Hysteroscopy, dx, sep proc

1,312.87
1
333.00

66.6058558
Hysteroscopy, biopsy

1,312.87
3
510.00

102.0058559
Hysteroscopy, lysis

1,312.87
2
446.00

89.2058560
Hysteroscopy, resect septum

2,090.86
3
510.00

102.0058561
Hysteroscopy, remove myoma

2,090.86
3
510.00

102.0058562
Hysteroscopy, remove fb

1,312.87
3
510.00

102.0058563
Hysteroscopy, ablation

2,090.86
9
1,339.00

267.8058565
Hysteroscopy, sterilization

2,642.48
9
1,339.00

267.8058660
Laparoscopy, lysis

2,676.86
5
717.00

143.4058661
Laparoscopy, remove adnexa

2,676.86
5
717.00

143.4058662
Laparoscopy, excise lesions

2,676.86
5
717.00

143.4058670
Laparoscopy, tubal cautery

2,676.86
3
510.00

102.0058671
Laparoscopy, tubal block

2,676.86
3
510.00

102.0058672
Laparoscopy, fimbrioplasty

2,676.86
5
717.00

143.4058673
Laparoscopy, salpingostomy

2,676.86
5
717.00

143.4058800
Drainage of ovarian cyst(s)

912.73
3
510.00

102.0058820
Drain ovary abscess, open

1,752.42
3
510.00

102.0058900
Biopsy of ovary(s)

912.73
3
510.00

102.00( print page 68277)58970
Retrieval of oocyte

245.92
1
245.92
Y
49.1858974
Transfer of embryo

245.92
1
245.92
Y
49.1858976
Transfer of embryo

245.92
1
245.92
Y
49.1859160
D& c after delivery

1,091.05
3
510.00

102.0059320
Revision of cervix

1,260.59
1
333.00

66.6059812
Treatment of miscarriage

1,138.39
5
717.00

143.4059820
Care of miscarriage

1,138.39
5
717.00

143.4059821
Treatment of miscarriage

1,138.39
5
717.00

143.4059840
Abortion

1,040.83
5
717.00

143.4059841
Abortion

1,040.83
5
717.00

143.4059870
Evacuate mole of uterus

1,138.39
5
717.00

143.4059871
Remove cerclage suture

1,260.59
5
717.00

143.4060000
Drain thyroid/tongue cyst

464.15
1
333.00

66.6060200
Remove thyroid lesion

2,318.72
2
446.00

89.2060280
Remove thyroid duct lesion

2,318.72
4
630.00

126.0060281
Remove thyroid duct lesion

2,318.72
4
630.00

126.0061020
Remove brain cavity fluid

183.83
1
183.83
Y
36.7761026
Injection into brain canal

183.83
1
183.83
Y
36.7761050
Remove brain canal fluid

183.83
1
183.83
Y
36.7761055
Injection into brain canal

183.83
1
183.83
Y
36.7761070
Brain canal shunt procedure

183.83
1
183.83
Y
36.7761215
Insert brain-fluid device

2,891.10
3
510.00

102.0061790
Treat trigeminal nerve

1,097.20
3
510.00

102.0061791
Treat trigeminal tract

351.92
3
351.92
Y
70.3861795
Brain surgery using computer
A*
302.04
1
302.04
Y
60.4161885
Insrt/redo neurostim 1 array

11,518.00
2
446.00

89.2061886
Implant neurostim arrays

14,932.81
3
510.00

102.0061888
Revise/remove neuroreceiver

2,186.43
1
333.00

66.6062194
Replace/irrigate catheter

716.56
1
333.00

66.6062225
Replace/irrigate catheter

716.56
1
333.00

66.6062230
Replace/revise brain shunt

2,891.10
2
446.00

89.2062263
Epidural lysis mult sessions

748.08
1
333.00

66.6062264
Epidural lysis on single day

748.08
1
333.00

66.6062268
Drain spinal cord cyst

183.83
1
183.83
Y
36.7762269
Needle biopsy, spinal cord

377.32
1
333.00

66.6062270
Spinal fluid tap, diagnostic

139.00
1
139.00
Y
27.8062272
Drain cerebro spinal fluid

139.00
1
139.00
Y
27.8062273
Inject epidural patch

351.92
1
333.00

66.6062280
Treat spinal cord lesion

390.95
1
333.00

66.6062281
Treat spinal cord lesion

390.95
1
333.00

66.6062282
Treat spinal canal lesion

390.95
1
333.00

66.6062287
Percutaneous diskectomy

2,037.79
9
1,339.00

267.8062294
Injection into spinal artery

183.83
3
183.83
Y
36.7762310
Inject spine c/t

390.95
1
333.00

66.6062311
Inject spine l/s (cd)

390.95
1
333.00

66.6062318
Inject spine w/cath, c/t

390.95
1
333.00

66.6062319
Inject spine w/cath l/s (cd)

390.95
1
333.00

66.6062350
Implant spinal canal cath

1,895.64
2
446.00

89.2062355
Remove spinal canal catheter

748.08
2
446.00

89.2062360
Insert spine infusion device

6,923.28
2
446.00

89.2062361
Implant spine infusion pump

10,720.36
2
446.00

89.2062362
Implant spine infusion pump

10,720.36
2
446.00

89.2062365
Remove spine infusion device

2,037.79
2
446.00

89.2063600
Remove spinal cord lesion

1,097.20
2
446.00

89.2063610
Stimulation of spinal cord

1,097.20
1
333.00

66.6063650
Implant neuroelectrodes

3,477.28
2
446.00

89.2063660
Revise/remove neuroelectrode

1,096.18
1
333.00

66.6063685
Insrt/redo spine n generator

11,164.12
2
446.00

89.2063688
Revise/remove neuroreceiver

2,186.43
1
333.00

66.6063744
Revision of spinal shunt

2,413.44
3
510.00

102.0063746
Removal of spinal shunt

675.64
2
446.00

89.2064410
Nblock inj, phrenic

351.92
1
333.00

66.6064415
Nblock inj, brachial plexus

139.00
1
139.00
Y
27.8064417
Nblock inj, axillary

139.00
1
139.00
Y
27.8064420
Nblock inj, intercost, sng

139.00
1
139.00
Y
27.80( print page 68278)64421
Nblock inj, intercost, mlt

351.92
1
333.00

66.6064430
Nblock inj, pudendal

139.00
1
139.00
Y
27.8064470
Inj paravertebral c/t

390.95
1
333.00

66.6064472
Inj paravertebral c/t add-on

351.92
1
333.00

66.6064475
Inj paravertebral l/s

390.95
1
333.00

66.6064476
Inj paravertebral l/s add-on

351.92
1
333.00

66.6064479
Inj foramen epidural c/t

390.95
1
333.00

66.6064480
Inj foramen epidural add-on

390.95
1
333.00

66.6064483
Inj foramen epidural l/s

390.95
1
333.00

66.6064484
Inj foramen epidural add-on

390.95
1
333.00

66.6064510
Nblock, stellate ganglion

390.95
1
333.00

66.6064517
Nblock inj, hypogas plxs

139.00
2
139.00
Y
27.8064520
Nblock, lumbar/thoracic

390.95
1
333.00

66.6064530
Nblock inj, celiac pelus

390.95
1
333.00

66.6064553
Implant neuroelectrodes

13,593.72
1
333.00

66.6064561
Implant neuroelectrodes

3,477.28
3
510.00

102.0064573
Implant neuroelectrodes

13,593.72
1
333.00

66.6064575
Implant neuroelectrodes

5,175.40
1
333.00

66.6064577
Implant neuroelectrodes

5,175.40
1
333.00

66.6064580
Implant neuroelectrodes

5,175.40
1
333.00

66.6064581
Implant neuroelectrodes

5,175.40
3
510.00

102.0064585
Revise/remove neuroelectrode

1,096.18
1
333.00

66.6064590
Insrt/redo pn/gastr stimul

11,164.12
2
446.00

89.2064595
Revise/rmv pn/gastr stimul

2,186.43
1
333.00

66.6064600
Injection treatment of nerve

748.08
1
333.00

66.6064605
Injection treatment of nerve

748.08
1
333.00

66.6064610
Injection treatment of nerve

748.08
1
333.00

66.6064620
Injection treatment of nerve

748.08
1
333.00

66.6064622
Destr paravertebrl nerve l/s

748.08
1
333.00

66.6064623
Destr paravertebral n add-on

390.95
1
333.00

66.6064626
Destr paravertebrl nerve c/t

748.08
1
333.00

66.6064627
Destr paravertebral n add-on

390.95
1
333.00

66.6064630
Injection treatment of nerve

351.92
2
351.92
Y
70.3864680
Injection treatment of nerve

390.95
2
390.95
Y
78.1964681
Injection treatment of nerve

748.08
2
446.00

89.2064702
Revise finger/toe nerve

1,097.20
1
333.00

66.6064704
Revise hand/foot nerve

1,097.20
1
333.00

66.6064708
Revise arm/leg nerve

1,097.20
2
446.00

89.2064712
Revision of sciatic nerve

1,097.20
2
446.00

89.2064713
Revision of arm nerve(s)

1,097.20
2
446.00

89.2064714
Revise low back nerve(s)

1,097.20
2
446.00

89.2064716
Revision of cranial nerve

1,097.20
3
510.00

102.0064718
Revise ulnar nerve at elbow

1,097.20
2
446.00

89.2064719
Revise ulnar nerve at wrist

1,097.20
2
446.00

89.2064721
Carpal tunnel surgery

1,097.20
2
446.00

89.2064722
Relieve pressure on nerve(s)

1,097.20
1
333.00

66.6064726
Release foot/toe nerve

1,097.20
1
333.00

66.6064727
Internal nerve revision

1,097.20
1
333.00

66.6064732
Incision of brow nerve

1,097.20
2
446.00

89.2064734
Incision of cheek nerve

1,097.20
2
446.00

89.2064736
Incision of chin nerve

1,097.20
2
446.00

89.2064738
Incision of jaw nerve

1,097.20
2
446.00

89.2064740
Incision of tongue nerve

1,097.20
2
446.00

89.2064742
Incision of facial nerve

1,097.20
2
446.00

89.2064744
Incise nerve, back of head

1,097.20
2
446.00

89.2064746
Incise diaphragm nerve

1,097.20
2
446.00

89.2064771
Sever cranial nerve

1,097.20
2
446.00

89.2064772
Incision of spinal nerve

1,097.20
2
446.00

89.2064774
Remove skin nerve lesion

1,097.20
2
446.00

89.2064776
Remove digit nerve lesion

1,097.20
3
510.00

102.0064778
Digit nerve surgery add-on

1,097.20
2
446.00

89.2064782
Remove limb nerve lesion

1,097.20
3
510.00

102.0064783
Limb nerve surgery add-on

1,097.20
2
446.00

89.2064784
Remove nerve lesion

1,097.20
3
510.00

102.0064786
Remove sciatic nerve lesion

2,037.79
3
510.00

102.00( print page 68279)64787
Implant nerve end

1,097.20
2
446.00

89.2064788
Remove skin nerve lesion

1,097.20
3
510.00

102.0064790
Removal of nerve lesion

1,097.20
3
510.00

102.0064792
Removal of nerve lesion

2,037.79
3
510.00

102.0064795
Biopsy of nerve

1,097.20
2
446.00

89.2064802
Remove sympathetic nerves

1,097.20
2
446.00

89.2064821
Remove sympathetic nerves

1,590.53
4
630.00

126.0064831
Repair of digit nerve

2,037.79
4
630.00

126.0064832
Repair nerve add-on

2,037.79
1
333.00

66.6064834
Repair of hand or foot nerve

2,037.79
2
446.00

89.2064835
Repair of hand or foot nerve

2,037.79
3
510.00

102.0064836
Repair of hand or foot nerve

2,037.79
3
510.00

102.0064837
Repair nerve add-on

2,037.79
1
333.00

66.6064840
Repair of leg nerve

2,037.79
2
446.00

89.2064856
Repair/transpose nerve

2,037.79
2
446.00

89.2064857
Repair arm/leg nerve

2,037.79
2
446.00

89.2064858
Repair sciatic nerve

2,037.79
2
446.00

89.2064859
Nerve surgery

2,037.79
1
333.00

66.6064861
Repair of arm nerves

2,037.79
3
510.00

102.0064862
Repair of low back nerves

2,037.79
3
510.00

102.0064864
Repair of facial nerve

2,037.79
3
510.00

102.0064865
Repair of facial nerve

2,037.79
4
630.00

126.0064870
Fusion of facial/other nerve

2,037.79
4
630.00

126.0064872
Subsequent repair of nerve

2,037.79
2
446.00

89.2064874
Repair & revise nerve add-on

2,037.79
3
510.00

102.0064876
Repair nerve/shorten bone

2,037.79
3
510.00

102.0064885
Nerve graft, head or neck

2,037.79
2
446.00

89.2064886
Nerve graft, head or neck

2,037.79
2
446.00

89.2064890
Nerve graft, hand or foot

2,037.79
2
446.00

89.2064891
Nerve graft, hand or foot

2,037.79
2
446.00

89.2064892
Nerve graft, arm or leg

2,037.79
2
446.00

89.2064893
Nerve graft, arm or leg

2,037.79
2
446.00

89.2064895
Nerve graft, hand or foot

2,037.79
3
510.00

102.0064896
Nerve graft, hand or foot

2,037.79
3
510.00

102.0064897
Nerve graft, arm or leg

2,037.79
3
510.00

102.0064898
Nerve graft, arm or leg

2,037.79
3
510.00

102.0064901
Nerve graft add-on

2,037.79
2
446.00

89.2064902
Nerve graft add-on

2,037.79
2
446.00

89.2064905
Nerve pedicle transfer

2,037.79
2
446.00

89.2064907
Nerve pedicle transfer

2,037.79
1
333.00

66.6065091
Revise eye

2,165.47
3
510.00

102.0065093
Revise eye with implant

2,165.47
3
510.00

102.0065101
Removal of eye

2,165.47
3
510.00

102.0065103
Remove eye/insert implant

2,165.47
3
510.00

102.0065105
Remove eye/attach implant

2,165.47
4
630.00

126.0065110
Removal of eye

2,165.47
5
717.00

143.4065112
Remove eye/revise socket

2,165.47
7
995.00

199.0065114
Remove eye/revise socket

2,165.47
7
995.00

199.0065130
Insert ocular implant

1,552.37
3
510.00

102.0065135
Insert ocular implant

1,552.37
2
446.00

89.2065140
Attach ocular implant

2,165.47
3
510.00

102.0065150
Revise ocular implant

1,552.37
2
446.00

89.2065155
Reinsert ocular implant

2,165.47
3
510.00

102.0065175
Removal of ocular implant

1,052.60
1
333.00

66.6065235
Remove foreign body from eye

935.91
2
446.00

89.2065260
Remove foreign body from eye

1,015.69
3
510.00

102.0065265
Remove foreign body from eye

1,696.64
4
630.00

126.0065270
Repair of eye wound

1,052.60
2
446.00

89.2065272
Repair of eye wound

1,413.58
2
446.00

89.2065275
Repair of eye wound

1,413.58
4
630.00

126.0065280
Repair of eye wound

1,015.69
4
630.00

126.0065285
Repair of eye wound

2,300.69
4
630.00

126.0065290
Repair of eye socket wound

1,308.05
3
510.00

102.0065400
Removal of eye lesion

935.91
1
333.00

66.6065410
Biopsy of cornea

935.91
2
446.00

89.20( print page 68280)65420
Removal of eye lesion

935.91
2
446.00

89.2065426
Removal of eye lesion

1,413.58
5
717.00

143.4065710
Corneal transplant

2,352.42
7
995.00

199.0065730
Corneal transplant

2,352.42
7
995.00

199.0065750
Corneal transplant

2,352.42
7
995.00

199.0065755
Corneal transplant

2,352.42
7
995.00

199.0065770
Revise cornea with implant

3,195.68
7
995.00

199.0065772
Correction of astigmatism

935.91
4
630.00

126.0065775
Correction of astigmatism

935.91
4
630.00

126.0065780
Ocular reconst, transplant

2,352.42
5
717.00

143.4065781
Ocular reconst, transplant

2,352.42
5
717.00

143.4065782
Ocular reconst, transplant

2,352.42
5
717.00

143.4065800
Drainage of eye

935.91
1
333.00

66.6065805
Drainage of eye

935.91
1
333.00

66.6065810
Drainage of eye

1,413.58
3
510.00

102.0065815
Drainage of eye

1,413.58
2
446.00

89.2065820
Relieve inner eye pressure

372.94
1
333.00

66.6065850
Incision of eye

1,413.58
4
630.00

126.0065865
Incise inner eye adhesions

935.91
1
333.00

66.6065870
Incise inner eye adhesions

1,413.58
4
630.00

126.0065875
Incise inner eye adhesions

1,413.58
4
630.00

126.0065880
Incise inner eye adhesions

935.91
4
630.00

126.0065900
Remove eye lesion

935.91
5
717.00

143.4065920
Remove implant of eye

1,413.58
7
995.00

199.0065930
Remove blood clot from eye

1,413.58
5
717.00

143.4066020
Injection treatment of eye

935.91
1
333.00

66.6066030
Injection treatment of eye

372.94
1
333.00

66.6066130
Remove eye lesion

1,413.58
7
995.00

199.0066150
Glaucoma surgery

1,413.58
4
630.00

126.0066155
Glaucoma surgery

1,413.58
4
630.00

126.0066160
Glaucoma surgery

1,413.58
2
446.00

89.2066165
Glaucoma surgery

1,413.58
4
630.00

126.0066170
Glaucoma surgery

1,413.58
4
630.00

126.0066172
Incision of eye

1,413.58
4
630.00

126.0066180
Implant eye shunt

2,329.43
5
717.00

143.4066185
Revise eye shunt

2,329.43
2
446.00

89.2066220
Repair eye lesion

2,300.69
3
510.00

102.0066225
Repair/graft eye lesion

2,329.43
4
630.00

126.0066250
Follow-up surgery of eye

935.91
2
446.00

89.2066500
Incision of iris

372.94
1
333.00

66.6066505
Incision of iris

372.94
1
333.00

66.6066600
Remove iris and lesion

1,413.58
3
510.00

102.0066605
Removal of iris

1,413.58
3
510.00

102.0066625
Removal of iris

372.94
3
372.94
Y
74.5966630
Removal of iris

1,413.58
3
510.00

102.0066635
Removal of iris

1,413.58
3
510.00

102.0066680
Repair iris & ciliary body

1,413.58
3
510.00

102.0066682
Repair iris & ciliary body

1,413.58
2
446.00

89.2066700
Destruction, ciliary body

935.91
2
446.00

89.2066710
Ciliary transsleral therapy

935.91
2
446.00

89.2066711
Ciliary endoscopic ablation

935.91
2
446.00

89.2066720
Destruction, ciliary body

935.91
2
446.00

89.2066740
Destruction, ciliary body

1,413.58
2
446.00

89.2066821
After cataract laser surgery

312.50
2
312.50
Y
62.5066825
Reposition intraocular lens

1,413.58
4
630.00

126.0066830
Removal of lens lesion

372.94
4
372.94
Y
74.5966840
Removal of lens material

914.04
4
630.00

126.0066850
Removal of lens material

1,796.59
7
995.00

199.0066852
Removal of lens material

1,796.59
4
630.00

126.0066920
Extraction of lens

1,796.59
4
630.00

126.0066930
Extraction of lens

1,796.59
5
717.00

143.4066940
Extraction of lens

914.04
5
717.00

143.4066982
Cataract surgery, complex

1,452.57
8
973.00

194.6066983
Cataract surg w/iol, 1 stage

1,452.57
8
973.00

194.6066984
Cataract surg w/iol, 1 stage

1,452.57
8
973.00

194.60( print page 68281)66985
Insert lens prosthesis

1,452.57
6
826.00

165.2066986
Exchange lens prosthesis

1,452.57
6
826.00

165.2067005
Partial removal of eye fluid

1,696.64
4
630.00

126.0067010
Partial removal of eye fluid

1,696.64
4
630.00

126.0067015
Release of eye fluid

1,696.64
1
333.00

66.6067025
Replace eye fluid

1,696.64
1
333.00

66.6067027
Implant eye drug system

2,300.69
4
630.00

126.0067030
Incise inner eye strands

1,015.69
1
333.00

66.6067031
Laser surgery, eye strands

312.50
2
312.50
Y
62.5067036
Removal of inner eye fluid

2,300.69
4
630.00

126.0067038
Strip retinal membrane

2,300.69
5
717.00

143.4067039
Laser treatment of retina

2,300.69
7
995.00

199.0067040
Laser treatment of retina

2,300.69
7
995.00

199.0067107
Repair detached retina

2,300.69
5
717.00

143.4067108
Repair detached retina

2,300.69
7
995.00

199.0067112
Rerepair detached retina

2,300.69
7
995.00

199.0067115
Release encircling material

1,015.69
2
446.00

89.2067120
Remove eye implant material

1,015.69
2
446.00

89.2067121
Remove eye implant material

1,696.64
2
446.00

89.2067141
Treatment of retina

241.77
2
241.77
Y
48.3567218
Treatment of retinal lesion

1,015.69
5
717.00

143.4067227
Treatment of retinal lesion

1,696.64
1
333.00

66.6067250
Reinforce eye wall

1,052.60
3
510.00

102.0067255
Reinforce/graft eye wall

1,696.64
3
510.00

102.0067311
Revise eye muscle

1,308.05
3
510.00

102.0067312
Revise two eye muscles

1,308.05
4
630.00

126.0067314
Revise eye muscle

1,308.05
4
630.00

126.0067316
Revise two eye muscles

1,308.05
4
630.00

126.0067318
Revise eye muscle(s)

1,308.05
4
630.00

126.0067320
Revise eye muscle(s) add-on

1,308.05
4
630.00

126.0067331
Eye surgery follow-up add-on

1,308.05
4
630.00

126.0067332
Rerevise eye muscles add-on

1,308.05
4
630.00

126.0067334
Revise eye muscle w/suture

1,308.05
4
630.00

126.0067335
Eye suture during surgery

1,308.05
4
630.00

126.0067340
Revise eye muscle add-on

1,308.05
4
630.00

126.0067343
Release eye tissue

1,308.05
7
995.00

199.0067346
Biopsy, eye muscle
A
884.19
1
333.00

66.6067350
Biopsy eye muscle
D

1
333.0067400
Explore/biopsy eye socket

1,552.37
3
510.00

102.0067405
Explore/drain eye socket

1,552.37
4
630.00

126.0067412
Explore/treat eye socket

1,552.37
5
717.00

143.4067413
Explore/treat eye socket

1,552.37
5
717.00

143.4067415
Aspiration, orbital contents

1,052.60
1
333.00

66.6067420
Explore/treat eye socket

2,165.47
5
717.00

143.4067430
Explore/treat eye socket

2,165.47
5
717.00

143.4067440
Explore/drain eye socket

2,165.47
5
717.00

143.4067445
Explr/decompress eye socket

2,165.47
5
717.00

143.4067450
Explore/biopsy eye socket

2,165.47
5
717.00

143.4067550
Insert eye socket implant

2,165.47
4
630.00

126.0067560
Revise eye socket implant

1,552.37
2
446.00

89.2067570
Decompress optic nerve

2,165.47
4
630.00

126.0067715
Incision of eyelid fold

1,052.60
1
333.00

66.6067808
Remove eyelid lesion(s)

1,052.60
2
446.00

89.2067830
Revise eyelashes

447.60
2
446.00

89.2067835
Revise eyelashes

1,052.60
2
446.00

89.2067880
Revision of eyelid

935.91
3
510.00

102.0067882
Revision of eyelid

1,052.60
3
510.00

102.0067900
Repair brow defect

1,052.60
4
630.00

126.0067901
Repair eyelid defect

1,052.60
5
717.00

143.4067902
Repair eyelid defect

1,052.60
5
717.00

143.4067903
Repair eyelid defect

1,052.60
4
630.00

126.0067904
Repair eyelid defect

1,052.60
4
630.00

126.0067906
Repair eyelid defect

1,052.60
5
717.00

143.4067908
Repair eyelid defect

1,052.60
4
630.00

126.0067909
Revise eyelid defect

1,052.60
4
630.00

126.00( print page 68282)67911
Revise eyelid defect

1,052.60
3
510.00

102.0067912
Correction eyelid w/implant

1,052.60
3
510.00

102.0067914
Repair eyelid defect

1,052.60
3
510.00

102.0067916
Repair eyelid defect

1,052.60
4
630.00

126.0067917
Repair eyelid defect

1,052.60
4
630.00

126.0067921
Repair eyelid defect

1,052.60
3
510.00

102.0067923
Repair eyelid defect

1,052.60
4
630.00

126.0067924
Repair eyelid defect

1,052.60
4
630.00

126.0067935
Repair eyelid wound

1,052.60
2
446.00

89.2067950
Revision of eyelid

1,052.60
2
446.00

89.2067961
Revision of eyelid

1,052.60
3
510.00

102.0067966
Revision of eyelid

1,052.60
3
510.00

102.0067971
Reconstruction of eyelid

1,552.37
3
510.00

102.0067973
Reconstruction of eyelid

1,552.37
3
510.00

102.0067974
Reconstruction of eyelid

1,552.37
3
510.00

102.0067975
Reconstruction of eyelid

1,052.60
3
510.00

102.0068115
Remove eyelid lining lesion

1,052.60
2
446.00

89.2068130
Remove eyelid lining lesion

935.91
2
446.00

89.2068320
Revise/graft eyelid lining

1,052.60
4
630.00

126.0068325
Revise/graft eyelid lining

1,552.37
4
630.00

126.0068326
Revise/graft eyelid lining

1,552.37
4
630.00

126.0068328
Revise/graft eyelid lining

1,552.37
4
630.00

126.0068330
Revise eyelid lining

1,413.58
4
630.00

126.0068335
Revise/graft eyelid lining

1,552.37
4
630.00

126.0068340
Separate eyelid adhesions

1,052.60
4
630.00

126.0068360
Revise eyelid lining

1,413.58
2
446.00

89.2068362
Revise eyelid lining

1,413.58
2
446.00

89.2068371
Harvest eye tissue, alograft

935.91
2
446.00

89.2068500
Removal of tear gland

1,552.37
3
510.00

102.0068505
Partial removal, tear gland

1,552.37
3
510.00

102.0068510
Biopsy of tear gland

1,052.60
1
333.00

66.6068520
Removal of tear sac

1,552.37
3
510.00

102.0068525
Biopsy of tear sac

1,052.60
1
333.00

66.6068540
Remove tear gland lesion

1,552.37
3
510.00

102.0068550
Remove tear gland lesion

1,552.37
3
510.00

102.0068700
Repair tear ducts

1,552.37
2
446.00

89.2068720
Create tear sac drain

1,552.37
4
630.00

126.0068745
Create tear duct drain

1,552.37
4
630.00

126.0068750
Create tear duct drain

1,552.37
4
630.00

126.0068770
Close tear system fistula

1,052.60
4
630.00

126.0068810
Probe nasolacrimal duct

131.86
1
131.86
Y
26.3768811
Probe nasolacrimal duct

1,052.60
2
446.00

89.2068815
Probe nasolacrimal duct

1,052.60
2
446.00

89.2069110
Remove external ear, partial

928.31
1
333.00

66.6069120
Removal of external ear

1,434.04
2
446.00

89.2069140
Remove ear canal lesion(s)

1,434.04
2
446.00

89.2069145
Remove ear canal lesion(s)

928.31
2
446.00

89.2069150
Extensive ear canal surgery

464.15
3
464.15
Y
92.8369205
Clear outer ear canal

1,233.39
1
333.00

66.6069300
Revise external ear

1,434.04
3
510.00

102.0069310
Rebuild outer ear canal

2,348.02
3
510.00

102.0069320
Rebuild outer ear canal

2,348.02
7
995.00

199.0069421
Incision of eardrum

1,009.71
3
510.00

102.0069436
Create eardrum opening

1,009.71
3
510.00

102.0069440
Exploration of middle ear

1,434.04
3
510.00

102.0069450
Eardrum revision

2,348.02
1
333.00

66.6069501
Mastoidectomy

2,348.02
7
995.00

199.0069502
Mastoidectomy

1,434.04
7
995.00

199.0069505
Remove mastoid structures

2,348.02
7
995.00

199.0069511
Extensive mastoid surgery

2,348.02
7
995.00

199.0069530
Extensive mastoid surgery

2,348.02
7
995.00

199.0069550
Remove ear lesion

2,348.02
5
717.00

143.4069552
Remove ear lesion

2,348.02
7
995.00

199.0069601
Mastoid surgery revision

2,348.02
7
995.00

199.0069602
Mastoid surgery revision

2,348.02
7
995.00

199.00( print page 68283)69603
Mastoid surgery revision

2,348.02
7
995.00

199.0069604
Mastoid surgery revision

2,348.02
7
995.00

199.0069605
Mastoid surgery revision

2,348.02
7
995.00

199.0069620
Repair of eardrum

1,434.04
2
446.00

89.2069631
Repair eardrum structures

2,348.02
5
717.00

143.4069632
Rebuild eardrum structures

2,348.02
5
717.00

143.4069633
Rebuild eardrum structures

2,348.02
5
717.00

143.4069635
Repair eardrum structures

2,348.02
7
995.00

199.0069636
Rebuild eardrum structures

2,348.02
7
995.00

199.0069637
Rebuild eardrum structures

2,348.02
7
995.00

199.0069641
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069642
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069643
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069644
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069645
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069646
Revise middle ear & mastoid

2,348.02
7
995.00

199.0069650
Release middle ear bone

1,434.04
7
995.00

199.0069660
Revise middle ear bone

2,348.02
5
717.00

143.4069661
Revise middle ear bone

2,348.02
5
717.00

143.4069662
Revise middle ear bone

2,348.02
5
717.00

143.4069666
Repair middle ear structures

2,348.02
4
630.00

126.0069667
Repair middle ear structures

2,348.02
4
630.00

126.0069670
Remove mastoid air cells

2,348.02
3
510.00

102.0069676
Remove middle ear nerve

2,348.02
3
510.00

102.0069700
Close mastoid fistula

2,348.02
3
510.00

102.0069711
Remove/repair hearing aid

2,348.02
1
333.00

66.6069714
Implant temple bone w/stimul

2,348.02
9
1,339.00

267.8069715
Temple bne implnt w/stimulat

2,348.02
9
1,339.00

267.8069717
Temple bone implant revision

2,348.02
9
1,339.00

267.8069718
Revise temple bone implant

2,348.02
9
1,339.00

267.8069720
Release facial nerve

2,348.02
5
717.00

143.4069740
Repair facial nerve

2,348.02
5
717.00

143.4069745
Repair facial nerve

2,348.02
5
717.00

143.4069801
Incise inner ear

2,348.02
5
717.00

143.4069802
Incise inner ear

2,348.02
7
995.00

199.0069805
Explore inner ear

2,348.02
7
995.00

199.0069806
Explore inner ear

2,348.02
7
995.00

199.0069820
Establish inner ear window

2,348.02
5
717.00

143.4069840
Revise inner ear window

2,348.02
5
717.00

143.4069905
Remove inner ear

2,348.02
7
995.00

199.0069910
Remove inner ear & mastoid

2,348.02
7
995.00

199.0069915
Incise inner ear nerve

2,348.02
7
995.00

199.0069930
Implant cochlear device

25,499.72
7
995.00

199.000176T
Aqu canal dilat w/o retent
A
2,329.43
9
1,339.00

267.800177T
Aqu canal dilat w retent
A
2,329.43
9
1,339.00

267.80G0105
Colorectal scrn; hi risk ind

446.00
2
446.00

111.50G0121
Colon ca scrn not hi rsk ind

446.00
2
446.00

111.50G0260
Inj for sacroiliac jt anesth

351.92
1
333.00

66.60G0392
AV fistula or graft arterial
A
2,624.19
9
1,339.00

334.75G0393
AV fistula or graft venous
A
2,624.19
9
1,339.00

334.75
 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 copayment00100
Anesth, salivary gland

N00102
Anesth, repair of cleft lip

N00103
Anesth, blepharoplasty

N00104
Anesth, electroshock

N00120
Anesth, ear surgery

N00124
Anesth, ear exam

N00126
Anesth, tympanotomy

N( print page 68284)00140
Anesth, procedures on eye

N00142
Anesth, lens surgery

N00144
Anesth, corneal transplant

N00145
Anesth, vitreoretinal surg

N00147
Anesth, iridectomy

N00148
Anesth, eye exam

N00160
Anesth, nose/sinus surgery

N00162
Anesth, nose/sinus surgery

N00164
Anesth, biopsy of nose

N00170
Anesth, procedure on mouth

N00172
Anesth, cleft palate repair

N00174
Anesth, pharyngeal surgery

N00190
Anesth, face/skull bone surg

N00210
Anesth, open head surgery

N00212
Anesth, skull drainage

N00216
Anesth, head vessel surgery

N00218
Anesth, special head surgery

N00220
Anesth, intrcrn nerve

N00222
Anesth, head nerve surgery

N00300
Anesth, head/neck/ptrunk

N00320
Anesth, neck organ, 1 & over

N00322
Anesth, biopsy of thyroid

N00326
Anesth, larynx/trach, < 1 yr

N00350
Anesth, neck vessel surgery

N00352
Anesth, neck vessel surgery

N00400
Anesth, skin, ext/per/atrunk

N00402
Anesth, surgery of breast

N00404
Anesth, surgery of breast
CH
N00406
Anesth, surgery of breast
CH
N00410
Anesth, correct heart rhythm

N00450
Anesth, surgery of shoulder

N00454
Anesth, collar bone biopsy

N00470
Anesth, removal of rib

N00472
Anesth, chest wall repair

N00500
Anesth, esophageal surgery

N00520
Anesth, chest procedure

N00522
Anesth, chest lining biopsy

N00528
Anesth, chest partition view

N00529
Anesth, chest partition view

N00530
Anesth, pacemaker insertion

N00532
Anesth, vascular access

N00534
Anesth, cardioverter/defib

N00537
Anesth, cardiac electrophys

N00539
Anesth, trach-bronch reconst

N00541
Anesth, one lung ventilation

N00548
Anesth, trachea,bronchi surg

N00550
Anesth, sternal debridement

N00563
Anesth, heart surg w/arrest

N00566
Anesth, cabg w/o pump

N00600
Anesth, spine, cord surgery

N00620
Anesth, spine, cord surgery

N00625
Anes spine tranthor w/o vent
NI
N00626
Anes, spine transthor w/vent
NI
N00630
Anesth, spine, cord surgery

N00634
Anesth for chemonucleolysis

N00635
Anesth, lumbar puncture

N00640
Anesth, spine manipulation

N00700
Anesth, abdominal wall surg

N00702
Anesth, for liver biopsy

N00730
Anesth, abdominal wall surg

N00740
Anesth, upper gi visualize

N00750
Anesth, repair of hernia

N00752
Anesth, repair of hernia

N00754
Anesth, repair of hernia

N00756
Anesth, repair of hernia

N00770
Anesth, blood vessel repair

N00790
Anesth, surg upper abdomen

N00797
Anesth, surgery for obesity

N00800
Anesth, abdominal wall surg

N00810
Anesth, low intestine scope

N( print page 68285)00820
Anesth, abdominal wall surg

N00830
Anesth, repair of hernia

N00832
Anesth, repair of hernia

N00834
Anesth, hernia repair< 1 yr

N00836
Anesth hernia repair preemie

N00840
Anesth, surg lower abdomen

N00842
Anesth, amniocentesis

N00851
Anesth, tubal ligation

N00860
Anesth, surgery of abdomen

N00862
Anesth, kidney/ureter surg

N00870
Anesth, bladder stone surg

N00872
Anesth kidney stone destruct

N00873
Anesth kidney stone destruct

N00880
Anesth, abdomen vessel surg

N00902
Anesth, anorectal surgery

N00906
Anesth, removal of vulva

N00910
Anesth, bladder surgery

N00912
Anesth, bladder tumor surg

N00914
Anesth, removal of prostate

N00916
Anesth, bleeding control

N00918
Anesth, stone removal

N00920
Anesth, genitalia surgery

N00921
Anesth, vasectomy

N00922
Anesth, sperm duct surgery

N00924
Anesth, testis exploration

N00926
Anesth, removal of testis

N00928
Anesth, removal of testis

N00930
Anesth, testis suspension

N00938
Anesth, insert penis device

N00940
Anesth, vaginal procedures

N00942
Anesth, surg on vag/urethral

N00948
Anesth, repair of cervix

N00950
Anesth, vaginal endoscopy

N00952
Anesth, hysteroscope/graph

N01112
Anesth, bone aspirate/bx

N01120
Anesth, pelvis surgery

N01130
Anesth, body cast procedure

N01160
Anesth, pelvis procedure

N01170
Anesth, pelvis surgery

N01173
Anesth, fx repair, pelvis

N01180
Anesth, pelvis nerve removal

N01190
Anesth, pelvis nerve removal

N01200
Anesth, hip joint procedure

N01202
Anesth, arthroscopy of hip

N01210
Anesth, hip joint surgery

N01215
Anesth, revise hip repair

N01220
Anesth, procedure on femur

N01230
Anesth, surgery of femur

N01250
Anesth, upper leg surgery

N01260
Anesth, upper leg veins surg

N01270
Anesth, thigh arteries surg

N01320
Anesth, knee area surgery

N01340
Anesth, knee area procedure

N01360
Anesth, knee area surgery

N01380
Anesth, knee joint procedure

N01382
Anesth, dx knee arthroscopy

N01390
Anesth, knee area procedure

N01392
Anesth, knee area surgery

N01400
Anesth, knee joint surgery

N01420
Anesth, knee joint casting

N01430
Anesth, knee veins surgery

N01432
Anesth, knee vessel surg

N01440
Anesth, knee arteries surg

N01462
Anesth, lower leg procedure

N01464
Anesth, ankle/ft arthroscopy

N01470
Anesth, lower leg surgery

N01472
Anesth, achilles tendon surg

N01474
Anesth, lower leg surgery

N01480
Anesth, lower leg bone surg

N01482
Anesth, radical leg surgery

N( print page 68286)01484
Anesth, lower leg revision

N01490
Anesth, lower leg casting

N01500
Anesth, leg arteries surg

N01520
Anesth, lower leg vein surg

N01522
Anesth, lower leg vein surg

N01610
Anesth, surgery of shoulder

N01620
Anesth, shoulder procedure

N01622
Anes dx shoulder arthroscopy

N01630
Anesth, surgery of shoulder

N01650
Anesth, shoulder artery surg

N01670
Anesth, shoulder vein surg

N01680
Anesth, shoulder casting

N01682
Anesth, airplane cast

N01710
Anesth, elbow area surgery

N01712
Anesth, uppr arm tendon surg

N01714
Anesth, uppr arm tendon surg

N01716
Anesth, biceps tendon repair

N01730
Anesth, uppr arm procedure

N01732
Anesth, dx elbow arthroscopy

N01740
Anesth, upper arm surgery

N01742
Anesth, humerus surgery

N01744
Anesth, humerus repair

N01758
Anesth, humeral lesion surg

N01760
Anesth, elbow replacement

N01770
Anesth, uppr arm artery surg

N01772
Anesth, uppr arm embolectomy

N01780
Anesth, upper arm vein surg

N01782
Anesth, uppr arm vein repair

N01810
Anesth, lower arm surgery

N01820
Anesth, lower arm procedure

N01829
Anesth, dx wrist arthroscopy

N01830
Anesth, lower arm surgery

N01832
Anesth, wrist replacement

N01840
Anesth, lwr arm artery surg

N01842
Anesth, lwr arm embolectomy

N01844
Anesth, vascular shunt surg

N01850
Anesth, lower arm vein surg

N01852
Anesth, lwr arm vein repair

N01860
Anesth, lower arm casting

N01905
Anes, spine inject, x-ray/re

N01916
Anesth, dx arteriography

N01920
Anesth, catheterize heart

N01922
Anesth, cat or MRI scan

N01924
Anes, ther interven rad, art

N01925
Anes, ther interven rad, car

N01926
Anes, tx interv rad hrt/cran

N01930
Anes, ther interven rad, vei

N01931
Anes, ther interven rad, tip

N01932
Anes, tx interv rad, th vein

N01933
Anes, tx interv rad, cran v

N01951
Anesth, burn, less 4 percent

N01952
Anesth, burn, 4-9 percent

N01953
Anesth, burn, each 9 percent

N01958
Anesth, antepartum manipul

N01960
Anesth, vaginal delivery

N01961
Anesth, cs delivery

N01962
Anesth, emer hysterectomy

N01963
Anesth, cs hysterectomy

N01965
Anesth, inc/missed ab proc

N01966
Anesth, induced ab procedure

N01967
Anesth/analg, vag delivery

N01968
Anes/analg cs deliver add-on

N01969
Anesth/analg cs hyst add-on

N01991
Anesth, nerve block/inj

N01992
Anesth, n block/inj, prone

N01995
Regional anesthesia limb
CH
D01996
Hosp manage cont drug admin

N01999
Unlisted anesth procedure

N10021
Fna w/o image

T
0002
1.0995
67.58

13.5210022
Fna w/image

T
0036
2.0738
127.47

25.49( print page 68287)10040
Acne surgery

T
0010
0.476
29.26
8.02
5.8510060
Drainage of skin abscess

T
0006
1.4392
88.46

17.6910061
Drainage of skin abscess

T
0006
1.4392
88.46

17.6910080
Drainage of pilonidal cyst

T
0006
1.4392
88.46

17.6910081
Drainage of pilonidal cyst

T
0007
11.1535
685.58

137.1210120
Remove foreign body

T
0006
1.4392
88.46

17.6910121
Remove foreign body

T
0021
15.1024
928.31
219.48
185.6610140
Drainage of hematoma/fluid

T
0007
11.1535
685.58

137.1210160
Puncture drainage of lesion

T
0018
1.0259
63.06
15.44
12.6110180
Complex drainage, wound

T
0008
17.5086
1,076.22

215.2411000
Debride infected skin

T
0013
1.0918
67.11

13.4211001
Debride infected skin add-on

T
0012
0.8432
51.83
11.18
10.3711010
Debride skin, fx

T
0019
4.0919
251.52
71.87
50.3011011
Debride skin/muscle, fx

T
0019
4.0919
251.52
71.87
50.3011012
Debride skin/muscle/bone, fx

T
0019
4.0919
251.52
71.87
50.3011040
Debride skin, partial

T
0015
1.6241
99.83
20.13
19.9711041
Debride skin, full

T
0015
1.6241
99.83
20.13
19.9711042
Debride skin/tissue

T
0016
2.6749
164.42

32.8811043
Debride tissue/muscle

T
0016
2.6749
164.42

32.8811044
Debride tissue/muscle/bone

T
0682
6.8832
423.10
158.65
84.6211055
Trim skin lesion

T
0012
0.8432
51.83
11.18
10.3711056
Trim skin lesions, 2 to 4

T
0012
0.8432
51.83
11.18
10.3711057
Trim skin lesions, over 4

T
0013
1.0918
67.11

13.4211100
Biopsy, skin lesion

T
0018
1.0259
63.06
15.44
12.6111101
Biopsy, skin add-on

T
0018
1.0259
63.06
15.44
12.6111200
Removal of skin tags

T
0013
1.0918
67.11

13.4211201
Remove skin tags add-on

T
0015
1.6241
99.83
20.13
19.9711300
Shave skin lesion

T
0012
0.8432
51.83
11.18
10.3711301
Shave skin lesion

T
0012
0.8432
51.83
11.18
10.3711302
Shave skin lesion

T
0013
1.0918
67.11

13.4211303
Shave skin lesion

T
0015
1.6241
99.83
20.13
19.9711305
Shave skin lesion

T
0013
1.0918
67.11

13.4211306
Shave skin lesion

T
0013
1.0918
67.11

13.4211307
Shave skin lesion

T
0013
1.0918
67.11

13.4211308
Shave skin lesion

T
0013
1.0918
67.11

13.4211310
Shave skin lesion

T
0013
1.0918
67.11

13.4211311
Shave skin lesion

T
0013
1.0918
67.11

13.4211312
Shave skin lesion

T
0013
1.0918
67.11

13.4211313
Shave skin lesion

T
0016
2.6749
164.42

32.8811400
Exc tr-ext b9+marg 0.5 < cm

T
0019
4.0919
251.52
71.87
50.3011401
Exc tr-ext b9+marg 0.6-1 cm

T
0019
4.0919
251.52
71.87
50.3011402
Exc tr-ext b9+marg 1.1-2 cm

T
0019
4.0919
251.52
71.87
50.3011403
Exc tr-ext b9+marg 2.1-3 cm

T
0020
6.8083
418.49
107.67
83.7011404
Exc tr-ext b9+marg 3.1-4 cm

T
0021
15.1024
928.31
219.48
185.6611406
Exc tr-ext b9+marg > 4.0 cm

T
0021
15.1024
928.31
219.48
185.6611420
Exc h-f-nk-sp b9+marg 0.5 <

T
0020
6.8083
418.49
107.67
83.7011421
Exc h-f-nk-sp b9+marg 0.6-1

T
0020
6.8083
418.49
107.67
83.7011422
Exc h-f-nk-sp b9+marg 1.1-2

T
0020
6.8083
418.49
107.67
83.7011423
Exc h-f-nk-sp b9+marg 2.1-3

T
0021
15.1024
928.31
219.48
185.6611424
Exc h-f-nk-sp b9+marg 3.1-4

T
0021
15.1024
928.31
219.48
185.6611426
Exc h-f-nk-sp b9+marg > 4 cm

T
0022
20.0656
1,233.39
354.45
246.6811440
Exc face-mm b9+marg 0.5 < cm

T
0019
4.0919
251.52
71.87
50.3011441
Exc face-mm b9+marg 0.6-1 cm

T
0019
4.0919
251.52
71.87
50.3011442
Exc face-mm b9+marg 1.1-2 cm

T
0020
6.8083
418.49
107.67
83.7011443
Exc face-mm b9+marg 2.1-3 cm

T
0020
6.8083
418.49
107.67
83.7011444
Exc face-mm b9+marg 3.1-4 cm

T
0020
6.8083
418.49
107.67
83.7011446
Exc face-mm b9+marg > 4 cm

T
0022
20.0656
1,233.39
354.45
246.6811450
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811451
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811462
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811463
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811470
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811471
Removal, sweat gland lesion

T
0022
20.0656
1,233.39
354.45
246.6811600
Exc tr-ext mlg+marg 0.5 < cm

T
0019
4.0919
251.52
71.87
50.3011601
Exc tr-ext mlg+marg 0.6-1 cm

T
0019
4.0919
251.52
71.87
50.3011602
Exc tr-ext mlg+marg 1.1-2 cm

T
0019
4.0919
251.52
71.87
50.3011603
Exc tr-ext mlg+marg 2.1-3 cm

T
0020
6.8083
418.49
107.67
83.7011604
Exc tr-ext mlg+marg 3.1-4 cm

T
0020
6.8083
418.49
107.67
83.7011606
Exc tr-ext mlg+marg > 4 cm

T
0021
15.1024
928.31
219.48
185.6611620
Exc h-f-nk-sp mlg+marg 0.5 <

T
0020
6.8083
418.49
107.67
83.70( print page 68288)11621
Exc h-f-nk-sp mlg+marg 0.6-1

T
0019
4.0919
251.52
71.87
50.3011622
Exc h-f-nk-sp mlg+marg 1.1-2

T
0020
6.8083
418.49
107.67
83.7011623
Exc h-f-nk-sp mlg+marg 2.1-3

T
0021
15.1024
928.31
219.48
185.6611624
Exc h-f-nk-sp mlg+marg 3.1-4

T
0021
15.1024
928.31
219.48
185.6611626
Exc h-f-nk-sp mlg+mar > 4 cm

T
0022
20.0656
1,233.39
354.45
246.6811640
Exc face-mm malig+marg 0.5 <

T
0020
6.8083
418.49
107.67
83.7011641
Exc face-mm malig+marg 0.6-1

T
0020
6.8083
418.49
107.67
83.7011642
Exc face-mm malig+marg 1.1-2

T
0020
6.8083
418.49
107.67
83.7011643
Exc face-mm malig+marg 2.1-3

T
0020
6.8083
418.49
107.67
83.7011644
Exc face-mm malig+marg 3.1-4

T
0021
15.1024
928.31
219.48
185.6611646
Exc face-mm mlg+marg > 4 cm

T
0022
20.0656
1,233.39
354.45
246.6811719
Trim nail(s)

T
0009
0.7744
47.60

9.5211720
Debride nail, 1-5

T
0009
0.7744
47.60

9.5211721
Debride nail, 6 or more

T
0009
0.7744
47.60

9.5211730
Removal of nail plate

T
0013
1.0918
67.11

13.4211732
Remove nail plate, add-on

T
0012
0.8432
51.83
11.18
10.3711740
Drain blood from under nail

T
0009
0.7744
47.60

9.5211750
Removal of nail bed

T
0019
4.0919
251.52
71.87
50.3011752
Remove nail bed/finger tip

T
0022
20.0656
1,233.39
354.45
246.6811755
Biopsy, nail unit

T
0019
4.0919
251.52
71.87
50.3011760
Repair of nail bed

T
0024
1.4843
91.24
29.88
18.2511762
Reconstruction of nail bed

T
0024
1.4843
91.24
29.88
18.2511765
Excision of nail fold, toe

T
0015
1.6241
99.83
20.13
19.9711770
Removal of pilonidal lesion

T
0022
20.0656
1,233.39
354.45
246.6811771
Removal of pilonidal lesion

T
0022
20.0656
1,233.39
354.45
246.6811772
Removal of pilonidal lesion

T
0022
20.0656
1,233.39
354.45
246.6811900
Injection into skin lesions

T
0012
0.8432
51.83
11.18
10.3711901
Added skin lesions injection

T
0012
0.8432
51.83
11.18
10.3711920
Correct skin color defects

T
0024
1.4843
91.24
29.88
18.2511921
Correct skin color defects

T
0024
1.4843
91.24
29.88
18.2511922
Correct skin color defects

T
0024
1.4843
91.24
29.88
18.2511950
Therapy for contour defects

T
0024
1.4843
91.24
29.88
18.2511951
Therapy for contour defects

T
0024
1.4843
91.24
29.88
18.2511952
Therapy for contour defects

T
0024
1.4843
91.24
29.88
18.2511954
Therapy for contour defects

T
0024
1.4843
91.24
29.88
18.2511960
Insert tissue expander(s)

T
0027
21.4302
1,317.27
329.72
263.4511970
Replace tissue expander
CH
T
0051
41.0893
2,525.68

505.1411971
Remove tissue expander(s)

T
0022
20.0656
1,233.39
354.45
246.6811976
Removal of contraceptive cap

T
0019
4.0919
251.52
71.87
50.3011980
Implant hormone pellet(s)

X
0340
0.6102
37.51

7.5011981
Insert drug implant device

X
0340
0.6102
37.51

7.5011982
Remove drug implant device

X
0340
0.6102
37.51

7.5011983
Remove/insert drug implant

X
0340
0.6102
37.51

7.5012001
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512002
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512004
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512005
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512006
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512007
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512011
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512013
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512014
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512015
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512016
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512017
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512018
Repair superficial wound(s)

T
0024
1.4843
91.24
29.88
18.2512020
Closure of split wound

T
0024
1.4843
91.24
29.88
18.2512021
Closure of split wound

T
0024
1.4843
91.24
29.88
18.2512031
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512032
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512034
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512035
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512036
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512037
Layer closure of wound(s)

T
0025
5.2594
323.28
101.85
64.6612041
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512042
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512044
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512045
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512046
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512047
Layer closure of wound(s)

T
0025
5.2594
323.28
101.85
64.66( print page 68289)12051
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512052
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512053
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512054
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512055
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512056
Layer closure of wound(s)

T
0024
1.4843
91.24
29.88
18.2512057
Layer closure of wound(s)

T
0025
5.2594
323.28
101.85
64.6613100
Repair of wound or lesion

T
0025
5.2594
323.28
101.85
64.6613101
Repair of wound or lesion

T
0025
5.2594
323.28
101.85
64.6613102
Repair wound/lesion add-on

T
0024
1.4843
91.24
29.88
18.2513120
Repair of wound or lesion

T
0024
1.4843
91.24
29.88
18.2513121
Repair of wound or lesion

T
0024
1.4843
91.24
29.88
18.2513122
Repair wound/lesion add-on

T
0024
1.4843
91.24
29.88
18.2513131
Repair of wound or lesion

T
0024
1.4843
91.24
29.88
18.2513132
Repair of wound or lesion

T
0024
1.4843
91.24
29.88
18.2513133
Repair wound/lesion add-on

T
0024
1.4843
91.24
29.88
18.2513150
Repair of wound or lesion

T
0025
5.2594
323.28
101.85
64.6613151
Repair of wound or lesion
CH
T
0025
5.2594
323.28
101.85
64.6613152
Repair of wound or lesion

T
0025
5.2594
323.28
101.85
64.6613153
Repair wound/lesion add-on

T
0024
1.4843
91.24
29.88
18.2513160
Late closure of wound

T
0027
21.4302
1,317.27
329.72
263.4514000
Skin tissue rearrangement

T
0686
14.0346
862.68

172.5414001
Skin tissue rearrangement

T
0027
21.4302
1,317.27
329.72
263.4514020
Skin tissue rearrangement

T
0686
14.0346
862.68

172.5414021
Skin tissue rearrangement
CH
T
0686
14.0346
862.68

172.5414040
Skin tissue rearrangement

T
0686
14.0346
862.68

172.5414041
Skin tissue rearrangement
CH
T
0686
14.0346
862.68

172.5414060
Skin tissue rearrangement
CH
T
0686
14.0346
862.68

172.5414061
Skin tissue rearrangement

T
0686
14.0346
862.68

172.5414300
Skin tissue rearrangement

T
0027
21.4302
1,317.27
329.72
263.4514350
Skin tissue rearrangement

T
0027
21.4302
1,317.27
329.72
263.4515000
Wound prep, 1st 100 sq cm
CH
D15001
Wound prep, addl 100 sq cm
CH
D15002
Wnd prep, ch/inf, trk/arm/lg
NI
T
0025
5.2594
323.28
101.85
64.6615003
Wnd prep, ch/inf addl 100 cm
NI
T
0025
5.2594
323.28
101.85
64.6615004
Wnd prep ch/inf, f/n/hf/g
NI
T
0025
5.2594
323.28
101.85
64.6615005
Wnd prep, f/n/hf/g, addl cm
NI
T
0025
5.2594
323.28
101.85
64.6615040
Harvest cultured skin graft

T
0024
1.4843
91.24
29.88
18.2515050
Skin pinch graft

T
0025
5.2594
323.28
101.85
64.6615100
Skin splt grft, trnk/arm/leg

T
0027
21.4302
1,317.27
329.72
263.4515101
Skin splt grft t/a/l, add-on

T
0027
21.4302
1,317.27
329.72
263.4515110
Epidrm autogrft trnk/arm/leg

T
0027
21.4302
1,317.27
329.72
263.4515111
Epidrm autogrft t/a/l add-on

T
0027
21.4302
1,317.27
329.72
263.4515115
Epidrm a-grft face/nck/hf/g

T
0027
21.4302
1,317.27
329.72
263.4515116
Epidrm a-grft f/n/hf/g addl

T
0027
21.4302
1,317.27
329.72
263.4515120
Skn splt a-grft fac/nck/hf/g

T
0027
21.4302
1,317.27
329.72
263.4515121
Skn splt a-grft f/n/hf/g add

T
0027
21.4302
1,317.27
329.72
263.4515130
Derm autograft, trnk/arm/leg

T
0027
21.4302
1,317.27
329.72
263.4515131
Derm autograft t/a/l add-on

T
0027
21.4302
1,317.27
329.72
263.4515135
Derm autograft face/nck/hf/g

T
0027
21.4302
1,317.27
329.72
263.4515136
Derm autograft, f/n/hf/g add

T
0027
21.4302
1,317.27
329.72
263.4515150
Cult epiderm grft t/arm/leg

T
0027
21.4302
1,317.27
329.72
263.4515151
Cult epiderm grft t/a/l addl

T
0027
21.4302
1,317.27
329.72
263.4515152
Cult epiderm graft t/a/l +%

T
0027
21.4302
1,317.27
329.72
263.4515155
Cult epiderm graft, f/n/hf/g

T
0027
21.4302
1,317.27
329.72
263.4515156
Cult epidrm grft f/n/hfg add

T
0027
21.4302
1,317.27
329.72
263.4515157
Cult epiderm grft f/n/hfg +%

T
0027
21.4302
1,317.27
329.72
263.4515170
Acell graft trunk/arms/legs
CH
T
0025
5.2594
323.28
101.85
64.6615171
Acell graft t/arm/leg add-on
CH
T
0025
5.2594
323.28
101.85
64.6615175
Acellular graft, f/n/hf/g
CH
T
0025
5.2594
323.28
101.85
64.6615176
Acell graft, f/n/hf/g add-on
CH
T
0025
5.2594
323.28
101.85
64.6615200
Skin full graft, trunk
CH
T
0686
14.0346
862.68

172.5415201
Skin full graft trunk add-on

T
0025
5.2594
323.28
101.85
64.6615220
Skin full graft sclp/arm/leg
CH
T
0686
14.0346
862.68

172.5415221
Skin full graft add-on

T
0025
5.2594
323.28
101.85
64.6615240
Skin full grft face/genit/hf

T
0686
14.0346
862.68

172.5415241
Skin full graft add-on

T
0025
5.2594
323.28
101.85
64.6615260
Skin full graft een & lips

T
0686
14.0346
862.68

172.5415261
Skin full graft add-on

T
0025
5.2594
323.28
101.85
64.6615300
Apply skinallogrft, t/arm/lg
CH
T
0025
5.2594
323.28
101.85
64.66( print page 68290)15301
Apply sknallogrft t/a/l addl

T
0025
5.2594
323.28
101.85
64.6615320
Apply skin allogrft f/n/hf/g

T
0025
5.2594
323.28
101.85
64.6615321
Aply sknallogrft f/n/hfg add

T
0025
5.2594
323.28
101.85
64.6615330
Aply acell alogrft t/arm/leg

T
0025
5.2594
323.28
101.85
64.6615331
Aply acell grft t/a/l add-on

T
0025
5.2594
323.28
101.85
64.6615335
Apply acell graft, f/n/hf/g

T
0025
5.2594
323.28
101.85
64.6615336
Aply acell grft f/n/hf/g add

T
0025
5.2594
323.28
101.85
64.6615340
Apply cult skin substitute
CH
T
0025
5.2594
323.28
101.85
64.6615341
Apply cult skin sub add-on
CH
T
0025
5.2594
323.28
101.85
64.6615360
Apply cult derm sub, t/a/l
CH
T
0025
5.2594
323.28
101.85
64.6615361
Aply cult derm sub t/a/l add
CH
T
0025
5.2594
323.28
101.85
64.6615365
Apply cult derm sub f/n/hf/g
CH
T
0025
5.2594
323.28
101.85
64.6615366
Apply cult derm f/hf/g add
CH
T
0025
5.2594
323.28
101.85
64.6615400
Apply skin xenograft, t/a/l

T
0025
5.2594
323.28
101.85
64.6615401
Apply skn xenogrft t/a/l add

T
0025
5.2594
323.28
101.85
64.6615420
Apply skin xgraft, f/n/hf/g

T
0025
5.2594
323.28
101.85
64.6615421
Apply skn xgrft f/n/hf/g add

T
0025
5.2594
323.28
101.85
64.6615430
Apply acellular xenograft

T
0025
5.2594
323.28
101.85
64.6615431
Apply acellular xgraft add

T
0025
5.2594
323.28
101.85
64.6615570
Form skin pedicle flap

T
0027
21.4302
1,317.27
329.72
263.4515572
Form skin pedicle flap

T
0027
21.4302
1,317.27
329.72
263.4515574
Form skin pedicle flap

T
0027
21.4302
1,317.27
329.72
263.4515576
Form skin pedicle flap

T
0686
14.0346
862.68

172.5415600
Skin graft

T
0027
21.4302
1,317.27
329.72
263.4515610
Skin graft

T
0027
21.4302
1,317.27
329.72
263.4515620
Skin graft

T
0027
21.4302
1,317.27
329.72
263.4515630
Skin graft

T
0027
21.4302
1,317.27
329.72
263.4515650
Transfer skin pedicle flap

T
0027
21.4302
1,317.27
329.72
263.4515731
Forehead flap w/vasc pedicle
NI
T
0686
14.0346
862.68

172.5415732
Muscle-skin graft, head/neck

T
0027
21.4302
1,317.27
329.72
263.4515734
Muscle-skin graft, trunk

T
0027
21.4302
1,317.27
329.72
263.4515736
Muscle-skin graft, arm

T
0027
21.4302
1,317.27
329.72
263.4515738
Muscle-skin graft, leg

T
0027
21.4302
1,317.27
329.72
263.4515740
Island pedicle flap graft

T
0686
14.0346
862.68

172.5415750
Neurovascular pedicle graft

T
0027
21.4302
1,317.27
329.72
263.4515760
Composite skin graft

T
0027
21.4302
1,317.27
329.72
263.4515770
Derma-fat-fascia graft

T
0027
21.4302
1,317.27
329.72
263.4515775
Hair transplant punch grafts

T
0025
5.2594
323.28
101.85
64.6615776
Hair transplant punch grafts

T
0025
5.2594
323.28
101.85
64.6615780
Abrasion treatment of skin

T
0022
20.0656
1,233.39
354.45
246.6815781
Abrasion treatment of skin

T
0019
4.0919
251.52
71.87
50.3015782
Abrasion treatment of skin

T
0019
4.0919
251.52
71.87
50.3015783
Abrasion treatment of skin

T
0016
2.6749
164.42

32.8815786
Abrasion, lesion, single

T
0013
1.0918
67.11

13.4215787
Abrasion, lesions, add-on

T
0013
1.0918
67.11

13.4215788
Chemical peel, face, epiderm

T
0012
0.8432
51.83
11.18
10.3715789
Chemical peel, face, dermal

T
0015
1.6241
99.83
20.13
19.9715792
Chemical peel, nonfacial

T
0013
1.0918
67.11

13.4215793
Chemical peel, nonfacial

T
0012
0.8432
51.83
11.18
10.3715819
Plastic surgery, neck

T
0025
5.2594
323.28
101.85
64.6615820
Revision of lower eyelid

T
0027
21.4302
1,317.27
329.72
263.4515821
Revision of lower eyelid

T
0027
21.4302
1,317.27
329.72
263.4515822
Revision of upper eyelid

T
0027
21.4302
1,317.27
329.72
263.4515823
Revision of upper eyelid
CH
T
0686
14.0346
862.68

172.5415824
Removal of forehead wrinkles

T
0027
21.4302
1,317.27
329.72
263.4515825
Removal of neck wrinkles

T
0027
21.4302
1,317.27
329.72
263.4515826
Removal of brow wrinkles

T
0027
21.4302
1,317.27
329.72
263.4515828
Removal of face wrinkles

T
0027
21.4302
1,317.27
329.72
263.4515829
Removal of skin wrinkles

T
0027
21.4302
1,317.27
329.72
263.4515830
Exc skin abd
NI
T
0022
20.0656
1,233.39
354.45
246.6815831
Excise excessive skin tissue
CH
D15832
Excise excessive skin tissue

T
0022
20.0656
1,233.39
354.45
246.6815833
Excise excessive skin tissue

T
0022
20.0656
1,233.39
354.45
246.6815834
Excise excessive skin tissue

T
0022
20.0656
1,233.39
354.45
246.6815835
Excise excessive skin tissue

T
0025
5.2594
323.28
101.85
64.6615836
Excise excessive skin tissue

T
0021
15.1024
928.31
219.48
185.6615837
Excise excessive skin tissue

T
0021
15.1024
928.31
219.48
185.6615838
Excise excessive skin tissue

T
0021
15.1024
928.31
219.48
185.6615839
Excise excessive skin tissue

T
0021
15.1024
928.31
219.48
185.6615840
Graft for face nerve palsy

T
0027
21.4302
1,317.27
329.72
263.45( print page 68291)15841
Graft for face nerve palsy

T
0027
21.4302
1,317.27
329.72
263.4515842
Flap for face nerve palsy

T
0686
14.0346
862.68

172.5415845
Skin and muscle repair, face

T
0027
21.4302
1,317.27
329.72
263.4515847
Exc skin abd add-on
NI
T
0022
20.0656
1,233.39
354.45
246.6815850
Removal of sutures

T
0016
2.6749
164.42

32.8815851
Removal of sutures

T
0016
2.6749
164.42

32.8815852
Dressing change not for burn

X
0340
0.6102
37.51

7.5015860
Test for blood flow in graft
CH
X
0340
0.6102
37.51

7.5015876
Suction assisted lipectomy

T
0027
21.4302
1,317.27
329.72
263.4515877
Suction assisted lipectomy

T
0027
21.4302
1,317.27
329.72
263.4515878
Suction assisted lipectomy

T
0686
14.0346
862.68

172.5415879
Suction assisted lipectomy

T
0027
21.4302
1,317.27
329.72
263.4515920
Removal of tail bone ulcer

T
0019
4.0919
251.52
71.87
50.3015922
Removal of tail bone ulcer

T
0027
21.4302
1,317.27
329.72
263.4515931
Remove sacrum pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815933
Remove sacrum pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815934
Remove sacrum pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515935
Remove sacrum pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515936
Remove sacrum pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515937
Remove sacrum pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515940
Remove hip pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815941
Remove hip pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815944
Remove hip pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515945
Remove hip pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515946
Remove hip pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515950
Remove thigh pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815951
Remove thigh pressure sore

T
0022
20.0656
1,233.39
354.45
246.6815952
Remove thigh pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515953
Remove thigh pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515956
Remove thigh pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515958
Remove thigh pressure sore

T
0027
21.4302
1,317.27
329.72
263.4515999
Removal of pressure sore

T
0019
4.0919
251.52
71.87
50.3016000
Initial treatment of burn(s)

T
0012
0.8432
51.83
11.18
10.3716020
Dress/debrid p-thick burn, s

T
0013
1.0918
67.11

13.4216025
Dress/debrid p-thick burn, m

T
0013
1.0918
67.11

13.4216030
Dress/debrid p-thick burn, l

T
0015
1.6241
99.83
20.13
19.9716035
Incision of burn scab, initi
CH
T
0016
2.6749
164.42

32.8817000
Destruct premalg lesion

T
0010
0.476
29.26
8.02
5.8517003
Destruct premalg les, 2-14

T
0010
0.476
29.26
8.02
5.8517004
Destroy premlg lesions 15+

T
0011
2.5665
157.76

31.5517106
Destruction of skin lesions

T
0011
2.5665
157.76

31.5517107
Destruction of skin lesions

T
0011
2.5665
157.76

31.5517108
Destruction of skin lesions

T
0011
2.5665
157.76

31.5517110
Destruct b9 lesion, 1-14
CH
T
0012
0.8432
51.83
11.18
10.3717111
Destruct lesion, 15 or more

T
0013
1.0918
67.11

13.4217250
Chemical cautery, tissue

T
0013
1.0918
67.11

13.4217260
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717261
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717262
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717263
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717264
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717266
Destruction of skin lesions

T
0016
2.6749
164.42

32.8817270
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717271
Destruction of skin lesions

T
0013
1.0918
67.11

13.4217272
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717273
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717274
Destruction of skin lesions

T
0016
2.6749
164.42

32.8817276
Destruction of skin lesions

T
0016
2.6749
164.42

32.8817280
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717281
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717282
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717283
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717284
Destruction of skin lesions

T
0016
2.6749
164.42

32.8817286
Destruction of skin lesions

T
0015
1.6241
99.83
20.13
19.9717304
1 stage mohs, up to 5 spec
CH
D17305
2 stage mohs, up to 5 spec
CH
D17306
3 stage mohs, up to 5 spec
CH
D17307
Mohs addl stage up to 5 spec
CH
D17310
Mohs any stage > 5 spec each
CH
D17311
Mohs, 1 stage, h/n/hf/g
NI
T
0694
3.7292
229.23
91.69
45.85( print page 68292)17312
Mohs addl stage
NI
T
0694
3.7292
229.23
91.69
45.8517313
Mohs, 1 stage, t/a/l
NI
T
0694
3.7292
229.23
91.69
45.8517314
Mohs, addl stage, t/a/l
NI
T
0694
3.7292
229.23
91.69
45.8517315
Mohs surg, addl block
NI
T
0694
3.7292
229.23
91.69
45.8517340
Cryotherapy of skin
CH
T
0016
2.6749
164.42

32.8817360
Skin peel therapy

T
0013
1.0918
67.11

13.4217380
Hair removal by electrolysis

T
0013
1.0918
67.11

13.4217999
Skin tissue procedure
CH
T
0012
0.8432
51.83
11.18
10.3719000
Drainage of breast lesion

T
0004
2.0687
127.16

25.4319001
Drain breast lesion add-on
CH
T
0002
1.0995
67.58

13.5219020
Incision of breast lesion

T
0008
17.5086
1,076.22

215.2419030
Injection for breast x-ray

N19100
Bx breast percut w/o image

T
0005
3.9045
240.00
71.59
48.0019101
Biopsy of breast, open

T
0028
19.2788
1,185.03
303.74
237.0119102
Bx breast percut w/image

T
0005
3.9045
240.00
71.59
48.0019103
Bx breast percut w/device

T
0658
6.4387
395.77

79.1519105
Cryosurg ablate fa, each
NI
T
0029
28.0166
1,722.12
581.52
344.4219110
Nipple exploration

T
0028
19.2788
1,185.03
303.74
237.0119112
Excise breast duct fistula

T
0028
19.2788
1,185.03
303.74
237.0119120
Removal of breast lesion

T
0028
19.2788
1,185.03
303.74
237.0119125
Excision, breast lesion

T
0028
19.2788
1,185.03
303.74
237.0119126
Excision, addl breast lesion

T
0028
19.2788
1,185.03
303.74
237.0119140
Removal of breast tissue
CH
D19160
Partial mastectomy
CH
D19162
P-mastectomy w/ln removal
CH
D19180
Removal of breast
CH
D19182
Removal of breast
CH
D19200
Removal of breast
CH
D19220
Removal of breast
CH
D19240
Removal of breast
CH
D19260
Removal of chest wall lesion

T
0021
15.1024
928.31
219.48
185.6619290
Place needle wire, breast

N19291
Place needle wire, breast

N19295
Place breast clip, percut

S
0657
1.7369
106.76

21.3519296
Place po breast cath for rad
CH
T
0648
51.2269
3,148.82

629.7619297
Place breast cath for rad
CH
T
0648
51.2269
3,148.82

629.7619298
Place breast rad tube/caths

S
1524

3,250.00

650.0019300
Removal of breast tissue
NI
T
0028
19.2788
1,185.03
303.74
237.0119301
Partical mastectomy
NI
T
0028
19.2788
1,185.03
303.74
237.0119302
P-mastectomy w/ln removal
NI
T
0693
36.9988
2,274.24
721.30
454.8519303
Mast, simple, complete
NI
T
0029
28.0166
1,722.12
581.52
344.4219304
Mast, subq
NI
T
0029
28.0166
1,722.12
581.52
344.4219305
Mast, radical
NI
C19306
Mast, rad, urban type
NI
C19307
Mast, mod rad
NI
T
0030
37.8692
2,327.74
747.07
465.5519316
Suspension of breast

T
0029
28.0166
1,722.12
581.52
344.4219318
Reduction of large breast

T
0693
36.9988
2,274.24
721.30
454.8519324
Enlarge breast

T
0693
36.9988
2,274.24
721.30
454.8519325
Enlarge breast with implant

T
0648
51.2269
3,148.82

629.7619328
Removal of breast implant

T
0029
28.0166
1,722.12
581.52
344.4219330
Removal of implant material

T
0029
28.0166
1,722.12
581.52
344.4219340
Immediate breast prosthesis

T
0030
37.8692
2,327.74
747.07
465.5519342
Delayed breast prosthesis

T
0648
51.2269
3,148.82

629.7619350
Breast reconstruction

T
0028
19.2788
1,185.03
303.74
237.0119355
Correct inverted nipple(s)

T
0029
28.0166
1,722.12
581.52
344.4219357
Breast reconstruction

T
0648
51.2269
3,148.82

629.7619366
Breast reconstruction

T
0029
28.0166
1,722.12
581.52
344.4219370
Surgery of breast capsule

T
0029
28.0166
1,722.12
581.52
344.4219371
Removal of breast capsule

T
0029
28.0166
1,722.12
581.52
344.4219380
Revise breast reconstruction

T
0030
37.8692
2,327.74
747.07
465.5519396
Design custom breast implant

T
0029
28.0166
1,722.12
581.52
344.4219499
Breast surgery procedure

T
0028
19.2788
1,185.03
303.74
237.0120000
Incision of abscess

T
0006
1.4392
88.46

17.6920005
Incision of deep abscess

T
0049
20.8706
1,282.87

256.5720100
Explore wound, neck

T
0023
4.2212
259.47

51.8920101
Explore wound, chest

T
0027
21.4302
1,317.27
329.72
263.4520102
Explore wound, abdomen

T
0027
21.4302
1,317.27
329.72
263.4520103
Explore wound, extremity

T
0023
4.2212
259.47

51.8920150
Excise epiphyseal bar

T
0051
41.0893
2,525.68

505.1420200
Muscle biopsy

T
0021
15.1024
928.31
219.48
185.66( print page 68293)20205
Deep muscle biopsy

T
0021
15.1024
928.31
219.48
185.6620206
Needle biopsy, muscle

T
0005
3.9045
240.00
71.59
48.0020220
Bone biopsy, trocar/needle

T
0019
4.0919
251.52
71.87
50.3020225
Bone biopsy, trocar/needle

T
0020
6.8083
418.49
107.67
83.7020240
Bone biopsy, excisional

T
0022
20.0656
1,233.39
354.45
246.6820245
Bone biopsy, excisional

T
0022
20.0656
1,233.39
354.45
246.6820250
Open bone biopsy

T
0049
20.8706
1,282.87

256.5720251
Open bone biopsy

T
0049
20.8706
1,282.87

256.5720500
Injection of sinus tract

T
0251
2.452
150.72

30.1420501
Inject sinus tract for x-ray

N20520
Removal of foreign body

T
0019
4.0919
251.52
71.87
50.3020525
Removal of foreign body

T
0022
20.0656
1,233.39
354.45
246.6820526
Ther injection, carp tunnel

T
0204
2.2614
139.00
40.13
27.8020550
Inj tendon sheath/ligament

T
0204
2.2614
139.00
40.13
27.8020551
Inj tendon origin/insertion

T
0204
2.2614
139.00
40.13
27.8020552
Inj trigger point, 1/2 muscl

T
0204
2.2614
139.00
40.13
27.8020553
Inject trigger points, ≧ 3

T
0204
2.2614
139.00
40.13
27.8020600
Drain/inject, joint/bursa

T
0204
2.2614
139.00
40.13
27.8020605
Drain/inject, joint/bursa

T
0204
2.2614
139.00
40.13
27.8020610
Drain/inject, joint/bursa

T
0204
2.2614
139.00
40.13
27.8020612
Aspirate/inj ganglion cyst

T
0204
2.2614
139.00
40.13
27.8020615
Treatment of bone cyst

T
0004
2.0687
127.16

25.4320650
Insert and remove bone pin

T
0049
20.8706
1,282.87

256.5720662
Application of pelvis brace

T
0049
20.8706
1,282.87

256.5720663
Application of thigh brace

T
0049
20.8706
1,282.87

256.5720665
Removal of fixation device

X
0340
0.6102
37.51

7.5020670
Removal of support implant

T
0021
15.1024
928.31
219.48
185.6620680
Removal of support implant

T
0022
20.0656
1,233.39
354.45
246.6820690
Apply bone fixation device

T
0050
25.1296
1,544.67

308.9320692
Apply bone fixation device

T
0050
25.1296
1,544.67

308.9320693
Adjust bone fixation device

T
0049
20.8706
1,282.87

256.5720694
Remove bone fixation device

T
0049
20.8706
1,282.87

256.5720822
Replantation digit, complete

T
0054
25.8758
1,590.53

318.1120900
Removal of bone for graft

T
0050
25.1296
1,544.67

308.9320902
Removal of bone for graft

T
0050
25.1296
1,544.67

308.9320910
Remove cartilage for graft

T
0027
21.4302
1,317.27
329.72
263.4520912
Remove cartilage for graft

T
0027
21.4302
1,317.27
329.72
263.4520920
Removal of fascia for graft

T
0686
14.0346
862.68

172.5420922
Removal of fascia for graft

T
0027
21.4302
1,317.27
329.72
263.4520924
Removal of tendon for graft

T
0050
25.1296
1,544.67

308.9320926
Removal of tissue for graft

T
0686
14.0346
862.68

172.5420950
Fluid pressure, muscle

T
0006
1.4392
88.46

17.6920972
Bone/skin graft, metatarsal

T
0056
40.8559
2,511.33

502.2720973
Bone/skin graft, great toe

T
0056
40.8559
2,511.33

502.2720975
Electrical bone stimulation

X
0340
0.6102
37.51

7.5020979
Us bone stimulation

X
0340
0.6102
37.51

7.5020982
Ablate, bone tumor(s) perq
CH
T
0051
41.0893
2,525.68

505.1420999
Musculoskeletal surgery

T
0049
20.8706
1,282.87

256.5721010
Incision of jaw joint

T
0254
23.3299
1,434.04
321.35
286.8121015
Resection of facial tumor

T
0253
16.4266
1,009.71
282.29
201.9421025
Excision of bone, lower jaw

T
0256
38.1991
2,348.02

469.6021026
Excision of facial bone(s)

T
0256
38.1991
2,348.02

469.6021029
Contour of face bone lesion

T
0256
38.1991
2,348.02

469.6021030
Excise max/zygoma b9 tumor

T
0254
23.3299
1,434.04
321.35
286.8121031
Remove exostosis, mandible

T
0254
23.3299
1,434.04
321.35
286.8121032
Remove exostosis, maxilla

T
0254
23.3299
1,434.04
321.35
286.8121034
Excise max/zygoma mlg tumor

T
0256
38.1991
2,348.02

469.6021040
Excise mandible lesion

T
0254
23.3299
1,434.04
321.35
286.8121044
Removal of jaw bone lesion

T
0256
38.1991
2,348.02

469.6021046
Remove mandible cyst complex

T
0256
38.1991
2,348.02

469.6021047
Excise lwr jaw cyst w/repair

T
0256
38.1991
2,348.02

469.6021048
Remove maxilla cyst complex

T
0256
38.1991
2,348.02

469.6021049
Excis uppr jaw cyst w/repair

T
0256
38.1991
2,348.02

469.6021050
Removal of jaw joint

T
0256
38.1991
2,348.02

469.6021060
Remove jaw joint cartilage

T
0256
38.1991
2,348.02

469.6021070
Remove coronoid process

T
0256
38.1991
2,348.02

469.6021076
Prepare face/oral prosthesis

T
0254
23.3299
1,434.04
321.35
286.8121077
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021079
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021080
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.60( print page 68294)21081
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021082
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021083
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021084
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021085
Prepare face/oral prosthesis

