67960 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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 

Medicare Program; Hospital Outpatient 

Prospective Payment System and CY 

2007 Payment Rates; CY 2007 Update 

to the Ambulatory Surgical Center 

Covered Procedures List; Medicare 

Administrative Contractors; and 

Reporting Hospital Quality Data for FY 

2008 Inpatient Prospective Payment 

System Annual Payment Update 

Program—HCAHPS Survey, SCIP, and 

Mortality 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: 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. 


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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 


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67962 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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) 


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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 PassThrough Status in CY 2007 

B. Payment for Drugs, Biologicals, and 

Radiopharmaceuticals Without PassThrough Status 

1. Background 

2. Criteria for Packaging Payment for 

Drugs, Biologicals, and 

Radiopharmaceuticals 

3. Payment for Drugs, Biologicals, and 

Radiopharmaceuticals Without PassThrough 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 PassThrough 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 


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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-forService 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 MultiCampus 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 costbased payment methodology with a 

prospective payment system (PPS). The 

Balanced Budget Act (BBA) of 1997 

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


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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 laborrelated amount is adjusted for area wage 

differences using the inpatient hospital 

wage index value for the locality in 

which the hospital or CMHC is located. 

All services and items within an APC 

group are comparable clinically and 

with respect to resource use (section 

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

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

subject to certain exceptions, services 

and items within an APC group cannot 

be considered comparable with respect 

to the use of resources if the highest 

median (or mean cost, if elected by the 

Secretary) for an item or service in the 

APC group is more than 2 times greater 

than the lowest median cost for an item 

or service within the same APC group 

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

implementing this provision, we use the 

median cost of the item or service 

assigned to an APC group. 

Special payments under the OPPS 

may be made for new technology items 

and services in one of two ways. Section 

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

temporary additional payments which 

we refer to as ‘‘transitional pass-through 

payments’’ for at least 2 but not more 

than 3 years for certain drugs, biological 

agents, brachytherapy devices used for 

the treatment of cancer, and categories 

of other medical devices. For new 

technology services that are not eligible 

for transitional pass-through payments 

and for which we lack sufficient data to 

appropriately assign them to a clinical 

APC group, we have established special 

APC groups based on costs, which we 

refer to as new technology APCs. These 

new technology APCs are designated by 

cost bands which allow us to provide 

appropriate and consistent payment for 

designated new procedures that are not 

yet reflected in our claims data. Similar 

to pass-through payments, an 

assignment to a new technology APC is 

temporary; that is, we retain a service 

within a new technology APC until we 

acquire sufficient data to assign it to a 

clinically appropriate APC group. 

B. Excluded OPPS Services and 

Hospitals 

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

authorizes the Secretary to designate the 

hospital outpatient services that are 

paid under the OPPS. While most 

hospital outpatient services are payable 

under the OPPS, section 

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

payment for ambulance, physical and 

occupational therapy, and speechlanguage pathology services, for which 

payment is made under a fee schedule. 

Section 614 of Pub. L. 108–173 

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

Act to exclude OPPS payment for 

screening and diagnostic mammography 

services. The Secretary exercised the 

authority granted under the statute to 

exclude from the OPPS those services 

that are paid under fee schedules or 

other payment systems. Such excluded 

services include, for example, the 

professional services of physicians and 

nonphysician practitioners paid under 

the Medicare Physician Fee Schedule 

(MPFS); laboratory services paid under 

the clinical diagnostic laboratory fee 

schedule; services for beneficiaries with 

end-stage renal disease (ESRD) that are 

paid under the ESRD composite rate; 

and, services and procedures that 

require an inpatient stay that are paid 

under the hospital inpatient prospective 

payment system (IPPS). We set forth the 

services that are excluded from payment 

under the OPPS in § 419.22 of the 

regulations. 

Under § 419.20(b) of the regulations, 

we specify the types of hospitals and 

entities that are excluded from payment 

under the OPPS. These excluded 

entities include Maryland hospitals, but 

only for services that are paid under a 

cost containment waiver in accordance 

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

critical access hospitals (CAHs); 

hospitals located outside of the 50 

States, the District of Columbia, and 

Puerto Rico; and Indian Health Service 

hospitals. 

C. Prior Rulemaking 

On April 7, 2000, we published in the 

Federal Register a final rule with 

comment period (65 FR 18434) to 

implement a prospective payment 

system for hospital outpatient services. 

The hospital OPPS was first 

implemented for services furnished on 

or after August 1, 2000. Section 

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

Secretary to review certain components 

of the OPPS not less often than annually 

and to revise the groups, relative 

payment weights, and other adjustments 

to take into account changes in medical 

practice, changes in technology, and the 

addition of new services, new cost data, 

and other relevant information and 

factors. 

Since initially implementing the 

OPPS, we have published final rules in 

the Federal Register annually to 

implement statutory requirements and 

changes arising from our experience 

with this system. We last published 

such a document on November 10, 2005 

(70 FR 68516). In that final rule with 

comment period, we revised the OPPS 

to update the payment weights and 

conversion factor for services payable 

under the CY 2006 OPPS on the basis 

of claims data from January 1, 2004, 

through December 31, 2004, and to 

implement certain provisions of Pub. L. 

108–173. In addition, we responded to 

public comments received on the 

provisions of November 15, 2004 final 

rule with comment period pertaining to 


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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 devicedependent 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. 


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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). 


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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-tocharge 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 


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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 


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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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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-toCharge Ratios (CCRs) and Instructions 

on Cost Report Treatment of Hospital 

Outpatient Services Paid on a 

Reasonable Cost Basis’’ (January 17, 

2003), we revised the overall CCR 

calculation that the fiscal intermediaries 

use in determining outlier and other 

cost payments. Until this point, each 

fiscal intermediary had used an overall 

CCR provided by CMS, or calculated an 

updated CCR at the provider’s request 

using the same calculation. The 

calculation in Program Transmittal A–

03–04, that is, the fiscal intermediary 

calculation, diverged from the 

‘‘traditional’’ overall CCR that we used 

for modeling. It should be noted that the 

fiscal intermediary overall CCR 

calculation noted in Program 

Transmittal A–03–04 was created with 

feedback and input from the fiscal 

intermediaries. 

CMS’ ‘‘traditional’’ calculation 

consists of summing the total costs from 

Worksheet B, Part I (Column 27), after 

removing the costs for nursing and 

paramedical education (Columns 21 and 

24), for those ancillary cost centers that 

we believe contain most OPPS services, 

summing the total charges from 

Worksheet C, Part I (Columns 6 and 7) 

for the same set of ancillary cost centers, 

and dividing the former by the latter. 

We exclude selected ancillary cost 

centers from our overall CCR 

calculation, such as 5700 Renal Dialysis, 

because we believe that the costs and 


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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 


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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 wellestablished 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 centerspecific 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 


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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 nonOPPS 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 


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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 postreclassification wage indices, and would 

result in the most accurate adjusted 

median costs. 

We also excluded claims that were 

outside 3 standard deviations from the 

geometric mean of units for each HCPCS 

code on the bypass list (because, as 

discussed above, we used claims that 

contain multiple units of the bypass 

codes). We then deleted 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. 


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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 


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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 devicedependent 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 devicedependent 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 Description 

250 .................................................. PHARMACY. 


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TABLE 2.—CY 2007 PACKAGED SERVICES BY REVENUE CODE—Continued 

Revenue code Description 

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 


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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)). 


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• 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 


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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 xray, 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 addon 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 postprocessing 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 


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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 computeraided 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 


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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 lowlevel 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. 


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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 

median 

36540 .......... Collect blood, venous access device ................................................................... 0624 S .................. $31.44 

36600 .......... Arterial puncture; withdrawal of blood for diagnosis ............................................ 0035 T .................. 12.22 

38792 .......... Sentinel node identification .................................................................................. 0389 S .................. 84.05 

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

supervision and interpretation.

0668 S .................. 381.71 

94762 .......... Noninvasive ear or pulse oximetry for oxygen saturation by continuous overnight monitoring.0443 X .................. 63.61 

96523 .......... 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 procedurespecific fluoroscopy code should 

probably have been billed, instead of 

CPT code 76001. The Packaging 

Subcommittee believed that CPT code 

76000 could often be provided as a sole 

service, with no other separately 

payable procedures. The Packaging 

Subcommittee recommended that CMS 

continue to pay separately for CPT code 

76000, consistent with the AMA’s 

definition of this code, which specifies 

that it is a separate procedure, and to 

continue to package CPT codes 76001, 

76003, and 76005. 

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 


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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 


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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 hospitalbased 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 hospitalspecific 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 hospitalbased 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 hospitalbased 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 hospitalbased 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 


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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 passthrough 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 passthrough 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 ‘‘nonIPPS’’ hospitals). 

As discussed in section II.A. of this 

preamble, we standardize 60 percent of 

estimated costs (labor-related costs) for 

geographic area wage variation using the 

IPPS wage indices that are calculated 

prior to adjustments for reclassification 

to remove the effects of differences in 

area wage levels in determining the 

OPPS payment rate and the copayment 

standardized amount. 

As published in the original OPPS 

April 7, 2000 final rule with comment 

period (65 FR 18545), OPPS has 

consistently adopted the final IPPS 

wage indices as the wage indices for 

adjusting the OPPS standard payment 

amounts for labor market differences. 

Thus, the wage index that applies to a 

particular hospital under the IPPS will 

also apply to that hospital under the 

OPPS. As initially explained in the 

September 8, 1998 OPPS proposed rule, 

we believed and continue to believe that 


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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 outmigration 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-torural transition to non-IPPS hospitals 

paid under the OPPS. That is, we would 

maintain the wage index of the MSA 

where the hospital was previously 

located for purposes of determining a 

wage index for CY 2007. Beginning in 

FY 2008, the 3-year transition will end 

and these hospitals will receive their 

statewide rural wage index. However, 

hospitals paid under the IPPS will be 

eligible to apply for reclassification. 

For the occupational mix adjustment, 

we refer readers to 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 outmigration wage adjustment, discussed 


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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 outmigration.) For OPPS purposes, we 

proposed to continue our policy from 

CY 2006 to allow non-IPPS hospitals 

paid under the OPPS to qualify for outmigration adjustment if they are located 

in a section 505 out-migration county. 

Because non-IPPS hospitals cannot 

reclassify, they are eligible for the outmigration wage adjustment. Tables 

identifying counties eligible for the outmigration 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 outmigration wage adjustment both through 

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

2007. 

With the exception of reclassifications 

resulting from the implementation of 

the one-time appeal process under 

section 508 of Pub. L. 108–173, all 

changes to the wage index resulting 

from geographic labor market area 

reclassifications or other adjustments 

must be incorporated in a budget 

neutral manner. Accordingly, in 

calculating the OPPS budget neutrality 

estimates for CY 2007, in this 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 onetime appeal process. Because the 

increased OPPS payments already count 

against the $900 million limit, we did 

not consider these reclassifications 

when we calculated the 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. 


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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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 


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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 


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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 


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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 


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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. 


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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 passthrough 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 JCode effective January 1, 2007 

HCPCS CCode Description 

Assigned 

status indicator Assigned APC 

J2248 ..................... C9227 ......... Injection, micafungin sodium, per 1 mg ....................................................... G ................. 9227 

J3243 ..................... C9228 ......... Injection, tigecycline, per 1 mg .................................................................... G ................. 9228 

J1740 ..................... C9229 ......... Injection, ibandronate sodium, per 1 mg ..................................................... G ................. 9229 

J0129 ..................... 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. 


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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 (NonCoronary Angioplasty or Atherectomy), 

with a CY 2007 final median cost of 

$2,450.64. We will also assign both Gcodes 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. 


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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 

APC 

0155T .......... Laparoscopy, surgical, implantation or replacement of gastric 

stimulation electrodes, lesser curvature (ie, morbid obesity).

T .................. 0130 ............ T .................. 0130 

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

electrodes, lesser curvature (ie, morbid obesity).

T .................. 0130 ............ T .................. 0130 

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

electrodes, lesser curvature (ie, morbid obesity).

C.

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

0159T .......... Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, 

pharmacokinetic analysis, with further physician review for interpretation, breast MRI.

N.

0160T .......... Therapeutic repetitive transcranial magnetic stimulation treatment planning.X .................. 0340 ............ S .................. 0216 

0161T .......... 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 (Computeraided 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 (Computeraided 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 lowvolume 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 lowvolume 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 description 

0007 ................... 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 costefficient settings. Further, we believe 

that our rates are adequate to assure 

access to services for most beneficiaries. 

For many emerging technologies there 

is a transitional period during which 

utilization may be low, often because 

providers are first learning about the 

techniques and their clinical utility. 

Quite often, the requests for higher 

payment amounts are for new 

procedures in that transitional phase. 

These requests, and their accompanying 

estimates for expected Medicare 

beneficiary or total patient utilization, 

often reflect very low rates of patient 

use, resulting in high per use costs for 

which requesters believe Medicare 

should make full payment. Medicare 

does not, and we believe should not, 

assume responsibility for more than its 

share of the costs of procedures based 

on Medicare beneficiary projected 

utilization and does not set its payment 

rates based on initial projections of low 

utilization for services that require 

expensive capital equipment. For the 

OPPS, we rely on hospitals to make 

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 Gcodes 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 


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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 Gcodes (G0339 and G0340) to describe 

complete and fractionated image-guided 

robotic linear accelerator-based SRS 

treatment. We placed HCPCS code 

G0339 in APC 1528 at a payment rate 

of $5,250, and HCPCS code G0340 in 

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

Second, we received comments on 

HCPCS code G0242 which requested 

that we modify the code descriptor to 

avoid confusion and misuse of the code, 

and also to appropriately describe 

treatment planning for both linear 

accelerator-based and Cobalt 60-based 

SRS treatments. In response, for CY 

2004, we created HCPCS code G0338 to 

distinguish linear accelerator-based SRS 

treatment planning from Cobalt 60- 

based SRS treatment planning. We 

placed HCPCS code G0338 in APC 1516 

at a payment rate of $1,450. 

In CY 2005, there were no changes to 

the coding or New Technology APC 

payment rates for the SRS planning or 

treatment delivery codes from CY 2004. 

We stated in the CY 2005 OPPS final 

rule with comment period (69 FR 

65711) that any SRS code changes 

would be premature without cost data to 

support a code restructuring. Therefore, 

we maintained HCPCS codes G0173, 

G0242, G0243, G0251, G0338, G0339, 

and G0340 in their respective New 

Technology APCs for CY 2005. We 

further stated that until we had 

completed an analysis of claims for 

these procedure codes, we would 

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 acceleratorbased 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, nonrobotic 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 


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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 acceleratorbased 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, nonrobotic 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 


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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 acceleratorbased 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 cobaltbased 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 acceleratorbased 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 acceleratorbased 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 acceleratorbased 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 acceleratorbased 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 acceleratorbased SRS. During CY 2006, CPT code 


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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 

cost 

G0173 .... Linear acc stereo radsur com .. S .................. 1528 $5,250.00 S .................. 0067 $3,872.87 

G0251 .... Linear acc based stero radio .... S .................. 1513 1,150.00 S .................. 0065 1,241.89 

G0339 .... Robot lin-radsurg com, first ...... S .................. 1528 5,250.00 S .................. 0067 3,872.87 

G0340 .... 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 


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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 costefficient settings. For emerging 

technologies, we establish payment 

rates for new services that lack hospital 

claims data based on realistic utilization 

projections for all such services 

delivered in cost-efficient hospital 

outpatient settings. 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 


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single claim for that service. In the event 

there is no applicable departmental 

CCR, we use the overall hospitalspecific 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 

cost 

95965 ..... Meg, spontaneous .................... S .................. 1523 $2,750.00 S .................. 0038 $3,270.35 

95966 ..... Meg, evoked, single ................. S .................. 1514 1,250.00 S .................. 0209 687.26 

95967 ..... 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 


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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 nondevicedependent 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-todevice 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 


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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 devicedependent 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 passthrough 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 procedureto-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 


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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 devicedependent APC because the APCs for 

the vascular access device services that 

require devices of significant cost 

generally have been considered devicedependent 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 resourcewise 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 deviceintensive 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 lineitem 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 capsulebased 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 Gcodes, 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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 


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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 rate 

0144T ............................................... CT heart wo dye; qual calc ....................................................................... 0398 $261.66 

0145T ............................................... CT heart w/wo dye funct ........................................................................... 0376 306.34 

0146T ............................................... CCTA w/wo dye ........................................................................................ 0376 306.64 

0147T ............................................... CCTA w/wo, quan calcium ........................................................................ 0376 306.34 

0148T ............................................... CCTA w/wo, strxr ...................................................................................... 0377 415.12 

0149T ............................................... CCTA w/wo, strxr quan calcium ................................................................ 0377 415.12 

0150T ............................................... CCTA w/wo, disease strxr ......................................................................... 0398 261.66 

0151T ............................................... 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 carrierpriced 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 


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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 


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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 


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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 Gcode for multiple scan procedures that 

was reported for the first 3 months of 

CY 2005. The median cost for that Gcode 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 

cost 

78459 ................................... Heart muscle imaging (PET) .......................................... S 0307 $784.42 $726.98 

78491 ................................... Heart image (pet), single ............................................... S 0307 1,014.61 726.98 

78492 ................................... 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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 Ccodes, 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) 


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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 cost 

Ancillary Codes Packaged ........................ 7180 (1 lost to trimming) .......................... $828.46 $11,202.81 $3,326.50 $3,062.99 

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

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 

cost 

Ancillary Codes Packaged ....................................................................... 6,748 $890.56 $10,224.17 $3,240.13 $3,026.62 

Ancillary 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 


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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. 


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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 


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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 


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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 cardioverterdefibrillator), 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 


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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 lineitem 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. 


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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 cost 

C1762 (billed with 57267) ............................................ Conn tiss, human (inc fascia) ....................................... 22 $810.72 

C1763 (billed with 57267) ............................................ Conn tissue, non-human .............................................. 55 503.71 

C1781 (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 technologyspecific 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 


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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 noninvasive 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 


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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 costefficient 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. 


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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 


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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 passthrough 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 twopart keratoprosthesis with a lower 

device cost than the cost of the onepiece 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 


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68054 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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-todevice 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, 


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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 


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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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 


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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 servicespecific 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 APC 

21336 ........................................................... Treat nasal septal fracture ................................................................................................ 0063 

21805 ........................................................... Treatment of rib fracture .................................................................................................... 0062 

23515 ........................................................... Treat clavicle fracture ........................................................................................................ 0064 

23530 ........................................................... Treat clavicle dislocation ................................................................................................... 0063 

23532 ........................................................... Treat clavicle dislocation ................................................................................................... 0062 

23550 ........................................................... Treat clavicle dislocation ................................................................................................... 0063 

23552 ........................................................... Treat clavicle dislocation ................................................................................................... 0063 

23585 ........................................................... Treat scapula fracture ....................................................................................................... 0064 

23615 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

23616 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

23630 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

23660 ........................................................... Treat shoulder dislocation ................................................................................................. 0063 

23670 ........................................................... Treat dislocation/fracture ................................................................................................... 0064 

23680 ........................................................... Treat dislocation/fracture ................................................................................................... 0063 

24515 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24516 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24538 ........................................................... Treat humerus fracture ...................................................................................................... 0062 

24545 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24546 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24566 ........................................................... Treat humerus fracture ...................................................................................................... 0062 

24575 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24579 ........................................................... Treat humerus fracture ...................................................................................................... 0064 

24582 ........................................................... Treat humerus fracture ...................................................................................................... 0062 

24586 ........................................................... Treat elbow fracture .......................................................................................................... 0064 

24587 ........................................................... Treat elbow fracture .......................................................................................................... 0064 

24615 ........................................................... Treat elbow dislocation ...................................................................................................... 0064 

24635 ........................................................... Treat elbow fracture .......................................................................................................... 0064 

24665 ........................................................... Treat radius fracture .......................................................................................................... 0063 


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TABLE 17.—RECONFIGURATION OF APC 0046—Continued 

HCPCS 

code Description CY 2007 APC 

24666 ........................................................... Treat radius fracture .......................................................................................................... 0064 

24685 ........................................................... Treat ulnar fracture ............................................................................................................ 0063 

25515 ........................................................... Treat fracture of radius ...................................................................................................... 0063 

25525 ........................................................... Treat fracture of radius ...................................................................................................... 0063 

25526 ........................................................... Treat fracture of radius ...................................................................................................... 0063 

25545 ........................................................... Treat fracture of ulna ......................................................................................................... 0063 

25574 ........................................................... Treat fracture radius & ulna .............................................................................................. 0064 

25575 ........................................................... Treat fracture radius/ulna .................................................................................................. 0064 

25606 (25611 deleted) ................................ Treat fx distal radial ........................................................................................................... 0062 

25607 (25620 deleted) ................................ Treat fx rad extra-articul .................................................................................................... 0064 

25608 (25620 deleted) ................................ Treat fx rad intra-articul ..................................................................................................... 0064 

25609 (25620 deleted) ................................ Treat fx radial 3+ frag ........................................................................................................ 0064 

25628 ........................................................... Treat wrist bone fracture ................................................................................................... 0063 

25645 ........................................................... Treat wrist bone fracture ................................................................................................... 0063 

25651 ........................................................... Pin ulnar styloid fracture .................................................................................................... 0062 

25652 ........................................................... Treat fracture ulnar styloid ................................................................................................ 0063 

25670 ........................................................... Treat wrist dislocation ........................................................................................................ 0062 

25671 ........................................................... Pin radioulnar dislocation .................................................................................................. 0062 

25676 ........................................................... Treat wrist dislocation ........................................................................................................ 0062 

25685 ........................................................... Treat wrist fracture ............................................................................................................ 0062 

25695 ........................................................... Treat wrist dislocation ........................................................................................................ 0062 

26608 ........................................................... Treat metacarpal fracture .................................................................................................. 0062 

26615 ........................................................... Treat metacarpal fracture .................................................................................................. 0063 

26650 ........................................................... Treat thumb fracture .......................................................................................................... 0062 

26665 ........................................................... Treat thumb fracture .......................................................................................................... 0063 

26676 ........................................................... Pin hand dislocation .......................................................................................................... 0062 

26685 ........................................................... Treat hand dislocation ....................................................................................................... 0063 

26686 ........................................................... Treat hand dislocation ....................................................................................................... 0064 

26715 ........................................................... Treat knuckle dislocation ................................................................................................... 0063 

26727 ........................................................... Treat finger fracture, each ................................................................................................. 0062 

26735 ........................................................... Treat finger fracture, each ................................................................................................. 0063 

26746 ........................................................... Treat finger fracture, each ................................................................................................. 0063 

26756 ........................................................... Pin finger fracture, each .................................................................................................... 0062 

26765 ........................................................... Treat finger fracture, each ................................................................................................. 0063 

26776 ........................................................... Pin finger dislocation ......................................................................................................... 0062 

26785 ........................................................... Treat finger dislocation ...................................................................................................... 0062 

27202 ........................................................... Treat tail bone fracture ...................................................................................................... 0063 

27509 ........................................................... Treatment of thigh fracture ................................................................................................ 0062 

27524 ........................................................... Treat kneecap fracture ...................................................................................................... 0063 

27566 ........................................................... Treat kneecap dislocation ................................................................................................. 0063 

27615 ........................................................... Remove tumor, lower leg .................................................................................................. 0050 

27756 ........................................................... Treatment of tibia fracture ................................................................................................. 0062 

27758 ........................................................... Treatment of tibia fracture ................................................................................................. 0063 

27759 ........................................................... Treatment of tibia fracture ................................................................................................. 0064 

27766 ........................................................... Treatment of ankle fracture ............................................................................................... 0063 

27784 ........................................................... Treatment of fibula fracture ............................................................................................... 0063 

27792 ........................................................... Treatment of ankle fracture ............................................................................................... 0063 

27814 ........................................................... Treatment of ankle fracture ............................................................................................... 0063 

27822 ........................................................... Treatment of ankle fracture ............................................................................................... 0063 

27823 ........................................................... Treatment of ankle fracture ............................................................................................... 0064 

27826 ........................................................... Treat lower leg fracture ..................................................................................................... 0063 

27827 ........................................................... Treat lower leg fracture ..................................................................................................... 0064 

27828 ........................................................... Treat lower leg fracture ..................................................................................................... 0064 

27829 ........................................................... Treat lower leg joint ........................................................................................................... 0063 

27832 ........................................................... Treat lower leg dislocation ................................................................................................ 0063 

27846 ........................................................... Treat ankle dislocation ...................................................................................................... 0063 

27848 ........................................................... Treat ankle dislocation ...................................................................................................... 0063 

28406 ........................................................... Treatment of heel fracture ................................................................................................. 0062 

28415 ........................................................... Treat heel fracture ............................................................................................................. 0063 

28420 ........................................................... Treat/graft heel fracture ..................................................................................................... 0063 

28436 ........................................................... Treatment of ankle fracture ............................................................................................... 0062 

28445 ........................................................... Treat ankle fracture ........................................................................................................... 0063 

28456 ........................................................... Treat midfoot fracture ........................................................................................................ 0062 

28465 ........................................................... Treat midfoot fracture, each .............................................................................................. 0063 

28476 ........................................................... Treat metatarsal fracture ................................................................................................... 0062 

28485 ........................................................... Treat metatarsal fracture ................................................................................................... 0063 

28496 ........................................................... Treat big toe fracture ......................................................................................................... 0062 

28505 ........................................................... Treat big toe fracture ......................................................................................................... 0063 

28525 ........................................................... Treat toe fracture ............................................................................................................... 0063 

28531 ........................................................... Treat sesamoid bone fracture ........................................................................................... 0063 

28545 ........................................................... Treat foot dislocation ......................................................................................................... 0062 


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TABLE 17.—RECONFIGURATION OF APC 0046—Continued 

HCPCS 

code Description CY 2007 APC 

28546 ........................................................... Treat foot dislocation ......................................................................................................... 0062 

28555 ........................................................... Repair foot dislocation ....................................................................................................... 0063 

28576 ........................................................... Treat foot dislocation ......................................................................................................... 0062 

28585 ........................................................... Repair foot dislocation ....................................................................................................... 0063 

28606 ........................................................... Treat foot dislocation ......................................................................................................... 0062 

28615 ........................................................... Repair foot dislocation ....................................................................................................... 0063 

28636 ........................................................... Treat toe dislocation .......................................................................................................... 0062 

28645 ........................................................... Repair toe dislocation ........................................................................................................ 0063 

28666 ........................................................... Treat toe dislocation .......................................................................................................... 0062 

28675 ........................................................... 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 


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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 


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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 


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(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-ofservice 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 passthrough payment. For the CY 2002 

OPPS, we estimated that the total 

amount of pass-through payments 

would far exceed the limit imposed by 

statute. To reduce the amount of a pro 

rata adjustment to all pass-through 


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items, we packaged 75 percent of the 

cost of the devices, using external data 

furnished by commenters on the August 

24, 2001 proposed rule and information 

furnished on applications for passthrough payment, into the median costs 

for the device-dependent APCs 

associated with these pass-through 

devices. The remaining 25 percent of 

the cost was considered to be passthrough payment. 

In the CY 2003 OPPS, we determined 

APC medians for device-dependent 

APCs using a three-pronged approach. 

First, we used only claims with device 

codes on the claim to set the medians 

for these APCs. Second, we used 

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 devicecoded claims in median calculations as 

a proxy for completeness of the coding 

and charges on the claims. For the CY 

2005 OPPS, we adjusted devicedependent APC medians for those 

device-dependent APCs for which the 

CY 2005 OPPS payment median was 

less than 95 percent of the CY 2004 

OPPS payment median. In these cases, 

the CY 2005 OPPS payment median was 

adjusted to 95 percent of the CY 2004 

OPPS payment median. We also 

reinstated the device codes and made 

the use of the device codes mandatory 

where an appropriate code exists to 

describe a device utilized in a 

procedure. 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 devicedependent APCs. In the case of some 

procedures assigned to other devicedependent APCs, where we determined 

that no device was required to provide 

a particular service or where there were 

no HCPCS codes that described all 

devices that could be used to furnish the 

service, we removed the requirement for 

a device code for the individual 

procedure code but retained the device 

requirement for other procedure codes 

assigned to that device-dependent APC. 

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 CardioverterDefibrillator Leads) by bypassing the 

line-item costs of CPT code 33241 

(Subcutaneous removal of single or dual 

chamber pacing cardioverterdefibrillator pulse generator) and 

packaging the line item-costs of CPT 

codes 93640 (Electrophysiological 

evaluation of single or dual chamber 

pacing cardioverter-defibrillator leads 

including defibrillation threshold 

evaluation (induction of arrhythmia, 

evaluation of sensing and pacing for 

arrhythmia termination) at time of 

initial implantation or replacement) and 

93641 (Electrophysiological evaluation 

of single or dual chamber pacing 

cardioverter-defibrillator leads 

including defibrillation threshold 

evaluation (induction of arrhythmia, 

evaluation of sensing and pacing for 

arrhythmia termination) at time of 

initial implantation or replacement; 

with testing of single or dual chamber 

pacing cardioverter-defibrillator) when 

these codes, separately or in 

combination, are reported on the same 

claim with HCPCS codes G0297 

(Insertion of single chamber pacing 

cardioverter defibrillator pulse 

generator), G0298 (Insertion of dual 

chamber pacing cardioverter 

defibrillator pulse generator), G0299 ( 

Insertion or repositioning of electrode 

lead for single chamber pacing 

cardioverter defibrillator and insertion 

of pulse generator), and G0300 

(Insertion or repositioning of electrode 

lead(s) for dual chamber pacing 

cardioverter defibrillator and insertion 


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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 


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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 devicedependent APCs. 

Comment: The commenters supported 

limiting the set of claims used to 

calculate median costs for devicedependent 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 deviceintensive 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 devicedependent 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 devicedependent 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 devicedependent 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. 


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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 hospitalspecific 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 devicedependent 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 devicedependent 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 


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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 devicedependent 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 devicedependent APCs are found in section 

III.D of this preamble, where other APCspecific policies are also discussed. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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. 


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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 Description 

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

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

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

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

coil. 

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

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

VDD. 

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

TABLE 19.—DEVICES WHICH MUST BE

BILLED WITH ASSOCIATED PROCEDURE CODES—Continued 

Device Description 

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 


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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 passthrough 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 devicedependent 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 


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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 passthrough 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 passthrough 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 


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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 


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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 wellestablished 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 


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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 

percent 

0039 ................... S Level I Implantation of Neurostimulator .......................................................................................................... 78.85 

0040 ................... S Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve ................................... 54.06 

0061 ................... S Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excludin ...................................... 60.06 

0089 ................... T Insertion/Replacement of Permanent Pacemaker and Electrodes ................................................................. 77.11 

0090 ................... T Insertion/Replacement of Pacemaker Pulse Generator ................................................................................. 74.74 

0106 ................... T Insertion/Replacement/Repair of Pacemaker and/or Electrodes .................................................................... 41.88 

0107 ................... T Insertion of Cardioverter-Defibrillator .............................................................................................................. 90.44 

0108 ................... T Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads ................................................................. 89.40 

0222 ................... T Implantation of Neurological Device ............................................................................................................... 77.65 

0225 ................... S Implantation of Neurostimulator Electrodes, Cranial Nerve ............................................................................ 79.04 

0227 ................... T Implantation of Drug Infusion Device .............................................................................................................. 80.27 

0229 ................... T Transcatherter Placement of Intravascular Shunts ......................................................................................... 46.17 

0259 ................... T Level VI ENT Procedures ............................................................................................................................... 84.61 

0315 ................... T Level II Implantation of Neurostimulator ......................................................................................................... 76.03 

0385 ................... S Level I Prosthetic Urological Procedures ........................................................................................................ 83.19 

0386 ................... S Level II Prosthetic Urological Procedures ....................................................................................................... 61.16 

0418 ................... T Insertion of Left Ventricular Pacing Elect. ....................................................................................................... 87.32 

0654 ................... T Insertion/Replacement of a permanent dual chamber pacemaker ................................................................. 77.35 

0655 ................... T Insertion/Replacement/Conversion of a permanent dual chamber pacemaker ............................................. 76.59 

0680 ................... S Insertion of Patient Activated Event Recorders .............................................................................................. 76.40 

0681 ................... 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 Description 

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

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

C1764 ............ Event recorder, cardiac. 

C1767 ............ Generator, neurostim, imp. 

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

C1772 ............ Infusion pump, programmable. 

C1776 ............ Joint device (implantable). 

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

coil. 

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

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

VDD. 

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

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

C1813 ............ Prosthesis, penile, inflatab. 

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

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

sys. 

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

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

perm. 

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

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

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

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

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

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—Continued 

Device Description 

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 PassThrough Payments for Certain Devices 

a. Background 

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

requires that, under the OPPS, a 

category of devices be eligible for 

transitional pass-through payments for 

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

This period begins with the first date on 

which a transitional pass-through 

payment is made for any medical device 

that is described by the category. The 

device category codes became effective 

April 1, 2001, under the provisions of 

the BIPA. Prior to pass-through device 

categories, Medicare payments for passthrough devices under the OPPS were 

made on a brand-specific basis. All of 

the initial 97 category codes that were 

established as of April 1, 2001, have 

expired; 95 categories expired after CY 

2002, and 2 categories expired after CY 

2003. In addition, nine new categories 

have expired since their creation. We 

currently have no category codes for 

pass-through devices that will expire 

January 1, 2007. We created one new 

category effective January 1, 2006, for 

C1820 (Generator, neurostimulator 

(implantable), with rechargeable battery 

and charging system), which we 

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 


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established policy, we base the 

expiration dates for the category codes 

on the date on which a category was 

first eligible for pass-through payment. 

In the November 1, 2002 OPPS final 

rule, we established a policy for 

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

(67 FR 66763). For CY 2003 through CY 

2006, we packaged the costs of the 

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

procedures with which the devices were 

billed in the claims data used to set the 

payment rates for those years. 

Brachytherapy sources, which are now 

separately paid in accordance with 

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

exception to this established policy 

(with the exception of brachytherapy 

sources for prostate brachytherapy, 

which were packaged in the CY 2003 

OPPS only). 

b. 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 Ccodes 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 passthrough payments. Specifically, we 

indicated that we would apply an offset 

to a new device category only when we 

could determine that an APC contains 

costs associated with the device. We 

continued our existing methodology for 

determining the offset amount, 

described earlier. We were able to use 

this methodology to establish the device 

offset amounts for CY 2004 because 

providers reported device codes 

(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 Ccodes in CY 2004 on a voluntary basis. 

We reviewed our CY 2004 data and 

found that the numbers of claims for 

services in many of the APCs for which 

we calculated device percentages using 

CY 2004 data were quite small. We also 

found that many of these APCs already 

had relatively few single claims 

available for median calculations 

compared with the total bill frequencies 

because of our inability to use many 

multiple bills in establishing median 

costs for all APCs. In addition, we found 

that our claims demonstrated that 

relatively few hospitals specifically 

coded for devices utilized in CY 2004. 

Thus, we were not confident that CY 

2004 claims reporting 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 


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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, 


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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 passthrough 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 drugby-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. 


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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 descriptor 

J7319 .............................................................. C9220 0896 Sodium hyaluronate injection 

J7344 .............................................................. C9221 9156 Nonmetabolic active tissue 

J7346 .............................................................. C9222 9222 Injectable human tissue 

J0128* ............................................................. .................... 9216 Abarelix injection 

J0878* ............................................................. .................... 9124 Daptomycin injection 

J2357* ............................................................. .................... 9300 Omalizumab injection 

J2783 .............................................................. .................... 0738 Rasburicase 

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

J7518 .............................................................. .................... 9219 Mycophenolic acid 

J9035* ............................................................. .................... 9214 Bevacizumab injection 

J9055* ............................................................. .................... 9215 Cetuximab injection 

J9305* ............................................................. .................... 9213 Pemetrexed injection 

* 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 PassThrough 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 passthrough payments in CY 2007 that were 

also covered under the Part B drug CAP. 


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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 passthrough radiopharmaceuticals at WAC 

was closely aligned with our proposal to 

pay for separately payable nonpassthrough 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 passthrough 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 passthrough application for the item. 

Accordingly, in CY 2007 the passthrough payment amount would equal 

zero for those new drugs and biologicals 

that we determine have pass-through 

status. That is, when we subtract the 

amount to be paid for pass-through 

drugs and biologicals under section 

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

the Act, if the drug or biological is 

covered under a competitive acquisition 

contract), from the portion of the 

otherwise applicable fee schedule 

amount or the APC payment rate 

associated with the drug or biological 

that would be the amount paid for drugs 

and biologicals under section 1842(o) of 

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

the drug or biological is covered under 

a competitive acquisition contract), the 

resulting difference is equal to zero. 

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 passthrough 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. 


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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 descriptor 

C9232 ............................................................................................... ** 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 PassThrough 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 


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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 


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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 fourquarter moving average PPI. 

Comment: Most commenters, in 

general, disagreed with an increase to 

the packaging threshold. However, one 

commenter disagreed with our use of 


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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, wellestablished, 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. 


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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 APC 

J0580 .................................................... Penicillin g benzathine inj ..................................................... K N 

J1205 .................................................... Chlorothiazide sodium inj ..................................................... N K 0747 

J2354 .................................................... Octreotide inj, non-depot ...................................................... K N 

J3320 .................................................... Spectinomycn di-hcl inj ........................................................ N K 0753 

J8600 .................................................... Melphalan oral 2 MG ............................................................ K N 

J9040 .................................................... Bleomycin sulfate injection ................................................... N K 0748 

J9120 .................................................... Dactinomycin actinomycin d ................................................. N K 0752 

J9130 .................................................... Dacarbazine 100 mg inj ....................................................... N K 0746 

J9230 .................................................... 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 description 

J1260 ................. Dolasetron mesylate. 

J1626 ................. Granisetron HCl injection. 

TABLE 25.—ANTI-EMETICS EXEMPTED

FROM $55 PACKAGING REQUIREMENT—Continued 

HCPCS code Short description 

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 PassThrough 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 


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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 ASPbased 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 


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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_AdvisoryPanelonAmbulatory

PaymentClassificationGroups.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 nonlyophilized 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 brandspecific 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 ASPbased 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-tocharge 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 


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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 meanbased 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), 


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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 


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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 NonpassThrough 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 passthrough 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 passthrough status under the OPPS. (Section 

V.A. of this final rule with comment 

period provides additional details on 

our final policies for CY 2007 passthrough 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 passthrough 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 


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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-tocharge 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 APC 

C9234 .. Inj, alglucosidase alfa ............................................................................................................................ K 9234 

C9235 .. Injection, panitumumab ......................................................................................................................... K 9235 

J0364 ... Apomorphine hydrochloride .................................................................................................................. K 0766 

J1324 ... Enfuvirtide injection ............................................................................................................................... K 0767 

J1562 ... Immune globulin subcutaneous ............................................................................................................ K 0804 

J2170 ... Mecasermin injection ............................................................................................................................. K 0805 

J2315 ... Naltrexone, depot form .......................................................................................................................... K 0759 

J8650 ... Nabilone oral ......................................................................................................................................... K 0808 

J9261 ... 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. 


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Response: As we noted in the CY 

2007 proposed rule, we have an ASPbased 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 passthrough 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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 


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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 PassThrough 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 passthrough payments made in that year to 

ensure that the limit is not exceeded. 

We make an estimate of pass-through 

spending to determine not only whether 

payments exceed the applicable 

percentage, but also to determine the 

appropriate reduction to the conversion 

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

For devices, 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 


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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 passthrough 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 passthrough 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 passthrough applications for new 

radiopharmaceuticals that are assigned a 

HCPCS code on or after January 1, 2005. 

(Prior to this date, radiopharmaceuticals 

were not included in the category of 

drugs paid under the OPPS, and 

therefore, were not eligible for passthrough status.) 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 passthrough payments 

C1820 1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system 5,483 $43,974,519 

Because we estimate that passthrough 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 


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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 palladium103 (C1720) based on claims data, the 

GAO states that it expects CMS to have 

data available to set prospective 

payment rates for high activity iodine125 (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, 


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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 


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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 cost 

Iodine-125 .................................................................................... $31.33 $36.35 $25.37 $32.63 $36.12 

Palladium-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. 


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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), nonHDR iridium-192 (C1719), and yttrium90 (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 iodine125 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). 


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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 passthrough 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 


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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 


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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, iodine125, per source and C1720, palladium103, 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 


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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 

indicator 

C1716 ............... Brachytherapy source, Gold 198, per source ...................................................... 1716 $36.61 K 

C1717 ............... Brachytherapy source, High Dose Rate Iridium 192, per source ........................ 1717 141.75 K 

C1718 ............... Brachytherapy source, Iodine 125, per source .................................................... 1718 36.12 K 

C1719 ............... Brachytherapy source, Non-High Dose Rate Iridium 192, per source ................ 1719 23.01 K 

C1720 ............... Brachytherapy source, Palladium 103, per source .............................................. 1720 48.53 K 

C2616 ............... Brachytherapy source, Yttrium-90, per source .................................................... 2616 10,525.13 K 

A9527 (C2632 

deleted).

Iodine I–125, sodium iodide solution, therapeutic, per millicurie ......................... 2632 20.30 K 

C2633 ............... Brachytherapy source, Cesium-131, per source .................................................. 2633 90.31 K 


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TABLE 30.—SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007—Continued 

HCPCS code Long descriptor CY 2007 

APC 

CY 2005 

median cost 

CY 2007 

status 

indicator 

C2634 ............... Brachytherapy source, High Activity, Iodine-125, greater than 1.01 mCi (NIST), 

per source.

2634 32.49 K 

C2635 ............... Brachytherapy source, High Activity, Palladium-103, greater than 2.2 mCi 

(NIST), per source.

2635 54.25 K 

C2636 ............... 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 Ytterbium169 (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, Palladium103, 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 Iodine125, 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 longterm 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 ‘‘customstranded’’ 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 palladium103, 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 wellrepresented 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 wellrepresented 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 pervisit payment included payment for all 

hospital resources (except separately 

payable drugs) associated with the drug 

administration procedures. For CY 

2004, we discontinued using HCPCS 

code Q0085 to identify drug 

administration services and moved to a 

combination of HCPCS codes Q0083 

and Q0084 that allowed more accurate 

calculations when determining OPPS 

payment rates. 

In CY 2005, in response to the 

recommendations made by commenters 

and the hospital industry, OPPS 

transitioned to the use of CPT codes for 

drug administration services. These CPT 

codes allowed for more specific 

reporting of services, especially 

regarding the number of hours for an 

infusion, and provided consistency in 

coding between Medicare and other 

payers. However, we did not have any 

data to revise the CY 2005 per-visit APC 

payment structure for infusion services. 

In order to collect data for future 

ratesetting purposes, we implemented 

claims processing logic that collapsed 

payments for drug administration 

services and paid a single APC amount 

for those services for each visit, unless 

a modifier was used to identify drug 

administration services provided in a 

separate encounter on the same day. 

Hospitals were instructed to bill all 

applicable CPT codes for drug 

administration services provided in a 

hospital outpatient department, without 

regard to whether or not the CPT code 

would receive a separate APC payment 

during OPPS claims processing. 

While hospitals were just adopting 

CPT codes for outpatient drug 

administration services in CY 2005, 

physicians paid under the 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 Ccodes. 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 nonMedicare 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 nonMedicare 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 CCODES THAT WILL NO LONGER BE

REPORTABLE UNDER THE OPPS IN

CY 2007 

HCPCS 

Code Long description 

C8950 ...... 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 


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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 

SI 

90760 ....... Intravenous Infusion, hydration; initial, up to one hour ......................................................................................... 0440 S 

90761 ....... Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary procedure).0437 S 

90765 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); initial, up to one 

hour.

0440 S 

90766 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); each additional hour 

(List separately in addition to code for primary procedure).

0437 S 

90767 ....... 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 S 

90768 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); concurrent infusion 

(List separately in addition to code for primary procedure).

— N 

90774 ....... Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug.0438 S 

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).0438 S 

96409 ....... Chemotherapy administration; intravenous, push technique, single or initial substance/drug ............................. 0439 S 

96411 ....... Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately 

in addition to code for primary procedure).

0439 S 

96413 ....... Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug ... 0441 S 

96415 ....... Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure).0438 S 

96417 ....... 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 RNAbased 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 antineoplastic drugs; and also to antineoplastic 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, nonchemotherapy 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 


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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, intraarterial; 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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C In the proposed rule, we noted that 

proposed placement of the CY 2005 

drug administration HCPCS codes into 

the six APC levels followed logical, 


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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. 


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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 


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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 sixlevel 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. 

BILLING CODE 4120–01–P 


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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). 


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TABLE 35.—CY 2006 CPT CODES

USED TO REPORT CLINIC AND

EMERGENCY DEPARTMENT VISITS

AND CRITICAL CARE SERVICES—

Continued 

CPT 

Code Descriptor 

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 fieldtested several times by panel members 

at different stages of their development. 

The guidelines are based on an 

intervention model, where the levels are 

determined by the numbers and types of 

interventions performed by nursing or 

ancillary hospital staff. Higher levels of 

services are reported as the number and/ 

or complexity of staff interventions 

increase. 

Although we did not publish the 

guidelines, the AHA and AHIMA 

released the guidelines through their 

Web sites. Consequently, we received 

numerous comments from providers 

and associations, some in favor and 

some opposed to the guidelines. We 

undertook a critical review of the 

recommendations from the AHA and 

AHIMA and made some modifications 

to the guidelines based on comments we 

received from outside hospitals and 

associations on the AHA/AHIMA 

guidelines, clinical review, and 

changing payment policies in the OPPS 

regarding some separately payable 

services. 

In an attempt to validate the modified 

AHA/AHIMA guidelines and examine 

the distribution of services that would 

result from their application to hospital 

clinic and emergency 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 facilityspecific codes and guidelines, we have 

advised that each hospital’s internal 

guidelines should follow the intent of 

the CPT code descriptors, in that the 

guidelines should be designed to 

reasonably relate the intensity of 

hospital resources to the different levels 

of effort represented by the codes. 

In the November 1, 2002 OPPS final 

rule, we specified that we would not 

create new codes to replace existing 

CPT E/M codes for reporting hospital 

visits until national guidelines have 

been developed, in response to 

commenters who were concerned about 

implementing code definitions without 

national guidelines. While we do not yet 

have a formal set of guidelines that we 

believe may be appropriately applied 

nationally to report different levels of 

hospital clinic and emergency 

department 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 Gcodes 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 descriptor 

Gxxx1 Level 1 hosp 

clinic visit.

Level 1 hospital 

clinic visit. 

Gxxx2 Level 2 hosp 

clinic visit.

Level 2 hospital 

clinic visit. 

Gxxx3 Level 3 hosp 

clinic visit.

Level 3 hospital 

clinic visit. 

Gxxx4 Level 4 hosp 

clinic visit.

Level 4 hospital 

clinic visit. 

Gxxx5 Level 5 hosp 

clinic visit.

Level 5 hospital 

clinic visit. 

Comment: Although a few 

commenters were in favor of creating Gcodes 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 fulltime 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.’’


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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 descriptor 

G0380 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 descriptor 

Gyyy1 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 Gcodes 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 descriptor 

Gccc1 Hosp critical care, 30–74 

min.

Hospital critical care services, first 30–74 minutes. 

Gccc2 Hosp critical care, add 30 

min.

Hospital critical care services, each additional 30 minutes. 

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 Gcode 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 resourceintensive 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 welldeveloped 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 Gcode, 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 highlevel 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. 

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BILLING CODE 4120–01–C 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. 

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BILLING CODE 4120–01–C 

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 fulltime 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 lowlevel clinic visit would be necessary to 

support all aspects of that intervention. 

In another case, the intervention 

‘‘Frequent monitoring/assessment as 

evidenced by two sets of vital sign 

measurements or assessments’’ that is 

attributable to a mid-level emergency 

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 Gcodes to replace the CPT new and 

established clinic visit and consultation 

E/M codes. We did not finalize the 

codes for CY 2003 because of concerns 

then about creating new G-codes 

without national guidelines. 

During CY 2006 and earlier, there has 

not been a payment difference between 

new and established patient visits of the 

same level, as generally both were 

mapped to the same APC. The 

information describing the AHA/ 

AHIMA guidelines indicates that only 

one set of guidelines was developed for 

five levels of codes for clinic visits, 

regardless of a patient’s status as a new 

or established patient or the provision of 

a consultation visit. This approach may 

have been related to the lack of a 

payment differential for different types 

of clinic visits of the same level under 

the OPPS when those guidelines were 

developed. However, several years of 

hospital claims data regarding the 

median costs of the specific CPT clinic 

visit E/M codes consistently indicate 

that new patients generally are more 

resource intensive than existing patients 

across all visit levels, and that 

consultations are more resource 

intensive than standard visits, 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 resourceintensive 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. 


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68146 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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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Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68147 

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 hospitalspecific 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 claimsbased 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. 

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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. 

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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 Descriptor 

57282 .............................................. 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. 


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TABLE 45.—ADDITIONAL PROCEDURES RECOMMENDED BY THE APC PANEL FOR REMOVAL FROM THE INPATIENT LIST FOR

CY 2007—Continued 

HCPCS 

Code Long Descriptor 

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 


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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 

Indicator 

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

21181 ............................................... Reconstruction by contouring of benign tumor of cranial bones, 

extracranial.

0254 T 

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

57282 ............................................... Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, 

iliococcygeus).

0202 T 

57283 ............................................... Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator 

myorrhaphy).

0202 T 

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

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

58260 ............................................... Vaginal hysterectromy, for uterus 250 grams or less ............................... 0195 T 


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TABLE 46.—PROCEDURE CODES REMOVED FROM INPATIENT LIST AND NEW APC ASSIGNMENTS, EFFECTIVE JANUARY 1, 

2007—Continued 

HCPCS 

code Long Descriptor 

CY 2007 

APC 

Assignment 

CY 2007 

Status 

Indicator 

58262 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with removal of 

tube(s) and/or ovary(s).

0195 T 

58263 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with removal of 

tube(s), and/or ovary(s), with repair of enterocele.

0195 T 

58270 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with repair of 

enterocele.

0195 T 

58290 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams ....................... 0202 T 

58291 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with removal 

of tube(s) and/or ovary(s).

0202 T 

58292 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with removal 

of tube(s) and/or ovary(s), with repair of enterocele.

0202 T 

58294 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with repair of 

enterocele..

0202 T 

60502 ............................................... Parathyroidectomy or exploration of thyroid(s); re-exploration ................. 0256 T 

60520 ............................................... Thymectomy, partial or total; transcervical approach ............................... 0256 T 

61720 ............................................... Creation of lesion by stereotactic method, including burr holes and localizing and recording techniques, single of multiple stages; globus 

pallidus or thalamus.

0221 T 

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

64804 ............................................... 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 


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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 


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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 


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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. 


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CY 2007 PROPOSED PAYMENT STATUS INDICATORS (CORRECTED) 

Indicator Item/code/service OPPS payment status 

G .......................................... 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 status 

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

under a fee schedule or payment system other than 

OPPS, for example: 

∑ Ambulance Services ...................................................

∑ Clinical Diagnostic Laboratory Services .....................

∑ Non-Implantable Prosthetic and Orthotic Devices ......

∑ 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 


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Indicator Item/code/service OPPS payment status 

B ........................................... Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x 

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 status 

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. 

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 


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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 status 

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 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 


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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_AdvisoryPanelonAmbulatory

PaymentClassificationGroups.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_AdvisoryPanelonAmbulatory

PaymentClassification

Groups.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. 


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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 


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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 


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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 

group 

13102 Repair wound/lesion add-on.1 

13122 Repair wound/lesion add-on.1 

13133 Repair wound/lesion add-on.1 

19297 Place breast cath 

for rad.

9 

21356 Treat cheek bone 

fracture.

3 

22520 Percutaneous 

vertebroplasty, 

thor.

9 

22521 Percutaneous 

vertebroplasty, 

lumb.

9 

22522 Percutaneous 

vertebroplasty, 

add’l.

1 

35476 Repair venous 

blockage.

9 

36818 AV fuse, upper 

arm, cephalic.

3 

37205 Transcath IV stent, 

percutaneous.

9 

37206 Transcath IV stent/ 

perc, add’l.

1 

43761 Reposition gastrostomy tube.1 

46946 Ligation of hemorrhoids.1 

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 


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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 

group 

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

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

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

19297 ........... Place breast cath 

for rad.

9 

21356 ........... Treat cheek bone 

fracture.

3 

22520 ........... Percutaneous 

vertebroplasty, 

thor.

9 

22521 ........... Percutaneous 

vertebroplasty, 

lumb.

9 

22522 ........... Percutaneous 

vertebroplasty, 

add’l.

9 

36818 ........... AV fuse, upper 

arm, cephalic.

3 

43761 ........... Reposition gastrostomy tube.1 

46946 ........... Ligation of hemorrhoids.1 


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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 


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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 

group 

13153 ............ Repair wound/lesion add-on.3 

19295 ............ Place breast clip, 

percut.

1 

31620 ............ Endobronchial us 

add-on.

1 

43257 ............ Upper gi scope w/ 

thrml txmnt.

3 

57267 ............ Insert mesh/pelvic 

flr add-on.

7 

61795 ............ Brain surgery 

using computer.

1 

G0392 ........... AV fistula or graft 

arterial.

9 

G0393 ........... AV fistula or graft 

venous.

9 

0176T ........... Aqu canal dilat w/ 

o retent.

9 

0177T ........... 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 descriptor 

11603 .. 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 lifethreatening; 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 descriptor 

21390 ...................... Treat eye socket fracture. 

21406 ...................... Treat eye socket fracture. 

21407 ...................... Treat eye socket fracture. 

27412 ...................... Autochondrocyte implant knee. 

27415 ...................... Osteochondral knee 

allograft. 


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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—Continued 

CPT Short descriptor 

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 addon) 

• 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 


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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 resourceintensive 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. 


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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 resourceintensive 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 


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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 of Public 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 of Public 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 crossreference 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 CMSsponsored 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 MMAmandated 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 


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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 adjustment 

1 .......... Q1001 May 18, 2000, through May 18, 2005 .. Multifocal ............................................... Allergan AMO Array Multifocal lens, 

model SA40N. 


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TABLE 51.—CLASSES OF NTIOLS APPROVED FOR PAYMENT ADJUSTMENT—Continued 

NTIOL 

category 

HCPCS 

code 

$50 Approved for services 

furnished on or after NTIOL characteristic IOLs eligible for adjustment 

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 


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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 passthrough 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, classdefining 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 allinclusive, 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 allinclusive 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 classdefining 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. 


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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 FDAapproved 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, caseby-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 


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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. 


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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 peerreviewed 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 peerreviewed 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 


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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-forService and Medicare Administrative 

Contractors (MAC) 

CMS’ vision for the Medicare fee-forservice (FFS) program is that of a 

premier health plan that allows for 

comprehensive, quality care and worldclass beneficiary and provider 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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68182 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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 costreimbursement 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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68184 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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 multiState 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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Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68185 

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 in 42 CFR 

400.202) will generally be assigned to 

the MAC with claims processing 

jurisdiction over the geographic locale 

in which the provider is physically 

located. 

• Large chain providers comprised of 

individual providers that were formerly 

permitted by CMS to ‘‘nominate’’ an 

intermediary, which we refer to as 

‘‘qualified chain providers,’’ will be 

permitted to request opportunity to 

consolidate their Medicare billing 

activities to the MAC with jurisdiction 

over the geographic locale in which the 

chain’s home office is located. 

• Qualified chain providers that were 

formerly granted single intermediary 

status do not need to re-request such 

privileges on behalf of the entire chain. 

• 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/precommencement 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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Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68189 

§ 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 2007 

Incurred Cost ....................................................................... 17.702 19.158 20.8102 23.702 26.518 29.809 32.540 

Percent Increase .................................................................. ................ 8.2 8.6 13.9 11.9 12.4 9.2 

Source: 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 9.7 

Source: 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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68190 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

1The Premier Hospital Quality Incentive 

Demonstration was authorized under section 402 of 

Pub. L. 90–248, Social Security Amendments of 

1967 (42 U.S.C. 1395b–1). This section authorizes 

certain types of demonstration projects that waive 

compliance with the regular payment methods used 

in the Medicare program. 

2Additional information on the Premier Hospital 

Quality Incentive Demonstration is available on the 

CMS Web site at: http://www.cms.hhs.gov/

HospitalQualityInits/35_HospitalPremier.asp. 

3Additional information on CMS’ Hospital 

Quality Initiative is available on the CMS Web site 

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

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 valuebased 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? 


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4 Institute of Medicine, ‘‘Performance 

Measurement: Accelerating Improvement,’’

December 1, 2005, available at http://www.iom.edu/ 

CMS/3809/19805/31310.aspx. 

• 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 


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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 welldeveloped quality measures reported for 

the FY 2007 IPPS regarding inpatient 

hospital discharges should reasonably 

represent the quality of care provided to 

hospital outpatients, so we 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 valuedriven 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 patientcenteredness, 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 noninpatient 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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68196 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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 payfor-reporting toward pay-forperformance, 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-forservice 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 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68197 

5RAND News Release: Rand Study Says 

Computerizing Medical Records Could Save $81 

Billion Annually and Improve the Quality of 

Medical Care, September 14, 2005, available at: 

http://rand.org/news/press.05/09.14.html. 

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 evidencebased medicine, and reminder 

mechanisms for screening and 

preventive care. Despite such large 

potential benefits, the study found that 

only about 20 to 25 percent of hospitals 

have adopted HIT systems. 

It is important to note the caveats to 

the RAND study. The projected savings 

are across the health care sector, and 

any Federal savings would be a 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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68198 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

6Transforming Health Care: The President’s 

Health Information Technology Plan, available at: 

http://www.whitehouse.gov/infocus/technology/ 

economiclpolicy200404/chap3.html. 

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 valuebased 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, patientcenteredness, 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 valuebased 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 nonproprietary. 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. 


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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 antikickback 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. 


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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-ofpocket 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 


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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 ConsumerPurchaser Disclosure Project, the AARP, 

the American Federation of LaborCongress 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 


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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 NQFendorsed 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 


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+ 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 selfadministering 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 


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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 lowmolecular 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; 


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• Outcome measures for all 

hospitalized patients, at 90 days for rehospitalization 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 NQFendorsed 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 inhospital 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 inhospital 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 


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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 in 42 

CFR Part 480. 

In addition, for purposes of the 

annual payment update, we will 

continue to require hospitals to pass our 

validation requirements 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 


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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 selfadminister 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 selfadministering the survey and survey 

vendors in the spring of 2007. 

• Review and follow the HCAHPS 

Quality Assurance Guidelines and 

Updates. HCAHPS Quality Assurance 

Guidelines have been developed to 

standardize the survey data collection 

process and to ensure comparability of 

data reported through HCAHPS. They 

are located on http:// 

www.HCAHPSonline.org and will also 

be presented at the HCAHPS hospital/ 

survey vendor training. 

The HCAHPS Quality Assurance 

Guidelines (the Guidelines) provide 

detailed information regarding: 

technical support; sampling protocols; 

the four allowed modes of survey 

administration; data specifications and 

coding; data preparation and 

submission; data reporting and the 

exceptions process. The Guidelines 

describe technical support that is 

available to hospitals and survey 

vendors administering HCAHPS by 

using a toll-free number or by e-mail. 

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 


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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 selfadministering the survey their specific 

Quality Assurance Plans, survey 

management procedures, sampling and 

data collection protocols, and data 

preparation and submission. This 

review may take place in-person or 

through other means of communication. 

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 


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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, patientmix, 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 MultiCampus 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 


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beginning with discharges in the third 

quarter 2007 (July through September 

2007). 

Response: Collection of SCIPInfection 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 SCIPInf-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 SCIPInf-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 standardsetting 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 publicprivate collaboration of numerous 

stakeholder groups. One goal of HQA is 

to identify a robust set of standardized 

and easy-to-understand hospital quality 

measures that would be used by all 

stakeholders in the health care system 

in order to improve quality of care and 

the ability of consumers to make 

informed health care choices. We also 

note that HQA currently relies on the 

NQF process as part of its process. 

CMS anticipates that other consensus 

building entities that take into account 

the issues of validity, reliability, impact 

and feasibility of the measures and 

involves a wide array of stakeholders 

may develop. 

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 


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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 


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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 forprofit 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 


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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 Gcode 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 Gcodes 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 


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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 fixeddollar 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 passthrough 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 passthrough 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 lowvolume 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. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

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 Transfers 

Annualized 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 providerspecific 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 


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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 Transfers 

Annualized 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 


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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 welldesigned studies that have found at least 

some impact on hospital clinical 

performance (Abt report). 

HCAHPS provides many benefits to 

hospitals and also to society at-large. 

The HCAHPS initiative has taken 

substantial steps to assure that the 

survey will be credible, useful, and 

practical. First, the survey is designed to 

produce comparable data on the 

patient’s perspective 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 


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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, Xrays. 

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 Amounts of payment. 

* * * * * 

(i) Amount of payment: ASC facility 

services. (1) For ASC facility services 

furnished on or after July 1, 1987 and 

before January 1, 2008, in connection 

with the surgical procedures specified 

in part 416 of this chapter, Medicare 

Part B pays 80 percent of a standard 

overhead amount as specified in 

§ 416.120(c) of this chapter, except that, 


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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 Basis and scope. 

(a) * * * 

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

requires the Secretary to specify the 

surgical procedures that can be 

performed safely on an ambulatory basis 

in an ambulatory surgical center. 

(3) Sections 1833(i)(2)(A) and (D) and 

1833(a)(1)(G) of the Act specify the 

amounts to be paid for facility services 

furnished in connection with the 

specified surgical procedures when they 

are performed in an ASC. 

(4) Section 1833(i)(2)(C) of the Act 

provides that if the Secretary has not 

updated amounts for ASC facility 

services furnished during a fiscal year 

through 2005 or a calendar year 

beginning with 2006, the amounts shall 

be increased by the percentage increase 

in the Consumer Price Index for all 

urban consumers as estimated by the 

Secretary for the 12-month period 

ending with the midpoint of the year 

involved, except that, in fiscal year 

2005, the last quarter of calendar year 

2005, and each of the calendar years 

2006 through 2009, the increase shall be 

zero percent. 

(5) Section 1833(i)(2)(E) of the Act 

provides that, with respect to surgical 

procedures furnished on or after January 

1, 2007, and before the effective date of 

the implementation of a revised 

payment system, the payment amount 

shall be the lesser of the ASC payment 

rate established under section 

1833(i)(2)(A) of the Act or the 

prospective payment rate for hospital 

outpatient department services 

established under section 1833(t)(3)(D) 

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 Definitions. 

* * * * * 

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 Covered surgical procedures. 

Effective for services furnished before 

January 1, 2008, covered surgical 

procedures are those procedures that 

meet the standards described in 

paragraphs (a) and (b) of this section 

and are included in the list published in 

accordance with paragraph (c) of this 

section. 

(a) * * * 

(4) Are not otherwise excluded under 

§ 411.15 of this chapter. 

* * * * * 

■ 8. A new § 416.76 is added to Subpart 

D to read as follows: 

§ 416.76 Applicability. 

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 [Amended] 

■ 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 Applicability. 

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 ASC facility services payment 

rate. 

* * * * * 

(c) For services furnished on or after 

January 1, 2007, and before the effective 

date of implementation of a revised 

payment system, the ASC payment rate 

for a surgical procedure 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 [Removed] 

■ 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 

Sec. 

416.180 Basis and scope. 

416.185 Process for establishing a new class 

of new technology IOLs. 

416.190 Request for review of payment 

amount. 

416.195 Determination of membership in 

new classes of new technology IOLs. 

416.200 Payment adjustment. 

§ 416.180 Basis and scope. 

(a) Basis. This subpart implements 

section 141 of Public Law 103–432, 

which provides for adjustments to 

payment amounts for new technology 

intraocular lenses (IOLs) furnished at 

ambulatory surgical centers (ASCs). 

(b) Scope. This subpart sets forth—

(1) The process for interested parties 

to request that CMS review the 

appropriateness of the ASC facility fee 

for insertion of an IOL. This process 

includes a review of whether that 

payment is reasonable and related to the 

cost of acquiring a lens determined by 

CMS as belonging to a class of new 

technology IOLs; 

(2) Factors that CMS considers for 

determination of a new class of new 

technology IOLs; and 


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(3) Application of the payment 

adjustment. 

§ 416.185 Process for establishing a new 

class of new technology IOLs. 

(a) Announcement of deadline for 

requests for review. CMS announces the 

deadline for each year’s requests for 

review of a new class of new technology 

IOLs in the final rule updating the ASC 

payment rates for that calendar year. 

(b) Announcement of new classes of 

new technology IOLs for which review 

requests have been made and 

solicitation of public comments. CMS 

announces the requests for review 

received in a calendar year and the 

deadline for public comments regarding 

the requests in the proposed rule 

updating the ASC payment rates for the 

following calendar year. The deadline 

for submission of public comments is 30 

days following the date of the 

publication of the proposed rule. 

(c) Announcement of determinations 

regarding requests for review. CMS 

announces its determinations for a 

calendar year in the final rule updating 

the ASC payment rates for the following 

calendar year. CMS publishes the codes 

and effective dates allowed for those 

lenses recognized by CMS as belonging 

to a class of new technology IOLs. New 

classes of new technology IOLs are 

effective 30 days following the date of 

publication of the final rule. 

§ 416.190 Request for review of payment 

amount. 

(a) When requests can be submitted. A 

request for review of the 

appropriateness of ASC payment for 

insertion of an IOL that might qualify 

for a payment adjustment as belonging 

to a new class of new technology IOLs 

must be submitted to CMS in 

accordance with the annual published 

deadline. 

(b) Who may submit a request. Any 

individual, partnership, corporation, 

association, society, scientific or 

academic establishment, or professional 

or trade organization able to furnish the 

information required in paragraph (c) of 

this section may request that CMS 

review the appropriateness of the 

payment amount provided under 

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

respect to an IOL that meets the criteria 

of a new technology IOL under 

§ 416.195. 

(c) Content of a request. In order to be 

accepted by CMS for review, a request 

for review of the ASC payment amount 

for insertion of an IOL must include all 

the information as specified by CMS. 

(d) Confidential information. In order 

for CMS to invoke the protection 

allowed under Exemption 4 of the 

Freedom of Information Act (5 U.S.C. 

552(b)(4)) and, with respect to trade 

secrets, the Trade Secrets Act (18 U.S.C. 

1905), the requestor must clearly 

identify all information that is to be 

characterized as confidential. 

§ 416.195 Determination of membership in 

new classes of new technology IOLs. 

(a) Factors to be considered. CMS uses 

the following criteria to determine 

whether an IOL qualifies for a payment 

adjustment as a member of a new class 

of new technology IOLs when inserted 

at an ASC: 

(1) The IOL is approved by the FDA. 

(2) Claims of specific clinical benefits 

and/or lens characteristics with 

established clinical relevance in 

comparison to currently available IOLs 

are approved by the FDA for use in 

labeling and advertising. 

(3) The IOL is not described by an 

active or expired class of new 

technology IOLs; that is, it does not 

share a predominant, class-defining 

characteristic associated with improved 

clinical outcomes with members of an 

active or expired class. 

(4) Evidence 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 Payment adjustment. 

(a) CMS establishes the amount of the 

payment adjustment for classes of new 

technology IOLs through proposed and 

final rulemaking in connection with 

ASC 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 Hospital outpatient services 

subject to the outpatient prospective 

payment system. 

* * * * * 

(d) The following medical and other 

health services furnished by a home 

health agency (HHA) to patients who are 

not under an HHA plan or treatment or 

by a hospice program furnishing 

services to patients outside the hospice 

benefit: 

* * * * * 

■ 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 Adjustments to national program 

payment and beneficiary copayment 

amounts. 

* * * * * 

(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 


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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 Payment and copayment 

reduction for devices replaced without cost 

or full credit is received. 

(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 Transitional adjustment to limit 

decline in payments. 

* * * * * 

(d) Hold harmless provisions—(1) 

Temporary treatment for small rural 

hospitals before January 1, 2006. For 

covered hospital outpatient services 

furnished in a calendar year before 

January 1, 2006, for which the 

prospective payment system amount is 

less than the pre-BBA amount, the 

amount of payment under this part is 

increased by the amount of that 

difference if the hospital—

(i) Is located in a rural area as defined 

in § 412.63(b) of this chapter or is 

treated as being located in a rural area 

under section 1886(d)(8)(E) of the Act; 

and 

(ii) Has 100 or fewer beds as defined 

in § 412.105(b) of this chapter. 

(2) Temporary treatment for small 

rural hospitals on or after January 1, 

2006. For covered hospital outpatient 

services furnished in a calendar year 

from January 1, 2006, through December 

31, 2008, for which the prospective 

payment system amount is less than the 

pre-BBA amount, the amount of 

payment under this paragraph is 

increased by 95 percent of that 

difference for services furnished during 

2006, 90 percent of that difference for 

services furnished during 2007, and 85 

percent of that difference for services 

furnished during 2008 if the hospital—

(i) Is located in a rural area as defined 

in § 412.63(b) of this chapter or is 

treated as being located in a rural area 

under section 1886(d)(8)(E) of the Act; 

(ii) Has 100 or fewer beds as defined 

in § 412.105(b) of this chapter; 

(iii) Is not a sole community hospital 

as defined in § 412.92 of this chapter; 

and 

(iv) Is not an essential access 

community hospital under § 412.109 of 

this chapter. 

* * * * * 

PART 421—MEDICARE CONTRACTING 

■ 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 Definitions. 

As used in this part—

Intermediary means an entity that has 

a contract with CMS (under statutory 

provisions in effect prior to October 1, 

2005) to determine and make Medicare 

payments for Part A or Part B benefits 

payable on a cost basis (or under the 

prospective payment system for 

hospitals) and to perform other related 

functions. For purposes of applying the 

performance criteria in § 421.120 and 

the performance standards in § 421.122 

and any adverse action resulting from 

that application, the term 

‘‘intermediary’’ also means a Blue Cross 

plan that has entered into a subcontract 

approved by CMS with the Blue Cross 

and Blue Shield Association to perform 

intermediary functions. 

■ 25. Section 421.100 is amended by 

revising paragraph (i) to read as follows: 

§ 421.100 Intermediary functions. 

* * * * * 

(i) Dual intermediary responsibilities. 

Regarding the responsibility for service 

to provider-based HHAs and providerbased hospices, where the HHA or the 

hospice and its parent provider will be 

served by different intermediaries, the 

designated regional intermediary will 

process bills, make coverage 

determinations, and make payments to 

the HHAs and the hospices. The 

intermediary serving the parent 

provider will perform all fiscal 

functions, including audits and 

settlement of the Medicare cost reports 

and the HHA and hospice supplement 

worksheets. 

■ 26. Section 421.103 is revised to read 

as follows: 

§ 421.103 Payment to providers. 

Providers are assigned to 

intermediaries in accordance with 

§ 421.104. As the Medicare 

Administrative Contractors (MACs) are 

implemented, providers are reassigned 

from intermediaries to MACs in 

accordance with § 412.404 of this 

chapter. 

■ 27. Section 421.104 is revised to read 

as follows: 

§ 421.104 Assignment of providers of 

services to intermediaries during transition 

to Medicare Administrative Contractors 

(MACs). 

(a) Beginning October 1, 2005, CMS 

assigns providers of services and other 

entities that may bill Part A benefits to 

intermediaries in a manner that will 

best support the transition to Medicare 

Administrative Contractors (MACs) 

under section 1874A of the Act in 

accordance with Subpart E of this part. 

(b) These providers of services and 

other entities must continue to bill the 

intermediary that they were billing prior 

to October 1, 2005, until one of the 

following events occurs: 

(1) The intermediary’s agreement with 

CMS ends, and the provider or entity is 


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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 [Removed] 

■ 28. Section 421.105 is removed. 

§ 421.106 [Removed] 

■ 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 Considerations relating to the 

effective and efficient administration of the 

program. 

(a) In order to accomplish the most 

effective and efficient administration of 

the Medicare program, the Secretary 

may make determinations with respect 

to the termination of an intermediary 

agreement, and CMS may make 

determinations with respect to renewal 

of an intermediary agreement under 

§ 421.110. 

(b) When taking the actions specified 

in paragraph (a) of this section, the 

Secretary or CMS will consider the 

performance of the individual 

intermediary in its Medicare operations 

using the factors contained in the 

performance criteria specified in 

§ 421.120 and the performance 

standards specified in § 421.122. 

* * * * * 

■ 31. Section 421.114 is revised to read 

as follows: 

§ 421.114 Assignment and reassignment 

of providers by CMS. 

CMS may assign or reassign any 

provider to any intermediary if it 

determines that the assignment or 

reassignment will be in the best 

interests of the Medicare program. 

§ 421.116 [Removed] 

■ 32. Section 421.116 is removed. 

§ 421.117 [Removed] 

■ 33. Section 421.117 is removed. 

§ 421.118 [Removed] 

■ 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) 

Sec. 

421.400 Statutory basis and scope. 

421.401 Definitions. 

421.404 Assignment of providers and 

suppliers to MACs. 

§ 421.400 Statutory basis and scope. 

(a) Statutory basis. This subpart 

implements section 1874A of the Act, 

which provides for the transition of the 

claims processing functions and 

operations for both Medicare Part A and 

Part B intermediaries and carriers to 

Medicare Administrative Contractors 

(MACs). The transition will occur 

between October 1, 2005, and October 1, 

2011. MACs will be fully operational in 

distinct, nonoverlapping geographic 

jurisdictions by October 1, 2011. 

(b) Scope. This subpart specifies the 

requirements under which providers 

and suppliers will be assigned to MACs. 

§ 421.401 Definitions. 

For purposes of this subpart—

Appropriate MAC means a MAC that 

has a contract under section 1874A of 

the Act to perform a particular Medicare 

administrative function in relation to: 

(1) A particular individual entitled to 

benefits under Part A or enrolled under 

Part B, or both; 

(2) A specific provider of services or 

supplier; or 

(3) A class of providers of services or 

suppliers. 

Medicare Administrative Contractor 

(MAC) means an agency, organization, 

or other person with a contract under 

section 1874A of the Act. 

§ 421.404 Assignment of providers and 

suppliers to MACs. 

(a) Definitions. As used in this 

section—

Chain provider means a group of two 

or more providers under common 

ownership or control. 

Common control exists when an 

individual, a group of individuals, or an 

organization has the power, directly or 

indirectly, to significantly influence or 

direct the actions or policies of the 

group of suppliers or eligible providers. 

Common ownership exists when an 

individual, a group of individuals, or an 

organization possesses significant equity 

in the group of suppliers or eligible 

providers. 

Durable medical equipment, 

prosthetics, orthotics, and supplies 

(DMEPOS) means the types of services 

specified in § 421.210(b). 

Eligible provider means a hospital, 

skilled nursing facility, or critical access 

hospital that meets the definition of a 

provider under § 400.202 of this 

chapter. 

Home office means the entity that 

provides centralized management and 

administrative services to the individual 

providers or suppliers under common 

ownership and common control, such as 

centralized accounting, purchasing, 

personnel services, management 

direction and control, and other similar 

services. 

Ineligible provider means a provider 

under § 400.202 of this chapter that is 

not an eligible provider. 

Medicare benefit category means a 

category of covered benefits under Part 

A or Part B of the Medicare program (for 

example, inpatient hospital services, 

post-hospital extended care services, 

and physicians’ services). 

Provider has the same meaning as 

specified under § 400.202 of this 

chapter. 

Qualified chain provider means a 

chain provider comprised of—

(1) 10 or more eligible providers 

collectively totaling 500 or more 

certified beds; or 

(2) 5 or more eligible providers 

collectively totaling 300 or more 

certified beds, with eligible providers in 

3 or more 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 


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68230 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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 crossreference ‘‘paragraph (d)(3)(iii)’’ in its 

place. 

■ e. In redesignated paragraph (d)(4), 

removing the cross-reference ‘‘paragraph 

(d)(2)(iii)’’ and adding the crossreference ‘‘paragraph (d)(3)(iii)’’ in its 

place. 

The revisions and additions read as 

follows: 

§ 485.618 Condition of participation: 

Emergency services. 

* * * * * 

(d) Standard: Personnel. (1) Except as 

specified in paragraph (d)(3) of this 

section, there must be a doctor of 

medicine or osteopathy, a physician 

assistant, a nurse practitioner, or a 

clinical nurse specialist, with training or 

experience in emergency care, on call 

and immediately available by telephone 

or radio contact, and available 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 Definitions. 

* * * * * 

Supplier means any of the following: 

Independent laboratory; portable X-ray 

services; physical therapist in 

independent practice; ESRD facility; 

rural health clinic; Federally qualified 

health center; chiropractor; or 

ambulatory surgical center. 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, 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. 


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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 

Copayment 

0001 ......... Level I Photochemotherapy .......................................................... S 0.4914 30.21 7.00 6.04 

0002 ......... Level I Fine Needle Biopsy/Aspiration ......................................... T 1.0995 67.58 .................... 13.52 

0003 ......... Bone Marrow Biopsy/Aspiration ................................................... T 2.4011 147.59 .................... 29.52 

0004 ......... Level I Needle Biopsy/Aspiration Except Bone Marrow ............... T 2.0687 127.16 .................... 25.43 

0005 ......... Level II Needle Biopsy/Aspiration Except Bone Marrow .............. T 3.9045 240.00 71.59 48.00 

0006 ......... Level I Incision & Drainage .......................................................... T 1.4392 88.46 .................... 17.69 

0007 ......... Level II Incision & Drainage ......................................................... T 11.1535 685.58 .................... 137.12 

0008 ......... Level III Incision and Drainage ..................................................... T 17.5086 1,076.22 .................... 215.24 

0009 ......... Nail Procedures ............................................................................ T 0.7744 47.60 .................... 9.52 

0010 ......... Level I Destruction of Lesion ........................................................ T 0.4760 29.26 8.02 5.85 

0011 ......... Level II Destruction of Lesion ....................................................... T 2.5665 157.76 .................... 31.55 

0012 ......... Level I Debridement & Destruction .............................................. T 0.8432 51.83 11.18 10.37 

0013 ......... Level II Debridement & Destruction ............................................. T 1.0918 67.11 .................... 13.42 

0015 ......... Level III Debridement & Destruction ............................................ T 1.6241 99.83 20.13 19.97 

0016 ......... Level IV Debridement & Destruction ............................................ T 2.6749 164.42 .................... 32.88 

0017 ......... Level VI Debridement & Destruction ............................................ T 17.4423 1,072.14 227.84 214.43 

0018 ......... Biopsy of Skin/Puncture of Lesion ............................................... T 1.0259 63.06 15.44 12.61 

0019 ......... Level I Excision/ Biopsy ................................................................ T 4.0919 251.52 71.87 50.30 

0020 ......... Level II Excision/ Biopsy ............................................................... T 6.8083 418.49 107.67 83.70 

0021 ......... Level III Excision/ Biopsy .............................................................. T 15.1024 928.31 219.48 185.66 

0022 ......... Level IV Excision/ Biopsy ............................................................. T 20.0656 1,233.39 354.45 246.68 

0023 ......... Exploration Penetrating Wound .................................................... T 4.2212 259.47 .................... 51.89 

0024 ......... Level I Skin Repair ....................................................................... T 1.4843 91.24 29.88 18.25 

0025 ......... Level II Skin Repair ...................................................................... T 5.2594 323.28 101.85 64.66 

0027 ......... Level IV Skin Repair ..................................................................... T 21.4302 1,317.27 329.72 263.45 

0028 ......... Level I Breast Surgery .................................................................. T 19.2788 1,185.03 303.74 237.01 

0029 ......... Level II Breast Surgery ................................................................. T 28.0166 1,722.12 581.52 344.42 

0030 ......... Level III Breast Surgery ................................................................ T 37.8692 2,327.74 747.07 465.55 

0031 ......... Smoking Cessation Services ........................................................ X 0.1766 10.86 .................... 2.17 

0033 ......... Partial Hospitalization ................................................................... P 3.8188 234.73 .................... 46.95 

0035 ......... Arterial/Venous Puncture .............................................................. T 0.1999 12.29 .................... 2.46 

0036 ......... Level II Fine Needle Biopsy/Aspiration ........................................ T 2.0738 127.47 .................... 25.49 

0037 ......... Level IV Needle Biopsy/Aspiration Except Bone Marrow ............ T 10.2655 631.00 228.76 126.20 

0038 ......... Spontaneous MEG ....................................................................... S 53.5161 3,289.53 .................... 657.91 

0039 ......... Level I Implantation of Neurostimulator ........................................ S 187.3821 11,518.00 .................... 2,303.60 

0040 ......... Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve.S 56.5705 3,477.28 .................... 695.46 

0041 ......... Level I Arthroscopy ....................................................................... T 28.6245 1,759.49 .................... 351.90 

0042 ......... Level II Arthroscopy ...................................................................... T 45.5027 2,796.96 804.74 559.39 

0043 ......... Closed Treatment Fracture Finger/Toe/Trunk .............................. T 1.6857 103.62 .................... 20.72 

0045 ......... Bone/Joint Manipulation Under Anesthesia ................................. T 14.5947 897.11 268.47 179.42 

0047 ......... Arthroplasty without Prosthesis .................................................... T 33.4505 2,056.14 537.03 411.23 

0048 ......... Level I Arthroplasty with Prosthesis ............................................. T 47.4378 2,915.91 .................... 583.18 

0049 ......... Level I Musculoskeletal Procedures Except Hand and Foot ....... T 20.8706 1,282.87 .................... 256.57 

0050 ......... Level II Musculoskeletal Procedures Except Hand and Foot ...... T 25.1296 1,544.67 .................... 308.93 

0051 ......... Level III Musculoskeletal Procedures Except Hand and Foot ..... T 41.0893 2,525.68 .................... 505.14 

0052 ......... Level IV Musculoskeletal Procedures Except Hand and Foot ..... T 66.5800 4,092.54 .................... 818.51 

0053 ......... Level I Hand Musculoskeletal Procedures ................................... T 16.1540 992.95 253.49 198.59 

0054 ......... Level II Hand Musculoskeletal Procedures .................................. T 25.8758 1,590.53 .................... 318.11 

0055 ......... Level I Foot Musculoskeletal Procedures .................................... T 20.4263 1,255.56 355.34 251.11 

0056 ......... Level II Foot Musculoskeletal Procedures ................................... T 40.8559 2,511.33 .................... 502.27 

0057 ......... Bunion Procedures ....................................................................... T 28.2349 1,735.54 475.91 347.11 

0058 ......... Level I Strapping and Cast Application ........................................ S 1.0607 65.20 .................... 13.04 

0060 ......... Manipulation Therapy ................................................................... S 0.4657 28.63 .................... 5.73 

0061 ......... Laminectomy or Incision for Implantation of Neurostimulator 

Electrodes, Excluding Cranial Nerve.

S 84.1967 5,175.40 .................... 1,035.08 

0062 ......... Level I Treatment Fracture/Dislocation ........................................ T 25.5264 1,569.06 372.87 313.81 

0063 ......... Level II Treatment Fracture/Dislocation ....................................... T 37.5382 2,307.40 548.33 461.48 

0064 ......... Level III Treatment Fracture/Dislocation ...................................... T 57.2172 3,517.03 835.79 703.41 

0065 ......... Level I Stereotactic Radiosurgery ................................................ S 20.3224 1,249.18 .................... 249.84 

0066 ......... Level II Stereotactic Radiosurgery ............................................... S 43.0297 2,644.95 .................... 528.99 

0067 ......... Level III Stereotactic Radiosurgery .............................................. S 63.3759 3,895.59 .................... 779.12 

0068 ......... CPAP Initiation .............................................................................. S 1.5353 94.37 29.48 18.87 

0069 ......... Thoracoscopy ............................................................................... T 31.9442 1,963.55 591.64 392.71 

0070 ......... Thoracentesis/Lavage Procedures ............................................... T 3.6244 222.78 .................... 44.56 

0071 ......... Level I Endoscopy Upper Airway ................................................. T 0.7698 47.32 11.20 9.46 

0072 ......... Level II Endoscopy Upper Airway ................................................ T 1.4054 86.39 21.27 17.28 

0073 ......... Level III Endoscopy Upper Airway ............................................... T 3.8463 236.42 69.15 47.28 

0074 ......... Level IV Endoscopy Upper Airway ............................................... T 14.7928 909.28 292.25 181.86 


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68232 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0075 ......... Level V Endoscopy Upper Airway ................................................ T 21.9512 1,349.30 445.92 269.86 

0076 ......... Level I Endoscopy Lower Airway ................................................. T 9.5228 585.35 189.82 117.07 

0077 ......... Level I Pulmonary Treatment ....................................................... S 0.3527 21.68 7.74 4.34 

0078 ......... Level II Pulmonary Treatment ...................................................... S 1.1206 68.88 14.55 13.78 

0079 ......... Ventilation Initiation and Management ......................................... S 2.6116 160.53 .................... 32.11 

0080 ......... Diagnostic Cardiac Catheterization .............................................. T 37.0615 2,278.10 838.92 455.62 

0081 ......... Non-Coronary Angioplasty or Atherectomy .................................. T 42.9360 2,639.19 .................... 527.84 

0082 ......... Coronary Atherectomy .................................................................. T 72.1982 4,437.88 954.62 887.58 

0083 ......... Coronary Angioplasty and Percutaneous Valvuloplasty .............. T 58.7904 3,613.73 .................... 722.75 

0084 ......... Level I Electrophysiologic Evaluation ........................................... S 9.8924 608.07 .................... 121.61 

0085 ......... Level II Electrophysiologic Evaluation .......................................... T 34.2808 2,107.17 426.25 421.43 

0086 ......... Ablate Heart Dysrhythm Focus .................................................... T 47.4931 2,919.31 812.36 583.86 

0087 ......... Cardiac Electrophysiologic Recording/Mapping ........................... T 32.8988 2,022.22 .................... 404.44 

0088 ......... Thrombectomy .............................................................................. T 37.7391 2,319.75 655.22 463.95 

0089 ......... Insertion/Replacement of Permanent Pacemaker and Electrodes.T 123.6693 7,601.70 1,682.28 1,520.34 

0090 ......... Insertion/Replacement of Pacemaker Pulse Generator ............... T 98.3023 6,042.45 1,612.80 1,208.49 

0091 ......... Level II Vascular Ligation ............................................................. T 34.7288 2,134.71 .................... 426.94 

0092 ......... Level I Vascular Ligation .............................................................. T 24.8809 1,529.38 309.87 305.88 

0093 ......... Vascular Reconstruction/Fistula Repair without Device ............... T 22.8653 1,405.48 .................... 281.10 

0094 ......... Level I Resuscitation and Cardioversion ...................................... S 2.4233 148.96 46.29 29.79 

0095 ......... Cardiac Rehabilitation ................................................................... S 0.5748 35.33 13.86 7.07

0096 ......... Non-Invasive Vascular Studies ..................................................... S 1.5303 94.06 37.62 18.81 

0097 ......... Cardiac and Ambulatory Blood Pressure Monitoring ................... X 1.0225 62.85 23.79 12.57 

0098 ......... Injection of Sclerosing Solution .................................................... T 1.0798 66.37 .................... 13.27 

0099 ......... Electrocardiograms ....................................................................... S 0.3789 23.29 .................... 4.66 

0100 ......... Cardiac Stress Tests .................................................................... X 2.5336 155.74 41.44 31.15 

0101 ......... Tilt Table Evaluation ..................................................................... S 4.2769 262.89 100.24 52.58 

0103 ......... Miscellaneous Vascular Procedures ............................................ T 16.2375 998.09 223.63 199.62 

0104 ......... Transcatheter Placement of Intracoronary Stents ........................ T 87.7183 5,391.87 .................... 1,078.37 

0105 ......... Repair/Revision/Removal of Pacemakers, AICDs, or Vascular 

Devices.

T 25.6142 1,574.45 370.40 314.89 

0106 ......... Insertion/Replacement of Pacemaker Leads and/or Electrodes .. T 58.8594 3,617.97 .................... 723.59 

0107 ......... Insertion of Cardioverter-Defibrillator ............................................ T 304.4894 18,716.35 .................... 3,743.27 

0108 ......... Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads T 379.7339 23,341.48 .................... 4,668.30

0109 ......... Removal of Implanted Devices ..................................................... T 10.9918 675.64 .................... 135.13 

0110 ......... Transfusion ................................................................................... S 3.4584 212.58 .................... 42.52 

0111 ......... Blood Product Exchange .............................................................. S 11.7134 720.00 198.40 144.00

0112 ......... Apheresis, Photopheresis, and Plasmapheresis .......................... S 30.2231 1,857.75 433.29 371.55 

0113 ......... Excision Lymphatic System .......................................................... T 21.2621 1,306.94 .................... 261.39 

0114 ......... Thyroid/Lymphadenectomy Procedures ....................................... T 37.7224 2,318.72 467.95 463.74 

0115 ......... Cannula/Access Device Procedures ............................................ T 29.2133 1,795.68 374.81 359.14 

0121 ......... Level I Tube changes and Repositioning ..................................... T 2.3587 144.98 43.80 29.00 

0122 ......... Level II Tube changes and Repositioning .................................... T 7.4800 459.78 .................... 91.96 

0123 ......... Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant.S 20.3582 1,251.38 .................... 250.28 

0125 ......... Refilling of Infusion Pump ............................................................. T 2.2041 135.48 .................... 27.10 

0126 ......... Level I Urinary and Anal Procedures ........................................... T 1.0887 66.92 16.45 13.38 

0127 ......... Level IV Stereotactic Radiosurgery .............................................. S 138.4486 8,510.16 .................... 1,702.03 

0130 ......... Level I Laparoscopy ..................................................................... T 32.1241 1,974.60 659.53 394.92 

0131 ......... Level II Laparoscopy .................................................................... T 43.5488 2,676.86 1,001.89 535.37 

0132 ......... Level III Laparoscopy ................................................................... T 70.5066 4,333.90 1,239.22 866.78 

0140 ......... Esophageal Dilation without Endoscopy ...................................... T 5.4566 335.41 91.40 67.08 

0141 ......... Level I Upper GI Procedures ........................................................ T 8.3175 511.26 143.38 102.25 

0142 ......... Small Intestine Endoscopy ........................................................... T 9.4946 583.61 152.78 116.72 

0143 ......... Lower GI Endoscopy .................................................................... T 8.7686 538.99 186.06 107.80 

0146 ......... Level I Sigmoidoscopy and Anoscopy ......................................... T 4.8683 299.24 64.40 59.85 

0147 ......... Level II Sigmoidoscopy and Anoscopy ........................................ T 8.5477 525.41 .................... 105.08 

0148 ......... Level I Anal/Rectal Procedures .................................................... T 5.0770 312.07 .................... 62.41 

0149 ......... Level III Anal/Rectal Procedures .................................................. T 22.2682 1,368.78 293.06 273.76

0150 ......... Level IV Anal/Rectal Procedures .................................................. T 29.6189 1,820.61 437.12 364.12 

0151 ......... Endoscopic Retrograde Cholangio-Pancreatography (ERCP) ..... T 19.8381 1,219.41 245.46 243.88 

0152 ......... Level I Percutaneous Abdominal and Biliary Procedures ............ T 20.2682 1,245.85 .................... 249.17 

0153 ......... Peritoneal and Abdominal Procedures ......................................... T 22.0832 1,357.41 397.95 271.48 

0154 ......... Hernia/Hydrocele Procedures ....................................................... T 29.2182 1,795.98 464.85 359.20

0155 ......... Level II Anal/Rectal Procedures ................................................... T 12.7389 783.03 .................... 156.61 

0156 ......... Level III Urinary and Anal Procedures ......................................... T 3.4079 209.48 .................... 41.90 

0157 ......... Colorectal Cancer Screening: Barium Enema ............................. S 2.1149 130.00 .................... 26.00 

0158 ......... Colorectal Cancer Screening: Colonoscopy ................................. T 7.8492 446.00 .................... 111.50 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68233 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0159 ......... Colorectal Cancer Screening: Flexible Sigmoidoscopy ............... S 3.6592 224.92 .................... 56.23 

0160 ......... Level I Cystourethroscopy and other Genitourinary Procedures T 6.4951 399.24 101.58 79.85 

0161 ......... Level II Cystourethroscopy and other Genitourinary Procedures T 19.2251 1,181.73 249.36 236.35 

0162 ......... Level III Cystourethroscopy and other Genitourinary Procedures T 23.8700 1,467.24 .................... 293.45 

0163 ......... Level IV Cystourethroscopy and other Genitourinary Procedures T 34.9261 2,146.84 .................... 429.37 

0164 ......... Level II Urinary and Anal Procedures .......................................... T 2.1393 131.50 .................... 26.30 

0165 ......... Level IV Urinary and Anal Procedures ......................................... T 18.1679 1,116.74 .................... 223.35 

0166 ......... Level I Urethral Procedures .......................................................... T 18.3960 1,130.77 .................... 226.15 

0168 ......... Level II Urethral Procedures ......................................................... T 29.0253 1,784.13 388.16 356.83 

0169 ......... Lithotripsy ...................................................................................... T 43.5398 2,676.30 1,009.47 535.26 

0170 ......... Dialysis .......................................................................................... S 6.6089 406.24 .................... 81.25 

0171 ......... Level V Anal/Rectal Procedures ................................................... T 37.8991 2,329.58 716.76 465.92 

0180 ......... Circumcision ................................................................................. T 20.5513 1,263.25 304.87 252.65 

0181 ......... Penile Procedures ........................................................................ T 32.9873 2,027.66 621.82 405.53 

0183 ......... Testes/Epididymis Procedures ..................................................... T 23.5310 1,446.40 .................... 289.28 

0184 ......... Prostate Biopsy ............................................................................. T 5.6262 345.83 96.27 69.17 

0188 ......... Level II Female Reproductive Proc .............................................. T 1.2900 79.29 .................... 15.86 

0189 ......... Level III Female Reproductive Proc ............................................. T 2.8966 178.05 .................... 35.61 

0190 ......... Level I Hysteroscopy .................................................................... T 21.3586 1,312.87 424.28 262.57 

0191 ......... Level I Female Reproductive Proc ............................................... T 0.1468 9.02 2.55 1.80 

0192 ......... Level IV Female Reproductive Proc ............................................. T 6.6592 409.33 .................... 81.87 

0193 ......... Level V Female Reproductive Proc .............................................. T 14.8489 912.73 .................... 182.55 

0194 ......... Level VIII Female Reproductive Proc ........................................... T 20.5081 1,260.59 397.84 252.12 

0195 ......... Level IX Female Reproductive Proc ............................................. T 28.5095 1,752.42 483.80 350.48 

0196 ......... Dilation and Curettage .................................................................. T 17.7499 1,091.05 338.23 218.21 

0197 ......... Infertility Procedures ..................................................................... T 4.0007 245.92 .................... 49.18 

0198 ......... Pregnancy and Neonatal Care Procedures ................................. T 1.4222 87.42 32.19 17.48 

0200 ......... Level VII Female Reproductive Proc ............................................ T 16.9328 1,040.83 243.36 208.17 

0201 ......... Level VI Female Reproductive Proc ............................................. T 18.5201 1,138.39 329.65 227.68 

0202 ......... Level X Female Reproductive Proc .............................................. T 42.9896 2,642.48 981.50 528.50 

0203 ......... Level IV Nerve Injections .............................................................. T 12.1702 748.08 240.33 149.62 

0204 ......... Level I Nerve Injections ................................................................ T 2.2614 139.00 40.13 27.80 

0206 ......... Level II Nerve Injections ............................................................... T 5.7253 351.92 75.55 70.38 

0207 ......... Level III Nerve Injections .............................................................. T 6.3603 390.95 86.92 78.19 

0208 ......... Laminotomies and Laminectomies ............................................... T 44.1489 2,713.74 .................... 542.75 

0209 ......... Level II MEG, Extended EEG Studies and Sleep Studies ........... S 11.2463 691.29 268.73 138.26 

0212 ......... Nervous System Injections ........................................................... T 2.9907 183.83 65.96 36.77 

0213 ......... Level I MEG, Extended EEG Studies and Sleep Studies ............ S 2.2755 139.87 53.58 27.97 

0214 ......... Electroencephalogram .................................................................. S 1.1968 73.56 28.24 14.71 

0215 ......... Level I Nerve and Muscle Tests ................................................... S 0.5741 35.29 .................... 7.06 

0216 ......... Level III Nerve and Muscle Tests ................................................. S 2.7199 167.19 .................... 33.44 

0218 ......... Level II Nerve and Muscle Tests .................................................. S 1.1872 72.97 .................... 14.59 

0220 ......... Level I Nerve Procedures ............................................................. T 17.8499 1,097.20 .................... 219.44 

0221 ......... Level II Nerve Procedures ............................................................ T 33.1520 2,037.79 463.62 407.56 

0222 ......... Implantation of Neurological Device ............................................. T 181.6249 11,164.12 .................... 2,232.82 

0223 ......... Implantation or Revision of Pain Management Catheter ............. T 30.8394 1,895.64 .................... 379.13 

0224 ......... Implantation of Reservoir/Pump/Shunt ......................................... T 47.0342 2,891.10 .................... 578.22 

0225 ......... Implantation of Neurostimulator Electrodes, Cranial Nerve ......... S 221.1512 13,593.72 .................... 2,718.74 

0226 ......... Implantation of Drug Infusion Reservoir ....................................... T 112.6322 6,923.28 .................... 1,384.66 

0227 ......... Implantation of Drug Infusion Device ........................................... T 174.4056 10,720.36 .................... 2,144.07 

0228 ......... Creation of Lumbar Subarachnoid Shunt ..................................... T 39.2633 2,413.44 .................... 482.69 

0229 ......... Transcatherter Placement of Intravascular Shunts ...................... T 68.4697 4,208.70 .................... 841.74 

0230 ......... Level I Eye Tests & Treatments ................................................... S 0.7898 48.55 14.97 9.71 

0231 ......... Level III Eye Tests & Treatments ................................................. S 2.1451 131.86 .................... 26.37 

0232 ......... Level I Anterior Segment Eye Procedures ................................... T 6.0673 372.94 93.43 74.59 

0233 ......... Level II Anterior Segment Eye Procedures .................................. T 15.2259 935.91 266.33 187.18 

0234 ......... Level III Anterior Segment Eye Procedures ................................. T 22.9970 1,413.58 511.31 282.72 

0235 ......... Level I Posterior Segment Eye Procedures ................................. T 3.9333 241.77 58.93 48.35 

0236 ......... Level II Posterior Segment Eye Procedures ................................ T 16.5239 1,015.69 .................... 203.14 

0237 ......... Level III Posterior Segment Eye Procedures ............................... T 27.6020 1,696.64 .................... 339.33 

0238 ......... Level I Repair and Plastic Eye Procedures ................................. T 2.8954 177.97 .................... 35.59 

0239 ......... Level II Repair and Plastic Eye Procedures ................................ T 7.2819 447.60 .................... 89.52 

0240 ......... Level III Repair and Plastic Eye Procedures ............................... T 17.1243 1,052.60 309.52 210.52 

0241 ......... Level IV Repair and Plastic Eye Procedures ............................... T 25.2550 1,552.37 384.47 310.47 

0242 ......... Level V Repair and Plastic Eye Procedures ................................ T 35.2292 2,165.47 597.36 433.09 

0243 ......... Strabismus/Muscle Procedures .................................................... T 21.2801 1,308.05 430.35 261.61 

0244 ......... Corneal Transplant ....................................................................... T 38.2707 2,352.42 803.26 470.48 

0245 ......... Level I Cataract Procedures without IOL Insert ........................... T 14.8702 914.04 217.05 182.81 

0246 ......... Cataract Procedures with IOL Insert ............................................ T 23.6313 1,452.57 495.96 290.51 


cprice-sewell on PRODPC62 with RULES2
68234 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0247 ......... Laser Eye Procedures Except Retinal ......................................... T 5.0839 312.50 104.31 62.50 

0248 ......... Laser Retinal Procedures ............................................................. T 5.0841 312.51 95.08 62.50 

0249 ......... Level II Cataract Procedures without IOL Insert .......................... T 29.2281 1,796.59 524.67 359.32 

0250 ......... Nasal Cauterization/Packing ......................................................... T 1.1791 72.48 25.39 14.50 

0251 ......... Level I ENT Procedures ............................................................... T 2.4520 150.72 .................... 30.14 

0252 ......... Level II ENT Procedures .............................................................. T 7.5511 464.15 109.16 92.83 

0253 ......... Level III ENT Procedures ............................................................. T 16.4266 1,009.71 282.29 201.94 

0254 ......... Level IV ENT Procedures ............................................................. T 23.3299 1,434.04 321.35 286.81 

0256 ......... Level V ENT Procedures .............................................................. T 38.1991 2,348.02 .................... 469.60 

0257 ......... Level I Therapeutic Radiologic Procedures ................................. S 1.0974 67.45 .................... 13.49

0258 ......... Tonsil and Adenoid Procedures ................................................... T 22.1165 1,359.46 437.25 271.89 

0259 ......... Level VI ENT Procedures ............................................................. T 414.8455 25,499.72 8,698.43 5,099.94 

0260 ......... Level I Plain Film Except Teeth ................................................... X 0.7093 43.60 .................... 8.72 

0261 ......... Level II Plain Film Except Teeth Including Bone Density Measurement.X 1.2224 75.14 .................... 15.03 

0262 ......... Plain Film of Teeth ....................................................................... X 0.6550 40.26 .................... 8.05 

0263 ......... Level I Miscellaneous Radiology Procedures .............................. X 1.6956 104.23 23.77 20.85 

0264 ......... Level II Miscellaneous Radiology Procedures ............................. X 2.9586 181.86 70.27 36.37 

0265 ......... Level I Diagnostic and Screening Ultrasound .............................. S 0.9923 60.99 23.63 12.20 

0266 ......... Level II Diagnostic and Screening Ultrasound ............................. S 1.5607 95.93 37.80 19.19 

0267 ......... Level III Diagnostic and Screening Ultrasound ............................ S 2.4606 151.25 60.50 30.25 

0268 ......... Level I Ultrasound Guidance Procedures .................................... S 1.1882 73.04 .................... 14.61

0269 ......... Level II Echocardiogram Except Transesophageal ...................... S 3.2154 197.64 75.60 39.53 

0270 ......... Transesophageal Echocardiogram ............................................... S 6.2505 384.21 141.32 76.84 

0272 ......... Fluoroscopy .................................................................................. X 1.2908 79.34 31.64 15.87 

0274 ......... Myelography ................................................................................. S 2.5544 157.01 62.80 31.40 

0275 ......... Arthrography ................................................................................. S 3.6915 226.91 69.09 45.38 

0276 ......... Level I Digestive Radiology .......................................................... S 1.4294 87.86 34.97 17.57 

0277 ......... Level II Digestive Radiology ......................................................... S 2.2176 136.31 54.52 27.26 

0278 ......... Diagnostic Urography ................................................................... S 2.4159 148.50 59.40 29.70

0279 ......... Level II Angiography and Venography ......................................... S 9.5061 584.32 150.03 116.86 

0280 ......... Level III Angiography and Venography ........................................ S 20.8225 1,279.92 353.85 255.98 

0282 ......... Miscellaneous Computerized Axial Tomography ......................... S 1.5379 94.53 37.81 18.91 

0283 ......... Computed Tomography with Contrast .......................................... S 4.0825 250.94 100.37 50.19 

0284 ......... Magnetic Resonance Imaging and Magnetic Resonance 

Angiography with Contrast.

S 6.1231 376.37 148.40 75.27 

0288 ......... Bone Density:Axial Skeleton ........................................................ S 1.1755 72.26 28.90 14.45 

0293 ......... Level V Anterior Segment Eye Procedures ................................. T 51.9894 3,195.68 1,128.29 639.14 

0296 ......... Level II Therapeutic Radiologic Procedures ................................ S 2.6802 164.75 53.99 32.95 

0297 ......... Level III Therapeutic Radiologic Procedures ............................... S 3.6392 223.69 89.47 44.74 

0298 ......... Level IV Therapeutic Radiologic Procedures ............................... S 8.3906 515.75 206.30 103.15 

0299 ......... Miscellaneous Radiation Treatment ............................................. S 5.8839 361.67 .................... 72.33 

0300 ......... Level I Radiation Therapy ............................................................ S 1.4826 91.13 .................... 18.23 

0301 ......... Level II Radiation Therapy ........................................................... S 2.2295 137.04 .................... 27.41 

0302 ......... Computer Assisted Navigational Procedures ............................... S 4.9138 302.04 105.94 60.41 

0303 ......... Treatment Device Construction .................................................... X 2.9430 180.90 66.95 36.18 

0304 ......... Level I Therapeutic Radiation Treatment Preparation ................. X 1.5735 96.72 38.68 19.34 

0305 ......... Level II Therapeutic Radiation Treatment Preparation ................ X 3.9723 244.17 91.38 48.83 

0307 ......... Myocardial Positron Emission Tomography (PET) imaging ......... S 11.8963 731.24 292.49 146.25 

0308 ......... Non-Myocardial Positron Emission Tomography (PET) imaging S 13.9166 855.43 .................... 171.09 

0309 ......... Level II Ultrasound Guidance Procedures ................................... S 2.1012 129.16 .................... 25.83 

0310 ......... Level III Therapeutic Radiation Treatment Preparation ............... X 13.8081 848.76 325.27 169.75 

0312 ......... Radioelement Applications ........................................................... S 4.8569 298.54 .................... 59.71 

0313 ......... Brachytherapy ............................................................................... S 12.8473 789.70 .................... 157.94 

0314 ......... Hyperthermic Therapies ............................................................... S 3.3461 205.68 60.88 41.14 

0315 ......... Level II Implantation of Neurostimulator ....................................... T 242.9363 14,932.81 .................... 2,986.56 

0320 ......... Electroconvulsive Therapy ............................................................ S 5.5676 342.23 80.06 68.45 

0321 ......... Biofeedback and Other Training ................................................... S 1.3384 82.27 21.72 16.45 

0322 ......... Brief Individual Psychotherapy ..................................................... S 1.1798 72.52 .................... 14.50 

0323 ......... Extended Individual Psychotherapy ............................................. S 1.7066 104.90 .................... 20.98 

0324 ......... Family Psychotherapy .................................................................. S 2.1633 132.97 .................... 26.59 

0325 ......... Group Psychotherapy ................................................................... S 1.0765 66.17 14.47 13.23 

0330 ......... Dental Procedures ........................................................................ S 7.0550 433.66 .................... 86.73 

0332 ......... Computed Tomography without Contrast ..................................... S 3.0908 189.99 75.24 38.00 

0333 ......... Computed Tomography without Contrast followed by Contrast) S 4.8405 297.54 119.01 59.51 

0335 ......... Magnetic Resonance Imaging, Miscellaneous ............................. S 4.5523 279.82 111.92 55.96 

0336 ......... Magnetic Resonance Imaging and Magnetic Resonance 

Angiography without Contrast.

S 5.6745 348.80 139.51 69.76 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68235 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0337 ......... Magnetic Resonance Imaging and Magnetic Resonance 

Angiography without Contrast followed by Contrast.

S 8.1155 498.84 199.53 99.77 

0339 ......... Observation ................................................................................... S 7.2039 442.81 .................... 88.56 

0340 ......... Minor Ancillary Procedures ........................................................... X 0.6102 37.51 .................... 7.50 

0341 ......... Skin Tests ..................................................................................... X 0.0914 5.62 2.24 1.12 

0342 ......... Level I Pathology .......................................................................... X 0.0824 5.06 2.02 1.01

0343 ......... Level III Pathology ........................................................................ X 0.5211 32.03 10.84 6.41 

0344 ......... Level IV Pathology ........................................................................ X 0.7927 48.73 15.66 9.75 

0345 ......... Level I Transfusion Laboratory Procedures ................................. X 0.2178 13.39 2.87 2.68 

0346 ......... Level II Transfusion Laboratory Procedures ................................ X 0.3484 21.42 4.39 4.28 

0347 ......... Level III Transfusion Laboratory Procedures ............................... X 0.7423 45.63 11.28 9.13 

0348 ......... Fertility Laboratory Procedures .................................................... X 0.8321 51.15 .................... 10.23 

0350 ......... Administration of flu and PPV vaccine ......................................... S 0.3945 24.25 .................... 0.00 

0360 ......... Level I Alimentary Tests ............................................................... X 1.4154 87.00 33.88 17.40 

0361 ......... Level II Alimentary Tests .............................................................. X 3.8887 239.03 83.23 47.81

0362 ......... Contact Lens and Spectacle Services ......................................... X 0.5865 36.05 .................... 7.21 

0363 ......... Level I Otorhinolaryngologic Function Tests ................................ X 0.8525 52.40 17.44 10.48 

0364 ......... Level I Audiometry ........................................................................ X 0.4627 28.44 7.06 5.69

0365 ......... Level II Audiometry ....................................................................... X 1.2419 76.34 18.52 15.27 

0366 ......... Level III Audiometry ...................................................................... X 1.8511 113.78 26.14 22.76 

0367 ......... Level I Pulmonary Test ................................................................. X 0.6277 38.58 14.68 7.72 

0368 ......... Level II Pulmonary Tests .............................................................. X 0.9454 58.11 22.77 11.62 

0369 ......... Level III Pulmonary Tests ............................................................. X 2.7669 170.08 44.18 34.02 

0370 ......... Allergy Tests ................................................................................. X 1.0270 63.13 .................... 12.63 

0372 ......... Therapeutic Phlebotomy ............................................................... X 0.5723 35.18 10.09 7.04 

0373 ......... Level I Neuropsychological Testing .............................................. X 1.7682 108.69 .................... 21.74 

0374 ......... Monitoring Psychiatric Drugs ........................................................ X 1.1418 70.18 .................... 14.04 

0375 ......... Ancillary Outpatient Services When Patient Expires ................... S 58.0781 3,569.94 .................... 713.99

0376 ......... Level II Cardiac Imaging ............................................................... S 4.9832 306.31 119.77 61.26 

0377 ......... Level III Cardiac Imaging .............................................................. S 6.5012 399.62 158.84 79.92 

0378 ......... Level II Pulmonary Imaging .......................................................... S 5.0975 313.33 125.33 62.67 

0379 ......... Injection adenosine 6 MG ............................................................. K .................... 30.49 .................... 6.10 

0381 ......... Single Allergy Tests ...................................................................... X 0.2688 16.52 .................... 3.30 

0382 ......... Level II Neuropsychological Testing ............................................. X 2.8460 174.94 69.97 34.99 

0384 ......... GI Procedures with Stents ............................................................ T 22.9475 1,410.54 295.41 282.11 

0385 ......... Level I Prosthetic Urological Procedures ..................................... S 79.2092 4,868.83 .................... 973.77 

0386 ......... Level II Prosthetic Urological Procedures .................................... S 137.3897 8,445.07 .................... 1,689.01 

0387 ......... Level II Hysteroscopy ................................................................... T 34.0155 2,090.86 655.55 418.17 

0388 ......... Discography .................................................................................. S 15.9758 982.00 289.72 196.40 

0389 ......... Level I Non-imaging Nuclear Medicine ........................................ S 1.3754 84.54 33.81 16.91 

0390 ......... Level I Endocrine Imaging ............................................................ S 2.3432 144.03 57.61 28.81 

0391 ......... Level II Endocrine Imaging ........................................................... S 2.7146 166.86 66.18 33.37 

0392 ......... Level II Non-imaging Nuclear Medicine ....................................... S 2.0057 123.29 49.31 24.66 

0393 ......... Red Cell/Plasma Studies .............................................................. S 3.7562 230.89 82.04 46.18 

0394 ......... Hepatobiliary Imaging ................................................................... S 4.3774 269.07 102.61 53.81 

0395 ......... GI Tract Imaging ........................................................................... S 3.6526 224.52 89.73 44.90 

0396 ......... Bone Imaging ................................................................................ S 3.9174 240.79 95.02 48.16 

0397 ......... Vascular Imaging .......................................................................... S 2.4204 148.78 49.58 29.76 

0398 ......... Level I Cardiac Imaging ................................................................ S 4.1265 253.65 100.06 50.73 

0399 ......... Nuclear Medicine Add-on Imaging ............................................... S 1.5054 92.53 35.80 18.51 

0400 ......... Hematopoietic Imaging ................................................................. S 3.9073 240.17 93.22 48.03 

0401 ......... Level I Pulmonary Imaging ........................................................... S 3.1802 195.48 78.19 39.10 

0402 ......... Brain Imaging ................................................................................ S 4.6418 285.32 114.12 57.06 

0403 ......... CSF Imaging ................................................................................. S 3.4923 214.66 83.35 42.93 

0404 ......... Renal and Genitourinary Studies Level I ..................................... S 3.4209 210.28 84.11 42.06 

0405 ......... Renal and Genitourinary Studies Level II .................................... S 4.0378 248.20 98.77 49.64 

0406 ......... Level I Tumor/Infection Imaging ................................................... S 3.9934 245.47 98.18 49.09 

0407 ......... Level I Radionuclide Therapy ....................................................... S 3.1779 195.34 78.13 39.07 

0408 ......... Level II Tumor/Infection Imaging .................................................. S 5.9245 364.17 .................... 72.83 

0409 ......... Red Blood Cell Tests .................................................................... X 0.1227 7.54 2.20 1.51 

0411 ......... Respiratory Procedures ................................................................ S 0.3848 23.65 .................... 4.73 

0412 ......... IMRT Treatment Delivery ............................................................. S 5.4731 336.42 .................... 67.28 

0413 ......... Level II Radionuclide Therapy ...................................................... S 5.2957 325.52 .................... 65.10 

0415 ......... Level II Endoscopy Lower Airway ................................................ T 22.0099 1,352.90 459.92 270.58 

0416 ......... Level I Intravascular and Intracardiac Ultrasound and Flow Reserve.S 32.5472 2,000.61 .................... 400.12 

0417 ......... Computerized Reconstruction ...................................................... S 3.2393 199.11 .................... 39.82 

0418 ......... Insertion of Left Ventricular Pacing Elect. .................................... T 307.2828 18,888.06 .................... 3,777.61 

0421 ......... Prolonged Physiologic Monitoring ................................................ X 1.6270 100.01 .................... 20.00 


cprice-sewell on PRODPC62 with RULES2
68236 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0422 ......... Level II Upper GI Procedures ....................................................... T 25.7552 1,583.12 448.81 316.62 

0423 ......... Level II Percutaneous Abdominal and Biliary Procedures ........... T 37.3604 2,296.47 .................... 459.29 

0425 ......... Level II Arthroplasty with Prosthesis ............................................ T 107.1942 6,589.01 1,378.01 1,317.80 

0426 ......... Level II Strapping and Cast Application ....................................... S 2.2777 140.01 .................... 28.00 

0427 ......... Level III Tube Changes and Repositioning .................................. T 11.6575 716.56 .................... 143.31 

0428 ......... Level III Sigmoidoscopy and Anoscopy ....................................... T 20.6375 1,268.55 .................... 253.71 

0429 ......... Level V Cystourethroscopy and other Genitourinary Procedures T 43.1004 2,649.30 .................... 529.86 

0432 ......... Health and Behavior Services ...................................................... S 0.6072 37.32 .................... 7.46 

0433 ......... Level II Pathology ......................................................................... X 0.2557 15.72 5.93 3.14 

0434 ......... Cardiac Defect Repair .................................................................. T 88.0728 5,413.66 .................... 1,082.73 

0436 ......... Level I Drug Administration .......................................................... S 0.1809 11.12 .................... 2.22 

0437 ......... Level II Drug Administration ......................................................... S 0.3945 24.25 .................... 4.85 

0438 ......... Level III Drug Administration ........................................................ S 0.7942 48.82 .................... 9.76 

0439 ......... Level IV Drug Administration ........................................................ S 1.5848 97.41 .................... 19.48 

0440 ......... Level V Drug Administration ......................................................... S 1.8090 111.20 .................... 22.24 

0441 ......... Level VI Drug Administration ........................................................ S 2.4851 152.75 .................... 30.55 

0442 ......... Dosimetric Drug Administration .................................................... S 22.3666 1,374.83 .................... 274.97 

0443 ......... Overnight Pulse Oximetry ............................................................. X 1.0409 63.98 25.59 12.80 

0604 ......... Level 1 Hospital Clinic Visits ........................................................ V 0.8242 50.66 .................... 10.13 

0605 ......... Level 2 Hospital Clinic Visits ........................................................ V 0.9840 60.48 .................... 12.10 

0606 ......... Level 3 Hospital Clinic Visits ........................................................ V 1.3646 83.88 .................... 16.78 

0607 ......... Level 4 Hospital Clinic Visits ........................................................ V 1.7096 105.09 .................... 21.02 

0608 ......... Level 5 Hospital Clinic Visits ........................................................ V 2.1794 133.96 .................... 26.79 

0609 ......... Level 1 Emergency Visits ............................................................. V 0.8136 50.01 12.70 10.00 

0613 ......... Level 2 Emergency Visits ............................................................. V 1.3497 82.96 21.06 16.59 

0614 ......... Level 3 Emergency Visits ............................................................. V 2.1150 130.00 34.50 26.00 

0615 ......... Level 4 Emergency Visits ............................................................. V 3.4163 209.99 48.49 42.00 

0616 ......... Level 5 Emergency Visits ............................................................. V 5.2915 325.26 75.11 65.05 

0617 ......... Critical Care .................................................................................. S 6.5894 405.04 111.59 81.01 

0618 ......... Trauma Response with Critical Care ........................................... S 8.0455 494.54 197.81 98.91 

0621 ......... Level I Vascular Access Procedures ............................................ T 8.7846 539.97 .................... 107.99 

0622 ......... Level II Vascular Access Procedures ........................................... T 22.6665 1,393.26 .................... 278.65 

0623 ......... Level III Vascular Access Procedures .......................................... T 28.5032 1,752.03 .................... 350.41 

0624 ......... Minor Vascular Access Device Procedures ................................. X 0.5145 31.63 12.65 6.33 

0625 ......... Level IV Vascular Access Procedures ......................................... T 83.4609 5,130.17 .................... 1,026.03 

0648 ......... Level IV Breast Surgery ............................................................... T 51.2269 3,148.82 .................... 629.76 

0651 ......... Complex Interstitial Radiation Source Application ....................... S 16.8462 1,035.50 .................... 207.10 

0652 ......... Insertion of Intraperitoneal and Pleural Catheters ....................... T 29.5416 1,815.86 .................... 363.17 

0653 ......... Vascular Reconstruction/Fistula Repair with Device .................... T 32.3818 1,990.44 .................... 398.09 

0654 ......... Insertion/Replacement of a permanent dual chamber pacemaker.T 112.7719 6,931.86 .................... 1,386.37 

0655 ......... Insertion/Replacement/Conversion of a permanent dual chamber pacemaker.T 152.6392 9,382.43 .................... 1,876.49 

0656 ......... Transcatheter Placement of Intracoronary Drug-Eluting Stents .. T 108.3003 6,657.00 .................... 1,331.40 

0657 ......... Placement of Tissue Clips ............................................................ S 1.7369 106.76 .................... 21.35 

0658 ......... Percutaneous Breast Biopsies ..................................................... T 6.4387 395.77 .................... 79.15 

0659 ......... Hyperbaric Oxygen ....................................................................... S 1.5906 97.77 .................... 19.55 

0660 ......... Level II Otorhinolaryngologic Function Tests ............................... X 1.4461 88.89 28.06 17.78 

0661 ......... Level V Pathology ......................................................................... X 2.5255 155.24 62.09 31.05 

0662 ......... CT Angiography ............................................................................ S 4.8552 298.44 118.88 59.69 

0663 ......... Level I Electronic Analysis of Neurostimulator Pulse Generators S 1.1067 68.03 17.45 13.61 

0664 ......... Level I Proton Beam Radiation Therapy ...................................... S 18.8926 1,161.29 .................... 232.26 

0665 ......... Bone Density:AppendicularSkeleton ............................................ S 0.5497 33.79 13.51 6.76 

0667 ......... Level II Proton Beam Radiation Therapy ..................................... S 22.6031 1,389.37 .................... 277.87 

0668 ......... Level I Angiography and Venography .......................................... S 6.2463 383.95 88.26 76.79 

0670 ......... Level II Intravascular and Intracardiac Ultrasound and Flow Reserve.S 32.2854 1,984.52 536.10 396.90 

0672 ......... Level IV Posterior Segment Eye Procedures ............................... T 37.4290 2,300.69 .................... 460.14 

0673 ......... Level IV Anterior Segment Eye Procedures ................................ T 37.8967 2,329.43 649.56 465.89 

0674 ......... Prostate Cryoablation ................................................................... T 108.7566 6,685.05 .................... 1,337.01 

0675 ......... Prostatic Thermotherapy .............................................................. T 41.1375 2,528.64 .................... 505.73 

0676 ......... Thrombolysis and Thrombectomy ................................................ T 2.0726 127.40 .................... 25.48 

0678 ......... External Counterpulsation ............................................................ T 1.7418 107.06 .................... 21.41 

0679 ......... Level II Resuscitation and Cardioversion ..................................... S 5.5233 339.51 95.30 67.90 

0680 ......... Insertion of Patient Activated Event Recorders ........................... S 72.6022 4,462.71 .................... 892.54 

0681 ......... Knee Arthroplasty ......................................................................... T 205.6815 12,642.83 .................... 2,528.57 

0682 ......... Level V Debridement & Destruction ............................................. T 6.8832 423.10 158.65 84.62 

0683 ......... Level II Photochemotherapy ......................................................... S 2.6734 164.33 .................... 32.87 

0685 ......... Level III Needle Biopsy/Aspiration Except Bone Marrow ............. T 6.1384 377.32 115.47 75.46 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68237 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0686 ......... Level III Skin Repair ..................................................................... T 14.0346 862.68 .................... 172.54 

0687 ......... Revision/Removal of Neurostimulator Electrodes ........................ T 17.8334 1,096.18 438.47 219.24 

0688 ......... Revision/Removal of Neurostimulator Pulse Generator Receiver T 35.5702 2,186.43 874.57 437.29 

0689 ......... Electronic Analysis of Cardioverter-defibrillators .......................... S 0.6003 36.90 .................... 7.38 

0690 ......... Electronic Analysis of Pacemakers and other Cardiac Devices .. S 0.3613 22.21 8.67 4.44 

0691 ......... Electronic Analysis of Programmable Shunts/Pumps .................. S 2.8942 177.90 60.61 35.58 

0692 ......... Level II Electronic Analysis of Neurostimulator Pulse Generators S 1.9323 118.77 30.16 23.75 

0693 ......... Breast Reconstruction .................................................................. T 36.9988 2,274.24 721.30 454.85 

0694 ......... Mohs Surgery ............................................................................... T 3.7292 229.23 91.69 45.85 

0695 ......... Level VII Debridement & Destruction ........................................... T 20.4276 1,255.64 266.59 251.13 

0697 ......... Level I Echocardiogram Except Transesophageal ....................... S 1.5973 98.18 35.99 19.64 

0698 ......... Level II Eye Tests & Treatments .................................................. S 1.1607 71.35 .................... 14.27 

0699 ......... Level IV Eye Tests & Treatments ................................................ T 14.3845 884.19 .................... 176.84 

0700 ......... Antepartum Manipulation .............................................................. T 2.3864 146.69 .................... 29.34 

0701 ......... Sr89 strontium .............................................................................. H .................... .................... .................... ....................

0702 ......... Sm 153 lexidronm ......................................................................... H .................... .................... .................... ....................

0704 ......... In111 satumomab ......................................................................... H .................... .................... .................... ....................

0705 ......... Tc99m tetrofosmin ........................................................................ H .................... .................... .................... ....................

0722 ......... Tc99m pentetate ........................................................................... H .................... .................... .................... ....................

0723 ......... Co57/58 ........................................................................................ H .................... .................... .................... ....................

0724 ......... Co57 cyano ................................................................................... H .................... .................... .................... ....................

0726 ......... Dexrazoxane HCl injection ........................................................... K .................... 180.13 .................... 36.03 

0728 ......... Filgrastim 300 mcg injection ......................................................... K .................... 188.07 .................... 37.61 

0730 ......... Pamidronate disodium /30 MG ..................................................... K .................... 34.80 .................... 6.96 

0731 ......... Sargramostim injection ................................................................. K .................... 25.55 .................... 5.11 

0732 ......... Mesna injection ............................................................................. K .................... 10.10 .................... 2.02 

0735 ......... Ampho b cholesteryl sulfate ......................................................... K .................... 12.00 .................... 2.40 

0736 ......... Amphotericin b liposome inj ......................................................... K .................... 21.25 .................... 4.25 

0737 ......... Nitrogen N-13 ammonia ............................................................... H .................... .................... .................... ....................

0738 ......... Rasburicase .................................................................................. K .................... 121.26 .................... 24.25 

0739 ......... Tc99m depreotide ......................................................................... H .................... .................... .................... ....................

0740 ......... Tc99m gluceptate ......................................................................... H .................... .................... .................... ....................

0741 ......... Cr51 chromate .............................................................................. H .................... .................... .................... ....................

0742 ......... Tc99m labeled rbc ........................................................................ H .................... .................... .................... ....................

0743 ......... Tc99m mertiatide .......................................................................... H .................... .................... .................... ....................

0744 ......... Plague vaccine, im ....................................................................... K .................... 150.00 .................... 30.00 

0746 ......... Dacarbazine 100 mg inj ................................................................ K .................... 4.90 .................... 0.98 

0747 ......... Chlorothiazide sodium inj ............................................................. K .................... 123.84 .................... 24.77 

0748 ......... Bleomycin sulfate injection ........................................................... K .................... 37.62 .................... 7.52 

0750 ......... Dolasetron mesylate ..................................................................... K .................... 6.89 .................... 1.38 

0751 ......... Mechlorethamine hcl inj ................................................................ K .................... 141.61 .................... 28.32 

0752 ......... Dactinomycin actinomycin d ......................................................... K .................... 493.43 .................... 98.69 

0753 ......... Spectinomycn di-hcl inj ................................................................. K .................... 30.08 .................... 6.02 

0759 ......... Naltrexone, depot form ................................................................. K .................... 1.94 .................... 0.39 

0760 ......... Anadulafungin injection ................................................................. G .................... 1.91 .................... 0.38 

0763 ......... Dolasetron mesylate oral .............................................................. K .................... 48.91 .................... 9.78 

0764 ......... Granisetron HCl injection .............................................................. K .................... 7.21 .................... 1.44 

0765 ......... Granisetron HCl 1 mg oral ........................................................... K .................... 41.18 .................... 8.24 

0766 ......... Apomorphine hydrochloride .......................................................... K .................... 2.92 .................... 0.58 

0767 ......... Enfuvirtide injection ....................................................................... K .................... 21.82 .................... 4.36 

0768 ......... Ondansetron hcl injection ............................................................. K .................... 3.72 .................... 0.74 

0769 ......... Ondansetron HCl 8mg oral ........................................................... K .................... 36.06 .................... 7.21 

0800 ......... Leuprolide acetate /3.75 MG ........................................................ K .................... 437.58 .................... 87.52 

0802 ......... Etoposide oral 50 MG ................................................................... K .................... 32.01 .................... 6.40 

0804 ......... Immune globulin subcutaneous .................................................... K .................... 7.08 .................... 1.42 

0805 ......... Mecasermin injection .................................................................... K .................... 11.93 .................... 2.39 

0806 ......... Hyaluronidase recombinant .......................................................... G .................... 0.40 .................... 0.08 

0807 ......... Aldesleukin/single use vial ............................................................ K .................... 726.69 .................... 145.34 

0808 ......... Nabilone oral ................................................................................. K .................... 16.96 .................... 3.39 

0809 ......... Bcg live intravesical vac ............................................................... K .................... 113.44 .................... 22.69 

0810 ......... Goserelin acetate implant ............................................................. K .................... 199.12 .................... 39.82 

0811 ......... Carboplatin injection ..................................................................... K .................... 10.12 .................... 2.02 

0812 ......... Carmus bischl nitro inj .................................................................. K .................... 139.84 .................... 27.97 

0814 ......... Asparaginase injection .................................................................. K .................... 54.46 .................... 10.89 

0820 ......... Daunorubicin ................................................................................. K .................... 24.56 .................... 4.91 

0821 ......... Daunorubicin citrate liposom ........................................................ K 56.21 .................... 11.24 

0823 ......... Docetaxel ...................................................................................... K .................... 302.68 .................... 60.54 

0825 ......... Nelarabine injection ...................................................................... K .................... 83.10 .................... 16.62 

0827 ......... Floxuridine injection ...................................................................... K .................... 64.17 .................... 12.83 


cprice-sewell on PRODPC62 with RULES2
68238 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0828 ......... Gemcitabine HCl ........................................................................... K .................... 121.30 .................... 24.26 

0829 ......... Technetium TC-99m aerosol ........................................................ H .................... .................... .................... ....................

0830 ......... Irinotecan injection ........................................................................ K .................... 126.88 .................... 25.38 

0831 ......... Ifosfomide injection ....................................................................... K .................... 52.39 .................... 10.48 

0832 ......... Idarubicin hcl injection .................................................................. K .................... 308.97 .................... 61.79 

0834 ......... Interferon alfa-2a inj ...................................................................... K .................... 37.56 .................... 7.51 

0835 ......... Inj cosyntropin per 0.25 MG ......................................................... K .................... 62.91 .................... 12.58 

0836 ......... Interferon alfa-2b inj ...................................................................... K .................... 13.75 .................... 2.75 

0838 ......... Interferon gamma 1-b inj .............................................................. K .................... 289.87 .................... 57.97 

0840 ......... Inj melphalan hydrochl 50 MG ..................................................... K .................... 1,194.15 .................... 238.83 

0842 ......... Fludarabine phosphate inj ............................................................ K .................... 243.82 .................... 48.76 

0843 ......... Pegaspargase/singl dose vial ....................................................... K .................... 1,687.04 .................... 337.41 

0844 ......... Pentostatin injection ...................................................................... K .................... 2,034.63 .................... 406.93 

0849 ......... Rituximab cancer treatment .......................................................... K .................... 481.69 .................... 96.34 

0850 ......... Streptozocin injection .................................................................... K .................... 152.92 .................... 30.58 

0851 ......... Thiotepa injection .......................................................................... K .................... 44.58 .................... 8.92 

0852 ......... Topotecan ..................................................................................... K .................... 813.08 .................... 162.62 

0855 ......... Vinorelbine tartrate/10 mg ............................................................ K .................... 22.82 .................... 4.56 

0856 ......... Porfimer sodium ............................................................................ K .................... 2,505.40 .................... 501.08 

0858 ......... Inj cladribine per 1 MG ................................................................. K .................... 37.87 .................... 7.57 

0860 ......... Plicamycin (mithramycin) inj ......................................................... K .................... 61.36 .................... 12.27 

0861 ......... Leuprolide acetate injeciton .......................................................... K .................... 11.10 .................... 2.22 

0862 ......... Mitomycin 5 MG inj ....................................................................... K .................... 18.31 .................... 3.66 

0863 ......... Paclitaxel injection ........................................................................ K .................... 14.35 .................... 2.87 

0864 ......... Mitoxantrone hydrochl / 5 MG ...................................................... K .................... 223.27 .................... 44.65 

0865 ......... Interferon alfa-n3 inj ...................................................................... K .................... 39.48 .................... 7.90 

0868 ......... Oral aprepitant .............................................................................. G .................... 4.85 .................... 0.97 

0876 ......... Caffeine citrate injection ............................................................... K .................... 3.54 .................... 0.71 

0884 ......... Rho d immune globulin inj ............................................................ K .................... 80.52 .................... 16.10 

0887 ......... Azathioprine parenteral ................................................................. K .................... 49.17 .................... 9.83 

0888 ......... Cyclosporine oral 100 mg ............................................................. K .................... 3.66 .................... 0.73 

0890 ......... Lymphocyte immune globulin ....................................................... K .................... 315.76 .................... 63.15 

0891 ......... Tacrolimus oral per 1 MG ............................................................. K .................... 3.55 .................... 0.71 

0892 ......... Edetate calcium disodium inj ........................................................ K .................... 40.19 .................... 8.04 

0895 ......... Deferoxamine mesylate inj ........................................................... K .................... 14.84 .................... 2.97 

0896 ......... Sodium Hyaluronate Injection ....................................................... K .................... 124.68 .................... 24.94 

0900 ......... Alglucerase injection ..................................................................... K .................... 39.22 .................... 7.84 

0901 ......... Alpha 1 proteinase inhibitor .......................................................... K .................... 3.31 .................... 0.66 

0902 ......... Botulinum toxin a per unit ............................................................. K .................... 5.04 .................... 1.01 

0903 ......... Cytomegalovirus imm IV /vial ....................................................... K .................... 853.18 .................... 170.64 

0906 ......... RSV-ivig ........................................................................................ K .................... 16.18 .................... 3.24 

0910 ......... Interferon beta-1b / .25 MG .......................................................... K .................... 90.00 .................... 18.00 

0911 ......... Inj streptokinase /250000 IU ......................................................... K .................... 79.50 .................... 15.90 

0912 ......... Interferon alfacon-1 ....................................................................... K .................... 4.65 .................... 0.93 

0913 ......... Ganciclovir long act implant ......................................................... K .................... 4,766.14 .................... 953.23 

0916 ......... Injection imiglucerase /unit ........................................................... K .................... 3.91 .................... 0.78 

0917 ......... Adenosine injection ....................................................................... K .................... 30.49 .................... 6.10 

0925 ......... Factor viii ...................................................................................... K .................... 0.69 .................... 0.14 

0926 ......... Factor VIII (porcine) ...................................................................... K .................... 1.33 .................... 0.27 

0927 ......... Factor viii recombinant ................................................................. K .................... 1.06 .................... 0.21 

0928 ......... Factor ix complex ......................................................................... K .................... 0.72 .................... 0.14 

0929 ......... Anti-inhibitor .................................................................................. K .................... 1.36 .................... 0.27 

0930 ......... Antithrombin iii injection ................................................................ K .................... 1.62 .................... 0.32 

0931 ......... Factor IX non-recombinant ........................................................... K .................... 0.90 .................... 0.18 

0932 ......... Factor IX recombinant .................................................................. K .................... 0.99 .................... 0.20 

0935 ......... Clonidine hydrochloride ................................................................ K .................... 66.04 .................... 13.21 

0949 ......... Frozen plasma, pooled, sd ........................................................... K 0.9346 57.45 .................... 11.49 

0950 ......... Whole blood for transfusion .......................................................... K 2.1472 131.98 .................... 26.40 

0952 ......... Cryoprecipitate each unit .............................................................. K 0.7905 48.59 .................... 9.72 

0954 ......... RBC leukocytes reduced .............................................................. K 2.8590 175.74 .................... 35.15 

0955 ......... Plasma, frz between 8-24hour ..................................................... K 1.2489 76.77 .................... 15.35 

0956 ......... Plasma protein fract,5%,50ml ....................................................... K 0.8339 51.26 .................... 10.25 

0957 ......... Platelets, each unit ....................................................................... K 0.9590 58.95 .................... 11.79 

0958 ......... Plaelet rich plasma unit ................................................................ K 3.4048 209.29 .................... 41.86 

0959 ......... Red blood cells unit ...................................................................... K 2.1073 129.53 .................... 25.91 

0960 ......... Washed red blood cells unit ......................................................... K 3.4331 211.03 .................... 42.21 

0961 ......... Albumin (human), 5%, 50ml ......................................................... K .................... 29.68 .................... 5.94 

0963 ......... Albumin (human), 5%, 250 ml ...................................................... K .................... 76.81 .................... 15.36 

0964 ......... Albumin (human), 25%, 20 ml ...................................................... K .................... 28.80 .................... 5.76 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68239 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

0965 ......... Albumin (human), 25%, 50ml ....................................................... K .................... 65.26 .................... 13.05 

0966 ......... Plasmaprotein fract, 5%,250ml ..................................................... K 3.8746 238.16 .................... 47.63 

0967 ......... Blood split unit .............................................................................. K 2.2323 137.22 .................... 27.44 

0968 ......... Platelets leukoreduced irrad ......................................................... K 2.0390 125.33 .................... 25.07 

0969 ......... RBC leukoreduced irradiated ....................................................... K 3.5394 217.56 .................... 43.51 

1009 ......... Cryoprecipitatereducedplasma ..................................................... K 1.3404 82.39 .................... 16.48 

1010 ......... Blood, l/r, cmv-neg ........................................................................ K 2.5493 156.70 .................... 31.34 

1011 ......... Platelets, hla-m, l/r, unit ................................................................ K 10.9263 671.62 .................... 134.32 

1013 ......... Platelets leukocytes reduced ........................................................ K 1.5469 95.08 .................... 19.02 

1016 ......... Blood, l/r, froz/degly/wash ............................................................ K 3.4335 211.05 .................... 42.21 

1017 ......... Plt, aph/pher, l/r, cmv-neg ............................................................ K 6.4556 396.81 .................... 79.36 

1018 ......... Blood, l/r, irradiated ...................................................................... K 2.3472 144.28 .................... 28.86 

1019 ......... Plate pheres leukoredu irrad ........................................................ K 10.0443 617.40 .................... 123.48 

1020 ......... Plt, pher, l/r cmv-neg, irr ............................................................... K 11.4755 705.38 .................... 141.08 

1021 ......... RBC, frz/deg/wsh, l/r, irrad ........................................................... K 8.0727 496.21 .................... 99.24 

1022 ......... RBC, l/r, cmv-neg, irrad ................................................................ K 4.2653 262.18 .................... 52.44 

1032 ......... Aud osseo dev, int/ext comp ........................................................ H .................... .................... .................... ....................

1045 ......... I131 iodobenguate, dx .................................................................. H .................... .................... .................... ....................

1052 ......... Injection, voriconazole .................................................................. K .................... 4.66 .................... 0.93 

1064 ......... I131 iodide cap, rx ........................................................................ H .................... .................... .................... ....................

1083 ......... Adalimumab injection .................................................................... K .................... 308.33 .................... 61.67 

1084 ......... Denileukin diftitox, 300 mcg ......................................................... K .................... 1,403.23 .................... 280.65 

1086 ......... Temozolomide .............................................................................. K .................... 7.30 .................... 1.46 

1088 ......... Iodine I-131 iodide cap, dx ........................................................... H .................... .................... .................... ....................

1096 ......... Tc99m exametazime .................................................................... H .................... .................... .................... ....................

1150 ......... I131 iodide sol, rx ......................................................................... H .................... .................... .................... ....................

1166 ......... Cytarabine liposome ..................................................................... K .................... 396.66 .................... 79.33 

1167 ......... Inj, epirubicin hcl, 2 mg ................................................................ K .................... 24.67 .................... 4.93 

1178 ......... Busulfan injection .......................................................................... K .................... 8.89 .................... 1.78 

1203 ......... Verteporfin injection ...................................................................... K .................... 8.91 .................... 1.78 

1207 ......... Octreotide injection, depot ............................................................ K .................... 93.35 .................... 18.67 

1280 ......... Corticotropin injection ................................................................... K .................... 116.60 .................... 23.32 

1330 ......... Ergonovine maleate injection ....................................................... K .................... 33.11 .................... 6.62 

1436 ......... Etidronate disodium inj ................................................................. K .................... 71.41 .................... 14.28 

1491 ......... New Technology—Level IA ($0–$10) ........................................... S .................... 5.00 .................... 1.00 

1492 ......... New Technology—Level IB ($10–$20) ......................................... S .................... 15.00 .................... 3.00 

1493 ......... New Technology—Level IC ($20–$30) ........................................ S .................... 25.00 .................... 5.00 

1494 ......... New Technology—Level ID ($30–$40) ........................................ S .................... 35.00 .................... 7.00 

1495 ......... New Technology—Level IE ($40–$50) ......................................... S .................... 45.00 .................... 9.00 

1496 ......... New Technology—Level IA ($0–$10) ........................................... T .................... 5.00 .................... 1.00 

1497 ......... New Technology—Level IB($10–$20) .......................................... T .................... 15.00 .................... 3.00 

1498 ......... New Technology—Level IC ($20–$30) ........................................ T .................... 25.00 .................... 5.00 

1499 ......... New Technology—Level ID($30–$40) .......................................... T .................... 35.00 .................... 7.00 

1500 ......... New Technology—Level IE ($40–$50) ......................................... T .................... 45.00 .................... 9.00 

1502 ......... New Technology—Level II ($50–$100) ........................................ S .................... 75.00 .................... 15.00 

1503 ......... New Technology—Level III ($100–$200) ..................................... S .................... 150.00 .................... 30.00 

1504 ......... New Technology—Level IV ($200–$300) ..................................... S .................... 250.00 .................... 50.00 

1505 ......... New Technology—Level V ($300–$400) ...................................... S .................... 350.00 .................... 70.00 

1506 ......... New Technology—Level VI ($400–$500) ..................................... S .................... 450.00 .................... 90.00 

1507 ......... New Technology—Level VII ($500–$600) .................................... S .................... 550.00 .................... 110.00 

1508 ......... New Technology—Level VIII ($600–$700) ................................... S .................... 650.00 .................... 130.00 

1509 ......... New Technology—Level IX ($700–$800) ..................................... S .................... 750.00 .................... 150.00 

1510 ......... New Technology—Level X ($800–$900) ...................................... S .................... 850.00 .................... 170.00 

1511 ......... New Technology—Level XI ($900–$1000) ................................... S .................... 950.00 .................... 190.00 

1512 ......... New Technology—Level XII ($1000–$1100) ................................ S .................... 1,050.00 .................... 210.00 

1513 ......... New Technology—Level XIII ($1100–$1200) ............................... S .................... 1,150.00 .................... 230.00 

1514 ......... New Technology—Level XIV ($1200–$1300) .............................. S .................... 1,250.00 .................... 250.00 

1515 ......... New Technology—Level XV ($1300–$1400) ............................... S .................... 1,350.00 .................... 270.00 

1516 ......... New Technology—Level XVI ($1400–$1500) .............................. S .................... 1,450.00 .................... 290.00 

1517 ......... New Technology—Level XVII ($1500–$1600) ............................. S .................... 1,550.00 .................... 310.00 

1518 ......... New Technology—Level XVIII ($1600–$1700) ............................ S .................... 1,650.00 .................... 330.00 

1519 ......... New Technology—Level IXX ($1700–$1800) .............................. S .................... 1,750.00 .................... 350.00 

1520 ......... New Technology—Level XX ($1800–$1900) ............................... S .................... 1,850.00 .................... 370.00 

1521 ......... New Technology—Level XXI ($1900–$2000) .............................. S .................... 1,950.00 .................... 390.00 

1522 ......... New Technology—Level XXII ($2000–$2500) ............................. S .................... 2,250.00 .................... 450.00 

1523 ......... New Technology—Level XXIII ($2500–$3000) ............................ S .................... 2,750.00 .................... 550.00 

1524 ......... New Technology—Level XXIV ($3000–$3500) ............................ S .................... 3,250.00 .................... 650.00 

1525 ......... New Technology—Level XXV ($3500–$4000) ............................. S .................... 3,750.00 .................... 750.00 

1526 ......... New Technology—Level XXVI ($4000–$4500) ............................ S .................... 4,250.00 .................... 850.00 


cprice-sewell on PRODPC62 with RULES2
68240 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

1527 ......... New Technology—Level XXVII ($4500–$5000) ........................... S .................... 4,750.00 .................... 950.00 

1528 ......... New Technology—Level XXVIII ($5000–$5500) .......................... S .................... 5,250.00 .................... 1,050.00 

1529 ......... New Technology—Level XXIX ($5500–$6000) ............................ S .................... 5,750.00 .................... 1,150.00 

1530 ......... New Technology—Level XXX ($6000–$6500) ............................. S .................... 6,250.00 .................... 1,250.00 

1531 ......... New Technology—Level XXXI ($6500–$7000) ............................ S .................... 6,750.00 .................... 1,350.00 

1532 ......... New Technology—Level XXXII ($7000–$7500) ........................... S .................... 7,250.00 .................... 1,450.00 

1533 ......... New Technology—Level XXXIII ($7500–$8000) .......................... S .................... 7,750.00 .................... 1,550.00 

1534 ......... New Technology—Level XXXIV ($8000–$8500) ......................... S .................... 8,250.00 .................... 1,650.00 

1535 ......... New Technology—Level XXXV ($8500–$9000) .......................... S .................... 8,750.00 .................... 1,750.00 

1536 ......... New Technology—Level XXXVI ($9000–$9500) ......................... S .................... 9,250.00 .................... 1,850.00 

1537 ......... New Technology—Level XXXVII ($9500–$10000) ...................... S .................... 9,750.00 .................... 1,950.00 

1539 ......... New Technology—Level II ($50–$100) ........................................ T .................... 75.00 .................... 15.00 

1540 ......... New Technology—Level III ($100–$200) ..................................... T .................... 150.00 .................... 30.00 

1541 ......... New Technology—Level IV ($200–$300) ..................................... T .................... 250.00 .................... 50.00 

1542 ......... New Technology—Level V ($300–$400) ...................................... T .................... 350.00 .................... 70.00 

1543 ......... New Technology—Level VI ($400–$500) ..................................... T .................... 450.00 .................... 90.00 

1544 ......... New Technology—Level VII ($500–$600) .................................... T .................... 550.00 .................... 110.00 

1545 ......... New Technology—Level VIII ($600–$700) ................................... T .................... 650.00 .................... 130.00 

1546 ......... New Technology—Level IX ($700–$800) ..................................... T .................... 750.00 .................... 150.00 

1547 ......... New Technology—Level X ($800–$900) ...................................... T .................... 850.00 .................... 170.00 

1548 ......... New Technology—Level XI ($900–$1000) ................................... T .................... 950.00 .................... 190.00 

1549 ......... New Technology—Level XII ($1000–$1100) ................................ T .................... 1,050.00 .................... 210.00 

1550 ......... New Technology—Level XIII ($1100–$1200) ............................... T .................... 1,150.00 .................... 230.00 

1551 ......... New Technology—Level XIV ($1200–$1300) .............................. T .................... 1,250.00 .................... 250.00 

1552 ......... New Technology—Level XV ($1300–$1400) ............................... T .................... 1,350.00 .................... 270.00 

1553 ......... New Technology—Level XVI ($1400–$1500) .............................. T .................... 1,450.00 .................... 290.00 

1554 ......... New Technology—Level XVII ($1500–$1600) ............................. T .................... 1,550.00 .................... 310.00 

1555 ......... New Technology—Level XVIII ($1600–$1700) ............................ T .................... 1,650.00 .................... 330.00 

1556 ......... New Technology—Level XIX ($1700–$1800) .............................. T .................... 1,750.00 .................... 350.00 

1557 ......... New Technology—Level XX ($1800–$1900) ............................... T .................... 1,850.00 .................... 370.00 

1558 ......... New Technology—Level XXI ($1900–$2000) .............................. T .................... 1,950.00 .................... 390.00 

1559 ......... New Technology—Level XXII ($2000–$2500) ............................. T .................... 2,250.00 .................... 450.00 

1560 ......... New Technology—Level XXIII ($2500–$3000) ............................ T .................... 2,750.00 .................... 550.00 

1561 ......... New Technology—Level XXIV ($3000–$3500) ............................ T .................... 3,250.00 .................... 650.00 

1562 ......... New Technology—Level XXV ($3500–$4000) ............................. T .................... 3,750.00 .................... 750.00 

1563 ......... New Technology—Level XXVI ($4000–$4500) ............................ T .................... 4,250.00 .................... 850.00 

1564 ......... New Technology—Level XXVII ($4500–$5000) ........................... T .................... 4,750.00 .................... 950.00 

1565 ......... New Technology—Level XXVIII ($5000–$5500) .......................... T .................... 5,250.00 .................... 1,050.00 

1566 ......... New Technology—Level XXIX ($5500–$6000) ............................ T .................... 5,750.00 .................... 1,150.00 

1567 ......... New Technology—Level XXX ($6000–$6500) ............................. T .................... 6,250.00 .................... 1,250.00 

1568 ......... New Technology—Level XXXI ($6500–$7000) ............................ T .................... 6,750.00 .................... 1,350.00 

1569 ......... New Technology—Level XXXII ($7000–$7500) ........................... T .................... 7,250.00 .................... 1,450.00 

1570 ......... New Technology—Level XXXIII ($7500–$8000) .......................... T .................... 7,750.00 .................... 1,550.00 

1571 ......... New Technology—Level XXXIV ($8000–$8500) ......................... T .................... 8,250.00 .................... 1,650.00 

1572 ......... New Technology—Level XXXV ($8500–$9000) .......................... T .................... 8,750.00 .................... 1,750.00 

1573 ......... New Technology—Level XXXVI ($9000–$9500) ......................... T .................... 9,250.00 .................... 1,850.00 

1574 ......... New Technology—Level XXXVII ($9500–$10000) ...................... T .................... 9,750.00 .................... 1,950.00 

1600 ......... Tc99m sestamibi ........................................................................... H .................... .................... .................... ....................

