DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Parts 403, 405, 410, 411, 412, 413, 414, 425, 489, 495, and 498 

[CMS-1612-FC] 

RIN 0938-AS12 

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

Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare 

and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 

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

ACTION: Final rule with comment period. 

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

schedule, and other Medicare Part B payment policies to ensure that our payment systems are 

updated to reflect changes in medical practice and the relative value of services, as well as 

changes in the statute. See the Table of Contents for a listing of the specific issues addressed in 

this rule. 

DATES: Effective date: The provisions of this final rule are effective on January 1, 2015, with 

the exception of amendments to parts 412, 413, and 495 which are effective October 31, 2014. 

Comment date: To be assured consideration, comments must be received at one of the addresses 

provided below, no later than 5 p.m. on December 30, 2014. 

Compliance date: The compliance date for new data collection requirements in §403.904(c)(8) is 

January 1, 2016. 

ADDRESSES: In commenting, please refer to file code CMS-1612-FC. Because of staff and 

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

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

listed): 
CMS-1612-FC 2

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

www.regulations.gov. Follow the instructions for "submitting a comment." 

 2. By regular mail. You may mail written comments to the following address ONLY: 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Attention: CMS-1612-FC, 

P.O. Box 8013, 

Baltimore, MD 21244-8013. 

Please allow sufficient time for mailed comments to be received before the close of the 

comment period. 

3. By express or overnight mail. You may send written comments to the following 

address ONLY: 

 Centers for Medicare & Medicaid Services, 

 Department of Health and Human Services, 

 Attention: CMS-1612-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 before the close of the comment period to either of the following addresses: 

a. For delivery in Washington, DC-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Room 445-G, Hubert H. Humphrey Building, 
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 200 Independence Avenue, SW., 

 Washington, DC 20201 

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

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

leave their comments in the CMS drop slots located in the main lobby of the building. A stampin clock is available for persons wishing to retain a proof of filing by stamping in and retaining 

an extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

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

number (410) 786-7195 in advance to schedule your arrival with one of our staff members. 

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

may be delayed and received after the comment period.

FOR FURTHER INFORMATION CONTACT: 

Donta Henson, (410) 786-1947 for any physician payment issues not identified below.

Gail Addis, (410) 786-4522, for issues related to the refinement panel. 

Chava Sheffield, (410) 786–2298, for issues related to practice expense methodology, 

impacts, the sustainable growth rate, conscious sedation, or conversion factors. 

Kathy Kersell, (410) 786–2033, for issues related to direct practice expense inputs. 

Jessica Bruton, (410) 786-5991, for issues related to potentially misvalued services or 

work RVUs. 
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Craig Dobyski, (410) 786–4584, for issues related to geographic practice cost indices or 

malpractice RVUs. 

Ken Marsalek, (410) 786–4502, for issues related to telehealth services. 

Pam West, (410) 786-2302, for issues related to conditions for therapists in private 

practice or therapy caps. 

Ann Marshall, (410) 786-3059, for issues related to chronic care management. 

Marianne Myers, (410) 786-5962, for issues related to ambulance extender provisions. 

Amy Gruber, (410) 786-1542, for issues related to changes in geographic area 

designations for ambulance payment. 

Anne Tayloe-Hauswald, (410) 786–4546, for issues related to clinical lab fee schedule. 

Corinne Axelrod, (410) 786–5620, for issues related to Rural Health Clinics or Federally 

Qualified Health Centers. 

Renee Mentnech, (410) 786-6692, for issues related to access to identifiable data for the 

Centers for Medicare & Medicaid models. 

Marie Casey, (410) 786-7861 or Karen Reinhardt (410) 786-0189 for issues related to 

local coverage determination process for clinical diagnostic laboratory tests. 

Frederick Grabau, (410) 786-0206, for issues related to private contracting/opt-out. 

David Walczak, (410) 786-4475, for issues related to payment policy for substitute 

physician billing arrangements (locum tenens). 

Melissa Heesters, (410) 786-0618, for issues related to reports of payments or other 

transfers of value to covered recipients. 

Alesia Hovatter, (410) 786-6861, for issues related to physician compare. 

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

system. 

Alexandra Mugge (410) 786-4457, for issues related to EHR incentive program. 
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Patrice Holtz, (410)786–5663, for issues related to comprehensive primary care initiative. 

Terri Postma, (410) 786-4169, for issues related to Medicare Shared Savings Program. 

Kimberly Spalding Bush, (410) 786-3232, for issues related to value-based modifier and 

improvements to physician feedback. 

Elizabeth Holland, (410) 786-1309, Medicare EHR Incentive Program (Medicare 

payment adjustments and hardship exceptions). 

Elisabeth Myers (CMS), (410) 786-4751, Medicare EHR Incentive Program (Medicare 

payment adjustments and hardship exceptions). 

SUPPLEMENTARY INFORMATION: 

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

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

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

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

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

to view public comments. 

 Comments received timely will also be available for public inspection as they are 

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

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

Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To 

schedule an appointment to view public comments, phone 1-800-743-3951. 

Table of Contents 

I. Executive Summary and Background 

A. Executive Summary 

B. Background 

C. Health Information Technology 
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II. Provisions of the Final Rule with Comment Period for PFS 

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

B. Potentially Misvalued Services Under the Physician Fee Schedule 

C. Malpractice Relative Value Units (RVUs) 

D. Geographic Practice Cost Indices (GPCIs) 

E. Medicare Telehealth Services 

F. Valuing New, Revised and Potentially Misvalued Codes 

G. Establishing RVUs for CY 2015 

H. Chronic Care Management (CCM) 

I. Therapy Caps for CY 2015 

J. Definition of Colorectal Cancer Screening Tests 

K. Payment of Secondary Interpretation of Images 

L. Conditions Regarding Permissible Practice Types for Therapists in Private Practice 

M. Payments for Practitioners Managing Patients on Home Dialysis 

N. Sustainable Growth Rate 

III. Other Provisions of the Final Rule with Comment Period Regulation 

A. Ambulance Extender Provisions 

B. Changes in Geographic Area Delineations for Ambulance Payment 

C. Clinical Laboratory Fee Schedule 

D. Removal of Employment Requirements for Services Furnished “Incident to” Rural 

Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Visits

E. Access to Identifiable Data for the Center for Medicare and Medicaid Innovation 

Models 

F. Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests 

G. Private Contracting/Opt-out 
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H. Solicitation of Comments on the Payment Policy for Substitute Physician Billing 

Arrangements 

I. Reports of Payments or Other Transfers of Value to Covered Recipients 

J. Physician Compare Website 

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

Reporting System 

L. Electronic Health Record (EHR) Incentive Program 

M. Medicare Shared Savings Program 

N. Value-Based Payment Modifier and Physician Feedback Program 

O. Establishment of the Federally Qualified Health Center Prospective Payment System 

(FQHC PPS) 

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

Codes 

Q. Interim Final Revisions to the Electronic Health Record (EHR) Incentive Program 

IV. Collection of Information Requirements 

V. Response to Comments 

VI. Waiver of Proposed Rulemaking and Waiver of Delay in Effective Date 

VII. Regulatory Impact Analysis 

Regulations Text 

Acronyms 

 In addition, because of the many organizations and terms to which we refer by acronym 

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

terms in alphabetical order below: 

AAA Abdominal aortic aneurysms 

ACO Accountable care organization 
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AMA American Medical Association 

ASC Ambulatory surgical center 

ATA American Telehealth Association 

ATRA American Taxpayer Relief Act (Pub. L. 112-240) 

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

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

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

CAD Coronary artery disease 

CAH Critical access hospital 

CBSA Core-Based Statistical Area 

CCM Chronic care management 

CEHRT Certified EHR technology 

CF Conversion factor 

CG-CAHPS Clinician and Group Consumer Assessment of Healthcare Providers and Systems 

CLFS Clinical Laboratory Fee Schedule 

CNM Certified nurse-midwife 

CP Clinical psychologist 

CPC Comprehensive Primary Care 

CPEP Clinical Practice Expert Panel 

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

data only are copyright 2014 American Medical Association. All rights 

reserved.) 

CQM Clinical quality measure 

CSW Clinical social worker 

CT Computed tomography 
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CY Calendar year 

DFAR Defense Federal Acquisition Regulations 

DHS Designated health services 

DM Diabetes mellitus 

DSMT Diabetes self-management training 

eCQM Electronic clinical quality measures 

EHR Electronic health record 

E/M Evaluation and management 

EP Eligible professional 

eRx Electronic prescribing 

ESRD End-stage renal disease 

FAR Federal Acquisition Regulations 

FFS Fee-for-service 

FQHC Federally qualified health center 

FR Federal Register 

GAF Geographic adjustment factor 

GAO Government Accountability Office

GPCI Geographic practice cost index 

GPO Group purchasing organization 

GPRO Group practice reporting option 

GTR Genetic Testing Registry 

HCPCS Healthcare Common Procedure Coding System 

HHS [Department of] Health and Human Services 

HOPD Hospital outpatient department 

HPSA Health professional shortage area 
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IDTF Independent diagnostic testing facility 

IPPS Inpatient Prospective Payment System 

IQR Inpatient Quality Reporting 

ISO Insurance service office 

IWPUT Intensity of work per unit of time 

LCD Local coverage determination 

MA Medicare Advantage 

MAC Medicare Administrative Contractor 

MAP Measure Applications Partnership 

MAPCP Multi-payer Advanced Primary Care Practice 

MAV Measure application validity [process] 

MCP Monthly capitation payment 

MedPAC Medicare Payment Advisory Commission 

MEI Medicare Economic Index 

MFP Multi-Factor Productivity 

MIPPA Medicare Improvements for Patients and Providers Act (Pub. L. 110-275) 

MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003 

(Pub. L. 108-173, enacted on December 8, 2003) 

MP Malpractice 

MPPR Multiple procedure payment reduction 

MRA Magnetic resonance angiography 

MRI Magnetic resonance imaging 

MSA Metropolitan Statistical Areas 

MSPB Medicare Spending per Beneficiary 

MSSP Medicare Shared Savings Program 
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MU Meaningful use 

NCD National coverage determination 

NCQDIS National Coalition of Quality Diagnostic Imaging Services 

NP Nurse practitioner 

NPI National Provider Identifier 

NPP Nonphysician practitioner 

NQS National Quality Strategy 

OACT CMS’s Office of the Actuary 

OBRA ‘89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) 

OBRA ’90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101- 508) 

OES Occupational Employment Statistics 

OMB Office of Management and Budget 

OPPS Outpatient prospective payment system 

OT Occupational therapy 

PA Physician assistant 

PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113-93) 

PC Professional component 

PCIP Primary Care Incentive Payment 

PE Practice expense 

PE/HR Practice expense per hour 

PEAC Practice Expense Advisory Committee 

PECOS Provider Enrollment, Chain, and Ownership System 

PFS Physician Fee Schedule 

PLI Professional Liability Insurance 

PMA Premarket approval 
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PQRS Physician Quality Reporting System 

PPIS Physician Practice Expense Information Survey 

PT Physical therapy 

PY Performance year 

QCDR Qualified clinical data registry 

QRUR Quality and Resources Use Report 

RBRVS Resource-based relative value scale 

RFA Regulatory Flexibility Act 

RHC Rural health clinic 

RIA Regulatory impact analysis 

RUC American Medical Association/Specialty Society Relative (Value) Update 

Committee 

RUCA Rural Urban Commuting Area 

RVU Relative value unit 

SBA Small Business Administration 

SGR Sustainable growth rate 

SIM State Innovation Model 

SLP Speech-language pathology 

SMS Socioeconomic Monitoring System 

SNF Skilled nursing facility 

TAP Technical Advisory Panel 

TC Technical component 

TIN Tax identification number 

UAF Update adjustment factor 

UPIN Unique Physician Identification Number 
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USPSTF United States Preventive Services Task Force 

VBP Value-based purchasing 

VM Value-Based Payment Modifier 

Addenda Available Only Through the Internet on the CMS Website 

The PFS Addenda along with other supporting documents and tables referenced in this 

final rule with comment period are available through the Internet on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. Click on the link on the left side of the screen titled, ‘‘PFS 

Federal Regulations Notices’’ for a chronological list of PFS Federal Register and other related 

documents. For the CY 2015 PFS final rule with comment period, refer to item CMS–1612–FC. 

Readers who experience any problems accessing any of the Addenda or other documents 

referenced in this rule and posted on the CMS website identified above should contact 

donta.henson1@cms.hhs.gov. 

CPT (Current Procedural Terminology) Copyright Notice 

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

refer to a variety of services. We note that CPT codes and descriptions are copyright 2013 

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

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

Defense Federal Acquisition Regulations (DFAR) apply. 

I. Executive Summary and Background 

A. Executive Summary 

1. Purpose 

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

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

payment. These changes are applicable to services furnished in CY 2015. 
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2. Summary of the Major Provisions 

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

on national uniform relative value units (RVUs) that account for the relative resources used in 

furnishing a service. The Act requires that RVUs be established for three categories of 

resources: work, practice expense (PE); and malpractice (MP) expense; and, that we establish by 

regulation each year’s payment amounts for all physicians’ services, incorporating geographic 

adjustments to reflect the variations in the costs of furnishing services in different geographic 

areas. In this major final rule with comment period, we establish RVUs for CY 2015 for the 

PFS, and other Medicare Part B payment policies, to ensure that our payment systems are 

updated to reflect changes in medical practice and the relative value of services, as well as 

changes in the statute. In addition, this final rule with comment period includes discussions and 

proposals regarding: 

● Misvalued PFS Codes. 

● Telehealth Services. 

● Chronic Care Management Services. 

● Establishing Values for New, Revised, and Misvalued Codes. 

● Updating the Ambulance Fee Schedule regulations. 

● Changes in Geographic Area Delineations for Ambulance Payment. 

● Updating the- 

++ Physician Compare Website. 

++ Physician Quality Reporting System. 

++ Medicare Shared Savings Program. 

++ Electronic Health Record (EHR) Incentive Program. 

● Value-Based Payment Modifier and the Physician Feedback Program. 

3. Summary of Costs and Benefits 
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 The Act requires that annual adjustments to PFS RVUs may not cause annual estimated 

expenditures to differ by more than $20 million from what they would have been had the 

adjustments not been made. If adjustments to RVUs would cause expenditures to change by 

more than $20 million, we must make adjustments to preserve budget neutrality. These 

adjustments can affect the distribution of Medicare expenditures across specialties. In addition, 

several proposed changes would affect the specialty distribution of Medicare expenditures. 

When considering the combined impact of work, PE, and MP RVU changes, the projected 

payment impacts are small for most specialties; however, the impact would be larger for a few 

specialties. 

 We have determined that this final rule with comment period is economically significant. 

For a detailed discussion of the economic impacts, see section VII. of this final rule with 

comment period. 

B. Background 

Since January 1, 1992, Medicare has paid for physicians’ services under section 1848 of 

the Act, “Payment for Physicians' Services.” The system relies on national relative values that 

are established for work, PE, and MP, which are adjusted for geographic cost variations. These 

values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. The 

concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget 

Reconciliation Act of 1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA ’89), and 

the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on November 5, 

1990) (OBRA ’90). The final rule published on November 25, 1991 (56 FR 59502) set forth the 

first fee schedule used for payment for physicians’ services. 

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

term “practitioner” is used to describe both physicians and nonphysician practitioners (NPPs) 
CMS-1612-FC 16

who are permitted to bill Medicare under the PFS for services furnished to Medicare 

beneficiaries. 

1. Development of the Relative Values 

a. Work RVUs 

The work RVUs established for the initial fee schedule, which was implemented on 

January 1, 1992, were developed with extensive input from the physician community. A 

research team at the Harvard School of Public Health developed the original work RVUs for 

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

(HHS). In constructing the code-specific vignettes used in determining the original physician 

work RVUs, Harvard worked with panels of experts, both inside and outside the federal 

government, and obtained input from numerous physician specialty groups. 

 As specified in section 1848(c)(1)(A) of the Act, the work component of physicians’ 

services means the portion of the resources used in furnishing the service that reflects physician 

time and intensity. We establish work RVUs for new, revised and potentially misvalued codes 

based on our review of information that generally includes, but is not limited to, 

recommendations received from the American Medical Association/Specialty Society Relative 

Value Update Committee (RUC), the Health Care Professionals Advisory Committee (HCPAC), 

the Medicare Payment Advisory Commission (MedPAC), and other public commenters; medical 

literature and comparative databases; as well as a comparison of the work for other codes within 

the Medicare PFS, and consultation with other physicians and health care professionals within 

CMS and the federal government. We also assess the methodology and data used to develop the 

recommendations submitted to us by the RUC and other public commenters, and the rationale for 

their recommendations. 

b. Practice Expense RVUs 
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Initially, only the work RVUs were resource-based, and the PE and MP RVUs were 

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

of 1994 (Pub. L. 103-432, enacted on October 31, 1994), amended section 1848(c)(2)(C)(ii) of 

the Act and required us to develop resource-based PE RVUs for each physicians’ service 

beginning in 1998. We were required to consider general categories of expenses (such as office 

rent and wages of personnel, but excluding malpractice expenses) comprising PEs. The PE 

RVUs continue to represent the portion of these resources involved in furnishing PFS services. 

Originally, the resource-based method was to be used beginning in 1998, but section 

4505(a) of the Balanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) (BBA) 

delayed implementation of the resource-based PE RVU system until January 1, 1999. In 

addition, section 4505(b) of the BBA provided for a 4-year transition period from the 

charge-based PE RVUs to the resource-based PE RVUs. 

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

published on November 2, 1998 (63 FR 58814), effective for services furnished in CY 1999. 

Based on the requirement to transition to a resource-based system for PE over a 4-year period, 

payment rates were not fully based upon resource-based PE RVUs until CY 2002. This 

resource-based system was based on two significant sources of actual PE data: the Clinical 

Practice Expert Panel (CPEP) data and the AMA’s Socioeconomic Monitoring System (SMS) 

data. (These data sources are described in greater detail in the CY 2012 final rule with comment 

period (76 FR 73033).) 

Separate PE RVUs are established for services furnished in facility settings, such as a 

hospital outpatient department (HOPD) or an ambulatory surgical center (ASC), and in 

nonfacility settings, such as a physician’s office. The nonfacility RVUs reflect all of the direct 

and indirect PEs involved in furnishing a service described by a particular HCPCS code. The 

difference, if any, in these PE RVUs generally results in a higher payment in the nonfacility 
CMS-1612-FC 18

setting because in the facility settings some costs are borne by the facility. Medicare’s payment 

to the facility (such as the outpatient prospective payment system (OPPS) payment to the HOPD) 

would reflect costs typically incurred by the facility. Thus, payment associated with those 

facility resources is not made under the PFS. 

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

on November 29, 1999) (BBRA) directed the Secretary of Health and Human Services (the 

Secretary) to establish a process under which we accept and use, to the maximum extent 

practicable and consistent with sound data practices, data collected or developed by entities and 

organizations to supplement the data we normally collect in determining the PE component. On 

May 3, 2000, we published the interim final rule (65 FR 25664) that set forth the criteria for the 

submission of these supplemental PE survey data. The criteria were modified in response to 

comments received, and published in the Federal Register (65 FR 65376) as part of a 

November 1, 2000 final rule. The PFS final rules published in 2001 and 2003, respectively, 

(66 FR 55246 and 68 FR 63196) extended the period during which we would accept these 

supplemental data through March 1, 2005. 

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

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

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

completed for CY 2010. In the CY 2010 PFS final rule with comment period, we updated the 

practice expense per hour (PE/HR) data that are used in the calculation of PE RVUs for most 

specialties (74 FR 61749). In CY 2010, we began a 4-year transition to the new PE RVUs using 

the updated PE/HR data, which was completed for CY 2013. 

c. Malpractice RVUs 

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

implement resource-based MP RVUs for services furnished on or after CY 2000. The 
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resource-based MP RVUs were implemented in the PFS final rule with comment period 

published November 2, 1999 (64 FR 59380). The MP RVUs are based on commercial and 

physician-owned insurers’ malpractice insurance premium data from all the states, the District of 

Columbia, and Puerto Rico. For more information on MP RVUs, see section II.C. of this final 

rule with comment period. 

d. Refinements to the RVUs 

Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than 

every 5 years. Prior to CY 2013, we conducted periodic reviews of work RVUs and PE RVUs 

independently. We completed five-year reviews of work RVUs that were effective for calendar 

years 1997, 2002, 2007, and 2012. 

Although refinements to the direct PE inputs initially relied heavily on input from the 

RUC Practice Expense Advisory Committee (PEAC), the shifts to the bottom-up PE 

methodology in CY 2007 and to the use of the updated PE/HR data in CY 2010 have resulted in 

significant refinements to the PE RVUs in recent years. 

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

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

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

annual process. 

With regard to MP RVUs, we completed five-year reviews of MP that were effective in 

CY 2005 and CY 2010. This final rule with comment period establishes a five-year review for 

CY 2015. 

In addition to the five-year reviews, beginning for CY 2009, CMS, and the RUC have 

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

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

misvalued codes was supplemented by the amendments to section 1848 of the Act, as enacted by 
CMS-1612-FC 20

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

review and adjust values for potentially misvalued codes. 

e. Application of Budget Neutrality to Adjustments of RVUs 

 As described in section VI.C. of this final rule with comment period, in accordance with 

section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs caused expenditures for the year 

to change by more than $20 million, we make adjustments to ensure that expenditures did not 

increase or decrease by more than $20 million. 

2. Calculation of Payments Based on RVUs 

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

schedule (work, PE, and MP RVUs) are adjusted by geographic practice cost indices (GPCIs) to 

reflect the variations in the costs of furnishing the services. The GPCIs reflect the relative costs 

of physician work, PE, and MP in an area compared to the national average costs for each 

component. (See section II.D. of this final rule with comment period for more information about 

GPCIs.) 

RVUs are converted to dollar amounts through the application of a CF, which is 

calculated based on a statutory formula by CMS’s Office of the Actuary (OACT). The CF for a 

given year is calculated using (a) the productivity-adjusted increase in the Medicare Economic 

Index (MEI) and (b) the Update Adjustment Factor (UAF), which is calculated by taking into 

account the Medicare Sustainable Growth Rate (SGR), an annual growth rate intended to control 

growth in aggregate Medicare expenditures for physicians’ services, and the allowed and actual 

expenditures for physicians’ services. The formula for calculating the Medicare fee schedule 

payment amount for a given service and fee schedule area can be expressed as: 

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI 

MP)] x CF. 

3. Separate Fee Schedule Methodology for Anesthesia Services 
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Section 1848(b)(2)(B) of the Act specifies that the fee schedule amounts for anesthesia 

services are to be based on a uniform relative value guide, with appropriate adjustment of an 

anesthesia conversion factor, in a manner to assure that fee schedule amounts for anesthesia 

services are consistent with those for other services of comparable value. Therefore, there is a 

separate fee schedule methodology for anesthesia services. Specifically, we establish a separate 

conversion factor for anesthesia services and we utilize the uniform relative value guide, or base 

units, as well as time units, to calculate the fee schedule amounts for anesthesia services. Since 

anesthesia services are not valued using RVUs, a separate methodology for locality adjustments 

is also necessary. This involves an adjustment to the national anesthesia CF for each payment 

locality. 

4. Most Recent Changes to the Fee Schedule 

The CY 2014 PFS final rule with comment period (78 FR 74230) implemented changes 

to the PFS and other Medicare Part B payment policies. It also finalized many of the CY 2013 

interim final RVUs and established interim final RVUs for new and revised codes for CY 2014 

to ensure that our payment system is updated to reflect changes in medical practice, coding 

changes, and the relative values of services. It also implemented section 635 of the American 

Taxpayer Relief Act of 2012 (Pub. L. 112-240, enacted on January 2, 2013) (ATRA), which 

revised the equipment utilization rate assumption for advanced imaging services furnished on or 

after January 1, 2014. 

Also, in the CY 2014 PFS final rule with comment period, we announced the following 

for CY 2014: the total PFS update of -20.1 percent; the initial estimate for the SGR of -

16.7 percent; and a CF of $27.2006. These figures were calculated based on the statutory 

provisions in effect on November 27, 2013, when the CY 2014 PFS final rule with comment 

period was issued. 
CMS-1612-FC 22

The Pathway for SGR Reform Act of 2013 (Pub. L. 113-67, enacted on December 26, 

2013) established a 0.5 percent update to the PFS CF through March 31, 2014 and the Protecting 

Access to Medicare Act of 2014 (Pub. L. 113-93, enacted on April 1, 2014) (PAMA) extended 

this 0.5 percent update through December 31, 2014. As a result, the CF for CY 2014 that was 

published in the CY 2014 final rule with comment period (78 FR 74230) was revised to 

$35.8228 for services furnished on or after January 1, 2014 and on or before December 31, 2014. 

The PAMA provides for a 0.0 percent update to the PFS for services furnished on or after 

January 1, 2015 and on or before March 31, 2015. 

The Pathway for SGR Reform Act extended through March 31, 2014 several provisions 

of Medicare law that would have otherwise expired on December 31, 2013. The PAMA 

extended these same provisions further through March 31, 2015. A list of these provisions 

follows. 

● The 1.0 floor on the work geographic practice cost index 

● The exceptions process for outpatient therapy caps 

● The manual medical review process for therapy services 

● The application of the therapy caps and related provisions to services furnished in 

HOPDs 

 In addition, section 220 of the PAMA included several provisions affecting the valuation 

process for services under the PFS. Section 220(a) of the PAMA amended section 1848(c)(2) of 

the Act to add a new subparagraph (M). The new subparagraph (M) provides that the Secretary 

may collect or obtain information from any eligible professional or any other source on the 

resources directly or indirectly related to furnishing services for which payment is made under 

the PFS, and that such information may be used in the determination of relative values for 

services under the PFS. Such information may include the time involved in furnishing services; 

the amounts, types and prices of practice expense inputs; overhead and accounting information 
CMS-1612-FC 23

for practices of physicians and other suppliers, and any other elements that would improve the 

valuation of services under the PFS. This information may be collected or obtained through 

surveys of physicians or other suppliers, providers of services, manufacturers, and vendors; 

surgical logs, billing systems, or other practice or facility records; EHRs; and any other 

mechanism determined appropriate by the Secretary. If we use this information, we are required 

to disclose the source and use of the information in rulemaking, and to make available 

aggregated information that does not disclose individual eligible professionals, group practices, 

or information obtained pursuant to a nondisclosure agreement. Beginning with fiscal year 2014, 

the Secretary may compensate eligible professionals for submission of data. 

Section 220(c) of the PAMA amended section 1848(c)(2)(K)(ii) of the Act to expand the 

categories of services that the Secretary is directed to examine for the purpose of identifying 

potentially misvalued codes. The nine new categories are as follows: 

• Codes that account for the majority of spending under the PFS. 

• Codes for services that have experienced a substantial change in the hospital length of 

stay or procedure time. 

• Codes for which there may be a change in the typical site of service since the code was 

last valued. 

• Codes for which there is a significant difference in payment for the same service 

between different sites of service. 

• Codes for which there may be anomalies in relative values within a family of codes. 

• Codes for services where there may be efficiencies when a service is furnished at the 

same time as other services. 

• Codes with high intra-service work per unit of time. 

• Codes with high PE RVUs. 
CMS-1612-FC 24

• Codes with high cost supplies. 

(See section II.B. of this final rule with comment period for more information about misvalued 

codes.). 

 Section 220(i) of the PAMA also requires the Secretary to make publicly available the 

information we considered when establishing the multiple procedure payment reduction (MPPR) 

policy for the professional component of advanced imaging procedures. The policy reduces the 

amount paid for the professional component when two advanced imaging procedures are 

furnished in the same session. The policy was effective for individual physicians on January 1, 

2012 and for physicians in the same group practice on January 1, 2013. 

In addition, section 220 of the PAMA includes other provisions regarding valuation of 

services under the PFS that take effect in future years. Section 220(d) of the PAMA establishes 

an annual target from CY 2017 through CY 2020 for reductions in PFS expenditures resulting 

from adjustments to relative values of misvalued services. The target is calculated as 0.5 percent 

of the estimated amount of expenditures under the fee schedule for the year. If the net reduction 

in expenditures for the year is equal to or greater than the target for the year, the funds shall be 

redistributed in a budget-neutral manner within the PFS. The amount by which such reduced 

expenditures exceed the target for the year shall be treated as a reduction in expenditures for the 

subsequent year, for purposes of determining whether the target has or has not been met. The 

legislation includes an exemption from budget neutrality of reduced expenditures if the target is 

not met. Other provisions of section 220 of the PAMA include a 2-year phase-in for reductions 

in RVUs of at least 20 percent for potentially misvalued codes that do not involve coding 

changes, and certain adjustments to the fee schedule areas in California. These provisions will 

be addressed as we implement them in future rulemaking. 

On March 5, 2014, we submitted to MedPAC an estimate of the SGR and CF applicable 

to Medicare payments for physicians’ services for CY 2015, as required by section 1848(d)(1)(E) 
CMS-1612-FC 25

of the Act. The actual values used to compute physician payments for CY 2015 will be based on 

later data and are scheduled to be published by November 1, 2014, as part of the CY 2015 PFS 

final rule with comment period. 

C. Health Information Technology 

The Department of Health and Human Services (HHS) believes all patients, their 

families, and their health care providers should have consistent and timely access to patient 

health information in a standardized format that can be securely exchanged between the patient, 

providers, and others involved in the patient’s care. (HHS August 2013 Statement, “Principles 

and Strategies for Accelerating Health Information Exchange,” see 

http://www.healthit.gov/sites/default/files/acceleratinghieprinciples_strategy.pdf) HHS is 

committed to accelerating health information exchange (HIE) through the use of safe, 

interoperable health information technology (health IT), including electronic health records 

(EHRs), across the broader care continuum through a number of initiatives: (1) alignment of 

incentives and payment adjustments to encourage provider adoption and optimization of health 

IT and HIE services through Medicare and Medicaid payment policies; (2) adoption of common 

standards and certification requirements for interoperable HIT; (3) support for privacy and 

security of patient information across all HIE-focused initiatives; and (4) governance of health 

information. These initiatives are designed to encourage HIE among health care providers, 

including professionals and hospitals eligible for the Medicare and Medicaid EHR Incentive 

Programs and those who are not eligible for the EHR Incentive Programs, and are designed to 

improve care delivery and coordination across the entire care continuum. For example, the 

Transition of Care Measure #2 in Stage 2 of the Medicare and Medicaid EHR Incentive 

Programs requires HIE to share summary records for more than 10 percent of care transitions. In 

addition, to increase flexibility in the Office of the National Coordinator for Health Information 

Technology’s (ONC) regulatory certification structure, ONC expressed in the 2014 Edition 
CMS-1612-FC 26

Release 2 final rule (79 FR 54472-73) an intent to propose future changes to the ONC HIT 

Certification Program that would permit more efficient certification of health IT for other health 

care settings, such as long-term and post-acute care and behavioral health settings. 

We believe that health IT that incorporates usability features and has been certified to 

interoperable standards can effectively and efficiently help all providers improve internal care 

delivery practices, support management of patient care across the continuum, and support the 

reporting of electronically specified clinical quality measures (eCQMs). 

 
CMS-1612-FC 27

II. Provisions of the Proposed Rule for PFS 

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

1. Overview 

Practice expense (PE) is the portion of the resources used in furnishing a service 

that reflects the general categories of physician and practitioner expenses, such as office 

rent and personnel wages, but excluding malpractice expenses, as specified in section 

1848(c)(1)(B) of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a 

resource-based system for determining PE RVUs for each physician’s service. We 

develop PE RVUs by considering the direct and indirect practice resources involved in 

furnishing each service. Direct expense categories include clinical labor, medical 

supplies, and medical equipment. Indirect expenses include administrative labor, office 

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

information about the methodology for translating the resources involved in furnishing 

each service into service-specific PE RVUs. We refer readers to the CY 2010 PFS final 

rule with comment period (74 FR 61743 through 61748) for a more detailed explanation 

of the PE methodology. 

2. Practice Expense Methodology 

a. Direct Practice Expense 

 We determine the direct PE for a specific service by adding the costs of the direct 

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

with furnishing that service. The costs of the resources are calculated using the refined direct PE 

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

recommendations received from the RUC and those provided in response to public comment 

periods. For a detailed explanation of the direct PE methodology, including examples, we refer 
CMS-1612-FC 28

readers to the Five-Year Review of Work Relative Value Units under the PFS and Proposed 

Changes to the Practice Expense Methodology proposed notice (71 FR 37242) and the CY 2007 

PFS final rule with comment period (71 FR 69629). 

b. Indirect Practice Expense per Hour Data 

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

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

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

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

Expense Information Survey (PPIS). The PPIS is a multispecialty, nationally representative, PE 

survey of both physicians and nonphysician practitioners (NPPs) paid under the PFS using a 

survey instrument and methods highly consistent with those used for the SMS and the 

supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 

physician specialty and health care professional groups. We believe the PPIS is the most 

comprehensive source of PE survey information available. We used the PPIS data to update the 

PE/HR data for the CY 2010 PFS for almost all of the Medicare-recognized specialties that 

participated in the survey. 

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

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

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

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

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

its use over a 4-year period from the previous PE RVUs to the PE RVUs developed using the 

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

the transition to the PPIS data was complete for CY 2013. Therefore, PE RVUs from CY 2013 
CMS-1612-FC 29

forward are developed based entirely on the PPIS data, except as noted in this section. 

 Section 1848(c)(2)(H)(i) of the Act requires us to use the medical oncology supplemental 

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

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

supplemental survey data. 

 Supplemental survey data on independent labs from the College of American 

Pathologists were implemented for payments beginning in CY 2005. Supplemental survey data 

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

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

from the American College of Radiology (ACR) and implemented for payments beginning in 

CY 2007. Neither IDTFs, nor independent labs, participated in the PPIS. Therefore, we 

continue to use the PE/HR that was developed from their supplemental survey data. 

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

supplemental surveys for these specialties were updated to CY 2006 using the MEI to put them 

on a comparable basis with the PPIS data. 

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

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

to blend the PPIS data with Medicare-recognized specialty data. 

Previously, we established PE/HR values for various specialties without SMS or 

supplemental survey data by crosswalking them to other similar specialties to estimate a proxy 

PE/HR. For specialties that were part of the PPIS for which we previously used a crosswalked 

PE/HR, we instead used the PPIS-based PE/HR. We continue previous crosswalks for 

specialties that did not participate in the PPIS. However, beginning in CY 2010 we changed the 

PE/HR crosswalk for portable x-ray suppliers from radiology to IDTF, a more appropriate 
CMS-1612-FC 30

crosswalk because these specialties are more similar to each other for work time. 

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

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

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

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

c. Allocation of PE to Services 

To establish PE RVUs for specific services, it is necessary to establish the direct 

and indirect PE associated with each service. 

(1) Direct Costs 

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

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

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

involved with furnishing each of the services. The costs of these resources are calculated 

from the refined direct PE inputs in our PE database. For example, if one service has a 

direct cost sum of $400 from our PE database and another service has a direct cost sum of 

$200, the direct portion of the PE RVUs of the first service would be twice as much as 

the direct portion of the PE RVUs for the second service. 

(2) Indirect Costs 

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

sources for specialty-specific indirect costs used in our PE calculations. We allocated the 

indirect costs to the code level on the basis of the direct costs specifically associated with 

a code and the greater of either the clinical labor costs or the physician work RVUs. We 

also incorporated the survey data described earlier in the PE/HR discussion. The general 

approach to developing the indirect portion of the PE RVUs is as follows: 
CMS-1612-FC 31

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

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

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

initial indirect allocator. In other words, the initial indirect allocator is calculated so that 

the direct costs equal the average percentage of direct costs of those specialties furnishing 

the service. For example, if the direct portion of the PE RVUs for a given service is 2.00 

and direct costs, on average, represented 25 percent of total costs for the specialties that 

furnished the service, the initial indirect allocator would be calculated so that it equals 75 

percent of the total PE RVUs. Thus, in this example, the initial indirect allocator would 

equal 6.00, resulting in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75 

percent of 8.00). 

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

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

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

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

labor portion) to the initial indirect allocator of 6.00 to get an indirect allocator of 10.00. 

In the absence of any further use of the survey data, the relative relationship between the 

indirect cost portions of the PE RVUs for any two services would be determined by the 

relative relationship between these indirect cost allocators. For example, if one service 

had an indirect cost allocator of 10.00 and another service had an indirect cost allocator 

of 5.00, the indirect portion of the PE RVUs of the first service would be twice as great as 

the indirect portion of the PE RVUs for the second service. 

• Next, we incorporate the specialty-specific indirect PE/HR data into the 

calculation. In our example, if, based on the survey data, the average indirect cost of the 
CMS-1612-FC 32

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

indirect cost of the specialties furnishing the second service with an indirect allocator of 

5.00, the indirect portion of the PE RVUs of the first service would be equal to that of the 

second service. 

d. Facility and Nonfacility Costs 

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

hospital or other facility setting, we establish two PE RVUs: facility and nonfacility. The 

methodology for calculating PE RVUs is the same for both the facility and nonfacility 

RVUs, but is applied independently to yield two separate PE RVUs. Because in 

calculating the PE RVUs for services furnished in a facility, we do not include resources 

that would generally not be provided by physicians when furnishing the service in a 

facility, the facility PE RVUs are generally lower than the nonfacility PE RVUs. 

Medicare makes a separate payment to the facility for its costs of furnishing a service. 

e. Services with Technical Components (TCs) and Professional Components (PCs) 

Diagnostic services are generally comprised of two components: a professional 

component (PC); and a technical component (TC). The PC and TC may be furnished 

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

service. When services have separately billable PC and TC components, the payment for 

the global service equals the sum of the payment for the TC and PC. To achieve this we 

use a weighted average of the ratio of indirect to direct costs across all the specialties that 

furnish the global service, TCs, and PCs; that is, we apply the same weighted average 

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

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

f. PE RVU Methodology 
CMS-1612-FC 33

For a more detailed description of the PE RVU methodology, we refer readers to 

the CY 2010 PFS final rule with comment period (74 FR 61745 through 61746). 

(1) Setup File 

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

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

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

calculated from the surveys. 

(2) Calculate the Direct Cost PE RVUs 

Sum the costs of each direct input. 

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

adjustment to the direct inputs. 

Step 2: Calculate the aggregate pool of direct PE costs for the current year. This 

is the product of the current aggregate PE (direct and indirect) RVUs, the CF, and the 

average direct PE percentage from the survey data used for calculating the PE/HR by 

specialty. 

Step 3: Calculate the aggregate pool of direct PE costs for use in ratesetting. This 

is the product of the aggregated direct costs for all services from Step 1 and the utilization 

data for that service. 

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

adjustment to ensure that the aggregate pool of direct PE costs calculated in Step 3 does 

not vary from the aggregate pool of direct PE costs for the current year. Apply the 

scaling factor to the direct costs for each service (as calculated in Step 1). 

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

this, divide the results of Step 4 by the CF. Note that the actual value of the CF used in 
CMS-1612-FC 34

this calculation does not influence the final direct cost PE RVUs, as long as the same CF 

is used in Step 2 and Step 5. Different CFs will result in different direct PE scaling 

factors, but this has no effect on the final direct cost PE RVUs since changes in the CFs 

and changes in the associated direct scaling factors offset one another. 

(3) Create the Indirect Cost PE RVUs 

Create indirect allocators. 

Step 6: Based on the survey data, calculate direct and indirect PE percentages for 

each physician specialty. 

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

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

Note that for services with TCs and PCs, the direct and indirect percentages for a given 

service do not vary by the PC, TC, and global service. 

Step 8: Calculate the service level allocators for the indirect PEs based on 

the percentages calculated in Step 7. The indirect PEs are allocated based on the three 

components: the direct PE RVUs; the clinical PE RVUs; and the work RVUs. 

For most services the indirect allocator is: indirect PE percentage * (direct PE 

RVUs/direct percentage) + work RVUs. 

There are two situations where this formula is modified: 

• If the service is a global service (that is, a service with global, professional, and 

technical components), then the indirect PE allocator is: indirect percentage (direct 

PE RVUs/direct percentage) + clinical labor PE RVUs + work RVUs. 

• If the clinical labor PE RVUs exceed the work RVUs (and the service is not a 

global service), then the indirect allocator is: indirect PE percentage (direct 

PE RVUs/direct percentage) + clinical labor PE RVUs. 
CMS-1612-FC 35

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

the clinical labor PE RVUs. We do this to recognize that, for the PC service, indirect PEs 

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

allocated using the direct PE RVUs and the clinical labor PE RVUs. This also allows the 

global component RVUs to equal the sum of the PC and TC RVUs.) 

For presentation purposes in the examples in Table 1, the formulas were divided 

into two parts for each service. 

• The first part does not vary by service and is the indirect percentage (direct PE 

RVUs/direct percentage). 

• The second part is either the work RVU, clinical labor PE RVU, or both 

depending on whether the service is a global service and whether the clinical PE RVUs 

exceed the work RVUs (as described earlier in this step). 

Apply a scaling adjustment to the indirect allocators. 

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

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

survey data. 

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

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

utilization data for that service. 

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

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

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

Calculate the indirect practice cost index. 

Step 12: Using the results of Step 11, calculate aggregate pools of 
CMS-1612-FC 36

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

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

utilization data for that service. 

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

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

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

and the specialty’s utilization for the service across all services furnished by the specialty. 

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

indirect PE scaling factors. 

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

the specialty level by dividing each specialty-specific indirect scaling factor by the 

average indirect scaling factor for the entire PFS. 

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

the capture of all indirect costs. Calculate a weighted average of the practice cost index 

values for the specialties that furnish the service. (Note: For services with TCs and PCs, 

we calculate the indirect practice cost index across the global service, PCs, and TCs. 

Under this method, the indirect practice cost index for a given service (for example, 

echocardiogram) does not vary by the PC, TC, and global service.) 

Step 17: Apply the service level indirect practice cost index calculated in Step 16 

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

RVUs. 

(4) Calculate the Final PE RVUs 

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

Step 17 and apply the final PE budget neutrality (BN) adjustment. The final PE BN 
CMS-1612-FC 37

adjustment is calculated by comparing the results of Step 18 to the current pool of PE 

RVUs. This final BN adjustment is required to redistribute RVUs from step 18 to all PE 

RVUs in the PFS, and because certain specialties are excluded from the PE RVU 

calculation for ratesetting purposes, but we note that all specialties are included for 

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

ratesetting calculation” later in this section.) 

(5) Setup File Information 

• Specialties excluded from ratesetting calculation: For the purposes of 

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

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

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

adjustment. They are displayed in Table 1. 

 
CMS-1612-FC 38

TABLE 1: Specialties Excluded From Ratesetting Calculation 

Specialty 

Code 

Specialty Description 

49 Ambulatory surgical center 

50 Nurse practitioner 

51 Medical supply company with certified orthotist 

52 Medical supply company with certified prosthetist 

53 Medical supply company with certified prosthetist-orthotist 

54 Medical supply company not included in 51, 52, or 53. 

55 Individual certified orthotist 

56 Individual certified prosthetist 

57 Individual certified prosthetist-orthotist 

58 Medical supply company with registered pharmacist 

59 Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc. 

60 Public health or welfare agencies 

61 Voluntary health or charitable agencies 

73 Mass immunization roster biller 

74 Radiation therapy centers 

87 All other suppliers (e.g., drug and department stores) 

88 Unknown supplier/provider specialty 

89 Certified clinical nurse specialist 

96 Optician 

97 Physician assistant 

A0 Hospital 

A1 SNF 

A2 Intermediate care nursing facility 

A3 Nursing facility, other 

A4 HHA 

A5 Pharmacy 

A6 Medical supply company with respiratory therapist 

A7 Department store 

B2 Pedorthic personnel 

B3 Medical supply company with pedorthic personnel 

● Crosswalk certain low volume physician specialties: Crosswalk the utilization 

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

• Physical therapy utilization: Crosswalk the utilization associated with all 

physical therapy services to the specialty of physical therapy. 

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

and 26 modifiers: Flag the services that are PC and TC services, but do not use TC and 
CMS-1612-FC 39

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

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

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

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

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

report). 

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

consistent with current payment policy as implemented in claims processing. For example, 

services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for 

that service; therefore, the utilization file is modified to only account for 16 percent of any 

service that contains the assistant at surgery modifier. Similarly, for those services to which 

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

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

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

contractors to process Medicare claims is used instead. Where neither is available, we use the 

payment adjustment ratio to adjust the time accordingly. Table 2 details the manner in which the 

modifiers are applied. 

 
CMS-1612-FC 40

TABLE 2: Application of Payment Modifiers to Utilization Files

Modifier Description Volume Adjustment Time Adjustment 

80,81,82 Assistant at Surgery 16% Intraoperative 

portion 

AS Assistant at Surgery – 

Physician Assistant 

14% (85% * 16%) Intraoperative 

portion 

50 or 

LT and RT 

Bilateral Surgery 150% 150% of work time 

51 Multiple Procedure 50% Intraoperative 

portion 

52 Reduced Services 50% 50% 

53 Discontinued Procedure 50% 50% 

54 Intraoperative Care only Preoperative + 

Intraoperative 

Percentages on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Preoperative + 

Intraoperative 

portion 

55 Postoperative Care only Postoperative 

Percentage on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Postoperative 

portion 

62 Co-surgeons 62.5% 50% 

66 Team Surgeons 33% 33% 

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

including special multiple procedure endoscopy rules and multiple procedure payment reductions 

(MPPR). We note that section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments 

for multiple imaging procedures and multiple therapy services from the BN calculation under 

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

the RVUs. 

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

allowed charge is used when simulating RVUs, and therefore, includes all adjustments. 

A time adjustment of 33 percent is made only for medical direction of two to four cases 
CMS-1612-FC 41

since that is the only situation where time units are duplicative. 

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

comment period.

(6) Equipment Cost Per Minute 

The equipment cost per minute is calculated as: 

(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 + interest rate)^ 

life of equipment)))) + maintenance) 

Where: 

minutes per year = maximum minutes per year if usage were continuous (that is, 

usage = 1); generally 150,000 minutes. 

usage = variable, see discussion below. 

price = price of the particular piece of equipment. 

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

maintenance = factor for maintenance; 0.05. 

interest rate = variable, see discussion below. 

Usage: We currently use an equipment utilization rate assumption of 50 percent 

for most equipment, with the exception of expensive diagnostic imaging equipment, for 

which we use a 90 percent assumption as required by Section 1848(b)(4)(C) of the Act. 

Maintenance: This factor for maintenance was proposed and finalized during 

rulemaking for CY 1998 PFS (62 FR 33164). Several stakeholders have suggested that 

this maintenance factor assumption should be variable. We solicited comments regarding 

reliable data on maintenance costs that vary for particular equipment items. We received 

several comments about variable maintenance costs, which we will consider in future 

rulemaking. We note, however, that we do not believe that high-level summary data 
CMS-1612-FC 42

from informal surveys constitutes reliable data. Rather than assertions that a particular 

maintenance rate is typical, multiple invoices containing equipment prices that are 

accompanied by maintenance contracts would provide support for a maintenance cost 

other than our currently assumed 5 percent. We continue to seek reliable data about 

variable maintenance costs, as we consider adjustments to our methodology to 

accommodate variable maintenance costs. 

 Per-use Equipment Costs: Several stakeholders have also suggested that our PE 

methodology should incorporate usage fees and other per-use equipment costs as direct 

costs. We also solicited comment on adjusting our cost formula to include equipment 

costs that do not vary based on the equipment time. We received a comment that 

addressed how to incorporate usage fees and other per-use equipment costs into our 

methodology, and received several comments that addressed how we should reclassify 

the anomalous supply inputs removed from the direct PE database. We will consider 

these comments in future rulemaking, including the way these anomalous supply inputs 

fit in to any future proposals related to per-use costs. 

Interest Rate: In the CY 2013 final rule with comment period (77 FR 68902), we 

updated the interest rates used in developing an equipment cost per minute calculation. 

The interest rate was based on the Small Business Administration (SBA) maximum 

interest rates for different categories of loan size (equipment cost) and maturity (useful 

life). The interest rates are listed in Table 3. (See 77 FR 68902 for a thorough discussion 

of this issue.) 

 
CMS-1612-FC 43

TABLE 3: SBA Maximum Interest Rates 

Price Useful Life Interest Rate 

<$25K <7 Years 7.50% 

$25K to $50K <7 Years 6.50% 

>$50K <7 Years 5.50% 

<$25K 7+ Years 8.00% 

$25K to $50K 7+ Years 7.00% 

>$50K 7+ Years 6.00% 
CMS-1612-FC 44

TABLE 4: CALCULATION OF PE RVUS UNDER METHODOLOGY FOR SELECTED  Step Source Formula 99213 

Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 

71020-TC Chest xray, Nonfacility 

71020-26 Chest xray, Nonfacility 

93000 ECG, complete, Nonfacility 

93005 ECG, tracing Nonfacility 

(1) Labor cost (Lab) 

Step 1 AMA 

13.32 77.52 5.74 5.74 - 5.10 5.10 

(2) Supply cost (Sup) 

Step 1 AMA 

2.98 7.34 0.53 0.53 - 1.19 1.19 

(3) Equipment cost (Eqp) 

Step 1 AMA 

0.17 0.58 6.92 6.92 - 0.09 0.09 

(4) Direct cost (Dir) 

Step 1 =(1)+(2)+(3) 

16.48 85.45 13.19 13.19 - 6.38 6.38 

(5) Direct adjustment (Dir. Adj.) 

Steps 2-4 See 

footnote* 0.5898 0.5898 0.5898 0.5898 0.5898 0.5898 0.5898 

(6) Adjusted Labor 

Steps 2-4 =Labor * 

Dir Adj 

=(1)*(5) 

7.86 45.72 3.39 3.39 - 3.01 3.01 

(7) Adjusted Supplies 

Steps 2-4 =Eqp * Dir 

Adj 

=(2)*(5) 

1.76 4.33 0.31 0.31 - 0.70 0.70 

(8) Adjusted Equipment 

Steps 2-4 =Sup * Dir 

Adj 

=(3)*(5) 

0.10 0.34 4.08 4.08 - 0.05 0.05 

(9) Adjusted Direct 

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

9.72 50.40 7.78 7.78 - 3.77 3.77 

(10) Conversion 

Step 5 PFS 

35.82 35.82 35.82 35.82 35.82 35.82 35.82 
CMS-1612-FC 45

 Step Source Formula 99213 

Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 

71020-TC Chest xray, Nonfacility 

71020-26 Chest xray, Nonfacility 

93000 ECG, complete, Nonfacility 

93005 ECG, tracing Nonfacility 

Factor (CF) (11) Adj. labor cost convertedStep 5 =(Lab * Dir Adj)/CF =(6)/(10) 0.22 1.28 0.09 0.09 - 0.08 0.08 (12) Adj. supply cost converted 

Step 5 =(Sup * Dir 

Adj)/CF 

=(7)/(10) 

0.05 0.12 0.01 0.01 - 0.02 0.02 

(13) Adj. equipment cost converted 

Step 5 =(Eqp * Dir 

Adj)/CF 

=(8)/(10) - 

0.01 0.11 0.11 - 

 - 

(14) Adj. direct cost converted 

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

13) 0.27 1.41 0.22 0.22 - 0.11 0.11 

(15) Work RVU 

Setup File 

PFS 

0.97 33.75 0.22 - 0.22 0.17 

 

(16) Dir_pct 

Steps 6,7 Surveys 

0.25 0.17 0.29 0.29 0.29 0.29 0.29 

(17) Ind_pct 

Steps 6,7 Surveys 

0.75 0.83 0.71 0.71 0.71 0.71 0.71 

(18) Ind. Alloc. Formula (1st part) 

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

)*(17) 

((14)/(16)*(17) 

((14)/(16)*(17) 

((14)/(16)*(17) 

((14)/(16)*(17) 

((14)/(16)*(17) 

((14)/(1*(17) 

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

Step 8 See 18 

0.82 6.67 0.53 0.53 - 0.26 0.26 

(20) Ind. Alloc. Formula 

Step 8 See Step 8 (15) (15) (15+11) (11) (15) (15+11) (11) 
CMS-1612-FC 46

 Step Source Formula 99213 

Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 

71020-TC Chest xray, Nonfacility 

71020-26 Chest xray, Nonfacility 

93000 ECG, complete, Nonfacility 

93005 ECG, tracing Nonfacility 

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

Step 8 See 20 

0.97 33.75 0.31 0.09 0.22 0.25 0.08 

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

Step 8 =(19)+(21) 

1.79 40.42 0.84 0.62 0.22 0.51 0.34 

(23) Indirect Adjustment (Ind. Adj.) 

Steps 9-11 

See Footnote** 

0.3813 0.3813 0.3813 0.3813 0.3813 0.3813 0.3813 

(24) Adjusted Indirect Allocator 

Steps 9-11 

=Ind Alloc * Ind Adj 0.68 15.41 0.32 0.24 0.08 0.20 0.13 

(25) Ind. Practice Cost Index (IPCI) 

Steps 12-16 1.07 0.75 0.99 0.99 0.99 0.91 0.91 

(26) Adjusted Indirect 

Step 17 = Adj.Ind 

Alloc * PCI 

=(24)*(25) 

0.73 11.59 0.32 0.24 0.08 0.18 0.12 

(27) Final PE RVU 

Step 18 =(Adj Dir + 

Adj Ind) * Other Adj 

=((14)+(26)) * Other Adj) 1.01 13.04 0.54 0.46 0.08 0.29 0.23 

Note: PE RVUs in Table 5, row 27, may not match Addendum B due to rounding. *The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3] **The indirect adj = [current pe rvus * avg ind pct]/[sum of ind allocators] = 
CMS-1612-FC 47

 Step Source Formula 99213 

Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 

71020-TC Chest xray, Nonfacility 

71020-26 Chest xray, Nonfacility 

93000 ECG, complete, Nonfacility 

93005 ECG, tracing Nonfacility 

[step9]/[step10] Note: The use of any particular conversion factor (CF) in Table 5 to illustrate the PE Calculation has no effect on the resulting RVUs. 

Note: The Other Adjustment includes an adjustment for the equipment utilization change. 
CMS-1612-FC 48

3. Changes to Direct PE Inputs for Specific Services 

In this section, we discuss other CY 2015 revisions related to direct PE inputs for specific 

services. The final direct PE inputs are included in the final rule CY 2015 direct PE input 

database, which is available on the CMS website under downloads for the CY 2015 PFS final 

rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. 

a. RUC Recommendation for Monitoring Time following Moderate Sedation 

We received a recommendation from the RUC regarding appropriate clinical labor 

minutes for post-procedure moderate sedation monitoring and post-procedure monitoring. The 

RUC recommended 15 minutes of RN time for one hour of monitoring following moderate 

sedation and 15 minutes of RN time per hour for post-procedure monitoring (unrelated to 

moderate sedation). For 17 procedures listed in Table 5, the recommended clinical labor minutes 

differed from the clinical labor minutes in the direct PE database. We proposed to accept, 

without refinement, the RUC recommendation to adjust these clinical labor minutes as indicated 

in Table 5 as “Change to Clinical Labor Time.” 

 
CMS-1612-FC 49

TABLE 5: Codes with Changes to Post-Procedure Clinical Labor Monitoring Time 

CPT 

Code 

Current 

Monitoring 

Time (Min) 

RUC Recommended 

Total Post-Procedure 

Monitoring Time (Min) 

Change to 

Clinical 

Labor Time 

(Min) 

32553 30 60 30 

35471 21 60 39 

35475 60 30 -30 

35476 60 30 -30 

36147 18 30 12 

37191 60 30 -30 

47525 6 15 9 

49411 30 60 30 

50593 30 60 30 

50200 15 60 45 

31625 20 15 -5 

31626 25 15 -10 

31628 25 15 -10 

31629 25 15 -10 

31634 25 15 -10 

31645 10 15 5 

31646 10 15 5 

Comment: We received two comments supporting our proposal to accept the 

RUC recommendation, without refinement, to adjust the clinical labor minutes as 

indicated in Table 5. One commenter noted that the RUC recommendation was a more 

accurate reflection of the monitoring time, particularly for codes 50593 (Ablation, renal 

tumor(s), unilateral, percutaneous, cryotherapy) and 50200 (Renal biopsy; percutaneous, 

by trocar or needle), than the current time. 

Response: We appreciate commenters’ support for our proposal. After 

consideration of comments received, we are finalizing our proposal to accept, without 

refinement, the RUC recommendation to adjust the clinical labor minutes as indicated in 

Table 5 as “Change to Clinical Labor Time.” 

b. RUC Recommendation for Standard Moderate Sedation Package 
CMS-1612-FC 50

We received a RUC recommendation to modify PE inputs included in the standard 

moderate sedation package. Specifically, the RUC indicated that several specialty societies have 

pointed to the need for a stretcher during procedures for which moderate sedation is inherent in 

the procedure. Although the RUC did not recommend that we make changes to PE inputs for 

codes at this time, the RUC indicated that its future recommendations would include the stretcher 

as a direct input for procedures including moderate sedation. 

The RUC recommended three scenarios that it would use in the future to allocate the 

equipment time for the stretcher based on the procedure time and whether the stretcher would be 

available for other patients to use during a portion of the procedure. Although we appreciate the 

RUC’s attention to the differences in the time required for the stretcher based on the time for the 

procedure, we believe that one of the purposes of standard PE input packages is to reduce the 

complexity associated with assigning appropriate PE inputs to individual procedures while, at the 

same time, maintaining relativity between procedures. Since we generally allocate inexpensive 

equipment items to the entire service period when they are likely to be unavailable for another 

use during the full service period, we believe it is preferable to treat the stretcher consistently 

across services. Therefore, we proposed to modify the standard moderate sedation input package 

to include a stretcher for the same length of time as the other equipment items in the moderate 

sedation package. The revised moderate sedation input package will be applied to relevant codes 

as we review them through future notice and comment rulemaking. In seeking comments on the 

proposal, we stated that it would be useful to hear stakeholders’ views and the reasoning behind 

them on this issue, especially from those who think that the stretcher, as expressed through the 

allocation of equipment minutes, should be allocated with more granularity than the equipment 

costs that are allocated to other similar items. 
CMS-1612-FC 51

Comment: We received comments supporting our proposal to add the stretcher to the 

moderate sedation package, including support to include the stretcher for the same length of time 

as the other equipment items included in the moderate sedation package since it is used by the 

patient for the duration of their recovery and not available to other patients during that time. 

Response: We appreciate the commenters’ support for our proposal. After 

consideration of comments received, we are finalizing our proposal to add the stretcher to 

the moderate sedation package for the same length of time as the other equipment items 

in the moderate sedation package. We note that we will not apply this change 

retroactively, but will make the change to the moderate sedation package for codes being 

finalized for 2015, as well as interim final codes for 2015. For a detailed discussion of 

the specific codes impacted by this change, we refer readers to sections II.F. of this final 

rule with comment period. 

c. RUC Recommendation for Migration from Film to Digital Practice Expense Inputs 

The RUC provided a recommendation regarding the PE inputs for digital imaging 

services. Specifically, the RUC recommended that we remove a list of supply and equipment 

items associated with film technology since these items are no longer a typical resource input; 

these items are detailed in Table 6. The RUC also recommended that the Picture Archiving and 

Communication System (PACS) equipment be included for these imaging services since these 

items are now typically used in furnishing imaging services. We received a description of the 

PACS system as part of the recommendation, which included both items that appear to be direct 

PE items and items for which indirect PE RVUs are allocated in the PE methodology. As we 

have previously indicated, items which are not clinical labor, medical supplies, or medical 

equipment, or are not individually allocable to a particular patient for a particular procedure, are 

not categorized as direct costs in the PE methodology. Since we did not receive any invoices for 
CMS-1612-FC 52

the PACS system prior to the proposed rule, we were unable to determine the appropriate pricing 

to use for the inputs. We proposed to accept the RUC recommendation to remove the film 

supply and equipment items, and to allocate minutes for a desktop computer (ED021) as a proxy 

for the PACS workstation as a direct expense. Specifically, for the 31 services that already 

contain ED021 (computer, desktop, w-monitor), we proposed to retain the time that is currently 

included in the direct PE input database. For the remaining services that are valued in the 

nonfacility setting, we proposed to allocate the full clinical labor intraservice time to ED021, 

except for codes without clinical labor, in which case we proposed to allocate the intraservice 

work time to ED021. For services valued only in the facility setting, we proposed to allocate the 

post-service clinical labor time to ED021, since the film supply and/or equipment inputs were 

previously associated with the post-service period. 

 
CMS-1612-FC 53

TABLE 6: RUC-Recommended Supply and Equipment Items Removed for Digital 

Imaging Services

CMS Code Description 

SK013 computer media, dvd 

SK014 computer media, floppy disk 1.44mb 

SK015 computer media, optical disk 128mb 

SK016 computer media, optical disk 2.6gb 

SK022 film, 8inx10in (ultrasound, MRI) 

SK025 film, dry, radiographic, 8in x 10in 

SK028 film, fluoroscopic 14 x 17 

SK033 film, x-ray 10in x 12in 

SK034 film, x-ray 14in x 17in 

SK035 film, x-ray 14in x 36in 

SK037 film, x-ray 8in x 10in 

SK038 film, x-ray 8in x 10in (X-omat, Radiomat) 

SK086 video tape, VHS 

SK089 x-ray developer solution 

SK090 x-ray digitalization separator sheet 

SK091 x-ray envelope 

SK092 x-ray fixer solution 

SK093 x-ray ID card (flashcard) 

SK094 x-ray marking pencil 

SK098 film, x-ray, laser print 

SM009 cleaner, x-ray cassette-screen 

ED014 computer workstation, 3D reconstruction CT-MR 

ED016 computer workstation, MRA post processing 

ED023 film processor, PET imaging 

ED024 film processor, dry, laser 

ED025 film processor, wet 

ED027 film processor, x-omat (M6B) 

ER018 densitometer, film 

ER029 film alternator (motorized film viewbox) 

ER067 x-ray view box, 4 panel 

 We note that the RUC exempted certain procedures from its recommendation because (a) 

the dominant specialty indicated that digital technology is not yet typical or (b) the procedure 

only contained a single input associated with film technology, and it was determined that the 

sharing of images, but not actual imaging, may be involved in the service. However, we do not 

believe that the most appropriate approach in establishing relative values for services that 
CMS-1612-FC 54

involve imaging is to exempt services from the transition from film to digital PE inputs based on 

information reported by individual specialties. Although we understand that the migration from 

film technology to digital technology may progress at different paces for particular specialties, 

we do not have information to suggest that the migration is not occurring for all procedures that 

require the storage of images. Just as it was appropriate to use film inputs as a proxy for some 

services for which digital inputs were typical pending these changes in the direct PE input 

database, we believe it is appropriate to use digital inputs as a proxy for the services that may 

still use film, pending their migration to digital technology. In addition, since the RUC 

conducted its collection of information from the specialties over several years, we believe the 

migration process from film to digital inputs has likely continued over the time period during 

which the information was gathered, and that the digital PE inputs will reflect typical use of 

technology for most if not all of these services before the change to digital inputs would take 

effect beginning January 1, 2015. 

 We noted that we believed that, for the sake of relativity, we should remove the 

equipment and supply inputs noted below from all procedures in the direct PE database, 

including those listed in Table 7. We sought comment on whether the computer workstation, 

which we proposed to use as a proxy for the PACS workstation, is the appropriate input for the 

services listed in Table 7, or whether an alternative input is a more appropriate reflection of 

direct PE costs. 
CMS-1612-FC 55

TABLE 7: Codes Containing Film Inputs But Excluded From the RUC Recommendation

HCPCS Short Descriptor 

21077 Prepare face/oral prosthesis 

28293 Correction of bunion 

61580 Craniofacial approach skull 

61581 Craniofacial approach skull 

61582 Craniofacial approach skull 

61583 Craniofacial approach skull 

61584 Orbitocranial approach/skull 

61585 Orbitocranial approach/skull 

61586 Resect nasopharynx skull 

64517 N block inj hypogas plxs 

64681 Injection treatment of nerve 

70310 X-ray exam of teeth 

77326 Brachytx isodose calc simp 

77327 Brachytx isodose calc interm 

77328 Brachytx isodose plan compl 

91010 Esophagus motility study 

91020 Gastric motility studies 

91034 Gastroesophageal reflux test 

91035 G-esoph reflx tst w/electrod 

91037 Esoph imped function test 

91038 Esoph imped funct test > 1hr 

91040 Esoph balloon distension tst 

91120 Rectal sensation test 

91122 Anal pressure record 

91132 Electrogastrography 

91133 Electrogastrography w/test 

92521 Evaluation of speech fluency 

92523 Speech sound lang comprehend 

HCPCS Short Descriptor 

92524 Behavioral qualit analys voice 

92601 Cochlear implt f/up exam <7 

92603 Cochlear implt f/up exam 7/> 

92611 Motion fluoroscopy/swallow 

92612 Endoscopy swallow tst (fees) 

92614 Laryngoscopic sensory test 

92616 Fees w/laryngeal sense test 

95800 Slp stdy unattended 

95801 Slp stdy unatnd w/anal 

95803 Actigraphy testing 

95805 Multiple sleep latency test 

95806 Sleep study unatt&resp efft 

95807 Sleep study attended 

95808 Polysom any age 1-3> param 

95810 Polysom 6/> yrs 4/> param 

95811 Polysom 6/>yrs cpap 4/> parm 

95812 Eeg 41-60 minutes 

95813 Eeg over 1 hour 

95829 Surgery electrocorticogram 

95950 Ambulatory eeg monitoring 

95953 Eeg monitoring/computer 

95954 Eeg monitoring/giving drugs 

95955 Eeg during surgery 

95956 Eeg monitor technol attended 

95957 Eeg digital analysis 

96904 Whole body photography 

G0270 Mnt subs tx for change dx 

G0271 Group mnt 2 or more 30 mins 
CMS-1612-FC 56

 Finally, we noted that the RUC recommendation also indicated that, given the laborintensive nature of reviewing all clinical labor tasks associated with film technology, these times 

would be addressed as these codes are reviewed. We agreed with the RUC that reviewing and 

adjusting the times for each code would be difficult and labor-intensive since the direct PE input 

database does not allow for a comprehensive adjustment of the clinical labor time based on 

changes in particular clinical labor tasks. To make broad adjustments such as this across codes, 

the PE database would need to contain the time associated with individual clinical labor tasks 

rather than reflecting only the sum of times for the pre-service period, service period, and postservice period, as it does now. We recognized this situation presents a challenge in 

implementing RUC recommendations such as this one, and makes it difficult to understand the 

basis of both the RUC’s recommended clinical labor times and our refinements of those 

recommendations. Therefore, we stated that we were considering revising the direct PE input 

database to include task-level clinical labor time information for every code in the database. As 

an example, we referred readers to the supporting data files for the direct PE inputs, which 

include public use files that display clinical labor times as allocated to each individual clinical 

labor task for a sample of procedures. We displayed this information as we attempt to increase 

the transparency of the direct PE database. We stated that we hoped that this modification would 

enable us to more accurately allocate equipment minutes to clinical labor tasks in a more 

consistent and efficient manner. Given the number of procedures and the volume of information 

involved, we sought comments on the feasibility of this approach. We note that we did not 

propose to make any changes to PE inputs for CY 2015 based on this modification to the design 

of the direct PE input database. 

 As discussed in section II.G. of this final rule with comment period, some of the RUC 

recommendations for 2015 included film items as practice expense inputs. For existing codes, 
CMS-1612-FC 57

the database from the proposed rule already included the PACS workstation proxy. However, for 

new services, as with the current items in the database, we have replaced the film items with the 

PACS workstation proxy. The codes affected by this change are listed in Table 8. 

TABLE 8: 2015 Codes Affected by Removal of Film Inputs 

HCPCS Short Descriptor HCPCS Short Descriptor 

22510 Perq cervicothoracic inject 93314 Echo transesophageal 

22511 Perq lumbosacral injection 93320 Doppler echo exam heart 

22513 Perq vertebral augmentation 93321 Doppler echo exam heart 

22514 Perq vertebral augmentation 93325 Doppler color flow add-on 

62302 Myelography lumbar injection 93880 Extracranial bilat study 

62303 Myelography lumbar injection 93882 Extracranial uni/ltd study 

62304 Myelography lumbar injection 93886 Intracranial complete study 

62305 Myelography lumbar injection 93888 Intracranial limited study 

71275 Ct angiography chest 93895 Carotid intima atheroma eval 

72191 Ct angiograph pelv w/o&w/dye 93925 Lower extremity study 

72240 Myelography neck spine 93926 Lower extremity study 

72255 Myelography thoracic spine 93930 Upper extremity study 

72265 Myelography l-s spine 93931 Upper extremity study 

72270 Myelogphy 2/> spine regions 93970 Extremity study 

74174 Ct angio abd&pelv w/o&w/dye 93971 Extremity study 

74175 Ct angio abdom w/o & w/dye 93975 Vascular study 

74230 Cine/vid x-ray throat/esoph 93976 Vascular study 

76942 Echo guide for biopsy 93978 Vascular study 

93312 Echo transesophageal 93979 Vascular study 

Comment: We received many comments on our proposal to remove the 

equipment and supply inputs associated with film technology from the direct PE 

database. In general, commenters supported our proposal to remove the film inputs from 

the direct PE database. Some commenters supported our use of the desktop computer as 

a proxy for the PACS workstation, but other commenters opposed using this item as a 

proxy. Commenters opposed to using the desktop computer as the proxy item stated that 

the PACS workstation was significantly more expensive and included greater 

functionality than a desktop computer. Some commenters opposed our proposal to 
CMS-1612-FC 58

maintain the current equipment time allocated to the computer desktop for the 31 services 

that already included this equipment item, suggesting that it was incorrect to eliminate the 

film inputs without proportionately increasing the proxy time for ED021. Some 

commenters requested a delay in implementation until stakeholders provide invoices or 

otherwise work with CMS to identify prices for the PACS items. Some commenters 

suggested CMS should develop a means to allocate digital technology costs to individual 

services, even if it is difficult to do so. Another commenter explained that it is difficult 

for stakeholders to obtain invoices that display prices for individual items, such as the 

PACS workstation, since the price of the particular items is often bundled with other 

related equipment and services. Many commenters urged CMS to work with 

stakeholders to obtain invoices, while other commenters requested that CMS accept the 

RUC recommendation regarding the PACS workstation. 

Response: We appreciate commenters’ support for our proposal to incorporate 

the transition from film to digital imaging technology into the direct PE input database. 

With regard to the pricing of the PACS workstation, as with all inputs, we would prefer 

to use actual paid invoices to establish the input price. However, in the absence of 

invoices demonstrating the actual cost, we believe that use of a proxy to price the 

appropriate inputs, in this case the PACS workstation, is preferable to continuing to use 

inputs that we know are no longer typical. We made the proposal to use the computer, 

desktop, w-monitor (ED021), priced at $2,501, as a proxy based on our assessment of 

similar resource costs between the item and the PACS workstation. Although some 

commenters stated that the item was not an appropriate proxy, these commenters did not 

provide any evidence to indicate that the resource costs are not similar or to suggest a 

more appropriate proxy. Nor were any paid invoices submitted. Absent such 
CMS-1612-FC 59

information, we continue to believe that using the proxy item is the best approach to 

incorporate the direct PE cost of the digital imaging technology. 

 With regard to the 31 services that already included the desktop computer as an 

equipment input, we will include the desktop computer as a proxy for the PACS 

workstation using the same methodology as for the services that did not previously 

contain the desktop computer. To clearly differentiate the desktop computer proxy from 

the desktop computer currently included in these services, and to facilitate accurate 

replacement of this input when we do receive pricing information, we will create a new 

equipment item called “desktop computer (proxy for PACS workstation),” which will be 

allocated to each procedure using the methodology described above. 

Comment: Some commenters opposed our removal of the film inputs from 

services that were not included in the RUC recommendation, but did not provide a 

rationale for their opposition. 

Response: For the reasons we explained in making the proposal and reiterate 

above, we continue to believe that it is appropriate to remove these items from the direct 

PE database. 

Comment: Some commenters provided specific suggestions regarding the use of 

digital inputs should CMS decide to move forward with the proposal. Commenters 

requested that for portable x-ray services, CMS include a flat plate receptor/image 

capture plate to capture the image, specialized software to process the image, and 

multiple high definition monitors used by the interpreting radiologist. Commenters 

provided an invoice for the image capture plate at a price of $25,600 indicating that this 

item replaces the film as the media to record the image. 

Response: We appreciate that commenters provided us with an invoice for the 
CMS-1612-FC 60

image capture plate. However, services furnished by portable x-ray providers are 

reported using the same procedure codes as services provided using fixed machines. 

Since the typical x-ray service is furnished using fixed equipment, we are not including 

the image capture plate that is associated with portable equipment as an input for the 

imaging procedure codes. We also do not believe that high definition monitors used by 

the interpreting radiologist are appropriately included in the technical component of 

imaging procedures; rather, these are indirect costs associated with the professional 

component of the service. Therefore, we are not including the high definition monitors as 

an input for these services. Finally, to determine whether the software is appropriately 

categorized as a direct PE input, we need more information about the functionality of the 

software, and whether it is used in furnishing the typical x-ray service (including services 

furnished using fixed machinery). Until we have information that supports the inclusion 

of this item as a direct cost, we will not include the software for x-ray services. 

Comment: Commenters were supportive of the increased transparency with regard to the 

direct PE inputs, but several commenters suggested that there may be more feasible approaches 

to break out the individual clinical labor tasks associated with each portion of the service (preservice period, service period, and post-service period). The RUC suggested that we post all PE 

worksheets and supporting materials in code-order on our website. Other commenters did not 

suggest a specific alternative approach to providing detail for the individual clinical labor tasks. 

Response: We appreciate the RUC’s suggestion regarding the posting of the PE 

worksheets, but we do not believe that this would enable us to accomplish a comprehensive 

cross-code analysis and refinement to clinical labor times within the direct PE input database to 

increase consistency for identical clinical labor tasks between codes. Since we did not receive 

other suggestions from commenters on an approach to break out the individual clinical labor 
CMS-1612-FC 61

tasks associated with each service period to enable us to conduct the necessary analysis, we will 

pursue the approach described in the proposed rule. We will consider the comments submitted 

and continue to work with interested stakeholders regarding the best approaches to displaying the 

supporting files. We note that public use files continue to be available in the same format as in 

previous years, but that additional public use files now display the clinical labor tasks for each 

service period, providing greater transparency and enabling comparisons across codes. We note 

that we have refined the file structure based on comments, and we continue to seek input on 

whether there are additional or alternative ways to display this information to enhance its clarity, 

and note that there are challenges inherent in the display of this information in a two-dimensional 

format. We refer readers to the public use files available on the CMS website under downloads 

for the CY 2015 PFS final rule with comment period at http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html

d. Inputs for Digital Mammography Services 

 Mammography services are currently reported and paid using both CPT codes and Gcodes. To meet the requirements of the Medicare, Medicaid, and SCHIP Benefits Improvement 

and Protection Act of 2000 (BIPA), we established G-codes for use beginning in CY 2002 to pay 

for mammography services using new digital technologies (G0202 screening mammography 

digital; G0204 diagnostic mammography digital; G0206 diagnostic mammography digital). We 

continued to use the CPT codes for mammography services furnished using film technology 

(77055 (Mammography; unilateral); 77056 (Mammography; bilateral); 77057 (Screening 

mammography, bilateral (2-view film study of each breast)). As we discussed previously in this 

section, the RUC has recommended that all imaging codes, including mammography, be valued 

using digital rather than film inputs because the use of film is no longer typical. A review of 

Medicare claims data shows that the mammography CPT codes are billed extremely 
CMS-1612-FC 62

infrequently, and that the G-codes are billed for the vast majority of mammography claims, 

confirming the RUC’s conclusion that the typical service uses digital technology. As such, we 

stated that we do not believe there is a reason to continue the separate CPT codes and G-codes 

for mammography services since both sets of codes would have the same values when priced 

based upon the typical digital technology. Accordingly, we proposed to delete the 

mammography G-codes beginning for CY 2015 and to pay all mammography using the CPT 

codes. 

 We indicated that, although we believed that the CPT codes should now be used to report 

all mammography services, we had concerns about whether the current values for the CPT codes 

accurately reflect the resource inputs associated with furnishing the services. Because the CPT 

codes have not been recently reviewed and significant technological changes have occurred since 

the current values were established, we did not believe it would be appropriate to retain the 

current values for the CPT codes. Therefore, we proposed to value the CPT codes using the 

RVUs previously established for the G-codes. We believed these values would be most 

appropriate since they were established to reflect the use of digital technology, which is now 

typical. 

 As discussed in section II.B of this final rule with comment period, we proposed these 

CPT codes as potentially misvalued and requested that the RUC and other interested 

stakeholders review these services in terms of appropriate work RVUs, work time assumptions, 

and direct PE inputs. However, as discussed in section II.B. of this final rule with comment 

period, we will continue to maintain separate payment rates for film and digital mammography 

while we consider revaluation of all mammography services. For CY 2015, we will therefore 

maintain both the G-codes and CPT codes; we will continue using the 2014 RVUs from each of 

the following codes to price them for 2015: G0202, G0204, G0206, 77055, 77056, and 77057. 
CMS-1612-FC 63

2015. We also note that we will continue to pay for film mammography services at the 2014 

rates until we revalue the mammography services. 

We refer readers to section II.B. of this final rule with comment period, where we address 

comments received on this proposal. 

e. Radiation Treatment Vault 

In previous rulemaking (77 FR 68922, 78 FR 74346), we indicated that we included the 

radiation treatment vault as a direct PE input for several recently reviewed radiation treatment 

codes for the sake of consistency with its previous inclusion as a direct PE input for some other 

radiation treatment services, but that we intended to review the radiation treatment vault input 

and address whether or not it should be included in the direct PE input database for all services in 

future rulemaking. Specifically, we questioned whether it was consistent with the principles 

underlying the PE methodology to include the radiation treatment vault as a direct cost given that 

it appears to be more similar to building infrastructure costs than to medical equipment costs. In 

response to this discussion, we received comments and invoices from stakeholders who indicated 

that the vault should be classified as a direct cost. However, upon review of the information 

received, we believed that the specific structural components required to house the linear 

accelerator are similar in concept to components required to house other medical equipment such 

as expensive imaging equipment. In general, the electrical, plumbing, and other building 

specifications are often unique to the intended functionality of a given building, including costs 

that are attributable to the specific medical equipment housed in the building, but those building 

characteristics do not represent direct medical equipment costs in our established PE 

methodology. Therefore, we believed that the special building requirements indicated for the 

radiation treatment vault to house a linear accelerator do not represent a direct cost in our PE 

methodology, and that the vault construction is instead accounted for in the indirect PE 
CMS-1612-FC 64

methodology, just as the building and infrastructure costs are treated for other PFS services 

including those with specialized infrastructure costs to accommodate specific equipment. 

Therefore, we proposed to remove the radiation treatment vault as a direct PE input from the 

radiation treatment procedures listed in Table 9, because we believed that the vault is not, itself, 

medical equipment; and therefore, it is accounted for in the indirect PE methodology. 

TABLE 9: HCPCS Codes Affected by Proposed Removal of Radiation Treatment Vault 

HCPCS Short Descriptor 

77373 Sbrt delivery 

77402 Radiation treatment delivery 

77403 Radiation treatment delivery 

77404 Radiation treatment delivery 

77406 Radiation treatment delivery 

77407 Radiation treatment delivery 

77408 Radiation treatment delivery 

77409 Radiation treatment delivery 

77411 Radiation treatment delivery 

77412 Radiation treatment delivery 

77413 Radiation treatment delivery 

77414 Radiation treatment delivery 

77416 Radiation treatment delivery 

77418 Radiation tx delivery imrt 

Comment: We received many comments regarding our proposal to remove the radiation 

treatment vault as a direct cost from the radiation treatment delivery codes. Although one 

commenter supported the proposal, most commenters opposed the proposal. In general, 

commenters reiterated their rationale for inclusion of the vault as a direct practice expense input, 

asserting that the vault is necessary for the functioning of the equipment, serves a unique 

medical need, cannot be separated from the treatment delivered by the linear accelerator, and 

cannot be repurposed for another use. Commenters also stated that the Internal Revenue Code 

treats the vault as medical equipment that is separately depreciable from the building itself. For 

the most part, commenters objected to the removal of the vault given the context of declining 
CMS-1612-FC 65

Medicare payment for radiation oncology services over the past few years, or in conjunction with 

the revised radiation treatment code set. Specifically, several commenters suggested that 

stakeholders cannot provide meaningful comment about the impact of the vault proposal in the 

context of other pending changes. Some commenters requested a phase-in of any decrease in 

payment so that providers of radiation therapy services have an opportunity to adjust their 

practice costs. Several commenters also suggested that the change in payment could exacerbate 

problems in access to oncology services for Medicare patients. 

Response: We appreciate commenters’ concerns regarding the proposal to remove the 

vault as a direct practice expense input. We understand the essential nature of the vault in the 

provision of radiation therapy services and its uniqueness to a particular piece of medical 

equipment but are not convinced that either of these factors leads to the conclusion that the vault 

should be considered medical equipment for purposes of the PE methodology under the PFS. 

We appreciate the information commenters provided regarding the IRS treatment of the vault 

under tax laws, but the purposes and goals of the tax code and the PFS PE methodology are 

different, and, as such, attempts to draw parallels between the two are not necessarily instructive 

or relevant. We are not finalizing our proposal at this time, but intend to further study the issues 

raised by the vault and how it relates to our PE methodology. 

Comment: A commenter noted that removing the vault as a direct cost also reduces the 

amount of indirect PE allocated for these procedures, and that this proposal does not shift the 

vault from direct PE to indirect PE, but rather drops the cost of the vault entirely. Another 

commenter stated that since the pool of indirect PE RVUs associated with radiation oncology 

services is fixed, the issue in question is how the indirect costs involved in furnishing treatment 

services compare to the indirect costs in providing other radiation oncology services. 
CMS-1612-FC 66

Response: We understand the concerns of commenters regarding the importance of 

ensuring that the costs related to the vault are included in the PE methodology. We want to point 

out, however, that within the established PE methodology, the allocation of indirect PE to 

individual codes has significant impact on the PE RVUs that determine Medicare payment for 

individual services. In other words, we believe it is important for stakeholders to recognize that 

practice expense costs not included in the direct PE input database contribute to the development 

of PE RVUs through the data used to allocate indirect PE RVUs. We also want to point out that 

the pool of indirect PE RVUs is not fixed at the specialty level. Rather, the pool of indirect costs 

under the entire PFS is maintained from year to year, as delineated in step 11 of the PE 

methodology above. Therefore, changes in the allocation of indirect PE for particular PFS 

services based on changes in either direct PE inputs, work RVUs, work time, or utilization data, 

impacts the amount of indirect PE allocated to all other PFS services , not just those furnished by 

specialties that furnish that service. 

 After continued review of the issues pertaining to the vault in the context of the 

comments, we believe that these issues require further study. Therefore, at this time, we will 

continue to include the vault as a direct PE input for the services listed in Table 9. 

f. Clinical Labor Input Errors 

Subsequent to the publication of the CY 2014 PFS final rule with comment period, it 

came to our attention that, due to a clerical error, the clinical labor type for CPT code 77293 

(Respiratory Motion Management Simulation (list separately in addition to code for primary 

procedure)) was entered as L052A (Audiologist) instead of L152A (Medical Physicist), which 

has a higher cost per minute. We proposed a correction to the clinical labor type for this service. 

Comment: Commenters appreciated our proposal to correct this error. 
CMS-1612-FC 67

Response: We appreciate commenters’ support for our proposal, and are finalizing the 

assignment of clinical labor type L152A to code 77293 as proposed. The CY 2015 Direct 

Practice Expense Input database reflects this correction. 

In conducting a routine data review of the database, we also discovered that, due to a 

clerical error, the RN time allocated to CPT codes 33620 (Apply r&l pulm art bands), 33621 

(Transthor cath for stent), and 33622 (Redo compl cardiac anomaly) was entered in the 

nonfacility setting, rather than in the facility setting where the code is valued. When a service is 

not valued in a particular setting, any inputs included in that setting are not included in the 

calculation of the PE RVUs for that service. Therefore, we proposed to move the RN time 

allocated to these procedures to the facility setting. The PE RVUs listed in Addendum B reflect 

these technical corrections. 

We did not receive any comments on this proposal; therefore, we are finalizing our 

proposal to move the RN time allocated to these procedures to the facility setting. The CY 2015 

Direct Practice Expense Input database reflects this correction. 

g. Work Time 

Subsequent to the publication of the CY PFS 2014 final rule with comment period, 

several inconsistencies in the work time file came to our attention. First, for some services, the 

total work time, which is used in our PE methodology, did not equal the sum of the component 

parts (pre-service, intra-service, post-service, and times associated with global period visits). 

The times in the CY 2015 work time file reflect our corrected values for total work time. Second, 

for a subset of services, the values in the pre-positioning time, pre-evaluation time, and prescrub-dress-wait time, were inadvertently transposed. We note that this error had no impact on 

calculation of the total times, but has been corrected in the CY 2015 work time file. Third, minor 

discrepancies for a series of interim final codes were identified between the work time file and 
CMS-1612-FC 68

the way we addressed these codes in the preamble text. Therefore, we have made adjustments to 

the work time file to reflect the decisions indicated in the preamble text. The work time file is 

available on the CMS website under the supporting data files for the CY 2015 PFS final rule 

with comment period at http://www.cms.gov/PhysicianFeeSched/. Note that for comparison 

purposes, the CY 2014 work time file is located at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-

FC.html. 

Comment: A commenter supported our proposal to correct the work times associated 

with the procedures affected by this proposal. 

Response: We appreciate the commenter’s support for our proposal. After consideration 

of the comment received, we are finalizing our proposal to adjust the work time file as proposed. 

The work time file is available on the CMS website under the supporting data files for the CY 

2015 PFS final rule with comment period at http://www.cms.gov/PhysicianFeeSched/

h. Updates to Price for Existing Direct Inputs. 

In the CY 2011 PFS final rule with comment period (75 FR 73205), we finalized a 

process to act on public requests to update equipment and supply price and equipment useful life 

inputs through annual rulemaking beginning with the CY 2012 PFS proposed rule. During 2013, 

we received a request to update the price of SD216 (catheter, balloon, esophageal or rectal 

(graded distention test)) from $217 to $237.50. We also received a request to update the price of 

SL196 (kit, HER-2/neu DNA Probe) from $105 to $144.50. We received invoices that 

documented updated pricing for each of these supply items. We proposed to increase the price 

associated with these supply items. 

We continue to believe it is important to maintain a periodic and transparent process to 

update the price of items to reflect typical market prices in our ratesetting methodology, and we 
CMS-1612-FC 69

continue to study the best way to improve our current process. We remind stakeholders that we 

have difficulty obtaining accurate pricing information. The goal of the current transparent 

process is to offer the opportunity for the community to both request supply price updates by 

providing us copies of paid invoices, and to object to proposed changes in price inputs for 

particular items by providing additional information about prices available to the practitioner 

community. We remind stakeholders that PFS payment rates are developed within a budget 

neutral, relative value system, and any increases in price inputs for particular supply items result 

in corresponding decreases to the relative values of all other direct PE inputs. 

 We also received a RUC recommendation to update the prices associated with two supply 

items. Specifically, the RUC recommended that we increase the price of SA042 (pack, cleaning 

and disinfecting, endoscope) from $15.52 to $17.06 to reflect the addition of supply item SJ009 

(basin, irrigation) to the pack, and increase the price of SA019 (kit, IV starter) from $1.37 to 

$1.60 to reflect the addition of supply item SA044 (underpad 2 ft. x 3 ft. (Chux)) to the kit. We 

proposed to update the prices for both of these items based on these recommendations. 

Comment: We received several comments regarding our concern about obtaining 

accurate pricing information for equipment and supply items included in the direct PE database. 

The RUC indicated that it would continue to work with specialty societies to obtain paid 

invoices. A commenter suggested that a sample of paid invoices be obtained from practices and 

submitted with the PE materials to the RUC, or directly to CMS. Another commenter expressed 

concern regarding CMS’s assertion that invoices are difficult to obtain, given that the RUC 

process collects lists of resources required to furnish services in the physician office using a 

standardized process that is typically accompanied by invoices. Another commenter stated that 

CMS used only the lowest-cost invoice for a particular equipment item since the other invoices 
CMS-1612-FC 70

included “soft costs,” and that CMS should establish an approach that would allow invoices to be 

used even if they contain “soft costs.” 

Response: We appreciate the RUC’s assistance in obtaining paid invoices from the 

specialty societies. These invoices are helpful in pricing inputs. We disagree that we use the 

lowest-cost invoice because it had the lowest cost; rather, we often use the lowest-cost invoice 

because we do not have a method to use invoices that include costs that are not included as part 

of the equipment costs, so called “soft costs,” within the PE methodology. We do not believe it 

would serve accuracy or relativity to include as part of the pricing inputs “soft costs” that 

increase the price of particular supply or equipment items. We would welcome further input on 

potential approaches for “backing out” these costs. 

Comment: One commenter disagreed with CMS’s position that the RUC PE 

Subcommittee’s review results in biased or inaccurate resource input costs because the prices are 

largely maintained in the direct PE input database by CMS. 

Response: Although we did not raise this point in the CY 2015 PFS proposed rule, we 

refer readers to our discussion in previous rulemaking (for example, the CY 2011 PFS final rule 

with comment period at 75 FR 73250 and the CY 2014 PFS final rule with comment period at 78 

FR 74246) regarding issues associated with obtaining appropriate prices for medical equipment 

and supply items included in the direct PE database. We note that the RUC provides 

recommendations regarding the use of particular items in furnishing a service, but does not 

provide CMS with recommendations regarding the prices of direct PE item. Without assigning a 

price, the input cannot be factored in to our PE RVU methodology. Our price information is 

almost exclusively anecdotal, and generally updated only through voluntary submission of a 

small number of invoices from the same practitioners that furnish and are paid for the services 
CMS-1612-FC 71

that use the particular inputs. Therefore, we continue to believe there is potential for bias in the 

information we receive. 

Comment: In its comment, the RUC suggested that an annual CMS review of paid 

invoices for high-cost supplies would be appropriate. A commenter referenced comments made 

on the CY 2014 PFS final rule with comment period, and expressed agreement with those 

commenters that the provision of pricing information is sensitive because of issues involving 

proprietary pricing information and price negotiations for individual practitioners. This 

commenter also agreed with CMS that such information would be less sensitive if it confirmed 

inputs contained in the direct PE database. However, the commenter noted that requiring paid 

invoices from this point forward only partially addresses the concern since many existing inputs 

are not based on paid invoices; specifically, societies working on inputs for new, revised, or 

potentially misvalued services are disadvantaged in comparison to many existing inputs due to 

fee schedule relativity. The commenter suggested that CMS may need to undertake a 

comprehensive review of all direct PE inputs and obtain paid invoices to systematically address 

its concerns. 

Response: We share commenters’ concerns that codes that are being reviewed may be 

disadvantaged relative to codes that contain input prices that may not be based on paid invoices; 

and note that we rely on the public process to ensure continued relativity within the direct PE 

inputs. We encourage interested stakeholders to review updates to prices, as well as prices for 

new items, to ensure that they appear reasonable and current, and to provide us with updated 

pricing information, particularly regarding high cost supplies that have a greater impact on 

relativity. We refer readers to section II.F. of this final rule with comment period, in which we 

detail price updates, as well as establish new prices, for inputs included in new, revised, and 

potentially misvalued codes. 
CMS-1612-FC 72

Comment: We received some comments in support of our proposal to update the price 

for SL196 (kit, HER-2/neu DNA Probe). 

Response: We appreciate the commenters’ support for our proposal to update the price 

for SL196. After publication of our proposal, we obtained new information suggesting that 

further study of the price of this item is necessary before proceeding to update the input price. 

Therefore, we are not finalizing our proposal to update the price for SL196, and will consider 

this matter in future rulemaking. 

Comment: We did not receive any comments regarding our proposal to update the price 

for of SD216 (catheter, balloon, esophageal or rectal (graded distention test)). 

Response: We are finalizing the price updates for SD216. 

Comment: We received comments in support of the price update to SA019 (kit, IV 

starter) and SA042 (pack, cleaning and disinfecting, endoscope). 

Response: We appreciate the commenters’ support for our proposal to update the price 

for SA019 and SA042. After consideration of comments received, we are finalizing the price 

updates for SA019 and SA042. 

i. New Standard Supply Package for Contrast Imaging 

 The RUC recommended creating a new direct PE input standard supply package 

“Imaging w/contrast, standard package” for contrast enhanced imaging, with a price of $6.82. 

This price reflects the combined prices of the medical supplies included in the package; these 

items are listed in Table 10. We proposed to accept this recommendation, but sought comment 

on whether all of the items included in the package are used in the typical case. The CY 2015 

direct PE database reflects this change and is available on the CMS website under the supporting 

data files for the CY 2015 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. 

 
CMS-1612-FC 73

TABLE 10: Standard Contrast Imaging Supply Package 

Medical Supply Description CMS 

Supply 

Code 

Unit Quantity Price 

Kit, IV starter SA019 Kit 1 $1.60

Gloves, non-sterile SB022 Pair 1 0.084

Angiocatheter 14g-24g SC001 Item 1 1.505

Heparin lock SC012 Item 1 0.917

IV tubing (extension) SC019 Foot 3* 1.590

Needle, 18-27g SC029 Item 1 0.089

Syringe 20ml SC053 Item 1 0.558

Sodium chloride 0.9% inj. bacteriostatic (30ml uou) SH068 Item 1 0.700

Swab-pad, alcohol SJ053 Item 1 0.013

TOTAL $7.06

* The price for SC019 (IV tubing, (extension)) is $0.53 per foot. 

Comment: Commenters supported our proposal to create the standard supply package for 

contrast imaging. Some commenters expressed concern that the proposed supply package did 

not include the full range of supplies typically used when performing contrast imaging. One 

commenter stated that, for echocardiography labs that utilize contrast-enhanced ultrasound, 

additional items are typically part of the contrast imaging supply package, including 2x2 gauze 

pads, a stopcock, and tape. Another commenter suggested that a power injector should also be 

included in the standard contrast imaging supply package. Commenters also noted that CMS 

provided limited information regarding how the prices were assigned to the supply items, and 

pointed to discrepancies between the direct PE database files and the prices quoted in the table. 

Response: We appreciate commenters’ support for our proposal. We note that the RUC 

recommendation for the standard contrast imaging supply package also noted that the inputs for 

CTA and MRA studies would include the standard contrast imaging supply pack in addition to a 

stop cock (SC050) and additional tubing. While we acknowledge a commenter’s suggestion that 

additional items may be used when echocardiography labs conduct contrast-enhanced ultrasound 

studies, we do not have information to suggest that these items are used for other imaging 

studies, such as CT and MRI contrast-enhanced studies. We would welcome more information 
CMS-1612-FC 74

on whether these items should be included in the newly created standard contrast imaging kit, as 

well as whether the power injector is used whenever the other inputs in the standard contrast 

imaging supply package are used, or whether they are used only in certain instances. We note 

that the reason for the discrepancy in the price for the IV starter kit is that we proposed to update 

the price at the same time that we proposed to create a new contrast imaging kit. Since we are 

finalizing the price update for SA019 (kit, IV starter), we are also finalizing a revised price for 

the new standard contrast imaging package of $7.06. Finally, we disagree with the commenter’s 

suggestion that CMS provided limited information about the pricing for the items included in the 

kit, as these items are existing inputs in the direct PE database, and the codes associated with 

these items were listed in the table in the proposed rule. After consideration of comments 

received, we are finalizing our proposal to create a standard contrast imaging supply pack, with a 

revised price of $7.06. 

j. Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT Codes 77372 and 77373) 

In the CY 2014 PFS final rule with comment period (78 FR 74245), we summarized 

comments received about whether CPT codes 77372 and 77373 would accurately reflect the 

resources used in furnishing the typical SRS delivery if there were no coding distinction between 

robotic and non-robotic delivery methods. Until now, SRS services furnished using robotic 

methods were billed using contractor-priced G-codes G0339 (Image-guided robotic linear 

accelerator based stereotactic radiosurgery, complete course of therapy in one session or first 

session of fractionated treatment), and G0340 (Image-guided robotic linear accelerator-based 

stereotactic radiosurgery, delivery including collimator changes and custom plugging, 

fractionated treatment, all lesions, per session, second through fifth sessions, maximum five 

sessions per course of treatment). We indicated that we would consider deleting these codes in 

future rulemaking. 
CMS-1612-FC 75

Most commenters responded that the CPT codes accurately described both services, and 

the RUC stated that the direct PE inputs for the CPT codes accurately accounted for the resource 

costs of the described services. One commenter objected to the deletion of the G-codes but did 

not include any information to suggest that the CPT codes did not describe the services or that 

the direct PE inputs for the CPT codes were inaccurate. Based on a review of the comments 

received, we had no indication that the direct PE inputs included in the CPT codes would not 

reflect the typical resource inputs involved in furnishing an SRS service. Therefore, in the CY 

2014 proposed rule we proposed to recognize only the CPT codes for SRS services, and to delete 

the G-codes used to report robotic delivery of SRS. 

Comment: We received several comments regarding our proposal to delete the SRS Gcodes. Some commenters supported our proposal, but most opposed our proposal on the grounds 

that the direct PE inputs included in the CPT codes do not reflect the typical resource inputs used 

in furnishing robotic SRS services. Some commenters urged CMS to delay this policy change 

and continue to contractor price the G-codes until a more appropriate solution can be found. 

Response: After consideration of the comments regarding the appropriate inputs to use in 

pricing the SRS services, we have concluded that at this time, we lack sufficient information to 

make a determination about the appropriateness of deleting the G-codes and paying for all 

SRS/SBRT services using the CPT codes. Therefore, we will not delete the G-codes for 2015, 

but will instead work with stakeholders to identify an alternate approach and reconsider this issue 

in future rulemaking. 

k. Inclusion of Capnograph for Pediatric Polysomnography Services 

 We proposed to include equipment item EQ358, Sleep capnograph, polysomnography 

(pediatric), for CPT codes 95782 (Polysomnography; younger than 6 years, sleep staging with 4 

or more additional parameters of sleep, attended by a technologist) and 95783 
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(Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of 

sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, 

attended by a technologist). Based upon our understanding that capnography is a required 

element of sleep studies for patients younger than 6 years, we proposed to allocate this 

equipment item to 95782 for 602 minutes, and 95783 for 647 minutes. Based on the invoice we 

received for this equipment item, we proposed to price EQ358 at $4,534.23. 

Comment: We received two comments in support of our proposal to include the 

capnograph in CPT codes 95782 and 95783. 

Response: We appreciate commenters’ support for our proposal. After consideration of 

comments received, we are finalizing our proposal to include the capnograph in CPT codes 

95782 and 95783. 

4. Using OPPS and ASC Rates in Developing PE RVUs 

Accurate and reliable pricing information for both individual items and indirect PEs is 

critical to establish accurate PE RVUs for PFS services. As we have addressed in previous 

rulemaking, we have serious concerns regarding the accuracy of some of the information we use 

in developing PE RVUs. In particular, as discussed in the CY 2014 PFS final rule with comment 

period, we have several longstanding concerns regarding the accuracy of direct PE inputs, 

including both items and procedure time assumptions, and prices of individual supplies and 

equipment (78 FR 74248– 74250). In addition to the concerns regarding the inputs used in 

valuing particular procedures, we also noted that the allocation of indirect PE is based on 

information collected several years ago (as described above) and will likely need to be updated 

in the coming years. 

To mitigate the impact of some of these potentially problematic data used in developing 

values for individual services, in rulemaking for the CY 2014 PFS, we proposed to limit the 
CMS-1612-FC 77

nonfacility PE RVUs for individual codes so that the total nonfacility PFS payment amount 

would not exceed the total combined amount that Medicare would pay for the same code in the 

facility setting. In developing the proposal, we sought a reliable means for Medicare to set upper 

payment limits for office-based procedures and believed OPPS and ASC payment rates would 

provide an appropriate comparison because these rates are based on relatively more reliable cost 

information in settings with cost structures that generally would be expected to be higher than in 

the office setting. 

We received many comments regarding our proposal, the vast majority of which urged us 

to withdraw the proposal. Some commenters questioned the validity of our assumption that 

facilities’ costs for providing all services are necessarily higher than the costs of physician 

offices or other nonfacility settings. Other commenters expressed serious concerns with the 

asymmetrical comparisons between PFS payment amounts and OPPS/ASC payment amounts. 

Finally, many commenters suggested revisions to technical aspects of our proposed policy. 

In considering all the comments, however, we were persuaded that the comparison of 

OPPS (or ASC) payment amounts to PFS payment amounts for particular procedures is not the 

most appropriate or effective approach to ensuring that PFS payment rates are based on accurate 

cost assumptions. Commenters noted several flaws with the approach. First, unlike PFS 

payments, OPPS and ASC payments for individual services are grouped into rates that reflect the 

costs of a range of services. Second, commenters suggested that since the ASC rates reflect the 

OPPS relative weights to determine payment rates under the ASC payment system, and are not 

based on cost information collected from ASCs, the ASC rates should not be used in the 

proposed policy. For these and other reasons raised by commenters, we did not propose a similar 

policy for the CY 2015 PFS. If we consider using OPPS or ASC payment rates in developing 
CMS-1612-FC 78

PFS PE RVUs in future rulemaking, we would consider all of the comments received regarding 

the technical application of the previous proposal. 

After thorough consideration of the comments regarding the CY 2014 proposal, we 

continue to believe that there are various possibilities for leveraging the use of available hospital 

cost data in the PE RVU methodology to ensure that the relative costs for PFS services are 

developed using data that is auditable and comprehensively and regularly updated. Although 

some commenters questioned the premise that the hospital cost data are more accurate than the 

information used to establish PE RVUs, we continue to believe that the routinely updated, 

auditable resource cost information submitted contemporaneously by a wide array of providers 

across the country is a valid reflection of ‘‘relative’’ resources and could be useful to supplement 

the resource cost information developed under our current methodology based upon a typical 

case that are developed with information from a small number of representative practitioners for 

a small percentage of codes in any particular year. 

Section 220(a)(1) of the PAMA added a new subparagraph (M) under section 1848(c)(2) 

of the Act that gives us authority to collect information on resources used to furnish services 

from eligible professionals (including physicians, non-physician practitioners, PTs, OTs, SLPs 

and qualified audiologists), and other sources. It also authorizes us to pay eligible professionals 

for submitting solicited information. We will be exploring ways of collecting better and updated 

resource data from physician practices, including those that are provider-based, and other nonfacility entities paid through the PFS. We believe such efforts will be challenging given the wide 

variety of practices, and that any effort will likely impose some burden on eligible professionals 

paid through the PFS regardless of the scope and manner of data collection. Currently, through 

one of the validation contracts discussed in section II.B. of this final rule with comment period, 

we have been gathering time data directly from physician practices. Through this project, we 
CMS-1612-FC 79

have learned much about the challenges for both CMS and the eligible professionals of collecting 

data directly from practices. Our own experience has shown that is difficult to obtain invoices 

for supply and equipment items that we can use in pricing direct PE inputs. 

Many specialty societies also have noted the challenges in obtaining recent invoices for 

medical supplies and equipment (78 FR 74249). Further, PE calculations rely heavily on 

information from the Physician Practice Expense Information Survey (PPIS) survey, which, as 

discussed earlier, was conducted in 2007 and 2008. When we implemented the results of the 

survey, many in the community expressed serious concerns over the accuracy of this or other PE 

surveys as a way of gathering data on PE inputs from the diversity of providers paid under the 

PFS. 

In addition to data collection, section 1848(c)(2)(M) of the Act as added by section 

220(a) of the PAMA provides authority to develop and use alternative approaches to establish PE 

relative values, including the use of data from other suppliers and providers of services. We are 

exploring the best approaches for exercising this authority, including with respect to use of 

hospital outpatient cost data. We understand that many stakeholders will have concerns 

regarding the possibility of using hospital outpatient cost data in developing PE RVUs under the 

PFS, and we want to be sure we are aware of these prior to considering or developing any future 

proposal relying on those data. 

Therefore, in the CY 2015 PFS proposed rule (79 FR 40333), we sought comment on the 

possible uses of the Medicare hospital outpatient cost data (not the APC payment amount) in 

potential revisions of the PFS PE methodology. This could be as a means to validate or, perhaps, 

in setting the relative resource cost assumptions within the PFS PE methodology. We noted that 

the resulting PFS payment amounts would not necessarily conform to OPPS payment amounts 

since OPPS payments are grouped into APCs, while PFS payments would continue to be valued 
CMS-1612-FC 80

individually and would remain subject to the relativity inherent in establishing PE RVUs, budget 

neutrality adjustments, and PFS updates. We expressed particular interest in comments that 

compare such possibilities to other broad-based, auditable, mechanisms for data collection, 

including any we might consider under the authority provided under section 220(a) of the 

PAMA. We urged commenters to consider a wide range of options for gathering and using the 

data, including using the data to validate or set resource assumptions for only a subset of PFS 

services, or as a base amount to be adjusted by code or specialty-level recommended 

adjustments, or other potential uses. We appreciate the many thoughtful comments that we 

received on whether and how to use the OPPS cost data in establishing PE relative values. We 

will consider these as we continue to think about mechanisms to improve the accuracy of PE 

values. 

In addition to soliciting comments as noted above, in the CY 2015 proposed rule we 

stated that we continue to seek a better understanding regarding the growing trend toward 

hospital acquisition of physicians’ offices and how the subsequent treatment of those locations as 

off-campus provider-based outpatient departments affects payments under PFS and beneficiary 

cost-sharing. MedPAC continues to question the appropriateness of increased Medicare payment 

and beneficiary cost-sharing when physicians’ offices become hospital outpatient departments, 

and to recommend that Medicare pay selected hospital outpatient services at PFS rates (MedPAC 

March 2012 and June 2013 Report to Congress). We noted that we also remain concerned about 

the validity of the resource data as more physician practices become provider-based. Our survey 

data reflects the PE costs for particular PFS specialties, including a proportion of practices that 

may have become provider-based since the survey was conducted. Additionally, as the 

proportion of provider-based offices varies among physician specialties, so do the relative 

accuracy of the PE survey data. Our current PE methodology primarily distinguishes between 
CMS-1612-FC 81

the resources involved in furnishing services in two sites of service: The non-facility setting and 

the facility setting. In principle, when services are furnished in the non-facility setting, the costs 

associated with furnishing services include all direct and indirect PEs associated with the work 

and the PE of the service. In contrast, when services are furnished in the facility setting, some 

costs that would be PEs in the office setting are incurred by the facility. Medicare makes a 

separate payment to the facility to account for some portion of these costs, and we adjust PEs 

accordingly under the PFS. As more physician practices become hospital-based, it is difficult to 

know which PE costs typically are actually incurred by the physician, which are incurred by the 

hospital, and whether our bifurcated site-of service differential adequately accounts for the 

typical resource costs given these relationships. We also have discussed this issue as it relates to 

accurate valuation of visits within the postoperative period of 10- and 90-day global codes in 

section II.B.4 of this final rule with comment period. 

To understand how this trend is affecting Medicare, including the accuracy of payments 

made through the PFS, we need to develop data to assess the extent to which this shift toward 

hospital-based physician practices is occurring. To that end, during CY 2014 rulemaking we 

sought comment regarding the best method for collecting information that would allow us to 

analyze the frequency, type, and payment for services furnished in off-campus provider-based 

hospital departments (78 FR 74427). We received many thoughtful comments. However, the 

commenters did not present a consensus opinion regarding the options we presented in last year’s 

rule. Based on our analysis of the comments, we stated that we believed the most efficient and 

equitable means of gathering this important information across two different payment systems 

would be to create a HCPCS modifier to be reported with every code for physicians’ and hospital 

services furnished in an off-campus provider-based department of a hospital. 
CMS-1612-FC 82

We proposed that the modifier would be reported on both the CMS–1500 claim form for 

physicians’ services and the UB–04 (CMS form 1450) for hospital outpatient claims. (We note 

that the requirements for a determination that a facility or an organization has provider-based 

status are specified in §413.65, and we define a hospital campus to be the physical area 

immediately adjacent to the provider’s main buildings, other areas and structures that are not 

strictly contiguous to the main buildings but are located within 250 yards of the main buildings, 

and any other areas determined on an individual case basis, by the CMS regional office.) 

Therefore, we proposed to collect this information on the type and frequency of services 

furnished in off-campus provider-based departments in accordance with our authority under 

section 1848(c)(2)(M) of the Act (as added by section 220(a) of the PAMA) beginning January 

1, 2015. The collection of this information would allow us to begin to assess the accuracy of the 

PE data, including both the service-level direct PE inputs and the specialty-level indirect PE 

information that we currently use to value PFS services. Furthermore, this information would be 

critical in order to develop proposed improvements to our PE data or methodology that would 

appropriately account for the different resource costs among traditional office, facility, and offcampus provider-based settings. We also sought additional comment on whether a code modifier 

is the best mechanism for collecting this service-level information. 

Comment: Many commenters agreed on the need to collect information on the frequency, 

type, and payment of services furnished in off-campus provider-based departments of hospitals, 

however, several commenters expressed concern that the HCPCS modifier would create 

additional administrative burden for providers. Many of these commenters stated that the new 

modifier would require significant changes to hospitals’ billing systems, including a separate 

charge master for outpatient off-campus PBDs and training for staff on how to use the new 

modifier. Several commenters thought that education and training would be required for 
CMS-1612-FC 83

physician offices to attach a modifier to services furnished in an off-campus provider-based 

department. These same commenters suggested that a new place of service (POS) code would be 

more appropriate for physician billing. Several commenters suggested that CMS should repropose a detailed data collection methodology, test it with providers, make adjustments, and 

allow additional time for implementation. 

Response: While we understand commenters’ concerns about the additional 

administrative burden of reporting a new HCPCS modifier, we have weighed the burden of 

reporting the modifier for each service against the benefit of having data that will allow us to 

obtain and assess accurate information on the type and frequency of outpatient hospital services 

furnished in off-campus provider-based departments, and we do not believe that the modifier is 

excessively burdensome for providers to report. When billing for hospital services, providers 

must know where services are furnished in order to accurately complete value code 78 of an 

outpatient claim or item 32 for service location on the practitioner claim. However, as discussed 

later in this section, we agree that a POS code on the professional claim allows for the same type 

of data collection as a modifier and would be less burdensome than the modifier for practitioners. 

We discuss the timeframe for implementation later in this section. 

Comment: Some commenters who were concerned about the administrative burden of 

the new HCPCS modifier suggested several alternative methods for CMS to collect data on 

services furnished in off-campus provider-based departments. Several of these commenters 

recommended that CMS consider establishing of a new POS code for professional claims, or for 

both professional and hospital claims, because they believed this approach would be less 

administratively burdensome than attaching a modifier to each service reported on the claim that 

was furnished in an off-campus provider-based department. Some commenters preferred 

identifying services furnished in provider-based departments on the Medicare cost report (CMS-
CMS-1612-FC 84

2552-10). Some commenters suggested using provider numbers and addresses to identify offcampus PBDs, or changing the provider enrollment process to be able to track this data. Yet 

other commenters suggested creating a new bill type to track off-campus PBD services. 

Commenters generally recommended that CMS choose the least administratively 

burdensome approach that would ensure accurate data collection, but did not necessarily agree 

on what approach would optimally achieve that result. Some commenters believed that a 

HCPCS modifier would more clearly identify specific services furnished at off-campus PBDs, 

and would provide better information about the type and level of care furnished. Some 

commenters believed that a HCPCS modifier would be the least administratively burdensome 

approach because hospitals and physicians already report a number of claims-based modifiers. 

However, other commenters stated that additional modifiers would increase administrative 

burden because this approach would increase the modifiers that would need to be considered 

when billing. 

Response: With respect to creating a new POS code to obtain data on services furnished 

in off-campus PBDs of a hospital, we note that POS codes are only reported on professional 

claims and are not included on institutional claims. Therefore, a POS code could not be easily 

implemented for hospital claims. However, POS codes are already required to be reported on 

every professional claim, and POS 22 is currently used when physicians’ services are furnished 

in an outpatient hospital department. (More information on existing POS codes is available on 

the CMS Website at http://www.cms.gov/Medicare/Coding/place-of-servicecodes/Place_of_Service_Code_Set.html). 

Though we considered proposing a new POS code for professional claims to collect data 

on services furnished in the off-campus hospital setting, we note that previous GAO and OIG 

reports (October 2004 A-05-04-0025, January 2005 A-06-04-00046, July 2010 A-01-09-00503 , 
CMS-1612-FC 85

September 2011 A-01-10-00516 ) have noted frequent inaccuracies in the reporting of POS 

codes. Additionally, at the time the proposed rule was developed, we had concerns that using a 

POS code to report this information might not give us the reliable data we are looking to collect, 

especially if such data were to be cross-walked with hospital claims for the same service, since 

the hospital claim would have a modifier, not a POS code. However, we have been persuaded by 

public comments suggesting that use of a POS code on professional claims would be less 

administratively burdensome than use of a modifier, and would be more familiar to those 

involved in practitioner billing. Specifically, since a POS code is already required on every 

professional claim, we believe that creating a new POS code to distinguish outpatient hospital 

services that are furnished on the hospital campus versus in an off-campus provider-based 

department would require less staff training and education than would the use of a modifier on 

the professional claim. Additionally, professional claims only have space for four modifiers; 

while a very small percentage of professional claims have four modifiers, required use of an 

additional modifier for every professional claim could lead to more occurrences where there 

would not be space for all applicable payment modifiers for a specific service. Unlike 

institutional claims, we note that a new professional claim is required whenever the place of 

service changes. That is, even if the same practitioner treats the same patient on the same day in 

the office and the hospital, the services furnished in the office setting must be submitted on one 

claim with POS 11 (Office), while those furnished in the outpatient hospital department would 

be submitted on a separate claim with POS 22 (Outpatient Hospital). Likewise, if a new POS 

code were to be created for off-campus outpatient provider-based hospital department, a separate 

claim for services furnished in that setting would be required relative to a claim for outpatient 

services furnished on the hospital’s main campus by the same practitioner to the same patient on 

the same day. Based on public comments and after further consultation with Medicare billing 
CMS-1612-FC 86

experts, we believe that use of the POS code on professional claims would be no less accurate 

than use of a modifier on professional claims in identifying services furnished in off-campus 

PBDs. In addition, we believe that the POS code would be less administratively burdensome for 

practitioners billing using the professional claim since a POS code is already required for every 

professional claim. 

With respect to adding new fields to existing claim forms or creating a new bill type, we 

do not believe that this data collection warrants these measures. We believe that those changes 

would create greater administrative burden than the proposed HCPCS modifier and POS codes, 

especially since providers are already accustomed to using modifiers and POS codes. Revisions 

to the claim form to add new fields or an additional bill type would create significant 

administrative burden to revise claims processing systems and educate providers that is not 

necessary given the availability of a modifier and POS codes. Though providers may not be 

familiar with this new modifier or any new POS code; since these types of codes already exist 

generally for hospital and professional claims, providers and suppliers should already have an 

understanding of these types of codes and how to apply them. Finally, we do not believe that 

expansions to the claim form or use of a new bill type would provide us with detailed 

information on exactly which services were furnished in an off-campus PBD versus those 

furnished on the main campus when those services are furnished on the same day. 

We also do not believe that we could accurately determine which services are furnished 

at off-campus provider-base departments (PBDs) using currently available NPI and facility 

address data. Hospitals are required to report the nine-digit ZIP code indicating where a service 

was furnished for purposes of paying properly for physician and anesthesia services paid off the 

PFS when that ZIP code differs from the master address for the hospital on file in CMS claims 

systems in value code 78 (pub 100-04, transmittal 1681, February 13, 2009). However, the 
CMS-1612-FC 87

billing ZIP code for the hospital main campus could be broad enough to incorporate on and offcampus provider-based departments. Further, a ZIP code reported in value code 78 does not 

allow CMS to distinguish between services furnished in different locations on the same date. 

Therefore, we do not believe that a comparison of the ZIP code captured in value code 78 and 

the main campus ZIP code is sufficiently precise. 

Finally, while we considered the suggestion that CMS use currently reported Medicare 

hospital cost report (CMS-2552-10) data to identify services furnished at off-campus PBDs, we 

note that though aggregate data on services furnished in different settings must be reported 

through the appropriate cost center, we would not be able to obtain the service-specific level of 

detail that we would be able to obtain from claims data. 

We will take under consideration the suggestion that CMS create a way for hospitals to 

report their acquisition of physician offices as off-campus PBDs through the enrollment process, 

although this information, as currently reported, would not allow us to know exactly which 

services are furnished in off-campus provider based departments and which services are 

furnished on the hospital’s main campus when a hospital provides both on the same day. 

Comment: Commenters noted that the proposed modifier would not allow CMS to know 

the precise location of the off-campus provider-based department for billed services or when 

services are furnished at different off-campus provider-based locations in the same day. 

Response: We agree that neither the proposed modifier nor a POS code provides details 

on the specific provider-based location for each furnished service. However, we believe that 

collecting information on the type and frequency of services furnished at all off-campus 

locations will assist CMS in better understanding the distribution of services between on and offcampus locations. 
CMS-1612-FC 88

Comment: MedPAC believed there may be some value in collecting data on services 

furnished in off-campus provider-based departments to validate the accuracy of site-of-service 

reporting when the physician’s office is off-campus but bills as an outpatient department. 

MedPAC indicated that any data collection effort should not prevent the development of policies 

to align payment rates across settings. MedPAC encouraged CMS to seek legislative authority to 

set equal payment rates across settings for evaluation and management office visits and other 

select services. 

Response: We thank MedPAC for its support of our data collection efforts to learn more 

about the frequency and types of services that are being furnished in off-campus PBDs. 

Comment: Many commenters suggested that providers would not be able to accurately 

apply the new modifier by the January 1, 2015 implementation timeline and recommended a 

one-year delay before providers would be required to apply the modifier to services furnished at 

off-campus PBDs. Some commenters requested only a six-month delay in implementation. 

Commenters indicated that significant revisions to internal billing processes would require 

additional time to implement. 

Response: Though we believe that the January 1st effective date that applies to most 

policies adopted in the final rules with comment period for both the PFS and the OPPS would 

provide sufficient lead time, we understand commenters’ concerns with the proposed timeline for 

implementation given that the new reporting requirements may require changes to billing 

systems as well as education and training for staff. With respect to the POS code for 

professional claims, we will request two new POS codes to replace POS code 22 (Hospital 

Outpatient) through the POS Workgroup and expect that it will take some time for these new 

codes to be established. Once the revised POS codes are ready and integrated into CMS claims 

systems, practitioners would be required to use them, as applicable. More information on the 
CMS-1612-FC 89

availability of the new POS codes will be forthcoming in subregulatory guidance, but we do not 

expect the new codes to be available prior to July 1, 2015. There will be no voluntary reporting 

period of the POS codes for applicable professional claims because each professional claim 

requires a POS code in order to be accepted by Medicare. However, we do not view this to be 

problematic because we intend to give prior notice on the POS coding changes and, as many 

public commenters noted, because practitioners are already accustomed to using a POS on every 

claim they submit. 

We also are finalizing our proposal to create a HCPCs modifier for hospital services 

furnished in an off-campus PBD setting; but we are adopting a voluntary reporting period for the 

new HCPCS modifier for one year. That is, reporting the new HCPCS modifier for services 

furnished at an off-campus PBD will not be mandatory until January 1, 2016, in order to allow 

providers time to make systems changes, test these changes, and train staff on use of the new 

modifier before reporting is required. We welcome early reporting of the modifier and believe a 

full year of preparation should provide hospitals with sufficient time to modify their systems for 

accurate reporting. 

Comment: Many commenters expressed concern that this data collection would 

eventually lead to equalizing payment for similar services furnished in the non-facility setting 

and the off-campus PBD setting. Several commenters noted that the trend of hospitals acquiring 

physician practices is due to efforts to better integrate care delivery, and suggested that CMS 

weigh the benefits of care integration when deciding payment changes. Some commenters 

suggested that CMS should use the data to equalize payment for similar services between these 

two settings. These commenters suggest that there is little difference in costs and care between 

the two settings that would warrant the difference in payment. Several of these commenters 

highlighted beneficiary cost sharing as one reason for site-neutral payment, noting that the total 
CMS-1612-FC 90

payment amount for hospital outpatient services is generally higher than the total payment 

amount for those same services when furnished in a physician’s office. 

Response: We appreciate the comments received. At this time, we are only finalizing a 

data collection in this final rule with comment period. We did not propose, and therefore, are not 

finalizing any adjustment to payments furnished in the off-campus PBD setting. 

Comment: Several commenters noted that the CMS proposal would not provide 

additional information on how a physician practice billed prior to becoming an off-campus PBD, 

which would be important for analyzing the impact of this trend. 

Response: We agree that, in analyzing the impact of this trend, it is important to 

understand physician billing patterns that were in place prior to becoming an off-campus PBD, 

and we will continue to evaluate ways to analyze claims data to gather this information. We 

believe that collecting data using the additional modifier and POS code as finalized in this rule 

will be an important tool in furthering this analysis. 

Comment: Some commenters suggested that the term “off-campus” needs to be better 

defined. Commenters asked how billing would occur for hospitals with multiple campuses since 

the CMS definition of campus references main buildings and does not include remote locations. 

One commenter also asked whether the modifier is intended to cover services furnished in freestanding emergency departments. 

Response: For purposes of the modifier and the POS codes we are finalizing in this final 

rule with comment period, we define a “campus” using the definition at §413.65(a)(2) to be the 

physical area immediately adjacent to the provider’s main buildings, other areas and structures 

that are not strictly contiguous to the main buildings but are located within 250 yards of the main 

buildings, and any other areas determined on an individual case basis, by the CMS regional 

office, to be part of the provider’s campus. We agree with commenters that our intent is to 
CMS-1612-FC 91

capture data on outpatient services furnished off of the hospital’s main campus and off of any of 

the hospital’s other campuses. The term “remote location of a hospital” is defined in our 

regulations at section 413.65(a)(2). Under the regulation, a “remote location” includes a hospital 

campus other than the main hospital campus. Specifically, a remote location is “a facility or an 

organization that is either created by, or acquired by, a hospital that is a main provider for the 

purposes of furnishing inpatient hospital services under the name, ownership, and financial and 

administrative control of the main provider....” Therefore, we agree with the commenters that 

the new HCPCS modifier and the POS code for off-campus PBDs should not be reported for 

services furnished in remote locations of a hospital. The term “remote location” does not include 

“satellite” locations of a hospital. However, since a satellite facility is one that provides inpatient 

services in a building also used by another hospital, or in one or more entire buildings located on 

the same campus as buildings used by another hospital, the new HCPCS modifier and the POS 

code for off-campus hospital PBDs should not be reported for services furnished in satellite 

facilities. Satellite facilities are described in our regulations at §412.22(h). Accordingly, 

reporting of the modifier and the POS code that identifies an off-campus hospital PBD would be 

required for outpatient services furnished in PBDs that are located beyond 250 yards from the 

main campus of the hospital, excluding services furnished in a remote location or satellite facility 

of the hospital. 

We also appreciate the comment on emergency departments. We do not intend for 

hospitals to report the new modifier for services furnished in emergency departments. We note 

that there is already a POS code for the emergency department, POS 23 (emergency roomhospital), and this would continue to be used on professional claims for services furnished in 

emergency departments. That is, the new POS code for off-campus hospital PBDs that will be 

created for purposes of this data collection would not apply to emergency department services. 
CMS-1612-FC 92

Hospitals and practitioners that have questions about which departments are considered to be 

“off-campus PBDs” should review additional guidance that CMS releases on this policy and 

work with the appropriate CMS regional office if individual, specific questions remain. 

Comment: Several commenters asked for clarification on when to report the modifier for 

services furnished both on and off-campus on the same day. Commenters provided several 

scenarios of visits and diagnostic services furnished on the same day. 

Response: The location where the service is actually furnished would dictate the use of 

the modifier and the POS codes, regardless of where the order for services is initiated. We 

expect the modifier and the POS code for off-campus PBDs to be reported in locations in which 

the hospital expends resources to furnish the service in an off-campus PBD setting. For 

example, hospitals would not report the modifier for a diagnostic test that is ordered by a 

practitioner who is located in an off-campus PBD when the service is actually furnished on the 

main campus of the hospital. This issue does not impact use of the POS codes since practitioners 

submit a different claim for each POS where they furnish services for a specific beneficiary. 

Comment: A few commenters asked for clarification on whether their entity constitutes a 

provider-based department. 

Response: Provider-based departments are departments of the hospital that meet the 

criteria in §413.65. 

Comment: A commenter recommended that CMS publish the data it acquires through 

adoption of this modifier. 

Response: Data collected through the new HCPCS modifier would be part of the 

Medicare Limited Data Set and would be available to the public for purchase along with the rest 

of the Limited Data Set. Similarly, professional claims data with revised POS coding would be 

available as a standard analytic file for purchase. 
CMS-1612-FC 93

In summary, after consideration of the comments received, we are finalizing our proposal 

with modifications. For professional claims, instead of finalizing a HCPCS modifier, in response 

to comments, we will be deleting current POS code 22 (outpatient hospital department) and 

establishing two new POS codes— one to identify outpatient services furnished in on-campus, 

remote or satellite locations of a hospital, and another to identify services furnished in an offcampus hospital PBD setting that is not a remote location of a hospital, a satellite location of a 

hospital or a hospital emergency department. We will maintain the separate POS code 23 

(emergency room-hospital) to identify services furnished in an emergency department of the 

hospital. These new POS codes will be required to be reported as soon as they become available, 

however advance notice of the availability of these codes will be shared publicly as soon as 

practicable. 

For hospital claims, we are creating a HCPCS modifier that is to be reported with every 

code for outpatient hospital services furnished in an off-campus PBD of a hospital. This code 

will not be required to be reported for remote locations of a hospital defined at §412.65, satellite 

facilities of a hospital defined at §412.22(h) or for services furnished in an emergency 

department. This 2-digit modifier will be added to the HCPCS annual file as of January 1, 2015, 

with the label “PO,” the short descriptor “Serv/proc off-campus pbd,” and the long descriptor 

“Services, procedures and/or surgeries furnished at off-campus provider-based outpatient 

departments.” Reporting of this new modifier will be voluntary for 1 year (CY 2015), with 

reporting required beginning on January 1, 2016. Additional instruction and provider education 

will be forthcoming in subregulatory guidance. 
CMS-1612-FC 94

B. Potentially Misvalued Services Under the Physician Fee Schedule 

1. Valuing Services Under the PFS 

Section 1848(c) of the Act requires the Secretary to determine relative values for 

physicians' services based on three components: work, PE, and malpractice. Section 

1848(c)(1)(A) of the Act defines the work component to mean, “the portion of the resources used 

in furnishing the service that reflects physician time and intensity in furnishing the service.” In 

addition, section 1848(c)(2)(C)(i) of the Act specifies that “the Secretary shall determine a 

number of work relative value units (RVUs) for the service based on the relative resources 

incorporating physician time and intensity required in furnishing the service.” 

Section 1848(c)(1)(B) of the Act defines the PE component as “the portion of the 

resources used in furnishing the service that reflects the general categories of expenses (such as 

office rent and wages of personnel, but excluding malpractice expenses) comprising practice 

expenses.” Section 1848(c)(2)(C)(ii) of the Act requires that PE RVUs be determined based 

upon the relative PE resources involved in furnishing the service. (See section II.A. of this final 

rule with comment period for more detail on the PE component.) 

Section 1848(c)(1)(C) of the Act defines the MP component as “the portion of the 

resources used in furnishing the service that reflects malpractice expenses in furnishing the 

service.” Section 1848(c)(2)(C)(iii) of the Act specifies that MP expense RVUs shall be 

determined based on the relative MP expense resources involved in furnishing the service. (See 

section II.C. of this final rule with comment period for more detail on the MP component.) 

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

a. Background 

Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a periodic review, not 

less often than every 5 years, of the RVUs established under the PFS. Section 1848(c)(2)(K) of 
CMS-1612-FC 95

the Act requires the Secretary to periodically identify potentially misvalued services using 

certain criteria and to review and make appropriate adjustments to the relative values for those 

services. Section 1848(c)(2)(L) of the Act also requires the Secretary to develop a process to 

validate the RVUs of certain potentially misvalued codes under the PFS, using the same criteria 

used to identify potentially misvalued codes, and to make appropriate adjustments. 

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

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

American Medical Association/Specialty Society Relative Value Scale Update Committee 

(RUC), the Medicare Payment Advisory Commission (MedPAC), and others. For many years, 

the RUC has provided us with recommendations on the appropriate relative values for new, 

revised, and potentially misvalued PFS services. We review these recommendations on a codeby-code basis and consider these recommendations in conjunction with analyses of other data, 

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

also consider analyses of work time, work RVUs, or direct PE inputs using other data sources, 

such as Department of Veteran Affairs (VA), National Surgical Quality Improvement Program 

(NSQIP), the Society for Thoracic Surgeons (STS), and the Physician Quality Reporting 

Initiative (PQRI) databases. In addition to considering the most recently available data, we also 

assess the results of physician surveys and specialty recommendations submitted to us by the 

RUC. We also consider information provided by other stakeholders. We conduct a review to 

assess the appropriate RVUs in the context of contemporary medical practice. We note that 

section 1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and other techniques to 

determine the RVUs for physicians’ services for which specific data are not available, in addition 

to taking into account the results of consultations with organizations representing physicians. In 
CMS-1612-FC 96

accordance with section 1848(c) of the Act, we determine and make appropriate adjustments to 

the RVUs. 

In its March 2006 Report to the Congress, MedPAC discussed the importance of 

appropriately valuing physicians’ services, noting that “misvalued services can distort the price 

signals for physicians' services as well as for other health care services that physicians order, 

such as hospital services.” In that same report MedPAC postulated that physicians' services 

under the PFS can become misvalued over time. MedPAC stated, “When a new service is added 

to the physician fee schedule, it may be assigned a relatively high value because of the time, 

technical skill, and psychological stress that are often required to furnish that service. Over time, 

the work required for certain services would be expected to decline as physicians become more 

familiar with the service and more efficient in furnishing it.” We believe services can also 

become overvalued when PE declines. This can happen when the costs of equipment and 

supplies fall, or when equipment is used more frequently than is estimated in the PE 

methodology, reducing its cost per use. Likewise, services can become undervalued when 

physician work increases or PE rises. 

As MedPAC noted in its March 2009 Report to Congress, in the intervening years since 

MedPAC made its initial recommendations, “CMS and the RUC have taken several steps to 

improve the review process.” Also, since that time the Congress added section 1848(c)(2)(K)(ii) 

to the Act, which augments our efforts. It directs the Secretary to specifically examine, as 

determined appropriate, potentially misvalued services in the following seven categories: 

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

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

● Codes that are recently established for new technologies or services; 
CMS-1612-FC 97

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

service; 

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

for a single treatment; 

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

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

● Other codes determined to be appropriate by the Secretary. 

Section 220(c) of the Protecting Access to Medicare Act of 2014 (PAMA) further 

expanded the categories of codes that the Secretary is directed to examine by adding nine 

additional categories. These are: 

● Codes that account for the majority of spending under the PFS; 

● Codes for services that have experienced a substantial change in the hospital length of 

stay or procedure time; 

● Codes for which there may be a change in the typical site of service since the code was 

last valued; 

● Codes for which there is a significant difference in payment for the same service 

between different sites of service; 

● Codes for which there may be anomalies in relative values within a family of codes; 

● Codes for services where there may be efficiencies when a service is furnished at the 

same time as other services; 

● Codes with high intra-service work per unit of time; 

● Codes with high PE RVUs; and 

● Codes with high cost supplies. 
CMS-1612-FC 98

Section 1848(c)(2)(K)(iii) of the Act also specifies that the Secretary may use existing 

processes to receive recommendations on the review and appropriate adjustment of potentially 

misvalued services. In addition, the Secretary may conduct surveys, other data collection 

activities, studies, or other analyses, as the Secretary determines to be appropriate, to facilitate 

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

also authorizes the use of analytic contractors to identify and analyze potentially misvalued 

codes, conduct surveys or collect data, and make recommendations on the review and 

appropriate adjustment of potentially misvalued services. Additionally, this section provides that 

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

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

that the Secretary may make appropriate coding revisions (including using existing processes for 

consideration of coding changes) that may include consolidation of individual services into 

bundled codes for payment under the physician fee schedule. 

b. Progress in Identifying and Reviewing Potentially Misvalued Codes 

To fulfill our statutory mandate, we have identified and reviewed numerous potentially 

misvalued codes as specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to continue our 

work examining potentially misvalued codes as authorized by statute over the coming years. As 

part of our current process, we identify potentially misvalued codes for review, and request 

recommendations from the RUC and other public commenters on revised work RVUs and direct 

PE inputs for those codes. The RUC, through its own processes, also identifies potentially 

misvalued codes for review. Through our public nomination process for potentially misvalued 

codes established in the CY 2012 PFS final rule with comment period, other individuals and 

stakeholder groups submit nominations for review of potentially misvalued codes as well. 
CMS-1612-FC 99

Since CY 2009, as a part of the annual potentially misvalued code review and Five-Year 

Review process, we have reviewed over 1,250 potentially misvalued codes to refine work RVUs 

and direct PE inputs. We have assigned appropriate work RVUs and direct PE inputs for these 

services as a result of these reviews. A more detailed discussion of the extensive prior reviews 

of potentially misvalued codes is included in the CY 2012 PFS final rule with comment period 

(76 FR 73052 through 73055). In the CY 2012 final rule with comment period, we finalized our 

policy to consolidate the review of physician work and PE at the same time (76 FR 73055 

through 73958), and established a process for the annual public nomination of potentially 

misvalued services. 

In the CY 2013 final rule with comment period, we built upon the work we began in CY 

2009 to review potentially misvalued codes that have not been reviewed since the 

implementation of the PFS (so-called “Harvard-valued codes”). In CY 2009, we requested 

recommendations from the RUC to aid in our review of Harvard-valued codes that had not yet 

been reviewed, focusing first on high-volume, low intensity codes (73 FR 38589). In the fourth 

Five-Year Review, we requested recommendations from the RUC to aid in our review of 

Harvard-valued codes with annual utilization of greater than 30,000 (76 FR 32410). In the CY 

2013 final rule with comment period, we identified Harvard-valued services with annual allowed 

charges that total at least $10,000,000 as potentially misvalued. In addition to the Harvardvalued codes, in the CY 2013 final rule with comment period we finalized for review a list of 

potentially misvalued codes that have stand-alone PE (codes with physician work and no listed 

work time, and codes with no physician work that have listed work time). 

In the CY 2014 final rule with comment period, we finalized for review a list of 

potentially misvalued services. We included on the list for review ultrasound guidance codes 

that had longer procedure times than the typical procedure with which the code is billed to 
CMS-1612-FC 100

Medicare. We also finalized our proposal to replace missing post-operative hospital E/M visit 

information and work time for approximately 100 global surgery codes. For CY 2014, we also 

considered a proposal to limit PFS payments for services furnished in a nonfacility setting when 

the nonfacility PFS payment for a given service exceeds the combined Medicare Part B payment 

for the same service when it is furnished in a facility (separate payments being made to the 

practitioner under the PFS and to the facility under the OPPS). Based upon extensive public 

comment, we did not finalize this proposal. We address our current consideration of the 

potential use of OPPS data in establishing RVUs for PFS services, as well as comments received, 

in section II.B. of this final rule with comment period. 

c. Validating RVUs of Potentially Misvalued Codes 

Section 1848(c)(2)(L) of the Act requires the Secretary to establish a formal process to 

validate RVUs under the PFS. The Act specifies that the validation process may include 

validation of work elements (such as time, mental effort and professional judgment, technical 

skill and physical effort, and stress due to risk) involved with furnishing a service and may 

include validation of the pre-, post-, and intra-service components of work. The Secretary is 

directed, as part of the validation, to validate a sampling of the work RVUs of codes identified 

through any of the 16 categories of potentially misvalued codes specified in section 

1848(c)(2)(K)(ii)of the Act. Furthermore, the Secretary may conduct the validation using 

methods similar to those used to review potentially misvalued codes, including conducting 

surveys, other data collection activities, studies, or other analyses as the Secretary determines 

appropriate to facilitate the validation of RVUs of services. 

In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS proposed rule (76 

FR 42790), we solicited public comments on possible approaches, methodologies, and data 

sources that we should consider for a validation process. We provided a summary of the 
CMS-1612-FC 101

comments along with our responses in the CY 2011 PFS final rule with comment period (75 FR 

73217) and the CY 2012 PFS final rule with comment period (76 FR 73054 through 73055). 

We contracted with two outside entities to develop validation models for RVUs. Given 

the central role of time in establishing work RVUs and the concerns that have been raised about 

the current time values used in rate setting, we contracted with the Urban Institute to collect time 

data from several practices for services selected by the contractor in consultation with CMS. 

These data will be used to develop time estimates. The Urban Institute will use a variety of 

approaches to develop objective time estimates, depending on the type of service. Objective 

time estimates will be compared to the current time values used in the fee schedule. The project 

team will then convene groups of physicians from a range of specialties to review the new time 

data and their potential implications for work and the ratio of work to time. The Urban Institute 

has prepared an interim report, Development of a Model for the Valuation of Work Relative 

Value Units, which discusses the challenges encountered in collecting objective time data and 

offers some thoughts on how these can be overcome. This interim report is available on the 

CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/RVUs-Validation-Urban Interim Report.pdf. 

Collection of time data under this project has just begun. A final report will be available once 

the project is complete. 

The second contract is with the RAND Corporation, which is using available data to 

build a validation model to predict work RVUs and the individual components of work RVUs, 

time, and intensity. The model design was informed by the statistical methodologies and 

approach used to develop the initial work RVUs and to identify potentially misvalued procedures 

under current CMS and RUC processes. RAND will use a representative set of CMS-provided 

codes to test the model. RAND consulted with a technical expert panel on model design issues 
CMS-1612-FC 102

and the test results. We anticipate a report from this project by the end of the year and will make 

the report available on the CMS website. 

Descriptions of both projects are available on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/RVUs-Validation-Model.pdf. 

We acknowledge comments received regarding the Urban Institute and RAND projects, 

but note that we did not solicit comments on these projects because we made no proposals 

related to them. Any changes to payment policies under the PFS that we might make after 

considering these reports would be issued in a proposed rule and subjected to public comment 

before they would be finalized and implemented. 

3. CY 2015 Identification and Review of Potentially Misvalued Services 

a. Public Nomination of Potentially Misvalued Codes 

In the CY 2012 PFS final rule with comment period, we finalized a process for the public 

to nominate potentially misvalued codes (76 FR 73058). The public and stakeholders may 

nominate potentially misvalued codes for review by submitting the code with supporting 

documentation during the 60-day public comment period following the release of the annual PFS 

final rule with comment period. Supporting documentation for codes nominated for the annual 

review of potentially misvalued codes may include the following: 

● Documentation in the peer reviewed medical literature or other reliable data that there 

have been changes in physician work due to one or more of the following: technique; knowledge 

and technology; patient population; site-of-service; length of hospital stay; and work time. 

● An anomalous relationship between the code being proposed for review and other 

codes. 

● Evidence that technology has changed physician work, that is, diffusion of technology. 
CMS-1612-FC 103

● Analysis of other data on time and effort measures, such as operating room logs or 

national and other representative databases. 

● Evidence that incorrect assumptions were made in the previous valuation of the 

service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous 

evaluation. 

● Prices for certain high cost supplies or other direct PE inputs that are used to determine 

PE RVUs are inaccurate and do not reflect current information. 

● Analyses of work time, work RVU, or direct PE inputs using other data sources (for 

example, VA NSQIP, STS National Database, and the PQRS databases). 

● National surveys of work time and intensity from professional and management 

societies and organizations, such as hospital associations. 

After we receive the nominated codes during the 60-day comment period following the 

release of the annual PFS final rule with comment period, we evaluate the supporting 

documentation and assess whether the nominated codes appear to be potentially misvalued codes 

appropriate for review under the annual process. In the following year’s PFS proposed rule, we 

publish the list of nominated codes and indicate whether we are proposing each nominated code 

as a potentially misvalued code. 

During the comment period to the CY 2014 final rule with comment period, we received 

nominations and supporting documentation for four codes to be considered as potentially 

misvalued codes. Although we evaluated the supporting documentation for two of the 

nominated codes to ascertain whether the submitted information demonstrated that the code 

should be proposed as potentially misvalued, we did not identify the other two codes until after 

the publication of the proposed rule. We apologize for this oversight and will address the 

nomination of CPT codes 92227 and 92228 in the proposed rule for CY 2016. 
CMS-1612-FC 104

We proposed CPT code 41530 (submucosal ablation of the tongue base, radiofrequency, 

1 or more sites, per session) as potentially misvalued based on public nomination due to a 

significant decrease in two of the direct PE inputs. 

Comment: The commenter that nominated this code as potentially misvalued thanked 

CMS for proposing this code as potentially misvalued, but indicated that the RUC had made 

recommendations for this code for CY 2015 and further review was no longer necessary. 

Another commenter suggested that this code should be removed from the list of potentially 

misvalued codes since it saves Medicare millions of dollars per year. 

Response: The RUC only provided us with recommendations for PE inputs for CPT code 

41530. Under our usual process, we value work and PE at the same time and would expect to 

receive RUC recommendations on both before we revalue this service. We disagree with the 

commenter’s statement that codes that may save money for the Medicare program should not be 

considered as potentially misvalued. Our aim, consistent with our statutory directive, is to value 

all services appropriately under the PFS to reflect the relative resources involved in furnishing 

them. After consideration of public comments, we are finalizing CPT code 41530 as potentially 

misvalued. 

We did not propose CPT code 99174 (instrument-based ocular screening (for example, 

photoscreening, automated-refraction), bilateral) as potentially misvalued, because it is a noncovered service, and we only consider nominations of active codes that are covered by Medicare 

at the time of the nomination (see 76 FR 73059). 

Comment: Commenters did not disagree with CMS not proposing this code as 

potentially misvalued, but did raise a variety of comments about the code that were unrelated to 

our proposal. 
CMS-1612-FC 105

Response: We continue to believe that our policy to limit the designation of potentially 

misvalued to those codes that are covered by Medicare is appropriate, so that we focus our 

limited resources on those services that have an impact on the Medicare program and its 

beneficiaries. Therefore, we are not including CPT code 99174 on our final list of potentially 

misvalued codes for CY 2015. 

b. Potentially Misvalued Codes 

(1) Review of High Expenditure Services across Specialties with Medicare Allowed Charges of 

$10,000,000 or More 

We proposed 68 codes listed in Table 11 as potentially misvalued codes under the newly 

established statutory category, “codes that account for the majority of spending under the 

physician fee schedule.” To develop this list, we identified the top 20 codes by specialty (using 

the specialties used in Table 11) in terms of allowed charges. We excluded those codes that we 

have reviewed since CY 2009, those codes with fewer than $10 million in allowed charges, and 

E/M services. E/M services were excluded for the same reason that we excluded them in a 

similar review for CY 2012. The reason was explained in the CY 2012 final rule with comment 

period (76 FR 73062 through 73065). 

We stated that we believed that a review of the codes in Table 11 is warranted to assess 

changes in physician work and to update direct PE inputs since these codes have not been 

reviewed since CY 2009 or earlier. Furthermore, since these codes have significant impact on 

PFS payment at the specialty level, a review of the relativity of the codes is essential to ensure 

that the work and PE RVUs are appropriately relative within the specialty and across specialties, 

as discussed previously. For these reasons, we proposed the codes listed in Table 11 as 

potentially misvalued. 
CMS-1612-FC 106

TABLE 11: Potentially Misvalued Codes Identified Through the High Expenditure 

by Specialty Screen 

HCPCS Short Descriptor 

11100 Biopsy skin lesion 

11101 Biopsy skin add-on 

11730 Removal of nail plate 

11750 Removal of nail bed 

14060 Tis trnfr e/n/e/l 10 sq cm/ 

17110 Destruct b9 lesion 1–14 

31575 Diagnostic laryngoscopy 

31579 Diagnostic laryngoscopy 

36215 Place catheter in artery 

36475 Endovenous rf 1st vein 

36478 Endovenous laser 1st vein 

36870 Percut thrombect av fistula 

51720 Treatment of bladder lesion 

51728 Cystometrogram w/vp 

51798 Us urine capacity measure 

52000 Cystoscopy 

55700 Biopsy of prostate 

65855 Laser surgery of eye 

66821 After cataract laser surgery 

67228 Treatment of retinal lesion 

68761 Close tear duct opening 

71010 Chest x-ray 1 view frontal 

71020 Chest x-ray 2vw frontal&latl 

71260 Ct thorax w/dye 

73560 X-ray exam of knee 1 or 2 

73562 X-ray exam of knee 3 

73564 X-ray exam knee 4 or more 

74183 Mri abdomen w/o & w/dye 

75978 Repair venous blockage 

76536 Us exam of head and neck 

76700 Us exam abdom complete 

76770 Us exam abdo back wall comp 

76775 Us exam abdo back wall lim 

HCPCS Short Descriptor 

77263 Radiation therapy planning 

77334 Radiation treatment aid(s) 

78452 Ht muscle image spect mult 

88185 Flowcytometry/tc add-on 

91110 Gi tract capsule endoscopy 

92136 Ophthalmic biometry 

92250 Eye exam with photos 

92557 Comprehensive hearing test 

93280 Pm device progr eval dual 

93306 Tte w/doppler complete 

93351 Stress tte complete 

93978 Vascular study 

94010 Breathing capacity test 

95004 Percut allergy skin tests 

95165 Antigen therapy services 

95957 Eeg digital analysis 

96101 Psycho testing by psych/phys 

96118 Neuropsych tst by psych/phys 

96372 Ther/proph/diag inj sc/im 

96375 Tx/pro/dx inj new drug addon 

96401 Chemo anti-neopl sq/im 

96409 Chemo iv push sngl drug 

97032 Electrical stimulation 

97035 Ultrasound therapy 

97110 Therapeutic exercises 

97112 Neuromuscular reeducation 

97113 Aquatic therapy/exercises 

97116 Gait training therapy 

97140 Manual therapy 1/> regions 

97530 Therapeutic activities 

G0283 Elec stim other than wound 
CMS-1612-FC 107

 Comment: Many commenters disagreed with the high expenditure screen in principle, 

stating that the frequency with which a service is furnished (and therefore the total expenditures) 

is not an indication that the service is misvalued. Specifically, commenters explained that many 

of the services are highly utilized because of the nature of the Medicare beneficiary population, 

and not because there is abuse or overutilization. Commenters asserted that the current 

misvalued code screens can produce a redundant list of potentially misvalued codes while failing 

to identify codes that are being incorrectly reported. Another commenter urged CMS to work 

with the RUC to ensure that the code lists identified by the misvalued code screens are accurate. 

A commenter asked CMS to provide justification for including codes with charges greater than 

$10 million on the potentially misvalued codes list. Some commenters urged us to reconsider 

including particular families of codes that were reviewed prior to 2009; others asked that CMS 

exclude all codes that have been reviewed in the last 10 years; and still others requested that we 

exclude codes that were bundled several years ago. A commenter stated that the emphasis on 

codes with spending of more than $10 million demonstrates an agenda to cut spending rather 

than to ensure appropriate payment, and expressed concern that CMS was simply nominating 

high value services. Commenters recommended that CMS not finalize its proposed list of 

potentially misvalued codes, and instead develop a more targeted list of codes that are likely to 

be misvalued (not just potentially misvalued). Commenters wanted CMS to exempt codes when 

there have not been fundamental changes in the way the services are furnished or there is no 

indication that their values are inaccurate, so that specialty societies do not have to go through 

the work of reviewing them. 

Several commenters questioned the statutory authority for CMS’s proposal. One 

commenter questioned CMS’s authority under the relevant statute to select potentially misvalued 
CMS-1612-FC 108

codes by specialty. The commenter stated that identifying the top 20 codes by specialty in terms 

of allowed charges does not appear to align with a direct reading of the relevant statutory 

authority, which allows CMS to identify codes that account for the majority of spending under 

the PFS, but does not provide for the identification of codes by specialty. The commenter said 

that a more direct interpretation of the statutory authority would be to select codes based on 

allowed charges irrespective of specialty, and then to narrow the universe of codes based upon 

the top codes in terms of allowed charges. Another commenter believed the proposed screen did 

not comport with the statutory selection criteria because the majority or near majority of 

spending under the PFS is for evaluation and management (E/M) codes, which CMS excluded 

from review. The commenter said that if CMS believes that E/M services should not be 

reviewed - a position the commenter said they would certainly understand- then such a 

determination is sufficient to meet the statutory mandate to review codes accounting for the 

majority of PFS spending, and it would then be appropriate for CMS and the RUC to focus 

efforts on other categories of potentially misvalued codes. The commenter urged CMS at the 

very least to develop a more targeted list of potentially misvalued services in the category of 

codes accounting for the majority of PFS spending, and to include codes that are likely to be 

misvalued, not just potentially misvalued. 

 Response: Potentially misvalued code screens are intended to identify codes that are 

possibly misvalued. By definition, these screens do not assert that codes are certainly or even 

likely misvalued. As we discussed in the CY 2012 PFS final rule with comment period 

(76 FR 73056), the screens serve to focus our limited resources on categories of codes where 

there is a high risk of significant payment distortions. One goal is to avoid perpetuating payment 

for the services at a rate that does not appropriately reflect the relative resources involved in 

furnishing the service. In implementing this statutory provision, we consider whether the codes 
CMS-1612-FC 109

meeting the screening criteria have a significant impact on payment for all PFS services due to 

the budget neutral nature of the PFS. That is, if codes meeting the screening criteria are indeed 

misvalued, they would be inappropriately impacting the relative values of all PFS services. 

Addressing included codes therefore indirectly addresses other codes that do not meet the 

screening criteria but are themselves misvalued because high expenditure codes are misvalued. 

We agree with the commenters that high program expenditures and high utilization have varying 

causes and do not necessarily reflect misvalued codes. However, we continue to believe that the 

high expenditure screen is nevertheless an appropriate means of focusing our reviews, ensuring 

appropriate relativity among PFS services, and identifying services that are either over or 

undervalued. The high expenditure screen is likely to identify misvalued codes, both directly 

and indirectly. 

 Regarding screening for codes by specialty, as we discussed above, the included codes 

have significant impact on PFS payment at the specialty level, therefore a review of the relativity 

of the codes is essential to ensure that the work and PE RVUs are appropriately relative within 

the specialty and across specialties. We mentioned in the CY 2012 final rule with comment 

period how stakeholders have noted that many of the services previously identified under the 

potentially misvalued codes initiative were concentrated in certain specialties. To develop a 

robust and representative list of codes for review, we examine the highest PFS expenditure 

services by specialty and we identify those codes that have not been recently reviewed (76 FR 

73060). 

Although we understand commenters’ concerns that the screens can produce redundant 

results, we note that we exempted codes that have been reviewed since 2009 for this very reason. 

We believe that the practice of medicine can change significantly over a 10-year period, and 
CMS-1612-FC 110

disagree with commenters’ suggestions that no changes would occur over a 10-year period that 

would significantly affect a procedure’s valuation. 

Regarding the exclusion of E/M services, we refer the commenters to the extensive 

discussion in the CY 2012 PFS final rule with comment period (76 FR 73060 through 73065). It 

is true that E/M services account for significant volume under the PFS, but there are significant 

issues with reviewing these codes as discussed in the CY 2012 final rule with comment period, 

and as a result we did not propose to include these codes as potentially misvalued. 

 Comment: Some commenters suggested other screens that could be used to identify 

misvalued codes. In addition, even though our proposal only relates to identifying potentially 

misvalued codes, some commenters commented on our mechanisms for re-valuing misvalued 

codes. 

 Response: The only screen for which we made a proposal and sought comments was the 

high expenditure screen. However, we will consider the suggestions for other screens as we 

develop proposals in future years. Similarly, our proposal only related to identifying potentially 

misvalued codes and not how to re-value them if they were finalized as potentially misvalued. 

 Comment: Several commenters requested that CMS postpone the review of potentially 

misvalued codes until the revised process we proposed for reviewing new, revised, and 

potentially misvalued codes is in place. 

 Response: Although we believe that the revised process for reviewing new, revised, and 

potentially misvalued codes will improve the transparency of the PFS code review process, we 

do not believe it is appropriate to postpone the review of all potentially misvalued codes until the 

new process is implemented. We note that the codes identified in this rule as potentially 

misvalued would be revalued under the new process, which will be phased in starting for CY 

2016 and will apply for all codes revalued for CY 2017. 
CMS-1612-FC 111

 Comment: Commenters raised several codes that they believed should not be included in 

the high expenditure screen for a variety of reasons, for example if the code is related to other 

codes that were recently reviewed and the utilization for the identified service is expected to 

change significantly as a result of coding changes in the family. Commenters also suggested that 

codes that have been referred to the CPT Editorial Panel should be excluded from the potentially 

misvalued codes list. 

 Response: We acknowledge commenters’ suggestion that we exclude particular codes 

from the screen, but since we are not finalizing a particular list of codes for this screen in this 

final rule we are not addressing these at this time. We note that we do not agree with 

commenters that codes that have been referred to CPT by the RUC should be excluded from the 

potentially misvalued list; rather, we believe that only when these codes are either deleted or 

revised, and/or we receive new RUC recommendations for re-valuing these codes, would it be 

appropriate to remove these services from the list. 

 Comment: A commenter suggested that CMS’s high expenditure screen may not account 

for the fact that many radiology codes have already gone through numerous five-year reviews; 

have well-established RVUs that are included on the RUC’s multispecialty point of comparison 

(MPC) list; have been included in new, bundled codes; or have PE RVUs that were affected by 

changes in clinical labor times or equipment utilization assumption changes. The commenter 

also suggested that the screens do not account for the value that patients receive in terms of 

better, timelier diagnoses and avoidance of invasive procedures. 

 Response: We acknowledge that certain types of procedures have been identified 

through multiple screens; however, we continue to believe that it is appropriate to include most 

codes that are identified via these screens and not to exclude codes simply because many other 

procedures furnished by that specialty have already been reviewed. We further note that the 
CMS-1612-FC 112

presence of codes on the MPC list makes the case for their review more compelling, given their 

importance in ensuring overall relativity throughout the PFS. With respect to changes in PE 

RVUs, we note that cross-cutting policies that affect large numbers of codes are aimed at 

ensuring overall relativity but do not address the inputs associated with each procedure affected 

by the change. Finally, a code’s status as potentially misvalued does not imply that the service 

itself is not of inherent value; rather, that its valuation may be inaccurate in either direction. 

 After considering the comments received, as well as the other proposals we are finalizing, 

we believe it is appropriate to finalize the high expenditure screen as a tool to identify potentially 

misvalued codes. However, given the resources required over the next several years to revalue 

the services with global periods, we believe it is best to concentrate our efforts on these 

valuations. Therefore, we are not finalizing the codes identified through the high expenditure 

screen as potentially misvalued at this time. Also, we are not responding to comments at this 

time regarding whether particular codes should or should not be included in the high expenditure 

code screen and identified as potentially misvalued codes. We will re-run the high expenditure 

screen at a future date, and will propose at that time the specific set of codes to be reviewed that 

meet the high expenditure criteria. 

(2) Epidural Injection and Fluoroscopic Guidance − CPT Codes 62310, 62311, 62318, 62319, 

77001, 77002 and 77003 

For CY 2014, we established interim final rates for four epidural injection procedures, 

CPT codes 62310 (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, 

antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 

needle or catheter placement, includes contrast for localization when performed, epidural or 

subarachnoid; cervical or thoracic), 62311 (Injection(s), of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
CMS-1612-FC 113

substances, including needle or catheter placement, includes contrast for localization when 

performed, epidural or subarachnoid; lumbar or sacral (caudal)), 62318 (Injection(s), including 

indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or 

therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, includes contrast for localization when performed, epidural or 

subarachnoid; cervical or thoracic) and 62319 (Injection(s), including indwelling catheter 

placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 

substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar 

or sacral (caudal)). These interim final values resulted in CY 2014 payment reductions from the 

CY 2013 rates for all four procedures. 