T
0253
16.4266
1,009.71
282.29
201.9421086
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021087
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021088
Prepare face/oral prosthesis

T
0256
38.1991
2,348.02

469.6021089
Prepare face/oral prosthesis

T
0251
2.452
150.72

30.1421100
Maxillofacial fixation

T
0256
38.1991
2,348.02

469.6021110
Interdental fixation

T
0252
7.5511
464.15
109.16
92.8321116
Injection, jaw joint x-ray

N21120
Reconstruction of chin

T
0254
23.3299
1,434.04
321.35
286.8121121
Reconstruction of chin

T
0254
23.3299
1,434.04
321.35
286.8121122
Reconstruction of chin

T
0254
23.3299
1,434.04
321.35
286.8121123
Reconstruction of chin

T
0254
23.3299
1,434.04
321.35
286.8121125
Augmentation, lower jaw bone

T
0254
23.3299
1,434.04
321.35
286.8121127
Augmentation, lower jaw bone

T
0256
38.1991
2,348.02

469.6021137
Reduction of forehead

T
0254
23.3299
1,434.04
321.35
286.8121138
Reduction of forehead

T
0256
38.1991
2,348.02

469.6021139
Reduction of forehead

T
0256
38.1991
2,348.02

469.6021150
Reconstruct midface, lefort

T
0256
38.1991
2,348.02

469.6021175
Reconstruct orbit/forehead

T
0256
38.1991
2,348.02

469.6021181
Contour cranial bone lesion

T
0254
23.3299
1,434.04
321.35
286.8121195
Reconst lwr jaw w/o fixation

T
0256
38.1991
2,348.02

469.6021198
Reconstr lwr jaw segment

T
0256
38.1991
2,348.02

469.6021199
Reconstr lwr jaw w/advance

T
0256
38.1991
2,348.02

469.6021206
Reconstruct upper jaw bone

T
0256
38.1991
2,348.02

469.6021208
Augmentation of facial bones

T
0256
38.1991
2,348.02

469.6021209
Reduction of facial bones

T
0256
38.1991
2,348.02

469.6021210
Face bone graft

T
0256
38.1991
2,348.02

469.6021215
Lower jaw bone graft

T
0256
38.1991
2,348.02

469.6021230
Rib cartilage graft

T
0256
38.1991
2,348.02

469.6021235
Ear cartilage graft

T
0254
23.3299
1,434.04
321.35
286.8121240
Reconstruction of jaw joint

T
0256
38.1991
2,348.02

469.6021242
Reconstruction of jaw joint

T
0256
38.1991
2,348.02

469.6021243
Reconstruction of jaw joint

T
0256
38.1991
2,348.02

469.6021244
Reconstruction of lower jaw

T
0256
38.1991
2,348.02

469.6021245
Reconstruction of jaw

T
0256
38.1991
2,348.02

469.6021246
Reconstruction of jaw

T
0256
38.1991
2,348.02

469.6021248
Reconstruction of jaw

T
0256
38.1991
2,348.02

469.6021249
Reconstruction of jaw

T
0256
38.1991
2,348.02

469.6021260
Revise eye sockets

T
0256
38.1991
2,348.02

469.6021261
Revise eye sockets

T
0256
38.1991
2,348.02

469.6021263
Revise eye sockets

T
0256
38.1991
2,348.02

469.6021267
Revise eye sockets

T
0256
38.1991
2,348.02

469.6021270
Augmentation, cheek bone

T
0256
38.1991
2,348.02

469.6021275
Revision, orbitofacial bones

T
0256
38.1991
2,348.02

469.6021280
Revision of eyelid

T
0256
38.1991
2,348.02

469.6021282
Revision of eyelid

T
0253
16.4266
1,009.71
282.29
201.9421295
Revision of jaw muscle/bone

T
0252
7.5511
464.15
109.16
92.8321296
Revision of jaw muscle/bone

T
0254
23.3299
1,434.04
321.35
286.8121299
Cranio/maxillofacial surgery

T
0251
2.452
150.72

30.1421300
Treatment of skull fracture
CH
D21310
Treatment of nose fracture

T
0251
2.452
150.72

30.1421315
Treatment of nose fracture

T
0251
2.452
150.72

30.1421320
Treatment of nose fracture

T
0252
7.5511
464.15
109.16
92.8321325
Treatment of nose fracture

T
0254
23.3299
1,434.04
321.35
286.8121330
Treatment of nose fracture

T
0254
23.3299
1,434.04
321.35
286.8121335
Treatment of nose fracture

T
0254
23.3299
1,434.04
321.35
286.8121336
Treat nasal septal fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4821337
Treat nasal septal fracture

T
0253
16.4266
1,009.71
282.29
201.9421338
Treat nasoethmoid fracture

T
0254
23.3299
1,434.04
321.35
286.8121339
Treat nasoethmoid fracture

T
0254
23.3299
1,434.04
321.35
286.8121340
Treatment of nose fracture

T
0256
38.1991
2,348.02

469.6021345
Treat nose/jaw fracture

T
0254
23.3299
1,434.04
321.35
286.8121355
Treat cheek bone fracture

T
0256
38.1991
2,348.02

469.6021356
Treat cheek bone fracture

T
0254
23.3299
1,434.04
321.35
286.8121390
Treat eye socket fracture

T
0256
38.1991
2,348.02

469.6021400
Treat eye socket fracture

T
0252
7.5511
464.15
109.16
92.83( print page 68295)21401
Treat eye socket fracture

T
0253
16.4266
1,009.71
282.29
201.9421406
Treat eye socket fracture

T
0256
38.1991
2,348.02

469.6021407
Treat eye socket fracture

T
0256
38.1991
2,348.02

469.6021408
Treat eye socket fracture

T
0256
38.1991
2,348.02

469.6021421
Treat mouth roof fracture

T
0254
23.3299
1,434.04
321.35
286.8121440
Treat dental ridge fracture

T
0254
23.3299
1,434.04
321.35
286.8121445
Treat dental ridge fracture

T
0254
23.3299
1,434.04
321.35
286.8121450
Treat lower jaw fracture

T
0251
2.452
150.72

30.1421451
Treat lower jaw fracture

T
0252
7.5511
464.15
109.16
92.8321452
Treat lower jaw fracture

T
0253
16.4266
1,009.71
282.29
201.9421453
Treat lower jaw fracture

T
0256
38.1991
2,348.02

469.6021454
Treat lower jaw fracture

T
0254
23.3299
1,434.04
321.35
286.8121461
Treat lower jaw fracture

T
0256
38.1991
2,348.02

469.6021462
Treat lower jaw fracture

T
0256
38.1991
2,348.02

469.6021465
Treat lower jaw fracture

T
0256
38.1991
2,348.02

469.6021470
Treat lower jaw fracture

T
0256
38.1991
2,348.02

469.6021480
Reset dislocated jaw

T
0251
2.452
150.72

30.1421485
Reset dislocated jaw

T
0253
16.4266
1,009.71
282.29
201.9421490
Repair dislocated jaw

T
0256
38.1991
2,348.02

469.6021495
Treat hyoid bone fracture

T
0253
16.4266
1,009.71
282.29
201.9421497
Interdental wiring

T
0253
16.4266
1,009.71
282.29
201.9421499
Head surgery procedure

T
0251
2.452
150.72

30.1421501
Drain neck/chest lesion

T
0008
17.5086
1,076.22

215.2421502
Drain chest lesion

T
0049
20.8706
1,282.87

256.5721550
Biopsy of neck/chest
CH
T
0020
6.8083
418.49
107.67
83.7021555
Remove lesion, neck/chest

T
0022
20.0656
1,233.39
354.45
246.6821556
Remove lesion, neck/chest

T
0022
20.0656
1,233.39
354.45
246.6821557
Remove tumor, neck/chest

T
0022
20.0656
1,233.39
354.45
246.6821600
Partial removal of rib

T
0050
25.1296
1,544.67

308.9321610
Partial removal of rib

T
0050
25.1296
1,544.67

308.9321685
Hyoid myotomy & suspension

T
0252
7.5511
464.15
109.16
92.8321700
Revision of neck muscle

T
0049
20.8706
1,282.87

256.5721720
Revision of neck muscle

T
0049
20.8706
1,282.87

256.5721725
Revision of neck muscle

T
0006
1.4392
88.46

17.6921742
Repair stern/nuss w/o scope

T
0051
41.0893
2,525.68

505.1421743
Repair sternum/nuss w/scope

T
0051
41.0893
2,525.68

505.1421800
Treatment of rib fracture

T
0043
1.6857
103.62

20.7221805
Treatment of rib fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8121820
Treat sternum fracture

T
0043
1.6857
103.62

20.7221899
Neck/chest surgery procedure

T
0251
2.452
150.72

30.1421920
Biopsy soft tissue of back

T
0020
6.8083
418.49
107.67
83.7021925
Biopsy soft tissue of back

T
0022
20.0656
1,233.39
354.45
246.6821930
Remove lesion, back or flank

T
0022
20.0656
1,233.39
354.45
246.6821935
Remove tumor, back

T
0022
20.0656
1,233.39
354.45
246.6822100
Remove part of neck vertebra

T
0208
44.1489
2,713.74

542.7522101
Remove part, thorax vertebra

T
0208
44.1489
2,713.74

542.7522102
Remove part, lumbar vertebra

T
0208
44.1489
2,713.74

542.7522103
Remove extra spine segment

T
0208
44.1489
2,713.74

542.7522222
Revision of thorax spine

T
0208
44.1489
2,713.74

542.7522305
Treat spine process fracture

T
0043
1.6857
103.62

20.7222310
Treat spine fracture

T
0043
1.6857
103.62

20.7222315
Treat spine fracture

T
0043
1.6857
103.62

20.7222505
Manipulation of spine

T
0045
14.5947
897.11
268.47
179.4222520
Percut vertebroplasty thor

T
0050
25.1296
1,544.67

308.9322521
Percut vertebroplasty lumb

T
0050
25.1296
1,544.67

308.9322522
Percut vertebroplasty addÆl

T
0050
25.1296
1,544.67

308.9322523
Percut kyphoplasty, thor

T
0052
66.58
4,092.54

818.5122524
Percut kyphoplasty, lumbar

T
0052
66.58
4,092.54

818.5122525
Percut kyphoplasty, add-on

T
0052
66.58
4,092.54

818.5122526
Idet, single level
NI
T
0050
25.1296
1,544.67

308.9322527
Idet, 1 or more levels
NI
T
0050
25.1296
1,544.67

308.9322612
Lumbar spine fusion

T
0208
44.1489
2,713.74

542.7522614
Spine fusion, extra segment

T
0208
44.1489
2,713.74

542.7522851
Apply spine prosth device
CH
T
0049
20.8706
1,282.87

256.5722857
Lumbar artif diskectomy
NI
C22862
Revise lumbar artif disc
NI
C22865
Remove lumb artif disc
NI
C22899
Spine surgery procedure
CH
T
0049
20.8706
1,282.87

256.5722900
Remove abdominal wall lesion

T
0022
20.0656
1,233.39
354.45
246.6822999
Abdomen surgery procedure
CH
T
0049
20.8706
1,282.87

256.57( print page 68296)23000
Removal of calcium deposits

T
0021
15.1024
928.31
219.48
185.6623020
Release shoulder joint

T
0051
41.0893
2,525.68

505.1423030
Drain shoulder lesion

T
0008
17.5086
1,076.22

215.2423031
Drain shoulder bursa

T
0008
17.5086
1,076.22

215.2423035
Drain shoulder bone lesion

T
0049
20.8706
1,282.87

256.5723040
Exploratory shoulder surgery

T
0050
25.1296
1,544.67

308.9323044
Exploratory shoulder surgery

T
0050
25.1296
1,544.67

308.9323065
Biopsy shoulder tissues
CH
T
0020
6.8083
418.49
107.67
83.7023066
Biopsy shoulder tissues

T
0022
20.0656
1,233.39
354.45
246.6823075
Removal of shoulder lesion

T
0021
15.1024
928.31
219.48
185.6623076
Removal of shoulder lesion

T
0022
20.0656
1,233.39
354.45
246.6823077
Remove tumor of shoulder

T
0022
20.0656
1,233.39
354.45
246.6823100
Biopsy of shoulder joint

T
0049
20.8706
1,282.87

256.5723101
Shoulder joint surgery

T
0050
25.1296
1,544.67

308.9323105
Remove shoulder joint lining

T
0050
25.1296
1,544.67

308.9323106
Incision of collarbone joint

T
0050
25.1296
1,544.67

308.9323107
Explore treat shoulder joint

T
0050
25.1296
1,544.67

308.9323120
Partial removal, collar bone

T
0051
41.0893
2,525.68

505.1423125
Removal of collar bone

T
0051
41.0893
2,525.68

505.1423130
Remove shoulder bone, part

T
0051
41.0893
2,525.68

505.1423140
Removal of bone lesion

T
0049
20.8706
1,282.87

256.5723145
Removal of bone lesion

T
0050
25.1296
1,544.67

308.9323146
Removal of bone lesion

T
0050
25.1296
1,544.67

308.9323150
Removal of humerus lesion

T
0050
25.1296
1,544.67

308.9323155
Removal of humerus lesion

T
0050
25.1296
1,544.67

308.9323156
Removal of humerus lesion

T
0050
25.1296
1,544.67

308.9323170
Remove collar bone lesion

T
0050
25.1296
1,544.67

308.9323172
Remove shoulder blade lesion

T
0050
25.1296
1,544.67

308.9323174
Remove humerus lesion

T
0050
25.1296
1,544.67

308.9323180
Remove collar bone lesion

T
0050
25.1296
1,544.67

308.9323182
Remove shoulder blade lesion

T
0050
25.1296
1,544.67

308.9323184
Remove humerus lesion

T
0050
25.1296
1,544.67

308.9323190
Partial removal of scapula

T
0050
25.1296
1,544.67

308.9323195
Removal of head of humerus

T
0050
25.1296
1,544.67

308.9323330
Remove shoulder foreign body

T
0020
6.8083
418.49
107.67
83.7023331
Remove shoulder foreign body

T
0022
20.0656
1,233.39
354.45
246.6823350
Injection for shoulder x-ray

N23395
Muscle transfer,shoulder/arm

T
0051
41.0893
2,525.68

505.1423397
Muscle transfers

T
0052
66.58
4,092.54

818.5123400
Fixation of shoulder blade

T
0050
25.1296
1,544.67

308.9323405
Incision of tendon & muscle

T
0050
25.1296
1,544.67

308.9323406
Incise tendon(s) & muscle(s)

T
0050
25.1296
1,544.67

308.9323410
Repair rotator cuff, acute
CH
T
0051
41.0893
2,525.68

505.1423412
Repair rotator cuff, chronic
CH
T
0051
41.0893
2,525.68

505.1423415
Release of shoulder ligament

T
0051
41.0893
2,525.68

505.1423420
Repair of shoulder
CH
T
0051
41.0893
2,525.68

505.1423430
Repair biceps tendon
CH
T
0051
41.0893
2,525.68

505.1423440
Remove/transplant tendon
CH
T
0051
41.0893
2,525.68

505.1423450
Repair shoulder capsule

T
0052
66.58
4,092.54

818.5123455
Repair shoulder capsule

T
0052
66.58
4,092.54

818.5123460
Repair shoulder capsule

T
0052
66.58
4,092.54

818.5123462
Repair shoulder capsule
CH
T
0051
41.0893
2,525.68

505.1423465
Repair shoulder capsule

T
0052
66.58
4,092.54

818.5123466
Repair shoulder capsule
CH
T
0051
41.0893
2,525.68

505.1423470
Reconstruct shoulder joint

T
0425
107.1942
6,589.01
1,378.01
1,317.8023480
Revision of collar bone

T
0051
41.0893
2,525.68

505.1423485
Revision of collar bone
CH
T
0052
66.58
4,092.54

818.5123490
Reinforce clavicle

T
0051
41.0893
2,525.68

505.1423491
Reinforce shoulder bones
CH
T
0052
66.58
4,092.54

818.5123500
Treat clavicle fracture

T
0043
1.6857
103.62

20.7223505
Treat clavicle fracture

T
0043
1.6857
103.62

20.7223515
Treat clavicle fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123520
Treat clavicle dislocation

T
0043
1.6857
103.62

20.7223525
Treat clavicle dislocation

T
0043
1.6857
103.62

20.7223530
Treat clavicle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4823532
Treat clavicle dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8123540
Treat clavicle dislocation

T
0043
1.6857
103.62

20.7223545
Treat clavicle dislocation

T
0043
1.6857
103.62

20.7223550
Treat clavicle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4823552
Treat clavicle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.48( print page 68297)23570
Treat shoulder blade fx

T
0043
1.6857
103.62

20.7223575
Treat shoulder blade fx

T
0043
1.6857
103.62

20.7223585
Treat scapula fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123600
Treat humerus fracture

T
0043
1.6857
103.62

20.7223605
Treat humerus fracture

T
0043
1.6857
103.62

20.7223615
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123616
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123620
Treat humerus fracture

T
0043
1.6857
103.62

20.7223625
Treat humerus fracture

T
0043
1.6857
103.62

20.7223630
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123650
Treat shoulder dislocation

T
0043
1.6857
103.62

20.7223655
Treat shoulder dislocation

T
0045
14.5947
897.11
268.47
179.4223660
Treat shoulder dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4823665
Treat dislocation/fracture

T
0043
1.6857
103.62

20.7223670
Treat dislocation/fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4123675
Treat dislocation/fracture

T
0043
1.6857
103.62

20.7223680
Treat dislocation/fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4823700
Fixation of shoulder

T
0045
14.5947
897.11
268.47
179.4223800
Fusion of shoulder joint
CH
T
0052
66.58
4,092.54

818.5123802
Fusion of shoulder joint

T
0051
41.0893
2,525.68

505.1423921
Amputation follow-up surgery

T
0025
5.2594
323.28
101.85
64.6623929
Shoulder surgery procedure

T
0043
1.6857
103.62

20.7223930
Drainage of arm lesion

T
0008
17.5086
1,076.22

215.2423931
Drainage of arm bursa

T
0008
17.5086
1,076.22

215.2423935
Drain arm/elbow bone lesion

T
0049
20.8706
1,282.87

256.5724000
Exploratory elbow surgery

T
0050
25.1296
1,544.67

308.9324006
Release elbow joint

T
0050
25.1296
1,544.67

308.9324065
Biopsy arm/elbow soft tissue

T
0021
15.1024
928.31
219.48
185.6624066
Biopsy arm/elbow soft tissue

T
0021
15.1024
928.31
219.48
185.6624075
Remove arm/elbow lesion

T
0021
15.1024
928.31
219.48
185.6624076
Remove arm/elbow lesion

T
0022
20.0656
1,233.39
354.45
246.6824077
Remove tumor of arm/elbow

T
0022
20.0656
1,233.39
354.45
246.6824100
Biopsy elbow joint lining

T
0049
20.8706
1,282.87

256.5724101
Explore/treat elbow joint

T
0050
25.1296
1,544.67

308.9324102
Remove elbow joint lining

T
0050
25.1296
1,544.67

308.9324105
Removal of elbow bursa

T
0049
20.8706
1,282.87

256.5724110
Remove humerus lesion

T
0049
20.8706
1,282.87

256.5724115
Remove/graft bone lesion

T
0050
25.1296
1,544.67

308.9324116
Remove/graft bone lesion

T
0050
25.1296
1,544.67

308.9324120
Remove elbow lesion

T
0049
20.8706
1,282.87

256.5724125
Remove/graft bone lesion

T
0050
25.1296
1,544.67

308.9324126
Remove/graft bone lesion

T
0050
25.1296
1,544.67

308.9324130
Removal of head of radius

T
0050
25.1296
1,544.67

308.9324134
Removal of arm bone lesion

T
0050
25.1296
1,544.67

308.9324136
Remove radius bone lesion

T
0050
25.1296
1,544.67

308.9324138
Remove elbow bone lesion

T
0050
25.1296
1,544.67

308.9324140
Partial removal of arm bone

T
0050
25.1296
1,544.67

308.9324145
Partial removal of radius

T
0050
25.1296
1,544.67

308.9324147
Partial removal of elbow

T
0050
25.1296
1,544.67

308.9324149
Radical resection of elbow

T
0050
25.1296
1,544.67

308.9324150
Extensive humerus surgery
CH
T
0051
41.0893
2,525.68

505.1424151
Extensive humerus surgery

T
0052
66.58
4,092.54

818.5124152
Extensive radius surgery
CH
T
0051
41.0893
2,525.68

505.1424153
Extensive radius surgery

T
0052
66.58
4,092.54

818.5124155
Removal of elbow joint

T
0051
41.0893
2,525.68

505.1424160
Remove elbow joint implant

T
0050
25.1296
1,544.67

308.9324164
Remove radius head implant

T
0050
25.1296
1,544.67

308.9324200
Removal of arm foreign body

T
0019
4.0919
251.52
71.87
50.3024201
Removal of arm foreign body

T
0021
15.1024
928.31
219.48
185.6624220
Injection for elbow x-ray

N24300
Manipulate elbow w/anesth

T
0045
14.5947
897.11
268.47
179.4224301
Muscle/tendon transfer

T
0050
25.1296
1,544.67

308.9324305
Arm tendon lengthening

T
0050
25.1296
1,544.67

308.9324310
Revision of arm tendon

T
0049
20.8706
1,282.87

256.5724320
Repair of arm tendon

T
0051
41.0893
2,525.68

505.1424330
Revision of arm muscles
CH
T
0052
66.58
4,092.54

818.5124331
Revision of arm muscles

T
0051
41.0893
2,525.68

505.1424332
Tenolysis, triceps

T
0049
20.8706
1,282.87

256.5724340
Repair of biceps tendon

T
0051
41.0893
2,525.68

505.1424341
Repair arm tendon/muscle

T
0051
41.0893
2,525.68

505.14( print page 68298)24342
Repair of ruptured tendon

T
0051
41.0893
2,525.68

505.1424343
Repr elbow lat ligmnt w/tiss

T
0050
25.1296
1,544.67

308.9324344
Reconstruct elbow lat ligmnt
CH
T
0052
66.58
4,092.54

818.5124345
Repr elbw med ligmnt w/tissu

T
0050
25.1296
1,544.67

308.9324346
Reconstruct elbow med ligmnt

T
0051
41.0893
2,525.68

505.1424350
Repair of tennis elbow

T
0050
25.1296
1,544.67

308.9324351
Repair of tennis elbow

T
0050
25.1296
1,544.67

308.9324352
Repair of tennis elbow

T
0050
25.1296
1,544.67

308.9324354
Repair of tennis elbow

T
0050
25.1296
1,544.67

308.9324356
Revision of tennis elbow

T
0050
25.1296
1,544.67

308.9324360
Reconstruct elbow joint

T
0047
33.4505
2,056.14
537.03
411.2324361
Reconstruct elbow joint

T
0425
107.1942
6,589.01
1,378.01
1,317.8024362
Reconstruct elbow joint

T
0048
47.4378
2,915.91

583.1824363
Replace elbow joint

T
0425
107.1942
6,589.01
1,378.01
1,317.8024365
Reconstruct head of radius

T
0047
33.4505
2,056.14
537.03
411.2324366
Reconstruct head of radius

T
0425
107.1942
6,589.01
1,378.01
1,317.8024400
Revision of humerus

T
0050
25.1296
1,544.67

308.9324410
Revision of humerus

T
0050
25.1296
1,544.67

308.9324420
Revision of humerus

T
0051
41.0893
2,525.68

505.1424430
Repair of humerus
CH
T
0052
66.58
4,092.54

818.5124435
Repair humerus with graft
CH
T
0052
66.58
4,092.54

818.5124470
Revision of elbow joint

T
0051
41.0893
2,525.68

505.1424495
Decompression of forearm

T
0050
25.1296
1,544.67

308.9324498
Reinforce humerus
CH
T
0052
66.58
4,092.54

818.5124500
Treat humerus fracture

T
0043
1.6857
103.62

20.7224505
Treat humerus fracture

T
0043
1.6857
103.62

20.7224515
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124516
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124530
Treat humerus fracture

T
0043
1.6857
103.62

20.7224535
Treat humerus fracture

T
0043
1.6857
103.62

20.7224538
Treat humerus fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8124545
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124546
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124560
Treat humerus fracture

T
0043
1.6857
103.62

20.7224565
Treat humerus fracture

T
0043
1.6857
103.62

20.7224566
Treat humerus fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8124575
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124576
Treat humerus fracture

T
0043
1.6857
103.62

20.7224577
Treat humerus fracture

T
0043
1.6857
103.62

20.7224579
Treat humerus fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124582
Treat humerus fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8124586
Treat elbow fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124587
Treat elbow fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124600
Treat elbow dislocation

T
0043
1.6857
103.62

20.7224605
Treat elbow dislocation

T
0045
14.5947
897.11
268.47
179.4224615
Treat elbow dislocation
CH
T
0064
57.2172
3,517.03
835.79
703.4124620
Treat elbow fracture

T
0043
1.6857
103.62

20.7224635
Treat elbow fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124640
Treat elbow dislocation

T
0043
1.6857
103.62

20.7224650
Treat radius fracture

T
0043
1.6857
103.62

20.7224655
Treat radius fracture

T
0043
1.6857
103.62

20.7224665
Treat radius fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4824666
Treat radius fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4124670
Treat ulnar fracture

T
0043
1.6857
103.62

20.7224675
Treat ulnar fracture

T
0043
1.6857
103.62

20.7224685
Treat ulnar fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4824800
Fusion of elbow joint

T
0051
41.0893
2,525.68

505.1424802
Fusion/graft of elbow joint

T
0051
41.0893
2,525.68

505.1424925
Amputation follow-up surgery

T
0049
20.8706
1,282.87

256.5724935
Revision of amputation

T
0052
66.58
4,092.54

818.5124999
Upper arm/elbow surgery

T
0043
1.6857
103.62

20.7225000
Incision of tendon sheath

T
0049
20.8706
1,282.87

256.5725001
Incise flexor carpi radialis

T
0049
20.8706
1,282.87

256.5725020
Decompress forearm 1 space

T
0049
20.8706
1,282.87

256.5725023
Decompress forearm 1 space

T
0050
25.1296
1,544.67

308.9325024
Decompress forearm 2 spaces

T
0050
25.1296
1,544.67

308.9325025
Decompress forearm 2 spaces

T
0050
25.1296
1,544.67

308.9325028
Drainage of forearm lesion

T
0049
20.8706
1,282.87

256.5725031
Drainage of forearm bursa

T
0049
20.8706
1,282.87

256.5725035
Treat forearm bone lesion

T
0049
20.8706
1,282.87

256.57( print page 68299)25040
Explore/treat wrist joint

T
0050
25.1296
1,544.67

308.9325065
Biopsy forearm soft tissues
CH
T
0020
6.8083
418.49
107.67
83.7025066
Biopsy forearm soft tissues

T
0022
20.0656
1,233.39
354.45
246.6825075
Removal forearm lesion subcu

T
0021
15.1024
928.31
219.48
185.6625076
Removal forearm lesion deep

T
0022
20.0656
1,233.39
354.45
246.6825077
Remove tumor, forearm/wrist

T
0022
20.0656
1,233.39
354.45
246.6825085
Incision of wrist capsule

T
0049
20.8706
1,282.87

256.5725100
Biopsy of wrist joint

T
0049
20.8706
1,282.87

256.5725101
Explore/treat wrist joint

T
0050
25.1296
1,544.67

308.9325105
Remove wrist joint lining

T
0050
25.1296
1,544.67

308.9325107
Remove wrist joint cartilage

T
0050
25.1296
1,544.67

308.9325109
Excise tendon forearm/wrist
NI
T
0049
20.8706
1,282.87

256.5725110
Remove wrist tendon lesion

T
0049
20.8706
1,282.87

256.5725111
Remove wrist tendon lesion

T
0053
16.154
992.95
253.49
198.5925112
Reremove wrist tendon lesion

T
0053
16.154
992.95
253.49
198.5925115
Remove wrist/forearm lesion

T
0049
20.8706
1,282.87

256.5725116
Remove wrist/forearm lesion

T
0049
20.8706
1,282.87

256.5725118
Excise wrist tendon sheath

T
0050
25.1296
1,544.67

308.9325119
Partial removal of ulna

T
0050
25.1296
1,544.67

308.9325120
Removal of forearm lesion

T
0050
25.1296
1,544.67

308.9325125
Remove/graft forearm lesion

T
0050
25.1296
1,544.67

308.9325126
Remove/graft forearm lesion

T
0050
25.1296
1,544.67

308.9325130
Removal of wrist lesion

T
0050
25.1296
1,544.67

308.9325135
Remove & graft wrist lesion

T
0050
25.1296
1,544.67

308.9325136
Remove & graft wrist lesion

T
0050
25.1296
1,544.67

308.9325145
Remove forearm bone lesion

T
0050
25.1296
1,544.67

308.9325150
Partial removal of ulna

T
0050
25.1296
1,544.67

308.9325151
Partial removal of radius

T
0050
25.1296
1,544.67

308.9325170
Extensive forearm surgery
CH
T
0051
41.0893
2,525.68

505.1425210
Removal of wrist bone

T
0054
25.8758
1,590.53

318.1125215
Removal of wrist bones

T
0054
25.8758
1,590.53

318.1125230
Partial removal of radius

T
0050
25.1296
1,544.67

308.9325240
Partial removal of ulna

T
0050
25.1296
1,544.67

308.9325246
Injection for wrist x-ray

N25248
Remove forearm foreign body

T
0049
20.8706
1,282.87

256.5725250
Removal of wrist prosthesis

T
0050
25.1296
1,544.67

308.9325251
Removal of wrist prosthesis

T
0050
25.1296
1,544.67

308.9325259
Manipulate wrist w/anesthes

T
0043
1.6857
103.62

20.7225260
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325263
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325265
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325270
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325272
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325274
Repair forearm tendon/muscle

T
0050
25.1296
1,544.67

308.9325275
Repair forearm tendon sheath

T
0050
25.1296
1,544.67

308.9325280
Revise wrist/forearm tendon

T
0050
25.1296
1,544.67

308.9325290
Incise wrist/forearm tendon

T
0050
25.1296
1,544.67

308.9325295
Release wrist/forearm tendon

T
0049
20.8706
1,282.87

256.5725300
Fusion of tendons at wrist

T
0050
25.1296
1,544.67

308.9325301
Fusion of tendons at wrist

T
0050
25.1296
1,544.67

308.9325310
Transplant forearm tendon

T
0051
41.0893
2,525.68

505.1425312
Transplant forearm tendon

T
0051
41.0893
2,525.68

505.1425315
Revise palsy hand tendon(s)

T
0051
41.0893
2,525.68

505.1425316
Revise palsy hand tendon(s)
CH
T
0052
66.58
4,092.54

818.5125320
Repair/revise wrist joint

T
0051
41.0893
2,525.68

505.1425332
Revise wrist joint

T
0047
33.4505
2,056.14
537.03
411.2325335
Realignment of hand

T
0051
41.0893
2,525.68

505.1425337
Reconstruct ulna/radioulnar

T
0051
41.0893
2,525.68

505.1425350
Revision of radius
CH
T
0052
66.58
4,092.54

818.5125355
Revision of radius

T
0051
41.0893
2,525.68

505.1425360
Revision of ulna

T
0050
25.1296
1,544.67

308.9325365
Revise radius & ulna

T
0050
25.1296
1,544.67

308.9325370
Revise radius or ulna

T
0051
41.0893
2,525.68

505.1425375
Revise radius & ulna

T
0051
41.0893
2,525.68

505.1425390
Shorten radius or ulna

T
0050
25.1296
1,544.67

308.9325391
Lengthen radius or ulna

T
0051
41.0893
2,525.68

505.1425392
Shorten radius & ulna

T
0050
25.1296
1,544.67

308.9325393
Lengthen radius & ulna

T
0051
41.0893
2,525.68

505.1425394
Repair carpal bone, shorten

T
0053
16.154
992.95
253.49
198.5925400
Repair radius or ulna

T
0050
25.1296
1,544.67

308.93( print page 68300)25405
Repair/graft radius or ulna

T
0050
25.1296
1,544.67

308.9325415
Repair radius & ulna

T
0050
25.1296
1,544.67

308.9325420
Repair/graft radius & ulna
CH
T
0052
66.58
4,092.54

818.5125425
Repair/graft radius or ulna

T
0051
41.0893
2,525.68

505.1425426
Repair/graft radius & ulna

T
0051
41.0893
2,525.68

505.1425430
Vasc graft into carpal bone

T
0054
25.8758
1,590.53

318.1125431
Repair nonunion carpal bone

T
0054
25.8758
1,590.53

318.1125440
Repair/graft wrist bone
CH
T
0052
66.58
4,092.54

818.5125441
Reconstruct wrist joint

T
0425
107.1942
6,589.01
1,378.01
1,317.8025442
Reconstruct wrist joint

T
0425
107.1942
6,589.01
1,378.01
1,317.8025443
Reconstruct wrist joint

T
0048
47.4378
2,915.91

583.1825444
Reconstruct wrist joint

T
0048
47.4378
2,915.91

583.1825445
Reconstruct wrist joint

T
0048
47.4378
2,915.91

583.1825446
Wrist replacement

T
0425
107.1942
6,589.01
1,378.01
1,317.8025447
Repair wrist joint(s)

T
0047
33.4505
2,056.14
537.03
411.2325449
Remove wrist joint implant

T
0047
33.4505
2,056.14
537.03
411.2325450
Revision of wrist joint

T
0051
41.0893
2,525.68

505.1425455
Revision of wrist joint

T
0051
41.0893
2,525.68

505.1425490
Reinforce radius

T
0051
41.0893
2,525.68

505.1425491
Reinforce ulna

T
0051
41.0893
2,525.68

505.1425492
Reinforce radius and ulna

T
0051
41.0893
2,525.68

505.1425500
Treat fracture of radius

T
0043
1.6857
103.62

20.7225505
Treat fracture of radius

T
0043
1.6857
103.62

20.7225515
Treat fracture of radius
CH
T
0063
37.5382
2,307.40
548.33
461.4825520
Treat fracture of radius

T
0043
1.6857
103.62

20.7225525
Treat fracture of radius
CH
T
0063
37.5382
2,307.40
548.33
461.4825526
Treat fracture of radius
CH
T
0063
37.5382
2,307.40
548.33
461.4825530
Treat fracture of ulna

T
0043
1.6857
103.62

20.7225535
Treat fracture of ulna

T
0043
1.6857
103.62

20.7225545
Treat fracture of ulna
CH
T
0063
37.5382
2,307.40
548.33
461.4825560
Treat fracture radius & ulna

T
0043
1.6857
103.62

20.7225565
Treat fracture radius & ulna

T
0043
1.6857
103.62

20.7225574
Treat fracture radius & ulna
CH
T
0064
57.2172
3,517.03
835.79
703.4125575
Treat fracture radius/ulna
CH
T
0064
57.2172
3,517.03
835.79
703.4125600
Treat fracture radius/ulna

T
0043
1.6857
103.62

20.7225605
Treat fracture radius/ulna

T
0043
1.6857
103.62

20.7225606
Treat fx distal radial
NI
T
0062
25.5264
1,569.06
372.87
313.8125607
Treat fx rad extra-articul
NI
T
0064
57.2172
3,517.03
835.79
703.4125608
Treat fx rad intra-articul
NI
T
0064
57.2172
3,517.03
835.79
703.4125609
Treat fx radial 3+ frag
NI
T
0064
57.2172
3,517.03
835.79
703.4125611
Treat fracture radius/ulna
CH
D25620
Treat fracture radius/ulna
CH
D25622
Treat wrist bone fracture

T
0043
1.6857
103.62

20.7225624
Treat wrist bone fracture

T
0043
1.6857
103.62

20.7225628
Treat wrist bone fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4825630
Treat wrist bone fracture

T
0043
1.6857
103.62

20.7225635
Treat wrist bone fracture

T
0043
1.6857
103.62

20.7225645
Treat wrist bone fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4825650
Treat wrist bone fracture

T
0043
1.6857
103.62

20.7225651
Pin ulnar styloid fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8125652
Treat fracture ulnar styloid
CH
T
0063
37.5382
2,307.40
548.33
461.4825660
Treat wrist dislocation

T
0043
1.6857
103.62

20.7225670
Treat wrist dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8125671
Pin radioulnar dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8125675
Treat wrist dislocation

T
0043
1.6857
103.62

20.7225676
Treat wrist dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8125680
Treat wrist fracture

T
0043
1.6857
103.62

20.7225685
Treat wrist fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8125690
Treat wrist dislocation

T
0043
1.6857
103.62

20.7225695
Treat wrist dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8125800
Fusion of wrist joint
CH
T
0052
66.58
4,092.54

818.5125805
Fusion/graft of wrist joint

T
0051
41.0893
2,525.68

505.1425810
Fusion/graft of wrist joint
CH
T
0052
66.58
4,092.54

818.5125820
Fusion of hand bones

T
0053
16.154
992.95
253.49
198.5925825
Fuse hand bones with graft

T
0054
25.8758
1,590.53

318.1125830
Fusion, radioulnar jnt/ulna
CH
T
0052
66.58
4,092.54

818.5125907
Amputation follow-up surgery

T
0049
20.8706
1,282.87

256.5725922
Amputate hand at wrist

T
0049
20.8706
1,282.87

256.5725929
Amputation follow-up surgery

T
0686
14.0346
862.68

172.5425999
Forearm or wrist surgery

T
0043
1.6857
103.62

20.72( print page 68301)26010
Drainage of finger abscess

T
0006
1.4392
88.46

17.6926011
Drainage of finger abscess

T
0007
11.1535
685.58

137.1226020
Drain hand tendon sheath

T
0053
16.154
992.95
253.49
198.5926025
Drainage of palm bursa

T
0053
16.154
992.95
253.49
198.5926030
Drainage of palm bursa(s)

T
0053
16.154
992.95
253.49
198.5926034
Treat hand bone lesion

T
0053
16.154
992.95
253.49
198.5926035
Decompress fingers/hand

T
0053
16.154
992.95
253.49
198.5926037
Decompress fingers/hand

T
0053
16.154
992.95
253.49
198.5926040
Release palm contracture

T
0054
25.8758
1,590.53

318.1126045
Release palm contracture

T
0054
25.8758
1,590.53

318.1126055
Incise finger tendon sheath

T
0053
16.154
992.95
253.49
198.5926060
Incision of finger tendon

T
0053
16.154
992.95
253.49
198.5926070
Explore/treat hand joint

T
0053
16.154
992.95
253.49
198.5926075
Explore/treat finger joint

T
0053
16.154
992.95
253.49
198.5926080
Explore/treat finger joint

T
0053
16.154
992.95
253.49
198.5926100
Biopsy hand joint lining

T
0053
16.154
992.95
253.49
198.5926105
Biopsy finger joint lining

T
0053
16.154
992.95
253.49
198.5926110
Biopsy finger joint lining

T
0053
16.154
992.95
253.49
198.5926115
Removal hand lesion subcut

T
0022
20.0656
1,233.39
354.45
246.6826116
Removal hand lesion, deep

T
0022
20.0656
1,233.39
354.45
246.6826117
Remove tumor, hand/finger

T
0022
20.0656
1,233.39
354.45
246.6826121
Release palm contracture

T
0054
25.8758
1,590.53

318.1126123
Release palm contracture

T
0054
25.8758
1,590.53

318.1126125
Release palm contracture

T
0053
16.154
992.95
253.49
198.5926130
Remove wrist joint lining

T
0053
16.154
992.95
253.49
198.5926135
Revise finger joint, each

T
0054
25.8758
1,590.53

318.1126140
Revise finger joint, each

T
0053
16.154
992.95
253.49
198.5926145
Tendon excision, palm/finger

T
0053
16.154
992.95
253.49
198.5926160
Remove tendon sheath lesion

T
0053
16.154
992.95
253.49
198.5926170
Removal of palm tendon, each

T
0053
16.154
992.95
253.49
198.5926180
Removal of finger tendon

T
0053
16.154
992.95
253.49
198.5926185
Remove finger bone

T
0053
16.154
992.95
253.49
198.5926200
Remove hand bone lesion

T
0053
16.154
992.95
253.49
198.5926205
Remove/graft bone lesion

T
0054
25.8758
1,590.53

318.1126210
Removal of finger lesion

T
0053
16.154
992.95
253.49
198.5926215
Remove/graft finger lesion

T
0053
16.154
992.95
253.49
198.5926230
Partial removal of hand bone

T
0053
16.154
992.95
253.49
198.5926235
Partial removal, finger bone

T
0053
16.154
992.95
253.49
198.5926236
Partial removal, finger bone

T
0053
16.154
992.95
253.49
198.5926250
Extensive hand surgery

T
0053
16.154
992.95
253.49
198.5926255
Extensive hand surgery

T
0054
25.8758
1,590.53

318.1126260
Extensive finger surgery

T
0053
16.154
992.95
253.49
198.5926261
Extensive finger surgery

T
0053
16.154
992.95
253.49
198.5926262
Partial removal of finger

T
0053
16.154
992.95
253.49
198.5926320
Removal of implant from hand

T
0021
15.1024
928.31
219.48
185.6626340
Manipulate finger w/anesth

T
0043
1.6857
103.62

20.7226350
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126352
Repair/graft hand tendon

T
0054
25.8758
1,590.53

318.1126356
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126357
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126358
Repair/graft hand tendon

T
0054
25.8758
1,590.53

318.1126370
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126372
Repair/graft hand tendon

T
0054
25.8758
1,590.53

318.1126373
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126390
Revise hand/finger tendon

T
0054
25.8758
1,590.53

318.1126392
Repair/graft hand tendon

T
0054
25.8758
1,590.53

318.1126410
Repair hand tendon

T
0053
16.154
992.95
253.49
198.5926412
Repair/graft hand tendon

T
0054
25.8758
1,590.53

318.1126415
Excision, hand/finger tendon

T
0054
25.8758
1,590.53

318.1126416
Graft hand or finger tendon

T
0054
25.8758
1,590.53

318.1126418
Repair finger tendon

T
0053
16.154
992.95
253.49
198.5926420
Repair/graft finger tendon

T
0054
25.8758
1,590.53

318.1126426
Repair finger/hand tendon

T
0054
25.8758
1,590.53

318.1126428
Repair/graft finger tendon

T
0054
25.8758
1,590.53

318.1126432
Repair finger tendon

T
0053
16.154
992.95
253.49
198.5926433
Repair finger tendon

T
0053
16.154
992.95
253.49
198.5926434
Repair/graft finger tendon

T
0054
25.8758
1,590.53

318.1126437
Realignment of tendons

T
0053
16.154
992.95
253.49
198.5926440
Release palm/finger tendon

T
0053
16.154
992.95
253.49
198.5926442
Release palm & finger tendon

T
0054
25.8758
1,590.53

318.11( print page 68302)26445
Release hand/finger tendon

T
0053
16.154
992.95
253.49
198.5926449
Release forearm/hand tendon

T
0054
25.8758
1,590.53

318.1126450
Incision of palm tendon

T
0053
16.154
992.95
253.49
198.5926455
Incision of finger tendon

T
0053
16.154
992.95
253.49
198.5926460
Incise hand/finger tendon

T
0053
16.154
992.95
253.49
198.5926471
Fusion of finger tendons

T
0053
16.154
992.95
253.49
198.5926474
Fusion of finger tendons

T
0053
16.154
992.95
253.49
198.5926476
Tendon lengthening

T
0053
16.154
992.95
253.49
198.5926477
Tendon shortening

T
0053
16.154
992.95
253.49
198.5926478
Lengthening of hand tendon

T
0053
16.154
992.95
253.49
198.5926479
Shortening of hand tendon

T
0053
16.154
992.95
253.49
198.5926480
Transplant hand tendon

T
0054
25.8758
1,590.53

318.1126483
Transplant/graft hand tendon

T
0054
25.8758
1,590.53

318.1126485
Transplant palm tendon

T
0054
25.8758
1,590.53

318.1126489
Transplant/graft palm tendon

T
0054
25.8758
1,590.53

318.1126490
Revise thumb tendon

T
0054
25.8758
1,590.53

318.1126492
Tendon transfer with graft

T
0054
25.8758
1,590.53

318.1126494
Hand tendon/muscle transfer

T
0054
25.8758
1,590.53

318.1126496
Revise thumb tendon

T
0054
25.8758
1,590.53

318.1126497
Finger tendon transfer

T
0054
25.8758
1,590.53

318.1126498
Finger tendon transfer

T
0054
25.8758
1,590.53

318.1126499
Revision of finger

T
0054
25.8758
1,590.53

318.1126500
Hand tendon reconstruction

T
0053
16.154
992.95
253.49
198.5926502
Hand tendon reconstruction

T
0054
25.8758
1,590.53

318.1126504
Hand tendon reconstruction
CH
D26508
Release thumb contracture

T
0053
16.154
992.95
253.49
198.5926510
Thumb tendon transfer

T
0054
25.8758
1,590.53

318.1126516
Fusion of knuckle joint

T
0054
25.8758
1,590.53

318.1126517
Fusion of knuckle joints

T
0054
25.8758
1,590.53

318.1126518
Fusion of knuckle joints

T
0054
25.8758
1,590.53

318.1126520
Release knuckle contracture

T
0053
16.154
992.95
253.49
198.5926525
Release finger contracture

T
0053
16.154
992.95
253.49
198.5926530
Revise knuckle joint

T
0047
33.4505
2,056.14
537.03
411.2326531
Revise knuckle with implant

T
0048
47.4378
2,915.91

583.1826535
Revise finger joint

T
0047
33.4505
2,056.14
537.03
411.2326536
Revise/implant finger joint

T
0048
47.4378
2,915.91

583.1826540
Repair hand joint

T
0053
16.154
992.95
253.49
198.5926541
Repair hand joint with graft

T
0054
25.8758
1,590.53

318.1126542
Repair hand joint with graft

T
0053
16.154
992.95
253.49
198.5926545
Reconstruct finger joint

T
0054
25.8758
1,590.53

318.1126546
Repair nonunion hand

T
0054
25.8758
1,590.53

318.1126548
Reconstruct finger joint

T
0054
25.8758
1,590.53

318.1126550
Construct thumb replacement

T
0054
25.8758
1,590.53

318.1126555
Positional change of finger

T
0054
25.8758
1,590.53

318.1126560
Repair of web finger

T
0053
16.154
992.95
253.49
198.5926561
Repair of web finger

T
0054
25.8758
1,590.53

318.1126562
Repair of web finger

T
0054
25.8758
1,590.53

318.1126565
Correct metacarpal flaw

T
0054
25.8758
1,590.53

318.1126567
Correct finger deformity

T
0054
25.8758
1,590.53

318.1126568
Lengthen metacarpal/finger

T
0054
25.8758
1,590.53

318.1126580
Repair hand deformity

T
0053
16.154
992.95
253.49
198.5926587
Reconstruct extra finger

T
0053
16.154
992.95
253.49
198.5926590
Repair finger deformity

T
0053
16.154
992.95
253.49
198.5926591
Repair muscles of hand

T
0054
25.8758
1,590.53

318.1126593
Release muscles of hand

T
0053
16.154
992.95
253.49
198.5926596
Excision constricting tissue

T
0053
16.154
992.95
253.49
198.5926600
Treat metacarpal fracture

T
0043
1.6857
103.62

20.7226605
Treat metacarpal fracture

T
0043
1.6857
103.62

20.7226607
Treat metacarpal fracture

T
0043
1.6857
103.62

20.7226608
Treat metacarpal fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8126615
Treat metacarpal fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4826641
Treat thumb dislocation

T
0043
1.6857
103.62

20.7226645
Treat thumb fracture

T
0043
1.6857
103.62

20.7226650
Treat thumb fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8126665
Treat thumb fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4826670
Treat hand dislocation

T
0043
1.6857
103.62

20.7226675
Treat hand dislocation

T
0043
1.6857
103.62

20.7226676
Pin hand dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8126685
Treat hand dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4826686
Treat hand dislocation
CH
T
0064
57.2172
3,517.03
835.79
703.41( print page 68303)26700
Treat knuckle dislocation

T
0043
1.6857
103.62

20.7226705
Treat knuckle dislocation

T
0043
1.6857
103.62

20.7226706
Pin knuckle dislocation

T
0043
1.6857
103.62

20.7226715
Treat knuckle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4826720
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226725
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226727
Treat finger fracture, each
CH
T
0062
25.5264
1,569.06
372.87
313.8126735
Treat finger fracture, each
CH
T
0063
37.5382
2,307.40
548.33
461.4826740
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226742
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226746
Treat finger fracture, each
CH
T
0063
37.5382
2,307.40
548.33
461.4826750
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226755
Treat finger fracture, each

T
0043
1.6857
103.62

20.7226756
Pin finger fracture, each
CH
T
0062
25.5264
1,569.06
372.87
313.8126765
Treat finger fracture, each
CH
T
0063
37.5382
2,307.40
548.33
461.4826770
Treat finger dislocation

T
0043
1.6857
103.62

20.7226775
Treat finger dislocation

T
0045
14.5947
897.11
268.47
179.4226776
Pin finger dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8126785
Treat finger dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8126820
Thumb fusion with graft

T
0054
25.8758
1,590.53

318.1126841
Fusion of thumb

T
0054
25.8758
1,590.53

318.1126842
Thumb fusion with graft

T
0054
25.8758
1,590.53

318.1126843
Fusion of hand joint

T
0054
25.8758
1,590.53

318.1126844
Fusion/graft of hand joint

T
0054
25.8758
1,590.53

318.1126850
Fusion of knuckle

T
0054
25.8758
1,590.53

318.1126852
Fusion of knuckle with graft

T
0054
25.8758
1,590.53

318.1126860
Fusion of finger joint

T
0054
25.8758
1,590.53

318.1126861
Fusion of finger jnt, add-on

T
0054
25.8758
1,590.53

318.1126862
Fusion/graft of finger joint

T
0054
25.8758
1,590.53

318.1126863
Fuse/graft added joint

T
0054
25.8758
1,590.53

318.1126910
Amputate metacarpal bone

T
0054
25.8758
1,590.53

318.1126951
Amputation of finger/thumb

T
0053
16.154
992.95
253.49
198.5926952
Amputation of finger/thumb

T
0053
16.154
992.95
253.49
198.5926989
Hand/finger surgery

T
0043
1.6857
103.62

20.7226990
Drainage of pelvis lesion

T
0049
20.8706
1,282.87

256.5726991
Drainage of pelvis bursa

T
0049
20.8706
1,282.87

256.5727000
Incision of hip tendon

T
0049
20.8706
1,282.87

256.5727001
Incision of hip tendon

T
0050
25.1296
1,544.67

308.9327003
Incision of hip tendon

T
0050
25.1296
1,544.67

308.9327033
Exploration of hip joint

T
0051
41.0893
2,525.68

505.1427035
Denervation of hip joint
CH
T
0051
41.0893
2,525.68

505.1427040
Biopsy of soft tissues

T
0020
6.8083
418.49
107.67
83.7027041
Biopsy of soft tissues

T
0020
6.8083
418.49
107.67
83.7027047
Remove hip/pelvis lesion

T
0022
20.0656
1,233.39
354.45
246.6827048
Remove hip/pelvis lesion

T
0022
20.0656
1,233.39
354.45
246.6827049
Remove tumor, hip/pelvis

T
0022
20.0656
1,233.39
354.45
246.6827050
Biopsy of sacroiliac joint

T
0049
20.8706
1,282.87

256.5727052
Biopsy of hip joint

T
0049
20.8706
1,282.87

256.5727060
Removal of ischial bursa

T
0049
20.8706
1,282.87

256.5727062
Remove femur lesion/bursa

T
0049
20.8706
1,282.87

256.5727065
Removal of hip bone lesion

T
0049
20.8706
1,282.87

256.5727066
Removal of hip bone lesion

T
0050
25.1296
1,544.67

308.9327067
Remove/graft hip bone lesion

T
0050
25.1296
1,544.67

308.9327080
Removal of tail bone

T
0050
25.1296
1,544.67

308.9327086
Remove hip foreign body

T
0020
6.8083
418.49
107.67
83.7027087
Remove hip foreign body

T
0049
20.8706
1,282.87

256.5727093
Injection for hip x-ray

N27095
Injection for hip x-ray

N27097
Revision of hip tendon

T
0050
25.1296
1,544.67

308.9327098
Transfer tendon to pelvis

T
0050
25.1296
1,544.67

308.9327100
Transfer of abdominal muscle

T
0051
41.0893
2,525.68

505.1427105
Transfer of spinal muscle

T
0051
41.0893
2,525.68

505.1427110
Transfer of iliopsoas muscle

T
0051
41.0893
2,525.68

505.1427111
Transfer of iliopsoas muscle

T
0051
41.0893
2,525.68

505.1427193
Treat pelvic ring fracture

T
0043
1.6857
103.62

20.7227194
Treat pelvic ring fracture

T
0045
14.5947
897.11
268.47
179.4227200
Treat tail bone fracture

T
0043
1.6857
103.62

20.7227202
Treat tail bone fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827216
Treat pelvic ring fracture

T
0050
25.1296
1,544.67

308.9327220
Treat hip socket fracture

T
0043
1.6857
103.62

20.72( print page 68304)27230
Treat thigh fracture

T
0043
1.6857
103.62

20.7227235
Treat thigh fracture

T
0050
25.1296
1,544.67

308.9327238
Treat thigh fracture

T
0043
1.6857
103.62

20.7227246
Treat thigh fracture

T
0043
1.6857
103.62

20.7227250
Treat hip dislocation

T
0043
1.6857
103.62

20.7227252
Treat hip dislocation

T
0045
14.5947
897.11
268.47
179.4227256
Treat hip dislocation

T
0043
1.6857
103.62

20.7227257
Treat hip dislocation

T
0045
14.5947
897.11
268.47
179.4227265
Treat hip dislocation

T
0043
1.6857
103.62

20.7227266
Treat hip dislocation

T
0045
14.5947
897.11
268.47
179.4227275
Manipulation of hip joint

T
0045
14.5947
897.11
268.47
179.4227299
Pelvis/hip joint surgery

T
0043
1.6857
103.62

20.7227301
Drain thigh/knee lesion

T
0008
17.5086
1,076.22

215.2427305
Incise thigh tendon & fascia

T
0049
20.8706
1,282.87

256.5727306
Incision of thigh tendon

T
0049
20.8706
1,282.87

256.5727307
Incision of thigh tendons

T
0049
20.8706
1,282.87

256.5727310
Exploration of knee joint

T
0050
25.1296
1,544.67

308.9327315
Partial removal, thigh nerve
CH
D27320
Partial removal, thigh nerve
CH
D27323
Biopsy, thigh soft tissues
CH
T
0020
6.8083
418.49
107.67
83.7027324
Biopsy, thigh soft tissues

T
0022
20.0656
1,233.39
354.45
246.6827325
Neurectomy, hamstring
NI
T
0220
17.8499
1,097.20

219.4427326
Neurectomy, popliteal
NI
T
0220
17.8499
1,097.20

219.4427327
Removal of thigh lesion

T
0022
20.0656
1,233.39
354.45
246.6827328
Removal of thigh lesion

T
0022
20.0656
1,233.39
354.45
246.6827329
Remove tumor, thigh/knee

T
0022
20.0656
1,233.39
354.45
246.6827330
Biopsy, knee joint lining

T
0050
25.1296
1,544.67

308.9327331
Explore/treat knee joint

T
0050
25.1296
1,544.67

308.9327332
Removal of knee cartilage

T
0050
25.1296
1,544.67

308.9327333
Removal of knee cartilage

T
0050
25.1296
1,544.67

308.9327334
Remove knee joint lining

T
0050
25.1296
1,544.67

308.9327335
Remove knee joint lining

T
0050
25.1296
1,544.67

308.9327340
Removal of kneecap bursa

T
0049
20.8706
1,282.87

256.5727345
Removal of knee cyst

T
0049
20.8706
1,282.87

256.5727347
Remove knee cyst

T
0049
20.8706
1,282.87

256.5727350
Removal of kneecap

T
0050
25.1296
1,544.67

308.9327355
Remove femur lesion

T
0050
25.1296
1,544.67

308.9327356
Remove femur lesion/graft

T
0050
25.1296
1,544.67

308.9327357
Remove femur lesion/graft

T
0050
25.1296
1,544.67

308.9327358
Remove femur lesion/fixation

T
0050
25.1296
1,544.67

308.9327360
Partial removal, leg bone(s)

T
0050
25.1296
1,544.67

308.9327370
Injection for knee x-ray

N27372
Removal of foreign body

T
0022
20.0656
1,233.39
354.45
246.6827380
Repair of kneecap tendon

T
0049
20.8706
1,282.87

256.5727381
Repair/graft kneecap tendon

T
0049
20.8706
1,282.87

256.5727385
Repair of thigh muscle

T
0049
20.8706
1,282.87

256.5727386
Repair/graft of thigh muscle

T
0049
20.8706
1,282.87

256.5727390
Incision of thigh tendon

T
0049
20.8706
1,282.87

256.5727391
Incision of thigh tendons

T
0049
20.8706
1,282.87

256.5727392
Incision of thigh tendons

T
0049
20.8706
1,282.87

256.5727393
Lengthening of thigh tendon

T
0050
25.1296
1,544.67

308.9327394
Lengthening of thigh tendons

T
0050
25.1296
1,544.67

308.9327395
Lengthening of thigh tendons

T
0051
41.0893
2,525.68

505.1427396
Transplant of thigh tendon

T
0050
25.1296
1,544.67

308.9327397
Transplants of thigh tendons

T
0051
41.0893
2,525.68

505.1427400
Revise thigh muscles/tendons

T
0051
41.0893
2,525.68

505.1427403
Repair of knee cartilage

T
0050
25.1296
1,544.67

308.9327405
Repair of knee ligament

T
0051
41.0893
2,525.68

505.1427407
Repair of knee ligament
CH
T
0052
66.58
4,092.54

818.5127409
Repair of knee ligaments

T
0051
41.0893
2,525.68

505.1427412
Autochondrocyte implant knee

T
0042
45.5027
2,796.96
804.74
559.3927415
Osteochondral knee allograft

T
0042
45.5027
2,796.96
804.74
559.3927418
Repair degenerated kneecap

T
0051
41.0893
2,525.68

505.1427420
Revision of unstable kneecap

T
0051
41.0893
2,525.68

505.1427422
Revision of unstable kneecap

T
0051
41.0893
2,525.68

505.1427424
Revision/removal of kneecap

T
0051
41.0893
2,525.68

505.1427425
Lat retinacular release open

T
0050
25.1296
1,544.67

308.9327427
Reconstruction, knee
CH
T
0051
41.0893
2,525.68

505.1427428
Reconstruction, knee

T
0052
66.58
4,092.54

818.5127429
Reconstruction, knee

T
0052
66.58
4,092.54

818.51( print page 68305)27430
Revision of thigh muscles

T
0051
41.0893
2,525.68

505.1427435
Incision of knee joint

T
0051
41.0893
2,525.68

505.1427437
Revise kneecap

T
0047
33.4505
2,056.14
537.03
411.2327438
Revise kneecap with implant

T
0048
47.4378
2,915.91

583.1827440
Revision of knee joint

T
0047
33.4505
2,056.14
537.03
411.2327441
Revision of knee joint

T
0047
33.4505
2,056.14
537.03
411.2327442
Revision of knee joint

T
0047
33.4505
2,056.14
537.03
411.2327443
Revision of knee joint

T
0047
33.4505
2,056.14
537.03
411.2327446
Revision of knee joint

T
0681
205.6815
12,642.83

2,528.5727475
Surgery to stop leg growth

T
0050
25.1296
1,544.67

308.9327496
Decompression of thigh/knee

T
0049
20.8706
1,282.87

256.5727497
Decompression of thigh/knee

T
0049
20.8706
1,282.87

256.5727498
Decompression of thigh/knee

T
0049
20.8706
1,282.87

256.5727499
Decompression of thigh/knee

T
0049
20.8706
1,282.87

256.5727500
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227501
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227502
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227503
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227508
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227509
Treatment of thigh fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8127510
Treatment of thigh fracture

T
0043
1.6857
103.62

20.7227516
Treat thigh fx growth plate

T
0043
1.6857
103.62

20.7227517
Treat thigh fx growth plate

T
0043
1.6857
103.62

20.7227520
Treat kneecap fracture

T
0043
1.6857
103.62

20.7227524
Treat kneecap fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827530
Treat knee fracture

T
0043
1.6857
103.62

20.7227532
Treat knee fracture

T
0043
1.6857
103.62

20.7227538
Treat knee fracture(s)

T
0043
1.6857
103.62

20.7227550
Treat knee dislocation

T
0043
1.6857
103.62

20.7227552
Treat knee dislocation

T
0045
14.5947
897.11
268.47
179.4227560
Treat kneecap dislocation

T
0043
1.6857
103.62

20.7227562
Treat kneecap dislocation

T
0045
14.5947
897.11
268.47
179.4227566
Treat kneecap dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4827570
Fixation of knee joint

T
0045
14.5947
897.11
268.47
179.4227594
Amputation follow-up surgery

T
0049
20.8706
1,282.87

256.5727599
Leg surgery procedure

T
0043
1.6857
103.62

20.7227600
Decompression of lower leg

T
0049
20.8706
1,282.87

256.5727601
Decompression of lower leg

T
0049
20.8706
1,282.87

256.5727602
Decompression of lower leg

T
0049
20.8706
1,282.87

256.5727603
Drain lower leg lesion

T
0008
17.5086
1,076.22

215.2427604
Drain lower leg bursa

T
0049
20.8706
1,282.87

256.5727605
Incision of achilles tendon

T
0055
20.4263
1,255.56
355.34
251.1127606
Incision of achilles tendon

T
0049
20.8706
1,282.87

256.5727607
Treat lower leg bone lesion

T
0049
20.8706
1,282.87

256.5727610
Explore/treat ankle joint

T
0050
25.1296
1,544.67

308.9327612
Exploration of ankle joint

T
0050
25.1296
1,544.67

308.9327613
Biopsy lower leg soft tissue

T
0020
6.8083
418.49
107.67
83.7027614
Biopsy lower leg soft tissue

T
0022
20.0656
1,233.39
354.45
246.6827615
Remove tumor, lower leg
CH
T
0050
25.1296
1,544.67

308.9327618
Remove lower leg lesion

T
0021
15.1024
928.31
219.48
185.6627619
Remove lower leg lesion

T
0022
20.0656
1,233.39
354.45
246.6827620
Explore/treat ankle joint

T
0050
25.1296
1,544.67

308.9327625
Remove ankle joint lining

T
0050
25.1296
1,544.67

308.9327626
Remove ankle joint lining

T
0050
25.1296
1,544.67

308.9327630
Removal of tendon lesion

T
0049
20.8706
1,282.87

256.5727635
Remove lower leg bone lesion

T
0050
25.1296
1,544.67

308.9327637
Remove/graft leg bone lesion

T
0050
25.1296
1,544.67

308.9327638
Remove/graft leg bone lesion

T
0050
25.1296
1,544.67

308.9327640
Partial removal of tibia

T
0051
41.0893
2,525.68

505.1427641
Partial removal of fibula

T
0050
25.1296
1,544.67

308.9327647
Extensive ankle/heel surgery

T
0051
41.0893
2,525.68

505.1427648
Injection for ankle x-ray

N27650
Repair achilles tendon

T
0051
41.0893
2,525.68

505.1427652
Repair/graft achilles tendon
CH
T
0052
66.58
4,092.54

818.5127654
Repair of achilles tendon

T
0051
41.0893
2,525.68

505.1427656
Repair leg fascia defect

T
0049
20.8706
1,282.87

256.5727658
Repair of leg tendon, each

T
0049
20.8706
1,282.87

256.5727659
Repair of leg tendon, each

T
0049
20.8706
1,282.87

256.5727664
Repair of leg tendon, each

T
0049
20.8706
1,282.87

256.5727665
Repair of leg tendon, each

T
0050
25.1296
1,544.67

308.93( print page 68306)27675
Repair lower leg tendons

T
0049
20.8706
1,282.87

256.5727676
Repair lower leg tendons

T
0050
25.1296
1,544.67

308.9327680
Release of lower leg tendon

T
0050
25.1296
1,544.67

308.9327681
Release of lower leg tendons

T
0050
25.1296
1,544.67

308.9327685
Revision of lower leg tendon

T
0050
25.1296
1,544.67

308.9327686
Revise lower leg tendons

T
0050
25.1296
1,544.67

308.9327687
Revision of calf tendon

T
0050
25.1296
1,544.67

308.9327690
Revise lower leg tendon

T
0051
41.0893
2,525.68

505.1427691
Revise lower leg tendon

T
0051
41.0893
2,525.68

505.1427692
Revise additional leg tendon

T
0051
41.0893
2,525.68

505.1427695
Repair of ankle ligament

T
0050
25.1296
1,544.67

308.9327696
Repair of ankle ligaments

T
0050
25.1296
1,544.67

308.9327698
Repair of ankle ligament

T
0050
25.1296
1,544.67

308.9327700
Revision of ankle joint

T
0047
33.4505
2,056.14
537.03
411.2327704
Removal of ankle implant

T
0049
20.8706
1,282.87

256.5727705
Incision of tibia

T
0051
41.0893
2,525.68

505.1427707
Incision of fibula

T
0049
20.8706
1,282.87

256.5727709
Incision of tibia & fibula

T
0050
25.1296
1,544.67

308.9327730
Repair of tibia epiphysis

T
0050
25.1296
1,544.67

308.9327732
Repair of fibula epiphysis

T
0050
25.1296
1,544.67

308.9327734
Repair lower leg epiphyses

T
0050
25.1296
1,544.67

308.9327740
Repair of leg epiphyses

T
0050
25.1296
1,544.67

308.9327742
Repair of leg epiphyses

T
0051
41.0893
2,525.68

505.1427745
Reinforce tibia
CH
T
0052
66.58
4,092.54

818.5127750
Treatment of tibia fracture

T
0043
1.6857
103.62

20.7227752
Treatment of tibia fracture

T
0043
1.6857
103.62

20.7227756
Treatment of tibia fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8127758
Treatment of tibia fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827759
Treatment of tibia fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4127760
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227762
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227766
Treatment of ankle fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827780
Treatment of fibula fracture

T
0043
1.6857
103.62

20.7227781
Treatment of fibula fracture

T
0043
1.6857
103.62

20.7227784
Treatment of fibula fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827786
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227788
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227792
Treatment of ankle fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827808
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227810
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227814
Treatment of ankle fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827816
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227818
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7227822
Treatment of ankle fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827823
Treatment of ankle fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4127824
Treat lower leg fracture

T
0043
1.6857
103.62

20.7227825
Treat lower leg fracture

T
0043
1.6857
103.62

20.7227826
Treat lower leg fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4827827
Treat lower leg fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4127828
Treat lower leg fracture
CH
T
0064
57.2172
3,517.03
835.79
703.4127829
Treat lower leg joint
CH
T
0063
37.5382
2,307.40
548.33
461.4827830
Treat lower leg dislocation

T
0043
1.6857
103.62

20.7227831
Treat lower leg dislocation

T
0043
1.6857
103.62

20.7227832
Treat lower leg dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4827840
Treat ankle dislocation

T
0043
1.6857
103.62

20.7227842
Treat ankle dislocation

T
0045
14.5947
897.11
268.47
179.4227846
Treat ankle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4827848
Treat ankle dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4827860
Fixation of ankle joint

T
0045
14.5947
897.11
268.47
179.4227870
Fusion of ankle joint, open
CH
T
0052
66.58
4,092.54

818.5127871
Fusion of tibiofibular joint
CH
T
0052
66.58
4,092.54

818.5127884
Amputation follow-up surgery

T
0049
20.8706
1,282.87

256.5727889
Amputation of foot at ankle

T
0050
25.1296
1,544.67

308.9327892
Decompression of leg

T
0049
20.8706
1,282.87

256.5727893
Decompression of leg

T
0049
20.8706
1,282.87

256.5727894
Decompression of leg

T
0049
20.8706
1,282.87

256.5727899
Leg/ankle surgery procedure

T
0043
1.6857
103.62

20.7228001
Drainage of bursa of foot

T
0007
11.1535
685.58

137.1228002
Treatment of foot infection

T
0049
20.8706
1,282.87

256.5728003
Treatment of foot infection

T
0049
20.8706
1,282.87

256.57( print page 68307)28005
Treat foot bone lesion

T
0055
20.4263
1,255.56
355.34
251.1128008
Incision of foot fascia

T
0055
20.4263
1,255.56
355.34
251.1128010
Incision of toe tendon

T
0055
20.4263
1,255.56
355.34
251.1128011
Incision of toe tendons

T
0055
20.4263
1,255.56
355.34
251.1128020
Exploration of foot joint

T
0055
20.4263
1,255.56
355.34
251.1128022
Exploration of foot joint

T
0055
20.4263
1,255.56
355.34
251.1128024
Exploration of toe joint

T
0055
20.4263
1,255.56
355.34
251.1128030
Removal of foot nerve
CH
D28035
Decompression of tibia nerve

T
0220
17.8499
1,097.20

219.4428043
Excision of foot lesion
CH
T
0022
20.0656
1,233.39
354.45
246.6828045
Excision of foot lesion

T
0055
20.4263
1,255.56
355.34
251.1128046
Resection of tumor, foot

T
0055
20.4263
1,255.56
355.34
251.1128050
Biopsy of foot joint lining

T
0055
20.4263
1,255.56
355.34
251.1128052
Biopsy of foot joint lining

T
0055
20.4263
1,255.56
355.34
251.1128054
Biopsy of toe joint lining

T
0055
20.4263
1,255.56
355.34
251.1128055
Neurectomy, foot
NI
T
0220
17.8499
1,097.20

219.4428060
Partial removal, foot fascia

T
0055
20.4263
1,255.56
355.34
251.1128062
Removal of foot fascia

T
0055
20.4263
1,255.56
355.34
251.1128070
Removal of foot joint lining

T
0055
20.4263
1,255.56
355.34
251.1128072
Removal of foot joint lining

T
0055
20.4263
1,255.56
355.34
251.1128080
Removal of foot lesion

T
0055
20.4263
1,255.56
355.34
251.1128086
Excise foot tendon sheath

T
0055
20.4263
1,255.56
355.34
251.1128088
Excise foot tendon sheath

T
0055
20.4263
1,255.56
355.34
251.1128090
Removal of foot lesion

T
0055
20.4263
1,255.56
355.34
251.1128092
Removal of toe lesions

T
0055
20.4263
1,255.56
355.34
251.1128100
Removal of ankle/heel lesion

T
0055
20.4263
1,255.56
355.34
251.1128102
Remove/graft foot lesion

T
0056
40.8559
2,511.33

502.2728103
Remove/graft foot lesion

T
0056
40.8559
2,511.33

502.2728104
Removal of foot lesion

T
0055
20.4263
1,255.56
355.34
251.1128106
Remove/graft foot lesion

T
0056
40.8559
2,511.33

502.2728107
Remove/graft foot lesion

T
0056
40.8559
2,511.33

502.2728108
Removal of toe lesions

T
0055
20.4263
1,255.56
355.34
251.1128110
Part removal of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128111
Part removal of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128112
Part removal of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128113
Part removal of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128114
Removal of metatarsal heads

T
0055
20.4263
1,255.56
355.34
251.1128116
Revision of foot

T
0055
20.4263
1,255.56
355.34
251.1128118
Removal of heel bone

T
0055
20.4263
1,255.56
355.34
251.1128119
Removal of heel spur

T
0055
20.4263
1,255.56
355.34
251.1128120
Part removal of ankle/heel

T
0055
20.4263
1,255.56
355.34
251.1128122
Partial removal of foot bone

T
0055
20.4263
1,255.56
355.34
251.1128124
Partial removal of toe

T
0055
20.4263
1,255.56
355.34
251.1128126
Partial removal of toe

T
0055
20.4263
1,255.56
355.34
251.1128130
Removal of ankle bone

T
0055
20.4263
1,255.56
355.34
251.1128140
Removal of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128150
Removal of toe

T
0055
20.4263
1,255.56
355.34
251.1128153
Partial removal of toe

T
0055
20.4263
1,255.56
355.34
251.1128160
Partial removal of toe

T
0055
20.4263
1,255.56
355.34
251.1128171
Extensive foot surgery

T
0055
20.4263
1,255.56
355.34
251.1128173
Extensive foot surgery

T
0055
20.4263
1,255.56
355.34
251.1128175
Extensive foot surgery

T
0055
20.4263
1,255.56
355.34
251.1128190
Removal of foot foreign body

T
0019
4.0919
251.52
71.87
50.3028192
Removal of foot foreign body

T
0021
15.1024
928.31
219.48
185.6628193
Removal of foot foreign body

T
0020
6.8083
418.49
107.67
83.7028200
Repair of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128202
Repair/graft of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128208
Repair of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128210
Repair/graft of foot tendon

T
0056
40.8559
2,511.33

502.2728220
Release of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128222
Release of foot tendons

T
0055
20.4263
1,255.56
355.34
251.1128225
Release of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128226
Release of foot tendons

T
0055
20.4263
1,255.56
355.34
251.1128230
Incision of foot tendon(s)

T
0055
20.4263
1,255.56
355.34
251.1128232
Incision of toe tendon

T
0055
20.4263
1,255.56
355.34
251.1128234
Incision of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128238
Revision of foot tendon

T
0056
40.8559
2,511.33

502.2728240
Release of big toe

T
0055
20.4263
1,255.56
355.34
251.1128250
Revision of foot fascia

T
0055
20.4263
1,255.56
355.34
251.1128260
Release of midfoot joint

T
0055
20.4263
1,255.56
355.34
251.11( print page 68308)28261
Revision of foot tendon

T
0055
20.4263
1,255.56
355.34
251.1128262
Revision of foot and ankle

T
0055
20.4263
1,255.56
355.34
251.1128264
Release of midfoot joint

T
0056
40.8559
2,511.33

502.2728270
Release of foot contracture

T
0055
20.4263
1,255.56
355.34
251.1128272
Release of toe joint, each

T
0055
20.4263
1,255.56
355.34
251.1128280
Fusion of toes

T
0055
20.4263
1,255.56
355.34
251.1128285
Repair of hammertoe

T
0055
20.4263
1,255.56
355.34
251.1128286
Repair of hammertoe

T
0055
20.4263
1,255.56
355.34
251.1128288
Partial removal of foot bone

T
0055
20.4263
1,255.56
355.34
251.1128289
Repair hallux rigidus

T
0055
20.4263
1,255.56
355.34
251.1128290
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128292
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128293
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128294
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128296
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128297
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128298
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128299
Correction of bunion

T
0057
28.2349
1,735.54
475.91
347.1128300
Incision of heel bone

T
0056
40.8559
2,511.33

502.2728302
Incision of ankle bone

T
0055
20.4263
1,255.56
355.34
251.1128304
Incision of midfoot bones

T
0056
40.8559
2,511.33

502.2728305
Incise/graft midfoot bones

T
0056
40.8559
2,511.33

502.2728306
Incision of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128307
Incision of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128308
Incision of metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128309
Incision of metatarsals

T
0056
40.8559
2,511.33

502.2728310
Revision of big toe

T
0055
20.4263
1,255.56
355.34
251.1128312
Revision of toe

T
0055
20.4263
1,255.56
355.34
251.1128313
Repair deformity of toe

T
0055
20.4263
1,255.56
355.34
251.1128315
Removal of sesamoid bone

T
0055
20.4263
1,255.56
355.34
251.1128320
Repair of foot bones

T
0056
40.8559
2,511.33

502.2728322
Repair of metatarsals

T
0056
40.8559
2,511.33

502.2728340
Resect enlarged toe tissue

T
0055
20.4263
1,255.56
355.34
251.1128341
Resect enlarged toe

T
0055
20.4263
1,255.56
355.34
251.1128344
Repair extra toe(s)

T
0055
20.4263
1,255.56
355.34
251.1128345
Repair webbed toe(s)

T
0055
20.4263
1,255.56
355.34
251.1128360
Reconstruct cleft foot

T
0056
40.8559
2,511.33

502.2728400
Treatment of heel fracture

T
0043
1.6857
103.62

20.7228405
Treatment of heel fracture

T
0043
1.6857
103.62

20.7228406
Treatment of heel fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8128415
Treat heel fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828420
Treat/graft heel fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828430
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7228435
Treatment of ankle fracture

T
0043
1.6857
103.62

20.7228436
Treatment of ankle fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8128445
Treat ankle fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828450
Treat midfoot fracture, each

T
0043
1.6857
103.62

20.7228455
Treat midfoot fracture, each

T
0043
1.6857
103.62

20.7228456
Treat midfoot fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8128465
Treat midfoot fracture, each
CH
T
0063
37.5382
2,307.40
548.33
461.4828470
Treat metatarsal fracture

T
0043
1.6857
103.62

20.7228475
Treat metatarsal fracture

T
0043
1.6857
103.62

20.7228476
Treat metatarsal fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8128485
Treat metatarsal fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828490
Treat big toe fracture

T
0043
1.6857
103.62

20.7228495
Treat big toe fracture

T
0043
1.6857
103.62

20.7228496
Treat big toe fracture
CH
T
0062
25.5264
1,569.06
372.87
313.8128505
Treat big toe fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828510
Treatment of toe fracture

T
0043
1.6857
103.62

20.7228515
Treatment of toe fracture

T
0043
1.6857
103.62

20.7228525
Treat toe fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828530
Treat sesamoid bone fracture

T
0043
1.6857
103.62

20.7228531
Treat sesamoid bone fracture
CH
T
0063
37.5382
2,307.40
548.33
461.4828540
Treat foot dislocation

T
0043
1.6857
103.62

20.7228545
Treat foot dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8128546
Treat foot dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8128555
Repair foot dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4828570
Treat foot dislocation

T
0043
1.6857
103.62

20.7228575
Treat foot dislocation

T
0043
1.6857
103.62

20.7228576
Treat foot dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.81( print page 68309)28585
Repair foot dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4828600
Treat foot dislocation