1603 ......... TL201 thallium .............................................................................. H .................... .................... .................... ....................

1604 ......... In111 capromab ............................................................................ H .................... .................... .................... ....................

1605 ......... Abciximab injection ....................................................................... K .................... 416.27 .................... 83.25 

1606 ......... Injection anistreplase 30 u ............................................................ K .................... 2,268.46 .................... 453.69 

1607 ......... Eptifibatide injection ...................................................................... K .................... 15.37 .................... 3.07 

1608 ......... Etanercept injection ...................................................................... K .................... 160.39 .................... 32.08 

1609 ......... Rho(D) immune globulin h, sd ...................................................... K .................... 14.30 .................... 2.86 

1612 ......... Daclizumab, parenteral ................................................................. K .................... 328.83 .................... 65.77 

1613 ......... Trastuzumab ................................................................................. K .................... 56.17 .................... 11.23 

1629 ......... Nonmetabolic act d/e tissue ......................................................... K .................... 18.49 .................... 3.70 

1630 ......... Hep b ig, im .................................................................................. K .................... 119.06 .................... 23.81 

1631 ......... Baclofen intrathecal trial ............................................................... K .................... 69.63 .................... 13.93 

1632 ......... Metabolic active D/E tissue .......................................................... K .................... 27.89 .................... 5.58 

1633 ......... Alefacept ....................................................................................... K .................... 26.31 .................... 5.26 

1642 ......... In111 ibritumomab, dx .................................................................. H .................... .................... .................... ....................

1643 ......... Y90 ibritumomab, rx ..................................................................... H .................... .................... .................... ....................

1644 ......... I131 tositumomab, dx ................................................................... H .................... .................... .................... ....................

1645 ......... 1131 tositumomab, rx ................................................................... H .................... .................... .................... ....................

1646 ......... In111 oxyquinoline ........................................................................ H .................... .................... .................... ....................

1647 ......... In111 pentetate ............................................................................. H .................... .................... .................... ....................

1648 ......... Technetium tc99m arcitumomab .................................................. H .................... .................... .................... ....................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68241 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

1650 ......... Tc99m succimer ........................................................................... H .................... .................... .................... ....................

1651 ......... F18 fdg .......................................................................................... H .................... .................... .................... ....................

1654 ......... Rb82 rubidium .............................................................................. H .................... .................... .................... ....................

1655 ......... Tinzaparin sodium injection .......................................................... K .................... 2.48 .................... 0.50 

1670 ......... Tetanus immune globulin inj ......................................................... K .................... 87.77 .................... 17.55 

1671 ......... Ga67 gallium ................................................................................. H .................... .................... .................... ....................

1672 ......... Tc99m bicisate .............................................................................. H .................... .................... .................... ....................

1675 ......... P32 Na phosphate ........................................................................ H .................... .................... .................... ....................

1676 ......... P32 chromic phosphate ................................................................ H .................... .................... .................... ....................

1677 ......... In111 pentetreotide ....................................................................... H .................... .................... .................... ....................

1678 ......... Tc99m fanolesomab ..................................................................... H .................... .................... .................... ....................

1680 ......... Acetylcysteine injection ................................................................. K .................... 1.94 .................... 0.39 

1682 ......... Aprotonin, 10,000 kiu .................................................................... K .................... 2.52 .................... 0.50 

1683 ......... Basiliximab .................................................................................... K .................... 1,385.86 .................... 277.17 

1684 ......... Corticorelin ovine triflutal .............................................................. K .................... 4.17 .................... 0.83 

1685 ......... Darbepoetin alfa, non-esrd ........................................................... K .................... 2.99 .................... 0.60 

1686 ......... Epoetin alfa, non-esrd .................................................................. K .................... 9.36 .................... 1.87 

1687 ......... Digoxin immune fab (ovine) .......................................................... K .................... 533.72 .................... 106.74 

1688 ......... Ethanolamine oleate 100 mg ........................................................ K .................... 69.60 .................... 13.92 

1689 ......... Fomepizole, 15 mg ....................................................................... K .................... 12.33 .................... 2.47 

1690 ......... Hemin, 1 mg ................................................................................. K .................... 6.80 .................... 1.36 

1691 ......... Iron dextran 165 injection ............................................................. K .................... 11.78 .................... 2.36 

1692 ......... Iron dextran 267 injection ............................................................. K .................... 10.38 .................... 2.08 

1693 ......... Lepirudin ....................................................................................... K .................... 153.54 .................... 30.71 

1694 ......... Ziconotide injection ....................................................................... G .................... 6.34 .................... 1.27 

1695 ......... Nesiritide injection ......................................................................... K .................... 30.13 .................... 6.03 

1696 ......... Palifermin injection ........................................................................ K .................... 11.43 .................... 2.29 

1697 ......... Pegaptanib sodium injection ......................................................... G .................... 1,107.54 .................... 221.51 

1700 ......... Inj secretin synthetic human ......................................................... K .................... 20.31 .................... 4.06 

1701 ......... Treprostinil injection ...................................................................... K .................... 54.02 .................... 10.80 

1703 ......... Ovine, 1000 USP units ................................................................. K .................... 137.43 .................... 27.49 

1704 ......... Inj Vonwillebrand factor IU ........................................................... K .................... 0.88 .................... 0.18 

1705 ......... Factor viia ..................................................................................... K .................... 1.10 .................... 0.22 

1707 ......... Non-human, metabolic tissue ....................................................... K .................... 1.78 .................... 0.36 

1709 ......... Azacitidine injection ...................................................................... K .................... 4.22 .................... 0.84 

1710 ......... Clofarabine injection ..................................................................... G .................... 116.62 .................... 23.32 

1711 ......... Histrelin implant ............................................................................ K .................... 1,741.71 .................... 348.34 

1712 ......... Paclitaxel protein bound ............................................................... G .................... 8.73 .................... 1.75 

1713 ......... Inj Fe-based MR contrast,1ml ...................................................... K .................... 30.41 .................... 6.08 

1716 ......... Brachytx source, Gold 198 ........................................................... K 0.5991 36.83 .................... 7.37 

1717 ......... Brachytx source, HDR Ir-192 ....................................................... K 2.3195 142.58 .................... 28.52 

1718 ......... Brachytx source, Iodine 125 ......................................................... K 0.5910 36.33 .................... 7.27 

1719 ......... Brachytx sour,Non-HDR Ir-192 ..................................................... K 0.3765 23.14 .................... 4.63 

1720 ......... Brachytx sour, Palladium 103 ....................................................... K 0.7942 48.82 .................... 9.76 

1738 ......... Oxaliplatin ..................................................................................... K .................... 8.77 .................... 1.75 

1739 ......... Pegademase bovine, 25 iu ........................................................... K .................... 177.83 .................... 35.57 

1740 ......... Diazoxide injection ........................................................................ K .................... 111.89 .................... 22.38 

1741 ......... Urofollitropin, 75 iu ........................................................................ K .................... 49.35 .................... 9.87 

1820 ......... Generator neuro rechg bat sys .................................................... H .................... .................... .................... ....................

1821 ......... Interspinous implant ...................................................................... H .................... .................... .................... ....................

2210 ......... Methyldopate hcl injection ............................................................ K .................... 10.01 .................... 2.00 

2616 ......... Brachytx source, Yttrium-90 ......................................................... K 172.2337 10,586.86 .................... 2,117.37 

2632 ......... Iodine I-125 sodium iodide ........................................................... K 0.3321 20.41 .................... 4.08 

2633 ......... Brachytx source, Cesium-131 ...................................................... K 1.4779 90.84 .................... 18.17 

2634 ......... Brachytx source, HA, I-125 .......................................................... K 0.5316 32.68 .................... 6.54 

2635 ......... Brachytx source, HA, P-103 ......................................................... K 0.8878 54.57 .................... 10.91 

2636 ......... Brachytx linear source,P-103 ....................................................... K 0.6427 39.51 .................... 7.90 

2731 ......... Immune globulin, powder ............................................................. K .................... 25.27 .................... 5.05 

2732 ......... Immune globulin, liquid ................................................................. K .................... 30.33 .................... 6.07 

2770 ......... Quinupristin/dalfopristin ................................................................ K .................... 114.49 .................... 22.90 

2940 ......... Somatrem injection ....................................................................... K .................... 35.60 .................... 7.12 

3030 ......... Sumatriptan succinate / 6 MG ...................................................... K .................... 57.40 .................... 11.48 

3032 ......... Dtp/hib vaccine, im ....................................................................... K .................... 45.01 .................... 9.00 

3038 ......... Inj biperiden lactate/5 mg ............................................................. K .................... 88.15 .................... 17.63 

3039 ......... Inj metaraminol bitartrate .............................................................. K .................... 2.62 .................... 0.52 

3041 ......... Bivalirudin ..................................................................................... K .................... 1.75 .................... 0.35 

3042 ......... Foscarnet sodium injection ........................................................... K .................... 10.49 .................... 2.10 

3043 ......... Gamma globulin 1 CC inj ............................................................. K .................... 10.34 .................... 2.07 

3045 ......... Meropenem ................................................................................... K .................... 3.68 .................... 0.74 


cprice-sewell on PRODPC62 with RULES2
68242 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

3048 ......... Doxorubic hcl 10 MG vl chemo .................................................... K .................... 6.00 .................... 1.20 

3049 ......... Cyclophosphamide lyophilized ..................................................... K .................... 5.72 .................... 1.14 

3050 ......... Sermorelin acetate injection ......................................................... K .................... 1.75 .................... 0.35 

7000 ......... Amifostine ..................................................................................... K .................... 463.27 .................... 92.65 

7005 ......... Gonadorelin hydroch/ 100 mcg .................................................... K .................... 189.84 .................... 37.97 

7011 ......... Oprelvekin injection ...................................................................... K .................... 245.98 .................... 49.20 

7015 ......... Oral busulfan ................................................................................ K .................... 2.14 .................... 0.43 

7028 ......... Fosphenytoin, 50 mg .................................................................... K .................... 5.59 .................... 1.12 

7034 ......... Somatropin injection ..................................................................... K .................... 46.80 .................... 9.36 

7035 ......... Teniposide, 50 mg ........................................................................ K .................... 264.88 .................... 52.98 

7036 ......... Urokinase 250,000 IU inj .............................................................. K .................... 457.73 .................... 91.55 

7038 ......... Monoclonal antibodies .................................................................. K .................... 856.05 .................... 171.21 

7041 ......... Tirofiban HCl ................................................................................. K .................... 8.74 .................... 1.75 

7042 ......... Capecitabine, oral, 150 mg .......................................................... K .................... 3.83 .................... 0.77 

7043 ......... Infliximab injection ........................................................................ K .................... 53.74 .................... 10.75 

7045 ......... Inj trimetrexate glucoronate .......................................................... K .................... 145.17 .................... 29.03 

7046 ......... Doxorubicin hcl liposome inj ......................................................... K .................... 379.21 .................... 75.84 

7048 ......... Alteplase recombinant .................................................................. K .................... 32.07 .................... 6.41 

7049 ......... Filgrastim 480 mcg injection ......................................................... K .................... 298.70 .................... 59.74 

7051 ......... Leuprolide acetate implant ........................................................... K .................... 2,208.90 .................... 441.78 

7308 ......... Aminolevulinic acid hcl top ........................................................... K .................... 107.72 .................... 21.54 

9001 ......... Linezolid injection ......................................................................... K .................... 24.16 .................... 4.83 

9002 ......... Tenecteplase injection .................................................................. K .................... 2,036.66 .................... 407.33 

9003 ......... Palivizumab, per 50 mg ................................................................ K .................... 609.62 .................... 121.92 

9004 ......... Gemtuzumab ozogamicin ............................................................. K .................... 2,317.16 .................... 463.43 

9005 ......... Reteplase injection ....................................................................... K .................... 902.72 .................... 180.54 

9006 ......... Tacrolimus injection ...................................................................... K .................... 140.72 .................... 28.14 

9012 ......... Arsenic trioxide ............................................................................. K .................... 33.36 .................... 6.67 

9015 ......... Mycophenolate mofetil oral ........................................................... K .................... 2.50 .................... 0.50 

9018 ......... Botulinum toxin type B .................................................................. K .................... 8.16 .................... 1.63 

9019 ......... Caspofungin acetate ..................................................................... K .................... 32.25 .................... 6.45 

9020 ......... Sirolimus, oral ............................................................................... K .................... 7.25 .................... 1.45 

9022 ......... IM inj interferon beta 1-a .............................................................. K .................... 108.04 .................... 21.61 

9023 ......... Rho d immune globulin 50 mcg ................................................... K .................... 27.70 .................... 5.54 

9024 ......... Amphotericin b lipid complex ........................................................ K .................... 11.11 .................... 2.22 

9031 ......... Arbutamine HCl injection .............................................................. K .................... 160.00 .................... 32.00 

9032 ......... Baclofen 10 MG injection ............................................................. K .................... 198.54 .................... 39.71 

9033 ......... Cidofovir injection ......................................................................... K .................... 763.15 .................... 152.63 

9038 ......... Inj estrogen conjugate 25 MG ...................................................... K .................... 58.05 .................... 11.61 

9040 ......... Intraocular Fomivirsen na ............................................................. K .................... 212.00 .................... 42.40 

9042 ......... Glucagon hydrochloride/1 MG ...................................................... K .................... 70.23 .................... 14.05 

9044 ......... Ibutilide fumarate injection ............................................................ K .................... 265.75 .................... 53.15 

9046 ......... Iron sucrose injection .................................................................... K .................... 0.36 .................... 0.07 

9047 ......... Itraconazole injection .................................................................... K .................... 36.45 .................... 7.29 

9051 ......... Urea injection ................................................................................ K .................... 37.81 .................... 7.56 

9054 ......... Metabolically active tissue ............................................................ K .................... 13.87 .................... 2.77 

9100 ......... I131 serum albumin, dx ................................................................ H .................... .................... .................... ....................

9104 ......... Antithymocyte globuln rabbit ........................................................ K .................... 329.62 .................... 65.92 

9108 ......... Thyrotropin injection ..................................................................... K .................... 765.76 .................... 153.15 

9110 ......... Alemtuzumab injection .................................................................. K .................... 531.24 .................... 106.25 

9112 ......... Inj perflutren lip micros,ml ............................................................ K .................... 61.64 .................... 12.33 

9115 ......... Zoledronic acid ............................................................................. K .................... 204.03 .................... 40.81 

9119 ......... Injection, pegfilgrastim 6mg .......................................................... K .................... 2,163.61 .................... 432.72 

9120 ......... Injection, Fulvestrant ..................................................................... K .................... 80.66 .................... 16.13 

9121 ......... Injection, argatroban ..................................................................... K .................... 17.48 .................... 3.50 

9122 ......... Triptorelin pamoate ....................................................................... K .................... 218.53 .................... 43.71 

9124 ......... Daptomycin injection ..................................................................... K .................... 0.33 .................... 0.07 

9125 ......... Risperidone, long acting ............................................................... K .................... 4.80 .................... 0.96 

9126 ......... Natalizumab injection .................................................................... G .................... 7.72 .................... 1.54 

9133 ......... Rabies ig, im/sc ............................................................................ K .................... 64.53 .................... 12.91 

9134 ......... Rabies ig, heat treated ................................................................. K .................... 68.24 .................... 13.65 

9135 ......... Varicella-zoster ig, im ................................................................... K .................... 140.92 .................... 28.18 

9137 ......... Bcg vaccine, percut ...................................................................... K .................... 117.39 .................... 23.48 

9139 ......... Rabies vaccine, im ....................................................................... K .................... 157.74 .................... 31.55 

9140 ......... Rabies vaccine, id ........................................................................ K .................... 166.16 .................... 33.23 

9141 ......... Measles-rubella vaccine, sc ......................................................... K .................... 60.82 .................... 12.16 

9143 ......... Meningococcal vaccine, sc ........................................................... K .................... 84.46 .................... 16.89 

9144 ......... Encephalitis vaccine, sc ............................................................... K .................... 96.22 .................... 19.24 

9145 ......... Meningococcal vaccine, im ........................................................... K .................... 53.71 .................... 10.74 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68243 

ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI), 

RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

9148 ......... I123 iodide cap, dx ....................................................................... H .................... .................... .................... ....................

9156 ......... Nonmetabolic active tissue ........................................................... K .................... 45.02 .................... 9.00 

9157 ......... LOCM <=149 mg/ml iodine, 1ml .................................................. K .................... 0.29 .................... 0.06 

9158 ......... LOCM 150–199mg/ml iodine,1ml ................................................. K .................... 1.96 .................... 0.39 

9159 ......... LOCM 200–249mg/ml iodine,1ml ................................................. K .................... 1.42 .................... 0.28 

9160 ......... LOCM 250–299mg/ml iodine,1ml ................................................. K .................... 0.27 .................... 0.05 

9161 ......... LOCM 300–349mg/ml iodine,1ml ................................................. K .................... 0.35 .................... 0.07 

9162 ......... LOCM 350–399mg/ml iodine,1ml ................................................. K .................... 0.21 .................... 0.04 

9163 ......... LOCM >= 400 mg/ml iodine,1ml .................................................. K .................... 0.30 .................... 0.06 

9164 ......... Inj Gad-base MR contrast,1ml ...................................................... K .................... 2.87 .................... 0.57 

9165 ......... Oral MR contrast, 100 ml ............................................................. K .................... 8.90 .................... 1.78 

9167 ......... Valrubicin, 200 mg ........................................................................ K .................... 369.60 .................... 73.92 

9202 ......... Inj octafluoropropane mic,ml ........................................................ K .................... 49.61 .................... 9.92 

9203 ......... Inj perflexane lip micros,ml ........................................................... K .................... 7.05 .................... 1.41 

9207 ......... Bortezomib injection ..................................................................... K .................... 31.87 .................... 6.37 

9208 ......... Agalsidase beta injection .............................................................. K .................... 127.20 .................... 25.44 

9209 ......... Laronidase injection ...................................................................... K .................... 23.87 .................... 4.77 

9210 ......... Palonosetron HCl .......................................................................... K .................... 18.08 .................... 3.62 

9213 ......... Pemetrexed injection .................................................................... K .................... 42.49 .................... 8.50 

9214 ......... Bevacizumab injection .................................................................. K .................... 56.88 .................... 11.38 

9215 ......... Cetuximab injection ...................................................................... K .................... 49.86 .................... 9.97 

9216 ......... Abarelix injection ........................................................................... K .................... 71.18 .................... 14.24 

9217 ......... Leuprolide acetate suspnsion ....................................................... K .................... 227.63 .................... 45.53 

9219 ......... Mycophenolic acid ........................................................................ K .................... 2.15 .................... 0.43 

9222 ......... Injectable human tissue ................................................................ K .................... 743.96 .................... 148.79 

9224 ......... Galsulfase injection ....................................................................... K .................... 1,516.12 .................... 303.22 

9225 ......... Fluocinolone acetonide implt ........................................................ G .................... 18,250.00 .................... 3,650.00 

9227 ......... Micafungin sodium injection ......................................................... G .................... 1.87 .................... 0.37 

9228 ......... Tigecycline injection ...................................................................... G .................... 0.91 .................... 0.18 

9229 ......... Ibandronate sodium injection ........................................................ G .................... 139.12 .................... 27.82 

9230 ......... Abatacept injection ....................................................................... G .................... 18.70 .................... 3.74 

9231 ......... Decitabine injection ....................................................................... G .................... 26.50 .................... 5.30 

9232 ......... Injection, idursulfase ..................................................................... G .................... 464.32 .................... 92.86 

9233 ......... Injection, ranibizumab ................................................................... G .................... 2,067.00 .................... 413.40 

9234 ......... Inj, alglucosidase alfa ................................................................... K .................... 127.20 .................... 25.44 

9235 ......... Injection, panitumumab ................................................................. K .................... 84.80 .................... 16.96 

9300 ......... Omalizumab injection ................................................................... K .................... 16.61 .................... 3.32 

9350 ......... Porous collagen tube per cm ....................................................... G .................... 494.53 .................... 98.91 

9351 ......... Acellular derm tissue percm2 ....................................................... G .................... 44.01 .................... 8.80 

9500 ......... Platelets, irradiated ....................................................................... K 2.1079 129.57 .................... 25.91 

9501 ......... Platelet pheres leukoreduced ....................................................... K 7.9511 488.74 .................... 97.75 

9502 ......... Platelet pheresis irradiated ........................................................... K 6.8088 418.52 .................... 83.70 

9503 ......... Fr frz plasma donor retested ........................................................ K 1.2119 74.49 .................... 14.90 

9504 ......... RBC deglycerolized ...................................................................... K 5.8292 358.31 .................... 71.66 

9505 ......... RBC irradiated .............................................................................. K 3.2049 197.00 .................... 39.40 

9506 ......... Granulocytes, pheresis unit .......................................................... K 12.2073 750.36 .................... 150.07 

9507 ......... Platelets, pheresis ........................................................................ K 7.3686 452.93 .................... 90.59 

9508 ......... 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 .................. 89.20 

10180 ....... Complex drainage, wound ............................. .................. 1,076.22 2 446.00 .................. 89.20 

11010 ....... Debride skin, fx .............................................. .................. 251.52 2 251.52 Y .............. 50.30 

11011 ....... Debride skin/muscle, fx ................................. .................. 251.52 2 251.52 Y .............. 50.30 

11012 ....... Debride skin/muscle/bone, fx ........................ .................. 251.52 2 251.52 Y .............. 50.30 

11042 ....... Debride skin/tissue ........................................ .................. 164.42 2 164.42 Y .............. 32.88 

11043 ....... Debride tissue/muscle ................................... .................. 164.42 2 164.42 Y .............. 32.88 

11044 ....... Debride tissue/muscle/bone .......................... .................. 423.10 2 423.10 Y .............. 84.62 


cprice-sewell on PRODPC62 with RULES2
68244 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

11404 ....... Exc tr-ext b9+marg 3.1–4 cm ........................ .................. 928.31 1 333.00 .................. 66.60 

11406 ....... Exc tr-ext b9+marg > 4.0 cm ......................... .................. 928.31 2 446.00 .................. 89.20 

11424 ....... Exc h-f-nk-sp b9+marg 3.1–4 ........................ .................. 928.31 2 446.00 .................. 89.20 

11426 ....... Exc h-f-nk-sp b9+marg > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20 

11444 ....... Exc face-mm b9+marg 3.1–4 cm .................. .................. 418.49 1 333.00 .................. 66.60 

11446 ....... Exc face-mm b9+marg > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20 

11450 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11451 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11462 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11463 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11470 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11471 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20 

11604 ....... Exc tr-ext mlg+marg 3.1–4 cm ...................... .................. 418.49 2 418.49 Y .............. 83.70 

11606 ....... Exc tr-ext mlg+marg > 4 cm .......................... .................. 928.31 2 446.00 .................. 89.20 

11624 ....... Exc h-f-nk-sp mlg+marg 3.1–4 ...................... .................. 928.31 2 446.00 .................. 89.20 

11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20 

11644 ....... Exc face-mm malig+marg 3.1–4 ................... .................. 928.31 2 446.00 .................. 89.20 

11646 ....... Exc face-mm mlg+marg > 4 cm .................... .................. 1,233.39 2 446.00 .................. 89.20 

11770 ....... Removal of pilonidal lesion ............................ .................. 1,233.39 3 510.00 .................. 102.00

11771 ....... Removal of pilonidal lesion ............................ .................. 1,233.39 3 510.00 .................. 102.00

11772 ....... Removal of pilonidal lesion ............................ .................. 1,233.39 3 510.00 .................. 102.00

11960 ....... Insert tissue expander(s) ............................... .................. 1,317.27 2 446.00 .................. 89.20

11970 ....... Replace tissue expander ............................... .................. 2,525.68 3 510.00 .................. 102.00 

11971 ....... Remove tissue expander(s) ........................... .................. 1,233.39 1 333.00 .................. 66.60 

12005 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12006 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12007 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12016 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12017 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12018 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25 

12020 ....... Closure of split wound ................................... .................. 91.24 1 91.24 Y .............. 18.25 

12021 ....... Closure of split wound ................................... .................. 91.24 1 91.24 Y .............. 18.25 

12034 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12035 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12036 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12037 ....... Layer closure of wound(s) ............................. .................. 323.28 2 323.28 Y .............. 64.66 

12044 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12045 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12046 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12047 ....... Layer closure of wound(s) ............................. .................. 323.28 2 323.28 Y .............. 64.66 

12054 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12055 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12056 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25 

12057 ....... Layer closure of wound(s) ............................. .................. 323.28 2 323.28 Y .............. 64.66 

13100 ....... Repair of wound or lesion ............................. .................. 323.28 2 323.28 Y .............. 64.66 

13101 ....... Repair of wound or lesion ............................. .................. 323.28 3 323.28 Y .............. 64.66 

13102 ....... Repair wound/lesion add-on .......................... A* ............. 91.24 1 91.24 Y .............. 18.25 

13120 ....... Repair of wound or lesion ............................. .................. 91.24 2 91.24 Y .............. 18.25 

13121 ....... Repair of wound or lesion ............................. .................. 91.24 3 91.24 Y .............. 18.25 

13122 ....... Repair wound/lesion add-on .......................... A* ............. 91.24 1 91.24 Y .............. 18.25 

13131 ....... Repair of wound or lesion ............................. .................. 91.24 2 91.24 Y .............. 18.25 

13132 ....... Repair of wound or lesion ............................. .................. 91.24 3 91.24 Y .............. 18.25 

13133 ....... Repair wound/lesion add-on .......................... A* ............. 91.24 1 91.24 Y .............. 18.25 

13150 ....... Repair of wound or lesion ............................. .................. 323.28 3 323.28 Y .............. 64.66 

13151 ....... Repair of wound or lesion ............................. .................. 323.28 3 323.28 Y .............. 64.66 

13152 ....... Repair of wound or lesion ............................. .................. 323.28 3 323.28 Y .............. 64.66 

13153 ....... Repair wound/lesion add-on .......................... A* ............. 91.24 3 91.24 Y .............. 18.25 

13160 ....... Late closure of wound ................................... .................. 1,317.27 2 446.00 .................. 89.20

14000 ....... Skin tissue rearrangement ............................. .................. 862.68 2 446.00 .................. 89.20 

14001 ....... Skin tissue rearrangement ............................. .................. 1,317.27 3 510.00 .................. 102.00 

14020 ....... Skin tissue rearrangement ............................. .................. 862.68 3 510.00 .................. 102.00 

14021 ....... Skin tissue rearrangement ............................. .................. 862.68 3 510.00 .................. 102.00 

14040 ....... Skin tissue rearrangement ............................. .................. 862.68 2 446.00 .................. 89.20 

14041 ....... Skin tissue rearrangement ............................. .................. 862.68 3 510.00 .................. 102.00 

14060 ....... Skin tissue rearrangement ............................. .................. 862.68 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68245 

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—Continued 

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 

($) 

14061 ....... Skin tissue rearrangement ............................. .................. 862.68 3 510.00 .................. 102.00 

14300 ....... Skin tissue rearrangement ............................. .................. 1,317.27 4 630.00 .................. 126.00 

14350 ....... Skin tissue rearrangement ............................. .................. 1,317.27 3 510.00 .................. 102.00 

15000 ....... Wound prep, 1st 100 sq cm .......................... D .............. .................... 2 446.00 .................. ....................

15001 ....... Wound prep, addl 100 sq cm ........................ D .............. .................... 1 333.00 .................. ....................

15002 ....... Wnd prep, ch/inf, trk/arm/lg ........................... A .............. 323.28 2 323.28 Y .............. 64.66 

15003 ....... Wnd prep, ch/inf addl 100 cm ....................... A .............. 323.28 1 323.28 Y .............. 64.66 

15004 ....... Wnd prep ch/inf, f/n/hf/g ................................ A .............. 323.28 2 323.28 Y .............. 64.66 

15005 ....... Wnd prep, f/n/hf/g, addl cm ........................... A .............. 323.28 1 323.28 Y .............. 64.66 

15040 ....... Harvest cultured skin graft ............................. .................. 91.24 2 91.24 Y .............. 18.25 

15050 ....... Skin pinch graft .............................................. .................. 323.28 2 323.28 Y .............. 64.66 

15100 ....... Skin splt grft, trnk/arm/leg .............................. .................. 1,317.27 2 446.00 .................. 89.20 

15101 ....... Skin splt grft t/a/l, add-on .............................. .................. 1,317.27 3 510.00 .................. 102.00 

15110 ....... Epidrm autogrft trnk/arm/leg .......................... .................. 1,317.27 2 446.00 .................. 89.20 

15111 ....... Epidrm autogrft t/a/l add-on ........................... .................. 1,317.27 1 333.00 .................. 66.60 

15115 ....... Epidrm a-grft face/nck/hf/g ............................ .................. 1,317.27 2 446.00 .................. 89.20 

15116 ....... Epidrm a-grft f/n/hf/g addl .............................. .................. 1,317.27 1 333.00 .................. 66.60 

15120 ....... Skn splt a-grft fac/nck/hf/g ............................. .................. 1,317.27 2 446.00 .................. 89.20 

15121 ....... Skn splt a-grft f/n/hf/g add ............................. .................. 1,317.27 3 510.00 .................. 102.00 

15130 ....... Derm autograft, trnk/arm/leg .......................... .................. 1,317.27 2 446.00 .................. 89.20 

15131 ....... Derm autograft t/a/l add-on ........................... .................. 1,317.27 1 333.00 .................. 66.60 

15135 ....... Derm autograft face/nck/hf/g ......................... .................. 1,317.27 2 446.00 .................. 89.20 

15136 ....... Derm autograft, f/n/hf/g add .......................... .................. 1,317.27 1 333.00 .................. 66.60 

15150 ....... Cult epiderm grft t/arm/leg ............................. .................. 1,317.27 2 446.00 .................. 89.20

15151 ....... Cult epiderm grft t/a/l addl ............................. .................. 1,317.27 1 333.00 .................. 66.60 

15152 ....... Cult epiderm graft t/a/l +% ............................ .................. 1,317.27 1 333.00 .................. 66.60 

15155 ....... Cult epiderm graft, f/n/hf/g ............................. .................. 1,317.27 2 446.00 .................. 89.20 

15156 ....... Cult epidrm grft f/n/hfg add ............................ .................. 1,317.27 1 333.00 .................. 66.60

15157 ....... Cult epiderm grft f/n/hfg +% .......................... .................. 1,317.27 1 333.00 .................. 66.60 

15200 ....... Skin full graft, trunk ........................................ .................. 862.68 3 510.00 .................. 102.00 

15201 ....... Skin full graft trunk add-on ............................ .................. 323.28 2 323.28 Y .............. 64.66 

15220 ....... Skin full graft sclp/arm/leg ............................. .................. 862.68 2 446.00 .................. 89.20 

15221 ....... Skin full graft add-on ..................................... .................. 323.28 2 323.28 Y .............. 64.66 

15240 ....... Skin full grft face/genit/hf ............................... .................. 862.68 3 510.00 .................. 102.00 

15241 ....... Skin full graft add-on ..................................... .................. 323.28 3 323.28 Y .............. 64.66 

15260 ....... Skin full graft een & lips ................................ .................. 862.68 2 446.00 .................. 89.20

15261 ....... Skin full graft add-on ..................................... .................. 323.28 2 323.28 Y .............. 64.66 

15300 ....... Apply skinallogrft, t/arm/lg ............................. .................. 323.28 2 323.28 Y .............. 64.66 

15301 ....... Apply sknallogrft t/a/l addl ............................. .................. 323.28 1 323.28 Y .............. 64.66 

15320 ....... Apply skin allogrft f/n/hf/g .............................. .................. 323.28 2 323.28 Y .............. 64.66 

15321 ....... Aply sknallogrft f/n/hfg add ............................ .................. 323.28 1 323.28 Y .............. 64.66 

15330 ....... Aply acell alogrft t/arm/leg ............................. .................. 323.28 2 323.28 Y .............. 64.66 

15331 ....... Aply acell grft t/a/l add-on .............................. .................. 323.28 1 323.28 Y .............. 64.66 

15335 ....... Apply acell graft, f/n/hf/g ................................ .................. 323.28 2 323.28 Y .............. 64.66 

15336 ....... Aply acell grft f/n/hf/g add .............................. .................. 323.28 1 323.28 Y .............. 64.66 

15400 ....... Apply skin xenograft, t/a/l .............................. .................. 323.28 2 323.28 Y .............. 64.66 

15401 ....... Apply skn xenogrft t/a/l add ........................... .................. 323.28 2 323.28 Y .............. 64.66 

15420 ....... Apply skin xgraft, f/n/hf/g ............................... .................. 323.28 2 323.28 Y .............. 64.66 

15421 ....... Apply skn xgrft f/n/hf/g add ............................ .................. 323.28 1 323.28 Y .............. 64.66 

15430 ....... Apply acellular xenograft ............................... .................. 323.28 2 323.28 Y .............. 64.66 

15431 ....... Apply acellular xgraft add .............................. .................. 323.28 1 323.28 Y .............. 64.66 

15570 ....... Form skin pedicle flap ................................... .................. 1,317.27 3 510.00 .................. 102.00 

15572 ....... Form skin pedicle flap ................................... .................. 1,317.27 3 510.00 .................. 102.00 

15574 ....... Form skin pedicle flap ................................... .................. 1,317.27 3 510.00 .................. 102.00 

15576 ....... Form skin pedicle flap ................................... .................. 862.68 3 510.00 .................. 102.00

15600 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00 

15610 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00 

15620 ....... Skin graft ........................................................ .................. 1,317.27 4 630.00 .................. 126.00 

15630 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00 

15650 ....... Transfer skin pedicle flap .............................. .................. 1,317.27 5 717.00 .................. 143.40 

15731 ....... Forehead flap w/vasc pedicle ........................ A .............. 862.68 3 510.00 .................. 102.00 

15732 ....... Muscle-skin graft, head/neck ......................... .................. 1,317.27 3 510.00 .................. 102.00 

15734 ....... Muscle-skin graft, trunk ................................. .................. 1,317.27 3 510.00 .................. 102.00 

15736 ....... Muscle-skin graft, arm ................................... .................. 1,317.27 3 510.00 .................. 102.00 

15738 ....... Muscle-skin graft, leg ..................................... .................. 1,317.27 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
68246 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

15740 ....... Island pedicle flap graft ................................. .................. 862.68 2 446.00 .................. 89.20

15750 ....... Neurovascular pedicle graft ........................... .................. 1,317.27 2 446.00 .................. 89.20 

15760 ....... Composite skin graft ...................................... .................. 1,317.27 2 446.00 .................. 89.20 

15770 ....... Derma-fat-fascia graft .................................... .................. 1,317.27 3 510.00 .................. 102.00 

15775 ....... Hair transplant punch grafts .......................... .................. 323.28 3 323.28 Y .............. 64.66 

15776 ....... Hair transplant punch grafts .......................... .................. 323.28 3 323.28 Y .............. 64.66 

15820 ....... Revision of lower eyelid ................................. .................. 1,317.27 3 510.00 .................. 102.00 

15821 ....... Revision of lower eyelid ................................. .................. 1,317.27 3 510.00 .................. 102.00 

15822 ....... Revision of upper eyelid ................................ .................. 1,317.27 3 510.00 .................. 102.00 

15823 ....... Revision of upper eyelid ................................ .................. 862.68 5 717.00 .................. 143.40 

15824 ....... Removal of forehead wrinkles ....................... .................. 1,317.27 3 510.00 .................. 102.00 

15825 ....... Removal of neck wrinkles .............................. .................. 1,317.27 3 510.00 .................. 102.00 

15826 ....... Removal of brow wrinkles ............................. .................. 1,317.27 3 510.00 .................. 102.00 

15828 ....... Removal of face wrinkles .............................. .................. 1,317.27 3 510.00 .................. 102.00 

15829 ....... Removal of skin wrinkles ............................... .................. 1,317.27 5 717.00 .................. 143.40

15830 ....... Exc skin abd .................................................. A .............. 1,233.39 3 510.00 .................. 102.00 

15831 ....... Excise excessive skin tissue ......................... D .............. .................... 3 510.00 .................. ....................

15832 ....... Excise excessive skin tissue ......................... .................. 1,233.39 3 510.00 .................. 102.00 

15833 ....... Excise excessive skin tissue ......................... .................. 1,233.39 3 510.00 .................. 102.00 

15834 ....... Excise excessive skin tissue ......................... .................. 1,233.39 3 510.00 .................. 102.00 

15835 ....... Excise excessive skin tissue ......................... .................. 323.28 3 323.28 Y .............. 64.66 

15836 ....... Excise excessive skin tissue ......................... .................. 928.31 3 510.00 .................. 102.00 

15839 ....... Excise excessive skin tissue ......................... .................. 928.31 3 510.00 .................. 102.00 

15840 ....... Graft for face nerve palsy .............................. .................. 1,317.27 4 630.00 .................. 126.00 

15841 ....... Graft for face nerve palsy .............................. .................. 1,317.27 4 630.00 .................. 126.00 

15845 ....... Skin and muscle repair, face ......................... .................. 1,317.27 4 630.00 .................. 126.00 

15847 ....... Exc skin abd add-on ...................................... A .............. 1,233.39 3 510.00 .................. 102.00 

15876 ....... Suction assisted lipectomy ............................ .................. 1,317.27 3 510.00 .................. 102.00 

15877 ....... Suction assisted lipectomy ............................ .................. 1,317.27 3 510.00 .................. 102.00 

15878 ....... Suction assisted lipectomy ............................ .................. 862.68 3 510.00 .................. 102.00 

15879 ....... Suction assisted lipectomy ............................ .................. 1,317.27 3 510.00 .................. 102.00 

15920 ....... Removal of tail bone ulcer ............................. .................. 251.52 3 251.52 Y .............. 50.30 

15922 ....... Removal of tail bone ulcer ............................. .................. 1,317.27 4 630.00 .................. 126.00

15931 ....... Remove sacrum pressure sore ..................... .................. 1,233.39 3 510.00 .................. 102.00 

15933 ....... Remove sacrum pressure sore ..................... .................. 1,233.39 3 510.00 .................. 102.00 

15934 ....... Remove sacrum pressure sore ..................... .................. 1,317.27 3 510.00 .................. 102.00 

15935 ....... Remove sacrum pressure sore ..................... .................. 1,317.27 4 630.00 .................. 126.00 

15936 ....... Remove sacrum pressure sore ..................... .................. 1,317.27 4 630.00 .................. 126.00 

15937 ....... Remove sacrum pressure sore ..................... .................. 1,317.27 4 630.00 .................. 126.00 

15940 ....... Remove hip pressure sore ............................ .................. 1,233.39 3 510.00 .................. 102.00 

15941 ....... Remove hip pressure sore ............................ .................. 1,233.39 3 510.00 .................. 102.00 

15944 ....... Remove hip pressure sore ............................ .................. 1,317.27 3 510.00 .................. 102.00 

15945 ....... Remove hip pressure sore ............................ .................. 1,317.27 4 630.00 .................. 126.00 

15946 ....... Remove hip pressure sore ............................ .................. 1,317.27 4 630.00 .................. 126.00 

15950 ....... Remove thigh pressure sore ......................... .................. 1,233.39 3 510.00 .................. 102.00 

15951 ....... Remove thigh pressure sore ......................... .................. 1,233.39 4 630.00 .................. 126.00 

15952 ....... Remove thigh pressure sore ......................... .................. 1,317.27 3 510.00 .................. 102.00 

15953 ....... Remove thigh pressure sore ......................... .................. 1,317.27 4 630.00 .................. 126.00 

15956 ....... Remove thigh pressure sore ......................... .................. 1,317.27 3 510.00 .................. 102.00 

15958 ....... Remove thigh pressure sore ......................... .................. 1,317.27 4 630.00 .................. 126.00 

16025 ....... Dress/debrid p-thick burn, m ......................... .................. 67.11 2 67.11 Y .............. 13.42 

16030 ....... Dress/debrid p-thick burn, l ........................... .................. 99.83 2 99.83 Y .............. 19.97 

19020 ....... Incision of breast lesion ................................. .................. 1,076.22 2 446.00 .................. 89.20 

19100 ....... Bx breast percut w/o image ........................... .................. 240.00 1 240.00 Y .............. 48.00 

19101 ....... Biopsy of breast, open ................................... .................. 1,185.03 2 446.00 .................. 89.20 

19102 ....... Bx breast percut w/image .............................. .................. 240.00 2 240.00 Y .............. 48.00 

19103 ....... Bx breast percut w/device ............................. .................. 395.77 2 395.77 Y .............. 79.15 

19110 ....... Nipple exploration .......................................... .................. 1,185.03 2 446.00 .................. 89.20 

19112 ....... Excise breast duct fistula ............................... .................. 1,185.03 3 510.00 .................. 102.00 

19120 ....... Removal of breast lesion ............................... .................. 1,185.03 3 510.00 .................. 102.00

19125 ....... Excision, breast lesion ................................... .................. 1,185.03 3 510.00 .................. 102.00 

19126 ....... Excision, addl breast lesion ........................... .................. 1,185.03 3 510.00 .................. 102.00

19140 ....... Removal of breast tissue ............................... D .............. .................... 4 630.00 .................. ....................

19160 ....... Partial mastectomy ........................................ D .............. .................... 3 510.00 .................. ....................

19162 ....... P-mastectomy w/ln removal .......................... D .............. .................... 7 995.00 .................. ....................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68247 

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—Continued 

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 

($) 

19180 ....... Removal of breast ......................................... D .............. .................... 4 630.00 .................. ....................

19182 ....... Removal of breast ......................................... D .............. .................... 4 630.00 .................. ....................

19290 ....... Place needle wire, breast .............................. .................. .................... 1 333.00 .................. 66.60 

19291 ....... Place needle wire, breast .............................. .................. .................... 1 333.00 .................. 66.60 

19295 ....... Place breast clip, percut ................................ A* ............. 106.76 1 106.76 Y .............. 21.35 

19296 ....... Place po breast cath for rad .......................... .................. 3,148.82 9 1,339.00 .................. 267.80 

19297 ....... Place breast cath for rad ............................... A* ............. 3,148.82 9 1,339.00 .................. 267.80

19298 ....... Place breast rad tube/caths ........................... .................. 3,250.00 9 1,339.00 .................. 267.80 

19300 ....... Removal of breast tissue ............................... A .............. 1,185.03 4 630.00 .................. 126.00 

19301 ....... Partical mastectomy ...................................... A .............. 1,185.03 3 510.00 .................. 102.00 

19302 ....... P-mastectomy w/ln removal .......................... A .............. 2,274.24 7 995.00 .................. 199.00 

19303 ....... Mast, simple, complete .................................. A .............. 1,722.12 4 630.00 .................. 126.00 

19304 ....... Mast, subq ..................................................... A .............. 1,722.12 4 630.00 .................. 126.00 

19316 ....... Suspension of breast ..................................... .................. 1,722.12 4 630.00 .................. 126.00 

19318 ....... Reduction of large breast .............................. .................. 2,274.24 4 630.00 .................. 126.00

19324 ....... Enlarge breast ............................................... .................. 2,274.24 4 630.00 .................. 126.00 

19325 ....... Enlarge breast with implant ........................... .................. 3,148.82 9 1,339.00 .................. 267.80 

19328 ....... Removal of breast implant ............................. .................. 1,722.12 1 333.00 .................. 66.60 

19330 ....... Removal of implant material .......................... .................. 1,722.12 1 333.00 .................. 66.60 

19340 ....... Immediate breast prosthesis ......................... .................. 2,327.74 2 446.00 .................. 89.20 

19342 ....... Delayed breast prosthesis ............................. .................. 3,148.82 3 510.00 .................. 102.00 

19350 ....... Breast reconstruction ..................................... .................. 1,185.03 4 630.00 .................. 126.00 

19355 ....... Correct inverted nipple(s) .............................. .................. 1,722.12 4 630.00 .................. 126.00 

19357 ....... Breast reconstruction ..................................... .................. 3,148.82 5 717.00 .................. 143.40 

19366 ....... Breast reconstruction ..................................... .................. 1,722.12 5 717.00 .................. 143.40 

19370 ....... Surgery of breast capsule ............................. .................. 1,722.12 4 630.00 .................. 126.00 

19371 ....... Removal of breast capsule ............................ .................. 1,722.12 4 630.00 .................. 126.00 

19380 ....... Revise breast reconstruction ......................... .................. 2,327.74 5 717.00 .................. 143.40 

20005 ....... Incision of deep abscess ............................... .................. 1,282.87 2 446.00 .................. 89.20 

20200 ....... Muscle biopsy ................................................ .................. 928.31 2 446.00 .................. 89.20 

20205 ....... Deep muscle biopsy ...................................... .................. 928.31 3 510.00 .................. 102.00 

20206 ....... Needle biopsy, muscle .................................. .................. 240.00 1 240.00 Y .............. 48.00 

20220 ....... Bone biopsy, trocar/needle ............................ .................. 251.52 1 251.52 Y .............. 50.30 

20225 ....... Bone biopsy, trocar/needle ............................ .................. 418.49 2 418.49 Y .............. 83.70 

20240 ....... Bone biopsy, excisional ................................. .................. 1,233.39 2 446.00 .................. 89.20

20245 ....... Bone biopsy, excisional ................................. .................. 1,233.39 3 510.00 .................. 102.00 

20250 ....... Open bone biopsy ......................................... .................. 1,282.87 3 510.00 .................. 102.00 

20251 ....... Open bone biopsy ......................................... .................. 1,282.87 3 510.00 .................. 102.00 

20525 ....... Removal of foreign body ............................... .................. 1,233.39 3 510.00 .................. 102.00 

20650 ....... Insert and remove bone pin .......................... .................. 1,282.87 3 510.00 .................. 102.00 

20670 ....... Removal of support implant ........................... .................. 928.31 1 333.00 .................. 66.60 

20680 ....... Removal of support implant ........................... .................. 1,233.39 3 510.00 .................. 102.00 

20690 ....... Apply bone fixation device ............................. .................. 1,544.67 2 446.00 .................. 89.20 

20692 ....... Apply bone fixation device ............................. .................. 1,544.67 3 510.00 .................. 102.00

20693 ....... Adjust bone fixation device ............................ .................. 1,282.87 3 510.00 .................. 102.00

20694 ....... Remove bone fixation device ........................ .................. 1,282.87 1 333.00 .................. 66.60 

20900 ....... Removal of bone for graft .............................. .................. 1,544.67 3 510.00 .................. 102.00

20902 ....... Removal of bone for graft .............................. .................. 1,544.67 4 630.00 .................. 126.00

20910 ....... Remove cartilage for graft ............................. .................. 1,317.27 3 510.00 .................. 102.00

20912 ....... Remove cartilage for graft ............................. .................. 1,317.27 3 510.00 .................. 102.00

20920 ....... Removal of fascia for graft ............................ .................. 862.68 4 630.00 .................. 126.00 

20922 ....... Removal of fascia for graft ............................ .................. 1,317.27 3 510.00 .................. 102.00

20924 ....... Removal of tendon for graft ........................... .................. 1,544.67 4 630.00 .................. 126.00 

20926 ....... Removal of tissue for graft ............................ .................. 862.68 4 630.00 .................. 126.00 

20975 ....... Electrical bone stimulation ............................. .................. 37.51 2 37.51 Y .............. 7.50 

21010 ....... Incision of jaw joint ........................................ .................. 1,434.04 2 446.00 .................. 89.20 

21015 ....... Resection of facial tumor ............................... .................. 1,009.71 3 510.00 .................. 102.00 

21025 ....... Excision of bone, lower jaw ........................... .................. 2,348.02 2 446.00 .................. 89.20 

21026 ....... Excision of facial bone(s) .............................. .................. 2,348.02 2 446.00 .................. 89.20

21029 ....... Contour of face bone lesion .......................... .................. 2,348.02 2 446.00 .................. 89.20 

21034 ....... Excise max/zygoma mlg tumor ..................... .................. 2,348.02 3 510.00 .................. 102.00 

21040 ....... Excise mandible lesion .................................. .................. 1,434.04 2 446.00 .................. 89.20

21044 ....... Removal of jaw bone lesion .......................... .................. 2,348.02 2 446.00 .................. 89.20 

21046 ....... Remove mandible cyst complex .................... .................. 2,348.02 2 446.00 .................. 89.20 

21047 ....... Excise lwr jaw cyst w/repair .......................... .................. 2,348.02 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
68248 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

21050 ....... Removal of jaw joint ...................................... .................. 2,348.02 3 510.00 .................. 102.00 

21060 ....... Remove jaw joint cartilage ............................ .................. 2,348.02 2 446.00 .................. 89.20 

21070 ....... Remove coronoid process ............................. .................. 2,348.02 3 510.00 .................. 102.00 

21100 ....... Maxillofacial fixation ....................................... .................. 2,348.02 2 446.00 .................. 89.20 

21120 ....... Reconstruction of chin ................................... .................. 1,434.04 7 995.00 .................. 199.00 

21121 ....... Reconstruction of chin ................................... .................. 1,434.04 7 995.00 .................. 199.00 

21122 ....... Reconstruction of chin ................................... .................. 1,434.04 7 995.00 .................. 199.00 

21123 ....... Reconstruction of chin ................................... .................. 1,434.04 7 995.00 .................. 199.00 

21125 ....... Augmentation, lower jaw bone ...................... .................. 1,434.04 7 995.00 .................. 199.00 

21127 ....... Augmentation, lower jaw bone ...................... .................. 2,348.02 9 1,339.00 .................. 267.80 

21181 ....... Contour cranial bone lesion ........................... .................. 1,434.04 7 995.00 .................. 199.00 

21206 ....... Reconstruct upper jaw bone .......................... .................. 2,348.02 5 717.00 .................. 143.40 

21208 ....... Augmentation of facial bones ........................ .................. 2,348.02 7 995.00 .................. 199.00 

21209 ....... Reduction of facial bones .............................. .................. 2,348.02 5 717.00 .................. 143.40

21210 ....... Face bone graft ............................................. .................. 2,348.02 7 995.00 .................. 199.00 

21215 ....... Lower jaw bone graft ..................................... .................. 2,348.02 7 995.00 .................. 199.00 

21230 ....... Rib cartilage graft .......................................... .................. 2,348.02 7 995.00 .................. 199.00 

21235 ....... Ear cartilage graft .......................................... .................. 1,434.04 7 995.00 .................. 199.00 

21240 ....... Reconstruction of jaw joint ............................ .................. 2,348.02 4 630.00 .................. 126.00

21242 ....... Reconstruction of jaw joint ............................ .................. 2,348.02 5 717.00 .................. 143.40

21243 ....... Reconstruction of jaw joint ............................ .................. 2,348.02 5 717.00 .................. 143.40

21244 ....... Reconstruction of lower jaw .......................... .................. 2,348.02 7 995.00 .................. 199.00 

21245 ....... Reconstruction of jaw .................................... .................. 2,348.02 7 995.00 .................. 199.00 

21246 ....... Reconstruction of jaw .................................... .................. 2,348.02 7 995.00 .................. 199.00 

21248 ....... Reconstruction of jaw .................................... .................. 2,348.02 7 995.00 .................. 199.00 

21249 ....... Reconstruction of jaw .................................... .................. 2,348.02 7 995.00 .................. 199.00 

21267 ....... Revise eye sockets ........................................ .................. 2,348.02 7 995.00 .................. 199.00 

21270 ....... Augmentation, cheek bone ............................ .................. 2,348.02 5 717.00 .................. 143.40 

21275 ....... Revision, orbitofacial bones ........................... .................. 2,348.02 7 995.00 .................. 199.00

21280 ....... Revision of eyelid .......................................... .................. 2,348.02 5 717.00 .................. 143.40 

21282 ....... Revision of eyelid .......................................... .................. 1,009.71 5 717.00 .................. 143.40 

21295 ....... Revision of jaw muscle/bone ......................... .................. 464.15 1 333.00 .................. 66.60 

21296 ....... Revision of jaw muscle/bone ......................... .................. 1,434.04 1 333.00 .................. 66.60 

21300 ....... Treatment of skull fracture ............................. D .............. .................... 2 446.00 .................. ....................

21310 ....... Treatment of nose fracture ............................ .................. 150.72 2 150.72 Y .............. 30.14 

21315 ....... Treatment of nose fracture ............................ .................. 150.72 2 150.72 Y .............. 30.14 

21320 ....... Treatment of nose fracture ............................ .................. 464.15 2 446.00 .................. 89.20 

21325 ....... Treatment of nose fracture ............................ .................. 1,434.04 4 630.00 .................. 126.00 

21330 ....... Treatment of nose fracture ............................ .................. 1,434.04 5 717.00 .................. 143.40 

21335 ....... Treatment of nose fracture ............................ .................. 1,434.04 7 995.00 .................. 199.00 

21336 ....... Treat nasal septal fracture ............................. .................. 2,307.40 4 630.00 .................. 126.00 

21337 ....... Treat nasal septal fracture ............................. .................. 1,009.71 2 446.00 .................. 89.20

21338 ....... Treat nasoethmoid fracture ........................... .................. 1,434.04 4 630.00 .................. 126.00 

21339 ....... Treat nasoethmoid fracture ........................... .................. 1,434.04 5 717.00 .................. 143.40 

21340 ....... Treatment of nose fracture ............................ .................. 2,348.02 4 630.00 .................. 126.00 

21345 ....... Treat nose/jaw fracture .................................. .................. 1,434.04 7 995.00 .................. 199.00 

21355 ....... Treat cheek bone fracture ............................. .................. 2,348.02 3 510.00 .................. 102.00 

21356 ....... Treat cheek bone fracture ............................. A* ............. 1,434.04 3 510.00 .................. 102.00 

21400 ....... Treat eye socket fracture ............................... .................. 464.15 2 446.00 .................. 89.20 

21401 ....... Treat eye socket fracture ............................... .................. 1,009.71 3 510.00 .................. 102.00 

21421 ....... Treat mouth roof fracture ............................... .................. 1,434.04 4 630.00 .................. 126.00 

21445 ....... Treat dental ridge fracture ............................. .................. 1,434.04 4 630.00 .................. 126.00 

21450 ....... Treat lower jaw fracture ................................. .................. 150.72 3 150.72 Y .............. 30.14 

21451 ....... Treat lower jaw fracture ................................. .................. 464.15 4 464.15 Y .............. 92.83 

21452 ....... Treat lower jaw fracture ................................. .................. 1,009.71 2 446.00 .................. 89.20 

21453 ....... Treat lower jaw fracture ................................. .................. 2,348.02 3 510.00 .................. 102.00 

21454 ....... Treat lower jaw fracture ................................. .................. 1,434.04 5 717.00 .................. 143.40 

21461 ....... Treat lower jaw fracture ................................. .................. 2,348.02 4 630.00 .................. 126.00 

21462 ....... Treat lower jaw fracture ................................. .................. 2,348.02 5 717.00 .................. 143.40 

21465 ....... Treat lower jaw fracture ................................. .................. 2,348.02 4 630.00 .................. 126.00 

21480 ....... Reset dislocated jaw ...................................... .................. 150.72 1 150.72 Y .............. 30.14 

21485 ....... Reset dislocated jaw ...................................... .................. 1,009.71 2 446.00 .................. 89.20 

21490 ....... Repair dislocated jaw .................................... .................. 2,348.02 3 510.00 .................. 102.00 

21497 ....... Interdental wiring ........................................... .................. 1,009.71 2 446.00 .................. 89.20 

21501 ....... Drain neck/chest lesion ................................. .................. 1,076.22 2 446.00 .................. 89.20


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68249 

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—Continued 

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 

($) 

21502 ....... Drain chest lesion .......................................... .................. 1,282.87 2 446.00 .................. 89.20 

21555 ....... Remove lesion, neck/chest ............................ .................. 1,233.39 2 446.00 .................. 89.20 

21556 ....... Remove lesion, neck/chest ............................ .................. 1,233.39 2 446.00 .................. 89.20 

21600 ....... Partial removal of rib ..................................... .................. 1,544.67 2 446.00 .................. 89.20 

21610 ....... Partial removal of rib ..................................... .................. 1,544.67 2 446.00 .................. 89.20 

21700 ....... Revision of neck muscle ................................ .................. 1,282.87 2 446.00 .................. 89.20 

21720 ....... Revision of neck muscle ................................ .................. 1,282.87 3 510.00 .................. 102.00

21725 ....... Revision of neck muscle ................................ .................. 88.46 3 88.46 Y .............. 17.69 

21800 ....... Treatment of rib fracture ................................ .................. 103.62 1 103.62 Y .............. 20.72 

21805 ....... Treatment of rib fracture ................................ .................. 1,569.06 2 446.00 .................. 89.20 

21820 ....... Treat sternum fracture ................................... .................. 103.62 1 103.62 Y .............. 20.72 

21925 ....... Biopsy soft tissue of back .............................. .................. 1,233.39 2 446.00 .................. 89.20

21930 ....... Remove lesion, back or flank ........................ .................. 1,233.39 2 446.00 .................. 89.20 

21935 ....... Remove tumor, back ..................................... .................. 1,233.39 3 510.00 .................. 102.00

22305 ....... Treat spine process fracture .......................... .................. 103.62 1 103.62 Y .............. 20.72 

22310 ....... Treat spine fracture ....................................... .................. 103.62 1 103.62 Y .............. 20.72 

22315 ....... Treat spine fracture ....................................... .................. 103.62 2 103.62 Y .............. 20.72 

22505 ....... Manipulation of spine ..................................... .................. 897.11 2 446.00 .................. 89.20

22520 ....... Percut vertebroplasty thor ............................. A* ............. 1,544.67 9 1,339.00 .................. 267.80 

22521 ....... Percut vertebroplasty lumb ............................ A* ............. 1,544.67 9 1,339.00 .................. 267.80 

22522 ....... Percut vertebroplasty add" .......................... A* ............. 1,544.67 9 1,339.00 .................. 267.80 

22900 ....... Remove abdominal wall lesion ...................... .................. 1,233.39 4 630.00 .................. 126.00 

23000 ....... Removal of calcium deposits ......................... .................. 928.31 2 446.00 .................. 89.20 

23020 ....... Release shoulder joint ................................... .................. 2,525.68 2 446.00 .................. 89.20 

23030 ....... Drain shoulder lesion ..................................... .................. 1,076.22 1 333.00 .................. 66.60 

23031 ....... Drain shoulder bursa ..................................... .................. 1,076.22 3 510.00 .................. 102.00 

23035 ....... Drain shoulder bone lesion ............................ .................. 1,282.87 3 510.00 .................. 102.00 

23040 ....... Exploratory shoulder surgery ......................... .................. 1,544.67 3 510.00 .................. 102.00 

23044 ....... Exploratory shoulder surgery ......................... .................. 1,544.67 4 630.00 .................. 126.00 

23066 ....... Biopsy shoulder tissues ................................. .................. 1,233.39 2 446.00 .................. 89.20

23075 ....... Removal of shoulder lesion ........................... .................. 928.31 2 446.00 .................. 89.20 

23076 ....... Removal of shoulder lesion ........................... .................. 1,233.39 2 446.00 .................. 89.20 

23077 ....... Remove tumor of shoulder ............................ .................. 1,233.39 3 510.00 .................. 102.00 

23100 ....... Biopsy of shoulder joint ................................. .................. 1,282.87 2 446.00 .................. 89.20 

23101 ....... Shoulder joint surgery .................................... .................. 1,544.67 7 995.00 .................. 199.00 

23105 ....... Remove shoulder joint lining ......................... .................. 1,544.67 4 630.00 .................. 126.00 

23106 ....... Incision of collarbone joint ............................. .................. 1,544.67 4 630.00 .................. 126.00 

23107 ....... Explore treat shoulder joint ............................ .................. 1,544.67 4 630.00 .................. 126.00 

23120 ....... Partial removal, collar bone ........................... .................. 2,525.68 5 717.00 .................. 143.40

23125 ....... Removal of collar bone .................................. .................. 2,525.68 5 717.00 .................. 143.40 

23130 ....... Remove shoulder bone, part ......................... .................. 2,525.68 5 717.00 .................. 143.40 

23140 ....... Removal of bone lesion ................................. .................. 1,282.87 4 630.00 .................. 126.00

23145 ....... Removal of bone lesion ................................. .................. 1,544.67 5 717.00 .................. 143.40

23146 ....... Removal of bone lesion ................................. .................. 1,544.67 5 717.00 .................. 143.40

23150 ....... Removal of humerus lesion ........................... .................. 1,544.67 4 630.00 .................. 126.00 

23155 ....... Removal of humerus lesion ........................... .................. 1,544.67 5 717.00 .................. 143.40 

23156 ....... Removal of humerus lesion ........................... .................. 1,544.67 5 717.00 .................. 143.40 

23170 ....... Remove collar bone lesion ............................ .................. 1,544.67 2 446.00 .................. 89.20 

23172 ....... Remove shoulder blade lesion ...................... .................. 1,544.67 2 446.00 .................. 89.20 

23174 ....... Remove humerus lesion ................................ .................. 1,544.67 2 446.00 .................. 89.20 

23180 ....... Remove collar bone lesion ............................ .................. 1,544.67 4 630.00 .................. 126.00 

23182 ....... Remove shoulder blade lesion ...................... .................. 1,544.67 4 630.00 .................. 126.00 

23184 ....... Remove humerus lesion ................................ .................. 1,544.67 4 630.00 .................. 126.00 

23190 ....... Partial removal of scapula ............................. .................. 1,544.67 4 630.00 .................. 126.00

23195 ....... Removal of head of humerus ........................ .................. 1,544.67 5 717.00 .................. 143.40 

23330 ....... Remove shoulder foreign body ..................... .................. 418.49 1 333.00 .................. 66.60 

23331 ....... Remove shoulder foreign body ..................... .................. 1,233.39 1 333.00 .................. 66.60 

23395 ....... Muscle transfer,shoulder/arm ........................ .................. 2,525.68 5 717.00 .................. 143.40 

23397 ....... Muscle transfers ............................................ .................. 4,092.54 7 995.00 .................. 199.00 

23400 ....... Fixation of shoulder blade ............................. .................. 1,544.67 7 995.00 .................. 199.00

23405 ....... Incision of tendon & muscle .......................... .................. 1,544.67 2 446.00 .................. 89.20 

23406 ....... Incise tendon(s) & muscle(s) ......................... .................. 1,544.67 2 446.00 .................. 89.20 

23410 ....... Repair rotator cuff, acute ............................... .................. 2,525.68 5 717.00 .................. 143.40 

23412 ....... Repair rotator cuff, chronic ............................ .................. 2,525.68 7 995.00 .................. 199.00 

23415 ....... Release of shoulder ligament ........................ .................. 2,525.68 5 717.00 .................. 143.40 


cprice-sewell on PRODPC62 with RULES2
68250 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

23420 ....... Repair of shoulder ......................................... .................. 2,525.68 7 995.00 .................. 199.00 

23430 ....... Repair biceps tendon ..................................... .................. 2,525.68 4 630.00 .................. 126.00 

23440 ....... Remove/transplant tendon ............................. .................. 2,525.68 4 630.00 .................. 126.00 

23450 ....... Repair shoulder capsule ................................ .................. 4,092.54 5 717.00 .................. 143.40

23455 ....... Repair shoulder capsule ................................ .................. 4,092.54 7 995.00 .................. 199.00

23460 ....... Repair shoulder capsule ................................ .................. 4,092.54 5 717.00 .................. 143.40

23462 ....... Repair shoulder capsule ................................ .................. 2,525.68 7 995.00 .................. 199.00

23465 ....... Repair shoulder capsule ................................ .................. 4,092.54 5 717.00 .................. 143.40

23466 ....... Repair shoulder capsule ................................ .................. 2,525.68 7 995.00 .................. 199.00

23480 ....... Revision of collar bone .................................. .................. 2,525.68 4 630.00 .................. 126.00 

23485 ....... Revision of collar bone .................................. .................. 4,092.54 7 995.00 .................. 199.00 

23490 ....... Reinforce clavicle ........................................... .................. 2,525.68 3 510.00 .................. 102.00 

23491 ....... Reinforce shoulder bones .............................. .................. 4,092.54 3 510.00 .................. 102.00 

23500 ....... Treat clavicle fracture .................................... .................. 103.62 1 103.62 Y .............. 20.72 

23505 ....... Treat clavicle fracture .................................... .................. 103.62 1 103.62 Y .............. 20.72 

23515 ....... Treat clavicle fracture .................................... .................. 3,517.03 3 510.00 .................. 102.00 

23520 ....... Treat clavicle dislocation ............................... .................. 103.62 1 103.62 Y .............. 20.72 

23525 ....... Treat clavicle dislocation ............................... .................. 103.62 1 103.62 Y .............. 20.72 

23530 ....... Treat clavicle dislocation ............................... .................. 2,307.40 3 510.00 .................. 102.00 

23532 ....... Treat clavicle dislocation ............................... .................. 1,569.06 4 630.00 .................. 126.00 

23540 ....... Treat clavicle dislocation ............................... .................. 103.62 1 103.62 Y .............. 20.72 

23545 ....... Treat clavicle dislocation ............................... .................. 103.62 1 103.62 Y .............. 20.72 

23550 ....... Treat clavicle dislocation ............................... .................. 2,307.40 3 510.00 .................. 102.00 

23552 ....... Treat clavicle dislocation ............................... .................. 2,307.40 4 630.00 .................. 126.00 

23570 ....... Treat shoulder blade fx .................................. .................. 103.62 1 103.62 Y .............. 20.72 

23575 ....... Treat shoulder blade fx .................................. .................. 103.62 1 103.62 Y .............. 20.72 

23585 ....... Treat scapula fracture .................................... .................. 3,517.03 3 510.00 .................. 102.00 

23605 ....... Treat humerus fracture .................................. .................. 103.62 2 103.62 Y .............. 20.72 

23615 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00 

23616 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00 

23625 ....... Treat humerus fracture .................................. .................. 103.62 2 103.62 Y .............. 20.72 

23630 ....... Treat humerus fracture .................................. .................. 3,517.03 5 717.00 .................. 143.40 

23650 ....... Treat shoulder dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72 

23655 ....... Treat shoulder dislocation ............................. .................. 897.11 1 333.00 .................. 66.60 

23660 ....... Treat shoulder dislocation ............................. .................. 2,307.40 3 510.00 .................. 102.00

23665 ....... Treat dislocation/fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72 

23670 ....... Treat dislocation/fracture ............................... .................. 3,517.03 3 510.00 .................. 102.00 

23675 ....... Treat dislocation/fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72 

23680 ....... Treat dislocation/fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00 

23700 ....... Fixation of shoulder ....................................... .................. 897.11 1 333.00 .................. 66.60 

23800 ....... Fusion of shoulder joint ................................. .................. 4,092.54 4 630.00 .................. 126.00 

23802 ....... Fusion of shoulder joint ................................. .................. 2,525.68 7 995.00 .................. 199.00 

23921 ....... Amputation follow-up surgery ........................ .................. 323.28 3 323.28 Y .............. 64.66 

23930 ....... Drainage of arm lesion .................................. .................. 1,076.22 1 333.00 .................. 66.60

23931 ....... Drainage of arm bursa ................................... .................. 1,076.22 2 446.00 .................. 89.20

23935 ....... Drain arm/elbow bone lesion ......................... .................. 1,282.87 2 446.00 .................. 89.20 

24000 ....... Exploratory elbow surgery ............................. .................. 1,544.67 4 630.00 .................. 126.00 

24006 ....... Release elbow joint ....................................... .................. 1,544.67 4 630.00 .................. 126.00 

24066 ....... Biopsy arm/elbow soft tissue ......................... .................. 928.31 2 446.00 .................. 89.20 

24075 ....... Remove arm/elbow lesion ............................. .................. 928.31 2 446.00 .................. 89.20 

24076 ....... Remove arm/elbow lesion ............................. .................. 1,233.39 2 446.00 .................. 89.20 

24077 ....... Remove tumor of arm/elbow ......................... .................. 1,233.39 3 510.00 .................. 102.00 

24100 ....... Biopsy elbow joint lining ................................ .................. 1,282.87 1 333.00 .................. 66.60 

24101 ....... Explore/treat elbow joint ................................ .................. 1,544.67 4 630.00 .................. 126.00 

24102 ....... Remove elbow joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00

24105 ....... Removal of elbow bursa ................................ .................. 1,282.87 3 510.00 .................. 102.00 

24110 ....... Remove humerus lesion ................................ .................. 1,282.87 2 446.00 .................. 89.20 

24115 ....... Remove/graft bone lesion .............................. .................. 1,544.67 3 510.00 .................. 102.00 

24116 ....... Remove/graft bone lesion .............................. .................. 1,544.67 3 510.00 .................. 102.00 

24120 ....... Remove elbow lesion .................................... .................. 1,282.87 3 510.00 .................. 102.00

24125 ....... Remove/graft bone lesion .............................. .................. 1,544.67 3 510.00 .................. 102.00 

24126 ....... Remove/graft bone lesion .............................. .................. 1,544.67 3 510.00 .................. 102.00 

24130 ....... Removal of head of radius ............................ .................. 1,544.67 3 510.00 .................. 102.00 

24134 ....... Removal of arm bone lesion ......................... .................. 1,544.67 2 446.00 .................. 89.20 

24136 ....... Remove radius bone lesion ........................... .................. 1,544.67 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68251 

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—Continued 

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 

($) 

24138 ....... Remove elbow bone lesion ........................... .................. 1,544.67 2 446.00 .................. 89.20 

24140 ....... Partial removal of arm bone .......................... .................. 1,544.67 3 510.00 .................. 102.00 

24145 ....... Partial removal of radius ................................ .................. 1,544.67 3 510.00 .................. 102.00 

24147 ....... Partial removal of elbow ................................ .................. 1,544.67 2 446.00 .................. 89.20

24155 ....... Removal of elbow joint .................................. .................. 2,525.68 3 510.00 .................. 102.00 

24160 ....... Remove elbow joint implant .......................... .................. 1,544.67 2 446.00 .................. 89.20 

24164 ....... Remove radius head implant ......................... .................. 1,544.67 3 510.00 .................. 102.00 

24201 ....... Removal of arm foreign body ........................ .................. 928.31 2 446.00 .................. 89.20 

24301 ....... Muscle/tendon transfer .................................. .................. 1,544.67 4 630.00 .................. 126.00 

24305 ....... Arm tendon lengthening ................................ .................. 1,544.67 4 630.00 .................. 126.00 

24310 ....... Revision of arm tendon ................................. .................. 1,282.87 3 510.00 .................. 102.00

24320 ....... Repair of arm tendon ..................................... .................. 2,525.68 3 510.00 .................. 102.00 

24330 ....... Revision of arm muscles ............................... .................. 4,092.54 3 510.00 .................. 102.00 

24331 ....... Revision of arm muscles ............................... .................. 2,525.68 3 510.00 .................. 102.00 

24340 ....... Repair of biceps tendon ................................ .................. 2,525.68 3 510.00 .................. 102.00

24341 ....... Repair arm tendon/muscle ............................ .................. 2,525.68 3 510.00 .................. 102.00 

24342 ....... Repair of ruptured tendon ............................. .................. 2,525.68 3 510.00 .................. 102.00 

24345 ....... Repr elbw med ligmnt w/tissu ....................... .................. 1,544.67 2 446.00 .................. 89.20 

24350 ....... Repair of tennis elbow ................................... .................. 1,544.67 3 510.00 .................. 102.00 

24351 ....... Repair of tennis elbow ................................... .................. 1,544.67 3 510.00 .................. 102.00 

24352 ....... Repair of tennis elbow ................................... .................. 1,544.67 3 510.00 .................. 102.00 

24354 ....... Repair of tennis elbow ................................... .................. 1,544.67 3 510.00 .................. 102.00 

24356 ....... Revision of tennis elbow ................................ .................. 1,544.67 3 510.00 .................. 102.00 

24360 ....... Reconstruct elbow joint ................................. .................. 2,056.14 5 717.00 .................. 143.40 

24361 ....... Reconstruct elbow joint ................................. .................. 6,589.01 5 717.00 .................. 143.40 

24362 ....... Reconstruct elbow joint ................................. .................. 2,915.91 5 717.00 .................. 143.40 

24363 ....... Replace elbow joint ....................................... .................. 6,589.01 7 995.00 .................. 199.00 

24365 ....... Reconstruct head of radius ........................... .................. 2,056.14 5 717.00 .................. 143.40 

24366 ....... Reconstruct head of radius ........................... .................. 6,589.01 5 717.00 .................. 143.40 

24400 ....... Revision of humerus ...................................... .................. 1,544.67 4 630.00 .................. 126.00 

24410 ....... Revision of humerus ...................................... .................. 1,544.67 4 630.00 .................. 126.00 

24420 ....... Revision of humerus ...................................... .................. 2,525.68 3 510.00 .................. 102.00 

24430 ....... Repair of humerus ......................................... .................. 4,092.54 3 510.00 .................. 102.00 

24435 ....... Repair humerus with graft ............................. .................. 4,092.54 4 630.00 .................. 126.00 

24470 ....... Revision of elbow joint ................................... .................. 2,525.68 3 510.00 .................. 102.00 

24495 ....... Decompression of forearm ............................ .................. 1,544.67 2 446.00 .................. 89.20 

24498 ....... Reinforce humerus ........................................ .................. 4,092.54 3 510.00 .................. 102.00 

24500 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24505 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24515 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00 

24516 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00 

24530 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24535 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24538 ....... Treat humerus fracture .................................. .................. 1,569.06 2 446.00 .................. 89.20

24545 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00 

24546 ....... Treat humerus fracture .................................. .................. 3,517.03 5 717.00 .................. 143.40 

24560 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24565 ....... Treat humerus fracture .................................. .................. 103.62 2 103.62 Y .............. 20.72 

24566 ....... Treat humerus fracture .................................. .................. 1,569.06 2 446.00 .................. 89.20

24575 ....... Treat humerus fracture .................................. .................. 3,517.03 3 510.00 .................. 102.00 

24576 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24577 ....... Treat humerus fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24579 ....... Treat humerus fracture .................................. .................. 3,517.03 3 510.00 .................. 102.00 

24582 ....... Treat humerus fracture .................................. .................. 1,569.06 2 446.00 .................. 89.20

24586 ....... Treat elbow fracture ....................................... .................. 3,517.03 4 630.00 .................. 126.00 

24587 ....... Treat elbow fracture ....................................... .................. 3,517.03 5 717.00 .................. 143.40 

24600 ....... Treat elbow dislocation .................................. .................. 103.62 1 103.62 Y .............. 20.72 

24605 ....... Treat elbow dislocation .................................. .................. 897.11 2 446.00 .................. 89.20 

24615 ....... Treat elbow dislocation .................................. .................. 3,517.03 3 510.00 .................. 102.00 

24620 ....... Treat elbow fracture ....................................... .................. 103.62 2 103.62 Y .............. 20.72 

24635 ....... Treat elbow fracture ....................................... .................. 3,517.03 3 510.00 .................. 102.00 

24655 ....... Treat radius fracture ...................................... .................. 103.62 1 103.62 Y .............. 20.72 

24665 ....... Treat radius fracture ...................................... .................. 2,307.40 4 630.00 .................. 126.00 

24666 ....... Treat radius fracture ...................................... .................. 3,517.03 4 630.00 .................. 126.00 

24670 ....... Treat ulnar fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 


cprice-sewell on PRODPC62 with RULES2
68252 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

24675 ....... Treat ulnar fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 

24685 ....... Treat ulnar fracture ........................................ .................. 2,307.40 3 510.00 .................. 102.00 

24800 ....... Fusion of elbow joint ...................................... .................. 2,525.68 4 630.00 .................. 126.00 

24802 ....... Fusion/graft of elbow joint ............................. .................. 2,525.68 5 717.00 .................. 143.40 

24925 ....... Amputation follow-up surgery ........................ .................. 1,282.87 3 510.00 .................. 102.00 

25000 ....... Incision of tendon sheath .............................. .................. 1,282.87 3 510.00 .................. 102.00

25020 ....... Decompress forearm 1 space ....................... .................. 1,282.87 3 510.00 .................. 102.00 

25023 ....... Decompress forearm 1 space ....................... .................. 1,544.67 3 510.00 .................. 102.00 

25024 ....... Decompress forearm 2 spaces ..................... .................. 1,544.67 3 510.00 .................. 102.00 

25025 ....... Decompress forearm 2 spaces ..................... .................. 1,544.67 3 510.00 .................. 102.00 

25028 ....... Drainage of forearm lesion ............................ .................. 1,282.87 1 333.00 .................. 66.60 

25031 ....... Drainage of forearm bursa ............................ .................. 1,282.87 2 446.00 .................. 89.20 

25035 ....... Treat forearm bone lesion ............................. .................. 1,282.87 2 446.00 .................. 89.20 

25040 ....... Explore/treat wrist joint .................................. .................. 1,544.67 5 717.00 .................. 143.40 

25066 ....... Biopsy forearm soft tissues ........................... .................. 1,233.39 2 446.00 .................. 89.20 

25075 ....... Removal forearm lesion subcu ...................... .................. 928.31 2 446.00 .................. 89.20 

25076 ....... Removal forearm lesion deep ....................... .................. 1,233.39 3 510.00 .................. 102.00 

25077 ....... Remove tumor, forearm/wrist ........................ .................. 1,233.39 3 510.00 .................. 102.00 

25085 ....... Incision of wrist capsule ................................ .................. 1,282.87 3 510.00 .................. 102.00 

25100 ....... Biopsy of wrist joint ........................................ .................. 1,282.87 2 446.00 .................. 89.20 

25101 ....... Explore/treat wrist joint .................................. .................. 1,544.67 3 510.00 .................. 102.00 

25105 ....... Remove wrist joint lining ................................ .................. 1,544.67 4 630.00 .................. 126.00 

25107 ....... Remove wrist joint cartilage .......................... .................. 1,544.67 3 510.00 .................. 102.00 

25110 ....... Remove wrist tendon lesion .......................... .................. 1,282.87 3 510.00 .................. 102.00 

25111 ....... Remove wrist tendon lesion .......................... .................. 992.95 3 510.00 .................. 102.00 

25112 ....... Remove wrist tendon lesion .......................... .................. 992.95 4 630.00 .................. 126.00 

25115 ....... Remove wrist/forearm lesion ......................... .................. 1,282.87 4 630.00 .................. 126.00 

25116 ....... Remove wrist/forearm lesion ......................... .................. 1,282.87 4 630.00 .................. 126.00 

25118 ....... Excise wrist tendon sheath ............................ .................. 1,544.67 2 446.00 .................. 89.20 

25119 ....... Partial removal of ulna ................................... .................. 1,544.67 3 510.00 .................. 102.00 

25120 ....... Removal of forearm lesion ............................ .................. 1,544.67 3 510.00 .................. 102.00 

25125 ....... Remove/graft forearm lesion ......................... .................. 1,544.67 3 510.00 .................. 102.00 

25126 ....... Remove/graft forearm lesion ......................... .................. 1,544.67 3 510.00 .................. 102.00 

25130 ....... Removal of wrist lesion ................................. .................. 1,544.67 3 510.00 .................. 102.00 

25135 ....... Remove & graft wrist lesion .......................... .................. 1,544.67 3 510.00 .................. 102.00 

25136 ....... Remove & graft wrist lesion .......................... .................. 1,544.67 3 510.00 .................. 102.00 

25145 ....... Remove forearm bone lesion ........................ .................. 1,544.67 2 446.00 .................. 89.20 

25150 ....... Partial removal of ulna ................................... .................. 1,544.67 2 446.00 .................. 89.20 

25151 ....... Partial removal of radius ................................ .................. 1,544.67 2 446.00 .................. 89.20 

25210 ....... Removal of wrist bone ................................... .................. 1,590.53 3 510.00 .................. 102.00 

25215 ....... Removal of wrist bones ................................. .................. 1,590.53 4 630.00 .................. 126.00

25230 ....... Partial removal of radius ................................ .................. 1,544.67 4 630.00 .................. 126.00 

25240 ....... Partial removal of ulna ................................... .................. 1,544.67 4 630.00 .................. 126.00 

25248 ....... Remove forearm foreign body ....................... .................. 1,282.87 2 446.00 .................. 89.20 

25250 ....... Removal of wrist prosthesis .......................... .................. 1,544.67 1 333.00 .................. 66.60 

25251 ....... Removal of wrist prosthesis .......................... .................. 1,544.67 1 333.00 .................. 66.60 

25260 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 4 630.00 .................. 126.00 

25263 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 2 446.00 .................. 89.20 

25265 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 3 510.00 .................. 102.00 

25270 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 4 630.00 .................. 126.00 

25272 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 3 510.00 .................. 102.00 

25274 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 4 630.00 .................. 126.00 

25275 ....... Repair forearm tendon sheath ....................... .................. 1,544.67 4 630.00 .................. 126.00 

25280 ....... Revise wrist/forearm tendon .......................... .................. 1,544.67 4 630.00 .................. 126.00 

25290 ....... Incise wrist/forearm tendon ........................... .................. 1,544.67 3 510.00 .................. 102.00 

25295 ....... Release wrist/forearm tendon ........................ .................. 1,282.87 3 510.00 .................. 102.00 

25300 ....... Fusion of tendons at wrist ............................. .................. 1,544.67 3 510.00 .................. 102.00

25301 ....... Fusion of tendons at wrist ............................. .................. 1,544.67 3 510.00 .................. 102.00

25310 ....... Transplant forearm tendon ............................ .................. 2,525.68 3 510.00 .................. 102.00 

25312 ....... Transplant forearm tendon ............................ .................. 2,525.68 4 630.00 .................. 126.00 

25315 ....... Revise palsy hand tendon(s) ......................... .................. 2,525.68 3 510.00 .................. 102.00 

25316 ....... Revise palsy hand tendon(s) ......................... .................. 4,092.54 3 510.00 .................. 102.00 

25320 ....... Repair/revise wrist joint ................................. .................. 2,525.68 3 510.00 .................. 102.00 

25332 ....... Revise wrist joint ............................................ .................. 2,056.14 5 717.00 .................. 143.40 

25335 ....... Realignment of hand ..................................... .................. 2,525.68 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68253 

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—Continued 

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 

($) 

25337 ....... Reconstruct ulna/radioulnar ........................... .................. 2,525.68 5 717.00 .................. 143.40 

25350 ....... Revision of radius .......................................... .................. 4,092.54 3 510.00 .................. 102.00 

25355 ....... Revision of radius .......................................... .................. 2,525.68 3 510.00 .................. 102.00 

25360 ....... Revision of ulna ............................................. .................. 1,544.67 3 510.00 .................. 102.00 

25365 ....... Revise radius & ulna ..................................... .................. 1,544.67 3 510.00 .................. 102.00 

25370 ....... Revise radius or ulna ..................................... .................. 2,525.68 3 510.00 .................. 102.00 

25375 ....... Revise radius & ulna ..................................... .................. 2,525.68 4 630.00 .................. 126.00 

25390 ....... Shorten radius or ulna ................................... .................. 1,544.67 3 510.00 .................. 102.00 

25391 ....... Lengthen radius or ulna ................................. .................. 2,525.68 4 630.00 .................. 126.00 

25392 ....... Shorten radius & ulna .................................... .................. 1,544.67 3 510.00 .................. 102.00 

25393 ....... Lengthen radius & ulna ................................. .................. 2,525.68 4 630.00 .................. 126.00

25400 ....... Repair radius or ulna ..................................... .................. 1,544.67 3 510.00 .................. 102.00 

25405 ....... Repair/graft radius or ulna ............................. .................. 1,544.67 4 630.00 .................. 126.00 

25415 ....... Repair radius & ulna ...................................... .................. 1,544.67 3 510.00 .................. 102.00 

25420 ....... Repair/graft radius & ulna .............................. .................. 4,092.54 4 630.00 .................. 126.00 

25425 ....... Repair/graft radius or ulna ............................. .................. 2,525.68 3 510.00 .................. 102.00 

25426 ....... Repair/graft radius & ulna .............................. .................. 2,525.68 4 630.00 .................. 126.00 

25440 ....... Repair/graft wrist bone .................................. .................. 4,092.54 4 630.00 .................. 126.00 

25441 ....... Reconstruct wrist joint ................................... .................. 6,589.01 5 717.00 .................. 143.40 

25442 ....... Reconstruct wrist joint ................................... .................. 6,589.01 5 717.00 .................. 143.40 

25443 ....... Reconstruct wrist joint ................................... .................. 2,915.91 5 717.00 .................. 143.40 

25444 ....... Reconstruct wrist joint ................................... .................. 2,915.91 5 717.00 .................. 143.40 

25445 ....... Reconstruct wrist joint ................................... .................. 2,915.91 5 717.00 .................. 143.40 

25446 ....... Wrist replacement .......................................... .................. 6,589.01 7 995.00 .................. 199.00 

25447 ....... Repair wrist joint(s) ........................................ .................. 2,056.14 5 717.00 .................. 143.40 

25449 ....... Remove wrist joint implant ............................ .................. 2,056.14 5 717.00 .................. 143.40 

25450 ....... Revision of wrist joint ..................................... .................. 2,525.68 3 510.00 .................. 102.00 

25455 ....... Revision of wrist joint ..................................... .................. 2,525.68 3 510.00 .................. 102.00 

25490 ....... Reinforce radius ............................................. .................. 2,525.68 3 510.00 .................. 102.00 

25491 ....... Reinforce ulna ................................................ .................. 2,525.68 3 510.00 .................. 102.00 

25492 ....... Reinforce radius and ulna ............................. .................. 2,525.68 3 510.00 .................. 102.00 

25505 ....... Treat fracture of radius .................................. .................. 103.62 1 103.62 Y .............. 20.72 

25515 ....... Treat fracture of radius .................................. .................. 2,307.40 3 510.00 .................. 102.00 

25520 ....... Treat fracture of radius .................................. .................. 103.62 1 103.62 Y .............. 20.72 

25525 ....... Treat fracture of radius .................................. .................. 2,307.40 4 630.00 .................. 126.00 

25526 ....... Treat fracture of radius .................................. .................. 2,307.40 5 717.00 .................. 143.40 

25535 ....... Treat fracture of ulna ..................................... .................. 103.62 1 103.62 Y .............. 20.72 

25545 ....... Treat fracture of ulna ..................................... .................. 2,307.40 3 510.00 .................. 102.00 

25565 ....... Treat fracture radius & ulna ........................... .................. 103.62 2 103.62 Y .............. 20.72 

25574 ....... Treat fracture radius & ulna ........................... .................. 3,517.03 3 510.00 .................. 102.00

25575 ....... Treat fracture radius/ulna .............................. .................. 3,517.03 3 510.00 .................. 102.00 

25605 ....... Treat fracture radius/ulna .............................. .................. 103.62 3 103.62 Y .............. 20.72 

25606 ....... Treat fx distal radial ....................................... A .............. 1,569.06 3 510.00 .................. 102.00 

25607 ....... Treat fx rad extra-articul ................................ A .............. 3,517.03 5 717.00 .................. 143.40

25608 ....... Treat fx rad intra-articul ................................. A .............. 3,517.03 5 717.00 .................. 143.40 

25609 ....... Treat fx radial 3+ frag .................................... A .............. 3,517.03 5 717.00 .................. 143.40 

25611 ....... Treat fracture radius/ulna .............................. D .............. .................... 3 510.00 .................. ....................

25620 ....... Treat fracture radius/ulna .............................. D .............. .................... 5 717.00 .................. ....................

25624 ....... Treat wrist bone fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72 

25628 ....... Treat wrist bone fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00 

25635 ....... Treat wrist bone fracture ............................... .................. 103.62 1 103.62 Y .............. 20.72 

25645 ....... Treat wrist bone fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00 

25660 ....... Treat wrist dislocation .................................... .................. 103.62 1 103.62 Y .............. 20.72 

25670 ....... Treat wrist dislocation .................................... .................. 1,569.06 3 510.00 .................. 102.00 

25671 ....... Pin radioulnar dislocation .............................. .................. 1,569.06 1 333.00 .................. 66.60

25675 ....... Treat wrist dislocation .................................... .................. 103.62 1 103.62 Y .............. 20.72 

25676 ....... Treat wrist dislocation .................................... .................. 1,569.06 2 446.00 .................. 89.20 

25680 ....... Treat wrist fracture ......................................... .................. 103.62 2 103.62 Y .............. 20.72

25685 ....... Treat wrist fracture ......................................... .................. 1,569.06 3 510.00 .................. 102.00 

25690 ....... Treat wrist dislocation .................................... .................. 103.62 1 103.62 Y .............. 20.72 

25695 ....... Treat wrist dislocation .................................... .................. 1,569.06 2 446.00 .................. 89.20 

25800 ....... Fusion of wrist joint ........................................ .................. 4,092.54 4 630.00 .................. 126.00 

25805 ....... Fusion/graft of wrist joint ............................... .................. 2,525.68 5 717.00 .................. 143.40 

25810 ....... Fusion/graft of wrist joint ............................... .................. 4,092.54 5 717.00 .................. 143.40 

25820 ....... Fusion of hand bones .................................... .................. 992.95 4 630.00 .................. 126.00 


cprice-sewell on PRODPC62 with RULES2
68254 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

25825 ....... Fuse hand bones with graft ........................... .................. 1,590.53 5 717.00 .................. 143.40 

25830 ....... Fusion, radioulnar jnt/ulna ............................. .................. 4,092.54 5 717.00 .................. 143.40 

25907 ....... Amputation follow-up surgery ........................ .................. 1,282.87 3 510.00 .................. 102.00 

25922 ....... Amputate hand at wrist .................................. .................. 1,282.87 3 510.00 .................. 102.00 

25929 ....... Amputation follow-up surgery ........................ .................. 862.68 3 510.00 .................. 102.00 

26011 ....... Drainage of finger abscess ............................ .................. 685.58 1 333.00 .................. 66.60 

26020 ....... Drain hand tendon sheath ............................. .................. 992.95 2 446.00 .................. 89.20 

26025 ....... Drainage of palm bursa ................................. .................. 992.95 1 333.00 .................. 66.60 

26030 ....... Drainage of palm bursa(s) ............................. .................. 992.95 2 446.00 .................. 89.20 

26034 ....... Treat hand bone lesion .................................. .................. 992.95 2 446.00 .................. 89.20 

26040 ....... Release palm contracture .............................. .................. 1,590.53 4 630.00 .................. 126.00 

26045 ....... Release palm contracture .............................. .................. 1,590.53 3 510.00 .................. 102.00 

26055 ....... Incise finger tendon sheath ........................... .................. 992.95 2 446.00 .................. 89.20 

26060 ....... Incision of finger tendon ................................ .................. 992.95 2 446.00 .................. 89.20 

26070 ....... Explore/treat hand joint .................................. .................. 992.95 2 446.00 .................. 89.20

26075 ....... Explore/treat finger joint ................................. .................. 992.95 4 630.00 .................. 126.00 

26080 ....... Explore/treat finger joint ................................. .................. 992.95 4 630.00 .................. 126.00 

26100 ....... Biopsy hand joint lining .................................. .................. 992.95 2 446.00 .................. 89.20

26105 ....... Biopsy finger joint lining ................................. .................. 992.95 1 333.00 .................. 66.60 

26110 ....... Biopsy finger joint lining ................................. .................. 992.95 1 333.00 .................. 66.60 

26115 ....... Removal hand lesion subcut ......................... .................. 1,233.39 2 446.00 .................. 89.20 

26116 ....... Removal hand lesion, deep ........................... .................. 1,233.39 2 446.00 .................. 89.20 

26117 ....... Remove tumor, hand/finger ........................... .................. 1,233.39 3 510.00 .................. 102.00 

26121 ....... Release palm contracture .............................. .................. 1,590.53 4 630.00 .................. 126.00 

26123 ....... Release palm contracture .............................. .................. 1,590.53 4 630.00 .................. 126.00 

26125 ....... Release palm contracture .............................. .................. 992.95 4 630.00 .................. 126.00 

26130 ....... Remove wrist joint lining ................................ .................. 992.95 3 510.00 .................. 102.00

26135 ....... Revise finger joint, each ................................ .................. 1,590.53 4 630.00 .................. 126.00 

26140 ....... Revise finger joint, each ................................ .................. 992.95 2 446.00 .................. 89.20 

26145 ....... Tendon excision, palm/finger ......................... .................. 992.95 3 510.00 .................. 102.00 

26160 ....... Remove tendon sheath lesion ....................... .................. 992.95 3 510.00 .................. 102.00 

26170 ....... Removal of palm tendon, each ..................... .................. 992.95 3 510.00 .................. 102.00 

26180 ....... Removal of finger tendon .............................. .................. 992.95 3 510.00 .................. 102.00 

26185 ....... Remove finger bone ...................................... .................. 992.95 4 630.00 .................. 126.00 

26200 ....... Remove hand bone lesion ............................. .................. 992.95 2 446.00 .................. 89.20 

26205 ....... Remove/graft bone lesion .............................. .................. 1,590.53 3 510.00 .................. 102.00 

26210 ....... Removal of finger lesion ................................ .................. 992.95 2 446.00 .................. 89.20 

26215 ....... Remove/graft finger lesion ............................. .................. 992.95 3 510.00 .................. 102.00 

26230 ....... Partial removal of hand bone ........................ .................. 992.95 7 992.95 Y .............. 198.59 

26235 ....... Partial removal, finger bone .......................... .................. 992.95 3 510.00 .................. 102.00 

26236 ....... Partial removal, finger bone .......................... .................. 992.95 3 510.00 .................. 102.00 

26250 ....... Extensive hand surgery ................................. .................. 992.95 3 510.00 .................. 102.00 

26255 ....... Extensive hand surgery ................................. .................. 1,590.53 3 510.00 .................. 102.00

26260 ....... Extensive finger surgery ................................ .................. 992.95 3 510.00 .................. 102.00 

26261 ....... Extensive finger surgery ................................ .................. 992.95 3 510.00 .................. 102.00 

26262 ....... Partial removal of finger ................................ .................. 992.95 2 446.00 .................. 89.20 

26320 ....... Removal of implant from hand ...................... .................. 928.31 2 446.00 .................. 89.20 

26350 ....... Repair finger/hand tendon ............................. .................. 1,590.53 1 333.00 .................. 66.60 

26352 ....... Repair/graft hand tendon ............................... .................. 1,590.53 4 630.00 .................. 126.00

26356 ....... Repair finger/hand tendon ............................. .................. 1,590.53 4 630.00 .................. 126.00 

26357 ....... Repair finger/hand tendon ............................. .................. 1,590.53 4 630.00 .................. 126.00 

26358 ....... Repair/graft hand tendon ............................... .................. 1,590.53 4 630.00 .................. 126.00

26370 ....... Repair finger/hand tendon ............................. .................. 1,590.53 4 630.00 .................. 126.00 

26372 ....... Repair/graft hand tendon ............................... .................. 1,590.53 4 630.00 .................. 126.00

26373 ....... Repair finger/hand tendon ............................. .................. 1,590.53 3 510.00 .................. 102.00 

26390 ....... Revise hand/finger tendon ............................. .................. 1,590.53 4 630.00 .................. 126.00 

26392 ....... Repair/graft hand tendon ............................... .................. 1,590.53 3 510.00 .................. 102.00

26410 ....... Repair hand tendon ....................................... .................. 992.95 3 510.00 .................. 102.00

26412 ....... Repair/graft hand tendon ............................... .................. 1,590.53 3 510.00 .................. 102.00

26415 ....... Excision, hand/finger tendon ......................... .................. 1,590.53 4 630.00 .................. 126.00 

26416 ....... Graft hand or finger tendon ........................... .................. 1,590.53 3 510.00 .................. 102.00 

26418 ....... Repair finger tendon ...................................... .................. 992.95 4 630.00 .................. 126.00 

26420 ....... Repair/graft finger tendon .............................. .................. 1,590.53 4 630.00 .................. 126.00 

26426 ....... Repair finger/hand tendon ............................. .................. 1,590.53 3 510.00 .................. 102.00 

26428 ....... Repair/graft finger tendon .............................. .................. 1,590.53 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68255 

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—Continued 

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 

($) 

26432 ....... Repair finger tendon ...................................... .................. 992.95 3 510.00 .................. 102.00 

26433 ....... Repair finger tendon ...................................... .................. 992.95 3 510.00 .................. 102.00 

26434 ....... Repair/graft finger tendon .............................. .................. 1,590.53 3 510.00 .................. 102.00 

26437 ....... Realignment of tendons ................................. .................. 992.95 3 510.00 .................. 102.00 

26440 ....... Release palm/finger tendon ........................... .................. 992.95 3 510.00 .................. 102.00 

26442 ....... Release palm & finger tendon ....................... .................. 1,590.53 3 510.00 .................. 102.00 

26445 ....... Release hand/finger tendon .......................... .................. 992.95 3 510.00 .................. 102.00 

26449 ....... Release forearm/hand tendon ....................... .................. 1,590.53 3 510.00 .................. 102.00 

26450 ....... Incision of palm tendon ................................. .................. 992.95 3 510.00 .................. 102.00 

26455 ....... Incision of finger tendon ................................ .................. 992.95 3 510.00 .................. 102.00

26460 ....... Incise hand/finger tendon .............................. .................. 992.95 3 510.00 .................. 102.00 

26471 ....... Fusion of finger tendons ................................ .................. 992.95 2 446.00 .................. 89.20 

26474 ....... Fusion of finger tendons ................................ .................. 992.95 2 446.00 .................. 89.20 

26476 ....... Tendon lengthening ....................................... .................. 992.95 1 333.00 .................. 66.60 

26477 ....... Tendon shortening ......................................... .................. 992.95 1 333.00 .................. 66.60

26478 ....... Lengthening of hand tendon .......................... .................. 992.95 1 333.00 .................. 66.60 

26479 ....... Shortening of hand tendon ............................ .................. 992.95 1 333.00 .................. 66.60 

26480 ....... Transplant hand tendon ................................. .................. 1,590.53 3 510.00 .................. 102.00

26483 ....... Transplant/graft hand tendon ........................ .................. 1,590.53 3 510.00 .................. 102.00 

26485 ....... Transplant palm tendon ................................. .................. 1,590.53 2 446.00 .................. 89.20 

26489 ....... Transplant/graft palm tendon ......................... .................. 1,590.53 3 510.00 .................. 102.00 

26490 ....... Revise thumb tendon ..................................... .................. 1,590.53 3 510.00 .................. 102.00 

26492 ....... Tendon transfer with graft ............................. .................. 1,590.53 3 510.00 .................. 102.00

26494 ....... Hand tendon/muscle transfer ........................ .................. 1,590.53 3 510.00 .................. 102.00 

26496 ....... Revise thumb tendon ..................................... .................. 1,590.53 3 510.00 .................. 102.00 

26497 ....... Finger tendon transfer ................................... .................. 1,590.53 3 510.00 .................. 102.00 

26498 ....... Finger tendon transfer ................................... .................. 1,590.53 4 630.00 .................. 126.00 

26499 ....... Revision of finger ........................................... .................. 1,590.53 3 510.00 .................. 102.00 

26500 ....... Hand tendon reconstruction .......................... .................. 992.95 4 630.00 .................. 126.00 

26502 ....... Hand tendon reconstruction .......................... .................. 1,590.53 4 630.00 .................. 126.00 

26504 ....... Hand tendon reconstruction .......................... D .............. .................... 4 630.00 .................. ....................

26508 ....... Release thumb contracture ........................... .................. 992.95 3 510.00 .................. 102.00 

26510 ....... Thumb tendon transfer .................................. .................. 1,590.53 3 510.00 .................. 102.00

26516 ....... Fusion of knuckle joint ................................... .................. 1,590.53 1 333.00 .................. 66.60 

26517 ....... Fusion of knuckle joints ................................. .................. 1,590.53 3 510.00 .................. 102.00 

26518 ....... Fusion of knuckle joints ................................. .................. 1,590.53 3 510.00 .................. 102.00 

26520 ....... Release knuckle contracture ......................... .................. 992.95 3 510.00 .................. 102.00 

26525 ....... Release finger contracture ............................ .................. 992.95 3 510.00 .................. 102.00 

26530 ....... Revise knuckle joint ....................................... .................. 2,056.14 3 510.00 .................. 102.00 

26531 ....... Revise knuckle with implant .......................... .................. 2,915.91 7 995.00 .................. 199.00 

26535 ....... Revise finger joint .......................................... .................. 2,056.14 5 717.00 .................. 143.40 

26536 ....... Revise/implant finger joint ............................. .................. 2,915.91 5 717.00 .................. 143.40 

26540 ....... Repair hand joint ........................................... .................. 992.95 4 630.00 .................. 126.00 

26541 ....... Repair hand joint with graft ........................... .................. 1,590.53 7 995.00 .................. 199.00

26542 ....... Repair hand joint with graft ........................... .................. 992.95 4 630.00 .................. 126.00 

26545 ....... Reconstruct finger joint .................................. .................. 1,590.53 4 630.00 .................. 126.00 

26546 ....... Repair nonunion hand ................................... .................. 1,590.53 4 630.00 .................. 126.00

26548 ....... Reconstruct finger joint .................................. .................. 1,590.53 4 630.00 .................. 126.00 

26550 ....... Construct thumb replacement ....................... .................. 1,590.53 2 446.00 .................. 89.20 

26555 ....... Positional change of finger ............................ .................. 1,590.53 3 510.00 .................. 102.00

26560 ....... Repair of web finger ...................................... .................. 992.95 2 446.00 .................. 89.20

26561 ....... Repair of web finger ...................................... .................. 1,590.53 3 510.00 .................. 102.00 

26562 ....... Repair of web finger ...................................... .................. 1,590.53 4 630.00 .................. 126.00 

26565 ....... Correct metacarpal flaw ................................. .................. 1,590.53 5 717.00 .................. 143.40 

26567 ....... Correct finger deformity ................................. .................. 1,590.53 5 717.00 .................. 143.40 

26568 ....... Lengthen metacarpal/finger ........................... .................. 1,590.53 3 510.00 .................. 102.00 

26580 ....... Repair hand deformity ................................... .................. 992.95 5 717.00 .................. 143.40 

26587 ....... Reconstruct extra finger ................................ .................. 992.95 5 717.00 .................. 143.40 

26590 ....... Repair finger deformity .................................. .................. 992.95 5 717.00 .................. 143.40

26591 ....... Repair muscles of hand ................................. .................. 1,590.53 3 510.00 .................. 102.00

26593 ....... Release muscles of hand .............................. .................. 992.95 3 510.00 .................. 102.00 

26596 ....... Excision constricting tissue ............................ .................. 992.95 2 446.00 .................. 89.20 

26605 ....... Treat metacarpal fracture .............................. .................. 103.62 2 103.62 Y .............. 20.72 

26607 ....... Treat metacarpal fracture .............................. .................. 103.62 2 103.62 Y .............. 20.72 

26608 ....... Treat metacarpal fracture .............................. .................. 1,569.06 4 630.00 .................. 126.00


cprice-sewell on PRODPC62 with RULES2
68256 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

26615 ....... Treat metacarpal fracture .............................. .................. 2,307.40 4 630.00 .................. 126.00

26645 ....... Treat thumb fracture ...................................... .................. 103.62 1 103.62 Y .............. 20.72 

26650 ....... Treat thumb fracture ...................................... .................. 1,569.06 2 446.00 .................. 89.20 

26665 ....... Treat thumb fracture ...................................... .................. 2,307.40 4 630.00 .................. 126.00 

26675 ....... Treat hand dislocation ................................... .................. 103.62 2 103.62 Y .............. 20.72 

26676 ....... Pin hand dislocation ...................................... .................. 1,569.06 2 446.00 .................. 89.20 

26685 ....... Treat hand dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00 

26686 ....... Treat hand dislocation ................................... .................. 3,517.03 3 510.00 .................. 102.00 

26705 ....... Treat knuckle dislocation ............................... .................. 103.62 2 103.62 Y .............. 20.72 

26706 ....... Pin knuckle dislocation .................................. .................. 103.62 2 103.62 Y .............. 20.72 

26715 ....... Treat knuckle dislocation ............................... .................. 2,307.40 4 630.00 .................. 126.00 

26727 ....... Treat finger fracture, each ............................. .................. 1,569.06 7 995.00 .................. 199.00 

26735 ....... Treat finger fracture, each ............................. .................. 2,307.40 4 630.00 .................. 126.00 

26742 ....... Treat finger fracture, each ............................. .................. 103.62 2 103.62 Y .............. 20.72 

26746 ....... Treat finger fracture, each ............................. .................. 2,307.40 5 717.00 .................. 143.40 

26756 ....... Pin finger fracture, each ................................ .................. 1,569.06 2 446.00 .................. 89.20 

26765 ....... Treat finger fracture, each ............................. .................. 2,307.40 4 630.00 .................. 126.00 

26776 ....... Pin finger dislocation ..................................... .................. 1,569.06 2 446.00 .................. 89.20 

26785 ....... Treat finger dislocation .................................. .................. 1,569.06 2 446.00 .................. 89.20 

26820 ....... Thumb fusion with graft ................................. .................. 1,590.53 5 717.00 .................. 143.40 

26841 ....... Fusion of thumb ............................................. .................. 1,590.53 4 630.00 .................. 126.00 

26842 ....... Thumb fusion with graft ................................. .................. 1,590.53 4 630.00 .................. 126.00 

26843 ....... Fusion of hand joint ....................................... .................. 1,590.53 3 510.00 .................. 102.00 

26844 ....... Fusion/graft of hand joint ............................... .................. 1,590.53 3 510.00 .................. 102.00 

26850 ....... Fusion of knuckle ........................................... .................. 1,590.53 4 630.00 .................. 126.00 

26852 ....... Fusion of knuckle with graft ........................... .................. 1,590.53 4 630.00 .................. 126.00

26860 ....... Fusion of finger joint ...................................... .................. 1,590.53 3 510.00 .................. 102.00 

26861 ....... Fusion of finger jnt, add-on ........................... .................. 1,590.53 2 446.00 .................. 89.20 

26862 ....... Fusion/graft of finger joint .............................. .................. 1,590.53 4 630.00 .................. 126.00 

26863 ....... Fuse/graft added joint .................................... .................. 1,590.53 3 510.00 .................. 102.00 

26910 ....... Amputate metacarpal bone ........................... .................. 1,590.53 3 510.00 .................. 102.00 

26951 ....... Amputation of finger/thumb ........................... .................. 992.95 2 446.00 .................. 89.20 

26952 ....... Amputation of finger/thumb ........................... .................. 992.95 4 630.00 .................. 126.00 

26990 ....... Drainage of pelvis lesion ............................... .................. 1,282.87 1 333.00 .................. 66.60

26991 ....... Drainage of pelvis bursa ................................ .................. 1,282.87 1 333.00 .................. 66.60

27000 ....... Incision of hip tendon .................................... .................. 1,282.87 2 446.00 .................. 89.20 

27001 ....... Incision of hip tendon .................................... .................. 1,544.67 3 510.00 .................. 102.00 

27003 ....... Incision of hip tendon .................................... .................. 1,544.67 3 510.00 .................. 102.00 

27033 ....... Exploration of hip joint ................................... .................. 2,525.68 3 510.00 .................. 102.00 

27035 ....... Denervation of hip joint .................................. .................. 2,525.68 4 630.00 .................. 126.00 

27040 ....... Biopsy of soft tissues ..................................... .................. 418.49 1 333.00 .................. 66.60 

27041 ....... Biopsy of soft tissues ..................................... .................. 418.49 2 418.49 Y .............. 83.70 

27047 ....... Remove hip/pelvis lesion ............................... .................. 1,233.39 2 446.00 .................. 89.20 

27048 ....... Remove hip/pelvis lesion ............................... .................. 1,233.39 3 510.00 .................. 102.00

27049 ....... Remove tumor, hip/pelvis .............................. .................. 1,233.39 3 510.00 .................. 102.00 

27050 ....... Biopsy of sacroiliac joint ................................ .................. 1,282.87 3 510.00 .................. 102.00 

27052 ....... Biopsy of hip joint .......................................... .................. 1,282.87 3 510.00 .................. 102.00 

27060 ....... Removal of ischial bursa ............................... .................. 1,282.87 5 717.00 .................. 143.40

27062 ....... Remove femur lesion/bursa ........................... .................. 1,282.87 5 717.00 .................. 143.40 

27065 ....... Removal of hip bone lesion ........................... .................. 1,282.87 5 717.00 .................. 143.40 

27066 ....... Removal of hip bone lesion ........................... .................. 1,544.67 5 717.00 .................. 143.40 

27067 ....... Remove/graft hip bone lesion ........................ .................. 1,544.67 5 717.00 .................. 143.40 

27080 ....... Removal of tail bone ...................................... .................. 1,544.67 2 446.00 .................. 89.20 

27086 ....... Remove hip foreign body .............................. .................. 418.49 1 333.00 .................. 66.60 

27087 ....... Remove hip foreign body .............................. .................. 1,282.87 3 510.00 .................. 102.00 

27097 ....... Revision of hip tendon ................................... .................. 1,544.67 3 510.00 .................. 102.00 

27098 ....... Transfer tendon to pelvis ............................... .................. 1,544.67 3 510.00 .................. 102.00 

27100 ....... Transfer of abdominal muscle ....................... .................. 2,525.68 4 630.00 .................. 126.00 

27105 ....... Transfer of spinal muscle .............................. .................. 2,525.68 4 630.00 .................. 126.00

27110 ....... Transfer of iliopsoas muscle .......................... .................. 2,525.68 4 630.00 .................. 126.00 

27111 ....... Transfer of iliopsoas muscle .......................... .................. 2,525.68 4 630.00 .................. 126.00 

27193 ....... Treat pelvic ring fracture ................................ .................. 103.62 1 103.62 Y .............. 20.72 

27194 ....... Treat pelvic ring fracture ................................ .................. 897.11 2 446.00 .................. 89.20

27202 ....... Treat tail bone fracture .................................. .................. 2,307.40 2 446.00 .................. 89.20 

27230 ....... Treat thigh fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68257 

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—Continued 

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 

($) 

27238 ....... Treat thigh fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 

27246 ....... Treat thigh fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 

27250 ....... Treat hip dislocation ...................................... .................. 103.62 1 103.62 Y .............. 20.72 

27252 ....... Treat hip dislocation ...................................... .................. 897.11 2 446.00 .................. 89.20 

27257 ....... Treat hip dislocation ...................................... .................. 897.11 3 510.00 .................. 102.00 

27265 ....... Treat hip dislocation ...................................... .................. 103.62 1 103.62 Y .............. 20.72 

27266 ....... Treat hip dislocation ...................................... .................. 897.11 2 446.00 .................. 89.20 

27275 ....... Manipulation of hip joint ................................. .................. 897.11 2 446.00 .................. 89.20

27301 ....... Drain thigh/knee lesion .................................. .................. 1,076.22 3 510.00 .................. 102.00 

27305 ....... Incise thigh tendon & fascia .......................... .................. 1,282.87 2 446.00 .................. 89.20 

27306 ....... Incision of thigh tendon ................................. .................. 1,282.87 3 510.00 .................. 102.00 

27307 ....... Incision of thigh tendons ................................ .................. 1,282.87 3 510.00 .................. 102.00 

27310 ....... Exploration of knee joint ................................ .................. 1,544.67 4 630.00 .................. 126.00 

27315 ....... Partial removal, thigh nerve ........................... D .............. .................... 2 446.00 .................. ....................

27320 ....... Partial removal, thigh nerve ........................... D .............. .................... 2 446.00 .................. ....................

27323 ....... Biopsy, thigh soft tissues ............................... .................. 418.49 1 333.00 .................. 66.60 

27324 ....... Biopsy, thigh soft tissues ............................... .................. 1,233.39 1 333.00 .................. 66.60 

27325 ....... Neurectomy, hamstring .................................. A .............. 1,097.20 2 446.00 .................. 89.20 

27326 ....... Neurectomy, popliteal .................................... A .............. 1,097.20 2 446.00 .................. 89.20 

27327 ....... Removal of thigh lesion ................................. .................. 1,233.39 2 446.00 .................. 89.20

27328 ....... Removal of thigh lesion ................................. .................. 1,233.39 3 510.00 .................. 102.00 

27329 ....... Remove tumor, thigh/knee ............................ .................. 1,233.39 4 630.00 .................. 126.00 

27330 ....... Biopsy, knee joint lining ................................. .................. 1,544.67 4 630.00 .................. 126.00 

27331 ....... Explore/treat knee joint .................................. .................. 1,544.67 4 630.00 .................. 126.00 

27332 ....... Removal of knee cartilage ............................. .................. 1,544.67 4 630.00 .................. 126.00 

27333 ....... Removal of knee cartilage ............................. .................. 1,544.67 4 630.00 .................. 126.00 

27334 ....... Remove knee joint lining ............................... .................. 1,544.67 4 630.00 .................. 126.00

27335 ....... Remove knee joint lining ............................... .................. 1,544.67 4 630.00 .................. 126.00

27340 ....... Removal of kneecap bursa ............................ .................. 1,282.87 3 510.00 .................. 102.00 

27345 ....... Removal of knee cyst .................................... .................. 1,282.87 4 630.00 .................. 126.00 

27347 ....... Remove knee cyst ......................................... .................. 1,282.87 4 630.00 .................. 126.00 

27350 ....... Removal of kneecap ...................................... .................. 1,544.67 4 630.00 .................. 126.00 

27355 ....... Remove femur lesion ..................................... .................. 1,544.67 3 510.00 .................. 102.00 

27356 ....... Remove femur lesion/graft ............................ .................. 1,544.67 4 630.00 .................. 126.00 

27357 ....... Remove femur lesion/graft ............................ .................. 1,544.67 5 717.00 .................. 143.40 

27358 ....... Remove femur lesion/fixation ........................ .................. 1,544.67 5 717.00 .................. 143.40 

27360 ....... Partial removal, leg bone(s) .......................... .................. 1,544.67 5 717.00 .................. 143.40 

27372 ....... Removal of foreign body ............................... .................. 1,233.39 7 995.00 .................. 199.00 

27380 ....... Repair of kneecap tendon ............................. .................. 1,282.87 1 333.00 .................. 66.60 

27381 ....... Repair/graft kneecap tendon ......................... .................. 1,282.87 3 510.00 .................. 102.00 

27385 ....... Repair of thigh muscle ................................... .................. 1,282.87 3 510.00 .................. 102.00 

27386 ....... Repair/graft of thigh muscle .......................... .................. 1,282.87 3 510.00 .................. 102.00 

27390 ....... Incision of thigh tendon ................................. .................. 1,282.87 1 333.00 .................. 66.60 

27391 ....... Incision of thigh tendons ................................ .................. 1,282.87 2 446.00 .................. 89.20 

27392 ....... Incision of thigh tendons ................................ .................. 1,282.87 3 510.00 .................. 102.00 

27393 ....... Lengthening of thigh tendon .......................... .................. 1,544.67 2 446.00 .................. 89.20 

27394 ....... Lengthening of thigh tendons ........................ .................. 1,544.67 3 510.00 .................. 102.00 

27395 ....... Lengthening of thigh tendons ........................ .................. 2,525.68 3 510.00 .................. 102.00 

27396 ....... Transplant of thigh tendon ............................. .................. 1,544.67 3 510.00 .................. 102.00

27397 ....... Transplants of thigh tendons ......................... .................. 2,525.68 3 510.00 .................. 102.00 

27400 ....... Revise thigh muscles/tendons ....................... .................. 2,525.68 3 510.00 .................. 102.00 

27403 ....... Repair of knee cartilage ................................ .................. 1,544.67 4 630.00 .................. 126.00 

27405 ....... Repair of knee ligament ................................ .................. 2,525.68 4 630.00 .................. 126.00

27407 ....... Repair of knee ligament ................................ .................. 4,092.54 4 630.00 .................. 126.00

27409 ....... Repair of knee ligaments ............................... .................. 2,525.68 4 630.00 .................. 126.00

27418 ....... Repair degenerated kneecap ........................ .................. 2,525.68 3 510.00 .................. 102.00 

27420 ....... Revision of unstable kneecap ....................... .................. 2,525.68 3 510.00 .................. 102.00 

27422 ....... Revision of unstable kneecap ....................... .................. 2,525.68 7 995.00 .................. 199.00 

27424 ....... Revision/removal of kneecap ........................ .................. 2,525.68 3 510.00 .................. 102.00 

27425 ....... Lat retinacular release open .......................... .................. 1,544.67 7 995.00 .................. 199.00 

27427 ....... Reconstruction, knee ..................................... .................. 2,525.68 3 510.00 .................. 102.00 

27428 ....... Reconstruction, knee ..................................... .................. 4,092.54 4 630.00 .................. 126.00 

27429 ....... Reconstruction, knee ..................................... .................. 4,092.54 4 630.00 .................. 126.00 

27430 ....... Revision of thigh muscles .............................. .................. 2,525.68 4 630.00 .................. 126.00

27435 ....... Incision of knee joint ...................................... .................. 2,525.68 4 630.00 .................. 126.00 


cprice-sewell on PRODPC62 with RULES2
68258 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

27437 ....... Revise kneecap ............................................. .................. 2,056.14 4 630.00 .................. 126.00 

27438 ....... Revise kneecap with implant ......................... .................. 2,915.91 5 717.00 .................. 143.40 

27441 ....... Revision of knee joint .................................... .................. 2,056.14 5 717.00 .................. 143.40 

27442 ....... Revision of knee joint .................................... .................. 2,056.14 5 717.00 .................. 143.40 

27443 ....... Revision of knee joint .................................... .................. 2,056.14 5 717.00 .................. 143.40 

27496 ....... Decompression of thigh/knee ........................ .................. 1,282.87 5 717.00 .................. 143.40 

27497 ....... Decompression of thigh/knee ........................ .................. 1,282.87 3 510.00 .................. 102.00 

27498 ....... Decompression of thigh/knee ........................ .................. 1,282.87 3 510.00 .................. 102.00 

27499 ....... Decompression of thigh/knee ........................ .................. 1,282.87 3 510.00 .................. 102.00 

27500 ....... Treatment of thigh fracture ............................ .................. 103.62 1 103.62 Y .............. 20.72 

27501 ....... Treatment of thigh fracture ............................ .................. 103.62 2 103.62 Y .............. 20.72 

27502 ....... Treatment of thigh fracture ............................ .................. 103.62 2 103.62 Y .............. 20.72 

27503 ....... Treatment of thigh fracture ............................ .................. 103.62 3 103.62 Y .............. 20.72 

27508 ....... Treatment of thigh fracture ............................ .................. 103.62 1 103.62 Y .............. 20.72 

27509 ....... Treatment of thigh fracture ............................ .................. 1,569.06 3 510.00 .................. 102.00

27510 ....... Treatment of thigh fracture ............................ .................. 103.62 1 103.62 Y .............. 20.72 

27516 ....... Treat thigh fx growth plate ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27517 ....... Treat thigh fx growth plate ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27520 ....... Treat kneecap fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72 

27530 ....... Treat knee fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 

27532 ....... Treat knee fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72 

27538 ....... Treat knee fracture(s) .................................... .................. 103.62 1 103.62 Y .............. 20.72 

27550 ....... Treat knee dislocation ................................... .................. 103.62 1 103.62 Y .............. 20.72 

27552 ....... Treat knee dislocation ................................... .................. 897.11 1 333.00 .................. 66.60 

27560 ....... Treat kneecap dislocation .............................. .................. 103.62 1 103.62 Y .............. 20.72 

27562 ....... Treat kneecap dislocation .............................. .................. 897.11 1 333.00 .................. 66.60 

27566 ....... Treat kneecap dislocation .............................. .................. 2,307.40 2 446.00 .................. 89.20 

27570 ....... Fixation of knee joint ..................................... .................. 897.11 1 333.00 .................. 66.60 

27594 ....... Amputation follow-up surgery ........................ .................. 1,282.87 3 510.00 .................. 102.00 

27600 ....... Decompression of lower leg .......................... .................. 1,282.87 3 510.00 .................. 102.00 

27601 ....... Decompression of lower leg .......................... .................. 1,282.87 3 510.00 .................. 102.00 

27602 ....... Decompression of lower leg .......................... .................. 1,282.87 3 510.00 .................. 102.00 

27603 ....... Drain lower leg lesion .................................... .................. 1,076.22 2 446.00 .................. 89.20 

27604 ....... Drain lower leg bursa .................................... .................. 1,282.87 2 446.00 .................. 89.20 

27605 ....... Incision of achilles tendon ............................. .................. 1,255.56 1 333.00 .................. 66.60

27606 ....... Incision of achilles tendon ............................. .................. 1,282.87 1 333.00 .................. 66.60

27607 ....... Treat lower leg bone lesion ........................... .................. 1,282.87 2 446.00 .................. 89.20 

27610 ....... Explore/treat ankle joint ................................. .................. 1,544.67 2 446.00 .................. 89.20 

27612 ....... Exploration of ankle joint ............................... .................. 1,544.67 3 510.00 .................. 102.00 

27614 ....... Biopsy lower leg soft tissue ........................... .................. 1,233.39 2 446.00 .................. 89.20 

27615 ....... Remove tumor, lower leg .............................. .................. 1,544.67 3 510.00 .................. 102.00 

27618 ....... Remove lower leg lesion ............................... .................. 928.31 2 446.00 .................. 89.20 

27619 ....... Remove lower leg lesion ............................... .................. 1,233.39 3 510.00 .................. 102.00 

27620 ....... Explore/treat ankle joint ................................. .................. 1,544.67 4 630.00 .................. 126.00 

27625 ....... Remove ankle joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00

27626 ....... Remove ankle joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00

27630 ....... Removal of tendon lesion .............................. .................. 1,282.87 3 510.00 .................. 102.00 

27635 ....... Remove lower leg bone lesion ...................... .................. 1,544.67 3 510.00 .................. 102.00 

27637 ....... Remove/graft leg bone lesion ........................ .................. 1,544.67 3 510.00 .................. 102.00 

27638 ....... Remove/graft leg bone lesion ........................ .................. 1,544.67 3 510.00 .................. 102.00 

27640 ....... Partial removal of tibia ................................... .................. 2,525.68 2 446.00 .................. 89.20 

27641 ....... Partial removal of fibula ................................. .................. 1,544.67 2 446.00 .................. 89.20 

27647 ....... Extensive ankle/heel surgery ......................... .................. 2,525.68 3 510.00 .................. 102.00 

27650 ....... Repair achilles tendon ................................... .................. 2,525.68 3 510.00 .................. 102.00 

27652 ....... Repair/graft achilles tendon ........................... .................. 4,092.54 3 510.00 .................. 102.00

27654 ....... Repair of achilles tendon ............................... .................. 2,525.68 3 510.00 .................. 102.00 

27656 ....... Repair leg fascia defect ................................. .................. 1,282.87 2 446.00 .................. 89.20 

27658 ....... Repair of leg tendon, each ............................ .................. 1,282.87 1 333.00 .................. 66.60 

27659 ....... Repair of leg tendon, each ............................ .................. 1,282.87 2 446.00 .................. 89.20 

27664 ....... Repair of leg tendon, each ............................ .................. 1,282.87 2 446.00 .................. 89.20 

27665 ....... Repair of leg tendon, each ............................ .................. 1,544.67 2 446.00 .................. 89.20 

27675 ....... Repair lower leg tendons ............................... .................. 1,282.87 2 446.00 .................. 89.20 

27676 ....... Repair lower leg tendons ............................... .................. 1,544.67 3 510.00 .................. 102.00

27680 ....... Release of lower leg tendon .......................... .................. 1,544.67 3 510.00 .................. 102.00 

27681 ....... Release of lower leg tendons ........................ .................. 1,544.67 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68259 

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—Continued 

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 

($) 

27685 ....... Revision of lower leg tendon ......................... .................. 1,544.67 3 510.00 .................. 102.00 

27686 ....... Revise lower leg tendons .............................. .................. 1,544.67 3 510.00 .................. 102.00 

27687 ....... Revision of calf tendon .................................. .................. 1,544.67 3 510.00 .................. 102.00 

27690 ....... Revise lower leg tendon ................................ .................. 2,525.68 4 630.00 .................. 126.00

27691 ....... Revise lower leg tendon ................................ .................. 2,525.68 4 630.00 .................. 126.00

27692 ....... Revise additional leg tendon ......................... .................. 2,525.68 3 510.00 .................. 102.00 

27695 ....... Repair of ankle ligament ................................ .................. 1,544.67 2 446.00 .................. 89.20

27696 ....... Repair of ankle ligaments .............................. .................. 1,544.67 2 446.00 .................. 89.20 

27698 ....... Repair of ankle ligament ................................ .................. 1,544.67 2 446.00 .................. 89.20

27700 ....... Revision of ankle joint ................................... .................. 2,056.14 5 717.00 .................. 143.40 

27704 ....... Removal of ankle implant .............................. .................. 1,282.87 2 446.00 .................. 89.20 

27705 ....... Incision of tibia ............................................... .................. 2,525.68 2 446.00 .................. 89.20 

27707 ....... Incision of fibula ............................................. .................. 1,282.87 2 446.00 .................. 89.20 

27709 ....... Incision of tibia & fibula ................................. .................. 1,544.67 2 446.00 .................. 89.20 

27730 ....... Repair of tibia epiphysis ................................ .................. 1,544.67 2 446.00 .................. 89.20 

27732 ....... Repair of fibula epiphysis .............................. .................. 1,544.67 2 446.00 .................. 89.20

27734 ....... Repair lower leg epiphyses ........................... .................. 1,544.67 2 446.00 .................. 89.20 

27740 ....... Repair of leg epiphyses ................................. .................. 1,544.67 2 446.00 .................. 89.20

27742 ....... Repair of leg epiphyses ................................. .................. 2,525.68 2 446.00 .................. 89.20

27745 ....... Reinforce tibia ................................................ .................. 4,092.54 3 510.00 .................. 102.00 

27750 ....... Treatment of tibia fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27752 ....... Treatment of tibia fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27756 ....... Treatment of tibia fracture ............................. .................. 1,569.06 3 510.00 .................. 102.00 

27758 ....... Treatment of tibia fracture ............................. .................. 2,307.40 4 630.00 .................. 126.00 

27759 ....... Treatment of tibia fracture ............................. .................. 3,517.03 4 630.00 .................. 126.00 

27760 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27762 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27766 ....... Treatment of ankle fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00 

27780 ....... Treatment of fibula fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27781 ....... Treatment of fibula fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27784 ....... Treatment of fibula fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00

27786 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27788 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27792 ....... Treatment of ankle fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00 

27808 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27810 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27814 ....... Treatment of ankle fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00 

27816 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27818 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72 

27822 ....... Treatment of ankle fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00 

27823 ....... Treatment of ankle fracture ........................... .................. 3,517.03 3 510.00 .................. 102.00 

27824 ....... Treat lower leg fracture ................................. .................. 103.62 1 103.62 Y .............. 20.72 

27825 ....... Treat lower leg fracture ................................. .................. 103.62 2 103.62 Y .............. 20.72 

27826 ....... Treat lower leg fracture ................................. .................. 2,307.40 3 510.00 .................. 102.00 

27827 ....... Treat lower leg fracture ................................. .................. 3,517.03 3 510.00 .................. 102.00 

27828 ....... Treat lower leg fracture ................................. .................. 3,517.03 4 630.00 .................. 126.00 

27829 ....... Treat lower leg joint ....................................... .................. 2,307.40 2 446.00 .................. 89.20 

27830 ....... Treat lower leg dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27831 ....... Treat lower leg dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72 

27832 ....... Treat lower leg dislocation ............................. .................. 2,307.40 2 446.00 .................. 89.20

27840 ....... Treat ankle dislocation ................................... .................. 103.62 1 103.62 Y .............. 20.72 

27842 ....... Treat ankle dislocation ................................... .................. 897.11 1 333.00 .................. 66.60

27846 ....... Treat ankle dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00 

27848 ....... Treat ankle dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00 

27860 ....... Fixation of ankle joint ..................................... .................. 897.11 1 333.00 .................. 66.60 

27870 ....... Fusion of ankle joint, open ............................ .................. 4,092.54 4 630.00 .................. 126.00

27871 ....... Fusion of tibiofibular joint ............................... .................. 4,092.54 4 630.00 .................. 126.00 

27884 ....... Amputation follow-up surgery ........................ .................. 1,282.87 3 510.00 .................. 102.00 

27889 ....... Amputation of foot at ankle ........................... .................. 1,544.67 3 510.00 .................. 102.00 

27892 ....... Decompression of leg .................................... .................. 1,282.87 3 510.00 .................. 102.00 

27893 ....... Decompression of leg .................................... .................. 1,282.87 3 510.00 .................. 102.00 

27894 ....... Decompression of leg .................................... .................. 1,282.87 3 510.00 .................. 102.00 

28002 ....... Treatment of foot infection ............................. .................. 1,282.87 3 510.00 .................. 102.00 

28003 ....... Treatment of foot infection ............................. .................. 1,282.87 3 510.00 .................. 102.00 

28005 ....... Treat foot bone lesion .................................... .................. 1,255.56 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
68260 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

28008 ....... Incision of foot fascia ..................................... .................. 1,255.56 3 510.00 .................. 102.00 

28011 ....... Incision of toe tendons .................................. .................. 1,255.56 3 510.00 .................. 102.00 

28020 ....... Exploration of foot joint .................................. .................. 1,255.56 2 446.00 .................. 89.20 

28022 ....... Exploration of foot joint .................................. .................. 1,255.56 2 446.00 .................. 89.20 

28024 ....... Exploration of toe joint ................................... .................. 1,255.56 2 446.00 .................. 89.20 

28030 ....... Removal of foot nerve ................................... D .............. .................... 4 630.00 .................. ....................