In the CY 2014 final rule with comment period (78 FR 74340), we described in detail our 

interim valuation of these codes. We indicated we established interim final work RVUs for these 

codes that were less than those recommended by the RUC because we did not believe that the 

RUC-recommended work RVUs accounted for the substantial decrease in time it takes to furnish 

these services as reflected in the RUC survey data for these four codes. Since the RUC provided 

no indication that the intensity of the procedures had changed, we indicated that we believed the 

work RVUs should reflect the reduction in time. We also established interim final direct PE 

inputs for these four codes based on the RUC-recommended inputs without any refinement. 

These recommendations included the removal of the radiographic-fluoroscopy room for CPT 

codes 62310, 62311, and 62318 and a portable C-arm for CPT code 62319. 

In response to the comments we received objecting to the CY 2014 interim final values 

for these codes, we looked at other injection procedures. Other injection procedures, including 

some that commenters recommended we use to value these epidural injection codes, include the 
CMS-1612-FC 114

work and practice expenses of image guidance in the injection code. In the proposed rule, we 

detailed many of these procedures, which include the image guidance in the injection CPT code. 

Since our analysis of the Medicare data and comments received on the CY 2014 final rule with 

comment period indicated that these services are typically furnished with imaging guidance, we 

believe it would be appropriate for the codes to be bundled and the inputs for image guidance to 

be included in the valuation of the epidural injection codes as it is for transforaminal and 

paravertebral codes. We stated that we did not believe the epidural injection codes can be 

appropriately valued without considering the image guidance, and that bundling image guidance 

will help assure relativity with other injection codes that include the image guidance. To 

determine how to appropriately value resources for the combined codes, we indicated that we 

believed more information is needed. Accordingly, we proposed to include CPT codes 62310, 

62311, 62318, and 62319 on the potentially misvalued code list so that we can obtain 

information to value them with the image guidance included. In the meantime, we proposed to 

use the CY 2013 input values for CPT codes 62310, 62311, 62318 and 62319 to value these 

codes for CY 2015. Specifically, we proposed to use the CY 2013 work RVUs and work times. 

Because it was clear that inputs that are specifically related to image guidance, such as 

the radiographic fluoroscopic room, are included in these proposed direct PE inputs for the 

epidural injection codes, we believed allowing separate reporting of the image guidance codes 

would overestimate the resources used in furnishing the overall service. To avoid this situation, 

we also proposed to prohibit the billing of image guidance codes in conjunction with these four 

epidural injection codes. We stated that we believed our two-tiered proposal to utilize CY 2013 

input values for this family while prohibiting separate billing of imaging guidance best ensures 

that appropriate reimbursements continue to be made for these services, while we gather 

additional data and input on the best way to value them through codes that include both the 
CMS-1612-FC 115

injection and the image guidance. 

Comment: The commenters did not object to identifying these codes as potentially 

misvalued and generally agreed with our proposal to revert to the 2013 inputs for CY 2015. 

Response: We appreciate support for our proposal. 

Comment: Several commenters agreed that it would be appropriate to bundle the image 

guidance with the epidural procedures. Other commenters suggested that we create both a 

bundled code and a stand-alone epidural injection code. 

Response: We appreciate commenters’ support for our proposal to bundle image 

guidance with the epidural procedures. As part of the review process, consideration can be given 

to how to best implement bundled codes. 

Comment: Other commenters expressed concern that the bundling approach CMS 

proposed to use until these codes are reviewed did not incorporate the work or time for 

fluoroscopy. Some requested that we add the payment for fluoroscopic guidance to the epidural 

injection codes, as we have done in the past for facet joint injections and other services. 

Commenters requested that we continue to allow the image guidance codes to be separately 

billed until these services are revalued. Another commenter suggested that it may be premature 

to prohibit separate billing for image guidance, as there is considerable variation on the use of 

fluoroscopic guidance between codes within this family. 

Response: We understand commenters’ concerns about our proposal to prohibit separate 

billing for image guidance, and note that these concerns are part of the reason we are referring 

these codes to the RUC as potentially misvalued. However, given that significant resources are 

allocated to fluoroscopic guidance within the current injection codes, we do not believe it is 

appropriate to continue to allow the image guidance to be separately billed while we evaluate 

these epidural injection codes as potentially misvalued services. 
CMS-1612-FC 116

After considering comments received, we are finalizing CPT codes 62310, 62311, 62318, 

and 62319 as potentially misvalued, finalizing the proposed RVUs for these services, and 

prohibiting separate billing of image guidance in conjunction with these services. 

(3) Neurostimulator Implantation (CPT codes 64553 and 64555) 

We proposed CPT codes 64553 (Percutaneous implantation of neurostimulator electrode 

array; cranial nerve) and 64555 (Percutaneous implantation of neurostimulator electrode array; 

peripheral nerve (excludes sacral nerve)) as potentially misvalued after stakeholders questioned 

whether the codes included the appropriate direct PE inputs when furnished in the nonfacility 

setting. 

Comment: A commenter encouraged CMS to include these codes on the potentially 

misvalued code list to ensure that they are adequately reimbursed in the nonfacility setting, while 

another commenter disagreed that the work for CPT codes 64553 and 64555 needed to be 

reviewed. 

Response: In general, when a code is proposed as potentially misvalued, unless we 

receive information that clearly demonstrates it is not potentially misvalued, we finalize the code 

as potentially misvalued. When we finalize a code as potentially misvalued, we then review the 

inputs for the code. As a result of such review, inputs can be adjusted either upward or 

downward. 

We appreciate the support for our proposal expressed by some commenters. Since the 

commenter opposing the addition of these codes to the potentially misvalued code list did not 

provide justification for its assertion that the work RVUs for CPT codes 64553 and 64555 did 

not need to be reviewed, after consideration of comments received, we are finalizing CPT codes 

64553 and 64555 as potentially misvalued. 

(4) Mammography (CPT codes 77055, 77056, and 77057, and HCPCS codes G0202, G0204, and 
CMS-1612-FC 117

G0206) 

Medicare currently pays for mammography services through both CPT codes, (77055 

(mammography; unilateral), 77056 (mammography; bilateral) and 77057 (screening 

mammography, bilateral (2-view film study of each breast)) and HCPCS G-codes, (G0202 

(screening mammography, producing direct digital image, bilateral, all views), G0204 

(diagnostic mammography, producing direct digital image, bilateral, all views), and G0206 

(diagnostic mammography, producing direct digital image, unilateral, all views)). The CPT 

codes were designed to be used for mammography regardless of whether film or digital 

technology is used. However, for Medicare purposes, the HCPCS G-codes were created to 

describe mammograms using digital technology in response to special payment rules for digital 

mammography included in the Medicare Benefit Improvements and Protection Act of 2000 

(BIPA). 

The RUC recommended that CMS update the direct PE inputs for all imaging codes to 

reflect the migration from film-to-digital storage technologies since digital storage is now 

typically used in imaging services. Review of the Medicare data with regard to the application 

of this policy to mammography confirmed that virtually all mammography is now digital. As a 

result, we proposed that CPT codes 77055, 77056, and 77057 be used to report mammography 

regardless of whether film or digital technology is used, and to delete the HCPCS G-codes 

G0202, G0204, and G0206. We proposed to establish values for the CPT codes by crosswalking 

the values established for the digital mammography G-codes for CY 2015. (See section II.B. of 

this final rule with comment period for more discussion of this policy.) In addition, since the Gcode values have not been evaluated since they were created in CY 2002 we proposed to include 

CPT codes 77055, 77056, and 77057 on the list of potentially misvalued codes. 

Comment: With regard to whether the mammography codes should be included on the 
CMS-1612-FC 118

potentially misvalued codes list, commenters had differing opinions. One commenter stated that 

the work RVUs for digital mammography are the same as those for analog mammography, and 

maintained that the BIPA-directed payment for digital mammography of 1.5 times the TC of the 

analog mammography codes appropriately captures the practice expense resources required for 

digital mammography. Another commenter stated that digital mammography rates resulted from 

a statutory construct and do not reflect the actual costs of the digital resources necessary to 

furnish the services. One commenter noted that moving from the non-resource-based values to 

resource-based values will result in a significant reduction to the valuation of these services, and 

that this reduction will result from the resource-based PE methodology, not from the RUC 

review. Another commenter indicated that the RUC should not survey these codes, but requested 

that if the RUC does survey these codes, they should not do so until after CMS finalizes the new 

breast tomosynthesis codes (3D mammography) and film-to-digital transition. Another 

commenter indicated that CMS needed to consider that three-dimensional (3D) mammography 

codes involve additional resources over the two-dimensional (2D) mammography codes. A 

commenter suggested that this proposal fails to take into account the increasing use of 

tomography. 

Response: The commenters’ disagreement about whether these codes are misvalued 

would suggest that a review is warranted. Given that more than a decade has passed since these 

services were reviewed, we continue to believe that it is appropriate to review the work RVUs 

for these services. By including these codes on the potentially misvalued code list, we will have 

information to determine whether the current values are still appropriate. Finally, we anticipate 

that the survey results for the mammography codes will reflect the equipment that is typically 

used. We note that until these services are reviewed, we do not have adequate information to 

respond to the suggestion that the valuation for these services will be significantly reduced. 
CMS-1612-FC 119

However, we do acknowledge that the PE methodology is not intended to account for the actual 

costs in furnishing a service; rather, it is required to account for the relative resources in 

furnishing that service. We also note that there are new CPT codes for reporting mammography 

using tomosynthesis and we have RUC recommendations for these codes. We believe it is most 

appropriate to value the mammography code family together, and receipt of RUC 

recommendations on the other mammography codes will assist us in our review. Accordingly, 

we are including all mammography codes except those newly created for tomosynthesis on the 

potentially misvalued code list. 

Comment: Although commenters agreed with our assessment that digital technology has 

replaced analog mammography as typical, not all agreed that it was appropriate to delete Gcodes and use the CPT codes. One commenter supported the deletion of the G-codes. Other 

commenters suggested that deletion of the G-codes was unnecessary. Another commenter stated 

that the coding system frequently reflects differences in approach and technique, and that the 

equipment for analog and digital mammography are different enough to warrant separate 

reporting so we should not delete the G-codes. Some who supported continuation of the G-codes 

asked us to delay implementation as they were concerned that other payers would not have time 

to update their requirements by January 1, 2015. Another commenter applauded CMS’s decision 

to delete the G-codes. 

Response: In further consideration this proposal, we discovered that while the CPT codes 

for diagnostic mammography apply to mammography, whether film or digital technology is 

used, the descriptor for the screening mammography CPT code specifically refers to film. In 

light of this and that fact that we anticipate revaluing these codes when we have the benefit of 

RUC recommendations for all codes in the family, we believe it is appropriate to continue to 

recognize both the CPT codes and the G-codes for mammography for CY 2015, as we consider 
CMS-1612-FC 120

appropriate valuations now that digital mammography is typical. Therefore, we are not 

finalizing our proposal to delete the G-codes. We are, however, making a change in the 

descriptors to make clear that the G0202, G0204, and G0206 are specific to 2-D mammography. 

These codes are to be reported with either G0279 or CPT code 77063 when mammography is 

furnished using 3-D mammography. 

 Comment: A commenter requested that CMS ensure reimbursement rates remain 

adequate to protect access for Medicare beneficiaries. Another commenter suggested that these 

changes could result in barriers to access for Medicare beneficiaries. 

Response: We are strongly supportive of access to mammography for Medicare 

beneficiaries. As stated elsewhere in this final rule with comment period, we believe that 

accurate valuation incentivizes appropriate utilization of services. 

After consideration of public comments, we are modifying our proposal as follows: we 

will include CPT codes 77055, 77056, and 77057 on the potentially misvalued codes list; we will 

continue to recognize G0202, G0204 and G0206 but will modify the descriptors so that they are 

specific to 2-D digital mammography, and instead of using the digital values we will continue to 

use the CY 2014 work and PE RVUs to value the mammography CPT codes. We expect that the 

CPT Editorial Panel will consider the descriptor for screening mammography, CPT code 77057, 

in light of the prevailing use of digital mammography. 

(5) Abdominal Aortic Aneurysm Ultrasound Screening (G0389) 

 When Medicare began paying for abdominal aortic aneurysm (AAA) ultrasound 

screening, HCPCS code G0389 (Ultrasound, B-scan and/or real time with image documentation; 

for abdominal aortic aneurysm (AAA) screening) in CY 2007, we set the RVUs at the same level 

as CPT code 76775 (Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan and/or real 

time with image documentation; limited). We noted in the CY 2007 final rule with comment 
CMS-1612-FC 121

period that CPT code 76775 was used to report the service when furnished as a diagnostic test 

and that we believed the service reflected by G0389 used equivalent resources and work intensity 

to those contained in CPT code 76775 (71 FR 69664 through 69665). 

In the CY 2014 proposed rule, we proposed to replace the ultrasound room included as a 

direct PE input for CPT code 76775 with a portable ultrasound unit based upon a RUC 

recommendation. Since the RVUs for G0389 were crosswalked from CPT code 76775, the 

proposed PE RVUs for G0389 in the CY 2014 proposed rule were reduced as a result of this 

change. However, we did not discuss the applicability of this change to G0389 in the preamble 

to the proposed rule, and did not receive any comments on G0389 in response to the proposed 

rule. We finalized the change to CPT code 76775 in the CY 2014 final rule with comment 

period and as a result, the PE RVUs for G0389 were also reduced. 

We proposed G0389 as potentially misvalued in response to a stakeholder suggestion that 

the reduction in the RVUs for G0389 did not accurately reflect the resources involved in 

furnishing the service. We sought recommendations from the public and other stakeholders, 

including the RUC, regarding the appropriate work RVU, time, direct PE input, and malpractice 

risk factors that reflect the typical resources involved in furnishing the service. 

Until we receive the information needed to re-value this service, we proposed to value 

this code using the same work and PE RVUs we used for CY 2013. We proposed MP RVUs 

based on the five-year review update process as described in section II.C of this final rule with 

comment period. We stated that we believe this valuation would ameliorate the effect of the CY 

2014 reduction that resulted from the RVUs for G0389 being tied to those for another code while 

we assess appropriate valuation through our usual methodologies. Accordingly, we proposed a 

work RVU of 0.58 for G0389 and proposed to assign the 2013 PE RVUs until this procedure is 

reviewed. 
CMS-1612-FC 122

Comment: Many commenters supported our proposal to include this service on the 

potentially misvalued codes list. Some commenters agreed that the crosswalk used to set rates 

for this service does not appear to be appropriate at this time, whether due to changes in the way 

the service is provided, or because the specialty mix has shifted, and suggested that it would be 

appropriate to establish a Category I CPT code for this service. Another commenter suggested 

that CMS consider crosswalking G0389 to CPT code 93979 (Duplex scan of aorta, inferior vena 

cava, iliac vasculature, or bypass grafts; unilateral or limited study). One commenter believed it 

was unnecessary to survey this code, but recommended that we instead maintain the general 

ultrasound room as a direct PE input and 2013 PE RVUs. 

Response: We appreciate commenters’ support for our proposal to include G0389 on the 

potentially misvalued codes list and are finalizing this proposal. We are finalizing this code as 

potentially misvalued in large part because we are unsure of the correct valuation. Therefore, we 

believe it is most appropriate to retain the 2013 inputs until we receive new recommendations, 

rather than making another change or retaining these inputs indefinitely as commenters 

suggested. 

After consideration of comments received, we are finalizing our proposal to add G0389 

to the potentially misvalued codes list, and to maintain the 2013 work and PE RVUs while we 

complete our review of the code. The MP RVUs will be calculated as discussion in section II.C. 

of this rule. 

(6) Prostate Biopsy Codes – (HCPCS codes G0416, G0417, G0418, and G0419) 

For CY 2014, we modified the code descriptors of G0416 through G0419 so that these 

codes could be used for any method of prostate needle biopsy services, rather than only for 

prostate saturation biopsies. The CY 2014 descriptions are: 
CMS-1612-FC 123

● G0416 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 10–20 specimens). 

● G0417 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 21–40 specimens). 

● G0418 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; 41–60 specimens). 

● G0419 (Surgical pathology, gross and microscopic examination for prostate needle 

biopsies, any method; greater than 60 specimens). 

Subsequently, we have discussed prostate biopsies with stakeholders, and reviewed 

medical literature and Medicare claims data in considering how best to code and value prostate 

biopsy pathology services. After considering these discussions and information, we believed it 

would be appropriate to use only one code to report prostate biopsy pathology services. 

Therefore, we proposed to revise the descriptor for G0416 to define the service regardless of the 

number of specimens, and to delete codes G0417, G0418, and G0419. We believe that using 

G0416 to report all prostate biopsy pathology services, regardless of the number of specimens, 

would simplify the coding and mitigate overutilization incentives. Given the infrequency with 

which G0417, G0418, and G0419 are used, we did not believe that this was a significant change. 

Based on our review of medical literature and examination of Medicare claims data, we 

indicated that we believe that the typical number of specimens evaluated for prostate biopsies is 

between 10 and 12. Since G0416 currently is used for between 10 and 12 specimens, we 

proposed to use the existing values for G0416 for CY 2015, since the RVUs for this service were 

established based on similar assumptions. 

In addition, we proposed G0416 as a potentially misvalued code for CY 2015 and sought 

public comment on the appropriate work RVUs, work time, and direct PE inputs. 
CMS-1612-FC 124

 Comment: One commenter supported the elimination of the G-codes as a means of 

simplifying coding requirements, but other commenters opposed our proposal to consolidate the 

coding into G0416, disagreeing that this would help establish “straightforward coding and 

maintain accurate payment” as suggested in the proposed rule. Some commenters suggested that 

we retain the current codes so that biopsy procedures requiring more than 10 specimens can be 

reimbursed accurately, and indicated that consolidating the coding would further confuse 

physicians and their staff who have not yet adapted to the CY 2014 coding changes for these Gcodes. Other commenters asserted that these changes threaten to undermine access to high 

quality pathology services. Commenters also stated that the decision to furnish more extensive 

pathological analysis is not at the discretion of the pathologist, and the pathologist should not be 

penalized when he or she receives more cores to analyze. 

 With respect to our proposing G0416 as potentially misvalued, commenters stated that 

the recent change to these codes has already been confusing and suggests that there is not a clear 

understanding of what these codes represent, thus making an assessment of their valuation 

difficult. Commenters further stated that it is unreasonable to consider this a misvalued code 

when the payment is already 30 percent below what they think it should be, and that CMS has 

failed to provide justification for why it is potentially misvalued. 

 The RUC and others suggested that it would be most accurate to utilize CPT code 88305 

(Level IV - surgical pathology, gross and microscopic examination) for the reporting of prostate 

biopsies and to allow the reporting of multiple units. Given the additional granularity and 

scrutiny given to CPT code 88305 in the CY 2014 final rule, the commenters indicated that they 

believe that the agency’s intent to establish straightforward coding and accurate payment for 

these services would be realized with this approach. 
CMS-1612-FC 125

Response: Given that the typical analysis of prostate biopsy specimens differs 

significantly from the typical analyses reported using CPT code 88305, as regards the number of 

blocks used to process the specimen and thus the amount of work involved, we believe that by 

distinguishing prostate biopsies from other types of biopsies results in more accurate pricing for 

prostate biopsies. Since CPT code 88305 was revalued with the understanding that prostate 

biopsies are billed separately, we believe that allowing CPT code 88305 to be reported in 

multiple units for prostate biopsies would account for significantly more resources than is 

appropriate. With respect to the concern about higher numbers of specimens, we note that our 

claims data on the G-codes shows that the vast majority of the claims used G0416, rather than 

any of the G-codes for greater numbers of specimens. 

After consideration of comments received, we are finalizing our proposal to include 

G0416 on the potentially misvalued codes list, to modify the descriptor to reflect all prostate 

biopisies, and to maintain the current value until we receive and review information and 

recommendations from the RUC. We are also finalizing our proposal to delete codes G0417, 

G0418, and G0419. 

(7) Obesity Behavioral Group Counseling – GXXX2 and GXXX3 

Pursuant to section 1861(ddd) of the Act, we added coverage for a new preventive 

benefit, Intensive Behavioral Therapy for Obesity, effective November 29, 2011, and created 

HCPCS code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) for reporting 

and payment of individual behavioral counseling for obesity. Coverage requirements specific to 

this service are delineated in the Medicare National Coverage Determinations Manual, Pub. 100–

03, Chapter 1, Section 210, available at 

http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. 
CMS-1612-FC 126

It was brought to our attention that behavioral counseling for obesity is sometimes 

furnished in group sessions, and questions were raised about whether group sessions could be 

billed using HCPCS code G0447. To improve payment accuracy, we proposed to create two 

new HCPCS codes for the reporting and payment of group behavioral counseling for obesity. 

Specifically, we proposed to create GXXX2 (Face-to-face behavioral counseling for obesity, 

group (2-4), 30 minutes) and GXXX3 (Face-to-face behavioral counseling for obesity, group (5-

10), 30 minutes). We indicated that the coverage requirements for these services would remain 

in place, as described in the National Coverage Determination for Intensive Behavioral Therapy 

for Obesity cited above. The practitioner furnishing these services would report the relevant 

group code for each beneficiary participating in a group therapy session. 

Since we believed that the face-to-face behavioral counseling for obesity services 

described by GXXX2 and GXXX3 would require similar per minute work and intensity as 

HCPCS code G0447, we proposed work RVUs of 0.23 and 0.10 for HCPCS codes GXXX2 and 

GXXX3, with work times of 8 minutes and 3 minutes respectively. Since the services described 

by GXXX2 and GXXX3 would be billed per beneficiary receiving the service, the work RVUs 

and work time that we proposed for these codes were based upon the assumed typical number of 

beneficiaries per session, 4 and 9, respectively. Accordingly, we proposed a work RVU of 0.23 

with a work time of 8 minutes for GXXX2 and a work RVU of 0.10 with a work time of 3 

minutes for GXXX3. We proposed to use the direct PE inputs for GXXX2 and GXXX3 

currently included for G0447 prorated to account for the differences in time and number of 

beneficiaries, and to crosswalk the malpractice risk factor from HCPCS code G0447 to both 

HCPCS codes GXXX2 and GXXX3, as we believe the same specialty mix will furnish these 

services. We requested public comment on the proposed values for HCPCS codes GXXX2 and 

GXXX3. 
CMS-1612-FC 127

Comment: Commenters generally supported our proposal to establish a separate payment 

mechanism for obesity behavioral group counseling services, but raised several concerns 

regarding the coding structure and valuation of these services. Commenters stated that the work 

times were inaccurate, requested that the service be valued based on a smaller number of typical 

group participants, and questioned the need for two G-codes when group counseling services 

under the PFS are generally billed with a single G-code. A commenter also stated that the lower 

payment for larger groups will create disincentives for furnishing this service except when there 

is a full 10-person group, which could limit access. Commenters suggested that CMS only 

finalize a single G-code for group counseling for intensive behavioral therapy for obesity, and 

crosswalk the work RVU and work time for this service from the Medical Nutrition Therapy 

(MNT) group code. 

Response: We appreciate commenters’ support for our proposal to provide new codes for 

group obesity counseling services. After reviewing the comments, we agree that it is reasonable 

to create a single code for group obesity counseling and crosswalk the work RVU and work time 

from the MNT group code. The individual code for intensive obesity behavioral therapy and the 

individual MNT code are valued the same, so in the absence of evidence that group composition 

is different, we believe it makes sense to use the same values. Therefore, we will crosswalk the 

work RVU of 0.25 and the work time of 10 minutes to a single new G-code for group obesity 

counseling, G0473 (Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes). 

4. Improving the Valuation and Coding of the Global Package 

a. Overview 

Since the inception of the PFS, we have valued and paid for certain services, such as 

surgery, as part of global packages that include the procedure and the services typically furnished 

in the periods immediately before and after the procedure (56 FR 59502). For each of these 
CMS-1612-FC 128

codes (usually referred to as global surgery codes), we establish a single PFS payment that 

includes payment for particular services that we assume to be typically furnished during the 

established global period. 

There are three primary categories of global packages that are labeled based on the 

number of post-operative days included in the global period: 0-day; 10-day; and 90-day. The 

0-day global codes include the surgical procedure and the pre-operative and post-operative 

physicians’ services on the day of the procedure, including visits related to the service. The 

10-day global codes include these services and, in addition, visits related to the procedure during 

the 10 days following the procedure. The 90-day global codes include the same services as the 

0-day global codes plus the pre-operative services furnished one day prior to the procedure and 

post-operative services during the 90 days immediately following the day of the procedure. 

Section 40.1 of the Claims Processing Manual (Pub. 100–04, Chapter 12 

Physician/Nonphysician Practitioners) defines the global surgical package to include the 

following services when furnished during the global period: 

● Preoperative Visits − Preoperative visits after the decision is made to operate 

beginning with the day before the day of surgery for major procedures and the day of surgery for 

minor procedures; 

● Intra-operative Services − Intra-operative services that are normally a usual and 

necessary part of a surgical procedure; 

● Complications Following Surgery − All additional medical or surgical services 

required of the surgeon during the postoperative period of the surgery because of complications 

that do not require additional trips to the operating room; 

● Postoperative Visits − Follow-up visits during the postoperative period of the surgery 

that are related to recovery from the surgery; 
CMS-1612-FC 129

● Postsurgical Pain Management − By the surgeon; 

● Supplies − Except for those identified as exclusions; and 

● Miscellaneous Services − Items such as dressing changes; local incisional care; 

removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, 

casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral 

intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. 

b. Concerns with the 10- and 90-Day Global Packages 

CMS supports bundled payments as a mechanism to incentivize high-quality, efficient 

care. Although on the surface, the PFS global codes appear to function as bundled payments 

similar to those Medicare uses to make single payments for multiple services to hospitals under 

the inpatient and outpatient prospective payment systems, the practical reality is that these global 

codes function significantly differently than other bundled payments. First, the global surgical 

codes were established several decades ago when surgical follow-up care was far more 

homogenous than today. Today, there is more diversity in the kind of procedures covered by 

global periods, the settings in which the procedures and the follow-up care are furnished, the 

health care delivery system and business arrangements used by Medicare practitioners, and the 

care needs of Medicare beneficiaries. Despite these changes, the basic structures of the global 

surgery packages are the same as the packages that existed prior to the creation of the resourcebased relative value system in 1992. Another significant difference between this and other 

typical models of bundled payments is that the payment rates for the global surgery packages are 

not updated regularly based on any reporting of the actual costs of patient care. For example, the 

hospital inpatient and outpatient prospective payment systems (the IPPS and OPPS, respectively) 

derive payment rates from hospital cost and charge data reported through annual Medicare 
CMS-1612-FC 130

hospital cost reports and the most recent year of claims data available for an inpatient stay or 

primary outpatient service. 

Because payment rates are based on consistently updated data, over time, payment rates 

adjust to reflect the average resource costs of current practice. Similarly, many of the new 

demonstration and innovation models track costs and make adjustments to payments. Another 

significant difference is that payment for the PFS global packages relies on valuing the combined 

services together. This means that there are no separate PFS values established for the 

procedures or the follow-up care, making it difficult to estimate the costs of the individual global 

code component services. 

In the following paragraphs, we address a series of concerns regarding the accuracy of 

payment for 10- and 90- day global codes, including: the fundamental difficulties in establishing 

appropriate relative values for these packages, the potential inaccuracies in the current 

information used to price global codes, the limitations on appropriate pricing in the future, the 

potential for global packages to create unwarranted payment differentials among specialties, the 

possibility that the current codes are incompatible with current medical practice, and the 

potential for these codes to present obstacles to the adoption of new payment models. 

Concerns such as these commonly arise when developing payment mechanisms, for 

example fee-for-service payment rates, single payments for multiple services, or payment for 

episodes of care over a period of time. However, in the case of the post-operative portion of the 

10- and 90-day global codes, we believe that together with certain unique aspects of PFS rate 

setting methodology, these concerns create substantial barriers to accurate valuation of these 

services relative to other PFS services. 

(1) Fundamental Limitations in the Appropriate Valuation of the Global Packages with Postoperative days. 
CMS-1612-FC 131

In general, we face many challenges in valuing PFS services as accurately as possible. 

However, the unique nature of global surgery packages with 10- and 90-day post-operative 

periods presents additional challenges distinct from those presented in valuing other PFS 

services. Our valuation methodology for PFS services generally relies on assumptions regarding 

the resources involved in furnishing the “typical case” for each individual service unlike other 

payment systems that rely on actual data on the costs of furnishing services. Consistent with this 

valuation methodology, the RVUs for a global code should reflect the typical number and level 

of E/M services furnished in connection with the procedure. However, it is much easier to 

maintain relativity among services that are valued on this basis when each of the services is 

described by codes of similar unit sizes. In other words, because codes with long post-operative 

periods include such a large number of services, any variations between the “typical” resource 

costs used to value the service and the actual resource costs associated with particular services 

are multiplied. The effects of this problem can be two-fold, skewing the accuracy of both the 

RVUs for individual global codes and the Medicare payment made to individual practitioners. 

The RVUs of the individual global service codes are skewed whenever there is any inaccuracy in 

the assumption of the typical number or kind of services in the post-operative periods. This 

inaccuracy has a greater impact than inaccuracies in assumptions for non-global codes because it 

affects a greater number of service units over a period of time than for individually priced 

services. Furthermore, in contrast to prospective payment systems, such inaccuracies under the 

PFS are not corrected over time through a ratesetting process that makes year-to-year 

adjustments based on data on actual costs. For example, if a 90-day global code is valued based 

on an assumption or survey response that ten post-operative visits is typical, but practitioners 

reporting the code in fact typically only furnish six visits, then the resource assumptions are 

overestimated by the value of the four visits multiplied by the number of the times the procedure 
CMS-1612-FC 132

code is reported. In contrast, when our assumptions are incorrect about the typical resources 

involved in furnishing a PFS code that describes a single service, any inaccuracy in the RVUs is 

limited to the difference between the resource costs assumed for the typical service and the 

actual resource costs in furnishing one individual service. Such a variation between the 

assumptions used in calculating payment rates and the actual resource costs could be corrected if 

the payments for packaged services were updated regularly using data on actual services 

furnished. Medicare’s prospective payment systems have more mechanisms in place than the 

PFS does to adjust over time for such variation To make adjustments to the RVUs to account for 

inaccurate assumptions under the current PFS methodology, the global surgery code would need 

to be identified as potentially misvalued, survey data would have to reflect an accurate account 

of the number and level of typical post-operative visits, and we (with or without a corresponding 

recommendation from the RUC or others) would have to implement a change in RVUs based on 

the change in the number and level of visits to reflect the typical service. 

These amplified inaccuracies may also occur whenever Medicare pays an individual 

practitioner reporting a 10- or 90-day global code. Practitioners may furnish a wide range of 

post-operative services to individual Medicare beneficiaries, depending on individual patient 

needs, changes in medical practice, and dynamic business models. Due to the way the 10- and 

90-day global codes are constructed, the number and level of services included for purposes of 

calculating the payment for these services may vary greatly from the number and level of 

services that are actually furnished in any particular case. In contrast, the variation between the 

“typical” and the actual resource cost for the practitioner reporting an individually valued PFS 

service is constrained because the practitioner is only reporting and being paid for a specific 

service furnished on a particular date. 
CMS-1612-FC 133

For most PFS services, any difference between the “typical” case on which RVUs are 

based and the actual case for a particular service is limited to the variation between the resources 

assumed to be involved in furnishing the typical case and the actual resources involved in 

furnishing the single specific service. When the global surgical package includes more or a 

higher level of E/M services than are actually furnished in the typical post-operative period, the 

Medicare payment is based on an overestimate of the quantity or kind of services furnished, not 

merely an overestimation of the resources involved in furnishing an individual service. The 

converse is true if the RVUs for the global surgical package are based on fewer or a lower level 

of services than are typically furnished for a particular code. 

(2) Questions Regarding Accuracy of Current Assumptions 

In previous rulemaking (77 FR 68911 through 68913), we acknowledged evidence 

suggesting that the values included in the post-operative period for global codes may not reflect 

the typical number and level of post-operative E/M visits actually furnished. 

In 2005, the OIG examined whether global surgical packages are appropriately valued. 

In its report on eye and ocular surgeries, “National Review of Evaluation and Management 

Services Included in Eye and Ocular Adnexa Global Surgery Fees for Calendar Year 2005” (A05-07-00077), the OIG reviewed a sample of 300 eye and ocular surgeries, and counted the 

actual number of face-to-face services recorded in the patients’ medical records to establish 

whether and, if so, how many post-operative E/M services were furnished by the surgeons. For 

about two-thirds of the claims sampled by the OIG, surgeons furnished fewer E/M services in the 

post-operative period than were included in the global surgical package payment for each 

procedure. A small percentage of the surgeons furnished more E/M services than were included 

in the global surgical package payment. The OIG identified the number of face-to-face services 

recorded in the medical record, but did not review the medical necessity of the surgeries or the 
CMS-1612-FC 134

related E/M services. The OIG concluded that the RVUs for these global surgical packages are 

too high because they include a higher number of E/M services than typically are furnished 

within the global period for the reviewed procedures. 

Following that report, the OIG continued to investigate E/M services furnished during 

global surgical periods. In May 2012, the OIG published a report entitled “Musculoskeletal 

Global Surgery Fees Often Did Not Reflect the Number of Evaluation and Management Services 

Provided” (A-05-09-00053). For this investigation, the OIG sampled 300 musculoskeletal global 

surgeries and again found that, for the majority of sampled surgeries, physicians furnished fewer 

E/M services than were included as part of the global period payment for that service. Once 

again, a small percentage of surgeons furnished more E/M services than were included in the 

global surgical package payment. The OIG concluded that the RVUs for these global surgical 

packages are too high because they include a higher number of E/M services than typically are 

furnished within the global period for the reviewed procedures. 

In both reports, the OIG recommended that we adjust the number of E/M services 

identified with the studied global surgical payments to reflect the number of E/M services that 

are actually being furnished. However, since it is not necessary under our current global surgery 

payment policy for a surgeon to report the individual E/M services actually furnished during the 

global surgical period, we do not have objective data upon which to assess whether the RVUs for 

global period surgical services reflect the typical number or level of E/M services that are 

furnished. In the CY 2013 PFS proposed rule (77 FR 44738), we previously sought public 

comments on collecting these data. As summarized in the CY 2013 PFS final rule (77 FR 

68913) we did not discover a consensus among stakeholders regarding either the most 

appropriate means to gather the data, or the need for, or the appropriateness of using such data in 

valuing these services. In response to our comment solicitation, some commenters urged us to 
CMS-1612-FC 135

accept the RUC survey data as accurate in spite of the OIG reports and other concerns that have 

been expressed regarding whether the visits included in the global periods reflected the typical 

case. Others suggested that we should conduct new surveys using the RUC approach or that we 

should mine hospital data to identify the typical number of visits furnished. Some comments 

suggested eliminating the 10- and 90-day global codes. 

(3) Limitations on Appropriate Future Valuations of 10- and 90-day Global Codes 

Historically, our attempts to adjust RVUs for global services based on changes in the 

typical resource costs (especially with regard to site of service assumptions or changes to the 

number of post-surgery visits) have been difficult and controversial. At least in part, this is 

because the relationship between the work RVUs for the 10- and 90-day global codes (which 

includes the work RVU associated with the procedure itself) and the number of included postoperative visits in the existing values is not always clear. Some services with global periods 

have been valued by adding the work RVU of the surgical procedure and all pre- and postoperative E/M services included in the global period. However, in other cases, as many 

stakeholders have noted, the total work RVUs for surgical procedures and post-operative visits in 

global periods are estimated as a single value without any explicit correlation to the time and 

intensity values for the individual service components. Although we would welcome more 

objective information to improve our determination of the “typical” case, we believe that even if 

we engaged in the collection of better data on the number and level of E/M services typically 

furnished during the global periods for global surgery services, the valuation of individual codes 

with post-operative periods would not be straightforward. Furthermore, we believe it would be 

important to frequently update the data on the number and level of visits furnished during the 

post-operative periods in order to account for any changes in the patient population, medical 

practice, or business arrangements. Practitioners paid through the PFS do not report such data. 
CMS-1612-FC 136

(4) Unwarranted Payment Disparities 

Subsequent to our last comment solicitation regarding the valuation of the post-operative 

periods (77 FR 68911 through 68913), some stakeholders have raised concerns that global 

surgery packages contribute to unwarranted payment disparities between practitioners who do 

and do not furnish these services. These stakeholders have addressed several ways the 10- and 

90-day global packages may contribute to unwarranted payment disparities. 

The stakeholders noted that, through the global surgery packages, Medicare pays 

practitioners who furnish E/M services during post-surgery periods regardless of whether the 

services are actually furnished, while practitioners who do not furnish global procedures with 

post-operative visits are only paid for E/M services that are actually furnished. In some cases, it 

is possible that the practitioner furnishing the global surgery procedure may not furnish any postoperative visits. Although we have policies to address the situation when post-operative care is 

transferred from one practitioner to another, the beneficiary might simply choose to seek care 

from another practitioner without a formal transfer of care. The other practitioner would then 

bill Medicare separately for E/M services for which payment was included in the global payment 

to the original practitioner. Those services would not have been separately billable if furnished 

by the original practitioner. 

These circumstances can lead to unwarranted payment differences, allowing some 

practitioners to receive payment for fewer services than reflected in the Medicare payment. 

Practitioners who do not furnish global surgery services bill and are paid only for each individual 

service furnished. When global surgery values are based on inaccurate assumptions about the 

typical services furnished in the post-operative periods, these payment disparities can contribute 

to differences in aggregate RVUs across specialties. Since the RVUs are intended to reflect 

differences in the relative resource costs involved in furnishing a service, any disparity between 
CMS-1612-FC 137

assumed and actual costs results not only in paying some practitioners for some services that are 

not furnished, it also skews relativity between specialties. 

Stakeholders have also pointed out that payment disparities can arise because E/M 

services reflected in global periods generally include higher PE values than the same services 

when billed separately. The difference in PE values between separately billed visits and those 

included in global packages result primarily from two factors that are both inherent in the PFS 

pricing methodology. 

First, there is a different mix of PE inputs (clinical labor/supplies/ equipment) included in 

the direct PE inputs for a global period E/M service and a separately billed E/M service. For 

example, the clinical labor inputs for separately reportable E/M codes includes a staff blend 

listed as “RN/LPN/MTA” (L037D) and priced at $0.37 per minute. Instead of this input, some 

codes with post-operative visits include the staff type “RN” (L051A) priced at a higher rate of 

$0.51 per minute. For these codes, the higher resource cost may accurately reflect the typical 

resource costs associated with those particular visits. However, the different direct PE inputs 

may drive unwarranted payment disparities among specialties who report global surgery codes 

with post-operative periods and those that do not. The only way to correct these potential 

discrepancies under the current system, which result from the specialty-based differences in 

resource costs, would be to include standard direct PE inputs for these services regardless of 

whether or not the standard inputs are typical for the specialties furnishing the services. 

Second, the indirect PE allocated to the E/M visits included in global surgery codes is 

higher than that allocated to separately furnished E/M visits. This occurs because the range of 

specialties furnishing a particular global service is generally not as broad as the range of 

specialties that report separate individual E/M services. Since the specialty mix for a service is a 

key factor in determining the allocation of indirect PE to each code, a higher amount of indirect 
CMS-1612-FC 138

PE can be allocated to the E/M services that are valued as part of the global surgery codes than to 

the individual E/M codes. Practitioners who use E/M codes to report visits separately are paid 

based on PE RVUs that reflect the amount of indirect PE allocated across a wide range of 

specialties, which has the tendency to lower the amount of indirect PE. For practitioners who are 

paid for visits primarily through post-operative periods, indirect PE is generally allocated with 

greater specificity. Two significant steps would be required to alleviate the impact of this 

disparity. First, we would have to identify the exact mathematical relationship between the work 

RVU and the number and level of post-operative visits for each global code; and second, we 

would have to propose a significant alteration of the PE methodology in order to allocate indirect 

PE that does not correlate to the specialties reporting the code in the Medicare claims data. 

Furthermore, stakeholders have pointed out that the PE RVUs for codes with 10- or 

90-day post-operative periods reflect the assumption that all outpatient visits occur in the higherpaid non-facility office setting, when many of these visits are likely to be furnished in providerbased departments, which would be paid at the lower, PFS facility rate if they were billable 

separately. As we note elsewhere in this final rule with comment period, we do not have data on 

the volume of physicians’ services furnished in provider-based departments, but public 

information suggests that it is not insignificant and that it is growing. When these services are 

paid as part of a global package, there is no adjustment made based on the site of service. 

Therefore, even though the PFS payment for services furnished in post-operative global periods 

might include clinical labor, disposable supply, and medical equipment costs (and additional 

indirect PE allocation) that are incurred by the facility and not the practitioner reporting the 

service, the RVUs for global codes reflect all of these costs associated with the visits. 

(5) Incompatibility of Current Packages with Current Practice and Unreliability of RVUs for Use 

in New Payment Models 
CMS-1612-FC 139

In addition to these issues, the 10- and 90-day global periods reflect a long-established 

but no longer exclusive model of post-operative care that assumes the same practitioner who 

furnishes the procedure typically furnishes the follow-up visits related to that procedure. In 

many cases, we believe that models of post-operative care are increasingly heterogeneous, 

particularly given the overall shift of patient care to larger practices or team-based environments. 

We believe that RVUs used to establish PFS payments are likely to serve as critical 

building blocks to developing, testing, and implementing a number of new payment models, 

including those that focus on bundled payments to practitioners or payments for episodes of care. 

Therefore, we believe it is critical for us to ensure that the PFS RVUs accurately reflect the 

resource costs for individual PFS services instead of reflecting potentially skewed assumptions 

regarding the number of services furnished over a long period of time in the “typical” case. To 

the extent that the 10- and 90-day global periods reflect inaccurate assumptions regarding 

resource costs associated with individual PFS services, we believe they are likely to be obstacles 

to a wide range of potential improvements to PFS payments, including the potential 

incorporation of payment bundling designed to foster efficiency and quality care for Medicare 

beneficiaries. 

c. Proposed Transformation of 10- and 90-day Global Packages into 0-day Global Packages 

Although we have marginally addressed some of the concerns noted above with global 

packages in previous rulemaking, we do not believe that we have made significant progress in 

addressing the fundamental issues with the 10- and 90-day post-operative global packages. In 

the context of the misvalued code initiative, we believe it is critical for the RVUs used to develop 

PFS payment rates reflect the most accurate resource costs associated with PFS services. Based 

on the issues discussed above, we do not believe we can effectively address the issues inherent in 

establishing values for the 10- and 90-day global packages under our existing methodologies and 
CMS-1612-FC 140

with available data. As such, we do not believe that maintaining the post-operative 10-and 90-

day global periods is compatible with our continued interest in using more objective data in the 

valuation of PFS services and accurately valuing services relative to each other. Because the 

typical number and level of post-operative visits during global periods may vary greatly across 

Medicare practitioners and beneficiaries, we believe that continued valuation and payment of 

these face-to-face services as a multi-day package may skew relativity and create unwarranted 

payment disparities within PFS fee-for-service payment. We also believe that the resource based 

valuation of individual physicians’ services will continue to serve as a critical foundation for 

Medicare payment to physicians, whether through the current PFS or in any number of new 

payment models. Therefore, we believe it is critical that the RVUs under the PFS be based as 

closely and accurately as possible on the actual resources involved in furnishing the typical 

occurrence of specific services. 

To address the issues discussed above, we proposed to retain global bundles for surgical 

services, but to refine bundles by transforming over several years all 10- and 90-day global codes 

to 0-day global codes. Medically reasonable and necessary visits would be billed separately 

during the pre- and post-operative periods outside of the day of the surgical procedure. We 

propose to make this transition for current 10-day global codes in CY 2017 and for the current 

90-day global codes in CY 2018, pending the availability of data on which to base updated 

values for the global codes. 

We believe that transforming all 10- and 90-day global codes to 0-day global codes 

would: 

• Increase the accuracy of PFS payment by setting payment rates for individual services 

based more closely upon the typical resources used in furnishing the procedures; 
CMS-1612-FC 141

• Avoid potentially duplicative or unwarranted payments when a beneficiary receives 

post-operative care from a different practitioner during the global period; 

• Eliminate disparities between the payment for E/M services in global periods and those 

furnished individually; 

• Maintain the same-day packaging of pre- and post-operative physicians’ services in the 

0-day global; and 

• Facilitate availability of more accurate data for new payment models and quality 

research. 

As we transition these codes, we would need to establish RVUs that reflect the change in 

the global period for all the codes currently valued as 10- and 90-day global surgery services. 

We sought assistance from stakeholders on various aspects of this task. Prior to implementing 

these changes, we intend to gather objective data on the number of E/M and other services 

furnished during the current post-operative periods and use those data to inform both the 

valuation of particular services and the overall budget neutrality adjustments required to 

implement this proposal. We sought comment on the most efficient means of acquiring accurate 

data regarding the number of visits and other services actually being furnished by the practitioner 

during the current post-operative periods. For all the reasons stated above, we do not believe that 

survey data reflecting assumptions of the “typical case” meets the standards required to measure 

the resource costs of the wide range of services furnished during the post-operative periods. We 

acknowledge that collecting information on these services through claims submission may be the 

best approach, and we would propose such a collection through future rulemaking. However, we 

are also interested in alternatives. For example, we sought information on the extent to which 

individual practitioners or practices may currently maintain their own data on services furnished 

during the post-operative period, and how we might collect and objectively evaluate that data. 
CMS-1612-FC 142

We also sought comment on the best means to ensure that allowing separate payment of 

E/M visits during post-operative periods does not incentivize otherwise unnecessary office visits 

during post-operative periods. If we adopt this proposal, we intend to monitor any changes in the 

utilization of E/M visits following its implementation but we also solicited comment on potential 

payment policies that will mitigate such a change in behavior. 

In developing this proposal, we considered several alternatives to the transformation of 

all global codes to 0-day global codes. First, we again considered the possibility of gathering 

data and using the data to revalue the 10- and 90- day global codes. While this option would 

have maintained the status quo in terms of reporting services, it would have required much of the 

same effort as this proposal without alleviating many of the problems associated with the 10- and 

90-day global periods. For example, collecting accurate data would allow for more accurate 

estimates of the number and kind of visits included in the post-operative periods at the time of 

the survey. However, this alternative approach would only mitigate part of the potential for 

unwarranted payment disparities. For example, the values for the visits in the global codes 

would continue to include different amounts of PE RVUs than separately reportable visits and 

would continue to provide incentives to some practitioners to minimize patient visits. 

Additionally, it would not address the changes in practice patterns that we believe have been 

occurring whereby the physician furnishing the procedure is not necessarily the same physician 

providing the post-procedure follow up. 

This alternative option would also rest extensively on the effectiveness of using the new 

data to revalue the codes accurately. Given the unclear relationship between the assigned work 

RVUs and the post-operative visits across all of these services, incorporating objective data on 

the number of visits to adjust work RVUs would still necessitate extensive review of individual 

codes or families of codes by CMS and stakeholders, including the RUC. We believe the 
CMS-1612-FC 143

investment of resources for such an effort would be better made to solve a broader range of 

problems. 

We also considered other possibilities, such as altering our PE methodology to ensure 

that the PE inputs and indirect PE for visits in the global period were valued the same as 

separately reportable E/M codes or requiring reporting of the visits for all 10- and 90-day global 

services while maintaining the 10- and 90-day global period payment rates. However, we 

believe this option would require all of the same effort by practitioners, CMS, and other 

stakeholders without alleviating most of the problems addressed in the preceding paragraphs. 

We also considered maintaining the status quo and identifying each of the 10- and 90-day 

global codes as potentially misvalued through our potentially misvalued code process for review 

as 10- and 90-day globals. Inappropriate valuations of these services has a major effect on the 

fee schedule due to the percentage of PFS dollars paid through 10- and 90-day global codes (3 

percent and 11 percent, respectively), and thus, valuing them appropriately is critical to 

appropriate valuation and relativity throughout the PFS. Through the individual review 

approach, we could review the appropriateness of the global period and the accurate number of 

visits for each service. Yet revaluing all 3,000 global surgery codes through the potentially 

misvalued codes approach would not address many of the problems identified above. Unless 

such an effort was combined with changes in the PE methodology, it would only partially 

address the valuation and accuracy issues and would leave all the other issues unresolved. 

Moreover, the valuation and accuracy issues that could be addressed through this approach 

would rapidly be out of date as medical practice continues to change. Therefore, such an 

approach would be only partially effective and would impede our ability to address other 

potentially misvalued codes. 
CMS-1612-FC 144

We sought stakeholder input on an accurate and efficient means to revalue or adjust the 

work RVUs for the current 10- and 90-day global codes to reflect the typical resources involved 

in furnishing the services including both the pre- and post-operative care on the day of the 

procedure. We believe that collecting data on the number and level of post-operative visits 

furnished by the practitioner reporting current 10-and 90-day global codes will be important to 

ensuring work RVU relativity across these services. We also believe that these data will be 

important to determine the relationship between current work RVUs and current number of postoperative visits, within categories of codes and code families. However, we believe that once we 

collect those data, there is a wide range of possible approaches to the revaluation of the large 

number of individual global services, some of which may deviate from current processes like 

those undertaken by the RUC. To date, the potentially misvalued code initiative has focused on 

several hundred, generally high-volume codes per year. This proposal requires revaluing a larger 

number of codes over a shorter period of time and includes many services with relatively low 

volume in the Medicare population. Given these circumstances, it does not seem practical to 

survey time and intensity information on each of these procedures. Absent any new survey data 

regarding the procedures themselves, we believe that data regarding the number and level of 

post-service office visits can be used in conjunction with other methods of valuation, such as: 

• Using the current potentially misvalued code process to identify and value the 

relatively small number of codes that represent the majority of the volume of services that are 

currently reported with codes with post-operative periods, and then adjusting the aggregate 

RVUs to account for the number of visits and using magnitude estimation to value the remaining 

services in the family. 

• Valuing one code within a family through the current valuation process and then using 

magnitude estimation to value the remaining services in the family. 
CMS-1612-FC 145

• Surveying a sample of codes across all procedures to create an index that could be used 

to value the remaining codes. 

Although we believe these are plausible options for the revaluation of these services, we 

believed there may be others. Therefore, we sought input on the best approach to achieve this 

proposed transition from 10- and 90-day, to 0-day global periods, including the timing of the 

changes, the means for revaluation, and the most effective and least burdensome means to collect 

objective, representative data regarding the actual number of visits currently furnished in the 

post-operative global periods. We also solicited comment on whether the effective date for the 

transition to 0-day global periods should be staggered across families of codes or other 

categories. For example, while we proposed to transition 10-day global periods in 2017 and 

90-day global periods in 2018, we solicited comment on whether we should consider 

implementing the transition more or less quickly and over one or several years. We also 

solicited comment regarding the appropriate valuation of new, revised, or potentially misvalued 

10- or 90-day global codes before implementation of this proposal. 

We received many comments regarding the proposed transition to 0-day global packages. 

Many commenters expressed support or opposition to the proposal. Some commenters offered 

direct responses to the topics for which we specifically sought comment, while others raised 

questions regarding how the transition would be implemented. In the following paragraphs, we 

summarize and respond to these comments. 

Comment: Several commenters supported the proposal, including commenters 

representing several medical specialty societies and several health systems. Many of these 

commenters agreed with the reasons presented in the proposal. These commenters agreed that 

the current structure of the global surgery codes prevents CMS from accurately valuing and 

paying for these services, even if CMS had necessary visit data available. Many commenters 
CMS-1612-FC 146

agreed that the current arrangement may lead to unwarranted payment disparities and that the 

current packages have not evolved with changes in practice and because of this, likely provide 

unreliable building blocks for new payment methodologies. 

In agreeing with the proposal, MedPAC stated that it “is essential that the individual 

services that make up a bundle have accurate values and that there is a mechanism to ensure that 

the services that are part of the bundle are not paid separately (unbundling). Otherwise, the 

payment rate for the entire bundle will be inaccurate.” MedPAC urged CMS to finalize this 

proposal and plan to use the more accurate valuations to create more accurate bundles in the 

future. 

Response: We appreciate the commenters’ support for the proposal, and agree that there 

are many reasons why the current construction of the global surgery packages is difficult to 

reconcile with accurate valuation of individual services within the current payment construct of 

the PFS. We agree that achieving the agency’s goal of greater bundling requires accurate 

valuation of component services in a surgical procedure. 

Comment: Some commenters, including several of those representing specialty societies, 

urged CMS to postpone finalization of the proposal pending the report of stakeholder efforts to 

conduct a comprehensive analysis of the effect it would have on the provision of surgical care, 

surgical patients, and the surgeons who care for them. 

Response: We share stakeholders’ concerns regarding the potential impact of the change 

on Medicare beneficiaries and practitioners. However, based upon our analysis and the 

information that stakeholders have provided, we believe delaying the proposal to further study 

the problems is not warranted given the significant concerns that have been raised with the 

current construction of the global surgery packages . Instead, as we articulated in making the 

proposal, we anticipate that further analysis by stakeholders will contribute to implementing the 
CMS-1612-FC 147

transition in a manner that accurately values and pays for PFS services. We believe that accurate 

valuation of services furnished to Medicare beneficiaries is overwhelmingly in the best interest 

of both beneficiaries and those who care for them. 

Comment: We received several comments from commenters who opposed our proposal, 

and in general these commenters shared the concerns of those who urged a delay in finalizing or 

implementing the proposal. In addition, some commenters who opposed the proposal disputed 

our contention that the global periods contribute to unwarranted payment disparities, saying that 

the increased direct and indirect PE and MP RVUs for E/M services furnished in the global 

surgical post-operative periods accurately account for the increased PE and MP costs of 

practitioners who furnish these services relative to practitioners who typically furnish separately 

reportable E/M services. 

Response: Just as we do not agree that we should delay addressing significant problems 

with valuations while we further study the issues, we do not believe these same issues raised by 

commenters opposing the proposal are impediments to implementation. The issues relating to 

valuation of global period E/M services using our PE methodology are just one of several 

important considerations that led us to propose transforming 10- and 90-day global services to 0-

day global packages. We continue to believe the proposed transformation to 0-day global 

packages is a simple and immediate step to improve the valuation of the various services 

included in surgical care. However, Medicare remains committed to bundled payment as a 

mechanism for delivery system reform and we will continue to explore the best way to bundle 

surgical services, including alternatives to the 0-day global surgical bundle. 

Comment: Many commenters who opposed the proposal addressed valuation problems 

that would exist if the proposal were implemented. Some stated that, were CMS to finalize the 

proposal to pay for post-surgical E/Ms using the same codes, the PE and MP RVUs for the 
CMS-1612-FC 148

services would be artificially reduced because the data from other specialties would be 

incorporated. These commenters suggested CMS should consider how to maintain the current 

differences in payment for these services even if the proposal were finalized. Some commenters 

suggested that CMS would need to account for the additional practice expense and malpractice 

costs for post-operative surgical visits. 

Response: We develop and establish work, PE, and MP RVUs for specific services to 

reflect the relative resource costs involved in furnishing the typical PFS service. In developing 

the proposal, we noted that by including a significant number of E/Ms in the global periods for 

surgical services, the PFS ratesetting methodology distinguishes these services from other E/Ms 

for purposes of developing PE and MP RVUs, potentially to the advantage of particular 

specialties with higher PE and MP RVUs. In contrast, the work RVUs for individual, separately 

billed E/M services furnished, for example, by primary care practitioners are valued more 

generally as individual services, and values are not maintained separately from the work RVUs 

for E/Ms furnished by other practitioners. Therefore, we do not agree with commenters that 

Medicare should establish higher PE and MP values for E/M services furnished in the postsurgical period than for other E/M services. 

Comment: Several commenters suggested that CMS should not use the OIG reports to 

generalize its concerns about the provision of surgical care, because the OIG reports represent 

only a small sample of observations of specific procedures and specialties. Other commenters 

suggested that the OIG methodology might be flawed because, since CMS does not require 

documentation of post-operative visits, many practitioners may not document such visits in the 

medical record. 

Response: We do not have any reason to believe that the OIG findings on the global 

surgical service packages furnished by particular specialties that the OIG reviewed are not 
CMS-1612-FC 149

generalizable to other global surgery services. Nor did the commenters provide any evidence 

that the OIG conclusions are likely to be less accurate than the survey estimates that CMS uses to 

value the services. Finally, having an incorrect number of postoperative visits is only one of the 

many valuation problems that have been identified for global surgical packages. Additionally, 

we find the suggestion that physicians do not document medical visits that are occurring in the 

post-surgical period to be concerning. As a general matter, Medicare does not require 

documentation to support a billed service beyond information that the physician would normally 

maintain in the patient’s medical record. Even in the absence of billing Medicare or another 

insurer, we believe that physicians and other practitioners following standard medical practice 

would document what occurred during a patient encounter in order to ensure the patient’s 

medical history is accurate and up-to-date, and to facilitate continuity in the patient’s medical 

care.

Comment: One commenter asserted that the 90-day global period was created to prevent 

two behaviors referred to as “fee-splitting” and “itinerant surgery.” According to the 

commenter, these terms refer to the practice where a surgeon would provide only the surgery and 

leave postoperative care to other practitioners. The commenter believes these practices are 

inconsistent with professional standards, and that it is medically necessary and expected by 

patients that surgeons will evaluate their patients on a daily basis in the hospital and as needed on 

an outpatient basis during the recovery period. 

Response: We do not believe that the global surgical package was designed to ensure or 

allocate appropriate post-operative care among practitioners. Under Medicare’s current global 

surgery policy, practitioners can agree on the transfer of care during the global period and, in 

such cases, modifiers are used in order to split the payment between the procedure and the postoperative care. We do not agree that global surgical packages obligate the surgeon to furnish 
CMS-1612-FC 150

some or all of the post-operative care. Global surgical packages are valued based on the typical 

service, and we would not expect every surgery to require the same number of follow-up visits. 

However, we would expect that over a large number of services, the central tendency would 

reflect the number of visits we included as typical for purposes of valuing the global package; 

and as discussed above, we have not found that this is necessarily the case. . Even if Medicare 

maintains the 10- and 90-day global surgery packages, there would be no assurance that the 

surgeon, and not another practitioner, would furnish all or a certain amount of post-operative 

care (whether by the patient’s choice of practitioner or otherwise). The global payment includes 

payment for post-operative care with the payment for the surgery, which makes it difficult to 

know whether or by whom the post-operative care was actually furnished unless there is an 

official transfer of care. We are confident that the surgical community will continue to furnish 

appropriate care for Medicare beneficiaries irrespective of changes in the structure of payment 

for surgical services. 

Comment: Several commenters stated that if Medicare adopts a policy to pay for postoperative care using E/M codes rather than through a global package, Medicare will likely pay a 

higher level of E/M visits when they are separately billed than it does currently, as the existing 

global packages tend to include more lower level E/M services than those that are generally 

reported. 

Response: We acknowledge that the visits assumed in the global packages are generally 

valued as lower-level visits than are most commonly furnished, as reflected in Medicare 

utilization data for separately reportable E/Ms. However, this disparity is only pertinent to the 

proposal if the global packages are inaccurately valued or, if, under the proposed policy, 

practitioners who furnish these services are likely to inaccurately report the level of E/M service 

that is actually being furnished. If the former is true, then we believe this supports the proposal to 
CMS-1612-FC 151

revalue these services. As with every service, we expect physicians to bill the most appropriate 

E/M codes that reflect the care that is furnished, including for post-operative care. 

Comment: One commenter expressed concern that the proposal to require separate 

billing for postoperative surgical care provides a basis for the eventual denial of payment to one 

or more of the postoperative care providers, based on the notion that care furnished by other 

specialties is duplicative of or replaces care furnished by the surgeon. This commenter stated 

that multiple providers with differing expertise and training are essential to achieve optimal 

patient outcomes and expressed concern that this proposal will provide disincentives to optimal 

patient care. 

Response: As we stated in the proposal, we believe that there are various models for 

postoperative care that can often include multiple providers, and this is another important reason 

why we believe the services with longer global periods should be transformed to 0-day packages 

to accommodate heterogeneous models of care that optimize patient outcomes. 

Comment: One commenter recommended that CMS establish G-codes for three levels of 

post-operative visits furnished by the original surgeon or another surgeon with the same board 

certification, as well as a second set of three level G-codes for postoperative visits furnished by 

another provider. The commenter also suggested that CMS should develop methods to fairly 

measure the duration of E/M times through which a large sample of surgeons might report the 

number and intensity of post-operative visits. The commenter also recommended that CMS 

track E/M services furnished to surgical patients within the global period by a physician other 

than the operating surgeon, for the same or similar diagnosis, in order to begin to understand 

what portion of postoperative visits are being billed outside of the global period. 

The RUC informed CMS that it has identified several large hospital-based physician 

group practices that internally use CPT code 99024 to report each bundled post-operative visit, 
CMS-1612-FC 152

and therefore data is already being captured for some Medicare providers. The RUC also 

suggested that CMS may have denied-claims data available for CPT code 99024 via the 

Medicare claims processing system. The RUC recommends that CMS work with it to explore 

the availability, usefulness, and appropriateness of these data from group practices and the CMS 

denied-claims dataset, in order to gather existing, objective data to validate the actual number of 

post-operative visits for 10-day and 90-day procedures. The RUC also suggested that CMS 

should consider reviewing Medicare Part A claims data to determine the length of stay for 

surgical services furnished in the inpatient acute care hospital setting. 

MedPAC stated that data collection could take several years, would be burdensome for 

CMS and providers, and may be inaccurate since providers would have little incentive to report 

each visit. Furthermore, MedPAC suggested that such data collection would be unnecessary 

since the current ratesetting methodology already assumes particular numbers of visits. 

MedPAC suggested that CMS should reduce the RVUs for the 10- and 90-day global services 

based on the same assumptions currently used to pay for these services. 

Several other commenters agreed with the approach advocated by MedPAC (often 

referred to as “reverse-building block”) to revaluing the services. These commenters stated that 

since CMS has increased RVUs for these services proportionate to the number of E/M services 

assumed to be included in the postoperative period, for the sake of relativity, the RVUs attributed 

to the visits can be fairly removed in order to value the new 0-day global codes. Many of these 

commenters acknowledged that this approach would result in negative or other anomalous values 

for many of these codes, but asserted that codes with anomalous values might then be 

individually reviewed. MedPAC suggested that if specialty societies or the RUC believe that 

the new values for specific global codes are inaccurate, they could present evidence that the 

codes are misvalued to CMS, presumably through the potentially misvalued code public 
CMS-1612-FC 153

nomination process. MedPAC further states that for codes without accurate post-operative 

assumptions, CMS could calculate interim RVUs for these codes based on the average percent 

reduction for other global codes in the same family. 

Many other commenters were against the reverse-building block approach to revaluation. 

These commenters stated that backing out the bundled E/M services would be highly 

inappropriate and methodologically unsound since the services were not necessarily valued using 

a building-block methodology. Many of these commenters, including the RUC, stated that the 

amount of post-operative work included in the codes can only be appropriately surveyed, vetted, 

and valued by the RUC. 

Response: We appreciate the concerns of commenters regarding the difficulty of 

revaluing the global surgery codes as 0-day global packages. As we stated in making the 

proposal, we believe that such stakeholder input and participation in any revaluation will be 

critical to the accuracy of the resulting values. We will consider all of these comments as we 

consider mechanisms for revaluations and as we propose new values for specific services. We 

believe that the challenges involved in revaluation, such as those articulated by commenters, 

reinforce our understanding that the current construction of the 10- and 90-day global packages 

are not a sustainable, long-term approach to the accurate valuation of surgical care. . As noted 

above, we will continue to explore appropriate ways of bundling global surgical services. 

Comment: In general, commenters supporting the proposal also supported CMS’s 

proposed timeframe to transition 10-day global codes and 90-day global codes to 0-day global 

surgical packages by 2017 and 2018, respectively. In contrast, most commenters objecting to, or 

articulating reservations about, the proposal urged CMS to slow its implementation. Some of 

these commenters suggested that the process used to establish the current values for these CPT 
CMS-1612-FC 154

codes is ideal and stated that it would take many years to value the many individual services 

using the same methodologies. 

The RUC stated that there are over 4,200 services within the PFS with a 10-day or 90-day 

global period, so the scope of the proposal is very large and the transition should be staggered 

over many years. However, the RUC also pointed out that most of these services have relatively 

low utilization, as only 268 of them (or 6 percent of 10- or 90-day global surgery services) were 

performed more than 10,000 times annually based on 2013 Medicare claims data. 

Response: We appreciate the concerns of the commenters. We agree with those 

commenters who urged us to move quickly to value services as accurately as possible. We note 

that most comments suggesting a delay in revaluation were based on a common underlying view 

that code-level review of the full set of services by the RUC based on practitioner surveys is the 

only appropriate way to value the services. 

As we stated in making the proposal, we do not believe that surveying practitioners who 

furnish each of these services is a practical or necessarily advisable approach to appropriate 

valuation. Regardless of when the proposal is implemented, it seems likely that the number of 

codes to be revalued is much larger than the number of codes that should or can be surveyed. 

Through its normal process, the RUC routinely makes annual recommendations regarding 

several hundred codes, and we acknowledge that thousands of services cannot be valued using 

the typical RUC process in one year. On the other hand we believe that there are other options 

for revaluing some of the global surgery codes as 0-day global packages, particularly those of 

low volume, and we have indicated a willingness to work with the RUC to determine appropriate 

mechanisms for revaluations. Therefore, although we agree that revaluing such a high number of 

codes is a significant undertaking, we do not believe that that the required revaluations would 

represent an undue burden between the present and the proposed implementation dates. We also 
CMS-1612-FC 155

note that in order to focus efforts on revaluing the global surgery packages, we are not asking the 

RUC to review the nearly 100 services we proposed as potentially misvalued this year under the 

high expenditure screen. We continue to remain interested in other potential data sources for 

accurately valuing PFS services, especially the vast majority of 10- and 90-day global codes for 

which there is not significant volume. We also urge stakeholders to engage with us to help us 

understand why alternative approaches to the revaluation of the 10- and 90-day global services 

would require the kind of delay that was urged based on the assumption that the RUC survey 

approach would be used for all those services. 

Additionally, we request stakeholders, including the CPT Editorial Panel and the RUC, to 

consider the utility of establishing and maintaining separate coding and national Medicare RVUs 

for the many procedures that have little to no utilization in the Medicare population. For 

example, there are over 1,000 10- and 90-day global codes with fewer than 100 annual services 

in the Medicare database. Although we recognize that some portion of these services may be 

utilized more extensively by non-Medicare payers, it is also likely that many of these codes may 

reasonably be consolidated. We request that appropriate coding for surgical services be 

considered as part of revaluing global surgery. 

Comment: Many commenters expressed concerns that requiring beneficiary coinsurance 

for each follow-up visit could dissuade beneficiaries from returning for necessary follow-up care 

and, therefore, adversely affect surgical outcomes. Many of these commenters acknowledged 

that overall patient liability for the total amount of care could be reduced, depending on 

revaluation, but stated that paying separate coinsurance for follow-up care can cause patients to 

perceive the net payments as larger, given the frequency of payment required. These 

commenters stated that the magnitude of these problems might be directly proportionate to how 

sick the patient is. 
CMS-1612-FC 156

Response: We understand the concerns of the commenters, but do not agree that 

Medicare beneficiaries are unlikely to appreciate the difference between frequency of payment 

and overall financial liability. We also note that the significant majority of patient encounters 

with Medicare practitioners generate some degree of beneficiary liability. While liability could 

prompt the proportion of beneficiaries without secondary insurance to forgo medically 

reasonable and necessary care for the treatment of illness or injury, we have no reason to 

conclude that this would be the case specifically for post-operative care. We do acknowledge 

that surgeons may need to explain the importance of follow-up care so that patients understand 

and appreciate how compliance with follow-up care can improve the overall quality of care and 

outcomes. As noted above, while our proposal is to move to 0-day global packages as a simple, 

immediate adjustment, the agency remains committed to bundling as a key component of 

payment system delivery reform, and we will consider beneficiary impact as we further consider 

the appropriate size and construction of a surgical bundle. 

Comment: Several commenters expressed concerns that the proposal would result in 

disjointed or inadequate care and/or disrupt surgical registry data. These commenters suggested 

that neither patients nor alternate providers are as qualified to determine whether or not a 

postoperative visit by the surgeon is necessary. 

Response: As discussed above, we do not agree that patients who require the postoperative care of a surgeon are likely to forgo such care if Medicare changes how we pay the 

surgeon for furnishing that care. Although several commenters expressed these and similar kinds 

of concerns, none explained how the proposed change in payment would change post operative 

care. We continue to believe that surgeons will continue to furnish appropriate post operative 

care to Medicare beneficiaries, and we do not agree that concerns about increased patient 

liability or disjointed care are warranted. 
CMS-1612-FC 157

Comment: Several commenters expressed concerns over other Medicare payment 

policies related to surgical procedures. Some commenters stated that the current multiple 

procedure payment reduction policies that apply to all 0-, 10-, and 90-day global codes are only 

appropriate for 10-day and 90-day globals due to the overlap in resource costs during the postoperative period. Other commenters noted that potential reductions in payment to surgeons to 

account for the reduced post-operative period would negatively impact practitioners who assist at 

surgery despite the fact that their professional work and responsibilities have not changed. 

Response: We appreciate the issues raised by these commenters. Again, we seek 

continued input from the stakeholder community regarding these and other issues that need to be 

considered in order to implement the transition. In the case of the MPPR, we note there are 

several hundred 0-day global codes where these payment policies currently apply. We are 

especially interested in understanding why stakeholders do not believe the policies effective for 

the current 0-day global codes would not similarly be appropriate for the current 10-and 90-day 

codes that will be revalued as 0-day global codes. 

Comment: Many of the commenters who opposed or expressed concern about the 

proposal urged CMS to consider the extent to which this proposal would increase the 

administrative burden on CMS, MACs, and providers. Other commenters urged CMS to 

consider that post-operative visits would be subject to the same documentation requirements and 

other scrutiny as other separately-reportable PFS services. One commenter representing other 

payers opposed the proposal due to concerns about predicting the usage of post-operative 

services. 

Response: We considered the administrative burden on both CMS and practitioners who 

furnish these services in making the proposal. In both cases, we note the administrative burden 

would be no greater than the burden associated with the vast majority of other services paid 
CMS-1612-FC 158

through the Medicare PFS. We do not believe that the burden of separately reporting postoperative follow-up visits is particularly or unduly burdensome, given that most office visits paid 

through the PFS are separately reported under current Medicare policies. In comparison to the 

number of separately reported visits and other PFS services, the number of visits that likely occur 

in post-operative periods is relatively small. We do not agree that there are inherent reasons that 

medically necessary post-operative visits should be exempt from the same documentation and 

other requirements applicable to other PFS services. We appreciate that changes in Medicare 

policy may affect other insurers who choose to base their payments on the PFS; however, it is 

our obligation to set our policies based upon the needs of Medicare and its beneficiaries. 

Comment: A few commenters urged CMS to consider the possibility that there could be 

confusion among practitioners and payers if some payers continue to base payment on the 10- or 

90-day post-operative periods. 

Response: We believe that payment policies that are appropriate for Medicare may not 

always be optimal for all payers. However, we seek continued input and analysis from other 

payers as we engage stakeholders in developing our implementation strategy for the transition of 

10- and 90-day global services to 0-day global services. 

Comment: Several commenters urged CMS to consult with stakeholders as we develop 

appropriate plans for the global period transition. These commenters cautioned that the 

structural reorganization of these services is challenging due to the large set of services that will 

be impacted and could potentially disrupt well-established payment for certain providers. 

Response: We appreciate these recommendations and agree that we should continue to 

consult with stakeholders regarding the implementation of this proposal. 

After consideration of all the comments received regarding this proposal, we are 

finalizing the proposal to transition and revalue all 10- and 90-day global surgery services with 
CMS-1612-FC 159

0-day global periods, beginning with the 10-day global services in CY 2017 and following with 

the 90-day global services in CY 2018. We note that as we develop implementation details, 

including revaluations, we will take into consideration all of the comments we received to our 

global surgery proposal. We will provide additional details during the CY 2016 rulemaking. We 

are finalizing a transformation to 0-day global codes because we believe this is the most 

straightforward way to improve the accuracy of valuation for the various components of global 

surgical packages, including pre- and post-operative visits and performance of the surgical 

procedure. However, we remain committed to delivery system reform and ensuring Medicare 

makes appropriate payment for bundles of services whether our payment covers a period of 0, 10 

or 90 days. As we begin revaluation of services as 0-day globals, we will actively assess 

whether there is a better construction of a bundled payment for surgical services. 

 We also actively seek the analysis and perspective of all affected stakeholders regarding 

the best means to revalue these services as 0-day global codes. We urge all stakeholders to 

engage with us regarding potential means of making the transition as seamless as possible, both 

for patient care and provider impact. We are considering a wide range of approaches to all 

details of implementation from revaluation to communication and transition, and we are hopeful 

that sufficient agreement can be reached among stakeholders on important issues such as 

revaluation of the global services and appropriate coding for post-operative care. We remain 

committed to collecting objective data regarding the number of visits typically furnished during 

post-operative periods and will explore the extant source options presented by commenters as we 

consider other options as well. 

5. Valuing Services That Include Moderate Sedation as an Inherent Part of Furnishing the 

Procedure 
CMS-1612-FC 160

The CPT manual includes more than 300 diagnostic and therapeutic procedures, listed in 

Appendix G, for which CPT has determined that moderate sedation is an inherent part of 

furnishing the procedure and, therefore, only the single procedure code is appropriately reported 

when furnishing the service and the moderate sedation. The work of moderate sedation has been 

included in the work RVUs for these diagnostic and therapeutic procedures based upon their 

inclusion in Appendix G. Similarly, the direct PE inputs for these services include those inputs 

associated with furnishing a typical moderate sedation service. To the extent that moderate 

sedation is typically furnished as part of the diagnostic or therapeutic service, the inclusion of 

moderate sedation in the valuation of the procedure is appropriate. 

In the CY 2014 PFS proposed rule (79 FR 40349), we noted that it appeared that practice 

patterns for endoscopic procedures were changing, with anesthesia increasingly being separately 

reported for these procedures. For example, one study showed that while the use of a separate 

anesthesia professional for colonoscopies and upper endoscopies was just 13.5 percent in 2003, 

the rate more than doubled to 30.2 percent in 2009. An analysis of Medicare claims data showed 

that a similar pattern is occurring in the Medicare program. We found that, for certain types of 

procedures such as digestive surgical procedures, a separate anesthesia service is furnished 53 

percent of the time. For some of these digestive surgical procedures, the claims analysis showed 

that this rate was as high as 80 percent. 

Our data clearly indicated that moderate sedation was no longer typical for all of the 

procedures listed in CPT’s Appendix G, and, in fact, the data suggested that the percent of cases 

in which it is used is declining. For many of these procedures in Appendix G, moderate sedation 

continued to be furnished. The trend away from the use of moderate sedation toward a 

separately billed anesthesia service was not universal. We found that it differed by the class of 

procedures, sometimes at the procedure code level, and continued to evolve over time. Due to 
CMS-1612-FC 161

the changing nature of medical practice in this area, we noted that we were considering 

establishing a uniform approach to valuation for all Appendix G services for which moderate 

sedation is no longer inherent, rather than addressing this issue at the procedure level as 

individual procedures are revalued. 

We sought public comment on approaches to address the appropriate valuation of these 

services. Specifically, we were interested in approaches to valuing Appendix G codes that would 

allow Medicare to pay accurately for moderate sedation when it is furnished while avoiding 

potential duplicative payments when separate anesthesia is furnished and billed. To the extent 

that Appendix G procedure values are adjusted to no longer include moderate sedation, we 

requested suggestions as to how moderate sedation should be reported and valued, and how to 

remove from existing valuations the RVUs and inputs related to moderate sedation. 

We noted that in the CY 2014 PFS final rule with comment period, we established values 

for many upper gastrointestinal procedures, 58 of which were included in Appendix G. For 

those interim final values, we included the inputs related to moderate sedation. We stated that 

we did not expect to change existing policies for valuing moderate sedation as inherent in these 

procedures until we have the opportunity to assess and respond to the comments on the proposed 

rule on the overall valuation of Appendix G codes. 

 We received many helpful suggestions in response to our comment solicitation. At 

this time, we are not making any changes to how we value Appendix G codes for which 

moderate sedation is an inherent part of the procedure. We intend to address this topic in future 

notice and comment rulemaking, taking into account the comments we received. In section II.G. 

of this CY 2015 PFS final rule with comment period, we address interim final values and 

establish CY 2015 inputs for the lower gastrointestinal procedures, many of which are also listed 

in Appendix G. 
CMS-1612-FC 162

C. Malpractice Relative Value Units (RVUs) 

1. Overview 

 Section 1848(c) of the Act requires that each service paid under the PFS be comprised 

of three components: work; PE; and malpractice (MP) expense. As required by section 

1848(c) of the Act, beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs 

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

corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also requires that we review, 

and if necessary adjust, RVUs no less often than every 5 years. For CY 2015, we are proposing 

to implement the third comprehensive review and update of MP RVUs. For details about prior 

updates, see the CY 2010 final rule with comment period (74 FR 33537). 

2. Methodology for the Proposed Revision of Resource-Based Malpractice RVUs 

The proposed MP RVUs were calculated by a CMS contractor based on updated MP 

premium data obtained from state insurance rate filings. The methodology used in calculating 

the proposed CY 2015 review and update of resource-based MP RVUs largely paralleled the 

process used in the CY 2010 update. The calculation required using information on specialtyspecific MP premiums linked to a specific service based upon the relative risk factors of the 

various specialties that furnish a particular service. Because MP premiums vary by state and 

specialty, the MP premium information were weighted geographically and by specialty. 

Accordingly, the proposed MP RVUs were based upon three data sources: CY 2011 and CY 

2012 MP premium data; CY 2013 Medicare payment and utilization data; and CY 2015 

proposed work RVUs and geographic practice cost indices (GPCIs). 

Similar to the previous update, we calculated the proposed MP RVUs using 

specialty-specific MP premium data because they represent the actual expense incurred by 

practitioners to obtain MP insurance. We obtained and used MP premium data from state 
CMS-1612-FC 163

departments of insurance rate filings, primarily for physicians and surgeons. When the state 

insurance departments did not provide data, we used state rate filing data from the Perr and 

Knight database, which derives its data from state insurance departments. We used information 

obtained from MP insurance rate filings with effective dates in 2011 and 2012. These were the 

most current data available during our data collection process. 

We collected MP insurance premium data from all 50 States, the District of Columbia, 

and Puerto Rico. Rate filings were not available in American Samoa, Guam, or the Virgin 

Islands. Premiums were for $1 million/$3 million, mature, claims-made policies (policies 

covering claims made, rather than those covering services furnished, during the policy term). A 

$1 million/$3 million liability limit policy means that the most that would be paid on any claim 

is $1 million and the most that the policy would pay for claims over the timeframe of the policy 

is $3 million. We made adjustments to the premium data to reflect mandatory surcharges for 

patient compensation funds (funds to pay for any claim beyond the statutory amount, thereby 

limiting an individual physician’s liability in cases of a large suit) in states where participation in 

such funds is mandatory. We attempted to collect premium data representing at least 50 percent 

of the medical MP premiums paid. 

We included premium information for all physician and NPP specialties, and all risk 

classifications available in the collected rate filings. Most insurance companies provided 

crosswalks from insurance service office (ISO) codes to named specialties. We matched these 

crosswalks to Medicare primary specialty designations (specialty codes). We also used 

information we obtained regarding surgical and nonsurgical classes. Some companies provided 

additional surgical subclasses; for example, distinguishing family practice physicians who 

furnish obstetric services from those who do not. 
CMS-1612-FC 164

Although we collected premium data from all states and the District of Columbia, not all 

specialties had premium data in the rate filings from all states. Additionally, for some 

specialties, MP premiums were not available from the rate filings in any state. Therefore, for 

specialties for which there was not premium data for at least 35 states, and specialties for which 

there was not distinct premium data in the rate filings, we crosswalked the specialty to a similar 

specialty, conceptually or by available premium data, for which we did have sufficient and 

reliable data. Additionally, we crosswalked three specialties − physician assistant, registered 

dietitian and optometry − for which we had data from at least 35 states to a similar specialty type 

because the available data contained such extreme variations in premium amounts that we found 

it to be unreliable. The range in premium amounts for registered dietitians is $85 to $20,813 

(24,259 percent), for physician assistants is $614 to $35,404 (5,665 percent), and for optometry 

is $189 to $10,798 (5,614 percent). We crosswalked these specialties to allergy and 

immunology, the specialty with the lowest premiums for which we had sufficient and reliable 

data. 

Our proposed methodology for updating the MP RVUs conceptually followed the 

specialty-weighted approach, used in the CY 2010 update. The specialty-weighted approach 

bases the MP RVUs for a given service upon a weighted average of the risk factors of all 

specialties furnishing the service. This approach ensures that all specialties furnishing a given 

service are accounted for in the calculation of the MP RVUs. We also continued to use the risk 

factor of the dominant specialty for rarely billed services (that is, when CY 2013 claims data 

reflected allowed services of less than 100). 

We proposed minor refinements for updating the CY 2015 MP RVUs as compared to the 

previous update. These refinements included calculating a combined national average surgical 

premium and risk factor for neurosurgery and neurology and updating the list of invasive 
CMS-1612-FC 165

cardiology service HCPCS codes (for example, cardiac catheterization and angioplasty) to be 

classified as surgery for purposes of assigning service level risk factors. Additionally, we 

proposed to classify injection procedures used in conjunction with cardiac catheterization as 

surgery (for purposes of assigning a service specific risk factor). To calculate the risk factor for 

TC services we proposed to use the mean umbrella non-physician MP premiums obtained from 

Radiology Business Management Association (RBMA) survey data, used for the previous MP 

RVU update in 2010, and adjusted the premium data to reflect the change in non-surgical 

premiums for all specialties since the previous MP RVU update. 

As discussed in the CY 2015 proposed rule (79 FR 40354 through 40355), we did not 

include an adjustment under the anesthesia fee schedule to reflect updated MP premium 

information and stated that we intend to propose an anesthesia adjustment for MP in the CY 

2016 PFS proposed rule. We also requested comments on how to reflect updated MP premium 

amounts under the anesthesiology fee schedule. 

We posted our contractors report, “Report on the CY 2105 Update of Malpractice RVUs” 

on the CMS website. The report on MP RVUs for the CY 2015 proposed rule and the proposed 

MP premium amounts and specialty risk factors are accessible from the CMS website under the 

supporting documents section of the CY 2015 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. A more detailed explanation of our proposed MP 

RVU update can be found in the CY 2015 PFS proposed rule (79 FR 40349 through 40355). 

3. Response to Public Comments 

We received over 70 industry comments on the CY 2015 proposed MP RVU update. A 

summary of the comments we received on the proposed MP RVU update and our responses are 

discussed below. 
CMS-1612-FC 166

Comment: Two commenters supported our proposal to combine the surgical premium 

data for neurosurgery and neurology for establishing the surgical risk factor for neurosurgery. 

Response: We agree with the commenters and will finalize our approach for determining 

the surgical premium for neurosurgery as proposed. We will combine surgical premiums for 

neurology and neurosurgery to calculate a national average surgical premium and risk factor for 

neurosurgery. 

Comment: Three commenters requested that we phase in the reduction for 

ophthalmology and optometry services over 2 years. The commenters stated that the reduction is 

due in part to an error we made in calculating the MP RVUs for ophthalmology and optometry 

codes under the previous MP RVU update in CY 2010. The commenters stated that an 

immediate implementation of the correction would result in significant payment reductions for 

ophthalmologists. 

Response: We note that for the CY 2015 MP RVU update we did not correct the mistake 

that was made in CY 2010. For the CY 2015 MP update we recalculated the MP RVUs based 

upon the most recently available data for all services, including ophthalmic services. 

Accordingly, the proposed MP RVU update reflects the use of updated MP premium data and 

risk factors by specialty and is not affected in any way by the CY 2010 MP RVUs. In doing so, 

even though the proposed CY 2015 ophthalmology non-surgical risk factor was 14 percent 

greater than the CY 2010 non-surgical risk factor and the proposed surgical risk factor was 17 

percent greater, the proposed MP RVUs for most services with significant ophthalmology 

volume decreased because the CY 2010 error resulted in MP RVUs that were higher than they 

should have been. That is, the reduction in MP RVUs for ophthalmology and optometry are 

solely due to overpayments made due to a mistake during the previous MP RVU update rather 

than a proposed change in methodology or the use of updated premium data. We do not believe 
CMS-1612-FC 167

that a previous error is sufficient justification for not fully implementing updated MP RVUs 

based on more recent premium data. Therefore, we will implement the updated MP RVUs for 

ophthalmology and optometry services as proposed. 

Comment: We received comments regarding the application of our specialty weighted 

approach for calculating service level risk factors for surgical services. For instance, the same 

commenters that requested a 2-year phase in of the reduction to ophthalmology services also 

requested that we exclude optometry from calculating the risk factor for ophthalmic surgery. 

One commenter stated that “MP RVUs for cataract and other ophthalmic surgeries are deflated 

because CMS assumes that optometry is providing the surgical portion of the procedure.” The 

commenter also stated that optometrists are involved only during the pre- or post-procedure 

periods of ophthalmic surgery. Another specialty society stated that it appears that CMS’s 

methodology for calculating service level risk factors for surgical services “may include the 

allowed services for surgical assistance possibly discounted to reflect the assistant role under 

payment policy.” The commenter also stated that “specialties that assist at the procedure do not 

perform it, and the assistant’s associated MP risk factor has no bearing on the MP cost for the 

surgeon.” 

Response: The commenter is correct to say that we calculated service level risk factors 

based on the mix of all practitioners billing for a given service and that the specialty weighted 

approach is applied to both surgical and non-surgical services . That is, we apply the risk 

factor(s) of all specialties involved with furnishing the surgical procedure to calculate service 

level risk factors and MP RVUs. For assistants at surgery, we discount the utilization to reflect 

his or her role in furnishing the surgical procedure. Although we agree that MP cost for the 

surgeon may not be affected by the surgical assistant’s MP cost, we do not agree with the 

suggestion that assistants at surgery should be excluded from our specialty weighted approach 
CMS-1612-FC 168

for determining service level MP risk factors and MP RVUs for surgical services. We believe it 

is appropriate to apply the specialty risk factor(s) of all practitioners participating in and 

receiving a payment for the surgical procedure for purposes of determining a service level risk 

factor and thus the payment for that service. If we were to exclude the risk factors of some 

specialties that bill a specific code from the calculation of the service level risk factor, the 

resulting MP RVU would not reflect all utilization. Similarly, we also disagree with the 

suggestion that pre- and post- utilization should be removed from determining MP RVUs for 

ophthalmic surgical services. The resources associated with pre- and post-operative periods for 

ophthalmic surgery are included in the total RVUs for the global surgical package. Accordingly, 

if we did not include the portion of utilization attributed to pre- and post-operative visits in the 

calculation of service level risk factors, the MP RVUs for global surgery would overstate the MP 

costs. 

We note that in both of these cases by using the discounted utilization file the weighted 

average that we use reflects only the proportion of the utilization by these practitioners and only 

at the payment rate made. Including specialty utilization for all practitioners involved in 

furnishing the global service reflects the MP risk for the entire global service. 

Comment: We received two comments regarding how risk factors are assigned to 

existing services without Medicare utilization. The commenters stated that we crosswalk to the 

risk factor of an analogous source code with Medicare utilization for new codes but assign the 

average risk factor for all physicians to existing services without Medicare utilization. The 

commenters contend that “it is inappropriate for a service to have fluctuating MP risk factors 

simply due to whether it is reported in Medicare claims data for a given year.” The commenters 

requested that we crosswalk existing services without Medicare utilization to a recommended 

source code. 
CMS-1612-FC 169

Response: We used the most recently available Medicare claims data (that is, from CY 

2013) to determine the service level risk factors, either based on the risk factors of the actual mix 

of practitioners furnishing the service, or in the case of low volume services, the risk factor of the 

dominant specialty. We disagree with the commenters’ suggestion to assign the risk factor of a 

recommended specialty to an existing service without Medicare utilization as indicated by our 

most recently available claims data. In the absence of Medicare utilization we continue to 

believe that the most appropriate risk factor is the weighted average risk factor for all service 

codes. The proposed weighted average risk factor for all service codes was 2.11. Using the 

weighted average risk factor for all services effectively neutralizes the impact of updated MP 

premiums and risk factors for any specific specialty (or mix of specialties). 

Comment: The AMA and the RUC and other commenters agreed with the majority of 

our proposed claims based dominant specialty designations for codes with less than 100 allowed 

services; however, the commenters disagreed with our proposed dominant specialty for some 

services. The commenters believe that some claims have been miscoded, resulting in erroneous 

specialty designations. One commenter stated that using the dominant specialty from the claims 

data resulted in unjustifiably low MP RVUs for congenital heart surgery. The commenter stated 

that congenital heart surgery can only be done by a heart surgeon and requested that we override 

the dominant specialty in our claims data and use the RUCs recommended specialty. 

Response: As discussed in the previous response, we proposed to use CY 2013 claims 

data to determine the service level MP risk factors, either based on the mix of practitioners 

furnishing the service, or in the case of low volume services, assigning the risk factor of the 

dominant specialty. We continue to believe that use of actual claims data to determine the 

dominant specialty is preferable to using a “recommended” specialty. However, we recognize 

that anomalies in the claims data can occur that would affect the dominant specialty for low 
CMS-1612-FC 170

volume services, and therefore resulting in the need for a subjective review of some services in 

place of a complete reliance on claims data. To that end, we reviewed the commenter’s 

recommendations for overriding the dominant specialty from our claims data with a 

recommended specialty. After careful consideration of the comments, we will override the 

dominant specialty from Medicare claims data when the dominant specialty from our claims data 

is inconsistent with a specialty that could be reasonably expected to furnish the service. For 

example, our claims data indicates that pulmonary disease is the dominant specialty for HCPCS 

code 33622 (Reconstruction of complex cardiac anomaly), however as the commenter 

mentioned, this service is furnished by heart surgeons. A complete listing of low volume 

services for which we will override the claims based dominant specialty with the recommended 

specialty to assign a service level risk factor is illustrated in Table 12. 

 
CMS-1612-FC 171

TABLE 12: Low Volume Service Codes Where Assigned Specialty Used Rather than 

Claims Based Dominant Specialty 

HCPCS 

Code Short Descriptor 

Claims Based Dominant 

Specialty Assigned Specialty 

25490 Reinforce radius Otolaryngology Orthopedic Surgery 

26556 Toe joint transfer Pulmonary Disease Orthopedic Surgery 

31320 Diagnostic incision larynx Cardiology Otolaryngology 

33620 Apply r&l pulm art bands Anesthesiology Cardiac Surgery 

33621 Transthor cath for stent Cardiology Cardiac Surgery 

33622 Redo compl cardiac anomaly Pulmonary Disease Cardiac Surgery 

33697 Repair of heart defects Cardiology Cardiac Surgery 

33766 Major vessel shunt General Surgery Cardiac Surgery 

36261 Revision of infusion pump General Practice General Surgery 

43341 Fuse esophagus & intestine Gastroenterology Thoracic Surgery 

43350 Surgical opening esophagus General Practice General Surgery 

49491 Rpr hern preemie reduc General Practice General Surgery 

50686 Measure ureter pressure Internal Medicine Urology 

54352 Reconstruct urethra/penis Pediatric Medicine Urology 

54380 Repair penis Gastroenterology Urology 

61000 Remove cranial cavity fluid Family Practice Neurosurgery 

61558 Excision of skull/sutures Family Practice Neurosurgery 

61567 Incision of brain tissue Cardiology Neurosurgery 

74710 X-ray measurement of pelvis Thoracic Surgery Diagnostic Radiology 

96003 Dynamic fine wire emg Cardiology Physical Therapist/Independent Practice 

96420 Chemo ia push technique Urology Hematology Oncology 

99170 Anogenital exam child w imag Ophthalmology Pediatric Medicine 

99461 Init nb em per day non-fac Cardiac Electrophysiology Pediatric Medicine 

Comment: Some commenters requested that we crosswalk gynecological oncology to 

general surgery, instead of crosswalking to obstetrics/ gynecology because gynecological 

oncology is more akin to general surgery procedures than obstetrics/gynecology. One specialty 

society stated that gynecological oncologists are predominantly cancer surgeons with MP risk 

similar to general surgery. 

Response: We agree with the commenters and will crosswalk gynecological oncology to 

the general surgery premium data and risk factor. 
CMS-1612-FC 172

Comment: One commenter requested that we crosswalk clinical laboratory to pathology 

instead of the risk factor used for TC services because clinical laboratories and pathologists 

render essentially identical medical procedures that are paid on the Medicare PFS. 

Response: We believe that the MP risk for clinical laboratories is more akin to the MP 

risk of radiation therapy centers, mammography screening centers and IDTFs, for which we 

assigned the TC risk factor, than to the MP risks for pathologists. The commenters did not 

provide sufficient rationale to support that MP risk for clinical laboratories is similar to the MP 

risk of pathologists. Therefore, we will crosswalk clinical laboratory to the TC risk factor as 

proposed. 

Comment: One commenter encouraged us to crosswalk the interventional pain 

management specialty to a specialty that more closely reflects the risks and services associated 

with interventional pain management, such as interventional radiology or a comparable surgical 

subspecialty. 

Response: We believe that the MP risk associated with interventional pain management 

is conceptually similar to the MP risk for anesthesiology more so than to the MP risk for 

interventional radiology. Given that the commenters did not provide sufficient rationale to 

support that MP risk for interventional pain management is similar to interventional radiology or 

to a comparable surgical specialty, we will crosswalk interventional pain management to 

anesthesiology as proposed. 

Comment: We received contrasting comments on our proposal to crosswalk NPPs to the 

premium and risk factor calculated for allergy/immunology. For instance, one commenter 

acknowledged the difficulty in identifying comprehensive, accurate premium data across the 

majority of states, especially for NPPs. To that end, the commenter supported our decision to 

crosswalk the MP premiums of NPPs to the lowest physician risk factor, allergy/immunology. 
CMS-1612-FC 173

Another commenter, specifically supported crosswalking registered dieticians to the risk factor 

calculated for allergy/immunology. 

In contrast, the AMA and other commenters did not support crosswalking NPPs with 

insufficient or unreliable premium data to the premium amounts and risk factor used for 

allergy/immunology. The commenters stated that allergy/immunology premiums overstate NPP 

premiums and requested that we use the generally lower MP survey data from the Physician 

Practice Information Survey (PPIS) for NPPs instead of crosswalking NPPs to the lowest 

physician specialty (allergy/immunology) or use some other measure of central tendency within 

the existing collected premium data to determine accurate MP premium risk factors for NPPs. 

Another commenter suggested that we work with the AMA to obtain the necessary data to ensure 

the process for reviewing and updating MP rates is accurate for all providers. 

Response: As discussed previously in this section, the resource-based MP RVUs are 

based on verifiable MP premium data. We do not believe it would be appropriate to base the MP 

RVUs for nonphysician specialties on survey data and use premium data for all other specialties. 

Therefore, we do not agree with the commenters that suggested using survey data for NPPs and 

will finalize the specialty crosswalks for NPPs as proposed. However, in light of the 

commenter’s suggestions, we will explore ways to enhance our MP premium data collection 

efforts to obtain better premium data for NPPs for future updates. We will also explore other 

potential measures of central tendency for determining the “indexed” specialty as an alternative 

to using the premium values of the lowest specialty. 

Comment: We received two comments regarding the data and or methodology used to 

calculate the TC and PC of diagnostic services. One specialty group noted that the proposed MP 

RVUs for the TC of some diagnostic services increased while the MP RVUs for the PC 

decreased. Specifically, the commenter questioned why the MP RVUs for the PC of diagnostic 
CMS-1612-FC 174

cardiac catheterization as described by HCPCS codes 93451 through 93461 decreased by 6 to 12 

percent while the TC portion for these codes increased by 20 to 33 percent. The commenter 

encouraged us to review the reasons for this shift to TC MP RVUs. Additionally, the RBMA 

submitted updated MP premium information collected from IDTFs in 2014. The RBMA 

requested that we use the recently obtained data reflecting the median “50th percentile” premium 

data for “umbrella non-physician MP liability” for calculating CY 2015 MP RVUs for TC 

services. 

 Response: To calculate the risk factor for TC services we used the mean umbrella nonphysician MP premiums obtained from the RBMA survey data (used for the previous MP RVU 

update in 2010) and adjusted the data to reflect the change in non-surgical premiums for all 

specialties since the previous MP RVU update, for example, $9,374 deflated by -20.41 percent = 

$7,455. However, given that the premiums of the lowest physician specialty 

(allergy/immunology) decreased by more than 20 percent, the proposed CY 2015 risk factor for 

TC services increased from the previous update in CY 2010 from 0.86 to 0.91, resulting in minor 

increases in MP RVUs for TC services. However, given that the MP RVUs for TC services are 

generally low, any increase to the MP RVUs could result in a significant percentage increase. 

For example, the proposed CY 2015 MP RVU for HCPCS code 93455 increased from 0.04 to 

0.05 yielding a 25 percent increase. Therefore, a minor increase in MP RVUs for a TC service 

could result in a significant percentage change. 

 We believe that using the updated RBMA premium data without further study is 

problematic because the updated data reflects only the median umbrella non-physician MP 

premium, rather than the mean as was used for the 2010 MP RVU update and the proposed 2015 

MP RVU update. 
CMS-1612-FC 175

 We believe further study is necessary to reconcile comments on the use of updated 

RBMA premium data for TC services (which would result in an increase MP RVU for TC 

services) and our current methodology for calculating the risk factor for PC services relative to 

the global service and TC service. Therefore, we will finalize the TC premium data as proposed 

and maintain our current methodology for calculating the PC risk factor. We will consider the 

request to use the updated premium information from RBMA and alternatives to our current 

methodology for calculating the PC risk factor as part of our further study and would propose 

any changes through future rulemaking. 

Comment: Several commenters supported our proposal to classify cardiac catheterization 

and angioplasty services as surgical procedures for the purpose of establishing service level risk 

factors. The commenters also agreed with our proposal to apply the surgical risk factor to 

injection procedures used in conjunction with cardiac catheterization. The same commenters 

identified additional cardiac catheterization and angioplasty services that were not included on 

the proposed list of invasive cardiology services. Specifically, the commenters requested that we 

consider adding HCPCS codes 92961, 92986, 92987, 92990, 92992, 92993, 92997, and 92998 to 

the list of invasive cardiology procedures classified as surgery for purposes of assigning service 

level risk factors because the MP risk for these services is similar to surgery. 

Response: We agree that the MP risk associated with the cardiac catheterization and 

angioplasty services mentioned by the commenters are more akin to surgical procedures than 

most non-surgical services. Therefore, we will add cardiac catheterization and angioplasty 

services as described by HCPCS codes 92961, 92986, 92987, 92990, 92997, and 92998 to the list 

of services outside of the surgical HCPCS code range to be considered surgery for purposes of 

assigning service level MP risk factors. We note that HCPCS codes 92992 and 92993 are 

contractor-priced codes, wherein the Medicare claims processing contractors establish RVUs and 
CMS-1612-FC 176

payment amounts for these services. Therefore, we are not adding HCPCS codes 92992 and 

92993. 

Comment: One commenter stated that several injection codes were not included in the 

list of services outside of the surgical HCPCS code range considered surgery. The commenter 

requested that we add injection services as described by HCPCS codes 93565, 93566, 93567, and 

93568 to the services considered as surgery. 

Response: The commenter is mistaken. As discussed in the CY 2015 proposed rule (79 

FR 40353 through 40354), we included the injection procedure codes mentioned by the 

commenter on the list of services outside of the surgical HCPCS code range to be considered 

surgery for purposes of assigning service level MP risk factors. 

Comment: One commenter questioned why the MP RVUs decrease for cardiac 

catheterization services as described by HCPCS codes 93530, 93531 and 93580. The commenter 

stated that our proposal to assign the surgical risk factor to invasive cardiology services outside 

of the surgical HCPCS code range should result in an increase in MP RVUs. 

Response: Cardiac catheterizations as described by HCPCS codes 93530, 93531 and 

93580 are currently on the list of invasive cardiology services classified as surgery for purposes 

of assigning service level risk factors. Therefore, the MP RVUs for HCPCS codes 93530, 

93531, 93580 were calculated in the last update using the surgical risk factor applicable to the 

specialty(s) furnishing these services. As discussed previously in this section, the service level 

risk factors reflect the average risk factor (weighted by allowed services) of the specialties 

furnishing a given service. Changes in the specialty mix since the previous MP RVU update in 

2010 resulted in a decrease in MP RVUs for HCPCS codes 93530, 93531, and 93580. That is, 

the percentage of allowed services attributed to cardiology decreased for these service codes 
CMS-1612-FC 177

while the percentage of allowed services furnished by other specialties with risk factors lower 

than cardiology, such as internal medicine and pediatric medicine, increased. 

Comment: Many commenters requested an explanation as to why the MP RVUs 

decreased for 4 out of the 6 newly bundled image guided breast biopsy procedures. The 

commenters stated that given that the MP RVUs assigned to breast biopsy codes are being 

reduced, CMS is not appropriately capturing the risk a physician assumes when performing a 

procedure to diagnose cancer. Several commenters also explained that the misdiagnosis of breast 

cancer is a leading source of MP litigation and that reduction in payment for breast biopsies will 

have an impact on patient care. 

Response: For the image guided breast biopsy procedures as described by HCPCS codes 

19081 through 19086, we used the risk factors from source codes as recommended by the RUC. 

The source codes for breast biopsy codes 19081, 19082, 19083, 19084, 19085 and 19086 are 

HCPCS codes 32553, 64480, 32551, 64480, 36565, and 76812, respectively. Given that the 

proposed risk factors for HCPCS codes 32553, 64480, and 32551 decreased from 2014 to 2015, 

the corresponding “destination” service codes, that is HCPCS codes 19081, 19082, 19083, and 

19084 also decreased. 

 Comment: Several commenters recommended that we implement an annual collection 

and review of MP premium data and rescale the MP RVUs each year, as we do with the PE 

RVUs. The commenters also stated that an annual update would provide additional transparency 

and allow stakeholders to identify potential problems and or improvements to MP RVUs more 

frequently. 

 Response: We appreciate the comments from stakeholders regarding the frequency that 

we currently review changes in MP premium data. As discussed in the CY 2015 PFS proposed 

rule (79 FR 40349 through 40355), there are two main aspects to the update of MP RVUs, 
CMS-1612-FC 178

recalculation of specialty risk factors based upon updated premium data and recalculation of 

service level RVUs based upon the mix of practitioners providing the service. We will consider 

the recommendation from stakeholders to conduct annual MP RVU updates to reflect corrections 

and changes in the mix of practitioners providing services. We will also consider the appropriate 

frequency for collecting new MP premium data. After reviewing these issues, we would address 

potential changes regarding the frequency of MP RVU updates in a future proposed rule. 

Comment: One commenter urged us to calculate risk factors for all specialties approved 

by the American Board Medical Specialties (ABMS) since 2010. The commenter stated that by 

using the approved ABMS specialties, all specialties and subspecialties will be represented, 

including the recently approved sub-specialty of Female Pelvic Medicine and Reconstructive 

Surgery. 

Response: We calculate service level risk factors based on the mix of specialties that 

furnish a given service as indicated by our claims data. Medicare claims data reflects the service 

volume by Medicare primary specialty designations. Therefore, we can only use MP risk factors 

by Medicare primary specialty codes. 

Comment: We received two comments regarding our discussion of how to reflect 

updated MP premium data under the anesthesiology fee schedule. One commenter supported our 

decision to delay the anesthesia MP update and requested to work with us on developing an 

appropriate method for updating the MP component associated with anesthesia fee schedule 

services. Another commenter suggested using mean anesthesia MP premiums per provider over 

a 4- or 5-year period prorated by Medicare utilization to yield the MP expense for anesthesia 

services. The commenter stated that the calculation of premiums over a longer period of time 

renders the average more accurate and less volatile than a calculation over a 1-year period. 
CMS-1612-FC 179

Response: We appreciate the comments on our potential approach for updating the MP 

resource costs for anesthesia fee schedule services. We will consider the commenter’s 

suggestions to use multi-year average premiums as we develop a method for updating MP 

payments for services paid on the anesthesia fee schedule. 

4. Result of Evaluation of Comments 

After consideration of the public comments received on the CY 2015 MP RVU update, 

we are finalizing the CY 2015 MP RVU update as proposed with minor modifications. We are 

crosswalking gynecological oncology to the risk factor for general surgery (instead of the risk 

factor for obstetrics gynecology). We are also adding HCPCS codes 92961, 92986, 92987, 

92990, 92997, and 92998 to the list of services outside of the surgical HCPCS code range 

considered as surgery for purposes of assigning service level risk factors. Additionally, for 

determining the risk factor for low volume services, we are overriding the dominant specialty 

from our claims data with the recommended specialty for the low volume service codes listed in 

Table 12. For all other low volume services, we are finalizing our proposal to use the risk factor 

of the dominant specialty from our Medicare claims data. The MP premium amounts, specialty 

risk factors, and a complete list of service codes outside the surgical HCPCS code range 

considered surgery for the purpose of assigning service level risk factors, may be found on the 

CMS website under the supporting documents section of the CY 2015 PFS final rule with 

comment period. 

 Additional information on the CY 2015 update may be found in our contractor’s 

report, “Final Report on the CY 2105 Update of Malpractice RVUs,” which is available on the 

CMS website. It is also located under the supporting documents section of the CY 2015 PFS 

final rule with comment period located at http://www.cms.gov/PhysicianFeeSched/.
CMS-1612-FC 180

D. Geographic Practice Cost Indices (GPCIs) 

1. Background 

Section 1848(e)(1)(A) of the Act requires us to develop separate Geographic Practice 

Cost Indices (GPCIs) to measure relative cost differences among localities compared to the 

national average for each of the three fee schedule components (that is, work, PE, and MP). 

Although the statute requires that the PE and MP GPCIs reflect the full relative cost differences, 

section 1848(e)(1)(A)(iii) of the Act requires that the work GPCIs reflect only one-quarter of the 

relative cost differences compared to the national average. In addition, section 1848(e)(1)(G) of 

the Act sets a permanent 1.5 work GPCI floor for services furnished in Alaska beginning 

January 1, 2009, and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI floor for 

services furnished in frontier states (as defined in section 1848(e)(1)(I) of the Act) beginning 

January 1, 2011. Additionally, section 1848(e)(1)(E) of the Act provided for a 1.0 floor for the 

work GPCIs, which was set to expire on March 31, 2014. However, section 102 of the PAMA 

extended application of the 1.0 floor to the work GPCI through March 31, 2015. 

Section 1848(e)(1)(C) of the Act requires us to review and, if necessary, adjust the GPCIs 

at least every 3 years. Section 1848(e)(1)(C) of the Act requires that “if more than 1 year has 

elapsed since the date of the last previous adjustment, the adjustment to be applied in the first 

year of the next adjustment shall be 1/2 of the adjustment that otherwise would be made.” We 

completed a review and finalized updated GPCIs in the CY 2014 PFS final rule with comment 

period (78 FR 74390). Since the last GPCI update had been implemented over 2 years prior, CY 

2011 and CY 2012, we phased in 1/2 of the latest GPCI adjustment in CY 2014. We also revised 

the cost share weights that correspond to all three GPCIs in the CY 2014 PFS final rule with 

comment period. We calculated a corresponding geographic adjustment factor (GAF) for each 

PFS locality. The GAFs are a weighted composite of each area’s work, PE and MP GPCIs using 
CMS-1612-FC 181

the national GPCI cost share weights. Although the GAFs are not used in computing the fee 

schedule payment for a specific service, we provide them because they are useful in comparing 

overall areas costs and payments. The actual effect on payment for any actual service will 

deviate from the GAF to the extent that the proportions of work, PE and MP RVUs for the 

service differ from those of the GAF. 

As previously noted, section 102 of the PAMA extended the 1.0 work GPCI floor 

through March 31, 2015. Therefore, the CY 2015 work GPCIs and summarized GAFs were 

revised to reflect the 1.0 work floor. Additionally, as required by sections 1848(e)(1)(G) and 

1848(e)(1)(I) of the Act, the 1.5 work GPCI floor for Alaska and the 1.0 PE GPCI floor for 

frontier states are permanent, and therefore, applicable in CY 2015. 

Comment: A few commenters requested that we extend the 1.0 work GPCI floor beyond 

March 31, 2015. 

Response: As discussed in section II.D.1, the 1.0 work GPCI floor is established by 

statute and expires on March 31, 2015. We do not have authority to extend the 1.0 work GPCI 

floor beyond March 31, 2015. 

As discussed in the CY 2014 PFS final rule with comment period (78 FR 74380) the 

updated GPCIs were calculated by a contractor to CMS. We used updated Bureau of Labor and 

Statistics Occupational Employment Statistics (BLS OES) data (2009 through 2011) as a 

replacement for 2006 through 2008 data for purposes of calculating the work GPCI and the 

employee compensation component and purchased services component of the PE GPCI. We 

also used updated U.S. Census Bureau American Community Survey (ACS) data (2008 through 

2010) as a replacement for 2006 through 2008 data for calculating the office rent component of 

the PE GPCI. To calculate the MP GPCI we used updated malpractice premium data (2011 and 

2012) from state departments of insurance as a replacement for 2006 through 2007 premium 
CMS-1612-FC 182

data. We also noted that we do not adjust the medical equipment, supplies and other 

miscellaneous expenses component of the PE GPCI because we continue to believe there is a 

national market for these items such that there is not a significant geographic variation in relative 

costs. Additionally, we updated the GPCI cost share weights consistent with the modifications 

made to the 2006-based MEI cost share weights in the CY 2014 final rule with comment period. 

As discussed in the CY 2014 final rule with comment period, use of the revised GPCI cost share 

weights changed the weighting of the subcomponents within the PE GPCI (employee wages, 

office rent, purchased services, and medical equipment and supplies). For a detailed explanation 

of how the GPCI update was developed, see the CY 2014 final rule with comment period (78 FR 

74380 through 74391).

2. Proposed Changes to the GPCI Values for the Virgin Islands Payment Locality 

As discussed in the CY 2015 proposed rule (79 FR 40355 through 40356) the current 

methodology for calculating locality level GPCIs relies on the acquisition of county level data 

(when available). Where data for a specific county are not available, we assign the data from a 

similar county within the same payment locality. The Virgin Islands have county level 

equivalents identified as districts. Specifically, the Virgin Islands are divided into 3 districts: 

Saint Croix; Saint Thomas; and Saint John. These districts are, in turn, subdivided into 20 subdistricts. Although the Virgin Islands are divided into these county equivalents, county level 

data for the Virgin Islands are not represented in the BLS OES wage data. Additionally, the 

ACS, which is used to calculate the rent component of the PE GPCI, is not conducted in the 

Virgin Islands, and we have not been able to obtain malpractice insurance premium data for the 

Virgin Islands payment locality. Given the absence of county level wage and rent data and the 

insufficient malpractice premium data by specialty type, we have historically set the three GPCI 

values for the Virgin Islands payment locality at 1.0. 
CMS-1612-FC 183

For CY 2015, we explored using the available data from the Virgin Islands to more 

accurately reflect the geographic cost differences for the Virgin Islands payment locality as 

compared to other PFS localities. Although county level data for the Virgin Islands are not 

represented in the BLS OES wage data, aggregate territory level BLS OES wage data are 

available. We believe that using aggregate territory level data is a better reflection of the relative 

cost differences of operating a medical practice in the Virgin Islands payment locality as 

compared to other PFS localities than the current approach of assigning a value of 1.0. At our 

request, our contractor calculated the work GPCI, and the employee wage component and 

purchased services component of the PE GPCI, for the Virgin Islands payment locality using 

aggregated 2009 through 2011 BLS OES data. 

As discussed in this section, the ACS is not conducted in the Virgin Islands and we have 

not been able to obtain malpractice premium data for the Virgin Islands payment locality. 

Therefore, we assigned a value of 1.0 for the rent index of the PE GPCI and to the MP GPCI. 

Using aggregate territory-level BLS OES wage data resulted in a -2.3 percent decrease in 

the work GPCI, a -4.48 percent decrease in the PE GPCI and a -3.2 percent decrease to the GAF 

for the Virgin Islands payment locality. However, with the application of the 1.0 work GPCI 

floor, there is no change to the work GPCI and the overall impact of using actual BLS OES wage 

data on the Virgin Islands payment locality is only reflected by the change in PE GPCI (-4.48 

percent) resulting in a - 2.00 percent decrease to the GAF. As mentioned previously in this 

section, since we have not been able to obtain malpractice premium data for the Virgin Islands 

payment locality we maintained the MP GPCI at 1.0. As such, we did not propose any changes 

to the MP GPCI. 

 We requested comments on our proposal to use aggregate territory-level BLS OES 

wage data to calculate the work GPCI and the employee wage component and purchased services 
CMS-1612-FC 184

component of the PE GPCI for the Virgin Islands payment locality beginning for CY 2015, and 

for future GPCI updates. However, we did not receive any specific comments on this proposal. 

As discussed above, we believe that using aggregate territory level BLS OES wage data is a 

better reflection of the relative cost differences of operating a medical practice in the Virgin 

Islands payment locality as compared to other PFS localities than the current approach of 

assigning a value of 1.0. Therefore, we will finalize the changes to the GPCI values for the 

Virgin Islands payment locality as proposed. See Addenda D and E for the CY 2015 GPCIs and 

summarized GAFs. Additional information on the changes to GPCI values for the Virgin Islands 

payment locality may be found in our contractor’s report, “Revised Final Report on the CY 2014 

Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which 

is available on the CMS website. It is located under the supporting documents section of the 

CY 2015 PFS final rule with comment period located at 

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

3. Additional Comments 

 We received several comments on topics that are not within the scope of proposals in 

the CY 2015 PFS proposed rule. These comments are briefly discussed below. 

Comment: Many commenters continued to request an increase in the GPCI values for the 

Puerto Rico payment locality. The commenters stated that the cost of practicing medicine in 

Puerto Rico continues to rise. The commenters believe that commercial rent and utility costs, 

and the cost of obtaining medical equipment and supplies are higher in Puerto Rico than many 

states and territories. Commenters contend that the data used to calculate GPCIs do not 

accurately reflect the cost of operating a medical practice in Puerto Rico. 

Response: Aside from proposing to use territory-wide wage data for the Virgin Islands 

payment locality, we finalized the methodology and values for the 7th GPCI update in the CY 
CMS-1612-FC 185

2014 PFS final rule with comment period. We did not propose any changes to the GPCIs for the 

Puerto Rico payment locality, and the commenters on the CY 2015 PFS proposed rule raised the 

same issues they raised in response to the proposed GPCI update that we finalized in CY 2014. 

In the CY 2014 PFS final rule with comment period (78 FR 74380 through 74391), we 

summarized these comments and responded to these issues. 

Comment: A few commenters stated that GPCIs for rural areas are too low which leads 

to reduced numbers of rural practitioners and reduced access to care. Two commenters stated 

that the PE GPCI does not account for differences in practice costs for x-rays and imaging 

studies. The same commenters and another commenter also requested that we replace the 

current method for calculating the work GPCIs with one that reflects the labor market for 

physicians and other health professionals as recommended by MedPAC. Another commenter 

raised questions about state patient compensation fund surcharges for malpractice insurance and 

the implications of those for the MP GPCI values. Additionally, we received a comment about 

the physician fee schedule payment localities. 

 Response: As noted in this section, we finalized the 7th GPCI update in the CY 2014 

PFS final rule with comment period and, other than the proposal relating to the use of territorywide wage data for the Virgin Islands payment locality, we did not propose any further changes 

in the CY 2015 PFS proposed rule. We will consider these points raised by commenters when 

we develop a proposal for the 8th GPCI update. 
CMS-1612-FC 186

E. Medicare Telehealth Services 

1. Billing and Payment for Telehealth Services 

Several conditions must be met in order for Medicare payments to be made for telehealth 

services under the PFS. Specifically, the service must be on the list of Medicare telehealth 

services and meet all of the following additional requirements for coverage: 

● The service must be furnished via an interactive telecommunications system. 

● The practitioner furnishing the service must meet the telehealth requirements, as well 

as the usual Medicare requirements. 

● The service must be furnished to an eligible telehealth individual. 

● The individual receiving the services must be in an eligible originating site. 

When all of these conditions are met, Medicare pays an originating site fee to the 

originating site and provides separate payment to the distant site practitioner furnishing the 

service. 

Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include 

consultations, office visits, office psychiatry services, and any additional service specified by the 

Secretary, when furnished via a telecommunications system. We first implemented this statutory 

provision, which was effective October 1, 2001, in the CY 2002 PFS final rule with comment 

period (66 FR 55246). We established a process for annual updates to the list of Medicare 

telehealth services as required by section 1834(m)(4)(F)(ii) of the Act in the CY 2003 PFS final 

rule with comment period (67 FR 79988). 

As specified at §410.78(b), we generally require that a telehealth service be furnished via 

an interactive telecommunications system. Under §410.78(a)(3), an interactive 

telecommunications system is defined as multimedia communications equipment that includes, 
CMS-1612-FC 187

at a minimum, audio and video equipment permitting two-way, real-time interactive 

communication between the patient and distant site physician or practitioner. 

Telephones, facsimile machines, and electronic mail systems do not meet the definition 

of an interactive telecommunications system. An interactive telecommunications system is 

generally required as a condition of payment; however, section 1834(m)(1) of the Act allows the 

use of asynchronous ‘‘store-and-forward’’ technology when the originating site is part of a 

federal telemedicine demonstration program in Alaska or Hawaii. As specified in regulations at 

§410.78(a)(1), store-and-forward means the asynchronous transmission of medical information 

from an originating site to be reviewed at a later time by the practitioner at the distant site. 

Medicare telehealth services may be furnished to an eligible telehealth individual 

notwithstanding the fact that the practitioner furnishing the telehealth service is not at the same 

location as the beneficiary. An eligible telehealth individual means an individual enrolled under 

Part B who receives a telehealth service furnished at an originating site. 

Practitioners furnishing Medicare telehealth services are reminded that these services are 

subject to the same non-discrimination laws as other services, including the effective 

communication requirements for persons with disabilities of section 504 of the Rehabilitation 

Act and language access for persons with limited English proficiency, as required under Title VI 

of the Civil Rights Act of 1964. For more information, see 

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication. 

Practitioners furnishing Medicare telehealth services submit claims for telehealth services 

to the Medicare Administrative Contractors that process claims for the service area where their 

distant site is located. Section 1834(m)(2)(A) of the Act requires that a practitioner who 

furnishes a telehealth service to an eligible telehealth individual be paid an amount equal to the 
CMS-1612-FC 188

amount that the practitioner would have been paid if the service had been furnished without the 

use of a telecommunications system. 

Originating sites, which can be one of several types of sites specified in the statute where 

an eligible telehealth individual is located at the time the service is being furnished via a 

telecommunications system, are paid a fee under the PFS for each Medicare telehealth service. 

The statute specifies both the types of entities that can serve as originating sites and the 

geographic qualifications for originating sites. With regard to geographic qualifications, 

§410.78(b)(4) limits originating sites to those located in rural health professional shortage areas 

(HPSAs) or in a county that is not included in a metropolitan statistical areas (MSAs). 

Historically, we have defined rural HPSAs to be those located outside of MSAs. 

Effective January 1, 2014, we modified the regulations regarding originating sites to define rural 

HPSAs as those located in rural census tracts as determined by the Office of Rural Health Policy 

(ORHP) of the Health Resources and Services Administration (HRSA) (78 FR 74811). Defining 

‘‘rural’’ to include geographic areas located in rural census tracts within MSAs allows for 

broader inclusion of sites within HPSAs as telehealth originating sites. Adopting the more 

precise definition of ‘‘rural’’ for this purpose expands access to health care services for Medicare 

beneficiaries located in rural areas. HRSA has developed a website tool to provide assistance to 

potential originating sites to determine their geographic status. To access this tool, see the CMS 

website at www.cms.gov/teleheath/. 

An entity participating in a federal telemedicine demonstration project that has been 

approved by, or received funding from, the Secretary as of December 31, 2000 is eligible to be 

an originating site regardless of its geographic location. 

Effective January 1, 2014, we also changed our policy so that geographic eligibility for 

an originating site would be established and maintained on an annual basis, consistent with other 
CMS-1612-FC 189

telehealth payment policies (78 FR 74400). Geographic eligibility for Medicare telehealth 

originating sites for each calendar year is now based upon the status of the area as of December 

31 of the prior calendar year. 

For a detailed history of telehealth payment policy, see 78 FR 74399. 

2. Adding Services to the List of Medicare Telehealth Services 

As noted previously, in the December 31, 2002 Federal Register (67 FR 79988), we 

established a process for adding services to or deleting services from the list of Medicare 

telehealth services. This process provides the public with an ongoing opportunity to submit 

requests for adding services. Under this process, we assign any qualifying request to make 

additions to the list of telehealth services to one of two categories. Revisions to criteria that we 

use to review requests in the second category were finalized in the November 28, 2011 Federal 

Register (76 FR 73102). The two categories are: 

● Category 1: Services that are similar to professional consultations, office visits, and 

office psychiatry services that are currently on the list of telehealth services. In reviewing these 

requests, we look for similarities between the requested and existing telehealth services for the 

roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter, a practitioner with the beneficiary in the 

originating site. We also look for similarities in the telecommunications system used to deliver 

the proposed service; for example, the use of interactive audio and video equipment. 

● Category 2: Services that are not similar to the current list of telehealth services. Our 

review of these requests includes an assessment of whether the service is accurately described by 

the corresponding code when furnished via telehealth and whether the use of a 

telecommunications system to deliver the service produces demonstrated clinical benefit to the 

patient. In reviewing these requests, we look for evidence indicating that the use of a 
CMS-1612-FC 190

telecommunications system in furnishing the candidate telehealth service produces clinical 

benefit to the patient. Submitted evidence should include both a description of relevant clinical 

studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves 

the diagnosis or treatment of an illness or injury or improves the functioning of a malformed 

body part, including dates and findings, and a list and copies of published peer reviewed articles 

relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit 

does not include minor or incidental benefits. 

Some examples of clinical benefit include the following: 

● Ability to diagnose a medical condition in a patient population without access to 

clinically appropriate in-person diagnostic services. 

● Treatment option for a patient population without access to clinically appropriate inperson treatment options. 

● Reduced rate of complications. 

● Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due 

to reduced rate of recurrence of the disease process). 

● Decreased number of future hospitalizations or physician visits. 

● More rapid beneficial resolution of the disease process treatment. 

● Decreased pain, bleeding, or other quantifiable symptom. 

● Reduced recovery time. 

For the list of covered telehealth services, see the CMS website at 

www.cms.gov/teleheath/. Requests to add services to the list of Medicare telehealth services 

must be submitted and received no later than December 31 of each calendar year to be 

considered for the next rulemaking cycle. For example, qualifying requests submitted before the 

end of CY 2014 will be considered for the CY 2016 proposed rule. Each request to add a service 
CMS-1612-FC 191

to the list of Medicare telehealth services must include any supporting documentation the 

requester wishes us to consider as we review the request. Because we use the annual PFS 

rulemaking process as a vehicle for making changes to the list of Medicare telehealth services, 

requestors should be advised that any information submitted is subject to public disclosure for 

this purpose. For more information on submitting a request for an addition to the list of 

Medicare telehealth services, including where to mail these requests, see the CMS website at 

www.cms.gov/telehealth/. 

3. Submitted Requests to the List of Telehealth Services for CY 2015 

Under our existing policy, we add services to the telehealth list on a category 1 basis 

when we determine that they are similar to services on the existing telehealth list with respect to 

the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter. As we stated in the CY 2012 final rule with 

comment period (76 FR 73098), we believe that the category 1 criteria not only streamline our 

review process for publicly requested services that fall into this category, the criteria also 

expedite our ability to identify codes for the telehealth list that resemble those services already 

on this list. 

a. Submitted Requests 

We received several requests in CY 2013 to add various services as Medicare telehealth 

services effective for CY 2015. The following presents a discussion of these requests, and our 

proposals for additions to the CY 2015 telehealth list. Of the requests received, we find that the 

following services are sufficiently similar to psychiatric diagnostic procedures or 

office/outpatient visits currently on the telehealth list to qualify on a category one basis. 

Therefore, we propose to add the following services to the telehealth list on a category 1 basis for 

CY 2015: 
CMS-1612-FC 192

● CPT codes 90845 (Psychoanalysis); 90846 (family psychotherapy (without the patient 

present); and 90847 (family psychotherapy (conjoint psychotherapy) (with patient present); 

● CPT codes 99354 (prolonged service in the office or other outpatient setting requiring 

direct patient contact beyond the usual service; first hour (list separately in addition to code for 

office or other outpatient evaluation and management service); and, 99355 (prolonged service in 

the office or other outpatient setting requiring direct patient contact beyond the usual service; 

each additional 30 minutes (list separately in addition to code for prolonged service); and, 

● HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan 

of service (pps), initial visit; and, G0439 (annual wellness visit, includes a personalized 

prevention plan of service (pps), subsequent visit). 

We also received requests to add services to the telehealth list that do not meet our 

criteria for being on the Medicare telehealth list. We did not propose to add the following 

procedures for the reasons noted: 

● CPT codes 92250 (fundus photography with interpretation and report); 93010 

(electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), 93307 

(echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode 

recording, when performed, complete, without spectral or color Doppler echocardiography; 

93308 (echocardiography, transthoracic, real-time with image documentation (2d), includes mmode recording, when performed, follow-up or limited study); 93320 (Doppler 

echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in 

addition to codes for echocardiographic imaging); complete); 93321 (Doppler echocardiography, 

pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for 

echocardiographic imaging); follow-up or limited study (list separately in addition to codes for 

echocardiographic imaging); and 93325 (Doppler echocardiography color flow velocity mapping 
CMS-1612-FC 193

(list separately in addition to codes for echocardiography). These services include a technical 

component (TC) and a professional component (PC). By definition, the TC portion of these 

services needs to be furnished in the same location as the patient and thus cannot be furnished 

via telehealth. The PC portion of these services could be (and typically would be) furnished 

without the patient being present in the same location. (Note: For services that have a TC and a 

PC, there is sometimes an entirely different code that is used when only the PC portion of the 

service is being furnished, and other times the same CPT code is used with a –26 modifier to 

indicate that only the PC is being billed.) For example, the interpretation by a physician of an 

actual electrocardiogram or electroencephalogram tracing that has been transmitted 

electronically, can be furnished without the patient being present in the same location as the 

physician. Given the nature of these services, it is not necessary to consider including the PC of 

these services for addition to the telehealth list. When these PC services are furnished remotely, 

they do not meet the definition of Medicare telehealth services under section 1834(m) of the Act. 

Rather, these remote services are considered physicians’ services in the same way as services 

that are furnished in-person without the use of telecommunications technology; they are paid 

under the same conditions as in-person physicians’ services (with no requirements regarding 

permissible originating sites), and should be reported in the same way as other physicians’ 

services (that is, without the –GT or –GQ modifiers). 

● CPT codes 96103 (psychological testing (includes psychodiagnostic assessment of 

emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by 

a computer, with qualified health care professional interpretation and report); and, 96120 

(neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with 

qualified health care professional interpretation and report). These services involve testing by 

computer, can be furnished remotely without the patient being present, and are payable in the 
CMS-1612-FC 194

same way as other physicians’ services. These remote services are not Medicare telehealth 

services as defined under the Act; therefore, we need not consider them for addition to the 

telehealth list, and the restrictions that apply to telehealth services do not apply to these services. 

● CPT codes 90887 (interpretation or explanation of results of psychiatric, other medical 

examinations and procedures, or other accumulated data to family or other responsible persons, 

or advising them how to assist patient); 99090 (analysis of clinical data stored in computers (eg, 

ECGs, blood pressures, hematologic data); 99091 (collection and interpretation of physiologic 

data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the 

patient and/or caregiver to the physician or other qualified health care professional, qualified by 

education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of 

time); 99358 (prolonged evaluation and management service before and/or after direct patient 

care; first hour); and 99359 (prolonged evaluation and management service before and/or after 

direct patient care; each additional 30 minutes (list separately in addition to code for prolonged 

service). These services are not separately payable by Medicare. It would be inappropriate to 

include services as telehealth services when Medicare does not otherwise make a separate 

payment for them. 

● CPT codes 96101 (psychological testing (includes psychodiagnostic assessment of 

emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, 

WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering 

tests to the patient and time interpreting these test results and preparing the report); 96102 

(psychological testing (includes psychodiagnostic assessment of emotionality, intellectual 

abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care 

professional interpretation and report, administered by technician, per hour of technician time, 

face-to-face); 96118 (neuropsychological testing (eg, Halstead-Reitan Neuropsychological 
CMS-1612-FC 195

Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the 

psychologist’s or physician’s time, both face-to-face time administering tests to the patient and 

time interpreting these test results and preparing the report); and, 96119 (neuropsychological 

testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and 

Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, 

administered by technician, per hour of technician time, face-to-face). These services are not 

similar to other services on the telehealth list, as they require close observation of how a patient 

responds. The requestor did not submit evidence supporting the clinical benefit of furnishing 

these services on a category 2 basis. As such, we did not propose to add these services to the list 

of telehealth services. 

● CPT codes 57452 (colposcopy of the cervix including upper/adjacent vagina; 57454 

colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and 

endocervical curettage); and, 57460 (colposcopy of the cervix including upper/adjacent vagina; 

with loop electrode biopsy(s) of the cervix). These services are not similar to other services on 

the telehealth service list. Therefore, it would not be appropriate to add them on a category 1 

basis. The requestor did not submit evidence supporting the clinical benefit of furnishing these 

services on a category 2 basis. As such, we did not propose to add these services to the list of 

telehealth services. 

● HCPCS code M0064 (brief office visit for the sole purpose of monitoring or changing 

drug prescriptions used in the treatment of mental psychoneurotic and personality disorders) is 

being deleted for CY 2015. This code was created specifically to describe a service that is not 

subject to the statutory outpatient mental health limitation, which limited payment amounts for 

certain mental health services. Section 102 of the Medicare Improvements for Patients and 

Providers Act (Pub. L. 110– 275, enacted on July 15, 2008) (MIPPA) required that the limitation 
CMS-1612-FC 196

on payment for outpatient mental health treatment to 62.5 percent of incurred expenses, in effect 

since the inception of the Medicare program, be reduced over four years. This limitation on 

payment for mental health treatment created a higher share of beneficiary coinsurance for these 

services than for most other Medicare services paid under the PFS. Effective January 1, 2014, 

100 percent of expenses incurred for mental health treatment services are considered as incurred 

for purposes of Medicare, resulting in the same beneficiary cost sharing for these services as for 

other PFS services. Since the statute was amended to phase out the limitation, and the phase-out 

was complete effective January 1, 2014, Medicare no longer has a need to distinguish services 

subject to the mental health limitation from those that are not. Accordingly, the appropriate CPT 

code can now be used to bill Medicare for the services that would have otherwise been reported 

using M0064 and M0064 will be eliminated as a telehealth service, effective January 1, 2015. 

● Urgent Dermatologic Problems and Wound Care—The American Telemedicine 

Association (ATA) cited several studies to support adding dermatology services to the telehealth 

list. However, the request did not include specific codes. Since we did not have specific codes 

to consider for this request, we cannot evaluate whether the services are appropriate for addition 

to the Medicare telehealth services list. We note that some of the services that the requester had 

in mind may be billed under the telehealth office visit codes or the telehealth consultation 

G-codes. 

In summary, we proposed to add the following codes to the telehealth list on a category 1 

basis: 

● Psychotherapy services CPT codes 90845, 90846 and 90847. 

● Prolonged service office CPT codes 99354 and 99355. 

● Annual wellness visit HCPCS codes G0438 and G0439. 

3. Modifying §410.78 Regarding List of Telehealth Services 
CMS-1612-FC 197

As discussed in section II.E.2. of this final rule with comment period, under the statute, 

we created an annual process for considering the addition of services to the Medicare telehealth 

list. Under this process, we propose services to be added to the list in the proposed rule in 

response to public nominations or our own initiative and seek public comments on our proposals. 

After consideration of public comments, we finalize additions to the list in the final rule. We 

have also revised §410.78(b) each year to include the description of the added services. Because 

the list of Medicare telehealth services has grown quite lengthy, and given the other mechanisms 

by which we can make the public aware of the list of Medicare telehealth services for each year, 

we proposed to revise §410.78(b) by deleting the description of the individual services for which 

Medicare payment can be made when furnished via telehealth. Under this proposal, we would 

continue our current policy to address requests to add to the list of telehealth services through the 

PFS rulemaking process so that the public would have the opportunity to comment on additions 

to the list. We also proposed to revise §410.78(f) to indicate that a list of Medicare telehealth 

codes and descriptors is available on the CMS website. 

The following is a summary of the comments we received regarding the proposed 

addition of services to the list of Medicare telehealth services. 

 Comment: All commenters supported one or more of our proposals to add psychotherapy 

services (CPT codes 90845, 90846 and 90847); prolonged service office (CPT codes 99354 and 

99355); and annual wellness visit (HCPCS codes G0438 and G0439) to the list of Medicare 

telehealth services for CY 2015. 

Response: We appreciate the commenters’ support for the proposed additions to the list 

of Medicare telehealth services. After consideration of the public comments received, we are 

finalizing our CY 2015 proposal to add these services to the list of telehealth services for CY 

2015 on a category 1 basis. 
CMS-1612-FC 198

Comment: Commenters also agreed with our rationale for rejecting other requested 

additions to the telehealth list. However, one commenter disagreed with our decision not to 

propose adding dermatology services, including those furnished using store-and-forward 

technology, to the list of telehealth services. Another commenter objected to our proposal not to 

add psychological testing services to the telehealth services list. 

Response: As we noted in the proposed rule, the request to add dermatology services did 

not include specific codes. Without specific codes to consider, we cannot evaluate whether the 

services are appropriate for addition to the Medicare telehealth services list. We note that some 

of the services that the requester had in mind may be billed under the telehealth office visit codes 

or the telehealth consultation G–codes. 

Concerning payment for services furnished using store-and-forward technology, we note 

that the statute at section 1861(m) of the Act includes store-and-forward technology as a 

telecommunication system for telehealth services only in the case of federal telemedicine 

demonstration programs in Alaska and Hawaii (see §410.78(d)). 

Concerning psychological testing services, we noted that remote services (CPT codes 

96103 and 96120) are not Medicare telehealth services as defined under the Act and thus can be 

furnished when beneficiary is not in the same place as the practitioner. It would also be counterproductive to add these codes to the telehealth list because, if we did, the telehealth originating 

site, geographic, and other restrictions would apply to these services. 

CPT codes 90887, 90991, 93358 and 99359 are not separately payable by Medicare. It 

would be inappropriate to include services as telehealth services when Medicare does not 

otherwise make a separate payment for them. 

Finally, CPT codes 96101, 96102, 96118 and 96119 are not similar to other services on 

the telehealth list, as they require close observation of how a patient responds. The requestor did 
CMS-1612-FC 199

not submit evidence supporting the clinical benefit of furnishing these services on a category 2 

basis. As such, we did not propose to add these services to the list of telehealth services. 

We received other public comments on matters related to Medicare telehealth services 

that were not the subject of proposals in the CY 2015 PFS proposed rule. Because we did not 

make any proposals regarding these matters, we generally do not summarize or respond to such 

comments in the final rule. However, we are summarizing and responding to the following 

comments to acknowledge the interests and concerns of the commenters, and a mechanism to 

address some of those concerns. 

Many commenters supported the overall expansion of telehealth by: 

● Removing geographic restrictions to include both rural and urban areas. 

● Revising permissible originating sites to include a patient’s home, domiciliary care and 

first responder vehicles. 

● Adopting a broader definition of telehealth technologies to include services provide via 

mobile technology, including emails, phone calls, and store-and-forward technologies. 

● Adding physical and occupational therapists as practitioners who can remotely furnish 

telehealth services. 

● Adding more services to the telehealth list, including services under category 2. 

● Prioritizing coverage of services that include care coordination with the patient’s 

medical home and/or existing treating physicians. 

● Considering the use of telehealth technology for the purpose of furnishing direct 

supervision of services furnished by on-site practitioners. 

● Using demonstration projects under CMS’s Center for Medicare and Medicaid 

Innovation (CMMI) to collect clinical evidence on the effect of expanding telehealth and to 

address how telemedicine can be integrated into new payment and delivery models. 
CMS-1612-FC 200

Response: We appreciate the commenters’ suggestions. As some commenters noted, we 

do not have authority to implement many of these revisions under the current statute. The CMS 

Innovation Center is responsible for developing and testing new payment and service delivery 

models to lower costs and improve quality for Medicare, Medicaid, and CHIP beneficiaries. As 

part of that authority, the CMS Innovation Center can consider potential new payment and 

service delivery models to test changes to Medicare’s telehealth payment policies. 

In summary, after consideration of the comments we received, we are finalizing our 

proposal to add psychotherapy services CPT codes 90845, 90846 and 90847; prolonged service 

office CPT codes 99354 and 99355; and annual wellness visit HCPCS codes G0438 and G0439 

to the list of Medicare telehealth services. 

In addition, we are finalizing our proposal to change our regulation at §410.78(b) by 

deleting the description of the individual services for which Medicare payment can be made 

when furnished via telehealth. We will continue our current policy to address requests to add 

services to the list of Medicare telehealth services through the PFS rulemaking process so that 

the public has the opportunity to comment on additions to the list. We are also finalizing our 

proposal to revise §410.78(f) to indicate that a list of Medicare telehealth codes and descriptors is 

available on the CMS website. 

We remind all interested stakeholders that we are currently soliciting public requests to 

add services to the list of Medicare telehealth services. To be considered during PFS rulemaking 

for CY 2016, these requests must be submitted and received by December 31, 2014. Each 

request to add a service to the list of Medicare telehealth services must include any supporting 

documentation the requester wishes us to consider as we review the request. For more 

information on submitting a request for an addition to the list of Medicare telehealth services, 
CMS-1612-FC 201

including where to mail these requests, we refer readers to the CMS website at 

www.cms.gov/telehealth/. 

5. Telehealth Originating Site Facility Fee Payment Amount Update 

Section 1834(m)(2)(B) of the Act establishes the Medicare telehealth originating site 

facility fee for telehealth services furnished from October 1, 2001, through December 31 2002, at 

$20.00. For telehealth services furnished on or after January 1 of each subsequent calendar year, 

the telehealth originating site facility fee is increased by the percentage increase in the MEI as 

defined in section 1842(i)(3) of the Act. The MEI increase for 2015 is 0.8 percent. Therefore, 

for CY 2015, the payment amount for HCPCS code Q3014 (Telehealth originating site facility 

fee) is 80 percent of the lesser of the actual charge or $24.83. The Medicare telehealth 

originating site facility fee and MEI increase by the applicable time period is shown in Table 13. 

TABLE 13: The Medicare Telehealth Originating Site Facility Fee and MEI Increase by 

the Applicable Time Period 

Facility Fee MEI 

Increase 

Period 

$20.00 N/A 10/01/2001 – 12/31/2002 

$20.60 3.0% 01/01/2003 – 12/31/2003 

$21.20 2.9% 01/01/2004 – 12/31/2004 

$21.86 3.1% 01/01/2005 – 12/31/2005 

$22.47 2.8% 01/01/2006 – 12/31/2006 

$22.94 2.1% 01/01/2007 – 12/31/2007 

$23.35 1.8% 01/01/2008 – 12/31/2008 

$23.72 1.6% 01/01/2009 – 12/31/2009 

$24.00 1.2% 01/01/2010 – 12/31/2010 

$24.10 0.4% 01/01/2011 – 12/31/2011 

$24.24 0.6% 01/01/2012 – 12/31/2012 

$24.43 0.8% 01/01/2013 – 12/31/2013 

$24.63 0.8% 01/01/2014 – 12/31/2014 

$24.83 0.8% 01/01/2015 – 12/31/2015 
CMS-1612-FC 202

F. Valuing New, Revised and Potentially Misvalued Codes 

Establishing valuations for newly created and revised CPT codes is a routine part of 

maintaining the PFS. Since inception of the PFS, it has also been a priority to revalue services 

regularly to assure that the payment rates reflect the changing trends in the practice of medicine 

and current prices for inputs used in the PE calculations. Initially, this was accomplished 

primarily through the five-year review process, which resulted in revised RVUs for CY 1997, 

CY 2002, CY 2007, and CY 2012. Under the five-year review process, revisions in RVUs were 

proposed in a proposed rule and finalized in a final rule. In addition to the five-year reviews, in 

each year beginning with CY 2009, CMS and the RUC have identified a number of potentially 

misvalued codes using various identification screens, such as codes with high growth rates, 

codes that are frequently billed together, and high expenditure codes. Section 3134 of the 

Affordable Care Act codified the misvalued code initiative in section 1848(c)(2)(K) of the Act. 

In the CY 2012 rulemaking process, we proposed and finalized consolidation of the fiveyear review and the potentially misvalued code activities into an annual review of potentially 

misvalued codes to avoid redundancies in these efforts and better accomplish our goal of 

assuring regular assessment of code values. Under the consolidated process, we issue interim 

final RVUs for all revaluations and new codes in the PFS final rule with comment period, and 

make payment based upon those values during the calendar year covered by the final rule. 

(Changes in the PFS methodology that may affect valuations of a variety of codes are issued as 

proposals in the proposed rule.) We consider and respond to any public comments on the interim 

final values in the final rule with comment period for the subsequent year. When consolidating 

these processes, we indicated that it was appropriate to establish interim values for new, revised, 

and potentially misvalued codes because of the incongruity between the PFS rulemaking cycle 

and the release of codes by the AMA CPT Editorial Panel and the RUC review process. We 
CMS-1612-FC 203

stated that if we did not establish interim final values for revalued codes in the final rule with 

comment period, “a delay in implementing revised values for codes that have been identified as 

misvalued would perpetuate payment for the services at a rate that does not appropriately reflect 

the relative resources involved in furnishing the service and would continue unwarranted 

distortion in the payment for other services across the PFS.” We also reiterated that if we did not 

establish interim final values for new and revised codes, we would either have to delay the use of 

new and revised codes for one year, or permit each Medicare contractor to establish its own 

payment rate for these codes. We stated, “We believe it would be contrary to the public interest 

to delay adopting values for new and revised codes for the initial year, especially since we have 

an opportunity to receive significant input from the medical community [through the RUC] 

before adopting the values, and the alternatives could produce undesirable levels of uncertainty 

and inconsistency in payment for a year.” 

1. Current Process for Valuing New, Revised, and Potentially Misvalued Codes 

Under the process finalized in the CY 2012 PFS final rule with comment period, in each 

year’s proposed rule, we propose specific codes and/or groups of codes that we believe may be 

appropriate to consider under our potentially misvalued code initiative. As part of our process 

for developing the list of proposed potentially misvalued codes, we consider public nominations 

for potentially misvalued codes under a process also established in the CY 2012 PFS final rule 

with comment period. If appropriate, we include such codes in our proposed potentially 

misvalued code list. In the proposed rule, we solicit comments on the proposed potentially 

misvalued codes. We then respond to comments and establish a final list of potentially 

misvalued codes in the final rule for that year. These potentially misvalued codes are reviewed 

and revalued, if appropriate, in subsequent years. In addition, the RUC regularly identifies 
CMS-1612-FC 204

potentially misvalued codes using screens that have previously been identified by CMS, such as 

codes performed together more than 75 percent of the time. 

Generally, the first step in revaluing codes that have been identified as potentially 

misvalued is for the RUC to review these codes through its standard process, which includes 

active involvement of national specialty societies for the specialties that ordinarily use the codes. 

Frequently, the RUC’s discussion of potentially misvalued codes will lead the CPT Editorial 

Panel to make adjustments to the codes involved, such as bundling of codes, creation of new 

codes or revisions of code descriptors. The AMA has estimated that 75 percent of all annual 

CPT coding changes result from the potentially misvalued code initiative. 

The RUC provides CMS with recommendations for the work values and direct PE inputs 

for the codes we have identified as potentially misvalued codes or, in the case of a coding 

revision, for the new or revised codes that will replace these potentially misvalued codes. (This 

process is also applied to codes that the RUC identifies using code screens that we have 

identified, and to new or revised codes that are issued for reasons unrelated to the potentially 

misvalued code process.) Generally, we receive the RUC recommendations concurrently for all 

codes in the same family as the potentially misvalued code(s). We believe it is important to 

evaluate and establish appropriate work and MP RVUs and direct PE inputs for an entire code 

family at the same time to avoid rank order anomalies and to maintain appropriate relativity 

among codes. We generally receive the RUC recommendations for the code or replacement 

code(s) within a year or two following the identification of the code as potentially misvalued. 

We consider the RUC recommendations along with other information that we have, 

including information submitted by other stakeholders, and establish interim final RVUs for the 

potentially misvalued codes, new codes, and any other codes for which there are coding changes 

in the final rule with comment period for a year. There is a 60−day period for the public to 
CMS-1612-FC 205

comment on those interim final values after we issue the final rule. For services furnished during 

the calendar year following the publication of interim final rates, we pay for services based upon 

the interim final values established in the final rule. In the final rule with comment period for the 

subsequent year, we consider and respond to public comments received on the interim final 

values, and make any appropriate adjustments to values based on those comments. We then 

typically finalize the values for the codes. 

As we discussed in the CY 2012 PFS final rule with comment period, we adopted this 

consolidated review process to combine all coding revaluations into one annual process allowing 

for appropriate consideration of relativity in and across code families. In addition, this process 

assures that we have the benefit of the RUC recommendations for all codes being valued. 

2. Concerns with Current Process. 

Some stakeholders who have experienced reductions in payments as the result of interim 

final valuations have objected to the process by which we revise or establish values for new, 

revised, and potentially misvalued codes. Some have stated that they did not receive notice of 

the possible reductions before they occurred. Generally, stakeholders are aware that we are 

considering changes in the payment rates for particular services either because CPT has made 

changes to codes or because we have identified the codes as potentially misvalued. As the RUC 

considers the appropriate value for a service, representatives of the specialties that use the codes 

are involved in the process. The RUC usually surveys physicians or other practitioners who 

furnish the services described by the codes regarding the time it takes to furnish the services, and 

representatives of the specialty(ies) also participate in the RUC meetings where 

recommendations for work RVUs and direct PE inputs are considered. Through this process, 

representatives of the affected specialties are generally aware of the RUC recommendations. 
CMS-1612-FC 206

Some stakeholders have stated that even when they are aware that the RUC has made 

recommendations, they have no opportunity to respond to the RUC recommendations before we 

consider them in adopting interim final values because the RUC actions and recommendations 

are not public. Some stakeholders have also said that the individuals who participate in the RUC 

review process are not able to share the recommendations because they have signed a 

confidentiality agreement. We note, however, that at least one specialty society has raised funds 

via its website to fight a “pending cut” based upon its knowledge of RUC recommendations for 

specific codes prior to CMS action on the recommendation. Additionally, some stakeholders 

have pointed out that some types of suppliers that are paid under the PFS are not permitted to 

participate in the RUC process at all. 

We recognize that some stakeholders, including those practitioners represented by 

societies that are not participants in the RUC process, may not be aware of the specifics of the 

RUC recommendations before we consider them in establishing interim final values for new, 

revised, and potentially misvalued codes. We note that, as described above, before we review a 

service as a potentially misvalued code, we go through notice and comment rulemaking to 

identify it as a potentially misvalued code. Thus, the public has notice and an opportunity to 

comment on whether we should review the values for a code before we finalize the code as 

potentially misvalued and begin the valuation process. As a result, all stakeholders should be 

aware that a particular code is being considered as potentially misvalued and that we may 

establish revised interim final values in a subsequent final rule with comment period. As noted 

above, there may be some codes for which we receive RUC recommendations based upon their 

identification by the RUC through code screens that we establish. These codes are not 

specifically identified by CMS through notice and comment rulemaking as potentially misvalued 

codes. We recognize that if stakeholders are not monitoring RUC activities or evaluating 
CMS-1612-FC 207

Medicare claims data, they may be unaware that these codes are being reviewed and could be 

revalued on an interim final basis in a final rule with comment period for a year. 

In recent years, we have increased our scrutiny of the RUC recommendations and have 

increasingly found cause to modify the values recommended by the RUC in establishing interim 

final values under the PFS. Sometimes we also find it appropriate, on an interim final basis, to 

refine how the CPT codes are to be used for Medicare services or to create G-codes for reporting 

certain services to Medicare. Some stakeholders have objected to such interim final decisions 

because they do not learn of the CMS action until the final rule with comment period is issued. 

Stakeholders said that they do not have an opportunity to meaningfully comment and for CMS to 

address their comments before the coding or valuation decision takes effect. 

We received comments on the CY 2014 PFS final rule with comment period suggesting 

that the existing process for review and adoption of interim final values for new, revised, and 

misvalued codes violates section 1871(a)(2) of the Act, which prescribes the rulemaking 

requirements for the agency in establishing payment rates. In response to those commenters, we 

note that the process we use to establish interim final rates is in full accordance with the statute 

and we do not find this a persuasive reason to consider modifying the process that we use to 

establish PFS rates. 

Our recent revaluation of the four epidural injection codes provides an example of the 

concerns that have been expressed with the existing process. In the CY 2014 PFS final rule with 

comment period, we established interim final values for four epidural injection codes, which 

resulted in payment reductions for the services when furnished in the office setting of between 

35 percent and 56 percent. (In the facility setting, the reductions ranged from 17 percent to 33 

percent.) One of these codes had been identified as a potentially misvalued code 2 years earlier. 

The affected specialties had been involved in the RUC process and were generally aware that the 
CMS-1612-FC 208

family of codes would be revalued on an interim basis in an upcoming rule. They were also 

aware that the RUC had made significant changes to the direct PE inputs, including removal of 

the radiographic-fluoroscopy room, which explains, in large part, the reduction to values in the 

office setting. The societies representing the affected specialty were also aware of significant 

reductions in the RUC-recommended “time” to furnish the procedures based on the most recent 

survey of practitioners who furnish the services, which resulted in reductions in both the work 

and PE portion of the values. Although the specialties were aware of the changes that the RUC 

was recommending to direct PE inputs, they were not specifically aware of how those changes 

would affect the values and payment rate. In addition, we decreased the work RVUs for these 

procedures because we found the RUC-recommended work RVUs did not adequately reflect the 

RUC-recommended decreases in time. This decision is consistent with our general practice 

when the best available information shows that the time involved in furnishing the service has 

decreased, and in the absence of information suggesting an increase in work intensity. Since the 

interim final values for these codes were issued in the CY 2014 PFS final rule with comment 

period, we have received numerous comments that will be useful to us as we consider finalizing 

values for these codes. If we had followed a process that involved proposing values for these 

codes in a proposed rule, we would have been able to consider the additional information 

contained in these comments prior to making payments for the services based upon revised 

values. (See section II.B.3.b.(2) of this final rule with comment period for a discussion of 

proposed valuation of these epidural injection codes for CY 2015.) 

3. Alternatives to the Current Process 

In the proposed rule, we noted that given our heightened review of the RUC 

recommendations and the increased concerns expressed by some stakeholders, we believed that 

an assessment of our process for valuing these codes was warranted. To that end, we considered 
CMS-1612-FC 209

potential alternatives to address the timing and rulemaking issues associated with establishing 

values for new, revised and potentially misvalued codes (as well as for codes within the same 

families as these codes). Specifically, we explored three alternatives to our current approach: 

● Propose work and MP RVUs and direct PE inputs for all new, revised and potentially 

misvalued codes in a proposed rule. 

● Propose changes in work and MP RVUs and direct PE inputs in the proposed rule for 

new, revised, and potentially misvalued codes for which we receive RUC recommendations in 

time; continue to establish interim final values in the final rule for other new, revised, and 

potentially misvalued codes. 

● Increase our efforts to make available more information about the specific issues being 

considered in the course of developing values for new, revised and potentially misvalued codes 

to increase transparency, but without making changes to the existing process for establishing 

values. 

In the proposed rule we discussed each of these alternatives as follows. 

(a) Propose work and MP RVUs and direct PE inputs for new, revised, and potentially 

misvalued codes in the proposed rule: 

Under this approach, we stated that we would evaluate the RUC recommendations for all 

new, revised, and potentially misvalued codes, and include proposed work and MP RVUs and 

direct PE inputs for the codes in the first available PFS proposed rule. We would receive and 

consider public comments on those proposals and establish final values in the final rule. The 

primary obstacle to this approach relates to the current timing of the CPT coding changes and 

RUC activities. Under the current calendar, all CPT coding changes and most RUC 

recommendations are not available to us in time to include proposed values for all codes in the 

proposed rule for that year. 
CMS-1612-FC 210

Therefore, we stated that if we were to adopt this proposal, which would require us to 

propose changes in inputs before we revalue codes based upon those values, we would need a 

mechanism to pay for services for which the existing codes would no longer be available, or for 

which there would be changes for a given year. 

As we noted in the CY 2012 PFS final rule with comment period, the RUC 

recommendations are an essential element that we consider when valuing codes. Likewise, we 

recognize the significant contribution that the CPT Editorial Panel makes to the success of the 

potentially misvalued code initiative through its consideration and adoption of coding changes. 

Although we have increased our scrutiny of the RUC recommendations in recent years and 

accepted fewer of the recommendations without making our own refinements, the CPT codes 

and the RUC recommendations continue to play a major role in our valuations. For many codes, 

the surveys conducted by specialty societies as part of the RUC process are the best data that we 

have regarding the time and intensity of work. The RUC determines the criteria and the 

methodology for those surveys. It also reviews the survey results. This process allows for 

development of survey data that are more reliable and comparable across specialties and services 

than would be possible without having the RUC at the center of the survey vetting process. In 

addition, the debate and discussion of the services at the RUC meetings in which CMS staff 

participate provides a good understanding of what the service entails and how it compares to 

other services in the family, and to services furnished by other specialties. The debate among the 

specialties is also an important part of this process. Although we increasingly consider data and 

information from many other sources, and we intend to expand the scope of those data and 

sources, the RUC recommendations remain a vital part of our valuation process. 

Thus, if we were to adopt this approach, we would need to address how to make payment 

for the services for which new or revised codes take effect for the following year but for which 
CMS-1612-FC 211

we did not receive RUC recommendations in time to include proposed work values and PE 

inputs in the proposed rule. Because the annual coding changes are effective on January 1st of 

each year, we would need a mechanism for practitioners to report services and be paid 

appropriately during the interval between the date the code takes effect and the time that we 

receive RUC recommendations and complete rulemaking to establish values for the new and 

revised codes. One option would be to establish G-codes with identical descriptors to the 

predecessors of the new and revised codes and, to the fullest extent possible, carry over the 

existing values for those codes. This would effectively preserve the status quo for one year. 

The primary advantage of this approach would be that the RVUs for all services under 

the PFS would be established using a full notice and comment procedure, including 

consideration of the RUC recommendations, before they take effect. In addition to having the 

benefit of the RUC recommendations, this would provide the public the opportunity to comment 

on a specific proposal prior to it being implemented. This would be a far more transparent 

process, and would assure that we have the full benefit of stakeholder comments before 

establishing values. 