T
0043
1.6857
103.62

20.7228605
Treat foot dislocation

T
0043
1.6857
103.62

20.7228606
Treat foot dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8128615
Repair foot dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4828630
Treat toe dislocation

T
0043
1.6857
103.62

20.7228635
Treat toe dislocation

T
0045
14.5947
897.11
268.47
179.4228636
Treat toe dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8128645
Repair toe dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4828660
Treat toe dislocation

T
0043
1.6857
103.62

20.7228665
Treat toe dislocation

T
0045
14.5947
897.11
268.47
179.4228666
Treat toe dislocation
CH
T
0062
25.5264
1,569.06
372.87
313.8128675
Repair of toe dislocation
CH
T
0063
37.5382
2,307.40
548.33
461.4828705
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728715
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728725
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728730
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728735
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728737
Revision of foot bones

T
0056
40.8559
2,511.33

502.2728740
Fusion of foot bones

T
0056
40.8559
2,511.33

502.2728750
Fusion of big toe joint

T
0056
40.8559
2,511.33

502.2728755
Fusion of big toe joint

T
0055
20.4263
1,255.56
355.34
251.1128760
Fusion of big toe joint

T
0056
40.8559
2,511.33

502.2728810
Amputation toe & metatarsal

T
0055
20.4263
1,255.56
355.34
251.1128820
Amputation of toe

T
0055
20.4263
1,255.56
355.34
251.1128825
Partial amputation of toe

T
0055
20.4263
1,255.56
355.34
251.1128890
High energy eswt, plantar f
CH
T
0050
25.1296
1,544.67

308.9328899
Foot/toes surgery procedure

T
0043
1.6857
103.62

20.7229000
Application of body cast

S
0058
1.0607
65.20

13.0429010
Application of body cast

S
0426
2.2777
140.01

28.0029015
Application of body cast

S
0426
2.2777
140.01

28.0029020
Application of body cast

S
0058
1.0607
65.20

13.0429025
Application of body cast

S
0058
1.0607
65.20

13.0429035
Application of body cast

S
0426
2.2777
140.01

28.0029040
Application of body cast

S
0058
1.0607
65.20

13.0429044
Application of body cast

S
0426
2.2777
140.01

28.0029046
Application of body cast

S
0426
2.2777
140.01

28.0029049
Application of figure eight

S
0058
1.0607
65.20

13.0429055
Application of shoulder cast

S
0426
2.2777
140.01

28.0029058
Application of shoulder cast

S
0058
1.0607
65.20

13.0429065
Application of long arm cast

S
0426
2.2777
140.01

28.0029075
Application of forearm cast

S
0426
2.2777
140.01

28.0029085
Apply hand/wrist cast

S
0058
1.0607
65.20

13.0429086
Apply finger cast

S
0058
1.0607
65.20

13.0429105
Apply long arm splint

S
0058
1.0607
65.20

13.0429125
Apply forearm splint

S
0058
1.0607
65.20

13.0429126
Apply forearm splint

S
0058
1.0607
65.20

13.0429130
Application of finger splint

S
0058
1.0607
65.20

13.0429131
Application of finger splint

S
0058
1.0607
65.20

13.0429200
Strapping of chest

S
0058
1.0607
65.20

13.0429220
Strapping of low back

S
0058
1.0607
65.20

13.0429240
Strapping of shoulder

S
0058
1.0607
65.20

13.0429260
Strapping of elbow or wrist

S
0058
1.0607
65.20

13.0429280
Strapping of hand or finger

S
0058
1.0607
65.20

13.0429305
Application of hip cast

S
0426
2.2777
140.01

28.0029325
Application of hip casts

S
0426
2.2777
140.01

28.0029345
Application of long leg cast

S
0426
2.2777
140.01

28.0029355
Application of long leg cast

S
0426
2.2777
140.01

28.0029358
Apply long leg cast brace

S
0426
2.2777
140.01

28.0029365
Application of long leg cast

S
0426
2.2777
140.01

28.0029405
Apply short leg cast

S
0426
2.2777
140.01

28.0029425
Apply short leg cast

S
0426
2.2777
140.01

28.0029435
Apply short leg cast

S
0426
2.2777
140.01

28.0029440
Addition of walker to cast

S
0058
1.0607
65.20

13.0429445
Apply rigid leg cast

S
0426
2.2777
140.01

28.0029450
Application of leg cast

S
0058
1.0607
65.20

13.0429505
Application, long leg splint

S
0058
1.0607
65.20

13.0429515
Application lower leg splint

S
0058
1.0607
65.20

13.0429520
Strapping of hip

S
0058
1.0607
65.20

13.0429530
Strapping of knee

S
0058
1.0607
65.20

13.04( print page 68310)29540
Strapping of ankle and/or ft

S
0058
1.0607
65.20

13.0429550
Strapping of toes

S
0058
1.0607
65.20

13.0429580
Application of paste boot

S
0058
1.0607
65.20

13.0429590
Application of foot splint

S
0058
1.0607
65.20

13.0429700
Removal/revision of cast

S
0058
1.0607
65.20

13.0429705
Removal/revision of cast

S
0058
1.0607
65.20

13.0429710
Removal/revision of cast

S
0426
2.2777
140.01

28.0029715
Removal/revision of cast

S
0058
1.0607
65.20

13.0429720
Repair of body cast

S
0058
1.0607
65.20

13.0429730
Windowing of cast

S
0058
1.0607
65.20

13.0429740
Wedging of cast

S
0058
1.0607
65.20

13.0429750
Wedging of clubfoot cast

S
0058
1.0607
65.20

13.0429799
Casting/strapping procedure

S
0058
1.0607
65.20

13.0429800
Jaw arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029804
Jaw arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029805
Shoulder arthroscopy, dx

T
0041
28.6245
1,759.49

351.9029806
Shoulder arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929807
Shoulder arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929819
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029820
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029821
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029822
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029823
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029824
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029825
Shoulder arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029826
Shoulder arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929827
Arthroscop rotator cuff repr

T
0042
45.5027
2,796.96
804.74
559.3929830
Elbow arthroscopy

T
0041
28.6245
1,759.49

351.9029834
Elbow arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029835
Elbow arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029836
Elbow arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029837
Elbow arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029838
Elbow arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029840
Wrist arthroscopy

T
0041
28.6245
1,759.49

351.9029843
Wrist arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029844
Wrist arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029845
Wrist arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029846
Wrist arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029847
Wrist arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029848
Wrist endoscopy/surgery

T
0041
28.6245
1,759.49

351.9029850
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029851
Knee arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929855
Tibial arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929856
Tibial arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029860
Hip arthroscopy, dx

T
0041
28.6245
1,759.49

351.9029861
Hip arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029862
Hip arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929863
Hip arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929866
Autgrft implnt, knee w/scope

T
0042
45.5027
2,796.96
804.74
559.3929867
Allgrft implnt, knee w/scope

T
0042
45.5027
2,796.96
804.74
559.3929868
Meniscal trnspl, knee w/scpe

T
0042
45.5027
2,796.96
804.74
559.3929870
Knee arthroscopy, dx

T
0041
28.6245
1,759.49

351.9029871
Knee arthroscopy/drainage

T
0041
28.6245
1,759.49

351.9029873
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029874
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029875
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029876
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029877
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029879
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029880
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029881
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029882
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029883
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029884
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029885
Knee arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929886
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029887
Knee arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029888
Knee arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929889
Knee arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929891
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.90( print page 68311)29892
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029893
Scope, plantar fasciotomy

T
0055
20.4263
1,255.56
355.34
251.1129894
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029895
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029897
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029898
Ankle arthroscopy/surgery

T
0041
28.6245
1,759.49

351.9029899
Ankle arthroscopy/surgery

T
0042
45.5027
2,796.96
804.74
559.3929900
Mcp joint arthroscopy, dx

T
0053
16.154
992.95
253.49
198.5929901
Mcp joint arthroscopy, surg

T
0053
16.154
992.95
253.49
198.5929902
Mcp joint arthroscopy, surg

T
0053
16.154
992.95
253.49
198.5929999
Arthroscopy of joint

T
0041
28.6245
1,759.49

351.9030000
Drainage of nose lesion

T
0251
2.452
150.72

30.1430020
Drainage of nose lesion

T
0251
2.452
150.72

30.1430100
Intranasal biopsy

T
0252
7.5511
464.15
109.16
92.8330110
Removal of nose polyp(s)

T
0253
16.4266
1,009.71
282.29
201.9430115
Removal of nose polyp(s)

T
0253
16.4266
1,009.71
282.29
201.9430117
Removal of intranasal lesion

T
0253
16.4266
1,009.71
282.29
201.9430118
Removal of intranasal lesion

T
0254
23.3299
1,434.04
321.35
286.8130120
Revision of nose

T
0253
16.4266
1,009.71
282.29
201.9430124
Removal of nose lesion

T
0252
7.5511
464.15
109.16
92.8330125
Removal of nose lesion

T
0256
38.1991
2,348.02

469.6030130
Excise inferior turbinate

T
0253
16.4266
1,009.71
282.29
201.9430140
Resect inferior turbinate

T
0254
23.3299
1,434.04
321.35
286.8130150
Partial removal of nose

T
0256
38.1991
2,348.02

469.6030160
Removal of nose

T
0256
38.1991
2,348.02

469.6030200
Injection treatment of nose

T
0252
7.5511
464.15
109.16
92.8330210
Nasal sinus therapy

T
0252
7.5511
464.15
109.16
92.8330220
Insert nasal septal button

T
0252
7.5511
464.15
109.16
92.8330300
Remove nasal foreign body

X
0340
0.6102
37.51

7.5030310
Remove nasal foreign body

T
0253
16.4266
1,009.71
282.29
201.9430320
Remove nasal foreign body

T
0253
16.4266
1,009.71
282.29
201.9430400
Reconstruction of nose

T
0256
38.1991
2,348.02

469.6030410
Reconstruction of nose

T
0256
38.1991
2,348.02

469.6030420
Reconstruction of nose

T
0256
38.1991
2,348.02

469.6030430
Revision of nose

T
0254
23.3299
1,434.04
321.35
286.8130435
Revision of nose

T
0256
38.1991
2,348.02

469.6030450
Revision of nose

T
0256
38.1991
2,348.02

469.6030460
Revision of nose

T
0256
38.1991
2,348.02

469.6030462
Revision of nose

T
0256
38.1991
2,348.02

469.6030465
Repair nasal stenosis

T
0256
38.1991
2,348.02

469.6030520
Repair of nasal septum

T
0254
23.3299
1,434.04
321.35
286.8130540
Repair nasal defect

T
0256
38.1991
2,348.02

469.6030545
Repair nasal defect

T
0256
38.1991
2,348.02

469.6030560
Release of nasal adhesions

T
0251
2.452
150.72

30.1430580
Repair upper jaw fistula

T
0256
38.1991
2,348.02

469.6030600
Repair mouth/nose fistula

T
0256
38.1991
2,348.02

469.6030620
Intranasal reconstruction

T
0256
38.1991
2,348.02

469.6030630
Repair nasal septum defect

T
0254
23.3299
1,434.04
321.35
286.8130801
Ablate inf turbinate, superf

T
0252
7.5511
464.15
109.16
92.8330802
Cauterization, inner nose

T
0252
7.5511
464.15
109.16
92.8330901
Control of nosebleed

T
0250
1.1791
72.48
25.39
14.5030903
Control of nosebleed

T
0250
1.1791
72.48
25.39
14.5030905
Control of nosebleed

T
0250
1.1791
72.48
25.39
14.5030906
Repeat control of nosebleed

T
0250
1.1791
72.48
25.39
14.5030915
Ligation, nasal sinus artery
CH
T
0092
24.8809
1,529.38
309.87
305.8830920
Ligation, upper jaw artery

T
0092
24.8809
1,529.38
309.87
305.8830930
Ther fx, nasal inf turbinate

T
0253
16.4266
1,009.71
282.29
201.9430999
Nasal surgery procedure

T
0251
2.452
150.72

30.1431000
Irrigation, maxillary sinus

T
0251
2.452
150.72

30.1431002
Irrigation, sphenoid sinus

T
0252
7.5511
464.15
109.16
92.8331020
Exploration, maxillary sinus

T
0254
23.3299
1,434.04
321.35
286.8131030
Exploration, maxillary sinus

T
0256
38.1991
2,348.02

469.6031032
Explore sinus, remove polyps

T
0256
38.1991
2,348.02

469.6031040
Exploration behind upper jaw

T
0254
23.3299
1,434.04
321.35
286.8131050
Exploration, sphenoid sinus

T
0256
38.1991
2,348.02

469.6031051
Sphenoid sinus surgery

T
0256
38.1991
2,348.02

469.6031070
Exploration of frontal sinus

T
0254
23.3299
1,434.04
321.35
286.8131075
Exploration of frontal sinus

T
0256
38.1991
2,348.02

469.6031080
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.6031081
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.60( print page 68312)31084
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.6031085
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.6031086
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.6031087
Removal of frontal sinus

T
0256
38.1991
2,348.02

469.6031090
Exploration of sinuses

T
0256
38.1991
2,348.02

469.6031200
Removal of ethmoid sinus

T
0256
38.1991
2,348.02

469.6031201
Removal of ethmoid sinus

T
0256
38.1991
2,348.02

469.6031205
Removal of ethmoid sinus

T
0256
38.1991
2,348.02

469.6031231
Nasal endoscopy, dx

T
0072
1.4054
86.39
21.27
17.2831233
Nasal/sinus endoscopy, dx

T
0072
1.4054
86.39
21.27
17.2831235
Nasal/sinus endoscopy, dx

T
0074
14.7928
909.28
292.25
181.8631237
Nasal/sinus endoscopy, surg
CH
T
0074
14.7928
909.28
292.25
181.8631238
Nasal/sinus endoscopy, surg

T
0074
14.7928
909.28
292.25
181.8631239
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631240
Nasal/sinus endoscopy, surg

T
0074
14.7928
909.28
292.25
181.8631254
Revision of ethmoid sinus

T
0075
21.9512
1,349.30
445.92
269.8631255
Removal of ethmoid sinus

T
0075
21.9512
1,349.30
445.92
269.8631256
Exploration maxillary sinus

T
0075
21.9512
1,349.30
445.92
269.8631267
Endoscopy, maxillary sinus

T
0075
21.9512
1,349.30
445.92
269.8631276
Sinus endoscopy, surgical

T
0075
21.9512
1,349.30
445.92
269.8631287
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631288
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631292
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631293
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631294
Nasal/sinus endoscopy, surg

T
0075
21.9512
1,349.30
445.92
269.8631299
Sinus surgery procedure

T
0251
2.452
150.72

30.1431300
Removal of larynx lesion

T
0254
23.3299
1,434.04
321.35
286.8131320
Diagnostic incision, larynx

T
0256
38.1991
2,348.02

469.6031400
Revision of larynx

T
0256
38.1991
2,348.02

469.6031420
Removal of epiglottis

T
0256
38.1991
2,348.02

469.6031500
Insert emergency airway

S
0094
2.4233
148.96
46.29
29.7931502
Change of windpipe airway

T
0121
2.3587
144.98
43.80
29.0031505
Diagnostic laryngoscopy

T
0071
0.7698
47.32
11.20
9.4631510
Laryngoscopy with biopsy

T
0074
14.7928
909.28
292.25
181.8631511
Remove foreign body, larynx

T
0072
1.4054
86.39
21.27
17.2831512
Removal of larynx lesion

T
0074
14.7928
909.28
292.25
181.8631513
Injection into vocal cord

T
0072
1.4054
86.39
21.27
17.2831515
Laryngoscopy for aspiration

T
0074
14.7928
909.28
292.25
181.8631520
Dx laryngoscopy, newborn

T
0072
1.4054
86.39
21.27
17.2831525
Dx laryngoscopy excl nb

T
0074
14.7928
909.28
292.25
181.8631526
Dx laryngoscopy w/oper scope

T
0075
21.9512
1,349.30
445.92
269.8631527
Laryngoscopy for treatment

T
0075
21.9512
1,349.30
445.92
269.8631528
Laryngoscopy and dilation

T
0074
14.7928
909.28
292.25
181.8631529
Laryngoscopy and dilation

T
0074
14.7928
909.28
292.25
181.8631530
Laryngoscopy w/fb removal

T
0075
21.9512
1,349.30
445.92
269.8631531
Laryngoscopy w/fb & op scope

T
0075
21.9512
1,349.30
445.92
269.8631535
Laryngoscopy w/biopsy

T
0075
21.9512
1,349.30
445.92
269.8631536
Laryngoscopy w/bx & op scope

T
0075
21.9512
1,349.30
445.92
269.8631540
Laryngoscopy w/exc of tumor

T
0075
21.9512
1,349.30
445.92
269.8631541
Larynscop w/tumr exc + scope

T
0075
21.9512
1,349.30
445.92
269.8631545
Remove vc lesion w/scope

T
0075
21.9512
1,349.30
445.92
269.8631546
Remove vc lesion scope/graft

T
0075
21.9512
1,349.30
445.92
269.8631560
Laryngoscop w/arytenoidectom

T
0075
21.9512
1,349.30
445.92
269.8631561
Larynscop, remve cart + scop

T
0075
21.9512
1,349.30
445.92
269.8631570
Laryngoscope w/vc inj

T
0074
14.7928
909.28
292.25
181.8631571
Laryngoscop w/vc inj + scope

T
0075
21.9512
1,349.30
445.92
269.8631575
Diagnostic laryngoscopy

T
0072
1.4054
86.39
21.27
17.2831576
Laryngoscopy with biopsy

T
0075
21.9512
1,349.30
445.92
269.8631577
Remove foreign body, larynx

T
0073
3.8463
236.42
69.15
47.2831578
Removal of larynx lesion

T
0075
21.9512
1,349.30
445.92
269.8631579
Diagnostic laryngoscopy

T
0073
3.8463
236.42
69.15
47.2831580
Revision of larynx

T
0256
38.1991
2,348.02

469.6031582
Revision of larynx

T
0256
38.1991
2,348.02

469.6031588
Revision of larynx

T
0256
38.1991
2,348.02

469.6031590
Reinnervate larynx

T
0256
38.1991
2,348.02

469.6031595
Larynx nerve surgery

T
0256
38.1991
2,348.02

469.6031599
Larynx surgery procedure

T
0251
2.452
150.72

30.1431600
Incision of windpipe

T
0254
23.3299
1,434.04
321.35
286.8131601
Incision of windpipe

T
0254
23.3299
1,434.04
321.35
286.8131603
Incision of windpipe

T
0252
7.5511
464.15
109.16
92.83( print page 68313)31605
Incision of windpipe

T
0252
7.5511
464.15
109.16
92.8331610
Incision of windpipe

T
0254
23.3299
1,434.04
321.35
286.8131611
Surgery/speech prosthesis

T
0254
23.3299
1,434.04
321.35
286.8131612
Puncture/clear windpipe

T
0254
23.3299
1,434.04
321.35
286.8131613
Repair windpipe opening

T
0254
23.3299
1,434.04
321.35
286.8131614
Repair windpipe opening

T
0256
38.1991
2,348.02

469.6031615
Visualization of windpipe

T
0076
9.5228
585.35
189.82
117.0731620
Endobronchial us add-on

S
0670
32.2854
1,984.52
536.10
396.9031622
Dx bronchoscope/wash

T
0076
9.5228
585.35
189.82
117.0731623
Dx bronchoscope/brush

T
0076
9.5228
585.35
189.82
117.0731624
Dx bronchoscope/lavage

T
0076
9.5228
585.35
189.82
117.0731625
Bronchoscopy w/biopsy(s)

T
0076
9.5228
585.35
189.82
117.0731628
Bronchoscopy/lung bx, each

T
0076
9.5228
585.35
189.82
117.0731629
Bronchoscopy/needle bx, each

T
0076
9.5228
585.35
189.82
117.0731630
Bronchoscopy dilate/fx repr

T
0415
22.0099
1,352.90
459.92
270.5831631
Bronchoscopy, dilate w/stent

T
0415
22.0099
1,352.90
459.92
270.5831632
Bronchoscopy/lung bx, add'l

T
0076
9.5228
585.35
189.82
117.0731633
Bronchoscopy/needle bx add'l

T
0076
9.5228
585.35
189.82
117.0731635
Bronchoscopy w/fb removal

T
0076
9.5228
585.35
189.82
117.0731636
Bronchoscopy, bronch stents

T
0415
22.0099
1,352.90
459.92
270.5831637
Bronchoscopy, stent add-on

T
0076
9.5228
585.35
189.82
117.0731638
Bronchoscopy, revise stent

T
0415
22.0099
1,352.90
459.92
270.5831640
Bronchoscopy w/tumor excise

T
0415
22.0099
1,352.90
459.92
270.5831641
Bronchoscopy, treat blockage

T
0415
22.0099
1,352.90
459.92
270.5831643
Diag bronchoscope/catheter

T
0076
9.5228
585.35
189.82
117.0731645
Bronchoscopy, clear airways

T
0076
9.5228
585.35
189.82
117.0731646
Bronchoscopy, reclear airway

T
0076
9.5228
585.35
189.82
117.0731656
Bronchoscopy, inj for x-ray

T
0076
9.5228
585.35
189.82
117.0731700
Insertion of airway catheter
CH
D31708
Instill airway contrast dye
CH
D31710
Insertion of airway catheter
CH
D31715
Injection for bronchus x-ray

N31717
Bronchial brush biopsy

T
0073
3.8463
236.42
69.15
47.2831720
Clearance of airways

T
0071
0.7698
47.32
11.20
9.4631730
Intro, windpipe wire/tube

T
0073
3.8463
236.42
69.15
47.2831750
Repair of windpipe

T
0256
38.1991
2,348.02

469.6031755
Repair of windpipe

T
0256
38.1991
2,348.02

469.6031785
Remove windpipe lesion

T
0254
23.3299
1,434.04
321.35
286.8131820
Closure of windpipe lesion

T
0253
16.4266
1,009.71
282.29
201.9431825
Repair of windpipe defect

T
0254
23.3299
1,434.04
321.35
286.8131830
Revise windpipe scar

T
0254
23.3299
1,434.04
321.35
286.8131899
Airways surgical procedure

T
0076
9.5228
585.35
189.82
117.0732000
Drainage of chest

T
0070
3.6244
222.78

44.5632002
Treatment of collapsed lung

T
0070
3.6244
222.78

44.5632005
Treat lung lining chemically

T
0070
3.6244
222.78

44.5632019
Insert pleural catheter
CH
T
0652
29.5416
1,815.86

363.1732020
Insertion of chest tube

T
0070
3.6244
222.78

44.5632201
Drain, percut, lung lesion

T
0070
3.6244
222.78

44.5632400
Needle biopsy chest lining

T
0685
6.1384
377.32
115.47
75.4632405
Biopsy, lung or mediastinum

T
0685
6.1384
377.32
115.47
75.4632420
Puncture/clear lung

T
0070
3.6244
222.78

44.5632601
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132602
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132603
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132604
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132605
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132606
Thoracoscopy, diagnostic

T
0069
31.9442
1,963.55
591.64
392.7132960
Therapeutic pneumothorax

T
0070
3.6244
222.78

44.5632998
Perq rf ablate tx, pul tumor
NI
T
0423
37.3604
2,296.47

459.2932999
Chest surgery procedure

T
0070
3.6244
222.78

44.5633010
Drainage of heart sac

T
0070
3.6244
222.78

44.5633011
Repeat drainage of heart sac

T
0070
3.6244
222.78

44.5633200
Insertion of heart pacemaker
CH
D33201
Insertion of heart pacemaker
CH
D33202
Insert epicard eltrd, open
NI
C33203
Insert epicard eltrd, endo
NI
C33206
Insertion of heart pacemaker

T
0089
123.6693
7,601.70
1,682.28
1,520.3433207
Insertion of heart pacemaker

T
0089
123.6693
7,601.70
1,682.28
1,520.3433208
Insertion of heart pacemaker

T
0655
152.6392
9,382.43

1,876.4933210
Insertion of heart electrode

T
0106
58.8594
3,617.97

723.59( print page 68314)33211
Insertion of heart electrode

T
0106
58.8594
3,617.97

723.5933212
Insertion of pulse generator

T
0090
98.3023
6,042.45
1,612.80
1,208.4933213
Insertion of pulse generator

T
0654
112.7719
6,931.86

1,386.3733214
Upgrade of pacemaker system

T
0655
152.6392
9,382.43

1,876.4933215
Reposition pacing-defib lead

T
0105
25.6142
1,574.45
370.40
314.8933216
Insert lead pace-defib, one

T
0106
58.8594
3,617.97

723.5933217
Insert lead pace-defib, dual

T
0106
58.8594
3,617.97

723.5933218
Repair lead pace-defib, one
CH
T
0105
25.6142
1,574.45
370.40
314.8933220
Repair lead pace-defib, dual
CH
T
0105
25.6142
1,574.45
370.40
314.8933222
Revise pocket, pacemaker

T
0027
21.4302
1,317.27
329.72
263.4533223
Revise pocket, pacing-defib

T
0027
21.4302
1,317.27
329.72
263.4533224
Insert pacing lead & connect

T
0418
307.2828
18,888.06

3,777.6133225
Lventric pacing lead add-on

T
0418
307.2828
18,888.06

3,777.6133226
Reposition l ventric lead

T
0105
25.6142
1,574.45
370.40
314.8933233
Removal of pacemaker system

T
0105
25.6142
1,574.45
370.40
314.8933234
Removal of pacemaker system

T
0105
25.6142
1,574.45
370.40
314.8933235
Removal pacemaker electrode

T
0105
25.6142
1,574.45
370.40
314.8933241
Remove pulse generator

T
0105
25.6142
1,574.45
370.40
314.8933244
Remove eltrd, transven

T
0105
25.6142
1,574.45
370.40
314.8933245
Insert epic eltrd pace-defib
CH
D33246
Insert epic eltrd/generator
CH
D33253
Reconstruct atria
CH
D33254
Ablate atria, lmtd
NI
C33255
Ablate atria w/o bypass, ext
NI
C33256
Ablate atria w/bypass, exten
NI
C33265
Ablate atria w/bypass, endo
NI
C33266
Ablate atria w/o bypass endo
NI
C33282
Implant pat-active ht record

S
0680
72.6022
4,462.71

892.5433284
Remove pat-active ht record

T
0109
10.9918
675.64

135.1333508
Endoscopic vein harvest

N33675
Close mult vsd
NI
C33676
Close mult vsd w/resection
NI
C33677
Cl mult vsd w/rem pul band
NI
C33724
Repair venous anomaly
NI
C33726
Repair pul venous stenosis
NI
C33999
Cardiac surgery procedure

T
0070
3.6244
222.78

44.5634101
Removal of artery clot

T
0088
37.7391
2,319.75
655.22
463.9534111
Removal of arm artery clot

T
0088
37.7391
2,319.75
655.22
463.9534201
Removal of artery clot

T
0088
37.7391
2,319.75
655.22
463.9534203
Removal of leg artery clot

T
0088
37.7391
2,319.75
655.22
463.9534421
Removal of vein clot

T
0088
37.7391
2,319.75
655.22
463.9534471
Removal of vein clot

T
0088
37.7391
2,319.75
655.22
463.9534490
Removal of vein clot

T
0088
37.7391
2,319.75
655.22
463.9534501
Repair valve, femoral vein

T
0088
37.7391
2,319.75
655.22
463.9534510
Transposition of vein valve

T
0088
37.7391
2,319.75
655.22
463.9534520
Cross-over vein graft

T
0088
37.7391
2,319.75
655.22
463.9534530
Leg vein fusion

T
0088
37.7391
2,319.75
655.22
463.9535011
Repair defect of artery

T
0653
32.3818
1,990.44

398.0935180
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035184
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035188
Repair blood vessel lesion

T
0088
37.7391
2,319.75
655.22
463.9535190
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035201
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035206
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035207
Repair blood vessel lesion

T
0088
37.7391
2,319.75
655.22
463.9535226
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035231
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035236
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035256
Repair blood vessel lesion

T
0093
22.8653
1,405.48

281.1035261
Repair blood vessel lesion

T
0653
32.3818
1,990.44

398.0935266
Repair blood vessel lesion

T
0653
32.3818
1,990.44

398.0935286
Repair blood vessel lesion

T
0653
32.3818
1,990.44

398.0935302
Rechanneling of artery
NI
C35303
Rechanneling of artery
NI
C35304
Rechanneling of artery
NI
C35305
Rechanneling of artery
NI
C35306
Rechanneling of artery
NI
C35321
Rechanneling of artery

T
0093
22.8653
1,405.48

281.1035381
Rechanneling of artery
CH
D35458
Repair arterial blockage

T
0081
42.936
2,639.19

527.84( print page 68315)35459
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435460
Repair venous blockage

T
0081
42.936
2,639.19

527.8435470
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435471
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435472
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435473
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435474
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435475
Repair arterial blockage

T
0081
42.936
2,639.19

527.8435476
Repair venous blockage

T
0081
42.936
2,639.19

527.8435484
Atherectomy, open

T
0081
42.936
2,639.19

527.8435485
Atherectomy, open

T
0081
42.936
2,639.19

527.8435490
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435491
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435492
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435493
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435494
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435495
Atherectomy, percutaneous

T
0081
42.936
2,639.19

527.8435500
Harvest vein for bypass

T
0081
42.936
2,639.19

527.8435507
Artery bypass graft
CH
D35537
Artery bypass graft
NI
C35538
Artery bypass graft
NI
C35539
Artery bypass graft
NI
C35540
Artery bypass graft
NI
C35541
Artery bypass graft
CH
D35546
Artery bypass graft
CH
D35572
Harvest femoropopliteal vein

N35637
Artery bypass graft
NI
C35638
Artery bypass graft
NI
C35641
Artery bypass graft
CH
D35685
Bypass graft patency/patch

T
0093
22.8653
1,405.48

281.1035686
Bypass graft/av fist patency

T
0093
22.8653
1,405.48

281.1035761
Exploration of artery/vein

T
0115
29.2133
1,795.68
374.81
359.1435860
Explore limb vessels

T
0093
22.8653
1,405.48

281.1035875
Removal of clot in graft

T
0088
37.7391
2,319.75
655.22
463.9535876
Removal of clot in graft

T
0088
37.7391
2,319.75
655.22
463.9535879
Revise graft w/vein

T
0088
37.7391
2,319.75
655.22
463.9535881
Revise graft w/vein

T
0088
37.7391
2,319.75
655.22
463.9535883
Revise graft w/nonauto graft
NI
T
0088
37.7391
2,319.75
655.22
463.9535884
Revise graft w/vein
NI
T
0088
37.7391
2,319.75
655.22
463.9535903
Excision, graft, extremity

T
0115
29.2133
1,795.68
374.81
359.1436000
Place needle in vein

N36002
Pseudoaneurysm injection trt

S
0267
2.4606
151.25
60.50
30.2536005
Injection ext venography

N36010
Place catheter in vein

N36011
Place catheter in vein

N36012
Place catheter in vein

N36013
Place catheter in artery

N36014
Place catheter in artery

N36015
Place catheter in artery

N36100
Establish access to artery

N36120
Establish access to artery

N36140
Establish access to artery

N36145
Artery to vein shunt

N36160
Establish access to aorta

N36200
Place catheter in aorta

N36215
Place catheter in artery

N36216
Place catheter in artery

N36217
Place catheter in artery

N36218
Place catheter in artery

N36245
Place catheter in artery

N36246
Place catheter in artery

N36247
Place catheter in artery

N36248
Place catheter in artery

N36260
Insertion of infusion pump

T
0623
28.5032
1,752.03

350.4136261
Revision of infusion pump

T
0623
28.5032
1,752.03

350.4136262
Removal of infusion pump

T
0622
22.6665
1,393.26

278.6536299
Vessel injection procedure

N36400
Bl draw < 3 yrs fem/jugular

N36405
Bl draw < 3 yrs scalp vein

N36406
Bl draw < 3 yrs other vein

N( print page 68316)36410
Non-routine bl draw > 3 yrs

N36416
Capillary blood draw

N36420
Vein access cutdown < 1 yr

T
0035
0.1999
12.29

2.4636425
Vein access cutdown > 1 yr

T
0035
0.1999
12.29

2.4636430
Blood transfusion service

S
0110
3.4584
212.58

42.5236440
Bl push transfuse, 2 yr or <

S
0110
3.4584
212.58

42.5236450
Bl exchange/transfuse, nb

S
0110
3.4584
212.58

42.5236455
Bl exchange/transfuse non-nb

S
0110
3.4584
212.58

42.5236460
Transfusion service, fetal

S
0110
3.4584
212.58

42.5236468
Injection(s), spider veins

T
0098
1.0798
66.37

13.2736469
Injection(s), spider veins

T
0098
1.0798
66.37

13.2736470
Injection therapy of vein

T
0098
1.0798
66.37

13.2736471
Injection therapy of veins

T
0098
1.0798
66.37

13.2736475
Endovenous rf, 1st vein

T
0091
34.7288
2,134.71

426.9436476
Endovenous rf, vein add-on

T
0091
34.7288
2,134.71

426.9436478
Endovenous laser, 1st vein
CH
T
0092
24.8809
1,529.38
309.87
305.8836479
Endovenous laser vein addon
CH
T
0092
24.8809
1,529.38
309.87
305.8836481
Insertion of catheter, vein

N36500
Insertion of catheter, vein

N36510
Insertion of catheter, vein

N36511
Apheresis wbc

S
0111
11.7134
720.00
198.40
144.0036512
Apheresis rbc

S
0111
11.7134
720.00
198.40
144.0036513
Apheresis platelets

S
0111
11.7134
720.00
198.40
144.0036514
Apheresis plasma

S
0111
11.7134
720.00
198.40
144.0036515
Apheresis, adsorp/reinfuse

S
0112
30.2231
1,857.75
433.29
371.5536516
Apheresis, selective

S
0112
30.2231
1,857.75
433.29
371.5536522
Photopheresis

S
0112
30.2231
1,857.75
433.29
371.5536540
Collect blood venous device
CH
Q
0624
0.5145
31.63
12.65
6.3336550
Declot vascular device

T
0676
2.0726
127.40

25.4836555
Insert non-tunnel cv cath

T
0621
8.7846
539.97

107.9936556
Insert non-tunnel cv cath

T
0621
8.7846
539.97

107.9936557
Insert tunneled cv cath

T
0622
22.6665
1,393.26

278.6536558
Insert tunneled cv cath

T
0622
22.6665
1,393.26

278.6536560
Insert tunneled cv cath

T
0623
28.5032
1,752.03

350.4136561
Insert tunneled cv cath

T
0623
28.5032
1,752.03

350.4136563
Insert tunneled cv cath

T
0623
28.5032
1,752.03

350.4136565
Insert tunneled cv cath

T
0623
28.5032
1,752.03

350.4136566
Insert tunneled cv cath
CH
T
0625
83.4609
5,130.17

1,026.0336568
Insert picc cath

T
0621
8.7846
539.97

107.9936569
Insert picc cath

T
0621
8.7846
539.97

107.9936570
Insert picvad cath

T
0622
22.6665
1,393.26

278.6536571
Insert picvad cath

T
0622
22.6665
1,393.26

278.6536575
Repair tunneled cv cath

T
0621
8.7846
539.97

107.9936576
Repair tunneled cv cath

T
0621
8.7846
539.97

107.9936578
Replace tunneled cv cath

T
0622
22.6665
1,393.26

278.6536580
Replace cvad cath

T
0621
8.7846
539.97

107.9936581
Replace tunneled cv cath

T
0622
22.6665
1,393.26

278.6536582
Replace tunneled cv cath

T
0623
28.5032
1,752.03

350.4136583
Replace tunneled cv cath

T
0623
28.5032
1,752.03

350.4136584
Replace picc cath

T
0621
8.7846
539.97

107.9936585
Replace picvad cath

T
0622
22.6665
1,393.26

278.6536589
Removal tunneled cv cath

T
0621
8.7846
539.97

107.9936590
Removal tunneled cv cath

T
0621
8.7846
539.97

107.9936595
Mech remov tunneled cv cath

T
0622
22.6665
1,393.26

278.6536596
Mech remov tunneled cv cath

T
0621
8.7846
539.97

107.9936597
Reposition venous catheter

T
0621
8.7846
539.97

107.9936598
Inj w/fluor, eval cv device

X
0340
0.6102
37.51

7.5036600
Withdrawal of arterial blood
CH
Q
0035
0.1999
12.29

2.4636620
Insertion catheter, artery

N36625
Insertion catheter, artery

N36640
Insertion catheter, artery

T
0623
28.5032
1,752.03

350.4136680
Insert needle, bone cavity

T
0002
1.0995
67.58

13.5236800
Insertion of cannula

T
0115
29.2133
1,795.68
374.81
359.1436810
Insertion of cannula

T
0115
29.2133
1,795.68
374.81
359.1436815
Insertion of cannula

T
0115
29.2133
1,795.68
374.81
359.1436818
Av fuse, uppr arm, cephalic

T
0088
37.7391
2,319.75
655.22
463.9536819
Av fuse, uppr arm, basilic

T
0088
37.7391
2,319.75
655.22
463.9536820
Av fusion/forearm vein

T
0088
37.7391
2,319.75
655.22
463.9536821
Av fusion direct any site

T
0088
37.7391
2,319.75
655.22
463.9536825
Artery-vein autograft

T
0088
37.7391
2,319.75
655.22
463.95( print page 68317)36830
Artery-vein nonautograft

T
0088
37.7391
2,319.75
655.22
463.9536831
Open thrombect av fistula

T
0088
37.7391
2,319.75
655.22
463.9536832
Av fistula revision, open

T
0088
37.7391
2,319.75
655.22
463.9536833
Av fistula revision

T
0088
37.7391
2,319.75
655.22
463.9536834
Repair A-V aneurysm

T
0088
37.7391
2,319.75
655.22
463.9536835
Artery to vein shunt

T
0115
29.2133
1,795.68
374.81
359.1436838
Dist revas ligation, hemo

T
0088
37.7391
2,319.75
655.22
463.9536860
External cannula declotting

T
0676
2.0726
127.40

25.4836861
Cannula declotting

T
0115
29.2133
1,795.68
374.81
359.1436870
Percut thrombect av fistula

T
0653
32.3818
1,990.44

398.0937183
Remove hepatic shunt (tips)

T
0229
68.4697
4,208.70

841.7437184
Prim art mech thrombectomy
CH
T
0088
37.7391
2,319.75
655.22
463.9537185
Prim art m-thrombect add-on
CH
T
0088
37.7391
2,319.75
655.22
463.9537186
Sec art m-thrombect add-on
CH
T
0088
37.7391
2,319.75
655.22
463.9537187
Venous mech thrombectomy
CH
T
0088
37.7391
2,319.75
655.22
463.9537188
Venous m-thrombectomy add-on
CH
T
0088
37.7391
2,319.75
655.22
463.9537195
Thrombolytic therapy, stroke

T
0676
2.0726
127.40

25.4837200
Transcatheter biopsy

T
0685
6.1384
377.32
115.47
75.4637201
Transcatheter therapy infuse

T
0676
2.0726
127.40

25.4837202
Transcatheter therapy infuse

T
0676
2.0726
127.40

25.4837203
Transcatheter retrieval

T
0103
16.2375
998.09
223.63
199.6237204
Transcatheter occlusion

T
0115
29.2133
1,795.68
374.81
359.1437205
Transcath iv stent, percut

T
0229
68.4697
4,208.70

841.7437206
Transcath iv stent/perc addl

T
0229
68.4697
4,208.70

841.7437207
Transcath iv stent, open

T
0229
68.4697
4,208.70

841.7437208
Transcath iv stent/open addl

T
0229
68.4697
4,208.70

841.7437209
Change iv cath at thromb tx

T
0103
16.2375
998.09
223.63
199.6237210
Embolization uterine fibroid
NI
T
0202
42.9896
2,642.48
981.50
528.5037250
Iv us first vessel add-on

S
0416
32.5472
2,000.61

400.1237251
Iv us each add vessel add-on

S
0416
32.5472
2,000.61

400.1237500
Endoscopy ligate perf veins
CH
T
0091
34.7288
2,134.71

426.9437501
Vascular endoscopy procedure

T
0092
24.8809
1,529.38
309.87
305.8837565
Ligation of neck vein

T
0093
22.8653
1,405.48

281.1037600
Ligation of neck artery

T
0093
22.8653
1,405.48

281.1037605
Ligation of neck artery

T
0091
34.7288
2,134.71

426.9437606
Ligation of neck artery
CH
T
0092
24.8809
1,529.38
309.87
305.8837607
Ligation of a-v fistula

T
0092
24.8809
1,529.38
309.87
305.8837609
Temporal artery procedure

T
0021
15.1024
928.31
219.48
185.6637615
Ligation of neck artery
CH
T
0092
24.8809
1,529.38
309.87
305.8837620
Revision of major vein

T
0091
34.7288
2,134.71

426.9437650
Revision of major vein
CH
T
0092
24.8809
1,529.38
309.87
305.8837700
Revise leg vein

T
0091
34.7288
2,134.71

426.9437718
Ligate/strip short leg vein
CH
T
0091
34.7288
2,134.71

426.9437722
Ligate/strip long leg vein
CH
T
0091
34.7288
2,134.71

426.9437735
Removal of leg veins/lesion
CH
T
0091
34.7288
2,134.71

426.9437760
Ligation, leg veins, open
CH
T
0092
24.8809
1,529.38
309.87
305.8837765
Phleb veins—extrem—to 20
CH
T
0092
24.8809
1,529.38
309.87
305.8837766
Phleb veins—extrem 20+
CH
T
0092
24.8809
1,529.38
309.87
305.8837780
Revision of leg vein
CH
T
0092
24.8809
1,529.38
309.87
305.8837785
Ligate/divide/excise vein
CH
T
0092
24.8809
1,529.38
309.87
305.8837790
Penile venous occlusion

T
0181
32.9873
2,027.66
621.82
405.5337799
Vascular surgery procedure

T
0103
16.2375
998.09
223.63
199.6238120
Laparoscopy, splenectomy

T
0131
43.5488
2,676.86
1,001.89
535.3738129
Laparoscope proc, spleen

T
0130
32.1241
1,974.60
659.53
394.9238200
Injection for spleen x-ray

N38204
Bl donor search management

N38205
Harvest allogenic stem cells

S
0111
11.7134
720.00
198.40
144.0038206
Harvest auto stem cells

S
0111
11.7134
720.00
198.40
144.0038220
Bone marrow aspiration

T
0003
2.4011
147.59

29.5238221
Bone marrow biopsy

T
0003
2.4011
147.59

29.5238230
Bone marrow collection

S
0123
20.3582
1,251.38

250.2838240
Bone marrow/stem transplant

S
0123
20.3582
1,251.38

250.2838241
Bone marrow/stem transplant

S
0123
20.3582
1,251.38

250.2838242
Lymphocyte infuse transplant

S
0111
11.7134
720.00
198.40
144.0038300
Drainage, lymph node lesion

T
0007
11.1535
685.58

137.1238305
Drainage, lymph node lesion

T
0008
17.5086
1,076.22

215.2438308
Incision of lymph channels

T
0113
21.2621
1,306.94

261.3938500
Biopsy/removal, lymph nodes

T
0113
21.2621
1,306.94

261.3938505
Needle biopsy, lymph nodes

T
0005
3.9045
240.00
71.59
48.0038510
Biopsy/removal, lymph nodes

T
0113
21.2621
1,306.94

261.39( print page 68318)38520
Biopsy/removal, lymph nodes

T
0113
21.2621
1,306.94

261.3938525
Biopsy/removal, lymph nodes

T
0113
21.2621
1,306.94

261.3938530
Biopsy/removal, lymph nodes

T
0113
21.2621
1,306.94

261.3938542
Explore deep node(s), neck

T
0114
37.7224
2,318.72
467.95
463.7438550
Removal, neck/armpit lesion

T
0113
21.2621
1,306.94

261.3938555
Removal, neck/armpit lesion

T
0113
21.2621
1,306.94

261.3938570
Laparoscopy, lymph node biop

T
0131
43.5488
2,676.86
1,001.89
535.3738571
Laparoscopy, lymphadenectomy

T
0132
70.5066
4,333.90
1,239.22
866.7838572
Laparoscopy, lymphadenectomy

T
0131
43.5488
2,676.86
1,001.89
535.3738589
Laparoscope proc, lymphatic

T
0130
32.1241
1,974.60
659.53
394.9238700
Removal of lymph nodes, neck

T
0113
21.2621
1,306.94

261.3938720
Removal of lymph nodes, neck

T
0113
21.2621
1,306.94

261.3938740
Remove armpit lymph nodes

T
0114
37.7224
2,318.72
467.95
463.7438745
Remove armpit lymph nodes

T
0114
37.7224
2,318.72
467.95
463.7438760
Remove groin lymph nodes

T
0113
21.2621
1,306.94

261.3938790
Inject for lymphatic x-ray

N38792
Identify sentinel node
CH
Q
0389
1.3754
84.54
33.81
16.9138794
Access thoracic lymph duct

N38999
Blood/lymph system procedure

S
0110
3.4584
212.58

42.5239400
Visualization of chest

T
0069
31.9442
1,963.55
591.64
392.7140490
Biopsy of lip

T
0251
2.452
150.72

30.1440500
Partial excision of lip

T
0253
16.4266
1,009.71
282.29
201.9440510
Partial excision of lip

T
0254
23.3299
1,434.04
321.35
286.8140520
Partial excision of lip

T
0253
16.4266
1,009.71
282.29
201.9440525
Reconstruct lip with flap

T
0254
23.3299
1,434.04
321.35
286.8140527
Reconstruct lip with flap

T
0254
23.3299
1,434.04
321.35
286.8140530
Partial removal of lip

T
0254
23.3299
1,434.04
321.35
286.8140650
Repair lip

T
0252
7.5511
464.15
109.16
92.8340652
Repair lip

T
0252
7.5511
464.15
109.16
92.8340654
Repair lip

T
0252
7.5511
464.15
109.16
92.8340700
Repair cleft lip/nasal

T
0256
38.1991
2,348.02

469.6040701
Repair cleft lip/nasal

T
0256
38.1991
2,348.02

469.6040702
Repair cleft lip/nasal

T
0256
38.1991
2,348.02

469.6040720
Repair cleft lip/nasal

T
0256
38.1991
2,348.02

469.6040761
Repair cleft lip/nasal

T
0256
38.1991
2,348.02

469.6040799
Lip surgery procedure

T
0251
2.452
150.72

30.1440800
Drainage of mouth lesion
CH
T
0006
1.4392
88.46

17.6940801
Drainage of mouth lesion

T
0252
7.5511
464.15
109.16
92.8340804
Removal, foreign body, mouth

X
0340
0.6102
37.51

7.5040805
Removal, foreign body, mouth

T
0252
7.5511
464.15
109.16
92.8340806
Incision of lip fold

T
0251
2.452
150.72

30.1440808
Biopsy of mouth lesion

T
0251
2.452
150.72

30.1440810
Excision of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9440812
Excise/repair mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9440814
Excise/repair mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9440816
Excision of mouth lesion

T
0254
23.3299
1,434.04
321.35
286.8140818
Excise oral mucosa for graft

T
0251
2.452
150.72

30.1440819
Excise lip or cheek fold

T
0252
7.5511
464.15
109.16
92.8340820
Treatment of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9440830
Repair mouth laceration

T
0251
2.452
150.72

30.1440831
Repair mouth laceration

T
0252
7.5511
464.15
109.16
92.8340840
Reconstruction of mouth

T
0254
23.3299
1,434.04
321.35
286.8140842
Reconstruction of mouth

T
0254
23.3299
1,434.04
321.35
286.8140843
Reconstruction of mouth

T
0254
23.3299
1,434.04
321.35
286.8140844
Reconstruction of mouth

T
0256
38.1991
2,348.02

469.6040845
Reconstruction of mouth

T
0256
38.1991
2,348.02

469.6040899
Mouth surgery procedure

T
0251
2.452
150.72

30.1441000
Drainage of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9441005
Drainage of mouth lesion

T
0251
2.452
150.72

30.1441006
Drainage of mouth lesion

T
0254
23.3299
1,434.04
321.35
286.8141007
Drainage of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9441008
Drainage of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9441009
Drainage of mouth lesion

T
0251
2.452
150.72

30.1441010
Incision of tongue fold

T
0252
7.5511
464.15
109.16
92.8341015
Drainage of mouth lesion

T
0251
2.452
150.72

30.1441016
Drainage of mouth lesion

T
0252
7.5511
464.15
109.16
92.8341017
Drainage of mouth lesion

T
0252
7.5511
464.15
109.16
92.8341018
Drainage of mouth lesion

T
0252
7.5511
464.15
109.16
92.8341100
Biopsy of tongue

T
0252
7.5511
464.15
109.16
92.8341105
Biopsy of tongue

T
0253
16.4266
1,009.71
282.29
201.94( print page 68319)41108
Biopsy of floor of mouth

T
0252
7.5511
464.15
109.16
92.8341110
Excision of tongue lesion

T
0253
16.4266
1,009.71
282.29
201.9441112
Excision of tongue lesion

T
0253
16.4266
1,009.71
282.29
201.9441113
Excision of tongue lesion

T
0253
16.4266
1,009.71
282.29
201.9441114
Excision of tongue lesion

T
0254
23.3299
1,434.04
321.35
286.8141115
Excision of tongue fold

T
0252
7.5511
464.15
109.16
92.8341116
Excision of mouth lesion

T
0253
16.4266
1,009.71
282.29
201.9441120
Partial removal of tongue

T
0254
23.3299
1,434.04
321.35
286.8141250
Repair tongue laceration

T
0251
2.452
150.72

30.1441251
Repair tongue laceration

T
0251
2.452
150.72

30.1441252
Repair tongue laceration

T
0252
7.5511
464.15
109.16
92.8341500
Fixation of tongue

T
0254
23.3299
1,434.04
321.35
286.8141510
Tongue to lip surgery

T
0253
16.4266
1,009.71
282.29
201.9441520
Reconstruction, tongue fold

T
0252
7.5511
464.15
109.16
92.8341599
Tongue and mouth surgery

T
0251
2.452
150.72

30.1441800
Drainage of gum lesion
CH
T
0006
1.4392
88.46

17.6941805
Removal foreign body, gum

T
0254
23.3299
1,434.04
321.35
286.8141806
Removal foreign body,jawbone

T
0253
16.4266
1,009.71
282.29
201.9441820
Excision, gum, each quadrant

T
0252
7.5511
464.15
109.16
92.8341821
Excision of gum flap

T
0252
7.5511
464.15
109.16
92.8341822
Excision of gum lesion

T
0253
16.4266
1,009.71
282.29
201.9441823
Excision of gum lesion

T
0254
23.3299
1,434.04
321.35
286.8141825
Excision of gum lesion

T
0253
16.4266
1,009.71
282.29
201.9441826
Excision of gum lesion

T
0253
16.4266
1,009.71
282.29
201.9441827
Excision of gum lesion

T
0254
23.3299
1,434.04
321.35
286.8141828
Excision of gum lesion

T
0253
16.4266
1,009.71
282.29
201.9441830
Removal of gum tissue

T
0253
16.4266
1,009.71
282.29
201.9441850
Treatment of gum lesion

T
0253
16.4266
1,009.71
282.29
201.9441870
Gum graft

T
0254
23.3299
1,434.04
321.35
286.8141872
Repair gum

T
0253
16.4266
1,009.71
282.29
201.9441874
Repair tooth socket

T
0254
23.3299
1,434.04
321.35
286.8141899
Dental surgery procedure

T
0251
2.452
150.72

30.1442000
Drainage mouth roof lesion

T
0251
2.452
150.72

30.1442100
Biopsy roof of mouth

T
0252
7.5511
464.15
109.16
92.8342104
Excision lesion, mouth roof

T
0253
16.4266
1,009.71
282.29
201.9442106
Excision lesion, mouth roof

T
0253
16.4266
1,009.71
282.29
201.9442107
Excision lesion, mouth roof

T
0254
23.3299
1,434.04
321.35
286.8142120
Remove palate/lesion

T
0256
38.1991
2,348.02

469.6042140
Excision of uvula

T
0252
7.5511
464.15
109.16
92.8342145
Repair palate, pharynx/uvula

T
0254
23.3299
1,434.04
321.35
286.8142160
Treatment mouth roof lesion

T
0253
16.4266
1,009.71
282.29
201.9442180
Repair palate

T
0251
2.452
150.72

30.1442182
Repair palate

T
0256
38.1991
2,348.02

469.6042200
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042205
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042210
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042215
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042220
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042225
Reconstruct cleft palate

T
0256
38.1991
2,348.02

469.6042226
Lengthening of palate

T
0256
38.1991
2,348.02

469.6042227
Lengthening of palate

T
0256
38.1991
2,348.02

469.6042235
Repair palate

T
0253
16.4266
1,009.71
282.29
201.9442260
Repair nose to lip fistula

T
0254
23.3299
1,434.04
321.35
286.8142280
Preparation, palate mold

T
0251
2.452
150.72

30.1442281
Insertion, palate prosthesis

T
0253
16.4266
1,009.71
282.29
201.9442299
Palate/uvula surgery

T
0251
2.452
150.72

30.1442300
Drainage of salivary gland

T
0253
16.4266
1,009.71
282.29
201.9442305
Drainage of salivary gland

T
0253
16.4266
1,009.71
282.29
201.9442310
Drainage of salivary gland

T
0251
2.452
150.72

30.1442320
Drainage of salivary gland

T
0251
2.452
150.72

30.1442330
Removal of salivary stone

T
0253
16.4266
1,009.71
282.29
201.9442335
Removal of salivary stone

T
0253
16.4266
1,009.71
282.29
201.9442340
Removal of salivary stone

T
0253
16.4266
1,009.71
282.29
201.9442400
Biopsy of salivary gland

T
0005
3.9045
240.00
71.59
48.0042405
Biopsy of salivary gland

T
0253
16.4266
1,009.71
282.29
201.9442408
Excision of salivary cyst

T
0253
16.4266
1,009.71
282.29
201.9442409
Drainage of salivary cyst

T
0253
16.4266
1,009.71
282.29
201.9442410
Excise parotid gland/lesion

T
0256
38.1991
2,348.02

469.6042415
Excise parotid gland/lesion

T
0256
38.1991
2,348.02

469.6042420
Excise parotid gland/lesion

T
0256
38.1991
2,348.02

469.60( print page 68320)42425
Excise parotid gland/lesion

T
0256
38.1991
2,348.02

469.6042440
Excise submaxillary gland

T
0256
38.1991
2,348.02

469.6042450
Excise sublingual gland

T
0254
23.3299
1,434.04
321.35
286.8142500
Repair salivary duct

T
0254
23.3299
1,434.04
321.35
286.8142505
Repair salivary duct

T
0256
38.1991
2,348.02

469.6042507
Parotid duct diversion

T
0256
38.1991
2,348.02

469.6042508
Parotid duct diversion

T
0256
38.1991
2,348.02

469.6042509
Parotid duct diversion

T
0256
38.1991
2,348.02

469.6042510
Parotid duct diversion

T
0256
38.1991
2,348.02

469.6042550
Injection for salivary x-ray

N42600
Closure of salivary fistula

T
0253
16.4266
1,009.71
282.29
201.9442650
Dilation of salivary duct

T
0252
7.5511
464.15
109.16
92.8342660
Dilation of salivary duct

T
0251
2.452
150.72

30.1442665
Ligation of salivary duct

T
0254
23.3299
1,434.04
321.35
286.8142699
Salivary surgery procedure

T
0251
2.452
150.72

30.1442700
Drainage of tonsil abscess

T
0251
2.452
150.72

30.1442720
Drainage of throat abscess

T
0253
16.4266
1,009.71
282.29
201.9442725
Drainage of throat abscess

T
0256
38.1991
2,348.02

469.6042800
Biopsy of throat
CH
T
0252
7.5511
464.15
109.16
92.8342802
Biopsy of throat

T
0253
16.4266
1,009.71
282.29
201.9442804
Biopsy of upper nose/throat

T
0253
16.4266
1,009.71
282.29
201.9442806
Biopsy of upper nose/throat

T
0254
23.3299
1,434.04
321.35
286.8142808
Excise pharynx lesion

T
0253
16.4266
1,009.71
282.29
201.9442809
Remove pharynx foreign body

X
0340
0.6102
37.51

7.5042810
Excision of neck cyst

T
0254
23.3299
1,434.04
321.35
286.8142815
Excision of neck cyst

T
0256
38.1991
2,348.02

469.6042820
Remove tonsils and adenoids

T
0258
22.1165
1,359.46
437.25
271.8942821
Remove tonsils and adenoids

T
0258
22.1165
1,359.46
437.25
271.8942825
Removal of tonsils

T
0258
22.1165
1,359.46
437.25
271.8942826
Removal of tonsils

T
0258
22.1165
1,359.46
437.25
271.8942830
Removal of adenoids

T
0258
22.1165
1,359.46
437.25
271.8942831
Removal of adenoids

T
0258
22.1165
1,359.46
437.25
271.8942835
Removal of adenoids

T
0258
22.1165
1,359.46
437.25
271.8942836
Removal of adenoids

T
0258
22.1165
1,359.46
437.25
271.8942842
Extensive surgery of throat

T
0254
23.3299
1,434.04
321.35
286.8142844
Extensive surgery of throat

T
0256
38.1991
2,348.02

469.6042860
Excision of tonsil tags

T
0258
22.1165
1,359.46
437.25
271.8942870
Excision of lingual tonsil

T
0258
22.1165
1,359.46
437.25
271.8942890
Partial removal of pharynx

T
0256
38.1991
2,348.02

469.6042892
Revision of pharyngeal walls

T
0256
38.1991
2,348.02

469.6042900
Repair throat wound

T
0252
7.5511
464.15
109.16
92.8342950
Reconstruction of throat

T
0254
23.3299
1,434.04
321.35
286.8142955
Surgical opening of throat

T
0254
23.3299
1,434.04
321.35
286.8142960
Control throat bleeding

T
0250
1.1791
72.48
25.39
14.5042962
Control throat bleeding

T
0256
38.1991
2,348.02

469.6042970
Control nose/throat bleeding

T
0250
1.1791
72.48
25.39
14.5042972
Control nose/throat bleeding

T
0253
16.4266
1,009.71
282.29
201.9442999
Throat surgery procedure

T
0251
2.452
150.72

30.1443020
Incision of esophagus

T
0252
7.5511
464.15
109.16
92.8343030
Throat muscle surgery

T
0253
16.4266
1,009.71
282.29
201.9443130
Removal of esophagus pouch
CH
T
0256
38.1991
2,348.02

469.6043200
Esophagus endoscopy

T
0141
8.3175
511.26
143.38
102.2543201
Esoph scope w/submucous inj

T
0141
8.3175
511.26
143.38
102.2543202
Esophagus endoscopy, biopsy

T
0141
8.3175
511.26
143.38
102.2543204
Esoph scope w/sclerosis inj

T
0141
8.3175
511.26
143.38
102.2543205
Esophagus endoscopy/ligation

T
0141
8.3175
511.26
143.38
102.2543215
Esophagus endoscopy

T
0141
8.3175
511.26
143.38
102.2543216
Esophagus endoscopy/lesion

T
0141
8.3175
511.26
143.38
102.2543217
Esophagus endoscopy

T
0141
8.3175
511.26
143.38
102.2543219
Esophagus endoscopy

T
0384
22.9475
1,410.54
295.41
282.1143220
Esoph endoscopy, dilation

T
0141
8.3175
511.26
143.38
102.2543226
Esoph endoscopy, dilation

T
0141
8.3175
511.26
143.38
102.2543227
Esoph endoscopy, repair

T
0141
8.3175
511.26
143.38
102.2543228
Esoph endoscopy, ablation

T
0422
25.7552
1,583.12
448.81
316.6243231
Esoph endoscopy w/us exam

T
0141
8.3175
511.26
143.38
102.2543232
Esoph endoscopy w/us fn bx

T
0141
8.3175
511.26
143.38
102.2543234
Upper GI endoscopy, exam

T
0141
8.3175
511.26
143.38
102.2543235
Uppr gi endoscopy, diagnosis

T
0141
8.3175
511.26
143.38
102.2543236
Uppr gi scope w/submuc inj

T
0141
8.3175
511.26
143.38
102.2543237
Endoscopic us exam, esoph

T
0141
8.3175
511.26
143.38
102.25( print page 68321)43238
Uppr gi endoscopy w/us fn bx

T
0141
8.3175
511.26
143.38
102.2543239
Upper GI endoscopy, biopsy

T
0141
8.3175
511.26
143.38
102.2543240
Esoph endoscope w/drain cyst

T
0141
8.3175
511.26
143.38
102.2543241
Upper GI endoscopy with tube

T
0141
8.3175
511.26
143.38
102.2543242
Uppr gi endoscopy w/us fn bx

T
0141
8.3175
511.26
143.38
102.2543243
Upper gi endoscopy & inject

T
0141
8.3175
511.26
143.38
102.2543244
Upper GI endoscopy/ligation

T
0141
8.3175
511.26
143.38
102.2543245
Uppr gi scope dilate strictr

T
0141
8.3175
511.26
143.38
102.2543246
Place gastrostomy tube

T
0141
8.3175
511.26
143.38
102.2543247
Operative upper GI endoscopy

T
0141
8.3175
511.26
143.38
102.2543248
Uppr gi endoscopy/guide wire

T
0141
8.3175
511.26
143.38
102.2543249
Esoph endoscopy, dilation

T
0141
8.3175
511.26
143.38
102.2543250
Upper GI endoscopy/tumor

T
0141
8.3175
511.26
143.38
102.2543251
Operative upper GI endoscopy

T
0141
8.3175
511.26
143.38
102.2543255
Operative upper GI endoscopy

T
0141
8.3175
511.26
143.38
102.2543256
Uppr gi endoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1143257
Uppr gi scope w/thrml txmnt

T
0422
25.7552
1,583.12
448.81
316.6243258
Operative upper GI endoscopy

T
0141
8.3175
511.26
143.38
102.2543259
Endoscopic ultrasound exam

T
0141
8.3175
511.26
143.38
102.2543260
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843261
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843262
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843263
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843264
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843265
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843267
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843268
Endo cholangiopancreatograph

T
0384
22.9475
1,410.54
295.41
282.1143269
Endo cholangiopancreatograph

T
0384
22.9475
1,410.54
295.41
282.1143271
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843272
Endo cholangiopancreatograph

T
0151
19.8381
1,219.41
245.46
243.8843280
Laparoscopy, fundoplasty

T
0132
70.5066
4,333.90
1,239.22
866.7843289
Laparoscope proc, esoph

T
0130
32.1241
1,974.60
659.53
394.9243450
Dilate esophagus

T
0140
5.4566
335.41
91.40
67.0843453
Dilate esophagus

T
0140
5.4566
335.41
91.40
67.0843456
Dilate esophagus

T
0140
5.4566
335.41
91.40
67.0843458
Dilate esophagus

T
0140
5.4566
335.41
91.40
67.0843499
Esophagus surgery procedure

T
0141
8.3175
511.26
143.38
102.2543510
Surgical opening of stomach

T
0141
8.3175
511.26
143.38
102.2543600
Biopsy of stomach

T
0141
8.3175
511.26
143.38
102.2543647
Lap impl electrode, antrum
NI
T
0130
32.1241
1,974.60
659.53
394.9243648
Lap revise/remv eltrd antrum
NI
T
0130
32.1241
1,974.60
659.53
394.9243651
Laparoscopy, vagus nerve

T
0132
70.5066
4,333.90
1,239.22
866.7843652
Laparoscopy, vagus nerve

T
0132
70.5066
4,333.90
1,239.22
866.7843653
Laparoscopy, gastrostomy

T
0131
43.5488
2,676.86
1,001.89
535.3743659
Laparoscope proc, stom

T
0130
32.1241
1,974.60
659.53
394.9243750
Place gastrostomy tube

T
0141
8.3175
511.26
143.38
102.2543752
Nasal/orogastric w/stent

X
0272
1.2908
79.34
31.64
15.8743760
Change gastrostomy tube

T
0121
2.3587
144.98
43.80
29.0043761
Reposition gastrostomy tube

T
0122
7.48
459.78

91.9643830
Place gastrostomy tube

T
0422
25.7552
1,583.12
448.81
316.6243831
Place gastrostomy tube

T
0141
8.3175
511.26
143.38
102.2543870
Repair stomach opening

T
0141
8.3175
511.26
143.38
102.2543881
Impl/redo electrd, antrum
NI
C43882
Revise/remove electrd antrum
NI
C43886
Revise gastric port, open

T
0025
5.2594
323.28
101.85
64.6643887
Remove gastric port, open

T
0025
5.2594
323.28
101.85
64.6643888
Change gastric port, open

T
0686
14.0346
862.68

172.5443999
Stomach surgery procedure

T
0141
8.3175
511.26
143.38
102.2544100
Biopsy of bowel

T
0141
8.3175
511.26
143.38
102.2544152
Removal of colon/ileostomy
CH
D44153
Removal of colon/ileostomy
CH
D44157
Colectomy w/ileoanal anast
NI
C44158
Colectomy w/neo-rectum pouch
NI
C44180
Lap, enterolysis

T
0131
43.5488
2,676.86
1,001.89
535.3744186
Lap, jejunostomy

T
0131
43.5488
2,676.86
1,001.89
535.3744206
Lap part colectomy w/stoma

T
0132
70.5066
4,333.90
1,239.22
866.7844207
Lcolectomy/coloproctostomy

T
0132
70.5066
4,333.90
1,239.22
866.7844208
Lcolectomy/coloproctostomy

T
0132
70.5066
4,333.90
1,239.22
866.7844213
Lap, mobil splenic fl add-on

T
0130
32.1241
1,974.60
659.53
394.9244238
Laparoscope proc, intestine

T
0130
32.1241
1,974.60
659.53
394.92( print page 68322)44312
Revision of ileostomy

T
0027
21.4302
1,317.27
329.72
263.4544340
Revision of colostomy

T
0027
21.4302
1,317.27
329.72
263.4544360
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244361
Small bowel endoscopy/biopsy

T
0142
9.4946
583.61
152.78
116.7244363
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244364
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244365
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244366
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244369
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244370
Small bowel endoscopy/stent

T
0384
22.9475
1,410.54
295.41
282.1144372
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244373
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244376
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244377
Small bowel endoscopy/biopsy

T
0142
9.4946
583.61
152.78
116.7244378
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244379
Sbowel endoscope w/stent

T
0384
22.9475
1,410.54
295.41
282.1144380
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244382
Small bowel endoscopy

T
0142
9.4946
583.61
152.78
116.7244383
Ileoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1144385
Endoscopy of bowel pouch

T
0143
8.7686
538.99
186.06
107.8044386
Endoscopy, bowel pouch/biop

T
0143
8.7686
538.99
186.06
107.8044388
Colonoscopy

T
0143
8.7686
538.99
186.06
107.8044389
Colonoscopy with biopsy

T
0143
8.7686
538.99
186.06
107.8044390
Colonoscopy for foreign body

T
0143
8.7686
538.99
186.06
107.8044391
Colonoscopy for bleeding

T
0143
8.7686
538.99
186.06
107.8044392
Colonoscopy & polypectomy

T
0143
8.7686
538.99
186.06
107.8044393
Colonoscopy, lesion removal

T
0143
8.7686
538.99
186.06
107.8044394
Colonoscopy w/snare

T
0143
8.7686
538.99
186.06
107.8044397
Colonoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1144500
Intro, gastrointestinal tube

T
0121
2.3587
144.98
43.80
29.0044701
Intraop colon lavage add-on

N44799
Unlisted procedure intestine
CH
T
0153
22.0832
1,357.41
397.95
271.4844901
Drain app abscess, percut

T
0037
10.2655
631.00
228.76
126.2044970
Laparoscopy, appendectomy

T
0131
43.5488
2,676.86
1,001.89
535.3744979
Laparoscope proc, app

T
0130
32.1241
1,974.60
659.53
394.9245000
Drainage of pelvic abscess

T
0148
5.077
312.07

62.4145005
Drainage of rectal abscess

T
0155
12.7389
783.03

156.6145020
Drainage of rectal abscess

T
0155
12.7389
783.03

156.6145100
Biopsy of rectum

T
0149
22.2682
1,368.78
293.06
273.7645108
Removal of anorectal lesion
CH
T
0149
22.2682
1,368.78
293.06
273.7645150
Excision of rectal stricture

T
0149
22.2682
1,368.78
293.06
273.7645160
Excision of rectal lesion
CH
T
0149
22.2682
1,368.78
293.06
273.7645170
Excision of rectal lesion
CH
T
0149
22.2682
1,368.78
293.06
273.7645190
Destruction, rectal tumor
CH
T
0149
22.2682
1,368.78
293.06
273.7645300
Proctosigmoidoscopy dx

T
0146
4.8683
299.24
64.40
59.8545303
Proctosigmoidoscopy dilate

T
0147
8.5477
525.41

105.0845305
Proctosigmoidoscopy w/bx

T
0147
8.5477
525.41

105.0845307
Proctosigmoidoscopy fb

T
0428
20.6375
1,268.55

253.7145308
Proctosigmoidoscopy removal

T
0147
8.5477
525.41

105.0845309
Proctosigmoidoscopy removal

T
0147
8.5477
525.41

105.0845315
Proctosigmoidoscopy removal

T
0147
8.5477
525.41

105.0845317
Proctosigmoidoscopy bleed

T
0147
8.5477
525.41

105.0845320
Proctosigmoidoscopy ablate

T
0428
20.6375
1,268.55

253.7145321
Proctosigmoidoscopy volvul

T
0428
20.6375
1,268.55

253.7145327
Proctosigmoidoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1145330
Diagnostic sigmoidoscopy

T
0146
4.8683
299.24
64.40
59.8545331
Sigmoidoscopy and biopsy

T
0146
4.8683
299.24
64.40
59.8545332
Sigmoidoscopy w/fb removal

T
0146
4.8683
299.24
64.40
59.8545333
Sigmoidoscopy & polypectomy

T
0147
8.5477
525.41

105.0845334
Sigmoidoscopy for bleeding

T
0147
8.5477
525.41

105.0845335
Sigmoidoscopy w/submuc inj

T
0146
4.8683
299.24
64.40
59.8545337
Sigmoidoscopy & decompress

T
0146
4.8683
299.24
64.40
59.8545338
Sigmoidoscopy w/tumr remove

T
0147
8.5477
525.41

105.0845339
Sigmoidoscopy w/ablate tumr

T
0147
8.5477
525.41

105.0845340
Sig w/balloon dilation

T
0147
8.5477
525.41

105.0845341
Sigmoidoscopy w/ultrasound

T
0147
8.5477
525.41

105.0845342
Sigmoidoscopy w/us guide bx

T
0147
8.5477
525.41

105.0845345
Sigmoidoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1145355
Surgical colonoscopy

T
0143
8.7686
538.99
186.06
107.8045378
Diagnostic colonoscopy

T
0143
8.7686
538.99
186.06
107.80( print page 68323)45379
Colonoscopy w/fb removal

T
0143
8.7686
538.99
186.06
107.8045380
Colonoscopy and biopsy

T
0143
8.7686
538.99
186.06
107.8045381
Colonoscopy, submucous inj

T
0143
8.7686
538.99
186.06
107.8045382
Colonoscopy/control bleeding

T
0143
8.7686
538.99
186.06
107.8045383
Lesion removal colonoscopy

T
0143
8.7686
538.99
186.06
107.8045384
Lesion remove colonoscopy

T
0143
8.7686
538.99
186.06
107.8045385
Lesion removal colonoscopy

T
0143
8.7686
538.99
186.06
107.8045386
Colonoscopy dilate stricture

T
0143
8.7686
538.99
186.06
107.8045387
Colonoscopy w/stent

T
0384
22.9475
1,410.54
295.41
282.1145391
Colonoscopy w/endoscope us

T
0143
8.7686
538.99
186.06
107.8045392
Colonoscopy w/endoscopic fnb

T
0143
8.7686
538.99
186.06
107.8045499
Laparoscope proc, rectum

T
0130
32.1241
1,974.60
659.53
394.9245500
Repair of rectum

T
0149
22.2682
1,368.78
293.06
273.7645505
Repair of rectum

T
0150
29.6189
1,820.61
437.12
364.1245520
Treatment of rectal prolapse

T
0098
1.0798
66.37

13.2745541
Correct rectal prolapse

T
0150
29.6189
1,820.61
437.12
364.1245560
Repair of rectocele

T
0150
29.6189
1,820.61
437.12
364.1245900
Reduction of rectal prolapse

T
0148
5.077
312.07

62.4145905
Dilation of anal sphincter

T
0149
22.2682
1,368.78
293.06
273.7645910
Dilation of rectal narrowing

T
0149
22.2682
1,368.78
293.06
273.7645915
Remove rectal obstruction

T
0148
5.077
312.07

62.4145990
Surg dx exam, anorectal

T
0148
5.077
312.07

62.4145999
Rectum surgery procedure

T
0148
5.077
312.07

62.4146020
Placement of seton
CH
T
0149
22.2682
1,368.78
293.06
273.7646030
Removal of rectal marker

T
0148
5.077
312.07

62.4146040
Incision of rectal abscess

T
0149
22.2682
1,368.78
293.06
273.7646045
Incision of rectal abscess
CH
T
0149
22.2682
1,368.78
293.06
273.7646050
Incision of anal abscess

T
0148
5.077
312.07

62.4146060
Incision of rectal abscess
CH
T
0149
22.2682
1,368.78
293.06
273.7646070
Incision of anal septum

T
0155
12.7389
783.03

156.6146080
Incision of anal sphincter

T
0149
22.2682
1,368.78
293.06
273.7646083
Incise external hemorrhoid
CH
T
0164
2.1393
131.50

26.3046200
Removal of anal fissure
CH
T
0149
22.2682
1,368.78
293.06
273.7646210
Removal of anal crypt

T
0149
22.2682
1,368.78
293.06
273.7646211
Removal of anal crypts
CH
T
0149
22.2682
1,368.78
293.06
273.7646220
Removal of anal tag

T
0149
22.2682
1,368.78
293.06
273.7646221
Ligation of hemorrhoid(s)

T
0148
5.077
312.07

62.4146230
Removal of anal tags

T
0149
22.2682
1,368.78
293.06
273.7646250
Hemorrhoidectomy
CH
T
0149
22.2682
1,368.78
293.06
273.7646255
Hemorrhoidectomy
CH
T
0149
22.2682
1,368.78
293.06
273.7646257
Remove hemorrhoids & fissure
CH
T
0149
22.2682
1,368.78
293.06
273.7646258
Remove hemorrhoids & fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646260
Hemorrhoidectomy
CH
T
0149
22.2682
1,368.78
293.06
273.7646261
Remove hemorrhoids & fissure
CH
T
0149
22.2682
1,368.78
293.06
273.7646262
Remove hemorrhoids & fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646270
Removal of anal fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646275
Removal of anal fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646280
Removal of anal fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646285
Removal of anal fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646288
Repair anal fistula
CH
T
0149
22.2682
1,368.78
293.06
273.7646320
Removal of hemorrhoid clot
CH
T
0155
12.7389
783.03

156.6146500
Injection into hemorrhoid(s)

T
0155
12.7389
783.03

156.6146505
Chemodenervation anal musc

T
0148
5.077
312.07

62.4146600
Diagnostic anoscopy

X
0340
0.6102
37.51

7.5046604
Anoscopy and dilation

T
0147
8.5477
525.41

105.0846606
Anoscopy and biopsy

T
0146
4.8683
299.24
64.40
59.8546608
Anoscopy, remove for body

T
0147
8.5477
525.41

105.0846610
Anoscopy, remove lesion

T
0428
20.6375
1,268.55

253.7146611
Anoscopy

T
0147
8.5477
525.41

105.0846612
Anoscopy, remove lesions

T
0428
20.6375
1,268.55

253.7146614
Anoscopy, control bleeding

T
0146
4.8683
299.24
64.40
59.8546615
Anoscopy

T
0428
20.6375
1,268.55

253.7146700
Repair of anal stricture
CH
T
0149
22.2682
1,368.78
293.06
273.7646706
Repr of anal fistula w/glue

T
0150
29.6189
1,820.61
437.12
364.1246750
Repair of anal sphincter
CH
T
0171
37.8991
2,329.58
716.76
465.9246753
Reconstruction of anus
CH
T
0149
22.2682
1,368.78
293.06
273.7646754
Removal of suture from anus

T
0149
22.2682
1,368.78
293.06
273.7646760
Repair of anal sphincter
CH
T
0171
37.8991
2,329.58
716.76
465.9246761
Repair of anal sphincter
CH
T
0171
37.8991
2,329.58
716.76
465.9246762
Implant artificial sphincter
CH
T
0171
37.8991
2,329.58
716.76
465.92( print page 68324)46900
Destruction, anal lesion(s)

T
0016
2.6749
164.42

32.8846910
Destruction, anal lesion(s)

T
0017
17.4423
1,072.14
227.84
214.4346916
Cryosurgery, anal lesion(s)

T
0013
1.0918
67.11

13.4246917
Laser surgery, anal lesions

T
0695
20.4276
1,255.64
266.59
251.1346922
Excision of anal lesion(s)

T
0695
20.4276
1,255.64
266.59
251.1346924
Destruction, anal lesion(s)