28035 ....... Decompression of tibia nerve ........................ .................. 1,097.20 4 630.00 .................. 126.00 

28043 ....... Excision of foot lesion .................................... .................. 1,233.39 2 446.00 .................. 89.20 

28045 ....... Excision of foot lesion .................................... .................. 1,255.56 3 510.00 .................. 102.00 

28046 ....... Resection of tumor, foot ................................ .................. 1,255.56 3 510.00 .................. 102.00 

28050 ....... Biopsy of foot joint lining ............................... .................. 1,255.56 2 446.00 .................. 89.20 

28052 ....... Biopsy of foot joint lining ............................... .................. 1,255.56 2 446.00 .................. 89.20 

28054 ....... Biopsy of toe joint lining ................................ .................. 1,255.56 2 446.00 .................. 89.20 

28055 ....... Neurectomy, foot ........................................... A .............. 1,097.20 4 630.00 .................. 126.00 

28060 ....... Partial removal, foot fascia ............................ .................. 1,255.56 2 446.00 .................. 89.20

28062 ....... Removal of foot fascia ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28070 ....... Removal of foot joint lining ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28072 ....... Removal of foot joint lining ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28080 ....... Removal of foot lesion ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28086 ....... Excise foot tendon sheath ............................. .................. 1,255.56 2 446.00 .................. 89.20 

28088 ....... Excise foot tendon sheath ............................. .................. 1,255.56 2 446.00 .................. 89.20 

28090 ....... Removal of foot lesion ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28092 ....... Removal of toe lesions .................................. .................. 1,255.56 3 510.00 .................. 102.00 

28100 ....... Removal of ankle/heel lesion ........................ .................. 1,255.56 2 446.00 .................. 89.20 

28102 ....... Remove/graft foot lesion ................................ .................. 2,511.33 3 510.00 .................. 102.00 

28103 ....... Remove/graft foot lesion ................................ .................. 2,511.33 3 510.00 .................. 102.00 

28104 ....... Removal of foot lesion ................................... .................. 1,255.56 2 446.00 .................. 89.20 

28106 ....... Remove/graft foot lesion ................................ .................. 2,511.33 3 510.00 .................. 102.00 

28107 ....... Remove/graft foot lesion ................................ .................. 2,511.33 3 510.00 .................. 102.00 

28108 ....... Removal of toe lesions .................................. .................. 1,255.56 2 446.00 .................. 89.20

28110 ....... Part removal of metatarsal ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28111 ....... Part removal of metatarsal ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28112 ....... Part removal of metatarsal ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28113 ....... Part removal of metatarsal ............................ .................. 1,255.56 3 510.00 .................. 102.00 

28114 ....... Removal of metatarsal heads ........................ .................. 1,255.56 3 510.00 .................. 102.00 

28116 ....... Revision of foot .............................................. .................. 1,255.56 3 510.00 .................. 102.00 

28118 ....... Removal of heel bone ................................... .................. 1,255.56 4 630.00 .................. 126.00

28119 ....... Removal of heel spur .................................... .................. 1,255.56 4 630.00 .................. 126.00 

28120 ....... Part removal of ankle/heel ............................. .................. 1,255.56 7 995.00 .................. 199.00

28122 ....... Partial removal of foot bone .......................... .................. 1,255.56 3 510.00 .................. 102.00 

28126 ....... Partial removal of toe .................................... .................. 1,255.56 3 510.00 .................. 102.00 

28130 ....... Removal of ankle bone .................................. .................. 1,255.56 3 510.00 .................. 102.00

28140 ....... Removal of metatarsal ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28150 ....... Removal of toe .............................................. .................. 1,255.56 3 510.00 .................. 102.00 

28153 ....... Partial removal of toe .................................... .................. 1,255.56 3 510.00 .................. 102.00 

28160 ....... Partial removal of toe .................................... .................. 1,255.56 3 510.00 .................. 102.00 

28171 ....... Extensive foot surgery ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28173 ....... Extensive foot surgery ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28175 ....... Extensive foot surgery ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28192 ....... Removal of foot foreign body ........................ .................. 928.31 2 446.00 .................. 89.20 

28193 ....... Removal of foot foreign body ........................ .................. 418.49 4 418.49 Y .............. 83.70 

28200 ....... Repair of foot tendon ..................................... .................. 1,255.56 3 510.00 .................. 102.00 

28202 ....... Repair/graft of foot tendon ............................. .................. 1,255.56 3 510.00 .................. 102.00 

28208 ....... Repair of foot tendon ..................................... .................. 1,255.56 3 510.00 .................. 102.00 

28210 ....... Repair/graft of foot tendon ............................. .................. 2,511.33 3 510.00 .................. 102.00 

28222 ....... Release of foot tendons ................................ .................. 1,255.56 1 333.00 .................. 66.60 

28225 ....... Release of foot tendon .................................. .................. 1,255.56 1 333.00 .................. 66.60

28226 ....... Release of foot tendons ................................ .................. 1,255.56 1 333.00 .................. 66.60 

28234 ....... Incision of foot tendon ................................... .................. 1,255.56 2 446.00 .................. 89.20 

28238 ....... Revision of foot tendon .................................. .................. 2,511.33 3 510.00 .................. 102.00 

28240 ....... Release of big toe ......................................... .................. 1,255.56 2 446.00 .................. 89.20 

28250 ....... Revision of foot fascia ................................... .................. 1,255.56 3 510.00 .................. 102.00 

28260 ....... Release of midfoot joint ................................. .................. 1,255.56 3 510.00 .................. 102.00 

28261 ....... Revision of foot tendon .................................. .................. 1,255.56 3 510.00 .................. 102.00 

28262 ....... Revision of foot and ankle ............................. .................. 1,255.56 4 630.00 .................. 126.00


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68261 

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—Continued 

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 

($) 

28264 ....... Release of midfoot joint ................................. .................. 2,511.33 1 333.00 .................. 66.60 

28270 ....... Release of foot contracture ........................... .................. 1,255.56 3 510.00 .................. 102.00 

28280 ....... Fusion of toes ................................................ .................. 1,255.56 2 446.00 .................. 89.20 

28285 ....... Repair of hammertoe ..................................... .................. 1,255.56 3 510.00 .................. 102.00 

28286 ....... Repair of hammertoe ..................................... .................. 1,255.56 4 630.00 .................. 126.00 

28288 ....... Partial removal of foot bone .......................... .................. 1,255.56 3 510.00 .................. 102.00 

28289 ....... Repair hallux rigidus ...................................... .................. 1,255.56 3 510.00 .................. 102.00 

28290 ....... Correction of bunion ...................................... .................. 1,735.54 2 446.00 .................. 89.20 

28292 ....... Correction of bunion ...................................... .................. 1,735.54 2 446.00 .................. 89.20 

28293 ....... Correction of bunion ...................................... .................. 1,735.54 3 510.00 .................. 102.00 

28294 ....... Correction of bunion ...................................... .................. 1,735.54 3 510.00 .................. 102.00 

28296 ....... Correction of bunion ...................................... .................. 1,735.54 3 510.00 .................. 102.00 

28297 ....... Correction of bunion ...................................... .................. 1,735.54 3 510.00 .................. 102.00 

28298 ....... Correction of bunion ...................................... .................. 1,735.54 3 510.00 .................. 102.00 

28299 ....... Correction of bunion ...................................... .................. 1,735.54 5 717.00 .................. 143.40 

28300 ....... Incision of heel bone ..................................... .................. 2,511.33 2 446.00 .................. 89.20 

28302 ....... Incision of ankle bone .................................... .................. 1,255.56 2 446.00 .................. 89.20 

28304 ....... Incision of midfoot bones ............................... .................. 2,511.33 2 446.00 .................. 89.20

28305 ....... Incise/graft midfoot bones ............................. .................. 2,511.33 3 510.00 .................. 102.00

28306 ....... Incision of metatarsal ..................................... .................. 1,255.56 4 630.00 .................. 126.00 

28307 ....... Incision of metatarsal ..................................... .................. 1,255.56 4 630.00 .................. 126.00 

28308 ....... Incision of metatarsal ..................................... .................. 1,255.56 2 446.00 .................. 89.20 

28309 ....... Incision of metatarsals ................................... .................. 2,511.33 4 630.00 .................. 126.00 

28310 ....... Revision of big toe ......................................... .................. 1,255.56 3 510.00 .................. 102.00 

28312 ....... Revision of toe ............................................... .................. 1,255.56 3 510.00 .................. 102.00 

28313 ....... Repair deformity of toe .................................. .................. 1,255.56 2 446.00 .................. 89.20 

28315 ....... Removal of sesamoid bone ........................... .................. 1,255.56 4 630.00 .................. 126.00 

28320 ....... Repair of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28322 ....... Repair of metatarsals .................................... .................. 2,511.33 4 630.00 .................. 126.00 

28340 ....... Resect enlarged toe tissue ............................ .................. 1,255.56 4 630.00 .................. 126.00 

28341 ....... Resect enlarged toe ...................................... .................. 1,255.56 4 630.00 .................. 126.00 

28344 ....... Repair extra toe(s) ......................................... .................. 1,255.56 4 630.00 .................. 126.00 

28345 ....... Repair webbed toe(s) .................................... .................. 1,255.56 4 630.00 .................. 126.00 

28400 ....... Treatment of heel fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72 

28405 ....... Treatment of heel fracture ............................. .................. 103.62 2 103.62 Y .............. 20.72 

28406 ....... Treatment of heel fracture ............................. .................. 1,569.06 2 446.00 .................. 89.20 

28415 ....... Treat heel fracture ......................................... .................. 2,307.40 3 510.00 .................. 102.00 

28420 ....... Treat/graft heel fracture ................................. .................. 2,307.40 4 630.00 .................. 126.00 

28435 ....... Treatment of ankle fracture ........................... .................. 103.62 2 103.62 Y .............. 20.72 

28436 ....... Treatment of ankle fracture ........................... .................. 1,569.06 2 446.00 .................. 89.20 

28445 ....... Treat ankle fracture ....................................... .................. 2,307.40 3 510.00 .................. 102.00 

28456 ....... Treat midfoot fracture .................................... .................. 1,569.06 2 446.00 .................. 89.20 

28465 ....... Treat midfoot fracture, each .......................... .................. 2,307.40 3 510.00 .................. 102.00 

28476 ....... Treat metatarsal fracture ............................... .................. 1,569.06 2 446.00 .................. 89.20

28485 ....... Treat metatarsal fracture ............................... .................. 2,307.40 4 630.00 .................. 126.00 

28496 ....... Treat big toe fracture ..................................... .................. 1,569.06 2 446.00 .................. 89.20 

28505 ....... Treat big toe fracture ..................................... .................. 2,307.40 3 510.00 .................. 102.00 

28525 ....... Treat toe fracture ........................................... .................. 2,307.40 3 510.00 .................. 102.00 

28531 ....... Treat sesamoid bone fracture ....................... .................. 2,307.40 3 510.00 .................. 102.00 

28545 ....... Treat foot dislocation ..................................... .................. 1,569.06 1 333.00 .................. 66.60 

28546 ....... Treat foot dislocation ..................................... .................. 1,569.06 2 446.00 .................. 89.20 

28555 ....... Repair foot dislocation ................................... .................. 2,307.40 2 446.00 .................. 89.20 

28575 ....... Treat foot dislocation ..................................... .................. 103.62 1 103.62 Y .............. 20.72 

28576 ....... Treat foot dislocation ..................................... .................. 1,569.06 3 510.00 .................. 102.00 

28585 ....... Repair foot dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00 

28605 ....... Treat foot dislocation ..................................... .................. 103.62 1 103.62 Y .............. 20.72 

28606 ....... Treat foot dislocation ..................................... .................. 1,569.06 2 446.00 .................. 89.20 

28615 ....... Repair foot dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00 

28635 ....... Treat toe dislocation ...................................... .................. 897.11 1 333.00 .................. 66.60 

28636 ....... Treat toe dislocation ...................................... .................. 1,569.06 3 510.00 .................. 102.00 

28645 ....... Repair toe dislocation .................................... .................. 2,307.40 3 510.00 .................. 102.00 

28665 ....... Treat toe dislocation ...................................... .................. 897.11 1 333.00 .................. 66.60 

28666 ....... Treat toe dislocation ...................................... .................. 1,569.06 3 510.00 .................. 102.00 

28675 ....... Repair of toe dislocation ................................ .................. 2,307.40 3 510.00 .................. 102.00 

28705 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 


cprice-sewell on PRODPC62 with RULES2
68262 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

28715 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28725 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28730 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28735 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28737 ....... Revision of foot bones ................................... .................. 2,511.33 5 717.00 .................. 143.40 

28740 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00 

28750 ....... Fusion of big toe joint .................................... .................. 2,511.33 4 630.00 .................. 126.00 

28755 ....... Fusion of big toe joint .................................... .................. 1,255.56 4 630.00 .................. 126.00 

28760 ....... Fusion of big toe joint .................................... .................. 2,511.33 4 630.00 .................. 126.00 

28810 ....... Amputation toe & metatarsal ......................... .................. 1,255.56 2 446.00 .................. 89.20 

28820 ....... Amputation of toe .......................................... .................. 1,255.56 2 446.00 .................. 89.20 

28825 ....... Partial amputation of toe ............................... .................. 1,255.56 2 446.00 .................. 89.20

29800 ....... Jaw arthroscopy/surgery ................................ .................. 1,759.49 3 510.00 .................. 102.00

29804 ....... Jaw arthroscopy/surgery ................................ .................. 1,759.49 3 510.00 .................. 102.00

29805 ....... Shoulder arthroscopy, dx ............................... .................. 1,759.49 3 510.00 .................. 102.00

29806 ....... Shoulder arthroscopy/surgery ........................ .................. 2,796.96 3 510.00 .................. 102.00 

29807 ....... Shoulder arthroscopy/surgery ........................ .................. 2,796.96 3 510.00 .................. 102.00 

29819 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29820 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29821 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29822 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29823 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29824 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 5 717.00 .................. 143.40 

29825 ....... Shoulder arthroscopy/surgery ........................ .................. 1,759.49 3 510.00 .................. 102.00 

29826 ....... Shoulder arthroscopy/surgery ........................ .................. 2,796.96 3 510.00 .................. 102.00 

29827 ....... Arthroscop rotator cuff repr ........................... .................. 2,796.96 5 717.00 .................. 143.40

29830 ....... Elbow arthroscopy ......................................... .................. 1,759.49 3 510.00 .................. 102.00 

29834 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29835 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29836 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29837 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29838 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29840 ....... Wrist arthroscopy ........................................... .................. 1,759.49 3 510.00 .................. 102.00 

29843 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00

29844 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00

29845 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00

29846 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00

29847 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00

29848 ....... Wrist endoscopy/surgery ............................... .................. 1,759.49 9 1,339.00 .................. 267.80 

29850 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29851 ....... Knee arthroscopy/surgery .............................. .................. 2,796.96 4 630.00 .................. 126.00 

29855 ....... Tibial arthroscopy/surgery ............................. .................. 2,796.96 4 630.00 .................. 126.00

29856 ....... Tibial arthroscopy/surgery ............................. .................. 1,759.49 4 630.00 .................. 126.00

29860 ....... Hip arthroscopy, dx ........................................ .................. 1,759.49 4 630.00 .................. 126.00 

29861 ....... Hip arthroscopy/surgery ................................. .................. 1,759.49 4 630.00 .................. 126.00 

29862 ....... Hip arthroscopy/surgery ................................. .................. 2,796.96 9 1,339.00 .................. 267.80 

29863 ....... Hip arthroscopy/surgery ................................. .................. 2,796.96 4 630.00 .................. 126.00 

29870 ....... Knee arthroscopy, dx ..................................... .................. 1,759.49 3 510.00 .................. 102.00 

29871 ....... Knee arthroscopy/drainage ............................ .................. 1,759.49 3 510.00 .................. 102.00 

29873 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29874 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29875 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29876 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29877 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29879 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29880 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29881 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00 

29882 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29883 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29884 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29885 ....... Knee arthroscopy/surgery .............................. .................. 2,796.96 3 510.00 .................. 102.00 

29886 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29887 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00 

29888 ....... Knee arthroscopy/surgery .............................. .................. 2,796.96 3 510.00 .................. 102.00 

29889 ....... Knee arthroscopy/surgery .............................. .................. 2,796.96 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68263 

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—Continued 

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 

($) 

29891 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29892 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29893 ....... Scope, plantar fasciotomy ............................. .................. 1,255.56 9 1,255.56 Y .............. 251.11 

29894 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29895 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29897 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29898 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00 

29899 ....... Ankle arthroscopy/surgery ............................. .................. 2,796.96 3 510.00 .................. 102.00 

29900 ....... Mcp joint arthroscopy, dx .............................. .................. 992.95 3 510.00 .................. 102.00 

29901 ....... Mcp joint arthroscopy, surg ........................... .................. 992.95 3 510.00 .................. 102.00 

29902 ....... Mcp joint arthroscopy, surg ........................... .................. 992.95 3 510.00 .................. 102.00 

30115 ....... Removal of nose polyp(s) .............................. .................. 1,009.71 2 446.00 .................. 89.20 

30117 ....... Removal of intranasal lesion ......................... .................. 1,009.71 3 510.00 .................. 102.00 

30118 ....... Removal of intranasal lesion ......................... .................. 1,434.04 3 510.00 .................. 102.00 

30120 ....... Revision of nose ............................................ .................. 1,009.71 1 333.00 .................. 66.60 

30125 ....... Removal of nose lesion ................................. .................. 2,348.02 2 446.00 .................. 89.20 

30130 ....... Excise inferior turbinate ................................. .................. 1,009.71 3 510.00 .................. 102.00 

30140 ....... Resect inferior turbinate ................................ .................. 1,434.04 2 446.00 .................. 89.20 

30150 ....... Partial removal of nose .................................. .................. 2,348.02 3 510.00 .................. 102.00 

30160 ....... Removal of nose ............................................ .................. 2,348.02 4 630.00 .................. 126.00 

30220 ....... Insert nasal septal button .............................. .................. 464.15 3 464.15 Y .............. 92.83 

30310 ....... Remove nasal foreign body ........................... .................. 1,009.71 1 333.00 .................. 66.60 

30320 ....... Remove nasal foreign body ........................... .................. 1,009.71 2 446.00 .................. 89.20 

30400 ....... Reconstruction of nose .................................. .................. 2,348.02 4 630.00 .................. 126.00 

30410 ....... Reconstruction of nose .................................. .................. 2,348.02 5 717.00 .................. 143.40 

30420 ....... Reconstruction of nose .................................. .................. 2,348.02 5 717.00 .................. 143.40 

30430 ....... Revision of nose ............................................ .................. 1,434.04 3 510.00 .................. 102.00 

30435 ....... Revision of nose ............................................ .................. 2,348.02 5 717.00 .................. 143.40 

30450 ....... Revision of nose ............................................ .................. 2,348.02 7 995.00 .................. 199.00 

30460 ....... Revision of nose ............................................ .................. 2,348.02 7 995.00 .................. 199.00 

30462 ....... Revision of nose ............................................ .................. 2,348.02 9 1,339.00 .................. 267.80 

30465 ....... Repair nasal stenosis .................................... .................. 2,348.02 9 1,339.00 .................. 267.80 

30520 ....... Repair of nasal septum ................................. .................. 1,434.04 4 630.00 .................. 126.00

30540 ....... Repair nasal defect ........................................ .................. 2,348.02 5 717.00 .................. 143.40 

30545 ....... Repair nasal defect ........................................ .................. 2,348.02 5 717.00 .................. 143.40 

30560 ....... Release of nasal adhesions .......................... .................. 150.72 2 150.72 Y .............. 30.14 

30580 ....... Repair upper jaw fistula ................................. .................. 2,348.02 4 630.00 .................. 126.00 

30600 ....... Repair mouth/nose fistula .............................. .................. 2,348.02 4 630.00 .................. 126.00

30620 ....... Intranasal reconstruction ............................... .................. 2,348.02 7 995.00 .................. 199.00 

30630 ....... Repair nasal septum defect ........................... .................. 1,434.04 7 995.00 .................. 199.00 

30801 ....... Ablate inf turbinate, superf ............................ .................. 464.15 1 333.00 .................. 66.60 

30802 ....... Cauterization, inner nose ............................... .................. 464.15 1 333.00 .................. 66.60 

30903 ....... Control of nosebleed ..................................... .................. 72.48 1 72.48 Y .............. 14.50 

30905 ....... Control of nosebleed ..................................... .................. 72.48 1 72.48 Y .............. 14.50 

30906 ....... Repeat control of nosebleed ......................... .................. 72.48 1 72.48 Y .............. 14.50 

30915 ....... Ligation, nasal sinus artery ............................ .................. 1,529.38 2 446.00 .................. 89.20

30920 ....... Ligation, upper jaw artery .............................. .................. 1,529.38 3 510.00 .................. 102.00 

30930 ....... Ther fx, nasal inf turbinate ............................. .................. 1,009.71 4 630.00 .................. 126.00 

31020 ....... Exploration, maxillary sinus ........................... .................. 1,434.04 2 446.00 .................. 89.20 

31030 ....... Exploration, maxillary sinus ........................... .................. 2,348.02 3 510.00 .................. 102.00

31032 ....... Explore sinus, remove polyps ....................... .................. 2,348.02 4 630.00 .................. 126.00 

31050 ....... Exploration, sphenoid sinus ........................... .................. 2,348.02 2 446.00 .................. 89.20 

31051 ....... Sphenoid sinus surgery ................................. .................. 2,348.02 4 630.00 .................. 126.00

31070 ....... Exploration of frontal sinus ............................ .................. 1,434.04 2 446.00 .................. 89.20

31075 ....... Exploration of frontal sinus ............................ .................. 2,348.02 4 630.00 .................. 126.00 

31080 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31081 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31084 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31085 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31086 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31087 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00 

31090 ....... Exploration of sinuses ................................... .................. 2,348.02 5 717.00 .................. 143.40 

31200 ....... Removal of ethmoid sinus ............................. .................. 2,348.02 2 446.00 .................. 89.20 

31201 ....... Removal of ethmoid sinus ............................. .................. 2,348.02 5 717.00 .................. 143.40 

31205 ....... Removal of ethmoid sinus ............................. .................. 2,348.02 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
68264 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

31233 ....... Nasal/sinus endoscopy, dx ............................ .................. 86.39 2 86.39 Y .............. 17.28 

31235 ....... Nasal/sinus endoscopy, dx ............................ .................. 909.28 1 333.00 .................. 66.60 

31237 ....... Nasal/sinus endoscopy, surg ......................... .................. 909.28 2 446.00 .................. 89.20 

31238 ....... Nasal/sinus endoscopy, surg ......................... .................. 909.28 1 333.00 .................. 66.60 

31239 ....... Nasal/sinus endoscopy, surg ......................... .................. 1,349.30 4 630.00 .................. 126.00 

31240 ....... Nasal/sinus endoscopy, surg ......................... .................. 909.28 2 446.00 .................. 89.20 

31254 ....... Revision of ethmoid sinus ............................. .................. 1,349.30 3 510.00 .................. 102.00 

31255 ....... Removal of ethmoid sinus ............................. .................. 1,349.30 5 717.00 .................. 143.40 

31256 ....... Exploration maxillary sinus ............................ .................. 1,349.30 3 510.00 .................. 102.00

31267 ....... Endoscopy, maxillary sinus ........................... .................. 1,349.30 3 510.00 .................. 102.00 

31276 ....... Sinus endoscopy, surgical ............................. .................. 1,349.30 3 510.00 .................. 102.00 

31287 ....... Nasal/sinus endoscopy, surg ......................... .................. 1,349.30 3 510.00 .................. 102.00 

31288 ....... Nasal/sinus endoscopy, surg ......................... .................. 1,349.30 3 510.00 .................. 102.00 

31300 ....... Removal of larynx lesion ............................... .................. 1,434.04 5 717.00 .................. 143.40

31320 ....... Diagnostic incision, larynx ............................. .................. 2,348.02 2 446.00 .................. 89.20

31400 ....... Revision of larynx .......................................... .................. 2,348.02 2 446.00 .................. 89.20 

31420 ....... Removal of epiglottis ..................................... .................. 2,348.02 2 446.00 .................. 89.20 

31510 ....... Laryngoscopy with biopsy ............................. .................. 909.28 2 446.00 .................. 89.20 

31511 ....... Remove foreign body, larynx ......................... .................. 86.39 2 86.39 Y .............. 17.28 

31512 ....... Removal of larynx lesion ............................... .................. 909.28 2 446.00 .................. 89.20 

31513 ....... Injection into vocal cord ................................. .................. 86.39 2 86.39 Y .............. 17.28 

31515 ....... Laryngoscopy for aspiration .......................... .................. 909.28 1 333.00 .................. 66.60 

31525 ....... Dx laryngoscopy excl nb ............................... .................. 909.28 1 333.00 .................. 66.60 

31526 ....... Dx laryngoscopy w/oper scope ..................... .................. 1,349.30 2 446.00 .................. 89.20 

31527 ....... Laryngoscopy for treatment ........................... .................. 1,349.30 1 333.00 .................. 66.60 

31528 ....... Laryngoscopy and dilation ............................. .................. 909.28 2 446.00 .................. 89.20 

31529 ....... Laryngoscopy and dilation ............................. .................. 909.28 2 446.00 .................. 89.20 

31530 ....... Laryngoscopy w/fb removal ........................... .................. 1,349.30 2 446.00 .................. 89.20 

31531 ....... Laryngoscopy w/fb & op scope ..................... .................. 1,349.30 3 510.00 .................. 102.00 

31535 ....... Laryngoscopy w/biopsy ................................. .................. 1,349.30 2 446.00 .................. 89.20 

31536 ....... Laryngoscopy w/bx & op scope .................... .................. 1,349.30 3 510.00 .................. 102.00 

31540 ....... Laryngoscopy w/exc of tumor ........................ .................. 1,349.30 3 510.00 .................. 102.00 

31541 ....... Larynscop w/tumr exc + scope ..................... .................. 1,349.30 4 630.00 .................. 126.00 

31545 ....... Remove vc lesion w/scope ............................ .................. 1,349.30 4 630.00 .................. 126.00 

31546 ....... Remove vc lesion scope/graft ....................... .................. 1,349.30 4 630.00 .................. 126.00 

31560 ....... Laryngoscop w/arytenoidectom ..................... .................. 1,349.30 5 717.00 .................. 143.40 

31561 ....... Larynscop, remve cart + scop ....................... .................. 1,349.30 5 717.00 .................. 143.40 

31570 ....... Laryngoscope w/vc inj ................................... .................. 909.28 2 446.00 .................. 89.20 

31571 ....... Laryngoscop w/vc inj + scope ....................... .................. 1,349.30 2 446.00 .................. 89.20 

31576 ....... Laryngoscopy with biopsy ............................. .................. 1,349.30 2 446.00 .................. 89.20 

31577 ....... Remove foreign body, larynx ......................... .................. 236.42 2 236.42 Y .............. 47.28 

31578 ....... Removal of larynx lesion ............................... .................. 1,349.30 2 446.00 .................. 89.20 

31580 ....... Revision of larynx .......................................... .................. 2,348.02 5 717.00 .................. 143.40 

31582 ....... Revision of larynx .......................................... .................. 2,348.02 5 717.00 .................. 143.40 

31588 ....... Revision of larynx .......................................... .................. 2,348.02 5 717.00 .................. 143.40 

31590 ....... Reinnervate larynx ......................................... .................. 2,348.02 5 717.00 .................. 143.40 

31595 ....... Larynx nerve surgery ..................................... .................. 2,348.02 2 446.00 .................. 89.20 

31603 ....... Incision of windpipe ....................................... .................. 464.15 1 333.00 .................. 66.60 

31611 ....... Surgery/speech prosthesis ............................ .................. 1,434.04 3 510.00 .................. 102.00 

31612 ....... Puncture/clear windpipe ................................ .................. 1,434.04 1 333.00 .................. 66.60 

31613 ....... Repair windpipe opening ............................... .................. 1,434.04 2 446.00 .................. 89.20 

31614 ....... Repair windpipe opening ............................... .................. 2,348.02 2 446.00 .................. 89.20 

31615 ....... Visualization of windpipe ............................... .................. 585.35 1 333.00 .................. 66.60 

31620 ....... Endobronchial us add-on ............................... A* ............. 1,984.52 1 333.00 .................. 66.60 

31622 ....... Dx bronchoscope/wash ................................. .................. 585.35 1 333.00 .................. 66.60 

31623 ....... Dx bronchoscope/brush ................................. .................. 585.35 2 446.00 .................. 89.20 

31624 ....... Dx bronchoscope/lavage ............................... .................. 585.35 2 446.00 .................. 89.20 

31625 ....... Bronchoscopy w/biopsy(s) ............................. .................. 585.35 2 446.00 .................. 89.20 

31628 ....... Bronchoscopy/lung bx, each ......................... .................. 585.35 2 446.00 .................. 89.20 

31629 ....... Bronchoscopy/needle bx, each ..................... .................. 585.35 2 446.00 .................. 89.20 

31630 ....... Bronchoscopy dilate/fx repr ........................... .................. 1,352.90 2 446.00 .................. 89.20 

31631 ....... Bronchoscopy, dilate w/stent ......................... .................. 1,352.90 2 446.00 .................. 89.20 

31635 ....... Bronchoscopy w/fb removal .......................... .................. 585.35 2 446.00 .................. 89.20 

31636 ....... Bronchoscopy, bronch stents ........................ .................. 1,352.90 2 446.00 .................. 89.20 

31637 ....... Bronchoscopy, stent add-on .......................... .................. 585.35 1 333.00 .................. 66.60 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68265 

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—Continued 

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 

($) 

31638 ....... Bronchoscopy, revise stent ........................... .................. 1,352.90 2 446.00 .................. 89.20 

31640 ....... Bronchoscopy w/tumor excise ....................... .................. 1,352.90 2 446.00 .................. 89.20 

31641 ....... Bronchoscopy, treat blockage ....................... .................. 1,352.90 2 446.00 .................. 89.20 

31643 ....... Diag bronchoscope/catheter .......................... .................. 585.35 2 446.00 .................. 89.20 

31645 ....... Bronchoscopy, clear airways ......................... .................. 585.35 1 333.00 .................. 66.60 

31646 ....... Bronchoscopy, reclear airway ....................... .................. 585.35 1 333.00 .................. 66.60 

31656 ....... Bronchoscopy, inj for x-ray ............................ .................. 585.35 1 333.00 .................. 66.60 

31700 ....... Insertion of airway catheter ........................... D .............. .................... 1 333.00 .................. ....................

31717 ....... Bronchial brush biopsy .................................. .................. 236.42 1 236.42 Y .............. 47.28 

31720 ....... Clearance of airways ..................................... .................. 47.32 1 47.32 Y .............. 9.46 

31730 ....... Intro, windpipe wire/tube ................................ .................. 236.42 1 236.42 Y .............. 47.28 

31750 ....... Repair of windpipe ......................................... .................. 2,348.02 5 717.00 .................. 143.40 

31755 ....... Repair of windpipe ......................................... .................. 2,348.02 2 446.00 .................. 89.20 

31820 ....... Closure of windpipe lesion ............................ .................. 1,009.71 1 333.00 .................. 66.60 

31825 ....... Repair of windpipe defect .............................. .................. 1,434.04 2 446.00 .................. 89.20 

31830 ....... Revise windpipe scar ..................................... .................. 1,434.04 2 446.00 .................. 89.20 

32000 ....... Drainage of chest .......................................... .................. 222.78 1 222.78 Y .............. 44.56 

32400 ....... Needle biopsy chest lining ............................. .................. 377.32 1 333.00 .................. 66.60 

32405 ....... Biopsy, lung or mediastinum ......................... .................. 377.32 1 333.00 .................. 66.60 

32420 ....... Puncture/clear lung ........................................ .................. 222.78 1 222.78 Y .............. 44.56 

33010 ....... Drainage of heart sac .................................... .................. 222.78 2 222.78 Y .............. 44.56 

33011 ....... Repeat drainage of heart sac ........................ .................. 222.78 2 222.78 Y .............. 44.56 

33212 ....... Insertion of pulse generator ........................... .................. 6,042.45 3 510.00 .................. 102.00

33213 ....... Insertion of pulse generator ........................... .................. 6,931.86 3 510.00 .................. 102.00

33222 ....... Revise pocket, pacemaker ............................ .................. 1,317.27 2 446.00 .................. 89.20 

33223 ....... Revise pocket, pacing-defib .......................... .................. 1,317.27 2 446.00 .................. 89.20 

33233 ....... Removal of pacemaker system ..................... .................. 1,574.45 2 446.00 .................. 89.20 

35188 ....... Repair blood vessel lesion ............................ .................. 2,319.75 4 630.00 .................. 126.00 

35207 ....... Repair blood vessel lesion ............................ .................. 2,319.75 4 630.00 .................. 126.00 

35875 ....... Removal of clot in graft ................................. .................. 2,319.75 9 1,339.00 .................. 267.80 

35876 ....... Removal of clot in graft ................................. .................. 2,319.75 9 1,339.00 .................. 267.80 

36260 ....... Insertion of infusion pump ............................. .................. 1,752.03 3 510.00 .................. 102.00

36261 ....... Revision of infusion pump ............................. .................. 1,752.03 2 446.00 .................. 89.20 

36262 ....... Removal of infusion pump ............................. .................. 1,393.26 1 333.00 .................. 66.60 

36475 ....... Endovenous rf, 1st vein ................................. .................. 2,134.71 9 1,339.00 .................. 267.80 

36476 ....... Endovenous rf, vein add-on .......................... .................. 2,134.71 9 1,339.00 .................. 267.80 

36478 ....... Endovenous laser, 1st vein ........................... .................. 1,529.38 9 1,339.00 .................. 267.80

36479 ....... Endovenous laser vein addon ....................... .................. 1,529.38 9 1,339.00 .................. 267.80 

36555 ....... Insert non-tunnel cv cath ............................... .................. 539.97 1 333.00 .................. 66.60 

36556 ....... Insert non-tunnel cv cath ............................... .................. 539.97 1 333.00 .................. 66.60 

36557 ....... Insert tunneled cv cath .................................. .................. 1,393.26 2 446.00 .................. 89.20 

36558 ....... Insert tunneled cv cath .................................. .................. 1,393.26 2 446.00 .................. 89.20 

36560 ....... Insert tunneled cv cath .................................. .................. 1,752.03 3 510.00 .................. 102.00 

36561 ....... Insert tunneled cv cath .................................. .................. 1,752.03 3 510.00 .................. 102.00 

36563 ....... Insert tunneled cv cath .................................. .................. 1,752.03 3 510.00 .................. 102.00 

36565 ....... Insert tunneled cv cath .................................. .................. 1,752.03 3 510.00 .................. 102.00 

36566 ....... Insert tunneled cv cath .................................. .................. 5,130.17 3 510.00 .................. 102.00 

36568 ....... Insert picc cath .............................................. .................. 539.97 1 333.00 .................. 66.60 

36569 ....... Insert picc cath .............................................. .................. 539.97 1 333.00 .................. 66.60 

36570 ....... Insert picvad cath .......................................... .................. 1,393.26 3 510.00 .................. 102.00 

36571 ....... Insert picvad cath .......................................... .................. 1,393.26 3 510.00 .................. 102.00 

36575 ....... Repair tunneled cv cath ................................. .................. 539.97 2 446.00 .................. 89.20 

36576 ....... Repair tunneled cv cath ................................. .................. 539.97 2 446.00 .................. 89.20 

36578 ....... Replace tunneled cv cath .............................. .................. 1,393.26 2 446.00 .................. 89.20 

36580 ....... Replace cvad cath ......................................... .................. 539.97 1 333.00 .................. 66.60

36581 ....... Replace tunneled cv cath .............................. .................. 1,393.26 2 446.00 .................. 89.20 

36582 ....... Replace tunneled cv cath .............................. .................. 1,752.03 3 510.00 .................. 102.00 

36583 ....... Replace tunneled cv cath .............................. .................. 1,752.03 3 510.00 .................. 102.00 

36584 ....... Replace picc cath .......................................... .................. 539.97 1 333.00 .................. 66.60 

36585 ....... Replace picvad cath ...................................... .................. 1,393.26 3 510.00 .................. 102.00 

36589 ....... Removal tunneled cv cath ............................. .................. 539.97 1 333.00 .................. 66.60 

36590 ....... Removal tunneled cv cath ............................. .................. 539.97 1 333.00 .................. 66.60 

36640 ....... Insertion catheter, artery ................................ .................. 1,752.03 1 333.00 .................. 66.60 

36800 ....... Insertion of cannula ....................................... .................. 1,795.68 3 510.00 .................. 102.00 

36810 ....... Insertion of cannula ....................................... .................. 1,795.68 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
68266 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

36815 ....... Insertion of cannula ....................................... .................. 1,795.68 3 510.00 .................. 102.00 

36818 ....... Av fuse, uppr arm, cephalic ........................... A* ............. 2,319.75 3 510.00 .................. 102.00 

36819 ....... Av fuse, uppr arm, basilic .............................. .................. 2,319.75 3 510.00 .................. 102.00 

36820 ....... Av fusion/forearm vein ................................... .................. 2,319.75 3 510.00 .................. 102.00 

36821 ....... Av fusion direct any site ................................ .................. 2,319.75 3 510.00 .................. 102.00 

36825 ....... Artery-vein autograft ...................................... .................. 2,319.75 4 630.00 .................. 126.00 

36830 ....... Artery-vein nonautograft ................................ .................. 2,319.75 4 630.00 .................. 126.00 

36831 ....... Open thrombect av fistula ............................. .................. 2,319.75 9 1,339.00 .................. 267.80 

36832 ....... Av fistula revision, open ................................ .................. 2,319.75 4 630.00 .................. 126.00 

36833 ....... Av fistula revision ........................................... .................. 2,319.75 4 630.00 .................. 126.00 

36834 ....... Repair A-V aneurysm .................................... .................. 2,319.75 3 510.00 .................. 102.00

36835 ....... Artery to vein shunt ....................................... .................. 1,795.68 4 630.00 .................. 126.00 

36860 ....... External cannula declotting ........................... .................. 127.40 2 127.40 Y .............. 25.48 

36861 ....... Cannula declotting ......................................... .................. 1,795.68 3 510.00 .................. 102.00 

36870 ....... Percut thrombect av fistula ............................ .................. 1,990.44 9 1,339.00 .................. 267.80 

37500 ....... Endoscopy ligate perf veins .......................... .................. 2,134.71 3 510.00 .................. 102.00 

37607 ....... Ligation of a-v fistula ..................................... .................. 1,529.38 3 510.00 .................. 102.00 

37609 ....... Temporal artery procedure ............................ .................. 928.31 2 446.00 .................. 89.20 

37650 ....... Revision of major vein ................................... .................. 1,529.38 2 446.00 .................. 89.20 

37700 ....... Revise leg vein .............................................. .................. 2,134.71 2 446.00 .................. 89.20 

37718 ....... Ligate/strip short leg vein .............................. .................. 2,134.71 3 510.00 .................. 102.00 

37722 ....... Ligate/strip long leg vein ................................ .................. 2,134.71 3 510.00 .................. 102.00 

37735 ....... Removal of leg veins/lesion ........................... .................. 2,134.71 3 510.00 .................. 102.00 

37760 ....... Ligation, leg veins, open ................................ .................. 1,529.38 3 510.00 .................. 102.00 

37780 ....... Revision of leg vein ....................................... .................. 1,529.38 3 510.00 .................. 102.00 

37785 ....... Ligate/divide/excise vein ................................ .................. 1,529.38 3 510.00 .................. 102.00 

37790 ....... Penile venous occlusion ................................ .................. 2,027.66 3 510.00 .................. 102.00

38300 ....... Drainage, lymph node lesion ......................... .................. 685.58 1 333.00 .................. 66.60 

38305 ....... Drainage, lymph node lesion ......................... .................. 1,076.22 2 446.00 .................. 89.20 

38308 ....... Incision of lymph channels ............................ .................. 1,306.94 2 446.00 .................. 89.20 

38500 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20 

38505 ....... Needle biopsy, lymph nodes ......................... .................. 240.00 1 240.00 Y .............. 48.00 

38510 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20 

38520 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20 

38525 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20 

38530 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20 

38542 ....... Explore deep node(s), neck .......................... .................. 2,318.72 2 446.00 .................. 89.20 

38550 ....... Removal, neck/armpit lesion ......................... .................. 1,306.94 3 510.00 .................. 102.00 

38555 ....... Removal, neck/armpit lesion ......................... .................. 1,306.94 4 630.00 .................. 126.00 

38570 ....... Laparoscopy, lymph node biop ..................... .................. 2,676.86 9 1,339.00 .................. 267.80 

38571 ....... Laparoscopy, lymphadenectomy ................... .................. 4,333.90 9 1,339.00 .................. 267.80 

38572 ....... Laparoscopy, lymphadenectomy ................... .................. 2,676.86 9 1,339.00 .................. 267.80 

38740 ....... Remove armpit lymph nodes ......................... .................. 2,318.72 2 446.00 .................. 89.20 

38745 ....... Remove armpit lymph nodes ......................... .................. 2,318.72 4 630.00 .................. 126.00 

38760 ....... Remove groin lymph nodes ........................... .................. 1,306.94 2 446.00 .................. 89.20 

40500 ....... Partial excision of lip ...................................... .................. 1,009.71 2 446.00 .................. 89.20 

40510 ....... Partial excision of lip ...................................... .................. 1,434.04 2 446.00 .................. 89.20 

40520 ....... Partial excision of lip ...................................... .................. 1,009.71 2 446.00 .................. 89.20 

40525 ....... Reconstruct lip with flap ................................ .................. 1,434.04 2 446.00 .................. 89.20 

40527 ....... Reconstruct lip with flap ................................ .................. 1,434.04 2 446.00 .................. 89.20 

40530 ....... Partial removal of lip ...................................... .................. 1,434.04 2 446.00 .................. 89.20 

40650 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83 

40652 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83 

40654 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83 

40700 ....... Repair cleft lip/nasal ...................................... .................. 2,348.02 7 995.00 .................. 199.00 

40701 ....... Repair cleft lip/nasal ...................................... .................. 2,348.02 7 995.00 .................. 199.00 

40720 ....... Repair cleft lip/nasal ...................................... .................. 2,348.02 7 995.00 .................. 199.00 

40761 ....... Repair cleft lip/nasal ...................................... .................. 2,348.02 3 510.00 .................. 102.00 

40801 ....... Drainage of mouth lesion .............................. .................. 464.15 2 446.00 .................. 89.20 

40814 ....... Excise/repair mouth lesion ............................ .................. 1,009.71 2 446.00 .................. 89.20 

40816 ....... Excision of mouth lesion ................................ .................. 1,434.04 2 446.00 .................. 89.20

40818 ....... Excise oral mucosa for graft .......................... .................. 150.72 1 150.72 Y .............. 30.14 

40819 ....... Excise lip or cheek fold ................................. .................. 464.15 1 333.00 .................. 66.60 

40831 ....... Repair mouth laceration ................................ .................. 464.15 1 333.00 .................. 66.60 

40840 ....... Reconstruction of mouth ................................ .................. 1,434.04 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68267 

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—Continued 

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 

($) 

40842 ....... Reconstruction of mouth ................................ .................. 1,434.04 3 510.00 .................. 102.00

40843 ....... Reconstruction of mouth ................................ .................. 1,434.04 3 510.00 .................. 102.00

40844 ....... Reconstruction of mouth ................................ .................. 2,348.02 5 717.00 .................. 143.40

40845 ....... Reconstruction of mouth ................................ .................. 2,348.02 5 717.00 .................. 143.40

41005 ....... Drainage of mouth lesion .............................. .................. 150.72 1 150.72 Y .............. 30.14 

41006 ....... Drainage of mouth lesion .............................. .................. 1,434.04 1 333.00 .................. 66.60 

41007 ....... Drainage of mouth lesion .............................. .................. 1,009.71 1 333.00 .................. 66.60 

41008 ....... Drainage of mouth lesion .............................. .................. 1,009.71 1 333.00 .................. 66.60 

41009 ....... Drainage of mouth lesion .............................. .................. 150.72 1 150.72 Y .............. 30.14 

41010 ....... Incision of tongue fold ................................... .................. 464.15 1 333.00 .................. 66.60

41015 ....... Drainage of mouth lesion .............................. .................. 150.72 1 150.72 Y .............. 30.14 

41016 ....... Drainage of mouth lesion .............................. .................. 464.15 1 333.00 .................. 66.60 

41017 ....... Drainage of mouth lesion .............................. .................. 464.15 1 333.00 .................. 66.60 

41018 ....... Drainage of mouth lesion .............................. .................. 464.15 1 333.00 .................. 66.60 

41112 ....... Excision of tongue lesion ............................... .................. 1,009.71 2 446.00 .................. 89.20

41113 ....... Excision of tongue lesion ............................... .................. 1,009.71 2 446.00 .................. 89.20

41114 ....... Excision of tongue lesion ............................... .................. 1,434.04 2 446.00 .................. 89.20

41116 ....... Excision of mouth lesion ................................ .................. 1,009.71 1 333.00 .................. 66.60

41120 ....... Partial removal of tongue .............................. .................. 1,434.04 5 717.00 .................. 143.40

41250 ....... Repair tongue laceration ............................... .................. 150.72 2 150.72 Y .............. 30.14 

41251 ....... Repair tongue laceration ............................... .................. 150.72 2 150.72 Y .............. 30.14 

41252 ....... Repair tongue laceration ............................... .................. 464.15 2 446.00 .................. 89.20 

41500 ....... Fixation of tongue .......................................... .................. 1,434.04 1 333.00 .................. 66.60 

41510 ....... Tongue to lip surgery ..................................... .................. 1,009.71 1 333.00 .................. 66.60 

41520 ....... Reconstruction, tongue fold ........................... .................. 464.15 2 446.00 .................. 89.20 

41800 ....... Drainage of gum lesion ................................. .................. 88.46 1 88.46 Y .............. 17.69 

41827 ....... Excision of gum lesion ................................... .................. 1,434.04 2 446.00 .................. 89.20 

42000 ....... Drainage mouth roof lesion ........................... .................. 150.72 2 150.72 Y .............. 30.14 

42107 ....... Excision lesion, mouth roof ........................... .................. 1,434.04 2 446.00 .................. 89.20 

42120 ....... Remove palate/lesion .................................... .................. 2,348.02 4 630.00 .................. 126.00 

42140 ....... Excision of uvula ............................................ .................. 464.15 2 446.00 .................. 89.20 

42145 ....... Repair palate, pharynx/uvula ......................... .................. 1,434.04 5 717.00 .................. 143.40 

42180 ....... Repair palate ................................................. .................. 150.72 1 150.72 Y .............. 30.14 

42182 ....... Repair palate ................................................. .................. 2,348.02 2 446.00 .................. 89.20 

42200 ....... Reconstruct cleft palate ................................. .................. 2,348.02 5 717.00 .................. 143.40 

42205 ....... Reconstruct cleft palate ................................. .................. 2,348.02 5 717.00 .................. 143.40 

42210 ....... Reconstruct cleft palate ................................. .................. 2,348.02 5 717.00 .................. 143.40 

42215 ....... Reconstruct cleft palate ................................. .................. 2,348.02 7 995.00 .................. 199.00 

42220 ....... Reconstruct cleft palate ................................. .................. 2,348.02 5 717.00 .................. 143.40 

42226 ....... Lengthening of palate .................................... .................. 2,348.02 5 717.00 .................. 143.40 

42235 ....... Repair palate ................................................. .................. 1,009.71 5 717.00 .................. 143.40 

42260 ....... Repair nose to lip fistula ................................ .................. 1,434.04 4 630.00 .................. 126.00 

42300 ....... Drainage of salivary gland ............................. .................. 1,009.71 1 333.00 .................. 66.60 

42305 ....... Drainage of salivary gland ............................. .................. 1,009.71 2 446.00 .................. 89.20 

42310 ....... Drainage of salivary gland ............................. .................. 150.72 1 150.72 Y .............. 30.14 

42320 ....... Drainage of salivary gland ............................. .................. 150.72 1 150.72 Y .............. 30.14 

42340 ....... Removal of salivary stone ............................. .................. 1,009.71 2 446.00 .................. 89.20 

42405 ....... Biopsy of salivary gland ................................. .................. 1,009.71 2 446.00 .................. 89.20 

42408 ....... Excision of salivary cyst ................................ .................. 1,009.71 3 510.00 .................. 102.00 

42409 ....... Drainage of salivary cyst ............................... .................. 1,009.71 3 510.00 .................. 102.00 

42410 ....... Excise parotid gland/lesion ............................ .................. 2,348.02 3 510.00 .................. 102.00

42415 ....... Excise parotid gland/lesion ............................ .................. 2,348.02 7 995.00 .................. 199.00

42420 ....... Excise parotid gland/lesion ............................ .................. 2,348.02 7 995.00 .................. 199.00

42425 ....... Excise parotid gland/lesion ............................ .................. 2,348.02 7 995.00 .................. 199.00

42440 ....... Excise submaxillary gland ............................. .................. 2,348.02 3 510.00 .................. 102.00 

42450 ....... Excise sublingual gland ................................. .................. 1,434.04 2 446.00 .................. 89.20

42500 ....... Repair salivary duct ....................................... .................. 1,434.04 3 510.00 .................. 102.00 

42505 ....... Repair salivary duct ....................................... .................. 2,348.02 4 630.00 .................. 126.00 

42507 ....... Parotid duct diversion .................................... .................. 2,348.02 3 510.00 .................. 102.00 

42508 ....... Parotid duct diversion .................................... .................. 2,348.02 4 630.00 .................. 126.00 

42509 ....... Parotid duct diversion .................................... .................. 2,348.02 4 630.00 .................. 126.00 

42510 ....... Parotid duct diversion .................................... .................. 2,348.02 4 630.00 .................. 126.00 

42600 ....... Closure of salivary fistula .............................. .................. 1,009.71 1 333.00 .................. 66.60 

42665 ....... Ligation of salivary duct ................................. .................. 1,434.04 7 995.00 .................. 199.00 

42700 ....... Drainage of tonsil abscess ............................ .................. 150.72 1 150.72 Y .............. 30.14 


cprice-sewell on PRODPC62 with RULES2
68268 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

42720 ....... Drainage of throat abscess ........................... .................. 1,009.71 1 333.00 .................. 66.60 

42725 ....... Drainage of throat abscess ........................... .................. 2,348.02 2 446.00 .................. 89.20 

42802 ....... Biopsy of throat .............................................. .................. 1,009.71 1 333.00 .................. 66.60 

42804 ....... Biopsy of upper nose/throat .......................... .................. 1,009.71 1 333.00 .................. 66.60 

42806 ....... Biopsy of upper nose/throat .......................... .................. 1,434.04 2 446.00 .................. 89.20 

42808 ....... Excise pharynx lesion .................................... .................. 1,009.71 2 446.00 .................. 89.20 

42810 ....... Excision of neck cyst ..................................... .................. 1,434.04 3 510.00 .................. 102.00 

42815 ....... Excision of neck cyst ..................................... .................. 2,348.02 5 717.00 .................. 143.40 

42820 ....... Remove tonsils and adenoids ....................... .................. 1,359.46 3 510.00 .................. 102.00 

42821 ....... Remove tonsils and adenoids ....................... .................. 1,359.46 5 717.00 .................. 143.40 

42825 ....... Removal of tonsils ......................................... .................. 1,359.46 4 630.00 .................. 126.00 

42826 ....... Removal of tonsils ......................................... .................. 1,359.46 4 630.00 .................. 126.00 

42830 ....... Removal of adenoids ..................................... .................. 1,359.46 4 630.00 .................. 126.00 

42831 ....... Removal of adenoids ..................................... .................. 1,359.46 4 630.00 .................. 126.00 

42835 ....... Removal of adenoids ..................................... .................. 1,359.46 4 630.00 .................. 126.00 

42836 ....... Removal of adenoids ..................................... .................. 1,359.46 4 630.00 .................. 126.00 

42860 ....... Excision of tonsil tags .................................... .................. 1,359.46 3 510.00 .................. 102.00 

42870 ....... Excision of lingual tonsil ................................ .................. 1,359.46 3 510.00 .................. 102.00 

42890 ....... Partial removal of pharynx ............................. .................. 2,348.02 7 995.00 .................. 199.00

42892 ....... Revision of pharyngeal walls ......................... .................. 2,348.02 7 995.00 .................. 199.00 

42900 ....... Repair throat wound ...................................... .................. 464.15 1 333.00 .................. 66.60 

42950 ....... Reconstruction of throat ................................ .................. 1,434.04 2 446.00 .................. 89.20

42955 ....... Surgical opening of throat ............................. .................. 1,434.04 2 446.00 .................. 89.20 

42960 ....... Control throat bleeding .................................. .................. 72.48 1 72.48 Y .............. 14.50 

42962 ....... Control throat bleeding .................................. .................. 2,348.02 2 446.00 .................. 89.20 

42972 ....... Control nose/throat bleeding ......................... .................. 1,009.71 3 510.00 .................. 102.00 

43200 ....... Esophagus endoscopy .................................. .................. 511.26 1 333.00 .................. 66.60 

43201 ....... Esoph scope w/submucous inj ...................... .................. 511.26 1 333.00 .................. 66.60 

43202 ....... Esophagus endoscopy, biopsy ...................... .................. 511.26 1 333.00 .................. 66.60 

43204 ....... Esoph scope w/sclerosis inj .......................... .................. 511.26 1 333.00 .................. 66.60 

43205 ....... Esophagus endoscopy/ligation ...................... .................. 511.26 1 333.00 .................. 66.60 

43215 ....... Esophagus endoscopy .................................. .................. 511.26 1 333.00 .................. 66.60 

43216 ....... Esophagus endoscopy/lesion ........................ .................. 511.26 1 333.00 .................. 66.60 

43217 ....... Esophagus endoscopy .................................. .................. 511.26 1 333.00 .................. 66.60 

43219 ....... Esophagus endoscopy .................................. .................. 1,410.54 1 333.00 .................. 66.60 

43220 ....... Esoph endoscopy, dilation ............................. .................. 511.26 1 333.00 .................. 66.60 

43226 ....... Esoph endoscopy, dilation ............................. .................. 511.26 1 333.00 .................. 66.60 

43227 ....... Esoph endoscopy, repair ............................... .................. 511.26 2 446.00 .................. 89.20 

43228 ....... Esoph endoscopy, ablation ........................... .................. 1,583.12 2 446.00 .................. 89.20 

43231 ....... Esoph endoscopy w/us exam ........................ .................. 511.26 2 446.00 .................. 89.20 

43232 ....... Esoph endoscopy w/us fn bx ........................ .................. 511.26 2 446.00 .................. 89.20 

43234 ....... Upper GI endoscopy, exam ........................... .................. 511.26 1 333.00 .................. 66.60 

43235 ....... Uppr gi endoscopy, diagnosis ....................... .................. 511.26 1 333.00 .................. 66.60 

43236 ....... Uppr gi scope w/submuc inj .......................... .................. 511.26 2 446.00 .................. 89.20 

43237 ....... Endoscopic us exam, esoph ......................... .................. 511.26 2 446.00 .................. 89.20 

43238 ....... Uppr gi endoscopy w/us fn bx ....................... .................. 511.26 2 446.00 .................. 89.20 

43239 ....... Upper GI endoscopy, biopsy ......................... .................. 511.26 2 446.00 .................. 89.20 

43240 ....... Esoph endoscope w/drain cyst ...................... .................. 511.26 2 446.00 .................. 89.20 

43241 ....... Upper GI endoscopy with tube ...................... .................. 511.26 2 446.00 .................. 89.20 

43242 ....... Uppr gi endoscopy w/us fn bx ....................... .................. 511.26 2 446.00 .................. 89.20 

43243 ....... Upper gi endoscopy & inject ......................... .................. 511.26 2 446.00 .................. 89.20 

43244 ....... Upper GI endoscopy/ligation ......................... .................. 511.26 2 446.00 .................. 89.20 

43245 ....... Uppr gi scope dilate strictr ............................. .................. 511.26 2 446.00 .................. 89.20 

43246 ....... Place gastrostomy tube ................................. .................. 511.26 2 446.00 .................. 89.20 

43247 ....... Operative upper GI endoscopy ..................... .................. 511.26 2 446.00 .................. 89.20 

43248 ....... Uppr gi endoscopy/guide wire ....................... .................. 511.26 2 446.00 .................. 89.20 

43249 ....... Esoph endoscopy, dilation ............................. .................. 511.26 2 446.00 .................. 89.20 

43250 ....... Upper GI endoscopy/tumor ........................... .................. 511.26 2 446.00 .................. 89.20 

43251 ....... Operative upper GI endoscopy ..................... .................. 511.26 2 446.00 .................. 89.20 

43255 ....... Operative upper GI endoscopy ..................... .................. 511.26 2 446.00 .................. 89.20 

43256 ....... Uppr gi endoscopy w/stent ............................ .................. 1,410.54 3 510.00 .................. 102.00 

43257 ....... Uppr gi scope w/thrml txmnt .......................... A* ............. 1,583.12 3 510.00 .................. 102.00 

43258 ....... Operative upper GI endoscopy ..................... .................. 511.26 3 510.00 .................. 102.00 

43259 ....... Endoscopic ultrasound exam ........................ .................. 511.26 3 510.00 .................. 102.00 

43260 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68269 

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—Continued 

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 

($) 

43261 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43262 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43263 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43264 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43265 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43267 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43268 ....... Endo cholangiopancreatograph ..................... .................. 1,410.54 2 446.00 .................. 89.20 

43269 ....... Endo cholangiopancreatograph ..................... .................. 1,410.54 2 446.00 .................. 89.20 

43271 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43272 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20 

43450 ....... Dilate esophagus ........................................... .................. 335.41 1 333.00 .................. 66.60 

43453 ....... Dilate esophagus ........................................... .................. 335.41 1 333.00 .................. 66.60 

43456 ....... Dilate esophagus ........................................... .................. 335.41 2 335.41 Y .............. 67.08 

43458 ....... Dilate esophagus ........................................... .................. 335.41 2 335.41 Y .............. 67.08 

43600 ....... Biopsy of stomach ......................................... .................. 511.26 1 333.00 .................. 66.60

43653 ....... Laparoscopy, gastrostomy ............................. .................. 2,676.86 9 1,339.00 .................. 267.80

43750 ....... Place gastrostomy tube ................................. .................. 511.26 2 446.00 .................. 89.20 

43760 ....... Change gastrostomy tube ............................. .................. 144.98 1 144.98 Y .............. 29.00 

43761 ....... Reposition gastrostomy tube ......................... A* ............. 459.78 1 333.00 .................. 66.60 

43870 ....... Repair stomach opening ................................ .................. 511.26 1 333.00 .................. 66.60 

44100 ....... Biopsy of bowel ............................................. .................. 511.26 1 333.00 .................. 66.60 

44312 ....... Revision of ileostomy ..................................... .................. 1,317.27 1 333.00 .................. 66.60 

44340 ....... Revision of colostomy .................................... .................. 1,317.27 3 510.00 .................. 102.00 

44360 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44361 ....... Small bowel endoscopy/biopsy ..................... .................. 583.61 2 446.00 .................. 89.20 

44363 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44364 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44365 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44366 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44369 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44370 ....... Small bowel endoscopy/stent ........................ .................. 1,410.54 9 1,339.00 .................. 267.80 

44372 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44373 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44376 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44377 ....... Small bowel endoscopy/biopsy ..................... .................. 583.61 2 446.00 .................. 89.20 

44378 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20 

44379 ....... Sbowel endoscope w/stent ............................ .................. 1,410.54 9 1,339.00 .................. 267.80 

44380 ....... Small bowel endoscopy ................................. .................. 583.61 1 333.00 .................. 66.60 

44382 ....... Small bowel endoscopy ................................. .................. 583.61 1 333.00 .................. 66.60 

44383 ....... Ileoscopy w/stent ........................................... .................. 1,410.54 9 1,339.00 .................. 267.80 

44385 ....... Endoscopy of bowel pouch ........................... .................. 538.99 1 333.00 .................. 66.60 

44386 ....... Endoscopy, bowel pouch/biop ....................... .................. 538.99 1 333.00 .................. 66.60 

44388 ....... Colonoscopy .................................................. .................. 538.99 1 333.00 .................. 66.60 

44389 ....... Colonoscopy with biopsy ............................... .................. 538.99 1 333.00 .................. 66.60 

44390 ....... Colonoscopy for foreign body ........................ .................. 538.99 1 333.00 .................. 66.60 

44391 ....... Colonoscopy for bleeding .............................. .................. 538.99 1 333.00 .................. 66.60 

44392 ....... Colonoscopy & polypectomy ......................... .................. 538.99 1 333.00 .................. 66.60 

44393 ....... Colonoscopy, lesion removal ......................... .................. 538.99 1 333.00 .................. 66.60 

44394 ....... Colonoscopy w/snare .................................... .................. 538.99 1 333.00 .................. 66.60 

44397 ....... Colonoscopy w/stent ...................................... .................. 1,410.54 1 333.00 .................. 66.60 

45000 ....... Drainage of pelvic abscess ........................... .................. 312.07 1 312.07 Y .............. 62.41 

45005 ....... Drainage of rectal abscess ............................ .................. 783.03 2 446.00 .................. 89.20 

45020 ....... Drainage of rectal abscess ............................ .................. 783.03 2 446.00 .................. 89.20 

45100 ....... Biopsy of rectum ............................................ .................. 1,368.78 1 333.00 .................. 66.60 

45108 ....... Removal of anorectal lesion .......................... .................. 1,368.78 2 446.00 .................. 89.20 

45150 ....... Excision of rectal stricture ............................. .................. 1,368.78 2 446.00 .................. 89.20 

45160 ....... Excision of rectal lesion ................................. .................. 1,368.78 2 446.00 .................. 89.20 

45170 ....... Excision of rectal lesion ................................. .................. 1,368.78 2 446.00 .................. 89.20 

45190 ....... Destruction, rectal tumor ............................... .................. 1,368.78 9 1,339.00 .................. 267.80 

45305 ....... Proctosigmoidoscopy w/bx ............................ .................. 525.41 1 333.00 .................. 66.60 

45307 ....... Proctosigmoidoscopy fb ................................. .................. 1,268.55 1 333.00 .................. 66.60 

45308 ....... Proctosigmoidoscopy removal ....................... .................. 525.41 1 333.00 .................. 66.60 

45309 ....... Proctosigmoidoscopy removal ....................... .................. 525.41 1 333.00 .................. 66.60 

45315 ....... Proctosigmoidoscopy removal ....................... .................. 525.41 1 333.00 .................. 66.60 

45317 ....... Proctosigmoidoscopy bleed ........................... .................. 525.41 1 333.00 .................. 66.60 


cprice-sewell on PRODPC62 with RULES2
68270 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

45320 ....... Proctosigmoidoscopy ablate .......................... .................. 1,268.55 1 333.00 .................. 66.60 

45321 ....... Proctosigmoidoscopy volvul .......................... .................. 1,268.55 1 333.00 .................. 66.60 

45327 ....... Proctosigmoidoscopy w/stent ........................ .................. 1,410.54 1 333.00 .................. 66.60 

45331 ....... Sigmoidoscopy and biopsy ............................ .................. 299.24 1 299.24 Y .............. 59.85 

45332 ....... Sigmoidoscopy w/fb removal ......................... .................. 299.24 1 299.24 Y .............. 59.85 

45333 ....... Sigmoidoscopy & polypectomy ...................... .................. 525.41 1 333.00 .................. 66.60 

45334 ....... Sigmoidoscopy for bleeding .......................... .................. 525.41 1 333.00 .................. 66.60 

45335 ....... Sigmoidoscopy w/submuc inj ........................ .................. 299.24 1 299.24 Y .............. 59.85 

45337 ....... Sigmoidoscopy & decompress ...................... .................. 299.24 1 299.24 Y .............. 59.85 

45338 ....... Sigmoidoscopy w/tumr remove ..................... .................. 525.41 1 333.00 .................. 66.60 

45339 ....... Sigmoidoscopy w/ablate tumr ........................ .................. 525.41 1 333.00 .................. 66.60 

45340 ....... Sig w/balloon dilation ..................................... .................. 525.41 1 333.00 .................. 66.60 

45341 ....... Sigmoidoscopy w/ultrasound ......................... .................. 525.41 1 333.00 .................. 66.60 

45342 ....... Sigmoidoscopy w/us guide bx ....................... .................. 525.41 1 333.00 .................. 66.60 

45345 ....... Sigmoidoscopy w/stent .................................. .................. 1,410.54 1 333.00 .................. 66.60 

45355 ....... Surgical colonoscopy ..................................... .................. 538.99 1 333.00 .................. 66.60 

45378 ....... Diagnostic colonoscopy ................................. .................. 538.99 2 446.00 .................. 89.20 

45379 ....... Colonoscopy w/fb removal ............................ .................. 538.99 2 446.00 .................. 89.20 

45380 ....... Colonoscopy and biopsy ............................... .................. 538.99 2 446.00 .................. 89.20 

45381 ....... Colonoscopy, submucous inj ......................... .................. 538.99 2 446.00 .................. 89.20 

45382 ....... Colonoscopy/control bleeding ........................ .................. 538.99 2 446.00 .................. 89.20 

45383 ....... Lesion removal colonoscopy ......................... .................. 538.99 2 446.00 .................. 89.20 

45384 ....... Lesion remove colonoscopy .......................... .................. 538.99 2 446.00 .................. 89.20 

45385 ....... Lesion removal colonoscopy ......................... .................. 538.99 2 446.00 .................. 89.20 

45386 ....... Colonoscopy dilate stricture .......................... .................. 538.99 2 446.00 .................. 89.20 

45387 ....... Colonoscopy w/stent ...................................... .................. 1,410.54 1 333.00 .................. 66.60 

45391 ....... Colonoscopy w/endoscope us ....................... .................. 538.99 2 446.00 .................. 89.20 

45392 ....... Colonoscopy w/endoscopic fnb ..................... .................. 538.99 2 446.00 .................. 89.20 

45500 ....... Repair of rectum ............................................ .................. 1,368.78 2 446.00 .................. 89.20 

45505 ....... Repair of rectum ............................................ .................. 1,820.61 2 446.00 .................. 89.20 

45560 ....... Repair of rectocele ........................................ .................. 1,820.61 2 446.00 .................. 89.20 

45900 ....... Reduction of rectal prolapse .......................... .................. 312.07 1 312.07 Y .............. 62.41 

45905 ....... Dilation of anal sphincter ............................... .................. 1,368.78 1 333.00 .................. 66.60 

45910 ....... Dilation of rectal narrowing ............................ .................. 1,368.78 1 333.00 .................. 66.60

45915 ....... Remove rectal obstruction ............................. .................. 312.07 1 312.07 Y .............. 62.41 

45990 ....... Surg dx exam, anorectal ............................... .................. 312.07 2 312.07 Y .............. 62.41 

46020 ....... Placement of seton ........................................ .................. 1,368.78 3 510.00 .................. 102.00 

46030 ....... Removal of rectal marker .............................. .................. 312.07 1 312.07 Y .............. 62.41 

46040 ....... Incision of rectal abscess .............................. .................. 1,368.78 3 510.00 .................. 102.00 

46045 ....... Incision of rectal abscess .............................. .................. 1,368.78 2 446.00 .................. 89.20

46050 ....... Incision of anal abscess ................................ .................. 312.07 1 312.07 Y .............. 62.41 

46060 ....... Incision of rectal abscess .............................. .................. 1,368.78 2 446.00 .................. 89.20

46080 ....... Incision of anal sphincter ............................... .................. 1,368.78 3 510.00 .................. 102.00 

46200 ....... Removal of anal fissure ................................. .................. 1,368.78 2 446.00 .................. 89.20

46210 ....... Removal of anal crypt .................................... .................. 1,368.78 2 446.00 .................. 89.20 

46211 ....... Removal of anal crypts .................................. .................. 1,368.78 2 446.00 .................. 89.20

46220 ....... Removal of anal tag ...................................... .................. 1,368.78 1 333.00 .................. 66.60 

46230 ....... Removal of anal tags ..................................... .................. 1,368.78 1 333.00 .................. 66.60 

46250 ....... Hemorrhoidectomy ......................................... .................. 1,368.78 3 510.00 .................. 102.00 

46255 ....... Hemorrhoidectomy ......................................... .................. 1,368.78 3 510.00 .................. 102.00 

46257 ....... Remove hemorrhoids & fissure ..................... .................. 1,368.78 3 510.00 .................. 102.00 

46258 ....... Remove hemorrhoids & fistula ...................... .................. 1,368.78 3 510.00 .................. 102.00 

46260 ....... Hemorrhoidectomy ......................................... .................. 1,368.78 3 510.00 .................. 102.00 

46261 ....... Remove hemorrhoids & fissure ..................... .................. 1,368.78 4 630.00 .................. 126.00 

46262 ....... Remove hemorrhoids & fistula ...................... .................. 1,368.78 4 630.00 .................. 126.00 

46270 ....... Removal of anal fistula .................................. .................. 1,368.78 3 510.00 .................. 102.00 

46275 ....... Removal of anal fistula .................................. .................. 1,368.78 3 510.00 .................. 102.00 

46280 ....... Removal of anal fistula .................................. .................. 1,368.78 4 630.00 .................. 126.00 

46285 ....... Removal of anal fistula .................................. .................. 1,368.78 1 333.00 .................. 66.60 

46288 ....... Repair anal fistula .......................................... .................. 1,368.78 4 630.00 .................. 126.00 

46608 ....... Anoscopy, remove for body ........................... .................. 525.41 1 333.00 .................. 66.60 

46610 ....... Anoscopy, remove lesion .............................. .................. 1,268.55 1 333.00 .................. 66.60 

46611 ....... Anoscopy ....................................................... .................. 525.41 1 333.00 .................. 66.60 

46612 ....... Anoscopy, remove lesions ............................. .................. 1,268.55 1 333.00 .................. 66.60 

46615 ....... Anoscopy ....................................................... .................. 1,268.55 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68271 

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—Continued 

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 

($) 

46700 ....... Repair of anal stricture .................................. .................. 1,368.78 3 510.00 .................. 102.00 

46706 ....... Repr of anal fistula w/glue ............................. .................. 1,820.61 1 333.00 .................. 66.60

46750 ....... Repair of anal sphincter ................................ .................. 2,329.58 3 510.00 .................. 102.00 

46753 ....... Reconstruction of anus .................................. .................. 1,368.78 3 510.00 .................. 102.00 

46754 ....... Removal of suture from anus ........................ .................. 1,368.78 2 446.00 .................. 89.20 

46760 ....... Repair of anal sphincter ................................ .................. 2,329.58 2 446.00 .................. 89.20

46761 ....... Repair of anal sphincter ................................ .................. 2,329.58 3 510.00 .................. 102.00 

46762 ....... Implant artificial sphincter .............................. .................. 2,329.58 7 995.00 .................. 199.00 

46917 ....... Laser surgery, anal lesions ........................... .................. 1,255.64 1 333.00 .................. 66.60 

46922 ....... Excision of anal lesion(s) ............................... .................. 1,255.64 1 333.00 .................. 66.60 

46924 ....... Destruction, anal lesion(s) ............................. .................. 1,255.64 1 333.00 .................. 66.60

46937 ....... Cryotherapy of rectal lesion ........................... .................. 1,368.78 2 446.00 .................. 89.20 

46938 ....... Cryotherapy of rectal lesion ........................... .................. 1,820.61 2 446.00 .................. 89.20 

46946 ....... Ligation of hemorrhoids ................................. A* ............. 783.03 1 333.00 .................. 66.60 

46947 ....... Hemorrhoidopexy by stapling ........................ .................. 1,820.61 7 995.00 .................. 199.00 

47000 ....... Needle biopsy of liver .................................... .................. 377.32 1 333.00 .................. 66.60

47510 ....... Insert catheter, bile duct ................................ .................. 1,245.85 2 446.00 .................. 89.20 

47511 ....... Insert bile duct drain ...................................... .................. 1,245.85 9 1,245.85 Y .............. 249.17 

47525 ....... Change bile duct catheter ............................. .................. 716.56 1 333.00 .................. 66.60 

47530 ....... Revise/reinsert bile tube ................................ .................. 716.56 1 333.00 .................. 66.60 

47552 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 2 446.00 .................. 89.20 

47553 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 3 510.00 .................. 102.00

47554 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 3 510.00 .................. 102.00

47555 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 3 510.00 .................. 102.00

47556 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 9 1,245.85 Y .............. 249.17 

47560 ....... Laparoscopy w/cholangio .............................. .................. 1,974.60 3 510.00 .................. 102.00 

47561 ....... Laparo w/cholangio/biopsy ............................ .................. 1,974.60 3 510.00 .................. 102.00 

47630 ....... Remove bile duct stone ................................. .................. 1,245.85 3 510.00 .................. 102.00

48102 ....... Needle biopsy, pancreas ............................... .................. 377.32 1 333.00 .................. 66.60 

49080 ....... Puncture, peritoneal cavity ............................ .................. 222.78 2 222.78 Y .............. 44.56 

49081 ....... Removal of abdominal fluid ........................... .................. 222.78 2 222.78 Y .............. 44.56 

49085 ....... Remove abdomen foreign body .................... D .............. .................... 2 446.00 .................. ....................

49180 ....... Biopsy, abdominal mass ................................ .................. 377.32 1 333.00 .................. 66.60 

49250 ....... Excision of umbilicus ..................................... .................. 1,357.41 4 630.00 .................. 126.00 

49320 ....... Diag laparo separate proc ............................. .................. 1,974.60 3 510.00 .................. 102.00 

49321 ....... Laparoscopy, biopsy ...................................... .................. 1,974.60 4 630.00 .................. 126.00 

49322 ....... Laparoscopy, aspiration ................................. .................. 1,974.60 4 630.00 .................. 126.00 

49402 ....... Remove foreign body, adbomen ................... A .............. 1,357.41 2 446.00 .................. 89.20 

49419 ....... Insrt abdom cath for chemotx ........................ .................. 1,795.68 1 333.00 .................. 66.60 

49420 ....... Insert abdom drain, temp .............................. .................. 1,815.86 1 333.00 .................. 66.60 

49421 ....... Insert abdom drain, perm .............................. .................. 1,815.86 1 333.00 .................. 66.60 

49422 ....... Remove perm cannula/catheter .................... .................. 1,574.45 1 333.00 .................. 66.60 

49426 ....... Revise abdomen-venous shunt ..................... .................. 1,357.41 2 446.00 .................. 89.20 

49495 ....... Rpr ing hernia baby, reduc ............................ .................. 1,795.98 4 630.00 .................. 126.00 

49496 ....... Rpr ing hernia baby, blocked ........................ .................. 1,795.98 4 630.00 .................. 126.00 

49500 ....... Rpr ing hernia, init, reduce ............................ .................. 1,795.98 4 630.00 .................. 126.00 

49501 ....... Rpr ing hernia, init blocked ............................ .................. 1,795.98 9 1,339.00 .................. 267.80 

49505 ....... Prp i/hern init reduc >5 yr .............................. .................. 1,795.98 4 630.00 .................. 126.00 

49507 ....... Prp i/hern init block >5 yr .............................. .................. 1,795.98 9 1,339.00 .................. 267.80 

49520 ....... Rerepair ing hernia, reduce ........................... .................. 1,795.98 7 995.00 .................. 199.00 

49521 ....... Rerepair ing hernia, blocked ......................... .................. 1,795.98 9 1,339.00 .................. 267.80

49525 ....... Repair ing hernia, sliding ............................... .................. 1,795.98 4 630.00 .................. 126.00 

49540 ....... Repair lumbar hernia ..................................... .................. 1,795.98 2 446.00 .................. 89.20 

49550 ....... Rpr rem hernia, init, reduce ........................... .................. 1,795.98 5 717.00 .................. 143.40

49553 ....... Rpr fem hernia, init blocked .......................... .................. 1,795.98 9 1,339.00 .................. 267.80 

49555 ....... Rerepair fem hernia, reduce .......................... .................. 1,795.98 5 717.00 .................. 143.40 

49557 ....... Rerepair fem hernia, blocked ........................ .................. 1,795.98 9 1,339.00 .................. 267.80 

49560 ....... Rpr ventral hern init, reduc ............................ .................. 1,795.98 4 630.00 .................. 126.00 

49561 ....... Rpr ventral hern init, block ............................ .................. 1,795.98 9 1,339.00 .................. 267.80 

49565 ....... Rerepair ventrl hern, reduce .......................... .................. 1,795.98 4 630.00 .................. 126.00 

49566 ....... Rerepair ventrl hern, block ............................ .................. 1,795.98 9 1,339.00 .................. 267.80 

49568 ....... Hernia repair w/mesh .................................... .................. 1,795.98 7 995.00 .................. 199.00 

49570 ....... Rpr epigastric hern, reduce ........................... .................. 1,795.98 4 630.00 .................. 126.00 

49572 ....... Rpr epigastric hern, blocked .......................... .................. 1,795.98 9 1,339.00 .................. 267.80 

49580 ....... Rpr umbil hern, reduc < 5 yr ......................... .................. 1,795.98 4 630.00 .................. 126.00 


cprice-sewell on PRODPC62 with RULES2
68272 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

49582 ....... Rpr umbil hern, block < 5 yr .......................... .................. 1,795.98 9 1,339.00 .................. 267.80 

49585 ....... Rpr umbil hern, reduc > 5 yr ......................... .................. 1,795.98 4 630.00 .................. 126.00 

49587 ....... Rpr umbil hern, block > 5 yr .......................... .................. 1,795.98 9 1,339.00 .................. 267.80 

49590 ....... Repair spigelian hernia .................................. .................. 1,795.98 3 510.00 .................. 102.00 

49600 ....... Repair umbilical lesion ................................... .................. 1,795.98 4 630.00 .................. 126.00 

49650 ....... Laparo hernia repair initial ............................. .................. 2,676.86 4 630.00 .................. 126.00 

49651 ....... Laparo hernia repair recur ............................. .................. 2,676.86 7 995.00 .................. 199.00

50200 ....... Biopsy of kidney ............................................ .................. 377.32 1 333.00 .................. 66.60 

50390 ....... Drainage of kidney lesion .............................. .................. 377.32 1 333.00 .................. 66.60 

50392 ....... Insert kidney drain ......................................... .................. 1,181.73 1 333.00 .................. 66.60 

50393 ....... Insert ureteral tube ........................................ .................. 1,181.73 1 333.00 .................. 66.60 

50395 ....... Create passage to kidney .............................. .................. 1,181.73 1 333.00 .................. 66.60 

50396 ....... Measure kidney pressure .............................. .................. 131.50 1 131.50 Y .............. 26.30 

50398 ....... Change kidney tube ....................................... .................. 459.78 1 333.00 .................. 66.60 

50551 ....... Kidney endoscopy ......................................... .................. 399.24 1 333.00 .................. 66.60 

50553 ....... Kidney endoscopy ......................................... .................. 1,181.73 1 333.00 .................. 66.60 

50555 ....... Kidney endoscopy & biopsy .......................... .................. 399.24 1 333.00 .................. 66.60 

50557 ....... Kidney endoscopy & treatment ..................... .................. 1,467.24 1 333.00 .................. 66.60 

50561 ....... Kidney endoscopy & treatment ..................... .................. 1,181.73 1 333.00 .................. 66.60 

50688 ....... Change of ureter tube/stent ........................... .................. 459.78 1 333.00 .................. 66.60 

50947 ....... Laparo new ureter/bladder ............................ .................. 2,676.86 9 1,339.00 .................. 267.80

50948 ....... Laparo new ureter/bladder ............................ .................. 2,676.86 9 1,339.00 .................. 267.80

50951 ....... Endoscopy of ureter ...................................... .................. 399.24 1 333.00 .................. 66.60 

50953 ....... Endoscopy of ureter ...................................... .................. 399.24 1 333.00 .................. 66.60 

50955 ....... Ureter endoscopy & biopsy ........................... .................. 1,181.73 1 333.00 .................. 66.60 

50957 ....... Ureter endoscopy & treatment ...................... .................. 1,181.73 1 333.00 .................. 66.60 

50961 ....... Ureter endoscopy & treatment ...................... .................. 1,181.73 1 333.00 .................. 66.60 

50970 ....... Ureter endoscopy .......................................... .................. 399.24 1 333.00 .................. 66.60

50972 ....... Ureter endoscopy & catheter ......................... .................. 399.24 1 333.00 .................. 66.60 

50974 ....... Ureter endoscopy & biopsy ........................... .................. 1,181.73 1 333.00 .................. 66.60 

50976 ....... Ureter endoscopy & treatment ...................... .................. 1,181.73 1 333.00 .................. 66.60 

50980 ....... Ureter endoscopy & treatment ...................... .................. 1,181.73 1 333.00 .................. 66.60 

51010 ....... Drainage of bladder ....................................... .................. 1,116.74 1 333.00 .................. 66.60 

51020 ....... Incise & treat bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00 

51030 ....... Incise & treat bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00 

51040 ....... Incise & drain bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00 

51045 ....... Incise bladder/drain ureter ............................. .................. 399.24 4 399.24 Y .............. 79.85 

51050 ....... Removal of bladder stone ............................. .................. 1,467.24 4 630.00 .................. 126.00 

51065 ....... Remove ureter calculus ................................. .................. 1,467.24 4 630.00 .................. 126.00

51080 ....... Drainage of bladder abscess ......................... .................. 1,076.22 1 333.00 .................. 66.60 

51500 ....... Removal of bladder cyst ................................ .................. 1,795.98 4 630.00 .................. 126.00

51520 ....... Removal of bladder lesion ............................. .................. 1,467.24 4 630.00 .................. 126.00 

51710 ....... Change of bladder tube ................................. .................. 459.78 1 333.00 .................. 66.60 

51715 ....... Endoscopic injection/implant ......................... .................. 1,784.13 3 510.00 .................. 102.00 

51726 ....... Complex cystometrogram .............................. .................. 209.48 1 209.48 Y .............. 41.90 

51772 ....... Urethra pressure profile ................................. .................. 131.50 1 131.50 Y .............. 26.30 

51785 ....... Anal/urinary muscle study ............................. .................. 66.92 1 66.92 Y .............. 13.38 

51880 ....... Repair of bladder opening ............................. .................. 1,467.24 1 333.00 .................. 66.60 

51992 ....... Laparo sling operation ................................... .................. 2,676.86 5 717.00 .................. 143.40 

52000 ....... Cystoscopy .................................................... .................. 399.24 1 333.00 .................. 66.60 

52001 ....... Cystoscopy, removal of clots ......................... .................. 399.24 2 399.24 Y .............. 79.85 

52005 ....... Cystoscopy & ureter catheter ........................ .................. 1,181.73 2 446.00 .................. 89.20 

52007 ....... Cystoscopy and biopsy .................................. .................. 1,181.73 2 446.00 .................. 89.20 

52010 ....... Cystoscopy & duct catheter ........................... .................. 399.24 2 399.24 Y .............. 79.85 

52204 ....... Cystoscopy w/biopsy(s) ................................. .................. 1,181.73 2 446.00 .................. 89.20 

52214 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52224 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52234 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52235 ....... Cystoscopy and treatment ............................. .................. 1,467.24 3 510.00 .................. 102.00 

52240 ....... Cystoscopy and treatment ............................. .................. 1,467.24 3 510.00 .................. 102.00 

52250 ....... Cystoscopy and radiotracer ........................... .................. 1,467.24 4 630.00 .................. 126.00 

52260 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52270 ....... Cystoscopy & revise urethra ......................... .................. 1,181.73 2 446.00 .................. 89.20 

52275 ....... Cystoscopy & revise urethra ......................... .................. 1,181.73 2 446.00 .................. 89.20 

52276 ....... Cystoscopy and treatment ............................. .................. 1,181.73 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68273 

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—Continued 

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 

($) 

52277 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52281 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52282 ....... Cystoscopy, implant stent .............................. .................. 2,146.84 9 1,339.00 .................. 267.80 

52283 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52285 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52290 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52300 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52301 ....... Cystoscopy and treatment ............................. .................. 1,181.73 3 510.00 .................. 102.00 

52305 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52310 ....... Cystoscopy and treatment ............................. .................. 399.24 2 399.24 Y .............. 79.85 

52315 ....... Cystoscopy and treatment ............................. .................. 1,181.73 2 446.00 .................. 89.20 

52317 ....... Remove bladder stone .................................. .................. 1,467.24 1 333.00 .................. 66.60 

52318 ....... Remove bladder stone .................................. .................. 1,467.24 2 446.00 .................. 89.20 

52320 ....... Cystoscopy and treatment ............................. .................. 1,467.24 5 717.00 .................. 143.40 

52325 ....... Cystoscopy, stone removal ........................... .................. 1,467.24 4 630.00 .................. 126.00 

52327 ....... Cystoscopy, inject material ............................ .................. 1,467.24 2 446.00 .................. 89.20 

52330 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52332 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20 

52334 ....... Create passage to kidney .............................. .................. 1,467.24 3 510.00 .................. 102.00 

52341 ....... Cysto w/ureter stricture tx .............................. .................. 1,467.24 3 510.00 .................. 102.00 

52342 ....... Cysto w/up stricture tx ................................... .................. 1,467.24 3 510.00 .................. 102.00 

52343 ....... Cysto w/renal stricture tx ............................... .................. 1,467.24 3 510.00 .................. 102.00 

52344 ....... Cysto/uretero, stricture tx .............................. .................. 1,467.24 3 510.00 .................. 102.00 

52345 ....... Cysto/uretero w/up stricture ........................... .................. 1,467.24 3 510.00 .................. 102.00

52346 ....... Cystouretero w/renal strict ............................. .................. 1,467.24 3 510.00 .................. 102.00 

52351 ....... Cystouretero & or pyeloscope ....................... .................. 1,181.73 3 510.00 .................. 102.00 

52352 ....... Cystouretero w/stone remove ........................ .................. 1,467.24 4 630.00 .................. 126.00 

52353 ....... Cystouretero w/lithotripsy .............................. .................. 2,146.84 4 630.00 .................. 126.00 

52354 ....... Cystouretero w/biopsy ................................... .................. 1,467.24 4 630.00 .................. 126.00 

52355 ....... Cystouretero w/excise tumor ......................... .................. 1,467.24 4 630.00 .................. 126.00 

52400 ....... Cystouretero w/congen repr .......................... .................. 1,467.24 3 510.00 .................. 102.00 

52402 ....... Cystourethro cut ejacul duct .......................... .................. 1,467.24 3 510.00 .................. 102.00 

52450 ....... Incision of prostate ........................................ .................. 1,467.24 3 510.00 .................. 102.00 

52500 ....... Revision of bladder neck ............................... .................. 1,467.24 3 510.00 .................. 102.00

52510 ....... Dilation prostatic urethra ................................ .................. 1,181.73 3 510.00 .................. 102.00 

52601 ....... Prostatectomy (TURP) ................................... .................. 2,146.84 4 630.00 .................. 126.00

52606 ....... Control postop bleeding ................................. .................. 1,467.24 1 333.00 .................. 66.60

52612 ....... Prostatectomy, first stage .............................. .................. 2,146.84 2 446.00 .................. 89.20

52614 ....... Prostatectomy, second stage ........................ .................. 2,146.84 1 333.00 .................. 66.60 

52620 ....... Remove residual prostate .............................. .................. 2,146.84 1 333.00 .................. 66.60 

52630 ....... Remove prostate regrowth ............................ .................. 2,146.84 2 446.00 .................. 89.20 

52640 ....... Relieve bladder contracture ........................... .................. 1,467.24 2 446.00 .................. 89.20 

52647 ....... Laser surgery of prostate .............................. .................. 2,649.30 9 1,339.00 .................. 267.80 

52648 ....... Laser surgery of prostate .............................. .................. 2,649.30 9 1,339.00 .................. 267.80 

52700 ....... Drainage of prostate abscess ........................ .................. 1,467.24 2 446.00 .................. 89.20 

53000 ....... Incision of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60 

53010 ....... Incision of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60 

53020 ....... Incision of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60 

53040 ....... Drainage of urethra abscess ......................... .................. 1,130.77 2 446.00 .................. 89.20 

53080 ....... Drainage of urinary leakage .......................... .................. 1,130.77 3 510.00 .................. 102.00 

53200 ....... Biopsy of urethra ........................................... .................. 1,130.77 1 333.00 .................. 66.60 

53210 ....... Removal of urethra ........................................ .................. 1,784.13 5 717.00 .................. 143.40 

53215 ....... Removal of urethra ........................................ .................. 1,130.77 5 717.00 .................. 143.40 

53220 ....... Treatment of urethra lesion ........................... .................. 1,784.13 2 446.00 .................. 89.20 

53230 ....... Removal of urethra lesion ............................. .................. 1,784.13 2 446.00 .................. 89.20 

53235 ....... Removal of urethra lesion ............................. .................. 1,130.77 3 510.00 .................. 102.00 

53240 ....... Surgery for urethra pouch ............................. .................. 1,784.13 2 446.00 .................. 89.20 

53250 ....... Removal of urethra gland .............................. .................. 1,130.77 2 446.00 .................. 89.20 

53260 ....... Treatment of urethra lesion ........................... .................. 1,130.77 2 446.00 .................. 89.20 

53265 ....... Treatment of urethra lesion ........................... .................. 1,130.77 2 446.00 .................. 89.20 

53270 ....... Removal of urethra gland .............................. .................. 1,130.77 2 446.00 .................. 89.20 

53275 ....... Repair of urethra defect ................................. .................. 1,130.77 2 446.00 .................. 89.20 

53400 ....... Revise urethra, stage 1 ................................. .................. 1,784.13 3 510.00 .................. 102.00 

53405 ....... Revise urethra, stage 2 ................................. .................. 1,784.13 2 446.00 .................. 89.20

53410 ....... Reconstruction of urethra .............................. .................. 1,784.13 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
68274 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

53420 ....... Reconstruct urethra, stage 1 ......................... .................. 1,784.13 3 510.00 .................. 102.00 

53425 ....... Reconstruct urethra, stage 2 ......................... .................. 1,784.13 2 446.00 .................. 89.20 

53430 ....... Reconstruction of urethra .............................. .................. 1,784.13 2 446.00 .................. 89.20 

53431 ....... Reconstruct urethra/bladder .......................... .................. 1,784.13 2 446.00 .................. 89.20 

53440 ....... Male sling procedure ..................................... .................. 4,868.83 2 446.00 .................. 89.20 

53442 ....... Remove/revise male sling ............................. .................. 1,784.13 1 333.00 .................. 66.60 

53444 ....... Insert tandem cuff .......................................... .................. 4,868.83 2 446.00 .................. 89.20 

53445 ....... Insert uro/ves nck sphincter .......................... .................. 8,445.07 1 333.00 .................. 66.60 

53446 ....... Remove uro sphincter ................................... .................. 1,784.13 1 333.00 .................. 66.60 

53447 ....... Remove/replace ur sphincter ......................... .................. 8,445.07 1 333.00 .................. 66.60 

53449 ....... Repair uro sphincter ...................................... .................. 1,784.13 1 333.00 .................. 66.60 

53450 ....... Revision of urethra ........................................ .................. 1,784.13 1 333.00 .................. 66.60 

53460 ....... Revision of urethra ........................................ .................. 1,130.77 1 333.00 .................. 66.60 

53502 ....... Repair of urethra injury .................................. .................. 1,130.77 2 446.00 .................. 89.20 

53505 ....... Repair of urethra injury .................................. .................. 1,784.13 2 446.00 .................. 89.20 

53510 ....... Repair of urethra injury .................................. .................. 1,130.77 2 446.00 .................. 89.20 

53515 ....... Repair of urethra injury .................................. .................. 1,784.13 2 446.00 .................. 89.20 

53520 ....... Repair of urethra defect ................................. .................. 1,784.13 2 446.00 .................. 89.20 

53605 ....... Dilate urethra stricture ................................... .................. 1,181.73 2 446.00 .................. 89.20 

53665 ....... Dilation of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60 

54000 ....... Slitting of prepuce .......................................... .................. 1,130.77 2 446.00 .................. 89.20 

54001 ....... Slitting of prepuce .......................................... .................. 1,130.77 2 446.00 .................. 89.20 

54015 ....... Drain penis lesion .......................................... .................. 1,076.22 4 630.00 .................. 126.00 

54057 ....... Laser surg, penis lesion(s) ............................ .................. 1,072.14 1 333.00 .................. 66.60 

54060 ....... Excision of penis lesion(s) ............................. .................. 1,072.14 1 333.00 .................. 66.60

54065 ....... Destruction, penis lesion(s) ........................... .................. 1,255.64 1 333.00 .................. 66.60 

54100 ....... Biopsy of penis .............................................. .................. 928.31 1 333.00 .................. 66.60 

54105 ....... Biopsy of penis .............................................. .................. 1,233.39 1 333.00 .................. 66.60 

54110 ....... Treatment of penis lesion .............................. .................. 2,027.66 2 446.00 .................. 89.20 

54111 ....... Treat penis lesion, graft ................................. .................. 2,027.66 2 446.00 .................. 89.20 

54112 ....... Treat penis lesion, graft ................................. .................. 2,027.66 2 446.00 .................. 89.20 

54115 ....... Treatment of penis lesion .............................. .................. 1,076.22 1 333.00 .................. 66.60 

54120 ....... Partial removal of penis ................................. .................. 2,027.66 2 446.00 .................. 89.20 

54150 ....... Circumcision w/regionl block ......................... .................. 1,263.25 1 333.00 .................. 66.60 

54152 ....... Circumcision .................................................. .................. 1,263.25 1 333.00 .................. 66.60 

54160 ....... Circumcision, neonate ................................... .................. 1,263.25 2 446.00 .................. 89.20

54161 ....... Circum 28 days or older ................................ .................. 1,263.25 2 446.00 .................. 89.20 

54162 ....... Lysis penil circumic lesion ............................. .................. 1,263.25 2 446.00 .................. 89.20

54163 ....... Repair of circumcision ................................... .................. 1,263.25 2 446.00 .................. 89.20 

54164 ....... Frenulotomy of penis ..................................... .................. 1,263.25 2 446.00 .................. 89.20 

54205 ....... Treatment of penis lesion .............................. .................. 2,027.66 4 630.00 .................. 126.00

54220 ....... Treatment of penis lesion .............................. .................. 131.50 1 131.50 Y .............. 26.30 

54300 ....... Revision of penis ........................................... .................. 2,027.66 3 510.00 .................. 102.00 

54304 ....... Revision of penis ........................................... .................. 2,027.66 3 510.00 .................. 102.00 

54308 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54312 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54316 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54318 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54322 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54324 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54326 ....... Reconstruction of urethra .............................. .................. 2,027.66 3 510.00 .................. 102.00

54328 ....... Revise penis/urethra ...................................... .................. 2,027.66 3 510.00 .................. 102.00 

54340 ....... Secondary urethral surgery ........................... .................. 2,027.66 3 510.00 .................. 102.00 

54344 ....... Secondary urethral surgery ........................... .................. 2,027.66 3 510.00 .................. 102.00 

54348 ....... Secondary urethral surgery ........................... .................. 2,027.66 3 510.00 .................. 102.00 

54352 ....... Reconstruct urethra/penis .............................. .................. 2,027.66 3 510.00 .................. 102.00

54360 ....... Penis plastic surgery ..................................... .................. 2,027.66 3 510.00 .................. 102.00 

54380 ....... Repair penis ................................................... .................. 2,027.66 3 510.00 .................. 102.00 

54385 ....... Repair penis ................................................... .................. 2,027.66 3 510.00 .................. 102.00 

54400 ....... Insert semi-rigid prosthesis ............................ .................. 4,868.83 3 510.00 .................. 102.00 

54401 ....... Insert self-contd prosthesis ............................ .................. 8,445.07 3 510.00 .................. 102.00 

54405 ....... Insert multi-comp penis pros ......................... .................. 8,445.07 3 510.00 .................. 102.00 

54406 ....... Remove muti-comp penis pros ...................... .................. 2,027.66 3 510.00 .................. 102.00 

54408 ....... Repair multi-comp penis pros ........................ .................. 2,027.66 3 510.00 .................. 102.00 

54410 ....... Remove/replace penis prosth ........................ .................. 8,445.07 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68275 

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—Continued 

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 

($) 

54415 ....... Remove self-contd penis pros ....................... .................. 2,027.66 3 510.00 .................. 102.00 

54416 ....... Remv/repl penis contain pros ........................ .................. 8,445.07 3 510.00 .................. 102.00 

54420 ....... Revision of penis ........................................... .................. 2,027.66 4 630.00 .................. 126.00 

54435 ....... Revision of penis ........................................... .................. 2,027.66 4 630.00 .................. 126.00 

54440 ....... Repair of penis .............................................. .................. 2,027.66 4 630.00 .................. 126.00 

54450 ....... Preputial stretching ........................................ .................. 209.48 1 209.48 Y .............. 41.90 

54500 ....... Biopsy of testis .............................................. .................. 631.00 1 333.00 .................. 66.60 

54505 ....... Biopsy of testis .............................................. .................. 1,446.40 1 333.00 .................. 66.60 

54512 ....... Excise lesion testis ........................................ .................. 1,446.40 2 446.00 .................. 89.20 

54520 ....... Removal of testis ........................................... .................. 1,446.40 3 510.00 .................. 102.00 

54522 ....... Orchiectomy, partial ....................................... .................. 1,446.40 3 510.00 .................. 102.00 

54530 ....... Removal of testis ........................................... .................. 1,795.98 4 630.00 .................. 126.00 

54550 ....... Exploration for testis ...................................... .................. 1,795.98 4 630.00 .................. 126.00 

54600 ....... Reduce testis torsion ..................................... .................. 1,446.40 4 630.00 .................. 126.00 

54620 ....... Suspension of testis ...................................... .................. 1,446.40 3 510.00 .................. 102.00 

54640 ....... Suspension of testis ...................................... .................. 1,795.98 4 630.00 .................. 126.00 

54660 ....... Revision of testis ........................................... .................. 1,446.40 2 446.00 .................. 89.20 

54670 ....... Repair testis injury ......................................... .................. 1,446.40 3 510.00 .................. 102.00 

54680 ....... Relocation of testis(es) .................................. .................. 1,446.40 3 510.00 .................. 102.00 

54690 ....... Laparoscopy, orchiectomy ............................. .................. 2,676.86 9 1,339.00 .................. 267.80

54700 ....... Drainage of scrotum ...................................... .................. 1,446.40 2 446.00 .................. 89.20 

54800 ....... Biopsy of epididymis ...................................... .................. 127.16 1 127.16 Y .............. 25.43 

54820 ....... Exploration of epididymis ............................... D .............. .................... 1 333.00 .................. ....................

54830 ....... Remove epididymis lesion ............................. .................. 1,446.40 3 510.00 .................. 102.00 

54840 ....... Remove epididymis lesion ............................. .................. 1,446.40 4 630.00 .................. 126.00 

54860 ....... Removal of epididymis .................................. .................. 1,446.40 3 510.00 .................. 102.00

54861 ....... Removal of epididymis .................................. .................. 1,446.40 4 630.00 .................. 126.00

54865 ....... Explore epididymis ......................................... A .............. 1,446.40 1 333.00 .................. 66.60

54900 ....... Fusion of spermatic ducts ............................. .................. 1,446.40 4 630.00 .................. 126.00 

54901 ....... Fusion of spermatic ducts ............................. .................. 1,446.40 4 630.00 .................. 126.00 

55040 ....... Removal of hydrocele .................................... .................. 1,795.98 3 510.00 .................. 102.00 

55041 ....... Removal of hydroceles .................................. .................. 1,795.98 5 717.00 .................. 143.40

55060 ....... Repair of hydrocele ....................................... .................. 1,446.40 4 630.00 .................. 126.00 

55100 ....... Drainage of scrotum abscess ........................ .................. 685.58 1 333.00 .................. 66.60 

55110 ....... Explore scrotum ............................................. .................. 1,446.40 2 446.00 .................. 89.20 

55120 ....... Removal of scrotum lesion ............................ .................. 1,446.40 2 446.00 .................. 89.20 

55150 ....... Removal of scrotum ....................................... .................. 1,446.40 1 333.00 .................. 66.60 

55175 ....... Revision of scrotum ....................................... .................. 1,446.40 1 333.00 .................. 66.60 

55180 ....... Revision of scrotum ....................................... .................. 1,446.40 2 446.00 .................. 89.20 

55200 ....... Incision of sperm duct ................................... .................. 1,446.40 2 446.00 .................. 89.20 

55250 ....... Removal of sperm duct(s) ............................. .................. 1,446.40 2 446.00 .................. 89.20 

55400 ....... Repair of sperm duct ..................................... .................. 1,446.40 1 333.00 .................. 66.60 

55500 ....... Removal of hydrocele .................................... .................. 1,446.40 3 510.00 .................. 102.00 

55520 ....... Removal of sperm cord lesion ....................... .................. 1,446.40 4 630.00 .................. 126.00 

55530 ....... Revise spermatic cord veins ......................... .................. 1,446.40 4 630.00 .................. 126.00 

55535 ....... Revise spermatic cord veins ......................... .................. 1,795.98 4 630.00 .................. 126.00 

55540 ....... Revise hernia & sperm veins ........................ .................. 1,795.98 5 717.00 .................. 143.40 

55550 ....... Laparo ligate spermatic vein ......................... .................. 2,676.86 9 1,339.00 .................. 267.80

55680 ....... Remove sperm pouch lesion ......................... .................. 1,446.40 1 333.00 .................. 66.60 

55700 ....... Biopsy of prostate .......................................... .................. 345.83 2 345.83 Y .............. 69.17 

55705 ....... Biopsy of prostate .......................................... .................. 345.83 2 345.83 Y .............. 69.17 

55720 ....... Drainage of prostate abscess ........................ .................. 1,467.24 1 333.00 .................. 66.60 

55725 ....... Drainage of prostate abscess ........................ .................. 1,467.24 2 446.00 .................. 89.20 

55859 ....... Percut/needle insert, pros .............................. D .............. .................... 9 1,339.00 .................. ....................

55873 ....... Cryoablate prostate ....................................... .................. 6,685.05 9 1,339.00 .................. 267.80 

55875 ....... Transperi needle place, pros ......................... A .............. 2,146.84 9 1,339.00 .................. 267.80 

56440 ....... Surgery for vulva lesion ................................. .................. 1,260.59 2 446.00 .................. 89.20 

56441 ....... Lysis of labial lesion(s) .................................. .................. 912.73 1 333.00 .................. 66.60 

56442 ....... Hymenotomy .................................................. A .............. 912.73 1 333.00 .................. 66.60 

56515 ....... Destroy vulva lesion/s compl ......................... .................. 1,255.64 3 510.00 .................. 102.00 

56620 ....... Partial removal of vulva ................................. .................. 1,752.42 5 717.00 .................. 143.40 

56625 ....... Complete removal of vulva ............................ .................. 1,752.42 7 995.00 .................. 199.00 

56700 ....... Partial removal of hymen ............................... .................. 1,260.59 1 333.00 .................. 66.60 

56720 ....... Incision of hymen ........................................... D .............. .................... 1 333.00 .................. ....................

56740 ....... Remove vagina gland lesion ......................... .................. 1,260.59 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
68276 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

56800 ....... Repair of vagina ............................................ .................. 1,260.59 3 510.00 .................. 102.00 

56810 ....... Repair of perineum ........................................ .................. 1,260.59 5 717.00 .................. 143.40 

57000 ....... Exploration of vagina ..................................... .................. 912.73 1 333.00 .................. 66.60

57010 ....... Drainage of pelvic abscess ........................... .................. 912.73 2 446.00 .................. 89.20 

57020 ....... Drainage of pelvic fluid .................................. .................. 409.33 2 409.33 Y .............. 81.87 

57023 ....... I & d vag hematoma, non-ob ......................... .................. 1,076.22 1 333.00 .................. 66.60 

57065 ....... Destroy vag lesions, complex ........................ .................. 1,260.59 1 333.00 .................. 66.60 

57105 ....... Biopsy of vagina ............................................ .................. 1,260.59 2 446.00 .................. 89.20 

57130 ....... Remove vagina lesion ................................... .................. 1,260.59 2 446.00 .................. 89.20 

57135 ....... Remove vagina lesion ................................... .................. 1,260.59 2 446.00 .................. 89.20 

57155 ....... Insert uteri tandems/ovoids ........................... .................. 409.33 2 409.33 Y .............. 81.87 

57180 ....... Treat vaginal bleeding ................................... .................. 178.05 1 178.05 Y .............. 35.61 

57200 ....... Repair of vagina ............................................ .................. 1,260.59 1 333.00 .................. 66.60 

57210 ....... Repair vagina/perineum ................................. .................. 1,260.59 2 446.00 .................. 89.20 

57220 ....... Revision of urethra ........................................ .................. 2,642.48 3 510.00 .................. 102.00 

57230 ....... Repair of urethral lesion ................................ .................. 1,752.42 3 510.00 .................. 102.00 

57240 ....... Repair bladder & vagina ................................ .................. 1,752.42 5 717.00 .................. 143.40

57250 ....... Repair rectum & vagina ................................. .................. 1,752.42 5 717.00 .................. 143.40

57260 ....... Repair of vagina ............................................ .................. 1,752.42 5 717.00 .................. 143.40 

57265 ....... Extensive repair of vagina ............................. .................. 2,642.48 7 995.00 .................. 199.00

57267 ....... Insert mesh/pelvic flr addon .......................... A* ............. 1,752.42 7 995.00 .................. 199.00 

57268 ....... Repair of bowel bulge .................................... .................. 1,752.42 3 510.00 .................. 102.00 

57288 ....... Repair bladder defect .................................... .................. 2,642.48 5 717.00 .................. 143.40 

57289 ....... Repair bladder & vagina ................................ .................. 1,752.42 5 717.00 .................. 143.40

57291 ....... Construction of vagina ................................... .................. 1,752.42 5 717.00 .................. 143.40 

57300 ....... Repair rectum-vagina fistula .......................... .................. 1,752.42 3 510.00 .................. 102.00 

57400 ....... Dilation of vagina ........................................... .................. 1,260.59 2 446.00 .................. 89.20 

57410 ....... Pelvic examination ......................................... .................. 912.73 2 446.00 .................. 89.20 

57415 ....... Remove vaginal foreign body ........................ .................. 1,260.59 2 446.00 .................. 89.20 

57513 ....... Laser surgery of cervix .................................. .................. 912.73 2 446.00 .................. 89.20 

57520 ....... Conization of cervix ....................................... .................. 1,260.59 2 446.00 .................. 89.20 

57522 ....... Conization of cervix ....................................... .................. 1,752.42 2 446.00 .................. 89.20 

57530 ....... Removal of cervix .......................................... .................. 1,752.42 3 510.00 .................. 102.00 

57550 ....... Removal of residual cervix ............................ .................. 1,752.42 3 510.00 .................. 102.00 

57556 ....... Remove cervix, repair bowel ......................... .................. 2,642.48 5 717.00 .................. 143.40 

57558 ....... D&c of cervical stump .................................... A .............. 1,091.05 3 510.00 .................. 102.00 

57700 ....... Revision of cervix .......................................... .................. 1,260.59 1 333.00 .................. 66.60 

57720 ....... Revision of cervix .......................................... .................. 1,260.59 3 510.00 .................. 102.00 

57820 ....... D & c of residual cervix ................................. D .............. .................... 3 510.00 .................. ....................

58120 ....... Dilation and curettage .................................... .................. 1,091.05 2 446.00 .................. 89.20 

58145 ....... Myomectomy vag method ............................. .................. 1,752.42 5 717.00 .................. 143.40 

58346 ....... Insert heyman uteri capsule .......................... .................. 912.73 2 446.00 .................. 89.20 

58350 ....... Reopen fallopian tube .................................... .................. 1,752.42 3 510.00 .................. 102.00 

58353 ....... Endometr ablate, thermal .............................. .................. 1,752.42 7 995.00 .................. 199.00 

58545 ....... Laparoscopic myomectomy ........................... .................. 1,974.60 9 1,339.00 .................. 267.80 

58546 ....... Laparo-myomectomy, complex ...................... .................. 2,676.86 9 1,339.00 .................. 267.80 

58550 ....... Laparo-asst vag hysterectomy ...................... .................. 4,333.90 9 1,339.00 .................. 267.80 

58555 ....... Hysteroscopy, dx, sep proc ........................... .................. 1,312.87 1 333.00 .................. 66.60 

58558 ....... Hysteroscopy, biopsy ..................................... .................. 1,312.87 3 510.00 .................. 102.00 

58559 ....... Hysteroscopy, lysis ........................................ .................. 1,312.87 2 446.00 .................. 89.20 

58560 ....... Hysteroscopy, resect septum ........................ .................. 2,090.86 3 510.00 .................. 102.00 

58561 ....... Hysteroscopy, remove myoma ...................... .................. 2,090.86 3 510.00 .................. 102.00 

58562 ....... Hysteroscopy, remove fb ............................... .................. 1,312.87 3 510.00 .................. 102.00 

58563 ....... Hysteroscopy, ablation .................................. .................. 2,090.86 9 1,339.00 .................. 267.80 

58565 ....... Hysteroscopy, sterilization ............................. .................. 2,642.48 9 1,339.00 .................. 267.80 

58660 ....... Laparoscopy, lysis ......................................... .................. 2,676.86 5 717.00 .................. 143.40 

58661 ....... Laparoscopy, remove adnexa ....................... .................. 2,676.86 5 717.00 .................. 143.40 

58662 ....... Laparoscopy, excise lesions .......................... .................. 2,676.86 5 717.00 .................. 143.40 

58670 ....... Laparoscopy, tubal cautery ........................... .................. 2,676.86 3 510.00 .................. 102.00 

58671 ....... Laparoscopy, tubal block ............................... .................. 2,676.86 3 510.00 .................. 102.00

58672 ....... Laparoscopy, fimbrioplasty ............................ .................. 2,676.86 5 717.00 .................. 143.40 

58673 ....... Laparoscopy, salpingostomy ......................... .................. 2,676.86 5 717.00 .................. 143.40 

58800 ....... Drainage of ovarian cyst(s) ........................... .................. 912.73 3 510.00 .................. 102.00 

58820 ....... Drain ovary abscess, open ............................ .................. 1,752.42 3 510.00 .................. 102.00 

58900 ....... Biopsy of ovary(s) .......................................... .................. 912.73 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68277 

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—Continued 

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 

($) 

58970 ....... Retrieval of oocyte ......................................... .................. 245.92 1 245.92 Y .............. 49.18 

58974 ....... Transfer of embryo ........................................ .................. 245.92 1 245.92 Y .............. 49.18 

58976 ....... Transfer of embryo ........................................ .................. 245.92 1 245.92 Y .............. 49.18 

59160 ....... D& c after delivery ......................................... .................. 1,091.05 3 510.00 .................. 102.00 

59320 ....... Revision of cervix .......................................... .................. 1,260.59 1 333.00 .................. 66.60 

59812 ....... Treatment of miscarriage ............................... .................. 1,138.39 5 717.00 .................. 143.40

59820 ....... Care of miscarriage ....................................... .................. 1,138.39 5 717.00 .................. 143.40 

59821 ....... Treatment of miscarriage ............................... .................. 1,138.39 5 717.00 .................. 143.40

59840 ....... Abortion .......................................................... .................. 1,040.83 5 717.00 .................. 143.40 

59841 ....... Abortion .......................................................... .................. 1,040.83 5 717.00 .................. 143.40 

59870 ....... Evacuate mole of uterus ................................ .................. 1,138.39 5 717.00 .................. 143.40

59871 ....... Remove cerclage suture ................................ .................. 1,260.59 5 717.00 .................. 143.40 

60000 ....... Drain thyroid/tongue cyst ............................... .................. 464.15 1 333.00 .................. 66.60 

60200 ....... Remove thyroid lesion ................................... .................. 2,318.72 2 446.00 .................. 89.20

60280 ....... Remove thyroid duct lesion ........................... .................. 2,318.72 4 630.00 .................. 126.00 

60281 ....... Remove thyroid duct lesion ........................... .................. 2,318.72 4 630.00 .................. 126.00 

61020 ....... Remove brain cavity fluid .............................. .................. 183.83 1 183.83 Y .............. 36.77 

61026 ....... Injection into brain canal ................................ .................. 183.83 1 183.83 Y .............. 36.77 

61050 ....... Remove brain canal fluid ............................... .................. 183.83 1 183.83 Y .............. 36.77 

61055 ....... Injection into brain canal ................................ .................. 183.83 1 183.83 Y .............. 36.77 

61070 ....... Brain canal shunt procedure ......................... .................. 183.83 1 183.83 Y .............. 36.77 

61215 ....... Insert brain-fluid device ................................. .................. 2,891.10 3 510.00 .................. 102.00 

61790 ....... Treat trigeminal nerve .................................... .................. 1,097.20 3 510.00 .................. 102.00 

61791 ....... Treat trigeminal tract ...................................... .................. 351.92 3 351.92 Y .............. 70.38 

61795 ....... Brain surgery using computer ....................... A* ............. 302.04 1 302.04 Y .............. 60.41 

61885 ....... Insrt/redo neurostim 1 array .......................... .................. 11,518.00 2 446.00 .................. 89.20 

61886 ....... Implant neurostim arrays ............................... .................. 14,932.81 3 510.00 .................. 102.00 

61888 ....... Revise/remove neuroreceiver ........................ .................. 2,186.43 1 333.00 .................. 66.60 

62194 ....... Replace/irrigate catheter ................................ .................. 716.56 1 333.00 .................. 66.60 

62225 ....... Replace/irrigate catheter ................................ .................. 716.56 1 333.00 .................. 66.60 

62230 ....... Replace/revise brain shunt ............................ .................. 2,891.10 2 446.00 .................. 89.20 

62263 ....... Epidural lysis mult sessions .......................... .................. 748.08 1 333.00 .................. 66.60 

62264 ....... Epidural lysis on single day ........................... .................. 748.08 1 333.00 .................. 66.60 

62268 ....... Drain spinal cord cyst .................................... .................. 183.83 1 183.83 Y .............. 36.77 

62269 ....... Needle biopsy, spinal cord ............................ .................. 377.32 1 333.00 .................. 66.60 

62270 ....... Spinal fluid tap, diagnostic ............................. .................. 139.00 1 139.00 Y .............. 27.80 

62272 ....... Drain cerebro spinal fluid ............................... .................. 139.00 1 139.00 Y .............. 27.80 

62273 ....... Inject epidural patch ...................................... .................. 351.92 1 333.00 .................. 66.60 

62280 ....... Treat spinal cord lesion ................................. .................. 390.95 1 333.00 .................. 66.60 

62281 ....... Treat spinal cord lesion ................................. .................. 390.95 1 333.00 .................. 66.60 

62282 ....... Treat spinal canal lesion ................................ .................. 390.95 1 333.00 .................. 66.60 

62287 ....... Percutaneous diskectomy .............................. .................. 2,037.79 9 1,339.00 .................. 267.80

62294 ....... Injection into spinal artery .............................. .................. 183.83 3 183.83 Y .............. 36.77 

62310 ....... Inject spine c/t ................................................ .................. 390.95 1 333.00 .................. 66.60 

62311 ....... Inject spine l/s (cd) ........................................ .................. 390.95 1 333.00 .................. 66.60 

62318 ....... Inject spine w/cath, c/t ................................... .................. 390.95 1 333.00 .................. 66.60 

62319 ....... Inject spine w/cath l/s (cd) ............................. .................. 390.95 1 333.00 .................. 66.60 

62350 ....... Implant spinal canal cath ............................... .................. 1,895.64 2 446.00 .................. 89.20

62355 ....... Remove spinal canal catheter ....................... .................. 748.08 2 446.00 .................. 89.20 

62360 ....... Insert spine infusion device ........................... .................. 6,923.28 2 446.00 .................. 89.20 

62361 ....... Implant spine infusion pump .......................... .................. 10,720.36 2 446.00 .................. 89.20 

62362 ....... Implant spine infusion pump .......................... .................. 10,720.36 2 446.00 .................. 89.20 

62365 ....... Remove spine infusion device ....................... .................. 2,037.79 2 446.00 .................. 89.20 

63600 ....... Remove spinal cord lesion ............................ .................. 1,097.20 2 446.00 .................. 89.20 

63610 ....... Stimulation of spinal cord .............................. .................. 1,097.20 1 333.00 .................. 66.60

63650 ....... Implant neuroelectrodes ................................ .................. 3,477.28 2 446.00 .................. 89.20 

63660 ....... Revise/remove neuroelectrode ...................... .................. 1,096.18 1 333.00 .................. 66.60 

63685 ....... Insrt/redo spine n generator .......................... .................. 11,164.12 2 446.00 .................. 89.20 

63688 ....... Revise/remove neuroreceiver ........................ .................. 2,186.43 1 333.00 .................. 66.60 

63744 ....... Revision of spinal shunt ................................ .................. 2,413.44 3 510.00 .................. 102.00 

63746 ....... Removal of spinal shunt ................................ .................. 675.64 2 446.00 .................. 89.20 

64410 ....... Nblock inj, phrenic ......................................... .................. 351.92 1 333.00 .................. 66.60 

64415 ....... Nblock inj, brachial plexus ............................. .................. 139.00 1 139.00 Y .............. 27.80 

64417 ....... Nblock inj, axillary .......................................... .................. 139.00 1 139.00 Y .............. 27.80 

64420 ....... Nblock inj, intercost, sng ............................... .................. 139.00 1 139.00 Y .............. 27.80 


cprice-sewell on PRODPC62 with RULES2
68278 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

64421 ....... Nblock inj, intercost, mlt ................................ .................. 351.92 1 333.00 .................. 66.60

64430 ....... Nblock inj, pudendal ...................................... .................. 139.00 1 139.00 Y .............. 27.80 

64470 ....... Inj paravertebral c/t ........................................ .................. 390.95 1 333.00 .................. 66.60 

64472 ....... Inj paravertebral c/t add-on ........................... .................. 351.92 1 333.00 .................. 66.60 

64475 ....... Inj paravertebral l/s ........................................ .................. 390.95 1 333.00 .................. 66.60 

64476 ....... Inj paravertebral l/s add-on ............................ .................. 351.92 1 333.00 .................. 66.60 

64479 ....... Inj foramen epidural c/t .................................. .................. 390.95 1 333.00 .................. 66.60

64480 ....... Inj foramen epidural add-on .......................... .................. 390.95 1 333.00 .................. 66.60 

64483 ....... Inj foramen epidural l/s .................................. .................. 390.95 1 333.00 .................. 66.60

64484 ....... Inj foramen epidural add-on .......................... .................. 390.95 1 333.00 .................. 66.60 

64510 ....... Nblock, stellate ganglion ................................ .................. 390.95 1 333.00 .................. 66.60 

64517 ....... Nblock inj, hypogas plxs ................................ .................. 139.00 2 139.00 Y .............. 27.80 

64520 ....... Nblock, lumbar/thoracic ................................. .................. 390.95 1 333.00 .................. 66.60 

64530 ....... Nblock inj, celiac pelus .................................. .................. 390.95 1 333.00 .................. 66.60

64553 ....... Implant neuroelectrodes ................................ .................. 13,593.72 1 333.00 .................. 66.60

64561 ....... Implant neuroelectrodes ................................ .................. 3,477.28 3 510.00 .................. 102.00

64573 ....... Implant neuroelectrodes ................................ .................. 13,593.72 1 333.00 .................. 66.60

64575 ....... Implant neuroelectrodes ................................ .................. 5,175.40 1 333.00 .................. 66.60 

64577 ....... Implant neuroelectrodes ................................ .................. 5,175.40 1 333.00 .................. 66.60 

64580 ....... Implant neuroelectrodes ................................ .................. 5,175.40 1 333.00 .................. 66.60 

64581 ....... Implant neuroelectrodes ................................ .................. 5,175.40 3 510.00 .................. 102.00

64585 ....... Revise/remove neuroelectrode ...................... .................. 1,096.18 1 333.00 .................. 66.60 

64590 ....... Insrt/redo pn/gastr stimul ............................... .................. 11,164.12 2 446.00 .................. 89.20 

64595 ....... Revise/rmv pn/gastr stimul ............................ .................. 2,186.43 1 333.00 .................. 66.60 

64600 ....... Injection treatment of nerve ........................... .................. 748.08 1 333.00 .................. 66.60 

64605 ....... Injection treatment of nerve ........................... .................. 748.08 1 333.00 .................. 66.60 

64610 ....... Injection treatment of nerve ........................... .................. 748.08 1 333.00 .................. 66.60 

64620 ....... Injection treatment of nerve ........................... .................. 748.08 1 333.00 .................. 66.60 

64622 ....... Destr paravertebrl nerve l/s ........................... .................. 748.08 1 333.00 .................. 66.60 

64623 ....... Destr paravertebral n add-on ........................ .................. 390.95 1 333.00 .................. 66.60 

64626 ....... Destr paravertebrl nerve c/t ........................... .................. 748.08 1 333.00 .................. 66.60 

64627 ....... Destr paravertebral n add-on ........................ .................. 390.95 1 333.00 .................. 66.60 

64630 ....... Injection treatment of nerve ........................... .................. 351.92 2 351.92 Y .............. 70.38 

64680 ....... Injection treatment of nerve ........................... .................. 390.95 2 390.95 Y .............. 78.19 

64681 ....... Injection treatment of nerve ........................... .................. 748.08 2 446.00 .................. 89.20 

64702 ....... Revise finger/toe nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60 

64704 ....... Revise hand/foot nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60

64708 ....... Revise arm/leg nerve ..................................... .................. 1,097.20 2 446.00 .................. 89.20 

64712 ....... Revision of sciatic nerve ................................ .................. 1,097.20 2 446.00 .................. 89.20 

64713 ....... Revision of arm nerve(s) ............................... .................. 1,097.20 2 446.00 .................. 89.20 

64714 ....... Revise low back nerve(s) .............................. .................. 1,097.20 2 446.00 .................. 89.20 

64716 ....... Revision of cranial nerve ............................... .................. 1,097.20 3 510.00 .................. 102.00 

64718 ....... Revise ulnar nerve at elbow .......................... .................. 1,097.20 2 446.00 .................. 89.20 

64719 ....... Revise ulnar nerve at wrist ............................ .................. 1,097.20 2 446.00 .................. 89.20 

64721 ....... Carpal tunnel surgery .................................... .................. 1,097.20 2 446.00 .................. 89.20 

64722 ....... Relieve pressure on nerve(s) ........................ .................. 1,097.20 1 333.00 .................. 66.60 

64726 ....... Release foot/toe nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60

64727 ....... Internal nerve revision ................................... .................. 1,097.20 1 333.00 .................. 66.60 

64732 ....... Incision of brow nerve ................................... .................. 1,097.20 2 446.00 .................. 89.20 

64734 ....... Incision of cheek nerve .................................. .................. 1,097.20 2 446.00 .................. 89.20 

64736 ....... Incision of chin nerve ..................................... .................. 1,097.20 2 446.00 .................. 89.20 

64738 ....... Incision of jaw nerve ...................................... .................. 1,097.20 2 446.00 .................. 89.20 

64740 ....... Incision of tongue nerve ................................ .................. 1,097.20 2 446.00 .................. 89.20

64742 ....... Incision of facial nerve ................................... .................. 1,097.20 2 446.00 .................. 89.20 

64744 ....... Incise nerve, back of head ............................ .................. 1,097.20 2 446.00 .................. 89.20 

64746 ....... Incise diaphragm nerve ................................. .................. 1,097.20 2 446.00 .................. 89.20 

64771 ....... Sever cranial nerve ........................................ .................. 1,097.20 2 446.00 .................. 89.20 

64772 ....... Incision of spinal nerve .................................. .................. 1,097.20 2 446.00 .................. 89.20 

64774 ....... Remove skin nerve lesion ............................. .................. 1,097.20 2 446.00 .................. 89.20 

64776 ....... Remove digit nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00 

64778 ....... Digit nerve surgery add-on ............................ .................. 1,097.20 2 446.00 .................. 89.20 

64782 ....... Remove limb nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00 

64783 ....... Limb nerve surgery add-on ........................... .................. 1,097.20 2 446.00 .................. 89.20 

64784 ....... Remove nerve lesion ..................................... .................. 1,097.20 3 510.00 .................. 102.00 

64786 ....... Remove sciatic nerve lesion .......................... .................. 2,037.79 3 510.00 .................. 102.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68279 

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—Continued 

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 

($) 

64787 ....... Implant nerve end .......................................... .................. 1,097.20 2 446.00 .................. 89.20 

64788 ....... Remove skin nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00 

64790 ....... Removal of nerve lesion ................................ .................. 1,097.20 3 510.00 .................. 102.00

64792 ....... Removal of nerve lesion ................................ .................. 2,037.79 3 510.00 .................. 102.00

64795 ....... Biopsy of nerve .............................................. .................. 1,097.20 2 446.00 .................. 89.20 

64802 ....... Remove sympathetic nerves ......................... .................. 1,097.20 2 446.00 .................. 89.20 

64821 ....... Remove sympathetic nerves ......................... .................. 1,590.53 4 630.00 .................. 126.00 

64831 ....... Repair of digit nerve ...................................... .................. 2,037.79 4 630.00 .................. 126.00 

64832 ....... Repair nerve add-on ...................................... .................. 2,037.79 1 333.00 .................. 66.60 

64834 ....... Repair of hand or foot nerve ......................... .................. 2,037.79 2 446.00 .................. 89.20 

64835 ....... Repair of hand or foot nerve ......................... .................. 2,037.79 3 510.00 .................. 102.00 

64836 ....... Repair of hand or foot nerve ......................... .................. 2,037.79 3 510.00 .................. 102.00 

64837 ....... Repair nerve add-on ...................................... .................. 2,037.79 1 333.00 .................. 66.60 

64840 ....... Repair of leg nerve ........................................ .................. 2,037.79 2 446.00 .................. 89.20 

64856 ....... Repair/transpose nerve ................................. .................. 2,037.79 2 446.00 .................. 89.20 

64857 ....... Repair arm/leg nerve ..................................... .................. 2,037.79 2 446.00 .................. 89.20 

64858 ....... Repair sciatic nerve ....................................... .................. 2,037.79 2 446.00 .................. 89.20 

64859 ....... Nerve surgery ................................................ .................. 2,037.79 1 333.00 .................. 66.60 

64861 ....... Repair of arm nerves ..................................... .................. 2,037.79 3 510.00 .................. 102.00 

64862 ....... Repair of low back nerves ............................. .................. 2,037.79 3 510.00 .................. 102.00 

64864 ....... Repair of facial nerve .................................... .................. 2,037.79 3 510.00 .................. 102.00 

64865 ....... Repair of facial nerve .................................... .................. 2,037.79 4 630.00 .................. 126.00 

64870 ....... Fusion of facial/other nerve ........................... .................. 2,037.79 4 630.00 .................. 126.00

64872 ....... Subsequent repair of nerve ........................... .................. 2,037.79 2 446.00 .................. 89.20 

64874 ....... Repair & revise nerve add-on ....................... .................. 2,037.79 3 510.00 .................. 102.00 

64876 ....... Repair nerve/shorten bone ............................ .................. 2,037.79 3 510.00 .................. 102.00 

64885 ....... Nerve graft, head or neck .............................. .................. 2,037.79 2 446.00 .................. 89.20 

64886 ....... Nerve graft, head or neck .............................. .................. 2,037.79 2 446.00 .................. 89.20 

64890 ....... Nerve graft, hand or foot ............................... .................. 2,037.79 2 446.00 .................. 89.20

64891 ....... Nerve graft, hand or foot ............................... .................. 2,037.79 2 446.00 .................. 89.20

64892 ....... Nerve graft, arm or leg .................................. .................. 2,037.79 2 446.00 .................. 89.20 

64893 ....... Nerve graft, arm or leg .................................. .................. 2,037.79 2 446.00 .................. 89.20 

64895 ....... Nerve graft, hand or foot ............................... .................. 2,037.79 3 510.00 .................. 102.00 

64896 ....... Nerve graft, hand or foot ............................... .................. 2,037.79 3 510.00 .................. 102.00 

64897 ....... Nerve graft, arm or leg .................................. .................. 2,037.79 3 510.00 .................. 102.00 

64898 ....... Nerve graft, arm or leg .................................. .................. 2,037.79 3 510.00 .................. 102.00 

64901 ....... Nerve graft add-on ......................................... .................. 2,037.79 2 446.00 .................. 89.20 

64902 ....... Nerve graft add-on ......................................... .................. 2,037.79 2 446.00 .................. 89.20 

64905 ....... Nerve pedicle transfer ................................... .................. 2,037.79 2 446.00 .................. 89.20 

64907 ....... Nerve pedicle transfer ................................... .................. 2,037.79 1 333.00 .................. 66.60 

65091 ....... Revise eye ..................................................... .................. 2,165.47 3 510.00 .................. 102.00 

65093 ....... Revise eye with implant ................................. .................. 2,165.47 3 510.00 .................. 102.00 

65101 ....... Removal of eye .............................................. .................. 2,165.47 3 510.00 .................. 102.00 

65103 ....... Remove eye/insert implant ............................ .................. 2,165.47 3 510.00 .................. 102.00 

65105 ....... Remove eye/attach implant ........................... .................. 2,165.47 4 630.00 .................. 126.00 

65110 ....... Removal of eye .............................................. .................. 2,165.47 5 717.00 .................. 143.40 

65112 ....... Remove eye/revise socket ............................ .................. 2,165.47 7 995.00 .................. 199.00 

65114 ....... Remove eye/revise socket ............................ .................. 2,165.47 7 995.00 .................. 199.00 

65130 ....... Insert ocular implant ...................................... .................. 1,552.37 3 510.00 .................. 102.00 

65135 ....... Insert ocular implant ...................................... .................. 1,552.37 2 446.00 .................. 89.20 

65140 ....... Attach ocular implant ..................................... .................. 2,165.47 3 510.00 .................. 102.00 

65150 ....... Revise ocular implant .................................... .................. 1,552.37 2 446.00 .................. 89.20 

65155 ....... Reinsert ocular implant .................................. .................. 2,165.47 3 510.00 .................. 102.00 

65175 ....... Removal of ocular implant ............................. .................. 1,052.60 1 333.00 .................. 66.60 

65235 ....... Remove foreign body from eye ..................... .................. 935.91 2 446.00 .................. 89.20 

65260 ....... Remove foreign body from eye ..................... .................. 1,015.69 3 510.00 .................. 102.00 

65265 ....... Remove foreign body from eye ..................... .................. 1,696.64 4 630.00 .................. 126.00 

65270 ....... Repair of eye wound ..................................... .................. 1,052.60 2 446.00 .................. 89.20

65272 ....... Repair of eye wound ..................................... .................. 1,413.58 2 446.00 .................. 89.20

65275 ....... Repair of eye wound ..................................... .................. 1,413.58 4 630.00 .................. 126.00 

65280 ....... Repair of eye wound ..................................... .................. 1,015.69 4 630.00 .................. 126.00 

65285 ....... Repair of eye wound ..................................... .................. 2,300.69 4 630.00 .................. 126.00 

65290 ....... Repair of eye socket wound .......................... .................. 1,308.05 3 510.00 .................. 102.00 

65400 ....... Removal of eye lesion ................................... .................. 935.91 1 333.00 .................. 66.60 

65410 ....... Biopsy of cornea ............................................ .................. 935.91 2 446.00 .................. 89.20 


cprice-sewell on PRODPC62 with RULES2
68280 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

65420 ....... Removal of eye lesion ................................... .................. 935.91 2 446.00 .................. 89.20 

65426 ....... Removal of eye lesion ................................... .................. 1,413.58 5 717.00 .................. 143.40 

65710 ....... Corneal transplant ......................................... .................. 2,352.42 7 995.00 .................. 199.00 

65730 ....... Corneal transplant ......................................... .................. 2,352.42 7 995.00 .................. 199.00 

65750 ....... Corneal transplant ......................................... .................. 2,352.42 7 995.00 .................. 199.00 

65755 ....... Corneal transplant ......................................... .................. 2,352.42 7 995.00 .................. 199.00 

65770 ....... Revise cornea with implant ........................... .................. 3,195.68 7 995.00 .................. 199.00 

65772 ....... Correction of astigmatism .............................. .................. 935.91 4 630.00 .................. 126.00 

65775 ....... Correction of astigmatism .............................. .................. 935.91 4 630.00 .................. 126.00 

65780 ....... Ocular reconst, transplant ............................. .................. 2,352.42 5 717.00 .................. 143.40

65781 ....... Ocular reconst, transplant ............................. .................. 2,352.42 5 717.00 .................. 143.40

65782 ....... Ocular reconst, transplant ............................. .................. 2,352.42 5 717.00 .................. 143.40

65800 ....... Drainage of eye ............................................. .................. 935.91 1 333.00 .................. 66.60 

65805 ....... Drainage of eye ............................................. .................. 935.91 1 333.00 .................. 66.60 

65810 ....... Drainage of eye ............................................. .................. 1,413.58 3 510.00 .................. 102.00 

65815 ....... Drainage of eye ............................................. .................. 1,413.58 2 446.00 .................. 89.20 

65820 ....... Relieve inner eye pressure ............................ .................. 372.94 1 333.00 .................. 66.60 

65850 ....... Incision of eye ................................................ .................. 1,413.58 4 630.00 .................. 126.00 

65865 ....... Incise inner eye adhesions ............................ .................. 935.91 1 333.00 .................. 66.60 

65870 ....... Incise inner eye adhesions ............................ .................. 1,413.58 4 630.00 .................. 126.00 

65875 ....... Incise inner eye adhesions ............................ .................. 1,413.58 4 630.00 .................. 126.00 

65880 ....... Incise inner eye adhesions ............................ .................. 935.91 4 630.00 .................. 126.00 

65900 ....... Remove eye lesion ........................................ .................. 935.91 5 717.00 .................. 143.40

65920 ....... Remove implant of eye .................................. .................. 1,413.58 7 995.00 .................. 199.00

65930 ....... Remove blood clot from eye ......................... .................. 1,413.58 5 717.00 .................. 143.40 

66020 ....... Injection treatment of eye .............................. .................. 935.91 1 333.00 .................. 66.60 

66030 ....... Injection treatment of eye .............................. .................. 372.94 1 333.00 .................. 66.60 

66130 ....... Remove eye lesion ........................................ .................. 1,413.58 7 995.00 .................. 199.00 

66150 ....... Glaucoma surgery ......................................... .................. 1,413.58 4 630.00 .................. 126.00 

66155 ....... Glaucoma surgery ......................................... .................. 1,413.58 4 630.00 .................. 126.00 

66160 ....... Glaucoma surgery ......................................... .................. 1,413.58 2 446.00 .................. 89.20 

66165 ....... Glaucoma surgery ......................................... .................. 1,413.58 4 630.00 .................. 126.00 

66170 ....... Glaucoma surgery ......................................... .................. 1,413.58 4 630.00 .................. 126.00 

66172 ....... Incision of eye ................................................ .................. 1,413.58 4 630.00 .................. 126.00 

66180 ....... Implant eye shunt .......................................... .................. 2,329.43 5 717.00 .................. 143.40 

66185 ....... Revise eye shunt ........................................... .................. 2,329.43 2 446.00 .................. 89.20 

66220 ....... Repair eye lesion ........................................... .................. 2,300.69 3 510.00 .................. 102.00 

66225 ....... Repair/graft eye lesion ................................... .................. 2,329.43 4 630.00 .................. 126.00 

66250 ....... Follow-up surgery of eye ............................... .................. 935.91 2 446.00 .................. 89.20 

66500 ....... Incision of iris ................................................. .................. 372.94 1 333.00 .................. 66.60 

66505 ....... Incision of iris ................................................. .................. 372.94 1 333.00 .................. 66.60 

66600 ....... Remove iris and lesion .................................. .................. 1,413.58 3 510.00 .................. 102.00 

66605 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00 

66625 ....... Removal of iris ............................................... .................. 372.94 3 372.94 Y .............. 74.59 

66630 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00 

66635 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00 

66680 ....... Repair iris & ciliary body ................................ .................. 1,413.58 3 510.00 .................. 102.00 

66682 ....... Repair iris & ciliary body ................................ .................. 1,413.58 2 446.00 .................. 89.20 

66700 ....... Destruction, ciliary body ................................ .................. 935.91 2 446.00 .................. 89.20 

66710 ....... Ciliary transsleral therapy .............................. .................. 935.91 2 446.00 .................. 89.20 

66711 ....... Ciliary endoscopic ablation ............................ .................. 935.91 2 446.00 .................. 89.20 

66720 ....... Destruction, ciliary body ................................ .................. 935.91 2 446.00 .................. 89.20 

66740 ....... Destruction, ciliary body ................................ .................. 1,413.58 2 446.00 .................. 89.20 

66821 ....... After cataract laser surgery ........................... .................. 312.50 2 312.50 Y .............. 62.50 

66825 ....... Reposition intraocular lens ............................ .................. 1,413.58 4 630.00 .................. 126.00

66830 ....... Removal of lens lesion .................................. .................. 372.94 4 372.94 Y .............. 74.59 

66840 ....... Removal of lens material ............................... .................. 914.04 4 630.00 .................. 126.00 

66850 ....... Removal of lens material ............................... .................. 1,796.59 7 995.00 .................. 199.00

66852 ....... Removal of lens material ............................... .................. 1,796.59 4 630.00 .................. 126.00

66920 ....... Extraction of lens ........................................... .................. 1,796.59 4 630.00 .................. 126.00 

66930 ....... Extraction of lens ........................................... .................. 1,796.59 5 717.00 .................. 143.40 

66940 ....... Extraction of lens ........................................... .................. 914.04 5 717.00 .................. 143.40 

66982 ....... Cataract surgery, complex ............................. .................. 1,452.57 8 973.00 .................. 194.60 

66983 ....... Cataract surg w/iol, 1 stage ........................... .................. 1,452.57 8 973.00 .................. 194.60

66984 ....... Cataract surg w/iol, 1 stage ........................... .................. 1,452.57 8 973.00 .................. 194.60


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68281 

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—Continued 

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 

($) 

66985 ....... Insert lens prosthesis ..................................... .................. 1,452.57 6 826.00 .................. 165.20 

66986 ....... Exchange lens prosthesis .............................. .................. 1,452.57 6 826.00 .................. 165.20 

67005 ....... Partial removal of eye fluid ............................ .................. 1,696.64 4 630.00 .................. 126.00 

67010 ....... Partial removal of eye fluid ............................ .................. 1,696.64 4 630.00 .................. 126.00 

67015 ....... Release of eye fluid ....................................... .................. 1,696.64 1 333.00 .................. 66.60 

67025 ....... Replace eye fluid ........................................... .................. 1,696.64 1 333.00 .................. 66.60 

67027 ....... Implant eye drug system ............................... .................. 2,300.69 4 630.00 .................. 126.00 

67030 ....... Incise inner eye strands ................................ .................. 1,015.69 1 333.00 .................. 66.60

67031 ....... Laser surgery, eye strands ............................ .................. 312.50 2 312.50 Y .............. 62.50 

67036 ....... Removal of inner eye fluid ............................. .................. 2,300.69 4 630.00 .................. 126.00

67038 ....... Strip retinal membrane .................................. .................. 2,300.69 5 717.00 .................. 143.40 

67039 ....... Laser treatment of retina ............................... .................. 2,300.69 7 995.00 .................. 199.00 

67040 ....... Laser treatment of retina ............................... .................. 2,300.69 7 995.00 .................. 199.00 

67107 ....... Repair detached retina .................................. .................. 2,300.69 5 717.00 .................. 143.40 

67108 ....... Repair detached retina .................................. .................. 2,300.69 7 995.00 .................. 199.00 

67112 ....... Rerepair detached retina ............................... .................. 2,300.69 7 995.00 .................. 199.00

67115 ....... Release encircling material ........................... .................. 1,015.69 2 446.00 .................. 89.20 

67120 ....... Remove eye implant material ........................ .................. 1,015.69 2 446.00 .................. 89.20 

67121 ....... Remove eye implant material ........................ .................. 1,696.64 2 446.00 .................. 89.20 

67141 ....... Treatment of retina ........................................ .................. 241.77 2 241.77 Y .............. 48.35 

67218 ....... Treatment of retinal lesion ............................. .................. 1,015.69 5 717.00 .................. 143.40 

67227 ....... Treatment of retinal lesion ............................. .................. 1,696.64 1 333.00 .................. 66.60

67250 ....... Reinforce eye wall ......................................... .................. 1,052.60 3 510.00 .................. 102.00 

67255 ....... Reinforce/graft eye wall ................................. .................. 1,696.64 3 510.00 .................. 102.00 

67311 ....... Revise eye muscle ........................................ .................. 1,308.05 3 510.00 .................. 102.00 

67312 ....... Revise two eye muscles ................................ .................. 1,308.05 4 630.00 .................. 126.00 

67314 ....... Revise eye muscle ........................................ .................. 1,308.05 4 630.00 .................. 126.00 

67316 ....... Revise two eye muscles ................................ .................. 1,308.05 4 630.00 .................. 126.00 

67318 ....... Revise eye muscle(s) .................................... .................. 1,308.05 4 630.00 .................. 126.00 

67320 ....... Revise eye muscle(s) add-on ........................ .................. 1,308.05 4 630.00 .................. 126.00 

67331 ....... Eye surgery follow-up add-on ........................ .................. 1,308.05 4 630.00 .................. 126.00 

67332 ....... Rerevise eye muscles add-on ....................... .................. 1,308.05 4 630.00 .................. 126.00 

67334 ....... Revise eye muscle w/suture .......................... .................. 1,308.05 4 630.00 .................. 126.00 

67335 ....... Eye suture during surgery ............................. .................. 1,308.05 4 630.00 .................. 126.00 

67340 ....... Revise eye muscle add-on ............................ .................. 1,308.05 4 630.00 .................. 126.00 

67343 ....... Release eye tissue ........................................ .................. 1,308.05 7 995.00 .................. 199.00 

67346 ....... Biopsy, eye muscle ........................................ A .............. 884.19 1 333.00 .................. 66.60 

67350 ....... Biopsy eye muscle ......................................... D .............. .................... 1 333.00 .................. ....................

67400 ....... Explore/biopsy eye socket ............................. .................. 1,552.37 3 510.00 .................. 102.00 

67405 ....... Explore/drain eye socket ............................... .................. 1,552.37 4 630.00 .................. 126.00

67412 ....... Explore/treat eye socket ................................ .................. 1,552.37 5 717.00 .................. 143.40 

67413 ....... Explore/treat eye socket ................................ .................. 1,552.37 5 717.00 .................. 143.40 

67415 ....... Aspiration, orbital contents ............................ .................. 1,052.60 1 333.00 .................. 66.60

67420 ....... Explore/treat eye socket ................................ .................. 2,165.47 5 717.00 .................. 143.40 

67430 ....... Explore/treat eye socket ................................ .................. 2,165.47 5 717.00 .................. 143.40 

67440 ....... Explore/drain eye socket ............................... .................. 2,165.47 5 717.00 .................. 143.40

67445 ....... Explr/decompress eye socket ........................ .................. 2,165.47 5 717.00 .................. 143.40 

67450 ....... Explore/biopsy eye socket ............................. .................. 2,165.47 5 717.00 .................. 143.40 

67550 ....... Insert eye socket implant ............................... .................. 2,165.47 4 630.00 .................. 126.00 

67560 ....... Revise eye socket implant ............................. .................. 1,552.37 2 446.00 .................. 89.20 

67570 ....... Decompress optic nerve ................................ .................. 2,165.47 4 630.00 .................. 126.00 

67715 ....... Incision of eyelid fold ..................................... .................. 1,052.60 1 333.00 .................. 66.60 

67808 ....... Remove eyelid lesion(s) ................................ .................. 1,052.60 2 446.00 .................. 89.20 

67830 ....... Revise eyelashes ........................................... .................. 447.60 2 446.00 .................. 89.20 

67835 ....... Revise eyelashes ........................................... .................. 1,052.60 2 446.00 .................. 89.20 

67880 ....... Revision of eyelid .......................................... .................. 935.91 3 510.00 .................. 102.00 

67882 ....... Revision of eyelid .......................................... .................. 1,052.60 3 510.00 .................. 102.00 

67900 ....... Repair brow defect ........................................ .................. 1,052.60 4 630.00 .................. 126.00 

67901 ....... Repair eyelid defect ....................................... .................. 1,052.60 5 717.00 .................. 143.40 

67902 ....... Repair eyelid defect ....................................... .................. 1,052.60 5 717.00 .................. 143.40 

67903 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67904 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67906 ....... Repair eyelid defect ....................................... .................. 1,052.60 5 717.00 .................. 143.40 

67908 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67909 ....... Revise eyelid defect ...................................... .................. 1,052.60 4 630.00 .................. 126.00 


cprice-sewell on PRODPC62 with RULES2
68282 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

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—Continued 

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 

($) 

67911 ....... Revise eyelid defect ...................................... .................. 1,052.60 3 510.00 .................. 102.00 

67912 ....... Correction eyelid w/implant ........................... .................. 1,052.60 3 510.00 .................. 102.00 

67914 ....... Repair eyelid defect ....................................... .................. 1,052.60 3 510.00 .................. 102.00 

67916 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67917 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67921 ....... Repair eyelid defect ....................................... .................. 1,052.60 3 510.00 .................. 102.00 

67923 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67924 ....... Repair eyelid defect ....................................... .................. 1,052.60 4 630.00 .................. 126.00 

67935 ....... Repair eyelid wound ...................................... .................. 1,052.60 2 446.00 .................. 89.20 

67950 ....... Revision of eyelid .......................................... .................. 1,052.60 2 446.00 .................. 89.20 

67961 ....... Revision of eyelid .......................................... .................. 1,052.60 3 510.00 .................. 102.00 

67966 ....... Revision of eyelid .......................................... .................. 1,052.60 3 510.00 .................. 102.00 

67971 ....... Reconstruction of eyelid ................................ .................. 1,552.37 3 510.00 .................. 102.00 

67973 ....... Reconstruction of eyelid ................................ .................. 1,552.37 3 510.00 .................. 102.00 

67974 ....... Reconstruction of eyelid ................................ .................. 1,552.37 3 510.00 .................. 102.00 

67975 ....... Reconstruction of eyelid ................................ .................. 1,052.60 3 510.00 .................. 102.00 

68115 ....... Remove eyelid lining lesion ........................... .................. 1,052.60 2 446.00 .................. 89.20 

68130 ....... Remove eyelid lining lesion ........................... .................. 935.91 2 446.00 .................. 89.20 

68320 ....... Revise/graft eyelid lining ................................ .................. 1,052.60 4 630.00 .................. 126.00 

68325 ....... Revise/graft eyelid lining ................................ .................. 1,552.37 4 630.00 .................. 126.00 

68326 ....... Revise/graft eyelid lining ................................ .................. 1,552.37 4 630.00 .................. 126.00 

68328 ....... Revise/graft eyelid lining ................................ .................. 1,552.37 4 630.00 .................. 126.00 

68330 ....... Revise eyelid lining ........................................ .................. 1,413.58 4 630.00 .................. 126.00 

68335 ....... Revise/graft eyelid lining ................................ .................. 1,552.37 4 630.00 .................. 126.00 

68340 ....... Separate eyelid adhesions ............................ .................. 1,052.60 4 630.00 .................. 126.00 

68360 ....... Revise eyelid lining ........................................ .................. 1,413.58 2 446.00 .................. 89.20 

68362 ....... Revise eyelid lining ........................................ .................. 1,413.58 2 446.00 .................. 89.20 

68371 ....... Harvest eye tissue, alograft ........................... .................. 935.91 2 446.00 .................. 89.20 

68500 ....... Removal of tear gland ................................... .................. 1,552.37 3 510.00 .................. 102.00 

68505 ....... Partial removal, tear gland ............................ .................. 1,552.37 3 510.00 .................. 102.00

68510 ....... Biopsy of tear gland ....................................... .................. 1,052.60 1 333.00 .................. 66.60 

68520 ....... Removal of tear sac ...................................... .................. 1,552.37 3 510.00 .................. 102.00 

68525 ....... Biopsy of tear sac .......................................... .................. 1,052.60 1 333.00 .................. 66.60 

68540 ....... Remove tear gland lesion .............................. .................. 1,552.37 3 510.00 .................. 102.00 

68550 ....... Remove tear gland lesion .............................. .................. 1,552.37 3 510.00 .................. 102.00 

68700 ....... Repair tear ducts ........................................... .................. 1,552.37 2 446.00 .................. 89.20 

68720 ....... Create tear sac drain ..................................... .................. 1,552.37 4 630.00 .................. 126.00 

68745 ....... Create tear duct drain .................................... .................. 1,552.37 4 630.00 .................. 126.00 

68750 ....... Create tear duct drain .................................... .................. 1,552.37 4 630.00 .................. 126.00 

68770 ....... Close tear system fistula ............................... .................. 1,052.60 4 630.00 .................. 126.00 

68810 ....... Probe nasolacrimal duct ................................ .................. 131.86 1 131.86 Y .............. 26.37 

68811 ....... Probe nasolacrimal duct ................................ .................. 1,052.60 2 446.00 .................. 89.20 

68815 ....... Probe nasolacrimal duct ................................ .................. 1,052.60 2 446.00 .................. 89.20 

69110 ....... Remove external ear, partial ......................... .................. 928.31 1 333.00 .................. 66.60 

69120 ....... Removal of external ear ................................ .................. 1,434.04 2 446.00 .................. 89.20 

69140 ....... Remove ear canal lesion(s) ........................... .................. 1,434.04 2 446.00 .................. 89.20 

69145 ....... Remove ear canal lesion(s) ........................... .................. 928.31 2 446.00 .................. 89.20 

69150 ....... Extensive ear canal surgery .......................... .................. 464.15 3 464.15 Y .............. 92.83 

69205 ....... Clear outer ear canal ..................................... .................. 1,233.39 1 333.00 .................. 66.60 

69300 ....... Revise external ear ........................................ .................. 1,434.04 3 510.00 .................. 102.00 

69310 ....... Rebuild outer ear canal ................................. .................. 2,348.02 3 510.00 .................. 102.00 

69320 ....... Rebuild outer ear canal ................................. .................. 2,348.02 7 995.00 .................. 199.00 

69421 ....... Incision of eardrum ........................................ .................. 1,009.71 3 510.00 .................. 102.00 

69436 ....... Create eardrum opening ................................ .................. 1,009.71 3 510.00 .................. 102.00 

69440 ....... Exploration of middle ear ............................... .................. 1,434.04 3 510.00 .................. 102.00 

69450 ....... Eardrum revision ............................................ .................. 2,348.02 1 333.00 .................. 66.60 

69501 ....... Mastoidectomy ............................................... .................. 2,348.02 7 995.00 .................. 199.00 

69502 ....... Mastoidectomy ............................................... .................. 1,434.04 7 995.00 .................. 199.00 

69505 ....... Remove mastoid structures ........................... .................. 2,348.02 7 995.00 .................. 199.00 

69511 ....... Extensive mastoid surgery ............................ .................. 2,348.02 7 995.00 .................. 199.00 

69530 ....... Extensive mastoid surgery ............................ .................. 2,348.02 7 995.00 .................. 199.00 

69550 ....... Remove ear lesion ......................................... .................. 2,348.02 5 717.00 .................. 143.40 

69552 ....... Remove ear lesion ......................................... .................. 2,348.02 7 995.00 .................. 199.00 

69601 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00 

69602 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68283 

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—Continued 

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 

($) 

69603 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00 

69604 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00 

69605 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00 

69620 ....... Repair of eardrum .......................................... .................. 1,434.04 2 446.00 .................. 89.20 

69631 ....... Repair eardrum structures ............................. .................. 2,348.02 5 717.00 .................. 143.40 

69632 ....... Rebuild eardrum structures ........................... .................. 2,348.02 5 717.00 .................. 143.40 

69633 ....... Rebuild eardrum structures ........................... .................. 2,348.02 5 717.00 .................. 143.40 

69635 ....... Repair eardrum structures ............................. .................. 2,348.02 7 995.00 .................. 199.00 

69636 ....... Rebuild eardrum structures ........................... .................. 2,348.02 7 995.00 .................. 199.00 

69637 ....... Rebuild eardrum structures ........................... .................. 2,348.02 7 995.00 .................. 199.00 

69641 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69642 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69643 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69644 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69645 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69646 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00 

69650 ....... Release middle ear bone .............................. .................. 1,434.04 7 995.00 .................. 199.00 

69660 ....... Revise middle ear bone ................................. .................. 2,348.02 5 717.00 .................. 143.40

69661 ....... Revise middle ear bone ................................. .................. 2,348.02 5 717.00 .................. 143.40

69662 ....... Revise middle ear bone ................................. .................. 2,348.02 5 717.00 .................. 143.40

69666 ....... Repair middle ear structures ......................... .................. 2,348.02 4 630.00 .................. 126.00 

69667 ....... Repair middle ear structures ......................... .................. 2,348.02 4 630.00 .................. 126.00 

69670 ....... Remove mastoid air cells .............................. .................. 2,348.02 3 510.00 .................. 102.00 

69676 ....... Remove middle ear nerve ............................. .................. 2,348.02 3 510.00 .................. 102.00 

69700 ....... Close mastoid fistula ..................................... .................. 2,348.02 3 510.00 .................. 102.00 

69711 ....... Remove/repair hearing aid ............................ .................. 2,348.02 1 333.00 .................. 66.60 

69714 ....... Implant temple bone w/stimul ........................ .................. 2,348.02 9 1,339.00 .................. 267.80 

69715 ....... Temple bne implnt w/stimulat ........................ .................. 2,348.02 9 1,339.00 .................. 267.80 

69717 ....... Temple bone implant revision ....................... .................. 2,348.02 9 1,339.00 .................. 267.80 

69718 ....... Revise temple bone implant .......................... .................. 2,348.02 9 1,339.00 .................. 267.80 

69720 ....... Release facial nerve ...................................... .................. 2,348.02 5 717.00 .................. 143.40 

69740 ....... Repair facial nerve ......................................... .................. 2,348.02 5 717.00 .................. 143.40 

69745 ....... Repair facial nerve ......................................... .................. 2,348.02 5 717.00 .................. 143.40 

69801 ....... Incise inner ear .............................................. .................. 2,348.02 5 717.00 .................. 143.40 

69802 ....... Incise inner ear .............................................. .................. 2,348.02 7 995.00 .................. 199.00 

69805 ....... Explore inner ear ........................................... .................. 2,348.02 7 995.00 .................. 199.00 

69806 ....... Explore inner ear ........................................... .................. 2,348.02 7 995.00 .................. 199.00 

69820 ....... Establish inner ear window ............................ .................. 2,348.02 5 717.00 .................. 143.40 

69840 ....... Revise inner ear window ............................... .................. 2,348.02 5 717.00 .................. 143.40 

69905 ....... Remove inner ear .......................................... .................. 2,348.02 7 995.00 .................. 199.00 

69910 ....... Remove inner ear & mastoid ......................... .................. 2,348.02 7 995.00 .................. 199.00 

69915 ....... Incise inner ear nerve .................................... .................. 2,348.02 7 995.00 .................. 199.00 

69930 ....... Implant cochlear device ................................. .................. 25,499.72 7 995.00 .................. 199.00 

0176T ....... Aqu canal dilat w/o retent .............................. A .............. 2,329.43 9 1,339.00 .................. 267.80

0177T ....... Aqu canal dilat w retent ................................. A .............. 2,329.43 9 1,339.00 .................. 267.80 

G0105 ...... Colorectal scrn; hi risk ind ............................. .................. 446.00 2 446.00 .................. 111.50 

G0121 ...... Colon ca scrn not hi rsk ind .......................... .................. 446.00 2 446.00 .................. 111.50 

G0260 ...... Inj for sacroiliac jt anesth ............................... .................. 351.92 1 333.00 .................. 66.60

G0392 ...... AV fistula or graft arterial ............................... A .............. 2,624.19 9 1,339.00 .................. 334.75 

G0393 ...... 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 

copayment 

00100 ....... Anesth, salivary gland ....................................... ......... N .................. .................. .................. .................. ..................

00102 ....... Anesth, repair of cleft lip .................................... ......... N .................. .................. .................. .................. ..................

00103 ....... Anesth, blepharoplasty ...................................... ......... N .................. .................. .................. .................. ..................

00104 ....... Anesth, electroshock ......................................... ......... N .................. .................. .................. .................. ..................

00120 ....... Anesth, ear surgery ........................................... ......... N .................. .................. .................. .................. ..................

00124 ....... Anesth, ear exam .............................................. ......... N .................. .................. .................. .................. ..................

00126 ....... Anesth, tympanotomy ........................................ ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68284 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

00140 ....... Anesth, procedures on eye ............................... ......... N .................. .................. .................. .................. ..................

00142 ....... Anesth, lens surgery .......................................... ......... N .................. .................. .................. .................. ..................

00144 ....... Anesth, corneal transplant ................................. ......... N .................. .................. .................. .................. ..................

00145 ....... Anesth, vitreoretinal surg ................................... ......... N .................. .................. .................. .................. ..................

00147 ....... Anesth, iridectomy ............................................. ......... N .................. .................. .................. .................. ..................

00148 ....... Anesth, eye exam .............................................. ......... N .................. .................. .................. .................. ..................

00160 ....... Anesth, nose/sinus surgery ............................... ......... N .................. .................. .................. .................. ..................

00162 ....... Anesth, nose/sinus surgery ............................... ......... N .................. .................. .................. .................. ..................

00164 ....... Anesth, biopsy of nose ...................................... ......... N .................. .................. .................. .................. ..................

00170 ....... Anesth, procedure on mouth ............................. ......... N .................. .................. .................. .................. ..................

00172 ....... Anesth, cleft palate repair .................................. ......... N .................. .................. .................. .................. ..................

00174 ....... Anesth, pharyngeal surgery ............................... ......... N .................. .................. .................. .................. ..................

00190 ....... Anesth, face/skull bone surg ............................. ......... N .................. .................. .................. .................. ..................

00210 ....... Anesth, open head surgery ............................... ......... N .................. .................. .................. .................. ..................

00212 ....... Anesth, skull drainage ....................................... ......... N .................. .................. .................. .................. ..................

00216 ....... Anesth, head vessel surgery ............................. ......... N .................. .................. .................. .................. ..................