One drawback to such a process is that the use of G-codes for a significant number of 

codes may create an administrative burden for CMS and for practitioners. Presumably, 

practitioners would need to use the G-codes to report certain services for purposes of Medicare, 

but would use the new or revised CPT codes to report the same services to private insurers. The 

number of G-codes needed each year would depend on the number of CPT code changes for 

which we do not receive the RUC recommendations in time to formulate a proposal to be 

included in the proposed rule for the year. To the extent that we receive the RUC 

recommendations for all new and revised codes in time to develop proposed values for inclusion 

in the proposed rule, there would be no need to use G-codes for this purpose. 
CMS-1612-FC 212

Another drawback is that we would need to delay for at least one year the revision of 

values for any misvalued codes for which we do not receive RUC recommendations in time to 

include a proposal in the proposed rule. For a select set of codes, we would be continuing to use 

the RVUs for the codes for an additional year even though we know they do not reflect the most 

accurate resources. Since the PFS is a budget neutral system, misvalued services affect 

payments for all services across the fee schedule. On the other hand, if we were to take this 

approach, we would have the full benefit of public comments received on the proposed values 

for potentially misvalued services before implementing any revisions. 

(b) Propose changes in work and MP RVUs and PE inputs in the proposed rule for new, 

revised, and potentially misvalued codes for which we receive RUC recommendations in time; 

continue to establish interim final values in the final rule for other new, revised, and potentially 

misvalued codes: 

This alternative approach would allow for notice and comment rulemaking before we 

adopt values for some new, revised and potentially misvalued codes (those for which we receive 

RUC recommendations in time to include a proposal in the proposed rule), while others would be 

valued on an interim final basis (those for which we do not receive the RUC recommendations in 

time). Under this approach, we would establish values in a year for all new, revised, and 

potentially misvalued codes, and there would be no need to provide for a mechanism to continue 

payment for outdated codes pending receipt of the RUC recommendations and completion of a 

rulemaking cycle. For codes for which we do not receive the RUC recommendations in time to 

include a proposal in the proposed rule for a year, there would be no change from the existing 

valuation process. 

This would be a balanced approach that recognizes the benefits of a full opportunity for 

notice and comment rulemaking before establishing rates when timing allows, and the 
CMS-1612-FC 213

importance of establishing appropriate values for the current version of CPT codes and for 

potentially misvalued codes when the timing of the RUC recommendations does not allow for a 

full notice and comment procedure. 

However, this alternative would go only part of the way toward addressing concerns 

expressed by some stakeholders. For those codes for which the RUC recommendations are not 

received in time for us to include a proposal in the proposed rule, Medicare payment for one year 

would still be based on inputs established without the benefit of full public notice and comment. 

Another concern with this approach is that it could lead to the valuation of codes within the same 

family at different times depending on when we receive RUC recommendations for each code 

within a family. As discussed previously, we believe it is important to value an entire code 

family together to make adjustments to account appropriately for relativity within the family and 

between the family and other families. If we receive RUC recommendations in time to propose 

values for some, but not for all, codes within a family, we would respond to comments in the 

final rule to establish final values for some of the codes while adopting interim final values for 

other codes within the same family. The differences in the treatment of codes within the same 

family could limit our ability to value codes within the same family with appropriate relativity. 

Moreover, under this alternative, the main determinant of how a code would be handled would 

be the timing of our receipt of the RUC recommendation for the code. Although this approach 

would offer stakeholders the opportunity to comment on specific proposals in the proposed rule, 

the adoption of changes for a separate group of codes in the final rule could significantly change 

the proposed values simply due to the budget neutrality adjustments due to additional codes 

being valued in the final rule. 

(c) Increase our efforts to make available more information about the specific issues 

being considered in the course of developing values for new, revised and potentially misvalued 
CMS-1612-FC 214

codes in order to increase transparency, but without a change to the existing process for 

establishing values: 

The main concern with continuing our current approach is that stakeholders have 

expressed the desire to have adequate and timely information to permit the provision of relevant 

feedback to CMS for our consideration prior to establishing a payment rate for new, revised, and 

potentially misvalued codes. We could address some aspects of this issue by increasing the 

transparency of the current process. Specifically, we could make more information available on 

the CMS website before interim final values are established for codes. Examples of such 

information include an up-to-date list of all codes that have been identified as potentially 

misvalued, a list of all codes for which RUC recommendations have been received, and the RUC 

recommendations for all codes for which we have received them. 

Although the posting of this information would significantly increase transparency for all 

stakeholders, it still would not allow for full notice and comment rulemaking procedures before 

values are established for payment purposes. Nor would it provide the public with advance 

information about whether or how we will make refinements to the RUC recommendations or 

coding decisions in the final rule with comment period. Thus, stakeholders would not have an 

opportunity to provide input on our potential modifications before interim final values are 

adopted. 

4. Proposal to Modify the Process for Establishing Values for New, Revised, and Potentially 

Misvalued Codes. 

After considering the current process, including its strengths and weaknesses, and the 

alternatives to the current process described previously, we proposed to modify our process to 

make all changes in the work and MP RVUs and the direct PE inputs for new, revised and 

potentially misvalued services under the PFS by proposing the changes in the proposed rule, 
CMS-1612-FC 215

beginning with the PFS proposed rule for CY 2016. We proposed to include proposed values for 

all new, revised and potentially misvalued codes for which we have complete RUC 

recommendations by January 15th of the preceding year. We also proposed to delay revaluing 

the code for one year (or until we receive RUC recommendations for the code before January 

15th of a year) and include proposed values in the following year’s rule if the RUC 

recommendation was not received in time for inclusion in the proposed rule. Thus, we would 

include proposed values prior to using the new code (in the case of new or revised codes) or 

revising the value (in the case of potentially misvalued codes). Due to the complexities involved 

in code changes and rate setting, there could be some circumstances where, even when we 

receive the RUC recommendations by January 15th of a year, we are not able to propose values 

in that year’s proposed rule. For example, we might not have recommendations for the whole 

family or we might need additional information to appropriately value these codes. In situations 

where it would not be appropriate or possible to propose values for certain new, revised, or 

potentially misvalued codes, we would treat them in the same way as those for which we did not 

receive recommendations before January 15th. 

For new, revised, and potentially misvalued codes for which we do not receive RUC 

recommendations before January 15th of a year, we proposed to adopt coding policies and 

payment rates that conform, to the extent possible, to the policies and rates in place for the 

previous year. We would adopt these conforming policies on an interim basis pending our 

consideration of the RUC recommendations and the completion of notice and comment 

rulemaking to establish values for the codes. For codes for which there is no change in the CPT 

code, it is a simple matter to continue the current valuation. For services for which there are 

CPT coding changes, it is more complicated to maintain the current payment rates until the codes 

can be valued through the notice and comment rulemaking process. Since the changes in CPT 
CMS-1612-FC 216

codes are effective on January 1st of a year, and we would not have established values for the 

new or revised codes (or other codes within the code family), it would not be practical for 

Medicare to use those CPT codes. For codes that were revised or deleted as part of the annual 

CPT coding changes, when the changes could affect the value of a code and we have not had an 

opportunity to consider the relevant RUC recommendations prior to the proposed rule, we 

propose to create G-codes to describe the predecessor codes to these codes. If CPT codes are 

revised in a manner that would not affect the resource inputs used to value the service (for 

example, a grammatical changes to CPT code descriptors), we could use these revised codes and 

continue to pay at the rate developed through the use of the same resource inputs. For example, 

if a single CPT code was separated into two codes and we did not receive RUC 

recommendations for the two codes before January 15th of the year, we would assign each of 

those new codes an “I” status indicator (which denotes that the codes are “not valid for Medicare 

purposes”), and those codes could not be used for Medicare payment during the year. Instead, 

we would create a G-code with the same description as the single predecessor CPT code and 

continue to use the same inputs as the predecessor CPT code for that G-code during the year. 

For new codes that describe wholly new services, as opposed to new or revised codes that 

are created as part of a coding revision of a family or that describe services are already on the 

PFS, we would make every effort to work with the RUC to ensure that we receive 

recommendations in time to include proposed values in the proposed rule. However, if we do 

not receive timely recommendations from the RUC for such a code and we determine that it is in 

the public interest for Medicare to use a new code during the code’s initial year, we would 

establish values for the code’s initial year. As we do under our current policy, if we receive the 

RUC recommendations in time to consider them for the final rule, we propose to establish values 

for the initial year on an interim final basis subject to comment in the final rule. In the event we 
CMS-1612-FC 217

do not receive RUC recommendations in time to consider them for the final rule, or in other 

situations where it would not be appropriate to establish interim final values (for example, 

because of a lack of necessary information about the work or the price of the PE inputs 

involved), we would contractor price the code for the initial year. 

We specifically sought comments on the following topics: 

● Is this proposal preferable to the present process? Is another one of the alternatives 

better? 

● If we were to implement this proposal, is it better to move forward with the changes, 

or is more time needed to make the transition such that implementation should be delayed 

beyond CY 2016? What factors should we consider in selecting an implementation date? 

● Are there alternatives other than the use of G-codes that would allow us to address the 

annual CPT changes through notice and comment rather than interim final rulemaking? 

Comment: The vast majority of commenters support a process, such as the one we 

proposed, that would result in having an opportunity for public comment on specific CMS 

proposals to change rates prior to payments being made based upon those rates. Commenters 

supporting a more transparent process include most medical organizations. MedPAC supported 

including proposals for rate changes in the proposed rule, but disagreed with preserving existing 

rates when RUC recommendations were not received in time to value in the proposed rule stating 

that this perpetuates paying at rates that we know are misvalued. As an alternative, MedPAC 

suggested that for codes for which we received RUC recommendations after the deadline for the 

proposed rule, we establish interim final values using the existing process. MedPAC also 

encouraged us to work with the CPT Editorial Panel and the RUC to better disseminate 

information about coding and payment recommendations that might be used for interim values as 

far in advance as possible. Several commenters who do not currently participate in the 
CMS-1612-FC 218

development of RUC recommendations suggested that we require the RUC to make its 

operations more transparent. Most of the commenters that supported the proposal also suggested 

making at least some modifications to the proposal. Some commenters indicated there was no 

need for a change from the current process. Another commenter stated “CMS’s proposal is 

overly complex, potentially burdensome, and goes well beyond the principal request of the 

medical specialty societies and Congress – that is, for CMS to publish reimbursement changes 

for misvalued codes in the proposed rule, as opposed to waiting until the final rule.” 

Response: We appreciate the many comments in support of our proposal to be more 

transparent in our ratesetting process by including proposed changes in inputs for new, revised, 

and potentially misvalued codes in the PFS proposed rules each year. We received only minimal 

comments on the other alternatives we presented, and only one comment suggesting that the 

current process was ideal and should be maintained. Thus, we are finalizing the proposal, with 

the modifications discussed below, to change our process for establishing values for new, 

revised, and potentially misvalued codes each year by proposing values for them in the proposed 

rule. We note that the CPT Editorial Panel and the RUC have made significant efforts in recent 

years to make their processes more transparent, such as making minutes of meetings publicly 

available. We encourage them to continue these efforts and also to consider ways that all 

physicians, practitioners and other suppliers paid under the PFS are aware of issues that are being 

considered by the RUC, and have an opportunity to provide input. With regard to comments 

suggesting that we propose values for some codes in the proposed rule and establish values for 

others as interim final in the final rule with comment period, as we discussed in making the 

proposal, we believe this type of system has several flaws. Most significantly, since the PFS is a 

budget neutral system, proposals are more meaningful when they can be considered in relation to 

all codes being revalued in a year in order to allow public comment on the entire fee schedule at 
CMS-1612-FC 219

one time. Additionally, we believe it is difficult to justify the presence or absence of an 

opportunity for public comment in advance of our adopting and using new values and inputs for 

services when the outcome essentially depends upon when we receive RUC recommendations. 

Comment: Commenters expressed mixed opinions on when the new process should 

begin. The AMA, the RUC, and most medical specialties opposed the proposed CY 2016 

implementation and asked that it be delayed until CY 2017. Commenters supporting a delay 

suggested that much work had already been done for the CY 2016 coding cycle in anticipation 

that these codes could be used for CY 2016, and stated it seems unfair to now delay valuing 

these codes because the process is being changed. These commenters also suggested that by 

delaying until CY 2017, the CPT Editorial Panel and the RUC would have time to adjust their 

agendas and workload so as to provide more recommendations in time for the proposed rule. By 

contrast, several commenters, including those with major code revisions for CY 2015, such as 

codes for radiation therapy and upper gastrointestinal procedures, suggested that we should 

implement the new process immediately, and thus, delay implementation of the new code sets 

and values so that they could be issued as proposals in the CY 2016 proposed rule. Although 

each of the commenters took some unique positions in supporting a delay, they emphasized the 

importance of the opportunity to comment on our specific proposals for valuation as a major 

consideration for the delay. A few other commenters also suggested that the benefit of the 

opportunity for public comment prior to changing values warrants immediate implementation. 

Some commenters supported a CY 2016 implementation date as we proposed. A small group of 

commenters suggested an interim approach under which, for CY 2016, we would publish “some, 

but not all, values” in the proposed rule and use the interim final approach for others. 

 Response: After reviewing the comments, we understand that the implementation of a 

new process such as this one will affect stakeholders in differing ways. As we consider the most 
CMS-1612-FC 220

appropriate time frame for implementation, we believe that flexibility in implementation offers 

the optimal solution. Accordingly, we are delaying the adoption of two new codes sets (radiation 

therapy and lower gastrointestinal endoscopies) until CY 2016 as requested by affected 

stakeholders so that those most affected by these significant changes have the opportunity to 

comment on our proposals for valuing these codes sets before they are implemented. (See 

section II.G.3 of this final rule.) 

Similarly, as requested by the AMA and most other medical specialty societies, we are 

delaying the complete implementation of this process so that those who have requested new 

codes and modifications in existing codes with the expectation that they would be valued under 

the PFS for CY 2016 will not be negatively affected by timing of this change. We note that the 

AMA has been working to develop timeframes that would allow a much higher percentage of 

codes to be addressed in the proposed rule, and has shared with us some plans to achieve this 

goal. We appreciate AMA’s efforts and are confident that with the finalization of this process, 

the CPT Editorial Panel and the RUC will be able to adjust their timelines and processes so that 

most, if not all, of the annual coding changes and valuation recommendations can be addressed 

in the proposed rule prior to the effective date of the coding changes. This delay in 

implementation will provide additional time for these bodies to adjust their agendas and the 

timing of their recommendations to CMS to more appropriately align with the new process. As 

suggested by some commenters, we will use CY 2016 as a transition year. In the PFS proposed 

rule for CY 2016, we will propose values for the new, revised and potentially misvalued codes 

for which we receive the RUC recommendations in time for inclusion in the CY 2016 proposed 

rule. We will also include proposals for the two code sets delayed from CY 2015 in the CY 2016 

proposed rule, as discussed above. For those new, revised, and potentially misvalued codes for 

which we do not receive RUC recommendations in time for inclusion in the proposed rule, we 
CMS-1612-FC 221

anticipate establishing interim final values for them for CY 2016, consistent with the current 

process. Beginning with valuations for CY 2017, the new process will be applicable to all codes. 

In other words, beginning with rulemaking for CY 2017, we will propose values for the vast 

majority of new, revised, and potentially misvalued codes and consider public comments before 

establishing final values for the codes; use G-codes as necessary in order to facilitate continued 

payment for certain services for which we do not receive RUC recommendations in time to 

propose values; and adopt interim final values in the case of wholly new services for which there 

are no predecessor codes or values and for which we do not receive RUC recommendations in 

time to propose values. Consistent with this policy, we are finalizing our proposed regulatory 

change to §414.24 with the addition of the phrase “For valuations for calendar year 2017 and 

beyond,” to paragraph (b) to reflect the implementation for all CY 2017 valuations.” 

 Comment: Commenters also addressed the January 15th deadline for valuations to be 

considered for the proposed rule. The AMA recommended a deadline of 30 days after the 

RUC’s January meeting to allow time to submit complete recommendations for the proposed 

rule. Many others supported this, with some commenters suggesting a variety of dates between 

January 31st and April. Commenters suggested using an April deadline so that we could include 

the recommendations from the April RUC meeting in the proposed rule. 

 Response: In proposing a deadline for inclusion in the proposed rule, we attempted to 

strike a balance that allows CMS adequate time for CMS to do a thorough job in vetting 

recommendations and formulating proposals, and allows the RUC as much time as possible to 

complete its activities. Review of RUC recommendations and application of the PFS 

methodology to particular codes requires significant time to complete. With new statutory 

requirements being implemented in CY 2017, such as those requiring multi-year transitions of 

certain changes in values and modification to PFS payments if specified targets are not met, we 
CMS-1612-FC 222

believe we will need more time to complete the process of formulating proposals. We believe 

that we need to establish a consistent deadline for receipt of RUC recommendations in order to 

allow all stakeholders and CMS to plan appropriately. To balance competing priorities, we are 

finalizing a deadline of February 10th. Our ability to complete our work in this more limited time 

will depend in large part on the volume of recommendations handled at the last RUC meeting 

and when we receive those recommendations. We are seeking the RUC’s assistance in 

minimizing the recommendations that we receive after the beginning of the year. 

Comment: The majority of commenters opposed the use of G-codes, primarily citing the 

administrative burden of having to use a separate set of codes for Medicare claims. One 

commenter called the G-code proposal “unworkable.” In addition, MedPAC objected to the 

principal of attempting to maintain rates that are known to be misvalued. Those supporting the 

use of G-codes generally recognized the administrative burden, but believed the importance of 

the opportunity for public comment on proposed values before they take effect outweighed the 

administrative inconvenience. Commenters urged us to minimize the use of G-codes. 

Response: We recognize the commenters’ concerns with the use of G-codes. We agree 

that it is preferable to use CPT codes whenever possible. Under our finalized process, the use of 

G-codes for the purpose of holding over current coding and payment policies should not be 

necessary, generally, as long as we receive RUC recommendations for all new, revised and 

potentially misvalued codes before February 10th of the prior year. However, we need to 

preserve our ability to establish a proxy for current coding and values in situations where we 

receive the RUC recommendations too late or, for some other reason, encounter serious 

difficulty developing proposed values for revised code sets. In the proposed rule, we sought 

input as to ways to achieve this without using G-codes. The only suggestion offered by 

commenters was to value such codes on an interim final basis. As we discuss above, we believe 
CMS-1612-FC 223

the program and its stakeholders are better served by delaying revaluations for one year while we 

used the notice and comment process to obtain public comments in advance. The comments on 

this proposal were overall overwhelming supportive of this point of view. Accordingly, we are 

not foreclosing the possibility of using G-codes for this purpose when warranted by the 

circumstances. However, we are cognizant of the difficulties created by the use of G-codes and 

will seek to minimize their use. We also note that the RUC and stakeholders can assist us in 

minimizing the use of G-codes by taking steps to insure that we receive RUC recommendations 

as early as possible. 

5. Refinement Panel. 

As discussed in the 1993 PFS final rule with comment period (57 FR 55938), we adopted 

a refinement panel process to assist us in reviewing the public comments on CPT codes with 

interim final work RVUs for a year and in developing final work values for the subsequent year. 

We decided the panel would be comprised of a multispecialty group of physicians who would 

review and discuss the work involved in each procedure under review, and then each panel 

member would individually rate the work of the procedure. We believed establishing the panel 

with a multispecialty group would balance the interests of the specialty societies who 

commented on the work RVUs with the budgetary and redistributive effects that could occur if 

we accepted extensive increases in work RVUs across a broad range of services. 

Following enactment of section 1848(c)(2)(K) of the Act, which required the Secretary 

periodically to review potentially misvalued codes and make appropriate adjustments to the 

RVUs, we reassessed the refinement panel process. As detailed in the CY 2011 PFS final rule 

with comment period (75 FR 73306), we continued using the established refinement panel 

process with some modifications. 

As we considered making changes to the process for valuing codes, we reassessed the 
CMS-1612-FC 224

role that the refinement panel process plays in the code valuation process. We noted that the 

current refinement panel process is tied to interim final values. It provides an opportunity for 

stakeholders to provide new clinical information that was not available at the time of the RUC 

valuation that might affect work RVU values that are adopted in the interim final value process. 

We noted that if our proposal to modify the valuation process for new, revised, and potentially 

misvalued codes is adopted, there would no longer be interim final values except for very few 

codes that describe totally new services. Thus, we proposed eliminating the refinement panel 

process. 

We also noted that by using the proposed process for new, revised, and potentially 

misvalued codes, we believed the consideration of additional clinical information and any other 

issues associated with the CMS proposed values could be addressed through the notice and 

comment process. Similarly, prior to CY 2012 when we consolidated the five-year valuation, 

changes made as part of the five-year review process were addressed in the proposed rule and 

those codes were generally not subject to the refinement process. The notice and comment 

process would provide stakeholders with complete information on the basis and rationale for our 

proposed inputs and any relating coding policies. We also noted that an increasing number of 

requests for refinement do not include new clinical information that would justify a change in the 

work RVUs and that was not available at the time of the RUC meeting, in accordance with the 

current criteria for refinement. Thus, we did not believe the elimination of the refinement panel 

process would negatively affect the code valuation process. We believe the proposed process, 

which includes a full notice and comment procedure before values are used for purposes of 

payment, offers stakeholders a better mechanism for providing any additional data for our 

consideration and discussing any concerns with our proposed values than the current refinement 

process 
CMS-1612-FC 225

Comment: We received many comments on our proposal to eliminate the refinement 

panel, but most addressed problems with the existing refinement process and suggested 

improvements and alternatives rather than reasons not to eliminate the refinement panel. 

Concerns with the refinement panel process included that CMS imposed too high a standard for 

referring codes to refinement and that CMS decreasingly changed values based upon the 

refinement panel results. Some noted that organizations with limited resources are 

disadvantaged compared to those with significant resources to overturn any CMS interim final 

values without a refinement process. In addition, some commenters stated that elimination of the 

refinement panel runs contrary to the transparency that CMS is trying to achieve. Many 

discussed their previous understanding that the refinement panel was essentially an appeals 

process for interim final values. 

Commenters supported “a fair, objective, and consistently applied appeals process that 

would be open to any commenting organization.” Commenters expressed concern that the 

elimination of the refinement panel without a replacement mechanism “indicates that CMS will 

no longer seek the independent advice of contractor medical officers and practicing physicians 

and will solely rely on Agency staff to determine if the comment is persuasive in modifying a 

proposed value. The lack of any perceived organized appeal process will likely lead to a 

fragmented lobbying effort, rather than an objective review process.” 

MedPAC suggested that we use a panel with membership limited to those without a 

financial stake in the process, such as contractor medical directors, experts in medical economics 

and technology diffusion, private payer representatives, and a mix of physicians and other health 

professionals not directly affected by the RVUs in question. It also suggested user fees to 

provide the resources needed or such a refinement panel. 

 Response: We acknowledge the commenters’ concerns and believe that some of the 
CMS-1612-FC 226

dissatisfaction with the current refinement panel mechanism stems from the expectation that it 

constitutes an appeals process. We do not agree. We believe the purpose of the refinement 

panel is to give us additional information to consider in exercising our responsibility to establish 

appropriate RVUs for Medicare services. Like many of the commenters, we believe the 

refinement panel is not achieving its purpose. Rather than providing us with additional 

information to assist us in establishing work RVUs, most often the refinement panel discussion 

reiterates the issues raised and information discussed at the RUC. Since we had access to this 

information at the time interim final values were established, it seems unlikely that a repeat 

discussion of the same issues would lead us to change valuations based upon information that 

already had been carefully considered. We remain concerned about the amount of resources 

devoted to refinement panel activities as compared to the benefit received. However, in light of 

the significant concerns raised by commenters, we are not finalizing our proposal to eliminate 

the refinement panel. We will use the refinement panel for consideration of interim final rates 

for CY 2015 under the existing rules. We will also explore ways to address the many concerns 

that we and stakeholders have about the refinement panel process and whether the change in 

process eliminates the need for a refinement panel. 

 We are also finalizing our proposed change to the regulation at §414.24 with the 

addition of the phrase “For valuations for calendar year 2017 and beyond,” to paragraph (b) to 

reflect implementation of the revised process for all valuations beginning with those for CY 

2017. 
CMS-1612-FC 227

G. Establishing RVUs for CY 2015 

1. Methodology 

We conducted a review of each code identified in this section and reviewed the current 

work RVU, if one exists, the RUC-recommended work RVUs, intensity, and time to furnish the 

preservice, intraservice, and postservice activities, as well as other components of the service that 

contribute to the value. Our review generally includes, but is not limited to, a review of 

information provided by the RUC, Health Care Professionals Advisory Committee (HCPAC), 

and other public commenters, medical literature, and comparative databases, as well as a 

comparison with other codes within the Medicare PFS, consultation with other physicians and 

health care professionals within CMS and the federal government. We also assessed the 

methodology and data used to develop the recommendations submitted to us by the RUC and 

other public commenters and the rationale for the recommendations. In the CY 2011 PFS final 

rule with comment period (75 FR 73328 through 73329), we discussed a variety of 

methodologies and approaches used to develop work RVUs, including survey data, building 

blocks, crosswalk to key reference or similar codes, and magnitude estimation. More 

information on these issues is available in that rule. When referring to a survey, unless otherwise 

noted, we mean the surveys conducted by specialty societies as part of the formal RUC process. 

The building block methodology is used to construct, or deconstruct, the work RVU for a CPT 

code based on component pieces of the code. Components used in the building block approach 

may include preservice, intraservice, or postservice time and post-procedure visits. When 

referring to a bundled CPT code, the components could be the CPT codes that make up the 

bundled code. Magnitude estimation refers to a methodology for valuing physician work that 

determines the appropriate work RVU for a service by gauging the total amount of physician 
CMS-1612-FC 228

work for that service relative to the physician work for similar service across the PFS without 

explicitly valuing the components of that work. 

The PFS incorporates cross-specialty and cross-organ system relativity. Valuing services 

requires an assessment of relative value and takes into account the clinical intensity and time 

required to furnish a service. In selecting which methodological approach will best determine 

the appropriate value for a service, we consider the current and recommended work and time 

values, as well as the intensity of the service, all relative to other services. 

Several years ago, to aid in the development of preservice time recommendations for new 

and revised CPT codes, the RUC created standardized preservice time packages. The packages 

include preservice evaluation time, preservice positioning time, and preservice scrub, dress and 

wait time. Currently there are six preservice time packages for services typically furnished in the 

facility setting, reflecting the different combinations of straightforward or difficult procedure, 

straightforward or difficult patient, and without or with sedation/anesthesia. Currently, there are 

three preservice time packages for services typically furnished in the nonfacility setting, 

reflecting procedures without and with sedation/anesthesia care. 

We have developed several standard building block methodologies to appropriately value 

services when they have common billing patterns. In cases where a service is typically furnished 

to a beneficiary on the same day as an evaluation and management (E/M) service, we believe 

that there is overlap between the two services in some of the activities furnished during the 

preservice evaluation and postservice time. We believe that at least one-third of the physician 

time in both the preservice evaluation and postservice period is duplicative of work furnished 

during the E/M visit. Accordingly, in cases where we believe that the RUC has not adequately 

accounted for the overlapping activities in the recommended work RVU and/or times, we adjust 

the work RVU and/or times to account for the overlap. The work RVU for a service is the 
CMS-1612-FC 229

product of the time involved in furnishing the service times the intensity of the work. Preservice 

evaluation time and postservice time both have a long-established intensity of work per unit of 

time (IWPUT) of 0.0224, which means that 1 minute of preservice evaluation or postservice time 

equates to 0.0224 of a work RVU. Therefore, in many cases when we remove 2 minutes of 

preservice time and 2 minutes of postservice time from a procedure to account for the overlap 

with the same day E/M service, we also remove a work RVU of 0.09 (4 minutes × 0.0224 

IWPUT) if we do not believe the overlap in time has already been accounted for in the work 

RVU. The RUC has recognized this valuation policy and, in many cases, addresses the overlap 

in time and work when a service is typically provided on the same day as an E/M service. 

The RVUs and other payment information for all CY 2015 payable codes are available in 

Addendum B. The RVUs and other payment information for all codes subject to public 

comment are available in Addendum C. Both addenda are available on the CMS website under 

downloads for the CY 2015 PFS final rule with comment period at 

http://www.cms.gov/physicianfeesched/downloads/. The time values for all CY 2015 codes are 

listed in a file called “CY 2015 PFS Physician Time,” available on the CMS website under 

downloads for the CY 2015 PFS final rule with comment period at 

http://www.cms.gov/physicianfeesched/downloads/. 

2. Addressing CY 2014 Interim Final RVUs 

In this section, we are responding to the public comments received on specific interim 

final values established in the CY 2014 PFS final rule with comment period and discussing the 

final values that we are establishing for CY 2015. The final CY 2015 work, PE, and MP RVUs 

are in Addendum B of a file called “CY 2015 PFS Addenda,” available on the CMS website 

under downloads for the CY 2015 PFS final rule with comment period at 

http://www.cms.gov/physicianfeesched/PFS-Federal-Regulation-Notices.html/. The direct PE 
CMS-1612-FC 230

inputs are listed in a file called “CY 2015 PFS Direct PE Inputs,” available on the CMS website 

under downloads for the CY 2015 PFS final rule with comment period at 

http://www.cms.gov/physicianfeesched/PFS-Federal-Regulation-Notices.html/. 

a. Finalizing CY 2014 Interim Final Work RVUs for CY 2015 

(i) Refinement Panel 

(1) Refinement Panel Process 

As discussed in the 1993 PFS final rule with comment period (57 FR 55938), we adopted 

a refinement panel process soon after implementing the fee schedule to assist us in reviewing the 

public comments on CPT codes with interim final work RVUs and in developing final work 

values for the subsequent year. We decided the panel would be comprised of a multispecialty 

group of physicians who would review and discuss the work involved in each procedure under 

review, and then each panel member would individually rate the work of the procedure. We 

believed a multispecialty group would balance the interests of the specialty societies who 

commented on the work RVUs with the budgetary and redistributive effects that could occur if 

we accepted extensive increases in work RVUs across a broad range of services. Depending on 

the number and range of codes that are subject to refinement in a given year, we establish 

refinement panels with representatives from four groups: Clinicians representing the specialty 

identified with the procedures in question; physicians with practices in related specialties; 

primary care physicians; and contractor medical directors (CMDs). Typical panels have 

included 8 to 10 physicians across the four groups. 

Following the addition of section 1848(c)(2)(K) to the Act, which requires the Secretary 

periodically to review potentially misvalued codes and make appropriate adjustments to the 

RVUs, we reassessed the refinement panel process. As detailed in the CY 2011 PFS final rule 

with comment period (75 FR 73306), we believed that the refinement panel process might 
CMS-1612-FC 231

provide an opportunity to review and discuss the proposed and interim final work RVUs with a 

clinically diverse group of experts, who could provide informed recommendations following the 

discussion. Therefore, we indicated that we would continue the refinement process, but with 

administrative modification and clarification. We also noted that we would continue using the 

established panel composition that includes representatives from the four groups—clinicians 

representing the specialty identified with the procedures in question, physicians with practices in 

related specialties, primary care physicians, and CMDs. 

At that time, we made a change in how we calculated refinement panel results. The basis 

of the refinement panel process is that, following discussion of the information but without an 

attempt to reach a consensus, each member of the panel submits an independent rating to CMS. 

Historically, the refinement panel’s recommendation to change a work value or to retain the 

interim final value had hinged solely on the outcome of a statistical test on the ratings (an F-test 

of panel ratings among the groups of participants). Over time, we found the statistical test used 

to evaluate the RVU ratings of individual panel members became less reliable as the physicians 

in each group tended to select a previously discussed value, rather than developing a unique 

value, thereby reducing the observed variability needed to conduct a robust statistical test. In 

addition, reliance on values developed using the F-test also occasionally resulted in rank order 

anomalies among services (that is, a more complex procedure is assigned lower RVUs than a less 

complex procedure). As a result, we eliminated the use of the statistical F-test and replaced it 

with the median work value of the individual panel members’ ratings. We stated that this 

approach would simplify the refinement process administratively, while providing a result that 

reflects the summary opinion of the panel members based on a commonly used measure of 

central tendency that is not significantly affected by outlier values. We also clarified that we 

have the final authority to set the work RVUs, including making adjustments to the work RVUs 
CMS-1612-FC 232

resulting from the refinement process, and that we will make such adjustments if warranted by 

policy concerns (75 FR 73307). 

We remind readers that the refinement panels are not intended to review the work RVUs 

for every code for which we did not accept the RUC-recommended work RVUs. Rather, 

refinement panels are designed for situations where there is new clinical information available 

that might provide a reason for a change in work values and where a multispecialty panel of 

physicians might provide input that would assist us in establishing work RVUs. To facilitate the 

selection of services for the refinement panels, commenters seeking consideration by a 

refinement panel should specifically state in their public comments that they are requesting 

refinement panel review. Furthermore, we have asked commenters requesting refinement panel 

review to submit any new clinical information concerning the work required to furnish a service 

so that we can consider whether the new information warrants referral to the refinement panel 

(57 FR 55917). 

We note that most of the information presented during the last several refinement panel 

discussions has been duplicative of the information provided to the RUC during its development 

of recommendations and considered by CMS in establishing values. As detailed above, we 

consider information and recommendations from the RUC when assigning proposed and interim 

final RVUs to services. Thus, if the only information that a commenter has to present is 

information already considered by the RUC, referral to a refinement panel is not appropriate. 

We request that commenters seeking refinement panel review of work RVUs submit supporting 

information that has not already been considered by the RUC in developing recommendations or 

by CMS in assigning proposed and interim final work RVUs. We can make best use of our 

resources, as well as those of the specialties and physician volunteers involved, by avoiding 

duplicative consideration of information by the RUC, CMS, and a refinement panel. To achieve 
CMS-1612-FC 233

this goal, CMS will continue to critically evaluate the need to refer codes to refinement panels in 

future years, specifically considering any new information provided by commenters. 

(2) CY 2014 Interim Final Work RVUs Considered by the Refinement Panel 

We referred to the CY 2014 refinement panel 19 CPT codes with CY 2014 interim final 

work values for which we received a request for refinement that met the requirements described 

above. For these 19 CPT codes, all commenters requested increased work RVUs. For ease of 

discussion, we will be referring to these services as “refinement codes.” Consistent with the 

process described above, we convened a multi-specialty panel of physicians to assist us in the 

review of the information submitted to support increased work RVUs. The panel was moderated 

by our physician advisors, and consisted of the following voting members: 

● One to two clinicians representing the commenting organization. 

● One to two primary care clinicians nominated by the American Academy of Family 

Physicians and the American College of Physicians. 

● Four Contractor Medical Directors (CMDs). 

● One to two clinicians with practices in related specialties, who were expected to have 

knowledge of the services under review. 

The panel process was designed to capture each participant’s independent judgment and 

his or her clinical experience which informed and drove the discussion of the refinement code 

during the refinement panel proceedings. Following the discussion, each voting participant rated 

the work of the refinement code(s) and submitted those ratings to CMS directly and 

confidentially. We note that not all voting participants voted for every CPT code. There was no 

attempt to achieve consensus among the panel members. As finalized in the CY 2011 PFS final 

rule with comment period (75 FR 73307), we calculated the median value for each service based 

upon the individual ratings that were submitted to CMS by panel participants. 
CMS-1612-FC 234

Table 14 presents information on the work RVUs for the refinement codes, including the 

refinement panel ratings and the final CY 2015 work RVUs. In section II.G.2.a.ii., we discuss 

the CY 2015 work RVUs assigned each of the individual refinement codes. 

 
CMS-1612-FC 235

TABLE 14: Codes Reviewed by the 2014 Multi-Specialty Refinement Panel 

HCPCS 

Code Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

RUC 

Recommended 

Work RVU 

Refinement 

Panel 

Median 

Rating 

CY 

2015 

Work 

RVU 

19081 Biopsy of breast accessed through the skin with 

stereotactic guidance 3.29 3.29 3.40 3.29 

19082 Biopsy of breast accessed through the skin with 

stereotactic guidance 1.65 1.65 1.78 1.65 

19083 Biopsy of breast accessed through the skin with 

ultrasound guidance 3.10 3.10 3.10 3.10 

19084 Biopsy of breast accessed through the skin with 

ultrasound guidance 1.55 1.55 1.55 1.55 

19085 Biopsy of breast accessed through the skin with 

MRI guidance 3.64 3.64 3.64 3.64 

19086 Biopsy of breast accessed through the skin with 

MRI guidance 1.82 1.82 1.82 1.82 

19281 

Placement of breast localization devices 

accessed through the skin with mammographic 

guidance 

2.00 2.00 2.00 2.00 

19282 

Placement of breast localization devices 

accessed through the skin with mammographic 

guidance 

1.00 1.00 1.00 1.00 

19283 

Placement of breast localization devices 

accessed through the skin with stereotactic 

guidance 

2.00 2.00 2.00 2.00 

19284 

Placement of breast localization devices 

accessed through the skin with stereotactic 

guidance 

1.00 1.00 1.00 1.00 

19285 

Placement of breast localization devices 

accessed through the skin with ultrasound 

guidance 

1.70 1.70 1.70 1.70 

19286 

Placement of breast localization devices 

accessed through the skin with ultrasound 

guidance 

0.85 0.85 0.85 0.85 

19287 Placement of breast localization devices 

accessed through the skin with MRI guidance 2.55 3.02 3.02 2.55 

19288 Placement of breast localization devices 

accessed through the skin with MRI guidance 1.28 1.51 1.51 1.28 

43204 Injection of dilated esophageal veins using an 

endoscope 2.40 2.89 2.77 2.40 

43205 Tying of esophageal veins using an endoscope 2.51 3.00 2.88 2.51 

43213 Dilation of esophagus using an endoscope 4.73 5.00 5.00 4.73 
CMS-1612-FC 236

HCPCS 

Code Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

RUC 

Recommended 

Work RVU 

Refinement 

Panel 

Median 

Rating 

CY 

2015 

Work 

RVU 

43233 Balloon dilation of esophagus, stomach, and/or 

upper small bowel using an endoscope 4.05 4.45 4.26 4.26 

43255 Control of bleeding of esophagus, stomach, 

and/or upper small bowel using an endoscope 3.66 4.20 4.20 3.66 

 (ii) Code-Specific Issues 

For each code with an interim final work value, Table 15 lists the CY 2014 interim final 

work RVU and the CY 2015 work RVU and indicates whether we are finalizing the CY 2015 

work RVU. For codes without a work RVU, the table includes a PFS procedure status indicator. 

A list of the PFS procedure status indicators can be found in Addendum A. If the CY 2015 

Action column indicates that the CY 2015 values are interim final, we will accept public 

comments on these values during the public comment period for this final rule with comment 

period. A comprehensive list of all values for which public comments are being solicited is 

contained in Addendum C to the CY 2015 PFS final rule with comment period. A 

comprehensive list of all CY 2015 RVUs is in Addendum B to this final rule with comment 

period. All Addenda to PFS final rule are available on the CMS website under downloads at 

http://www.cms.gov/physician feesched/PFS Federal Regulation Notices.html/. The time values 

for all codes are listed in a file called “CY 2015 PFS Work Time,” available on the CMS website 

under downloads for the CY 2015 PFS final rule with comment period at 

http://www.cms.gov/physicianfeesched/downloads/. 

 
CMS-1612-FC 237

TABLE 15: CY 2015 Actions on Codes with CY 2014 Interim Final RVUs 

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

10030 

Image-guided fluid collection drainage by catheter (eg, 

abscess, hematoma, seroma, lymphocele, cyst), soft tissue 

(eg, extremity, abdominal wall, neck), percutaneous 

3.00 3.00 Finalize 

17000 

Destruction (eg, laser surgery, electrosurgery, cryosurgery, 

chemosurgery, surgical curettement), premalignant lesions 

(eg, actinic keratoses); first lesion 

0.61 0.61 Finalize 

17003 

Destruction (eg, laser surgery, electrosurgery, cryosurgery, 

chemosurgery, surgical curettement), premalignant lesions 

(eg, actinic keratoses); second through 14 lesions, each 

(list separately in addition to code for first lesion) 

0.04 0.04 Finalize 

17004 

Destruction (eg, laser surgery, electrosurgery, cryosurgery, 

chemosurgery, surgical curettement), premalignant lesions 

(eg, actinic keratoses), 15 or more lesions 

1.37 1.37 Finalize 

17311 

Mohs micrographic technique, including removal of all 

gross tumor, surgical excision of tissue specimens, 

mapping, color coding of specimens, microscopic 

examination of specimens by the surgeon, and 

histopathologic preparation including routine stain(s) (eg, 

hematoxylin and eosin, toluidine blue), head, neck, hands, 

feet, genitalia, or any location with surgery directly 

involving muscle, cartilage, bone, tendon, major nerves, or 

vessels; first stage, up to 5 tissue blocks 

6.20 6.20 Finalize 

17312 

Mohs micrographic technique, including removal of all 

gross tumor, surgical excision of tissue specimens, 

mapping, color coding of specimens, microscopic 

examination of specimens by the surgeon, and 

histopathologic preparation including routine stain(s) (eg, 

hematoxylin and eosin, toluidine blue), head, neck, hands, 

feet, genitalia, or any location with surgery directly 

involving muscle, cartilage, bone, tendon, major nerves, or 

vessels; each additional stage after the first stage, up to 5 

tissue blocks (list separately in addition to code for 

primary procedure) 

3.30 3.30 Finalize 

17313 

Mohs micrographic technique, including removal of all 

gross tumor, surgical excision of tissue specimens, 

mapping, color coding of specimens, microscopic 

examination of specimens by the surgeon, and 

histopathologic preparation including routine stain(s) (eg, 

hematoxylin and eosin, toluidine blue), of the trunk, arms, 

or legs; first stage, up to 5 tissue blocks 

5.56 5.56 Finalize 
CMS-1612-FC 238

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

17314 

Mohs micrographic technique, including removal of all 

gross tumor, surgical excision of tissue specimens, 

mapping, color coding of specimens, microscopic 

examination of specimens by the surgeon, and 

histopathologic preparation including routine stain(s) (eg, 

hematoxylin and eosin, toluidine blue), of the trunk, arms, 

or legs; each additional stage after the first stage, up to 5 

tissue blocks (list separately in addition to code for 

primary procedure) 

3.06 3.06 Finalize 

17315 

Mohs micrographic technique, including removal of all 

gross tumor, surgical excision of tissue specimens, 

mapping, color coding of specimens, microscopic 

examination of specimens by the surgeon, and 

histopathologic preparation including routine stain(s) (eg, 

hematoxylin and eosin, toluidine blue), each additional 

block after the first 5 tissue blocks, any stage (list 

separately in addition to code for primary procedure) 

0.87 0.87 Finalize 

19081 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; first lesion, including stereotactic guidance 

3.29 3.29 Finalize 

19082 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; each additional lesion, including stereotactic 

guidance (list separately in addition to code for primary 

procedure) 

1.65 1.65 Finalize 

19083 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; first lesion, including ultrasound guidance 

3.10 3.10 Finalize 

19084 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; each additional lesion, including ultrasound 

guidance (list separately in addition to code for primary 

procedure) 

1.55 1.55 Finalize 

19085 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; first lesion, including magnetic resonance 

guidance 

3.64 3.64 Finalize 

19086 

Biopsy, breast, with placement of breast localization 

device(s) (eg, clip, metallic pellet), when performed, and 

imaging of the biopsy specimen, when performed, 

percutaneous; each additional lesion, including magnetic 

resonance guidance (list separately in addition to code for 

primary procedure) 

1.82 1.82 Finalize 
CMS-1612-FC 239

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

19281 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; first lesion, including mammographic 

guidance 

2.00 2.00 Finalize 

19282 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; each additional lesion, including 

mammographic guidance (list separately in addition to 

code for primary procedure) 

1.00 1.00 Finalize 

19283 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; first lesion, including stereotactic guidance 

2.00 2.00 Finalize 

19284 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; each additional lesion, including stereotactic 

guidance (list separately in addition to code for primary 

procedure) 

1.00 1.00 Finalize 

19285 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; first lesion, including ultrasound guidance 

1.70 1.70 Finalize 

19286 

Placement of breast localization device(s) (eg, clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; each additional lesion, including ultrasound 

guidance (list separately in addition to code for primary 

procedure) 

0.85 0.85 Finalize 

19287 

Placement of breast localization device(s) (eg clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; first lesion, including magnetic resonance 

guidance 

2.55 2.55 Finalize 

19288 

Placement of breast localization device(s) (eg clip, 

metallic pellet, wire/needle, radioactive seeds), 

percutaneous; each additional lesion, including magnetic 

resonance guidance (list separately in addition to code for 

primary procedure) 

1.28 1.28 Finalize 

23333 Removal of foreign body, shoulder; deep (subfascial or 

intramuscular) 6.00 6.00 Finalize 

23334 

Removal of prosthesis, includes debridement and 

synovectomy when performed; humeral or glenoid 

component 

15.50 15.50 Finalize 

23335 

Removal of prosthesis, includes debridement and 

synovectomy when performed; humeral and glenoid 

components (eg, total shoulder) 

19.00 19.00 Finalize 

23600 Closed treatment of proximal humeral (surgical or 

anatomical neck) fracture; without manipulation 3.00 3.00 Finalize 
CMS-1612-FC 240

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

24160 

Removal of prosthesis, includes debridement and 

synovectomy when performed; humeral and ulnar 

components 

18.63 18.63 Finalize 

24164 Removal of prosthesis, includes debridement and 

synovectomy when performed; radial head 10.00 10.00 Finalize 

27130 

Arthroplasty, acetabular and proximal femoral prosthetic 

replacement (total hip arthroplasty), with or without 

autograft or allograft 

20.72 20.72 Finalize 

27236 Open treatment of femoral fracture, proximal end, neck, 

internal fixation or prosthetic replacement 17.61 17.61 Finalize 

27446 Arthroplasty, knee, condyle and plateau; medial or lateral 

compartment 17.48 17.48 Finalize 

27447 

Arthroplasty, knee, condyle and plateau; medial and lateral 

compartments with or without patella resurfacing (total 

knee arthroplasty) 

20.72 20.72 Finalize 

28470 Closed treatment of metatarsal fracture; without 

manipulation, each 2.03 2.03 Finalize 

29075 Application, cast; elbow to finger (short arm) 0.77 0.77 Finalize 

29581 Application of multi-layer compression system; leg (below 

knee), including ankle and foot 0.25 0.25 Finalize 

29582 Application of multi-layer compression system; thigh and 

leg, including ankle and foot, when performed 0.35 0.35 Finalize 

29583 Application of multi-layer compression system; upper arm 

and forearm 0.25 0.25 Finalize 

29584 Application of multi-layer compression system; upper 

arm, forearm, hand, and fingers 0.35 0.35 Finalize 

29824 Arthroscopy, shoulder, surgical; distal claviculectomy 

including distal articular surface (mumford procedure) 8.98 8.98 Finalize 

29826 

Arthroscopy, shoulder, surgical; decompression of 

subacromial space with partial acromioplasty, with 

coracoacromial ligament (ie, arch) release, when 

performed (list separately in addition to code for primary 

procedure) 

3.00 3.00 Finalize 

31237 Nasal/sinus endoscopy, surgical; with biopsy, 

polypectomy or debridement (separate procedure) 2.60 2.60 Finalize 

31238 Nasal/sinus endoscopy, surgical; with control of nasal 

hemorrhage 2.74 2.74 Finalize 

31239 Nasal/sinus endoscopy, surgical; with 

dacryocystorhinostomy 9.04 9.04 Finalize 

31240 Nasal/sinus endoscopy, surgical; with concha bullosa 

resection 2.61 2.61 Finalize 

33282 Implantation of patient-activated cardiac event recorder 3.50 3.50 Finalize 
CMS-1612-FC 241

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

33284 Removal of an implantable, patient-activated cardiac event 

recorder 3.00 3.00 Finalize 

33366 

Transcatheter aortic valve replacement (tavr/tavi) with 

prosthetic valve; transapical exposure (eg, left 

thoracotomy) 

35.88 35.88 Finalize 

34841 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, intramural 

hematoma, or traumatic disruption) by deployment of a 

fenestrated visceral aortic endograft and all associated 

radiological supervision and interpretation, including 

target zone angioplasty, when performed; including one 

visceral artery endoprosthesis (superior mesenteric, celiac 

or renal artery) 

C C Finalize 

34842 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, intramural 

hematoma, or traumatic disruption) by deployment of a 

fenestrated visceral aortic endograft and all associated 

radiological supervision and interpretation, including 

target zone angioplasty, when performed; including two 

visceral artery endoprostheses (superior mesenteric, celiac 

and/or renal artery[s]) 

C C Finalize 

34843 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, intramural 

hematoma, or traumatic disruption) by deployment of a 

fenestrated visceral aortic endograft and all associated 

radiological supervision and interpretation, including 

target zone angioplasty, when performed; including three 

visceral artery endoprostheses (superior mesenteric, celiac 

and/or renal artery[s]) 

C C Finalize 

34844 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, intramural 

hematoma, or traumatic disruption) by deployment of a 

fenestrated visceral aortic endograft and all associated 

radiological supervision and interpretation, including 

target zone angioplasty, when performed; including four or 

more visceral artery endoprostheses (superior mesenteric, 

celiac and/or renal artery[s]) 

C C Finalize 

34845 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, or 

traumatic disruption) with a fenestrated visceral aortic 

endograft and concomitant unibody or modular infrarenal 

aortic endograft and all associated radiological supervision 

and interpretation, including target zone angioplasty, when 

performed; including one visceral artery endoprosthesis 

(superior mesenteric, celiac or renal artery) 

C C Finalize 
CMS-1612-FC 242

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

34846 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, or 

traumatic disruption) with a fenestrated visceral aortic 

endograft and concomitant unibody or modular infrarenal 

aortic endograft and all associated radiological supervision 

and interpretation, including target zone angioplasty, when 

performed; including two visceral artery endoprostheses 

(superior mesenteric, celiac and/or renal artery[s]) 

C C Finalize 

34847 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, or 

traumatic disruption) with a fenestrated visceral aortic 

endograft and concomitant unibody or modular infrarenal 

aortic endograft and all associated radiological supervision 

and interpretation, including target zone angioplasty, when 

performed; including three visceral artery endoprostheses 

(superior mesenteric, celiac and/or renal artery[s]) 

C C Finalize 

34848 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, or 

traumatic disruption) with a fenestrated visceral aortic 

endograft and concomitant unibody or modular infrarenal 

aortic endograft and all associated radiological supervision 

and interpretation, including target zone angioplasty, when 

performed; including four or more visceral artery 

endoprostheses (superior mesenteric, celiac and/or renal 

artery[s]) 

C C Finalize 

35301 Thromboendarterectomy, including patch graft, if 

performed; carotid, vertebral, subclavian, by neck incision 21.16 21.16 Finalize 

36245 

Selective catheter placement, arterial system; each first 

order abdominal, pelvic, or lower extremity artery branch, 

within a vascular family 

4.90 4.90 Finalize 

37217 

Transcatheter placement of intravascular stent(s), 

intrathoracic common carotid artery or innominate artery 

by retrograde treatment, open ipsilateral cervical carotid 

artery exposure, including angioplasty, when performed, 

and radiological supervision and interpretation 

20.38 20.38 Finalize 

37236 

Transcatheter placement of an intravascular stent(s) 

(except lower extremity artery(s) for occlusive disease, 

cervical carotid, extracranial vertebral or intrathoracic 

carotid, intracranial, or coronary), open or percutaneous, 

including radiological supervision and interpretation and 

including all angioplasty within the same vessel, when 

performed; initial artery 

9.00 9.00 Finalize 
CMS-1612-FC 243

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

37237 

Transcatheter placement of an intravascular stent(s) 

(except lower extremity artery(s) for occlusive disease, 

cervical carotid, extracranial vertebral or intrathoracic 

carotid, intracranial, or coronary), open or percutaneous, 

including radiological supervision and interpretation and 

including all angioplasty within the same vessel, when 

performed; each additional artery (list separately in 

addition to code for primary procedure) 

4.25 4.25 Finalize 

37238 

Transcatheter placement of an intravascular stent(s), open 

or percutaneous, including radiological supervision and 

interpretation and including angioplasty within the same 

vessel, when performed; initial vein 

6.29 6.29 Finalize 

37239 

Transcatheter placement of an intravascular stent(s), open 

or percutaneous, including radiological supervision and 

interpretation and including angioplasty within the same 

vessel, when performed; each additional vein (list 

separately in addition to code for primary procedure) 

2.97 2.97 Finalize 

37241 

Vascular embolization or occlusion, inclusive of all 

radiological supervision and interpretation, intraprocedural 

roadmapping, and imaging guidance necessary to 

complete the intervention; venous, other than hemorrhage 

(eg, congenital or acquired venous malformations, venous 

and capillary hemangiomas, varices, varicoceles) 

9.00 9.00 Finalize 

37242 

Vascular embolization or occlusion, inclusive of all 

radiological supervision and interpretation, intraprocedural 

roadmapping, and imaging guidance necessary to 

complete the intervention; arterial, other than hemorrhage 

or tumor (eg, congenital or acquired arterial 

malformations, arteriovenous malformations, 

arteriovenous fistulas, aneurysms, pseudoaneurysms) 

10.05 10.05 Finalize 

37243 

Vascular embolization or occlusion, inclusive of all 

radiological supervision and interpretation, intraprocedural 

roadmapping, and imaging guidance necessary to 

complete the intervention; for tumors, organ ischemia, or 

infarction 

11.99 11.99 Finalize 

37244 

Vascular embolization or occlusion, inclusive of all 

radiological supervision and interpretation, intraprocedural 

roadmapping, and imaging guidance necessary to 

complete the intervention; for arterial or venous 

hemorrhage or lymphatic extravasation 

14.00 14.00 Finalize 

43191 

Esophagoscopy, rigid, transoral; diagnostic, including 

collection of specimen(s) by brushing or washing when 

performed (separate procedure) 

2.00 2.49 Finalize 

43192 Esophagoscopy, rigid, transoral; with directed submucosal 

injection(s), any substance 2.45 2.79 Finalize 
CMS-1612-FC 244

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

43193 Esophagoscopy, rigid, transoral; with biopsy, single or 

multiple 3.00 2.79 Finalize 

43194 Esophagoscopy, rigid, transoral; with removal of foreign 

body(s) 3.00 3.51 Finalize 

43195 Esophagoscopy, rigid, transoral; with balloon dilation (less 

than 30 mm diameter) 3.00 3.07 Finalize 

43196 Esophagoscopy, rigid, transoral; with insertion of guide 

wire followed by dilation over guide wire 3.30 3.31 Finalize 

43197 

Esophagoscopy, flexible, transnasal; diagnostic, including 

collection of specimen(s) by brushing or washing, when 

performed (separate procedure) 

1.48 1.52 Finalize 

43198 Esophagoscopy, flexible, transnasal; with biopsy, single or 

multiple 1.78 1.82 Finalize 

43200 

Esophagoscopy, flexible, transoral; diagnostic, including 

collection of specimen(s) by brushing or washing, when 

performed (separate procedure) 

1.50 1.52 Finalize 

43201 Esophagoscopy, flexible, transoral; with directed 

submucosal injection(s), any substance 1.80 1.82 Finalize 

43202 Esophagoscopy, flexible, transoral; with biopsy, single or 

multiple 1.80 1.82 Finalize 

43204 Esophagoscopy, flexible, transoral; with injection sclerosis 

of esophageal varices 2.40 2.43 Finalize 

43205 Esophagoscopy, flexible, transoral; with band ligation of 

esophageal varices 2.51 2.54 Finalize 

43206 Esophagoscopy, flexible, transoral; with optical 

endomicroscopy 2.39 2.39 Finalize 

43211 Esophagoscopy, flexible, transoral; with endoscopic 

mucosal resection 4.21 4.30 Finalize 

43212 

Esophagoscopy, flexible, transoral; with placement of 

endoscopic stent (includes pre- and post-dilation and guide 

wire passage, when performed) 

3.38 3.50 Finalize 

43213 

Esophagoscopy, flexible, transoral; with dilation of 

esophagus, by balloon or dilator, retrograde (includes 

fluoroscopic guidance, when performed) 

4.73 4.73 Finalize 

43214 

Esophagoscopy, flexible, transoral; with dilation of 

esophagus with balloon (30 mm diameter or larger) 

(includes fluoroscopic guidance, when performed) 

3.38 3.50 Finalize 

43215 Esophagoscopy, flexible, transoral; with removal of 

foreign body(s) 2.51 2.54 Finalize 

43216 Esophagoscopy, flexible, transoral; with removal of 

tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 2.40 2.40 Finalize 

43217 Esophagoscopy, flexible, transoral; with removal of 

tumor(s), polyp(s), or other lesion(s) by snare technique 2.90 2.90 Finalize 
CMS-1612-FC 245

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

43220 Esophagoscopy, flexible, transoral; with transendoscopic 

balloon dilation (less than 30 mm diameter) 2.10 2.10 Finalize 

43226 Esophagoscopy, flexible, transoral; with insertion of guide 

wire followed by passage of dilator(s) over guide wire 2.34 2.34 Finalize 

43227 Esophagoscopy, flexible, transoral; with control of 

bleeding, any method 2.99 2.99 Finalize 

43229 

Esophagoscopy, flexible, transoral; with ablation of 

tumor(s), polyp(s), or other lesion(s) (includes pre- and 

post-dilation and guide wire passage, when performed) 

3.54 3.59 Finalize 

43231 Esophagoscopy, flexible, transoral; with endoscopic 

ultrasound examination 2.90 2.90 Finalize 

43232 

Esophagoscopy, flexible, transoral; with transendoscopic 

ultrasound-guided intramural or transmural fine needle 

aspiration/biopsy(s) 

3.54 3.59 Finalize 

43233 

Esophagogastroduodenoscopy, flexible, transoral; with 

dilation of esophagus with balloon (30 mm diameter or 

larger) (includes fluoroscopic guidance, when performed) 

4.05 4.17 Finalize 

43235 

Esophagogastroduodenoscopy, flexible, transoral; 

diagnostic, including collection of specimen(s) by 

brushing or washing, when performed (separate 

procedure) 

2.17 2.19 Finalize 

43236 Esophagogastroduodenoscopy, flexible, transoral; with 

directed submucosal injection(s), any substance 2.47 2.49 Finalize 

43237 

Esophagogastroduodenoscopy, flexible, transoral; with 

endoscopic ultrasound examination limited to the 

esophagus, stomach or duodenum, and adjacent structures 

3.57 3.57 Finalize 

43238 

Esophagogastroduodenoscopy, flexible, transoral; with 

transendoscopic ultrasound-guided intramural or 

transmural fine needle aspiration/biopsy(s), (includes 

endoscopic ultrasound examination limited to the 

esophagus, stomach or duodenum, and adjacent structures) 

4.11 4.26 Finalize 

43239 Esophagogastroduodenoscopy, flexible, transoral; with 

biopsy, single or multiple 2.47 2.49 Finalize 

43240 

Esophagogastroduodenoscopy, flexible, transoral; with 

transmural drainage of pseudocyst (includes placement of 

transmural drainage catheter[s]/stent[s], when performed, 

and endoscopic ultrasound, when performed) 

7.25 7.25 Finalize 

43241 Esophagogastroduodenoscopy, flexible, transoral; with 

insertion of intraluminal tube or catheter 2.59 2.59 Finalize 
CMS-1612-FC 246

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

43242 

Esophagogastroduodenoscopy, flexible, transoral; with 

transendoscopic ultrasound-guided intramural or 

transmural fine needle aspiration/biopsy(s) (includes 

endoscopic ultrasound examination of the esophagus, 

stomach, and either the duodenum or a surgically altered 

stomach where the jejunum is examined distal to the 

anastomosis) 

4.68 4.83 Finalize 

43243 Esophagogastroduodenoscopy, flexible, transoral; with 

injection sclerosis of esophageal/gastric varices 4.37 4.37 Finalize 

43244 Esophagogastroduodenoscopy, flexible, transoral; with 

band ligation of esophageal/gastric varices 4.50 4.50 Finalize 

43245 

Esophagogastroduodenoscopy, flexible, transoral; with 

dilation of gastric/duodenal stricture(s) (eg, balloon, 

bougie) 

3.18 3.18 Finalize 

43246 Esophagogastroduodenoscopy, flexible, transoral; with 

directed placement of percutaneous gastrostomy tube 3.66 3.66 Finalize 

43247 Esophagogastroduodenoscopy, flexible, transoral; with 

removal of foreign body(s) 3.18 3.21 Finalize 

43248 

Esophagogastroduodenoscopy, flexible, transoral; with 

insertion of guide wire followed by passage of dilator(s) 

through esophagus over guide wire 

3.01 3.01 Finalize 

43249 

Esophagogastroduodenoscopy, flexible, transoral; with 

transendoscopic balloon dilation of esophagus (less than 

30 mm diameter) 

2.77 2.77 Finalize 

43250 

Esophagogastroduodenoscopy, flexible, transoral; with 

removal of tumor(s), polyp(s), or other lesion(s) by hot 

biopsy forceps 

3.07 3.07 Finalize 

43251 

Esophagogastroduodenoscopy, flexible, transoral; with 

removal of tumor(s), polyp(s), or other lesion(s) by snare 

technique 

3.57 3.57 Finalize 

43252 Esophagogastroduodenoscopy, flexible, transoral; with 

optical endomicroscopy 3.06 3.06 Finalize 

43253 

Esophagogastroduodenoscopy, flexible, transoral; with 

transendoscopic ultrasound-guided transmural injection of 

diagnostic or therapeutic substance(s) (eg, anesthetic, 

neurolytic agent) or fiducial marker(s) (includes 

endoscopic ultrasound examination of the esophagus, 

stomach, and either the duodenum or a surgically altered 

stomach where the jejunum is examined distal to the 

anastomosis) 

4.68 4.83 Finalize 

43254 Esophagogastroduodenoscopy, flexible, transoral; with 

endoscopic mucosal resection 4.88 4.97 Finalize 

43255 Esophagogastroduodenoscopy, flexible, transoral; with 

control of bleeding, any method 3.66 3.66 Finalize 
CMS-1612-FC 247

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

43257 

Esophagogastroduodenoscopy, flexible, transoral; with 

delivery of thermal energy to the muscle of lower 

esophageal sphincter and/or gastric cardia, for treatment of 

gastroesophageal reflux disease 

4.11 4.25 Finalize 

43259 

Esophagogastroduodenoscopy, flexible, transoral; with 

endoscopic ultrasound examination, including the 

esophagus, stomach, and either the duodenum or a 

surgically altered stomach where the jejunum is examined 

distal to the anastomosis 

4.14 4.14 Finalize 

43260 

Endoscopic retrograde cholangiopancreatography (ercp); 

diagnostic, including collection of specimen(s) by 

brushing or washing, when performed (separate 

procedure) 

5.95 5.95 Finalize 

43261 Endoscopic retrograde cholangiopancreatography (ercp); 

with biopsy, single or multiple 6.25 6.25 Finalize 

43262 Endoscopic retrograde cholangiopancreatography (ercp); 

with sphincterotomy/papillotomy 6.60 6.60 Finalize 

43263 Endoscopic retrograde cholangiopancreatography (ercp); 

with pressure measurement of sphincter of oddi 6.60 6.60 Finalize 

43264 

Endoscopic retrograde cholangiopancreatography (ercp); 

with removal of calculi/debris from biliary/pancreatic 

duct(s) 

6.73 6.73 Finalize 

43265 

Endoscopic retrograde cholangiopancreatography (ercp); 

with destruction of calculi, any method (eg, mechanical, 

electrohydraulic, lithotripsy) 

8.03 8.03 Finalize 

43266 

Esophagogastroduodenoscopy, flexible, transoral; with 

placement of endoscopic stent (includes pre- and postdilation and guide wire passage, when performed) 4.05 4.17 Finalize 

43270 

Esophagogastroduodenoscopy, flexible, transoral; with 

ablation of tumor(s), polyp(s), or other lesion(s) (includes 

pre- and post-dilation and guide wire passage, when 

performed) 

4.21 4.26 Finalize 

43273 

Endoscopic cannulation of papilla with direct visualization 

of pancreatic/common bile duct(s) (list separately in 

addition to code(s) for primary procedure) 

2.24 2.24 Finalize 

43274 

Endoscopic retrograde cholangiopancreatography (ercp); 

with placement of endoscopic stent into biliary or 

pancreatic duct, including pre- and post-dilation and guide 

wire passage, when performed, including sphincterotomy, 

when performed, each stent 

8.48 8.58 Finalize 

43275 

Endoscopic retrograde cholangiopancreatography (ercp); 

with removal of foreign body(s) or stent(s) from 

biliary/pancreatic duct(s) 

6.96 6.96 Finalize 
CMS-1612-FC 248

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

43276 

Endoscopic retrograde cholangiopancreatography (ercp); 

with removal and exchange of stent(s), biliary or 

pancreatic duct, including pre- and post-dilation and guide 

wire passage, when performed, including sphincterotomy, 

when performed, each stent exchanged 

8.84 8.94 Finalize 

43277 

Endoscopic retrograde cholangiopancreatography (ercp); 

with trans-endoscopic balloon dilation of 

biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), 

including sphincterotomy, when performed, each duct 

7.00 7.00 Finalize 

43278 

Endoscopic retrograde cholangiopancreatography (ercp); 

with ablation of tumor(s), polyp(s), or other lesion(s), 

including pre- and post-dilation and guide wire passage, 

when performed 

7.99 8.02 Finalize 

43450 Dilation of esophagus, by unguided sound or bougie, 

single or multiple passes 1.38 1.38 Finalize 

43453 Dilation of esophagus, over guide wire 1.51 1.51 Finalize 

49405 

Image-guided fluid collection drainage by catheter (eg, 

abscess, hematoma, seroma, lymphocele, cyst); visceral 

(eg, kidney, liver, spleen, lung/mediastinum), 

percutaneous 

4.25 4.25 Finalize 

49406 

Image-guided fluid collection drainage by catheter (eg, 

abscess, hematoma, seroma, lymphocele, cyst); peritoneal 

or retroperitoneal, percutaneous 

4.25 4.25 Finalize 

49407 

Image-guided fluid collection drainage by catheter (eg, 

abscess, hematoma, seroma, lymphocele, cyst); peritoneal 

or retroperitoneal, transvaginal or transrectal 

4.50 4.50 Finalize 

50360 Renal allotransplantation, implantation of graft; without 

recipient nephrectomy 39.88 39.88 Finalize 

52332 Cystourethroscopy, with insertion of indwelling ureteral 

stent (eg, gibbons or double-j type) 2.82 2.82 Finalize 

52356 

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; 

with lithotripsy including insertion of indwelling ureteral 

stent (eg, gibbons or double-j type) 

8.00 8.00 Finalize 

62310 

Injection(s), of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other 

solution), not including neurolytic substances, including 

needle or catheter placement, includes contrast for 

localization when performed, epidural or subarachnoid; 

cervical or thoracic 

1.18 See II.G.3.a 

62311 

Injection(s), of diagnostic or therapeutic substance(s) 

(including anesthetic, antispasmodic, opioid, steroid, other 

solution), not including neurolytic substances, including 

needle or catheter placement, includes contrast for 

localization when performed, epidural or subarachnoid; 

lumbar or sacral (caudal) 

1.17 See II.G.3.a 
CMS-1612-FC 249

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

62318 

Injection(s), including indwelling catheter placement, 

continuous infusion or intermittent bolus, of diagnostic or 

therapeutic substance(s) (including anesthetic, 

antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, includes contrast for 

localization when performed, epidural or subarachnoid; 

cervical or thoracic 

1.54 See II.G.3.a 

62319 

Injection(s), including indwelling catheter placement, 

continuous infusion or intermittent bolus, of diagnostic or 

therapeutic substance(s) (including anesthetic, 

antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, includes contrast for 

localization when performed, epidural or subarachnoid; 

lumbar or sacral (caudal) 

1.50 See II.G.3.a 

63047 

Laminectomy, facetectomy and foraminotomy (unilateral 

or bilateral with decompression of spinal cord, cauda 

equina and/or nerve root[s], [eg, spinal or lateral recess 

stenosis]), single vertebral segment; lumbar 

15.37 15.37 Finalize 

63048 

Laminectomy, facetectomy and foraminotomy (unilateral 

or bilateral with decompression of spinal cord, cauda 

equina and/or nerve root[s], [eg, spinal or lateral recess 

stenosis]), single vertebral segment; each additional 

segment, cervical, thoracic, or lumbar (list separately in 

addition to code for primary procedure) 

3.47 3.47 Finalize 

64616 

Chemodenervation of muscle(s); neck muscle(s), 

excluding muscles of the larynx, unilateral (eg, for cervical 

dystonia, spasmodic torticollis) 

1.53 1.53 Finalize 

64617 

Chemodenervation of muscle(s); larynx, unilateral, 

percutaneous (eg, for spasmodic dysphonia), includes 

guidance by needle electromyography, when performed 

1.90 1.90 Finalize 

64642 Chemodenervation of one extremity; 1-4 muscle(s) 1.65 1.65 Finalize 

64643 

Chemodenervation of one extremity; each additional 

extremity, 1-4 muscle(s) (list separately in addition to code 

for primary procedure) 

1.22 1.22 Finalize 

64644 Chemodenervation of one extremity; 5 or more muscles 1.82 1.82 Finalize 

64645 

Chemodenervation of one extremity; each additional 

extremity, 5 or more muscles (list separately in addition to 

code for primary procedure) 

1.39 1.39 Finalize 

64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) 1.80 1.80 Finalize 

64647 Chemodenervation of trunk muscle(s); 6 or more muscles 2.11 2.11 Finalize 

66183 Insertion of anterior segment aqueous drainage device, 

without extraocular reservoir, external approach 13.20 13.20 Finalize 

67914 Repair of ectropion; suture 3.75 3.75 Finalize 

67915 Repair of ectropion; thermocauterization 2.03 2.03 Finalize 
CMS-1612-FC 250

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

67916 Repair of ectropion; excision tarsal wedge 5.48 5.48 Finalize 

67917 Repair of ectropion; extensive (eg, tarsal strip operations) 5.93 5.93 Finalize 

67921 Repair of entropion; suture 3.47 3.47 Finalize 

67922 Repair of entropion; thermocauterization 2.03 2.03 Finalize 

67923 Repair of entropion; excision tarsal wedge 5.48 5.48 Finalize 

67924 Repair of entropion; extensive (eg, tarsal strip or 

capsulopalpebral fascia repairs operation) 5.93 5.93 Finalize 

69210 Removal impacted cerumen requiring instrumentation, 

unilateral 0.61 0.61 Finalize 

70450 Computed tomography, head or brain; without contrast 

material 0.85 0.85 Finalize 

70460 Computed tomography, head or brain; with contrast 

material(s) 1.13 1.13 Finalize 

70551 Magnetic resonance (eg, proton) imaging, brain (including 

brain stem); without contrast material 1.48 1.48 Finalize 

70552 Magnetic resonance (eg, proton) imaging, brain (including 

brain stem); with contrast material(s) 1.78 1.78 Finalize 

70553 

Magnetic resonance (eg, proton) imaging, brain (including 

brain stem); without contrast material, followed by 

contrast material(s) and further sequences 

2.29 2.29 Finalize 

72141 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, cervical; without contrast material 1.48 1.48 Finalize 

72142 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, cervical; with contrast material(s) 1.78 1.78 Finalize 

72146 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, thoracic; without contrast material 1.48 1.48 Finalize 

72147 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, thoracic; with contrast material(s) 1.78 1.78 Finalize 

72148 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, lumbar; without contrast material 1.48 1.48 Finalize 

72149 Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, lumbar; with contrast material(s) 1.78 1.78 Finalize 

72156 

Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, without contrast material, followed by contrast 

material(s) and further sequences; cervical 

2.29 2.29 Finalize 

72157 

Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, without contrast material, followed by contrast 

material(s) and further sequences; thoracic 

2.29 2.29 Finalize 

72158 

Magnetic resonance (eg, proton) imaging, spinal canal and 

contents, without contrast material, followed by contrast 

material(s) and further sequences; lumbar 

2.29 2.29 Finalize 
CMS-1612-FC 251

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

72191 

Computed tomographic angiography, pelvis, with contrast 

material(s), including noncontrast images, if performed, 

and image postprocessing 

1.81 1.81 Finalize 

75896-

26 

Transcatheter therapy, infusion, other than for 

thrombolysis, radiological supervision and interpretation 1.31 1.31 Finalize 

75896-

TC 

Transcatheter therapy, infusion, other than for 

thrombolysis, radiological supervision and interpretation C C Finalize 

75898-

26 

Angiography through existing catheter for follow-up study 

for transcatheter therapy, embolization or infusion, other 

than for thrombolysis 

1.65 1.65 Finalize 

75898-

TC 

Angiography through existing catheter for follow-up study 

for transcatheter therapy, embolization or infusion, other 

than for thrombolysis 

C C Finalize 

77001 

Fluoroscopic guidance for central venous access device 

placement, replacement (catheter only or complete), or 

removal (includes fluoroscopic guidance for vascular 

access and catheter manipulation, any necessary contrast 

injections through access site or catheter with related 

venography radiologic supervision and interpretation, and 

radiographic documentation of final catheter position) (list 

separately in addition to code for primary procedure) 

0.38 0.38 Finalize 

77002 Fluoroscopic guidance for needle placement (eg, biopsy, 

aspiration, injection, localization device) 0.54 0.54 Finalize 

77003 

Fluoroscopic guidance and localization of needle or 

catheter tip for spine or paraspinous diagnostic or 

therapeutic injection procedures (epidural or 

subarachnoid) 

0.60 0.60 Finalize 

77280 Therapeutic radiology simulation-aided field setting; 

simple 0.70 0.70 Finalize 

77285 Therapeutic radiology simulation-aided field setting; 

intermediate 1.05 1.05 Finalize 

77290 Therapeutic radiology simulation-aided field setting; 

complex 1.56 1.56 Finalize 

77293 Respiratory motion management simulation (list 

separately in addition to code for primary procedure) 2.00 2.00 Finalize 

77295 3-dimensional radiotherapy plan, including dose-volume 

histograms 4.29 4.29 Finalize 

81161 

Dmd (dystrophin) (eg, duchenne/becker muscular 

dystrophy) deletion analysis, and duplication analysis, if 

performed 

X X Finalize 

88112 

Cytopathology, selective cellular enhancement technique 

with interpretation (eg, liquid based slide preparation 

method), except cervical or vaginal 

0.56 0.56 Finalize 

88120 

Cytopathology, in situ hybridization (eg, fish), urinary 

tract specimen with morphometric analysis, 3-5 molecular 

probes, each specimen; manual 

1.20 1.20 Finalize 
CMS-1612-FC 252

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

88121 

Cytopathology, in situ hybridization (eg, fish), urinary 

tract specimen with morphometric analysis, 3-5 molecular 

probes, each specimen; using computer-assisted 

technology 

1.00 1.00 Finalize 

88342 Immunohistochemistry or immunocytochemistry, per 

specimen; initial single antibody stain procedure I See II.G.3.b 

88343 

Immunohistochemistry or immunocytochemistry, each 

separately identifiable antibody per block, cytologic 

preparation, or hematologic smear; each additional 

separately identifiable antibody per slide (list separately in 

addition to code for primary procedure) 

I See II.G.3.b 

88365 In situ hybridization (eg, fish), per specimen; initial single 

probe stain procedure 1.20 See II.G.3.b 

88367 

Morphometric analysis, in situ hybridization (quantitative 

or semi-quantitative), using computer-assisted technology, 

per specimen; initial single probe stain procedure 

1.30 See II. G.3.b 

88368 

Morphometric analysis, in situ hybridization (quantitative 

or semi-quantitative), manual, per specimen; initial single 

probe stain procedure 

1.40 See II.G3.b 

88375 Optical endomicroscopic image(s), interpretation and 

report, real-time or referred, each endoscopic session I 0.91 Finalize 

90785 Interactive complexity (list separately in addition to the 

code for primary procedure) 0.33 0.33 Finalize 

90791 Psychiatric diagnostic evaluation 3.00 3.00 Finalize 

90792 Psychiatric diagnostic evaluation with medical services 3.25 3.25 Finalize 

90832 Psychotherapy, 30 minutes with patient and/or family 

member 1.50 1.50 Finalize 

90833 

Psychotherapy, 30 minutes with patient and/or family 

member when performed with an evaluation and 

management service (list separately in addition to the code 

for primary procedure) 

1.50 1.50 Finalize 

90834 Psychotherapy, 45 minutes with patient and/or family 

member 2.00 2.00 Finalize 

90836 

Psychotherapy, 45 minutes with patient and/or family 

member when performed with an evaluation and 

management service (list separately in addition to the code 

for primary procedure) 

1.90 1.90 Finalize 

90837 Psychotherapy, 60 minutes with patient and/or family 

member 3.00 3.00 Finalize 

90838 

Psychotherapy, 60 minutes with patient and/or family 

member when performed with an evaluation and 

management service (list separately in addition to the code 

for primary procedure) 

2.50 2.50 Finalize 

90839 Psychotherapy for crisis; first 60 minutes 3.13 3.13 Finalize 
CMS-1612-FC 253

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

90840 Psychotherapy for crisis; each additional 30 minutes (list 

separately in addition to code for primary service) 1.50 1.50 Finalize 

90845 Psychoanalysis 2.10 2.10 Finalize 

90846 Family psychotherapy (without the patient present) 2.40 2.40 Finalize 

90847 Family psychotherapy (conjoint psychotherapy) (with 

patient present) 2.50 2.50 Finalize 

90853 Group psychotherapy (other than of a multiple-family 

group) 0.59 0.59 Finalize 

90863 

Pharmacologic management, including prescription and 

review of medication, when performed with 

psychotherapy services (list separately in addition to the 

code for primary procedure) 

I I Finalize 

92521 Evaluation of speech fluency (eg, stuttering, cluttering) 1.75 1.75 Finalize 

92522 Evaluation of speech sound production (eg, articulation, 

phonological process, apraxia, dysarthria); 1.50 1.50 Finalize 

92523 

Evaluation of speech sound production (eg, articulation, 

phonological process, apraxia, dysarthria); with evaluation 

of language comprehension and expression (eg, receptive 

and expressive language) 

3.00 3.00 Finalize 

92524 Behavioral and qualitative analysis of voice and resonance 1.50 1.50 Finalize 

93000 Electrocardiogram, routine ecg with at least 12 leads; with 

interpretation and report 0.17 0.17 Finalize 

93010 Electrocardiogram, routine ecg with at least 12 leads; 

interpretation and report only 0.17 0.17 Finalize 

93582 Percutaneous transcatheter closure of patent ductus 

arteriosus 12.56 12.56 Finalize 

93583 

Percutaneous transcatheter septal reduction therapy (eg, 

alcohol septal ablation) including temporary pacemaker 

insertion when performed 

14.00 14.00 Finalize 

93880 Duplex scan of extracranial arteries; complete bilateral 

study 0.60 See II.G.3.b 

93882 Duplex scan of extracranial arteries; unilateral or limited 

study 0.40 See II.G.3.b 

95816 Electroencephalogram (eeg); including recording awake 

and drowsy 1.08 1.08 Finalize 

95819 Electroencephalogram (eeg); including recording awake 

and asleep 1.08 1.08 Finalize 

95822 Electroencephalogram (eeg); recording in coma or sleep 

only 1.08 1.08 Finalize 

95928 Central motor evoked potential study (transcranial motor 

stimulation); upper limbs 1.50 1.50 Finalize 

95929 Central motor evoked potential study (transcranial motor 

stimulation); lower limbs 1.50 1.50 Finalize 
CMS-1612-FC 254

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

96365 Intravenous infusion, for therapy, prophylaxis, or 

diagnosis (specify substance or drug); initial, up to 1 hour 0.21 0.21 Finalize 

96366 

Intravenous infusion, for therapy, prophylaxis, or 

diagnosis (specify substance or drug); each additional hour 

(list separately in addition to code for primary procedure) 

0.18 0.18 Finalize 

96367 

Intravenous infusion, for therapy, prophylaxis, or 

diagnosis (specify substance or drug); additional 

sequential infusion of a new drug/substance, up to 1 hour 

(list separately in addition to code for primary procedure) 

0.19 0.19 Finalize 

96368 

Intravenous infusion, for therapy, prophylaxis, or 

diagnosis (specify substance or drug); concurrent infusion 

(list separately in addition to code for primary procedure) 

0.17 0.17 Finalize 

96413 Chemotherapy administration, intravenous infusion 

technique; up to 1 hour, single or initial substance/drug 0.28 0.28 Finalize 

96415 

Chemotherapy administration, intravenous infusion 

technique; each additional hour (list separately in addition 

to code for primary procedure) 

0.19 0.19 Finalize 

96417 

Chemotherapy administration, intravenous infusion 

technique; each additional sequential infusion (different 

substance/drug), up to 1 hour (list separately in addition to 

code for primary procedure) 

0.21 0.21 Finalize 

97610 

Low frequency, non-contact, non-thermal ultrasound, 

including topical application(s), when performed, wound 

assessment, and instruction(s) for ongoing care, per day 

C C Finalize 

98940 Chiropractic manipulative treatment (cmt); spinal, 1-2 

regions 0.46 0.46 Finalize 

98941 Chiropractic manipulative treatment (cmt); spinal, 3-4 

regions 0.71 0.71 Finalize 

98942 Chiropractic manipulative treatment (cmt); spinal, 5 

regions 0.96 0.96 Finalize 

99446 

Interprofessional telephone/internet assessment and 

management service provided by a consultative physician 

including a verbal and written report to the patient's 

treating/requesting physician or other qualified health care 

professional; 5-10 minutes of medical consultative 

discussion and review 

B B Finalize 

99447 

Interprofessional telephone/internet assessment and 

management service provided by a consultative physician 

including a verbal and written report to the patient's 

treating/requesting physician or other qualified health care 

professional; 11-20 minutes of medical consultative 

discussion and review 

B B Finalize 

99448 

Interprofessional telephone/internet assessment and 

management service provided by a consultative physician 

including a verbal and written report to the patient's 

treating/requesting physician or other qualified health care 

professional; 21-30 minutes of medical consultative 

discussion and review 

B B Finalize 
CMS-1612-FC 255

HCPCS 

Code Long Descriptor 

CY 2014 

Interim 

Final 

Work 

RVU 

CY 

2015 

Work 

RVU 

CY 2015 Action 

99449 

Interprofessional telephone/internet assessment and 

management service provided by a consultative physician 

including a verbal and written report to the patient's 

treating/requesting physician or other qualified health care 

professional; 31 minutes or more of medical consultative 

discussion and review 

B B Finalize 

99481 Reduce temperature of total body in a critically ill neonate, 

per day C Deleted 

99482 Reduce temperature of head in a critically ill neonate, per 

day C Deleted 

G0461 Immunohistochemistry or immunocytochemistry, per 

specimen; first single or multiplex antibody stain 0.60 Deleted 

G0462 

Immunohistochemistry or immunocytochemistry, per 

specimen; each additional single or multiplex antibody 

stain (list separately in addition to code for primary 

procedure) 

0.24 Deleted 

 In the following section, we discuss each code for which we received a comment on the 

CY 2014 interim final work value or work time during the comment period for the CY 2014 final 

rule with comment period or for which we are modifying the CY 2014 interim final work RVU, 

work time or procedure status indicator for CY 2015. If a code in Table 15 is not discussed in 

this section, we did not receive any comments on that code and are finalizing the interim final 

work RVU and time without modification for CY 2015. 

(1) Mohs Surgery (CPT codes 17311 and 17313) 

As detailed in the CY 2014 PFS final rule with comment period, we maintained the CY 

2013 work RVUs for CPT codes 17311 and 17313 codes, based upon the RUC-recommended 

work RVUs. 

Comment: We received a comment that was supportive of the interim final work RVU. 

Response: We thank the commenter for their support and are finalizing the CY 2014 

interim final values for CY 2015. 
CMS-1612-FC 256

(2) Breast Biopsy (CPT codes 19081, 19082, 19083, 19084, 19085, 19086, 19281, 19282, 

19283, 19284, 19285, 19286, 19287, and 19288) 

For CY 2014, the CPT Editorial Panel created 14 new codes, CPT codes 19081 through 

19288, to describe breast biopsy and placement of breast localization devices, and the RUC 

recommended work RVUs for each of these codes. In the 2014 final rule with comment period, 

we established interim final values for all of these codes as recommended by the RUC except for 

CPT code 19287 and its add-on CPT code, 19288, which are used for magnetic resonance (MR) 

guidance. We expressed concern that for CPT code 19287 the RUC-recommended work RVUs 

were too high in relation to those of other marker placement codes, and refined it to a lower 

value. Since we had adopted the RUC recommendation that all the add-on codes in this family 

have work RVUs equal to 50 percent of the base code’s work RVU, our refinement of CPT code 

19287 resulted in a refinement of CPT code 19288 also. We also changed the intraservice time 

of CPT code 19286, an add-on code, from 19 minutes to 15 minutes since we believed the 

intraservice time of an add-on code should not be higher than its base code and the base code for 

CPT code 19286, has an intraservice time of 15 minutes. 

 Comment: Several commenters disagreed with the new CPT coding structure for breast 

biopsy and placement of breast localization devices because, unlike the predecessor structure, it 

fails to distinguish between the two types of biopsy devices - standard core needle and vacuum 

assisted. One commenter suggested that the payment should be higher when services are 

vacuum assisted, and suggested that CMS create a modifier to report when these services are 

furnished using a vacuum assisted biopsy or create a series of G-codes that distinguish between 

standard core needle biopsy and vacuum assisted biopsy. 

 Response: We prefer to use the CPT coding structure unless a programmatic need 

suggests that an alternative coding structure is preferable. In this case, we believe that we can 
CMS-1612-FC 257

pay appropriately for these services using the new CPT coding structure. To the extent that the 

commenters think the CPT coding system is not ideal for these services, we believe the CPT 

Editorial Panel is the appropriate forum for this concern. The commenters are mistaken 

regarding how the inputs for these codes were determined as they are based upon the typical 

service being vacuum assisted. 

 Comment: Several commenters disagreed with the interim final work RVUs we 

established for CPT codes 19287 and 19288, stating that the higher RUC-recommended RVUs 

were more appropriate and would maintain relativity within the family. The commenters stated 

that these services have longer intraservice time than other codes in the marker placement 

family, are of high intensity, produce high patient and family anxiety, and have higher 

malpractice costs. One commenter requested that the entire breast biopsy code family be 

referred to refinement. Other commenters requested refinement panel review of selected codes 

within this family. 

Response: Based upon this request, we referred this family of codes to the CY 2014 

multi-specialty refinement panel for further review. Prior to CY 2014, breast biopsies and 

marker placements were billed using a single code. In addition, the appropriate image guidance 

code was separately billed. Prior to CY 2014, there were individual guidance codes for the 

different types of guidance including MR and stereotactic guidance. 

For CY 2013, the MR guidance code, CPT code 77032, had a lower work RVU than the 

stereotactic guidance code, CPT code 77031. Combining the values for the marker placement or 

biopsy codes with the guidance codes should not, in our view, result in a change in the rank order 

of the guidance. Accordingly, we do not believe the bundled code that includes MR guidance 

should now be valued significantly higher than one that includes the stereotactic guidance. Also, 

the refinement panel discussions did not provide new clinical information. Therefore, we 
CMS-1612-FC 258

continue to believe the CY 2014 interim final values are appropriate for CPT codes 19287 and 

19288, and are finalizing them for CY 2015. 

 Comment: Commenters stated that the RUC-recommended intraservice time of 19 

minutes for CPT code 19286, which is an add-on code, was incorrect and that the code should 

have the same intraservice time as its base code (15 minutes) rather than the 14 minutes assigned 

by CMS. The commenter said that this was consistent with the other base code/add-on 

relationships across the family. 

 Response: We agree and are finalizing the intraservice time for CPT code 19286 at 15 

minutes. 

 Comment: In response to our request for confirmation that a post procedure 

mammogram is typically furnished with a breast marker placement procedure, commenters 

agreed that it was. However, they disagreed with our assertion that if it was typical it should be 

bundled with the appropriate breast marker procedures. Commenters said that it should be a 

separately reportable service because it requires additional work not captured by the codes in this 

family. 

Response: We thank commenters for their feedback. We are not bundling post procedure 

mammograms with the appropriate breast marker codes at this time, but will consider whether as 

a services that typically occur together they should be bundled. 

(3) Hip and Knee Replacement (CPT Codes 27130, 27446 and 27447) 

In the CY 2014 final rule with comment period we established interim final values for 

three CPT codes for hip and knee replacements that had previously been identified as potentially 

misvalued codes under the CMS high expenditure procedural code screen. For CY 2014, we 

established the RUC-recommended work value of 17.48 as interim final work RVUs for CPT 

code 27446. As we explained in the CY 2014 final rule with comment period, we established 
CMS-1612-FC 259

interim final work RVUs for CPT codes 27130 and 27447 that varied from those recommended 

by the RUC based upon information that we received from the relevant specialty societies. We 

noted that the information presented by the specialty societies and the RUC raised concerns 

regarding the appropriate valuation of these services, especially related to the use of the best data 

source for determining the intraservice time involved in furnishing PFS services. Specifically, 

there was significant variation between the time values estimated through a survey versus those 

collected through specialty databases. We characterized our concerns saying, “The divergent 

recommendations from the specialty societies and the RUC regarding the accuracy of the 

estimates of time for these services, including both the source of time estimates for the procedure 

itself as well as the inpatient and outpatient visits included in the global periods for these codes, 

lead us to take a cautious approach in valuing these services.” 

With regard to the specific valuations, we agreed with the RUC’s recommendation to 

value CPT codes 27130 and 27447 equally. We explained that we modified the RUCrecommended work RVUs for these two codes to reflect the visits in the global period as 

recommended by the specialty societies, resulting in a 1.12 work RVU increase from the RUCrecommended value for each code. Accordingly, we assigned CPT codes 27130 and 27447 an 

interim final work RVU of 20.72. We sought public comment regarding, not only the 

appropriate work RVUs for these services, but also the most appropriate reconciliation for the 

conflicting information regarding time values for these services as presented to us by the 

physician community. We also sought public comment on the use of specialty databases as 

compared to surveys for determining time values, potential sources of objective data regarding 

procedure times, and levels of visits furnished during the global periods for the services 

described by these codes. 
CMS-1612-FC 260

Comment: The RUC submitted comments explaining how it reached its 

recommendations for these codes and that it followed its process consistently in developing its 

recommendations on these codes. All those who commented specifically on the interim final 

work RVUs for these codes objected to the interim final work RVUs - some citing potential 

access problems. Commenters suggested that we use more reliable time data. Commenters 

suggested that valuation should be based on actual time data, which demonstrates that the time 

for this code has not changed since the last valuation; and thus the work RVUs should not 

decrease from the CY 2013 values. Among the commenters’ suggestions were using data from 

the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement 

(FORCE-TJR), which includes data on more than 15,000 total lower extremity joint arthroplasty 

procedures, including time in/time out data for at least half of the procedures, and working with 

the specialty societies to explore the best data collection methods. A commenter suggested 

restoring the CY 2013 work RVUs until additional time data are available. Another commenter 

suggested valuing these services utilizing a reverse building block methodology resulting in 

work RVU of 21.18 for CPT codes 27130 and 22.11 for CPT code 27447. A commenter stated 

that the hip and knee replacement codes should be valued differently since they are clinically 

different procedures. Two commenters expressed concern regarding the use of a final rule to 

establish interim values for established hip and knee procedures due to the lack of opportunity it 

provides stakeholders to analyze and comment on reductions prior to implementation. 

Response: In the CY 2014 final rule with comment period, we noted concerns about the 

time data used in valuing these services and requested additional input from stakeholders 

regarding using other sources of data beyond the surveys typically used by the RUC. We do not 

believe that we received the kind of information and the level of detail about the other types of 

data suggested by commenters that we would need to be able to use routinely in valuing 
CMS-1612-FC 261

procedures. We will continue to explore the use of other data on time. As we discuss in section 

II.B. we have engaged contractors to assist us in exploring alternative data sources to use in 

determining the times associated with particular services. At this time, we are not convinced that 

data from another source would result in an improved value for these services. Nor did we find 

the reasons given for modifying the interim final work values established in CY 2014. The 

interim final values are based upon the best data we have available and preserve appropriate 

relativity with other codes. Accordingly, we are finalizing the interim final values for these 

procedures. 

(4) Transcatheter Placement Intravascular Stent (CPT Code 37236, 37237, 37238, and 37239) 

 For CY 2014, we established the RUC-recommended work RVUs for newly created CPT 

codes 37236, 37237, and 37238 as the interim final values. We disagreed with the RUCrecommended work RVU for CPT code 37239, which is the add-on code to CPT code 37238, for 

the placement of an intravascular stent in each additional vein. As we described in the CY 2014 

final rule with comment period we believe that the work for placement of an additional stent in a 

vein should bear the same relationship to the work of placing an initial stent in the vein as the 

placement of an additional stent in an artery to the placement of the initial stent in an artery. 

 

 Comment: Many commenters indicated that our valuation of CPT code 37239 was 

inappropriate. They indicated that instead we should use the RUC’s recommended work RVU of 

3.34 for this code since the procedure is more intense and requires more physician work than 

would result from the comparison made by CMS. One commenter requested that CPT code 

37239 be referred to the refinement panel. 

 Response: After re-review, we continue to believe that the ratio of the work of the 

placement of the initial stent to the placement of additional stents is the same whether the stents 
CMS-1612-FC 262

are placed in an artery or a vein, and accordingly the appropriate ratio is found in the RUCrecommended work RVUs of CPT codes 37236 and 37237, the comparable codes for the 

arteries. For that reason, we are finalizing our CY 2014 interim final values. Additionally, we 

did not refer these codes for refinement panel review because the criteria for refinement panel 

review were not met. 

(5) Embolization and Occlusion Procedures (CPT codes 37242 and 37243) 

 For CY 2014, we established interim final work RVUs for these two codes based upon 

the survey’s 25th percentile. As we discussed in the CY 2014 interim final rule with comment 

period, we believed that the RUC-recommended work RVU for CPT code 37242 did not 

adequately take into account the substantial decrease in intraservice time. We indicated that we 

believed that the survey’s 25th percentile work RVU of 10.05 was more consistent with the 

decreases in intraservice time since its last valuation and more appropriately reflected the work 

of the procedure. Similarly, we did not believe that the RUC-recommended work RVU for CPT 

code 37243 adequately considered the substantial decrease in intraservice time for the procedure; 

and we also use the survey’s 25th percentile for CPT code 37243. 

 Comment: Many commenters disagreed with our interim final valuation of 37242, 

including one who recommended a work RVU of 11.98. One commenter also believed the work 

RVU assigned to CPT code 37243 was inappropriate and recommended instead a work RVU of 

14.00. Commenters requested that the family of codes be referred for refinement. 

 Response: After consideration of the comments, we continue to believe that work RVUs 

should reflect the decreases in intraservice time that have occurred since the last valuation. As a 

result, we continue to believe that our CY 2014 interim final values are most appropriate and are 

finalizing them for CY 2015. Additionally, we did not refer these codes for refinement panel 

review because the criteria for refinement panel review were not met. 
CMS-1612-FC 263

(6) Rigid Transoral Esophagoscopy (CPT Codes 43191, 43192, 43193, 43194, 43195 and 

43196) 

We established CY 2014 interim final work RVUs for the rigid transoral esophagoscopy 

codes using a ratio of 1 RVU per 10 minutes of intraservice time, resulting in a RVU of 2.00 for 

CPT code 43191, 3.00 for CPT code 43193, 3.00 for CPT code 43194, 3.00 for CPT code 43195, 

and 3.30 for CPT code 43196. As we detailed in the CY 2014 final rule with comment period, 

the surveys showed that this ratio was reflected for about half of the rigid transoral 

esophagoscopy codes. Additionally, we noted that this ratio was further supported by the 

relationship between the CY 2013 work value of 1.59 RVUs for CPT code 43200 

(Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by 

brushing or washing (separate procedure)) and its intraservice time of 15 minutes. For CPT code 

43192, the 1 work RVU per 10 minutes ratio resulted in a value that was less than the survey 

low, and thus did not appear to be appropriate for this procedure. Therefore, we established a 

CY 2014 interim final work RVU for CPT code 43192 of 2.45 based upon the survey low. 

Comment: Multiple commenters objected to the interim final work RVUs assigned to 

CPT codes 43191-43196, and expressed dissatisfaction with CMS’s explanation for the 

valuations. The commenters specifically noted that CMS did not account for the difference in 

intensity between flexible and rigid scopes now that there are separate codes for these 

procedures. The commenters also suggested that the reduction in time in the RUC 

recommendations for codes 43191, 43193, 43195, and 43196 was also based on data from 

procedures with flexible scopes. The commenters also stated that our valuation of services based 

upon 1 work RVU per 10 minutes of intraservice time was inappropriate and was based on the 

survey low, which is an anomalous outlier. The commenters suggested the following work 

RVUs based upon the RUC recommended values: 2.78 for CPT code 43191, 3.21 for CPT code 
CMS-1612-FC 264

43192, 3.36 for CPT code 43193, 3.99 for CPT code 43194, 3.21 for CPT code 43195 and 3.36 

or CPT code 43196. Finally, the commenters asked that all these codes be referred to a 

refinement panel for reconsideration. 

Response: After consideration of the comments, we agree that modification of the CY 

2014 interim final values is appropriate. Based upon the information provided in comments and 

further investigation, we believe that greater intensity is involved in furnishing rigid than flexible 

transoral esophagoscopy. Accordingly, rather than assigning 1 work RVU per 10 minutes of 

intraservice time as we did for the CY 2014 interim final, we are assigning a final work RVU to 

the base code, CPT code 41391, of 2.49. This work RVU is based on increasing the work RVU 

of the previous comparable code (1.59) to reflect the percentage increase in time for the CY 2014 

code. For the remaining rigid esophagoscopy codes, we developed RVUs by starting with the 

RVUs for the corresponding flexible esophagoscopy codes, and increasing those values by 

adding the difference between the base flexible esophagoscopy and the base rigid esophagoscopy 

codes to arrive at final RVUs. We are establishing a final work RVU of 2.79 to CPT code 

43192, 2.79 to CPT code 43193, 3.51 to CPT code 43194, 3.07 to CPT code 43195, and 3.31 to 

CPT code 43196. These codes were not referred to refinement because the request did not meet 

the criteria for referral. 

(7) Flexible Transnasal Esophagoscopy (CPT codes 43197 and 43198) 

We established CY 2014 interim final work RVUs of 1.48 for CPT code 43197 and 1.78 

for CPT code 43198. As detailed in the CY 2014 final rule with comment period, we removed 2 

minutes of the pre-scrub, dress and wait preservice time from the calculation of the work RVUs 

that we established for CY 2014 for CPT codes 43200 and 43202 because we believed that 

unlike the transoral codes, which they correspond to, the transnasal services are not typically 

furnished with moderate sedation. 
CMS-1612-FC 265

Comment: Multiple commenters objected to the work RVUs for these codes and in 

particular to CMS basing its valuation on the fact that these codes typically do not involve 

moderate sedation. Although the commenters agreed that these codes typically do not involve 

moderate sedation, they said that procedures involving local/topical anesthesia often take more 

work than those involving general sedation due to the difficulties of furnishing services to a 

conscious and often anxious patient. Some also noted that it ignores the time necessary to apply 

local/topical anesthesia and wait for it to take effect. A commenter urged CMS to establish 

values based upon the RUC recommendations. Commenters requested that these codes be 

referred for refinement. 

Response: After consideration of the comments, we agree that the work RVUs for these 

codes should not be reduced because moderate sedation is not typically used. Accordingly, we 

agree with the RUC recommendation to assign the same work RVUs to these codes as to CPT 

code 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) 

by brushing or washing when performed) and 43202 (Esophagoscopy, flexible, transoral; with 

biopsy, single or multiple) the comparable transoral codes. We are finalizing work RVUs of 

1.52 and 1.82 for CPT codes 43197 and 43198, respectively. We did not refer these codes to 

refinement because the request did not meet the criteria for refinement panel review. 

(8) Flexible Transoral Esophagoscopy, (CPT Codes 43200, 43202, 43204, 43205, 43211, 

43212, 43213, 43214, 43215, 43227, 43229, 43231, and 43232) 

 We established CY 2014 interim final work RVUs for the flexible transoral 

esophagoscopy family, which are detailed in Table 15. As we described in the CY 2014 final 

rule with comment period, to establish work values for these codes we used a variety of 

methodologies as did the RUC. The methodologies used by CMS And the RUC include basing 

values on the surveys (either medians or 25th percentiles), crosswalking values to other codes, 
CMS-1612-FC 266

using the building block methodology, and valuing a family of codes based on the incremental 

differences in the work RVUs between the codes being valued and another family of codes. As 

we did for the rigid transoral esophagoscopy codes, in addition to the methodologies used by the 

RUC, we also reduced the work RVUs for particular codes in direct proportion to the reduction 

in times that were recommended by the RUC. Using these methodologies, we assigned the RUCrecommended work RVUs for five codes in this family; for the other eight codes we used these 

same methodologies but because of different values for a base code or variation in the crosswalk 

selected we obtained different values. 

Comment: Commenters objected to the interim final RVUs we assigned for CPT code 

43200, the base code for flexible transoral esophagoscopy, because they did not believe the work 

RVU for the code should be less than they were as of CY 2013 when there was a single code to 

report both flexible and rigid esophagoscopy services. Commenters also disagreed with the way 

we used standard methodologies to value many of these codes, including using the ratio of 1 

work RVU per 10 minutes of intraservice time to CPT code 43200. Commenters requested that 

we accept the RUC values for all the flexible transoral esophagoscopy codes and asked that we 

refer all these codes to the refinement panel. 

Response: Although refinement was requested for all of the flexible transoral 

esophagoscopy codes, we found that the codes (CPT codes 43204, 43205 and 43233) met the 

refinement criteria, and those were referred to the refinement panel. After consideration of the 

comments and the refinement panel results, we are revising the work RVUs for many of the 

codes in this family. 

For CPT code 43200, which is the base code for flexible transoral esophagoscopy, we 

agree with commenters that another methodology is preferable to applying the work RVU ratio 

of 1 RVU per 10 minutes of intraservice time. In revaluing this service, we subtracted 0.07 to 
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account for the 3 minute decrease in postservice time since the last valuation from the CY 2013 

work RVU for the predecessor base code, which resulted in a work RVU of 1.52. We are 

finalizing this work RVU. 

The CY 2014 interim final work RVUs for CPT codes 43201, 43202, 43204, 43205 and 

43215 were all based upon methodologies using the work RVU of the base code, 43200. As we 

are establishing a final value for CPT code 43200 that is higher than the CY 2014 interim final 

value, we are also adjusting the work RVUs for the other codes based upon the new work RVU 

for CPT code 43200. We are finalizing a work RVU of 1.82 for 43201, 1.82 for 43202, 2.43 for 

43204, 2.54 for 43205, and 2.54 for 43215. 

CPT codes 43204 and 43205 were considered by the refinement panel. The refinement 

panel median for each of these codes was 2.77 and 2.88, respectively. The refinement panel 

discussion reiterated the information presented to the RUC and in the comments in response to 

the CY 2014 final rule with comment period, such as that the typical patient for these codes are 

sicker and thus the work is more intense. Because we do not agree with commenters’ contention 

that higher work RVUs are warranted since these codes involve the sicker patients or that our 

methodology for calculating the interim final RVUs was inappropriate, we are establishing final 

values determined using these methodologies. However, due to the change in the base code, 

CPT code 43200, as discussed in the previous paragraph the final values for these codes are 

higher than the interim final values. 

In the CY 2014 final rule with comment period, we assigned an interim final work RVU 

of 4.21 to CPT code 43211 by using a comparable esophagogastroduodenoscopy (EGD) code 

and subtracting the difference in work between the base esophagoscopy and base EGD codes. 

After consideration of the comments that indicated the interim final work RVU of 4.21 was too 

low, we believe this code should instead be crosswalked to CPT code 31636 (Bronchoscopy 
CMS-1612-FC 268

bronch stents), which we believe is a comparable service with comparable intensity. It has the 

same intraservice time and slightly higher total time. As a result we are finalizing a work RVU 

of 4.30. 

As we noted in the CY 2014 final rule with comment period, we crosswalked the interim 

final work RVU for CPT 43212 to that of CPT code 43214. Since we are increasing the work 

RVU for CPT code 43214, we are also increasing the work RVU for CPT code 43212, which is 

consistent with comments that we had undervalued this procedure. 

As we detailed in the CY 2014 final rule with comment period, we based the work RVU 

of 4.73 for CPT code 43213 on the value of CPT code 43220, increased proportionately to reflect 

the longer intraservice time of CPT code 43213. The refinement panel median was 5.00 for this 

code. No new information was presented at the refinement panel. We continue to believe that 

4.73 is the appropriate work RVU and are finalizing it. 

Based upon the information presented by commenters about the typical patient and the 

advanced skills required for the procedure, we are changing our method of valuing CPT code 

43214. We believe it should be crosswalked to CPT 52214 (cystoscopy), which we believe is 

similar in intensity. This results in a final work RVU of 3.50 as compared to an interim final of 

3.38. This refinement also supports the belief made by commenters that the work of CPT code 

43214 is greater than the interim final work RVU. Therefore, we are finalizing a work RVU of 

3.50 for CPT code 43214. 

For CPT code 43227, we modified the CY 2013 work RVU to reflect the percentage 

decrease in intraservice time of 36 minutes to 30 minutes in the RUC recommendation to 

establish a CY 2014 interim final value of 2.99. The commenters stated that the survey validates 

the RUC recommendation of 3.26 and that the drop in intraservice time that upon which we 

based our change in the work RVU was inappropriate since the intraservice time had not really 
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changed. They contend that the change was from moving the time for moderate sedation from 

intraservice to preservice. We disagree. We have no information from the RUC that leads us to 

believe that when the pre-service packages were developed several years ago and moderate 

sedation was explicitly recognized as a pre-service item that the RUC also intended CMS to 

assume that the intraservice times were no longer correct. We believe that our proposed 

valuation methodology is correct and thus are finalizing a work RUV of 2.99. 

Commenters, disagreeing with our crosswalk of CPT code 43229 to CPT code 43232, 

stated that the two codes were not comparable. We disagree. We continue to believe this 

crosswalk is appropriate as the times and intensities are quite similar. We note that the RUC also 

bases crosswalks on the comparability of time and intensity of codes and not on the clinical 

similarity of work. Thus, we will continue this crosswalk. However, as discussed below, we are 

refining the interim final value of CPT code 43232 to 3.59 and thus are finalizing the work RVU 

of 3.59 for CPT code 43229. 

For CPT code 43231, we added the work of an endobronchial ultrasound (EBUS) to the 

work of the base esophagoscopy code to arrive at our interim final value. The commenters 

disagreed with our approach, stating that the EBUS code is an add-on code and as such does not 

have pre- and postservice work. We agree that pre- and postservice work is not included in the 

EBUS code nor should it be for the ultrasound portion of the examination of 

esophagus. Therefore, we are finalizing a work RVU of 2.90. 

For CPT code 43232, the commenters stated our interim final value is too low and that 

the work involved in this code is appropriately reflected in the RUC recommendation. They 

objected to our basing the work RVU for 43232 on the difference between the RUCrecommended values for this code and CPT code 43231. We learned from the comments that the 

typical patient for this service has advanced cancer and agree that our interim final value may not 
CMS-1612-FC 270

represent the full extent of the work involved in this procedure. Therefore, we are crosswalking 

this code to CPT code 36595 (Mechanical removal of pericatheter obstructive material (eg, fibrin 

sheath) from central venous device via separate venous access), which has identical intraservice 

time, slightly less total time, and a slightly higher intensity and are finalizing a work RVU of 

3.59. 

(10) Esophagogastroduodenoscopy (EGD) (CPT codes 43233, 43235, 43236, 43237, 43238, 

43239, 43242, 43244, 43246, 43247, 43249, 43253, 43254, 43255, 43257, 43259, 43266, and 

43270. 

We established interim final work RVUs for various EGD codes in the CY 2014 final 

rule with comment period. In this section, we discuss the 18 EGD codes on which we received 

comments disagreeing with or making recommendations for changes in our interim final values. 

As we detailed in the CY 2014 final rule with comment period, we valued many of these codes 

by adding the additional work of an EGD to the comparable esophagoscopy (ESO) code. We 

determined the additional work of an EGD by subtracting the work RVU of CPT code 43200, the 

base ESO code, from the work of CPT code 43235, the base EGD code. For example, CPT code 

43233 is an identical procedure to CPT code 43214 except that it uses EGD rather than ESO. 

We valued it by adding the additional work of EGD to the work RVU of CPT code 43214, 

resulting in an interim final work RVU of 4.05. We valued the additional work the same way the 

RUC did in its recommendations. The following EGD codes were valued in the same way using 

the code in parentheses as the corresponding ESO code: 43233 (43214), 43236 (43201), 43237 

(43231), 43238 (43232), 43247 (43215), 43254 (43211), 43255 (43227), 43266 (43212), and 

43270 (43229). In valuing CPT codes 43235, we agreed with the RUC recommended work 

RVU difference between this EGD base code and the esophagoscopy base code, CPT 43200 but 

applied the difference to our CY 2014 RVU values. In a similar fashion, in valuing CPT code 
CMS-1612-FC 271

43242 we agreed with the RUC recommended methodology of which took the increment 

between CPT code 43238 and CPT code 43237 but we applied the difference to our CY 2014 

values. In order to value other EGD codes, we crosswalked the services to similar procedures; 

specifically for CY 2014 we crosswalked CPT codes 43239 to 43236, 43246 to 43255, 43253 to 

43242 and 43257 to 43238. We valued CPT codes 43244 and 43249 through acceptance of the 

RUC work RVU recommendation. Lastly, we valued CPT code 43259 by adjusting the CY 2013 

work RVU to account for the CY 2014 RUC recommended reduction in total time. 

Comment: For all codes, commenters objected to our work RVUs and said that our 

reductions from the RUC recommendations were based on a decrease in intraservice time that 

did not reflect a change in the time required to furnish the procedures but rather only a change in 

which part of the procedure the RUC includes the moderate sedation time. Commenters disagree 

with our valuing CPT code 43233 based on the value of CPT code 43214, saying that CPT code 

43233 is more intense due to the risk of perforation, and that the achalasia patients are at high 

risk and poor candidates for surgery. Commenters disagreed with our methodology for valuing 

CPT code 43235, and suggested that we use the RUC crosswalk to CPT code 31579, contending 

that the slight reductions in pre- and post-service times are consistent with the slight drop in the 

RUC-recommended RVU. For CPT code 43237, commenters also noted a rank order anomaly 

because the interim final work RVU for this code is the same as for CPT code 43251. 

Commenters said that the robust survey data on CPT code 43238 should override CMS 

decisions. With regard to CPT code 43239, commenters suggest that the survey is wrong and 

further point to the fact that our valuation results in the same value for CPT code 43239 as the 

base EGD code, which they state is not appropriate due to the additional work in CPT code 

43239. Commenters disagreed with our value for CPT code 43242 stating that we 

inappropriately valued CPT code 43259, which we used in calculating the work RVUs for CPT 
CMS-1612-FC 272

code 43242. Commenters objected to our value of CPT code 43246 because they disagree with 

the work RVU for the code that it is crosswalked to, CPT code 43255. Commenters urged us to 

modify our work RVU for CPT code 43247 to equal the RUC recommendation. For CPT code 

43253, commenters did not disagree with the valuation approach, but disagreed with the 

valuation we had assigned to the base code, CPT code 43259, which affected the valuation of 

CPT code 43253. Comments indicated that they did not understand how the value of CPT code 

43254 was derived. Commenters indicated that they disagreed with the reduction in the work in 

CPT code 43255 due to a decrease in time. They also cited that this was an emergency 

procedure in unstable patients and that it was more difficult to control bleeding in the stomach 

than in the esophagus. For CPT code 43257, commenters disagreed with our crosswalk to CPT 

code 43238 indicating that CPT code 43257 was more intense than CPT code 43238. 

Commenters acknowledged that reduced times should result in reduced work, but disagreed with 

our proportional reduction approach. Commenters agreed with our approach to valuing CPT 

code 43266, but disagreed with the valuation of the CPT code 43212, that we used as the base. 

With regard to CPT code 43270, commenters disagreed with using CPT code 43229 as the base. 

Response: For each of these codes, commenters were concerned that we did not accept 

the RUC-recommended values. Their common reasoning for urging us to accept the RUCrecommended values was that moderate sedation time had been removed from intraservice time 

and that these intraservice time changes should not result in a change in the RUC-recommended 

RVU. However, for CPT codes 43233, 43236, 43237, 43238, 43247, 43254, 43255, 43266, and 

43270, we used the standard methodology described above for valuing EGD codes and did not 

base our values on the time change. Thus, any refinements to the RUC recommendations for the 

EGD codes are solely due to refinements in the ESO codes. We discussed our valuations of these 

codes in the previous section. Since we have finalized most of the ESO codes at higher levels 
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than the CY 2014 interim final values, we are making corresponding increases in the EGD codes. 

Therefore, we are finalizing these codes at the following work RVUs: 43233 at 4.17, 43235 at 

2.19, 43236 at 2.49, 43237 at 3.57, 43238 at 4.26, 43247 at 3.21, 43254 at 4.97, 43255 at 3.66, 

43266 at 4.17, and 43270 at 4.26. 

CPT code 43233 was referred to the refinement panel and received a median work RVU 

of 4.26. As outlined above, we are finalizing a work RVU of 4.17 for CPT code 43233 at 4.17, 

which is higher than our interim value of 4.05, but consistent with our valuation of the other 

EGD codes. We do not believe that the comments provided at the refinement panel justify 

adoption of the higher median value. 

The interim final work value of CPT code 43239 was crosswalked to the work RVU of 

CPT code 43236. Since we increased the final work RVU from the interim final for this code, 

the final work RUV of CPT code 43239 increases to 2.49. 

(11) Endoscopic Retrograde Cholangiopancreatography (ERCP) (CPT codes 43263, 43274, 

43276, 43277 and 43278) 

 In the CY 2014 final rule with comment period we established interim final work RVUs 

for several ERCP codes due to coding revisions. For all those codes not discussed in this 

section, we are finalizing the interim final work RVUs. For CPT code 43263, we established an 

interim final work RVU based upon a crosswalk to CPT code 43262. As we detailed in the CY 

2014 final rule with comment period, we valued CPT codes 43274, 43276, and 43278 using the 

same formula that the RUC used in determining its recommendations, but substituting our 

interim final work RVUs for codes used in the formula for the RUC-recommended values. CPT 

code 43277 was valued using the survey 25th percentile. 

Comment: Commenters objected to our valuation of CPT 43263 based upon a crosswalk 

to CPT code 43262, saying that CPT 43263 is more intense and has greater risks than CPT code 
CMS-1612-FC 274

43262. Commenters also indicated that we underestimated the intensity of CPT code 43276 

indicating that CPT code 43276 typically involves replacing stents that are overgrown with 

cancerous tissues. They also said that we underestimated the intensity of CPT coded 43274 and 

43277. Commenters further took issue with our valuing CPT code 43277 based upon the survey 

when most codes in this family were valued based upon the incremental formula. Commenters 

stated that CPT code 43278 is valued incorrectly because we did not correctly value CPT code 

43229, which is used in the formula we used to value CPT code 43278. 

Response: After consideration of the comments, we continue to believe that CPT code 

43263 is the appropriate crosswalk for CPT code 43262 and we are finalizing a work RVU of 

6.60 for that code. With regard to CPT code 43274, we continue to believe the formula 

described in the CY 2014 final rule with comment period is the appropriate methodology. We 

are finalizing a work RVU of 8.58 for CPT code 43274 using the final values for the codes used 

in the formula and thus increasing the work RVU from the interim final value of 8.48. Similarly, 

we are finalizing a work RVU of 8.94 for CPT code 43276 based upon the formula described in 

the CY 2014 final rule with comment period adjusted for changes in the final work RVUs for 

values used in the formula. For CPT code 43277, we continue to believe the survey 25th

percentile is appropriate. This valuation is supported by a drop in the intraservice time from the 

code it replaces. Thus, we are finalizing the interim final work RVU of 7.00. For CPT code 

43278, we continue to believe use of the RUC formula for this code is most appropriate, and we 

are adjusting the work RVU to reflect final work RVUs for values used in the formula. The final 

work RVU for CPT code 43278 is 8. 

(12) Spinal Injections (CPT codes 62310, 62311, 62318 and 62319) 
CMS-1612-FC 275

 We proposed new work RVUs for these codes in the PFS proposed rule. (79 FR 40338-

40339). See section II.B.3 for a discussion of the valuation of these codes, and a summary of 

public comments and our responses. 

(13) Laminectomy (CPT Codes 63045, 63046, 63047 and 63048) 

 We established interim final work RVUs for CPT codes 63047 and 63048 for CY 2014. 

As we indicated in the CY 2014 final rule with comment period, we had identified CPT code 

63047 as potentially misvalued through the high expenditure procedure code screen and the RUC 

included a recommendation for CPT code 63048. We noted that, to appropriately value these 

codes, we need to consider the other two codes in this family: CPT codes 63045 (Laminectomy, 

facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 

equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 

cervical) and 63046 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 

decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess 

stenosis]), single vertebral segment; thoracic). Although we did not receive recommendations for 

CPT codes 63045 and 63046, we established CY 2014 interim final work RVUs for CPT codes 

63047 and 63048 of 15.37 and 3.47, respectively, based upon the RUC recommendations. We 

noted that we expected to review these values in concert with the RUC recommendations for 

CPT codes 63045 and 63046 when we received them. 

 Comment: Commenters questioned our determination that CPT codes 63047, 63048, 

63045 and 63046 constituted a family, noting that CPT codes 63045 and 63046 require different 

work. Commenters questioned the value of resurveying this set of codes as a family since CPT 

codes 63045 and 63046 constitute a small percentage of the total volume of these codes. The 

survey of CPT codes 63047 and 63048 did not reveal significant change in the values of the 
CMS-1612-FC 276

codes, and the work involved in resurveying would be burdensome for those involved. One 

commenter urged us to withdraw our request to survey these codes. 

 Response: We continue to believe that it is appropriate to value a family of codes 

together in order to maintain relativity. We also continue to believe that CPT codes 63045 and 

63046 are indeed in the same family as CPT codes 63047 and 63048 due to similarity of service. 

We have received new RUC recommendations for CPT code 63045 and 63046, but did not 

receive them in time to include in this rule. As a result, we will finalize the interim work values 

for CPT codes 63047 and 63048 for CY 2015. 

(14) Chemodenervation of Muscles (CPT codes 64616, 64617, 64642, 64643, 64644, and 

64645) 

 We assigned refined interim final work RVU values of 1.53 to CPT code 64616 and 1.90 

to CPT code 64617. As detailed in the CY 2014 final rule with comment period, we refined the 

RUC-recommended work RVUs of 1.79 for CPT code 64616 and 2.06 for CPT code 64617 to 

reflect the deletion of an outpatient visit that was included in the predecessor code, CPT code 

64613 (chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic 

dysphonia)). We also explained that since CPT code 64617, chemodenervation of the larynx, 

includes EMG guidance when furnished we determined the interim final work RVU by adding 

the work RVU for CPT code 95874 (Needle electromyography for guidance in conjunction with 

chemodenervation (List separately in addition to code for primary procedure)) to the CY 2013 

work RVU for CPT 64616. 

 For CY 2014, we assigned interim final work RVUs for CPT code 64643 and CPT code 

64645 of 1.22 and 1.39, respectively. As we explained in the CY 2014 final rule with comment 

period, we refined the RUC-recommended work RVUs for these add-on codes by subtracting the 

RVUs to account for 19 minutes of pre-service time and the decrease in time for furnishing the 
CMS-1612-FC 277

add-on service. Additionally, we based the global period for these codes on the predecessor code, 

CPT code 64614 (chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for 

dystonia, cerebral palsy, multiple sclerosis)), which was deleted for CY 2014. Therefore, we 

assigned 10-day global periods to the services. 

 Comment: Most commenters disagreed with the CY 2014 interim final work RVU 

valuations for CPT codes 64616, 64643, and 64645. One commenter stated that the work RVU 

for the predecessor code, CPT code 64614, did not take into account the full level of intensity, 

time, and work that it takes to perform the service. This commenter also disagreed with the 

times for this service. Several commenters disagreed with the valuation of CPT code 64616 

saying that we ignored the RUC recommendation which was based on survey data and RUC 

deliberations and asked that we value the code based upon the RUC recommendation. Several 

commenters disagreed with the valuations for CPT codes 64643 and 64645 saying that CMS did 

not explain our valuation, ignored the fact that the RUC discounted the add-on codes based on 

the pre- and post-service time and did not articulate any basis for our valuation decision. Several 

commenters requested refinement of the codes in the chemodenervation family. 

 Response: After consideration of the comments we are finalizing the interim final work 

RVUs and time for these codes. We continue to believe that our valuations for this family take 

into account the full level of intensity, time, and work that are required to furnish these services. 

Additionally, we disagree with commenters that we did not explain our valuation of CPT codes 

64643 and 64645. In the CY 2014 final rule with comment period, we detail and thoroughly 

explain the methodology utilized to value CPT codes 64643 and 64645. Additionally, the 

request for refinement panel review was not granted as the criteria for refinement were not met. 

(15) Impacted Cerumen (CPT code 69210) 
CMS-1612-FC 278

 After it was identified as a potentially misvalued code pursuant to the CMS high 

expenditure screen, CPT code 69210, which describes removal of impacted cerumen, was 

revised from being applicable to ‘‘1 or both ears’’ to a unilateral code effective January 1, 2014. 

For Medicare purposes we limited the code to billing once whether it was furnished unilaterally 

or bilaterally because we believed the procedure would typically be furnished in both ears as 

the physiologic processes that create cerumen impaction likely would affect both ears. Similarly, 

we continued the CY 2013 value as our interim final CY 2014 value since for Medicare purposes 

the service was unchanged. 

Comment: Commenters requested that we allow CPT code 69210 to be billed twice 

when it is furnished bilaterally, consistent with code descriptor. Commenters stated that our 

assumption regarding the physiologic processes that create cerumen was flawed and requested 

we provide a clinical rationale and/or literature to support our claim. Lastly, the commenters 

requested guidance from the agency as to how best deal with this CPT code; specifically, if it 

should be sent to CPT for clarification or if not, that we provide further guidance as to how this 

procedure should be billed using the new code. 

 Response: We continue to believe that the procedure will be furnished in both ears as the 

physiologic processes that create cerumen impaction likely would affect both ears. As a result, 

we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally and 

are finalizing our CY 2014 interim final work RVU for this service. 

 (16) Magnetic Resonance Imaging (MRI) Brain (CPT codes 77001, 77002, and 77003) 

 As detailed in the CY 2014 final rule with comment period, we agreed with the RUCrecommended values for CPT codes 77001, 77002 and 77003 but were concerned that the 

recommended intraservice times for all three codes was generally higher than the procedure 

codes with which they were typically billed. We sought additional public comment and input 
CMS-1612-FC 279

from the RUC and other stakeholders regarding the appropriate relationship between the 

intraservice time associated with fluoroscopic guidance and the intraservice time of the 

procedure codes with which they are typically billed. 

 Comment: Some commenters disagreed with the concern expressed by CMS that the 

intraservice time for codes 77001, 77002 and 77003 is higher than the codes alongside which 

they are typically billed, as the commenters believed that the combinations being used to support 

this concern were not appropriate, and they requested additional examples to support its concern. 

The commenters believed that the concerns CMS expressed are unfounded and that we should 

assign work RVUs of 0.38, 0.54, and 0.60 for CPT code 77001, 77002, and 77003, respectively. 

 Response: We continue to have concerns regarding the appropriate relationship between 

the intraservice time associated with fluoroscopic guidance and the intraservice time of the 

procedure codes with which they are typically billed and will continue to study this issue. We 

are finalizing the CY 2014 interim final values for CY 2015. 

(17) Immunohistochemistry (CPT codes 88342 and 88343 and HCPCS codes G0461 and G0462) 

These codes were revised for CY 2015. For discussion of valuation for CY 2015, see 

section II.G.3.b. 

(18) Optical Endomicroscopy (Code 88375) 

 As detailed in the CY 2014 final rule with comment period, we believed that the typical 

optical endomicroscopy case would involve only the endoscopist, and CPT codes 43206 and 

43253 were valued to reflect this. Accordingly, we believed a separate payment for CPT code 

88375 would result in double payment for a portion of the overall optical endomicroscopy 

service. Therefore, we assigned a PFS procedure status of I (Not valid for Medicare purposes. 

Medicare uses another code for the reporting of and the payment for these services) to CPT code 

88375. 
CMS-1612-FC 280

 Comment: Multiple commenters objected to CMS’s decision to assign a PFS status 

indicator of “I” to code 88375, stating that the code already includes distinctions that would 

prevent a physician from billing the code when it would double count work. The commenters 

urge CMS to assign CPT code 88375 a Medicare status of A (Active Code), and to immediately 

publish RVUs associated with the service. 

 Response: In our re-review of this procedure and consideration of the information 

provided by commenters, we believe the coding is adequate to avoid double payment for a 

portion of the service. Accordingly, we assigned a Medicare status indicator of A (Active). To 

value this service, we based the RVUs on those assigned to CPT code 88329, adjusted for the 

difference in intraservice time between the two codes. We are assigning a final work RVU of 

0.91 for CPT code 88375 for CY 2015. 

(19) Speech Language (CPT codes 92521, 92522, 92523 and 92524) 

 In CY 2014, we assigned CY 2014 interim final work RVUs of 1.75 and 1.50 for CPT 

codes 92521 and 92522, respectively, as the HCPAC recommended. For CPT code 92523, we 

disagreed with the HCPAC-recommended work RVU of 3.36. We believed that the appropriate 

value for 60 minutes of work for the speech evaluation codes was reflected in CPT code 92522, 

for which the HCPAC recommended 1.50 RVUs. Because the intraservice time for CPT code 

92523 was twice that for CPT code 92522, we assigned a work RVU of 3.0 to CPT code 92523. 

Similarly, since CPT codes 92524 and 92522 had identical intraservice time recommendations 

and similar descriptions of work we believed that the work RVU for CPT code 92524 should be 

the same as the work RVU for CPT code 95922. Therefore, we assigned a work RVU of 1.50 to 

CPT code 92524. 

 Comment: Commenters disagreed with the interim final work RVUs assigned to CPT 

codes 92523 and 92524, saying they based on inaccurate assumptions. Commenters stated that 
CMS-1612-FC 281

survey respondents appropriately took time and effort into account when valuing CPT code 

92523 but had difficulty using a time-based reference code to value the RVU of an untimed code 

like CPT code 92523. Commenters noted that the HCPAC acknowledged that the work of the 

second hour involved in CPT code 92523 is indeed more intense than the first hour. 

Additionally, commenters stated that the work RVU reduction of CPT code 92524 was arbitrary 

because it was based solely on intraservice time and failed to recognize the more difficult aspects 

of performing the service compared to that of CPT code 92522. Commenters requested 

reconsideration of CPT codes 92523 and 92524 through refinement panel review. 

 Response: We believe that our interim final work RVU is most appropriate for these 

services. In the HCPAC recommendation for CPT code 92523 the affected specialty society 

stated that its survey results were faulty for this CPT code because those surveyed did not 

consider all the work necessary to perform the service. The commenters did not provide any 

information that demonstrates that our valuations fail to fully account for the intensity, work, and 

time required to perform these services. Therefore, we are finalizing our CY 2014 interim final 

values for CY 2015. We did not refer these codes to refinement because the request did not meet 

the criteria for refinement. 

(20) Percutaneous Transcatheter Closure (CPT code 93582) 

 As detailed in the CY 2014 final rule with comment period, we reviewed new CPT code 

93582. Although the RUC compared this code to CPT code 92941 (percutaneous transluminal 

revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary 

artery or coronary), which has a work RVU of 12.56 and 70 minutes of intraservice time, it 

recommended a work RVU of 14.00, the survey’s 25th percentile. We agreed with the RUC that 

CPT code 92941 is an appropriate comparison code and believed that due to the similarity in 
CMS-1612-FC 282

intensity and time that the codes should be valued with the same work RVU. Therefore, we 

assigned an interim final work RVU of 12.56 to CPT code 93582. 

 Comment: One commenter disagreed with the work RVU valuation of CPT code 93582 

because they believed it did not accurately reflect the intensity of the procedure, particularly in 

treating infants. The commenter stated that the RUC concluded that a 55 percent work 

differential exists between performing this service on a child versus an adult - a fact that they 

stated supports the higher work RVU recommended by the RUC. As a result, the commenter 

suggests we assign the RUC-recommended work RVU to CPT code 93582. A commenter 

requested referral to the refinement panel. 

 Response: We continue to believe that CPT code 92941 is an appropriate comparison 

code to CPT code 93582 due to similarity in intensity and time and, as a result, the codes should 

be valued with the same work RVU. Therefore, we are finalizing our CY 2014 interim final 

work RVU of 12.56 to CPT code 93582 for CY 2015. We did not refer this code to refinement 

because the request did not meet the criteria for refinement. 

(21) Duplex Scans (CPT Codes 93925, 93926, 93880 and 93882) 

 For CY 2014 we maintained the CY 2013 RVUs for CPT codes 93880 and 93882. We 

were concerned that the RUC-recommended values for CPT codes 93880 and 93882, as well as 

our final values for CPT codes 93925 (Duplex scan of lower extremity arteries or arterial bypass 

grafts; complete bilateral study) and 93926 (Duplex scan of lower extremity arteries or arterial 

bypass grafts; unilateral or limited study), did not maintain the appropriate relativity within the 

family and referred the entire family to the RUC to assess relativity among the codes and then 

recommend appropriate work RVUs. We also requested that the RUC consider CPT codes 93886 

(Transcranial Doppler study of the intracranial arteries; complete study) and 93888 (Transcranial 
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Doppler study of the intracranial arteries; limited study) in conjunction with the duplex scan 

codes to assess the relativity between and among the codes. 

 Comment: One commenter questioned why we did not include all duplex scan codes we 

determined to be part of the family in our original request to the RUC. Another commenter 

opposed our valuation approach and stated that we should not redefine the codes in this family 

and that we should reject the RUC recommendations. 

 Response: The valuations for CPT codes 93880, 93882, 93925, 93926, 93886 and 93888 

are included in this year’s valuations in section II.G.3.b 

(22) Interprofessional Telephone/Internet Consultative Services (CPT Codes 99446, 99447, 

99448 and 99449) 

 In CY 2014 we assigned CPT codes 99446, 99447, 99448, and 99449 a PFS procedure 

status indicator of B (Bundled code. Payments for covered services are always bundled into 

payment for other services, which are not specified. If RVUs are shown, they are not used for 

Medicare payment). If these services are covered, payment for them is subsumed by the 

payment for the services to which they are bundled (for example, a telephone call from a hospital 

nurse regarding care of a patient) because Medicare pays for telephone consultations regarding 

beneficiary services as a part of other services furnished to the beneficiary. 

 Comment: A commenter expressed concern that the services covered by codes 99446-

99449 were bundled together, and that no RVUs were published for these codes. The 

commenter observed that CMS compares the services to contact between nurses and patients in 

justifying its decision to bundle the services in with other work, and stated that this comparison 

is inappropriate to use regarding consultation between physicians. The commenter also stated 

that these services are vital in providing specific specialty expertise in areas where timely faceto-face service is not a viable option. The commenter urged that the status of these services be 
CMS-1612-FC 284

changed to “Active,” or at least “Non-covered,” and that the RUC-recommended values for these 

services be published. 

 Response: Medicare pays for telephone consultations regarding beneficiary services as 

part of other services furnished to a beneficiary. As a result, we continue to believe that CPT 

codes 99446- 99449 are bundled; and we are finalizing the PFS procedure status indicator of B 

for these codes for CY 2015. 

b. Finalizing CY 2014 Interim Direct PE Inputs 

i. Background and Methodology 

In this section, we address interim final direct PE inputs as presented in the CY 2014 PFS 

final rule with comment period and displayed in the final CY 2014 direct PE database available 

on the CMS website under the downloads at 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. 

On an annual basis, the RUC provides CMS with recommendations regarding PE inputs 

for new, revised, and potentially misvalued codes. We review the RUC-recommended direct PE 

inputs on a code-by-code basis. When we determine that the RUC recommendations 

appropriately estimate the direct PE inputs (clinical labor, disposable supplies, and medical 

equipment) required for the typical service and reflect our payment policies, we use those direct 

PE inputs to value a service. If not, we refine the PE inputs to better reflect our estimate of the 

PE resources required for the service. We also confirm whether CPT codes should have facility 

and/or nonfacility direct PE inputs and refine the inputs accordingly. 

In the CY 2014 PFS final rule with comment period (78 FR 74242), we addressed the 

general nature of some of our common refinements to the RUC-recommended direct PE inputs, 

as well as the reasons for refinements to particular inputs. In the following sections, we respond 

to the comments we received regarding common refinements we made based on established 
CMS-1612-FC 285

principles or policies. Following those discussions, we summarize and respond to comments 

received regarding other refinements to particular codes. 

We note that the interim final direct PE inputs for CY 2014 that are being finalized for 

CY 2015 are displayed in the final CY 2015 direct PE input database, available on the CMS 

website under the downloads for the CY 2015 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. The inputs displayed there have also been used in 

developing the CY 2015 PE RVUs as displayed in Addendum B of this final rule with comment 

period. 

Comment: Commenters indicated that it would be helpful to have additional information 

about the specific rationale used in developing refinements, and specifically requested that CMS 

provide more information regarding how CMS makes the determination of whether an item is 

typical. 

Response: We continually seek ways to increase opportunity for public comment. In 

response to comments received, we have provided more detailed explanations about refinements 

made for the CY 2015 interim final direct PE inputs. We recognize that we make assumptions 

about what is typical, and note that we welcome objective data that provides information about 

the typical case. We prefer that this information be submitted through the notice and comment 

rulemaking process. We also refer interested stakeholders to section II.F. of this final rule with 

comment period, in which we provide extensive discussion of the changes to the process that we 

are finalizing for valuing new, revised, and potentially misvalued codes. 

ii. Common Refinements 

(1) Equipment Time 

Prior to CY 2010, the RUC did not generally provide CMS with recommendations 

regarding equipment time inputs. In CY 2010, in the interest of ensuring the greatest possible 
CMS-1612-FC 286

degree of accuracy in allocating equipment minutes, we requested that the RUC provide 

equipment times along with the other direct PE recommendations, and we provided the RUC 

with general guidelines regarding appropriate equipment time inputs. We continue to appreciate 

the RUC’s willingness to provide us with these additional inputs as part of its PE 

recommendations.

In general, the equipment time inputs correspond to the service period portion of the 

clinical labor times. We have clarified this principle, indicating that we consider equipment time 

as the times within the intra-service period when a clinician is using the piece of equipment plus 

any additional time that the piece of equipment is not available for use for another patient due to 

its use during the designated procedure. For services in which we allocate cleaning time to 

portable equipment items, because the equipment does not need to be cleaned in the room that 

contains the remaining equipment items, we do not include that time for the remaining 

equipment items as they are available for use for other patients during that time. In addition, 

when a piece of equipment is typically used during any additional visits included in the global 

period for a service, the equipment time would also reflect that use. 

We believe that certain highly technical pieces of equipment and equipment rooms are 

less likely to be used during all of the pre-service or post-service tasks performed by clinical 

labor staff on the day of the procedure (the clinical labor service period) and are typically 

available for other patients even when one member of clinical staff may be occupied with a preservice or post-service task related to the procedure. 

Some commenters have repeatedly objected to our rationale for refinement of equipment 

minutes on this basis. We acknowledge the comments we received reiterating those objections 

to this rationale and refer readers to our extensive discussion in response to those objections in 
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the CY 2012 PFS final rule with comment period (76 FR 73182). In the following paragraphs, 

we address new comments on this policy. 

Comment: A commenter indicated that CMS removed minutes assigned to vascular 

ultrasound rooms for activities that CMS does not believe take place in the room, but CMS did 

not provide factual support for this assumption. The commenter further stated that CMS did not 

articulate the connection between the relevant data that the Administrative Procedures Act 

(APA) requires CMS to consider and the conclusion that CMS reached. The commenter 

indicated that they conducted a survey of a significant number of providers, in which most 

providers indicated that they performed these pre-service tasks in the room. 

Response: We note that we would welcome comments that include vetted survey results, 

especially where the data are included. Statements regarding the existence of data to support 

commenters’ assertions do not provide us with information to support conclusions based on the 

data. We acknowledge that we make assumptions about we believe to be typical. If there are 

data that support or refute these assumptions, we would be interested in reviewing that 

information. We would be most interested in reviewing survey data that address multiple points 

of our assumptions regarding high-cost equipment, including how many procedures are furnished 

in a day, how often the equipment is being used, and other such information. 

Comment: A commenter stated that CMS should publish, on a quarterly basis, 

refinements to the equipment times, rather than waiting until the final rule to publish these 

changes. 

Response: We appreciate the commenter’s concern about our making available timely 

information about refinements to practice expense inputs. We note that since we do not review 

and make refinements to practice expense inputs on a quarterly basis, we do not have 

information to publish on a quarterly basis. Rather, we have reviewed and refined practice 
CMS-1612-FC 288

expense recommendations from the RUC on an annual basis for the subset of codes for which 

recommendations have been provided to us. Because we have received many requests from 

stakeholders to publish our refinements as proposals in the proposed rule rather than in the final 

rule, we are finalizing a change in the process in which changes to RVUs and direct PE inputs 

will be included in the proposed rule rather than first appearing in the final rule with comment 

period. We refer readers to section II.F. of this final rule with comment period for further 

information about this change. We believe that this process will address commenters’ concerns 

about having an opportunity to review these changes prior to the publishing of the final rule. 

Comment: Several commenters asked that CMS identify what constitutes a highly 

technical piece of equipment. 

Response: As we have previously indicated, during our review of all recommended 

direct PE inputs, we consider such items as the degree of specificity of a piece of equipment, 

which may influence whether the equipment item is likely to be stored in the same room in 

which the clinical staff greets and gowns, obtains vitals, or provides education to a patient prior 

to the procedure itself. We would expect that items that are highly specific to particular 

procedures would be moved between rooms for those procedures. We also consider the level of 

portability (including the level of difficulty involved in cleaning the equipment item) to 

determine whether an item could be easily transferred between rooms before or after a given 

procedure. Items that are portable would also be expected to be moved between rooms. We also 

examine the prices for the particular equipment items to determine whether the equipment is 

likely to be located in the same room used for all the tasks undertaken by clinical staff prior to 

and following the procedure. We believe that highly expensive equipment would not be kept in a 

location that does not allow for its maximum utilization. For each service, on a case-by-case 

basis, we look at the description provided in the RUC recommendation and consider the overlap 
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of the equipment item’s level of specificity, portability, and cost; and, consistent with the review 

of other recommended direct PE inputs, we make the determination of whether the recommended 

equipment items are highly technical. We note that it is not practical to ensure that all of the 

existing equipment time in the database is allocated accordingly, but as we review any 

recommendations received from the RUC, we make this determination. To provide stakeholders 

with examples of the types of equipment items that are and are not considered highly technical, 

we have listed several items below and indicated whether they are highly technical. 

TABLE 16: Classification of Highly Technical Equipment 

Highly Technical Not Highly Technical 

Item CMS 

Code 

Price Item CMS 

Code 

Price 

room, CT EL007 $1,284,000.00 Light, exam EQ168 $1,630.12

accelerator, 6-18 MV ER010 $1,832,941.00 Table, exam EF023 $1,338.17

gamma camera 

system, single-dual 

head SPECT CT 

ER097 $600,272.00 Chair, medical 

recliner 

EF009 $829.03

(2) Standard Tasks and Minutes for Clinical Labor Tasks 

 In general, the pre-service, service period, and post-service clinical labor minutes 

associated with clinical labor inputs in the direct PE input database reflect the sum of particular 

tasks described in the information that accompanies the recommended direct PE inputs, 

commonly called the “PE worksheets.” For most of these described tasks, there are a 

standardized number of minutes, depending on the type of procedure, its typical setting, its 

global period, and the other procedures with which it is typically reported. The RUC sometimes 

recommends a number of minutes either greater than or less than the time typically allotted for 

certain tasks. In those cases, CMS staff reviews the deviations from the standards to determine 

their appropriateness. When we do not accept the RUC-recommended exceptions , we refine the 

interim final direct PE inputs to match the standard times for those tasks. In addition, in cases 
CMS-1612-FC 290

when a service is typically billed with an E/M, we remove the pre-service clinical labor tasks to 

avoid duplicative inputs and to reflect the resource costs of furnishing the typical service. 

 In general, clinical labor tasks fall into one of the categories on the PE worksheets. In 

cases where tasks cannot be attributed to an existing category, the tasks are labeled “other 

clinical activity.” In these instances, CMS staff reviews these tasks to determine whether they 

are similar to tasks delineated for other services under the PFS. For those tasks that do not meet 

this criterion, we do not accept those clinical labor tasks as direct inputs. 

(3) Equipment Minutes for Film Equipment Inputs 

 In section II.A. of this final rule with comment period, we finalize our proposal to accept 

the RUC recommendation to remove inputs associated with film technology that are associated 

with imaging services. We acknowledge comments received regarding the minutes allocated to 

equipment items associated with film technology; we will not address those comments below, 

because subsequent to the publication of the CY 2014 final rule with comment period, as 

discussed in section II.A. of this final rule with comment period, we finalized our proposal to 

remove these inputs from the Direct PE database, and thus the comments are no longer relevant. 

(4) Standard Inputs for Moderate Sedation 

In establishing interim final direct PE inputs for services that contain the standard 

moderate sedation input package, we refined the RUC’s recommendation by removing the 

stretcher (EF018) and adjusting the standard moderate sedation equipment inputs to conform to 

the standard moderate sedation equipment times. These procedures are listed in Table 17. 

Comment: Commenters objected to our refinement of the standard moderate sedation 

equipment input times to conform to the moderate sedation equipment standard times, since it 

decreased the time allocated to these equipment items. 

Response: We note that for moderate sedation procedures, the equipment time is tied to 
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the RN time rather than to the entire service period. Specifically, this time includes 2 minutes for 

sedate/apply anesthesia, 100 percent of physician intraservice time, and 60 minutes of postprocedure time for every 15 minutes of RN monitoring time. The times included in Table 17 

reflect this standard. We note that for all procedures in Table 17 the times allocated to the 

equipment items that were interim final for 2014 were already consistent with the moderate 

sedation standard equipment times, with the exception of CPT code 37238, which was 

mistakenly allocated 257 minutes, when the correct time is actually 242 minutes. 

Comment: Commenters indicated that for office endoscopic procedures, the stretcher is 

typically used throughout the entire procedure, as well as during post-procedure monitoring. 

Other commenters indicated that the stretcher is required during the moderate sedation recovery 

time. The commenters requested that we include the stretcher for those procedures, and that we 

reduce the increased time allocated to the power table. 

Response: In section II.A. of this final rule with comment period, we finalized our 

proposal to modify the standard moderate sedation input package to include a stretcher for the 

same length of time as the other equipment items in the moderate sedation package. We 

indicated that the revised package would be applied to relevant codes as we review them through 

future notice and comment rulemaking. We have therefore refined those inputs to incorporate 

the stretcher for these codes listed in Table 17. Since we are incorporating the stretcher, we have 

removed the power table for procedures in which a power table was previously included. We 

will hold these procedures as interim final for CY 2015 due to the insertion of the stretcher and 

removal of the power table. 

 We are therefore finalizing the PE inputs for the procedures containing the standard 

moderate sedation inputs, with the additional refinements of including the stretcher for all of 

these procedures, removing the power table for the codes noted in Table 17 as containing a 
CMS-1612-FC 292

power table, and adjusting the equipment time for CPT code 37238. We note that these changes 

are displayed in the final CY 2015 direct PE input database, available on the CMS website under 

the downloads for the CY 2015 PFS final rule at www.cms.gov/PhysicianFeeSched/. 

 
CMS-1612-FC 293

TABLE 17: CPT Codes with Stretcher Added 

CPT 

Code Short Descriptor Moderate Sedation 

Contained 

Power Table? 

10030 Guide cathet fluid drainage 152 

36245 Ins cath abd/l-ext art 1st 167 

37236 Open/perq place stent 1st 332 

37238 Open/perq place stent same 242 

37241 Vasc embolize/occlude venous 272 

37242 Vasc embolize/occlude artery 342 

37243 Vasc embolize/occlude organ 362 

37244 Vasc embolize/occlude bleed 332 

43200 Esophagoscopy flexible brush 77 Yes 

43201 Esoph scope w/submucous inj 80 Yes 

43202 Esophagoscopy flex biopsy 82 Yes 

43206 Esoph optical endomicroscopy 92 Yes 

43213 Esophagoscopy retro balloon 107 Yes 

43215 Esophagoscopy flex remove fb 82 Yes 

43216 Esophagoscopy lesion removal 84 Yes 

43217 Esophagoscopy snare les remv 92 Yes 

43220 Esophagoscopy balloon <30mm 82 Yes 

43226 Esoph endoscopy dilation 87 Yes 

43227 Esophagoscopy control bleed 92 Yes 

43229 Esophagoscopy lesion ablate 107 Yes 

43231 Esophagoscop ultrasound exam 107 Yes 

43232 Esophagoscopy w/us needle bx 122 Yes 

43235 Egd diagnostic brush wash 77 Yes 

43236 Uppr gi scope w/submuc inj 82 Yes 

43239 Egd biopsy single/multiple 77 Yes 

43245 Egd dilate stricture 85 Yes 

43247 Egd remove foreign body 92 Yes 

43248 Egd guide wire insertion 82 Yes 

43249 Esoph egd dilation <30 mm 82 Yes 

43250 Egd cautery tumor polyp 82 Yes 

43251 Egd remove lesion snare 82 Yes 

43252 Egd optical endomicroscopy 92 Yes 

43255 Egd control bleeding any 92 Yes 

43270 Egd lesion ablation 107 Yes 

43450 Dilate esophagus 1/mult pass 77 Yes 

43453 Dilate esophagus 87 Yes 

49405 Image cath fluid colxn visc 162 

49406 Image cath fluid peri/retro 162 

49407 Image cath fluid trns/vgnl 167 
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(5) Recommended PE Inputs Not Used in the Calculation of Practice Expense Relative Value 

Units 

 In preparing the Direct Practice Expense Input database for CY 2014, we noted that in 

some cases, there were recommended inputs in the database that were not used in the calculation 

of the PE RVUs. In cases where inputs are included for a particular service in a particular 

setting, but that service is not priced in that setting, the inputs are not used. In the documentation 

files for the CY 2014 final rule, we stated, “In previous years, we have displayed recommended 

inputs even when these inputs are not used in the calculation of the practice expense relative 

value units. We note that we are no longer displaying such inputs in these public use files since 

they are not used in the calculation of the practice expense relative value units that appear in the 

final rule.” 

Comment: Some commenters objected to our removing practice expense inputs for 

services that were not reviewed for CY 2014. 

Response: As indicated in the documentation files, the inputs removed were not used in 

the calculation of the PE RVUs. Therefore, their removal has no impact on the PE RVUs for 

these services or the payment for services. We remind readers that, from our perspective, the 

sole purpose of the Direct PE database is to establish PE RVUs. We believe it is more 

transparent for these inputs to not appear in the Direct Practice Expense Input database when 

they do not contribute to the PE RVU calculation for the relevant services. 

iii. Code-Specific Direct PE Inputs 

 We note that we received many comments objecting to refinements made based on “CMS 

clinical review” (including our determination that certain recommended PE inputs were 

duplicative of others already included with the service), statutory requirements, or established 

principles and policies under the PFS. We note that for many of our refinements, the specialty 
CMS-1612-FC 295

societies that represent the practitioners who furnish the service objected to most of these 

refinements for the general reasons described above or for the reasons we respond to in the 

“background and methodology” portion of this section, or stated that they supported the RUC 

recommended PE inputs. Below, we respond to comments in which commenters address 

specific CPT/HCPCS codes and explain their objections to our refinements by providing us with 

new information supporting the inclusion of the items and/or times requested. When discussing 

these refinements, rather than listing all refinements made for each service, we discuss only the 

specific refinements for which commenters provided supporting information. We indicate the 

presence of other refinements by noting “among other refinements” after delineating the specific 

refinements for a particular service or group of services. For those comments that stated that an 

item was “necessary for the service” and provided no additional rationale or information, we 

conducted further review to determine whether the inputs as refined were appropriate and 

concluded that the inputs as refined were indeed appropriate. We also note that in many cases, 

commenters objected to our indication that items were duplicative, stating that they did not know 

where the duplication existed. In future rulemaking, we do not intend to respond to comments 

where the commenters dispute the duplicative nature of inputs unless commenters specifically 

explain why the relevant items are not duplicative with the identical items included in a room, 

kit, pack, or tray. We expect that commenters will review the components of the room, kit, pack, 

or tray included for that procedure prior to commenting that the item is not duplicative. Finally, 

we note that in some cases we made proposals related to comments received in response to the 

CY 2014 final rule with comment period. In cases where we have addressed the concerns of 

commenters in the proposed rule, we do not respond to comments here as well. 

(1) Cross-Family Comments 

Comment: We received comments regarding refinements to equipment times for many 
CMS-1612-FC 296

procedures for which commenters indicated that the equipment time for the procedure should 

include the time that the equipment is unavailable for other patients, including while preparing 

equipment, positioning the patient, assisting the physician, and cleaning the room. Commenters 

also requested that we indicate which clinical labor tasks should be included in calculating the 

equipment time for highly technical equipment. 

Response: As stated above, we agree with commenters that the equipment time should 

include the times within the intra-service period when a clinician is using the piece of equipment 

plus any additional time the piece of equipment is not available for use for another patient due to 

its use during the designated procedure. We believe that some of these commenters are 

suggesting that we should allocate the full number of clinical labor minutes included in the 

service period to the equipment items. However, as we have explained, the clinical labor service 

period includes minutes based on some clinical labor tasks associated with pre- and post-service 

activities that we do not believe typically preclude equipment items from being used in 

furnishing services to other patients because these activities typically occur in other rooms. 

The equipment times allocated to the CPT codes in Table 18 already include the full intraservice 

time the equipment is typically used in furnishing the service, plus additional minutes to reflect 

time that the equipment is unavailable for use in furnishing services to other patients. In response 

to commenters request for clarification, Table 19 lists the standard clinical labor tasks to be 

included in the calculation of time allocated to highly technical equipment. We note that in some 

cases, some specialized intraservice clinical labor tasks are also included in the equipment time 

calculations; we have not detailed every possible case in this table. 

 
CMS-1612-FC 297

TABLE 18: Equipment Inputs that Include Appropriate Clinical Labor Tasks 

About Which Comments Were Received 

CPT 

Code 

Equipment 

Items 

70551 EL008 

70552 EL008 

70553 EL008 

93880 EL016 

93882 EL016 

TABLE 19: Clinical Labor Tasks Included in Calculation of Equipment Time for 

Highly Technical Equipment. 

Clinical Labor Task 

Prepare room, equipment, supplies 

Prepare and position patient 

Assist physician in performing procedure and/or Acquire images 

Clean room/equipment by physician staff 

Technologist QC's images in PACS, checking for all images, reformats, and dose page 

Comment: We received comments regarding refinements to clinical labor times for 

several procedures, in which commenters indicated that CMS reduced the clinical labor minutes 

inappropriately for tasks related to film inputs, since the recommended minutes were based on 

the PEAC surveyed times. Tasks included “Process images, complete data sheet, present images 

and data to the interpreting physician” and “Retrieve prior appropriate imaging exams.” 

Response: The surveyed times referenced by the commenters refer to the clinical labor 

tasks associated with film technology. In reviewing the times associated with these clinical labor 

tasks, we noted that it would be consistent with our policy finalized in this rule to adjust the 

times associated with clinical labor tasks for all interim final codes to be consistent with the RUC 

recommendations regarding clinical labor tasks for digital technology. We are making the 

associated changes and holding these direct PE inputs interim final for 2015. These clinical 

labor tasks associated with film and digital inputs are presented side-by-side, along with the 

range of typical times, in Table 20. The specific interim final codes and their time changes are 
CMS-1612-FC 298

listed in Table 21. 

TABLE 20: Clinical Labor Tasks Associated with Digital Technology 

Service 

Period Clinical Labor Task: Film Inputs Typical 

Minutes Clinical Labor Task: Digital Inputs Typical 

Minutes 

PreService 

Retrieve prior appropriate imaging 

exams and hang for MD review, verify 

orders, review the chart to incorporate 

relevant clinical information and 

confirm contrast protocol with 

interpreting MD / 

Retrieve Prior Image for Comparison 

4 to 7 

Availability of prior images confirmed 2 

Patient clinical information and 

questionnaire reviewed by technologist, 

order from physician confirmed and exam 

protocoled by radiologist 

2 

Service 

Period: 

PostService 

Process Images, complete data sheet, 

present images and data to the 

interpreting physician / 

Process films, hang films and review 

study with interpreting MD prior to 

patient discharge 

4 to 20 

Technologist QC's images in PACS, 

checking for all images, reformats, and dose 

page 

2 

Review examination with interpreting MD 2 

Exam documents scanned into PACS. Exam 

completed in RIS system to generate billing 

process and to populate images into 

Radiologist work queue 

1 

 
CMS-1612-FC 299

TABLE 21: Interim Final Codes with Adjusted Clinical Labor Times Due to Filmto-Digital Migration 

CPT 

Code 

CMS 

Code 

Total Film 

Task Time 

(2014) 

Total 

Digital 

Task 

Time 

Time 

Change 

19081 L043A 8 9 1 

19082 L043A 5 5 0 

19083 L051B 8 9 1 

19084 L051B 5 5* 0 

19085 L047A 8 9 1 

19086 L047A 5 5* 0 

19281 L043A 8 9 1 

19282 L043A 5 5* 0 

19283 L043A 8 9 1 

19284 L043A 5 5* 0 

19285 L051B 8 9 1 

19286 L051B 5 5* 0 

19287 L047A 8 9 1 

19288 L047A 5 5* 0 

19281 L043A 5 5 0 

19282 L043A 5 5 0 

70450 L046A 10 9 -1 

70460 L046A 11 9 -2 

70470 L046A 13 9 -4 

70551 L047A 6 9 2 

70552 L047A 8 9 0 

70553 L047A 8 9 0 

72141 L047A 14 9 -5 

72142 L047A 16 9 -7 

72156 L047A 18 9 -9 

72146 L047A 14 9 -5 

72147 L047A 16 9 -7 

72157 L047A 18 9 -9 

72148 L047A 14 9 -5 

72149 L047A 16 9 -7 

72158 L047A 18 9 -9 

74174 L046A 27 9 -22 

*Add-on codes are allocated fewer minutes for these activities. 

(2) Code-Specific Comments 

(a) Destruction of Premalignant Lesions (CPT Codes 17000, 17003, 17004) 

In establishing interim final direct PE inputs for CY 2014, CMS accepted the RUC’s 
CMS-1612-FC 300

recommendations for supply item LMX 4% anesthetic cream (SH092). 

Comment: Commenters indicated that the quantity of cream units in CPT code 17003 

created a rank order anomaly with CPT codes 17000 and 17004, and that the inclusion of 3 

grams was incorrect. Instead, 1 gram should have been included in CPT code 17003. 

Response: We agree with the commenters that the quantity of SH092 in 17003 should be 

1 gram. However, we also note that CPT code 17000 should also contain a quantity of 1 gram in 

order to avoid the rank order anomaly. After consideration of the comments received, we are 

finalizing the CY 2014 interim final direct PE inputs for CPT codes 17000, 17003, and 17004, 

with the additional refinement of changing the quantity of SH092 to 1 for CPT codes 17000 and 

17003. 

(b) Breast Biopsy (CPT Codes 19081, 19082, 19083, 19084, 19085, 19086, 19281, 19282, 

19283, 19284, 19285, 19286, 19287, and 19288) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 19085, 19086, 19287, and 19288 by removing several new PE 

inputs, including items called “20MM handpiece—MR,’’ ‘‘vacuum line assembly,’’ ‘‘introducer 

localization set (trocar),’’ and ‘‘tissue filter,’’ since we concluded that these items served 

redundant clinical purposes with other biopsy supplies already included in the PE inputs for these 

codes. We also removed three new equipment items, described as ‘‘breast biopsy software,’’ 

‘‘breast biopsy device (coil),’’ and “lateral grid,” because we determined that these items served 

clinical functions to items already included in the MR room. 