T
0695
20.4276
1,255.64
266.59
251.1346934
Destruction of hemorrhoids

T
0155
12.7389
783.03

156.6146935
Destruction of hemorrhoids

T
0155
12.7389
783.03

156.6146936
Destruction of hemorrhoids

T
0149
22.2682
1,368.78
293.06
273.7646937
Cryotherapy of rectal lesion

T
0149
22.2682
1,368.78
293.06
273.7646938
Cryotherapy of rectal lesion

T
0150
29.6189
1,820.61
437.12
364.1246940
Treatment of anal fissure

T
0149
22.2682
1,368.78
293.06
273.7646942
Treatment of anal fissure

T
0148
5.077
312.07

62.4146945
Ligation of hemorrhoids

T
0155
12.7389
783.03

156.6146946
Ligation of hemorrhoids

T
0155
12.7389
783.03

156.6146947
Hemorrhoidopexy by stapling

T
0150
29.6189
1,820.61
437.12
364.1246999
Anus surgery procedure

T
0148
5.077
312.07

62.4147000
Needle biopsy of liver

T
0685
6.1384
377.32
115.47
75.4647001
Needle biopsy, liver add-on

N47011
Percut drain, liver lesion

T
0037
10.2655
631.00
228.76
126.2047370
Laparo ablate liver tumor rf

T
0132
70.5066
4,333.90
1,239.22
866.7847371
Laparo ablate liver cryosurg

T
0131
43.5488
2,676.86
1,001.89
535.3747379
Laparoscope procedure, liver

T
0130
32.1241
1,974.60
659.53
394.9247382
Percut ablate liver rf

T
0423
37.3604
2,296.47

459.2947399
Liver surgery procedure
CH
T
0004
2.0687
127.16

25.4347490
Incision of gallbladder

T
0152
20.2682
1,245.85

249.1747500
Injection for liver x-rays

N47505
Injection for liver x-rays

N47510
Insert catheter, bile duct

T
0152
20.2682
1,245.85

249.1747511
Insert bile duct drain

T
0152
20.2682
1,245.85

249.1747525
Change bile duct catheter

T
0427
11.6575
716.56

143.3147530
Revise/reinsert bile tube

T
0427
11.6575
716.56

143.3147552
Biliary endoscopy thru skin

T
0152
20.2682
1,245.85

249.1747553
Biliary endoscopy thru skin

T
0152
20.2682
1,245.85

249.1747554
Biliary endoscopy thru skin

T
0152
20.2682
1,245.85

249.1747555
Biliary endoscopy thru skin

T
0152
20.2682
1,245.85

249.1747556
Biliary endoscopy thru skin

T
0152
20.2682
1,245.85

249.1747560
Laparoscopy w/cholangio

T
0130
32.1241
1,974.60
659.53
394.9247561
Laparo w/cholangio/biopsy

T
0130
32.1241
1,974.60
659.53
394.9247562
Laparoscopic cholecystectomy

T
0131
43.5488
2,676.86
1,001.89
535.3747563
Laparo cholecystectomy/graph

T
0131
43.5488
2,676.86
1,001.89
535.3747564
Laparo cholecystectomy/explr

T
0131
43.5488
2,676.86
1,001.89
535.3747579
Laparoscope proc, biliary

T
0130
32.1241
1,974.60
659.53
394.9247630
Remove bile duct stone

T
0152
20.2682
1,245.85

249.1747716
Fusion of bile duct cyst
CH
D47719
Fusion of bile duct cyst
NI
C47999
Bile tract surgery procedure

T
0152
20.2682
1,245.85

249.1748005
Resect/debride pancreas
CH
D48102
Needle biopsy, pancreas

T
0685
6.1384
377.32
115.47
75.4648105
Resect/debride pancreas
NI
C48180
Fuse pancreas and bowel
CH
D48511
Drain pancreatic pseudocyst

T
0037
10.2655
631.00
228.76
126.2048548
Fuse pancreas and bowel
NI
C48999
Pancreas surgery procedure

T
0004
2.0687
127.16

25.4349021
Drain abdominal abscess

T
0037
10.2655
631.00
228.76
126.2049041
Drain, percut, abdom abscess

T
0037
10.2655
631.00
228.76
126.2049061
Drain, percut, retroper absc

T
0037
10.2655
631.00
228.76
126.2049080
Puncture, peritoneal cavity

T
0070
3.6244
222.78

44.5649081
Removal of abdominal fluid

T
0070
3.6244
222.78

44.5649085
Remove abdomen foreign body
CH
D49180
Biopsy, abdominal mass

T
0685
6.1384
377.32
115.47
75.4649200
Removal of abdominal lesion

T
0130
32.1241
1,974.60
659.53
394.9249250
Excision of umbilicus

T
0153
22.0832
1,357.41
397.95
271.4849320
Diag laparo separate proc

T
0130
32.1241
1,974.60
659.53
394.9249321
Laparoscopy, biopsy

T
0130
32.1241
1,974.60
659.53
394.9249322
Laparoscopy, aspiration

T
0130
32.1241
1,974.60
659.53
394.9249323
Laparo drain lymphocele

T
0130
32.1241
1,974.60
659.53
394.9249324
Lap insertion perm ip cath
NI
T
0130
32.1241
1,974.60
659.53
394.9249325
Lap revision perm ip cath
NI
T
0130
32.1241
1,974.60
659.53
394.9249326
Lap w/omentopexy add-on
NI
T
0130
32.1241
1,974.60
659.53
394.92( print page 68325)49329
Laparo proc, abdm/per/oment

T
0130
32.1241
1,974.60
659.53
394.9249400
Air injection into abdomen

N49402
Remove foreign body, adbomen
NI
T
0153
22.0832
1,357.41
397.95
271.4849419
Insrt abdom cath for chemotx

T
0115
29.2133
1,795.68
374.81
359.1449420
Insert abdom drain, temp

T
0652
29.5416
1,815.86

363.1749421
Insert abdom drain, perm

T
0652
29.5416
1,815.86

363.1749422
Remove perm cannula/catheter

T
0105
25.6142
1,574.45
370.40
314.8949423
Exchange drainage catheter

T
0427
11.6575
716.56

143.3149424
Assess cyst, contrast inject

N49426
Revise abdomen-venous shunt

T
0153
22.0832
1,357.41
397.95
271.4849427
Injection, abdominal shunt

N49429
Removal of shunt

T
0105
25.6142
1,574.45
370.40
314.8949435
Insert subq exten to ip cath
NI
T
0427
11.6575
716.56

143.3149436
Embedded ip cath exit-site
NI
T
0427
11.6575
716.56

143.3149491
Rpr hern preemie reduc

T
0154
29.2182
1,795.98
464.85
359.2049492
Rpr ing hern premie, blocked

T
0154
29.2182
1,795.98
464.85
359.2049495
Rpr ing hernia baby, reduc

T
0154
29.2182
1,795.98
464.85
359.2049496
Rpr ing hernia baby, blocked

T
0154
29.2182
1,795.98
464.85
359.2049500
Rpr ing hernia, init, reduce

T
0154
29.2182
1,795.98
464.85
359.2049501
Rpr ing hernia, init blocked

T
0154
29.2182
1,795.98
464.85
359.2049505
Prp i/hern init reduc >5 yr

T
0154
29.2182
1,795.98
464.85
359.2049507
Prp i/hern init block >5 yr

T
0154
29.2182
1,795.98
464.85
359.2049520
Rerepair ing hernia, reduce

T
0154
29.2182
1,795.98
464.85
359.2049521
Rerepair ing hernia, blocked

T
0154
29.2182
1,795.98
464.85
359.2049525
Repair ing hernia, sliding

T
0154
29.2182
1,795.98
464.85
359.2049540
Repair lumbar hernia

T
0154
29.2182
1,795.98
464.85
359.2049550
Rpr rem hernia, init, reduce

T
0154
29.2182
1,795.98
464.85
359.2049553
Rpr fem hernia, init blocked

T
0154
29.2182
1,795.98
464.85
359.2049555
Rerepair fem hernia, reduce

T
0154
29.2182
1,795.98
464.85
359.2049557
Rerepair fem hernia, blocked

T
0154
29.2182
1,795.98
464.85
359.2049560
Rpr ventral hern init, reduc

T
0154
29.2182
1,795.98
464.85
359.2049561
Rpr ventral hern init, block

T
0154
29.2182
1,795.98
464.85
359.2049565
Rerepair ventrl hern, reduce

T
0154
29.2182
1,795.98
464.85
359.2049566
Rerepair ventrl hern, block

T
0154
29.2182
1,795.98
464.85
359.2049568
Hernia repair w/mesh

T
0154
29.2182
1,795.98
464.85
359.2049570
Rpr epigastric hern, reduce

T
0154
29.2182
1,795.98
464.85
359.2049572
Rpr epigastric hern, blocked

T
0154
29.2182
1,795.98
464.85
359.2049580
Rpr umbil hern, reduc < 5 yr

T
0154
29.2182
1,795.98
464.85
359.2049582
Rpr umbil hern, block < 5 yr

T
0154
29.2182
1,795.98
464.85
359.2049585
Rpr umbil hern, reduc > 5 yr

T
0154
29.2182
1,795.98
464.85
359.2049587
Rpr umbil hern, block > 5 yr

T
0154
29.2182
1,795.98
464.85
359.2049590
Repair spigelian hernia

T
0154
29.2182
1,795.98
464.85
359.2049600
Repair umbilical lesion

T
0154
29.2182
1,795.98
464.85
359.2049650
Laparo hernia repair initial

T
0131
43.5488
2,676.86
1,001.89
535.3749651
Laparo hernia repair recur

T
0131
43.5488
2,676.86
1,001.89
535.3749659
Laparo proc, hernia repair

T
0130
32.1241
1,974.60
659.53
394.9249999
Abdomen surgery procedure

T
0153
22.0832
1,357.41
397.95
271.4850020
Renal abscess, open drain

T
0162
23.87
1,467.24

293.4550021
Renal abscess, percut drain

T
0037
10.2655
631.00
228.76
126.2050080
Removal of kidney stone

T
0429
43.1004
2,649.30

529.8650081
Removal of kidney stone

T
0429
43.1004
2,649.30

529.8650200
Biopsy of kidney

T
0685
6.1384
377.32
115.47
75.4650382
Change ureter stent, percut

T
0161
19.2251
1,181.73
249.36
236.3550384
Remove ureter stent, percut

T
0161
19.2251
1,181.73
249.36
236.3550387
Change ext/int ureter stent

T
0122
7.48
459.78

91.9650389
Remove renal tube w/fluoro

T
0156
3.4079
209.48

41.9050390
Drainage of kidney lesion

T
0685
6.1384
377.32
115.47
75.4650391
Instll rx agnt into rnal tub
CH
T
0126
1.0887
66.92
16.45
13.3850392
Insert kidney drain

T
0161
19.2251
1,181.73
249.36
236.3550393
Insert ureteral tube

T
0161
19.2251
1,181.73
249.36
236.3550394
Injection for kidney x-ray

N50395
Create passage to kidney

T
0161
19.2251
1,181.73
249.36
236.3550396
Measure kidney pressure

T
0164
2.1393
131.50

26.3050398
Change kidney tube

T
0122
7.48
459.78

91.9650541
Laparo ablate renal cyst

T
0130
32.1241
1,974.60
659.53
394.9250542
Laparo ablate renal mass

T
0132
70.5066
4,333.90
1,239.22
866.7850543
Laparo partial nephrectomy

T
0131
43.5488
2,676.86
1,001.89
535.3750544
Laparoscopy, pyeloplasty

T
0130
32.1241
1,974.60
659.53
394.9250549
Laparoscope proc, renal

T
0130
32.1241
1,974.60
659.53
394.9250551
Kidney endoscopy

T
0160
6.4951
399.24
101.58
79.85( print page 68326)50553
Kidney endoscopy

T
0161
19.2251
1,181.73
249.36
236.3550555
Kidney endoscopy & biopsy

T
0160
6.4951
399.24
101.58
79.8550557
Kidney endoscopy & treatment

T
0162
23.87
1,467.24

293.4550561
Kidney endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3550562
Renal scope w/tumor resect

T
0160
6.4951
399.24
101.58
79.8550570
Kidney endoscopy

T
0160
6.4951
399.24
101.58
79.8550572
Kidney endoscopy

T
0160
6.4951
399.24
101.58
79.8550574
Kidney endoscopy & biopsy

T
0160
6.4951
399.24
101.58
79.8550575
Kidney endoscopy

T
0163
34.9261
2,146.84

429.3750576
Kidney endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3550590
Fragmenting of kidney stone

T
0169
43.5398
2,676.30
1,009.47
535.2650592
Perc rf ablate renal tumor

T
0423
37.3604
2,296.47

459.2950684
Injection for ureter x-ray

N50686
Measure ureter pressure
CH
T
0126
1.0887
66.92
16.45
13.3850688
Change of ureter tube/stent

T
0122
7.48
459.78

91.9650690
Injection for ureter x-ray

N50945
Laparoscopy ureterolithotomy

T
0131
43.5488
2,676.86
1,001.89
535.3750947
Laparo new ureter/bladder

T
0131
43.5488
2,676.86
1,001.89
535.3750948
Laparo new ureter/bladder

T
0131
43.5488
2,676.86
1,001.89
535.3750949
Laparoscope proc, ureter

T
0130
32.1241
1,974.60
659.53
394.9250951
Endoscopy of ureter

T
0160
6.4951
399.24
101.58
79.8550953
Endoscopy of ureter

T
0160
6.4951
399.24
101.58
79.8550955
Ureter endoscopy & biopsy

T
0161
19.2251
1,181.73
249.36
236.3550957
Ureter endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3550961
Ureter endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3550970
Ureter endoscopy

T
0160
6.4951
399.24
101.58
79.8550972
Ureter endoscopy & catheter

T
0160
6.4951
399.24
101.58
79.8550974
Ureter endoscopy & biopsy

T
0161
19.2251
1,181.73
249.36
236.3550976
Ureter endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3550980
Ureter endoscopy & treatment

T
0161
19.2251
1,181.73
249.36
236.3551000
Drainage of bladder

T
0164
2.1393
131.50

26.3051005
Drainage of bladder
CH
T
0126
1.0887
66.92
16.45
13.3851010
Drainage of bladder

T
0165
18.1679
1,116.74

223.3551020
Incise & treat bladder

T
0162
23.87
1,467.24

293.4551030
Incise & treat bladder

T
0162
23.87
1,467.24

293.4551040
Incise & drain bladder

T
0162
23.87
1,467.24

293.4551045
Incise bladder/drain ureter

T
0160
6.4951
399.24
101.58
79.8551050
Removal of bladder stone

T
0162
23.87
1,467.24

293.4551065
Remove ureter calculus

T
0162
23.87
1,467.24

293.4551080
Drainage of bladder abscess

T
0008
17.5086
1,076.22

215.2451500
Removal of bladder cyst

T
0154
29.2182
1,795.98
464.85
359.2051520
Removal of bladder lesion

T
0162
23.87
1,467.24

293.4551600
Injection for bladder x-ray

N51605
Preparation for bladder xray

N51610
Injection for bladder x-ray

N51700
Irrigation of bladder

T
0164
2.1393
131.50

26.3051701
Insert bladder catheter

X
0340
0.6102
37.51

7.5051702
Insert temp bladder cath

X
0340
0.6102
37.51

7.5051703
Insert bladder cath, complex
CH
T
0126
1.0887
66.92
16.45
13.3851705
Change of bladder tube

T
0121
2.3587
144.98
43.80
29.0051710
Change of bladder tube

T
0122
7.48
459.78

91.9651715
Endoscopic injection/implant

T
0168
29.0253
1,784.13
388.16
356.8351720
Treatment of bladder lesion
CH
T
0164
2.1393
131.50

26.3051725
Simple cystometrogram
CH
T
0164
2.1393
131.50

26.3051726
Complex cystometrogram

T
0156
3.4079
209.48

41.9051736
Urine flow measurement
CH
T
0126
1.0887
66.92
16.45
13.3851741
Electro-uroflowmetry, first
CH
T
0126
1.0887
66.92
16.45
13.3851772
Urethra pressure profile
CH
T
0164
2.1393
131.50

26.3051784
Anal/urinary muscle study
CH
T
0126
1.0887
66.92
16.45
13.3851785
Anal/urinary muscle study
CH
T
0126
1.0887
66.92
16.45
13.3851792
Urinary reflex study
CH
T
0126
1.0887
66.92
16.45
13.3851795
Urine voiding pressure study

T
0164
2.1393
131.50

26.3051797
Intraabdominal pressure test

T
0164
2.1393
131.50

26.3051798
Us urine capacity measure

X
0340
0.6102
37.51

7.5051880
Repair of bladder opening

T
0162
23.87
1,467.24

293.4551990
Laparo urethral suspension

T
0131
43.5488
2,676.86
1,001.89
535.3751992
Laparo sling operation
CH
T
0131
43.5488
2,676.86
1,001.89
535.3751999
Laparoscope proc, bladder

T
0130
32.1241
1,974.60
659.53
394.9252000
Cystoscopy

T
0160
6.4951
399.24
101.58
79.8552001
Cystoscopy, removal of clots

T
0160
6.4951
399.24
101.58
79.85( print page 68327)52005
Cystoscopy & ureter catheter

T
0161
19.2251
1,181.73
249.36
236.3552007
Cystoscopy and biopsy

T
0161
19.2251
1,181.73
249.36
236.3552010
Cystoscopy & duct catheter

T
0160
6.4951
399.24
101.58
79.8552204
Cystoscopy w/biopsy(s)

T
0161
19.2251
1,181.73
249.36
236.3552214
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552224
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552234
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552235
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552240
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552250
Cystoscopy and radiotracer

T
0162
23.87
1,467.24

293.4552260
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552265
Cystoscopy and treatment

T
0160
6.4951
399.24
101.58
79.8552270
Cystoscopy & revise urethra

T
0161
19.2251
1,181.73
249.36
236.3552275
Cystoscopy & revise urethra

T
0161
19.2251
1,181.73
249.36
236.3552276
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552277
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552281
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552282
Cystoscopy, implant stent

T
0163
34.9261
2,146.84

429.3752283
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552285
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552290
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552300
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552301
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552305
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552310
Cystoscopy and treatment

T
0160
6.4951
399.24
101.58
79.8552315
Cystoscopy and treatment

T
0161
19.2251
1,181.73
249.36
236.3552317
Remove bladder stone

T
0162
23.87
1,467.24

293.4552318
Remove bladder stone

T
0162
23.87
1,467.24

293.4552320
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552325
Cystoscopy, stone removal

T
0162
23.87
1,467.24

293.4552327
Cystoscopy, inject material

T
0162
23.87
1,467.24

293.4552330
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552332
Cystoscopy and treatment

T
0162
23.87
1,467.24

293.4552334
Create passage to kidney

T
0162
23.87
1,467.24

293.4552341
Cysto w/ureter stricture tx

T
0162
23.87
1,467.24

293.4552342
Cysto w/up stricture tx

T
0162
23.87
1,467.24

293.4552343
Cysto w/renal stricture tx

T
0162
23.87
1,467.24

293.4552344
Cysto/uretero, stricture tx

T
0162
23.87
1,467.24

293.4552345
Cysto/uretero w/up stricture

T
0162
23.87
1,467.24

293.4552346
Cystouretero w/renal strict

T
0162
23.87
1,467.24

293.4552351
Cystouretero & or pyeloscope

T
0161
19.2251
1,181.73
249.36
236.3552352
Cystouretero w/stone remove

T
0162
23.87
1,467.24

293.4552353
Cystouretero w/lithotripsy

T
0163
34.9261
2,146.84

429.3752354
Cystouretero w/biopsy

T
0162
23.87
1,467.24

293.4552355
Cystouretero w/excise tumor

T
0162
23.87
1,467.24

293.4552400
Cystouretero w/congen repr

T
0162
23.87
1,467.24

293.4552402
Cystourethro cut ejacul duct

T
0162
23.87
1,467.24

293.4552450
Incision of prostate

T
0162
23.87
1,467.24

293.4552500
Revision of bladder neck

T
0162
23.87
1,467.24

293.4552510
Dilation prostatic urethra

T
0161
19.2251
1,181.73
249.36
236.3552601
Prostatectomy (TURP)

T
0163
34.9261
2,146.84

429.3752606
Control postop bleeding

T
0162
23.87
1,467.24

293.4552612
Prostatectomy, first stage

T
0163
34.9261
2,146.84

429.3752614
Prostatectomy, second stage

T
0163
34.9261
2,146.84

429.3752620
Remove residual prostate

T
0163
34.9261
2,146.84

429.3752630
Remove prostate regrowth

T
0163
34.9261
2,146.84

429.3752640
Relieve bladder contracture

T
0162
23.87
1,467.24

293.4552647
Laser surgery of prostate

T
0429
43.1004
2,649.30

529.8652648
Laser surgery of prostate

T
0429
43.1004
2,649.30

529.8652700
Drainage of prostate abscess

T
0162
23.87
1,467.24

293.4553000
Incision of urethra

T
0166
18.396
1,130.77

226.1553010
Incision of urethra

T
0166
18.396
1,130.77

226.1553020
Incision of urethra

T
0166
18.396
1,130.77

226.1553025
Incision of urethra

T
0166
18.396
1,130.77

226.1553040
Drainage of urethra abscess

T
0166
18.396
1,130.77

226.1553060
Drainage of urethra abscess

T
0166
18.396
1,130.77

226.1553080
Drainage of urinary leakage

T
0166
18.396
1,130.77

226.1553085
Drainage of urinary leakage

T
0166
18.396
1,130.77

226.1553200
Biopsy of urethra

T
0166
18.396
1,130.77

226.1553210
Removal of urethra

T
0168
29.0253
1,784.13
388.16
356.83( print page 68328)53215
Removal of urethra

T
0166
18.396
1,130.77

226.1553220
Treatment of urethra lesion

T
0168
29.0253
1,784.13
388.16
356.8353230
Removal of urethra lesion

T
0168
29.0253
1,784.13
388.16
356.8353235
Removal of urethra lesion

T
0166
18.396
1,130.77

226.1553240
Surgery for urethra pouch

T
0168
29.0253
1,784.13
388.16
356.8353250
Removal of urethra gland

T
0166
18.396
1,130.77

226.1553260
Treatment of urethra lesion

T
0166
18.396
1,130.77

226.1553265
Treatment of urethra lesion

T
0166
18.396
1,130.77

226.1553270
Removal of urethra gland

T
0166
18.396
1,130.77

226.1553275
Repair of urethra defect

T
0166
18.396
1,130.77

226.1553400
Revise urethra, stage 1

T
0168
29.0253
1,784.13
388.16
356.8353405
Revise urethra, stage 2

T
0168
29.0253
1,784.13
388.16
356.8353410
Reconstruction of urethra

T
0168
29.0253
1,784.13
388.16
356.8353420
Reconstruct urethra, stage 1

T
0168
29.0253
1,784.13
388.16
356.8353425
Reconstruct urethra, stage 2

T
0168
29.0253
1,784.13
388.16
356.8353430
Reconstruction of urethra

T
0168
29.0253
1,784.13
388.16
356.8353431
Reconstruct urethra/bladder

T
0168
29.0253
1,784.13
388.16
356.8353440
Male sling procedure

S
0385
79.2092
4,868.83

973.7753442
Remove/revise male sling

T
0168
29.0253
1,784.13
388.16
356.8353444
Insert tandem cuff

S
0385
79.2092
4,868.83

973.7753445
Insert uro/ves nck sphincter

S
0386
137.3897
8,445.07

1,689.0153446
Remove uro sphincter

T
0168
29.0253
1,784.13
388.16
356.8353447
Remove/replace ur sphincter

S
0386
137.3897
8,445.07

1,689.0153449
Repair uro sphincter

T
0168
29.0253
1,784.13
388.16
356.8353450
Revision of urethra

T
0168
29.0253
1,784.13
388.16
356.8353460
Revision of urethra

T
0166
18.396
1,130.77

226.1553500
Urethrlys, transvag w/ scope

T
0168
29.0253
1,784.13
388.16
356.8353502
Repair of urethra injury

T
0166
18.396
1,130.77

226.1553505
Repair of urethra injury

T
0168
29.0253
1,784.13
388.16
356.8353510
Repair of urethra injury

T
0166
18.396
1,130.77

226.1553515
Repair of urethra injury

T
0168
29.0253
1,784.13
388.16
356.8353520
Repair of urethra defect

T
0168
29.0253
1,784.13
388.16
356.8353600
Dilate urethra stricture

T
0156
3.4079
209.48

41.9053601
Dilate urethra stricture
CH
T
0126
1.0887
66.92
16.45
13.3853605
Dilate urethra stricture

T
0161
19.2251
1,181.73
249.36
236.3553620
Dilate urethra stricture

T
0165
18.1679
1,116.74

223.3553621
Dilate urethra stricture

T
0164
2.1393
131.50

26.3053660
Dilation of urethra
CH
T
0126
1.0887
66.92
16.45
13.3853661
Dilation of urethra
CH
T
0126
1.0887
66.92
16.45
13.3853665
Dilation of urethra

T
0166
18.396
1,130.77

226.1553850
Prostatic microwave thermotx

T
0675
41.1375
2,528.64

505.7353852
Prostatic rf thermotx

T
0675
41.1375
2,528.64

505.7353853
Prostatic water thermother

T
0162
23.87
1,467.24

293.4553899
Urology surgery procedure
CH
T
0126
1.0887
66.92
16.45
13.3854000
Slitting of prepuce

T
0166
18.396
1,130.77

226.1554001
Slitting of prepuce

T
0166
18.396
1,130.77

226.1554015
Drain penis lesion

T
0008
17.5086
1,076.22

215.2454050
Destruction, penis lesion(s)

T
0013
1.0918
67.11

13.4254055
Destruction, penis lesion(s)

T
0017
17.4423
1,072.14
227.84
214.4354056
Cryosurgery, penis lesion(s)

T
0012
0.8432
51.83
11.18
10.3754057
Laser surg, penis lesion(s)

T
0017
17.4423
1,072.14
227.84
214.4354060
Excision of penis lesion(s)

T
0017
17.4423
1,072.14
227.84
214.4354065
Destruction, penis lesion(s)

T
0695
20.4276
1,255.64
266.59
251.1354100
Biopsy of penis

T
0021
15.1024
928.31
219.48
185.6654105
Biopsy of penis

T
0022
20.0656
1,233.39
354.45
246.6854110
Treatment of penis lesion

T
0181
32.9873
2,027.66
621.82
405.5354111
Treat penis lesion, graft

T
0181
32.9873
2,027.66
621.82
405.5354112
Treat penis lesion, graft

T
0181
32.9873
2,027.66
621.82
405.5354115
Treatment of penis lesion

T
0008
17.5086
1,076.22

215.2454120
Partial removal of penis

T
0181
32.9873
2,027.66
621.82
405.5354150
Circumcision w/regionl block

T
0180
20.5513
1,263.25
304.87
252.6554152
Circumcision

T
0180
20.5513
1,263.25
304.87
252.6554160
Circumcision, neonate

T
0180
20.5513
1,263.25
304.87
252.6554161
Circum 28 days or older

T
0180
20.5513
1,263.25
304.87
252.6554162
Lysis penil circumic lesion

T
0180
20.5513
1,263.25
304.87
252.6554163
Repair of circumcision

T
0180
20.5513
1,263.25
304.87
252.6554164
Frenulotomy of penis

T
0180
20.5513
1,263.25
304.87
252.6554200
Treatment of penis lesion
CH
T
0164
2.1393
131.50

26.3054205
Treatment of penis lesion

T
0181
32.9873
2,027.66
621.82
405.5354220
Treatment of penis lesion
CH
T
0164
2.1393
131.50

26.30( print page 68329)54230
Prepare penis study

N54231
Dynamic cavernosometry

T
0165
18.1679
1,116.74

223.3554235
Penile injection

T
0164
2.1393
131.50

26.3054240
Penis study
CH
T
0126
1.0887
66.92
16.45
13.3854250
Penis study

T
0164
2.1393
131.50

26.3054300
Revision of penis

T
0181
32.9873
2,027.66
621.82
405.5354304
Revision of penis

T
0181
32.9873
2,027.66
621.82
405.5354308
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354312
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354316
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354318
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354322
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354324
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354326
Reconstruction of urethra

T
0181
32.9873
2,027.66
621.82
405.5354328
Revise penis/urethra

T
0181
32.9873
2,027.66
621.82
405.5354340
Secondary urethral surgery

T
0181
32.9873
2,027.66
621.82
405.5354344
Secondary urethral surgery

T
0181
32.9873
2,027.66
621.82
405.5354348
Secondary urethral surgery

T
0181
32.9873
2,027.66
621.82
405.5354352
Reconstruct urethra/penis

T
0181
32.9873
2,027.66
621.82
405.5354360
Penis plastic surgery

T
0181
32.9873
2,027.66
621.82
405.5354380
Repair penis

T
0181
32.9873
2,027.66
621.82
405.5354385
Repair penis

T
0181
32.9873
2,027.66
621.82
405.5354400
Insert semi-rigid prosthesis

S
0385
79.2092
4,868.83

973.7754401
Insert self-contd prosthesis

S
0386
137.3897
8,445.07

1,689.0154405
Insert multi-comp penis pros

S
0386
137.3897
8,445.07

1,689.0154406
Remove muti-comp penis pros

T
0181
32.9873
2,027.66
621.82
405.5354408
Repair multi-comp penis pros

T
0181
32.9873
2,027.66
621.82
405.5354410
Remove/replace penis prosth

S
0386
137.3897
8,445.07

1,689.0154415
Remove self-contd penis pros

T
0181
32.9873
2,027.66
621.82
405.5354416
Remv/repl penis contain pros

S
0386
137.3897
8,445.07

1,689.0154420
Revision of penis

T
0181
32.9873
2,027.66
621.82
405.5354435
Revision of penis

T
0181
32.9873
2,027.66
621.82
405.5354440
Repair of penis

T
0181
32.9873
2,027.66
621.82
405.5354450
Preputial stretching

T
0156
3.4079
209.48

41.9054500
Biopsy of testis

T
0037
10.2655
631.00
228.76
126.2054505
Biopsy of testis

T
0183
23.531
1,446.40

289.2854512
Excise lesion testis

T
0183
23.531
1,446.40

289.2854520
Removal of testis

T
0183
23.531
1,446.40

289.2854522
Orchiectomy, partial

T
0183
23.531
1,446.40

289.2854530
Removal of testis

T
0154
29.2182
1,795.98
464.85
359.2054550
Exploration for testis

T
0154
29.2182
1,795.98
464.85
359.2054560
Exploration for testis

T
0183
23.531
1,446.40

289.2854600
Reduce testis torsion

T
0183
23.531
1,446.40

289.2854620
Suspension of testis

T
0183
23.531
1,446.40

289.2854640
Suspension of testis

T
0154
29.2182
1,795.98
464.85
359.2054660
Revision of testis

T
0183
23.531
1,446.40

289.2854670
Repair testis injury

T
0183
23.531
1,446.40

289.2854680
Relocation of testis(es)

T
0183
23.531
1,446.40

289.2854690
Laparoscopy, orchiectomy

T
0131
43.5488
2,676.86
1,001.89
535.3754692
Laparoscopy, orchiopexy

T
0132
70.5066
4,333.90
1,239.22
866.7854699
Laparoscope proc, testis

T
0130
32.1241
1,974.60
659.53
394.9254700
Drainage of scrotum

T
0183
23.531
1,446.40

289.2854800
Biopsy of epididymis

T
0004
2.0687
127.16

25.4354820
Exploration of epididymis
CH
D54830
Remove epididymis lesion

T
0183
23.531
1,446.40

289.2854840
Remove epididymis lesion

T
0183
23.531
1,446.40

289.2854860
Removal of epididymis

T
0183
23.531
1,446.40

289.2854861
Removal of epididymis

T
0183
23.531
1,446.40

289.2854865
Explore epididymis
NI
T
0183
23.531
1,446.40

289.2854900
Fusion of spermatic ducts

T
0183
23.531
1,446.40

289.2854901
Fusion of spermatic ducts

T
0183
23.531
1,446.40

289.2855000
Drainage of hydrocele

T
0004
2.0687
127.16

25.4355040
Removal of hydrocele

T
0154
29.2182
1,795.98
464.85
359.2055041
Removal of hydroceles

T
0154
29.2182
1,795.98
464.85
359.2055060
Repair of hydrocele

T
0183
23.531
1,446.40

289.2855100
Drainage of scrotum abscess
CH
T
0007
11.1535
685.58

137.1255110
Explore scrotum

T
0183
23.531
1,446.40

289.2855120
Removal of scrotum lesion

T
0183
23.531
1,446.40

289.2855150
Removal of scrotum

T
0183
23.531
1,446.40

289.2855175
Revision of scrotum

T
0183
23.531
1,446.40

289.28( print page 68330)55180
Revision of scrotum

T
0183
23.531
1,446.40

289.2855200
Incision of sperm duct

T
0183
23.531
1,446.40

289.2855250
Removal of sperm duct(s)

T
0183
23.531
1,446.40

289.2855300
Prepare, sperm duct x-ray

N55400
Repair of sperm duct

T
0183
23.531
1,446.40

289.2855450
Ligation of sperm duct

T
0183
23.531
1,446.40

289.2855500
Removal of hydrocele

T
0183
23.531
1,446.40

289.2855520
Removal of sperm cord lesion

T
0183
23.531
1,446.40

289.2855530
Revise spermatic cord veins

T
0183
23.531
1,446.40

289.2855535
Revise spermatic cord veins

T
0154
29.2182
1,795.98
464.85
359.2055540
Revise hernia & sperm veins

T
0154
29.2182
1,795.98
464.85
359.2055550
Laparo ligate spermatic vein

T
0131
43.5488
2,676.86
1,001.89
535.3755559
Laparo proc, spermatic cord

T
0130
32.1241
1,974.60
659.53
394.9255600
Incise sperm duct pouch

T
0183
23.531
1,446.40

289.2855680
Remove sperm pouch lesion

T
0183
23.531
1,446.40

289.2855700
Biopsy of prostate

T
0184
5.6262
345.83
96.27
69.1755705
Biopsy of prostate

T
0184
5.6262
345.83
96.27
69.1755720
Drainage of prostate abscess

T
0162
23.87
1,467.24

293.4555725
Drainage of prostate abscess

T
0162
23.87
1,467.24

293.4555859
Percut/needle insert, pros
CH
D55860
Surgical exposure, prostate

T
0165
18.1679
1,116.74

223.3555870
Electroejaculation

T
0197
4.0007
245.92

49.1855873
Cryoablate prostate

T
0674
108.7566
6,685.05

1,337.0155875
Transperi needle place, pros
NI
T
0163
34.9261
2,146.84

429.3755876
Place rt device/marker, pros
NI
T
0156
3.4079
209.48

41.9055899
Genital surgery procedure
CH
T
0126
1.0887
66.92
16.45
13.3856405
I & D of vulva/perineum

T
0189
2.8966
178.05

35.6156420
Drainage of gland abscess
CH
T
0188
1.29
79.29

15.8656440
Surgery for vulva lesion

T
0194
20.5081
1,260.59
397.84
252.1256441
Lysis of labial lesion(s)

T
0193
14.8489
912.73

182.5556442
Hymenotomy
NI
T
0193
14.8489
912.73

182.5556501
Destroy, vulva lesions, sim

T
0017
17.4423
1,072.14
227.84
214.4356515
Destroy vulva lesion/s compl

T
0695
20.4276
1,255.64
266.59
251.1356605
Biopsy of vulva/perineum

T
0019
4.0919
251.52
71.87
50.3056606
Biopsy of vulva/perineum

T
0019
4.0919
251.52
71.87
50.3056620
Partial removal of vulva

T
0195
28.5095
1,752.42
483.80
350.4856625
Complete removal of vulva

T
0195
28.5095
1,752.42
483.80
350.4856700
Partial removal of hymen

T
0194
20.5081
1,260.59
397.84
252.1256720
Incision of hymen
CH
D56740
Remove vagina gland lesion

T
0194
20.5081
1,260.59
397.84
252.1256800
Repair of vagina

T
0194
20.5081
1,260.59
397.84
252.1256805
Repair clitoris

T
0193
14.8489
912.73

182.5556810
Repair of perineum

T
0194
20.5081
1,260.59
397.84
252.1256820
Exam of vulva w/scope

T
0188
1.29
79.29

15.8656821
Exam/biopsy of vulva w/scope

T
0189
2.8966
178.05

35.6157000
Exploration of vagina

T
0193
14.8489
912.73

182.5557010
Drainage of pelvic abscess

T
0193
14.8489
912.73

182.5557020
Drainage of pelvic fluid

T
0192
6.6592
409.33

81.8757022
I & d vaginal hematoma, pp

T
0007
11.1535
685.58

137.1257023
I & d vag hematoma, non-ob

T
0008
17.5086
1,076.22

215.2457061
Destroy vag lesions, simple

T
0194
20.5081
1,260.59
397.84
252.1257065
Destroy vag lesions, complex

T
0194
20.5081
1,260.59
397.84
252.1257100
Biopsy of vagina

T
0192
6.6592
409.33

81.8757105
Biopsy of vagina

T
0194
20.5081
1,260.59
397.84
252.1257106
Remove vagina wall, partial

T
0194
20.5081
1,260.59
397.84
252.1257107
Remove vagina tissue, part

T
0195
28.5095
1,752.42
483.80
350.4857109
Vaginectomy partial w/nodes

T
0195
28.5095
1,752.42
483.80
350.4857120
Closure of vagina

T
0195
28.5095
1,752.42
483.80
350.4857130
Remove vagina lesion

T
0194
20.5081
1,260.59
397.84
252.1257135
Remove vagina lesion

T
0194
20.5081
1,260.59
397.84
252.1257150
Treat vagina infection

T
0191
0.1468
9.02
2.55
1.8057155
Insert uteri tandems/ovoids

T
0192
6.6592
409.33

81.8757160
Insert pessary/other device

T
0188
1.29
79.29

15.8657170
Fitting of diaphragm/cap

T
0191
0.1468
9.02
2.55
1.8057180
Treat vaginal bleeding

T
0189
2.8966
178.05

35.6157200
Repair of vagina

T
0194
20.5081
1,260.59
397.84
252.1257210
Repair vagina/perineum

T
0194
20.5081
1,260.59
397.84
252.1257220
Revision of urethra

T
0202
42.9896
2,642.48
981.50
528.5057230
Repair of urethral lesion

T
0195
28.5095
1,752.42
483.80
350.4857240
Repair bladder & vagina

T
0195
28.5095
1,752.42
483.80
350.48( print page 68331)57250
Repair rectum & vagina

T
0195
28.5095
1,752.42
483.80
350.4857260
Repair of vagina

T
0195
28.5095
1,752.42
483.80
350.4857265
Extensive repair of vagina

T
0202
42.9896
2,642.48
981.50
528.5057267
Insert mesh/pelvic flr addon
CH
T
0195
28.5095
1,752.42
483.80
350.4857268
Repair of bowel bulge

T
0195
28.5095
1,752.42
483.80
350.4857282
Colpopexy, extraperitoneal
CH
T
0202
42.9896
2,642.48
981.50
528.5057283
Colpopexy, intraperitoneal
CH
T
0202
42.9896
2,642.48
981.50
528.5057284
Repair paravaginal defect

T
0202
42.9896
2,642.48
981.50
528.5057287
Revise/remove sling repair
CH
T
0195
28.5095
1,752.42
483.80
350.4857288
Repair bladder defect

T
0202
42.9896
2,642.48
981.50
528.5057289
Repair bladder & vagina

T
0195
28.5095
1,752.42
483.80
350.4857291
Construction of vagina

T
0195
28.5095
1,752.42
483.80
350.4857292
Construct vagina with graft
CH
T
0195
28.5095
1,752.42
483.80
350.4857295
Change vaginal graft

T
0194
20.5081
1,260.59
397.84
252.1257296
Revise vag graft, open abd
NI
C57300
Repair rectum-vagina fistula

T
0195
28.5095
1,752.42
483.80
350.4857310
Repair urethrovaginal lesion

T
0202
42.9896
2,642.48
981.50
528.5057320
Repair bladder-vagina lesion

T
0195
28.5095
1,752.42
483.80
350.4857330
Repair bladder-vagina lesion

T
0195
28.5095
1,752.42
483.80
350.4857335
Repair vagina
CH
T
0195
28.5095
1,752.42
483.80
350.4857400
Dilation of vagina

T
0194
20.5081
1,260.59
397.84
252.1257410
Pelvic examination

T
0193
14.8489
912.73

182.5557415
Remove vaginal foreign body

T
0194
20.5081
1,260.59
397.84
252.1257420
Exam of vagina w/scope

T
0189
2.8966
178.05

35.6157421
Exam/biopsy of vag w/scope

T
0189
2.8966
178.05

35.6157425
Laparoscopy, surg, colpopexy

T
0130
32.1241
1,974.60
659.53
394.9257452
Exam of cervix w/scope
CH
T
0188
1.29
79.29

15.8657454
Bx/curett of cervix w/scope

T
0189
2.8966
178.05

35.6157455
Biopsy of cervix w/scope

T
0189
2.8966
178.05

35.6157456
Endocerv curettage w/scope

T
0189
2.8966
178.05

35.6157460
Bx of cervix w/scope, leep

T
0193
14.8489
912.73

182.5557461
Conz of cervix w/scope, leep

T
0194
20.5081
1,260.59
397.84
252.1257500
Biopsy of cervix
CH
T
0189
2.8966
178.05

35.6157505
Endocervical curettage

T
0189
2.8966
178.05

35.6157510
Cauterization of cervix

T
0193
14.8489
912.73

182.5557511
Cryocautery of cervix
CH
T
0188
1.29
79.29

15.8657513
Laser surgery of cervix

T
0193
14.8489
912.73

182.5557520
Conization of cervix

T
0194
20.5081
1,260.59
397.84
252.1257522
Conization of cervix

T
0195
28.5095
1,752.42
483.80
350.4857530
Removal of cervix

T
0195
28.5095
1,752.42
483.80
350.4857550
Removal of residual cervix

T
0195
28.5095
1,752.42
483.80
350.4857555
Remove cervix/repair vagina

T
0195
28.5095
1,752.42
483.80
350.4857556
Remove cervix, repair bowel

T
0202
42.9896
2,642.48
981.50
528.5057558
D&c of cervical stump
NI
T
0196
17.7499
1,091.05
338.23
218.2157700
Revision of cervix

T
0194
20.5081
1,260.59
397.84
252.1257720
Revision of cervix

T
0194
20.5081
1,260.59
397.84
252.1257800
Dilation of cervical canal

T
0193
14.8489
912.73

182.5557820
D & c of residual cervix
CH
D58100
Biopsy of uterus lining

T
0188
1.29
79.29

15.8658110
Bx done w/colposcopy add-on

T
0188
1.29
79.29

15.8658120
Dilation and curettage

T
0196
17.7499
1,091.05
338.23
218.2158145
Myomectomy vag method

T
0195
28.5095
1,752.42
483.80
350.4858260
Vaginal hysterectomy
CH
T
0195
28.5095
1,752.42
483.80
350.4858262
Vag hyst including t/o
CH
T
0195
28.5095
1,752.42
483.80
350.4858263
Vag hyst w/t/o & vag repair
CH
T
0195
28.5095
1,752.42
483.80
350.4858270
Vag hyst w/enterocele repair
CH
T
0195
28.5095
1,752.42
483.80
350.4858290
Vag hyst complex
CH
T
0202
42.9896
2,642.48
981.50
528.5058291
Vag hyst incl t/o, complex
CH
T
0202
42.9896
2,642.48
981.50
528.5058292
Vag hyst t/o & repair, compl
CH
T
0202
42.9896
2,642.48
981.50
528.5058294
Vag hyst w/enterocele, compl
CH
T
0202
42.9896
2,642.48
981.50
528.5058301
Remove intrauterine device
CH
T
0188
1.29
79.29

15.8658321
Artificial insemination

T
0197
4.0007
245.92

49.1858322
Artificial insemination

T
0197
4.0007
245.92

49.1858323
Sperm washing

T
0197
4.0007
245.92

49.1858340
Catheter for hysterography

N58345
Reopen fallopian tube

T
0193
14.8489
912.73

182.5558346
Insert heyman uteri capsule

T
0193
14.8489
912.73

182.5558350
Reopen fallopian tube

T
0195
28.5095
1,752.42
483.80
350.4858353
Endometr ablate, thermal

T
0195
28.5095
1,752.42
483.80
350.4858356
Endometrial cryoablation

T
0202
42.9896
2,642.48
981.50
528.50( print page 68332)58541
Lsh, uterus 250 g or less
NI
T
0131
43.5488
2,676.86
1,001.89
535.3758542
Lsh w/t/o ut 250 g or less
NI
T
0131
43.5488
2,676.86
1,001.89
535.3758543
Lsh uterus above 250 g
NI
T
0131
43.5488
2,676.86
1,001.89
535.3758544
Lsh w/t/o uterus above 250 g
NI
T
0131
43.5488
2,676.86
1,001.89
535.3758545
Laparoscopic myomectomy

T
0130
32.1241
1,974.60
659.53
394.9258546
Laparo-myomectomy, complex

T
0131
43.5488
2,676.86
1,001.89
535.3758548
Lap radical hyst
NI
C58550
Laparo-asst vag hysterectomy

T
0132
70.5066
4,333.90
1,239.22
866.7858552
Laparo-vag hyst incl t/o

T
0131
43.5488
2,676.86
1,001.89
535.3758553
Laparo-vag hyst, complex

T
0131
43.5488
2,676.86
1,001.89
535.3758554
Laparo-vag hyst w/t/o, compl

T
0131
43.5488
2,676.86
1,001.89
535.3758555
Hysteroscopy, dx, sep proc

T
0190
21.3586
1,312.87
424.28
262.5758558
Hysteroscopy, biopsy

T
0190
21.3586
1,312.87
424.28
262.5758559
Hysteroscopy, lysis

T
0190
21.3586
1,312.87
424.28
262.5758560
Hysteroscopy, resect septum

T
0387
34.0155
2,090.86
655.55
418.1758561
Hysteroscopy, remove myoma

T
0387
34.0155
2,090.86
655.55
418.1758562
Hysteroscopy, remove fb

T
0190
21.3586
1,312.87
424.28
262.5758563
Hysteroscopy, ablation

T
0387
34.0155
2,090.86
655.55
418.1758565
Hysteroscopy, sterilization

T
0202
42.9896
2,642.48
981.50
528.5058578
Laparo proc, uterus

T
0130
32.1241
1,974.60
659.53
394.9258579
Hysteroscope procedure

T
0190
21.3586
1,312.87
424.28
262.5758600
Division of fallopian tube

T
0195
28.5095
1,752.42
483.80
350.4858615
Occlude fallopian tube(s)

T
0194
20.5081
1,260.59
397.84
252.1258660
Laparoscopy, lysis

T
0131
43.5488
2,676.86
1,001.89
535.3758661
Laparoscopy, remove adnexa

T
0131
43.5488
2,676.86
1,001.89
535.3758662
Laparoscopy, excise lesions

T
0131
43.5488
2,676.86
1,001.89
535.3758670
Laparoscopy, tubal cautery

T
0131
43.5488
2,676.86
1,001.89
535.3758671
Laparoscopy, tubal block

T
0131
43.5488
2,676.86
1,001.89
535.3758672
Laparoscopy, fimbrioplasty

T
0131
43.5488
2,676.86
1,001.89
535.3758673
Laparoscopy, salpingostomy

T
0131
43.5488
2,676.86
1,001.89
535.3758679
Laparo proc, oviduct-ovary

T
0130
32.1241
1,974.60
659.53
394.9258770
Create new tubal opening

T
0195
28.5095
1,752.42
483.80
350.4858800
Drainage of ovarian cyst(s)

T
0193
14.8489
912.73

182.5558820
Drain ovary abscess, open

T
0195
28.5095
1,752.42
483.80
350.4858823
Drain pelvic abscess, percut

T
0193
14.8489
912.73

182.5558900
Biopsy of ovary(s)

T
0193
14.8489
912.73

182.5558920
Partial removal of ovary(s)

T
0195
28.5095
1,752.42
483.80
350.4858925
Removal of ovarian cyst(s)

T
0195
28.5095
1,752.42
483.80
350.4858957
Resect recurrent gyn mal
NI
C58958
Resect recur gyn mal w/lym
NI
C58970
Retrieval of oocyte

T
0197
4.0007
245.92

49.1858974
Transfer of embryo

T
0197
4.0007
245.92

49.1858976
Transfer of embryo

T
0197
4.0007
245.92

49.1858999
Genital surgery procedure

T
0191
0.1468
9.02
2.55
1.8059000
Amniocentesis, diagnostic

T
0198
1.4222
87.42
32.19
17.4859001
Amniocentesis, therapeutic

T
0192
6.6592
409.33

81.8759012
Fetal cord puncture,prenatal

T
0198
1.4222
87.42
32.19
17.4859015
Chorion biopsy

T
0198
1.4222
87.42
32.19
17.4859020
Fetal contract stress test
CH
T
0189
2.8966
178.05

35.6159025
Fetal non-stress test

T
0198
1.4222
87.42
32.19
17.4859030
Fetal scalp blood sample

T
0198
1.4222
87.42
32.19
17.4859070
Transabdom amnioinfus w/us

T
0198
1.4222
87.42
32.19
17.4859072
Umbilical cord occlud w/us

T
0198
1.4222
87.42
32.19
17.4859074
Fetal fluid drainage w/us

T
0198
1.4222
87.42
32.19
17.4859076
Fetal shunt placement, w/us

T
0198
1.4222
87.42
32.19
17.4859100
Remove uterus lesion

T
0195
28.5095
1,752.42
483.80
350.4859150
Treat ectopic pregnancy

T
0131
43.5488
2,676.86
1,001.89
535.3759151
Treat ectopic pregnancy

T
0131
43.5488
2,676.86
1,001.89
535.3759160
D& c after delivery

T
0196
17.7499
1,091.05
338.23
218.2159200
Insert cervical dilator

T
0189
2.8966
178.05

35.6159300
Episiotomy or vaginal repair

T
0193
14.8489
912.73

182.5559320
Revision of cervix

T
0194
20.5081
1,260.59
397.84
252.1259409
Obstetrical care

T
0194
20.5081
1,260.59
397.84
252.1259412
Antepartum manipulation

T
0700
2.3864
146.69

29.3459414
Deliver placenta

T
0193
14.8489
912.73

182.5559612
Vbac delivery only

T
0194
20.5081
1,260.59
397.84
252.1259812
Treatment of miscarriage

T
0201
18.5201
1,138.39
329.65
227.6859820
Care of miscarriage

T
0201
18.5201
1,138.39
329.65
227.6859821
Treatment of miscarriage

T
0201
18.5201
1,138.39
329.65
227.6859840
Abortion

T
0200
16.9328
1,040.83
243.36
208.17( print page 68333)59841
Abortion

T
0200
16.9328
1,040.83
243.36
208.1759866
Abortion (mpr)

T
0198
1.4222
87.42
32.19
17.4859870
Evacuate mole of uterus

T
0201
18.5201
1,138.39
329.65
227.6859871
Remove cerclage suture

T
0194
20.5081
1,260.59
397.84
252.1259897
Fetal invas px w/us

T
0198
1.4222
87.42
32.19
17.4859898
Laparo proc, ob care/deliver

T
0130
32.1241
1,974.60
659.53
394.9259899
Maternity care procedure

T
0198
1.4222
87.42
32.19
17.4860000
Drain thyroid/tongue cyst

T
0252
7.5511
464.15
109.16
92.8360001
Aspirate/inject thyriod cyst

T
0004
2.0687
127.16

25.4360100
Biopsy of thyroid

T
0004
2.0687
127.16

25.4360200
Remove thyroid lesion

T
0114
37.7224
2,318.72
467.95
463.7460210
Partial thyroid excision

T
0114
37.7224
2,318.72
467.95
463.7460212
Partial thyroid excision

T
0114
37.7224
2,318.72
467.95
463.7460220
Partial removal of thyroid

T
0114
37.7224
2,318.72
467.95
463.7460225
Partial removal of thyroid

T
0114
37.7224
2,318.72
467.95
463.7460240
Removal of thyroid

T
0114
37.7224
2,318.72
467.95
463.7460252
Removal of thyroid

T
0256
38.1991
2,348.02

469.6060260
Repeat thyroid surgery

T
0256
38.1991
2,348.02

469.6060280
Remove thyroid duct lesion

T
0114
37.7224
2,318.72
467.95
463.7460281
Remove thyroid duct lesion

T
0114
37.7224
2,318.72
467.95
463.7460500
Explore parathyroid glands

T
0256
38.1991
2,348.02

469.6060502
Re-explore parathyroids
CH
T
0256
38.1991
2,348.02

469.6060512
Autotransplant parathyroid

T
0022
20.0656
1,233.39
354.45
246.6860520
Removal of thymus gland
CH
T
0256
38.1991
2,348.02

469.6060659
Laparo proc, endocrine

T
0130
32.1241
1,974.60
659.53
394.9260699
Endocrine surgery procedure

T
0114
37.7224
2,318.72
467.95
463.7461000
Remove cranial cavity fluid

T
0212
2.9907
183.83
65.96
36.7761001
Remove cranial cavity fluid

T
0212
2.9907
183.83
65.96
36.7761020
Remove brain cavity fluid

T
0212
2.9907
183.83
65.96
36.7761026
Injection into brain canal

T
0212
2.9907
183.83
65.96
36.7761050
Remove brain canal fluid

T
0212
2.9907
183.83
65.96
36.7761055
Injection into brain canal

T
0212
2.9907
183.83
65.96
36.7761070
Brain canal shunt procedure

T
0212
2.9907
183.83
65.96
36.7761215
Insert brain-fluid device

T
0224
47.0342
2,891.10

578.2261330
Decompress eye socket

T
0256
38.1991
2,348.02

469.6061334
Explore orbit/remove object

T
0256
38.1991
2,348.02

469.6061623
Endovasc tempory vessel occl

T
0081
42.936
2,639.19

527.8461626
Transcath occlusion, non-cns

T
0081
42.936
2,639.19

527.8461720
Incise skull/brain surgery
CH
T
0221
33.152
2,037.79
463.62
407.5661790
Treat trigeminal nerve

T
0220
17.8499
1,097.20

219.4461791
Treat trigeminal tract

T
0206
5.7253
351.92
75.55
70.3861795
Brain surgery using computer

S
0302
4.9138
302.04
105.94
60.4161880
Revise/remove neuroelectrode

T
0687
17.8334
1,096.18
438.47
219.2461885
Insrt/redo neurostim 1 array

S
0039
187.3821
11,518.00

2,303.6061886
Implant neurostim arrays

T
0315
242.9363
14,932.81

2,986.5661888
Revise/remove neuroreceiver

T
0688
35.5702
2,186.43
874.57
437.2962000
Treat skull fracture
CH
T
0254
23.3299
1,434.04
321.35
286.8162160
Neuroendoscopy add-on

T
0122
7.48
459.78

91.9662194
Replace/irrigate catheter

T
0427
11.6575
716.56

143.3162225
Replace/irrigate catheter

T
0427
11.6575
716.56

143.3162230
Replace/revise brain shunt

T
0224
47.0342
2,891.10

578.2262252
Csf shunt reprogram

S
0691
2.8942
177.90
60.61
35.5862263
Epidural lysis mult sessions

T
0203
12.1702
748.08
240.33
149.6262264
Epidural lysis on single day

T
0203
12.1702
748.08
240.33
149.6262268
Drain spinal cord cyst

T
0212
2.9907
183.83
65.96
36.7762269
Needle biopsy, spinal cord

T
0685
6.1384
377.32
115.47
75.4662270
Spinal fluid tap, diagnostic

T
0204
2.2614
139.00
40.13
27.8062272
Drain cerebro spinal fluid

T
0204
2.2614
139.00
40.13
27.8062273
Inject epidural patch

T
0206
5.7253
351.92
75.55
70.3862280
Treat spinal cord lesion

T
0207
6.3603
390.95
86.92
78.1962281
Treat spinal cord lesion

T
0207
6.3603
390.95
86.92
78.1962282
Treat spinal canal lesion

T
0207
6.3603
390.95
86.92
78.1962284
Injection for myelogram

N62287
Percutaneous diskectomy

T
0221
33.152
2,037.79
463.62
407.5662290
Inject for spine disk x-ray

N62291
Inject for spine disk x-ray

N62292
Injection into disk lesion

T
0212
2.9907
183.83
65.96
36.7762294
Injection into spinal artery

T
0212
2.9907
183.83
65.96
36.7762310
Inject spine c/t

T
0207
6.3603
390.95
86.92
78.1962311
Inject spine l/s (cd)

T
0207
6.3603
390.95
86.92
78.19( print page 68334)62318
Inject spine w/cath, c/t

T
0207
6.3603
390.95
86.92
78.1962319
Inject spine w/cath l/s (cd)

T
0207
6.3603
390.95
86.92
78.1962350
Implant spinal canal cath

T
0223
30.8394
1,895.64

379.1362351
Implant spinal canal cath

T
0208
44.1489
2,713.74

542.7562355
Remove spinal canal catheter

T
0203
12.1702
748.08
240.33
149.6262360
Insert spine infusion device

T
0226
112.6322
6,923.28

1,384.6662361
Implant spine infusion pump

T
0227
174.4056
10,720.36

2,144.0762362
Implant spine infusion pump

T
0227
174.4056
10,720.36

2,144.0762365
Remove spine infusion device

T
0221
33.152
2,037.79
463.62
407.5662367
Analyze spine infusion pump

S
0691
2.8942
177.90
60.61
35.5862368
Analyze spine infusion pump

S
0691
2.8942
177.90
60.61
35.5863001
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563003
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563005
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563011
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563012
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563015
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563016
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563017
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563020
Neck spine disk surgery

T
0208
44.1489
2,713.74

542.7563030
Low back disk surgery

T
0208
44.1489
2,713.74

542.7563035
Spinal disk surgery add-on

T
0208
44.1489
2,713.74

542.7563040
Laminotomy, single cervical

T
0208
44.1489
2,713.74

542.7563042
Laminotomy, single lumbar

T
0208
44.1489
2,713.74

542.7563045
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563046
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563047
Removal of spinal lamina

T
0208
44.1489
2,713.74

542.7563048
Remove spinal lamina add-on

T
0208
44.1489
2,713.74

542.7563055
Decompress spinal cord

T
0208
44.1489
2,713.74

542.7563056
Decompress spinal cord

T
0208
44.1489
2,713.74

542.7563057
Decompress spine cord add-on

T
0208
44.1489
2,713.74

542.7563064
Decompress spinal cord

T
0208
44.1489
2,713.74

542.7563066
Decompress spine cord add-on

T
0208
44.1489
2,713.74

542.7563075
Neck spine disk surgery

T
0208
44.1489
2,713.74

542.7563600
Remove spinal cord lesion

T
0220
17.8499
1,097.20

219.4463610
Stimulation of spinal cord

T
0220
17.8499
1,097.20

219.4463615
Remove lesion of spinal cord

T
0220
17.8499
1,097.20

219.4463650
Implant neuroelectrodes

S
0040
56.5705
3,477.28

695.4663655
Implant neuroelectrodes

S
0061
84.1967
5,175.40

1,035.0863660
Revise/remove neuroelectrode

T
0687
17.8334
1,096.18
438.47
219.2463685
Insrt/redo spine n generator

T
0222
181.6249
11,164.12

2,232.8263688
Revise/remove neuroreceiver

T
0688
35.5702
2,186.43
874.57
437.2963741
Install spinal shunt

T
0228
39.2633
2,413.44

482.6963744
Revision of spinal shunt

T
0228
39.2633
2,413.44

482.6963746
Removal of spinal shunt

T
0109
10.9918
675.64

135.1364400
Nblock inj, trigeminal

T
0204
2.2614
139.00
40.13
27.8064402
Nblock inj, facial

T
0204
2.2614
139.00
40.13
27.8064405
Nblock inj, occipital

T
0204
2.2614
139.00
40.13
27.8064408
Nblock inj, vagus

T
0204
2.2614
139.00
40.13
27.8064410
Nblock inj, phrenic

T
0206
5.7253
351.92
75.55
70.3864412
Nblock inj, spinal accessor

T
0206
5.7253
351.92
75.55
70.3864413
Nblock inj, cervical plexus

T
0204
2.2614
139.00
40.13
27.8064415
Nblock inj, brachial plexus

T
0204
2.2614
139.00
40.13
27.8064416
Nblock cont infuse, b plex

T
0204
2.2614
139.00
40.13
27.8064417
Nblock inj, axillary

T
0204
2.2614
139.00
40.13
27.8064418
Nblock inj, suprascapular

T
0204
2.2614
139.00
40.13
27.8064420
Nblock inj, intercost, sng

T
0204
2.2614
139.00
40.13
27.8064421
Nblock inj, intercost, mlt

T
0206
5.7253
351.92
75.55
70.3864425
Nblock inj, ilio-ing/hypogi

T
0204
2.2614
139.00
40.13
27.8064430
Nblock inj, pudendal

T
0204
2.2614
139.00
40.13
27.8064435
Nblock inj, paracervical

T
0204
2.2614
139.00
40.13
27.8064445
Nblock inj, sciatic, sng

T
0204
2.2614
139.00
40.13
27.8064446
Nblk inj, sciatic, cont inf

T
0206
5.7253
351.92
75.55
70.3864447
Nblock inj fem, single

T
0204
2.2614
139.00
40.13
27.8064448
Nblock inj fem, cont inf

T
0204
2.2614
139.00
40.13
27.8064449
Nblock inj, lumbar plexus

T
0204
2.2614
139.00
40.13
27.8064450
Nblock, other peripheral

T
0204
2.2614
139.00
40.13
27.8064470
Inj paravertebral c/t

T
0207
6.3603
390.95
86.92
78.1964472
Inj paravertebral c/t add-on

T
0206
5.7253
351.92
75.55
70.3864475
Inj paravertebral l/s

T
0207
6.3603
390.95
86.92
78.19( print page 68335)64476
Inj paravertebral l/s add-on

T
0206
5.7253
351.92
75.55
70.3864479
Inj foramen epidural c/t

T
0207
6.3603
390.95
86.92
78.1964480
Inj foramen epidural add-on

T
0207
6.3603
390.95
86.92
78.1964483
Inj foramen epidural l/s

T
0207
6.3603
390.95
86.92
78.1964484
Inj foramen epidural add-on

T
0207
6.3603
390.95
86.92
78.1964505
Nblock, spenopalatine gangl

T
0204
2.2614
139.00
40.13
27.8064508
Nblock, carotid sinus s/p

T
0204
2.2614
139.00
40.13
27.8064510
Nblock, stellate ganglion

T
0207
6.3603
390.95
86.92
78.1964517
Nblock inj, hypogas plxs

T
0204
2.2614
139.00
40.13
27.8064520
Nblock, lumbar/thoracic

T
0207
6.3603
390.95
86.92
78.1964530
Nblock inj, celiac pelus

T
0207
6.3603
390.95
86.92
78.1964553
Implant neuroelectrodes

S
0225
221.1512
13,593.72

2,718.7464555
Implant neuroelectrodes

S
0040
56.5705
3,477.28

695.4664560
Implant neuroelectrodes

S
0040
56.5705
3,477.28

695.4664561
Implant neuroelectrodes

S
0040
56.5705
3,477.28

695.4664565
Implant neuroelectrodes

S
0040
56.5705
3,477.28

695.4664573
Implant neuroelectrodes

S
0225
221.1512
13,593.72

2,718.7464575
Implant neuroelectrodes

S
0061
84.1967
5,175.40

1,035.0864577
Implant neuroelectrodes

S
0061
84.1967
5,175.40

1,035.0864580
Implant neuroelectrodes

S
0061
84.1967
5,175.40

1,035.0864581
Implant neuroelectrodes

S
0061
84.1967
5,175.40

1,035.0864585
Revise/remove neuroelectrode

T
0687
17.8334
1,096.18
438.47
219.2464590
Insrt/redo pn/gastr stimul

T
0222
181.6249
11,164.12

2,232.8264595
Revise/rmv pn/gastr stimul

T
0688
35.5702
2,186.43
874.57
437.2964600
Injection treatment of nerve

T
0203
12.1702
748.08
240.33
149.6264605
Injection treatment of nerve

T
0203
12.1702
748.08
240.33
149.6264610
Injection treatment of nerve

T
0203
12.1702
748.08
240.33
149.6264612
Destroy nerve, face muscle

T
0204
2.2614
139.00
40.13
27.8064613
Destroy nerve, neck muscle

T
0204
2.2614
139.00
40.13
27.8064614
Destroy nerve, extrem musc

T
0204
2.2614
139.00
40.13
27.8064620
Injection treatment of nerve

T
0203
12.1702
748.08
240.33
149.6264622
Destr paravertebrl nerve l/s

T
0203
12.1702
748.08
240.33
149.6264623
Destr paravertebral n add-on

T
0207
6.3603
390.95
86.92
78.1964626
Destr paravertebrl nerve c/t

T
0203
12.1702
748.08
240.33
149.6264627
Destr paravertebral n add-on

T
0207
6.3603
390.95
86.92
78.1964630
Injection treatment of nerve

T
0206
5.7253
351.92
75.55
70.3864640
Injection treatment of nerve

T
0206
5.7253
351.92
75.55
70.3864650
Chemodenerv eccrine glands

T
0204
2.2614
139.00
40.13
27.8064653
Chemodenerv eccrine glands

T
0204
2.2614
139.00
40.13
27.8064680
Injection treatment of nerve

T
0207
6.3603
390.95
86.92
78.1964681
Injection treatment of nerve

T
0203
12.1702
748.08
240.33
149.6264702
Revise finger/toe nerve

T
0220
17.8499
1,097.20

219.4464704
Revise hand/foot nerve

T
0220
17.8499
1,097.20

219.4464708
Revise arm/leg nerve

T
0220
17.8499
1,097.20

219.4464712
Revision of sciatic nerve

T
0220
17.8499
1,097.20

219.4464713
Revision of arm nerve(s)

T
0220
17.8499
1,097.20

219.4464714
Revise low back nerve(s)

T
0220
17.8499
1,097.20

219.4464716
Revision of cranial nerve

T
0220
17.8499
1,097.20

219.4464718
Revise ulnar nerve at elbow

T
0220
17.8499
1,097.20

219.4464719
Revise ulnar nerve at wrist

T
0220
17.8499
1,097.20

219.4464721
Carpal tunnel surgery

T
0220
17.8499
1,097.20

219.4464722
Relieve pressure on nerve(s)

T
0220
17.8499
1,097.20

219.4464726
Release foot/toe nerve

T
0220
17.8499
1,097.20

219.4464727
Internal nerve revision

T
0220
17.8499
1,097.20

219.4464732
Incision of brow nerve

T
0220
17.8499
1,097.20

219.4464734
Incision of cheek nerve

T
0220
17.8499
1,097.20

219.4464736
Incision of chin nerve

T
0220
17.8499
1,097.20

219.4464738
Incision of jaw nerve

T
0220
17.8499
1,097.20

219.4464740
Incision of tongue nerve

T
0220
17.8499
1,097.20

219.4464742
Incision of facial nerve

T
0220
17.8499
1,097.20

219.4464744
Incise nerve, back of head

T
0220
17.8499
1,097.20

219.4464746
Incise diaphragm nerve

T
0220
17.8499
1,097.20

219.4464761
Incision of pelvis nerve

T
0220
17.8499
1,097.20

219.4464763
Incise hip/thigh nerve

T
0220
17.8499
1,097.20

219.4464766
Incise hip/thigh nerve

T
0221
33.152
2,037.79
463.62
407.5664771
Sever cranial nerve

T
0220
17.8499
1,097.20

219.4464772
Incision of spinal nerve

T
0220
17.8499
1,097.20

219.4464774
Remove skin nerve lesion

T
0220
17.8499
1,097.20

219.4464776
Remove digit nerve lesion

T
0220
17.8499
1,097.20

219.4464778
Digit nerve surgery add-on

T
0220
17.8499
1,097.20

219.44( print page 68336)64782
Remove limb nerve lesion

T
0220
17.8499
1,097.20

219.4464783
Limb nerve surgery add-on

T
0220
17.8499
1,097.20

219.4464784
Remove nerve lesion

T
0220
17.8499
1,097.20

219.4464786
Remove sciatic nerve lesion

T
0221
33.152
2,037.79
463.62
407.5664787
Implant nerve end

T
0220
17.8499
1,097.20

219.4464788
Remove skin nerve lesion

T
0220
17.8499
1,097.20

219.4464790
Removal of nerve lesion

T
0220
17.8499
1,097.20

219.4464792
Removal of nerve lesion

T
0221
33.152
2,037.79
463.62
407.5664795
Biopsy of nerve

T
0220
17.8499
1,097.20

219.4464802
Remove sympathetic nerves

T
0220
17.8499
1,097.20

219.4464804
Remove sympathetic nerves
CH
T
0220
17.8499
1,097.20

219.4464820
Remove sympathetic nerves

T
0220
17.8499
1,097.20

219.4464821
Remove sympathetic nerves

T
0054
25.8758
1,590.53

318.1164822
Remove sympathetic nerves

T
0054
25.8758
1,590.53

318.1164823
Remove sympathetic nerves

T
0054
25.8758
1,590.53

318.1164831
Repair of digit nerve

T
0221
33.152
2,037.79
463.62
407.5664832
Repair nerve add-on

T
0221
33.152
2,037.79
463.62
407.5664834
Repair of hand or foot nerve

T
0221
33.152
2,037.79
463.62
407.5664835
Repair of hand or foot nerve

T
0221
33.152
2,037.79
463.62
407.5664836
Repair of hand or foot nerve

T
0221
33.152
2,037.79
463.62
407.5664837
Repair nerve add-on

T
0221
33.152
2,037.79
463.62
407.5664840
Repair of leg nerve

T
0221
33.152
2,037.79
463.62
407.5664856
Repair/transpose nerve

T
0221
33.152
2,037.79
463.62
407.5664857
Repair arm/leg nerve

T
0221
33.152
2,037.79
463.62
407.5664858
Repair sciatic nerve

T
0221
33.152
2,037.79
463.62
407.5664859
Nerve surgery

T
0221
33.152
2,037.79
463.62
407.5664861
Repair of arm nerves

T
0221
33.152
2,037.79
463.62
407.5664862
Repair of low back nerves

T
0221
33.152
2,037.79
463.62
407.5664864
Repair of facial nerve

T
0221
33.152
2,037.79
463.62
407.5664865
Repair of facial nerve

T
0221
33.152
2,037.79
463.62
407.5664870
Fusion of facial/other nerve

T
0221
33.152
2,037.79
463.62
407.5664872
Subsequent repair of nerve

T
0221
33.152
2,037.79
463.62
407.5664874
Repair & revise nerve add-on

T
0221
33.152
2,037.79
463.62
407.5664876
Repair nerve/shorten bone

T
0221
33.152
2,037.79
463.62
407.5664885
Nerve graft, head or neck

T
0221
33.152
2,037.79
463.62
407.5664886
Nerve graft, head or neck

T
0221
33.152
2,037.79
463.62
407.5664890
Nerve graft, hand or foot

T
0221
33.152
2,037.79
463.62
407.5664891
Nerve graft, hand or foot

T
0221
33.152
2,037.79
463.62
407.5664892
Nerve graft, arm or leg

T
0221
33.152
2,037.79
463.62
407.5664893
Nerve graft, arm or leg

T
0221
33.152
2,037.79
463.62
407.5664895
Nerve graft, hand or foot

T
0221
33.152
2,037.79
463.62
407.5664896
Nerve graft, hand or foot

T
0221
33.152
2,037.79
463.62
407.5664897
Nerve graft, arm or leg

T
0221
33.152
2,037.79
463.62
407.5664898
Nerve graft, arm or leg

T
0221
33.152
2,037.79
463.62
407.5664901
Nerve graft add-on

T
0221
33.152
2,037.79
463.62
407.5664902
Nerve graft add-on

T
0221
33.152
2,037.79
463.62
407.5664905
Nerve pedicle transfer

T
0221
33.152
2,037.79
463.62
407.5664907
Nerve pedicle transfer

T
0221
33.152
2,037.79
463.62
407.5664910
Nerve repair w/allograft
NI
T
0220
17.8499
1,097.20

219.4464911
Neurorraphy w/vein autograft
NI
T
0220
17.8499
1,097.20

219.4464999
Nervous system surgery

T
0204
2.2614
139.00
40.13
27.8065091
Revise eye

T
0242
35.2292
2,165.47
597.36
433.0965093
Revise eye with implant
CH
T
0242
35.2292
2,165.47
597.36
433.0965101
Removal of eye

T
0242
35.2292
2,165.47
597.36
433.0965103
Remove eye/insert implant

T
0242
35.2292
2,165.47
597.36
433.0965105
Remove eye/attach implant

T
0242
35.2292
2,165.47
597.36
433.0965110
Removal of eye

T
0242
35.2292
2,165.47
597.36
433.0965112
Remove eye/revise socket

T
0242
35.2292
2,165.47
597.36
433.0965114
Remove eye/revise socket

T
0242
35.2292
2,165.47
597.36
433.0965125
Revise ocular implant

T
0240
17.1243
1,052.60
309.52
210.5265130
Insert ocular implant

T
0241
25.255
1,552.37
384.47
310.4765135
Insert ocular implant

T
0241
25.255
1,552.37
384.47
310.4765140
Attach ocular implant

T
0242
35.2292
2,165.47
597.36
433.0965150
Revise ocular implant

T
0241
25.255
1,552.37
384.47
310.4765155
Reinsert ocular implant

T
0242
35.2292
2,165.47
597.36
433.0965175
Removal of ocular implant

T
0240
17.1243
1,052.60
309.52
210.5265205
Remove foreign body from eye

S
0698
1.1607
71.35

14.2765210
Remove foreign body from eye

S
0698
1.1607
71.35

14.2765220
Remove foreign body from eye

S
0698
1.1607
71.35

14.2765222
Remove foreign body from eye

S
0698
1.1607
71.35

14.27( print page 68337)65235
Remove foreign body from eye

T
0233
15.2259
935.91
266.33
187.1865260
Remove foreign body from eye

T
0236
16.5239
1,015.69

203.1465265
Remove foreign body from eye

T
0237
27.602
1,696.64

339.3365270
Repair of eye wound

T
0240
17.1243
1,052.60
309.52
210.5265272
Repair of eye wound

T
0234
22.997
1,413.58
511.31
282.7265275
Repair of eye wound

T
0234
22.997
1,413.58
511.31
282.7265280
Repair of eye wound

T
0236
16.5239
1,015.69

203.1465285
Repair of eye wound

T
0672
37.429
2,300.69

460.1465286
Repair of eye wound

T
0232
6.0673
372.94
93.43
74.5965290
Repair of eye socket wound

T
0243
21.2801
1,308.05
430.35
261.6165400
Removal of eye lesion

T
0233
15.2259
935.91
266.33
187.1865410
Biopsy of cornea

T
0233
15.2259
935.91
266.33
187.1865420
Removal of eye lesion

T
0233
15.2259
935.91
266.33
187.1865426
Removal of eye lesion

T
0234
22.997
1,413.58
511.31
282.7265430
Corneal smear

S
0698
1.1607
71.35

14.2765435
Curette/treat cornea

T
0239
7.2819
447.60

89.5265436
Curette/treat cornea

T
0233
15.2259
935.91
266.33
187.1865450
Treatment of corneal lesion

S
0231
2.1451
131.86

26.3765600
Revision of cornea

T
0240
17.1243
1,052.60
309.52
210.5265710
Corneal transplant

T
0244
38.2707
2,352.42
803.26
470.4865730
Corneal transplant

T
0244
38.2707
2,352.42
803.26
470.4865750
Corneal transplant

T
0244
38.2707
2,352.42
803.26
470.4865755
Corneal transplant

T
0244
38.2707
2,352.42
803.26
470.4865770
Revise cornea with implant
CH
T
0293
51.9894
3,195.68
1,128.29
639.1465772
Correction of astigmatism

T
0233
15.2259
935.91
266.33
187.1865775
Correction of astigmatism

T
0233
15.2259
935.91
266.33
187.1865780
Ocular reconst, transplant

T
0244
38.2707
2,352.42
803.26
470.4865781
Ocular reconst, transplant

T
0244
38.2707
2,352.42
803.26
470.4865782
Ocular reconst, transplant

T
0244
38.2707
2,352.42
803.26
470.4865800
Drainage of eye

T
0233
15.2259
935.91
266.33
187.1865805
Drainage of eye

T
0233
15.2259
935.91
266.33
187.1865810
Drainage of eye

T
0234
22.997
1,413.58
511.31
282.7265815
Drainage of eye

T
0234
22.997
1,413.58
511.31
282.7265820
Relieve inner eye pressure

T
0232
6.0673
372.94
93.43
74.5965850
Incision of eye

T
0234
22.997
1,413.58
511.31
282.7265855
Laser surgery of eye

T
0247
5.0839
312.50
104.31
62.5065860
Incise inner eye adhesions

T
0247
5.0839
312.50
104.31
62.5065865
Incise inner eye adhesions

T
0233
15.2259
935.91
266.33
187.1865870
Incise inner eye adhesions

T
0234
22.997
1,413.58
511.31
282.7265875
Incise inner eye adhesions

T
0234
22.997
1,413.58
511.31
282.7265880
Incise inner eye adhesions

T
0233
15.2259
935.91
266.33
187.1865900
Remove eye lesion

T
0233
15.2259
935.91
266.33
187.1865920
Remove implant of eye

T
0234
22.997
1,413.58
511.31
282.7265930
Remove blood clot from eye

T
0234
22.997
1,413.58
511.31
282.7266020
Injection treatment of eye

T
0233
15.2259
935.91
266.33
187.1866030
Injection treatment of eye

T
0232
6.0673
372.94
93.43
74.5966130
Remove eye lesion

T
0234
22.997
1,413.58
511.31
282.7266150
Glaucoma surgery

T
0234
22.997
1,413.58
511.31
282.7266155
Glaucoma surgery

T
0234
22.997
1,413.58
511.31
282.7266160
Glaucoma surgery

T
0234
22.997
1,413.58
511.31
282.7266165
Glaucoma surgery

T
0234
22.997
1,413.58
511.31
282.7266170
Glaucoma surgery

T
0234
22.997
1,413.58
511.31
282.7266172
Incision of eye
CH
T
0234
22.997
1,413.58
511.31
282.7266180
Implant eye shunt

T
0673
37.8967
2,329.43
649.56
465.8966185
Revise eye shunt

T
0673
37.8967
2,329.43
649.56
465.8966220
Repair eye lesion

T
0672
37.429
2,300.69

460.1466225
Repair/graft eye lesion

T
0673
37.8967
2,329.43
649.56
465.8966250
Follow-up surgery of eye

T
0233
15.2259
935.91
266.33
187.1866500
Incision of iris

T
0232
6.0673
372.94
93.43
74.5966505
Incision of iris

T
0232
6.0673
372.94
93.43
74.5966600
Remove iris and lesion

T
0234
22.997
1,413.58
511.31
282.7266605
Removal of iris

T
0234
22.997
1,413.58
511.31
282.7266625
Removal of iris

T
0232
6.0673
372.94
93.43
74.5966630
Removal of iris

T
0234
22.997
1,413.58
511.31
282.7266635
Removal of iris

T
0234
22.997
1,413.58
511.31
282.7266680
Repair iris & ciliary body

T
0234
22.997
1,413.58
511.31
282.7266682
Repair iris & ciliary body

T
0234
22.997
1,413.58
511.31
282.7266700
Destruction, ciliary body

T
0233
15.2259
935.91
266.33
187.1866710
Ciliary transsleral therapy

T
0233
15.2259
935.91
266.33
187.1866711
Ciliary endoscopic ablation

T
0233
15.2259
935.91
266.33
187.18( print page 68338)66720
Destruction, ciliary body