00218 ....... Anesth, special head surgery ............................ ......... N .................. .................. .................. .................. ..................

00220 ....... Anesth, intrcrn nerve ......................................... ......... N .................. .................. .................. .................. ..................

00222 ....... Anesth, head nerve surgery .............................. ......... N .................. .................. .................. .................. ..................

00300 ....... Anesth, head/neck/ptrunk .................................. ......... N .................. .................. .................. .................. ..................

00320 ....... Anesth, neck organ, 1 & over ............................ ......... N .................. .................. .................. .................. ..................

00322 ....... Anesth, biopsy of thyroid ................................... ......... N .................. .................. .................. .................. ..................

00326 ....... Anesth, larynx/trach, < 1 yr ............................... ......... N .................. .................. .................. .................. ..................

00350 ....... Anesth, neck vessel surgery ............................. ......... N .................. .................. .................. .................. ..................

00352 ....... Anesth, neck vessel surgery ............................. ......... N .................. .................. .................. .................. ..................

00400 ....... Anesth, skin, ext/per/atrunk ............................... ......... N .................. .................. .................. .................. ..................

00402 ....... Anesth, surgery of breast .................................. ......... N .................. .................. .................. .................. ..................

00404 ....... Anesth, surgery of breast .................................. CH .. N .................. .................. .................. .................. ..................

00406 ....... Anesth, surgery of breast .................................. CH .. N .................. .................. .................. .................. ..................

00410 ....... Anesth, correct heart rhythm ............................. ......... N .................. .................. .................. .................. ..................

00450 ....... Anesth, surgery of shoulder .............................. ......... N .................. .................. .................. .................. ..................

00454 ....... Anesth, collar bone biopsy ................................ ......... N .................. .................. .................. .................. ..................

00470 ....... Anesth, removal of rib ....................................... ......... N .................. .................. .................. .................. ..................

00472 ....... Anesth, chest wall repair ................................... ......... N .................. .................. .................. .................. ..................

00500 ....... Anesth, esophageal surgery .............................. ......... N .................. .................. .................. .................. ..................

00520 ....... Anesth, chest procedure .................................... ......... N .................. .................. .................. .................. ..................

00522 ....... Anesth, chest lining biopsy ................................ ......... N .................. .................. .................. .................. ..................

00528 ....... Anesth, chest partition view ............................... ......... N .................. .................. .................. .................. ..................

00529 ....... Anesth, chest partition view ............................... ......... N .................. .................. .................. .................. ..................

00530 ....... Anesth, pacemaker insertion ............................. ......... N .................. .................. .................. .................. ..................

00532 ....... Anesth, vascular access .................................... ......... N .................. .................. .................. .................. ..................

00534 ....... Anesth, cardioverter/defib .................................. ......... N .................. .................. .................. .................. ..................

00537 ....... Anesth, cardiac electrophys .............................. ......... N .................. .................. .................. .................. ..................

00539 ....... Anesth, trach-bronch reconst ............................ ......... N .................. .................. .................. .................. ..................

00541 ....... Anesth, one lung ventilation .............................. ......... N .................. .................. .................. .................. ..................

00548 ....... Anesth, trachea,bronchi surg ............................. ......... N .................. .................. .................. .................. ..................

00550 ....... Anesth, sternal debridement .............................. ......... N .................. .................. .................. .................. ..................

00563 ....... Anesth, heart surg w/arrest ............................... ......... N .................. .................. .................. .................. ..................

00566 ....... Anesth, cabg w/o pump ..................................... ......... N .................. .................. .................. .................. ..................

00600 ....... Anesth, spine, cord surgery ............................... ......... N .................. .................. .................. .................. ..................

00620 ....... Anesth, spine, cord surgery ............................... ......... N .................. .................. .................. .................. ..................

00625 ....... Anes spine tranthor w/o vent ............................. NI .... N .................. .................. .................. .................. ..................

00626 ....... Anes, spine transthor w/vent ............................. NI .... N .................. .................. .................. .................. ..................

00630 ....... Anesth, spine, cord surgery ............................... ......... N .................. .................. .................. .................. ..................

00634 ....... Anesth for chemonucleolysis ............................. ......... N .................. .................. .................. .................. ..................

00635 ....... Anesth, lumbar puncture ................................... ......... N .................. .................. .................. .................. ..................

00640 ....... Anesth, spine manipulation ............................... ......... N .................. .................. .................. .................. ..................

00700 ....... Anesth, abdominal wall surg ............................. ......... N .................. .................. .................. .................. ..................

00702 ....... Anesth, for liver biopsy ...................................... ......... N .................. .................. .................. .................. ..................

00730 ....... Anesth, abdominal wall surg ............................. ......... N .................. .................. .................. .................. ..................

00740 ....... Anesth, upper gi visualize ................................. ......... N .................. .................. .................. .................. ..................

00750 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00752 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00754 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00756 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00770 ....... Anesth, blood vessel repair ............................... ......... N .................. .................. .................. .................. ..................

00790 ....... Anesth, surg upper abdomen ............................ ......... N .................. .................. .................. .................. ..................

00797 ....... Anesth, surgery for obesity ................................ ......... N .................. .................. .................. .................. ..................

00800 ....... Anesth, abdominal wall surg ............................. ......... N .................. .................. .................. .................. ..................

00810 ....... Anesth, low intestine scope ............................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68285 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

00820 ....... Anesth, abdominal wall surg ............................. ......... N .................. .................. .................. .................. ..................

00830 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00832 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................

00834 ....... Anesth, hernia repair< 1 yr ................................ ......... N .................. .................. .................. .................. ..................

00836 ....... Anesth hernia repair preemie ............................ ......... N .................. .................. .................. .................. ..................

00840 ....... Anesth, surg lower abdomen ............................. ......... N .................. .................. .................. .................. ..................

00842 ....... Anesth, amniocentesis ....................................... ......... N .................. .................. .................. .................. ..................

00851 ....... Anesth, tubal ligation ......................................... ......... N .................. .................. .................. .................. ..................

00860 ....... Anesth, surgery of abdomen ............................. ......... N .................. .................. .................. .................. ..................

00862 ....... Anesth, kidney/ureter surg ................................. ......... N .................. .................. .................. .................. ..................

00870 ....... Anesth, bladder stone surg ............................... ......... N .................. .................. .................. .................. ..................

00872 ....... Anesth kidney stone destruct ............................ ......... N .................. .................. .................. .................. ..................

00873 ....... Anesth kidney stone destruct ............................ ......... N .................. .................. .................. .................. ..................

00880 ....... Anesth, abdomen vessel surg ........................... ......... N .................. .................. .................. .................. ..................

00902 ....... Anesth, anorectal surgery .................................. ......... N .................. .................. .................. .................. ..................

00906 ....... Anesth, removal of vulva ................................... ......... N .................. .................. .................. .................. ..................

00910 ....... Anesth, bladder surgery .................................... ......... N .................. .................. .................. .................. ..................

00912 ....... Anesth, bladder tumor surg ............................... ......... N .................. .................. .................. .................. ..................

00914 ....... Anesth, removal of prostate .............................. ......... N .................. .................. .................. .................. ..................

00916 ....... Anesth, bleeding control .................................... ......... N .................. .................. .................. .................. ..................

00918 ....... Anesth, stone removal ....................................... ......... N .................. .................. .................. .................. ..................

00920 ....... Anesth, genitalia surgery ................................... ......... N .................. .................. .................. .................. ..................

00921 ....... Anesth, vasectomy ............................................ ......... N .................. .................. .................. .................. ..................

00922 ....... Anesth, sperm duct surgery .............................. ......... N .................. .................. .................. .................. ..................

00924 ....... Anesth, testis exploration .................................. ......... N .................. .................. .................. .................. ..................

00926 ....... Anesth, removal of testis ................................... ......... N .................. .................. .................. .................. ..................

00928 ....... Anesth, removal of testis ................................... ......... N .................. .................. .................. .................. ..................

00930 ....... Anesth, testis suspension .................................. ......... N .................. .................. .................. .................. ..................

00938 ....... Anesth, insert penis device ............................... ......... N .................. .................. .................. .................. ..................

00940 ....... Anesth, vaginal procedures ............................... ......... N .................. .................. .................. .................. ..................

00942 ....... Anesth, surg on vag/urethral ............................. ......... N .................. .................. .................. .................. ..................

00948 ....... Anesth, repair of cervix ...................................... ......... N .................. .................. .................. .................. ..................

00950 ....... Anesth, vaginal endoscopy ................................ ......... N .................. .................. .................. .................. ..................

00952 ....... Anesth, hysteroscope/graph .............................. ......... N .................. .................. .................. .................. ..................

01112 ....... Anesth, bone aspirate/bx ................................... ......... N .................. .................. .................. .................. ..................

01120 ....... Anesth, pelvis surgery ....................................... ......... N .................. .................. .................. .................. ..................

01130 ....... Anesth, body cast procedure ............................. ......... N .................. .................. .................. .................. ..................

01160 ....... Anesth, pelvis procedure ................................... ......... N .................. .................. .................. .................. ..................

01170 ....... Anesth, pelvis surgery ....................................... ......... N .................. .................. .................. .................. ..................

01173 ....... Anesth, fx repair, pelvis ..................................... ......... N .................. .................. .................. .................. ..................

01180 ....... Anesth, pelvis nerve removal ............................ ......... N .................. .................. .................. .................. ..................

01190 ....... Anesth, pelvis nerve removal ............................ ......... N .................. .................. .................. .................. ..................

01200 ....... Anesth, hip joint procedure ................................ ......... N .................. .................. .................. .................. ..................

01202 ....... Anesth, arthroscopy of hip ................................. ......... N .................. .................. .................. .................. ..................

01210 ....... Anesth, hip joint surgery .................................... ......... N .................. .................. .................. .................. ..................

01215 ....... Anesth, revise hip repair .................................... ......... N .................. .................. .................. .................. ..................

01220 ....... Anesth, procedure on femur .............................. ......... N .................. .................. .................. .................. ..................

01230 ....... Anesth, surgery of femur ................................... ......... N .................. .................. .................. .................. ..................

01250 ....... Anesth, upper leg surgery ................................. ......... N .................. .................. .................. .................. ..................

01260 ....... Anesth, upper leg veins surg ............................. ......... N .................. .................. .................. .................. ..................

01270 ....... Anesth, thigh arteries surg ................................ ......... N .................. .................. .................. .................. ..................

01320 ....... Anesth, knee area surgery ................................ ......... N .................. .................. .................. .................. ..................

01340 ....... Anesth, knee area procedure ............................ ......... N .................. .................. .................. .................. ..................

01360 ....... Anesth, knee area surgery ................................ ......... N .................. .................. .................. .................. ..................

01380 ....... Anesth, knee joint procedure ............................. ......... N .................. .................. .................. .................. ..................

01382 ....... Anesth, dx knee arthroscopy ............................. ......... N .................. .................. .................. .................. ..................

01390 ....... Anesth, knee area procedure ............................ ......... N .................. .................. .................. .................. ..................

01392 ....... Anesth, knee area surgery ................................ ......... N .................. .................. .................. .................. ..................

01400 ....... Anesth, knee joint surgery ................................. ......... N .................. .................. .................. .................. ..................

01420 ....... Anesth, knee joint casting ................................. ......... N .................. .................. .................. .................. ..................

01430 ....... Anesth, knee veins surgery ............................... ......... N .................. .................. .................. .................. ..................

01432 ....... Anesth, knee vessel surg .................................. ......... N .................. .................. .................. .................. ..................

01440 ....... Anesth, knee arteries surg ................................ ......... N .................. .................. .................. .................. ..................

01462 ....... Anesth, lower leg procedure .............................. ......... N .................. .................. .................. .................. ..................

01464 ....... Anesth, ankle/ft arthroscopy .............................. ......... N .................. .................. .................. .................. ..................

01470 ....... Anesth, lower leg surgery .................................. ......... N .................. .................. .................. .................. ..................

01472 ....... Anesth, achilles tendon surg ............................. ......... N .................. .................. .................. .................. ..................

01474 ....... Anesth, lower leg surgery .................................. ......... N .................. .................. .................. .................. ..................

01480 ....... Anesth, lower leg bone surg .............................. ......... N .................. .................. .................. .................. ..................

01482 ....... Anesth, radical leg surgery ................................ ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68286 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

01484 ....... Anesth, lower leg revision ................................. ......... N .................. .................. .................. .................. ..................

01490 ....... Anesth, lower leg casting .................................. ......... N .................. .................. .................. .................. ..................

01500 ....... Anesth, leg arteries surg ................................... ......... N .................. .................. .................. .................. ..................

01520 ....... Anesth, lower leg vein surg ............................... ......... N .................. .................. .................. .................. ..................

01522 ....... Anesth, lower leg vein surg ............................... ......... N .................. .................. .................. .................. ..................

01610 ....... Anesth, surgery of shoulder .............................. ......... N .................. .................. .................. .................. ..................

01620 ....... Anesth, shoulder procedure .............................. ......... N .................. .................. .................. .................. ..................

01622 ....... Anes dx shoulder arthroscopy ........................... ......... N .................. .................. .................. .................. ..................

01630 ....... Anesth, surgery of shoulder .............................. ......... N .................. .................. .................. .................. ..................

01650 ....... Anesth, shoulder artery surg ............................. ......... N .................. .................. .................. .................. ..................

01670 ....... Anesth, shoulder vein surg ................................ ......... N .................. .................. .................. .................. ..................

01680 ....... Anesth, shoulder casting ................................... ......... N .................. .................. .................. .................. ..................

01682 ....... Anesth, airplane cast ......................................... ......... N .................. .................. .................. .................. ..................

01710 ....... Anesth, elbow area surgery ............................... ......... N .................. .................. .................. .................. ..................

01712 ....... Anesth, uppr arm tendon surg ........................... ......... N .................. .................. .................. .................. ..................

01714 ....... Anesth, uppr arm tendon surg ........................... ......... N .................. .................. .................. .................. ..................

01716 ....... Anesth, biceps tendon repair ............................. ......... N .................. .................. .................. .................. ..................

01730 ....... Anesth, uppr arm procedure .............................. ......... N .................. .................. .................. .................. ..................

01732 ....... Anesth, dx elbow arthroscopy ........................... ......... N .................. .................. .................. .................. ..................

01740 ....... Anesth, upper arm surgery ................................ ......... N .................. .................. .................. .................. ..................

01742 ....... Anesth, humerus surgery .................................. ......... N .................. .................. .................. .................. ..................

01744 ....... Anesth, humerus repair ..................................... ......... N .................. .................. .................. .................. ..................

01758 ....... Anesth, humeral lesion surg .............................. ......... N .................. .................. .................. .................. ..................

01760 ....... Anesth, elbow replacement ............................... ......... N .................. .................. .................. .................. ..................

01770 ....... Anesth, uppr arm artery surg ............................ ......... N .................. .................. .................. .................. ..................

01772 ....... Anesth, uppr arm embolectomy ........................ ......... N .................. .................. .................. .................. ..................

01780 ....... Anesth, upper arm vein surg ............................. ......... N .................. .................. .................. .................. ..................

01782 ....... Anesth, uppr arm vein repair ............................. ......... N .................. .................. .................. .................. ..................

01810 ....... Anesth, lower arm surgery ................................ ......... N .................. .................. .................. .................. ..................

01820 ....... Anesth, lower arm procedure ............................ ......... N .................. .................. .................. .................. ..................

01829 ....... Anesth, dx wrist arthroscopy ............................. ......... N .................. .................. .................. .................. ..................

01830 ....... Anesth, lower arm surgery ................................ ......... N .................. .................. .................. .................. ..................

01832 ....... Anesth, wrist replacement ................................. ......... N .................. .................. .................. .................. ..................

01840 ....... Anesth, lwr arm artery surg ............................... ......... N .................. .................. .................. .................. ..................

01842 ....... Anesth, lwr arm embolectomy ........................... ......... N .................. .................. .................. .................. ..................

01844 ....... Anesth, vascular shunt surg .............................. ......... N .................. .................. .................. .................. ..................

01850 ....... Anesth, lower arm vein surg .............................. ......... N .................. .................. .................. .................. ..................

01852 ....... Anesth, lwr arm vein repair ............................... ......... N .................. .................. .................. .................. ..................

01860 ....... Anesth, lower arm casting ................................. ......... N .................. .................. .................. .................. ..................

01905 ....... Anes, spine inject, x-ray/re ................................ ......... N .................. .................. .................. .................. ..................

01916 ....... Anesth, dx arteriography ................................... ......... N .................. .................. .................. .................. ..................

01920 ....... Anesth, catheterize heart ................................... ......... N .................. .................. .................. .................. ..................

01922 ....... Anesth, cat or MRI scan .................................... ......... N .................. .................. .................. .................. ..................

01924 ....... Anes, ther interven rad, art ................................ ......... N .................. .................. .................. .................. ..................

01925 ....... Anes, ther interven rad, car ............................... ......... N .................. .................. .................. .................. ..................

01926 ....... Anes, tx interv rad hrt/cran ................................ ......... N .................. .................. .................. .................. ..................

01930 ....... Anes, ther interven rad, vei ............................... ......... N .................. .................. .................. .................. ..................

01931 ....... Anes, ther interven rad, tip ................................ ......... N .................. .................. .................. .................. ..................

01932 ....... Anes, tx interv rad, th vein ................................ ......... N .................. .................. .................. .................. ..................

01933 ....... Anes, tx interv rad, cran v ................................. ......... N .................. .................. .................. .................. ..................

01951 ....... Anesth, burn, less 4 percent ............................. ......... N .................. .................. .................. .................. ..................

01952 ....... Anesth, burn, 4–9 percent ................................. ......... N .................. .................. .................. .................. ..................

01953 ....... Anesth, burn, each 9 percent ............................ ......... N .................. .................. .................. .................. ..................

01958 ....... Anesth, antepartum manipul .............................. ......... N .................. .................. .................. .................. ..................

01960 ....... Anesth, vaginal delivery ..................................... ......... N .................. .................. .................. .................. ..................

01961 ....... Anesth, cs delivery ............................................ ......... N .................. .................. .................. .................. ..................

01962 ....... Anesth, emer hysterectomy ............................... ......... N .................. .................. .................. .................. ..................

01963 ....... Anesth, cs hysterectomy ................................... ......... N .................. .................. .................. .................. ..................

01965 ....... Anesth, inc/missed ab proc ............................... ......... N .................. .................. .................. .................. ..................

01966 ....... Anesth, induced ab procedure .......................... ......... N .................. .................. .................. .................. ..................

01967 ....... Anesth/analg, vag delivery ................................ ......... N .................. .................. .................. .................. ..................

01968 ....... Anes/analg cs deliver add-on ............................ ......... N .................. .................. .................. .................. ..................

01969 ....... Anesth/analg cs hyst add-on ............................. ......... N .................. .................. .................. .................. ..................

01991 ....... Anesth, nerve block/inj ...................................... ......... N .................. .................. .................. .................. ..................

01992 ....... Anesth, n block/inj, prone .................................. ......... N .................. .................. .................. .................. ..................

01995 ....... Regional anesthesia limb .................................. CH .. D .................. .................. .................. .................. ..................

01996 ....... Hosp manage cont drug admin ......................... ......... N .................. .................. .................. .................. ..................

01999 ....... Unlisted anesth procedure ................................. ......... N .................. .................. .................. .................. ..................

10021 ....... Fna w/o image ................................................... ......... T 0002 1.0995 67.58 .................. 13.52 

10022 ....... Fna w/image ...................................................... ......... T 0036 2.0738 127.47 .................. 25.49 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68287 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

10040 ....... Acne surgery ...................................................... ......... T 0010 0.476 29.26 8.02 5.85 

10060 ....... Drainage of skin abscess .................................. ......... T 0006 1.4392 88.46 .................. 17.69 

10061 ....... Drainage of skin abscess .................................. ......... T 0006 1.4392 88.46 .................. 17.69 

10080 ....... Drainage of pilonidal cyst .................................. ......... T 0006 1.4392 88.46 .................. 17.69 

10081 ....... Drainage of pilonidal cyst .................................. ......... T 0007 11.1535 685.58 .................. 137.12

10120 ....... Remove foreign body ........................................ ......... T 0006 1.4392 88.46 .................. 17.69 

10121 ....... Remove foreign body ........................................ ......... T 0021 15.1024 928.31 219.48 185.66 

10140 ....... Drainage of hematoma/fluid .............................. ......... T 0007 11.1535 685.58 .................. 137.12 

10160 ....... Puncture drainage of lesion ............................... ......... T 0018 1.0259 63.06 15.44 12.61 

10180 ....... Complex drainage, wound ................................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

11000 ....... Debride infected skin ......................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11001 ....... Debride infected skin add-on ............................. ......... T 0012 0.8432 51.83 11.18 10.37 

11010 ....... Debride skin, fx .................................................. ......... T 0019 4.0919 251.52 71.87 50.30 

11011 ....... Debride skin/muscle, fx ..................................... ......... T 0019 4.0919 251.52 71.87 50.30 

11012 ....... Debride skin/muscle/bone, fx ............................ ......... T 0019 4.0919 251.52 71.87 50.30 

11040 ....... Debride skin, partial ........................................... ......... T 0015 1.6241 99.83 20.13 19.97 

11041 ....... Debride skin, full ................................................ ......... T 0015 1.6241 99.83 20.13 19.97 

11042 ....... Debride skin/tissue ............................................ ......... T 0016 2.6749 164.42 .................. 32.88 

11043 ....... Debride tissue/muscle ....................................... ......... T 0016 2.6749 164.42 .................. 32.88 

11044 ....... Debride tissue/muscle/bone .............................. ......... T 0682 6.8832 423.10 158.65 84.62 

11055 ....... Trim skin lesion .................................................. ......... T 0012 0.8432 51.83 11.18 10.37 

11056 ....... Trim skin lesions, 2 to 4 .................................... ......... T 0012 0.8432 51.83 11.18 10.37 

11057 ....... Trim skin lesions, over 4 ................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11100 ....... Biopsy, skin lesion ............................................. ......... T 0018 1.0259 63.06 15.44 12.61 

11101 ....... Biopsy, skin add-on ........................................... ......... T 0018 1.0259 63.06 15.44 12.61 

11200 ....... Removal of skin tags ......................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11201 ....... Remove skin tags add-on .................................. ......... T 0015 1.6241 99.83 20.13 19.97 

11300 ....... Shave skin lesion ............................................... ......... T 0012 0.8432 51.83 11.18 10.37 

11301 ....... Shave skin lesion ............................................... ......... T 0012 0.8432 51.83 11.18 10.37 

11302 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11303 ....... Shave skin lesion ............................................... ......... T 0015 1.6241 99.83 20.13 19.97 

11305 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11306 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11307 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11308 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11310 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11311 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11312 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11313 ....... Shave skin lesion ............................................... ......... T 0016 2.6749 164.42 .................. 32.88 

11400 ....... Exc tr-ext b9+marg 0.5 < cm ............................. ......... T 0019 4.0919 251.52 71.87 50.30 

11401 ....... Exc tr-ext b9+marg 0.6–1 cm ............................ ......... T 0019 4.0919 251.52 71.87 50.30 

11402 ....... Exc tr-ext b9+marg 1.1–2 cm ............................ ......... T 0019 4.0919 251.52 71.87 50.30 

11403 ....... Exc tr-ext b9+marg 2.1–3 cm ............................ ......... T 0020 6.8083 418.49 107.67 83.70 

11404 ....... Exc tr-ext b9+marg 3.1–4 cm ............................ ......... T 0021 15.1024 928.31 219.48 185.66 

11406 ....... Exc tr-ext b9+marg > 4.0 cm ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

11420 ....... Exc h-f-nk-sp b9+marg 0.5 < ............................. ......... T 0020 6.8083 418.49 107.67 83.70 

11421 ....... Exc h-f-nk-sp b9+marg 0.6–1 ............................ ......... T 0020 6.8083 418.49 107.67 83.70 

11422 ....... Exc h-f-nk-sp b9+marg 1.1–2 ............................ ......... T 0020 6.8083 418.49 107.67 83.70 

11423 ....... Exc h-f-nk-sp b9+marg 2.1–3 ............................ ......... T 0021 15.1024 928.31 219.48 185.66 

11424 ....... Exc h-f-nk-sp b9+marg 3.1–4 ............................ ......... T 0021 15.1024 928.31 219.48 185.66 

11426 ....... Exc h-f-nk-sp b9+marg > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

11440 ....... Exc face-mm b9+marg 0.5 < cm ....................... ......... T 0019 4.0919 251.52 71.87 50.30 

11441 ....... Exc face-mm b9+marg 0.6–1 cm ...................... ......... T 0019 4.0919 251.52 71.87 50.30 

11442 ....... Exc face-mm b9+marg 1.1–2 cm ...................... ......... T 0020 6.8083 418.49 107.67 83.70 

11443 ....... Exc face-mm b9+marg 2.1–3 cm ...................... ......... T 0020 6.8083 418.49 107.67 83.70 

11444 ....... Exc face-mm b9+marg 3.1–4 cm ...................... ......... T 0020 6.8083 418.49 107.67 83.70 

11446 ....... Exc face-mm b9+marg > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

11450 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11451 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11462 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11463 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11470 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11471 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11600 ....... Exc tr-ext mlg+marg 0.5 < cm ........................... ......... T 0019 4.0919 251.52 71.87 50.30 

11601 ....... Exc tr-ext mlg+marg 0.6–1 cm .......................... ......... T 0019 4.0919 251.52 71.87 50.30 

11602 ....... Exc tr-ext mlg+marg 1.1–2 cm .......................... ......... T 0019 4.0919 251.52 71.87 50.30 

11603 ....... Exc tr-ext mlg+marg 2.1–3 cm .......................... ......... T 0020 6.8083 418.49 107.67 83.70 

11604 ....... Exc tr-ext mlg+marg 3.1–4 cm .......................... ......... T 0020 6.8083 418.49 107.67 83.70 

11606 ....... Exc tr-ext mlg+marg > 4 cm .............................. ......... T 0021 15.1024 928.31 219.48 185.66 

11620 ....... Exc h-f-nk-sp mlg+marg 0.5 < ........................... ......... T 0020 6.8083 418.49 107.67 83.70 


cprice-sewell on PRODPC62 with RULES2
68288 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

11621 ....... Exc h-f-nk-sp mlg+marg 0.6–1 .......................... ......... T 0019 4.0919 251.52 71.87 50.30 

11622 ....... Exc h-f-nk-sp mlg+marg 1.1–2 .......................... ......... T 0020 6.8083 418.49 107.67 83.70 

11623 ....... Exc h-f-nk-sp mlg+marg 2.1–3 .......................... ......... T 0021 15.1024 928.31 219.48 185.66 

11624 ....... Exc h-f-nk-sp mlg+marg 3.1–4 .......................... ......... T 0021 15.1024 928.31 219.48 185.66 

11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

11640 ....... Exc face-mm malig+marg 0.5 < ........................ ......... T 0020 6.8083 418.49 107.67 83.70 

11641 ....... Exc face-mm malig+marg 0.6–1 ....................... ......... T 0020 6.8083 418.49 107.67 83.70 

11642 ....... Exc face-mm malig+marg 1.1–2 ....................... ......... T 0020 6.8083 418.49 107.67 83.70 

11643 ....... Exc face-mm malig+marg 2.1–3 ....................... ......... T 0020 6.8083 418.49 107.67 83.70 

11644 ....... Exc face-mm malig+marg 3.1–4 ....................... ......... T 0021 15.1024 928.31 219.48 185.66 

11646 ....... Exc face-mm mlg+marg > 4 cm ........................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

11719 ....... Trim nail(s) ......................................................... ......... T 0009 0.7744 47.60 .................. 9.52 

11720 ....... Debride nail, 1–5 ............................................... ......... T 0009 0.7744 47.60 .................. 9.52 

11721 ....... Debride nail, 6 or more ...................................... ......... T 0009 0.7744 47.60 .................. 9.52 

11730 ....... Removal of nail plate ......................................... ......... T 0013 1.0918 67.11 .................. 13.42 

11732 ....... Remove nail plate, add-on ................................ ......... T 0012 0.8432 51.83 11.18 10.37 

11740 ....... Drain blood from under nail ............................... ......... T 0009 0.7744 47.60 .................. 9.52 

11750 ....... Removal of nail bed ........................................... ......... T 0019 4.0919 251.52 71.87 50.30 

11752 ....... Remove nail bed/finger tip ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

11755 ....... Biopsy, nail unit ................................................. ......... T 0019 4.0919 251.52 71.87 50.30 

11760 ....... Repair of nail bed .............................................. ......... T 0024 1.4843 91.24 29.88 18.25 

11762 ....... Reconstruction of nail bed ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

11765 ....... Excision of nail fold, toe .................................... ......... T 0015 1.6241 99.83 20.13 19.97 

11770 ....... Removal of pilonidal lesion ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

11771 ....... Removal of pilonidal lesion ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

11772 ....... Removal of pilonidal lesion ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

11900 ....... Injection into skin lesions ................................... ......... T 0012 0.8432 51.83 11.18 10.37 

11901 ....... Added skin lesions injection .............................. ......... T 0012 0.8432 51.83 11.18 10.37 

11920 ....... Correct skin color defects .................................. ......... T 0024 1.4843 91.24 29.88 18.25 

11921 ....... Correct skin color defects .................................. ......... T 0024 1.4843 91.24 29.88 18.25 

11922 ....... Correct skin color defects .................................. ......... T 0024 1.4843 91.24 29.88 18.25 

11950 ....... Therapy for contour defects .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

11951 ....... Therapy for contour defects .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

11952 ....... Therapy for contour defects .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

11954 ....... Therapy for contour defects .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

11960 ....... Insert tissue expander(s) ................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

11970 ....... Replace tissue expander ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

11971 ....... Remove tissue expander(s) ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

11976 ....... Removal of contraceptive cap ........................... ......... T 0019 4.0919 251.52 71.87 50.30 

11980 ....... Implant hormone pellet(s) .................................. ......... X 0340 0.6102 37.51 .................. 7.50 

11981 ....... Insert drug implant device ................................. ......... X 0340 0.6102 37.51 .................. 7.50 

11982 ....... Remove drug implant device ............................. ......... X 0340 0.6102 37.51 .................. 7.50 

11983 ....... Remove/insert drug implant ............................... ......... X 0340 0.6102 37.51 .................. 7.50 

12001 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12002 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12004 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12005 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12006 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12007 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12011 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12013 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12014 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12015 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12016 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12017 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12018 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25 

12020 ....... Closure of split wound ....................................... ......... T 0024 1.4843 91.24 29.88 18.25 

12021 ....... Closure of split wound ....................................... ......... T 0024 1.4843 91.24 29.88 18.25 

12031 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12032 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12034 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12035 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12036 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12037 ....... Layer closure of wound(s) ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

12041 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12042 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12044 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12045 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12046 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12047 ....... Layer closure of wound(s) ................................. ......... T 0025 5.2594 323.28 101.85 64.66 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68289 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

12051 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12052 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12053 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12054 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12055 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12056 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

12057 ....... Layer closure of wound(s) ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

13100 ....... Repair of wound or lesion ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

13101 ....... Repair of wound or lesion ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

13102 ....... Repair wound/lesion add-on .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

13120 ....... Repair of wound or lesion ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

13121 ....... Repair of wound or lesion ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

13122 ....... Repair wound/lesion add-on .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

13131 ....... Repair of wound or lesion ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

13132 ....... Repair of wound or lesion ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

13133 ....... Repair wound/lesion add-on .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

13150 ....... Repair of wound or lesion ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

13151 ....... Repair of wound or lesion ................................. CH .. T 0025 5.2594 323.28 101.85 64.66 

13152 ....... Repair of wound or lesion ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

13153 ....... Repair wound/lesion add-on .............................. ......... T 0024 1.4843 91.24 29.88 18.25 

13160 ....... Late closure of wound ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

14000 ....... Skin tissue rearrangement ................................. ......... T 0686 14.0346 862.68 .................. 172.54 

14001 ....... Skin tissue rearrangement ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

14020 ....... Skin tissue rearrangement ................................. ......... T 0686 14.0346 862.68 .................. 172.54 

14021 ....... Skin tissue rearrangement ................................. CH .. T 0686 14.0346 862.68 .................. 172.54 

14040 ....... Skin tissue rearrangement ................................. ......... T 0686 14.0346 862.68 .................. 172.54 

14041 ....... Skin tissue rearrangement ................................. CH .. T 0686 14.0346 862.68 .................. 172.54 

14060 ....... Skin tissue rearrangement ................................. CH .. T 0686 14.0346 862.68 .................. 172.54 

14061 ....... Skin tissue rearrangement ................................. ......... T 0686 14.0346 862.68 .................. 172.54 

14300 ....... Skin tissue rearrangement ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

14350 ....... Skin tissue rearrangement ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15000 ....... Wound prep, 1st 100 sq cm .............................. CH .. D .................. .................. .................. .................. ..................

15001 ....... Wound prep, addl 100 sq cm ............................ CH .. D .................. .................. .................. .................. ..................

15002 ....... Wnd prep, ch/inf, trk/arm/lg ............................... NI .... T 0025 5.2594 323.28 101.85 64.66 

15003 ....... Wnd prep, ch/inf addl 100 cm ........................... NI .... T 0025 5.2594 323.28 101.85 64.66 

15004 ....... Wnd prep ch/inf, f/n/hf/g .................................... NI .... T 0025 5.2594 323.28 101.85 64.66 

15005 ....... Wnd prep, f/n/hf/g, addl cm ............................... NI .... T 0025 5.2594 323.28 101.85 64.66 

15040 ....... Harvest cultured skin graft ................................. ......... T 0024 1.4843 91.24 29.88 18.25 

15050 ....... Skin pinch graft .................................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15100 ....... Skin splt grft, trnk/arm/leg .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15101 ....... Skin splt grft t/a/l, add-on .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15110 ....... Epidrm autogrft trnk/arm/leg .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15111 ....... Epidrm autogrft t/a/l add-on ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15115 ....... Epidrm a-grft face/nck/hf/g ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15116 ....... Epidrm a-grft f/n/hf/g addl .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15120 ....... Skn splt a-grft fac/nck/hf/g ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15121 ....... Skn splt a-grft f/n/hf/g add ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15130 ....... Derm autograft, trnk/arm/leg .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15131 ....... Derm autograft t/a/l add-on ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15135 ....... Derm autograft face/nck/hf/g ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15136 ....... Derm autograft, f/n/hf/g add .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15150 ....... Cult epiderm grft t/arm/leg ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15151 ....... Cult epiderm grft t/a/l addl ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15152 ....... Cult epiderm graft t/a/l +% ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15155 ....... Cult epiderm graft, f/n/hf/g ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15156 ....... Cult epidrm grft f/n/hfg add ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15157 ....... Cult epiderm grft f/n/hfg +% .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15170 ....... Acell graft trunk/arms/legs ................................. CH .. T 0025 5.2594 323.28 101.85 64.66 

15171 ....... Acell graft t/arm/leg add-on ............................... CH .. T 0025 5.2594 323.28 101.85 64.66 

15175 ....... Acellular graft, f/n/hf/g ........................................ CH .. T 0025 5.2594 323.28 101.85 64.66 

15176 ....... Acell graft, f/n/hf/g add-on ................................. CH .. T 0025 5.2594 323.28 101.85 64.66 

15200 ....... Skin full graft, trunk ............................................ CH .. T 0686 14.0346 862.68 .................. 172.54 

15201 ....... Skin full graft trunk add-on ................................ ......... T 0025 5.2594 323.28 101.85 64.66 

15220 ....... Skin full graft sclp/arm/leg ................................. CH .. T 0686 14.0346 862.68 .................. 172.54 

15221 ....... Skin full graft add-on ......................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15240 ....... Skin full grft face/genit/hf ................................... ......... T 0686 14.0346 862.68 .................. 172.54 

15241 ....... Skin full graft add-on ......................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15260 ....... Skin full graft een & lips .................................... ......... T 0686 14.0346 862.68 .................. 172.54 

15261 ....... Skin full graft add-on ......................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15300 ....... Apply skinallogrft, t/arm/lg ................................. CH .. T 0025 5.2594 323.28 101.85 64.66 


cprice-sewell on PRODPC62 with RULES2
68290 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

15301 ....... Apply sknallogrft t/a/l addl ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15320 ....... Apply skin allogrft f/n/hf/g .................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15321 ....... Aply sknallogrft f/n/hfg add ................................ ......... T 0025 5.2594 323.28 101.85 64.66 

15330 ....... Aply acell alogrft t/arm/leg ................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15331 ....... Aply acell grft t/a/l add-on .................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15335 ....... Apply acell graft, f/n/hf/g .................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15336 ....... Aply acell grft f/n/hf/g add .................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15340 ....... Apply cult skin substitute ................................... CH .. T 0025 5.2594 323.28 101.85 64.66 

15341 ....... Apply cult skin sub add-on ................................ CH .. T 0025 5.2594 323.28 101.85 64.66 

15360 ....... Apply cult derm sub, t/a/l ................................... CH .. T 0025 5.2594 323.28 101.85 64.66 

15361 ....... Aply cult derm sub t/a/l add ............................... CH .. T 0025 5.2594 323.28 101.85 64.66 

15365 ....... Apply cult derm sub f/n/hf/g ............................... CH .. T 0025 5.2594 323.28 101.85 64.66 

15366 ....... Apply cult derm f/hf/g add ................................. CH .. T 0025 5.2594 323.28 101.85 64.66 

15400 ....... Apply skin xenograft, t/a/l .................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15401 ....... Apply skn xenogrft t/a/l add ............................... ......... T 0025 5.2594 323.28 101.85 64.66 

15420 ....... Apply skin xgraft, f/n/hf/g ................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15421 ....... Apply skn xgrft f/n/hf/g add ................................ ......... T 0025 5.2594 323.28 101.85 64.66 

15430 ....... Apply acellular xenograft ................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15431 ....... Apply acellular xgraft add .................................. ......... T 0025 5.2594 323.28 101.85 64.66 

15570 ....... Form skin pedicle flap ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15572 ....... Form skin pedicle flap ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15574 ....... Form skin pedicle flap ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15576 ....... Form skin pedicle flap ....................................... ......... T 0686 14.0346 862.68 .................. 172.54 

15600 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15610 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15620 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15630 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15650 ....... Transfer skin pedicle flap .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15731 ....... Forehead flap w/vasc pedicle ............................ NI .... T 0686 14.0346 862.68 .................. 172.54 

15732 ....... Muscle-skin graft, head/neck ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15734 ....... Muscle-skin graft, trunk ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15736 ....... Muscle-skin graft, arm ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15738 ....... Muscle-skin graft, leg ......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15740 ....... Island pedicle flap graft ..................................... ......... T 0686 14.0346 862.68 .................. 172.54 

15750 ....... Neurovascular pedicle graft ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15760 ....... Composite skin graft .......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15770 ....... Derma-fat-fascia graft ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15775 ....... Hair transplant punch grafts .............................. ......... T 0025 5.2594 323.28 101.85 64.66 

15776 ....... Hair transplant punch grafts .............................. ......... T 0025 5.2594 323.28 101.85 64.66 

15780 ....... Abrasion treatment of skin ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15781 ....... Abrasion treatment of skin ................................. ......... T 0019 4.0919 251.52 71.87 50.30 

15782 ....... Abrasion treatment of skin ................................. ......... T 0019 4.0919 251.52 71.87 50.30 

15783 ....... Abrasion treatment of skin ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

15786 ....... Abrasion, lesion, single ...................................... ......... T 0013 1.0918 67.11 .................. 13.42 

15787 ....... Abrasion, lesions, add-on .................................. ......... T 0013 1.0918 67.11 .................. 13.42 

15788 ....... Chemical peel, face, epiderm ............................ ......... T 0012 0.8432 51.83 11.18 10.37 

15789 ....... Chemical peel, face, dermal .............................. ......... T 0015 1.6241 99.83 20.13 19.97 

15792 ....... Chemical peel, nonfacial ................................... ......... T 0013 1.0918 67.11 .................. 13.42 

15793 ....... Chemical peel, nonfacial ................................... ......... T 0012 0.8432 51.83 11.18 10.37 

15819 ....... Plastic surgery, neck ......................................... ......... T 0025 5.2594 323.28 101.85 64.66 

15820 ....... Revision of lower eyelid ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15821 ....... Revision of lower eyelid ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15822 ....... Revision of upper eyelid .................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15823 ....... Revision of upper eyelid .................................... CH .. T 0686 14.0346 862.68 .................. 172.54 

15824 ....... Removal of forehead wrinkles ........................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15825 ....... Removal of neck wrinkles .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15826 ....... Removal of brow wrinkles ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15828 ....... Removal of face wrinkles .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15829 ....... Removal of skin wrinkles ................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15830 ....... Exc skin abd ...................................................... NI .... T 0022 20.0656 1,233.39 354.45 246.68 

15831 ....... Excise excessive skin tissue ............................. CH .. D .................. .................. .................. .................. ..................

15832 ....... Excise excessive skin tissue ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15833 ....... Excise excessive skin tissue ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15834 ....... Excise excessive skin tissue ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15835 ....... Excise excessive skin tissue ............................. ......... T 0025 5.2594 323.28 101.85 64.66 

15836 ....... Excise excessive skin tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

15837 ....... Excise excessive skin tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

15838 ....... Excise excessive skin tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

15839 ....... Excise excessive skin tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

15840 ....... Graft for face nerve palsy .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68291 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

15841 ....... Graft for face nerve palsy .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15842 ....... Flap for face nerve palsy ................................... ......... T 0686 14.0346 862.68 .................. 172.54

15845 ....... Skin and muscle repair, face ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15847 ....... Exc skin abd add-on .......................................... NI .... T 0022 20.0656 1,233.39 354.45 246.68 

15850 ....... Removal of sutures ............................................ ......... T 0016 2.6749 164.42 .................. 32.88

15851 ....... Removal of sutures ............................................ ......... T 0016 2.6749 164.42 .................. 32.88

15852 ....... Dressing change not for burn ............................ ......... X 0340 0.6102 37.51 .................. 7.50 

15860 ....... Test for blood flow in graft ................................. CH .. X 0340 0.6102 37.51 .................. 7.50 

15876 ....... Suction assisted lipectomy ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15877 ....... Suction assisted lipectomy ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15878 ....... Suction assisted lipectomy ................................ ......... T 0686 14.0346 862.68 .................. 172.54 

15879 ....... Suction assisted lipectomy ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15920 ....... Removal of tail bone ulcer ................................. ......... T 0019 4.0919 251.52 71.87 50.30 

15922 ....... Removal of tail bone ulcer ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15931 ....... Remove sacrum pressure sore ......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

15933 ....... Remove sacrum pressure sore ......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

15934 ....... Remove sacrum pressure sore ......................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15935 ....... Remove sacrum pressure sore ......................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15936 ....... Remove sacrum pressure sore ......................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15937 ....... Remove sacrum pressure sore ......................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

15940 ....... Remove hip pressure sore ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

15941 ....... Remove hip pressure sore ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

15944 ....... Remove hip pressure sore ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15945 ....... Remove hip pressure sore ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15946 ....... Remove hip pressure sore ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

15950 ....... Remove thigh pressure sore ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15951 ....... Remove thigh pressure sore ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

15952 ....... Remove thigh pressure sore ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15953 ....... Remove thigh pressure sore ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15956 ....... Remove thigh pressure sore ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15958 ....... Remove thigh pressure sore ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

15999 ....... Removal of pressure sore ................................. ......... T 0019 4.0919 251.52 71.87 50.30 

16000 ....... Initial treatment of burn(s) ................................. ......... T 0012 0.8432 51.83 11.18 10.37 

16020 ....... Dress/debrid p-thick burn, s .............................. ......... T 0013 1.0918 67.11 .................. 13.42 

16025 ....... Dress/debrid p-thick burn, m ............................. ......... T 0013 1.0918 67.11 .................. 13.42 

16030 ....... Dress/debrid p-thick burn, l ............................... ......... T 0015 1.6241 99.83 20.13 19.97 

16035 ....... Incision of burn scab, initi .................................. CH .. T 0016 2.6749 164.42 .................. 32.88 

17000 ....... Destruct premalg lesion ..................................... ......... T 0010 0.476 29.26 8.02 5.85 

17003 ....... Destruct premalg les, 2–14 ............................... ......... T 0010 0.476 29.26 8.02 5.85 

17004 ....... Destroy premlg lesions 15+ ............................... ......... T 0011 2.5665 157.76 .................. 31.55 

17106 ....... Destruction of skin lesions ................................. ......... T 0011 2.5665 157.76 .................. 31.55 

17107 ....... Destruction of skin lesions ................................. ......... T 0011 2.5665 157.76 .................. 31.55 

17108 ....... Destruction of skin lesions ................................. ......... T 0011 2.5665 157.76 .................. 31.55 

17110 ....... Destruct b9 lesion, 1–14 .................................... CH .. T 0012 0.8432 51.83 11.18 10.37 

17111 ....... Destruct lesion, 15 or more ............................... ......... T 0013 1.0918 67.11 .................. 13.42 

17250 ....... Chemical cautery, tissue ................................... ......... T 0013 1.0918 67.11 .................. 13.42 

17260 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17261 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17262 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17263 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17264 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17266 ....... Destruction of skin lesions ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

17270 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17271 ....... Destruction of skin lesions ................................. ......... T 0013 1.0918 67.11 .................. 13.42 

17272 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17273 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17274 ....... Destruction of skin lesions ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

17276 ....... Destruction of skin lesions ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

17280 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17281 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17282 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17283 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17284 ....... Destruction of skin lesions ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

17286 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97 

17304 ....... 1 stage mohs, up to 5 spec ............................... CH .. D .................. .................. .................. .................. ..................

17305 ....... 2 stage mohs, up to 5 spec ............................... CH .. D .................. .................. .................. .................. ..................

17306 ....... 3 stage mohs, up to 5 spec ............................... CH .. D .................. .................. .................. .................. ..................

17307 ....... Mohs addl stage up to 5 spec ........................... CH .. D .................. .................. .................. .................. ..................

17310 ....... Mohs any stage > 5 spec each ......................... CH .. D .................. .................. .................. .................. ..................

17311 ....... Mohs, 1 stage, h/n/hf/g ...................................... NI .... T 0694 3.7292 229.23 91.69 45.85 


cprice-sewell on PRODPC62 with RULES2
68292 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

17312 ....... Mohs addl stage ................................................ NI .... T 0694 3.7292 229.23 91.69 45.85 

17313 ....... Mohs, 1 stage, t/a/l ............................................ NI .... T 0694 3.7292 229.23 91.69 45.85 

17314 ....... Mohs, addl stage, t/a/l ....................................... NI .... T 0694 3.7292 229.23 91.69 45.85 

17315 ....... Mohs surg, addl block ....................................... NI .... T 0694 3.7292 229.23 91.69 45.85 

17340 ....... Cryotherapy of skin ............................................ CH .. T 0016 2.6749 164.42 .................. 32.88 

17360 ....... Skin peel therapy ............................................... ......... T 0013 1.0918 67.11 .................. 13.42 

17380 ....... Hair removal by electrolysis .............................. ......... T 0013 1.0918 67.11 .................. 13.42 

17999 ....... Skin tissue procedure ........................................ CH .. T 0012 0.8432 51.83 11.18 10.37 

19000 ....... Drainage of breast lesion .................................. ......... T 0004 2.0687 127.16 .................. 25.43 

19001 ....... Drain breast lesion add-on ................................ CH .. T 0002 1.0995 67.58 .................. 13.52 

19020 ....... Incision of breast lesion ..................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

19030 ....... Injection for breast x-ray .................................... ......... N .................. .................. .................. .................. ..................

19100 ....... Bx breast percut w/o image ............................... ......... T 0005 3.9045 240.00 71.59 48.00 

19101 ....... Biopsy of breast, open ....................................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19102 ....... Bx breast percut w/image .................................. ......... T 0005 3.9045 240.00 71.59 48.00 

19103 ....... Bx breast percut w/device ................................. ......... T 0658 6.4387 395.77 .................. 79.15 

19105 ....... Cryosurg ablate fa, each ................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42 

19110 ....... Nipple exploration .............................................. ......... T 0028 19.2788 1,185.03 303.74 237.01 

19112 ....... Excise breast duct fistula ................................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19120 ....... Removal of breast lesion ................................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19125 ....... Excision, breast lesion ....................................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19126 ....... Excision, addl breast lesion ............................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19140 ....... Removal of breast tissue ................................... CH .. D .................. .................. .................. .................. ..................

19160 ....... Partial mastectomy ............................................ CH .. D .................. .................. .................. .................. ..................

19162 ....... P-mastectomy w/ln removal .............................. CH .. D .................. .................. .................. .................. ..................

19180 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................

19182 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................

19200 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................

19220 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................

19240 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................

19260 ....... Removal of chest wall lesion ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

19290 ....... Place needle wire, breast .................................. ......... N .................. .................. .................. .................. ..................

19291 ....... Place needle wire, breast .................................. ......... N .................. .................. .................. .................. ..................

19295 ....... Place breast clip, percut .................................... ......... S 0657 1.7369 106.76 .................. 21.35 

19296 ....... Place po breast cath for rad .............................. CH .. T 0648 51.2269 3,148.82 .................. 629.76 

19297 ....... Place breast cath for rad ................................... CH .. T 0648 51.2269 3,148.82 .................. 629.76 

19298 ....... Place breast rad tube/caths ............................... ......... S 1524 .................. 3,250.00 .................. 650.00 

19300 ....... Removal of breast tissue ................................... NI .... T 0028 19.2788 1,185.03 303.74 237.01 

19301 ....... Partical mastectomy .......................................... NI .... T 0028 19.2788 1,185.03 303.74 237.01 

19302 ....... P-mastectomy w/ln removal .............................. NI .... T 0693 36.9988 2,274.24 721.30 454.85 

19303 ....... Mast, simple, complete ...................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42 

19304 ....... Mast, subq ......................................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42 

19305 ....... Mast, radical ...................................................... NI .... C .................. .................. .................. .................. ..................

19306 ....... Mast, rad, urban type ........................................ NI .... C .................. .................. .................. .................. ..................

19307 ....... Mast, mod rad .................................................... NI .... T 0030 37.8692 2,327.74 747.07 465.55 

19316 ....... Suspension of breast ......................................... ......... T 0029 28.0166 1,722.12 581.52 344.42 

19318 ....... Reduction of large breast .................................. ......... T 0693 36.9988 2,274.24 721.30 454.85 

19324 ....... Enlarge breast ................................................... ......... T 0693 36.9988 2,274.24 721.30 454.85 

19325 ....... Enlarge breast with implant ............................... ......... T 0648 51.2269 3,148.82 .................. 629.76

19328 ....... Removal of breast implant ................................. ......... T 0029 28.0166 1,722.12 581.52 344.42 

19330 ....... Removal of implant material .............................. ......... T 0029 28.0166 1,722.12 581.52 344.42 

19340 ....... Immediate breast prosthesis ............................. ......... T 0030 37.8692 2,327.74 747.07 465.55 

19342 ....... Delayed breast prosthesis ................................. ......... T 0648 51.2269 3,148.82 .................. 629.76

19350 ....... Breast reconstruction ......................................... ......... T 0028 19.2788 1,185.03 303.74 237.01 

19355 ....... Correct inverted nipple(s) .................................. ......... T 0029 28.0166 1,722.12 581.52 344.42 

19357 ....... Breast reconstruction ......................................... ......... T 0648 51.2269 3,148.82 .................. 629.76 

19366 ....... Breast reconstruction ......................................... ......... T 0029 28.0166 1,722.12 581.52 344.42 

19370 ....... Surgery of breast capsule ................................. ......... T 0029 28.0166 1,722.12 581.52 344.42 

19371 ....... Removal of breast capsule ................................ ......... T 0029 28.0166 1,722.12 581.52 344.42 

19380 ....... Revise breast reconstruction ............................. ......... T 0030 37.8692 2,327.74 747.07 465.55 

19396 ....... Design custom breast implant ........................... ......... T 0029 28.0166 1,722.12 581.52 344.42 

19499 ....... Breast surgery procedure .................................. ......... T 0028 19.2788 1,185.03 303.74 237.01 

20000 ....... Incision of abscess ............................................ ......... T 0006 1.4392 88.46 .................. 17.69

20005 ....... Incision of deep abscess ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

20100 ....... Explore wound, neck ......................................... ......... T 0023 4.2212 259.47 .................. 51.89 

20101 ....... Explore wound, chest ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

20102 ....... Explore wound, abdomen .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

20103 ....... Explore wound, extremity .................................. ......... T 0023 4.2212 259.47 .................. 51.89 

20150 ....... Excise epiphyseal bar ........................................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

20200 ....... Muscle biopsy .................................................... ......... T 0021 15.1024 928.31 219.48 185.66 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68293 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

20205 ....... Deep muscle biopsy .......................................... ......... T 0021 15.1024 928.31 219.48 185.66 

20206 ....... Needle biopsy, muscle ...................................... ......... T 0005 3.9045 240.00 71.59 48.00 

20220 ....... Bone biopsy, trocar/needle ................................ ......... T 0019 4.0919 251.52 71.87 50.30 

20225 ....... Bone biopsy, trocar/needle ................................ ......... T 0020 6.8083 418.49 107.67 83.70 

20240 ....... Bone biopsy, excisional ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

20245 ....... Bone biopsy, excisional ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

20250 ....... Open bone biopsy ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

20251 ....... Open bone biopsy ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

20500 ....... Injection of sinus tract ........................................ ......... T 0251 2.452 150.72 .................. 30.14 

20501 ....... Inject sinus tract for x-ray .................................. ......... N .................. .................. .................. .................. ..................

20520 ....... Removal of foreign body ................................... ......... T 0019 4.0919 251.52 71.87 50.30 

20525 ....... Removal of foreign body ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

20526 ....... Ther injection, carp tunnel ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

20550 ....... Inj tendon sheath/ligament ................................ ......... T 0204 2.2614 139.00 40.13 27.80 

20551 ....... Inj tendon origin/insertion .................................. ......... T 0204 2.2614 139.00 40.13 27.80 

20552 ....... Inj trigger point, 1/2 muscl ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

20553 ....... Inject trigger points,  ́ 3 .................................... ......... T 0204 2.2614 139.00 40.13 27.80 

20600 ....... Drain/inject, joint/bursa ...................................... ......... T 0204 2.2614 139.00 40.13 27.80 

20605 ....... Drain/inject, joint/bursa ...................................... ......... T 0204 2.2614 139.00 40.13 27.80 

20610 ....... Drain/inject, joint/bursa ...................................... ......... T 0204 2.2614 139.00 40.13 27.80 

20612 ....... Aspirate/inj ganglion cyst ................................... ......... T 0204 2.2614 139.00 40.13 27.80 

20615 ....... Treatment of bone cyst ...................................... ......... T 0004 2.0687 127.16 .................. 25.43 

20650 ....... Insert and remove bone pin .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

20662 ....... Application of pelvis brace ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

20663 ....... Application of thigh brace .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

20665 ....... Removal of fixation device ................................ ......... X 0340 0.6102 37.51 .................. 7.50 

20670 ....... Removal of support implant ............................... ......... T 0021 15.1024 928.31 219.48 185.66 

20680 ....... Removal of support implant ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

20690 ....... Apply bone fixation device ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

20692 ....... Apply bone fixation device ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

20693 ....... Adjust bone fixation device ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

20694 ....... Remove bone fixation device ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

20822 ....... Replantation digit, complete .............................. ......... T 0054 25.8758 1,590.53 .................. 318.11

20900 ....... Removal of bone for graft .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

20902 ....... Removal of bone for graft .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

20910 ....... Remove cartilage for graft ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

20912 ....... Remove cartilage for graft ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

20920 ....... Removal of fascia for graft ................................ ......... T 0686 14.0346 862.68 .................. 172.54 

20922 ....... Removal of fascia for graft ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

20924 ....... Removal of tendon for graft ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93

20926 ....... Removal of tissue for graft ................................ ......... T 0686 14.0346 862.68 .................. 172.54 

20950 ....... Fluid pressure, muscle ...................................... ......... T 0006 1.4392 88.46 .................. 17.69 

20972 ....... Bone/skin graft, metatarsal ................................ ......... T 0056 40.8559 2,511.33 .................. 502.27 

20973 ....... Bone/skin graft, great toe .................................. ......... T 0056 40.8559 2,511.33 .................. 502.27 

20975 ....... Electrical bone stimulation ................................. ......... X 0340 0.6102 37.51 .................. 7.50 

20979 ....... Us bone stimulation ........................................... ......... X 0340 0.6102 37.51 .................. 7.50 

20982 ....... Ablate, bone tumor(s) perq ................................ CH .. T 0051 41.0893 2,525.68 .................. 505.14 

20999 ....... Musculoskeletal surgery .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

21010 ....... Incision of jaw joint ............................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

21015 ....... Resection of facial tumor ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

21025 ....... Excision of bone, lower jaw ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60

21026 ....... Excision of facial bone(s) .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21029 ....... Contour of face bone lesion .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21030 ....... Excise max/zygoma b9 tumor ........................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21031 ....... Remove exostosis, mandible ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21032 ....... Remove exostosis, maxilla ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

21034 ....... Excise max/zygoma mlg tumor ......................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21040 ....... Excise mandible lesion ...................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21044 ....... Removal of jaw bone lesion .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21046 ....... Remove mandible cyst complex ........................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21047 ....... Excise lwr jaw cyst w/repair .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21048 ....... Remove maxilla cyst complex ........................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21049 ....... Excis uppr jaw cyst w/repair .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21050 ....... Removal of jaw joint .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21060 ....... Remove jaw joint cartilage ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60

21070 ....... Remove coronoid process ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21076 ....... Prepare face/oral prosthesis .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21077 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21079 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21080 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60


cprice-sewell on PRODPC62 with RULES2
68294 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

21081 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21082 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21083 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21084 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21085 ....... Prepare face/oral prosthesis .............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

21086 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21087 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21088 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21089 ....... Prepare face/oral prosthesis .............................. ......... T 0251 2.452 150.72 .................. 30.14 

21100 ....... Maxillofacial fixation ........................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21110 ....... Interdental fixation ............................................. ......... T 0252 7.5511 464.15 109.16 92.83 

21116 ....... Injection, jaw joint x-ray ..................................... ......... N .................. .................. .................. .................. ..................

21120 ....... Reconstruction of chin ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21121 ....... Reconstruction of chin ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21122 ....... Reconstruction of chin ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21123 ....... Reconstruction of chin ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21125 ....... Augmentation, lower jaw bone .......................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21127 ....... Augmentation, lower jaw bone .......................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21137 ....... Reduction of forehead ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21138 ....... Reduction of forehead ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21139 ....... Reduction of forehead ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21150 ....... Reconstruct midface, lefort ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21175 ....... Reconstruct orbit/forehead ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60

21181 ....... Contour cranial bone lesion ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21195 ....... Reconst lwr jaw w/o fixation .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21198 ....... Reconstr lwr jaw segment ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21199 ....... Reconstr lwr jaw w/advance .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21206 ....... Reconstruct upper jaw bone .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21208 ....... Augmentation of facial bones ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21209 ....... Reduction of facial bones .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21210 ....... Face bone graft ................................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21215 ....... Lower jaw bone graft ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21230 ....... Rib cartilage graft .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21235 ....... Ear cartilage graft .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21240 ....... Reconstruction of jaw joint ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21242 ....... Reconstruction of jaw joint ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21243 ....... Reconstruction of jaw joint ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21244 ....... Reconstruction of lower jaw .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21245 ....... Reconstruction of jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21246 ....... Reconstruction of jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21248 ....... Reconstruction of jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21249 ....... Reconstruction of jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21260 ....... Revise eye sockets ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21261 ....... Revise eye sockets ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21263 ....... Revise eye sockets ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21267 ....... Revise eye sockets ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21270 ....... Augmentation, cheek bone ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21275 ....... Revision, orbitofacial bones ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21280 ....... Revision of eyelid .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

21282 ....... Revision of eyelid .............................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

21295 ....... Revision of jaw muscle/bone ............................. ......... T 0252 7.5511 464.15 109.16 92.83 

21296 ....... Revision of jaw muscle/bone ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21299 ....... Cranio/maxillofacial surgery ............................... ......... T 0251 2.452 150.72 .................. 30.14 

21300 ....... Treatment of skull fracture ................................. CH .. D .................. .................. .................. .................. ..................

21310 ....... Treatment of nose fracture ................................ ......... T 0251 2.452 150.72 .................. 30.14 

21315 ....... Treatment of nose fracture ................................ ......... T 0251 2.452 150.72 .................. 30.14 

21320 ....... Treatment of nose fracture ................................ ......... T 0252 7.5511 464.15 109.16 92.83 

21325 ....... Treatment of nose fracture ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

21330 ....... Treatment of nose fracture ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

21335 ....... Treatment of nose fracture ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

21336 ....... Treat nasal septal fracture ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

21337 ....... Treat nasal septal fracture ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

21338 ....... Treat nasoethmoid fracture ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21339 ....... Treat nasoethmoid fracture ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21340 ....... Treatment of nose fracture ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60

21345 ....... Treat nose/jaw fracture ...................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21355 ....... Treat cheek bone fracture ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60

21356 ....... Treat cheek bone fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21390 ....... Treat eye socket fracture ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21400 ....... Treat eye socket fracture ................................... ......... T 0252 7.5511 464.15 109.16 92.83 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68295 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

21401 ....... Treat eye socket fracture ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

21406 ....... Treat eye socket fracture ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21407 ....... Treat eye socket fracture ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21408 ....... Treat eye socket fracture ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21421 ....... Treat mouth roof fracture ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21440 ....... Treat dental ridge fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21445 ....... Treat dental ridge fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

21450 ....... Treat lower jaw fracture ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

21451 ....... Treat lower jaw fracture ..................................... ......... T 0252 7.5511 464.15 109.16 92.83 

21452 ....... Treat lower jaw fracture ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

21453 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21454 ....... Treat lower jaw fracture ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

21461 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21462 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21465 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21470 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

21480 ....... Reset dislocated jaw .......................................... ......... T 0251 2.452 150.72 .................. 30.14 

21485 ....... Reset dislocated jaw .......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

21490 ....... Repair dislocated jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

21495 ....... Treat hyoid bone fracture .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

21497 ....... Interdental wiring ............................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

21499 ....... Head surgery procedure .................................... ......... T 0251 2.452 150.72 .................. 30.14 

21501 ....... Drain neck/chest lesion ..................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

21502 ....... Drain chest lesion .............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

21550 ....... Biopsy of neck/chest .......................................... CH .. T 0020 6.8083 418.49 107.67 83.70 

21555 ....... Remove lesion, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

21556 ....... Remove lesion, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

21557 ....... Remove tumor, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

21600 ....... Partial removal of rib ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

21610 ....... Partial removal of rib ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

21685 ....... Hyoid myotomy & suspension ........................... ......... T 0252 7.5511 464.15 109.16 92.83 

21700 ....... Revision of neck muscle .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

21720 ....... Revision of neck muscle .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

21725 ....... Revision of neck muscle .................................... ......... T 0006 1.4392 88.46 .................. 17.69 

21742 ....... Repair stern/nuss w/o scope ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

21743 ....... Repair sternum/nuss w/scope ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

21800 ....... Treatment of rib fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72 

21805 ....... Treatment of rib fracture .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

21820 ....... Treat sternum fracture ....................................... ......... T 0043 1.6857 103.62 .................. 20.72 

21899 ....... Neck/chest surgery procedure ........................... ......... T 0251 2.452 150.72 .................. 30.14 

21920 ....... Biopsy soft tissue of back .................................. ......... T 0020 6.8083 418.49 107.67 83.70 

21925 ....... Biopsy soft tissue of back .................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

21930 ....... Remove lesion, back or flank ............................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

21935 ....... Remove tumor, back ......................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

22100 ....... Remove part of neck vertebra ........................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

22101 ....... Remove part, thorax vertebra ............................ ......... T 0208 44.1489 2,713.74 .................. 542.75 

22102 ....... Remove part, lumbar vertebra ........................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

22103 ....... Remove extra spine segment ............................ ......... T 0208 44.1489 2,713.74 .................. 542.75 

22222 ....... Revision of thorax spine .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

22305 ....... Treat spine process fracture .............................. ......... T 0043 1.6857 103.62 .................. 20.72 

22310 ....... Treat spine fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72 

22315 ....... Treat spine fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72 

22505 ....... Manipulation of spine ......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

22520 ....... Percut vertebroplasty thor ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

22521 ....... Percut vertebroplasty lumb ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93

22522 ....... Percut vertebroplasty add"l ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

22523 ....... Percut kyphoplasty, thor .................................... ......... T 0052 66.58 4,092.54 .................. 818.51

22524 ....... Percut kyphoplasty, lumbar ............................... ......... T 0052 66.58 4,092.54 .................. 818.51 

22525 ....... Percut kyphoplasty, add-on ............................... ......... T 0052 66.58 4,092.54 .................. 818.51 

22526 ....... Idet, single level ................................................. NI .... T 0050 25.1296 1,544.67 .................. 308.93 

22527 ....... Idet, 1 or more levels ......................................... NI .... T 0050 25.1296 1,544.67 .................. 308.93 

22612 ....... Lumbar spine fusion .......................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

22614 ....... Spine fusion, extra segment .............................. ......... T 0208 44.1489 2,713.74 .................. 542.75 

22851 ....... Apply spine prosth device ................................. CH .. T 0049 20.8706 1,282.87 .................. 256.57 

22857 ....... Lumbar artif diskectomy .................................... NI .... C .................. .................. .................. .................. ..................

22862 ....... Revise lumbar artif disc ..................................... NI .... C .................. .................. .................. .................. ..................

22865 ....... Remove lumb artif disc ...................................... NI .... C .................. .................. .................. .................. ..................

22899 ....... Spine surgery procedure ................................... CH .. T 0049 20.8706 1,282.87 .................. 256.57 

22900 ....... Remove abdominal wall lesion .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

22999 ....... Abdomen surgery procedure ............................. CH .. T 0049 20.8706 1,282.87 .................. 256.57 


cprice-sewell on PRODPC62 with RULES2
68296 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

23000 ....... Removal of calcium deposits ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

23020 ....... Release shoulder joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23030 ....... Drain shoulder lesion ......................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

23031 ....... Drain shoulder bursa ......................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

23035 ....... Drain shoulder bone lesion ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57

23040 ....... Exploratory shoulder surgery ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23044 ....... Exploratory shoulder surgery ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23065 ....... Biopsy shoulder tissues ..................................... CH .. T 0020 6.8083 418.49 107.67 83.70 

23066 ....... Biopsy shoulder tissues ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

23075 ....... Removal of shoulder lesion ............................... ......... T 0021 15.1024 928.31 219.48 185.66 

23076 ....... Removal of shoulder lesion ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

23077 ....... Remove tumor of shoulder ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

23100 ....... Biopsy of shoulder joint ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

23101 ....... Shoulder joint surgery ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

23105 ....... Remove shoulder joint lining ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23106 ....... Incision of collarbone joint ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23107 ....... Explore treat shoulder joint ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

23120 ....... Partial removal, collar bone ............................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23125 ....... Removal of collar bone ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23130 ....... Remove shoulder bone, part ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

23140 ....... Removal of bone lesion ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

23145 ....... Removal of bone lesion ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23146 ....... Removal of bone lesion ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23150 ....... Removal of humerus lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23155 ....... Removal of humerus lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23156 ....... Removal of humerus lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23170 ....... Remove collar bone lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

23172 ....... Remove shoulder blade lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23174 ....... Remove humerus lesion .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23180 ....... Remove collar bone lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

23182 ....... Remove shoulder blade lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23184 ....... Remove humerus lesion .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

23190 ....... Partial removal of scapula ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23195 ....... Removal of head of humerus ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

23330 ....... Remove shoulder foreign body ......................... ......... T 0020 6.8083 418.49 107.67 83.70 

23331 ....... Remove shoulder foreign body ......................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

23350 ....... Injection for shoulder x-ray ................................ ......... N .................. .................. .................. .................. ..................

23395 ....... Muscle transfer,shoulder/arm ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

23397 ....... Muscle transfers ................................................ ......... T 0052 66.58 4,092.54 .................. 818.51 

23400 ....... Fixation of shoulder blade ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23405 ....... Incision of tendon & muscle .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23406 ....... Incise tendon(s) & muscle(s) ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

23410 ....... Repair rotator cuff, acute ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23412 ....... Repair rotator cuff, chronic ................................ CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23415 ....... Release of shoulder ligament ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

23420 ....... Repair of shoulder ............................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14

23430 ....... Repair biceps tendon ......................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23440 ....... Remove/transplant tendon ................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23450 ....... Repair shoulder capsule .................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

23455 ....... Repair shoulder capsule .................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

23460 ....... Repair shoulder capsule .................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

23462 ....... Repair shoulder capsule .................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23465 ....... Repair shoulder capsule .................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

23466 ....... Repair shoulder capsule .................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

23470 ....... Reconstruct shoulder joint ................................. ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

23480 ....... Revision of collar bone ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23485 ....... Revision of collar bone ...................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

23490 ....... Reinforce clavicle ............................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23491 ....... Reinforce shoulder bones .................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

23500 ....... Treat clavicle fracture ........................................ ......... T 0043 1.6857 103.62 .................. 20.72 

23505 ....... Treat clavicle fracture ........................................ ......... T 0043 1.6857 103.62 .................. 20.72 

23515 ....... Treat clavicle fracture ........................................ CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23520 ....... Treat clavicle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23525 ....... Treat clavicle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23530 ....... Treat clavicle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

23532 ....... Treat clavicle dislocation ................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

23540 ....... Treat clavicle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23545 ....... Treat clavicle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23550 ....... Treat clavicle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

23552 ....... Treat clavicle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68297 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

23570 ....... Treat shoulder blade fx ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23575 ....... Treat shoulder blade fx ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23585 ....... Treat scapula fracture ........................................ CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23600 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23605 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23615 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23616 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23620 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23625 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23630 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23650 ....... Treat shoulder dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

23655 ....... Treat shoulder dislocation ................................. ......... T 0045 14.5947 897.11 268.47 179.42 

23660 ....... Treat shoulder dislocation ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

23665 ....... Treat dislocation/fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23670 ....... Treat dislocation/fracture ................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

23675 ....... Treat dislocation/fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

23680 ....... Treat dislocation/fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

23700 ....... Fixation of shoulder ........................................... ......... T 0045 14.5947 897.11 268.47 179.42 

23800 ....... Fusion of shoulder joint ..................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

23802 ....... Fusion of shoulder joint ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

23921 ....... Amputation follow-up surgery ............................ ......... T 0025 5.2594 323.28 101.85 64.66 

23929 ....... Shoulder surgery procedure .............................. ......... T 0043 1.6857 103.62 .................. 20.72 

23930 ....... Drainage of arm lesion ...................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

23931 ....... Drainage of arm bursa ....................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

23935 ....... Drain arm/elbow bone lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

24000 ....... Exploratory elbow surgery ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

24006 ....... Release elbow joint ........................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24065 ....... Biopsy arm/elbow soft tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

24066 ....... Biopsy arm/elbow soft tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

24075 ....... Remove arm/elbow lesion ................................. ......... T 0021 15.1024 928.31 219.48 185.66 

24076 ....... Remove arm/elbow lesion ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

24077 ....... Remove tumor of arm/elbow ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

24100 ....... Biopsy elbow joint lining .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

24101 ....... Explore/treat elbow joint .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24102 ....... Remove elbow joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

24105 ....... Removal of elbow bursa .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57

24110 ....... Remove humerus lesion .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

24115 ....... Remove/graft bone lesion .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

24116 ....... Remove/graft bone lesion .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

24120 ....... Remove elbow lesion ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

24125 ....... Remove/graft bone lesion .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

24126 ....... Remove/graft bone lesion .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

24130 ....... Removal of head of radius ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

24134 ....... Removal of arm bone lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

24136 ....... Remove radius bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24138 ....... Remove elbow bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24140 ....... Partial removal of arm bone .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

24145 ....... Partial removal of radius .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24147 ....... Partial removal of elbow .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24149 ....... Radical resection of elbow ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93

24150 ....... Extensive humerus surgery ............................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

24151 ....... Extensive humerus surgery ............................... ......... T 0052 66.58 4,092.54 .................. 818.51 

24152 ....... Extensive radius surgery ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

24153 ....... Extensive radius surgery ................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

24155 ....... Removal of elbow joint ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24160 ....... Remove elbow joint implant .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

24164 ....... Remove radius head implant ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

24200 ....... Removal of arm foreign body ............................ ......... T 0019 4.0919 251.52 71.87 50.30 

24201 ....... Removal of arm foreign body ............................ ......... T 0021 15.1024 928.31 219.48 185.66 

24220 ....... Injection for elbow x-ray .................................... ......... N .................. .................. .................. .................. ..................

24300 ....... Manipulate elbow w/anesth ............................... ......... T 0045 14.5947 897.11 268.47 179.42 

24301 ....... Muscle/tendon transfer ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24305 ....... Arm tendon lengthening .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93

24310 ....... Revision of arm tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

24320 ....... Repair of arm tendon ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24330 ....... Revision of arm muscles ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

24331 ....... Revision of arm muscles ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14

24332 ....... Tenolysis, triceps ............................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

24340 ....... Repair of biceps tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24341 ....... Repair arm tendon/muscle ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14 


cprice-sewell on PRODPC62 with RULES2
68298 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

24342 ....... Repair of ruptured tendon ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14

24343 ....... Repr elbow lat ligmnt w/tiss ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24344 ....... Reconstruct elbow lat ligmnt ............................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

24345 ....... Repr elbw med ligmnt w/tissu ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24346 ....... Reconstruct elbow med ligmnt .......................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24350 ....... Repair of tennis elbow ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24351 ....... Repair of tennis elbow ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24352 ....... Repair of tennis elbow ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24354 ....... Repair of tennis elbow ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24356 ....... Revision of tennis elbow .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24360 ....... Reconstruct elbow joint ..................................... ......... T 0047 33.4505 2,056.14 537.03 411.23 

24361 ....... Reconstruct elbow joint ..................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

24362 ....... Reconstruct elbow joint ..................................... ......... T 0048 47.4378 2,915.91 .................. 583.18 

24363 ....... Replace elbow joint ........................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

24365 ....... Reconstruct head of radius ............................... ......... T 0047 33.4505 2,056.14 537.03 411.23 

24366 ....... Reconstruct head of radius ............................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

24400 ....... Revision of humerus .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24410 ....... Revision of humerus .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

24420 ....... Revision of humerus .......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24430 ....... Repair of humerus ............................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

24435 ....... Repair humerus with graft ................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

24470 ....... Revision of elbow joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24495 ....... Decompression of forearm ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

24498 ....... Reinforce humerus ............................................ CH .. T 0052 66.58 4,092.54 .................. 818.51 

24500 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24505 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24515 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24516 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24530 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24535 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24538 ....... Treat humerus fracture ...................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

24545 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24546 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24560 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24565 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24566 ....... Treat humerus fracture ...................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

24575 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24576 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24577 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24579 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24582 ....... Treat humerus fracture ...................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

24586 ....... Treat elbow fracture ........................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24587 ....... Treat elbow fracture ........................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24600 ....... Treat elbow dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24605 ....... Treat elbow dislocation ...................................... ......... T 0045 14.5947 897.11 268.47 179.42 

24615 ....... Treat elbow dislocation ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24620 ....... Treat elbow fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24635 ....... Treat elbow fracture ........................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24640 ....... Treat elbow dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24650 ....... Treat radius fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24655 ....... Treat radius fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

24665 ....... Treat radius fracture .......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

24666 ....... Treat radius fracture .......................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

24670 ....... Treat ulnar fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

24675 ....... Treat ulnar fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

24685 ....... Treat ulnar fracture ............................................ CH .. T 0063 37.5382 2,307.40 548.33 461.48 

24800 ....... Fusion of elbow joint .......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

24802 ....... Fusion/graft of elbow joint ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

24925 ....... Amputation follow-up surgery ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

24935 ....... Revision of amputation ...................................... ......... T 0052 66.58 4,092.54 .................. 818.51

24999 ....... Upper arm/elbow surgery .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

25000 ....... Incision of tendon sheath .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

25001 ....... Incise flexor carpi radialis .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

25020 ....... Decompress forearm 1 space ........................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

25023 ....... Decompress forearm 1 space ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25024 ....... Decompress forearm 2 spaces ......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25025 ....... Decompress forearm 2 spaces ......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25028 ....... Drainage of forearm lesion ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57

25031 ....... Drainage of forearm bursa ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

25035 ....... Treat forearm bone lesion ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68299 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

25040 ....... Explore/treat wrist joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25065 ....... Biopsy forearm soft tissues ............................... CH .. T 0020 6.8083 418.49 107.67 83.70 

25066 ....... Biopsy forearm soft tissues ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

25075 ....... Removal forearm lesion subcu .......................... ......... T 0021 15.1024 928.31 219.48 185.66 

25076 ....... Removal forearm lesion deep ........................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

25077 ....... Remove tumor, forearm/wrist ............................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

25085 ....... Incision of wrist capsule .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

25100 ....... Biopsy of wrist joint ............................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

25101 ....... Explore/treat wrist joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25105 ....... Remove wrist joint lining .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25107 ....... Remove wrist joint cartilage .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93

25109 ....... Excise tendon forearm/wrist .............................. NI .... T 0049 20.8706 1,282.87 .................. 256.57 

25110 ....... Remove wrist tendon lesion .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

25111 ....... Remove wrist tendon lesion .............................. ......... T 0053 16.154 992.95 253.49 198.59 

25112 ....... Reremove wrist tendon lesion ........................... ......... T 0053 16.154 992.95 253.49 198.59 

25115 ....... Remove wrist/forearm lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

25116 ....... Remove wrist/forearm lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

25118 ....... Excise wrist tendon sheath ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93

25119 ....... Partial removal of ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25120 ....... Removal of forearm lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

25125 ....... Remove/graft forearm lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25126 ....... Remove/graft forearm lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25130 ....... Removal of wrist lesion ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25135 ....... Remove & graft wrist lesion .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25136 ....... Remove & graft wrist lesion .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25145 ....... Remove forearm bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

25150 ....... Partial removal of ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25151 ....... Partial removal of radius .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25170 ....... Extensive forearm surgery ................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14 

25210 ....... Removal of wrist bone ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

25215 ....... Removal of wrist bones ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

25230 ....... Partial removal of radius .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25240 ....... Partial removal of ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25246 ....... Injection for wrist x-ray ...................................... ......... N .................. .................. .................. .................. ..................

25248 ....... Remove forearm foreign body ........................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

25250 ....... Removal of wrist prosthesis .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25251 ....... Removal of wrist prosthesis .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25259 ....... Manipulate wrist w/anesthes ............................. ......... T 0043 1.6857 103.62 .................. 20.72 

25260 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25263 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25265 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25270 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25272 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25274 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25275 ....... Repair forearm tendon sheath ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25280 ....... Revise wrist/forearm tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25290 ....... Incise wrist/forearm tendon ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93

25295 ....... Release wrist/forearm tendon ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

25300 ....... Fusion of tendons at wrist ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25301 ....... Fusion of tendons at wrist ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25310 ....... Transplant forearm tendon ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

25312 ....... Transplant forearm tendon ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

25315 ....... Revise palsy hand tendon(s) ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

25316 ....... Revise palsy hand tendon(s) ............................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

25320 ....... Repair/revise wrist joint ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25332 ....... Revise wrist joint ................................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

25335 ....... Realignment of hand ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25337 ....... Reconstruct ulna/radioulnar ............................... ......... T 0051 41.0893 2,525.68 .................. 505.14

25350 ....... Revision of radius .............................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

25355 ....... Revision of radius .............................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

25360 ....... Revision of ulna ................................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25365 ....... Revise radius & ulna ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25370 ....... Revise radius or ulna ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25375 ....... Revise radius & ulna ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25390 ....... Shorten radius or ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25391 ....... Lengthen radius or ulna ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25392 ....... Shorten radius & ulna ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

25393 ....... Lengthen radius & ulna ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25394 ....... Repair carpal bone, shorten .............................. ......... T 0053 16.154 992.95 253.49 198.59 

25400 ....... Repair radius or ulna ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 


cprice-sewell on PRODPC62 with RULES2
68300 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

25405 ....... Repair/graft radius or ulna ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

25415 ....... Repair radius & ulna .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

25420 ....... Repair/graft radius & ulna .................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

25425 ....... Repair/graft radius or ulna ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

25426 ....... Repair/graft radius & ulna .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

25430 ....... Vasc graft into carpal bone ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11

25431 ....... Repair nonunion carpal bone ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11 

25440 ....... Repair/graft wrist bone ...................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

25441 ....... Reconstruct wrist joint ....................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

25442 ....... Reconstruct wrist joint ....................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

25443 ....... Reconstruct wrist joint ....................................... ......... T 0048 47.4378 2,915.91 .................. 583.18 

25444 ....... Reconstruct wrist joint ....................................... ......... T 0048 47.4378 2,915.91 .................. 583.18 

25445 ....... Reconstruct wrist joint ....................................... ......... T 0048 47.4378 2,915.91 .................. 583.18 

25446 ....... Wrist replacement .............................................. ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80 

25447 ....... Repair wrist joint(s) ............................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

25449 ....... Remove wrist joint implant ................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

25450 ....... Revision of wrist joint ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25455 ....... Revision of wrist joint ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25490 ....... Reinforce radius ................................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

25491 ....... Reinforce ulna .................................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25492 ....... Reinforce radius and ulna ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14

25500 ....... Treat fracture of radius ...................................... ......... T 0043 1.6857 103.62 .................. 20.72

25505 ....... Treat fracture of radius ...................................... ......... T 0043 1.6857 103.62 .................. 20.72

25515 ....... Treat fracture of radius ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25520 ....... Treat fracture of radius ...................................... ......... T 0043 1.6857 103.62 .................. 20.72

25525 ....... Treat fracture of radius ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25526 ....... Treat fracture of radius ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25530 ....... Treat fracture of ulna ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25535 ....... Treat fracture of ulna ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25545 ....... Treat fracture of ulna ......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25560 ....... Treat fracture radius & ulna ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

25565 ....... Treat fracture radius & ulna ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

25574 ....... Treat fracture radius & ulna ............................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

25575 ....... Treat fracture radius/ulna .................................. CH .. T 0064 57.2172 3,517.03 835.79 703.41 

25600 ....... Treat fracture radius/ulna .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

25605 ....... Treat fracture radius/ulna .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

25606 ....... Treat fx distal radial ........................................... NI .... T 0062 25.5264 1,569.06 372.87 313.81 

25607 ....... Treat fx rad extra-articul .................................... NI .... T 0064 57.2172 3,517.03 835.79 703.41 

25608 ....... Treat fx rad intra-articul ..................................... NI .... T 0064 57.2172 3,517.03 835.79 703.41 

25609 ....... Treat fx radial 3+ frag ........................................ NI .... T 0064 57.2172 3,517.03 835.79 703.41 

25611 ....... Treat fracture radius/ulna .................................. CH .. D .................. .................. .................. .................. ..................

25620 ....... Treat fracture radius/ulna .................................. CH .. D .................. .................. .................. .................. ..................

25622 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25624 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25628 ....... Treat wrist bone fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25630 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25635 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25645 ....... Treat wrist bone fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25650 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

25651 ....... Pin ulnar styloid fracture .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25652 ....... Treat fracture ulnar styloid ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

25660 ....... Treat wrist dislocation ........................................ ......... T 0043 1.6857 103.62 .................. 20.72 

25670 ....... Treat wrist dislocation ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25671 ....... Pin radioulnar dislocation .................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25675 ....... Treat wrist dislocation ........................................ ......... T 0043 1.6857 103.62 .................. 20.72 

25676 ....... Treat wrist dislocation ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25680 ....... Treat wrist fracture ............................................. ......... T 0043 1.6857 103.62 .................. 20.72 

25685 ....... Treat wrist fracture ............................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25690 ....... Treat wrist dislocation ........................................ ......... T 0043 1.6857 103.62 .................. 20.72 

25695 ....... Treat wrist dislocation ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81 

25800 ....... Fusion of wrist joint ............................................ CH .. T 0052 66.58 4,092.54 .................. 818.51

25805 ....... Fusion/graft of wrist joint ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

25810 ....... Fusion/graft of wrist joint ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

25820 ....... Fusion of hand bones ........................................ ......... T 0053 16.154 992.95 253.49 198.59 

25825 ....... Fuse hand bones with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

25830 ....... Fusion, radioulnar jnt/ulna ................................. CH .. T 0052 66.58 4,092.54 .................. 818.51 

25907 ....... Amputation follow-up surgery ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

25922 ....... Amputate hand at wrist ...................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

25929 ....... Amputation follow-up surgery ............................ ......... T 0686 14.0346 862.68 .................. 172.54 

25999 ....... Forearm or wrist surgery ................................... ......... T 0043 1.6857 103.62 .................. 20.72 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68301 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

26010 ....... Drainage of finger abscess ................................ ......... T 0006 1.4392 88.46 .................. 17.69 

26011 ....... Drainage of finger abscess ................................ ......... T 0007 11.1535 685.58 .................. 137.12 

26020 ....... Drain hand tendon sheath ................................. ......... T 0053 16.154 992.95 253.49 198.59 

26025 ....... Drainage of palm bursa ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26030 ....... Drainage of palm bursa(s) ................................. ......... T 0053 16.154 992.95 253.49 198.59 

26034 ....... Treat hand bone lesion ...................................... ......... T 0053 16.154 992.95 253.49 198.59 

26035 ....... Decompress fingers/hand .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26037 ....... Decompress fingers/hand .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26040 ....... Release palm contracture .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26045 ....... Release palm contracture .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26055 ....... Incise finger tendon sheath ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26060 ....... Incision of finger tendon .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26070 ....... Explore/treat hand joint ...................................... ......... T 0053 16.154 992.95 253.49 198.59 

26075 ....... Explore/treat finger joint ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26080 ....... Explore/treat finger joint ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26100 ....... Biopsy hand joint lining ...................................... ......... T 0053 16.154 992.95 253.49 198.59 

26105 ....... Biopsy finger joint lining ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26110 ....... Biopsy finger joint lining ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26115 ....... Removal hand lesion subcut ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

26116 ....... Removal hand lesion, deep ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

26117 ....... Remove tumor, hand/finger ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

26121 ....... Release palm contracture .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26123 ....... Release palm contracture .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26125 ....... Release palm contracture .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26130 ....... Remove wrist joint lining .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26135 ....... Revise finger joint, each .................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26140 ....... Revise finger joint, each .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26145 ....... Tendon excision, palm/finger ............................. ......... T 0053 16.154 992.95 253.49 198.59 

26160 ....... Remove tendon sheath lesion ........................... ......... T 0053 16.154 992.95 253.49 198.59 

26170 ....... Removal of palm tendon, each ......................... ......... T 0053 16.154 992.95 253.49 198.59 

26180 ....... Removal of finger tendon .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26185 ....... Remove finger bone .......................................... ......... T 0053 16.154 992.95 253.49 198.59 

26200 ....... Remove hand bone lesion ................................. ......... T 0053 16.154 992.95 253.49 198.59 

26205 ....... Remove/graft bone lesion .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26210 ....... Removal of finger lesion .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26215 ....... Remove/graft finger lesion ................................. ......... T 0053 16.154 992.95 253.49 198.59 

26230 ....... Partial removal of hand bone ............................ ......... T 0053 16.154 992.95 253.49 198.59 

26235 ....... Partial removal, finger bone .............................. ......... T 0053 16.154 992.95 253.49 198.59 

26236 ....... Partial removal, finger bone .............................. ......... T 0053 16.154 992.95 253.49 198.59 

26250 ....... Extensive hand surgery ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26255 ....... Extensive hand surgery ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26260 ....... Extensive finger surgery .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26261 ....... Extensive finger surgery .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26262 ....... Partial removal of finger .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26320 ....... Removal of implant from hand .......................... ......... T 0021 15.1024 928.31 219.48 185.66 

26340 ....... Manipulate finger w/anesth ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

26350 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26352 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26356 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26357 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26358 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26370 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26372 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26373 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26390 ....... Revise hand/finger tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26392 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26410 ....... Repair hand tendon ........................................... ......... T 0053 16.154 992.95 253.49 198.59 

26412 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26415 ....... Excision, hand/finger tendon ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26416 ....... Graft hand or finger tendon ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11

26418 ....... Repair finger tendon .......................................... ......... T 0053 16.154 992.95 253.49 198.59 

26420 ....... Repair/graft finger tendon .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26426 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11

26428 ....... Repair/graft finger tendon .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26432 ....... Repair finger tendon .......................................... ......... T 0053 16.154 992.95 253.49 198.59 

26433 ....... Repair finger tendon .......................................... ......... T 0053 16.154 992.95 253.49 198.59 

26434 ....... Repair/graft finger tendon .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26437 ....... Realignment of tendons ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26440 ....... Release palm/finger tendon ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26442 ....... Release palm & finger tendon ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11 


cprice-sewell on PRODPC62 with RULES2
68302 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

26445 ....... Release hand/finger tendon .............................. ......... T 0053 16.154 992.95 253.49 198.59 

26449 ....... Release forearm/hand tendon ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26450 ....... Incision of palm tendon ..................................... ......... T 0053 16.154 992.95 253.49 198.59 

26455 ....... Incision of finger tendon .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26460 ....... Incise hand/finger tendon .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26471 ....... Fusion of finger tendons .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26474 ....... Fusion of finger tendons .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26476 ....... Tendon lengthening ........................................... ......... T 0053 16.154 992.95 253.49 198.59 

26477 ....... Tendon shortening ............................................. ......... T 0053 16.154 992.95 253.49 198.59 

26478 ....... Lengthening of hand tendon .............................. ......... T 0053 16.154 992.95 253.49 198.59 

26479 ....... Shortening of hand tendon ................................ ......... T 0053 16.154 992.95 253.49 198.59 

26480 ....... Transplant hand tendon ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26483 ....... Transplant/graft hand tendon ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11 

26485 ....... Transplant palm tendon ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26489 ....... Transplant/graft palm tendon ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26490 ....... Revise thumb tendon ......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26492 ....... Tendon transfer with graft ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26494 ....... Hand tendon/muscle transfer ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11 

26496 ....... Revise thumb tendon ......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26497 ....... Finger tendon transfer ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26498 ....... Finger tendon transfer ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26499 ....... Revision of finger ............................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26500 ....... Hand tendon reconstruction .............................. ......... T 0053 16.154 992.95 253.49 198.59 

26502 ....... Hand tendon reconstruction .............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26504 ....... Hand tendon reconstruction .............................. CH .. D .................. .................. .................. .................. ..................

26508 ....... Release thumb contracture ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26510 ....... Thumb tendon transfer ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26516 ....... Fusion of knuckle joint ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26517 ....... Fusion of knuckle joints ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26518 ....... Fusion of knuckle joints ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26520 ....... Release knuckle contracture ............................. ......... T 0053 16.154 992.95 253.49 198.59 

26525 ....... Release finger contracture ................................ ......... T 0053 16.154 992.95 253.49 198.59 

26530 ....... Revise knuckle joint ........................................... ......... T 0047 33.4505 2,056.14 537.03 411.23 

26531 ....... Revise knuckle with implant .............................. ......... T 0048 47.4378 2,915.91 .................. 583.18 

26535 ....... Revise finger joint .............................................. ......... T 0047 33.4505 2,056.14 537.03 411.23 

26536 ....... Revise/implant finger joint ................................. ......... T 0048 47.4378 2,915.91 .................. 583.18 

26540 ....... Repair hand joint ............................................... ......... T 0053 16.154 992.95 253.49 198.59 

26541 ....... Repair hand joint with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26542 ....... Repair hand joint with graft ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26545 ....... Reconstruct finger joint ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26546 ....... Repair nonunion hand ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26548 ....... Reconstruct finger joint ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26550 ....... Construct thumb replacement ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26555 ....... Positional change of finger ................................ ......... T 0054 25.8758 1,590.53 .................. 318.11 

26560 ....... Repair of web finger .......................................... ......... T 0053 16.154 992.95 253.49 198.59 

26561 ....... Repair of web finger .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26562 ....... Repair of web finger .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26565 ....... Correct metacarpal flaw ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26567 ....... Correct finger deformity ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26568 ....... Lengthen metacarpal/finger ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26580 ....... Repair hand deformity ....................................... ......... T 0053 16.154 992.95 253.49 198.59 

26587 ....... Reconstruct extra finger .................................... ......... T 0053 16.154 992.95 253.49 198.59 

26590 ....... Repair finger deformity ...................................... ......... T 0053 16.154 992.95 253.49 198.59 

26591 ....... Repair muscles of hand ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26593 ....... Release muscles of hand .................................. ......... T 0053 16.154 992.95 253.49 198.59 

26596 ....... Excision constricting tissue ................................ ......... T 0053 16.154 992.95 253.49 198.59 

26600 ....... Treat metacarpal fracture .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26605 ....... Treat metacarpal fracture .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26607 ....... Treat metacarpal fracture .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26608 ....... Treat metacarpal fracture .................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26615 ....... Treat metacarpal fracture .................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26641 ....... Treat thumb dislocation ..................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26645 ....... Treat thumb fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72

26650 ....... Treat thumb fracture .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26665 ....... Treat thumb fracture .......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26670 ....... Treat hand dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26675 ....... Treat hand dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26676 ....... Pin hand dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26685 ....... Treat hand dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26686 ....... Treat hand dislocation ....................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68303 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

26700 ....... Treat knuckle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26705 ....... Treat knuckle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26706 ....... Pin knuckle dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

26715 ....... Treat knuckle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26720 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26725 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26727 ....... Treat finger fracture, each ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26735 ....... Treat finger fracture, each ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26740 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26742 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26746 ....... Treat finger fracture, each ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26750 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26755 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

26756 ....... Pin finger fracture, each .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26765 ....... Treat finger fracture, each ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

26770 ....... Treat finger dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72

26775 ....... Treat finger dislocation ...................................... ......... T 0045 14.5947 897.11 268.47 179.42 

26776 ....... Pin finger dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26785 ....... Treat finger dislocation ...................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

26820 ....... Thumb fusion with graft ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26841 ....... Fusion of thumb ................................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26842 ....... Thumb fusion with graft ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26843 ....... Fusion of hand joint ........................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26844 ....... Fusion/graft of hand joint ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26850 ....... Fusion of knuckle ............................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26852 ....... Fusion of knuckle with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26860 ....... Fusion of finger joint .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26861 ....... Fusion of finger jnt, add-on ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26862 ....... Fusion/graft of finger joint .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

26863 ....... Fuse/graft added joint ........................................ ......... T 0054 25.8758 1,590.53 .................. 318.11 

26910 ....... Amputate metacarpal bone ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11 

26951 ....... Amputation of finger/thumb ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26952 ....... Amputation of finger/thumb ............................... ......... T 0053 16.154 992.95 253.49 198.59 

26989 ....... Hand/finger surgery ........................................... ......... T 0043 1.6857 103.62 .................. 20.72

26990 ....... Drainage of pelvis lesion ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

26991 ....... Drainage of pelvis bursa .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27000 ....... Incision of hip tendon ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27001 ....... Incision of hip tendon ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27003 ....... Incision of hip tendon ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27033 ....... Exploration of hip joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27035 ....... Denervation of hip joint ...................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

27040 ....... Biopsy of soft tissues ......................................... ......... T 0020 6.8083 418.49 107.67 83.70 

27041 ....... Biopsy of soft tissues ......................................... ......... T 0020 6.8083 418.49 107.67 83.70 

27047 ....... Remove hip/pelvis lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27048 ....... Remove hip/pelvis lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27049 ....... Remove tumor, hip/pelvis .................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

27050 ....... Biopsy of sacroiliac joint .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27052 ....... Biopsy of hip joint .............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27060 ....... Removal of ischial bursa ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27062 ....... Remove femur lesion/bursa ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27065 ....... Removal of hip bone lesion ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27066 ....... Removal of hip bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27067 ....... Remove/graft hip bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27080 ....... Removal of tail bone .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27086 ....... Remove hip foreign body .................................. ......... T 0020 6.8083 418.49 107.67 83.70 

27087 ....... Remove hip foreign body .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27093 ....... Injection for hip x-ray ......................................... ......... N .................. .................. .................. .................. ..................

27095 ....... Injection for hip x-ray ......................................... ......... N .................. .................. .................. .................. ..................

27097 ....... Revision of hip tendon ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27098 ....... Transfer tendon to pelvis ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27100 ....... Transfer of abdominal muscle ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27105 ....... Transfer of spinal muscle .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

27110 ....... Transfer of iliopsoas muscle .............................. ......... T 0051 41.0893 2,525.68 .................. 505.14

27111 ....... Transfer of iliopsoas muscle .............................. ......... T 0051 41.0893 2,525.68 .................. 505.14

27193 ....... Treat pelvic ring fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72

27194 ....... Treat pelvic ring fracture .................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27200 ....... Treat tail bone fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72

27202 ....... Treat tail bone fracture ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27216 ....... Treat pelvic ring fracture .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27220 ....... Treat hip socket fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72 


cprice-sewell on PRODPC62 with RULES2
68304 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27230 ....... Treat thigh fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27235 ....... Treat thigh fracture ............................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27238 ....... Treat thigh fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27246 ....... Treat thigh fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27250 ....... Treat hip dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27252 ....... Treat hip dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27256 ....... Treat hip dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27257 ....... Treat hip dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27265 ....... Treat hip dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27266 ....... Treat hip dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27275 ....... Manipulation of hip joint ..................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27299 ....... Pelvis/hip joint surgery ....................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27301 ....... Drain thigh/knee lesion ...................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

27305 ....... Incise thigh tendon & fascia .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57

27306 ....... Incision of thigh tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27307 ....... Incision of thigh tendons .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27310 ....... Exploration of knee joint .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27315 ....... Partial removal, thigh nerve ............................... CH .. D .................. .................. .................. .................. ..................

27320 ....... Partial removal, thigh nerve ............................... CH .. D .................. .................. .................. .................. ..................

27323 ....... Biopsy, thigh soft tissues ................................... CH .. T 0020 6.8083 418.49 107.67 83.70 

27324 ....... Biopsy, thigh soft tissues ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27325 ....... Neurectomy, hamstring ...................................... NI .... T 0220 17.8499 1,097.20 .................. 219.44 

27326 ....... Neurectomy, popliteal ........................................ NI .... T 0220 17.8499 1,097.20 .................. 219.44

27327 ....... Removal of thigh lesion ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27328 ....... Removal of thigh lesion ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27329 ....... Remove tumor, thigh/knee ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68 

27330 ....... Biopsy, knee joint lining ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27331 ....... Explore/treat knee joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27332 ....... Removal of knee cartilage ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

27333 ....... Removal of knee cartilage ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

27334 ....... Remove knee joint lining ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27335 ....... Remove knee joint lining ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27340 ....... Removal of kneecap bursa ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27345 ....... Removal of knee cyst ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27347 ....... Remove knee cyst ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27350 ....... Removal of kneecap .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27355 ....... Remove femur lesion ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27356 ....... Remove femur lesion/graft ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27357 ....... Remove femur lesion/graft ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27358 ....... Remove femur lesion/fixation ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27360 ....... Partial removal, leg bone(s) .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93

27370 ....... Injection for knee x-ray ...................................... ......... N .................. .................. .................. .................. ..................

27372 ....... Removal of foreign body ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27380 ....... Repair of kneecap tendon ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27381 ....... Repair/graft kneecap tendon ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27385 ....... Repair of thigh muscle ....................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27386 ....... Repair/graft of thigh muscle .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57

27390 ....... Incision of thigh tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27391 ....... Incision of thigh tendons .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27392 ....... Incision of thigh tendons .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27393 ....... Lengthening of thigh tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27394 ....... Lengthening of thigh tendons ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27395 ....... Lengthening of thigh tendons ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

27396 ....... Transplant of thigh tendon ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27397 ....... Transplants of thigh tendons ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

27400 ....... Revise thigh muscles/tendons ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27403 ....... Repair of knee cartilage .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27405 ....... Repair of knee ligament .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27407 ....... Repair of knee ligament .................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

27409 ....... Repair of knee ligaments ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27412 ....... Autochondrocyte implant knee .......................... ......... T 0042 45.5027 2,796.96 804.74 559.39 

27415 ....... Osteochondral knee allograft ............................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

27418 ....... Repair degenerated kneecap ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

27420 ....... Revision of unstable kneecap ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27422 ....... Revision of unstable kneecap ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27424 ....... Revision/removal of kneecap ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14 

27425 ....... Lat retinacular release open .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93

27427 ....... Reconstruction, knee ......................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14 

27428 ....... Reconstruction, knee ......................................... ......... T 0052 66.58 4,092.54 .................. 818.51 

27429 ....... Reconstruction, knee ......................................... ......... T 0052 66.58 4,092.54 .................. 818.51 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68305 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27430 ....... Revision of thigh muscles .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

27435 ....... Incision of knee joint .......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27437 ....... Revise kneecap ................................................. ......... T 0047 33.4505 2,056.14 537.03 411.23 

27438 ....... Revise kneecap with implant ............................. ......... T 0048 47.4378 2,915.91 .................. 583.18 

27440 ....... Revision of knee joint ........................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

27441 ....... Revision of knee joint ........................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

27442 ....... Revision of knee joint ........................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

27443 ....... Revision of knee joint ........................................ ......... T 0047 33.4505 2,056.14 537.03 411.23 

27446 ....... Revision of knee joint ........................................ ......... T 0681 205.6815 12,642.83 .................. 2,528.57 

27475 ....... Surgery to stop leg growth ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93

27496 ....... Decompression of thigh/knee ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27497 ....... Decompression of thigh/knee ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27498 ....... Decompression of thigh/knee ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27499 ....... Decompression of thigh/knee ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27500 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27501 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27502 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27503 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27508 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27509 ....... Treatment of thigh fracture ................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81 

27510 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27516 ....... Treat thigh fx growth plate ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27517 ....... Treat thigh fx growth plate ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27520 ....... Treat kneecap fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27524 ....... Treat kneecap fracture ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27530 ....... Treat knee fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27532 ....... Treat knee fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72 

27538 ....... Treat knee fracture(s) ........................................ ......... T 0043 1.6857 103.62 .................. 20.72

27550 ....... Treat knee dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27552 ....... Treat knee dislocation ....................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27560 ....... Treat kneecap dislocation .................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27562 ....... Treat kneecap dislocation .................................. ......... T 0045 14.5947 897.11 268.47 179.42 

27566 ....... Treat kneecap dislocation .................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27570 ....... Fixation of knee joint ......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27594 ....... Amputation follow-up surgery ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27599 ....... Leg surgery procedure ...................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27600 ....... Decompression of lower leg .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27601 ....... Decompression of lower leg .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27602 ....... Decompression of lower leg .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27603 ....... Drain lower leg lesion ........................................ ......... T 0008 17.5086 1,076.22 .................. 215.24 

27604 ....... Drain lower leg bursa ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27605 ....... Incision of achilles tendon ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

27606 ....... Incision of achilles tendon ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27607 ....... Treat lower leg bone lesion ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57

27610 ....... Explore/treat ankle joint ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27612 ....... Exploration of ankle joint ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27613 ....... Biopsy lower leg soft tissue ............................... ......... T 0020 6.8083 418.49 107.67 83.70 

27614 ....... Biopsy lower leg soft tissue ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27615 ....... Remove tumor, lower leg .................................. CH .. T 0050 25.1296 1,544.67 .................. 308.93 

27618 ....... Remove lower leg lesion ................................... ......... T 0021 15.1024 928.31 219.48 185.66 

27619 ....... Remove lower leg lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

27620 ....... Explore/treat ankle joint ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27625 ....... Remove ankle joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27626 ....... Remove ankle joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27630 ....... Removal of tendon lesion .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57

27635 ....... Remove lower leg bone lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27637 ....... Remove/graft leg bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27638 ....... Remove/graft leg bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27640 ....... Partial removal of tibia ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27641 ....... Partial removal of fibula ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27647 ....... Extensive ankle/heel surgery ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

27648 ....... Injection for ankle x-ray ..................................... ......... N .................. .................. .................. .................. ..................

27650 ....... Repair achilles tendon ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27652 ....... Repair/graft achilles tendon ............................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

27654 ....... Repair of achilles tendon ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27656 ....... Repair leg fascia defect ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27658 ....... Repair of leg tendon, each ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57

27659 ....... Repair of leg tendon, each ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57

27664 ....... Repair of leg tendon, each ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57

27665 ....... Repair of leg tendon, each ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93


cprice-sewell on PRODPC62 with RULES2
68306 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27675 ....... Repair lower leg tendons ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57 

27676 ....... Repair lower leg tendons ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27680 ....... Release of lower leg tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27681 ....... Release of lower leg tendons ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93 

27685 ....... Revision of lower leg tendon ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27686 ....... Revise lower leg tendons .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93

27687 ....... Revision of calf tendon ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27690 ....... Revise lower leg tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27691 ....... Revise lower leg tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27692 ....... Revise additional leg tendon ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14 

27695 ....... Repair of ankle ligament .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27696 ....... Repair of ankle ligaments .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27698 ....... Repair of ankle ligament .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27700 ....... Revision of ankle joint ....................................... ......... T 0047 33.4505 2,056.14 537.03 411.23 

27704 ....... Removal of ankle implant .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57

27705 ....... Incision of tibia ................................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27707 ....... Incision of fibula ................................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

27709 ....... Incision of tibia & fibula ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27730 ....... Repair of tibia epiphysis .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27732 ....... Repair of fibula epiphysis .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

27734 ....... Repair lower leg epiphyses ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27740 ....... Repair of leg epiphyses ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93 

27742 ....... Repair of leg epiphyses ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14 

27745 ....... Reinforce tibia .................................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

27750 ....... Treatment of tibia fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27752 ....... Treatment of tibia fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27756 ....... Treatment of tibia fracture ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

27758 ....... Treatment of tibia fracture ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27759 ....... Treatment of tibia fracture ................................. CH .. T 0064 57.2172 3,517.03 835.79 703.41 

27760 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27762 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27766 ....... Treatment of ankle fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27780 ....... Treatment of fibula fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27781 ....... Treatment of fibula fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27784 ....... Treatment of fibula fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27786 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27788 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27792 ....... Treatment of ankle fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27808 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27810 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27814 ....... Treatment of ankle fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27816 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27818 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

27822 ....... Treatment of ankle fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27823 ....... Treatment of ankle fracture ............................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

27824 ....... Treat lower leg fracture ..................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27825 ....... Treat lower leg fracture ..................................... ......... T 0043 1.6857 103.62 .................. 20.72 

27826 ....... Treat lower leg fracture ..................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27827 ....... Treat lower leg fracture ..................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

27828 ....... Treat lower leg fracture ..................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41 

27829 ....... Treat lower leg joint ........................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27830 ....... Treat lower leg dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27831 ....... Treat lower leg dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

27832 ....... Treat lower leg dislocation ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27840 ....... Treat ankle dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72

27842 ....... Treat ankle dislocation ....................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27846 ....... Treat ankle dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27848 ....... Treat ankle dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

27860 ....... Fixation of ankle joint ......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

27870 ....... Fusion of ankle joint, open ................................ CH .. T 0052 66.58 4,092.54 .................. 818.51 

27871 ....... Fusion of tibiofibular joint ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51 

27884 ....... Amputation follow-up surgery ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27889 ....... Amputation of foot at ankle ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93

27892 ....... Decompression of leg ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27893 ....... Decompression of leg ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27894 ....... Decompression of leg ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57 

27899 ....... Leg/ankle surgery procedure ............................. ......... T 0043 1.6857 103.62 .................. 20.72 

28001 ....... Drainage of bursa of foot ................................... ......... T 0007 11.1535 685.58 .................. 137.12

28002 ....... Treatment of foot infection ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 

28003 ....... Treatment of foot infection ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68307 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

28005 ....... Treat foot bone lesion ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28008 ....... Incision of foot fascia ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28010 ....... Incision of toe tendon ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28011 ....... Incision of toe tendons ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28020 ....... Exploration of foot joint ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28022 ....... Exploration of foot joint ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28024 ....... Exploration of toe joint ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28030 ....... Removal of foot nerve ....................................... CH .. D .................. .................. .................. .................. ..................

28035 ....... Decompression of tibia nerve ............................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

28043 ....... Excision of foot lesion ........................................ CH .. T 0022 20.0656 1,233.39 354.45 246.68 

28045 ....... Excision of foot lesion ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28046 ....... Resection of tumor, foot .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28050 ....... Biopsy of foot joint lining ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28052 ....... Biopsy of foot joint lining ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28054 ....... Biopsy of toe joint lining .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28055 ....... Neurectomy, foot ............................................... NI .... T 0220 17.8499 1,097.20 .................. 219.44 

28060 ....... Partial removal, foot fascia ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28062 ....... Removal of foot fascia ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28070 ....... Removal of foot joint lining ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28072 ....... Removal of foot joint lining ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28080 ....... Removal of foot lesion ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28086 ....... Excise foot tendon sheath ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28088 ....... Excise foot tendon sheath ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28090 ....... Removal of foot lesion ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28092 ....... Removal of toe lesions ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28100 ....... Removal of ankle/heel lesion ............................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28102 ....... Remove/graft foot lesion .................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28103 ....... Remove/graft foot lesion .................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28104 ....... Removal of foot lesion ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28106 ....... Remove/graft foot lesion .................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28107 ....... Remove/graft foot lesion .................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28108 ....... Removal of toe lesions ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28110 ....... Part removal of metatarsal ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28111 ....... Part removal of metatarsal ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28112 ....... Part removal of metatarsal ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28113 ....... Part removal of metatarsal ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28114 ....... Removal of metatarsal heads ............................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28116 ....... Revision of foot .................................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28118 ....... Removal of heel bone ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28119 ....... Removal of heel spur ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28120 ....... Part removal of ankle/heel ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28122 ....... Partial removal of foot bone .............................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28124 ....... Partial removal of toe ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28126 ....... Partial removal of toe ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28130 ....... Removal of ankle bone ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28140 ....... Removal of metatarsal ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28150 ....... Removal of toe .................................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28153 ....... Partial removal of toe ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28160 ....... Partial removal of toe ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28171 ....... Extensive foot surgery ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28173 ....... Extensive foot surgery ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28175 ....... Extensive foot surgery ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28190 ....... Removal of foot foreign body ............................ ......... T 0019 4.0919 251.52 71.87 50.30 

28192 ....... Removal of foot foreign body ............................ ......... T 0021 15.1024 928.31 219.48 185.66 

28193 ....... Removal of foot foreign body ............................ ......... T 0020 6.8083 418.49 107.67 83.70 

28200 ....... Repair of foot tendon ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28202 ....... Repair/graft of foot tendon ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28208 ....... Repair of foot tendon ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28210 ....... Repair/graft of foot tendon ................................. ......... T 0056 40.8559 2,511.33 .................. 502.27 

28220 ....... Release of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28222 ....... Release of foot tendons .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28225 ....... Release of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28226 ....... Release of foot tendons .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28230 ....... Incision of foot tendon(s) ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28232 ....... Incision of toe tendon ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28234 ....... Incision of foot tendon ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28238 ....... Revision of foot tendon ...................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28240 ....... Release of big toe ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28250 ....... Revision of foot fascia ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28260 ....... Release of midfoot joint ..................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 


cprice-sewell on PRODPC62 with RULES2
68308 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

28261 ....... Revision of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28262 ....... Revision of foot and ankle ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28264 ....... Release of midfoot joint ..................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28270 ....... Release of foot contracture ............................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28272 ....... Release of toe joint, each .................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28280 ....... Fusion of toes .................................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28285 ....... Repair of hammertoe ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28286 ....... Repair of hammertoe ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28288 ....... Partial removal of foot bone .............................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28289 ....... Repair hallux rigidus .......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28290 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28292 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28293 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28294 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28296 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28297 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28298 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28299 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11 

28300 ....... Incision of heel bone ......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28302 ....... Incision of ankle bone ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28304 ....... Incision of midfoot bones ................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28305 ....... Incise/graft midfoot bones ................................. ......... T 0056 40.8559 2,511.33 .................. 502.27 

28306 ....... Incision of metatarsal ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28307 ....... Incision of metatarsal ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28308 ....... Incision of metatarsal ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28309 ....... Incision of metatarsals ....................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28310 ....... Revision of big toe ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28312 ....... Revision of toe ................................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28313 ....... Repair deformity of toe ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28315 ....... Removal of sesamoid bone ............................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28320 ....... Repair of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28322 ....... Repair of metatarsals ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27 

28340 ....... Resect enlarged toe tissue ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28341 ....... Resect enlarged toe .......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28344 ....... Repair extra toe(s) ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28345 ....... Repair webbed toe(s) ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28360 ....... Reconstruct cleft foot ......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28400 ....... Treatment of heel fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

28405 ....... Treatment of heel fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72 

28406 ....... Treatment of heel fracture ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28415 ....... Treat heel fracture ............................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28420 ....... Treat/graft heel fracture ..................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28430 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

28435 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72 

28436 ....... Treatment of ankle fracture ............................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28445 ....... Treat ankle fracture ........................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28450 ....... Treat midfoot fracture, each .............................. ......... T 0043 1.6857 103.62 .................. 20.72 

28455 ....... Treat midfoot fracture, each .............................. ......... T 0043 1.6857 103.62 .................. 20.72 

28456 ....... Treat midfoot fracture ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28465 ....... Treat midfoot fracture, each .............................. CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28470 ....... Treat metatarsal fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28475 ....... Treat metatarsal fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28476 ....... Treat metatarsal fracture ................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28485 ....... Treat metatarsal fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28490 ....... Treat big toe fracture ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28495 ....... Treat big toe fracture ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28496 ....... Treat big toe fracture ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28505 ....... Treat big toe fracture ......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28510 ....... Treatment of toe fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28515 ....... Treatment of toe fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28525 ....... Treat toe fracture ............................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28530 ....... Treat sesamoid bone fracture ........................... ......... T 0043 1.6857 103.62 .................. 20.72 

28531 ....... Treat sesamoid bone fracture ........................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28540 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28545 ....... Treat foot dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28546 ....... Treat foot dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28555 ....... Repair foot dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28570 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28575 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28576 ....... Treat foot dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68309 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

28585 ....... Repair foot dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28600 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28605 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28606 ....... Treat foot dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28615 ....... Repair foot dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28630 ....... Treat toe dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28635 ....... Treat toe dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

28636 ....... Treat toe dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28645 ....... Repair toe dislocation ........................................ CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28660 ....... Treat toe dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72 

28665 ....... Treat toe dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42 

28666 ....... Treat toe dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81 

28675 ....... Repair of toe dislocation .................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48 

28705 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28715 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28725 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28730 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28735 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28737 ....... Revision of foot bones ....................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28740 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27 

28750 ....... Fusion of big toe joint ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27 

28755 ....... Fusion of big toe joint ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11 

28760 ....... Fusion of big toe joint ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27 

28810 ....... Amputation toe & metatarsal ............................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28820 ....... Amputation of toe .............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

28825 ....... Partial amputation of toe ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11 

28890 ....... High energy eswt, plantar f ............................... CH .. T 0050 25.1296 1,544.67 .................. 308.93 

28899 ....... Foot/toes surgery procedure ............................. ......... T 0043 1.6857 103.62 .................. 20.72 

29000 ....... Application of body cast .................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29010 ....... Application of body cast .................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29015 ....... Application of body cast .................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29020 ....... Application of body cast .................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29025 ....... Application of body cast .................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29035 ....... Application of body cast .................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29040 ....... Application of body cast .................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29044 ....... Application of body cast .................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29046 ....... Application of body cast .................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29049 ....... Application of figure eight .................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29055 ....... Application of shoulder cast .............................. ......... S 0426 2.2777 140.01 .................. 28.00 

29058 ....... Application of shoulder cast .............................. ......... S 0058 1.0607 65.20 .................. 13.04 

29065 ....... Application of long arm cast .............................. ......... S 0426 2.2777 140.01 .................. 28.00 

29075 ....... Application of forearm cast ................................ ......... S 0426 2.2777 140.01 .................. 28.00 

29085 ....... Apply hand/wrist cast ......................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29086 ....... Apply finger cast ................................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29105 ....... Apply long arm splint ......................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29125 ....... Apply forearm splint ........................................... ......... S 0058 1.0607 65.20 .................. 13.04

29126 ....... Apply forearm splint ........................................... ......... S 0058 1.0607 65.20 .................. 13.04

29130 ....... Application of finger splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29131 ....... Application of finger splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29200 ....... Strapping of chest .............................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29220 ....... Strapping of low back ........................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29240 ....... Strapping of shoulder ........................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29260 ....... Strapping of elbow or wrist ................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29280 ....... Strapping of hand or finger ................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29305 ....... Application of hip cast ....................................... ......... S 0426 2.2777 140.01 .................. 28.00

29325 ....... Application of hip casts ...................................... ......... S 0426 2.2777 140.01 .................. 28.00

29345 ....... Application of long leg cast ............................... ......... S 0426 2.2777 140.01 .................. 28.00 

29355 ....... Application of long leg cast ............................... ......... S 0426 2.2777 140.01 .................. 28.00 

29358 ....... Apply long leg cast brace .................................. ......... S 0426 2.2777 140.01 .................. 28.00 

29365 ....... Application of long leg cast ............................... ......... S 0426 2.2777 140.01 .................. 28.00 

29405 ....... Apply short leg cast ........................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29425 ....... Apply short leg cast ........................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29435 ....... Apply short leg cast ........................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29440 ....... Addition of walker to cast .................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29445 ....... Apply rigid leg cast ............................................ ......... S 0426 2.2777 140.01 .................. 28.00 

29450 ....... Application of leg cast ....................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29505 ....... Application, long leg splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29515 ....... Application lower leg splint ................................ ......... S 0058 1.0607 65.20 .................. 13.04 

29520 ....... Strapping of hip ................................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29530 ....... Strapping of knee .............................................. ......... S 0058 1.0607 65.20 .................. 13.04


cprice-sewell on PRODPC62 with RULES2
68310 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

29540 ....... Strapping of ankle and/or ft ............................... ......... S 0058 1.0607 65.20 .................. 13.04 

29550 ....... Strapping of toes ............................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29580 ....... Application of paste boot ................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29590 ....... Application of foot splint .................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29700 ....... Removal/revision of cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29705 ....... Removal/revision of cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29710 ....... Removal/revision of cast ................................... ......... S 0426 2.2777 140.01 .................. 28.00 

29715 ....... Removal/revision of cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29720 ....... Repair of body cast ........................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29730 ....... Windowing of cast ............................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29740 ....... Wedging of cast ................................................. ......... S 0058 1.0607 65.20 .................. 13.04 

29750 ....... Wedging of clubfoot cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04 

29799 ....... Casting/strapping procedure .............................. ......... S 0058 1.0607 65.20 .................. 13.04 

29800 ....... Jaw arthroscopy/surgery .................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29804 ....... Jaw arthroscopy/surgery .................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29805 ....... Shoulder arthroscopy, dx ................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29806 ....... Shoulder arthroscopy/surgery ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39 

29807 ....... Shoulder arthroscopy/surgery ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39 

29819 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29820 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29821 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29822 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29823 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29824 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29825 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29826 ....... Shoulder arthroscopy/surgery ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39 

29827 ....... Arthroscop rotator cuff repr ............................... ......... T 0042 45.5027 2,796.96 804.74 559.39 

29830 ....... Elbow arthroscopy ............................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29834 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29835 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29836 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29837 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29838 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29840 ....... Wrist arthroscopy ............................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29843 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29844 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29845 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29846 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29847 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29848 ....... Wrist endoscopy/surgery ................................... ......... T 0041 28.6245 1,759.49 .................. 351.90

29850 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29851 ....... Knee arthroscopy/surgery .................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29855 ....... Tibial arthroscopy/surgery ................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29856 ....... Tibial arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90 

29860 ....... Hip arthroscopy, dx ............................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29861 ....... Hip arthroscopy/surgery ..................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29862 ....... Hip arthroscopy/surgery ..................................... ......... T 0042 45.5027 2,796.96 804.74 559.39 

29863 ....... Hip arthroscopy/surgery ..................................... ......... T 0042 45.5027 2,796.96 804.74 559.39 

29866 ....... Autgrft implnt, knee w/scope ............................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29867 ....... Allgrft implnt, knee w/scope ............................... ......... T 0042 45.5027 2,796.96 804.74 559.39 

29868 ....... Meniscal trnspl, knee w/scpe ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39 

29870 ....... Knee arthroscopy, dx ......................................... ......... T 0041 28.6245 1,759.49 .................. 351.90 

29871 ....... Knee arthroscopy/drainage ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

29873 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29874 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29875 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29876 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29877 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29879 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29880 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29881 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29882 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29883 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29884 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29885 ....... Knee arthroscopy/surgery .................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29886 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29887 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29888 ....... Knee arthroscopy/surgery .................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29889 ....... Knee arthroscopy/surgery .................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29891 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68311 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

29892 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29893 ....... Scope, plantar fasciotomy ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11 

29894 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29895 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29897 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29898 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90

29899 ....... Ankle arthroscopy/surgery ................................. ......... T 0042 45.5027 2,796.96 804.74 559.39 

29900 ....... Mcp joint arthroscopy, dx .................................. ......... T 0053 16.154 992.95 253.49 198.59 

29901 ....... Mcp joint arthroscopy, surg ............................... ......... T 0053 16.154 992.95 253.49 198.59 

29902 ....... Mcp joint arthroscopy, surg ............................... ......... T 0053 16.154 992.95 253.49 198.59 

29999 ....... Arthroscopy of joint ............................................ ......... T 0041 28.6245 1,759.49 .................. 351.90 

30000 ....... Drainage of nose lesion ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

30020 ....... Drainage of nose lesion ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

30100 ....... Intranasal biopsy ................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

30110 ....... Removal of nose polyp(s) .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

30115 ....... Removal of nose polyp(s) .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

30117 ....... Removal of intranasal lesion ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

30118 ....... Removal of intranasal lesion ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

30120 ....... Revision of nose ................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

30124 ....... Removal of nose lesion ..................................... ......... T 0252 7.5511 464.15 109.16 92.83 

30125 ....... Removal of nose lesion ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30130 ....... Excise inferior turbinate ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

30140 ....... Resect inferior turbinate .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

30150 ....... Partial removal of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30160 ....... Removal of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30200 ....... Injection treatment of nose ................................ ......... T 0252 7.5511 464.15 109.16 92.83 

30210 ....... Nasal sinus therapy ........................................... ......... T 0252 7.5511 464.15 109.16 92.83 

30220 ....... Insert nasal septal button .................................. ......... T 0252 7.5511 464.15 109.16 92.83 

30300 ....... Remove nasal foreign body ............................... ......... X 0340 0.6102 37.51 .................. 7.50 

30310 ....... Remove nasal foreign body ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

30320 ....... Remove nasal foreign body ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

30400 ....... Reconstruction of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30410 ....... Reconstruction of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30420 ....... Reconstruction of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30430 ....... Revision of nose ................................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

30435 ....... Revision of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30450 ....... Revision of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30460 ....... Revision of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30462 ....... Revision of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30465 ....... Repair nasal stenosis ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30520 ....... Repair of nasal septum ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

30540 ....... Repair nasal defect ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30545 ....... Repair nasal defect ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

30560 ....... Release of nasal adhesions .............................. ......... T 0251 2.452 150.72 .................. 30.14 

30580 ....... Repair upper jaw fistula ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30600 ....... Repair mouth/nose fistula .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

30620 ....... Intranasal reconstruction ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

30630 ....... Repair nasal septum defect ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

30801 ....... Ablate inf turbinate, superf ................................ ......... T 0252 7.5511 464.15 109.16 92.83 

30802 ....... Cauterization, inner nose ................................... ......... T 0252 7.5511 464.15 109.16 92.83 

30901 ....... Control of nosebleed ......................................... ......... T 0250 1.1791 72.48 25.39 14.50 

30903 ....... Control of nosebleed ......................................... ......... T 0250 1.1791 72.48 25.39 14.50 

30905 ....... Control of nosebleed ......................................... ......... T 0250 1.1791 72.48 25.39 14.50 

30906 ....... Repeat control of nosebleed ............................. ......... T 0250 1.1791 72.48 25.39 14.50 

30915 ....... Ligation, nasal sinus artery ................................ CH .. T 0092 24.8809 1,529.38 309.87 305.88 

30920 ....... Ligation, upper jaw artery .................................. ......... T 0092 24.8809 1,529.38 309.87 305.88 

30930 ....... Ther fx, nasal inf turbinate ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

30999 ....... Nasal surgery procedure ................................... ......... T 0251 2.452 150.72 .................. 30.14 

31000 ....... Irrigation, maxillary sinus ................................... ......... T 0251 2.452 150.72 .................. 30.14 

31002 ....... Irrigation, sphenoid sinus ................................... ......... T 0252 7.5511 464.15 109.16 92.83 

31020 ....... Exploration, maxillary sinus ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31030 ....... Exploration, maxillary sinus ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31032 ....... Explore sinus, remove polyps ........................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31040 ....... Exploration behind upper jaw ............................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

31050 ....... Exploration, sphenoid sinus ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60

31051 ....... Sphenoid sinus surgery ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31070 ....... Exploration of frontal sinus ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

31075 ....... Exploration of frontal sinus ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

31080 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31081 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 


cprice-sewell on PRODPC62 with RULES2
68312 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

31084 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31085 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31086 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31087 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31090 ....... Exploration of sinuses ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31200 ....... Removal of ethmoid sinus ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31201 ....... Removal of ethmoid sinus ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31205 ....... Removal of ethmoid sinus ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31231 ....... Nasal endoscopy, dx ......................................... ......... T 0072 1.4054 86.39 21.27 17.28 

31233 ....... Nasal/sinus endoscopy, dx ................................ ......... T 0072 1.4054 86.39 21.27 17.28 

31235 ....... Nasal/sinus endoscopy, dx ................................ ......... T 0074 14.7928 909.28 292.25 181.86 

31237 ....... Nasal/sinus endoscopy, surg ............................. CH .. T 0074 14.7928 909.28 292.25 181.86 

31238 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0074 14.7928 909.28 292.25 181.86 

31239 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31240 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0074 14.7928 909.28 292.25 181.86 

31254 ....... Revision of ethmoid sinus ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31255 ....... Removal of ethmoid sinus ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31256 ....... Exploration maxillary sinus ................................ ......... T 0075 21.9512 1,349.30 445.92 269.86 

31267 ....... Endoscopy, maxillary sinus ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31276 ....... Sinus endoscopy, surgical ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31287 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31288 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31292 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31293 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31294 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31299 ....... Sinus surgery procedure ................................... ......... T 0251 2.452 150.72 .................. 30.14 

31300 ....... Removal of larynx lesion ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31320 ....... Diagnostic incision, larynx ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31400 ....... Revision of larynx .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31420 ....... Removal of epiglottis ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31500 ....... Insert emergency airway ................................... ......... S 0094 2.4233 148.96 46.29 29.79 

31502 ....... Change of windpipe airway ............................... ......... T 0121 2.3587 144.98 43.80 29.00 

31505 ....... Diagnostic laryngoscopy .................................... ......... T 0071 0.7698 47.32 11.20 9.46 

31510 ....... Laryngoscopy with biopsy ................................. ......... T 0074 14.7928 909.28 292.25 181.86 

31511 ....... Remove foreign body, larynx ............................. ......... T 0072 1.4054 86.39 21.27 17.28 

31512 ....... Removal of larynx lesion ................................... ......... T 0074 14.7928 909.28 292.25 181.86 

31513 ....... Injection into vocal cord ..................................... ......... T 0072 1.4054 86.39 21.27 17.28 

31515 ....... Laryngoscopy for aspiration .............................. ......... T 0074 14.7928 909.28 292.25 181.86 

31520 ....... Dx laryngoscopy, newborn ................................ ......... T 0072 1.4054 86.39 21.27 17.28 

31525 ....... Dx laryngoscopy excl nb ................................... ......... T 0074 14.7928 909.28 292.25 181.86 

31526 ....... Dx laryngoscopy w/oper scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31527 ....... Laryngoscopy for treatment ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31528 ....... Laryngoscopy and dilation ................................. ......... T 0074 14.7928 909.28 292.25 181.86 

31529 ....... Laryngoscopy and dilation ................................. ......... T 0074 14.7928 909.28 292.25 181.86 

31530 ....... Laryngoscopy w/fb removal ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31531 ....... Laryngoscopy w/fb & op scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31535 ....... Laryngoscopy w/biopsy ..................................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31536 ....... Laryngoscopy w/bx & op scope ........................ ......... T 0075 21.9512 1,349.30 445.92 269.86 

31540 ....... Laryngoscopy w/exc of tumor ............................ ......... T 0075 21.9512 1,349.30 445.92 269.86 

31541 ....... Larynscop w/tumr exc + scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31545 ....... Remove vc lesion w/scope ................................ ......... T 0075 21.9512 1,349.30 445.92 269.86 

31546 ....... Remove vc lesion scope/graft ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31560 ....... Laryngoscop w/arytenoidectom ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31561 ....... Larynscop, remve cart + scop ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31570 ....... Laryngoscope w/vc inj ....................................... ......... T 0074 14.7928 909.28 292.25 181.86 

31571 ....... Laryngoscop w/vc inj + scope ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31575 ....... Diagnostic laryngoscopy .................................... ......... T 0072 1.4054 86.39 21.27 17.28 

31576 ....... Laryngoscopy with biopsy ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86 

31577 ....... Remove foreign body, larynx ............................. ......... T 0073 3.8463 236.42 69.15 47.28 

31578 ....... Removal of larynx lesion ................................... ......... T 0075 21.9512 1,349.30 445.92 269.86 

31579 ....... Diagnostic laryngoscopy .................................... ......... T 0073 3.8463 236.42 69.15 47.28 

31580 ....... Revision of larynx .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31582 ....... Revision of larynx .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31588 ....... Revision of larynx .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31590 ....... Reinnervate larynx ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31595 ....... Larynx nerve surgery ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

31599 ....... Larynx surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14 

31600 ....... Incision of windpipe ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31601 ....... Incision of windpipe ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31603 ....... Incision of windpipe ........................................... ......... T 0252 7.5511 464.15 109.16 92.83 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68313 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

31605 ....... Incision of windpipe ........................................... ......... T 0252 7.5511 464.15 109.16 92.83 

31610 ....... Incision of windpipe ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31611 ....... Surgery/speech prosthesis ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

31612 ....... Puncture/clear windpipe .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31613 ....... Repair windpipe opening ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31614 ....... Repair windpipe opening ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60

31615 ....... Visualization of windpipe ................................... ......... T 0076 9.5228 585.35 189.82 117.07 

31620 ....... Endobronchial us add-on ................................... ......... S 0670 32.2854 1,984.52 536.10 396.90 

31622 ....... Dx bronchoscope/wash ..................................... ......... T 0076 9.5228 585.35 189.82 117.07 

31623 ....... Dx bronchoscope/brush ..................................... ......... T 0076 9.5228 585.35 189.82 117.07 

31624 ....... Dx bronchoscope/lavage ................................... ......... T 0076 9.5228 585.35 189.82 117.07 

31625 ....... Bronchoscopy w/biopsy(s) ................................. ......... T 0076 9.5228 585.35 189.82 117.07 

31628 ....... Bronchoscopy/lung bx, each ............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31629 ....... Bronchoscopy/needle bx, each ......................... ......... T 0076 9.5228 585.35 189.82 117.07 

31630 ....... Bronchoscopy dilate/fx repr ............................... ......... T 0415 22.0099 1,352.90 459.92 270.58 

31631 ....... Bronchoscopy, dilate w/stent ............................. ......... T 0415 22.0099 1,352.90 459.92 270.58 

31632 ....... Bronchoscopy/lung bx, add’l .............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31633 ....... Bronchoscopy/needle bx add’l ........................... ......... T 0076 9.5228 585.35 189.82 117.07 

31635 ....... Bronchoscopy w/fb removal .............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31636 ....... Bronchoscopy, bronch stents ............................ ......... T 0415 22.0099 1,352.90 459.92 270.58 

31637 ....... Bronchoscopy, stent add-on .............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31638 ....... Bronchoscopy, revise stent ............................... ......... T 0415 22.0099 1,352.90 459.92 270.58 

31640 ....... Bronchoscopy w/tumor excise ........................... ......... T 0415 22.0099 1,352.90 459.92 270.58 

31641 ....... Bronchoscopy, treat blockage ........................... ......... T 0415 22.0099 1,352.90 459.92 270.58 

31643 ....... Diag bronchoscope/catheter .............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31645 ....... Bronchoscopy, clear airways ............................. ......... T 0076 9.5228 585.35 189.82 117.07 

31646 ....... Bronchoscopy, reclear airway ........................... ......... T 0076 9.5228 585.35 189.82 117.07 

31656 ....... Bronchoscopy, inj for x-ray ................................ ......... T 0076 9.5228 585.35 189.82 117.07 

31700 ....... Insertion of airway catheter ............................... CH .. D .................. .................. .................. .................. ..................

31708 ....... Instill airway contrast dye .................................. CH .. D .................. .................. .................. .................. ..................

31710 ....... Insertion of airway catheter ............................... CH .. D .................. .................. .................. .................. ..................

31715 ....... Injection for bronchus x-ray ............................... ......... N .................. .................. .................. .................. ..................

31717 ....... Bronchial brush biopsy ...................................... ......... T 0073 3.8463 236.42 69.15 47.28 

31720 ....... Clearance of airways ......................................... ......... T 0071 0.7698 47.32 11.20 9.46 

31730 ....... Intro, windpipe wire/tube .................................... ......... T 0073 3.8463 236.42 69.15 47.28 

31750 ....... Repair of windpipe ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31755 ....... Repair of windpipe ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

31785 ....... Remove windpipe lesion .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31820 ....... Closure of windpipe lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

31825 ....... Repair of windpipe defect .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

31830 ....... Revise windpipe scar ......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

31899 ....... Airways surgical procedure ............................... ......... T 0076 9.5228 585.35 189.82 117.07 

32000 ....... Drainage of chest .............................................. ......... T 0070 3.6244 222.78 .................. 44.56 

32002 ....... Treatment of collapsed lung .............................. ......... T 0070 3.6244 222.78 .................. 44.56 

32005 ....... Treat lung lining chemically ............................... ......... T 0070 3.6244 222.78 .................. 44.56 

32019 ....... Insert pleural catheter ........................................ CH .. T 0652 29.5416 1,815.86 .................. 363.17

32020 ....... Insertion of chest tube ....................................... ......... T 0070 3.6244 222.78 .................. 44.56

32201 ....... Drain, percut, lung lesion ................................... ......... T 0070 3.6244 222.78 .................. 44.56 

32400 ....... Needle biopsy chest lining ................................. ......... T 0685 6.1384 377.32 115.47 75.46 

32405 ....... Biopsy, lung or mediastinum ............................. ......... T 0685 6.1384 377.32 115.47 75.46 

32420 ....... Puncture/clear lung ............................................ ......... T 0070 3.6244 222.78 .................. 44.56 

32601 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32602 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32603 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32604 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32605 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32606 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71 

32960 ....... Therapeutic pneumothorax ................................ ......... T 0070 3.6244 222.78 .................. 44.56 

32998 ....... Perq rf ablate tx, pul tumor ................................ NI .... T 0423 37.3604 2,296.47 .................. 459.29 

32999 ....... Chest surgery procedure ................................... ......... T 0070 3.6244 222.78 .................. 44.56 

33010 ....... Drainage of heart sac ........................................ ......... T 0070 3.6244 222.78 .................. 44.56 

33011 ....... Repeat drainage of heart sac ............................ ......... T 0070 3.6244 222.78 .................. 44.56 

33200 ....... Insertion of heart pacemaker ............................. CH .. D .................. .................. .................. .................. ..................

33201 ....... Insertion of heart pacemaker ............................. CH .. D .................. .................. .................. .................. ..................

33202 ....... Insert epicard eltrd, open ................................... NI .... C .................. .................. .................. .................. ..................

33203 ....... Insert epicard eltrd, endo ................................... NI .... C .................. .................. .................. .................. ..................

33206 ....... Insertion of heart pacemaker ............................. ......... T 0089 123.6693 7,601.70 1,682.28 1,520.34 

33207 ....... Insertion of heart pacemaker ............................. ......... T 0089 123.6693 7,601.70 1,682.28 1,520.34 

33208 ....... Insertion of heart pacemaker ............................. ......... T 0655 152.6392 9,382.43 .................. 1,876.49 

33210 ....... Insertion of heart electrode ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59 


cprice-sewell on PRODPC62 with RULES2
68314 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

33211 ....... Insertion of heart electrode ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59 

33212 ....... Insertion of pulse generator ............................... ......... T 0090 98.3023 6,042.45 1,612.80 1,208.49 

33213 ....... Insertion of pulse generator ............................... ......... T 0654 112.7719 6,931.86 .................. 1,386.37 

33214 ....... Upgrade of pacemaker system ......................... ......... T 0655 152.6392 9,382.43 .................. 1,876.49 

33215 ....... Reposition pacing-defib lead ............................. ......... T 0105 25.6142 1,574.45 370.40 314.89 

33216 ....... Insert lead pace-defib, one ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59 

33217 ....... Insert lead pace-defib, dual ............................... ......... T 0106 58.8594 3,617.97 .................. 723.59 

33218 ....... Repair lead pace-defib, one .............................. CH .. T 0105 25.6142 1,574.45 370.40 314.89 

33220 ....... Repair lead pace-defib, dual ............................. CH .. T 0105 25.6142 1,574.45 370.40 314.89 

33222 ....... Revise pocket, pacemaker ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

33223 ....... Revise pocket, pacing-defib .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45 

33224 ....... Insert pacing lead & connect ............................. ......... T 0418 307.2828 18,888.06 .................. 3,777.61 

33225 ....... Lventric pacing lead add-on .............................. ......... T 0418 307.2828 18,888.06 .................. 3,777.61 

33226 ....... Reposition l ventric lead .................................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33233 ....... Removal of pacemaker system ......................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33234 ....... Removal of pacemaker system ......................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33235 ....... Removal pacemaker electrode .......................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33241 ....... Remove pulse generator ................................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33244 ....... Remove eltrd, transven ..................................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

33245 ....... Insert epic eltrd pace-defib ................................ CH .. D .................. .................. .................. .................. ..................

33246 ....... Insert epic eltrd/generator .................................. CH .. D .................. .................. .................. .................. ..................

33253 ....... Reconstruct atria ................................................ CH .. D .................. .................. .................. .................. ..................

33254 ....... Ablate atria, lmtd ................................................ NI .... C .................. .................. .................. .................. ..................

33255 ....... Ablate atria w/o bypass, ext .............................. NI .... C .................. .................. .................. .................. ..................

33256 ....... Ablate atria w/bypass, exten ............................. NI .... C .................. .................. .................. .................. ..................

33265 ....... Ablate atria w/bypass, endo .............................. NI .... C .................. .................. .................. .................. ..................

33266 ....... Ablate atria w/o bypass endo ............................ NI .... C .................. .................. .................. .................. ..................

33282 ....... Implant pat-active ht record ............................... ......... S 0680 72.6022 4,462.71 .................. 892.54 

33284 ....... Remove pat-active ht record ............................. ......... T 0109 10.9918 675.64 .................. 135.13 

33508 ....... Endoscopic vein harvest .................................... ......... N .................. .................. .................. .................. ..................

33675 ....... Close mult vsd ................................................... NI .... C .................. .................. .................. .................. ..................

33676 ....... Close mult vsd w/resection ................................ NI .... C .................. .................. .................. .................. ..................

33677 ....... Cl mult vsd w/rem pul band ............................... NI .... C .................. .................. .................. .................. ..................

33724 ....... Repair venous anomaly ..................................... NI .... C .................. .................. .................. .................. ..................

33726 ....... Repair pul venous stenosis ............................... NI .... C .................. .................. .................. .................. ..................

33999 ....... Cardiac surgery procedure ................................ ......... T 0070 3.6244 222.78 .................. 44.56 

34101 ....... Removal of artery clot ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34111 ....... Removal of arm artery clot ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

34201 ....... Removal of artery clot ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34203 ....... Removal of leg artery clot ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95 

34421 ....... Removal of vein clot .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34471 ....... Removal of vein clot .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34490 ....... Removal of vein clot .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34501 ....... Repair valve, femoral vein ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95 

34510 ....... Transposition of vein valve ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

34520 ....... Cross-over vein graft ......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

34530 ....... Leg vein fusion .................................................. ......... T 0088 37.7391 2,319.75 655.22 463.95 

35011 ....... Repair defect of artery ....................................... ......... T 0653 32.3818 1,990.44 .................. 398.09 

35180 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35184 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35188 ....... Repair blood vessel lesion ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

35190 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35201 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35206 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35207 ....... Repair blood vessel lesion ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

35226 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35231 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35236 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35256 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10

35261 ....... Repair blood vessel lesion ................................ ......... T 0653 32.3818 1,990.44 .................. 398.09

35266 ....... Repair blood vessel lesion ................................ ......... T 0653 32.3818 1,990.44 .................. 398.09

35286 ....... Repair blood vessel lesion ................................ ......... T 0653 32.3818 1,990.44 .................. 398.09

35302 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................

35303 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................

35304 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................

35305 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................

35306 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................

35321 ....... Rechanneling of artery ...................................... ......... T 0093 22.8653 1,405.48 .................. 281.10 

35381 ....... Rechanneling of artery ...................................... CH .. D .................. .................. .................. .................. ..................

35458 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68315 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

35459 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35460 ....... Repair venous blockage .................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35470 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35471 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35472 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35473 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35474 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35475 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35476 ....... Repair venous blockage .................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35484 ....... Atherectomy, open ............................................. ......... T 0081 42.936 2,639.19 .................. 527.84 

35485 ....... Atherectomy, open ............................................. ......... T 0081 42.936 2,639.19 .................. 527.84 

35490 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35491 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35492 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35493 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35494 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35495 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35500 ....... Harvest vein for bypass ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84 

35507 ....... Artery bypass graft ............................................ CH .. D .................. .................. .................. .................. ..................

35537 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35538 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35539 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35540 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35541 ....... Artery bypass graft ............................................ CH .. D .................. .................. .................. .................. ..................

35546 ....... Artery bypass graft ............................................ CH .. D .................. .................. .................. .................. ..................

35572 ....... Harvest femoropopliteal vein ............................. ......... N .................. .................. .................. .................. ..................

35637 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35638 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................

35641 ....... Artery bypass graft ............................................ CH .. D .................. .................. .................. .................. ..................

35685 ....... Bypass graft patency/patch ............................... ......... T 0093 22.8653 1,405.48 .................. 281.10 

35686 ....... Bypass graft/av fist patency .............................. ......... T 0093 22.8653 1,405.48 .................. 281.10

35761 ....... Exploration of artery/vein ................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

35860 ....... Explore limb vessels .......................................... ......... T 0093 22.8653 1,405.48 .................. 281.10 

35875 ....... Removal of clot in graft ..................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

35876 ....... Removal of clot in graft ..................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

35879 ....... Revise graft w/vein ............................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

35881 ....... Revise graft w/vein ............................................ ......... T 0088 37.7391 2,319.75 655.22 463.95 

35883 ....... Revise graft w/nonauto graft ............................. NI .... T 0088 37.7391 2,319.75 655.22 463.95 

35884 ....... Revise graft w/vein ............................................ NI .... T 0088 37.7391 2,319.75 655.22 463.95 

35903 ....... Excision, graft, extremity ................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

36000 ....... Place needle in vein .......................................... ......... N .................. .................. .................. .................. ..................

36002 ....... Pseudoaneurysm injection trt ............................ ......... S 0267 2.4606 151.25 60.50 30.25 

36005 ....... Injection ext venography .................................... ......... N .................. .................. .................. .................. ..................

36010 ....... Place catheter in vein ........................................ ......... N .................. .................. .................. .................. ..................

36011 ....... Place catheter in vein ........................................ ......... N .................. .................. .................. .................. ..................

36012 ....... Place catheter in vein ........................................ ......... N .................. .................. .................. .................. ..................

36013 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36014 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36015 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36100 ....... Establish access to artery ................................. ......... N .................. .................. .................. .................. ..................

36120 ....... Establish access to artery ................................. ......... N .................. .................. .................. .................. ..................

36140 ....... Establish access to artery ................................. ......... N .................. .................. .................. .................. ..................

36145 ....... Artery to vein shunt ........................................... ......... N .................. .................. .................. .................. ..................

36160 ....... Establish access to aorta .................................. ......... N .................. .................. .................. .................. ..................

36200 ....... Place catheter in aorta ...................................... ......... N .................. .................. .................. .................. ..................

36215 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36216 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36217 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36218 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36245 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36246 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36247 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36248 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................

36260 ....... Insertion of infusion pump ................................. ......... T 0623 28.5032 1,752.03 .................. 350.41 

36261 ....... Revision of infusion pump ................................. ......... T 0623 28.5032 1,752.03 .................. 350.41

36262 ....... Removal of infusion pump ................................. ......... T 0622 22.6665 1,393.26 .................. 278.65 

36299 ....... Vessel injection procedure ................................ ......... N .................. .................. .................. .................. ..................

36400 ....... Bl draw < 3 yrs fem/jugular ............................... ......... N .................. .................. .................. .................. ..................

36405 ....... Bl draw < 3 yrs scalp vein ................................. ......... N .................. .................. .................. .................. ..................