Comment: Commenters indicated that the vacuum assisted breast biopsy requires an 

assisted biopsy needle system, and tubing must be run from the biopsy device to the biopsy 

control unit. Commenters also discussed supply items “introducer localization set (trocar)” and 

“tissue filter,” stating that the trocar is used to target the biopsy on the correct lesion, and the 
CMS-1612-FC 301

tissue filter is necessary to remove the collected core samples from the collection chamber. 

Commenters described the importance of the “breast biopsy device (coil) ,” which is used to 

move one breast out of the way and the “breast biopsy software,” which is required to make the 

necessary calculations to target and biopsy the lesions. Finally, commenters stated that the 

lateral grid is necessary to place the trocar correctly. 

Response: The equipment item “breast biopsy device w-system (Mammotome)” 

(EQ074) is described as “an all-in-one platform designed for use under ultrasound, MRI, 

stereotactic and 3D image guidance” and is used with supply item “Mammotome probe” 

(SD094). Therefore, the supply items “20 MM handpiece, ” “vacuum line assembly,” “tissue 

filter,” and “trocar,” are duplicative of items already included in this procedure. We do note that 

we have used the invoice to create a price for equipment item “Breast biopsy device (coil)” 

(EQ371) at a price of $12,238. After consideration of the comments received, we are finalizing 

the CY 2014 interim final direct PE inputs for CPT codes 19085, 19086, 19287, and 19288 as 

established with the additional refinement of incorporating the equipment item “Breast biopsy 

device (coil)” (EQ371). 

Comment: A commenter noted that the new breast biopsy codes do not distinguish 

between the type of biopsy device used for the procedure, and that the cost of using the vacuumassisted biopsy device (including a Mammotome probe, a Mammotome probe guide, and tubing 

and vacuum for the Mammotome device) is nearly eight times the cost of the equipment and 

supplies required to perform a standard (mechanical) core needle biopsy. The commenter noted 

that vacuum-assisted biopsy devices are predominantly used in stereotactic and MRI-guided 

breast biopsy procedures and 50 percent of the time in ultrasound-guided breast biopsy 

procedures. 

Response: For a discussion about the change in coding, we refer readers to section II.F. 
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of this final rule with comment period, where we finalize the work RVUs for interim final 2014 

codes. With regard to the direct PE inputs for these services, we note that we include direct PE 

inputs based on the typical case, and since, as the commenter points out, the vacuum-assisted 

biopsy devices are typically used, we include these items as direct PE inputs. 

 In reviewing the breast biopsy codes, we noted that we inadvertently included supply and 

equipment items related to breast biopsies in CPT codes 19283, 19284, 19285, 19286, 19087, 

and 19088, which are procedures that describe the placement of a localization device, not a 

biopsy. We will therefore remove the items listed in Table 22, which are currently included as 

direct PE inputs for these procedures. After consideration of the comments received, we are 

finalizing the CY 2014 interim final direct PE inputs for CPT codes 19081, 19082, 19083, 

19084, 19085, 19086, 19281, 19282, 19283, 19284, 19285, 19286, 19287, and 19288 as 

established, with the additional refinements noted above. 

TABLE 22: Supply and Equipment Items Inadvertently Included in Localization Device 

Placement Breast Biopsy Codes 

CPT SD034 SC022 EQ074

19283 X X 

19284 X X 

19285 X 

19286 X 

19087 X X X 

19088 X X X 

(c) Nasal/Sinus Endoscopy (CPT Codes 31237, 31238) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 31237 and 31238 by refining the nurse blend (L037D) clinical 

labor time associated with task “Monitor pt. following service/check tubes, monitors, drains” 

from 15 minutes to 5 minutes. 

Comment: Commenters stated that CMS should maintain consistency in the direct PE 
CMS-1612-FC 303

inputs across services by allocating the standard 15 minutes for every hour of post-procedure 

monitoring time. Commenters indicated that monitoring after these procedures is critical, since 

the risk of recurrent bleeding is high and patients may become lightheaded. 

Response: There are two types of post-procedure monitoring time; a standard 15 minutes 

per hour of post-procedure monitoring time for moderate sedation, and a standard 15 minutes per 

hour of post-procedure monitoring time unrelated to moderate sedation. We understand the 

commenter’s position to mean that there is 60 minutes of post-procedure monitoring required for 

these services (in accordance with the 15 minutes of RN time per 60 minutes of monitoring). 

Because these procedures previously included 5 minutes of post-procedure monitoring time, we 

do not have a reason to believe that the monitoring time would have increased by 55 minutes. 

Should commenters believe this is the case, we invite commenters to provide information to 

justify this change. In cases where the specialty society is recommending post-procedure 

monitoring unrelated to moderate sedation, it is important that the recommendation clearly 

indicates the reason for the monitoring and the relationship between the clinical staff time and 

the monitoring time. After consideration of the comments received, we are finalizing the CY 

2014 interim final direct PE inputs for CPT codes 31237 and 31238 as established. 

(d) Implantation and Removal of Patient Activated Cardiac Event Recorder (CPT Codes 33282 

and 33284) 

 In the CY 2013 final rule with comment period, in response to nomination of CPT codes 

33282 and 33284 as potentially misvalued codes, we indicated that we did not consider the 

absence of pricing in a particular setting as an indicator of potentially misvalued codes. 

However, we requested that the RUC review these codes, including the work RVUs, for 

appropriate nonfacility and facility inputs. 
CMS-1612-FC 304

Comment: A commenter expressed disappointment that CMS did not price these 

services in the nonfacility setting but did not provide further information about this decision. 

Response: We received recommendations from the RUC for CPT codes 33282 and 

33284 that did not include nonfacility inputs. Stakeholders who are interested in providing 

information about the direct PE inputs used in furnishing these services are welcome to submit 

this information to us; information about the level of information we seek is available to 

stakeholders in the sample PE worksheet available on the CMS website under downloads at 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. We encourage 

commenters to submit the best data available on the appropriate inputs for these services. 

(e) Transcatheter Placement of Intravascular Stent (CPT Codes 37236, 37237) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 37236 and 37237 by including supply item “catheter, balloon, 

PTA” (SD152) as a proxy for “balloon expandable” because we believed that was an appropriate 

proxy. The invoices provided with the recommendation did not indicate the items on the PE 

worksheet with which they were associated. 

Comment: The specialty society representing practitioners who furnish these services 

indicated that the item “balloon expandable” actually referred to a “balloon implantable stent,” 

and that the invoices provided were associated with that item. 

Response: We acknowledge the specialty society’s clarification of the RUC 

recommendation. We will add item “balloon implantable stent” at a price of $1,500, and remove 

the proxy item SD152. We note that when line items on the invoices provided are not clearly 

labeled, it is often difficult for us to determine how to relate the items on the PE spreadsheet with 

the items on the invoices. For specialty societies to ensure that the requested items are considered 

for inclusion in the relevant procedure codes, it is important that invoices accompany the RUC 
CMS-1612-FC 305

recommendations and the line items associated with items on the PE spreadsheet are clearly 

labeled. 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 37236 and 37237 as established with the additional 

refinement of including “balloon implantable stent” and removing “catheter, balloon, PTA” 

(SD152). 

(f) Esophagoscopy (CPT Codes 43197 and 43198) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 43197 and 43198 to remove the Medical/Technical Assistant 

(L026A) time associated with clinical labor task “Clean Surgical Instrument Package,” since no 

surgical instrument package is included in the service, and to remove the endoscopic biopsy 

forceps (SD066) from CPT code 43198, among other refinements. 

Comment: Commenters acknowledged that the procedure did not contain a surgical 

instrument package, but stated that the time was still necessary for cleaning equipment, such as 

the nasal speculum, bayonette forceps, and biopsy forceps. 

Response: In general, as a matter of relativity throughout the PFS, the time allocated for 

the standard clinical labor task “Clean room/equipment following procedure” encompasses time 

for cleaning all equipment items. The only exceptions to this rule are for equipment items that 

are tied to specific clinical labor tasks, such as cleaning the surgical instrument pack or cleaning 

a scope. We do not believe it would serve relativity to separately break out time to clean various 

different types of equipment. 

 For the biopsy forceps, we indicated in the final rule with comment period that the 

information included with the RUC recommendation suggested that the biopsy forceps was 

reusable (as suggested by the cleaning time mentioned in this comment). As such, we have 
CMS-1612-FC 306

created a new equipment item based on the invoice provided with the recommendation and 

assigned 46 minutes to this equipment item. However, since we did not receive a paid invoice 

with this item, we will price it at $0 until we receive a paid invoice. 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 43197 and 43198 as established, with the additional 

refinement of including 46 minutes for the reusable biopsy forceps. 

(g) Esophagoscopy/Esophagoscopy Gastroscopy Duodenoscopy (EGD) (CPT Codes 43200, 

43201. 43202, 43206, 43215, 43216, 43217, 43220, 43226, 43227, 43231, 43232, 43235, 43236, 

43239, 43245, 43247, 43248, 43248, 43250, 43251, 43252, 43255, 43270) 

In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 43200, 43201. 43202, 43206, 43215, 43216, 43217, 43220, 

43226, 43227, 43231, 43232, 43235, 43236, 43239, 43245, 43247, 43248, 43248, 43250, 43251, 

43252, 43255, and 43270 by refining the quantity of item “canister, suction” (SD009) from 2 to 

1. 

Comment: Commenters indicated that, for patient safety reasons, one suction canister is 

needed for the mouth, and another for the scope for patient safety reasons. Other stakeholders, 

specifically, several specialty societies with whom we met during the comment period, informed 

us that one suction canister is sufficient and typical for these services. 

Response: We are persuaded by the information provided by the medical specialty 

societies during the comment period who indicated that one suction canister is typical. 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 43201 by removing needle, micropigmentation (tattoo) 

(SC079), as the needle required for this procedure needs to go through an endoscope, and no 

invoice was provided for this item. 
CMS-1612-FC 307

Comment: Commenters indicated that the tattoo needle was required to mark the site for 

injection.

Response: We did not receive an invoice for the tattoo needle and have no information 

about this item. We are also unable to include this item in the PE calculations without a method 

to price it. We do not believe that we have a reasonable proxy at this time. If we receive 

invoices for this item, we will be able to include it in the direct PE input database. 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 43201, 43220, 43226, and 43231 by removing supply item 

“cup, biopsy-specimen non-sterile 4oz” (SL035). 

Comment: Commenters indicated that the endoscopy base code, 43200, is included in all 

of these procedures. Since the biopsy cup is included in the endoscopy base code, it should be 

included for these codes as well. 

Response: We agree with commenters that it is appropriate to include this supply item for 

these procedures. We will include the supply item “cup, biopsy-specimen non-sterile 4oz” in the 

direct PE inputs for these procedures. 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT code 43220 by substituting supply item “SD019” as a proxy for 

“SD025.” 

Comment: Commenters requested that we include “endoscopic balloon, dilation” 

(SD287) rather than a proxy, as this supply item is now included in the database. 

Response: After receiving clarification regarding this request, we agree with commenters 

that SD287 is an appropriate supply input for this procedure. Therefore, we will include SD287 

for CPT code 43220. 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 
CMS-1612-FC 308

recommendations for CPT codes 43220, 43249, and 43270 by removing supply item “guidewire, 

STIFF” (SD090), among other refinements. 

Comment: Commenters indicated that the guidewire is required to safely straddle tumors 

for which there is impaired visibility and an inability to pass the scope through. 

Response: We agree with commenters that it would be appropriate to include supply 

item “guidewire – STIFF” in these procedures. We will include the supply item “guidewire – 

STIFF” in the direct PE inputs for these procedures. 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for codes 43200, 43201. 43202, 43206, 43215, 43216, 43217, 43220, 

43226, 43227, 43231, 43232, 43235, 43236, 43239, 43245, 43247, 43248, 43248, 43250, 43251, 

43252, 43255, and 43270 as established, with the additional refinements of including the supply 

items noted above. 

(h) Dilation of Esophagus (CPT Codes 43450, 43453) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 43450 and 43453 by removing equipment item “endoscope 

disinfector, rigid or fiberoptic, w-cart” (ES005), and not creating a new item “mobile stand, vital 

signs monitor,” and other refinements. 

 Comment: Commenters stated that the endoscope disinfector is a necessary part of all 

endoscopic procedures for sanitary and safety reasons, and that it should be restored for all 

gastrointestinal endoscopy codes. Commenters also noted that the mobile stand is the standard 

method of monitoring that must be moved along with the patient. 

Response: Since these are non-endoscopic dilation codes, there is no scope to clean, and 

thus the endoscope disinfector is unnecessary. The standard inputs for moderate sedation as 

recommended by the RUC were included in this procedure; the mobile stand overlaps with the 
CMS-1612-FC 309

standard moderate sedation input items. After consideration of the comments received, we are 

finalizing the CY 2014 interim final direct PE inputs for codes CPT codes 43450 and 43453 as 

established. 

(i) Spinal Injections (CPT Codes 62310, 62311, 62318, 62319) 

 In establishing interim final direct PE inputs for CY 2014, CMS accepted the RUC 

recommendations for CPT codes 62310, 62311, 62318, and 62319. Based on comments 

received, we made a proposal to maintain the CY 2014 direct PE inputs for CY 2015 while the 

codes are reexamined for bundling. We are finalizing this proposal, so while we acknowledge 

comments received on these codes, we will not respond to these comments as the interim final 

inputs to which the comments relate will not be used for 2015. 

(j) Percutaneous Implantation of Neurostimulator (CPT Code 63650) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT code time by removing the time associated with clinical labor task 

“Clean Surgical Instrument Package” and removing supply item “pack, cleaning, surgical 

instruments” (SA043) since no surgical instrument package is included in the service. 

Comment: Commenters indicated that clinical staff time is critical for the safety and 

efficiency of the procedure, and that the surgical instrument cleaning package is necessary to 

ensure proper adherence of the electrodes. 

Response: In general, as a matter of relativity throughout the PFS, the time allocated for 

the standard clinical labor task “Clean room/equipment following procedure” encompasses time 

for cleaning all equipment items. The only exceptions to this rule are for equipment items which 

are tied to specific clinical labor tasks, such as cleaning the surgical instrument pack or cleaning 

a scope. We do not believe it would serve relativity to separately break out time to clean various 

different types of equipment. After consideration of the comments received, we are finalizing 
CMS-1612-FC 310

the CY 2014 interim final direct PE inputs for CPT code 63650 as established. 

(k) Chemodenervation (CPT Codes 64616, 64642, 64644, 64646, 64647) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 64616, 64642, 64644, 64646, and 64647 by reducing the 

minutes allocated to “table, exam” (EF023) and removing the time associated with clinical labor 

task “Complete botox log,” as well as reducing the L037D time for clinical labor “assist 

physician performing procedure” for CPT code 64616, among other refinements. 

Comment: One commenter opposed our adjusting the minutes allocated to the exam 

table. Commenters stated that the reference code, 64615, included three minutes of clinical labor 

time for “complete botox log,” and requested that they be included since they are in the reference 

code. One commenter asked whether CMS planned to remove the minutes from the reference 

code as well. Other commenters indicated that as with most injections, it is necessary to 

document various elements of information for safety purposes. 

Response: Upon reviewing the time allocated to the exam table, we noted that our 

standard equipment policy is to allocate the entire service period for equipment that is not highly 

technical. Therefore, we will allocate minutes for the entire service period for the exam table, as 

follows: 28 minutes for 64616, 44 minutes for 64642, 49 minutes for 64644, 44 minutes for 

64646, and 49 minutes for 64647. We appreciate commenters pointing out the three minutes of 

time inadvertently allocated for “complete botox log” in the reference code, 64615, and will 

consider this issue in future rulemaking. We note that one of the benefits of having information 

stored in the direct PE database at the clinical labor task level is that it allows us to make 

comparisons of codes under review to existing codes in the PE database. This will help us 

ensure greater consistency in our refinements. As commenters point out, various injections are 

documented in logs, rather than medical records. The use of a different location for 
CMS-1612-FC 311

documentation is not a reason to allocate additional clinical labor time for a particular service. 

Comment: One commenter supported our adjustment of “assist physician” time from 7 

minutes to 5 minutes. Another commenter disagreed with the refinement and requested that 

CMS explain how physician time was calculated, while a different commenter stated that the 

“assist physician” time should be 28 minutes. 

Response: Upon reviewing the work time and the time allocated for assist physician, we 

determined that 7 minutes is actually appropriate for the assist physician task. 

After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 64616, 64642, 64644, 64646, and 64647 as established, with 

the additional refinement of adjusting the minutes for the exam table as indicated above and 

adding 2 minutes of clinical labor for the “assist physician” task for 64616. 

(l) MRI Brain (CPT Codes 70551, 70552, 70553) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 70551, 70552, and 70553 by adjusting the time for clinical 

labor task “assist physician in performing procedure/acquire images,” removing 2 minutes of 

clinical labor time for clinical labor task “escort patient from exam room due to magnetic 

sensitivity,” removing supply items “gauze,sterile 2in x 2in” (SG053), “tape, phix strips (for 

nasal catheter)” (SG089), “povidone swabsticks (3 pack uou” (SJ043), and “swab-pad, alcohol” 

(SJ 053) from CPT codes 70552 and 70553, among other refinements. 

Comment: Commenters indicated that the times associated with clinical labor task 

“assist physician in performing procedure/acquire images” reflected the PEAC surveyed times, 

and they had no reason to believe that the time had decreased since the PEAC review. 

Response: As indicated in the PFS CY 2014 final rule with comment period (78 FR 

74345), the procedure time for these services was last reviewed in 2002. We noted that we 
CMS-1612-FC 312

believe there should be no significant difference between the time to acquire images for an MRI 

of the brain and an MRI of the spine, and that, rather than rely on very old survey data, it would 

be appropriate to crosswalk the time associated with the MRI of the spine to the MRI of the 

brain. We continue to believe that this time is more accurate than that of the survey data. 

Comment: Commenters noted that the clinical labor task “escort patient from exam room 

due to magnetic sensitivity” is a necessary activity for patient safety. 

Response: Upon review of this clinical labor task, we noted that this task was included in 

the PE worksheets from when these codes were previously reviewed in 2002. Therefore, since 

this activity does not reflect a newly added clinical labor task, we agree with commenters that it 

would be appropriate to include 2 minutes for this clinical labor task. 

Comment: Commenters stated that the supplies removed from CPT codes 70552 and 

70553 were necessary supplies for the service, and that the specialty society incorrectly included 

supply item “tape, phix strips (for nasal catheter)” (SG089), when the correct supply item was 

“tape, surgical paper 1in (Micropore)” (SG079). 

Response: We note that these supplies were removed because they were already 

contained in the supply item “kit, IV starter” (SA019). Table 23 shows the items contained in 

the IV starter kit and the corresponding supply items removed due to redundancy. 

 
CMS-1612-FC 313

TABLE 23: Items Removed for Redundancy and Parallel Items Included in IV Starter Kit 

Items in IV starter kit Corresponding Items Removed 

for Redundancy 

1 tourniquet - 

1 PVP ointment povidone swabsticks (3 pack uou) 

1 PVP prep pad swab-pad, alcohol 

2 gauze sponges gauze, sterile 2in x 2in 

1 bandage (1"x3") - 

1 sm roll surgical tape tape, surgical paper 1in 

1 pr gloves - 

1 underpad 2ft x 3ft 

(Chux) - 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 70551, 70552, and 70553, with the additional refinement of 

including 2 minutes of clinical labor time as noted above. 

(m) MRI Spine (CPT Codes 72141, 72142, 72146, 72147, 72149, 72156, 72157, 72158) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 72141, 72142, 72146, 72147, 72149, 72156, 72157, and 72158 

by removing 2 minutes of clinical labor time for clinical labor task “escort patient from exam 

room due to magnetic sensitivity,” and other refinements. 

Comment: Commenters noted that the clinical labor task “escort patient from exam room 

due to magnetic sensitivity” is a necessary activity for patient safety. 

Response: Upon review of this clinical labor task, we noted that this task was included in 

the PE worksheets from when these codes were previously reviewed in 2002. Therefore, since 

this activity does not reflect a newly added clinical labor task, we agree with commenters that it 

would be appropriate to include 2 minutes for this clinical labor task. 

Comment: A commenter noted that CMS did not include a contrast imaging pack, which 

includes supplies necessary for contrast enhanced studies. 
CMS-1612-FC 314

Response: In section II.B. of this final rule with comment period, we finalized our policy 

to add a contrast imaging pack to be used for imaging services with contrast. Therefore, we will 

include the contrast supply pack (CMS code SA114) for CPT codes 72142, 74147, 72149, 

72156, 72157, and 72158. 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 72141, 72142, 72146, 72147, 72149, 72156, 72157, and 

72158, with the additional refinement of including 2 minutes of clinical labor time and including 

the supply pack for the services noted above. 

(n) Selective Catheter Placement (CPT Code 75726) 

 In establishing interim final direct PE inputs for CY 2014, when reviewing CPT code 

36245, which was identified through a misvalued code screen of codes reported together more 

than 75 percent of the time, we noted that it was frequently billed with 75726. We then noted that 

these two services had identical time for “assist physician in performing procedure,” and since 

the time for 36245 was reduced from 73 to 45 minutes, refined the clinical labor time for 75726 

to correspond to this change. 

Comment: Commenters indicated that the 73 minutes reflected the PEAC surveyed 

times, and that these activities are imaging-related, and in addition to the time and activities 

inherent in the accompanying surgical base code. 

Response: As indicated elsewhere in this section, we note that the PEAC survey data are 

very old, and that refinements based on more updated information are appropriate. We continue 

to believe that it is appropriate for the intraservice times for 36245 and 75726 to continue to 

correspond to one another, as they are frequently furnished together. After consideration of the 

comments received, we are finalizing the CY 2014 interim final direct PE inputs for CPT code 

75726 as established. 
CMS-1612-FC 315

(o) Radiation Treatment Delivery (CPT Codes 77373, 77422, 77423) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT code 77373 by refining the equipment time for “pulse oximeter wprinter” (EQ211) and “SRS system, SBRT, six systems, average” (ER083) to conform to 

established equipment policies. 

Comment: Commenters stated that the times should be maintained at 104 minutes, rather 

than being reduced to 86 minutes, and indicated the clinical labor task lines that should be 

included in the calculations. 

Response: Upon reviewing the equipment times associated with this procedure, we agree 

with commenters that the time allocated for the equipment should include the time associated 

with the indicated clinical labor tasks for these equipment items. After consideration of the 

comments received, we are finalizing the CY 2014 interim final direct PE inputs for CPT code 

77373 as established, with the additional refinement of adjusting the equipment times to 104 

minutes as noted above. 

 For CY 2014, we also eliminated several anomalous supply inputs included in the direct 

PE database, which affected 77422 and 77423, among other services. 

Comment: Commenters indicated that upon reviewing the inputs for these services, they 

noted that the Record and Verify System and the laser targeting system were missing in both of 

these services, despite being in the original 2005 recommendation. 

Response: We appreciate the commenters’ attention to detail. However, as indicated 

elsewhere, we do not believe that the record and verify system is medical equipment used in 

furnishing the technical component of the service. We refer readers to our discussion of this 

issue in the PFS 2014 Final rule with Comment period (78 FR 74317). Further, since these 

codes have not been reviewed in many years, we do not know if the laser targeting system 
CMS-1612-FC 316

continues to be an appropriate input for these services. Therefore, we request that the RUC 

examine the inputs for these services to ensure their accuracy. 

(p) Hyperthermia (CPT Code 77600) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT code 77600 by refining the time allocated to equipment item 

“hyperthermia system, ultrasound, external” (ER035) and removing the time associated with 

clinical labor task “clean scope,” among other refinements. 

Comment: Commenters indicated that the appropriate lines were not used to calculate 

the recommended equipment times, including cleaning the scope and check dressing. 

Response: Upon reviewing the comments, we re-examined the equipment time 

calculation and continue to believe that the time allocated to this equipment item is appropriate. 

We note that there is no scope used in this procedure, so time to clean the scope is unnecessary. 

After consideration of the comments received, we are finalizing the CY 2014 interim final direct 

PE inputs for CPT code 77600 as established. 

(q) High Dose Rate Brachytherapy (CPT Codes 77785, 77586, 77787) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 77785, 77786, and 77787 to remove “Emergency service 

container – safety kit,” as we consider it an indirect PE. 

Comment: Commenters noted that the emergency container is a safety device used when 

a source must be retrieved manually. Commenters indicated that it is a mobile item and that the 

service cannot be provided unless it is in the room, and thus it is a direct PE, since it is directly 

assumed by a physician in the course of providing the service. Commenters asked that we 

reclassify this item as a direct input. 
CMS-1612-FC 317

Response: In our clinical review, we reviewed the work vignettes for these procedures, 

which did not include the use of the “emergency service container - safety kit” as a part of the 

procedure. Although we acknowledge that the emergency service container safety kit needs to 

be readily available during the procedure, we note that “standby” equipment, or items that are 

not used in the typical case, are considered indirect costs. For further discussion of this issue, we 

refer readers to our discussion of “standby” equipment in the CY 2001 PFS proposed rule (65 FR 

44187). 

 When reviewing the interim final direct PE inputs for these services, we noted that the 

specialty societies conducted a survey of the technicians, which revealed higher procedure times 

than the current procedure times. However, since the RUC indicated that they did not have 

“compelling evidence,” the specialty society did not request the higher procedure times. We 

believe that if the specialty society believes that the code is undervalued relative to the expert 

panel value, and there is no indication that the survey was flawed, the specialty society should 

recommend the use of the surveyed procedure times. In doing so, the specialty society would 

give CMS the opportunity to consider the information provided alongside the RUC 

recommended times. We believe that surveys of technicians have the potential to be more 

accurate, rather than less accurate, than those of physicians, as the technicians do not have 

incentives to increase the surveyed time. We suggest that rather than attempting to insert items 

that are not standard in the PE methodology, that specialty societies make a strong, data-driven 

case, for why the survey times are correct. 

Comment: A commenter noted that there have been significant reductions to these CPT 

codes over the last several years, and urged CMS to phase in the reductions over time should the 

reductions be deemed appropriate after review of the methodology and data. 
CMS-1612-FC 318

Response: We note that reductions to CPT codes are made on the basis that they are 

potentially misvalued. We do not typically transition such reductions. However, the Protecting 

Access to Medicare Act (PAMA) requires that beginning in 2017, CMS transition code-level 

reductions of greater than or equal to 20 percent in a given year; therefore, beginning in 2017, 

such reductions will be transitioned. 

 After consideration of the comments received, we are finalizing the CY 2014 interim 

final direct PE inputs for CPT codes 77785, 77786, and 77787 as established. 

(r) Cytopathology (CPT Code 88112) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT code 88112 by removing the clinical labor time associated with 

several clinical labor tasks, including “Order, restock, and distribute specimen containers with 

requisition forms,” “Perform screening function (where applicable),” “Confirm patient ID, 

organize work, verify and review history,” and “Enter screening diagnosis in laboratory 

information system, complete workload recording logs, manage any relevant utilization 

review/quality assurance activities and regulatory compliance documentation and assemble and 

deliver slides with paperwork to pathologist.” 

Comment: Commenters pointed out that CPT code 88112 was inadvertently listed in 

Table 28 in the CY 2014 final rule with comment period as being unrefined by CMS. 

Commenters also opposed the reductions in clinical labor time, and noted that the PE 

subcommittee thoroughly reviewed these inputs. 

Response: We apologize for the inadvertent inclusion of CPT code 88112 in Table 28 of 

the CY 2014 final rule with comment period. We re-examined the clinical labor tasks in light of 

the comments received and noted that the clinical labor task “Order, restock, and distribute 

specimen containers with requisition forms” is not a clinical labor task associated with furnishing 
CMS-1612-FC 319

a service to a particular patient, and is therefore allocated in the indirect practice expense. 

Clinical labor task “Perform screening function (where applicable)” is not a task completed in 

the typical service, and is therefore not included. Further, clinical labor task “Confirm patient ID, 

organize work, verify and review history” is subsumed within clinical labor task “Remove slide 

from coverslipper; confirm patient ID, organize work, send slides to cytotech for screening”; 

including both would therefore be duplicative. Clinical labor task “Enter screening diagnosis in 

laboratory information system, complete workload recording logs, manage any relevant 

utilization review/quality assurance activities and regulatory compliance documentation and 

assemble and deliver slides with paperwork to pathologist” involves quality assurance activities. 

We refer readers to the CY 2014 PFS final rule with comment period (78 FR 74308) for a 

discussion regarding quality assurance activities. After consideration of the comments received, 

we are finalizing the CY 2014 interim final direct PE inputs for CPT code 88112. 

Comment: One commenter noted that the refinements to the PE inputs for CPT code 

88112 resulted in a rank-order anomaly, as CPT code 88108 has higher PE RVUs than CPT code 

88112, while CPT code 88108 is a less complex service than CPT code 88112. Specifically, 

commenters stated that it is illogical for a cytology specimen processing technique that involves 

an additional step that requires materially more resources to have an RVU that is less than an 

associated technique that requires fewer resources, and expressed concerns about the potential 

for misreporting. 

Response: We appreciate this commenter bringing this rank order anomaly to our 

attention. As indicated in section II.B. of this final rule with comment period, we are referring 

this code to the RUC as potentially misvalued based on the information received from the 

commenter. 

(s) Duplex Scans (CPT Codes 93880 and 93882) 
CMS-1612-FC 320

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 93880 and 93882 by removing the equipment time allocated for 

equipment items “video SVHS VCR (medical grade)” (ED034) and “video printer, color (Sony 

medical grade)” (ED036), and refining the equipment time for “computer desktop, w-monitor” 

(ED021) from 68 to 51 minutes, among other refinements. 

Comment: Commenters indicated that these items are not redundant and asked that CMS 

explain which items encompass ED034 and ED036. Commenters also stated that the desktop 

computer is used for the entire intraservice period. Commenters also stated that the refinements 

were expressed as a final decision effective January 1, 2014. 

Response: The equipment item “room, vascular ultrasound” (EL016) contains “room, 

ultrasound general” (EL015), which contains both “video SVHS VCR (medical grade)” and 

“digital printer (Sony UPD21).” We also note that the RUC has reviewed these codes again for 

2015; we refer readers to section II.F. of this rule for further discussion, including the new 

interim final inputs established for 2015. We further note that contrary to the commenters’ 

assertion, the refinements made were indeed effective January 1, 2014, but were not final 

decisions; rather, they were interim final for 2014 and subject to public comment. 

(t) Electroencephalogram (CPT Codes 95816, 95819, 95822) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 95816, 95819, and 95822 by refining the equipment time 

allocated to equipment item “EEG, digital, testing system (computer hardware, software & 

camera)” (EQ330), among other refinements. 

Comment: Commenters indicated that various staff activities are performed on the 

computer and requested that we restore the time previously removed. 
CMS-1612-FC 321

Response: Upon reviewing comments regarding the equipment time, we agree with 

commenters that we should allocate the entire service period for EQ330, since it is not highly 

technical equipment. After consideration of the comments received, we are finalizing the CY 

2014 interim final direct PE inputs for CPT codes 95816, 95819, and 95822 as established, with 

the additional refinement of assigning the intraservice time to EQ330. 

(u) Anogenital Examination With Colposcopic Magnification in Childhood for Suspected 

Trauma (CPT Code 99170) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes, we accepted the RUC’s recommendation to include a new 

clinical labor type called “child life specialist.” 

Comment: One commenter supported the inclusion of clinical labor staff time for the 

child life specialist. 

Response: We appreciate the commenter’s support for this decision. After consideration 

of the comments received, we are finalizing the CY 2014 interim final direct PE inputs for CPT 

code 99170 as established. 

(v) Immunohistochemistry (HCPCS Codes G0461 and G0462) 

 In establishing interim final direct PE inputs for CY 2014, CMS refined the RUC’s 

recommendations for CPT codes 88342 and 88343 by creating G-codes G0461 and G0462 and 

refining the inputs for these services. We acknowledge comments regarding the refinements 

CMS made to these inputs, as well as comments indicating that the direct practice expense inputs 

for these procedures implied that the reporting would be different than the reporting implied by 

the code descriptors. We note that the RUC has subsequently reviewed CPT codes 88342 and 

88343 again and we present the interim final values for 2015 in this final rule with comment 
CMS-1612-FC 322

period. Therefore, we will not address specific comments regarding G0461 and G0462 except, 

as discussed below, as they pertain to errors identified with regard to the pricing of supplies. 

Comment: Commenters alerted us to an error in the calculation of the supply price for 

SL483 and SL486. Commenters pointed out that the price for SL483 is $22.56/ml, rather than 

the .00256/ml that was listed in the database, and based on the unit of measure established in the 

direct PE inputs database for SL486, which costs $65.63 for 250 tests, the per test quantity 

should be 1, rather than 0.004. 

 Response: We agree with commenters that these prices were calculated incorrectly and 

have made the adjustments to the direct PE database. 

c. Finalizing CY 2014 Interim Malpractice Crosswalks for CY 2015 

In accordance with our malpractice methodology, we adjusted the malpractice RVUs for 

the CY 2014 new/revised/potentially misvalued codes for the difference in work RVUs (or, if 

greater, the clinical labor portion of the PE RVUs) between the source codes and the new/revised 

codes to reflect the specific risk-of-service for the new/revised codes. The interim final 

malpractice crosswalks were listed in Table 30 of the CY 2014 PFS final rule with comment 

period. 

We received only one comment on our CY 2014 interim final cross walks. As detailed in 

the CY 2014 final rule with comment period, we assigned malpractice crosswalk of CPT code 

31575 (Laryngoscopy, flexible fiberoptic; diagnostic) to CPT codes 43191-43195 and CPT code 

31638 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 

revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial 

dilation as required)) to CPT code 43196. 

Comment: A commenter said that the established PLI crosswalk, CPT code 31575, for 

CPT code 43191-43196 is not appropriate because the latter services have a life-threatening risk 
CMS-1612-FC 323

to patients and the same is not true for CPT code 31575. The commenter recommends instead 

that we utilize the RUC recommended crosswalk of bronchoscopy, rigid or flexible codes (CPT 

codes 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 

diagnostic, with cell washing, when performed (separate procedure)) for CPT code 43191, 31625 

(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 

bronchial or endobronchial biopsy(s), single or multiple sites) for CPT code 43192, 43193, and 

43195, and 31638 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 

performed; with revision of tracheal or bronchial stent inserted at previous session (includes 

tracheal/bronchial dilation as required)) for CPT codes 43194 and 43196. 

Response: We continue to believe that our assigned CY 2014 malpractice crosswalks best 

define the malpractice risk associated with CPT codes 43191-43196. Therefore, we are finalizing 

our CY 2014 interim final crosswalks. 

We received no comments on the CY 2014 interim final malpractice crosswalks and are 

finalizing them without modification for CY 2015. 

The malpractice RVUs for these services are reflected in Addendum B of this CY 2014 

PFS final rule with comment period. Since we are finalizing a five-year review of MP RVUs in 

this final rule with comment period, the MP RVUs assigned to this codes will also be affected by 

the updates due to this review. For details on the review, see section II.C. 

d. Other New, Revised or Potentially Misvalued Codes with CY 2014 Interim Final RVUs Not 

Specifically Discussed in the CY 2015 Final Rule with Comment Period 

For all other new, revised, or potentially misvalued codes with CY 2014 interim final 

RVUs that are not specifically discussed in this CY 2015 PFS final rule with comment period, 

we are finalizing for CY 2015, without modification, the CY 2014 interim final or CY 2014 

proposed work RVUs, malpractice crosswalks, and direct PE inputs. Unless otherwise indicated, 
CMS-1612-FC 324

we agreed with the time values recommended by the RUC or HCPAC for all codes addressed in 

this section. The time values for all codes are listed in a file called “CY 2014 PFS Work Time,” 

available on the CMS website under downloads for the CY 2015 PFS final rule with comment 

period at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. 

3. Establishing CY 2015 RVUs 

a. Finalizing CY 2015 Proposed RVUs 

In the CY 2015 proposed rule, we proposed CY 2015 work values for several codes. 

Table 24 contains a list of these codes and the final CY 2015 work RVUs. For more information 

on these codes and the establishment of the values, see section II.Bof this final rule with 

comment period. 

 
CMS-1612-FC 325

TABLE 24: CY 2015 Final Work RVUS for Codes with Proposed Work RVUs 

HCPCS 

Code Long Descriptor CY 2014 WRVU 

Proposed 

CY 2015 

Work 

RVU 

CY 

2015 

Work 

RVU 

G0389 Ultrasound, B-scan and/or real time with image documentation; 

for abdominal aortic aneurysm (AAA) screening 0.58 0.58 0.58 

G0416 Surgical pathology, gross and microscopic examination for 

prostate needle biopsies, any method; 3.09 3.09 3.09 

G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 

minutes New N/A 0.25 

62310 

Injection(s), of diagnostic or therapeutic substance(s) (including 

anesthetic, antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, including needle or catheter 

placement, includes contrast for localization when performed, 

epidural or subarachnoid; cervical or thoracic 

1.18 1.91 1.91 

62311 

Injection(s), of diagnostic or therapeutic substance(s) (including 

anesthetic, antispasmodic, opioid, steroid, other solution), not 

including neurolytic substances, including needle or catheter 

placement, includes contrast for localization when performed, 

epidural or subarachnoid; lumbar or sacral (caudal) 

 1.17 1.54 1.54 

62318 

Injection(s), including indwelling catheter placement, continuous 

infusion or intermittent bolus, of diagnostic or therapeutic 

substance(s) (including anesthetic, antispasmodic, opioid, 

steroid, other solution), not including neurolytic substances, 

includes contrast for localization when performed, epidural or 

subarachnoid; cervical or thoracic) 

 1.54 2.04 2.04 

62319 

Injection(s), including indwelling catheter placement, continuous 

infusion or intermittent bolus, of diagnostic or therapeutic 

substance(s) (including anesthetic, antispasmodic, opioid, 

steroid, other solution), not including neurolytic substances, 

includes contrast for localization when performed, epidural or 

subarachnoid; lumbar or sacral (caudal) 

1.50 1.87 1.87 

77055 mammography; unilateral, .70 .70 .70 

77056 mammography; bilateral .87 .87 .87 

77057 screening mammography, bilateral (2-view film study of each 

breast) .70 .70 .70 

99490 

Chronic care management services, at least 20 minutes of 

clinical staff time directed by a physician or other qualified 

health care professional, per calendar month, with the following 

required elements: multiple (two or more) chronic conditions 

expected to last at least 12 months, or until the death of the 

patient; chronic conditions place the patient at significant risk of 

death, acute exacerbation/decompensation, or functional decline; 

comprehensive care plan established, implemented, revised, or 

monitored. 

New .61 .61 

b. Establishing CY 2015 Interim Final Work RVUs 

Table 25 contains the CY 2015 interim final work RVUs for all codes for which we 

received RUC recommendations for CY 2015 and G-codes with interim final values for CY 
CMS-1612-FC 326

2015. These values are subject to public comment. The column labeled “CMS Time 

Refinement” indicates whether CMS refined the time values recommended by the RUC or 

HCPAC. 

This section discusses codes for which the interim final work RVU or time values 

assigned for CY 2015 vary from those recommended by the RUC or for which we do not have 

RUC recommendations. 

 
CMS-1612-FC 327

TABLE 25: CY 2015 Interim Final Work RVUS for New/Revised or Potentially Misvalued 

Codes 

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

11980 

Subcutaneous hormone pellet implantation 

(implantation of estradiol and/or testosterone pellets 

beneath the skin) 

1.48 1.10 1.10 No 

20604 

Arthrocentesis, aspiration and/or injection, small 

joint or bursa (eg, fingers, toes); with ultrasound 

guidance, with permanent recording and reporting 

New 0.89 0.89 No 

20606 

Arthrocentesis, aspiration and/or injection, 

intermediate joint or bursa (eg, temporomandibular, 

acromioclavicular, wrist, elbow or ankle, olecranon 

bursa); with ultrasound guidance, with permanent 

recording and reporting 

New 1.00 1.00 No 

20611 

Arthrocentesis, aspiration and/or injection, major 

joint or bursa (eg, shoulder, hip, knee, subacromial 

bursa); with ultrasound guidance, with permanent 

recording and reporting 

New 1.10 1.10 No 

20983 

Ablation therapy for reduction or eradication of 1 or 

more bone tumors (eg, metastasis) including 

adjacent soft tissue when involved by tumor 

extension, percutaneous, including imaging 

guidance when performed; cryoablation 

New 7.13 7.13 No 

21811 

Open treatment of rib fracture(s) with internal 

fixation, includes thoracoscopic visualization when 

performed, unilateral; 1-3 ribs 

New 19.55 10.79 Yes 

21812 

Open treatment of rib fracture(s) with internal 

fixation, includes thoracoscopic visualization when 

performed, unilateral; 4-6 ribs 

New 25.00 13.00 Yes 

21813 

Open treatment of rib fracture(s) with internal 

fixation, includes thoracoscopic visualization when 

performed, unilateral; 7 or more ribs 

New 35.00 17.61 Yes 

22510 

Percutaneous vertebroplasty (bone biopsy included 

when performed), 1 vertebral body, unilateral or 

bilateral injection, inclusive of all imaging 

guidance; cervicothoracic 

New 8.15 8.15 No 

22511 

Percutaneous vertebroplasty (bone biopsy included 

when performed), 1 vertebral body, unilateral or 

bilateral injection, inclusive of all imaging 

guidance; lumbosacral 

New 8.05 7.58 No 
CMS-1612-FC 328

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

22512 

Percutaneous vertebroplasty (bone biopsy included 

when performed), 1 vertebral body, unilateral or 

bilateral injection, inclusive of all imaging 

guidance; each additional cervicothoracic or 

lumbosacral vertebral body (list separately in 

addition to code for primary procedure) 

New 4.00 4.00 No 

22513 

Percutaneous vertebral augmentation, including 

cavity creation (fracture reduction and bone biopsy 

included when performed) using mechanical device 

(eg, kyphoplasty), 1 vertebral body, unilateral or 

bilateral cannulation, inclusive of all imaging 

guidance; thoracic 

New 8.90 8.90 No 

22514 

Percutaneous vertebral augmentation, including 

cavity creation (fracture reduction and bone biopsy 

included when performed) using mechanical device 

(eg, kyphoplasty), 1 vertebral body, unilateral or 

bilateral cannulation, inclusive of all imaging 

guidance; lumbar 

New 8.24 8.24 No 

22515 

Percutaneous vertebral augmentation, including 

cavity creation (fracture reduction and bone biopsy 

included when performed) using mechanical device 

(eg, kyphoplasty), 1 vertebral body, unilateral or 

bilateral cannulation, inclusive of all imaging 

guidance; each additional thoracic or lumbar 

vertebral body (list separately in addition to code for 

primary procedure) 

New 4.00 4.00 No 

22856 

Total disc arthroplasty (artificial disc), anterior 

approach, including discectomy with end plate 

preparation (includes osteophytectomy for nerve 

root or spinal cord decompression and 

microdissection); single interspace, cervical 

24.05 24.05 24.05 No 

22858 

Total disc arthroplasty (artificial disc), anterior 

approach, including discectomy with end plate 

preparation (includes osteophytectomy for nerve 

root or spinal cord decompression and 

microdissection); second level, cervical (list 

separately in addition to code for primary 

procedure) 

New 8.40 8.40 No 

27279 

Arthrodesis, sacroiliac joint, percutaneous or 

minimally invasive (indirect visualization), with 

image guidance, includes obtaining bone graft when 

performed, and placement of transfixing device 

New 9.03 9.03 No 

29200 Strapping; thorax 0.65 0.39 0.39 No 

29240 Strapping; shoulder (eg, velpeau) 0.71 0.39 0.39 No 

29260 Strapping; elbow or wrist 0.55 0.39 0.39 No 
CMS-1612-FC 329

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

29280 Strapping; hand or finger 0.51 0.39 0.39 No 

29520 Strapping; hip 0.54 0.39 0.39 No 

29530 Strapping; knee 0.57 0.39 0.39 No 

31620 

Endobronchial ultrasound (ebus) during 

bronchoscopic diagnostic or therapeutic 

intervention(s) (list separately in addition to code 

for primary procedure[s]) 

1.40 1.50 1.40 No 

33215 

Repositioning of previously implanted transvenous 

pacemaker or implantable defibrillator (right atrial 

or right ventricular) electrode 

4.92 4.92 4.92 No 

33216 Insertion of a single transvenous electrode, 

permanent pacemaker or implantable defibrillator 5.87 5.87 5.87 No 

33217 Insertion of 2 transvenous electrodes, permanent 

pacemaker or implantable defibrillator 5.84 5.84 5.84 No 

33218 Repair of single transvenous electrode, permanent 

pacemaker or implantable defibrillator 6.07 6.07 6.07 No 

33220 Repair of 2 transvenous electrodes for permanent 

pacemaker or implantable defibrillator 6.15 6.15 6.15 No 

33223 Relocation of skin pocket for implantable 

defibrillator 6.55 6.55 6.55 No 

33224 

Insertion of pacing electrode, cardiac venous 

system, for left ventricular pacing, with attachment 

to previously placed pacemaker or implantable 

defibrillator pulse generator (including revision of 

pocket, removal, insertion, and/or replacement of 

existing generator) 

9.04 9.04 9.04 No 

33225 

Insertion of pacing electrode, cardiac venous 

system, for left ventricular pacing, at time of 

insertion of implantable defibrillator or pacemaker 

pulse generator (eg, for upgrade to dual chamber 

system) (list separately in addition to code for 

primary procedure) 

8.33 8.33 8.33 No 

33240 Insertion of implantable defibrillator pulse generator 

only; with existing single lead 6.05 6.05 6.05 No 

33241 Removal of implantable defibrillator pulse 

generator only 3.29 3.29 3.29 No 

33243 Removal of single or dual chamber implantable 

defibrillator electrode(s); by thoracotomy 23.57 23.57 23.57 No 

33244 Removal of single or dual chamber implantable 

defibrillator electrode(s); by transvenous extraction 13.99 13.99 13.99 No 

33249 

Insertion or replacement of permanent implantable 

defibrillator system, with transvenous lead(s), single 

or dual chamber 

15.17 15.17 15.17 No 
CMS-1612-FC 330

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

33262 

Removal of implantable defibrillator pulse 

generator with replacement of implantable 

defibrillator pulse generator; single lead system 

6.06 6.06 6.06 No 

33263 

Removal of implantable defibrillator pulse 

generator with replacement of implantable 

defibrillator pulse generator; dual lead system 

6.33 6.33 6.33 No 

33270 

Insertion or replacement of permanent subcutaneous 

implantable defibrillator system, with subcutaneous 

electrode, including defibrillation threshold 

evaluation, induction of arrhythmia, evaluation of 

sensing for arrhythmia termination, and 

programming or reprogramming of sensing or 

therapeutic parameters, when performed 

New 9.10 9.10 No 

33271 Insertion of subcutaneous implantable defibrillator 

electrode New 7.50 7.50 No 

33272 Removal of subcutaneous implantable defibrillator 

electrode New 5.42 5.42 No 

33273 Repositioning of previously implanted subcutaneous 

implantable defibrillator electrode New 6.50 6.50 No 

33418 

Transcatheter mitral valve repair, percutaneous 

approach, including transseptal puncture when 

performed; initial prosthesis 

New 32.25 32.25 No 

33419 

Transcatheter mitral valve repair, percutaneous 

approach, including transseptal puncture when 

performed; additional prosthesis(es) during same 

session (list separately in addition to code for 

primary procedure) 

New 7.93 7.93 No 

33946 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; initiation, veno-venous 

New 6.00 6.00 No 

33947 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; initiation, veno-arterial 

New 6.63 6.63 No 

33949 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; daily management, each day, venoarterial 

New 4.60 4.60 No 

33951 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of peripheral (arterial and/or 

venous) cannula(e), percutaneous, birth through 5 

years of age (includes fluoroscopic guidance, when 

performed) 

New 8.15 8.15 No 
CMS-1612-FC 331

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

33952 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of peripheral (arterial and/or 

venous) cannula(e), percutaneous, 6 years and older 

(includes fluoroscopic guidance, when performed) 

New 8.43 8.15 No 

33953 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of peripheral (arterial and/or 

venous) cannula(e), open, birth through 5 years of 

age 

New 9.83 9.11 No 

33954 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of peripheral (arterial and/or 

venous) cannula(e), open, 6 years and older 

New 9.43 9.11 No 

33955 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of central cannula(e) by 

sternotomy or thoracotomy, birth through 5 years of 

age 

New 16.00 16.00 No 

33956 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; insertion of central cannula(e) by 

sternotomy or thoracotomy, 6 years and older 

New 16.00 16.00 No 

33957 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition peripheral (arterial and/or 

venous) cannula(e), percutaneous, birth through 5 

years of age (includes fluoroscopic guidance, when 

performed) 

New 4.00 3.51 No 

33958 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition peripheral (arterial and/or 

venous) cannula(e), percutaneous, 6 years and older 

(includes fluoroscopic guidance, when performed) 

New 4.05 3.51 No 

33959 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition peripheral (arterial and/or 

venous) cannula(e), open, birth through 5 years of 

age (includes fluoroscopic guidance, when 

performed) 

New 4.69 4.47 No 

33962 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition peripheral (arterial and/or 

venous) cannula(e), open, 6 years and older 

(includes fluoroscopic guidance, when performed) 

New 4.73 4.47 No 
CMS-1612-FC 332

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

33963 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition of central cannula(e) by 

sternotomy or thoracotomy, birth through 5 years of 

age (includes fluoroscopic guidance, when 

performed) 

New 9.00 9.00 No 

33964 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; reposition central cannula(e) by 

sternotomy or thoracotomy, 6 years and older 

(includes fluoroscopic guidance, when performed) 

New 9.50 9.50 No 

33965 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of peripheral (arterial and/or 

venous) cannula(e), percutaneous, birth through 5 

years of age 

New 3.51 3.51 No 

33966 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of peripheral (arterial and/or 

venous) cannula(e), percutaneous, 6 years and older 

New 4.50 4.50 No 

33969 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of peripheral (arterial and/or 

venous) cannula(e), open, birth through 5 years of 

age 

New 6.00 5.22 No 

33984 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of peripheral (arterial and/or 

venous) cannula(e), open, 6 years and older 

New 6.38 5.46 No 

33985 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of central cannula(e) by 

sternotomy or thoracotomy, birth through 5 years of 

age 

New 9.89 9.89 No 

33986 

Extracorporeal membrane oxygenation 

(ecmo)/extracorporeal life support (ecls) provided 

by physician; removal of central cannula(e) by 

sternotomy or thoracotomy, 6 years and older 

New 10.00 10.00 No 

33987 

Arterial exposure with creation of graft conduit (eg, 

chimney graft) to facilitate arterial perfusion for 

ecmo/ecls (list separately in addition to code for 

primary procedure) 

New 4.04 4.04 No 

33988 Insertion of left heart vent by thoracic incision (eg, 

sternotomy, thoracotomy) for ecmo/ecls New 15.00 15.00 No 
CMS-1612-FC 333

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

33989 Removal of left heart vent by thoracic incision (eg, 

sternotomy, thoracotomy) for ecmo/ecls New 9.50 9.50 No 

34839 

Physician planning of a patient-specific fenestrated 

visceral aortic endograft requiring a minimum of 90 

minutes of physician time 

New C B N/A 

34841 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, 

intramural hematoma, or traumatic disruption) by 

deployment of a fenestrated visceral aortic 

endograft and all associated radiological supervision 

and interpretation, including target zone 

angioplasty, when performed; including one visceral 

artery endoprosthesis (superior mesenteric, celiac or 

renal artery) 

C C C N/A 

34842 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, 

intramural hematoma, or traumatic disruption) by 

deployment of a fenestrated visceral aortic 

endograft and all associated radiological supervision 

and interpretation, including target zone 

angioplasty, when performed; including two 

visceral artery endoprostheses (superior mesenteric, 

celiac and/or renal artery[s]) 

C C C N/A 

34843 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, 

intramural hematoma, or traumatic disruption) by 

deployment of a fenestrated visceral aortic 

endograft and all associated radiological supervision 

and interpretation, including target zone 

angioplasty, when performed; including three 

visceral artery endoprostheses (superior mesenteric, 

celiac and/or renal artery[s]) 

C C C N/A 

34844 

Endovascular repair of visceral aorta (eg, aneurysm, 

pseudoaneurysm, dissection, penetrating ulcer, 

intramural hematoma, or traumatic disruption) by 

deployment of a fenestrated visceral aortic 

endograft and all associated radiological supervision 

and interpretation, including target zone 

angioplasty, when performed; including four or 

more visceral artery endoprostheses (superior 

mesenteric, celiac and/or renal artery[s]) 

C C C N/A 
CMS-1612-FC 334

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

34845 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, 

or traumatic disruption) with a fenestrated visceral 

aortic endograft and concomitant unibody or 

modular infrarenal aortic endograft and all 

associated radiological supervision and 

interpretation, including target zone angioplasty, 

when performed; including one visceral artery 

endoprosthesis (superior mesenteric, celiac or renal 

artery) 

C C C N/A 

34846 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, 

or traumatic disruption) with a fenestrated visceral 

aortic endograft and concomitant unibody or 

modular infrarenal aortic endograft and all 

associated radiological supervision and 

interpretation, including target zone angioplasty, 

when performed; including two visceral artery 

endoprostheses (superior mesenteric, celiac and/or 

renal artery[s]) 

C C C N/A 

34847 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, 

or traumatic disruption) with a fenestrated visceral 

aortic endograft and concomitant unibody or 

modular infrarenal aortic endograft and all 

associated radiological supervision and 

interpretation, including target zone angioplasty, 

when performed; including three visceral artery 

endoprostheses (superior mesenteric, celiac and/or 

renal artery[s]) 

C C C N/A 

34848 

Endovascular repair of visceral aorta and infrarenal 

abdominal aorta (eg, aneurysm, pseudoaneurysm, 

dissection, penetrating ulcer, intramural hematoma, 

or traumatic disruption) with a fenestrated visceral 

aortic endograft and concomitant unibody or 

modular infrarenal aortic endograft and all 

associated radiological supervision and 

interpretation, including target zone angioplasty, 

when performed; including four or more visceral 

artery endoprostheses (superior mesenteric, celiac 

and/or renal artery[s]) 

C C C N/A 

36475 

Endovenous ablation therapy of incompetent vein, 

extremity, inclusive of all imaging guidance and 

monitoring, percutaneous, radiofrequency; first vein 

treated 

6.72 5.30 5.30 No 
CMS-1612-FC 335

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

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 (list separately in 

addition to code for primary procedure) 

3.38 2.65 2.65 No 

36478 

Endovenous ablation therapy of incompetent vein, 

extremity, inclusive of all imaging guidance and 

monitoring, percutaneous, laser; first vein treated 

6.72 5.30 5.30 No 

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 (list separately in 

addition to code for primary procedure) 

3.38 2.65 2.65 No 

36818 Arteriovenous anastomosis, open; by upper arm 

cephalic vein transposition 11.89 13.00 12.39 No 

36819 Arteriovenous anastomosis, open; by upper arm 

basilic vein transposition 13.29 15.00 13.29 No 

36820 Arteriovenous anastomosis, open; by forearm vein 

transposition 14.47 13.99 13.07 No 

36821 Arteriovenous anastomosis, open; direct, any site 

(eg, cimino type) (separate procedure) 12.11 11.90 11.90 No 

36825 

Creation of arteriovenous fistula by other than direct 

arteriovenous anastomosis (separate procedure); 

autogenous graft 

14.17 15.93 14.17 No 

36830 

Creation of arteriovenous fistula by other than direct 

arteriovenous anastomosis (separate procedure); 

nonautogenous graft (eg, biological collagen, 

thermoplastic graft) 

12.03 11.90 12.03 No 

36831 

Thrombectomy, open, arteriovenous fistula without 

revision, autogenous or nonautogenous dialysis 

graft (separate procedure) 

8.04 11.00 11.00 Yes 

36832 

Revision, open, arteriovenous fistula; without 

thrombectomy, autogenous or nonautogenous 

dialysis graft (separate procedure) 

10.53 13.50 13.50 Yes 

36833 

Revision, open, arteriovenous fistula; with 

thrombectomy, autogenous or nonautogenous 

dialysis graft (separate procedure) 

11.98 14.50 14.50 Yes 
CMS-1612-FC 336

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

37218 

Transcatheter placement of intravascular stent(s), 

intrathoracic common carotid artery or innominate 

artery, open or percutaneous antegrade approach, 

including angioplasty, when performed, and 

radiological supervision and interpretation 

New 15.00 15.00 No 

43180 

Esophagoscopy, rigid, transoral with 

diverticulectomy of hypopharynx or cervical 

esophagus (eg, zenker's diverticulum), with 

cricopharyngeal myotomy, includes use of telescope 

or operating microscope and repair, when 

performed 

New 9.03 9.03 No 

44381 Ileoscopy, through stoma; with transendoscopic 

balloon dilation New 1.48 I N/A 

44384 

Ileoscopy, through stoma; with placement of 

endoscopic stent (includes pre- and post-dilation 

and guide wire passage, when performed) 

New 3.11 I N/A 

44401 

Colonoscopy through stoma; with ablation of 

tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when 

performed) 

New 4.44 I N/A 

44402 

Colonoscopy through stoma; with endoscopic stent 

placement (including pre- and post-dilation and 

guide wire passage, when performed) 

New 4.96 I N/A 

44403 Colonoscopy through stoma; with endoscopic 

mucosal resection New 5.81 I N/A 

44404 Colonoscopy through stoma; with directed 

submucosal injection(s), any substance New 3.13 I N/A 

44405 Colonoscopy through stoma; with transendoscopic 

balloon dilation New 3.33 I N/A 

44406 

Colonoscopy through stoma; with endoscopic 

ultrasound examination, limited to the sigmoid, 

descending, transverse, or ascending colon and 

cecum and adjacent structures 

New 4.41 I N/A 

44407 

Colonoscopy through stoma; with transendoscopic 

ultrasound guided intramural or transmural fine 

needle aspiration/biopsy(s), includes endoscopic 

ultrasound examination limited to the sigmoid, 

descending, transverse, or ascending colon and 

cecum and adjacent structures 

New 5.06 I N/A 

44408 

Colonoscopy through stoma; with decompression 

(for pathologic distention) (eg, volvulus, 

megacolon), including placement of decompression 

tube, when performed 

New 4.24 I N/A 
CMS-1612-FC 337

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

45346 

Sigmoidoscopy, flexible; with ablation of tumor(s), 

polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed) New 2.97 I N/A 

45347 

Sigmoidoscopy, flexible; with placement of 

endoscopic stent (includes pre- and post-dilation 

and guide wire passage, when performed) 

New 2.98 I N/A 

45349 Sigmoidoscopy, flexible; with endoscopic mucosal 

resection New 3.83 I N/A 

45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, 

hemorrhoids) New 1.78 I N/A 

45388 

Colonoscopy, flexible; with ablation of tumor(s), 

polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed) New 4.98 I N/A 

45389 

Colonoscopy, flexible; with endoscopic stent 

placement (includes pre- and post-dilation and guide 

wire passage, when performed) 

New 5.50 I N/A 

45390 Colonoscopy, flexible; with endoscopic mucosal 

resection New 6.35 I N/A 

45393 

Colonoscopy, flexible; with decompression (for 

pathologic distention) (eg, volvulus, megacolon), 

including placement of decompression tube, when 

performed 

New 4.78 I N/A 

45398 Colonoscopy, flexible; with band ligation(s) (eg, 

hemorrhoids) New 4.30 N/A 

45399 Unlisted procedure, colon New None I N/A 

46601 

Anoscopy; diagnostic, with high-resolution 

magnification (hra) (eg, colposcope, operating 

microscope) and chemical agent enhancement, 

including collection of specimen(s) by brushing or 

washing, when performed 

New 1.60 I N/A 

46607 

Anoscopy; with high-resolution magnification (hra) 

(eg, colposcope, operating microscope) and 

chemical agent enhancement, with biopsy, single or 

multiple 

New 2.20 I N/A 

47383 Ablation, 1 or more liver tumor(s), percutaneous, 

cryoablation New 9.13 9.13 No 

52441 Cystourethroscopy, with insertion of permanent 

adjustable transprostatic implant; single implant New 4.50 4.50 No 

52442 

Cystourethroscopy, with insertion of permanent 

adjustable transprostatic implant; each additional 

permanent adjustable transprostatic implant (list 

separately in addition to code for primary 

procedure) 

New 1.20 1.20 No 
CMS-1612-FC 338

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

55840 Prostatectomy, retropubic radical, with or without 

nerve sparing; 24.63 21.36 21.36 No 

55842 

Prostatectomy, retropubic radical, with or without 

nerve sparing; with lymph node biopsy(s) (limited 

pelvic lymphadenectomy) 

26.49 24.16 21.36 No 

55845 

Prostatectomy, retropubic radical, with or without 

nerve sparing; with bilateral pelvic 

lymphadenectomy, including external iliac, 

hypogastric, and obturator nodes 

30.67 29.07 25.18 No 

58541 Laparoscopy, surgical, supracervical hysterectomy, 

for uterus 250 g or less; 14.70 12.29 12.29 No 

58542 

Laparoscopy, surgical, supracervical hysterectomy, 

for uterus 250 g or less; with removal of tube(s) 

and/or ovary(s) 

16.56 14.16 14.16 No 

58543 Laparoscopy, surgical, supracervical hysterectomy, 

for uterus greater than 250 g; 16.87 14.39 14.39 No 

58544 

Laparoscopy, surgical, supracervical hysterectomy, 

for uterus greater than 250 g; with removal of 

tube(s) and/or ovary(s) 

18.37 15.60 15.60 No 

58570 Laparoscopy, surgical, with total hysterectomy, for 

uterus 250 g or less; 15.88 13.36 13.36 No 

58571 

Laparoscopy, surgical, with total hysterectomy, for 

uterus 250 g or less; with removal of tube(s) and/or 

ovary(s) 

17.69 15.00 15.00 No 

58572 Laparoscopy, surgical, with total hysterectomy, for 

uterus greater than 250 g; 20.09 17.71 17.71 No 

58573 

Laparoscopy, surgical, with total hysterectomy, for 

uterus greater than 250 g; with removal of tube(s) 

and/or ovary(s) 

23.11 20.79 20.79 No 

62284 

Injection procedure for myelography and/or 

computed tomography, lumbar (other than c1-c2 

and posterior fossa) 

1.54 1.54 1.54 No 

62302 Myelography via lumbar injection, including 

radiological supervision and interpretation; cervical New 2.29 2.29 No 

62303 Myelography via lumbar injection, including 

radiological supervision and interpretation; thoracic New 2.29 2.29 No 

62304 

Myelography via lumbar injection, including 

radiological supervision and interpretation; 

lumbosacral 

New 2.25 2.25 No 
CMS-1612-FC 339

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

62305 

Myelography via lumbar injection, including 

radiological supervision and interpretation; 2 or 

more regions (eg, lumbar/thoracic, cervical/thoracic, 

lumbar/cervical, lumbar/thoracic/cervical) 

New 2.35 2.35 No 

64486 

Transversus abdominis plane (tap) block 

(abdominal plane block, rectus sheath block) 

unilateral; by injection(s) (includes imaging 

guidance, when performed) 

New 1.27 1.27 No 

64487 

Transversus abdominis plane (tap) block 

(abdominal plane block, rectus sheath block) 

unilateral; by continuous infusion(s) (includes 

imaging guidance, when performed) 

New 1.48 1.48 No 

64488 

Transversus abdominis plane (tap) block 

(abdominal plane block, rectus sheath block) 

bilateral; by injections (includes imaging guidance, 

when performed) 

New 1.60 1.60 No 

64489 

Transversus abdominis plane (tap) block 

(abdominal plane block, rectus sheath block) 

bilateral; by continuous infusions (includes imaging 

guidance, when performed) 

New 1.80 1.80 No 

64561 

Percutaneous implantation of neurostimulator 

electrode array; sacral nerve (transforaminal 

placement) including image guidance, if performed 

7.15 5.44 5.44 No 

66179 Aqueous shunt to extraocular equatorial plate 

reservoir, external approach; without graft New 14.00 14.00 No 

66180 Aqueous shunt to extraocular equatorial plate 

reservoir, external approach; with graft 16.30 15.00 15.00 No 

66184 Revision of aqueous shunt to extraocular equatorial 

plate reservoir; without graft New 9.58 9.58 No 

66185 Revision of aqueous shunt to extraocular equatorial 

plate reservoir; with graft 9.58 10.58 10.58 No 

67036 Vitrectomy, mechanical, pars plana approach; 13.32 12.13 12.13 No 

67039 Vitrectomy, mechanical, pars plana approach; with 

focal endolaser photocoagulation 16.74 13.20 13.20 No 

67040 Vitrectomy, mechanical, pars plana approach; with 

endolaser panretinal photocoagulation 19.61 14.50 14.50 No 

67041 

Vitrectomy, mechanical, pars plana approach; with 

removal of preretinal cellular membrane (eg, 

macular pucker) 

19.25 16.33 16.33 No 
CMS-1612-FC 340

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

67042 

Vitrectomy, mechanical, pars plana approach; with 

removal of internal limiting membrane of retina (eg, 

for repair of macular hole, diabetic macular edema), 

includes, if performed, intraocular tamponade (ie, 

air, gas or silicone oil) 

22.38 16.33 16.33 No 

67043 

Vitrectomy, mechanical, pars plana approach; with 

removal of subretinal membrane (eg, choroidal 

neovascularization), includes, if performed, 

intraocular tamponade (ie, air, gas or silicone oil) 

and laser photocoagulation 

23.24 17.40 17.40 No 

67255 Scleral reinforcement (separate procedure); with 

graft 10.17 10.17 8.38 No 

70486 Computed tomography, maxillofacial area; without 

contrast material 1.14 0.85 0.85 No 

70487 Computed tomography, maxillofacial area; with 

contrast material(s) 1.30 1.17 1.13 No 

70488 

Computed tomography, maxillofacial area; without 

contrast material, followed by contrast material(s) 

and further sections 

1.42 1.30 1.27 No 

70496 

Computed tomographic angiography, head, with 

contrast material(s), including noncontrast images, 

if performed, and image postprocessing 

1.75 1.75 1.75 No 

70498 

Computed tomographic angiography, neck, with 

contrast material(s), including noncontrast images, 

if performed, and image postprocessing 

1.75 1.75 1.75 No 

71275 

Computed tomographic angiography, chest 

(noncoronary), with contrast material(s), including 

noncontrast images, if performed, and image 

postprocessing 

1.92 1.82 1.82 No 

72191 

Computed tomographic angiography, pelvis, with 

contrast material(s), including noncontrast images, 

if performed, and image postprocessing 

1.81 1.81 1.81 No 

72240 Myelography, cervical, radiological supervision and 

interpretation 0.91 0.91 0.91 No 

72255 Myelography, thoracic, radiological supervision and 

interpretation 0.91 0.91 0.91 No 

72265 Myelography, lumbosacral, radiological supervision 

and interpretation 0.83 0.83 0.83 No 

72270 

Myelography, 2 or more regions (eg, 

lumbar/thoracic, cervical/thoracic, lumbar/cervical, 

lumbar/thoracic/cervical), radiological supervision 

and interpretation 

1.33 1.33 1.33 No 
CMS-1612-FC 341

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

74174 

Computed tomographic angiography, abdomen and 

pelvis, with contrast material(s), including 

noncontrast images, if performed, and image 

postprocessing 

2.20 2.20 2.20 No 

74175 

Computed tomographic angiography, abdomen, 

with contrast material(s), including noncontrast 

images, if performed, and image postprocessing 

1.90 1.82 1.82 No 

74230 Swallowing function, with 

cineradiography/videoradiography 0.53 0.53 0.53 No 

76641 

Ultrasound, breast, unilateral, real time with image 

documentation, including axilla when performed; 

complete 

New 0.73 0.73 No 

76642 

Ultrasound, breast, unilateral, real time with image 

documentation, including axilla when performed; 

limited 

New 0.68 0.68 No 

76700 Ultrasound, abdominal, real time with image 

documentation; complete 0.81 0.81 0.81 No 

76705 

Ultrasound, abdominal, real time with image 

documentation; limited (eg, single organ, quadrant, 

follow-up) 

0.59 0.59 0.59 No 

76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), 

real time with image documentation; complete 0.74 0.74 0.74 No 

76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), 

real time with image documentation; limited 0.58 0.58 0.58 No 

76856 Ultrasound, pelvic (nonobstetric), real time with 

image documentation; complete 0.69 0.69 0.69 No 

76857 

Ultrasound, pelvic (nonobstetric), real time with 

image documentation; limited or follow-up (eg, for 

follicles) 

0.38 0.50 0.50 No 

76930 Ultrasonic guidance for pericardiocentesis, imaging 

supervision and interpretation 0.67 0.67 0.67 No 

76932 Ultrasonic guidance for endomyocardial biopsy, 

imaging supervision and interpretation C 0.85 0.85 No 

76942 

Ultrasonic guidance for needle placement (eg, 

biopsy, aspiration, injection, localization device), 

imaging supervision and interpretation 

0.67 0.67 0.67 No 

76948 Ultrasonic guidance for aspiration of ova, imaging 

supervision and interpretation 0.38 0.92 0.92 No 

77061 Digital breast tomosynthesis; unilateral New 0.70 I N/A 

77062 Digital breast tomosynthesis; bilateral New 0.90 I N/A 

77063 

Screening digital breast tomosynthesis, bilateral (list 

separately in addition to code for primary 

procedure) 

New 0.60 0.60 No 
CMS-1612-FC 342

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

77080 

Dual-energy x-ray absorptiometry (dxa), bone 

density study, 1 or more sites; axial skeleton (eg, 

hips, pelvis, spine) 

0.20 0.20 0.20 No 

77085 

Dual-energy x-ray absorptiometry (dxa), bone 

density study, 1 or more sites; axial skeleton (eg, 

hips, pelvis, spine), including vertebral fracture 

assessment 

New 0.30 0.30 No 

77086 Vertebral fracture assessment via dual-energy x-ray 

absorptiometry (dxa) New 0.17 0.17 No 

77300 

Basic radiation dosimetry calculation, central axis 

depth dose calculation, tdf, nsd, gap calculation, off 

axis factor, tissue inhomogeneity factors, 

calculation of non-ionizing radiation surface and 

depth dose, as required during course of treatment, 

only when prescribed by the treating physician 

0.62 0.62 0.62 No 

77306 

Teletherapy isodose plan; simple (1 or 2 unmodified 

ports directed to a single area of interest), includes 

basic dosimetry calculation(s) 

New 1.40 1.40 No 

77307 

Teletherapy isodose plan; complex (multiple 

treatment areas, tangential ports, the use of wedges, 

blocking, rotational beam, or special beam 

considerations), includes basic dosimetry 

calculation(s) 

New 2.90 2.90 No 

77316 

Brachytherapy isodose plan; simple (calculation[s] 

made from 1 to 4 sources, or remote afterloading 

brachytherapy, 1 channel), includes basic dosimetry 

calculation(s) 

New 1.50 1.40 No 

77317 

Brachytherapy isodose plan; intermediate 

(calculation[s] made from 5 to 10 sources, or remote 

afterloading brachytherapy, 2-12 channels), includes 

basic dosimetry calculation(s) 

New 1.83 1.83 No 

77318 

Brachytherapy isodose plan; complex 

(calculation[s] made from over 10 sources, or 

remote afterloading brachytherapy, over 12 

channels), includes basic dosimetry calculation(s) 

New 2.90 2.90 No 

77385 

Intensity modulated radiation treatment delivery 

(imrt), includes guidance and tracking, when 

performed; simple 

New I N/A 

77386 

Intensity modulated radiation treatment delivery 

(imrt), includes guidance and tracking, when 

performed; complex 

New I N/A 

77387 

Guidance for localization of target volume for 

delivery of radiation treatment delivery, includes 

intrafraction tracking, when performed 

New 0.58 I N/A 
CMS-1612-FC 343

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

77402 Radiation treatment delivery, >1 mev; simple 0.00 I N/A 

77407 Radiation treatment delivery, >1 mev; intermediate 0.00 I N/A 

77412 Radiation treatment delivery, >1 mev; complex 0.00 I N/A 

88341 

Immunohistochemistry or immunocytochemistry, 

per specimen; each additional single antibody stain 

procedure (list separately in addition to code for 

primary procedure) 

New 0.65 0.42 No 

88342 Immunohistochemistry or immunocytochemistry, 

per specimen; initial single antibody stain procedure I 0.70 0.70 No 

88344 

Immunohistochemistry or immunocytochemistry, 

per specimen; each multiplex antibody stain 

procedure 

New 0.77 0.77 No 

88356 Morphometric analysis; nerve 3.02 2.80 2.80 No 

88364 

In situ hybridization (eg, fish), per specimen; each 

additional single probe stain procedure (list 

separately in addition to code for primary 

procedure) 

New 0.88 0.53 No 

88365 In situ hybridization (eg, fish), per specimen; initial 

single probe stain procedure 1.20 0.88 0.88 No 

88366 In situ hybridization (eg, fish), per specimen; each 

multiplex probe stain procedure New 1.24 1.24 No 

88367 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), using computerassisted technology, per specimen; initial single 

probe stain procedure 

1.30 0.86 0.73 No 

88368 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), manual, per 

specimen; initial single probe stain procedure 

1.40 0.88 0.88 No 

88369 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), manual, per 

specimen; each additional single probe stain 

procedure (list separately in addition to code for 

primary procedure) 

New 0.88 0.53 No 

88373 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), using computerassisted technology, per specimen; each additional 

single probe stain procedure (list separately in 

addition to code for primary procedure) 

New 0.86 0.43 No 

88374 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), using computerassisted technology, per specimen; each multiplex 

probe stain procedure 

New 1.04 0.93 No 
CMS-1612-FC 344

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

88377 

Morphometric analysis, in situ hybridization 

(quantitative or semi-quantitative), manual, per 

specimen; each multiplex probe stain procedure 

New 1.40 1.40 No 

88380 Microdissection (ie, sample preparation of 

microscopically identified target); laser capture 1.56 1.14 1.14 No 

88381 Microdissection (ie, sample preparation of 

microscopically identified target); manual 1.18 0.53 0.53 No 

91200 

Liver elastography, mechanically induced shear 

wave (eg, vibration), without imaging, with 

interpretation and report 

New 0.30 0.30 No 

92145 

Corneal hysteresis determination, by air impulse 

stimulation, unilateral or bilateral, with 

interpretation and report 

New 0.17 0.17 No 

92540 

Basic vestibular evaluation, includes spontaneous 

nystagmus test with eccentric gaze fixation 

nystagmus, with recording, positional nystagmus 

test, minimum of 4 positions, with recording, 

optokinetic nystagmus test, bidirectional foveal and 

peripheral stimulation, with recording, and 

oscillating tracking test, with recording 

1.50 1.50 1.50 No 

92541 Spontaneous nystagmus test, including gaze and 

fixation nystagmus, with recording 0.40 0.40 0.40 No 

92542 Positional nystagmus test, minimum of 4 positions, 

with recording 0.33 0.48 0.48 No 

92543 

Caloric vestibular test, each irrigation (binaural, 

bithermal stimulation constitutes 4 tests), with 

recording 

0.10 0.35 0.10 No 

92544 Optokinetic nystagmus test, bidirectional, foveal or 

peripheral stimulation, with recording 0.26 0.27 0.27 No 

92545 Oscillating tracking test, with recording 0.23 0.27 0.27 No 

93260 

Programming device evaluation (in person) with 

iterative adjustment of the implantable device to test 

the function of the device and select optimal 

permanent programmed values with analysis, 

review and report by a physician or other qualified 

health care professional; implantable subcutaneous 

lead defibrillator system 

New 0.85 0.85 No 

93261 

Interrogation device evaluation (in person) with 

analysis, review and report by a physician or other 

qualified health care professional, includes 

connection, recording and disconnection per patient 

encounter; implantable subcutaneous lead 

defibrillator system 

New 0.74 0.74 No 
CMS-1612-FC 345

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

93282 

Programming device evaluation (in person) with 

iterative adjustment of the implantable device to test 

the function of the device and select optimal 

permanent programmed values with analysis, 

review and report by a physician or other qualified 

health care professional; single lead transvenous 

implantable defibrillator system 

0.85 0.85 0.85 No 

93283 

Programming device evaluation (in person) with 

iterative adjustment of the implantable device to test 

the function of the device and select optimal 

permanent programmed values with analysis, 

review and report by a physician or other qualified 

health care professional; dual lead transvenous 

implantable defibrillator system 

1.15 1.15 1.15 No 

93284 

Programming device evaluation (in person) with 

iterative adjustment of the implantable device to test 

the function of the device and select optimal 

permanent programmed values with analysis, 

review and report by a physician or other qualified 

health care professional; multiple lead transvenous 

implantable defibrillator system 

1.25 1.25 1.25 No 

93287 

Peri-procedural device evaluation (in person) and 

programming of device system parameters before or 

after a surgery, procedure, or test with analysis, 

review and report by a physician or other qualified 

health care professional; single, dual, or multiple 

lead implantable defibrillator system 

0.45 0.45 0.45 No 

93289 

Interrogation device evaluation (in person) with 

analysis, review and report by a physician or other 

qualified health care professional, includes 

connection, recording and disconnection per patient 

encounter; single, dual, or multiple lead transvenous 

implantable defibrillator system, including analysis 

of heart rhythm derived data elements 

0.92 0.92 0.92 No 

93312 

Echocardiography, transesophageal, real-time with 

image documentation (2d) (with or without m-mode 

recording); including probe placement, image 

acquisition, interpretation and report 

2.20 3.18 2.55 No 

93313 

Echocardiography, transesophageal, real-time with 

image documentation (2d) (with or without m-mode 

recording); placement of transesophageal probe 

only 

0.95 1.00 0.51 No 
CMS-1612-FC 346

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

93314 

Echocardiography, transesophageal, real-time with 

image documentation (2d) (with or without m-mode 

recording); image acquisition, interpretation and 

report only 

1.25 2.80 2.10 Yes 

93315 

Transesophageal echocardiography for congenital 

cardiac anomalies; including probe placement, 

image acquisition, interpretation and report 

C 3.29 2.94 No 

93316 

Transesophageal echocardiography for congenital 

cardiac anomalies; placement of transesophageal 

probe only 

0.95 1.50 0.85 No 

93317 

Transesophageal echocardiography for congenital 

cardiac anomalies; image acquisition, interpretation 

and report only 

C 3.00 2.09 Yes 

93318 

Echocardiography, transesophageal (tee) for 

monitoring purposes, including probe placement, 

real time 2-dimensional image acquisition and 

interpretation leading to ongoing (continuous) 

assessment of (dynamically changing) cardiac 

pumping function and to therapeutic measures on an 

immediate time basis 

C 2.40 2.40 No 

93320 

Doppler echocardiography, pulsed wave and/or 

continuous wave with spectral display (list 

separately in addition to codes for 

echocardiographic imaging); complete 

0.38 0.38 0.38 No 

93321 

Doppler echocardiography, pulsed wave and/or 

continuous wave with spectral display (list 

separately in addition to codes for 

echocardiographic imaging); follow-up or limited 

study (list separately in addition to codes for 

echocardiographic imaging) 

0.15 0.15 0.15 No 

93325 

Doppler echocardiography color flow velocity 

mapping (list separately in addition to codes for 

echocardiography) 

0.07 0.07 0.07 No 
CMS-1612-FC 347

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

93355 

Echocardiography, transesophageal (tee) for 

guidance of a transcatheter intracardiac or great 

vessel(s) structural intervention(s) (eg,tavr, 

transcathether pulmonary valve replacement, mitral 

valve repair, paravalvular regurgitation repair, left 

atrial appendage occlusion/closure, ventricular 

septal defect closure) (peri-and intra-procedural), 

real-time image acquisition and documentation, 

guidance with quantitative measurements, probe 

manipulation, interpretation, and report, including 

diagnostic transesophageal echocardiography and, 

when performed, administration of ultrasound 

contrast, doppler, color flow, and 3d 

New 4.66 4.66 No 

93644 

Electrophysiologic evaluation of subcutaneous 

implantable defibrillator (includes defibrillation 

threshold evaluation, induction of arrhythmia, 

evaluation of sensing for arrhythmia termination, 

and programming or reprogramming of sensing or 

therapeutic parameters) 

New 3.65 3.29 No 

93880 Duplex scan of extracranial arteries; complete 

bilateral study 0.60 0.80 0.80 No 

93882 Duplex scan of extracranial arteries; unilateral or 

limited study 0.40 0.50 0.50 No 

93886 Transcranial doppler study of the intracranial 

arteries; complete study 0.94 1.00 0.91 No 

93888 Transcranial doppler study of the intracranial 

arteries; limited study 0.62 0.70 0.50 No 

93895 Quantitative carotid intima media thickness and 

carotid atheroma evaluation, bilateral New 0.55 N No 

93925 Duplex scan of lower extremity arteries or arterial 

bypass grafts; complete bilateral study 0.80 0.80 0.80 No 

93926 Duplex scan of lower extremity arteries or arterial 

bypass grafts; unilateral or limited study 0.50 0.60 0.50 No 

93930 Duplex scan of upper extremity arteries or arterial 

bypass grafts; complete bilateral study 0.46 0.80 0.80 No 

93931 Duplex scan of upper extremity arteries or arterial 

bypass grafts; unilateral or limited study 0.31 0.50 0.50 No 

93970 

Duplex scan of extremity veins including responses 

to compression and other maneuvers; complete 

bilateral study 

0.70 0.70 0.70 No 

93971 

Duplex scan of extremity veins including responses 

to compression and other maneuvers; unilateral or 

limited study 

0.45 0.45 0.45 No 
CMS-1612-FC 348

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

93975 

Duplex scan of arterial inflow and venous outflow 

of abdominal, pelvic, scrotal contents and/or 

retroperitoneal organs; complete study 

1.80 1.30 1.16 No 

93976 

Duplex scan of arterial inflow and venous outflow 

of abdominal, pelvic, scrotal contents and/or 

retroperitoneal organs; limited study 

1.21 1.00 0.80 No 

93978 Duplex scan of aorta, inferior vena cava, iliac 

vasculature, or bypass grafts; complete study 0.65 0.97 0.80 No 

93979 

Duplex scan of aorta, inferior vena cava, iliac 

vasculature, or bypass grafts; unilateral or limited 

study 

0.44 0.70 0.50 No 

93990 Duplex scan of hemodialysis access (including 

arterial inflow, body of access and venous outflow) 0.25 0.60 0.50 No 

95971 

Electronic analysis of implanted neurostimulator 

pulse generator system (eg, rate, pulse amplitude, 

pulse duration, configuration of wave form, battery 

status, electrode selectability, output modulation, 

cycling, impedance and patient compliance 

measurements); simple spinal cord, or peripheral 

(ie, peripheral nerve, sacral nerve, neuromuscular) 

neurostimulator pulse generator/transmitter, with 

intraoperative or subsequent programming 

0.78 0.78 0.78 No 

95972 

Electronic analysis of implanted neurostimulator 

pulse generator system (eg, rate, pulse amplitude, 

pulse duration, configuration of wave form, battery 

status, electrode selectability, output modulation, 

cycling, impedance and patient compliance 

measurements); complex spinal cord, or peripheral 

(ie, peripheral nerve, sacral nerve, neuromuscular) 

(except cranial nerve) neurostimulator pulse 

generator/transmitter, with intraoperative or 

subsequent programming, up to 1 hour 

1.50 0.90 0.80 No 

95973 

Electronic analysis of implanted neurostimulator 

pulse generator system (eg, rate, pulse amplitude, 

pulse duration, configuration of wave form, battery 

status, electrode selectability, output modulation, 

cycling, impedance and patient compliance 

measurements); complex spinal cord, or peripheral 

(ie, peripheral nerve, sacral nerve, neuromuscular) 

(except cranial nerve) neurostimulator pulse 

generator/transmitter, with intraoperative or 

subsequent programming, each additional 30 

minutes after first hour (list separately in addition to 

code for primary procedure) 

0.92 NA 0.49 No 
CMS-1612-FC 349

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

97605 

Negative pressure wound therapy (eg, vacuum 

assisted drainage collection), utilizing durable 

medical equipment (dme), including topical 

application(s), wound assessment, and instruction(s) 

for ongoing care, per session; total wound(s) surface 

area less than or equal to 50 square centimeters 

0.55 0.55 0.55 No 

97606 

Negative pressure wound therapy (eg, vacuum 

assisted drainage collection), utilizing durable 

medical equipment (dme), including topical 

application(s), wound assessment, and instruction(s) 

for ongoing care, per session; total wound(s) surface 

area greater than 50 square centimeters 

0.60 0.60 0.60 No 

97607 

Negative pressure wound therapy, (eg, vacuum 

assisted drainage collection), utilizing disposable, 

non-durable medical equipment including provision 

of exudate management collection system, topical 

application(s), wound assessment, and instructions 

for ongoing care, per session; total wound(s) surface 

area less than or equal to 50 square centimeters 

New 0.41 C 

 

97608 

Negative pressure wound therapy, (eg, vacuum 

assisted drainage collection), utilizing disposable, 

non-durable medical equipment including provision 

of exudate management collection system, topical 

application(s), wound assessment, and instructions 

for ongoing care, per session; total wound(s) surface 

area greater than 50 square centimeters 

New 0.46 C Yes 

97610 

Low frequency, non-contact, non-thermal 

ultrasound, including topical application(s), when 

performed, wound assessment, and instruction(s) for 

ongoing care, per day 

C 0.35 0.35 No 

99183 

Physician or other qualified health care professional 

attendance and supervision of hyperbaric oxygen 

therapy, per session 

2.34 2.11 2.11 No 

99184 

Initiation of selective head or total body 

hypothermia in the critically ill neonate, includes 

appropriate patient selection by review of clinical, 

imaging and laboratory data, confirmation of 

esophageal temperature probe location, evaluation 

of amplitude eeg, supervision of controlled 

hypothermia, and assessment of patient tolerance of 

cooling 

New 4.50 4.50 No 

99188 Application of topical fluoride varnish by a 

physician or other qualified health care professional New 0.20 N N/A 
CMS-1612-FC 350

HCPCS 

Code Long Descriptor 

CY 

2014 

WRVU

RUC/HCPAC 

Recommended 

Work RVU 

CY 

2015 

Work 

RVU 

CMS Time 

Refinement

99487 

Complex chronic care management services, with 

the following required elements: multiple (two or 

more) chronic conditions expected to last at least 12 

months, or until the death of the patient; chronic 

conditions place the patient at significant risk of 

death, acute exacerbation/decompensation, or 

functional decline; establishment or substantial 

revision of a comprehensive care plan; moderate or 

high complexity medical decision making; 60 

minutes of clinical staff time directed by a physician 

or other qualified health care professional, per 

calendar month.; 

1.00 1.00 B N/A 

99497 

Advance care planning including the explanation 

and discussion of advance directives such as 

standard forms (with completion of such forms, 

when performed), by the physician or other 

qualified health care professional; first 30 minutes, 

face-to-face with the patient, family member(s), 

and/or surrogate 

New 1.50 I N/A 

99498 

Advance care planning including the explanation 

and discussion of advance directives such as 

standard forms (with completion of such forms, 

when performed), by the physician or other 

qualified health care professional; each additional 

30 minutes (list separately in addition to code for 

primary procedure) 

New 1.40 I N/A 

G0279 

Diagnostic digital breast tomosynthesis, unilateral 

or bilateral (list separately in addition to G0204 or 

G0206) 

New N/A 0.60 N/A 

i. Code Specific Issues 

(1) Internal Fixation of Rib Fracture (CPT Codes 21811, 21812 and 21813) 

For CY 2015, the CPT Editorial Panel deleted CPT code 21810 (Treatment of rib fracture 

requiring external fixation (flail chest)) and replaced it with three CPT codes 21811, 21812 and 

21813, to report internal fixation of rib fracture. The RUC recommended valuing these three 

codes as 90-day global services. For the reasons we articulate in section II.B.4 of this final rule 

with comment period about the difficulties in accurately valuing codes as 90-day global services, 

we believe that the valuation of these codes should be as 0-day global services. In addition, we 
CMS-1612-FC 351

believe this is particularly appropriate for these codes because the number of RUC-recommended 

inpatient and outpatient visits included in the postservice time seems higher than would likely 

occur. The vignette for CPT code 21811 describes an elderly patient who falls and experiences 

three rib fractures that require internal fixation. The seven visits included in the postservice time 

for this code seem high since the vignette does not describe a very ill patient. The vignettes for 

CPT codes 21812 and 21813 describe patients experiencing significant rib fractures in car 

accidents that require internal fixation. We believe that in these scenarios, injuries beyond rib 

fractures are likely, and as a result, we believe it is likely that multiple practitioners would be 

involved in providing post-operative care. If other practitioners would furnish care in the postsurgery period, we believe the ten and thirteen postservice visits included in CPT codes 21812 

and 21813 would likely not occur. By valuing these codes as 0-day globals, we do not need to 

address these issues because the surgeon will be able to bill separately for the postoperative 

services that are furnished after the day of the procedure. 

To value these services as 0-day global codes, we subtracted the work RVUs related to 

the postoperative services from the total work RVU. We are establishing CY 2015 interim work 

RVUs of 10.79 for CPT code 21811, of 13.00 for CPT code 21812, and of 17.61 for CPT code 

21813. We also refined the RUC recommended time by subtracting the time associated with the 

postoperative visits. By removing the work and time associated with visits in the postoperative 

period, the remaining work and time reflect the work and time of services furnished on the day of 

surgery. 

(2) Percutaneous Vertebroplasty and Augmentation (CPT Codes 22510, 22511, 22512, 22513, 

22514 and 22515) 

For CY 2015, the CPT Editorial Panel replaced the eight existing percutaneous 

vertebroplasty with six new codes, CPT codes 22510-22515, which include the percutaneous 
CMS-1612-FC 352

vertebroplasty and the image guidance together. We are establishing the RUC-recommended 

work values as interim final for CY 2015 for all of the codes in this family except CPT code 

22511. 

Unlike other codes in this family for which the RUC-recommended work RVU was 

based on the 25th percentile in the survey, the RUC established its recommended work value for 

CPT code 22511 by crosswalking this service to CPT code 39400 (Mediastinoscopy, includes 

biopsy(ies), when performed), which has a work RVU of 8.05. Because the level of work 

performed by a physician in the two services differs, we do not agree that this crosswalk is 

appropriate. Instead, we believe a more appropriate analogy is found in the difference between 

the work values for the predecessor codes for CPT codes 22510 and 22511, CPT codes 22520 

(Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, 

unilateral or bilateral injection; thoracic) and 22521 (Percutaneous vertebroplasty (bone biopsy 

included when performed), 1 vertebral body, unilateral or bilateral injection; thoracic; lumbar). 

Accordingly, we are applying the difference in the current work RVUs for CPT codes 22520 and 

22521 to the work RVU that we are establishing for CPT code 22510. We believe this increment 

establishes the appropriate rank order in this family and thus are assigning an interim final work 

RVU of 7.58 for CPT code 22511, which is 0.57 work RVUs lower than the CY 2015 work 

RVU for CPT code 22510. 

(3) Endobronchial Ultrasound (EBUS) (CPT Code 31620) 

For CY 2015, the RUC reviewed CPT code 31620 because it was identified through the 

High Volume Growth Services, which are those services for which Medicare utilization 

increased by at least 100 percent from 2006 to 2011. CPT code 31620 is an add-on code to CPT 

code 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 

with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)). 
CMS-1612-FC 353

Medicare data show that 82 percent of the time when EBUS is billed it is billed with CPT code 

31629. Given this relationship, we believe that CPT code 31620 should be bundled with CPT 

code 31629. The specialty societies maintain that EBUS is distinct from bronchoscopy with 

biopsy because the intraservice work of EBUS occurs between the two components of the base 

code, bronchoscopy and biopsy. However, based upon the discussion at the RUC meeting, we 

believe that the biopsy actually occurs during the EBUS and the biopsy is actually performed 

through the EBUS scope. Thus, we do not believe the EBUS code descriptor accurately 

describes the service nor is it possible to accurately value this service when the descriptor is 

inaccurate. Therefore, for CY 2015 we are maintaining the CY 2014 work RVU for CPT code 

31620. We understand that the RUC will review this code for CY 2016. 

(4) Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Life Support (ECLS) (CPT 

Codes 33946, 33947, 33948, 33949, 33951- 33959, 33962-33966, 33969, 33984 -33989) 

 In the CY 2014 PFS final rule with comment period, CPT codes 33960 (Prolonged 

extracorporeal circulation for cardiopulmonary insufficiency; initial day) and 33961 (Prolonged 

extracorporeal circulation for cardiopulmonary insufficiency; each subsequent day) were 

identified as potentially misvalued codes. Specifically, the services were originally valued when 

they were primarily provided to premature neonates; but the services are now typically used in 

treating adults with severe influenza, pneumonia, and respiratory distress syndrome. For CY 

2015, CPT codes 33960 and 33961 were deleted and replaced with 25 new codes to describe this 

treatment. We are assigning the RUC-recommended work values as interim final for CY 2015 

for all of the codes in this family except CPT codes 33952, 33953, 33954, 33957, 33958 and 

33959, 33962, 33969, and 33984. 

 We accepted the RUC-recommended work RVU of 8.15 for CPT code 33951, which 

describes an ECMO peripheral cannula(e) insertion for individuals up to 5 years of age. The 
CMS-1612-FC 354

RUC recommended a work RVU of 8.43 for CPT code 33952, which describes the same 

procedure for individuals 6 years and older. We do not believe this difference in the age of the 

patient increases the work of the service from the younger patient. The fact that the RUCrecommended intraservice time is identical for both codes supports our view that the work RVU 

should be the same for both codes. Therefore, for CY 2015, we are establishing an interim final 

work RVUs of 8.15 for CPT code 33952, the same as we established for CPT 33951 based upon 

the RUC-recommendation for the younger patient. 

 The RUC recommended work RVUs of 9.83 and 9.43 for CPT codes 33953 and 33954, 

respectively. For the same reasons discussed above, we are establishing the same work values 

for the code for treatment of patients from birth through 5 years of age and the code for treatment 

of patients 6 years and older. To determine the value for these codes, we adjusted the work RVU 

of the equivalent percutaneous codes, CPT code 33951 (Extracorporeal membrane oxygenation 

(ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral 

(arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes 

fluoroscopic guidance, when performed)) and CPT code 33952 (Extracorporeal membrane 

oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of 

peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes 

fluoroscopic guidance, when performed)), to reflect the greater work of the open procedure 

codes, CPT codes 33953 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life 

support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) 

cannula(e), open birth, through 5 years of age) and 33954 (Extracorporeal membrane 

oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of 

peripheral (arterial and/or venous) cannula(e), open, 6 years and older). To measure the 

difference in work between these two sets of codes we applied the 0.96 RVU differential 
CMS-1612-FC 355

between the percutaneous arterial CPT code 33620 (Application of right and left pulmonary 

artery bands (for example, hybrid approach stage 1)) and the open arterial CPT code 36625 

(Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate 

procedure); cutdown) codes. This measure allows us to establish the difference in work between 

the sets of codes based upon the difference in intensity. Accordingly, we are assigning an interim 

final work RVU to CPT codes 33953 and 33954 of 9.11. 

Unlike other codes in this family for which the RUC-recommended work value was 

based upon the 25th percentile of the survey, for CPT codes 33957 and 33958 the RUC 

recommended a work RVU of 4.00 and 4.05, respectively, based upon the survey median. We 

believe that, like other services in this family, these codes should be valued based upon the 25th 

percentile values of the survey because those values best describe the work involved in these 

procedures and results in the appropriate relativity amongst the codes in the family. Therefore, 

for CY 2015 we are assigning an interim final work RVU of 3.51 for CPT codes 33957 and 

33958. 

We believe the RUC-recommended work RVUs of 4.69 and 4.73 for CPT codes 33959 

and 33962 respectively, overstate the work involved in the services. As we discussed above for 

CPT codes 33953 and 33954, we believe the differential between the percutaneous arterial and 

open arterial CPT codes more appropriately reflects the work involved in these services. 

Accordingly we are establishing a CY 2015 interim final work RVU of 4.47 for CPT codes 

33959 and 33962. 

After researching comparable codes, we believe the RUC-recommended work RVUs of 

6.00 and 6.38 for CPT codes 33969 and 33984, respectively, overstates the work involved in the 

procedures. For the same reasons and following the same valuation methodology utilized above, 

we added the differential between the percutaneous arterial and arterial cutdown codes, 0.96 
CMS-1612-FC 356

RVU, to the CY 2015 interim final work RVU of 4.50 for CPT code 33966, which is the 

percutaneous counterpart of CPT code 33984. This results in a work RVU of 5.46 for CPT code 

33984. Because CPT code 33969 has 2 minutes less intraservice time than CPT code 33984 

(Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided 

by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older), 

we adjusted the work RVU of CPT code 33984 for the decrease in time to get a work RVU of 

5.22 for CPT code 33969 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life 

support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) 

cannula(e), open, birth through 5 years of age). Therefore, for CY 2015 we are establishing an 

interim final work RVU of 5.46 to CPT code 33984 and 5.22 to CPT code 33969. 

(5) Fenestrated Endovascular Repair (FEVAR) Endograft Planning (CPT Code 34839) 

For CY 2015, CPT code 34839 was created to report the planning that occurs prior to the 

work included in the global period for a FEVAR. The RUC recommended that we contractor 

price this service as the RUC survey response rate was too low to provide the basis for an 

appropriate valuation. In general, we prefer that planning be bundled with the underlying 

service, and we have no reason to believe bundling is not appropriate in this case. Accordingly, 

we are assigning a PFS procedure status indicator of B (Bundled Code) to CPT code 34839. 

(6) AV Anastomosis (CPT Codes 36818, 36819, 36820, 36821, 36825, 36830, 36831, 36832, 

and 36833) 

In the CY 2013 PFS final rule with comment period, the AV anastomosis family of 

services were determined to be potentially misvalued due to rank order anomalies, including 

CPT codes 36818-36821 and CPT codes 36825-36830. The RUC recommendations that we 

received in response also included CPT codes 36831-36833. We are assigning the RUCrecommended work RVUs as CY 2015 interim final values for CPT codes 36821, 36831, 36832 
CMS-1612-FC 357

and 36833. For CPT code 36831, 36832, and 36833, we are refining to remove the additional 10 

minutes of preservice evaluation time. The RUC added 10 minutes of additional pre-service 

time to these codes for determining the best source of access,. These three codes are 

revision/repair codes and as such do not need the additional time to determine the access source. 

For CPT code 36818, the RUC recommended an approximately 12 percent increase in work 

RVU but a total time increase of approximately 4.2 percent. We are assigning a CY 2015 

interim final work RVU of 12.39, which reflects a 4.2 percent increase from the current value 

based upon the increase in total time. 

For CPT code 36819, the RUC-recommended intraservice and total times are only 

minimally different than the current times. Even though the intraservice and total times 

decreased minimally, the RUC increased the work RVU. We believe that the small decrease in 

total time, 2 percent, suggest that the current work RUV is appropriate. Therefore, we are 

assigning a CY 2015 interim final work RVU of 13.29, which is the current work value. 

The RUC recommended a work value of 13.99 for CPT code 36820. The RUC 

recommended that the postservice time of CPT code 36820 be reduced by removing visits. 

Specifically, a CPT code 99231 and one-half of a CPT code 99238 were removed from the 

service, which would equal 1.40 RVU. We do not believe that this reduction was accounted for 

in the RUC-recommended work RVU. To account for this reduction in visits, we are 

establishing a CY 2015 interim final work RVU of 13.07 for CPT 36820 which reflects a 1.40 

work RVU reduction in the current work RVU. 

For CPT code 36825, the RUC-recommended intraservice and total times are only 

minimally different than the current times. However, the RUC increased the work RVU. We do 

not believe the work RVU should be increased without corresponding time changes. Therefore, 

we believe the appropriate CY 2015 interim final work RVU is the current work value of 14.17. 
CMS-1612-FC 358

For CPT code 36830, the RUC-recommended intraservice and total times are only minimally 

different than the current times. However, the RUC decreased the work RVU. We do not 

believe the work RVU should be decreased without corresponding time changes. Therefore, we 

are establishing a CY 2015 interim final work RVU of 12.03, which is equal to the current work 

RVU. 

Furthermore, we refined the total time values as follows: 238 minutes for CPT code 

36831, 266 minutes for CPT code 36832, and 296 minutes for CPT code 36833. 

(7) Illeoscopy, Pouchoscopy, Colonoscopy through Stoma, Flexible Sigmoidoscopy and 

Colonoscopy (CPT Codes 44380, 44381, 44382, 44383, 44384, 44385, 44386, 44388, 44389, 

44390, 44391, 44392, 44393, 44394, 44397, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 

44408, 44799, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45346, 45340, 45341, 

45342, 45345, 45347, 45349, 45350, 45378, 45379, 45380, 45381, 45382, 45383, 45388, 45384, 

45385, 45386, 45387, 45389, 45390, 45391, 45392, 45393, 45398, 45399, 0226T, 46601, 0227T, 

and 46607 and HCPCS Codes G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, 

G6027, G6028) 

CPT revised the lower gastrointestinal endoscopy code set for CY 2015 following 

identification of some of the codes as potentially misvalued and the affected specialty society’s 

contention that this code set did not allow for accurate reporting of services based upon the 

current practice. The RUC subsequently provided recommendations to CMS for valuing these 

services. In comments on the proposed rule, stakeholders noted our proposal to begin including 

proposed values for new, revised and potentially misvalued codes in the proposed rule. 

Commenters suggested that, rather than implementing this new process in CY 2016, we should 

implement it immediately and thus defer the valuation of the new GI code set until CY 2016. 

They indicated that the opportunity to comment prior to implementation of the new values was 
CMS-1612-FC 359

important for these codes, many of which have high utilization. In addition, in this final rule 

with comment period we discuss the need to modify how moderate sedation is reported and 

valued. Since the valuation of most codes in this code set includes moderate sedation, 

stakeholders suggested that we revalue these codes in conjunction with any changes in reporting 

and valuation of moderate sedation. 

We agree with the commenters. In light of the substantial nature of this code revision 

and its relationship to the policies on moderate sedation, we are delaying revaluation of these 

codes until CY 2016 when we will be able to include proposals in the proposed rule for their 

valuation, along with consideration of policies for moderate sedation. Accordingly for CY 2015, 

we are maintaining the inputs for the lower gastrointestinal endoscopy codes at the CY 2014 

levels. (Note: Due to budget neutrality adjustments and other system-wide changes, the payment 

rates may change.) Since the code set is changing for CY 2015, including the deletion of some 

of the CY 2014 codes, we are creating G-codes as necessary to allow practitioners to report 

services to CMS in the same way in CY 2015 that they did in CY 2014 and to maintain payment 

under the PFS based on the same inputs. All payment policies applicable to the CY 2014 CPT 

codes will apply to the replacement G-codes. The new and revised CY 2015 CPT codes for 

lower gastrointestinal endoscopy that will not be recognized by Medicare for CY 2015 are 

denoted with an “I” (Not valid for Medicare purposes) in Table 26. The chart below lists the Gcodes that we are creating and the CY 2014 CPT codes that they are replacing. 

 
CMS-1612-FC 360

TABLE 26: Lower Gastrointestinal Endoscopy G-Codes Replacing CY 2015 CPT Codes 

CY 2014 

CPT Code1

CY 

2015 

HCPCS 

Code 

Long Descriptor 

44383 G6018 Ileoscopy,through stoma;with transendoscopic stent placement (includes predilation ) 

44393 G6019 

Colonoscopy through stoma;with ablation of tumor(s),polp(s),or other lesion(s)not 

amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 

44397 G6020 Colonoscopy through stoma;with transendoscopic stent placement (includes predilation) 

44799 G6021 Unlisted procedure,intestine 

45339 G6022 

Sigmoidoscopy, flexible; with ablation of tumor(s),polyp(s),or other lesions(s)not 

amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 

45345 G6023 Sigmoidoscopy, flexible; with transenoscopic stent placement (includes predilation) 

45383 G6024 

Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or 

other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare 

technique 

45387 G6025 

Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement 

(includes predilation) 

0226T G6027 

Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); 

diagnostic, including collection of specimen(s) by brushing or washing when performed 

0227T G6028 

Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); 

with biopsy(ies) 

 

(8) Prostatectomy (CPT Codes 55842 and 55845) 

In the CY 2014 PFS final rule with comment period, we finalized CPT codes 55842 and 

55845 as potentially misvalued codes. For CY 2015, the RUC provided recommendations for 

these services of 29.07 and 24.16, respectively. We disagreed with the RUC-recommended 

crosswalk for CPT code 55842. To value CPT code 55842, we are crosswalking it to CPT code 

55840 (Prostatectomy, retropubic radical, with or without nerve sparing) due to their identical 

times. Therefore, we are establishing an interim final work RVU of 21.36. 

For CPT code 55845, we are establishing a work RVU of 25.18 based upon the 25th 

percentile of the survey. This work RVU results in an 18 percent decrease from the current work 

RVU, which we believe reflects the changes since the last valuation, based upon a 20 percent 

decrease in intraservice time and the 29 percent decrease in total time. 

 

1

 This chart only contains CY 2014 codes for which a HCPCS code is being used for CY 2015. Addendum B 

contains a complete list of CPT and HCPCS codes being recognized by Medicare under the PFS for CY 20115. 
CMS-1612-FC 361

(9) Aqueous Shunt (CPT Code 66179, 66180, 66184, 66185, and 67255) 

After identifying CPT code 66180 through the Harvard-Valued Annual Allowed Charges 

Greater than $10 million screen, the RUC recommended work RVUs for the aqueous shunt 

family for CY 2015. We are establishing the RUC-recommended work RVUs as interim final 

for all codes in this family except CPT code 67255. The RUC recommended maintaining the 

CY 2014 work RVU of 10.17 for CPT 67255. However, we believe maintaining this value 

would be inconsistent with the RUC-recommended decreases in total time for the service. As a 

result, we reduced the work RVU by the same percentage that the RUC recommended a 

reduction in total time, which results in a CY 2015 interim final work RVU of 8.38 for CPT code 

67255. 

(10) Computed Tomography (CT) – Maxillofacial (CPT Codes 70486, 70487 and 70488) 

The RUC’s Relativity Assessment Workgroup identified CPT code 70486 for review 

through the CMS/Other Source – Utilization over 250,000 screen. The involved specialty 

societies expanded the survey to include CPT codes 70487 and 70488, all of which involve 

maxillofacial CTs. We are establishing the RUC-recommended work RVU of 0.85 as the CY 

2015 interim final value for CPT code 70486, which is without contrast material. The RUC 

established this recommendation by crosswalking this code to the equivalent code in the CT for 

the head or brain, CPT code 70450 (Computed tomography, head or brain without contrast). We 

agree with that method and in order to maintain rank order within and across CT families, we 

crosswalked CPT code 70487, which is with contrast material(s), to the CPT code 70460, which 

is the equivalent code in the head or brain family and CPT code 70488, which is without contrast 

materials followed by contrast material(s) and further sections to CPT code 70470, which is the 

equivalent code in the head or brain family. Therefore, for CY 2015 we are establishing interim 

final work RVUs of 1.13 for CPT code 70487 and 1.27 for CPT code 70488. 
CMS-1612-FC 362

(11) Breast Ultrasound (CPT Codes 76641 and 76642) 

For CY 2015, the CPT Editorial Panel replaced CPT code 76645 (Ultrasound, breast(s) 

(unilateral or bilateral), real time with image documentation) with two codes, CPT codes 76641 

(Ultrasound, breast, unilateral, real time with image documentation, including axilla when 

performed; complete) and 76642 (Ultrasound, breast, unilateral, real time with image 

documentation, including axilla when performed; limited). The difference between the new 

codes is that one is for complete breast ultrasound procedures and the other is for limited. We 

are assigning the RUC-recommended work RVUs of 0.73 and 0.68 to CPT codes 76641 and 

76642, respectively, as interim final. One difference between the predecessor code and the new 

ones is that while the predecessor code was used to report unilateral or bilateral breast 

ultrasounds, the new codes are unilateral ones. To appropriately adjust payment when bilateral 

procedures are furnished under the PFS, payments are adjusted to 150 percent of the unilateral 

payment when a service has a bilateral payment indicator assigned. We are assigning a bilateral 

payment indicator to these codes. 

(12) Radiation Therapy Codes (CPT Codes 76950, 77014, 77421, 77387, 77401, 77402, 77403, 

77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77418, 77385, 77386, 

0073T, and 0197T and HCPCS Codes G6001, G6002, G6003, G6004, G6005, G6006, G6007, 

G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016 and G6017) 

CPT revised the radiation therapy code set for CY 2015 following identification of some 

of the codes as potentially misvalued and the affected specialty society’s contention that the 

provision of radiation therapy could not be accurately reported under the existing code set. The 

RUC subsequently provided recommendations to CMS for valuing these services. Some 

stakeholders approached CMS with concerns about these codes being revalued as interim final in 

the final rule with comment period, noting that these codes account for the vast majority of 
CMS-1612-FC 363

Medicare payment for radiation therapy centers. They noted our proposal to begin including 

proposals to value new, revised and potentially misvalued codes in the proposed rule, and 

suggested that these code valuations should be delayed to CY 2016 so that they could be 

addressed under this new process. This would provide affected stakeholders the opportunity to 

comment prior to the valuations being effective. They also noted that since they do not 

participate in the RUC, they did not have the opportunity to provide input to the 

recommendations nor will they have information about the RUC recommendations until CMS 

makes this information available in the final rule with comment period. 

In response to comments and in light of the substantial nature of this code revision, we 

are delaying revaluation of these codes until CY 2016. The coding changes for CY 2015 involve 

significant changes in how radiation therapy services and associated image guidance are 

reported. There is substantial work to be done to assure the new valuations for these codes 

accurately reflect the coding changes. Accordingly we are delaying the use of the revised 

radiation therapy code set until CY 2016 when we will be able to include proposals in the 

proposed rule for their valuation. We are maintaining the inputs for radiation therapy codes at 

the CY 2014 levels. (Note: Due to budget neutrality adjustments and other system-wide 

changes, the payment rates may change.) Since the code set has changed and some of the CY 

2014 codes are being deleted, we are creating G-codes as necessary to allow practitioners to 

continue to report services to CMS in CY 2015 as they did in CY 2014 and for payments to be 

made in the same way. All payment policies applicable to the CY 2014 CPT codes will apply to 

the replacement G-codes. The new and revised CY 2015 CPT codes that will not be recognized 

by Medicare for CY 2015 are denoted with an “I” (Not valid for Medicare purposes) on Table 

27. The chart below lists the G-codes that we are creating and the CY 2014 CPT codes that they 

are replacing. 
CMS-1612-FC 364

Additionally, we would like to note that changes to the prefatory text modify the services 

that are appropriately billed with CPT code 77401, which is used to report superficial radiation 

therapy. This change effectively means that CPT code 77401 is now bundled with many other 

procedures supporting superficial radiation therapy. However, the RUC did not review 

superficial radiation therapy procedures, and therefore, did not assess whether changes in its 

valuation were appropriate in light of this bundling. Stakeholders have suggested to us that the 

change to the prefatory text prohibits them from billing for codes that were previously frequently 

billed in addition to this code and as a result there will be a significant reduction in their 

payments.” We are interested in information on whether the new code set combined with 

modifications in prefatory text allows for appropriate reporting of the services associated with 

superficial radiation and whether the payment continues to reflect the relative resources required 

to furnish superficial radiation therapy services. 

 
CMS-1612-FC 365

TABLE 27: Radiation Therapy G-Codes Replacing CY 2015 CPT Codes 

CY 2014 

CPT Code2

CY 2015 

HCPCS 

Code Long Descriptor 

76950 G6001 Ultrasonic guidance for placement of radiation therapy fields 

77421 G6002 

Stereoscopic X-ray guidance for localization of target volume for the delivery of 

radiation therapy 

77402 G6003 

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, 

simple blocks or no blocks: up to 5MeV 

77403 G6004 

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, 

simple blocks or no blocks: 6-10MeV 

77404 G6005 

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, 

simple blocks or no blocks: 11-19MeV 

77406 G6006 

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, 

simple blocks or no blocks: 20 MeV or greater 

77407 G6007 

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single 

treatment area, use of multiple blocks; up to 5MeV 

77408 G6008 

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single 

treatment area, use of multiple blocks; 6-10MeV 

77409 G6009 

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single 

treatment area, use of multiple blocks; 11-19MeV 

77411 G6010 

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single 

treatment area, use of multiple blocks; 20 MeV or greater 

77412 G6011 

Radiation treatment delivery,3 or more separate treatment areas, custom blocking, 

tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV 

77413 G6012 

Radiation treatment delivery,3 or more separate treatment areas, custom blocking, 

tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV 

77414 G6013 

Radiation treatment delivery,3 or more separate treatment areas, custom blocking, 

tangential ports, wedges, rotational beam, compensators, electron beam; 11-19MeV 

77416 G6014 

Radiation treatment delivery,3 or more separate treatment areas, custom blocking, 

tangential ports, wedges, rotational beam, compensators, electron beam; 20MeV or 

greater 

77418 G6015 

Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow 

spatially and temporally modulated beams, binary, dynamic MLC, per treatment session 

0073T G6016 

Compensator-based beam modulation treatment delivery of inverse planned treatment 

using 3 or more high resolution (milled or cast) compensator, convergent beam 

modulated fields, per treatment session 

0197T G6017 

Intra-fraction localization and tracking of target or patient motion during delivery of 

radiation therapy(eg,3D positional tracking, gating, 3D surface tracking), each fraction 

of treatment 

(13) Breast Tomosynthesis (CPT codes 77061, 77062, and 77063) 

For CY 2015, the CPT Editorial Panel created three codes to describe digital breast 

tomosynthesis services: 77061 (Digital breast tomosynthesis; unilateral), 77062 (Digital breast 

 

2

 This chart only contains CY 2014 codes for which a HCPCS code is being used for CY 2015. Addendum B 

contains a complete list of CPT and HCPCS codes being recognized by Medicare under the PFS for CY 2015. 
CMS-1612-FC 366

tomosynthesis; bilateral) and 77063 (Screening digital breast tomosynthesis, bilateral (List 

separately in addition to code for primary procedure) and we received RUC recommendations 

for these codes. Currently, these services are reported to Medicare using G0202, G0204, and 

G0206, which describe the equivalent procedures using any digital technology (2-D or 3-D). In 

addition, film mammography is reported to Medicare using CPT codes 77055, 77056 and 

77057). 

In the proposed rule, based upon our belief that digital mammography is now typical, we 

proposed to replace the G-codes that currently describe all digital mammography services under 

Medicare with the CPT codes, to value the CPT codes for CY 2015 based upon the current Gcode values, and to include the CPT codes on the potentially misvalued code list since the 

resources involved in furnishing these services had not been evaluated in more than a decade. 

Having reassessed the proposal in light of the new codes and RUC recommendations for 

tomosynthesis and the comments received upon our proposal, we are finalizing a modified 

proposal. For a discussion of our proposal, a summary of the comments we received, and our 

policy for CY 2015, see section II.B.4. 

With regard to screening mammography, the CPT coding system now has an add-on CPT 

code for tomosynthesis. This coding scheme is consistent with the FDA requiring a 2-D 

mammography when tomosynthesis is used for screening purposes. Accordingly, we will 

recognize CPT code 77063 to be reported, when tomosynthesis is used in addition to 2-D 

mammography. Since CPT code 77063 is an add-on code, and does not have an equivalent CY 

2014 code, we believe it is appropriate to value it on an interim final basis in advance of 

receiving the RUC recommendations for other mammography services. We are assigning it a 

CY 2015 interim final work RVU of 0.60 as recommended by the RUC. 
CMS-1612-FC 367

Whenever feasible, it is our strong preference to value entire families together in order to 

avoid rank order anomalies. In this final rule with comment period, we are including the codes 

for digital mammography on the potentially misvalued code list, which currently include 

tomosynthesis as well as 2-D mammography. Accordingly, we will wait to value the new 

diagnostic mammography tomosynthesis codes until we have received recommendations from 

the RUC for all mammography services, In the interim, we are assigning a PFS indicator of “I” 

to 77061 and 77062. Those furnishing diagnostic mammography using tomosynthesis will 

continue to report G0204 and G0206 as appropriate. In addition, we are creating a new code, G2079 (Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition 

to G0204 or G0206)) as an add-on code that should be reported in addition to the relevant 2-D 

diagnostic mammography G-code to recognize the additional resources involved in furnishing 

diagnostic breast tomosynthesis. We will assign it the same inputs as CPT code 77063 because 

we believe it describes a similar service. 

(14) Isodose Calculation with Isodose Planning Bundle (CPT Code 77316) 

For CY 2015, the CPT Editorial Panel replaced six CPT codes (77305, 77310, 77315, 

77326, 77327, and 77328) with five new CPT codes to bundle basic dosimetry calculation(s) 

with teletherapy and brachytherapy isodose planning. We are establishing the RUCrecommended work RVUs for CY 2015 for all of the codes in this family except CPT code 

77316. We disagree with the RUC-recommended crosswalk for this service because we do not 

believe it is an appropriate match in work. The RUC crosswalked CPT code 77318 to CPT code 

77307, both of which are complex isodose planning codes in the same family. We believe that 

the RUC should have crosswalked CPT code 77316, a simple isodose planning code, to the 

corresponding simple isodose planning code in the same family, CPT code 77306. Therefore, for 

CY 2015 we are establishing an interim final work RVU of 1.40 for CPT code 77316. 
CMS-1612-FC 368

(15) Immunohistochemistry (CPT codes 88341, 88342, and 88344; HCPCS codes G0461 and 

G0462) 

In the CY 2014 PFS final rule with comment period (78 FR 74341), we assigned a status 

indicator of I (Not valid for Medicare purposes) to CPT codes 88341, 88342, and 88343 and 

instead created two G-codes, G0461 and G0462, to report immunohistochemistry services. We 

did this in part to avoid creating incentives for overutilization. For CY 2015, the CPT coding 

was revised with the creation of two new CPT codes, 88341 and 88344, the revision of CPT code 

88342 and the deletion of CPT code 88343. We believe that the revised coding structure 

addresses the concerns that we had with the CY 2014 coding regarding the creation of incentives 

and overutilization. Accordingly, we are deleting the G-codes and assigning interim final values 

for these CPT code codes for CY 2015. We are establishing the RUC-recommended work RVUs 

as interim final for CY 2015 for CPT codes 88342 and 88344. 

In the past for similar procedures in this family, the RUC recommended a work RVU for 

the add-on code that was 60 percent of the base code. For example, the RUC-recommended 

work RVU for CPT code 88334 (Pathology consultation during surgery; cytologic examination 

(for example, touch prep, squash prep), each additional site (List separately in addition to code 

for primary procedure)) is 60 percent of the work RVU of the base CPT code 88333 (Pathology 

consultation during surgery; cytologic examination (for example, touch prep, squash prep), initial 

site). Similarly, the RUC-recommended work RVU for CPT code 88177 (Cytopathology, 

evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for 

diagnosis, each separate additional evaluation episode, same site (List separately in addition to 

code for primary procedure)) is 60 percent of the recommended value for the base CPT code 

88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to 

determine adequacy for diagnosis, first evaluation episode, each site). We believe that the 
CMS-1612-FC 369

relative resources involved in furnishing an add-on service in this family would be reflected 

appropriately using the same 60 percent metric. To value CPT code 88341, we calculated 60 

percent of the work RVU of the base CPT code 88342, which has a work RVU of 0.70; resulting 

in a work RVU of 0.42 for CPT code 88341. 

(16) Morphometric Analysis In Situ Hybridization for Gene Rearrangement(s) (CPT Codes 

88364, 88365, 88366, 88368, 88369, 88373, and 88374 and 88377) 

For CY 2014, the in situ hybridization procedures, CPT codes 88365, 88367 and 88368, 

were revised to specify “each separately identifiable probe per block;” three new add-on codes 

(CPT codes 88364, 88373, 88369) were created to specify “each additional separately 

identifiable probe per slide;” and three new codes were created to specify “each multiplex probe 

stain procedure.” We are establishing the RUC-recommended work RVUs as interim final for 

CY 2015 for CPT codes 88365, 88366, 88368, and 88377. 

CPT code 88367 is the computer assisted version of morphometric analysis, analogous to 

88368 which is the manual version. We have accepted the RUC recommended work RVU of 

0.88 for 88368 which has 30 minutes of intraservice time. CPT code 88367 only has 25 minutes 

of intraservice time and we do not believe that the RUC recommended work RVU of 0.86 

adequately reflects that change in time. We believe that the ratio of the intraservice times 

(25/30) applied to the work RVU (0.88) adequately reflects the difference in work. Therefore, 

we are assigning an interim final work RVU to CPT code 88367 of 0.73. 

Similarly, CPT code 88374 is the computer assisted version of CPT code 88377 but with 

a drop in intraservice time from 45 minutes to 30 minutes. We believe applying this ratio to the 

work RUV of 88377 more accurately reflects the work. Therefore, we are assigning an interim 

final work RVU to CPT code 88374 of 0.93. 
CMS-1612-FC 370

As discussed in the previous section, some of the add-on codes in this family had RUCrecommended work RVUs that were 60 percent of the work RVU of the base procedure and we 

applied that reduction to 88341. We believe this accurately reflects the resources used in 

furnishing these add-on codes. Accordingly, we used this methodology to establish interim final 

work RVUs of 0.53 for code 88364 (60 percent of the work RVU of CPT code 88365); 0.53 for 

CPT code 88369 (60 percent of the work RVU of CPT code 88368); and 0.43 for CPT code 

88373 (60 percent of the work RVU of CPT code 88367). 

(17) Electro-oculography (EOG VNG) CPT Codes 92270, 92540, 92541, 92542, 92544, 92543, 

and 92545) 

After the RUC identified CPT code 92543 as potentially misvalued through the CMSOther Source – Utilization over 250,000 screen, CPT revised the parentheticals for this code for 

CY 2015. We received RUC recommendations for CY 2015 for this code and other codes in the 

family. We are assigning the RUC-recommended work values for CPT codes 92270, 92540, 

92541, 92542, 92544, and 92545. For CPT code 92543, however, we have been informed by the 

RUC that survey respondents may not have understood the revised code description for CPT 

code 92543, and thus the survey data may be unreliable. As a result, we believe the most 

accurate information upon which to base work RVUs for CPT code 92543 is its existing work 

RVU. Therefore, we are establishing a work RVU of 0.10 for CPT code 92543 as interim final 

for CY 2015. 

(18) Interventional Transesophageal Echocardiography (TEE) (CPT Codes 93312, 93313, 93314, 

93315, 93316, 93317, 93318, 93355, and 93644) 

For CY 2015, CPT code 93355 was created to describe transesophageal 

echocardiography during interventional cardiac procedures. The RUC provided 

recommendations for CPT code 93355, and for CPT codes 93312-93318 in order to ensure intra-
CMS-1612-FC 371

family relativity. We are establishing the RUC-recommended work RVU of 2.40 as interim final 

for CY 2015 for CPT code 93318 and 4.66 for CPT code 93355. 

The RUC based the work RVU for CPT code 93312 upon a crosswalk to CPT code 

43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body). This 

code has significant differences from CPT code 93312. We have been unable to identify a CPT 

code with 30 minutes of intraservice time and 60 minutes of total time with a work RVU higher 

than 2.55. We believe this service is more similar to CPT code 75573 (Computed tomography, 

heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of 

congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, 

RV structure and function and evaluation of venous structures, if performed) since it has similar 

work, time and the same global period. Based upon this crosswalk, we are assigning CPT code 

93312 a CY 2015 interim final work RVU of 2.55. 

Due to CPT descriptor for CPT code 93315, we believe that the appropriate work for this 

service is reflected in the combined work of CPT codes 93316 and 93317, resulting in a CY 2015 

interim final work RVU of 2.94. 

For CPT codes 93313, 93314, 93316 and 93317, we are assigning CY 2015 interim final 

work RVUs based upon the 25th percentile values from the survey: 0.51 for CPT code 93313, 

2.10 for CPT code 93314, 2.94 for CPT code 93315, 0.85 for CPT code 93316, 2.09 for CPT 

code 93317, and 4.66 for CPT code 93355. Each of these codes had a significant drop in 

intraservice time since the last valuation and RUC recommendations for higher work RVUs. As 

we have stated in the absence of information showing a change in intensity, we believe 

meaningful changes in time should be reflected in the work RVUs. For these codes, we believe 

the 25th percentile survey values better describe the work and time involved in these procedures 

than the RUC recommendations and also help maintain appropriate relativity in the family. 
CMS-1612-FC 372

Additionally, we are refining the preservice and intraservice times for CPT codes 93314 and 

93317 to 10 and 20 minutes, respectively, to maintain relativity among the interim final work 

RVUs and times. 

(19) Subcutaneous Implantable Defibrillator Procedures (CPT Codes 33270, 33271, 33272, 

33272, 93260, 93261 and 93644) 

For CY 2015, the CPT Editorial Panel added the word “implantable” to the descriptors 

for several codes in this family and created several new codes, CPT codes 33270, 33271, 33272, 

33272, 93260, 93261 and 93644. We received RUC recommendations for the new and revised 

codes. We are establishing the RUC-recommended work RVUs for all of the codes in this 

family except CPT code 93644. This code has an intraservice time of 20 minutes and a total 

time of 84 minutes. We disagree with the RUC-recommended crosswalk for CPT code 93644 

which has an intraservice time of 29 minutes and a total time of 115 minutes and believe that a 

crosswalk to CPT code 32551 would be better as that code’s intraservice time is 20 minutes and 

the total time is 83 minutes. Therefore, we are establishing a CY 2015 interim final work RVU 

of 3.29 for CPT code 93644. 

(20) Duplex Scans (CPT Codes 93886, 93888, 93926, 93975, 93976, 93977, 93978, and 93979) 

In the CY 2013 PFS final rule with comment period, we requested that the RUC assess 

the relativity among the entire family of duplex scans codes and recommend appropriate work 

RVUs. CMS also requested that the RUC consider CPT codes 93886, Transcranial Doppler 

study of the intracranial arteries; complete study, and 93888, Transcranial Doppler study of the 

intracranial arteries; limited study, in conjunction with the duplex scan codes in order to assess 

the relativity between and among those codes. The RUC reviewed this entire family of codes 

and provided recommendations for CY 2015. For CY 2015, we are establishing the RUC-
CMS-1612-FC 373

recommended work RVUs as interim final for all of the codes in the family except CPT codes 

93886, 93888, 93926, 93975, 93976, 93977, 93978, and 93979. 

For several codes in this family with 10 minutes of intraservice time, the RUC 

recommended 0.50 work RVUs. We believe that this relationship between intraservice time and 

work RVU accurately reflects the time and intensity involved, and should be used for the 

majority of the codes in the family. As a result, for CPT codes 93926, 93979, and 93888, which 

all have 10 minutes of intraservice time, we are assigning an interim final work RVU of 0.50. 

For several codes in this family with 15 minute of intraservice time, the RUC 

recommended work RVUs based upon the survey 25th percentile. We find this to appropriately 

reflect the work involved. Accordingly, for CPT codes 93975, 93976, and 93978, which all have 

15 minutes of intraservice time, we are disagreeing with the RUC work RVU recommendations 

and assigning the 25th percentile of the survey as CY 2015 interim final values. Therefore, for 

CY 2015 we are establishing the following interim final work RVUs: 1.16 for CPT code 93975, 

0.80 for CPT code 93976, 0.80 for CPT code 93978 and 0.50 for CPT code 93979. 

Lastly, we believe that the RUC recommendation for CPT code 93886 overvalues the work 

involved. We accepted the RUC recommendation for CPT code 93880 of 0.80 with an 

intraservice time of 15 minutes. CPT code 93886 has an intraservice time of 17 minutes. 

Applying the work RVU to time ratio of CPT code 93880 to the intraservice time of CPT code 

93886 (results in our interim final value of 0.91 for CPT code 93886. 

(21) Carotid Intima-Media Thickness Ultrasound (CPT Code 93895) 

For CY 2015, a new code, CPT code 93895, describes the work of using carotid 

ultrasound to measure atherosclerosis and quantify the intima-media thickness. After review of 

this code, we determined that it is used only for screening and therefore, we are assigning a PFS 

procedure status indicator of N (Noncovered service) to CPT code 93895. 
CMS-1612-FC 374

(22) Doppler Flow Testing (CPT Code 93990) 

For CY 2015, the RUC provided a recommendation for CPT code 93990 which had been 

identified through the High Volume Growth Services where Medicare utilization increased by at 

least 100 percent from 2006 to 2011. The RUC recommended a work RVU of 0.60 for this 

service. Due to the similarity of this service to duplex scans, we are establishing RVUs for CPT 

code 93990 that are consistent with duplex scans with 10 minutes of intraservice time; which we 

discussed above in section E.4.18. We assigned it an interim final work RVU of 0.50. 

(23) Electronic analysis of implanted neurostimulator (CPT Codes 95971 and 95972) 

For CY 2015, the RUC reviewed CPT codes 95971 and 95972 because they were 

identified by the High Volume Growth Services screen which identifies services in which 

Medicare utilization increased by at least 100 percent from 2006 to 2011 screen. It is unclear to 

us why CPT code 95973, the add-on code to CPT code 95972, was not also surveyed. We are 

valuing CPT code 95971 based upon the RUC recommended work RVU of 0.78. 

For CPT code 95972, we do not believe that the RUC recommended change in work 

RVU from 1.50 to 0.90 reflects the much more significant change in intraservice time from 60 

minutes to 23 minutes. Therefore, we used a building block methodology to develop a work 

RUV of 0.80. 

Even though the RUC did not survey 95973, we believe we should review it as part of 

this family. Not having a survey or RUC recommendations, we believe that the percent decrease 

in the work RVU from the base code 95972 should apply to this code. Therefore, we are 

establishing an interim final work RVU of 0.49 for CPT code 95973. 

We note that the descriptor for CPT code 95972 was changed from “...first hour” to 

“...up to one hour.” We note that for Medicare purposes this code should only be billed when a 
CMS-1612-FC 375

majority of an hour is completed. We would also note that the add-on code should only be 

reported after a full 60 minutes of service is furnished. 

The lack of a survey for CPT code 95973 along with the confusing descriptor language 

and intraservice time suggest the need for this family to be returned to CPT for clarification of 

the descriptor and then to the RUC for resurvey. 

(24) Negative Pressure Wound Therapy (CPT Codes 97607, and 97608, and HCPCS codes 

G0456 and G0457) 

Prior to CY 2013, the codes used to report negative pressure wound therapy were CPT 

codes 97605 and 97606, both of which were typically reported in conjunction with durable 

medical equipment that was paid separately. In the CY 2013 final rule with comment period, we 

created two HCPCS codes to provide a payment mechanism for negative pressure wound therapy 

services furnished to beneficiaries using equipment that is not paid for as durable medical 

equipment: G0456 (Negative pressure wound therapy, (for example, vacuum assisted drainage 

collection) using a mechanically-powered device, not durable medical equipment, including 

provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions 

for ongoing care, per session; total wound(s) surface area less than or equal to 50 square 

centimeters) and G0457 (Negative pressure wound therapy,(for example, vacuum assisted 

drainage collection) using a mechanically-powered device, not durable medical equipment, 

including provision of cartridge and dressing(s), topical application(s), wound assessment, and 

instructions for ongoing care, per session; total wound(s) surface area greater than 50 sq cm). 

For CY 2015, two new codes, CPT codes 97607 and 97608, were created to describe 

negative pressure wound therapy with the use of a disposable system. In addition, CPT codes 

97605 and 97606 were revised to specify the use of durable medical equipment. Based upon 

these the revised coding scheme for negative pressure wound therapy, we are deleting the 
CMS-1612-FC 376

G-codes. We are contractor pricing these codes for CY 2015. CPT codes 97607 and 97608 will 

be designated “Sometimes Therapy” on our Therapy Code List, which is consistent with the Gcodes. The Therapy Code List is available at 

http://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/therapyservices.” 

(25) Application of Topical Fluoride Varnish (CPT Code 99188) 

CPT Code 99188 is a new code for CY 2015 that describes the application of topical 

fluoride varnish to teeth. Since this code describes a service that involves the care of teeth, it is 

excluded from coverage under Medicare by section 1862(a)(12) of the Act, which provides 

“items and services in connection with the care, treatment, filling, removal, or replacement of 

teeth, or structures directly supporting the teeth are excluded from coverage.” Accordingly, we 

are assigning a PFS procedure status indicator of N (Noncovered service) to CPT code 99188. 

(26) Advance Care Planning (CPT codes 99497 and 99498) 

For CY 2015, the CPT Editorial Panel created two new codes describing advance care 

planning services: CPT code 99497 (Advance care planning including the explanation and 

discussion of advance directives such as standard forms (with completion of such forms, when 

performed), by the physician or other qualified health professional; first 30 minutes, face-to-face 

with the patient, family member(s) and/or surrogate); and an add-CPT code 99498 (Advance care 

planning including the explanation and discussion of advance directives such as standard forms 

(with completion of such forms, when performed), by the physician or other qualified health 

professional; each additional 30 minutes (List separately in addition to code for primary 

procedure)). For CY 2015, we are assigning a PFS status indicator of “I” (Not valid for Medicare 

purposes. Medicare uses another code for the reporting and payment of these services.) to CPT 

codes 99497 and 99498 for CY 2015. However, we will consider whether to pay for CPT codes 
CMS-1612-FC 377

99497 and 99498 after we have had the opportunity to go through notice and comment 

rulemaking. 

c. Establishing Interim Final Direct PE RVUs for CY 2015 

i. Background and Methodology 

The RUC provides CMS with recommendations regarding direct PE inputs, including 

clinical labor, disposable supplies, and medical equipment, for new, revised, and potentially 

misvalued codes. We review the RUC-recommended direct PE inputs on a code-by-code basis, 

including the recommended facility PE inputs and/or nonfacility PE inputs. This review is 

informed by both our clinical assessment of the typical resource requirements for furnishing the 

service and our intention to maintain the principles of accuracy and relativity in the database. 

We determine whether we agree with the RUC's recommended direct PE inputs for a service or, 

if we disagree, we refine the PE inputs to represent inputs that better reflect our estimate of the 

PE resources required to furnish the service in the facility and/or nonfacility settings. We also 

confirm that CPT codes should have facility and/or nonfacility direct PE inputs and make 

changes based on our clinical judgment and any PFS payment policies that would apply to the 

code. 

We have accepted for CY 2015, as interim final and without refinement, the direct PE 

inputs based on the recommendations submitted by the RUC for the codes listed in Table 28. 

For the remainder of the RUC's direct PE recommendations, we have accepted the PE 

recommendations submitted by the RUC as interim final, but with refinements. These codes and 

the refinements to their direct PE inputs are listed in Table 31. 

We note that the final CY 2015 PFS direct PE input database reflects the refined direct 

PE inputs that we are adopting on an interim final basis for CY 2015. That database is available 

under downloads for the CY 2015 PFS final rule with comment period on the CMS website at 
CMS-1612-FC 378

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. We also note that the PE RVUs displayed in Addenda B and 

C reflect the interim final values and policies described in this section. All PE RVUs adopted on 

an interim final basis for CY 2015 are included in Addendum C and are open for comment in this 

final rule with comment period.
CMS-1612-FC 379

TABLE 28: CY 2015 INTERIM FINAL CODES WITH 

DIRECT PE INPUT RECOMMENDATIONS ACCEPTED WITHOUT REFINEMENT 

HCPCS Short Descriptor 

11980 Implant hormone pellet(s) 

22512 Vertebroplasty addl inject 

22515 Perq vertebral augmentation 

22856 Cerv artific diskectomy 

27280 Fusion of sacroiliac joint 

31620 Endobronchial us add-on 

33270 Ins/rep subq defibrillator 

33271 Insj subq impltbl dfb elctrd 

33272 Rmvl of subq defibrillator 

33273 Repos prev impltbl subq dfb 

33951 Ecmo/ecls insj prph cannula 

33952 Ecmo/ecls insj prph cannula 

33953 Ecmo/ecls insj prph cannula 

33954 Ecmo/ecls insj prph cannula 

33955 Ecmo/ecls insj ctr cannula 

33956 Ecmo/ecls insj ctr cannula 

33957 Ecmo/ecls repos perph cnula 

33958 Ecmo/ecls repos perph cnula 

33959 Ecmo/ecls repos perph cnula 

33962 Ecmo/ecls repos perph cnula 

33963 Ecmo/ecls repos perph cnula 

33964 Ecmo/ecls repos perph cnula 

33969 Ecmo/ecls rmvl perph cannula 

33984 Ecmo/ecls rmvl prph cannula 

33985 Ecmo/ecls rmvl ctr cannula 

33986 Ecmo/ecls rmvl ctr cannula 

33988 Insertion of left heart vent 

33989 Removal of left heart vent 

36818 Av fuse uppr arm cephalic 

36819 Av fuse uppr arm basilic 

36820 Av fusion/forearm vein 

36821 Av fusion direct any site 

36825 Artery-vein autograft 

36830 Artery-vein nonautograft 

36831 Open thrombect av fistula 

36832 Av fistula revision open 

36833 Av fistula revision 

37218 Stent placemt ante carotid 

43180 Esophagoscopy rigid trnso 

52441 Cystourethro w/implant 

55840 Extensive prostate surgery 

55842 Extensive prostate surgery 

55845 Extensive prostate surgery 

58541 Lsh uterus 250 g or less 

58542 Lsh w/t/o ut 250 g or less 

58543 Lsh uterus above 250 g 

HCPCS Short Descriptor 

58544 Lsh w/t/o uterus above 250 g 

58570 Tlh uterus 250 g or less 

58571 Tlh w/t/o 250 g or less 

58572 Tlh uterus over 250 g 

58573 Tlh w/t/o uterus over 250 g 

64486 Tap block unil by injection 

64487 Tap block uni by infusion 

64488 Tap block bi injection 

64489 Tap block bi by infusion 

66179 Aqueous shunt eye w/o graft 

66180 Aqueous shunt eye w/graft 

66184 Revision of aqueous shunt 

66185 Revise aqueous shunt eye 

67036 Removal of inner eye fluid 

67039 Laser treatment of retina 

67040 Laser treatment of retina 

67041 Vit for macular pucker 

67042 Vit for macular hole 

67043 Vit for membrane dissect 

67255 Reinforce/graft eye wall 

70496 Ct angiography head 

70498 Ct angiography neck 

76770 Us exam abdo back wall comp 

76775 Us exam abdo back wall lim 

76856 Us exam pelvic complete 

76857 Us exam pelvic limited 

77080 Dxa bone density axial 

77316 Brachytx isodose plan simple 

77317 Brachytx isodose intermed 

77318 Brachytx isodose complex 

88348 Electron microscopy 

88356 Analysis nerve 

91200 Liver elastography 

92145 Corneal hysteresis deter 

92541 Spontaneous nystagmus test 

92542 Positional nystagmus test 

92544 Optokinetic nystagmus test 

92545 Oscillating tracking test 

93260 Prgrmg dev eval impltbl sys 

93261 Interrogate subq defib 

93644 Electrophysiology evaluation 

97610 Low frequency non-thermal us 
CMS-1612-FC 380

ii. Common Refinements

 Table 31 details our refinements of the RUC's direct PE recommendations at the 

code-specific level. In this section, we discuss the general nature of some common refinements 

and the reasons for particular refinements. 

(a) Changes in Physician Time 

Some direct PE inputs are directly affected by revisions in work time described in section 

II.E.3.a. of this final rule with comment period. We note that for many codes, changes in the 

intraservice portions of the work time and changes in the number or level of postoperative visits 

included in the global periods result in corresponding changes to direct PE inputs. We also note 

that, for a significant number of services, especially diagnostic tests, the procedure time 

assumptions used in determining direct PE inputs are distinct from, and therefore not dependent 

on, work intraservice time assumptions. For these services, we do not make refinements to the 

direct PE inputs based on changes to estimated work intraservice times. 

Changes in Intraservice Work Time in the Nonfacility Setting. For most codes valued in 

the nonfacility setting, a portion of the clinical labor time allocated to the intraservice period 

reflects minutes assigned for assisting the practitioner with the procedure. To the extent that we 

are refining the times associated with the intraservice portion of such procedures, we have 

adjusted the corresponding intraservice clinical labor minutes in the nonfacility setting. 

 For equipment associated with the intraservice period in the nonfacility setting, we 

generally allocate time based on the typical number of minutes a piece of equipment is being 

used, and therefore, not available for use with another patient during that period. In general, we 

allocate these minutes based on the description of typical clinical labor activities. To the extent 

that we are making changes in the clinical labor times associated with the intraservice portion of 

procedures, we have adjusted the corresponding equipment minutes associated with the codes. 
CMS-1612-FC 381

Changes in the Number or Level of Postoperative Office Visits in the Global Period. For 

codes valued with postservice office visits during a global period, most of the clinical labor time 

allocated to the postservice period reflects a standard number of minutes allocated for each of 

those visits. To the extent that we are refining the number or level of postoperative visits, we 

have modified the clinical staff time in the postservice period to reflect the change. We note that 

until the global periods are transitioned, consistent with other policies finalized in this rule, we 

will make these refinements. For codes valued with postservice office visits during a global 

period, we allocate standard equipment for each of those visits. To the extent that we are making 

a change in the number or level of postoperative visits associated with a code, we have adjusted 

the corresponding equipment minutes. For codes valued with postservice office visits during a 

global period, a certain number of supply items are allocated for each of those office visits. To 

the extent that we are making a change in the number of postoperative visits, we have adjusted 

the corresponding supply item quantities associated with the codes. We note that many supply 

items associated with postservice office visits are allocated for each office visit (for example, a 

minimum multi-specialty visit pack (SA048) in the CY 2015 direct PE input database). For these 

supply items, the quantities in the direct PE input database should reflect the number of office 

visits associated with the code's global period. However, some supply items are associated with 

postservice office visits but are only allocated once during the global period because they are 

typically used during only one of the postservice office visits (for example, pack, post-op 

incision care (suture) (SA054) in the direct PE input database). For these supply items, the 

quantities in the direct PE input database reflect that single quantity. 

 These refinements are reflected in the final CY 2015 PFS direct PE input database and 

detailed in Table 31. 

(b) Equipment Minutes
CMS-1612-FC 382

In general, the equipment time inputs reflect the sum of the times within the intraservice 

period when a clinician is using the piece of equipment, plus any additional time the piece of 

equipment is not available for use for another patient due to its use during the designated 

procedure. In cases where equipment times included time for clinical labor activities in the preservice period, we have refined these times to remove the minutes associated with these tasks, 

since the pre-service period ends “when patient enters office/facility for surgery/procedure.” 

Although some services include equipment that is typically unavailable during the entire clinical 

labor service period, certain highly technical pieces of equipment and equipment rooms are less 

likely to be used by a clinician for all tasks associated with a service, and therefore, are typically 

available for other patients during the preservice and postservice components of the service 

period. We adjust those equipment times accordingly. We refer interested stakeholders to our 

extensive discussion of these policies in the CY 2012 PFS final rule with comment period (76 FR 

73182-73183) and in section II.G.2.b. of this final rule with comment period. We are refining 

the CY 2015 RUC direct PE recommendations to conform to these equipment time policies. 

These refinements are reflected in the final CY 2015 PFS direct PE input database and detailed 

in Table 31. 

(c) Moderate Sedation Inputs 

In the CY 2012 PFS final rule (76 FR 73043-73049), we finalized a standard package of 

direct PE inputs for services where moderate sedation is considered inherent in the procedure. In 

section II.A. of this final rule with comment period, we finalized a refinement to the standard 

package to include a stretcher for the same length of time as the other equipment items in the 

standard package. We are refining the CY 2015 RUC direct PE recommendations to conform to 

these policies. This includes the removal of a power table where it was included during the 
CMS-1612-FC 383

intraservice period, as the stretcher takes the place of the table. These refinements are reflected 

in the final CY 2015 PFS direct PE input database and detailed in Table 31. 

(d) Standard Minutes for Clinical Labor Tasks 

In general, the preservice, intraservice period, and postservice clinical labor minutes 

associated with clinical labor inputs in the direct PE input database reflect the sum of particular 

tasks described in the information that accompanies the recommended direct PE inputs on “PE 

worksheets.” For most of these described tasks, there are a standardized number of minutes, 

depending on the type of procedure, its typical setting, its global period, and the other procedures 

with which it is typically reported. At times, the RUC recommends a number of minutes either 

greater than or less than the time typically allotted for certain tasks. In those cases, CMS reviews 

the deviations from the standards to assess whether they are clinically appropriate. Where the 

RUC-recommended exceptions are not accepted, we refine the interim final direct PE inputs to 

match the standard times for those tasks. In addition, in cases when a service is typically billed 

with an E/M or other evaluation service, we remove the preservice clinical labor tasks so that the 

inputs are not duplicative and reflect the resource costs of furnishing the typical service. 

 In some cases the RUC recommendations include additional minutes described by a 

category called “other clinical activity,” or through the addition of clinical labor tasks that are 

different from those previously included as standard. In these instances, CMS reviews the tasks 

as described in the recommendation to determine whether they are already incorporated into the 

total number of minutes based on the standard tasks. Additionally, CMS reviews these tasks in 

the context of the kinds of tasks delineated for other services under the PFS. For those tasks that 

are duplicative or not separately incorporated for other services, we do not accept those 

additional clinical labor tasks as direct inputs. For example, as we have previously discussed (78 

FR 74308), we believe that quality assurance documentation tasks for services across the PFS are 
CMS-1612-FC 384

already accounted for in the overall estimate of clinical labor time. We do not believe that it 

would serve the relativity of the direct PE input database were additional minutes added for each 

clinical task that could be discretely described for every code. These refinements are reflected in 

the final CY 2015 PFS direct PE input database and detailed in Table 31. 

(e) New Supply and Equipment Items 

The RUC generally recommends the use of supply and equipment items that already exist 

in the direct PE input database for new, revised, and potentially misvalued codes. Some 

recommendations include supply or equipment items that are not currently in the direct PE input 

database. In these cases, the RUC has historically recommended a new item be created and has 

facilitated CMS's pricing of that item by working with the specialty societies to provide sales 

invoices to us. 

We received invoices for several new supply and equipment items for CY 2015. We 

have accepted the majority of these items and added them to the direct PE input database. Tables 

29 and 30 detail the invoices received for new and existing items in the direct PE database. As 

discussed in section II.A. of this final rule with comment period, we encourage stakeholders to 

review the prices associated with these new and existing items to determine whether these prices 

appear reasonable. Where prices appear unreasonable, we encourage stakeholders to provide 

invoices that provide more accurate pricing for these items in the direct PE database. We remind 

stakeholders that due to the budget neutral nature of the PFS, increased prices for any items in 

the direct PE database decrease the pool of PE RVUs available to all other PFS services. Tables 

29 and 30 also include the number of invoices received as well as the number of nonfacility 

allowed services for procedures that use these equipment items. In cases where large numbers of 

allowed services exist, we question pricing the item based upon a single invoice. We are 
CMS-1612-FC 385

concerned that the single invoice may not be reflective of typical costs for these items and 

encourage stakeholders to provide additional invoices. 

In some cases we cannot adequately price a newly recommended item due to inadequate 

information. In some cases, no supporting information regarding the price of the item has been 

included in the recommendation to create a new item. In other cases, the supporting information 

does not demonstrate that the item has been purchased at the listed price (for example, price 

quotes instead of paid invoices). In cases where the information provided allowed us to identify 

clinically appropriate proxy items, we have used existing items as proxies for the newly 

recommended items. In other cases, we have included the item in the direct PE input database 

without an associated price. Although including the item without an associated price means that 

the item does not contribute to the calculation of the PE RVU for particular services, it facilitates 

our ability to incorporate a price once we are able to do so. 
CMS-1612-FC 386

TABLE 29: INVOICES RECEIVED FOR NEW DIRECT PE INPUTS 

CPT/HCPCS 

Codes Item Name CMS code Average Price Number of Invoices 

Non-Facility Allow

HCPCS Codes Usi

Projected Service

Code

20604, 

20606, 20611 

ultrasound transmission gel, sterile 

(single use) SJ089 $1.71 1 7482

22512 10g IVAS drill SD292 $139.33 1 9922512 10g cannulae SD293 $86.11 1 99

29200, 29240, 29260, 29280, 29520, 29530, 

29540, 29550 

foam underwrap SG097 $0.0043 per inch 1 4155

29200, 29240, 29260, 29280, 29520, 29530, 

29540, 29550 

rigid strapping tape (15 yards) SG098 $0.018 per inch 1 4155

29200, 29240, 29260, 29280, 29520, 29530, 

29540, 29550 

skin prep barrier wipes SM029 $0.20 1 4155

31620 Flexible dual-channeled EBUS bronchoscope, with radial probe EQ361 $160,260.06 6 10
CMS-1612-FC 387

CPT/HCPCS 

Codes Item Name CMS code Average Price Number of Invoices 

Non-Facility Allow

HCPCS Codes Usi

Projected Service

Code

31620 

Video system, Ultrasound 

(processor, digital capture, 

monitor, printer, cart) 

ER099 $13,379.57 6 10

31620 EBUS, single use aspiration needle, 21 g SC102 $145.82 5 1031620 Balloon for Bronchosopy Fiberscope SD294 $28.68 4 10

52441, 52442 Urolift Implant and implantation device SD291 $775.00 10 1264486, 64488 ultrasound needle SC101 $12.81 4 468564487, 64489 continuous peripehral nerve block tray SA116 $23.69 1 802

77063 multimodality software ED051 $11,570.00 12 297588341 Anti CD45 Monoclonal Antibody SL495 $3.61 per test 1 917688344 34 Beta E12 SL496 $4.27 per test 1 515988348 Digital Printer ED048 $774.89 1 6488348 Carbon Coater EQ366 $22,540.08 1 6488348 Diamond Milling Tool EQ365 $1,714.00 1 64

88356, 88348 Electron Microscopy Tissue processor EP115 $13,119.00 2 19188356, 88348 Block face milling machine EQ363 $18,139.00 1 19188356, 88348 Glass Knife Breaker EQ364 $9,585.14 1 191

88364 CMV DNA Probe Cocktail SL500 $0.10 per ul 1 337
CMS-1612-FC 388

CPT/HCPCS 

Codes Item Name CMS code Average Price Number of Invoices 

Non-Facility Allow

HCPCS Codes Usi

Projected Service

Code

88341, 88342, 88344, 88364, 88365, 88367, 88368, 

88369, 88373 

Universal Detection Kit SA117 $4.00 1 1380

88365 EBER positive control slide SL507 $20.15 1 84488365 (EBER) DNA Probe Cocktail SL497 $8.57 per test 2 844

88365, 88366, 88367, 88368, 

88374, 88377 

VP-2000 Processor EP116 $30,800.00 1 2282

88367, 88368 Kappa Probe Cocktails SL498 $0.10 per ul 1 36688369, 88373 Lambda Probe Cocktail SL499 $0.10 per ul 1 244288380, 88381 Surface Decontaminant (DNA Away) SL494 $0.07 per ml 1 664

91200 Fibroscan ER101 $124,950.00 1 8792145 Ocular Response Analyzer EQ360 $12,000.00 3 Unkn

92541, 92542, 

92544, 92545 

VNG Recording System EQ367 $29,607.50 2 1011

93702 BIS monitoring system (bioimpedance spectroscopy) EQ359 $3,316.93 1 Unkn
CMS-1612-FC 389

CPT/HCPCS 

Codes Item Name CMS code Average Price Number of Invoices 

Non-Facility Allow

HCPCS Codes Usi

Projected Service

Code

93702 electrode, BIS (bioimpedance spectroscopy) SD290 $28.33 1 Unkn96127 

Beck Youth Inventory, Second 

Edition (BYI-II); Combination 

Inventory Booklet 

SK119 $1.96 per booklet 1 Unkn

97610 MIST Therapy System EQ372 $28,000.00 2 2* 97610 MIST Therapy Cart EQ368 $1,250.00 1 2* 97610 kit, low frequency ultrasound wound therapy (MIST) SA119 $63.33 3 2* 99188 CavityShield 5% Varnish .25mL SH106 $0.91 1 Unkn

G0277 

HBOT air break breathing 

apparatus demand system (hoses, 

masks, penetrator and demand 

valve) 

EQ362 $986.00 1 1530
CMS-1612-FC 390

TABLE 30: INVOICES RECEIVED FOR EXISTING DIRECT PE INPUT

CPT/HCPCS 

Codes Item Name CMS code Current Price Updated Price % Change Num

of Invoi

20983, 47383 cryosurgery system (for tumor ablation) EQ302 missing $37,500.00 2 20983, 47383 gas, argon SD227 $0.25 per cubic foot $0.32 per cubic foot 28% 1 20983, 47383 gas, helium SD079 $0.25 per cubic foot $0.57 per cubic foot 128% 1 

31627 system, navigational bronchoscopy (superDimension) EQ326 $137,800.00 $189,327.66 37% 4 31627 kit, locatable guide, ext. working channel, w-b-scope adapter SA097 $995.00 $1,063.67 7% 3 64561 kit, percutaneous neuro test stimulation SA022 $305.00 $420.00 38% 1 88348 camera, digital system, for electron microscopy ED006 $41,000.00 $82,000.00 100% 1 

88348, 88356 microtome, ultra ER043 $25,950.00 $34,379.00 32% 1 

G0277 

HBOT (hyperbaric oxygen therapy) 

monochamber, incl. gurney and integrated 

grounding assembly 

EQ131 $125,000.00 $127,017.98 2% 1 

*New procedure - Projected volume 
CMS-1612-FC 391

(f) Recommended Items that are not Direct PE Inputs 

In some cases, the recommended direct PE inputs included items that are not clinical 

labor, disposable supplies, or medical equipment resources. We have addressed these kinds of 

recommendations in previous rulemaking and in sections II.G.2.b. and II.B.4.a. of this final rule 

with comment period. Refinements to adjust for these recommended inputs are reflected in the 

final CY 2015 PFS direct PE input database and detailed in Table 31. 

(g) Film-to-digital Migration 

 As discussed in section II.A.3 of this final rule with comment period, we are finalizing 

our policy to remove equipment and supply inputs associated with film technology from the 

direct PE database. Since the recommendations we received for 2015 were prepared before the 

transition occurred, in some cases, the RUC recommendations included film inputs. Where 

recommendations included these inputs, we have removed these inputs and replaced them with 

“PACS workstation proxy” as described in section II.A.3 of this final rule with comment period. 

Since the film-to-digital transition results from our acceptance of a RUC recommendation, we do 

not consider the removal of these items to be refinements of RUC recommendations, and 

therefore do not include them in Table 31. 

(h) Pre-service and post-service tasks for Add-on codes 

 In general, we believe that certain pre-service and post-service tasks are not repeated for 

services reported using add-on codes. In some cases, we also believe that the time for certain 

equipment items are not duplicated for add-on codes. In these cases, we removed the time 

associated with those tasks and/or equipment items from those codes. These refinements appear 

in Table 31. 

iii. Code-Specific Refinements 
CMS-1612-FC 392

(a) Rib Fractures (CPT codes 21811, 21812, and 21813) 

 For the newly created rib fracture codes, which are frequently furnished as emergency 

surgeries, the RUC did not include time for the standard pre-service activities “Provide preservice education/obtain consent” and “Follow-up phone calls & prescriptions.” However, the 

RUC recommendation included time for pre-service activities “Complete pre-service diagnostic 

& referral forms,” “Coordinate pre-surgery services”, and “Schedule space and equipment in 

facility.” Since these codes would typically be provided as emergency surgeries, we question 

whether these tasks would typically be performed. 