T
0233
15.2259
935.91
266.33
187.1866740
Destruction, ciliary body

T
0234
22.997
1,413.58
511.31
282.7266761
Revision of iris

T
0247
5.0839
312.50
104.31
62.5066762
Revision of iris

T
0247
5.0839
312.50
104.31
62.5066770
Removal of inner eye lesion

T
0247
5.0839
312.50
104.31
62.5066820
Incision, secondary cataract

T
0232
6.0673
372.94
93.43
74.5966821
After cataract laser surgery

T
0247
5.0839
312.50
104.31
62.5066825
Reposition intraocular lens

T
0234
22.997
1,413.58
511.31
282.7266830
Removal of lens lesion

T
0232
6.0673
372.94
93.43
74.5966840
Removal of lens material

T
0245
14.8702
914.04
217.05
182.8166850
Removal of lens material

T
0249
29.2281
1,796.59
524.67
359.3266852
Removal of lens material

T
0249
29.2281
1,796.59
524.67
359.3266920
Extraction of lens

T
0249
29.2281
1,796.59
524.67
359.3266930
Extraction of lens

T
0249
29.2281
1,796.59
524.67
359.3266940
Extraction of lens

T
0245
14.8702
914.04
217.05
182.8166982
Cataract surgery, complex

T
0246
23.6313
1,452.57
495.96
290.5166983
Cataract surg w/iol, 1 stage

T
0246
23.6313
1,452.57
495.96
290.5166984
Cataract surg w/iol, 1 stage

T
0246
23.6313
1,452.57
495.96
290.5166985
Insert lens prosthesis

T
0246
23.6313
1,452.57
495.96
290.5166986
Exchange lens prosthesis

T
0246
23.6313
1,452.57
495.96
290.5166990
Ophthalmic endoscope add-on

N66999
Eye surgery procedure

T
0232
6.0673
372.94
93.43
74.5967005
Partial removal of eye fluid

T
0237
27.602
1,696.64

339.3367010
Partial removal of eye fluid

T
0237
27.602
1,696.64

339.3367015
Release of eye fluid

T
0237
27.602
1,696.64

339.3367025
Replace eye fluid

T
0237
27.602
1,696.64

339.3367027
Implant eye drug system

T
0672
37.429
2,300.69

460.1467028
Injection eye drug

T
0235
3.9333
241.77
58.93
48.3567030
Incise inner eye strands

T
0236
16.5239
1,015.69

203.1467031
Laser surgery, eye strands

T
0247
5.0839
312.50
104.31
62.5067036
Removal of inner eye fluid

T
0672
37.429
2,300.69

460.1467038
Strip retinal membrane

T
0672
37.429
2,300.69

460.1467039
Laser treatment of retina

T
0672
37.429
2,300.69

460.1467040
Laser treatment of retina

T
0672
37.429
2,300.69

460.1467101
Repair detached retina

T
0236
16.5239
1,015.69

203.1467105
Repair detached retina

T
0248
5.0841
312.51
95.08
62.5067107
Repair detached retina

T
0672
37.429
2,300.69

460.1467108
Repair detached retina

T
0672
37.429
2,300.69

460.1467110
Repair detached retina

T
0236
16.5239
1,015.69

203.1467112
Rerepair detached retina

T
0672
37.429
2,300.69

460.1467115
Release encircling material

T
0236
16.5239
1,015.69

203.1467120
Remove eye implant material

T
0236
16.5239
1,015.69

203.1467121
Remove eye implant material

T
0237
27.602
1,696.64

339.3367141
Treatment of retina

T
0235
3.9333
241.77
58.93
48.3567145
Treatment of retina

T
0248
5.0841
312.51
95.08
62.5067208
Treatment of retinal lesion

T
0236
16.5239
1,015.69

203.1467210
Treatment of retinal lesion

T
0248
5.0841
312.51
95.08
62.5067218
Treatment of retinal lesion

T
0236
16.5239
1,015.69

203.1467220
Treatment of choroid lesion

T
0235
3.9333
241.77
58.93
48.3567221
Ocular photodynamic ther

T
0235
3.9333
241.77
58.93
48.3567225
Eye photodynamic ther add-on

T
0235
3.9333
241.77
58.93
48.3567227
Treatment of retinal lesion
CH
T
0237
27.602
1,696.64

339.3367228
Treatment of retinal lesion

T
0248
5.0841
312.51
95.08
62.5067250
Reinforce eye wall

T
0240
17.1243
1,052.60
309.52
210.5267255
Reinforce/graft eye wall

T
0237
27.602
1,696.64

339.3367299
Eye surgery procedure

T
0235
3.9333
241.77
58.93
48.3567311
Revise eye muscle

T
0243
21.2801
1,308.05
430.35
261.6167312
Revise two eye muscles

T
0243
21.2801
1,308.05
430.35
261.6167314
Revise eye muscle

T
0243
21.2801
1,308.05
430.35
261.6167316
Revise two eye muscles

T
0243
21.2801
1,308.05
430.35
261.6167318
Revise eye muscle(s)

T
0243
21.2801
1,308.05
430.35
261.6167320
Revise eye muscle(s) add-on

T
0243
21.2801
1,308.05
430.35
261.6167331
Eye surgery follow-up add-on

T
0243
21.2801
1,308.05
430.35
261.6167332
Rerevise eye muscles add-on

T
0243
21.2801
1,308.05
430.35
261.6167334
Revise eye muscle w/suture

T
0243
21.2801
1,308.05
430.35
261.6167335
Eye suture during surgery

T
0243
21.2801
1,308.05
430.35
261.6167340
Revise eye muscle add-on

T
0243
21.2801
1,308.05
430.35
261.6167343
Release eye tissue

T
0243
21.2801
1,308.05
430.35
261.6167345
Destroy nerve of eye muscle

T
0238
2.8954
177.97

35.5967346
Biopsy, eye muscle
NI
T
0699
14.3845
884.19

176.84( print page 68339)67350
Biopsy eye muscle
CH
D67399
Eye muscle surgery procedure

T
0243
21.2801
1,308.05
430.35
261.6167400
Explore/biopsy eye socket

T
0241
25.255
1,552.37
384.47
310.4767405
Explore/drain eye socket

T
0241
25.255
1,552.37
384.47
310.4767412
Explore/treat eye socket

T
0241
25.255
1,552.37
384.47
310.4767413
Explore/treat eye socket

T
0241
25.255
1,552.37
384.47
310.4767414
Explr/decompress eye socket

T
0242
35.2292
2,165.47
597.36
433.0967415
Aspiration, orbital contents

T
0240
17.1243
1,052.60
309.52
210.5267420
Explore/treat eye socket

T
0242
35.2292
2,165.47
597.36
433.0967430
Explore/treat eye socket

T
0242
35.2292
2,165.47
597.36
433.0967440
Explore/drain eye socket

T
0242
35.2292
2,165.47
597.36
433.0967445
Explr/decompress eye socket

T
0242
35.2292
2,165.47
597.36
433.0967450
Explore/biopsy eye socket

T
0242
35.2292
2,165.47
597.36
433.0967500
Inject/treat eye socket

S
0231
2.1451
131.86

26.3767505
Inject/treat eye socket

T
0238
2.8954
177.97

35.5967515
Inject/treat eye socket

T
0238
2.8954
177.97

35.5967550
Insert eye socket implant

T
0242
35.2292
2,165.47
597.36
433.0967560
Revise eye socket implant

T
0241
25.255
1,552.37
384.47
310.4767570
Decompress optic nerve

T
0242
35.2292
2,165.47
597.36
433.0967599
Orbit surgery procedure

T
0238
2.8954
177.97

35.5967700
Drainage of eyelid abscess

T
0238
2.8954
177.97

35.5967710
Incision of eyelid

T
0239
7.2819
447.60

89.5267715
Incision of eyelid fold

T
0240
17.1243
1,052.60
309.52
210.5267800
Remove eyelid lesion

T
0238
2.8954
177.97

35.5967801
Remove eyelid lesions

T
0239
7.2819
447.60

89.5267805
Remove eyelid lesions

T
0238
2.8954
177.97

35.5967808
Remove eyelid lesion(s)

T
0240
17.1243
1,052.60
309.52
210.5267810
Biopsy of eyelid

T
0238
2.8954
177.97

35.5967820
Revise eyelashes

S
0698
1.1607
71.35

14.2767825
Revise eyelashes

T
0238
2.8954
177.97

35.5967830
Revise eyelashes

T
0239
7.2819
447.60

89.5267835
Revise eyelashes

T
0240
17.1243
1,052.60
309.52
210.5267840
Remove eyelid lesion

T
0239
7.2819
447.60

89.5267850
Treat eyelid lesion

T
0239
7.2819
447.60

89.5267875
Closure of eyelid by suture

T
0239
7.2819
447.60

89.5267880
Revision of eyelid

T
0233
15.2259
935.91
266.33
187.1867882
Revision of eyelid

T
0240
17.1243
1,052.60
309.52
210.5267900
Repair brow defect

T
0240
17.1243
1,052.60
309.52
210.5267901
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267902
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267903
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267904
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267906
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267908
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267909
Revise eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267911
Revise eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267912
Correction eyelid w/implant

T
0240
17.1243
1,052.60
309.52
210.5267914
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267915
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267916
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267917
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267921
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267922
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267923
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267924
Repair eyelid defect

T
0240
17.1243
1,052.60
309.52
210.5267930
Repair eyelid wound

T
0240
17.1243
1,052.60
309.52
210.5267935
Repair eyelid wound

T
0240
17.1243
1,052.60
309.52
210.5267938
Remove eyelid foreign body

S
0698
1.1607
71.35

14.2767950
Revision of eyelid

T
0240
17.1243
1,052.60
309.52
210.5267961
Revision of eyelid

T
0240
17.1243
1,052.60
309.52
210.5267966
Revision of eyelid

T
0240
17.1243
1,052.60
309.52
210.5267971
Reconstruction of eyelid

T
0241
25.255
1,552.37
384.47
310.4767973
Reconstruction of eyelid

T
0241
25.255
1,552.37
384.47
310.4767974
Reconstruction of eyelid

T
0241
25.255
1,552.37
384.47
310.4767975
Reconstruction of eyelid

T
0240
17.1243
1,052.60
309.52
210.5267999
Revision of eyelid

T
0238
2.8954
177.97

35.5968020
Incise/drain eyelid lining

T
0240
17.1243
1,052.60
309.52
210.5268040
Treatment of eyelid lesions

S
0698
1.1607
71.35

14.2768100
Biopsy of eyelid lining

T
0232
6.0673
372.94
93.43
74.5968110
Remove eyelid lining lesion

T
0699
14.3845
884.19

176.84( print page 68340)68115
Remove eyelid lining lesion

T
0240
17.1243
1,052.60
309.52
210.5268130
Remove eyelid lining lesion

T
0233
15.2259
935.91
266.33
187.1868135
Remove eyelid lining lesion

T
0239
7.2819
447.60

89.5268200
Treat eyelid by injection

S
0230
0.7898
48.55
14.97
9.7168320
Revise/graft eyelid lining

T
0240
17.1243
1,052.60
309.52
210.5268325
Revise/graft eyelid lining
CH
T
0241
25.255
1,552.37
384.47
310.4768326
Revise/graft eyelid lining

T
0241
25.255
1,552.37
384.47
310.4768328
Revise/graft eyelid lining

T
0241
25.255
1,552.37
384.47
310.4768330
Revise eyelid lining

T
0234
22.997
1,413.58
511.31
282.7268335
Revise/graft eyelid lining

T
0241
25.255
1,552.37
384.47
310.4768340
Separate eyelid adhesions

T
0240
17.1243
1,052.60
309.52
210.5268360
Revise eyelid lining

T
0234
22.997
1,413.58
511.31
282.7268362
Revise eyelid lining

T
0234
22.997
1,413.58
511.31
282.7268371
Harvest eye tissue, alograft

T
0233
15.2259
935.91
266.33
187.1868399
Eyelid lining surgery

T
0238
2.8954
177.97

35.5968400
Incise/drain tear gland

T
0238
2.8954
177.97

35.5968420
Incise/drain tear sac

T
0240
17.1243
1,052.60
309.52
210.5268440
Incise tear duct opening

T
0238
2.8954
177.97

35.5968500
Removal of tear gland

T
0241
25.255
1,552.37
384.47
310.4768505
Partial removal, tear gland

T
0241
25.255
1,552.37
384.47
310.4768510
Biopsy of tear gland

T
0240
17.1243
1,052.60
309.52
210.5268520
Removal of tear sac

T
0241
25.255
1,552.37
384.47
310.4768525
Biopsy of tear sac

T
0240
17.1243
1,052.60
309.52
210.5268530
Clearance of tear duct

T
0240
17.1243
1,052.60
309.52
210.5268540
Remove tear gland lesion

T
0241
25.255
1,552.37
384.47
310.4768550
Remove tear gland lesion
CH
T
0241
25.255
1,552.37
384.47
310.4768700
Repair tear ducts

T
0241
25.255
1,552.37
384.47
310.4768705
Revise tear duct opening

T
0238
2.8954
177.97

35.5968720
Create tear sac drain
CH
T
0241
25.255
1,552.37
384.47
310.4768745
Create tear duct drain

T
0241
25.255
1,552.37
384.47
310.4768750
Create tear duct drain
CH
T
0241
25.255
1,552.37
384.47
310.4768760
Close tear duct opening
CH
S
0231
2.1451
131.86

26.3768761
Close tear duct opening

S
0231
2.1451
131.86

26.3768770
Close tear system fistula

T
0240
17.1243
1,052.60
309.52
210.5268801
Dilate tear duct opening

S
0698
1.1607
71.35

14.2768810
Probe nasolacrimal duct

S
0231
2.1451
131.86

26.3768811
Probe nasolacrimal duct

T
0240
17.1243
1,052.60
309.52
210.5268815
Probe nasolacrimal duct

T
0240
17.1243
1,052.60
309.52
210.5268840
Explore/irrigate tear ducts
CH
S
0698
1.1607
71.35

14.2768850
Injection for tear sac x-ray

N68899
Tear duct system surgery
CH
T
0238
2.8954
177.97

35.5969000
Drain external ear lesion

T
0006
1.4392
88.46

17.6969005
Drain external ear lesion

T
0008
17.5086
1,076.22

215.2469020
Drain outer ear canal lesion

T
0006
1.4392
88.46

17.6969100
Biopsy of external ear

T
0019
4.0919
251.52
71.87
50.3069105
Biopsy of external ear canal

T
0253
16.4266
1,009.71
282.29
201.9469110
Remove external ear, partial

T
0021
15.1024
928.31
219.48
185.6669120
Removal of external ear

T
0254
23.3299
1,434.04
321.35
286.8169140
Remove ear canal lesion(s)

T
0254
23.3299
1,434.04
321.35
286.8169145
Remove ear canal lesion(s)

T
0021
15.1024
928.31
219.48
185.6669150
Extensive ear canal surgery

T
0252
7.5511
464.15
109.16
92.8369200
Clear outer ear canal

X
0340
0.6102
37.51

7.5069205
Clear outer ear canal

T
0022
20.0656
1,233.39
354.45
246.6869210
Remove impacted ear wax

X
0340
0.6102
37.51

7.5069220
Clean out mastoid cavity

T
0012
0.8432
51.83
11.18
10.3769222
Clean out mastoid cavity
CH
T
0252
7.5511
464.15
109.16
92.8369300
Revise external ear

T
0254
23.3299
1,434.04
321.35
286.8169310
Rebuild outer ear canal

T
0256
38.1991
2,348.02

469.6069320
Rebuild outer ear canal

T
0256
38.1991
2,348.02

469.6069399
Outer ear surgery procedure

T
0251
2.452
150.72

30.1469400
Inflate middle ear canal

T
0251
2.452
150.72

30.1469401
Inflate middle ear canal

T
0251
2.452
150.72

30.1469405
Catheterize middle ear canal

T
0252
7.5511
464.15
109.16
92.8369420
Incision of eardrum

T
0251
2.452
150.72

30.1469421
Incision of eardrum

T
0253
16.4266
1,009.71
282.29
201.9469424
Remove ventilating tube

T
0252
7.5511
464.15
109.16
92.8369433
Create eardrum opening

T
0252
7.5511
464.15
109.16
92.8369436
Create eardrum opening

T
0253
16.4266
1,009.71
282.29
201.9469440
Exploration of middle ear

T
0254
23.3299
1,434.04
321.35
286.8169450
Eardrum revision

T
0256
38.1991
2,348.02

469.60( print page 68341)69501
Mastoidectomy

T
0256
38.1991
2,348.02

469.6069502
Mastoidectomy

T
0254
23.3299
1,434.04
321.35
286.8169505
Remove mastoid structures

T
0256
38.1991
2,348.02

469.6069511
Extensive mastoid surgery

T
0256
38.1991
2,348.02

469.6069530
Extensive mastoid surgery

T
0256
38.1991
2,348.02

469.6069540
Remove ear lesion

T
0253
16.4266
1,009.71
282.29
201.9469550
Remove ear lesion

T
0256
38.1991
2,348.02

469.6069552
Remove ear lesion

T
0256
38.1991
2,348.02

469.6069601
Mastoid surgery revision

T
0256
38.1991
2,348.02

469.6069602
Mastoid surgery revision

T
0256
38.1991
2,348.02

469.6069603
Mastoid surgery revision

T
0256
38.1991
2,348.02

469.6069604
Mastoid surgery revision

T
0256
38.1991
2,348.02

469.6069605
Mastoid surgery revision

T
0256
38.1991
2,348.02

469.6069610
Repair of eardrum

T
0254
23.3299
1,434.04
321.35
286.8169620
Repair of eardrum

T
0254
23.3299
1,434.04
321.35
286.8169631
Repair eardrum structures

T
0256
38.1991
2,348.02

469.6069632
Rebuild eardrum structures

T
0256
38.1991
2,348.02

469.6069633
Rebuild eardrum structures

T
0256
38.1991
2,348.02

469.6069635
Repair eardrum structures

T
0256
38.1991
2,348.02

469.6069636
Rebuild eardrum structures

T
0256
38.1991
2,348.02

469.6069637
Rebuild eardrum structures

T
0256
38.1991
2,348.02

469.6069641
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069642
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069643
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069644
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069645
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069646
Revise middle ear & mastoid

T
0256
38.1991
2,348.02

469.6069650
Release middle ear bone

T
0254
23.3299
1,434.04
321.35
286.8169660
Revise middle ear bone

T
0256
38.1991
2,348.02

469.6069661
Revise middle ear bone

T
0256
38.1991
2,348.02

469.6069662
Revise middle ear bone

T
0256
38.1991
2,348.02

469.6069666
Repair middle ear structures

T
0256
38.1991
2,348.02

469.6069667
Repair middle ear structures

T
0256
38.1991
2,348.02

469.6069670
Remove mastoid air cells

T
0256
38.1991
2,348.02

469.6069676
Remove middle ear nerve

T
0256
38.1991
2,348.02

469.6069700
Close mastoid fistula

T
0256
38.1991
2,348.02

469.6069711
Remove/repair hearing aid

T
0256
38.1991
2,348.02

469.6069714
Implant temple bone w/stimul

T
0256
38.1991
2,348.02

469.6069715
Temple bne implnt w/stimulat

T
0256
38.1991
2,348.02

469.6069717
Temple bone implant revision

T
0256
38.1991
2,348.02

469.6069718
Revise temple bone implant

T
0256
38.1991
2,348.02

469.6069720
Release facial nerve

T
0256
38.1991
2,348.02

469.6069725
Release facial nerve

T
0256
38.1991
2,348.02

469.6069740
Repair facial nerve

T
0256
38.1991
2,348.02

469.6069745
Repair facial nerve

T
0256
38.1991
2,348.02

469.6069799
Middle ear surgery procedure

T
0251
2.452
150.72

30.1469801
Incise inner ear

T
0256
38.1991
2,348.02

469.6069802
Incise inner ear

T
0256
38.1991
2,348.02

469.6069805
Explore inner ear

T
0256
38.1991
2,348.02

469.6069806
Explore inner ear

T
0256
38.1991
2,348.02

469.6069820
Establish inner ear window

T
0256
38.1991
2,348.02

469.6069840
Revise inner ear window

T
0256
38.1991
2,348.02

469.6069905
Remove inner ear

T
0256
38.1991
2,348.02

469.6069910
Remove inner ear & mastoid

T
0256
38.1991
2,348.02

469.6069915
Incise inner ear nerve

T
0256
38.1991
2,348.02

469.6069930
Implant cochlear device

T
0259
414.8455
25,499.72
8,698.43
5,099.9469949
Inner ear surgery procedure

T
0251
2.452
150.72

30.1469955
Release facial nerve

T
0256
38.1991
2,348.02

469.6069960
Release inner ear canal

T
0256
38.1991
2,348.02

469.6069979
Temporal bone surgery

T
0251
2.452
150.72

30.1469990
Microsurgery add-on

N70010
Contrast x-ray of brain

S
0274
2.5544
157.01
62.80
31.4070015
Contrast x-ray of brain

S
0274
2.5544
157.01
62.80
31.4070030
X-ray eye for foreign body

X
0260
0.7093
43.60

8.7270100
X-ray exam of jaw

X
0260
0.7093
43.60

8.7270110
X-ray exam of jaw

X
0260
0.7093
43.60

8.7270120
X-ray exam of mastoids

X
0260
0.7093
43.60

8.7270130
X-ray exam of mastoids

X
0260
0.7093
43.60

8.7270134
X-ray exam of middle ear

X
0261
1.2224
75.14

15.0370140
X-ray exam of facial bones

X
0260
0.7093
43.60

8.72( print page 68342)70150
X-ray exam of facial bones

X
0260
0.7093
43.60

8.7270160
X-ray exam of nasal bones

X
0260
0.7093
43.60

8.7270170
X-ray exam of tear duct

X
0264
2.9586
181.86
70.27
36.3770190
X-ray exam of eye sockets

X
0260
0.7093
43.60

8.7270200
X-ray exam of eye sockets

X
0260
0.7093
43.60

8.7270210
X-ray exam of sinuses

X
0260
0.7093
43.60

8.7270220
X-ray exam of sinuses

X
0260
0.7093
43.60

8.7270240
X-ray exam, pituitary saddle

X
0260
0.7093
43.60

8.7270250
X-ray exam of skull

X
0260
0.7093
43.60

8.7270260
X-ray exam of skull

X
0261
1.2224
75.14

15.0370300
X-ray exam of teeth

X
0262
0.655
40.26

8.0570310
X-ray exam of teeth

X
0262
0.655
40.26

8.0570320
Full mouth x-ray of teeth

X
0262
0.655
40.26

8.0570328
X-ray exam of jaw joint

X
0260
0.7093
43.60

8.7270330
X-ray exam of jaw joints

X
0260
0.7093
43.60

8.7270332
X-ray exam of jaw joint

S
0275
3.6915
226.91
69.09
45.3870336
Magnetic image, jaw joint

S
0335
4.5523
279.82
111.92
55.9670350
X-ray head for orthodontia

X
0260
0.7093
43.60

8.7270355
Panoramic x-ray of jaws

X
0260
0.7093
43.60

8.7270360
X-ray exam of neck

X
0260
0.7093
43.60

8.7270370
Throat x-ray & fluoroscopy

X
0272
1.2908
79.34
31.64
15.8770371
Speech evaluation, complex

X
0272
1.2908
79.34
31.64
15.8770373
Contrast x-ray of larynx

X
0263
1.6956
104.23
23.77
20.8570380
X-ray exam of salivary gland

X
0260
0.7093
43.60

8.7270390
X-ray exam of salivary duct

X
0263
1.6956
104.23
23.77
20.8570450
Ct head/brain w/o dye

S
0332
3.0908
189.99
75.24
38.0070460
Ct head/brain w/dye

S
0283
4.0825
250.94
100.37
50.1970470
Ct head/brain w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5170480
Ct orbit/ear/fossa w/o dye

S
0332
3.0908
189.99
75.24
38.0070481
Ct orbit/ear/fossa w/dye

S
0283
4.0825
250.94
100.37
50.1970482
Ct orbit/ear/fossa w/o&w/dye

S
0333
4.8405
297.54
119.01
59.5170486
Ct maxillofacial w/o dye

S
0332
3.0908
189.99
75.24
38.0070487
Ct maxillofacial w/dye

S
0283
4.0825
250.94
100.37
50.1970488
Ct maxillofacial w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5170490
Ct soft tissue neck w/o dye

S
0332
3.0908
189.99
75.24
38.0070491
Ct soft tissue neck w/dye

S
0283
4.0825
250.94
100.37
50.1970492
Ct sft tsue nck w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5170496
Ct angiography, head

S
0662
4.8552
298.44
118.88
59.6970498
Ct angiography, neck

S
0662
4.8552
298.44
118.88
59.6970540
Mri orbit/face/neck w/o dye

S
0336
5.6745
348.80
139.51
69.7670542
Mri orbit/face/neck w/dye

S
0284
6.1231
376.37
148.40
75.2770543
Mri orbt/fac/nck w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7770544
Mr angiography head w/o dye

S
0336
5.6745
348.80
139.51
69.7670545
Mr angiography head w/dye

S
0284
6.1231
376.37
148.40
75.2770546
Mr angiograph head w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7770547
Mr angiography neck w/o dye

S
0336
5.6745
348.80
139.51
69.7670548
Mr angiography neck w/dye

S
0284
6.1231
376.37
148.40
75.2770549
Mr angiograph neck w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7770551
Mri brain w/o dye

S
0336
5.6745
348.80
139.51
69.7670552
Mri brain w/dye

S
0284
6.1231
376.37
148.40
75.2770553
Mri brain w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7770554
Fmri brain by tech
NI
S
0336
5.6745
348.80
139.51
69.7670555
Fmri brain by phys/psych
NI
S
0336
5.6745
348.80
139.51
69.7670557
Mri brain w/o dye

S
0336
5.6745
348.80
139.51
69.7670558
Mri brain w/dye

S
0284
6.1231
376.37
148.40
75.2770559
Mri brain w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7771010
Chest x-ray

X
0260
0.7093
43.60

8.7271015
Chest x-ray

X
0260
0.7093
43.60

8.7271020
Chest x-ray

X
0260
0.7093
43.60

8.7271021
Chest x-ray

X
0260
0.7093
43.60

8.7271022
Chest x-ray

X
0260
0.7093
43.60

8.7271023
Chest x-ray and fluoroscopy

X
0272
1.2908
79.34
31.64
15.8771030
Chest x-ray

X
0260
0.7093
43.60

8.7271034
Chest x-ray and fluoroscopy

X
0272
1.2908
79.34
31.64
15.8771035
Chest x-ray

X
0260
0.7093
43.60

8.7271040
Contrast x-ray of bronchi

X
0263
1.6956
104.23
23.77
20.8571060
Contrast x-ray of bronchi

X
0263
1.6956
104.23
23.77
20.8571090
X-ray & pacemaker insertion

X
0272
1.2908
79.34
31.64
15.8771100
X-ray exam of ribs

X
0260
0.7093
43.60

8.7271101
X-ray exam of ribs/chest

X
0260
0.7093
43.60

8.72( print page 68343)71110
X-ray exam of ribs

X
0260
0.7093
43.60

8.7271111
X-ray exam of ribs/chest

X
0261
1.2224
75.14

15.0371120
X-ray exam of breastbone

X
0260
0.7093
43.60

8.7271130
X-ray exam of breastbone

X
0260
0.7093
43.60

8.7271250
Ct thorax w/o dye

S
0332
3.0908
189.99
75.24
38.0071260
Ct thorax w/dye

S
0283
4.0825
250.94
100.37
50.1971270
Ct thorax w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5171275
Ct angiography, chest

S
0662
4.8552
298.44
118.88
59.6971550
Mri chest w/o dye

S
0336
5.6745
348.80
139.51
69.7671551
Mri chest w/dye

S
0284
6.1231
376.37
148.40
75.2771552
Mri chest w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7772010
X-ray exam of spine

X
0260
0.7093
43.60

8.7272020
X-ray exam of spine

X
0260
0.7093
43.60

8.7272040
X-ray exam of neck spine

X
0260
0.7093
43.60

8.7272050
X-ray exam of neck spine

X
0261
1.2224
75.14

15.0372052
X-ray exam of neck spine

X
0261
1.2224
75.14

15.0372069
X-ray exam of trunk spine

X
0260
0.7093
43.60

8.7272070
X-ray exam of thoracic spine

X
0260
0.7093
43.60

8.7272072
X-ray exam of thoracic spine

X
0260
0.7093
43.60

8.7272074
X-ray exam of thoracic spine

X
0260
0.7093
43.60

8.7272080
X-ray exam of trunk spine

X
0260
0.7093
43.60

8.7272090
X-ray exam of trunk spine

X
0261
1.2224
75.14

15.0372100
X-ray exam of lower spine

X
0260
0.7093
43.60

8.7272110
X-ray exam of lower spine

X
0261
1.2224
75.14

15.0372114
X-ray exam of lower spine

X
0261
1.2224
75.14

15.0372120
X-ray exam of lower spine

X
0261
1.2224
75.14

15.0372125
Ct neck spine w/o dye

S
0332
3.0908
189.99
75.24
38.0072126
Ct neck spine w/dye

S
0283
4.0825
250.94
100.37
50.1972127
Ct neck spine w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5172128
Ct chest spine w/o dye

S
0332
3.0908
189.99
75.24
38.0072129
Ct chest spine w/dye

S
0283
4.0825
250.94
100.37
50.1972130
Ct chest spine w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5172131
Ct lumbar spine w/o dye

S
0332
3.0908
189.99
75.24
38.0072132
Ct lumbar spine w/dye

S
0283
4.0825
250.94
100.37
50.1972133
Ct lumbar spine w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5172141
Mri neck spine w/o dye

S
0336
5.6745
348.80
139.51
69.7672142
Mri neck spine w/dye

S
0284
6.1231
376.37
148.40
75.2772146
Mri chest spine w/o dye

S
0336
5.6745
348.80
139.51
69.7672147
Mri chest spine w/dye

S
0284
6.1231
376.37
148.40
75.2772148
Mri lumbar spine w/o dye

S
0336
5.6745
348.80
139.51
69.7672149
Mri lumbar spine w/dye

S
0284
6.1231
376.37
148.40
75.2772156
Mri neck spine w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7772157
Mri chest spine w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7772158
Mri lumbar spine w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7772170
X-ray exam of pelvis

X
0260
0.7093
43.60

8.7272190
X-ray exam of pelvis

X
0260
0.7093
43.60

8.7272191
Ct angiograph pelv w/o&w/dye

S
0662
4.8552
298.44
118.88
59.6972192
Ct pelvis w/o dye

S
0332
3.0908
189.99
75.24
38.0072193
Ct pelvis w/dye

S
0283
4.0825
250.94
100.37
50.1972194
Ct pelvis w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5172195
Mri pelvis w/o dye

S
0336
5.6745
348.80
139.51
69.7672196
Mri pelvis w/dye

S
0284
6.1231
376.37
148.40
75.2772197
Mri pelvis w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7772200
X-ray exam sacroiliac joints

X
0260
0.7093
43.60

8.7272202
X-ray exam sacroiliac joints

X
0260
0.7093
43.60

8.7272220
X-ray exam of tailbone

X
0260
0.7093
43.60

8.7272240
Contrast x-ray of neck spine

S
0274
2.5544
157.01
62.80
31.4072255
Contrast x-ray, thorax spine

S
0274
2.5544
157.01
62.80
31.4072265
Contrast x-ray, lower spine

S
0274
2.5544
157.01
62.80
31.4072270
Contrast x-ray, spine

S
0274
2.5544
157.01
62.80
31.4072275
Epidurography

S
0274
2.5544
157.01
62.80
31.4072285
X-ray c/t spine disk

S
0388
15.9758
982.00
289.72
196.4072291
Perq vertebroplasty, fluor
NI
S
0274
2.5544
157.01
62.80
31.4072292
Perq vertebroplasty, ct
NI
S
0274
2.5544
157.01
62.80
31.4072295
X-ray of lower spine disk

S
0388
15.9758
982.00
289.72
196.4073000
X-ray exam of collar bone

X
0260
0.7093
43.60

8.7273010
X-ray exam of shoulder blade

X
0260
0.7093
43.60

8.7273020
X-ray exam of shoulder

X
0260
0.7093
43.60

8.7273030
X-ray exam of shoulder

X
0260
0.7093
43.60

8.7273040
Contrast x-ray of shoulder

S
0275
3.6915
226.91
69.09
45.38( print page 68344)73050
X-ray exam of shoulders

X
0260
0.7093
43.60

8.7273060
X-ray exam of humerus

X
0260
0.7093
43.60

8.7273070
X-ray exam of elbow

X
0260
0.7093
43.60

8.7273080
X-ray exam of elbow

X
0260
0.7093
43.60

8.7273085
Contrast x-ray of elbow

S
0275
3.6915
226.91
69.09
45.3873090
X-ray exam of forearm

X
0260
0.7093
43.60

8.7273092
X-ray exam of arm, infant

X
0260
0.7093
43.60

8.7273100
X-ray exam of wrist

X
0260
0.7093
43.60

8.7273110
X-ray exam of wrist

X
0260
0.7093
43.60

8.7273115
Contrast x-ray of wrist

S
0275
3.6915
226.91
69.09
45.3873120
X-ray exam of hand

X
0260
0.7093
43.60

8.7273130
X-ray exam of hand

X
0260
0.7093
43.60

8.7273140
X-ray exam of finger(s)

X
0260
0.7093
43.60

8.7273200
Ct upper extremity w/o dye

S
0332
3.0908
189.99
75.24
38.0073201
Ct upper extremity w/dye

S
0283
4.0825
250.94
100.37
50.1973202
Ct uppr extremity w/o&w/dye

S
0333
4.8405
297.54
119.01
59.5173206
Ct angio upr extrm w/o&w/dye

S
0662
4.8552
298.44
118.88
59.6973218
Mri upper extremity w/o dye

S
0336
5.6745
348.80
139.51
69.7673219
Mri upper extremity w/dye

S
0284
6.1231
376.37
148.40
75.2773220
Mri uppr extremity w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7773221
Mri joint upr extrem w/o dye

S
0336
5.6745
348.80
139.51
69.7673222
Mri joint upr extrem w/dye

S
0284
6.1231
376.37
148.40
75.2773223
Mri joint upr extr w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7773500
X-ray exam of hip

X
0260
0.7093
43.60

8.7273510
X-ray exam of hip

X
0260
0.7093
43.60

8.7273520
X-ray exam of hips

X
0261
1.2224
75.14

15.0373525
Contrast x-ray of hip

S
0275
3.6915
226.91
69.09
45.3873530
X-ray exam of hip

X
0261
1.2224
75.14

15.0373540
X-ray exam of pelvis & hips

X
0260
0.7093
43.60

8.7273542
X-ray exam, sacroiliac joint

S
0275
3.6915
226.91
69.09
45.3873550
X-ray exam of thigh

X
0260
0.7093
43.60

8.7273560
X-ray exam of knee, 1 or 2

X
0260
0.7093
43.60

8.7273562
X-ray exam of knee, 3

X
0260
0.7093
43.60

8.7273564
X-ray exam, knee, 4 or more

X
0260
0.7093
43.60

8.7273565
X-ray exam of knees

X
0260
0.7093
43.60

8.7273580
Contrast x-ray of knee joint

S
0275
3.6915
226.91
69.09
45.3873590
X-ray exam of lower leg

X
0260
0.7093
43.60

8.7273592
X-ray exam of leg, infant

X
0260
0.7093
43.60

8.7273600
X-ray exam of ankle

X
0260
0.7093
43.60

8.7273610
X-ray exam of ankle

X
0260
0.7093
43.60

8.7273615
Contrast x-ray of ankle

S
0275
3.6915
226.91
69.09
45.3873620
X-ray exam of foot

X
0260
0.7093
43.60

8.7273630
X-ray exam of foot

X
0260
0.7093
43.60

8.7273650
X-ray exam of heel

X
0260
0.7093
43.60

8.7273660
X-ray exam of toe(s)

X
0260
0.7093
43.60

8.7273700
Ct lower extremity w/o dye

S
0332
3.0908
189.99
75.24
38.0073701
Ct lower extremity w/dye

S
0283
4.0825
250.94
100.37
50.1973702
Ct lwr extremity w/o&w/dye

S
0333
4.8405
297.54
119.01
59.5173706
Ct angio lwr extr w/o&w/dye

S
0662
4.8552
298.44
118.88
59.6973718
Mri lower extremity w/o dye

S
0336
5.6745
348.80
139.51
69.7673719
Mri lower extremity w/dye

S
0284
6.1231
376.37
148.40
75.2773720
Mri lwr extremity w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7773721
Mri jnt of lwr extre w/o dye

S
0336
5.6745
348.80
139.51
69.7673722
Mri joint of lwr extr w/dye

S
0284
6.1231
376.37
148.40
75.2773723
Mri joint lwr extr w/o&w/dye

S
0337
8.1155
498.84
199.53
99.7774000
X-ray exam of abdomen

X
0260
0.7093
43.60

8.7274010
X-ray exam of abdomen

X
0260
0.7093
43.60

8.7274020
X-ray exam of abdomen

X
0260
0.7093
43.60

8.7274022
X-ray exam series, abdomen

X
0261
1.2224
75.14

15.0374150
Ct abdomen w/o dye

S
0332
3.0908
189.99
75.24
38.0074160
Ct abdomen w/dye

S
0283
4.0825
250.94
100.37
50.1974170
Ct abdomen w/o & w/dye

S
0333
4.8405
297.54
119.01
59.5174175
Ct angio abdom w/o & w/dye

S
0662
4.8552
298.44
118.88
59.6974181
Mri abdomen w/o dye

S
0336
5.6745
348.80
139.51
69.7674182
Mri abdomen w/dye

S
0284
6.1231
376.37
148.40
75.2774183
Mri abdomen w/o & w/dye

S
0337
8.1155
498.84
199.53
99.7774190
X-ray exam of peritoneum

X
0264
2.9586
181.86
70.27
36.3774210
Contrst x-ray exam of throat

S
0276
1.4294
87.86
34.97
17.5774220
Contrast x-ray, esophagus

S
0276
1.4294
87.86
34.97
17.5774230
Cine/vid x-ray, throat/esoph

S
0276
1.4294
87.86
34.97
17.57( print page 68345)74235
Remove esophagus obstruction
CH
S
0257
1.0974
67.45

13.4974240
X-ray exam, upper gi tract

S
0276
1.4294
87.86
34.97
17.5774241
X-ray exam, upper gi tract

S
0276
1.4294
87.86
34.97
17.5774245
X-ray exam, upper gi tract

S
0277
2.2176
136.31
54.52
27.2674246
Contrst x-ray uppr gi tract

S
0276
1.4294
87.86
34.97
17.5774247
Contrst x-ray uppr gi tract

S
0276
1.4294
87.86
34.97
17.5774249
Contrst x-ray uppr gi tract

S
0277
2.2176
136.31
54.52
27.2674250
X-ray exam of small bowel

S
0276
1.4294
87.86
34.97
17.5774251
X-ray exam of small bowel

S
0277
2.2176
136.31
54.52
27.2674260
X-ray exam of small bowel
CH
S
0276
1.4294
87.86
34.97
17.5774270
Contrast x-ray exam of colon

S
0276
1.4294
87.86
34.97
17.5774280
Contrast x-ray exam of colon

S
0277
2.2176
136.31
54.52
27.2674283
Contrast x-ray exam of colon

S
0276
1.4294
87.86
34.97
17.5774290
Contrast x-ray, gallbladder

S
0276
1.4294
87.86
34.97
17.5774291
Contrast x-rays, gallbladder

S
0276
1.4294
87.86
34.97
17.5774300
X-ray bile ducts/pancreas

X
0263
1.6956
104.23
23.77
20.8574301
X-rays at surgery add-on

X
0263
1.6956
104.23
23.77
20.8574305
X-ray bile ducts/pancreas

X
0263
1.6956
104.23
23.77
20.8574320
Contrast x-ray of bile ducts

X
0264
2.9586
181.86
70.27
36.3774327
X-ray bile stone removal

S
0296
2.6802
164.75
53.99
32.9574328
X-ray bile duct endoscopy

N74329
X-ray for pancreas endoscopy

N74330
X-ray bile/panc endoscopy

N74340
X-ray guide for GI tube

X
0272
1.2908
79.34
31.64
15.8774350
X-ray guide, stomach tube

X
0263
1.6956
104.23
23.77
20.8574355
X-ray guide, intestinal tube

X
0263
1.6956
104.23
23.77
20.8574360
X-ray guide, GI dilation
CH
S
0257
1.0974
67.45

13.4974363
X-ray, bile duct dilation

S
0297
3.6392
223.69
89.47
44.7474400
Contrst x-ray, urinary tract

S
0278
2.4159
148.50
59.40
29.7074410
Contrst x-ray, urinary tract

S
0278
2.4159
148.50
59.40
29.7074415
Contrst x-ray, urinary tract

S
0278
2.4159
148.50
59.40
29.7074420
Contrst x-ray, urinary tract

S
0278
2.4159
148.50
59.40
29.7074425
Contrst x-ray, urinary tract

S
0278
2.4159
148.50
59.40
29.7074430
Contrast x-ray, bladder

S
0278
2.4159
148.50
59.40
29.7074440
X-ray, male genital tract

S
0278
2.4159
148.50
59.40
29.7074445
X-ray exam of penis

S
0278
2.4159
148.50
59.40
29.7074450
X-ray, urethra/bladder

S
0278
2.4159
148.50
59.40
29.7074455
X-ray, urethra/bladder

S
0278
2.4159
148.50
59.40
29.7074470
X-ray exam of kidney lesion

X
0263
1.6956
104.23
23.77
20.8574475
X-ray control, cath insert

S
0297
3.6392
223.69
89.47
44.7474480
X-ray control, cath insert

S
0296
2.6802
164.75
53.99
32.9574485
X-ray guide, GU dilation

S
0296
2.6802
164.75
53.99
32.9574710
X-ray measurement of pelvis

X
0261
1.2224
75.14

15.0374740
X-ray, female genital tract

X
0264
2.9586
181.86
70.27
36.3774742
X-ray, fallopian tube

X
0264
2.9586
181.86
70.27
36.3774775
X-ray exam of perineum

S
0278
2.4159
148.50
59.40
29.7075552
Heart mri for morph w/o dye

S
0336
5.6745
348.80
139.51
69.7675553
Heart mri for morph w/dye

S
0284
6.1231
376.37
148.40
75.2775554
Cardiac MRI/function

S
0336
5.6745
348.80
139.51
69.7675555
Cardiac MRI/limited study

S
0336
5.6745
348.80
139.51
69.7675600
Contrast x-ray exam of aorta

S
0280
20.8225
1,279.92
353.85
255.9875605
Contrast x-ray exam of aorta

S
0280
20.8225
1,279.92
353.85
255.9875625
Contrast x-ray exam of aorta

S
0280
20.8225
1,279.92
353.85
255.9875630
X-ray aorta, leg arteries

S
0280
20.8225
1,279.92
353.85
255.9875635
Ct angio abdominal arteries

S
0662
4.8552
298.44
118.88
59.6975650
Artery x-rays, head & neck

S
0280
20.8225
1,279.92
353.85
255.9875658
Artery x-rays, arm

S
0279
9.5061
584.32
150.03
116.8675660
Artery x-rays, head & neck

S
0668
6.2463
383.95
88.26
76.7975662
Artery x-rays, head & neck

S
0280
20.8225
1,279.92
353.85
255.9875665
Artery x-rays, head & neck

S
0280
20.8225
1,279.92
353.85
255.9875671
Artery x-rays, head & neck

S
0280
20.8225
1,279.92
353.85
255.9875676
Artery x-rays, neck

S
0280
20.8225
1,279.92
353.85
255.9875680
Artery x-rays, neck

S
0280
20.8225
1,279.92
353.85
255.9875685
Artery x-rays, spine

S
0280
20.8225
1,279.92
353.85
255.9875705
Artery x-rays, spine

S
0668
6.2463
383.95
88.26
76.7975710
Artery x-rays, arm/leg

S
0280
20.8225
1,279.92
353.85
255.9875716
Artery x-rays, arms/legs

S
0280
20.8225
1,279.92
353.85
255.9875722
Artery x-rays, kidney

S
0280
20.8225
1,279.92
353.85
255.9875724
Artery x-rays, kidneys

S
0280
20.8225
1,279.92
353.85
255.9875726
Artery x-rays, abdomen

S
0280
20.8225
1,279.92
353.85
255.98( print page 68346)75731
Artery x-rays, adrenal gland

S
0280
20.8225
1,279.92
353.85
255.9875733
Artery x-rays, adrenals

S
0668
6.2463
383.95
88.26
76.7975736
Artery x-rays, pelvis

S
0280
20.8225
1,279.92
353.85
255.9875741
Artery x-rays, lung

S
0279
9.5061
584.32
150.03
116.8675743
Artery x-rays, lungs

S
0280
20.8225
1,279.92
353.85
255.9875746
Artery x-rays, lung

S
0279
9.5061
584.32
150.03
116.8675756
Artery x-rays, chest

S
0279
9.5061
584.32
150.03
116.8675774
Artery x-ray, each vessel

S
0279
9.5061
584.32
150.03
116.8675790
Visualize A-V shunt

S
0279
9.5061
584.32
150.03
116.8675801
Lymph vessel x-ray, arm/leg

X
0264
2.9586
181.86
70.27
36.3775803
Lymph vessel x-ray,arms/legs

X
0264
2.9586
181.86
70.27
36.3775805
Lymph vessel x-ray, trunk

X
0264
2.9586
181.86
70.27
36.3775807
Lymph vessel x-ray, trunk

X
0264
2.9586
181.86
70.27
36.3775809
Nonvascular shunt, x-ray

X
0263
1.6956
104.23
23.77
20.8575810
Vein x-ray, spleen/liver

S
0279
9.5061
584.32
150.03
116.8675820
Vein x-ray, arm/leg

S
0668
6.2463
383.95
88.26
76.7975822
Vein x-ray, arms/legs

S
0668
6.2463
383.95
88.26
76.7975825
Vein x-ray, trunk

S
0279
9.5061
584.32
150.03
116.8675827
Vein x-ray, chest

S
0279
9.5061
584.32
150.03
116.8675831
Vein x-ray, kidney

S
0279
9.5061
584.32
150.03
116.8675833
Vein x-ray, kidneys

S
0279
9.5061
584.32
150.03
116.8675840
Vein x-ray, adrenal gland

S
0280
20.8225
1,279.92
353.85
255.9875842
Vein x-ray, adrenal glands

S
0280
20.8225
1,279.92
353.85
255.9875860
Vein x-ray, neck

S
0668
6.2463
383.95
88.26
76.7975870
Vein x-ray, skull

S
0668
6.2463
383.95
88.26
76.7975872
Vein x-ray, skull

S
0279
9.5061
584.32
150.03
116.8675880
Vein x-ray, eye socket

S
0668
6.2463
383.95
88.26
76.7975885
Vein x-ray, liver

S
0280
20.8225
1,279.92
353.85
255.9875887
Vein x-ray, liver

S
0279
9.5061
584.32
150.03
116.8675889
Vein x-ray, liver

S
0280
20.8225
1,279.92
353.85
255.9875891
Vein x-ray, liver

S
0279
9.5061
584.32
150.03
116.8675893
Venous sampling by catheter
CH
Q
0668
6.2463
383.95
88.26
76.7975894
X-rays, transcath therapy
CH
S
0298
8.3906
515.75
206.30
103.1575896
X-rays, transcath therapy
CH
S
0298
8.3906
515.75
206.30
103.1575898
Follow-up angiography

X
0263
1.6956
104.23
23.77
20.8575901
Remove cva device obstruct

X
0263
1.6956
104.23
23.77
20.8575902
Remove cva lumen obstruct

X
0263
1.6956
104.23
23.77
20.8575940
X-ray placement, vein filter
CH
S
0298
8.3906
515.75
206.30
103.1575945
Intravascular us

S
0267
2.4606
151.25
60.50
30.2575946
Intravascular us add-on

S
0266
1.5607
95.93
37.80
19.1975960
Transcath iv stent rs&i

S
0668
6.2463
383.95
88.26
76.7975961
Retrieval, broken catheter

S
0668
6.2463
383.95
88.26
76.7975962
Repair arterial blockage

S
0668
6.2463
383.95
88.26
76.7975964
Repair artery blockage, each

S
0668
6.2463
383.95
88.26
76.7975966
Repair arterial blockage

S
0668
6.2463
383.95
88.26
76.7975968
Repair artery blockage, each

S
0668
6.2463
383.95
88.26
76.7975970
Vascular biopsy

S
0668
6.2463
383.95
88.26
76.7975978
Repair venous blockage

S
0668
6.2463
383.95
88.26
76.7975980
Contrast xray exam bile duct

S
0297
3.6392
223.69
89.47
44.7475982
Contrast xray exam bile duct

S
0297
3.6392
223.69
89.47
44.7475984
Xray control catheter change

X
0263
1.6956
104.23
23.77
20.8575989
Abscess drainage under x-ray

N75992
Atherectomy, x-ray exam
CH
S
0668
6.2463
383.95
88.26
76.7975993
Atherectomy, x-ray exam
CH
S
0668
6.2463
383.95
88.26
76.7975994
Atherectomy, x-ray exam
CH
S
0668
6.2463
383.95
88.26
76.7975995
Atherectomy, x-ray exam
CH
S
0668
6.2463
383.95
88.26
76.7975996
Atherectomy, x-ray exam
CH
S
0668
6.2463
383.95
88.26
76.7975998
Fluoroguide for vein device
CH
D76000
Fluoroscope examination

X
0272
1.2908
79.34
31.64
15.8776001
Fluoroscope exam, extensive

N76003
Needle localization by x-ray
CH
D76005
Fluoroguide for spine inject
CH
D76006
X-ray stress view
CH
D76010
X-ray, nose to rectum

X
0260
0.7093
43.60

8.7276012
Percut vertebroplasty fluor
CH
D76013
Percut vertebroplasty, ct
CH
D76020
X-rays for bone age
CH
D76040
X-rays, bone evaluation
CH
D76061
X-rays, bone survey
CH
D76062
X-rays, bone survey
CH
D( print page 68347)76065
X-rays, bone evaluation
CH
D76066
Joint survey, single view
CH
D76070
Ct bone density, axial
CH
D76071
Ct bone density, peripheral
CH
D76075
Dxa bone density,  axial
CH
D76076
Dxa bone density/peripheral
CH
D76077
Dxa bone density/v-fracture
CH
D76078
Radiographic absorptiometry
CH
D76080
X-ray exam of fistula

X
0263
1.6956
104.23
23.77
20.8576082
Computer mammogram add-on
CH
D76083
Computer mammogram add-on
CH
D76086
X-ray of mammary duct
CH
D76088
X-ray of mammary ducts
CH
D76090
Mammogram, one breast
CH
D76091
Mammogram, both breasts
CH
D76092
Mammogram, screening
CH
D76093
Magnetic image, breast
CH
D76094
Magnetic image, both breasts
CH
D76095
Stereotactic breast biopsy
CH
D76096
X-ray of needle wire, breast
CH
D76098
X-ray exam, breast specimen

X
0260
0.7093
43.60

8.7276100
X-ray exam of body section

X
0261
1.2224
75.14

15.0376101
Complex body section x-ray

X
0263
1.6956
104.23
23.77
20.8576102
Complex body section x-rays

X
0264
2.9586
181.86
70.27
36.3776120
Cine/video x-rays

X
0272
1.2908
79.34
31.64
15.8776125
Cine/video x-rays add-on

X
0260
0.7093
43.60

8.7276150
X-ray exam, dry process

X
0260
0.7093
43.60

8.7276350
Special x-ray contrast study

N76355
Ct scan for localization
CH
D76360
Ct scan for needle biopsy
CH
D76362
Ct guide for tissue ablation
CH
D76370
Ct scan for therapy guide
CH
D76376
3d render w/o postprocess

X
0340
0.6102
37.51

7.5076377
3d rendering w/postprocess

S
0282
1.5379
94.53
37.81
18.9176380
CAT scan follow-up study

S
0282
1.5379
94.53
37.81
18.9176393
Mr guidance for needle place
CH
D76394
Mri for tissue ablation
CH
D76400
Magnetic image, bone marrow
CH
D76496
Fluoroscopic procedure

X
0272
1.2908
79.34
31.64
15.8776497
Ct procedure

S
0282
1.5379
94.53
37.81
18.9176498
Mri procedure

S
0335
4.5523
279.82
111.92
55.9676499
Radiographic procedure

X
0260
0.7093
43.60

8.7276506
Echo exam of head

S
0265
0.9923
60.99
23.63
12.2076510
Ophth us, b & quant a

S
0266
1.5607
95.93
37.80
19.1976511
Ophth us, quant a only

S
0266
1.5607
95.93
37.80
19.1976512
Ophth us, b w/non-quant a

S
0266
1.5607
95.93
37.80
19.1976513
Echo exam of eye, water bath

S
0266
1.5607
95.93
37.80
19.1976514
Echo exam of eye, thickness

X
0340
0.6102
37.51

7.5076516
Echo exam of eye

S
0265
0.9923
60.99
23.63
12.2076519
Echo exam of eye

S
0266
1.5607
95.93
37.80
19.1976529
Echo exam of eye

S
0265
0.9923
60.99
23.63
12.2076536
Us exam of head and neck

S
0266
1.5607
95.93
37.80
19.1976604
Us exam, chest
CH
S
0265
0.9923
60.99
23.63
12.2076645
Us exam, breast(s)

S
0265
0.9923
60.99
23.63
12.2076700
Us exam, abdom, complete

S
0266
1.5607
95.93
37.80
19.1976705
Echo exam of abdomen

S
0266
1.5607
95.93
37.80
19.1976770
Us exam abdo back wall, comp

S
0266
1.5607
95.93
37.80
19.1976775
Us exam abdo back wall, lim

S
0266
1.5607
95.93
37.80
19.1976776
Us exam k transpl w/doppler
NI
S
0266
1.5607
95.93
37.80
19.1976778
Us exam kidney transplant
CH
D76800
Us exam, spinal canal

S
0266
1.5607
95.93
37.80
19.1976801
Ob us < 14 wks, single fetus

S
0266
1.5607
95.93
37.80
19.1976802
Ob us < 14 wks, addÆl fetus

S
0265
0.9923
60.99
23.63
12.2076805
Ob us ≧ 14 wks, sngl fetus

S
0266
1.5607
95.93
37.80
19.1976810
Ob us ≧ 14 wks, addl fetus

S
0266
1.5607
95.93
37.80
19.1976811
Ob us, detailed, sngl fetus

S
0267
2.4606
151.25
60.50
30.2576812
Ob us, detailed, addl fetus
CH
S
0265
0.9923
60.99
23.63
12.2076813
Ob us nuchal meas, 1 gest
NI
S
0266
1.5607
95.93
37.80
19.1976814
Ob us nuchal meas, add-on
NI
S
0265
0.9923
60.99
23.63
12.2076815
Ob us, limited, fetus(s)

S
0265
0.9923
60.99
23.63
12.20( print page 68348)76816
Ob us, follow-up, per fetus

S
0265
0.9923
60.99
23.63
12.2076817
Transvaginal us, obstetric
CH
S
0265
0.9923
60.99
23.63
12.2076818
Fetal biophys profile w/nst

S
0266
1.5607
95.93
37.80
19.1976819
Fetal biophys profil w/o nst

S
0266
1.5607
95.93
37.80
19.1976820
Umbilical artery echo

S
0096
1.5303
94.06
37.62
18.8176821
Middle cerebral artery echo

S
0096
1.5303
94.06
37.62
18.8176825
Echo exam of fetal heart
CH
S
0697
1.5973
98.18
35.99
19.6476826
Echo exam of fetal heart

S
0697
1.5973
98.18
35.99
19.6476827
Echo exam of fetal heart
CH
S
0697
1.5973
98.18
35.99
19.6476828
Echo exam of fetal heart

S
0697
1.5973
98.18
35.99
19.6476830
Transvaginal us, non-ob

S
0266
1.5607
95.93
37.80
19.1976831
Echo exam, uterus

S
0267
2.4606
151.25
60.50
30.2576856
Us exam, pelvic, complete

S
0266
1.5607
95.93
37.80
19.1976857
Us exam, pelvic, limited

S
0265
0.9923
60.99
23.63
12.2076870
Us exam, scrotum

S
0266
1.5607
95.93
37.80
19.1976872
Us, transrectal

S
0266
1.5607
95.93
37.80
19.1976873
Echograp trans r, pros study

S
0266
1.5607
95.93
37.80
19.1976880
Us exam, extremity

S
0266
1.5607
95.93
37.80
19.1976885
Us exam infant hips, dynamic

S
0265
0.9923
60.99
23.63
12.2076886
Us exam infant hips, static
CH
S
0265
0.9923
60.99
23.63
12.2076930
Echo guide, cardiocentesis

S
0268
1.1882
73.04

14.6176932
Echo guide for heart biopsy
CH
S
0309
2.1012
129.16

25.8376936
Echo guide for artery repair
CH
S
0309
2.1012
129.16

25.8376937
Us guide, vascular access

N76940
Us guide, tissue ablation

S
0268
1.1882
73.04

14.6176941
Echo guide for transfusion

S
0268
1.1882
73.04

14.6176942
Echo guide for biopsy

S
0268
1.1882
73.04

14.6176945
Echo guide, villus sampling

S
0268
1.1882
73.04

14.6176946
Echo guide for amniocentesis

S
0268
1.1882
73.04

14.6176948
Echo guide, ova aspiration
CH
S
0309
2.1012
129.16

25.8376950
Echo guidance radiotherapy

S
0268
1.1882
73.04

14.6176965
Echo guidance radiotherapy
CH
S
0309
2.1012
129.16

25.8376970
Ultrasound exam follow-up

S
0265
0.9923
60.99
23.63
12.2076975
GI endoscopic ultrasound

S
0266
1.5607
95.93
37.80
19.1976977
Us bone density measure

X
0340
0.6102
37.51

7.5076986
Ultrasound guide intraoper
CH
D76998
Us guide, intraop
NI
S
0266
1.5607
95.93
37.80
19.1976999
Echo examination procedure

S
0265
0.9923
60.99
23.63
12.2077001
Fluoroguide for vein device
NI
N77002
Needle localization by xray
NI
N77003
Fluoroguide for spine inject
NI
N77011
Ct scan for localization
NI
S
0283
4.0825
250.94
100.37
50.1977012
Ct scan for needle biopsy
NI
S
0283
4.0825
250.94
100.37
50.1977013
Ct guide for tissue ablation
NI
S
0333
4.8405
297.54
119.01
59.5177014
Ct scan for therapy guide
NI
S
0282
1.5379
94.53
37.81
18.9177021
Mr guidance for needle place
NI
S
0335
4.5523
279.82
111.92
55.9677022
Mri for tissue ablation
NI
S
0335
4.5523
279.82
111.92
55.9677031
Stereotact guide for brst bx
NI
X
0264
2.9586
181.86
70.27
36.3777032
Guidance for needle, breast
NI
X
0263
1.6956
104.23
23.77
20.8577051
Computer dx mammogram add-on
NI
A77052
Comp screen mammogram add-on
NI
A77053
X-ray of mammary duct
NI
X
0263
1.6956
104.23
23.77
20.8577054
X-ray of mammary ducts
NI
X
0263
1.6956
104.23
23.77
20.8577055
Mammogram, one breast
NI
A77056
Mammogram, both breasts
NI
A77057
Mammogram, screening
NI
A77058
Mri, one breast
NI
B77059
Mri, both breasts
NI
B77071
X-ray stress view
NI
X
0260
0.7093
43.60

8.7277072
X-rays for bone age
NI
X
0260
0.7093
43.60

8.7277073
X-rays, bone length studies
NI
X
0260
0.7093
43.60

8.7277074
X-rays, bone survey, limited
NI
X
0261
1.2224
75.14

15.0377075
X-rays, bone survey complete
NI
X
0261
1.2224
75.14

15.0377076
X-rays, bone survey, infant
NI
X
0260
0.7093
43.60

8.7277077
Joint survey, single view
NI
X
0260
0.7093
43.60

8.7277078
Ct bone density, axial
NI
S
0288
1.1755
72.26
28.90
14.4577079
Ct bone density, peripheral
NI
S
0282
1.5379
94.53
37.81
18.9177080
Dxa bone density, axial
NI
S
0288
1.1755
72.26
28.90
14.4577081
Dxa bone density/peripheral
NI
S
0665
0.5497
33.79
13.51
6.7677082
Dxa bone density, vert fx
NI
X
0260
0.7093
43.60

8.72( print page 68349)77083
Radiographic absorptiometry
NI
X
0261
1.2224
75.14

15.0377084
Magnetic image, bone marrow
NI
S
0335
4.5523
279.82
111.92
55.9677280
Sbrt management

X
0304
1.5735
96.72
38.68
19.3477285
Set radiation therapy field

X
0305
3.9723
244.17
91.38
48.8377290
Set radiation therapy field

X
0305
3.9723
244.17
91.38
48.8377295
Set radiation therapy field

X
0310
13.8081
848.76
325.27
169.7577299
Radiation therapy planning

X
0304
1.5735
96.72
38.68
19.3477300
Radiation therapy dose plan

X
0304
1.5735
96.72
38.68
19.3477301
Radiotherapy dose plan, imrt

X
0310
13.8081
848.76
325.27
169.7577305
Teletx isodose plan simple

X
0304
1.5735
96.72
38.68
19.3477310
Teletx isodose plan intermed

X
0305
3.9723
244.17
91.38
48.8377315
Teletx isodose plan complex

X
0305
3.9723
244.17
91.38
48.8377321
Special teletx port plan

X
0305
3.9723
244.17
91.38
48.8377326
Brachytx isodose calc simp

X
0304
1.5735
96.72
38.68
19.3477327
Brachytx isodose calc interm

X
0305
3.9723
244.17
91.38
48.8377328
Brachytx isodose plan compl

X
0305
3.9723
244.17
91.38
48.8377331
Special radiation dosimetry

X
0304
1.5735
96.72
38.68
19.3477332
Radiation treatment aid(s)

X
0303
2.943
180.90
66.95
36.1877333
Radiation treatment aid(s)

X
0303
2.943
180.90
66.95
36.1877334
Radiation treatment aid(s)

X
0303
2.943
180.90
66.95
36.1877336
Radiation physics consult

X
0304
1.5735
96.72
38.68
19.3477370
Radiation physics consult

X
0304
1.5735
96.72
38.68
19.3477371
Srs, multisource
NI
S
0127
138.4486
8,510.16

1,702.0377372
Srs, linear based
NI
B77373
Sbrt delivery
NI
B77399
External radiation dosimetry

X
0304
1.5735
96.72
38.68
19.3477401
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377402
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377403
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377404
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377406
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377407
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377408
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377409
Radiation treatment delivery

S
0300
1.4826
91.13

18.2377411
Radiation treatment delivery

S
0301
2.2295
137.04

27.4177412
Radiation treatment delivery

S
0301
2.2295
137.04

27.4177413
Radiation treatment delivery

S
0301
2.2295
137.04

27.4177414
Radiation treatment delivery

S
0301
2.2295
137.04

27.4177416
Radiation treatment delivery

S
0301
2.2295
137.04

27.4177417
Radiology port film(s)

X
0260
0.7093
43.60

8.7277418
Radiation tx delivery, imrt

S
0412
5.4731
336.42

67.2877421
Stereoscopic x-ray guidance
CH
S
0257
1.0974
67.45

13.4977422
Neutron beam tx, simple

S
0301
2.2295
137.04

27.4177423
Neutron beam tx, complex

S
0301
2.2295
137.04

27.4177435
Sbrt management
NI
N77470
Special radiation treatment

S
0299
5.8839
361.67

72.3377520
Proton trmt, simple w/o comp

S
0664
18.8926
1,161.29

232.2677522
Proton trmt, simple w/comp

S
0664
18.8926
1,161.29

232.2677523
Proton trmt, intermediate

S
0667
22.6031
1,389.37

277.8777525
Proton treatment, complex

S
0667
22.6031
1,389.37

277.8777600
Hyperthermia treatment

S
0314
3.3461
205.68
60.88
41.1477605
Hyperthermia treatment

S
0314
3.3461
205.68
60.88
41.1477610
Hyperthermia treatment

S
0314
3.3461
205.68
60.88
41.1477615
Hyperthermia treatment

S
0314
3.3461
205.68
60.88
41.1477620
Hyperthermia treatment

S
0314
3.3461
205.68
60.88
41.1477750
Infuse radioactive materials

S
0301
2.2295
137.04

27.4177761
Apply intrcav radiat simple

S
0312
4.8569
298.54

59.7177762
Apply intrcav radiat interm

S
0312
4.8569
298.54

59.7177763
Apply intrcav radiat compl

S
0312
4.8569
298.54

59.7177776
Apply interstit radiat simpl

S
0312
4.8569
298.54

59.7177777
Apply interstit radiat inter

S
0312
4.8569
298.54

59.7177778
Apply interstit radiat compl

S
0651
16.8462
1,035.50

207.1077781
High intensity brachytherapy

S
0313
12.8473
789.70

157.9477782
High intensity brachytherapy

S
0313
12.8473
789.70

157.9477783
High intensity brachytherapy

S
0313
12.8473
789.70

157.9477784
High intensity brachytherapy

S
0313
12.8473
789.70

157.9477789
Apply surface radiation

S
0300
1.4826
91.13

18.2377790
Radiation handling

N77799
Radium/radioisotope therapy
CH
S
0312
4.8569
298.54

59.7178000
Thyroid, single uptake

S
0389
1.3754
84.54
33.81
16.91( print page 68350)78001
Thyroid, multiple uptakes

S
0389
1.3754
84.54
33.81
16.9178003
Thyroid suppress/stimul

S
0392
2.0057
123.29
49.31
24.6678006
Thyroid imaging with uptake

S
0390
2.3432
144.03
57.61
28.8178007
Thyroid image, mult uptakes

S
0391
2.7146
166.86
66.18
33.3778010
Thyroid imaging

S
0390
2.3432
144.03
57.61
28.8178011
Thyroid imaging with flow

S
0390
2.3432
144.03
57.61
28.8178015
Thyroid met imaging

S
0406
3.9934
245.47
98.18
49.0978016
Thyroid met imaging/studies

S
0406
3.9934
245.47
98.18
49.0978018
Thyroid met imaging, body

S
0406
3.9934
245.47
98.18
49.0978020
Thyroid met uptake

S
0399
1.5054
92.53
35.80
18.5178070
Parathyroid nuclear imaging

S
0391
2.7146
166.86
66.18
33.3778075
Adrenal nuclear imaging

S
0391
2.7146
166.86
66.18
33.3778099
Endocrine nuclear procedure

S
0390
2.3432
144.03
57.61
28.8178102
Bone marrow imaging, ltd

S
0400
3.9073
240.17
93.22
48.0378103
Bone marrow imaging, mult

S
0400
3.9073
240.17
93.22
48.0378104
Bone marrow imaging, body

S
0400
3.9073
240.17
93.22
48.0378110
Plasma volume, single

S
0393
3.7562
230.89
82.04
46.1878111
Plasma volume, multiple

S
0393
3.7562
230.89
82.04
46.1878120
Red cell mass, single

S
0393
3.7562
230.89
82.04
46.1878121
Red cell mass, multiple

S
0393
3.7562
230.89
82.04
46.1878122
Blood volume

S
0393
3.7562
230.89
82.04
46.1878130
Red cell survival study

S
0393
3.7562
230.89
82.04
46.1878135
Red cell survival kinetics

S
0393
3.7562
230.89
82.04
46.1878140
Red cell sequestration

S
0393
3.7562
230.89
82.04
46.1878185
Spleen imaging

S
0400
3.9073
240.17
93.22
48.0378190
Platelet survival, kinetics

S
0392
2.0057
123.29
49.31
24.6678191
Platelet survival

S
0392
2.0057
123.29
49.31
24.6678195
Lymph system imaging

S
0400
3.9073
240.17
93.22
48.0378199
Blood/lymph nuclear exam

S
0400
3.9073
240.17
93.22
48.0378201
Liver imaging

S
0394
4.3774
269.07
102.61
53.8178202
Liver imaging with flow

S
0394
4.3774
269.07
102.61
53.8178205
Liver imaging (3D)

S
0394
4.3774
269.07
102.61
53.8178206
Liver image (3d) with flow

S
0394
4.3774
269.07
102.61
53.8178215
Liver and spleen imaging

S
0394
4.3774
269.07
102.61
53.8178216
Liver & spleen image/flow

S
0394
4.3774
269.07
102.61
53.8178220
Liver function study

S
0394
4.3774
269.07
102.61
53.8178223
Hepatobiliary imaging

S
0394
4.3774
269.07
102.61
53.8178230
Salivary gland imaging

S
0395
3.6526
224.52
89.73
44.9078231
Serial salivary imaging

S
0395
3.6526
224.52
89.73
44.9078232
Salivary gland function exam

S
0395
3.6526
224.52
89.73
44.9078258
Esophageal motility study

S
0395
3.6526
224.52
89.73
44.9078261
Gastric mucosa imaging

S
0395
3.6526
224.52
89.73
44.9078262
Gastroesophageal reflux exam

S
0395
3.6526
224.52
89.73
44.9078264
Gastric emptying study

S
0395
3.6526
224.52
89.73
44.9078270
Vit B-12 absorption exam

S
0392
2.0057
123.29
49.31
24.6678271
Vit b-12 absrp exam, int fac

S
0392
2.0057
123.29
49.31
24.6678272
Vit B-12 absorp, combined

S
0392
2.0057
123.29
49.31
24.6678278
Acute GI blood loss imaging

S
0395
3.6526
224.52
89.73
44.9078282
GI protein loss exam

S
0395
3.6526
224.52
89.73
44.9078290
MeckelÆs divert exam

S
0395
3.6526
224.52
89.73
44.9078291
Leveen/shunt patency exam

S
0395
3.6526
224.52
89.73
44.9078299
GI nuclear procedure

S
0395
3.6526
224.52
89.73
44.9078300
Bone imaging, limited area

S
0396
3.9174
240.79
95.02
48.1678305
Bone imaging, multiple areas

S
0396
3.9174
240.79
95.02
48.1678306
Bone imaging, whole body

S
0396
3.9174
240.79
95.02
48.1678315
Bone imaging, 3 phase

S
0396
3.9174
240.79
95.02
48.1678320
Bone imaging (3D)

S
0396
3.9174
240.79
95.02
48.1678350
Bone mineral, single photon

X
0260
0.7093
43.60

8.7278399
Musculoskeletal nuclear exam

S
0396
3.9174
240.79
95.02
48.1678414
Non-imaging heart function

S
0398
4.1265
253.65
100.06
50.7378428
Cardiac shunt imaging

S
0398
4.1265
253.65
100.06
50.7378445
Vascular flow imaging

S
0397
2.4204
148.78
49.58
29.7678456
Acute venous thrombus image

S
0397
2.4204
148.78
49.58
29.7678457
Venous thrombosis imaging

S
0397
2.4204
148.78
49.58
29.7678458
Ven thrombosis images, bilat

S
0397
2.4204
148.78
49.58
29.7678459
Heart muscle imaging (PET)
CH
S
0307
11.8963
731.24
292.49
146.2578460
Heart muscle blood, single

S
0398
4.1265
253.65
100.06
50.7378461
Heart muscle blood, multiple

S
0377
6.5012
399.62
158.84
79.9278464
Heart image (3d), single

S
0398
4.1265
253.65
100.06
50.7378465
Heart image (3d), multiple

S
0377
6.5012
399.62
158.84
79.92( print page 68351)78466
Heart infarct image

S
0398
4.1265
253.65
100.06
50.7378468
Heart infarct image (ef)

S
0398
4.1265
253.65
100.06
50.7378469
Heart infarct image (3D)

S
0398
4.1265
253.65
100.06
50.7378472
Gated heart, planar, single

S
0398
4.1265
253.65
100.06
50.7378473
Gated heart, multiple

S
0376
4.9832
306.31
119.77
61.2678478
Heart wall motion add-on

S
0399
1.5054
92.53
35.80
18.5178480
Heart function add-on

S
0399
1.5054
92.53
35.80
18.5178481
Heart first pass, single

S
0398
4.1265
253.65
100.06
50.7378483
Heart first pass, multiple

S
0376
4.9832
306.31
119.77
61.2678491
Heart image (pet), single
CH
S
0307
11.8963
731.24
292.49
146.2578492
Heart image (pet), multiple

S
0307
11.8963
731.24
292.49
146.2578494
Heart image, spect

S
0398
4.1265
253.65
100.06
50.7378496
Heart first pass add-on

S
0399
1.5054
92.53
35.80
18.5178499
Cardiovascular nuclear exam

S
0398
4.1265
253.65
100.06
50.7378580
Lung perfusion imaging

S
0401
3.1802
195.48
78.19
39.1078584
Lung V/Q image single breath

S
0378
5.0975
313.33
125.33
62.6778585
Lung V/Q imaging

S
0378
5.0975
313.33
125.33
62.6778586
Aerosol lung image, single

S
0401
3.1802
195.48
78.19
39.1078587
Aerosol lung image, multiple

S
0401
3.1802
195.48
78.19
39.1078588
Perfusion lung image

S
0378
5.0975
313.33
125.33
62.6778591
Vent image, 1 breath, 1 proj

S
0401
3.1802
195.48
78.19
39.1078593
Vent image, 1 proj, gas

S
0401
3.1802
195.48
78.19
39.1078594
Vent image, mult proj, gas

S
0401
3.1802
195.48
78.19
39.1078596
Lung differential function

S
0378
5.0975
313.33
125.33
62.6778599
Respiratory nuclear exam

S
0401
3.1802
195.48
78.19
39.1078600
Brain imaging, ltd static

S
0402
4.6418
285.32
114.12
57.0678601
Brain imaging, ltd w/flow

S
0402
4.6418
285.32
114.12
57.0678605
Brain imaging, complete

S
0402
4.6418
285.32
114.12
57.0678606
Brain imaging, compl w/flow

S
0402
4.6418
285.32
114.12
57.0678607
Brain imaging (3D)

S
0402
4.6418
285.32
114.12
57.0678608
Brain imaging (PET)
CH
S
0308
13.9166
855.43

171.0978610
Brain flow imaging only

S
0402
4.6418
285.32
114.12
57.0678615
Cerebral vascular flow image

S
0402
4.6418
285.32
114.12
57.0678630
Cerebrospinal fluid scan

S
0403
3.4923
214.66
83.35
42.9378635
CSF ventriculography

S
0403
3.4923
214.66
83.35
42.9378645
CSF shunt evaluation

S
0403
3.4923
214.66
83.35
42.9378647
Cerebrospinal fluid scan

S
0403
3.4923
214.66
83.35
42.9378650
CSF leakage imaging

S
0403
3.4923
214.66
83.35
42.9378660
Nuclear exam of tear flow

S
0403
3.4923
214.66
83.35
42.9378699
Nervous system nuclear exam

S
0402
4.6418
285.32
114.12
57.0678700
Kidney imaging, morphol

S
0404
3.4209
210.28
84.11
42.0678701
Kidney imaging with flow

S
0404
3.4209
210.28
84.11
42.0678704
Imaging renogram
CH
D78707
Kflow/funct image w/o drug

S
0404
3.4209
210.28
84.11
42.0678708
Kflow/funct image w/drug

S
0405
4.0378
248.20
98.77
49.6478709
Kflow/funct image, multiple

S
0405
4.0378
248.20
98.77
49.6478710
Kidney imaging (3D)

S
0404
3.4209
210.28
84.11
42.0678715
Renal vascular flow exam
CH
D78725
Kidney function study

S
0389
1.3754
84.54
33.81
16.9178730
Urinary bladder retention

X
0340
0.6102
37.51

7.5078740
Ureteral reflux study

S
0404
3.4209
210.28
84.11
42.0678760
Testicular imaging
CH
D78761
Testicular imaging w/flow

S
0404
3.4209
210.28
84.11
42.0678799
Genitourinary nuclear exam

S
0404
3.4209
210.28
84.11
42.0678800
Tumor imaging, limited area

S
0406
3.9934
245.47
98.18
49.0978801
Tumor imaging, mult areas

S
0406
3.9934
245.47
98.18
49.0978802
Tumor imaging, whole body

S
0406
3.9934
245.47
98.18
49.0978803
Tumor imaging (3D)

S
0406
3.9934
245.47
98.18
49.0978804
Tumor imaging, whole body
CH
S
0408
5.9245
364.17

72.8378805
Abscess imaging, ltd area

S
0406
3.9934
245.47
98.18
49.0978806
Abscess imaging, whole body

S
0406
3.9934
245.47
98.18
49.0978807
Nuclear localization/abscess

S
0406
3.9934
245.47
98.18
49.0978811
Tumor imaging (pet), limited
CH
S
0308
13.9166
855.43

171.0978812
Tumor image (pet)/skul-thigh
CH
S
0308
13.9166
855.43

171.0978813
Tumor image (pet) full body
CH
S
0308
13.9166
855.43

171.0978814
Tumor image pet/ct, limited
CH
S
1511

950.00

190.0078815
Tumorimage pet/ct skul-thigh
CH
S
1511

950.00

190.0078816
Tumor image pet/ct full body
CH
S
1511

950.00

190.0078890
Nuclear medicine data proc

N78891
Nuclear med data proc

N( print page 68352)78999
Nuclear diagnostic exam

S
0389
1.3754
84.54
33.81
16.9179005
Nuclear rx, oral admin

S
0407
3.1779
195.34
78.13
39.0779101
Nuclear rx, iv admin

S
0407
3.1779
195.34
78.13
39.0779200
Nuclear rx, intracav admin
CH
S
0413
5.2957
325.52

65.1079300
Nuclr rx, interstit colloid

S
0407
3.1779
195.34
78.13
39.0779403
Hematopoietic nuclear tx
CH
S
0413
5.2957
325.52