36406 ....... Bl draw < 3 yrs other vein ................................. ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68316 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

36410 ....... Non-routine bl draw > 3 yrs ............................... ......... N .................. .................. .................. .................. ..................

36416 ....... Capillary blood draw .......................................... ......... N .................. .................. .................. .................. ..................

36420 ....... Vein access cutdown < 1 yr .............................. ......... T 0035 0.1999 12.29 .................. 2.46 

36425 ....... Vein access cutdown > 1 yr .............................. ......... T 0035 0.1999 12.29 .................. 2.46 

36430 ....... Blood transfusion service .................................. ......... S 0110 3.4584 212.58 .................. 42.52 

36440 ....... Bl push transfuse, 2 yr or < ............................... ......... S 0110 3.4584 212.58 .................. 42.52 

36450 ....... Bl exchange/transfuse, nb ................................. ......... S 0110 3.4584 212.58 .................. 42.52 

36455 ....... Bl exchange/transfuse non-nb ........................... ......... S 0110 3.4584 212.58 .................. 42.52 

36460 ....... Transfusion service, fetal ................................... ......... S 0110 3.4584 212.58 .................. 42.52 

36468 ....... Injection(s), spider veins .................................... ......... T 0098 1.0798 66.37 .................. 13.27 

36469 ....... Injection(s), spider veins .................................... ......... T 0098 1.0798 66.37 .................. 13.27 

36470 ....... Injection therapy of vein .................................... ......... T 0098 1.0798 66.37 .................. 13.27 

36471 ....... Injection therapy of veins ................................... ......... T 0098 1.0798 66.37 .................. 13.27 

36475 ....... Endovenous rf, 1st vein ..................................... ......... T 0091 34.7288 2,134.71 .................. 426.94 

36476 ....... Endovenous rf, vein add-on .............................. ......... T 0091 34.7288 2,134.71 .................. 426.94 

36478 ....... Endovenous laser, 1st vein ............................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

36479 ....... Endovenous laser vein addon ........................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

36481 ....... Insertion of catheter, vein .................................. ......... N .................. .................. .................. .................. ..................

36500 ....... Insertion of catheter, vein .................................. ......... N .................. .................. .................. .................. ..................

36510 ....... Insertion of catheter, vein .................................. ......... N .................. .................. .................. .................. ..................

36511 ....... Apheresis wbc ................................................... ......... S 0111 11.7134 720.00 198.40 144.00 

36512 ....... Apheresis rbc ..................................................... ......... S 0111 11.7134 720.00 198.40 144.00 

36513 ....... Apheresis platelets ............................................ ......... S 0111 11.7134 720.00 198.40 144.00 

36514 ....... Apheresis plasma .............................................. ......... S 0111 11.7134 720.00 198.40 144.00 

36515 ....... Apheresis, adsorp/reinfuse ................................ ......... S 0112 30.2231 1,857.75 433.29 371.55 

36516 ....... Apheresis, selective ........................................... ......... S 0112 30.2231 1,857.75 433.29 371.55 

36522 ....... Photopheresis .................................................... ......... S 0112 30.2231 1,857.75 433.29 371.55 

36540 ....... Collect blood venous device .............................. CH .. Q 0624 0.5145 31.63 12.65 6.33 

36550 ....... Declot vascular device ....................................... ......... T 0676 2.0726 127.40 .................. 25.48 

36555 ....... Insert non-tunnel cv cath ................................... ......... T 0621 8.7846 539.97 .................. 107.99 

36556 ....... Insert non-tunnel cv cath ................................... ......... T 0621 8.7846 539.97 .................. 107.99 

36557 ....... Insert tunneled cv cath ...................................... ......... T 0622 22.6665 1,393.26 .................. 278.65 

36558 ....... Insert tunneled cv cath ...................................... ......... T 0622 22.6665 1,393.26 .................. 278.65 

36560 ....... Insert tunneled cv cath ...................................... ......... T 0623 28.5032 1,752.03 .................. 350.41 

36561 ....... Insert tunneled cv cath ...................................... ......... T 0623 28.5032 1,752.03 .................. 350.41 

36563 ....... Insert tunneled cv cath ...................................... ......... T 0623 28.5032 1,752.03 .................. 350.41 

36565 ....... Insert tunneled cv cath ...................................... ......... T 0623 28.5032 1,752.03 .................. 350.41 

36566 ....... Insert tunneled cv cath ...................................... CH .. T 0625 83.4609 5,130.17 .................. 1,026.03

36568 ....... Insert picc cath .................................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36569 ....... Insert picc cath .................................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36570 ....... Insert picvad cath .............................................. ......... T 0622 22.6665 1,393.26 .................. 278.65 

36571 ....... Insert picvad cath .............................................. ......... T 0622 22.6665 1,393.26 .................. 278.65 

36575 ....... Repair tunneled cv cath ..................................... ......... T 0621 8.7846 539.97 .................. 107.99 

36576 ....... Repair tunneled cv cath ..................................... ......... T 0621 8.7846 539.97 .................. 107.99 

36578 ....... Replace tunneled cv cath .................................. ......... T 0622 22.6665 1,393.26 .................. 278.65

36580 ....... Replace cvad cath ............................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36581 ....... Replace tunneled cv cath .................................. ......... T 0622 22.6665 1,393.26 .................. 278.65

36582 ....... Replace tunneled cv cath .................................. ......... T 0623 28.5032 1,752.03 .................. 350.41

36583 ....... Replace tunneled cv cath .................................. ......... T 0623 28.5032 1,752.03 .................. 350.41

36584 ....... Replace picc cath .............................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36585 ....... Replace picvad cath .......................................... ......... T 0622 22.6665 1,393.26 .................. 278.65 

36589 ....... Removal tunneled cv cath ................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36590 ....... Removal tunneled cv cath ................................. ......... T 0621 8.7846 539.97 .................. 107.99 

36595 ....... Mech remov tunneled cv cath ........................... ......... T 0622 22.6665 1,393.26 .................. 278.65 

36596 ....... Mech remov tunneled cv cath ........................... ......... T 0621 8.7846 539.97 .................. 107.99 

36597 ....... Reposition venous catheter ............................... ......... T 0621 8.7846 539.97 .................. 107.99 

36598 ....... Inj w/fluor, eval cv device .................................. ......... X 0340 0.6102 37.51 .................. 7.50 

36600 ....... Withdrawal of arterial blood ............................... CH .. Q 0035 0.1999 12.29 .................. 2.46 

36620 ....... Insertion catheter, artery .................................... ......... N .................. .................. .................. .................. ..................

36625 ....... Insertion catheter, artery .................................... ......... N .................. .................. .................. .................. ..................

36640 ....... Insertion catheter, artery .................................... ......... T 0623 28.5032 1,752.03 .................. 350.41 

36680 ....... Insert needle, bone cavity ................................. ......... T 0002 1.0995 67.58 .................. 13.52 

36800 ....... Insertion of cannula ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

36810 ....... Insertion of cannula ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

36815 ....... Insertion of cannula ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

36818 ....... Av fuse, uppr arm, cephalic ............................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36819 ....... Av fuse, uppr arm, basilic .................................. ......... T 0088 37.7391 2,319.75 655.22 463.95 

36820 ....... Av fusion/forearm vein ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36821 ....... Av fusion direct any site .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36825 ....... Artery-vein autograft .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68317 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

36830 ....... Artery-vein nonautograft .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36831 ....... Open thrombect av fistula ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95 

36832 ....... Av fistula revision, open .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36833 ....... Av fistula revision ............................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36834 ....... Repair A–V aneurysm ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36835 ....... Artery to vein shunt ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

36838 ....... Dist revas ligation, hemo ................................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

36860 ....... External cannula declotting ............................... ......... T 0676 2.0726 127.40 .................. 25.48 

36861 ....... Cannula declotting ............................................. ......... T 0115 29.2133 1,795.68 374.81 359.14 

36870 ....... Percut thrombect av fistula ................................ ......... T 0653 32.3818 1,990.44 .................. 398.09 

37183 ....... Remove hepatic shunt (tips) .............................. ......... T 0229 68.4697 4,208.70 .................. 841.74 

37184 ....... Prim art mech thrombectomy ............................ CH .. T 0088 37.7391 2,319.75 655.22 463.95 

37185 ....... Prim art m-thrombect add-on ............................ CH .. T 0088 37.7391 2,319.75 655.22 463.95 

37186 ....... Sec art m-thrombect add-on .............................. CH .. T 0088 37.7391 2,319.75 655.22 463.95 

37187 ....... Venous mech thrombectomy ............................. CH .. T 0088 37.7391 2,319.75 655.22 463.95 

37188 ....... Venous m-thrombectomy add-on ...................... CH .. T 0088 37.7391 2,319.75 655.22 463.95 

37195 ....... Thrombolytic therapy, stroke ............................. ......... T 0676 2.0726 127.40 .................. 25.48 

37200 ....... Transcatheter biopsy ......................................... ......... T 0685 6.1384 377.32 115.47 75.46 

37201 ....... Transcatheter therapy infuse ............................. ......... T 0676 2.0726 127.40 .................. 25.48 

37202 ....... Transcatheter therapy infuse ............................. ......... T 0676 2.0726 127.40 .................. 25.48 

37203 ....... Transcatheter retrieval ....................................... ......... T 0103 16.2375 998.09 223.63 199.62 

37204 ....... Transcatheter occlusion ..................................... ......... T 0115 29.2133 1,795.68 374.81 359.14 

37205 ....... Transcath iv stent, percut .................................. ......... T 0229 68.4697 4,208.70 .................. 841.74 

37206 ....... Transcath iv stent/perc addl .............................. ......... T 0229 68.4697 4,208.70 .................. 841.74

37207 ....... Transcath iv stent, open .................................... ......... T 0229 68.4697 4,208.70 .................. 841.74 

37208 ....... Transcath iv stent/open addl ............................. ......... T 0229 68.4697 4,208.70 .................. 841.74 

37209 ....... Change iv cath at thromb tx .............................. ......... T 0103 16.2375 998.09 223.63 199.62 

37210 ....... Embolization uterine fibroid ............................... NI .... T 0202 42.9896 2,642.48 981.50 528.50 

37250 ....... Iv us first vessel add-on .................................... ......... S 0416 32.5472 2,000.61 .................. 400.12 

37251 ....... Iv us each add vessel add-on ........................... ......... S 0416 32.5472 2,000.61 .................. 400.12 

37500 ....... Endoscopy ligate perf veins .............................. CH .. T 0091 34.7288 2,134.71 .................. 426.94 

37501 ....... Vascular endoscopy procedure ......................... ......... T 0092 24.8809 1,529.38 309.87 305.88 

37565 ....... Ligation of neck vein .......................................... ......... T 0093 22.8653 1,405.48 .................. 281.10 

37600 ....... Ligation of neck artery ....................................... ......... T 0093 22.8653 1,405.48 .................. 281.10 

37605 ....... Ligation of neck artery ....................................... ......... T 0091 34.7288 2,134.71 .................. 426.94 

37606 ....... Ligation of neck artery ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37607 ....... Ligation of a-v fistula ......................................... ......... T 0092 24.8809 1,529.38 309.87 305.88 

37609 ....... Temporal artery procedure ................................ ......... T 0021 15.1024 928.31 219.48 185.66 

37615 ....... Ligation of neck artery ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37620 ....... Revision of major vein ....................................... ......... T 0091 34.7288 2,134.71 .................. 426.94 

37650 ....... Revision of major vein ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37700 ....... Revise leg vein .................................................. ......... T 0091 34.7288 2,134.71 .................. 426.94 

37718 ....... Ligate/strip short leg vein .................................. CH .. T 0091 34.7288 2,134.71 .................. 426.94 

37722 ....... Ligate/strip long leg vein .................................... CH .. T 0091 34.7288 2,134.71 .................. 426.94 

37735 ....... Removal of leg veins/lesion ............................... CH .. T 0091 34.7288 2,134.71 .................. 426.94 

37760 ....... Ligation, leg veins, open .................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37765 ....... Phleb veins—extrem—to 20 .............................. CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37766 ....... Phleb veins—extrem 20+ .................................. CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37780 ....... Revision of leg vein ........................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37785 ....... Ligate/divide/excise vein .................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88 

37790 ....... Penile venous occlusion .................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

37799 ....... Vascular surgery procedure .............................. ......... T 0103 16.2375 998.09 223.63 199.62 

38120 ....... Laparoscopy, splenectomy ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

38129 ....... Laparoscope proc, spleen ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

38200 ....... Injection for spleen x-ray ................................... ......... N .................. .................. .................. .................. ..................

38204 ....... Bl donor search management ........................... ......... N .................. .................. .................. .................. ..................

38205 ....... Harvest allogenic stem cells .............................. ......... S 0111 11.7134 720.00 198.40 144.00 

38206 ....... Harvest auto stem cells ..................................... ......... S 0111 11.7134 720.00 198.40 144.00 

38220 ....... Bone marrow aspiration ..................................... ......... T 0003 2.4011 147.59 .................. 29.52 

38221 ....... Bone marrow biopsy .......................................... ......... T 0003 2.4011 147.59 .................. 29.52 

38230 ....... Bone marrow collection ..................................... ......... S 0123 20.3582 1,251.38 .................. 250.28 

38240 ....... Bone marrow/stem transplant ............................ ......... S 0123 20.3582 1,251.38 .................. 250.28 

38241 ....... Bone marrow/stem transplant ............................ ......... S 0123 20.3582 1,251.38 .................. 250.28 

38242 ....... Lymphocyte infuse transplant ............................ ......... S 0111 11.7134 720.00 198.40 144.00 

38300 ....... Drainage, lymph node lesion ............................. ......... T 0007 11.1535 685.58 .................. 137.12 

38305 ....... Drainage, lymph node lesion ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

38308 ....... Incision of lymph channels ................................ ......... T 0113 21.2621 1,306.94 .................. 261.39

38500 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39 

38505 ....... Needle biopsy, lymph nodes ............................. ......... T 0005 3.9045 240.00 71.59 48.00 

38510 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39 


cprice-sewell on PRODPC62 with RULES2
68318 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

38520 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39 

38525 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39 

38530 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39 

38542 ....... Explore deep node(s), neck .............................. ......... T 0114 37.7224 2,318.72 467.95 463.74 

38550 ....... Removal, neck/armpit lesion ............................. ......... T 0113 21.2621 1,306.94 .................. 261.39 

38555 ....... Removal, neck/armpit lesion ............................. ......... T 0113 21.2621 1,306.94 .................. 261.39 

38570 ....... Laparoscopy, lymph node biop ......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

38571 ....... Laparoscopy, lymphadenectomy ....................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

38572 ....... Laparoscopy, lymphadenectomy ....................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

38589 ....... Laparoscope proc, lymphatic ............................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

38700 ....... Removal of lymph nodes, neck ......................... ......... T 0113 21.2621 1,306.94 .................. 261.39 

38720 ....... Removal of lymph nodes, neck ......................... ......... T 0113 21.2621 1,306.94 .................. 261.39 

38740 ....... Remove armpit lymph nodes ............................. ......... T 0114 37.7224 2,318.72 467.95 463.74 

38745 ....... Remove armpit lymph nodes ............................. ......... T 0114 37.7224 2,318.72 467.95 463.74 

38760 ....... Remove groin lymph nodes ............................... ......... T 0113 21.2621 1,306.94 .................. 261.39 

38790 ....... Inject for lymphatic x-ray ................................... ......... N .................. .................. .................. .................. ..................

38792 ....... Identify sentinel node ......................................... CH .. Q 0389 1.3754 84.54 33.81 16.91 

38794 ....... Access thoracic lymph duct ............................... ......... N .................. .................. .................. .................. ..................

38999 ....... Blood/lymph system procedure ......................... ......... S 0110 3.4584 212.58 .................. 42.52 

39400 ....... Visualization of chest ......................................... ......... T 0069 31.9442 1,963.55 591.64 392.71 

40490 ....... Biopsy of lip ....................................................... ......... T 0251 2.452 150.72 .................. 30.14 

40500 ....... Partial excision of lip .......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

40510 ....... Partial excision of lip .......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40520 ....... Partial excision of lip .......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

40525 ....... Reconstruct lip with flap .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40527 ....... Reconstruct lip with flap .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40530 ....... Partial removal of lip .......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40650 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

40652 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

40654 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

40700 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40701 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40702 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40720 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40761 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40799 ....... Lip surgery procedure ........................................ ......... T 0251 2.452 150.72 .................. 30.14 

40800 ....... Drainage of mouth lesion .................................. CH .. T 0006 1.4392 88.46 .................. 17.69 

40801 ....... Drainage of mouth lesion .................................. ......... T 0252 7.5511 464.15 109.16 92.83 

40804 ....... Removal, foreign body, mouth .......................... ......... X 0340 0.6102 37.51 .................. 7.50 

40805 ....... Removal, foreign body, mouth .......................... ......... T 0252 7.5511 464.15 109.16 92.83 

40806 ....... Incision of lip fold ............................................... ......... T 0251 2.452 150.72 .................. 30.14 

40808 ....... Biopsy of mouth lesion ...................................... ......... T 0251 2.452 150.72 .................. 30.14 

40810 ....... Excision of mouth lesion .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

40812 ....... Excise/repair mouth lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

40814 ....... Excise/repair mouth lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

40816 ....... Excision of mouth lesion .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40818 ....... Excise oral mucosa for graft .............................. ......... T 0251 2.452 150.72 .................. 30.14 

40819 ....... Excise lip or cheek fold ..................................... ......... T 0252 7.5511 464.15 109.16 92.83 

40820 ....... Treatment of mouth lesion ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

40830 ....... Repair mouth laceration .................................... ......... T 0251 2.452 150.72 .................. 30.14 

40831 ....... Repair mouth laceration .................................... ......... T 0252 7.5511 464.15 109.16 92.83 

40840 ....... Reconstruction of mouth .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40842 ....... Reconstruction of mouth .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40843 ....... Reconstruction of mouth .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

40844 ....... Reconstruction of mouth .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40845 ....... Reconstruction of mouth .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

40899 ....... Mouth surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14 

41000 ....... Drainage of mouth lesion .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

41005 ....... Drainage of mouth lesion .................................. ......... T 0251 2.452 150.72 .................. 30.14 

41006 ....... Drainage of mouth lesion .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

41007 ....... Drainage of mouth lesion .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

41008 ....... Drainage of mouth lesion .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

41009 ....... Drainage of mouth lesion .................................. ......... T 0251 2.452 150.72 .................. 30.14 

41010 ....... Incision of tongue fold ....................................... ......... T 0252 7.5511 464.15 109.16 92.83 

41015 ....... Drainage of mouth lesion .................................. ......... T 0251 2.452 150.72 .................. 30.14 

41016 ....... Drainage of mouth lesion .................................. ......... T 0252 7.5511 464.15 109.16 92.83 

41017 ....... Drainage of mouth lesion .................................. ......... T 0252 7.5511 464.15 109.16 92.83 

41018 ....... Drainage of mouth lesion .................................. ......... T 0252 7.5511 464.15 109.16 92.83 

41100 ....... Biopsy of tongue ................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

41105 ....... Biopsy of tongue ................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68319 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

41108 ....... Biopsy of floor of mouth .................................... ......... T 0252 7.5511 464.15 109.16 92.83 

41110 ....... Excision of tongue lesion ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41112 ....... Excision of tongue lesion ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41113 ....... Excision of tongue lesion ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41114 ....... Excision of tongue lesion ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

41115 ....... Excision of tongue fold ...................................... ......... T 0252 7.5511 464.15 109.16 92.83 

41116 ....... Excision of mouth lesion .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41120 ....... Partial removal of tongue .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

41250 ....... Repair tongue laceration ................................... ......... T 0251 2.452 150.72 .................. 30.14 

41251 ....... Repair tongue laceration ................................... ......... T 0251 2.452 150.72 .................. 30.14 

41252 ....... Repair tongue laceration ................................... ......... T 0252 7.5511 464.15 109.16 92.83 

41500 ....... Fixation of tongue .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

41510 ....... Tongue to lip surgery ......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41520 ....... Reconstruction, tongue fold ............................... ......... T 0252 7.5511 464.15 109.16 92.83 

41599 ....... Tongue and mouth surgery ............................... ......... T 0251 2.452 150.72 .................. 30.14 

41800 ....... Drainage of gum lesion ..................................... CH .. T 0006 1.4392 88.46 .................. 17.69 

41805 ....... Removal foreign body, gum .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

41806 ....... Removal foreign body,jawbone ......................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41820 ....... Excision, gum, each quadrant ........................... ......... T 0252 7.5511 464.15 109.16 92.83 

41821 ....... Excision of gum flap .......................................... ......... T 0252 7.5511 464.15 109.16 92.83 

41822 ....... Excision of gum lesion ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41823 ....... Excision of gum lesion ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

41825 ....... Excision of gum lesion ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41826 ....... Excision of gum lesion ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41827 ....... Excision of gum lesion ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

41828 ....... Excision of gum lesion ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41830 ....... Removal of gum tissue ...................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41850 ....... Treatment of gum lesion .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

41870 ....... Gum graft ........................................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

41872 ....... Repair gum ........................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

41874 ....... Repair tooth socket ............................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

41899 ....... Dental surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14 

42000 ....... Drainage mouth roof lesion ............................... ......... T 0251 2.452 150.72 .................. 30.14 

42100 ....... Biopsy roof of mouth ......................................... ......... T 0252 7.5511 464.15 109.16 92.83 

42104 ....... Excision lesion, mouth roof ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42106 ....... Excision lesion, mouth roof ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42107 ....... Excision lesion, mouth roof ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42120 ....... Remove palate/lesion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42140 ....... Excision of uvula ................................................ ......... T 0252 7.5511 464.15 109.16 92.83 

42145 ....... Repair palate, pharynx/uvula ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

42160 ....... Treatment mouth roof lesion ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42180 ....... Repair palate ..................................................... ......... T 0251 2.452 150.72 .................. 30.14 

42182 ....... Repair palate ..................................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42200 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42205 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42210 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42215 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42220 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42225 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42226 ....... Lengthening of palate ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42227 ....... Lengthening of palate ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42235 ....... Repair palate ..................................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42260 ....... Repair nose to lip fistula .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42280 ....... Preparation, palate mold ................................... ......... T 0251 2.452 150.72 .................. 30.14 

42281 ....... Insertion, palate prosthesis ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

42299 ....... Palate/uvula surgery .......................................... ......... T 0251 2.452 150.72 .................. 30.14 

42300 ....... Drainage of salivary gland ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42305 ....... Drainage of salivary gland ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42310 ....... Drainage of salivary gland ................................. ......... T 0251 2.452 150.72 .................. 30.14 

42320 ....... Drainage of salivary gland ................................. ......... T 0251 2.452 150.72 .................. 30.14 

42330 ....... Removal of salivary stone ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42335 ....... Removal of salivary stone ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42340 ....... Removal of salivary stone ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42400 ....... Biopsy of salivary gland ..................................... ......... T 0005 3.9045 240.00 71.59 48.00 

42405 ....... Biopsy of salivary gland ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42408 ....... Excision of salivary cyst .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42409 ....... Drainage of salivary cyst ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42410 ....... Excise parotid gland/lesion ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42415 ....... Excise parotid gland/lesion ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42420 ....... Excise parotid gland/lesion ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 


cprice-sewell on PRODPC62 with RULES2
68320 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

42425 ....... Excise parotid gland/lesion ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42440 ....... Excise submaxillary gland ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60

42450 ....... Excise sublingual gland ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42500 ....... Repair salivary duct ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42505 ....... Repair salivary duct ........................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42507 ....... Parotid duct diversion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42508 ....... Parotid duct diversion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42509 ....... Parotid duct diversion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42510 ....... Parotid duct diversion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42550 ....... Injection for salivary x-ray .................................. ......... N .................. .................. .................. .................. ..................

42600 ....... Closure of salivary fistula .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42650 ....... Dilation of salivary duct ..................................... ......... T 0252 7.5511 464.15 109.16 92.83 

42660 ....... Dilation of salivary duct ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

42665 ....... Ligation of salivary duct ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42699 ....... Salivary surgery procedure ................................ ......... T 0251 2.452 150.72 .................. 30.14 

42700 ....... Drainage of tonsil abscess ................................ ......... T 0251 2.452 150.72 .................. 30.14 

42720 ....... Drainage of throat abscess ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

42725 ....... Drainage of throat abscess ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42800 ....... Biopsy of throat .................................................. CH .. T 0252 7.5511 464.15 109.16 92.83 

42802 ....... Biopsy of throat .................................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42804 ....... Biopsy of upper nose/throat .............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42806 ....... Biopsy of upper nose/throat .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

42808 ....... Excise pharynx lesion ........................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

42809 ....... Remove pharynx foreign body .......................... ......... X 0340 0.6102 37.51 .................. 7.50 

42810 ....... Excision of neck cyst ......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42815 ....... Excision of neck cyst ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42820 ....... Remove tonsils and adenoids ........................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42821 ....... Remove tonsils and adenoids ........................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42825 ....... Removal of tonsils ............................................. ......... T 0258 22.1165 1,359.46 437.25 271.89 

42826 ....... Removal of tonsils ............................................. ......... T 0258 22.1165 1,359.46 437.25 271.89 

42830 ....... Removal of adenoids ......................................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42831 ....... Removal of adenoids ......................................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42835 ....... Removal of adenoids ......................................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42836 ....... Removal of adenoids ......................................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42842 ....... Extensive surgery of throat ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

42844 ....... Extensive surgery of throat ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

42860 ....... Excision of tonsil tags ........................................ ......... T 0258 22.1165 1,359.46 437.25 271.89 

42870 ....... Excision of lingual tonsil .................................... ......... T 0258 22.1165 1,359.46 437.25 271.89 

42890 ....... Partial removal of pharynx ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

42892 ....... Revision of pharyngeal walls ............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

42900 ....... Repair throat wound .......................................... ......... T 0252 7.5511 464.15 109.16 92.83 

42950 ....... Reconstruction of throat .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

42955 ....... Surgical opening of throat ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

42960 ....... Control throat bleeding ...................................... ......... T 0250 1.1791 72.48 25.39 14.50 

42962 ....... Control throat bleeding ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

42970 ....... Control nose/throat bleeding ............................. ......... T 0250 1.1791 72.48 25.39 14.50 

42972 ....... Control nose/throat bleeding ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

42999 ....... Throat surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14 

43020 ....... Incision of esophagus ........................................ ......... T 0252 7.5511 464.15 109.16 92.83 

43030 ....... Throat muscle surgery ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

43130 ....... Removal of esophagus pouch ........................... CH .. T 0256 38.1991 2,348.02 .................. 469.60 

43200 ....... Esophagus endoscopy ...................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43201 ....... Esoph scope w/submucous inj .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43202 ....... Esophagus endoscopy, biopsy .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43204 ....... Esoph scope w/sclerosis inj .............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43205 ....... Esophagus endoscopy/ligation .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43215 ....... Esophagus endoscopy ...................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43216 ....... Esophagus endoscopy/lesion ............................ ......... T 0141 8.3175 511.26 143.38 102.25 

43217 ....... Esophagus endoscopy ...................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43219 ....... Esophagus endoscopy ...................................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

43220 ....... Esoph endoscopy, dilation ................................. ......... T 0141 8.3175 511.26 143.38 102.25 

43226 ....... Esoph endoscopy, dilation ................................. ......... T 0141 8.3175 511.26 143.38 102.25 

43227 ....... Esoph endoscopy, repair ................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43228 ....... Esoph endoscopy, ablation ............................... ......... T 0422 25.7552 1,583.12 448.81 316.62 

43231 ....... Esoph endoscopy w/us exam ............................ ......... T 0141 8.3175 511.26 143.38 102.25 

43232 ....... Esoph endoscopy w/us fn bx ............................ ......... T 0141 8.3175 511.26 143.38 102.25 

43234 ....... Upper GI endoscopy, exam ............................... ......... T 0141 8.3175 511.26 143.38 102.25 

43235 ....... Uppr gi endoscopy, diagnosis ........................... ......... T 0141 8.3175 511.26 143.38 102.25 

43236 ....... Uppr gi scope w/submuc inj .............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43237 ....... Endoscopic us exam, esoph ............................. ......... T 0141 8.3175 511.26 143.38 102.25 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68321 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

43238 ....... Uppr gi endoscopy w/us fn bx ........................... ......... T 0141 8.3175 511.26 143.38 102.25 

43239 ....... Upper GI endoscopy, biopsy ............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43240 ....... Esoph endoscope w/drain cyst .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43241 ....... Upper GI endoscopy with tube .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43242 ....... Uppr gi endoscopy w/us fn bx ........................... ......... T 0141 8.3175 511.26 143.38 102.25 

43243 ....... Upper gi endoscopy & inject ............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43244 ....... Upper GI endoscopy/ligation ............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43245 ....... Uppr gi scope dilate strictr ................................. ......... T 0141 8.3175 511.26 143.38 102.25 

43246 ....... Place gastrostomy tube ..................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43247 ....... Operative upper GI endoscopy ......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43248 ....... Uppr gi endoscopy/guide wire ........................... ......... T 0141 8.3175 511.26 143.38 102.25 

43249 ....... Esoph endoscopy, dilation ................................. ......... T 0141 8.3175 511.26 143.38 102.25 

43250 ....... Upper GI endoscopy/tumor ............................... ......... T 0141 8.3175 511.26 143.38 102.25 

43251 ....... Operative upper GI endoscopy ......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43255 ....... Operative upper GI endoscopy ......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43256 ....... Uppr gi endoscopy w/stent ................................ ......... T 0384 22.9475 1,410.54 295.41 282.11 

43257 ....... Uppr gi scope w/thrml txmnt .............................. ......... T 0422 25.7552 1,583.12 448.81 316.62 

43258 ....... Operative upper GI endoscopy ......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43259 ....... Endoscopic ultrasound exam ............................ ......... T 0141 8.3175 511.26 143.38 102.25 

43260 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43261 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43262 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43263 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43264 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43265 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43267 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43268 ....... Endo cholangiopancreatograph ......................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

43269 ....... Endo cholangiopancreatograph ......................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

43271 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43272 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88 

43280 ....... Laparoscopy, fundoplasty .................................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

43289 ....... Laparoscope proc, esoph .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

43450 ....... Dilate esophagus ............................................... ......... T 0140 5.4566 335.41 91.40 67.08 

43453 ....... Dilate esophagus ............................................... ......... T 0140 5.4566 335.41 91.40 67.08 

43456 ....... Dilate esophagus ............................................... ......... T 0140 5.4566 335.41 91.40 67.08 

43458 ....... Dilate esophagus ............................................... ......... T 0140 5.4566 335.41 91.40 67.08 

43499 ....... Esophagus surgery procedure .......................... ......... T 0141 8.3175 511.26 143.38 102.25 

43510 ....... Surgical opening of stomach ............................. ......... T 0141 8.3175 511.26 143.38 102.25 

43600 ....... Biopsy of stomach ............................................. ......... T 0141 8.3175 511.26 143.38 102.25 

43647 ....... Lap impl electrode, antrum ................................ NI .... T 0130 32.1241 1,974.60 659.53 394.92 

43648 ....... Lap revise/remv eltrd antrum ............................. NI .... T 0130 32.1241 1,974.60 659.53 394.92 

43651 ....... Laparoscopy, vagus nerve ................................ ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

43652 ....... Laparoscopy, vagus nerve ................................ ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

43653 ....... Laparoscopy, gastrostomy ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

43659 ....... Laparoscope proc, stom .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

43750 ....... Place gastrostomy tube ..................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43752 ....... Nasal/orogastric w/stent .................................... ......... X 0272 1.2908 79.34 31.64 15.87 

43760 ....... Change gastrostomy tube ................................. ......... T 0121 2.3587 144.98 43.80 29.00 

43761 ....... Reposition gastrostomy tube ............................. ......... T 0122 7.48 459.78 .................. 91.96 

43830 ....... Place gastrostomy tube ..................................... ......... T 0422 25.7552 1,583.12 448.81 316.62 

43831 ....... Place gastrostomy tube ..................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43870 ....... Repair stomach opening .................................... ......... T 0141 8.3175 511.26 143.38 102.25 

43881 ....... Impl/redo electrd, antrum ................................... NI .... C .................. .................. .................. .................. ..................

43882 ....... Revise/remove electrd antrum ........................... NI .... C .................. .................. .................. .................. ..................

43886 ....... Revise gastric port, open ................................... ......... T 0025 5.2594 323.28 101.85 64.66 

43887 ....... Remove gastric port, open ................................ ......... T 0025 5.2594 323.28 101.85 64.66 

43888 ....... Change gastric port, open ................................. ......... T 0686 14.0346 862.68 .................. 172.54 

43999 ....... Stomach surgery procedure .............................. ......... T 0141 8.3175 511.26 143.38 102.25 

44100 ....... Biopsy of bowel ................................................. ......... T 0141 8.3175 511.26 143.38 102.25 

44152 ....... Removal of colon/ileostomy ............................... CH .. D .................. .................. .................. .................. ..................

44153 ....... Removal of colon/ileostomy ............................... CH .. D .................. .................. .................. .................. ..................

44157 ....... Colectomy w/ileoanal anast ............................... NI .... C .................. .................. .................. .................. ..................

44158 ....... Colectomy w/neo-rectum pouch ........................ NI .... C .................. .................. .................. .................. ..................

44180 ....... Lap, enterolysis .................................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

44186 ....... Lap, jejunostomy ................................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

44206 ....... Lap part colectomy w/stoma .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

44207 ....... Lcolectomy/coloproctostomy .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

44208 ....... Lcolectomy/coloproctostomy .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

44213 ....... Lap, mobil splenic fl add-on .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

44238 ....... Laparoscope proc, intestine .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92 


cprice-sewell on PRODPC62 with RULES2
68322 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

44312 ....... Revision of ileostomy ......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45 

44340 ....... Revision of colostomy ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45 

44360 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44361 ....... Small bowel endoscopy/biopsy ......................... ......... T 0142 9.4946 583.61 152.78 116.72 

44363 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44364 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44365 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44366 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44369 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44370 ....... Small bowel endoscopy/stent ............................ ......... T 0384 22.9475 1,410.54 295.41 282.11 

44372 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44373 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44376 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44377 ....... Small bowel endoscopy/biopsy ......................... ......... T 0142 9.4946 583.61 152.78 116.72 

44378 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44379 ....... Sbowel endoscope w/stent ................................ ......... T 0384 22.9475 1,410.54 295.41 282.11 

44380 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44382 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72 

44383 ....... Ileoscopy w/stent ............................................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

44385 ....... Endoscopy of bowel pouch ............................... ......... T 0143 8.7686 538.99 186.06 107.80 

44386 ....... Endoscopy, bowel pouch/biop ........................... ......... T 0143 8.7686 538.99 186.06 107.80 

44388 ....... Colonoscopy ...................................................... ......... T 0143 8.7686 538.99 186.06 107.80 

44389 ....... Colonoscopy with biopsy ................................... ......... T 0143 8.7686 538.99 186.06 107.80 

44390 ....... Colonoscopy for foreign body ............................ ......... T 0143 8.7686 538.99 186.06 107.80 

44391 ....... Colonoscopy for bleeding .................................. ......... T 0143 8.7686 538.99 186.06 107.80 

44392 ....... Colonoscopy & polypectomy ............................. ......... T 0143 8.7686 538.99 186.06 107.80 

44393 ....... Colonoscopy, lesion removal ............................. ......... T 0143 8.7686 538.99 186.06 107.80 

44394 ....... Colonoscopy w/snare ........................................ ......... T 0143 8.7686 538.99 186.06 107.80 

44397 ....... Colonoscopy w/stent .......................................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

44500 ....... Intro, gastrointestinal tube ................................. ......... T 0121 2.3587 144.98 43.80 29.00 

44701 ....... Intraop colon lavage add-on .............................. ......... N .................. .................. .................. .................. ..................

44799 ....... Unlisted procedure intestine .............................. CH .. T 0153 22.0832 1,357.41 397.95 271.48 

44901 ....... Drain app abscess, percut ................................. ......... T 0037 10.2655 631.00 228.76 126.20 

44970 ....... Laparoscopy, appendectomy ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

44979 ....... Laparoscope proc, app ...................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

45000 ....... Drainage of pelvic abscess ............................... ......... T 0148 5.077 312.07 .................. 62.41 

45005 ....... Drainage of rectal abscess ................................ ......... T 0155 12.7389 783.03 .................. 156.61 

45020 ....... Drainage of rectal abscess ................................ ......... T 0155 12.7389 783.03 .................. 156.61 

45100 ....... Biopsy of rectum ................................................ ......... T 0149 22.2682 1,368.78 293.06 273.76 

45108 ....... Removal of anorectal lesion .............................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

45150 ....... Excision of rectal stricture ................................. ......... T 0149 22.2682 1,368.78 293.06 273.76 

45160 ....... Excision of rectal lesion ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

45170 ....... Excision of rectal lesion ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

45190 ....... Destruction, rectal tumor ................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

45300 ....... Proctosigmoidoscopy dx .................................... ......... T 0146 4.8683 299.24 64.40 59.85 

45303 ....... Proctosigmoidoscopy dilate ............................... ......... T 0147 8.5477 525.41 .................. 105.08 

45305 ....... Proctosigmoidoscopy w/bx ................................ ......... T 0147 8.5477 525.41 .................. 105.08 

45307 ....... Proctosigmoidoscopy fb ..................................... ......... T 0428 20.6375 1,268.55 .................. 253.71 

45308 ....... Proctosigmoidoscopy removal ........................... ......... T 0147 8.5477 525.41 .................. 105.08 

45309 ....... Proctosigmoidoscopy removal ........................... ......... T 0147 8.5477 525.41 .................. 105.08 

45315 ....... Proctosigmoidoscopy removal ........................... ......... T 0147 8.5477 525.41 .................. 105.08 

45317 ....... Proctosigmoidoscopy bleed ............................... ......... T 0147 8.5477 525.41 .................. 105.08 

45320 ....... Proctosigmoidoscopy ablate .............................. ......... T 0428 20.6375 1,268.55 .................. 253.71 

45321 ....... Proctosigmoidoscopy volvul .............................. ......... T 0428 20.6375 1,268.55 .................. 253.71 

45327 ....... Proctosigmoidoscopy w/stent ............................ ......... T 0384 22.9475 1,410.54 295.41 282.11 

45330 ....... Diagnostic sigmoidoscopy ................................. ......... T 0146 4.8683 299.24 64.40 59.85 

45331 ....... Sigmoidoscopy and biopsy ................................ ......... T 0146 4.8683 299.24 64.40 59.85 

45332 ....... Sigmoidoscopy w/fb removal ............................. ......... T 0146 4.8683 299.24 64.40 59.85 

45333 ....... Sigmoidoscopy & polypectomy .......................... ......... T 0147 8.5477 525.41 .................. 105.08 

45334 ....... Sigmoidoscopy for bleeding .............................. ......... T 0147 8.5477 525.41 .................. 105.08 

45335 ....... Sigmoidoscopy w/submuc inj ............................ ......... T 0146 4.8683 299.24 64.40 59.85 

45337 ....... Sigmoidoscopy & decompress .......................... ......... T 0146 4.8683 299.24 64.40 59.85 

45338 ....... Sigmoidoscopy w/tumr remove ......................... ......... T 0147 8.5477 525.41 .................. 105.08 

45339 ....... Sigmoidoscopy w/ablate tumr ............................ ......... T 0147 8.5477 525.41 .................. 105.08 

45340 ....... Sig w/balloon dilation ......................................... ......... T 0147 8.5477 525.41 .................. 105.08 

45341 ....... Sigmoidoscopy w/ultrasound ............................. ......... T 0147 8.5477 525.41 .................. 105.08 

45342 ....... Sigmoidoscopy w/us guide bx ........................... ......... T 0147 8.5477 525.41 .................. 105.08 

45345 ....... Sigmoidoscopy w/stent ...................................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

45355 ....... Surgical colonoscopy ......................................... ......... T 0143 8.7686 538.99 186.06 107.80 

45378 ....... Diagnostic colonoscopy ..................................... ......... T 0143 8.7686 538.99 186.06 107.80 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68323 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

45379 ....... Colonoscopy w/fb removal ................................ ......... T 0143 8.7686 538.99 186.06 107.80 

45380 ....... Colonoscopy and biopsy ................................... ......... T 0143 8.7686 538.99 186.06 107.80 

45381 ....... Colonoscopy, submucous inj ............................. ......... T 0143 8.7686 538.99 186.06 107.80 

45382 ....... Colonoscopy/control bleeding ............................ ......... T 0143 8.7686 538.99 186.06 107.80 

45383 ....... Lesion removal colonoscopy ............................. ......... T 0143 8.7686 538.99 186.06 107.80 

45384 ....... Lesion remove colonoscopy .............................. ......... T 0143 8.7686 538.99 186.06 107.80 

45385 ....... Lesion removal colonoscopy ............................. ......... T 0143 8.7686 538.99 186.06 107.80 

45386 ....... Colonoscopy dilate stricture .............................. ......... T 0143 8.7686 538.99 186.06 107.80 

45387 ....... Colonoscopy w/stent .......................................... ......... T 0384 22.9475 1,410.54 295.41 282.11 

45391 ....... Colonoscopy w/endoscope us ........................... ......... T 0143 8.7686 538.99 186.06 107.80 

45392 ....... Colonoscopy w/endoscopic fnb ......................... ......... T 0143 8.7686 538.99 186.06 107.80 

45499 ....... Laparoscope proc, rectum ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

45500 ....... Repair of rectum ................................................ ......... T 0149 22.2682 1,368.78 293.06 273.76 

45505 ....... Repair of rectum ................................................ ......... T 0150 29.6189 1,820.61 437.12 364.12 

45520 ....... Treatment of rectal prolapse ............................. ......... T 0098 1.0798 66.37 .................. 13.27 

45541 ....... Correct rectal prolapse ...................................... ......... T 0150 29.6189 1,820.61 437.12 364.12 

45560 ....... Repair of rectocele ............................................ ......... T 0150 29.6189 1,820.61 437.12 364.12 

45900 ....... Reduction of rectal prolapse .............................. ......... T 0148 5.077 312.07 .................. 62.41 

45905 ....... Dilation of anal sphincter ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

45910 ....... Dilation of rectal narrowing ................................ ......... T 0149 22.2682 1,368.78 293.06 273.76 

45915 ....... Remove rectal obstruction ................................. ......... T 0148 5.077 312.07 .................. 62.41 

45990 ....... Surg dx exam, anorectal ................................... ......... T 0148 5.077 312.07 .................. 62.41 

45999 ....... Rectum surgery procedure ................................ ......... T 0148 5.077 312.07 .................. 62.41 

46020 ....... Placement of seton ............................................ CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46030 ....... Removal of rectal marker .................................. ......... T 0148 5.077 312.07 .................. 62.41 

46040 ....... Incision of rectal abscess .................................. ......... T 0149 22.2682 1,368.78 293.06 273.76 

46045 ....... Incision of rectal abscess .................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46050 ....... Incision of anal abscess .................................... ......... T 0148 5.077 312.07 .................. 62.41 

46060 ....... Incision of rectal abscess .................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46070 ....... Incision of anal septum ...................................... ......... T 0155 12.7389 783.03 .................. 156.61 

46080 ....... Incision of anal sphincter ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46083 ....... Incise external hemorrhoid ................................ CH .. T 0164 2.1393 131.50 .................. 26.30 

46200 ....... Removal of anal fissure ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46210 ....... Removal of anal crypt ........................................ ......... T 0149 22.2682 1,368.78 293.06 273.76 

46211 ....... Removal of anal crypts ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46220 ....... Removal of anal tag .......................................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46221 ....... Ligation of hemorrhoid(s) ................................... ......... T 0148 5.077 312.07 .................. 62.41 

46230 ....... Removal of anal tags ......................................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46250 ....... Hemorrhoidectomy ............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46255 ....... Hemorrhoidectomy ............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46257 ....... Remove hemorrhoids & fissure ......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46258 ....... Remove hemorrhoids & fistula .......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46260 ....... Hemorrhoidectomy ............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46261 ....... Remove hemorrhoids & fissure ......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46262 ....... Remove hemorrhoids & fistula .......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46270 ....... Removal of anal fistula ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46275 ....... Removal of anal fistula ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46280 ....... Removal of anal fistula ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46285 ....... Removal of anal fistula ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46288 ....... Repair anal fistula .............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46320 ....... Removal of hemorrhoid clot .............................. CH .. T 0155 12.7389 783.03 .................. 156.61 

46500 ....... Injection into hemorrhoid(s) ............................... ......... T 0155 12.7389 783.03 .................. 156.61 

46505 ....... Chemodenervation anal musc ........................... ......... T 0148 5.077 312.07 .................. 62.41 

46600 ....... Diagnostic anoscopy .......................................... ......... X 0340 0.6102 37.51 .................. 7.50 

46604 ....... Anoscopy and dilation ....................................... ......... T 0147 8.5477 525.41 .................. 105.08 

46606 ....... Anoscopy and biopsy ........................................ ......... T 0146 4.8683 299.24 64.40 59.85 

46608 ....... Anoscopy, remove for body ............................... ......... T 0147 8.5477 525.41 .................. 105.08 

46610 ....... Anoscopy, remove lesion .................................. ......... T 0428 20.6375 1,268.55 .................. 253.71 

46611 ....... Anoscopy ........................................................... ......... T 0147 8.5477 525.41 .................. 105.08 

46612 ....... Anoscopy, remove lesions ................................. ......... T 0428 20.6375 1,268.55 .................. 253.71 

46614 ....... Anoscopy, control bleeding ............................... ......... T 0146 4.8683 299.24 64.40 59.85 

46615 ....... Anoscopy ........................................................... ......... T 0428 20.6375 1,268.55 .................. 253.71 

46700 ....... Repair of anal stricture ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46706 ....... Repr of anal fistula w/glue ................................. ......... T 0150 29.6189 1,820.61 437.12 364.12 

46750 ....... Repair of anal sphincter .................................... CH .. T 0171 37.8991 2,329.58 716.76 465.92 

46753 ....... Reconstruction of anus ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76 

46754 ....... Removal of suture from anus ............................ ......... T 0149 22.2682 1,368.78 293.06 273.76 

46760 ....... Repair of anal sphincter .................................... CH .. T 0171 37.8991 2,329.58 716.76 465.92 

46761 ....... Repair of anal sphincter .................................... CH .. T 0171 37.8991 2,329.58 716.76 465.92 

46762 ....... Implant artificial sphincter .................................. CH .. T 0171 37.8991 2,329.58 716.76 465.92 


cprice-sewell on PRODPC62 with RULES2
68324 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

46900 ....... Destruction, anal lesion(s) ................................. ......... T 0016 2.6749 164.42 .................. 32.88 

46910 ....... Destruction, anal lesion(s) ................................. ......... T 0017 17.4423 1,072.14 227.84 214.43 

46916 ....... Cryosurgery, anal lesion(s) ................................ ......... T 0013 1.0918 67.11 .................. 13.42 

46917 ....... Laser surgery, anal lesions ............................... ......... T 0695 20.4276 1,255.64 266.59 251.13 

46922 ....... Excision of anal lesion(s) ................................... ......... T 0695 20.4276 1,255.64 266.59 251.13 

46924 ....... Destruction, anal lesion(s) ................................. ......... T 0695 20.4276 1,255.64 266.59 251.13 

46934 ....... Destruction of hemorrhoids ............................... ......... T 0155 12.7389 783.03 .................. 156.61 

46935 ....... Destruction of hemorrhoids ............................... ......... T 0155 12.7389 783.03 .................. 156.61 

46936 ....... Destruction of hemorrhoids ............................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46937 ....... Cryotherapy of rectal lesion ............................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46938 ....... Cryotherapy of rectal lesion ............................... ......... T 0150 29.6189 1,820.61 437.12 364.12 

46940 ....... Treatment of anal fissure ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76 

46942 ....... Treatment of anal fissure ................................... ......... T 0148 5.077 312.07 .................. 62.41 

46945 ....... Ligation of hemorrhoids ..................................... ......... T 0155 12.7389 783.03 .................. 156.61

46946 ....... Ligation of hemorrhoids ..................................... ......... T 0155 12.7389 783.03 .................. 156.61

46947 ....... Hemorrhoidopexy by stapling ............................ ......... T 0150 29.6189 1,820.61 437.12 364.12 

46999 ....... Anus surgery procedure .................................... ......... T 0148 5.077 312.07 .................. 62.41 

47000 ....... Needle biopsy of liver ........................................ ......... T 0685 6.1384 377.32 115.47 75.46 

47001 ....... Needle biopsy, liver add-on ............................... ......... N .................. .................. .................. .................. ..................

47011 ....... Percut drain, liver lesion .................................... ......... T 0037 10.2655 631.00 228.76 126.20 

47370 ....... Laparo ablate liver tumor rf ............................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

47371 ....... Laparo ablate liver cryosurg .............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

47379 ....... Laparoscope procedure, liver ............................ ......... T 0130 32.1241 1,974.60 659.53 394.92 

47382 ....... Percut ablate liver rf .......................................... ......... T 0423 37.3604 2,296.47 .................. 459.29 

47399 ....... Liver surgery procedure ..................................... CH .. T 0004 2.0687 127.16 .................. 25.43 

47490 ....... Incision of gallbladder ........................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47500 ....... Injection for liver x-rays ..................................... ......... N .................. .................. .................. .................. ..................

47505 ....... Injection for liver x-rays ..................................... ......... N .................. .................. .................. .................. ..................

47510 ....... Insert catheter, bile duct .................................... ......... T 0152 20.2682 1,245.85 .................. 249.17 

47511 ....... Insert bile duct drain .......................................... ......... T 0152 20.2682 1,245.85 .................. 249.17 

47525 ....... Change bile duct catheter ................................. ......... T 0427 11.6575 716.56 .................. 143.31 

47530 ....... Revise/reinsert bile tube .................................... ......... T 0427 11.6575 716.56 .................. 143.31 

47552 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47553 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47554 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47555 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47556 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17 

47560 ....... Laparoscopy w/cholangio .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

47561 ....... Laparo w/cholangio/biopsy ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92 

47562 ....... Laparoscopic cholecystectomy .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

47563 ....... Laparo cholecystectomy/graph .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

47564 ....... Laparo cholecystectomy/explr ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

47579 ....... Laparoscope proc, biliary .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

47630 ....... Remove bile duct stone ..................................... ......... T 0152 20.2682 1,245.85 .................. 249.17 

47716 ....... Fusion of bile duct cyst ...................................... CH .. D .................. .................. .................. .................. ..................

47719 ....... Fusion of bile duct cyst ...................................... NI .... C .................. .................. .................. .................. ..................

47999 ....... Bile tract surgery procedure .............................. ......... T 0152 20.2682 1,245.85 .................. 249.17

48005 ....... Resect/debride pancreas ................................... CH .. D .................. .................. .................. .................. ..................

48102 ....... Needle biopsy, pancreas ................................... ......... T 0685 6.1384 377.32 115.47 75.46 

48105 ....... Resect/debride pancreas ................................... NI .... C .................. .................. .................. .................. ..................

48180 ....... Fuse pancreas and bowel ................................. CH .. D .................. .................. .................. .................. ..................

48511 ....... Drain pancreatic pseudocyst ............................. ......... T 0037 10.2655 631.00 228.76 126.20 

48548 ....... Fuse pancreas and bowel ................................. NI .... C .................. .................. .................. .................. ..................

48999 ....... Pancreas surgery procedure ............................. ......... T 0004 2.0687 127.16 .................. 25.43 

49021 ....... Drain abdominal abscess .................................. ......... T 0037 10.2655 631.00 228.76 126.20 

49041 ....... Drain, percut, abdom abscess ........................... ......... T 0037 10.2655 631.00 228.76 126.20 

49061 ....... Drain, percut, retroper absc ............................... ......... T 0037 10.2655 631.00 228.76 126.20 

49080 ....... Puncture, peritoneal cavity ................................ ......... T 0070 3.6244 222.78 .................. 44.56 

49081 ....... Removal of abdominal fluid ............................... ......... T 0070 3.6244 222.78 .................. 44.56 

49085 ....... Remove abdomen foreign body ........................ CH .. D .................. .................. .................. .................. ..................

49180 ....... Biopsy, abdominal mass .................................... ......... T 0685 6.1384 377.32 115.47 75.46 

49200 ....... Removal of abdominal lesion ............................ ......... T 0130 32.1241 1,974.60 659.53 394.92 

49250 ....... Excision of umbilicus ......................................... ......... T 0153 22.0832 1,357.41 397.95 271.48 

49320 ....... Diag laparo separate proc ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

49321 ....... Laparoscopy, biopsy .......................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

49322 ....... Laparoscopy, aspiration ..................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

49323 ....... Laparo drain lymphocele ................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

49324 ....... Lap insertion perm ip cath ................................. NI .... T 0130 32.1241 1,974.60 659.53 394.92 

49325 ....... Lap revision perm ip cath .................................. NI .... T 0130 32.1241 1,974.60 659.53 394.92 

49326 ....... Lap w/omentopexy add-on ................................ NI .... T 0130 32.1241 1,974.60 659.53 394.92 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68325 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

49329 ....... Laparo proc, abdm/per/oment ........................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

49400 ....... Air injection into abdomen ................................. ......... N .................. .................. .................. .................. ..................

49402 ....... Remove foreign body, adbomen ....................... NI .... T 0153 22.0832 1,357.41 397.95 271.48 

49419 ....... Insrt abdom cath for chemotx ............................ ......... T 0115 29.2133 1,795.68 374.81 359.14 

49420 ....... Insert abdom drain, temp .................................. ......... T 0652 29.5416 1,815.86 .................. 363.17

49421 ....... Insert abdom drain, perm .................................. ......... T 0652 29.5416 1,815.86 .................. 363.17

49422 ....... Remove perm cannula/catheter ........................ ......... T 0105 25.6142 1,574.45 370.40 314.89 

49423 ....... Exchange drainage catheter .............................. ......... T 0427 11.6575 716.56 .................. 143.31 

49424 ....... Assess cyst, contrast inject ............................... ......... N .................. .................. .................. .................. ..................

49426 ....... Revise abdomen-venous shunt ......................... ......... T 0153 22.0832 1,357.41 397.95 271.48 

49427 ....... Injection, abdominal shunt ................................. ......... N .................. .................. .................. .................. ..................

49429 ....... Removal of shunt ............................................... ......... T 0105 25.6142 1,574.45 370.40 314.89 

49435 ....... Insert subq exten to ip cath ............................... NI .... T 0427 11.6575 716.56 .................. 143.31 

49436 ....... Embedded ip cath exit-site ................................ NI .... T 0427 11.6575 716.56 .................. 143.31 

49491 ....... Rpr hern preemie reduc .................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49492 ....... Rpr ing hern premie, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49495 ....... Rpr ing hernia baby, reduc ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49496 ....... Rpr ing hernia baby, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49500 ....... Rpr ing hernia, init, reduce ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49501 ....... Rpr ing hernia, init blocked ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49505 ....... Prp i/hern init reduc >5 yr .................................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49507 ....... Prp i/hern init block >5 yr .................................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49520 ....... Rerepair ing hernia, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49521 ....... Rerepair ing hernia, blocked ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49525 ....... Repair ing hernia, sliding ................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49540 ....... Repair lumbar hernia ......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49550 ....... Rpr rem hernia, init, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49553 ....... Rpr fem hernia, init blocked .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49555 ....... Rerepair fem hernia, reduce .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49557 ....... Rerepair fem hernia, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49560 ....... Rpr ventral hern init, reduc ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49561 ....... Rpr ventral hern init, block ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49565 ....... Rerepair ventrl hern, reduce .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49566 ....... Rerepair ventrl hern, block ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49568 ....... Hernia repair w/mesh ........................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

49570 ....... Rpr epigastric hern, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49572 ....... Rpr epigastric hern, blocked .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49580 ....... Rpr umbil hern, reduc < 5 yr ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49582 ....... Rpr umbil hern, block < 5 yr .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49585 ....... Rpr umbil hern, reduc > 5 yr ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49587 ....... Rpr umbil hern, block > 5 yr .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

49590 ....... Repair spigelian hernia ...................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49600 ....... Repair umbilical lesion ....................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

49650 ....... Laparo hernia repair initial ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

49651 ....... Laparo hernia repair recur ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

49659 ....... Laparo proc, hernia repair ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

49999 ....... Abdomen surgery procedure ............................. ......... T 0153 22.0832 1,357.41 397.95 271.48 

50020 ....... Renal abscess, open drain ................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

50021 ....... Renal abscess, percut drain .............................. ......... T 0037 10.2655 631.00 228.76 126.20 

50080 ....... Removal of kidney stone ................................... ......... T 0429 43.1004 2,649.30 .................. 529.86

50081 ....... Removal of kidney stone ................................... ......... T 0429 43.1004 2,649.30 .................. 529.86

50200 ....... Biopsy of kidney ................................................ ......... T 0685 6.1384 377.32 115.47 75.46 

50382 ....... Change ureter stent, percut ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50384 ....... Remove ureter stent, percut .............................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

50387 ....... Change ext/int ureter stent ................................ ......... T 0122 7.48 459.78 .................. 91.96 

50389 ....... Remove renal tube w/fluoro .............................. ......... T 0156 3.4079 209.48 .................. 41.90 

50390 ....... Drainage of kidney lesion .................................. ......... T 0685 6.1384 377.32 115.47 75.46 

50391 ....... Instll rx agnt into rnal tub ................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

50392 ....... Insert kidney drain ............................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

50393 ....... Insert ureteral tube ............................................ ......... T 0161 19.2251 1,181.73 249.36 236.35 

50394 ....... Injection for kidney x-ray ................................... ......... N .................. .................. .................. .................. ..................

50395 ....... Create passage to kidney .................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

50396 ....... Measure kidney pressure .................................. ......... T 0164 2.1393 131.50 .................. 26.30 

50398 ....... Change kidney tube ........................................... ......... T 0122 7.48 459.78 .................. 91.96 

50541 ....... Laparo ablate renal cyst .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

50542 ....... Laparo ablate renal mass .................................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

50543 ....... Laparo partial nephrectomy ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

50544 ....... Laparoscopy, pyeloplasty .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

50549 ....... Laparoscope proc, renal .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

50551 ....... Kidney endoscopy ............................................. ......... T 0160 6.4951 399.24 101.58 79.85 


cprice-sewell on PRODPC62 with RULES2
68326 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

50553 ....... Kidney endoscopy ............................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

50555 ....... Kidney endoscopy & biopsy .............................. ......... T 0160 6.4951 399.24 101.58 79.85 

50557 ....... Kidney endoscopy & treatment ......................... ......... T 0162 23.87 1,467.24 .................. 293.45 

50561 ....... Kidney endoscopy & treatment ......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50562 ....... Renal scope w/tumor resect .............................. ......... T 0160 6.4951 399.24 101.58 79.85 

50570 ....... Kidney endoscopy ............................................. ......... T 0160 6.4951 399.24 101.58 79.85 

50572 ....... Kidney endoscopy ............................................. ......... T 0160 6.4951 399.24 101.58 79.85 

50574 ....... Kidney endoscopy & biopsy .............................. ......... T 0160 6.4951 399.24 101.58 79.85 

50575 ....... Kidney endoscopy ............................................. ......... T 0163 34.9261 2,146.84 .................. 429.37 

50576 ....... Kidney endoscopy & treatment ......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50590 ....... Fragmenting of kidney stone ............................. ......... T 0169 43.5398 2,676.30 1,009.47 535.26 

50592 ....... Perc rf ablate renal tumor .................................. ......... T 0423 37.3604 2,296.47 .................. 459.29 

50684 ....... Injection for ureter x-ray .................................... ......... N .................. .................. .................. .................. ..................

50686 ....... Measure ureter pressure ................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

50688 ....... Change of ureter tube/stent ............................... ......... T 0122 7.48 459.78 .................. 91.96 

50690 ....... Injection for ureter x-ray .................................... ......... N .................. .................. .................. .................. ..................

50945 ....... Laparoscopy ureterolithotomy ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

50947 ....... Laparo new ureter/bladder ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

50948 ....... Laparo new ureter/bladder ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

50949 ....... Laparoscope proc, ureter .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

50951 ....... Endoscopy of ureter .......................................... ......... T 0160 6.4951 399.24 101.58 79.85 

50953 ....... Endoscopy of ureter .......................................... ......... T 0160 6.4951 399.24 101.58 79.85 

50955 ....... Ureter endoscopy & biopsy ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50957 ....... Ureter endoscopy & treatment .......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50961 ....... Ureter endoscopy & treatment .......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50970 ....... Ureter endoscopy .............................................. ......... T 0160 6.4951 399.24 101.58 79.85 

50972 ....... Ureter endoscopy & catheter ............................. ......... T 0160 6.4951 399.24 101.58 79.85 

50974 ....... Ureter endoscopy & biopsy ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50976 ....... Ureter endoscopy & treatment .......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

50980 ....... Ureter endoscopy & treatment .......................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

51000 ....... Drainage of bladder ........................................... ......... T 0164 2.1393 131.50 .................. 26.30

51005 ....... Drainage of bladder ........................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

51010 ....... Drainage of bladder ........................................... ......... T 0165 18.1679 1,116.74 .................. 223.35 

51020 ....... Incise & treat bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

51030 ....... Incise & treat bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

51040 ....... Incise & drain bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

51045 ....... Incise bladder/drain ureter ................................. ......... T 0160 6.4951 399.24 101.58 79.85 

51050 ....... Removal of bladder stone ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

51065 ....... Remove ureter calculus ..................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

51080 ....... Drainage of bladder abscess ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

51500 ....... Removal of bladder cyst .................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

51520 ....... Removal of bladder lesion ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

51600 ....... Injection for bladder x-ray .................................. ......... N .................. .................. .................. .................. ..................

51605 ....... Preparation for bladder xray .............................. ......... N .................. .................. .................. .................. ..................

51610 ....... Injection for bladder x-ray .................................. ......... N .................. .................. .................. .................. ..................

51700 ....... Irrigation of bladder ............................................ ......... T 0164 2.1393 131.50 .................. 26.30 

51701 ....... Insert bladder catheter ....................................... ......... X 0340 0.6102 37.51 .................. 7.50 

51702 ....... Insert temp bladder cath .................................... ......... X 0340 0.6102 37.51 .................. 7.50 

51703 ....... Insert bladder cath, complex ............................. CH .. T 0126 1.0887 66.92 16.45 13.38 

51705 ....... Change of bladder tube ..................................... ......... T 0121 2.3587 144.98 43.80 29.00 

51710 ....... Change of bladder tube ..................................... ......... T 0122 7.48 459.78 .................. 91.96 

51715 ....... Endoscopic injection/implant ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

51720 ....... Treatment of bladder lesion ............................... CH .. T 0164 2.1393 131.50 .................. 26.30 

51725 ....... Simple cystometrogram ..................................... CH .. T 0164 2.1393 131.50 .................. 26.30 

51726 ....... Complex cystometrogram .................................. ......... T 0156 3.4079 209.48 .................. 41.90 

51736 ....... Urine flow measurement .................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

51741 ....... Electro-uroflowmetry, first .................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

51772 ....... Urethra pressure profile ..................................... CH .. T 0164 2.1393 131.50 .................. 26.30 

51784 ....... Anal/urinary muscle study ................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

51785 ....... Anal/urinary muscle study ................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

51792 ....... Urinary reflex study ............................................ CH .. T 0126 1.0887 66.92 16.45 13.38 

51795 ....... Urine voiding pressure study ............................. ......... T 0164 2.1393 131.50 .................. 26.30 

51797 ....... Intraabdominal pressure test ............................. ......... T 0164 2.1393 131.50 .................. 26.30 

51798 ....... Us urine capacity measure ................................ ......... X 0340 0.6102 37.51 .................. 7.50 

51880 ....... Repair of bladder opening ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

51990 ....... Laparo urethral suspension ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

51992 ....... Laparo sling operation ....................................... CH .. T 0131 43.5488 2,676.86 1,001.89 535.37 

51999 ....... Laparoscope proc, bladder ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92 

52000 ....... Cystoscopy ........................................................ ......... T 0160 6.4951 399.24 101.58 79.85 

52001 ....... Cystoscopy, removal of clots ............................. ......... T 0160 6.4951 399.24 101.58 79.85 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68327 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

52005 ....... Cystoscopy & ureter catheter ............................ ......... T 0161 19.2251 1,181.73 249.36 236.35 

52007 ....... Cystoscopy and biopsy ...................................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

52010 ....... Cystoscopy & duct catheter ............................... ......... T 0160 6.4951 399.24 101.58 79.85 

52204 ....... Cystoscopy w/biopsy(s) ..................................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

52214 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52224 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52234 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52235 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52240 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52250 ....... Cystoscopy and radiotracer ............................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52260 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52265 ....... Cystoscopy and treatment ................................. ......... T 0160 6.4951 399.24 101.58 79.85 

52270 ....... Cystoscopy & revise urethra ............................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52275 ....... Cystoscopy & revise urethra ............................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52276 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52277 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52281 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52282 ....... Cystoscopy, implant stent .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37 

52283 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52285 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52290 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52300 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52301 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52305 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52310 ....... Cystoscopy and treatment ................................. ......... T 0160 6.4951 399.24 101.58 79.85 

52315 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35 

52317 ....... Remove bladder stone ...................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52318 ....... Remove bladder stone ...................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52320 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52325 ....... Cystoscopy, stone removal ............................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52327 ....... Cystoscopy, inject material ................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

52330 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52332 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52334 ....... Create passage to kidney .................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52341 ....... Cysto w/ureter stricture tx .................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52342 ....... Cysto w/up stricture tx ....................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52343 ....... Cysto w/renal stricture tx ................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52344 ....... Cysto/uretero, stricture tx .................................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52345 ....... Cysto/uretero w/up stricture ............................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52346 ....... Cystouretero w/renal strict ................................. ......... T 0162 23.87 1,467.24 .................. 293.45

52351 ....... Cystouretero & or pyeloscope ........................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

52352 ....... Cystouretero w/stone remove ............................ ......... T 0162 23.87 1,467.24 .................. 293.45 

52353 ....... Cystouretero w/lithotripsy .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37 

52354 ....... Cystouretero w/biopsy ....................................... ......... T 0162 23.87 1,467.24 .................. 293.45

52355 ....... Cystouretero w/excise tumor ............................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52400 ....... Cystouretero w/congen repr .............................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52402 ....... Cystourethro cut ejacul duct .............................. ......... T 0162 23.87 1,467.24 .................. 293.45 

52450 ....... Incision of prostate ............................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

52500 ....... Revision of bladder neck ................................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52510 ....... Dilation prostatic urethra .................................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

52601 ....... Prostatectomy (TURP) ....................................... ......... T 0163 34.9261 2,146.84 .................. 429.37 

52606 ....... Control postop bleeding ..................................... ......... T 0162 23.87 1,467.24 .................. 293.45

52612 ....... Prostatectomy, first stage .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37 

52614 ....... Prostatectomy, second stage ............................ ......... T 0163 34.9261 2,146.84 .................. 429.37 

52620 ....... Remove residual prostate .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37

52630 ....... Remove prostate regrowth ................................ ......... T 0163 34.9261 2,146.84 .................. 429.37 

52640 ....... Relieve bladder contracture ............................... ......... T 0162 23.87 1,467.24 .................. 293.45 

52647 ....... Laser surgery of prostate .................................. ......... T 0429 43.1004 2,649.30 .................. 529.86 

52648 ....... Laser surgery of prostate .................................. ......... T 0429 43.1004 2,649.30 .................. 529.86 

52700 ....... Drainage of prostate abscess ............................ ......... T 0162 23.87 1,467.24 .................. 293.45 

53000 ....... Incision of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53010 ....... Incision of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53020 ....... Incision of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53025 ....... Incision of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53040 ....... Drainage of urethra abscess ............................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53060 ....... Drainage of urethra abscess ............................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53080 ....... Drainage of urinary leakage .............................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53085 ....... Drainage of urinary leakage .............................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53200 ....... Biopsy of urethra ............................................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53210 ....... Removal of urethra ............................................ ......... T 0168 29.0253 1,784.13 388.16 356.83 


cprice-sewell on PRODPC62 with RULES2
68328 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

53215 ....... Removal of urethra ............................................ ......... T 0166 18.396 1,130.77 .................. 226.15 

53220 ....... Treatment of urethra lesion ............................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53230 ....... Removal of urethra lesion ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53235 ....... Removal of urethra lesion ................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53240 ....... Surgery for urethra pouch ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53250 ....... Removal of urethra gland .................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53260 ....... Treatment of urethra lesion ............................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53265 ....... Treatment of urethra lesion ............................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53270 ....... Removal of urethra gland .................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53275 ....... Repair of urethra defect ..................................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53400 ....... Revise urethra, stage 1 ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53405 ....... Revise urethra, stage 2 ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53410 ....... Reconstruction of urethra .................................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53420 ....... Reconstruct urethra, stage 1 ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53425 ....... Reconstruct urethra, stage 2 ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53430 ....... Reconstruction of urethra .................................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53431 ....... Reconstruct urethra/bladder .............................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53440 ....... Male sling procedure ......................................... ......... S 0385 79.2092 4,868.83 .................. 973.77 

53442 ....... Remove/revise male sling ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53444 ....... Insert tandem cuff .............................................. ......... S 0385 79.2092 4,868.83 .................. 973.77 

53445 ....... Insert uro/ves nck sphincter .............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01 

53446 ....... Remove uro sphincter ....................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53447 ....... Remove/replace ur sphincter ............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01 

53449 ....... Repair uro sphincter .......................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53450 ....... Revision of urethra ............................................ ......... T 0168 29.0253 1,784.13 388.16 356.83 

53460 ....... Revision of urethra ............................................ ......... T 0166 18.396 1,130.77 .................. 226.15 

53500 ....... Urethrlys, transvag w/ scope ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83 

53502 ....... Repair of urethra injury ...................................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53505 ....... Repair of urethra injury ...................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53510 ....... Repair of urethra injury ...................................... ......... T 0166 18.396 1,130.77 .................. 226.15 

53515 ....... Repair of urethra injury ...................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53520 ....... Repair of urethra defect ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83 

53600 ....... Dilate urethra stricture ....................................... ......... T 0156 3.4079 209.48 .................. 41.90 

53601 ....... Dilate urethra stricture ....................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

53605 ....... Dilate urethra stricture ....................................... ......... T 0161 19.2251 1,181.73 249.36 236.35 

53620 ....... Dilate urethra stricture ....................................... ......... T 0165 18.1679 1,116.74 .................. 223.35 

53621 ....... Dilate urethra stricture ....................................... ......... T 0164 2.1393 131.50 .................. 26.30 

53660 ....... Dilation of urethra .............................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

53661 ....... Dilation of urethra .............................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

53665 ....... Dilation of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

53850 ....... Prostatic microwave thermotx ........................... ......... T 0675 41.1375 2,528.64 .................. 505.73 

53852 ....... Prostatic rf thermotx .......................................... ......... T 0675 41.1375 2,528.64 .................. 505.73 

53853 ....... Prostatic water thermother ................................ ......... T 0162 23.87 1,467.24 .................. 293.45 

53899 ....... Urology surgery procedure ................................ CH .. T 0126 1.0887 66.92 16.45 13.38 

54000 ....... Slitting of prepuce .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

54001 ....... Slitting of prepuce .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15 

54015 ....... Drain penis lesion .............................................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

54050 ....... Destruction, penis lesion(s) ............................... ......... T 0013 1.0918 67.11 .................. 13.42 

54055 ....... Destruction, penis lesion(s) ............................... ......... T 0017 17.4423 1,072.14 227.84 214.43 

54056 ....... Cryosurgery, penis lesion(s) .............................. ......... T 0012 0.8432 51.83 11.18 10.37 

54057 ....... Laser surg, penis lesion(s) ................................ ......... T 0017 17.4423 1,072.14 227.84 214.43 

54060 ....... Excision of penis lesion(s) ................................. ......... T 0017 17.4423 1,072.14 227.84 214.43 

54065 ....... Destruction, penis lesion(s) ............................... ......... T 0695 20.4276 1,255.64 266.59 251.13 

54100 ....... Biopsy of penis .................................................. ......... T 0021 15.1024 928.31 219.48 185.66 

54105 ....... Biopsy of penis .................................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

54110 ....... Treatment of penis lesion .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54111 ....... Treat penis lesion, graft ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54112 ....... Treat penis lesion, graft ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54115 ....... Treatment of penis lesion .................................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

54120 ....... Partial removal of penis ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54150 ....... Circumcision w/regionl block ............................. ......... T 0180 20.5513 1,263.25 304.87 252.65 

54152 ....... Circumcision ...................................................... ......... T 0180 20.5513 1,263.25 304.87 252.65 

54160 ....... Circumcision, neonate ....................................... ......... T 0180 20.5513 1,263.25 304.87 252.65 

54161 ....... Circum 28 days or older .................................... ......... T 0180 20.5513 1,263.25 304.87 252.65 

54162 ....... Lysis penil circumic lesion ................................. ......... T 0180 20.5513 1,263.25 304.87 252.65 

54163 ....... Repair of circumcision ....................................... ......... T 0180 20.5513 1,263.25 304.87 252.65 

54164 ....... Frenulotomy of penis ......................................... ......... T 0180 20.5513 1,263.25 304.87 252.65 

54200 ....... Treatment of penis lesion .................................. CH .. T 0164 2.1393 131.50 .................. 26.30 

54205 ....... Treatment of penis lesion .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54220 ....... Treatment of penis lesion .................................. CH .. T 0164 2.1393 131.50 .................. 26.30 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68329 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

54230 ....... Prepare penis study ........................................... ......... N .................. .................. .................. .................. ..................

54231 ....... Dynamic cavernosometry .................................. ......... T 0165 18.1679 1,116.74 .................. 223.35 

54235 ....... Penile injection ................................................... ......... T 0164 2.1393 131.50 .................. 26.30 

54240 ....... Penis study ........................................................ CH .. T 0126 1.0887 66.92 16.45 13.38 

54250 ....... Penis study ........................................................ ......... T 0164 2.1393 131.50 .................. 26.30 

54300 ....... Revision of penis ............................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54304 ....... Revision of penis ............................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54308 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54312 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54316 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54318 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54322 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54324 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54326 ....... Reconstruction of urethra .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54328 ....... Revise penis/urethra .......................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54340 ....... Secondary urethral surgery ............................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54344 ....... Secondary urethral surgery ............................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54348 ....... Secondary urethral surgery ............................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54352 ....... Reconstruct urethra/penis .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54360 ....... Penis plastic surgery ......................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54380 ....... Repair penis ....................................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54385 ....... Repair penis ....................................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54400 ....... Insert semi-rigid prosthesis ................................ ......... S 0385 79.2092 4,868.83 .................. 973.77 

54401 ....... Insert self-contd prosthesis ................................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01 

54405 ....... Insert multi-comp penis pros ............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01 

54406 ....... Remove muti-comp penis pros .......................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54408 ....... Repair multi-comp penis pros ............................ ......... T 0181 32.9873 2,027.66 621.82 405.53 

54410 ....... Remove/replace penis prosth ............................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01

54415 ....... Remove self-contd penis pros ........................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54416 ....... Remv/repl penis contain pros ............................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01 

54420 ....... Revision of penis ............................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54435 ....... Revision of penis ............................................... ......... T 0181 32.9873 2,027.66 621.82 405.53 

54440 ....... Repair of penis .................................................. ......... T 0181 32.9873 2,027.66 621.82 405.53 

54450 ....... Preputial stretching ............................................ ......... T 0156 3.4079 209.48 .................. 41.90 

54500 ....... Biopsy of testis .................................................. ......... T 0037 10.2655 631.00 228.76 126.20 

54505 ....... Biopsy of testis .................................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

54512 ....... Excise lesion testis ............................................ ......... T 0183 23.531 1,446.40 .................. 289.28 

54520 ....... Removal of testis ............................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54522 ....... Orchiectomy, partial ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54530 ....... Removal of testis ............................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

54550 ....... Exploration for testis .......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

54560 ....... Exploration for testis .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54600 ....... Reduce testis torsion ......................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54620 ....... Suspension of testis .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54640 ....... Suspension of testis .......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

54660 ....... Revision of testis ............................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54670 ....... Repair testis injury ............................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

54680 ....... Relocation of testis(es) ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54690 ....... Laparoscopy, orchiectomy ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

54692 ....... Laparoscopy, orchiopexy ................................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

54699 ....... Laparoscope proc, testis ................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

54700 ....... Drainage of scrotum .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

54800 ....... Biopsy of epididymis .......................................... ......... T 0004 2.0687 127.16 .................. 25.43

54820 ....... Exploration of epididymis ................................... CH .. D .................. .................. .................. .................. ..................

54830 ....... Remove epididymis lesion ................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

54840 ....... Remove epididymis lesion ................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

54860 ....... Removal of epididymis ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28

54861 ....... Removal of epididymis ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28

54865 ....... Explore epididymis ............................................. NI .... T 0183 23.531 1,446.40 .................. 289.28 

54900 ....... Fusion of spermatic ducts ................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

54901 ....... Fusion of spermatic ducts ................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

55000 ....... Drainage of hydrocele ....................................... ......... T 0004 2.0687 127.16 .................. 25.43 

55040 ....... Removal of hydrocele ........................................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

55041 ....... Removal of hydroceles ...................................... ......... T 0154 29.2182 1,795.98 464.85 359.20 

55060 ....... Repair of hydrocele ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55100 ....... Drainage of scrotum abscess ............................ CH .. T 0007 11.1535 685.58 .................. 137.12 

55110 ....... Explore scrotum ................................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

55120 ....... Removal of scrotum lesion ................................ ......... T 0183 23.531 1,446.40 .................. 289.28 

55150 ....... Removal of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55175 ....... Revision of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28 


cprice-sewell on PRODPC62 with RULES2
68330 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

55180 ....... Revision of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55200 ....... Incision of sperm duct ....................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55250 ....... Removal of sperm duct(s) ................................. ......... T 0183 23.531 1,446.40 .................. 289.28 

55300 ....... Prepare, sperm duct x-ray ................................. ......... N .................. .................. .................. .................. ..................

55400 ....... Repair of sperm duct ......................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55450 ....... Ligation of sperm duct ....................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55500 ....... Removal of hydrocele ........................................ ......... T 0183 23.531 1,446.40 .................. 289.28 

55520 ....... Removal of sperm cord lesion ........................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55530 ....... Revise spermatic cord veins ............................. ......... T 0183 23.531 1,446.40 .................. 289.28 

55535 ....... Revise spermatic cord veins ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20 

55540 ....... Revise hernia & sperm veins ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20 

55550 ....... Laparo ligate spermatic vein ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

55559 ....... Laparo proc, spermatic cord .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

55600 ....... Incise sperm duct pouch ................................... ......... T 0183 23.531 1,446.40 .................. 289.28 

55680 ....... Remove sperm pouch lesion ............................. ......... T 0183 23.531 1,446.40 .................. 289.28 

55700 ....... Biopsy of prostate .............................................. ......... T 0184 5.6262 345.83 96.27 69.17 

55705 ....... Biopsy of prostate .............................................. ......... T 0184 5.6262 345.83 96.27 69.17 

55720 ....... Drainage of prostate abscess ............................ ......... T 0162 23.87 1,467.24 .................. 293.45 

55725 ....... Drainage of prostate abscess ............................ ......... T 0162 23.87 1,467.24 .................. 293.45 

55859 ....... Percut/needle insert, pros .................................. CH .. D .................. .................. .................. .................. ..................

55860 ....... Surgical exposure, prostate ............................... ......... T 0165 18.1679 1,116.74 .................. 223.35

55870 ....... Electroejaculation ............................................... ......... T 0197 4.0007 245.92 .................. 49.18 

55873 ....... Cryoablate prostate ........................................... ......... T 0674 108.7566 6,685.05 .................. 1,337.01 

55875 ....... Transperi needle place, pros ............................. NI .... T 0163 34.9261 2,146.84 .................. 429.37 

55876 ....... Place rt device/marker, pros .............................. NI .... T 0156 3.4079 209.48 .................. 41.90 

55899 ....... Genital surgery procedure ................................. CH .. T 0126 1.0887 66.92 16.45 13.38 

56405 ....... I & D of vulva/perineum ..................................... ......... T 0189 2.8966 178.05 .................. 35.61 

56420 ....... Drainage of gland abscess ................................ CH .. T 0188 1.29 79.29 .................. 15.86 

56440 ....... Surgery for vulva lesion ..................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

56441 ....... Lysis of labial lesion(s) ...................................... ......... T 0193 14.8489 912.73 .................. 182.55 

56442 ....... Hymenotomy ...................................................... NI .... T 0193 14.8489 912.73 .................. 182.55 

56501 ....... Destroy, vulva lesions, sim ................................ ......... T 0017 17.4423 1,072.14 227.84 214.43 

56515 ....... Destroy vulva lesion/s compl ............................. ......... T 0695 20.4276 1,255.64 266.59 251.13 

56605 ....... Biopsy of vulva/perineum .................................. ......... T 0019 4.0919 251.52 71.87 50.30 

56606 ....... Biopsy of vulva/perineum .................................. ......... T 0019 4.0919 251.52 71.87 50.30 

56620 ....... Partial removal of vulva ..................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

56625 ....... Complete removal of vulva ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

56700 ....... Partial removal of hymen ................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

56720 ....... Incision of hymen ............................................... CH .. D .................. .................. .................. .................. ..................

56740 ....... Remove vagina gland lesion ............................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

56800 ....... Repair of vagina ................................................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

56805 ....... Repair clitoris ..................................................... ......... T 0193 14.8489 912.73 .................. 182.55 

56810 ....... Repair of perineum ............................................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

56820 ....... Exam of vulva w/scope ...................................... ......... T 0188 1.29 79.29 .................. 15.86 

56821 ....... Exam/biopsy of vulva w/scope .......................... ......... T 0189 2.8966 178.05 .................. 35.61 

57000 ....... Exploration of vagina ......................................... ......... T 0193 14.8489 912.73 .................. 182.55 

57010 ....... Drainage of pelvic abscess ............................... ......... T 0193 14.8489 912.73 .................. 182.55 

57020 ....... Drainage of pelvic fluid ...................................... ......... T 0192 6.6592 409.33 .................. 81.87

57022 ....... I & d vaginal hematoma, pp .............................. ......... T 0007 11.1535 685.58 .................. 137.12 

57023 ....... I & d vag hematoma, non-ob ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24 

57061 ....... Destroy vag lesions, simple ............................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57065 ....... Destroy vag lesions, complex ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

57100 ....... Biopsy of vagina ................................................ ......... T 0192 6.6592 409.33 .................. 81.87 

57105 ....... Biopsy of vagina ................................................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

57106 ....... Remove vagina wall, partial .............................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

57107 ....... Remove vagina tissue, part ............................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57109 ....... Vaginectomy partial w/nodes ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57120 ....... Closure of vagina ............................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57130 ....... Remove vagina lesion ....................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57135 ....... Remove vagina lesion ....................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57150 ....... Treat vagina infection ........................................ ......... T 0191 0.1468 9.02 2.55 1.80 

57155 ....... Insert uteri tandems/ovoids ............................... ......... T 0192 6.6592 409.33 .................. 81.87 

57160 ....... Insert pessary/other device ............................... ......... T 0188 1.29 79.29 .................. 15.86 

57170 ....... Fitting of diaphragm/cap .................................... ......... T 0191 0.1468 9.02 2.55 1.80 

57180 ....... Treat vaginal bleeding ....................................... ......... T 0189 2.8966 178.05 .................. 35.61 

57200 ....... Repair of vagina ................................................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

57210 ....... Repair vagina/perineum ..................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57220 ....... Revision of urethra ............................................ ......... T 0202 42.9896 2,642.48 981.50 528.50 

57230 ....... Repair of urethral lesion .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57240 ....... Repair bladder & vagina .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68331 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

57250 ....... Repair rectum & vagina ..................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57260 ....... Repair of vagina ................................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

57265 ....... Extensive repair of vagina ................................. ......... T 0202 42.9896 2,642.48 981.50 528.50 

57267 ....... Insert mesh/pelvic flr addon .............................. CH .. T 0195 28.5095 1,752.42 483.80 350.48 

57268 ....... Repair of bowel bulge ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

57282 ....... Colpopexy, extraperitoneal ................................ CH .. T 0202 42.9896 2,642.48 981.50 528.50 

57283 ....... Colpopexy, intraperitoneal ................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50 

57284 ....... Repair paravaginal defect .................................. ......... T 0202 42.9896 2,642.48 981.50 528.50 

57287 ....... Revise/remove sling repair ................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48 

57288 ....... Repair bladder defect ........................................ ......... T 0202 42.9896 2,642.48 981.50 528.50 

57289 ....... Repair bladder & vagina .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57291 ....... Construction of vagina ....................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57292 ....... Construct vagina with graft ................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48 

57295 ....... Change vaginal graft ......................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57296 ....... Revise vag graft, open abd ............................... NI .... C .................. .................. .................. .................. ..................

57300 ....... Repair rectum-vagina fistula .............................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57310 ....... Repair urethrovaginal lesion .............................. ......... T 0202 42.9896 2,642.48 981.50 528.50 

57320 ....... Repair bladder-vagina lesion ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57330 ....... Repair bladder-vagina lesion ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57335 ....... Repair vagina ..................................................... CH .. T 0195 28.5095 1,752.42 483.80 350.48 

57400 ....... Dilation of vagina ............................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57410 ....... Pelvic examination ............................................. ......... T 0193 14.8489 912.73 .................. 182.55 

57415 ....... Remove vaginal foreign body ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

57420 ....... Exam of vagina w/scope ................................... ......... T 0189 2.8966 178.05 .................. 35.61 

57421 ....... Exam/biopsy of vag w/scope ............................. ......... T 0189 2.8966 178.05 .................. 35.61 

57425 ....... Laparoscopy, surg, colpopexy ........................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

57452 ....... Exam of cervix w/scope ..................................... CH .. T 0188 1.29 79.29 .................. 15.86 

57454 ....... Bx/curett of cervix w/scope ................................ ......... T 0189 2.8966 178.05 .................. 35.61 

57455 ....... Biopsy of cervix w/scope ................................... ......... T 0189 2.8966 178.05 .................. 35.61 

57456 ....... Endocerv curettage w/scope ............................. ......... T 0189 2.8966 178.05 .................. 35.61 

57460 ....... Bx of cervix w/scope, leep ................................. ......... T 0193 14.8489 912.73 .................. 182.55 

57461 ....... Conz of cervix w/scope, leep ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12 

57500 ....... Biopsy of cervix ................................................. CH .. T 0189 2.8966 178.05 .................. 35.61 

57505 ....... Endocervical curettage ...................................... ......... T 0189 2.8966 178.05 .................. 35.61 

57510 ....... Cauterization of cervix ....................................... ......... T 0193 14.8489 912.73 .................. 182.55 

57511 ....... Cryocautery of cervix ......................................... CH .. T 0188 1.29 79.29 .................. 15.86 

57513 ....... Laser surgery of cervix ...................................... ......... T 0193 14.8489 912.73 .................. 182.55 

57520 ....... Conization of cervix ........................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

57522 ....... Conization of cervix ........................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

57530 ....... Removal of cervix .............................................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57550 ....... Removal of residual cervix ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

57555 ....... Remove cervix/repair vagina ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

57556 ....... Remove cervix, repair bowel ............................. ......... T 0202 42.9896 2,642.48 981.50 528.50 

57558 ....... D&c of cervical stump ........................................ NI .... T 0196 17.7499 1,091.05 338.23 218.21 

57700 ....... Revision of cervix .............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

57720 ....... Revision of cervix .............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

57800 ....... Dilation of cervical canal .................................... ......... T 0193 14.8489 912.73 .................. 182.55 

57820 ....... D & c of residual cervix ..................................... CH .. D .................. .................. .................. .................. ..................

58100 ....... Biopsy of uterus lining ....................................... ......... T 0188 1.29 79.29 .................. 15.86 

58110 ....... Bx done w/colposcopy add-on .......................... ......... T 0188 1.29 79.29 .................. 15.86 

58120 ....... Dilation and curettage ........................................ ......... T 0196 17.7499 1,091.05 338.23 218.21 

58145 ....... Myomectomy vag method ................................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

58260 ....... Vaginal hysterectomy ........................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48 

58262 ....... Vag hyst including t/o ........................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48 

58263 ....... Vag hyst w/t/o & vag repair ............................... CH .. T 0195 28.5095 1,752.42 483.80 350.48 

58270 ....... Vag hyst w/enterocele repair ............................. CH .. T 0195 28.5095 1,752.42 483.80 350.48 

58290 ....... Vag hyst complex .............................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50 

58291 ....... Vag hyst incl t/o, complex ................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50 

58292 ....... Vag hyst t/o & repair, compl .............................. CH .. T 0202 42.9896 2,642.48 981.50 528.50 

58294 ....... Vag hyst w/enterocele, compl ........................... CH .. T 0202 42.9896 2,642.48 981.50 528.50 

58301 ....... Remove intrauterine device ............................... CH .. T 0188 1.29 79.29 .................. 15.86 

58321 ....... Artificial insemination ......................................... ......... T 0197 4.0007 245.92 .................. 49.18 

58322 ....... Artificial insemination ......................................... ......... T 0197 4.0007 245.92 .................. 49.18 

58323 ....... Sperm washing .................................................. ......... T 0197 4.0007 245.92 .................. 49.18 

58340 ....... Catheter for hysterography ................................ ......... N .................. .................. .................. .................. ..................

58345 ....... Reopen fallopian tube ........................................ ......... T 0193 14.8489 912.73 .................. 182.55 

58346 ....... Insert heyman uteri capsule .............................. ......... T 0193 14.8489 912.73 .................. 182.55 

58350 ....... Reopen fallopian tube ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

58353 ....... Endometr ablate, thermal .................................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

58356 ....... Endometrial cryoablation ................................... ......... T 0202 42.9896 2,642.48 981.50 528.50 


cprice-sewell on PRODPC62 with RULES2
68332 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

58541 ....... Lsh, uterus 250 g or less ................................... NI .... T 0131 43.5488 2,676.86 1,001.89 535.37 

58542 ....... Lsh w/t/o ut 250 g or less .................................. NI .... T 0131 43.5488 2,676.86 1,001.89 535.37 

58543 ....... Lsh uterus above 250 g ..................................... NI .... T 0131 43.5488 2,676.86 1,001.89 535.37 

58544 ....... Lsh w/t/o uterus above 250 g ............................ NI .... T 0131 43.5488 2,676.86 1,001.89 535.37 

58545 ....... Laparoscopic myomectomy ............................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

58546 ....... Laparo-myomectomy, complex .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58548 ....... Lap radical hyst ................................................. NI .... C .................. .................. .................. .................. ..................

58550 ....... Laparo-asst vag hysterectomy .......................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78 

58552 ....... Laparo-vag hyst incl t/o ..................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58553 ....... Laparo-vag hyst, complex ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58554 ....... Laparo-vag hyst w/t/o, compl ............................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58555 ....... Hysteroscopy, dx, sep proc ............................... ......... T 0190 21.3586 1,312.87 424.28 262.57 

58558 ....... Hysteroscopy, biopsy ......................................... ......... T 0190 21.3586 1,312.87 424.28 262.57 

58559 ....... Hysteroscopy, lysis ............................................ ......... T 0190 21.3586 1,312.87 424.28 262.57 

58560 ....... Hysteroscopy, resect septum ............................ ......... T 0387 34.0155 2,090.86 655.55 418.17 

58561 ....... Hysteroscopy, remove myoma .......................... ......... T 0387 34.0155 2,090.86 655.55 418.17 

58562 ....... Hysteroscopy, remove fb ................................... ......... T 0190 21.3586 1,312.87 424.28 262.57 

58563 ....... Hysteroscopy, ablation ...................................... ......... T 0387 34.0155 2,090.86 655.55 418.17 

58565 ....... Hysteroscopy, sterilization ................................. ......... T 0202 42.9896 2,642.48 981.50 528.50 

58578 ....... Laparo proc, uterus ........................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

58579 ....... Hysteroscope procedure .................................... ......... T 0190 21.3586 1,312.87 424.28 262.57 

58600 ....... Division of fallopian tube ................................... ......... T 0195 28.5095 1,752.42 483.80 350.48 

58615 ....... Occlude fallopian tube(s) ................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

58660 ....... Laparoscopy, lysis ............................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58661 ....... Laparoscopy, remove adnexa ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58662 ....... Laparoscopy, excise lesions .............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58670 ....... Laparoscopy, tubal cautery ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58671 ....... Laparoscopy, tubal block ................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58672 ....... Laparoscopy, fimbrioplasty ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58673 ....... Laparoscopy, salpingostomy ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

58679 ....... Laparo proc, oviduct-ovary ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92 

58770 ....... Create new tubal opening ................................. ......... T 0195 28.5095 1,752.42 483.80 350.48 

58800 ....... Drainage of ovarian cyst(s) ............................... ......... T 0193 14.8489 912.73 .................. 182.55 

58820 ....... Drain ovary abscess, open ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

58823 ....... Drain pelvic abscess, percut ............................. ......... T 0193 14.8489 912.73 .................. 182.55 

58900 ....... Biopsy of ovary(s) .............................................. ......... T 0193 14.8489 912.73 .................. 182.55 

58920 ....... Partial removal of ovary(s) ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

58925 ....... Removal of ovarian cyst(s) ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

58957 ....... Resect recurrent gyn mal .................................. NI .... C .................. .................. .................. .................. ..................

58958 ....... Resect recur gyn mal w/lym .............................. NI .... C .................. .................. .................. .................. ..................

58970 ....... Retrieval of oocyte ............................................. ......... T 0197 4.0007 245.92 .................. 49.18 

58974 ....... Transfer of embryo ............................................ ......... T 0197 4.0007 245.92 .................. 49.18

58976 ....... Transfer of embryo ............................................ ......... T 0197 4.0007 245.92 .................. 49.18

58999 ....... Genital surgery procedure ................................. ......... T 0191 0.1468 9.02 2.55 1.80 

59000 ....... Amniocentesis, diagnostic ................................. ......... T 0198 1.4222 87.42 32.19 17.48 

59001 ....... Amniocentesis, therapeutic ................................ ......... T 0192 6.6592 409.33 .................. 81.87 

59012 ....... Fetal cord puncture,prenatal .............................. ......... T 0198 1.4222 87.42 32.19 17.48 

59015 ....... Chorion biopsy ................................................... ......... T 0198 1.4222 87.42 32.19 17.48 

59020 ....... Fetal contract stress test ................................... CH .. T 0189 2.8966 178.05 .................. 35.61 

59025 ....... Fetal non-stress test .......................................... ......... T 0198 1.4222 87.42 32.19 17.48 

59030 ....... Fetal scalp blood sample ................................... ......... T 0198 1.4222 87.42 32.19 17.48 

59070 ....... Transabdom amnioinfus w/us ............................ ......... T 0198 1.4222 87.42 32.19 17.48 

59072 ....... Umbilical cord occlud w/us ................................ ......... T 0198 1.4222 87.42 32.19 17.48 

59074 ....... Fetal fluid drainage w/us ................................... ......... T 0198 1.4222 87.42 32.19 17.48 

59076 ....... Fetal shunt placement, w/us .............................. ......... T 0198 1.4222 87.42 32.19 17.48 

59100 ....... Remove uterus lesion ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

59150 ....... Treat ectopic pregnancy .................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

59151 ....... Treat ectopic pregnancy .................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37 

59160 ....... D& c after delivery ............................................. ......... T 0196 17.7499 1,091.05 338.23 218.21 

59200 ....... Insert cervical dilator .......................................... ......... T 0189 2.8966 178.05 .................. 35.61 

59300 ....... Episiotomy or vaginal repair .............................. ......... T 0193 14.8489 912.73 .................. 182.55 

59320 ....... Revision of cervix .............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

59409 ....... Obstetrical care .................................................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

59412 ....... Antepartum manipulation ................................... ......... T 0700 2.3864 146.69 .................. 29.34 

59414 ....... Deliver placenta ................................................. ......... T 0193 14.8489 912.73 .................. 182.55 

59612 ....... Vbac delivery only ............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12 

59812 ....... Treatment of miscarriage ................................... ......... T 0201 18.5201 1,138.39 329.65 227.68 

59820 ....... Care of miscarriage ........................................... ......... T 0201 18.5201 1,138.39 329.65 227.68 

59821 ....... Treatment of miscarriage ................................... ......... T 0201 18.5201 1,138.39 329.65 227.68 

59840 ....... Abortion .............................................................. ......... T 0200 16.9328 1,040.83 243.36 208.17 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68333 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

59841 ....... Abortion .............................................................. ......... T 0200 16.9328 1,040.83 243.36 208.17 

59866 ....... Abortion (mpr) .................................................... ......... T 0198 1.4222 87.42 32.19 17.48 

59870 ....... Evacuate mole of uterus .................................... ......... T 0201 18.5201 1,138.39 329.65 227.68 

59871 ....... Remove cerclage suture .................................... ......... T 0194 20.5081 1,260.59 397.84 252.12 

59897 ....... Fetal invas px w/us ............................................ ......... T 0198 1.4222 87.42 32.19 17.48 

59898 ....... Laparo proc, ob care/deliver .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92 

59899 ....... Maternity care procedure ................................... ......... T 0198 1.4222 87.42 32.19 17.48 

60000 ....... Drain thyroid/tongue cyst ................................... ......... T 0252 7.5511 464.15 109.16 92.83 

60001 ....... Aspirate/inject thyriod cyst ................................. ......... T 0004 2.0687 127.16 .................. 25.43 

60100 ....... Biopsy of thyroid ................................................ ......... T 0004 2.0687 127.16 .................. 25.43 

60200 ....... Remove thyroid lesion ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60210 ....... Partial thyroid excision ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60212 ....... Partial thyroid excision ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60220 ....... Partial removal of thyroid ................................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60225 ....... Partial removal of thyroid ................................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60240 ....... Removal of thyroid ............................................. ......... T 0114 37.7224 2,318.72 467.95 463.74 

60252 ....... Removal of thyroid ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

60260 ....... Repeat thyroid surgery ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

60280 ....... Remove thyroid duct lesion ............................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60281 ....... Remove thyroid duct lesion ............................... ......... T 0114 37.7224 2,318.72 467.95 463.74 

60500 ....... Explore parathyroid glands ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60

60502 ....... Re-explore parathyroids .................................... CH .. T 0256 38.1991 2,348.02 .................. 469.60 

60512 ....... Autotransplant parathyroid ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68 

60520 ....... Removal of thymus gland .................................. CH .. T 0256 38.1991 2,348.02 .................. 469.60 

60659 ....... Laparo proc, endocrine ...................................... ......... T 0130 32.1241 1,974.60 659.53 394.92 

60699 ....... Endocrine surgery procedure ............................ ......... T 0114 37.7224 2,318.72 467.95 463.74 

61000 ....... Remove cranial cavity fluid ................................ ......... T 0212 2.9907 183.83 65.96 36.77 

61001 ....... Remove cranial cavity fluid ................................ ......... T 0212 2.9907 183.83 65.96 36.77 

61020 ....... Remove brain cavity fluid .................................. ......... T 0212 2.9907 183.83 65.96 36.77 

61026 ....... Injection into brain canal .................................... ......... T 0212 2.9907 183.83 65.96 36.77 

61050 ....... Remove brain canal fluid ................................... ......... T 0212 2.9907 183.83 65.96 36.77 

61055 ....... Injection into brain canal .................................... ......... T 0212 2.9907 183.83 65.96 36.77 

61070 ....... Brain canal shunt procedure ............................. ......... T 0212 2.9907 183.83 65.96 36.77 

61215 ....... Insert brain-fluid device ..................................... ......... T 0224 47.0342 2,891.10 .................. 578.22 

61330 ....... Decompress eye socket .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

61334 ....... Explore orbit/remove object ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60

61623 ....... Endovasc tempory vessel occl .......................... ......... T 0081 42.936 2,639.19 .................. 527.84 

61626 ....... Transcath occlusion, non-cns ............................ ......... T 0081 42.936 2,639.19 .................. 527.84 

61720 ....... Incise skull/brain surgery ................................... CH .. T 0221 33.152 2,037.79 463.62 407.56 

61790 ....... Treat trigeminal nerve ........................................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

61791 ....... Treat trigeminal tract .......................................... ......... T 0206 5.7253 351.92 75.55 70.38 

61795 ....... Brain surgery using computer ........................... ......... S 0302 4.9138 302.04 105.94 60.41 

61880 ....... Revise/remove neuroelectrode .......................... ......... T 0687 17.8334 1,096.18 438.47 219.24 

61885 ....... Insrt/redo neurostim 1 array .............................. ......... S 0039 187.3821 11,518.00 .................. 2,303.60 

61886 ....... Implant neurostim arrays ................................... ......... T 0315 242.9363 14,932.81 .................. 2,986.56 

61888 ....... Revise/remove neuroreceiver ............................ ......... T 0688 35.5702 2,186.43 874.57 437.29 

62000 ....... Treat skull fracture ............................................. CH .. T 0254 23.3299 1,434.04 321.35 286.81 

62160 ....... Neuroendoscopy add-on ................................... ......... T 0122 7.48 459.78 .................. 91.96 

62194 ....... Replace/irrigate catheter .................................... ......... T 0427 11.6575 716.56 .................. 143.31 

62225 ....... Replace/irrigate catheter .................................... ......... T 0427 11.6575 716.56 .................. 143.31 

62230 ....... Replace/revise brain shunt ................................ ......... T 0224 47.0342 2,891.10 .................. 578.22

62252 ....... Csf shunt reprogram .......................................... ......... S 0691 2.8942 177.90 60.61 35.58 

62263 ....... Epidural lysis mult sessions .............................. ......... T 0203 12.1702 748.08 240.33 149.62 

62264 ....... Epidural lysis on single day ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

62268 ....... Drain spinal cord cyst ........................................ ......... T 0212 2.9907 183.83 65.96 36.77 

62269 ....... Needle biopsy, spinal cord ................................ ......... T 0685 6.1384 377.32 115.47 75.46 

62270 ....... Spinal fluid tap, diagnostic ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

62272 ....... Drain cerebro spinal fluid ................................... ......... T 0204 2.2614 139.00 40.13 27.80 

62273 ....... Inject epidural patch .......................................... ......... T 0206 5.7253 351.92 75.55 70.38 

62280 ....... Treat spinal cord lesion ..................................... ......... T 0207 6.3603 390.95 86.92 78.19 

62281 ....... Treat spinal cord lesion ..................................... ......... T 0207 6.3603 390.95 86.92 78.19 

62282 ....... Treat spinal canal lesion .................................... ......... T 0207 6.3603 390.95 86.92 78.19 

62284 ....... Injection for myelogram ..................................... ......... N .................. .................. .................. .................. ..................

62287 ....... Percutaneous diskectomy .................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

62290 ....... Inject for spine disk x-ray .................................. ......... N .................. .................. .................. .................. ..................

62291 ....... Inject for spine disk x-ray .................................. ......... N .................. .................. .................. .................. ..................

62292 ....... Injection into disk lesion .................................... ......... T 0212 2.9907 183.83 65.96 36.77 

62294 ....... Injection into spinal artery .................................. ......... T 0212 2.9907 183.83 65.96 36.77 

62310 ....... Inject spine c/t .................................................... ......... T 0207 6.3603 390.95 86.92 78.19 

62311 ....... Inject spine l/s (cd) ............................................ ......... T 0207 6.3603 390.95 86.92 78.19 


cprice-sewell on PRODPC62 with RULES2
68334 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

62318 ....... Inject spine w/cath, c/t ....................................... ......... T 0207 6.3603 390.95 86.92 78.19 

62319 ....... Inject spine w/cath l/s (cd) ................................. ......... T 0207 6.3603 390.95 86.92 78.19 

62350 ....... Implant spinal canal cath ................................... ......... T 0223 30.8394 1,895.64 .................. 379.13 

62351 ....... Implant spinal canal cath ................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

62355 ....... Remove spinal canal catheter ........................... ......... T 0203 12.1702 748.08 240.33 149.62 

62360 ....... Insert spine infusion device ............................... ......... T 0226 112.6322 6,923.28 .................. 1,384.66 

62361 ....... Implant spine infusion pump .............................. ......... T 0227 174.4056 10,720.36 .................. 2,144.07 

62362 ....... Implant spine infusion pump .............................. ......... T 0227 174.4056 10,720.36 .................. 2,144.07 

62365 ....... Remove spine infusion device ........................... ......... T 0221 33.152 2,037.79 463.62 407.56 

62367 ....... Analyze spine infusion pump ............................. ......... S 0691 2.8942 177.90 60.61 35.58 

62368 ....... Analyze spine infusion pump ............................. ......... S 0691 2.8942 177.90 60.61 35.58 

63001 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63003 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63005 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63011 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63012 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63015 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63016 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63017 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63020 ....... Neck spine disk surgery .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

63030 ....... Low back disk surgery ....................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

63035 ....... Spinal disk surgery add-on ................................ ......... T 0208 44.1489 2,713.74 .................. 542.75

63040 ....... Laminotomy, single cervical .............................. ......... T 0208 44.1489 2,713.74 .................. 542.75 

63042 ....... Laminotomy, single lumbar ................................ ......... T 0208 44.1489 2,713.74 .................. 542.75 

63045 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63046 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63047 ....... Removal of spinal lamina .................................. ......... T 0208 44.1489 2,713.74 .................. 542.75

63048 ....... Remove spinal lamina add-on ........................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

63055 ....... Decompress spinal cord .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75

63056 ....... Decompress spinal cord .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75

63057 ....... Decompress spine cord add-on ........................ ......... T 0208 44.1489 2,713.74 .................. 542.75 

63064 ....... Decompress spinal cord .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75

63066 ....... Decompress spine cord add-on ........................ ......... T 0208 44.1489 2,713.74 .................. 542.75 

63075 ....... Neck spine disk surgery .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75 

63600 ....... Remove spinal cord lesion ................................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

63610 ....... Stimulation of spinal cord .................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

63615 ....... Remove lesion of spinal cord ............................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

63650 ....... Implant neuroelectrodes .................................... ......... S 0040 56.5705 3,477.28 .................. 695.46 

63655 ....... Implant neuroelectrodes .................................... ......... S 0061 84.1967 5,175.40 .................. 1,035.08 

63660 ....... Revise/remove neuroelectrode .......................... ......... T 0687 17.8334 1,096.18 438.47 219.24 

63685 ....... Insrt/redo spine n generator .............................. ......... T 0222 181.6249 11,164.12 .................. 2,232.82 

63688 ....... Revise/remove neuroreceiver ............................ ......... T 0688 35.5702 2,186.43 874.57 437.29 

63741 ....... Install spinal shunt ............................................. ......... T 0228 39.2633 2,413.44 .................. 482.69 

63744 ....... Revision of spinal shunt .................................... ......... T 0228 39.2633 2,413.44 .................. 482.69 

63746 ....... Removal of spinal shunt .................................... ......... T 0109 10.9918 675.64 .................. 135.13 

64400 ....... Nblock inj, trigeminal ......................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64402 ....... Nblock inj, facial ................................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64405 ....... Nblock inj, occipital ............................................ ......... T 0204 2.2614 139.00 40.13 27.80 

64408 ....... Nblock inj, vagus ............................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64410 ....... Nblock inj, phrenic ............................................. ......... T 0206 5.7253 351.92 75.55 70.38 

64412 ....... Nblock inj, spinal accessor ................................ ......... T 0206 5.7253 351.92 75.55 70.38 

64413 ....... Nblock inj, cervical plexus ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64415 ....... Nblock inj, brachial plexus ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64416 ....... Nblock cont infuse, b plex ................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64417 ....... Nblock inj, axillary .............................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64418 ....... Nblock inj, suprascapular .................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64420 ....... Nblock inj, intercost, sng ................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64421 ....... Nblock inj, intercost, mlt .................................... ......... T 0206 5.7253 351.92 75.55 70.38 

64425 ....... Nblock inj, ilio-ing/hypogi ................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64430 ....... Nblock inj, pudendal .......................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64435 ....... Nblock inj, paracervical ...................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64445 ....... Nblock inj, sciatic, sng ....................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64446 ....... Nblk inj, sciatic, cont inf ..................................... ......... T 0206 5.7253 351.92 75.55 70.38 

64447 ....... Nblock inj fem, single ........................................ ......... T 0204 2.2614 139.00 40.13 27.80 

64448 ....... Nblock inj fem, cont inf ...................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64449 ....... Nblock inj, lumbar plexus .................................. ......... T 0204 2.2614 139.00 40.13 27.80 

64450 ....... Nblock, other peripheral .................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64470 ....... Inj paravertebral c/t ............................................ ......... T 0207 6.3603 390.95 86.92 78.19 

64472 ....... Inj paravertebral c/t add-on ............................... ......... T 0206 5.7253 351.92 75.55 70.38 

64475 ....... Inj paravertebral l/s ............................................ ......... T 0207 6.3603 390.95 86.92 78.19 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68335 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

64476 ....... Inj paravertebral l/s add-on ................................ ......... T 0206 5.7253 351.92 75.55 70.38 

64479 ....... Inj foramen epidural c/t ...................................... ......... T 0207 6.3603 390.95 86.92 78.19 

64480 ....... Inj foramen epidural add-on .............................. ......... T 0207 6.3603 390.95 86.92 78.19 

64483 ....... Inj foramen epidural l/s ...................................... ......... T 0207 6.3603 390.95 86.92 78.19 

64484 ....... Inj foramen epidural add-on .............................. ......... T 0207 6.3603 390.95 86.92 78.19 

64505 ....... Nblock, spenopalatine gangl ............................. ......... T 0204 2.2614 139.00 40.13 27.80 

64508 ....... Nblock, carotid sinus s/p ................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64510 ....... Nblock, stellate ganglion .................................... ......... T 0207 6.3603 390.95 86.92 78.19 

64517 ....... Nblock inj, hypogas plxs .................................... ......... T 0204 2.2614 139.00 40.13 27.80 

64520 ....... Nblock, lumbar/thoracic ..................................... ......... T 0207 6.3603 390.95 86.92 78.19 

64530 ....... Nblock inj, celiac pelus ...................................... ......... T 0207 6.3603 390.95 86.92 78.19 

64553 ....... Implant neuroelectrodes .................................... ......... S 0225 221.1512 13,593.72 .................. 2,718.74 

64555 ....... Implant neuroelectrodes .................................... ......... S 0040 56.5705 3,477.28 .................. 695.46 

64560 ....... Implant neuroelectrodes .................................... ......... S 0040 56.5705 3,477.28 .................. 695.46 

64561 ....... Implant neuroelectrodes .................................... ......... S 0040 56.5705 3,477.28 .................. 695.46 

64565 ....... Implant neuroelectrodes .................................... ......... S 0040 56.5705 3,477.28 .................. 695.46 

64573 ....... Implant neuroelectrodes .................................... ......... S 0225 221.1512 13,593.72 .................. 2,718.74 

64575 ....... Implant neuroelectrodes .................................... ......... S 0061 84.1967 5,175.40 .................. 1,035.08 

64577 ....... Implant neuroelectrodes .................................... ......... S 0061 84.1967 5,175.40 .................. 1,035.08 

64580 ....... Implant neuroelectrodes .................................... ......... S 0061 84.1967 5,175.40 .................. 1,035.08 

64581 ....... Implant neuroelectrodes .................................... ......... S 0061 84.1967 5,175.40 .................. 1,035.08 

64585 ....... Revise/remove neuroelectrode .......................... ......... T 0687 17.8334 1,096.18 438.47 219.24 

64590 ....... Insrt/redo pn/gastr stimul ................................... ......... T 0222 181.6249 11,164.12 .................. 2,232.82 

64595 ....... Revise/rmv pn/gastr stimul ................................ ......... T 0688 35.5702 2,186.43 874.57 437.29 

64600 ....... Injection treatment of nerve ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64605 ....... Injection treatment of nerve ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64610 ....... Injection treatment of nerve ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64612 ....... Destroy nerve, face muscle ............................... ......... T 0204 2.2614 139.00 40.13 27.80 

64613 ....... Destroy nerve, neck muscle .............................. ......... T 0204 2.2614 139.00 40.13 27.80 

64614 ....... Destroy nerve, extrem musc ............................. ......... T 0204 2.2614 139.00 40.13 27.80 

64620 ....... Injection treatment of nerve ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64622 ....... Destr paravertebrl nerve l/s ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64623 ....... Destr paravertebral n add-on ............................ ......... T 0207 6.3603 390.95 86.92 78.19 

64626 ....... Destr paravertebrl nerve c/t ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64627 ....... Destr paravertebral n add-on ............................ ......... T 0207 6.3603 390.95 86.92 78.19 

64630 ....... Injection treatment of nerve ............................... ......... T 0206 5.7253 351.92 75.55 70.38 

64640 ....... Injection treatment of nerve ............................... ......... T 0206 5.7253 351.92 75.55 70.38 

64650 ....... Chemodenerv eccrine glands ............................ ......... T 0204 2.2614 139.00 40.13 27.80 

64653 ....... Chemodenerv eccrine glands ............................ ......... T 0204 2.2614 139.00 40.13 27.80 

64680 ....... Injection treatment of nerve ............................... ......... T 0207 6.3603 390.95 86.92 78.19 

64681 ....... Injection treatment of nerve ............................... ......... T 0203 12.1702 748.08 240.33 149.62 

64702 ....... Revise finger/toe nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64704 ....... Revise hand/foot nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64708 ....... Revise arm/leg nerve ......................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64712 ....... Revision of sciatic nerve .................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64713 ....... Revision of arm nerve(s) ................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64714 ....... Revise low back nerve(s) .................................. ......... T 0220 17.8499 1,097.20 .................. 219.44

64716 ....... Revision of cranial nerve ................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64718 ....... Revise ulnar nerve at elbow .............................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64719 ....... Revise ulnar nerve at wrist ................................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

64721 ....... Carpal tunnel surgery ........................................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

64722 ....... Relieve pressure on nerve(s) ............................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

64726 ....... Release foot/toe nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64727 ....... Internal nerve revision ....................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64732 ....... Incision of brow nerve ....................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64734 ....... Incision of cheek nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64736 ....... Incision of chin nerve ......................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64738 ....... Incision of jaw nerve .......................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64740 ....... Incision of tongue nerve .................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64742 ....... Incision of facial nerve ....................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64744 ....... Incise nerve, back of head ................................ ......... T 0220 17.8499 1,097.20 .................. 219.44

64746 ....... Incise diaphragm nerve ..................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64761 ....... Incision of pelvis nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64763 ....... Incise hip/thigh nerve ......................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64766 ....... Incise hip/thigh nerve ......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64771 ....... Sever cranial nerve ............................................ ......... T 0220 17.8499 1,097.20 .................. 219.44 

64772 ....... Incision of spinal nerve ...................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64774 ....... Remove skin nerve lesion ................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64776 ....... Remove digit nerve lesion ................................. ......... T 0220 17.8499 1,097.20 .................. 219.44

64778 ....... Digit nerve surgery add-on ................................ ......... T 0220 17.8499 1,097.20 .................. 219.44


cprice-sewell on PRODPC62 with RULES2
68336 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

64782 ....... Remove limb nerve lesion ................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64783 ....... Limb nerve surgery add-on ............................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64784 ....... Remove nerve lesion ......................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64786 ....... Remove sciatic nerve lesion .............................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64787 ....... Implant nerve end .............................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64788 ....... Remove skin nerve lesion ................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64790 ....... Removal of nerve lesion .................................... ......... T 0220 17.8499 1,097.20 .................. 219.44 

64792 ....... Removal of nerve lesion .................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64795 ....... Biopsy of nerve .................................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64802 ....... Remove sympathetic nerves ............................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64804 ....... Remove sympathetic nerves ............................. CH .. T 0220 17.8499 1,097.20 .................. 219.44 

64820 ....... Remove sympathetic nerves ............................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

64821 ....... Remove sympathetic nerves ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

64822 ....... Remove sympathetic nerves ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

64823 ....... Remove sympathetic nerves ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11 

64831 ....... Repair of digit nerve .......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64832 ....... Repair nerve add-on .......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64834 ....... Repair of hand or foot nerve ............................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64835 ....... Repair of hand or foot nerve ............................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64836 ....... Repair of hand or foot nerve ............................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64837 ....... Repair nerve add-on .......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64840 ....... Repair of leg nerve ............................................ ......... T 0221 33.152 2,037.79 463.62 407.56 

64856 ....... Repair/transpose nerve ..................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64857 ....... Repair arm/leg nerve ......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64858 ....... Repair sciatic nerve ........................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64859 ....... Nerve surgery .................................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64861 ....... Repair of arm nerves ......................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64862 ....... Repair of low back nerves ................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64864 ....... Repair of facial nerve ........................................ ......... T 0221 33.152 2,037.79 463.62 407.56 

64865 ....... Repair of facial nerve ........................................ ......... T 0221 33.152 2,037.79 463.62 407.56 

64870 ....... Fusion of facial/other nerve ............................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64872 ....... Subsequent repair of nerve ............................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64874 ....... Repair & revise nerve add-on ........................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64876 ....... Repair nerve/shorten bone ................................ ......... T 0221 33.152 2,037.79 463.62 407.56 

64885 ....... Nerve graft, head or neck .................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64886 ....... Nerve graft, head or neck .................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64890 ....... Nerve graft, hand or foot ................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64891 ....... Nerve graft, hand or foot ................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64892 ....... Nerve graft, arm or leg ...................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64893 ....... Nerve graft, arm or leg ...................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64895 ....... Nerve graft, hand or foot ................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64896 ....... Nerve graft, hand or foot ................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64897 ....... Nerve graft, arm or leg ...................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64898 ....... Nerve graft, arm or leg ...................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64901 ....... Nerve graft add-on ............................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64902 ....... Nerve graft add-on ............................................. ......... T 0221 33.152 2,037.79 463.62 407.56 

64905 ....... Nerve pedicle transfer ....................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64907 ....... Nerve pedicle transfer ....................................... ......... T 0221 33.152 2,037.79 463.62 407.56 

64910 ....... Nerve repair w/allograft ..................................... NI .... T 0220 17.8499 1,097.20 .................. 219.44

64911 ....... Neurorraphy w/vein autograft ............................ NI .... T 0220 17.8499 1,097.20 .................. 219.44 

64999 ....... Nervous system surgery .................................... ......... T 0204 2.2614 139.00 40.13 27.80 

65091 ....... Revise eye ......................................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

65093 ....... Revise eye with implant ..................................... CH .. T 0242 35.2292 2,165.47 597.36 433.09 

65101 ....... Removal of eye .................................................. ......... T 0242 35.2292 2,165.47 597.36 433.09 

65103 ....... Remove eye/insert implant ................................ ......... T 0242 35.2292 2,165.47 597.36 433.09 

65105 ....... Remove eye/attach implant ............................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

65110 ....... Removal of eye .................................................. ......... T 0242 35.2292 2,165.47 597.36 433.09 

65112 ....... Remove eye/revise socket ................................ ......... T 0242 35.2292 2,165.47 597.36 433.09 

65114 ....... Remove eye/revise socket ................................ ......... T 0242 35.2292 2,165.47 597.36 433.09 

65125 ....... Revise ocular implant ........................................ ......... T 0240 17.1243 1,052.60 309.52 210.52 

65130 ....... Insert ocular implant .......................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

65135 ....... Insert ocular implant .......................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

65140 ....... Attach ocular implant ......................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

65150 ....... Revise ocular implant ........................................ ......... T 0241 25.255 1,552.37 384.47 310.47 

65155 ....... Reinsert ocular implant ...................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

65175 ....... Removal of ocular implant ................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

65205 ....... Remove foreign body from eye ......................... ......... S 0698 1.1607 71.35 .................. 14.27 

65210 ....... Remove foreign body from eye ......................... ......... S 0698 1.1607 71.35 .................. 14.27 

65220 ....... Remove foreign body from eye ......................... ......... S 0698 1.1607 71.35 .................. 14.27 

65222 ....... Remove foreign body from eye ......................... ......... S 0698 1.1607 71.35 .................. 14.27 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68337 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

65235 ....... Remove foreign body from eye ......................... ......... T 0233 15.2259 935.91 266.33 187.18 

65260 ....... Remove foreign body from eye ......................... ......... T 0236 16.5239 1,015.69 .................. 203.14 

65265 ....... Remove foreign body from eye ......................... ......... T 0237 27.602 1,696.64 .................. 339.33 

65270 ....... Repair of eye wound ......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

65272 ....... Repair of eye wound ......................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

65275 ....... Repair of eye wound ......................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

65280 ....... Repair of eye wound ......................................... ......... T 0236 16.5239 1,015.69 .................. 203.14 

65285 ....... Repair of eye wound ......................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

65286 ....... Repair of eye wound ......................................... ......... T 0232 6.0673 372.94 93.43 74.59 

65290 ....... Repair of eye socket wound .............................. ......... T 0243 21.2801 1,308.05 430.35 261.61 

65400 ....... Removal of eye lesion ....................................... ......... T 0233 15.2259 935.91 266.33 187.18 

65410 ....... Biopsy of cornea ................................................ ......... T 0233 15.2259 935.91 266.33 187.18 

65420 ....... Removal of eye lesion ....................................... ......... T 0233 15.2259 935.91 266.33 187.18 

65426 ....... Removal of eye lesion ....................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

65430 ....... Corneal smear ................................................... ......... S 0698 1.1607 71.35 .................. 14.27 

65435 ....... Curette/treat cornea ........................................... ......... T 0239 7.2819 447.60 .................. 89.52 

65436 ....... Curette/treat cornea ........................................... ......... T 0233 15.2259 935.91 266.33 187.18 

65450 ....... Treatment of corneal lesion ............................... ......... S 0231 2.1451 131.86 .................. 26.37 

65600 ....... Revision of cornea ............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

65710 ....... Corneal transplant ............................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65730 ....... Corneal transplant ............................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65750 ....... Corneal transplant ............................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65755 ....... Corneal transplant ............................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65770 ....... Revise cornea with implant ............................... CH .. T 0293 51.9894 3,195.68 1,128.29 639.14 

65772 ....... Correction of astigmatism .................................. ......... T 0233 15.2259 935.91 266.33 187.18 

65775 ....... Correction of astigmatism .................................. ......... T 0233 15.2259 935.91 266.33 187.18 

65780 ....... Ocular reconst, transplant ................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65781 ....... Ocular reconst, transplant ................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65782 ....... Ocular reconst, transplant ................................. ......... T 0244 38.2707 2,352.42 803.26 470.48 

65800 ....... Drainage of eye ................................................. ......... T 0233 15.2259 935.91 266.33 187.18 

65805 ....... Drainage of eye ................................................. ......... T 0233 15.2259 935.91 266.33 187.18 

65810 ....... Drainage of eye ................................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

65815 ....... Drainage of eye ................................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

65820 ....... Relieve inner eye pressure ................................ ......... T 0232 6.0673 372.94 93.43 74.59 

65850 ....... Incision of eye .................................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

65855 ....... Laser surgery of eye .......................................... ......... T 0247 5.0839 312.50 104.31 62.50 

65860 ....... Incise inner eye adhesions ................................ ......... T 0247 5.0839 312.50 104.31 62.50 

65865 ....... Incise inner eye adhesions ................................ ......... T 0233 15.2259 935.91 266.33 187.18 

65870 ....... Incise inner eye adhesions ................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

65875 ....... Incise inner eye adhesions ................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

65880 ....... Incise inner eye adhesions ................................ ......... T 0233 15.2259 935.91 266.33 187.18 

65900 ....... Remove eye lesion ............................................ ......... T 0233 15.2259 935.91 266.33 187.18 

65920 ....... Remove implant of eye ...................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

65930 ....... Remove blood clot from eye ............................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66020 ....... Injection treatment of eye .................................. ......... T 0233 15.2259 935.91 266.33 187.18 

66030 ....... Injection treatment of eye .................................. ......... T 0232 6.0673 372.94 93.43 74.59 

66130 ....... Remove eye lesion ............................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

66150 ....... Glaucoma surgery ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66155 ....... Glaucoma surgery ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66160 ....... Glaucoma surgery ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66165 ....... Glaucoma surgery ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66170 ....... Glaucoma surgery ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

66172 ....... Incision of eye .................................................... CH .. T 0234 22.997 1,413.58 511.31 282.72 

66180 ....... Implant eye shunt .............................................. ......... T 0673 37.8967 2,329.43 649.56 465.89 

66185 ....... Revise eye shunt ............................................... ......... T 0673 37.8967 2,329.43 649.56 465.89 

66220 ....... Repair eye lesion ............................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

66225 ....... Repair/graft eye lesion ....................................... ......... T 0673 37.8967 2,329.43 649.56 465.89 

66250 ....... Follow-up surgery of eye ................................... ......... T 0233 15.2259 935.91 266.33 187.18 

66500 ....... Incision of iris ..................................................... ......... T 0232 6.0673 372.94 93.43 74.59 

66505 ....... Incision of iris ..................................................... ......... T 0232 6.0673 372.94 93.43 74.59 

66600 ....... Remove iris and lesion ...................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66605 ....... Removal of iris ................................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66625 ....... Removal of iris ................................................... ......... T 0232 6.0673 372.94 93.43 74.59 

66630 ....... Removal of iris ................................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66635 ....... Removal of iris ................................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66680 ....... Repair iris & ciliary body .................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66682 ....... Repair iris & ciliary body .................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66700 ....... Destruction, ciliary body .................................... ......... T 0233 15.2259 935.91 266.33 187.18 

66710 ....... Ciliary transsleral therapy .................................. ......... T 0233 15.2259 935.91 266.33 187.18 

66711 ....... Ciliary endoscopic ablation ................................ ......... T 0233 15.2259 935.91 266.33 187.18 


cprice-sewell on PRODPC62 with RULES2
68338 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

66720 ....... Destruction, ciliary body .................................... ......... T 0233 15.2259 935.91 266.33 187.18 

66740 ....... Destruction, ciliary body .................................... ......... T 0234 22.997 1,413.58 511.31 282.72 

66761 ....... Revision of iris ................................................... ......... T 0247 5.0839 312.50 104.31 62.50 

66762 ....... Revision of iris ................................................... ......... T 0247 5.0839 312.50 104.31 62.50 

66770 ....... Removal of inner eye lesion .............................. ......... T 0247 5.0839 312.50 104.31 62.50 

66820 ....... Incision, secondary cataract .............................. ......... T 0232 6.0673 372.94 93.43 74.59 

66821 ....... After cataract laser surgery ............................... ......... T 0247 5.0839 312.50 104.31 62.50 

66825 ....... Reposition intraocular lens ................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

66830 ....... Removal of lens lesion ...................................... ......... T 0232 6.0673 372.94 93.43 74.59 

66840 ....... Removal of lens material ................................... ......... T 0245 14.8702 914.04 217.05 182.81 

66850 ....... Removal of lens material ................................... ......... T 0249 29.2281 1,796.59 524.67 359.32 

66852 ....... Removal of lens material ................................... ......... T 0249 29.2281 1,796.59 524.67 359.32 

66920 ....... Extraction of lens ............................................... ......... T 0249 29.2281 1,796.59 524.67 359.32 

66930 ....... Extraction of lens ............................................... ......... T 0249 29.2281 1,796.59 524.67 359.32 

66940 ....... Extraction of lens ............................................... ......... T 0245 14.8702 914.04 217.05 182.81 

66982 ....... Cataract surgery, complex ................................. ......... T 0246 23.6313 1,452.57 495.96 290.51 

66983 ....... Cataract surg w/iol, 1 stage ............................... ......... T 0246 23.6313 1,452.57 495.96 290.51 

66984 ....... Cataract surg w/iol, 1 stage ............................... ......... T 0246 23.6313 1,452.57 495.96 290.51 

66985 ....... Insert lens prosthesis ......................................... ......... T 0246 23.6313 1,452.57 495.96 290.51 

66986 ....... Exchange lens prosthesis .................................. ......... T 0246 23.6313 1,452.57 495.96 290.51 

66990 ....... Ophthalmic endoscope add-on .......................... ......... N .................. .................. .................. .................. ..................

66999 ....... Eye surgery procedure ...................................... ......... T 0232 6.0673 372.94 93.43 74.59 

67005 ....... Partial removal of eye fluid ................................ ......... T 0237 27.602 1,696.64 .................. 339.33 

67010 ....... Partial removal of eye fluid ................................ ......... T 0237 27.602 1,696.64 .................. 339.33 

67015 ....... Release of eye fluid ........................................... ......... T 0237 27.602 1,696.64 .................. 339.33 

67025 ....... Replace eye fluid ............................................... ......... T 0237 27.602 1,696.64 .................. 339.33 

67027 ....... Implant eye drug system ................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67028 ....... Injection eye drug .............................................. ......... T 0235 3.9333 241.77 58.93 48.35 

67030 ....... Incise inner eye strands .................................... ......... T 0236 16.5239 1,015.69 .................. 203.14 

67031 ....... Laser surgery, eye strands ................................ ......... T 0247 5.0839 312.50 104.31 62.50 

67036 ....... Removal of inner eye fluid ................................. ......... T 0672 37.429 2,300.69 .................. 460.14

67038 ....... Strip retinal membrane ...................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67039 ....... Laser treatment of retina ................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67040 ....... Laser treatment of retina ................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67101 ....... Repair detached retina ...................................... ......... T 0236 16.5239 1,015.69 .................. 203.14 

67105 ....... Repair detached retina ...................................... ......... T 0248 5.0841 312.51 95.08 62.50 

67107 ....... Repair detached retina ...................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67108 ....... Repair detached retina ...................................... ......... T 0672 37.429 2,300.69 .................. 460.14 

67110 ....... Repair detached retina ...................................... ......... T 0236 16.5239 1,015.69 .................. 203.14 

67112 ....... Rerepair detached retina ................................... ......... T 0672 37.429 2,300.69 .................. 460.14

67115 ....... Release encircling material ............................... ......... T 0236 16.5239 1,015.69 .................. 203.14

67120 ....... Remove eye implant material ............................ ......... T 0236 16.5239 1,015.69 .................. 203.14 

67121 ....... Remove eye implant material ............................ ......... T 0237 27.602 1,696.64 .................. 339.33 

67141 ....... Treatment of retina ............................................ ......... T 0235 3.9333 241.77 58.93 48.35 

67145 ....... Treatment of retina ............................................ ......... T 0248 5.0841 312.51 95.08 62.50 

67208 ....... Treatment of retinal lesion ................................. ......... T 0236 16.5239 1,015.69 .................. 203.14 

67210 ....... Treatment of retinal lesion ................................. ......... T 0248 5.0841 312.51 95.08 62.50 

67218 ....... Treatment of retinal lesion ................................. ......... T 0236 16.5239 1,015.69 .................. 203.14 

67220 ....... Treatment of choroid lesion ............................... ......... T 0235 3.9333 241.77 58.93 48.35 

67221 ....... Ocular photodynamic ther ................................. ......... T 0235 3.9333 241.77 58.93 48.35 

67225 ....... Eye photodynamic ther add-on ......................... ......... T 0235 3.9333 241.77 58.93 48.35 

67227 ....... Treatment of retinal lesion ................................. CH .. T 0237 27.602 1,696.64 .................. 339.33 

67228 ....... Treatment of retinal lesion ................................. ......... T 0248 5.0841 312.51 95.08 62.50 

67250 ....... Reinforce eye wall ............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

67255 ....... Reinforce/graft eye wall ..................................... ......... T 0237 27.602 1,696.64 .................. 339.33 

67299 ....... Eye surgery procedure ...................................... ......... T 0235 3.9333 241.77 58.93 48.35 

67311 ....... Revise eye muscle ............................................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67312 ....... Revise two eye muscles .................................... ......... T 0243 21.2801 1,308.05 430.35 261.61 

67314 ....... Revise eye muscle ............................................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67316 ....... Revise two eye muscles .................................... ......... T 0243 21.2801 1,308.05 430.35 261.61 

67318 ....... Revise eye muscle(s) ........................................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67320 ....... Revise eye muscle(s) add-on ............................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67331 ....... Eye surgery follow-up add-on ............................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67332 ....... Rerevise eye muscles add-on ........................... ......... T 0243 21.2801 1,308.05 430.35 261.61 

67334 ....... Revise eye muscle w/suture .............................. ......... T 0243 21.2801 1,308.05 430.35 261.61 

67335 ....... Eye suture during surgery ................................. ......... T 0243 21.2801 1,308.05 430.35 261.61 

67340 ....... Revise eye muscle add-on ................................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67343 ....... Release eye tissue ............................................ ......... T 0243 21.2801 1,308.05 430.35 261.61 

67345 ....... Destroy nerve of eye muscle ............................. ......... T 0238 2.8954 177.97 .................. 35.59 

67346 ....... Biopsy, eye muscle ............................................ NI .... T 0699 14.3845 884.19 .................. 176.84 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68339 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

67350 ....... Biopsy eye muscle ............................................. CH .. D .................. .................. .................. .................. ..................

67399 ....... Eye muscle surgery procedure .......................... ......... T 0243 21.2801 1,308.05 430.35 261.61 

67400 ....... Explore/biopsy eye socket ................................. ......... T 0241 25.255 1,552.37 384.47 310.47 

67405 ....... Explore/drain eye socket ................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67412 ....... Explore/treat eye socket .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67413 ....... Explore/treat eye socket .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67414 ....... Explr/decompress eye socket ............................ ......... T 0242 35.2292 2,165.47 597.36 433.09 

67415 ....... Aspiration, orbital contents ................................ ......... T 0240 17.1243 1,052.60 309.52 210.52 

67420 ....... Explore/treat eye socket .................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

67430 ....... Explore/treat eye socket .................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

67440 ....... Explore/drain eye socket ................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

67445 ....... Explr/decompress eye socket ............................ ......... T 0242 35.2292 2,165.47 597.36 433.09 

67450 ....... Explore/biopsy eye socket ................................. ......... T 0242 35.2292 2,165.47 597.36 433.09 

67500 ....... Inject/treat eye socket ........................................ ......... S 0231 2.1451 131.86 .................. 26.37 

67505 ....... Inject/treat eye socket ........................................ ......... T 0238 2.8954 177.97 .................. 35.59 

67515 ....... Inject/treat eye socket ........................................ ......... T 0238 2.8954 177.97 .................. 35.59 

67550 ....... Insert eye socket implant ................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

67560 ....... Revise eye socket implant ................................. ......... T 0241 25.255 1,552.37 384.47 310.47 

67570 ....... Decompress optic nerve .................................... ......... T 0242 35.2292 2,165.47 597.36 433.09 

67599 ....... Orbit surgery procedure ..................................... ......... T 0238 2.8954 177.97 .................. 35.59 

67700 ....... Drainage of eyelid abscess ............................... ......... T 0238 2.8954 177.97 .................. 35.59 

67710 ....... Incision of eyelid ................................................ ......... T 0239 7.2819 447.60 .................. 89.52 

67715 ....... Incision of eyelid fold ......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67800 ....... Remove eyelid lesion ........................................ ......... T 0238 2.8954 177.97 .................. 35.59 

67801 ....... Remove eyelid lesions ....................................... ......... T 0239 7.2819 447.60 .................. 89.52 

67805 ....... Remove eyelid lesions ....................................... ......... T 0238 2.8954 177.97 .................. 35.59 

67808 ....... Remove eyelid lesion(s) .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67810 ....... Biopsy of eyelid ................................................. ......... T 0238 2.8954 177.97 .................. 35.59 

67820 ....... Revise eyelashes ............................................... ......... S 0698 1.1607 71.35 .................. 14.27

67825 ....... Revise eyelashes ............................................... ......... T 0238 2.8954 177.97 .................. 35.59 

67830 ....... Revise eyelashes ............................................... ......... T 0239 7.2819 447.60 .................. 89.52 

67835 ....... Revise eyelashes ............................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67840 ....... Remove eyelid lesion ........................................ ......... T 0239 7.2819 447.60 .................. 89.52 

67850 ....... Treat eyelid lesion ............................................. ......... T 0239 7.2819 447.60 .................. 89.52 

67875 ....... Closure of eyelid by suture ................................ ......... T 0239 7.2819 447.60 .................. 89.52 

67880 ....... Revision of eyelid .............................................. ......... T 0233 15.2259 935.91 266.33 187.18 

67882 ....... Revision of eyelid .............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

67900 ....... Repair brow defect ............................................ ......... T 0240 17.1243 1,052.60 309.52 210.52 

67901 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67902 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67903 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67904 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67906 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67908 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67909 ....... Revise eyelid defect .......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67911 ....... Revise eyelid defect .......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67912 ....... Correction eyelid w/implant ............................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67914 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67915 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67916 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67917 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67921 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67922 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67923 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67924 ....... Repair eyelid defect ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67930 ....... Repair eyelid wound .......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67935 ....... Repair eyelid wound .......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67938 ....... Remove eyelid foreign body .............................. ......... S 0698 1.1607 71.35 .................. 14.27 

67950 ....... Revision of eyelid .............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

67961 ....... Revision of eyelid .............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

67966 ....... Revision of eyelid .............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

67971 ....... Reconstruction of eyelid .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67973 ....... Reconstruction of eyelid .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67974 ....... Reconstruction of eyelid .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

67975 ....... Reconstruction of eyelid .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

67999 ....... Revision of eyelid .............................................. ......... T 0238 2.8954 177.97 .................. 35.59 

68020 ....... Incise/drain eyelid lining .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68040 ....... Treatment of eyelid lesions ............................... ......... S 0698 1.1607 71.35 .................. 14.27 

68100 ....... Biopsy of eyelid lining ........................................ ......... T 0232 6.0673 372.94 93.43 74.59 

68110 ....... Remove eyelid lining lesion ............................... ......... T 0699 14.3845 884.19 .................. 176.84 


cprice-sewell on PRODPC62 with RULES2
68340 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

68115 ....... Remove eyelid lining lesion ............................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68130 ....... Remove eyelid lining lesion ............................... ......... T 0233 15.2259 935.91 266.33 187.18 

68135 ....... Remove eyelid lining lesion ............................... ......... T 0239 7.2819 447.60 .................. 89.52 

68200 ....... Treat eyelid by injection ..................................... ......... S 0230 0.7898 48.55 14.97 9.71 

68320 ....... Revise/graft eyelid lining .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68325 ....... Revise/graft eyelid lining .................................... CH .. T 0241 25.255 1,552.37 384.47 310.47 

68326 ....... Revise/graft eyelid lining .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68328 ....... Revise/graft eyelid lining .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68330 ....... Revise eyelid lining ............................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

68335 ....... Revise/graft eyelid lining .................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68340 ....... Separate eyelid adhesions ................................ ......... T 0240 17.1243 1,052.60 309.52 210.52 

68360 ....... Revise eyelid lining ............................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

68362 ....... Revise eyelid lining ............................................ ......... T 0234 22.997 1,413.58 511.31 282.72 

68371 ....... Harvest eye tissue, alograft ............................... ......... T 0233 15.2259 935.91 266.33 187.18 

68399 ....... Eyelid lining surgery .......................................... ......... T 0238 2.8954 177.97 .................. 35.59 

68400 ....... Incise/drain tear gland ....................................... ......... T 0238 2.8954 177.97 .................. 35.59

68420 ....... Incise/drain tear sac .......................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68440 ....... Incise tear duct opening .................................... ......... T 0238 2.8954 177.97 .................. 35.59 

68500 ....... Removal of tear gland ....................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68505 ....... Partial removal, tear gland ................................ ......... T 0241 25.255 1,552.37 384.47 310.47 

68510 ....... Biopsy of tear gland ........................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68520 ....... Removal of tear sac .......................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68525 ....... Biopsy of tear sac .............................................. ......... T 0240 17.1243 1,052.60 309.52 210.52 

68530 ....... Clearance of tear duct ....................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68540 ....... Remove tear gland lesion .................................. ......... T 0241 25.255 1,552.37 384.47 310.47 

68550 ....... Remove tear gland lesion .................................. CH .. T 0241 25.255 1,552.37 384.47 310.47 

68700 ....... Repair tear ducts ............................................... ......... T 0241 25.255 1,552.37 384.47 310.47 

68705 ....... Revise tear duct opening ................................... ......... T 0238 2.8954 177.97 .................. 35.59 

68720 ....... Create tear sac drain ......................................... CH .. T 0241 25.255 1,552.37 384.47 310.47 

68745 ....... Create tear duct drain ........................................ ......... T 0241 25.255 1,552.37 384.47 310.47 

68750 ....... Create tear duct drain ........................................ CH .. T 0241 25.255 1,552.37 384.47 310.47 

68760 ....... Close tear duct opening .................................... CH .. S 0231 2.1451 131.86 .................. 26.37 

68761 ....... Close tear duct opening .................................... ......... S 0231 2.1451 131.86 .................. 26.37 

68770 ....... Close tear system fistula ................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68801 ....... Dilate tear duct opening .................................... ......... S 0698 1.1607 71.35 .................. 14.27 

68810 ....... Probe nasolacrimal duct .................................... ......... S 0231 2.1451 131.86 .................. 26.37 

68811 ....... Probe nasolacrimal duct .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68815 ....... Probe nasolacrimal duct .................................... ......... T 0240 17.1243 1,052.60 309.52 210.52 

68840 ....... Explore/irrigate tear ducts .................................. CH .. S 0698 1.1607 71.35 .................. 14.27 

68850 ....... Injection for tear sac x-ray ................................. ......... N .................. .................. .................. .................. ..................

68899 ....... Tear duct system surgery .................................. CH .. T 0238 2.8954 177.97 .................. 35.59 

69000 ....... Drain external ear lesion ................................... ......... T 0006 1.4392 88.46 .................. 17.69 

69005 ....... Drain external ear lesion ................................... ......... T 0008 17.5086 1,076.22 .................. 215.24 

69020 ....... Drain outer ear canal lesion .............................. ......... T 0006 1.4392 88.46 .................. 17.69 

69100 ....... Biopsy of external ear ........................................ ......... T 0019 4.0919 251.52 71.87 50.30 

69105 ....... Biopsy of external ear canal .............................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

69110 ....... Remove external ear, partial ............................. ......... T 0021 15.1024 928.31 219.48 185.66 

69120 ....... Removal of external ear .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

69140 ....... Remove ear canal lesion(s) ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

69145 ....... Remove ear canal lesion(s) ............................... ......... T 0021 15.1024 928.31 219.48 185.66 

69150 ....... Extensive ear canal surgery .............................. ......... T 0252 7.5511 464.15 109.16 92.83 

69200 ....... Clear outer ear canal ......................................... ......... X 0340 0.6102 37.51 .................. 7.50 

69205 ....... Clear outer ear canal ......................................... ......... T 0022 20.0656 1,233.39 354.45 246.68 

69210 ....... Remove impacted ear wax ................................ ......... X 0340 0.6102 37.51 .................. 7.50 

69220 ....... Clean out mastoid cavity ................................... ......... T 0012 0.8432 51.83 11.18 10.37 

69222 ....... Clean out mastoid cavity ................................... CH .. T 0252 7.5511 464.15 109.16 92.83 

69300 ....... Revise external ear ............................................ ......... T 0254 23.3299 1,434.04 321.35 286.81 

69310 ....... Rebuild outer ear canal ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69320 ....... Rebuild outer ear canal ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69399 ....... Outer ear surgery procedure ............................. ......... T 0251 2.452 150.72 .................. 30.14 

69400 ....... Inflate middle ear canal ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

69401 ....... Inflate middle ear canal ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

69405 ....... Catheterize middle ear canal ............................. ......... T 0252 7.5511 464.15 109.16 92.83 

69420 ....... Incision of eardrum ............................................ ......... T 0251 2.452 150.72 .................. 30.14

69421 ....... Incision of eardrum ............................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

69424 ....... Remove ventilating tube .................................... ......... T 0252 7.5511 464.15 109.16 92.83 

69433 ....... Create eardrum opening .................................... ......... T 0252 7.5511 464.15 109.16 92.83 

69436 ....... Create eardrum opening .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94 

69440 ....... Exploration of middle ear ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

69450 ....... Eardrum revision ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68341 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

69501 ....... Mastoidectomy ................................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69502 ....... Mastoidectomy ................................................... ......... T 0254 23.3299 1,434.04 321.35 286.81 

69505 ....... Remove mastoid structures ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69511 ....... Extensive mastoid surgery ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69530 ....... Extensive mastoid surgery ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69540 ....... Remove ear lesion ............................................. ......... T 0253 16.4266 1,009.71 282.29 201.94 

69550 ....... Remove ear lesion ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69552 ....... Remove ear lesion ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69601 ....... Mastoid surgery revision .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69602 ....... Mastoid surgery revision .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69603 ....... Mastoid surgery revision .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69604 ....... Mastoid surgery revision .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69605 ....... Mastoid surgery revision .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69610 ....... Repair of eardrum .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

69620 ....... Repair of eardrum .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

69631 ....... Repair eardrum structures ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60

69632 ....... Rebuild eardrum structures ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69633 ....... Rebuild eardrum structures ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69635 ....... Repair eardrum structures ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60

69636 ....... Rebuild eardrum structures ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69637 ....... Rebuild eardrum structures ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69641 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69642 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69643 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69644 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69645 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69646 ....... Revise middle ear & mastoid ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69650 ....... Release middle ear bone .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81 

69660 ....... Revise middle ear bone ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69661 ....... Revise middle ear bone ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69662 ....... Revise middle ear bone ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69666 ....... Repair middle ear structures ............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69667 ....... Repair middle ear structures ............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69670 ....... Remove mastoid air cells .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60

69676 ....... Remove middle ear nerve ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69700 ....... Close mastoid fistula ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69711 ....... Remove/repair hearing aid ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69714 ....... Implant temple bone w/stimul ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69715 ....... Temple bne implnt w/stimulat ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69717 ....... Temple bone implant revision ........................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69718 ....... Revise temple bone implant .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69720 ....... Release facial nerve .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69725 ....... Release facial nerve .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69740 ....... Repair facial nerve ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69745 ....... Repair facial nerve ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69799 ....... Middle ear surgery procedure ........................... ......... T 0251 2.452 150.72 .................. 30.14 

69801 ....... Incise inner ear .................................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69802 ....... Incise inner ear .................................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69805 ....... Explore inner ear ............................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69806 ....... Explore inner ear ............................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69820 ....... Establish inner ear window ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60

69840 ....... Revise inner ear window ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60

69905 ....... Remove inner ear .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69910 ....... Remove inner ear & mastoid ............................. ......... T 0256 38.1991 2,348.02 .................. 469.60 

69915 ....... Incise inner ear nerve ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60 

69930 ....... Implant cochlear device ..................................... ......... T 0259 414.8455 25,499.72 8,698.43 5,099.94 

69949 ....... Inner ear surgery procedure .............................. ......... T 0251 2.452 150.72 .................. 30.14 

69955 ....... Release facial nerve .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69960 ....... Release inner ear canal .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60 

69979 ....... Temporal bone surgery ..................................... ......... T 0251 2.452 150.72 .................. 30.14 

69990 ....... Microsurgery add-on .......................................... ......... N .................. .................. .................. .................. ..................