 We reviewed other emergency procedures in the PFS to determine whether pre-service 

clinical labor activities were typically included in the PE worksheets. We found that the 

recommendations for these procedures were inconsistent. Therefore, we will not remove the time 

allocated for these clinical labor activities at this time. However, we believe that for emergency 

procedures, none of the pre-service tasks listed above would typically be performed. We seek 

comment to clarify this issue, and plan to consider this issue in future rulemaking. 

 As discussed earlier in this section of this final rule with comment period, we have valued 

CPT codes 21811, 21812, and 21813 as 0-day globals. We have therefore removed direct PE 

inputs associated with the postoperative visits. 

(b) Percutaneous Vertebroplasty and Augmentation (CPT codes 22510, 22511, 22512, 22513, 

22514, and 22515) 

 The RUC recommendation regarding add-on CPT code 22512 (Percutaneous 

vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral 

injection, inclusive of all imaging guidance, each additional cervicothoracic or lumbosacral 

vertebral body)) included new supply item “10g IVAS drill.” We note that the recommendations 

for the base codes did not contain this supply item, and the vertebroplasty kit does not appear to 
CMS-1612-FC 393

contain this drill either. We do not understand why the drill would be required for the add-on 

code when it is not required for the base code. Therefore, we will not include supply item “10g 

IVAS drill” in CPT code 22512 at this time. 

(c) Endobronchial Ultrasound (EBUS) (CPT code 31620) 

 As indicated earlier in this section of this final rule with comment period, we are 

maintaining the CY 2014 work RVU for CPT code 31620 in light of our concerns regarding 

coding structure. As such, we are maintaining the CY 2014 direct PE inputs for 31620 as well. 

(d) Breast Tomosynthesis (CPT codes 77061, 77062, and 77063) 

 For CY 2015, the CPT Editorial Panel created three codes to describe digital breast 

tomosynthesis services: 77061(Digital breast tomosynthesis; unilateral), 77062 (Digital breast 

tomosynthesis; bilateral) and 77063 (Screening digital breast tomosynthesis, bilateral (List 

separately in addition to code for primary procedure)). For these newly created codes, the RUC 

recommended creating a new equipment item, “room, breast tomosynthesis”, at a price of 

$667,669, as well as a list of items contained in the room. We believe that several of the items 

included in the room are not appropriately characterized as direct costs. We also believe that the 

creation of rooms sometimes causes confusion when items in the room are also included as 

stand-alone PE inputs, as specialty societies do not consider the items included in the room when 

preparing the PE worksheets. Further, we believe that the prices for the rooms sometimes result 

in less transparency, as prices for items within the room tend to remain static over time. 

Therefore, we are not creating this new equipment item, but will instead include the individual 

equipment items that we believe are appropriately characterized as direct costs. 

 The price for the digital breast tomosynthesis unit indicated on the invoice received by 

the RUC was $498,412. We received many invoices for this equipment item with an average 

price of $381,380. Therefore, we will create a new equipment item “DBT unit”, at a price of 
CMS-1612-FC 394

$381,380. 

 The RUC also recommended including a new equipment item, “PACS cache”, for these 

procedures. We do not believe that digital storage constitutes a direct cost, as it is not 

individually allocable to an individual patient for a particular service. . Therefore, we will not 

add this new equipment item to the direct PE database. 

(e) Radiation Treatment (CPT codes 77385, 77386, 77387, 77402, 77407, 77412) 

For CY 2015, the CPT Editorial Panel revised the set of codes that describe radiation 

treatment delivery services. These revisions included the addition and deletion of several codes 

and the development of new guidelines and coding instructions. Due to the significant code 

restructuring and potential for changes in payment, some specialty societies representing 

providers of radiation treatment services have requested that we delay implementation of the new 

code set. We believe that given the large scale of the changes in this code set restructuring, in the 

context of our upcoming revised process for valuing new, revised, and potentially misvalued 

codes, it is prudent to propose the values for the revised code set in the CY 2016 rule with 

opportunity for public comment prior to establishing payment rates. 

(f) Immunohistochemistry (CPT codes 88341, 88342, and 88344) 

 The RUC recommended including supply item “UltraView Universal DAB Detection 

Kit” (SL488) for CPT codes 88341, 88342, and 88344, which is priced at $10.49 per kit, and 

“UltraView Universal Alkaline Phosphatase Red Detection Kit”, which is priced at $20.64. We 

noted that for other similar services, CPT codes 88364, 88365, 88367, 88368, 88369, and 88373, 

the RUC recommended including supply item “Universal Detection Kit” (SA117), which is 

priced at $4.00 per kit. After reviewing information about these two kits, we believe that 

functions provided by SL488 and SL489 are also provided by SA117. The recommendations did 

not explain why the more expensive kit was necessary for 88341, 88342, and 88344 when the 
CMS-1612-FC 395

less expensive kit was sufficient for CPT codes 88364, 88365, 88367, 88368, 88369, and 88373. 

Absent any rationale for the use of the more expensive kit, we are including SA117 for 88341, 

88342, and 88344 in place of SL488. 

(g) Electron Microscopy (CPT code 88348) 

 The RUC recommended including a new supply item, “diamond milling tool”, for use 

with CPT code 88348. However, upon reviewing the invoice, we believe that “diamond milling 

tool” is more appropriately characterized as equipment. We have therefore created an equipment 

item for this tool, as listed in Table 29. 

(h) Morphometric Analysis (CPT codes 88364, 88365, 88366, 88367, 88373, 88374, 88377, 

88368, and 88369) 

 The CPT Editorial Panel revised the in situ hybridization codes (88365, 88367, and 

88368) and created three new add-on codes for reporting each additional separately identifiable 

probe per slide. The RUC reviewed CPT codes 88365, 88367, and 88368, among other services 

in this family, in October 2013 and recommended direct inputs for these procedures, including 

supply item “kit, FISH paraffin pretreatment” (SL195), with quantities of 1 unit for CPT code 

88365, 0.75 units for CPT code 88367, and 1 unit for CPT code 88368. 

 After the CY 2014 PFS final rule with comment period was published, the specialty 

societies determined that additional clarification was necessary, and requested that the CPT 

Editorial Panel review the entire family again. The CPT editorial panel added three new codes 

for “each multiplex probe stain procedure.” The specialty societies then resurveyed these 

procedures. The RUC reviewed the entire family at the April 2014 meeting and recommended 

supply item SL195 with a quantity of 2 units for CPT code 88365, 1.4 units for CPT code 88367, 

and 2 units for CPT code 88368. These quantities are double what the RUC recommended to us 

in October 2013, which was 1 unit for CPT code 88365, 0.75 units for CPT code 88367, and one 
CMS-1612-FC 396

unit for CPT code 88368. Without an explanation for this significant change, we are including 

SL195 with the following quantities: 1 unit for CPT code 88365, 0.75 units for CPT code 88367, 

and 1 unit for CPT code 88368. Similarly, for add-on services CPT codes 88364, 88366, 88369, 

88373, 88374, and 88377, more than one unit of SL195 was included. We believe that the unit 

of the kit should be consistent between the base code and the add-on code. We will therefore 

include 1 unit of SL195 for CPT codes 88364, 88366, 88369, and 88377, and 0.75 units for CPT 

codes 88373 and 88374. We are also interested in learning more about why a partial kit would 

be used in furnishing the typical service. 

 CPT codes 88374 and 88377, which are add-on codes, contain more than one unit of 

supply item “kit, HER-2/neu DNA Probe” (SL196). Because these codes describe a service that 

includes a single specimen with one stain, we do not understand why more than one kit would be 

required. We have therefore included a unit of 1 for SL196 in CPT codes 88374 and 88377. 

 We also believe that the units of positive control slides and negative control slides should 

be consistent throughout this entire family. We note that CPT codes 88367, 88373, and 88374 

included a recommended 0.2 units of positive and/or negative control slide; supply items SL118 

and SL119 for CPT code 88367, supply items SL120 and SL121 for CPT code 88373, and 

supply items SL184 and SL185 for CPT code 88374.) However, for CPT codes 88368, 88369, 

and 88377, the recommendation included 0.5 units of the positive and/or negative control slide 

(supply item SL112 for CPT codes 88368 and 88369, and supply items SL184 and SL185 for 

CPT code 88377). No rationale was provided for why a greater quantity of the control slide 

would be required. Therefore, we will include 0.2 units of positive and/or negative control 

slides, as appropriate, to maintain consistency throughout this family of codes. 

 As with the positive and negative control slides, we believe that the number of units of 

supply item SL498 (“Kappa probe cocktails”) and SL499 (Lambda probe cocktails”) should be 
CMS-1612-FC 397

consistent across procedures. The recommendations for CPT codes 88367 and 88373 contain 28 

ul of SL498 for 88367 and 27 ul of SL499 for 88373. Therefore, to maintain consistency, we 

refined the units of SL498 for CPT code 88368 and SL499 for CPT code 88369 to 28 ul. 

 The RUC recommended a quantity of 1.6 for SL497 “(EBER) DNA Probe Cocktail” for 

CPT code 88365. Since this procedure describes a single stain, and the stain needs to be added 

to the positive control slide and the specimen slide, we believe that a quantity of 2 is more 

appropriate. We have therefore included 2 units of SL497 for CPT code 88365. 

 The RUC recommendation also included a new equipment item “VP-2000 processor” 

(EP116). Among the purposes of this equipment item is to reduce the amount of technician time 

needed to complete the clinical labor task. However, in the recommendations we received, rather 

than the clinical labor time for these codes decreasing with the addition of this new equipment 

item, the RUC recommended increased clinical labor times associated with this task for CPT 

codes 88365, 88366, 88368, and 88377 increased. We are unable to reconcile as typical the new 

equipment item, which is intended to reduce technician time, with the increased technician time 

for this same clinical labor task. Therefore, we will not allocate time for equipment item “VP2000 processor” (EP116) in CPT codes 88365, 88366, 88368, and 88377. 

(h) Microdissection (CPT codes 88380 and 88381) 

 In reviewing the RUC recommendations for CPT code 88380, the work vignette 

indicated that the microdissection is performed by the pathologist. However, the PE worksheet 

also included several subtasks of “Microdissect each stained slide sequentially while reviewing 

H and E stained slide” that are performed by the cytotechnologist. Since we do not believe that 

both the pathologist and the cytotechnologist are completing these tasks, we have refined out the 

lines associated with the specific tasks we believe are completed by the pathologist. Table 31 

details our refinements to the clinical labor tasks. 
CMS-1612-FC 398

(j) Interventional Transesophageal Echocardiography (TEE) (CPT codes 93312 and 93314) 

 CPT code 93314 describes a service in which the acquisition and interpretation of images 

is furnished by a different practitioner than the placement of the probe. CPT code 93312 includes 

all services encompassed by CPT code 93314 and included a recommendation for 30 minutes of 

assist physician time. We do not believe that CPT code 93314 should have more clinical labor 

than CPT code 93312, which is the more extensive code. We have therefore refined this time to 

30 minutes, which is the same as the time allocated to 93312. We also note that the time 

allocated to equipment item “room, ultrasound, vascular” (EL016) was affected by this 

refinement. 

(k) Hyperbaric Oxygen Therapy (HBOT) (HCPCS code G0277) 

 We received a RUC recommendation for CPT code 99183 (Physician or other qualified 

health care professional attendance and supervision of hyperbaric oxygen therapy, per session), 

which included significant increases to the direct PE inputs, which assumes a treatment time of 

120 minutes. Currently, CPT code 99183 is used for both the professional attendance and 

supervision and the actual treatment delivery. Stakeholders have pointed out that although we 

include the PE inputs for treatment delivery in this code, the descriptor describes only attendance 

and supervision. We note that under the OPPS, the treatment is reported using separate 

treatment code C1300 (Hyperbaric oxygen under pressure, full body chamber, per 30 minute 

interval). After considering this issue, we believe the OPPS approach would also be appropriate 

for the PFS. We are therefore creating a G-code to report the treatment delivery and to maintain 

consistency with the OPPS coding. We will use the same descriptor as previously used for 

OPPS code C1300 for a timed 30-minute code, which can then be used across settings. To value this 

G-code, we used the RUC recommended direct PE inputs for 99183 and adjusted them to align 

with the 30 minute treatment interval. 
CMS-1612-FC 399

 In reviewing the recommended direct PE inputs, we observed that the quantity of oxygen 

increased significantly relative to the previous value. To better understand this change, we 

reviewed the instruction manual for the most commonly used HBOT chamber, which provide 

guidance regarding the quantity of Oxygen used. Based on our review, we determined that 

12,000, rather than 47,000, was the typical number of units. Therefore, in aligning the direct PE 

inputs as described above, we first adjusted the units of oxygen to 12,000 for the recommended 

120 minute time, and subsequently adjusted it to align with the 30 minute G-code. 

(l) EOG VNG (CPT code 92543) 

 As described earlier in this section of this final rule with comment period, we are 

maintaining the CY 2014 work RVU for CPT code 92543 due to possible confusion among 

survey respondents. Similarly, we are also maintaining the CY 2014 direct PE inputs for 92543. 

These refinements, as well as other applicable standard and common refinements for 

these codes, are reflected in the final CY 2015 PFS direct PE input database and detailed in 

Table 31.
CMS-1612-FC 400

TABLE 31: CY 2015 INTERIM FINAL CODES WITH DIRECT PE INPUT RECOMMENDA

WITH REFINEMENTS 

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

20604 Drain/inj joint/bursa w/us 

L037D RN/LPN/MTA F Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

L037D RN/LPN/MTA NF Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

20606 Drain/inj joint/bursa w/us 

L037D RN/LPN/MTA F Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

L037D RN/LPN/MTA NF Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

20611 Drain/inj joint/bursa w/us 

L037D RN/LPN/MTA F Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

L037D RN/LPN/MTA NF Conduct phone 

calls/call in prescriptions 

3 0 Typically bi

service 

20983 Ablate bone tumor(s) perq 

EF018 stretcher NF 60 193 Standard equ

for moderate 

EF027 table, instrument, 

mobile 

NF 134 193 Standard equ

for moderate 

EL007 room, CT NF 134 133 Refined equ

conform to epolicies for hequipment. 

EQ011 ECG, 3-channel 

(with SpO2, NIBP, temp, resp) 

NF 194 193 Standard equ

for moderate 
CMS-1612-FC 401

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

EQ032 IV infusion 

pump 

NF 194 193 Standard equ

for moderate 

EQ168 light, exam NF 194 133 Refined equ

conform to epolicies for ntechnical equ

EQ302 cryosurgery 

system (for tumor ablation) 

NF 134 133 Refined equ

conform to epolicies for hequipment. 

21811 Optx of rib fx w/fixj scope 

L037D RN/LPN/MTA F Discharge day 

management 99238 --12 minutes 

12 0 Post-operativ

see preamble 

EF014 light, surgical PO 72 0 Post-operativ

see preamble 

EF031 table, power PO 72 0 Post-operativ

see preamble 

SA048 pack, minimum 

multi-specialty visit 

PO 2 0 Post-operativ

see preamble 

SA052 pack, post-op 

incision care (staple) 

PO 1 0 Post-operativ

see preamble 

21812 Treatment of rib fracture 

L037D RN/LPN/MTA F Discharge day 

management 99238 --12 minutes 

12 0 Post-operativ

see preamble 

EF014 light, surgical PO 99 0 Post-operativ

see preamble 

EF031 table, power PO 99 0 Post-operativ

see preamble 

SA048 pack, minimum 

multi-specialty visit 

PO 3 0 Post-operativ

see preamble 
CMS-1612-FC 402

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SA052 pack, post-op 

incision care (staple) 

PO 1 0 Post-operativ

see preamble 

21813 Treatment of rib fracture 

L037D RN/LPN/MTA F Discharge day 

management 99238 --12 minutes 

12 0 Post-operativ

see preamble 

EF014 light, surgical PO 99 0 Post-operativ

see preamble 

EF031 table, power PO 99 0 Post-operativ

see preamble 

SA048 pack, minimum 

multi-specialty visit 

PO 3 0 Post-operativ

see preamble 

SA052 pack, post-op 

incision care (staple) 

PO 1 0 Post-operativ

see preamble 

22513 Perq vertebral augmentation 

SA053 pack, post-op 

incision care (suture & staple) 

NF 1 0 No justificat

use of staple Suture pack typical proce

SA054 pack, post-op 

incision care (suture) 

NF 0 1 No justificat

use of staple Suture pack typical proce

22514 Perq vertebral augmentation 

SA053 pack, post-op 

incision care (suture & staple) 

NF 1 0 No justificat

use of staple Suture pack typical proce

SA054 pack, post-op 

incision care (suture) 

NF 0 1 No justificat

use of staple Suture pack typical proce
CMS-1612-FC 403

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

27279 Arthrodesis sacroiliac joint 

L037D RN/LPN/MTA F Discharge day 

management 99238 --12 minutes 

12 6 Aligned clin

discharge datime with thdischarge da

29200 Strapping of chest L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29240 Strapping of shoulder L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29260 Strapping of elbow or wrist L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29280 Strapping of hand or finger L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29520 Strapping of hip 

L023A Physical Therapy 

Aide 

NF Greet patient and 

provide gowning 

3 0 Typically bi

or other eval

29530 Strapping of knee L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29540 Strapping of ankle and/or ft L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

29550 Strapping of toes L023A Physical Therapy Aide NF Greet patient and provide gowning 3 0 Typically bi

or other eval

31627 Navigational bronchoscopy 

EF027 table, instrument, 

mobile 

NF 45 30 Standard equ

for moderate 

EQ011 ECG, 3-channel 

(with SpO2, NIBP, temp, resp) 

NF 45 30 Standard equ

for moderate 
CMS-1612-FC 404

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

EQ032 IV infusion 

pump 

NF 45 30 Standard equ

for moderate 

L047C RN/Respiratory 

Therapist 

NF Prepare and 

position pt/ monitor pt/ set up IV 

2 0 Add-on code

time requireposition pati

33418 Repair tcat mitral valve 

L037D RN/LPN/MTA F Discharge day 

management 99238 --12 minutes 

12 0 Aligned clin

discharge datime with thdischarge da

L037D RN/LPN/MTA F Discharge day 

management 99239 -- 15 minutes 

0 15 Aligned clin

discharge datime with thdischarge da

33965 Ecmo/ecls rmvl perph cannula L051A RN F Schedule space and equipment in facility 0 5 Standard inp

with 90 day 

33966 Ecmo/ecls rmvl prph cannula L051A RN F Schedule space and equipment in facility 0 5 Standard inp

with 90 day 

36475 Endovenous rf 1st vein EF019 stretcher chair NF 30 31 Refined equ

conform to c

36476 Endovenous rf vein add-on 

EL015 room, 

ultrasound, general 

NF 32 30 Refined equ

conform to clabor time. 

EQ215 radiofrequency 

generator (vascular) 

NF 32 30 Refined equ

conform to clabor time. 

L054A Vascular 

Technologist 

NF Review 

examination with interpreting MD 

1 0 Add-on code

time requiretasks associaimaging 
CMS-1612-FC 405

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF Technologist QCs 

images US machine, checking for all images, reformats, and dose page 

1 0 Add-on code

time requiretasks associaimaging 

36478 Endovenous laser 1st vein EF019 stretcher chair NF 30 31 Refined equ

conform to time. 

36479 Endovenous laser vein addon 

EL015 room, 

ultrasound, general 

NF 32 30 Refined equ

conform to clabor time. 

EQ160 laser, 

endovascular ablation (ELVS) 

NF 32 30 Refined equ

conform to clabor time. 

L054A Vascular 

Technologist 

NF Review 

examination with interpreting MD 

1 0 Add-on code

time requiretasks associaimaging 

L054A Vascular 

Technologist 

NF Technologist QCs 

images US machine, checking for all images, reformats, and dose page 

1 0 Add-on code

time requiretasks associaimaging 

47383 Perq abltj lvr cryoablation 

EF018 stretcher NF 240 166 Standard equ

for moderate 

EF027 table, instrument, 

mobile 

NF 104 166 Standard equ

for moderate 

EQ011 ECG, 3-channel 

(with SpO2, NIBP, temp, resp) 

NF 164 166 Standard equ

for moderate 

EQ032 IV infusion NF 164 166 Standard equ
CMS-1612-FC 406

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

pump for moderate 

EQ168 light, exam NF 164 106 Refined equ

conform to epolicies for ntechnical equ

52442 Cystourethro w/addl implant 

EF027 table, instrument, 

mobile 

NF 0 25 No equipme

included; alitime with astime. 

EF031 table, power NF 0 25 No equipme

included; alitime with astime. 

EQ170 light, fiberoptic 

headlight wsource 

NF 0 25 No equipme

included; alitime with astime. 

ES018 fiberscope, 

flexible, cystoscopy 

NF 0 25 No equipme

included; alitime with astime. 

ES031 video system, 

endoscopy (processor, digital capture, monitor, printer, cart) 

NF 0 25 No equipme

included; alitime with astime. 

62284 Injection for myelogram 

EF018 stretcher NF 60 48 Refined equ

conform to epolicies for ntechnical equ
CMS-1612-FC 407

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

62302 

Myelography 

lumbar 

injection 

L037D RN/LPN/MTA NF Assist physician 

in performing procedure 

26 13 All clinical l

were assgineReassigned iL041B. 

L041B Radiologic 

Technologist 

NF Assist physician 

in performing procedure 

0 13 All clinical l

were assgineReassigned iL041B. 

62303 

Myelography 

lumbar 

injection 

EF018 stretcher NF 60 64 Refined equ

conform to epolicies for ntechnical equ

L037D RN/LPN/MTA NF Assist physician 

in performing procedure 

25 13 All clinical l

were assgineReassigned iL041B. 

L041B Radiologic 

Technologist 

NF Assist physician 

in performing procedure 

0 12 All clinical l

were assgineReassigned iL041B. 

62304 

Myelography 

lumbar 

injection 

EF018 stretcher NF 60 59 Refined equ

conform to epolicies for ntechnical equ

L037D RN/LPN/MTA NF Assist physician 

in performing procedure 

25 13 All clinical l

were assgineReassigned iL041B. 

L041B Radiologic 

Technologist 

NF Assist physician 

in performing procedure 

0 12 All clinical l

were assgineReassigned iL041B. 

62305 

Myelography 

lumbar 

injection 

EF018 stretcher NF 60 64 Refined equ

conform to epolicies for n
CMS-1612-FC 408

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

technical equ

L037D RN/LPN/MTA NF Assist physician 

in performing procedure 

30 15 All clinical l

were assgineReassigned iL041B. 

L041B Radiologic 

Technologist 

NF Assist physician 

in performing procedure 

0 15 All clinical l

were assgineReassigned iL041B. 

64561 Implant neuroelectrodes 

EQ202 percutaneous 

neuro test stimulator 

NF 0 65 Neuro test st

required to cPercutaneouneurostimula

SB012 drape, sterile, for 

Mayo stand 

NF 1 0 Duplicative; 

percutaneoustimulation k

SG074 steri-strip (6 strip 

uou) 

NF 1 0 Duplicative; 

percutaneoustimulation k

SJ043 povidone 

swabsticks (3 pack uou) 

NF 1 0 Duplicative; 

percutaneoustimulation k

70486 Ct maxillofacial w/o dye 

L041B Radiologic 

Technologist 

NF Patient clinical 

information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by radiologist 

3 2 Standard tim

labor tasks adigital imagi
CMS-1612-FC 409

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

70487 Ct maxillofacial w/dye 

L041B Radiologic 

Technologist 

NF Patient clinical 

information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by radiologist 

3 2 Standard tim

labor tasks adigital imagi

L046A CT Technologist NF SVC Provide preservice 

education/obtain consent 

3 2 CT Angiogr

2 minutes fomaintain confamily 

70488 Ct maxillofacial w/o & w/dye 

L041B Radiologic 

Technologist 

NF Patient clinical 

information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by radiologist 

3 2 Standard tim

labor tasks adigital imagi

L046A CT Technologist NF SVC Provide preservice 

education/obtain consent 

3 2 CT Angiogr

2 minutes fomaintain confamily 

74174 

Ct angio 

abd&pelv 

w/o&w/dye 

L046A CT Technologist NF Availability of 

prior images confirmed 

3 2 Standard tim

labor tasks adigital imagi

76641 Ultrasound breast complete 

EL015 room, 

ultrasound, general 

NF 30 27 Refined equ

conform to epolicies for hequipment. 
CMS-1612-FC 410

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

76642 Ultrasound breast limited 

EL015 room, 

ultrasound, general 

NF 28 20 Refined equ

conform to epolicies for hequipment. 

L046A CT Technologist NF Acquire images 15 10 Limited stud

to complete study; used rabdomen coto adjust 15 

76942 Echo guide for biopsy L051B RN/Diagnostic Medical Sonographer NF Availability of prior images confirmed 3 2 Standard tim

labor tasks adigital imagi

77061 

Breast 

tomosynthesis 

uni 

L043A Mammography 

Technologist 

NF Availability of 

prior images confirmed 

3 2 Standard tim

labor tasks adigital imagi

77062 

Breast 

tomosynthesis 

bi 

L043A Mammography 

Technologist 

NF Availability of 

prior images confirmed 

3 2 Standard tim

labor tasks adigital imagi

77063 

Breast 

tomosynthesis 

bi 

L043A Mammography 

Technologist 

NF Federally 

Mandated MQSA Activities Allocated To Each Mammogram 

4 0 Add-on code

time require

77085 Dxa bone density study 

ER019 densitometry 

unit, fan beam, DXA (wcomputer hardward & software) 

NF 38 34 Refined equ

conform to clabor time. 

L041B Radiologic 

Technologist 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

6 2 Standard tim

labor tasks adigital imagi
CMS-1612-FC 411

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

77086 

Fracture 

assessment via 

dxa 

ER019 densitometry 

unit, fan beam, DXA (wcomputer hardward & software) 

NF 21 19 Refined equ

conform to clabor time. 

L041B Radiologic 

Technologist 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

4 2 Standard tim

labor tasks adigital imagi

77300 

Radiation 

therapy dose 

plan 

ED011 computer 

system, record and verify 

NF 5 0 Item was no

included for rationale for provided. Sefurther discu

77306 Telethx isodose plan simple 

ED011 computer 

system, record and verify 

NF 5 0 Item was no

included for rationale for provided. Sefurther discu

77307 Telethx isodose plan cplx 

ED011 computer 

system, record and verify 

NF 5 0 Item was no

included for rationale for provided. Sefurther discu

88341 Immunohisto antibody slide 

EP024 microscope, 

compound 

NF 21 13 Decreased p

88341 to 60% adjustment wequipment u

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se
CMS-1612-FC 412

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SA117 Universal 

Detection Kit 

NF 0 2 Maintain con

type of univwith remainiwithin this f

SL488 UltraView 

Universal DAB Detection Kit 

NF 2 0 Maintain con

type of univwith remainiwithin this f

88342 Immunohisto antibody stain 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

SA117 Universal 

Detection Kit 

NF 0 2 Maintain con

type of univwith remainiwithin this f

SL488 UltraView 

Universal DAB Detection Kit 

NF 2 0 Maintain con

type of univwith remainiwithin this f

88344 Immunohisto antibody slide 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

EP112 Benchmark 

ULTRA automated slide preparation system 

NF 33 30 Multiplex se

typical; sincrequires 15 mrequires no mminutes 

SA117 Universal 

Detection Kit 

NF 0 4 Maintain con

type of univwith remainiwithin this f
CMS-1612-FC 413

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SL488 UltraView 

Universal DAB Detection Kit 

NF 2 0 Maintain con

type of univwith remainiwithin this f

SL489 UtraView 

Universal Alkaline Phosphatase Red Detection Kit 

NF 2 0 Maintain con

type of univwith remainiwithin this f

88364 

Insitu 

hybridization 

(fish) 

EP024 microscope, 

compound 

NF 37 22 Decreased p

88341 to 60% adjustment wequipment u

EP045 chamber, 

hybridization 

NF 240 0 Add-on code

includes the chamber, whconcurrently 

EP054 water bath, FISH 

procedures (lab) 

NF 13 0 Add on code

used concurrcode and add

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

L037B Histotechnologis

t 

NF Clean 

room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 

0.5 0 Add-on code

clinical laboservice task preamble. 

SB023 gloves, nonsterile, nitrile NF 0.25 0 Add-on code

changed betw
CMS-1612-FC 414

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

and add-on c

SL189 ethanol, 100% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 Maintain con

of the kit betand add-on cpreamble. 

SL248 ethanol, 95% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value

88365 

Insitu 

hybridization 

(fish) 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

EP116 VP-2000 

Processor 

NF 30 0 We are unab

new equipmincreased tecpreamble. 

SL189 ethanol, 100% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 No rationale 

quantity chacurrent valuecurrent value

SL248 ethanol, 95% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value
CMS-1612-FC 415

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SL497 (EBER) DNA 

Probe Cocktail 

NF 1.6 2 Stain needs t

positive conspecimen sli

88366 

Insitu 

hybridization 

(fish) 

EP088 ThermoBrite NF 2.5 0 This input is 

within any ofamily. Mainconsistency codes within 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

EP116 VP-2000 

Processor 

NF 30 0 We are unab

new equipmincreased tecpreamble. 

L037B Histotechnologis

t 

NF Examine signals 

in each cell and generate data for the pathologist to interpret 

20 15 Refined clin

this multiplereflect efficiexamining twsingle slide. 

SL189 ethanol, 100% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 Maintain con

of the kit betand add-on cpreamble. 

SL248 ethanol, 95% NF 62.5 37.5 No rationale 

quantity chacurrent valuecurrent value

88367 Insitu hybridization EP110 Freezer NF 1 0 Indirect Prac

individually 
CMS-1612-FC 416

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

auto particular pa

particular se

SL189 ethanol, 100% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 1.4 0.75 No rationale 

quantity chapreamble. 

SL248 ethanol, 95% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value

88368 

Insitu 

hybridization 

manual 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

EP116 VP-2000 

Processor 

NF 30 0 We are unab

new equipmincreased tecpreamble. 

SL508 positive control 

slide (proxy for Kappa Positive Control Slide) 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL509 positive control 

slide (proxy for Kappa Negative Control Slide) 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL189 ethanol, 100% NF 37.5 18.75 No rationale 

quantity chacurrent valuecurrent value
CMS-1612-FC 417

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SL190 ethanol, 70% NF 12.5 6.25 No rationale 

quantity chacurrent valuecurrent value

SL191 ethanol, 85% NF 12.5 6.25 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 No rationale 

quantity chapreamble. 

SL248 ethanol, 95% NF 37.5 18.75 No rationale 

quantity chacurrent valuecurrent value

SL498 Kappa Probe 

Cocktail 

NF 40 28 Maintain con

of probe cocfamily of co

88369 

M/phmtrc 

alysishquant/se

miq 

EP024 microscope, 

compound 

NF 42 25 Refined equ

this multiplereflect efficiwhen examia single slide

EP045 chamber, 

hybridization 

NF 240 0 Add-on code

includes the chamber, whconcurrently 

EP054 water bath, FISH 

procedures (lab) 

NF 13 0 Add on code

used concurrcode and add

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se
CMS-1612-FC 418

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L037B Histotechnologis

t 

NF Clean 

room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 

0.5 0 Add-on code

clinical laboservice task preamble. 

SB023 gloves, nonsterile, nitrile NF 0.25 0 Not necessar

gloves betwethe same pro

SL510 positive control 

slide (proxy for Lambda Positive Control Slide) 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL511 positive control 

slide (proxy for Lambda Negative Control Slide) 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL189 ethanol, 100% NF 37.5 18.75 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 Maintain con

of the kit betand add-on cpreamble. 

SL248 ethanol, 95% NF 37.5 18.75 No rationale 

quantity chacurrent valuecurrent value
CMS-1612-FC 419

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SL499 Lambda Probe 

Cocktail 

NF 40 28 Maintain con

of probe cocfamily of co

88373 M/phmtrc alys ishquant/semiq 

EP024 microscope, 

compound 

NF 42 25 Refined equ

this multiplereflect efficiwhen examia single slide

EP045 chamber, 

hybridization 

NF 120 0 Add-on code

includes the chamber, whconcurrently 

EP054 water bath, FISH 

procedures (lab) 

NF 7 0 Add on code

used concurrcode and add

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

SB023 gloves, nonsterile, nitrile NF 0.125 0 Not necessar

gloves betwethe same pro

SL189 ethanol, 100% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 1.4 0.75 Maintain con

of the kit betand add-on cpreamble. 

SL248 ethanol, 95% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value
CMS-1612-FC 420

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

88374 M/phmtrc alys ishquant/semiq 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

SL030 cover slip, glass NF 2.8 1.4 Quantity of 

this multiplenot differ froprocedure (ostains per sli

SL189 ethanol, 100% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 1.4 0.75 Maintain con

of the kit betand add-on cpreamble. 

SL196 kit, HER-2/neu 

DNA Probe 

NF 2.4 1 A single kit 

procedure wsingle specimstain. 

SL248 ethanol, 95% NF 31.25 18.75 No rationale 

quantity chacurrent valuecurrent value

88377 M/phmtrc alys ishquant/semiq 

EP110 Freezer NF 1 0 Indirect Prac

individually particular paparticular se

EP116 VP-2000 

Processor 

NF 30 0 We are unab

new equipmincreased tecpreamble. 
CMS-1612-FC 421

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L037B Histotechnologis

t 

NF Signal 

Enumeration: Count signals in malignant cells and generate data for pathologist to interpret 

24 18 Refined clin

this multiplereflect efficiexamining twsingle slide. 

SL184 slide, negative 

control, Her-2 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL185 slide, positive 

control, Her-2 

NF 0.5 0.2 Maintain con

of control slof codes. Se

SL189 ethanol, 100% NF 37.5 18.75 No rationale 

quantity chacurrent valuecurrent value

SL190 ethanol, 70% NF 12.5 6.25 No rationale 

quantity chacurrent valuecurrent value

SL191 ethanol, 85% NF 12.5 6.25 No rationale 

quantity chacurrent valuecurrent value

SL195 kit, FISH 

paraffin pretreatment 

NF 2 1 Maintain con

of the kit betand add-on cpreamble. 

SL196 kit, HER-2/neu 

DNA Probe 

NF 3 1 A single kit 

procedure wsingle specimstain. 

SL248 ethanol, 95% NF 37.5 18.75 No rationale 

quantity cha
CMS-1612-FC 422

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

current valuecurrent value

88380 Microdissection laser 

EP087 instrument, 

microdissection (Veritas) 

NF 34 32 Since physic

task, equipmcalculated by physician intime to set utime to clean 

L045A Cytotechnologist NF Dispose of razor 

blade, Cap tube and vortex specimens. Visually inspect tube to make sure microdissected material are at the bottom of tube. 

3 0 Included in c

"clean roomsupplies" 

L045A Cytotechnologist NF Turn on dissecting 

microscope, place slide on scope, remove razor blade from box. Microdissect tissue within etched area, while viewing slide under dissecting scope, place tissue into cap of collection tube with blade. Repeat 

18 0 Work vignet

the microdisperformed b

88381 Microdissection manual SL085 label for microscope NF 4 9 9 slides is ty

required 
CMS-1612-FC 423

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

slides 

93312 Echo transesophageal 

ED021 computer, 

desktop, wmonitor 

NF 91 0 Duplicative; 

vascular ultr(EL016) 

ED034 video SVHS 

VCR (medical grade) 

NF 43 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 57 0 Duplicative; 

vascular ultr(EL016) 

EF027 table, instrument, 

mobile 

NF 105 92 Standard equ

for moderate 

EL016 room, 

ultrasound, vascular 

NF 57 43 Refined equ

conform to epolicies for hequipment. 

EQ011 ECG, 3-channel 

(with SpO2, NIBP, temp, resp) 

NF 105 92 Standard equ

for moderate 

EQ032 IV infusion 

pump 

NF 0 92 Standard equ

for moderate 

L037D RN/LPN/MTA NF Exam documents 

scanned into PACS. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue 

3 1 Standard tim

labor tasks adigital imagi
CMS-1612-FC 424

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L050A Cardiac 

Sonographer 

NF Clean scope 0 10 Time for cle

moved from surgical instto “clean scounchanged 

L050A Cardiac 

Sonographer 

NF Clean surgical 

instrument package 

10 0 Time for cle

moved from surgical instto “clean scounchanged 

L050A Cardiac 

Sonographer 

NF Process data: 

measure, record, preliminary findings 

8 0 Standard tim

labor tasks adigital imagi

L050A Cardiac 

Sonographer 

NF Review images 

with MD 

0 2 Standard tim

labor tasks adigital imagi

L050A Cardiac 

Sonographer 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

5 2 Standard tim

labor tasks adigital imagi

SB026 gown, patient NF 1 0 Duplicative; 

included in pmulti-specia

SB036 paper, exam 

table 

NF 7 0 Duplicative; 

included in pmulti-specia

SB037 pillow case NF 1 0 Duplicative; 

included in pmulti-specia

93314 Echo transesophageal ED021 computer, desktop, w- monitor NF 61 0 Duplicative; 

vascular ultr(EL016) 
CMS-1612-FC 425

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

ED034 video SVHS 

VCR (medical grade) 

NF 53 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 67 0 Duplicative; 

vascular ultr(EL016) 

EF027 table, instrument, 

mobile 

NF 115 92 Standard equ

for moderate 

EL016 room, 

ultrasound, vascular 

NF 67 43 Refined equ

conform to clabor time; S

EQ011 ECG, 3-channel 

(with SpO2, NIBP, temp, resp) 

NF 115 92 Standard equ

for moderate 

EQ032 IV infusion 

pump 

NF 0 92 Standard equ

for moderate 

L037D RN/LPN/MTA NF Exam documents 

scanned into PACS. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue 

3 1 Standard tim

labor tasks adigital imagi

L050A Cardiac 

Sonographer 

NF Assist physician 

in performing procedure (acquire ultrasound data) 

40 30 CPT code 93

involved sercode 93312, would not be preamble. 
CMS-1612-FC 426

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L050A Cardiac 

Sonographer 

NF Clean scope 0 10 Time for cle

moved from surgical instto “clean scounchanged 

L050A Cardiac 

Sonographer 

NF Clean surgical 

instrument package 

10 0 Time for cle

moved from surgical instto “clean scounchanged 

L050A Cardiac 

Sonographer 

NF Process data: 

measure, record, preliminary findings 

8 0 Standard tim

labor tasks adigital imagi

L050A Cardiac 

Sonographer 

NF Review images 

with MD 

0 2 Standard tim

labor tasks adigital imagi

L050A Cardiac 

Sonographer 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

5 2 Standard tim

labor tasks adigital imagi

L051A RN NF Assist 

physician/moderate sedation (% of physician time) 

40 30 CPT code 93

involved sercode 93312, would not be preamble. 

SB026 gown, patient NF 1 0 Duplicative; 

included in pmulti-specia

SB036 paper, exam 

table 

NF 7 0 Duplicative; 

included in pmulti-specia
CMS-1612-FC 427

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

SB037 pillow case NF 1 0 Duplicative; 

included in pmulti-specia

93320 Doppler echo exam heart ED021 computer, desktop, w- monitor NF 5 0 Duplicative; 

vascular ultr(EL016) 

93321 Doppler echo exam heart ED021 computer, desktop, w- monitor NF 2 0 Duplicative; 

vascular ultr(EL016) 

93325 Doppler color flow add-on ED021 computer, desktop, w- monitor NF 2 0 Duplicative; 

vascular ultr(EL016) 

93702 Bis xtracell fluid analysis 

L037D RN/LPN/MTA NF Results are 

uploaded from the device into the analysis software and a report is generated and printed for physician review. 

2 0 Included as 

process for t

93880 Extracranial bilat study 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s
CMS-1612-FC 428

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF Technologist 

reviews & optimizes all duplex images; reviews & optimizes spectrum analysis measuring velocities & assuring proper angle acquisition. Compiles findings with sufficient data for physician review & diagnosis. 

8 2 Standard tim

labor tasks adigital imagi

93882 Extracranial uni/ltd study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

L054A Vascular 

Technologist 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

5 2 Standard tim

labor tasks adigital imagi

93886 Intracranial complete study ED021 computer, desktop, w- monitor NF 7 0 Duplicative; 

vascular ultr(EL016) 
CMS-1612-FC 429

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

L054A Vascular 

Technologist 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

8 2 Standard tim

labor tasks adigital imagi

93888 Intracranial limited study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

L054A Vascular 

Technologist 

NF Technologist QCs 

images in PACS, checking all images, reformats, and dose page 

4 2 Standard tim

labor tasks adigital imagi

93925 Lower extremity study 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 
CMS-1612-FC 430

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

L054A Vascular 

Technologist 

NF Technologist 

reviews & optimizes all duplex images; reviews & optimizes spectrum analysis measuring velocities & assuring proper angle acquisition. Compiles findings with sufficient data for physician review & diagnosis. 

8 2 Standard tim

labor tasks adigital imagi

93926 Lower extremity study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s
CMS-1612-FC 431

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF Technologist 

reviews & optimizes all duplex images; reviews & optimizes spectrum analysis measuring velocities & assuring proper angle acquisition. Compiles findings with sufficient data for physician review & diagnosis. 

5 2 Standard tim

labor tasks adigital imagi

93930 Upper extremity study 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

93931 Upper extremity study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s
CMS-1612-FC 432

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

93970 Extremity study 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

93971 Extremity study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

93975 Vascular study 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s
CMS-1612-FC 433

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF Technologist 

reviews & optimizes all duplex images; reviews & optimizes spectrum analysis measuring velocities & assuring proper angle acquisition. Compiles findings with sufficient data for physician review & diagnosis. 

8 2 Standard tim

labor tasks adigital imagi

93976 Vascular study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s
CMS-1612-FC 434

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF Technologist 

reviews & optimizes all duplex images; reviews & optimizes spectrum analysis measuring velocities & assuring proper angle acquisition. Compiles findings with sufficient data for physician review & diagnosis. 

5 2 Standard tim

labor tasks adigital imagi

93978 Vascular study 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED021 computer, 

desktop, wmonitor 

NF 7 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

93979 Vascular study 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 10 0 Duplicative; 

vascular ultr(EL016) 
CMS-1612-FC 435

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

93990 Doppler flow testing 

ED021 computer, 

desktop, wmonitor 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

ED036 video printer, 

color (Sony medical grade) 

NF 4 0 Duplicative; 

vascular ultr(EL016) 

L054A Vascular 

Technologist 

NF QA 

Documentation 

4 0 Included in o

labor time; s

95971 

Analyze 

neurostim 

simple 

EF023 table, exam NF 27 33 Include 100% 

time for equclinical labo66% of phys

EQ209 programmer, 

neurostimulator (w-printer) 

NF 27 33 Include 100% 

time for equclinical labo66% of phys

95972 

Analyze 

neurostim 

complex 

EF023 table, exam NF 30 36 Include 100% 

time for equclinical labo66% of phys

EQ209 programmer, 

neurostimulator (w-printer) 

NF 30 36 Include 100% 

time for equclinical laboassist physic

96127 

Brief 

emotional/beha

v assmt 

L026A Medical/Technic

al Assistant 

NF Scoring 

completed behavior assessment tool 

15 7 Instructions 

typically takscoring the tstandardized procedure. 

97605 Neg press wound tx </=50 EF014 light, surgical NF 28 25 Refined equ

conform to c
CMS-1612-FC 436

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

cm labor time. 

EF031 table, power NF 28 25 Refined equ

conform to clabor time. 

L037D RN/LPN/MTA NF Check dressings 

& wound/ home care instructions /coordinate office visits /prescriptions 

5 2 Intraservice 

also includechecking 

97606 

Neg press 

wound tx >50 

cm 

EF014 light, surgical NF 38 35 Refined equ

conform to clabor time. 

EF031 table, power NF 38 35 Refined equ

conform to clabor time. 

L037D RN/LPN/MTA NF Check dressings 

& wound/ home care instructions /coordinate office visits /prescriptions 

5 2 Intraservice 

also includechecking 

EF031 table, power NF 38 35 Refined equ

conform to clabor time. 

L037D RN/LPN/MTA NF Check dressings 

& wound/ home care instructions /coordinate office visits /prescriptions 

5 2 Intraservice 

also includechecking 
CMS-1612-FC 437

HCPCS 

Code

HCPCS Code 

Description

Input 

Code

Input Code 

Description NF/F/ PO Labor Activity (where applicable)

RUC 

Recommendation or 

current value 

(min or qty)

CMS 

Refinement 

(min or 

qty)

C

99490 

Chron care 

mgmt srvc 20 

min 

Chron care 

mgmt srvc 20 

min 

L051A RN NF Care management 

activities performed by clinical staff 

60 0 20 minutes R

time reflects service; see 

L037D RN/LPN/MTA NF Care management 

activities performed by clinical staff 

0 20 20 minutes R

time reflects service; see 
CMS-1612-FC 438

iii. Procedures Subject to the Cap on Imaging Codes Defined by Section 5102(b) of the DRA 

We are proposing to add the new codes to the list of procedures subject to the DRA cap, 

effective January 1, 2015. The codes are: (76641 (Ultrasound breast complete), 76642 

(Ultrasound breast limited), 77085 (Dxa bone density study), 77086 (Fracture assessment via 

dxa), 77387 (Guidance for radiaj tx dlvr), G6001 (Stereoscopic x-ray guidance), and G6002 

(Echo guidance radiotherapy). These codes, which are new for CY 2015, replace codes deleted 

for CY 2015 that were subject to the cap, and meet the definition of imaging under section 

5102(b) of the DRA. These codes are being added on an interim final basis and are open to 

public comment in this final rule with comment period. 

d. Establishing CY 2015 Interim Final Malpractice RVUs 

According to our malpractice methodology discussed in section II.C, we are assigning 

malpractice RVUs for CY 2015 new, revised, and potentially misvalued codes by utilizing a 

crosswalk to a source code with a similar malpractice risk. We have reviewed the RUC 

recommended malpractice source code crosswalks for CY 2015 new, revised, and potentially 

misvalued codes, and we are accepting all of them on an interim final basis for CY 2015. For Gcodes that we are creating, we are also assigning source code crosswalks to similar codes. 

 Table 32 lists the CY 2015 HCPCS codes and their respective source codes used to set 

the interim final CY 2015 MP RVUs. The MP RVUs for these services are reflected in 

Addendum B of this CY 2015 PFS final rule with comment period. 

TABLE 32: Crosswalk for Establishing CY 2015 New/Revised/Potentially Misvalued 

Codes Malpractice RVUs 

CY 2015 New, Revised or Misvalued Code Malpractice Risk Factor Crosswalk Code 

20604 Drain/inj joint/bursa w/us 20600 Drain/inject joint/bursa 

20606 Drain/inj joint/bursa w/us 20605 Drain/inject joint/bursa 

20611 Drain/inj joint/bursa w/us 20610 Drain/inject joint/bursa 

20983 Ablate bone tumor(s) perq 20982 Ablate bone tumor(s) perq 

21811 Optx of rib fx w/fixj scope 21805 Treatment of rib fracture 
CMS-1612-FC 439

CY 2015 New, Revised or Misvalued Code Malpractice Risk Factor Crosswalk Code 

21812 Treatment of rib fracture 21805 Treatment of rib fracture 

21813 Treatment of rib fracture 21805 Treatment of rib fracture 

22510 Perq cervicothoracic inject 22520 Percut vertebroplasty thor 

22511 Perq lumbosacral injection 22521 Percut vertebroplasty lumb 

22512 Vertebroplasty addl inject 22522 Percut vertebroplasty addl 

22513 Perq vertebral augmentation 22523 Percut kyphoplasty thor 

22514 Perq vertebral augmentation 22524 Percut kyphoplasty lumbar 

22515 Perq vertebral augmentation 22525 Percut kyphoplasty add-on 

22858 Second level cer diskectomy 22856 Cerv artific diskectomy 

27279 Arthrodesis sacroiliac joint 62287 Percutaneous diskectomy 

33270 Ins/rep subq defibrillator 33249 Nsert pace-defib w/lead 

33271 Insj subq impltbl dfb elctrd 33216 Insert 1 electrode pm-defib 

33272 Rmvl of subq defibrillator 33244 Remove eltrd transven 

33273 Repos prev impltbl subq dfb 33215 Reposition pacing-defib lead 

33418 Repair tcat mitral valve 92987 Revision of mitral valve 

33419 Repair tcat mitral valve 92987 Revision of mitral valve 

33946 Ecmo/ecls initiation venous 33960 External circulation assist 

33947 Ecmo/ecls initiation artery 33960 External circulation assist 

33948 Ecmo/ecls daily mgmt-venous 33961 External circulation assist 

33949 Ecmo/ecls daily mgmt artery 33961 External circulation assist 

33951 Ecmo/ecls insj prph cannula 36822 Insertion of cannula(s) 

33952 Ecmo/ecls insj prph cannula 36822 Insertion of cannula(s) 

33953 Ecmo/ecls insj prph cannula 36822 Insertion of cannula(s) 

33954 Ecmo/ecls insj prph cannula 36822 Insertion of cannula(s) 

33955 Ecmo/ecls insj ctr cannula 33981 Replace vad pump ext 

33956 Ecmo/ecls insj ctr cannula 33981 Replace vad pump ext 

33957 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33958 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33959 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33962 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33963 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33964 Ecmo/ecls repos perph cnula 33981 Replace vad pump ext 

33965 Ecmo/ecls rmvl perph cannula 33981 Replace vad pump ext 

33966 Ecmo/ecls rmvl prph cannula 33981 Replace vad pump ext 

33969 Ecmo/ecls rmvl perph cannula 33971 Aortic circulation assist 

33984 Ecmo/ecls rmvl prph cannula 33971 Aortic circulation assist 

33985 Ecmo/ecls rmvl ctr cannula 33977 Remove ventricular device 

33986 Ecmo/ecls rmvl ctr cannula 33977 Remove ventricular device 

33987 Artery expos/graft artery 33530 Coronary artery bypass/reop 

33988 Insertion of left heart vent 33530 Coronary artery bypass/reop 

33989 Removal of left heart vent 33257 Ablate atria lmtd add-on 

37218 Stent placemt ante carotid 37217 Stent placemt retro carotid 

43180 Esophagoscopy rigid trnso 43130 Removal of esophagus pouch 

44381 Small bowel endoscopy br/wa 45340 Sig w/balloon dilation 

44384 Small bowel endoscopy 44383 Ileoscopy w/stent 

45346 Sigmoidoscopy w/ablation 45339 Sigmoidoscopy w/ablate tumr 

45347 Sigmoidoscopy w/plcmt stent 45345 Sigmoidoscopy w/stent 

45349 Sigmoidoscopy w/resection 43236 Uppr gi scope w/submuc inj 
CMS-1612-FC 440

CY 2015 New, Revised or Misvalued Code Malpractice Risk Factor Crosswalk Code 

45350 Sgmdsc w/band ligation 45332 Sigmoidoscopy w/fb removal 

45388 Colonoscopy w/ablation 45383 Lesion removal colonoscopy 

45389 Colonoscopy w/stent plcmt 45387 Colonoscopy w/stent 

45390 Colonoscopy w/resection 45385 Lesion removal colonoscopy 

45393 Colonoscopy w/decompression 45379 Colonoscopy w/fb removal 

45398 Colonoscopy w/band ligation 45379 Colonoscopy w/fb removal 

47383 Perq abltj lvr cryoablation 47382 Percut ablate liver rf 

52441 Cystourethro w/implant 52282 Cystoscopy implant stent 

52442 Cystourethro w/addl implant 52282 Cystoscopy implant stent 

62302 Myelography lumbar injection 62284 Injection for myelogram 

62303 Myelography lumbar injection 62284 Injection for myelogram 

62304 Myelography lumbar injection 62284 Injection for myelogram 

62305 Myelography lumbar injection 62284 Injection for myelogram 

64486 Tap block unil by injection 64447 N block inj fem single 

64487 Tap block uni by infusion 64448 N block inj fem cont inf 

64488 Tap block bi injection 64447 N block inj fem single 

64489 Tap block bi by infusion 64448 N block inj fem cont inf 

66179 Aqueous shunt eye w/o graft 66180 Implant eye shunt 

66184 Revision of aqueous shunt 66185 Revise eye shunt 

76641 Ultrasound breast complete 76645 Us exam breast(s) 

76642 Ultrasound breast limited 76645 Us exam breast(s) 

77063 Breast tomosynthesis bi 77057 Mammogram screening 

77085 Dxa bone density study 77080 Dxa bone density axial 

77086 Fracture assessment via dxa 77082 Dxa bone density vert fx 

77306 Telethx isodose plan simple 77305 Teletx isodose plan simple 

77307 Telethx isodose plan cplx 77315 Teletx isodose plan complex 

77316 Brachytx isodose plan simple 77326 Brachytx isodose calc simp 

77317 Brachytx isodose intermed 77327 Brachytx isodose calc interm 

77318 Brachytx isodose complex 77328 Brachytx isodose plan compl 

88341 Immunohisto antibody slide 88342 Immunohisto antibody slide 

88344 Immunohisto antibody slide 88342 Immunohisto antibody slide 

88364 Insitu hybridization (fish) 88365 Insitu hybridization (fish) 

88366 Insitu hybridization (fish) 88365 Insitu hybridization (fish) 

88369 M/phmtrc alysishquant/semiq 88368 Insitu hybridization manual 

88373 M/phmtrc alys ishquant/semiq 88367 Insitu hybridization auto 

88374 M/phmtrc alys ishquant/semiq 88367 Insitu hybridization auto 

88377 M/phmtrc alys ishquant/semiq 88368 Insitu hybridization manual 

91200 Liver elastography 91132 Electrogastrography 

92145 Corneal hysteresis deter 76514 Echo exam of eye thickness 

93260 Prgrmg dev eval impltbl sys 93282 Icd device progr eval 1 sngl 

93261 Interrogate subq defib 93289 Icd device interrogate 

93355 Echo transesophageal (tee) 93312 Echo transesophageal 

93644 Electrophysiology evaluation 93642 Electrophysiology evaluation 

93702 Bis xtracell fluid analysis 93701 Bioimpedance cv analysis 

93895 Carotid intima atheroma eval 93882 Extracranial uni/ltd study 

96127 Brief emotional/behav assmt 96110 Developmental screen 

99184 Hypothermia ill neonate 99291 Critical care first hour 

99490 Chron care mgmt srvc 20 min 99212 Office/outpatient visit est 
CMS-1612-FC 441

CY 2015 New, Revised or Misvalued Code Malpractice Risk Factor Crosswalk Code 

G0277 Hbot, full body chamber, 30m 99183 Hyperbaric oxygen therapy 

G0279 tomosynthesis, mamo scre 77055 Mammogram one breast 

G0473 Face-to-face behavioral counseling for 

obesity, group (2-10), 30 minutes G0477 Behavior counsel obesity 15m 
CMS-1612-FC 442

H. Chronic Care Management (CCM) 

As we discussed in the CY 2013 PFS final rule with comment period, we are committed 

to supporting primary care and we have increasingly recognized care management as one of the 

critical components of primary care that contributes to better health for individuals and reduced 

expenditure growth (77 FR 68978). Accordingly, we have prioritized the development and 

implementation of a series of initiatives designed to improve payment for, and encourage longterm investment in, care management services. These initiatives include the following programs 

and demonstrations: 

● The Medicare Shared Savings Program (described in ‘‘Medicare Program; Medicare 

Shared Savings Program: Accountable Care Organizations; Final Rule,’’ which appeared in the 

November 2, 2011 Federal Register (76 FR 67802)). 

● The testing of the Pioneer ACO model, designed for experienced health care 

organizations (described on the Centers for Medicare and Medicaid Innovation’s (Innovation 

Center’s) website at http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/index.html). 

● The testing of the Advance Payment ACO model, designed to support organizations 

participating in the Medicare Shared Savings Program (described on the Innovation Center’s 

website at http://innovation.cms.gov/initiatives/Advance-Payment-ACO-Model/). 

● The Primary Care Incentive Payment (PCIP) Program (described on the CMS website 

at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf). 

● The patient-centered medical home model in the Multi-payer Advanced Primary Care 

Practice (MAPCP) Demonstration designed to test whether the quality and coordination of health 

care services are improved by making advanced primary care practices more broadly available 
CMS-1612-FC 443

(described on the CMS website at www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf). 

● The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice 

demonstration (described on the CMS website at http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/Downloads/FQHC_APCP_Demo_FAQsOct2011.pdf and the 

Innovation Center’s website at www.innovations.cms.gov/initiatives/FQHCs/index.html). 

● The Comprehensive Primary Care (CPC) initiative (described on the Innovation 

Center’s website at http://innovations.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html). The CPC initiative is a multi-payer initiative fostering collaboration 

between public and private health care payers to strengthen primary care in certain markets 

across the country. 

In addition, HHS leads a broad initiative focused on optimizing health and quality of life 

for individuals with multiple chronic conditions. HHS’s Strategic Framework on Multiple 

Chronic Conditions outlines specific objectives and strategies for HHS and private sector 

partners centered on strengthening the health care and public health systems; empowering the 

individual to use self-care management with the assistance of a healthcare provider who can 

assess the patient’s health literacy level; equipping care providers with tools, information, and 

other interventions; and supporting targeted research about individuals with multiple chronic 

conditions and effective interventions. Further information on this initiative is available on the 

HHS website at http://www.hhs.gov/ash/initiatives/mcc/index.html. 

In coordination with all of these initiatives, we also have continued to explore potential 

refinements to the PFS that would appropriately value care management within Medicare’s 

statutory structure for fee-for-service physician payment and quality reporting. For example, in 
CMS-1612-FC 444

the CY 2013 PFS final rule with comment period, we adopted a policy to pay separately for care 

management involving the transition of a beneficiary from care furnished by a treating physician 

during a hospital stay to care furnished by the beneficiary’s primary physician in the community 

(77 FR 68978 through 68993). 

In the CY 2014 PFS final rule with comment period, we finalized a policy to pay 

separately for care management services furnished to Medicare beneficiaries with two or more 

chronic conditions beginning in CY 2015 (78 FR 74414). 

1. Valuation of CCM Services − GXXX1 

CCM is a unique PFS service designed to pay separately for non-face-to-face care 

coordination services furnished to Medicare beneficiaries with multiple chronic conditions. (See 

78 FR 74414 for a more thorough discussion of the beneficiaries for whom this service may be 

billed and the scope of service elements.) In the CY 2014 PFS final rule with comment period, 

we indicated that, to recognize the additional resources required to furnish CCM services to 

patients with multiple chronic conditions, we were creating the following code to use for 

reporting this service (78 FR 74422): 

● GXXX1 Chronic care management services furnished to patients with multiple (two or 

more) chronic conditions expected to last at least 12 months, or until the death of the patient, that 

place the patient at significant risk of death, acute exacerbation/decompensation, or functional 

decline; 20 minutes or more; per 30 days. 

Although this service is unique in that it was created to separately pay for care 

management services, other codes include care management components. To value CCM, we 

compared it to other codes that involve care management. In doing so, we concluded that the 

CCM services were similar in work (time and intensity) to that of the non-face-to-face portion of 
CMS-1612-FC 445

the lower level code for transitional care management (TCM) services (CPT code 99495 

(Transitional Care Management Services with the following required elements: Communication 

(direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of 

discharge Medical decision making of at least moderate complexity during the service period 

face-to-face visit, within 14 calendar days of discharge)). Accordingly, we based the proposed 

inputs on the non-face-to-face portion of CPT code 99495. 

Specifically, we proposed a work RVU for GXXX1 of 0.61, which is the portion of the 

work RVU for CPT code 99495 that remains after subtracting the work attributable to the faceto-face visit. (CPT code 99214 (Office/outpatient visit est) was used to value CPT code 99495, 

which has a work RVU of 1.50). Similarly, we proposed a work time of 15 minutes for HCPCS 

code GXXX1 for CY 2015 based on the time attributable to the non-face-to-face portion of CPT 

99495. 

For direct PE inputs, we proposed 20 minutes of clinical labor time. As established in the 

CY 2014 PFS final rule with comment period, in order to bill for this code, at least 20 minutes of 

CCM services must be furnished during the 30-day billing interval (78 FR 74422). Based upon 

input from stakeholders and the nature of care management services, we believed that many 

aspects of this service will be provided by clinical staff, and thus, clinical staff would be 

involved in the typical service for the full 20 minutes. CPT code 99495 has 45 minutes of nonface-to-face clinical labor time and we assumed the typical case for CCM would involve 20 

minutes based upon the code descriptor and a broad eligible population that would require 

limited monthly services. The proposed CY 2015 direct PE input database reflected the input of 

20 minutes of clinical labor time and is available on the CMS website under the supporting data 

files for the CY 2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-
CMS-1612-FC 446

Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The resulting 

proposed PE RVUs were 0.57 for CCM furnished in non-facility locations and 0.26 for CCM 

furnished in a facility. 

The proposed MP RVU of 0.04 was calculated using the weighted risk factors for the 

specialties that we believed would furnish this service. We believed the proposed malpractice 

risk factor would appropriately reflect the relative malpractice risk associated with furnishing 

CCM services. 

We received many public comments on our proposed valuation. In general, the 

commenters commended CMS for ongoing recognition of the value of non-face-to-face time 

expended by physicians and staff to improve outcomes for beneficiaries with chronic conditions, 

and the proposal to pay separately for the non-face-to-face services. However, the commenters 

generally believed the proposed valuation for CCM services underestimated the resources 

involved with complex beneficiaries, and recommended various alternatives for valuing the 

services. We summarize these comments in the following paragraphs. 

Comment: Several commenters noted that the CPT Editorial Panel created a new code 

for CY 2015 that is extremely similar to the G-code we developed to report these services. 

These commenters suggested that we use the new CPT code 99490 (Chronic care management 

services, at least 20 minutes of clinical staff time directed by a physician or other qualified health 

care professional, per calendar month, with the following required elements: 

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the 

death of the patient; 

• Chronic conditions place the patient at significant risk of death, acute 

exacerbation/decompensation, or functional decline; 
CMS-1612-FC 447

• Comprehensive care plan established, implemented, revised, or monitored). 

Many of these commenters expressed a preference for the “per calendar month” used in 

the CPT descriptor to the “per 30 days” used in the G-code. The commenters said a calendar 

month rather than 30 days would be less complex administratively. 

Response: It is our preference to use CPT codes unless Medicare has a programmatic 

need that is not met by the CPT coding structure. Accordingly, in the CY 2014 final rule with 

comment period we indicated that we would consider using a CPT code if one was created that 

reflected the service we were describing with the G-code. We believe that the new CPT code 

99490 appropriately describes CCM services for Medicare beneficiaries. 

We had used 30 days rather than a calendar month as the service period for the G-code so 

that the number of days in the service period would not vary based upon when CCM services 

were initiated for a given period. For example, if the services were initiated near the end of a 

calendar month, using the CPT code’s period of “per calendar month” would make it harder for 

the practitioner to meet the required minimum time for the month and be able to bill CMM for 

that month. 

However, after learning about the administrative difficulties that the 30-day period would 

create, we believe that the calendar month creates a reasonable period. Accordingly, we will 

adopt CPT code 99490 for Medicare CCM services, effective January 1, 2015 instead of the 

G code. 

Comment: Several commenters suggested alternative approaches to the use of codes that 

describe CCM services. For example, one commenter said that the code should be for one year, 

with average of 20 minutes per month across the year. Another commenter was concerned about 

how the 20 minutes of care per month per patient will be calculated, because some patients 
CMS-1612-FC 448

(those whose condition is less well controlled) will demand more attention and care than average 

patients, while those whose condition is well controlled might require very little attention. This 

commenter suggested that a reasonable solution would be for the care minutes per patient per 

month to be calculated as an average across a number of CCM patients. The commenter added 

that for patients entering and exiting mid-month, the average minutes of care could be calculated 

on a pro rata basis which adjusts for the partial months they are eligible for CCM services. 

Several other commenters said that CMS should use a capitated payment methodology for CCM 

services in the long run, but supported CCM services using the CPT codes as valued by the RUC 

as a short-term transitional strategy until CMS is able to expand the per beneficiary per month 

care management fee under CMS’s primary care demonstration initiatives to all physicians. 

Others commented similarly that the long-term goal is capitated payments like the 

demonstrations/models that better encourage population-based health management and reducing 

utilization. 

Several commenters submitted recommendations for valuation based on their experience 

in CMS’s Patient-Centered Medical Home multipayer initiative. Assuming CCM services are 

furnished by a care manager receiving an annual salary of $150,000, and taking into account a 

commonly accepted patient to care manager ratio of 1:150, these commenters believed that under 

the proposed payment rate, the average service time possible would be a ceiling of 23 minutes 

(not a floor of 20 minutes). Based on one tracking study of care manager activity in minutes per 

patient per month, they believed complex care management would require 42 minutes of face-toface and non-face-to-face time per month. Assuming the same care manger salary and patient 

load, the commenters asserted that the monthly payment amount necessary to provide this 

amount of care would be $83 per beneficiary per month. 
CMS-1612-FC 449

Response: Our proposal to pay separately for these services is part of a broader series of 

potential refinements to the PFS that appropriately value care management within Medicare’s 

statutory structure for fee-for-service physician payment. We do not have statutory authority to 

base payment under the PFS on a recurring per beneficiary per month basis. The PFS is limited 

to a fee-for-service model at present, and as such we do not use capitated payment for services 

that may or may not be furnished in a given month. We refer the commenter and other interested 

stakeholders to the preceding paragraphs that describe a broader set of initiatives that are 

designed to improve payment for, and encourage long-term investment in, care management 

services, including a variety of CMS and HHS programs and demonstrations. 

Comment: Many commenters recommended a higher valuation for CCM services than 

was proposed, with some commenters providing specific suggestions as to changes in inputs and 

others simply asserting that a higher payment was appropriate or necessary to achieve access or 

the desired benefit. One commenter recommended a payment of $75 but did not provide 

supporting information. Several other commenters recommended that CMS adopt the RUCrecommended values for CPT code 99490 (work time of 30 minutes, work RVU of 1.0, and 60 

minutes of clinical labor time). Several commenters believed CMS should adopt the work, PE 

and MP RVUs for CPT code 99495, with one commenter suggesting that CMS crosswalk the PE 

and MP RVU from the TCM code and not just the work RVU from the code in order to equalize 

payment for the CCM code with a per beneficiary per month payment that is made for similar 

services through a state Medicaid program. Another commenter pointed out that the proposed 

combined MP and PE RVU of 0.61 for CCM is significantly lower than for the following similar 

services that cannot be billed during same period with CCM: HCPCS code G0181 (Home 

Healthcare Oversight) which has a combined MP and PE RVU of 1.28; HCPCS code G0182 
CMS-1612-FC 450

(Hospice Care Plan Oversight) which has a combined MP and PE RVU of 1.30; CPT code 99339 

(Care Plan Oversight Services) which has a combined MP and PE RVU of 0.94; and CPT code 

99358 (Prolonged Services without Direct Patient Contact) which has a combined MP and PE 

RVU of 0.98. 

Several commenters suggested that CMS’s comparison with TCM, CPT code 99495, was 

not an appropriate comparison. One commenter asked what codes other than CPT code 99495 

CMS considered as similar to CCM for purposes of CCM valuation. This commenter believed 

the time and intensity required for the non-face-to-face portion of CPT code 99495 is not the 

same as for CCM services. 

Several commenters suggested that CMS should develop PE RVUs for the service using 

alternative methodologies than for other PFS services. For example, several commenters stated 

that CMS should adjust the PE RVUs to account for major infrastructure and other costs required 

for CCM, especially health information technology, computer equipment, 24/7 beneficiary 

access, extensive documentation, nursing staff and other overhead costs. One commenter 

believed the proposed RVUs accounted for personnel costs but not the practice expense for 

health information technology, workforce retooling, and analytics. 

We received many public comments on the appropriate work time and direct PE inputs 

for clinical staff time. Most suggested that the proposed inputs for time were too low and 

recommended using the RUC-recommended values (work time of 30 minutes and 60 minutes of 

clinical labor time). Regarding clinical labor time, some commenters believed the proposed 20 

minutes of clinical labor was too low, being the 25th percentile for work time in the RUC survey, 

and they noted the significantly higher time reported in response to the RUC survey of 60 

minutes of clinical labor time. Another commenter said that assuming 20 minutes of service 
CMS-1612-FC 451

time per month as typical significantly undervalues the service and questioned how CMS arrived 

at that number. Regarding the work time, several commenters addressed the work RVU, 

recommending that the proposed RVU be adjusted upwards but did not specify by how much. 

Several commenters noted that the RUC recommendation of 1.0 work RVU for CPT codes 

99490 and 99487 (Cmplx chron care w/o pt visit) is based on median survey work times of 30 

minutes and 26 minutes, respectively, for these CCM codes. (The long descriptor for CPT code 

99487 is, Complex chronic care management services, with the following required elements: 

• Multiple (two or more) chronic conditions expected to last at least 12 months, or 

until the death of the patient; 

• Chronic conditions place the patient at significant risk of death, acute 

exacerbation/decompensation, or functional decline; 

• Establishment or substantial revision of a comprehensive care plan; 

• Moderate or high complexity medical decision making; 

• 60 minutes of clinical staff time directed by a physician or other qualified health 

care professional, per calendar month). 

However several commenters did not object to the proposed valuation for GXXX1 and 

recommended that CMS monitor payment adequacy and appropriate valuation once the code is 

implemented. 

Response: After consideration of the various comments on the work RVUs, we continue 

to believe that the most appropriate mechanism for determining the appropriate work RVU for 

this service is by using the non-face-to-face portion of the lower level TCM code, CPT code 

99495. We continue to believe that the work and intensity for CCM services furnished to the 

eligible beneficiaries is comparable to the work and intensity involved in furnishing the non-
CMS-1612-FC 452

face-to-face portion of the service described by CPT code 99495. Therefore, we believe that 

using CPT code 99495 as the comparison code assures appropriate relativity with other similar 

services. The services suggested by the commenters as comparable to the CCM code require 

significantly more time. CPT code 99358 is for an hour of non-face-to-face time and has a work 

time of 60 minutes. CPT code 99339 has a work time of 40 minutes and is furnished to a 

significantly different patient population (those in a domiciliary or rest home). HCPCS codes 

G0181 and G0182 have work time of almost 60 minutes and also are furnished to significantly 

different patient populations. 

We appreciate commenters’ concerns regarding the various kinds of practice expense and 

malpractice liability costs that practices incur as they manage beneficiaries requiring CCM 

services. However, we continue to believe that our established PE and MP methodology used to 

value the wide ranges of services across the PFS assures that we have the appropriate relativity in 

our payments. 

Although many commenters recommended that we use the time from the RUC survey of 

60 minutes of clinical labor and 30 minutes of work time, we believe that since CCM is a new 

separately billable service, the survey data may be less reliable as the practitioners would have 

no experience with the code. Since at least 20 minutes of services are required to be furnished in 

order to report the service and our information, including comments, suggests that many 

beneficiaries who meet Medicare’s criteria for CCM services would not need more than the 

minimum required minutes of service, we believe 60 minutes would overestimate the typical 

number of clinical labor minutes during one month for the typical eligible beneficiary. 

Accordingly, we are finalizing our proposed work and clinical labor times. 

Comment: A number of commenters recommended that coinsurance should not apply to 
CMS-1612-FC 453

CCM services. These commenters were concerned that the $8 estimated coinsurance amount in 

the proposed rule would hinder beneficiary access. Several commenters believed that CCM is a 

preventive service that should be exempt from beneficiary cost sharing. They noted that costsharing will make it challenging to reach the 20 minutes required for billing, because 

beneficiaries will delay care until face-to-face is necessary 

Response: CCM services do not fall into any of the statutory preventive services benefit 

categories of the Act. The Secretary has the authority to add “additional preventive services” 

that, among other things, have been assigned an “A” or “B” rating by the United States 

Preventive Services Task Force, but CCM has not earned such a rating. Since CCM does not 

meet the criteria, we cannot designate it as an additional preventive service under section 

1861(s)(2)(BB) of the Act. Further, we do not have other statutory authority that would allow us 

to waive the applicable coinsurance for CCM services. As discussed in the CY 2014 PFS final 

rule with comment period (78 FR 74424), in order to assure that beneficiaries are aware of the 

coinsurance for this non-face-to-face service, we are requiring that providers explain to 

beneficiaries the cost-sharing obligation involved in receiving CCM services and obtain their 

consent prior to furnishing the service. Practitioners should explain that a likely benefit of 

agreeing to receive CCM services is that although cost-sharing applies to these services, CCM 

services may help them avoid the need for more costly face to face services that entail greater 

cost-sharing. 

Comment: Most of the commenters were concerned that the proposed payment would 

not be adequate for beneficiaries with complex needs who would benefit the most from CCM 

services. Most of the commenters recommended that we adopt more than one code to provide 

differential payment for more and less complex beneficiaries, using CPT CCM codes, G-code(s) 
CMS-1612-FC 454

or some combination thereof. Many commenters distinguished between beneficiaries that 

require significantly different clinical resources--those needing “complex chronic care 

management” and those needing only “standard chronic care or disease management.” Some 

commenters asserted that there is a disconnect between the code descriptor for GXXX1 and the 

Medicare CCM scope of service, such that ambiguity in the descriptor will result in use of 

GXXX1 to treat a very broad spectrum of beneficiaries inconsistent with the scope of service 

that the commenters believed was consistent with beneficiaries with more complex needs. They 

believed the proposed payment amount is appropriate for beneficiaries on needing only standard 

chronic care management, but would significantly underpay for beneficiaries requiring complex 

chronic care management. 

Many commenters recommended that CMS adopt the three CPT codes describing chronic 

care management. In addition to the CPT code that is similar to the G-code described above 

(CPT code 99490), there are two additional complex chronic care coordination codes (a base 

code and an add-on code). Since CY 2013 when the complex chronic care coordination codes 

became available, CMS has bundled these codes. The base code is CPT code 99487 (Cmplx 

chron care w/o pt visit), and the add-on is CPT code 99489 (Complex chronic care coordination 

services; each additional 30 minutes of clinical staff time directed by a physician or other 

qualified health care professional, per calendar month (list separately in addition to code for 

primary procedure). 

Other commenters recommended using two codes to describe CCM for different patient 

populations, or a base code and an add-on code to describe CCM for a single patient population. 

Some commenters recommended adoption of GXXX1 or CPT code 99490, plus CPT code 99487 

along with the RUC-recommended values, to describe CCM for the two distinct populations that 
CMS-1612-FC 455

require different services. These commenters stated that there is no “typical” patient that 

characterizes both groups of patients, and that a large number of eligible beneficiaries (those 

having 2 or more chronic conditions) have serious mental health and/or substance abuse 

disorders and would benefit greatly from CCM services). Other commenters recommended 

using two G-codes, one being an add-on code for each additional 20 minutes or other time spent 

caring for a beneficiary with more complex needs. One commenter urged CMS to adopt an addon code for time increments over 60 minutes. Several commenters recommended a cap on 

additional minutes, particularly if CMS finalizes an applicable beneficiary coinsurance for CCM 

services. One commenter recommended that we finalize the proposed valuation for GXXX1, 

also recognize CPT code 99490 (Chron care mgmt srvc 20 min) with a higher payment amount, 

and then collect data on the impacts of differential payment amounts. 

Other commenters recommended that CMS adopt CPT code 99487 (Cmplx chron care 

w/o pt visit) with the scope of services for GXXX1. One commenter recommended that CMS 

redefine its requirements and the scope of services for GXXX1 to be more consistent with 

chronic disease management, using CPT code 99487. The commenter believed we should adopt 

CPT code 99487 with the RUC-recommended valuation. One commenter more generally 

recommended that CMS adopt a higher intensity code for patients requiring 45-60 minutes or 

more of clinical staff time for assessment, medication management, care planning, coordination, 

education and advocacy. 

Response: At this time, we believe that Medicare beneficiaries with two or more chronic 

conditions as defined under the CCM code can benefit from care management and want to make 

this service available to all such beneficiaries. Like all services, we recognize that some 

beneficiaries will need more services and some less, and thus we pay based upon the typical 
CMS-1612-FC 456

service. However all scope of service elements apply for delivery of CCM services to any 

eligible Medicare beneficiary. We will evaluate the utilization of this service to evaluate what 

types of beneficiaries receive the service described by this CPT code, what types of practitioners 

are reporting it, and consider any changes in payment that may be warranted in the coming years. 

We are maintaining the status indicator “B” (Bundled) for CY 2015 for the complex care 

coordination codes, CPT codes 99487 and 99489. 

Comment: Several commenters requested that CMS create codes specific to remote 

patient biometric monitoring (recording vital signs and other physiological data and transmitting 

real-time data to physicians). Several commenters requested codes specific to or inclusive of 

certain hematology, nephrology, endocrine and allergy/immunology conditions, such as chronic 

kidney disease, end-stage renal disease, diabetes and severe asthma. One commenter 

recommended that CMS delay implementation of this service for CY 2015 and propose for 

CY 2016 specific complex chronic care codes for each of the major chronic diseases, especially 

diabetes. 

Response: We are not convinced that the care management services are sufficiently 

unique based upon the beneficiary’s specific chronic conditions to warrant separate codes, 

especially given the beneficiary must have at least two chronic conditions. As noted above, we 

will be monitoring this service and will consider making changes if they appear warranted. 

After consideration of the comments received on this proposal, we are finalizing the 

proposal with the following modification. Rather than creating a G-code we are adopting the 

new CPT code, 99490, to describe CCM services effective January 1, 2015. We intend to 

evaluate this service closely to assess whether the service is targeted to the right population and 

whether the payment is appropriate for the services being furnished. As part of our evaluation, 
CMS-1612-FC 457

we will consider the whether this new service meets the care coordination needs of Medicare 

beneficiaries and if not how best to address the unmet needs. 

2. CCM and TCM Services Furnished Incident to a Physician’s Service under General Physician 

Supervision 

In the CY 2014 PFS final rule with comment period (78 FR 74425 through 74427), we 

discussed how the policies relating to services furnished incident to a practitioner’s professional 

services apply to CCM services. (In this discussion, the term practitioner means both physicians 

and NPPs who are permitted to bill for services furnished incident to their own professional 

services.) Specifically, we addressed the policy for counting clinical staff time for services 

furnished incident to the billing practitioner’s services toward the minimum amount of service 

time required to bill for CCM services. 

We established an exception to the usual rules that apply to services furnished incident to 

the services of a billing practitioner. Generally, under the “incident to” rules, practitioners may 

bill for services furnished incident to their own services if the services meet the requirements 

specified in our regulations at §410.26. One of these requirements is that the “incident to” 

services must be furnished under direct supervision, which means that the supervising 

practitioner must be present in the office suite and be immediately available to provide assistance 

and direction throughout the service (but does not mean that the supervising practitioner must be 

present in the room where the service is furnished). We noted in last year’s PFS final rule with 

comment period that, because one of the required elements of the CCM service is beneficiary 

access to the practice 24-hours-a-day, 7-days-a-week, to address the beneficiary’s chronic care 

needs (78 FR 74426), we expect the beneficiary to be provided with a means to make timely 

contact with health care providers in the practice whenever necessary to address chronic care 
CMS-1612-FC 458

needs regardless of the time of day or day of the week. In those cases when the need for contact 

arises outside normal business hours, it is likely that the beneficiary’s initial contact would be 

with clinical staff employed by the practice (for example, a nurse) and not necessarily with a 

practitioner. Under these circumstances, it would be unlikely that a practitioner would be 

available to provide direct supervision of the service. 

Therefore, in the CY 2014 PFS final rule with comment period, we created an exception 

to the generally applicable requirement that “incident to” services must be furnished under direct 

supervision. Specifically, we finalized a policy to require only general, rather than direct, 

supervision when CCM services are furnished incident to a practitioner’s services outside of the 

practice’s normal business hours by clinical staff who are direct employees of the practitioner or 

practice. We explained that, given the potential risk to beneficiaries that the exception to direct 

supervision could create, we believed that it was appropriate to design the exception as narrowly 

as possible (78 FR 74426). The direct employment requirement was intended to balance the less 

stringent general supervision requirement by ensuring that there is a direct oversight relationship 

between the supervising practitioner and the clinical staff personnel who provide after-hours 

services. 

In the CY 2015 PFS proposed rule, we proposed to revise the policy that we adopted in 

the CY 2014 PFS final rule with comment period. We also proposed to amend our regulations to 

codify the requirements for CCM and TCM services furnished incident to a practitioner’s 

services. Specifically, we proposed to remove the requirement that, in order to count the time 

spent by clinical staff providing aspects of CCM services toward the CCM time requirement, the 

clinical staff person must be a direct employee of the practitioner or the practitioner’s practice. 

(We note that the existing requirement that these services be provided by clinical staff, 
CMS-1612-FC 459

specifically, rather than by other auxiliary personnel is an element of the service for both CCM 

and TCM services, rather than a requirement imposed by the “incident to” rules themselves.) 

We also proposed to remove the restriction that services provided by clinical staff under general 

(rather than direct) supervision may be counted only if they are provided outside of the practice’s 

normal business hours. Under our proposed revised policy, then, the time spent by clinical staff 

providing aspects of CCM services can be counted toward the CCM time requirement at any 

time, provided that the clinical staff are under the general supervision of a practitioner and all 

other requirements of the “incident to” regulations at §410.26 are met. 

We proposed to revise these aspects of the policy for several reasons. First, one of the 

required elements of the CCM service is the availability of a means for the beneficiary to make 

contact with health care practitioners in the practice to address a beneficiary’s urgent chronic 

care needs (78 FR 74418 through 74419). Other elements within the scope of CCM services are 

similarly required to be furnished by practitioners or clinical staff. We believe that these 

elements of the CCM scope of service require the presence of an organizational infrastructure 

sufficient to adequately support CCM services, irrespective of the nature of the employment or 

contractual relationship between the clinical staff and the practitioner or practice. We also 

believe that the elements of the CCM scope of service, such as the requirement of a care plan, 

ensure a close relationship between a practitioner furnishing ongoing care for a beneficiary and 

clinical staff providing aspects of CCM services under general supervision; and that this close 

working relationship is sufficient to render a requirement of a direct employment relationship or 

direct supervision unnecessary. Under our proposal, CCM services could be furnished “incident 

to” if the services are provided by clinical staff under general supervision of a practitioner 

whether or not they are direct employees of the practitioner or practice that is billing for the 
CMS-1612-FC 460

service; but the clinical staff must meet the other requirements for auxiliary personnel including 

those at §410.26(a)(1). Other than the exception to permit general supervision for clinical staff, 

the same requirements apply to CCM services furnished incident to a practitioner’s professional 

services as apply to other “incident to” services. Furthermore, since last year’s final rule, we 

have had many consultations with physicians and others about the organizational structures and 

other factors that contribute to effective provision of CCM services. These consultations have 

convinced us that, for purposes of clinical staff providing aspects of CCM services, it does not 

matter whether the practitioner is directly available to supervise because the nature of the 

services are such that they can be, and frequently are, provided outside of normal business hours 

or while the physician is away from the office during normal business hours. This is because, 

unlike most other services to which the “incident to” rules apply, the CCM services are 

intrinsically non-face-to-face care coordination services. 

In conjunction with this proposed revision to the requirements for CCM services 

provided by clinical staff incident to the services of a practitioner, we also proposed to adopt the 

same requirements for equivalent purposes in relation to TCM services. As in the case of CCM, 

TCM explicitly includes separate payment for services that are not necessarily furnished face-toface, such as coordination with other providers and follow-up with beneficiaries. It would also 

not be uncommon for auxiliary personnel to provide elements of the TCM services when the 

physician was not in the office. Generally, we believe that it is appropriate to treat separately 

billable care coordination services similarly whether in the form of CCM or TCM. We also 

believe that it would be appropriate to apply the same “incident to” rules that we are proposing 

for CCM services to TCM services. We did not propose to extend this policy to the required 

face-to-face portion of TCM. Rather, the required face-to-face portion of the service must still 
CMS-1612-FC 461

be furnished under direct supervision. 

Therefore, we proposed to revise our regulation at §410.26, which sets out the applicable 

requirements for “incident to” services, to permit TCM and CCM services provided by clinical 

staff incident to the services of a practitioner to be furnished under the general supervision of a 

physician or other practitioner. As with other “incident to” services, the physician (or other 

practitioner) supervising the auxiliary personnel need not be the same physician (or other 

practitioner) upon whose professional service the “incident to” service is based. We note that all 

other “incident to” requirements continue to apply and that the usual documentation of services 

provided must be included in the medical record. 

Commenters uniformly supported our proposal to revise our regulation at §410.26, which 

sets out the applicable requirements for “incident to” services, to permit TCM and CCM services 

provided by clinical staff incident to the services of a practitioner to be furnished under the 

general supervision of a physician or other practitioner. Under the revised regulation, then, the 

time spent by clinical staff providing aspects of TCM and CCM services can be counted toward 

the TCM or CCM time requirement at any time, provided that the clinical staff are under the 

general supervision of a practitioner and all requirements of the revised “incident to” regulations 

at §410.26 are met. 

Comment: One commenter requested guidance concerning whether (as has been the case 

with E/M codes) activities billed under “incident to” will not be able to also be billed under the 

CCM code. 

Response: The purpose of our proposal was to allow elements of CCM services that are 

furnished by clinical staff incident to a practitioner’s professional services (under the “incident 

to” regulations) to be included and reported as CCM services. We are not entirely clear what the 
CMS-1612-FC 462

commenter is asking, but the time spent furnishing CCM services can only be counted once and 

for only one purpose, and each discrete service can be billed only once. Although we and our 

contractors provide many educational materials, practitioners who furnish Medicare covered 

items and services are responsible for learning how to appropriately bill each service. 

Comment: One commenter urged us to revise the terminology by which we define the 

CCM and TCM services to reflect non-hierarchical interdisciplinary team care, rather than 

relying on an incident-to structure that obscures the actual provider of direct patient care. This 

commenter expressed concern about loss of benefits to clinicians under contract with a practice, 

rather than being employed by the practice. Another commenter similarly expressed concern 

that the expanded authorization for “general supervision” rather than “direct supervision” would 

provide an even greater incentive for physicians to require that any E/M service provided by an 

Advanced Practice Registered Nurse (APRN) in their practice be billed as “incident to” a 

physician’s service. This could reduce transparency in billing data and diminish accountability 

for services for Part B beneficiaries. 

Response: We do not entirely understand the basis for these concerns. We have 

accommodated numerous requests to include contracted employees within the scope of the 

“incident to” rules for purposes of counting time toward the TCM and CCM requirements. We 

have not otherwise proposed to revise the “incident to” and other regulations within which 

practitioners operate as they make decisions about whether to contract or directly employ clinical 

staff, or about how to bill for services provided. Although they are important within the context 

of the new TCM and CCM services, we believe that the revisions to our “incident to” regulation 

that are adopted in this final rule, are peripheral in the context of the overall employment and 

billing practices of physicians and group practices. 
CMS-1612-FC 463

 After consideration of the comments, we are finalizing our proposal to revise our 

regulation at §410.26, which sets out the applicable requirements for “incident to” services, to 

permit the CCM and non-face-to-face portion of the TCM services provided by clinical staff 

incident to the services of a practitioner to be furnished under the general supervision of a 

physician or other practitioner. 

3. Scope of Services and Standards for CCM Services 

In the CY 2014 final rule with comment period (78 FR 74414 through 74428), we 

defined the elements of the scope of service for CCM that are required for a practitioner to bill 

Medicare for the CCM service. In addition, we indicated that we intended to develop standards 

for practices that furnish CCM services to ensure that the practitioners who bill for these services 

have the capability to fully furnish them (78 FR 74415, 74418). At that time, we anticipated that 

we would propose these standards in the CY 2015 PFS proposed rule. We actively sought input 

toward development of these standards by soliciting public comments on the CY 2014 PFS final 

rule with comment period, through outreach to stakeholders in meetings, by convening a 

Technical Expert Panel, and by collaborating with federal partners such as the Office of the 

Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Health, 

the Office of the National Coordinator for Health Information Technology (ONC), and the 

Health Resources and Services Administration. Our goal is to recognize the trend toward 

practice transformation and overall improved quality of care, while preventing unwanted and 

unnecessary care. 

As we worked to develop appropriate practice standards that would meet this goal, we 

consistently found that many of the standards we thought were important overlapped in 

significant ways with the scope of service or with the billing requirements for the CCM services 
CMS-1612-FC 464

that had been finalized in the CY 2014 final rule with comment period. In cases where the 

standards we identified were not unique to CCM requirements, we found that the standards 

overlapped with other Medicare requirements or other federal requirements that apply generally 

to health care practitioners. Based upon the feedback we received, we sought to avoid 

duplicating other requirements or, worse, imposing conflicting requirements on practitioners that 

would furnish CCM services. Given the standards and requirements that are already in place for 

health care practitioners and applicable to those who furnish and bill for CCM services, we 

decided not to propose an additional set of standards that would have to be met in order for 

practitioners to furnish and bill for CCM services. Instead of proposing a new set of standards 

applicable to only CCM services, we decided to emphasize that certain requirements are inherent 

in the elements of the existing scope of service for CCM services, and clarify that these must be 

met in order to bill for CCM services. The CCM scope of service elements finalized in the CY 

2014 PFS final rule (78 FR 74414 through 74428) are as follows. 

● The provision of 24-hour-a-day, 7-day-a-week access to address the patient’s acute 

chronic care needs. To accomplish this, the patient must be provided with a means to make 

timely contact with health care providers in the practice to address the patient’s urgent chronic 

care needs regardless of the time of day or day of the week. 

● Continuity of care with a designated practitioner or member of the care team with 

whom the patient is able to get successive routine appointments. 

● Care management for chronic conditions including systematic assessment of the 

patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely 

receipt of all recommended preventive care services; medication reconciliation with review of 

adherence and potential interactions; and oversight of patient self-management of medications. 
CMS-1612-FC 465

• In consultation with the patient, any caregiver and other key practitioners treating the 

patient, the practitioner furnishing CCM services must create a patient-centered care plan 

document to assure that care is provided in a way that is congruent with patient choices and 

values. The care plan is based on a physical, mental, cognitive, psychosocial, functional and 

environmental (re)assessment and an inventory of resources and supports. It is a comprehensive 

plan of care for all health issues, and typically includes, but is not limited to, the following 

elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom 

management, planned interventions, medication management, community/social services 

ordered, how the services of agencies and specialists unconnected to the billing practice will be 

directed/coordinated, identify the individuals responsible for each intervention, requirements for 

periodic review and, when applicable, revision of the care plan. A full list of problems, 

medications and medication allergies in the EHR must inform the care plan, care coordination 

and ongoing clinical care. 

● Management of care transitions within health care, including referrals to other 

clinicians, follow-up after the patient’s visit to an emergency department, and follow-up after 

discharges from hospitals, skilled nursing facilities, or other health care facilities. The practice 

must facilitate communication of relevant patient information through electronic exchange of a 

summary care record with other health care providers regarding these transitions. The practice 

must also have qualified personnel who are available to deliver transitional care services to the 

patient in a timely way so as to reduce the need for repeat visits to emergency departments and 

readmissions to hospitals, skilled nursing facilities or other health care facilities. 

● Coordination with home and community based clinical service providers required to 

support the patient’s psychosocial needs and functional deficits. Communication to and from 
CMS-1612-FC 466

home and community based providers regarding these patient needs must be documented in the 

patient’s medical record. 

● Enhanced opportunities for the beneficiary and any relevant caregiver to communicate 

with the practitioner regarding the beneficiary’s care through, not only telephone access, but also 

through the use of secure messaging, internet or other asynchronous non face-to-face 

consultation methods. 

Similarly, we reminded stakeholders of the following additional billing requirements 

established in the CY 2014 final rule with comment period (in the following list, we have 

changed the service period from the 2015 proposed 30-day period to the final 2015 service 

period of one calendar month): 

● Inform the beneficiary about the availability of the CCM services from the practitioner 

and obtain his or her written agreement to have the services provided, including the beneficiary’s 

authorization for the electronic communication of the patient’s medical information with other 

treating providers as part of care coordination. 

● Document in the beneficiary’s medical record that all elements of the CCM service 

were explained and offered to the beneficiary, and note the beneficiary’s decision to accept or 

decline the service. 

● Provide the beneficiary a written or electronic copy of the care plan and document in 

the electronic medical record that the care plan was provided to the beneficiary. 

● Inform the beneficiary of the right to stop the CCM services at any time (effective at 

the end of a calendar month) and the effect of a revocation of the agreement to receive CCM 

services. 
CMS-1612-FC 467

● Inform the beneficiary that only one practitioner can furnish and be paid for these 

services during the calendar month service period. 

In one area, electronic health records (EHRs), we were concerned that the existing 

elements of the CCM service could leave some gaps in assuring that beneficiaries consistently 

receive care management services that offer the benefits of advanced primary care as it was 

envisioned when this service was created. It is clear that effective care management can be 

accomplished only through regular monitoring of the patient’s health status, needs, and services, 

and through frequent communication and exchange of information with the patient and among 

the various health care practitioners and providers treating the patient. After gathering input 

from stakeholders through the CY 2014 rulemaking cycle, for 2015 we proposed a new scope of 

service element that would require use of a certified EHR and electronic care planning to furnish 

CCM services. We believed that requiring those who furnish CCM services to utilize EHR 

technology that has been certified by a certifying body authorized by the National Coordinator 

for Health Information Technology was necessary to ensure that key patient information is 

stored, shared and reconciled among the many practitioners and providers involved in managing 

the patient’s chronic conditions, otherwise care could not be coordinated and managed. 

Requiring a certified EHR would enable members of the interdisciplinary care team to have 

immediate access to the most updated information informing the care plan. Therefore we 

proposed that the billing practitioner must utilize EHR technology certified by a certifying body 

authorized by the National Coordinator for Health Information Technology to an edition of the 

EHR certification criteria identified in the then-applicable version of 45 CFR part 170. We 

proposed that at a minimum, the practice must utilize EHR technology that meets the 

certification criteria adopted at 45 CFR 170.314(a)(3), 170.314(a)(4), 170.314(a)(5), 
CMS-1612-FC 468

170.314(a)(6), 170.314(a)(7) and 170.314(e)(2) pertaining to the capture of demographics, 

problem lists, medications, and other key elements related to the ultimate creation of an 

electronic summary care record. These sections of the regulation comprise the certification 

criteria for specific core technology capabilities (structured recording of demographics, 

problems, medications, medication allergies, and the creation of a structured clinical summary) 

for the 2014 edition. Under the proposal, practitioners furnishing CCM services beginning in 

CY 2015 would be required to utilize an EHR certified to at least these 2014 edition certification 

criteria. Given these 2014 edition criteria, the EHR technology would be certified to capture 

data and ultimately produce summary records according to the HL7 Consolidated Clinical 

Document Architecture standard (see 45 CFR 170.205(a)(3)). 

In addition, when any of the CCM scope of service elements refers to a health or medical 

record, we proposed to require use of an EHR certified to at least the 2014 edition certification 

criteria to fulfill the scope of service element in relation to the health or medical record. As 

finalized in the CY 2014 PFS final rule, the scope of service elements that reference a health or 

medical record are: 

● A full list of problems, medications and medication allergies in the EHR must inform 

the care plan, care coordination and ongoing clinical care. 

● Communication to and from home and community based providers regarding the 

patient’s psychosocial needs and functional deficits must be documented in the patient’s medical 

record. 

● Inform the beneficiary of the availability of CCM services and obtain his or her written 

agreement to have the services provided, including authorization for the electronic 

communication of his or her medical information with other treating providers. Document in the 
CMS-1612-FC 469

beneficiary’s medical record that all of the CCM services were explained and offered, and note 

the beneficiary’s decision to accept or decline these services. 

● Provide the beneficiary a written or electronic copy of the care plan and document in 

the electronic medical record that the care plan was provided to the beneficiary. 

Regarding the care plan in particular, we believed that requiring practitioners furnishing 

CCM services to maintain and share an electronic care plan would alleviate the errors that can 

occur when care plans are not systematically reconciled. To ensure that practices offering CCM 

services meet these needs, we proposed that CCM services must be furnished with the use of an 

EHR or other health IT or health information exchange platform that includes an electronic care 

plan that is accessible to all practitioners within the practice, including being accessible to those 

who are furnishing care outside of normal business hours, and that is available to be shared 

electronically with care team members outside of the practice. This was a more limited proposal 

compared to our CY 2014 proposal that we did not finalize that would have required members of 

the chronic care team who are involved in the after-hours care of the patient to have access to the 

beneficiary’s full electronic medical record (78 FR 74416 through 74417). 

Regarding the clinical summary, we proposed to require technology certified to the 2014 

edition for the electronic creation of the clinical summary, formatted according to the standard 

adopted at 45 CFR 170.205(a)(3), but we did not specify that this format must be used for the 

exchange of beneficiary information (79 FR 40367). For instance, we did not propose that 

practitioners billing for CCM services must adopt certified technology related to the exchange of 

a summary care record such as the transmission standard related to Direct Project Transport in 45 

CFR 170.314(b)(2)(ii). 
CMS-1612-FC 470

We indicated that we believed our proposed new scope of service element for a certified 

EHR and electronic care planning would ensure that practitioners billing for CCM could fully 

furnish the services, allow practitioners to innovate around the systems that they use to furnish 

these services, and avoid overburdening small practices. We indicated that we believed that 

allowing flexibility as to how practitioners capture, update, and share care plan information was 

important at this stage given the maturity of current EHR standards and other electronic tools in 

use in the market today for care planning. 

In addition to seeking comment on this new proposed scope of service element, we 

sought comment on any changes to the scope of service or billing requirements for CCM 

services that may be necessary to ensure that the practitioners who bill for these services have the 

capability to furnish them and that we can appropriately monitor billing for these services. With 

the addition of the electronic health information technology element that we proposed, we 

believed that the elements of the scope of service for CCM services, when combined with other 

important federal health and safety regulations, would provide sufficient assurance that 

practitioners billing for CCM could fully furnish the services, and that Medicare beneficiaries 

receiving CCM would receive appropriate services. However we expressed special interest in 

receiving public feedback regarding any meaningful elements of the CCM service or beneficiary 

protections that may be missing from the scope of service elements and billing requirements. 

The following paragraphs summarize the comments we received regarding these 

elements of the scope of service for CCM services and our responses. 

Comment: Some commenters were disappointed that CMS did not propose an additional 

set of standards. The commenters expressed concern that there would not be sufficient 

accountability for high quality CCM services. Some commenters recommended further 
CMS-1612-FC 471

development of standards such as inclusion of evidence-based self-management programs 

offered by community organizations, quality measures that engage patients and demonstrate 

improved outcomes, or a best practices guide to assist the physician community with 

implementation. However, many commenters opposed further standards, and agreed with CMS 

that additional standards would largely overlap with other Medicare requirements or were 

already reflected in the scope of service elements. 

Response: We appreciate the commenters’ concerns about ensuring quality of care. We 

continue to believe that with the addition of the EHR element, the required scope of service 

elements are sufficient for ensuring high quality CCM services in 2015. We note that section 

III.K of this final rule with comment period addresses quality measures for physicians’ services, 

and stakeholders may submit suggestions for quality measures related to CCM in response to this 

section of the regulation. 

Comment: Many commenters expressed broad support for our EHR proposal. The 

commenters commended the strong emphasis on data sharing and requirements for a robust EHR 

as vital to successful care coordination and continuity of care. Several commenters did not 

believe the proposal would pose a significant administrative burden. One commenter noted that 

use of an EHR would help practitioners to document the time spent furnishing CCM services. 

Although commenters supported adoption of certified EHR technology (CEHRT) 

generally, many were concerned that an insufficient number of physicians have adopted CEHRT 

with the functionalities we proposed for CCM, especially interoperability with other providers. 

The commenters were also concerned that physicians practicing in rural or economically 

depressed areas would not have the resources to implement such technology and would be 

disqualified from furnishing separately billable CCM services. Many believed the proposal was 
CMS-1612-FC 472

laudable but premature, recommending that CMS delay adoption of the 2014 EHR certification 

criteria for CCM services by 3 to 4 years when they will be more widely adopted, or phase in the 

2014 certification criteria over 2 years as a requirement for 2017. Several commenters 

recommended that we finalize our proposal but provide hardship exceptions for certain smaller 

or rural practices to enable them to bill separately for CCM services in the absence of an 

interoperable EHR in certain circumstances, provide financial incentives, or allow other 

flexibility around the requirements for physicians who cannot meet them at this time. One 

commenter supported the proposal but suggested we allow aspects of CCM services to be 

furnished using fax and secure messaging technology if physicians encounter challenges with 

interoperability. Until EHR systems are interoperable, some commenters suggested allowing 

practitioners to attest that all requirements for billing CCM were met using CEHRT or an 

alternative technology, or to attest that all members of the care team have timely access (24/7 

access in “real time” or “near real time”) to the most updated information regarding the care plan 

through either electronic or non-electronic means, with ongoing efforts to implement 

interoperable EHRs. The commenters stated many practices are making patient information 

accessible in a timely manner to the entire care team, but have not yet fully implemented an 

interoperable EHR with other providers. Several commenters were concerned about the ability 

of current EHR technologies to share information across different providers and EHR systems. 

Commenters requested that CMS ensure that no certified EHR contains technological or business 

impediments to data sharing across disparate technology platforms used by multiple providers 

trying to coordinate care. In addition, many commenters were concerned about access to CCM 

services, and recommended that CMS prioritize access over adoption of CEHRT. Several 
CMS-1612-FC 473

commenters stated that not all types of physicians have access to an EHR that meets the needs of 

their specialty. 

A number of commenters stated that CCM could be (and already is) effectively provided 

without any EHR or a without a certified EHR, and recommended that CMS rescind the proposal 

or make the EHR requirement optional. These commenters disagreed with the requirement that 

CCM services must be furnished with use of a certified EHR, information technology (IT) 

platform or exchange platform that includes a care plan, with some stating that certified EHR 

systems have not demonstrated improvements in the management of chronic conditions, 

especially complex cases, and suggested postponing the care plan and other EHR requirements 

until they are proven effective and adopted by most providers. Others stated that an EHR was 

necessary and that CMS should require an EHR that promotes communication among various 

professional on the care team, includes the patient as part of the team, and enables clinical 

monitoring and effective care planning. Commenters indicated that many physicians accomplish 

this through generating or receiving electronic discharge summaries, clinical documentation, and 

patient-centered plans of care, but are not using certified technologies to carry out these 

functions and should not be penalized. 

One commenter stated that only about half of all physicians had an EHR system with 

advanced functionalities in 2013, many current systems were not designed with interoperability 

in mind and transition costs are high. The commenter believed the proposed payment amount 

would not sufficiently cover the cost of purchasing or upgrading an EHR system, and requiring a 

certified EHR would limit the number of eligible physicians without significantly adding value 

to CCM services. Another commenter stated that only 1,000 physicians and other eligible health 
CMS-1612-FC 474

professionals have achieved Stage 2 of Meaningful Use of certified EHR technology, compared 

with more than 300,000 physicians and eligible professionals who have achieved Stage 1. 

Response: We continue to believe that it is necessary to require the use of EHR 

technology that has been certified under the ONC Health IT Certification Program as requisite 

for receiving separate payment for CCM services, to ensure that practitioners have adequate 

capabilities to allow members of the interdisciplinary care team to have timely access to the most 

updated information informing the care plan. We agree with commenters that health IT tools are 

most effective when there are no technological or business impediments to data sharing, or 

disparate technology platforms used by multiple providers trying to coordinate care, and that we 

should ensure common functionalities as much as possible across providers. However, we also 

agree with commenters who expressed concern that requiring the most recent edition of EHR 

certification criteria could be an impediment to the broad utilization of the CCM service. In 

response to comments, we are modifying our proposal regarding which edition of certified EHR 

technology will be required, in order to allow more flexibility as practitioners transition to the 

use of certified EHR technology. Accordingly, we are modifying our proposal to specify that the 

CCM service must be furnished using, at a minimum, the edition(s) of certification criteria that is 

acceptable for purposes of the EHR Incentive Programs as of December 31st of the calendar year 

preceding each PFS payment year (hereinafter “CCM certified technology”) to meet the final 

core technology capabilities (structured recording of demographics, problems, medications, 

medication allergies, and the creation of a structured clinical summary). Practitioners must also 

use this CCM certified technology to fulfill the CCM scope of service requirements whenever 

the requirements reference a health or medical record. This will ensure that requirements for 

CCM billing under the PFS are consistent throughout each PFS payment year and are 
CMS-1612-FC 475

automatically updated annually according to the certification criteria required for the EHR 

Incentive Programs. For CCM payment in CY 2015, this policy will allow practitioners to use 

EHR technology certified to either the 2011 or 2014 edition(s) of certification criteria to meet the 

final core capabilities for CCM and to fulfill the CCM scope of service requirements whenever 

the requirements reference a health or medical record. We are finalizing the separate provision 

we proposed for the electronic care plan scope of service element without modification as 

discussed below. We remind stakeholders that for all electronic sharing of beneficiary 

information under our final CCM policies, HIPAA standards apply in the usual manner. 

Comment: Several commenters questioned the relationship between the Meaningful Use 

criteria and the proposed EHR scope of service element for CCM. One commenter stated that 

none of the requirements for EHR capability for payment of CCM services should be tied to or 

related to Meaningful Use, because many of the Meaningful Use requirements do not apply to 

CCM. Another commenter supported what they understood to be our proposal, to require billing 

physicians to adopt an EHR and utilize it to meet the most recent standard for Meaningful Use. 

However, the commenter noted (similar to the previous commenter) that the current 

functionalities and standards for EHR technology required for Meaningful Use are not entirely 

aligned with the functionalities required for CCM, for example the commenter believed that the 

electronic care plan need only be shared 10 percent of the time to meet Meaningful Use 

measures, but that CCM would require it to be available 24/7 and to all practitioners. The 

commenter expressed concern that practitioners might not be able to furnish CCM as envisioned 

by CMS due to discrepancies with the Meaningful Use criteria, and urged CMS to adopt 

interoperability standards for Meaningful Use that would enable successful care coordination 

models. Another commenter recommended that enforcement of the proposed EHR requirement 
CMS-1612-FC 476

be coterminous with the enforcement of Meaningful Use Stage 2 to ensure practices have the 

ability to comply. 

Response: Although we understand why some commenters would like for the 

requirements for the EHR Incentive Programs and the EHR scope of service element for CCM to 

be identical, we do not believe that is entirely possible because of the different nature and 

purpose of the respective EHR specifications. In many respects they are not comparable 

requirements. For example, the PFS sets payment requirements prospectively for a given 

calendar year, while the EHR Incentive Program may change requirements mid-year. In 

addition, many of the Meaningful Use measures are not relevant for the provision of CCM and 

we believe we should only require practitioners to adopt the certified technology that is relevant 

to the scope of CCM services. In their attempts to meet Meaningful Use criteria for a given year, 

practitioners are required to use technology certified to a specific edition(s) of certification 

criteria to meet the CEHRT definition, and as we discussed above we are aligning the edition 

required to bill CCM with the edition(s) required for Meaningful Use each year. However, it is 

conceivable that a practitioner could use CCM certified technology to provide and be paid for 

CCM in a given calendar year that will not be sufficient for achieving Meaningful Use in that 

same year because CCM must be furnished using at least the edition(s) of certified EHR 

technology required for the EHR Incentive Programs as of December 31st of the prior calendar 

year. Also, it is possible that a practitioner could use technology certified to an edition that 

qualifies for CCM payment that could also be used to achieve Meaningful Use for a given 

calendar year, but still not meet the objectives and associated measures of a particular stage of 

Meaningful Use that are required to qualify for an EHR Incentive payment or avoid a downward 

adjustment to payments. As the commenters noted, the Meaningful Use measures are not all 
CMS-1612-FC 477

relevant to the provision of CCM services, and the practitioner may not have sufficient certified 

technology to support all the necessary or relevant Meaningful Use objectives and measures 

under the EHR Incentive Programs. Certified technology is used in different ways to meet the 

requirements of each program. We believe that the policy we are finalizing here aligns the CCM 

scope of service element to the extent appropriate with the EHR Incentive Programs to achieve 

maximum consistency. 

Comment: Several commenters asked us to clarify the requirement for the electronic care 

plan in relationship to the overall requirement for a certified EHR and in relationship to the 24/7 

access requirement. The commenters stated they were not sure whether these proposals were 

independent provisions or impacted one another. The commenters stated that if CMS intended 

these as independent provisions, the agency should identify objective criteria to evaluate whether 

a particular health IT product has adequate capabilities to meet the separate requirement for the 

electronic care plan. The commenters stated they were not sure whether the electronic care plan 

would require a certified EHR, or whether there would be an exception to use of CEHRT for the 

care plan. The commenters recommended flexibility in how practitioners and providers capture, 

develop, update and share care plan information. One commenter recommended that if 

practitioners must attest to use of a qualifying electronic care plan, CMS should only require a 

simple yes/no response to minimize billing impediments. One commenter asked us to clarify the 

required elements of the care plan in relation to different EHR systems. 

In addition, several commenters requested that we clarify whether the care plan must be 

electronically accessible 24/7 to all providers treating the patient’s chronic conditions, those 

within the billing practice, or those within the billing practice who are communicating with the 

patient after hours. The commenters noted that providers other than the billing practitioner may 
CMS-1612-FC 478

not use the same certified EHR, so it would be unreasonable to expect the same care plan and 

other relevant information to be accessible to all providers at all times. Other commenters 

believed we proposed flexibility around the certified EHR requirement in relation to the 

electronic care plan, and supported this proposed flexibility. 

Response: Regarding the care plan, we proposed that CCM services must be furnished 

with the use of an EHR or other health IT or health information exchange platform (not 

necessarily a certified EHR) that includes an electronic care plan that is accessible at all times to 

the practitioners within the practice, including those who are furnishing CCM outside of normal 

business hours. By practitioners “within the practice,” we mean any practitioners furnishing 

CCM services whose minutes count towards a given practice’s time requirement for reporting 

the CCM billing code. 

In addition, we proposed that the electronic care plan must be available to be shared 

electronically with care team members outside the practice (who are not billing for CCM). We 

sought to convey that practitioners could satisfy these requirements related to the care plan 

without using the certified EHR technology. We specified that the certified EHR technology is 

only required to accomplish activities described in the scope of service elements that specifically 

mention a medical record or EHR. We said that a full list of problems, medications and 

medication allergies in the certified EHR (which would follow structured recording formats) 

must inform the care plan, not that the care plan itself must be created or transmitted among 

providers using certified EHR technology. We note that this was a limited proposal compared to 

our CY 2014 proposal that we did not finalize that would have required members of the chronic 

care team who are involved in the after-hours care of the patient to have access to the patient’s 

full electronic medical record instead of just the care plan (78 FR 74416 through 74417). 
CMS-1612-FC 479

Through separate requirements for the electronic care plan and the certified EHR, our 

intent was to require practitioners to use some form of electronic technology tool or service in 

fulfilling the care plan element (other than facsimile transmission), recognizing that certified 

EHR technology is limited in its ability to support electronic care planning at this time, and that 

practitioners must have flexibility to use a wide range of tools and services beyond certified EHR 

technology now available in the market to support electronic care planning. We intended that all 

care team members furnishing CCM services that are billed by a given practice (contributing to 

the minimum time required for billing) must have access to the electronic care plan at all times 

when furnishing CCM services. However, the electronic care plan would not have to be 

available at all times to other non-billing practices, recognizing that other practices may not be 

using compatible electronic technology or participating in a health information exchange. 

We are finalizing the electronic care plan and 24/7 access elements as proposed, 

clarifying that to satisfy the care plan scope of service element, practitioners must electronically 

capture care plan information and make this information available to all care team members 

furnishing CCM services that are billed by a given practice (counting towards the minimum 

monthly service time), even when furnishing CCM outside of normal business hours. In 

addition, practitioners must electronically share care plan information as appropriate with other 

providers and practitioners who are furnishing care to the patient. We are not requiring that 

practitioners use a specific electronic technology to meet the requirement for 24/7 access to the 

care plan or its transmission, only that they use an electronic technology other than facsimile. 

For instance, practices may satisfy the 24/7 care plan access requirement through remote access 

to an EHR, web-based access to a care management application, or web-based access to a health 

information exchange service that captures and maintains care plan information. Likewise, we 
CMS-1612-FC 480

are not requiring that practitioners use a specific electronic technology to meet the requirement to 

share care plan information electronically with other practitioners and providers who are not 

billing for CCM. For instance, practitioners may meet this sharing requirement through the use 

of secure messaging or participation in a health information exchange with those practitioners 

and providers, although they may not use facsimile transmission. 

While we are not requiring that practitioners use a specific electronic technology at this 

time (other than not allowing facsimile), we may revisit this requirement as standards-based 

exchange of care plan information becomes more widely available in the future. We remind 

stakeholders that for all electronic sharing of beneficiary information under our final CCM 

policies, HIPAA standards apply in the usual manner. 

Comment: Several commenters asked us to clarify the relationship between the certified 

EHR proposal and the summary record exchange requirement. Commenters believed that CMS 

had cited specific regulatory provisions around exchange in the proposed rule (identified by the 

commenter as a Summary Record Exchange (SRE) capability tag, referring to a designation used 

to identify those products on the Certified Health IT Product List maintained by ONC offering 

technology certified to criteria around the exchange of summary care records) and should 

consider alternatives. The commenters were not clear as to whether they objected to what they 

believed to be the proposed format or the transmission method of the summary record exchange. 

Response: In the CY 2014 PFS final rule with comment period, as part of the care 

transitions management scope of service element, we indicated that the practice must be able to 

facilitate the communication of relevant patient information through electronic exchange of a 

summary care record with other health care providers (78 FR 74418). We did not specify a 

standard for the “summary care record” that providers must exchange electronically, nor did we 
CMS-1612-FC 481

specify a method by which providers must facilitate the communication of beneficiary 

information, such as use of certified EHR technology. In the CY 2015 PFS proposed rule (79 FR 

40367), we proposed that the practitioner must utilize EHR technology certified by a certifying 

body authorized by the National Coordinator for Health Information Technology to an edition of 

the EHR certification criteria identified in the then-applicable version of 45 CFR part 170. Under 

one of the specific certification criteria cited, we proposed that practitioners must use technology 

that meets the criterion adopted at §170.314(e)(2), which would ensure that they produce 

summary records formatted according to the standard adopted at §170.205(a)(3). However, we 

did not propose that this formatting standard must be used for the exchange of patient 

information, only that in furnishing CCM services, practitioners must format their summaries 

according to this standard. We did not propose that providers billing for CCM services must 

adopt any certified technology for the exchange of a summary care record, such as the 

transmission standard related to Direct Project Transport in § 170.314(b)(2)(ii). We recognized 

that providers are currently exchanging patient information to support transitions of care in a 

variety of meaningful ways beyond the methods specified with 2014 edition certified technology, 

with the exception of faxing which would not meet the proposed scope of service requirement. 

The 2014 edition sets specific requirements for transmission or exchange of the summary record 

that technology must meet for certification, and we expected that only some practitioners could 

adopt and use such technology in CY 2015. Therefore we did not constrain practitioners to the 

exchange functionality in the 2014 edition if they utilized an alternative electronic tool. 

As discussed above, our final policy will allow practitioners billing the PFS for CCM 

services to use the edition(s) of certification criteria that is acceptable for the EHR Incentive 

Programs as of December 31st of each calendar year preceding each PFS payment year to meet 
CMS-1612-FC 482

the final core technology capabilities (structured recording of demographics, problems, 

medications, medication allergies, and the creation of a structured clinical summary). (Also 

practitioners must use this CCM certified technology to fulfill the CCM scope of service 

requirements whenever the requirements reference a health or medical record). Under this final 

policy, practitioners must format their structured clinical summaries according to, at a minimum, 

the standard that is acceptable for the EHR Incentive Programs as of December 31st of the 

calendar year preceding each PFS payment year. 

We are finalizing our proposal that practitioners must communicate relevant patient 

information through electronic exchange of a summary care record to support transitions of care, 

with a clarification that practitioners do not have to use any specific content exchange standard 

in CY 2015. We did not propose and are not finalizing a requirement to use a specific tool or 

service to communicate beneficiary information, as long as providers do so electronically. We 

note however that faxing will not fulfill this requirement for exchange of the summary care 

record. We did not propose to modify our view, discussed in the CY 2014 PFS final rule with 

comment period, that practitioners furnishing and billing for CCM services must be able to 

support care transitions through the electronic exchange of beneficiary information in a summary 

care record (78 FR 74418). While certain 2014 edition certification criteria address a content 

standard and transmission method for exchange of a summary record, we continue to expect that 

only some practitioners could adopt and use such technology. Moreover, we recognize that 

providers are currently exchanging patient information to support transitions of care in a variety 

of meaningful ways beyond the methods specified in 2014 edition certification criteria. We 

continue to believe that at least for CY 2015, we should allow flexibility in the selection of the 

electronic tool or service that is used to transmit beneficiary information in support of care 
CMS-1612-FC 483

transitions, as long as practitioners electronically share beneficiary information to support 

transitions of care. Finally we remind stakeholders that for all electronic sharing of beneficiary 

information under our final CCM policies, HIPAA standards apply in the usual manner. 

Comment: Several commenters expressed concern about requiring a certified EHR for 

billing CCM. The commenters were concerned that CMS would not allow the use of noncertified technologies that may be more innovative and effective than certified technologies. 

Commenters requested that we clarify whether only the certified EHR (and no other electronic 

tool) could be used to conduct CCM services, for example the use of enhanced communication 

methods other than telephone. One commenter stated that many times the practice will be using 

the certified EHR system to carry out such activities, and there are strong Meaningful Use 

incentives to employ the certified EHR for these activities. However, a practice may also have 

other capabilities and tools that would support elements of the CCM services. These 

commenters asked us to clarify whether the requirement to utilize certified EHR technology is a 

literal statement that only certified EHR technology may be used in furnishing the scope of 

service elements for CCM services. 

Response: We continue to believe that health IT tools are most effective when there are 

no technological or business impediments to data sharing, or disparate technology platforms used 

by multiple practitioners trying to coordinate care. For the separately billable CCM service, we 

believe it is necessary to establish as part of the scope of the service a certified EHR that allows 

for the data capture, accessibility and sharing capabilities necessary to furnish the service. 

Therefore, we are finalizing our proposal to require use of CCM certified technology to meet the 

final core technology capabilities (structured recording of demographics, problems, medications, 

medication allergies, and the creation of a structured clinical summary). In addition, whenever a 
CMS-1612-FC 484

scope of service element references a health or medical record, CCM certified technology must 

be used to fulfill that scope of service element in relation to the health or medical record. We 

have listed above the current scope of service elements that include a reference to a health or 

medical record. If both CCM certified technology and other methods are available to the 

practitioner to fulfill the final core technology capabilities for CCM (structured recording of 

demographics, problems, medications, medication allergies, and the creation of a structured 

clinical summary) or the CCM scope of service elements referencing a the health or medical 

record, practitioners may only use the certified capability. We remind stakeholders that for all 

electronic sharing of beneficiary information under our final CCM policies, HIPAA standards 

apply in the usual manner. 

Comment: One commenter recommended that we adopt the following additional 2014 

EHR certification criteria: 

• Patient List Creation (45 CFR 170.314(a)(14)), which would support the required 

element of service for preventive services and routine appointments, and could help provide 

registry types of functions for the practice to use in managing patients who have agreed to 

participate in the chronic care management service. 

• Patient-Specific Education Resources (§170.314(a)(15)), which would help assure the 

ability to provide the patient with relevant educational materials about their chronic disease 

conditions. 

• Clinical Reconciliation (§170.314(b)(4)), which would serve support the medication 

reconciliation requirement and the requirement to review patient adherence to their medication 

regime. 

• View/Download/Transmit to a 3rd Party (§170.314(e)(1)), which would enable 
CMS-1612-FC 485

patients to access their own electronic health record and have access to information related to 

their care at their own convenience. 

• Secure Messaging, Ambulatory Setting Only (§170.314(e)(3)). 

Response: Some of these 2014 certification criteria are not relevant (have no corollary) 

in the 2011 certification criteria, so we would not require them because practitioners are not 

required to use the 2014 edition in CY 2015. In addition, we are requiring that providers use 

certified EHR technology to fulfill a limited number of the scope of service elements 

(summarized in Table 33). We are requiring the certified technology only for certain 

foundational elements, and believe we should avoid making the EHR requirement for CCM 

unnecessarily complex at this time. While we agree that the other features of certified EHR 

products mentioned by the commenter would certainly help many practitioners fulfill the other 

elements of the CCM service, practitioners may be using tools other than certified technology 

that are adequate for the required task(s), for example, registry tools for patient list creation, 

educational resources, patient portals, third party reconciliation services, and secure messaging 

systems. 

Comment: We received many comments on the scope of service elements other than the 

EHR, some requesting that we implement additional standards. A few commenters said CMS 

should consider adding a requirement for use of community based providers through a home visit 

at least once every 12 months to assess the home environment and the need for community based 

resources, or that CMS should include home and domiciliary care, group visits and community 

based care. Several commenters wanted us to include “remote patient monitoring” or “patient 

generated health data” in the scope of services, such as daily remote monitoring of physiology 

and biometrics. Several commenters recommended additional tools for patient self-management 
CMS-1612-FC 486

education and training, or “patient activation” tools. One commenter recommended we require a 

patient experience survey to assess the patient’s perspective regarding the CCM services they 

receive. Several commenters believed we should expand the medication management and 

medication reconciliation element to include more comprehensive medication management and 

more clearly define “review of adherence” to the medication regimen. 

Response: Other than the scope of service element for EHR and other electronic 

technology, we do not believe additional changes to the scope of service elements for CCM are 

warranted at this time. We are requiring certified EHR technology for certain foundational or 

“core” elements, including structured recording of medications and medication allergies. As 

finalized in the scope of service in the CY 2014 PFS final rule with comment period we are also 

requiring medication reconciliation with review of adherence and potential interactions, and 

oversight of patient self-management of medications. We believe it would be overly 

burdensome, especially given the broad eligible beneficiary population and final RVU inputs, to 

include more specific requirements related to medication management, especially when greater 

specificity is likely not necessary to ensure adequate care. The CCM services are by definition 

non-face-to-face services; therefore we are not including a requirement for home or domiciliary 

visits or community based care (although there is a requirement related to coordinating home and 

community based care). Practitioners who engage in remote monitoring of patient physiological 

data of eligible beneficiaries may count the time they spend reviewing the reported data towards 

the monthly minimum time for billing the CCM code, but cannot include the entire time the 

beneficiary spends under monitoring or wearing a monitoring device. If we believe changes to 

the scope of service elements are warranted in the future, we will propose them through notice 

and comment rulemaking taking the comments we received to date into consideration. 
CMS-1612-FC 487

 Comment: We received many comments on the scope of service elements other than the 

EHR, requesting that CMS implement fewer standards. Some commenters believed that other 

than the “incident to” provisions, the scope of service elements are administratively burdensome 

and it will be difficult for physicians to adequately document that they have fulfilled the 

requirements. Several commenters did not believe it was necessary to require written beneficiary 

consent. Others asked that CMS develop model beneficiary consent forms. 

 Response: We understand the commenters’ concerns about adequate documentation, 

although this issue is not unique to CCM services. We believe the additional scope of service 

element for the EHR and electronic sharing of the care plan and clinical summary record will 

create an electronic “footprint” that will facilitate documentation, including documentation of the 

minimum monthly amount of time spent in providing CCM services. 

Regarding beneficiary consent, we believe written beneficiary consent and its 

documentation in the medical record is necessary because we are requiring practices to share 

beneficiaries’ protected health information both within and outside of the billing practice in the 

course of furnishing CCM services and because beneficiaries will be required to pay coinsurance 

on non-face-to-face services. We do not believe the content or nature of the required consent is 

so complex that we should develop model formats. If we believe changes to the scope of service 

elements are warranted in the future, we will propose them through notice and comment 

rulemaking taking the comments we received to date into consideration. 

In summary, we are finalizing our proposal for the CCM scope of service element for 

EHR technology as proposed, with the following modification. We are including as an element 

of the separately billable CCM service the use of, at a minimum, technology certified to the 

edition(s) of certification criteria that is acceptable for the EHR Incentive Programs as of 
CMS-1612-FC 488

December 31st of the calendar year prior to the PFS payment year (CCM certified technology), to 

meet the final core EHR capabilities (structured recording of demographics, problems, 

medications, medication allergies and the creation of a structured clinical summary record) and 

to fulfill all activities within the final scope of service elements that reference a health or medical 

record. For CCM payment in CY 2015, this policy will allow practitioners to use EHR 

technology certified to either the 2011 or 2014 edition(s) of certification criteria. The final scope 

of service elements that refer to a health or medical record, and that must be fulfilled using the 

CCM certified technology, are summarized in Table 33 and include the following: 

● A full list of problems, medications and medication allergies in the EHR must inform 

the care plan, care coordination and ongoing clinical care. 

● Communication to and from home and community based providers regarding the 

patient’s psychosocial needs and functional deficits must be documented in the patient’s medical 

record. 

● Inform the beneficiary of the availability of CCM services and obtain his or her written 

agreement to have the services provided, including authorization for the electronic 

communication of his or her medical information with other treating providers. Document in the 

beneficiary’s medical record that all of the CCM services were explained and offered, and note 

the beneficiary’s decision to accept or decline these services. 

● Provide the beneficiary a written or electronic copy of the care plan and document in 

the electronic medical record that the care plan was provided to the beneficiary. 

 We are finalizing our proposal regarding the electronic care plan scope of service element 

without modification. To satisfy this element, practitioners must at least electronically capture 

care plan information; make this information available on a 24/7 basis to all practitioners within 
CMS-1612-FC 489

the practice who are furnishing CCM services whose time counts towards the time requirement 

for the practice to bill the CCM code; and share care plan information electronically (other than 

by facsimile) as appropriate with other practitioners and providers who are furnishing care to the 

beneficiary. We are not requiring practitioners to use a specific electronic solution to furnish the 

care plan element of the CCM service, only that the method must be electronic and cannot 

include facsimile transmission. 

Similarly, we are not requiring practitioners to use a specific tool or service to 

communicate clinical summaries in managing care transitions, as long as practitioners transmit 

the clinical summaries electronically, with the exception of faxing which will not fulfill the 

requirement for exchange of a summary care record. However practitioners must format their 

clinical summaries according to, at a minimum, the standard that is acceptable for the EHR 

Incentive Programs as of December 31st of the calendar year preceding each PFS payment year. 

We remind stakeholders that for all electronic sharing of beneficiary information under our final 

CCM policies, HIPAA standards apply in the usual manner. We summarize the final 

requirements for the CCM scope of service elements and billing requirements for CY 2015 and 

their relationship to the final EHR requirements in Table 33. 
CMS-1612-FC 490

TABLE 33: Summary of Final CCM Scope of Service Elements and Billing Requirements for CY 2015 

CCM Scope of Service Element/Billing Requirement Certified EHR or Other Electronic 

Requirement 

Structured recording of demographics, problems, medications, 

medication allergies, and the creation of a structured clinical 

summary record. A full list of problems, medications and 

medication allergies in the EHR must inform the care plan, care 

coordination and ongoing clinical care. 

Structured recording of demographic

medications, medication allergies, and crea

clinical summary records using CCM cert

Access to care management services 24/7 (providing the 

beneficiary with a means to make timely contact with health care 

providers in the practice to address his or her urgent chronic care 

needs regardless of the time of day or day of the week). 

None 

Continuity of care with a designated practitioner or member of the 

care team with whom the beneficiary is able to get successive 

routine appointments. 

None 

Care management for chronic conditions including systematic 

assessment of the beneficiary’s medical, functional, and 

psychosocial needs; system-based approaches to ensure timely 

receipt of all recommended preventive care services; medication 

reconciliation with review of adherence and potential interactions; 

and oversight of beneficiary self-management of medications. 

None 

Creation of a patient-centered care plan based on a physical, 

mental, cognitive, psychosocial, functional and environmental 

(re)assessment and an inventory of resources and supports; a 

comprehensive care plan for all health issues. Share the care plan 

as appropriate with other practitioners and providers. 

Must at least electronically capture care p

make this information available on a 24

practitioners within the practice whose tim

the time requirement for the practice to bi

and share care plan information electronica

fax) as appropriate with other practitione

Provide the beneficiary with a written or electronic copy of the care 

plan and document its provision in the electronic medical record. 

Document provision of the care plan as 

beneficiary in the EHR using CCM certi
CMS-1612-FC 491

CCM Scope of Service Element/Billing Requirement Certified EHR or Other Electronic 

Requirement 

Management of care transitions between and among health care 

providers and settings, including referrals to other clinicians; 

follow-up after an emergency department visit; and follow-up after 

discharges from hospitals, skilled nursing facilities or other health 

care facilities. 

• Format clinical summaries acco

certified technolog

• Not required to use a specific to

exchange/transmit clinical summ

they are transmitted electronicall

fax). 

Coordination with home and community based clinical service 

providers. 

Communication to and from home and co

providers regarding the patient’s psycho

functional deficits must be documented 

medical record using CCM certified 

Enhanced opportunities for the beneficiary and any caregiver to 

communicate with the practitioner regarding the beneficiary’s care 

through not only telephone access, but also through the use of 

secure messaging, internet or other asynchronous non face-to-face 

consultation methods. 

None 

Beneficiary consent - Inform the beneficiary of the availability of 

CCM services and obtain his or her written agreement to have the 

services provided, including authorization for the electronic 

communication of his or her medical information with other 

treating providers. Document in the beneficiary’s medical record 

that all of the CCM services were explained and offered, and note 

the beneficiary’s decision to accept or decline these services. 

Document the beneficiary’s written 

authorization in the EHR using CCM cert

Beneficiary consent - Inform the beneficiary of the right to stop the 

CCM services at any time (effective at the end of the calendar 

month) and the effect of a revocation of the agreement on CCM 

services. 

None 
CMS-1612-FC 492

CCM Scope of Service Element/Billing Requirement Certified EHR or Other Electronic 

Requirement 

Beneficiary consent - Inform the beneficiary that only one 

practitioner can furnish and be paid for these services during a 

calendar month. 

None 
CMS-1612-FC 493

4. Payment of CCM Services in CMS Models and Demonstrations 

As discussed in section II.G., several CMS models and demonstrations address payment 

for care management services. The Multi-payer Advanced Primary Care Practice (MAPCP) 

Demonstration and the Comprehensive Primary Care (CPC) Initiative both include payments for 

care management services that closely overlap with the scope of service for the new chronic care 

management services code. In these two initiatives, primary care practices are receiving per 

beneficiary per month payments for care management services furnished to Medicare fee-forservice beneficiaries attributed to their practices. We proposed that practitioners participating in 

one of these two models may not bill Medicare for CCM services furnished to any beneficiary 

attributed to the practice for purposes of participating in one of these initiatives, as we believe 

the payment for CCM services would be a duplicative payment for substantially the same 

services for which payment is made through the per beneficiary per month payment. However, 

we proposed that these practitioners may bill Medicare for CCM services furnished to eligible 

beneficiaries who are not attributed to the practice for the purpose of the practice’s participation 

as part of one of these initiatives. As the Innovation Center implements new models or 

demonstrations that include payments for care management services, or as changes take place 

that affect existing models or demonstrations, we will address potential overlaps with the CCM 

service and seek to implement appropriate reimbursement policies. We solicited comments on 

this proposal. We also solicited comments on the extent to which these services may not actually 

be duplicative and, if so, how our reimbursement policy could be tailored to address those 

situations. 

We received several comments that either supported or did not oppose our proposed 

policy regarding the payment of CCM services in CMS models and demonstrations that also pay 

for care management services. 
CMS-1612-FC 494

The following is a summary of the other comments we received regarding our proposals 

on reimbursement policies. 

Comment: Two commenters requested that we reconsider our proposed policy to exclude 

demonstration practitioners from billing for CCM services to ensure that these practitioners are 

not disadvantaged relative to those practitioners who do not participate in demonstrations or 

models. 

Response: Our proposed policy does not exclude practitioners participating in 

demonstrations or models from billing for CCM services. To reiterate, practitioners participating 

in demonstrations or models may bill Medicare for CCM services for beneficiaries who are not 

attributed to the practices for purposes of participating in either the MAPCP or CPC. For 

beneficiaries who are not attributed to the practice, no care management payment is made under 

the MAPCP or CPC models. If the beneficiary otherwise meets the criteria for CCM services, 

the practitioner may furnish and bill Medicare for CCM. However, Medicare will not pay 

practitioners participating in MAPCP or CPC for CCM services furnished to beneficiaries 

attributed to the practice for the purpose of the practice’s participation in either these models. 

We believe we have created a pathway to enable practitioners participating in CPC or MAPCP to 

bill Medicare for the CCM services, as not all beneficiaries treated in a practice will be attributed 

to the practice. 

Comment: We received two comments expressing concern for confusion that might 

occur regarding the interaction of CCM services and the CPC model. 

Response: We acknowledge that the Innovation Center will need to engage in extensive 

communications efforts with practitioners participating in either CPC or MAPCP to inform them 

of our policies regarding billing for CCM services. 

Comment: One individual commented that payment for CCM “should not be 
CMS-1612-FC 495

constrained” by the payment in a demonstration. The commenter also said, “The two payments 

are completely unrelated and are made for different purposes to very different physician 

practices. Also, we do not believe it is possible to know with certainty whether there is overlap 

between a fee‐for‐service chronic care management payment and a payment for care 

coordination in a demonstration.” 

Response: The proposed policy aims not to constrain practitioners voluntarily 

participating in Innovation Center models and demonstrations, specifically CPC and MAPCP, by 

allowing them to bill Medicare for CCM services furnished to beneficiaries for whom they are 

not receiving payments as part of these initiatives. We expect the practitioners participating in 

these initiatives will be eligible to bill the CCM service for some beneficiaries, as there is 

overlap between elements of the CCM service and the models. For example, the CPC model 

requires practitioners to use electronic health records that have been certified by the National 

Coordinator for Health Information Technology, provide patients with 24/7 access to the 

practice, ensure continuity of care with a designated practitioner or care team for each patient, 

provide care management that includes a systematic assessment of patient needs, use patientcentered care plans, and give enhanced opportunities for patient and caregiver communications. 

Similarly, the MAPCP demonstration is testing the patient-centered medical home model, which 

focuses on care management, continuity of care, and care coordination. All practitioners, who 

are voluntarily participating in these initiatives, receive quarterly reports indicating which 

beneficiaries have been attributed to their practices. After reviewing and comparing the features 

of the CPC and MAPCP models with the CCM service, we continue to be convinced that there is 

overlap. The CCM service provides appropriate payment for care management and care 

coordination furnished to beneficiaries with multiple chronic conditions within the current feefor-service Medicare program, while Innovation Center models and demonstrations test 
CMS-1612-FC 496

alternative payment methods that promote less reliance on a fee-for-service funding stream and 

support primary care delivery transformation at the practice level to identify potential future 

alternative approaches to payment. 

In response to these comments, we will engage in extensive communications explaining 

to practices participating in CMMI models and demonstrations, specifically the CPC and 

MAPCP initiatives, the policies related to care management payments under these initiatives and 

the CCM service. We continue to believe the payment for CCM services would be a duplicative 

payment for substantially the same services included in the per beneficiary per month payment 

under the CPC and MAPCP models. Therefore, we are finalizing our proposed policy that CMS 

will not pay practitioners participating in one of these two initiatives for CCM services furnished 

to any beneficiary attributed by the initiative to the practice. These practitioners may bill 

Medicare for CCM services furnished to eligible beneficiaries who are not attributed by the 

initiative to the practice. As the Innovation Center implements new models or demonstrations 

that include payments for care management services, or as changes take place that affect existing 

models or demonstrations, we will address potential overlaps with the CCM service and seek to 

implement appropriate payment policies. 
CMS-1612-FC 497

I. Outpatient Therapy Caps for CY 2015 

 Section 1833(g) of the Act requires application of annual, per beneficiary, limitations on 

the amount of expenses that can be considered as incurred expenses for outpatient therapy 

services under Medicare Part B, commonly referred to as “therapy caps.” There is one therapy 

cap for outpatient occupational therapy (OT) services and another separate therapy cap for 

physical therapy (PT) and speech-language pathology (SLP) services combined. 

 The therapy caps apply to outpatient therapy services furnished in all settings, including 

the once-exempt outpatient hospital setting (effective October 1, 2012) and critical access 

hospitals (effective January 1, 2014). 

 The therapy cap amounts under section 1833(g) of the Act are updated each year based 

on the Medicare Economic Index (MEI). Specifically, the annual caps are calculated by 

updating the previous year’s cap by the MEI for the upcoming calendar year and rounding to the 

nearest $10.00. Increasing the CY 2014 therapy cap of $1,920 by the CY 2015 MEI of 0.8 

percent and rounding to the nearest $10.00 results in a CY 2015 therapy cap amount of $1,940. 

 An exceptions process for the therapy caps has been in effect since January 1, 2006. 

Originally required by section 5107 of the Deficit Reduction Act of 2005 (DRA), which 

amended section 1833(g)(5) of the Act, the exceptions process for the therapy caps has been 

extended multiple times through subsequent legislation (MIEA-TRHCA, MMSEA, MIPPA, the 

Affordable Care Act, MMEA, TPTCCA, MCTRJCA, ATRA and PAMA). The Agency’s 

current authority to provide an exceptions process for therapy caps expires on March 31, 2015. 

 After expenses incurred for the beneficiary’s outpatient therapy services for the year have 

exceeded one or both of the therapy caps, therapy suppliers and providers use the KX modifier 

on claims for subsequent services to request an exception to the therapy caps. By use of the KX 

modifier, the therapist is attesting that the services above the therapy caps are reasonable and 
CMS-1612-FC 498

necessary and that there is documentation of medical necessity for the services in the 

beneficiary’s medical record. 

 Under section 1833(g)(5)(C) of the Act, we are required to apply a manual medical 

review process to therapy claims when a beneficiary’s incurred expenses for outpatient therapy 

services exceed a threshold amount of $3,700. There are two separate thresholds of $3,700, just 

as there are two separate therapy caps, one for OT services and one for PT and SLP services 

combined, and incurred expenses are counted towards the thresholds in the same manner as the 

caps. The statutorily required manual medical review expires March 31, 2015, consistent with 

the expiration of the Agency’s authority to provide an exceptions process for the therapy caps. 

For information on the manual medical review process, go to www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medical-Review/TherapyCap.html.
CMS-1612-FC 499

J. Definition of Colorectal Cancer Screening Tests 

 As discussed in the proposed rule (79 FR 40368), section 1861(pp) of the Act defines 

“colorectal cancer screening tests” and, under section 1861(pp)(1)(C), a “screening colonoscopy” 

is one of the recognized procedures. Among other things, section 1861(pp)(1)(D) of the Act 

authorizes the Secretary to modify the tests and procedures covered under this subsection, “with 

such frequency and payment limits, as the Secretary determines appropriate,” in consultation 

with appropriate organizations. The current definition of “colorectal cancer screening tests” at 

§410.37(a)(1) includes “screening colonoscopies.” Until recently, the prevailing practice for 

screening colonoscopies has been moderate sedation provided intravenously by the endoscopist, 

without resort to separately provided anesthesia.3 Based on this prevailing practice, payment for 

moderate sedation has accordingly been bundled into the payment for the colorectal cancer 

screening tests, (for example, G0104, G0105). For these procedures, because moderate sedation 

is bundled into the payment, the same physician cannot also report a sedation code. An 

anesthesia service can be billed by a second physician. 

 However, a recent study in The Journal of the American Medical Association (JAMA) 

cited an increase in the percentage of colonoscopies and upper endoscopy procedures furnished 

using an anesthesia professional, from 13.5 percent in 2003 to 30.2 percent in 2009 within the 

Medicare population, with a similar increase in the commercially-insured population.4

 A 2010 

study projected that the percentage of this class of procedures involving an anesthesia 

professional would grow to 53.4 percent by 2015.5 These studies suggest that the prevailing 

practice for endoscopies in general and screening colonoscopies in particular is undergoing a 

 

3 Faulx, A. L. et al. (2005). The changing landscape of practice patterns regarding unsedated colonoscopy and propofol use: A 

national web survey. Gastrointestinal Endoscopy, 62. 9-15. 4 Liu H, Waxman DA, Main R, Mattke S. Utilization of Anesthesia Services during Outpatient Endoscopies and Colonoscopies 

and Associated Spending in 2003-2009. (2012). JAMA, 307(11):1178-1184. 5 Inadomi, J. M. et al. (2010). Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and

EGD in the United States: 2009 to 2015. Gastrointestinal Endoscopy, 72, 580-586.
CMS-1612-FC 500

transition, and that anesthesia separately provided by an anesthesia professional is becoming the 

prevalent practice. In preparation for the proposed rule, we reviewed these studies and analyzed 

Medicare claims data. We saw the same trend in screening colonoscopies for Medicare 

beneficiaries with 53 percent of the screening colonoscopies for Medicare claims submitted in 

2013 had a separate anesthesia claim reported. 

 In light of these developments, we expressed our concern in the proposed rule that the 

mere reference to “screening colonoscopies” in the definition of “colorectal cancer screening 

tests” has become inadequate. Indeed, we were convinced that the growing prevalence of 

separately provided anesthesia services in conjunction with screening colonoscopies reflects a 

change in practice patterns. Therefore, consistent with the authority delegated by section 

1861(pp)(1)(D) of the Act, we proposed to revise the definition of “colorectal cancer screening 

tests” to adequately reflect these new patterns. Specifically, we proposed to revise the definition 

of “colorectal cancer screening tests” at §410.37(a)(1)(iii) to include anesthesia that is separately 

furnished in conjunction with screening colonoscopies (79 FR 40369). 

 We also stated that our proposal to revise the definition of “colorectal cancer screening 

tests” in this manner would further reduce our beneficiaries’ cost-sharing obligations under Part 

B. Screening colonoscopies have been recommended with a grade of A by the United States 

Preventive Services Task Force (USPSTF) and §410.152(l)(5) provides that Medicare Part B 

pays 100 percent of the Medicare payment amount established under the PFS for colorectal 

cancer screening tests except for barium enemas (which do not have a grade A or B 

recommendation from the USPSTF). This regulation is based on section 1833(a)(1) of the Act, 

as amended by section 4104 of the Affordable Care Act, which requires 100 percent Medicare 

payment of the fee schedule amount for those “preventive services” that are appropriate for the 

individual and are recommended with a grade of A or B by the USPSTF. Section 4104 of the 
CMS-1612-FC 501

Affordable Care Act amended section 1833(a)(1) of the Act to effectively waive any Part B 

coinsurance that would otherwise apply for certain recommended preventive services, including 

screening colonoscopies For additional discussion of the impact of section 4104 of the 

Affordable Care Act, and our prior rulemaking based on this provision see the CY 2011 PFS 

final rule with comment period (75 FR 73412 through 73431). We also noted that under 

§410.160(b)(7) colorectal cancer screening tests are not subject to the Part B annual deductible 

and do not count toward meeting that deductible. 

 In implementing the amendments made by section 4104 of the Affordable Care Act, we 

did not provide at that time for waiving the Part B deductible and coinsurance for covered 

anesthesia services separately furnished in conjunction with screening colonoscopies. At that 

time, we believed that our payment for the screening colonoscopy, which included payment for 

moderate sedation services, reflected the typical screening colonoscopy. Under the current 

regulations, Medicare beneficiaries who receive anesthesia from a different professional than the 

one furnishing the screening colonoscopy would be incurring costs for the coinsurance and 

deductible under Part B for those separate services. With the changes in the standard of care and 

shifting practice patterns toward increased use of anesthesia in conjunction with screening 

colonoscopy, beneficiaries who receive covered anesthesia services from a different professional 

than the one furnishing the colonoscopy would incur costs for any coinsurance and any unmet 

part of the deductible for this component of the service. However, our proposed revision to the 

definition of “colorectal cancer screening tests” would lead to Medicare paying 100 percent of 

the fee schedule amounts for screening colonoscopies, including any portion attributable to 

anesthesia services furnished by a separate practitioner in conjunction with such tests, under 

§410.152(l)(5). Similarly, this revision would also mean that expenses incurred for a screening 

colonoscopy, and the anesthesia services furnished in conjunction with such tests, will not be 
CMS-1612-FC 502

subject to the Part B deductible and will not count toward meeting that deductible under 

§410.160(b)(7). We believe the proposal encourages more beneficiaries to obtain a screening 

colonoscopy, which is consistent with the intent of the statutory provision to waive Medicare 

cost-sharing for certain recommended preventive services, and is consistent with the authority 

delegated to the Secretary in section 1861(pp)(1)(D) of the Act. 

 In light of the changing practice patterns for screening colonoscopies, continuing to 

require Medicare beneficiaries to bear the deductible and coinsurance expenses for separately 

billed anesthesia services furnished and covered by Medicare in conjunction with screening 

colonoscopies could become a significant barrier to these essential preventive services. As we 

noted when we implemented the provisions of the Affordable Care Act waiving the Part B 

deductible and coinsurance for these preventive services, the goal of these provisions was to 

eliminate financial barriers so that beneficiaries would not be deterred from receiving them 

(75 FR 73412). Therefore, we proposed to exercise our authority under section 1861(pp)(1)(D) 

of the Act to revise the definition of colorectal cancer screening tests to encourage beneficiaries 

to seek these services by extending the waiver of coinsurance and deductible to anesthesia or 

sedation services furnished in conjunction with a screening colonoscopy. 

 We noted in the proposed rule (79 FR 40370) that, in implementing these proposed 

revisions to the regulations, it would be necessary to establish a modifier for use when billing the 

relevant anesthesia codes for services that are furnished in conjunction with a screening 

colonoscopy, and thus, qualify for the waiver of the Part B deductible and coinsurance. 

Therefore, we noted that we would provide appropriate and timely information on this new 

modifier and its proper use so that physicians will be able to bill correctly for these services 

when the revised regulations become effective. We also noted that the valuation of colonoscopy 

codes, which include moderate sedation, would be subject to the same proposed review as other 
CMS-1612-FC 503

codes that include moderate sedation, as discussed in section II.B.6 of this final rule with 

comment period. 

 The following is a summary of the comments received on this proposal. 

 Comment: The majority of commenters strongly supported finalizing our proposal to 

revise the definition of “colorectal cancer screening tests” at §410.37(a)(1)(iii) to include 

anesthesia that is furnished in conjunction with screening colonoscopies. However, one 

commenter expressed concern about the timing of the proposal, and specifically that it leaves 

little time for implementation in CY 2015. Therefore, the commenter recommended that the 

proposal should be considered for implementation in CY 2016. 

 Response: We appreciate the support for our proposal and are finalizing it as proposed. 

Specifically, we are revising the definition of “colorectal cancer screening tests” at 

§410.37(a)(1)(iii) to include anesthesia that is furnished in conjunction with screening 

colonoscopies. We disagree with the recommendation to delay implementation until CY 2016. 

The proposed implementation on January 1st following the finalization of the policy in the final 

rule follows the usual PFS schedule for implementation of payment changes. We are not aware 

of a reason for deviating from the usual schedule for this policy. Therefore, we are 

implementing this final rule, effective January 1, 2015. 

 Comment: Many commenters urged us to extend our proposed revision, by identifying a 

way under our existing authority to redefine colorectal cancer screening to include screening 

colonoscopy with removal of polyp, abnormal growth, or tissue during the screening encounter. 

Commenters stated that there is already substantial confusion among beneficiaries about why 

colonoscopy with polyp removal requires payment of coinsurance, while colonoscopy without 

polyp removal does not. The commenters maintained that our proposal to include anesthesia that 

is separately furnished in conjunction with screening colonoscopies within the definition of 
CMS-1612-FC 504

screening colonoscopy would only cause additional confusion, unless screening colonoscopies 

with removal of polyp, along with any anesthesia separately furnished in conjunction with such 

procedures, are also included within the definition. Because our proposal rule did not seek to 

make changes to our policies with respect to diagnostic colonoscopies, the commenters were 

concerned that, beneficiaries may be liable for part B coinsurance for both diagnostic 

colonoscopy and any anesthesia furnished in conjunction with the colonoscopy when a polyp is 

removed. Commenters also stated that extending our proposal in this manner would be good 

public policy, because it would reduce the disincentives to this essential preventive service posed 

by possible liability for coinsurance if a polyp is discovered and removed during a screening 

colonoscopy. The commenters also emphasized that further extending the definition in this way 

would remove an inconsistency between Medicare policy and the new requirements for private 

health plans that prohibit the imposition of cost sharing when a polyp is removed under the 

Affordable Care Act. 

 Response: We understand the commenters’ concerns, however, we do not have the 

authority to adopt the recommended revisions by regulation. 

 Our authority is limited by the language of the Medicare Act. Specifically, section 

1834(d)(3)(D) of the Act states that, “[i]f during the course of such a screening colonoscopy, a 

lesion or growth is detected which results in a biopsy or removal of the lesion or growth, 

payment under this part shall not be made for the screening colonoscopy but shall be made for 

the procedure classified as a colonoscopy with such biopsy or removal.” As a result of this 

statutory provision, when an anticipated screening colonoscopy ends up involving a biopsy or 

polyp removal, Medicare cannot pay for this procedure as a screening colonoscopy. In these 

circumstances, Medicare pays 80 percent of the diagnostic colonoscopy procedure and the 

beneficiary is responsible for paying Part B coinsurance. Under the statute, when a polyp or 
CMS-1612-FC 505

other growth is removed, beneficiaries are responsible for Part B coinsurance for the diagnostic 

colonoscopy, and similarly, any Part B coinsurance for any covered anesthesia. 

 Comment: Commenters stated that the proposal was not clear on how the deductible will 

be treated in the case of anesthesia services when a polyp or other tissue is removed during a 

screening colonoscopy. 

 Response: Section 1833(b)(1) of the Act, as amended by section 4104(c) of the 

Affordable Care Act, waives the Part B deductible for “colorectal screening tests regardless of 

the code billed for the establishment of a diagnosis as a result of the test, or the removal of tissue 

or other matter or other procedure that is furnished in connection with, as a result of, and in the 

same clinical encounter as a screening test.” We explained this provision in the CY 2011 PFS 

final rule with comment period (75 FR 73431). We apply this policy to any surgical service 

furnished on the same date as a planned colorectal cancer screening test. Our regulations at 

§410.152(l)(5) already require Medicare Part B to pay 100 percent of the Medicare payment 

amount for colorectal cancer screening tests (excluding barium enema). The statutory waiver of 

deductible will apply to the anesthesia services furnished in conjunction with a colorectal cancer 

screening test even when a polyp or other tissue is removed during a colonoscopy. As in the 

case of the physician furnishing the colonoscopy service, the anesthesia professional reporting 

the anesthesia in conjunction with the colonoscopy where a polyp is removed would also report 

the PT modifier. 

 Comment: Commenters urged CMS to provide guidance as to whether CPT code 00810 

(Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to 

duodenum) would be billed with a modifier to indicate whether the procedure was screening or 

not. 
CMS-1612-FC 506

 Response: Effective January 1, 2015, beneficiary coinsurance and deductible do not 

apply to the following anesthesia claim lines billed when furnished in conjunction with screening 

colonoscopy services and billed with the appropriate modifier (33): 00810 (Anesthesia for lower 

intestinal endoscopic procedures, endoscope introduced distal to duodenum). Anesthesia 

professionals who furnish a separately payable anesthesia service in conjunction with a 

colorectal cancer screening test should include the 33 modifier on the claim line with the 

anesthesia service. As noted above in situations that begin as a colorectal cancer screening test, 

but for which another service such as colonoscopy with polyp removal is actually furnished, the 

anesthesia professional should report a PT modifier on the claim line rather than the 33 modifier. 

 Comment: Several commenters recommended that we not only finalize the revised 

definition of “colorectal cancer screening tests,” but also take steps to ensure that our Medicare 

Administrative Contractors (MACs) are not inappropriately taking actions that have the effect of 

nullifying some or much of the intended benefit of this policy change. Specifically, these 

commenters requested that we prevent the current efforts by one or more Medicare contractors to 

limit Medicare coverage for anesthesia services furnished during a screening colonoscopy by an 

anesthesia professional. Another commenter urged us to clarify that this proposed expanded 

definition of colorectal cancer screening to include anesthesia services should not be construed to 

override or preempt existing or planned coverage policies on the appropriate use of these 

services by MACs. 

 Response: This final rule with comment period establishes national policy and takes 

precedence over any local coverage policy that limits Medicare coverage for anesthesia services 

furnished during a screening colonoscopy by an anesthesia professional. 
CMS-1612-FC 507

K. Payment of Secondary Interpretation of Images 

In general, Medicare makes one payment for the professional component of an imaging 

service for each technical component (TC) service that is furnished. Under “unusual 

circumstances,” physicians can bill for a secondary interpretation using modifier -77, for 

instance, when an emergency room physician conducts an x-ray, provides an interpretation, 

identified a questionable finding, and subsequently requests a second interpretation from a 

radiologist to inform treatment decisions. In all cases, a “professional component” (PC) 

interpretation service should only be billed for a full interpretation and report, rather than a 

“review,” which is paid for as part of an E/M payment. 

In recent years, technological advances such as the integration of picture and archiving 

communications systems across health systems, growth in image sharing networks and health 

information exchange platforms through which providers can share images, and consumermediated exchange of images, have greatly increased physicians’ access to existing diagnosticquality radiology images. Accessing and utilizing these images to inform the diagnosis and 

record an interpretation in the medical record may allow physicians to avoid ordering duplicative 

tests. 

We solicited comments on the appropriateness of more routine billing for secondary 

interpretations, although we did not propose to make any changes to the treatment of these 

services in 2015. We wanted to determine whether there were an expanded set of circumstances 

under which more routine Medicare payment for a second PC for radiology services would be 

appropriate, and whether such a policy would be likely to reduce the incidence of duplicative 

advanced imaging studies. 

To achieve that goal, we solicited comments on the following: the circumstances under 

which physicians are currently conducting secondary interpretations and whether they are 
CMS-1612-FC 508

seeking payment for these interpretations; whether more routine payment for secondary 

interpretations should be restricted to certain high-cost advanced diagnostic imaging services; 

considerations for valuing secondary interpretation services; the settings in which secondary 

interpretations chiefly occur; and considerations for operationalizing more routine payment of 

secondary interpretations in a manner that would minimize burden on providers and others. 

Comment: Many commenters responded to our secondary interpretation solicitation. In 

addition to comments on the merits of the proposals, commenters also provided helpful 

information about how to implement this policy. Commenters offered diverse opinions on the 

time period for which an existing image would be pertinent in support of a secondary 

interpretation. Most commenters were in agreement that cost savings would be derived from the 

implementation of a secondary interpretation policy but there was no consensus as to the amount 

of such savings. Moreover, many commenters pointed out that they were already furnishing 

secondary interpretations and would appreciate adoption of a policy that would allow them to 

receive payment for these services. 

 Response: We thank all the commenters for their input. Any changes to our current 

policy on allowing physicians to more routinely bill for secondary interpretations of images will 

be addressed in future rulemaking. 
CMS-1612-FC 509

L. Conditions Regarding Permissible Practice Types for Therapists in Private Practice 

Section 1861(p) of the Act defines outpatient therapy services to include physical therapy 

(PT), occupational therapy (OT), and speech-language pathology (SLP) services furnished by 

qualified occupational therapists, physical therapists, and speech-language pathologists in their 

offices and in the homes of beneficiaries. The regulations at §§410.59(c), 410.60(c), and 

410.62(c) set forth special provisions for services furnished by therapists in private practice, 

including basic qualifications necessary to qualify as a supplier of OT, PT, and SLP services, 

respectively. As part of these basic qualifications, the current regulatory language includes 

descriptions of the various practice types for therapists’ private practices. Based on our review 

of these three sections of our regulations, we became concerned that the language is not as clear 

as it could be – especially with regard to the relevance of whether a practice is incorporated. The 

regulations appear to make distinctions between unincorporated and incorporated practices, and 

some practice types are listed twice. Accordingly, we proposed changes to the regulatory 

language to remove unnecessary distinctions and redundancies within the regulations for OT, PT, 

and SLP. We noted that these changes are for clarification only, and do not reflect any change in 

our current policy. 