65.1079440
Nuclear rx, intra-articular
CH
S
0413
5.2957
325.52

65.1079445
Nuclear rx, intra-arterial

S
0407
3.1779
195.34
78.13
39.0779999
Nuclear medicine therapy

S
0407
3.1779
195.34
78.13
39.0780103
Drug analysis, tissue prep

N80500
Lab pathology consultation

X
0433
0.2557
15.72
5.93
3.1480502
Lab pathology consultation

X
0342
0.0824
5.06
2.02
1.0181099
Urinalysis test procedure

X
0342
0.0824
5.06
2.02
1.0182107
Alpha-fetoprotein l3
NI
A83698
Assay lipoprotein pla2
NI
A83913
Molecular, rna stabilization
NI
A84999
Clinical chemistry test

X
0342
0.0824
5.06
2.02
1.0185097
Bone marrow interpretation

X
0343
0.5211
32.03
10.84
6.4185396
Clotting assay, whole blood

N85999
Hematology procedure

X
0342
0.0824
5.06
2.02
1.0186077
Physician blood bank service

X
0433
0.2557
15.72
5.93
3.1486078
Physician blood bank service

X
0343
0.5211
32.03
10.84
6.4186079
Physician blood bank service

X
0433
0.2557
15.72
5.93
3.1486485
Skin test, candida

X
0341
0.0914
5.62
2.24
1.1286490
Coccidioidomycosis skin test

X
0341
0.0914
5.62
2.24
1.1286510
Histoplasmosis skin test

X
0341
0.0914
5.62
2.24
1.1286580
TB intradermal test

X
0341
0.0914
5.62
2.24
1.1286788
West nile virus ab, igm
NI
A86789
West nile virus antibody
NI
A86849
Immunology procedure

X
0342
0.0824
5.06
2.02
1.0186850
RBC antibody screen

X
0345
0.2178
13.39
2.87
2.6886860
RBC antibody elution

X
0346
0.3484
21.42
4.39
4.2886870
RBC antibody identification

X
0346
0.3484
21.42
4.39
4.2886880
Coombs test, direct

X
0409
0.1227
7.54
2.20
1.5186885
Coombs test, indirect, qual

X
0409
0.1227
7.54
2.20
1.5186886
Coombs test, indirect, titer

X
0409
0.1227
7.54
2.20
1.5186890
Autologous blood process

X
0347
0.7423
45.63
11.28
9.1386891
Autologous blood, op salvage

X
0346
0.3484
21.42
4.39
4.2886900
Blood typing, ABO

X
0409
0.1227
7.54
2.20
1.5186901
Blood typing, Rh (D)

X
0409
0.1227
7.54
2.20
1.5186903
Blood typing, antigen screen

X
0345
0.2178
13.39
2.87
2.6886904
Blood typing, patient serum

X
0346
0.3484
21.42
4.39
4.2886905
Blood typing, RBC antigens

X
0345
0.2178
13.39
2.87
2.6886906
Blood typing, Rh phenotype

X
0345
0.2178
13.39
2.87
2.6886920
Compatibility test, spin

X
0346
0.3484
21.42
4.39
4.2886921
Compatibility test, incubate

X
0345
0.2178
13.39
2.87
2.6886922
Compatibility test, antiglob

X
0346
0.3484
21.42
4.39
4.2886923
Compatibility test, electric

X
0345
0.2178
13.39
2.87
2.6886927
Plasma, fresh frozen

X
0345
0.2178
13.39
2.87
2.6886930
Frozen blood prep

X
0347
0.7423
45.63
11.28
9.1386931
Frozen blood thaw

X
0347
0.7423
45.63
11.28
9.1386932
Frozen blood freeze/thaw

X
0347
0.7423
45.63
11.28
9.1386945
Blood product/irradiation

X
0345
0.2178
13.39
2.87
2.6886950
Leukacyte transfusion

X
0345
0.2178
13.39
2.87
2.6886960
Vol reduction of blood/prod

X
0345
0.2178
13.39
2.87
2.6886965
Pooling blood platelets
CH
X
0346
0.3484
21.42
4.39
4.2886970
RBC pretreatment

X
0345
0.2178
13.39
2.87
2.6886971
RBC pretreatment

X
0345
0.2178
13.39
2.87
2.6886972
RBC pretreatment

X
0346
0.3484
21.42
4.39
4.2886975
RBC pretreatment, serum
CH
X
0346
0.3484
21.42
4.39
4.2886976
RBC pretreatment, serum

X
0345
0.2178
13.39
2.87
2.6886977
RBC pretreatment, serum
CH
X
0346
0.3484
21.42
4.39
4.2886978
RBC pretreatment, serum
CH
X
0346
0.3484
21.42
4.39
4.2886985
Split blood or products

X
0345
0.2178
13.39
2.87
2.6886999
Transfusion procedure

X
0345
0.2178
13.39
2.87
2.6887305
Aspergillus ag, eia
NI
A87498
Enterovirus, dna, amp probe
NI
A87640
Staph a, dna, amp probe
NI
A87641
Mr-staph, dna, amp probe
NI
A87653
Strep b, dna, amp probe
NI
A( print page 68353)87808
Trichomonas assay w/optic
NI
A87999
Microbiology procedure

X
0342
0.0824
5.06
2.02
1.0188104
Cytopath fl nongyn, smears

X
0433
0.2557
15.72
5.93
3.1488106
Cytopath fl nongyn, filter

X
0433
0.2557
15.72
5.93
3.1488107
Cytopath fl nongyn, sm/fltr

X
0433
0.2557
15.72
5.93
3.1488108
Cytopath, concentrate tech

X
0433
0.2557
15.72
5.93
3.1488112
Cytopath, cell enhance tech

X
0343
0.5211
32.03
10.84
6.4188125
Forensic cytopathology
CH
X
0433
0.2557
15.72
5.93
3.1488141
Cytopath, c/v, interpret

N88160
Cytopath smear, other source

X
0433
0.2557
15.72
5.93
3.1488161
Cytopath smear, other source

X
0433
0.2557
15.72
5.93
3.1488162
Cytopath smear, other source

X
0433
0.2557
15.72
5.93
3.1488172
Cytopathology eval of fna

X
0343
0.5211
32.03
10.84
6.4188173
Cytopath eval, fna, report

X
0343
0.5211
32.03
10.84
6.4188182
Cell marker study
CH
X
0343
0.5211
32.03
10.84
6.4188184
Flowcytometry/ tc, 1 marker
CH
X
0433
0.2557
15.72
5.93
3.1488185
Flowcytometry/tc, add-on
CH
X
0433
0.2557
15.72
5.93
3.1488187
Flowcytometry/read, 2-8

X
0433
0.2557
15.72
5.93
3.1488188
Flowcytometry/read, 9-15

X
0433
0.2557
15.72
5.93
3.1488189
Flowcytometry/read, 16 & >

X
0343
0.5211
32.03
10.84
6.4188199
Cytopathology procedure

X
0342
0.0824
5.06
2.02
1.0188299
Cytogenetic study

X
0342
0.0824
5.06
2.02
1.0188300
Surgical path, gross

X
0433
0.2557
15.72
5.93
3.1488302
Tissue exam by pathologist

X
0433
0.2557
15.72
5.93
3.1488304
Tissue exam by pathologist

X
0343
0.5211
32.03
10.84
6.4188305
Tissue exam by pathologist

X
0343
0.5211
32.03
10.84
6.4188307
Tissue exam by pathologist

X
0344
0.7927
48.73
15.66
9.7588309
Tissue exam by pathologist

X
0344
0.7927
48.73
15.66
9.7588311
Decalcify tissue
CH
X
0433
0.2557
15.72
5.93
3.1488312
Special stains

X
0433
0.2557
15.72
5.93
3.1488313
Special stains

X
0433
0.2557
15.72
5.93
3.1488314
Histochemical stain

X
0342
0.0824
5.06
2.02
1.0188318
Chemical histochemistry

X
0433
0.2557
15.72
5.93
3.1488319
Enzyme histochemistry

X
0343
0.5211
32.03
10.84
6.4188321
Microslide consultation

X
0433
0.2557
15.72
5.93
3.1488323
Microslide consultation

X
0343
0.5211
32.03
10.84
6.4188325
Comprehensive review of data

X
0344
0.7927
48.73
15.66
9.7588329
Path consult introp

X
0433
0.2557
15.72
5.93
3.1488331
Path consult intraop, 1 bloc

X
0343
0.5211
32.03
10.84
6.4188332
Path consult intraop, addÆl

X
0433
0.2557
15.72
5.93
3.1488333
Intraop cyto path consult, 1

X
0343
0.5211
32.03
10.84
6.4188334
Intraop cyto path consult, 2

X
0433
0.2557
15.72
5.93
3.1488342
Immunohistochemistry

X
0343
0.5211
32.03
10.84
6.4188346
Immunofluorescent study

X
0343
0.5211
32.03
10.84
6.4188347
Immunofluorescent study

X
0343
0.5211
32.03
10.84
6.4188348
Electron microscopy

X
0661
2.5255
155.24
62.09
31.0588349
Scanning electron microscopy

X
0661
2.5255
155.24
62.09
31.0588355
Analysis, skeletal muscle

X
0343
0.5211
32.03
10.84
6.4188356
Analysis, nerve

X
0344
0.7927
48.73
15.66
9.7588358
Analysis, tumor

X
0344
0.7927
48.73
15.66
9.7588360
Tumor immunohistochem/manual
CH
X
0343
0.5211
32.03
10.84
6.4188361
Tumor immunohistochem/comput

X
0344
0.7927
48.73
15.66
9.7588362
Nerve teasing preparations

X
0344
0.7927
48.73
15.66
9.7588365
Insitu hybridization (fish)

X
0344
0.7927
48.73
15.66
9.7588367
Insitu hybridization, auto

X
0344
0.7927
48.73
15.66
9.7588368
Insitu hybridization, manual

X
0344
0.7927
48.73
15.66
9.7588380
Microdissection

N88384
Eval molecular probes, 11-50

X
0433
0.2557
15.72
5.93
3.1488385
Eval  molecul probes, 51-250

X
0343
0.5211
32.03
10.84
6.4188386
Eval molecul probes, 251-500

X
0344
0.7927
48.73
15.66
9.7588399
Surgical pathology procedure

X
0342
0.0824
5.06
2.02
1.0189049
Chct for mal hyperthermia

X
0343
0.5211
32.03
10.84
6.4189100
Sample intestinal contents

X
0360
1.4154
87.00
33.88
17.4089105
Sample intestinal contents

X
0360
1.4154
87.00
33.88
17.4089130
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.4089132
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.4089135
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.4089136
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.4089140
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.4089141
Sample stomach contents

X
0360
1.4154
87.00
33.88
17.40( print page 68354)89220
Sputum specimen collection

X
0343
0.5211
32.03
10.84
6.4189230
Collect sweat for test

X
0433
0.2557
15.72
5.93
3.1489240
Pathology lab procedure

X
0342
0.0824
5.06
2.02
1.0189250
Cultr oocyte/embryo <4 days

X
0348
0.8321
51.15

10.2389251
Cultr oocyte/embryo <4 days

X
0348
0.8321
51.15

10.2389253
Embryo hatching

X
0348
0.8321
51.15

10.2389254
Oocyte identification

X
0348
0.8321
51.15

10.2389255
Prepare embryo for transfer

X
0348
0.8321
51.15

10.2389257
Sperm identification

X
0348
0.8321
51.15

10.2389258
Cryopreservation; embryo(s)

X
0348
0.8321
51.15

10.2389259
Cryopreservation, sperm

X
0348
0.8321
51.15

10.2389260
Sperm isolation, simple

X
0348
0.8321
51.15

10.2389261
Sperm isolation, complex

X
0348
0.8321
51.15

10.2389264
Identify sperm tissue

X
0348
0.8321
51.15

10.2389268
Insemination of oocytes

X
0348
0.8321
51.15

10.2389272
Extended culture of oocytes

X
0348
0.8321
51.15

10.2389280
Assist oocyte fertilization

X
0348
0.8321
51.15

10.2389281
Assist oocyte fertilization

X
0348
0.8321
51.15

10.2389290
Biopsy, oocyte polar body

X
0348
0.8321
51.15

10.2389291
Biopsy, oocyte polar body

X
0348
0.8321
51.15

10.2389335
Cryopreserve testicular tiss

X
0348
0.8321
51.15

10.2389342
Storage/year; embryo(s)

X
0348
0.8321
51.15

10.2389343
Storage/year; sperm/semen

X
0348
0.8321
51.15

10.2389344
Storage/year; reprod tissue

X
0348
0.8321
51.15

10.2389346
Storage/year; oocyte(s)

X
0348
0.8321
51.15

10.2389352
Thawing cryopresrved; embryo

X
0348
0.8321
51.15

10.2389353
Thawing cryopresrved; sperm

X
0348
0.8321
51.15

10.2389354
Thaw cryoprsvrd; reprod tiss

X
0348
0.8321
51.15

10.2389356
Thawing cryopresrved; oocyte

X
0348
0.8321
51.15

10.2390296
Diphtheria antitoxin

N90371
Hep b ig, im

K
1630

119.06

23.8190375
Rabies ig, im/sc

K
9133

64.53

12.9190376
Rabies ig, heat treated

K
9134

68.24

13.6590385
Rh ig, minidose, im

N90393
Vaccina ig, im

N90396
Varicella-zoster ig, im

K
9135

140.92

28.1890471
Immunization admin
CH
S
0437
0.3945
24.25

4.8590472
Immunization admin, each add
CH
S
0436
0.1809
11.12

2.2290473
Immune admin oral/nasal
CH
S
0436
0.1809
11.12

2.2290474
Immune admin oral/nasal addl
CH
S
0436
0.1809
11.12

2.2290476
Adenovirus vaccine, type 4
CH
N90477
Adenovirus vaccine, type 7

N90581
Anthrax vaccine, sc
CH
N90585
Bcg vaccine, percut

K
9137

117.39

23.4890632
Hep a vaccine, adult im

N90633
Hep a vacc, ped/adol, 2 dose

N90634
Hep a vacc, ped/adol, 3 dose

N90636
Hep a/hep b vacc, adult im
CH
N90645
Hib vaccine, hboc, im

N90646
Hib vaccine, prp-d, im

N90647
Hib vaccine, prp-omp, im

N90648
Hib vaccine, prp-t, im

N90649
Hpapilloma vacc 3 dose im
CH
B90665
Lyme disease vaccine, im
CH
N90675
Rabies vaccine, im

K
9139

157.74

31.5590676
Rabies vaccine, id

K
9140

166.16

33.2390680
Rotovirus vacc 3 dose, oral

N90690
Typhoid vaccine, oral

N90691
Typhoid vaccine, im

N90692
Typhoid vaccine, h-p, sc/id

N90693
Typhoid vaccine, akd, sc
CH
B90698
Dtap-hib-ip vaccine, im

N90700
Dtap vaccine, < 7 yrs, im

N90701
Dtp vaccine, im

N90702
Dt vaccine < 7, im

N90703
Tetanus vaccine, im

N90704
Mumps vaccine, sc

N90705
Measles vaccine, sc

N90706
Rubella vaccine, sc

N90707
Mmr vaccine, sc

N( print page 68355)90708
Measles-rubella vaccine, sc

K
9141

60.82

12.1690710
Mmrv vaccine, sc

N90712
Oral poliovirus vaccine

N90713
Poliovirus, ipv, sc/im

N90714
Td vaccine no prsrv ≧ 7 im
CH
N90715
Tdap vaccine >7 im

N90716
Chicken pox vaccine, sc
CH
B90717
Yellow fever vaccine, sc
CH
N90718
Td vaccine > 7, im

N90719
Diphtheria vaccine, im

N90720
Dtp/hib vaccine, im
CH
K
3032

45.01

9.0090721
Dtap/hib vaccine, im

N90725
Cholera vaccine, injectable

N90727
Plague vaccine, im
CH
K
0744

150.00

30.0090733
Meningococcal vaccine, sc

K
9143

84.46

16.8990734
Meningococcal vaccine, im

K
9145

53.71

10.7490735
Encephalitis vaccine, sc

K
9144

96.22

19.2490736
Zoster vacc, sc
CH
B90749
Vaccine toxoid

N90760
Hydration iv infusion, init
CH
S
0440
1.809
111.20

22.2490761
Hydrate iv infusion, add-on
CH
S
0437
0.3945
24.25

4.8590765
Ther/proph/diag iv inf, init
CH
S
0440
1.809
111.20

22.2490766
Ther/proph/dg iv inf, add-on
CH
S
0437
0.3945
24.25

4.8590767
Tx/proph/dg addl seq iv inf
CH
S
0437
0.3945
24.25

4.8590768
Ther/diag concurrent inf
CH
N90772
Ther/proph/diag inj, sc/im
CH
S
0437
0.3945
24.25

4.8590773
Ther/proph/diag inj, ia
CH
S
0438
0.7942
48.82

9.7690774
Ther/proph/diag inj, iv push
CH
S
0438
0.7942
48.82

9.7690775
Ther/proph/diag inj add-on
CH
S
0438
0.7942
48.82

9.7690779
Ther/prop/diag inj/inf proc
CH
S
0436
0.1809
11.12

2.2290801
Psy dx interview

S
0323
1.7066
104.90

20.9890802
Intac psy dx interview

S
0323
1.7066
104.90

20.9890804
Psytx, office, 20-30 min

S
0322
1.1798
72.52

14.5090805
Psytx, off, 20-30 min w/e&m

S
0322
1.1798
72.52

14.5090806
Psytx, off, 45-50 min

S
0323
1.7066
104.90

20.9890807
Psytx, off, 45-50 min w/e&m

S
0323
1.7066
104.90

20.9890808
Psytx, office, 75-80 min

S
0323
1.7066
104.90

20.9890809
Psytx, off, 75-80, w/e&m

S
0323
1.7066
104.90

20.9890810
Intac psytx, off, 20-30 min

S
0322
1.1798
72.52

14.5090811
Intac psytx, 20-30, w/e&m

S
0322
1.1798
72.52

14.5090812
Intac psytx, off, 45-50 min

S
0323
1.7066
104.90

20.9890813
Intac psytx, 45-50 min w/e&m

S
0323
1.7066
104.90

20.9890814
Intac psytx, off, 75-80 min

S
0323
1.7066
104.90

20.9890815
Intac psytx, 75-80 w/e&m

S
0323
1.7066
104.90

20.9890816
Psytx, hosp, 20-30 min

S
0322
1.1798
72.52

14.5090817
Psytx, hosp, 20-30 min w/e&m

S
0322
1.1798
72.52

14.5090818
Psytx, hosp, 45-50 min

S
0323
1.7066
104.90

20.9890819
Psytx, hosp, 45-50 min w/e&m

S
0323
1.7066
104.90

20.9890821
Psytx, hosp, 75-80 min

S
0323
1.7066
104.90

20.9890822
Psytx, hosp, 75-80 min w/e&m

S
0323
1.7066
104.90

20.9890823
Intac psytx, hosp, 20-30 min

S
0322
1.1798
72.52

14.5090824
Intac psytx, hsp 20-30 w/e&m

S
0322
1.1798
72.52

14.5090826
Intac psytx, hosp, 45-50 min

S
0323
1.7066
104.90

20.9890827
Intac psytx, hsp 45-50 w/e&m

S
0323
1.7066
104.90

20.9890828
Intac psytx, hosp, 75-80 min

S
0323
1.7066
104.90

20.9890829
Intac psytx, hsp 75-80 w/e&m

S
0323
1.7066
104.90

20.9890845
Psychoanalysis

S
0323
1.7066
104.90

20.9890846
Family psytx w/o patient

S
0324
2.1633
132.97

26.5990847
Family psytx w/patient

S
0324
2.1633
132.97

26.5990849
Multiple family group psytx

S
0325
1.0765
66.17
14.47
13.2390853
Group psychotherapy

S
0325
1.0765
66.17
14.47
13.2390857
Intac group psytx

S
0325
1.0765
66.17
14.47
13.2390862
Medication management

X
0374
1.1418
70.18

14.0490865
Narcosynthesis

S
0323
1.7066
104.90

20.9890870
Electroconvulsive therapy

S
0320
5.5676
342.23
80.06
68.4590880
Hypnotherapy

S
0323
1.7066
104.90

20.9890885
Psy evaluation of records

N90887
Consultation with family

N90889
Preparation of report

N90899
Psychiatric service/therapy

S
0322
1.1798
72.52

14.50( print page 68356)90911
Biofeedback peri/uro/rectal

S
0321
1.3384
82.27
21.72
16.4590935
Hemodialysis, one evaluation

S
0170
6.6089
406.24

81.2590940
Hemodialysis access study

N90945
Dialysis, one evaluation

S
0170
6.6089
406.24

81.2591000
Esophageal intubation

X
0361
3.8887
239.03
83.23
47.8191010
Esophagus motility study

X
0361
3.8887
239.03
83.23
47.8191011
Esophagus motility study

X
0361
3.8887
239.03
83.23
47.8191012
Esophagus motility study

X
0361
3.8887
239.03
83.23
47.8191020
Gastric motility studies

X
0361
3.8887
239.03
83.23
47.8191022
Duodenal motility study

X
0361
3.8887
239.03
83.23
47.8191030
Acid perfusion of esophagus

X
0361
3.8887
239.03
83.23
47.8191034
Gastroesophageal reflux test

X
0361
3.8887
239.03
83.23
47.8191035
G-esoph reflx tst w/electrod
CH
X
0361
3.8887
239.03
83.23
47.8191037
Esoph imped function test

X
0361
3.8887
239.03
83.23
47.8191038
Esoph imped funct test > 1h

X
0361
3.8887
239.03
83.23
47.8191040
Esoph balloon distension tst

X
0360
1.4154
87.00
33.88
17.4091052
Gastric analysis test

X
0361
3.8887
239.03
83.23
47.8191055
Gastric intubation for smear

X
0360
1.4154
87.00
33.88
17.4091060
Gastric saline load test
CH
D91065
Breath hydrogen test

X
0360
1.4154
87.00
33.88
17.4091100
Pass intestine bleeding tube

X
0360
1.4154
87.00
33.88
17.4091105
Gastric intubation treatment

X
0360
1.4154
87.00
33.88
17.4091110
Gi tract capsule endoscopy

T
0142
9.4946
583.61
152.78
116.7291111
Esophageal capsule endoscopy
NI
T
0141
8.3175
511.26
143.38
102.2591120
Rectal sensation test
CH
T
0126
1.0887
66.92
16.45
13.3891122
Anal pressure record
CH
T
0164
2.1393
131.50

26.3091123
Irrigate fecal impaction

N91132
Electrogastrography

X
0360
1.4154
87.00
33.88
17.4091133
Electrogastrography w/test

X
0360
1.4154
87.00
33.88
17.4091299
Gastroenterology procedure

X
0360
1.4154
87.00
33.88
17.4092002
Eye exam, new patient
CH
V
0605
0.984
60.48

12.1092004
Eye exam, new patient
CH
V
0606
1.3646
83.88

16.7892012
Eye exam established pat
CH
V
0604
0.8242
50.66

10.1392014
Eye exam & treatment
CH
V
0605
0.984
60.48

12.1092018
New eye exam & treatment

T
0699
14.3845
884.19

176.8492019
Eye exam & treatment

T
0699
14.3845
884.19

176.8492020
Special eye evaluation

S
0230
0.7898
48.55
14.97
9.7192025
Corneal topography
NI
S
0698
1.1607
71.35

14.2792060
Special eye evaluation

S
0230
0.7898
48.55
14.97
9.7192065
Orthoptic/pleoptic training
CH
S
0230
0.7898
48.55
14.97
9.7192070
Fitting of contact lens

N92081
Visual field examination(s)

S
0230
0.7898
48.55
14.97
9.7192082
Visual field examination(s)

S
0230
0.7898
48.55
14.97
9.7192083
Visual field examination(s)

S
0230
0.7898
48.55
14.97
9.7192100
Serial tonometry exam(s)

N92120
Tonography & eye evaluation

S
0230
0.7898
48.55
14.97
9.7192130
Water provocation tonography

S
0230
0.7898
48.55
14.97
9.7192135
Opthalmic dx imaging

S
0230
0.7898
48.55
14.97
9.7192136
Ophthalmic biometry

S
0698
1.1607
71.35

14.2792140
Glaucoma provocative tests
CH
S
0230
0.7898
48.55
14.97
9.7192225
Special eye exam, initial
CH
S
0230
0.7898
48.55
14.97
9.7192226
Special eye exam, subsequent
CH
S
0230
0.7898
48.55
14.97
9.7192230
Eye exam with photos
CH
S
0231
2.1451
131.86

26.3792235
Eye exam with photos

S
0231
2.1451
131.86

26.3792240
Icg angiography

S
0231
2.1451
131.86

26.3792250
Eye exam with photos

S
0230
0.7898
48.55
14.97
9.7192260
Ophthalmoscopy/dynamometry
CH
S
0230
0.7898
48.55
14.97
9.7192265
Eye muscle evaluation

S
0230
0.7898
48.55
14.97
9.7192270
Electro-oculography

S
0230
0.7898
48.55
14.97
9.7192275
Electroretinography

S
0231
2.1451
131.86

26.3792283
Color vision examination

S
0230
0.7898
48.55
14.97
9.7192284
Dark adaptation eye exam

S
0698
1.1607
71.35

14.2792285
Eye photography

S
0230
0.7898
48.55
14.97
9.7192286
Internal eye photography

S
0698
1.1607
71.35

14.2792287
Internal eye photography

S
0698
1.1607
71.35

14.2792311
Contact lens fitting

X
0362
0.5865
36.05

7.2192312
Contact lens fitting

X
0362
0.5865
36.05

7.2192313
Contact lens fitting

X
0362
0.5865
36.05

7.2192315
Prescription of contact lens

X
0362
0.5865
36.05

7.2192316
Prescription of contact lens

X
0362
0.5865
36.05

7.21( print page 68357)92317
Prescription of contact lens

X
0362
0.5865
36.05

7.2192325
Modification of contact lens

X
0362
0.5865
36.05

7.2192326
Replacement of contact lens

X
0362
0.5865
36.05

7.2192352
Special spectacles fitting

X
0362
0.5865
36.05

7.2192353
Special spectacles fitting

X
0362
0.5865
36.05

7.2192354
Special spectacles fitting

X
0362
0.5865
36.05

7.2192355
Special spectacles fitting

X
0362
0.5865
36.05

7.2192358
Eye prosthesis service

X
0362
0.5865
36.05

7.2192371
Repair & adjust spectacles

X
0362
0.5865
36.05

7.2192499
Eye service or procedure

S
0230
0.7898
48.55
14.97
9.7192502
Ear and throat examination

T
0251
2.452
150.72

30.1492504
Ear microscopy examination

N92511
Nasopharyngoscopy

T
0071
0.7698
47.32
11.20
9.4692512
Nasal function studies

X
0363
0.8525
52.40
17.44
10.4892516
Facial nerve function test

X
0660
1.4461
88.89
28.06
17.7892520
Laryngeal function studies

X
0660
1.4461
88.89
28.06
17.7892531
Spontaneous nystagmus study

N92532
Positional nystagmus test

N92533
Caloric vestibular test

N92534
Optokinetic nystagmus test

N92541
Spontaneous nystagmus test

X
0363
0.8525
52.40
17.44
10.4892542
Positional nystagmus test

X
0363
0.8525
52.40
17.44
10.4892543
Caloric vestibular test

X
0660
1.4461
88.89
28.06
17.7892544
Optokinetic nystagmus test

X
0363
0.8525
52.40
17.44
10.4892545
Oscillating tracking test

X
0363
0.8525
52.40
17.44
10.4892546
Sinusoidal rotational test

X
0660
1.4461
88.89
28.06
17.7892547
Supplemental electrical test

X
0363
0.8525
52.40
17.44
10.4892548
Posturography

X
0660
1.4461
88.89
28.06
17.7892552
Pure tone audiometry, air

X
0364
0.4627
28.44
7.06
5.6992553
Audiometry, air & bone

X
0365
1.2419
76.34
18.52
15.2792555
Speech threshold audiometry

X
0364
0.4627
28.44
7.06
5.6992556
Speech audiometry, complete

X
0364
0.4627
28.44
7.06
5.6992557
Comprehensive hearing test

X
0365
1.2419
76.34
18.52
15.2792561
Bekesy audiometry, diagnosis

X
0364
0.4627
28.44
7.06
5.6992562
Loudness balance test

X
0364
0.4627
28.44
7.06
5.6992563
Tone decay hearing test

X
0364
0.4627
28.44
7.06
5.6992564
Sisi hearing test

X
0364
0.4627
28.44
7.06
5.6992565
Stenger test, pure tone

X
0364
0.4627
28.44
7.06
5.6992567
Tympanometry

X
0364
0.4627
28.44
7.06
5.6992568
Acoustic refl threshold tst

X
0364
0.4627
28.44
7.06
5.6992569
Acoustic reflex decay test

X
0364
0.4627
28.44
7.06
5.6992571
Filtered speech hearing test

X
0364
0.4627
28.44
7.06
5.6992572
Staggered spondaic word test

X
0366
1.8511
113.78
26.14
22.7692573
Lombard test
CH
D92575
Sensorineural acuity test

X
0364
0.4627
28.44
7.06
5.6992576
Synthetic sentence test

X
0364
0.4627
28.44
7.06
5.6992577
Stenger test, speech

X
0366
1.8511
113.78
26.14
22.7692579
Visual audiometry (vra)

X
0365
1.2419
76.34
18.52
15.2792582
Conditioning play audiometry

X
0365
1.2419
76.34
18.52
15.2792583
Select picture audiometry

X
0364
0.4627
28.44
7.06
5.6992584
Electrocochleography

X
0660
1.4461
88.89
28.06
17.7892585
Auditor evoke potent, compre

S
0216
2.7199
167.19

33.4492586
Auditor evoke potent, limit

S
0218
1.1872
72.97

14.5992587
Evoked auditory test

X
0363
0.8525
52.40
17.44
10.4892588
Evoked auditory test

X
0660
1.4461
88.89
28.06
17.7892596
Ear protector evaluation

X
0364
0.4627
28.44
7.06
5.6992601
Cochlear implt f/up exam < 7

X
0366
1.8511
113.78
26.14
22.7692602
Reprogram cochlear implt < 7

X
0366
1.8511
113.78
26.14
22.7692603
Cochlear implt f/up exam 7 >

X
0366
1.8511
113.78
26.14
22.7692604
Reprogram cochlear implt 7 >

X
0366
1.8511
113.78
26.14
22.7692620
Auditory function, 60 min

X
0365
1.2419
76.34
18.52
15.2792621
Auditory function, + 15 min

N92625
Tinnitus assessment

X
0365
1.2419
76.34
18.52
15.2792626
Eval aud rehab status

X
0365
1.2419
76.34
18.52
15.2792627
Eval aud status rehab add-on

N92640
Aud brainstem implt programg
NI
X
0365
1.2419
76.34
18.52
15.2792700
Ent procedure/service

X
0364
0.4627
28.44
7.06
5.6992950
Heart/lung resuscitation cpr

S
0094
2.4233
148.96
46.29
29.7992953
Temporary external pacing

S
0094
2.4233
148.96
46.29
29.7992960
Cardioversion electric, ext

S
0679
5.5233
339.51
95.30
67.90( print page 68358)92961
Cardioversion, electric, int

S
0679
5.5233
339.51
95.30
67.9092973
Percut coronary thrombectomy

T
0088
37.7391
2,319.75
655.22
463.9592974
Cath place, cardio brachytx

T
0103
16.2375
998.09
223.63
199.6292977
Dissolve clot, heart vessel

T
0676
2.0726
127.40

25.4892978
Intravasc us, heart add-on

S
0670
32.2854
1,984.52
536.10
396.9092979
Intravasc us, heart add-on

S
0416
32.5472
2,000.61

400.1292980
Insert intracoronary stent

T
0104
87.7183
5,391.87

1,078.3792981
Insert intracoronary stent

T
0104
87.7183
5,391.87

1,078.3792982
Coronary artery dilation

T
0083
58.7904
3,613.73

722.7592984
Coronary artery dilation

T
0083
58.7904
3,613.73

722.7592986
Revision of aortic valve

T
0083
58.7904
3,613.73

722.7592987
Revision of mitral valve

T
0083
58.7904
3,613.73

722.7592990
Revision of pulmonary valve

T
0083
58.7904
3,613.73

722.7592995
Coronary atherectomy

T
0082
72.1982
4,437.88
954.62
887.5892996
Coronary atherectomy add-on

T
0082
72.1982
4,437.88
954.62
887.5892997
Pul art balloon repr, percut

T
0081
42.936
2,639.19

527.8492998
Pul art balloon repr, percut

T
0081
42.936
2,639.19

527.8493005
Electrocardiogram, tracing

S
0099
0.3789
23.29

4.6693012
Transmission of ecg

N93017
Cardiovascular stress test

X
0100
2.5336
155.74
41.44
31.1593024
Cardiac drug stress test

X
0100
2.5336
155.74
41.44
31.1593025
Microvolt t-wave assess

X
0100
2.5336
155.74
41.44
31.1593041
Rhythm ECG, tracing

S
0099
0.3789
23.29

4.6693225
ECG monitor/record, 24 hrs

X
0097
1.0225
62.85
23.79
12.5793226
ECG monitor/report, 24 hrs

X
0097
1.0225
62.85
23.79
12.5793231
Ecg monitor/record, 24 hrs

X
0097
1.0225
62.85
23.79
12.5793232
ECG monitor/report, 24 hrs

X
0097
1.0225
62.85
23.79
12.5793236
ECG monitor/report, 24 hrs

X
0097
1.0225
62.85
23.79
12.5793270
ECG recording

X
0097
1.0225
62.85
23.79
12.5793271
Ecg/monitoring and analysis

X
0097
1.0225
62.85
23.79
12.5793278
ECG/signal-averaged

S
0099
0.3789
23.29

4.6693303
Echo transthoracic

S
0269
3.2154
197.64
75.60
39.5393304
Echo transthoracic

S
0697
1.5973
98.18
35.99
19.6493307
Echo exam of heart

S
0269
3.2154
197.64
75.60
39.5393308
Echo exam of heart

S
0697
1.5973
98.18
35.99
19.6493312
Echo transesophageal

S
0270
6.2505
384.21
141.32
76.8493313
Echo transesophageal

S
0270
6.2505
384.21
141.32
76.8493314
Echo transesophageal

N93315
Echo transesophageal

S
0270
6.2505
384.21
141.32
76.8493316
Echo transesophageal

S
0270
6.2505
384.21
141.32
76.8493317
Echo transesophageal

N93318
Echo transesophageal intraop

S
0270
6.2505
384.21
141.32
76.8493320
Doppler echo exam, heart
CH
S
0697
1.5973
98.18
35.99
19.6493321
Doppler echo exam, heart

S
0697
1.5973
98.18
35.99
19.6493325
Doppler color flow add-on

S
0697
1.5973
98.18
35.99
19.6493350
Echo transthoracic

S
0269
3.2154
197.64
75.60
39.5393501
Right heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293503
Insert/place heart catheter

T
0103
16.2375
998.09
223.63
199.6293505
Biopsy of heart lining

T
0103
16.2375
998.09
223.63
199.6293508
Cath placement, angiography

T
0080
37.0615
2,278.10
838.92
455.6293510
Left heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293511
Left heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293514
Left heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293524
Left heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293526
Rt & lT heart catheters

T
0080
37.0615
2,278.10
838.92
455.6293527
Rt & lT heart catheters

T
0080
37.0615
2,278.10
838.92
455.6293528
Rt & lT heart catheters

T
0080
37.0615
2,278.10
838.92
455.6293529
Rt, lt heart catheterization

T
0080
37.0615
2,278.10
838.92
455.6293530
Rt heart cath, congenital

T
0080
37.0615
2,278.10
838.92
455.6293531
R& l heart cath, congenital

T
0080
37.0615
2,278.10
838.92
455.6293532
R& l heart cath, congenital

T
0080
37.0615
2,278.10
838.92
455.6293533
R& l heart cath, congenital

T
0080
37.0615
2,278.10
838.92
455.6293539
Injection, cardiac cath

N93540
Injection, cardiac cath

N93541
Injection for lung angiogram

N93542
Injection for heart x-rays

N93543
Injection for heart x-rays

N93544
Injection for aortography

N93545
Inject for coronary x-rays

N93555
Imaging, cardiac cath

N( print page 68359)93556
Imaging, cardiac cath

N93561
Cardiac output measurement

N93562
Cardiac output measurement

N93571
Heart flow reserve measure

S
0670
32.2854
1,984.52
536.10
396.9093572
Heart flow reserve measure

S
0416
32.5472
2,000.61

400.1293580
Transcath closure of asd

T
0434
88.0728
5,413.66

1,082.7393581
Transcath closure of vsd

T
0434
88.0728
5,413.66

1,082.7393600
Bundle of His recording

T
0087
32.8988
2,022.22

404.4493602
Intra-atrial recording

T
0087
32.8988
2,022.22

404.4493603
Right ventricular recording

T
0087
32.8988
2,022.22

404.4493609
Map tachycardia, add-on

T
0087
32.8988
2,022.22

404.4493610
Intra-atrial pacing

T
0087
32.8988
2,022.22

404.4493612
Intraventricular pacing

T
0087
32.8988
2,022.22

404.4493613
Electrophys map 3d, add-on

T
0087
32.8988
2,022.22

404.4493615
Esophageal recording

T
0087
32.8988
2,022.22

404.4493616
Esophageal recording

T
0087
32.8988
2,022.22

404.4493618
Heart rhythm pacing

T
0087
32.8988
2,022.22

404.4493619
Electrophysiology evaluation

T
0085
34.2808
2,107.17
426.25
421.4393620
Electrophysiology evaluation

T
0085
34.2808
2,107.17
426.25
421.4393621
Electrophysiology evaluation

T
0085
34.2808
2,107.17
426.25
421.4393622
Electrophysiology evaluation

T
0085
34.2808
2,107.17
426.25
421.4393623
Stimulation, pacing heart

T
0087
32.8988
2,022.22

404.4493624
Electrophysiologic study

T
0085
34.2808
2,107.17
426.25
421.4393631
Heart pacing, mapping

T
0087
32.8988
2,022.22

404.4493640
Evaluation heart device
CH
N93641
Electrophysiology evaluation
CH
N93642
Electrophysiology evaluation

S
0084
9.8924
608.07

121.6193650
Ablate heart dysrhythm focus

T
0086
47.4931
2,919.31
812.36
583.8693651
Ablate heart dysrhythm focus

T
0086
47.4931
2,919.31
812.36
583.8693652
Ablate heart dysrhythm focus

T
0086
47.4931
2,919.31
812.36
583.8693660
Tilt table evaluation

S
0101
4.2769
262.89
100.24
52.5893662
Intracardiac ecg (ice)

S
0670
32.2854
1,984.52
536.10
396.9093701
Bioimpedance, thoracic

S
0099
0.3789
23.29

4.6693721
Plethysmography tracing

X
0368
0.9454
58.11
22.77
11.6293724
Analyze pacemaker system

S
0690
0.3613
22.21
8.67
4.4493727
Analyze ilr system

S
0690
0.3613
22.21
8.67
4.4493731
Analyze pacemaker system

S
0690
0.3613
22.21
8.67
4.4493732
Analyze pacemaker system

S
0690
0.3613
22.21
8.67
4.4493733
Telephone analy, pacemaker

S
0690
0.3613
22.21
8.67
4.4493734
Analyze pacemaker system

S
0690
0.3613
22.21
8.67
4.4493735
Analyze pacemaker system

S
0690
0.3613
22.21
8.67
4.4493736
Telephonic analy, pacemaker

S
0690
0.3613
22.21
8.67
4.4493740
Temperature gradient studies

X
0368
0.9454
58.11
22.77
11.6293741
Analyze ht pace device sngl

S
0689
0.6003
36.90

7.3893742
Analyze ht pace device sngl

S
0689
0.6003
36.90

7.3893743
Analyze ht pace device dual

S
0689
0.6003
36.90

7.3893744
Analyze ht pace device dual

S
0689
0.6003
36.90

7.3893745
Set-up cardiovert-defibrill

S
0689
0.6003
36.90

7.3893770
Measure venous pressure

N93786
Ambulatory BP recording

X
0097
1.0225
62.85
23.79
12.5793788
Ambulatory BP analysis

X
0097
1.0225
62.85
23.79
12.5793797
Cardiac rehab

S
0095
0.5748
35.33
13.86
7.0793798
Cardiac rehab/monitor

S
0095
0.5748
35.33
13.86
7.0793799
Cardiovascular procedure
CH
X
0097
1.0225
62.85
23.79
12.5793875
Extracranial study

S
0096
1.5303
94.06
37.62
18.8193880
Extracranial study

S
0267
2.4606
151.25
60.50
30.2593882
Extracranial study

S
0267
2.4606
151.25
60.50
30.2593886
Intracranial study

S
0267
2.4606
151.25
60.50
30.2593888
Intracranial study
CH
S
0265
0.9923
60.99
23.63
12.2093890
Tcd, vasoreactivity study

S
0266
1.5607
95.93
37.80
19.1993892
Tcd, emboli detect w/o inj

S
0266
1.5607
95.93
37.80
19.1993893
Tcd, emboli detect w/inj

S
0266
1.5607
95.93
37.80
19.1993922
Extremity study

S
0096
1.5303
94.06
37.62
18.8193923
Extremity study

S
0096
1.5303
94.06
37.62
18.8193924
Extremity study

S
0096
1.5303
94.06
37.62
18.8193925
Lower extremity study

S
0267
2.4606
151.25
60.50
30.2593926
Lower extremity study

S
0266
1.5607
95.93
37.80
19.1993930
Upper extremity study

S
0267
2.4606
151.25
60.50
30.2593931
Upper extremity study

S
0266
1.5607
95.93
37.80
19.1993965
Extremity study

S
0096
1.5303
94.06
37.62
18.81( print page 68360)93970
Extremity study

S
0267
2.4606
151.25
60.50
30.2593971
Extremity study

S
0266
1.5607
95.93
37.80
19.1993975
Vascular study

S
0267
2.4606
151.25
60.50
30.2593976
Vascular study

S
0267
2.4606
151.25
60.50
30.2593978
Vascular study

S
0266
1.5607
95.93
37.80
19.1993979
Vascular study

S
0266
1.5607
95.93
37.80
19.1993980
Penile vascular study

S
0267
2.4606
151.25
60.50
30.2593981
Penile vascular study

S
0266
1.5607
95.93
37.80
19.1993990
Doppler flow testing

S
0266
1.5607
95.93
37.80
19.1994002
Vent mgmt inpat, init day
NI
S
0079
2.6116
160.53

32.1194003
Vent mgmt inpat, subq day
NI
S
0079
2.6116
160.53

32.1194004
Vent mgmt nf per day
NI
B94005
Home vent mgmt supervision
NI
E94010
Breathing capacity test

X
0368
0.9454
58.11
22.77
11.6294014
Patient recorded spirometry

X
0367
0.6277
38.58
14.68
7.7294015
Patient recorded spirometry

X
0367
0.6277
38.58
14.68
7.7294060
Evaluation of wheezing

X
0368
0.9454
58.11
22.77
11.6294070
Evaluation of wheezing

X
0369
2.7669
170.08
44.18
34.0294150
Vital capacity test

X
0367
0.6277
38.58
14.68
7.7294200
Lung function test (MBC/MVV)

X
0367
0.6277
38.58
14.68
7.7294240
Residual lung capacity

X
0368
0.9454
58.11
22.77
11.6294250
Expired gas collection

X
0367
0.6277
38.58
14.68
7.7294260
Thoracic gas volume
CH
X
0368
0.9454
58.11
22.77
11.6294350
Lung nitrogen washout curve
CH
X
0368
0.9454
58.11
22.77
11.6294360
Measure airflow resistance

X
0367
0.6277
38.58
14.68
7.7294370
Breath airway closing volume

X
0367
0.6277
38.58
14.68
7.7294375
Respiratory flow volume loop

X
0367
0.6277
38.58
14.68
7.7294400
CO2 breathing response curve

X
0367
0.6277
38.58
14.68
7.7294450
Hypoxia response curve

X
0368
0.9454
58.11
22.77
11.6294452
Hast w/report

X
0368
0.9454
58.11
22.77
11.6294453
Hast w/oxygen titrate
CH
X
0367
0.6277
38.58
14.68
7.7294610
Surfactant admin thru tube
NI
S
0077
0.3527
21.68
7.74
4.3494620
Pulmonary stress test/simple

X
0368
0.9454
58.11
22.77
11.6294621
Pulm stress test/complex

X
0369
2.7669
170.08
44.18
34.0294640
Airway inhalation treatment

S
0077
0.3527
21.68
7.74
4.3494642
Aerosol inhalation treatment

S
0078
1.1206
68.88
14.55
13.7894644
Cbt, 1st hour
NI
S
0078
1.1206
68.88
14.55
13.7894645
Cbt, each addl hour
NI
S
0078
1.1206
68.88
14.55
13.7894656
Initial ventilator mgmt
CH
D94657
Continued ventilator mgmt
CH
D94660
Pos airway pressure, CPAP

S
0068
1.5353
94.37
29.48
18.8794662
Neg press ventilation, cnp

S
0079
2.6116
160.53

32.1194664
Evaluate pt use of inhaler

S
0077
0.3527
21.68
7.74
4.3494667
Chest wall manipulation

S
0077
0.3527
21.68
7.74
4.3494668
Chest wall manipulation

S
0077
0.3527
21.68
7.74
4.3494680
Exhaled air analysis, o2

X
0367
0.6277
38.58
14.68
7.7294681
Exhaled air analysis, o2/co2

X
0368
0.9454
58.11
22.77
11.6294690
Exhaled air analysis
CH
X
0367
0.6277
38.58
14.68
7.7294720
Monoxide diffusing capacity

X
0368
0.9454
58.11
22.77
11.6294725
Membrane diffusion capacity

X
0368
0.9454
58.11
22.77
11.6294750
Pulmonary compliance study
CH
X
0367
0.6277
38.58
14.68
7.7294760
Measure blood oxygen level

N94761
Measure blood oxygen level

N94762
Measure blood oxygen level
CH
Q
0443
1.0409
63.98
25.59
12.8094770
Exhaled carbon dioxide test

X
0367
0.6277
38.58
14.68
7.7294772
Breath recording, infant

X
0369
2.7669
170.08
44.18
34.0294774
Ped home apnea rec, compl
NI
B94775
Ped home apnea rec, hk-up
NI
X
0097
1.0225
62.85
23.79
12.5794776
Ped home apnea rec, downld
NI
X
0097
1.0225
62.85
23.79
12.5794777
Ped home apnea rec, report
NI
B94799
Pulmonary service/procedure

X
0367
0.6277
38.58
14.68
7.7295004
Percut allergy skin tests

X
0381
0.2688
16.52

3.3095010
Percut allergy titrate test

X
0381
0.2688
16.52

3.3095012
Exhaled nitric oxide meas
NI
X
0367
0.6277
38.58
14.68
7.7295015
Id allergy titrate-drug/bug

X
0381
0.2688
16.52

3.3095024
Id allergy test, drug/bug

X
0381
0.2688
16.52

3.3095027
Id allergy titrate-airborne

X
0381
0.2688
16.52

3.3095028
Id allergy test-delayed type

X
0381
0.2688
16.52

3.3095044
Allergy patch tests

X
0381
0.2688
16.52

3.3095052
Photo patch test

X
0381
0.2688
16.52

3.30( print page 68361)95056
Photosensitivity tests

X
0370
1.027
63.13

12.6395060
Eye allergy tests

X
0370
1.027
63.13

12.6395065
Nose allergy test

X
0381
0.2688
16.52

3.3095070
Bronchial allergy tests

X
0369
2.7669
170.08
44.18
34.0295071
Bronchial allergy tests

X
0369
2.7669
170.08
44.18
34.0295075
Ingestion challenge test

X
0361
3.8887
239.03
83.23
47.8195078
Provocative testing
CH
D95115
Immunotherapy, one injection
CH
S
0436
0.1809
11.12

2.2295117
Immunotherapy injections
CH
S
0437
0.3945
24.25

4.8595144
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595145
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595146
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595147
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595148
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595149
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595165
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595170
Antigen therapy services
CH
S
0437
0.3945
24.25

4.8595180
Rapid desensitization

X
0370
1.027
63.13

12.6395199
Allergy immunology services
CH
X
0381
0.2688
16.52

3.3095250
Glucose monitoring, cont

X
0421
1.627
100.01

20.0095805
Multiple sleep latency test

S
0209
11.2463
691.29
268.73
138.2695806
Sleep study, unattended

S
0213
2.2755
139.87
53.58
27.9795807
Sleep study, attended

S
0209
11.2463
691.29
268.73
138.2695808
Polysomnography, 1-3

S
0209
11.2463
691.29
268.73
138.2695810
Polysomnography, 4 or more

S
0209
11.2463
691.29
268.73
138.2695811
Polysomnography w/cpap

S
0209
11.2463
691.29
268.73
138.2695812
Eeg, 41-60 minutes

S
0213
2.2755
139.87
53.58
27.9795813
Eeg, over 1 hour

S
0213
2.2755
139.87
53.58
27.9795816
Eeg, awake and drowsy

S
0213
2.2755
139.87
53.58
27.9795819
Eeg, awake and asleep

S
0213
2.2755
139.87
53.58
27.9795822
Eeg, coma or sleep only

S
0213
2.2755
139.87
53.58
27.9795824
Eeg, cerebral death only

S
0214
1.1968
73.56
28.24
14.7195827
Eeg, all night recording

S
0213
2.2755
139.87
53.58
27.9795829
Surgery electrocorticogram

S
0214
1.1968
73.56
28.24
14.7195857
Tensilon test

S
0218
1.1872
72.97

14.5995860
Muscle test, one limb

S
0218
1.1872
72.97

14.5995861
Muscle test, 2 limbs

S
0218
1.1872
72.97

14.5995863
Muscle test, 3 limbs

S
0218
1.1872
72.97

14.5995864
Muscle test, 4 limbs

S
0218
1.1872
72.97

14.5995865
Muscle test, larynx

S
0218
1.1872
72.97

14.5995866
Muscle test, hemidiaphragm

S
0218
1.1872
72.97

14.5995867
Muscle test cran nerv unilat

S
0218
1.1872
72.97

14.5995868
Muscle test cran nerve bilat

S
0218
1.1872
72.97

14.5995869
Muscle test, thor paraspinal

S
0215
0.5741
35.29

7.0695870
Muscle test, nonparaspinal

S
0215
0.5741
35.29

7.0695872
Muscle test, one fiber

S
0218
1.1872
72.97

14.5995873
Guide nerv destr, elec stim

S
0215
0.5741
35.29

7.0695874
Guide nerv destr, needle emg

S
0215
0.5741
35.29

7.0695875
Limb exercise test

S
0215
0.5741
35.29

7.0695900
Motor nerve conduction test

S
0215
0.5741
35.29

7.0695903
Motor nerve conduction test

S
0215
0.5741
35.29

7.0695904
Sense nerve conduction test

S
0215
0.5741
35.29

7.0695920
Intraop nerve test add-on

S
0216
2.7199
167.19

33.4495921
Autonomic nerv function test
CH
S
0215
0.5741
35.29

7.0695922
Autonomic nerv function test
CH
S
0215
0.5741
35.29

7.0695923
Autonomic nerv function test
CH
S
0215
0.5741
35.29

7.0695925
Somatosensory testing

S
0216
2.7199
167.19

33.4495926
Somatosensory testing

S
0216
2.7199
167.19

33.4495927
Somatosensory testing

S
0216
2.7199
167.19

33.4495928
Cmotor evoked, uppr limbs

S
0218
1.1872
72.97

14.5995929
Cmotor evoked, lwr limbs

S
0218
1.1872
72.97

14.5995930
Visual evoked potential test

S
0216
2.7199
167.19

33.4495933
Blink reflex test

S
0215
0.5741
35.29

7.0695934
H-reflex test

S
0215
0.5741
35.29

7.0695936
H-reflex test

S
0215
0.5741
35.29

7.0695937
Neuromuscular junction test
CH
S
0215
0.5741
35.29

7.0695950
Ambulatory eeg monitoring

S
0209
11.2463
691.29
268.73
138.2695951
EEG monitoring/videorecord

S
0209
11.2463
691.29
268.73
138.2695953
EEG monitoring/computer

S
0209
11.2463
691.29
268.73
138.2695954
EEG monitoring/giving drugs

S
0214
1.1968
73.56
28.24
14.71( print page 68362)95955
EEG during surgery

S
0213
2.2755
139.87
53.58
27.9795956
Eeg monitoring, cable/radio

S
0209
11.2463
691.29
268.73
138.2695957
EEG digital analysis

S
0214
1.1968
73.56
28.24
14.7195958
EEG monitoring/function test

S
0213
2.2755
139.87
53.58
27.9795961
Electrode stimulation, brain

S
0216
2.7199
167.19

33.4495962
Electrode stim, brain add-on

S
0216
2.7199
167.19

33.4495965
Meg, spontaneous
CH
S
0038
53.5161
3,289.53

657.9195966
Meg, evoked, single
CH
S
0209
11.2463
691.29
268.73
138.2695967
Meg, evoked, each addÆl
CH
S
0209
11.2463
691.29
268.73
138.2695970
Analyze neurostim, no prog

S
0218
1.1872
72.97

14.5995971
Analyze neurostim, simple

S
0692
1.9323
118.77
30.16
23.7595972
Analyze neurostim, complex

S
0692
1.9323
118.77
30.16
23.7595973
Analyze neurostim, complex
CH
S
0663
1.1067
68.03
17.45
13.6195974
Cranial neurostim, complex

S
0692
1.9323
118.77
30.16
23.7595975
Cranial neurostim, complex

S
0692
1.9323
118.77
30.16
23.7595978
Analyze neurostim brain/1h

S
0692
1.9323
118.77
30.16
23.7595979
Analyz neurostim brain addon
CH
S
0663
1.1067
68.03
17.45
13.6195990
Spin/brain pump refil & main

T
0125
2.2041
135.48

27.1095991
Spin/brain pump refil & main

T
0125
2.2041
135.48

27.1095999
Neurological procedure

S
0215
0.5741
35.29

7.0696000
Motion analysis, video/3d

S
0216
2.7199
167.19

33.4496001
Motion test w/ft press meas

S
0216
2.7199
167.19

33.4496002
Dynamic surface emg

S
0218
1.1872
72.97

14.5996003
Dynamic fine wire emg

S
0215
0.5741
35.29

7.0696020
Functional brain mapping
NI
X
0373
1.7682
108.69

21.7496040
Genetic counseling, 30 min
NI
E96101
Psycho testing by psych/phys

X
0373
1.7682
108.69

21.7496102
Psycho testing by technician

X
0382
2.846
174.94
69.97
34.9996103
Psycho testing admin by comp

X
0373
1.7682
108.69

21.7496110
Developmental test, lim

X
0373
1.7682
108.69

21.7496111
Developmental test, extend

X
0373
1.7682
108.69

21.7496116
Neurobehavioral status exam

X
0373
1.7682
108.69

21.7496118
Neuropsych tst by psych/phys

X
0373
1.7682
108.69

21.7496119
Neuropsych testing by tec

X
0382
2.846
174.94
69.97
34.9996120
Neuropsych tst admin w/comp

X
0373
1.7682
108.69

21.7496150
Assess hlth/behave, init

S
0432
0.6072
37.32

7.4696151
Assess hlth/behave, subseq

S
0432
0.6072
37.32

7.4696152
Intervene hlth/behave, indiv

S
0432
0.6072
37.32

7.4696153
Intervene hlth/behave, group

S
0432
0.6072
37.32

7.4696154
Interv hlth/behav, fam w/pt

S
0432
0.6072
37.32

7.4696401
Chemo, anti-neopl, sq/im
CH
S
0438
0.7942
48.82

9.7696402
Chemo hormon antineopl sq/im
CH
S
0438
0.7942
48.82

9.7696405
Chemo intralesional, up to 7
CH
S
0438
0.7942
48.82

9.7696406
Chemo intralesional over 7
CH
S
0438
0.7942
48.82

9.7696409
Chemo, iv push, sngl drug
CH
S
0439
1.5848
97.41

19.4896411
Chemo, iv push, addl drug
CH
S
0439
1.5848
97.41

19.4896413
Chemo, iv infusion, 1 hr
CH
S
0441
2.4851
152.75

30.5596415
Chemo, iv infusion, addl hr
CH
S
0438
0.7942
48.82

9.7696416
Chemo prolong infuse w/pump
CH
S
0441
2.4851
152.75

30.5596417
Chemo iv infus each addl seq
CH
S
0438
0.7942
48.82

9.7696420
Chemo, ia, push tecnique
CH
S
0439
1.5848
97.41

19.4896422
Chemo ia infusion up to 1 hr
CH
S
0441
2.4851
152.75

30.5596423
Chemo ia infuse each addl hr
CH
S
0438
0.7942
48.82

9.7696425
Chemotherapy,infusion method
CH
S
0441
2.4851
152.75

30.5596440
Chemotherapy, intracavitary
CH
S
0441
2.4851
152.75

30.5596445
Chemotherapy, intracavitary
CH
S
0441
2.4851
152.75

30.5596450
Chemotherapy, into CNS
CH
S
0441
2.4851
152.75

30.5596521
Refill/maint, portable pump
CH
S
0440
1.809
111.20

22.2496522
Refill/maint pump/resvr syst
CH
S
0440
1.809
111.20

22.2496523
Irrig drug delivery device
CH
Q
0624
0.5145
31.63
12.65
6.3396542
Chemotherapy injection
CH
S
0438
0.7942
48.82

9.7696549
Chemotherapy, unspecified
CH
S
0436
0.1809
11.12

2.2296567
Photodynamic tx, skin

T
0016
2.6749
164.42

32.8896570
Photodynamic tx, 30 min

T
0015
1.6241
99.83
20.13
19.9796571
Photodynamic tx, addl 15 min

T
0015
1.6241
99.83
20.13
19.9796900
Ultraviolet light therapy

S
0001
0.4914
30.21
7.00
6.0496902
Trichogram

N96904
Whole body photography
NI
N96910
Photochemotherapy with UV-B

S
0001
0.4914
30.21
7.00
6.0496912
Photochemotherapy with UV-A

S
0001
0.4914
30.21
7.00
6.04( print page 68363)96913
Photochemotherapy, UV-A or B

S
0683
2.6734
164.33

32.8796920
Laser tx, skin < 250 sq cm

T
0013
1.0918
67.11

13.4296921
Laser tx, skin 250-500 sq cm

T
0013
1.0918
67.11

13.4296922
Laser tx, skin > 500 sq cm

T
0013
1.0918
67.11

13.4296999
Dermatological procedure

T
0010
0.476
29.26
8.02
5.8597597
Active wound care/20 cm or <

T
0012
0.8432
51.83
11.18
10.3797598
Active wound care > 20 cm

T
0013
1.0918
67.11

13.4297602
Wound(s) care non-selective

X
0340
0.6102
37.51

7.5097605
Neg press wound tx, < 50 cm

T
0012
0.8432
51.83
11.18
10.3797606
Neg press wound tx, > 50 cm

T
0013
1.0918
67.11

13.4298925
Osteopathic manipulation

S
0060
0.4657
28.63

5.7398926
Osteopathic manipulation

S
0060
0.4657
28.63

5.7398927
Osteopathic manipulation

S
0060
0.4657
28.63

5.7398928
Osteopathic manipulation

S
0060
0.4657
28.63

5.7398929
Osteopathic manipulation

S
0060
0.4657
28.63

5.7398940
Chiropractic manipulation

S
0060
0.4657
28.63

5.7398941
Chiropractic manipulation

S
0060
0.4657
28.63

5.7398942
Chiropractic manipulation

S
0060
0.4657
28.63

5.7399078
Group health education

N99091
Collect/review data from pt

N99143
Mod cs by same phys, < 5 yrs

N99144
Mod cs by same phys, 5 yrs +

N99145
Mod cs by same phys add-on

N99148
Mod cs diff phys < 5 yrs

N99149
Mod cs diff phys 5 yrs +

N99150
Mod cs diff phys add-on

N99170
Anogenital exam, child

T
0191
0.1468
9.02
2.55
1.8099175
Induction of vomiting

N99185
Regional hypothermia

N99186
Total body hypothermia

N99195
Phlebotomy

X
0372
0.5723
35.18
10.09
7.0499201
Office/outpatient visit, new
CH
V
0604
0.8242
50.66

10.1399202
Office/outpatient visit, new
CH
V
0605
0.984
60.48

12.1099203
Office/outpatient visit, new
CH
V
0606
1.3646
83.88

16.7899204
Office/outpatient visit, new
CH
V
0607
1.7096
105.09

21.0299205
Office/outpatient visit, new
CH
V
0608
2.1794
133.96

26.7999211
Office/outpatient visit, est
CH
V
0604
0.8242
50.66

10.1399212
Office/outpatient visit, est
CH
V
0605
0.984
60.48

12.1099213
Office/outpatient visit, est
CH
V
0605
0.984
60.48

12.1099214
Office/outpatient visit, est
CH
V
0606
1.3646
83.88

16.7899215
Office/outpatient visit, est
CH
V
0607
1.7096
105.09

21.0299241
Office consultation
CH
V
0604
0.8242
50.66

10.1399242
Office consultation
CH
V
0605
0.984
60.48

12.1099243
Office consultation
CH
V
0605
0.984
60.48

12.1099244
Office consultation
CH
V
0606
1.3646
83.88

16.7899245
Office consultation
CH
V
0607
1.7096
105.09

21.0299281
Emergency dept visit
CH
V
0609
0.8136
50.01
12.70
10.0099282
Emergency dept visit
CH
V
0613
1.3497
82.96
21.06
16.5999283
Emergency dept visit
CH
V
0614
2.115
130.00
34.50
26.0099284
Emergency dept visit
CH
V
0615
3.4163
209.99
48.49
42.0099285
Emergency dept visit
CH
V
0616
5.2915
325.26
75.11
65.0599289
Ped crit care transport

N99290
Ped crit care transport addl

N99291
Critical care, first hour
CH
S
0617
6.5894
405.04
111.59
81.0199292
Critical care, add'l 30 min

N99300
Ic, infant pbw 2501-5000 gm

N99354
Prolonged service, office

N99355
Prolonged service, office

N99358
Prolonged serv, w/o contact

N99359
Prolonged serv, w/o contact

N99361
Physician/team conference

N99362
Physician/team conference

N99363
Anticoag mgmt, init
NI
E99364
Anticoag mgmt, subseq
NI
E99431
Initial care, normal newborn
CH
V
0605
0.984
60.48

12.1099432
Newborn care, not in hosp

N99436
Attendance, birth

N99440
Newborn resuscitation

S
0094
2.4233
148.96
46.29
29.790003T
Cervicography
CH
D0008T
Upper gi endoscopy w/suture
CH
D( print page 68364)0012F
Cap bacterial assess
NI
M0016T
Thermotx choroid vasc lesion

T
0235
3.9333
241.77
58.93
48.350017T
Photocoagulat macular drusen

T
0235
3.9333
241.77
58.93
48.350018T
Transcranial magnetic stimul
CH
D0021T
Fetal oximetry, trnsvag/cerv
CH
D0027T
Endoscopic epidural lysis

T
0220
17.8499
1,097.20

219.440028T
Dexa body composition study

N0031T
Speculoscopy

N0032T
Speculoscopy w/direct sample

N0042T
Ct perfusion w/contrast, cbf

N0044T
Whole body photography
CH
D0045T
Whole body photography
CH
D0046T
Cath lavage, mammary duct(s)

T
0021
15.1024
928.31
219.48
185.660047T
Cath lavage, mammary duct(s)

T
0021
15.1024
928.31
219.48
185.660054T
Bone surgery using computer

S
0302
4.9138
302.04
105.94
60.410055T
Bone surgery using computer

S
0302
4.9138
302.04
105.94
60.410056T
Bone surgery using computer

S
0302
4.9138
302.04
105.94
60.410058T
Cryopreservation, ovary tiss

X
0348
0.8321
51.15

10.230059T
Cryopreservation, oocyte

X
0348
0.8321
51.15

10.230062T
Rep intradisc annulus;1 lev

T
0050
25.1296
1,544.67

308.930063T
Rep intradisc annulus;>1lev

T
0050
25.1296
1,544.67

308.930064T
Spectroscop eval expired gas

X
0367
0.6277
38.58
14.68
7.720067T
Ct colonography;dx

S
0333
4.8405
297.54
119.01
59.510069T
Analysis only heart sound

N0071T
U/s leiomyomata ablate <200

T
0195
28.5095
1,752.42
483.80
350.480072T
U/s leiomyomata ablate >200

T
0202
42.9896
2,642.48
981.50
528.500073T
Delivery, comp imrt

S
0412
5.4731
336.42

67.280082T
Stereotactic rad delivery
CH
D0083T
Stereotactic rad tx mngmt
CH
D0084T
Temp prostate urethral stent

T
0164
2.1393
131.50

26.300085T
Breath test heart reject

X
0340
0.6102
37.51

7.500086T
Lventricle fill pressure

N0087T
Sperm eval hyaluronan

X
0348
0.8321
51.15

10.230088T
Rf tongue base vol reduxn

T
0253
16.4266
1,009.71
282.29
201.940089T
Actigraphy testing, 3-day

S
0218
1.1872
72.97

14.590090T
Cervical artific disc
CH
E0091T
Lumbar artific disc
CH
D0094T
Lumbar artific diskectomy
CH
D0097T
Rev lumbar artific disc
CH
D0099T
Implant corneal ring

T
0233
15.2259
935.91
266.33
187.180100T
Prosth retina receive&gen

T
0672
37.429
2,300.69

460.140101T
Extracorp shockwv tx,hi enrg
CH
T
0050
25.1296
1,544.67

308.930102T
Extracorp shockwv tx,anesth
CH
T
0050
25.1296
1,544.67

308.930106T
Touch quant sensory test

X
0341
0.0914
5.62
2.24
1.120107T
Vibrate quant sensory test

X
0341
0.0914
5.62
2.24
1.120108T
Cool quant sensory test

X
0341
0.0914
5.62
2.24
1.120109T
Heat quant sensory test

X
0341
0.0914
5.62
2.24
1.120110T
Nos quant sensory test

X
0341
0.0914
5.62
2.24
1.120120T
Fibroadenoma cryoablate, ea
CH
D0123T
Scleral fistulization

T
0234
22.997
1,413.58
511.31
282.720124T
Conjunctival drug placement

T
0232
6.0673
372.94
93.43
74.590126T
Chd risk imt study

N0133T
Esophageal implant injexn
CH
T
0422
25.7552
1,583.12
448.81
316.620135T
Perq cryoablate renal tumor
CH
T
0423
37.3604
2,296.47

459.290137T
Prostate saturation sampling

T
0184
5.6262
345.83
96.27
69.170144T
CT heart wo dye; qual calc

S
0398
4.1265
253.65
100.06
50.730145T
CT heart w/wo dye funct

S
0376
4.9832
306.31
119.77
61.260146T
CCTA w/wo dye

S
0376
4.9832
306.31
119.77
61.260147T
CCTA w/wo, quan calcium

S
0376
4.9832
306.31
119.77
61.260148T
CCTA w/wo, strxr

S
0377
6.5012
399.62
158.84
79.920149T
CCTA w/wo, strxr quan calc

S
0377
6.5012
399.62
158.84
79.920150T
CCTA w/wo, disease strxr

S
0398
4.1265
253.65
100.06
50.730151T
CT heart funct add-on

S
0282
1.5379
94.53
37.81
18.910152T
Computer chest add-on

N0154T
Study sensor aneurysm sac

X
0097
1.0225
62.85
23.79
12.570155T
Lap impl gast curve electrd
NF
T
0130
32.1241
1,974.60
659.53
394.920156T
Lap remv gast curve electrd
NF
T
0130
32.1241
1,974.60
659.53
394.920157T
Open impl gast curve electrd
NF
C0158T
Open remv gast curve electrd
NF
C0159T
Cad breast mri
NF
N( print page 68365)0160T
Tcranial magn stim tx plan
CH
S
0216
2.7199
167.19

33.440161T
Tcranial magn stim tx deliv
CH
S
0216
2.7199
167.19

33.440162T
Anal program gast neurostim
NI
S
0692
1.9323
118.77
30.16
23.750163T
Lumb artif diskectomy addl
NI
C0164T
Remove lumb artif disc addl
NI
C0165T
Revise lumb artif disc addl
NI
C0166T
Tcath vsd close w/o bypass
NI
C0167T
Tcath vsd close w bypass
NI
C0168T
Rhinophototx light app bilat
NI
T
0251
2.452
150.72

30.140169T
Place stereo cath brain
NI
C0170T
Anorectal fistula plug rpr
NI
T
0150
29.6189
1,820.61
437.12
364.120171T
Lumbar spine proces distract
NI
T
0050
25.1296
1,544.67

308.930172T
Lumbar spine proces addl
NI
T
0050
25.1296
1,544.67

308.930173T
Iop monit io pressure
NI
N0174T
Cad cxr with interp
NI
N0175T
Cad cxr remote
NI
N0176T
Aqu canal dilat w/o retent
NI
T
0673
37.8967
2,329.43
649.56
465.890177T
Aqu canal dilat w retent
NI
T
0673
37.8967
2,329.43
649.56
465.890505F
Hemodialysis plan doc'd
NI
M0507F
Periton dialysis plan doc'd
NI
M1001F
Tobacco use, non-smoking
CH
D1015F
Copd symptoms assess
NI
M1018F
Assess dyspnea not present
NI
M1019F
Assess dyspnea present
NI
M1022F
Pneumo imm status assess
NI
M1026F
Co-morbid condition assess
NI
M1030F
Influenza imm status assess
NI
M1034F
Current tobacco smoker
NI
M1035F
Smokeless tobacco user
NI
M1036F
Tobacco non-user
NI
M1038F
Persistent asthma
NI
M1039F
Intermittent asthma
NI
M1040F
Dsm-ivÖ info mdd doc'd
NI
M2003F
Auscultation heart perform
CH
D2010F
Vital signs recorded
NI
M2014F
Mental status assess
NI
M2018F
Hydration status assess
NI
M2022F
Dil retina exam interp rev
NI
M2024F
7 field photo interp doc rev
NI
M2026F
Eye image valid to dx rev
NI
M2028F
Foot exam performed
NI
M2030F
H2O stat docÆd, normal
NI
M2031F
H2O stat docÆd, dehydrated
NI
M3000F
Blood press ≦ 140/90 mmhg
CH
D3002F
Blood pressure > 140/90 mmhg
CH
D3006F
Cxr doc rev
NI
M3011F
Lipid panel doc rev
NI
M3014F
Screen mammo doc rev
NI
M3017F
Colorectal ca screen doc rev
NI
M3020F
Lvf assess
NI
M3021F
Lvef mod/sever deprs syst
NI
M3022F
Lvef ?40% systolic
NI
M3023F
Spirom doc rev
NI
M3025F
Spirom fev/fvc<70% w copd
NI
M3027F
Spirom fev/fvc?70%/ w/o copd
NI
M3028F
O2 saturation doc rev
NI
M3035F
O2 saturation ?88% /pa0 ?55
NI
M3037F
O2 saturation> 88% /pa0>55
NI
M3040F
Fev<40% predicted value
NI
M3042F
Fev? 40% predicted value
NI
M3046F
Hemoglobin a1c level > 9.0%
NI
M3047F
Hemoglobin A1c level ? 9.0%
NI
M3048F
LDL-C <100 mg/dL
NI
M3049F
LDL-C 100-129 mg/dL
NI
M3050F
LDL-C ? 130 mg/dL
NI
M3060F
Pos microalbuminuria rev
NI
M3061F
Neg microalbuminuria rev
NI
M3062F
Pos macroalbuminuria rev
NI
M3066F
Nephropathy doc tx
NI
M3072F
Low risk for retinopathy
NI
M( print page 68366)3076F
Syst bp < 140 mm hg
NI
M3077F
Syst bp ? 140 mm hg
NI
M3078F
Diast bp < 80 mm hg
NI
M3079F
Diast bp 80-89 mm hg
NI
M3080F
Diast bp ? 90 mm hg
NI
M3082F
Kt/v <1.2
NI
M3083F
Kt/v ≧ 1.2 and <1.7
NI
M3084F
Kt/v ? 1.7
NI
M3085F
Suicide risk assessed
NI
M3088F
Mdd, mild
NI
M3089F
Mdd, moderate
NI
M3090F
Mdd, severe; w/o psych
NI
M3091F
Mdd, severe; w/ psych
NI
M3092F
Mdd, in remission
NI
M3093F
Doc new diag 1st/addl. mdd
NI
M4025F
Inhaled broncholidator rx
NI
M4030F
Oxygen therapy rx
NI
M4033F
Pulmonary rehab rec
NI
M4035F
Influenza imm rec
NI
M4037F
Influenza imm order/admin
NI
M4040F
pneumoc imm order/admin
NI
M4045F
Empiric antibiotic rx
NI
M4050F
Ht care plan doc
NI
M4051F
Referred for an av fistula
NI
M4052F
Hemodialysis via av fistula
NI
M4053F
Hemodialysis via av graft
NI
M4054F
Hemodialysis via catheter
NI
M4055F
Pt. rcvng periton dialysis
NI
M4056F
Approp. oral rehyd. recommÆd
NI
M4058F
Ped gastro ed given, caregvr
NI
M4060F
Psych svcs provided
NI
M4062F
Pt referral psych docÆd
NI
M4064F
Antidepressant rx
NI
M4065F
Antipsychotic rx
NI
M4066F
Ect provided
NI
M4067F
Pt referral for ect docÆd
NI
M6005F
Care level rationale doc
NI
MA0800
Amb trans 7pm-7am
CH
DA4211
Supp for self-adm injections
CH
EA4218
Sterile saline or water

NA4220
Infusion pump refill kit

NA4248
Chlorhexidine antisept

NA4262
Temporary tear duct plug

NA4263
Permanent tear duct plug

NA4270
Disposable endoscope sheath

NA4300
Cath impl vasc access portal

NA4301
Implantable access syst perc

NA4305
Drug delivery system ≧50 ML
CH
NA4306
Drug delivery system ≦50 ml
CH
NA4348
Male ext cath extended wear
CH
DA4359
Urinary suspensory w/o leg b
CH
DA4461
Surgicl dress hold non-reuse
NI
AA4462
Abdmnl drssng holder/binder
CH
DA4463
Surgical dress holder reuse
NI
AA4559
Coupling gel or paste
NI
YA4561
Pessary rubber, any type

NA4562
Pessary, non rubber,any type

NA4600
Sleeve, inter limb comp dev
NI
YA4601
Lith ion batt, non-pros use
NI
YA4614
Hand-held PEFR meter
CH
NA4632
Infus pump rplcemnt battery
CH
DA4641
Radiopharm dx agent noc

NA4642
In111 satumomab

H
0704A5512
Multi den insert direct form
CH
YA5513
Multi den insert custom mold
CH
YA8000
Soft protect helmet prefab
NI
YA8001
Hard protect helmet prefab
NI
YA8002
Soft protect helmet custom
NI
YA8003
Hard protect helmet custom
NI
YA8004
Repl soft interface, helmet
NI
Y( print page 68367)A9279
Monitoring feature/deviceNOC
NI
EA9500
Tc99m sestamibi

H
1600A9502
Tc99m tetrofosmin

H
0705A9503
Tc99m medronate

NA9504
Tc99m apcitide
CH
NA9505
TL201 thallium

H
1603A9507
In111 capromab

H
1604A9508
I131 iodobenguate, dx

H
1045A9510
Tc99m disofenin
CH
NA9512
Tc99m pertechnetate

NA9516
I123 iodide cap, dx
CH
H
9148A9517
I131 iodide cap, rx
CH
H
1064A9521
Tc99m exametazime

H
1096A9524
I131 serum albumin, dx

H
9100A9526
Nitrogen N-13 ammonia

H
0737A9527
Iodine I-125 sodium iodide
NI
K
2632
0.3321
20.41

4.08A9528
Iodine I-131 iodide cap, dx

H
1088A9529
I131 iodide sol, dx
CH
NA9530
I131 iodide sol, rx

H
1150A9531
I131 max 100uCi
CH
NA9532
I125 serum albumin, dx
CH
NA9535
Injection, methylene blue
CH
NA9536
Tc99m depreotide
CH
H
0739A9537
Tc99m mebrofenin

NA9538
Tc99m pyrophosphate

NA9539
Tc99m pentetate
CH
H
0722A9540
Tc99m MAA

NA9541
Tc99m sulfur colloid

NA9542
In111 ibritumomab, dx

H
1642A9543
Y90 ibritumomab, rx

H
1643A9544
I131 tositumomab, dx

H
1644A9545
I131 tositumomab, rx

H
1645A9546
Co57/58
CH
H
0723A9547
In111 oxyquinoline

H
1646A9548
In111 pentetate

H
1647A9549
Tc99m arcitumomab
CH
DA9550
Tc99m gluceptate
CH
H
0740A9551
Tc99m succimer

H
1650A9552
F18 fdg

H
1651A9553
Cr51 chromate
CH
H
0741A9554
I125 iothalamate, dx
CH
NA9555
Rb82 rubidium

H
1654A9556
Ga67 gallium

H
1671A9557
Tc99m bicisate

H
1672A9558
Xe133 xenon 10mci

NA9559
Co57 cyano
CH
H
0724A9560
Tc99m labeled rbc
CH
H
0742A9561
Tc99m oxidronate

NA9562
Tc99m mertiatide
CH
H
0743A9563
P32 Na phosphate

H
1675A9564
P32 chromic phosphate

H
1676A9565
In111 pentetreotide

H
1677A9566
Tc99m fanolesomab

H
1678A9567
Technetium TC-99m aerosol
CH
H
0829A9568
Technetium tc99m arcitumomab
NI
H
1648A9600
Sr89 strontium