70010 ....... Contrast x-ray of brain ....................................... ......... S 0274 2.5544 157.01 62.80 31.40 

70015 ....... Contrast x-ray of brain ....................................... ......... S 0274 2.5544 157.01 62.80 31.40 

70030 ....... X-ray eye for foreign body ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

70100 ....... X-ray exam of jaw .............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

70110 ....... X-ray exam of jaw .............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

70120 ....... X-ray exam of mastoids ..................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70130 ....... X-ray exam of mastoids ..................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70134 ....... X-ray exam of middle ear .................................. ......... X 0261 1.2224 75.14 .................. 15.03 

70140 ....... X-ray exam of facial bones ................................ ......... X 0260 0.7093 43.60 .................. 8.72 


cprice-sewell on PRODPC62 with RULES2
68342 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

70150 ....... X-ray exam of facial bones ................................ ......... X 0260 0.7093 43.60 .................. 8.72 

70160 ....... X-ray exam of nasal bones ............................... ......... X 0260 0.7093 43.60 .................. 8.72 

70170 ....... X-ray exam of tear duct ..................................... ......... X 0264 2.9586 181.86 70.27 36.37 

70190 ....... X-ray exam of eye sockets ................................ ......... X 0260 0.7093 43.60 .................. 8.72 

70200 ....... X-ray exam of eye sockets ................................ ......... X 0260 0.7093 43.60 .................. 8.72 

70210 ....... X-ray exam of sinuses ....................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70220 ....... X-ray exam of sinuses ....................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70240 ....... X-ray exam, pituitary saddle .............................. ......... X 0260 0.7093 43.60 .................. 8.72 

70250 ....... X-ray exam of skull ............................................ ......... X 0260 0.7093 43.60 .................. 8.72 

70260 ....... X-ray exam of skull ............................................ ......... X 0261 1.2224 75.14 .................. 15.03

70300 ....... X-ray exam of teeth ........................................... ......... X 0262 0.655 40.26 .................. 8.05 

70310 ....... X-ray exam of teeth ........................................... ......... X 0262 0.655 40.26 .................. 8.05 

70320 ....... Full mouth x-ray of teeth ................................... ......... X 0262 0.655 40.26 .................. 8.05 

70328 ....... X-ray exam of jaw joint ...................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70330 ....... X-ray exam of jaw joints .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70332 ....... X-ray exam of jaw joint ...................................... ......... S 0275 3.6915 226.91 69.09 45.38 

70336 ....... Magnetic image, jaw joint .................................. ......... S 0335 4.5523 279.82 111.92 55.96 

70350 ....... X-ray head for orthodontia ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

70355 ....... Panoramic x-ray of jaws .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70360 ....... X-ray exam of neck ........................................... ......... X 0260 0.7093 43.60 .................. 8.72 

70370 ....... Throat x-ray & fluoroscopy ................................ ......... X 0272 1.2908 79.34 31.64 15.87 

70371 ....... Speech evaluation, complex .............................. ......... X 0272 1.2908 79.34 31.64 15.87 

70373 ....... Contrast x-ray of larynx ..................................... ......... X 0263 1.6956 104.23 23.77 20.85 

70380 ....... X-ray exam of salivary gland ............................. ......... X 0260 0.7093 43.60 .................. 8.72 

70390 ....... X-ray exam of salivary duct ............................... ......... X 0263 1.6956 104.23 23.77 20.85 

70450 ....... Ct head/brain w/o dye ....................................... ......... S 0332 3.0908 189.99 75.24 38.00 

70460 ....... Ct head/brain w/dye ........................................... ......... S 0283 4.0825 250.94 100.37 50.19 

70470 ....... Ct head/brain w/o & w/dye ................................ ......... S 0333 4.8405 297.54 119.01 59.51 

70480 ....... Ct orbit/ear/fossa w/o dye .................................. ......... S 0332 3.0908 189.99 75.24 38.00 

70481 ....... Ct orbit/ear/fossa w/dye ..................................... ......... S 0283 4.0825 250.94 100.37 50.19 

70482 ....... Ct orbit/ear/fossa w/o&w/dye ............................. ......... S 0333 4.8405 297.54 119.01 59.51 

70486 ....... Ct maxillofacial w/o dye ..................................... ......... S 0332 3.0908 189.99 75.24 38.00 

70487 ....... Ct maxillofacial w/dye ........................................ ......... S 0283 4.0825 250.94 100.37 50.19 

70488 ....... Ct maxillofacial w/o & w/dye .............................. ......... S 0333 4.8405 297.54 119.01 59.51 

70490 ....... Ct soft tissue neck w/o dye ............................... ......... S 0332 3.0908 189.99 75.24 38.00 

70491 ....... Ct soft tissue neck w/dye .................................. ......... S 0283 4.0825 250.94 100.37 50.19 

70492 ....... Ct sft tsue nck w/o & w/dye ............................... ......... S 0333 4.8405 297.54 119.01 59.51 

70496 ....... Ct angiography, head ........................................ ......... S 0662 4.8552 298.44 118.88 59.69 

70498 ....... Ct angiography, neck ......................................... ......... S 0662 4.8552 298.44 118.88 59.69 

70540 ....... Mri orbit/face/neck w/o dye ................................ ......... S 0336 5.6745 348.80 139.51 69.76 

70542 ....... Mri orbit/face/neck w/dye ................................... ......... S 0284 6.1231 376.37 148.40 75.27 

70543 ....... Mri orbt/fac/nck w/o & w/dye ............................. ......... S 0337 8.1155 498.84 199.53 99.77 

70544 ....... Mr angiography head w/o dye ........................... ......... S 0336 5.6745 348.80 139.51 69.76 

70545 ....... Mr angiography head w/dye .............................. ......... S 0284 6.1231 376.37 148.40 75.27 

70546 ....... Mr angiograph head w/o&w/dye ........................ ......... S 0337 8.1155 498.84 199.53 99.77 

70547 ....... Mr angiography neck w/o dye ........................... ......... S 0336 5.6745 348.80 139.51 69.76 

70548 ....... Mr angiography neck w/dye .............................. ......... S 0284 6.1231 376.37 148.40 75.27 

70549 ....... Mr angiograph neck w/o&w/dye ........................ ......... S 0337 8.1155 498.84 199.53 99.77 

70551 ....... Mri brain w/o dye ............................................... ......... S 0336 5.6745 348.80 139.51 69.76 

70552 ....... Mri brain w/dye .................................................. ......... S 0284 6.1231 376.37 148.40 75.27 

70553 ....... Mri brain w/o & w/dye ........................................ ......... S 0337 8.1155 498.84 199.53 99.77 

70554 ....... Fmri brain by tech .............................................. NI .... S 0336 5.6745 348.80 139.51 69.76 

70555 ....... Fmri brain by phys/psych .................................. NI .... S 0336 5.6745 348.80 139.51 69.76 

70557 ....... Mri brain w/o dye ............................................... ......... S 0336 5.6745 348.80 139.51 69.76 

70558 ....... Mri brain w/dye .................................................. ......... S 0284 6.1231 376.37 148.40 75.27 

70559 ....... Mri brain w/o & w/dye ........................................ ......... S 0337 8.1155 498.84 199.53 99.77 

71010 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71015 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71020 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71021 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71022 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71023 ....... Chest x-ray and fluoroscopy .............................. ......... X 0272 1.2908 79.34 31.64 15.87 

71030 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71034 ....... Chest x-ray and fluoroscopy .............................. ......... X 0272 1.2908 79.34 31.64 15.87 

71035 ....... Chest x-ray ........................................................ ......... X 0260 0.7093 43.60 .................. 8.72 

71040 ....... Contrast x-ray of bronchi ................................... ......... X 0263 1.6956 104.23 23.77 20.85 

71060 ....... Contrast x-ray of bronchi ................................... ......... X 0263 1.6956 104.23 23.77 20.85 

71090 ....... X-ray & pacemaker insertion ............................. ......... X 0272 1.2908 79.34 31.64 15.87 

71100 ....... X-ray exam of ribs ............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

71101 ....... X-ray exam of ribs/chest .................................... ......... X 0260 0.7093 43.60 .................. 8.72 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68343 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

71110 ....... X-ray exam of ribs ............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

71111 ....... X-ray exam of ribs/chest .................................... ......... X 0261 1.2224 75.14 .................. 15.03 

71120 ....... X-ray exam of breastbone ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

71130 ....... X-ray exam of breastbone ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

71250 ....... Ct thorax w/o dye .............................................. ......... S 0332 3.0908 189.99 75.24 38.00 

71260 ....... Ct thorax w/dye .................................................. ......... S 0283 4.0825 250.94 100.37 50.19 

71270 ....... Ct thorax w/o & w/dye ....................................... ......... S 0333 4.8405 297.54 119.01 59.51 

71275 ....... Ct angiography, chest ........................................ ......... S 0662 4.8552 298.44 118.88 59.69 

71550 ....... Mri chest w/o dye .............................................. ......... S 0336 5.6745 348.80 139.51 69.76 

71551 ....... Mri chest w/dye .................................................. ......... S 0284 6.1231 376.37 148.40 75.27 

71552 ....... Mri chest w/o & w/dye ....................................... ......... S 0337 8.1155 498.84 199.53 99.77 

72010 ....... X-ray exam of spine .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

72020 ....... X-ray exam of spine .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

72040 ....... X-ray exam of neck spine .................................. ......... X 0260 0.7093 43.60 .................. 8.72 

72050 ....... X-ray exam of neck spine .................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72052 ....... X-ray exam of neck spine .................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72069 ....... X-ray exam of trunk spine ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

72070 ....... X-ray exam of thoracic spine ............................. ......... X 0260 0.7093 43.60 .................. 8.72 

72072 ....... X-ray exam of thoracic spine ............................. ......... X 0260 0.7093 43.60 .................. 8.72 

72074 ....... X-ray exam of thoracic spine ............................. ......... X 0260 0.7093 43.60 .................. 8.72 

72080 ....... X-ray exam of trunk spine ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

72090 ....... X-ray exam of trunk spine ................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72100 ....... X-ray exam of lower spine ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

72110 ....... X-ray exam of lower spine ................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72114 ....... X-ray exam of lower spine ................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72120 ....... X-ray exam of lower spine ................................. ......... X 0261 1.2224 75.14 .................. 15.03 

72125 ....... Ct neck spine w/o dye ....................................... ......... S 0332 3.0908 189.99 75.24 38.00 

72126 ....... Ct neck spine w/dye .......................................... ......... S 0283 4.0825 250.94 100.37 50.19 

72127 ....... Ct neck spine w/o & w/dye ................................ ......... S 0333 4.8405 297.54 119.01 59.51 

72128 ....... Ct chest spine w/o dye ...................................... ......... S 0332 3.0908 189.99 75.24 38.00 

72129 ....... Ct chest spine w/dye ......................................... ......... S 0283 4.0825 250.94 100.37 50.19 

72130 ....... Ct chest spine w/o & w/dye ............................... ......... S 0333 4.8405 297.54 119.01 59.51 

72131 ....... Ct lumbar spine w/o dye .................................... ......... S 0332 3.0908 189.99 75.24 38.00 

72132 ....... Ct lumbar spine w/dye ....................................... ......... S 0283 4.0825 250.94 100.37 50.19 

72133 ....... Ct lumbar spine w/o & w/dye ............................ ......... S 0333 4.8405 297.54 119.01 59.51 

72141 ....... Mri neck spine w/o dye ...................................... ......... S 0336 5.6745 348.80 139.51 69.76 

72142 ....... Mri neck spine w/dye ......................................... ......... S 0284 6.1231 376.37 148.40 75.27 

72146 ....... Mri chest spine w/o dye ..................................... ......... S 0336 5.6745 348.80 139.51 69.76 

72147 ....... Mri chest spine w/dye ........................................ ......... S 0284 6.1231 376.37 148.40 75.27 

72148 ....... Mri lumbar spine w/o dye .................................. ......... S 0336 5.6745 348.80 139.51 69.76 

72149 ....... Mri lumbar spine w/dye ..................................... ......... S 0284 6.1231 376.37 148.40 75.27 

72156 ....... Mri neck spine w/o & w/dye .............................. ......... S 0337 8.1155 498.84 199.53 99.77 

72157 ....... Mri chest spine w/o & w/dye ............................. ......... S 0337 8.1155 498.84 199.53 99.77 

72158 ....... Mri lumbar spine w/o & w/dye ........................... ......... S 0337 8.1155 498.84 199.53 99.77 

72170 ....... X-ray exam of pelvis .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

72190 ....... X-ray exam of pelvis .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

72191 ....... Ct angiograph pelv w/o&w/dye .......................... ......... S 0662 4.8552 298.44 118.88 59.69 

72192 ....... Ct pelvis w/o dye ............................................... ......... S 0332 3.0908 189.99 75.24 38.00 

72193 ....... Ct pelvis w/dye .................................................. ......... S 0283 4.0825 250.94 100.37 50.19 

72194 ....... Ct pelvis w/o & w/dye ........................................ ......... S 0333 4.8405 297.54 119.01 59.51 

72195 ....... Mri pelvis w/o dye .............................................. ......... S 0336 5.6745 348.80 139.51 69.76 

72196 ....... Mri pelvis w/dye ................................................. ......... S 0284 6.1231 376.37 148.40 75.27 

72197 ....... Mri pelvis w/o & w/dye ....................................... ......... S 0337 8.1155 498.84 199.53 99.77 

72200 ....... X-ray exam sacroiliac joints ............................... ......... X 0260 0.7093 43.60 .................. 8.72 

72202 ....... X-ray exam sacroiliac joints ............................... ......... X 0260 0.7093 43.60 .................. 8.72 

72220 ....... X-ray exam of tailbone ...................................... ......... X 0260 0.7093 43.60 .................. 8.72 

72240 ....... Contrast x-ray of neck spine ............................. ......... S 0274 2.5544 157.01 62.80 31.40 

72255 ....... Contrast x-ray, thorax spine .............................. ......... S 0274 2.5544 157.01 62.80 31.40 

72265 ....... Contrast x-ray, lower spine ................................ ......... S 0274 2.5544 157.01 62.80 31.40 

72270 ....... Contrast x-ray, spine ......................................... ......... S 0274 2.5544 157.01 62.80 31.40 

72275 ....... Epidurography .................................................... ......... S 0274 2.5544 157.01 62.80 31.40 

72285 ....... X-ray c/t spine disk ............................................ ......... S 0388 15.9758 982.00 289.72 196.40 

72291 ....... Perq vertebroplasty, fluor .................................. NI .... S 0274 2.5544 157.01 62.80 31.40 

72292 ....... Perq vertebroplasty, ct ....................................... NI .... S 0274 2.5544 157.01 62.80 31.40 

72295 ....... X-ray of lower spine disk ................................... ......... S 0388 15.9758 982.00 289.72 196.40 

73000 ....... X-ray exam of collar bone ................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73010 ....... X-ray exam of shoulder blade ........................... ......... X 0260 0.7093 43.60 .................. 8.72 

73020 ....... X-ray exam of shoulder ..................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73030 ....... X-ray exam of shoulder ..................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73040 ....... Contrast x-ray of shoulder ................................. ......... S 0275 3.6915 226.91 69.09 45.38 


cprice-sewell on PRODPC62 with RULES2
68344 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

73050 ....... X-ray exam of shoulders ................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73060 ....... X-ray exam of humerus ..................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73070 ....... X-ray exam of elbow .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73080 ....... X-ray exam of elbow .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73085 ....... Contrast x-ray of elbow ..................................... ......... S 0275 3.6915 226.91 69.09 45.38 

73090 ....... X-ray exam of forearm ....................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73092 ....... X-ray exam of arm, infant .................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73100 ....... X-ray exam of wrist ............................................ ......... X 0260 0.7093 43.60 .................. 8.72 

73110 ....... X-ray exam of wrist ............................................ ......... X 0260 0.7093 43.60 .................. 8.72 

73115 ....... Contrast x-ray of wrist ....................................... ......... S 0275 3.6915 226.91 69.09 45.38 

73120 ....... X-ray exam of hand ........................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73130 ....... X-ray exam of hand ........................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73140 ....... X-ray exam of finger(s) ...................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73200 ....... Ct upper extremity w/o dye ............................... ......... S 0332 3.0908 189.99 75.24 38.00 

73201 ....... Ct upper extremity w/dye ................................... ......... S 0283 4.0825 250.94 100.37 50.19 

73202 ....... Ct uppr extremity w/o&w/dye ............................. ......... S 0333 4.8405 297.54 119.01 59.51 

73206 ....... Ct angio upr extrm w/o&w/dye .......................... ......... S 0662 4.8552 298.44 118.88 59.69 

73218 ....... Mri upper extremity w/o dye .............................. ......... S 0336 5.6745 348.80 139.51 69.76 

73219 ....... Mri upper extremity w/dye ................................. ......... S 0284 6.1231 376.37 148.40 75.27 

73220 ....... Mri uppr extremity w/o&w/dye ........................... ......... S 0337 8.1155 498.84 199.53 99.77 

73221 ....... Mri joint upr extrem w/o dye .............................. ......... S 0336 5.6745 348.80 139.51 69.76 

73222 ....... Mri joint upr extrem w/dye ................................. ......... S 0284 6.1231 376.37 148.40 75.27 

73223 ....... Mri joint upr extr w/o&w/dye .............................. ......... S 0337 8.1155 498.84 199.53 99.77 

73500 ....... X-ray exam of hip .............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73510 ....... X-ray exam of hip .............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73520 ....... X-ray exam of hips ............................................ ......... X 0261 1.2224 75.14 .................. 15.03 

73525 ....... Contrast x-ray of hip .......................................... ......... S 0275 3.6915 226.91 69.09 45.38 

73530 ....... X-ray exam of hip .............................................. ......... X 0261 1.2224 75.14 .................. 15.03

73540 ....... X-ray exam of pelvis & hips .............................. ......... X 0260 0.7093 43.60 .................. 8.72 

73542 ....... X-ray exam, sacroiliac joint ............................... ......... S 0275 3.6915 226.91 69.09 45.38 

73550 ....... X-ray exam of thigh ........................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73560 ....... X-ray exam of knee, 1 or 2 ............................... ......... X 0260 0.7093 43.60 .................. 8.72 

73562 ....... X-ray exam of knee, 3 ....................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73564 ....... X-ray exam, knee, 4 or more ............................ ......... X 0260 0.7093 43.60 .................. 8.72 

73565 ....... X-ray exam of knees ......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73580 ....... Contrast x-ray of knee joint ............................... ......... S 0275 3.6915 226.91 69.09 45.38 

73590 ....... X-ray exam of lower leg .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73592 ....... X-ray exam of leg, infant ................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73600 ....... X-ray exam of ankle .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73610 ....... X-ray exam of ankle .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73615 ....... Contrast x-ray of ankle ...................................... ......... S 0275 3.6915 226.91 69.09 45.38 

73620 ....... X-ray exam of foot ............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73630 ....... X-ray exam of foot ............................................. ......... X 0260 0.7093 43.60 .................. 8.72 

73650 ....... X-ray exam of heel ............................................ ......... X 0260 0.7093 43.60 .................. 8.72 

73660 ....... X-ray exam of toe(s) .......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

73700 ....... Ct lower extremity w/o dye ................................ ......... S 0332 3.0908 189.99 75.24 38.00 

73701 ....... Ct lower extremity w/dye ................................... ......... S 0283 4.0825 250.94 100.37 50.19 

73702 ....... Ct lwr extremity w/o&w/dye ............................... ......... S 0333 4.8405 297.54 119.01 59.51 

73706 ....... Ct angio lwr extr w/o&w/dye .............................. ......... S 0662 4.8552 298.44 118.88 59.69 

73718 ....... Mri lower extremity w/o dye ............................... ......... S 0336 5.6745 348.80 139.51 69.76 

73719 ....... Mri lower extremity w/dye .................................. ......... S 0284 6.1231 376.37 148.40 75.27 

73720 ....... Mri lwr extremity w/o&w/dye .............................. ......... S 0337 8.1155 498.84 199.53 99.77 

73721 ....... Mri jnt of lwr extre w/o dye ................................ ......... S 0336 5.6745 348.80 139.51 69.76 

73722 ....... Mri joint of lwr extr w/dye .................................. ......... S 0284 6.1231 376.37 148.40 75.27 

73723 ....... Mri joint lwr extr w/o&w/dye ............................... ......... S 0337 8.1155 498.84 199.53 99.77 

74000 ....... X-ray exam of abdomen .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

74010 ....... X-ray exam of abdomen .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

74020 ....... X-ray exam of abdomen .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

74022 ....... X-ray exam series, abdomen ............................ ......... X 0261 1.2224 75.14 .................. 15.03 

74150 ....... Ct abdomen w/o dye ......................................... ......... S 0332 3.0908 189.99 75.24 38.00 

74160 ....... Ct abdomen w/dye ............................................. ......... S 0283 4.0825 250.94 100.37 50.19 

74170 ....... Ct abdomen w/o & w/dye .................................. ......... S 0333 4.8405 297.54 119.01 59.51 

74175 ....... Ct angio abdom w/o & w/dye ............................ ......... S 0662 4.8552 298.44 118.88 59.69 

74181 ....... Mri abdomen w/o dye ........................................ ......... S 0336 5.6745 348.80 139.51 69.76 

74182 ....... Mri abdomen w/dye ........................................... ......... S 0284 6.1231 376.37 148.40 75.27 

74183 ....... Mri abdomen w/o & w/dye ................................. ......... S 0337 8.1155 498.84 199.53 99.77 

74190 ....... X-ray exam of peritoneum ................................. ......... X 0264 2.9586 181.86 70.27 36.37 

74210 ....... Contrst x-ray exam of throat .............................. ......... S 0276 1.4294 87.86 34.97 17.57 

74220 ....... Contrast x-ray, esophagus ................................ ......... S 0276 1.4294 87.86 34.97 17.57 

74230 ....... Cine/vid x-ray, throat/esoph ............................... ......... S 0276 1.4294 87.86 34.97 17.57 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68345 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

74235 ....... Remove esophagus obstruction ........................ CH .. S 0257 1.0974 67.45 .................. 13.49 

74240 ....... X-ray exam, upper gi tract ................................. ......... S 0276 1.4294 87.86 34.97 17.57 

74241 ....... X-ray exam, upper gi tract ................................. ......... S 0276 1.4294 87.86 34.97 17.57 

74245 ....... X-ray exam, upper gi tract ................................. ......... S 0277 2.2176 136.31 54.52 27.26 

74246 ....... Contrst x-ray uppr gi tract .................................. ......... S 0276 1.4294 87.86 34.97 17.57 

74247 ....... Contrst x-ray uppr gi tract .................................. ......... S 0276 1.4294 87.86 34.97 17.57 

74249 ....... Contrst x-ray uppr gi tract .................................. ......... S 0277 2.2176 136.31 54.52 27.26 

74250 ....... X-ray exam of small bowel ................................ ......... S 0276 1.4294 87.86 34.97 17.57 

74251 ....... X-ray exam of small bowel ................................ ......... S 0277 2.2176 136.31 54.52 27.26 

74260 ....... X-ray exam of small bowel ................................ CH .. S 0276 1.4294 87.86 34.97 17.57 

74270 ....... Contrast x-ray exam of colon ............................ ......... S 0276 1.4294 87.86 34.97 17.57 

74280 ....... Contrast x-ray exam of colon ............................ ......... S 0277 2.2176 136.31 54.52 27.26 

74283 ....... Contrast x-ray exam of colon ............................ ......... S 0276 1.4294 87.86 34.97 17.57 

74290 ....... Contrast x-ray, gallbladder ................................ ......... S 0276 1.4294 87.86 34.97 17.57 

74291 ....... Contrast x-rays, gallbladder ............................... ......... S 0276 1.4294 87.86 34.97 17.57 

74300 ....... X-ray bile ducts/pancreas .................................. ......... X 0263 1.6956 104.23 23.77 20.85 

74301 ....... X-rays at surgery add-on ................................... ......... X 0263 1.6956 104.23 23.77 20.85 

74305 ....... X-ray bile ducts/pancreas .................................. ......... X 0263 1.6956 104.23 23.77 20.85 

74320 ....... Contrast x-ray of bile ducts ............................... ......... X 0264 2.9586 181.86 70.27 36.37 

74327 ....... X-ray bile stone removal .................................... ......... S 0296 2.6802 164.75 53.99 32.95 

74328 ....... X-ray bile duct endoscopy ................................. ......... N .................. .................. .................. .................. ..................

74329 ....... X-ray for pancreas endoscopy .......................... ......... N .................. .................. .................. .................. ..................

74330 ....... X-ray bile/panc endoscopy ................................ ......... N .................. .................. .................. .................. ..................

74340 ....... X-ray guide for GI tube ...................................... ......... X 0272 1.2908 79.34 31.64 15.87 

74350 ....... X-ray guide, stomach tube ................................ ......... X 0263 1.6956 104.23 23.77 20.85 

74355 ....... X-ray guide, intestinal tube ................................ ......... X 0263 1.6956 104.23 23.77 20.85 

74360 ....... X-ray guide, GI dilation ...................................... CH .. S 0257 1.0974 67.45 .................. 13.49 

74363 ....... X-ray, bile duct dilation ...................................... ......... S 0297 3.6392 223.69 89.47 44.74 

74400 ....... Contrst x-ray, urinary tract ................................. ......... S 0278 2.4159 148.50 59.40 29.70 

74410 ....... Contrst x-ray, urinary tract ................................. ......... S 0278 2.4159 148.50 59.40 29.70 

74415 ....... Contrst x-ray, urinary tract ................................. ......... S 0278 2.4159 148.50 59.40 29.70 

74420 ....... Contrst x-ray, urinary tract ................................. ......... S 0278 2.4159 148.50 59.40 29.70 

74425 ....... Contrst x-ray, urinary tract ................................. ......... S 0278 2.4159 148.50 59.40 29.70 

74430 ....... Contrast x-ray, bladder ...................................... ......... S 0278 2.4159 148.50 59.40 29.70 

74440 ....... X-ray, male genital tract .................................... ......... S 0278 2.4159 148.50 59.40 29.70 

74445 ....... X-ray exam of penis .......................................... ......... S 0278 2.4159 148.50 59.40 29.70 

74450 ....... X-ray, urethra/bladder ........................................ ......... S 0278 2.4159 148.50 59.40 29.70 

74455 ....... X-ray, urethra/bladder ........................................ ......... S 0278 2.4159 148.50 59.40 29.70 

74470 ....... X-ray exam of kidney lesion .............................. ......... X 0263 1.6956 104.23 23.77 20.85 

74475 ....... X-ray control, cath insert ................................... ......... S 0297 3.6392 223.69 89.47 44.74 

74480 ....... X-ray control, cath insert ................................... ......... S 0296 2.6802 164.75 53.99 32.95 

74485 ....... X-ray guide, GU dilation .................................... ......... S 0296 2.6802 164.75 53.99 32.95 

74710 ....... X-ray measurement of pelvis ............................. ......... X 0261 1.2224 75.14 .................. 15.03 

74740 ....... X-ray, female genital tract ................................. ......... X 0264 2.9586 181.86 70.27 36.37 

74742 ....... X-ray, fallopian tube ........................................... ......... X 0264 2.9586 181.86 70.27 36.37 

74775 ....... X-ray exam of perineum .................................... ......... S 0278 2.4159 148.50 59.40 29.70 

75552 ....... Heart mri for morph w/o dye ............................. ......... S 0336 5.6745 348.80 139.51 69.76 

75553 ....... Heart mri for morph w/dye ................................. ......... S 0284 6.1231 376.37 148.40 75.27 

75554 ....... Cardiac MRI/function ......................................... ......... S 0336 5.6745 348.80 139.51 69.76 

75555 ....... Cardiac MRI/limited study .................................. ......... S 0336 5.6745 348.80 139.51 69.76 

75600 ....... Contrast x-ray exam of aorta ............................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75605 ....... Contrast x-ray exam of aorta ............................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75625 ....... Contrast x-ray exam of aorta ............................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75630 ....... X-ray aorta, leg arteries ..................................... ......... S 0280 20.8225 1,279.92 353.85 255.98 

75635 ....... Ct angio abdominal arteries .............................. ......... S 0662 4.8552 298.44 118.88 59.69 

75650 ....... Artery x-rays, head & neck ................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75658 ....... Artery x-rays, arm .............................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75660 ....... Artery x-rays, head & neck ................................ ......... S 0668 6.2463 383.95 88.26 76.79 

75662 ....... Artery x-rays, head & neck ................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75665 ....... Artery x-rays, head & neck ................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75671 ....... Artery x-rays, head & neck ................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75676 ....... Artery x-rays, neck ............................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75680 ....... Artery x-rays, neck ............................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75685 ....... Artery x-rays, spine ............................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75705 ....... Artery x-rays, spine ............................................ ......... S 0668 6.2463 383.95 88.26 76.79 

75710 ....... Artery x-rays, arm/leg ........................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75716 ....... Artery x-rays, arms/legs ..................................... ......... S 0280 20.8225 1,279.92 353.85 255.98 

75722 ....... Artery x-rays, kidney .......................................... ......... S 0280 20.8225 1,279.92 353.85 255.98 

75724 ....... Artery x-rays, kidneys ........................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75726 ....... Artery x-rays, abdomen ..................................... ......... S 0280 20.8225 1,279.92 353.85 255.98 


cprice-sewell on PRODPC62 with RULES2
68346 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

75731 ....... Artery x-rays, adrenal gland .............................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75733 ....... Artery x-rays, adrenals ...................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75736 ....... Artery x-rays, pelvis ........................................... ......... S 0280 20.8225 1,279.92 353.85 255.98 

75741 ....... Artery x-rays, lung ............................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75743 ....... Artery x-rays, lungs ............................................ ......... S 0280 20.8225 1,279.92 353.85 255.98 

75746 ....... Artery x-rays, lung ............................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75756 ....... Artery x-rays, chest ............................................ ......... S 0279 9.5061 584.32 150.03 116.86 

75774 ....... Artery x-ray, each vessel ................................... ......... S 0279 9.5061 584.32 150.03 116.86 

75790 ....... Visualize A–V shunt ........................................... ......... S 0279 9.5061 584.32 150.03 116.86 

75801 ....... Lymph vessel x-ray, arm/leg ............................. ......... X 0264 2.9586 181.86 70.27 36.37 

75803 ....... Lymph vessel x-ray,arms/legs ........................... ......... X 0264 2.9586 181.86 70.27 36.37 

75805 ....... Lymph vessel x-ray, trunk ................................. ......... X 0264 2.9586 181.86 70.27 36.37 

75807 ....... Lymph vessel x-ray, trunk ................................. ......... X 0264 2.9586 181.86 70.27 36.37 

75809 ....... Nonvascular shunt, x-ray ................................... ......... X 0263 1.6956 104.23 23.77 20.85 

75810 ....... Vein x-ray, spleen/liver ...................................... ......... S 0279 9.5061 584.32 150.03 116.86 

75820 ....... Vein x-ray, arm/leg ............................................ ......... S 0668 6.2463 383.95 88.26 76.79 

75822 ....... Vein x-ray, arms/legs ......................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75825 ....... Vein x-ray, trunk ................................................ ......... S 0279 9.5061 584.32 150.03 116.86 

75827 ....... Vein x-ray, chest ................................................ ......... S 0279 9.5061 584.32 150.03 116.86 

75831 ....... Vein x-ray, kidney .............................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75833 ....... Vein x-ray, kidneys ............................................ ......... S 0279 9.5061 584.32 150.03 116.86 

75840 ....... Vein x-ray, adrenal gland .................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75842 ....... Vein x-ray, adrenal glands ................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75860 ....... Vein x-ray, neck ................................................. ......... S 0668 6.2463 383.95 88.26 76.79 

75870 ....... Vein x-ray, skull ................................................. ......... S 0668 6.2463 383.95 88.26 76.79 

75872 ....... Vein x-ray, skull ................................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75880 ....... Vein x-ray, eye socket ....................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75885 ....... Vein x-ray, liver .................................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75887 ....... Vein x-ray, liver .................................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75889 ....... Vein x-ray, liver .................................................. ......... S 0280 20.8225 1,279.92 353.85 255.98 

75891 ....... Vein x-ray, liver .................................................. ......... S 0279 9.5061 584.32 150.03 116.86 

75893 ....... Venous sampling by catheter ............................ CH .. Q 0668 6.2463 383.95 88.26 76.79 

75894 ....... X-rays, transcath therapy .................................. CH .. S 0298 8.3906 515.75 206.30 103.15 

75896 ....... X-rays, transcath therapy .................................. CH .. S 0298 8.3906 515.75 206.30 103.15 

75898 ....... Follow-up angiography ...................................... ......... X 0263 1.6956 104.23 23.77 20.85 

75901 ....... Remove cva device obstruct ............................. ......... X 0263 1.6956 104.23 23.77 20.85 

75902 ....... Remove cva lumen obstruct .............................. ......... X 0263 1.6956 104.23 23.77 20.85 

75940 ....... X-ray placement, vein filter ................................ CH .. S 0298 8.3906 515.75 206.30 103.15 

75945 ....... Intravascular us ................................................. ......... S 0267 2.4606 151.25 60.50 30.25 

75946 ....... Intravascular us add-on ..................................... ......... S 0266 1.5607 95.93 37.80 19.19 

75960 ....... Transcath iv stent rs&i ....................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75961 ....... Retrieval, broken catheter ................................. ......... S 0668 6.2463 383.95 88.26 76.79 

75962 ....... Repair arterial blockage ..................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75964 ....... Repair artery blockage, each ............................ ......... S 0668 6.2463 383.95 88.26 76.79 

75966 ....... Repair arterial blockage ..................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75968 ....... Repair artery blockage, each ............................ ......... S 0668 6.2463 383.95 88.26 76.79 

75970 ....... Vascular biopsy ................................................. ......... S 0668 6.2463 383.95 88.26 76.79 

75978 ....... Repair venous blockage .................................... ......... S 0668 6.2463 383.95 88.26 76.79 

75980 ....... Contrast xray exam bile duct ............................. ......... S 0297 3.6392 223.69 89.47 44.74 

75982 ....... Contrast xray exam bile duct ............................. ......... S 0297 3.6392 223.69 89.47 44.74 

75984 ....... Xray control catheter change ............................ ......... X 0263 1.6956 104.23 23.77 20.85 

75989 ....... Abscess drainage under x-ray ........................... ......... N .................. .................. .................. .................. ..................

75992 ....... Atherectomy, x-ray exam ................................... CH .. S 0668 6.2463 383.95 88.26 76.79 

75993 ....... Atherectomy, x-ray exam ................................... CH .. S 0668 6.2463 383.95 88.26 76.79 

75994 ....... Atherectomy, x-ray exam ................................... CH .. S 0668 6.2463 383.95 88.26 76.79 

75995 ....... Atherectomy, x-ray exam ................................... CH .. S 0668 6.2463 383.95 88.26 76.79 

75996 ....... Atherectomy, x-ray exam ................................... CH .. S 0668 6.2463 383.95 88.26 76.79 

75998 ....... Fluoroguide for vein device ............................... CH .. D .................. .................. .................. .................. ..................

76000 ....... Fluoroscope examination ................................... ......... X 0272 1.2908 79.34 31.64 15.87 

76001 ....... Fluoroscope exam, extensive ............................ ......... N .................. .................. .................. .................. ..................

76003 ....... Needle localization by x-ray .............................. CH .. D .................. .................. .................. .................. ..................

76005 ....... Fluoroguide for spine inject ............................... CH .. D .................. .................. .................. .................. ..................

76006 ....... X-ray stress view ............................................... CH .. D .................. .................. .................. .................. ..................

76010 ....... X-ray, nose to rectum ........................................ ......... X 0260 0.7093 43.60 .................. 8.72 

76012 ....... Percut vertebroplasty fluor ................................. CH .. D .................. .................. .................. .................. ..................

76013 ....... Percut vertebroplasty, ct .................................... CH .. D .................. .................. .................. .................. ..................

76020 ....... X-rays for bone age ........................................... CH .. D .................. .................. .................. .................. ..................

76040 ....... X-rays, bone evaluation ..................................... CH .. D .................. .................. .................. .................. ..................

76061 ....... X-rays, bone survey ........................................... CH .. D .................. .................. .................. .................. ..................

76062 ....... X-rays, bone survey ........................................... CH .. D .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68347 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

76065 ....... X-rays, bone evaluation ..................................... CH .. D .................. .................. .................. .................. ..................

76066 ....... Joint survey, single view .................................... CH .. D .................. .................. .................. .................. ..................

76070 ....... Ct bone density, axial ........................................ CH .. D .................. .................. .................. .................. ..................

76071 ....... Ct bone density, peripheral ............................... CH .. D .................. .................. .................. .................. ..................

76075 ....... Dxa bone density, axial ..................................... CH .. D .................. .................. .................. .................. ..................

76076 ....... Dxa bone density/peripheral .............................. CH .. D .................. .................. .................. .................. ..................

76077 ....... Dxa bone density/v-fracture ............................... CH .. D .................. .................. .................. .................. ..................

76078 ....... Radiographic absorptiometry ............................. CH .. D .................. .................. .................. .................. ..................

76080 ....... X-ray exam of fistula .......................................... ......... X 0263 1.6956 104.23 23.77 20.85 

76082 ....... Computer mammogram add-on ........................ CH .. D .................. .................. .................. .................. ..................

76083 ....... Computer mammogram add-on ........................ CH .. D .................. .................. .................. .................. ..................

76086 ....... X-ray of mammary duct ..................................... CH .. D .................. .................. .................. .................. ..................

76088 ....... X-ray of mammary ducts ................................... CH .. D .................. .................. .................. .................. ..................

76090 ....... Mammogram, one breast .................................. CH .. D .................. .................. .................. .................. ..................

76091 ....... Mammogram, both breasts ................................ CH .. D .................. .................. .................. .................. ..................

76092 ....... Mammogram, screening .................................... CH .. D .................. .................. .................. .................. ..................

76093 ....... Magnetic image, breast ..................................... CH .. D .................. .................. .................. .................. ..................

76094 ....... Magnetic image, both breasts ........................... CH .. D .................. .................. .................. .................. ..................

76095 ....... Stereotactic breast biopsy ................................. CH .. D .................. .................. .................. .................. ..................

76096 ....... X-ray of needle wire, breast .............................. CH .. D .................. .................. .................. .................. ..................

76098 ....... X-ray exam, breast specimen ............................ ......... X 0260 0.7093 43.60 .................. 8.72 

76100 ....... X-ray exam of body section ............................... ......... X 0261 1.2224 75.14 .................. 15.03 

76101 ....... Complex body section x-ray .............................. ......... X 0263 1.6956 104.23 23.77 20.85 

76102 ....... Complex body section x-rays ............................ ......... X 0264 2.9586 181.86 70.27 36.37 

76120 ....... Cine/video x-rays ............................................... ......... X 0272 1.2908 79.34 31.64 15.87 

76125 ....... Cine/video x-rays add-on ................................... ......... X 0260 0.7093 43.60 .................. 8.72 

76150 ....... X-ray exam, dry process ................................... ......... X 0260 0.7093 43.60 .................. 8.72 

76350 ....... Special x-ray contrast study .............................. ......... N .................. .................. .................. .................. ..................

76355 ....... Ct scan for localization ...................................... CH .. D .................. .................. .................. .................. ..................

76360 ....... Ct scan for needle biopsy .................................. CH .. D .................. .................. .................. .................. ..................

76362 ....... Ct guide for tissue ablation ................................ CH .. D .................. .................. .................. .................. ..................

76370 ....... Ct scan for therapy guide .................................. CH .. D .................. .................. .................. .................. ..................

76376 ....... 3d render w/o postprocess ................................ ......... X 0340 0.6102 37.51 .................. 7.50 

76377 ....... 3d rendering w/postprocess .............................. ......... S 0282 1.5379 94.53 37.81 18.91 

76380 ....... CAT scan follow-up study .................................. ......... S 0282 1.5379 94.53 37.81 18.91 

76393 ....... Mr guidance for needle place ............................ CH .. D .................. .................. .................. .................. ..................

76394 ....... Mri for tissue ablation ........................................ CH .. D .................. .................. .................. .................. ..................

76400 ....... Magnetic image, bone marrow .......................... CH .. D .................. .................. .................. .................. ..................

76496 ....... Fluoroscopic procedure ..................................... ......... X 0272 1.2908 79.34 31.64 15.87 

76497 ....... Ct procedure ...................................................... ......... S 0282 1.5379 94.53 37.81 18.91 

76498 ....... Mri procedure ..................................................... ......... S 0335 4.5523 279.82 111.92 55.96 

76499 ....... Radiographic procedure .................................... ......... X 0260 0.7093 43.60 .................. 8.72 

76506 ....... Echo exam of head ........................................... ......... S 0265 0.9923 60.99 23.63 12.20 

76510 ....... Ophth us, b & quant a ....................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76511 ....... Ophth us, quant a only ...................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76512 ....... Ophth us, b w/non-quant a ................................ ......... S 0266 1.5607 95.93 37.80 19.19 

76513 ....... Echo exam of eye, water bath .......................... ......... S 0266 1.5607 95.93 37.80 19.19 

76514 ....... Echo exam of eye, thickness ............................ ......... X 0340 0.6102 37.51 .................. 7.50 

76516 ....... Echo exam of eye .............................................. ......... S 0265 0.9923 60.99 23.63 12.20 

76519 ....... Echo exam of eye .............................................. ......... S 0266 1.5607 95.93 37.80 19.19 

76529 ....... Echo exam of eye .............................................. ......... S 0265 0.9923 60.99 23.63 12.20 

76536 ....... Us exam of head and neck ............................... ......... S 0266 1.5607 95.93 37.80 19.19 

76604 ....... Us exam, chest .................................................. CH .. S 0265 0.9923 60.99 23.63 12.20 

76645 ....... Us exam, breast(s) ............................................ ......... S 0265 0.9923 60.99 23.63 12.20 

76700 ....... Us exam, abdom, complete ............................... ......... S 0266 1.5607 95.93 37.80 19.19 

76705 ....... Echo exam of abdomen .................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76770 ....... Us exam abdo back wall, comp ........................ ......... S 0266 1.5607 95.93 37.80 19.19 

76775 ....... Us exam abdo back wall, lim ............................ ......... S 0266 1.5607 95.93 37.80 19.19 

76776 ....... Us exam k transpl w/doppler ............................. NI .... S 0266 1.5607 95.93 37.80 19.19 

76778 ....... Us exam kidney transplant ................................ CH .. D .................. .................. .................. .................. ..................

76800 ....... Us exam, spinal canal ....................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76801 ....... Ob us < 14 wks, single fetus ............................. ......... S 0266 1.5607 95.93 37.80 19.19 

76802 ....... Ob us < 14 wks, add"l fetus ............................ ......... S 0265 0.9923 60.99 23.63 12.20 

76805 ....... Ob us  ́ 14 wks, sngl fetus ............................... ......... S 0266 1.5607 95.93 37.80 19.19 

76810 ....... Ob us  ́ 14 wks, addl fetus .............................. ......... S 0266 1.5607 95.93 37.80 19.19 

76811 ....... Ob us, detailed, sngl fetus ................................. ......... S 0267 2.4606 151.25 60.50 30.25 

76812 ....... Ob us, detailed, addl fetus ................................ CH .. S 0265 0.9923 60.99 23.63 12.20 

76813 ....... Ob us nuchal meas, 1 gest ............................... NI .... S 0266 1.5607 95.93 37.80 19.19 

76814 ....... Ob us nuchal meas, add-on .............................. NI .... S 0265 0.9923 60.99 23.63 12.20 

76815 ....... Ob us, limited, fetus(s) ...................................... ......... S 0265 0.9923 60.99 23.63 12.20 


cprice-sewell on PRODPC62 with RULES2
68348 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

76816 ....... Ob us, follow-up, per fetus ................................ ......... S 0265 0.9923 60.99 23.63 12.20 

76817 ....... Transvaginal us, obstetric .................................. CH .. S 0265 0.9923 60.99 23.63 12.20 

76818 ....... Fetal biophys profile w/nst ................................. ......... S 0266 1.5607 95.93 37.80 19.19 

76819 ....... Fetal biophys profil w/o nst ................................ ......... S 0266 1.5607 95.93 37.80 19.19 

76820 ....... Umbilical artery echo ......................................... ......... S 0096 1.5303 94.06 37.62 18.81 

76821 ....... Middle cerebral artery echo ............................... ......... S 0096 1.5303 94.06 37.62 18.81 

76825 ....... Echo exam of fetal heart ................................... CH .. S 0697 1.5973 98.18 35.99 19.64 

76826 ....... Echo exam of fetal heart ................................... ......... S 0697 1.5973 98.18 35.99 19.64 

76827 ....... Echo exam of fetal heart ................................... CH .. S 0697 1.5973 98.18 35.99 19.64 

76828 ....... Echo exam of fetal heart ................................... ......... S 0697 1.5973 98.18 35.99 19.64 

76830 ....... Transvaginal us, non-ob .................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76831 ....... Echo exam, uterus ............................................. ......... S 0267 2.4606 151.25 60.50 30.25 

76856 ....... Us exam, pelvic, complete ................................ ......... S 0266 1.5607 95.93 37.80 19.19 

76857 ....... Us exam, pelvic, limited ..................................... ......... S 0265 0.9923 60.99 23.63 12.20 

76870 ....... Us exam, scrotum .............................................. ......... S 0266 1.5607 95.93 37.80 19.19 

76872 ....... Us, transrectal .................................................... ......... S 0266 1.5607 95.93 37.80 19.19 

76873 ....... Echograp trans r, pros study ............................. ......... S 0266 1.5607 95.93 37.80 19.19 

76880 ....... Us exam, extremity ............................................ ......... S 0266 1.5607 95.93 37.80 19.19 

76885 ....... Us exam infant hips, dynamic ........................... ......... S 0265 0.9923 60.99 23.63 12.20 

76886 ....... Us exam infant hips, static ................................ CH .. S 0265 0.9923 60.99 23.63 12.20 

76930 ....... Echo guide, cardiocentesis ................................ ......... S 0268 1.1882 73.04 .................. 14.61 

76932 ....... Echo guide for heart biopsy .............................. CH .. S 0309 2.1012 129.16 .................. 25.83 

76936 ....... Echo guide for artery repair ............................... CH .. S 0309 2.1012 129.16 .................. 25.83 

76937 ....... Us guide, vascular access ................................. ......... N .................. .................. .................. .................. ..................

76940 ....... Us guide, tissue ablation ................................... ......... S 0268 1.1882 73.04 .................. 14.61 

76941 ....... Echo guide for transfusion ................................. ......... S 0268 1.1882 73.04 .................. 14.61 

76942 ....... Echo guide for biopsy ........................................ ......... S 0268 1.1882 73.04 .................. 14.61 

76945 ....... Echo guide, villus sampling ............................... ......... S 0268 1.1882 73.04 .................. 14.61 

76946 ....... Echo guide for amniocentesis ........................... ......... S 0268 1.1882 73.04 .................. 14.61 

76948 ....... Echo guide, ova aspiration ................................ CH .. S 0309 2.1012 129.16 .................. 25.83 

76950 ....... Echo guidance radiotherapy .............................. ......... S 0268 1.1882 73.04 .................. 14.61 

76965 ....... Echo guidance radiotherapy .............................. CH .. S 0309 2.1012 129.16 .................. 25.83 

76970 ....... Ultrasound exam follow-up ................................ ......... S 0265 0.9923 60.99 23.63 12.20 

76975 ....... GI endoscopic ultrasound .................................. ......... S 0266 1.5607 95.93 37.80 19.19 

76977 ....... Us bone density measure .................................. ......... X 0340 0.6102 37.51 .................. 7.50 

76986 ....... Ultrasound guide intraoper ................................ CH .. D .................. .................. .................. .................. ..................

76998 ....... Us guide, intraop ............................................... NI .... S 0266 1.5607 95.93 37.80 19.19 

76999 ....... Echo examination procedure ............................. ......... S 0265 0.9923 60.99 23.63 12.20 

77001 ....... Fluoroguide for vein device ............................... NI .... N .................. .................. .................. .................. ..................

77002 ....... Needle localization by xray ................................ NI .... N .................. .................. .................. .................. ..................

77003 ....... Fluoroguide for spine inject ............................... NI .... N .................. .................. .................. .................. ..................

77011 ....... Ct scan for localization ...................................... NI .... S 0283 4.0825 250.94 100.37 50.19 

77012 ....... Ct scan for needle biopsy .................................. NI .... S 0283 4.0825 250.94 100.37 50.19 

77013 ....... Ct guide for tissue ablation ................................ NI .... S 0333 4.8405 297.54 119.01 59.51 

77014 ....... Ct scan for therapy guide .................................. NI .... S 0282 1.5379 94.53 37.81 18.91 

77021 ....... Mr guidance for needle place ............................ NI .... S 0335 4.5523 279.82 111.92 55.96 

77022 ....... Mri for tissue ablation ........................................ NI .... S 0335 4.5523 279.82 111.92 55.96 

77031 ....... Stereotact guide for brst bx ............................... NI .... X 0264 2.9586 181.86 70.27 36.37 

77032 ....... Guidance for needle, breast .............................. NI .... X 0263 1.6956 104.23 23.77 20.85 

77051 ....... Computer dx mammogram add-on ................... NI .... A .................. .................. .................. .................. ..................

77052 ....... Comp screen mammogram add-on ................... NI .... A .................. .................. .................. .................. ..................

77053 ....... X-ray of mammary duct ..................................... NI .... X 0263 1.6956 104.23 23.77 20.85 

77054 ....... X-ray of mammary ducts ................................... NI .... X 0263 1.6956 104.23 23.77 20.85 

77055 ....... Mammogram, one breast .................................. NI .... A .................. .................. .................. .................. ..................

77056 ....... Mammogram, both breasts ................................ NI .... A .................. .................. .................. .................. ..................

77057 ....... Mammogram, screening .................................... NI .... A .................. .................. .................. .................. ..................

77058 ....... Mri, one breast ................................................... NI .... B .................. .................. .................. .................. ..................

77059 ....... Mri, both breasts ................................................ NI .... B .................. .................. .................. .................. ..................

77071 ....... X-ray stress view ............................................... NI .... X 0260 0.7093 43.60 .................. 8.72 

77072 ....... X-rays for bone age ........................................... NI .... X 0260 0.7093 43.60 .................. 8.72 

77073 ....... X-rays, bone length studies ............................... NI .... X 0260 0.7093 43.60 .................. 8.72 

77074 ....... X-rays, bone survey, limited .............................. NI .... X 0261 1.2224 75.14 .................. 15.03 

77075 ....... X-rays, bone survey complete ........................... NI .... X 0261 1.2224 75.14 .................. 15.03 

77076 ....... X-rays, bone survey, infant ................................ NI .... X 0260 0.7093 43.60 .................. 8.72 

77077 ....... Joint survey, single view .................................... NI .... X 0260 0.7093 43.60 .................. 8.72 

77078 ....... Ct bone density, axial ........................................ NI .... S 0288 1.1755 72.26 28.90 14.45 

77079 ....... Ct bone density, peripheral ............................... NI .... S 0282 1.5379 94.53 37.81 18.91 

77080 ....... Dxa bone density, axial ..................................... NI .... S 0288 1.1755 72.26 28.90 14.45 

77081 ....... Dxa bone density/peripheral .............................. NI .... S 0665 0.5497 33.79 13.51 6.76 

77082 ....... Dxa bone density, vert fx ................................... NI .... X 0260 0.7093 43.60 .................. 8.72 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68349 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

77083 ....... Radiographic absorptiometry ............................. NI .... X 0261 1.2224 75.14 .................. 15.03 

77084 ....... Magnetic image, bone marrow .......................... NI .... S 0335 4.5523 279.82 111.92 55.96 

77280 ....... Sbrt management .............................................. ......... X 0304 1.5735 96.72 38.68 19.34 

77285 ....... Set radiation therapy field .................................. ......... X 0305 3.9723 244.17 91.38 48.83 

77290 ....... Set radiation therapy field .................................. ......... X 0305 3.9723 244.17 91.38 48.83 

77295 ....... Set radiation therapy field .................................. ......... X 0310 13.8081 848.76 325.27 169.75 

77299 ....... Radiation therapy planning ................................ ......... X 0304 1.5735 96.72 38.68 19.34 

77300 ....... Radiation therapy dose plan .............................. ......... X 0304 1.5735 96.72 38.68 19.34 

77301 ....... Radiotherapy dose plan, imrt ............................ ......... X 0310 13.8081 848.76 325.27 169.75 

77305 ....... Teletx isodose plan simple ................................ ......... X 0304 1.5735 96.72 38.68 19.34 

77310 ....... Teletx isodose plan intermed ............................ ......... X 0305 3.9723 244.17 91.38 48.83 

77315 ....... Teletx isodose plan complex ............................. ......... X 0305 3.9723 244.17 91.38 48.83 

77321 ....... Special teletx port plan ...................................... ......... X 0305 3.9723 244.17 91.38 48.83 

77326 ....... Brachytx isodose calc simp ............................... ......... X 0304 1.5735 96.72 38.68 19.34 

77327 ....... Brachytx isodose calc interm ............................. ......... X 0305 3.9723 244.17 91.38 48.83 

77328 ....... Brachytx isodose plan compl ............................. ......... X 0305 3.9723 244.17 91.38 48.83 

77331 ....... Special radiation dosimetry ............................... ......... X 0304 1.5735 96.72 38.68 19.34 

77332 ....... Radiation treatment aid(s) ................................. ......... X 0303 2.943 180.90 66.95 36.18 

77333 ....... Radiation treatment aid(s) ................................. ......... X 0303 2.943 180.90 66.95 36.18 

77334 ....... Radiation treatment aid(s) ................................. ......... X 0303 2.943 180.90 66.95 36.18 

77336 ....... Radiation physics consult .................................. ......... X 0304 1.5735 96.72 38.68 19.34 

77370 ....... Radiation physics consult .................................. ......... X 0304 1.5735 96.72 38.68 19.34 

77371 ....... Srs, multisource ................................................. NI .... S 0127 138.4486 8,510.16 .................. 1,702.03 

77372 ....... Srs, linear based ................................................ NI .... B .................. .................. .................. .................. ..................

77373 ....... Sbrt delivery ....................................................... NI .... B .................. .................. .................. .................. ..................

77399 ....... External radiation dosimetry .............................. ......... X 0304 1.5735 96.72 38.68 19.34 

77401 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77402 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77403 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77404 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77406 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77407 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77408 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77409 ....... Radiation treatment delivery .............................. ......... S 0300 1.4826 91.13 .................. 18.23 

77411 ....... Radiation treatment delivery .............................. ......... S 0301 2.2295 137.04 .................. 27.41 

77412 ....... Radiation treatment delivery .............................. ......... S 0301 2.2295 137.04 .................. 27.41 

77413 ....... Radiation treatment delivery .............................. ......... S 0301 2.2295 137.04 .................. 27.41 

77414 ....... Radiation treatment delivery .............................. ......... S 0301 2.2295 137.04 .................. 27.41 

77416 ....... Radiation treatment delivery .............................. ......... S 0301 2.2295 137.04 .................. 27.41 

77417 ....... Radiology port film(s) ......................................... ......... X 0260 0.7093 43.60 .................. 8.72 

77418 ....... Radiation tx delivery, imrt .................................. ......... S 0412 5.4731 336.42 .................. 67.28 

77421 ....... Stereoscopic x-ray guidance ............................. CH .. S 0257 1.0974 67.45 .................. 13.49 

77422 ....... Neutron beam tx, simple ................................... ......... S 0301 2.2295 137.04 .................. 27.41 

77423 ....... Neutron beam tx, complex ................................ ......... S 0301 2.2295 137.04 .................. 27.41 

77435 ....... Sbrt management .............................................. NI .... N .................. .................. .................. .................. ..................

77470 ....... Special radiation treatment ................................ ......... S 0299 5.8839 361.67 .................. 72.33 

77520 ....... Proton trmt, simple w/o comp ............................ ......... S 0664 18.8926 1,161.29 .................. 232.26 

77522 ....... Proton trmt, simple w/comp ............................... ......... S 0664 18.8926 1,161.29 .................. 232.26 

77523 ....... Proton trmt, intermediate ................................... ......... S 0667 22.6031 1,389.37 .................. 277.87 

77525 ....... Proton treatment, complex ................................ ......... S 0667 22.6031 1,389.37 .................. 277.87 

77600 ....... Hyperthermia treatment ..................................... ......... S 0314 3.3461 205.68 60.88 41.14 

77605 ....... Hyperthermia treatment ..................................... ......... S 0314 3.3461 205.68 60.88 41.14 

77610 ....... Hyperthermia treatment ..................................... ......... S 0314 3.3461 205.68 60.88 41.14 

77615 ....... Hyperthermia treatment ..................................... ......... S 0314 3.3461 205.68 60.88 41.14 

77620 ....... Hyperthermia treatment ..................................... ......... S 0314 3.3461 205.68 60.88 41.14 

77750 ....... Infuse radioactive materials ............................... ......... S 0301 2.2295 137.04 .................. 27.41 

77761 ....... Apply intrcav radiat simple ................................ ......... S 0312 4.8569 298.54 .................. 59.71 

77762 ....... Apply intrcav radiat interm ................................. ......... S 0312 4.8569 298.54 .................. 59.71 

77763 ....... Apply intrcav radiat compl ................................. ......... S 0312 4.8569 298.54 .................. 59.71 

77776 ....... Apply interstit radiat simpl ................................. ......... S 0312 4.8569 298.54 .................. 59.71 

77777 ....... Apply interstit radiat inter ................................... ......... S 0312 4.8569 298.54 .................. 59.71 

77778 ....... Apply interstit radiat compl ................................ ......... S 0651 16.8462 1,035.50 .................. 207.10 

77781 ....... High intensity brachytherapy ............................. ......... S 0313 12.8473 789.70 .................. 157.94 

77782 ....... High intensity brachytherapy ............................. ......... S 0313 12.8473 789.70 .................. 157.94 

77783 ....... High intensity brachytherapy ............................. ......... S 0313 12.8473 789.70 .................. 157.94 

77784 ....... High intensity brachytherapy ............................. ......... S 0313 12.8473 789.70 .................. 157.94 

77789 ....... Apply surface radiation ...................................... ......... S 0300 1.4826 91.13 .................. 18.23 

77790 ....... Radiation handling ............................................. ......... N .................. .................. .................. .................. ..................

77799 ....... Radium/radioisotope therapy ............................. CH .. S 0312 4.8569 298.54 .................. 59.71 

78000 ....... Thyroid, single uptake ....................................... ......... S 0389 1.3754 84.54 33.81 16.91 


cprice-sewell on PRODPC62 with RULES2
68350 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

78001 ....... Thyroid, multiple uptakes ................................... ......... S 0389 1.3754 84.54 33.81 16.91 

78003 ....... Thyroid suppress/stimul ..................................... ......... S 0392 2.0057 123.29 49.31 24.66 

78006 ....... Thyroid imaging with uptake .............................. ......... S 0390 2.3432 144.03 57.61 28.81 

78007 ....... Thyroid image, mult uptakes ............................. ......... S 0391 2.7146 166.86 66.18 33.37 

78010 ....... Thyroid imaging ................................................. ......... S 0390 2.3432 144.03 57.61 28.81 

78011 ....... Thyroid imaging with flow .................................. ......... S 0390 2.3432 144.03 57.61 28.81 

78015 ....... Thyroid met imaging .......................................... ......... S 0406 3.9934 245.47 98.18 49.09 

78016 ....... Thyroid met imaging/studies .............................. ......... S 0406 3.9934 245.47 98.18 49.09 

78018 ....... Thyroid met imaging, body ................................ ......... S 0406 3.9934 245.47 98.18 49.09 

78020 ....... Thyroid met uptake ............................................ ......... S 0399 1.5054 92.53 35.80 18.51 

78070 ....... Parathyroid nuclear imaging .............................. ......... S 0391 2.7146 166.86 66.18 33.37 

78075 ....... Adrenal nuclear imaging .................................... ......... S 0391 2.7146 166.86 66.18 33.37 

78099 ....... Endocrine nuclear procedure ............................ ......... S 0390 2.3432 144.03 57.61 28.81 

78102 ....... Bone marrow imaging, ltd .................................. ......... S 0400 3.9073 240.17 93.22 48.03 

78103 ....... Bone marrow imaging, mult ............................... ......... S 0400 3.9073 240.17 93.22 48.03 

78104 ....... Bone marrow imaging, body .............................. ......... S 0400 3.9073 240.17 93.22 48.03 

78110 ....... Plasma volume, single ....................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78111 ....... Plasma volume, multiple .................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78120 ....... Red cell mass, single ........................................ ......... S 0393 3.7562 230.89 82.04 46.18 

78121 ....... Red cell mass, multiple ..................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78122 ....... Blood volume ..................................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78130 ....... Red cell survival study ....................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78135 ....... Red cell survival kinetics ................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78140 ....... Red cell sequestration ....................................... ......... S 0393 3.7562 230.89 82.04 46.18 

78185 ....... Spleen imaging .................................................. ......... S 0400 3.9073 240.17 93.22 48.03 

78190 ....... Platelet survival, kinetics ................................... ......... S 0392 2.0057 123.29 49.31 24.66 

78191 ....... Platelet survival .................................................. ......... S 0392 2.0057 123.29 49.31 24.66 

78195 ....... Lymph system imaging ...................................... ......... S 0400 3.9073 240.17 93.22 48.03 

78199 ....... Blood/lymph nuclear exam ................................ ......... S 0400 3.9073 240.17 93.22 48.03 

78201 ....... Liver imaging ..................................................... ......... S 0394 4.3774 269.07 102.61 53.81 

78202 ....... Liver imaging with flow ...................................... ......... S 0394 4.3774 269.07 102.61 53.81 

78205 ....... Liver imaging (3D) ............................................. ......... S 0394 4.3774 269.07 102.61 53.81 

78206 ....... Liver image (3d) with flow ................................. ......... S 0394 4.3774 269.07 102.61 53.81 

78215 ....... Liver and spleen imaging .................................. ......... S 0394 4.3774 269.07 102.61 53.81 

78216 ....... Liver & spleen image/flow ................................. ......... S 0394 4.3774 269.07 102.61 53.81 

78220 ....... Liver function study ............................................ ......... S 0394 4.3774 269.07 102.61 53.81 

78223 ....... Hepatobiliary imaging ........................................ ......... S 0394 4.3774 269.07 102.61 53.81 

78230 ....... Salivary gland imaging ...................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78231 ....... Serial salivary imaging ....................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78232 ....... Salivary gland function exam ............................ ......... S 0395 3.6526 224.52 89.73 44.90 

78258 ....... Esophageal motility study .................................. ......... S 0395 3.6526 224.52 89.73 44.90 

78261 ....... Gastric mucosa imaging .................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78262 ....... Gastroesophageal reflux exam .......................... ......... S 0395 3.6526 224.52 89.73 44.90 

78264 ....... Gastric emptying study ...................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78270 ....... Vit B-12 absorption exam .................................. ......... S 0392 2.0057 123.29 49.31 24.66 

78271 ....... Vit b-12 absrp exam, int fac .............................. ......... S 0392 2.0057 123.29 49.31 24.66 

78272 ....... Vit B-12 absorp, combined ................................ ......... S 0392 2.0057 123.29 49.31 24.66 

78278 ....... Acute GI blood loss imaging ............................. ......... S 0395 3.6526 224.52 89.73 44.90 

78282 ....... GI protein loss exam ......................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78290 ....... Meckel"s divert exam ...................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78291 ....... Leveen/shunt patency exam .............................. ......... S 0395 3.6526 224.52 89.73 44.90 

78299 ....... GI nuclear procedure ......................................... ......... S 0395 3.6526 224.52 89.73 44.90 

78300 ....... Bone imaging, limited area ................................ ......... S 0396 3.9174 240.79 95.02 48.16 

78305 ....... Bone imaging, multiple areas ............................ ......... S 0396 3.9174 240.79 95.02 48.16 

78306 ....... Bone imaging, whole body ................................ ......... S 0396 3.9174 240.79 95.02 48.16 

78315 ....... Bone imaging, 3 phase ...................................... ......... S 0396 3.9174 240.79 95.02 48.16 

78320 ....... Bone imaging (3D) ............................................. ......... S 0396 3.9174 240.79 95.02 48.16 

78350 ....... Bone mineral, single photon .............................. ......... X 0260 0.7093 43.60 .................. 8.72 

78399 ....... Musculoskeletal nuclear exam .......................... ......... S 0396 3.9174 240.79 95.02 48.16 

78414 ....... Non-imaging heart function ............................... ......... S 0398 4.1265 253.65 100.06 50.73 

78428 ....... Cardiac shunt imaging ....................................... ......... S 0398 4.1265 253.65 100.06 50.73 

78445 ....... Vascular flow imaging ........................................ ......... S 0397 2.4204 148.78 49.58 29.76 

78456 ....... Acute venous thrombus image .......................... ......... S 0397 2.4204 148.78 49.58 29.76 

78457 ....... Venous thrombosis imaging .............................. ......... S 0397 2.4204 148.78 49.58 29.76 

78458 ....... Ven thrombosis images, bilat ............................ ......... S 0397 2.4204 148.78 49.58 29.76 

78459 ....... Heart muscle imaging (PET) ............................. CH .. S 0307 11.8963 731.24 292.49 146.25 

78460 ....... Heart muscle blood, single ................................ ......... S 0398 4.1265 253.65 100.06 50.73 

78461 ....... Heart muscle blood, multiple ............................. ......... S 0377 6.5012 399.62 158.84 79.92 

78464 ....... Heart image (3d), single .................................... ......... S 0398 4.1265 253.65 100.06 50.73 

78465 ....... Heart image (3d), multiple ................................. ......... S 0377 6.5012 399.62 158.84 79.92 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68351 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

78466 ....... Heart infarct image ............................................ ......... S 0398 4.1265 253.65 100.06 50.73 

78468 ....... Heart infarct image (ef) ...................................... ......... S 0398 4.1265 253.65 100.06 50.73 

78469 ....... Heart infarct image (3D) .................................... ......... S 0398 4.1265 253.65 100.06 50.73 

78472 ....... Gated heart, planar, single ................................ ......... S 0398 4.1265 253.65 100.06 50.73 

78473 ....... Gated heart, multiple ......................................... ......... S 0376 4.9832 306.31 119.77 61.26 

78478 ....... Heart wall motion add-on .................................. ......... S 0399 1.5054 92.53 35.80 18.51 

78480 ....... Heart function add-on ........................................ ......... S 0399 1.5054 92.53 35.80 18.51 

78481 ....... Heart first pass, single ....................................... ......... S 0398 4.1265 253.65 100.06 50.73 

78483 ....... Heart first pass, multiple .................................... ......... S 0376 4.9832 306.31 119.77 61.26 

78491 ....... Heart image (pet), single ................................... CH .. S 0307 11.8963 731.24 292.49 146.25 

78492 ....... Heart image (pet), multiple ................................ ......... S 0307 11.8963 731.24 292.49 146.25 

78494 ....... Heart image, spect ............................................ ......... S 0398 4.1265 253.65 100.06 50.73 

78496 ....... Heart first pass add-on ...................................... ......... S 0399 1.5054 92.53 35.80 18.51 

78499 ....... Cardiovascular nuclear exam ............................ ......... S 0398 4.1265 253.65 100.06 50.73 

78580 ....... Lung perfusion imaging ..................................... ......... S 0401 3.1802 195.48 78.19 39.10 

78584 ....... Lung V/Q image single breath ........................... ......... S 0378 5.0975 313.33 125.33 62.67 

78585 ....... Lung V/Q imaging .............................................. ......... S 0378 5.0975 313.33 125.33 62.67 

78586 ....... Aerosol lung image, single ................................ ......... S 0401 3.1802 195.48 78.19 39.10 

78587 ....... Aerosol lung image, multiple ............................. ......... S 0401 3.1802 195.48 78.19 39.10 

78588 ....... Perfusion lung image ......................................... ......... S 0378 5.0975 313.33 125.33 62.67 

78591 ....... Vent image, 1 breath, 1 proj .............................. ......... S 0401 3.1802 195.48 78.19 39.10 

78593 ....... Vent image, 1 proj, gas ..................................... ......... S 0401 3.1802 195.48 78.19 39.10 

78594 ....... Vent image, mult proj, gas ................................ ......... S 0401 3.1802 195.48 78.19 39.10 

78596 ....... Lung differential function ................................... ......... S 0378 5.0975 313.33 125.33 62.67 

78599 ....... Respiratory nuclear exam .................................. ......... S 0401 3.1802 195.48 78.19 39.10 

78600 ....... Brain imaging, ltd static ..................................... ......... S 0402 4.6418 285.32 114.12 57.06 

78601 ....... Brain imaging, ltd w/flow .................................... ......... S 0402 4.6418 285.32 114.12 57.06 

78605 ....... Brain imaging, complete .................................... ......... S 0402 4.6418 285.32 114.12 57.06 

78606 ....... Brain imaging, compl w/flow .............................. ......... S 0402 4.6418 285.32 114.12 57.06 

78607 ....... Brain imaging (3D) ............................................. ......... S 0402 4.6418 285.32 114.12 57.06 

78608 ....... Brain imaging (PET) .......................................... CH .. S 0308 13.9166 855.43 .................. 171.09 

78610 ....... Brain flow imaging only ..................................... ......... S 0402 4.6418 285.32 114.12 57.06 

78615 ....... Cerebral vascular flow image ............................ ......... S 0402 4.6418 285.32 114.12 57.06 

78630 ....... Cerebrospinal fluid scan .................................... ......... S 0403 3.4923 214.66 83.35 42.93 

78635 ....... CSF ventriculography ........................................ ......... S 0403 3.4923 214.66 83.35 42.93 

78645 ....... CSF shunt evaluation ........................................ ......... S 0403 3.4923 214.66 83.35 42.93 

78647 ....... Cerebrospinal fluid scan .................................... ......... S 0403 3.4923 214.66 83.35 42.93 

78650 ....... CSF leakage imaging ........................................ ......... S 0403 3.4923 214.66 83.35 42.93 

78660 ....... Nuclear exam of tear flow ................................. ......... S 0403 3.4923 214.66 83.35 42.93 

78699 ....... Nervous system nuclear exam .......................... ......... S 0402 4.6418 285.32 114.12 57.06 

78700 ....... Kidney imaging, morphol ................................... ......... S 0404 3.4209 210.28 84.11 42.06 

78701 ....... Kidney imaging with flow ................................... ......... S 0404 3.4209 210.28 84.11 42.06 

78704 ....... Imaging renogram .............................................. CH .. D .................. .................. .................. .................. ..................

78707 ....... Kflow/funct image w/o drug ............................... ......... S 0404 3.4209 210.28 84.11 42.06 

78708 ....... Kflow/funct image w/drug .................................. ......... S 0405 4.0378 248.20 98.77 49.64 

78709 ....... Kflow/funct image, multiple ................................ ......... S 0405 4.0378 248.20 98.77 49.64 

78710 ....... Kidney imaging (3D) .......................................... ......... S 0404 3.4209 210.28 84.11 42.06 

78715 ....... Renal vascular flow exam ................................. CH .. D .................. .................. .................. .................. ..................

78725 ....... Kidney function study ........................................ ......... S 0389 1.3754 84.54 33.81 16.91 

78730 ....... Urinary bladder retention ................................... ......... X 0340 0.6102 37.51 .................. 7.50 

78740 ....... Ureteral reflux study .......................................... ......... S 0404 3.4209 210.28 84.11 42.06 

78760 ....... Testicular imaging .............................................. CH .. D .................. .................. .................. .................. ..................

78761 ....... Testicular imaging w/flow .................................. ......... S 0404 3.4209 210.28 84.11 42.06 

78799 ....... Genitourinary nuclear exam .............................. ......... S 0404 3.4209 210.28 84.11 42.06 

78800 ....... Tumor imaging, limited area .............................. ......... S 0406 3.9934 245.47 98.18 49.09 

78801 ....... Tumor imaging, mult areas ................................ ......... S 0406 3.9934 245.47 98.18 49.09 

78802 ....... Tumor imaging, whole body .............................. ......... S 0406 3.9934 245.47 98.18 49.09 

78803 ....... Tumor imaging (3D) ........................................... ......... S 0406 3.9934 245.47 98.18 49.09 

78804 ....... Tumor imaging, whole body .............................. CH .. S 0408 5.9245 364.17 .................. 72.83 

78805 ....... Abscess imaging, ltd area ................................. ......... S 0406 3.9934 245.47 98.18 49.09 

78806 ....... Abscess imaging, whole body ........................... ......... S 0406 3.9934 245.47 98.18 49.09 

78807 ....... Nuclear localization/abscess ............................. ......... S 0406 3.9934 245.47 98.18 49.09 

78811 ....... Tumor imaging (pet), limited .............................. CH .. S 0308 13.9166 855.43 .................. 171.09 

78812 ....... Tumor image (pet)/skul-thigh ............................. CH .. S 0308 13.9166 855.43 .................. 171.09 

78813 ....... Tumor image (pet) full body .............................. CH .. S 0308 13.9166 855.43 .................. 171.09 

78814 ....... Tumor image pet/ct, limited ............................... CH .. S 1511 .................. 950.00 .................. 190.00 

78815 ....... Tumorimage pet/ct skul-thigh ............................ CH .. S 1511 .................. 950.00 .................. 190.00 

78816 ....... Tumor image pet/ct full body ............................. CH .. S 1511 .................. 950.00 .................. 190.00 

78890 ....... Nuclear medicine data proc ............................... ......... N .................. .................. .................. .................. ..................

78891 ....... Nuclear med data proc ...................................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68352 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

78999 ....... Nuclear diagnostic exam ................................... ......... S 0389 1.3754 84.54 33.81 16.91 

79005 ....... Nuclear rx, oral admin ....................................... ......... S 0407 3.1779 195.34 78.13 39.07 

79101 ....... Nuclear rx, iv admin ........................................... ......... S 0407 3.1779 195.34 78.13 39.07 

79200 ....... Nuclear rx, intracav admin ................................. CH .. S 0413 5.2957 325.52 .................. 65.10 

79300 ....... Nuclr rx, interstit colloid ..................................... ......... S 0407 3.1779 195.34 78.13 39.07 

79403 ....... Hematopoietic nuclear tx ................................... CH .. S 0413 5.2957 325.52 .................. 65.10 

79440 ....... Nuclear rx, intra-articular ................................... CH .. S 0413 5.2957 325.52 .................. 65.10 

79445 ....... Nuclear rx, intra-arterial ..................................... ......... S 0407 3.1779 195.34 78.13 39.07 

79999 ....... Nuclear medicine therapy .................................. ......... S 0407 3.1779 195.34 78.13 39.07 

80103 ....... Drug analysis, tissue prep ................................. ......... N .................. .................. .................. .................. ..................

80500 ....... Lab pathology consultation ................................ ......... X 0433 0.2557 15.72 5.93 3.14 

80502 ....... Lab pathology consultation ................................ ......... X 0342 0.0824 5.06 2.02 1.01 

81099 ....... Urinalysis test procedure ................................... ......... X 0342 0.0824 5.06 2.02 1.01 

82107 ....... Alpha-fetoprotein l3 ............................................ NI .... A .................. .................. .................. .................. ..................

83698 ....... Assay lipoprotein pla2 ....................................... NI .... A .................. .................. .................. .................. ..................

83913 ....... Molecular, rna stabilization ................................ NI .... A .................. .................. .................. .................. ..................

84999 ....... Clinical chemistry test ........................................ ......... X 0342 0.0824 5.06 2.02 1.01 

85097 ....... Bone marrow interpretation ............................... ......... X 0343 0.5211 32.03 10.84 6.41 

85396 ....... Clotting assay, whole blood ............................... ......... N .................. .................. .................. .................. ..................

85999 ....... Hematology procedure ...................................... ......... X 0342 0.0824 5.06 2.02 1.01 

86077 ....... Physician blood bank service ............................ ......... X 0433 0.2557 15.72 5.93 3.14 

86078 ....... Physician blood bank service ............................ ......... X 0343 0.5211 32.03 10.84 6.41 

86079 ....... Physician blood bank service ............................ ......... X 0433 0.2557 15.72 5.93 3.14 

86485 ....... Skin test, candida .............................................. ......... X 0341 0.0914 5.62 2.24 1.12 

86490 ....... Coccidioidomycosis skin test ............................. ......... X 0341 0.0914 5.62 2.24 1.12 

86510 ....... Histoplasmosis skin test .................................... ......... X 0341 0.0914 5.62 2.24 1.12 

86580 ....... TB intradermal test ............................................ ......... X 0341 0.0914 5.62 2.24 1.12 

86788 ....... West nile virus ab, igm ...................................... NI .... A .................. .................. .................. .................. ..................

86789 ....... West nile virus antibody .................................... NI .... A .................. .................. .................. .................. ..................

86849 ....... Immunology procedure ...................................... ......... X 0342 0.0824 5.06 2.02 1.01 

86850 ....... RBC antibody screen ......................................... ......... X 0345 0.2178 13.39 2.87 2.68 

86860 ....... RBC antibody elution ......................................... ......... X 0346 0.3484 21.42 4.39 4.28 

86870 ....... RBC antibody identification ............................... ......... X 0346 0.3484 21.42 4.39 4.28 

86880 ....... Coombs test, direct ............................................ ......... X 0409 0.1227 7.54 2.20 1.51 

86885 ....... Coombs test, indirect, qual ................................ ......... X 0409 0.1227 7.54 2.20 1.51 

86886 ....... Coombs test, indirect, titer ................................. ......... X 0409 0.1227 7.54 2.20 1.51 

86890 ....... Autologous blood process ................................. ......... X 0347 0.7423 45.63 11.28 9.13 

86891 ....... Autologous blood, op salvage ........................... ......... X 0346 0.3484 21.42 4.39 4.28 

86900 ....... Blood typing, ABO ............................................. ......... X 0409 0.1227 7.54 2.20 1.51 

86901 ....... Blood typing, Rh (D) .......................................... ......... X 0409 0.1227 7.54 2.20 1.51 

86903 ....... Blood typing, antigen screen ............................. ......... X 0345 0.2178 13.39 2.87 2.68 

86904 ....... Blood typing, patient serum ............................... ......... X 0346 0.3484 21.42 4.39 4.28 

86905 ....... Blood typing, RBC antigens .............................. ......... X 0345 0.2178 13.39 2.87 2.68 

86906 ....... Blood typing, Rh phenotype .............................. ......... X 0345 0.2178 13.39 2.87 2.68 

86920 ....... Compatibility test, spin ....................................... ......... X 0346 0.3484 21.42 4.39 4.28 

86921 ....... Compatibility test, incubate ................................ ......... X 0345 0.2178 13.39 2.87 2.68 

86922 ....... Compatibility test, antiglob ................................. ......... X 0346 0.3484 21.42 4.39 4.28 

86923 ....... Compatibility test, electric .................................. ......... X 0345 0.2178 13.39 2.87 2.68 

86927 ....... Plasma, fresh frozen .......................................... ......... X 0345 0.2178 13.39 2.87 2.68 

86930 ....... Frozen blood prep ............................................. ......... X 0347 0.7423 45.63 11.28 9.13 

86931 ....... Frozen blood thaw ............................................. ......... X 0347 0.7423 45.63 11.28 9.13 

86932 ....... Frozen blood freeze/thaw .................................. ......... X 0347 0.7423 45.63 11.28 9.13 

86945 ....... Blood product/irradiation .................................... ......... X 0345 0.2178 13.39 2.87 2.68 

86950 ....... Leukacyte transfusion ........................................ ......... X 0345 0.2178 13.39 2.87 2.68 

86960 ....... Vol reduction of blood/prod ............................... ......... X 0345 0.2178 13.39 2.87 2.68 

86965 ....... Pooling blood platelets ...................................... CH .. X 0346 0.3484 21.42 4.39 4.28 

86970 ....... RBC pretreatment .............................................. ......... X 0345 0.2178 13.39 2.87 2.68 

86971 ....... RBC pretreatment .............................................. ......... X 0345 0.2178 13.39 2.87 2.68 

86972 ....... RBC pretreatment .............................................. ......... X 0346 0.3484 21.42 4.39 4.28 

86975 ....... RBC pretreatment, serum .................................. CH .. X 0346 0.3484 21.42 4.39 4.28 

86976 ....... RBC pretreatment, serum .................................. ......... X 0345 0.2178 13.39 2.87 2.68 

86977 ....... RBC pretreatment, serum .................................. CH .. X 0346 0.3484 21.42 4.39 4.28 

86978 ....... RBC pretreatment, serum .................................. CH .. X 0346 0.3484 21.42 4.39 4.28 

86985 ....... Split blood or products ....................................... ......... X 0345 0.2178 13.39 2.87 2.68 

86999 ....... Transfusion procedure ....................................... ......... X 0345 0.2178 13.39 2.87 2.68 

87305 ....... Aspergillus ag, eia ............................................. NI .... A .................. .................. .................. .................. ..................

87498 ....... Enterovirus, dna, amp probe ............................. NI .... A .................. .................. .................. .................. ..................

87640 ....... Staph a, dna, amp probe ................................... NI .... A .................. .................. .................. .................. ..................

87641 ....... Mr-staph, dna, amp probe ................................. NI .... A .................. .................. .................. .................. ..................

87653 ....... Strep b, dna, amp probe ................................... NI .... A .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68353 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

87808 ....... Trichomonas assay w/optic ............................... NI .... A .................. .................. .................. .................. ..................

87999 ....... Microbiology procedure ..................................... ......... X 0342 0.0824 5.06 2.02 1.01 

88104 ....... Cytopath fl nongyn, smears ............................... ......... X 0433 0.2557 15.72 5.93 3.14 

88106 ....... Cytopath fl nongyn, filter .................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88107 ....... Cytopath fl nongyn, sm/fltr ................................. ......... X 0433 0.2557 15.72 5.93 3.14 

88108 ....... Cytopath, concentrate tech ................................ ......... X 0433 0.2557 15.72 5.93 3.14 

88112 ....... Cytopath, cell enhance tech .............................. ......... X 0343 0.5211 32.03 10.84 6.41 

88125 ....... Forensic cytopathology ...................................... CH .. X 0433 0.2557 15.72 5.93 3.14 

88141 ....... Cytopath, c/v, interpret ...................................... ......... N .................. .................. .................. .................. ..................

88160 ....... Cytopath smear, other source ........................... ......... X 0433 0.2557 15.72 5.93 3.14 

88161 ....... Cytopath smear, other source ........................... ......... X 0433 0.2557 15.72 5.93 3.14 

88162 ....... Cytopath smear, other source ........................... ......... X 0433 0.2557 15.72 5.93 3.14 

88172 ....... Cytopathology eval of fna .................................. ......... X 0343 0.5211 32.03 10.84 6.41 

88173 ....... Cytopath eval, fna, report .................................. ......... X 0343 0.5211 32.03 10.84 6.41 

88182 ....... Cell marker study ............................................... CH .. X 0343 0.5211 32.03 10.84 6.41 

88184 ....... Flowcytometry/ tc, 1 marker .............................. CH .. X 0433 0.2557 15.72 5.93 3.14 

88185 ....... Flowcytometry/tc, add-on ................................... CH .. X 0433 0.2557 15.72 5.93 3.14 

88187 ....... Flowcytometry/read, 2–8 ................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88188 ....... Flowcytometry/read, 9–15 ................................. ......... X 0433 0.2557 15.72 5.93 3.14 

88189 ....... Flowcytometry/read, 16 & > .............................. ......... X 0343 0.5211 32.03 10.84 6.41 

88199 ....... Cytopathology procedure ................................... ......... X 0342 0.0824 5.06 2.02 1.01 

88299 ....... Cytogenetic study .............................................. ......... X 0342 0.0824 5.06 2.02 1.01 

88300 ....... Surgical path, gross ........................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88302 ....... Tissue exam by pathologist ............................... ......... X 0433 0.2557 15.72 5.93 3.14 

88304 ....... Tissue exam by pathologist ............................... ......... X 0343 0.5211 32.03 10.84 6.41 

88305 ....... Tissue exam by pathologist ............................... ......... X 0343 0.5211 32.03 10.84 6.41 

88307 ....... Tissue exam by pathologist ............................... ......... X 0344 0.7927 48.73 15.66 9.75 

88309 ....... Tissue exam by pathologist ............................... ......... X 0344 0.7927 48.73 15.66 9.75 

88311 ....... Decalcify tissue .................................................. CH .. X 0433 0.2557 15.72 5.93 3.14 

88312 ....... Special stains ..................................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88313 ....... Special stains ..................................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88314 ....... Histochemical stain ............................................ ......... X 0342 0.0824 5.06 2.02 1.01 

88318 ....... Chemical histochemistry .................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88319 ....... Enzyme histochemistry ...................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88321 ....... Microslide consultation ...................................... ......... X 0433 0.2557 15.72 5.93 3.14 

88323 ....... Microslide consultation ...................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88325 ....... Comprehensive review of data .......................... ......... X 0344 0.7927 48.73 15.66 9.75 

88329 ....... Path consult introp ............................................. ......... X 0433 0.2557 15.72 5.93 3.14 

88331 ....... Path consult intraop, 1 bloc ............................... ......... X 0343 0.5211 32.03 10.84 6.41 

88332 ....... Path consult intraop, add"l .............................. ......... X 0433 0.2557 15.72 5.93 3.14 

88333 ....... Intraop cyto path consult, 1 ............................... ......... X 0343 0.5211 32.03 10.84 6.41 

88334 ....... Intraop cyto path consult, 2 ............................... ......... X 0433 0.2557 15.72 5.93 3.14 

88342 ....... Immunohistochemistry ....................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88346 ....... Immunofluorescent study ................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88347 ....... Immunofluorescent study ................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88348 ....... Electron microscopy .......................................... ......... X 0661 2.5255 155.24 62.09 31.05 

88349 ....... Scanning electron microscopy ........................... ......... X 0661 2.5255 155.24 62.09 31.05 

88355 ....... Analysis, skeletal muscle ................................... ......... X 0343 0.5211 32.03 10.84 6.41 

88356 ....... Analysis, nerve .................................................. ......... X 0344 0.7927 48.73 15.66 9.75 

88358 ....... Analysis, tumor .................................................. ......... X 0344 0.7927 48.73 15.66 9.75 

88360 ....... Tumor immunohistochem/manual ..................... CH .. X 0343 0.5211 32.03 10.84 6.41 

88361 ....... Tumor immunohistochem/comput ..................... ......... X 0344 0.7927 48.73 15.66 9.75 

88362 ....... Nerve teasing preparations ............................... ......... X 0344 0.7927 48.73 15.66 9.75 

88365 ....... Insitu hybridization (fish) .................................... ......... X 0344 0.7927 48.73 15.66 9.75 

88367 ....... Insitu hybridization, auto .................................... ......... X 0344 0.7927 48.73 15.66 9.75 

88368 ....... Insitu hybridization, manual ............................... ......... X 0344 0.7927 48.73 15.66 9.75 

88380 ....... Microdissection .................................................. ......... N .................. .................. .................. .................. ..................

88384 ....... Eval molecular probes, 11–50 ........................... ......... X 0433 0.2557 15.72 5.93 3.14 

88385 ....... Eval molecul probes, 51–250 ............................ ......... X 0343 0.5211 32.03 10.84 6.41 

88386 ....... Eval molecul probes, 251–500 .......................... ......... X 0344 0.7927 48.73 15.66 9.75 

88399 ....... Surgical pathology procedure ............................ ......... X 0342 0.0824 5.06 2.02 1.01 

89049 ....... Chct for mal hyperthermia ................................. ......... X 0343 0.5211 32.03 10.84 6.41 

89100 ....... Sample intestinal contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89105 ....... Sample intestinal contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89130 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89132 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89135 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89136 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89140 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 

89141 ....... Sample stomach contents ................................. ......... X 0360 1.4154 87.00 33.88 17.40 


cprice-sewell on PRODPC62 with RULES2
68354 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

89220 ....... Sputum specimen collection .............................. ......... X 0343 0.5211 32.03 10.84 6.41 

89230 ....... Collect sweat for test ......................................... ......... X 0433 0.2557 15.72 5.93 3.14 

89240 ....... Pathology lab procedure .................................... ......... X 0342 0.0824 5.06 2.02 1.01 

89250 ....... Cultr oocyte/embryo <4 days ............................ ......... X 0348 0.8321 51.15 .................. 10.23 

89251 ....... Cultr oocyte/embryo <4 days ............................ ......... X 0348 0.8321 51.15 .................. 10.23 

89253 ....... Embryo hatching ................................................ ......... X 0348 0.8321 51.15 .................. 10.23

89254 ....... Oocyte identification .......................................... ......... X 0348 0.8321 51.15 .................. 10.23

89255 ....... Prepare embryo for transfer .............................. ......... X 0348 0.8321 51.15 .................. 10.23 

89257 ....... Sperm identification ........................................... ......... X 0348 0.8321 51.15 .................. 10.23

89258 ....... Cryopreservation; embryo(s) ............................. ......... X 0348 0.8321 51.15 .................. 10.23 

89259 ....... Cryopreservation, sperm ................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89260 ....... Sperm isolation, simple ..................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89261 ....... Sperm isolation, complex .................................. ......... X 0348 0.8321 51.15 .................. 10.23 

89264 ....... Identify sperm tissue .......................................... ......... X 0348 0.8321 51.15 .................. 10.23

89268 ....... Insemination of oocytes ..................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89272 ....... Extended culture of oocytes .............................. ......... X 0348 0.8321 51.15 .................. 10.23 

89280 ....... Assist oocyte fertilization ................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89281 ....... Assist oocyte fertilization ................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89290 ....... Biopsy, oocyte polar body ................................. ......... X 0348 0.8321 51.15 .................. 10.23 

89291 ....... Biopsy, oocyte polar body ................................. ......... X 0348 0.8321 51.15 .................. 10.23 

89335 ....... Cryopreserve testicular tiss ............................... ......... X 0348 0.8321 51.15 .................. 10.23 

89342 ....... Storage/year; embryo(s) .................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89343 ....... Storage/year; sperm/semen .............................. ......... X 0348 0.8321 51.15 .................. 10.23 

89344 ....... Storage/year; reprod tissue ............................... ......... X 0348 0.8321 51.15 .................. 10.23 

89346 ....... Storage/year; oocyte(s) ..................................... ......... X 0348 0.8321 51.15 .................. 10.23 

89352 ....... Thawing cryopresrved; embryo ......................... ......... X 0348 0.8321 51.15 .................. 10.23 

89353 ....... Thawing cryopresrved; sperm ........................... ......... X 0348 0.8321 51.15 .................. 10.23 

89354 ....... Thaw cryoprsvrd; reprod tiss ............................. ......... X 0348 0.8321 51.15 .................. 10.23 

89356 ....... Thawing cryopresrved; oocyte ........................... ......... X 0348 0.8321 51.15 .................. 10.23 

90296 ....... Diphtheria antitoxin ............................................ ......... N .................. .................. .................. .................. ..................

90371 ....... Hep b ig, im ....................................................... ......... K 1630 .................. 119.06 .................. 23.81 

90375 ....... Rabies ig, im/sc ................................................. ......... K 9133 .................. 64.53 .................. 12.91 

90376 ....... Rabies ig, heat treated ...................................... ......... K 9134 .................. 68.24 .................. 13.65 

90385 ....... Rh ig, minidose, im ............................................ ......... N .................. .................. .................. .................. ..................

90393 ....... Vaccina ig, im .................................................... ......... N .................. .................. .................. .................. ..................

90396 ....... Varicella-zoster ig, im ........................................ ......... K 9135 .................. 140.92 .................. 28.18 

90471 ....... Immunization admin ........................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

90472 ....... Immunization admin, each add ......................... CH .. S 0436 0.1809 11.12 .................. 2.22 

90473 ....... Immune admin oral/nasal .................................. CH .. S 0436 0.1809 11.12 .................. 2.22 

90474 ....... Immune admin oral/nasal addl .......................... CH .. S 0436 0.1809 11.12 .................. 2.22 

90476 ....... Adenovirus vaccine, type 4 ............................... CH .. N .................. .................. .................. .................. ..................

90477 ....... Adenovirus vaccine, type 7 ............................... ......... N .................. .................. .................. .................. ..................

90581 ....... Anthrax vaccine, sc ........................................... CH .. N .................. .................. .................. .................. ..................

90585 ....... Bcg vaccine, percut ........................................... ......... K 9137 .................. 117.39 .................. 23.48 

90632 ....... Hep a vaccine, adult im ..................................... ......... N .................. .................. .................. .................. ..................

90633 ....... Hep a vacc, ped/adol, 2 dose ........................... ......... N .................. .................. .................. .................. ..................

90634 ....... Hep a vacc, ped/adol, 3 dose ........................... ......... N .................. .................. .................. .................. ..................

90636 ....... Hep a/hep b vacc, adult im ............................... CH .. N .................. .................. .................. .................. ..................

90645 ....... Hib vaccine, hboc, im ........................................ ......... N .................. .................. .................. .................. ..................

90646 ....... Hib vaccine, prp-d, im ........................................ ......... N .................. .................. .................. .................. ..................

90647 ....... Hib vaccine, prp-omp, im ................................... ......... N .................. .................. .................. .................. ..................

90648 ....... Hib vaccine, prp-t, im ......................................... ......... N .................. .................. .................. .................. ..................

90649 ....... Hpapilloma vacc 3 dose im ............................... CH .. B .................. .................. .................. .................. ..................

90665 ....... Lyme disease vaccine, im ................................. CH .. N .................. .................. .................. .................. ..................

90675 ....... Rabies vaccine, im ............................................ ......... K 9139 .................. 157.74 .................. 31.55 

90676 ....... Rabies vaccine, id ............................................. ......... K 9140 .................. 166.16 .................. 33.23 

90680 ....... Rotovirus vacc 3 dose, oral ............................... ......... N .................. .................. .................. .................. ..................

90690 ....... Typhoid vaccine, oral ......................................... ......... N .................. .................. .................. .................. ..................

90691 ....... Typhoid vaccine, im ........................................... ......... N .................. .................. .................. .................. ..................

90692 ....... Typhoid vaccine, h-p, sc/id ................................ ......... N .................. .................. .................. .................. ..................

90693 ....... Typhoid vaccine, akd, sc ................................... CH .. B .................. .................. .................. .................. ..................

90698 ....... Dtap-hib-ip vaccine, im ...................................... ......... N .................. .................. .................. .................. ..................

90700 ....... Dtap vaccine, < 7 yrs, im .................................. ......... N .................. .................. .................. .................. ..................

90701 ....... Dtp vaccine, im .................................................. ......... N .................. .................. .................. .................. ..................

90702 ....... Dt vaccine < 7, im ............................................. ......... N .................. .................. .................. .................. ..................

90703 ....... Tetanus vaccine, im ........................................... ......... N .................. .................. .................. .................. ..................

90704 ....... Mumps vaccine, sc ............................................ ......... N .................. .................. .................. .................. ..................

90705 ....... Measles vaccine, sc .......................................... ......... N .................. .................. .................. .................. ..................

90706 ....... Rubella vaccine, sc ............................................ ......... N .................. .................. .................. .................. ..................

90707 ....... Mmr vaccine, sc ................................................. ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68355 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

90708 ....... Measles-rubella vaccine, sc .............................. ......... K 9141 .................. 60.82 .................. 12.16 

90710 ....... Mmrv vaccine, sc ............................................... ......... N .................. .................. .................. .................. ..................

90712 ....... Oral poliovirus vaccine ...................................... ......... N .................. .................. .................. .................. ..................

90713 ....... Poliovirus, ipv, sc/im .......................................... ......... N .................. .................. .................. .................. ..................

90714 ....... Td vaccine no prsrv  ́ 7 im ............................... CH .. N .................. .................. .................. .................. ..................

90715 ....... Tdap vaccine >7 im ........................................... ......... N .................. .................. .................. .................. ..................

90716 ....... Chicken pox vaccine, sc .................................... CH .. B .................. .................. .................. .................. ..................

90717 ....... Yellow fever vaccine, sc .................................... CH .. N .................. .................. .................. .................. ..................

90718 ....... Td vaccine > 7, im ............................................. ......... N .................. .................. .................. .................. ..................

90719 ....... Diphtheria vaccine, im ....................................... ......... N .................. .................. .................. .................. ..................

90720 ....... Dtp/hib vaccine, im ............................................ CH .. K 3032 .................. 45.01 .................. 9.00 

90721 ....... Dtap/hib vaccine, im .......................................... ......... N .................. .................. .................. .................. ..................

90725 ....... Cholera vaccine, injectable ................................ ......... N .................. .................. .................. .................. ..................

90727 ....... Plague vaccine, im ............................................ CH .. K 0744 .................. 150.00 .................. 30.00 

90733 ....... Meningococcal vaccine, sc ................................ ......... K 9143 .................. 84.46 .................. 16.89 

90734 ....... Meningococcal vaccine, im ................................ ......... K 9145 .................. 53.71 .................. 10.74 

90735 ....... Encephalitis vaccine, sc .................................... ......... K 9144 .................. 96.22 .................. 19.24 

90736 ....... Zoster vacc, sc .................................................. CH .. B .................. .................. .................. .................. ..................

90749 ....... Vaccine toxoid ................................................... ......... N .................. .................. .................. .................. ..................

90760 ....... Hydration iv infusion, init ................................... CH .. S 0440 1.809 111.20 .................. 22.24 

90761 ....... Hydrate iv infusion, add-on ................................ CH .. S 0437 0.3945 24.25 .................. 4.85 

90765 ....... Ther/proph/diag iv inf, init .................................. CH .. S 0440 1.809 111.20 .................. 22.24 

90766 ....... Ther/proph/dg iv inf, add-on .............................. CH .. S 0437 0.3945 24.25 .................. 4.85 

90767 ....... Tx/proph/dg addl seq iv inf ................................ CH .. S 0437 0.3945 24.25 .................. 4.85 

90768 ....... Ther/diag concurrent inf ..................................... CH .. N .................. .................. .................. .................. ..................

90772 ....... Ther/proph/diag inj, sc/im .................................. CH .. S 0437 0.3945 24.25 .................. 4.85 

90773 ....... Ther/proph/diag inj, ia ........................................ CH .. S 0438 0.7942 48.82 .................. 9.76 

90774 ....... Ther/proph/diag inj, iv push ............................... CH .. S 0438 0.7942 48.82 .................. 9.76 

90775 ....... Ther/proph/diag inj add-on ................................ CH .. S 0438 0.7942 48.82 .................. 9.76 

90779 ....... Ther/prop/diag inj/inf proc .................................. CH .. S 0436 0.1809 11.12 .................. 2.22 

90801 ....... Psy dx interview ................................................. ......... S 0323 1.7066 104.90 .................. 20.98 

90802 ....... Intac psy dx interview ........................................ ......... S 0323 1.7066 104.90 .................. 20.98

90804 ....... Psytx, office, 20–30 min .................................... ......... S 0322 1.1798 72.52 .................. 14.50 

90805 ....... Psytx, off, 20–30 min w/e&m ............................. ......... S 0322 1.1798 72.52 .................. 14.50 

90806 ....... Psytx, off, 45–50 min ......................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90807 ....... Psytx, off, 45–50 min w/e&m ............................. ......... S 0323 1.7066 104.90 .................. 20.98 

90808 ....... Psytx, office, 75–80 min .................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90809 ....... Psytx, off, 75–80, w/e&m ................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90810 ....... Intac psytx, off, 20–30 min ................................ ......... S 0322 1.1798 72.52 .................. 14.50 

90811 ....... Intac psytx, 20–30, w/e&m ................................ ......... S 0322 1.1798 72.52 .................. 14.50 

90812 ....... Intac psytx, off, 45–50 min ................................ ......... S 0323 1.7066 104.90 .................. 20.98 

90813 ....... Intac psytx, 45–50 min w/e&m .......................... ......... S 0323 1.7066 104.90 .................. 20.98 

90814 ....... Intac psytx, off, 75–80 min ................................ ......... S 0323 1.7066 104.90 .................. 20.98 

90815 ....... Intac psytx, 75–80 w/e&m ................................. ......... S 0323 1.7066 104.90 .................. 20.98 

90816 ....... Psytx, hosp, 20–30 min ..................................... ......... S 0322 1.1798 72.52 .................. 14.50 

90817 ....... Psytx, hosp, 20–30 min w/e&m ......................... ......... S 0322 1.1798 72.52 .................. 14.50 

90818 ....... Psytx, hosp, 45–50 min ..................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90819 ....... Psytx, hosp, 45–50 min w/e&m ......................... ......... S 0323 1.7066 104.90 .................. 20.98 

90821 ....... Psytx, hosp, 75–80 min ..................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90822 ....... Psytx, hosp, 75–80 min w/e&m ......................... ......... S 0323 1.7066 104.90 .................. 20.98 

90823 ....... Intac psytx, hosp, 20–30 min ............................ ......... S 0322 1.1798 72.52 .................. 14.50 

90824 ....... Intac psytx, hsp 20–30 w/e&m .......................... ......... S 0322 1.1798 72.52 .................. 14.50 

90826 ....... Intac psytx, hosp, 45–50 min ............................ ......... S 0323 1.7066 104.90 .................. 20.98 

90827 ....... Intac psytx, hsp 45–50 w/e&m .......................... ......... S 0323 1.7066 104.90 .................. 20.98 

90828 ....... Intac psytx, hosp, 75–80 min ............................ ......... S 0323 1.7066 104.90 .................. 20.98 

90829 ....... Intac psytx, hsp 75–80 w/e&m .......................... ......... S 0323 1.7066 104.90 .................. 20.98 

90845 ....... Psychoanalysis .................................................. ......... S 0323 1.7066 104.90 .................. 20.98 

90846 ....... Family psytx w/o patient .................................... ......... S 0324 2.1633 132.97 .................. 26.59 

90847 ....... Family psytx w/patient ....................................... ......... S 0324 2.1633 132.97 .................. 26.59 

90849 ....... Multiple family group psytx ................................ ......... S 0325 1.0765 66.17 14.47 13.23 

90853 ....... Group psychotherapy ........................................ ......... S 0325 1.0765 66.17 14.47 13.23 

90857 ....... Intac group psytx ............................................... ......... S 0325 1.0765 66.17 14.47 13.23 

90862 ....... Medication management ................................... ......... X 0374 1.1418 70.18 .................. 14.04 

90865 ....... Narcosynthesis .................................................. ......... S 0323 1.7066 104.90 .................. 20.98 

90870 ....... Electroconvulsive therapy .................................. ......... S 0320 5.5676 342.23 80.06 68.45 

90880 ....... Hypnotherapy ..................................................... ......... S 0323 1.7066 104.90 .................. 20.98 

90885 ....... Psy evaluation of records .................................. ......... N .................. .................. .................. .................. ..................

90887 ....... Consultation with family ..................................... ......... N .................. .................. .................. .................. ..................

90889 ....... Preparation of report .......................................... ......... N .................. .................. .................. .................. ..................

90899 ....... Psychiatric service/therapy ................................ ......... S 0322 1.1798 72.52 .................. 14.50 


cprice-sewell on PRODPC62 with RULES2
68356 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

90911 ....... Biofeedback peri/uro/rectal ................................ ......... S 0321 1.3384 82.27 21.72 16.45 

90935 ....... Hemodialysis, one evaluation ............................ ......... S 0170 6.6089 406.24 .................. 81.25 

90940 ....... Hemodialysis access study ............................... ......... N .................. .................. .................. .................. ..................

90945 ....... Dialysis, one evaluation ..................................... ......... S 0170 6.6089 406.24 .................. 81.25 

91000 ....... Esophageal intubation ....................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91010 ....... Esophagus motility study ................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91011 ....... Esophagus motility study ................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91012 ....... Esophagus motility study ................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91020 ....... Gastric motility studies ....................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91022 ....... Duodenal motility study ..................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91030 ....... Acid perfusion of esophagus ............................. ......... X 0361 3.8887 239.03 83.23 47.81 

91034 ....... Gastroesophageal reflux test ............................. ......... X 0361 3.8887 239.03 83.23 47.81 

91035 ....... G-esoph reflx tst w/electrod ............................... CH .. X 0361 3.8887 239.03 83.23 47.81 

91037 ....... Esoph imped function test ................................. ......... X 0361 3.8887 239.03 83.23 47.81 

91038 ....... Esoph imped funct test > 1h ............................. ......... X 0361 3.8887 239.03 83.23 47.81 

91040 ....... Esoph balloon distension tst .............................. ......... X 0360 1.4154 87.00 33.88 17.40 

91052 ....... Gastric analysis test .......................................... ......... X 0361 3.8887 239.03 83.23 47.81 

91055 ....... Gastric intubation for smear .............................. ......... X 0360 1.4154 87.00 33.88 17.40 

91060 ....... Gastric saline load test ...................................... CH .. D .................. .................. .................. .................. ..................

91065 ....... Breath hydrogen test ......................................... ......... X 0360 1.4154 87.00 33.88 17.40 

91100 ....... Pass intestine bleeding tube ............................. ......... X 0360 1.4154 87.00 33.88 17.40 

91105 ....... Gastric intubation treatment .............................. ......... X 0360 1.4154 87.00 33.88 17.40 

91110 ....... Gi tract capsule endoscopy ............................... ......... T 0142 9.4946 583.61 152.78 116.72 

91111 ....... Esophageal capsule endoscopy ........................ NI .... T 0141 8.3175 511.26 143.38 102.25 

91120 ....... Rectal sensation test ......................................... CH .. T 0126 1.0887 66.92 16.45 13.38 

91122 ....... Anal pressure record ......................................... CH .. T 0164 2.1393 131.50 .................. 26.30 

91123 ....... Irrigate fecal impaction ...................................... ......... N .................. .................. .................. .................. ..................

91132 ....... Electrogastrography ........................................... ......... X 0360 1.4154 87.00 33.88 17.40 

91133 ....... Electrogastrography w/test ................................ ......... X 0360 1.4154 87.00 33.88 17.40 

91299 ....... Gastroenterology procedure .............................. ......... X 0360 1.4154 87.00 33.88 17.40 

92002 ....... Eye exam, new patient ...................................... CH .. V 0605 0.984 60.48 .................. 12.10 

92004 ....... Eye exam, new patient ...................................... CH .. V 0606 1.3646 83.88 .................. 16.78 

92012 ....... Eye exam established pat ................................. CH .. V 0604 0.8242 50.66 .................. 10.13 

92014 ....... Eye exam & treatment ....................................... CH .. V 0605 0.984 60.48 .................. 12.10 

92018 ....... New eye exam & treatment ............................... ......... T 0699 14.3845 884.19 .................. 176.84 

92019 ....... Eye exam & treatment ....................................... ......... T 0699 14.3845 884.19 .................. 176.84 

92020 ....... Special eye evaluation ....................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92025 ....... Corneal topography ........................................... NI .... S 0698 1.1607 71.35 .................. 14.27 

92060 ....... Special eye evaluation ....................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92065 ....... Orthoptic/pleoptic training .................................. CH .. S 0230 0.7898 48.55 14.97 9.71 

92070 ....... Fitting of contact lens ........................................ ......... N .................. .................. .................. .................. ..................

92081 ....... Visual field examination(s) ................................. ......... S 0230 0.7898 48.55 14.97 9.71 

92082 ....... Visual field examination(s) ................................. ......... S 0230 0.7898 48.55 14.97 9.71 

92083 ....... Visual field examination(s) ................................. ......... S 0230 0.7898 48.55 14.97 9.71 

92100 ....... Serial tonometry exam(s) .................................. ......... N .................. .................. .................. .................. ..................

92120 ....... Tonography & eye evaluation ............................ ......... S 0230 0.7898 48.55 14.97 9.71 

92130 ....... Water provocation tonography .......................... ......... S 0230 0.7898 48.55 14.97 9.71 

92135 ....... Opthalmic dx imaging ........................................ ......... S 0230 0.7898 48.55 14.97 9.71 

92136 ....... Ophthalmic biometry .......................................... ......... S 0698 1.1607 71.35 .................. 14.27 

92140 ....... Glaucoma provocative tests .............................. CH .. S 0230 0.7898 48.55 14.97 9.71 

92225 ....... Special eye exam, initial .................................... CH .. S 0230 0.7898 48.55 14.97 9.71 

92226 ....... Special eye exam, subsequent ......................... CH .. S 0230 0.7898 48.55 14.97 9.71 

92230 ....... Eye exam with photos ....................................... CH .. S 0231 2.1451 131.86 .................. 26.37 

92235 ....... Eye exam with photos ....................................... ......... S 0231 2.1451 131.86 .................. 26.37 

92240 ....... Icg angiography ................................................. ......... S 0231 2.1451 131.86 .................. 26.37 

92250 ....... Eye exam with photos ....................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92260 ....... Ophthalmoscopy/dynamometry ......................... CH .. S 0230 0.7898 48.55 14.97 9.71 

92265 ....... Eye muscle evaluation ....................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92270 ....... Electro-oculography ........................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92275 ....... Electroretinography ............................................ ......... S 0231 2.1451 131.86 .................. 26.37 

92283 ....... Color vision examination ................................... ......... S 0230 0.7898 48.55 14.97 9.71 

92284 ....... Dark adaptation eye exam ................................ ......... S 0698 1.1607 71.35 .................. 14.27 

92285 ....... Eye photography ................................................ ......... S 0230 0.7898 48.55 14.97 9.71 

92286 ....... Internal eye photography ................................... ......... S 0698 1.1607 71.35 .................. 14.27 

92287 ....... Internal eye photography ................................... ......... S 0698 1.1607 71.35 .................. 14.27 

92311 ....... Contact lens fitting ............................................. ......... X 0362 0.5865 36.05 .................. 7.21 

92312 ....... Contact lens fitting ............................................. ......... X 0362 0.5865 36.05 .................. 7.21 

92313 ....... Contact lens fitting ............................................. ......... X 0362 0.5865 36.05 .................. 7.21 

92315 ....... Prescription of contact lens ............................... ......... X 0362 0.5865 36.05 .................. 7.21 

92316 ....... Prescription of contact lens ............................... ......... X 0362 0.5865 36.05 .................. 7.21 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68357 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

92317 ....... Prescription of contact lens ............................... ......... X 0362 0.5865 36.05 .................. 7.21 

92325 ....... Modification of contact lens ............................... ......... X 0362 0.5865 36.05 .................. 7.21 

92326 ....... Replacement of contact lens ............................. ......... X 0362 0.5865 36.05 .................. 7.21 

92352 ....... Special spectacles fitting ................................... ......... X 0362 0.5865 36.05 .................. 7.21 

92353 ....... Special spectacles fitting ................................... ......... X 0362 0.5865 36.05 .................. 7.21 

92354 ....... Special spectacles fitting ................................... ......... X 0362 0.5865 36.05 .................. 7.21 

92355 ....... Special spectacles fitting ................................... ......... X 0362 0.5865 36.05 .................. 7.21 

92358 ....... Eye prosthesis service ....................................... ......... X 0362 0.5865 36.05 .................. 7.21 

92371 ....... Repair & adjust spectacles ................................ ......... X 0362 0.5865 36.05 .................. 7.21 

92499 ....... Eye service or procedure .................................. ......... S 0230 0.7898 48.55 14.97 9.71 

92502 ....... Ear and throat examination ............................... ......... T 0251 2.452 150.72 .................. 30.14 

92504 ....... Ear microscopy examination ............................. ......... N .................. .................. .................. .................. ..................

92511 ....... Nasopharyngoscopy .......................................... ......... T 0071 0.7698 47.32 11.20 9.46 

92512 ....... Nasal function studies ....................................... ......... X 0363 0.8525 52.40 17.44 10.48 

92516 ....... Facial nerve function test .................................. ......... X 0660 1.4461 88.89 28.06 17.78 

92520 ....... Laryngeal function studies ................................. ......... X 0660 1.4461 88.89 28.06 17.78 

92531 ....... Spontaneous nystagmus study ......................... ......... N .................. .................. .................. .................. ..................

92532 ....... Positional nystagmus test .................................. ......... N .................. .................. .................. .................. ..................

92533 ....... Caloric vestibular test ........................................ ......... N .................. .................. .................. .................. ..................

92534 ....... Optokinetic nystagmus test ............................... ......... N .................. .................. .................. .................. ..................

92541 ....... Spontaneous nystagmus test ............................ ......... X 0363 0.8525 52.40 17.44 10.48 

92542 ....... Positional nystagmus test .................................. ......... X 0363 0.8525 52.40 17.44 10.48 

92543 ....... Caloric vestibular test ........................................ ......... X 0660 1.4461 88.89 28.06 17.78 

92544 ....... Optokinetic nystagmus test ............................... ......... X 0363 0.8525 52.40 17.44 10.48 

92545 ....... Oscillating tracking test ...................................... ......... X 0363 0.8525 52.40 17.44 10.48 

92546 ....... Sinusoidal rotational test ................................... ......... X 0660 1.4461 88.89 28.06 17.78 

92547 ....... Supplemental electrical test ............................... ......... X 0363 0.8525 52.40 17.44 10.48 

92548 ....... Posturography .................................................... ......... X 0660 1.4461 88.89 28.06 17.78 

92552 ....... Pure tone audiometry, air .................................. ......... X 0364 0.4627 28.44 7.06 5.69 

92553 ....... Audiometry, air & bone ...................................... ......... X 0365 1.2419 76.34 18.52 15.27 

92555 ....... Speech threshold audiometry ............................ ......... X 0364 0.4627 28.44 7.06 5.69 

92556 ....... Speech audiometry, complete ........................... ......... X 0364 0.4627 28.44 7.06 5.69 

92557 ....... Comprehensive hearing test .............................. ......... X 0365 1.2419 76.34 18.52 15.27 

92561 ....... Bekesy audiometry, diagnosis ........................... ......... X 0364 0.4627 28.44 7.06 5.69 

92562 ....... Loudness balance test ....................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92563 ....... Tone decay hearing test .................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92564 ....... Sisi hearing test ................................................. ......... X 0364 0.4627 28.44 7.06 5.69 

92565 ....... Stenger test, pure tone ...................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92567 ....... Tympanometry ................................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92568 ....... Acoustic refl threshold tst .................................. ......... X 0364 0.4627 28.44 7.06 5.69 

92569 ....... Acoustic reflex decay test .................................. ......... X 0364 0.4627 28.44 7.06 5.69 

92571 ....... Filtered speech hearing test .............................. ......... X 0364 0.4627 28.44 7.06 5.69 

92572 ....... Staggered spondaic word test ........................... ......... X 0366 1.8511 113.78 26.14 22.76 

92573 ....... Lombard test ...................................................... CH .. D .................. .................. .................. .................. ..................

92575 ....... Sensorineural acuity test ................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92576 ....... Synthetic sentence test ..................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92577 ....... Stenger test, speech .......................................... ......... X 0366 1.8511 113.78 26.14 22.76 

92579 ....... Visual audiometry (vra) ...................................... ......... X 0365 1.2419 76.34 18.52 15.27 

92582 ....... Conditioning play audiometry ............................ ......... X 0365 1.2419 76.34 18.52 15.27 

92583 ....... Select picture audiometry .................................. ......... X 0364 0.4627 28.44 7.06 5.69 

92584 ....... Electrocochleography ........................................ ......... X 0660 1.4461 88.89 28.06 17.78 

92585 ....... Auditor evoke potent, compre ........................... ......... S 0216 2.7199 167.19 .................. 33.44 

92586 ....... Auditor evoke potent, limit ................................. ......... S 0218 1.1872 72.97 .................. 14.59 

92587 ....... Evoked auditory test .......................................... ......... X 0363 0.8525 52.40 17.44 10.48 

92588 ....... Evoked auditory test .......................................... ......... X 0660 1.4461 88.89 28.06 17.78 

92596 ....... Ear protector evaluation .................................... ......... X 0364 0.4627 28.44 7.06 5.69 

92601 ....... Cochlear implt f/up exam < 7 ............................ ......... X 0366 1.8511 113.78 26.14 22.76 

92602 ....... Reprogram cochlear implt < 7 ........................... ......... X 0366 1.8511 113.78 26.14 22.76 

92603 ....... Cochlear implt f/up exam 7 > ............................ ......... X 0366 1.8511 113.78 26.14 22.76 

92604 ....... Reprogram cochlear implt 7 > ........................... ......... X 0366 1.8511 113.78 26.14 22.76 

92620 ....... Auditory function, 60 min ................................... ......... X 0365 1.2419 76.34 18.52 15.27 

92621 ....... Auditory function, + 15 min ............................... ......... N .................. .................. .................. .................. ..................

92625 ....... Tinnitus assessment .......................................... ......... X 0365 1.2419 76.34 18.52 15.27 

92626 ....... Eval aud rehab status ........................................ ......... X 0365 1.2419 76.34 18.52 15.27 

92627 ....... Eval aud status rehab add-on ........................... ......... N .................. .................. .................. .................. ..................

92640 ....... Aud brainstem implt programg .......................... NI .... X 0365 1.2419 76.34 18.52 15.27 

92700 ....... Ent procedure/service ........................................ ......... X 0364 0.4627 28.44 7.06 5.69 

92950 ....... Heart/lung resuscitation cpr ............................... ......... S 0094 2.4233 148.96 46.29 29.79 

92953 ....... Temporary external pacing ................................ ......... S 0094 2.4233 148.96 46.29 29.79 

92960 ....... Cardioversion electric, ext ................................. ......... S 0679 5.5233 339.51 95.30 67.90 


cprice-sewell on PRODPC62 with RULES2
68358 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

92961 ....... Cardioversion, electric, int ................................. ......... S 0679 5.5233 339.51 95.30 67.90 

92973 ....... Percut coronary thrombectomy ......................... ......... T 0088 37.7391 2,319.75 655.22 463.95 

92974 ....... Cath place, cardio brachytx ............................... ......... T 0103 16.2375 998.09 223.63 199.62 

92977 ....... Dissolve clot, heart vessel ................................. ......... T 0676 2.0726 127.40 .................. 25.48 

92978 ....... Intravasc us, heart add-on ................................. ......... S 0670 32.2854 1,984.52 536.10 396.90 

92979 ....... Intravasc us, heart add-on ................................. ......... S 0416 32.5472 2,000.61 .................. 400.12 

92980 ....... Insert intracoronary stent ................................... ......... T 0104 87.7183 5,391.87 .................. 1,078.37 

92981 ....... Insert intracoronary stent ................................... ......... T 0104 87.7183 5,391.87 .................. 1,078.37 

92982 ....... Coronary artery dilation ..................................... ......... T 0083 58.7904 3,613.73 .................. 722.75 

92984 ....... Coronary artery dilation ..................................... ......... T 0083 58.7904 3,613.73 .................. 722.75 

92986 ....... Revision of aortic valve ..................................... ......... T 0083 58.7904 3,613.73 .................. 722.75 

92987 ....... Revision of mitral valve ..................................... ......... T 0083 58.7904 3,613.73 .................. 722.75 

92990 ....... Revision of pulmonary valve ............................. ......... T 0083 58.7904 3,613.73 .................. 722.75 

92995 ....... Coronary atherectomy ....................................... ......... T 0082 72.1982 4,437.88 954.62 887.58 

92996 ....... Coronary atherectomy add-on ........................... ......... T 0082 72.1982 4,437.88 954.62 887.58 

92997 ....... Pul art balloon repr, percut ................................ ......... T 0081 42.936 2,639.19 .................. 527.84 

92998 ....... Pul art balloon repr, percut ................................ ......... T 0081 42.936 2,639.19 .................. 527.84 

93005 ....... Electrocardiogram, tracing ................................. ......... S 0099 0.3789 23.29 .................. 4.66 

93012 ....... Transmission of ecg .......................................... ......... N .................. .................. .................. .................. ..................

93017 ....... Cardiovascular stress test ................................. ......... X 0100 2.5336 155.74 41.44 31.15 

93024 ....... Cardiac drug stress test .................................... ......... X 0100 2.5336 155.74 41.44 31.15 

93025 ....... Microvolt t-wave assess .................................... ......... X 0100 2.5336 155.74 41.44 31.15 

93041 ....... Rhythm ECG, tracing ......................................... ......... S 0099 0.3789 23.29 .................. 4.66 

93225 ....... ECG monitor/record, 24 hrs .............................. ......... X 0097 1.0225 62.85 23.79 12.57 

93226 ....... ECG monitor/report, 24 hrs ............................... ......... X 0097 1.0225 62.85 23.79 12.57 

93231 ....... Ecg monitor/record, 24 hrs ................................ ......... X 0097 1.0225 62.85 23.79 12.57 

93232 ....... ECG monitor/report, 24 hrs ............................... ......... X 0097 1.0225 62.85 23.79 12.57 

93236 ....... ECG monitor/report, 24 hrs ............................... ......... X 0097 1.0225 62.85 23.79 12.57 

93270 ....... ECG recording ................................................... ......... X 0097 1.0225 62.85 23.79 12.57 

93271 ....... Ecg/monitoring and analysis .............................. ......... X 0097 1.0225 62.85 23.79 12.57 

93278 ....... ECG/signal-averaged ......................................... ......... S 0099 0.3789 23.29 .................. 4.66 

93303 ....... Echo transthoracic ............................................. ......... S 0269 3.2154 197.64 75.60 39.53 

93304 ....... Echo transthoracic ............................................. ......... S 0697 1.5973 98.18 35.99 19.64 

93307 ....... Echo exam of heart ........................................... ......... S 0269 3.2154 197.64 75.60 39.53 

93308 ....... Echo exam of heart ........................................... ......... S 0697 1.5973 98.18 35.99 19.64 

93312 ....... Echo transesophageal ....................................... ......... S 0270 6.2505 384.21 141.32 76.84 

93313 ....... Echo transesophageal ....................................... ......... S 0270 6.2505 384.21 141.32 76.84 

93314 ....... Echo transesophageal ....................................... ......... N .................. .................. .................. .................. ..................

93315 ....... Echo transesophageal ....................................... ......... S 0270 6.2505 384.21 141.32 76.84 

93316 ....... Echo transesophageal ....................................... ......... S 0270 6.2505 384.21 141.32 76.84 

93317 ....... Echo transesophageal ....................................... ......... N .................. .................. .................. .................. ..................

93318 ....... Echo transesophageal intraop ........................... ......... S 0270 6.2505 384.21 141.32 76.84 

93320 ....... Doppler echo exam, heart ................................. CH .. S 0697 1.5973 98.18 35.99 19.64 

93321 ....... Doppler echo exam, heart ................................. ......... S 0697 1.5973 98.18 35.99 19.64 

93325 ....... Doppler color flow add-on ................................. ......... S 0697 1.5973 98.18 35.99 19.64 

93350 ....... Echo transthoracic ............................................. ......... S 0269 3.2154 197.64 75.60 39.53 

93501 ....... Right heart catheterization ................................. ......... T 0080 37.0615 2,278.10 838.92 455.62 

93503 ....... Insert/place heart catheter ................................. ......... T 0103 16.2375 998.09 223.63 199.62 

93505 ....... Biopsy of heart lining ......................................... ......... T 0103 16.2375 998.09 223.63 199.62 

93508 ....... Cath placement, angiography ............................ ......... T 0080 37.0615 2,278.10 838.92 455.62 

93510 ....... Left heart catheterization ................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93511 ....... Left heart catheterization ................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93514 ....... Left heart catheterization ................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93524 ....... Left heart catheterization ................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93526 ....... Rt & lT heart catheters ...................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93527 ....... Rt & lT heart catheters ...................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93528 ....... Rt & lT heart catheters ...................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93529 ....... Rt, lt heart catheterization ................................. ......... T 0080 37.0615 2,278.10 838.92 455.62 

93530 ....... Rt heart cath, congenital ................................... ......... T 0080 37.0615 2,278.10 838.92 455.62 

93531 ....... R& l heart cath, congenital ................................ ......... T 0080 37.0615 2,278.10 838.92 455.62 

93532 ....... R& l heart cath, congenital ................................ ......... T 0080 37.0615 2,278.10 838.92 455.62 

93533 ....... R& l heart cath, congenital ................................ ......... T 0080 37.0615 2,278.10 838.92 455.62 

93539 ....... Injection, cardiac cath ........................................ ......... N .................. .................. .................. .................. ..................

93540 ....... Injection, cardiac cath ........................................ ......... N .................. .................. .................. .................. ..................

93541 ....... Injection for lung angiogram .............................. ......... N .................. .................. .................. .................. ..................

93542 ....... Injection for heart x-rays .................................... ......... N .................. .................. .................. .................. ..................

93543 ....... Injection for heart x-rays .................................... ......... N .................. .................. .................. .................. ..................

93544 ....... Injection for aortography .................................... ......... N .................. .................. .................. .................. ..................

93545 ....... Inject for coronary x-rays ................................... ......... N .................. .................. .................. .................. ..................

93555 ....... Imaging, cardiac cath ........................................ ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68359 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

93556 ....... Imaging, cardiac cath ........................................ ......... N .................. .................. .................. .................. ..................

93561 ....... Cardiac output measurement ............................ ......... N .................. .................. .................. .................. ..................

93562 ....... Cardiac output measurement ............................ ......... N .................. .................. .................. .................. ..................

93571 ....... Heart flow reserve measure .............................. ......... S 0670 32.2854 1,984.52 536.10 396.90 

93572 ....... Heart flow reserve measure .............................. ......... S 0416 32.5472 2,000.61 .................. 400.12 

93580 ....... Transcath closure of asd ................................... ......... T 0434 88.0728 5,413.66 .................. 1,082.73 

93581 ....... Transcath closure of vsd ................................... ......... T 0434 88.0728 5,413.66 .................. 1,082.73 

93600 ....... Bundle of His recording ..................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93602 ....... Intra-atrial recording ........................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93603 ....... Right ventricular recording ................................. ......... T 0087 32.8988 2,022.22 .................. 404.44 

93609 ....... Map tachycardia, add-on ................................... ......... T 0087 32.8988 2,022.22 .................. 404.44

93610 ....... Intra-atrial pacing ............................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93612 ....... Intraventricular pacing ....................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93613 ....... Electrophys map 3d, add-on ............................. ......... T 0087 32.8988 2,022.22 .................. 404.44 

93615 ....... Esophageal recording ........................................ ......... T 0087 32.8988 2,022.22 .................. 404.44 

93616 ....... Esophageal recording ........................................ ......... T 0087 32.8988 2,022.22 .................. 404.44 

93618 ....... Heart rhythm pacing .......................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93619 ....... Electrophysiology evaluation ............................. ......... T 0085 34.2808 2,107.17 426.25 421.43 

93620 ....... Electrophysiology evaluation ............................. ......... T 0085 34.2808 2,107.17 426.25 421.43 

93621 ....... Electrophysiology evaluation ............................. ......... T 0085 34.2808 2,107.17 426.25 421.43 

93622 ....... Electrophysiology evaluation ............................. ......... T 0085 34.2808 2,107.17 426.25 421.43 

93623 ....... Stimulation, pacing heart ................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93624 ....... Electrophysiologic study .................................... ......... T 0085 34.2808 2,107.17 426.25 421.43 

93631 ....... Heart pacing, mapping ...................................... ......... T 0087 32.8988 2,022.22 .................. 404.44 

93640 ....... Evaluation heart device ..................................... CH .. N .................. .................. .................. .................. ..................

93641 ....... Electrophysiology evaluation ............................. CH .. N .................. .................. .................. .................. ..................

93642 ....... Electrophysiology evaluation ............................. ......... S 0084 9.8924 608.07 .................. 121.61 

93650 ....... Ablate heart dysrhythm focus ............................ ......... T 0086 47.4931 2,919.31 812.36 583.86 

93651 ....... Ablate heart dysrhythm focus ............................ ......... T 0086 47.4931 2,919.31 812.36 583.86 

93652 ....... Ablate heart dysrhythm focus ............................ ......... T 0086 47.4931 2,919.31 812.36 583.86 

93660 ....... Tilt table evaluation ............................................ ......... S 0101 4.2769 262.89 100.24 52.58 

93662 ....... Intracardiac ecg (ice) ......................................... ......... S 0670 32.2854 1,984.52 536.10 396.90 

93701 ....... Bioimpedance, thoracic ..................................... ......... S 0099 0.3789 23.29 .................. 4.66 

93721 ....... Plethysmography tracing ................................... ......... X 0368 0.9454 58.11 22.77 11.62 

93724 ....... Analyze pacemaker system ............................... ......... S 0690 0.3613 22.21 8.67 4.44 

93727 ....... Analyze ilr system .............................................. ......... S 0690 0.3613 22.21 8.67 4.44 

93731 ....... Analyze pacemaker system ............................... ......... S 0690 0.3613 22.21 8.67 4.44 

93732 ....... Analyze pacemaker system ............................... ......... S 0690 0.3613 22.21 8.67 4.44 

93733 ....... Telephone analy, pacemaker ............................ ......... S 0690 0.3613 22.21 8.67 4.44 

93734 ....... Analyze pacemaker system ............................... ......... S 0690 0.3613 22.21 8.67 4.44 

93735 ....... Analyze pacemaker system ............................... ......... S 0690 0.3613 22.21 8.67 4.44 

93736 ....... Telephonic analy, pacemaker ............................ ......... S 0690 0.3613 22.21 8.67 4.44 

93740 ....... Temperature gradient studies ............................ ......... X 0368 0.9454 58.11 22.77 11.62 

93741 ....... Analyze ht pace device sngl .............................. ......... S 0689 0.6003 36.90 .................. 7.38 

93742 ....... Analyze ht pace device sngl .............................. ......... S 0689 0.6003 36.90 .................. 7.38 

93743 ....... Analyze ht pace device dual ............................. ......... S 0689 0.6003 36.90 .................. 7.38 

93744 ....... Analyze ht pace device dual ............................. ......... S 0689 0.6003 36.90 .................. 7.38 

93745 ....... Set-up cardiovert-defibrill ................................... ......... S 0689 0.6003 36.90 .................. 7.38 

93770 ....... Measure venous pressure ................................. ......... N .................. .................. .................. .................. ..................

93786 ....... Ambulatory BP recording ................................... ......... X 0097 1.0225 62.85 23.79 12.57 

93788 ....... Ambulatory BP analysis ..................................... ......... X 0097 1.0225 62.85 23.79 12.57 

93797 ....... Cardiac rehab .................................................... ......... S 0095 0.5748 35.33 13.86 7.07 

93798 ....... Cardiac rehab/monitor ....................................... ......... S 0095 0.5748 35.33 13.86 7.07 

93799 ....... Cardiovascular procedure .................................. CH .. X 0097 1.0225 62.85 23.79 12.57 

93875 ....... Extracranial study .............................................. ......... S 0096 1.5303 94.06 37.62 18.81 

93880 ....... Extracranial study .............................................. ......... S 0267 2.4606 151.25 60.50 30.25 

93882 ....... Extracranial study .............................................. ......... S 0267 2.4606 151.25 60.50 30.25 

93886 ....... Intracranial study ............................................... ......... S 0267 2.4606 151.25 60.50 30.25 

93888 ....... Intracranial study ............................................... CH .. S 0265 0.9923 60.99 23.63 12.20 

93890 ....... Tcd, vasoreactivity study ................................... ......... S 0266 1.5607 95.93 37.80 19.19 

93892 ....... Tcd, emboli detect w/o inj .................................. ......... S 0266 1.5607 95.93 37.80 19.19 

93893 ....... Tcd, emboli detect w/inj ..................................... ......... S 0266 1.5607 95.93 37.80 19.19 

93922 ....... Extremity study .................................................. ......... S 0096 1.5303 94.06 37.62 18.81 

93923 ....... Extremity study .................................................. ......... S 0096 1.5303 94.06 37.62 18.81 

93924 ....... Extremity study .................................................. ......... S 0096 1.5303 94.06 37.62 18.81 

93925 ....... Lower extremity study ........................................ ......... S 0267 2.4606 151.25 60.50 30.25 

93926 ....... Lower extremity study ........................................ ......... S 0266 1.5607 95.93 37.80 19.19 

93930 ....... Upper extremity study ........................................ ......... S 0267 2.4606 151.25 60.50 30.25 

93931 ....... Upper extremity study ........................................ ......... S 0266 1.5607 95.93 37.80 19.19 

93965 ....... Extremity study .................................................. ......... S 0096 1.5303 94.06 37.62 18.81 


cprice-sewell on PRODPC62 with RULES2
68360 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

93970 ....... Extremity study .................................................. ......... S 0267 2.4606 151.25 60.50 30.25 

93971 ....... Extremity study .................................................. ......... S 0266 1.5607 95.93 37.80 19.19 

93975 ....... Vascular study ................................................... ......... S 0267 2.4606 151.25 60.50 30.25 

93976 ....... Vascular study ................................................... ......... S 0267 2.4606 151.25 60.50 30.25 

93978 ....... Vascular study ................................................... ......... S 0266 1.5607 95.93 37.80 19.19 

93979 ....... Vascular study ................................................... ......... S 0266 1.5607 95.93 37.80 19.19 

93980 ....... Penile vascular study ......................................... ......... S 0267 2.4606 151.25 60.50 30.25 

93981 ....... Penile vascular study ......................................... ......... S 0266 1.5607 95.93 37.80 19.19 

93990 ....... Doppler flow testing ........................................... ......... S 0266 1.5607 95.93 37.80 19.19 

94002 ....... Vent mgmt inpat, init day ................................... NI .... S 0079 2.6116 160.53 .................. 32.11 

94003 ....... Vent mgmt inpat, subq day ............................... NI .... S 0079 2.6116 160.53 .................. 32.11 

94004 ....... Vent mgmt nf per day ........................................ NI .... B .................. .................. .................. .................. ..................

94005 ....... Home vent mgmt supervision ............................ NI .... E .................. .................. .................. .................. ..................

94010 ....... Breathing capacity test ...................................... ......... X 0368 0.9454 58.11 22.77 11.62 

94014 ....... Patient recorded spirometry .............................. ......... X 0367 0.6277 38.58 14.68 7.72 

94015 ....... Patient recorded spirometry .............................. ......... X 0367 0.6277 38.58 14.68 7.72 

94060 ....... Evaluation of wheezing ...................................... ......... X 0368 0.9454 58.11 22.77 11.62 

94070 ....... Evaluation of wheezing ...................................... ......... X 0369 2.7669 170.08 44.18 34.02 

94150 ....... Vital capacity test ............................................... ......... X 0367 0.6277 38.58 14.68 7.72 

94200 ....... Lung function test (MBC/MVV) .......................... ......... X 0367 0.6277 38.58 14.68 7.72 

94240 ....... Residual lung capacity ....................................... ......... X 0368 0.9454 58.11 22.77 11.62 

94250 ....... Expired gas collection ........................................ ......... X 0367 0.6277 38.58 14.68 7.72 

94260 ....... Thoracic gas volume ......................................... CH .. X 0368 0.9454 58.11 22.77 11.62 

94350 ....... Lung nitrogen washout curve ............................ CH .. X 0368 0.9454 58.11 22.77 11.62 

94360 ....... Measure airflow resistance ................................ ......... X 0367 0.6277 38.58 14.68 7.72 

94370 ....... Breath airway closing volume ............................ ......... X 0367 0.6277 38.58 14.68 7.72 

94375 ....... Respiratory flow volume loop ............................ ......... X 0367 0.6277 38.58 14.68 7.72 

94400 ....... CO2 breathing response curve ......................... ......... X 0367 0.6277 38.58 14.68 7.72 

94450 ....... Hypoxia response curve .................................... ......... X 0368 0.9454 58.11 22.77 11.62 

94452 ....... Hast w/report ..................................................... ......... X 0368 0.9454 58.11 22.77 11.62 

94453 ....... Hast w/oxygen titrate ......................................... CH .. X 0367 0.6277 38.58 14.68 7.72 

94610 ....... Surfactant admin thru tube ................................ NI .... S 0077 0.3527 21.68 7.74 4.34 

94620 ....... Pulmonary stress test/simple ............................. ......... X 0368 0.9454 58.11 22.77 11.62 

94621 ....... Pulm stress test/complex ................................... ......... X 0369 2.7669 170.08 44.18 34.02 

94640 ....... Airway inhalation treatment ............................... ......... S 0077 0.3527 21.68 7.74 4.34 

94642 ....... Aerosol inhalation treatment .............................. ......... S 0078 1.1206 68.88 14.55 13.78 

94644 ....... Cbt, 1st hour ...................................................... NI .... S 0078 1.1206 68.88 14.55 13.78 

94645 ....... Cbt, each addl hour ........................................... NI .... S 0078 1.1206 68.88 14.55 13.78 

94656 ....... Initial ventilator mgmt ......................................... CH .. D .................. .................. .................. .................. ..................

94657 ....... Continued ventilator mgmt ................................. CH .. D .................. .................. .................. .................. ..................

94660 ....... Pos airway pressure, CPAP .............................. ......... S 0068 1.5353 94.37 29.48 18.87 

94662 ....... Neg press ventilation, cnp ................................. ......... S 0079 2.6116 160.53 .................. 32.11 

94664 ....... Evaluate pt use of inhaler .................................. ......... S 0077 0.3527 21.68 7.74 4.34 

94667 ....... Chest wall manipulation ..................................... ......... S 0077 0.3527 21.68 7.74 4.34 

94668 ....... Chest wall manipulation ..................................... ......... S 0077 0.3527 21.68 7.74 4.34 

94680 ....... Exhaled air analysis, o2 .................................... ......... X 0367 0.6277 38.58 14.68 7.72 

94681 ....... Exhaled air analysis, o2/co2 .............................. ......... X 0368 0.9454 58.11 22.77 11.62 

94690 ....... Exhaled air analysis ........................................... CH .. X 0367 0.6277 38.58 14.68 7.72 

94720 ....... Monoxide diffusing capacity .............................. ......... X 0368 0.9454 58.11 22.77 11.62 

94725 ....... Membrane diffusion capacity ............................. ......... X 0368 0.9454 58.11 22.77 11.62 

94750 ....... Pulmonary compliance study ............................. CH .. X 0367 0.6277 38.58 14.68 7.72 

94760 ....... Measure blood oxygen level .............................. ......... N .................. .................. .................. .................. ..................

94761 ....... Measure blood oxygen level .............................. ......... N .................. .................. .................. .................. ..................

94762 ....... Measure blood oxygen level .............................. CH .. Q 0443 1.0409 63.98 25.59 12.80 

94770 ....... Exhaled carbon dioxide test .............................. ......... X 0367 0.6277 38.58 14.68 7.72 

94772 ....... Breath recording, infant ..................................... ......... X 0369 2.7669 170.08 44.18 34.02 

94774 ....... Ped home apnea rec, compl ............................. NI .... B .................. .................. .................. .................. ..................

94775 ....... Ped home apnea rec, hk-up .............................. NI .... X 0097 1.0225 62.85 23.79 12.57 

94776 ....... Ped home apnea rec, downld ........................... NI .... X 0097 1.0225 62.85 23.79 12.57 

94777 ....... Ped home apnea rec, report ............................. NI .... B .................. .................. .................. .................. ..................

94799 ....... Pulmonary service/procedure ............................ ......... X 0367 0.6277 38.58 14.68 7.72 

95004 ....... Percut allergy skin tests .................................... ......... X 0381 0.2688 16.52 .................. 3.30 

95010 ....... Percut allergy titrate test .................................... ......... X 0381 0.2688 16.52 .................. 3.30 

95012 ....... Exhaled nitric oxide meas ................................. NI .... X 0367 0.6277 38.58 14.68 7.72 

95015 ....... Id allergy titrate-drug/bug ................................... ......... X 0381 0.2688 16.52 .................. 3.30 

95024 ....... Id allergy test, drug/bug ..................................... ......... X 0381 0.2688 16.52 .................. 3.30 

95027 ....... Id allergy titrate-airborne .................................... ......... X 0381 0.2688 16.52 .................. 3.30 

95028 ....... Id allergy test-delayed type ............................... ......... X 0381 0.2688 16.52 .................. 3.30 

95044 ....... Allergy patch tests ............................................. ......... X 0381 0.2688 16.52 .................. 3.30

95052 ....... Photo patch test ................................................. ......... X 0381 0.2688 16.52 .................. 3.30 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68361 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

95056 ....... Photosensitivity tests ......................................... ......... X 0370 1.027 63.13 .................. 12.63 

95060 ....... Eye allergy tests ................................................ ......... X 0370 1.027 63.13 .................. 12.63 

95065 ....... Nose allergy test ................................................ ......... X 0381 0.2688 16.52 .................. 3.30 

95070 ....... Bronchial allergy tests ....................................... ......... X 0369 2.7669 170.08 44.18 34.02 

95071 ....... Bronchial allergy tests ....................................... ......... X 0369 2.7669 170.08 44.18 34.02 

95075 ....... Ingestion challenge test ..................................... ......... X 0361 3.8887 239.03 83.23 47.81 

95078 ....... Provocative testing ............................................ CH .. D .................. .................. .................. .................. ..................