To consistently specify the permissible practice types (a solo practice, partnership, or 

group practice; or as an employee of one of these) for suppliers of outpatient therapy services in 

private practice (specifically for occupational therapists, physical therapists and speech-language 

pathologists), we proposed to replace the regulatory text at §410.59(c)(1)(ii)(A) through (E), 

§410.60(c)(1)(ii)(A) through (E), and §410.62(c)(1)(ii)(A) through (E) and to replace it with 

language listing the permissible practice types without limitations for incorporated or 

unincorporated. 
CMS-1612-FC 510

Comment: We received comments from two therapist membership associations 

supporting our proposed changes to the regulations. Both commenters agree that the proposed 

language more consistently and accurately reflects the permissible practice types for therapists in 

private practice. 

Another commenter representing a membership association of rehabilitation physicians 

told us that, rather than clarifying or simplifying the existing regulations, the proposed language 

is more ambiguous. The commenter urged us to clarify that our proposed language would 

continue to allow therapists in private practice to be employed by physician groups as specified 

in current provisions. 

Response: We appreciate the commenters’ support for our proposal. With regard to the 

commenter that expressed concern about the clarity of the proposed regulation text as to whether 

therapists in private practice can be employed by a physician group, we acknowledge that the 

current regulation explicitly permits that practice arrangement. However, we believe that our 

proposed language describing the practice arrangements of private practice therapists–a solo 

practice, partnership, or group practice; or as an employee of one of these–clearly continues to 

permit therapists to practice as an employee of a physician group, whether or not incorporated. 

We believe the reference in the proposed regulation to “group practice” is sufficiently broad to 

encompass a physician group, and thus permits therapists in private practice to practice as 

employees of these groups, where permissible under state law. 

 Therefore, we are finalizing our proposed changes to the regulations for permissible 

practice types for therapists in private practice at §410.59(c)(1)(ii)(A) through (E), 

§410.60(c)(1)(ii)(A) through (E), and §410.62(c)(1)(ii)(A) through(E). 
CMS-1612-FC 511

M. Payments for Practitioners Managing Patients on Home Dialysis 

In the CY 2005 PFS final rule with comment period (69 FR 66357 through 66359), we 

established criteria for furnishing outpatient per diem ESRD-related services in partial month 

scenarios. We specified that use of per diem ESRD-related services is intended to accommodate 

unusual circumstances when the outpatient ESRD-related services would not be paid for under 

the monthly capitation payment (MCP), and that use of the per diem services is limited to the 

circumstances listed below. 

• Transient patients – Patients traveling away from home (less than full month); 

• Home dialysis patients (less than full month); 

• Partial month where there were one or more face-to-face visits without the 

comprehensive visit and either the patient was hospitalized before a complete assessment was 

furnished, dialysis stopped due to death, or the patient received a kidney transplant. 

• Patients who have a permanent change in their MCP physician during the month. 

Additionally, we provided billing guidelines for partial month scenarios in the Medicare 

claims processing manual, publication 100-04, chapter 8, section 140.2.1. For center-based 

patients, we specified that if the MCP practitioner furnishes a complete assessment of the ESRD 

beneficiary, the MCP practitioner should bill for the full MCP service that reflects the number of 

visits furnished during the month. However, we did not extend this policy to home dialysis (less 

than a full month) because the home dialysis MCP service did not include a specific frequency of 

required patient visits. In other words, unlike the ESRD MCP service for center-based patients, a 

visit was not required for the home dialysis MCP service as a condition of payment. 

In the CY 2011 PFS final rule with comment period (75 FR 73295 through 73296), we 

changed our policy for the home dialysis MCP service to require the MCP practitioner to furnish 

at least one face-to-face patient visit per month as a condition of payment. However, we 
CMS-1612-FC 512

inadvertently did not modify our billing guidelines for home dialysis (less than a full month) to 

be consistent with partial month scenarios for center-based dialysis patients. As discussed in the 

CY 2015 proposed rule (79 FR 40371) stakeholders have recently brought this inconsistency to 

our attention. After reviewing this issue, we proposed to allow the MCP physician or 

practitioner to bill for the age appropriate home dialysis MCP service (as described by HCPCS 

codes 90963 through 90966) for the home dialysis (less than a full month) scenario if the MCP 

practitioner furnishes a complete monthly assessment of the ESRD beneficiary and at least one 

face-to-face patient visit. For example, if a home dialysis patient was hospitalized during the 

month and at least one face-to-face outpatient visit and complete monthly assessment was 

furnished, the MCP practitioner should bill for the full home dialysis MCP service. We 

explained that this proposed change to home dialysis (less than a full month) would provide 

consistency with our policy for partial month scenarios pertaining to patients dialyzing in a 

dialysis center. We also stated that if this proposal is adopted, we would modify the Medicare 

Claims Processing Manual to reflect the revised billing guidelines for home dialysis in the less 

than a full month scenario. 

A summary of the comments on this proposal and our response is provided below. 

Comment: Several stakeholders strongly supported our proposed change for practitioners 

managing patients on home dialysis. Specifically, the commenters stated that the proposed 

change in policy for the home dialysis MCP service is necessary to appropriately align 

practitioner payment for managing home dialysis patients with center based patients, and 

encouraged us to finalize the change in policy as proposed. One commenter explained that the 

current policy for home dialysis less than a full month requires the nephrologist to “separate out 

the time their home dialysis patients spend in the hospital and bill for outpatient services at a 

daily rate instead of the full capitated payment.” The same commenter stated that “properly 
CMS-1612-FC 513

aligning physician payments for managing home dialysis patients (with managing center based 

dialysis patients) may enable more patients to consider dialyzing at home, when appropriate.” 

Response: We agree with the commenters and will finalize our proposed policy change 

for home dialysis. We will allow the MCP practitioner to bill for the home dialysis MCP service 

for the home dialysis (less than a full month) scenario if the MCP practitioner furnishes a 

complete monthly assessment of the ESRD beneficiary and at least one face-to-face patient visit 

during the month. 
CMS-1612-FC 514

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

1. Medicare Sustainable Growth Rate (SGR) 

The SGR is an annual growth rate that applies to physicians’ services paid by Medicare. 

The use of the SGR is intended to control growth in aggregate Medicare expenditures for 

physicians’ services. Payments for services are not withheld if the percentage increase in actual 

expenditures exceeds the SGR. Rather, the PFS update, as specified in section 1848(d)(4) of the 

Act, is adjusted based on a comparison of allowed expenditures (determined using the SGR) and 

actual expenditures. If actual expenditures exceed allowed expenditures, the update is reduced. 

If actual expenditures are less than allowed expenditures, the update is increased. 

Section 1848(f)(2) of the Act specifies that the SGR for a year (beginning with CY 2001) 

is equal to the product of the following four factors: 

(1) The estimated change in fees for physicians’ services; 

(2) The estimated change in the average number of Medicare fee-for-service 

beneficiaries; 

(3) The estimated projected growth in real Gross Domestic Product per capita; and 

(4) The estimated change in expenditures due to changes in statute or regulations. 

In general, section 1848(f)(3) of the Act requires us to determine the SGRs for 3 different 

time periods, using the best data available as of September 1 of each year. Under section 

1848(f)(3) of the Act, (beginning with the FY and CY 2000 SGRs) the SGR is estimated and 

subsequently revised twice based on later data. (The Act also provides for adjustments to be 

made to the SGRs for FY 1998 and FY 1999. See the February 28, 2003 Federal Register

(68 FR 9567) for a discussion of these SGRs). Under section 1848(f)(3)(C)(ii) of the Act, there 

are no further revisions to the SGR once it has been estimated and subsequently revised in each 

of the 2 years following the preliminary estimate. In this final rule with comment, we are 
CMS-1612-FC 515

making our preliminary estimate of the CY 2015 SGR, a revision to the CY 2014 SGR, and our 

final revision to the CY 2013 SGR. 

a. Physicians’ Services 

Section 1848(f)(4)(A) of the Act defines the scope of physicians’ services covered by the 

SGR. The statute indicates that “the term ‘physicians’ services’ includes other items and 

services (such as clinical diagnostic laboratory tests and radiology services), specified by the 

Secretary, that are commonly performed or furnished by a physician or in a physician’s office, 

but does not include services furnished to a Medicare+Choice plan enrollee.” 

We published a definition of physicians’ services for use in the SGR in the 

November 1, 2001 Federal Register (66 FR 55316). We defined physicians’ services to include 

many of the medical and other health services listed in section 1861(s) of the Act. Since that 

time, the statute has been amended to add new Medicare benefits. As the statute changed, we 

modified the definition of physicians’ services for the SGR to include the additional benefits 

added to the statute that meet the criteria specified in section 1848(f)(4)(A). 

As discussed in the CY 2010 PFS final rule with comment period (74 FR 61961), the 

statute provides the Secretary with clear discretion to decide whether physician-administered 

drugs should be included or excluded from the definition of “physicians’ services.” Exercising 

this discretion, we removed physician-administered drugs from the definition of physicians’ 

services in section 1848(f)(4)(A) of the Act for purposes of computing the SGR and the levels of 

allowed expenditures and actual expenditures beginning with CY 2010, and for all subsequent 

years. Furthermore, in order to effectuate fully the Secretary’s policy decision to remove drugs 

from the definition of physicians’ services, we removed physician-administered drugs from the 

calculation of allowed and actual expenditures for all prior years. 
CMS-1612-FC 516

Thus, for purposes of determining allowed expenditures, actual expenditures for all years, 

and SGRs beginning with CY 2010 and for all subsequent years, we specified that physicians’ 

services include the following medical and other health services if bills for the items and services 

are processed and paid by Medicare carriers (and those paid through intermediaries where 

specified) or the equivalent services processed by the Medicare Administrative Contractors: 

● Physicians’ services. 

● Services and supplies furnished incident to physicians’ services, except for the 

expenditures for “drugs and biologicals which are not usually self-administered by the patient.” 

● Outpatient physical therapy services and outpatient occupational therapy services, 

● Services of PAs, certified registered nurse anesthetists, certified nurse midwives, 

clinical psychologists, clinical social workers, nurse practitioners, and certified nurse specialists. 

● Screening tests for prostate cancer, colorectal cancer, and glaucoma. 

● Screening mammography, screening pap smears, and screening pelvic exams. 

● Diabetes outpatient self-management training (DSMT) services. 

● Medical Nutrition Therapy (MNT) services. 

● Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests (including 

outpatient diagnostic laboratory tests paid through intermediaries). 

● X-ray, radium, and radioactive isotope therapy. 

● Surgical dressings, splints, casts, and other devices used for the reduction of fractures 

and dislocations. 

● Bone mass measurements. 

● An initial preventive physical exam. 

● Cardiovascular screening blood tests. 

● Diabetes screening tests. 
CMS-1612-FC 517

● Telehealth services. 

● Physician work and resources to establish and document the need for a power mobility 

device. 

● Additional preventive services. 

● Pulmonary rehabilitation. 

● Cardiac rehabilitation. 

● Intensive cardiac rehabilitation. 

● Kidney disease education (KDE) services. 

● Personalized prevention plan services 

b. Preliminary Estimate of the SGR for 2015 

We first estimated the CY 2015 SGR in March 2014, and we made the estimate available 

to the MedPAC and on our website. Table 34 shows the March 2014 estimate and our current 

estimates of the factors included in the 2015 SGR. Our March 2014 estimate of the SGR was -

3.6 percent. Our current estimate of the 2015 SGR is -13.7 percent. The majority of the 

difference between the March estimate and our current estimate of the CY 2015 SGR is 

explained by adjustments to reflect intervening legislative changes that occurred after our March 

estimate was prepared. Subsequent to the display of the March 2014 estimate, section 101 of the 

Protecting Access to Medicare Act (PAMA) of 2014 continued a 0.5 percent update to the PFS 

conversion factor from April 1, 2014, through December 31, 2014 (relative to the 2013 

conversion factor), in place of the 24.1 percent reduction that would have occurred under the 

SGR system on April 1, 2014. In addition, section 101 of PAMA also provides for a 0.0 percent 

update for services furnished on or after January 1, 2015, through March 31, 2015. While 

PAMA averted the large reduction in PFS rates scheduled to occur on April 1, 2014, there will 

be a large reduction in PFS rates on April 1, 2015, as a result of the expiration of the temporary 
CMS-1612-FC 518

0.0 percent update. . The law and regulation factor of the current estimate of the SGR is now a 

much larger reduction than previously estimated to account for the current law reduction in PFS 

rates scheduled to occur on April 1, 2015. We will provide more detail on the change in each of 

these factors below. 

TABLE 34: CY 2015 SGR Calculations 

Statutory Factors March Estimate Current Estimate 

Fees 1.1 percent (1.011) 0.7 percent (1.007) 

Enrollment 4.0 percent (1.040) 3.9 percent (1.039) 

Real Per Capita GDP 0.8 percent (1.008) 0.7 percent (1.007) 

Law and Regulation -9.0 percent (0.910) -18.1 percent (0.819) 

Total -3.6 percent (0.964) -13.7 percent (0.863) 

 Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to 

produce the total (that is, 1.007 x 1.039 x 1.007 x 0.819 = 0.863). A more detailed explanation of each 

figure is provided in section II.N.1.e. of this final rule with comment period. 

c. Revised Sustainable Growth Rate for CY 2014 

Our current estimate of the CY 2014 SGR is -0.8 percent. Table 35 shows our 

preliminary estimate of the CY 2014 SGR, which was published in the CY 2014 PFS final rule 

with comment period, and our current estimate. The majority of the difference between the 

preliminary estimate and our current estimate of the CY 2014 SGR is explained by adjustments 

to reflect intervening legislative changes that have occurred since publication of the CY 2014 

PFS final rule with comment period. The PFS update reduction that would have occurred on 

April 1, 2014 was averted by PAMA, which has resulted in a much higher legislative factor than 

our estimate of the 2014 SGR in CY 2014 PFS final rule with comment period. We will provide 

more detail on the change in each of these factors below. 
CMS-1612-FC 519

TABLE 35: CY 2014 SGR Calculation 

Statutory Factors Estimate from CY 2014 Final Rule Current Estimate 

Fees 0.6 percent (1.006) 0.7 Percent (1.007) 

Enrollment 2.2 percent (1.022) 0.2 Percent (1.002) 

Real Per Capita GDP 0.8 percent (1.008) 0.7 Percent (1.007) 

Law and Regulation -19.6 percent (0.804) -2.4 Percent (0.976) 

Total -16.7 percent (0.833) -0.8 Percent (0.992) 

Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to produce the 

total (that is, 1.007 x 1.002 x 1.007 x 0.976 = 0.992). A more detailed explanation of each figure is provided in 

section II.N.1.e. of this final rule with comment period. 

d. Final Sustainable Growth Rate for CY 2013 

The SGR for CY 2013 is 1.3 percent. Table 36 shows our preliminary estimate of the CY 2013 

SGR from the CY 2013 PFS final rule with comment period, our revised estimate from the CY 2014 PFS 

final rule with comment period, and the final figures determined using the best available data as of 

September 1, 2014. We will provide more detail on the change in each of these factors below. 

TABLE 36: CY 2013 SGR Calculation 

Statutory Factors 

Estimate from 

CY 2013 

Final Rule 

Estimate from 

CY 2014 

Final Rule Final 

Fees 0.3 percent (1.003) 0.4 percent (1.004) 0.4 Percent (1.004) 

Enrollment 3.6 percent (1.036) 1.0 percent (1.010) 0.5 Percent (1.005) 

Real Per Capita GDP 0.7 percent (1.007) 0.9 percent (1.009) 0.9 Percent (1.009) 

Law and Regulation -23.3 percent (0.767) -.05 percent (.995) -0.5 Percent (0.995) 

Total -19.7 percent (0.803 1.8 percent (1.018) 1.3 Percent (1.013) 

Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to produce the 

total (that is, 1.004 x 1.005 x 1.009 x 0.995 = 1.013). A more detailed explanation of each figure is provided in 

section II.N.1.e. of this final rule with comment period. 

e. Calculation of CYs 2015, 2014, and 2013 SGRs 

(1) Detail on the CY 2015 SGR 

 All of the figures used to determine the CY 2015 SGR are estimates that will be revised 

based on subsequent data. Any differences between these estimates and the actual measurement 
CMS-1612-FC 520

of these figures will be included in future revisions of the SGR and allowed expenditures and 

incorporated into subsequent PFS updates. 

(a) Factor 1– Changes in Fees for Physicians’ Services (Before Applying Legislative 

Adjustments) for CY 2015 

 This factor is calculated as a weighted average of the CY 2015 changes in fees for the 

different types of services included in the definition of physicians’ services for the SGR. 

Medical and other health services paid using the PFS are estimated to account for approximately 

89.6 percent of total allowed charges included in the SGR in CY 2015 and are updated using the 

percent change in the MEI. As discussed in section A of this final rule with comment period, the 

percent change in the MEI for CY 2015 is 0.8 percent. Diagnostic laboratory tests are estimated 

to represent approximately 10.4 percent of Medicare allowed charges included in the SGR for 

CY 2015. Medicare payments for these tests are updated by the Consumer Price Index for Urban 

Areas (CPI-U), which is 2.1 percent for CY 2015. Section 1833(h)(2)(A)(iv) of the Act requires 

that the CPI-U update applied to clinical laboratory tests be reduced by a multi-factor 

productivity adjustment (MFP adjustment) and, for each of years 2011 through 2015, by 1.75 

percentage points (percentage adjustment). The MFP adjustment will not apply in a year where 

the CPI-U is zero or a percentage decrease. Further, the application of the MFP adjustment shall 

not result in an adjustment to the fee schedule of less than zero for a year. However, the 

application of the percentage adjustment may result in an adjustment to the fee schedule being 

less than zero for a year and may result in payment rates for a year being less than such payment 

rates for the preceding year. The applicable productivity adjustment for CY 2015 is -0.6 percent. 

Adjusting the CPI-U update by the productivity adjustment results in a 1.5 percent (2.1 percent 

(CPI-U) minus 0.6 percent (MFP adjustment)) update for CY 2015. Additionally, the percentage 

reduction of 1.75 percent is applied for CYs 2011 through 2015, as discussed previously. 
CMS-1612-FC 521

Therefore, for CY 2015, diagnostic laboratory tests will receive an update of -0.3 percent. Table 

37 shows the weighted average of the MEI and laboratory price changes for CY 2015. 

TABLE 37: Weighted-Average of the MEI and Laboratory Price Changes for CY 2015 

 Weight Update 

Physician 0.896 0.8% 

Laboratory 0.104 -0.3% 

Weighted-average 1.000 0.7% 

 We estimate that the weighted average increase in fees for physicians’ services in CY 

2015 under the SGR (before applying any legislative adjustments) will be 0.7 percent. 

(b) Factor 2 – Percentage Change in the Average Number of Part B Enrollees from CY 2014 to 

CY 2015 

 This factor is our estimate of the percent change in the average number of fee-for-service 

enrollees from CY 2014 to CY 2015. Services provided to Medicare Advantage (MA) plan 

enrollees are outside the scope of the SGR and are excluded from this estimate. We estimate that 

the average number of Medicare Part B fee-for-service enrollees will increase by 3.9 percent 

from CY 2014 to CY 2015. Table 38 illustrates how this figure was determined. 

TABLE 38: Average Number of Medicare Part B Fee-For-Service Enrollees from CY 2014

to CY 2015 (Excluding Beneficiaries Enrolled in MA Plans) 

 CY 2014 CY 2015 

Overall 49.350 million 50.794 million 

Medicare Advantage (MA) 16.237 million 16.389 million 

Net 33.113 million 34.405 million 

Percent Increase 0.2 percent 3.9 percent 

 An important factor affecting fee-for-service enrollment is beneficiary enrollment in MA 

plans. Because it is difficult to estimate the size of the MA enrollee population before the start 

of a CY, at this time we do not know how actual enrollment in MA plans will compare to current 

estimates. For this reason, the estimate may change substantially as actual Medicare fee-forservice enrollment for CY 2015 becomes known. 
CMS-1612-FC 522

(c) Factor 3– Estimated Real Gross Domestic Product Per Capita Growth in CY 2015 

 We estimate that the growth in real GDP per capita from CY 2014 to CY 2015 will be 0.7 

percent (based on the annual growth in the 10-year moving average of real GDP per capita 2006 

through 2015). Our past experience indicates that there have also been changes in estimates of 

real GDP per capita growth made before the year begins and the actual change in real GDP per 

capita growth computed after the year is complete. Thus, it is possible that this figure will 

change as actual information on economic performance becomes available to us in CY 2015. 

(d) Factor 4 – Percentage Change in Expenditures for Physicians' Services Resulting From 

Changes in Statute or Regulations in CY 2015 Compared With CY 2014 

 The statutory and regulatory provisions that will affect expenditures for CY 2015 relative 

to CY 2014 are estimated to have an impact on expenditures of -18.1 percent. This is primarily 

due to payment reductions for eligible professionals that are not meaningful users of health 

information technology, the estimated reduction in PFS rates that will occur on April 1, 2015 

absent a change in law, and expiration of the work GPCI floor. 

(2) Detail on the CY 2014 SGR 

A more detailed discussion of our revised estimates of the four elements of the CY 2014 

SGR follows. 

(a) Factor 1 – Changes in Fees for Physicians' Services (Before Applying Legislative 

Adjustments) for CY 2014 

This factor was calculated as a weighted-average of the CY 2014 changes in fees that 

apply for the different types of services included in the definition of physicians' services for the 

SGR in CY 2014. 

We estimate that services paid using the PFS account for approximately 91.1 percent of 

total allowed charges included in the SGR in CY 2014. These services were updated using the 
CMS-1612-FC 523

CY 2014 percent change in the MEI of 0.8 percent. We estimate that diagnostic laboratory tests 

represent approximately 8.9 percent of total allowed charges included in the SGR in CY 2014. 

For CY 2014, diagnostic laboratory tests received an update of -0.8 percent. 

Table 39 shows the weighted-average of the MEI and laboratory price changes for 

CY 2014. 

TABLE 39: Weighted-Average of the MEI, and Laboratory Price Changes for CY 2014 

 Weight Update 

Physician 0.911 0.8 

Laboratory 0.089 -0.8 

Weighted-average 1.000 0.7 

After considering the elements described in Table 39, we estimate that the 

weighted-average increase in fees for physicians' services in CY 2014 under the SGR was 

0.7 percent. Our estimate of this factor in the CY 2014 PFS final rule with comment period was 

0.6 percent (78 FR 74393). 

(b) Factor 2 – Percentage Change in the Average Number of Part B Enrollees from CY 2013 to 

CY 2014 

We estimate that the average number of Medicare Part B fee-for-service enrollees 

(excluding beneficiaries enrolled in Medicare Advantage plans) increased by 0.2 percent in 

CY 2014. Table 40 illustrates how we determined this figure. 

TABLE 40: Average Number of Medicare Part B Fee-For-Service Enrollees from CY 2013 to 

CY 2014 (Excluding Beneficiaries Enrolled in MA Plans) 

 CY 2013 CY 2014 

Overall 47.878 million 49.350 million 

Medicare Advantage (MA) 14.842 million 16.237 million 

Net 33.036 million 33.113 million 

Percent Increase 0.5 percent 0.2 percent 

 
CMS-1612-FC 524

Our estimate of the 0.2 percent change in the number of fee-for-service enrollees, net of 

Medicare Advantage enrollment for CY 2014 compared to CY 2013, is different than our 

estimate of an increase of 2.2 percent in the CY 2014 PFS final rule with comment period (78 FR 

74393). While our current projection based on data from 8 months of CY 2014 differs from our 

estimate of 2.2 percent when we had no actual data, it is still possible that our final estimate of 

this figure will be different once we have complete information on CY 2014 fee-for-service 

enrollment. 

(c) Factor 3 –Estimated Real GDP Per Capita Growth in CY 2014 

We estimate that the growth in real GDP per capita will be 0.7 percent for CY 2014 

(based on the annual growth in the 10-year moving average of real GDP per capita (2005 through 

2014)). Our past experience indicates that there have also been differences between our estimates 

of real per capita GDP growth made prior to the year's end and the actual change in this factor. 

Thus, it is possible that this figure will change further as complete actual information on 

CY 2014 economic performance becomes available to us in CY 2015. 

(d) Factor 4 – Percentage Change in Expenditures for Physicians' Services Resulting From 

Changes in Statute or Regulations in CY 2014 Compared With CY 2013 

The statutory and regulatory provisions that affected expenditures in CY 2014 relative to 

CY 2013 are estimated to have an impact on expenditures of -2.4 percent. This impact is due to 

many different legislative or regulatory provisions affecting spending in 2014 relative to 2013 

including a 0.5 percent update for PFS services in 2014. 

(3) Detail on the CY 2013 SGR 

A more detailed discussion of our final revised estimates of the four elements of the 

CY 2013 SGR follows. 

(a) Factor 1 – Changes in Fees for Physicians' Services for CY 2013 
CMS-1612-FC 525

This factor was calculated as a weighted average of the CY 2013 changes in fees that 

apply for the different types of services included in the definition of physicians' services for the 

SGR in CY 2013. 

We estimate that services paid under the PFS account for approximately 90.1 percent of 

total allowed charges included in the SGR in CY 2013. These services were updated using the 

CY 2013 percent change in the MEI of 0.8 percent. We estimate that diagnostic laboratory tests 

represent approximately 9.9 percent of total allowed charges included in the SGR in CY 2013. 

For CY 2013, diagnostic laboratory tests received an update of -3.0 percent. 

Table 41 shows the weighted-average of the MEI and laboratory price changes for 

CY 2013. 

TABLE 41: Weighted-Average of the MEI, Laboratory, and Drug Price Changes for 2013 

 Weight Update 

Physician 0.901 0.8 

Laboratory 0.099 -3.0 

Weighted-average 1.00 0.4 

After considering the elements described in Table 41, we estimate that the 

weighted-average increase in fees for physicians' services in CY 2013 under the SGR (before 

applying any legislative adjustments) was 0.4 percent. This figure is a final one based on 

complete data for CY 2013. 

(b) Factor 2 – Percentage Change in the Average Number of Part B Enrollees from CY 2012 to 

CY 2013 

We estimate the change in the number of fee-for-service enrollees (excluding 

beneficiaries enrolled in MA plans) from CY 2012 to CY 2013 was 0.5 percent. Our calculation 

of this factor is based on complete data from CY 2013. Table 42 illustrates the calculation of 

this factor. 
CMS-1612-FC 526

TABLE 42: Average Number of Medicare Part B Fee-For-Service Enrollees from CY 2012 

to CY 2013 (Excluding Beneficiaries Enrolled in MA Plans) 

 CY 2012 CY 2013

Overall 46.468 million 47.878 million 

Medicare Advantage (MA) 13.587 million 14.842 million 

Net 32.881 million 33.036 million 

Percent Change .................. 0.5 percent 

(c) Factor 3 – Estimated Real GDP Per Capita Growth in CY 2013 

We estimate that the growth in real per capita GDP was 0.9 percent in CY 2013 (based on 

the annual growth in the 10-year moving average of real GDP per capita (2004 through 2013)). 

This figure is a final one based on complete data for CY 2013. 

(d) Factor 4 – Percentage Change in Expenditures for Physicians’ Services Resulting From 

Changes in Statute or Regulations in CY 2013 Compared With CY 2012. 

Our final estimate for the net impact on expenditures from the statutory and regulatory 

provisions that affect expenditures in CY 2013 relative to CY 2012 is -0.5 percent. This impact 

is due to many different legislative or regulatory provisions affecting spending in 2013 relative to 

2012, including provisions of the American Taxpayer Relief Act in 2013. 

2. The Update Adjustment Factor (UAF) 

Section 1848(d) of the Act provides that the PFS update is equal to the product of the 

MEI and the UAF. The UAF is applied to make actual and target expenditures (referred to in the 

statute as “allowed expenditures”) equal. As discussed previously, allowed expenditures are 

equal to actual expenditures in a base period updated each year by the SGR. The SGR sets the 

annual rate of growth in allowed expenditures and is determined by a formula specified in 

section 1848(f) of the Act. We note that the conversion factor for the time period from January 1, 

2015 through March 31, 2015 will reflect a 0.0 percent update based on section 101 of PAMA. 
CMS-1612-FC 527

Beginning on April 1, 2015 through December 31, 2015, the standard calculation of the PFS CF 

under the SGR formula would apply 

 The calculation of the UAF is not affected by sequestration. Pursuant to 2 U.S.C. 

906(d)(6), “The Secretary of Health and Human Services shall not take into account any 

reductions in payment amounts which have been or may be effected under [sequestration], for 

purposes of computing any adjustments to payment rates under such title XVIII.” Therefore, 

allowed charges, which are unaffected by sequestration, were used to calculate physician 

expenditures in lieu of Medicare payments plus beneficiary cost-sharing. As a result, neither 

actual expenditures nor allowed expenditures were adjusted to reflect the impact of 

sequestration. 

a. Calculation under Current Law 

Under section 1848(d)(4)(B) of the Act, the UAF for a year beginning with CY 2001 is 

equal to the sum of the following-- 

● Prior Year Adjustment Component. An amount determined by— 

++ Computing the difference (which may be positive or negative) between the amount of 

the allowed expenditures for physicians’ services for the prior year (the year prior to the year for 

which the update is being determined) and the amount of the actual expenditures for those 

services for that year; 

++ Dividing that difference by the amount of the actual expenditures for those services 

for that year; and 

++ Multiplying that quotient by 0.75. 

● Cumulative Adjustment Component. An amount determined by— 
CMS-1612-FC 528

++ Computing the difference (which may be positive or negative) between the amount of 

the allowed expenditures for physicians' services from April 1, 1996, through the end of the prior 

year and the amount of the actual expenditures for those services during that period; 

++ Dividing that difference by actual expenditures for those services for the prior year as 

increased by the SGR for the year for which the UAF is to be determined; and 

++ Multiplying that quotient by 0.33. 

Section 1848(d)(4)(E) of the Act requires the Secretary to recalculate allowed 

expenditures consistent with section 1848(f)(3) of the Act. As discussed previously, section 

1848(f)(3) specifies that the SGR (and, in turn, allowed expenditures) for the upcoming CY 

(CY 2015 in this case), the current CY (that is, CY 2014) and the preceding CY (that is, 

CY 2013) are to be determined on the basis of the best data available as of September 1 of the 

current year. Allowed expenditures for a year generally are estimated initially and subsequently 

revised twice. The second revision occurs after the CY has ended (that is, we are making the 

second revision to CY 2013 allowed expenditures in this final rule with comment). 

Table 43 shows the historical SGRs corresponding to each period through CY 2015. 

 
CMS-1612-FC 529

TABLE 43: Annual and Cumulative Allowed and Actual Expenditures for Physicians' 

Services from April 1, 1996 through the End of the Upcoming Calendar Year 

Period 

Annual 

Allowed 

Expenditures 

($ in billions) 

Annual 

Actual 

Expenditures 

($ in billions) 

Cumulative 

Allowed 

Expenditures 

($ in billions) 

Cumulative 

Actual 

Expenditures 

($ in billions) 

FY/CY SGR 

4/1/96-3/31/97 47.0 47.0 47.0 47.0 ........................ 

4/1/97-3/31/98 48.5 47.2 95.6 94.3 3.2 

4/1/98-3/31/99 50.6 48.1 146.2 142.4 4.2 

1/1/99-3/31/99 12.7 12.5 146.2 142.4 ........................ 

4/1/99-12/31/99 40.5 37.2 186.7 179.6 6.9 

1/1/99-12/31/99 53.2 49.7 186.7 179.6 ........................ 

1/1/00-12/31/00 57.1 54.4 243.7 234.0 7.3 

1/1/01-12/31/01 59.7 61.5 303.4 295.5 4.5 

1/1/02-12/31/02 64.6 64.8 368.0 360.3 8.3 

1/1/03-12/31/03 69.3 70.4 437.3 430.7 7.3 

1/1/04-12/31/04 73.9 78.5 511.2 509.1 6.6 

1/1/05-12/31/05 77.0 83.8 588.2 593.0 4.2 

1/1/06-12/31/06 78.2 85.1 666.4 678.1 1.5 

1/1/07-12/31/07 80.9 85.1 747.2 763.1 3.5 

1/1/08-12/31/08 84.5 87.3 831.8 850.4 4.5 

1/1/09-12/31/09 89.9 91.1 921.7 941.5 6.4 

1/1/10-12/31/10 97.9 96 1,019.6 1,037.4 8.9 

1/1/11-12/31/11 102.5 99.5 1,122.2 1,136.9 4.7 

1/1/12-12/31/12 107.8 101.1 1,230.0 1,238.0 5.1 

1/1/13-12/31/13 109.2 102.5 1,339.1 1,340.5 1.3 

1/1/14-12/31/14 108.3 103.3 1,447.4 1,443.8 -0.8 

1/1/15-12/31/15 93.5 N/A 1,540.9 N/A -13.7 

Notes: (1) Allowed expenditures in the first year (April 1, 1996-March 31, 1997) are equal to actual expenditures. All subsequent figures are 

equal to quarterly allowed expenditure figures increased by the applicable SGR. Cumulative allowed expenditures are equal to the sum of annual 

allowed expenditures. We provide more detailed quarterly allowed and actual expenditure data on our website at the following address: 

http://www.cms.hhs.gov/SustainableGRatesConFact/. We expect to update the website with the most current information later this month. 

(2) Allowed expenditures for the first quarter of 1999 are based on the FY 1999 SGR. 

(3) Allowed expenditures for the last three quarters of 1999 are based on the FY 2000 SGR. 

Consistent with section 1848(d)(4)(E) of the Act, Table 43 includes our second revision 

of allowed expenditures for CY 2013, a recalculation of allowed expenditures for CY 2014, and 

our initial estimate of allowed expenditures for CY 2015. To determine the UAF for CY 2015, 

the statute requires that we use allowed and actual expenditures from April 1, 1996 through 

December 31, 2014 and the CY 2015 SGR. Consistent with section 1848(d)(4)(E) of the Act, we 

will be making revisions to the CY 2014 and CY 2015 SGRs and CY 2014 and CY 2015 allowed 
CMS-1612-FC 530

expenditures. Because we have incomplete actual expenditure data for CY 2014, we are using 

an estimate for this period. Any difference between current estimates and final figures will be 

taken into account in determining the UAF for future years. 

We are using figures from EE10 in the following statutory formula: 

0.75 0.33 4 / 96 12 / 14 4 / 96 12 / 14

15 ×

×

− × + − − −

=

14 14 15

14 14

Actual SGR

Target Actual

Actual

Target Actual UAF

UAF15 = Update Adjustment Factor for CY 2015= 3.0 percent 

Target14 = Allowed Expenditures for CY 2014= $108.3 billion 

Actual14 = Estimated Actual Expenditures for CY 2014 = $103.3 billion 

Target4/96-12/14 = Allowed Expenditures from 4/1/1996 - 12/31/2014 = $1,447.40 billion 

Actual4/96-12/14 = Estimated Actual Expenditures from 4/1/1996 - 12/31/2014 = $1,443.80 billion 

SGR15= -13.7 percent (0.863) 

Section 1848(d)(4)(D) of the Act indicates that the UAF determined under section 

1848(d)(4)(B) of the Act for a year may not be less than -0.07 or greater than 0.03. Since 0.049 

(4.9 percent) is greater than 0.03, the UAF for CY 2015 will be 3 percent. 

Section 1848(d)(4)(A)(ii) of the Act indicates that 1.0 should be added to the UAF 

determined under section 1848(d)(4)(B) of the Act. Thus, adding 1.0 to 0.03 makes the UAF 

equal to 1.03. 

3. Percentage Change in the MEI for CY 2015 

The MEI is required by section 1842(b)(3) of the Act, which states that prevailing charge 

levels beginning after June 30, 1973, may not exceed the level from the previous year except to 

0.33 4.9%

$103.3 .863

$1,447.4 $1443.80 0.75

$103.3

$108.3 $103.3

× = ×

− × + −
CMS-1612-FC 531

the extent that the Secretary finds, on the basis of appropriate economic index data, that the 

higher level is justified by year-to-year economic changes. The current form of the MEI was 

detailed in the CY 2014 PFS final rule (78 FR 74264), which revised and reclassified certain cost 

categories, price proxies, and expense categories. 

The MEI measures the weighted-average annual price change for various inputs needed 

to produce physicians' services. The MEI is a fixed-weight input price index, with an adjustment 

for the change in economy-wide multifactor productivity. This index, which has CY 2006 base 

year weights, is comprised of two broad categories: (1) physician's own time; and (2) physician's 

practice expense (PE). 

The physician’s compensation (own time) component represents the net income portion 

of business receipts and primarily reflects the input of the physician's own time into the 

production of physicians' services in physicians' offices. This category consists of two 

subcomponents: (1) wages and salaries; and (2) fringe benefits. 

The physician’s practice expense (PE) category represents nonphysician inputs used in 

the production of services in physicians' offices. This category consists of wages and salaries 

and fringe benefits for nonphysician staff (who cannot bill independently) and other nonlabor 

inputs. The physician's PE component also includes the following categories of nonlabor inputs: 

office expenses; medical materials and supplies; professional liability insurance; medical 

equipment; medical materials and supplies; and other professional expenses. 

 Table 44 lists the MEI cost categories with associated weights and percent changes for 

price proxies for the CY 2015 update. The CY 2015 non-productivity adjusted MEI update is 

1.7 percent and reflects a 1.9 percent increase in physician’s own time and a 1.5 percent increase 

in physician’s PE. Within the physician’s PE, the largest increase occurred in postage, which 

increased 5.4 percent. 
CMS-1612-FC 532

For CY 2015, the increase in the MEI is 0.8 percent, which reflects an increase in the 

non-productivity adjusted MEI of 1.7 percent and a productivity adjustment of 0.9 percent 

(which is based on the 10-year moving average of economy-wide private nonfarm business 

multifactor productivity). The BLS is the agency that publishes the official measure of private 

non-farm business MFP. Please see http://www.bls.gov/mfp, which is the link to the BLS 

historical published data on the measure of MFP. 

 
CMS-1612-FC 533

TABLE 44: Increase in the Medicare Economic Index Update for CY 20151

Revised Cost Category 

2006 Revised Cost 

Weight (percent)2

CY15 Update 

(percent) 

MEI Total, productivity adjusted 100.000 0.8 

Productivity: 10-year moving average of MFP1 N/A5 0.9 

MEI Total, without productivity adjustment 100.000 1.7 

Physician Compensation3 50.866 1.9 

 Wages and Salaries 43.641 1.9 

 Benefits 7.225 2.0 

Practice Expense 49.134 1.5 

 Non-physician compensation 16.553 1.8 

 Non-physician wages 11.885 1.8 

 Non-health, non-physician wages 7.249 2.0 

 Professional & Related 0.800 1.9 

 Management 1.529 2.2 

 Clerical 4.720 1.9 

 Services 0.200 1.2 

 Health related, non-physician wages 4.636 1.5 

 Non-physician benefits 4.668 1.9 

 Other Practice Expense 32.581 1.4 

 Utilities 1.266 4.0 

 Miscellaneous Office Expenses 2.478 1.0 

 Chemicals 0.723 -1.1 

 Paper 0.656 3.3 

 Rubber & Plastics 0.598 1.0 

 All other products 0.500 1.7 

 Telephone 1.501 0.0 

 Postage 0.898 5.4 

 All Other Professional Services 8.095 1.7 

 Professional, Scientific, and Tech. Services 2.592 1.8 

 Administrative and support & waste 3.052 1.9 

 All Other Services 2.451 1.2 

 Capital 10.310 1.8 

 Fixed 8.957 1.9 

 Moveable 1.353 0.8 

 Professional Liability Insurance4 4.295 -0.1 

 Medical Equipment 1.978 -0.3 

 Medical supplies 1.760 -0.2 1

 The forecasts are based upon the latest available Bureau of Labor Statistics data on the 10-year average of 

BLS private nonfarm business multifactor productivity published on July 9, 2014. 

(http://www.bls.gov/news.release/prod3.nr0.htm) 2

 The weights shown for the MEI components are the 2006 base-year weights, which may not sum to subtotals 

or totals because of rounding. The MEI is a fixed-weight, Laspeyres-type input price index whose category 

weights indicate the distribution of expenditures among the inputs to physicians' services for CY 2006. To 
CMS-1612-FC 534

determine the MEI level for a given year, the price proxy level for each component is multiplied by its 2006 

weight. The sum of these products (weights multiplied by the price index levels) over all cost categories yields 

the composite MEI level for a given year. The annual percent change in the MEI levels is an estimate of price 

change over time for a fixed market basket of inputs to physicians' services. 3

 The measures of Productivity, Employment Cost Indexes, as well as the various Producer and Consumer Price 

Indexes can be found on the Bureau of Labor Statistics Web site at http://stats.bls.gov. 4

 Derived from a CMS survey of several major commercial insurers. 

5

 Productivity is factored into the MEI categories as an adjustment; therefore, no explicit weight exists for 

productivity in the MEI.

4. Physician and Anesthesia Fee Schedule Conversion Factors for CY 2015 

 The CY 2015 PFS CF for January 1, 2015 through March 31, 2015 is $35.8013. The CY 

2015 PFS CF for April 1, 2015 through December 31, 2015 is $28.2239. The CY 2015 national 

average anesthesia CF for January 1, 2015 through March 31, 2015 is $22.5550 The CY 2015 

national average anesthesia CF for April 1, 2015 through December 31, 2015 is $17.7913. 

a. PFS Update and Conversion Factors 

(1) CY 2014 PFS Update 

The formula for calculating the PFS update is set forth in section 1848(d)(4)(A) of the 

Act. In general, the PFS update is determined by multiplying the CF for the previous year by the 

percentage increase in the MEI less productivity times the UAF, which is calculated as specified 

under section 1848(d)(4)(B) of the Act. 

(2) CY 2015 PFS Conversion Factors 

Generally, the PFS CF for a year is calculated in accordance with section 1848(d)(1)(A) 

of the Act by multiplying the previous year’s CF by the PFS update. 

We note section 101 of the Medicare Improvements and Extension Act, Division B of the 

Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) provided a 1-year increase in the 

CY 2007 CF and specified that the CF for CY 2008 must be computed as if the 1-year increase 

had never applied. 

Section 101 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) 

provided a 6-month increase in the CY 2008 CF, from January 1, 2008, through June 30, 2008, 
CMS-1612-FC 535

and specified that the CF for the remaining portion of CY 2008 and the CFs for CY 2009 and 

subsequent years must be computed as if the 6-month increase had never applied. 

Section 131 of the MIPPA extended the increase in the CY 2008 CF that applied during 

the first half of the year to the entire year, provided for a 1.1 percent increase to the CY 2009 CF, 

and specified that the CFs for CY 2010 and subsequent years must be computed as if the 

increases for CYs 2007, 2008, and 2009 had never applied. 

Section 1011(a) of the DODAA and section 5 of the TEA specified a zero percent update 

for CY 2010, effective January 1, 2010 through March 31, 2010. 

Section 4 of the Continuing Extension Act of 2010 (CEA) extended the zero percent 

update for CY 2010 through May 31, 2010. 

Subsequently, section 101(a)(2) of the PACMBPRA provided for a 2.2 percent update to 

the CF, effective from June 1, 2010 to November 30, 2010. 

Section 2 of the Physician Payment and Therapy Relief Act of 2010 (Pub. L. No. 111-

286) extended the 2.2 percent update through the end of CY 2010. 

Section 101 of the MMEA provided a zero percent update for CY 2011, effective January 

1, 2011 through December 31, 2011, and specified that the CFs for CY 2012 and subsequent 

years must be computed as if the increases in previous years had never applied. 

Section 301 of the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) 

provided a zero percent update effective January 1, 2012 through February 29, 2012, and 

specified that the CFs for subsequent time periods must be computed as if the increases in 

previous years had never applied. 

Section 3003 of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation 

Act) provided a zero percent update effective March 1, 2012 through December 31, 2012, and 
CMS-1612-FC 536

specified that the CFs for subsequent time periods must be computed as if the increases in 

previous years had never applied. 

Section 601 of the American Taxpayer Relief Act (ATRA) of 2012 (Pub. L. 112-240) 

provided a zero percent update for CY 2013, effective January 1, 2013 through December 31, 

2013, and specified that the CFs for subsequent time periods must be computed as if the 

increases in previous years had not been applied. 

Section 1101 of the Pathway for SGR Reform Act of 2013 (Pub. L. 113-67) provided a 

0.5 percent update to the PFS CF, effective January 1, 2014 through March 31, 2014 and 

specified that the CFs for subsequent time periods must be computed as if the increases in 

previous years had not been applied. 

Section 101 of the Protecting Access to Medicare Act of 2014 (Pub. L. 113-93) (PAMA) 

extended this 0.5 percent update through December 31, 2014. Section 101 of the PAMA also 

provides a 0.0 percent update for services furnished on or after January 1, 2015, through March 

31, 2015, and specified that the CFs for subsequent time periods must be computed as if the 

increases in previous years had not been applied. 

Therefore, under current law, the CF that would be in effect in CY 2014 had the prior 

increases specified above not applied is $27.2006. 

In addition, when calculating the PFS CF for a year, section 1848(c)(2)(B)(ii)(II) of the 

Act requires that increases or decreases in RVUs may not cause the amount of expenditures for 

the year to differ more than $20 million from what it would have been in the absence of these 

changes. If this threshold is exceeded, we must make adjustments to preserve budget neutrality. 

We estimate that CY 2015 RVU changes would result in an increase in Medicare physician 

expenditures of more than $20 million. Accordingly, we are decreasing the CF by 0.06 percent 
CMS-1612-FC 537

to offset this estimated increase in Medicare physician expenditures due to the CY 2015 RVU 

changes. 

For January 1, 2015 through March 31, 2015, the PFS update will be 0.0 percent 

consistent with section 101 of PAMA. After applying the budget neutrality adjustment described 

above, the conversion factor for January 1, 2015 through March 31, 2015 will be $35.8013. 

After March 31, 2015 the standard calculation of the PFS CF under the SGR formula 

would apply. Therefore, from April 1, 2015 through December 31, 2015 the conversion factor 

would be $28.2239. This final rule with comment period announces a reduction to payment rates 

for physicians' services of 21.2 percent during this time period in CY 2015 under the SGR 

formula. 

By law, we are required to make these reductions in accordance with section 1848(d) and 

(f) of the Act, and these reductions can only be averted by an Act of Congress. While Congress 

has provided temporary relief from these reductions every year since 2003, a long-term solution 

is critical. We will continue to work with Congress to fix this untenable situation so doctors and 

beneficiaries no longer have to worry about the stability and adequacy of payments from 

Medicare under the PFS. 

We illustrate the calculation of the CY 2015 PFS CF in Table 45. 
CMS-1612-FC 538

TABLE 45: Calculation of the CY 2015 PFS CF 

January 1, 2015 through March 31, 2015

Conversion Factor in effect in CY 2014 $35.8228 

Update 0.0 percent (1.00) 

CY 2015 RVU Budget Neutrality Adjustment -0.06 percent (0.9994) 

CY 2015 Conversion Factor (1/1/2015 

through 3/31/2015) $35.8013

April 1, 2015 through December 31, 2015 

Conversion Factor in effect in CY 2014 $35.8228 

CY 2014 Conversion Factor had statutory 

increases not applied $27.2006 

CY 2015 Medicare Economic Index 0.8 percent (1.008) 

CY 2015 Update Adjustment Factor -3.0 percent (1.03) 

CY 2015 RVU Budget Neutrality Adjustment -0.06 percent (0.9994) 

CY 2015 Conversion Factor (4/1/2015 

through 12/31/2015) $28.2239 

Percent Change in Conversion Factor on 

4/1/2015 (relative to the CY 2014 CF) -21.2% 

Percent Change in Update (without budget 

neutrality adjustment) on 4/1/2015 (relative 

to the CY 2014 CF) -20.9% 

We note payment for services under the PFS will be calculated as follows: 

Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (Malpractice RVU x 

Malpractice GPCI)] x CF. 

b. Anesthesia Conversion Factors 

We calculate the anesthesia CFs as indicated in Table 46. Anesthesia services do not 

have RVUs like other PFS services. Therefore, we account for any necessary RVU adjustments 

through an adjustment to the anesthesia CF to simulate changes to RVUs. More specifically, if 

there is an adjustment to the work, PE, or malpractice RVUs, these adjustments are applied to the 

respective shares of the anesthesia CF as these shares are proxies for the work, PE, and 

malpractice RVUs for anesthesia services. Information regarding the anesthesia work, PE, and 

malpractice shares can be found at the following: https://www.cms.gov/center/anesth.asp. 
CMS-1612-FC 539

The anesthesia CF in effect in CY 2014 is $22.6765. Section 101 of PAMA provides for 

a 0.0 percent update from January 1, 2015 through March 31, 2015. After applying the 0.9994 

budget neutrality factor described above, the anesthesia CF in effect from January 1, 2015 

through March 31, 2015 will be $22.5550. 

The table below includes adjustments to the anesthesia CF that are analogous to the 

physician fee schedule CF with other adjustments that are specific to anesthesia. In order to 

calculate the CY 2015 anesthesia CF for April 1, 2015 through December 31, 2015, the statute 

requires us to calculate the CFs for all previous years as if the various legislative changes to the 

CFs for those years had not occurred. The resulting CF is then adjusted for the update (the MEI, 

less multi-factor productivity and increased by the UAF). The national average CF is then 

adjusted for anesthesia specific work, practice expense and malpractice factors that must be 

applied to the anesthesia CF as the anesthesia fee schedule does not have RVUs. Accordingly, 

under current law, the anesthesia CF in effect in CY 2015 for the time period from April 1, 2015 

through December 31, 2015 is $17.7913. We illustrate the calculation of the CY 2015 anesthesia 

CFs in Table 45. 
CMS-1612-FC 540

TABLE 46: Calculation of the CY 2015 Anesthesia CF 

January 1, 2015 through March 31, 2015

CY 2014 National Average Anesthesia CF $22.6765 

Update 0.0 percent (1.00) 

CY 2015 RVU Budget Neutrality Adjustment 0.0006 percent (0.9994) 

CY 2015 Anesthesia Fee Schedule Practice Expense 

Adjustment 

0.005 percent (.99524) 

CY 2015 National Average Anesthesia CF (1/1/2015 

through 3/31/2015) 

$22.5550 

April 1, 2015 through December 31, 2015

2014 National Average Anesthesia Conversion Factor in 

effect in CY 2015 

 $22.6765 

2014 National Anesthesia Conversion Factor had 

Statutory Increases Not Applied 

 $17.2283 

CY 2015 Medicare Economic Index 0.8 percent (1.008) 

CY 2015 Update Adjustment Factor 3.0 percent (0.9994) 

CY 2015 Budget Neutrality Work and Malpractice 

Adjustment 

-0.06 percent (0.9994) 

CY 2015 Anesthesia Fee Schedule Practice Expense 

Adjustment 

0.005 percent (.99524) 

CY 2015 Anesthesia Conversion Factor (4/1/2015 

through 12/31/2015)

$17.7913 

Percent Change from 2014 to 2015 (4/1/2015 through 

12/31/2015)

 -21.5% 
CMS-1612-FC 541

III. Other Provisions of the Final Rule with Comment Period Regulation 

A. Ambulance Extender Provisions 

1. Amendment to Section 1834(l)(13) of the Act 

Section 146(a) of the MIPPA amended section 1834(l)(13)(A) of the Act to specify that, 

effective for ground ambulance services furnished on or after July 1, 2008 and before January 1, 

2010, the ambulance fee schedule amounts for ground ambulance services shall be increased as 

follows: 

● For covered ground ambulance transports that originate in a rural area or in a rural 

census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 

3 percent. 

● For covered ground ambulance transports that do not originate in a rural area or in a 

rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased 

by 2 percent. 

The payment add-ons under section 1834(l)(13)(A) of the Act have been extended several 

times. Recently, section 1104(a) of the Pathway for SGR Reform Act of 2013, enacted on 

December 26, 2013, as Division B (Medicare and Other Health Provisions) of Pub L. 113-67, 

amended section 1834(l)(13)(A) of the Act to extend the payment add-ons described above 

through March 31, 2014. Subsequently, section 104(a) of the Protecting Access to Medicare Act 

of 2014 (Pub. L. 113-93, enacted on April 1, 2014) amended section 1834(l)(13)(A) of the Act to 

extend the payment add-ons again through March 31, 2015. Thus, these payment add-ons also 

apply to covered ground ambulance transports furnished before April 1, 2015. (For a discussion 

of past legislation extending section 1834(l)(13) of the Act, please see the CY 2014 PFS final 

rule (78 FR 74438 through 74439)). 

These statutory requirements are self-implementing. A plain reading of the statute 
CMS-1612-FC 542

requires only a ministerial application of the mandated rate increase, and does not require any 

substantive exercise of discretion on the part of the Secretary. In the CY 2015 PFS proposed rule 

(79 FR 40372), we proposed to revise §414.610(c)(1)(ii) to conform the regulations to these 

statutory requirements. We received one comment regarding this proposal. A summary of the 

comment we received and our response are set forth below. 

Comment: One commenter supported the implementation of the ambulance payment 

add-ons. The commenter also agreed that these provisions are self-implementing. 

Response: We thank the commenter for their support of these provisions. 

After consideration of the public comment received, we are finalizing our proposal to 

revise §414.610(c)(1)(ii) to conform the regulations to these statutory requirements.

2. Amendment to Section 1834(l)(12) of the Act 

 Section 414(c) of the Medicare Prescription Drug, Improvement and Modernization Act 

of 2003 (Pub. L. 108-173, enacted on December 8, 2003) (MMA) added section 1834(l)(12) to 

the Act, which specified that in the case of ground ambulance services furnished on or after 

July 1, 2004, and before January 1, 2010, for which transportation originates in a qualified rural 

area (as described in the statute), the Secretary shall provide for a percent increase in the base 

rate of the fee schedule for such transports. The statute requires this percent increase to be based 

on the Secretary’s estimate of the average cost per trip for such services (not taking into account 

mileage) in the lowest quartile of all rural county populations as compared to the average cost 

per trip for such services (not taking into account mileage) in the highest quartile of rural county 

populations. Using the methodology specified in the July 1, 2004 interim final rule (69 FR 

40288), we determined that this percent increase was equal to 22.6 percent. As required by the 

MMA, this payment increase was applied to ground ambulance transports that originated in a 

“qualified rural area”; that is, to transports that originated in a rural area included in those areas 
CMS-1612-FC 543

comprising the lowest 25th percentile of all rural populations arrayed by population density. For 

this purpose, rural areas included Goldsmith areas (a type of rural census tract). This rural bonus 

is sometimes referred to as the “Super Rural Bonus” and the qualified rural areas (also known as 

“super rural” areas) are identified during the claims adjudicative process via the use of a data 

field included on the CMS-supplied ZIP code File. 

The Super Rural Bonus under section 1834(l)(12) of the Act has been extended several 

times. Recently, section 1104(b) of the Pathway for SGR Reform Act of 2013, enacted on 

December 26, 2013, as Division B (Medicare and Other Health Provisions) of Pub. L. 113-67, 

amended section 1834(l)(12)(A) of the Act to extend this rural bonus through March 31, 2014. 

Subsequently, section 104(b) of the Protecting Access to Medicare Act of 2014 (Pub. L. 113-93, 

enacted on April 1, 2014) amended section 1834(l)(12)(A) of the Act to extend this rural bonus 

again through March 31, 2015. Therefore, we are continuing to apply the 22.6 percent rural 

bonus described above (in the same manner as in previous years) to ground ambulance services 

with dates of service before April 1, 2015 where transportation originates in a qualified rural 

area. (For a discussion of past legislation extending section 1834(l)(12) of the Act, please see the 

CY 2014 PFS final rule (78 FR 74439 through 74440)).

 These statutory provisions are self-implementing. Together, these statutory provisions 

require a 15-month extension of this rural bonus (which was previously established by the 

Secretary) through March 31, 2015, and do not require any substantive exercise of discretion on 

the part of the Secretary. In the CY 2015 PFS proposed rule (79 FR 40372), we proposed to 

revise §414.610(c)(5)(ii) to conform the regulations to these statutory requirements. We 

received one comment regarding this proposal. A summary of the comment we received and our 

response are set forth below. 

Comment: One commenter supported the implementation of the percent increase in the 
CMS-1612-FC 544

base rate of the fee schedule for transports in areas defined as super rural. The commenter also 

agreed with CMS that these provisions are self-implementing. 

Response: We thank the commenter for their support of these provisions. 

After consideration of the public comment received, we are finalizing our proposal to 

revise §414.610(c)(5)(ii) to conform the regulations to these statutory requirements. 

B. Changes in Geographic Area Delineations for Ambulance Payment 

1. Background

Under the ambulance fee schedule, the Medicare program pays for ambulance 

transportation services for Medicare beneficiaries when other means of transportation are 

contraindicated by the beneficiary’s medical condition, and all other coverage requirements are 

met. Ambulance services are classified into different levels of ground (including water) and air 

ambulance services based on the medically necessary treatment provided during transport. 

These services include the following levels of service: 

● For Ground-- 

++ Basic Life Support (BLS) (emergency and non-emergency) 

++ Advanced Life Support, Level 1 (ALS1) (emergency and non-emergency) 

++ Advanced Life Support, Level 2 (ALS2) 

++ Paramedic ALS Intercept (PI) 

++ Specialty Care Transport (SCT) 

● For Air-- 

++ Fixed Wing Air Ambulance (FW) 

++ Rotary Wing Air Ambulance (RW) 

a. Statutory Coverage of Ambulance Services 

Under sections 1834(l) and 1861(s)(7) of the Act, Medicare Part B (Supplemental 
CMS-1612-FC 545

Medical Insurance) covers and pays for ambulance services, to the extent prescribed in 

regulations, when the use of other methods of transportation would be contraindicated by the 

beneficiary’s medical condition. 

The House Ways and Means Committee and Senate Finance Committee Reports that 

accompanied the 1965 Social Security Amendments suggest that the Congress intended that-- 

● The ambulance benefit cover transportation services only if other means of 

transportation are contraindicated by the beneficiary’s medical condition; and 

● Only ambulance service to local facilities be covered unless necessary services are not 

available locally, in which case, transportation to the nearest facility furnishing those services is 

covered (H.R. Rep. No. 213, 89th Cong., 1st Sess. 37 and Rep. No. 404, 89th Cong., 1st Sess. Pt 1, 

43 (1965)). 

The reports indicate that transportation may also be provided from one hospital to 

another, to the beneficiary’s home, or to an extended care facility. 

b. Medicare Regulations for Ambulance Services 

Our regulations relating to ambulance services are set forth at 42 CFR part 410, subpart B 

and 42 CFR part 414, subpart H. Section 410.10(i) lists ambulance services as one of the 

covered medical and other health services under Medicare Part B. Therefore, ambulance 

services are subject to basic conditions and limitations set forth at §410.12 and to specific 

conditions and limitations included at §410.40 and §410.41. Part 414, subpart H, describes how 

payment is made for ambulance services covered by Medicare. 

2. Provisions of the Final Rule 

Historically, the Medicare ambulance fee schedule has used the same geographic area 

designations as the acute care hospital inpatient prospective payment system (IPPS) and other 

Medicare payment systems to take into account appropriate urban and rural differences. This 
CMS-1612-FC 546

promotes consistency across the Medicare program, and it provides for use of consistent 

geographic standards for Medicare payment purposes. 

The current geographic areas used under the ambulance fee schedule are based on OMB 

standards published on December 27, 2000 (65 FR 82228 through 82238), Census 2000 data, 

and Census Bureau population estimates for 2007 and 2008 (OMB Bulletin No. 10-02). For a 

discussion of OMB’s delineation of Core-Based Statistical Areas (CBSAs) and our 

implementation of the CBSA definitions under the ambulance fee schedule, we refer readers to 

the preamble of the CY 2007 Ambulance Fee Schedule proposed rule (71 FR 30358 through 

30361) and the CY 2007 PFS final rule (71 FR 69712 through 69716). On February 28, 2013, 

OMB issued OMB Bulletin No. 13-01, which established revised delineations for Metropolitan 

Statistical Areas (MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas, and 

provided guidance on the use of the delineations of these statistical areas. A copy of this bulletin 

may be obtained at http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-

01.pdf. According to OMB, “[t]his bulletin provides the delineations of all Metropolitan 

Statistical Areas, Metropolitan Divisions, Micropolitan Statistical Areas, Combined Statistical 

Areas, and New England City and Town Areas in the United States and Puerto Rico based on the 

standards published on June 28, 2010, in the Federal Register (75 FR 37246 - 37252) and 

Census Bureau data.” OMB defines an MSA as a CBSA associated with at least one urbanized 

area that has a population of at least 50,000, and a Micropolitan Statistical Area (referred to in 

this discussion as a Micropolitan Area) as a CBSA associated with at least one urban cluster that 

has a population of at least 10,000 but less than 50,000 (75 FR 37252). Counties that do not 

qualify for inclusion in a CBSA are deemed “Outside CBSAs.” We note that, when referencing 

the new OMB geographic boundaries of statistical areas, we are using the term “delineations” 

consistent with OMB’s use of the term (75 FR 37249). 
CMS-1612-FC 547

Although the revisions OMB published on February 28, 2013 are not as sweeping as the 

changes made when we adopted the CBSA geographic designations for CY 2007, the 

February 28, 2013 OMB bulletin does contain a number of significant changes. For example, we 

stated in the CY 2015 PFS proposed rule (79 FR 40373) that if we adopt the revised OMB 

delineations, there would be new CBSAs, urban counties that would become rural, rural counties 

that would become urban, and existing CBSAs that would be split apart. We have reviewed our 

findings and impacts relating to the new OMB delineations, and find no compelling reason to 

further delay implementation. We stated in the proposed rule that we believe it is important for 

the ambulance fee schedule to use the latest labor market area delineations available as soon as 

reasonably possible to maintain a more accurate and up-to-date payment system that reflects the 

reality of population shifts. 

Additionally, in the FY 2015 IPPS proposed rule (79 FR 28055), we also proposed to 

adopt OMB’s revised delineations to identify urban areas and rural areas for purposes of the 

IPPS wage index. This proposal was finalized in the FY 2015 IPPS final rule (79 FR 49952). 

For the reasons discussed above, we believe it would be appropriate to adopt the same 

geographic area delineations for use under the ambulance fee schedule as are used under the 

IPPS and other Medicare payment systems. Thus, we proposed to implement the new OMB 

delineations as described in the February 28, 2013 OMB Bulletin No. 13-01 beginning in CY 

2015 to more accurately identify urban and rural areas for ambulance fee schedule payment 

purposes. We believe that the updated OMB delineations more realistically reflect rural and 

urban populations, and that the use of such delineations under the ambulance fee schedule would 

result in more accurate payment. Under the ambulance fee schedule, consistent with our current 

definitions of urban and rural areas (§414.605), MSAs would continue to be recognized as urban 

areas, while Micropolitan and other areas outside MSAs, and rural census tracts within MSAs (as 
CMS-1612-FC 548

discussed below), would be recognized as rural areas. 

In addition to the OMB’s statistical area delineations, the current geographic areas used 

in the ambulance fee schedule also are based on rural census tracts determined under the most 

recent version of the Goldsmith Modification. These rural census tracts are considered rural 

areas under the ambulance fee schedule (see §414.605). For certain rural add-ons, section 

1834(l) of the Act requires that we use the most recent version of the Goldsmith Modification to 

determine rural census tracts within MSAs. In the CY 2007 PFS final rule (71 FR 69714 through 

69716), we adopted the most recent (at that time) version of the Goldsmith Modification, 

designated as Rural-Urban Commuting Area (RUCA) codes. RUCA codes use urbanization, 

population density, and daily commuting data to categorize every census tract in the country. 

For a discussion about RUCA codes, we refer the reader to the CY 2007 PFS final rule (71 FR 

69714 through 69716). As stated previously, on February 28, 2013, OMB issued OMB Bulletin 

No. 13-01, which established revised delineations for Metropolitan Statistical Areas, 

Micropolitan Statistical Areas, and Combined Statistical Areas, and provided guidance on the 

use of the delineations of these statistical areas. Several modifications of the RUCA codes were 

necessary to take into account updated commuting data and the revised OMB delineations. We 

refer readers to the U.S. Department of Agriculture’s Economic Research Service website for a 

detailed listing of updated RUCA codes found at http://www.ers.usda.gov/data-products/ruralurban-commuting-area-codes.aspx. The updated RUCA code definitions were introduced in late 

2013 and are based on data from the 2010 decennial census and the 2006-10 American 

Community Survey. We proposed to adopt the most recent modifications of the RUCA codes 

beginning in CY 2015, to recognize levels of rurality in census tracts located in every county 

across the nation, for purposes of payment under the ambulance fee schedule. In the CY 2015 

PFS proposed rule (79 FR 40373), we stated that if we adopt the most recent RUCA codes, many 
CMS-1612-FC 549

counties that are designated as urban at the county level based on population would have rural 

census tracts within them that would be recognized as rural areas through our use of RUCA 

codes. 

As we stated in the CY 2015 PFS proposed rule (79 FR 40373 through 40374), the 2010 

Primary RUCA codes are as follows: 

(1) Metropolitan area core: primary flow with an urbanized area (UA). 

(2) Metropolitan area high commuting: primary flow 30 percent or more to a UA. 

(3) Metropolitan area low commuting: primary flow 10 to 30 percent to a UA. 

(4) Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 

(large UC). 

(5) Micropolitan high commuting: primary flow 30 percent or more to a large UC. 

(6) Micropolitan low commuting: primary flow 10 to 30 percent to a large UC. 

(7) Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small 

UC). 

(8) Small town high commuting: primary flow 30 percent or more to a small UC. 

(9) Small town low commuting: primary flow 10 to 30 percent to a small UC. 

(10) Rural areas: primary flow to a tract outside a UA or UC. 

Based on this classification, and consistent with our current policy (71 FR 69715), we 

proposed to continue to designate any census tracts falling at or above RUCA level 4.0 as rural 

areas for purposes of payment for ambulance services under the ambulance fee schedule. As 

discussed in the CY 2007 PFS final rule (71 FR 69715), the Office of Rural Health Policy within 

the Health Resources and Services Administration (HRSA) determines eligibility for its rural 

grant programs through the use of the RUCA code methodology. Under this methodology, 

HRSA designates any census tract that falls in RUCA level 4.0 or higher as a rural census tract. 
CMS-1612-FC 550

In addition to designating any census tracts falling at or above RUCA level 4.0 as rural areas, 

under the updated RUCA code definitions, HRSA has also designated as rural census tracts those 

census tracts with RUCA codes 2 or 3 that are at least 400 square miles in area with a population 

density of no more than 35 people. We refer readers to HRSA’s website: 

ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf for additional information. Consistent with the 

HRSA guidelines discussed above, we proposed, beginning in CY 2015, to designate as rural 

areas (1) those census tracts that fall at or above RUCA level 4.0, and (2) those census tracts that 

fall within RUCA levels 2 or 3 that are at least 400 square miles in area with a population density 

of no more than 35 people. We stated in the CY 2015 PFS proposed rule (79 FR 40374) that we 

continue to believe that HRSA’s guidelines accurately identify rural census tracts throughout the 

country, and thus would be appropriate to apply for ambulance payment purposes. We invited 

comments on this proposal. 

We stated in the CY 2015 PFS proposed rule (79 FR 40374) that the adoption of the most 

current OMB delineations and the updated RUCA codes would affect whether certain areas are 

recognized as rural or urban. The distinction between urban and rural is important for ambulance 

payment purposes because urban and rural transports are paid differently. The determination of 

whether a transport is urban or rural is based on the point of pick-up for the transport, and thus a 

transport is paid differently depending on whether the point of pick-up is in an urban or a rural 

area. During claims processing, a geographic designation of urban, rural, or super rural is 

assigned to each claim for an ambulance transport based on the point of pick-up ZIP code that is 

indicated on the claim. 

Currently, section 1834(l)(12) of the Act (as amended by section 104(b) of the PAMA) 

specifies that, for services furnished during the period July 1, 2004 through March 31, 2015, the 

payment amount for the ground ambulance base rate is increased by a “percent increase” (Super 
CMS-1612-FC 551

Rural Bonus) where the ambulance transport originates in a “qualified rural area,” which is a 

rural area that we determine to be in the lowest 25th percentile of all rural populations arrayed by 

population density (also known as a “super rural area”). We implement this Super Rural Bonus 

in §414.610(c)(5)(ii). We stated in the CY 2015 PFS proposed rule (79 FR 40374) that adoption 

of the revised OMB delineations and the updated RUCA codes would have no negative impact 

on ambulance transports in super rural areas, as none of the current super rural areas would lose 

their status due to the revised OMB delineations and the updated RUCA codes. 

As we stated in the CY 2015 PFS proposed rule (79 FR 40374), the adoption of the new 

OMB delineations and the updated RUCA codes would affect whether or not transports would be 

eligible for other rural adjustments under the ambulance fee schedule statute and regulations. 

For ground ambulance transports where the point of pick-up is in a rural area, the mileage rate is 

increased by 50 percent for each of the first 17 miles (§414.610(c)(5)(i)). For air ambulance 

services where the point of pick-up is in a rural area, the total payment (base rate and mileage 

rate) is increased by 50 percent (§414.610(c)(5)(i)). Furthermore, under section 1834(l)(13) of 

the Act (as amended by section 104(a) of the PAMA), for ground ambulance transports furnished 

through March 31, 2015, transports originating in rural areas are paid based on a rate (both base 

rate and mileage rate) that is 3 percent higher than otherwise is applicable. (See also 

§414.610(c)(1)(ii)). 

We stated in the CY 2015 PFS proposed rule (79 FR 40374) that if we adopt OMB’s 

revised delineations and the updated RUCA codes, ambulance providers and suppliers that pick 

up Medicare beneficiaries in areas that would be Micropolitan or otherwise outside of MSAs 

based on OMB’s revised delineations or in a rural census tract of an MSA based on the updated 

RUCA codes (but are currently within urban areas) may experience increases in payment for 

such transports because they may be eligible for the rural adjustment factors discussed above, 
CMS-1612-FC 552

while those ambulance providers and suppliers that pick up Medicare beneficiaries in areas that 

would be urban based on OMB’s revised delineations and the updated RUCA codes (but are 

currently in Micropolitan Areas or otherwise outside of MSAs, or in a rural census tract of an 

MSA) may experience decreases in payment for such transports because they would no longer be 

eligible for the rural adjustment factors discussed above. 

 The use of the revised OMB delineations and the updated RUCA codes would mean the 

recognition of new urban and rural boundaries based on the population migration that occurred 

over a 10-year period, between 2000 and 2010. In the CY 2015 PFS proposed rule (79 FR 

40374), we stated that, based on the latest United States Postal Service (USPS) ZIP code file, 

there are a total of 42,914 ZIP codes in the U.S. We stated in the proposed rule that the 

geographic designations for approximately 99.48 percent of ZIP codes would be unchanged by 

OMB’s revised delineations and the updated RUCA codes, and that a similar number of ZIP 

codes would change from rural to urban (122, or 0.28 percent) as would change from urban to 

rural (100, or 0.23 percent). We stated in the proposed rule that, in general, it was expected that 

ambulance providers and suppliers in 100 ZIP codes within 11 states may experience payment 

increases if we adopt the revised OMB delineations and the updated RUCA codes, as these areas 

would be redesignated from urban to rural. We stated that the state of Ohio would have the most 

ZIP codes changing from urban to rural with a total of 40, or 2.69 percent. We also stated in the 

CY 2015 PFS proposed rule that ambulance providers and suppliers in 122 ZIP codes within 22 

states may experience payment decreases if we adopt the revised OMB delineations and the 

updated RUCA codes, as these areas would be redesignated from rural to urban. We stated that 

the state of West Virginia would have the most ZIP codes changing from rural to urban (17, or 

1.82 percent), while Connecticut would have the greatest percentage of ZIP codes changing from 

rural to urban (15 ZIP codes, or 3.37 percent). Our findings were illustrated in Table 17 of the 
CMS-1612-FC 553

CY 2015 PFS proposed rule (79 FR 40375). 

We stated in the CY 2015 PFS proposed rule (79 FR 40375 and 40376) that we believe 

the most current OMB statistical area delineations, coupled with the updated RUCA codes, more 

accurately reflect the contemporary urban and rural nature of areas across the country, and that 

use of the most current OMB delineations and RUCA codes under the ambulance fee schedule 

would enhance the accuracy of ambulance fee schedule payments. We solicited comments on 

our proposal to implement the new OMB delineations and the updated RUCA codes as discussed 

above beginning in CY 2015, for purposes of payment under the Medicare ambulance fee 

schedule. 

 We received four comments from two associations representing ambulance service 

providers and suppliers and two ambulance suppliers on our proposal to implement the new 

OMB delineations and the updated RUCA codes for purposes of payment under the Medicare 

ambulance fee schedule. Those comments are summarized below along with our responses. 

Comment: All of the commenters agreed with CMS that it is appropriate to adjust the 

geographic area designations periodically so that the ambulance fee schedule reflects population 

shifts. 

Response: We appreciate the support of the commenters. 

Comment: Commenters expressed concern that the analysis of the proposed modification 

in the CY 2015 PFS proposed rule did not describe the actual impact of the proposed change 

because it did not take into account the most recent modifications to the RUCA codes. When 

these codes are applied, the commenters stated that there would be substantially more ZIP codes 

that would shift. The commenters estimated that more than 1,500 ZIP codes would shift from 

rural to urban and about three times the number of ZIP codes identified in the proposed rule 

would change from urban to rural. The commenters also stated that some ZIP codes would no 
CMS-1612-FC 554

longer have super rural status. 

Response: The commenters are correct that the analysis published in the CY 2015 PFS 

proposed rule (see Table 17 (79 FR 40375)) presented the impact of the revised OMB 

delineations only and did not include the impact of the updated RUCA codes. We did not 

receive the ZIP code approximation of the 2010 RUCA codes file in time to be included in our 

analysis in the proposed rule. 

We have completed an updated analysis of both the revised OMB delineations and the 

updated RUCA codes. Based on the latest United States Postal Service (USPS) ZIP code file, 

there are a total of 42,918 ZIP codes in the U.S. Based on our updated analysis, we have 

concluded that the geographic designations for approximately 92.02 percent of ZIP codes would 

be unchanged by OMB’s revised delineations and the updated RUCA codes. There are more ZIP 

codes that would change from rural to urban (3,038 or 7.08 percent) than from urban to rural 

(387 or 0.90 percent). The differences in the data provided in the proposed rule compared to the 

final rule are due to inclusion of the updated RUCA codes. In general, it is expected that 

ambulance providers and suppliers in 387 ZIP codes within 41 states, may experience payment 

increases under the revised OMB delineations and the updated RUCA codes, as these areas have 

been redesignated from urban to rural. The state of California has the most ZIP codes changing 

from urban to rural with a total of 43, or 1.58 percent. Ambulance providers and suppliers in 

3,038 ZIP codes within 46 states and Puerto Rico may experience payment decreases under the 

revised OMB delineations and the updated RUCA codes, as these areas have been redesignated 

from rural to urban. The state of Pennsylvania has the most ZIP codes changing from rural to 

urban (293, or 13.06 percent), while West Virginia has the greatest percentage of ZIP codes 

changing from rural to urban (269 ZIP codes, or 28.74 percent). Our findings are illustrated in 

Table 47. 
CMS-1612-FC 555

TABLE 47: Updated ZIP Codes Analysis Based on OMB’s Revised Delineations 

and Updated RUCA Codes 

State/ 

Territory* 

Total ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Rural to 

Urban 

Percentage of 

Total ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Urban to 

Rural 

Percentage 

of Total ZIP 

Codes 

Total 

ZIP 

Codes 

Not 

Changed 

Percentage 

of Total ZIP 

Codes Not 

Changed 

AK 276 0 0.00% 0 0.00% 276 100.00% 

AL 854 83 9.72% 8 0.94% 763 89.34% 

AR 725 41 5.66% 6 0.83% 678 93.52% 

AS 1 0 0.00% 0 0.00% 1 100.00% 

AZ 569 21 3.69% 7 1.23% 541 95.08% 

CA 2723 94 3.45% 43 1.58% 2586 94.97% 

CO 677 4 0.59% 9 1.33% 664 98.08% 

CT 445 56 12.58% 0 0.00% 389 87.42% 

DC 303 0 0.00% 0 0.00% 303 100.00% 

DE 99 6 6.06% 0 0.00% 93 93.94% 

EK 63 0 0.00% 0 0.00% 63 100.00% 

EM 856 71 8.29% 2 0.23% 783 91.47% 

FL 1513 105 6.94% 9 0.59% 1399 92.47% 

FM 4 0 0.00% 0 0.00% 4 100.00% 

GA 1032 101 9.79% 4 0.39% 927 89.83% 

GU 21 0 0.00% 0 0.00% 21 100.00% 

HI 143 9 6.29% 3 2.10% 131 91.61% 

IA 1080 42 3.89% 3 0.28% 1035 95.83% 

ID 335 3 0.90% 0 0.00% 332 99.10% 

IL 1628 159 9.77% 7 0.43% 1462 89.80% 

IN 1000 110 11.00% 7 0.70% 883 88.30% 

KY 1030 81 7.86% 5 0.49% 944 91.65% 

LA 739 101 13.67% 1 0.14% 637 86.20% 

MA 751 14 1.86% 6 0.80% 731 97.34% 

MD 630 84 13.33% 0 0.00% 546 86.67% 

ME 505 19 3.76% 12 2.38% 474 93.86% 

MH 2 0 0.00% 0 0.00% 2 100.00% 

MI 1185 63 5.32% 13 1.10% 1109 93.59% 

MN 1043 47 4.51% 7 0.67% 989 94.82% 

MP 3 0 0.00% 0 0.00% 3 100.00% 

MS 541 36 6.65% 1 0.18% 504 93.16% 

MT 411 0 0.00% 3 0.73% 408 99.27% 

NC 1101 163 14.80% 6 0.54% 932 84.65% 

ND 419 2 0.48% 0 0.00% 417 99.52% 

NE 632 7 1.11% 6 0.95% 619 97.94% 

NH 292 6 2.05% 2 0.68% 284 97.26% 

NJ 747 1 0.13% 2 0.27% 744 99.60% 

NM 438 4 0.91% 2 0.46% 432 98.63% 

NV 257 4 1.56% 2 0.78% 251 97.67% 
CMS-1612-FC 556

State/ 

Territory* 

Total ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Rural to 

Urban 

Percentage of 

Total ZIP 

Codes 

Total ZIP 

Codes 

Changed 

Urban to 

Rural 

Percentage 

of Total ZIP 

Codes 

Total 

ZIP 

Codes 

Not 

Changed 

Percentage 

of Total ZIP 

Codes Not 

Changed 

NY 2246 180 8.01% 42 1.87% 2024 90.12% 

OH 1487 80 5.38% 34 2.29% 1373 92.33% 

OK 791 23 2.91% 7 0.88% 761 96.21% 

OR 495 26 5.25% 9 1.82% 460 92.93% 

PA 2244 293 13.06% 38 1.69% 1913 85.25% 

PR 177 21 11.86% 0 0.00% 156 88.14% 

PW 2 0 0.00% 0 0.00% 2 100.00% 

RI 91 2 2.20% 1 1.10% 88 96.70% 

SC 543 91 16.76% 2 0.37% 450 82.87% 

SD 418 0 0.00% 1 0.24% 417 99.76% 

TN 814 82 10.07% 12 1.47% 720 88.45% 

TX 2726 155 5.69% 32 1.17% 2539 93.14% 

UT 359 2 0.56% 0 0.00% 357 99.44% 

VA 1277 147 11.51% 13 1.02% 1117 87.47% 

VI 16 0 0.00% 0 0.00% 16 100.00% 

VT 309 15 4.85% 0 0.00% 294 95.15% 

WA 744 29 3.90% 6 0.81% 709 95.30% 

WI 919 66 7.18% 5 0.54% 848 92.27% 

WK 711 16 2.25% 5 0.70% 690 97.05% 

WM 342 4 1.17% 3 0.88% 335 97.95% 

WV 936 269 28.74% 0 0.00% 667 71.26% 

WY 198 0 0.00% 1 0.51% 197 99.49% 

TOTALS 42918 3038 7.08% 387 0.90% 39493 92.02% 

* ZIP code analysis includes U.S. States and Territories (FM- Federated States of Micronesia, GU – Guam, MHMarshall Islands, MP-Northern Mariana Islands, PW- Palau, AS- American Samoa; VI- Virgin Islands; PR- Puerto 

Rico). [ Missouri is divided into east and west regions due to work distribution of the Medicare Administrative 

Contractors (MACs) : EM- East Missouri, WM – West Missouri. Johnson and Wyandotte counties in Kansas were 

changed as of January 2010 to East Kansas (EK) and the rest of the state is West Kansas (WK). 

As discussed above, in the CY 2015 PFS proposed rule (79 FR 40374), we proposed to 

designate as rural those census tracts that fall in RUCA codes 2 or 3 that are at least 400 square 

miles in area with a population density of no more than 35 people. However, upon further 

analysis, we have determined that it is not feasible to implement this proposal. Payment under 

the ambulance fee schedule is based on the ZIP codes; therefore, if the ZIP code is 

predominantly metropolitan but has some rural census tracts, we do not split the ZIP code areas 

to distinguish further granularity to provide different payments within the same ZIP code. We 
CMS-1612-FC 557

believe that payment for all ambulance transportation services at the ZIP code level provides a 

consistent payment system. Therefore, such census tracts were not considered rural areas in the 

updated analysis set forth above. 

For more detail on the impact of these changes, in addition to Table 47, the following 

files are available through the Internet on the AFS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AmbulanceFeeSchedule/index.html: ZIP codes by state that changed from urban to 

rural, ZIP codes by state that changed from rural to urban, list of ZIP codes with RUCA code 

designations, and a complete list of ZIP codes identifying their designation as super rural, rural 

or urban. 

As reflected in Table 47, our findings are generally consistent with the commenters’ 

findings that more than 1,500 ZIP codes would change from rural to urban (our updated analysis 

indicates that 3,038 ZIP codes are changing), and that about three times the number of ZIP codes 

identified in the proposed rule (100) would change from urban to rural (our updated analysis 

indicates 387 ZIP codes are changing). 

As we stated in the proposed rule (79 FR 40374), none of the current super rural areas 

will lose their super rural status upon implementation of the revised OMB delineations and the 

updated RUCA codes. 

Comment: One commenter suggested that we delay the implementation of the 

adjustment until CY 2016 to allow CMS sufficient time to publish the changes in rural and urban 

status and allow all interested parties to provide comments on the proposal. In addition to 

delaying implementation, the commenter suggested implementing a 4-year transition that would 

phase-in the payment reduction over a specified period for those ZIP codes losing rural status. 

Other commenters requested that the implementation of the geographic adjustments 
CMS-1612-FC 558

outlined in the proposed rule be delayed until such time as the data is available to complete a full 

and accurate analysis of the ZIP codes affected and the financial impact to industry. Absent such 

a delay, the commenters stated that the final rule must clarify, in a complete and transparent 

manner, the accuracy of the analysis used in the proposed rule. 

Response: We believe that ambulance providers and suppliers had sufficient notice of 

and opportunity to comment on the proposed adoption of the revised OMB delineations and the 

updated RUCA codes under the ambulance fee schedule, and thus we do not believe a delay in 

implementation is warranted. In the proposed rule, we proposed to adopt the revised OMB 

delineations as set forth in OMB Bulletin No. 13-01 and the updated RUCA codes for purposes 

of payment under the ambulance fee schedule consistent with the policy we implemented in CY 

2007 (see the CY 2007 PFS final rule (71 FR 69713 through 69716)). We explained in the 

proposed rule that the adoption of the revised OMB delineations and updated RUCA codes 

would affect the urban/rural designation of certain areas, and thus would affect whether 

transports in certain areas would be eligible for rural adjustments under the ambulance fee 

schedule. In addition, OMB Bulletin No. 13-01was available on February 28, 2013, and 

contained additional information regarding the changes in OMB geographic area delineations. 

As discussed above, the ZIP code analysis set forth in the proposed rule reflected the impact of 

the revised OMB delineations. The 2010 RUCA codes and definitions were available on 

December 31, 2013 on the U.S. Department of Agriculture’s Economic Research Service’s 

website, which provided ambulance providers and suppliers with additional information 

regarding changes to the level of rurality in census tracts. Furthermore, section 1834(l) requires 

that we use the most recent modification of the Goldsmith Modification to determine rural 

census tracts for purposes of certain rural add-ons, and our established policy, as set forth in 

§414.605, is that rural areas include rural census tracts as determined under the most recent 
CMS-1612-FC 559

version of the Goldsmith modification. 

As discussed above and in the CY 2015 PFS proposed rule, we believe the most current 

OMB statistical area delineations, coupled with the updated RUCA codes, more accurately 

reflect the contemporary urban and rural nature of areas across the country, and thus we believe 

the use of the most current OMB delineations and RUCA codes under the ambulance fee 

schedule will enhance the accuracy of ambulance fee schedule payments. We believe that it is 

important to use the most current OMB delineations and RUCA codes available as soon as 

reasonably possible to maintain a more accurate and up-to-date payment system that reflects the 

reality of population shifts. Because we believe the revised OMB delineations and updated 

RUCA codes more accurately identify urban and rural areas and enhance the accuracy of the 

Medicare ambulance fee schedule, we do not believe a delay in implementation or a transition 

period would be appropriate. Areas that lose their rural status and become urban have become 

urban because of recent population shifts. We believe it is important to base payment on the 

most accurate and up-to-date geographic area delineations available. Furthermore, we believe a 

delay would disadvantage the ambulance providers or suppliers experiencing payment increases 

based on these updated and more accurate OMB delineations and RUCA codes. 

Finally, given the relatively small percentage of ZIP codes affected by the revised OMB 

delineations and updated RUCA codes (a total of 3,425 ZIP codes changing their urban/rural 

status out of 42,918 ZIP codes, or 7.98 percent), we do not believe that a delay is warranted. As 

commenters requested, we have included in Table 47 our updated analysis of the impact of 

adopting the revised OMB delineations and the updated RUCA codes. 

Comment: One commenter recommended that if any ZIP codes would lose their super 

rural status as a result of the proposed adoption of the revised OMB delineations and the updated 

RUCA codes, then CMS should grandfather the current super rural ZIP codes. Another 
CMS-1612-FC 560

commenter stated that the ambulance providers must have verification from CMS that the super 

rural ZIP codes will not be affected by the changes described in the proposed rule in advance of 

their implementation in the final rule. 

Response: As we stated previously, the adoption of the OMB’s revised delineations and 

the updated RUCA codes will have no negative impact on ambulance transports in super rural 

areas, as none of the current super rural areas will lose their status upon implementation of the 

revised OMB delineations and the updated RUCA codes. Current areas designated as super rural 

areas will continue to be eligible for the super rural bonus. 

After consideration of the public comments received, and for the reasons discussed 

above, we are finalizing our proposals to adopt, beginning in CY 2015, the revised OMB 

delineations as set forth in OMB’s February 28, 2013 bulletin (No. 13-01) and the most recent 

modifications of the RUCA codes for purposes of payment under the ambulance fee schedule. 

As we proposed, using the updated RUCA codes definitions, we will continue to designate any 

census tracts falling at or above RUCA level 4.0 as rural areas. However, as discussed above, 

we are not finalizing our proposal to designate as rural those census tracts that fall within RUCA 

codes 2 or 3 that are at least 400 square miles in area with a population density of no more than 

35 people. Finally, as discussed above, none of the current super rural areas will lose their super 

rural status upon implementation of the revised OMB delineations and the updated RUCA codes. 

C. Clinical Laboratory Fee Schedule 

In the CY 2014 PFS final rule with comment period (78 FR 74440 through 74445, 

74820), we finalized a process under which we would reexamine the payment amounts for test 

codes on the Clinical Laboratory Fee Schedule (CLFS) for possible payment revision based on 

technological changes beginning with the CY 2015 proposed rule, and we codified this process 

at §414.511. After we finalized this process, the Congress enacted the PAMA. Section 216 of 
CMS-1612-FC 561

the PAMA creates new section 1834A of the Act, which requires us to implement a new 

Medicare payment system for clinical diagnostic laboratory tests based on private payor rates. 

Section 216 of the PAMA also rescinds the statutory authority in section 1833(h)(2)(A)(i) of the 

Act for adjustments based on technological changes for tests furnished on or after April 1, 2014 

(PAMA’s enactment date). As a result of these provisions, we did not propose any revisions to 

payment amounts for test codes on the CLFS based on technological changes, and we proposed 

to remove §414.511. 

We did not receive any public comments on this proposal. Therefore, we are finalizing our 

proposal to remove §414.511. In addition, we will establish through rulemaking the parameters 

for the collection of private payor rate information and other requirements to implement section 

216 of the PAMA. 
CMS-1612-FC 562

D. Removal of Employment Requirements for Services Furnished “Incident to” Rural Health 

Clinics (RHC) and Federally Qualified Health Center (FQHC) Visits 

1. Background 

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) furnish 

physicians’ services; services and supplies “incident to” the services of physicians: nurse 

practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist 

(CP), and clinical social worker (CSW) services; and services and supplies incident to the 

services of NPs, PAs, CNMs, CPs, and CSWs. They may also furnish diabetes self-management 

training and medical nutrition therapy (DSMT/MNT), transitional care management services, 

and in some cases, visiting nurse services furnished by a registered professional nurse or a 

licensed practical nurse. (For additional information on coverage requirements for services 

furnished in RHCs and FQHCs, see Chapter 13 of the CMS Benefit Policy Manual.) 

In the May 2, 2014 final rule with comment period entitled “Prospective Payment System 

for Federally Qualified Health Centers; Changes to Contracting Policies for Rural Health Clinics; 

and Changes to Clinical Laboratory Improvement Amendments of 1988 Enforcement Actions 

for Proficiency Testing Referral” (79 FR 25436), we removed the regulatory requirements that 

NPs, PAs, CNMs, CSWs, and CPs furnishing services in a RHC must be employees of the RHC. 

RHCs are now allowed to contract with NPs, PAs, CNMs, CSWs, and CPs, as long as at least 

one NP or PA is employed by the RHC, as required under clause (iii) in the first sentence of the 

flush material following subparagraph (K) of section 1861(aa)(2) of the Act. 

Services furnished in RHCs and FQHCs by nurses, medical assistants, and other auxiliary 

personnel are considered “incident to” a RHC or FQHC visit furnished by a RHC or FQHC 

practitioner. Sections 405.2413(a)(6), 405.2415(a)(6), and 405.2452(a)(6) currently state that 

services furnished incident to an RHC or FQHC visit must be furnished by an employee of the 
CMS-1612-FC 563

RHC or FQHC. Since there is no separate benefit under Medicare law that specifically 

authorizes payment to nurses, medical assistants, and other auxiliary personnel for their 

professional services, they cannot bill the program directly and receive payment for their 

services, and can only be remunerated when furnishing services to Medicare patients in an 

“incident to” capacity. 

To provide RHCs and FQHCs with as much flexibility as possible to meet their staffing 

needs, we proposed to revise §405.2413(a)(5), §405.2415(a)(5) and §405.2452(a)(5) and delete 

§405.2413(a)(6), §405.2415(a)(6) and §405.2452(a)(6) to remove the requirement that services 

furnished incident to an RHC or FQHC visit must be furnished by an employee of the RHC or 

FQHC, in order to allow nurses, medical assistants, and other auxiliary personnel to furnish 

“incident to” services under contract in RHCs and FQHCs. We believe that removing the 

requirements will provide RHCs and FQHCs with additional flexibility without adversely 

impacting the quality or continuity of care. 

We received 23 comments on our proposal. The following is a summary of the 

comments received. 

Comment: Most commenters were strongly in favor of removing these employment 

requirements. Several commenters stated that this flexibility will assist RHCs and FQHCs in 

increasing access to care, enable them to recruit highly qualified health professionals, and fill 

temporary staffing voids without adversely impacting the quality of care. Some commenters 

expressed concerns about maintaining professional standards, and others were concerned about 

the potential loss of benefits for contracted staff. 

A few commenters stated that they support removal of the employment requirement, 

provided that RHC and FQHC auxiliary personnel are held to the same high professional 

standards for the quality of care, regardless of whether they are working under contract or as 
CMS-1612-FC 564

employees. Commenters also added that all members of a physician-led health care team should 

be enabled to perform medical interventions that they are capable of performing according to 

their education, training, licensure, and experience. 

Response: The proposal to remove the requirement that auxiliary workers in RHCs and 

FQHCs be employees of the RHC or FQHC does not change either their professional standards 

of care or their scope of practice. Nurses, medical assistants, and other auxiliary personnel are 

expected to maintain their professional standards of care and furnish services in adherence to 

their scope of practice, regardless of whether they are employed or contracted by the RHC or 

FQHC. 

Comment: Some commenters stated that although they understand the need for greater 

staffing flexibility, they were concerned about the potential loss of benefit packages to 

individuals that are contracted and not employed. The commenters questioned whether the issue 

was investigated or vetted, and how RHCs and FQHCs would compensate for this loss of 

compensation for individuals providing incident to services under contract rather than as an 

employee. 

Response: We appreciate the concern that these commenters raised regarding the 

potential loss of benefit packages for contracted individuals; however, we do not regulate 

employment agreements or benefit packages for individuals working at RHCs and FQHCs. 

After consideration of the public comments, we are finalizing this provision as proposed. 
CMS-1612-FC 565

E. Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models 

1. Background and Statutory Authority 

 Section 3021 of the Affordable Care Act amended the Social Security Act to include a 

new section 1115A, which established the Center for Medicare and Medicaid Innovation 

(Innovation Center). Section 1115A tasks the Innovation Center with testing innovative payment 

and service delivery models that could reduce program expenditures while preserving and/or 

enhancing the quality of care furnished to individuals under titles XVIII, XIX, and XXI of the 

Act. The Secretary is also required to conduct an evaluation of each model tested. 

Evaluations will typically include quantitative and qualitative methods to assess the 

impact of the model on quality of care and health care expenditures. To comply with the 

statutory requirement to evaluate all models conducted under section 1115A of the Act, we will 

conduct rigorous quantitative analyses of the impact of the model test on health care 

expenditures, as well as an assessment of measures of the quality of care furnished under the 

model test. Evaluations will also include qualitative analyses to capture the qualitative 

differences between model participants, and to form the context within which to interpret the 

quantitative findings. Through the qualitative analyses, we will assess the experiences and 

perceptions of model participants, providers, and individuals affected by the model. 

In the evaluations we use advanced statistical methods to measure effectiveness. Our 

methods are intended to provide results that meet a high standard of evidence, even when 

randomization is not feasible. To successfully carry out evaluations of Innovation Center 

models, we must be able to determine specifically which individuals are receiving services from 

or are the subject of the intervention being tested by the entity participating in the model test. 

Identification of such individuals is necessary for a variety of purposes, including the 

construction of control groups against which model performance can be compared. In addition, 
CMS-1612-FC 566

to determine whether the observed impacts are due to the model being tested and not due to 

differences between the intervention and comparison groups, our evaluations will have to 

account for potential confounding factors at the individual level, which will require the ability to 

identify every individual associated with the model test, control or comparison groups, and the 

details of the intervention at the individual level. 

Evaluations will need to consider such factors as outcomes, clinical quality, adverse 

effects, access, utilization, patient and provider satisfaction, sustainability, potential for the 

model to be applied on a broader scale, and total cost of care. Individuals receiving services 

from or who are the subjects of the intervention will be compared to clinically, sociodemographically, and geographically similar matched individuals along various process, 

outcome, and patient-reported measures. Research questions in a typical evaluation will include, 

but are not limited to, the following: 

● Clinical Quality: 

++ Did the model improve or have a negative impact on clinical process measures, such 

as adherence to evidence-based guidelines? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on clinical outcome measures, such 

as mortality rates, and the incidence and prevalence of chronic conditions? If so, how, how 

much, and for which individuals? 

++ Did the model improve or have a negative impact on access to care? If so, how, how 

much, and for which individuals? 

++ Did the model improve or have a negative impact on care coordination among 

providers? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on medication management? If so, 

how, how much, and for which individuals? 
CMS-1612-FC 567

● Patient Experience: 

++ Did the model improve or have a negative impact on patient-provider 

communication? If so, how, how much, and for which individuals? 

++ Did the model improve or have a negative impact on patient experiences of care, 

quality of life, or functional status? If so, how, how much, and for which individuals? 

● Utilization/Expenditures: 

++ Did the model result in decreased utilization of emergency department visits, 

hospitalizations, and readmissions? If so how, how much, and for which individuals? 

++ Did the model result in increased utilization of physician or pharmacy services? If so 

how, how much, and for which individuals? 

++ Did the model result in decreased total cost of care? Were changes in total costs of 

care driven by changes in utilization for specific types of settings or health care services? What 

specific aspects of the model led to these changes? Were any savings due to improper costshifting to the Medicaid program? 

To carry out this research we must have access to patient records not generally available 

to us. As such, we proposed to exercise our authority in section 1115A(b)(4)(B) of the Act to 

establish requirements for states and other entities participating in the testing of past, present, and 

future models under section 1115A of the Act to collect and report information that we have 

determined is necessary to monitor and evaluate such models. Thus, we proposed to require 

model participants, and providers and suppliers working under the models operated by such 

participants, to produce such individually identifiable health information and such other 

information as the Secretary identifies as being necessary to conduct the statutorily mandated 

research described above. Such research will include the monitoring and evaluation of such 

models. Further, we view engagement with other payers, both public and private, as a critical 
CMS-1612-FC 568

driver of the success of these models. CMS programs constitute only a share of any provider’s 

revenue. Therefore, efforts to improve quality and reduce cost are more likely to be successful if 

efforts are aligned across payers. Section 1115A of the Act specifically allows the Secretary of 

Health and Human Services to consider, in selecting which models to choose for testing, 

“whether the model demonstrates effective linkage with other public sector or private sector 

payers.” Multi-payer models, such as but not limited to the Comprehensive Primary Care model, 

will conduct quality measurement across all patients regardless of payer in order to maximize 

alignment and increase efficiency. Construction of multi-payer quality measures requires the 

ability to identify all individuals subject to the model test regardless of payer. In addition, 

section 1115A also permits the Secretary to consider models that allow states to test and evaluate 

systems of all-payer payment reform for the medical care of residents of the state, including dual 

eligible individuals. Under the State Innovation Model (SIM), the Innovation Center is testing 

the ability for state governments to accelerate transformation. The premise of the SIM initiative 

is to support Governor-sponsored, multi-payer models that are focused on public and private 

sector collaboration to transform the state’s payment and delivery system. States have policy 

and regulatory authorities, as well as ongoing relationships with private payers, health plans, and 

providers that can accelerate delivery system reform. SIM models must impact the 

preponderance of care in the state and are expected to work with public and private payers to 

create multi-payer alignment. The evaluation of SIM will include all populations and payers 

involved in the state initiative, which in many cases includes private payers. The absence of 

identifiable data from private payers would result in considerable limitations on the level of 

evaluation conducted. Therefore, under this authority, we also proposed to require the 

submission of identifiable health and utilization information for patients of private payers treated 

by providers/suppliers participating in the testing of a model under section 1115A of the Act 
CMS-1612-FC 569

when an explicit purpose of the model test is to engage private sector payers. This regulation 

will provide clear legal authority for Health Insurance Portability and Accountability Act 

(HIPAA) Covered Entities to disclose any required protected health information. Identifiable 

data submitted by entities participating in the testing of models under section 1115A of the Act 

will meet CMS Acceptable Risks Safeguards (ARS) guidelines. When data is expected to be 

exchanged over the internet, such exchange will also meet all E-Gov requirements. In 

accordance with the requirements of the Privacy Act of 1974, upon receipt by CMS or its 

contractors, these data will be covered under a CMS-established system of records (System No. 

09–70–0591), which serves as the Master system for all demonstrations, evaluations, and 

research studies administered by the Innovation Center. These data will be stored until the 

evaluation is complete and all necessary policy deliberations have been finalized. 

2. Provisions of the Proposed Regulations 

 Wherever possible, evaluations will make use of claims, assessment, and enrollment 

data available through CMS’ existing administrative systems. However, evaluations will 

generally also need to include additional data not available through existing CMS administrative 

systems. As such, depending on the particular project, CMS or its contractor will require the 

production of the minimum data necessary to carry out the statutorily mandated research work 

described in section E.1. of this final rule with comment period. Such data may include the 

identities of the patients served under the model, relevant clinical details about the services 

furnished and outcomes achieved, and any confounding factors that might influence the 

evaluation results achieved through the delivery of such services. For illustrative purposes, 

below are examples of some of the types of information that could be required to carry out an 

evaluation, and for which the evaluator would need patient-level identifiers. 
CMS-1612-FC 570

● Utilization data not otherwise available through existing Centers for Medicare & 

Medicaid Services (CMS) systems. 

● Beneficiary, patient, participant, family, and provider experiences. 

● Beneficiary, patient, participant, and provider rosters with identifiers that allow 

linkages across time and datasets. 

● Beneficiary, patient, participant, and family socio-demographic and ethnic 

characteristics. 

● Care management details, such as details regarding the provision of services, payments 

or goods to beneficiaries, patients, participants, families, or other providers. 

● Beneficiary, patient, and participant functional status and assessment data. 

● Beneficiary, patient, and participant health behaviors. 

● Clinical data, such as, but not limited to lab values and information from EHRs. 

● Beneficiary, patient, participant quality data not otherwise available through claims.

● Other data relevant to identified outcomes—for example, participant employment 

status, participant educational degrees pursued/achieved, and income. 

 We invited public comment on this proposal to mandate the production of the 

individually identifiable information necessary to conduct the statutorily mandated research 

under section 1115A of the Act. 

 In addition, we proposed a new subpart K in part 403 to implement section 1115A of 

the Act. 

The following is a summary of the comments we received regarding our proposal to 

mandate the production of the individually identifiable information necessary to conduct the 

statutorily mandated research under section 1115A of the Act. 
CMS-1612-FC 571

Comment: Commenters consistently recognized the need to evaluate Innovation Center 

models as an important component of the effort to test new payment and service delivery models. 

Further, several commenters supported the need for rigorous evaluations that include control 

groups. One commenter further recommended the Innovation Center make the aggregated deidentified data from evaluations available to external researchers. Although supportive of the 

need to evaluate Innovation Center models, several commenters stated the Innovation Center had 

not sufficiently justified the need for individually identifiable patient information, and suggested 

aggregate or de-identified data should be sufficient. One commenter suggested the submission 

of performance rates, patient outcomes information, and/or composite scores for participating 

providers instead of individual patient-level data. The commenter further stated that CMS 

should not have access to proprietary patient-level data in registries. Some of the commenters 

stated CMS should publish its evaluation methodologies and solicit feedback from independent 

research experts as to the need for patient-level data. 

Response: We appreciate the commenters’ support for rigorous evaluations, and 

understand the desire for access to the aggregate de-identified data from these evaluations. We 

always make our data available in accordance with applicable law, HHS and CMS policies, and, 

where relevant, the availability of funding. Such laws include HIPAA, the Privacy Act, the 

Trade Secrets Act and the Freedom of Information Act. With respect to comments 

recommending the use of aggregate or de-identified data instead of individually identifiable data, 

as we discussed in the preamble of the proposed rule, we believe individually identifiable data is 

necessary. As noted in this final rule with comment and in the preamble of our proposed rule, 

evaluations will need to consider such factors as outcomes, clinical quality, adverse effects, 

access, utilization, patient and provider satisfaction, sustainability, potential for the model to be 

applied on a broader scale, and total cost of care. Furthermore, individuals receiving services 
CMS-1612-FC 572

from or who are the subjects of the intervention will be compared to clinically, sociodemographically, and geographically similar matched individuals along various process, 

outcome, and patient-reported measures. Many of these assessments will require person-level 

data. We will make use of aggregate information on system performance through the use of 

provider submitted aggregate performance rates for selected measures, patient outcomes 

information, and/or composite scores. However, without the ability to identify specifically 

which beneficiaries are receiving services as a result of the model, the evaluation analyses could 

include individuals not even subject to the intervention, and therefore, there would be a very real 

possibility that positive impacts of the model may be diluted and unobservable. While aggregate 

data could be limited to the target population, identification of which individuals are within the 

target population of the model, are receiving items and services under the model, or are subject 

to the interventions being tested under the model will also allow the evaluators to construct 

matched comparison groups that look as similar as possible to the intervention group. The 

absence of a well-matched comparison group, which can only be achieved when individually 

identifiable characteristics are known, could result in impact estimates that are inaccurate 

because these impact estimates could be due to differences between the intervention group and 

the comparison group and not the intervention itself. Further, while we will need to know the 

identifiers of beneficiaries that are the subject of the model test, the submission of other patientlevel data from proprietary registries would be limited to data necessary to conduct a credible 

evaluation. Data on individuals are also needed to assess differential impacts among subgroups 

of beneficiaries to identify who benefits most from the intervention. We agree it is important to 

seek expert opinion on the structure of our assessment methods, and so these models are 

developed in concert with and run through our evaluation contractors, which are independent 

research firms and academic institutions. Where needed, these contractors also reach out to 
CMS-1612-FC 573

technical expert panels for added guidance. As a result, the design and implementation of these 

assessments are informed by those with expertise in health services research, economics, 

statistics, program evaluation, epidemiology, and public health. 

Comment: Although generally supportive of the need for rigorous evaluations, some 

commenters worried that any requirement to provide individually identifiable data for 

monitoring and/or assessment purposes would impose an undue administrative burden on model 

participants, and could lead to the need to submit large (and, potentially, overbroad) amounts of 

individually identifiable patient-level data. A few commenters suggested that the Innovation 

Center should first look to other federal government sources before requesting data from model 

participants. Several commenters noted that it would be costly to produce patient-level data for 

models with a multi-payer focus, and others stated additional payment should be made to model 

participants to offset the cost of data reporting. Further, it was suggested that CMS estimate the 

potential burden and cost on physicians and other providers, and if found to be burdensome, 

give physicians the right to opt out of producing information that may not be available due to 

cost limitations or other administrative barriers, such as barriers to producing data stored in 

electronic health records. 

Response: We agree that our determination of what data are necessary to evaluate a 

model should be made taking into consideration the burden and cost associated with collecting 

and reporting such data, including the complexities associated with abstracting data from 

electronic health records. We further agree that in making such determinations, we should take 

advantage of all existing federal data systems, wherever possible so that we may minimize the 

amount of data that we must obtain from model participants. Our regulation will only require 

that model participants collect and report data as is necessary for monitoring or evaluation; thus, 

if we do not need the data, we would not seek to collect it from model participants. 
CMS-1612-FC 574

Reimbursement may be considered for future models, but if adopted, any such 

reimbursement, and any conditions for such reimbursement, would be prominently noted in the 

solicitation or modifications to model agreements. To the extent feasible, we also agree that it is 

important for potential model participants to understand the data collection requirements before 

the model begins, so that they may take these requirements into consideration. We do not agree, 

though, that model participants should be given the opportunity to opt out of producing the 

required information, as this would undermine the evaluation and skew results. 

With respect to the specific data needed for evaluation purposes, in many models, the 

evaluators will be able to determine who the individuals are that are the subjects of the model 

test without the need to obtain identifiers from the model participants. In those cases, there is a 

beneficiary-specific payment under the model and the evaluator can use our existing 

administrative data systems to identify which beneficiaries are in the model. In this last 

example, although we may not need to obtain the identifiers, we may still need to obtain other 

person-level data, such as clinical information. In other models, where a specific beneficiarylevel payment is not being made, the evaluation contractor will not have an ability to identify the 

individuals targeted by the model participants. In this latter circumstance, the participants will 

need to provide the identifiers that would then be used by the evaluator to link to existing 

administrative data systems. Although the exact data needs will vary by model, in some cases 

we would determine that only the identifiers (such as, but not limited to, the Medicare Health 

Insurance Claim number) are required. In other circumstances, it is possible the evaluators will 

need other data, such as clinical data not otherwise available in claims to properly account for 

severity of disease. In this manner we will limit data demands, and the attendant costs, to the 

data necessary to accomplish the required monitoring and assessment. 
CMS-1612-FC 575

Comment: Some commenters stated the requirement could result in requests for data 

from providers tangentially involved in an Innovation Center project to report any data the 

agency decides it needs. A few commenters further stated the Innovation Center should ensure 

that all participating entities seek patient authorizations to use their records for the purpose of 

evaluating the model. 

Response: Section 1115A(b)(4) of the Act authorizes us to establish requirements for 

“States and other entities participating in the testing of models” to collect and report data 

necessary for monitoring and evaluating the models. Our regulation, therefore, establishes this 

requirement only with respect to model participants. We consider model participants to include 

any party that has agreed to participate in, or that receives payment from us under, a model we 

are testing. In response to the comment suggesting that the Innovation Center ensure that all 

participating entities seek patient authorizations to use their records for the purpose of evaluating 

the model, we decline to impose such a requirement in implementing section 1115A(b)(4) of the 

Act, and we refer such entities to their own legal counsel for advice on whether any form of 

consent would be required by other applicable law. 

Comment: Some commenters stated the Innovation Center should publish and be 

transparent about what the exact data reporting and collection requirements would be so that 

participants would have notice of what data they would be required to collect. Commenters 

stated that without a notice and comment period as part of the model test, there will be no 

opportunity for stakeholders to weigh in with their perspective of what constitutes the minimum 

necessary information to achieve the evaluation goals. A few commenters stated the Innovation 

Center should first determine the specific data elements that are required for evaluation purposes 

for the existing programs and this information should be shared with participants who should, at 

minimum, be given an opportunity to provide comment on the required inputs for which they 
CMS-1612-FC 576

will be responsible as part of the evaluation. These commenters also stated the Innovation 

Center should develop such requirements in advance of the program start for participants to 

allow them an opportunity to provide feedback and weigh the information as part of their 

decision to participate in the model. 

Response: We agree it is important to restrict data requests to the data necessary to 

conduct credible monitoring and evaluation. We frequently provide stakeholders the opportunity 

to weigh in on what data they believe would be necessary to evaluate a model, generally through 

webinars that we conduct during model development and implementation. Further, in order for 

potential model participants to understand the likely data reporting requirements, to the extent 

feasible, these requirements are incorporated into the solicitation process. However, we decline 

to adopt a requirement to undertake a notice and comment process as part of our determination of 

what data are necessary for monitoring or evaluation because we believe the process already in 

place allows for model participant feedback. We also disagree with commenters who 

recommend that we make the determination and specify the particular data elements that will be 

required for monitoring and evaluation prior to the start of the model. It is not always possible at 

that early stage of the model to know precisely what data elements will be necessary. However, 

we will strive to provide as much relevant detail as possible about data collection and reporting 

requirements in any solicitation process and in any ongoing communications with potential 

participants, and we will continue to take any comments received into account in determining 

our data needs. 

Comment: A few commenters stated that CMS has not provided sufficient assurances 

that providers, in responding to these data requests, would be protected or deemed to be in 

compliance with the HIPAA requirements for the use and disclosure of protected health 

information (PHI). These commenters stated the Innovation Center reference to requiring 
CMS-1612-FC 577

reporting of individually identifiable patient-level data raises significant privacy concerns for 

providers who would be required to report such data. These commenters stated HIPAA requires 

that providers limit the use and disclosure of personal health information to the minimum 

necessary to accomplish the intended purpose of the disclosure. These commenters stated the 

Innovation Center requests for such data must be in compliance with providers’ HIPAA 

obligations. As such, some commenters stated CMS should work with the Office for Civil 

Rights (OCR) to ensure providers reporting data as part of an evaluation are doing so consistent 

with their HIPAA obligations. These commenters stated it is HHS’s Office for Civil Rights 

(OCR) – not CMS – that ultimately determines whether a particular provider is properly 

compliant and not subject to penalties. These same commenters suggested that the Innovation 

Center should work with OCR to issue OCR guidance stating that providers reporting data as 

part of an evaluation are doing so consistent with their HIPAA obligations. Some commenters 

stated CMS should consider the necessary data elements on a program-by-program basis rather 

than establishing a blanket approval, or at minimum limit the scope of the approved data 

requirements and uses, and should provide clear instructions and other educational resources to 

ensure that collection and reporting of the data complies with the HIPAA Privacy and Security 

rules. 

Response: We appreciate the concerns expressed about compliance with the HIPAA 

requirements and the recommendation to work with OCR. However, we respectfully disagree 

that sufficient assurances have not been provided. The disclosure would be required by a 

regulation, so it would be “required by law” under HIPAA. See 45 CFR 164.512(a) and the 

definition of “required by law” at 45 CFR 164.103. A HIPAA covered entity is permitted to 

disclose protected health information as required by law under these provisions so long as the 

disclosure complies with and is limited to the relevant requirements of the law. A separate 
CMS-1612-FC 578

minimum data necessary determination is not required under the HIPAA Privacy Rule for 

required by law disclosures under 45 CFR 164.512(a). See 45 CFR 164.502(b) (2). Although a 

separate minimum data necessary determination is not required, as a policy matter and consistent 

with the statutory authority under 1115A(b) (4), CMS will only require that data we determine is 

necessary for evaluation and monitoring of Innovation Center models. 

Comment: Several commenters stated that collection of beneficiary-level health 

information raises significant security concerns. Although supportive of sharing relevant and 

medically necessary patient information, one commenter raised a particular concern that some 

data could be sensitive information related to mental health or substance abuse. Some 

commenters stated CMS should adopt safeguards against inappropriate use or disclosure of 

patient identifiable data. 

Response: We agree that it is critical to abide by rigorous security standards, and we take 

patient privacy seriously. As CMMI is part of Fee-for-Service Medicare, a Health Care 

Component that is subject to the HIPAA requirements, providers’ and suppliers’ data will 

generally be subject to the same HIPAA privacy and security requirements as that data was 

subject to in the hands of the providers and suppliers from which it came. Furthermore, if stored 

in a manner searchable by individual identifiers, it will also be subject to the Privacy Act of 

1974. 

As HIPAA Business Associates, this data will be equally well protected when held by 

one of our evaluation contractors. In addition, the disclosure of substance abuse records will, 

where applicable, also be subject to the Part 2 regulations. 

Comment: One commenter stated CMS should not use these data for purposes other than 

those articulated in the proposed rule, and that the assessments should comply with the 

applicable statutory requirements, meaning that: (1) The assessments should take into account 
CMS-1612-FC 579

all of the factors outlined under section 1115A(b)(4) of the Act (that is, quality of care, including 

patient-level outcomes and patient-centeredness criteria); (2) the assessments should be made 

publicly available; and (3) CMS should pursue notice-and-comment rulemaking before any of 

the CMS demonstrations are expanded based on these assessments, as required by section 

1115A(c) of the Act. 

Response: We agree that evaluations should assess quality of care, and the patient-deidentified results should be made publicly available, as required by section 1115A(b)(4) of the 

Act. We would pursue model expansion according to the terms of the statute. 

After consideration of the public comments we received, we are finalizing our proposal to 

mandate the production of the individually identifiable information necessary to conduct the 

statutorily mandated research under section 1115A of the Act. We are accepting the 

recommendations made by commenters to minimize participant burden, seek input from 

providers, and use independent researchers. In addition, we are finalizing our proposal to add a 

new subpart K in part 403 to implement section 1115A of the Act without modification. 
CMS-1612-FC 580

F. Local Coverage Determination Process for Clinical Diagnostic Laboratory Testing 

The CY 2015 proposed rule (79 FR 40378 through 40380), section III.F., included 

discussion of a proposal to modify the existing process used by the Medicare Administrative 

Contractors (MACs) in developing local coverage determinations (LCDs) for clinical diagnostic 

laboratory tests. Briefly, the proposal would have expedited the timeline for LCD development 

for clinical diagnostic laboratory test LCDs by reducing the calendar days for some of the steps 

and by making optional or eliminating other steps within the current process. A detailed 

discussion of the proposal is available in section III.F. of the CY 2015 PFS Proposed Rule. 

We would like to thank the numerous public commenters for their time in submitting 

thoughtful comments to the agency on this issue. Comments were received from individual 

members of the public, insurers, drug manufacturers, medical specialty societies, laboratory 

groups and individual laboratories. The commenters focused their comments on the following 

issues: the proposal to reduce the draft LCD public comment period to 30 days; the proposal for 

a meeting of the Carrier Advisory Committee to be optional; the proposal to remove the 

requirement for a public meeting; and the proposal to eliminate the 45-day notice period prior to 

final LCDs becoming effective. In addition, commenters were concerned about the proposed 

changes in light of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), titled 

“Improving Medicare Policies for Clinical Diagnostic Laboratory Tests.” 

The comments received have given the agency much to consider prior to moving forward with 

any changes to the LCD process; therefore, we will not finalize any changes to the LCD process 

in this final rule. We will explore the possibility of future notice-and-comment rulemaking on 

this issue. 
CMS-1612-FC 581

G. Private Contracting/Opt-out 

1. Background 

Effective January 1, 1998, section 1802(b) of the Act permits certain physicians and 

practitioners to opt-out of Medicare if certain conditions are met, and to furnish through private 

contracts services that would otherwise be covered by Medicare. For those physicians and 

practitioners who opt-out of Medicare in accordance with section 1802(b) of the Act, the 

mandatory claims submission and limiting charge rules of section 1848(g) of the Act would not 

apply. As a result, if the conditions necessary for an effective opt-out are met, physicians and 

practitioners are permitted to privately contract with Medicare beneficiaries and to charge them 

without regard to Medicare’s limiting charge rules. Regulations governing the requirements and 

procedures for private contracts appear at 42 CFR part 405, subpart D. 

a. Opt-out Determinations (§405.450) 

 The private contracting regulation at §405.450 describes certain opt-out determinations 

made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to 

appeal those determinations. Section 405.450(a) describes the process available for physicians 

or practitioners to appeal Medicare enrollment determinations related to opting out of the 

program, and §405.450(b) describes the process available to challenge payment determinations 

related to claims for services furnished by physicians who have opted out. Both provisions refer 

to §405.803, the Part B claims appeals process that was in place at the time the opt-out 

regulations were issued (November 2, 1998). When those regulations were issued, a process for 

a physician or practitioner to appeal enrollment related decisions had not been implemented in 

regulation. Thus, to ensure an appeals process was available to physicians and practitioners for 

opt-out related issues, we chose to utilize the existing claims appeals process in §405.803 for 

both enrollment and claims related appeals. 
CMS-1612-FC 582

In May 16, 2012 Federal Register (77 FR 29002), we published a final rule entitled 

“Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, 

Transparency and Burden Reduction.” In that final rule, we deleted the provisions relating to 

initial determinations, appeals, and reopenings of Medicare Part A and Part B claims, and 

relating to determinations and appeals regarding an individual’s entitlement to benefits under 

Medicare Part A and Part B, which were contained in part 405, subparts G and H (including 

§405.803) because these provisions were obsolete and had been replaced by the regulations at 

part 405, subpart I. We inadvertently neglected to revise the cross-reference in §405.450(a) and 

(b) of the private contracting regulations to direct appeals of opt-out determinations through the 

current appeal process. However, it is important to note that our policy regarding the appeal of 

opt-out determinations did not change when the appeal regulations at part 405, subpart I were 

finalized. 

The procedures set forth in current part 498 establish the appeals procedures regarding 

decisions made by Medicare that affect enrollment in the program. We believe this process, and 

not the appeal process in part 405, subpart I, is the appropriate channel for physicians and 

practitioners to challenge an enrollment related opt-out decision made by Medicare. There are 

now two different sets of appeal regulations for initial determinations; and the appeal of 

enrollment related opt-out determinations is more like the types of determinations now addressed 

under part 498 than those under part 405, subpart I. Specifically, the appeal process under part 

405, subpart I focuses on reviews of determinations regarding beneficiary entitlement to 

Medicare and claims for benefits for particular services. The appeal process under part 498 is 

focused on the review of determinations regarding the participation or enrollment status of 

providers and suppliers. Enrollment related opt-out determinations involve only the status of 

particular physician or practitioners under Medicare, and do not involve beneficiary eligibility or 
CMS-1612-FC 583

claims for specific services. As such, the appeal process under part 498 is better suited for the 

review of enrollment related opt-out determinations. 

However, we do not believe the enrollment appeals process established in part 498 is the 

appropriate mechanism for challenging payment decisions on claims for services furnished by a 

physician and practitioner who has opted out of the program. Appeals for such claims should 

continue to follow the appeals procedures now set forth in part 405 subpart I. 

b. Definitions, Requirements of the Opt Out Affidavit, Effects of Opting Out of Medicare, 

Application to Medicare Advantage Contracts (§§405.400, 405.420(e), 405.425(a), and 405.455) 

Section 405.400 sets forth certain definitions for purposes of the private contracting 

regulations. Among the defined terms is “Emergency care services” which means services 

furnished to an individual for treatment of an “emergency medical condition” as that term is 

defined in §422.2. The cross-referenced regulation at §422.2 included within the definition of 

emergency care services was deleted on June 29, 2000 (65 FR 40314) and at that time we 

inadvertently neglected to revise that cross-reference. The cross-reference within the definition 

of emergency care services should have been amended at that time to cite the definition of 

“emergency services” in §424.101. 

 The private contracting regulations at §405.420(e), §405.425(a) and §405.455 all use the 

term Medicare+Choice when referring to Part C plans. However, we no longer use the term 

Medicare+Choice when referring to Part C plans; instead the plans are referred to as Medicare 

Advantage plans. When part 422 of the regulations was updated on January 28, 2005 

(70 FR 4741), we inadvertently neglected to revise §405.420(e), §405.425(a) and §405.455 to 

replace the term Medicare+Choice with Medicare Advantage plan. 

2. Provisions of the Proposed Regulation 
CMS-1612-FC 584

For the reasons discussed above, we proposed that a determination described in 

§405.450(a) (relating to the status of opt-out or private contracts) is an initial determination for 

purposes of §498.3(b), and a physician or practitioner who is dissatisfied with a Medicare 

determination under §405.450(a) may utilize the enrollment appeals process currently available 

for providers and suppliers in part 498. In addition, we proposed that a determination described 

in §405.450(b) (that payment cannot be made to a beneficiary for services furnished by a 

physician or practitioner who has opted out) is an initial determination for the purposes of 

§405.924 and may be challenged through the existing claims appeals procedures in part 405 

subpart I. Accordingly, we proposed that the cross reference to §405.803 in §405.450(a) be 

replaced with a cross reference to §498.3(b). We also proposed that the cross reference to 

§405.803 in §405.450(b) be replaced with a cross reference to §405.924. We also proposed 

corresponding edits to §498.3(b) and §405.924 to note that the determinations under §405.450(a) 

and (b), respectively, are initial determinations. 

 For the reasons discussed above, we also proposed that the definition of Emergency care 

services at §405.400 be revised to cite the definition of Emergency services in §424.101 and that 

all references to Medicare+Choice in §405.420(e), §405.425(a) and §405.455 be replaced with 

the term “Medicare Advantage.” 

The following is a summary of the comments we received regarding our proposals. 

Comment: Commenters requested that physicians and practitioners be allowed to opt out 

of Medicare indefinitely instead of submitting a new affidavit every 2 years. 

Response: These comments are outside the scope of this rule as they are not related to 

the proposed changes to the opt-out regulations. Nevertheless, we note that section 

1802(b)(3)(B)(ii) of the Act specifies that the opt-out affidavit must provide that the “physician 

or practitioner will not submit any claim under this title for any item or service provided to any 
CMS-1612-FC 585

medicare beneficiary... during the 2-year period beginning on the date the affidavit is signed.” 

As such, the longest interval for which an opt-out can be effective is 2 years. We have no 

authority to modify that statutory requirement. 

Because we did not receive any comments on our proposals, we are finalizing the rule as 

proposed. 

H. Solicitation of Comments on the Payment Policy for Substitute Physician Billing 

Arrangements 

1. Background 

In accordance with section 1842(b)(6) of the Act, no payment under Medicare Part B 

may be made to anyone other than to the beneficiary to whom a service was furnished or to the 

physician or other person who furnished the service. However, there are certain limited 

exceptions to this general prohibition. For example, section 1842(b)(6)(D) of the Act describes 

an exception for substitute physician billing arrangements, which states that “payment may be 

made to a physician for physicians’ services (and services furnished incident to such services) 

furnished by a second physician to patients of the first physician if (i) the first physician is 

unavailable to provide the services; (ii) the services are furnished pursuant to an arrangement 

between the two physicians that (I) is informal and reciprocal, or (II) involves per diem or other 

fee-for-time compensation for such services; (iii) the services are not provided by the second 

physician over a continuous period of more than 60 days or are provided over a longer 

continuous period during all of which the first physician has been called or ordered to active duty 

as a member of a reserve component of the Armed Forces; and (iv) the claim form submitted to 

the [Medicare Administrative contractor (MAC)] for such services includes the second 

physician’s unique identifier . . . and indicates that the claim meets the requirements of this 
CMS-1612-FC 586

subparagraph for payment to the first physician.” Section 1842(b)(6) of the Act is selfimplementing and we have not interpreted the statutory provisions through regulations. 

In practice, section 1842(b)(6)(D) of the Act generally allows for two types of substitute 

physician billing arrangements: (1) an informal reciprocal arrangement where doctor A 

substitutes for doctor B on an occasional basis and doctor B substitutes for doctor A on an 

occasional basis; and (2) an arrangement where the services of the substitute physician are paid 

for on a per diem basis or according to the amount of time worked. Substitute physicians in the 

second type of arrangement are sometimes referred to as “locum tenens” physicians. It is our 

understanding that locum tenens physicians are substitute physicians who often do not have a 

practice of their own, are geographically mobile, and work on an as-needed basis as independent 

contractors. They are utilized by physician practices, hospitals, and health care entities enrolled 

in Part B as Medicare suppliers to cover for physicians who are absent for reasons such as 

illness, pregnancy, vacation, or continuing medical education. Also, we have heard anecdotally 

that locum tenens physicians are used to fill staffing needs (for example, in physician shortage 

areas) or, on a temporary basis, to replace physicians who have permanently left a medical group 

or employer. 

We are concerned about the operational and program integrity issues that result from the 

use of substitute physicians to fill staffing needs or to replace a physician who has permanently 

left a medical group or employer. For example, although our Medicare enrollment rules require 

physicians and physician groups or organizations to notify us promptly of any enrollment 

changes (including reassignment changes) (see §424.516(d)), processing delays or 

miscommunication between the departing physician and his or her former medical group or 

employer regarding which party would report the change to Medicare could result in the Provider 

Transaction Access Number (PTAN) that links the departed physician and his or her former 
CMS-1612-FC 587

medical group remaining “open” or “attached” for a period of time. During such period, both the 

departed physician and the departed physician’s former medical group might bill Medicare under 

the departed physician’s National Provider Identifier (NPI) for furnished services. This could 

occur where a substitute physician is furnishing services in place of the departed physician in the 

departed physician’s former medical group, while the departed physician is also furnishing 

services to beneficiaries following departure from the former group. Operationally, either or 

both types of claims could be rejected or denied, even though the claims filed by the departed 

physician were billed appropriately. Moreover, the continued use of a departed physician’s NPI 

to bill for services furnished to beneficiaries by a substitute physician raises program integrity 

issues, particularly if the departed physician is unaware of his or her former medical group or 

employer’s actions. 

Finally, as noted above, section 1842(b)(6)(D)(iv) of the Act requires that the claim form 

submitted to the MAC include the substitute physician’s unique identifier. Currently, the unique 

identifier used to identify a physician is the physician’s NPI. Prior to the implementation of the 

NPI, the Unique Physician Identification Number (UPIN) was used. Because a substitute 

physician’s NPI is not captured on the CMS-1500 claim form or on the appropriate electronic 

claim, physicians and other entities that furnish services to beneficiaries through the use of a 

substitute physician are required to enter a modifier on the CMS-1500 claim form or on the 

appropriate electronic claim indicating that the services were furnished by a substitute physician; 

and to keep a record of each service provided by the substitute physician, associated with the 

substitute physician’s UPIN or NPI; and to make this record available to the MAC upon request. 

(See Medicare Claims Processing Manual (Pub. 100-4), Chapter 1, Sections 30.2.10 and 30.2.11) 

However, having a NPI or UPIN does not necessarily mean that the substitute physician is 

enrolled in the Medicare program. Without being enrolled in Medicare, we do not know whether 
CMS-1612-FC 588

the substitute physician has the proper credentials to furnish the services being billed under 

section 1842(b)(6)(D) of the Act or if the substitute physician is sanctioned or excluded from 

Medicare. The importance of enrollment and the resulting transparency afforded the Medicare 

program and its beneficiaries was recognized by the Congress when it included in the Affordable 

Care Act a requirement that physicians and other eligible non-physician practitioners (NPPs) 

enroll in the Medicare program if they wish to order or refer certain items or services for 

Medicare beneficiaries. This includes those physicians and other eligible NPPs who do not and 

will not submit claims to a Medicare contractor for the services they furnish. We solicited 

comments regarding how to achieve similar transparency in the context of substitute physician 

billing arrangements for the identity of the individual actually furnishing the service to a 

beneficiary. 

2. Analysis of Comments 

To help inform our decision whether and, if so, how to address the issues discussed in 

section III.H.1., and whether to adopt regulations interpreting section 1842(b)(6)(D) of the Act, 

we solicited comments on the policy for substitute physician billing arrangements. We noted 

that any regulations would be proposed in a future rulemaking with opportunity for public 

comment. Through this solicitation, we hoped to understand better current industry practices for 

the use of substitute physicians and the impact that policy changes limiting the use of substitute 

physicians might have on beneficiary access to physician services. 

We received a few comments on the issues raised in this solicitation. We thank the 

commenters for their input, and we will carefully consider their comments in any future 

rulemaking on this subject. 
CMS-1612-FC 589

I. Reports of Payments or Other Transfers of Value to Covered Recipients 

1. Background 

 In the February 8, 2013 Federal Register (78 FR 9458), we published the “Transparency 

Reports and Reporting of Physician Ownership or Investment Interests” final rule which 

implemented section 1128G of the Social Security Act (“Act”), as added by section 6002 of the 

Affordable Care Act. Under section 1128G(a)(1) of the Act, manufacturers of covered drugs, 

devices, biologicals, and medical supplies (applicable manufacturers) are required to submit on 

an annual basis information about certain payments or other transfers of value made to 

physicians and teaching hospitals (collectively called covered recipients) during the course of the 

preceding calendar year. Section 1128G(a)(2) of the Act requires applicable manufacturers and 

applicable group purchasing organizations (GPOs) to disclose any ownership or investment 

interests in such entities held by physicians or their immediate family members, as well as 

information on any payments or other transfers of value provided to such physician owners or 

investors. The implementing regulations are at 42 CFR part 402, subpart A, and part 403, 

subpart I. We have organized these reporting requirements under the “Open Payments” 

program. 

 The Open Payments program creates transparency around the nature and extent of 

relationships that exist between drug, device, biologicals and medical supply manufacturers, and 

physicians and teaching hospitals (covered recipients and physician owner or investors). The 

implementing regulations, which describe procedures for applicable manufacturers and 

applicable GPOs to submit electronic reports detailing payments or other transfers of value and 

ownership or investment interests provided to covered recipients and physician owners or 

investors, are codified at §403.908. 
CMS-1612-FC 590

Since the publication and implementation of the February 8, 2013 final rule, various 

stakeholders have provided feedback to CMS regarding certain aspects of these reporting 

requirements. Specifically, §403.904(g)(1) excludes the reporting of payments associated with 

certain continuing education events, and §403.904(c)(8) requires reporting of the marketed name 

for drugs and biologicals but makes reporting the marketed name of devices or medical supplies 

optional. We proposed a change to §403.904(g) to correct an unintended consequence of the 

current regulatory text. Additionally, at §403.904(c)(8), we proposed to make the reporting 

requirements consistent by requiring the reporting of the marketed name for drugs, devices, 

biologicals, or medical supplies which are associated with a payment or other transfer of value. 

Additionally, at §403.902, we proposed to remove the definition of a “covered device” 

because we believe it is duplicative of the definition of “covered drug, device, biological or 

medical supply” which is codified in the same section. We also proposed to require the reporting 

of the following distinct forms of payment: stock; stock option; or any other ownership interests 

specified in §403.904(d)(3) to collect more specific data regarding the forms of payment. 

2. Continuing Education Exclusion (§403.904(g)(1)) 

In the February 8, 2013 final rule, many commenters recommended that accredited or 

certified continuing education payments to speakers should not be reported because there are 

safeguards already in place, and they are not direct payments to a covered recipient. In the final 

rule preamble, we noted that “industry support for accredited or certified continuing education is 

a unique relationship” (78 FR 9492). Section 403.904(g)(1) states that payments or other 

transfers of value provided as compensation for speaking at a continuing education program need 

not be reported if the following three conditions are met: 

● The event at which the covered recipient is speaking must meet the accreditation or 

certification requirements and standards for continuing education for one of the following 
CMS-1612-FC 591

organizations: the Accreditation Council for Continuing Medical Education (ACCME); the 

American Academy of Family Physicians (AAFP); the American Dental Association’s 

Continuing Education Recognition Program (ADA CERP); the American Medical Association 

(AMA); or the American Osteopathic Association (AOA). 

● The applicable manufacturer does not pay the covered recipient speaker directly. 

● The applicable manufacturer does not select the covered recipient speaker or provide 

the third party (such as a continuing education vendor) with a distinct, identifiable set of 

individuals to be considered as speakers for the continuing education program. 

Since the implementation of §403.904(g)(1), other accrediting organizations have 

requested that payments made to speakers at their events also be exempted from reporting. 

These organizations have stated that they follow the same accreditation standards as the 

organizations specified in §403.904(g)(1)(i). Other stakeholders have recommended that the 

exemption be removed in its entirety stating removal of the exclusion will allow for consistent 

reporting for compensation provided to physician speakers at all continuing education events, as 

well as transparency regarding compensation paid to physician speakers. Many stakeholders 

raised concerns that the reporting requirements are inconsistent because certain continuing 

education payments are reportable, while others are not. CMS’ apparent endorsement or support 

to organizations sponsoring continuing education events was an unintended consequence of the 

final rule. 

After consideration of these comments, we proposed to remove the language in 

§403.904(g) in its entirety, in part because it is redundant with the exclusion in §403.904(i)(1). 

That provision excludes indirect payments or other transfers of value where the applicable 

manufacturer is “unaware” of, that is, “does not know,” the identity of the covered recipient 

during the reporting year or by the end of the second quarter of the following reporting year. 
CMS-1612-FC 592

When an applicable manufacturer or applicable GPO provides funding to a continuing education 

provider, but does not either select or pay the covered recipient speaker directly, or provide the 

continuing education provider with a distinct, identifiable set of covered recipients to be 

considered as speakers for the continuing education program, CMS will consider those payments 

to be excluded from reporting under §403.904(i)(1). This approach is consistent with our 

discussion in the preamble to the final rule, in which we explained that if an applicable 

manufacturer conveys “full discretion” to the continuing education provider, those payments are 

outside the scope of the rule (78 FR 9492). In contrast, for example, when an applicable 

manufacturer conditions its financial sponsorship of a continuing education event on the 

participation of particular covered recipients, or pays a covered recipient directly for speaking at 

such an event, those payments are subject to disclosure. 

We considered two alternative approaches to address this issue. First, we explored 

expanding the list of organizations in §403.904(g)(1)(i) by name; however, we believe that this 

approach might imply CMS’s endorsement of the named continuing education providers over 

others. Second, we considered expansion of the organizations in §403.904(g)(1)(i) by 

articulating accreditation or certification standards that would allow a CME program to qualify 

for the exclusion. This approach is not easily implemented because it would require evaluating 

both the language of the standards, as well as the enforcement of the standards of any 

organization professing to meet the criteria. We solicited comments on both alternatives 

presented, including commenters’ suggestions about what standards, if any, CMS should 

incorporate. 

The following is summary of the comments we received regarding both alternatives 

presented, and what standards, if any, CMS should incorporate. 

Comment: We received numerous comments addressing our proposal to remove the 
CMS-1612-FC 593

exclusion for compensation for speaking at a continuing education program. Some comments 

were in support to remove the exclusion stating it is an important step toward ensuring 

transparency. Supporting comments also agreed removing the exclusion will level the playing 

field with the medical education community. Numerous commenters questioned our proposal to 

remove the exclusion for compensation for speaking at a continuing education program. 

Commenters provided background regarding accrediting continuing education organizations 

stating that creating continuing education accreditation standards is a function of professional 

self-regulation and additional government regulation is not necessary. 

Many commenters recommend modifying the indirect payment exclusion currently at 

§ 403.904(i)(1) to specify a continuing education indirect payment should be excluded if the 

manufacturer did not know the identity of the covered recipient before providing the payment to 

a third party, such as a continuing education organization. This differs from the current indirect 

payment exclusion language which states the payment is excluded if the manufacturer did not 

know the identity of the covered recipient during the reporting year or by the end of the second 

quarter of the following reporting year. Commenters stated it is not practical for a manufacturer 

to not know the identity of a physician speaker receiving compensation for speaking at a 

continuing education event during the reporting year or by the end of the second quarter of the 

following reporting year because manufacturers could learn the identities of physician speakers 

through brochures, programs and other publications. Therefore, commenters assert that the 

indirect payment exclusion is not applicable to exclude compensation provided to physicians at a 

continuing education event and recommend the indirect payment exclusion is modified to 

accommodate indirect payments provided to a physician covered recipient through a continuing 

medical education organization. 

Additionally, commenters suggested an alternative approach where CMS would adopt 
CMS-1612-FC 594

established criteria, such as the Standards for Commercial Support: Standards to Ensure 

Independence in CME Activities, in order to have payments provided to physicians at continuing 

education events excluded. Similar criteria suggested by commenters to modify the exclusion 

were: does not pay covered speakers or attendees directly, does not select covered recipient 

speakers or provide a third party with a distinct, identifiable set of individuals to be considered as 

speakers or attendees for the continuing education program, and does not control the continuing 

education program content. 

Response: We appreciate commenters support to remove the exclusion for compensation 

for speaking at a continuing education program. We appreciate the comments stating that 

continuing medical education accrediting organizations is a function of professional selfregulation. We believe creating consistent reporting requirements for all continuing education 

events, by removing the language in §403.904(g) in its entirety, will provide enhanced regulatory 

clarity for stakeholders. Manufacturers reporting compensation paid to physician speakers may 

opt to distinguish if the payment was provided at an accredited or certified continuing education 

program versus an unaccredited or non-certified continuing education program by selecting the 

appropriate nature of payment category at §403.904(e). 

We understand commenters concern regarding learning the identity of the physician during the 

reporting year or by the end of the second quarter of the following reporting year. In the 

situation of an applicable manufacturer providing an indirect payment through a continuing 

education organization and learning the identity of the physician covered recipient in the allotted 

timeframe (during the reporting year or by the end of the second quarter of the following 

reporting year) the indirect payment would not meet the criteria of the indirect payment 

exclusion and would need to be reported. However, payments or other transfers of value, 

including payments made to physician covered recipients for purposes of attending or speaking 
CMS-1612-FC 595

at continuing education events, which do not meet the definition of an indirect payment, as 

defined at §403.902, are not reportable. For example, if an applicable manufacturer or applicable 

GPO provides funding to support a continuing education event but does not require, instruct, 

direct, or otherwise cause the continuing education event provider to provide the payment or 

other transfer or value in whole or in part to a covered recipient, the applicable manufacturer or 

applicable GPO is not required to report the payment or other transfer of value. The payment is 

not reportable regardless if the applicable manufacturer or applicable GPO learns the identity of 

the covered recipient during the reporting year or by the end of the second quarter of the 

following reporting year because the payment or other transfer of value did not meet the 

definition of an indirect payment. This approach is also consistent with our statement at (78 FR 

9490), where we explained that “if an applicable manufacturer provided an unrestricted donation 

to a physician professional organization to use at the organization’s discretion, and the 

organization chose to use the donation to make grants to physicians, those grants would not 

constitute ‘indirect payments’ because the applicable manufacturer did not require, instruct, or 

direct the organization to use the donation for grants to physicians.” Therefore, because such 

payments are not indirect payments, we do not need to create an additional exclusion specific to 

continuing education indirect payments by modifying the indirect payment exclusion at 

§403.904(i)(1). 

Comment: Many commenters interpreted the removal of physician speaker 

compensation at continuing education events would also remove the reporting exclusion for 

attendees at accredited or certified continuing education events whose fees have been subsidized 

through the continuing medical education organization by an applicable manufacturers. 

Response: We did not intend to remove the exclusion regarding subsidized fees provided 

to physician attendees by manufacturers at continuing education events. However, we intend for 
CMS-1612-FC 596

physician speaker compensation and physician attendees fees which have been subsidized 

through the continuing medical education organization by an applicable manufacturer to be 

reported unless the payment meets the indirect payment exclusion at §403.904(i)(1). This allows 

for consistent reporting for physician attendees and speakers at continuing education events. We 

will provide sub-regulatory guidance specifying tuition fees provided to physician attendees that 

have been generally subsidized at continuing education events by manufacturers are not expected 

to be reported. However, if a manufacturer does instruct, direct, or otherwise cause the 

subsidized tuition fee for a continuing education event to go to a specific physician attendee, the 

payment will not be excluded, since the indirect payment exclusion only applies if the 

manufacturer did not know the identity of the physician attendee. 

Comment: Many commenters interpreted the proposed removal of§403.904(g) to expand 

the exclusion to account for continuing education programs accredited or certified for nurses, 

optometrists, pharmacists, and others. 

Response: We appreciate the comments, but the removal of§403.904(g) was not intended 

to expand the exclusion. The intent is to allow for consistent reporting for compensation 

provided to physician speakers at all continuing education events, as well as transparency 

regarding compensation paid to physician speakers. 

Comment: A few commenters requested CMS provide clear and realistic timeframes 

regarding payments related to continuing education events to allow manufacturers to provide 

sponsor notice as it considers proposals to eliminate the current CME exclusion. 

Response: We agree with commenters that manufacturers may need additional time to 

comply with reporting requirements; therefore, we are finalizing data collection requirements 

that would begin January 1, 2016 according to this final rule for applicable manufacturers. 

3. Reporting of Marketed Name (§403.904(c)(8)) 
CMS-1612-FC 597

Section 1128G(a)(1)(A)(vii) of the Act requires applicable manufacturers to report the 

name of the covered drug, device, biological or medical supply associated with that payment, if 

the payment is related to ‘‘marketing, education, or research’’ of a particular covered drug, 

device, biological, or medical supply. Section 403.904(c)(8)(i) requires applicable 

manufacturers to report the marketed name for each drug or biological related to a payment or 

other transfer of value. At §403.904(c)(8)(ii), we require an applicable manufacturer of devices 

or medical supplies to report one of the following: the marketed name; product category; or 

therapeutic area. In the February 8, 2013, final rule, we provided applicable manufactures with 

flexibility when it was determined that the marketed name for all devices and medical supplies 

may not be useful for the general audience. We did not define product categories or therapeutic 

areas in §403.904(c). However, since implementation of the February 8, 2013 final rule and the 

development of the Open Payments system, we have determined that aligning the reporting 

requirements for marketed name across drugs, biologics, devices and medical supplies will make 

the data fields consistent within the system, and also enhance consumer’s use of the data. 

 Accordingly, we proposed to revise §403.904(c)(8) to require applicable manufacturers to 

report the marketed name for all covered drugs, devices, biologicals or medical supplies. We 

believe this would facilitate consistent reporting for the consumers and researchers using the data 

displayed publicly on the Open Payments. Manufacturers would still have the option to report 

product category or therapeutic area, in addition to reporting the market name, for devices and 

medical supplies. 

 Comment: We received a few comments regarding revising reporting requirements at 

§403.904(c)(8). These comments mainly stated that the marketed name for a device or medical 

supply is not useful for the public because the public is not familiar with device or medical 

supply marketed names. We also received a few comments that supported requiring the 
CMS-1612-FC 598

reporting of marketed name for devices and medical supplies. Supporting commenters believe 

that reporting marketed name for all products will allow the public (including researchers and 

consumers) to search the data via the Open Payments public website for a specific device or 

medical supply. Commenters also stated that reporting marketed name for non-covered products 

is not required by the statute and therefore manufacturers should not be required to report 

marketed names for non-covered products. Additionally, some comments indicated reporting 

marketed name for devices and medical supplies for research payments is not practical because 

there is not a marketed name for every device or medical supply associated with research 

payments; rather there may only be a connection to an associated research study. A few 

commenters addressed that manufacturers will have an increased burden to modify reporting 

systems to accommodate reporting marketed name for devices and medical supplies. 

 Response: We appreciate the comments supporting our proposed revisions requiring 

reporting marketed name for devices and medical supplies. We have finalized a modified 

approach to accommodate concerns regarding reporting related covered drug, device, biological 

or medical supply information. We agree manufacturers should not be required to report 

marketed names for non-covered products; therefore, we are finalizing the proposal that 

reporting marketed names for non-covered drugs, devices, biologicals, or medical supplies will 

continue to be optional. We also agree a payment or other transfer of value associated with a 

research payment regarding a device or medical supply may not have a marketed name. 

Therefore, we are finalizing the proposal that manufacturers will continue to have an option to 

report either a device or medical supply marketed name, therapeutic area or product category 

when reporting research payments. 

 After consideration of comments received, we agree that displaying therapeutic areas or 

product categories are useful for the public reviewing data on the Open Payments public website 
CMS-1612-FC 599

because the public is not familiar with marketed names for devices and medical supplies. We 

agree therapeutic areas and products categories are more recognizable by the public. Yet, 

reporting marketed names for all covered products is necessary to achieve consistent reporting 

and to have the ability to aggregate all payments or other transfers of value associated with a 

specific device or medical supply. Therefore to achieve consistent reporting by manufacturers, 

we will require manufacturers to report marketed name and therapeutic area or product category 

for all covered drugs, devices, biologicals or medical supplies. We also agree with commenters 

that complying with this reporting requirement will require a change in manufacturers’ reporting 

systems; therefore, data collection for this reporting requirement would begin January 1, 2016. 

4. Reporting of Stock, Stock Option, or any other Ownership Interest 

 Section 403.904(d)(3) requires the reporting of stock, stock option, or any other 

ownership interest. We proposed to require applicable manufacturers to report such payments as 

distinct categories. This will enable us to collect more specific data regarding the forms of 

payment made by applicable manufacturers. After issuing the February 8, 2013 final rule and 

the development of the Open Payments system, we determined that this specificity will increase 

the ease of data aggregation within the system, and also enhance consumer’s use of the data. We 

solicited comments on the extent to which users of this data set find this disaggregation to be 

useful, and whether this change presents operational or other issues on the part of applicable 

manufacturers. 

The following is summary of the comments we received regarding the extent to which 

users of this data set find this disaggregation to be useful, requiring reporting of marketed name 

for covered devices and medical supplies, and whether this change presents operational or other 

issues on the part of applicable manufacturers. 

Comment: Commenters agreed that requiring reporting of stock, stock option or any 
CMS-1612-FC 600

other ownership interest in distinct categories is useful. 

Response: We agree the disaggregation of reporting stock, stock option or any other ownership 

interest in distinct categories. Therefore, we have finalized this provision as proposed, which 

requires reporting stock, stock option, or any other ownership interest form of payment or other 

transfer of value in distinct categories. 
CMS-1612-FC 601

J. Physician Compare Website

1. Background and Statutory Authority 

 Section 10331(a)(1) of the Affordable Care Act, requires that, by no later than 

January 1, 2011, we develop a Physician Compare Internet website with information on 

physicians enrolled in the Medicare program under section 1866(j) of the Act, as well as 

information on other eligible professionals (EPs) who participate in the Physician Quality 

Reporting System (PQRS) under section 1848 of the Act. 

 CMS launched the first phase of Physician Compare on December 30, 2010 

(http://www.medicare.gov/physiciancompare). In the initial phase, we posted the names of EPs 

that satisfactorily submitted quality data for the 2009 PQRS, as required by section 

1848(m)(5)(G) of the Act. 

 Section 10331(a)(2) of the Affordable Care Act also requires that, no later than 

January 1, 2013, and for reporting periods that began no earlier than January 1, 2012, we 

implement a plan for making publicly available through Physician Compare information on 

physician performance that provides comparable information on quality and patient experience 

measures. We met this requirement in advance of January 1, 2013, as outlined below, and plan 

to continue addressing elements of the plan through rulemaking. 

 To the extent that scientifically sound measures are developed and are available, we are 

required to include, to the extent practicable, the following types of measures for public 

reporting: 

● Measures collected under the Physician Quality Reporting System (PQRS). 

● An assessment of patient health outcomes and functional status of patients. 

● An assessment of the continuity and coordination of care and care transitions, 

including episodes of care and risk-adjusted resource use. 
CMS-1612-FC 602

● An assessment of efficiency. 

● An assessment of patient experience and patient, caregiver, and family engagement. 

● An assessment of the safety, effectiveness, and timeliness of care. 

● Other information as determined appropriate by the Secretary. 

As required under section 10331(b) of the Affordable Care Act, in developing and implementing 

the plan, we must include, to the extent practicable, the following: 

● Processes to ensure that data made public are statistically valid, reliable, and accurate, 

including risk adjustment mechanisms used by the Secretary. 

● Processes for physicians and eligible professionals whose information is being 

publicly reported to have a reasonable opportunity, as determined by the Secretary, to review 

their results before posting to Physician Compare. We have established a 30-day preview period 

for all measurement performance data that will allow physicians and other EPs to view their data 

as it will appear on the website in advance of publication on Physician Compare (77 FR 69166 

and 78 FR 74450). Details of the preview process will be communicated directly to those with 

measures to preview and will also be published on the Physician Compare Initiative page 

(http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physiciancompare-initiative/) in advance of the preview period. 

● Processes to ensure the data published on Physician Compare provides a robust and 

accurate portrayal of a physician’s performance. 

● Data that reflects the care provided to all patients seen by physicians, under both the 

Medicare program and, to the extent applicable, other payers, to the extent such information 

would provide a more accurate portrayal of physician performance. 

● Processes to ensure appropriate attribution of care when multiple physicians and other 

providers are involved in the care of the patient. 
CMS-1612-FC 603

● Processes to ensure timely statistical performance feedback is provided to physicians 

concerning the data published on Physician Compare. 

● Implementation of computer and data infrastructure and systems used to support valid, 

reliable and accurate reporting activities. 

 Section 10331(d) of the Affordable Care Act requires us to consider input from 

multi-stakeholder groups, consistent with sections 1890(b)(7) and 1890A of the Act, when 

selecting quality measures for Physician Compare. We also continue to get general input from 

stakeholders on Physician Compare through a variety of means, including rulemaking and 

different forms of stakeholder outreach (for example, Town Hall meetings, Open Door Forums, 

webinars, education and outreach, Technical Expert Panels, etc.). In developing the plan for 

making information on physician performance publicly available through Physician Compare, 

section 10331(e) of the Affordable Care Act requires the Secretary, as the Secretary determines 

appropriate, to consider the plan to transition to value-based purchasing for physicians and other 

practitioners that was developed under section 131(d) of the MIPPA. 

 Under section 10331(f) of the Affordable Care Act, we are required to submit a report to 

the Congress by January 1, 2015, on Physician Compare development, and include information 

on the efforts and plans to collect and publish data on physician quality and efficiency and on 

patient experience of care in support of value-based purchasing and consumer choice. Section 

10331(g) of the Affordable Care Act provides that any time before that date, we may continue to 

expand the information made available on Physician Compare. 

 We believe section 10331 of the Affordable Care Act supports our overarching goals of 

providing consumers with quality of care information that will help them make informed 

decisions about their health care, while encouraging clinicians to improve the quality of care they 
CMS-1612-FC 604

provide to their patients. In accordance with section 10331 of the Affordable Care Act, we plan 

to publicly report physician performance information on Physician Compare. 

2. Public Reporting of Performance and Other Data 

 Since the initial launch of the website, we have continued to build on and improve 

Physician Compare. On June 27, 2013, we launched a full redesign of Physician Compare 

bringing significant improvements including a complete overhaul of the underlying database and 

a new Intelligent Search feature, addressing two of our stakeholders’ primary critiques of the site 

– the accuracy and currency of the database and the limitations of the search function – and 

considerably improving website functionality and usability. Provider Enrollment, Chain, and 

Ownership System (PECOS), as the sole source of verified Medicare professional information, is 

the primary source of administrative information on Physician Compare. With the redesign, 

however, we incorporated the use of Medicare Fee-For-Service claims information to verify the 

information in PECOS to help ensure only the most current and accurate information is included 

on the site. For example, claims information is used to determine which of the active and 

approved practice locations in PECOS are where the professional is currently providing services. 

Claims information helps confirm that only the most current group practice affiliations are 

included on the site. Our use of claims also helps ensure that we are posting on Physician 

Compare the most current and accurate information available about the professionals for 

Medicare consumers. 

 We received several comments about the enhancements made to the Physician Compare 

website and the data currently on the website. 

 Comment: Several commenters noted the improvements made to the Physician Compare 

website, including the additional labeling, improvements to the “Is this you?” link, the reordering 

of the search results, the Intelligent Search functionality, the use of claims data to verify 
CMS-1612-FC 605

professionals’ demographic information, denoting board certified physicians with contextual 

text, and explanations and disclaimers about each of the federal quality reporting programs 

included on the website. Commenters also noted an appreciation for the transparency and easyto-use, comprehensive information available on the site to aid consumers in making informed 

health care decisions. 

Some commenters provided suggestions for future Physician Compare enhancements. A 

few commenters suggested continued improvements to the Intelligent Search functionality to 

better find health care professionals other than physicians and additional specialty labels for 

Advanced Practice Registered Nurses (APRNs) and allied health professionals. 

 Response: We appreciate the commenters’ feedback and the continued support for the 

Physician Compare website. We are committed to continuing to improve the site and its 

functionality to ensure it is a useful resource for Medicare consumers, including information that 

can help these consumers make informed health care decisions. We also appreciate the 

recommendations regarding other health care professionals, and we will evaluate these 

recommendations for potential future inclusion. Also, we are continually working to improve 

and enhance the Intelligent Search functionality. 

Comment: Some commenters expressed concerns about the accuracy of data such as 

demographic information, specialty classification, and hospital affiliation. Several commenters 

urged CMS to address these concerns prior to posting additional quality measure performance 

information on the website. Other commenters requested we implement a streamlined process 

by which professionals can confirm or correct their information in a timely manner. One 

commenter urged CMS to ensure that updates made in PECOS are reflected on Physician 

Compare within 30 days, while another commenter cautioned against using PECOS for updating 

information. Several commenters suggested continuing to work with stakeholders, particularly 
CMS-1612-FC 606

health care professionals, and/or providing educational material regarding how to keep data 

current to ensure the accuracy of the website. 

 Response: We appreciate the commenters’ feedback regarding concerns over the 

accuracy of the information currently available on Physician Compare. We are committed to 

including accurate and up-to-date information on Physician Compare and continue to work to 

make improvements to the information presented. 

The underlying database on Physician Compare is generated from PECOS, as well as 

Fee-For-Service (FFS) claims, and it is therefore critical that physicians, other health care 

professionals, and group practices ensure that their information is up-to-date and as complete as 

possible in the national PECOS database. Currently, the most immediate way to address 

inaccurate PECOS data on Physician Compare is by updating information via Internet-based 

PECOS at https://pecos.cms.hhs.gov/pecos/login.do. Please note that the specialties as reported 

on Physician Compare are those specialties reported to Medicare when a physician or other 

health care professional enrolls in Medicare and are limited to the specialties noted on the 855i 

Enrollment Form. All addresses listed on Physician Compare must be entered in and verified in 

PECOS. 

There is a lag between when an edit is made in PECOS and when that edit is processed 

by the Medicare Administrative Contractor (MAC) and available in the PECOS data pulled for 

Physician Compare. This time is necessary for data verification but unfortunately results in a 

delay updating information. We are continually working to find ways to minimize this delay. 

To update information not found in PECOS, such as hospital affiliation and foreign 

language, professionals and group practices should contact the Physician Compare support team 

directly at PhysicianCompare@Westat.com. Information regarding how to keep your 

information current can also be found on the Physician Compare Initiative page on CMS.gov 
CMS-1612-FC 607

(http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physiciancompare-initiative/). 