H
0701A9605
Sm 153 lexidronm

H
0702A9698
Non-rad contrast materialNOC

NA9699
Radiopharm rx agent noc

NA9900
Supply/accessory/service
CH
YB4034
Enter feed supkit syr by day
CH
YB4035
Enteral feed supp pump per d
CH
YB4036
Enteral feed sup kit grav by
CH
YB4081
Enteral ng tubing w/ stylet
CH
YB4082
Enteral ng tubing w/o stylet
CH
YB4083
Enteral stomach tube levine
CH
YB4086
Gastrostomy/jejunostomy tube
CH
YB4102
EF adult fluids and electro
CH
YB4103
EF ped fluid and electrolyte
CH
YB4149
EF blenderized foods
CH
Y( print page 68368)B4150
EF complet w/intact nutrient
CH
YB4152
EF calorie dense≧1.5Kcal
CH
YB4153
EF hydrolyzed/amino acids
CH
YB4154
EF spec metabolic noninherit
CH
YB4155
EF incomplete/modular
CH
YB4157
EF special metabolic inherit
CH
YB4158
EF ped complete intact nut
CH
YB4159
EF ped complete soy based
CH
YB4160
EF ped caloric dense≧0.7kc
CH
YB4161
EF ped hydrolyzed/amino acid
CH
YB4162
EF ped specmetabolic inherit
CH
YB4164
Parenteral 50% dextrose solu
CH
YB4168
Parenteral sol amino acid 3.
CH
YB4172
Parenteral sol amino acid 5.
CH
YB4176
Parenteral sol amino acid 7-
CH
YB4178
Parenteral sol amino acid >
CH
YB4180
Parenteral sol carb > 50%
CH
YB4189
Parenteral sol amino acid &
CH
YB4193
Parenteral sol 52-73 gm prot
CH
YB4197
Parenteral sol 74-100 gm pro
CH
YB4199
Parenteral sol > 100gm prote
CH
YB4216
Parenteral nutrition additiv
CH
YB4220
Parenteral supply kit premix
CH
YB4222
Parenteral supply kit homemi
CH
YB4224
Parenteral administration ki
CH
YB5000
Parenteral sol renal-amirosy
CH
YB5100
Parenteral sol hepatic-fream
CH
YB5200
Parenteral sol stres-brnch c
CH
YB9000
Enter infusion pump w/o alrm
CH
YB9002
Enteral infusion pump w/ ala
CH
YB9004
Parenteral infus pump portab
CH
YB9006
Parenteral infus pump statio
CH
YB9998
Enteral supp not otherwise c
CH
YB9999
Parenteral supp not othrws c
CH
YC1178
BUSULFAN IV, 6 Mg
CH
DC1300
HYPERBARIC Oxygen

S
0659
1.5906
97.77

19.55C1713
Anchor/screw bn/bn,tis/bn

NC1714
Cath, trans atherectomy, dir

NC1715
Brachytherapy needle

NC1716
Brachytx source, Gold 198
CH
K
1716
0.5991
36.83

7.37C1717
Brachytx source, HDR Ir-192
CH
K
1717
2.3195
142.58

28.52C1718
Brachytx source, Iodine 125
CH
K
1718
0.591
36.33

7.27C1719
Brachytx sour,Non-HDR Ir-192
CH
K
1719
0.3765
23.14

4.63C1720
Brachytx sour, Palladium 103
CH
K
1720
0.7942
48.82

9.76C1721
AICD, dual chamber

NC1722
AICD, single chamber

NC1724
Cath, trans atherec,rotation

NC1725
Cath, translumin non-laser

NC1726
Cath, bal dil, non-vascular

NC1727
Cath, bal tis dis, non-vas

NC1728
Cath, brachytx seed adm

NC1729
Cath, drainage

NC1730
Cath, EP, 19 or few elect

NC1731
Cath, EP, 20 or more elec

NC1732
Cath, EP, diag/abl, 3D/vect

NC1733
Cath, EP, othr than cool-tip

NC1750
Cath, hemodialysis,long-term

NC1751
Cath, inf, per/cent/midline

NC1752
Cath,hemodialysis,short-term

NC1753
Cath, intravas ultrasound

NC1754
Catheter, intradiscal

NC1755
Catheter, intraspinal

NC1756
Cath, pacing, transesoph

NC1757
Cath, thrombectomy/embolect

NC1758
Catheter, ureteral

NC1759
Cath, intra echocardiography

NC1760
Closure dev, vasc

NC1762
Conn tiss, human(inc fascia)

NC1763
Conn tiss, non-human

NC1764
Event recorder, cardiac

N( print page 68369)C1765
Adhesion barrier

NC1766
Intro/sheath,strble,non-peel

NC1767
Generator, neuro non-recharg

NC1768
Graft, vascular

NC1769
Guide wire

NC1770
Imaging coil, MR, insertable

NC1771
Rep dev, urinary, w/sling

NC1772
Infusion pump, programmable

NC1773
Ret dev, insertable

NC1776
Joint device (implantable)

NC1777
Lead, AICD, endo single coil

NC1778
Lead, neurostimulator

NC1779
Lead, pmkr, transvenous VDD

NC1780
Lens, intraocular (new tech)

NC1781
Mesh (implantable)

NC1782
Morcellator

NC1783
Ocular imp, aqueous drain de

NC1784
Ocular dev, intraop, det ret

NC1785
Pmkr, dual, rate-resp

NC1786
Pmkr, single, rate-resp

NC1787
Patient progr, neurostim

NC1788
Port, indwelling, imp

NC1789
Prosthesis, breast, imp

NC1813
Prosthesis, penile, inflatab

NC1814
Retinal tamp, silicone oil

NC1815
Pros, urinary sph, imp

NC1816
Receiver/transmitter, neuro

NC1817
Septal defect imp sys

NC1818
Integrated keratoprosthesis

NC1819
Tissue localization-excision

NC1820
Generator neuro rechg bat sy

H
1820C1821
Interspinous implant
NI
H
1821C1874
Stent, coated/cov w/del sys

NC1875
Stent, coated/cov w/o del sy

NC1876
Stent, non-coa/non-cov w/del

NC1877
Stent, non-coat/cov w/o del

NC1878
Matrl for vocal cord

NC1879
Tissue marker, implantable

NC1880
Vena cava filter

NC1881
Dialysis access system

NC1882
AICD, other than sing/dual

NC1883
Adapt/ext, pacing/neuro lead

NC1884
Embolization Protect syst

NC1885
Cath, translumin angio laser

NC1887
Catheter, guiding

NC1888
Endovas non-cardiac abl cath

NC1891
Infusion pump,non-prog, perm

NC1892
Intro/sheath,fixed,peel-away

NC1893
Intro/sheath, fixed,non-peel

NC1894
Intro/sheath, non-laser

NC1895
Lead, AICD, endo dual coil

NC1896
Lead, AICD, non sing/dual

NC1897
Lead, neurostim test kit

NC1898
Lead, pmkr, other than trans

NC1899
Lead, pmkr/AICD combination

NC1900
Lead, coronary venous

NC2614
Probe, perc lumb disc

NC2615
Sealant, pulmonary, liquid

NC2616
Brachytx source, Yttrium-90
CH
K
2616
172.2337
10,586.86

2,117.37C2617
Stent, non-cor, tem w/o del

NC2618
Probe, cryoablation

NC2619
Pmkr, dual, non rate-resp

NC2620
Pmkr, single, non rate-resp

NC2621
Pmkr, other than sing/dual

NC2622
Prosthesis, penile, non-inf

NC2625
Stent, non-cor, tem w/del sy

NC2626
Infusion pump, non-prog,temp

NC2627
Cath, suprapubic/cystoscopic

NC2628
Catheter, occlusion

NC2629
Intro/sheath, laser

N( print page 68370)C2630
Cath, EP, cool-tip

NC2631
Rep dev, urinary, w/o sling

NC2632
Brachytx sol, I-125, per mCi
CH
DC2633
Brachytx source, Cesium-131
CH
K
2633
1.4779
90.84

18.17C2634
Brachytx source, HA, I-125
CH
K
2634
0.5316
32.68

6.54C2635
Brachytx source, HA, P-103
CH
K
2635
0.8878
54.57

10.91C2636
Brachytx linear source,P-103
CH
K
2636
0.6427
39.51

7.90C2637
Brachytx, Ytterbium-169
CH
BC8900
MRA w/cont, abd

S
0284
6.1231
376.37
148.40
75.27C8901
MRA w/o cont, abd

S
0336
5.6745
348.80
139.51
69.76C8902
MRA w/o fol w/cont, abd

S
0337
8.1155
498.84
199.53
99.77C8903
MRI w/cont, breast,  uni

S
0284
6.1231
376.37
148.40
75.27C8904
MRI w/o cont, breast, uni

S
0336
5.6745
348.80
139.51
69.76C8905
MRI w/o fol w/cont, brst, un

S
0337
8.1155
498.84
199.53
99.77C8906
MRI w/cont, breast,  bi

S
0284
6.1231
376.37
148.40
75.27C8907
MRI w/o cont, breast, bi

S
0336
5.6745
348.80
139.51
69.76C8908
MRI w/o fol w/cont, breast,

S
0337
8.1155
498.84
199.53
99.77C8909
MRA w/cont, chest

S
0284
6.1231
376.37
148.40
75.27C8910
MRA w/o cont, chest

S
0336
5.6745
348.80
139.51
69.76C8911
MRA w/o fol w/cont, chest

S
0337
8.1155
498.84
199.53
99.77C8912
MRA w/cont, lwr ext

S
0284
6.1231
376.37
148.40
75.27C8913
MRA w/o cont, lwr ext

S
0336
5.6745
348.80
139.51
69.76C8914
MRA w/o fol w/cont, lwr ext

S
0337
8.1155
498.84
199.53
99.77C8918
MRA w/cont, pelvis

S
0284
6.1231
376.37
148.40
75.27C8919
MRA w/o cont, pelvis

S
0336
5.6745
348.80
139.51
69.76C8920
MRA w/o fol w/cont, pelvis

S
0337
8.1155
498.84
199.53
99.77C8950
IV inf, tx/dx, up to 1 hr
CH
DC8951
IV inf, tx/dx, each addl hr
CH
DC8952
Tx, prophy, dx IV push
CH
DC8953
Chemotx adm, IV push
CH
DC8954
Chemotx adm, IV inf up to 1h
CH
DC8955
Chemotx adm, IV inf, addl hr
CH
DC8957
Prolonged IV inf, req pump
CH
S
0441
2.4851
152.75

30.55C9003
Palivizumab, per 50 mg

K
9003

609.62

121.92C9113
Inj pantoprazole sodium, via

NC9121
Injection, argatroban

K
9121

17.48

3.50C9220
Sodium hyaluronate
CH
DC9221
Graftjacket Reg Matrix
CH
DC9222
Graftjacket SftTis
CH
DC9224
Injection, galsulfase
CH
DC9225
Fluocinolone acetonide
CH
DC9227
Injection, micafungin sodium
CH
DC9228
Injection, tigecycline
CH
DC9229
Injection ibandronate sodium
CH
DC9230
Injection, abatacept
CH
DC9231
Injection, decitabine
CH
DC9232
Injection, idursulfase
NI
G
9232

464.32

92.86C9233
Injection, ranibizumab
NI
G
9233

2,067.00

413.40C9234
Inj, alglucosidase alfa
NI
K
9234

127.20

25.44C9235
Injection, panitumumab
NI
K
9235

84.80

16.96C9350
Porous collagen tube per cm
NI
G
9350

494.53

98.91C9351
Acellular derm tissue percm2
NI
G
9351

44.01

8.80C9716
Radiofrequency energy to anu
CH
T
0150
29.6189
1,820.61
437.12
364.12C9723
Dyn IR Perf Img

S
1502

75.00

15.00C9724
EPS gast cardia plic

T
0422
25.7552
1,583.12
448.81
316.62C9725
Place endorectal app

S
1507

550.00

110.00C9726
Rxt breast appl place/remov

S
1508

650.00

130.00C9727
Insert palate implants
NI
S
1510

850.00

170.00D0150
Comprehensve oral evaluation

S
0330
7.055
433.66

86.73D0240
Intraoral occlusal film

S
0330
7.055
433.66

86.73D0250
Extraoral first film

S
0330
7.055
433.66

86.73D0260
Extraoral ea additional film

S
0330
7.055
433.66

86.73D0270
Dental bitewing single film

S
0330
7.055
433.66

86.73D0272
Dental bitewings two films

S
0330
7.055
433.66

86.73D0274
Dental bitewings four films

S
0330
7.055
433.66

86.73D0277
Vert bitewings-sev to eight

S
0330
7.055
433.66

86.73D0460
Pulp vitality test

S
0330
7.055
433.66

86.73D1510
Space maintainer fxd unilat

S
0330
7.055
433.66

86.73D1515
Fixed bilat space maintainer

S
0330
7.055
433.66

86.73D1520
Remove unilat space maintain

S
0330
7.055
433.66

86.73( print page 68371)D1525
Remove bilat space maintain

S
0330
7.055
433.66

86.73D1550
Recement space maintainer

S
0330
7.055
433.66

86.73D2999
Dental unspec restorative pr

S
0330
7.055
433.66

86.73D3460
Endodontic endosseous implan

S
0330
7.055
433.66

86.73D3999
Endodontic procedure

S
0330
7.055
433.66

86.73D4260
Osseous surgery per quadrant

S
0330
7.055
433.66

86.73D4263
Bone replce graft first site

S
0330
7.055
433.66

86.73D4264
Bone replce graft each add

S
0330
7.055
433.66

86.73D4268
Surgical revision procedure

S
0330
7.055
433.66

86.73D4270
Pedicle soft tissue graft pr

S
0330
7.055
433.66

86.73D4271
Free soft tissue graft proc

S
0330
7.055
433.66

86.73D4273
Subepithelial tissue graft

S
0330
7.055
433.66

86.73D4355
Full mouth debridement

S
0330
7.055
433.66

86.73D4381
Localized delivery antimicro

S
0330
7.055
433.66

86.73D5911
Facial moulage sectional

S
0330
7.055
433.66

86.73D5912
Facial moulage complete

S
0330
7.055
433.66

86.73D5983
Radiation applicator

S
0330
7.055
433.66

86.73D5984
Radiation shield

S
0330
7.055
433.66

86.73D5985
Radiation cone locator

S
0330
7.055
433.66

86.73D5987
Commissure splint

S
0330
7.055
433.66

86.73D6920
Dental connector bar

S
0330
7.055
433.66

86.73D7111
Extraction coronal remnants

S
0330
7.055
433.66

86.73D7140
Extraction erupted tooth/exr

S
0330
7.055
433.66

86.73D7210
Rem imp tooth w mucoper flp

S
0330
7.055
433.66

86.73D7220
Impact tooth remov soft tiss

S
0330
7.055
433.66

86.73D7230
Impact tooth remov part bony

S
0330
7.055
433.66

86.73D7240
Impact tooth remov comp bony

S
0330
7.055
433.66

86.73D7241
Impact tooth rem bony w/comp

S
0330
7.055
433.66

86.73D7250
Tooth root removal

S
0330
7.055
433.66

86.73D7260
Oral antral fistula closure

S
0330
7.055
433.66

86.73D7261
Primary closure sinus perf

S
0330
7.055
433.66

86.73D7291
Transseptal fiberotomy

S
0330
7.055
433.66

86.73D7940
Reshaping bone orthognathic

S
0330
7.055
433.66

86.73D9110
Tx dental pain minor proc

ND9230
Analgesia

ND9248
Sedation (non-iv)

ND9630
Other drugs/medicaments

S
0330
7.055
433.66

86.73D9930
Treatment of complications

S
0330
7.055
433.66

86.73D9940
Dental occlusal guard

S
0330
7.055
433.66

86.73D9950
Occlusion analysis

S
0330
7.055
433.66

86.73D9951
Limited occlusal adjustment

S
0330
7.055
433.66

86.73D9952
Complete occlusal adjustment

S
0330
7.055
433.66

86.73E0164
Commode chair mobile fixed a
CH
DE0166
Commode chair mobile detach
CH
DE0180
Press pad alternating w pump
CH
DE0305
Rails bed side half length
CH
DE0310
Rails bed side full length
CH
DE0616
Cardiac event recorder

NE0676
Inter limb compress dev NOS
NI
YE0701
Helmet w face guard prefab
CH
DE0749
Elec osteogen stim implanted

NE0782
Non-programble infusion pump

NE0783
Programmable infusion pump

NE0785
Replacement impl pump cathet

NE0786
Implantable pump replacement

NE0830
Ambulatory traction device

NE0936
CPM device, other than knee
NI
EE0977
Wheelchair wedge cushion
CH
DE0997
Wheelchair caster w/ a fork
CH
DE0998
Wheelchair caster w/o a fork
CH
DE0999
Wheelchr pneumatic tire w/wh
CH
DE1399
Durable medical equipment mi
CH
YE2320
Hand chin control
CH
DE2373
Hand/chin ctrl spec joystick
NI
YE2374
Hand/chin ctrl std joystick
NI
YE2375
Non-expandable controller
NI
YE2376
Expandable controller, repl
NI
YE2377
Expandable controller, initl
NI
YE2381
Pneum drive wheel tire
NI
YE2382
Tube, pneum wheel drive tire
NI
Y( print page 68372)E2383
Insert, pneum wheel drive
NI
YE2384
Pneumatic caster tire
NI
YE2385
Tube, pneumatic caster tire
NI
YE2386
Foam filled drive wheel tire
NI
YE2387
Foam filled caster tire
NI
YE2388
Foam drive wheel tire
NI
YE2389
Foam caster tire
NI
YE2390
Solid drive wheel tire
NI
YE2391
Solid caster tire
NI
YE2392
Solid caster tire, integrate
NI
YE2393
Valve, pneumatic tire tube
NI
YE2394
Drive wheel excludes tire
NI
YE2395
Caster wheel excludes tire
NI
YE2396
Caster fork
NI
YG0008
Admin influenza virus vac
CH
S
0350
0.3945
24.25G0009
Admin pneumococcal vaccine
CH
S
0350
0.3945
24.25G0101
CA screen;pelvic/breast exam
CH
V
0604
0.8242
50.66

10.13G0102
Prostate ca screening; dre

NG0104
CA screen;flexi sigmoidscope

S
0159
3.6592
224.92

56.23G0105
Colorectal scrn; hi risk ind

T
0158
7.8492
446.00

111.50G0106
Colon CA screen;barium enema

S
0157
2.1149
130.00

26.00G0107
CA screen; fecal blood test
CH
DG0117
Glaucoma scrn hgh risk direc

S
0230
0.7898
48.55
14.97
9.71G0118
Glaucoma scrn hgh risk direc

S
0230
0.7898
48.55
14.97
9.71G0120
Colon ca scrn; barium enema

S
0157
2.1149
130.00

26.00G0121
Colon ca scrn not hi rsk ind

T
0158
7.8492
446.00

111.50G0127
Trim nail(s)

T
0009
0.7744
47.60

9.52G0129
Partial hosp prog service

P
0033
3.8188
234.73

46.95G0130
Single energy x-ray study

X
0260
0.7093
43.60

8.72G0166
Extrnl counterpulse, per tx

T
0678
1.7418
107.06

21.41G0173
Linear acc stereo radsur com
CH
S
0067
63.3759
3,895.59

779.12G0175
OPPS Service,sched team conf
CH
V
0608
2.1794
133.96

26.79G0176
OPPS/PHP;activity therapy

P
0033
3.8188
234.73

46.95G0177
OPPS/PHP; train & educ serv

P
0033
3.8188
234.73

46.95G0186
Dstry eye lesn,fdr vssl tech

T
0235
3.9333
241.77
58.93
48.35G0237
Therapeutic procd strg endur

S
0411
0.3848
23.65

4.73G0238
Oth resp proc, indiv

S
0411
0.3848
23.65

4.73G0239
Oth resp proc, group

S
0411
0.3848
23.65

4.73G0243
Multisour photon stero treat
CH
DG0245
Initial foot exam pt lops
CH
V
0604
0.8242
50.66

10.13G0246
Followup eval of foot pt lop
CH
V
0605
0.984
60.48

12.10G0247
Routine footcare pt w lops

T
0009
0.7744
47.60

9.52G0248
Demonstrate use home inr mon
CH
X
0421
1.627
100.01

20.00G0249
Provide test material,equipm
CH
X
0421
1.627
100.01

20.00G0251
Linear acc based stero radio
CH
S
0065
20.3224
1,249.18

249.84G0257
Unsched dialysis ESRD pt hos

S
0170
6.6089
406.24

81.25G0259
Inject for sacroiliac joint

NG0260
Inj for sacroiliac jt anesth

T
0206
5.7253
351.92
75.55
70.38G0267
Bone marrow or psc harvest

S
0110
3.4584
212.58

42.52G0268
Removal of impacted wax md

X
0340
0.6102
37.51

7.50G0269
Occlusive device in vein art

NG0275
Renal angio, cardiac cath

NG0278
Iliac art angio,cardiac cath

NG0288
Recon, CTA for surg plan

S
0417
3.2393
199.11

39.82G0289
Arthro, loose body + chondro

NG0290
Drug-eluting stents, single

T
0656
108.3003
6,657.00

1,331.40G0291
Drug-eluting stents,each add

T
0656
108.3003
6,657.00

1,331.40G0293
Non-cov surg proc,clin trial
CH
X
0340
0.6102
37.51

7.50G0294
Non-cov proc, clinical trial
CH
X
0340
0.6102
37.51

7.50G0297
Insert single chamber/cd

T
0107
304.4894
18,716.35

3,743.27G0298
Insert dual chamber/cd

T
0107
304.4894
18,716.35

3,743.27G0299
Inser/repos single icd+leads

T
0108
379.7339
23,341.48

4,668.30G0300
Insert reposit lead dual+gen

T
0108
379.7339
23,341.48

4,668.30G0302
Pre-op service LVRS complete

S
1509

750.00

150.00G0303
Pre-op service LVRS 10-15dos

S
1507

550.00

110.00G0304
Pre-op service LVRS 1-9 dos

S
1504

250.00

50.00G0305
Post op service LVRS min 6

S
1504

250.00

50.00G0332
Preadmin IV immunoglobulin

S
1502

75.00

15.00G0339
Robot lin-radsurg com, first
CH
S
0067
63.3759
3,895.59

779.12G0340
Robt lin-radsurg fractx 2-5
CH
S
0066
43.0297
2,644.95

528.99( print page 68373)G0344
Initial preventive exam
CH
V
0605
0.984
60.48

12.10G0364
Bone marrow aspirate &biopsy
CH
T
0002
1.0995
67.58

13.52G0365
Vessel mapping hemo access

S
0267
2.4606
151.25
60.50
30.25G0367
EKG tracing for initial prev

S
0099
0.3789
23.29

4.66G0375
Smoke/tobacco counselng 3-10
CH
X
0031
0.1766
10.86

2.17G0376
Smoke/tobacco counseling >10
CH
X
0031
0.1766
10.86

2.17G0378
Hospital observation per hr

Q
0339
7.2039
442.81

88.56G0379
Direct admit hospital observ
CH
Q
0604
0.8242
50.66

10.13G0380
Lev 1 hosp type B ED visit
NF
V
0604
0.8242
50.66

10.13G0381
Lev 2 hosp type B ED visit
NF
V
0605
0.984
60.48

12.10G0382
Lev 3 hosp type B ED visit
NF
V
0606
1.3646
83.88

16.78G0383
Lev 4 hosp type B ED visit
NF
V
0607
1.7096
105.09

21.02G0384
Lev 5 hosp type B ED visit
NF
V
0608
2.1794
133.96

26.79G0389
Ultrasound exam AAA screen
NI
S
0266
1.5607
95.93
37.80
19.19G0390
Trauma respon w/hosp cirtica
NI
S
0618
8.0455
494.54
197.81
98.91G0392
AV fistula or graft arterial
NI
T
0081
42.936
2,639.19

527.84G0393
AV fistula or graft venous
NI
T
0081
42.936
2,639.19

527.84G0394
Blood occult test, colorecta
NI
AG3001
Admin + supply, tositumomab
CH
S
0442
22.3666
1,374.83

274.97G8085
ESRD pt inelig autogenous Fi
NI
MJ0120
Tetracyclin injection

NJ0128
Abarelix injection
CH
K
9216

71.18

14.24J0129
Abatacept injection
NI
G
9230

18.70

3.74J0130
Abciximab injection

K
1605

416.27

83.25J0132
Acetylcysteine injection

K
1680

1.94

0.39J0133
Acyclovir injection

NJ0135
Adalimumab injection

K
1083

308.33

61.67J0150
Injection adenosine 6 MG

K
0379

30.49

6.10J0152
Adenosine injection

K
0917

30.49

6.10J0170
Adrenalin epinephrin inject

NJ0180
Agalsidase beta injection

K
9208

127.20

25.44J0190
Inj biperiden lactate/5 mg
CH
K
3038

88.15

17.63J0200
Alatrofloxacin mesylate

NJ0205
Alglucerase injection

K
0900

39.22

7.84J0207
Amifostine

K
7000

463.27

92.65J0210
Methyldopate hcl injection

K
2210

10.01

2.00J0215
Alefacept

K
1633

26.31

5.26J0256
Alpha 1 proteinase inhibitor

K
0901

3.31

0.66J0278
Amikacin sulfate injection
CH
NJ0280
Aminophyllin 250 MG inj

NJ0282
Amiodarone HCl

NJ0285
Amphotericin B
CH
NJ0287
Amphotericin b lipid complex

K
9024

11.11

2.22J0288
Ampho b cholesteryl sulfate

K
0735

12.00

2.40J0289
Amphotericin b liposome inj

K
0736

21.25

4.25J0290
Ampicillin 500 MG inj

NJ0295
Ampicillin sodium per 1.5 gm

NJ0300
Amobarbital 125 MG inj

NJ0330
Succinycholine chloride inj

NJ0348
Anadulafungin injection
NI
G
0760

1.91

0.38J0350
Injection anistreplase 30 u

K
1606

2,268.46

453.69J0360
Hydralazine hcl injection

NJ0364
Apomorphine hydrochloride
NI
K
0766

2.92

0.58J0365
Aprotonin, 10,000 kiu

K
1682

2.52

0.50J0380
Inj metaraminol bitartrate
CH
K
3039

2.62

0.52J0390
Chloroquine injection

NJ0395
Arbutamine HCl injection

K
9031

160.00

32.00J0456
Azithromycin

NJ0460
Atropine sulfate injection

NJ0470
Dimecaprol injection
CH
NJ0475
Baclofen 10 MG injection

K
9032

198.54

39.71J0476
Baclofen intrathecal trial

K
1631

69.63

13.93J0480
Basiliximab

K
1683

1,385.86

277.17J0500
Dicyclomine injection

NJ0515
Inj benztropine mesylate

NJ0520
Bethanechol chloride inject

NJ0530
Penicillin g benzathine inj

NJ0540
Penicillin g benzathine inj

NJ0550
Penicillin g benzathine inj

NJ0560
Penicillin g benzathine inj

N( print page 68374)J0570
Penicillin g benzathine inj

NJ0580
Penicillin g benzathine inj

NJ0583
Bivalirudin
CH
K
3041

1.75

0.35J0585
Botulinum toxin a per unit

K
0902

5.04

1.01J0587
Botulinum toxin type B

K
9018

8.16

1.63J0592
Buprenorphine hydrochloride

NJ0594
Busulfan injection
NI
K
1178

8.89

1.78J0595
Butorphanol tartrate 1 mg

NJ0600
Edetate calcium disodium inj

K
0892

40.19

8.04J0610
Calcium gluconate injection

NJ0620
Calcium glycer & lact/10 ML

NJ0630
Calcitonin salmon injection
CH
NJ0636
Inj calcitriol per 0.1 mcg

NJ0637
Caspofungin acetate

K
9019

32.25

6.45J0640
Leucovorin calcium injection

NJ0670
Inj mepivacaine HCL/10 ml

NJ0690
Cefazolin sodium injection

NJ0692
Cefepime HCl for injection

NJ0694
Cefoxitin sodium injection

NJ0696
Ceftriaxone sodium injection

NJ0697
Sterile cefuroxime injection

NJ0698
Cefotaxime sodium injection

NJ0702
Betamethasone acet&sod phosp

NJ0704
Betamethasone sod phosp/4 MG

NJ0706
Caffeine citrate injection

K
0876

3.54

0.71J0710
Cephapirin sodium injection

NJ0713
Inj ceftazidime per 500 mg

NJ0715
Ceftizoxime sodium / 500 MG

NJ0720
Chloramphenicol sodium injec

NJ0725
Chorionic gonadotropin/1000u

NJ0735
Clonidine hydrochloride

K
0935

66.04

13.21J0740
Cidofovir injection

K
9033

763.15

152.63J0743
Cilastatin sodium injection

NJ0744
Ciprofloxacin iv

NJ0745
Inj codeine phosphate /30 MG

NJ0760
Colchicine injection

NJ0770
Colistimethate sodium inj

NJ0780
Prochlorperazine injection

NJ0795
Corticorelin ovine triflutal

K
1684

4.17

0.83J0800
Corticotropin injection

K
1280

116.60

23.32J0835
Inj cosyntropin per 0.25 MG

K
0835

62.91

12.58J0850
Cytomegalovirus imm IV /vial

K
0903

853.18

170.64J0878
Daptomycin injection
CH
K
9124

0.33

0.07J0881
Darbepoetin alfa, non-esrd

K
1685

2.99

0.60J0882
Darbepoetin alfa, esrd use
CH
AJ0885
Epoetin alfa, non-esrd

K
1686

9.36

1.87J0886
Epoetin alfa 1000 units ESRD
CH
AJ0894
Decitabine injection
NI
G
9231

26.50

5.30J0895
Deferoxamine mesylate inj

K
0895

14.84

2.97J0900
Testosterone enanthate inj

NJ0945
Brompheniramine maleate inj

NJ0970
Estradiol valerate injection

NJ1000
Depo-estradiol cypionate inj

NJ1020
Methylprednisolone 20 MG inj

NJ1030
Methylprednisolone 40 MG inj

NJ1040
Methylprednisolone 80 MG inj

NJ1051
Medroxyprogesterone inj

NJ1060
Testosterone cypionate 1 ML

NJ1070
Testosterone cypionat 100 MG

NJ1080
Testosterone cypionat 200 MG

NJ1094
Inj dexamethasone acetate

NJ1100
Dexamethasone sodium phos

NJ1110
Inj dihydroergotamine mesylt
CH
NJ1120
Acetazolamid sodium injectio

NJ1160
Digoxin injection

NJ1162
Digoxin immune fab (ovine)

K
1687

533.72

106.74J1165
Phenytoin sodium injection

NJ1170
Hydromorphone injection

NJ1180
Dyphylline injection
CH
NJ1190
Dexrazoxane HCl injection

K
0726

180.13

36.03( print page 68375)J1200
Diphenhydramine hcl injectio

NJ1205
Chlorothiazide sodium inj
CH
K
0747

123.84

24.77J1212
Dimethyl sulfoxide 50% 50 ML

NJ1230
Methadone injection

NJ1240
Dimenhydrinate injection

NJ1245
Dipyridamole injection

NJ1250
Inj dobutamine HCL/250 mg

NJ1260
Dolasetron mesylate

K
0750

6.89

1.38J1265
Dopamine injection

NJ1270
Injection, doxercalciferol

NJ1320
Amitriptyline injection

NJ1324
Enfuvirtide injection
NI
K
0767

21.82

4.36J1325
Epoprostenol injection

NJ1327
Eptifibatide injection

K
1607

15.37

3.07J1330
Ergonovine maleate injection

K
1330

33.11

6.62J1335
Ertapenem injection

NJ1364
Erythro lactobionate /500 MG

NJ1380
Estradiol valerate 10 MG inj

NJ1390
Estradiol valerate 20 MG inj

NJ1410
Inj estrogen conjugate 25 MG

K
9038

58.05

11.61J1430
Ethanolamine oleate 100 mg

K
1688

69.60

13.92J1435
Injection estrone per 1 MG

NJ1436
Etidronate disodium inj

K
1436

71.41

14.28J1438
Etanercept injection

K
1608

160.39

32.08J1440
Filgrastim 300 mcg injection

K
0728

188.07

37.61J1441
Filgrastim 480 mcg injection

K
7049

298.70

59.74J1450
Fluconazole

NJ1451
Fomepizole, 15 mg

K
1689

12.33

2.47J1452
Intraocular Fomivirsen na

K
9040

212.00

42.40J1455
Foscarnet sodium injection
CH
K
3042

10.49

2.10J1457
Gallium nitrate injection
CH
NJ1458
Galsulfase injection
NI
K
9224

1,516.12

303.22J1460
Gamma globulin 1 CC inj
CH
K
3043

10.34

2.07J1562
Immune globulin subcutaneous
NI
K
0804

7.08

1.42J1565
RSV-ivig

K
0906

16.18

3.24J1566
Immune globulin, powder

K
2731

25.27

5.05J1567
Immune globulin, liquid

K
2732

30.33

6.07J1570
Ganciclovir sodium injection

NJ1580
Garamycin gentamicin inj

NJ1590
Gatifloxacin injection

NJ1595
Injection glatiramer acetate

NJ1600
Gold sodium thiomaleate inj

NJ1610
Glucagon hydrochloride/1 MG

K
9042

70.23

14.05J1620
Gonadorelin hydroch/ 100 mcg

K
7005

189.84

37.97J1626
Granisetron HCl injection

K
0764

7.21

1.44J1630
Haloperidol injection

NJ1631
Haloperidol decanoate inj

NJ1640
Hemin, 1 mg

K
1690

6.80

1.36J1642
Inj heparin sodium per 10 u

NJ1644
Inj heparin sodium per 1000u

NJ1645
Dalteparin sodium

NJ1650
Inj enoxaparin sodium

NJ1652
Fondaparinux sodium

NJ1655
Tinzaparin sodium injection

K
1655

2.48

0.50J1670
Tetanus immune globulin inj

K
1670

87.77

17.55J1700
Hydrocortisone acetate inj

NJ1710
Hydrocortisone sodium ph inj

NJ1720
Hydrocortisone sodium succ i

NJ1730
Diazoxide injection

K
1740

111.89

22.38J1740
Ibandronate sodium injection
NI
G
9229

139.12

27.82J1742
Ibutilide fumarate injection

K
9044

265.75

53.15J1745
Infliximab injection

K
7043

53.74

10.75J1751
Iron dextran 165 injection

K
1691

11.78

2.36J1752
Iron dextran 267 injection

K
1692

10.38

2.08J1756
Iron sucrose injection

K
9046

0.36

0.07J1785
Injection imiglucerase /unit

K
0916

3.91

0.78J1790
Droperidol injection

NJ1800
Propranolol injection

NJ1815
Insulin injection

NJ1817
Insulin for insulin pump use

N( print page 68376)J1830
Interferon beta-1b / .25 MG

K
0910

90.00

18.00J1835
Itraconazole injection

K
9047

36.45

7.29J1840
Kanamycin sulfate 500 MG inj

NJ1850
Kanamycin sulfate 75 MG inj

NJ1885
Ketorolac tromethamine inj

NJ1890
Cephalothin sodium injection

NJ1931
Laronidase injection

K
9209

23.87

4.77J1940
Furosemide injection

NJ1945
Lepirudin

K
1693

153.54

30.71J1950
Leuprolide acetate /3.75 MG

K
0800

437.58

87.52J1956
Levofloxacin injection

NJ1960
Levorphanol tartrate inj

NJ1980
Hyoscyamine sulfate inj

NJ1990
Chlordiazepoxide injection

NJ2001
Lidocaine injection

NJ2010
Lincomycin injection

NJ2020
Linezolid injection

K
9001

24.16

4.83J2060
Lorazepam injection

NJ2150
Mannitol injection

NJ2170
Mecasermin injection
NI
K
0805

11.93

2.39J2175
Meperidine hydrochl /100 MG

NJ2180
Meperidine/promethazine inj

NJ2185
Meropenem
CH
K
3045

3.68

0.74J2210
Methylergonovin maleate inj

NJ2248
Micafungin sodium injection
NI
G
9227

1.87

0.37J2250
Inj midazolam hydrochloride

NJ2260
Inj milrinone lactate / 5 MG

NJ2270
Morphine sulfate injection

NJ2271
Morphine so4 injection 100mg

NJ2275
Morphine sulfate injection

NJ2278
Ziconotide injection

G
1694

6.34

1.27J2280
Inj, moxifloxacin 100 mg

NJ2300
Inj nalbuphine hydrochloride

NJ2310
Inj naloxone hydrochloride

NJ2315
Naltrexone, depot form
NI
K
0759

1.94

0.39J2320
Nandrolone decanoate 50 MG

NJ2321
Nandrolone decanoate 100 MG

NJ2322
Nandrolone decanoate 200 MG

NJ2325
Nesiritide injection

K
1695

30.13

6.03J2353
Octreotide injection, depot

K
1207

93.35

18.67J2354
Octreotide inj, non-depot

NJ2355
Oprelvekin injection

K
7011

245.98

49.20J2357
Omalizumab injection
CH
K
9300

16.61

3.32J2360
Orphenadrine injection

NJ2370
Phenylephrine hcl injection

NJ2400
Chloroprocaine hcl injection

NJ2405
Ondansetron hcl injection

K
0768

3.72

0.74J2410
Oxymorphone hcl injection

NJ2425
Palifermin injection

K
1696

11.43

2.29J2430
Pamidronate disodium /30 MG

K
0730

34.80

6.96J2440
Papaverin hcl injection

NJ2460
Oxytetracycline injection

NJ2469
Palonosetron HCl

K
9210

18.08

3.62J2501
Paricalcitol

NJ2503
Pegaptanib sodium injection

G
1697

1,107.54

221.51J2504
Pegademase bovine, 25 iu

K
1739

177.83

35.57J2505
Injection, pegfilgrastim 6mg

K
9119

2,163.61

432.72J2510
Penicillin g procaine inj

NJ2513
Pentastarch 10% solution
CH
NJ2515
Pentobarbital sodium inj

NJ2540
Penicillin g potassium inj

NJ2543
Piperacillin/tazobactam

NJ2550
Promethazine hcl injection

NJ2560
Phenobarbital sodium inj

NJ2590
Oxytocin injection

NJ2597
Inj desmopressin acetate

NJ2650
Prednisolone acetate inj

NJ2670
Totazoline hcl injection

NJ2675
Inj progesterone per 50 MG

NJ2680
Fluphenazine decanoate 25 MG

N( print page 68377)J2690
Procainamide hcl injection

NJ2700
Oxacillin sodium injeciton
CH
NJ2710
Neostigmine methylslfte inj

NJ2720
Inj protamine sulfate/10 MG

NJ2725
Inj protirelin per 250 mcg

NJ2730
Pralidoxime chloride inj
CH
NJ2760
Phentolaine mesylate inj

NJ2765
Metoclopramide hcl injection

NJ2770
Quinupristin/dalfopristin

K
2770

114.49

22.90J2780
Ranitidine hydrochloride inj

NJ2783
Rasburicase
CH
K
0738

121.26

24.25J2788
Rho d immune globulin 50 mcg

K
9023

27.70

5.54J2790
Rho d immune globulin inj

K
0884

80.52

16.10J2792
Rho(D) immune globulin h, sd

K
1609

14.30

2.86J2794
Risperidone, long acting
CH
K
9125

4.80

0.96J2795
Ropivacaine HCl injection

NJ2800
Methocarbamol injection

NJ2805
Sincalide injection
CH
NJ2810
Inj theophylline per 40 MG

NJ2820
Sargramostim injection

K
0731

25.55

5.11J2850
Inj secretin synthetic human

K
1700

20.31

4.06J2910
Aurothioglucose injeciton
CH
NJ2912
Sodium chloride injection
CH
DJ2916
Na ferric gluconate complex

NJ2920
Methylprednisolone injection

NJ2930
Methylprednisolone injection

NJ2940
Somatrem injection

K
2940

35.60

7.12J2941
Somatropin injection

K
7034

46.80

9.36J2950
Promazine hcl injection

NJ2993
Reteplase injection

K
9005

902.72

180.54J2995
Inj streptokinase /250000 IU

K
0911

79.50

15.90J2997
Alteplase recombinant

K
7048

32.07

6.41J3000
Streptomycin injection

NJ3010
Fentanyl citrate injeciton

NJ3030
Sumatriptan succinate / 6 MG

K
3030

57.40

11.48J3070
Pentazocine injection

NJ3100
Tenecteplase injection

K
9002

2,036.66

407.33J3105
Terbutaline sulfate inj

NJ3120
Testosterone enanthate inj

NJ3130
Testosterone enanthate inj

NJ3140
Testosterone suspension inj

NJ3150
Testosteron propionate inj

NJ3230
Chlorpromazine hcl injection

NJ3240
Thyrotropin injection

K
9108

765.76

153.15J3243
Tigecycline injection
NI
G
9228

0.91

0.18J3246
Tirofiban HCl

K
7041

8.74

1.75J3250
Trimethobenzamide hcl inj

NJ3260
Tobramycin sulfate injection

NJ3265
Injection torsemide 10 mg/ml

NJ3280
Thiethylperazine maleate inj

NJ3285
Treprostinil injection

K
1701

54.02

10.80J3301
Triamcinolone acetonide inj

NJ3302
Triamcinolone diacetate inj

NJ3303
Triamcinolone hexacetonl inj

NJ3305
Inj trimetrexate glucoronate

K
7045

145.17

29.03J3310
Perphenazine injeciton

NJ3315
Triptorelin pamoate

K
9122

218.53

43.71J3320
Spectinomycn di-hcl inj
CH
K
0753

30.08

6.02J3350
Urea injection

K
9051

37.81

7.56J3355
Urofollitropin, 75 iu

K
1741

49.35

9.87J3360
Diazepam injection

NJ3364
Urokinase 5000 IU injection

NJ3365
Urokinase 250,000 IU inj

K
7036

457.73

91.55J3370
Vancomycin hcl injection

NJ3396
Verteporfin injection

K
1203

8.91

1.78J3400
Triflupromazine hcl inj

NJ3410
Hydroxyzine hcl injection

NJ3411
Thiamine hcl 100 mg

NJ3415
Pyridoxine hcl 100 mg

NJ3420
Vitamin b12 injection

N( print page 68378)J3430
Vitamin k phytonadione inj

NJ3465
Injection, voriconazole

K
1052

4.66

0.93J3470
Hyaluronidase injection
CH
NJ3471
Ovine, up to 999 USP units
CH
NJ3472
Ovine, 1000 USP units

K
1703

137.43

27.49J3473
Hyaluronidase recombinant
NI
G
0806

0.40

0.08J3475
Inj magnesium sulfate

NJ3480
Inj potassium chloride

NJ3485
Zidovudine

NJ3486
Ziprasidone mesylate

NJ3487
Zoledronic acid

K
9115

204.03

40.81J3490
Drugs unclassified injection

NJ3530
Nasal vaccine inhalation

NJ3590
Unclassified biologics

NJ7030
Normal saline solution infus

NJ7040
Normal saline solution infus

NJ7042
5% dextrose/normal saline

NJ7050
Normal saline solution infus

NJ7060
5% dextrose/water

NJ7070
D5w infusion

NJ7100
Dextran 40 infusion

NJ7110
Dextran 75 infusion

NJ7120
Ringers lactate infusion

NJ7130
Hypertonic saline solution

NJ7187
Inj Vonwillebrand factor IU
NI
K
1704

0.88

0.18J7188
Inj Vonwillebrand factor iu
CH
DJ7189
Factor viia

K
1705

1.10

0.22J7190
Factor viii

K
0925

0.69

0.14J7191
Factor VIII (porcine)

K
0926

1.33

0.27J7192
Factor viii recombinant

K
0927

1.06

0.21J7193
Factor IX non-recombinant

K
0931

0.90

0.18J7194
Factor ix complex

K
0928

0.72

0.14J7195
Factor IX recombinant

K
0932

0.99

0.20J7197
Antithrombin iii injection

K
0930

1.62

0.32J7198
Anti-inhibitor

K
0929

1.36

0.27J7308
Aminolevulinic acid hcl top

K
7308

107.72

21.54J7310
Ganciclovir long act implant

K
0913

4,766.14

953.23J7311
Fluocinolone acetonide implt
NI
G
9225

18,250.00

3,650.00J7317
Sodium hyaluronate injection
CH
DJ7319
Sodium Hyaluronate Injection
NI
K
0896

124.68

24.94J7320
Hylan G-F 20 injection
CH
DJ7340
Metabolic active D/E tissue

K
1632

27.89

5.58J7341
Non-human, metabolic tissue

K
1707

1.78

0.36J7342
Metabolically active tissue

K
9054

13.87

2.77J7343
Nonmetabolic act d/e tissue

K
1629

18.49

3.70J7344
Nonmetabolic active tissue

K
9156

45.02

9.00J7345
Non-human, non-metab tissue
NI
BJ7346
Injectable human tissue
NI
K
9222

743.96

148.79J7350
Injectable human tissue
CH
DJ7500
Azathioprine oral 50mg

NJ7501
Azathioprine parenteral

K
0887

49.17

9.83J7502
Cyclosporine oral 100 mg

K
0888

3.66

0.73J7504
Lymphocyte immune globulin

K
0890

315.76

63.15J7505
Monoclonal antibodies

K
7038

856.05

171.21J7506
Prednisone oral

NJ7507
Tacrolimus oral per 1 MG

K
0891

3.55

0.71J7509
Methylprednisolone oral

NJ7510
Prednisolone oral per 5 mg

NJ7511
Antithymocyte globuln rabbit

K
9104

329.62

65.92J7513
Daclizumab, parenteral

K
1612

328.83

65.77J7515
Cyclosporine oral 25 mg
CH
NJ7516
Cyclosporin parenteral 250mg

NJ7517
Mycophenolate mofetil oral

K
9015

2.50

0.50J7518
Mycophenolic acid
CH
K
9219

2.15

0.43J7520
Sirolimus, oral

K
9020

7.25

1.45J7525
Tacrolimus injection

K
9006

140.72

28.14J7599
Immunosuppressive drug noc

NJ7607
Levalbuterol comp con
NI
BJ7609
Albuterol comp unit
NI
BJ7610
Albuterol comp con
NI
B( print page 68379)J7615
Levalbuterol comp unit
NI
BJ7634
Budesonide comp con
NI
BJ7645
Ipratropium bromide comp
NI
BJ7647
Isoetharine comp con
NI
BJ7650
Isoetharine comp unit
NI
BJ7657
Isoproterenol comp con
NI
BJ7660
Isoproterenol comp unit
NI
BJ7667
Metaproterenol comp con
NI
BJ7670
Metaproterenol comp unit
NI
BJ7674
Methacholine chloride, neb

NJ7685
Tobramycin comp unit
NI
BJ7799
Non-inhalation drug for DME

NJ8501
Oral aprepitant

G
0868

4.85

0.97J8510
Oral busulfan

K
7015

2.14

0.43J8520
Capecitabine, oral, 150 mg

K
7042

3.83

0.77J8530
Cyclophosphamide oral 25 MG

NJ8540
Oral dexamethasone
CH
NJ8560
Etoposide oral 50 MG

K
0802

32.01

6.40J8597
Antiemetic drug oral NOS

NJ8600
Melphalan oral 2 MG

NJ8610
Methotrexate oral 2.5 MG

NJ8650
Nabilone oral
NI
K
0808

16.96

3.39J8700
Temozolomide

K
1086

7.30

1.46J9000
Doxorubic hcl 10 MG vl chemo
CH
K
3048

6.00

1.20J9001
Doxorubicin hcl liposome inj

K
7046

379.21

75.84J9010
Alemtuzumab injection

K
9110

531.24

106.25J9015
Aldesleukin/single use vial

K
0807

726.69

145.34J9017
Arsenic trioxide

K
9012

33.36

6.67J9020
Asparaginase injection

K
0814

54.46

10.89J9025
Azacitidine injection

K
1709

4.22

0.84J9027
Clofarabine injection

G
1710

116.62

23.32J9031
Bcg live intravesical vac

K
0809

113.44

22.69J9035
Bevacizumab injection
CH
K
9214

56.88

11.38J9040
Bleomycin sulfate injection
CH
K
0748

37.62

7.52J9041
Bortezomib injection

K
9207

31.87

6.37J9045
Carboplatin injection

K
0811

10.12

2.02J9050
Carmus bischl nitro inj

K
0812

139.84

27.97J9055
Cetuximab injection
CH
K
9215

49.86

9.97J9060
Cisplatin 10 MG injection

NJ9065
Inj cladribine per 1 MG

K
0858

37.87

7.57J9070
Cyclophosphamide 100 MG inj

NJ9093
Cyclophosphamide lyophilized
CH
K
3049

5.72

1.14J9098
Cytarabine liposome

K
1166

396.66

79.33J9100
Cytarabine hcl 100 MG inj

NJ9120
Dactinomycin actinomycin d
CH
K
0752

493.43

98.69J9130
Dacarbazine 100 mg inj
CH
K
0746

4.90

0.98J9150
Daunorubicin

K
0820

24.56

4.91J9151
Daunorubicin citrate liposom

K
0821

56.21

11.24J9160
Denileukin diftitox, 300 mcg

K
1084

1,403.23

280.65J9165
Diethylstilbestrol injection

NJ9170
Docetaxel

K
0823

302.68

60.54J9175
Elliotts b solution per ml

NJ9178
Inj, epirubicin hcl, 2 mg

K
1167

24.67

4.93J9181
Etoposide 10 MG inj

NJ9185
Fludarabine phosphate inj

K
0842

243.82

48.76J9190
Fluorouracil injection

NJ9200
Floxuridine injection

K
0827

64.17

12.83J9201
Gemcitabine HCl

K
0828

121.30

24.26J9202
Goserelin acetate implant

K
0810

199.12

39.82J9206
Irinotecan injection

K
0830

126.88

25.38J9208
Ifosfomide injection

K
0831

52.39

10.48J9209
Mesna injection

K
0732

10.10

2.02J9211
Idarubicin hcl injection

K
0832

308.97

61.79J9212
Interferon alfacon-1

K
0912

4.65

0.93J9213
Interferon alfa-2a inj

K
0834

37.56

7.51J9214
Interferon alfa-2b inj

K
0836

13.75

2.75J9215
Interferon alfa-n3 inj

K
0865

39.48

7.90J9216
Interferon gamma 1-b inj

K
0838

289.87

57.97J9217
Leuprolide acetate suspnsion

K
9217

227.63

45.53J9218
Leuprolide acetate injeciton

K
0861

11.10

2.22( print page 68380)J9219
Leuprolide acetate implant

K
7051

2,208.90

441.78J9225
Histrelin implant

K
1711

1,741.71

348.34J9230
Mechlorethamine hcl inj
CH
K
0751

141.61

28.32J9245
Inj melphalan hydrochl 50 MG

K
0840

1,194.15

238.83J9250
Methotrexate sodium inj

NJ9261
Nelarabine injection
NI
K
0825

83.10

16.62J9263
Oxaliplatin

K
1738

8.77

1.75J9264
Paclitaxel protein bound

G
1712

8.73

1.75J9265
Paclitaxel injection

K
0863

14.35

2.87J9266
Pegaspargase/singl dose vial

K
0843

1,687.04

337.41J9268
Pentostatin injection

K
0844

2,034.63

406.93J9270
Plicamycin (mithramycin) inj

K
0860

61.36

12.27J9280
Mitomycin 5 MG inj

K
0862

18.31

3.66J9293
Mitoxantrone hydrochl / 5 MG

K
0864

223.27

44.65J9300
Gemtuzumab ozogamicin

K
9004

2,317.16

463.43J9305
Pemetrexed injection
CH
K
9213

42.49

8.50J9310
Rituximab cancer treatment

K
0849

481.69

96.34J9320
Streptozocin injection

K
0850

152.92

30.58J9340
Thiotepa injection

K
0851

44.58

8.92J9350
Topotecan

K
0852

813.08

162.62J9355
Trastuzumab

K
1613

56.17

11.23J9357
Valrubicin, 200 mg

K
9167

369.60

73.92J9360
Vinblastine sulfate inj

NJ9370
Vincristine sulfate 1 MG inj

NJ9390
Vinorelbine tartrate/10 mg

K
0855

22.82

4.56J9395
Injection, Fulvestrant

K
9120

80.66

16.13J9600
Porfimer sodium

K
0856

2,505.40

501.08J9999
Chemotherapy drug

NK0090
Rear tire power wheelchair
CH
DK0091
Rear tire tube power whlchr
CH
DK0092
Rear assem cmplt powr whlchr
CH
DK0093
Rear zero pressure tire tube
CH
DK0094
Wheel tire for power base
CH
DK0095
Wheel tire tube each base
CH
DK0096
Wheel assem powr base complt
CH
DK0097
Wheel zero presure tire tube
CH
DK0098
Drive belt power wheelchair
CH
DK0733
12-24hr sealed lead acid
NI
YK0734
Adj skin pro w/c cus wd<22in
NI
YK0735
Adj skin pro wc cus wd≧22in
NI
YK0736
Adj skin pro/pos wc cus<22in
NI
YK0737
Adj skin pro/pos wc cus≧22′′
NI
YK0738
Portable gas oxygen system
NI
YK0800
POV group 1 std up to 300 lb
NI
YK0801
POV group 1 hd 301-450 lbs
NI
YK0802
POV group 1 vhd 451-600 lbs
NI
YK0806
POV group 2 std up to 300lbs
NI
YK0807
POV group 2 hd 301-450 lbs
NI
YK0808
POV group 2 vhd 451-600 lbs
NI
YK0812
Power operated vehicle NOC
NI
YK0813
PWC gp 1 std port seat/back
NI
YK0814
PWC gp 1 std port cap chair
NI
YK0815
PWC gp 1 std seat/back
NI
YK0816
PWC gp 1 std cap chair
NI
YK0820
PWC gp 2 std port seat/back
NI
YK0821
PWC gp 2 std port cap chair
NI
YK0822
PWC gp 2 std seat/back
NI
YK0823
PWC gp 2 std cap chair
NI
YK0824
PWC gp 2 hd seat/back
NI
YK0825
PWC gp 2 hd cap chair
NI
YK0826
PWC gp2 vhd seat/back
NI
YK0827
PWC gp 2 vhd cap chair
NI
YK0828
PWC gp 2 xtra hd seat/back
NI
YK0829
PWC gp 2 xtra hd cap chair
NI
YK0830
PWC gp2 std seat elevate s/b
NI
YK0831
PWC gp2 std seat elevate cap
NI
YK0835
PWC gp2 std sing pow opt s/b
NI
YK0836
PWC gp2 std sing pow opt cap
NI
YK0837
PWC gp 2 hd sing pow opt s/b
NI
YK0838
PWC gp 2 hd sing pow opt cap
NI
Y( print page 68381)K0839
PWC gp2 vhd sing pow opt s/b
NI
YK0840
PWC gp2 xhd sing pow opt s/b
NI
YK0841
PWC gp2 std mult pow opt s/b
NI
YK0842
PWC gp2 std mult pow opt cap
NI
YK0843
PWC gp2 hd mult pow opt s/b
NI
YK0848
PWC gp 3 std seat/back
NI
YK0849
PWC gp 3 std cap chair
NI
YK0850
PWC gp 3 hd seat/back
NI
YK0851
PWC gp 3 hd cap chair
NI
YK0852
PWC gp 3 vhd seat/back
NI
YK0853
PWC gp 3 vhd cap chair
NI
YK0854
PWC gp 3 xhd seat/back
NI
YK0855
PWC gp 3 xhd cap chair
NI
YK0856
PWC gp3 std sing pow opt s/b
NI
YK0857
PWC gp3 std sing pow opt cap
NI
YK0858
PWC gp3 hd sing pow opt s/b
NI
YK0859
PWC gp3 hd sing pow opt cap
NI
YK0860
PWC gp3 vhd sing pow opt s/b
NI
YK0861
PWC gp3 std mult pow opt s/b
NI
YK0862
PWC gp3 hd mult pow opt s/b
NI
YK0863
PWC gp3 vhd mult pow opt s/b
NI
YK0864
PWC gp3 xhd mult pow opt s/b
NI
YK0868
PWC gp 4 std seat/back
NI
YK0869
PWC gp 4 std cap chair
NI
YK0870
PWC gp 4 hd seat/back
NI
YK0871
PWC gp 4 vhd seat/back
NI
YK0877
PWC gp4 std sing pow opt s/b
NI
YK0878
PWC gp4 std sing pow opt cap
NI
YK0879
PWC gp4 hd sing pow opt s/b
NI
YK0880
PWC gp4 vhd sing pow opt s/b
NI
YK0884
PWc gp4 std mult pow opt s/b
NI
YK0885
PWC gp4 std mult pow opt cap
NI
YK0886
PWC gp4 hd mult pow s/b
NI
YK0890
PWC gp5 ped sing pow opt s/b
NI
YK0891
PWC gp5 ped mult pow opt s/b
NI
YK0898
Power wheelchair NOC
NI
YK0899
Pow mobility dev no sadmerc
NI
YL0100
Cranial orthosis/helmet mold
CH
DL0110
Cranial orthosis/helmet nonm
CH
DL1001
CTLSO infant immobilizer
NI
AL3806
WHFO w/joint(s) custom fab
NI
AL3808
WHFO, rigid w/o joints
NI
AL3902
Whfo ext power compress gas
CH
DL3914
WHO wrist extension cock-up
CH
DL3915
WHO w nontor jnt(s) prefab
NI
AL5993
Heavy duty feature, foot
NI
AL5994
Heavy duty feature, knee
NI
AL6611
Additional switch, ext power
NI
AL6624
Flex/ext/rotation wrist unit
NI
AL6639
Heavy duty elbow feature
NI
AL6700
Terminal device model #3
CH
DL6703
Term dev, passive hand mitt
NI
AL6704
Term dev, sport/rec/work att
NI
AL6705
Terminal device model #5
CH
DL6706
Term dev mech hook vol open
NI
AL6707
Term dev mech hook vol close
NI
AL6708
Term dev mech hand vol open
NI
AL6709
Term dev mech hand vol close
NI
AL6710
Terminal device model #5x
CH
DL6715
Terminal device model #5xa
CH
DL6720
Terminal device model #6
CH
DL6725
Terminal device model #7
CH
DL6730
Terminal device model #7lo
CH
DL6735
Terminal device model #8
CH
DL6740
Terminal device model #8x
CH
DL6745
Terminal device model #88x
CH
DL6750
Terminal device model #10p
CH
DL6755
Terminal device model #10x
CH
DL6765
Terminal device model #12p
CH
DL6770
Terminal device model #99x
CH
D( print page 68382)L6775
Terminal device model#555
CH
DL6780
Terminal device model #ss555
CH
DL6790
Hooks-accu hook or equal
CH
DL6795
Hooks-2 load or equal
CH
DL6800
Hooks-aprl vc or equal
CH
DL6806
Trs grip vc or equal
CH
DL6807
Term device grip1/2 or equal
CH
DL6808
Term device infant or child
CH
DL6809
Trs super sport passive
CH
DL6825
Hands dorrance vo
CH
DL6830
Hand aprl vc
CH
DL6835
Hand sierra vo
CH
DL6840
Hand becker imperial
CH
DL6845
Hand becker lock grip
CH
DL6850
Term dvc-hand becker plylite
CH
DL6855
Hand robin-aids vo
CH
DL6860
Hand robin-aids vo soft
CH
DL6865
Hand passive hand
CH
DL6867
Hand detroit infant hand
CH
DL6868
Passive inf hand steeper/hos
CH
DL6870
Hand child mitt
CH
DL6872
Hand nyu child hand
CH
DL6873
Hand mech inf steeper or equ
CH
DL6875
Hand bock vc
CH
DL6880
Hand bock vo
CH
DL7007
Adult electric hand
NI
AL7008
Pediatric electric hand
NI
AL7009
Adult electric hook
NI
AL7010
Hand otto back steeper/eq sw
CH
DL7015
Hand sys teknik village swit
CH
DL7020
Electronic greifer switch ct
CH
DL7025
Electron hand myoelectronic
CH
DL7030
Hand sys teknik vill myoelec
CH
DL7035
Electron greifer myoelectro
CH
DL8600
Implant breast silicone/eq

NL8603
Collagen imp urinary 2.5 ml

NL8606
Synthetic implnt urinary 1ml

NL8609
Artificial cornea

NL8610
Ocular implant

NL8612
Aqueous shunt prosthesis

NL8613
Ossicular implant

NL8614
Cochlear device

NL8630
Metacarpophalangeal implant

NL8631
MCP joint repl 2 pc or more

NL8641
Metatarsal joint implant

NL8642
Hallux implant

NL8658
Interphalangeal joint spacer

NL8659
Interphalangeal joint repl

NL8670
Vascular graft, synthetic

NL8682
Implt neurostim radiofq rec

NL8690
Aud osseo dev, int/ext comp
NI
H
1032L8691
Aud osseo dev, int/ext comp
NI
AL8695
External recharg sys extern
NI
AL8699
Prosthetic implant NOS

NM0064
Visit for drug monitoring

X
0374
1.1418
70.18

14.04P9010
Whole blood for transfusion

K
0950
2.1472
131.98

26.40P9011
Blood split unit

K
0967
2.2323
137.22

27.44P9012
Cryoprecipitate each unit

K
0952
0.7905
48.59

9.72P9016
RBC leukocytes reduced

K
0954
2.859
175.74

35.15P9017
Plasma 1 donor frz w/in 8 hr

K
9508
1.1422
70.21

14.04P9019
Platelets, each unit

K
0957
0.959
58.95

11.79P9020
Plaelet rich plasma unit

K
0958
3.4048
209.29

41.86P9021
Red blood cells unit

K
0959
2.1073
129.53

25.91P9022
Washed red blood cells unit

K
0960
3.4331
211.03

42.21P9023
Frozen plasma, pooled, sd

K
0949
0.9346
57.45

11.49P9031
Platelets leukocytes reduced

K
1013
1.5469
95.08

19.02P9032
Platelets, irradiated

K
9500
2.1079
129.57

25.91P9033
Platelets leukoreduced irrad

K
0968
2.039
125.33

25.07P9034
Platelets, pheresis

K
9507
7.3686
452.93

90.59P9035
Platelet pheres leukoreduced

K
9501
7.9511
488.74

97.75( print page 68383)P9036
Platelet pheresis irradiated

K
9502
6.8088
418.52

83.70P9037
Plate pheres leukoredu irrad

K
1019
10.0443
617.40

123.48P9038
RBC irradiated

K
9505
3.2049
197.00

39.40P9039
RBC deglycerolized

K
9504
5.8292
358.31

71.66P9040
RBC leukoreduced irradiated

K
0969
3.5394
217.56

43.51P9041
Albumin (human),5%, 50ml

K
0961

29.68

5.94P9043
Plasma protein fract,5%,50ml

K
0956
0.8339
51.26

10.25P9044
Cryoprecipitatereducedplasma

K
1009
1.3404
82.39

16.48P9045
Albumin (human), 5%, 250 ml

K
0963

76.81

15.36P9046
Albumin (human), 25%, 20 ml

K
0964

28.80

5.76P9047
Albumin (human), 25%, 50ml

K
0965

65.26

13.05P9048
Plasmaprotein fract,5%,250ml

K
0966
3.8746
238.16

47.63P9050
Granulocytes, pheresis unit

K
9506
12.2073
750.36

150.07P9051
Blood, l/r, cmv-neg

K
1010
2.5493
156.70

31.34P9052
Platelets, hla-m, l/r, unit

K
1011
10.9263
671.62

134.32P9053
Plt, pher, l/r cmv-neg, irr

K
1020
11.4755
705.38

141.08P9054
Blood, l/r, froz/degly/wash

K
1016
3.4335
211.05

42.21P9055
Plt, aph/pher, l/r, cmv-neg

K
1017
6.4556
396.81

79.36P9056
Blood, l/r, irradiated

K
1018
2.3472
144.28

28.86P9057
RBC, frz/deg/wsh, l/r, irrad

K
1021
8.0727
496.21

99.24P9058
RBC, l/r, cmv-neg, irrad

K
1022
4.2653
262.18

52.44P9059
Plasma, frz between 8-24hour

K
0955
1.2489
76.77

15.35P9060
Fr frz plasma donor retested

K
9503
1.2119
74.49

14.90P9612
Catheterize for urine spec
CH
AP9615
Urine specimen collect mult

NQ0035
Cardiokymography

X
0100
2.5336
155.74
41.44
31.15Q0091
Obtaining screen pap smear

T
0191
0.1468
9.02
2.55
1.80Q0092
Set up port xray equipment

NQ0163
Diphenhydramine HCl 50mg

NQ0164
Prochlorperazine maleate 5mg

NQ0166
Granisetron HCl 1 mg oral

K
0765

41.18

8.24Q0167
Dronabinol 2.5mg oral

NQ0169
Promethazine HCl 12.5mg oral

NQ0171
Chlorpromazine HCl 10mg oral

NQ0173
Trimethobenzamide HCl 250mg

NQ0174
Thiethylperazine maleate10mg

NQ0175
Perphenazine 4mg oral

NQ0177
Hydroxyzine pamoate 25mg

NQ0179
Ondansetron HCl 8mg oral

K
0769

36.06

7.21Q0180
Dolasetron mesylate oral

K
0763

48.91

9.78Q0512
Px sup fee anti-can sub pres
CH
BQ0515
Sermorelin acetate injection
CH
K
3050

1.75

0.35Q1003
NTIOL category 3

NQ1004
Ntiol category 4

NQ1005
Ntiol category 5

NQ2004
Bladder calculi irrig sol

NQ2009
Fosphenytoin, 50 mg

K
7028

5.59

1.12Q2017
Teniposide, 50 mg

K
7035

264.88

52.98Q3025
IM inj interferon beta 1-a

K
9022

108.04

21.61Q3031
Collagen skin test

NQ4079
Natalizumab injection

G
9126

7.72

1.54Q4081
Epoetin alfa, 100 units ESRD
NI
AQ4082
Drug/bio NOC part B drug CAP
NI
BQ5001
Hospice in patient home
NI
BQ5002
Hospice in assisted living
NI
BQ5003
Hospice in LT/non-skilled NF
NI
BQ5004
Hospice in SNF
NI
BQ5005
Hospice, inpatient hospital
NI
BQ5006
Hospice in hospice facility
NI
BQ5007
Hospice in LTCH
NI
BQ5008
Hospice in inpatient psych
NI
BQ5009
Hospice care, NOS
NI
BQ9945
LOCM ≦149 mg/ml iodine, 1ml

K
9157

0.29

0.06Q9946
LOCM 150-199mg/ml iodine,1ml

K
9158

1.96

0.39Q9947
LOCM 200-249mg/ml iodine,1ml

K
9159

1.42

0.28Q9948
LOCM 250-299mg/ml iodine,1ml

K
9160

0.27

0.05Q9949
LOCM 300-349mg/ml iodine,1ml

K
9161

0.35

0.07Q9950
LOCM 350-399mg/ml iodine,1ml

K
9162

0.21

0.04Q9951
LOCM ≧ 400 mg/ml iodine,1ml

K
9163

0.30

0.06Q9952
Inj Gad-base MR contrast,1ml

K
9164

2.87

0.57( print page 68384)Q9953
Inj Fe-based MR contrast,1ml

K
1713

30.41

6.08Q9954
Oral MR contrast, 100 ml

K
9165

8.90

1.78Q9955
Inj perflexane lip micros,ml

K
9203

7.05

1.41Q9956
Inj octafluoropropane mic,ml

K
9202

49.61

9.92Q9957
Inj perflutren lip micros,ml

K
9112

61.64

12.33Q9958
HOCM ≦149 mg/ml iodine, 1ml
CH
NQ9959
HOCM 150-199mg/ml iodine,1ml

NQ9960
HOCM 200-249mg/ml iodine,1ml
CH
NQ9961
HOCM 250-299mg/ml iodine,1ml
CH
NQ9962
HOCM 300-349mg/ml iodine,1ml
CH
NQ9963
HOCM 350-399mg/ml iodine,1ml
CH
NQ9964
HOCM≧ 400mg/ml iodine, 1ml
CH
NV2630
Anter chamber intraocul lens