95115 ....... Immunotherapy, one injection ........................... CH .. S 0436 0.1809 11.12 .................. 2.22 

95117 ....... Immunotherapy injections .................................. CH .. S 0437 0.3945 24.25 .................. 4.85 

95144 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95145 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95146 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95147 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95148 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95149 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95165 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95170 ....... Antigen therapy services ................................... CH .. S 0437 0.3945 24.25 .................. 4.85 

95180 ....... Rapid desensitization ......................................... ......... X 0370 1.027 63.13 .................. 12.63 

95199 ....... Allergy immunology services ............................. CH .. X 0381 0.2688 16.52 .................. 3.30 

95250 ....... Glucose monitoring, cont ................................... ......... X 0421 1.627 100.01 .................. 20.00 

95805 ....... Multiple sleep latency test ................................. ......... S 0209 11.2463 691.29 268.73 138.26 

95806 ....... Sleep study, unattended .................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95807 ....... Sleep study, attended ........................................ ......... S 0209 11.2463 691.29 268.73 138.26 

95808 ....... Polysomnography, 1–3 ...................................... ......... S 0209 11.2463 691.29 268.73 138.26 

95810 ....... Polysomnography, 4 or more ............................ ......... S 0209 11.2463 691.29 268.73 138.26 

95811 ....... Polysomnography w/cpap .................................. ......... S 0209 11.2463 691.29 268.73 138.26 

95812 ....... Eeg, 41–60 minutes ........................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95813 ....... Eeg, over 1 hour ................................................ ......... S 0213 2.2755 139.87 53.58 27.97 

95816 ....... Eeg, awake and drowsy .................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95819 ....... Eeg, awake and asleep ..................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95822 ....... Eeg, coma or sleep only .................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95824 ....... Eeg, cerebral death only ................................... ......... S 0214 1.1968 73.56 28.24 14.71 

95827 ....... Eeg, all night recording ...................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95829 ....... Surgery electrocorticogram ................................ ......... S 0214 1.1968 73.56 28.24 14.71 

95857 ....... Tensilon test ...................................................... ......... S 0218 1.1872 72.97 .................. 14.59 

95860 ....... Muscle test, one limb ......................................... ......... S 0218 1.1872 72.97 .................. 14.59 

95861 ....... Muscle test, 2 limbs ........................................... ......... S 0218 1.1872 72.97 .................. 14.59

95863 ....... Muscle test, 3 limbs ........................................... ......... S 0218 1.1872 72.97 .................. 14.59

95864 ....... Muscle test, 4 limbs ........................................... ......... S 0218 1.1872 72.97 .................. 14.59

95865 ....... Muscle test, larynx ............................................. ......... S 0218 1.1872 72.97 .................. 14.59 

95866 ....... Muscle test, hemidiaphragm .............................. ......... S 0218 1.1872 72.97 .................. 14.59 

95867 ....... Muscle test cran nerv unilat .............................. ......... S 0218 1.1872 72.97 .................. 14.59 

95868 ....... Muscle test cran nerve bilat .............................. ......... S 0218 1.1872 72.97 .................. 14.59 

95869 ....... Muscle test, thor paraspinal .............................. ......... S 0215 0.5741 35.29 .................. 7.06 

95870 ....... Muscle test, nonparaspinal ................................ ......... S 0215 0.5741 35.29 .................. 7.06 

95872 ....... Muscle test, one fiber ........................................ ......... S 0218 1.1872 72.97 .................. 14.59 

95873 ....... Guide nerv destr, elec stim ............................... ......... S 0215 0.5741 35.29 .................. 7.06 

95874 ....... Guide nerv destr, needle emg ........................... ......... S 0215 0.5741 35.29 .................. 7.06 

95875 ....... Limb exercise test .............................................. ......... S 0215 0.5741 35.29 .................. 7.06

95900 ....... Motor nerve conduction test .............................. ......... S 0215 0.5741 35.29 .................. 7.06 

95903 ....... Motor nerve conduction test .............................. ......... S 0215 0.5741 35.29 .................. 7.06 

95904 ....... Sense nerve conduction test ............................. ......... S 0215 0.5741 35.29 .................. 7.06 

95920 ....... Intraop nerve test add-on .................................. ......... S 0216 2.7199 167.19 .................. 33.44 

95921 ....... Autonomic nerv function test ............................. CH .. S 0215 0.5741 35.29 .................. 7.06 

95922 ....... Autonomic nerv function test ............................. CH .. S 0215 0.5741 35.29 .................. 7.06 

95923 ....... Autonomic nerv function test ............................. CH .. S 0215 0.5741 35.29 .................. 7.06 

95925 ....... Somatosensory testing ...................................... ......... S 0216 2.7199 167.19 .................. 33.44 

95926 ....... Somatosensory testing ...................................... ......... S 0216 2.7199 167.19 .................. 33.44 

95927 ....... Somatosensory testing ...................................... ......... S 0216 2.7199 167.19 .................. 33.44 

95928 ....... Cmotor evoked, uppr limbs ............................... ......... S 0218 1.1872 72.97 .................. 14.59 

95929 ....... Cmotor evoked, lwr limbs .................................. ......... S 0218 1.1872 72.97 .................. 14.59 

95930 ....... Visual evoked potential test ............................... ......... S 0216 2.7199 167.19 .................. 33.44 

95933 ....... Blink reflex test .................................................. ......... S 0215 0.5741 35.29 .................. 7.06 

95934 ....... H-reflex test ....................................................... ......... S 0215 0.5741 35.29 .................. 7.06 

95936 ....... H-reflex test ....................................................... ......... S 0215 0.5741 35.29 .................. 7.06 

95937 ....... Neuromuscular junction test .............................. CH .. S 0215 0.5741 35.29 .................. 7.06 

95950 ....... Ambulatory eeg monitoring ................................ ......... S 0209 11.2463 691.29 268.73 138.26 

95951 ....... EEG monitoring/videorecord .............................. ......... S 0209 11.2463 691.29 268.73 138.26 

95953 ....... EEG monitoring/computer ................................. ......... S 0209 11.2463 691.29 268.73 138.26 

95954 ....... EEG monitoring/giving drugs ............................. ......... S 0214 1.1968 73.56 28.24 14.71 


cprice-sewell on PRODPC62 with RULES2
68362 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

95955 ....... EEG during surgery ........................................... ......... S 0213 2.2755 139.87 53.58 27.97 

95956 ....... Eeg monitoring, cable/radio ............................... ......... S 0209 11.2463 691.29 268.73 138.26 

95957 ....... EEG digital analysis ........................................... ......... S 0214 1.1968 73.56 28.24 14.71 

95958 ....... EEG monitoring/function test ............................. ......... S 0213 2.2755 139.87 53.58 27.97 

95961 ....... Electrode stimulation, brain ............................... ......... S 0216 2.7199 167.19 .................. 33.44 

95962 ....... Electrode stim, brain add-on ............................. ......... S 0216 2.7199 167.19 .................. 33.44 

95965 ....... Meg, spontaneous ............................................. CH .. S 0038 53.5161 3,289.53 .................. 657.91 

95966 ....... Meg, evoked, single ........................................... CH .. S 0209 11.2463 691.29 268.73 138.26 

95967 ....... Meg, evoked, each add"l ................................. CH .. S 0209 11.2463 691.29 268.73 138.26 

95970 ....... Analyze neurostim, no prog ............................... ......... S 0218 1.1872 72.97 .................. 14.59 

95971 ....... Analyze neurostim, simple ................................. ......... S 0692 1.9323 118.77 30.16 23.75 

95972 ....... Analyze neurostim, complex .............................. ......... S 0692 1.9323 118.77 30.16 23.75 

95973 ....... Analyze neurostim, complex .............................. CH .. S 0663 1.1067 68.03 17.45 13.61 

95974 ....... Cranial neurostim, complex ............................... ......... S 0692 1.9323 118.77 30.16 23.75 

95975 ....... Cranial neurostim, complex ............................... ......... S 0692 1.9323 118.77 30.16 23.75 

95978 ....... Analyze neurostim brain/1h ............................... ......... S 0692 1.9323 118.77 30.16 23.75 

95979 ....... Analyz neurostim brain addon ........................... CH .. S 0663 1.1067 68.03 17.45 13.61 

95990 ....... Spin/brain pump refil & main ............................. ......... T 0125 2.2041 135.48 .................. 27.10 

95991 ....... Spin/brain pump refil & main ............................. ......... T 0125 2.2041 135.48 .................. 27.10 

95999 ....... Neurological procedure ...................................... ......... S 0215 0.5741 35.29 .................. 7.06 

96000 ....... Motion analysis, video/3d .................................. ......... S 0216 2.7199 167.19 .................. 33.44 

96001 ....... Motion test w/ft press meas .............................. ......... S 0216 2.7199 167.19 .................. 33.44 

96002 ....... Dynamic surface emg ........................................ ......... S 0218 1.1872 72.97 .................. 14.59 

96003 ....... Dynamic fine wire emg ...................................... ......... S 0215 0.5741 35.29 .................. 7.06 

96020 ....... Functional brain mapping .................................. NI .... X 0373 1.7682 108.69 .................. 21.74 

96040 ....... Genetic counseling, 30 min ............................... NI .... E .................. .................. .................. .................. ..................

96101 ....... Psycho testing by psych/phys ........................... ......... X 0373 1.7682 108.69 .................. 21.74 

96102 ....... Psycho testing by technician ............................. ......... X 0382 2.846 174.94 69.97 34.99 

96103 ....... Psycho testing admin by comp ......................... ......... X 0373 1.7682 108.69 .................. 21.74 

96110 ....... Developmental test, lim ..................................... ......... X 0373 1.7682 108.69 .................. 21.74 

96111 ....... Developmental test, extend ............................... ......... X 0373 1.7682 108.69 .................. 21.74 

96116 ....... Neurobehavioral status exam ............................ ......... X 0373 1.7682 108.69 .................. 21.74 

96118 ....... Neuropsych tst by psych/phys ........................... ......... X 0373 1.7682 108.69 .................. 21.74 

96119 ....... Neuropsych testing by tec ................................. ......... X 0382 2.846 174.94 69.97 34.99 

96120 ....... Neuropsych tst admin w/comp .......................... ......... X 0373 1.7682 108.69 .................. 21.74 

96150 ....... Assess hlth/behave, init ..................................... ......... S 0432 0.6072 37.32 .................. 7.46 

96151 ....... Assess hlth/behave, subseq .............................. ......... S 0432 0.6072 37.32 .................. 7.46 

96152 ....... Intervene hlth/behave, indiv ............................... ......... S 0432 0.6072 37.32 .................. 7.46 

96153 ....... Intervene hlth/behave, group ............................. ......... S 0432 0.6072 37.32 .................. 7.46 

96154 ....... Interv hlth/behav, fam w/pt ................................ ......... S 0432 0.6072 37.32 .................. 7.46 

96401 ....... Chemo, anti-neopl, sq/im ................................... CH .. S 0438 0.7942 48.82 .................. 9.76 

96402 ....... Chemo hormon antineopl sq/im ........................ CH .. S 0438 0.7942 48.82 .................. 9.76 

96405 ....... Chemo intralesional, up to 7 ............................. CH .. S 0438 0.7942 48.82 .................. 9.76 

96406 ....... Chemo intralesional over 7 ................................ CH .. S 0438 0.7942 48.82 .................. 9.76 

96409 ....... Chemo, iv push, sngl drug ................................ CH .. S 0439 1.5848 97.41 .................. 19.48 

96411 ....... Chemo, iv push, addl drug ................................ CH .. S 0439 1.5848 97.41 .................. 19.48 

96413 ....... Chemo, iv infusion, 1 hr .................................... CH .. S 0441 2.4851 152.75 .................. 30.55 

96415 ....... Chemo, iv infusion, addl hr ................................ CH .. S 0438 0.7942 48.82 .................. 9.76 

96416 ....... Chemo prolong infuse w/pump .......................... CH .. S 0441 2.4851 152.75 .................. 30.55 

96417 ....... Chemo iv infus each addl seq ........................... CH .. S 0438 0.7942 48.82 .................. 9.76 

96420 ....... Chemo, ia, push tecnique .................................. CH .. S 0439 1.5848 97.41 .................. 19.48 

96422 ....... Chemo ia infusion up to 1 hr ............................. CH .. S 0441 2.4851 152.75 .................. 30.55 

96423 ....... Chemo ia infuse each addl hr ........................... CH .. S 0438 0.7942 48.82 .................. 9.76 

96425 ....... Chemotherapy,infusion method ......................... CH .. S 0441 2.4851 152.75 .................. 30.55 

96440 ....... Chemotherapy, intracavitary .............................. CH .. S 0441 2.4851 152.75 .................. 30.55 

96445 ....... Chemotherapy, intracavitary .............................. CH .. S 0441 2.4851 152.75 .................. 30.55 

96450 ....... Chemotherapy, into CNS ................................... CH .. S 0441 2.4851 152.75 .................. 30.55 

96521 ....... Refill/maint, portable pump ................................ CH .. S 0440 1.809 111.20 .................. 22.24 

96522 ....... Refill/maint pump/resvr syst .............................. CH .. S 0440 1.809 111.20 .................. 22.24 

96523 ....... Irrig drug delivery device ................................... CH .. Q 0624 0.5145 31.63 12.65 6.33 

96542 ....... Chemotherapy injection ..................................... CH .. S 0438 0.7942 48.82 .................. 9.76 

96549 ....... Chemotherapy, unspecified ............................... CH .. S 0436 0.1809 11.12 .................. 2.22 

96567 ....... Photodynamic tx, skin ........................................ ......... T 0016 2.6749 164.42 .................. 32.88 

96570 ....... Photodynamic tx, 30 min ................................... ......... T 0015 1.6241 99.83 20.13 19.97 

96571 ....... Photodynamic tx, addl 15 min ........................... ......... T 0015 1.6241 99.83 20.13 19.97 

96900 ....... Ultraviolet light therapy ...................................... ......... S 0001 0.4914 30.21 7.00 6.04 

96902 ....... Trichogram ......................................................... ......... N .................. .................. .................. .................. ..................

96904 ....... Whole body photography ................................... NI .... N .................. .................. .................. .................. ..................

96910 ....... Photochemotherapy with UV–B ......................... ......... S 0001 0.4914 30.21 7.00 6.04 

96912 ....... Photochemotherapy with UV–A ......................... ......... S 0001 0.4914 30.21 7.00 6.04 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68363 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

96913 ....... Photochemotherapy, UV–A or B ....................... ......... S 0683 2.6734 164.33 .................. 32.87 

96920 ....... Laser tx, skin < 250 sq cm ................................ ......... T 0013 1.0918 67.11 .................. 13.42 

96921 ....... Laser tx, skin 250–500 sq cm ........................... ......... T 0013 1.0918 67.11 .................. 13.42 

96922 ....... Laser tx, skin > 500 sq cm ................................ ......... T 0013 1.0918 67.11 .................. 13.42 

96999 ....... Dermatological procedure .................................. ......... T 0010 0.476 29.26 8.02 5.85 

97597 ....... Active wound care/20 cm or < .......................... ......... T 0012 0.8432 51.83 11.18 10.37 

97598 ....... Active wound care > 20 cm ............................... ......... T 0013 1.0918 67.11 .................. 13.42 

97602 ....... Wound(s) care non-selective ............................. ......... X 0340 0.6102 37.51 .................. 7.50 

97605 ....... Neg press wound tx, < 50 cm ........................... ......... T 0012 0.8432 51.83 11.18 10.37 

97606 ....... Neg press wound tx, > 50 cm ........................... ......... T 0013 1.0918 67.11 .................. 13.42 

98925 ....... Osteopathic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98926 ....... Osteopathic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98927 ....... Osteopathic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98928 ....... Osteopathic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98929 ....... Osteopathic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98940 ....... Chiropractic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98941 ....... Chiropractic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

98942 ....... Chiropractic manipulation .................................. ......... S 0060 0.4657 28.63 .................. 5.73 

99078 ....... Group health education ..................................... ......... N .................. .................. .................. .................. ..................

99091 ....... Collect/review data from pt ................................ ......... N .................. .................. .................. .................. ..................

99143 ....... Mod cs by same phys, < 5 yrs .......................... ......... N .................. .................. .................. .................. ..................

99144 ....... Mod cs by same phys, 5 yrs + .......................... ......... N .................. .................. .................. .................. ..................

99145 ....... Mod cs by same phys add-on ........................... ......... N .................. .................. .................. .................. ..................

99148 ....... Mod cs diff phys < 5 yrs .................................... ......... N .................. .................. .................. .................. ..................

99149 ....... Mod cs diff phys 5 yrs + .................................... ......... N .................. .................. .................. .................. ..................

99150 ....... Mod cs diff phys add-on .................................... ......... N .................. .................. .................. .................. ..................

99170 ....... Anogenital exam, child ...................................... ......... T 0191 0.1468 9.02 2.55 1.80 

99175 ....... Induction of vomiting .......................................... ......... N .................. .................. .................. .................. ..................

99185 ....... Regional hypothermia ........................................ ......... N .................. .................. .................. .................. ..................

99186 ....... Total body hypothermia ..................................... ......... N .................. .................. .................. .................. ..................

99195 ....... Phlebotomy ........................................................ ......... X 0372 0.5723 35.18 10.09 7.04 

99201 ....... Office/outpatient visit, new ................................. CH .. V 0604 0.8242 50.66 .................. 10.13 

99202 ....... Office/outpatient visit, new ................................. CH .. V 0605 0.984 60.48 .................. 12.10 

99203 ....... Office/outpatient visit, new ................................. CH .. V 0606 1.3646 83.88 .................. 16.78 

99204 ....... Office/outpatient visit, new ................................. CH .. V 0607 1.7096 105.09 .................. 21.02 

99205 ....... Office/outpatient visit, new ................................. CH .. V 0608 2.1794 133.96 .................. 26.79 

99211 ....... Office/outpatient visit, est .................................. CH .. V 0604 0.8242 50.66 .................. 10.13 

99212 ....... Office/outpatient visit, est .................................. CH .. V 0605 0.984 60.48 .................. 12.10 

99213 ....... Office/outpatient visit, est .................................. CH .. V 0605 0.984 60.48 .................. 12.10 

99214 ....... Office/outpatient visit, est .................................. CH .. V 0606 1.3646 83.88 .................. 16.78 

99215 ....... Office/outpatient visit, est .................................. CH .. V 0607 1.7096 105.09 .................. 21.02 

99241 ....... Office consultation ............................................. CH .. V 0604 0.8242 50.66 .................. 10.13 

99242 ....... Office consultation ............................................. CH .. V 0605 0.984 60.48 .................. 12.10 

99243 ....... Office consultation ............................................. CH .. V 0605 0.984 60.48 .................. 12.10 

99244 ....... Office consultation ............................................. CH .. V 0606 1.3646 83.88 .................. 16.78 

99245 ....... Office consultation ............................................. CH .. V 0607 1.7096 105.09 .................. 21.02 

99281 ....... Emergency dept visit ......................................... CH .. V 0609 0.8136 50.01 12.70 10.00 

99282 ....... Emergency dept visit ......................................... CH .. V 0613 1.3497 82.96 21.06 16.59 

99283 ....... Emergency dept visit ......................................... CH .. V 0614 2.115 130.00 34.50 26.00 

99284 ....... Emergency dept visit ......................................... CH .. V 0615 3.4163 209.99 48.49 42.00 

99285 ....... Emergency dept visit ......................................... CH .. V 0616 5.2915 325.26 75.11 65.05 

99289 ....... Ped crit care transport ....................................... ......... N .................. .................. .................. .................. ..................

99290 ....... Ped crit care transport addl ............................... ......... N .................. .................. .................. .................. ..................

99291 ....... Critical care, first hour ....................................... CH .. S 0617 6.5894 405.04 111.59 81.01 

99292 ....... Critical care, add’l 30 min .................................. ......... N .................. .................. .................. .................. ..................

99300 ....... Ic, infant pbw 2501–5000 gm ............................ ......... N .................. .................. .................. .................. ..................

99354 ....... Prolonged service, office ................................... ......... N .................. .................. .................. .................. ..................

99355 ....... Prolonged service, office ................................... ......... N .................. .................. .................. .................. ..................

99358 ....... Prolonged serv, w/o contact .............................. ......... N .................. .................. .................. .................. ..................

99359 ....... Prolonged serv, w/o contact .............................. ......... N .................. .................. .................. .................. ..................

99361 ....... Physician/team conference ................................ ......... N .................. .................. .................. .................. ..................

99362 ....... Physician/team conference ................................ ......... N .................. .................. .................. .................. ..................

99363 ....... Anticoag mgmt, init ............................................ NI .... E .................. .................. .................. .................. ..................

99364 ....... Anticoag mgmt, subseq ..................................... NI .... E .................. .................. .................. .................. ..................

99431 ....... Initial care, normal newborn .............................. CH .. V 0605 0.984 60.48 .................. 12.10 

99432 ....... Newborn care, not in hosp ................................ ......... N .................. .................. .................. .................. ..................

99436 ....... Attendance, birth ................................................ ......... N .................. .................. .................. .................. ..................

99440 ....... Newborn resuscitation ....................................... ......... S 0094 2.4233 148.96 46.29 29.79 

0003T ....... Cervicography .................................................... CH .. D .................. .................. .................. .................. ..................

0008T ....... Upper gi endoscopy w/suture ............................ CH .. D .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68364 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

0012F ....... Cap bacterial assess ......................................... NI .... M .................. .................. .................. .................. ..................

0016T ....... Thermotx choroid vasc lesion ............................ ......... T 0235 3.9333 241.77 58.93 48.35 

0017T ....... Photocoagulat macular drusen .......................... ......... T 0235 3.9333 241.77 58.93 48.35 

0018T ....... Transcranial magnetic stimul ............................. CH .. D .................. .................. .................. .................. ..................

0021T ....... Fetal oximetry, trnsvag/cerv .............................. CH .. D .................. .................. .................. .................. ..................

0027T ....... Endoscopic epidural lysis .................................. ......... T 0220 17.8499 1,097.20 .................. 219.44 

0028T ....... Dexa body composition study ........................... ......... N .................. .................. .................. .................. ..................

0031T ....... Speculoscopy ..................................................... ......... N .................. .................. .................. .................. ..................

0032T ....... Speculoscopy w/direct sample .......................... ......... N .................. .................. .................. .................. ..................

0042T ....... Ct perfusion w/contrast, cbf ............................... ......... N .................. .................. .................. .................. ..................

0044T ....... Whole body photography ................................... CH .. D .................. .................. .................. .................. ..................

0045T ....... Whole body photography ................................... CH .. D .................. .................. .................. .................. ..................

0046T ....... Cath lavage, mammary duct(s) ......................... ......... T 0021 15.1024 928.31 219.48 185.66 

0047T ....... Cath lavage, mammary duct(s) ......................... ......... T 0021 15.1024 928.31 219.48 185.66 

0054T ....... Bone surgery using computer ........................... ......... S 0302 4.9138 302.04 105.94 60.41 

0055T ....... Bone surgery using computer ........................... ......... S 0302 4.9138 302.04 105.94 60.41 

0056T ....... Bone surgery using computer ........................... ......... S 0302 4.9138 302.04 105.94 60.41 

0058T ....... Cryopreservation, ovary tiss .............................. ......... X 0348 0.8321 51.15 .................. 10.23 

0059T ....... Cryopreservation, oocyte ................................... ......... X 0348 0.8321 51.15 .................. 10.23 

0062T ....... Rep intradisc annulus;1 lev ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93

0063T ....... Rep intradisc annulus;>1lev .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93 

0064T ....... Spectroscop eval expired gas ........................... ......... X 0367 0.6277 38.58 14.68 7.72 

0067T ....... Ct colonography;dx ............................................ ......... S 0333 4.8405 297.54 119.01 59.51 

0069T ....... Analysis only heart sound ................................. ......... N .................. .................. .................. .................. ..................

0071T ....... U/s leiomyomata ablate <200 ............................ ......... T 0195 28.5095 1,752.42 483.80 350.48 

0072T ....... U/s leiomyomata ablate >200 ............................ ......... T 0202 42.9896 2,642.48 981.50 528.50 

0073T ....... Delivery, comp imrt ............................................ ......... S 0412 5.4731 336.42 .................. 67.28 

0082T ....... Stereotactic rad delivery .................................... CH .. D .................. .................. .................. .................. ..................

0083T ....... Stereotactic rad tx mngmt ................................. CH .. D .................. .................. .................. .................. ..................

0084T ....... Temp prostate urethral stent ............................. ......... T 0164 2.1393 131.50 .................. 26.30 

0085T ....... Breath test heart reject ...................................... ......... X 0340 0.6102 37.51 .................. 7.50 

0086T ....... Lventricle fill pressure ........................................ ......... N .................. .................. .................. .................. ..................

0087T ....... Sperm eval hyaluronan ...................................... ......... X 0348 0.8321 51.15 .................. 10.23 

0088T ....... Rf tongue base vol reduxn ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94 

0089T ....... Actigraphy testing, 3-day ................................... ......... S 0218 1.1872 72.97 .................. 14.59 

0090T ....... Cervical artific disc ............................................. CH .. E .................. .................. .................. .................. ..................

0091T ....... Lumbar artific disc ............................................. CH .. D .................. .................. .................. .................. ..................

0094T ....... Lumbar artific diskectomy .................................. CH .. D .................. .................. .................. .................. ..................

0097T ....... Rev lumbar artific disc ....................................... CH .. D .................. .................. .................. .................. ..................

0099T ....... Implant corneal ring ........................................... ......... T 0233 15.2259 935.91 266.33 187.18 

0100T ....... Prosth retina receive&gen ................................. ......... T 0672 37.429 2,300.69 .................. 460.14 

0101T ....... Extracorp shockwv tx,hi enrg ............................ CH .. T 0050 25.1296 1,544.67 .................. 308.93 

0102T ....... Extracorp shockwv tx,anesth ............................. CH .. T 0050 25.1296 1,544.67 .................. 308.93 

0106T ....... Touch quant sensory test .................................. ......... X 0341 0.0914 5.62 2.24 1.12 

0107T ....... Vibrate quant sensory test ................................. ......... X 0341 0.0914 5.62 2.24 1.12 

0108T ....... Cool quant sensory test ..................................... ......... X 0341 0.0914 5.62 2.24 1.12 

0109T ....... Heat quant sensory test .................................... ......... X 0341 0.0914 5.62 2.24 1.12 

0110T ....... Nos quant sensory test ...................................... ......... X 0341 0.0914 5.62 2.24 1.12 

0120T ....... Fibroadenoma cryoablate, ea ............................ CH .. D .................. .................. .................. .................. ..................

0123T ....... Scleral fistulization ............................................. ......... T 0234 22.997 1,413.58 511.31 282.72 

0124T ....... Conjunctival drug placement ............................. ......... T 0232 6.0673 372.94 93.43 74.59 

0126T ....... Chd risk imt study .............................................. ......... N .................. .................. .................. .................. ..................

0133T ....... Esophageal implant injexn ................................. CH .. T 0422 25.7552 1,583.12 448.81 316.62 

0135T ....... Perq cryoablate renal tumor .............................. CH .. T 0423 37.3604 2,296.47 .................. 459.29 

0137T ....... Prostate saturation sampling ............................. ......... T 0184 5.6262 345.83 96.27 69.17 

0144T ....... CT heart wo dye; qual calc ............................... ......... S 0398 4.1265 253.65 100.06 50.73 

0145T ....... CT heart w/wo dye funct ................................... ......... S 0376 4.9832 306.31 119.77 61.26 

0146T ....... CCTA w/wo dye ................................................. ......... S 0376 4.9832 306.31 119.77 61.26 

0147T ....... CCTA w/wo, quan calcium ................................ ......... S 0376 4.9832 306.31 119.77 61.26 

0148T ....... CCTA w/wo, strxr ............................................... ......... S 0377 6.5012 399.62 158.84 79.92 

0149T ....... CCTA w/wo, strxr quan calc .............................. ......... S 0377 6.5012 399.62 158.84 79.92 

0150T ....... CCTA w/wo, disease strxr ................................. ......... S 0398 4.1265 253.65 100.06 50.73 

0151T ....... CT heart funct add-on ....................................... ......... S 0282 1.5379 94.53 37.81 18.91 

0152T ....... Computer chest add-on ..................................... ......... N .................. .................. .................. .................. ..................

0154T ....... Study sensor aneurysm sac .............................. ......... X 0097 1.0225 62.85 23.79 12.57 

0155T ....... Lap impl gast curve electrd ............................... NF ... T 0130 32.1241 1,974.60 659.53 394.92 

0156T ....... Lap remv gast curve electrd .............................. NF ... T 0130 32.1241 1,974.60 659.53 394.92 

0157T ....... Open impl gast curve electrd ............................ NF ... C .................. .................. .................. .................. ..................

0158T ....... Open remv gast curve electrd ........................... NF ... C .................. .................. .................. .................. ..................

0159T ....... Cad breast mri ................................................... NF ... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68365 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

0160T ....... Tcranial magn stim tx plan ................................ CH .. S 0216 2.7199 167.19 .................. 33.44 

0161T ....... Tcranial magn stim tx deliv ................................ CH .. S 0216 2.7199 167.19 .................. 33.44 

0162T ....... Anal program gast neurostim ............................ NI .... S 0692 1.9323 118.77 30.16 23.75 

0163T ....... Lumb artif diskectomy addl ................................ NI .... C .................. .................. .................. .................. ..................

0164T ....... Remove lumb artif disc addl .............................. NI .... C .................. .................. .................. .................. ..................

0165T ....... Revise lumb artif disc addl ................................ NI .... C .................. .................. .................. .................. ..................

0166T ....... Tcath vsd close w/o bypass .............................. NI .... C .................. .................. .................. .................. ..................

0167T ....... Tcath vsd close w bypass ................................. NI .... C .................. .................. .................. .................. ..................

0168T ....... Rhinophototx light app bilat ............................... NI .... T 0251 2.452 150.72 .................. 30.14 

0169T ....... Place stereo cath brain ...................................... NI .... C .................. .................. .................. .................. ..................

0170T ....... Anorectal fistula plug rpr .................................... NI .... T 0150 29.6189 1,820.61 437.12 364.12 

0171T ....... Lumbar spine proces distract ............................ NI .... T 0050 25.1296 1,544.67 .................. 308.93 

0172T ....... Lumbar spine proces addl ................................. NI .... T 0050 25.1296 1,544.67 .................. 308.93 

0173T ....... Iop monit io pressure ......................................... NI .... N .................. .................. .................. .................. ..................

0174T ....... Cad cxr with interp ............................................. NI .... N .................. .................. .................. .................. ..................

0175T ....... Cad cxr remote .................................................. NI .... N .................. .................. .................. .................. ..................

0176T ....... Aqu canal dilat w/o retent .................................. NI .... T 0673 37.8967 2,329.43 649.56 465.89 

0177T ....... Aqu canal dilat w retent ..................................... NI .... T 0673 37.8967 2,329.43 649.56 465.89 

0505F ....... Hemodialysis plan doc’d .................................... NI .... M .................. .................. .................. .................. ..................

0507F ....... Periton dialysis plan doc’d ................................. NI .... M .................. .................. .................. .................. ..................

1001F ....... Tobacco use, non-smoking ............................... CH .. D .................. .................. .................. .................. ..................

1015F ....... Copd symptoms assess .................................... NI .... M .................. .................. .................. .................. ..................

1018F ....... Assess dyspnea not present ............................. NI .... M .................. .................. .................. .................. ..................

1019F ....... Assess dyspnea present ................................... NI .... M .................. .................. .................. .................. ..................

1022F ....... Pneumo imm status assess .............................. NI .... M .................. .................. .................. .................. ..................

1026F ....... Co-morbid condition assess .............................. NI .... M .................. .................. .................. .................. ..................

1030F ....... Influenza imm status assess ............................. NI .... M .................. .................. .................. .................. ..................

1034F ....... Current tobacco smoker .................................... NI .... M .................. .................. .................. .................. ..................

1035F ....... Smokeless tobacco user ................................... NI .... M .................. .................. .................. .................. ..................

1036F ....... Tobacco non-user .............................................. NI .... M .................. .................. .................. .................. ..................

1038F ....... Persistent asthma .............................................. NI .... M .................. .................. .................. .................. ..................

1039F ....... Intermittent asthma ............................................ NI .... M .................. .................. .................. .................. ..................

1040F ....... Dsm-ivO ̈ info mdd doc’d .................................... NI .... M .................. .................. .................. .................. ..................

2003F ....... Auscultation heart perform ................................ CH .. D .................. .................. .................. .................. ..................

2010F ....... Vital signs recorded ........................................... NI .... M .................. .................. .................. .................. ..................

2014F ....... Mental status assess ......................................... NI .... M .................. .................. .................. .................. ..................

2018F ....... Hydration status assess .................................... NI .... M .................. .................. .................. .................. ..................

2022F ....... Dil retina exam interp rev .................................. NI .... M .................. .................. .................. .................. ..................

2024F ....... 7 field photo interp doc rev ................................ NI .... M .................. .................. .................. .................. ..................

2026F ....... Eye image valid to dx rev .................................. NI .... M .................. .................. .................. .................. ..................

2028F ....... Foot exam performed ........................................ NI .... M .................. .................. .................. .................. ..................

2030F ....... H2O stat doc"d, normal ................................... NI .... M .................. .................. .................. .................. ..................

2031F ....... H2O stat doc"d, dehydrated ............................ NI .... M .................. .................. .................. .................. ..................

3000F ....... Blood press TM 140/90 mmhg ............................ CH .. D .................. .................. .................. .................. ..................

3002F ....... Blood pressure > 140/90 mmhg ........................ CH .. D .................. .................. .................. .................. ..................

3006F ....... Cxr doc rev ........................................................ NI .... M .................. .................. .................. .................. ..................

3011F ....... Lipid panel doc rev ............................................ NI .... M .................. .................. .................. .................. ..................

3014F ....... Screen mammo doc rev .................................... NI .... M .................. .................. .................. .................. ..................

3017F ....... Colorectal ca screen doc rev ............................. NI .... M .................. .................. .................. .................. ..................

3020F ....... Lvf assess .......................................................... NI .... M .................. .................. .................. .................. ..................

3021F ....... Lvef mod/sever deprs syst ................................ NI .... M .................. .................. .................. .................. ..................

3022F ....... Lvef ?40% systolic ............................................. NI .... M .................. .................. .................. .................. ..................

3023F ....... Spirom doc rev .................................................. NI .... M .................. .................. .................. .................. ..................

3025F ....... Spirom fev/fvc<70% w copd .............................. NI .... M .................. .................. .................. .................. ..................

3027F ....... Spirom fev/fvc?70%/ w/o copd .......................... NI .... M .................. .................. .................. .................. ..................

3028F ....... O2 saturation doc rev ........................................ NI .... M .................. .................. .................. .................. ..................

3035F ....... O2 saturation ?88% /pa0 ?55 ........................... NI .... M .................. .................. .................. .................. ..................

3037F ....... O2 saturation> 88% /pa0>55 ............................ NI .... M .................. .................. .................. .................. ..................

3040F ....... Fev<40% predicted value .................................. NI .... M .................. .................. .................. .................. ..................

3042F ....... Fev? 40% predicted value ................................. NI .... M .................. .................. .................. .................. ..................

3046F ....... Hemoglobin a1c level > 9.0% ........................... NI .... M .................. .................. .................. .................. ..................

3047F ....... Hemoglobin A1c level ? 9.0% ........................... NI .... M .................. .................. .................. .................. ..................

3048F ....... LDL–C <100 mg/dL ........................................... NI .... M .................. .................. .................. .................. ..................

3049F ....... LDL–C 100–129 mg/dL ..................................... NI .... M .................. .................. .................. .................. ..................

3050F ....... LDL–C ? 130 mg/dL .......................................... NI .... M .................. .................. .................. .................. ..................

3060F ....... Pos microalbuminuria rev .................................. NI .... M .................. .................. .................. .................. ..................

3061F ....... Neg microalbuminuria rev .................................. NI .... M .................. .................. .................. .................. ..................

3062F ....... Pos macroalbuminuria rev ................................. NI .... M .................. .................. .................. .................. ..................

3066F ....... Nephropathy doc tx ........................................... NI .... M .................. .................. .................. .................. ..................

3072F ....... Low risk for retinopathy ..................................... NI .... M .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68366 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

3076F ....... Syst bp < 140 mm hg ........................................ NI .... M .................. .................. .................. .................. ..................

3077F ....... Syst bp ? 140 mm hg ........................................ NI .... M .................. .................. .................. .................. ..................

3078F ....... Diast bp < 80 mm hg ......................................... NI .... M .................. .................. .................. .................. ..................

3079F ....... Diast bp 80–89 mm hg ...................................... NI .... M .................. .................. .................. .................. ..................

3080F ....... Diast bp ? 90 mm hg ......................................... NI .... M .................. .................. .................. .................. ..................

3082F ....... Kt/v <1.2 ............................................................ NI .... M .................. .................. .................. .................. ..................

3083F ....... Kt/v  ́ 1.2 and <1.7 ........................................... NI .... M .................. .................. .................. .................. ..................

3084F ....... Kt/v ? 1.7 ........................................................... NI .... M .................. .................. .................. .................. ..................

3085F ....... Suicide risk assessed ........................................ NI .... M .................. .................. .................. .................. ..................

3088F ....... Mdd, mild ........................................................... NI .... M .................. .................. .................. .................. ..................

3089F ....... Mdd, moderate ................................................... NI .... M .................. .................. .................. .................. ..................

3090F ....... Mdd, severe; w/o psych ..................................... NI .... M .................. .................. .................. .................. ..................

3091F ....... Mdd, severe; w/ psych ....................................... NI .... M .................. .................. .................. .................. ..................

3092F ....... Mdd, in remission .............................................. NI .... M .................. .................. .................. .................. ..................

3093F ....... Doc new diag 1st/addl. mdd .............................. NI .... M .................. .................. .................. .................. ..................

4025F ....... Inhaled broncholidator rx ................................... NI .... M .................. .................. .................. .................. ..................

4030F ....... Oxygen therapy rx ............................................. NI .... M .................. .................. .................. .................. ..................

4033F ....... Pulmonary rehab rec ......................................... NI .... M .................. .................. .................. .................. ..................

4035F ....... Influenza imm rec .............................................. NI .... M .................. .................. .................. .................. ..................

4037F ....... Influenza imm order/admin ................................ NI .... M .................. .................. .................. .................. ..................

4040F ....... pneumoc imm order/admin ................................ NI .... M .................. .................. .................. .................. ..................

4045F ....... Empiric antibiotic rx ........................................... NI .... M .................. .................. .................. .................. ..................

4050F ....... Ht care plan doc ................................................ NI .... M .................. .................. .................. .................. ..................

4051F ....... Referred for an av fistula ................................... NI .... M .................. .................. .................. .................. ..................

4052F ....... Hemodialysis via av fistula ................................ NI .... M .................. .................. .................. .................. ..................

4053F ....... Hemodialysis via av graft .................................. NI .... M .................. .................. .................. .................. ..................

4054F ....... Hemodialysis via catheter .................................. NI .... M .................. .................. .................. .................. ..................

4055F ....... Pt. rcvng periton dialysis ................................... NI .... M .................. .................. .................. .................. ..................

4056F ....... Approp. oral rehyd. recomm"d ........................ NI .... M .................. .................. .................. .................. ..................

4058F ....... Ped gastro ed given, caregvr ............................ NI .... M .................. .................. .................. .................. ..................

4060F ....... Psych svcs provided .......................................... NI .... M .................. .................. .................. .................. ..................

4062F ....... Pt referral psych doc"d .................................... NI .... M .................. .................. .................. .................. ..................

4064F ....... Antidepressant rx ............................................... NI .... M .................. .................. .................. .................. ..................

4065F ....... Antipsychotic rx .................................................. NI .... M .................. .................. .................. .................. ..................

4066F ....... Ect provided ....................................................... NI .... M .................. .................. .................. .................. ..................

4067F ....... Pt referral for ect doc"d ................................... NI .... M .................. .................. .................. .................. ..................

6005F ....... Care level rationale doc ..................................... NI .... M .................. .................. .................. .................. ..................

A0800 ...... Amb trans 7pm–7am ......................................... CH .. D .................. .................. .................. .................. ..................

A4211 ...... Supp for self-adm injections .............................. CH .. E .................. .................. .................. .................. ..................

A4218 ...... Sterile saline or water ........................................ ......... N .................. .................. .................. .................. ..................

A4220 ...... Infusion pump refill kit ........................................ ......... N .................. .................. .................. .................. ..................

A4248 ...... Chlorhexidine antisept ....................................... ......... N .................. .................. .................. .................. ..................

A4262 ...... Temporary tear duct plug .................................. ......... N .................. .................. .................. .................. ..................

A4263 ...... Permanent tear duct plug .................................. ......... N .................. .................. .................. .................. ..................

A4270 ...... Disposable endoscope sheath .......................... ......... N .................. .................. .................. .................. ..................

A4300 ...... Cath impl vasc access portal ............................ ......... N .................. .................. .................. .................. ..................

A4301 ...... Implantable access syst perc ............................ ......... N .................. .................. .................. .................. ..................

A4305 ...... Drug delivery system  ́50 ML ........................... CH .. N .................. .................. .................. .................. ..................

A4306 ...... Drug delivery system TM50 ml ............................ CH .. N .................. .................. .................. .................. ..................

A4348 ...... Male ext cath extended wear ............................ CH .. D .................. .................. .................. .................. ..................

A4359 ...... Urinary suspensory w/o leg b ............................ CH .. D .................. .................. .................. .................. ..................

A4461 ...... Surgicl dress hold non-reuse ............................. NI .... A .................. .................. .................. .................. ..................

A4462 ...... Abdmnl drssng holder/binder ............................. CH .. D .................. .................. .................. .................. ..................

A4463 ...... Surgical dress holder reuse ............................... NI .... A .................. .................. .................. .................. ..................

A4559 ...... Coupling gel or paste ........................................ NI .... Y .................. .................. .................. .................. ..................

A4561 ...... Pessary rubber, any type .................................. ......... N .................. .................. .................. .................. ..................

A4562 ...... Pessary, non rubber,any type ........................... ......... N .................. .................. .................. .................. ..................

A4600 ...... Sleeve, inter limb comp dev .............................. NI .... Y .................. .................. .................. .................. ..................

A4601 ...... Lith ion batt, non-pros use ................................. NI .... Y .................. .................. .................. .................. ..................

A4614 ...... Hand-held PEFR meter ..................................... CH .. N .................. .................. .................. .................. ..................

A4632 ...... Infus pump rplcemnt battery .............................. CH .. D .................. .................. .................. .................. ..................

A4641 ...... Radiopharm dx agent noc ................................. ......... N .................. .................. .................. .................. ..................

A4642 ...... In111 satumomab .............................................. ......... H 0704 .................. .................. .................. ..................

A5512 ...... Multi den insert direct form ................................ CH .. Y .................. .................. .................. .................. ..................

A5513 ...... Multi den insert custom mold ............................ CH .. Y .................. .................. .................. .................. ..................

A8000 ...... Soft protect helmet prefab ................................. NI .... Y .................. .................. .................. .................. ..................

A8001 ...... Hard protect helmet prefab ................................ NI .... Y .................. .................. .................. .................. ..................

A8002 ...... Soft protect helmet custom ................................ NI .... Y .................. .................. .................. .................. ..................

A8003 ...... Hard protect helmet custom .............................. NI .... Y .................. .................. .................. .................. ..................

A8004 ...... Repl soft interface, helmet ................................. NI .... Y .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68367 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

A9279 ...... Monitoring feature/deviceNOC .......................... NI .... E .................. .................. .................. .................. ..................

A9500 ...... Tc99m sestamibi ................................................ ......... H 1600 .................. .................. .................. ..................

A9502 ...... Tc99m tetrofosmin ............................................. ......... H 0705 .................. .................. .................. ..................

A9503 ...... Tc99m medronate .............................................. ......... N .................. .................. .................. .................. ..................

A9504 ...... Tc99m apcitide .................................................. CH .. N .................. .................. .................. .................. ..................

A9505 ...... TL201 thallium ................................................... ......... H 1603 .................. .................. .................. ..................

A9507 ...... In111 capromab ................................................. ......... H 1604 .................. .................. .................. ..................

A9508 ...... I131 iodobenguate, dx ....................................... ......... H 1045 .................. .................. .................. ..................

A9510 ...... Tc99m disofenin ................................................ CH .. N .................. .................. .................. .................. ..................

A9512 ...... Tc99m pertechnetate ......................................... ......... N .................. .................. .................. .................. ..................

A9516 ...... I123 iodide cap, dx ............................................ CH .. H 9148 .................. .................. .................. ..................

A9517 ...... I131 iodide cap, rx ............................................. CH .. H 1064 .................. .................. .................. ..................

A9521 ...... Tc99m exametazime ......................................... ......... H 1096 .................. .................. .................. ..................

A9524 ...... I131 serum albumin, dx ..................................... ......... H 9100 .................. .................. .................. ..................

A9526 ...... Nitrogen N–13 ammonia .................................... ......... H 0737 .................. .................. .................. ..................

A9527 ...... Iodine I–125 sodium iodide ............................... NI .... K 2632 0.3321 20.41 .................. 4.08 

A9528 ...... Iodine I–131 iodide cap, dx ............................... ......... H 1088 .................. .................. .................. ..................

A9529 ...... I131 iodide sol, dx ............................................. CH .. N .................. .................. .................. .................. ..................

A9530 ...... I131 iodide sol, rx .............................................. ......... H 1150 .................. .................. .................. ..................

A9531 ...... I131 max 100uCi ............................................... CH .. N .................. .................. .................. .................. ..................

A9532 ...... I125 serum albumin, dx ..................................... CH .. N .................. .................. .................. .................. ..................

A9535 ...... Injection, methylene blue ................................... CH .. N .................. .................. .................. .................. ..................

A9536 ...... Tc99m depreotide .............................................. CH .. H 0739 .................. .................. .................. ..................

A9537 ...... Tc99m mebrofenin ............................................. ......... N .................. .................. .................. .................. ..................

A9538 ...... Tc99m pyrophosphate ....................................... ......... N .................. .................. .................. .................. ..................

A9539 ...... Tc99m pentetate ................................................ CH .. H 0722 .................. .................. .................. ..................

A9540 ...... Tc99m MAA ....................................................... ......... N .................. .................. .................. .................. ..................

A9541 ...... Tc99m sulfur colloid ........................................... ......... N .................. .................. .................. .................. ..................

A9542 ...... In111 ibritumomab, dx ....................................... ......... H 1642 .................. .................. .................. ..................

A9543 ...... Y90 ibritumomab, rx .......................................... ......... H 1643 .................. .................. .................. ..................

A9544 ...... I131 tositumomab, dx ........................................ ......... H 1644 .................. .................. .................. ..................

A9545 ...... I131 tositumomab, rx ......................................... ......... H 1645 .................. .................. .................. ..................

A9546 ...... Co57/58 ............................................................. CH .. H 0723 .................. .................. .................. ..................

A9547 ...... In111 oxyquinoline ............................................. ......... H 1646 .................. .................. .................. ..................

A9548 ...... In111 pentetate .................................................. ......... H 1647 .................. .................. .................. ..................

A9549 ...... Tc99m arcitumomab .......................................... CH .. D .................. .................. .................. .................. ..................

A9550 ...... Tc99m gluceptate .............................................. CH .. H 0740 .................. .................. .................. ..................

A9551 ...... Tc99m succimer ................................................ ......... H 1650 .................. .................. .................. ..................

A9552 ...... F18 fdg ............................................................... ......... H 1651 .................. .................. .................. ..................

A9553 ...... Cr51 chromate ................................................... CH .. H 0741 .................. .................. .................. ..................

A9554 ...... I125 iothalamate, dx .......................................... CH .. N .................. .................. .................. .................. ..................

A9555 ...... Rb82 rubidium ................................................... ......... H 1654 .................. .................. .................. ..................

A9556 ...... Ga67 gallium ...................................................... ......... H 1671 .................. .................. .................. ..................

A9557 ...... Tc99m bicisate ................................................... ......... H 1672 .................. .................. .................. ..................

A9558 ...... Xe133 xenon 10mci ........................................... ......... N .................. .................. .................. .................. ..................

A9559 ...... Co57 cyano ........................................................ CH .. H 0724 .................. .................. .................. ..................

A9560 ...... Tc99m labeled rbc ............................................. CH .. H 0742 .................. .................. .................. ..................

A9561 ...... Tc99m oxidronate .............................................. ......... N .................. .................. .................. .................. ..................

A9562 ...... Tc99m mertiatide ............................................... CH .. H 0743 .................. .................. .................. ..................

A9563 ...... P32 Na phosphate ............................................. ......... H 1675 .................. .................. .................. ..................

A9564 ...... P32 chromic phosphate ..................................... ......... H 1676 .................. .................. .................. ..................

A9565 ...... In111 pentetreotide ............................................ ......... H 1677 .................. .................. .................. ..................

A9566 ...... Tc99m fanolesomab .......................................... ......... H 1678 .................. .................. .................. ..................

A9567 ...... Technetium TC–99m aerosol ............................ CH .. H 0829 .................. .................. .................. ..................

A9568 ...... Technetium tc99m arcitumomab ....................... NI .... H 1648 .................. .................. .................. ..................

A9600 ...... Sr89 strontium ................................................... ......... H 0701 .................. .................. .................. ..................

A9605 ...... Sm 153 lexidronm .............................................. ......... H 0702 .................. .................. .................. ..................

A9698 ...... Non-rad contrast materialNOC .......................... ......... N .................. .................. .................. .................. ..................

A9699 ...... Radiopharm rx agent noc .................................. ......... N .................. .................. .................. .................. ..................

A9900 ...... Supply/accessory/service .................................. CH .. Y .................. .................. .................. .................. ..................

B4034 ...... Enter feed supkit syr by day .............................. CH .. Y .................. .................. .................. .................. ..................

B4035 ...... Enteral feed supp pump per d ........................... CH .. Y .................. .................. .................. .................. ..................

B4036 ...... Enteral feed sup kit grav by .............................. CH .. Y .................. .................. .................. .................. ..................

B4081 ...... Enteral ng tubing w/ stylet ................................. CH .. Y .................. .................. .................. .................. ..................

B4082 ...... Enteral ng tubing w/o stylet ............................... CH .. Y .................. .................. .................. .................. ..................

B4083 ...... Enteral stomach tube levine .............................. CH .. Y .................. .................. .................. .................. ..................

B4086 ...... Gastrostomy/jejunostomy tube .......................... CH .. Y .................. .................. .................. .................. ..................

B4102 ...... EF adult fluids and electro ................................. CH .. Y .................. .................. .................. .................. ..................

B4103 ...... EF ped fluid and electrolyte ............................... CH .. Y .................. .................. .................. .................. ..................

B4149 ...... EF blenderized foods ......................................... CH .. Y .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68368 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

B4150 ...... EF complet w/intact nutrient .............................. CH .. Y .................. .................. .................. .................. ..................

B4152 ...... EF calorie dense ́1.5Kcal ................................. CH .. Y .................. .................. .................. .................. ..................

B4153 ...... EF hydrolyzed/amino acids ............................... CH .. Y .................. .................. .................. .................. ..................

B4154 ...... EF spec metabolic noninherit ............................ CH .. Y .................. .................. .................. .................. ..................

B4155 ...... EF incomplete/modular ...................................... CH .. Y .................. .................. .................. .................. ..................

B4157 ...... EF special metabolic inherit .............................. CH .. Y .................. .................. .................. .................. ..................

B4158 ...... EF ped complete intact nut ............................... CH .. Y .................. .................. .................. .................. ..................

B4159 ...... EF ped complete soy based .............................. CH .. Y .................. .................. .................. .................. ..................

B4160 ...... EF ped caloric dense ́0.7kc ............................. CH .. Y .................. .................. .................. .................. ..................

B4161 ...... EF ped hydrolyzed/amino acid .......................... CH .. Y .................. .................. .................. .................. ..................

B4162 ...... EF ped specmetabolic inherit ............................ CH .. Y .................. .................. .................. .................. ..................

B4164 ...... Parenteral 50% dextrose solu ........................... CH .. Y .................. .................. .................. .................. ..................

B4168 ...... Parenteral sol amino acid 3. .............................. CH .. Y .................. .................. .................. .................. ..................

B4172 ...... Parenteral sol amino acid 5. .............................. CH .. Y .................. .................. .................. .................. ..................

B4176 ...... Parenteral sol amino acid 7– ............................. CH .. Y .................. .................. .................. .................. ..................

B4178 ...... Parenteral sol amino acid > .............................. CH .. Y .................. .................. .................. .................. ..................

B4180 ...... Parenteral sol carb > 50% ................................. CH .. Y .................. .................. .................. .................. ..................

B4189 ...... Parenteral sol amino acid & .............................. CH .. Y .................. .................. .................. .................. ..................

B4193 ...... Parenteral sol 52–73 gm prot ............................ CH .. Y .................. .................. .................. .................. ..................

B4197 ...... Parenteral sol 74–100 gm pro ........................... CH .. Y .................. .................. .................. .................. ..................

B4199 ...... Parenteral sol > 100gm prote ............................ CH .. Y .................. .................. .................. .................. ..................

B4216 ...... Parenteral nutrition additiv ................................. CH .. Y .................. .................. .................. .................. ..................

B4220 ...... Parenteral supply kit premix .............................. CH .. Y .................. .................. .................. .................. ..................

B4222 ...... Parenteral supply kit homemi ............................ CH .. Y .................. .................. .................. .................. ..................

B4224 ...... Parenteral administration ki ............................... CH .. Y .................. .................. .................. .................. ..................

B5000 ...... Parenteral sol renal-amirosy .............................. CH .. Y .................. .................. .................. .................. ..................

B5100 ...... Parenteral sol hepatic-fream ............................. CH .. Y .................. .................. .................. .................. ..................

B5200 ...... Parenteral sol stres-brnch c .............................. CH .. Y .................. .................. .................. .................. ..................

B9000 ...... Enter infusion pump w/o alrm ............................ CH .. Y .................. .................. .................. .................. ..................

B9002 ...... Enteral infusion pump w/ ala ............................. CH .. Y .................. .................. .................. .................. ..................

B9004 ...... Parenteral infus pump portab ............................ CH .. Y .................. .................. .................. .................. ..................

B9006 ...... Parenteral infus pump statio .............................. CH .. Y .................. .................. .................. .................. ..................

B9998 ...... Enteral supp not otherwise c ............................. CH .. Y .................. .................. .................. .................. ..................

B9999 ...... Parenteral supp not othrws c ............................ CH .. Y .................. .................. .................. .................. ..................

C1178 ...... BUSULFAN IV, 6 Mg ......................................... CH .. D .................. .................. .................. .................. ..................

C1300 ...... HYPERBARIC Oxygen ...................................... ......... S 0659 1.5906 97.77 .................. 19.55 

C1713 ...... Anchor/screw bn/bn,tis/bn ................................. ......... N .................. .................. .................. .................. ..................

C1714 ...... Cath, trans atherectomy, dir .............................. ......... N .................. .................. .................. .................. ..................

C1715 ...... Brachytherapy needle ........................................ ......... N .................. .................. .................. .................. ..................

C1716 ...... Brachytx source, Gold 198 ................................ CH .. K 1716 0.5991 36.83 .................. 7.37 

C1717 ...... Brachytx source, HDR Ir–192 ............................ CH .. K 1717 2.3195 142.58 .................. 28.52 

C1718 ...... Brachytx source, Iodine 125 .............................. CH .. K 1718 0.591 36.33 .................. 7.27 

C1719 ...... Brachytx sour,Non-HDR Ir-192 .......................... CH .. K 1719 0.3765 23.14 .................. 4.63 

C1720 ...... Brachytx sour, Palladium 103 ............................ CH .. K 1720 0.7942 48.82 .................. 9.76 

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

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

C1724 ...... Cath, trans atherec,rotation ............................... ......... N .................. .................. .................. .................. ..................

C1725 ...... Cath, translumin non-laser ................................ ......... N .................. .................. .................. .................. ..................

C1726 ...... Cath, bal dil, non-vascular ................................. ......... N .................. .................. .................. .................. ..................

C1727 ...... Cath, bal tis dis, non-vas ................................... ......... N .................. .................. .................. .................. ..................

C1728 ...... Cath, brachytx seed adm .................................. ......... N .................. .................. .................. .................. ..................

C1729 ...... Cath, drainage ................................................... ......... N .................. .................. .................. .................. ..................

C1730 ...... Cath, EP, 19 or few elect .................................. ......... N .................. .................. .................. .................. ..................

C1731 ...... Cath, EP, 20 or more elec ................................. ......... N .................. .................. .................. .................. ..................

C1732 ...... Cath, EP, diag/abl, 3D/vect ............................... ......... N .................. .................. .................. .................. ..................

C1733 ...... Cath, EP, othr than cool-tip ............................... ......... N .................. .................. .................. .................. ..................

C1750 ...... Cath, hemodialysis,long-term ............................ ......... N .................. .................. .................. .................. ..................

C1751 ...... Cath, inf, per/cent/midline .................................. ......... N .................. .................. .................. .................. ..................

C1752 ...... Cath,hemodialysis,short-term ............................ ......... N .................. .................. .................. .................. ..................

C1753 ...... Cath, intravas ultrasound ................................... ......... N .................. .................. .................. .................. ..................

C1754 ...... Catheter, intradiscal ........................................... ......... N .................. .................. .................. .................. ..................

C1755 ...... Catheter, intraspinal ........................................... ......... N .................. .................. .................. .................. ..................

C1756 ...... Cath, pacing, transesoph ................................... ......... N .................. .................. .................. .................. ..................

C1757 ...... Cath, thrombectomy/embolect ........................... ......... N .................. .................. .................. .................. ..................

C1758 ...... Catheter, ureteral ............................................... ......... N .................. .................. .................. .................. ..................

C1759 ...... Cath, intra echocardiography ............................ ......... N .................. .................. .................. .................. ..................

C1760 ...... Closure dev, vasc .............................................. ......... N .................. .................. .................. .................. ..................

C1762 ...... Conn tiss, human(inc fascia) ............................. ......... N .................. .................. .................. .................. ..................

C1763 ...... Conn tiss, non-human ....................................... ......... N .................. .................. .................. .................. ..................

C1764 ...... Event recorder, cardiac ..................................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68369 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

C1765 ...... Adhesion barrier ................................................ ......... N .................. .................. .................. .................. ..................

C1766 ...... Intro/sheath,strble,non-peel ............................... ......... N .................. .................. .................. .................. ..................

C1767 ...... Generator, neuro non-recharg ........................... ......... N .................. .................. .................. .................. ..................

C1768 ...... Graft, vascular ................................................... ......... N .................. .................. .................. .................. ..................

C1769 ...... Guide wire .......................................................... ......... N .................. .................. .................. .................. ..................

C1770 ...... Imaging coil, MR, insertable .............................. ......... N .................. .................. .................. .................. ..................

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

C1772 ...... Infusion pump, programmable ........................... ......... N .................. .................. .................. .................. ..................

C1773 ...... Ret dev, insertable ............................................. ......... N .................. .................. .................. .................. ..................

C1776 ...... Joint device (implantable) .................................. ......... N .................. .................. .................. .................. ..................

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

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

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

C1780 ...... Lens, intraocular (new tech) .............................. ......... N .................. .................. .................. .................. ..................

C1781 ...... Mesh (implantable) ............................................ ......... N .................. .................. .................. .................. ..................

C1782 ...... Morcellator ......................................................... ......... N .................. .................. .................. .................. ..................

C1783 ...... Ocular imp, aqueous drain de ........................... ......... N .................. .................. .................. .................. ..................

C1784 ...... Ocular dev, intraop, det ret ................................ ......... N .................. .................. .................. .................. ..................

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

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

C1787 ...... Patient progr, neurostim .................................... ......... N .................. .................. .................. .................. ..................

C1788 ...... Port, indwelling, imp .......................................... ......... N .................. .................. .................. .................. ..................

C1789 ...... Prosthesis, breast, imp ...................................... ......... N .................. .................. .................. .................. ..................

C1813 ...... Prosthesis, penile, inflatab ................................. ......... N .................. .................. .................. .................. ..................

C1814 ...... Retinal tamp, silicone oil .................................... ......... N .................. .................. .................. .................. ..................

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

C1816 ...... Receiver/transmitter, neuro ............................... ......... N .................. .................. .................. .................. ..................

C1817 ...... Septal defect imp sys ........................................ ......... N .................. .................. .................. .................. ..................

C1818 ...... Integrated keratoprosthesis ............................... ......... N .................. .................. .................. .................. ..................

C1819 ...... Tissue localization-excision ............................... ......... N .................. .................. .................. .................. ..................

C1820 ...... Generator neuro rechg bat sy ........................... ......... H 1820 .................. .................. .................. ..................

C1821 ...... Interspinous implant ........................................... NI .... H 1821 .................. .................. .................. ..................

C1874 ...... Stent, coated/cov w/del sys ............................... ......... N .................. .................. .................. .................. ..................

C1875 ...... Stent, coated/cov w/o del sy ............................. ......... N .................. .................. .................. .................. ..................

C1876 ...... Stent, non-coa/non-cov w/del ............................ ......... N .................. .................. .................. .................. ..................

C1877 ...... Stent, non-coat/cov w/o del ............................... ......... N .................. .................. .................. .................. ..................

C1878 ...... Matrl for vocal cord ............................................ ......... N .................. .................. .................. .................. ..................

C1879 ...... Tissue marker, implantable ............................... ......... N .................. .................. .................. .................. ..................

C1880 ...... Vena cava filter .................................................. ......... N .................. .................. .................. .................. ..................

C1881 ...... Dialysis access system ...................................... ......... N .................. .................. .................. .................. ..................

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

C1883 ...... Adapt/ext, pacing/neuro lead ............................. ......... N .................. .................. .................. .................. ..................

C1884 ...... Embolization Protect syst .................................. ......... N .................. .................. .................. .................. ..................

C1885 ...... Cath, translumin angio laser .............................. ......... N .................. .................. .................. .................. ..................

C1887 ...... Catheter, guiding ............................................... ......... N .................. .................. .................. .................. ..................

C1888 ...... Endovas non-cardiac abl cath ........................... ......... N .................. .................. .................. .................. ..................

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

C1892 ...... Intro/sheath,fixed,peel-away .............................. ......... N .................. .................. .................. .................. ..................

C1893 ...... Intro/sheath, fixed,non-peel ............................... ......... N .................. .................. .................. .................. ..................

C1894 ...... Intro/sheath, non-laser ....................................... ......... N .................. .................. .................. .................. ..................

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

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

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

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

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

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

C2614 ...... Probe, perc lumb disc ........................................ ......... N .................. .................. .................. .................. ..................

C2615 ...... Sealant, pulmonary, liquid ................................. ......... N .................. .................. .................. .................. ..................

C2616 ...... Brachytx source, Yttrium-90 .............................. CH .. K 2616 172.2337 10,586.86 .................. 2,117.37 

C2617 ...... Stent, non-cor, tem w/o del ............................... ......... N .................. .................. .................. .................. ..................

C2618 ...... Probe, cryoablation ............................................ ......... N .................. .................. .................. .................. ..................

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

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

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

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

C2625 ...... Stent, non-cor, tem w/del sy .............................. ......... N .................. .................. .................. .................. ..................

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

C2627 ...... Cath, suprapubic/cystoscopic ............................ ......... N .................. .................. .................. .................. ..................

C2628 ...... Catheter, occlusion ............................................ ......... N .................. .................. .................. .................. ..................

C2629 ...... Intro/sheath, laser .............................................. ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68370 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

C2630 ...... Cath, EP, cool-tip ............................................... ......... N .................. .................. .................. .................. ..................

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

C2632 ...... Brachytx sol, I-125, per mCi .............................. CH .. D .................. .................. .................. .................. ..................

C2633 ...... Brachytx source, Cesium-131 ........................... CH .. K 2633 1.4779 90.84 .................. 18.17 

C2634 ...... Brachytx source, HA, I-125 ............................... CH .. K 2634 0.5316 32.68 .................. 6.54 

C2635 ...... Brachytx source, HA, P-103 .............................. CH .. K 2635 0.8878 54.57 .................. 10.91 

C2636 ...... Brachytx linear source,P-103 ............................ CH .. K 2636 0.6427 39.51 .................. 7.90 

C2637 ...... Brachytx, Ytterbium-169 .................................... CH .. B .................. .................. .................. .................. ..................

C8900 ...... MRA w/cont, abd ............................................... ......... S 0284 6.1231 376.37 148.40 75.27 

C8901 ...... MRA w/o cont, abd ............................................ ......... S 0336 5.6745 348.80 139.51 69.76 

C8902 ...... MRA w/o fol w/cont, abd ................................... ......... S 0337 8.1155 498.84 199.53 99.77 

C8903 ...... MRI w/cont, breast, uni ...................................... ......... S 0284 6.1231 376.37 148.40 75.27 

C8904 ...... MRI w/o cont, breast, uni .................................. ......... S 0336 5.6745 348.80 139.51 69.76 

C8905 ...... MRI w/o fol w/cont, brst, un ............................... ......... S 0337 8.1155 498.84 199.53 99.77 

C8906 ...... MRI w/cont, breast, bi ........................................ ......... S 0284 6.1231 376.37 148.40 75.27 

C8907 ...... MRI w/o cont, breast, bi .................................... ......... S 0336 5.6745 348.80 139.51 69.76 

C8908 ...... MRI w/o fol w/cont, breast, ................................ ......... S 0337 8.1155 498.84 199.53 99.77 

C8909 ...... MRA w/cont, chest ............................................. ......... S 0284 6.1231 376.37 148.40 75.27 

C8910 ...... MRA w/o cont, chest ......................................... ......... S 0336 5.6745 348.80 139.51 69.76 

C8911 ...... MRA w/o fol w/cont, chest ................................. ......... S 0337 8.1155 498.84 199.53 99.77 

C8912 ...... MRA w/cont, lwr ext ........................................... ......... S 0284 6.1231 376.37 148.40 75.27 

C8913 ...... MRA w/o cont, lwr ext ....................................... ......... S 0336 5.6745 348.80 139.51 69.76 

C8914 ...... MRA w/o fol w/cont, lwr ext ............................... ......... S 0337 8.1155 498.84 199.53 99.77 

C8918 ...... MRA w/cont, pelvis ............................................ ......... S 0284 6.1231 376.37 148.40 75.27 

C8919 ...... MRA w/o cont, pelvis ......................................... ......... S 0336 5.6745 348.80 139.51 69.76 

C8920 ...... MRA w/o fol w/cont, pelvis ................................ ......... S 0337 8.1155 498.84 199.53 99.77 

C8950 ...... IV inf, tx/dx, up to 1 hr ....................................... CH .. D .................. .................. .................. .................. ..................

C8951 ...... IV inf, tx/dx, each addl hr .................................. CH .. D .................. .................. .................. .................. ..................

C8952 ...... Tx, prophy, dx IV push ...................................... CH .. D .................. .................. .................. .................. ..................

C8953 ...... Chemotx adm, IV push ...................................... CH .. D .................. .................. .................. .................. ..................

C8954 ...... Chemotx adm, IV inf up to 1h ........................... CH .. D .................. .................. .................. .................. ..................

C8955 ...... Chemotx adm, IV inf, addl hr ............................ CH .. D .................. .................. .................. .................. ..................

C8957 ...... Prolonged IV inf, req pump ............................... CH .. S 0441 2.4851 152.75 .................. 30.55 

C9003 ...... Palivizumab, per 50 mg ..................................... ......... K 9003 .................. 609.62 .................. 121.92 

C9113 ...... Inj pantoprazole sodium, via .............................. ......... N .................. .................. .................. .................. ..................

C9121 ...... Injection, argatroban .......................................... ......... K 9121 .................. 17.48 .................. 3.50 

C9220 ...... Sodium hyaluronate ........................................... CH .. D .................. .................. .................. .................. ..................

C9221 ...... Graftjacket Reg Matrix ....................................... CH .. D .................. .................. .................. .................. ..................

C9222 ...... Graftjacket SftTis ............................................... CH .. D .................. .................. .................. .................. ..................

C9224 ...... Injection, galsulfase ........................................... CH .. D .................. .................. .................. .................. ..................

C9225 ...... Fluocinolone acetonide ...................................... CH .. D .................. .................. .................. .................. ..................

C9227 ...... Injection, micafungin sodium ............................. CH .. D .................. .................. .................. .................. ..................

C9228 ...... Injection, tigecycline ........................................... CH .. D .................. .................. .................. .................. ..................

C9229 ...... Injection ibandronate sodium ............................. CH .. D .................. .................. .................. .................. ..................

C9230 ...... Injection, abatacept ............................................ CH .. D .................. .................. .................. .................. ..................

C9231 ...... Injection, decitabine ........................................... CH .. D .................. .................. .................. .................. ..................

C9232 ...... Injection, idursulfase .......................................... NI .... G 9232 .................. 464.32 .................. 92.86 

C9233 ...... Injection, ranibizumab ........................................ NI .... G 9233 .................. 2,067.00 .................. 413.40 

C9234 ...... Inj, alglucosidase alfa ........................................ NI .... K 9234 .................. 127.20 .................. 25.44 

C9235 ...... Injection, panitumumab ...................................... NI .... K 9235 .................. 84.80 .................. 16.96 

C9350 ...... Porous collagen tube per cm ............................ NI .... G 9350 .................. 494.53 .................. 98.91

C9351 ...... Acellular derm tissue percm2 ............................ NI .... G 9351 .................. 44.01 .................. 8.80 

C9716 ...... Radiofrequency energy to anu .......................... CH .. T 0150 29.6189 1,820.61 437.12 364.12 

C9723 ...... Dyn IR Perf Img ................................................. ......... S 1502 .................. 75.00 .................. 15.00 

C9724 ...... EPS gast cardia plic .......................................... ......... T 0422 25.7552 1,583.12 448.81 316.62 

C9725 ...... Place endorectal app ......................................... ......... S 1507 .................. 550.00 .................. 110.00 

C9726 ...... Rxt breast appl place/remov .............................. ......... S 1508 .................. 650.00 .................. 130.00 

C9727 ...... Insert palate implants ........................................ NI .... S 1510 .................. 850.00 .................. 170.00 

D0150 ...... Comprehensve oral evaluation .......................... ......... S 0330 7.055 433.66 .................. 86.73 

D0240 ...... Intraoral occlusal film ......................................... ......... S 0330 7.055 433.66 .................. 86.73

D0250 ...... Extraoral first film ............................................... ......... S 0330 7.055 433.66 .................. 86.73 

D0260 ...... Extraoral ea additional film ................................ ......... S 0330 7.055 433.66 .................. 86.73 

D0270 ...... Dental bitewing single film ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D0272 ...... Dental bitewings two films ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D0274 ...... Dental bitewings four films ................................ ......... S 0330 7.055 433.66 .................. 86.73 

D0277 ...... Vert bitewings-sev to eight ................................ ......... S 0330 7.055 433.66 .................. 86.73 

D0460 ...... Pulp vitality test .................................................. ......... S 0330 7.055 433.66 .................. 86.73 

D1510 ...... Space maintainer fxd unilat ............................... ......... S 0330 7.055 433.66 .................. 86.73 

D1515 ...... Fixed bilat space maintainer .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D1520 ...... Remove unilat space maintain .......................... ......... S 0330 7.055 433.66 .................. 86.73 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68371 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

D1525 ...... Remove bilat space maintain ............................ ......... S 0330 7.055 433.66 .................. 86.73 

D1550 ...... Recement space maintainer .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D2999 ...... Dental unspec restorative pr ............................. ......... S 0330 7.055 433.66 .................. 86.73 

D3460 ...... Endodontic endosseous implan ......................... ......... S 0330 7.055 433.66 .................. 86.73 

D3999 ...... Endodontic procedure ........................................ ......... S 0330 7.055 433.66 .................. 86.73 

D4260 ...... Osseous surgery per quadrant .......................... ......... S 0330 7.055 433.66 .................. 86.73 

D4263 ...... Bone replce graft first site ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D4264 ...... Bone replce graft each add ............................... ......... S 0330 7.055 433.66 .................. 86.73 

D4268 ...... Surgical revision procedure ............................... ......... S 0330 7.055 433.66 .................. 86.73 

D4270 ...... Pedicle soft tissue graft pr ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D4271 ...... Free soft tissue graft proc ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D4273 ...... Subepithelial tissue graft ................................... ......... S 0330 7.055 433.66 .................. 86.73 

D4355 ...... Full mouth debridement ..................................... ......... S 0330 7.055 433.66 .................. 86.73 

D4381 ...... Localized delivery antimicro .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D5911 ...... Facial moulage sectional ................................... ......... S 0330 7.055 433.66 .................. 86.73 

D5912 ...... Facial moulage complete ................................... ......... S 0330 7.055 433.66 .................. 86.73 

D5983 ...... Radiation applicator ........................................... ......... S 0330 7.055 433.66 .................. 86.73 

D5984 ...... Radiation shield ................................................. ......... S 0330 7.055 433.66 .................. 86.73 

D5985 ...... Radiation cone locator ....................................... ......... S 0330 7.055 433.66 .................. 86.73 

D5987 ...... Commissure splint ............................................. ......... S 0330 7.055 433.66 .................. 86.73 

D6920 ...... Dental connector bar ......................................... ......... S 0330 7.055 433.66 .................. 86.73 

D7111 ...... Extraction coronal remnants .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D7140 ...... Extraction erupted tooth/exr .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D7210 ...... Rem imp tooth w mucoper flp ........................... ......... S 0330 7.055 433.66 .................. 86.73 

D7220 ...... Impact tooth remov soft tiss .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D7230 ...... Impact tooth remov part bony ........................... ......... S 0330 7.055 433.66 .................. 86.73 

D7240 ...... Impact tooth remov comp bony ......................... ......... S 0330 7.055 433.66 .................. 86.73 

D7241 ...... Impact tooth rem bony w/comp ......................... ......... S 0330 7.055 433.66 .................. 86.73 

D7250 ...... Tooth root removal ............................................ ......... S 0330 7.055 433.66 .................. 86.73 

D7260 ...... Oral antral fistula closure ................................... ......... S 0330 7.055 433.66 .................. 86.73 

D7261 ...... Primary closure sinus perf ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D7291 ...... Transseptal fiberotomy ...................................... ......... S 0330 7.055 433.66 .................. 86.73 

D7940 ...... Reshaping bone orthognathic ............................ ......... S 0330 7.055 433.66 .................. 86.73 

D9110 ...... Tx dental pain minor proc .................................. ......... N .................. .................. .................. .................. ..................

D9230 ...... Analgesia ........................................................... ......... N .................. .................. .................. .................. ..................

D9248 ...... Sedation (non-iv) ............................................... ......... N .................. .................. .................. .................. ..................

D9630 ...... Other drugs/medicaments ................................. ......... S 0330 7.055 433.66 .................. 86.73 

D9930 ...... Treatment of complications ............................... ......... S 0330 7.055 433.66 .................. 86.73 

D9940 ...... Dental occlusal guard ........................................ ......... S 0330 7.055 433.66 .................. 86.73 

D9950 ...... Occlusion analysis ............................................. ......... S 0330 7.055 433.66 .................. 86.73 

D9951 ...... Limited occlusal adjustment .............................. ......... S 0330 7.055 433.66 .................. 86.73 

D9952 ...... Complete occlusal adjustment ........................... ......... S 0330 7.055 433.66 .................. 86.73 

E0164 ...... Commode chair mobile fixed a .......................... CH .. D .................. .................. .................. .................. ..................

E0166 ...... Commode chair mobile detach .......................... CH .. D .................. .................. .................. .................. ..................

E0180 ...... Press pad alternating w pump ........................... CH .. D .................. .................. .................. .................. ..................

E0305 ...... Rails bed side half length .................................. CH .. D .................. .................. .................. .................. ..................

E0310 ...... Rails bed side full length ................................... CH .. D .................. .................. .................. .................. ..................

E0616 ...... Cardiac event recorder ...................................... ......... N .................. .................. .................. .................. ..................

E0676 ...... Inter limb compress dev NOS ........................... NI .... Y .................. .................. .................. .................. ..................

E0701 ...... Helmet w face guard prefab .............................. CH .. D .................. .................. .................. .................. ..................

E0749 ...... Elec osteogen stim implanted ........................... ......... N .................. .................. .................. .................. ..................

E0782 ...... Non-programble infusion pump ......................... ......... N .................. .................. .................. .................. ..................

E0783 ...... Programmable infusion pump ............................ ......... N .................. .................. .................. .................. ..................

E0785 ...... Replacement impl pump cathet ......................... ......... N .................. .................. .................. .................. ..................

E0786 ...... Implantable pump replacement ......................... ......... N .................. .................. .................. .................. ..................

E0830 ...... Ambulatory traction device ................................ ......... N .................. .................. .................. .................. ..................

E0936 ...... CPM device, other than knee ............................ NI .... E .................. .................. .................. .................. ..................

E0977 ...... Wheelchair wedge cushion ................................ CH .. D .................. .................. .................. .................. ..................

E0997 ...... Wheelchair caster w/ a fork ............................... CH .. D .................. .................. .................. .................. ..................

E0998 ...... Wheelchair caster w/o a fork ............................. CH .. D .................. .................. .................. .................. ..................

E0999 ...... Wheelchr pneumatic tire w/wh .......................... CH .. D .................. .................. .................. .................. ..................

E1399 ...... Durable medical equipment mi .......................... CH .. Y .................. .................. .................. .................. ..................

E2320 ...... Hand chin control ............................................... CH .. D .................. .................. .................. .................. ..................

E2373 ...... Hand/chin ctrl spec joystick ............................... NI .... Y .................. .................. .................. .................. ..................

E2374 ...... Hand/chin ctrl std joystick .................................. NI .... Y .................. .................. .................. .................. ..................

E2375 ...... Non-expandable controller ................................. NI .... Y .................. .................. .................. .................. ..................

E2376 ...... Expandable controller, repl ................................ NI .... Y .................. .................. .................. .................. ..................

E2377 ...... Expandable controller, initl ................................ NI .... Y .................. .................. .................. .................. ..................

E2381 ...... Pneum drive wheel tire ...................................... NI .... Y .................. .................. .................. .................. ..................

E2382 ...... Tube, pneum wheel drive tire ............................ NI .... Y .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68372 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

E2383 ...... Insert, pneum wheel drive ................................. NI .... Y .................. .................. .................. .................. ..................

E2384 ...... Pneumatic caster tire ......................................... NI .... Y .................. .................. .................. .................. ..................

E2385 ...... Tube, pneumatic caster tire ............................... NI .... Y .................. .................. .................. .................. ..................

E2386 ...... Foam filled drive wheel tire ............................... NI .... Y .................. .................. .................. .................. ..................

E2387 ...... Foam filled caster tire ........................................ NI .... Y .................. .................. .................. .................. ..................

E2388 ...... Foam drive wheel tire ........................................ NI .... Y .................. .................. .................. .................. ..................

E2389 ...... Foam caster tire ................................................. NI .... Y .................. .................. .................. .................. ..................

E2390 ...... Solid drive wheel tire ......................................... NI .... Y .................. .................. .................. .................. ..................

E2391 ...... Solid caster tire .................................................. NI .... Y .................. .................. .................. .................. ..................

E2392 ...... Solid caster tire, integrate .................................. NI .... Y .................. .................. .................. .................. ..................

E2393 ...... Valve, pneumatic tire tube ................................. NI .... Y .................. .................. .................. .................. ..................

E2394 ...... Drive wheel excludes tire .................................. NI .... Y .................. .................. .................. .................. ..................

E2395 ...... Caster wheel excludes tire ................................ NI .... Y .................. .................. .................. .................. ..................

E2396 ...... Caster fork ......................................................... NI .... Y .................. .................. .................. .................. ..................

G0008 ...... Admin influenza virus vac .................................. CH .. S 0350 0.3945 24.25 .................. ..................

G0009 ...... Admin pneumococcal vaccine ........................... CH .. S 0350 0.3945 24.25 .................. ..................

G0101 ...... CA screen;pelvic/breast exam ........................... CH .. V 0604 0.8242 50.66 .................. 10.13 

G0102 ...... Prostate ca screening; dre ................................ ......... N .................. .................. .................. .................. ..................

G0104 ...... CA screen;flexi sigmoidscope ........................... ......... S 0159 3.6592 224.92 .................. 56.23 

G0105 ...... Colorectal scrn; hi risk ind ................................. ......... T 0158 7.8492 446.00 .................. 111.50 

G0106 ...... Colon CA screen;barium enema ....................... ......... S 0157 2.1149 130.00 .................. 26.00 

G0107 ...... CA screen; fecal blood test ............................... CH .. D .................. .................. .................. .................. ..................

G0117 ...... Glaucoma scrn hgh risk direc ............................ ......... S 0230 0.7898 48.55 14.97 9.71 

G0118 ...... Glaucoma scrn hgh risk direc ............................ ......... S 0230 0.7898 48.55 14.97 9.71 

G0120 ...... Colon ca scrn; barium enema ........................... ......... S 0157 2.1149 130.00 .................. 26.00 

G0121 ...... Colon ca scrn not hi rsk ind .............................. ......... T 0158 7.8492 446.00 .................. 111.50 

G0127 ...... Trim nail(s) ......................................................... ......... T 0009 0.7744 47.60 .................. 9.52 

G0129 ...... Partial hosp prog service ................................... ......... P 0033 3.8188 234.73 .................. 46.95 

G0130 ...... Single energy x-ray study .................................. ......... X 0260 0.7093 43.60 .................. 8.72 

G0166 ...... Extrnl counterpulse, per tx ................................. ......... T 0678 1.7418 107.06 .................. 21.41 

G0173 ...... Linear acc stereo radsur com ............................ CH .. S 0067 63.3759 3,895.59 .................. 779.12 

G0175 ...... OPPS Service,sched team conf ........................ CH .. V 0608 2.1794 133.96 .................. 26.79 

G0176 ...... OPPS/PHP;activity therapy ............................... ......... P 0033 3.8188 234.73 .................. 46.95 

G0177 ...... OPPS/PHP; train & educ serv ........................... ......... P 0033 3.8188 234.73 .................. 46.95 

G0186 ...... Dstry eye lesn,fdr vssl tech ............................... ......... T 0235 3.9333 241.77 58.93 48.35 

G0237 ...... Therapeutic procd strg endur ............................ ......... S 0411 0.3848 23.65 .................. 4.73 

G0238 ...... Oth resp proc, indiv ........................................... ......... S 0411 0.3848 23.65 .................. 4.73 

G0239 ...... Oth resp proc, group ......................................... ......... S 0411 0.3848 23.65 .................. 4.73 

G0243 ...... Multisour photon stero treat ............................... CH .. D .................. .................. .................. .................. ..................

G0245 ...... Initial foot exam pt lops ..................................... CH .. V 0604 0.8242 50.66 .................. 10.13 

G0246 ...... Followup eval of foot pt lop ............................... CH .. V 0605 0.984 60.48 .................. 12.10 

G0247 ...... Routine footcare pt w lops ................................. ......... T 0009 0.7744 47.60 .................. 9.52 

G0248 ...... Demonstrate use home inr mon ........................ CH .. X 0421 1.627 100.01 .................. 20.00 

G0249 ...... Provide test material,equipm ............................. CH .. X 0421 1.627 100.01 .................. 20.00 

G0251 ...... Linear acc based stero radio ............................. CH .. S 0065 20.3224 1,249.18 .................. 249.84 

G0257 ...... Unsched dialysis ESRD pt hos ......................... ......... S 0170 6.6089 406.24 .................. 81.25 

G0259 ...... Inject for sacroiliac joint ..................................... ......... N .................. .................. .................. .................. ..................

G0260 ...... Inj for sacroiliac jt anesth ................................... ......... T 0206 5.7253 351.92 75.55 70.38 

G0267 ...... Bone marrow or psc harvest ............................. ......... S 0110 3.4584 212.58 .................. 42.52 

G0268 ...... Removal of impacted wax md ........................... ......... X 0340 0.6102 37.51 .................. 7.50 

G0269 ...... Occlusive device in vein art ............................... ......... N .................. .................. .................. .................. ..................

G0275 ...... Renal angio, cardiac cath .................................. ......... N .................. .................. .................. .................. ..................

G0278 ...... Iliac art angio,cardiac cath ................................. ......... N .................. .................. .................. .................. ..................

G0288 ...... Recon, CTA for surg plan .................................. ......... S 0417 3.2393 199.11 .................. 39.82 

G0289 ...... Arthro, loose body + chondro ............................ ......... N .................. .................. .................. .................. ..................

G0290 ...... Drug-eluting stents, single ................................. ......... T 0656 108.3003 6,657.00 .................. 1,331.40 

G0291 ...... Drug-eluting stents,each add ............................. ......... T 0656 108.3003 6,657.00 .................. 1,331.40 

G0293 ...... Non-cov surg proc,clin trial ................................ CH .. X 0340 0.6102 37.51 .................. 7.50 

G0294 ...... Non-cov proc, clinical trial ................................. CH .. X 0340 0.6102 37.51 .................. 7.50 

G0297 ...... Insert single chamber/cd ................................... ......... T 0107 304.4894 18,716.35 .................. 3,743.27 

G0298 ...... Insert dual chamber/cd ...................................... ......... T 0107 304.4894 18,716.35 .................. 3,743.27 

G0299 ...... Inser/repos single icd+leads .............................. ......... T 0108 379.7339 23,341.48 .................. 4,668.30 

G0300 ...... Insert reposit lead dual+gen .............................. ......... T 0108 379.7339 23,341.48 .................. 4,668.30 

G0302 ...... Pre-op service LVRS complete ......................... ......... S 1509 .................. 750.00 .................. 150.00 

G0303 ...... Pre-op service LVRS 10–15dos ........................ ......... S 1507 .................. 550.00 .................. 110.00 

G0304 ...... Pre-op service LVRS 1–9 dos ........................... ......... S 1504 .................. 250.00 .................. 50.00 

G0305 ...... Post op service LVRS min 6 ............................. ......... S 1504 .................. 250.00 .................. 50.00 

G0332 ...... Preadmin IV immunoglobulin ............................. ......... S 1502 .................. 75.00 .................. 15.00 

G0339 ...... Robot lin-radsurg com, first ............................... CH .. S 0067 63.3759 3,895.59 .................. 779.12 

G0340 ...... Robt lin-radsurg fractx 2–5 ................................ CH .. S 0066 43.0297 2,644.95 .................. 528.99 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68373 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

G0344 ...... Initial preventive exam ....................................... CH .. V 0605 0.984 60.48 .................. 12.10 

G0364 ...... Bone marrow aspirate &biopsy ......................... CH .. T 0002 1.0995 67.58 .................. 13.52 

G0365 ...... Vessel mapping hemo access ........................... ......... S 0267 2.4606 151.25 60.50 30.25 

G0367 ...... EKG tracing for initial prev ................................ ......... S 0099 0.3789 23.29 .................. 4.66 

G0375 ...... Smoke/tobacco counselng 3–10 ....................... CH .. X 0031 0.1766 10.86 .................. 2.17 

G0376 ...... Smoke/tobacco counseling >10 ........................ CH .. X 0031 0.1766 10.86 .................. 2.17 

G0378 ...... Hospital observation per hr ............................... ......... Q 0339 7.2039 442.81 .................. 88.56 

G0379 ...... Direct admit hospital observ .............................. CH .. Q 0604 0.8242 50.66 .................. 10.13 

G0380 ...... Lev 1 hosp type B ED visit ................................ NF ... V 0604 0.8242 50.66 .................. 10.13 

G0381 ...... Lev 2 hosp type B ED visit ................................ NF ... V 0605 0.984 60.48 .................. 12.10 

G0382 ...... Lev 3 hosp type B ED visit ................................ NF ... V 0606 1.3646 83.88 .................. 16.78 

G0383 ...... Lev 4 hosp type B ED visit ................................ NF ... V 0607 1.7096 105.09 .................. 21.02 

G0384 ...... Lev 5 hosp type B ED visit ................................ NF ... V 0608 2.1794 133.96 .................. 26.79 

G0389 ...... Ultrasound exam AAA screen ........................... NI .... S 0266 1.5607 95.93 37.80 19.19 

G0390 ...... Trauma respon w/hosp cirtica ........................... NI .... S 0618 8.0455 494.54 197.81 98.91 

G0392 ...... AV fistula or graft arterial ................................... NI .... T 0081 42.936 2,639.19 .................. 527.84

G0393 ...... AV fistula or graft venous .................................. NI .... T 0081 42.936 2,639.19 .................. 527.84 

G0394 ...... Blood occult test, colorecta ............................... NI .... A .................. .................. .................. .................. ..................

G3001 ...... Admin + supply, tositumomab ........................... CH .. S 0442 22.3666 1,374.83 .................. 274.97 

G8085 ...... ESRD pt inelig autogenous Fi ........................... NI .... M .................. .................. .................. .................. ..................

J0120 ....... Tetracyclin injection ........................................... ......... N .................. .................. .................. .................. ..................

J0128 ....... Abarelix injection ................................................ CH .. K 9216 .................. 71.18 .................. 14.24 

J0129 ....... Abatacept injection ............................................ NI .... G 9230 .................. 18.70 .................. 3.74 

J0130 ....... Abciximab injection ............................................ ......... K 1605 .................. 416.27 .................. 83.25 

J0132 ....... Acetylcysteine injection ...................................... ......... K 1680 .................. 1.94 .................. 0.39 

J0133 ....... Acyclovir injection .............................................. ......... N .................. .................. .................. .................. ..................

J0135 ....... Adalimumab injection ......................................... ......... K 1083 .................. 308.33 .................. 61.67 

J0150 ....... Injection adenosine 6 MG .................................. ......... K 0379 .................. 30.49 .................. 6.10 

J0152 ....... Adenosine injection ............................................ ......... K 0917 .................. 30.49 .................. 6.10 

J0170 ....... Adrenalin epinephrin inject ................................ ......... N .................. .................. .................. .................. ..................

J0180 ....... Agalsidase beta injection ................................... ......... K 9208 .................. 127.20 .................. 25.44 

J0190 ....... Inj biperiden lactate/5 mg .................................. CH .. K 3038 .................. 88.15 .................. 17.63 

J0200 ....... Alatrofloxacin mesylate ...................................... ......... N .................. .................. .................. .................. ..................

J0205 ....... Alglucerase injection .......................................... ......... K 0900 .................. 39.22 .................. 7.84 

J0207 ....... Amifostine .......................................................... ......... K 7000 .................. 463.27 .................. 92.65 

J0210 ....... Methyldopate hcl injection ................................. ......... K 2210 .................. 10.01 .................. 2.00 

J0215 ....... Alefacept ............................................................ ......... K 1633 .................. 26.31 .................. 5.26 

J0256 ....... Alpha 1 proteinase inhibitor ............................... ......... K 0901 .................. 3.31 .................. 0.66 

J0278 ....... Amikacin sulfate injection .................................. CH .. N .................. .................. .................. .................. ..................

J0280 ....... Aminophyllin 250 MG inj .................................... ......... N .................. .................. .................. .................. ..................

J0282 ....... Amiodarone HCl ................................................ ......... N .................. .................. .................. .................. ..................

J0285 ....... Amphotericin B .................................................. CH .. N .................. .................. .................. .................. ..................

J0287 ....... Amphotericin b lipid complex ............................. ......... K 9024 .................. 11.11 .................. 2.22 

J0288 ....... Ampho b cholesteryl sulfate .............................. ......... K 0735 .................. 12.00 .................. 2.40 

J0289 ....... Amphotericin b liposome inj .............................. ......... K 0736 .................. 21.25 .................. 4.25 

J0290 ....... Ampicillin 500 MG inj ......................................... ......... N .................. .................. .................. .................. ..................

J0295 ....... Ampicillin sodium per 1.5 gm ............................ ......... N .................. .................. .................. .................. ..................

J0300 ....... Amobarbital 125 MG inj ..................................... ......... N .................. .................. .................. .................. ..................

J0330 ....... Succinycholine chloride inj ................................ ......... N .................. .................. .................. .................. ..................

J0348 ....... Anadulafungin injection ...................................... NI .... G 0760 .................. 1.91 .................. 0.38 

J0350 ....... Injection anistreplase 30 u ................................. ......... K 1606 .................. 2,268.46 .................. 453.69 

J0360 ....... Hydralazine hcl injection .................................... ......... N .................. .................. .................. .................. ..................

J0364 ....... Apomorphine hydrochloride ............................... NI .... K 0766 .................. 2.92 .................. 0.58 

J0365 ....... Aprotonin, 10,000 kiu ......................................... ......... K 1682 .................. 2.52 .................. 0.50 

J0380 ....... Inj metaraminol bitartrate ................................... CH .. K 3039 .................. 2.62 .................. 0.52 

J0390 ....... Chloroquine injection ......................................... ......... N .................. .................. .................. .................. ..................

J0395 ....... Arbutamine HCl injection ................................... ......... K 9031 .................. 160.00 .................. 32.00 

J0456 ....... Azithromycin ...................................................... ......... N .................. .................. .................. .................. ..................

J0460 ....... Atropine sulfate injection ................................... ......... N .................. .................. .................. .................. ..................

J0470 ....... Dimecaprol injection .......................................... CH .. N .................. .................. .................. .................. ..................

J0475 ....... Baclofen 10 MG injection .................................. ......... K 9032 .................. 198.54 .................. 39.71 

J0476 ....... Baclofen intrathecal trial .................................... ......... K 1631 .................. 69.63 .................. 13.93 

J0480 ....... Basiliximab ......................................................... ......... K 1683 .................. 1,385.86 .................. 277.17 

J0500 ....... Dicyclomine injection ......................................... ......... N .................. .................. .................. .................. ..................

J0515 ....... Inj benztropine mesylate .................................... ......... N .................. .................. .................. .................. ..................

J0520 ....... Bethanechol chloride inject ................................ ......... N .................. .................. .................. .................. ..................

J0530 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................

J0540 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................

J0550 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................

J0560 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68374 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J0570 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................

J0580 ....... Penicillin g benzathine inj .................................. ......... N .................. .................. .................. .................. ..................

J0583 ....... Bivalirudin .......................................................... CH .. K 3041 .................. 1.75 .................. 0.35 

J0585 ....... Botulinum toxin a per unit .................................. ......... K 0902 .................. 5.04 .................. 1.01 

J0587 ....... Botulinum toxin type B ....................................... ......... K 9018 .................. 8.16 .................. 1.63 

J0592 ....... Buprenorphine hydrochloride ............................. ......... N .................. .................. .................. .................. ..................

J0594 ....... Busulfan injection ............................................... NI .... K 1178 .................. 8.89 .................. 1.78 

J0595 ....... Butorphanol tartrate 1 mg .................................. ......... N .................. .................. .................. .................. ..................

J0600 ....... Edetate calcium disodium inj ............................. ......... K 0892 .................. 40.19 .................. 8.04 

J0610 ....... Calcium gluconate injection ............................... ......... N .................. .................. .................. .................. ..................

J0620 ....... Calcium glycer & lact/10 ML .............................. ......... N .................. .................. .................. .................. ..................

J0630 ....... Calcitonin salmon injection ................................ CH .. N .................. .................. .................. .................. ..................

J0636 ....... Inj calcitriol per 0.1 mcg .................................... ......... N .................. .................. .................. .................. ..................

J0637 ....... Caspofungin acetate .......................................... ......... K 9019 .................. 32.25 .................. 6.45 

J0640 ....... Leucovorin calcium injection .............................. ......... N .................. .................. .................. .................. ..................

J0670 ....... Inj mepivacaine HCL/10 ml ............................... ......... N .................. .................. .................. .................. ..................

J0690 ....... Cefazolin sodium injection ................................. ......... N .................. .................. .................. .................. ..................

J0692 ....... Cefepime HCl for injection ................................. ......... N .................. .................. .................. .................. ..................

J0694 ....... Cefoxitin sodium injection .................................. ......... N .................. .................. .................. .................. ..................

J0696 ....... Ceftriaxone sodium injection ............................. ......... N .................. .................. .................. .................. ..................

J0697 ....... Sterile cefuroxime injection ................................ ......... N .................. .................. .................. .................. ..................

J0698 ....... Cefotaxime sodium injection .............................. ......... N .................. .................. .................. .................. ..................

J0702 ....... Betamethasone acet&sod phosp ....................... ......... N .................. .................. .................. .................. ..................

J0704 ....... Betamethasone sod phosp/4 MG ...................... ......... N .................. .................. .................. .................. ..................

J0706 ....... Caffeine citrate injection .................................... ......... K 0876 .................. 3.54 .................. 0.71 

J0710 ....... Cephapirin sodium injection .............................. ......... N .................. .................. .................. .................. ..................

J0713 ....... Inj ceftazidime per 500 mg ................................ ......... N .................. .................. .................. .................. ..................

J0715 ....... Ceftizoxime sodium / 500 MG ........................... ......... N .................. .................. .................. .................. ..................

J0720 ....... Chloramphenicol sodium injec ........................... ......... N .................. .................. .................. .................. ..................

J0725 ....... Chorionic gonadotropin/1000u ........................... ......... N .................. .................. .................. .................. ..................

J0735 ....... Clonidine hydrochloride ..................................... ......... K 0935 .................. 66.04 .................. 13.21 

J0740 ....... Cidofovir injection .............................................. ......... K 9033 .................. 763.15 .................. 152.63 

J0743 ....... Cilastatin sodium injection ................................. ......... N .................. .................. .................. .................. ..................

J0744 ....... Ciprofloxacin iv .................................................. ......... N .................. .................. .................. .................. ..................

J0745 ....... Inj codeine phosphate /30 MG .......................... ......... N .................. .................. .................. .................. ..................

J0760 ....... Colchicine injection ............................................ ......... N .................. .................. .................. .................. ..................

J0770 ....... Colistimethate sodium inj ................................... ......... N .................. .................. .................. .................. ..................

J0780 ....... Prochlorperazine injection ................................. ......... N .................. .................. .................. .................. ..................

J0795 ....... Corticorelin ovine triflutal ................................... ......... K 1684 .................. 4.17 .................. 0.83 

J0800 ....... Corticotropin injection ........................................ ......... K 1280 .................. 116.60 .................. 23.32 

J0835 ....... Inj cosyntropin per 0.25 MG .............................. ......... K 0835 .................. 62.91 .................. 12.58 

J0850 ....... Cytomegalovirus imm IV /vial ............................ ......... K 0903 .................. 853.18 .................. 170.64 

J0878 ....... Daptomycin injection .......................................... CH .. K 9124 .................. 0.33 .................. 0.07 

J0881 ....... Darbepoetin alfa, non-esrd ................................ ......... K 1685 .................. 2.99 .................. 0.60 

J0882 ....... Darbepoetin alfa, esrd use ................................ CH .. A .................. .................. .................. .................. ..................

J0885 ....... Epoetin alfa, non-esrd ....................................... ......... K 1686 .................. 9.36 .................. 1.87 

J0886 ....... Epoetin alfa 1000 units ESRD ........................... CH .. A .................. .................. .................. .................. ..................

J0894 ....... Decitabine injection ............................................ NI .... G 9231 .................. 26.50 .................. 5.30 

J0895 ....... Deferoxamine mesylate inj ................................ ......... K 0895 .................. 14.84 .................. 2.97 

J0900 ....... Testosterone enanthate inj ................................ ......... N .................. .................. .................. .................. ..................

J0945 ....... Brompheniramine maleate inj ............................ ......... N .................. .................. .................. .................. ..................

J0970 ....... Estradiol valerate injection ................................. ......... N .................. .................. .................. .................. ..................

J1000 ....... Depo-estradiol cypionate inj .............................. ......... N .................. .................. .................. .................. ..................

J1020 ....... Methylprednisolone 20 MG inj ........................... ......... N .................. .................. .................. .................. ..................

J1030 ....... Methylprednisolone 40 MG inj ........................... ......... N .................. .................. .................. .................. ..................

J1040 ....... Methylprednisolone 80 MG inj ........................... ......... N .................. .................. .................. .................. ..................

J1051 ....... Medroxyprogesterone inj ................................... ......... N .................. .................. .................. .................. ..................

J1060 ....... Testosterone cypionate 1 ML ............................ ......... N .................. .................. .................. .................. ..................

J1070 ....... Testosterone cypionat 100 MG ......................... ......... N .................. .................. .................. .................. ..................

J1080 ....... Testosterone cypionat 200 MG ......................... ......... N .................. .................. .................. .................. ..................

J1094 ....... Inj dexamethasone acetate ............................... ......... N .................. .................. .................. .................. ..................

J1100 ....... Dexamethasone sodium phos ........................... ......... N .................. .................. .................. .................. ..................

J1110 ....... Inj dihydroergotamine mesylt ............................. CH .. N .................. .................. .................. .................. ..................

J1120 ....... Acetazolamid sodium injectio ............................ ......... N .................. .................. .................. .................. ..................

J1160 ....... Digoxin injection ................................................. ......... N .................. .................. .................. .................. ..................

J1162 ....... Digoxin immune fab (ovine) ............................... ......... K 1687 .................. 533.72 .................. 106.74 

J1165 ....... Phenytoin sodium injection ................................ ......... N .................. .................. .................. .................. ..................

J1170 ....... Hydromorphone injection ................................... ......... N .................. .................. .................. .................. ..................

J1180 ....... Dyphylline injection ............................................ CH .. N .................. .................. .................. .................. ..................

J1190 ....... Dexrazoxane HCl injection ................................ ......... K 0726 .................. 180.13 .................. 36.03 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68375 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J1200 ....... Diphenhydramine hcl injectio ............................. ......... N .................. .................. .................. .................. ..................

J1205 ....... Chlorothiazide sodium inj .................................. CH .. K 0747 .................. 123.84 .................. 24.77 

J1212 ....... Dimethyl sulfoxide 50% 50 ML .......................... ......... N .................. .................. .................. .................. ..................

J1230 ....... Methadone injection ........................................... ......... N .................. .................. .................. .................. ..................

J1240 ....... Dimenhydrinate injection ................................... ......... N .................. .................. .................. .................. ..................

J1245 ....... Dipyridamole injection ........................................ ......... N .................. .................. .................. .................. ..................

J1250 ....... Inj dobutamine HCL/250 mg .............................. ......... N .................. .................. .................. .................. ..................

J1260 ....... Dolasetron mesylate .......................................... ......... K 0750 .................. 6.89 .................. 1.38 

J1265 ....... Dopamine injection ............................................ ......... N .................. .................. .................. .................. ..................

J1270 ....... Injection, doxercalciferol .................................... ......... N .................. .................. .................. .................. ..................

J1320 ....... Amitriptyline injection ......................................... ......... N .................. .................. .................. .................. ..................

J1324 ....... Enfuvirtide injection ............................................ NI .... K 0767 .................. 21.82 .................. 4.36 

J1325 ....... Epoprostenol injection ....................................... ......... N .................. .................. .................. .................. ..................

J1327 ....... Eptifibatide injection ........................................... ......... K 1607 .................. 15.37 .................. 3.07 

J1330 ....... Ergonovine maleate injection ............................ ......... K 1330 .................. 33.11 .................. 6.62 

J1335 ....... Ertapenem injection ........................................... ......... N .................. .................. .................. .................. ..................

J1364 ....... Erythro lactobionate /500 MG ............................ ......... N .................. .................. .................. .................. ..................

J1380 ....... Estradiol valerate 10 MG inj .............................. ......... N .................. .................. .................. .................. ..................

J1390 ....... Estradiol valerate 20 MG inj .............................. ......... N .................. .................. .................. .................. ..................

J1410 ....... Inj estrogen conjugate 25 MG ........................... ......... K 9038 .................. 58.05 .................. 11.61 

J1430 ....... Ethanolamine oleate 100 mg ............................. ......... K 1688 .................. 69.60 .................. 13.92 

J1435 ....... Injection estrone per 1 MG ................................ ......... N .................. .................. .................. .................. ..................

J1436 ....... Etidronate disodium inj ...................................... ......... K 1436 .................. 71.41 .................. 14.28 

J1438 ....... Etanercept injection ........................................... ......... K 1608 .................. 160.39 .................. 32.08 

J1440 ....... Filgrastim 300 mcg injection .............................. ......... K 0728 .................. 188.07 .................. 37.61 

J1441 ....... Filgrastim 480 mcg injection .............................. ......... K 7049 .................. 298.70 .................. 59.74 

J1450 ....... Fluconazole ........................................................ ......... N .................. .................. .................. .................. ..................

J1451 ....... Fomepizole, 15 mg ............................................ ......... K 1689 .................. 12.33 .................. 2.47 

J1452 ....... Intraocular Fomivirsen na .................................. ......... K 9040 .................. 212.00 .................. 42.40 

J1455 ....... Foscarnet sodium injection ................................ CH .. K 3042 .................. 10.49 .................. 2.10

J1457 ....... Gallium nitrate injection ..................................... CH .. N .................. .................. .................. .................. ..................

J1458 ....... Galsulfase injection ............................................ NI .... K 9224 .................. 1,516.12 .................. 303.22 

J1460 ....... Gamma globulin 1 CC inj .................................. CH .. K 3043 .................. 10.34 .................. 2.07 

J1562 ....... Immune globulin subcutaneous ......................... NI .... K 0804 .................. 7.08 .................. 1.42 

J1565 ....... RSV-ivig ............................................................. ......... K 0906 .................. 16.18 .................. 3.24 

J1566 ....... Immune globulin, powder .................................. ......... K 2731 .................. 25.27 .................. 5.05 

J1567 ....... Immune globulin, liquid ...................................... ......... K 2732 .................. 30.33 .................. 6.07 

J1570 ....... Ganciclovir sodium injection .............................. ......... N .................. .................. .................. .................. ..................

J1580 ....... Garamycin gentamicin inj .................................. ......... N .................. .................. .................. .................. ..................

J1590 ....... Gatifloxacin injection .......................................... ......... N .................. .................. .................. .................. ..................

J1595 ....... Injection glatiramer acetate ............................... ......... N .................. .................. .................. .................. ..................

J1600 ....... Gold sodium thiomaleate inj .............................. ......... N .................. .................. .................. .................. ..................

J1610 ....... Glucagon hydrochloride/1 MG ........................... ......... K 9042 .................. 70.23 .................. 14.05 

J1620 ....... Gonadorelin hydroch/ 100 mcg ......................... ......... K 7005 .................. 189.84 .................. 37.97 

J1626 ....... Granisetron HCl injection ................................... ......... K 0764 .................. 7.21 .................. 1.44 

J1630 ....... Haloperidol injection .......................................... ......... N .................. .................. .................. .................. ..................

J1631 ....... Haloperidol decanoate inj .................................. ......... N .................. .................. .................. .................. ..................

J1640 ....... Hemin, 1 mg ...................................................... ......... K 1690 .................. 6.80 .................. 1.36 

J1642 ....... Inj heparin sodium per 10 u .............................. ......... N .................. .................. .................. .................. ..................

J1644 ....... Inj heparin sodium per 1000u ............................ ......... N .................. .................. .................. .................. ..................

J1645 ....... Dalteparin sodium .............................................. ......... N .................. .................. .................. .................. ..................

J1650 ....... Inj enoxaparin sodium ....................................... ......... N .................. .................. .................. .................. ..................

J1652 ....... Fondaparinux sodium ........................................ ......... N .................. .................. .................. .................. ..................

J1655 ....... Tinzaparin sodium injection ............................... ......... K 1655 .................. 2.48 .................. 0.50 

J1670 ....... Tetanus immune globulin inj .............................. ......... K 1670 .................. 87.77 .................. 17.55 

J1700 ....... Hydrocortisone acetate inj ................................. ......... N .................. .................. .................. .................. ..................

J1710 ....... Hydrocortisone sodium ph inj ............................ ......... N .................. .................. .................. .................. ..................

J1720 ....... Hydrocortisone sodium succ i ........................... ......... N .................. .................. .................. .................. ..................

J1730 ....... Diazoxide injection ............................................. ......... K 1740 .................. 111.89 .................. 22.38 

J1740 ....... Ibandronate sodium injection ............................. NI .... G 9229 .................. 139.12 .................. 27.82 

J1742 ....... Ibutilide fumarate injection ................................. ......... K 9044 .................. 265.75 .................. 53.15 

J1745 ....... Infliximab injection ............................................. ......... K 7043 .................. 53.74 .................. 10.75 

J1751 ....... Iron dextran 165 injection .................................. ......... K 1691 .................. 11.78 .................. 2.36 

J1752 ....... Iron dextran 267 injection .................................. ......... K 1692 .................. 10.38 .................. 2.08 

J1756 ....... Iron sucrose injection ......................................... ......... K 9046 .................. 0.36 .................. 0.07 

J1785 ....... Injection imiglucerase /unit ................................ ......... K 0916 .................. 3.91 .................. 0.78 

J1790 ....... Droperidol injection ............................................ ......... N .................. .................. .................. .................. ..................

J1800 ....... Propranolol injection .......................................... ......... N .................. .................. .................. .................. ..................

J1815 ....... Insulin injection .................................................. ......... N .................. .................. .................. .................. ..................

J1817 ....... Insulin for insulin pump use ............................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68376 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J1830 ....... Interferon beta-1b / .25 MG ............................... ......... K 0910 .................. 90.00 .................. 18.00 

J1835 ....... Itraconazole injection ......................................... ......... K 9047 .................. 36.45 .................. 7.29 

J1840 ....... Kanamycin sulfate 500 MG inj .......................... ......... N .................. .................. .................. .................. ..................

J1850 ....... Kanamycin sulfate 75 MG inj ............................ ......... N .................. .................. .................. .................. ..................

J1885 ....... Ketorolac tromethamine inj ................................ ......... N .................. .................. .................. .................. ..................

J1890 ....... Cephalothin sodium injection ............................. ......... N .................. .................. .................. .................. ..................

J1931 ....... Laronidase injection ........................................... ......... K 9209 .................. 23.87 .................. 4.77 

J1940 ....... Furosemide injection .......................................... ......... N .................. .................. .................. .................. ..................

J1945 ....... Lepirudin ............................................................ ......... K 1693 .................. 153.54 .................. 30.71 

J1950 ....... Leuprolide acetate /3.75 MG ............................. ......... K 0800 .................. 437.58 .................. 87.52 

J1956 ....... Levofloxacin injection ......................................... ......... N .................. .................. .................. .................. ..................

J1960 ....... Levorphanol tartrate inj ...................................... ......... N .................. .................. .................. .................. ..................

J1980 ....... Hyoscyamine sulfate inj ..................................... ......... N .................. .................. .................. .................. ..................

J1990 ....... Chlordiazepoxide injection ................................. ......... N .................. .................. .................. .................. ..................

J2001 ....... Lidocaine injection ............................................. ......... N .................. .................. .................. .................. ..................

J2010 ....... Lincomycin injection ........................................... ......... N .................. .................. .................. .................. ..................

J2020 ....... Linezolid injection .............................................. ......... K 9001 .................. 24.16 .................. 4.83 

J2060 ....... Lorazepam injection ........................................... ......... N .................. .................. .................. .................. ..................

J2150 ....... Mannitol injection ............................................... ......... N .................. .................. .................. .................. ..................

J2170 ....... Mecasermin injection ......................................... NI .... K 0805 .................. 11.93 .................. 2.39 

J2175 ....... Meperidine hydrochl /100 MG ........................... ......... N .................. .................. .................. .................. ..................

J2180 ....... Meperidine/promethazine inj .............................. ......... N .................. .................. .................. .................. ..................

J2185 ....... Meropenem ........................................................ CH .. K 3045 .................. 3.68 .................. 0.74 

J2210 ....... Methylergonovin maleate inj .............................. ......... N .................. .................. .................. .................. ..................

J2248 ....... Micafungin sodium injection .............................. NI .... G 9227 .................. 1.87 .................. 0.37

J2250 ....... Inj midazolam hydrochloride .............................. ......... N .................. .................. .................. .................. ..................

J2260 ....... Inj milrinone lactate / 5 MG ............................... ......... N .................. .................. .................. .................. ..................

J2270 ....... Morphine sulfate injection .................................. ......... N .................. .................. .................. .................. ..................

J2271 ....... Morphine so4 injection 100mg .......................... ......... N .................. .................. .................. .................. ..................

J2275 ....... Morphine sulfate injection .................................. ......... N .................. .................. .................. .................. ..................

J2278 ....... Ziconotide injection ............................................ ......... G 1694 .................. 6.34 .................. 1.27 

J2280 ....... Inj, moxifloxacin 100 mg .................................... ......... N .................. .................. .................. .................. ..................

J2300 ....... Inj nalbuphine hydrochloride .............................. ......... N .................. .................. .................. .................. ..................

J2310 ....... Inj naloxone hydrochloride ................................. ......... N .................. .................. .................. .................. ..................

J2315 ....... Naltrexone, depot form ...................................... NI .... K 0759 .................. 1.94 .................. 0.39 

J2320 ....... Nandrolone decanoate 50 MG .......................... ......... N .................. .................. .................. .................. ..................

J2321 ....... Nandrolone decanoate 100 MG ........................ ......... N .................. .................. .................. .................. ..................

J2322 ....... Nandrolone decanoate 200 MG ........................ ......... N .................. .................. .................. .................. ..................

J2325 ....... Nesiritide injection .............................................. ......... K 1695 .................. 30.13 .................. 6.03 

J2353 ....... Octreotide injection, depot ................................. ......... K 1207 .................. 93.35 .................. 18.67 

J2354 ....... Octreotide inj, non-depot ................................... ......... N .................. .................. .................. .................. ..................

J2355 ....... Oprelvekin injection ........................................... ......... K 7011 .................. 245.98 .................. 49.20 

J2357 ....... Omalizumab injection ........................................ CH .. K 9300 .................. 16.61 .................. 3.32 

J2360 ....... Orphenadrine injection ....................................... ......... N .................. .................. .................. .................. ..................

J2370 ....... Phenylephrine hcl injection ................................ ......... N .................. .................. .................. .................. ..................

J2400 ....... Chloroprocaine hcl injection .............................. ......... N .................. .................. .................. .................. ..................

J2405 ....... Ondansetron hcl injection .................................. ......... K 0768 .................. 3.72 .................. 0.74 

J2410 ....... Oxymorphone hcl injection ................................ ......... N .................. .................. .................. .................. ..................

J2425 ....... Palifermin injection ............................................. ......... K 1696 .................. 11.43 .................. 2.29 

J2430 ....... Pamidronate disodium /30 MG .......................... ......... K 0730 .................. 34.80 .................. 6.96

J2440 ....... Papaverin hcl injection ....................................... ......... N .................. .................. .................. .................. ..................

J2460 ....... Oxytetracycline injection .................................... ......... N .................. .................. .................. .................. ..................

J2469 ....... Palonosetron HCl ............................................... ......... K 9210 .................. 18.08 .................. 3.62 

J2501 ....... Paricalcitol .......................................................... ......... N .................. .................. .................. .................. ..................

J2503 ....... Pegaptanib sodium injection .............................. ......... G 1697 .................. 1,107.54 .................. 221.51 

J2504 ....... Pegademase bovine, 25 iu ................................ ......... K 1739 .................. 177.83 .................. 35.57 

J2505 ....... Injection, pegfilgrastim 6mg ............................... ......... K 9119 .................. 2,163.61 .................. 432.72 

J2510 ....... Penicillin g procaine inj ...................................... ......... N .................. .................. .................. .................. ..................

J2513 ....... Pentastarch 10% solution .................................. CH .. N .................. .................. .................. .................. ..................

J2515 ....... Pentobarbital sodium inj .................................... ......... N .................. .................. .................. .................. ..................

J2540 ....... Penicillin g potassium inj ................................... ......... N .................. .................. .................. .................. ..................

J2543 ....... Piperacillin/tazobactam ...................................... ......... N .................. .................. .................. .................. ..................

J2550 ....... Promethazine hcl injection ................................. ......... N .................. .................. .................. .................. ..................

J2560 ....... Phenobarbital sodium inj ................................... ......... N .................. .................. .................. .................. ..................

J2590 ....... Oxytocin injection ............................................... ......... N .................. .................. .................. .................. ..................

J2597 ....... Inj desmopressin acetate ................................... ......... N .................. .................. .................. .................. ..................

J2650 ....... Prednisolone acetate inj .................................... ......... N .................. .................. .................. .................. ..................

J2670 ....... Totazoline hcl injection ...................................... ......... N .................. .................. .................. .................. ..................

J2675 ....... Inj progesterone per 50 MG .............................. ......... N .................. .................. .................. .................. ..................

J2680 ....... Fluphenazine decanoate 25 MG ....................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68377 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J2690 ....... Procainamide hcl injection ................................. ......... N .................. .................. .................. .................. ..................

J2700 ....... Oxacillin sodium injeciton .................................. CH .. N .................. .................. .................. .................. ..................

J2710 ....... Neostigmine methylslfte inj ................................ ......... N .................. .................. .................. .................. ..................

J2720 ....... Inj protamine sulfate/10 MG .............................. ......... N .................. .................. .................. .................. ..................

J2725 ....... Inj protirelin per 250 mcg ................................... ......... N .................. .................. .................. .................. ..................

J2730 ....... Pralidoxime chloride inj ...................................... CH .. N .................. .................. .................. .................. ..................

J2760 ....... Phentolaine mesylate inj .................................... ......... N .................. .................. .................. .................. ..................

J2765 ....... Metoclopramide hcl injection ............................. ......... N .................. .................. .................. .................. ..................

J2770 ....... Quinupristin/dalfopristin ..................................... ......... K 2770 .................. 114.49 .................. 22.90 

J2780 ....... Ranitidine hydrochloride inj ............................... ......... N .................. .................. .................. .................. ..................

J2783 ....... Rasburicase ....................................................... CH .. K 0738 .................. 121.26 .................. 24.25 

J2788 ....... Rho d immune globulin 50 mcg ........................ ......... K 9023 .................. 27.70 .................. 5.54 

J2790 ....... Rho d immune globulin inj ................................. ......... K 0884 .................. 80.52 .................. 16.10 

J2792 ....... Rho(D) immune globulin h, sd ........................... ......... K 1609 .................. 14.30 .................. 2.86 

J2794 ....... Risperidone, long acting .................................... CH .. K 9125 .................. 4.80 .................. 0.96 

J2795 ....... Ropivacaine HCl injection .................................. ......... N .................. .................. .................. .................. ..................

J2800 ....... Methocarbamol injection .................................... ......... N .................. .................. .................. .................. ..................

J2805 ....... Sincalide injection .............................................. CH .. N .................. .................. .................. .................. ..................

J2810 ....... Inj theophylline per 40 MG ................................ ......... N .................. .................. .................. .................. ..................

J2820 ....... Sargramostim injection ...................................... ......... K 0731 .................. 25.55 .................. 5.11 

J2850 ....... Inj secretin synthetic human .............................. ......... K 1700 .................. 20.31 .................. 4.06 

J2910 ....... Aurothioglucose injeciton ................................... CH .. N .................. .................. .................. .................. ..................

J2912 ....... Sodium chloride injection ................................... CH .. D .................. .................. .................. .................. ..................

J2916 ....... Na ferric gluconate complex .............................. ......... N .................. .................. .................. .................. ..................

J2920 ....... Methylprednisolone injection ............................. ......... N .................. .................. .................. .................. ..................

J2930 ....... Methylprednisolone injection ............................. ......... N .................. .................. .................. .................. ..................

J2940 ....... Somatrem injection ............................................ ......... K 2940 .................. 35.60 .................. 7.12 

J2941 ....... Somatropin injection .......................................... ......... K 7034 .................. 46.80 .................. 9.36 

J2950 ....... Promazine hcl injection ...................................... ......... N .................. .................. .................. .................. ..................

J2993 ....... Reteplase injection ............................................ ......... K 9005 .................. 902.72 .................. 180.54 

J2995 ....... Inj streptokinase /250000 IU .............................. ......... K 0911 .................. 79.50 .................. 15.90 

J2997 ....... Alteplase recombinant ....................................... ......... K 7048 .................. 32.07 .................. 6.41 

J3000 ....... Streptomycin injection ........................................ ......... N .................. .................. .................. .................. ..................

J3010 ....... Fentanyl citrate injeciton .................................... ......... N .................. .................. .................. .................. ..................

J3030 ....... Sumatriptan succinate / 6 MG ........................... ......... K 3030 .................. 57.40 .................. 11.48 

J3070 ....... Pentazocine injection ......................................... ......... N .................. .................. .................. .................. ..................

J3100 ....... Tenecteplase injection ....................................... ......... K 9002 .................. 2,036.66 .................. 407.33 

J3105 ....... Terbutaline sulfate inj ........................................ ......... N .................. .................. .................. .................. ..................

J3120 ....... Testosterone enanthate inj ................................ ......... N .................. .................. .................. .................. ..................

J3130 ....... Testosterone enanthate inj ................................ ......... N .................. .................. .................. .................. ..................

J3140 ....... Testosterone suspension inj .............................. ......... N .................. .................. .................. .................. ..................

J3150 ....... Testosteron propionate inj ................................. ......... N .................. .................. .................. .................. ..................

J3230 ....... Chlorpromazine hcl injection ............................. ......... N .................. .................. .................. .................. ..................

J3240 ....... Thyrotropin injection .......................................... ......... K 9108 .................. 765.76 .................. 153.15 

J3243 ....... Tigecycline injection ........................................... NI .... G 9228 .................. 0.91 .................. 0.18 

J3246 ....... Tirofiban HCl ...................................................... ......... K 7041 .................. 8.74 .................. 1.75 

J3250 ....... Trimethobenzamide hcl inj ................................. ......... N .................. .................. .................. .................. ..................

J3260 ....... Tobramycin sulfate injection .............................. ......... N .................. .................. .................. .................. ..................

J3265 ....... Injection torsemide 10 mg/ml ............................ ......... N .................. .................. .................. .................. ..................

J3280 ....... Thiethylperazine maleate inj .............................. ......... N .................. .................. .................. .................. ..................

J3285 ....... Treprostinil injection ........................................... ......... K 1701 .................. 54.02 .................. 10.80 

J3301 ....... Triamcinolone acetonide inj ............................... ......... N .................. .................. .................. .................. ..................

J3302 ....... Triamcinolone diacetate inj ................................ ......... N .................. .................. .................. .................. ..................

J3303 ....... Triamcinolone hexacetonl inj ............................. ......... N .................. .................. .................. .................. ..................

J3305 ....... Inj trimetrexate glucoronate ............................... ......... K 7045 .................. 145.17 .................. 29.03 

J3310 ....... Perphenazine injeciton ...................................... ......... N .................. .................. .................. .................. ..................

J3315 ....... Triptorelin pamoate ............................................ ......... K 9122 .................. 218.53 .................. 43.71 

J3320 ....... Spectinomycn di-hcl inj ...................................... CH .. K 0753 .................. 30.08 .................. 6.02 

J3350 ....... Urea injection ..................................................... ......... K 9051 .................. 37.81 .................. 7.56 

J3355 ....... Urofollitropin, 75 iu ............................................. ......... K 1741 .................. 49.35 .................. 9.87 

J3360 ....... Diazepam injection ............................................ ......... N .................. .................. .................. .................. ..................

J3364 ....... Urokinase 5000 IU injection .............................. ......... N .................. .................. .................. .................. ..................

J3365 ....... Urokinase 250,000 IU inj ................................... ......... K 7036 .................. 457.73 .................. 91.55 

J3370 ....... Vancomycin hcl injection ................................... ......... N .................. .................. .................. .................. ..................

J3396 ....... Verteporfin injection ........................................... ......... K 1203 .................. 8.91 .................. 1.78 

J3400 ....... Triflupromazine hcl inj ........................................ ......... N .................. .................. .................. .................. ..................

J3410 ....... Hydroxyzine hcl injection ................................... ......... N .................. .................. .................. .................. ..................

J3411 ....... Thiamine hcl 100 mg ......................................... ......... N .................. .................. .................. .................. ..................

J3415 ....... Pyridoxine hcl 100 mg ....................................... ......... N .................. .................. .................. .................. ..................

J3420 ....... Vitamin b12 injection ......................................... ......... N .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68378 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J3430 ....... Vitamin k phytonadione inj ................................ ......... N .................. .................. .................. .................. ..................

J3465 ....... Injection, voriconazole ....................................... ......... K 1052 .................. 4.66 .................. 0.93 

J3470 ....... Hyaluronidase injection ...................................... CH .. N .................. .................. .................. .................. ..................

J3471 ....... Ovine, up to 999 USP units ............................... CH .. N .................. .................. .................. .................. ..................

J3472 ....... Ovine, 1000 USP units ...................................... ......... K 1703 .................. 137.43 .................. 27.49 

J3473 ....... Hyaluronidase recombinant ............................... NI .... G 0806 .................. 0.40 .................. 0.08 

J3475 ....... Inj magnesium sulfate ........................................ ......... N .................. .................. .................. .................. ..................

J3480 ....... Inj potassium chloride ........................................ ......... N .................. .................. .................. .................. ..................

J3485 ....... Zidovudine ......................................................... ......... N .................. .................. .................. .................. ..................

J3486 ....... Ziprasidone mesylate ......................................... ......... N .................. .................. .................. .................. ..................

J3487 ....... Zoledronic acid .................................................. ......... K 9115 .................. 204.03 .................. 40.81 

J3490 ....... Drugs unclassified injection ............................... ......... N .................. .................. .................. .................. ..................

J3530 ....... Nasal vaccine inhalation .................................... ......... N .................. .................. .................. .................. ..................

J3590 ....... Unclassified biologics ........................................ ......... N .................. .................. .................. .................. ..................

J7030 ....... Normal saline solution infus .............................. ......... N .................. .................. .................. .................. ..................

J7040 ....... Normal saline solution infus .............................. ......... N .................. .................. .................. .................. ..................

J7042 ....... 5% dextrose/normal saline ................................ ......... N .................. .................. .................. .................. ..................

J7050 ....... Normal saline solution infus .............................. ......... N .................. .................. .................. .................. ..................

J7060 ....... 5% dextrose/water ............................................. ......... N .................. .................. .................. .................. ..................

J7070 ....... D5w infusion ...................................................... ......... N .................. .................. .................. .................. ..................

J7100 ....... Dextran 40 infusion ............................................ ......... N .................. .................. .................. .................. ..................

J7110 ....... Dextran 75 infusion ............................................ ......... N .................. .................. .................. .................. ..................

J7120 ....... Ringers lactate infusion ..................................... ......... N .................. .................. .................. .................. ..................

J7130 ....... Hypertonic saline solution .................................. ......... N .................. .................. .................. .................. ..................

J7187 ....... Inj Vonwillebrand factor IU ................................ NI .... K 1704 .................. 0.88 .................. 0.18 

J7188 ....... Inj Vonwillebrand factor iu ................................. CH .. D .................. .................. .................. .................. ..................

J7189 ....... Factor viia .......................................................... ......... K 1705 .................. 1.10 .................. 0.22 

J7190 ....... Factor viii ........................................................... ......... K 0925 .................. 0.69 .................. 0.14 

J7191 ....... Factor VIII (porcine) ........................................... ......... K 0926 .................. 1.33 .................. 0.27 

J7192 ....... Factor viii recombinant ...................................... ......... K 0927 .................. 1.06 .................. 0.21 

J7193 ....... Factor IX non-recombinant ................................ ......... K 0931 .................. 0.90 .................. 0.18 

J7194 ....... Factor ix complex .............................................. ......... K 0928 .................. 0.72 .................. 0.14 

J7195 ....... Factor IX recombinant ....................................... ......... K 0932 .................. 0.99 .................. 0.20 

J7197 ....... Antithrombin iii injection ..................................... ......... K 0930 .................. 1.62 .................. 0.32 

J7198 ....... Anti-inhibitor ....................................................... ......... K 0929 .................. 1.36 .................. 0.27 

J7308 ....... Aminolevulinic acid hcl top ................................ ......... K 7308 .................. 107.72 .................. 21.54 

J7310 ....... Ganciclovir long act implant .............................. ......... K 0913 .................. 4,766.14 .................. 953.23 

J7311 ....... Fluocinolone acetonide implt ............................. NI .... G 9225 .................. 18,250.00 .................. 3,650.00 

J7317 ....... Sodium hyaluronate injection ............................ CH .. D .................. .................. .................. .................. ..................

J7319 ....... Sodium Hyaluronate Injection ............................ NI .... K 0896 .................. 124.68 .................. 24.94 

J7320 ....... Hylan G–F 20 injection ...................................... CH .. D .................. .................. .................. .................. ..................

J7340 ....... Metabolic active D/E tissue ............................... ......... K 1632 .................. 27.89 .................. 5.58 

J7341 ....... Non-human, metabolic tissue ............................ ......... K 1707 .................. 1.78 .................. 0.36 

J7342 ....... Metabolically active tissue ................................. ......... K 9054 .................. 13.87 .................. 2.77 

J7343 ....... Nonmetabolic act d/e tissue .............................. ......... K 1629 .................. 18.49 .................. 3.70 

J7344 ....... Nonmetabolic active tissue ................................ ......... K 9156 .................. 45.02 .................. 9.00 

J7345 ....... Non-human, non-metab tissue .......................... NI .... B .................. .................. .................. .................. ..................

J7346 ....... Injectable human tissue ..................................... NI .... K 9222 .................. 743.96 .................. 148.79 

J7350 ....... Injectable human tissue ..................................... CH .. D .................. .................. .................. .................. ..................

J7500 ....... Azathioprine oral 50mg ...................................... ......... N .................. .................. .................. .................. ..................

J7501 ....... Azathioprine parenteral ...................................... ......... K 0887 .................. 49.17 .................. 9.83 

J7502 ....... Cyclosporine oral 100 mg .................................. ......... K 0888 .................. 3.66 .................. 0.73 

J7504 ....... Lymphocyte immune globulin ............................ ......... K 0890 .................. 315.76 .................. 63.15 

J7505 ....... Monoclonal antibodies ....................................... ......... K 7038 .................. 856.05 .................. 171.21 

J7506 ....... Prednisone oral .................................................. ......... N .................. .................. .................. .................. ..................

J7507 ....... Tacrolimus oral per 1 MG .................................. ......... K 0891 .................. 3.55 .................. 0.71 

J7509 ....... Methylprednisolone oral ..................................... ......... N .................. .................. .................. .................. ..................

J7510 ....... Prednisolone oral per 5 mg ............................... ......... N .................. .................. .................. .................. ..................

J7511 ....... Antithymocyte globuln rabbit ............................. ......... K 9104 .................. 329.62 .................. 65.92 

J7513 ....... Daclizumab, parenteral ...................................... ......... K 1612 .................. 328.83 .................. 65.77 

J7515 ....... Cyclosporine oral 25 mg .................................... CH .. N .................. .................. .................. .................. ..................

J7516 ....... Cyclosporin parenteral 250mg ........................... ......... N .................. .................. .................. .................. ..................

J7517 ....... Mycophenolate mofetil oral ................................ ......... K 9015 .................. 2.50 .................. 0.50 

J7518 ....... Mycophenolic acid ............................................. CH .. K 9219 .................. 2.15 .................. 0.43 

J7520 ....... Sirolimus, oral .................................................... ......... K 9020 .................. 7.25 .................. 1.45 

J7525 ....... Tacrolimus injection ........................................... ......... K 9006 .................. 140.72 .................. 28.14 

J7599 ....... Immunosuppressive drug noc ........................... ......... N .................. .................. .................. .................. ..................

J7607 ....... Levalbuterol comp con ...................................... NI .... B .................. .................. .................. .................. ..................

J7609 ....... Albuterol comp unit ............................................ NI .... B .................. .................. .................. .................. ..................

J7610 ....... Albuterol comp con ............................................ NI .... B .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68379 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J7615 ....... Levalbuterol comp unit ...................................... NI .... B .................. .................. .................. .................. ..................

J7634 ....... Budesonide comp con ....................................... NI .... B .................. .................. .................. .................. ..................

J7645 ....... Ipratropium bromide comp ................................. NI .... B .................. .................. .................. .................. ..................

J7647 ....... Isoetharine comp con ........................................ NI .... B .................. .................. .................. .................. ..................

J7650 ....... Isoetharine comp unit ........................................ NI .... B .................. .................. .................. .................. ..................

J7657 ....... Isoproterenol comp con ..................................... NI .... B .................. .................. .................. .................. ..................

J7660 ....... Isoproterenol comp unit ..................................... NI .... B .................. .................. .................. .................. ..................

J7667 ....... Metaproterenol comp con .................................. NI .... B .................. .................. .................. .................. ..................

J7670 ....... Metaproterenol comp unit .................................. NI .... B .................. .................. .................. .................. ..................

J7674 ....... Methacholine chloride, neb ................................ ......... N .................. .................. .................. .................. ..................

J7685 ....... Tobramycin comp unit ....................................... NI .... B .................. .................. .................. .................. ..................

J7799 ....... Non-inhalation drug for DME ............................. ......... N .................. .................. .................. .................. ..................

J8501 ....... Oral aprepitant ................................................... ......... G 0868 .................. 4.85 .................. 0.97 

J8510 ....... Oral busulfan ..................................................... ......... K 7015 .................. 2.14 .................. 0.43 

J8520 ....... Capecitabine, oral, 150 mg ............................... ......... K 7042 .................. 3.83 .................. 0.77 

J8530 ....... Cyclophosphamide oral 25 MG ......................... ......... N .................. .................. .................. .................. ..................

J8540 ....... Oral dexamethasone ......................................... CH .. N .................. .................. .................. .................. ..................

J8560 ....... Etoposide oral 50 MG ........................................ ......... K 0802 .................. 32.01 .................. 6.40 

J8597 ....... Antiemetic drug oral NOS .................................. ......... N .................. .................. .................. .................. ..................

J8600 ....... Melphalan oral 2 MG ......................................... ......... N .................. .................. .................. .................. ..................

J8610 ....... Methotrexate oral 2.5 MG .................................. ......... N .................. .................. .................. .................. ..................

J8650 ....... Nabilone oral ...................................................... NI .... K 0808 .................. 16.96 .................. 3.39 

J8700 ....... Temozolomide ................................................... ......... K 1086 .................. 7.30 .................. 1.46 

J9000 ....... Doxorubic hcl 10 MG vl chemo ......................... CH .. K 3048 .................. 6.00 .................. 1.20 

J9001 ....... Doxorubicin hcl liposome inj .............................. ......... K 7046 .................. 379.21 .................. 75.84 

J9010 ....... Alemtuzumab injection ....................................... ......... K 9110 .................. 531.24 .................. 106.25 

J9015 ....... Aldesleukin/single use vial ................................. ......... K 0807 .................. 726.69 .................. 145.34 

J9017 ....... Arsenic trioxide .................................................. ......... K 9012 .................. 33.36 .................. 6.67 

J9020 ....... Asparaginase injection ....................................... ......... K 0814 .................. 54.46 .................. 10.89 

J9025 ....... Azacitidine injection ........................................... ......... K 1709 .................. 4.22 .................. 0.84 

J9027 ....... Clofarabine injection .......................................... ......... G 1710 .................. 116.62 .................. 23.32 

J9031 ....... Bcg live intravesical vac .................................... ......... K 0809 .................. 113.44 .................. 22.69 

J9035 ....... Bevacizumab injection ....................................... CH .. K 9214 .................. 56.88 .................. 11.38 

J9040 ....... Bleomycin sulfate injection ................................ CH .. K 0748 .................. 37.62 .................. 7.52 

J9041 ....... Bortezomib injection .......................................... ......... K 9207 .................. 31.87 .................. 6.37 

J9045 ....... Carboplatin injection .......................................... ......... K 0811 .................. 10.12 .................. 2.02 

J9050 ....... Carmus bischl nitro inj ....................................... ......... K 0812 .................. 139.84 .................. 27.97 

J9055 ....... Cetuximab injection ........................................... CH .. K 9215 .................. 49.86 .................. 9.97 

J9060 ....... Cisplatin 10 MG injection ................................... ......... N .................. .................. .................. .................. ..................

J9065 ....... Inj cladribine per 1 MG ...................................... ......... K 0858 .................. 37.87 .................. 7.57 

J9070 ....... Cyclophosphamide 100 MG inj ......................... ......... N .................. .................. .................. .................. ..................

J9093 ....... Cyclophosphamide lyophilized .......................... CH .. K 3049 .................. 5.72 .................. 1.14 

J9098 ....... Cytarabine liposome .......................................... ......... K 1166 .................. 396.66 .................. 79.33 

J9100 ....... Cytarabine hcl 100 MG inj ................................. ......... N .................. .................. .................. .................. ..................

J9120 ....... Dactinomycin actinomycin d .............................. CH .. K 0752 .................. 493.43 .................. 98.69

J9130 ....... Dacarbazine 100 mg inj ..................................... CH .. K 0746 .................. 4.90 .................. 0.98

J9150 ....... Daunorubicin ...................................................... ......... K 0820 .................. 24.56 .................. 4.91 

J9151 ....... Daunorubicin citrate liposom ............................. ......... K 0821 .................. 56.21 .................. 11.24 

J9160 ....... Denileukin diftitox, 300 mcg .............................. ......... K 1084 .................. 1,403.23 .................. 280.65 

J9165 ....... Diethylstilbestrol injection .................................. ......... N .................. .................. .................. .................. ..................

J9170 ....... Docetaxel ........................................................... ......... K 0823 .................. 302.68 .................. 60.54 

J9175 ....... Elliotts b solution per ml .................................... ......... N .................. .................. .................. .................. ..................

J9178 ....... Inj, epirubicin hcl, 2 mg ..................................... ......... K 1167 .................. 24.67 .................. 4.93 

J9181 ....... Etoposide 10 MG inj .......................................... ......... N .................. .................. .................. .................. ..................

J9185 ....... Fludarabine phosphate inj ................................. ......... K 0842 .................. 243.82 .................. 48.76 

J9190 ....... Fluorouracil injection .......................................... ......... N .................. .................. .................. .................. ..................

J9200 ....... Floxuridine injection ........................................... ......... K 0827 .................. 64.17 .................. 12.83 

J9201 ....... Gemcitabine HCl ................................................ ......... K 0828 .................. 121.30 .................. 24.26 

J9202 ....... Goserelin acetate implant .................................. ......... K 0810 .................. 199.12 .................. 39.82 

J9206 ....... Irinotecan injection ............................................. ......... K 0830 .................. 126.88 .................. 25.38 

J9208 ....... Ifosfomide injection ............................................ ......... K 0831 .................. 52.39 .................. 10.48 

J9209 ....... Mesna injection .................................................. ......... K 0732 .................. 10.10 .................. 2.02 

J9211 ....... Idarubicin hcl injection ....................................... ......... K 0832 .................. 308.97 .................. 61.79 

J9212 ....... Interferon alfacon-1 ............................................ ......... K 0912 .................. 4.65 .................. 0.93 

J9213 ....... Interferon alfa-2a inj ........................................... ......... K 0834 .................. 37.56 .................. 7.51 

J9214 ....... Interferon alfa-2b inj ........................................... ......... K 0836 .................. 13.75 .................. 2.75 

J9215 ....... Interferon alfa-n3 inj ........................................... ......... K 0865 .................. 39.48 .................. 7.90 

J9216 ....... Interferon gamma 1-b inj ................................... ......... K 0838 .................. 289.87 .................. 57.97 

J9217 ....... Leuprolide acetate suspnsion ............................ ......... K 9217 .................. 227.63 .................. 45.53 

J9218 ....... Leuprolide acetate injeciton ............................... ......... K 0861 .................. 11.10 .................. 2.22 


cprice-sewell on PRODPC62 with RULES2
68380 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J9219 ....... Leuprolide acetate implant ................................ ......... K 7051 .................. 2,208.90 .................. 441.78 

J9225 ....... Histrelin implant ................................................. ......... K 1711 .................. 1,741.71 .................. 348.34 

J9230 ....... Mechlorethamine hcl inj ..................................... CH .. K 0751 .................. 141.61 .................. 28.32 

J9245 ....... Inj melphalan hydrochl 50 MG .......................... ......... K 0840 .................. 1,194.15 .................. 238.83 

J9250 ....... Methotrexate sodium inj .................................... ......... N .................. .................. .................. .................. ..................

J9261 ....... Nelarabine injection ........................................... NI .... K 0825 .................. 83.10 .................. 16.62 

J9263 ....... Oxaliplatin .......................................................... ......... K 1738 .................. 8.77 .................. 1.75 

J9264 ....... Paclitaxel protein bound .................................... ......... G 1712 .................. 8.73 .................. 1.75 

J9265 ....... Paclitaxel injection ............................................. ......... K 0863 .................. 14.35 .................. 2.87 

J9266 ....... Pegaspargase/singl dose vial ............................ ......... K 0843 .................. 1,687.04 .................. 337.41 

J9268 ....... Pentostatin injection ........................................... ......... K 0844 .................. 2,034.63 .................. 406.93 

J9270 ....... Plicamycin (mithramycin) inj .............................. ......... K 0860 .................. 61.36 .................. 12.27 

J9280 ....... Mitomycin 5 MG inj ............................................ ......... K 0862 .................. 18.31 .................. 3.66 

J9293 ....... Mitoxantrone hydrochl / 5 MG ........................... ......... K 0864 .................. 223.27 .................. 44.65 

J9300 ....... Gemtuzumab ozogamicin .................................. ......... K 9004 .................. 2,317.16 .................. 463.43 

J9305 ....... Pemetrexed injection ......................................... CH .. K 9213 .................. 42.49 .................. 8.50 

J9310 ....... Rituximab cancer treatment ............................... ......... K 0849 .................. 481.69 .................. 96.34 

J9320 ....... Streptozocin injection ......................................... ......... K 0850 .................. 152.92 .................. 30.58 

J9340 ....... Thiotepa injection ............................................... ......... K 0851 .................. 44.58 .................. 8.92 

J9350 ....... Topotecan .......................................................... ......... K 0852 .................. 813.08 .................. 162.62 

J9355 ....... Trastuzumab ...................................................... ......... K 1613 .................. 56.17 .................. 11.23 

J9357 ....... Valrubicin, 200 mg ............................................. ......... K 9167 .................. 369.60 .................. 73.92 

J9360 ....... Vinblastine sulfate inj ......................................... ......... N .................. .................. .................. .................. ..................

J9370 ....... Vincristine sulfate 1 MG inj ................................ ......... N .................. .................. .................. .................. ..................

J9390 ....... Vinorelbine tartrate/10 mg ................................. ......... K 0855 .................. 22.82 .................. 4.56 

J9395 ....... Injection, Fulvestrant .......................................... ......... K 9120 .................. 80.66 .................. 16.13 

J9600 ....... Porfimer sodium ................................................. ......... K 0856 .................. 2,505.40 .................. 501.08 

J9999 ....... Chemotherapy drug ........................................... ......... N .................. .................. .................. .................. ..................

K0090 ...... Rear tire power wheelchair ................................ CH .. D .................. .................. .................. .................. ..................

K0091 ...... Rear tire tube power whlchr .............................. CH .. D .................. .................. .................. .................. ..................

K0092 ...... Rear assem cmplt powr whlchr ......................... CH .. D .................. .................. .................. .................. ..................

K0093 ...... Rear zero pressure tire tube ............................. CH .. D .................. .................. .................. .................. ..................

K0094 ...... Wheel tire for power base ................................. CH .. D .................. .................. .................. .................. ..................

K0095 ...... Wheel tire tube each base ................................ CH .. D .................. .................. .................. .................. ..................

K0096 ...... Wheel assem powr base complt ....................... CH .. D .................. .................. .................. .................. ..................

K0097 ...... Wheel zero presure tire tube ............................. CH .. D .................. .................. .................. .................. ..................

K0098 ...... Drive belt power wheelchair .............................. CH .. D .................. .................. .................. .................. ..................

K0733 ...... 12–24hr sealed lead acid .................................. NI .... Y .................. .................. .................. .................. ..................

K0734 ...... Adj skin pro w/c cus wd<22in ............................ NI .... Y .................. .................. .................. .................. ..................

K0735 ...... Adj skin pro wc cus wd ́22in ............................ NI .... Y .................. .................. .................. .................. ..................

K0736 ...... Adj skin pro/pos wc cus<22in ............................ NI .... Y .................. .................. .................. .................. ..................

K0737 ...... Adj skin pro/pos wc cus ́22′′ ............................ NI .... Y .................. .................. .................. .................. ..................

K0738 ...... Portable gas oxygen system ............................. NI .... Y .................. .................. .................. .................. ..................

K0800 ...... POV group 1 std up to 300 lb ........................... NI .... Y .................. .................. .................. .................. ..................

K0801 ...... POV group 1 hd 301–450 lbs ............................ NI .... Y .................. .................. .................. .................. ..................

K0802 ...... POV group 1 vhd 451–600 lbs .......................... NI .... Y .................. .................. .................. .................. ..................

K0806 ...... POV group 2 std up to 300lbs ........................... NI .... Y .................. .................. .................. .................. ..................

K0807 ...... POV group 2 hd 301–450 lbs ............................ NI .... Y .................. .................. .................. .................. ..................

K0808 ...... POV group 2 vhd 451–600 lbs .......................... NI .... Y .................. .................. .................. .................. ..................

K0812 ...... Power operated vehicle NOC ............................ NI .... Y .................. .................. .................. .................. ..................

K0813 ...... PWC gp 1 std port seat/back ............................ NI .... Y .................. .................. .................. .................. ..................

K0814 ...... PWC gp 1 std port cap chair ............................. NI .... Y .................. .................. .................. .................. ..................

K0815 ...... PWC gp 1 std seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0816 ...... PWC gp 1 std cap chair .................................... NI .... Y .................. .................. .................. .................. ..................

K0820 ...... PWC gp 2 std port seat/back ............................ NI .... Y .................. .................. .................. .................. ..................

K0821 ...... PWC gp 2 std port cap chair ............................. NI .... Y .................. .................. .................. .................. ..................

K0822 ...... PWC gp 2 std seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0823 ...... PWC gp 2 std cap chair .................................... NI .... Y .................. .................. .................. .................. ..................

K0824 ...... PWC gp 2 hd seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0825 ...... PWC gp 2 hd cap chair ..................................... NI .... Y .................. .................. .................. .................. ..................

K0826 ...... PWC gp2 vhd seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0827 ...... PWC gp 2 vhd cap chair ................................... NI .... Y .................. .................. .................. .................. ..................

K0828 ...... PWC gp 2 xtra hd seat/back ............................. NI .... Y .................. .................. .................. .................. ..................

K0829 ...... PWC gp 2 xtra hd cap chair .............................. NI .... Y .................. .................. .................. .................. ..................

K0830 ...... PWC gp2 std seat elevate s/b ........................... NI .... Y .................. .................. .................. .................. ..................

K0831 ...... PWC gp2 std seat elevate cap .......................... NI .... Y .................. .................. .................. .................. ..................

K0835 ...... PWC gp2 std sing pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0836 ...... PWC gp2 std sing pow opt cap ......................... NI .... Y .................. .................. .................. .................. ..................

K0837 ...... PWC gp 2 hd sing pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0838 ...... PWC gp 2 hd sing pow opt cap ........................ NI .... Y .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68381 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

K0839 ...... PWC gp2 vhd sing pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0840 ...... PWC gp2 xhd sing pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0841 ...... PWC gp2 std mult pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0842 ...... PWC gp2 std mult pow opt cap ........................ NI .... Y .................. .................. .................. .................. ..................

K0843 ...... PWC gp2 hd mult pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0848 ...... PWC gp 3 std seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0849 ...... PWC gp 3 std cap chair .................................... NI .... Y .................. .................. .................. .................. ..................

K0850 ...... PWC gp 3 hd seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0851 ...... PWC gp 3 hd cap chair ..................................... NI .... Y .................. .................. .................. .................. ..................

K0852 ...... PWC gp 3 vhd seat/back ................................... NI .... Y .................. .................. .................. .................. ..................

K0853 ...... PWC gp 3 vhd cap chair ................................... NI .... Y .................. .................. .................. .................. ..................

K0854 ...... PWC gp 3 xhd seat/back ................................... NI .... Y .................. .................. .................. .................. ..................

K0855 ...... PWC gp 3 xhd cap chair ................................... NI .... Y .................. .................. .................. .................. ..................

K0856 ...... PWC gp3 std sing pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0857 ...... PWC gp3 std sing pow opt cap ......................... NI .... Y .................. .................. .................. .................. ..................

K0858 ...... PWC gp3 hd sing pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0859 ...... PWC gp3 hd sing pow opt cap ......................... NI .... Y .................. .................. .................. .................. ..................

K0860 ...... PWC gp3 vhd sing pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0861 ...... PWC gp3 std mult pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0862 ...... PWC gp3 hd mult pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0863 ...... PWC gp3 vhd mult pow opt s/b ........................ NI .... Y .................. .................. .................. .................. ..................

K0864 ...... PWC gp3 xhd mult pow opt s/b ........................ NI .... Y .................. .................. .................. .................. ..................