Although we appreciate the concerns raised around the PECOS data included on 

Physician Compare, it is necessary to continue the use of the PECOS data as it is the sole, 

verified source of Medicare information. However, we are aware of its limitations. For these 

reasons, we have instituted the use of claims information and are continuing to work to find ways 

to further improve the data. The data are significantly better today than they were prior to the 

2013 redesign and continues to improve. We strongly encourage all professionals and group 

practices listed on the site to regularly check their data and to contact the support team with any 

questions or concerns. 

Currently, website users can view information about approved Medicare professionals 

such as name, primary and secondary specialties, practice locations, group affiliations, hospital 

affiliations that link to the hospital’s profile on Hospital Compare as available, Medicare 

Assignment status, education, languages spoken, and American Board of Medical Specialties 

(ABMS) board certification information. In addition, for group practices, users can also view 

group practice names, specialties, practice locations, Medicare assignment status, and affiliated 

professionals. 

We post on the website the names of individual EPs who satisfactorily report under 

PQRS, as well as those EPs who are successful electronic prescribers under the Medicare 

Electronic Prescribing (eRx) Incentive Program. Physician Compare contains a link to a 

downloadable database of all information on Physician Compare 

(https://data.medicare.gov/data/physician-compare), including information on this quality 

program participation. In addition, there is a section on each Medicare professional’s profile 

page indicating with a green check mark the quality programs under which the EP satisfactorily 
CMS-1612-FC 608

or successfully reported. We proposed (79 FR 40386) to continue to include this information 

annually in the year following the year it is reported (for example, 2015 PQRS reporting will be 

included on the website in 2016). We did not receive any comments on this proposal. We are 

finalizing this proposal at this time, and therefore, will include satisfactory 2015 PQRS reporters 

on the website in 2016. The eRx Incentive Program ends in 2014 so those data will not be 

available in 2015 or beyond. 

With the Physician Compare redesign, we added a quality programs section to each group 

practice profile page in order to indicate which group practices are satisfactorily reporting in the 

Group Practice Reporting Option (GPRO) under PQRS or are successful electronic prescribers 

under the eRx Incentive Program. We have also included a notation and check mark for 

individuals that successfully participate in the Medicare EHR Incentive Program, as authorized 

by section 1848(o)(3)(D) of the Act. We proposed (79 FR 40386) to continue to include this 

information annually in the year following the year it is reported (for example, 2015 data will be 

included on the website in 2016). 

We did not receive any comments regarding our proposal regarding this PQRS GPRO. 

We are finalizing the proposal to include a notation for satisfactory PQRS GPRO reporters. As 

noted above, the eRx Incentive Program is ending in 2014, and therefore, there will not be data 

for this program in 2015 or beyond. We did receive comments regarding including a notation for 

individuals that successfully participate in the Medicare EHR Incentive Program. 

Comment: Two commenters urged CMS to reconsider its decision to publicly report 

participation in the Medicare EHR Incentive Program due to ongoing issues related to the 

program--including unresolved challenges related to vendor certification delays, concerns about 

the relevancy to consumers, and limited ability to implement core measures. One commenter 

suggested including a disclaimer next to the indicator explaining these barriers and clarifying 
CMS-1612-FC 609

that successful participation in the EHR Incentive Program is only one of various ways to 

demonstrate an investment in higher quality care. 

Response: We appreciate the commenters’ feedback, and we will take the suggestions 

provided regarding a disclaimer into consideration for possible future enhancements. We also 

appreciate the concerns raised about the program, specifically around vendor certification and 

core measures. However, despite those potential limitations, a number of professionals and 

groups are successfully taking part at this time and we believe it is important to continue to 

recognize them. Also, consumers find this information interesting and helpful. This is only one 

of multiple quality programs included on Physician Compare that we find important to highlight. 

As a result, we are going to finalize our proposal to continue including an indicator for 

participation in the EHR Incentive Program on the website. 

We previously finalized a decision to publicly report the names of those EPs who report 

the 2014 PQRS Cardiovascular Prevention measures group in support of Million Hearts on 

Physician Compare in 2015, by including a check mark in the quality programs section of the 

profile page (78 FR 74450). We proposed (79 FR 40386) to also continue to include this 

information annually in the year following the year it is reported (for example, 2015 data will be 

included on Physician Compare in 2016). 

Comment: Some commenters supported our proposal to publicly report and include an 

indicator for EPs who report the 2015 PQRS Cardiovascular Prevention measures group in 

support of Million Hearts. Commenters noted that Million Hearts is an important initiative for 

supporting cardiovascular health. 

Response: We appreciate the commenters’ support. We agree that Million Hearts is an 

important initiative that is improving outcomes for cardiovascular health. However, we are 

finalizing the removal of the Cardiovascular Prevention measure group from the PQRS program 
CMS-1612-FC 610

given that the two cholesterol control measures included in the measure group are no longer 

clinically relevant, and therefore, the measure group no longer meets the necessary threshold for 

PQRS of six measures and will no longer be available for reporting under the program. With the 

removal of the 2 cholesterol control measures, the remaining measures from the original 

Cardiovascular Prevention measure group are: 

● Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic. 

● Preventive Care and Screening: Tobacco Use. 

● Controlling High Blood Pressure. 

● Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up 

Documented. 

All of these measures are available as individual measures under PQRS. Given that the 

Cardiovascular Prevention measure group is being eliminated from the PQRS, but that the 

remaining measures identified above will be available for individual reporting, we are modifying 

our final policy with regard to our proposal to support Million Hearts on Physician Compare. 

Specifically, we are finalizing that any EP that satisfactorily reports all four of the individual 

measures noted above will receive a green check mark indicating support for Million Hearts. A 

key strategy of the Million Hearts initiative is to reduce the number of heart attacks and strokes, 

and the program has found that reporting these quality measures is a first step toward 

performance improvement. We are committed to supporting this initiative, and even though the 

measure group is no longer available under PQRS, we think it is important to continue 

recognizing those individual EPs who are reporting these quality measures as individual 

measures. Even though the individual measures require that a potentially higher number of 

patients are reported on – 50 percent of patients that meet the sample requirements versus just 20 

patients for the measure group – we believe this does not increase burden on reporters because as 
CMS-1612-FC 611

currently available claims data show, significantly more EPs are already reporting these 

measures as individual PQRS measures versus as part of the Cardiovascular Prevention measures 

group. Ensuring these professionals are recognized for reporting these measures is important in 

ensuring we are continuing support for this important program despite the measure group no 

longer being available for reporting. 

Finally, we will also indicate with a green check mark those individuals who have earned 

the 2014 PQRS Maintenance of Certification Incentive (Additional Incentive) on the website in 

2015 (78 FR 74450). 

Comment: Several commenters supported publicly reporting earners of the PQRS 

Maintenance of Certification (MOC) program Additional Incentive, as well as ABMS Board 

Certification data, while other commenters are concerned that ABMS data are not complete or 

only include some specialists. Multiple commenters suggested including other Boards’ 

certifications and MOC programs, contextual certification process information, and the certifying 

Board’s identification. 

Response: We appreciate the commenters' feedback and support for including ABMS 

and PQRS MOC information on Physician Compare. We also understand the concerns that not 

all specialties are presented by the ABMS data and will review the recommendations made to 

include additional certification and MOC program information on the website for possible 

inclusion in the future. 

We continue to implement our plan for a phased approach to public reporting 

performance information on Physician Compare. The first phase of this plan was finalized with 

the CY 2012 PFS final rule with comment period (76 FR 73419-73420), where we established 

that PQRS GPRO measures collected through the GPRO Web Interface for 2012 would be 

publicly reported on Physician Compare. The plan was expanded with the CY 2013 PFS final 
CMS-1612-FC 612

rule with comment period (77 FR 69166), where we established that the specific GPRO Web 

Interface measures that would be posted on Physician Compare would include the PQRS GPRO 

measures for Diabetes Mellitus (DM) and Coronary Artery Disease (CAD), and we noted that we 

would report composite measures for these measure groups in 2014, if technically feasible.6

 The 

2012 PQRS GPRO measures were publicly reported on Physician Compare in February 2014. 

Data reported in 2013 on the GPRO DM and GPRO CAD measures and composites collected via 

the GPRO Web Interface that meet the minimum sample size of 20 patients and prove to be 

statistically valid and reliable will be publicly reported on Physician Compare in December CY 

2014, if technically feasible. If the minimum threshold is not met for a particular measure, or the 

measure is otherwise deemed not to be suitable for public reporting, the group’s performance 

rate on that measure will not be publicly reported. We will only publish on Physician Compare 

those measures that are statistically valid and reliable, and therefore, most likely to help 

consumers make informed decisions about the Medicare professionals they choose to meet their 

health care needs. 

Measures must be based on reliable and valid data elements to be useful to consumers 

and thus included on Physician Compare. A reliable data element is consistently measuring the 

same thing regardless of when or where it is collected, while a valid data element is measuring 

what it is meant to measure. To address the reliability of performance scores, we will measure 

the extent to which differences in each quality measure are due to actual differences in clinician 

performance versus variation that arises from measurement error. Statistically, reliability 

depends on performance variation for a measure across clinicians (“signal”), the random 

variation in performance for a measure within a clinician’s panel of attributed beneficiaries 

 

6

 By “technically feasible” we mean that there are no operational constraints inhibiting us from moving forward on a 

given public reporting objective. Operational constraints include delays and/or issues related to data collection 

which render a set of quality data unavailable in the timeframe necessary for public reporting. 
CMS-1612-FC 613

(“noise”), and the number of beneficiaries attributed to the clinician. High reliability for a 

measure suggests that comparisons of relative performance across clinicians are likely to be 

stable over different performance periods and that the performance of one clinician on the quality 

measure can confidently be distinguished from another. Potential reliability values range from 

zero to one, where one (highest possible reliability) means that all variation in the measure’s 

rates is the result of variation in differences in performance, while zero (lowest possible 

reliability) means that all variation is a result of measurement error. Reliability testing methods 

included in the CMS Measures Management System Blueprint 

(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/MMS/MeasuresManagementSystemBlueprint.html) include test-retest reliability and 

analysis of variance (ANOVA). Reliability tests endorsed by the NQF include the beta-binomial 

model test. 

The validity of a measure refers to the ability to record or quantify what it claims to 

measure. To analyze validity, we can investigate the extent to which each quality measure is 

correlated with related, previously validated, measures. We can assess both concurrent and 

predictive validity. Predictive validity is most appropriate for process measures or intermediate 

outcome measures, in which a cause-and-effect relationship is hypothesized between the measure 

in question and a validated outcome measure. Therefore, the measure in question is computed 

first, and the validated measure is computed using data from a later period. To examine 

concurrent validity, the measure in question and a previously validated measure are computed 

using contemporaneous data. In this context, the previously validated measure should measure a 

health outcome related to the outcome of interest. 

Comment: Many commenters supported only publishing on Physician Compare those 

measures that are statistically valid and reliable. Several commenters urged CMS to carefully 
CMS-1612-FC 614

assess if all GPRO measure data is sufficiently reliable and valid for public reporting before 

posting the data. One commenter recommended removing any measures deemed unreliable or 

inaccurate. One commenter recommended a one-year delay in public reporting of all new 

measures to enable professionals to accurately report the measures and to account for measure 

testing and validity. 

One commenter requested CMS publish the results of validity and reliability studies, as 

well as the methodology for choosing measures prior to posting on Physician Compare. Another 

commenter is concerned that measures related to patient behavior, preferences, or abilities do not 

provide a statistically valid portrayal of a health care professional’s performance and should not 

be published unless the data is appropriately risk adjusted. Several other commenters also 

strongly urged CMS to move forward with expanding its risk adjustment methodology. 

Response: We appreciate the commenters’ feedback, and understand the concerns raised. 

As required under section 10331(b) of the Affordable Care Act, in developing and implementing 

the plan to include performance data on Physician Compare, we must include, to the extent 

practicable, processes to ensure that the data posted on the website are statistically valid, reliable, 

and accurate, including risk adjustment mechanisms used by the Secretary. We understand that 

this information is complex and are committed to providing data on Physician Compare that are 

useful to beneficiaries in assisting them in making informed health care decisions, while being 

accurate, valid, reliable, and complete. We will closely evaluate all quality measures under 

consideration for public reporting on the website to ensure they are meeting these standards. We 

will also only post data that meet the established standards of reliability and validity regardless 

of threshold, and regardless of measure type. Should we find a measure meeting the minimum 

threshold to be invalid or unreliable for any reason, the measure will not be reported. We are 

also making changes in light of the concerns about first year measures. We will not publicly post 
CMS-1612-FC 615

measures that are in their first year given the concerns raised about their validity, reliability, 

accuracy, and comparability. After a measure’s first year in the program, CMS will evaluate the 

measure to see if and when the measure is suitable for pubic reporting. Also, we will continue to 

analyze the measure data to ensure that risk adjustment concerns are taken into consideration. 

All data are analyzed and reviewed by our Technical Expert Panel (TEP). A summary of the 

TEP recommendations is made public on the Physician Compare Initiative page 

(http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physiciancompare-initiative/Informational-Materials.html) when available. 

In the November 2011 Medicare Shared Savings Program final rule (76 FR 67948), we 

noted that because Accountable Care Organization (ACO) providers/suppliers that are EPs are 

considered to be a group practice for purposes of qualifying for a PQRS incentive under the 

Shared Savings Program, we would publicly report ACO performance on quality measures on 

Physician Compare in the same way as we report performance on quality measures for PQRS 

GPRO group practices. Public reporting of performance on these measures is presented at the 

ACO level only. The first sub-set of ACO measures was also published on the website in 

February 2014. ACO measures can be viewed by following the link for Accountable Care 

Organization (ACO) Quality Data on the homepage of the Physician Compare website 

(http://medicare.gov/physiciancompare/aco/search.html). 

As part of our public reporting plan for Physician Compare, in the CY 2013 PFS final 

rule with comment period (77 FR 69166 and 69167), we also finalized the decision to publicly 

report Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) data for group practices of 100 or more eligible professionals reporting data in 2013 

under the GPRO and for ACOs participating in the Shared Savings Program, if technically 

feasible. We anticipate posting these data on Physician Compare in late 2014, if available. 
CMS-1612-FC 616

We continued to expand our plan for public reporting data on Physician Compare in the 

CY 2014 PFS final rule with comment period (78 FR 74449). In that final rule we finalized a 

decision that all measures collected through the GPRO Web Interface for groups of two or more 

EPs participating in 2014 under the PQRS GPRO and for ACOs participating in the Medicare 

Shared Savings Program would be available for public reporting in CY 2015. As with all 

measures we finalized with regard to Physician Compare, these data would include measure 

performance rates for measures reported that meet the minimum sample size of 20 patients and 

prove to be statistically valid and reliable. We also finalized a 30-day preview period prior to 

publication of quality data on Physician Compare. This will allow group practices to view their 

data as it will appear on Physician Compare before it is publicly reported. We decided that we 

will detail the process for the 30-day preview and provide a detailed timeline and instructions for 

preview in advance of the start of the preview period. ACOs will be able to view their quality 

data that will be publicly reported on Physician Compare through the ACO Quality Reports, 

which will be made available to ACOs for review at least 30 days prior to the start of public 

reporting on Physician Compare. 

We also finalized a decision to publicly report in CY 2015 on Physician Compare 

performance on certain measures that group practices report via registries and EHRs in 2014 for 

the PQRS GPRO (78 FR 74451). Specifically, we finalized making available for public 

reporting performance on 16 registry measures and 13 EHR measures (78 FR 74451). These 

measures are consistent with the measures available for public reporting via the Web Interface. 

We will indicate the mechanism by which these data were collected and only those data deemed 

statistically comparable, valid, and reliable would be published on the site. 

We also finalized publicly reporting patient experience survey-based measures from the 

CG-CAHPS measures for groups of 100 or more eligible professionals who participate in PQRS 
CMS-1612-FC 617

GPRO, regardless of GPRO submission method, and for Shared Savings Program ACOs 

reporting through the GPRO Web Interface or other CMS-approved tool or interface (78 FR 

74452). For 2014 data, we finalized publicly reporting data for the 12 summary survey measures 

also finalized for groups of 25 to 99 for PQRS reporting requirements (78 FR 74452). These 

summary survey measures would be available for public reporting group practices of 100 or 

more EPs participating in PQRS GPRO, as well as group practices of 25 to 99 EPs when 

collected via any certified CAHPS vendor regardless of PQRS participation, as technically 

feasible. For ACOs participating in the Shared Savings Program, the patient experience 

measures that are included in the Patient/Caregiver Experience domain of the Quality 

Performance Standard under the Shared Savings Program (78 FR 74452) will be available for 

public reporting in 2015. 

For 2014, we also finalized publicly reporting 2014 PQRS measure data reported by 

individual EPs in late CY 2015 for individual PQRS quality measures specifically identified in 

the final rule with comment period, if technically feasible. Specifically, we finalized to make 

available for public reporting 20 individual measures collected through a registry, EHR, or 

claims (78 FR 74453-74454). These are measures that are in line with those measures reported 

by groups via the GPRO Web Interface. 

Finally, in support of the HHS-wide Million Hearts Initiative, we finalized a decision to 

publicly report, no earlier than CY 2015, performance rates on measures in the PQRS 

Cardiovascular Prevention measures group at the individual EP level for data collected in 2014 

for the PQRS (78 FR 74454). See Table 48 for a summary of our final policies for public 

reporting data on Physician Compare. 

 
CMS-1612-FC 618

TABLE 48: Summary of Previously Finalized Policies for Public Reporting on Physician 

Compare 

Data 

Collection 

Year 

Public 

Reporting 

Year 

Reporting 

Mechanism(s) Quality Measures and Data for Public Reporting 

2012 2013 Web Interface 

(WI), EHR, 

Registry, Claims 

Include an indicator for satisfactory reporters under PQRS 

successful e-prescribers under eRx, and participants in the 

EHR Incentive Program. 

2012 2014 WI 5 Diabetes Mellitus (DM) and Coronary Artery Disease 

(CAD) measures collected via the WI for group practices 

reporting under PQRS GPRO with a minimum sample size of 

25 patients and Shared Savings Program ACOs. 

2013 2014 WI, EHR, 

Registry, Claims 

Include an indicator for satisfactory reporters under PQRS, 

successful e-prescribers under eRx, and participants in the 

EHR Incentive Program. Include an indicator for EPs who 

earn a PQRS Maintenance of Certification Incentive and EPs 

who report the PQRS Cardiovascular 

Prevention measures group in support of Million Hearts. 

2013 Expected to 

be 

December 

2014 

WI Up to 6 DM and 2 CAD measures collected via the GPRO WI 

for groups of 25 or more EPs and Shared Savings Program 

ACOs with a minimum sample size of 20 patients. 

Will include composites for DM and CAD, if feasible. 

2013 Expected to 

be 

December 

2014 

WI Up to 5 CG-CAHPS summary measures for groups of 100 or 

more EPs reporting under PQRS GPRO via the WI and up to 

6 ACO CAHPS summary measures for Shared Savings 

Program ACOs. 

2014 Expected to 

be 2015 

WI, EHR, 

Registry, Claims 

Include an indicator for satisfactory reporters under PQRS 

and participants in the EHR Incentive Program. Include an 

indicator for EPs who earn a PQRS Maintenance of 

Certification Incentive and EPs who report the PQRS 

Cardiovascular Prevention measures group in support of 

Million Hearts. 

2014 Expected to 

be late 2015 

WI, EHR, 

Registry, 

Administrative 

Claims 

All measures reported via the GPRO WI, 13 EHR, and 16 

Registry GPRO measures are also available for group 

practices of 2 or more EPs reporting under PQRS GPRO with 

a minimum sample size of 20 patients. Also, all Shared 

Savings Program ACO measures are available for public 

reporting. 

Include composites for DM and CAD, if feasible. 

2014 Expected to 

be late 2015 

WI, Certified 

Survey Vendor 

Up to 12 CG-CAHPS summary measures for groups of 100 or 

more EPs reporting via the WI and group practices of 25 to 99 

EPs reporting via a CMS-approved certified survey vendor, as 

well as 6 ACO CAHPS summary measures for Shared 

Savings Program ACOs reporting through the GPRO Web 

Interface or other CMS-approved tool or interface. 

2014 Expected to 

be late 2015 

Registry, EHR, or 

Claims 

A sub-set of 20 PQRS measures submitted by individual EPs 

that align with those available for group reporting via the WI 

and that are collected through a Registry, EHR, or claims with 

a minimum sample size of 20 patients. 

2014 Expected to 

be late 2015 

Registry Measures from the Cardiovascular Prevention measures group 

reported by individual EPs in support of the Million Hearts 

Initiative with a minimum sample size of 20 patients. 
CMS-1612-FC 619

3. Final Policies for Public Data Disclosure on Physician Compare in 2015 and 2016 

 We are continuing the expansion of public reporting on Physician Compare by making an 

even broader set of quality measures available for publication on the website. We started the 

phased approach with a small number of possible PQRS GPRO Web Interface measures for 2012 

and have been steadily building on this to provide Medicare consumers with more information to 

help them make informed health care decisions. As a result, we proposed (79 FR 40388) to 

increase the measures available for public reporting in the CY 2015 proposed PFS rule. 

 Comment: Although multiple commenters supported continuing the phased approach to 

public reporting of quality data, a number of commenters are concerned with the aggressive 

timeline for publicly reporting performance data. Several commenters supported a more gradual 

approach to public reporting to evaluate the public response to data prior to widespread 

implementation, ensure accuracy, and present data in a format that is easy to understand, 

meaningful, and actionable for both patients and health care professionals. A few commenters 

were unsure if CMS conducted analysis of consumer use of the site and urged CMS to do so. 

Other commenters opposed the extensive expansion until existing website problems are 

addressed. 

 Response: We appreciate the commenters’ feedback, and we appreciate the concerns 

raised. However, we believe that public reporting of quality data has been a measured, phased 

approach which started with the publication of just five 2012 PQRS GPRO measures collected 

via the Web Interface for 66 group practices and 141 ACOs (76 FR 73417) and continues with a 

similarly limited set of 2013 PQRS GPRO Web Interface measures (77 FR 69166). We started 

to build on this plan with the 2014 Physician Fee Schedule (PFS) final rule (78 FR 74446). This 

rule made additional PQRS GPRO measures available for public reporting, including a subset of 

measures reported via Registry and EHR, as well as a sub-set of 20 individual EP PQRS 
CMS-1612-FC 620

measures. Therefore, the proposals put forth this year are just the next step in the process to 

realize goals for authorization of Physician Compare. We are confident that taking this phased 

approach has afforded us the opportunity to prepare for this significant expansion. 

Throughout this process, we have been engaging with consumers and stakeholders and 

regularly testing the site and the information to be included to ensure it is accurately presented 

and understood. We are also continually working to improve the website and the administrative 

and demographic information included. We continue to encourage physicians, other health care 

professionals, and group practices to ensure their information is updated in PECOS so that we 

can ensure the most accurate information is available on Physician Compare. We also encourage 

individuals and groups to reach out to the Physician Compare support team at 

PhysicianCompare@Westat.com for any questions or concerns regarding the information 

included on the website. 

We proposed (79 FR 40388) to expand public reporting of group-level measures by 

making all 2015 PQRS GPRO measure sets across group reporting mechanisms – GPRO Web 

Interface, registry, and EHR – available for public reporting on Physician Compare in CY 2016 

for groups of 2 or more EPs, as appropriate by reporting mechanism.7

 Similarly, we also 

proposed that all measures reported by Shared Savings Program ACOs would be available for 

public reporting on Physician Compare. As with all quality measures proposed for inclusion on 

Physician Compare, we noted that only measures that prove to be valid, reliable, and accurate 

upon analysis and review at the conclusion of data collection would be included on the website. 

Comment: Commenters were both positive and negative in regard to our proposal to 

expand the group-level measures available for public reporting to all measures reported under 

 

7

 Tables Q1-Q27 detail proposed changes to available PQRS measures. Additional information on PQRS measures 

can be found on the CMS.gov PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 
CMS-1612-FC 621

2015 PQRS GPRO. Commenters in support of the proposal noted group-level measures are a 

robust indication of care team quality and helpful to consumers. Some commenters opposed the 

expansion and cited concerns with the accuracy of current data as well as measure fidelity. One 

commenter encouraged CMS to ensure that GPRO quality data is accurately labeled and 

accessible through the group entry only to ensure it is clear what the quality measure represents. 

One commenter asked for clarification on the availability of the PQRS GPRO Web Interface 

reporting option for groups of two or more EPs. 

Response: We appreciate the commenters’ feedback on our proposal to report all 2015 

PQRS measures reported via the Web Interface, EHR, and Registry for group practices of 2 or 

more EPs participating in the PQRS GPRO. As noted, Physician Compare will only publicly 

report those measures evaluated to be comparable, reliable, and valid. Also, we will continue to 

work to ensure that measures are labeled accurately and accompanied by explanations that are 

both true to the measure specifications and accurately understood by health care consumers, 

while adhering to HHS plain language guidelines. Measure data accuracy is of paramount 

importance to CMS. The measure data currently available on Physician Compare was previewed 

by those group practices that currently have 2012 PQRS GPRO data available on Physician 

Compare prior to publication with no concerns raised regarding accuracy. Since being 

published, no group practices with GPRO data have raised concerns regarding the accuracy of 

the measure data available. To confirm, the Web Interface reporting option will remain limited 

to groups of 25 or more EPs. Smaller groups, groups of 2 to 24 EPs, can report under the PQRS 

via EHR or Registry. We also clarify that group-level data is only published at the group level – 

included on the group practice profile page -- on Physician Compare. And, in response to 

comments that raised concern about measures reported in the first year, we have decided that we 
CMS-1612-FC 622

will not publicly report a measure that is in its first year. By first year we mean a measure that is 

newly available for reporting under PQRS. 

We also received comments specifically about EHR measures. 

Comment: Commenters were opposed to publicly reporting EHR measures, citing that it 

is too soon to publicly post performance data from eCQMs without additional work to verify the 

validity and accuracy of the measure results. One commenter suggested that new quality 

measures could be piloted by health care professionals prior to requiring their use within a 

federal program. One commenter strongly encouraged developing a tutorial that allows the 

public to better understand this data. 

Response: We appreciate the commenters' feedback regarding including measures 

collected via EHRs. Group practices will have the ability to report measures via an EHR prior 

the 2015 data collection. Therefore, this reporting mechanism will not be in its first year of use at 

this time. As a result, we do not believe it is too soon to report these quality measures. As noted, 

only comparable, valid, reliable, and accurate data will be included on Physician Compare. All 

measures slated for public reporting will be consumer tested to ensure they are accurately 

understood prior to publication. If concerns surface from this testing, we will evaluate if the 

requirements for public reporting are not suitably met and if the measure or measures in question 

should be suppressed and not publicly reported to ensure only those measures that are valid, 

reliable, and accurate and inform quality choice are included on the site. 

Given the value of these group-level data, and the successful publication of such data to 

date, we are finalizing our proposal to report all 2015 PQRS measures for all reporting options 

for group practices of 2 or more EPs participating in PQRS GPRO, and all 2015 measures 

reported by ACOs. Consistent with this final policy, we are making a conforming change to the 
CMS-1612-FC 623

regulation at §425.308(e) to provide that all quality measures reported by ACOs will be reported 

on Physician Compare in the same way as for group practices that report under the PQRS. 

We also proposed (79 FR 40389) that measures must meet the public reporting criteria of 

a minimum sample size of 20 patients. 

Comment: Several commenters supported the proposed minimum sample size of 20 

patients. However, the majority of commenters believed a patient threshold of 20 is too low to 

be statistically valid, which commenters claim may result in inaccurate quality scores based on 

one outlier. Commenters recommended CMS use a higher threshold to ensure validity. Several 

commenters also urged CMS to test measures and composites with 20 patients and to provide an 

opportunity for public comment and to review reliability and validity. 

Response: We appreciate the commenters’ feedback and understand the concerns raised 

regarding the 20 patient minimum sample size. However, we believe this threshold of 20 

patients is a large enough sample to protect patient privacy for reporting on the website, and 

aligns with the reliability threshold previously finalized for the Value-Based Modifier (VM) 

(77 FR 69166). As we continue to work to align quality initiatives and minimize reporting 

burden on physicians and other health care professionals, we are finalizing a patient sample size 

of 20 patients. 

We proposed to include an indicator of which reporting mechanism was used and to only 

include on the site measures deemed statistically comparable.8

 We received several comments 

regarding data comparability, generally. 

Comment: Some commenters expressed concern with the comparability of measures 

reported through different reporting mechanisms and requested notation specifying the measure 

differences. One commenter supported only publicly reporting measures with specifications 

 

8

 By statistically comparable, CMS means that the quality measures are analyzed and proven to measure the same 

phenomena in the same way regardless of the mechanism through which they were collected. 
CMS-1612-FC 624

consistent across all reporting mechanisms, while another commenter recommended that CMS 

group results by the data collection methodology to improve comparability. 

Response: Though we understand concerns regarding including measures collected via 

different mechanisms, CMS is conducting analyses to ensure that these measures align across 

different reporting mechanisms. This analysis is done on a measure per measure basis. For 

example, if a measure is reported via claims, then the measure specifications would be aligned 

with a measure being reported via EHR as long as it stays consistent with the original measure 

intent. Only those measures that are proven to be comparable and most suitable for public 

reporting will be included on Physician Compare and made publicly available. Therefore, we are 

finalizing our proposal to report data from the available reporting mechanisms and to include a 

notation indicating which reporting mechanism was used. 

We proposed (79 FR 40389) to publicly report all measures submitted and reviewed and 

found to be statistically valid and reliable in the Physician Compare downloadable file. 

However, we proposed that not all of these measures necessarily would be included on the 

Physician Compare profile pages. As we noted, consumer testing has shown profile pages with 

too much information and/or measures that are not well understood by consumers can negatively 

impact a consumer’s ability to make informed decisions. Our analysis of the collected measure 

data, along with consumer testing and stakeholder feedback, will determine specifically which 

measures are published on profile pages on the website. Statistical analyses will ensure the 

measures included are statistically valid and reliable and comparable across data collection 

mechanisms. Stakeholder feedback will ensure all measures meet current clinical standards. 

CMS will continue to reach out to stakeholders in the professional community, such as specialty 

societies, to ensure that the measures under consideration for public reporting remain clinically 

relevant and accurate. When measures are finalized significantly in advance of moment they are 
CMS-1612-FC 625

collected, it is possible that clinical guidelines can change rendering a measure no longer 

relevant. Publishing that measure can lead to consumer confusion regarding what best practices 

their health care professional should be subscribing to. 

As we noted in the proposed rule (79 FR 40389), the primary goal of Physician Compare 

is to help consumers make informed health care decisions. If a consumer does not properly 

interpret a quality measure and thus misunderstands what the quality score represents, the 

consumer cannot use this information to make an informed decision. Through concept testing, 

CMS will test with consumers how well they understand each measure under consideration for 

public reporting. If a measure is not consistently understood and/or if consumers do not 

understand the relevance of the measure to their health care decision making process, CMS will 

not include the measure on the Physician Compare profile page as inclusion will not aid 

informed decision making. Finally, consumer testing will help ensure the measures included on 

the profile pages are accurately understood and relevant to consumers, thus helping them make 

informed decisions. This will be done to ensure that the information included on Physician 

Compare is consumer friendly and consumer focused. 

Comment: Several commenters supported the proposal to have all 2015 measures 

available for download with only a select group of measures on the website. One commenter 

further emphasized CMS should create consistent formatting with Hospital Compare 

downloadable files. 

Response: We appreciate the commenters’ feedback and support for this proposal. We 

are finalizing the proposal to include all measures in a downloadable file and limiting the 

measures available on Physician Compare profile pages to those measures that not only meet the 

requirements of public reporting such as validity, reliability, accuracy, and comparability, but 

that also are accurately understood and interpreted by consumers as evidenced via consumer 
CMS-1612-FC 626

testing. This will ensure that the measures presented on Physician Compare help them make 

informed health care decisions without overwhelming them with too much information. We will 

also take into future consideration the recommendation regarding the Hospital Compare file. 

We also received comments regarding stakeholder involvement and consumer testing. 

Comment: Commenters encouraged continued involvement of measure developers and 

stakeholders in the public reporting development process. Several commenters appreciated the 

continued collaboration with specialty societies via town hall meetings and other mechanisms. 

Several commenters advocated for more transparency by providing the opportunity for the public 

to comment on the deliberations of the Physician Compare TEP; regular engagement with 

interested stakeholders; and increased communication about the measure consideration process, 

including methods and interpretation of performance. Some commenters appreciated that CMS 

will continue to reach out to stakeholders in the professional community to ensure that the 

measures under consideration for public reporting remain clinically relevant and accurate. One 

commenter suggested an opportunity for stakeholder associations to participate in the 30-day 

measure preview process. 

Response: We appreciate the commenters’ feedback regarding stakeholder outreach and 

involvement in Physician Compare. As we noted, section 10331(d) of the Affordable Care Act 

requires that the Secretary take into consideration input provided by multi-stakeholder groups, 

consistent with sections 1890(b)(7) and 1890A of the Act, as added by section 3014 of the Act, 

in selecting quality measures for use on Physician Compare. We also are dedicated to providing 

opportunities for stakeholders to provide input. We will continue to identify the best ways to 

accomplish this. We will also review all recommendations provided for future consideration. 

Comment: Many commenters supported consumer testing to ensure only meaningful 

measures are included on the site. One commenter suggested CMS first focus on communicating 
CMS-1612-FC 627

validated and meaningful information in a user-friendly way. One commenter urged CMS to 

consult a broader array of stakeholders during concept testing, while another commenter 

specified the inclusion of health care professionals. Some commenters requested that CMS share 

with professional associations or measure developers any information obtained through 

consumer concept testing. A few commenters asked for more details on concept testing plans, 

while another recommended CMS use concept testing for the information currently on the 

Physician Compare. One commenter emphasized testing must occur prior to placing these 

additional measures on the website in late 2016. One commenter believed health care 

professionals must be aware of what measures will be reported to the Physician Compare website 

before the reporting period begins. 

Response: We appreciate the commenters’ feedback. We will continue to conduct 

consumer testing in terms of both usability testing -- to ensure the site is easy to navigate and 

functioning appropriately -- and concept testing -- to ensure users understand the information 

included on the website and that information included resonates with health care consumers. We 

are continually working to test the information planned for public reporting with consumers. We 

regularly test the information currently on the website with site users. We are planning concept 

testing of the measures being finalized in this rule prior to publication in 2016 and we will work 

to ensure that valid, reliable, and meaningful information is included on the website. This testing 

ensures that the best information is shared and that it is shared in a way that is correctly 

interpreted. 

We will also engage stakeholders for feedback, including input from the public, 

consumers, and health care professionals, as appropriate and feasible through such opportunities 

as Town Halls, Listening Sessions, Open Door Forums, and Webinars. We will review feedback 

for future consideration. Although we establish in rulemaking the subset of measures available 
CMS-1612-FC 628

for posting on the Physician Compare website, at this time, however, it is not possible for us to 

provide stakeholders with the exact list of measures that will be included on the website prior to 

our analysis of the reported data to know which measures meet the criteria we specified 

previously for public reporting. 

As is the case for all measures published on Physician Compare, group practices will be 

given a 30-day preview period to view their measures as they will appear on Physician Compare 

prior to the measures being published. As in previous years, we will detail the process for the 

30-day preview and provide a detailed timeline and instructions for preview in advance of the 

start of the preview period. ACOs will be able to view their quality data that will be publicly 

reported on Physician Compare through the ACO Quality Reports, which will be made available 

to ACOs for review at least 30 days prior to the start of public reporting on Physician Compare. 

Comment: Several commenters were in support of the 30-day preview period prior to 

publication of quality data. Many commenters urged CMS to also allow group practices, ACOs, 

and EPs the opportunity to correct and/or appeal any errors found in the performance information 

before it is posted on the website. Several commenters recommended CMS postpone posting 

information if a group practice or EP files an appeal and flags their demographic data or quality 

information as problematic. Other commenters noted that a 30-day preview period is insufficient 

and requested that CMS extend the period to 60 or 90 days. One commenter believed the 

preview period should match the PQRS committee's measure review timeline of 9 months. 

Some commenters sought clarification on how CMS plans to notify EPs of the preview period 

and requested more detail about correcting errors found during the preview period. 

Response: We appreciate the commenters’ feedback regarding the 30-day preview 

period for quality measures on Physician Compare. Detailed instructions regarding how to 

preview measure data, the time frame for the measure preview, and directions for how to address 
CMS-1612-FC 629

any concerns or get additional help during this process is shared at the start of the preview period 

with all groups and individuals that have data to preview. If an error is found in the measure 

display during this 30-day preview, the directions explain how to contact the Physician Compare 

team by both phone and e-mail to have concerns addressed. Errors will be corrected prior to 

publication. If measure data has been collected and the measure has been deemed suitable for 

pubic reporting, the data will be published. This 30-day period is in line with the preview period 

provided for other public reporting programs such as Hospital Compare. To date, our experience 

with this preview period for group practices demonstrates that 30 days is sufficient time to allow 

for preview to be conducted. It is important that quality data be shared with the public as soon as 

possible so it is as current and relevant as possible when published. To avoid further delaying 

this publication we will maintain the 30-day preview period. 

Group practices and EPs with available data for public reporting will be informed via 

email when the preview period is going to take place. Group practices and EPs will be provided 

instructions for previewing data and information for on how to request help or have questions 

answered. Additionally, information regarding the preview period will be included on the 

Physician Compare Initiative page on CMS.gov. As noted, ACOs will preview their data via 

their ACO Quality Reports, which will be sent at least 30 days before data are publicly reported. 

There is no preview period for demographic data. These data are currently publicly available. If 

a group practice or EP has questions about their demographic data, they should contact the 

Physician Compare support team at PhysicianCompare@Westat.com. 

 In addition to making all 2015 PQRS GPRO measures available for public reporting, we 

solicited comment (78 FR 40389) on creating composites using 2015 data and publishing 

composite scores in 2016 by grouping measures based on the PQRS GPRO measure groups, if 

technically feasible. We indicated we would analyze the data collected in 2015 and conduct 
CMS-1612-FC 630

psychometric and statistical analyses, looking at how the measures best fit together and how 

accurately they are measuring the composite concept, to create composites for certain PQRS 

GPRO measure groups, including but not limited to: 

● Care Coordination/Patient Safety (CARE) Measures 

● Coronary Artery Disease (CAD) Disease Module 

● Diabetes Mellitus (DM) Disease Module 

● Preventive (PREV) Care Measures 

In particular, we would analyze the component measures that make up each of these 

measure groups to see if a statistically viable composite can be constructed with the data reported 

for 2015. Composite scores have proven to be beneficial in providing consumers a better way to 

understand quality measure data, as composites provide a more concise, easy to understand 

picture of physician quality. 

Comment: Commenters were both positive and negative in regard to our request for 

information on publicly reporting composite scores. Some commenters stated composites should 

only be publicly reported if statistically reliable, risk adjusted, or medically meaningful, and 

should be scientifically or consumer tested prior to public display. A few commenters also 

suggested NQF endorsement of individual components and composites before finalizing any 

composites. Several commenters strongly urged CMS to seek input from relevant specialty 

societies, measure developers, consumers, and other stakeholders on the construction and display 

if the composites. A few commenters opposed public reporting of composites, but suggested 

providing physicians the composite scores confidentially through the QRURs. Several 

commenters noted concerns about the proposal to create composites given the variability in the 

methodologies, difficulty validating the results, and use of stand-alone measures developed to be 

reported individually. One commenter suggested stand-alone measures are preferable to 
CMS-1612-FC 631

composites in relatively small and heterogeneous measure sets. A few commenters suggested 

posting additional information about composite measures on Physician Compare clarifying that 

composite groups are not readily available at this time for all measure groups. One commenter 

urged CMS to retain more comprehensive information about the measures within each composite 

measure in the downloadable file. One commenter does not specifically support the Oncology 

Composite Score on Physician Compare. 

Response: We appreciate the commenters’ feedback on this request for information. We 

will be carefully reviewing all concerns raised and recommendations made as we continue to 

evaluate options for including composites in future rulemaking. This concept was put forth 

merely to seek comment and no formal proposal was made, so we are not finalizing any 

decisions regarding composite scores at this time. However, given that we received feedback 

from stakeholders indicating such composite scores are desired, we plan to analyze the data once 

it is collected to establish the best possible composite, which would help consumers use these 

quality data to make informed health care decisions, and will consider proposing such 

composites in future rulemaking. 

 Similar to composite scores, benchmarks are also important to ensuring that the quality 

data published on Physician Compare are accurately interpreted and appropriately understood. A 

benchmark will allow consumers to more easily evaluate the information published by providing 

a point of comparison between groups. We continue to receive requests from all stakeholders, 

but especially consumers, to add this information to Physician Compare. As a result, we 

proposed (79 FR 40389) to publicly report on Physician Compare in 2016 benchmarks for 2015 

PQRS GPRO data using the same methodology currently used under the Shared Savings 

Program. This ACO benchmark methodology was previously finalized in the November 2011 

Shared Savings Program final rule (76 FR 67898), as amended in the CY 2014 PFS final rule 
CMS-1612-FC 632

with comment period (78 FR 74759). Details on this methodology can be found on CMS.gov at 

http://cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks.pdf. We proposed to 

follow this methodology using the 2014 PQRS GPRO data. 

We proposed to calculate benchmarks using data at the group practice TIN level for all 

EPs who have at least 20 cases in the denominator. A benchmark per this methodology is the 

performance rate a group practice must achieve to earn the corresponding quality points for each 

measure. Benchmarks would be established for each percentile, starting with the 30th percentile 

(corresponding to the minimum attainment level) and ending with the 90th percentile 

(corresponding to the maximum attainment level). A quality scoring point system would then be 

determined. Quality scoring would be based on the group practice’s actual level of performance 

on each measure. A group practice would earn quality points on a sliding scale based on level of 

performance: performance below the minimum attainment level (the 30th percentile) for a 

measure would receive zero points for that measure; performance at or above the 90th percentile 

of the performance benchmark would earn the maximum points available for the measure. The 

total points earned for measures in each measure group would be summed and divided by the 

total points available for that measure group to produce an overall measure group score of the 

percentage of points earned versus points available. The percentage score for each measure 

group would be averaged together to generate a final overall quality score for each group 

practice. The goal of including such benchmarks would be to help consumers see how each 

group practice performs on each measure, measure group, and overall in relation to other group 

practices. 

Comment: Many commenters supported the use of benchmarks to help consumers make 

informed health care decisions. However, several commenters did not support the calculation of 
CMS-1612-FC 633

an overall quality score, as they believe it will result in the unfair comparison of all group 

practices. Additional commenters noted that benchmarks using percentiles will be difficult for 

consumers to understand and encouraged consumer testing to remedy this problem. Some 

commenters noted appropriate methodology is needed when potential data constraints impact the 

calculation of benchmarks. Several commenters also asked for clarification on the impact of 

exception rates on quality scores and how benchmarks will be displayed, noting the risk of 

arbitrary thresholds potentially exaggerating minor performance differences. A commenter 

asked for the opportunity to review sample data prior to supporting the proposed methodology, 

while another noted that benchmarks need to be set prior to the beginning of the new 

measurement period. One commenter sought clarification on whether the benchmarking 

methodology would be the same as the methodology applied under the Value-Modifier. Several 

commenters urged CMS to use consistent benchmarking across its programs to promote 

consistency and minimize confusion. One commenter cautioned the use of benchmarks, noting it 

can lead to an incomplete and potentially misleading indicator of quality. 

Response: We appreciate the commenters’ feedback on our proposal to include on 

Physician Compare a benchmark for 2015 PQRS GPRO measures (and measures reported by 

individual EPs) measures based on the current Shared Savings Program benchmark 

methodology. Although we agree benchmarks can add great value for consumers, we understand 

the many concerns raised. As a result, we have made a decision not to finalize this proposal at 

this time. We want to be sure to discuss more thoroughly potential benchmarking methodologies 

with our stakeholders prior to finalizing the proposal. We also want to evaluate other programs’ 

methodologies, including the Value Modifier, to work toward better alignment across programs. 

We therefore feel it would be best to forego finalizing a methodology at this time in favor of a 

stronger, potentially better aligned methodology that can be included in future rulemaking. 
CMS-1612-FC 634

 Understanding the value consumers place on patient experience data and the commitment 

to reporting these data on Physician Compare, we proposed (79 FR 40390) publicly reporting in 

CY 2016 patient experience data from 2015 for all group practices of two or more EPs, who 

meet the specified sample size requirements and collect data via a CMS-specified certified 

CAHPS vendor. The patient experience data available are specifically the CAHPS for PQRS 

and CAHPS for ACO measures, which include the CG-CAHPS core measures. For group 

practices, we proposed to make available for public reporting these 12 summary survey 

measures: 

● Getting Timely Care, Appointments, and Information. 

● How Well Providers Communicate. 

● Patient’s Rating of Provider. 

● Access to Specialists. 

● Health Promotion & Education. 

● Shared Decision Making. 

● Health Status/Functional Status. 

● Courteous and Helpful Office Staff. 

● Care Coordination. 

● Between Visit Communication. 

● Helping You to Take Medication as Directed. 

● Stewardship of Patient Resources. 

We proposed that these 12 summary survey measures would be available for public 

reporting for all group practices. For ACOs participating in the Shared Savings Program, we 

proposed (79 FR 40390) that the patient experience measures that are included in the 

Patient/Caregiver Experience domain of the Quality Performance Standard under the Shared 
CMS-1612-FC 635

Savings Program in 2015 would be available for public reporting in 2016. We would review all 

quality measures after they are collected to ensure that only those measures deemed valid and 

reliable are included on the website. 

We received a number of comments around our proposals to include CAHPS measures 

on Physician Compare. 

Comment: Several commenters supported our proposal to publicly report CAHPS for 

PQRS data for all group practices that have met the minimum sample size requirements and 

collect the data using a certified CMS-approved vendor. One commenter strongly encouraged 

CMS to make public reporting on patient experience measures mandatory for groups of all sizes 

and individual EPs. However, a few commenters were concerned with public reporting of 

CAHPS or other patient experience survey data due to the subjectivity of the surveys or the cost 

of administering the surveys. 

Response: We appreciate the commenters’ feedback. At this time reporting of CAHPS 

measures for PQRS is only available at the group practice level, so we will continue to consider 

these data for group practices. We understand the concerns raised regarding subjectivity and 

cost. However, we are confident that CAHPS is a well-tested collection mechanism that 

produces valid and comparable measures of physician quality based on the extensive testing and 

work that has been done by the Agency for Healthcare Research and Quality's (AHRQ) and 

specifically the CAHPS Consortium (for more information visit https://cahps.ahrq.gov/). This 

work illustrates that these measures are accurate measures of patient experience. Because 

CAHPS for PQRS can be one part of a group’s participation in PQRS and are data greatly 

desired by consumers, we also believe concerns regarding cost are outweighed. For these 

reasons, we are finalizing our proposal to make available for public reporting the 12 summary 
CMS-1612-FC 636

survey CAHPS measures outlined in this rule on Physician Compare for group practices and 

ACOs, as appropriate. 

Comment: Commenters were generally supportive of the proposal to publicly report 12 

summary CAHPS scores; however, some are concerned that several CAHPS summary survey 

measures cannot accurately capture aspects of care over which an individual physician does not 

have direct control, such as “Getting Timely Care, Appointments and Information” and “Access 

to Specialists,” and urged CMS to only report these measures on an aggregate, group level. 

Another commenter is concerned with “Stewardship of Patient Resources” survey measure, 

noting that it is not a physician’s role to manage a patient’s pocketbook and that other barriers, 

apart from costs, can impede access to care. 

One commenter supported the creation of benchmarks for CAHPS for PQRS measures, 

and suggested CMS clarify whether those benchmarks will be the same as the ACO CAHPS 

measure benchmarks, or whether the benchmarks will be specific to the PQRS program, but 

calculated using the same methodology. 

Response: The CAHPS for PQRS measures are designed to be group-level measures. 

These data will not be calculated for individual EPs; they will be evaluated at the group practice 

level. We do appreciate the commenters’ feedback regarding concerns over specific measures. 

One important consideration is that because the CAHPS measures are group-level, they are not 

attributing aspects of care to an individual EP, as not all aspects of care can be easily attributed 

to a single professional. Prior to deciding the specific measures that will be publicly reported on 

Physician Compare, we will ensure the measures meet the reliability and validity requirements 

set for public reporting and that the measures are understood and accurately interpreted by 

consumers. If a summary survey measure does not meet these criteria, it will not be publicly 
CMS-1612-FC 637

reported on Physician Compare. At this time, we are not adopting any benchmarks for CAHPS 

for PQRS on Physician Compare. 

Comment: One commenter sought additional information on how CAHPS for PQRS 

performance measures will be displayed. Another commenter suggested that public reporting of 

CAHPS for PQRS utilize the Hospital Compare model by displaying aggregate scores for 

measures with a footnote or click-through option to view the performance data. 

Response: We appreciate the commenters’ feedback regarding display of CAHPS for 

PQRS measures. We generally make decisions about measure display after consumer testing and 

stakeholder outreach, so we will take these recommendations into consideration. 

 We previously finalized in the 2014 PFS final rule with comment period (78 FR 74454) 

that 20 measures in the 2014 PQRS measures for individual EPs collected via registry, EHR, or 

claims would be available for public reporting in late 2015, if technically feasible. We proposed 

(79 FR 40390) to expand on this in two ways. First, we proposed to publicly report these same 

20 measures for 2013 PQRS data in early 2015. We stated that publicly reporting these 2013 

individual measures would help ensure individual level measures are made available as soon as 

possible. We believe that consumers are looking for measures about individual doctors and other 

health care professionals, and this would make these quality data available to the public sooner. 

 Comment: One commenter supported our proposal to publicly report 20 individual EPlevel 2013 PQRS measures in early 2015, while another commenter opposed the proposal noting 

that physicians were unaware at the time of data collection that these performance rates would be 

published. Concerns were raised that timelines needed to be finalized before the public reporting 

period had ended. 
CMS-1612-FC 638

 Response: We appreciate the commenters’ feedback and understand concerns that the 

2013 individual EP PQRS data were submitted without an explicit understanding that these data 

would be made public. As a result, we are not finalizing this proposal. 

 Second, we proposed (79 FR 40390) to make all individual EP-level PQRS measures 

collected via registry, EHR, or claims available for public reporting on Physician Compare for 

data collected in 2015 to be publicly reported in late CY 2016, if technically feasible.9

 We stated 

that this would provide the opportunity for more EPs to have measures included on Physician 

Compare, and it would provide more information to consumers to make informed decisions 

about their health care. As with group-level measures, we proposed to publicly report all 

measures submitted and reviewed and deemed valid and reliable in the Physician Compare 

downloadable file. However, not all of these measures necessarily would be included on the 

Physician Compare profile pages. Our analysis of the reported measure data, along with 

consumer testing and stakeholder feedback, would determine specifically which measures are 

published on profile pages on the website. In this way, quality information on individual 

practitioners would be available, as has been regularly requested by Medicare consumers, 

without overwhelming consumers with too much information. 

 Comment: Some commenters supported expanding public reporting of individual-level 

quality measures to all 2015 PQRS measures collected through a Registry, EHR, or claims, 

noting consumers are looking for individual doctors so this information is helpful. Several 

commenters opposed making 2015 PQRS individual EP measures available for public reporting 

in 2016 and are concerned that individual quality measurement is technically challenging to 

validate and may be difficult for consumers to understand. Another commenter suggested it is 

 

9

 Tables Q1-Q27 detail proposed changes to available PQRS measures. Additional information on PQRS measures 

can be found on the CMS.gov PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 
CMS-1612-FC 639

too much information for consumers. One commenter stated that data reported through different 

reporting mechanisms is not comparable so this proposal should not be finalized. One 

commenter believed that the relatively small numbers of patients seen by individual physicians 

raises questions about the ability to truly differentiate quality. Several commenters supported 

group practice level public reporting as an alternative to individual public reporting. 

 Response: We appreciate the commenters’ feedback and agree with those comments that 

support individual-level measure data should be posted on the site as soon as technically feasible. 

We also strongly agree with commenters that these data will help health care consumers make 

informed decisions about the care they receive. However, we appreciate the concerns raised by 

other commenters’ in opposition to posting individual EP measures. We are committed to 

including only the most accurate, statistically reliable, and valid quality of care measure data on 

Physician Compare. We will also ensure that only those data that are evaluated to be comparable 

will be publicly reported understanding the concerns regarding data collected via different 

reporting mechanisms. 

We will continue to test the PQRS measures with consumers to ensure the measures are 

presented and described in a way that is accurately understood. We will only include on the 

website those measures that resonate with consumers to ensure they are not overwhelmed with 

too much information. Regarding concerns around the number of patients seen, only those 

measures that are reported for the accepted sample size of 20 patients will be publicly reported. 

Because of the overwhelming consumer demand for individual EP data and the value these data 

provide to patients, we are finalizing our proposal to publicly report all 2015 individual EP 

PQRS measures collected through a Registry, EHR, or claims, except for those measure that are 

new to PQRS and thus in their first year. 
CMS-1612-FC 640

 As noted above for group-level reporting, composite scores and benchmarks are critical 

in helping consumers best understand the quality measure information presented. For that 

reason, in addition to making all 2015 PQRS measures available for public reporting, we sought 

comment (79 FR 40390) to create composites and publish composite scores by grouping 

measures based on the PQRS measure groups, if technically feasible. We indicated that we 

would analyze the data collected in 2015 and conduct psychometric and statistical analyses to 

create composites for PQRS measure groups to be published in 2016, including: 

● Coronary Artery Disease (CAD) (see Table 30) 

● Diabetes Mellitus (DM) (see Table 32) 

● General Surgery (see Table 33) 

● Oncology (see Table 38) 

● Preventive Care (see Table 41) 

● Rheumatoid Arthritis (RA) (see Table 42) 

● Total Knee Replacement (TKR) (see Table 45) 

We would analyze the component measures that make up each of these measure groups 

to see if a statistically viable composite can be constructed with the data reported for 2015. As 

noted for group practices, we believe that providing composite scores will give consumers the 

tools needed to most accurately interpret the quality data published on Physician Compare. We 

would analyze the component measures that make up each of these measure groups to see if a 

statistically viable composite can be constructed with the data reported for 2015. 

As noted above, we received multiple comments about creating composites at both the 

group practice and individual EP-level. Those comments are addressed above. Since we were 

only seeking comments on possible future composites, we are not finalizing any at this time, but 

we will take those comments into consideration for the future. 
CMS-1612-FC 641

In addition, we proposed (79 FR 40390) to use the same methodology outlined above for 

group practices to develop benchmarks for individual practitioners. We believe that providing 

benchmarks will give consumers the tools needed to most accurately interpret the quality data 

published on Physician Compare. As discussed above, we received comments on the proposed 

benchmarking methodology for both group practices and individual EPs. Those comments were 

previously addressed. As noted, we are not finalizing this proposed benchmarking methodology 

at this time. 

Previously, we indicated an interest in including specialty society measures on Physician 

Compare. In the proposed rule, we solicited comment (79 FR 40390) on posting these measures 

on the website. We also solicited comment on the option of linking from Physician Compare to 

specialty society websites that publish non-PQRS measures. Including specialty society 

measures on the site or linking to specific specialty society measures would provide the 

opportunity for more eligible professionals to have measures included on Physician Compare and 

thus help Medicare consumers make more informed choices. The quality measures developed by 

specialty societies that would be considered for future posting on Physician Compare are those 

that have been comprehensively vetted and tested and are trusted by the physician community. 

These measures would provide access to available specialty specific quality measures that are 

often highly regarded and trusted by the stakeholder community and, most importantly, by the 

specialties they represent. We indicated that we were working to identify possible societies to 

reach out to, and solicited comment on the concept, as well as potential specific society measures 

of interest. 

 Comment: Many commenters supported specialty society measures on Physician 

Compare or linking to specialty society websites that publish non-PQRS measures. Several 

commenters specified that the specialty society measures should be supported by scientific 
CMS-1612-FC 642

evidence, developed by relevant clinical experts, and adequately vetted. Some commenters 

suggested a disclaimer specifying, along with the measure description, the limitations of PQRS 

or clarification that CMS is not endorsing and has not validated specialty society measures. One 

commenter supported specialty measures as long as data is open sourced, provided at no cost, 

and made available to all. One commenter suggested also including links to additional patientfriendly educational materials on specialty societies’ websites. 

Several commenters opposed posting non-PQRS data or linking to non-governmental, 

privately managed websites. One commenter stated CMS should maintain control over the 

public disclosure process to reduce potential for variable data. One commenter is concerned that 

the approach will lead to more confusion for consumers and added burden for physicians, and 

another commenter cautioned CMS to ensure measures that are meaningful to consumers and 

comparable to those reported upon under the PQRS. A few commenters sought additional 

information on this process if this becomes a formal proposal in future years. 

Response: We appreciate commenters’ feedback on our request for information. We 

were only seeking comment at this time. We will consider feedback, recommendations made, 

and concerns raised, and may consider addressing specialty society measures and website links 

on Physician Compare in future rulemaking. 

 Finally, we proposed (79 FR 40390) to make available on Physician Compare, 2015 

Qualified Clinical Data Registry (QCDR) measure data collected at the individual level or 

aggregated to a higher level of the QCDR’s choosing – such as the group practice level, if 

technically feasible. QCDRs are able to collect both PQRS measures and non-PQRS measures.10 

We believe that making QCDR data available on Physician Compare further supports the 

expansion of quality measure data available for EPs and group practices regardless of specialty 

 

10http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaimsRegistry_MeasureSpec

s_SupportingDocs_12132013.zip 
CMS-1612-FC 643

therefore providing more quality data to consumers to help them make informed decisions. Per 

the proposal, the QCDR would be required to declare during their self-nomination if they plan to 

post data on their own website and allow Physician Compare to link to it or if they will provide 

data to CMS for public reporting on Physician Compare. We proposed that measures collected 

via QCDRs must also meet the established public reporting criteria, including a 20 patient 

minimum sample size. As with PQRS data, we proposed to publicly report in the Physician 

Compare downloadable file all measures submitted, reviewed, and deemed valid and reliable. 

However, not all of these measures necessarily would be included on the Physician Compare 

profile pages. Our analysis of the reported measure data, along with consumer testing and 

stakeholder feedback would determine specifically which measures are published on profile 

pages on the website. 

Comment: We received many comments on publicly reporting 2015 QCDR measure 

data. Some commenters supported publicly reporting QCDR data to provide specialty-specific 

quality information for patients. One commenter proposed CMS consumer test QCDR measures 

to ensure valid sampling, consistent methods, and comparable results across specialties. 

A number of commenters did not support the proposal, however. Most notably, 

commenters believed that public reporting first year data for new measures would be 

problematic. Other commenters opposed publicly reporting QCDR data until accurate 

benchmarking data can be developed, or professionals have the opportunity to analyze the data 

and make improvements. Several commenters requested NQF endorsement for all QCDR 

measures, and one commenter suggested that CMS develop rules and guidelines for measure 

stewards who develop non-PQRS measures housed in QCDR’s. One commenter stated societysponsored non-PQRS measures need to be subjected to the same reliability, validity, and 

consumer testing that CMS promises for other information on Physician Compare. Another 
CMS-1612-FC 644

commenter noted that QCDR measures are collected for quality improvement purposes and have 

not been vetted for public reporting. 

Response: We appreciate the commenters’ feedback on our proposal to include all 2015 

QCDR data at the individual level or aggregated to a higher level of the QCDR’s choosing. We 

understand the many concerns raised. We specifically appreciate the concerns that the QCDR 

non-PQRS measures be held to the same standards as the PQRS measures in terms of reliability, 

validity, and accuracy, and that these measures be adequately tested and vetted for public 

reporting. Understanding these concerns, we will review all data prior to public reporting to 

ensure that the measures included meet the same standards as the PQRS measures being publicly 

reported. As with the PQRS measures being made available for public reporting, if the QCDR 

measures do not meet the requirements for public reporting we have set out, the measures will 

not be publicly reported. Regarding the comment that QCDR data should not be publicly 

reported until accurate benchmarks are available, we appreciate this concern but are moving 

forward with the proposal because we believe that even without benchmarks, these data can 

provide consumers with very valuable and instructive information as is the case, and thus 

consistent, with the PQRS measures we are finalizing for publication without a benchmark. We 

do feel it is important to include QCDR data in our public reporting plan, as some commenters 

agreed, because using QCDR data can ultimately provide an opportunity to have measures 

available for public reporting for a greater number of health care professionals covering more 

specialties, providing more and more useful information to health care consumers. We are 

therefore finalizing our proposal to publicly report QCDR measures with some modifications. 

We agree that it may be problematic to publicly report first year measures. Health care 

professionals should be afforded the opportunity to simply learn from the first year data, and not 

have this information shared publicly until the measure can be vetted for accuracy. As a result, 
CMS-1612-FC 645

we will not publicly report any QCDR measures newly available for reporting for at least one 

year. This is consistent with the VM policy regarding first year measures and addresses a 

significant number of the concerns raised, which were specifically in regard to not including first 

year measures for public reporting. If first year measures are not publicly reported this will 

provide us the necessary time to review and vet the QCDR measures to ensure that only those 

truly suitable for public reporting are posted on Physician Compare when they mature. 

Comment: A number of commenters considered the proposed timeline for publicly 

reporting 2015 QCDR measure data too aggressive to ensure that data will be valid and reliable 

and in a format which consumers can understand; some suggested delaying or implementing a 

gradual approach. A few commenters were concerned public reporting so soon will damage start 

up efforts of new registries. 

Several commenters supported the proposal only if the QCDR measures are posted on 

Physician Compare. One commenter believed this will streamline the public reporting process. 

One commenter noted that QCDRs websites are not intended for public consumption and would 

require new infrastructure, while another commenter was concerned with a potential conflict of 

interest by linking to nongovernmental websites. Two commenters support linking to the QCDR 

websites to view the data to reduce consumer confusion. Another commenter urged consistent 

and uniform public reporting. 

Response: We appreciate the commenters’ feedback and do acknowledge the concerns 

regarding the timeline. To mitigate some of these concerns, we are adopting some refinements 

to what we proposed, such as not reporting first year measures. We believe that not publicly 

reporting measures on Physician Compare that are not ready for public reporting will help 

QCDRs early in their development and not reflect negatively on the new QCDR. We are also 

finalizing a decision to publish QCDR 2015 data on the Physician Compare website in 2016. 
CMS-1612-FC 646

However, as finalized in the PQRS section of this rule, we are not requiring these data to be 

publicly reported on the QCDR websites in order to address concerns that there is not enough 

time for QCDRs to establish user-friendly websites for sharing data as well as concerns about 

data consistency. Publicly reporting the QCDR data on Physician Compare also provides a 

uniform public reporting approach, eliminates the need for health care professionals to verify 

their data in multiple locations, and provides one, user-friendly website for consumers trying to 

locate quality data. After this first year of pubic reporting QCDR data, we will evaluate if 

maintaining this policy is most desirable. 

Comment: A few commenters supported reporting individual or data aggregating to a 

higher level, but the majority recommend QCDR measure data only be reported on Physician 

Compare at the group practice level. One commenter suggested requiring the individual level 

data to be made publicly available, so long as results are valid and reliable. One commenter 

believed QCDRs should have the option to publicly disclose performance data by physician 

specialty within a group, in addition to at the individual or group levels. 

Response: We appreciate the commenters’ feedback. As stated above, only those data 

that are deemed valid, reliable, and accurate will be publicly reported on Physician Compare. 

This will be true for all QCDR data as well. Given that we will publish QCDR data on Physician 

Compare, but not first year measures, this will enable us to review and vet the QCDR measures 

prior to public reporting in 2016. In this way, we can ensure only the most appropriate available 

QCDR measures are publicly reported, and that they are reported in a way that will help 

consumers make informed decisions. 

QCDR data will only be publicly reported at the individual-EP level. We appreciate the 

commenters’ concerns and support for group-level data. However, QCDR data is not necessarily 

aggregated to a level consistent with how PQRS defines a group practice. Therefore, aggregated 
CMS-1612-FC 647

data cannot be accommodated on Physician Compare at this time. And, under PQRS, only 

individual EPs can report via a QCDR. Therefore, only including individual-level QCDR data on 

Physician Compare is consistent with the PQRS program’s implementation of the data. As with 

all data included on Physician Compare, only data deemed valid, reliable, and accurate will be 

publicly reported on the website. 

 Table 49 summarizes the Physician Compare proposals we are finalizing for with regard 

to 2015 data. 

TABLE 49: Summary of Finalized Data for Public Reporting 

Data 

Collection 

Year 

Publication 

Year Data Type Reporting Mechanism 

Finalized Proposals Regarding Quality 

Measures and Data for Public Reporting 

2015 2016 

PQRS, 

PQRS 

GPRO, 

EHR, and 

Million 

Hearts 

Web Interface, 

EHR, 

Registry, 

Claims 

Include an indicator for satisfactory reporters under 

PQRS, participants in the EHR Incentive Program, 

and EPs who satisfactorily report the individual 

PQRS Cardiovascular Prevention measures in 

support of Million Hearts. 

2015 2016 PQRS 

GPRO & 

ACO GPRO 

Web Interface, 

EHR, 

Registry, and 

Administrative 

Claims 

All 2015 PQRS GPRO measures reported via the 

Web Interface, EHR, and Registry that are available 

for public reporting for group practices of 2 or more 

EPs and all measures reported by ACOs with a 

minimum sample size of 20 patients. 

2015 2016 CAHPS for 

PQRS& 

CAHPS for 

ACOs 

CMSSpecified 

Certified 

CAHPS 

Vendor 

2015 CAHPS for PQRS for groups of 2 or more 

EPs and CAHPS for ACOs for those who meet the 

specified sample size requirements and collect data 

via a CMS-specified certified CAHPS vendor. 

2015 2016 PQRS Registry, 

EHR, or 

Claims 

All 2015 PQRS measures for individual EPs 

collected through a Registry, EHR, or claims. 

2015 2016 QCDR data QCDR All individual-EP level 2015 QCDR data. 

4. Additional Comments Received Beyond the Scope of this Rulemaking 

We received comments regarding the availability of measures at the individual and 

group-levels for certain types of specialties and for other health care professionals, but that were 

beyond the scope of this rule. We have summarized and addressed those comments below. 

Comment: Several commenters are concerned about the availability of specialty-specific 

and non-physician measures available for public reporting due to the proposed removal of PQRS 
CMS-1612-FC 648

measures and/or limitations of measures reported via claims or the Web Interface. Two 

commenters noted that some specialty specific measures are not suitable for public reporting, as 

the data is not meaningful to consumers. Commenters also noted that the absence of measure 

data on Physician Compare due to limited available or meaningful measures may mislead 

consumers. Commenters requested disclaimers be added or additional education be conducted to 

explain that there could be the absence of measure data due to measure limitations and not poor 

quality. Several commenters expressed concern with publicly reporting any data until measure 

limitations can be analyzed or addressed. Two commenters supported the continued work of 

CMS with professional societies to address measure concerns. 

Response: We appreciate the commenters’ feedback. We understand that availability of 

PQRS measures may make it difficult for some specialties to report. We hope that the 

introduction of additional measures, such as QCDR measures and patient experience measures, 

will help mitigate concerns regarding quality data availability in the short term. And, it is 

important to realize that as most searches on Physician Compare are specialty based, if there are 

not measures for a given specialty, users will not be evaluating some physicians or nonphysicians with measures and some without within that specialty. That can also work to mitigate 

these concerns. Finally, we also understand that disclaimers and other types of explanatory 

language are necessary to help inform health care consumers as they use the website. We will 

continue to work to ensure that the language included on Physician Compare addresses the 

concerns raised and helps users understand that there are a number of reasons a physician or 

other health care professional may not have quality data on the website. 

Comment: We received comments on how quality measures are displayed on Physician 

Compare. Several commenters opposed star rankings or similar systems and are concerned that 

disparate quality scores will result in inappropriate distinctions of quality for physicians whose 
CMS-1612-FC 649

performance scores are not statistically different. One commenter suggested increased efforts to 

establish the best method for presenting performance information to consumers and to educate 

consumers on the meaning of performance differences. 

Response: At the time this rule is finalized, Physician Compare does not employ a 

ranking system – the site does not provide a system that determines that one professional is better 

than other professionals based on any set of defined criteria. Performance scores are displayed 

visually using five stars as a pictographic representation of the percent. In this way, each star 

represents 20 percentage points. The performance rate is also displayed as a percent. Consumer 

testing has shown that this display is most accurately understood and interpreted by website 

users. Stakeholders were provided opportunities to view alternate display options and this 

display was also supported by a majority of those who took part in review sessions prior to the 

initial publication of measure data. That said, we intend to continue to work with consumers and 

stakeholders to find the best way to display data that will best serve consumers and most 

accurately represent the data. 

Comment: Several commenters are concerned with the use of physician-centric language 

in the proposed rule and on Physician Compare, noting that the name of the site could be more 

inclusive of all eligible health care professionals. One commenter suggested providing 

information throughout the website about the full array of qualified professionals. One 

commenter requested the definition of the Clinical Nurse Specialist change, while another 

specified changes for Registered Dietitian/Nutrition Professionals. One commenter asked CMS 

to assure that audiologists are meaningfully represented and can be easily identified by other 

professionals and patients. One commenter recommended that the enrollment application 

process also be refined to provide a provider neutral enrollment process. 

Response: We appreciate the commenters’ feedback, and will take all recommendations 
CMS-1612-FC 650

into consideration for the future. The site was named consistent with section 10331 of the 

Affordable Care Act. Throughout the site we note that both physicians and other health care 

professionals are available to search and view. If a professional is in approved status in PECOS 

and has submitted Medicare Fee-For-Service claims in their name in the last 12 months, they will 

be included on Physician Compare. We are always working to ensure the plain language 

definitions of the various types of professionals included on the site are accurate and up-to-date. 

We will review the recommendations made around this information and work with relevant 

stakeholders to update as appropriate. 

Comment: Commenters provided suggestions for additional information to publicly 

report on Physician Compare, including participation in a quality improvement registry for 

certain services, fellowship status, other voluntary quality improvement initiatives, educational 

materials about a disease or procedure, specialist-specific training and certification data, and 

other qualifications, such as the Certified Medical Director designation and the Certificate of 

Added Qualifications in Geriatric Medicine. One commenter supported inclusion of information 

about physician compliance with Medicare rules. Another commenter suggested including 

measures related to cancer care. 

Response: We appreciate the commenters’ feedback and recommendations for including 

additional information on the website. We will review all recommendations provided and 

evaluate the feasibility for potential inclusion in the future. One important consideration around 

many of these recommendations is whether there is a readily available national-level data source. 

With this in mind, the recommendations will be closely evaluated. 

Comment: Several commenters noted the limitations of CAHPS for PQRS measures for 

some health care professionals and supported adding other types of patient experience data to 

Physician Compare, including the Surgical CAHPS® and experience data collected via other 
CMS-1612-FC 651

sources. One commenter suggested publicly reporting beneficiary satisfaction information in 

addition to CAHPS for PQRS measures. Another commenter suggested reporting patient 

experience data for primary care physicians and clinical quality performance for specialists. 

Response: We appreciate the commenters’ feedback. We agree that Surgical CAHPS® 

data is useful to consumers and we are exploring how we can incorporate this information into 

Physician Compare. 

Comment: One commenter encouraged CMS to recognize improvements by individual 

professionals and groups over time, while another noted the benefits of cross-sectional and crosstime comparisons. 

Response: We appreciate the commenters’ feedback and the recommendation to consider 

longitudinal as well as other comparisons. We will evaluate these recommendations as we move 

forward with Physician Compare. 

Comment: One commenter suggested that the measures being removed from PQRS due 

to 100 percent performance be added to the Physician Compare website as display measures 

believing that these topped out measures would add value to Physician Compare. 

Response: We appreciate the commenter’s feedback. However, if the measure data are 

no longer going to be reported in PQRS, these data will not be available to consider for posting 

on Physician Compare. 

Comment: One commenter urged CMS to create mechanisms to attribute Medicare 

Advantage quality data to physician groups for display on Physician Compare and enable 

CG-CAHPS vendors to include beneficiaries enrolled in MA, as well as in traditional Medicare 

fee-for-service. 

Response: We appreciate the commenters’ suggestions and will evaluate the feasibility 

of these recommendations for the future. 
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5. Report to Congress 

 Section 10331(f) of the Affordable Care Act, requires that no later than January 1, 

2015, we submit a report to Congress on the Physician Compare website that includes 

information on the efforts of and plans made by the Secretary of Health and Human Services to 

collect and publish data on physician quality and efficiency and on patient experience of care in 

support of consumer choice and value-based purchasing. We anticipate timely submission of this 

report, including discussion about the phase-in of the website and developments to date. The 

report will also address the expansion of data on the website, in regard to section 10331(g) of the 

Affordable Care Act, and future plans for the website. 
CMS-1612-FC 653

K. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting System 

This section contains the requirements for the Physician Quality Reporting System (PQRS). The 

PQRS, as set forth in sections 1848(a), (k), and (m) of the Act, is a quality reporting program that 

provides incentive payments (ending with 2014) and payment adjustments (beginning in 2015) to eligible 

professionals and group practices based on whether they satisfactorily report data on quality measures for 

covered professional services furnished during a specified reporting period or to individual eligible 

professionals that satisfactorily participate in a qualified clinical data registry (QCDR). 

The requirements in this rule primarily focus on the 2017 PQRS payment adjustment, which will 

be based on an eligible professional’s or a group practice’s reporting of quality measures data during the 

12-month calendar year reporting period occurring in 2015 (that is, January 1 through December 31, 

2015). Please note that, during the comment period, we received comments that were not related to our 

specific proposals for the requirements for the 2017 PQRS payment adjustment in the CY 2015 PFS 

proposed rule. While we appreciate the commenters’ feedback, these comments will not be specifically 

addressed in this CY 2015 PFS final rule with comment period, as they are beyond the scope of this rule. 

However, we will consider these comments when developing policies and program requirements for 

future years. Please note that we continue to focus on aligning our requirements with other quality 

reporting programs, such as the Medicare EHR Incentive Program for Eligible Professionals, the VM, and 

the Medicare Shared Savings Program, where and to the extent appropriate and feasible. 

The PQRS regulations are located at §414.90. The program requirements for the 2007 through 

2014 PQRS incentives and the 2015 and 2016 PQRS payment adjustment that were previously 

established, as well as information on the PQRS, including related laws and established requirements, are 

available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. In addition, the 2012 PQRS and eRx Experience Report, which provides 

information about eligible professional participation in PQRS, is available for download at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip. 
CMS-1612-FC 654

We note that eligible professionals in critical access hospitals billing under Method II (CAH-IIs) 

were previously not able to participate in the PQRS. Due to a change we made in the manner in which 

Medicare reimburses eligible professionals in CAH-IIs, it is feasible for eligible professionals in CAH-IIs 

to participate in the PQRS for reporting beginning in 2014. Although eligible professionals in CAH-IIs 

are not able to use the claims-based reporting mechanism to report PQRS quality measures data in 2014, 

beginning in 2015, these eligible professionals in CAH-IIs may participate in the PQRS using ALL 

reporting mechanisms available, including the claims-based reporting mechanism. Finally, please note 

that in accordance with section 1848(a)(8) of the Act, all eligible professionals who do not meet the 

criteria for satisfactory reporting or satisfactory participation for the 2017 PQRS payment adjustment will 

be subject to the 2017 PQRS payment adjustment with no exceptions. 

In addition, in the CY 2013 PFS final rule with comment period, we introduced the reporting of 

the Agency for Healthcare Research and Quality’s (AHRQ’s) Clinician & Group (CG) Consumer 

Assessment of Healthcare Providers and Systems (CAHPS) survey measures, referenced at 

https://cahps.ahrq.gov/Surveys-Guidance/CG/index.html. AHRQ's CAHPS Clinician & Group Survey 

Version 2.0 (CG-CAHPS) includes 34 core CG-CAHPS survey questions. In addition to these 34 core 

questions, the CAHPS survey measures that are used in the PQRS include supplemental questions from 

CAHPS Patient-Centered Medical Home Survey, Core CAHPS Health Plan Survey Version 5.0, other 

CAHPS supplemental items, and some additional questions. Since the CAHPS survey used in the PQRS 

covers more than just the 34 core CG-CAHPS survey measures, we will refer to the CG-CAHPS survey 

measures used in the PQRS as “CAHPS for PQRS.” We proposed to make this revision throughout 

§414.90. We did not receive comments on referring to the CG-CAHPS survey measures as reported in 

the PQRS as CAHPS for PQRS, and are therefore finalizing this proposal as proposed. 

1. Requirements for the PQRS Reporting Mechanisms 

The PQRS includes the following reporting mechanisms: claims; qualified registry; EHR 

(including direct EHR products and EHR data submission vendor products); the Group Practice Reporting 

Option (GPRO) web interface; certified survey vendors, for the CAHPS for PQRS survey measures; and 

the QCDR. Under the existing PQRS regulation, §414.90(h) through (k) govern which reporting 
CMS-1612-FC 655

mechanisms are available for use by individuals and group practices for the PQRS incentive and payment 

adjustment. This section III.K.1 contains our proposals to change the qualified registry, direct EHR and 

EHR data submission vendor products, QCDR, and GPRO web interface reporting mechanisms, as well 

as public comments and our final decisions on those proposals. Please note that we did not propose to 

make changes to the claims-based reporting mechanism. 

Please note that, in the CY 2015 PFS proposed rule, we solicited comments on whether, in future 

years, we should allow for more frequent submissions, such as quarterly or year-round submissions, for 

PQRS quality measures data submitted via the qualified registry, EHR, QCDR, and GPRO web interface 

reporting mechanisms (79 FR 40392, 40393, and 40395 respectively). Many commenters supported this 

concept, as it would provide vendors and their products greater flexibility in data submission. However, 

some of these commenters who expressed support for more frequent submissions of data preferred that 

the ability to provide more frequent submission of data be optional, not mandatory. We appreciate the 

commenters’ support for this concept and will consider the commenters’ feedback if and when we 

propose this policy in future rulemaking. 

a. Changes to the Requirements for the Qualified Registry 

In the CY 2013 and 2014 PFS final rules with comment period, we established certain 

requirements for entities to become qualified registries for the purpose of verifying that a qualified 

registry is prepared to submit data on PQRS quality measures for the reporting period in which the 

qualified registry seeks to be qualified (77 FR 69179 through 69180 and 78 FR 74456). Specifically, in 

the CY 2014 PFS final rule with comment period, in accordance with the satisfactory reporting criterion 

we finalized for individual eligible professionals or group practices reporting PQRS quality measures via 

qualified registry, we finalized the following requirement that a qualified registry must be able to collect 

all needed data elements and transmit to CMS the data at the TIN/NPI level for at least 9 measures 

covering at least 3 of the National Quality Strategy (NQS) domains (78 FR 74456). 

As we explain in further detail in this section III.K, we proposed that – in addition to requiring 

that an eligible professional or group practice report on at least 9 measures covering 3 NQS domains –an 

eligible professional or group practice who sees at least 1 Medicare patient in a face-to-face encounter, as 
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we define that term in section III.K.2.a., and wishes to meet the criterion for satisfactory reporting of 

PQRS quality measures via a qualified registry for the 2017 PQRS payment adjustment would be required 

to report on at least 2 cross-cutting PQRS measures specified in Table 52. In accordance with this 

proposal, we proposed to require that, in addition to being required to be able to collect all needed data 

elements and transmit to CMS the data at the TIN/NPI level for at least 9 measures covering at least 3 of 

the NQS domains for which a qualified registry transmits data, a qualified registry would be required to 

be able to collect all needed data elements and transmit to CMS the data at the TIN/NPI level for ALL 

cross-cutting measures specified in Table 52 for which the registry’s participating eligible professionals 

are able to report. 

Comment: Some commenters opposed this proposed requirement, stating that this requirement 

seems overly burdensome. The commenters noted that, in some instances, certain registries report PQRS 

quality measures data for certain specialties for which the proposed cross-cutting measure set does not 

apply. Commenters also requested exceptions to this requirement for “closed registries,” which the 

commenter defined as registries not open to all eligible professionals for participation. 

Response: We understand the commenters’ concerns regarding requiring registries to be able to 

report on all cross-cutting measures specified in Table 52. We made this proposal to allow eligible 

professionals and group practices the option to report on as many cross-cutting measures as are 

applicable. However, we understand that it may by overly burdensome for certain registries, such as 

those registries geared towards specialties for which the cross-cutting measures do not apply or “closed 

registries.” Therefore, based on the comments received, we are not finalizing our proposal to require that 

qualified registries be able to report on all cross-cutting measures specified in Table 52 for which the 

registry’s participating eligible professionals are able to report. We note, however, as we describe in 

greater detail below, eligible professionals and group practices using the registry-based reporting 

mechanism that see at least 1 Medicare patient in a face-to-face encounter must still report on 1 crosscutting measure to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 

Therefore, in order for the registry’s participating eligible professionals and group practices to meet the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment, the registry must be able to 
CMS-1612-FC 657

report to report on at least 1 cross-cutting measure on behalf of its participating eligible professionals and 

group practices. 

Furthermore, in the CY 2013 PFS final rule, we noted that qualified registries have until the last 

Friday of February following the applicable reporting period (for example, February 28, 2014, for 

reporting periods ending in 2013) to submit quality measures data on behalf of its eligible professionals 

(77 FR 69182). We continue to receive stakeholder feedback, particularly from qualified registries 

currently participating in the PQRS, urging us to extend this submission deadline due to the time it takes 

for these qualified registries to collect and analyze the quality measures data received after the end of the 

reporting period. Although, at the time, we emphasized the need to have quality measures data received 

by CMS no later than the last Friday of the February occurring after the end of the applicable reporting 

period, we believe it is now feasible to extend this deadline. Therefore, we proposed to extend the 

deadline for qualified registries to submit quality measures data, including, but not limited to, calculations 

and results, to March 31 following the end of the applicable reporting period (for example, March 31, 

2016, for reporting periods ending in 2015). We invited and received the following public comments on 

this proposal: 

Comment: Commenters supported this proposal, as it would allow qualified registries an 

additional month to submit quality measures data. 

Response: We appreciate the commenters’ positive feedback. Based on the comments received 

and for the reasons stated in the proposed rule, we are finalizing our proposal to extend the deadline for 

qualified registries to submit quality measures data, including, but not limited to, calculations and results, 

to March 31 following the end of the applicable reporting period (for example, March 31, 2016, for 

reporting periods ending in 2015). 

b. Changes to the Requirements for the Direct EHR and EHR Data Submission Vendor Products That 

Are CEHRT 

In the CY 2013 PFS final rule with comment period, we finalized requirements that although 

EHR vendors and their products would no longer be required to undergo the previously existing 

qualification process, we would only accept the data if the data are: (1) transmitted in a CMS-approved 
CMS-1612-FC 658

XML format utilizing a Clinical Document Architecture (CDA) standard such as Quality Reporting Data 

Architecture (QRDA) level 1 (and for EHR data submission vendor products that intend to report for 

purposes of the proposed PQRS-Medicare EHR Incentive Program Pilot, if the aggregate data are 

transmitted in a CMS-approved XML format); and (2) in compliance with a CMS-specified secure 

method for data submission (77 FR 69183 through 69187). To further clarify, EHR vendors and their 

products must be able to submit data in the form and manner specified by CMS. Accordingly, direct 

EHRs and EHR data submission vendors must comply with CMS Implementation Guides for both the 

QRDA-I and QRDA-III data file formats. The Implementation Guides for 2014 are available at 

http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Guide_QRDA_2014eCQM.pdf. Updated 

guides for 2015, when available, will be posted on the CMS EHR Incentive Program website at 

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms. These 

implementation guides further describe the technical requirements for data submission to ensure the data 

elements required for measure calculation and verification are provided. We proposed to continue 

applying these requirements to direct EHR products and EHR data submission vendor products for 2015 

and beyond. We received no public comment on our proposal to continue applying these requirements. 

Therefore, we are finalizing our proposal to have direct EHRs and EHR data submission vendors comply 

with CMS Implementation Guides for both the QRDA-I and QRDA-III data file formats for 2015 and 

beyond. 

For 2015 and beyond, we also proposed to have the eligible professional or group practice 

provide the CMS EHR Certification Number of the product used by the eligible professional or group 

practice for direct EHRs and EHR data submission vendors. We believe this requirement is necessary to 

ensure that the eligible professionals and group practices that are using EHR technology are using a 

product that is certified EHR technology (CEHRT) and will allow CMS to ensure that the eligible 

professional or group practice’s data is derived from a product that is CEHRT. We solicited but received 

no public comment on this proposal. However, we do not believe it is feasible for us to collect this 
CMS-1612-FC 659

information at this time, because we do not have a venue in which to store this information. Therefore, 

we are not finalizing this proposal. 

c. Changes to the Requirements for the QCDR 

Reporting Outcome Measures: 

In accordance with the criterion for satisfactory participation in a QCDR that we proposed for the 

2017 PQRS payment adjustment, we proposed to require a QCDR to possess at least 3 outcome measures 

(or, in lieu of 3 outcome measures, at least 2 outcome measures and at least 1 of the following other types 

of measures - resource use, patient experience of care, or efficiency/appropriate use) (79 FR 40393). We 

solicited and received the following comment on this proposal: 

Comment: The majority of commenters opposed this proposal. The commenters believed this 

proposed requirement was overly burdensome, particularly for the QCDRs that do not have 3 outcome 

measures available for reporting currently. The commenters urged CMS not to bring about change to a 

reporting option that is still relatively new. 

Response: We understand the commenters’ concerns. As we describe in greater detail in section 

III.K.3.a. below, we are modifying our final criterion for satisfactory participation in a QCDR for the 

2017 PQRS payment adjustment by only requiring that an eligible professional report on at least 2 

outcome measures (or, in lieu of 2 outcome measures, at least 1 outcome measure and 1 of the following 

other types of measures – resource use, patient experience of care, efficiency/appropriate use, or safety). 

Since this proposal was intended to be consistent with our final criterion for the satisfactory participation 

in a QCDR for the 2017 PQRS payment adjustment, we are modifying this proposal and finalizing the 

following requirement for QCDRs: a QCDR must possess at least 2 outcome measures. If the QCDR 

does not possess 2 outcome measures, then, in lieu of 2 outcome measures, the QCDR must possess at 

least 1 outcome measures and 1 of the following other types of measures – resource use, patient 

experience of care, efficiency/appropriate use, or safety. We believe this modification does not 

significantly change the current QCDR requirement to possess at least 1 outcome measure, as a QCDR 

may still possess only one measure for reporting in 2015 and still qualify to become or remain a QCDR 
CMS-1612-FC 660

provided that the QCDR possesses 1 of the following other types of measures – resource use, patient 

experience of care, efficiency/appropriate use, or safety. 

Reporting Non-PQRS Measures: 

To establish the minimum number of measures (9 measures covering at least 3 NQS domains) a 

QCDR may report for the PQRS, we placed a limit on the number of non-PQRS measures (20) that a 

QCDR may submit on behalf of an eligible professional at this time (78 FR 74476). We proposed to 

change this limit from 20 measures to 30 (79 FR 40393). We solicited and received the following public 

comment on this proposal: 

Comment: Some commenters supported this proposal, as it would allow QCDRs to report on 

more measures that may cover a broader range of specialties and sub-specialties. A few commenters 

opposed this proposal, as the commenters urged CMS not to bring about change to a reporting option that 

is still relatively new. 

Response: We appreciate the commenters’ positive feedback. While we understand the need to 

provide continuity and stability in this reporting option, particularly during its early stages, we believe 

that the benefits of allowing QCDRs potentially to cover a broader range of specialties and sub-specialties 

outweigh the commenters’ concerns. Therefore, we are finalizing our proposal that beginning with the 

criteria for satisfactory participation for the 2017 PQRS payment adjustment, a QCDR may submit 

quality measures data for a maximum of 30 non-PQRS measures. Please note that this limit does not 

apply to measures contained in the PQRS measure set, as QCDRs can report on as many measures in the 

PQRS measure set as they wish. Also, please note that QCDRs are not required to report on 30 nonPQRS measures. Rather, the reporting of non-PQRS measures is optional, and our final rule here 

increases the number of optional additional measures that a QCDR may elect to submit. 

Definition of a Non-PQRS Measure: 

Additionally, CMS’ experience during the 2014 self-nomination process shed light on 

clarifications needed on what is considered a non-PQRS measure. Therefore, to clarify the definition of 

non-PQRS measures, we proposed the following parameters for a measure to be considered a non-PQRS 

measure: 
CMS-1612-FC 661

● A measure that is not contained in the PQRS measure set for the applicable reporting period. 

● A measure that may be in the PQRS measure set but has substantive differences in the manner 

it is reported by the QCDR. For example, PQRS measure 319 is reportable only via the GPRO web 

interface. A QCDR wishes to report this measure on behalf of its eligible professionals. However, as 

CMS has only extracted the data collected from this quality measure using the GPRO web interface, in 

which CMS utilizes a claims-based assignment and sampling methodology to inform the groups on which 

patients they are to report, the reporting of this measure would require changes to the way that the 

measure is calculated and reported to CMS via a QCDR instead of through the GPRO web interface. 

Therefore, due to the substantive changes needed to report this measure via a QCDR, PQRS measure 319 

would be considered a non-PQRS measure. In addition, CAHPS for PQRS is currently reportable only 

via a CMS-certified survey vendor. However, although CAHPS for PQRS is technically contained in the 

PQRS measure set, we consider the changes that will need to be made to be available for reporting by 

individual eligible professionals (and not as a part of a group practice) significant enough as to treat 

CAHPS for PQRS as a non-PQRS measure for purposes of reporting CAHPS for PQRS via a QCDR. 

To the extent that further clarification on the distinction between a PQRS and a non-PQRS 

measure is necessary, we will provide additional guidance on our website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html. 

Public Reporting of QCDR Quality Measures Data: 

Furthermore, under our authority to establish the requirements for an entity to be considered a 

QCDR under section 1848(m)(3)(E)(i) of the Act, we established certain requirements for an entity to be 

considered a QCDR in the CY 2014 PFS final rule with comment period (78 FR 74467 through 74473). 

Under this same authority, we proposed here to add the following requirement that an entity must meet to 

serve as a QCDR under the PQRS for reporting periods beginning in 2015: 

● Require that the entity make available to the public the quality measures data for which its 

eligible professionals report. 

To clarify this proposal, we proposed that, at a minimum, the QCDR publicly report the following 

quality measures data information that we believe will give patients adequate information on the care 
CMS-1612-FC 662

provided by an eligible professional: the title and description of the measures that a QCDR reports for 

purposes of the PQRS, as well as the performance results for each measure the QCDR reports. We 

solicited and received the following public comment on this proposal: 

Comment: Some commenters supported this proposal, as the commenters believed it was 

reasonable to require that this information be made available to the public. These commenters supported 

our proposal to defer to the QCDR in terms of what platform and in what manner this data may be made 

available to the public. Some commenters opposed this proposal, stating that the public reporting 

requirement was overly burdensome, and urged CMS to delay requiring the posting of measures data until 

the measures have been tested for validity and reliability. The commenters believed that CMS should not 

make substantial changes in the QCDR requirements as the QCDR option is new and the entities need 

time to familiarize themselves with the QCDR option before new requirements are established. 

Response: With respect to the commenters who opposed this proposal and urged CMS not to 

make additional changes to the QCDR option while entities become more familiar with this option, we 

understand the commenters’ concerns. However, we believe that transparency of data is a key component 

of a QCDR option. We believe that it is appropriate to finalize this public reporting requirement at this 

time. In the CY 2014 PFS final rule, while we did not finalize our proposal that a QCDR have a plan to 

publicly report quality measures data, we noted that we encouraged “these qualified clinical data 

registries to move towards the public reporting of quality measures data” and that we planned to 

“establish such a requirement in the future” and would “revisit this proposed requirement as part of CY 

2015 rulemaking” (78 FR 74471). Therefore, we believe that QCDRs were on notice that we would 

propose and finalize a requirement to make quality measures data available to the public beginning with 

the CY 2015 reporting. 

However, although we do not believe we should further delay requiring public report of QCDR 

quality measures data, we do agree with the commenters on delaying public posting of measures 

information until a measure has been tested for validity and reliability. Therefore, we are providing an 

exception to this requirement for new measures (both PQRS and non-PQRS measures) that are in their 

first year of reporting by a QCDR under the PQRS. We define a measure being introduced in the PQRS 
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for the first time as the first time a quality measure is either introduced in the PQRS measure set in 

rulemaking as a new measure for that reporting period or, for non-PQRS measures that can be reported by 

a QCDR, the first time a QCDR submits a measure (including its measure specifications) for reporting for 

the PQRS for the first time. Please note that, to the extent that a QCDR first reports on a non-PQRS 

measure that is already being reported by another QCDR, we would consider the measure a measure that 

is in its first year of reporting for that respective QCDR who is reporting the measure for the first time. 

We believe that providing QCDRs with one year to test and validate new measures provides sufficient 

time for QCDRs to find potential data issues and correct those issues prior to a measure’s second year of 

reporting in the PQRS. 

Based on the comments received and for the reasons stated in the proposed rule, we are finalizing 

this proposal to require that the entity make available to the public the quality measures data for which its 

eligible professionals report. However, as we explained above, we are providing an exception to this 

requirement for new PQRS and non-PQRS measures that are in their first year of reporting by a QCDR 

under the PQRS. Therefore, quality measure data for a PQRS or non-PQRS measure that is being 

reported by a QCDR in the PQRS for the first time does not need to be posted for at least the initial year. 

After the initial year of reporting a new measure, as we believe it is important for a QCDR to be 

transparent in the quality performance of its eligible professionals, quality measures performance data for 

the measure (except for the data collected in the measure’s first year of reporting in the PQRS) would be 

required to be made available to the public. 

Please note that, in finalizing these requirements on public reporting, we defer to the entity in 

terms of the method it will use to publicly report the quality measures data it collects for the PQRS. For 

example, to meet this requirement, it would be sufficient for a QCDR to publicly report performance rates 

of eligible professionals through means such as board or specialty websites, or listserv dashboards or 

announcements. We also note that a QCDR would meet this public reporting requirement if the QCDR’s 

measures data were posted on Physician Compare. In addition, we defer to the QCDR to determine 

whether to report performance results at the individual eligible professional level or aggregate the results 

for certain sets of eligible professionals who are in the same practice together (but who are not registered 
CMS-1612-FC 664

as a group practice for the purposes of PQRS reporting). We believe it is appropriate to allow a QCDR to 

publicly report performance results at an aggregate level for certain eligible professionals when those who 

are in the same practice contribute to the overall care provided to a patient. 

● With respect to when the quality measures data must be publicly reported, we proposed that 

the QCDR must have the quality measures data by April 31 of the year following the applicable reporting 

period (that is, April 31, 2016, for reporting periods occurring in 2015). The deadline of April 31 will 

provide QCDRs with one month to post quality measures data and information following the March 31 

deadline for the QCDRs to transmit quality measures data for purposes of the PQRS payment 

adjustments. Please note that we erroneously stated the proposed deadline as April 31, which does not 

exist in the calendar. We intended to propose a deadline that falls at the end of April—specifically, a 

deadline of April 30, not April 31, of the year following the applicable reporting period (that is, April 30, 

2016, for reporting periods occurring in 2015). This was an inadvertent technical error, and we are 

therefore correcting this proposal here and our responses to comments below to reflect our intention to 

propose a deadline of April 30 of the year following the applicable reporting period. We believe this does 

not materially modify this proposal, and as April 31 does not exist in the calendar, we believe that the 

public and commenters could reasonably infer that we intended to refer to the end of April in this 

proposed deadline, which is April 30 and thus reasonably foresee that we would adopt such a deadline. 

Therefore, we will address the comments and frame our responses below as they relate to an April 30 

deadline of the year following the applicable reporting period (that is, April 30, 2016, for reporting 

periods occurring in 2015). We also proposed that this data be available on a continuous basis and be 

continuously updated as the measures undergo changes in measure title and description, as well as when 

new performance results are calculated. We solicited and received the following public comments on this 

proposal: 

Comment: A few commenters opposed our proposal to require that a QCDR must have the 

quality measures data by April 30 of the year following the applicable reporting period. The commenter 

noted that any performance data publicly posted should be tested for accuracy and reliability. One 

commenter stated that QCDRs need more time following the QCDR submission deadline of March 31 to 
CMS-1612-FC 665

publicly post quality measures data. Another commenter noted that this timeline is more aggressive than 

that proposed on Physician Compare. 

Response: We believe that the proposed April 30 deadline to make available quality measures 

data (except for PQRS and non-PQRS measures in their initial year of reporting under the PQRS) is 

reasonable, as we assume QCDRs would have already tested quality measures data and results for 

accuracy and reliability for the particular reporting period prior to submitting these quality measures data 

calculations and results by the March 31 submission deadline. However, we agree with the commenter on 

the need to provide accurate and reliable data prior to the data being publicly reported. Therefore, given 

concerns from commenters that April 30 does not provide the QCDRs with enough time to accurately post 

quality measures data, we are extending the deadline by which a QCDR must publicly report quality 

measures data outside of Physician Compare to the deadline by which Physician Compare posts QCDR 

quality measures data as discussed in section III.J above. That is, as indicated in Table 49 in section 

III.J.3 above, QCDRs wishing to publicly report quality measures data outside of Physician Compare 

must do so in 2016. 

Proposals Related to Collaboration of Entities to Become a QCDR: 

Based on our experience with the qualifying entities wishing to become QCDRs for reporting 

periods occurring in 2014, we received feedback from many organizations who expressed concern that 

the entity wishing to become a QCDR may not meet the requirements of a QCDR solely on its own. 

Therefore, we provided the following proposals beginning in 2015 on situations where an entity may not 

meet the requirements of a QCDR solely on its own but, in conjunction with another entity, may be able 

to meet the requirements of a QCDR and therefore be eligible for qualification: 

● We proposed to allow that an entity that uses an external organization for purposes of data 

collection, calculation or transmission may meet the definition of a QCDR so long as the entity has a 

signed, written agreement that specifically details the relationship and responsibilities of the entity with 

the external organizations effective as of January 1 the year prior to the year for which the entity seeks to 

become a QCDR (for example, January 1, 2014, to be eligible to participate for purposes of data collected 

in 2015). Entities that have a mere verbal, non-written agreement to work together to become a QCDR by 
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January 1 the year prior to the year for which the entity seeks to become a QCDR would not fulfill this 

proposed requirement. We solicited and received the following public comment on this proposal: 

Comment: A few commenters supported this proposal, as it allowed entities such as medical 

boards that may not have the technical capabilities to submit quality measures data calculations and 

results to CMS to collaborate with other entities. 

Response: We appreciate the commenters’ support. Based on the comments received, for the 

reasons stated here, and in the proposed rule, we are finalizing this proposal. 

● In addition, we proposed that an entity that has broken off from a larger organization may be 

considered to be in existence for the purposes of QCDR qualification as of the earliest date the larger 

organization begins continual existence. We received questions from entities who used to be part of a 

larger organization but have recently become independent from the larger organization as to whether the 

entities would meet the requirement established in the CY 2014 PFS final rule with comment period that 

the entity be in existence as of January 1 the year prior to the year for which the entity seeks to become a 

QCDR (78 FR 74467). For example, a registry that was previously a part of a larger medical society as of 

January 1, 2013, could have broken off from the medical society and become an independent registry in 

2014. Likewise, a member of a medical society could create a registry separate from the medical society. 

As such, there would be concern as to whether that entity would meet the requirement of being in 

existence prior to January 1, 2013, to be considered for qualification for reporting periods occurring in 

2014. In these examples, for purposes of meeting the requirement that the entity be in existence as of 

January 1 the year prior to the year for which the entity seeks to become a QCDR, we may consider this 

entity as being in existence as of the date the larger medical society was in existence. We solicited and 

received the following comments on this proposal: 

Comment: Commenters supported this proposal. 

Response: We appreciate the commenters’ support and, based on the comments received and for 

the reasons stated above, we are finalizing this proposal. 

Data Submission Deadline: 
CMS-1612-FC 667

 In the CY 2014 PFS final rule with comment period, in accordance with the submission deadline 

of quality measures data for qualified registries, we noted a deadline of the last Friday in February 

occurring after the end of the applicable reporting period to submit quality measures data to CMS (78 FR 

74471). In accordance with our proposal to extend this deadline for qualified registries, we proposed to 

extend the deadline for QCDRs to submit quality measures data calculations and results by March 31 

following the end of the applicable reporting period (that is, March 31, 2016, for reporting periods ending 

in 2015). 

We solicited and received the following public comments on this proposal: 

Comment: Commenters supported this proposal, as it would allow qualified registries an 

additional month to submit quality measures data and aligns with our proposal to extend the submission 

deadline for qualified registries. 

Response: We appreciate the commenters’ positive feedback. Based on the comments received 

and for the reasons stated in the proposed rule, we are finalizing our proposal to extend the deadline for 

QCDRs to submit quality measures data, including, but not limited to, calculations and results, to March 

31 following the end of the applicable reporting period (for example, March 31, 2016, for reporting 

periods ending in 2015). 

d. Changes to the GPRO Web Interface 

In the CY 2014 PFS final rule with comment period (78 FR 74456), we finalized our proposal to 

require “that group practices register to participate in the GPRO by September 30 of the year in which the 

reporting period occurs (that is September 30, 2014 for reporting periods occurring in 2014), as 

proposed.” However, we noted that, in order “to respond to the commenters concerns to provide timelier 

feedback on performance on CG CAHPS in the future, we anticipate proposing an earlier deadline for 

group practices to register to participate in the GPRO in future years” (78 FR 74456). Indeed, to provide 

timelier feedback on performance on CAHPS for PQRS, we proposed to modify the deadline that a group 

practice must register to participate in the GPRO to June 30 of the year in which the reporting period 

occurs (that is, June 30, 2015, for reporting periods occurring in 2015). Specifically, although we still 

seek to provide group practices with as much time as feasible to decide whether to register to participate 
CMS-1612-FC 668

in the PQRS as a GPRO, we weigh this priority with others, such as our desire to provide more timely 

feedback to participants of the PQRS, as well as other CMS quality reporting programs such as the VM. 

Therefore, in an effort to provide timelier feedback, we proposed to change the deadline by which a group 

practice must register to participate in the GPRO to June 30 of the applicable 12-month reporting period 

(that is, June 30, 2015, for reporting periods occurring in 2015). This proposed change would allow us to 

provide timelier feedback while still providing group practices with over 6 months to determine whether 

they should participate in the PQRS GPRO or, in the alternative, participate in the PQRS as individual 

eligible professionals. Although this proposed GPRO registration deadline would provide less time for a 

group practice to decide whether to participate in the GPRO, we believe the benefit of providing timelier 

feedback reports outweighs this concern. We solicited and received the following public comments on 

these proposals: 

Comment: Some commenters supported our proposal to shorten the deadline that a group 

practice must register to participate in the GPRO to June 30 of the year in which the reporting period 

occurs (that is, June 30, 2015, for reporting periods occurring in 2015) in order to provide timelier 

feedback reports. Other commenters opposed our proposal to shorten the deadline from September 30 to 

June 30, as the commenters believed that the extra time was needed to weigh the advantages and 

disadvantages of all the reporting options prior to registering for the GPRO and electing a reporting 

mechanism. One commenter noted that this is particularly important when reporting via EHR, as updates 

are required for EHR products. Some commenters requested that information for the various reporting 

mechanisms, such as the list of qualified registries for the reporting period, be made available earlier. 

Other commenters believed that it would be difficult for group practices to transition to an earlier 

registration date and requested that CMS delay finalizing this proposal to 2016. Other commenters stated 

that the proposed deadline would negatively affect group practices that change their Taxpayer 

Identification Number (TIN) after June 30, as the group practice would be required to report individually, 

adding to administrative and reporting burden. 

Response: With respect to the comments opposing this proposal, we believe that June 30 

provides group practices with ample time to decide to register to participate in the PQRS as a GPRO, as 
CMS-1612-FC 669

well as choose a reporting mechanism. With respect to the concern of having to choose a reporting option 

and not having all information on the PQRS reporting options prior to the June 30 deadline, we note that 

CMS makes numerous guidance documents available on the CMS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html, and 

group practices can submit any questions to the QualityNet Help Desk at Qnetsupport@hcqis.org. 

With respect to some commenters’ requests that information for the various reporting mechanisms, such 

as the list of qualified registries for the reporting period, be made available earlier, we note that the list of 

qualified registries for 2014 – available at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Downloads/2014QualifiedRegistries.pdf -- was made available in May 

2014, prior to June 30, 2014, and we anticipate making the list of qualified registries for the given 

reporting period available in advance of the proposed June 30 registration deadline. With respect to the 

commenters who stated that the proposed deadline would negatively affect group practices that change 

their Taxpayer Identification Numbers (TINs) after June 30, as the group practice would be required to 

report individually, adding to administrative and reporting burden, we understand this potential burden. 

We note that this proposed deadline is only 3 months earlier than the September 30 registration deadline 

we finalized in the CY 2014 PFS final rule (78 FR 74455). Therefore, we believe the issues associated 

with group practices that change their TINs would be exacerbated by finalizing the proposed June 30th

registration deadline or ameliorated by keeping the current September 30 registration deadline. To the 

extent that finalizing an earlier deadline would increase the number of group practices affected by these 

issues, we believe that our interest in providing feedback sooner outweighs the concern of those group 

practices that change their TINs after June 30 not being able to participate in the GPRO. Based on the 

reasons stated here and in the proposed rule, we are finalizing our proposal to modify the deadline that a 

group practice must register to participate in the GPRO to June 30 of the year in which the reporting 

period occurs (that is, June 30, 2015, for reporting periods occurring in 2015). Please note that this 

GPRO registration deadline refers to all group practices wishing to participate in the GPRO using any 

reporting mechanism available for reporting in the GPRO (that is, GPRO web interface, registry, EHR, 

and/or CMS-certified survey vendor). 
CMS-1612-FC 670

2. Criteria for the Satisfactory Reporting for Individual Eligible Professionals for the 2017 PQRS 

Payment Adjustment 

Section 1848(a)(8) of the Act, as added by section 3002(b) of the Affordable Care Act, provides 

that for covered professional services furnished by an eligible professional during 2015 or any subsequent 

year, if the eligible professional does not satisfactorily report data on quality measures for covered 

professional services for the quality reporting period for the year, the fee schedule amount for services 

furnished by such professional during the year (including the fee schedule amount for purposes of 

determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule 

amount that would otherwise apply to such services. For 2016 and subsequent years, the applicable 

percent is 98.0 percent. 

a. Criterion for the Satisfactory Reporting of Individual Quality Measures via Claims and Registry for 

Individual Eligible Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2014 PFS final rule with comment period (see Table 47 at 78 FR 74479), we finalized 

the following criteria for satisfactory reporting for the submission of individual quality measures via 

claims and registry for the 2014 PQRS incentive: For the 12-month reporting period for the 2014 PQRS 

incentive, the eligible professional would report at least 9 measures, covering at least 3 of the NQS 

domains, OR, if less than 9 measures apply to the eligible professional, report 1—8 measures, AND 

report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting 

period to which the measure applies. Measures with a 0 percent performance rate would not be counted. 

For an eligible professional who reports fewer than 9 measures covering less than 3 NQS domains via the 

claims- or registry-based reporting mechanism, the eligible professional would be subject to the measure 

application validity (MAV) process, which would allow us to determine whether the eligible professional 

should have reported quality data codes for additional measures. 

To be consistent with the satisfactory reporting criterion we finalized for the 2014 PQRS 

incentive, for the 2017 PQRS payment adjustment, we proposed to modify §414.90(j) and proposed the 

following criterion for individual eligible professionals reporting via claims and registry: For the 12-

month reporting period for the 2017 PQRS payment adjustment, the eligible professional would report at 
CMS-1612-FC 671

least 9 measures, covering at least 3 of the NQS domains AND report each measure for at least 50 percent 

of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Of the measures reported, if the eligible professional sees at least 1 Medicare patient in 

a face-to-face encounter, as we proposed to define that term below, the eligible professional would report 

on at least 2 measures contained in the proposed cross-cutting measure set specified in Table 52. If less 

than 9 measures apply to the eligible professional, the eligible professional would report up to 8 

measure(s), AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Measures with a 0 percent performance rate 

would not be counted (79 FR 40395). 

We noted that, unlike the criterion we finalized for the 2014 PQRS incentive, we proposed to 

require an eligible professional who sees at least 1 Medicare patient in a face-to-face encounter, as we 

defined that term below, during the 12-month 2017 PQRS payment adjustment reporting period to report 

at least 2 measures contained in the cross-cutting measure set specified in Table 52. As we noted in the 

CY 2014 PFS proposed rule (78 FR 43359), we are dedicated to collecting data that provides us with a 

better picture of the overall quality of care furnished by eligible professionals, particularly for the purpose 

of having PQRS reporting being used to assess quality performance under the VM. We believe that 

requiring an eligible professional to report on at least 2 broadly applicable, cross-cutting measures will 

provide us with quality data on more varied aspects of an eligible professional’s practice. We also noted 

that in its 2014 pre-rulemaking final report (available at 

http://www.qualityforum.org/Publications/2014/01/MAP_PreRulemaking_Report__2014_Recommendations_on_Measures_for_More_than_20_Federal_Programs.asp

x), the Measure Applications Partnership (MAP) encouraged the development of a core measure set (see 

page 16 of the “MAP Pre-Rulemaking Report: 2014 Recommendations on Measures for More than 20 

Federal Programs”). The MAP stated, “a core [measure set] would address critical improvement gaps, 

align payment incentives across clinician types, and reduce reporting burden.” 

For what defines a “face-to-face” encounter, for purposes of reporting of at least 2 cross-cutting 

measures specified in Table 52, we proposed to determine whether an eligible professional had a “face-to-
CMS-1612-FC 672

face” encounter by seeing whether the eligible professional billed for services under the PFS that are 

associated with face-to-face encounters, such as whether an eligible professional billed general office visit 

codes, outpatient visits, and surgical procedures. We would not include telehealth visits as face-to-face 

encounters for purposes of the required reporting of at least 2 cross-cutting measures specified in Table 52 

(79 FR 40395 and40396). 

In addition, we understand that there may be instances where an eligible professional may not 

have at least 9 measures applicable to an eligible professional’s practice. In this instance, like the 

criterion we finalized for the 2014 PQRS incentive (see Table 47 at 78 FR 74479), an eligible 

professional reporting on less than 9 measures would still be able to meet the satisfactory reporting 

criterion via claims and registry if the eligible professional reports on 1-8 measures, as applicable, to the 

eligible professional’s practice. If an eligible professional reports on 1-8 measures, the eligible 

professional would be subject to the MAV process, which would allow us to determine whether an 

eligible professional should have reported quality data codes for additional measures. In addition, the 

MAV will also allow us to determine whether a group practice should have reported on any of the crosscutting measures specified in Table 52. The MAV process we proposed (79 FR 40396) to implement for 

claims and registry is the same process that was established for reporting periods occurring in 2014 for 

the 2014 PQRS incentive. 

We solicited public comment on our satisfactory reporting criterion for individual eligible 

professionals reporting via claims or registry for the 2017 PQRS payment adjustment. The following is a 

summary of the comments we received regarding our proposal for satisfactory reporting criterion for 

individual eligible professionals reporting via claims or registry for the 2017 PQRS payment adjustment. 

Comment: A few commenters supported our intention to move towards eliminating the claimsbased reporting option, while the majority of the commenters opposed our proposals related to moving 

away from the claims-based reporting option. Some of these commenters noted that, for certain eligible 

professionals, the claims-based reporting mechanism remains the only option by which eligible 

professionals may report PQRS quality measures data, as many eligible professionals do not have the 

capabilities to report via EHR or registry. The commenters believe the claim-based reporting mechanism 
CMS-1612-FC 673

is a necessary option for eligible professionals with limited resources, such as solo practitioners. Should 

we intend to phase out this reporting mechanism, commenters urged a gradual phase out of the claimsbased reporting mechanism. 

Response: We appreciate the commenters' feedback. We understand the concerns associated 

with moving away from the claims-based reporting mechanism. For the 2017 PQRS payment adjustment, 

we are finalizing an option by which eligible professionals may meet the criteria for satisfactory reporting 

by using the claims-based reporting mechanism. Eligible professionals using the other reporting 

mechanisms have seen greater success at meeting the criteria for satisfactory reporting for the PQRS. 

However, while we continue to eliminate measures available for reporting via claims, we understand the 

importance of maintaining the claims-based reporting mechanism as an option at this time. We 

understand that the claims-based reporting mechanism remains the most popular reporting mechanism. 

However, to streamline the PQRS reporting options, as well as to encourage reporting options where 

eligible professionals are found to be more successful in reporting, it is our intention to eliminate the 

claims-based reporting mechanism in future rulemaking. During this time, we encourage eligible 

professionals to use alternative reporting methods to become familiar with reporting mechanisms other 

than the claims-based reporting mechanism. 

Comment: The majority of commenters opposed our proposal to require the reporting of 9 

measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. Some of 

these commenters noted that eligible professionals have been successful at meeting the criteria for 

satisfactory reporting for the PQRS incentives and payment adjustments in the past by reporting 3 

measures, and increasing the number of measures to be reported would make it more difficult for these 

eligible professionals to meet the criteria for satisfactory reporting for the 2017 PQRS payment 

adjustment. Other commenters also noted that certain eligible professionals do not have 9 measures 

covering 3 NQS domains to report. For these reasons, some commenters suggested a more gradual 

approach to requiring the reporting of at least 9 measures covering 3 NQS domains, such as requiring the 

reporting of 5 or 6 measures rather than 9 measures. A few commenters also recommended establishing a 
CMS-1612-FC 674

lower reporting threshold for those eligible professionals practicing in specialties for which few PQRS 

measures exist. 

Response: While we understand the commenters concerns related to requiring the reporting of 9 

measures covering up to 3 NQS domains, we believe we provided the public with adequate time to 

prepare for reporting criteria that requires the reporting of 9 measures. For example, we finalized criteria 

for the satisfactory reporting for the 2016 PQRS payment adjustment via claims and registry that only 

required the reporting of 3 measures covering 1 NQS domain (see Table 48 at 78 FR 74480). However, 

we also finalized criteria for the 2016 PQRS payment adjustment using the claims- and registry-based 

reporting mechanisms that aligned with the following criteria we finalized for the 2014 PQRS incentive: 

Report at least 9 measures covering at least 3 NQS domains, OR, if less than 9 measures covering at least 

3 NQS domains apply to the eligible professional, report 1-9 measures covering 1-3 NQS domains, AND 

report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting 

period to which the measures applies (see Table 48 at 78 FR 74480). Additionally, in the CY 2014 PFS 

final rule, we noted that "it is our intent to ramp up the criteria for satisfactory reporting for the 2017 

PQRS payment adjustment to be on par or more stringent than the criteria for satisfactory reporting for 

the 2014 PQRS incentive" (78 FR 74465). We believe that establishing criteria for the satisfactory 

reporting of the 2016 PQRS payment adjustment that are consistent with these proposed criteria, as well 

as signaling our intent to ramp up the satisfactory reporting criteria, provided enough advance notice to 

encourage eligible professionals to prepare to report 9 measures to meet the criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment. 

Furthermore, with respect to those commenters concerned that an eligible professional may not 

have 9 measures covering at least 3 NQS domains applicable to his/her practice, in the proposed rule we 

noted that in this instance, like the criterion we finalized for the 2014 PQRS incentive (see Table 47 at 78 

FR 74479), an eligible professional reporting on less than 9 measures would still be able to meet the 

satisfactory reporting criterion via claims and registry if the eligible professional reports on 1–8 measures, 

as applicable, to the eligible professional’s practice. If an eligible professional reports on 1–8 measures, 

the eligible professional would be subject to the MAV process, which would allow us to determine 
CMS-1612-FC 675

whether an eligible professional should have reported quality data codes for additional measures. In 

addition, the MAV process will also allow us to determine whether a group practice should have reported 

on any of the cross-cutting measures specified in Table 52. As such, under this proposed criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment, an eligible professional who does not have 

at least 9 measures covering at least 3 NQS domains applicable to his/her practice may still meet the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment provided that the eligible 

professional reports all measures as are applicable to his/her practice. 

Based on the comments received and for the reasons stated above and in the proposed rule, we are 

finalizing our proposal to require the reporting of 9 measures covering at least 3 NQS domains to meet the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 

In the case that an eligible professional may not have at least 9 measures applicable to an eligible 

professional’s practice, the eligible professional may still be able to meet the satisfactory reporting 

criterion via claims and/or registry for the 2017 PQRS payment adjustment if the eligible professional 

reports on 1–8 measures. The eligible professional would be required to report as many measures as are 

applicable to the eligible professional’s practice. If reporting less than 9 measures covering 3 NQS 

domains, the eligible professional would be subject to the MAV process, which would allow us to 

determine whether an eligible professional should have reported quality data codes for additional 

measures. 

Comment: Some commenters provided general support for the option to report cross-cutting 

measures, as it may help bring alignment with respect to a set of measures all eligible professionals may 

report. However, most of these commenters believed that the reporting of cross-cutting measures should 

be voluntary, not mandatory. The majority of commenters opposed our proposal to require an eligible 

professional who sees at least 1 Medicare patient in a face-to-face encounter during the 12-month 2017 

PQRS payment adjustment reporting period to report at least 2 measures contained in the proposed crosscutting measure set specified in Table 52 (78 FR 40395). Some of these commenters believed that the 

proposed requirement is unfair, as the requirement to report on at least 2 cross-cutting measures placed an 

additional burden on certain specialists, such as those that do not provide primary care services, and not 
CMS-1612-FC 676

on others. Other commenters emphasized that the cross-cutting measures did not apply to many specialty 

practices. Contrary to these commenters, some commenters expressed support for this proposal. Some of 

those who supported, this proposal, however, recommended a more phased-in approach to the reporting 

of cross-cutting measures. One of these commenters recommended that the proposal be amended to 

require only the reporting of 1 measure in the cross-cutting measure set. Some of these commenters were 

confused as to whether this proposal would increase the proposed number of measures to be reported to 

11 measures. 

Response: With respect to the commenters’ concerns that requiring reporting of at least 2 crosscutting measures for eligible professionals who see at least 1 Medicare patient in a face-to-face encounter, 

we understand that the cross-cutting measures we are finalizing in Table 52 are limited and should only 

apply to certain eligible professionals for which the measures apply. We believe we sufficiently exclude 

eligible professionals for which the cross-cutting measures do not apply by only proposing this 

requirement for eligible professionals who see at least 1 Medicare patient in a face-to-face encounter. We 

believe our interest in collecting data that are more varied to better capture the overall quality of care 

provided to patients as well as our desire to create a core set of measures for PQRS outweighs this 

concern. In the future, we will consider adding to this cross-cutting measures set so that more 

professionals that are eligible may be able to participate in the reporting of a core set of measures. With 

respect to the commenters who expressed concern that the proposed measures in the proposed crosscutting measures set did not apply to many specialties, we note that an eligible professional would not be 

required to report on the measures contained in the cross-cutting measures set if none of the measures 

applied to the eligible professional’s practice. With respect to taking a more phased-in approach to 

introducing the cross-cutting measure set, for the 2017 PQRS payment adjustment, we agree with these 

commenters and will therefore phase-in the requirement to report on cross-cutting measures by only 

requiring the reporting of 1 cross-cutting measure. We do note, however, that we believe that requiring 

the reporting of 2 measures in the cross-cutting measures set is not overly burdensome. Rather, we 

believe it helps eligible professionals narrow the choices of measures for which to report in the PQRS 

measure set. Regardless, we understand the commenters’ concerns regarding the need for a gradual phase 
CMS-1612-FC 677

in of the cross-cutting measure set. Therefore, based on the comments received and for the reasons stated 

above and in the proposed rule, we are modifying our proposal to require that an eligible professional who 

sees at least 1 Medicare patient in a face-to-face encounter during the 12-month 2017 PQRS payment 

adjustment reporting period report at least 1 measure contained in the cross-cutting measure set we are 

finalizing specified in Table 52. Please note that it is our intention to move towards requiring the 

reporting of more cross-cutting measures in the future. 

Please also note that this does not bring the total number of measures required to be reported 

under this criterion to 10 measures. Rather, if an eligible professional sees at least 1 Medicare patient in a 

face-to-face encounter during the 12-month PQRS payment adjustment reporting period, 1 of the 9 

measures the eligible professional reports must be measures contained in the cross-cutting measure set. 

Therefore, an eligible professional would report at least 1 cross-cutting measure and 8 additional PQRS 

measures covering 3 NQS domains. 

In the instance where an eligible professional may not have at least 9 measures applicable to 

his/her practice, the eligible professional would still be required to report at least 1 cross-cutting measure, 

if applicable. As we noted, we believe we sufficiently exclude eligible professionals for which the crosscutting measures do not apply by only proposing this requirement for eligible professionals who see at 

least 1 Medicare patient in a face-to-face encounter. 

Comment: One commenter believes that the threshold of seeing 1 Medicare patient in a face-toface encounter for the requirement to report on cross-cutting measures is too low. The commenter was 

concerned that this would further burden eligible professionals who rarely see Medicare patients. 

Response: We understand the commenter’s concern. However, as we believe in the importance 

of the cross-cutting measures set we are finalizing in Table 52, it is our desire to encourage reporting of 

the measures contained in the cross-cutting measures set when applicable. We proposed this threshold to 

exclude certain specialties that do not see Medicare patients. However, we expect those eligible 

professionals who see Medicare patients to report on the cross-cutting measures we specify in Table 52. 
CMS-1612-FC 678

Comment: One commenter sought clarification on the definition of a face-to-face encounter by 

specifying which codes apply to this definition and urged that procedural encounters not be included in 

the list of face-to-face encounters. 

Response: As we stated in the proposed rule, we will determine whether an eligible professional 

had a ‘‘face-to-face’’ encounter by seeing whether the eligible professional billed for services under the 

PFS that are associated with face-to-face encounters, such as whether an eligible professional billed 

general office visit codes, outpatient visits, and surgical procedures. We would not include telehealth 

visits as face-to-face encounters for purposes of the requirements to report at least 1 cross-cutting measure 

specified in Table 52 (79 FR 40395 through 40396). While we will not provide the specific codes for 

what we define as a “face-to-face” encounter here, we will provide the codes and any additional guidance 

on the PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

Comment: Some commenters opposed our proposal to require that, to meet the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment, an eligible professional reporting 

individual measures via claims or registry report each measure for at least 50 percent of the eligible 

professional’s Medicare Part B FFS patients seen during the reporting period to which the measure 

applies. The commenters noted that, particularly for those eligible professionals who see many patients, 

requiring the reporting of quality measures for more than 50 percent of the eligible professional’s 

Medicare Part B FFS patients is burdensome. 

Response: We understand this concern, particularly with those eligible professionals who see a 

large number of patients. However, it is important to collect sufficient quality measures data to ensure an 

adequate sample. We believe that the 50 percent threshold provides us with an adequate sample to 

properly determine the quality of care provided. We also believe that requiring that an eligible 

professional report on at least 50 percent of his/her Medicare Part B FFS patients helps to prevent 

potential selection bias that could skew the representation of quality of care; while the potential for 

selection bias still remains, we were mindful of concerns about provider burden during this period where 

eligible professionals are still becoming accustomed to PQRS reporting. Based on the comments received 
CMS-1612-FC 679

and for the reasons stated above and in the proposed rule, we are finalizing our proposal to require that, to 

meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment, an eligible 

professional reporting individual measures via claims or registry report each measure for at least 50 

percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. 

Comment: Some commenters generally supported the MAV process. However, some 

commenters expressed the need to clarify the MAV process for both claims and registry as well as to 

provide greater transparency in this process. 

Response: We understand the need to further clarify the MAV process for both claims and 

registry, as well as to provide transparency in this process. We believe the 2015 MAV process that we 

proposed for the 2017 PQRS payment adjustment is transparent, as it is very similar to the 2014 MAV 

process that we finalized for the 2014 PQRS incentive and 2016 PQRS payment adjustment, for which we 

have already provided detailed technical guidance. Specifically, we have made education and outreach 

documents, as well as the MAV measure clusters, (that is, sets of measures that determine when other 

measures could have been reported and therefore trigger use of the MAV process), available for the 2014 

MAV process at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/AnalysisAndPayment.html, and we will update these materials as necessary for the 

2015 MAV process. Please note that, as the MAV process evolves, we expect to be able to provide 

further guidance to aid eligible professionals in understanding the MAV process. We will post additional 

clarifying information, including a document explaining the MAV process for 2015, on the PQRS website 

at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html. 

We believe that posting this guidance as we have in years prior provides adequate transparency in this 

process. Moreover, should an eligible professional have further questions regarding the MAV process, he 

or she may contact our QualityNet Help Desk for more information. The contact information for the Help 

Desk can be found here: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/HelpDeskSupport.html. 
CMS-1612-FC 680

After reviewing the comments, we are finalizing our proposal to modify §414.90(j) and finalize 

the following criterion for individual eligible professionals reporting via claims and registry: 

For the 12-month reporting period for the 2017 PQRS payment adjustment, report at least 9 

measures, covering at least 3 of the NQS domains AND report each measure for at least 50 percent of the 

eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Of the measures reported, if the eligible professional sees at least 1 Medicare patient in 

a face-to-face encounter, the eligible professional will report on at least 1 measure contained in the 

proposed cross-cutting measure set specified in Table 52. If less than 9 measures apply to the eligible 

professional, the eligible professional would report up to 8 measure(s), AND report each measure for at 

least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Measures with a 0 percent performance rate would not be counted. 

We understand that there may be instances where an eligible professional may not have at least 9 

measures applicable to an eligible professional’s practice. In this instance, an eligible professional 

reporting on less than 9 measures would still be able to meet the satisfactory reporting criterion via claims 

and registry if the eligible professional reports on 1-8 measures, as applicable, to the eligible 

professional’s practice. If an eligible professional reports on 1-8 measures, the eligible professional 

would be subject to the MAV process, which would allow us to determine whether an eligible 

professional should have reported quality data codes for additional measures. In addition, the MAV 

process will also allow us to determine whether a group practice should have reported on any of the crosscutting measures specified in Table 52. The MAV process we will implement for claims and registry for 

the 2017 PQRS payment adjustment is the same process that was established for reporting periods 

occurring in 2014 for the 2014 PQRS incentive. For more information on the claims MAV process, 

please visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013.zip. For 

more information on the registry MAV process, please visit http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_12132013.zip. 
CMS-1612-FC 681

b. Criterion for Satisfactory Reporting of Individual Quality Measures via EHR for Individual Eligible 

Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2013 PFS final rule with comment period, we finalized the following criterion for the 

satisfactory reporting for individual eligible professionals reporting individual measures via a direct EHR 

product that is CEHRT or an EHR data submission vendor product that is CEHRT for the 2014 PQRS 

incentive: Report 9 measures covering at least 3 of the NQS domains. If an eligible professional's 

CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the eligible 

professional must report all of the measures for which there is Medicare patient data. An eligible 

professional must report on at least 1 measure for which there is Medicare patient data (see Table 47 at 78 

FR 74479). 

To be consistent with the criterion we finalized for the 2014 PQRS incentive, as well as to 

continue to align with the final criterion for meeting the clinical quality measure (CQM) component of 

achieving meaningful use under the Medicare EHR Incentive Program, we proposed to modify §414.90(j) 

and proposed the following criterion for the satisfactory reporting for individual eligible professionals to 

report individual measures via a direct EHR product that is CEHRT or an EHR data submission vendor 

product that is CEHRT for the 2017 PQRS payment adjustment: The eligible professional would report 9 

measures covering at least 3 of the NQS domains. If an eligible professional’s CEHRT does not contain 

patient data for at least 9 measures covering at least 3 domains, then the eligible professional would be 

required to report all of the measures for which there is Medicare patient data. An eligible professional 

would be required to report on at least 1 measure for which there is Medicare patient data. 

We solicited public comment on this proposal. 

The following is summary of the comments we received regarding our proposed criterion for the 

satisfactory reporting for individual eligible professionals to report individual measures via a direct EHR 

product that is CEHRT or an EHR data submission vendor product that is CEHRT for the 2017 PQRS 

payment adjustment. 

Comment: The majority of commenters opposed our proposal to require the reporting of 9 

measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 
CMS-1612-FC 682

Commenters also noted that certain eligible professionals do not have 9 measures covering 3 NQS 

domains to report. For these reasons, some commenters suggested a more gradual approach to requiring 

the reporting of at least 9 measures covering 3 NQS domains, such as requiring the reporting of 5 or 6 

measures rather than 9 measures. A few commenters also recommended establishing a lower reporting 

threshold for those eligible professionals practicing in specialties for which few PQRS measures exist. 

Response: We understand the commenters’ concerns. We note that we addressed these 

comments related to the reporting of 9 measures covering 3 domains as it relates to reporting via claims 

and registry above in section III.K.1.a., and that explanation also applies here with reporting via a direct 

EHR product that is CEHRT or EHR data submission vendor product that is CEHRT. Furthermore, we 

believe that aligning our EHR reporting options with the CQM component of meaningful use under the 

EHR Incentive Program actually reduces burden on eligible professionals when reporting. For the 

reasons explained above and to be consistent with the criterion we are finalizing for claims and registry as 

well as to be consistent with the requirements to meet the CQM component of meaningful use under the 

EHR Incentive Program, we are finalizing this proposal. 

After reviewing the comments, we are finalizing our proposal as proposed to modify §414.90(j) 

and to indicate the following criterion for the satisfactory reporting for individual eligible professionals to 

report individual measures via a direct EHR product that is CEHRT or an EHR data submission vendor 

product that is CEHRT for the 2017 PQRS payment adjustment: For the 12-month reporting period for 

the 2017 PQRS payment adjustment, report 9 measures covering at least 3 of the NQS domains. If an 

eligible professional’s CEHRT does not contain patient data for at least 9 measures covering at least 3 

domains, then the eligible professional would be required to report all of the measures for which there is 

Medicare patient data. An eligible professional would be required to report on at least 1 measure for 

which there is Medicare patient data. 

c. Criterion for Satisfactory Reporting of Measures Groups via Registry for Individual Eligible 

Professionals for the 2017 PQRS Payment Adjustment 

In the CY 2013 PFS final rule with comment period, we finalized the following criterion for the 

satisfactory reporting for individual eligible professionals to report measures groups via registry for the 
CMS-1612-FC 683

2014 PQRS incentive: For the 12-month reporting period for the 2014 PQRS incentive, report at least 1 

measures group AND report each measures group for at least 20 patients, the majority (11 patients) of 

which must be Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted (see Table 47 at 78 FR 74479). 

To be consistent with the criterion we finalized for the 2014 PQRS incentive, we proposed to 

modify §414.90(j) to indicate the following criterion for the satisfactory reporting for individual eligible 

professionals to report measures groups via registry for the 2017 PQRS payment adjustment: For the 12-

month reporting period for the 2017 PQRS payment adjustment, the eligible professional would report at 

least 1 measures group AND report each measures group for at least 20 patients, the majority (11 patients) 

of which would be required to be Medicare Part B FFS patients. Measures groups containing a measure 

with a 0 percent performance rate would not be counted. 

Although we proposed a satisfactory reporting criterion for individual eligible professionals to 

report measures groups via registry for the 2017 PQRS payment adjustment that is consistent with 

criterion finalized for the 2014 PQRS incentive, please note that in section III.K of this final rule with 

comment period, we are changing the definition of a PQRS measures group. 

We solicited but received no public comment on our proposed satisfactory reporting criterion for 

individual eligible professionals reporting measures groups via registry for the 2017 PQRS payment 

adjustment. Therefore, we are finalizing our proposal as proposed to modify §414.90(j) to indicate the 

following criterion for the satisfactory reporting for individual eligible professionals to report measures 

groups via registry for the 2017 PQRS payment adjustment: For the 12-month reporting period for the 

2017 PQRS payment adjustment, report at least 1 measures group AND report each measures group for at 

least 20 patients, the majority (11 patients) of which are required to be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance rate will not be counted. 

3. Satisfactory Participation in a QCDR by Individual Eligible Professionals 

Section 601(b) of the ATRA amended section 1848(m)(3) of the Act, by redesignating 

subparagraph (D) as subparagraph (F) and adding new subparagraphs (D) and (E), to provide for a new 
CMS-1612-FC 684

standard for individual eligible professionals to satisfy the PQRS beginning in 2014, based on satisfactory 

participation in a QCDR. 

a. Criterion for the Satisfactory Participation for Individual Eligible Professionals in a QCDR for the 

2017 PQRS Payment Adjustment 

Section 1848(a)(8) of the Act provides that for covered professional services furnished by an 

eligible professional during 2015 or any subsequent year, if the eligible professional does not 

satisfactorily report data on quality measures for covered professional services for the quality reporting 

period for the year, the fee schedule amount for services furnished by such professional during the year 

shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such 

services. For 2016 and subsequent years, the applicable percent is 98.0 percent. 

Section 1848(m)(3)(D) of the Act, as added by section 601(b) of the ATRA, authorizes the 

Secretary to treat an individual eligible professional as satisfactorily submitting data on quality measures 

under section 1848(m)(3)(A) of the Act if, in lieu of reporting measures under section 1848(k)(2)(C) of 

the Act, the eligible professional is satisfactorily participating in a QCDR for the year. “Satisfactory 

participation” is a new standard under the PQRS and is a substitute for the underlying standard of 

“satisfactory reporting” data on covered professional services that eligible professionals must meet to 

avoid the PQRS payment adjustment. Currently, §414.90(e)(2) states that individual eligible 

professionals must be treated as satisfactorily reporting data on quality measures if the individual eligible 

professional satisfactorily participates in a QCDR. 

In the CY 2014 PFS final rule with comment period, although we finalized satisfactory 

participation criteria for the 2016 PQRS payment adjustment that are less stringent than the satisfactory 

participation criteria we finalized for the 2014 PQRS incentive, we noted that it was “our intention to 

fully move towards the reporting of 9 measures covering at least 3 domains to meet the criteria for 

satisfactory participation for the 2017 PQRS payment adjustment” (78 FR 74477). Specifically, we 

finalized the following two criteria for the satisfactory participation in a QCDR for the 2014 PQRS 

incentive at §414.90(i)(3): For the 12-month 2014 reporting period, report at least 9 measures available 

for reporting under the QCDR covering at least 3 of the NQS domains, and report each measure for at 
CMS-1612-FC 685

least 50 percent of the eligible professional’s applicable patients. Of the measures reported via a QCDR, 

the eligible professional must report on at least 1 outcome measure. 

To be consistent with the number of measures reported for the satisfactory participation criterion 

we finalized for the 2014 PQRS incentive, for purposes of the 2017 PQRS payment adjustment (which 

would be based on data reported during the 12-month period that falls in CY 2015), we proposed to 

modify §414.90(k) to add the following criteria for individual eligible professionals to satisfactorily 

participate in a QCDR for the 2017 PQRS payment adjustment: For the 12-month reporting period for 

the 2017 PQRS payment adjustment, the eligible professional would report at least 9 measures available 

for reporting under a QCDR covering at least 3 of the NQS domains, AND report each measure for at 

least 50 percent of the eligible professional’s patients. Of these measures, the eligible professional would 

report on at least 3 outcome measures, OR, if 3 outcomes measures are not available, report on at least 2 

outcome measures and at least 1 of the following types of measures – resource use, patient experience of 

care, or efficiency/appropriate use. 

Unlike the satisfactory participation criteria that were established for the 2014 PQRS incentive, 

we proposed to modify §414.90(k)(4) to require that an eligible professional report on not only 1 but at 

least 3 outcome measures (or, 2 outcome measures and at least 1 resource use, patient experience of care, 

or efficiency/appropriate use if 3 outcomes measures are not available). We proposed this increase 

because it is our goal to, when appropriate, move towards the reporting of more outcome measures. We 

believe the reporting of outcome measures (for example, unplanned hospital readmission after a 

procedure) better captures the quality of care an eligible professional provides than, for example, process 

measures (for example, whether a Hemoglobin A1c test was performed for diabetic patients). In 

establishing this proposal, we understood that a QCDR may not have 3 outcomes measures within its 

quality measure data set. Therefore, as an alternative to a third outcome measure, we proposed to allow 

an eligible professional to report on at least 1 resource use, patient experience of care, or 

efficiency/appropriate use measure in lieu of an outcome measure. 

We solicited public comment on these proposals. The following is summary of the comments we 

received regarding on these proposals. 
CMS-1612-FC 686

Comment: Commenters generally urged more flexibility in allowing QCDRs to determine 

reporting criteria under this option. 

Response: While we agree that QCDRs should generally be given some flexibility when 

participating in the PQRS, we do not agree that QCDRs be given flexibility in determining reporting 

criteria. We believe it is necessary to have consistent reporting criteria, so that quality measures data on 

eligible professionals may be more easily compared for purposes of other programs that use PQRS quality 

data to rate and compare eligible professionals, such as the VM. 

Comment: The majority of commenters opposed our proposal to require the reporting of 9 

measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 

Commenters also noted that certain eligible professionals do not have 9 measures covering 3 NQS 

domains to report. For these reasons, some commenters suggested a more gradual approach to requiring 

the reporting of at least 9 measures covering 3 NQS domains, such as requiring the reporting of 5 or 6 

measures rather than 9 measures. 

Response: While we understand the commenters’ concerns related to requiring the reporting of 9 

measures covering up to 3 NQS domains, we believe we provided the public with adequate time to 

prepare to reporting criteria that requires the reporting of 9 measures. For example, we finalized criteria 

for satisfactory participation for the 2016 PQRS payment adjustment via a QCDR that aligned with the 

criteria we finalized for the 2014 PQRS incentive: For the 12-month 2016 PQRS payment adjustment 

reporting period, report at least 9 measures covering at least 3 NQS domains AND report each measure 

for at least 50 percent of the applicable patients seen during the reporting period to which the measure 

applies. Measures with a 0 percent performance rate would not be counted. Of the measures reported via 

a QCDR, the eligible professional must report on at least 1 outcome measure (78 FR 74478). 

Additionally, in the CY 2014 PFS final rule, we noted that "it is our intent to ramp up the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment to be on par or more stringent than the 

criteria for satisfactory reporting for the 2014 PQRS incentive" (78 FR 74465). We believe that 

establishing criteria for the satisfactory reporting of the 2017 PQRS payment adjustment that are 

consistent with these proposed criteria as well as signaling our intent to ramp up the satisfactory reporting 
CMS-1612-FC 687

criteria provided enough advance notice to encourage eligible professionals to prepare to report 9 

measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. Based on 

the comments received and for the reasons stated, we are finalizing our proposal for QCDRs to require the 

reporting of 9 measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment 

adjustment. 

Comment: Some commenters opposed our proposal to require that, to meet the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment, an eligible professional reporting 

individual measures via a QCDR report each measure for at least 50 percent of the eligible professional’s 

patients seen during the reporting period to which the measure applies. The commenters noted that, 

particularly for those eligible professionals who see many patients, requiring the reporting of quality 

measures for more than 50 percent of the eligible professional’s patients is an enormous burden. 

Response: We understand this concern, particularly with respect to those eligible professionals 

who see a large number of patients. However, it is important to collect sufficient quality measures data to 

ensure an adequate sample. We also believe that requiring that an eligible professional report on at least 

50 percent of his/her Medicare Part B FFS patients helps to prevent potential selection bias that could 

skew the representation of quality of care; while the potential for selection bias still remains, we were 

mindful of concerns about provider burden during this period where eligible professionals are still 

becoming accustomed to PQRS reporting. Based on the comments received and for the reasons stated 

above and in the proposed rule, we are finalizing our proposal to require that, to meet the criteria for 

satisfactory participation for the 2017 PQRS payment adjustment, an eligible professional reporting 

individual measures via a QCDR report each measure for at least 50 percent of the eligible professional’s 

patients seen during the reporting period to which the measure applies. Please note that, unlike the claims 

and registry-based reporting mechanisms, if using a QCDR, an eligible professional must report on ALL 

(Medicare and non-Medicare) patients. 

Comment: The majority of commenters opposed our proposal to report on at least 3 outcome 

measures, as many of these commenters believed QCDRs might not have 3 outcome measures available 
CMS-1612-FC 688

to report. The commenters urged a more gradual approach to the reporting of outcome measures via a 

QCDR. 

Response: We understand the commenters’ concerns. To accommodate these concerns, we are 

modifying this proposal to require only reporting of 2 outcome measures or, if 2 outcome measures are 

not available, report on 1 outcome measure and 1 of the following types of measures – resource use, 

patient experience of care, efficiency/appropriate use or patient safety. We believe this compromise still 

raises the bar on the types of measures eligible professionals must report, but allows QCDRs that may 

only have 1 outcome measure available to still qualify and participate in the PQRS. We note, however, 

our intention to increase the number of outcome measures that must be reported in the future. 

In addition, we note that we are adding another category – patient safety – of measures that an 

eligible professional may report in lieu of an outcome measure. While we did not include this category 

before, we believe the addition of the patient safety category is appropriate, as we believe that it is equally 

important to measure patient safety, as it is to measure resource use, patient experience of care, or 

appropriate use. Furthermore, we believe the addition of another category of measures that may be 

reported in lieu of an outcome measure benefits eligible professionals and QCDRs and is responsive to 

some of the commenters’ concerns regarding having enough measures to report, as it provides more 

options in terms of the measures an eligible professional may report in lieu of an outcome measure. We 

define the term “patient safety” as it applies to QCDRs in the QCDR measure section in III.K.6 below. 

As a result of the comments, we are revising our proposal to modify §414.90(k) to indicate the 

following criterion for satisfactory participation in a QCDR for the 2017 PQRS payment adjustment: For 

the 12-month reporting period for the 2017 PQRS payment adjustment, report at least 9 measures 

available for reporting under a QCDR covering at least 3 of the NQS domains, AND report each measure 

for at least 50 percent of the eligible professional’s patients. Of these measures, the eligible professional 

would report on at least 2 outcome measures, OR, if 2 outcomes measures are not available, report on at 

least 1 outcome measures and at least 1 of the following types of measures – resource use, patient 

experience of care, efficiency/appropriate use, or patient safety. 
CMS-1612-FC 689

4. Criteria for Satisfactory Reporting for Group Practices Selected to Participate in the Group Practice 

Reporting Option (GPRO) 

In lieu of reporting measures under section 1848(k)(2)(C) of the Act, section 1848(m)(3)(C) of 

the Act provides the Secretary with the authority to establish and have in place a process under which 

eligible professionals in a group practice (as defined by the Secretary) shall be treated as satisfactorily 

submitting data on quality measures. Accordingly, this section III.K.4 contains our satisfactory reporting 

criteria for group practices selected to participate in the GPRO. Please note that, for a group practice to 

participate in the PQRS GPRO in lieu of participating as individual eligible professionals, a group 

practice is required to register to participate in the PQRS GPRO. For more information on GPRO 

participation, please visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Group_Practice_Reporting_Option.html. For more information on registration, please 

visit http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/SelfNomination-Registration.html. 

a. Criteria for Satisfactory Reporting on PQRS Quality Measures Via the GPRO Web Interface for the 

2017 PQRS Payment Adjustment 

Consistent with the group practice reporting requirements under section 1848(m)(3)(C) of the 

Act, we proposed to modify §414.90(j) to incorporate the following criterion for the satisfactory reporting 

of PQRS quality measures for group practices registered to participate in the GPRO for the 12-month 

reporting period for the 2017 PQRS payment adjustment using the GPRO web interface for groups 

practices of 25–99 eligible professionals: The group practice would report on all measures included in the 

web interface; AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries 

in the order in which they appear in the group’s sample for each module or preventive care measure. If 

the pool of eligible assigned beneficiaries is less than 248, then the group practice would report on 100 

percent of assigned beneficiaries. In other words, we understand that, in some instances, the sampling 

methodology CMS provides will not be able to assign at least 248 patients on which a group practice may 

report, particularly those group practices on the smaller end of the range of 25–99 eligible professionals. 

If the group practice is assigned less than 248 Medicare beneficiaries, then the group practice would 
CMS-1612-FC 690

report on 100 percent of its assigned beneficiaries. A group practice would be required to report on at 

least 1 measure for which there is Medicare patient data. 

In addition, we proposed to modify §414.90(j) to incorporate the following criteria for the 

satisfactory reporting of PQRS quality measures for group practices that registered to participate in the 

GPRO for the 12-month reporting period for the 2017 PQRS payment adjustment using the GPRO web 

interface for groups practices of 100 or more eligible professionals: The group practice would report all 

CAHPS for PQRS survey measures via a certified survey vendor. In addition, the group practice would 

report on all measures included in the GPRO web interface; AND populate data fields for the first 248 

consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample 

for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, 

then the group practice would report on 100 percent of assigned beneficiaries. A group practice would be 

required to report on at least 1 measure for which there is Medicare patient data. 

To maintain consistency in this reporting criteria, we note that this criteria is similar to the 

criterion we finalized for the satisfactory reporting of PQRS quality measures for group practices selected 

to participate in the GPRO for the 12-month reporting periods for the 2013 and 2014 PQRS incentives for 

group practices of 100 or more eligible professionals in the CY 2013 PFS final rule with comment period 

(see Table 49 at 78 FR 74486). However, we proposed to reduce the patient sample size on which a 

group practice is required to report quality measures data from 411 to 248. We examined the sample size 

of this reporting criterion and determined that the sample size we proposed reduces provider reporting 

burden while still allowing for statistically valid and reliable performance results. For the 25-99 sized 

groups reporting via the web interface, we recognized the proposal to move from reporting 218 to 248 

patients per sample represents a slight increase in reporting. However, based on experience with the 218 

count and subsequent statistical analysis, we believe that there are increased performance reliabilities and 

validities gained when changing the minimum reporting requirement to 248. We believe statistical 

reliability and validity is extremely important when measuring provider performance, particularly given 

the implications of the Physician VM and Physician Compare public reporting, discussed in section III.N 
CMS-1612-FC 691

and section III.J respectively. Therefore, we believe this criterion improves on the criterion previously 

finalized. 

For assignment of patients for group practices reporting via the GPRO web interface, in previous 

years, we have aligned with the Medicare Shared Savings Program methodology of beneficiary 

assignment (see 77 FR 69195). We note that, in section III.N. of the CY 2015 PFS proposed rule, we 

proposed to use a beneficiary attribution methodology for the VM for the claims-based quality measures 

and cost measures that is slightly different from the Medicare Shared Savings Program methodology, 

namely (1) eliminating the primary care service pre-step that is statutorily required for the Shared Savings 

Program and (2) including NPs, PA, and CNSs in step 1 rather than in step 2 of the attribution process. 

We believe that aligning with the VM’s proposed method of attribution is appropriate, as the VM is 

directly tied to participation in the PQRS. Therefore, to achieve further alignment with the VM and for 

the reasons proposed in section III.N., we proposed to adopt the attribution methodology changes 

proposed for the VM into the GPRO web interface beneficiary assignment methodology. We invited 

public comment on these proposals. The following is summary of the comments we received regarding 

on these proposals. 

Comment: A majority of the commenters supported our proposal for a group practice of 25 or 

more eligible professionals using the GPRO web interface to report on a patient sample of 248. With 

respect to having group practices of 100 or more eligible professionals report on a patient sample of 248 

in lieu of 411 (the required patient sample for group practices of 100 or more eligible professionals for the 

2014 PQRS incentive), the commenters agreed that this would reduce the reporting burden while still 

ensuring statistically valid and reliable performance results. 

Response: We appreciate the commenters’ feedback. Based on the positive comments received 

and for the reasons stated in the proposed rule, we are finalizing this proposal. Therefore, to meet the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment for a group practice of 25 or 

more eligible professionals using the GPRO web interface, a group practice would be required to report 

on at least 248 patients. 
CMS-1612-FC 692

As a result of the comments, we are finalizing the following criteria for satisfactory reporting for 

the 2017 PQRS payment adjustment for group practices comprised of 25 to 99 eligible professionals 

using the GPRO web interface: report on all measures included in the web interface; AND populate data 

fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which they appear 

in the group’s sample for each module or preventive care measure. If the pool of eligible assigned 

beneficiaries is less than 248, then the group practice must report on 100 percent of assigned 

beneficiaries. In other words, we understand that, in some instances, the sampling methodology we 

provide will not be able to assign at least 248 patients on which a group practice may report, particularly 

those group practices on the smaller end of the range of 25–99 eligible professionals. If the group 

practice is assigned less than 248 Medicare beneficiaries, then the group practice must report on 100 

percent of its assigned beneficiaries. A group practice must report on at least 1 measure for which there is 

Medicare patient data. 

In addition, we note that, in the past, we have not provided guidance on those group practices that 

choose the GPRO web interface to report PQRS quality measures but have seen no Medicare patients for 

which the GPRO measures are applicable, or if they have no (that is, 0 percent) responses for a particular 

module or measure. Since we are moving solely towards the implementation of PQRS payment 

adjustments, we sought to clarify this scenario here. If a group practice has no Medicare patients for 

which any of the GPRO measures are applicable, the group practice will not meet the criteria for 

satisfactory reporting using the GPRO web interface. Therefore, to meet the criteria for satisfactory 

reporting using the GPRO web interface, a group practice must be assigned and have sampled at least 1 

Medicare patient for any of the applicable GPRO web interface measures (specified in Table 52). If a 

group practice does not typically see Medicare patients for which the GPRO web interface measures are 

applicable, we advise the group practice to participate in the PQRS via another reporting mechanism. 

Please note that the discussion in this section III.K.4.a is limited to the criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment for group practices comprised of 25-99 eligible 

professionals who register to participate in the GPRO and who have at least 1 Medicare patient for which 

any of the GPRO measures are applicable. As we discuss in greater detail in section III.K.4 below, since 
CMS-1612-FC 693

we are requiring that group practices report on CAHPS for PQRS, the final criteria for group practices 

comprised of 100 or more eligible professionals are addressed in section III.K.4.c . 

b. Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group Practices 

Registered To Participate in the GPRO via Registry and EHR for the 2017 PQRS Payment Adjustment 

For registry reporting in the GPRO, in the CY 2014 PFS final rule with comment period (see 

Table 49 at 78 FR 74486), we finalized the following satisfactory reporting criteria for the submission of 

individual quality measures via registry for group practices comprised of 2 or more eligible professionals 

in the GPRO for the 2014 PQRS incentive: Report at least 9 measures, covering at least 3 of the NQS 

domains, OR, if less than 9 measures covering at least 3 NQS domains apply to the group practice, report 

1—8 measures covering 1-3 NQS domains for which there is Medicare patient data, AND report each 

measure for at least 50 percent of the group practice’s Medicare Part B FFS patients seen during the 

reporting period to which the measure applies. Measures with a 0 percent performance rate would not be 

counted. In the CY 2014 PFS final rule with comment period, we signaled that it was “our intent to ramp 

up the criteria for satisfactory reporting for the 2017 PQRS payment adjustment to be on par or more 

stringent than the criteria for satisfactory reporting for the 2014 PQRS incentive” (78 FR 74465). 

Consistent with the criterion finalized for the 2014 PQRS incentive and the group practice 

reporting requirements under section 1848(m)(3)(C) of the Act, for those group practices that choose to 

report using a qualified registry, we modified §414.90(j) to include the following satisfactory reporting 

criterion via qualified registry for ALL group practices who select to participate in the GPRO for the 2017 

PQRS payment adjustment: The group practice would report at least 9 measures, covering at least 3 of 

the NQS domains. Of these measures, if a group practice sees at least 1 Medicare patient in a face-to-face 

encounter, the group practice would report on at least 2 measures in the cross-cutting measure set 

specified in Table 52. If less than 9 measures covering at least 3 NQS domains apply to the eligible 

professional, the group practice would report up to 8 measures covering 1-3 NQS domains for which 

there is Medicare patient data, AND report each measure for at least 50 percent of the eligible 

professional’s Medicare Part B FFS patients seen during the reporting period to which the measure 

applies. Measures with a 0 percent performance rate would not be counted. 
CMS-1612-FC 694

As with individual reporting, we understand that there may be instances where a group practice 

may not have at least 9 measures applicable to a group practice’s practice. In this instance, like the 

criterion we finalized for the 2014 PQRS incentive (see Table 49 at 78 FR 74486), a group practice 

reporting on less than 9 measures would still be able to meet the satisfactory reporting criterion via 

registry if the group practice reports on as many measures as are applicable to the group practice’s 

practice. If a group practice reports on less than 9 measures, the group practice would be subject to the 

MAV process, which would allow us to determine whether a group practice should have reported quality 

data codes for additional measures and/or measures covering additional NQS domains. Please note that 

this MAV process does not apply to the application of the cross-cutting measure reporting requirement, as 

we require that all group practices report on at least 1 cross-cutting measure if an eligible professional in 

the group practice see at least sees at least 1 Medicare patient in a face-to-face encounter. The MAV 

process we proposed to implement for registry reporting is the same process that was established for 

reporting periods occurring in 2014 for the 2014 PQRS incentive. For more information on the registry 

MAV process, please visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_12132013.zip. 

For EHR reporting, consistent with the criterion finalized for the 2014 PQRS incentive that aligns 

with the criteria established for meeting the CQM component of meaningful use under the Medicare EHR 

Incentive Program and in accordance with the group practice reporting requirements under section 

1848(m)(3)(C) of the Act, for those group practices that choose to report using an EHR, we proposed to 

modify §414.90(j) to indicate the following satisfactory reporting criterion via a direct EHR product that 

is CEHRT or an EHR data submission vendor that is CEHRT for ALL group practices who select to 

participate in the GPRO for the 2017 PQRS payment adjustment: For the 12-month reporting period for 

the 2017 PQRS payment adjustment, the group practice would report 9 measures covering at least 3 

domains. If the group practice’s CEHRT does not contain patient data for at least 9 measures covering at 

least 3 domains, then the group practice must report the measures for which there is patient data. A group 

practice must report on at least 1 measure for which there is Medicare patient data. We invited public 
CMS-1612-FC 695

comment on these proposals. The following is summary of the comments we received regarding on these 

proposals. 

Comment: The majority of commenters opposed our proposal to require the reporting of 9 

measures to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. Some 

commenters supported the reporting of 9 measures when using the EHR reporting mechanisms, indicating 

that the proposed criterion aligns with the criterion for meeting the eCQM component of meaningful use 

under the EHR Incentive Program. Some of the commenters opposing this proposal noted that group 

practices have been successful at meeting the criteria for satisfactory reporting for the PQRS incentives 

and payment adjustments in the past by reporting 3 measures, and increasing the number of measures to 

be reported would make it more difficult for these group practices to meet the criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment. Other commenters also noted that certain group 

practices do not have 9 measures covering 3 NQS domains to report. For these reasons, some 

commenters suggested a more gradual approach to requiring the reporting of at least 9 measures covering 

3 NQS domains, such as requiring the reporting of 5 or 6 measures rather than 9 measures. A few 

commenters also recommended establishing a lower reporting threshold for those group practices 

practicing in specialties for which few PQRS measures exist. 

Response: While we understand the commenters concerns related to requiring the reporting of 9 

measures covering up to 3 NQS domains, we believe we provided the public with adequate time to 

prepare to reporting criteria that requires the reporting of 9 measures. For example, we finalized criteria 

for the satisfactory reporting for the 2016 PQRS payment adjustment via registry that only required the 

reporting of 3 measures covering 1 NQS domain (see Table 50 at 78 FR 74486). However, we also 

finalized criteria for the 2016 PQRS payment adjustment using the registry- and EHR-based reporting 

mechanisms that aligned with the criteria we finalized for the 2014 PQRS incentive that generally 

required reporting of at least 9 measures covering at least 3 NQS domains. Additionally, in the CY 2014 

PFS final rule, we noted that "it is our intent to ramp up the criteria for satisfactory reporting for the 2017 

PQRS payment adjustment to be on par or more stringent than the criteria for satisfactory reporting for 

the 2014 PQRS incentive" (78 FR 74465). We believe that establishing criteria for the satisfactory 
CMS-1612-FC 696

reporting of the 2016 PQRS payment adjustment that are consistent with this proposed criteria, as well as 

signaling our intent to ramp up the satisfactory reporting criteria, provided enough advanced notice to 

encourage eligible professionals to prepare to report 9 measures to meet the criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment. 