NV2631
Iris support intraoclr lens

NV2632
Post chmbr intraocular lens

NV2790
Amniotic membrane

N
 Addendum D1.—Payment Status Indicators
Indicator
Item/code/service
OPPS payment statusA
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 
                                 • 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
Not paid under OPPS.  Paid by fiscal intermediaries under a fee schedule or payment system other than OPPS.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. 
                                 • 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.
Not paid under OPPS or any other Medicare payment system.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 pass through 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.K
(1) Non-Pass-Through Drugs, Biologicals, and
(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.( print page 68385)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.—Comment Indicators
Comment 
                                 indicator
DescriptorNF
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 code in current year and next calendar year, status indicator and/or APC assignment has changed; or active HCPCS code that is discontinued at the end of the current calendar year.
 Addendum E.—CPT Codes That Are Paid Only as Inpatient Procedures
CPT/ HCPCS
Description
CY 2007 SI00176
Anesth, pharyngeal surgery
C00192
Anesth, facial bone surgery
C00214
Anesth, skull drainage
C00215
Anesth, skull repair/fract
C00452
Anesth, surgery of shoulder
C00474
Anesth, surgery of rib(s)
C00524
Anesth, chest drainage
C00540
Anesth, chest surgery
C00542
Anesth, release of lung
C00546
Anesth, lung,chest wall surg
C00560
Anesth, heart surg w/o pump
C00561
Anesth, heart surg <age 1
C00562
Anesth, heart surg w/pump
C00580
Anesth, heart/lung transplnt
C00604
Anesth, sitting procedure
C00622
Anesth, removal of nerves
C00632
Anesth, removal of nerves
C00670
Anesth, spine, cord surgery
C00792
Anesth, hemorr/excise liver
C00794
Anesth, pancreas removal
C00796
Anesth, for liver transplant
C00802
Anesth, fat layer removal
C00844
Anesth, pelvis surgery
C00846
Anesth, hysterectomy
C00848
Anesth, pelvic organ surg
C00864
Anesth, removal of bladder
C00865
Anesth, removal of prostate
C00866
Anesth, removal of adrenal
C00868
Anesth, kidney transplant
C00882
Anesth, major vein ligation
C00904
Anesth, perineal surgery
C00908
Anesth, removal of prostate
C00932
Anesth, amputation of penis
C00934
Anesth, penis, nodes removal
C00936
Anesth, penis, nodes removal
C00944
Anesth, vaginal hysterectomy
C01140
Anesth, amputation at pelvis
C01150
Anesth, pelvic tumor surgery
C01212
Anesth, hip disarticulation
C01214
Anesth, hip arthroplasty
C01232
Anesth, amputation of femur
C01234
Anesth, radical femur surg
C01272
Anesth, femoral artery surg
C01274
Anesth, femoral embolectomy
C01402
Anesth, knee arthroplasty
C01404
Anesth, amputation at knee
C01442
Anesth, knee artery surg
C01444
Anesth, knee artery repair
C01486
Anesth, ankle replacement
C01502
Anesth, lwr leg embolectomy
C01632
Anesth, surgery of shoulder
C01634
Anesth, shoulder joint amput
C01636
Anesth, forequarter amput
C01638
Anesth, shoulder replacement
C01652
Anesth, shoulder vessel surg
C01654
Anesth, shoulder vessel surg
C01656
Anesth, arm-leg vessel surg
C01756
Anesth, radical humerus surg
C01990
Support for organ donor
C11004
Debride genitalia & perineum
C11005
Debride abdom wall
C11006
Debride genit/per/abdom wall
C11008
Remove mesh from abd wall
C( print page 68386)15756
Free myo/skin flap microvasc
C15757
Free skin flap, microvasc
C15758
Free fascial flap, microvasc
C16036
Escharotomy; add′l incision
C19271
Revision of chest wall
C19272
Extensive chest wall surgery
C19305
Mast, radical
C19306
Mast, rad, urban type
C19361
Breast reconstr w/lat flap
C19364
Breast reconstruction
C19367
Breast reconstruction
C19368
Breast reconstruction
C19369
Breast reconstruction
C20660
Apply, rem fixation device
C20661
Application of head brace
C20664
Halo brace application
C20802
Replantation, arm, complete
C20805
Replant forearm, complete
C20808
Replantation hand, complete
C20816
Replantation digit, complete
C20824
Replantation thumb, complete
C20827
Replantation thumb, complete
C20838
Replantation foot, complete
C20930
Spinal bone allograft
C20931
Spinal bone allograft
C20936
Spinal bone autograft
C20937
Spinal bone autograft
C20938
Spinal bone autograft
C20955
Fibula bone graft, microvasc
C20956
Iliac bone graft, microvasc
C20957
Mt bone graft, microvasc
C20962
Other bone graft, microvasc
C20969
Bone/skin graft, microvasc
C20970
Bone/skin graft, iliac crest
C21045
Extensive jaw surgery
C21141
Reconstruct midface, lefort
C21142
Reconstruct midface, lefort
C21143
Reconstruct midface, lefort
C21145
Reconstruct midface, lefort
C21146
Reconstruct midface, lefort
C21147
Reconstruct midface, lefort
C21151
Reconstruct midface, lefort
C21154
Reconstruct midface, lefort
C21155
Reconstruct midface, lefort
C21159
Reconstruct midface, lefort
C21160
Reconstruct midface, lefort
C21172
Reconstruct orbit/forehead
C21179
Reconstruct entire forehead
C21180
Reconstruct entire forehead
C21182
Reconstruct cranial bone
C21183
Reconstruct cranial bone
C21184
Reconstruct cranial bone
C21188
Reconstruction of midface
C21193
Reconst lwr jaw w/o graft
C21194
Reconst lwr jaw w/graft
C21196
Reconst lwr jaw w/fixation
C21247
Reconstruct lower jaw bone
C21255
Reconstruct lower jaw bone
C21256
Reconstruction of orbit
C21268
Revise eye sockets
C21343
Treatment of sinus fracture
C21344
Treatment of sinus fracture
C21346
Treat nose/jaw fracture
C21347
Treat nose/jaw fracture
C21348
Treat nose/jaw fracture
C21360
Treat cheek bone fracture
C21365
Treat cheek bone fracture
C21366
Treat cheek bone fracture
C21385
Treat eye socket fracture
C21386
Treat eye socket fracture
C21387
Treat eye socket fracture
C21395
Treat eye socket fracture
C21422
Treat mouth roof fracture
C21423
Treat mouth roof fracture
C21431
Treat craniofacial fracture
C21432
Treat craniofacial fracture
C21433
Treat craniofacial fracture
C21435
Treat craniofacial fracture
C21436
Treat craniofacial fracture
C21510
Drainage of bone lesion
C21615
Removal of rib
C21616
Removal of rib and nerves
C21620
Partial removal of sternum
C21627
Sternal debridement
C21630
Extensive sternum surgery
C21632
Extensive sternum surgery
C21705
Revision of neck muscle/rib
C21740
Reconstruction of sternum
C21750
Repair of sternum separation
C21810
Treatment of rib fracture(s)
C21825
Treat sternum fracture
C22010
I&d, p-spine, c/t/cerv-thor
C22015
I&d, p-spine, l/s/ls
C22110
Remove part of neck vertebra
C22112
Remove part, thorax vertebra
C22114
Remove part, lumbar vertebra
C22116
Remove extra spine segment
C22210
Revision of neck spine
C22212
Revision of thorax spine
C22214
Revision of lumbar spine
C22216
Revise, extra spine segment
C22220
Revision of neck spine
C22224
Revision of lumbar spine
C22226
Revise, extra spine segment
C22318
Treat odontoid fx w/o graft
C22319
Treat odontoid fx w/graft
C22325
Treat spine fracture
C22326
Treat neck spine fracture
C22327
Treat thorax spine fracture
C22328
Treat each add spine fx
C22532
Lat thorax spine fusion
C22533
Lat lumbar spine fusion
C22534
Lat thor/lumb, add'l seg
C22548
Neck spine fusion
C22554
Neck spine fusion
C22556
Thorax spine fusion
C22558
Lumbar spine fusion
C22585
Additional spinal fusion
C22590
Spine & skull spinal fusion
C22595
Neck spinal fusion
C22600
Neck spine fusion
C22610
Thorax spine fusion
C22630
Lumbar spine fusion
C22632
Spine fusion, extra segment
C22800
Fusion of spine
C22802
Fusion of spine
C22804
Fusion of spine
C22808
Fusion of spine
C22810
Fusion of spine
C( print page 68387)22812
Fusion of spine
C22818
Kyphectomy, 1-2 segments
C22819
Kyphectomy, 3 or more
C22830
Exploration of spinal fusion
C22840
Insert spine fixation device
C22841
Insert spine fixation device
C22842
Insert spine fixation device
C22843
Insert spine fixation device
C22844
Insert spine fixation device
C22845
Insert spine fixation device
C22846
Insert spine fixation device
C22847
Insert spine fixation device
C22848
Insert pelv fixation device
C22849
Reinsert spinal fixation
C22850
Remove spine fixation device
C22852
Remove spine fixation device
C22855
Remove spine fixation device
C22857
Lumbar artif diskectomy
C22862
Revise lumbar artif disc
C22865
Remove lumb artif disc
C23200
Removal of collar bone
C23210
Removal of shoulder blade
C23220
Partial removal of humerus
C23221
Partial removal of humerus
C23222
Partial removal of humerus
C23332
Remove shoulder foreign body
C23472
Reconstruct shoulder joint
C23900
Amputation of arm & girdle
C23920
Amputation at shoulder joint
C24900
Amputation of upper arm
C24920
Amputation of upper arm
C24930
Amputation follow-up surgery
C24931
Amputate upper arm & implant
C24940
Revision of upper arm
C25900
Amputation of forearm
C25905
Amputation of forearm
C25909
Amputation follow-up surgery
C25915
Amputation of forearm
C25920
Amputate hand at wrist
C25924
Amputation follow-up surgery
C25927
Amputation of hand
C25931
Amputation follow-up surgery
C26551
Great toe-hand transfer
C26553
Single transfer, toe-hand
C26554
Double transfer, toe-hand
C26556
Toe joint transfer
C26992
Drainage of bone lesion
C27005
Incision of hip tendon
C27006
Incision of hip tendons
C27025
Incision of hip/thigh fascia
C27030
Drainage of hip joint
C27036
Excision of hip joint/muscle
C27054
Removal of hip joint lining
C27070
Partial removal of hip bone
C27071
Partial removal of hip bone
C27075
Extensive hip surgery
C27076
Extensive hip surgery
C27077
Extensive hip surgery
C27078
Extensive hip surgery
C27079
Extensive hip surgery
C27090
Removal of hip prosthesis
C27091
Removal of hip prosthesis
C27120
Reconstruction of hip socket
C27122
Reconstruction of hip socket
C27125
Partial hip replacement
C27130
Total hip arthroplasty
C27132
Total hip arthroplasty
C27134
Revise hip joint replacement
C27137
Revise hip joint replacement
C27138
Revise hip joint replacement
C27140
Transplant femur ridge
C27146
Incision of hip bone
C27147
Revision of hip bone
C27151
Incision of hip bones
C27156
Revision of hip bones
C27158
Revision of pelvis
C27161
Incision of neck of femur
C27165
Incision/fixation of femur
C27170
Repair/graft femur head/neck
C27175
Treat slipped epiphysis
C27176
Treat slipped epiphysis
C27177
Treat slipped epiphysis
C27178
Treat slipped epiphysis
C27179
Revise head/neck of femur
C27181
Treat slipped epiphysis
C27185
Revision of femur epiphysis
C27187
Reinforce hip bones
C27215
Treat pelvic fracture(s)
C27217
Treat pelvic ring fracture
C27218
Treat pelvic ring fracture
C27222
Treat hip socket fracture
C27226
Treat hip wall fracture
C27227
Treat hip fracture(s)
C27228
Treat hip fracture(s)
C27232
Treat thigh fracture
C27236
Treat thigh fracture
C27240
Treat thigh fracture
C27244
Treat thigh fracture
C27245
Treat thigh fracture
C27248
Treat thigh fracture
C27253
Treat hip dislocation
C27254
Treat hip dislocation
C27258
Treat hip dislocation
C27259
Treat hip dislocation
C27280
Fusion of sacroiliac joint
C27282
Fusion of pubic bones
C27284
Fusion of hip joint
C27286
Fusion of hip joint
C27290
Amputation of leg at hip
C27295
Amputation of leg at hip
C27303
Drainage of bone lesion
C27365
Extensive leg surgery
C27445
Revision of knee joint
C27447
Total knee arthroplasty
C27448
Incision of thigh
C27450
Incision of thigh
C27454
Realignment of thigh bone
C27455
Realignment of knee
C27457
Realignment of knee
C27465
Shortening of thigh bone
C27466
Lengthening of thigh bone
C27468
Shorten/lengthen thighs
C27470
Repair of thigh
C27472
Repair/graft of thigh
C27477
Surgery to stop leg growth
C27479
Surgery to stop leg growth
C27485
Surgery to stop leg growth
C27486
Revise/replace knee joint
C27487
Revise/replace knee joint
C27488
Removal of knee prosthesis
C27495
Reinforce thigh
C27506
Treatment of thigh fracture
C27507
Treatment of thigh fracture
C27511
Treatment of thigh fracture
C27513
Treatment of thigh fracture
C27514
Treatment of thigh fracture
C27519
Treat thigh fx growth plate
C27535
Treat knee fracture
C27536
Treat knee fracture
C27540
Treat knee fracture
C27556
Treat knee dislocation
C27557
Treat knee dislocation
C27558
Treat knee dislocation
C27580
Fusion of knee
C27590
Amputate leg at thigh
C27591
Amputate leg at thigh
C( print page 68388)27592
Amputate leg at thigh
C27596
Amputation follow-up surgery
C27598
Amputate lower leg at knee
C27645
Extensive lower leg surgery
C27646
Extensive lower leg surgery
C27702
Reconstruct ankle joint
C27703
Reconstruction, ankle joint
C27712
Realignment of lower leg
C27715
Revision of lower leg
C27720
Repair of tibia
C27722
Repair/graft of tibia
C27724
Repair/graft of tibia
C27725
Repair of lower leg
C27727
Repair of lower leg
C27880
Amputation of lower leg
C27881
Amputation of lower leg
C27882
Amputation of lower leg
C27886
Amputation follow-up surgery
C27888
Amputation of foot at ankle
C28800
Amputation of midfoot
C28805
Amputation thru metatarsal
C31225
Removal of upper jaw
C31230
Removal of upper jaw
C31290
Nasal/sinus endoscopy, surg
C31291
Nasal/sinus endoscopy, surg
C31360
Removal of larynx
C31365
Removal of larynx
C31367
Partial removal of larynx
C31368
Partial removal of larynx
C31370
Partial removal of larynx
C31375
Partial removal of larynx
C31380
Partial removal of larynx
C31382
Partial removal of larynx
C31390
Removal of larynx & pharynx
C31395
Reconstruct larynx & pharynx
C31584
Treat larynx fracture
C31587
Revision of larynx
C31725
Clearance of airways
C31760
Repair of windpipe
C31766
Reconstruction of windpipe
C31770
Repair/graft of bronchus
C31775
Reconstruct bronchus
C31780
Reconstruct windpipe
C31781
Reconstruct windpipe
C31786
Remove windpipe lesion
C31800
Repair of windpipe injury
C31805
Repair of windpipe injury
C32035
Exploration of chest
C32036
Exploration of chest
C32095
Biopsy through chest wall
C32100
Exploration/biopsy of chest
C32110
Explore/repair chest
C32120
Re-exploration of chest
C32124
Explore chest free adhesions
C32140
Removal of lung lesion(s)
C32141
Remove/treat lung lesions
C32150
Removal of lung lesion(s)
C32151
Remove lung foreign body
C32160
Open chest heart massage
C32200
Drain, open, lung lesion
C32215
Treat chest lining
C32220
Release of lung
C32225
Partial release of lung
C32310
Removal of chest lining
C32320
Free/remove chest lining
C32402
Open biopsy chest lining
C32440
Removal of lung
C32442
Sleeve pneumonectomy
C32445
Removal of lung
C32480
Partial removal of lung
C32482
Bilobectomy
C32484
Segmentectomy
C32486
Sleeve lobectomy
C32488
Completion pneumonectomy
C32491
Lung volume reduction
C32500
Partial removal of lung
C32501
Repair bronchus add-on
C32503
Resect apical lung tumor
C32504
Resect apical lung tum/chest
C32540
Removal of lung lesion
C32650
Thoracoscopy, surgical
C32651
Thoracoscopy, surgical
C32652
Thoracoscopy, surgical
C32653
Thoracoscopy, surgical
C32654
Thoracoscopy, surgical
C32655
Thoracoscopy, surgical
C32656
Thoracoscopy, surgical
C32657
Thoracoscopy, surgical
C32658
Thoracoscopy, surgical
C32659
Thoracoscopy, surgical
C32660
Thoracoscopy, surgical
C32661
Thoracoscopy, surgical
C32662
Thoracoscopy, surgical
C32663
Thoracoscopy, surgical
C32664
Thoracoscopy, surgical
C32665
Thoracoscopy, surgical
C32800
Repair lung hernia
C32810
Close chest after drainage
C32815
Close bronchial fistula
C32820
Reconstruct injured chest
C32850
Donor pneumonectomy
C32851
Lung transplant, single
C32852
Lung transplant with bypass
C32853
Lung transplant, double
C32854
Lung transplant with bypass
C32855
Prepare donor lung, single
C32856
Prepare donor lung, double
C32900
Removal of rib(s)
C32905
Revise & repair chest wall
C32906
Revise & repair chest wall
C32940
Revision of lung
C32997
Total lung lavage
C33015
Incision of heart sac
C33020
Incision of heart sac
C33025
Incision of heart sac
C33030
Partial removal of heart sac
C33031
Partial removal of heart sac
C33050
Removal of heart sac lesion
C33120
Removal of heart lesion
C33130
Removal of heart lesion
C33140
Heart revascularize (tmr)
C33141
Heart tmr w/other procedure
C33202
Insert epicard eltrd, open
C33203
Insert epicard eltrd, endo
C33236
Remove electrode/thoracotomy
C33237
Remove electrode/thoracotomy
C33238
Remove electrode/thoracotomy
C33243
Remove eltrd/thoracotomy
C33250
Ablate heart dysrhythm focus
C33251
Ablate heart dysrhythm focus
C33254
Ablate atria, lmtd
C33255
Ablate atria w/o bypass, ext
C33256
Ablate atria w/bypass, exten
C33261
Ablate heart dysrhythm focus
C33265
Ablate atria w/bypass, endo
C33266
Ablate atria w/o bypass endo
C33300
Repair of heart wound
C33305
Repair of heart wound
C33310
Exploratory heart surgery
C33315
Exploratory heart surgery
C33320
Repair major blood vessel(s)
C33321
Repair major vessel
C33322
Repair major blood vessel(s)
C33330
Insert major vessel graft
C33332
Insert major vessel graft
C33335
Insert major vessel graft
C33400
Repair of aortic valve
C33401
Valvuloplasty, open
C33403
Valvuloplasty, w/cp bypass
C33404
Prepare heart-aorta conduit
C( print page 68389)33405
Replacement of aortic valve
C33406
Replacement of aortic valve
C33410
Replacement of aortic valve
C33411
Replacement of aortic valve
C33412
Replacement of aortic valve
C33413
Replacement of aortic valve
C33414
Repair of aortic valve
C33415
Revision, subvalvular tissue
C33416
Revise ventricle muscle
C33417
Repair of aortic valve
C33420
Revision of mitral valve
C33422
Revision of mitral valve
C33425
Repair of mitral valve
C33426
Repair of mitral valve
C33427
Repair of mitral valve
C33430
Replacement of mitral valve
C33460
Revision of tricuspid valve
C33463
Valvuloplasty, tricuspid
C33464
Valvuloplasty, tricuspid
C33465
Replace tricuspid valve
C33468
Revision of tricuspid valve
C33470
Revision of pulmonary valve
C33471
Valvotomy, pulmonary valve
C33472
Revision of pulmonary valve
C33474
Revision of pulmonary valve
C33475
Replacement, pulmonary valve
C33476
Revision of heart chamber
C33478
Revision of heart chamber
C33496
Repair, prosth valve clot
C33500
Repair heart vessel fistula
C33501
Repair heart vessel fistula
C33502
Coronary artery correction
C33503
Coronary artery graft
C33504
Coronary artery graft
C33505
Repair artery w/tunnel
C33506
Repair artery, translocation
C33507
Repair art, intramural
C33510
CABG, vein, single
C33511
CABG, vein, two
C33512
CABG, vein, three
C33513
CABG, vein, four
C33514
CABG, vein, five
C33516
Cabg, vein, six or more
C33517
CABG, artery-vein, single
C33518
CABG, artery-vein, two
C33519
CABG, artery-vein, three
C33521
CABG, artery-vein, four
C33522
CABG, artery-vein, five
C33523
Cabg, art-vein, six or more
C33530
Coronary artery, bypass/reop
C33533
CABG, arterial, single
C33534
CABG, arterial, two
C33535
CABG, arterial, three
C33536
Cabg, arterial, four or more
C33542
Removal of heart lesion
C33545
Repair of heart damage
C33548
Restore/remodel, ventricle
C33572
Open coronary endarterectomy
C33600
Closure of valve
C33602
Closure of valve
C33606
Anastomosis/artery-aorta
C33608
Repair anomaly w/conduit
C33610
Repair by enlargement
C33611
Repair double ventricle
C33612
Repair double ventricle
C33615
Repair, modified fontan
C33617
Repair single ventricle
C33619
Repair single ventricle
C33641
Repair heart septum defect
C33645
Revision of heart veins
C33647
Repair heart septum defects
C33660
Repair of heart defects
C33665
Repair of heart defects
C33670
Repair of heart chambers
C33675
Close mult vsd
C33676
Close mult vsd w/resection
C33677
Cl mult vsd w/rem pul band
C33681
Repair heart septum defect
C33684
Repair heart septum defect
C33688
Repair heart septum defect
C33690
Reinforce pulmonary artery
C33692
Repair of heart defects
C33694
Repair of heart defects
C33697
Repair of heart defects
C33702
Repair of heart defects
C33710
Repair of heart defects
C33720
Repair of heart defect
C33722
Repair of heart defect
C33724
Repair venous anomaly
C33726
Repair pul venous stenosis
C33730
Repair heart-vein defect(s)
C33732
Repair heart-vein defect
C33735
Revision of heart chamber
C33736
Revision of heart chamber
C33737
Revision of heart chamber
C33750
Major vessel shunt
C33755
Major vessel shunt
C33762
Major vessel shunt
C33764
Major vessel shunt & graft
C33766
Major vessel shunt
C33767
Major vessel shunt
C33768
Cavopulmonary shunting
C33770
Repair great vessels defect
C33771
Repair great vessels defect
C33774
Repair great vessels defect
C33775
Repair great vessels defect
C33776
Repair great vessels defect
C33777
Repair great vessels defect
C33778
Repair great vessels defect
C33779
Repair great vessels defect
C33780
Repair great vessels defect
C33781
Repair great vessels defect
C33786
Repair arterial trunk
C33788
Revision of pulmonary artery
C33800
Aortic suspension
C33802
Repair vessel defect
C33803
Repair vessel defect
C33813
Repair septal defect
C33814
Repair septal defect
C33820
Revise major vessel
C33822
Revise major vessel
C33824
Revise major vessel
C33840
Remove aorta constriction
C33845
Remove aorta constriction
C33851
Remove aorta constriction
C33852
Repair septal defect
C33853
Repair septal defect
C33860
Ascending aortic graft
C33861
Ascending aortic graft
C33863
Ascending aortic graft
C33870
Transverse aortic arch graft
C33875
Thoracic aortic graft
C33877
Thoracoabdominal graft
C33880
Endovasc taa repr incl subcl
C33881
Endovasc taa repr w/o subcl
C33883
Insert endovasc prosth, taa
C33884
Endovasc prosth, taa, add-on
C33886
Endovasc prosth, delayed
C33889
Artery transpose/endovas taa
C( print page 68390)33891
Car-car bp grft/endovas taa
C33910
Remove lung artery emboli
C33915
Remove lung artery emboli
C33916
Surgery of great vessel
C33917
Repair pulmonary artery
C33920
Repair pulmonary atresia
C33922
Transect pulmonary artery
C33924
Remove pulmonary shunt
C33925
Rpr pul art unifocal w/o cpb
C33926
Repr pul art, unifocal w/cpb
C33930
Removal of donor heart/lung
C33933
Prepare donor heart/lung
C33935
Transplantation, heart/lung
C33940
Removal of donor heart
C33944
Prepare donor heart
C33945
Transplantation of heart
C33960
External circulation assist
C33961
External circulation assist
C33967
Insert ia percut device
C33968
Remove aortic assist device
C33970
Aortic circulation assist
C33971
Aortic circulation assist
C33973
Insert balloon device
C33974
Remove intra-aortic balloon
C33975
Implant ventricular device
C33976
Implant ventricular device
C33977
Remove ventricular device
C33978
Remove ventricular device
C33979
Insert intracorporeal device
C33980
Remove intracorporeal device
C34001
Removal of artery clot
C34051
Removal of artery clot
C34151
Removal of artery clot
C34401
Removal of vein clot
C34451
Removal of vein clot
C34502
Reconstruct vena cava
C34800
Endovas aaa repr w/sm tube
C34802
Endovas aaa repr w/2-p part
C34803
Endovas aaa repr w/3-p part
C34804
Endovas aaa repr w/1-p part
C34805
Endovas aaa repr w/long tube
C34808
Endovas iliac a device addon
C34812
Xpose for endoprosth, femorl
C34813
Femoral endovas graft add-on
C34820
Xpose for endoprosth, iliac
C34825
Endovasc extend prosth, init
C34826
Endovasc exten prosth, add?l
C34830
Open aortic tube prosth repr
C34831
Open aortoiliac prosth repr
C34832
Open aortofemor prosth repr
C34833
Xpose for endoprosth, iliac
C34834
Xpose, endoprosth, brachial
C34900
Endovasc iliac repr w/graft
C35001
Repair defect of artery
C35002
Repair artery rupture, neck
C35005
Repair defect of artery
C35013
Repair artery rupture, arm
C35021
Repair defect of artery
C35022
Repair artery rupture, chest
C35045
Repair defect of arm artery
C35081
Repair defect of artery
C35082
Repair artery rupture, aorta
C35091
Repair defect of artery
C35092
Repair artery rupture, aorta
C35102
Repair defect of artery
C35103
Repair artery rupture, groin
C35111
Repair defect of artery
C35112
Repair artery rupture,spleen
C35121
Repair defect of artery
C35122
Repair artery rupture, belly
C35131
Repair defect of artery
C35132
Repair artery rupture, groin
C35141
Repair defect of artery
C35142
Repair artery rupture, thigh
C35151
Repair defect of artery
C35152
Repair artery rupture, knee
C35182
Repair blood vessel lesion
C35189
Repair blood vessel lesion
C35211
Repair blood vessel lesion
C35216
Repair blood vessel lesion
C35221
Repair blood vessel lesion
C35241
Repair blood vessel lesion
C35246
Repair blood vessel lesion
C35251
Repair blood vessel lesion
C35271
Repair blood vessel lesion
C35276
Repair blood vessel lesion
C35281
Repair blood vessel lesion
C35301
Rechanneling of artery
C35302
Rechanneling of artery
C35303
Rechanneling of artery
C35304
Rechanneling of artery
C35305
Rechanneling of artery
C35306
Rechanneling of artery
C35311
Rechanneling of artery
C35331
Rechanneling of artery
C35341
Rechanneling of artery
C35351
Rechanneling of artery
C35355
Rechanneling of artery
C35361
Rechanneling of artery
C35363
Rechanneling of artery
C35371
Rechanneling of artery
C35372
Rechanneling of artery
C35390
Reoperation, carotid add-on
C35400
Angioscopy
C35450
Repair arterial blockage
C35452
Repair arterial blockage
C35454
Repair arterial blockage
C35456
Repair arterial blockage
C35480
Atherectomy, open
C35481
Atherectomy, open
C35482
Atherectomy, open
C35483
Atherectomy, open
C35501
Artery bypass graft
C35506
Artery bypass graft
C35508
Artery bypass graft
C35509
Artery bypass graft
C35510
Artery bypass graft
C35511
Artery bypass graft
C35512
Artery bypass graft
C35515
Artery bypass graft
C35516
Artery bypass graft
C35518
Artery bypass graft
C35521
Artery bypass graft
C35522
Artery bypass graft
C35525
Artery bypass graft
C35526
Artery bypass graft
C35531
Artery bypass graft
C35533
Artery bypass graft
C35536
Artery bypass graft
C35537
Artery bypass graft
C35538
Artery bypass graft
C35539
Artery bypass graft
C35540
Artery bypass graft
C35548
Artery bypass graft
C35549
Artery bypass graft
C35551
Artery bypass graft
C35556
Artery bypass graft
C35558
Artery bypass graft
C35560
Artery bypass graft
C35563
Artery bypass graft
C( print page 68391)35565
Artery bypass graft
C35566
Artery bypass graft
C35571
Artery bypass graft
C35583
Vein bypass graft
C35585
Vein bypass graft
C35587
Vein bypass graft
C35600
Harvest artery for cabg
C35601
Artery bypass graft
C35606
Artery bypass graft
C35612
Artery bypass graft
C35616
Artery bypass graft
C35621
Artery bypass graft
C35623
Bypass graft, not vein
C35626
Artery bypass graft
C35631
Artery bypass graft
C35636
Artery bypass graft
C35637
Artery bypass graft
C35638
Artery bypass graft
C35642
Artery bypass graft
C35645
Artery bypass graft
C35646
Artery bypass graft
C35647
Artery bypass graft
C35650
Artery bypass graft
C35651
Artery bypass graft
C35654
Artery bypass graft
C35656
Artery bypass graft
C35661
Artery bypass graft
C35663
Artery bypass graft
C35665
Artery bypass graft
C35666
Artery bypass graft
C35671
Artery bypass graft
C35681
Composite bypass graft
C35682
Composite bypass graft
C35683
Composite bypass graft
C35691
Arterial transposition
C35693
Arterial transposition
C35694
Arterial transposition
C35695
Arterial transposition
C35697
Reimplant artery each
C35700
Reoperation, bypass graft
C35701
Exploration, carotid artery
C35721
Exploration, femoral artery
C35741
Exploration popliteal artery
C35800
Explore neck vessels
C35820
Explore chest vessels
C35840
Explore abdominal vessels
C35870
Repair vessel graft defect
C35901
Excision, graft, neck
C35905
Excision, graft, thorax
C35907
Excision, graft, abdomen
C36660
Insertion catheter, artery
C36822
Insertion of cannula(s)
C36823
Insertion of cannula(s)
C37140
Revision of circulation
C37145
Revision of circulation
C37160
Revision of circulation
C37180
Revision of circulation
C37181
Splice spleen/kidney veins
C37182
Insert hepatic shunt (tips)
C37215
Transcath stent, cca w/eps
C37616
Ligation of chest artery
C37617
Ligation of abdomen artery
C37618
Ligation of extremity artery
C37660
Revision of major vein
C37788
Revascularization, penis
C38100
Removal of spleen, total
C38101
Removal of spleen, partial
C38102
Removal of spleen, total
C38115
Repair of ruptured spleen
C38380
Thoracic duct procedure
C38381
Thoracic duct procedure
C38382
Thoracic duct procedure
C38562
Removal, pelvic lymph nodes
C38564
Removal, abdomen lymph nodes
C38724
Removal of lymph nodes, neck
C38746
Remove thoracic lymph nodes
C38747
Remove abdominal lymph nodes
C38765
Remove groin lymph nodes
C38770
Remove pelvis lymph nodes
C38780
Remove abdomen lymph nodes
C39000
Exploration of chest
C39010
Exploration of chest
C39200
Removal chest lesion
C39220
Removal chest lesion
C39499
Chest procedure
C39501
Repair diaphragm laceration
C39502
Repair paraesophageal hernia
C39503
Repair of diaphragm hernia
C39520
Repair of diaphragm hernia
C39530
Repair of diaphragm hernia
C39531
Repair of diaphragm hernia
C39540
Repair of diaphragm hernia
C39541
Repair of diaphragm hernia
C39545
Revision of diaphragm
C39560
Resect diaphragm, simple
C39561
Resect diaphragm, complex
C39599
Diaphragm surgery procedure
C41130
Partial removal of tongue
C41135
Tongue and neck surgery
C41140
Removal of tongue
C41145
Tongue removal, neck surgery
C41150
Tongue, mouth, jaw surgery
C41153
Tongue, mouth, neck surgery
C41155
Tongue, jaw, & neck surgery
C42426
Excise parotid gland/lesion
C42845
Extensive surgery of throat
C42894
Revision of pharyngeal walls
C42953
Repair throat, esophagus
C42961
Control throat bleeding
C42971
Control nose/throat bleeding
C43045
Incision of esophagus
C43100
Excision of esophagus lesion
C43101
Excision of esophagus lesion
C43107
Removal of esophagus
C43108
Removal of esophagus
C43112
Removal of esophagus
C43113
Removal of esophagus
C43116
Partial removal of esophagus
C43117
Partial removal of esophagus
C43118
Partial removal of esophagus
C43121
Partial removal of esophagus
C43122
Partial removal of esophagus
C43123
Partial removal of esophagus
C43124
Removal of esophagus
C43135
Removal of esophagus pouch
C43300
Repair of esophagus
C43305
Repair esophagus and fistula
C43310
Repair of esophagus
C43312
Repair esophagus and fistula
C43313
Esophagoplasty congenital
C43314
Tracheo-esophagoplasty cong
C43320
Fuse esophagus & stomach
C43324
Revise esophagus & stomach
C43325
Revise esophagus & stomach
C43326
Revise esophagus & stomach
C43330
Repair of esophagus
C43331
Repair of esophagus
C43340
Fuse esophagus & intestine
C43341
Fuse esophagus & intestine
C( print page 68392)43350
Surgical opening, esophagus
C43351
Surgical opening, esophagus
C43352
Surgical opening, esophagus
C43360
Gastrointestinal repair
C43361
Gastrointestinal repair
C43400
Ligate esophagus veins
C43401
Esophagus surgery for veins
C43405
Ligate/staple esophagus
C43410
Repair esophagus wound
C43415
Repair esophagus wound
C43420
Repair esophagus opening
C43425
Repair esophagus opening
C43460
Pressure treatment esophagus
C43496
Free jejunum flap, microvasc
C43500
Surgical opening of stomach
C43501
Surgical repair of stomach
C43502
Surgical repair of stomach
C43520
Incision of pyloric muscle
C43605
Biopsy of stomach
C43610
Excision of stomach lesion
C43611
Excision of stomach lesion
C43620
Removal of stomach
C43621
Removal of stomach
C43622
Removal of stomach
C43631
Removal of stomach, partial
C43632
Removal of stomach, partial
C43633
Removal of stomach, partial
C43634
Removal of stomach, partial
C43635
Removal of stomach, partial
C43640
Vagotomy & pylorus repair
C43641
Vagotomy & pylorus repair
C43644
Lap gastric bypass/roux-en-y
C43645
Lap gastr bypass incl smll i
C43770
Lap, place gastr adjust band
C43771
Lap, revise adjust gast band
C43772
Lap, remove adjust gast band
C43773
Lap, change adjust gast band
C43774
Lap remov adj gast band/port
C43800
Reconstruction of pylorus
C43810
Fusion of stomach and bowel
C43820
Fusion of stomach and bowel
C43825
Fusion of stomach and bowel
C43832
Place gastrostomy tube
C43840
Repair of stomach lesion
C43843
Gastroplasty w/o v-band
C43845
Gastroplasty duodenal switch
C43846
Gastric bypass for obesity
C43847
Gastric bypass incl small i
C43848
Revision gastroplasty
C43850
Revise stomach-bowel fusion
C43855
Revise stomach-bowel fusion
C43860
Revise stomach-bowel fusion
C43865
Revise stomach-bowel fusion
C43880
Repair stomach-bowel fistula
C43881
Impl/redo electrd, antrum
C43882
Revise/remove electrd antrum
C44005
Freeing of bowel adhesion
C44010
Incision of small bowel
C44015
Insert needle cath bowel
C44020
Explore small intestine
C44021
Decompress small bowel
C44025
Incision of large bowel
C44050
Reduce bowel obstruction
C44055
Correct malrotation of bowel
C44110
Excise intestine lesion(s)
C44111
Excision of bowel lesion(s)
C44120
Removal of small intestine
C44121
Removal of small intestine
C44125
Removal of small intestine
C44126
Enterectomy w/o taper, cong
C44127
Enterectomy w/taper, cong
C44128
Enterectomy cong, add-on
C44130
Bowel to bowel fusion
C44132
Enterectomy, cadaver donor
C44133
Enterectomy, live donor
C44135
Intestine transplnt, cadaver
C44136
Intestine transplant, live
C44137
Remove intestinal allograft
C44139
Mobilization of colon
C44140
Partial removal of colon
C44141
Partial removal of colon
C44143
Partial removal of colon
C44144
Partial removal of colon
C44145
Partial removal of colon
C44146
Partial removal of colon
C44147
Partial removal of colon
C44150
Removal of colon
C44151
Removal of colon/ileostomy
C44155
Removal of colon/ileostomy
C44156
Removal of colon/ileostomy
C44157
Colectomy w/ileoanal anast
C44158
Colectomy w/neo-rectum pouch
C44160
Removal of colon
C44187
Lap, ileo/jejuno-stomy
C44188
Lap, colostomy
C44202
Lap, enterectomy
C44203
Lap resect s/intestine, addl
C44204
Laparo partial colectomy
C44205
Lap colectomy part w/ileum
C44210
Laparo total proctocolectomy
C44211
Lap colectomy w/proctectomy
C44212
Laparo total proctocolectomy
C44227
Lap, close enterostomy
C44300
Open bowel to skin
C44310
Ileostomy/jejunostomy
C44314
Revision of ileostomy
C44316
Devise bowel pouch
C44320
Colostomy
C44322
Colostomy with biopsies
C44345
Revision of colostomy
C44346
Revision of colostomy
C44602
Suture, small intestine
C44603
Suture, small intestine
C44604
Suture, large intestine
C44605
Repair of bowel lesion
C44615
Intestinal stricturoplasty
C44620
Repair bowel opening
C44625
Repair bowel opening
C44626
Repair bowel opening
C44640
Repair bowel-skin fistula
C44650
Repair bowel fistula
C44660
Repair bowel-bladder fistula
C44661
Repair bowel-bladder fistula
C44680
Surgical revision, intestine
C44700
Suspend bowel w/prosthesis
C44715
Prepare donor intestine
C44720
Prep donor intestine/venous
C44721
Prep donor intestine/artery
C44800
Excision of bowel pouch
C( print page 68393)44820
Excision of mesentery lesion
C44850
Repair of mesentery
C44899
Bowel surgery procedure
C44900
Drain app abscess, open
C44950
Appendectomy
C44955
Appendectomy add-on
C44960
Appendectomy
C45110
Removal of rectum
C45111
Partial removal of rectum
C45112
Removal of rectum
C45113
Partial proctectomy
C45114
Partial removal of rectum
C45116
Partial removal of rectum
C45119
Remove rectum w/reservoir
C45120
Removal of rectum
C45121
Removal of rectum and colon
C45123
Partial proctectomy
C45126
Pelvic exenteration
C45130
Excision of rectal prolapse
C45135
Excision of rectal prolapse
C45136
Excise ileoanal reservior
C45395
Lap, removal of rectum
C45397
Lap, remove rectum w/pouch
C45400
Laparoscopic proctopexy
C45402
Lap proctopexy w/sig resect
C45540
Correct rectal prolapse
C45550
Repair rectum/remove sigmoid
C45562
Exploration/repair of rectum
C45563
Exploration/repair of rectum
C45800
Repair rect/bladder fistula
C45805
Repair fistula w/colostomy
C45820
Repair rectourethral fistula
C45825
Repair fistula w/colostomy
C46705
Repair of anal stricture
C46710
Repr per/vag pouch sngl proc
C46712
Repr per/vag pouch dbl proc
C46715
Rep perf anoper fistu
C46716
Rep perf anoper/vestib fistu
C46730
Construction of absent anus
C46735
Construction of absent anus
C46740
Construction of absent anus
C46742
Repair of imperforated anus
C46744
Repair of cloacal anomaly
C46746
Repair of cloacal anomaly
C46748
Repair of cloacal anomaly
C46751
Repair of anal sphincter
C47010
Open drainage, liver lesion
C47015
Inject/aspirate liver cyst
C47100
Wedge biopsy of liver
C47120
Partial removal of liver
C47122
Extensive removal of liver
C47125
Partial removal of liver
C47130
Partial removal of liver
C47133
Removal of donor liver
C47135
Transplantation of liver
C47136
Transplantation of liver
C47140
Partial removal, donor liver
C47141
Partial removal, donor liver
C47142
Partial removal, donor liver
C47143
Prep donor liver, whole
C47144
Prep donor liver, 3-segment
C47145
Prep donor liver, lobe split
C47146
Prep donor liver/venous
C47147
Prep donor liver/arterial
C47300
Surgery for liver lesion
C47350
Repair liver wound
C47360
Repair liver wound
C47361
Repair liver wound
C47362
Repair liver wound
C47380
Open ablate liver tumor rf
C47381
Open ablate liver tumor cryo
C47400
Incision of liver duct
C47420
Incision of bile duct
C47425
Incision of bile duct
C47460
Incise bile duct sphincter
C47480
Incision of gallbladder
C47550
Bile duct endoscopy add-on
C47570
Laparo cholecystoenterostomy
C47600
Removal of gallbladder
C47605
Removal of gallbladder
C47610
Removal of gallbladder
C47612
Removal of gallbladder
C47620
Removal of gallbladder
C47700
Exploration of bile ducts
C47701
Bile duct revision
C47711
Excision of bile duct tumor
C47712
Excision of bile duct tumor
C47715
Excision of bile duct cyst
C47719
Fusion of bile duct cyst
C47720
Fuse gallbladder & bowel
C47721
Fuse upper gi structures
C47740
Fuse gallbladder & bowel
C47741
Fuse gallbladder & bowel
C47760
Fuse bile ducts and bowel
C47765
Fuse liver ducts & bowel
C47780
Fuse bile ducts and bowel
C47785
Fuse bile ducts and bowel
C47800
Reconstruction of bile ducts
C47801
Placement, bile duct support
C47802
Fuse liver duct & intestine
C47900
Suture bile duct injury
C48000
Drainage of abdomen
C48001
Placement of drain, pancreas
C48020
Removal of pancreatic stone
C48100
Biopsy of pancreas, open
C48105
Resect/debride pancreas
C48120
Removal of pancreas lesion
C48140
Partial removal of pancreas
C48145
Partial removal of pancreas
C48146
Pancreatectomy
C48148
Removal of pancreatic duct
C48150
Partial removal of pancreas
C48152
Pancreatectomy
C48153
Pancreatectomy
C48154
Pancreatectomy
C48155
Removal of pancreas
C48400
Injection, intraop add-on
C48500
Surgery of pancreatic cyst
C48510
Drain pancreatic pseudocyst
C48520
Fuse pancreas cyst and bowel
C48540
Fuse pancreas cyst and bowel
C48545
Pancreatorrhaphy
C48547
Duodenal exclusion
C48548
Fuse pancreas and bowel
C48551
Prep donor pancreas
C48552
Prep donor pancreas/venous
C48554
Transpl allograft pancreas
C48556
Removal, allograft pancreas
C49000
Exploration of abdomen
C49002
Reopening of abdomen
C49010
Exploration behind abdomen
C49020
Drain abdominal abscess
C( print page 68394)49040
Drain, open, abdom abscess
C49060
Drain, open, retrop abscess
C49062
Drain to peritoneal cavity
C49201
Remove abdom lesion, complex
C49215
Excise sacral spine tumor
C49220
Multiple surgery, abdomen
C49255
Removal of omentum
C49425
Insert abdomen-venous drain
C49428
Ligation of shunt
C49605
Repair umbilical lesion
C49606
Repair umbilical lesion
C49610
Repair umbilical lesion
C49611
Repair umbilical lesion
C49900
Repair of abdominal wall
C49904
Omental flap, extra-abdom
C49905
Omental flap, intra-abdom
C49906
Free omental flap, microvasc
C50010
Exploration of kidney
C50040
Drainage of kidney
C50045
Exploration of kidney
C50060
Removal of kidney stone
C50065
Incision of kidney
C50070
Incision of kidney
C50075
Removal of kidney stone
C50100
Revise kidney blood vessels
C50120
Exploration of kidney
C50125
Explore and drain kidney
C50130
Removal of kidney stone
C50135
Exploration of kidney
C50205
Biopsy of kidney
C50220
Remove kidney, open
C50225
Removal kidney open, complex
C50230
Removal kidney open, radical
C50234
Removal of kidney & ureter
C50236
Removal of kidney & ureter
C50240
Partial removal of kidney
C50250
Cryoablate renal mass open
C50280
Removal of kidney lesion
C50290
Removal of kidney lesion
C50300
Remove cadaver donor kidney
C50320
Remove kidney, living donor
C50323
Prep cadaver renal allograft
C50325
Prep donor renal graft
C50327
Prep renal graft/venous
C50328
Prep renal graft/arterial
C50329
Prep renal graft/ureteral
C50340
Removal of kidney
C50360
Transplantation of kidney
C50365
Transplantation of kidney
C50370
Remove transplanted kidney
C50380
Reimplantation of kidney
C50400
Revision of kidney/ureter
C50405
Revision of kidney/ureter
C50500
Repair of kidney wound
C50520
Close kidney-skin fistula
C50525
Repair renal-abdomen fistula
C50526
Repair renal-abdomen fistula
C50540
Revision of horseshoe kidney
C50545
Laparo radical nephrectomy
C50546
Laparoscopic nephrectomy
C50547
Laparo removal donor kidney
C50548
Laparo remove w/ureter
C50580
Kidney endoscopy & treatment
C50600
Exploration of ureter
C50605
Insert ureteral support
C50610
Removal of ureter stone
C50620
Removal of ureter stone
C50630
Removal of ureter stone
C50650
Removal of ureter
C50660
Removal of ureter
C50700
Revision of ureter
C50715
Release of ureter
C50722
Release of ureter
C50725
Release/revise ureter
C50727
Revise ureter
C50728
Revise ureter
C50740
Fusion of ureter & kidney
C50750
Fusion of ureter & kidney
C50760
Fusion of ureters
C50770
Splicing of ureters
C50780
Reimplant ureter in bladder
C50782
Reimplant ureter in bladder
C50783
Reimplant ureter in bladder
C50785
Reimplant ureter in bladder
C50800
Implant ureter in bowel
C50810
Fusion of ureter & bowel
C50815
Urine shunt to intestine
C50820
Construct bowel bladder
C50825
Construct bowel bladder
C50830
Revise urine flow
C50840
Replace ureter by bowel
C50845
Appendico-vesicostomy
C50860
Transplant ureter to skin
C50900
Repair of ureter
C50920
Closure ureter/skin fistula
C50930
Closure ureter/bowel fistula
C50940
Release of ureter
C51060
Removal of ureter stone
C51525
Removal of bladder lesion
C51530
Removal of bladder lesion
C51535
Repair of ureter lesion
C51550
Partial removal of bladder
C51555
Partial removal of bladder
C51565
Revise bladder & ureter(s)
C51570
Removal of bladder
C51575
Removal of bladder & nodes
C51580
Remove bladder/revise tract
C51585
Removal of bladder & nodes
C51590
Remove bladder/revise tract
C51595
Remove bladder/revise tract
C51596
Remove bladder/create pouch
C51597
Removal of pelvic structures
C51800
Revision of bladder/urethra
C51820
Revision of urinary tract
C51840
Attach bladder/urethra
C51841
Attach bladder/urethra
C51845
Repair bladder neck
C51860
Repair of bladder wound
C51865
Repair of bladder wound
C51900
Repair bladder/vagina lesion
C51920
Close bladder-uterus fistula
C51925
Hysterectomy/bladder repair
C51940
Correction of bladder defect
C51960
Revision of bladder & bowel
C51980
Construct bladder opening
C53415
Reconstruction of urethra
C53448
Remov/replc ur sphinctr comp
C54125
Removal of penis
C54130
Remove penis & nodes
C54135
Remove penis & nodes
C54332
Revise penis/urethra
C54336
Revise penis/urethra
C54390
Repair penis and bladder
C54411
Remov/replc penis pros, comp
C54417
Remv/replc penis pros, compl
C54430
Revision of penis
C54535
Extensive testis surgery
C54650
Orchiopexy (Fowler-Stephens)
C55605
Incise sperm duct pouch
C( print page 68395)55650
Remove sperm duct pouch
C55801
Removal of prostate
C55810
Extensive prostate surgery
C55812
Extensive prostate surgery
C55815
Extensive prostate surgery
C55821
Removal of prostate
C55831
Removal of prostate
C55840
Extensive prostate surgery
C55842
Extensive prostate surgery
C55845
Extensive prostate surgery
C55862
Extensive prostate surgery
C55865
Extensive prostate surgery
C55866
Laparo radical prostatectomy
C56630
Extensive vulva surgery
C56631
Extensive vulva surgery
C56632
Extensive vulva surgery
C56633
Extensive vulva surgery
C56634
Extensive vulva surgery
C56637
Extensive vulva surgery
C56640
Extensive vulva surgery
C57110
Remove vagina wall, complete
C57111
Remove vagina tissue, compl
C57112
Vaginectomy w/nodes, compl
C57270
Repair of bowel pouch
C57280
Suspension of vagina
C57296
Revise vag graft, open abd
C57305
Repair rectum-vagina fistula
C57307
Fistula repair & colostomy
C57308
Fistula repair, transperine
C57311
Repair urethrovaginal lesion
C57531
Removal of cervix, radical
C57540
Removal of residual cervix
C57545
Remove cervix/repair pelvis
C58140
Myomectomy abdom method
C58146
Myomectomy abdom complex
C58150
Total hysterectomy
C58152
Total hysterectomy
C58180
Partial hysterectomy
C58200
Extensive hysterectomy
C58210
Extensive hysterectomy
C58240
Removal of pelvis contents
C58267
Vag hyst w/urinary repair
C58275
Hysterectomy/revise vagina
C58280
Hysterectomy/revise vagina
C58285
Extensive hysterectomy
C58293
Vag hyst w/uro repair, compl
C58400
Suspension of uterus
C58410
Suspension of uterus
C58520
Repair of ruptured uterus
C58540
Revision of uterus
C58548
Lap radical hyst
C58605
Division of fallopian tube
C58611
Ligate oviduct(s) add-on
C58700
Removal of fallopian tube
C58720
Removal of ovary/tube(s)
C58740
Revise fallopian tube(s)
C58750
Repair oviduct
C58752
Revise ovarian tube(s)
C58760
Remove tubal obstruction
C58805
Drainage of ovarian cyst(s)
C58822
Drain ovary abscess, percut
C58825
Transposition, ovary(s)
C58940
Removal of ovary(s)
C58943
Removal of ovary(s)
C58950
Resect ovarian malignancy
C58951
Resect ovarian malignancy
C58952
Resect ovarian malignancy
C58953
Tah, rad dissect for debulk
C58954
Tah rad debulk/lymph remove
C58956
Bso, omentectomy w/tah
C58957
Resect recurrent gyn mal
C58958
Resect recur gyn mal w/lym
C58960
Exploration of abdomen
C59120
Treat ectopic pregnancy
C59121
Treat ectopic pregnancy
C59130
Treat ectopic pregnancy
C59135
Treat ectopic pregnancy
C59136
Treat ectopic pregnancy
C59140
Treat ectopic pregnancy
C59325
Revision of cervix
C59350
Repair of uterus
C59514
Cesarean delivery only
C59525
Remove uterus after cesarean
C59620
Attempted vbac delivery only
C59830
Treat uterus infection
C59850
Abortion
C59851
Abortion
C59852
Abortion
C59855
Abortion
C59856
Abortion
C59857
Abortion
C60254
Extensive thyroid surgery
C60270
Removal of thyroid
C60271
Removal of thyroid
C60505
Explore parathyroid glands
C60521
Removal of thymus gland
C60522
Removal of thymus gland
C60540
Explore adrenal gland
C60545
Explore adrenal gland
C60600
Remove carotid body lesion
C60605
Remove carotid body lesion
C60650
Laparoscopy adrenalectomy
C61105
Twist drill hole
C61107
Drill skull for implantation
C61108
Drill skull for drainage
C61120
Burr hole for puncture
C61140
Pierce skull for biopsy
C61150
Pierce skull for drainage
C61151
Pierce skull for drainage
C61154
Pierce skull & remove clot
C61156
Pierce skull for drainage
C61210
Pierce skull, implant device
C61250
Pierce skull & explore
C61253
Pierce skull & explore
C61304
Open skull for exploration
C61305
Open skull for exploration
C61312
Open skull for drainage
C61313
Open skull for drainage
C61314
Open skull for drainage
C61315
Open skull for drainage
C61316
Implt cran bone flap to abdo
C61320
Open skull for drainage
C61321
Open skull for drainage
C61322
Decompressive craniotomy
C61323
Decompressive lobectomy
C61332
Explore/biopsy eye socket
C61333
Explore orbit/remove lesion
C61340
Subtemporal decompression
C61343
Incise skull (press relief)
C61345
Relieve cranial pressure
C61440
Incise skull for surgery
C61450
Incise skull for surgery
C61458
Incise skull for brain wound
C61460
Incise skull for surgery
C61470
Incise skull for surgery
C61480
Incise skull for surgery
C61490
Incise skull for surgery
C61500
Removal of skull lesion
C61501
Remove infected skull bone
C( print page 68396)61510
Removal of brain lesion
C61512
Remove brain lining lesion
C61514
Removal of brain abscess
C61516
Removal of brain lesion
C61517
Implt brain chemotx add-on
C61518
Removal of brain lesion
C61519
Remove brain lining lesion
C61520
Removal of brain lesion
C61521
Removal of brain lesion
C61522
Removal of brain abscess
C61524
Removal of brain lesion
C61526
Removal of brain lesion
C61530
Removal of brain lesion
C61531
Implant brain electrodes
C61533
Implant brain electrodes
C61534
Removal of brain lesion
C61535
Remove brain electrodes
C61536
Removal of brain lesion
C61537
Removal of brain tissue
C61538
Removal of brain tissue
C61539
Removal of brain tissue
C61540
Removal of brain tissue
C61541
Incision of brain tissue
C61542
Removal of brain tissue
C61543
Removal of brain tissue
C61544
Remove & treat brain lesion
C61545
Excision of brain tumor
C61546
Removal of pituitary gland
C61548
Removal of pituitary gland
C61550
Release of skull seams
C61552
Release of skull seams
C61556
Incise skull/sutures
C61557
Incise skull/sutures
C61558
Excision of skull/sutures
C61559
Excision of skull/sutures
C61563
Excision of skull tumor
C61564
Excision of skull tumor
C61566
Removal of brain tissue
C61567
Incision of brain tissue
C61570
Remove foreign body, brain
C61571
Incise skull for brain wound
C61575
Skull base/brainstem surgery
C61576
Skull base/brainstem surgery
C61580
Craniofacial approach, skull
C61581
Craniofacial approach, skull
C61582
Craniofacial approach, skull
C61583
Craniofacial approach, skull
C61584
Orbitocranial approach/skull
C61585
Orbitocranial approach/skull
C61586
Resect nasopharynx, skull
C61590
Infratemporal approach/skull
C61591
Infratemporal approach/skull
C61592
Orbitocranial approach/skull
C61595
Transtemporal approach/skull
C61596
Transcochlear approach/skull
C61597
Transcondylar approach/skull
C61598
Transpetrosal approach/skull
C61600
Resect/excise cranial lesion
C61601
Resect/excise cranial lesion
C61605
Resect/excise cranial lesion
C61606
Resect/excise cranial lesion
C61607
Resect/excise cranial lesion
C61608
Resect/excise cranial lesion
C61609
Transect artery, sinus
C61610
Transect artery, sinus
C61611
Transect artery, sinus
C61612
Transect artery, sinus
C61613
Remove aneurysm, sinus
C61615
Resect/excise lesion, skull
C61616
Resect/excise lesion, skull
C61618
Repair dura
C61619
Repair dura
C61624
Transcath occlusion, cns
C61680
Intracranial vessel surgery
C61682
Intracranial vessel surgery
C61684
Intracranial vessel surgery
C61686
Intracranial vessel surgery
C61690
Intracranial vessel surgery
C61692
Intracranial vessel surgery
C61697
Brain aneurysm repr, complx
C61698
Brain aneurysm repr, complx
C61700
Brain aneurysm repr, simple
C61702
Inner skull vessel surgery
C61703
Clamp neck artery
C61705
Revise circulation to head
C61708
Revise circulation to head
C61710
Revise circulation to head
C61711
Fusion of skull arteries
C61735
Incise skull/brain surgery
C61750
Incise skull/brain biopsy
C61751
Brain biopsy w/ct/mr guide
C61760
Implant brain electrodes
C61770
Incise skull for treatment
C61850
Implant neuroelectrodes
C61860
Implant neuroelectrodes
C61863
Implant neuroelectrode
C61864
Implant neuroelectrde, addl
C61867
Implant neuroelectrode
C61868
Implant neuroelectrde, add'l
C61870
Implant neuroelectrodes
C61875
Implant neuroelectrodes
C62005
Treat skull fracture
C62010
Treatment of head injury
C62100
Repair brain fluid leakage
C62115
Reduction of skull defect
C62116
Reduction of skull defect
C62117
Reduction of skull defect
C62120
Repair skull cavity lesion
C62121
Incise skull repair
C62140
Repair of skull defect
C62141
Repair of skull defect
C62142
Remove skull plate/flap
C62143
Replace skull plate/flap
C62145
Repair of skull & brain
C62146
Repair of skull with graft
C62147
Repair of skull with graft
C62148
Retr bone flap to fix skull
C62161
Dissect brain w/scope
C62162
Remove colloid cyst w/scope
C62163
Neuroendoscopy w/fb removal
C62164
Remove brain tumor w/scope
C62165
Remove pituit tumor w/scope
C62180
Establish brain cavity shunt
C62190
Establish brain cavity shunt
C62192
Establish brain cavity shunt
C62200
Establish brain cavity shunt
C62201
Brain cavity shunt w/scope
C62220
Establish brain cavity shunt
C62223
Establish brain cavity shunt
C62256
Remove brain cavity shunt
C62258
Replace brain cavity shunt
C63043
Laminotomy, add'l cervical
C63044
Laminotomy, add'l lumbar
C63050
Cervical laminoplasty
C( print page 68397)63051
C-laminoplasty w/graft/plate
C63076
Neck spine disk surgery
C63077
Spine disk surgery, thorax
C63078
Spine disk surgery, thorax
C63081
Removal of vertebral body
C63082
Remove vertebral body add-on
C63085
Removal of vertebral body
C63086
Remove vertebral body add-on
C63087
Removal of vertebral body
C63088
Remove vertebral body add-on
C63090
Removal of vertebral body
C63091
Remove vertebral body add-on
C63101
Removal of vertebral body
C63102
Removal of vertebral body
C63103
Remove vertebral body add-on
C63170
Incise spinal cord tract(s)
C63172
Drainage of spinal cyst
C63173
Drainage of spinal cyst
C63180
Revise spinal cord ligaments
C63182
Revise spinal cord ligaments
C63185
Incise spinal column/nerves
C63190
Incise spinal column/nerves
C63191
Incise spinal column/nerves
C63194
Incise spinal column & cord
C63195
Incise spinal column & cord
C63196
Incise spinal column & cord
C63197
Incise spinal column & cord
C63198
Incise spinal column & cord
C63199
Incise spinal column & cord
C63200
Release of spinal cord
C63250
Revise spinal cord vessels
C63251
Revise spinal cord vessels
C63252
Revise spinal cord vessels
C63265
Excise intraspinal lesion
C63266
Excise intraspinal lesion
C63267
Excise intraspinal lesion
C63268
Excise intraspinal lesion
C63270
Excise intraspinal lesion
C63271
Excise intraspinal lesion
C63272
Excise intraspinal lesion
C63273
Excise intraspinal lesion
C63275
Biopsy/excise spinal tumor
C63276
Biopsy/excise spinal tumor
C63277
Biopsy/excise spinal tumor
C63278
Biopsy/excise spinal tumor
C63280
Biopsy/excise spinal tumor
C63281
Biopsy/excise spinal tumor
C63282
Biopsy/excise spinal tumor
C63283
Biopsy/excise spinal tumor
C63285
Biopsy/excise spinal tumor
C63286
Biopsy/excise spinal tumor
C63287
Biopsy/excise spinal tumor
C63290
Biopsy/excise spinal tumor
C63295
Repair of laminectomy defect
C63300
Removal of vertebral body
C63301
Removal of vertebral body
C63302
Removal of vertebral body
C63303
Removal of vertebral body
C63304
Removal of vertebral body
C63305
Removal of vertebral body
C63306
Removal of vertebral body
C63307
Removal of vertebral body
C63308
Remove vertebral body add-on
C63700
Repair of spinal herniation
C63702
Repair of spinal herniation
C63704
Repair of spinal herniation
C63706
Repair of spinal herniation
C63707
Repair spinal fluid leakage
C63709
Repair spinal fluid leakage
C63710
Graft repair of spine defect
C63740
Install spinal shunt
C64752
Incision of vagus nerve
C64755
Incision of stomach nerves
C64760
Incision of vagus nerve
C64809
Remove sympathetic nerves
C64818
Remove sympathetic nerves
C64866
Fusion of facial/other nerve
C64868
Fusion of facial/other nerve
C65273
Repair of eye wound
C69155
Extensive ear/neck surgery
C69535
Remove part of temporal bone
C69554
Remove ear lesion
C69950
Incise inner ear nerve
C69970
Remove inner ear lesion
C75900
Intravascular cath exchange
C75952
Endovasc repair abdom aorta
C75953
Abdom aneurysm endovas rpr
C75954
Iliac aneurysm endovas rpr
C75956
Xray, endovasc thor ao repr
C75957
Xray, endovasc thor ao repr
C75958
Xray, place prox ext thor ao
C75959
Xray, place dist ext thor ao
C92970
Cardioassist, internal
C92971
Cardioassist, external
C92975
Dissolve clot, heart vessel
C92992
Revision of heart chamber
C92993
Revision of heart chamber
C99190
Special pump services
C99191
Special pump services
C99192
Special pump services
C99251
Inpatient consultation
C99252
Inpatient consultation
C99253
Inpatient consultation
C99254
Inpatient consultation
C99255
Inpatient consultation
C99293
Ped critical care, initial
C99294
Ped critical care, subseq
C99295
Neonate crit care, initial
C99296
Neonate critical care subseq
C99298
Ic for lbw infant <1500 gm
C99299
Ic, lbw infant 1500-2500 gm
C99356
Prolonged service, inpatient
C99357
Prolonged service, inpatient
C99433
Normal newborn care/hospital
C0024T
Transcath cardiac reduction
C0048T
Implant ventricular device
C0049T
External circulation assist
C( print page 68398)0050T
Removal circulation assist
C0051T
Implant total heart system
C0052T
Replace component heart syst
C0053T
Replace component heart syst
C0075T
Perq stent/chest vert art
C0076T
S&i stent/chest vert art
C0077T
Cereb therm perfusion probe
C0078T
Endovasc aort repr w/device
C0079T
Endovasc visc extnsn repr
C0080T
Endovasc aort repr rad s&i
C0081T
Endovasc visc extnsn s&i
C0092T
Artific disc addl
C0093T
Cervical artific diskectomy
C0095T
Artific diskectomy addl
C0096T
Rev cervical artific disc
C0098T
Rev artific disc addl
C0153T
Tcath sensor aneurysm sac
C0157T
Open impl gast curve electrd
C0158T
Open remv gast curve electrd
C0163T
Lumb artif diskectomy addl
C0164T
Remove lumb artif disc addl
C0165T
Revise lumb artif disc addl
C0166T
Tcath vsd close w/o bypass
C0167T
Tcath vsd close w bypass
C0169T
Place stereo cath brain
CG0341
Percutaneous islet celltrans
CG0342
Laparoscopy islet cell trans
CG0343
Laparotomy islet cell transp
C
 Addendum L.—Out-Migration Adjustment
Provider No.
Out-
                                 migration  
                                 adjustment
Qualifying county name010005
0.0259
MARSHALL010008
0.0212
CRENSHAW010009
0.0092
MORGAN010010
0.0259
MARSHALL010012
0.0205
DE KALB010022
0.0714
CHEROKEE010025
0.0235
CHAMBERS010029
0.0107
LEE010035
0.0375
CULLMAN010038
0.0062
CALHOUN010045
0.0160
FAYETTE010047
0.0155
BUTLER010052
0.0103
TALLAPOOSA010054
0.0092
MORGAN010061
0.0506
JACKSON010065
0.0103
TALLAPOOSA010078
0.0062
CALHOUN010083
0.0121
BALDWIN010085
0.0092
MORGAN010100
0.0121
BALDWIN010101
0.0310
TALLADEGA010109
0.0451
PICKENS010129
0.0121
BALDWIN010143
0.0375
CULLMAN010146
0.0062
CALHOUN010150
0.0155
BUTLER010158
0.0093
FRANKLIN010164
0.0310
TALLADEGA013027
0.0121
BALDWIN014008
0.0121
BALDWIN014009
0.0092
MORGAN040014
0.0159
WHITE040019
0.0697
ST. FRANCIS040047
0.0090
RANDOLPH040069
0.0140
MISSISSIPPI040071
0.0026
JEFFERSON040076
0.1075
HOT SPRING040100
0.0159
WHITE042007
0.0026
JEFFERSON050008
0.0026
SAN FRANCISCO050009
0.0478
NAPA050013
0.0478
NAPA050014
0.0131
AMADOR050016
0.0103
SAN LUIS OBISPO050042
0.0219
TEHAMA050046
0.0156
VENTURA050047
0.0026
SAN FRANCISCO050055
0.0026
SAN FRANCISCO050065
0.0029
ORANGE050069
0.0029
ORANGE050073
0.0269
SOLANO050076
0.0026
SAN FRANCISCO050082
0.0156
VENTURA050084
0.0555
SAN JOAQUIN050089
0.0152
SAN BERNARDINO050090
0.0308
SONOMA050099
0.0152
SAN BERNARDINO050101
0.0269
SOLANO050117
0.0463
MERCED050118
0.0555
SAN JOAQUIN050122
0.0555
SAN JOAQUIN050129
0.0152
SAN BERNARDINO050133
0.0170
YUBA050136
0.0308
SONOMA050140
0.0152
SAN BERNARDINO050150
0.0316
NEVADA050152
0.0026
SAN FRANCISCO050159
0.0156
VENTURA050167
0.0555
SAN JOAQUIN050168
0.0029
ORANGE050173
0.0029
ORANGE050174
0.0308
SONOMA050193
0.0029
ORANGE050194
0.0052
SANTA CRUZ050224
0.0029
ORANGE050226
0.0029
ORANGE050228
0.0026
SAN FRANCISCO050230
0.0029
ORANGE050232
0.0103
SAN LUIS OBISPO050236
0.0156
VENTURA050242
0.0052
SANTA CRUZ050245
0.0152
SAN BERNARDINO050272
0.0152
SAN BERNARDINO050279
0.0152
SAN BERNARDINO050291
0.0308
SONOMA050298
0.0152
SAN BERNARDINO050300
0.0152
SAN BERNARDINO050313
0.0555
SAN JOAQUIN050325
0.0176
TUOLUMNE050327
0.0152
SAN BERNARDINO050335
0.0176
TUOLUMNE050336
0.0555
SAN JOAQUIN050348
0.0029
ORANGE050367
0.0269
SOLANO050385
0.0308
SONOMA050394
0.0156
VENTURA050407
0.0026
SAN FRANCISCO050426
0.0029
ORANGE050444
0.0463
MERCED050454
0.0026
SAN FRANCISCO050457
0.0026
SAN FRANCISCO050469
0.0152
SAN BERNARDINO050476
0.0257
LAKE050494
0.0316
NEVADA050506
0.0103
SAN LUIS OBISPO050517
0.0152
SAN BERNARDINO050526
0.0029
ORANGE050528
0.0463
MERCED050535
0.0029
ORANGE050543
0.0029
ORANGE050547
0.0308
SONOMA050548
0.0029
ORANGE050549
0.0156
VENTURA050550
0.0029
ORANGE050551
0.0029
ORANGE050567
0.0029
ORANGE050568
0.0062
MADERA050570
0.0029
ORANGE050580
0.0029
ORANGE050584
0.0152
SAN BERNARDINO050585
0.0029
ORANGE050586
0.0152
SAN BERNARDINO050589
0.0029
ORANGE050592
0.0029
ORANGE050594
0.0029
ORANGE050603
0.0029
ORANGE050609
0.0029
ORANGE050616
0.0156
VENTURA050618
0.0152
SAN BERNARDINO050633
0.0103
SAN LUIS OBISPO050667
0.0478
NAPA050668
0.0026
SAN FRANCISCO050678
0.0029
ORANGE050680
0.0269
SOLANO050690
0.0308
SONOMA050693
0.0029
ORANGE050695
0.0555
SAN JOAQUIN050714
0.0052
SANTA CRUZ050720
0.0029
ORANGE050728
0.0308
SONOMA050744
0.0029
ORANGE050745
0.0029
ORANGE050746
0.0029
ORANGE050747
0.0029
ORANGE050749
0.0156
VENTURA052035
0.0029
ORANGE052037
0.0152
SAN BERNARDINO052039
0.0029
ORANGE( print page 68399)053034
0.0029
ORANGE053037
0.0152
SAN BERNARDINO053304
0.0029
ORANGE053306
0.0029
ORANGE053308
0.0029
ORANGE054074
0.0269
SOLANO054077
0.0156
VENTURA054089
0.0026
SAN FRANCISCO054093
0.0152
SAN BERNARDINO054111
0.0152
SAN BERNARDINO054122
0.0478
NAPA054123
0.0555
SAN JOAQUIN054135
0.0029
ORANGE054141
0.0269
SOLANO054144
0.0026
SAN FRANCISCO060001
0.0294
WELD060003
0.0203
BOULDER060010
0.0153
LARIMER060027
0.0203
BOULDER060030
0.0153
LARIMER060103
0.0203
BOULDER060116
0.0203
BOULDER063033
0.0153
LARIMER064007
0.0203
BOULDER070003
0.0009
WINDHAM070006
0.0047
FAIRFIELD070010
0.0047
FAIRFIELD070018
0.0047
FAIRFIELD070020
0.0073
MIDDLESEX070021
0.0009
WINDHAM070028
0.0047
FAIRFIELD070033
0.0047
FAIRFIELD070034
0.0047
FAIRFIELD074000
0.0047
FAIRFIELD074003
0.0073
MIDDLESEX074012
0.0047
FAIRFIELD074014
0.0047
FAIRFIELD080001
0.0063
NEW CASTLE080003
0.0063
NEW CASTLE082000
0.0063
NEW CASTLE083300
0.0063
NEW CASTLE084001
0.0063
NEW CASTLE084002
0.0063
NEW CASTLE084003
0.0063
NEW CASTLE100014
0.0118
VOLUSIA100017
0.0118
VOLUSIA100045
0.0118
VOLUSIA100047
0.0021
CHARLOTTE100062
0.0060
MARION100068
0.0118
VOLUSIA100072
0.0118
VOLUSIA100077
0.0021
CHARLOTTE100102
0.0125
COLUMBIA100118
0.0398
FLAGLER100156
0.0125
COLUMBIA100175
0.0231
DE SOTO100212
0.0060
MARION100232
0.0347
PUTNAM100236
0.0021
CHARLOTTE100252
0.0233
OKEECHOBEE100290
0.0582
SUMTER110023
0.0500
GORDON110027
0.0387
FRANKLIN110029
0.0063
HALL110041
0.0777
HABERSHAM110069
0.0474
HOUSTON110124
0.0428
WAYNE110146
0.0805
CAMDEN110150
0.0261
BALDWIN110153
0.0474
HOUSTON110187
0.1172
LUMPKIN110189
0.0031
FANNIN110190
0.0182
MACON110205
0.0779
GILMER114018
0.0261
BALDWIN130003
0.0095
NEZ PERCE130024
0.0275
BONNER130049
0.0349
KOOTENAI130066
0.0349
KOOTENAI140012
0.0220
LEE140026
0.0346
LA SALLE140033
0.0147
LAKE140043
0.0046
WHITESIDE140058
0.0081
MORGAN140084
0.0147
LAKE140100
0.0147
LAKE140110
0.0346
LA SALLE140130
0.0147
LAKE140155
0.0027
KANKAKEE140160
0.0286
STEPHENSON140161
0.0138
LIVINGSTON140186
0.0027
KANKAKEE140202
0.0147
LAKE140205
0.0163
BOONE140234
0.0346
LA SALLE140291
0.0147
LAKE150006
0.0113
LA PORTE150015
0.0113
LA PORTE150022
0.0249
MONTGOMERY150030
0.0201
HENRY150035
0.0083
PORTER150045
0.0416
DE KALB150065
0.0139
JACKSON150076
0.0189
MARSHALL150088
0.0196
MADISON150091
0.0573
HUNTINGTON150102
0.0160
STARKE150113
0.0196
MADISON150122
0.0199
RIPLEY150146
0.0319
NOBLE154047
0.0189
MARSHALL154050
0.0416
DE KALB160013
0.0218
MUSCATINE160030
0.0040
STORY160032
0.0272
JASPER160080
0.0049
CLINTON170137
0.0336
DOUGLAS180012
0.0083
HARDIN180066
0.0567
LOGAN180127
0.0352
FRANKLIN180128
0.0282
LAWRENCE183028
0.0083
HARDIN184012
0.0083
HARDIN190001
0.0645
WASHINGTON190003
0.0107
IBERIA190015
0.0401
TANGIPAHOA190017
0.0235
ST. LANDRY190054
0.0107
IBERIA190078
0.0235
ST. LANDRY190088
0.0705
WEBSTER190099
0.0390
AVOYELLES190106
0.0238
ALLEN190133
0.0238
ALLEN190144
0.0705
WEBSTER190184
0.0161
CALDWELL190190
0.0161
CALDWELL190191
0.0235
ST. LANDRY190246
0.0161
CALDWELL192034
0.0235
ST. LANDRY192036
0.0401
TANGIPAHOA192040
0.0401
TANGIPAHOA192046
0.0645
WASHINGTON193044
0.0401
TANGIPAHOA193079
0.0401
TANGIPAHOA193091
0.0107
IBERIA194080
0.0645
WASHINGTON200002
0.0129
LINCOLN200024
0.0071
ANDROSCOGGIN200032
0.0466
OXFORD200034
0.0071
ANDROSCOGGIN200050
0.0140
HANCOCK210001
0.0129
WASHINGTON210004
0.0040
MONTGOMERY210016
0.0040
MONTGOMERY210018
0.0040
MONTGOMERY210022
0.0040
MONTGOMERY210023
0.0209
ANNE ARUNDEL210028
0.0512
ST. MARYS210043
0.0209
ANNE ARUNDEL210048
0.0287
HOWARD210057
0.0040
MONTGOMERY212002
0.0129
WASHINGTON213029
0.004
MONTGOMERY214003
0.0129
WASHINGTON214013
0.004
MONTGOMERY220001
0.0056
WORCESTER220002
0.0249
MIDDLESEX220010
0.0306
ESSEX220011
0.0249
MIDDLESEX220019
0.0056
WORCESTER220025
0.0056
WORCESTER220028
0.0056
WORCESTER220029
0.0306
ESSEX220033
0.0306
ESSEX220035
0.0306
ESSEX220049
0.0249
MIDDLESEX220058
0.0056
WORCESTER220062
0.0056
WORCESTER220063
0.0249
MIDDLESEX220070
0.0249
MIDDLESEX220080
0.0306
ESSEX220082
0.0249
MIDDLESEX220084
0.0249
MIDDLESEX220089
0.0249
MIDDLESEX220090
0.0056
WORCESTER220095
0.0056
WORCESTER220098
0.0249
MIDDLESEX220101
0.0249
MIDDLESEX220105
0.0249
MIDDLESEX220163
0.0056
WORCESTER220171
0.0249
MIDDLESEX220174
0.0306
ESSEX220176
0.0056
WORCESTER222000
0.0249
MIDDLESEX222003
0.0249
MIDDLESEX222026
0.0306
ESSEX222044
0.0306
ESSEX222047
0.0306
ESSEX222048
0.0056
WORCESTER223026
0.0249
MIDDLESEX223028
0.0306
ESSEX223029
0.0056
WORCESTER223033
0.0056
WORCESTER224007
0.0249
MIDDLESEX224022
0.0249
MIDDLESEX224026
0.0056
WORCESTER224032
0.0056
WORCESTER( print page 68400)224033
0.0306
ESSEX224038
0.0249
MIDDLESEX230003
0.0035
OTTAWA230013
0.0091
OAKLAND230015
0.0359
ST. JOSEPH230019
0.0091
OAKLAND230021
0.0136
BERRIEN230022
0.0113
BRANCH230029
0.0091
OAKLAND230037
0.0178
HILLSDALE230041
0.0099
BAY230047
0.0082
MACOMB230069
0.0487
LIVINGSTON230071
0.0091
OAKLAND230072
0.0035
OTTAWA230075
0.0145
CALHOUN230078
0.0136
BERRIEN230092
0.0389
JACKSON230093
0.0079
MECOSTA230096
0.0359
ST. JOSEPH230099
0.0339
MONROE230106
0.0030
NEWAYGO230121
0.0691
SHIAWASSEE230130
0.0091
OAKLAND230151
0.0091
OAKLAND230174
0.0035
OTTAWA230195
0.0082
MACOMB230204
0.0082
MACOMB230207
0.0091
OAKLAND230217
0.0145
CALHOUN230222
0.0228
MIDLAND230223
0.0091
OAKLAND230227
0.0082
MACOMB230254
0.0091
OAKLAND230257
0.0082
MACOMB230264
0.0082
MACOMB230269
0.0091
OAKLAND230277
0.0091
OAKLAND230279
0.0487
LIVINGSTON232020
0.0099
BAY232023
0.0082
MACOMB232025
0.0136
BERRIEN232028
0.0145
CALHOUN232036
0.0389
JACKSON233025
0.0145
CALHOUN233028
0.0091
OAKLAND234011
0.0091
OAKLAND234021
0.0082
MACOMB234023
0.0091
OAKLAND234039
0.0082
MACOMB240018
0.1196
GOODHUE240044
0.0868
WINONA240064
0.0138
ITASCA240069
0.0419
STEELE240071
0.0454
RICE240187
0.0506
MC LEOD240211
0.0705
PINE250040
0.0294
JACKSON254009
0.0294
JACKSON260011
0.0007
COLE260047
0.0007
COLE260074
0.0158
RANDOLPH260097
0.0425
JOHNSON280077
0.0089
DODGE280123
0.0137
GAGE290019
0.0026
CARSON CITY290049
0.0026
CARSON CITY290051
0.0026
CARSON CITY293029
0.0026
CARSON CITY300011
0.0069
HILLSBOROUGH300012
0.0069
HILLSBOROUGH300017
0.0361
ROCKINGHAM300020
0.0069
HILLSBOROUGH300023
0.0361
ROCKINGHAM300029
0.0361
ROCKINGHAM300034
0.0069
HILLSBOROUGH303026
0.0361
ROCKINGHAM304001
0.0361
ROCKINGHAM310002
0.0351
ESSEX310009
0.0351
ESSEX310010
0.0092
MERCER310011
0.0115
CAPE MAY310013
0.0351
ESSEX310018
0.0351
ESSEX310021
0.0092
MERCER310038
0.0350
MIDDLESEX310039
0.0350
MIDDLESEX310044
0.0092
MERCER310054
0.0351
ESSEX310070
0.0350
MIDDLESEX310076
0.0351
ESSEX310083
0.0351
ESSEX310092
0.0092
MERCER310093
0.0351
ESSEX310096
0.0351
ESSEX310108
0.0350
MIDDLESEX310110
0.0092
MERCER310119
0.0351
ESSEX310123
0.0351
ESSEX310124
0.0350
MIDDLESEX312018
0.035
MIDDLESEX312019
0.0351
ESSEX313025
0.0351
ESSEX313027
0.0092
MERCER314010
0.0351
ESSEX314011
0.035
MIDDLESEX314013
0.0092
MERCER314020
0.0351
ESSEX320003
0.0629
SAN MIGUEL320011
0.0442
RIO ARRIBA320018
0.0063
DONA ANA320085
0.0063
DONA ANA323032
0.0063
DONA ANA324010
0.0063
DONA ANA324012
0.0063
DONA ANA330004
0.0959
ULSTER330008
0.0470
WYOMING330027
0.0137
NASSAU330094
0.0778
COLUMBIA330106
0.0137
NASSAU330126
0.0560
ORANGE330135
0.0560
ORANGE330167
0.0137
NASSAU330181
0.0137
NASSAU330182
0.0137
NASSAU330191
0.0026
WARREN330198
0.0137
NASSAU330205
0.0560
ORANGE330224
0.0959
ULSTER330225
0.0137
NASSAU330235
0.0270
CAYUGA330259
0.0137
NASSAU330264
0.0560
ORANGE330276
0.0063
FULTON330331
0.0137
NASSAU330332
0.0137
NASSAU330372
0.0137
NASSAU330386
0.1139
SULLIVAN334017
0.056
ORANGE334061
0.056
ORANGE340015
0.0267
ROWAN340020
0.0207
LEE340021
0.0216
CLEVELAND340037
0.0216
CLEVELAND340039
0.0144
IREDELL340069
0.0053
WAKE340070
0.0448
ALAMANCE340073
0.0053
WAKE340085
0.0377
DAVIDSON340096
0.0377
DAVIDSON340104
0.0216
CLEVELAND340114
0.0053
WAKE340126
0.0161
WILSON340127
0.0961
GRANVILLE340129
0.0144
IREDELL340133
0.0308
MARTIN340138
0.0053
WAKE340144
0.0144
IREDELL340145
0.0563
LINCOLN340173
0.0053
WAKE344001
0.0053
WAKE344004
0.0961
GRANVILLE344014
0.0053
WAKE360013
0.0166
SHELBY360025
0.0087
ERIE360036
0.0263
WAYNE360065
0.0141
HURON360070
0.0028
STARK360078
0.0159
PORTAGE360084
0.0028
STARK360086
0.0168
CLARK360095
0.0087
HANCOCK360100
0.0028
STARK360107
0.0213
SANDUSKY360131
0.0028
STARK360151
0.0028
STARK360156
0.0213
SANDUSKY360175
0.0159
CLINTON360187
0.0168
CLARK360197
0.0092
LOGAN360270
0.0120
DEFIANCE362007
0.0213
SANDUSKY362032
0.0028
STARK364031
0.0028
STARK364040
0.0168
CLARK370004
0.0193
OTTAWA370014
0.0831
BRYAN370015
0.0463
MAYES370023
0.0084
STEPHENS370065
0.0121
CRAIG370113
0.0205
DELAWARE370149
0.0356
POTTAWATOMIE370219
0.0356
POTTAWATOMIE372019
0.0356
POTTAWATOMIE374017
0.0193
OTTAWA380002
0.0130
JOSEPHINE380022
0.0201
LINN380029
0.0075
MARION380051
0.0075
MARION380056
0.0075
MARION384008
0.0075
MARION390011
0.0012
CAMBRIA390030
0.0284
SCHUYLKILL390031
0.0284
SCHUYLKILL390044
0.0200
BERKS390046
0.0098
YORK390056
0.0042
HUNTINGDON( print page 68401)390065
0.0501
ADAMS390066
0.0259
LEBANON390096
0.0200
BERKS390101
0.0098
YORK390110
0.0012
CAMBRIA390130
0.0012
CAMBRIA390138
0.0325
FRANKLIN390146
0.0053
WARREN390150
0.0206
GREENE390151
0.0325
FRANKLIN390162
0.0200
NORTHAMPTON390181
0.0284
SCHUYLKILL390183
0.0284
SCHUYLKILL390201
0.1127
MONROE390233
0.0098
YORK392031
0.0012
CAMBRIA392034
0.02
NORTHAMPTON393026
0.02
BERKS393037
0.0098
YORK394014
0.02
BERKS394016
0.0053
WARREN394020
0.0259
LEBANON420007
0.0001
SPARTANBURG420009
0.0113
OCONEE420020
0.0035
GEORGETOWN420027
0.0210
ANDERSON420030
0.0103
COLLETON420039
0.0153
UNION420043
0.0177
CHEROKEE420062
0.0109
CHESTERFIELD420068
0.0097
ORANGEBURG420070
0.0101
SUMTER420083
0.0001
SPARTANBURG420098
0.0035
GEORGETOWN423029
0.021
ANDERSON424011
0.021
ANDERSON440008
0.0663
HENDERSON440024
0.0387
BRADLEY440030
0.0056
HAMBLEN440035
0.0441
MONTGOMERY440047
0.0499
GIBSON440056
0.0321
JEFFERSON440060
0.0499
GIBSON440063
0.0011
WASHINGTON440067
0.0056
HAMBLEN440073
0.0513
MAURY440105
0.0011
WASHINGTON440115
0.0499
GIBSON440148
0.0568
DE KALB440153
0.0007
COCKE440174
0.0372
HAYWOOD440181
0.0407
HARDEMAN440184
0.0011
WASHINGTON440185
0.0387
BRADLEY444008
0.0407
HARDEMAN450032
0.0416
HARRISON450039
0.0097
TARRANT450059
0.0073
COMAL450064
0.0097
TARRANT450087
0.0097
TARRANT450099
0.0180
GRAY450121
0.0097
TARRANT450135
0.0097
TARRANT450137
0.0097
TARRANT450144
0.0573
ANDREWS450163
0.0134
KLEBERG450187
0.0264
WASHINGTON450194
0.0328
CHEROKEE450214
0.0368
WHARTON450224
0.0411
WOOD450324
0.0132
GRAYSON450347
0.0427
WALKER450370
0.0258
COLORADO450389
0.0881
HENDERSON450393
0.0132
GRAYSON450395
0.0484
POLK450419
0.0097
TARRANT450438
0.0258
COLORADO450447
0.0358
NAVARRO450451
0.0551
SOMERVELL450465
0.0435
MATAGORDA450469
0.0132
GRAYSON450547
0.0411
WOOD450563
0.0097
TARRANT450565
0.0486
PALO PINTO450596
0.0808
HOOD450597
0.0077
DE WITT450639
0.0097
TARRANT450672
0.0097
TARRANT450675
0.0097
TARRANT450677
0.0097
TARRANT450694
0.0368
WHARTON450747
0.0195
ANDERSON450755
0.0484
HOCKLEY450779
0.0097
TARRANT450813
0.0195
ANDERSON450872
0.0097
TARRANT450880
0.0097
TARRANT450886
0.0097
TARRANT450888
0.0097
TARRANT452018
0.0097
TARRANT452019
0.0097
TARRANT452028
0.0097
TARRANT452041
0.0132
GRAYSON452088
0.0097
TARRANT453040
0.0097
TARRANT453041
0.0097
TARRANT453042
0.0097
TARRANT453089
0.0195
ANDERSON453094
0.0097
TARRANT453300
0.0097
TARRANT454009
0.0328
CHEROKEE454012
0.0097
TARRANT460017
0.0392
BOX ELDER460039
0.0392
BOX ELDER490019
0.1240
CULPEPER490038
0.0022
SMYTH490084
0.0167
ESSEX490105
0.0022
SMYTH490110
0.0082
MONTGOMERY494029
0.0022
SMYTH500003
0.0208
SKAGIT500007
0.0208
SKAGIT500019
0.0213
LEWIS500021
0.0055
PIERCE500024
0.0023
THURSTON500039
0.0174
KITSAP500041
0.0118
COWLITZ500079
0.0055
PIERCE500108
0.0055
PIERCE500129
0.0055
PIERCE500139
0.0023
THURSTON500143
0.0023
THURSTON503301
0.0055
PIERCE504003
0.0055
PIERCE510018
0.0209
JACKSON510039
0.0112
OHIO510047
0.0275
MARION510050
0.0112
OHIO510077
0.0021
MINGO513025
0.0112
OHIO520028
0.0157
GREEN520035
0.0077
SHEBOYGAN520044
0.0077
SHEBOYGAN520057
0.0118
SAUK520059
0.0200
RACINE520071
0.0239
JEFFERSON520095
0.0118
SAUK520096
0.0200
RACINE520102
0.0298
WALWORTH520116
0.0239
JEFFERSON520132
0.0077
SHEBOYGAN522005
0.02
RACINE


# Footnotes

1.
    
                             The 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. Back to Citation
 2.
    
                             Additional 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.* Back to Citation
 3.
    
                             Additional information on CMS' Hospital Quality Initiative is available on the CMS Web site at: 
                            *http://www.cms.hhs.gov/​HospitalQualityInits/​.* Back to Citation
 4.
    
                             Institute of Medicine, “Performance Measurement: Accelerating Improvement,” December 1, 2005, available at 
                            *http://www.iom.edu/​CMS/​3809/​19805/​31310.aspx.* Back to Citation
 5.
    
                             RAND 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.* Back to Citation
 6.
    
                             Transforming Health Care: The President's Health Information Technology Plan, available at: 
                            *http://www.whitehouse.gov/​infocus/​technology/​economic_​policy200404/​chap3.html.* Back to Citation


BILLING CODE 4120-01-P BILLING CODE 4120-01-C [FR Doc. 06-9079 Filed 11-1-06; 4:00 pm]