K0868 ...... PWC gp 4 std seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0869 ...... PWC gp 4 std cap chair .................................... NI .... Y .................. .................. .................. .................. ..................

K0870 ...... PWC gp 4 hd seat/back .................................... NI .... Y .................. .................. .................. .................. ..................

K0871 ...... PWC gp 4 vhd seat/back ................................... NI .... Y .................. .................. .................. .................. ..................

K0877 ...... PWC gp4 std sing pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0878 ...... PWC gp4 std sing pow opt cap ......................... NI .... Y .................. .................. .................. .................. ..................

K0879 ...... PWC gp4 hd sing pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0880 ...... PWC gp4 vhd sing pow opt s/b ......................... NI .... Y .................. .................. .................. .................. ..................

K0884 ...... PWc gp4 std mult pow opt s/b .......................... NI .... Y .................. .................. .................. .................. ..................

K0885 ...... PWC gp4 std mult pow opt cap ........................ NI .... Y .................. .................. .................. .................. ..................

K0886 ...... PWC gp4 hd mult pow s/b ................................ NI .... Y .................. .................. .................. .................. ..................

K0890 ...... PWC gp5 ped sing pow opt s/b ........................ NI .... Y .................. .................. .................. .................. ..................

K0891 ...... PWC gp5 ped mult pow opt s/b ........................ NI .... Y .................. .................. .................. .................. ..................

K0898 ...... Power wheelchair NOC ..................................... NI .... Y .................. .................. .................. .................. ..................

K0899 ...... Pow mobility dev no sadmerc ........................... NI .... Y .................. .................. .................. .................. ..................

L0100 ....... Cranial orthosis/helmet mold ............................. CH .. D .................. .................. .................. .................. ..................

L0110 ....... Cranial orthosis/helmet nonm ............................ CH .. D .................. .................. .................. .................. ..................

L1001 ....... CTLSO infant immobilizer .................................. NI .... A .................. .................. .................. .................. ..................

L3806 ....... WHFO w/joint(s) custom fab ............................. NI .... A .................. .................. .................. .................. ..................

L3808 ....... WHFO, rigid w/o joints ....................................... NI .... A .................. .................. .................. .................. ..................

L3902 ....... Whfo ext power compress gas .......................... CH .. D .................. .................. .................. .................. ..................

L3914 ....... WHO wrist extension cock-up ........................... CH .. D .................. .................. .................. .................. ..................

L3915 ....... WHO w nontor jnt(s) prefab .............................. NI .... A .................. .................. .................. .................. ..................

L5993 ....... Heavy duty feature, foot .................................... NI .... A .................. .................. .................. .................. ..................

L5994 ....... Heavy duty feature, knee .................................. NI .... A .................. .................. .................. .................. ..................

L6611 ....... Additional switch, ext power .............................. NI .... A .................. .................. .................. .................. ..................

L6624 ....... Flex/ext/rotation wrist unit .................................. NI .... A .................. .................. .................. .................. ..................

L6639 ....... Heavy duty elbow feature .................................. NI .... A .................. .................. .................. .................. ..................

L6700 ....... Terminal device model #3 ................................. CH .. D .................. .................. .................. .................. ..................

L6703 ....... Term dev, passive hand mitt ............................. NI .... A .................. .................. .................. .................. ..................

L6704 ....... Term dev, sport/rec/work att .............................. NI .... A .................. .................. .................. .................. ..................

L6705 ....... Terminal device model #5 ................................. CH .. D .................. .................. .................. .................. ..................

L6706 ....... Term dev mech hook vol open .......................... NI .... A .................. .................. .................. .................. ..................

L6707 ....... Term dev mech hook vol close ......................... NI .... A .................. .................. .................. .................. ..................

L6708 ....... Term dev mech hand vol open ......................... NI .... A .................. .................. .................. .................. ..................

L6709 ....... Term dev mech hand vol close ......................... NI .... A .................. .................. .................. .................. ..................

L6710 ....... Terminal device model #5x ............................... CH .. D .................. .................. .................. .................. ..................

L6715 ....... Terminal device model #5xa ............................. CH .. D .................. .................. .................. .................. ..................

L6720 ....... Terminal device model #6 ................................. CH .. D .................. .................. .................. .................. ..................

L6725 ....... Terminal device model #7 ................................. CH .. D .................. .................. .................. .................. ..................

L6730 ....... Terminal device model #7lo .............................. CH .. D .................. .................. .................. .................. ..................

L6735 ....... Terminal device model #8 ................................. CH .. D .................. .................. .................. .................. ..................

L6740 ....... Terminal device model #8x ............................... CH .. D .................. .................. .................. .................. ..................

L6745 ....... Terminal device model #88x ............................. CH .. D .................. .................. .................. .................. ..................

L6750 ....... Terminal device model #10p ............................. CH .. D .................. .................. .................. .................. ..................

L6755 ....... Terminal device model #10x ............................. CH .. D .................. .................. .................. .................. ..................

L6765 ....... Terminal device model #12p ............................. CH .. D .................. .................. .................. .................. ..................

L6770 ....... Terminal device model #99x ............................. CH .. D .................. .................. .................. .................. ..................


cprice-sewell on PRODPC62 with RULES2
68382 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

L6775 ....... Terminal device model#555 .............................. CH .. D .................. .................. .................. .................. ..................

L6780 ....... Terminal device model #ss555 .......................... CH .. D .................. .................. .................. .................. ..................

L6790 ....... Hooks-accu hook or equal ................................. CH .. D .................. .................. .................. .................. ..................

L6795 ....... Hooks-2 load or equal ....................................... CH .. D .................. .................. .................. .................. ..................

L6800 ....... Hooks-aprl vc or equal ...................................... CH .. D .................. .................. .................. .................. ..................

L6806 ....... Trs grip vc or equal ........................................... CH .. D .................. .................. .................. .................. ..................

L6807 ....... Term device grip1/2 or equal ............................ CH .. D .................. .................. .................. .................. ..................

L6808 ....... Term device infant or child ................................ CH .. D .................. .................. .................. .................. ..................

L6809 ....... Trs super sport passive ..................................... CH .. D .................. .................. .................. .................. ..................

L6825 ....... Hands dorrance vo ............................................ CH .. D .................. .................. .................. .................. ..................

L6830 ....... Hand aprl vc ...................................................... CH .. D .................. .................. .................. .................. ..................

L6835 ....... Hand sierra vo ................................................... CH .. D .................. .................. .................. .................. ..................

L6840 ....... Hand becker imperial ......................................... CH .. D .................. .................. .................. .................. ..................

L6845 ....... Hand becker lock grip ........................................ CH .. D .................. .................. .................. .................. ..................

L6850 ....... Term dvc-hand becker plylite ............................ CH .. D .................. .................. .................. .................. ..................

L6855 ....... Hand robin-aids vo ............................................ CH .. D .................. .................. .................. .................. ..................

L6860 ....... Hand robin-aids vo soft ..................................... CH .. D .................. .................. .................. .................. ..................

L6865 ....... Hand passive hand ............................................ CH .. D .................. .................. .................. .................. ..................

L6867 ....... Hand detroit infant hand .................................... CH .. D .................. .................. .................. .................. ..................

L6868 ....... Passive inf hand steeper/hos ............................ CH .. D .................. .................. .................. .................. ..................

L6870 ....... Hand child mitt ................................................... CH .. D .................. .................. .................. .................. ..................

L6872 ....... Hand nyu child hand .......................................... CH .. D .................. .................. .................. .................. ..................

L6873 ....... Hand mech inf steeper or equ ........................... CH .. D .................. .................. .................. .................. ..................

L6875 ....... Hand bock vc ..................................................... CH .. D .................. .................. .................. .................. ..................

L6880 ....... Hand bock vo ..................................................... CH .. D .................. .................. .................. .................. ..................

L7007 ....... Adult electric hand ............................................. NI .... A .................. .................. .................. .................. ..................

L7008 ....... Pediatric electric hand ....................................... NI .... A .................. .................. .................. .................. ..................

L7009 ....... Adult electric hook ............................................. NI .... A .................. .................. .................. .................. ..................

L7010 ....... Hand otto back steeper/eq sw ........................... CH .. D .................. .................. .................. .................. ..................

L7015 ....... Hand sys teknik village swit .............................. CH .. D .................. .................. .................. .................. ..................

L7020 ....... Electronic greifer switch ct ................................. CH .. D .................. .................. .................. .................. ..................

L7025 ....... Electron hand myoelectronic ............................. CH .. D .................. .................. .................. .................. ..................

L7030 ....... Hand sys teknik vill myoelec ............................. CH .. D .................. .................. .................. .................. ..................

L7035 ....... Electron greifer myoelectro ................................ CH .. D .................. .................. .................. .................. ..................

L8600 ....... Implant breast silicone/eq .................................. ......... N .................. .................. .................. .................. ..................

L8603 ....... Collagen imp urinary 2.5 ml .............................. ......... N .................. .................. .................. .................. ..................

L8606 ....... Synthetic implnt urinary 1ml .............................. ......... N .................. .................. .................. .................. ..................

L8609 ....... Artificial cornea .................................................. ......... N .................. .................. .................. .................. ..................

L8610 ....... Ocular implant .................................................... ......... N .................. .................. .................. .................. ..................

L8612 ....... Aqueous shunt prosthesis ................................. ......... N .................. .................. .................. .................. ..................

L8613 ....... Ossicular implant ............................................... ......... N .................. .................. .................. .................. ..................

L8614 ....... Cochlear device ................................................. ......... N .................. .................. .................. .................. ..................

L8630 ....... Metacarpophalangeal implant ............................ ......... N .................. .................. .................. .................. ..................

L8631 ....... MCP joint repl 2 pc or more .............................. ......... N .................. .................. .................. .................. ..................

L8641 ....... Metatarsal joint implant ...................................... ......... N .................. .................. .................. .................. ..................

L8642 ....... Hallux implant .................................................... ......... N .................. .................. .................. .................. ..................

L8658 ....... Interphalangeal joint spacer .............................. ......... N .................. .................. .................. .................. ..................

L8659 ....... Interphalangeal joint repl ................................... ......... N .................. .................. .................. .................. ..................

L8670 ....... Vascular graft, synthetic .................................... ......... N .................. .................. .................. .................. ..................

L8682 ....... Implt neurostim radiofq rec ................................ ......... N .................. .................. .................. .................. ..................

L8690 ....... Aud osseo dev, int/ext comp ............................. NI .... H 1032 .................. .................. .................. ..................

L8691 ....... Aud osseo dev, int/ext comp ............................. NI .... A .................. .................. .................. .................. ..................

L8695 ....... External recharg sys extern ............................... NI .... A .................. .................. .................. .................. ..................

L8699 ....... Prosthetic implant NOS ..................................... ......... N .................. .................. .................. .................. ..................

M0064 ...... Visit for drug monitoring .................................... ......... X 0374 1.1418 70.18 .................. 14.04 

P9010 ...... Whole blood for transfusion ............................... ......... K 0950 2.1472 131.98 .................. 26.40 

P9011 ...... Blood split unit ................................................... ......... K 0967 2.2323 137.22 .................. 27.44 

P9012 ...... Cryoprecipitate each unit ................................... ......... K 0952 0.7905 48.59 .................. 9.72 

P9016 ...... RBC leukocytes reduced ................................... ......... K 0954 2.859 175.74 .................. 35.15 

P9017 ...... Plasma 1 donor frz w/in 8 hr ............................. ......... K 9508 1.1422 70.21 .................. 14.04 

P9019 ...... Platelets, each unit ............................................ ......... K 0957 0.959 58.95 .................. 11.79 

P9020 ...... Plaelet rich plasma unit ..................................... ......... K 0958 3.4048 209.29 .................. 41.86 

P9021 ...... Red blood cells unit ........................................... ......... K 0959 2.1073 129.53 .................. 25.91

P9022 ...... Washed red blood cells unit .............................. ......... K 0960 3.4331 211.03 .................. 42.21 

P9023 ...... Frozen plasma, pooled, sd ................................ ......... K 0949 0.9346 57.45 .................. 11.49 

P9031 ...... Platelets leukocytes reduced ............................. ......... K 1013 1.5469 95.08 .................. 19.02 

P9032 ...... Platelets, irradiated ............................................ ......... K 9500 2.1079 129.57 .................. 25.91 

P9033 ...... Platelets leukoreduced irrad .............................. ......... K 0968 2.039 125.33 .................. 25.07 

P9034 ...... Platelets, pheresis ............................................. ......... K 9507 7.3686 452.93 .................. 90.59 

P9035 ...... Platelet pheres leukoreduced ............................ ......... K 9501 7.9511 488.74 .................. 97.75 


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Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68383 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

P9036 ...... Platelet pheresis irradiated ................................ ......... K 9502 6.8088 418.52 .................. 83.70 

P9037 ...... Plate pheres leukoredu irrad ............................. ......... K 1019 10.0443 617.40 .................. 123.48 

P9038 ...... RBC irradiated ................................................... ......... K 9505 3.2049 197.00 .................. 39.40 

P9039 ...... RBC deglycerolized ........................................... ......... K 9504 5.8292 358.31 .................. 71.66 

P9040 ...... RBC leukoreduced irradiated ............................ ......... K 0969 3.5394 217.56 .................. 43.51 

P9041 ...... Albumin (human),5%, 50ml ............................... ......... K 0961 .................. 29.68 .................. 5.94 

P9043 ...... Plasma protein fract,5%,50ml ............................ ......... K 0956 0.8339 51.26 .................. 10.25 

P9044 ...... Cryoprecipitatereducedplasma .......................... ......... K 1009 1.3404 82.39 .................. 16.48 

P9045 ...... Albumin (human), 5%, 250 ml ........................... ......... K 0963 .................. 76.81 .................. 15.36 

P9046 ...... Albumin (human), 25%, 20 ml ........................... ......... K 0964 .................. 28.80 .................. 5.76

P9047 ...... Albumin (human), 25%, 50ml ............................ ......... K 0965 .................. 65.26 .................. 13.05 

P9048 ...... Plasmaprotein fract,5%,250ml ........................... ......... K 0966 3.8746 238.16 .................. 47.63 

P9050 ...... Granulocytes, pheresis unit ............................... ......... K 9506 12.2073 750.36 .................. 150.07 

P9051 ...... Blood, l/r, cmv-neg ............................................. ......... K 1010 2.5493 156.70 .................. 31.34 

P9052 ...... Platelets, hla-m, l/r, unit ..................................... ......... K 1011 10.9263 671.62 .................. 134.32 

P9053 ...... Plt, pher, l/r cmv-neg, irr .................................... ......... K 1020 11.4755 705.38 .................. 141.08 

P9054 ...... Blood, l/r, froz/degly/wash ................................. ......... K 1016 3.4335 211.05 .................. 42.21 

P9055 ...... Plt, aph/pher, l/r, cmv-neg ................................. ......... K 1017 6.4556 396.81 .................. 79.36 

P9056 ...... Blood, l/r, irradiated ........................................... ......... K 1018 2.3472 144.28 .................. 28.86 

P9057 ...... RBC, frz/deg/wsh, l/r, irrad ................................ ......... K 1021 8.0727 496.21 .................. 99.24 

P9058 ...... RBC, l/r, cmv-neg, irrad ..................................... ......... K 1022 4.2653 262.18 .................. 52.44 

P9059 ...... Plasma, frz between 8–24hour .......................... ......... K 0955 1.2489 76.77 .................. 15.35 

P9060 ...... Fr frz plasma donor retested ............................. ......... K 9503 1.2119 74.49 .................. 14.90 

P9612 ...... Catheterize for urine spec ................................. CH .. A .................. .................. .................. .................. ..................

P9615 ...... Urine specimen collect mult .............................. ......... N .................. .................. .................. .................. ..................

Q0035 ...... Cardiokymography ............................................. ......... X 0100 2.5336 155.74 41.44 31.15 

Q0091 ...... Obtaining screen pap smear ............................. ......... T 0191 0.1468 9.02 2.55 1.80 

Q0092 ...... Set up port xray equipment ............................... ......... N .................. .................. .................. .................. ..................

Q0163 ...... Diphenhydramine HCl 50mg ............................. ......... N .................. .................. .................. .................. ..................

Q0164 ...... Prochlorperazine maleate 5mg .......................... ......... N .................. .................. .................. .................. ..................

Q0166 ...... Granisetron HCl 1 mg oral ................................ ......... K 0765 .................. 41.18 .................. 8.24 

Q0167 ...... Dronabinol 2.5mg oral ....................................... ......... N .................. .................. .................. .................. ..................

Q0169 ...... Promethazine HCl 12.5mg oral ......................... ......... N .................. .................. .................. .................. ..................

Q0171 ...... Chlorpromazine HCl 10mg oral ......................... ......... N .................. .................. .................. .................. ..................

Q0173 ...... Trimethobenzamide HCl 250mg ........................ ......... N .................. .................. .................. .................. ..................

Q0174 ...... Thiethylperazine maleate10mg .......................... ......... N .................. .................. .................. .................. ..................

Q0175 ...... Perphenazine 4mg oral ..................................... ......... N .................. .................. .................. .................. ..................

Q0177 ...... Hydroxyzine pamoate 25mg .............................. ......... N .................. .................. .................. .................. ..................

Q0179 ...... Ondansetron HCl 8mg oral ................................ ......... K 0769 .................. 36.06 .................. 7.21 

Q0180 ...... Dolasetron mesylate oral ................................... ......... K 0763 .................. 48.91 .................. 9.78 

Q0512 ...... Px sup fee anti-can sub pres ............................ CH .. B .................. .................. .................. .................. ..................

Q0515 ...... Sermorelin acetate injection .............................. CH .. K 3050 .................. 1.75 .................. 0.35 

Q1003 ...... NTIOL category 3 .............................................. ......... N .................. .................. .................. .................. ..................

Q1004 ...... Ntiol category 4 .................................................. ......... N .................. .................. .................. .................. ..................

Q1005 ...... Ntiol category 5 .................................................. ......... N .................. .................. .................. .................. ..................

Q2004 ...... Bladder calculi irrig sol ...................................... ......... N .................. .................. .................. .................. ..................

Q2009 ...... Fosphenytoin, 50 mg ......................................... ......... K 7028 .................. 5.59 .................. 1.12 

Q2017 ...... Teniposide, 50 mg ............................................. ......... K 7035 .................. 264.88 .................. 52.98 

Q3025 ...... IM inj interferon beta 1-a ................................... ......... K 9022 .................. 108.04 .................. 21.61 

Q3031 ...... Collagen skin test .............................................. ......... N .................. .................. .................. .................. ..................

Q4079 ...... Natalizumab injection ......................................... ......... G 9126 .................. 7.72 .................. 1.54 

Q4081 ...... Epoetin alfa, 100 units ESRD ............................ NI .... A .................. .................. .................. .................. ..................

Q4082 ...... Drug/bio NOC part B drug CAP ........................ NI .... B .................. .................. .................. .................. ..................

Q5001 ...... Hospice in patient home .................................... NI .... B .................. .................. .................. .................. ..................

Q5002 ...... Hospice in assisted living .................................. NI .... B .................. .................. .................. .................. ..................

Q5003 ...... Hospice in LT/non-skilled NF ............................ NI .... B .................. .................. .................. .................. ..................

Q5004 ...... Hospice in SNF .................................................. NI .... B .................. .................. .................. .................. ..................

Q5005 ...... Hospice, inpatient hospital ................................. NI .... B .................. .................. .................. .................. ..................

Q5006 ...... Hospice in hospice facility ................................. NI .... B .................. .................. .................. .................. ..................

Q5007 ...... Hospice in LTCH ............................................... NI .... B .................. .................. .................. .................. ..................

Q5008 ...... Hospice in inpatient psych ................................. NI .... B .................. .................. .................. .................. ..................

Q5009 ...... Hospice care, NOS ............................................ NI .... B .................. .................. .................. .................. ..................

Q9945 ...... LOCM TM149 mg/ml iodine, 1ml ......................... ......... K 9157 .................. 0.29 .................. 0.06 

Q9946 ...... LOCM 150–199mg/ml iodine,1ml ...................... ......... K 9158 .................. 1.96 .................. 0.39 

Q9947 ...... LOCM 200–249mg/ml iodine,1ml ...................... ......... K 9159 .................. 1.42 .................. 0.28 

Q9948 ...... LOCM 250–299mg/ml iodine,1ml ...................... ......... K 9160 .................. 0.27 .................. 0.05 

Q9949 ...... LOCM 300–349mg/ml iodine,1ml ...................... ......... K 9161 .................. 0.35 .................. 0.07 

Q9950 ...... LOCM 350–399mg/ml iodine,1ml ...................... ......... K 9162 .................. 0.21 .................. 0.04 

Q9951 ...... LOCM  ́ 400 mg/ml iodine,1ml ......................... ......... K 9163 .................. 0.30 .................. 0.06 

Q9952 ...... Inj Gad-base MR contrast,1ml ........................... ......... K 9164 .................. 2.87 .................. 0.57


cprice-sewell on PRODPC62 with RULES2
68384 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

Q9953 ...... Inj Fe-based MR contrast,1ml ........................... ......... K 1713 .................. 30.41 .................. 6.08 

Q9954 ...... Oral MR contrast, 100 ml .................................. ......... K 9165 .................. 8.90 .................. 1.78 

Q9955 ...... Inj perflexane lip micros,ml ................................ ......... K 9203 .................. 7.05 .................. 1.41 

Q9956 ...... Inj octafluoropropane mic,ml ............................. ......... K 9202 .................. 49.61 .................. 9.92 

Q9957 ...... Inj perflutren lip micros,ml ................................. ......... K 9112 .................. 61.64 .................. 12.33 

Q9958 ...... HOCM TM149 mg/ml iodine, 1ml ........................ CH .. N .................. .................. .................. .................. ..................

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

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

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

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

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

Q9964 ...... HOCM ́ 400mg/ml iodine, 1ml ......................... CH .. N .................. .................. .................. .................. ..................

V2630 ...... Anter chamber intraocul lens ............................. ......... N .................. .................. .................. .................. ..................

V2631 ...... Iris support intraoclr lens ................................... ......... N .................. .................. .................. .................. ..................

V2632 ...... Post chmbr intraocular lens ............................... ......... N .................. .................. .................. .................. ..................

V2790 ...... Amniotic membrane ........................................... ......... N .................. .................. .................. .................. ..................

ADDENDUM D1.—PAYMENT STATUS INDICATORS

Indicator Item/code/service OPPS payment status 

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

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

• Ambulance Services 

• Clinical Diagnostic Laboratory Services 

• Non-Implantable Prosthetic and Orthotic Devices 

• 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. 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68385 

ADDENDUM D1.—PAYMENT STATUS INDICATORS—Continued 

Indicator Item/code/service OPPS payment status 

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 Descriptor 

NF ................. New code, final APC assignment; comments were accepted on a proposed APC assignment in the proposed rule; APC assignment is no longer open to comment. 

NI .................. New code, interim APC assignment; comments will be accepted on the interim APC assignment for the new code.

CH ................. Active HCPCS 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 

SI 

00176 ....... Anesth, pharyngeal surgery.C 

00192 ....... Anesth, facial bone surgery.C 

00214 ....... Anesth, skull drainage ... C 

00215 ....... Anesth, skull repair/fract C 

00452 ....... Anesth, surgery of 

shoulder.

C 

00474 ....... Anesth, surgery of rib(s) C 

00524 ....... Anesth, chest drainage C 

00540 ....... Anesth, chest surgery ... C 

00542 ....... Anesth, release of lung C 

00546 ....... Anesth, lung,chest wall 

surg.

C 

00560 ....... Anesth, heart surg w/o 

pump.

C 

00561 ....... Anesth, heart surg <age 

1.

C 

00562 ....... Anesth, heart surg w/ 

pump.

C 

00580 ....... Anesth, heart/lung 

transplnt.

C 

00604 ....... Anesth, sitting procedure C 

00622 ....... Anesth, removal of 

nerves.

C 

00632 ....... Anesth, removal of 

nerves.

C 

00670 ....... Anesth, spine, cord surgery.C 

00792 ....... Anesth, hemorr/excise 

liver.

C 

00794 ....... Anesth, pancreas removal.C 

00796 ....... Anesth, for liver transplant.C 

00802 ....... Anesth, fat layer removal.C 

00844 ....... Anesth, pelvis surgery ... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

00846 ....... Anesth, hysterectomy .... C 

00848 ....... Anesth, pelvic organ 

surg.

C 

00864 ....... Anesth, removal of bladder.C 

00865 ....... Anesth, removal of prostate.C 

00866 ....... Anesth, removal of adrenal.C 

00868 ....... Anesth, kidney transplant.C 

00882 ....... Anesth, major vein ligation.C 

00904 ....... Anesth, perineal surgery C 

00908 ....... Anesth, removal of prostate.C 

00932 ....... Anesth, amputation of 

penis.

C 

00934 ....... Anesth, penis, nodes removal.C 

00936 ....... Anesth, penis, nodes removal.C 

00944 ....... Anesth, vaginal 

hysterectomy.

C 

01140 ....... Anesth, amputation at 

pelvis.

C 

01150 ....... Anesth, pelvic tumor 

surgery.

C 

01212 ....... Anesth, hip 

disarticulation.

C 

01214 ....... Anesth, hip arthroplasty C 

01232 ....... Anesth, amputation of 

femur.

C 

01234 ....... Anesth, radical femur 

surg.

C 

01272 ....... Anesth, femoral artery 

surg.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

01274 ....... Anesth, femoral 

embolectomy.

C 

01402 ....... Anesth, knee 

arthroplasty.

C 

01404 ....... Anesth, amputation at 

knee.

C 

01442 ....... Anesth, knee artery surg C 

01444 ....... Anesth, knee artery repair.C 

01486 ....... Anesth, ankle replacement.C 

01502 ....... Anesth, lwr leg 

embolectomy.

C 

01632 ....... Anesth, surgery of 

shoulder.

C 

01634 ....... Anesth, shoulder joint 

amput.

C 

01636 ....... Anesth, forequarter 

amput.

C 

01638 ....... Anesth, shoulder replacement.C 

01652 ....... Anesth, shoulder vessel 

surg.

C 

01654 ....... Anesth, shoulder vessel 

surg.

C 

01656 ....... Anesth, arm-leg vessel 

surg.

C 

01756 ....... Anesth, radical humerus 

surg.

C 

01990 ....... Support for organ donor C 

11004 ....... Debride genitalia & perineum.C 

11005 ....... Debride abdom wall ...... C 

11006 ....... Debride genit/per/abdom 

wall.

C 

11008 ....... Remove mesh from abd 

wall.

C 


cprice-sewell on PRODPC62 with RULES2
68386 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

15756 ....... Free myo/skin flap 

microvasc.

C 

15757 ....... Free skin flap, 

microvasc.

C 

15758 ....... Free fascial flap, 

microvasc.

C 

16036 ....... Escharotomy; add′l incision.C 

19271 ....... Revision of chest wall ... C 

19272 ....... Extensive chest wall surgery.C 

19305 ....... Mast, radical .................. C 

19306 ....... Mast, rad, urban type .... C 

19361 ....... Breast reconstr w/lat flap C 

19364 ....... Breast reconstruction .... C 

19367 ....... Breast reconstruction .... C 

19368 ....... Breast reconstruction .... C 

19369 ....... Breast reconstruction .... C 

20660 ....... Apply, rem fixation device.C 

20661 ....... Application of head 

brace.

C 

20664 ....... Halo brace application ... C 

20802 ....... Replantation, arm, complete.C 

20805 ....... Replant forearm, complete.C 

20808 ....... Replantation hand, complete.C 

20816 ....... Replantation digit, complete.C 

20824 ....... Replantation thumb, 

complete.

C 

20827 ....... Replantation thumb, 

complete.

C 

20838 ....... Replantation foot, complete.C 

20930 ....... Spinal bone allograft ..... C 

20931 ....... Spinal bone allograft ..... C 

20936 ....... Spinal bone autograft .... C 

20937 ....... Spinal bone autograft .... C 

20938 ....... Spinal bone autograft .... C 

20955 ....... Fibula bone graft, 

microvasc.

C 

20956 ....... Iliac bone graft, 

microvasc.

C 

20957 ....... Mt bone graft, microvasc C 

20962 ....... Other bone graft, 

microvasc.

C 

20969 ....... Bone/skin graft, 

microvasc.

C 

20970 ....... Bone/skin graft, iliac 

crest.

C 

21045 ....... Extensive jaw surgery ... C 

21141 ....... Reconstruct midface, 

lefort.

C 

21142 ....... Reconstruct midface, 

lefort.

C 

21143 ....... Reconstruct midface, 

lefort.

C 

21145 ....... Reconstruct midface, 

lefort.

C 

21146 ....... Reconstruct midface, 

lefort.

C 

21147 ....... Reconstruct midface, 

lefort.

C 

21151 ....... Reconstruct midface, 

lefort.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

21154 ....... Reconstruct midface, 

lefort.

C 

21155 ....... Reconstruct midface, 

lefort.

C 

21159 ....... Reconstruct midface, 

lefort.

C 

21160 ....... Reconstruct midface, 

lefort.

C 

21172 ....... Reconstruct orbit/forehead.C 

21179 ....... Reconstruct entire forehead.C 

21180 ....... Reconstruct entire forehead.C 

21182 ....... Reconstruct cranial bone C 

21183 ....... Reconstruct cranial bone C 

21184 ....... Reconstruct cranial bone C 

21188 ....... Reconstruction of 

midface.

C 

21193 ....... Reconst lwr jaw w/o 

graft.

C 

21194 ....... Reconst lwr jaw w/graft C 

21196 ....... Reconst lwr jaw w/fixation.C 

21247 ....... Reconstruct lower jaw 

bone.

C 

21255 ....... Reconstruct lower jaw 

bone.

C 

21256 ....... Reconstruction of orbit .. C 

21268 ....... Revise eye sockets ....... C 

21343 ....... Treatment of sinus fracture.C 

21344 ....... Treatment of sinus fracture.C 

21346 ....... Treat nose/jaw fracture C 

21347 ....... Treat nose/jaw fracture C 

21348 ....... Treat nose/jaw fracture C 

21360 ....... Treat cheek bone fracture.C 

21365 ....... Treat cheek bone fracture.C 

21366 ....... Treat cheek bone fracture.C 

21385 ....... Treat eye socket fracture.C 

21386 ....... Treat eye socket fracture.C 

21387 ....... Treat eye socket fracture.C 

21395 ....... Treat eye socket fracture.C 

21422 ....... Treat mouth roof fracture.C 

21423 ....... Treat mouth roof fracture.C 

21431 ....... Treat craniofacial fracture.C 

21432 ....... Treat craniofacial fracture.C 

21433 ....... Treat craniofacial fracture.C 

21435 ....... Treat craniofacial fracture.C 

21436 ....... Treat craniofacial fracture.C 

21510 ....... Drainage of bone lesion C 

21615 ....... Removal of rib ............... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

21616 ....... Removal of rib and 

nerves.

C 

21620 ....... Partial removal of sternum.C 

21627 ....... Sternal debridement ...... C 

21630 ....... Extensive sternum surgery.C 

21632 ....... Extensive sternum surgery.C 

21705 ....... Revision of neck muscle/rib.C 

21740 ....... Reconstruction of sternum.C 

21750 ....... Repair of sternum separation.C 

21810 ....... Treatment of rib fracture(s).C 

21825 ....... Treat sternum fracture ... C 

22010 ....... I&d, p-spine, c/t/cervthor.C 

22015 ....... I&d, p-spine, l/s/ls .......... C 

22110 ....... Remove part of neck 

vertebra.

C 

22112 ....... Remove part, thorax 

vertebra.

C 

22114 ....... Remove part, lumbar 

vertebra.

C 

22116 ....... Remove extra spine 

segment.

C 

22210 ....... Revision of neck spine .. C 

22212 ....... Revision of thorax spine C 

22214 ....... Revision of lumbar spine C 

22216 ....... Revise, extra spine segment.C 

22220 ....... Revision of neck spine .. C 

22224 ....... Revision of lumbar spine C 

22226 ....... Revise, extra spine segment.C 

22318 ....... Treat odontoid fx w/o 

graft.

C 

22319 ....... Treat odontoid fx w/graft C 

22325 ....... Treat spine fracture ....... C 

22326 ....... Treat neck spine fracture.C 

22327 ....... Treat thorax spine fracture.C 

22328 ....... Treat each add spine fx C 

22532 ....... Lat thorax spine fusion .. C 

22533 ....... Lat lumbar spine fusion C 

22534 ....... Lat thor/lumb, add’l seg C 

22548 ....... Neck spine fusion .......... C 

22554 ....... Neck spine fusion .......... C 

22556 ....... Thorax spine fusion ....... C 

22558 ....... Lumbar spine fusion ...... C 

22585 ....... Additional spinal fusion C 

22590 ....... Spine & skull spinal fusion.C 

22595 ....... Neck spinal fusion ......... C 

22600 ....... Neck spine fusion .......... C 

22610 ....... Thorax spine fusion ....... C 

22630 ....... Lumbar spine fusion ...... C 

22632 ....... Spine fusion, extra segment.C 

22800 ....... Fusion of spine .............. C 

22802 ....... Fusion of spine .............. C 

22804 ....... Fusion of spine .............. C 

22808 ....... Fusion of spine .............. C 

22810 ....... Fusion of spine .............. C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68387 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

22812 ....... Fusion of spine .............. C 

22818 ....... Kyphectomy, 1-2 segments.C 

22819 ....... Kyphectomy, 3 or more C 

22830 ....... Exploration of spinal fusion.C 

22840 ....... Insert spine fixation device.C 

22841 ....... Insert spine fixation device.C 

22842 ....... Insert spine fixation device.C 

22843 ....... Insert spine fixation device.C 

22844 ....... Insert spine fixation device.C 

22845 ....... Insert spine fixation device.C 

22846 ....... Insert spine fixation device.C 

22847 ....... Insert spine fixation device.C 

22848 ....... Insert pelv fixation device.C 

22849 ....... Reinsert spinal fixation .. C 

22850 ....... Remove spine fixation 

device.

C 

22852 ....... Remove spine fixation 

device.

C 

22855 ....... Remove spine fixation 

device.

C 

22857 ....... Lumbar artif diskectomy C 

22862 ....... Revise lumbar artif disc C 

22865 ....... Remove lumb artif disc C 

23200 ....... Removal of collar bone C 

23210 ....... Removal of shoulder 

blade.

C 

23220 ....... Partial removal of humerus.C 

23221 ....... Partial removal of humerus.C 

23222 ....... Partial removal of humerus.C 

23332 ....... Remove shoulder foreign body.C 

23472 ....... Reconstruct shoulder 

joint.

C 

23900 ....... Amputation of arm & girdle.C 

23920 ....... Amputation at shoulder 

joint.

C 

24900 ....... Amputation of upper arm C 

24920 ....... Amputation of upper arm C 

24930 ....... Amputation follow-up 

surgery.

C 

24931 ....... Amputate upper arm & 

implant.

C 

24940 ....... Revision of upper arm ... C 

25900 ....... Amputation of forearm ... C 

25905 ....... Amputation of forearm ... C 

25909 ....... Amputation follow-up 

surgery.

C 

25915 ....... Amputation of forearm ... C 

25920 ....... Amputate hand at wrist C 

25924 ....... Amputation follow-up 

surgery.

C 

25927 ....... Amputation of hand ....... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

25931 ....... Amputation follow-up 

surgery.

C 

26551 ....... Great toe-hand transfer C 

26553 ....... Single transfer, toe-hand C 

26554 ....... Double transfer, toehand.C 

26556 ....... Toe joint transfer ........... C 

26992 ....... Drainage of bone lesion C 

27005 ....... Incision of hip tendon .... C 

27006 ....... Incision of hip tendons .. C 

27025 ....... Incision of hip/thigh fascia.C 

27030 ....... Drainage of hip joint ...... C 

27036 ....... Excision of hip joint/ 

muscle.

C 

27054 ....... Removal of hip joint lining.C 

27070 ....... Partial removal of hip 

bone.

C 

27071 ....... Partial removal of hip 

bone.

C 

27075 ....... Extensive hip surgery .... C 

27076 ....... Extensive hip surgery .... C 

27077 ....... Extensive hip surgery .... C 

27078 ....... Extensive hip surgery .... C 

27079 ....... Extensive hip surgery .... C 

27090 ....... Removal of hip prosthesis.C 

27091 ....... Removal of hip prosthesis.C 

27120 ....... Reconstruction of hip 

socket.

C 

27122 ....... Reconstruction of hip 

socket.

C 

27125 ....... Partial hip replacement C 

27130 ....... Total hip arthroplasty ..... C 

27132 ....... Total hip arthroplasty ..... C 

27134 ....... Revise hip joint replacement.C 

27137 ....... Revise hip joint replacement.C 

27138 ....... Revise hip joint replacement.C 

27140 ....... Transplant femur ridge .. C 

27146 ....... Incision of hip bone ....... C 

27147 ....... Revision of hip bone ..... C 

27151 ....... Incision of hip bones ..... C 

27156 ....... Revision of hip bones .... C 

27158 ....... Revision of pelvis .......... C 

27161 ....... Incision of neck of femur C 

27165 ....... Incision/fixation of femur C 

27170 ....... Repair/graft femur head/ 

neck.

C 

27175 ....... Treat slipped epiphysis C 

27176 ....... Treat slipped epiphysis C 

27177 ....... Treat slipped epiphysis C 

27178 ....... Treat slipped epiphysis C 

27179 ....... Revise head/neck of 

femur.

C 

27181 ....... Treat slipped epiphysis C 

27185 ....... Revision of femur epiphysis.C 

27187 ....... Reinforce hip bones ...... C 

27215 ....... Treat pelvic fracture(s) .. C 

27217 ....... Treat pelvic ring fracture C 

27218 ....... Treat pelvic ring fracture C 

27222 ....... Treat hip socket fracture C 

27226 ....... Treat hip wall fracture ... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

27227 ....... Treat hip fracture(s) ....... C 

27228 ....... Treat hip fracture(s) ....... C 

27232 ....... Treat thigh fracture ........ C 

27236 ....... Treat thigh fracture ........ C 

27240 ....... Treat thigh fracture ........ C 

27244 ....... Treat thigh fracture ........ C 

27245 ....... Treat thigh fracture ........ C 

27248 ....... Treat thigh fracture ........ C 

27253 ....... Treat hip dislocation ...... C 

27254 ....... Treat hip dislocation ...... C 

27258 ....... Treat hip dislocation ...... C 

27259 ....... Treat hip dislocation ...... C 

27280 ....... Fusion of sacroiliac joint C 

27282 ....... Fusion of pubic bones ... C 

27284 ....... Fusion of hip joint .......... C 

27286 ....... Fusion of hip joint .......... C 

27290 ....... Amputation of leg at hip C 

27295 ....... Amputation of leg at hip C 

27303 ....... Drainage of bone lesion C 

27365 ....... Extensive leg surgery .... C 

27445 ....... Revision of knee joint .... C 

27447 ....... Total knee arthroplasty .. C 

27448 ....... Incision of thigh ............. C 

27450 ....... Incision of thigh ............. C 

27454 ....... Realignment of thigh 

bone.

C 

27455 ....... Realignment of knee ..... C 

27457 ....... Realignment of knee ..... C 

27465 ....... Shortening of thigh bone C 

27466 ....... Lengthening of thigh 

bone.

C 

27468 ....... Shorten/lengthen thighs C 

27470 ....... Repair of thigh ............... C 

27472 ....... Repair/graft of thigh ....... C 

27477 ....... Surgery to stop leg 

growth.

C 

27479 ....... Surgery to stop leg 

growth.

C 

27485 ....... Surgery to stop leg 

growth.

C 

27486 ....... Revise/replace knee 

joint.

C 

27487 ....... Revise/replace knee 

joint.

C 

27488 ....... Removal of knee prosthesis.C 

27495 ....... Reinforce thigh .............. C 

27506 ....... Treatment of thigh fracture.C 

27507 ....... Treatment of thigh fracture.C 

27511 ....... Treatment of thigh fracture.C 

27513 ....... Treatment of thigh fracture.C 

27514 ....... Treatment of thigh fracture.C 

27519 ....... Treat thigh fx growth 

plate.

C 

27535 ....... Treat knee fracture ........ C 

27536 ....... Treat knee fracture ........ C 

27540 ....... Treat knee fracture ........ C 

27556 ....... Treat knee dislocation ... C 

27557 ....... Treat knee dislocation ... C 

27558 ....... Treat knee dislocation ... C 

27580 ....... Fusion of knee ............... C 

27590 ....... Amputate leg at thigh .... C 

27591 ....... Amputate leg at thigh .... C 


cprice-sewell on PRODPC62 with RULES2
68388 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

27592 ....... Amputate leg at thigh .... C 

27596 ....... Amputation follow-up 

surgery.

C 

27598 ....... Amputate lower leg at 

knee.

C 

27645 ....... Extensive lower leg surgery.C 

27646 ....... Extensive lower leg surgery.C 

27702 ....... Reconstruct ankle joint .. C 

27703 ....... Reconstruction, ankle 

joint.

C 

27712 ....... Realignment of lower leg C 

27715 ....... Revision of lower leg ..... C 

27720 ....... Repair of tibia ................ C 

27722 ....... Repair/graft of tibia ........ C 

27724 ....... Repair/graft of tibia ........ C 

27725 ....... Repair of lower leg ........ C 

27727 ....... Repair of lower leg ........ C 

27880 ....... Amputation of lower leg C 

27881 ....... Amputation of lower leg C 

27882 ....... Amputation of lower leg C 

27886 ....... Amputation follow-up 

surgery.

C 

27888 ....... Amputation of foot at 

ankle.

C 

28800 ....... Amputation of midfoot ... C 

28805 ....... Amputation thru metatarsal.C 

31225 ....... Removal of upper jaw ... C 

31230 ....... Removal of upper jaw ... C 

31290 ....... Nasal/sinus endoscopy, 

surg.

C 

31291 ....... Nasal/sinus endoscopy, 

surg.

C 

31360 ....... Removal of larynx ......... C 

31365 ....... Removal of larynx ......... C 

31367 ....... Partial removal of larynx C 

31368 ....... Partial removal of larynx C 

31370 ....... Partial removal of larynx C 

31375 ....... Partial removal of larynx C 

31380 ....... Partial removal of larynx C 

31382 ....... Partial removal of larynx C 

31390 ....... Removal of larynx & 

pharynx.

C 

31395 ....... Reconstruct larynx & 

pharynx.

C 

31584 ....... Treat larynx fracture ...... C 

31587 ....... Revision of larynx .......... C 

31725 ....... Clearance of airways ..... C 

31760 ....... Repair of windpipe ........ C 

31766 ....... Reconstruction of windpipe.C 

31770 ....... Repair/graft of bronchus C 

31775 ....... Reconstruct bronchus ... C 

31780 ....... Reconstruct windpipe .... C 

31781 ....... Reconstruct windpipe .... C 

31786 ....... Remove windpipe lesion C 

31800 ....... Repair of windpipe injury C 

31805 ....... Repair of windpipe injury C 

32035 ....... Exploration of chest ....... C 

32036 ....... Exploration of chest ....... C 

32095 ....... Biopsy through chest 

wall.

C 

32100 ....... Exploration/biopsy of 

chest.

C 

32110 ....... Explore/repair chest ...... C 

32120 ....... Re-exploration of chest C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

32124 ....... Explore chest free adhesions.C 

32140 ....... Removal of lung lesion(s).C 

32141 ....... Remove/treat lung lesions.C 

32150 ....... Removal of lung lesion(s).C 

32151 ....... Remove lung foreign 

body.

C 

32160 ....... Open chest heart massage.C 

32200 ....... Drain, open, lung lesion C 

32215 ....... Treat chest lining ........... C 

32220 ....... Release of lung ............. C 

32225 ....... Partial release of lung ... C 

32310 ....... Removal of chest lining C 

32320 ....... Free/remove chest lining C 

32402 ....... Open biopsy chest lining C 

32440 ....... Removal of lung ............ C 

32442 ....... Sleeve pneumonectomy C 

32445 ....... Removal of lung ............ C 

32480 ....... Partial removal of lung .. C 

32482 ....... Bilobectomy ................... C 

32484 ....... Segmentectomy ............. C 

32486 ....... Sleeve lobectomy .......... C 

32488 ....... Completion pneumonectomy.C 

32491 ....... Lung volume reduction .. C 

32500 ....... Partial removal of lung .. C 

32501 ....... Repair bronchus add-on C 

32503 ....... Resect apical lung tumor C 

32504 ....... Resect apical lung tum/ 

chest.

C 

32540 ....... Removal of lung lesion .. C 

32650 ....... Thoracoscopy, surgical C 

32651 ....... Thoracoscopy, surgical C 

32652 ....... Thoracoscopy, surgical C 

32653 ....... Thoracoscopy, surgical C 

32654 ....... Thoracoscopy, surgical C 

32655 ....... Thoracoscopy, surgical C 

32656 ....... Thoracoscopy, surgical C 

32657 ....... Thoracoscopy, surgical C 

32658 ....... Thoracoscopy, surgical C 

32659 ....... Thoracoscopy, surgical C 

32660 ....... Thoracoscopy, surgical C 

32661 ....... Thoracoscopy, surgical C 

32662 ....... Thoracoscopy, surgical C 

32663 ....... Thoracoscopy, surgical C 

32664 ....... Thoracoscopy, surgical C 

32665 ....... Thoracoscopy, surgical C 

32800 ....... Repair lung hernia ......... C 

32810 ....... Close chest after drainage.C 

32815 ....... Close bronchial fistula ... C 

32820 ....... Reconstruct injured 

chest.

C 

32850 ....... Donor pneumonectomy C 

32851 ....... Lung transplant, single .. C 

32852 ....... Lung transplant with bypass.C 

32853 ....... Lung transplant, double C 

32854 ....... Lung transplant with bypass.C 

32855 ....... Prepare donor lung, single.C 

32856 ....... Prepare donor lung, 

double.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

32900 ....... Removal of rib(s) ........... C 

32905 ....... Revise & repair chest 

wall.

C 

32906 ....... Revise & repair chest 

wall.

C 

32940 ....... Revision of lung ............. C 

32997 ....... Total lung lavage ........... C 

33015 ....... Incision of heart sac ...... C 

33020 ....... Incision of heart sac ...... C 

33025 ....... Incision of heart sac ...... C 

33030 ....... Partial removal of heart 

sac.

C 

33031 ....... Partial removal of heart 

sac.

C 

33050 ....... Removal of heart sac lesion.C 

33120 ....... Removal of heart lesion C 

33130 ....... Removal of heart lesion C 

33140 ....... Heart revascularize (tmr) C 

33141 ....... Heart tmr w/other procedure.C 

33202 ....... Insert epicard eltrd, 

open.

C 

33203 ....... Insert epicard eltrd, 

endo.

C 

33236 ....... Remove electrode/ 

thoracotomy.

C 

33237 ....... Remove electrode/ 

thoracotomy.

C 

33238 ....... Remove electrode/ 

thoracotomy.

C 

33243 ....... Remove eltrd/ 

thoracotomy.

C 

33250 ....... Ablate heart dysrhythm 

focus.

C 

33251 ....... Ablate heart dysrhythm 

focus.

C 

33254 ....... Ablate atria, lmtd ........... C 

33255 ....... Ablate atria w/o bypass, 

ext.

C 

33256 ....... Ablate atria w/bypass, 

exten.

C 

33261 ....... Ablate heart dysrhythm 

focus.

C 

33265 ....... Ablate atria w/bypass, 

endo.

C 

33266 ....... Ablate atria w/o bypass 

endo.

C 

33300 ....... Repair of heart wound ... C 

33305 ....... Repair of heart wound ... C 

33310 ....... Exploratory heart surgery.C 

33315 ....... Exploratory heart surgery.C 

33320 ....... Repair major blood vessel(s).C 

33321 ....... Repair major vessel ...... C 

33322 ....... Repair major blood vessel(s).C 

33330 ....... Insert major vessel graft C 

33332 ....... Insert major vessel graft C 

33335 ....... Insert major vessel graft C 

33400 ....... Repair of aortic valve .... C 

33401 ....... Valvuloplasty, open ....... C 

33403 ....... Valvuloplasty, w/cp bypass.C 

33404 ....... Prepare heart-aorta conduit.C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68389 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

33405 ....... Replacement of aortic 

valve.

C 

33406 ....... Replacement of aortic 

valve.

C 

33410 ....... Replacement of aortic 

valve.

C 

33411 ....... Replacement of aortic 

valve.

C 

33412 ....... Replacement of aortic 

valve.

C 

33413 ....... Replacement of aortic 

valve.

C 

33414 ....... Repair of aortic valve .... C 

33415 ....... Revision, subvalvular tissue.C 

33416 ....... Revise ventricle muscle C 

33417 ....... Repair of aortic valve .... C 

33420 ....... Revision of mitral valve C 

33422 ....... Revision of mitral valve C 

33425 ....... Repair of mitral valve .... C 

33426 ....... Repair of mitral valve .... C 

33427 ....... Repair of mitral valve .... C 

33430 ....... Replacement of mitral 

valve.

C 

33460 ....... Revision of tricuspid 

valve.

C 

33463 ....... Valvuloplasty, tricuspid .. C 

33464 ....... Valvuloplasty, tricuspid .. C 

33465 ....... Replace tricuspid valve C 

33468 ....... Revision of tricuspid 

valve.

C 

33470 ....... Revision of pulmonary 

valve.

C 

33471 ....... Valvotomy, pulmonary 

valve.

C 

33472 ....... Revision of pulmonary 

valve.

C 

33474 ....... Revision of pulmonary 

valve.

C 

33475 ....... Replacement, pulmonary 

valve.

C 

33476 ....... Revision of heart chamber.C 

33478 ....... Revision of heart chamber.C 

33496 ....... Repair, prosth valve clot C 

33500 ....... Repair heart vessel fistula.C 

33501 ....... Repair heart vessel fistula.C 

33502 ....... Coronary artery correction.C 

33503 ....... Coronary artery graft ..... C 

33504 ....... Coronary artery graft ..... C 

33505 ....... Repair artery w/tunnel ... C 

33506 ....... Repair artery, 

translocation.

C 

33507 ....... Repair art, intramural .... C 

33510 ....... CABG, vein, single ........ C 

33511 ....... CABG, vein, two ............ C 

33512 ....... CABG, vein, three ......... C 

33513 ....... CABG, vein, four ........... C 

33514 ....... CABG, vein, five ............ C 

33516 ....... Cabg, vein, six or more C 

33517 ....... CABG, artery-vein, single.C 

33518 ....... CABG, artery-vein, two C 

33519 ....... CABG, artery-vein, three C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

33521 ....... CABG, artery-vein, four C 

33522 ....... CABG, artery-vein, five C 

33523 ....... Cabg, art-vein, six or 

more.

C 

33530 ....... Coronary artery, bypass/ 

reop.

C 

33533 ....... CABG, arterial, single .... C 

33534 ....... CABG, arterial, two ....... C 

33535 ....... CABG, arterial, three ..... C 

33536 ....... Cabg, arterial, four or 

more.

C 

33542 ....... Removal of heart lesion C 

33545 ....... Repair of heart damage C 

33548 ....... Restore/remodel, ventricle.C 

33572 ....... Open coronary 

endarterectomy.

C 

33600 ....... Closure of valve ............ C 

33602 ....... Closure of valve ............ C 

33606 ....... Anastomosis/artery-aorta C 

33608 ....... Repair anomaly w/conduit.C 

33610 ....... Repair by enlargement .. C 

33611 ....... Repair double ventricle C 

33612 ....... Repair double ventricle C 

33615 ....... Repair, modified fontan C 

33617 ....... Repair single ventricle ... C 

33619 ....... Repair single ventricle ... C 

33641 ....... Repair heart septum defect.C 

33645 ....... Revision of heart veins .. C 

33647 ....... Repair heart septum defects.C 

33660 ....... Repair of heart defects .. C 

33665 ....... Repair of heart defects .. C 

33670 ....... Repair of heart chambers.C 

33675 ....... Close mult vsd ............... C 

33676 ....... Close mult vsd w/resection.C 

33677 ....... Cl mult vsd w/rem pul 

band.

C 

33681 ....... Repair heart septum defect.C 

33684 ....... Repair heart septum defect.C 

33688 ....... Repair heart septum defect.C 

33690 ....... Reinforce pulmonary artery.C 

33692 ....... Repair of heart defects .. C 

33694 ....... Repair of heart defects .. C 

33697 ....... Repair of heart defects .. C 

33702 ....... Repair of heart defects .. C 

33710 ....... Repair of heart defects .. C 

33720 ....... Repair of heart defect ... C 

33722 ....... Repair of heart defect ... C 

33724 ....... Repair venous anomaly C 

33726 ....... Repair pul venous stenosis.C 

33730 ....... Repair heart-vein defect(s).C 

33732 ....... Repair heart-vein defect C 

33735 ....... Revision of heart chamber.C 

33736 ....... Revision of heart chamber.C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

33737 ....... Revision of heart chamber.C 

33750 ....... Major vessel shunt ........ C 

33755 ....... Major vessel shunt ........ C 

33762 ....... Major vessel shunt ........ C 

33764 ....... Major vessel shunt & 

graft.

C 

33766 ....... Major vessel shunt ........ C 

33767 ....... Major vessel shunt ........ C 

33768 ....... Cavopulmonary shunting C 

33770 ....... Repair great vessels defect.C 

33771 ....... Repair great vessels defect.C 

33774 ....... Repair great vessels defect.C 

33775 ....... Repair great vessels defect.C 

33776 ....... Repair great vessels defect.C 

33777 ....... Repair great vessels defect.C 

33778 ....... Repair great vessels defect.C 

33779 ....... Repair great vessels defect.C 

33780 ....... Repair great vessels defect.C 

33781 ....... Repair great vessels defect.C 

33786 ....... Repair arterial trunk ....... C 

33788 ....... Revision of pulmonary 

artery.

C 

33800 ....... Aortic suspension .......... C 

33802 ....... Repair vessel defect ...... C 

33803 ....... Repair vessel defect ...... C 

33813 ....... Repair septal defect ...... C 

33814 ....... Repair septal defect ...... C 

33820 ....... Revise major vessel ...... C 

33822 ....... Revise major vessel ...... C 

33824 ....... Revise major vessel ...... C 

33840 ....... Remove aorta constriction.C 

33845 ....... Remove aorta constriction.C 

33851 ....... Remove aorta constriction.C 

33852 ....... Repair septal defect ...... C 

33853 ....... Repair septal defect ...... C 

33860 ....... Ascending aortic graft ... C 

33861 ....... Ascending aortic graft ... C 

33863 ....... Ascending aortic graft ... C 

33870 ....... Transverse aortic arch 

graft.

C 

33875 ....... Thoracic aortic graft ...... C 

33877 ....... Thoracoabdominal graft C 

33880 ....... Endovasc taa repr incl 

subcl.

C 

33881 ....... Endovasc taa repr w/o 

subcl.

C 

33883 ....... Insert endovasc prosth, 

taa.

C 

33884 ....... Endovasc prosth, taa, 

add-on.

C 

33886 ....... Endovasc prosth, delayed.C 

33889 ....... Artery transpose/ 

endovas taa.

C 


cprice-sewell on PRODPC62 with RULES2
68390 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

33891 ....... Car-car bp grft/endovas 

taa.

C 

33910 ....... Remove lung artery 

emboli.

C 

33915 ....... Remove lung artery 

emboli.

C 

33916 ....... Surgery of great vessel C 

33917 ....... Repair pulmonary artery C 

33920 ....... Repair pulmonary atresia.C 

33922 ....... Transect pulmonary artery.C 

33924 ....... Remove pulmonary 

shunt.

C 

33925 ....... Rpr pul art unifocal w/o 

cpb.

C 

33926 ....... Repr pul art, unifocal w/ 

cpb.

C 

33930 ....... Removal of donor heart/ 

lung.

C 

33933 ....... Prepare donor heart/ 

lung.

C 

33935 ....... Transplantation, heart/ 

lung.

C 

33940 ....... Removal of donor heart C 

33944 ....... Prepare donor heart ...... C 

33945 ....... Transplantation of heart C 

33960 ....... External circulation assist.C 

33961 ....... External circulation assist.C 

33967 ....... Insert ia percut device ... C 

33968 ....... Remove aortic assist device.C 

33970 ....... Aortic circulation assist .. C 

33971 ....... Aortic circulation assist .. C 

33973 ....... Insert balloon device ..... C 

33974 ....... Remove intra-aortic balloon.C 

33975 ....... Implant ventricular device.C 

33976 ....... Implant ventricular device.C 

33977 ....... Remove ventricular device.C 

33978 ....... Remove ventricular device.C 

33979 ....... Insert intracorporeal device.C 

33980 ....... Remove intracorporeal 

device.

C 

34001 ....... Removal of artery clot ... C 

34051 ....... Removal of artery clot ... C 

34151 ....... Removal of artery clot ... C 

34401 ....... Removal of vein clot ...... C 

34451 ....... Removal of vein clot ...... C 

34502 ....... Reconstruct vena cava .. C 

34800 ....... Endovas aaa repr w/sm 

tube.

C 

34802 ....... Endovas aaa repr w/2-p 

part.

C 

34803 ....... Endovas aaa repr w/3-p 

part.

C 

34804 ....... Endovas aaa repr w/1-p 

part.

C 

34805 ....... Endovas aaa repr w/ 

long tube.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

34808 ....... Endovas iliac a device 

addon.

C 

34812 ....... Xpose for endoprosth, 

femorl.

C 

34813 ....... Femoral endovas graft 

add-on.

C 

34820 ....... Xpose for endoprosth, 

iliac.

C 

34825 ....... Endovasc extend prosth, 

init.

C 

34826 ....... Endovasc exten prosth, 

add?l.

C 

34830 ....... Open aortic tube prosth 

repr.

C 

34831 ....... Open aortoiliac prosth 

repr.

C 

34832 ....... Open aortofemor prosth 

repr.

C 

34833 ....... Xpose for endoprosth, 

iliac.

C 

34834 ....... Xpose, endoprosth, 

brachial.

C 

34900 ....... Endovasc iliac repr w/ 

graft.

C 

35001 ....... Repair defect of artery .. C 

35002 ....... Repair artery rupture, 

neck.

C 

35005 ....... Repair defect of artery .. C 

35013 ....... Repair artery rupture, 

arm.

C 

35021 ....... Repair defect of artery .. C 

35022 ....... Repair artery rupture, 

chest.

C 

35045 ....... Repair defect of arm artery.C 

35081 ....... Repair defect of artery .. C 

35082 ....... Repair artery rupture, 

aorta.

C 

35091 ....... Repair defect of artery .. C 

35092 ....... Repair artery rupture, 

aorta.

C 

35102 ....... Repair defect of artery .. C 

35103 ....... Repair artery rupture, 

groin.

C 

35111 ....... Repair defect of artery .. C 

35112 ....... Repair artery rupture,spleen.C 

35121 ....... Repair defect of artery .. C 

35122 ....... Repair artery rupture, 

belly.

C 

35131 ....... Repair defect of artery .. C 

35132 ....... Repair artery rupture, 

groin.

C 

35141 ....... Repair defect of artery .. C 

35142 ....... Repair artery rupture, 

thigh.

C 

35151 ....... Repair defect of artery .. C 

35152 ....... Repair artery rupture, 

knee.

C 

35182 ....... Repair blood vessel lesion.C 

35189 ....... Repair blood vessel lesion.C 

35211 ....... Repair blood vessel lesion.C 

35216 ....... Repair blood vessel lesion.C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

35221 ....... Repair blood vessel lesion.C 

35241 ....... Repair blood vessel lesion.C 

35246 ....... Repair blood vessel lesion.C 

35251 ....... Repair blood vessel lesion.C 

35271 ....... Repair blood vessel lesion.C 

35276 ....... Repair blood vessel lesion.C 

35281 ....... Repair blood vessel lesion.C 

35301 ....... Rechanneling of artery .. C 

35302 ....... Rechanneling of artery .. C 

35303 ....... Rechanneling of artery .. C 

35304 ....... Rechanneling of artery .. C 

35305 ....... Rechanneling of artery .. C 

35306 ....... Rechanneling of artery .. C 

35311 ....... Rechanneling of artery .. C 

35331 ....... Rechanneling of artery .. C 

35341 ....... Rechanneling of artery .. C 

35351 ....... Rechanneling of artery .. C 

35355 ....... Rechanneling of artery .. C 

35361 ....... Rechanneling of artery .. C 

35363 ....... Rechanneling of artery .. C 

35371 ....... Rechanneling of artery .. C 

35372 ....... Rechanneling of artery .. C 

35390 ....... Reoperation, carotid 

add-on.

C 

35400 ....... Angioscopy .................... C 

35450 ....... Repair arterial blockage C 

35452 ....... Repair arterial blockage C 

35454 ....... Repair arterial blockage C 

35456 ....... Repair arterial blockage C 

35480 ....... Atherectomy, open ........ C 

35481 ....... Atherectomy, open ........ C 

35482 ....... Atherectomy, open ........ C 

35483 ....... Atherectomy, open ........ C 

35501 ....... Artery bypass graft ........ C 

35506 ....... Artery bypass graft ........ C 

35508 ....... Artery bypass graft ........ C 

35509 ....... Artery bypass graft ........ C 

35510 ....... Artery bypass graft ........ C 

35511 ....... Artery bypass graft ........ C 

35512 ....... Artery bypass graft ........ C 

35515 ....... Artery bypass graft ........ C 

35516 ....... Artery bypass graft ........ C 

35518 ....... Artery bypass graft ........ C 

35521 ....... Artery bypass graft ........ C 

35522 ....... Artery bypass graft ........ C 

35525 ....... Artery bypass graft ........ C 

35526 ....... Artery bypass graft ........ C 

35531 ....... Artery bypass graft ........ C 

35533 ....... Artery bypass graft ........ C 

35536 ....... Artery bypass graft ........ C 

35537 ....... Artery bypass graft ........ C 

35538 ....... Artery bypass graft ........ C 

35539 ....... Artery bypass graft ........ C 

35540 ....... Artery bypass graft ........ C 

35548 ....... Artery bypass graft ........ C 

35549 ....... Artery bypass graft ........ C 

35551 ....... Artery bypass graft ........ C 

35556 ....... Artery bypass graft ........ C 

35558 ....... Artery bypass graft ........ C 

35560 ....... Artery bypass graft ........ C 

35563 ....... Artery bypass graft ........ C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68391 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

35565 ....... Artery bypass graft ........ C 

35566 ....... Artery bypass graft ........ C 

35571 ....... Artery bypass graft ........ C 

35583 ....... Vein bypass graft .......... C 

35585 ....... Vein bypass graft .......... C 

35587 ....... Vein bypass graft .......... C 

35600 ....... Harvest artery for cabg C 

35601 ....... Artery bypass graft ........ C 

35606 ....... Artery bypass graft ........ C 

35612 ....... Artery bypass graft ........ C 

35616 ....... Artery bypass graft ........ C 

35621 ....... Artery bypass graft ........ C 

35623 ....... Bypass graft, not vein ... C 

35626 ....... Artery bypass graft ........ C 

35631 ....... Artery bypass graft ........ C 

35636 ....... Artery bypass graft ........ C 

35637 ....... Artery bypass graft ........ C 

35638 ....... Artery bypass graft ........ C 

35642 ....... Artery bypass graft ........ C 

35645 ....... Artery bypass graft ........ C 

35646 ....... Artery bypass graft ........ C 

35647 ....... Artery bypass graft ........ C 

35650 ....... Artery bypass graft ........ C 

35651 ....... Artery bypass graft ........ C 

35654 ....... Artery bypass graft ........ C 

35656 ....... Artery bypass graft ........ C 

35661 ....... Artery bypass graft ........ C 

35663 ....... Artery bypass graft ........ C 

35665 ....... Artery bypass graft ........ C 

35666 ....... Artery bypass graft ........ C 

35671 ....... Artery bypass graft ........ C 

35681 ....... Composite bypass graft C 

35682 ....... Composite bypass graft C 

35683 ....... Composite bypass graft C 

35691 ....... Arterial transposition ...... C 

35693 ....... Arterial transposition ...... C 

35694 ....... Arterial transposition ...... C 

35695 ....... Arterial transposition ...... C 

35697 ....... Reimplant artery each ... C 

35700 ....... Reoperation, bypass 

graft.

C 

35701 ....... Exploration, carotid artery.C 

35721 ....... Exploration, femoral artery.C 

35741 ....... Exploration popliteal artery.C 

35800 ....... Explore neck vessels .... C 

35820 ....... Explore chest vessels ... C 

35840 ....... Explore abdominal vessels.C 

35870 ....... Repair vessel graft defect.C 

35901 ....... Excision, graft, neck ...... C 

35905 ....... Excision, graft, thorax .... C 

35907 ....... Excision, graft, abdomen C 

36660 ....... Insertion catheter, artery C 

36822 ....... Insertion of cannula(s) ... C 

36823 ....... Insertion of cannula(s) ... C 

37140 ....... Revision of circulation ... C 

37145 ....... Revision of circulation ... C 

37160 ....... Revision of circulation ... C 

37180 ....... Revision of circulation ... C 

37181 ....... Splice spleen/kidney 

veins.

C 

37182 ....... Insert hepatic shunt 

(tips).

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

37215 ....... Transcath stent, cca w/ 

eps.

C 

37616 ....... Ligation of chest artery .. C 

37617 ....... Ligation of abdomen artery.C 

37618 ....... Ligation of extremity artery.C 

37660 ....... Revision of major vein ... C 

37788 ....... Revascularization, penis C 

38100 ....... Removal of spleen, total C 

38101 ....... Removal of spleen, partial.C 

38102 ....... Removal of spleen, total C 

38115 ....... Repair of ruptured 

spleen.

C 

38380 ....... Thoracic duct procedure C 

38381 ....... Thoracic duct procedure C 

38382 ....... Thoracic duct procedure C 

38562 ....... Removal, pelvic lymph 

nodes.

C 

38564 ....... Removal, abdomen 

lymph nodes.

C 

38724 ....... Removal of lymph 

nodes, neck.

C 

38746 ....... Remove thoracic lymph 

nodes.

C 

38747 ....... Remove abdominal 

lymph nodes.

C 

38765 ....... Remove groin lymph 

nodes.

C 

38770 ....... Remove pelvis lymph 

nodes.

C 

38780 ....... Remove abdomen 

lymph nodes.

C 

39000 ....... Exploration of chest ....... C 

39010 ....... Exploration of chest ....... C 

39200 ....... Removal chest lesion .... C 

39220 ....... Removal chest lesion .... C 

39499 ....... Chest procedure ............ C 

39501 ....... Repair diaphragm laceration.C 

39502 ....... Repair paraesophageal 

hernia.

C 

39503 ....... Repair of diaphragm 

hernia.

C 

39520 ....... Repair of diaphragm 

hernia.

C 

39530 ....... Repair of diaphragm 

hernia.

C 

39531 ....... Repair of diaphragm 

hernia.

C 

39540 ....... Repair of diaphragm 

hernia.

C 

39541 ....... Repair of diaphragm 

hernia.

C 

39545 ....... Revision of diaphragm .. C 

39560 ....... Resect diaphragm, simple.C 

39561 ....... Resect diaphragm, complex.C 

39599 ....... Diaphragm surgery procedure.C 

41130 ....... Partial removal of 

tongue.

C 

41135 ....... Tongue and neck surgery.C 

41140 ....... Removal of tongue ........ C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

41145 ....... Tongue removal, neck 

surgery.

C 

41150 ....... Tongue, mouth, jaw surgery.C 

41153 ....... Tongue, mouth, neck 

surgery.

C 

41155 ....... Tongue, jaw, & neck 

surgery.

C 

42426 ....... Excise parotid gland/lesion.C 

42845 ....... Extensive surgery of 

throat.

C 

42894 ....... Revision of pharyngeal 

walls.

C 

42953 ....... Repair throat, esophagus.C 

42961 ....... Control throat bleeding .. C 

42971 ....... Control nose/throat 

bleeding.

C 

43045 ....... Incision of esophagus ... C 

43100 ....... Excision of esophagus 

lesion.

C 

43101 ....... Excision of esophagus 

lesion.

C 

43107 ....... Removal of esophagus C 

43108 ....... Removal of esophagus C 

43112 ....... Removal of esophagus C 

43113 ....... Removal of esophagus C 

43116 ....... Partial removal of 

esophagus.

C 

43117 ....... Partial removal of 

esophagus.

C 

43118 ....... Partial removal of 

esophagus.

C 

43121 ....... Partial removal of 

esophagus.

C 

43122 ....... Partial removal of 

esophagus.

C 

43123 ....... Partial removal of 

esophagus.

C 

43124 ....... Removal of esophagus C 

43135 ....... Removal of esophagus 

pouch.

C 

43300 ....... Repair of esophagus ..... C 

43305 ....... Repair esophagus and 

fistula.

C 

43310 ....... Repair of esophagus ..... C 

43312 ....... Repair esophagus and 

fistula.

C 

43313 ....... Esophagoplasty congenital.C 

43314 ....... Tracheo-esophagoplasty 

cong.

C 

43320 ....... Fuse esophagus & 

stomach.

C 

43324 ....... Revise esophagus & 

stomach.

C 

43325 ....... Revise esophagus & 

stomach.

C 

43326 ....... Revise esophagus & 

stomach.

C 

43330 ....... Repair of esophagus ..... C 

43331 ....... Repair of esophagus ..... C 

43340 ....... Fuse esophagus & intestine.C 

43341 ....... Fuse esophagus & intestine.C 


cprice-sewell on PRODPC62 with RULES2
68392 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

43350 ....... Surgical opening, esophagus.C 

43351 ....... Surgical opening, esophagus.C 

43352 ....... Surgical opening, esophagus.C 

43360 ....... Gastrointestinal repair ... C 

43361 ....... Gastrointestinal repair ... C 

43400 ....... Ligate esophagus veins C 

43401 ....... Esophagus surgery for 

veins.

C 

43405 ....... Ligate/staple esophagus C 

43410 ....... Repair esophagus 

wound.

C 

43415 ....... Repair esophagus 

wound.

C 

43420 ....... Repair esophagus opening.C 

43425 ....... Repair esophagus opening.C 

43460 ....... Pressure treatment 

esophagus.

C 

43496 ....... Free jejunum flap, 

microvasc.

C 

43500 ....... Surgical opening of 

stomach.

C 

43501 ....... Surgical repair of stomach.C 

43502 ....... Surgical repair of stomach.C 

43520 ....... Incision of pyloric muscle.C 

43605 ....... Biopsy of stomach ......... C 

43610 ....... Excision of stomach lesion.C 

43611 ....... Excision of stomach lesion.C 

43620 ....... Removal of stomach ..... C 

43621 ....... Removal of stomach ..... C 

43622 ....... Removal of stomach ..... C 

43631 ....... Removal of stomach, 

partial.

C 

43632 ....... Removal of stomach, 

partial.

C 

43633 ....... Removal of stomach, 

partial.

C 

43634 ....... Removal of stomach, 

partial.

C 

43635 ....... Removal of stomach, 

partial.

C 

43640 ....... Vagotomy & pylorus repair.C 

43641 ....... Vagotomy & pylorus repair.C 

43644 ....... Lap gastric bypass/rouxen-y.C 

43645 ....... Lap gastr bypass incl 

smll i.

C 

43770 ....... Lap, place gastr adjust 

band.

C 

43771 ....... Lap, revise adjust gast 

band.

C 

43772 ....... Lap, remove adjust gast 

band.

C 

43773 ....... Lap, change adjust gast 

band.

C 

43774 ....... Lap remov adj gast 

band/port.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

43800 ....... Reconstruction of pylorus.C 

43810 ....... Fusion of stomach and 

bowel.

C 

43820 ....... Fusion of stomach and 

bowel.

C 

43825 ....... Fusion of stomach and 

bowel.

C 

43832 ....... Place gastrostomy tube C 

43840 ....... Repair of stomach lesion C 

43843 ....... Gastroplasty w/o v-band C 

43845 ....... Gastroplasty duodenal 

switch.

C 

43846 ....... Gastric bypass for obesity.C 

43847 ....... Gastric bypass incl small 

i.

C 

43848 ....... Revision gastroplasty .... C 

43850 ....... Revise stomach-bowel 

fusion.

C 

43855 ....... Revise stomach-bowel 

fusion.

C 

43860 ....... Revise stomach-bowel 

fusion.

C 

43865 ....... Revise stomach-bowel 

fusion.

C 

43880 ....... Repair stomach-bowel 

fistula.

C 

43881 ....... Impl/redo electrd, antrum.C 

43882 ....... Revise/remove electrd 

antrum.

C 

44005 ....... Freeing of bowel adhesion.C 

44010 ....... Incision of small bowel .. C 

44015 ....... Insert needle cath bowel C 

44020 ....... Explore small intestine .. C 

44021 ....... Decompress small 

bowel.

C 

44025 ....... Incision of large bowel .. C 

44050 ....... Reduce bowel obstruction.C 

44055 ....... Correct malrotation of 

bowel.

C 

44110 ....... Excise intestine lesion(s) C 

44111 ....... Excision of bowel lesion(s).C 

44120 ....... Removal of small intestine.C 

44121 ....... Removal of small intestine.C 

44125 ....... Removal of small intestine.C 

44126 ....... Enterectomy w/o taper, 

cong.

C 

44127 ....... Enterectomy w/taper, 

cong.

C 

44128 ....... Enterectomy cong, addon.C 

44130 ....... Bowel to bowel fusion ... C 

44132 ....... Enterectomy, cadaver 

donor.

C 

44133 ....... Enterectomy, live donor C 

44135 ....... Intestine transplnt, cadaver.C 

44136 ....... Intestine transplant, live C 

44137 ....... Remove intestinal 

allograft.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

44139 ....... Mobilization of colon ...... C 

44140 ....... Partial removal of colon C 

44141 ....... Partial removal of colon C 

44143 ....... Partial removal of colon C 

44144 ....... Partial removal of colon C 

44145 ....... Partial removal of colon C 

44146 ....... Partial removal of colon C 

44147 ....... Partial removal of colon C 

44150 ....... Removal of colon .......... C 

44151 ....... Removal of colon/ileostomy.C 

44155 ....... Removal of colon/ileostomy.C 

44156 ....... Removal of colon/ileostomy.C 

44157 ....... Colectomy w/ileoanal 

anast.

C 

44158 ....... Colectomy w/neo-rectum 

pouch.

C 

44160 ....... Removal of colon .......... C 

44187 ....... Lap, ileo/jejuno-stomy ... C 

44188 ....... Lap, colostomy .............. C 

44202 ....... Lap, enterectomy ........... C 

44203 ....... Lap resect s/intestine, 

addl.

C 

44204 ....... Laparo partial colectomy C 

44205 ....... Lap colectomy part w/ 

ileum.

C 

44210 ....... Laparo total 

proctocolectomy.

C 

44211 ....... Lap colectomy w/ 

proctectomy.

C 

44212 ....... Laparo total 

proctocolectomy.

C 

44227 ....... Lap, close enterostomy C 

44300 ....... Open bowel to skin ....... C 

44310 ....... Ileostomy/jejunostomy ... C 

44314 ....... Revision of ileostomy .... C 

44316 ....... Devise bowel pouch ...... C 

44320 ....... Colostomy ...................... C 

44322 ....... Colostomy with biopsies C 

44345 ....... Revision of colostomy ... C 

44346 ....... Revision of colostomy ... C 

44602 ....... Suture, small intestine ... C 

44603 ....... Suture, small intestine ... C 

44604 ....... Suture, large intestine ... C 

44605 ....... Repair of bowel lesion ... C 

44615 ....... Intestinal stricturoplasty C 

44620 ....... Repair bowel opening ... C 

44625 ....... Repair bowel opening ... C 

44626 ....... Repair bowel opening ... C 

44640 ....... Repair bowel-skin fistula C 

44650 ....... Repair bowel fistula ....... C 

44660 ....... Repair bowel-bladder 

fistula.

C 

44661 ....... Repair bowel-bladder 

fistula.

C 

44680 ....... Surgical revision, intestine.C 

44700 ....... Suspend bowel w/prosthesis.C 

44715 ....... Prepare donor intestine C 

44720 ....... Prep donor intestine/venous.C 

44721 ....... Prep donor intestine/artery.C 

44800 ....... Excision of bowel pouch C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68393 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

44820 ....... Excision of mesentery 

lesion.

C 

44850 ....... Repair of mesentery ...... C 

44899 ....... Bowel surgery procedure.C 

44900 ....... Drain app abscess, 

open.

C 

44950 ....... Appendectomy ............... C 

44955 ....... Appendectomy add-on .. C 

44960 ....... Appendectomy ............... C 

45110 ....... Removal of rectum ........ C 

45111 ....... Partial removal of rectum.C 

45112 ....... Removal of rectum ........ C 

45113 ....... Partial proctectomy ........ C 

45114 ....... Partial removal of rectum.C 

45116 ....... Partial removal of rectum.C 

45119 ....... Remove rectum w/reservoir.C 

45120 ....... Removal of rectum ........ C 

45121 ....... Removal of rectum and 

colon.

C 

45123 ....... Partial proctectomy ........ C 

45126 ....... Pelvic exenteration ........ C 

45130 ....... Excision of rectal 

prolapse.

C 

45135 ....... Excision of rectal 

prolapse.

C 

45136 ....... Excise ileoanal reservior C 

45395 ....... Lap, removal of rectum C 

45397 ....... Lap, remove rectum w/ 

pouch.

C 

45400 ....... Laparoscopic proctopexy C 

45402 ....... Lap proctopexy w/sig 

resect.

C 

45540 ....... Correct rectal prolapse .. C 

45550 ....... Repair rectum/remove 

sigmoid.

C 

45562 ....... Exploration/repair of rectum.C 

45563 ....... Exploration/repair of rectum.C 

45800 ....... Repair rect/bladder fistula.C 

45805 ....... Repair fistula w/colostomy.C 

45820 ....... Repair rectourethral fistula.C 

45825 ....... Repair fistula w/colostomy.C 

46705 ....... Repair of anal stricture .. C 

46710 ....... Repr per/vag pouch sngl 

proc.

C 

46712 ....... Repr per/vag pouch dbl 

proc.

C 

46715 ....... Rep perf anoper fistu .... C 

46716 ....... Rep perf anoper/vestib 

fistu.

C 

46730 ....... Construction of absent 

anus.

C 

46735 ....... Construction of absent 

anus.

C 

46740 ....... Construction of absent 

anus.

C 

46742 ....... Repair of imperforated 

anus.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

46744 ....... Repair of cloacal anomaly.C 

46746 ....... Repair of cloacal anomaly.C 

46748 ....... Repair of cloacal anomaly.C 

46751 ....... Repair of anal sphincter C 

47010 ....... Open drainage, liver lesion.C 

47015 ....... Inject/aspirate liver cyst C 

47100 ....... Wedge biopsy of liver .... C 

47120 ....... Partial removal of liver .. C 

47122 ....... Extensive removal of 

liver.

C 

47125 ....... Partial removal of liver .. C 

47130 ....... Partial removal of liver .. C 

47133 ....... Removal of donor liver .. C 

47135 ....... Transplantation of liver .. C 

47136 ....... Transplantation of liver .. C 

47140 ....... Partial removal, donor 

liver.

C 

47141 ....... Partial removal, donor 

liver.

C 

47142 ....... Partial removal, donor 

liver.

C 

47143 ....... Prep donor liver, whole C 

47144 ....... Prep donor liver, 3-segment.C 

47145 ....... Prep donor liver, lobe 

split.

C 

47146 ....... Prep donor liver/venous C 

47147 ....... Prep donor liver/arterial C 

47300 ....... Surgery for liver lesion .. C 

47350 ....... Repair liver wound ........ C 

47360 ....... Repair liver wound ........ C 

47361 ....... Repair liver wound ........ C 

47362 ....... Repair liver wound ........ C 

47380 ....... Open ablate liver tumor 

rf.

C 

47381 ....... Open ablate liver tumor 

cryo.

C 

47400 ....... Incision of liver duct ...... C 

47420 ....... Incision of bile duct ....... C 

47425 ....... Incision of bile duct ....... C 

47460 ....... Incise bile duct sphincter C 

47480 ....... Incision of gallbladder ... C 

47550 ....... Bile duct endoscopy 

add-on.

C 

47570 ....... Laparo 

cholecystoenterostomy.

C 

47600 ....... Removal of gallbladder C 

47605 ....... Removal of gallbladder C 

47610 ....... Removal of gallbladder C 

47612 ....... Removal of gallbladder C 

47620 ....... Removal of gallbladder C 

47700 ....... Exploration of bile ducts C 

47701 ....... Bile duct revision ........... C 

47711 ....... Excision of bile duct 

tumor.

C 

47712 ....... Excision of bile duct 

tumor.

C 

47715 ....... Excision of bile duct cyst C 

47719 ....... Fusion of bile duct cyst C 

47720 ....... Fuse gallbladder & 

bowel.

C 

47721 ....... Fuse upper gi structures C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

47740 ....... Fuse gallbladder & 

bowel.

C 

47741 ....... Fuse gallbladder & 

bowel.

C 

47760 ....... Fuse bile ducts and 

bowel.

C 

47765 ....... Fuse liver ducts & bowel C 

47780 ....... Fuse bile ducts and 

bowel.

C 

47785 ....... Fuse bile ducts and 

bowel.

C 

47800 ....... Reconstruction of bile 

ducts.

C 

47801 ....... Placement, bile duct 

support.

C 

47802 ....... Fuse liver duct & intestine.C 

47900 ....... Suture bile duct injury ... C 

48000 ....... Drainage of abdomen .... C 

48001 ....... Placement of drain, pancreas.C 

48020 ....... Removal of pancreatic 

stone.

C 

48100 ....... Biopsy of pancreas, 

open.

C 

48105 ....... Resect/debride pancreas C 

48120 ....... Removal of pancreas lesion.C 

48140 ....... Partial removal of pancreas.C 

48145 ....... Partial removal of pancreas.C 

48146 ....... Pancreatectomy ............. C 

48148 ....... Removal of pancreatic 

duct.

C 

48150 ....... Partial removal of pancreas.C 

48152 ....... Pancreatectomy ............. C 

48153 ....... Pancreatectomy ............. C 

48154 ....... Pancreatectomy ............. C 

48155 ....... Removal of pancreas .... C 

48400 ....... Injection, intraop add-on C 

48500 ....... Surgery of pancreatic 

cyst.

C 

48510 ....... Drain pancreatic 

pseudocyst.

C 

48520 ....... Fuse pancreas cyst and 

bowel.

C 

48540 ....... Fuse pancreas cyst and 

bowel.

C 

48545 ....... Pancreatorrhaphy .......... C 

48547 ....... Duodenal exclusion ....... C 

48548 ....... Fuse pancreas and 

bowel.

C 

48551 ....... Prep donor pancreas ..... C 

48552 ....... Prep donor pancreas/venous.C 

48554 ....... Transpl allograft pancreas.C 

48556 ....... Removal, allograft pancreas.C 

49000 ....... Exploration of abdomen C 

49002 ....... Reopening of abdomen C 

49010 ....... Exploration behind abdomen.C 

49020 ....... Drain abdominal abscess.C 


cprice-sewell on PRODPC62 with RULES2
68394 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

49040 ....... Drain, open, abdom abscess.C 

49060 ....... Drain, open, retrop abscess.C 

49062 ....... Drain to peritoneal cavity C 

49201 ....... Remove abdom lesion, 

complex.

C 

49215 ....... Excise sacral spine 

tumor.

C 

49220 ....... Multiple surgery, abdomen.C 

49255 ....... Removal of omentum .... C 

49425 ....... Insert abdomen-venous 

drain.

C 

49428 ....... Ligation of shunt ............ C 

49605 ....... Repair umbilical lesion .. C 

49606 ....... Repair umbilical lesion .. C 

49610 ....... Repair umbilical lesion .. C 

49611 ....... Repair umbilical lesion .. C 

49900 ....... Repair of abdominal wall C 

49904 ....... Omental flap, extraabdom.C 

49905 ....... Omental flap, intraabdom.C 

49906 ....... Free omental flap, 

microvasc.

C 

50010 ....... Exploration of kidney ..... C 

50040 ....... Drainage of kidney ........ C 

50045 ....... Exploration of kidney ..... C 

50060 ....... Removal of kidney stone C 

50065 ....... Incision of kidney ........... C 

50070 ....... Incision of kidney ........... C 

50075 ....... Removal of kidney stone C 

50100 ....... Revise kidney blood 

vessels.

C 

50120 ....... Exploration of kidney ..... C 

50125 ....... Explore and drain kidney C 

50130 ....... Removal of kidney stone C 

50135 ....... Exploration of kidney ..... C 

50205 ....... Biopsy of kidney ............ C 

50220 ....... Remove kidney, open ... C 

50225 ....... Removal kidney open, 

complex.

C 

50230 ....... Removal kidney open, 

radical.

C 

50234 ....... Removal of kidney & 

ureter.

C 

50236 ....... Removal of kidney & 

ureter.

C 

50240 ....... Partial removal of kidney C 

50250 ....... Cryoablate renal mass 

open.

C 

50280 ....... Removal of kidney lesion.C 

50290 ....... Removal of kidney lesion.C 

50300 ....... Remove cadaver donor 

kidney.

C 

50320 ....... Remove kidney, living 

donor.

C 

50323 ....... Prep cadaver renal 

allograft.

C 

50325 ....... Prep donor renal graft ... C 

50327 ....... Prep renal graft/venous C 

50328 ....... Prep renal graft/arterial C 

50329 ....... Prep renal graft/ureteral C 

50340 ....... Removal of kidney ......... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

50360 ....... Transplantation of kidney.C 

50365 ....... Transplantation of kidney.C 

50370 ....... Remove transplanted 

kidney.

C 

50380 ....... Reimplantation of kidney C 

50400 ....... Revision of kidney/ureter C 

50405 ....... Revision of kidney/ureter C 

50500 ....... Repair of kidney wound C 

50520 ....... Close kidney-skin fistula C 

50525 ....... Repair renal-abdomen 

fistula.

C 

50526 ....... Repair renal-abdomen 

fistula.

C 

50540 ....... Revision of horseshoe 

kidney.

C 

50545 ....... Laparo radical nephrectomy.C 

50546 ....... Laparoscopic nephrectomy.C 

50547 ....... Laparo removal donor 

kidney.

C 

50548 ....... Laparo remove w/ureter C 

50580 ....... Kidney endoscopy & 

treatment.

C 

50600 ....... Exploration of ureter ...... C 

50605 ....... Insert ureteral support ... C 

50610 ....... Removal of ureter stone C 

50620 ....... Removal of ureter stone C 

50630 ....... Removal of ureter stone C 

50650 ....... Removal of ureter .......... C 

50660 ....... Removal of ureter .......... C 

50700 ....... Revision of ureter .......... C 

50715 ....... Release of ureter ........... C 

50722 ....... Release of ureter ........... C 

50725 ....... Release/revise ureter .... C 

50727 ....... Revise ureter ................. C 

50728 ....... Revise ureter ................. C 

50740 ....... Fusion of ureter & kidney.C 

50750 ....... Fusion of ureter & kidney.C 

50760 ....... Fusion of ureters ........... C 

50770 ....... Splicing of ureters ......... C 

50780 ....... Reimplant ureter in bladder.C 

50782 ....... Reimplant ureter in bladder.C 

50783 ....... Reimplant ureter in bladder.C 

50785 ....... Reimplant ureter in bladder.C 

50800 ....... Implant ureter in bowel .. C 

50810 ....... Fusion of ureter & bowel C 

50815 ....... Urine shunt to intestine C 

50820 ....... Construct bowel bladder C 

50825 ....... Construct bowel bladder C 

50830 ....... Revise urine flow ........... C 

50840 ....... Replace ureter by bowel C 

50845 ....... Appendico-vesicostomy C 

50860 ....... Transplant ureter to skin C 

50900 ....... Repair of ureter ............. C 

50920 ....... Closure ureter/skin fistula.C 

50930 ....... Closure ureter/bowel fistula.C 

50940 ....... Release of ureter ........... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

51060 ....... Removal of ureter stone C 

51525 ....... Removal of bladder lesion.C 

51530 ....... Removal of bladder lesion.C 

51535 ....... Repair of ureter lesion ... C 

51550 ....... Partial removal of bladder.C 

51555 ....... Partial removal of bladder.C 

51565 ....... Revise bladder & ureter(s).C 

51570 ....... Removal of bladder ....... C 

51575 ....... Removal of bladder & 

nodes.

C 

51580 ....... Remove bladder/revise 

tract.

C 

51585 ....... Removal of bladder & 

nodes.

C 

51590 ....... Remove bladder/revise 

tract.

C 

51595 ....... Remove bladder/revise 

tract.

C 

51596 ....... Remove bladder/create 

pouch.

C 

51597 ....... Removal of pelvic structures.C 

51800 ....... Revision of bladder/urethra.C 

51820 ....... Revision of urinary tract C 

51840 ....... Attach bladder/urethra ... C 

51841 ....... Attach bladder/urethra ... C 

51845 ....... Repair bladder neck ...... C 

51860 ....... Repair of bladder wound C 

51865 ....... Repair of bladder wound C 

51900 ....... Repair bladder/vagina 

lesion.

C 

51920 ....... Close bladder-uterus fistula.C 

51925 ....... Hysterectomy/bladder 

repair.

C 

51940 ....... Correction of bladder 

defect.

C 

51960 ....... Revision of bladder & 

bowel.

C 

51980 ....... Construct bladder opening.C 

53415 ....... Reconstruction of urethra.C 

53448 ....... Remov/replc ur sphinctr 

comp.

C 

54125 ....... Removal of penis .......... C 

54130 ....... Remove penis & nodes C 

54135 ....... Remove penis & nodes C 

54332 ....... Revise penis/urethra ..... C 

54336 ....... Revise penis/urethra ..... C 

54390 ....... Repair penis and bladder.C 

54411 ....... Remov/replc penis pros, 

comp.

C 

54417 ....... Remv/replc penis pros, 

compl.

C 

54430 ....... Revision of penis ........... C 

54535 ....... Extensive testis surgery C 

54650 ....... Orchiopexy (Fowler-Stephens).C 

55605 ....... Incise sperm duct pouch C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68395 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

55650 ....... Remove sperm duct 

pouch.

C 

55801 ....... Removal of prostate ...... C 

55810 ....... Extensive prostate surgery.C 

55812 ....... Extensive prostate surgery.C 

55815 ....... Extensive prostate surgery.C 

55821 ....... Removal of prostate ...... C 

55831 ....... Removal of prostate ...... C 

55840 ....... Extensive prostate surgery.C 

55842 ....... Extensive prostate surgery.C 

55845 ....... Extensive prostate surgery.C 

55862 ....... Extensive prostate surgery.C 

55865 ....... Extensive prostate surgery.C 

55866 ....... Laparo radical prostatectomy.C 

56630 ....... Extensive vulva surgery C 

56631 ....... Extensive vulva surgery C 

56632 ....... Extensive vulva surgery C 

56633 ....... Extensive vulva surgery C 

56634 ....... Extensive vulva surgery C 

56637 ....... Extensive vulva surgery C 

56640 ....... Extensive vulva surgery C 

57110 ....... Remove vagina wall, 

complete.

C 

57111 ....... Remove vagina tissue, 

compl.

C 

57112 ....... Vaginectomy w/nodes, 

compl.

C 

57270 ....... Repair of bowel pouch .. C 

57280 ....... Suspension of vagina .... C 

57296 ....... Revise vag graft, open 

abd.

C 

57305 ....... Repair rectum-vagina 

fistula.

C 

57307 ....... Fistula repair & colostomy.C 

57308 ....... Fistula repair, 

transperine.

C 

57311 ....... Repair urethrovaginal lesion.C 

57531 ....... Removal of cervix, radical.C 

57540 ....... Removal of residual cervix.C 

57545 ....... Remove cervix/repair 

pelvis.

C 

58140 ....... Myomectomy abdom 

method.

C 

58146 ....... Myomectomy abdom 

complex.

C 

58150 ....... Total hysterectomy ........ C 

58152 ....... Total hysterectomy ........ C 

58180 ....... Partial hysterectomy ...... C 

58200 ....... Extensive hysterectomy C 

58210 ....... Extensive hysterectomy C 

58240 ....... Removal of pelvis contents.C 

58267 ....... Vag hyst w/urinary repair.C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

58275 ....... Hysterectomy/revise vagina.C 

58280 ....... Hysterectomy/revise vagina.C 

58285 ....... Extensive hysterectomy C 

58293 ....... Vag hyst w/uro repair, 

compl.

C 

58400 ....... Suspension of uterus .... C 

58410 ....... Suspension of uterus .... C 

58520 ....... Repair of ruptured uterus.C 

58540 ....... Revision of uterus ......... C 

58548 ....... Lap radical hyst ............. C 

58605 ....... Division of fallopian tube C 

58611 ....... Ligate oviduct(s) add-on C 

58700 ....... Removal of fallopian 

tube.

C 

58720 ....... Removal of ovary/ 

tube(s).

C 

58740 ....... Revise fallopian tube(s) C 

58750 ....... Repair oviduct ............... C 

58752 ....... Revise ovarian tube(s) .. C 

58760 ....... Remove tubal obstruction.C 

58805 ....... Drainage of ovarian 

cyst(s).

C 

58822 ....... Drain ovary abscess, 

percut.

C 

58825 ....... Transposition, ovary(s) .. C 

58940 ....... Removal of ovary(s) ...... C 

58943 ....... Removal of ovary(s) ...... C 

58950 ....... Resect ovarian malignancy.C 

58951 ....... Resect ovarian malignancy.C 

58952 ....... Resect ovarian malignancy.C 

58953 ....... Tah, rad dissect for 

debulk.

C 

58954 ....... Tah rad debulk/lymph 

remove.

C 

58956 ....... Bso, omentectomy w/tah C 

58957 ....... Resect recurrent gyn 

mal.

C 

58958 ....... Resect recur gyn mal w/ 

lym.

C 

58960 ....... Exploration of abdomen C 

59120 ....... Treat ectopic pregnancy C 

59121 ....... Treat ectopic pregnancy C 

59130 ....... Treat ectopic pregnancy C 

59135 ....... Treat ectopic pregnancy C 

59136 ....... Treat ectopic pregnancy C 

59140 ....... Treat ectopic pregnancy C 

59325 ....... Revision of cervix .......... C 

59350 ....... Repair of uterus ............. C 

59514 ....... Cesarean delivery only .. C 

59525 ....... Remove uterus after cesarean.C 

59620 ....... Attempted vbac delivery 

only.

C 

59830 ....... Treat uterus infection .... C 

59850 ....... Abortion ......................... C 

59851 ....... Abortion ......................... C 

59852 ....... Abortion ......................... C 

59855 ....... Abortion ......................... C 

59856 ....... Abortion ......................... C 

59857 ....... Abortion ......................... C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

60254 ....... Extensive thyroid surgery.C 

60270 ....... Removal of thyroid ........ C 

60271 ....... Removal of thyroid ........ C 

60505 ....... Explore parathyroid 

glands.

C 

60521 ....... Removal of thymus 

gland.

C 

60522 ....... Removal of thymus 

gland.

C 

60540 ....... Explore adrenal gland ... C 

60545 ....... Explore adrenal gland ... C 

60600 ....... Remove carotid body lesion.C 

60605 ....... Remove carotid body lesion.C 

60650 ....... Laparoscopy 

adrenalectomy.

C 

61105 ....... Twist drill hole ............... C 

61107 ....... Drill skull for implantation.C 

61108 ....... Drill skull for drainage ... C 

61120 ....... Burr hole for puncture ... C 

61140 ....... Pierce skull for biopsy ... C 

61150 ....... Pierce skull for drainage C 

61151 ....... Pierce skull for drainage C 

61154 ....... Pierce skull & remove 

clot.

C 

61156 ....... Pierce skull for drainage C 

61210 ....... Pierce skull, implant device.C 

61250 ....... Pierce skull & explore ... C 

61253 ....... Pierce skull & explore ... C 

61304 ....... Open skull for exploration.C 

61305 ....... Open skull for exploration.C 

61312 ....... Open skull for drainage C 

61313 ....... Open skull for drainage C 

61314 ....... Open skull for drainage C 

61315 ....... Open skull for drainage C 

61316 ....... Implt cran bone flap to 

abdo.

C 

61320 ....... Open skull for drainage C 

61321 ....... Open skull for drainage C 

61322 ....... Decompressive 

craniotomy.

C 

61323 ....... Decompressive lobectomy.C 

61332 ....... Explore/biopsy eye 

socket.

C 

61333 ....... Explore orbit/remove lesion.C 

61340 ....... Subtemporal decompression.C 

61343 ....... Incise skull (press relief) C 

61345 ....... Relieve cranial pressure C 

61440 ....... Incise skull for surgery .. C 

61450 ....... Incise skull for surgery .. C 

61458 ....... Incise skull for brain 

wound.

C 

61460 ....... Incise skull for surgery .. C 

61470 ....... Incise skull for surgery .. C 

61480 ....... Incise skull for surgery .. C 

61490 ....... Incise skull for surgery .. C 

61500 ....... Removal of skull lesion C 

61501 ....... Remove infected skull 

bone.

C 


cprice-sewell on PRODPC62 with RULES2
68396 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

61510 ....... Removal of brain lesion C 

61512 ....... Remove brain lining lesion.C 

61514 ....... Removal of brain abscess.C 

61516 ....... Removal of brain lesion C 

61517 ....... Implt brain chemotx addon.C 

61518 ....... Removal of brain lesion C 

61519 ....... Remove brain lining lesion.C 

61520 ....... Removal of brain lesion C 

61521 ....... Removal of brain lesion C 

61522 ....... Removal of brain abscess.C 

61524 ....... Removal of brain lesion C 

61526 ....... Removal of brain lesion C 

61530 ....... Removal of brain lesion C 

61531 ....... Implant brain electrodes C 

61533 ....... Implant brain electrodes C 

61534 ....... Removal of brain lesion C 

61535 ....... Remove brain electrodes.C 

61536 ....... Removal of brain lesion C 

61537 ....... Removal of brain tissue C 

61538 ....... Removal of brain tissue C 

61539 ....... Removal of brain tissue C 

61540 ....... Removal of brain tissue C 

61541 ....... Incision of brain tissue .. C 

61542 ....... Removal of brain tissue C 

61543 ....... Removal of brain tissue C 

61544 ....... Remove & treat brain lesion.C 

61545 ....... Excision of brain tumor C 

61546 ....... Removal of pituitary 

gland.

C 

61548 ....... Removal of pituitary 

gland.

C 

61550 ....... Release of skull seams C 

61552 ....... Release of skull seams C 

61556 ....... Incise skull/sutures ........ C 

61557 ....... Incise skull/sutures ........ C 

61558 ....... Excision of skull/sutures C 

61559 ....... Excision of skull/sutures C 

61563 ....... Excision of skull tumor .. C 

61564 ....... Excision of skull tumor .. C 

61566 ....... Removal of brain tissue C 

61567 ....... Incision of brain tissue .. C 

61570 ....... Remove foreign body, 

brain.

C 

61571 ....... Incise skull for brain 

wound.

C 

61575 ....... Skull base/brainstem 

surgery.

C 

61576 ....... Skull base/brainstem 

surgery.

C 

61580 ....... Craniofacial approach, 

skull.

C 

61581 ....... Craniofacial approach, 

skull.

C 

61582 ....... Craniofacial approach, 

skull.

C 

61583 ....... Craniofacial approach, 

skull.

C 

61584 ....... Orbitocranial approach/ 

skull.

C 

61585 ....... Orbitocranial approach/ 

skull.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

61586 ....... Resect nasopharynx, 

skull.

C 

61590 ....... Infratemporal approach/ 

skull.

C 

61591 ....... Infratemporal approach/ 

skull.

C 

61592 ....... Orbitocranial approach/ 

skull.

C 

61595 ....... Transtemporal approach/skull.C 

61596 ....... Transcochlear approach/ 

skull.

C 

61597 ....... Transcondylar approach/ 

skull.

C 

61598 ....... Transpetrosal approach/ 

skull.

C 

61600 ....... Resect/excise cranial lesion.C 

61601 ....... Resect/excise cranial lesion.C 

61605 ....... Resect/excise cranial lesion.C 

61606 ....... Resect/excise cranial lesion.C 

61607 ....... Resect/excise cranial lesion.C 

61608 ....... Resect/excise cranial lesion.C 

61609 ....... Transect artery, sinus .... C 

61610 ....... Transect artery, sinus .... C 

61611 ....... Transect artery, sinus .... C 

61612 ....... Transect artery, sinus .... C 

61613 ....... Remove aneurysm, 

sinus.

C 

61615 ....... Resect/excise lesion, 

skull.

C 

61616 ....... Resect/excise lesion, 

skull.

C 

61618 ....... Repair dura .................... C 

61619 ....... Repair dura .................... C 

61624 ....... Transcath occlusion, cns C 

61680 ....... Intracranial vessel surgery.C 

61682 ....... Intracranial vessel surgery.C 

61684 ....... Intracranial vessel surgery.C 

61686 ....... Intracranial vessel surgery.C 

61690 ....... Intracranial vessel surgery.C 

61692 ....... Intracranial vessel surgery.C 

61697 ....... Brain aneurysm repr, 

complx.

C 

61698 ....... Brain aneurysm repr, 

complx.

C 

61700 ....... Brain aneurysm repr, 

simple.

C 

61702 ....... Inner skull vessel surgery.C 

61703 ....... Clamp neck artery ......... C 

61705 ....... Revise circulation to 

head.

C 

61708 ....... Revise circulation to 

head.

C 

61710 ....... Revise circulation to 

head.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

61711 ....... Fusion of skull arteries .. C 

61735 ....... Incise skull/brain surgery C 

61750 ....... Incise skull/brain biopsy C 

61751 ....... Brain biopsy w/ct/mr 

guide.

C 

61760 ....... Implant brain electrodes C 

61770 ....... Incise skull for treatment C 

61850 ....... Implant neuroelectrodes C 

61860 ....... Implant neuroelectrodes C 

61863 ....... Implant neuroelectrode .. C 

61864 ....... Implant neuroelectrde, 

addl.

C 

61867 ....... Implant neuroelectrode .. C 

61868 ....... Implant neuroelectrde, 

add’l.

C 

61870 ....... Implant neuroelectrodes C 

61875 ....... Implant neuroelectrodes C 

62005 ....... Treat skull fracture ........ C 

62010 ....... Treatment of head injury C 

62100 ....... Repair brain fluid leakage.C 

62115 ....... Reduction of skull defect C 

62116 ....... Reduction of skull defect C 

62117 ....... Reduction of skull defect C 

62120 ....... Repair skull cavity lesion C 

62121 ....... Incise skull repair .......... C 

62140 ....... Repair of skull defect .... C 

62141 ....... Repair of skull defect .... C 

62142 ....... Remove skull plate/flap C 

62143 ....... Replace skull plate/flap C 

62145 ....... Repair of skull & brain ... C 

62146 ....... Repair of skull with graft C 

62147 ....... Repair of skull with graft C 

62148 ....... Retr bone flap to fix 

skull.

C 

62161 ....... Dissect brain w/scope ... C 

62162 ....... Remove colloid cyst w/ 

scope.

C 

62163 ....... Neuroendoscopy w/fb 

removal.

C 

62164 ....... Remove brain tumor w/ 

scope.

C 

62165 ....... Remove pituit tumor w/ 

scope.

C 

62180 ....... Establish brain cavity 

shunt.

C 

62190 ....... Establish brain cavity 

shunt.

C 

62192 ....... Establish brain cavity 

shunt.

C 

62200 ....... Establish brain cavity 

shunt.

C 

62201 ....... Brain cavity shunt w/ 

scope.

C 

62220 ....... Establish brain cavity 

shunt.

C 

62223 ....... Establish brain cavity 

shunt.

C 

62256 ....... Remove brain cavity 

shunt.

C 

62258 ....... Replace brain cavity 

shunt.

C 

63043 ....... Laminotomy, add’l cervical.C 

63044 ....... Laminotomy, add’l lumbar.C 

63050 ....... Cervical laminoplasty .... C 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68397 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

63051 ....... C-laminoplasty w/graft/ 

plate.

C 

63076 ....... Neck spine disk surgery C 

63077 ....... Spine disk surgery, thorax.C 

63078 ....... Spine disk surgery, thorax.C 

63081 ....... Removal of vertebral 

body.

C 

63082 ....... Remove vertebral body 

add-on.

C 

63085 ....... Removal of vertebral 

body.

C 

63086 ....... Remove vertebral body 

add-on.

C 

63087 ....... Removal of vertebral 

body.

C 

63088 ....... Remove vertebral body 

add-on.

C 

63090 ....... Removal of vertebral 

body.

C 

63091 ....... Remove vertebral body 

add-on.

C 

63101 ....... Removal of vertebral 

body.

C 

63102 ....... Removal of vertebral 

body.

C 

63103 ....... Remove vertebral body 

add-on.

C 

63170 ....... Incise spinal cord 

tract(s).

C 

63172 ....... Drainage of spinal cyst .. C 

63173 ....... Drainage of spinal cyst .. C 

63180 ....... Revise spinal cord ligaments.C 

63182 ....... Revise spinal cord ligaments.C 

63185 ....... Incise spinal column/ 

nerves.

C 

63190 ....... Incise spinal column/ 

nerves.

C 

63191 ....... Incise spinal column/ 

nerves.

C 

63194 ....... Incise spinal column & 

cord.

C 

63195 ....... Incise spinal column & 

cord.

C 

63196 ....... Incise spinal column & 

cord.

C 

63197 ....... Incise spinal column & 

cord.

C 

63198 ....... Incise spinal column & 

cord.

C 

63199 ....... Incise spinal column & 

cord.

C 

63200 ....... Release of spinal cord .. C 

63250 ....... Revise spinal cord vessels.C 

63251 ....... Revise spinal cord vessels.C 

63252 ....... Revise spinal cord vessels.C 

63265 ....... Excise intraspinal lesion C 

63266 ....... Excise intraspinal lesion C 

63267 ....... Excise intraspinal lesion C 

63268 ....... Excise intraspinal lesion C 

63270 ....... Excise intraspinal lesion C 

63271 ....... Excise intraspinal lesion C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

63272 ....... Excise intraspinal lesion C 

63273 ....... Excise intraspinal lesion C 

63275 ....... Biopsy/excise spinal 

tumor.

C 

63276 ....... Biopsy/excise spinal 

tumor.

C 

63277 ....... Biopsy/excise spinal 

tumor.

C 

63278 ....... Biopsy/excise spinal 

tumor.

C 

63280 ....... Biopsy/excise spinal 

tumor.

C 

63281 ....... Biopsy/excise spinal 

tumor.

C 

63282 ....... Biopsy/excise spinal 

tumor.

C 

63283 ....... Biopsy/excise spinal 

tumor.

C 

63285 ....... Biopsy/excise spinal 

tumor.

C 

63286 ....... Biopsy/excise spinal 

tumor.

C 

63287 ....... Biopsy/excise spinal 

tumor.

C 

63290 ....... Biopsy/excise spinal 

tumor.

C 

63295 ....... Repair of laminectomy 

defect.

C 

63300 ....... Removal of vertebral 

body.

C 

63301 ....... Removal of vertebral 

body.

C 

63302 ....... Removal of vertebral 

body.

C 

63303 ....... Removal of vertebral 

body.

C 

63304 ....... Removal of vertebral 

body.

C 

63305 ....... Removal of vertebral 

body.

C 

63306 ....... Removal of vertebral 

body.

C 

63307 ....... Removal of vertebral 

body.

C 

63308 ....... Remove vertebral body 

add-on.

C 

63700 ....... Repair of spinal herniation.C 

63702 ....... Repair of spinal herniation.C 

63704 ....... Repair of spinal herniation.C 

63706 ....... Repair of spinal herniation.C 

63707 ....... Repair spinal fluid leakage.C 

63709 ....... Repair spinal fluid leakage.C 

63710 ....... Graft repair of spine defect.C 

63740 ....... Install spinal shunt ......... C 

64752 ....... Incision of vagus nerve C 

64755 ....... Incision of stomach 

nerves.

C 

64760 ....... Incision of vagus nerve C 

64809 ....... Remove sympathetic 

nerves.

C 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

64818 ....... Remove sympathetic 

nerves.

C 

64866 ....... Fusion of facial/other 

nerve.

C 

64868 ....... Fusion of facial/other 

nerve.

C 

65273 ....... Repair of eye wound ..... C 

69155 ....... Extensive ear/neck surgery.C 

69535 ....... Remove part of temporal 

bone.

C 

69554 ....... Remove ear lesion ........ C 

69950 ....... Incise inner ear nerve ... C 

69970 ....... Remove inner ear lesion C 

75900 ....... Intravascular cath exchange.C 

75952 ....... Endovasc repair abdom 

aorta.

C 

75953 ....... Abdom aneurysm 

endovas rpr.

C 

75954 ....... Iliac aneurysm endovas 

rpr.

C 

75956 ....... Xray, endovasc thor ao 

repr.

C 

75957 ....... Xray, endovasc thor ao 

repr.

C 

75958 ....... Xray, place prox ext thor 

ao.

C 

75959 ....... Xray, place dist ext thor 

ao.

C 

92970 ....... Cardioassist, internal ..... C 

92971 ....... Cardioassist, external .... C 

92975 ....... Dissolve clot, heart vessel.C 

92992 ....... Revision of heart chamber.C 

92993 ....... Revision of heart chamber.C 

99190 ....... Special pump services .. C 

99191 ....... Special pump services .. C 

99192 ....... Special pump services .. C 

99251 ....... Inpatient consultation .... C 

99252 ....... Inpatient consultation .... C 

99253 ....... Inpatient consultation .... C 

99254 ....... Inpatient consultation .... C 

99255 ....... Inpatient consultation .... C 

99293 ....... Ped critical care, initial .. C 

99294 ....... Ped critical care, subseq C 

99295 ....... Neonate crit care, initial C 

99296 ....... Neonate critical care 

subseq.

C 

99298 ....... Ic for lbw infant <1500 

gm.

C 

99299 ....... Ic, lbw infant 1500-2500 

gm.

C 

99356 ....... Prolonged service, inpatient.C 

99357 ....... Prolonged service, inpatient.C 

99433 ....... Normal newborn care/ 

hospital.

C 

0024T ....... Transcath cardiac reduction.C 

0048T ....... Implant ventricular device.C 

0049T ....... External circulation assist.C 


cprice-sewell on PRODPC62 with RULES2
68398 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM E.—CPT CODES THAT

ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/ 

HCPCS Description 

CY 

2007 

SI 

0050T ....... Removal circulation assist.C 

0051T ....... Implant total heart system.C 

0052T ....... Replace component 

heart syst.

C 

0053T ....... Replace component 

heart syst.

C 

0075T ....... Perq stent/chest vert art C 

0076T ....... S&i stent/chest vert art .. C 

0077T ....... Cereb therm perfusion 

probe.

C 

0078T ....... Endovasc aort repr w/ 

device.

C 

0079T ....... Endovasc visc extnsn 

repr.

C 

0080T ....... Endovasc aort repr rad 

s&i.

C 

0081T ....... Endovasc visc extnsn 

s&i.

C 

0092T ....... Artific disc addl .............. C 

0093T ....... Cervical artific 

diskectomy.

C 

0095T ....... Artific diskectomy addl .. C 

0096T ....... Rev cervical artific disc C 

0098T ....... Rev artific disc addl ....... C 

0153T ....... Tcath sensor aneurysm 

sac.

C 

0157T ....... Open impl gast curve 

electrd.

C 

0158T ....... Open remv gast curve 

electrd.

C 

0163T ....... Lumb artif diskectomy 

addl.

C 

0164T ....... Remove lumb artif disc 

addl.

C 

0165T ....... Revise lumb artif disc 

addl.

C 

0166T ....... Tcath vsd close w/o bypass.C 

0167T ....... Tcath vsd close w bypass.C 

0169T ....... Place stereo cath brain C 

G0341 ...... Percutaneous islet 

celltrans.

C 

G0342 ...... Laparoscopy islet cell 

trans.

C 

G0343 ...... Laparotomy islet cell 

transp.

C 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

010005 ... 0.0259 MARSHALL 

010008 ... 0.0212 CRENSHAW 

010009 ... 0.0092 MORGAN 

010010 ... 0.0259 MARSHALL 

010012 ... 0.0205 DE KALB 

010022 ... 0.0714 CHEROKEE 

010025 ... 0.0235 CHAMBERS 

010029 ... 0.0107 LEE 

010035 ... 0.0375 CULLMAN 

010038 ... 0.0062 CALHOUN 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

010045 ... 0.0160 FAYETTE 

010047 ... 0.0155 BUTLER 

010052 ... 0.0103 TALLAPOOSA 

010054 ... 0.0092 MORGAN 

010061 ... 0.0506 JACKSON 

010065 ... 0.0103 TALLAPOOSA 

010078 ... 0.0062 CALHOUN 

010083 ... 0.0121 BALDWIN 

010085 ... 0.0092 MORGAN 

010100 ... 0.0121 BALDWIN 

010101 ... 0.0310 TALLADEGA 

010109 ... 0.0451 PICKENS 

010129 ... 0.0121 BALDWIN 

010143 ... 0.0375 CULLMAN 

010146 ... 0.0062 CALHOUN 

010150 ... 0.0155 BUTLER 

010158 ... 0.0093 FRANKLIN 

010164 ... 0.0310 TALLADEGA 

013027 ... 0.0121 BALDWIN 

014008 ... 0.0121 BALDWIN 

014009 ... 0.0092 MORGAN 

040014 ... 0.0159 WHITE 

040019 ... 0.0697 ST. FRANCIS 

040047 ... 0.0090 RANDOLPH 

040069 ... 0.0140 MISSISSIPPI 

040071 ... 0.0026 JEFFERSON 

040076 ... 0.1075 HOT SPRING 

040100 ... 0.0159 WHITE 

042007 ... 0.0026 JEFFERSON 

050008 ... 0.0026 SAN FRANCISCO 

050009 ... 0.0478 NAPA 

050013 ... 0.0478 NAPA 

050014 ... 0.0131 AMADOR 

050016 ... 0.0103 SAN LUIS OBISPO 

050042 ... 0.0219 TEHAMA 

050046 ... 0.0156 VENTURA 

050047 ... 0.0026 SAN FRANCISCO 

050055 ... 0.0026 SAN FRANCISCO 

050065 ... 0.0029 ORANGE 

050069 ... 0.0029 ORANGE 

050073 ... 0.0269 SOLANO 

050076 ... 0.0026 SAN FRANCISCO 

050082 ... 0.0156 VENTURA 

050084 ... 0.0555 SAN JOAQUIN 

050089 ... 0.0152 SAN BERNARDINO 

050090 ... 0.0308 SONOMA 

050099 ... 0.0152 SAN BERNARDINO 

050101 ... 0.0269 SOLANO 

050117 ... 0.0463 MERCED 

050118 ... 0.0555 SAN JOAQUIN 

050122 ... 0.0555 SAN JOAQUIN 

050129 ... 0.0152 SAN BERNARDINO 

050133 ... 0.0170 YUBA 

050136 ... 0.0308 SONOMA 

050140 ... 0.0152 SAN BERNARDINO 

050150 ... 0.0316 NEVADA 

050152 ... 0.0026 SAN FRANCISCO 

050159 ... 0.0156 VENTURA 

050167 ... 0.0555 SAN JOAQUIN 

050168 ... 0.0029 ORANGE 

050173 ... 0.0029 ORANGE 

050174 ... 0.0308 SONOMA 

050193 ... 0.0029 ORANGE 

050194 ... 0.0052 SANTA CRUZ 

050224 ... 0.0029 ORANGE 

050226 ... 0.0029 ORANGE 

050228 ... 0.0026 SAN FRANCISCO 

050230 ... 0.0029 ORANGE 

050232 ... 0.0103 SAN LUIS OBISPO 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

050236 ... 0.0156 VENTURA 

050242 ... 0.0052 SANTA CRUZ 

050245 ... 0.0152 SAN BERNARDINO 

050272 ... 0.0152 SAN BERNARDINO 

050279 ... 0.0152 SAN BERNARDINO 

050291 ... 0.0308 SONOMA 

050298 ... 0.0152 SAN BERNARDINO 

050300 ... 0.0152 SAN BERNARDINO 

050313 ... 0.0555 SAN JOAQUIN 

050325 ... 0.0176 TUOLUMNE 

050327 ... 0.0152 SAN BERNARDINO 

050335 ... 0.0176 TUOLUMNE 

050336 ... 0.0555 SAN JOAQUIN 

050348 ... 0.0029 ORANGE 

050367 ... 0.0269 SOLANO 

050385 ... 0.0308 SONOMA 

050394 ... 0.0156 VENTURA 

050407 ... 0.0026 SAN FRANCISCO 

050426 ... 0.0029 ORANGE 

050444 ... 0.0463 MERCED 

050454 ... 0.0026 SAN FRANCISCO 

050457 ... 0.0026 SAN FRANCISCO 

050469 ... 0.0152 SAN BERNARDINO 

050476 ... 0.0257 LAKE 

050494 ... 0.0316 NEVADA 

050506 ... 0.0103 SAN LUIS OBISPO 

050517 ... 0.0152 SAN BERNARDINO 

050526 ... 0.0029 ORANGE 

050528 ... 0.0463 MERCED 

050535 ... 0.0029 ORANGE 

050543 ... 0.0029 ORANGE 

050547 ... 0.0308 SONOMA 

050548 ... 0.0029 ORANGE 

050549 ... 0.0156 VENTURA 

050550 ... 0.0029 ORANGE 

050551 ... 0.0029 ORANGE 

050567 ... 0.0029 ORANGE 

050568 ... 0.0062 MADERA 

050570 ... 0.0029 ORANGE 

050580 ... 0.0029 ORANGE 

050584 ... 0.0152 SAN BERNARDINO 

050585 ... 0.0029 ORANGE 

050586 ... 0.0152 SAN BERNARDINO 

050589 ... 0.0029 ORANGE 

050592 ... 0.0029 ORANGE 

050594 ... 0.0029 ORANGE 

050603 ... 0.0029 ORANGE 

050609 ... 0.0029 ORANGE 

050616 ... 0.0156 VENTURA 

050618 ... 0.0152 SAN BERNARDINO 

050633 ... 0.0103 SAN LUIS OBISPO 

050667 ... 0.0478 NAPA 

050668 ... 0.0026 SAN FRANCISCO 

050678 ... 0.0029 ORANGE 

050680 ... 0.0269 SOLANO 

050690 ... 0.0308 SONOMA 

050693 ... 0.0029 ORANGE 

050695 ... 0.0555 SAN JOAQUIN 

050714 ... 0.0052 SANTA CRUZ 

050720 ... 0.0029 ORANGE 

050728 ... 0.0308 SONOMA 

050744 ... 0.0029 ORANGE 

050745 ... 0.0029 ORANGE 

050746 ... 0.0029 ORANGE 

050747 ... 0.0029 ORANGE 

050749 ... 0.0156 VENTURA 

052035 ... 0.0029 ORANGE 

052037 ... 0.0152 SAN BERNARDINO 

052039 ... 0.0029 ORANGE 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68399 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

053034 ... 0.0029 ORANGE 

053037 ... 0.0152 SAN BERNARDINO 

053304 ... 0.0029 ORANGE 

053306 ... 0.0029 ORANGE 

053308 ... 0.0029 ORANGE 

054074 ... 0.0269 SOLANO 

054077 ... 0.0156 VENTURA 

054089 ... 0.0026 SAN FRANCISCO 

054093 ... 0.0152 SAN BERNARDINO 

054111 ... 0.0152 SAN BERNARDINO 

054122 ... 0.0478 NAPA 

054123 ... 0.0555 SAN JOAQUIN 

054135 ... 0.0029 ORANGE 

054141 ... 0.0269 SOLANO 

054144 ... 0.0026 SAN FRANCISCO 

060001 ... 0.0294 WELD 

060003 ... 0.0203 BOULDER 

060010 ... 0.0153 LARIMER 

060027 ... 0.0203 BOULDER 

060030 ... 0.0153 LARIMER 

060103 ... 0.0203 BOULDER 

060116 ... 0.0203 BOULDER 

063033 ... 0.0153 LARIMER 

064007 ... 0.0203 BOULDER 

070003 ... 0.0009 WINDHAM 

070006 ... 0.0047 FAIRFIELD 

070010 ... 0.0047 FAIRFIELD 

070018 ... 0.0047 FAIRFIELD 

070020 ... 0.0073 MIDDLESEX 

070021 ... 0.0009 WINDHAM 

070028 ... 0.0047 FAIRFIELD 

070033 ... 0.0047 FAIRFIELD 

070034 ... 0.0047 FAIRFIELD 

074000 ... 0.0047 FAIRFIELD 

074003 ... 0.0073 MIDDLESEX 

074012 ... 0.0047 FAIRFIELD 

074014 ... 0.0047 FAIRFIELD 

080001 ... 0.0063 NEW CASTLE 

080003 ... 0.0063 NEW CASTLE 

082000 ... 0.0063 NEW CASTLE 

083300 ... 0.0063 NEW CASTLE 

084001 ... 0.0063 NEW CASTLE 

084002 ... 0.0063 NEW CASTLE 

084003 ... 0.0063 NEW CASTLE 

100014 ... 0.0118 VOLUSIA 

100017 ... 0.0118 VOLUSIA 

100045 ... 0.0118 VOLUSIA 

100047 ... 0.0021 CHARLOTTE 

100062 ... 0.0060 MARION 

100068 ... 0.0118 VOLUSIA 

100072 ... 0.0118 VOLUSIA 

100077 ... 0.0021 CHARLOTTE 

100102 ... 0.0125 COLUMBIA 

100118 ... 0.0398 FLAGLER 

100156 ... 0.0125 COLUMBIA 

100175 ... 0.0231 DE SOTO 

100212 ... 0.0060 MARION 

100232 ... 0.0347 PUTNAM 

100236 ... 0.0021 CHARLOTTE 

100252 ... 0.0233 OKEECHOBEE 

100290 ... 0.0582 SUMTER 

110023 ... 0.0500 GORDON 

110027 ... 0.0387 FRANKLIN 

110029 ... 0.0063 HALL 

110041 ... 0.0777 HABERSHAM 

110069 ... 0.0474 HOUSTON 

110124 ... 0.0428 WAYNE 

110146 ... 0.0805 CAMDEN 

110150 ... 0.0261 BALDWIN 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

110153 ... 0.0474 HOUSTON 

110187 ... 0.1172 LUMPKIN 

110189 ... 0.0031 FANNIN 

110190 ... 0.0182 MACON 

110205 ... 0.0779 GILMER 

114018 ... 0.0261 BALDWIN 

130003 ... 0.0095 NEZ PERCE 

130024 ... 0.0275 BONNER 

130049 ... 0.0349 KOOTENAI 

130066 ... 0.0349 KOOTENAI 

140012 ... 0.0220 LEE 

140026 ... 0.0346 LA SALLE 

140033 ... 0.0147 LAKE 

140043 ... 0.0046 WHITESIDE 

140058 ... 0.0081 MORGAN 

140084 ... 0.0147 LAKE 

140100 ... 0.0147 LAKE 

140110 ... 0.0346 LA SALLE 

140130 ... 0.0147 LAKE 

140155 ... 0.0027 KANKAKEE 

140160 ... 0.0286 STEPHENSON 

140161 ... 0.0138 LIVINGSTON 

140186 ... 0.0027 KANKAKEE 

140202 ... 0.0147 LAKE 

140205 ... 0.0163 BOONE 

140234 ... 0.0346 LA SALLE 

140291 ... 0.0147 LAKE 

150006 ... 0.0113 LA PORTE 

150015 ... 0.0113 LA PORTE 

150022 ... 0.0249 MONTGOMERY 

150030 ... 0.0201 HENRY 

150035 ... 0.0083 PORTER 

150045 ... 0.0416 DE KALB 

150065 ... 0.0139 JACKSON 

150076 ... 0.0189 MARSHALL 

150088 ... 0.0196 MADISON 

150091 ... 0.0573 HUNTINGTON 

150102 ... 0.0160 STARKE 

150113 ... 0.0196 MADISON 

150122 ... 0.0199 RIPLEY 

150146 ... 0.0319 NOBLE 

154047 ... 0.0189 MARSHALL 

154050 ... 0.0416 DE KALB 

160013 ... 0.0218 MUSCATINE 

160030 ... 0.0040 STORY 

160032 ... 0.0272 JASPER 

160080 ... 0.0049 CLINTON 

170137 ... 0.0336 DOUGLAS 

180012 ... 0.0083 HARDIN 

180066 ... 0.0567 LOGAN 

180127 ... 0.0352 FRANKLIN 

180128 ... 0.0282 LAWRENCE 

183028 ... 0.0083 HARDIN 

184012 ... 0.0083 HARDIN 

190001 ... 0.0645 WASHINGTON 

190003 ... 0.0107 IBERIA 

190015 ... 0.0401 TANGIPAHOA 

190017 ... 0.0235 ST. LANDRY 

190054 ... 0.0107 IBERIA 

190078 ... 0.0235 ST. LANDRY 

190088 ... 0.0705 WEBSTER 

190099 ... 0.0390 AVOYELLES 

190106 ... 0.0238 ALLEN 

190133 ... 0.0238 ALLEN 

190144 ... 0.0705 WEBSTER 

190184 ... 0.0161 CALDWELL 

190190 ... 0.0161 CALDWELL 

190191 ... 0.0235 ST. LANDRY 

190246 ... 0.0161 CALDWELL 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

192034 ... 0.0235 ST. LANDRY 

192036 ... 0.0401 TANGIPAHOA 

192040 ... 0.0401 TANGIPAHOA 

192046 ... 0.0645 WASHINGTON 

193044 ... 0.0401 TANGIPAHOA 

193079 ... 0.0401 TANGIPAHOA 

193091 ... 0.0107 IBERIA 

194080 ... 0.0645 WASHINGTON 

200002 ... 0.0129 LINCOLN 

200024 ... 0.0071 ANDROSCOGGIN 

200032 ... 0.0466 OXFORD 

200034 ... 0.0071 ANDROSCOGGIN 

200050 ... 0.0140 HANCOCK 

210001 ... 0.0129 WASHINGTON 

210004 ... 0.0040 MONTGOMERY 

210016 ... 0.0040 MONTGOMERY 

210018 ... 0.0040 MONTGOMERY 

210022 ... 0.0040 MONTGOMERY 

210023 ... 0.0209 ANNE ARUNDEL 

210028 ... 0.0512 ST. MARYS 

210043 ... 0.0209 ANNE ARUNDEL 

210048 ... 0.0287 HOWARD 

210057 ... 0.0040 MONTGOMERY 

212002 ... 0.0129 WASHINGTON 

213029 ... 0.004 MONTGOMERY 

214003 ... 0.0129 WASHINGTON 

214013 ... 0.004 MONTGOMERY 

220001 ... 0.0056 WORCESTER 

220002 ... 0.0249 MIDDLESEX 

220010 ... 0.0306 ESSEX 

220011 ... 0.0249 MIDDLESEX 

220019 ... 0.0056 WORCESTER 

220025 ... 0.0056 WORCESTER 

220028 ... 0.0056 WORCESTER 

220029 ... 0.0306 ESSEX 

220033 ... 0.0306 ESSEX 

220035 ... 0.0306 ESSEX 

220049 ... 0.0249 MIDDLESEX 

220058 ... 0.0056 WORCESTER 

220062 ... 0.0056 WORCESTER 

220063 ... 0.0249 MIDDLESEX 

220070 ... 0.0249 MIDDLESEX 

220080 ... 0.0306 ESSEX 

220082 ... 0.0249 MIDDLESEX 

220084 ... 0.0249 MIDDLESEX 

220089 ... 0.0249 MIDDLESEX 

220090 ... 0.0056 WORCESTER 

220095 ... 0.0056 WORCESTER 

220098 ... 0.0249 MIDDLESEX 

220101 ... 0.0249 MIDDLESEX 

220105 ... 0.0249 MIDDLESEX 

220163 ... 0.0056 WORCESTER 

220171 ... 0.0249 MIDDLESEX 

220174 ... 0.0306 ESSEX 

220176 ... 0.0056 WORCESTER 

222000 ... 0.0249 MIDDLESEX 

222003 ... 0.0249 MIDDLESEX 

222026 ... 0.0306 ESSEX 

222044 ... 0.0306 ESSEX 

222047 ... 0.0306 ESSEX 

222048 ... 0.0056 WORCESTER 

223026 ... 0.0249 MIDDLESEX 

223028 ... 0.0306 ESSEX 

223029 ... 0.0056 WORCESTER 

223033 ... 0.0056 WORCESTER 

224007 ... 0.0249 MIDDLESEX 

224022 ... 0.0249 MIDDLESEX 

224026 ... 0.0056 WORCESTER 

224032 ... 0.0056 WORCESTER 


cprice-sewell on PRODPC62 with RULES2
68400 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

224033 ... 0.0306 ESSEX 

224038 ... 0.0249 MIDDLESEX 

230003 ... 0.0035 OTTAWA 

230013 ... 0.0091 OAKLAND 

230015 ... 0.0359 ST. JOSEPH 

230019 ... 0.0091 OAKLAND 

230021 ... 0.0136 BERRIEN 

230022 ... 0.0113 BRANCH 

230029 ... 0.0091 OAKLAND 

230037 ... 0.0178 HILLSDALE 

230041 ... 0.0099 BAY 

230047 ... 0.0082 MACOMB 

230069 ... 0.0487 LIVINGSTON 

230071 ... 0.0091 OAKLAND 

230072 ... 0.0035 OTTAWA 

230075 ... 0.0145 CALHOUN 

230078 ... 0.0136 BERRIEN 

230092 ... 0.0389 JACKSON 

230093 ... 0.0079 MECOSTA 

230096 ... 0.0359 ST. JOSEPH 

230099 ... 0.0339 MONROE 

230106 ... 0.0030 NEWAYGO 

230121 ... 0.0691 SHIAWASSEE 

230130 ... 0.0091 OAKLAND 

230151 ... 0.0091 OAKLAND 

230174 ... 0.0035 OTTAWA 

230195 ... 0.0082 MACOMB 

230204 ... 0.0082 MACOMB 

230207 ... 0.0091 OAKLAND 

230217 ... 0.0145 CALHOUN 

230222 ... 0.0228 MIDLAND 

230223 ... 0.0091 OAKLAND 

230227 ... 0.0082 MACOMB 

230254 ... 0.0091 OAKLAND 

230257 ... 0.0082 MACOMB 

230264 ... 0.0082 MACOMB 

230269 ... 0.0091 OAKLAND 

230277 ... 0.0091 OAKLAND 

230279 ... 0.0487 LIVINGSTON 

232020 ... 0.0099 BAY 

232023 ... 0.0082 MACOMB 

232025 ... 0.0136 BERRIEN 

232028 ... 0.0145 CALHOUN 

232036 ... 0.0389 JACKSON 

233025 ... 0.0145 CALHOUN 

233028 ... 0.0091 OAKLAND 

234011 ... 0.0091 OAKLAND 

234021 ... 0.0082 MACOMB 

234023 ... 0.0091 OAKLAND 

234039 ... 0.0082 MACOMB 

240018 ... 0.1196 GOODHUE 

240044 ... 0.0868 WINONA 

240064 ... 0.0138 ITASCA 

240069 ... 0.0419 STEELE 

240071 ... 0.0454 RICE 

240187 ... 0.0506 MC LEOD 

240211 ... 0.0705 PINE 

250040 ... 0.0294 JACKSON 

254009 ... 0.0294 JACKSON 

260011 ... 0.0007 COLE 

260047 ... 0.0007 COLE 

260074 ... 0.0158 RANDOLPH 

260097 ... 0.0425 JOHNSON 

280077 ... 0.0089 DODGE 

280123 ... 0.0137 GAGE 

290019 ... 0.0026 CARSON CITY 

290049 ... 0.0026 CARSON CITY 

290051 ... 0.0026 CARSON CITY 

293029 ... 0.0026 CARSON CITY 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

300011 ... 0.0069 HILLSBOROUGH 

300012 ... 0.0069 HILLSBOROUGH 

300017 ... 0.0361 ROCKINGHAM 

300020 ... 0.0069 HILLSBOROUGH 

300023 ... 0.0361 ROCKINGHAM 

300029 ... 0.0361 ROCKINGHAM 

300034 ... 0.0069 HILLSBOROUGH 

303026 ... 0.0361 ROCKINGHAM 

304001 ... 0.0361 ROCKINGHAM 

310002 ... 0.0351 ESSEX 

310009 ... 0.0351 ESSEX 

310010 ... 0.0092 MERCER 

310011 ... 0.0115 CAPE MAY 

310013 ... 0.0351 ESSEX 

310018 ... 0.0351 ESSEX 

310021 ... 0.0092 MERCER 

310038 ... 0.0350 MIDDLESEX 

310039 ... 0.0350 MIDDLESEX 

310044 ... 0.0092 MERCER 

310054 ... 0.0351 ESSEX 

310070 ... 0.0350 MIDDLESEX 

310076 ... 0.0351 ESSEX 

310083 ... 0.0351 ESSEX 

310092 ... 0.0092 MERCER 

310093 ... 0.0351 ESSEX 

310096 ... 0.0351 ESSEX 

310108 ... 0.0350 MIDDLESEX 

310110 ... 0.0092 MERCER 

310119 ... 0.0351 ESSEX 

310123 ... 0.0351 ESSEX 

310124 ... 0.0350 MIDDLESEX 

312018 ... 0.035 MIDDLESEX 

312019 ... 0.0351 ESSEX 

313025 ... 0.0351 ESSEX 

313027 ... 0.0092 MERCER 

314010 ... 0.0351 ESSEX 

314011 ... 0.035 MIDDLESEX 

314013 ... 0.0092 MERCER 

314020 ... 0.0351 ESSEX 

320003 ... 0.0629 SAN MIGUEL 

320011 ... 0.0442 RIO ARRIBA 

320018 ... 0.0063 DONA ANA 

320085 ... 0.0063 DONA ANA 

323032 ... 0.0063 DONA ANA 

324010 ... 0.0063 DONA ANA 

324012 ... 0.0063 DONA ANA 

330004 ... 0.0959 ULSTER 

330008 ... 0.0470 WYOMING 

330027 ... 0.0137 NASSAU 

330094 ... 0.0778 COLUMBIA 

330106 ... 0.0137 NASSAU 

330126 ... 0.0560 ORANGE 

330135 ... 0.0560 ORANGE 

330167 ... 0.0137 NASSAU 

330181 ... 0.0137 NASSAU 

330182 ... 0.0137 NASSAU 

330191 ... 0.0026 WARREN 

330198 ... 0.0137 NASSAU 

330205 ... 0.0560 ORANGE 

330224 ... 0.0959 ULSTER 

330225 ... 0.0137 NASSAU 

330235 ... 0.0270 CAYUGA 

330259 ... 0.0137 NASSAU 

330264 ... 0.0560 ORANGE 

330276 ... 0.0063 FULTON 

330331 ... 0.0137 NASSAU 

330332 ... 0.0137 NASSAU 

330372 ... 0.0137 NASSAU 

330386 ... 0.1139 SULLIVAN 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

334017 ... 0.056 ORANGE 

334061 ... 0.056 ORANGE 

340015 ... 0.0267 ROWAN 

340020 ... 0.0207 LEE 

340021 ... 0.0216 CLEVELAND 

340037 ... 0.0216 CLEVELAND 

340039 ... 0.0144 IREDELL 

340069 ... 0.0053 WAKE 

340070 ... 0.0448 ALAMANCE 

340073 ... 0.0053 WAKE 

340085 ... 0.0377 DAVIDSON 

340096 ... 0.0377 DAVIDSON 

340104 ... 0.0216 CLEVELAND 

340114 ... 0.0053 WAKE 

340126 ... 0.0161 WILSON 

340127 ... 0.0961 GRANVILLE 

340129 ... 0.0144 IREDELL 

340133 ... 0.0308 MARTIN 

340138 ... 0.0053 WAKE 

340144 ... 0.0144 IREDELL 

340145 ... 0.0563 LINCOLN 

340173 ... 0.0053 WAKE 

344001 ... 0.0053 WAKE 

344004 ... 0.0961 GRANVILLE 

344014 ... 0.0053 WAKE 

360013 ... 0.0166 SHELBY 

360025 ... 0.0087 ERIE 

360036 ... 0.0263 WAYNE 

360065 ... 0.0141 HURON 

360070 ... 0.0028 STARK 

360078 ... 0.0159 PORTAGE 

360084 ... 0.0028 STARK 

360086 ... 0.0168 CLARK 

360095 ... 0.0087 HANCOCK 

360100 ... 0.0028 STARK 

360107 ... 0.0213 SANDUSKY 

360131 ... 0.0028 STARK 

360151 ... 0.0028 STARK 

360156 ... 0.0213 SANDUSKY 

360175 ... 0.0159 CLINTON 

360187 ... 0.0168 CLARK 

360197 ... 0.0092 LOGAN 

360270 ... 0.0120 DEFIANCE 

362007 ... 0.0213 SANDUSKY 

362032 ... 0.0028 STARK 

364031 ... 0.0028 STARK 

364040 ... 0.0168 CLARK 

370004 ... 0.0193 OTTAWA 

370014 ... 0.0831 BRYAN 

370015 ... 0.0463 MAYES 

370023 ... 0.0084 STEPHENS 

370065 ... 0.0121 CRAIG 

370113 ... 0.0205 DELAWARE 

370149 ... 0.0356 POTTAWATOMIE 

370219 ... 0.0356 POTTAWATOMIE 

372019 ... 0.0356 POTTAWATOMIE 

374017 ... 0.0193 OTTAWA 

380002 ... 0.0130 JOSEPHINE 

380022 ... 0.0201 LINN 

380029 ... 0.0075 MARION 

380051 ... 0.0075 MARION 

380056 ... 0.0075 MARION 

384008 ... 0.0075 MARION 

390011 ... 0.0012 CAMBRIA 

390030 ... 0.0284 SCHUYLKILL 

390031 ... 0.0284 SCHUYLKILL 

390044 ... 0.0200 BERKS 

390046 ... 0.0098 YORK 

390056 ... 0.0042 HUNTINGDON 


cprice-sewell on PRODPC62 with RULES2
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 68401 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

390065 ... 0.0501 ADAMS 

390066 ... 0.0259 LEBANON 

390096 ... 0.0200 BERKS 

390101 ... 0.0098 YORK 

390110 ... 0.0012 CAMBRIA 

390130 ... 0.0012 CAMBRIA 

390138 ... 0.0325 FRANKLIN 

390146 ... 0.0053 WARREN 

390150 ... 0.0206 GREENE 

390151 ... 0.0325 FRANKLIN 

390162 ... 0.0200 NORTHAMPTON 

390181 ... 0.0284 SCHUYLKILL 

390183 ... 0.0284 SCHUYLKILL 

390201 ... 0.1127 MONROE 

390233 ... 0.0098 YORK 

392031 ... 0.0012 CAMBRIA 

392034 ... 0.02 NORTHAMPTON 

393026 ... 0.02 BERKS 

393037 ... 0.0098 YORK 

394014 ... 0.02 BERKS 

394016 ... 0.0053 WARREN 

394020 ... 0.0259 LEBANON 

420007 ... 0.0001 SPARTANBURG 

420009 ... 0.0113 OCONEE 

420020 ... 0.0035 GEORGETOWN 

420027 ... 0.0210 ANDERSON 

420030 ... 0.0103 COLLETON 

420039 ... 0.0153 UNION 

420043 ... 0.0177 CHEROKEE 

420062 ... 0.0109 CHESTERFIELD 

420068 ... 0.0097 ORANGEBURG 

420070 ... 0.0101 SUMTER 

420083 ... 0.0001 SPARTANBURG 

420098 ... 0.0035 GEORGETOWN 

423029 ... 0.021 ANDERSON 

424011 ... 0.021 ANDERSON 

440008 ... 0.0663 HENDERSON 

440024 ... 0.0387 BRADLEY 

440030 ... 0.0056 HAMBLEN 

440035 ... 0.0441 MONTGOMERY 

440047 ... 0.0499 GIBSON 

440056 ... 0.0321 JEFFERSON 

440060 ... 0.0499 GIBSON 

440063 ... 0.0011 WASHINGTON 

440067 ... 0.0056 HAMBLEN 

440073 ... 0.0513 MAURY 

440105 ... 0.0011 WASHINGTON 

440115 ... 0.0499 GIBSON 

440148 ... 0.0568 DE KALB 

440153 ... 0.0007 COCKE 

440174 ... 0.0372 HAYWOOD 

440181 ... 0.0407 HARDEMAN 

440184 ... 0.0011 WASHINGTON 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

440185 ... 0.0387 BRADLEY 

444008 ... 0.0407 HARDEMAN 

450032 ... 0.0416 HARRISON 

450039 ... 0.0097 TARRANT 

450059 ... 0.0073 COMAL 

450064 ... 0.0097 TARRANT 

450087 ... 0.0097 TARRANT 

450099 ... 0.0180 GRAY 

450121 ... 0.0097 TARRANT 

450135 ... 0.0097 TARRANT 

450137 ... 0.0097 TARRANT 

450144 ... 0.0573 ANDREWS 

450163 ... 0.0134 KLEBERG 

450187 ... 0.0264 WASHINGTON 

450194 ... 0.0328 CHEROKEE 

450214 ... 0.0368 WHARTON 

450224 ... 0.0411 WOOD 

450324 ... 0.0132 GRAYSON 

450347 ... 0.0427 WALKER 

450370 ... 0.0258 COLORADO 

450389 ... 0.0881 HENDERSON 

450393 ... 0.0132 GRAYSON 

450395 ... 0.0484 POLK 

450419 ... 0.0097 TARRANT 

450438 ... 0.0258 COLORADO 

450447 ... 0.0358 NAVARRO 

450451 ... 0.0551 SOMERVELL 

450465 ... 0.0435 MATAGORDA 

450469 ... 0.0132 GRAYSON 

450547 ... 0.0411 WOOD 

450563 ... 0.0097 TARRANT 

450565 ... 0.0486 PALO PINTO 

450596 ... 0.0808 HOOD 

450597 ... 0.0077 DE WITT 

450639 ... 0.0097 TARRANT 

450672 ... 0.0097 TARRANT 

450675 ... 0.0097 TARRANT 

450677 ... 0.0097 TARRANT 

450694 ... 0.0368 WHARTON 

450747 ... 0.0195 ANDERSON 

450755 ... 0.0484 HOCKLEY 

450779 ... 0.0097 TARRANT 

450813 ... 0.0195 ANDERSON 

450872 ... 0.0097 TARRANT 

450880 ... 0.0097 TARRANT 

450886 ... 0.0097 TARRANT 

450888 ... 0.0097 TARRANT 

452018 ... 0.0097 TARRANT 

452019 ... 0.0097 TARRANT 

452028 ... 0.0097 TARRANT 

452041 ... 0.0132 GRAYSON 

452088 ... 0.0097 TARRANT 

453040 ... 0.0097 TARRANT 

ADDENDUM L.—OUT-MIGRATION

ADJUSTMENT—Continued 

Provider 

No. 

Outmigration 

adjustment 

Qualifying county 

name 

453041 ... 0.0097 TARRANT 

453042 ... 0.0097 TARRANT 

453089 ... 0.0195 ANDERSON 

453094 ... 0.0097 TARRANT 

453300 ... 0.0097 TARRANT 

454009 ... 0.0328 CHEROKEE 

454012 ... 0.0097 TARRANT 

460017 ... 0.0392 BOX ELDER 

460039 ... 0.0392 BOX ELDER 

490019 ... 0.1240 CULPEPER 

490038 ... 0.0022 SMYTH 

490084 ... 0.0167 ESSEX 

490105 ... 0.0022 SMYTH 

490110 ... 0.0082 MONTGOMERY 

494029 ... 0.0022 SMYTH 

500003 ... 0.0208 SKAGIT 

500007 ... 0.0208 SKAGIT 

500019 ... 0.0213 LEWIS 

500021 ... 0.0055 PIERCE 

500024 ... 0.0023 THURSTON 

500039 ... 0.0174 KITSAP 

500041 ... 0.0118 COWLITZ 

500079 ... 0.0055 PIERCE 

500108 ... 0.0055 PIERCE 

500129 ... 0.0055 PIERCE 

500139 ... 0.0023 THURSTON 

500143 ... 0.0023 THURSTON 

503301 ... 0.0055 PIERCE 

504003 ... 0.0055 PIERCE 

510018 ... 0.0209 JACKSON 

510039 ... 0.0112 OHIO 

510047 ... 0.0275 MARION 

510050 ... 0.0112 OHIO 

510077 ... 0.0021 MINGO 

513025 ... 0.0112 OHIO 

520028 ... 0.0157 GREEN 

520035 ... 0.0077 SHEBOYGAN 

520044 ... 0.0077 SHEBOYGAN 

520057 ... 0.0118 SAUK 

520059 ... 0.0200 RACINE 

520071 ... 0.0239 JEFFERSON 

520095 ... 0.0118 SAUK 

520096 ... 0.0200 RACINE 

520102 ... 0.0298 WALWORTH 

520116 ... 0.0239 JEFFERSON 

520132 ... 0.0077 SHEBOYGAN 

522005 ... 0.02 RACINE 

[FR Doc. 06–9079 Filed 11–1–06; 4:00 pm] 

BILLING CODE 4120–01–P 


cprice-sewell on PRODPC62 with RULES2