Furthermore, with respect to those commenters concerned that a group practice may not have 9 

measures covering at least 3 NQS domains applicable to his or her practice, in the proposed rule, with 

respect to reporting via registry, we noted that “as with individual reporting, we understand that there may 

be instances where a group practice may not have at least 9 measures applicable to a group practice’s 

practice. In this instance, like the criterion we finalized for the 2014 PQRS incentive (see Table 49 at 78 

FR 74486), a group practice reporting on less than 9 measures would still be able to meet the satisfactory 

reporting criterion via registry if the group practice reports on as many measures as are applicable to the 

group practice’s practice” (79 FR 40399). Under this proposed criterion for satisfactory reporting for the 

2017 PQRS payment adjustment for group practices reporting via registry, a group practice who does not 

have at least 9 measures covering at least 3 NQS domains applicable to the practice may still meet the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment provided that the group practice 

reports all measures as are applicable to his or her practice. 

With respect to reporting via an EHR, we noted that if the group practice’s CEHRT does not 

contain patient data for at least 9 measures covering at least 3 domains, then the group practice must 

report the measures for which there is patient data. A group practice must report on at least 1 measure for 

which there is Medicare patient data. 

Based on the comments received and for the reasons stated above and in the proposed rule, we are 

finalizing our proposal to require the reporting of 9 measures covering at least 3 NQS domains via 

registry and EHR to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 

Comment: Commenters provided the same comments for requiring the reporting of cross-cutting 

measures for group practice reporting as individual reporting in section III.K.2.a. Some commenters 

provided general support for the option to report cross-cutting measures via registry, as it may help bring 

alignment with respect to a set of measures all group practices may report. However, most of these 
CMS-1612-FC 697

commenters believed that the reporting of cross-cutting measures should be voluntary, not mandatory. 

The majority of commenters opposed our proposal to require a group practice that sees at least 1 

Medicare patient in a face-to-face encounter during the 12-month 2017 PQRS payment adjustment 

reporting period to report at least 2 measures contained in the proposed cross-cutting measure set 

specified in Table 21 of the CY 2015 PFS proposed rule (79 FR 40395). Some of these commenters 

believed the proposed requirement to be unfair, as the requirement to report on at least 2 cross-cutting 

measures placed an additional burden on certain specialists and not others. Other commenters 

emphasized that the cross-cutting measures did not apply to many specialty practices. Contrary to these 

commenters, some commenters expressed support for this proposal. Some of those who supported, this 

proposal, however, recommended a more phased-in approach to the reporting of cross-cutting measures. 

One of these commenters recommended that the proposal be amended to require only the reporting of 1 

measure in the cross-cutting measure set. Some of these commenters were confused as to whether this 

proposal would increase the proposed number of measures to be reported to 11 measures. 

Response: Please note that our responses to these comments are the same responses we provided 

previously regarding our proposal to require the reporting of cross-cutting measures for individual 

reporting. Therefore, based on the comments received and for the reasons stated previously and in the 

proposed rule, we are modifying our proposal to require that a group practice who sees at least 1 

Medicare patient in a face-to-face encounter during the 12-month 2017 PQRS payment adjustment 

reporting period report at least 1 measure contained in the cross-cutting measure set we are finalizing 

specified in Table 52. 

Please note that this does not bring the total number of measures required to be reported under 

this criterion to 10 measures. Rather, if a group practice sees at least 1 Medicare patient in a face-to-face 

encounter during the 12-month PQRS payment adjustment reporting period, 1 of the 9 measures the 

group practice reports must be measures contained in the cross-cutting measure set. Therefore, a group 

practice would report at least 1 cross-cutting measure and 8 additional PQRS measures. 

In the instance where a group practice may not have at least 9 measures applicable to his/her 

practice, the eligible professional would still be required to report at least 1 cross-cutting measure, if 
CMS-1612-FC 698

applicable. If a group practice reporting on less than 9 measures does not have at least 1 cross-cutting 

measure applicable to his or her practice, then the group practice would report on as many measures as 

our applicable to his or her practice. 

Comment: One commenter believes that the threshold of seeing 1 Medicare patient in a face-toface encounter for the requirement to report on cross-cutting measures is too low. The commenter was 

concerned that this would further burden group practices who rarely see Medicare patients. 

Response: We understand the commenter’s concern. However, as we believe in the importance 

of the cross-cutting measures set we are finalizing in Table 52, it is our desire to encourage reporting of 

the measures contained in the cross-cutting measures set when applicable. We proposed this threshold to 

exclude certain specialties that do not see Medicare patients. However, we expect those group practices 

that see Medicare patients to report on the cross-cutting measures we specify in Table 52. 

Comment: One commenter sought clarification on the definition of a face-to-face encounter by 

specifying which codes apply to this definition and urged that procedural encounters not be included in 

the list of face-to-face encounters. 

Response: As we stated in the proposed rule, we will determine whether an eligible professional 

in a group practice had a ‘‘face-to-face’’ encounter by seeing whether the eligible professional billed for 

services under the PFS that are associated with face-to-face encounters, such as whether an eligible 

professional billed general office visit codes, outpatient visits, and surgical procedures. We would not 

include telehealth visits as face-to-face encounters for purposes of the proposals requiring reporting of at 

least 2 cross-cutting measures specified in Table 52. While we will not provide the specific codes for 

what we definite as a “face-to-face” encounter here, we will provide additional guidance on the PQRS 

website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

Comment: Some commenters opposed our proposal to require that, to meet the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment, a group practice reporting individual 

measures via registry report each measure for at least 50 percent of the group practice’s Medicare Part B 

FFS patients seen during the reporting period to which the measure applies. The commenters noted that, 
CMS-1612-FC 699

particularly for those group practices that see many patients, requiring the reporting of quality measures 

for more than 50 percent of the group practice’s Medicare Part B FFS patients is an enormous burden. 

Response: We understand this concern, particularly with those group practices that see a large 

number of patients. However, it is important to collect sufficient quality measures data to ensure an 

adequate sample. We also believe that requiring that a group practice report on at least 50 percent of its 

Medicare Part B FFS patients helps to prevent potential selection bias that could skew the representation 

of quality of care; while the potential for selection bias still remains, we were mindful of concerns about 

provider burden during this period where group practices are still becoming accustomed to PQRS 

reporting. Based on the comments received and for the reasons stated above and in the proposed rule, we 

are finalizing our proposal to require that, to meet the criteria for satisfactory reporting for the 2017 PQRS 

payment adjustment, a group practice reporting individual measures via registry report each measure for 

at least 50 percent of the group practice’s Medicare Part B FFS patients seen during the reporting period 

to which the measure applies. 

Comment: Some commenters generally supported the MAV process. However, some 

commenters expressed the need to clarify the MAV process for registry as well as to provide greater 

transparency in this process. 

Response: We understand the need to clarify further the MAV process for both claims and 

registry. Please note that, as the MAV process evolves, we expect to be able to provide further guidance 

to aid group practices in understanding the MAV process. We will post additional clarifying information, 

including a “made simple” document on the MAV process for 2015 on the PQRS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html. We 

believe that posting this guidance as we have in years prior provides adequate transparency in this 

process. Moreover, should a group practice have further questions regarding the MAV process, he/she 

may contact our QualityNet Help Desk for more information. The contact information for the Help Desk 

can be found here: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/HelpDeskSupport.html. 
CMS-1612-FC 700

Because of the comments, we are finalizing our proposal to modify §414.90(j) and finalize the 

following criteria for satisfactory reporting for group practices participating in the GPRO via registry and 

EHR for the 2017 PQRS payment adjustment: 

For group practices comprised of 2-99 eligible professionals reporting for the 12-month reporting 

period for the 2017 PQRS payment adjustment via registry, report at least 9 measures, covering at least 3 

of the NQS domains. Of these measures, if a group practice sees at least 1 Medicare patient in a face-toface encounter, the group practice would report on at least 1 measure in the cross-cutting measure set 

specified in Table 52. If less than 9 measures covering at least 3 NQS domains apply to the group 

practice, the group practice would report up to 8 measures covering 1–3 NQS domains for which there is 

Medicare patient data, AND report each measure for at least 50 percent of the group’s Medicare Part B 

FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent 

performance rate would not be counted. 

We understand that there may be instances where a group practice may not have at least 9 

measures applicable to an eligible professional’s practice. In this instance, a group practice reporting on 

less than 9 measures would still be able to meet the satisfactory reporting criterion via claims and registry 

if the group practice reports on 1-8 measures, as applicable, to the group’s practice. If a group practice 

reports on 1-8 measures, the group practice would be subject to the MAV process, which would allow us 

to determine whether a group practice should have reported quality data codes for additional measures. In 

addition, the MAV will also allow us to determine whether a group practice should have reported on any 

of the cross-cutting measures specified in Table 52. The MAV process we will implement for claims and 

registry for the 2017 PQRS payment adjustment is the same process that was established for reporting 

periods occurring in 2014 for the 2014 PQRS incentive. For more information on the claims MAV 

process, please visit http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013.zip. For 

more information on the registry MAV process, please visit http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_12132013.zip. 
CMS-1612-FC 701

For group practices comprised of 2-99 eligible professionals reporting for the 12-month reporting 

period for the 2017 PQRS payment adjustment via EHR: report 9 measures covering at least 3 domains. 

If the group practice’s CEHRT does not contain patient data for at least 9 measures covering at least 3 

domains, then the group practice must report the measures for which there is patient data. A group 

practice must report on at least 1 measure for which there is Medicare patient data. 

Please note that the discussion in this section III.K.4.b is limited to the criteria for the satisfactory 

reporting of group practices registered to participate in the GPRO for the 2017 PQRS payment adjustment 

using the EHR-based reporting mechanism to group practices comprised of 2-99 eligible professionals. 

The final criteria for group practices comprised of 100 or more eligible professionals are addressed in 

section III.K.1.c. following this section. 

c. Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group Practices 

Registered to Participate in the GPRO via a CMS-Certified Survey Vendor for the 2017 PQRS Payment 

Adjustment 

In the CY 2014 PFS final rule with comment period, we introduced satisfactory reporting 

criterion for the 2014 PQRS incentive related to reporting the CG CAHPS survey measures via a CMScertified survey vendor (see Table 49 at 78 FR 74486). Consistent with the criterion finalized for the 

2014 PQRS incentive and the group practice reporting requirements under section 1848(m)(3)(C) of the 

Act, we proposed 3 options (of which a group practice would be able to select 1 out of the 3 options) for 

satisfactory reporting for the 2017 PQRS payment adjustment for group practices comprised of 25 or 

more eligible professionals (79 FR 40399). 

Furthermore, as was required for group practices reporting via the GPRO web interface for the 

reporting periods occurring in 2014 (78 FR 74485), we proposed that all group practices comprised of 

100 or more eligible professionals that register to participate in the PQRS GPRO, regardless of the 

reporting mechanism the group practice chooses, would be required to select a CMS-certified survey 

vendor to administer the CAHPS for PQRS survey on their behalf. As such, for purposes of meeting the 

criteria for satisfactory reporting for the 2017 PQRS payment adjustment, a group practice participating in 

the PQRS GPRO would be required to use 1 of these 3 proposed reporting options mentioned above (that 
CMS-1612-FC 702

is, GPRO web interface, qualified registry or EHR). We noted that, for reporting periods occurring in 

2014, we stated that we would administer and fund the collection of (CG-CAHPS) data for these groups 

(of 100 or more eligible professionals using the GPRO web interface that are required to report on 

CAHPS for PQRS survey measures) (78 FR 74452). We stated that we would bear the cost of 

administering the CAHPS for PQRS survey measures, as we were requiring the group practices to report 

on CAHPS for PQRS survey measures. Unfortunately, beginning in 2015, it will no longer be feasible 

for us to continue to bear the cost of group practices of 100 or more eligible professionals to report the 

CAHPS for PQRS survey measures. Therefore, the group practice would be required to bear the cost of 

administering the CAHPS for PQRS survey measures. 

However, as CAHPS for PQRS was optional for group practices comprised of 25-99 eligible 

professionals in 2014 (78 FR 74485) and whereas we proposed to require reporting of CAHPS for PQRS 

for group practices comprised of 100 or more eligible professionals, we proposed that CAHPS for PQRS 

would be optional for groups of 25-99 and 2-24 eligible professionals. We noted that all group practices 

that would be required to report or voluntarily elect to report CAHPS for PQRS would need to select and 

pay a CMS-certified survey vendor to administer the CAHPS for PQRS survey on their behalf. 

We invited public comment on these proposals related to our proposals to require reporting of 

CAHPS for PQRS for group practices comprised of 100 or more eligible professionals that register to 

participate in the PQRS GPRO as well as our proposal making the reporting of CAHPS for PQRS 

optional for group practices comprised of 2-99 eligible professionals that registry to participate in the 

PQRS GPRO to meet the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. The 

following is a summary of the comments we received regarding on these proposals. 

Comment: Commenters supported the option to report CAHPS for PQRS, as long as reporting 

CAHPS for PQRS remained optional. The majority of commenters opposed our proposal to require 

group practices comprised of 100 or more eligible professionals that register to participate in the PQRS 

GPRO, regardless of the reporting mechanism the group practice chooses, to select a CMS-certified 

survey vendor to administer the CAHPS for PQRS survey on their behalf. These commenters believe that 

this requirement was too burdensome, particularly because CMS is not bearing the cost of administering 
CMS-1612-FC 703

the survey. Some of these commenters requested that CMS delay requiring the reporting of CAHPS for 

PQRS to the 2016 reporting period. Other commenters requested that CMS continue to bear the cost of 

administering the CAHPS for PQRS survey. 

Response: While we understand the commenters’ concerns regarding requiring the reporting of 

CAHPS for PQRS, group practices comprised of 100 or more eligible professionals participating in the 

GPRO web interface reporting option have had 2 years of experience reporting CAHPS for PQRS as they 

have been required to report CAHPS for PQRS for both the 2013 and 2014 PQRS incentive. Groups of 

25-99 eligible professionals reporting via GPRO web interface, qualified registry or EHR and groups of 

100 or more eligible professionals reporting via qualified registry or EHR had the option to report 

CAHPS for PQRS in 2014. We believe that 2 years is enough time to become familiar with how the 

survey is administered. Therefore, we believe it is reasonable to require group practices of 100 of more 

eligible professionals to report on CAHPS for PQRS. With respect to some commenters’ concerns about 

the additional burden the proposal to require group practices comprised of 100 or more eligible 

professionals that register to participate in the PQRS GPRO to report CAHPS for PQRS places on these 

group practices, we understand that this proposed requirement could bring additional reporting burden on 

these larger group practices. We believe that the value of the information contained in the CAHPS for 

PQRS survey outweighs this concern. In addition, we note that large group practices tend to be more 

sophisticated than other group practices with respect to resources, and, as such, we believe that this 

mitigates any additional burden on group practices of 100 or more eligible professionals. Therefore, 

based on the reasons we state here and in the proposed rule, we are finalizing our proposal to require 

reporting of CAHPS for PQRS for group practices comprised of 100 or more eligible professionals that 

register to participate in the PQRS GPRO. 

We are also finalizing our proposal to make the reporting of CAHPS for PQRS optional for group 

practices comprised of 2-99 eligible professionals that register to participate in the PQRS GPRO to meet 

the criteria for satisfactory reporting for the 2017 PQRS payment adjustment. 

Furthermore, we understand the commenters’ concerns regarding having the group practices bear 

the cost of administering the CAHPS for PQRS survey, particularly for those group practices who will be 
CMS-1612-FC 704

required to report CAHPS for PQRS to meet the criteria for satisfactory reporting for the 2017 PQRS 

payment adjustment. However, it is not feasible for us to continue to bear the cost of administering the 

CAHPS for PQRS survey. We believe that bearing the cost of the CAHPS for PQRS survey for 2013 and 

2014 provided adequate time for group practices to become familiar with administering the CAHPS for 

PQRS survey as well as signaled our commitment to reporting of the CAHPS for PQRS survey into the 

future. 

Because of the comments received, we are finalizing the following final criteria for satisfactory 

reporting for the 2017 PQRS payment adjustment for group practices comprised of 2 or more eligible 

professionals. The following options are voluntary ways to meet the criteria for satisfactory reporting for 

the 2017 PQRS payment adjustment for groups comprised of 2-99 eligible professionals. However, 

group practices comprised of 100 or more eligible professionals that are registered to participate in the 

GPRO must select one of these options to meet the criteria for satisfactory reporting for the 2017 PQRS 

payment adjustment. 

Option 1 – Registry: If a group practice of 2 or more eligible professionals chooses to use a 

qualified registry, in conjunction with reporting the CAHPS for PQRS survey measures, for the 12-month 

reporting period for the 2017 PQRS payment adjustment, the group practice must have all CAHPS for 

PQRS survey measures reported on its behalf via a CMS-certified survey vendor, and report at least 6 

additional measures, outside of CAHPS for PQRS, covering at least 2 of the NQS domains using the 

qualified registry. If less than 6 measures apply to the group practice, the group practice must report up to 

5 measures. Of the additional measures that must be reported in conjunction with reporting the CAHPS 

for PQRS survey measures, if any eligible professional in the group practice sees at least 1 Medicare 

patient in a face-to-face encounter, the group practice must report on at least 1 measure in the crosscutting measure set specified in Table 52. 

Consistent with the group practice reporting option solely using a qualified registry for the 2017 

PQRS payment adjustment, we understand that there may be instances where a group practice may not 

have at least 6 measures applicable to a group practice’s practice. In this instance, a group practice 

reporting on less than 6 measures would still be able to meet the satisfactory reporting criterion via 
CMS-1612-FC 705

registry if the group practice reports on as many measures as are applicable to the group practice’s 

practice, including the measures in the cross-cutting measure set specified in Table 52. If a group practice 

reports on less than 6 individual measures using the qualified registry reporting mechanism in conjunction 

with a CMS-certified survey vendor to report CAHPS for PQRS, the group practice would be subject to 

the MAV process, which would allow us to determine whether a group practice should have reported 

quality data codes for additional measures and/or measures covering additional NQS domains. For more 

information on the registry MAV process, please visit http://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Registry_MeasureApplicabilityValidation_12132013.zip. 

Option 2 – EHR: If a group practice of 2 or more eligible professionals chooses to use a direct 

EHR product that is CEHRT or EHR data submission vendor that is CEHRT in conjunction with 

reporting the CAHPS for PQRS survey measures, for the 12-month reporting period for the 2017 PQRS 

payment adjustment, the group practice must have all CAHPS for PQRS survey measures reported on its 

behalf via a CMS-certified survey vendor, and report at least 6 additional measures, outside of CAHPS 

for PQRS, covering at least 2 of the NQS domains using the direct EHR product that is CEHRT or EHR 

data submission vendor product that is CEHRT. If less than 6 measures apply to the group practice, the 

group practice must report up to 5 measures. Of the additional 6 measures that must be reported in 

conjunction with reporting the CAHPS for PQRS survey measures, a group practice would be required to 

report on at least 1 measure for which there is Medicare patient data. 

Option 3 – GPRO Web Interface: Alternatively, if a group practice of 25-99 eligible 

professionals chooses to use the GPRO web interface in conjunction with reporting the CAHPS for PQRS 

survey measures, for the 12-month reporting period for the 2017 PQRS payment adjustment, the group 

practice must have all CAHPS for PQRS survey measures reported on its behalf via a CMS-certified 

survey vendor. In addition, the group practice must report on all measures included in the GPRO web 

interface; AND populate data fields for the first 248 consecutively ranked and assigned beneficiaries in 

the order in which they appear in the group’s sample for each module or preventive care measure. If the 

pool of eligible assigned beneficiaries is less than 248, then the group practice must report on 100 percent 
CMS-1612-FC 706

of assigned beneficiaries. A group practice will be required to report on at least 1 measure for which 

there is Medicare patient data. 

Tables 50 and 51 provide a summary of the final criteria for satisfactory reporting – or, in lieu of 

satisfactory reporting, satisfactory participation in a QCDR – for the 2017 PQRS payment adjustment for 

eligible professionals and group practices. As you can see below, there are a total of 5 individual 

reporting options and 9 group practice reporting options. Therefore, there are a total of 14 reporting 

options under the PQRS for purposes of meeting the criteria for satisfactory reporting – or, in lieu of 

satisfactory reporting, satisfactory participation in a QCDR – for the 2017 PQRS payment adjustment. 

d. The Consumer Assessment of Healthcare Providers Surgical Care Survey (S-CAHPS) 

In addition to CAHPS for PQRS, we received comments last year supporting the inclusion of the 

Consumer Assessment of Healthcare Providers Surgical Care Survey (S-CAHPS). The S-CAHPS 

expands on the CG-CAHPS by focusing on aspects of surgical quality, which are important from the 

patient’s perspective and for which the patient is the best source of information. The survey asks patients 

to provide feedback on surgical care, surgeons, their staff, and anesthesia care. It assesses patients’ 

experiences with surgical care in both the inpatient and outpatient settings by asking respondents about 

their experience before, during and after surgery. The commenters stated that the CG-CAHPS survey 

would not accurately reflect the care provided by single- or multispecialty surgical or anesthesia groups. 

The commenters noted that S-CAHPS has been tested by the same standards as CG-CAHPS and follows 

the same collection mechanism as the CG-CAHPS. We agree with the commenters on the importance of 

allowing for the administration of S-CAHPS reporting and wish to allow for reporting of S-CAHPS in the 

PQRS for reporting mechanisms other than the QCDR. However, at this time, due to the cost and time it 

would take to find vendors to collect S-CAHPS data, it is not technically feasible to implement the 

reporting of the S-CAHPS survey measures for the 2017 PQRS payment adjustment. In the CY 2015 

PFS proposed rule (79 FR 40400), we solicited comments on how to allow for reporting of the S-CAHPS 

survey measures for the 2018 PQRS payment adjustment and beyond. In addition, we sought comments 

on how to allow for reporting of the S–CAHPS survey measures for the 2018 PQRS payment adjustment 

and beyond. The following is a summary of the comments we received on these proposal: 
CMS-1612-FC 707

Comment: The majority of commenters supported the introduction of S-CAHPS in the PQRS. 

These commenters supported our proposal to allow the reporting of S-CAHPS via a QCDR, and other 

commenters requested that group practices be able to report S-CAHPS via a CMS-certified survey 

vendor, similar to the way CAHPS for PQRS is currently being reported under the PQRS. Other 

commenters expressed concerns on introducing S-CAHPS for the PQRS. One commenter stated that SCAHPS does not adequately capture the patient and caregiver experience with all types of anesthesia 

professionals. Another commenter expressed concerns related to determining how to select patients for 

which to administer S-CAHPS. Commenters were also concerned with the financial burden of 

administering the S-CAHPS survey, and asked CMS to explore ways to fund the administration of the SCAHPS survey. 

Response: We appreciate the commenters’ feedback. However, at this time, due to the cost and 

time it would take to find vendors to collect S-CAHPS data, it is not technically feasible to implement the 

reporting of the S-CAHPS survey measures for the 2017 or 2018 PQRS payment adjustments. We note, 

however, that if a QCDR wishes to administer the S-CAHPS as a non-PQRS measure for the 2017 or 

2018 PQRS payment adjustments, we would allow the QCDR to do so. We will take these comments 

into consideration as we continue to work to introduce S-CAHPS in the PQRS measure set for future 

years. 

 
CMS-1612-FC 708

TABLE 50: Summary of Requirements for the 2017 PQRS Payment Adjustment: 

Individual Reporting Criteria for the Satisfactory Reporting of Quality Measures Data via Claims, 

Qualified Registry, and EHRs and Satisfactory Participation Criterion in QCDRs 

Reporting 

Period

Measure 

Type

Reporting 

Mechanism

Satisfactory Reporting/Satisfactory Participation Criteria

12-month 

(Jan 1–

Dec 31, 

2015)

Individual 

Measures

Claims Report at least 9 measures, covering at least 3 of the NQS domains 

AND report each measure for at least 50 percent of the eligible 

professional’s Medicare Part B FFS patients seen during the 

reporting period to which the measure applies. Of the measures 

reported, if the eligible professional sees at least 1 Medicare patient 

in a face-to-face encounter, the eligible professional will report on at 

least 1 measure contained in the proposed cross-cutting measure set 

specified in Table 52. If less than 9 measures apply to the eligible 

professional, the eligible professional would report up to 8 

measure(s), AND report each measure for at least 50 percent of the 

Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a 0 percent performance 

rate would not be counted.

12-month 

(Jan 1–

Dec 31, 

2015)

Individual 

Measures

Qualified 

Registry

Report at least 9 measures, covering at least 3 of the NQS domains 

AND report each measure for at least 50 percent of the eligible 

professional’s Medicare Part B FFS patients seen during the 

reporting period to which the measure applies. Of the measures 

reported, if the eligible professional sees at least 1 Medicare patient 

in a face-to-face encounter, the eligible professional will report on at 

least 1 measure contained in the proposed cross-cutting measure set 

specified in Table 52. If less than 9 measures apply to the eligible 

professional, the eligible professional would report up to 8 

measure(s), AND report each measure for at least 50 percent of the 

Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a 0 percent performance 

rate would not be counted.

12-month 

(Jan 1–

Dec 31, 

2015)

Individual 

Measures

Direct EHR 

Product or 

EHR Data 

Submission 

Vendor 

Product

Report 9 measures covering at least 3 of the NQS domains. If an 

eligible professional’s direct EHR product or EHR data submission 

vendor product does not contain patient data for at least 9 measures 

covering at least 3 domains, then the eligible professional would be 

required to report all of the measures for which there is Medicare 

patient data. An eligible professional would be required to report on 

at least 1 measure for which there is Medicare patient data. 

12-month 

(Jan 1–

Dec 31, 

2015)

Measures 

Groups

Qualified 

Registry

Report at least 1 measures group AND report each measures group 

for at least 20 patients, the majority (11 patients) of which are 

required to be Medicare Part B FFS patients. Measures groups 

containing a measure with a 0 percent performance rate will not be 

counted. 

12-month 

(Jan 1–

Dec 31, 

2015)

Individual 

PQRS 

measures 

and/or nonPQRS 

measures 

reportable 

via a QCDR

Qualified 

Clinical Data 

Registry 

(QCDR)

Report at least 9 measures available for reporting under a QCDR 

covering at least 3 of the NQS domains, AND report each measure 

for at least 50 percent of the eligible professional’s patients. Of these 

measures, the eligible professional would report on at least 2 

outcome measures, OR, if 2 outcomes measures are not available, 

report on at least 1 outcome measures and at least 1 of the following 

types of measures – resource use, patient experience of care, 

efficiency/appropriate use, or patient safety

 
CMS-1612-FC 709

TABLE 51: Summary of Requirements for the 2017 PQRS Payment Adjustment: Group Practice 

Reporting Criteria for Satisfactory Reporting of Quality Measures Data via the GPRO 

Reporting 

Period

Group 

Practice 

Size

Measure 

Type

Reporting 

Mechanism

Satisfactory Reporting Criteria

12-month 

(Jan 1–

Dec 31, 

2015)

25-99 

eligible 

professio

nals

Individual 

GPRO 

Measures in 

the GPRO 

Web 

Interface

GPRO Web 

Interface

Report on all measures included in the web interface; 

AND populate data fields for the first 248 consecutively 

ranked and assigned beneficiaries in the order in which 

they appear in the group’s sample for each module or 

preventive care measure. If the pool of eligible assigned 

beneficiaries is less than 248, then the group practice 

must report on 100 percent of assigned beneficiaries. In 

other words, we understand that, in some instances, the 

sampling methodology we provide will not be able to 

assign at least 248 patients on which a group practice 

may report, particularly those group practices on the 

smaller end of the range of 25–99 eligible professionals. 

If the group practice is assigned less than 248 Medicare 

beneficiaries, then the group practice must report on 100 

percent of its assigned beneficiaries. A group practice 

must report on at least 1 measure for which there is 

Medicare patient data. 

12-month 

(Jan 1–

Dec 31, 

2015) 

25-99 

eligible 

professio

nals 

and100+ 

eligible 

professio

nals 

Individual 

GPRO 

Measures in 

the GPRO 

Web 

Interface + 

CAHPS for 

PQRS 

GPRO Web 

Interface + 

CMSCertified 

Survey 

Vendor 

The group practice must have all CAHPS for PQRS 

survey measures reported on its behalf via a CMScertified survey vendor. In addition, the group practice 

must report on all measures included in the GPRO web 

interface; AND populate data fields for the first 248 

consecutively ranked and assigned beneficiaries in the 

order in which they appear in the group’s sample for 

each module or preventive care measure. If the pool of 

eligible assigned beneficiaries is less than 248, then the 

group practice must report on 100 percent of assigned 

beneficiaries. A group practice will be required to report 

on at least 1 measure for which there is Medicare patient 

data. 

12-month 

(Jan 1–

Dec 31, 

2015)

2-99 

eligible 

professio

nals

Individual 

Measures

Qualified 

Registry

Report at least 9 measures, covering at least 3 of the 

NQS domains. Of these measures, if a group practice 

sees at least 1 Medicare patient in a face-to-face 

encounter, the group practice would report on at least 1 

measure in the cross-cutting measure set specified in 

Table 52. If less than 9 measures covering at least 3 

NQS domains apply to the group practice, the group 

practice would report up to 8 measures covering 1–3 

NQS domains for which there is Medicare patient data, 

AND report each measure for at least 50 percent of the 

group’s Medicare Part B FFS patients seen during the 

reporting period to which the measure applies. 

Measures with a 0 percent performance rate would not 

be counted.

12-month 

(Jan 1–

Dec 31, 

2015) 

2-99 

eligible 

professio

nals and 

100+ 

eligible 

professio

Individual 

Measures + 

CAHPS for 

PQRS 

Qualified 

Registry + 

CMSCertified 

Survey 

Vendor 

The group practice must have all CAHPS for PQRS 

survey measures reported on its behalf via a CMScertified survey vendor, and report at least 6 additional 

measures, outside of CAHPS for PQRS, covering at 

least 2 of the NQS domains using the qualified registry. 

If less than 6 measures apply to the group practice, the 

group practice must report up to 5 measures. Of the 
CMS-1612-FC 710

Reporting 

Period

Group 

Practice 

Size

Measure 

Type

Reporting 

Mechanism

Satisfactory Reporting Criteria

nals additional measures that must be reported in conjunction 

with reporting the CAHPS for PQRS survey measures, if 

any eligible professional in the group practice sees at 

least 1 Medicare patient in a face-to-face encounter, the 

group practice must report on at least 1 measure in the 

cross-cutting measure set specified in Table 52. 

12-month 

(Jan 1–

Dec 31, 

2015)

2-99 

eligible 

professio

nals

Individual 

Measures

Direct EHR 

Product or 

EHR Data 

Submission 

Vendor 

Product

Report 9 measures covering at least 3 domains. If the 

group practice’s direct EHR product or EHR data 

submission vendor product does not contain patient data 

for at least 9 measures covering at least 3 domains, then 

the group practice must report the measures for which 

there is patient data. A group practice must report on at 

least 1 measure for which there is Medicare patient data.

12-month 

(Jan 1–

Dec 31, 

2015)

2-99 

eligible 

professio

nals and 

100+ 

eligible 

professio

nals

Individual 

Measures + 

CAHPS for 

PQRS

Direct EHR 

Product or 

EHR Data 

Submission 

Vendor 

Product + 

CMSCertified 

Survey 

Vendor

The group practice must have all CAHPS for PQRS 

survey measures reported on its behalf via a CMScertified survey vendor, and report at least 6 additional 

measures, outside of CAHPS for PQRS, covering at 

least 2 of the NQS domains using the direct EHR 

product or EHR data submission vendor product. If less 

than 6 measures apply to the group practice, the group 

practice must report up to 5 measures. Of the additional 

6 measures that must be reported in conjunction with 

reporting the CAHPS for PQRS survey measures, a 

group practice would be required to report on at least 1 

measure for which there is Medicare patient data. 

5. Statutory Requirements and Other Considerations for the Selection of PQRS Quality Measures for 

Meeting the Criteria for Satisfactory Reporting for 2015 and Beyond for Individual Eligible Professionals 

and Group Practices 

CMS undergoes an annual Call for Measures that solicits new measures from the public for 

possible inclusion in the PQRS. During the Call for Measures, we request measures for inclusion in 

PQRS that meet the following statutory and non-statutory criteria. 

Sections 1848(k)(2)(C) and 1848(m)(3)(C)(i) of the Act, respectively, govern the quality 

measures reported by individual eligible professionals and group practices under the PQRS. Under 

section 1848(k)(2)(C)(i) of the Act, the PQRS quality measures shall be such measures selected by the 

Secretary from measures that have been endorsed by the entity with a contract with the Secretary under 

section 1890(a) of the Act, which is currently the National Quality Forum (NQF). However, in the case 

of a specified area or medical topic determined appropriate by the Secretary for which a feasible and 

practical measure has not been endorsed by the NQF, section 1848(k)(2)(C)(ii) of the Act authorizes the 
CMS-1612-FC 711

Secretary to specify a measure that is not so endorsed as long as due consideration is given to measures 

that have been endorsed or adopted by a consensus organization identified by the Secretary, such as the 

Ambulatory Quality Alliance (AQA). In light of these statutory requirements, we believe that, except in 

the circumstances specified in the statute, each PQRS quality measure must be endorsed by the NQF. 

Additionally, section 1848(k)(2)(D) of the Act requires that for each PQRS quality measure, ‘‘the 

Secretary shall ensure that eligible professionals have the opportunity to provide input during the 

development, endorsement, or selection of measures applicable to services they furnish.” The statutory 

requirements under section 1848(k)(2)(C) of the Act, subject to the exception noted previously, require 

only that the measures be selected from measures that have been endorsed by the entity with a contract 

with the Secretary under section 1890(a) of the Act (that is, the NQF) and are silent as to how the 

measures that are submitted to the NQF for endorsement are developed. 

The basic steps for developing measures applicable to physicians and other eligible professionals 

prior to submission of the measures for endorsement may be carried out by a variety of different 

organizations. We do not believe there need to be special restrictions on the type or make-up of the 

organizations carrying out this basic process of development of physician measures, such as restricting 

the initial development to physician-controlled organizations. Any such restriction would unduly limit 

the basic development of quality measures and the scope and utility of measures that may be considered 

for endorsement as voluntary consensus standards for purposes of the PQRS. 

In addition to section 1848(k)(2)(C) of the Act, section 1890A of the Act, which was added by 

section 3014(b) of the Affordable Care Act, requires that the Secretary establish a pre-rulemaking process 

under which certain steps occur with respect to the selection of certain categories of quality and efficiency 

measures, one of which is that the entity with a contract with the Secretary under section 1890(a) of the 

Act (that is, the NQF) convene multi-stakeholder groups to provide input to the Secretary on the selection 

of such measures. These categories are described in section 1890(b)(7)(B) of the Act, and include such 

measures as the quality measures selected for reporting under the PQRS. In accordance with section 

1890A(a)(1) of the Act, the NQF convened multi-stakeholder groups by creating the Measure 

Applications Partnership (MAP). Section 1890A(a)(2) of the Act requires that the Secretary must make 
CMS-1612-FC 712

publicly available by December 1st of each year a list of the quality and efficiency measures that the 

Secretary is considering for selection through rulemaking for use in the Medicare program. The NQF 

must provide CMS with the MAP’s input on the selection of measures by February 1st of each year. The 

lists of measures under consideration for selection through rulemaking in 2014 are available at 

http://www.qualityforum.org/map/. 

As we noted above, section 1848(k)(2)(C)(ii) of the Act provides an exception to the requirement 

that the Secretary select measures that have been endorsed by the entity with a contract under section 

1890(a) of the Act (that is, the NQF). We may select measures under this exception if there is a specified 

area or medical topic for which a feasible and practical measure has not been endorsed by the entity, as 

long as due consideration is given to measures that have been endorsed or adopted by a consensus 

organization identified by the Secretary. Under this exception, aside from NQF endorsement, we 

requested that stakeholders apply the following considerations when submitting measures for possible 

inclusion in the PQRS measure set: 

● Measures that are not duplicative of another existing or proposed measure. 

● Measures that are further along in development than a measure concept. 

● CMS is not accepting claims-based-only reporting measures in this process. 

● Measures that are outcome-based are preferred to clinical process measures. 

● Measures that address patient safety and adverse events. 

● Measures that identify appropriate use of diagnosis and therapeutics. 

● Measures that identify care coordination and communication. 

● Measures that identify care coordination of patient experience and patient-reported outcomes. 

● Measures that address efficiency, cost and resource use. 

As a general matter, please note that the measure tables contained in this section III.K. may also contain 

discussions of comments we received related to proposed changes to the measures included in the quality 

performance standard under the Shared Savings Program. 

a. PQRS Quality Measures 
CMS-1612-FC 713

Taking into consideration the statutory and non-statutory criteria we described previously, this 

section contains our responses to our proposals related to the measures in the PQRS for 2015 and beyond. 

We classified all measures against six domains based on the NQS’s six priorities, as follows: 

(1) Patient Safety. These measures reflect the safe delivery of clinical services in all healthcare 

settings. These measures may address a structure or process that is designed to reduce risk in the delivery 

of healthcare or measure the occurrence of an untoward outcome such as adverse events and 

complications of procedures or other interventions. 

(2) Person and Caregiver-Centered Experience and Outcomes. These are measures that reflect 

the potential to improve patient-centered care and the quality of care delivered to patients. They 

emphasize the importance of collecting patient-reported data and the ability to impact care at the 

individual patient level, as well as the population level. These are measures of organizational structures 

or processes that foster both the inclusion of persons and family members as active members of the health 

care team and collaborative partnerships with providers and provider organizations or can be measures of 

patient-reported experiences and outcomes that reflect greater involvement of patients and families in 

decision making, self-care, activation, and understanding of their health condition and its effective 

management. 

(3) Communication and care coordination. These measures demonstrate appropriate and timely 

sharing of information and coordination of clinical and preventive services among health professionals in 

the care team and with patients, caregivers, and families to improve appropriate and timely patient and 

care team communication. They may also be measures that reflect outcomes of successful coordination 

of care. 

 (4) Effective clinical care. These are measures that reflect clinical care processes closely linked 

to outcomes based on evidence and practice guidelines or measures of patient-centered outcomes of 

disease states.

 (5) Community/population health. These measures reflect the use of clinical and preventive 

services and achieve improvements in the health of the population served. They may be measures of 
CMS-1612-FC 714

processes focused on primary prevention of disease or general screening for early detection of disease 

unrelated to a current or prior condition-. 

(6) Efficiency and cost reduction. These measures reflect efforts to lower costs and to 

significantly improve outcomes and reduce errors. These are measures of cost, resource use and 

appropriate use of healthcare resources or inefficiencies in healthcare delivery. 

Please note that the PQRS quality measure specifications for any given PQRS individual quality 

measure may differ from specifications for the same quality measure used in prior years. For example, 

for the PQRS quality measures that were selected for reporting in 2014 and beyond, please note that 

detailed measure specifications, including the measure’s title, for the individual PQRS quality measures 

for 2013 and beyond may have been updated or modified during the NQF endorsement process or for 

other reasons. 

In addition, due to our desire to align measure titles with the measure titles that have been 

finalized for 2013, 2014, 2015, and potentially subsequent years of the EHR Incentive Program for 

Eligible Professionals, we note that the measure titles for measures available for reporting via EHR may 

change. To the extent that the EHR Incentive Program for Eligible Professionals updates its measure 

titles to include version numbers (77 FR 13744), we will use these version numbers to describe the PQRS 

EHR measures that will also be available for reporting for the EHR Incentive Program for Eligible 

Professionals. We will continue to work toward complete alignment of measure specifications across 

programs, whenever possible. 

Through NQF’s measure maintenance process, NQF-endorsed measures are sometimes updated 

to incorporate changes that we believe do not substantively change the nature of the measure. Examples 

of such changes could be updated diagnosis or procedure codes or changes to exclusions to the patient 

population or definitions. We believe these types of maintenance changes are distinct from substantive 

changes to measures that result in what are considered new or different measures. Further, we believe 

that non-substantive maintenance changes of this type do not trigger the same agency obligations under 

the Administrative Procedure Act. 
CMS-1612-FC 715

In the CY 2013 PFS final rule with comment period, we finalized our proposal providing that if 

the NQF updates an endorsed measure that we have adopted for the PQRS in a manner that we consider 

to not substantively change the nature of the measure, we would use a subregulatory process to 

incorporate those updates to the measure specifications that apply to the program (77 FR 69207). We 

believe this adequately balances our need to incorporate non-substantive NQF updates to NQF-endorsed 

measures in the most expeditious manner possible, while preserving the public’s ability to comment on 

updates that so fundamentally change an endorsed measure that it is no longer the same measure that we 

originally adopted. We also noted that the NQF process incorporates an opportunity for public comment 

and engagement in the measure maintenance process. We will revise the Specifications Manual and post 

notices to clearly identify the updates and provide links to where additional information on the updates 

can be found. Updates will also be available on the CMS PQRS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html. 

 CMS is not the measure steward for most of the measures available for reporting under the 

PQRS. We rely on outside measure stewards and developers to maintain these measures. In Table 55, we 

proposed that certain measures be removed from the PQRS measure set due to the measure 

owner/developer indicating that it will not be able to maintain the measure. We noted that this proposal is 

contingent upon the measure owner/developer not being able to maintain the measure. Should we learn 

that a certain measure owner/developer is able to maintain the measure, or that another entity is able to 

maintain the measure in a manner that allows the measure to be available for reporting under the PQRS 

for the CY 2017 PQRS payment adjustment, we proposed to keep the measure available for reporting 

under the PQRS and therefore not finalize our proposal to remove the measure. In addition, if, after the 

display of this final rule with comment period, we discover additional measures within the current PQRS 

measure set that a measure owner/developer can no longer maintain, we proposed to remove these 

measures from reporting for the PQRS beginning in 2015. We will discuss any such instances in the 

PQRS measure tables below. 

In addition, we noted that we have received feedback from stakeholders, particularly first-time 

participants who find it difficult to understand which measures are applicable to their particular practice. 
CMS-1612-FC 716

In an effort to aid eligible professionals and group practices to determine what measures best fit their 

practice, and in collaboration with specialty societies, we are beginning to group our final measures 

available for reporting according to specialty. The current listing of our measures by specialty can be 

found on our website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Please note that these groups of measures are meant to provide guidance 

to those eligible professionals seeking to determine what measures to report. Eligible professionals are 

not required to report measures according to these suggested groups of measures. In addition to group 

measures according to specialty, we also plan to have a measure subset for measures that specifically 

addresses multiple chronic conditions. As measures are adopted or revised, we will continue to update 

these groups to reflect the measures available under the PQRS, as well as add more specialties. 

 In the CY 2014 PFS final rule with comment period, we stated that “unless there are errors 

discovered in updated electronic measure specifications, the PQRS intends to use the most recent, updated 

versions of electronically specified clinical quality measures for that year” (78 FR 74489). We proposed 

that, if we discovered errors in the most recently updated electronic measure specifications for a certain 

measure, we would use the version of electronic measure specifications that immediately precedes the 

most recently updated electronic measure specifications. Any such change to a measure is also described 

in the PQRS measure tables below. 

Additionally, we noted that, with respect to the following e-measure CMS140v2, Breast Cancer 

Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast 

Cancer (NQF 0387), a substantive error was discovered in the June 2013 version of this electronically 

specified clinical quality measure. Therefore, the PQRS required the use of the prior, December 2012 

version of this measure, which is CMS140v1 (78 FR 74489). Please note that, consistent with other EHR 

measures, since a more recent and corrected version of this measure has been developed, we will require 

the reporting of the most recent, updated versions of the measure Breast Cancer Hormonal Therapy for 

Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF 0387) – 

currently version CMS140v3 – for the year. 

b. Cross-Cutting Measure Set for 2015 and Beyond 
CMS-1612-FC 717

In accordance with our criteria for the satisfactory reporting of PQRS measures for the 2017 

PQRS payment adjustment via claims and registry that requires an eligible professional or group practice 

to report on at least 2 cross-cutting measures, we proposed 18 cross-cutting measure set specified in Table 

21 in the CY 2015 PFS proposed rule for 2015 and beyond (79 FR 40404). Please note that we are 

finalizing all measures as proposed (see Table 52). We are also adding a measure to the list of crosscutting measures, based on comments that were submitted. Please note that our response and final 

decision for each of these measures is found in Table 52. We have also indicated the PQRS reporting 

mechanism or mechanisms through which each measure could be submitted. Please note that we are 

changing some of the reporting mechanisms available for certain cross-cutting measures in Table 52 from 

the reporting options we proposed would be available in the CY 2015 PFS proposed rule (79 FR 40404). 

To the extent that changes to the reporting mechanisms for the cross-cutting measures specified in Table 

52 were made from what was specified in the proposed rule, we provide the explanation and rationale for 

those changes in Table 53. 

The following are high-level comments regarding our proposals related to the proposed crosscutting measure set: 

Comment: Several commenters supported the development of a cross-cutting measure 

set as well as the composition as proposed, while other commenters were concerned about this 

new requirement noting the measures may not be as applicable to some specialists. 

Response: With respect to the commenters who expressed concern that the proposed 

measures in the proposed cross-cutting measures set did not apply to many specialties, we note 

that limitations such as only requiring reporting of a cross-cutting measures in a face-to-face 

encounter would exclude those eligible professionals for which the measures do not apply. With 

respect to taking a more phased-in approach to introducing the cross-cutting measure set, please 

note that we have modified this proposal to only require the reporting of 1 cross-cutting measure. 

We believe that requiring the reporting of 1 measure in the cross-cutting measures set is not 

overly burdensome and may help eligible professionals by providing direction on what measures 
CMS-1612-FC 718

to report. We are modifying our proposal to only require eligible professionals who see at least 1 

Medicare patient in a face-to-face encounter to report on 1 cross-cutting measure. 

TABLE 52: Individual Quality Cross-Cutting Measures for the PQRS to Be Available for 

Satisfactory Reporting Via Claims, Registry, and EHR Beginning in 2015 

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

Measures Finalized as Proposed or with Modifications

N/A 

/402 

N/

A 

Communit

y/Populati

on Health 

Tobacco Use and Help with Quitting 

Among Adolescents: The percentage of 

adolescents 12 to 20 years of age with a 

primary care visit during the 

measurement year for whom tobacco use 

status was documented and received help 

with quitting if identified as a tobacco 

user 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

NCQA / 

NCIQM X X 

N/A/

400 

N/

A 

Effective 

Clinical 

Care 

Hepatitis C: One-Time Screening for 

Hepatitis C Virus (HCV) for Patients 

at Risk: Percentage of patients aged 18 

years and older with one or more of the 

following: a history of injection drug use, 

receipt of a blood transfusion prior to 

1992, receiving maintenance 

hemodialysis OR birthdate in the years 

1945-1965 who received a one-time 

screening for HCV infection 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS.

AGA / 

AASLD / 

AMAPCPI 

 X 

0097 

/046 

N/

A 

Communi

cation and 

Care 

Coordinati

on 

Medication Reconciliation: Percentage 

of patients aged 18 years and older 

discharged from any inpatient facility (for 

example, hospital, skilled nursing facility, 

or rehabilitation facility) and seen within 

30 days following discharge in the office 

by the physician, prescribing practitioner, 

registered nurse, or clinical pharmacist 

providing on-going care who had a 

reconciliation of the discharge 

medications with the current medication 

list in the outpatient medical record 

documented 

This measure is reported as two rates 

NCQA/ 

AMAPCPI X X 
CMS-1612-FC 719 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

stratified by age group: 

Reporting Age Criteria 1: 18-64 years of 

age 

Reporting Age Criteria 2: 65 years and 

older. 

Commenters supported the inclusion of 

this measure as cross cutting “due to its 

focus on critical care coordination 

transitions between hospitals and 

ambulatory care providers.” As such, 

CMS is finalizing its proposal to make 

this measure reportable as a cross-cutting 

measure for 2015 PQRS. We note that 

while the proposed rule limited the 

applicability of this measure to patients 

65 years and older, the range of this 

mesaure was changed to include patients 

18-64 years of age by the measure 

steward. This measure update is endorsed 

by NQF. 

0326 

/047 

N/

A 

Communi

cation and 

Care 

Coordinati

on 

Care Plan: Percentage of patients aged 

65 years and older who have an advance 

care plan or surrogate decision maker 

documented in the medical record or 

documentation in the medical record that 

an advance care plan was discussed but 

the patient did not wish or was not able to 

name a surrogate decision maker or 

provide an advance care plan 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS.

NCQA/ 

AMAPCPI X X X 

0041 

/110 

147

v4 

Communit

y/Populati

on Health 

Preventive Care and Screening: 

Influenza Immunization: Percentage of 

patients aged 6 months and older seen for 

a visit between October 1 and March 31 

who received an influenza immunization 

OR who reported previous receipt of an 

influenza immunization 

 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

AMAPCPI X X X X X ACO 

MU2 

0043 

/111 

127

v3 

Communit

y/Populati

on Health 

Pneumonia Vaccination Status for 

Older Adults: Percentage of patients 65 

years of age and older who have ever 

received a pneumococcal vaccine 

NCQA X X X X X ACO 

MU2 
CMS-1612-FC 720 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS.

0421 

/128 

69v

3 

Communit

y/Populati

on Health 

Preventive Care and Screening: Body 

Mass Index (BMI) Screening and 

Follow-Up Plan: Percentage of patients 

aged 18 years and older with a BMI 

documented during the current encounter 

or during the previous six months AND 

with a BMI outside of normal parameters, 

a follow-up plan is documented during 

the encounter or during the previous six 

months of the current encounter 

Normal Parameters: Age 65 years and 

older BMI ≥ 23 and < 30 kg/m2

; Age 18-

64 years BMI ≥ 18.5 and < 25 kg/m2

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

CMS/QIP X X X X X ACO 

MU2 

0419 

/130 

68v

4 

Patient 

Safety 

Documentation of Current Medications 

in the Medical Record: Percentage of 

visits for patients aged 18 years and older 

for which the eligible professional attests 

to documenting a list of current 

medications using all immediate 

resources available on the date of the 

encounter. This list must include ALL 

known prescriptions, over-the-counters, 

herbals, and vitamin/mineral/dietary 

(nutritional) supplements AND must 

contain the medications’ name, dosage, 

frequency and route of administration 

 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

CMS/QIP X X X X X ACO 

MU2 

0420 

/131 

N/

A 

Communi

cation and 

Care 

Coordinati

on 

Pain Assessment and Follow-Up:

Percentage of visits for patients aged 18 

years and older with documentation of a 

pain assessment using a standardized 

tool(s) on each visit AND documentation 

of a follow-up plan when pain is present 

No comments were received regarding 

this measure being classified as crosscutting. CMS is finalizing its proposal to 

CMS/QIP X X X 
CMS-1612-FC 721 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

make this measure reportable as a crosscutting measure for 2015 PQRS.

0418 

/134 2v4 

Communit

y/Populati

on Health 

Preventive Care and Screening: 

Screening for Clinical Depression and 

Follow-Up Plan: Percentage of patients 

aged 12 years and older screened for 

clinical depression on the date of the 

encounter using an age appropriate 

standardized depression screening tool 

AND if positive, a follow-up plan is 

documented on the date of the positive 

screen 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

CMS/QIP X X X X X ACO 

MU2 

N/A 

/182 

N/

A 

Communi

cation and 

Care 

Coordinati

on 

Functional Outcome Assessment:

Percentage of visits for patients aged 18 

years and older with documentation of a 

current functional outcome assessment 

using a standardized functional outcome 

assessment tool on the date of encounter 

AND documentation of a care plan based 

on identified functional outcome 

deficiencies on the date of the identified 

deficiencies 

No comments were received regarding 

this measure being classified as crosscutting. CMS is finalizing its proposal to 

make this measure reportable as a crosscutting measure for 2015 PQRS.

CMS/QIP X X 

0028 

/226 

138

v3 

Communit

y/Populati

on Health 

Preventive Care and Screening: 

Tobacco Use: Screening and Cessation 

Intervention: Percentage of patients aged 

18 years and older who were screened for 

tobacco use one or more times within 24 

months AND who received cessation 

counseling intervention if identified as a 

tobacco user 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

AMAPCPI X X X X X 

ACO 

MU2 

Million 

Hearts 
CMS-1612-FC 722 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

0018 

/236 

165

v3 

Effective 

Clinical 

Care 

Controlling High Blood Pressure: 

Percentage of patients 18-85 years of age 

who had a diagnosis of hypertension and 

whose blood pressure was adequately 

controlled (<140/90 mmHg) during the 

measurement period 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. This measure was part of the 

cardiovascular prevention and ischemic 

vascular disease measures group. 

Therefore, the details and rationale 

regarding the changes we are making to 

this measure can be found in our 

discussion of the cardiovascular 

prevention and ischemic vascular disease 

measures group in section III.K.5.d of this 

final rule.

NCQA X X X X 

ACO 

MU2 

Million 

Hearts 

0038 

/240 

117

v3 

Communit

y/Populati

on Health 

Childhood Immunization Status:

Percentage of children 2 years of age who 

had four diphtheria, tetanus and acellular 

pertussis (DTaP); three polio (IPV), one 

measles, mumps and rubella (MMR); 

three H influenza type B (HiB); three 

hepatitis B (Hep B); one chicken pox 

(VZV); four pneumococcal conjugate 

(PCV); one hepatitis A (Hep A); two or 

three rotavirus (RV); and two influenza 

(flu) vaccines by their second birthday 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

NCQA X MU2 

N/A 

/317 

22v

3 

Communit

y/Populati

on Health 

Preventive Care and Screening: 

Screening for High Blood Pressure and 

Follow-Up Documented: Percentage of 

patients aged 18 years and older seen 

during the reporting period who were 

screened for high blood pressure (BP) 

AND a recommended follow-up plan is 

documented based on the current blood 

pressure reading as indicated 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS.

CMS/QIP X X X X X 

ACO 

MU2 

Million 

Hearts 
CMS-1612-FC 723 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

0101 

/318 

139

v3 

Patient 

Safety 

Falls: Screening for Fall Risk:

Percentage of patients 65 years of age and 

older who were screened for future fall 

risk at least once during the measurement 

period 

Commenters agreed this measure was 

appropriately classified as cross-cutting. 

For this reason, CMS is finalizing its 

proposal to make this measure reportable 

as a cross-cutting measure for 2015 

PQRS. 

NCQA X X ACO 

MU2 

0005

&00

06 

/321 

N/

A 

Person 

and 

Caregiver 

Experienc

e and 

Outcomes 

CAHPS for PQRS Clinician/Group 

Survey: 

• Getting timely care, appointments, and 

information; 

• How well providers Communicate; 

• Patient’s Rating of Provider; 

• Access to Specialists; 

• Health Promotion & Education; 

• Shared Decision Making; 

• Health Status/Functional Status; 

• Courteous and Helpful Office Staff; 

• Care Coordination; 

• Between Visit Communication; 

• Helping Your to Take Medication as 

Directed; and 

• Stewardship of Patient Resources 

No comments were received regarding 

this measure being classified as crosscutting. CMS is finalizing its proposal to 

make this measure reportable as a crosscutting measure for 2015 PQRS.

AHRQ X ACO 

N/A 

/374 

50v

3 

Communi

cation and 

Care 

Coordinati

on 

Closing the Referral Loop: Receipt of 

Specialist Report: Percentage of patients 

with referrals, regardless of age, for 

which the referring provider receives a 

report from the provider to whom the 

patient was referred 

No comments were received regarding 

this measure being classified as crosscutting. CMS is finalizing its proposal to 

make this measure reportable as a crosscutting measure for 2015 PQRS. 

CMS/BA

H X MU2 

Additional Measures Finalized in Response to Public Comment 

0059

/001 

122

v3 

Effective 

Clinical 

Care 

Diabetes: Hemoglobin A1c Poor 

Control: Percentage of patients 18-75 

years of age with diabetes who had 

hemoglobin A1c > 9.0% during the 

measurement period 

This measure was not proposed for the 

cross-cutting measure set for 2015 and 

beyond. However, in addition to seeking 

comment on the proposed cross-cutting 

NCQA X X X X X ACO 

MU2 
CMS-1612-FC 724 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure 

Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface) 

Measures Groups 

Other Quality 

Reporting 

Programs 

measure set specified in Table 21 of the 

proposed rule, we sought comment on 

other measures that commenters believed 

should be included in that proposed crosscutting measure set for 2015 and beyond 

(79 FR 40403). Commenters suggested 

that CMS “include a diabetes-related 

measure such as NQF 0059 "Hemoglobin 

Al C Poor Control" or other diabetes 

measure in the cross-cutting measure set 

for reporting under PQRS” as it is a 

measure that most eligible professionals 

can report. CMS agrees and is, therefore, 

finalizing the addition of PQRS #001 to 

the cross-cutting measure set for 2015 

PQRS. CMS may consider additional 

measures for the cross-cutting measure 

set in future program years.

¥ Measure details including titles, descriptions and measure owner information may vary during a particular 

program year. This is due to the timing of measure specification preparation and the measure versions used by the 

various reporting options/methods. Please refer to the measure specifications that apply for each of the reporting 

options/methods for specific measure details. 

c. New PQRS Measures Available for Reporting for 2015 and Beyond 

Table 22 in the CY 2015 PFS proposed rule (79 FR 40410) contained the additional measures we 

proposed to include in the PQRS measure set for CY 2015 and beyond. In Table 53, we provide our 

response to the comments we received on these measures as well as our final decisions on these proposed 

measures. We have also indicated the PQRS reporting mechanism or mechanisms through which each 

measure could be submitted. As stated above, please note that the following tables may also contain 

discussions of comments we received related to proposed changes to the measures included in the quality 

performance standard under the Shared Savings Program. 
CMS-1612-FC 725

TABLE 53: New Individual Quality Measures and Those Included in Measures Groups for the 

PQRS to Be Available for Satisfactory Reporting Beginning in 2015

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Measures Finalized as Proposed or with Modifications 

187

9 

/38

3 

N/

A 

Patient 

Safety 

Adherence to Antipsychotic Medications 

for Individuals with Schizophrenia: The 

percentage of individuals 18 years of age or 

greater as of the beginning of the 

measurement period with schizophrenia or 

schizoaffective disorder who are prescribed 

an antipsychotic medication, with 

adherence to the antipsychotic medication 

[defined as a Proportion of Days Covered 

(PDC)] of at least 0.8 during the 

measurement period (12 consecutive 

months) 

Commenters supported the inclusion of this 

measure in PQRS but request this measure 

also be reportable through claims. Although 

CMS understands commenters’ concern 

regarding reporting via registry only, we 

have determined that the complexity of the 

measure warrants reportability only through 

the registry reporting option. For this 

reason, CMS is finalizing this measure to 

be reportable beginning in 2015 for PQRS. 

CMS / 

FMQAI X 

N/

A 

/38

4 

N/

A 

Effective 

Clinical 

Care 

Adult Primary Rhegmatogenous Retinal 

Detachment Repair Success Rate:

Percentage of surgeries for primary 

rhegmatogenous retinal detachment where 

the retina remains attached after only one 

surgery 

CMS received no comments on this 

measure. This is an outcome-based measure 

that addresses a new clinical concept not 

currently captured within PQRS and targets 

a specialty provider group, 

ophthalmologist, who are often 

underrepresented in the PQRS program. As 

such, this measure provides meaningful 

value for the PQRS program. For these 

reasons, CMS is finalizing its proposal to 

make this measure reportable beginning in 

2015 for PQRS. 

American 

Associatio

n of Eye 

and Ear 

Centers of 

Excellenc

e 

 X 

N/

A 

/38

5 

N/

A 

Effective 

Clinical 

Care 

Adult Primary Rhegmatogenous Retinal 

Detachment Surgery Success Rate:

Percentage of retinal detachment cases 

achieving flat retinas six months postsurgery 

Commenters disagreed with CMS’s 

proposal to include this measure in PQRS, 

noting the measure has not been broadly 

American 

Associatio

n of Eye 

and Ear 

Centers of 

Excellenc

e/ The 

Australian 

Council 

 X 
CMS-1612-FC 726

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

tested and possible unintended 

consequences that may drive physicians to 

perform retinal detachment surgeries in the 

hospital setting. This is an outcome-based 

measure that addresses a new clinical 

concept not currently captured within 

PQRS and targets a specialty provider 

group, ophthalmologists, who are often 

underrepresented in the PQRS program. 

Furthermore, the steward confirmed the 

setting of service is not relevant as a 

negative consequence of this measure. 

CMS agrees with this assessment that the 

setting of care is not an unintended 

consequence that would negatively impact 

the patient if this surgery were conducted in 

a hospital and believes this measure 

provides meaningful value for the PQRS 

program. For these reasons, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

on 

Healthcar

e 

Standards 

N/

A 

/38

6 

N/

A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Amyotrophic Lateral Sclerosis (ALS) 

Patient Care Preferences: Percentage of 

patients diagnosed with Amyotrophic 

Lateral Sclerosis (ALS) who were offered 

assistance in planning for end of life issues 

(for example, advance directives, invasive 

ventilation, hospice) at least once annually 

No comments were received regarding this 

measure being added to PQRS. CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

AAN X 

N/

A 

/38

7 

N/

A 

Effective 

Clinical 

Care 

Annual Hepatitis C Virus (HCV) 

Screening for Patients who are Active 

Injection Drug Users: Percentage of 

patients regardless of age who are active 

injection drug users who received screening 

for HCV infection within the 12 month 

reporting period 

Although one commenter requested this 

measure be adjusted to include more than 

“injection drug use,” citing its limiting risk 

factor, several commenters supported the 

inclusion of this measure in PQRS. 

Injection drug use has been associated as a 

high risk factor for HCV. Therefore, CMS 

is finalizing its proposal to make this 

measure reportable beginning in 2015 for 

PQRS. 

AGA / 

AASLD / 

PCPI 

 X 

N/

A 

/38

8 

N/

A 

Patient 

Safety 

Cataract Surgery with Intra-Operative 

Complications (Unplanned Rupture of 

Posterior Capsule Requiring Unplanned 

Vsitrectomy): Rupture of the posterior 

capsule during anterior segment surgery 

AAEECE 

/ ACHS X X 
CMS-1612-FC 727

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

requiring vsitrectomy 

Several commenters submitted positive 

comments about the inclusion of this 

measure in the PQRS program and 

requested that CMS make this measure 

reportable via claims. In addition, there 

were commenters that encouraged CMS to 

“test this measure before implementation.” 

Commenters did not specify the type of 

testing. This measure, per the guidelines of 

quality measure inclusion required for the 

PQRS program, has been tested by the 

steward. Furthermore, this is an outcome 

measure that complements the existing 

cataracts measures with a clinical focus not 

currently captured within PQRS. For these 

reasons, CMS is finalizing its proposal to 

make this measure reportable beginning in 

2015 for PQRS for registry and measure 

group reporting only. CMS is moving away 

from claims-based reporting and as such is 

not finalizing this measure for claims 

reporting in 2015 PQRS. 

N/

A 

/38

9 

N/

A 

Effective 

Clinical 

Care 

Cataract Surgery: Difference Between 

Planned and Final Refraction: Percentage 

of patients who achieve planned refraction 

within +-1,0 D 

Several commenters submitted positive 

comments about the inclusion of this 

measure in the PQRS program and 

requested that CMS make this measure 

reportable via claims. In addition, there 

were commenters that encouraged CMS to 

test this measure before implementation. 

Commenters did not specify the type of 

testing. This measure, per the guidelines of 

quality measure inclusion in the PQRS 

program, has been tested by the steward. 

Furthermore, this is an outcome measure 

that complements the existing cataracts 

measures with a clinical focus not currently 

captured within PQRS. For these reasons, 

CMS is finalizing its proposal to make this 

measure reportable beginning in 2015 for 

PQRS for registry and measure group 

reporting only. CMS is moving away from 

the claims reporting option and as such is 

not finalizing this measure as reportable for 

claims in 2015 PQRS. 

AAEECE 

/ ACHS X X 

N/

A 

/39

0 

N/

A 

Person and 

CaregiverCentered 

Experience 

and 

Discussion and Shared Decision Making 

Surrounding Treatment Options:

Percentage of patients aged 18 years and 

older with a diagnosis of hepatitis C with 

whom a physician or other qualified 

AGA / 

AASLD / 

PCPI 

 X X 
CMS-1612-FC 728

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Outcomes healthcare professional reviewed the range 

of treatment options appropriate to their 

genotype and demonstrated a shared 

decision making approach with the patient. 

To meet the measure, there must be 

documentation in the patient record of a 

discussion between the physician or other 

qualified healthcare professional and the 

patient that includes all of the following: 

treatment choices appropriate to genotype, 

risks and benefits, evidence of 

effectiveness, and patient preferences 

toward treatment 

Some commenters expressed concern that 

this measure might incentivize providers 

not to treat patients, indicating a provider 

might “simply note “the patient expressed 

reservations about potential side effects and 

we decided to defer treatment,” rather than 

working with the patient to address 

concerns and optimize uptake of the 

appropriate care.” However, CMS feels 

strongly that patients need to be provided 

appropriate information that would help 

patients to make their decision on treatment 

options. This measure focuses on 

discussion and shared decision making on 

treatment options. For these reasons, CMS 

is finalizing its proposal to include this 

measure for registry and measure group 

reporting in 2015 PQRS. 

N/

A 

/39

1 

N/

A 

Communica

tion and 

Care 

Coordinatio

n 

Follow-up After Hospitalization for 

Mental Illness (FUH): The percentage of 

discharges for patients 6 years of age and 

older who were hospitalized for treatment 

of selected mental illness diagnoses and 

who had an outpatient visit, an intensive 

outpatient encounter or partial 

hospitalization with a mental health 

practitioner. Two rates are reported: 

- The percentage of discharges for which 

the patient received follow-up within 30 

days of discharge 

- The percentage of discharges for which 

the patient received follow-up within 7 

days of discharge 

Commenters supported the inclusion of this 

measure in PQRS but request this measure 

also be reportable through claims. It is a 

priority for PQRS to ultimately increase the 

quality of health care. In order to achieve 

this goal, PQRS needs reliable and robust 

data on health service delivery and claimsbased reporting has demonstrated, over 

NCQA X 
CMS-1612-FC 729

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

several years, the highest error rate among 

the PQRS reporting options. For this 

reason, CMS is finalizing its proposal to 

make this measure reportable beginning in 

2015 for PQRS for registry reporting only.

N/

A 

/39

2 

N/

A 

Patient 

Safety 

HRS-12: Cardiac Tamponade and/or 

Pericardiocentesis Following Atrial 

Fibrillation Ablation: Rate of cardiac 

tamponade and/or pericardiocentesis 

following atrial fibrillation ablation 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

HRS X 

N/

A 

/39

3 

N/

A 

Patient 

Safety 

HRS-9: Infection within 180 Days of 

Cardiac Implantable Electronic Device 

(CIED) Implantation, Replacement, or 

Revision: Infection rate following CIED 

device implantation, replacement, or 

revision 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

HRS X 

140

7 

/39

4 

N/

A 

Community/

Population 

Health 

Immunizations for Adolescents: The 

percentage of adolescents 13 years of age 

who had the recommended immunizations 

by their 13th birthday 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

NCQA X 

N/

A 

/39

5 

N/

A 

Communica

tion and 

Care 

Coordinatio

n 

Lung Cancer Reporting 

(Biopsy/Cytology Specimens): Pathology 

reports based on biopsy and/or cytology 

specimens with a diagnosis of primary 

nonsmall cell lung cancer classified into 

specific histologic type or classified as 

NSCLC-NOS with an explanation included 

in the pathology report 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

CAP X X 

N/

A 

/39

6 

N/

A 

Communica

tion and 

Care 

Coordinatio

n 

Lung Cancer Reporting (Resection 

Specimens): Pathology reports based on 

resection specimens with a diagnosis of 

primary lung carcinoma that include the pT 

category, pN category and for non-small 

cell lung cancer, histologic type 

Commenters supported the inclusion of this 

CAP X X 
CMS-1612-FC 730

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

N/

A 

/39

7 

N/

A 

Communica

tion and 

Care 

Coordinatio

n 

Melanoma Reporting: Pathology reports 

for primary malignant cutaneous melanoma 

that include the pT category and a 

statement on thickness and ulceration and 

for pT1, mitotic rate 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

CAP X X 

N/

A 

/39

8 

N/

A 

Effective 

Clinical 

Care 

Optimal Asthma Control: Patients ages 5-

50 (pediatrics ages 5-17) whose asthma is 

well-controlled as demonstrated by one of 

three age appropriate patient reported 

outcome tools 

 

Several commenters disagreed with CMS’s 

proposal to replace existing measure 

(PQRS #064 “Asthma: Assessment of 

Asthma Control – Ambulatory Care 

Setting”) with this new measure. Details 

regarding commenters concerns with 

removing PQRS #064 can be found in 

Table 56. Although CMS understands the 

limitations of the current measure as it 

relates to the upper age limit, risk 

adjustment and the calculation of 

improvement over time, this measure 

represents a more robust clinical outcome 

for asthma care. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS for 

registry only. 

In addition, CMS re-evaluated the 

categorization of this measure to the Person 

and Caregiver Experience and Outcomes 

domain and determined it was more 

appropriately categorized under Effective 

Clinical Care. As such, CMS is finalizing 

this measure under Effective Clinical Care 

for 2015 PQRS program. 

MNCM X 

N/

A 

/39

9 

N/

A 

Effective 

Clinical 

Care 

Post-Procedural Optimal Medical 

Therapy Composite (Percutaneous 

Coronary Intervention): Percentage of 

patients aged 18 years and older for whom 

PCI is performed who are prescribed 

optimal medical therapy at discharge 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

ACCAHA X 
CMS-1612-FC 731

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

N/

A/ 

/40

0 

N/

A 

Effective 

Clinical 

Care 

Hepatitis C: One-Time Screening for 

Hepatitis C Virus (HCV) for Patients at 

Risk: Percentage of patients aged 18 years 

and older with one or more of the 

following: a history of injection drug use, 

receipt of a blood transfusion prior to 1992, 

receiving maintenance hemodialysis OR 

birthdate in the years 1945-1965 who 

received a one-time screening for HCV 

infection 

Although one commenter requested this 

measure be adjusted to include more than 

“injection drug use,” citing its limiting risk 

factor, injection drug use has been 

associated as a high-risk factor for HCV. 

Additionally, the commenter suggested that 

this measure include “risk groups” to 

encompass men who have sex with men 

(MSM). Transmission of HCV by sex is 

low and does not necessitate routine 

screening. Furthermore, several 

commenters supported the inclusion of this 

measure in PQRS. CMS received public 

comment from the measure steward 

indicating this measure should be classified 

under the domain of Effective Clinical 

Care. After further review, CMS 

determined this measure was more 

appropriately categorized under the 

Effective Clinical Care domain based on 

the HHS decision rule guidelines for 

categorizing measures. For these reasons, 

CMS is finalizing its proposal to make this 

measure reportable beginning in 2015 for 

PQRS. 

AGA / 

AASLD / 

AMAPCPI 

 X 

N/

A 

/40

1 

N/

A 

Effective 

Clinical 

Care 

Screening for Hepatocellular Carcinoma 

(HCC) in patients with Hepatitis C 

Cirrhosis: Percentage of patients aged 18 

years and older with a diagnosis of chronic 

hepatitis C cirrhosis who underwent 

imaging with either ultrasound, contrast 

enhanced CT or MRI for hepatocellular 

carcinoma (HCC) at least once within the 

12 month reporting period 

Commenters supported the inclusion of this 

measure in PQRS, but also suggested CMS 

refine the measure language to include 

other risk groups and diagnosis. We 

appreciate the commenters’ support for this 

measure. With respect to the measure 

language, we note that we have decided not 

to make changes to this measure in order to 

maintain consistency with the 

specifications maintained by the measure 

AGA / 

AASLD / 

AMAPCPI 

 X X 
CMS-1612-FC 732

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

developper and owner. Based on the 

comments received, CMS is finalizing its 

proposal to make this measure reportable 

beginning in 2015 for PQRS. 

N/

A 

/40

2 

N/

A 

Community/

Population 

Health 

Tobacco Use and Help with Quitting 

Among Adolescents: The percentage of 

adolescents 12 to 20 years of age with a 

primary care visit during the measurement 

year for whom tobacco use status was 

documented and received help with quitting 

if identified as a tobacco user 

Commenters supported the inclusion of this 

measure in PQRS. For this reason, CMS is 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS. 

NCQA / 

NCIQM X X 

Measures Not Finalized as Proposed 

188

0 

/N/

A 

N/

A 

Patient 

Safety 

Adherence to Mood Stabilizers for 

Individuals with Bipolar I Disorder: The 

measure calculates the percentage of 

individuals aged 18 years and older with 

bipolar I disorder who are prescribed a 

mood stabilizer medication, with adherence 

to the mood stabilizer medication [defined 

as a Proportion of Days Covered (PDC)] of 

at least 0.8 during the measurement period 

(12 consecutive months) 

Commenters supported the inclusion of this 

measure in PQRS but request this measure 

also be reportable through registry. CMS 

confirmed with the measure steward that 

this measure was tested for reportability 

through claims and not registry. Given this, 

CMS does not believe this measure is ready 

for implementation in 2015 PQRS as CMS 

does not believe this measure is appropriate 

for claims-based reporting and thus CMS is 

not finalizing this measure for reporting in 

2015 PQRS. 

CMS/FM

QAI X 

N/

A 

/N/

A 

N/

A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Average change in functional status 

following lumbar spine fusion surgery:

Average change from pre-operative 

functional status assessment to one year 

(nine to fifteen months) post-operative 

functional status using the Oswestry 

Disability Index (ODI version 2.1a) patient 

reported outcome tool 

Commenters note this measure has not been 

fully vetted or tested. Furthermore, there 

are analytic challenges to implementing this 

measure and the lack of a performance 

target to assess this measure against. For 

this reason, CMS is not finalizing this 

measure for inclusion in 2015 PQRS. 

MNCM X 
CMS-1612-FC 733

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

N/

A 

/N/

A 

N/

A 

Efficiency 

and Cost 

Reduction 

Avoidance of inappropriate use of 

imaging for adult ED patients with 

traumatic low back pain: Avoidance of 

inappropriate use of imaging for adult ED 

patients with traumatic low back pain 

While one commenter supported the 

addition of this measure to PQRS noting it 

“will incentivize providers to minimize 

unnecessary or excessive radiation 

exposure, which insures to the benefit of 

beneficiaries,” the measure steward 

withdrew support of this measure as the 

measure is not yet sufficiently specified nor 

has it undergone public review and 

comment. For this reason, CMS is not 

finalizing this measure for PQRS 2015. 

ACEP X 

188

5 

/N/

A 

N/

A 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Depression Response at Twelve MonthsProgress Towards Remission: Adult 

patients age 18 and older with major 

depression or dysthymia and an initial 

PHQ-9 (Patient Health Questionnaire 9) 

score greater than nine who demonstrate a 

response to treatment at twelve months 

defined as a PHQ-9 score that is reduced by 

50% or greater from the initial PHQ-9 

score. This measure applies to both patients 

with newly diagnosed or existing 

depression identified during the defined 

measurement period whose current PHQ-9 

score indicates a need for treatment 

CMS believes that NQF 1885 is duplicative 

of PQRS 370 “Depression Remission at 

Twelve Months.” As such, CMS is not 

finalizing its proposal to add NQF 1885 as 

a new measure for reporting in the 2015 

PQRS Program. 

MNCM X 

N/

A 

/N/

A 

N/

A 

Patient 

Safety 

Discontinuation of Antiviral Therapy for 

Inadequate Viral Response: Percentage of 

patients aged 18 years and older with a 

diagnosis of hepatitis C genotype 1 who 

had an inadequate response to antiviral 

treatment for whom antiviral treatment was 

discontinued 

Commenters, including the measure 

steward, suggest clinical guidelines are 

changing for Hepatitis C virus therapy, 

impacting the clinical appropriateness of 

this measure specifically. No other 

measures under consideration were 

affected. As such, CMS is not finalizing 

this measure for PQRS 2015, allowing time 

for the evolving clinical guidance to be 

finalized. 

AGA / 

AASLD / 

PCPI 

 X 
CMS-1612-FC 734

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

N/

A 

/N/

A 

N/

A 

Effective 

Clinical 

Care 

Freedom from Reintervention or 

Amputation Following Endovascular 

Infrainguinal Lower Extremity 

Revascularization for Non-limb 

threatening ischemia: Percentage of 

patients undergoing endovascular 

infrainguinal revascularization for non-limb 

threatening ischemia (claudication or 

asymptomatic) who do not require 

ipsilateral repeat revascularization or any 

amputation within one year 

The measure steward withdrew support of 

this measure as the measure specifications 

are incomplete at this time. For this reason, 

CMS is not finalizing this measure for 

PQRS 2015 but may consider this measure 

for a future program year. 

SVS X 

N/

A 

/N/

A 

N/

A 

Effective 

Clinical 

Care 

Freedom from Reintervention or 

Amputation Following Open 

Infrainguinal Lower Extremity 

Revascularization for non-limb 

threatening ischemia: Percentage of 

patients undergoing open infrainguinal 

revascularization for non-limb threatening 

ischemia (claudication or asymptomatic) 

who do not require ipsilateral repeat 

revascularization or any amputation within 

one year 

The measure steward withdrew support of 

this measure as the measure specifications 

are incomplete at this time. For this reason, 

CMS is not finalizing this measure for 

PQRS 2015 but may consider this measure 

for a future program year. 

SVS X 

662

/N/

A 

N/

A 

Communica

tion and 

Care 

Coordinatio

n 

Median Time to Pain Management for 

Long Bone Fracture: Median time from 

emergency department (ED) arrival to time 

of initial oral, intranasal or parenteral pain 

medication administration for emergency 

department patients with a principal 

diagnosis of long bone fracture (LBF) 

While some commenters supported the 

inclusion of this measure in PQRS, after 

further review CMS determined that 

comparison across measurement periods, 

particularly when the reporting period for 

the PQRS payment adjustments is a 12-

month calendar year, poses an analytic 

challenge for reporting purposes. CMS 

currently does not have a measure in the 

PQRS where data is collected outside a 

respective reporting period and compared 

to an existing reporting period without an 

CMS/OF

MQ X 
CMS-1612-FC 735

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

establised performance met target. While 

we welcome intermediate outcome 

measures such as these, it is not technically 

feasible at this time to include this measure 

in the PQRS. For this reason, CMS is not 

finalizing its proposal to make this measure 

reportable beginning in 2015 for PQRS.

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is 

due to the timing of measure specification preparation and the measure versions used by the various reporting options/methods. 

Please refer to the measure specifications that apply for each of the reporting options/methods for specific measure details. 

In Table 54, we provide our responses and final decisions on the measures for which we proposed 

a NQS domain change for reporting under the PQRS (79 FR 40419). Please note that we received 

comments regarding the process for changing a measure’s domain. With respect to these comments, we 

appreciate the commenters’ suggestions regarding the process for domain changes for measures and will 

take these comments under consideration. We are developing guidelines for assigning measure domains 

and will use these guidelines to assign each measure in the PQRS program to a NQS domain when 

measure stewards submit measures through the Call for Measures process each program year. We value 

feedback from measure developers and are dedicated to making updates to the PQRS program a 

transparent and collaborative process as it works to establish measures that are applicable to various 

domain categories. 

 
CMS-1612-FC 736

TABLE 54: NQS Domain Changes for Individual Quality Measures and Those Included in 

Measures Groups for the PQRS Beginning in 2015

NQF/ 

PQRS 

CMS 

E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

Measures Finalized as Proposed 

009

7/0

46 

N/

A 

Patient 

Safety 

Commun

ication 

and Care 

Coordina

tion

Medication Reconciliation: Percentage of patients 

aged 18 years and older discharged from any inpatient 

facility (for example, hospital, skilled nursing facility, 

or rehabilitation facility) and seen within 30 days 

following discharge in the office by the physician, 

prescribing practitioner, registered nurse, or clinical 

pharmacist providing on-going care who had a 

reconciliation of the discharge medications with the 

current medication list in the outpatient medical record 

documented. 

This measure is reported as two rates stratified by age 

group: 

Reporting Age Criteria 1: 18-64 years of age 

Reporting Age Criteria 2: 65 years and older. 

Commenters supported the proposed domain change 

for PQRS #46 from Patient Safety to Communication 

and Care Coordination. For this reason, CMS is 

finalizing its proposal to change the domain of this 

measure for 2015 PQRS.

X X 

065

0/1

37 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion

Melanoma: Continuity of Care – Recall System:

Percentage of patients, regardless of age, with a current 

diagnosis of melanoma or a history of melanoma 

whose information was entered, at least once within a 

12 month period, into a recall system that includes: 

 • A target date for the next complete physical skin 

exam, AND 

 • A process to follow up with patients who either did 

not make an appointment within the specified 

timeframe or who missed a scheduled appointment 

Commenters supported the proposed domain change 

for PQRS #137 from Effective Clinical Care to 

Communication and Care Coordination. For this 

reason, CMS is finalizing its proposal to change the 

domain of this measure for 2015 PQRS. 

 X 

N/

A/2

88 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion 

Dementia: Caregiver Education and Support:

Percentage of patients, regardless of age, with a 

diagnosis of dementia whose caregiver(s) were 

provided with education on dementia disease 

management and health behavior changes AND 

referred to additional sources for support within a 12 

month period 

Commenters disagreed with the proposed domain 

change but did not explain why. However, while this 

measure does fall into both the Communication and 

Care Coordination and Person and Caregiver-Centered 

 X 
CMS-1612-FC 737 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

Experience and Outcomes domains, Communication 

and Care Coordination should become the new primary 

domain. While the measure does target the education 

and referral of the patient's caregiver to supportive 

services, this is a secondary goal of the measure -- the 

primary intent is to disseminate information related to 

caring for a patient with dementia, including making 

connections to all potentially necessary providers. For 

these reasons, CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

N/

A/2

93 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion 

Parkinson’s Disease: Rehabilitative Therapy 

Options: All patients with a diagnosis of Parkinson’s 

disease (or caregiver(s), as appropriate) who had 

rehabilitative therapy options (for example, physical, 

occupational, or speech therapy) discussed at least 

annually 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/2

94 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion 

Parkinson’s Disease: Parkinson’s Disease Medical 

and Surgical Treatment Options Reviewed: All 

patients with a diagnosis of Parkinson’s disease (or 

caregiver(s), as appropriate) who had the Parkinson’s 

disease treatment options (for example, nonpharmacological treatment, pharmacological treatment, 

or surgical treatment) reviewed at least once annually 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/3

25 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion 

Adult Major Depressive Disorder (MDD): 

Coordination of Care of Patients with Specific 

Comorbid Conditions: Percentage of medical records 

of patients aged 18 years and older with a diagnosis of 

major depressive disorder (MDD) and a specific 

diagnosed comorbid condition (diabetes, coronary 

artery disease, ischemic stroke, intracranial 

hemorrhage, chronic kidney disease [stages 4 or 5], 

End Stage Renal Disease [ESRD] or congestive heart 

failure) being treated by another clinician with 

communication to the clinician treating the comorbid 

condition 

Commenters supported the proposed domain change 

for PQRS #325 from Effective Clinical Care to 

Communication and Care Coordination. For this 

reason, CMS is finalizing its proposal to change the 

domain of this measure for 2015 PQRS. 

 X 

N/

A/3

03 

N/

A 

Effective 

Clinical 

Care 

Person 

and 

Caregive

rCataracts: Improvement in Patient’s Visual 

Function within 90 Days Following Cataract 

Surgery: Percentage of patients aged 18 years and 

older in sample who had cataract surgery and had 

 X X 
CMS-1612-FC 738 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

Centered 

Experien

ce and 

Outcome

s 

improvement in visual function achieved within 90 

days following the cataract surgery, based on 

completing a pre-operative and post-operative visual 

function survey 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS.

N/

A/3

31 

N/

A 

Effective 

Clinical 

Care 

Efficienc

y and 

Cost 

Reductio

n 

Adult Sinusitis: Antibiotic Prescribed for Acute 

Sinusitis (Appropriate Use): Percentage of patients, 

aged 18 years and older, with a diagnosis of acute 

sinusitis who were prescribed an antibiotic within 7 

days of diagnosis or within 10 days after onset of 

symptoms 

Commenters supported the proposed domain change 

for PQRS #331 from Effective Clinical Care to 

Efficiency and Cost Reduction. For this reason, CMS is 

finalizing its proposal to change the domain of this 

measure for 2015 PQRS. 

 X X 

N/

A/3

32 

N/

A 

Effective 

Clinical 

Care 

Efficienc

y and 

Cost 

Reductio

n 

Adult Sinusitis: Appropriate Choice of Antibiotic: 

Amoxicillin Prescribed for Patients with Acute 

Bacterial Sinusitis (Appropriate Use): Percentage of 

patients aged 18 years and older with a diagnosis of 

acute bacterial sinusitis that were prescribed 

amoxicillin, with or without clavulante, as a first line 

antibiotic at the time of diagnosis 

Commenters supported the proposed domain change 

for PQRS #332 from Effective Clinical Care to 

Efficiency and Cost Reduction. For this reason, CMS is 

finalizing its proposal to change the domain of this 

measure for 2015 PQRS. 

 X X 

N/

A/3

47 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Rate of Endovascular Aneurysm Repair (EVAR) of 

Small or Moderate Non-Ruptured Abdominal 

Aortic Aneurysms (AAA) Who Die While in 

Hospital: Percent of patients undergoing endovascular 

repair of small or moderate abdominal aortic 

aneurysms (AAA) who die while in the hospital 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/3

48 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

HRS-3: Implantable Cardioverter-Defibrillator 

(ICD) Complications Rate: Patients with physicianspecific risk-standardized rates of procedural 

complications following the first time implantation of 

an ICD 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/3

54 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Anastomotic Leak Intervention: Percentage of 

patients aged 18 years and older who required an 

anastomotic leak intervention following gastric bypass 

 X 
CMS-1612-FC 739 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

or colectomy surgery

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS.

N/

A/3

55 

N/

A 

Effective 

Clinical 

Care 

Patient 

Safety 

Unplanned Reoperation within the 30 Day 

Postoperative Period: Percentage of patients aged 18 

years and older who had any unplanned reoperation 

within the 30 day postoperative period 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

004

3 

/11

1 

12

7v

3 

Effective 

Clinical 

Care 

Commun

ity/Popul

ation 

Health 

Pneumonia Vaccination Status for Older Adults:

Percentage of patients 65 years of age and older who 

have ever received a pneumococcal vaccine 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS.

X X X X X ACO 

MU2 

032

1/0

82 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Effective 

Clinical 

Care

Adult Kidney Disease: Peritoneal Dialysis 

Adequacy: Solute: Percentage of patients aged 18 

years and older with a diagnosis of End Stage Renal 

Disease (ESRD) receiving peritoneal dialysis who have 

a total Kt/V ≥ 1.7 per week measured once every 4 

months 

Commenters supported the proposed domain change 

for PQRS #82 from Communication and Care 

Coordination to Effective Clinical Care. For this 

reason, CMS is finalizing its proposal to change the 

domain of this measure for 2015 PQRS. 

 X 

N/

A/1

80 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Effective 

Clinical 

Care

Rheumatoid Arthritis (RA): Glucocorticoid 

Management: Percentage of patients aged 18 years 

and older with a diagnosis of rheumatoid arthritis (RA) 

who have been assessed for glucocorticoid use and, for 

those on prolonged doses of prednisone ≥ 10 mg daily 

(or equivalent) with improvement or no change in 

disease activity, documentation of glucocorticoid 

management plan within 12 months 

Commenters supported the proposed domain change 

for PQRS #180 from Communication and Care 

Coordination to Effective Clinical Care. For this 

reason, CMS is finalizing its proposal to change the 

domain of this measure for 2015 PQRS. 

 X AQA 

N/

A/2

80 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Effective 

Clinical 

Care 

Dementia: Staging of Dementia: Percentage of 

patients, regardless of age, with a diagnosis of 

dementia whose severity of dementia was classified as 

mild, moderate or severe at least once within a 12 

month period

Commenters supported the proposed domain change 

 X 
CMS-1612-FC 740 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

for PQRS #280 from Communication and Care 

Coordination to Effective Clinical Care. For this 

reason, CMS is finalizing its proposal to change the 

domain of this measure for 2015 PQRS.

065

4/0

93 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Efficienc

y and 

Cost 

Reductio

n

Acute Otitis Externa (AOE): Systemic 

Antimicrobial Therapy – Avoidance of 

Inappropriate Use: Percentage of patients aged 2 

years and older with a diagnosis of AOE who were not 

prescribed systemic antimicrobial therapy 

Commenters supported the proposed domain change 

for PQRS #93 from Communication and Care 

Coordination to Efficiency and Cost Reduction. For 

this reason, CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

X X X 

N/

A/2

58 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Patient 

Safety 

Rate of Open Repair of Small or Moderate NonRuptured Abdominal Aortic Aneurysms (AAA) 

without Major Complications (Discharged to Home 

by Post-Operative Day #7): Percent of patients 

undergoing open repair of small or moderate sized nonruptured abdominal aortic aneurysms who do not 

experience a major complication (discharge to home no 

later than post-operative day #7) 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/2

59 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Patient 

Safety 

Rate of Endovascular Aneurysm Repair (EVAR) of 

Small or Moderate Non-Ruptured Abdominal 

Aortic Aneurysms (AAA) without Major 

Complications (Discharged to Home by PostOperative Day #2): Percent of patients undergoing 

endovascular repair of small or moderate non-ruptured 

abdominal aortic aneurysms (AAA) that do not 

experience a major complication (discharged to home 

no later than post-operative day #2) 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

N/

A/2

60 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Patient 

Safety 

Rate of Carotid Endarterectomy (CEA) for 

Asymptomatic Patients, without Major 

Complications (Discharged to Home by PostOperative Day #2): Percent of asymptomatic patients 

undergoing CEA who are discharged to home no later 

than post-operative day #2 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X 

152

5/3

26 

N/

A 

Patient 

Safety 

Effective 

Clinical 

Care 

Atrial Fibrillation and Atrial Flutter: Chronic 

Anticoagulation Therapy: Percentage of patients aged 

18 years and older with a diagnosis of nonvalvular 

X X 
CMS-1612-FC 741 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

atrial fibrillation (AF) or atrial flutter whose assessment 

of the specified thromboembolic risk factors indicate 

one or more high-risk factors or more than one 

moderate risk factor, as determined by CHADS2 risk 

stratification, who are prescribed warfarin OR another 

oral anticoagulant drug that is FDA approved for the 

prevention of thromboembolism 

One commenter agreed while another commenter 

disagreed with the proposal to change the domain of 

PQRS #326 from Patient Safety to Effective Clinical 

Care noting “providing anticoagulation therapy for 

atrial fibrillation and atrial flutter patients is a means of 

reducing the risk of stroke in patients presenting for 

more high- or moderate-risk factors.” While not using 

warfarin or another anticoagulation therapy is "a means 

of reducing the risk of stroke in patients presenting for 

more high- or moderate-risk factors," this is a 

secondary outcome of providing the medication, not a 

direct risk caused by the delivery of care. So, while 

taking warfarin or another anticoagulant may provide 

protection against stroke, it is not the primary intent of 

the measure. For these reasons, CMS is finalizing its 

proposal to change the domain of this measure for 2015 

PQRS. 

N/

A/3

21 

N/

A 

Commun

ication 

and Care 

Coordina

tion 

Person 

and 

Caregive

r 

Experien

ce and 

Outcome

s 

CAHPS for PQRS Clinician/Group Survey: 

• Getting timely care, appointments, and information; 

• How well providers Communicate; 

• Patient’s Rating of Provider; 

• Access to Specialists; 

• Health Promotion & Education; 

• Shared Decision Making; 

• Health Status/Functional Status; 

• Courteous and Helpful Office Staff; 

• Care Coordination; 

• Between Visit Communication; 

• Helping Your to Take Medication as Directed; and 

• Stewardship of Patient Resources 

No comments were received regarding the domain for 

this measure. CMS is finalizing its proposal to change 

the domain of this measure for 2015 PQRS. 

 X ACO 

Measures Not Finalized as Proposed 

N/

A/3

56 

N/

A 

Effective 

Clinical 

Care 

Commun

ication 

and Care 

Coordina

tion 

Unplanned Hospital Readmission within 30 Days of 

Principal Procedure: Percentage of patients aged 18 

years and older who had an unplanned hospital 

readmission within 30 days of principal procedure 

One commenter disagreed with CMS’ proposal to 

change the domain of this measure noting that 

"unplanned readmissions can be the result of many 

factors which extend well beyond communication and 

care coordination." The commenter suggested keeping 

 X 
CMS-1612-FC 742 NQF/ PQRS CMS E-Measure ID 

NQS 

Domain 

2014 

NQS 

Domain 

2015 

Measure Title and Description 

Claims 

CSV 

Registry 

EHR 

GPRO (Web Interface) 

Measures Groups 

Other Quality Reporting 

Programs 

Effective Clinical Care as the NQS domain. CMS 

agreed with the commenter and is not finalizing its 

proposal to change the domain of PQRS #356 from 

Effective Clinical Care to Communication and Care 

Coordination for 2015 PQRS. This measure will 

remain as Effective Clinical Care in the 2015 PQRS 

measure set. 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program 

year. This is due to the timing of measure specification preparation and the measure versions used by the various 

reporting options/methods. Please refer to the measure specifications that apply for each of the reporting 

options/methods for specific measure details. 

In Table 55, we provide the responses and final decisions related to the measures we proposed to 

remove from reporting under the PQRS (79 FR 40426). 

 
CMS-1612-FC 743

TABLE 55: Measures Being Removed from the Existing PQRS Measure Set Beginning in 2015 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Measures Finalized as Proposed 

0270/020 Patient 

Safety 

Perioperative Care: Timing of 

Prophylactic Parenteral Antibiotic – 

Ordering Physician: Percentage of surgical 

patients aged 18 years and older undergoing 

procedures with the indications for 

prophylactic parenteral antibiotics, who 

have an order for prophylactic parenteral 

antibiotic to be given within one hour (if 

fluoroquinolone or vancomycin, 2 hours), 

prior to the surgical incision (or start of 

procedure when no incision is required) 

Some commenters disagreed with CMS’ 

proposal to remove this measure noting 

“disparate practice patterns among 

clinicians when selecting the more 

appropriate prophylactic antibiotic.” 

However, other commenters agreed with 

CMS’ proposal to remove this measure 

given the measure’s “emphasis on 

administration rather than ordering of 

antibiotics.” For this reason and given the 

measure’s high rate of performance in 

previous reporting years, CMS is finalizing 

its proposal to remove this measure from 

reporting in 2015 PQRS. 

AMAPCPI 

NCQA 

X X X 

0092/028 

Effective 

Clinical 

Care 

Aspirin at Arrival for Acute Myocardial 

Infarction (AMI): Percentage of patients, 

regardless of age, with an emergency 

department discharge diagnosis of acute 

myocardial infarction (AMI) who had 

documentation of receiving aspirin within 

24 hours before emergency department 

arrival or during emergency department stay 

Commenters disagreed with CMS’ proposal 

to remove this measure noting it presents a 

“reporting opportunity for emergency 

physicians” which could create a reporting 

gap for that segment of providers reporting 

to PQRS. However, CMS continues to 

believe this measure represents a clinical 

concept that has been substantially adopted 

for initial treatment of patients suffering 

from acute myocardial infarction when 

clinically indicated. For this reason, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

AMAPCPI 

NCQA 

X X 

0269/030 Patient 

Safety 

Perioperative Care: Timing of 

Prophylactic Antibiotic—Administering 

Physician: Percentage of surgical patients 

aged 18 years and older who receive an 

anesthetic when undergoing procedures 

with the indications for prophylactic 

AAO X X 
CMS-1612-FC 744 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

parenteral antibiotics for whom 

administration of a prophylactic parenteral 

antibiotic ordered has been initiated within 

1 hour (if fluoroquinolone or vancomycin, 2 

hours) prior to the surgical incision (or start 

of procedure when no incision is required) 

Commenters disagreed with CMS’ proposal 

to remove this measure noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

its potential, and no longer represents a 

clinical performance gap that should be 

measured by the PQRS Program. 

Additionally, CMS will apply the Measure 

Applicability Validation (MAV) process for 

claims-based reporting in those cases where 

specialists do not have enough relevant 

measures to report. For this reason, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

0240/031 

Effective 

Clinical 

Care 

Stroke and Stroke Rehabilitation: 

Venous Thromboembolism (VTE) 

Prophylaxis for Ischemic Stroke or 

Intracranial Hemorrhage: Percentage of 

patients aged 18 years and older with a 

diagnosis of ischemic stroke or intracranial 

hemorrhage who were administered venous 

thromboembolism (VTE) prophylaxis the 

day of or the day after hospital admission 

Commenters disagreed with CMS' proposal 

to remove this measure. Commenters 

maintain that these clinical concepts are 

appropriate for measurement at the 

individual physician level in addition to the 

facility level to help ensure the continuous 

care of stroke patients. CMS believes this 

measure represents a basic standard of care 

and does not add clinical value to PQRS at 

this time. For this reason, CMS is finalizing 

its proposal to remove this measure from 

reporting in 2015 PQRS. 

AANI X X 

0243/035 

Effective 

Clinical 

Care 

Stroke and Stroke Rehabilitation: 

Screening for Dysphagia: Percentage of 

patients aged 18 years and older with a 

diagnosis of ischemic stroke or intracranial 

hemorrhage who receive any food, fluids or 

medication by mouth (PO) for whom a 

dysphagia screening was performed prior to 

PO intake in accordance with a dysphagia 

screening tool approved by the institution in 

which the patient is receiving care 

AANI X X 
CMS-1612-FC 745 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Commenters disagreed with CMS' proposal 

to remove this measure as they maintain that 

these clinical concepts are appropriate for 

measurement at the individual physician 

level in addition to the facility level to help 

ensure the continuous care of stroke 

patients. CMS continues to believe this 

measure represents a basic standard of care 

and does not add clinical value to PQRS at 

this time. For this reason, CMS is finalizing 

its proposal to remove this measure from 

reporting in 2015 PQRS.

0244/036 

Effective 

Clinical 

Care 

Stroke and Stroke Rehabilitation: 

Rehabilitation Services Ordered: 

Percentage of patients aged 18 years and 

older with a diagnosis of ischemic stroke or 

intracranial hemorrhage for whom 

occupational, physical, or speech 

rehabilitation services were ordered at or 

prior to inpatient discharge OR 

documentation that no rehabilitation 

services are indicated at or prior to inpatient 

discharge 

Commenters disagreed with CMS' proposal 

to remove this measure as they maintain that 

these clinical concepts are appropriate for 

measurement at the individual physician 

level in addition to the facility level to help 

ensure the continuous care of stroke 

patients. CMS continues to believe this 

measure represents a basic standard of care 

and does not add clinical value to PQRS at 

this time. For this reason, CMS is finalizing 

its proposal to remove this measure from 

reporting in 2015 PQRS.

AANI X X 

0637/045 Patient 

Safety 

Perioperative Care: Discontinuation of 

Prophylactic Parenteral Antibiotics 

(Cardiac Procedures): Percentage of 

cardiac surgical patients aged 18 years and 

older undergoing procedures with the 

indications for prophylactic parenteral 

antibiotics AND who received a 

prophylactic parenteral antibiotic, who have 

an order for discontinuation of prophylactic 

parenteral antibiotics within 48 hours of 

surgical end time 

Commenters disagreed with CMS’ proposal 

to remove this measure, noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

AMAPCPI 

NCQA 

X X 
CMS-1612-FC 746 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

its potential, and no longer represent a 

clinical performance gap that should be 

measured by the PQRS Program. The 

PQRS will continue to focus on measures 

with maximal potential for improvement 

and that answer a clinical performance gap. 

For this reason, CMS is finalizing its 

proposal to remove this measure from 

reporting in 2015 PQRS.

0099/049 

Effective 

Clinical 

Care 

Urinary Incontinence: Characterization 

of Urinary Incontinence in Women Aged 

65 Years and Older: Percentage of female 

patients aged 65 years and older with a 

diagnosis of urinary incontinence whose 

urinary incontinence was characterized at 

least once within 12 months 

Commenters disagreed with removal of this 

measure due to high performance rates 

indicating this is not a good enough reason 

to remove a measure from the program. 

With a performance rate above 90 percent 

for multiple consecutive years, CMS 

considers the measure to have reached its 

potential, and no longer represent a clinical 

performance gap that should be measured 

by the PQRS Program. The PQRS will 

continue to focus on measures with 

maximal potential for improvement and that 

answer a clinical performance gap. For this 

reason, CMS is finalizing its proposal to 

remove this measure from 2015 PQRS.

NCQA/ 

AMAPCPI X X 

0093 

/055 

Effective 

Clinical 

Care 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed for 

Syncope: Percentage of patients aged 60 

years and older with an emergency 

department discharge diagnosis of syncope 

who had a 12-lead electrocardiogram (ECG) 

performed 

Commenters disagreed with CMS’ proposal 

to remove this measure, noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

its potential, and no longer represent a 

clinical performance gap that should be 

measured by the PQRS Program. The 

PQRS will continue to focus on measures 

with maximal potential for improvement 

and that answer a clinical performance gap. 

For this reason, CMS is finalizing its 

proposal to remove this measure from 

reporting in 2015 PQRS. 

AMAPCPI 

/NCQA 

X X 
CMS-1612-FC 747 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

0232 

/056 

Effective 

Clinical 

Care 

Emergency Medicine: CommunityAcquired Bacterial Pneumonia (CAP): 

Vital Signs: Percentage of patients aged 18 

years and older with a diagnosis of 

community-acquired bacterial pneumonia 

(CAP) with vital signs documented and 

reviewed 

Commenters disagreed with CMS’ proposal 

to remove this measure noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

its potential, and no longer represent a 

clinical performance gap that should be 

measured by the PQRS Program. The PQRS 

will continue to focus on measures with 

maximal potential for improvement and that 

answer a clinical performance gap. For this 

reason, CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

AMAPCPI 

/NCQA 

X X 

0096 

/059 

Effective 

Clinical 

Care 

Emergency Medicine: CommunityAcquired Bacterial Pneumonia (CAP): 

Empiric Antibiotic: Percentage of patients 

aged 18 years and older with a diagnosis of 

community-acquired bacterial pneumonia 

(CAP) with an appropriate empiric 

antibiotic prescribed 

Commenters disagreed with CMS’ proposal 

to remove this measure noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

its potential, and no longer represent a 

clinical performance gap that should be 

measured by the PQRS Program. The 

PQRS will continue to focus on measures 

with maximal potential for improvement 

and that answer a clinical performance gap. 

For this reason, CMS is finalizing its 

proposal to remove this measure from 

reporting in 2015 PQRS. 

AMAPCPI 

/NCQA 

X X 

0001/064 

Effective 

Clinical 

Care 

Asthma: Assessment of Asthma Control – 

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64 years with a 

diagnosis of asthma who were evaluated at 

least once during the measurement period 

for asthma control (comprising asthma 

impairment and asthma risk) 

AMAPCPI 

NCQA 

 X X 
CMS-1612-FC 748 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Some commenters disagreed with the 

removal of this measure noting “this 

[assessment] is essential in order to ensure 

appropriate treatment for asthma which 

currently is less than optimal.” However, 

other commenters supported the removal of 

this measure. CMS continues to believe this 

measure represents a basic clinical concept 

that does not add clinical value to PQRS 

because in order to provide effective 

treatment for asthma, assessment of asthma 

control is essential. As such, CMS is 

finalizing its proposal to remove PQRS 

#064, “Asthma: Assessment of Asthma 

Control – Ambulatory Care Setting," which 

is a process measure, and replace it with the 

more robust outcome measure, Optimal 

Asthma - Control Component based on our 

exception authority under section 

1848(k)(2)(C)(ii) of the Act that provides an 

exception to the requirement that the 

Secretary select measures must be endorsed 

by NQF. 

0393/083 

Effective 

Clinical 

Care 

Hepatitis C: Confirmation of Hepatitis C 

Viremia: Percentage of patients aged 18 

years and older who are hepatitis C antibody 

positive seen for an initial evaluation for 

whom hepatitis C virus (HCV) RNA testing 

was ordered or previously performed 

One commenter disagreed with the removal 

of this measure noting a recent study of four 

large health systems revealed that “less than 

two-thirds of persons with positive HCV 

antibody test had a follow-up RNA test.” 

Despite these findings, eligible 

professionals have consistently reported 

performance rates close to 100% for this 

measure. With a performance rate above 90 

percent for multiple consecutive years, 

CMS considers the measure to have reached 

its potential, and no longer represents a 

clinical performance gap that should be 

measured by the PQRS Program. The 

PQRS will continue to focus on measures 

with maximal potential for improvement 

and that answer a clinical performance gap. 

For these reasons, CMS is finalizing its 

proposal to remove this measure from 

reporting in 2015 PQRS. 

AGA X 

0103/106 

Effective 

Clinical 

Care 

Adult Major Depressive Disorder 

(MDD): Comprehensive Depression 

Evaluation: Diagnosis and Severity: 

Percentage of patients aged 18 years and 

older with a new diagnosis or recurrent 

episode of major depressive disorder 

APA X X 
CMS-1612-FC 749 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

(MDD) with evidence that they met the 

Diagnostic and Statistical Manual of Mental 

Disorders (DSM)-5 criteria for MDD AND 

for whom there is an assessment of 

depression severity during the visit in which 

a new diagnosis or recurrent episode was 

identified 

Commenters disagreed with CMS’ proposal 

to remove this measure noting “appropriate 

diagnosis and classification of severity are 

essential in order to ensure appropriate 

treatment for major depressive disorder. The 

use of the diagnostic tools included in the 

measure is currently less than optimal.” 

Furthermore, commenters suggest the other 

MDD measure (PQRS #370) “does not 

include screening for bipolar disorder and 

could potentially exclude some patients 

from screening.” However, CMS continues 

to believe it represents a clinically 

diagnostic reference that is commonly 

utilized as a standard practice of care in 

order to diagnose and treat mental health 

disorders. This measure is not robust and 

does not add clinical value to the PQRS 

program. It is a goal of CMS to increase the 

number of outcome-based measures in the 

PQRS program, and measures that work to 

appropriately diagnose and classify the 

severity of illnesses and include quality care 

action are essential for this effort. For these 

reasons, CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

1666/123 

Effective 

Clinical 

Care 

Adult Kidney Disease: Patients On 

Erythropoiesis-Stimulating Agent (ESA) - 

Hemoglobin Level > 12.0 g/dL: Percentage 

of calendar months within a 12-month 

period during which a hemoglobin level is 

measured for patients aged 18 years and 

older with a diagnosis of advanced chronic 

kidney disease (CKD) (stage 4 or 5, not 

receiving Renal Replacement Therapy 

([RRT]) or End Stage Renal Disease 

(ESRD) (who are on hemodialysis or 

peritoneal dialysis) who are also receiving 

erythropoiesis-stimulating agent (ESA) 

therapy AND have a hemoglobin level > 

12.0 g/dL 

Some commenters suggested CMS not 

remove this measure, noting it is “an 

assessment that is required for making 

treatment decisions.” CMS agrees this 

measure is both an effective clinical care 

and overuse measure. However, 

RPA X X X 
CMS-1612-FC 750 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

commenters that agreed with removal of 

this measure came from specialists who 

would most likely be reporting this measure. 

As such, CMS is finalizing its proposal to 

remove PQRS 123.

0051/142 

Effective 

Clinical 

Care 

Osteoarthritis (OA): Assessment for Use 

of Anti-Inflammatory or Analgesic Overthe-Counter (OTC) Medications: 

Percentage of patient visits for patients aged 

21 years and older with a diagnosis of 

osteoarthritis (OA) with an assessment for 

use of anti-inflammatory or analgesic overthe-counter (OTC) medications 

A steward has still not been identified for 

this measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AMAPCPI X X 

0322/148 

Efficiency 

and Cost 

Reduction 

Back Pain: Initial Visit: The percentage of 

patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back 

surgery who had back pain and function 

assessed during the initial visit to the 

clinician for the episode of back pain 

Some commenters supported the removal of 

this measure while others expressed concern 

over its removal and the negative impact on 

anesthesiologists and pain medicine 

physicians to report PQRS. CMS 

understands the commenters’ concerns. It is 

a priority for PQRS to ultimately increase 

the quality of health care, and promoting 

outcome-based measures is part of this 

effort. This measure and others in the Back 

Pain Measure Group represent clinical 

assessments and recommendations 

commonly utilized to provide effective 

treatment for patients diagnosed with back 

pain, and thus, were determined to be low 

bar, process-based measures that do not 

meaningfully contribute to improved patient 

outcomes or the PQRS program. For this 

reason, CMS is finalizing its proposal to 

remove this measure and other measures in 

the Back Pain Measures Group from the 

PQRS program in 2015. 

NCQA X 

0319/149 

Effective 

Clinical 

Care 

Back Pain: Physical Exam: Percentage of 

patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back 

surgery who received a physical 

examination at the initial visit to the 

clinician for the episode of back pain 

Some commenters supported the removal of 

this measure while others expressed concern 

NCQA X 
CMS-1612-FC 751 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

over its removal and the negative impact on 

anesthesiologists and pain medicine 

physicians to report PRQS. CMS 

understands the commenters’ concerns. It is 

a priority for PQRS to ultimately increase 

the quality of health care and promoting 

outcome-based measures is part of this 

effort. This measure and others in the Back 

Pain Measure Group represent clinical 

assessments and recommendations 

commonly utilized to provide effective 

treatment for patients diagnosed with back 

pain, and thus, were determined to be low 

bar, process-based measures that do not 

meaningfully contribute to improved patient 

outcomes or the PQRS program. For this 

reason, CMS is finalizing its proposal to 

remove this measure and other measures in 

the Back Pain Measures Group from the 

PQRS program in 2015. 

0314/150 

Effective 

Clinical 

Care 

Back Pain: Advice for Normal Activities: 

The percentage of patients aged 18 through 

79 years with a diagnosis of back pain or 

undergoing back surgery who received 

advice for normal activities at the initial 

visit to the clinician for the episode of back 

pain 

Some commenters expressed concern over 

the removal of this measure and the 

negative impact on anesthesiologists and 

pain medicine physicians to report PRQS. 

CMS understands the commenters’ 

concerns. It is a priority for PQRS to 

ultimately increase the quality of health care 

and promoting outcome-based measures is 

part of this effort. This measure and others 

in the Back Pain Measure Group represent 

clinical assessments and recommendations 

commonly utilized to provide effective 

treatment for patients diagnosed with back 

pain, and thus, were determined to be low 

bar, process-based measures that do not 

meaningfully contribute to improved patient 

outcomes or the PQRS program. For this 

reason, CMS is finalizing its proposal to 

remove this measure and other measures in 

the Back Pain Measures Group from the 

PQRS program in 2015. 

NCQA X 

0313/151 

Effective 

Clinical 

Care 

Back Pain: Advice Against Bed Rest: The 

percentage of patients aged 18 through 79 

years with a diagnosis of back pain or 

undergoing back surgery who received 

advice against bed rest lasting four days or 

longer at the initial visit to the clinician for 

the episode of back pain 

NCQA X 
CMS-1612-FC 752 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Some commenters supported the removal of 

this measure while others expressed concern 

over its removal and the negative impact on 

anesthesiologists and pain medicine 

physicians to report PRQS. CMS 

understands the commenters’ concerns. It is 

a priority for PQRS to ultimately increase 

the quality of health care and promoting 

outcome-based measures is part of this 

effort. This measure and others in the Back 

Pain Measure Group represent clinical 

assessments and recommendations 

commonly utilized to provide effective 

treatment for patients diagnosed with back 

pain, and thus, were determined to be low 

bar, process-based measures that do not 

meaningfully contribute to improved patient 

outcomes or the PQRS program. For this 

reason, CMS is finalizing its proposal to 

remove this measure and other measures in 

the Back Pain Measures Group from the 

PQRS program in 2015.

0455/157 Patient 

Safety 

Thoracic Surgery: Recording of Clinical 

Stage Prior to Lung Cancer or 

Esophageal Cancer Resection: Percentage 

of surgical patients aged 18 years and older 

undergoing resection for lung or esophageal 

cancer who had clinical staging provided 

prior to surgery 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

STS X X 

0404/159 

Effective 

Clinical 

Care 

HIV/AIDS: CD4+ Cell Count or CD4+ 

Percentage Performed: Percentage of 

patients aged 6 months and older with a 

diagnosis of HIV/AIDS for whom a CD4+ 

cell count or CD4+ cell percentage was 

performed at least once every 6 months 

Commenters disagreed with the removal of 

this measure based on a rationale of a high 

performance rate. With a performance rate 

above 90 percent for multiple consecutive 

years, CMS considers the measure to have 

reached its potential, and no longer 

AMAPCPI 

NCQA 

 X X 
CMS-1612-FC 753 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

represent a clinical performance gap that 

should be measured by the PQRS Program. 

The PQRS will continue to focus on 

measures with maximal potential for 

improvement and that answer a clinical 

performance gap. Furthermore, other 

commenters agreed with the removal of this 

measure indicating “this measure is no 

longer as relevant now that we are 

measuring CD4 less frequently and such 

measurement is optional in the Department 

of Health and Human Services Guidelines 

for the Use of Antiretroviral Agents in HIV1-Infected Adults and Adolescents for those 

suppressed for at least 2 years.” For these 

reasons, CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

0116/169 

Effective 

Clinical 

Care 

Coronary Artery Bypass Graft (CABG): 

Antiplatelet Medications at Discharge: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG surgery 

who were discharged on antiplatelet 

medication 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

STS X X 

0117/170 

Effective 

Clinical 

Care 

Coronary Artery Bypass Graft (CABG): 

Beta-Blockers Administered at 

Discharge: Percentage of patients aged 18 

years and older undergoing isolated CABG 

surgery who were discharged on betablockers 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

STS X X 
CMS-1612-FC 754 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

0118/171 

Effective 

Clinical 

Care 

Coronary Artery Bypass Graft (CABG): 

Anti-Lipid Treatment at Discharge: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG surgery 

who were discharged on a statin or other 

lipid-lowering regimen 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

STS X X 

0074/197 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): Lipid 

Control: Percentage of patients aged 18 

years and older with a diagnosis of coronary 

artery disease seen within a 12 month period 

who have a LDL-C result < 100 mg/dL OR 

patients who have a LDL-C result ≥ 100 

mg/dL and have a documented plan of care 

to achieve LDL-C <100 mg/dL, including at 

a minimum the prescription of a statin 

Many commenters supported the proposed 

removal of the measure because the 

measure may not align with current clinical 

guidelines. Other commenters disagreed 

with the removal of this measure indicating 

the measure is currently in the process of 

being updated. CMS continues to believe 

that because of changes to the applicable 

evidence-based guidelines, this measure is 

no longer clinically valid. For this reason, 

CMS is finalizing its proposal to remove 

this measure from reporting for 2015 PQRS 

and Medicare Shared Savings Program. 

AMAPCPI 

ACCF 

AHA 

 X X X 

0079/198 

Effective 

Clinical 

Care 

Heart Failure: Left Ventricular Ejection 

Fraction (LVEF) Assessment: Percentage 

of patients aged 18 years and older with a 

diagnosis of heart failure for whom the 

quantitative or qualitative results of a recent 

or prior [any time in the past] LVEF 

assessment is documented within a 12 

month period 

AMAPCPI 

ACCF 

AHA 

 X X 
CMS-1612-FC 755 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Several comments suggested CMS maintain 

this measure as it is important to clinical 

practice and has strong impact on patient 

symptom management. However, CMS 

continues to believe this measure represents 

a clinical concept that does not add clinical 

value to PQRS. LVEF testing is basic 

assessment for patients with heart failure. 

For these reasons, CMS is finalizing its 

proposal to remove this measure from 2015 

PQRS. 

N/A 

/228 

Effective 

Clinical 

Care 

Heart Failure (HF): Left Ventricular 

Function (LVF) Testing: Percentage of 

patients 18 years and older with Left 

Ventricular Function (LVF) testing 

documented as being performed within the 

previous 12 months or LVF testing 

performed prior to discharge for patients 

who are hospitalized with a principal 

diagnosis of Heart Failure (HF) during the 

reporting period 

Several comments suggested CMS maintain 

this measure as it is important to clinical 

practice. However, CMS continues to 

believe this measure represents a clinical 

concept that does not add clinical value to 

PQRS. LVF testing is basic assessment for 

patients with heart failure. For these 

reasons, CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

CMS/QIP X 

N/A/231 

Effective 

Clinical 

Care 

Asthma: Tobacco Use: Screening - 

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64 years with a 

diagnosis of asthma (or their primary 

caregiver) who were queried about tobacco 

use and exposure to second hand smoke 

within their home environment at least once 

during the one-year measurement period 

Commenters disagreed with CMS' proposal 

to replace PQRS #231 (Asthma: Tobacco 

Use: Screening - Ambulatory Care Setting) 

with PQRS #226 "Preventive Care and 

Screening: Tobacco Use: Screening and 

Cessation Intervention" because PQRS #231 

includes an age range of 5-64 while the 

lower bound age for PQRS #226 is 18 years, 

missing the pediatric population. 

Furthermore, PQRS #226 does not include 

the query regarding exposure to second 

hand smoke which is critical for the 18 and 

under population with Asthma. However, 

CMS continues to believe this is measure is 

appropriate and more broadly applicable 

and for this reason is finalizing the proposal 

AMAPCPI 

NCQA 

X X X 
CMS-1612-FC 756 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

to remove this measure from 2015 PQRS 

reporting.

N/A/232 

Effective 

Clinical 

Care 

Asthma: Tobacco Use: Intervention - 

Ambulatory Care Setting: Percentage of 

patients aged 5 through 64 years with a 

diagnosis of asthma who were identified as 

tobacco users (or their primary caregiver) 

who received tobacco cessation intervention 

at least once during the one-year 

measurement period 

Commenters disagreed with CMS' proposal 

to replace PQRS #232 (Asthma: Tobacco 

Use: Intervention - Ambulatory Care 

Setting) with PQRS #226 "Preventive Care 

and Screening: Tobacco Use: Screening and 

Cessation Intervention" because PQRS #231 

and #232 include an age range of 5-64 while 

the lower bound age for PQRS #226 is 18 

years, missing the pediatric population. 

Furthermore, PQRS #226 does not include 

the query regarding exposure to second 

hand smoke which is critical for the 18 and 

under population with Asthma. However, 

CMS continues to believe #226 is 

appropriate and more broadly applicable 

and for this reason is finalizing its proposal 

to remove #232 from 2015 PQRS reporting.

AMAPCPI 

NCQA 

X X X 

0457/233 

Effective 

Clinical 

Care 

Thoracic Surgery: Recording of 

Performance Status Prior to Lung or 

Esophageal Cancer Resection: Percentage 

of patients aged 18 years and older 

undergoing resection for lung or esophageal 

cancer for whom performance status was 

documented and reviewed within 2 weeks 

prior to surgery 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

STS X 

0458/234 Patient 

Safety 

Thoracic Surgery: Pulmonary Function 

Tests Before Major Anatomic Lung 

Resection (Pneumonectomy, Lobectomy, 

or Formal Segmentectomy): Percentage of 

thoracic surgical patients aged 18 years and 

STS X 
CMS-1612-FC 757 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

older undergoing at least one pulmonary 

function test within 12 months prior to a 

major lung resection (pneumonectomy, 

lobectomy, or formal segmentectomy) 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. With a performance 

rate above 90 percent for multiple 

consecutive years, CMS considers the 

measure to have reached its potential, and 

no longer represent a clinical performance 

gap that should be measured by the PQRS 

Program. The PQRS will continue to focus 

on measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from 2015 PQRS.

AQA 

Adopted 

/245 

Effective 

Clinical 

Care 

Chronic Wound Care: Use of Wound 

Surface Culture Technique in Patients 

with Chronic Skin Ulcers (Overuse 

Measure): Percentage of patient visits for 

those patients aged 18 years and older with 

a diagnosis of chronic skin ulcer without the 

use of a wound surface culture technique 

Commenters disagreed with removal of this 

measure based on a rationale of high 

performance rates. With a performance rate 

above 90 percent for multiple consecutive 

years, CMS considers the measure to have 

reached its potential, and no longer 

represent a clinical performance gap that 

should be measured by the PQRS Program. 

The PQRS will continue to focus on 

measures with maximal potential for 

improvement and that answer a clinical 

performance gap. However, other 

commenters supported the removal of this 

measure. For these reasons, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ASPS X X 

AQA 

Adopted 

/246 

Effective 

Clinical 

Care 

Chronic Wound Care: Use of Wet to Dry 

Dressings in Patients with Chronic Skin 

Ulcers (Overuse Measure): Percentage of 

patient visits for those patients aged 18 

years and older with a diagnosis of chronic 

skin ulcer without a prescription or 

recommendation to use wet to dry dressings 

Commenters disagreed with removal of this 

measure based on a rationale of high 

performance rates. With a performance rate 

above 90 percent for multiple consecutive 

years, CMS considers the measure to have 

reached its potential, and no longer 

ASPS X X 
CMS-1612-FC 758 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

represent a clinical performance gap that 

should be measured by the PQRS Program. 

The PQRS will continue to focus on 

measures with maximal potential for 

improvement and that answer a clinical 

performance gap. However, other 

commenters supported the removal of this 

measure. For these reasons, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

AQA 

Adopted/

247 

Effective 

Clinical 

Care 

Substance Use Disorders: Counseling 

Regarding Psychosocial and 

Pharmacologic Treatment Options for 

Alcohol Dependence: Percentage of 

patients aged 18 years and older with a 

diagnosis of current alcohol dependence 

who were counseled regarding psychosocial 

AND pharmacologic treatment options for 

alcohol dependence within the 12-month 

reporting period 

Commenters disagreed with removal of this 

measure based on a rationale of high 

performance rates. With a performance rate 

above 90 percent for multiple consecutive 

years, CMS considers the measure to have 

reached its potential, and no longer 

represent a clinical performance gap that 

should be measured by the PQRS Program. 

The PQRS will continue to focus on 

measures with maximal potential for 

improvement and that answer a clinical 

performance gap. For this reason, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

APA X X AQA 

AQA 

Adopted/

248 

Effective 

Clinical 

Care 

Substance Use Disorders: Screening for 

Depression Among Patients with 

Substance Abuse or Dependence: 

Percentage of patients aged 18 years and 

older with a diagnosis of current substance 

abuse or dependence who were screened for 

depression within the 12-month reporting 

period 

One commenter reported this measure is not 

applicable to nursing home providers. No 

other comments were received regarding 

this measure. CMS is finalizing its proposal 

to remove this measure from reporting in 

2015 PQRS.

APA X X AQA 

N/A 

/266 

Effective 

Clinical 

Care 

Epilepsy: Seizure Type(s) and Current 

Seizure Frequency(ies): Percentage of 

patient visits with a diagnosis of epilepsy 

who had the type(s) of seizure(s) and 

current seizure frequency(ies) for each 

seizure type documented in the medical 

AAN X X 
CMS-1612-FC 759 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

record 

No comments were received regarding this 

measure. CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

N/A/ 

267 

Effective 

Clinical 

Care 

Epilepsy: Documentation of Etiology of 

Epilepsy or Epilepsy Syndrome: All visits 

for patients with a diagnosis of epilepsy 

who had their etiology of epilepsy or with 

epilepsy syndrome(s) reviewed and 

documented if known, or documented as 

unknown or cryptogenic 

No comments were received regarding this 

measure. CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS.

AAN X X 

N/A/ 

269 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Type, Anatomic Location and Activity 

All Documented: Percentage of patients 

aged 18 years and older with a diagnosis of 

inflammatory bowel disease who have 

documented the disease type, anatomic 

location and activity, at least once during 

the reporting period 

One commenter disagreed with the removal 

of this measure but did not provide a reason. 

However, CMS continues to believe that, as 

a measurement tool, PQRS #269 did not add 

clinical value to the PQRS Program because 

in order to provide care for IBD patients, 

documentation of type, anatomic location 

and activity would be essential for effective 

treatment of the disease. For this reason, 

CMS is finalizing its proposal to remove 

this measure from reporting in 2015 PQRS. 

AGA X 

N/A/ 

272 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Influenza 

Immunization: Percentage of patients aged 

18 years and older with a diagnosis of 

inflammatory bowel disease for whom 

influenza immunization was recommended, 

administered or previously received during 

the reporting year 

Commenters were supportive of the removal 

of this measure and its replacement with 

PQRS #110 (Preventive Care and 

Screening: Influenza Immunization) if 

language were added to the replacement 

measure to include IBD. CMS continues to 

believe this measure is duplicative of PQRS 

#110, which is also more broadly 

applicable. For this reason, CMS is 

AGA X 
CMS-1612-FC 760 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS and 

will work with the measure steward to 

address the question of expanding the age 

range of PQRS #110. 

N/A/ 

273 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Pneumococcal 

Immunization: Percentage of patients aged 

18 years and older with a diagnosis of 

inflammatory bowel disease that had 

pneumococcal vaccination administered or 

previously received 

Commenters were supportive of the removal 

of this measure and its replacement with 

PQRS #111 (Pneumonia Vaccination Status 

for Older Adults) if language were added to 

the replacement measure to include IBD 

patients and address age range differences 

between the two measures as PQRS #111 

does not address the under 65 population. 

CMS has confirmed with the measure 

steward for PQRS #111 that the age range 

can be adjusted. For this reason, CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AGA X 

N/A/295 

Effective 

Clinical 

Care 

Hypertension: Use of Aspirin or Other 

Antithrombotic Therapy: Percentage of 

patients aged 30 through 90 years old with a 

diagnosis of hypertension and are eligible 

for aspirin or other antithrombotic therapy 

who were prescribed aspirin or other 

antithrombotic therapy 

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ABIM X 

N/A/ 

296 

Effective 

Clinical 

Care 

Hypertension: Complete Lipid Profile:

Percentage of patients aged 18 through 90 

years old with a diagnosis of hypertension 

who received a complete lipid profile within 

60 months 

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

ABIM X 

N/A/297 

Effective 

Clinical 

Care 

Hypertension: Urine Protein Test:

Percentage of patients aged 18 through 90 

years old with a diagnosis of hypertension 

who either have chronic kidney disease 

diagnosis documented or had a urine protein 

test done within 36 months. 

Commenters disagreed with the removal of 

ABIM X 
CMS-1612-FC 761 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

this measure noting that without it, there 

will “no longer be a quality measure in 

PQRS that assesses kidney function for 

people at high risk of chronic kidney 

disease.” Unfortunately, these measures 

cannot remain in the PQRS program 

without a measure steward. Given a steward 

has not been identified for this measure 

CMS is finalizing its proposal to remove 

this measure from reporting in 2015 PQRS. 

N/A/298 

Effective 

Clinical 

Care 

Hypertension: Annual Serum Creatinine 

Test: Percentage of patients aged 18 

through 90 years old with a diagnosis of 

hypertension who had a serum creatinine 

test done within 12 months 

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ABIM X 

N/A/299 

Effective 

Clinical 

Care 

Hypertension: Diabetes Mellitus 

Screening Test: Percentage of patients aged 

18 through 90 years old with a diagnosis of 

hypertension who had a diabetes screening 

test within 36 months 

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ABIM X 

N/A/300 

Effective 

Clinical 

Care 

Hypertension: Blood Pressure Control: 

Percentage of patients aged 18 through 90 

years old with a diagnosis of hypertension 

whose most recent blood pressure was 

under control (< 140/90 mmHg)

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ABIM X 

N/A/ 

301 

Effective 

Clinical 

Care 

Hypertension: Low Density Lipoprotein 

(LDL-C) Control: Percentage of patients 

aged 18 through 90 years old with a 

diagnosis of hypertension who had most 

recent LDL cholesterol level under control 

(at goal) 

Commenters disagreed with the proposal to 

remove this measure “until new measures 

that are more consistent with new and 

existing guidelines are put in place to 

replace it.” However, this measure is no 

longer in accordance with new evidencebased clinical guidelines regarding lipid 

control. CMS understands the commenters’ 

concerns that removing measures may lead 

ABIM X 
CMS-1612-FC 762 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

to program gaps; however, it is a priority for 

PQRS to ultimately increase the quality of 

health care and this goal was at the forefront 

of consideration for the removal of these 

measures. For this reason, CMS is finalizing 

its proposal to remove this measure from 

reporting in 2015 PQRS. 

N/A/302 

Effective 

Clinical 

Care 

Hypertension: Dietary and Physical 

Activity Modifications Appropriately 

Prescribed: Percentage of patients aged 18 

through 90 years old with a diagnosis of 

hypertension who received dietary and 

physical activity counseling at least once 

within 12 months 

A steward has not been identified for this 

measure, and for this reason CMS is 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

ABIM X 

2080/341 

Efficiency 

and Cost 

Reduction 

Gap in HIV Medical Visits: Percentage of 

patients, regardless of age, with a diagnosis 

of HIV who did not have a medical visit in 

the last 6 months 

No comments were received regarding this 

measure. CMS is finalizing its proposal to 

remove this measure from reporting in 2015 

PQRS. 

HRSA X X 

Measures Not Finalized as Proposed 

0087/014 

Effective 

Clinical 

Care 

Age-Related Macular Degeneration 

(AMD): Dilated Macular Examination:

Percentage of patients aged 50 years and 

older with a diagnosis of age-related 

macular degeneration (AMD) who had a 

dilated macular examination performed 

which included documentation of the 

presence or absence of macular thickening 

or hemorrhage AND the level of macular 

degeneration severity during one or more 

office visits within 12 months 

Commenters disagreed with removal of this 

measure, noting that removal based on a 

“high-performance rate when EP reporting 

within the PQRS program is low” may not 

be appropriate. We have also received 

strong comments and feedback from outside 

stakeholders that this measure is still 

relevant to its eligible professionals. Some 

commenters note that the “high performance 

rate” may be skewed and not accurately 

reflect the existing gap addressed by this 

measure. CMS agrees with commenters and 

therefore is not finalizing its proposal to 

remove this measure from 2015 PQRS. 

However, CMS continues to look for better 

AAO X X 
CMS-1612-FC 763 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

outcome measures, and as such this measure 

may be considered for removal in a future 

program year. 

0268/021 Patient 

Safety 

Perioperative Care: Selection of 

Prophylactic Antibiotic – First OR 

Second Generation Cephalosporin: 

Percentage of surgical patients aged 18 

years and older undergoing procedures with 

the indications for a first OR second 

generation cephalosporin prophylactic 

antibiotic, who had an order for a first OR 

second generation cephalosporin for 

antimicrobial prophylaxis 

Commenters disagreed with CMS’ proposal 

to remove this measure, noting “it is 

premature to remove a measure based on a 

high-performance rate when the EP 

reporting rate within the PQRS program is 

low.” CMS agrees with commenters that 

removing this measure may negatively 

impact providers’ ability to report to PQRS 

and therefore is not finalizing its proposal to 

remove this measure from 2015 PQRS. 

However, CMS is finalizing its proposal to 

remove the Perioperative Care Measure 

Group, and for this reason this measure will 

only be reportable through claims and 

registry for 2015 PQRS. CMS continues to 

look for better outcome measures, and as 

such this measure may be considered for 

removal in a future program year. 

AMAPCPI 

NCQA 

X X 

0271/022 Patient 

Safety 

Perioperative Care: Discontinuation of 

Prophylactic Parenteral Antibiotics (NonCardiac Procedures): Percentage of noncardiac surgical patients aged 18 years and 

older undergoing procedures with the 

indications for prophylactic parenteral 

antibiotics AND who received a 

prophylactic parenteral antibiotic, who have 

an order for discontinuation of prophylactic 

parenteral antibiotics within 24 hours of 

surgical end time 

Some commenters disagreed with CMS’ 

proposal to remove this measure, noting 

“disparate practice patterns among 

clinicians when selecting the more 

appropriate prophylactic antibiotic.” 

Furthermore, commenters note it might be 

premature to remove a measure based on a 

high-performance rate. CMS agrees with 

commenters and therefore is not finalizing 

its proposal to remove this measure from 

2015 PQRS. However, CMS is finalizing its 

proposal to remove the Perioperative Care 

Measure Group, and for this reason this 

AMAPCPI 

NCQA 

X X 
CMS-1612-FC 764 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

measure will only be reportable through 

claims and registry for 2015 PQRS. CMS 

continues to look for better outcome 

measures, and as such this measure may be 

considered for removal in a future program 

year.

0239/023 Patient 

Safety 

Perioperative Care: Venous 

Thromboembolism (VTE) Prophylaxis 

(When Indicated in ALL Patients): 

Percentage of surgical patients aged 18 

years and older undergoing procedures for 

which VTE prophylaxis is indicated in all 

patients, who had an order for Low 

Molecular Weight Heparin (LMWH), LowDose Unfractionated Heparin (LDUH), 

adjusted-dose warfarin, fondaparinux or 

mechanical prophylaxis to be given within 

24 hours prior to incision time or within 24 

hours after surgery end time 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. CMS agrees with 

commenters that removing this measure 

may negatively impact providers’ ability to 

report to PQRS and therefore is not 

finalizing its proposal to remove this 

measure from 2015 PQRS. However, CMS 

is finalizing its proposal to remove the 

Perioperative Care Measure Group, and for 

this reason this measure will only be 

reportable through claims and registry for 

2015 PQRS. CMS continues to look for 

better outcome measures, and as such this 

measure may be considered for removal in a 

future program year.

AMAPCPI 

NCQA 

X X 

0325/032 

Effective 

Clinical 

Care 

Stroke and Stroke Rehabilitation: 

Discharged on Antithrombotic Therapy: 

Percentage of patients aged 18 years and 

older with a diagnosis of ischemic stroke or 

transient ischemic attack (TIA) who were 

prescribed antithrombotic therapy at 

discharge 

Some commenters agreed while others 

disagreed with CMS’ proposal to remove 

this measure due to this measure 

representing a clinical concept that is 

currently included within inpatient standard 

of care to decrease risk of complications in 

patients diagnosed with ischemic or 

intracranial stroke when clinically indicated. 

CMS agrees with commenters, and for this 

reason CMS is not finalizing its proposal to 

remove this measure from reporting for 

2015 PQRS. However, CMS continues to 

look for better outcome measures, and as 

AANI X X 
CMS-1612-FC 765 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

such this measure may be considered for 

removal in a future program year. 

0241/033 

Effective 

Clinical 

Care 

Stroke and Stroke Rehabilitation: 

Anticoagulant Therapy Prescribed for 

Atrial Fibrillation (AF) at Discharge: 

Percentage of patients aged 18 years and 

older with a diagnosis of ischemic stroke or 

transient ischemic attack (TIA) with 

documented permanent, persistent, or 

paroxysmal atrial fibrillation who were 

prescribed an anticoagulant at discharge 

Commenters disagreed with CMS' proposal 

to remove this measures based on the 

rationale that they represent clinical 

concepts that are currently included within 

inpatient standards of care to improve 

patient outcomes for those diagnosed with 

ischemic or intracranial stroke when 

clinically indicated. Commenters maintain 

that these clinical concepts are appropriate 

for measurement at the individual physician 

level in addition to the facility level to help 

ensure the continuous care of stroke 

patients. CMS agrees with commenters, and 

for this reason CMS is not finalizing its 

proposal to remove this measure from 

reporting for 2015 PQRS. However, CMS 

continues to look for better outcome 

measures, and as such this measure may be 

considered for removal in a future program 

year. 

AANI X 

0091/051 

Effective 

Clinical 

Care 

Chronic Obstructive Pulmonary Disease 

(COPD): Spirometry Evaluation: 

Percentage of patients aged 18 years and 

older with a diagnosis of COPD who had 

spirometry evaluation results documented 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

American 

Thoracic 

Society X X 

0102/052 

Effective 

Clinical 

Care 

Chronic Obstructive Pulmonary Disease 

(COPD): Inhaled Bronchodilator 

Therapy: Percentage of patients aged 18 

years and older with a diagnosis of COPD 

and who have an FEV1/FVC less than 60% 

and have symptoms who were prescribed an 

inhaled bronchodilator 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

American 

Thoracic 

Society X X 

0050/109 Person and 

CaregiverOsteoarthritis (OA): Function and Pain Assessment: Percentage of patient visits for 

AAOS X 
CMS-1612-FC 766 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Centered 

Experience 

and 

Outcomes 

patients aged 21 years and older with a 

diagnosis of osteoarthritis (OA) with 

assessment for function and pain 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

0566/140 

Effective 

Clinical 

Care 

Age-Related Macular Degeneration 

(AMD): Counseling on Antioxidant 

Supplement: Percentage of patients aged 

50 years and older with a diagnosis of agerelated macular degeneration (AMD) or 

their caregiver(s) who were counseled 

within 12 months on the benefits and/or 

risks of the Age-Related Eye Disease Study 

(AREDS) formulation for preventing 

progression of AMD 

Commenters disagreed with removal of this 

measure noting that removal based on a 

“high-performance rate when EP reporting 

within the PQRS program is low” may not 

be appropriate. CMS agrees with 

commenters, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting for 2015 PQRS. 

However, CMS continues to look for better 

outcome measures, and as such this measure 

may be considered for removal in a future 

program year.

AAO X X 

0508/146 

Efficiency 

and Cost 

Reduction 

Radiology: Inappropriate Use of 

“Probably Benign” Assessment Category 

in Mammography Screening: Percentage 

of final reports for screening mammograms 

that are classified as “probably benign” 

Commenters disagreed with the removal of 

this measure based on a rationale of a high 

performance rate. Furthermore one 

commenter notes “this measure is important 

in that it ensures the integrity of the 

complete mammography audit.” CMS 

agrees with commenters, and for this reason 

CMS is not finalizing its proposal to remove 

this measure from reporting for 2015 PQRS. 

However, CMS continues to look for better 

outcome measures, and as such this measure 

may be considered for removal in a future 

program year.

AC 

Radiology

/ AMAPCPI 

X X 

N/A/147 

Communic

ation and 

Care 

Coordinatio

n 

Nuclear Medicine: Correlation with 

Existing Imaging Studies for All Patients 

Undergoing Bone Scintigraphy:

Percentage of final reports for all patients, 

regardless of age, undergoing bone 

scintigraphy that include physician 

SNMMI X X 
CMS-1612-FC 767 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

documentation of correlation with existing 

relevant imaging studies (for example, xray, MRI, CT, etc.) that were performed. 

A steward has been identified for this 

measure, and as a result CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

0115/168 

Effective 

Clinical 

Care 

Coronary Artery Bypass Graft (CABG): 

Surgical Re-Exploration: Percentage of 

patients aged 18 years and older undergoing 

isolated CABG surgery who require a return 

to the operating room (OR) during the 

current hospitalization for mediastinal 

bleeding with or without tamponade, graft 

occlusion, valve dysfunction, or other 

cardiac reason 

Commenters disagreed with removal of this 

measure noting that removal based on a 

high-performance rate. CMS agrees with 

commenters that this may negatively impact 

the ability of certain specialties to report 

PQRS, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting for 2015 PQRS. 

However, CMS continues to look for better 

outcome measures, and as such this measure 

may be considered for removal in a future 

program year.

STS X X 

AQA 

Adopted/

173 

Community

/Population 

Health 

Preventive Care and Screening: 

Unhealthy Alcohol Use – Screening:

Percentage of patients aged 18 years and 

older who were screened for unhealthy 

alcohol use using a systematic screening 

method within 24 months 

A measure steward has been identified for 

this measure, and as such CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS. 

AMAPCPI 

 X X 

0643/243 

Effective 

Clinical 

Care 

Cardiac Rehabilitation Patient Referral 

from an Outpatient Setting: Percentage of 

patients evaluated in an outpatient setting 

who within the previous 12 months have 

experienced an acute myocardial infarction 

(MI), coronary artery bypass graft (CABG) 

surgery, a percutaneous coronary 

intervention (PCI), cardiac valve surgery, or 

cardiac transplantation, or who have chronic 

stable angina (CSA) and have not already 

participated in an early outpatient cardiac 

rehabilitation/secondary prevention (CR) 

program for the qualifying event/diagnosis 

who were referred to a CR program 

ACCF 

AHA X 
CMS-1612-FC 768 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

Commenters disagreed with CMS' proposal 

to remove this measure, suggesting that 

“while the clinical condition may initiate in 

the inpatient setting, the clinical process 

being measured is limited to the outpatient 

setting and would therefore add clinical 

value to outpatient care of the cardiac 

rehabilitation patient.” Further, commenters 

note that there is “clear evidence that 

processes to improve referral of eligible 

patients to cardiac rehabilitation result in 

improved cardiac rehabilitation participation 

rates and improved patient outcomes.” CMS 

agrees with the commenters, and for this 

reason CMS is not finalizing its proposal to 

remove this measure from reporting for 

2015 PQRS. However, CMS continues to 

look for better outcome measures, and as 

such this measure may be considered for 

removal in a future program year. 

N/A/ 

257 

Effective 

Clinical 

Care 

Statin Therapy at Discharge after Lower 

Extremity Bypass (LEB): Percentage of 

patients aged 18 years and older undergoing 

infra-inguinal lower extremity bypass who 

are prescribed a statin medication at 

discharge 

Commenters disagreed with the proposed 

removal of this measure on the basis that the 

measure represents a current standard of 

care. CMS agrees with commenters, and for 

this reason CMS is not finalizing its 

proposal to remove this measure from 

reporting for 2015 PQRS. However, CMS 

continues to look for better outcome 

measures, and as such this measure may be 

considered for removal in a future program 

year. 

SVS X 

N/A/ 

261 

Communic

ation and 

Care 

Coordinatio

n 

Referral for Otologic Evaluation for 

Patients with Acute or Chronic Dizziness: 

Percentage of patients aged birth and older 

referred to a physician (preferably a 

physician specially trained in disorders of 

the ear) for an otologic evaluation 

subsequent to an audiologic evaluation after 

presenting with acute or chronic dizziness 

Commenters disagreed with CMS' proposal 

to remove this measure with the rationale 

that it represents a clinical concept that is 

common practice in order to provide 

effective treatment for patients. 

Commenters request reconsideration for CY 

2015 to ensure audiologists have enough 

clinically-relevant measures to report. For 

this reason, CMS is not finalizing its 

proposal to remove this measure from 

AQC X X 
CMS-1612-FC 769 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

reporting in 2015 PQRS. 

N/A/276 

Effective 

Clinical 

Care 

Sleep Apnea: Assessment of Sleep 

Symptoms: Percentage of visits for patients 

aged 18 years and older with a diagnosis of 

obstructive sleep apnea that includes 

documentation of an assessment of sleep 

symptoms, including presence or absence of 

snoring and daytime sleepiness 

A steward has been identified for this 

measure and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AASM/ 

AMAPCPI  X 

N/A/277 

Effective 

Clinical 

Care 

Sleep Apnea: Severity Assessment at 

Initial Diagnosis: Percentage of patients 

aged 18 years and older with a diagnosis of 

obstructive sleep apnea who had an apnea 

hypopnea index (AHI) or a respiratory 

disturbance index (RDI) measured at the 

time of initial diagnosis 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AASM/ 

AMAPCPI  X 

N/A/278 

Effective 

Clinical 

Care 

Sleep Apnea: Positive Airway Pressure 

Therapy Prescribed: Percentage of 

patients aged 18 years and older with a 

diagnosis of moderate or severe obstructive 

sleep apnea who were prescribed positive 

airway pressure therapy 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AASM/ 

AMAPCPI  X 

N/A/279 

Effective 

Clinical 

Care 

Sleep Apnea: Assessment of Adherence to 

Positive Airway Pressure Therapy:

Percentage of visits for patients aged 18 

years and older with a diagnosis of 

obstructive sleep apnea who were 

prescribed positive airway pressure therapy 

who had documentation that adherence to 

positive airway pressure therapy was 

objectively measured 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AASM/ 

AMAPCPI  X 

N/A/335 Patient 

Safety 

Maternity Care: Elective Delivery or 

Early Induction Without Medical 

Indication at ≥ 37 and < 39 Weeks:

Percentage of patients, regardless of age, 

who gave birth during a 12-month period 

who delivered a live singleton at ≥ 37 and < 

AMAPCPI X 
CMS-1612-FC 770 NQF/ PQRS 

NQS 

Domain Measure Title and Description¥

Measure Steward 

Claims 

CSV 

Registry 

EHR 

GPRO (Web 

Interface)

Measures Groups 

Other Quality 

Reporting 

Programs 

39 weeks of gestation completed who had 

elective deliveries or early inductions 

without medical indication 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

N/A/336 

Communic

ation and 

Care 

Coordinatio

n 

Maternity Care: Post-Partum Follow-Up 

and Care Coordination: Percentage of 

patients, regardless of age, who gave birth 

during a 12-month period who were seen for 

post-partum care within 8 weeks of giving 

birth who received a breast feeding 

evaluation and education, post-partum 

depression screening, post-partum glucose 

screening for gestational diabetes patients, 

and family and contraceptive planning 

A steward has been identified for this 

measure, and for this reason CMS is not 

finalizing its proposal to remove this 

measure from reporting in 2015 PQRS.

AMAPCPI  X 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular 

program year. This is due to the timing of measure specification preparation and the measure versions used by the 

various reporting options/methods. Please refer to the measure specifications that apply for each of the reporting 

options/methods for specific measure details. 

In Table 56, we provide our responses and final decisions related to our proposals to change the 

way in which previously established measures in the PQRS will be reported beginning in 2015 (79 FR 

40441). 

 
CMS-1612-FC 771

TABLE 56: Existing Individual Quality Measures and Those Included in Measures Groups for the 

PQRS for Which Measure Reporting Updates Will Be Effective Beginning in 2015 

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

Measures Finalized as Proposed 

006

4/0

02 

163

v3 

Effective 

Clinical 

Care 

Diabetes: Low Density Lipoprotein (LDLC) Control (<100 mg/Dl: Percentage of 

patients 18–75 years of age with diabetes 

whose LDL-C was adequately controlled (< 

100 mg/dL) during the measurement period 

Commenters expressed concern with 

maintaining this measure in PQRS for EHR 

reporting only for the “sake of alignment 

with the EHR Incentive Program especially 

in the face of changing [clinical] evidence.” 

However, due to our desire to align with the 

EHR Incentive Program, CMS will not make 

changes to EHR measures until the EHR 

Incentive Program is able to change this 

measure. CMS understands commenters’ 

concerns and will track these issues for future 

program years when changes are possible. 

CMS is finalizing its proposal to make this 

measure reportable in 2015 PQRS through 

EHR only. 

NCQA X 

MU2 

Million 

Hearts 

006

7/0

06 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): 

Antiplatelet Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of coronary artery disease (CAD) 

seen within a 12 month period who were 

prescribed aspirin or clopidogrel 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. CMS also received comments 

supporting inclusion of the measure in the 

Shared Savings Program CAD Composite 

measure but with composite measure testing 

and NQF review. Therefore, CMS is 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS as part of its goal to lower the 

data error rate and decrease provider burden. 

CMS will not finalize adding this measure in 

the Shared Savings Program CAD 

Composite. 

AMAPCPI 

ACCF 

AHA 

 X X X ACO 

010

5/0

128

v3 

Effective 

Clinical 

Anti-Depressant Medication Management: 

Percentage of patients 18 years of age and NCQA X MU2 
CMS-1612-FC 772

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

09 Care older who were diagnosed with major 

depression and treated with antidepressant 

medication, and who remained on 

antidepressant medication treatment. Two 

rates are reported: 

a. Percentage of patients who remained on an 

antidepressant medication for at least 84 days 

(12 weeks). 

b. Percentage of patients who remained on an 

antidepressant medication for at least 180 

days (6 months).

CMS is finalizing its proposal to change the 

reporting option of PQRS #9 to EHR-only 

reporting as part of its efforts to align with 

the EHR Incentive Program. PQRS would 

otherwise propose to remove this measure 

from PQRS, as it is a process measure that is 

analytically challenging to report. 

008

8/0

18 

167

v3 

Effective 

Clinical 

Care 

Diabetic Retinopathy: Documentation of 

Presence or Absence of Macular Edema 

and Level of Severity of Retinopathy: 

Percentage of patients aged 18 years and 

older with a diagnosis of diabetic retinopathy 

who had a dilated macular or fundus exam 

performed which included documentation of 

the level of severity of retinopathy and the 

presence or absence of macular edema during 

one or more office visits within 12 months 

One commenter disagreed with the removal 

of this measure. CMS initially wanted to 

propose removal of this measure as eligible 

professionals are consistently meeting 

performance on this measure with 

performance rates close to 100%. However, 

due to our desire to align with the EHR 

Incentive Program, under which this measure 

is also available for reporting in 2015, CMS 

proposed to maintain this measure in PQRS 

for EHR reporting only, removing all other 

reporting options, until the EHR Incentive 

Program can change this measure. CMS is 

finalizing removal of this measure from 

reporting for 2015 PQRS for all other 

reporting options. 

AMAPCPI 

NCQA 

 X MU2 

013

4/0

43 

Effective 

Clinical 

Care 

Coronary Artery Bypass Graft (CABG): 

Use of Internal Mammary Artery (IMA) 

in Patients with Isolated CABG Surgery: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG surgery 

who received an IMA graft 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

STS X X 
CMS-1612-FC 773

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS as part of its goal to lower the data 

error rate and decrease provider burden.

037

7/0

67 

Effective 

Clinical 

Care 

Hematology: Myelodysplastic Syndrome 

(MDS) and Acute Leukemias: Baseline 

Cytogenetic Testing Performed on Bone 

Marrow: Percentage of patients aged 18 

years and older with a diagnosis of 

myelodysplastic syndrome (MDS) or an 

acute leukemia who had baseline cytogenetic 

testing performed on bone marrow 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS as part of its goal to lower the data 

error rate and decrease provider burden. 

AMAPCPI 

ASH 

 X 

037

8/0

68 

Effective 

Clinical 

Care 

Hematology: Myelodysplastic Syndrome 

(MDS): Documentation of Iron Stores in 

Patients Receiving Erythropoietin 

Therapy: Percentage of patients aged 18 

years and older with a diagnosis of 

myelodysplastic syndrome (MDS) who are 

receiving erythropoietin therapy with 

documentation of iron stores within 60 days 

prior to initiating erythropoietin therapy 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

AMAPCPI 

ASH 

 X 
CMS-1612-FC 774

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

038

0/0

69 

Effective 

Clinical 

Care 

Hematology: Multiple Myeloma: 

Treatment with Bisphosphonates: 

Percentage of patients aged 18 years and 

older with a diagnosis of multiple myeloma, 

not in remission, who were prescribed or 

received intravenous bisphosphonate therapy 

within the 12-month reporting period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

AMAPCPI 

ASH 

 X 

037

9/0

70 

Effective 

Clinical 

Care 

Hematology: Chronic Lymphocytic 

Leukemia (CLL): Baseline Flow 

Cytometry: Percentage of patients aged 18 

years and older seen within a 12 month 

reporting period with a diagnosis of chronic 

lymphocytic leukemia (CLL) made at any 

time during or prior to the reporting period 

who had baseline flow cytometry studies 

performed and documented in the chart 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

AMAPCPI 

ASH X 

039

5 

/08

4 

Effective 

Clinical 

Care 

Hepatitis C: Ribonucleic Acid (RNA) 

Testing Before Initiating Treatment: 

Percentage of patients aged 18 years and 

older with a diagnosis of chronic hepatitis C 

who started antiviral treatment within the 12 

month reporting period for whom 

quantitative hepatitis C virus (HCV) RNA 

AGA X 
CMS-1612-FC 775

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

testing was performed within 12 months 

prior to initiation of antiviral treatment 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures. 

039

6 

/08

5 

Effective 

Clinical 

Care 

Hepatitis C: HCV Genotype Testing Prior 

to Treatment: Percentage of patients aged 

18 years and older with a diagnosis of 

chronic hepatitis C who started antiviral 

treatment within the 12 month reporting 

period for whom hepatitis C virus (HCV) 

genotype testing was performed within 12 

months prior to initiation of antiviral 

treatment 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

AGA X 

039

8/0

87 

Effective 

Clinical 

Care 

Hepatitis C: Hepatitis C Virus (HCV) 

Ribonucleic Acid (RNA) Testing Between 

4-12 Weeks After Initiation of Treatment: 

Percentage of patients aged 18 years and 

older with a diagnosis of chronic hepatitis C 

who are receiving antiviral treatment for 

AGA X 
CMS-1612-FC 776

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

whom quantitative hepatitis C virus (HCV) 

RNA testing was performed between 4-12 

weeks after the initiation of antiviral 

treatment 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

038

9 

/10

2 

129

v3 

Efficiency 

and Cost 

Reduction 

Prostate Cancer: Avoidance of Overuse of 

Bone Scan for Staging Low Risk Prostate 

Cancer Patients: Percentage of patients, 

regardless of age, with a diagnosis of prostate 

cancer at low risk of recurrence receiving 

interstitial prostate brachytherapy, OR 

external beam radiotherapy to the prostate, 

OR radical prostatectomy, OR cryotherapy 

who did not have a bone scan performed at 

any time since diagnosis of prostate cancer 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

AMAPCPI X X MU2 

039

0 

/10

4 

Effective 

Clinical 

Care 

Prostate Cancer: Adjuvant Hormonal 

Therapy for High Risk Prostate Cancer 

Patients: Percentage of patients, regardless 

of age, with a diagnosis of prostate cancer at 

high or very high risk of recurrence receiving 

external beam radiotherapy to the prostate 

who were prescribed adjuvant hormonal 

therapy (GnRH [gonadotropin-releasing 

AMAPCPI X 
CMS-1612-FC 777

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

hormone] agonist or antagonist) 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

010

4/1

07 

161

v3 

Effective 

Clinical 

Care 

Adult Major Depressive Disorder (MDD): 

Suicide Risk Assessment: Percentage of 

patients aged 18 years and older with a 

diagnosis of major depressive disorder 

(MDD) with a suicide risk assessment 

completed during the visit in which a new 

diagnosis or recurrent episode was identified 

CMS is finalizing its proposal to change the 

reporting option of PQRS #107 to EHR-only 

reporting as part of its efforts to align with 

the EHR Incentive Program when PQRS 

would otherwise propose to remove this 

measure from PQRS, as it is a process 

measure that is analytically challenging to 

report. PQRS will keep this measure as EHRreportable until the EHR Incentive Program 

is able to change this measure. 

AMAPCPI X MU2 

005

4 

/10

8 

Effective 

Clinical 

Care 

Rheumatoid Arthritis (RA): Disease 

Modifying Anti-Rheumatic Drug 

(DMARD) Therapy: Percentage of patients 

aged 18 years and older who were diagnosed 

with RA and were prescribed, dispensed, or 

administered at least one ambulatory 

prescription for a disease-modifying antirheumatic drug (DMARD) 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

NCQA X 
CMS-1612-FC 778

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

166

8 

/12

1 

Effective 

Clinical 

Care 

Adult Kidney Disease: Laboratory Testing 

(Lipid Profile): Percentage of patients aged 

18 years and older with a diagnosis of 

chronic kidney disease (CKD) (stage 3, 4, or 

5, not receiving Renal Replacement Therapy 

[RRT]) who had a fasting lipid profile 

performed at least once within a 12-month 

period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

RPA X X 

AQ

A 

Ad

opt

ed 

/12

2 

Effective 

Clinical 

Care 

Adult Kidney Disease: Blood Pressure 

Management: Percentage of patient visits 

for those patients aged 18 years and older 

with a diagnosis of chronic kidney disease 

(CKD) (stage 3, 4, or 5, not receiving Renal 

Replacement Therapy [RRT]) with a blood 

pressure < 140/90 mmHg OR ≥ 140/90 

mmHg with a documented plan of care 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

RPA X X AQA 

040

5 

/16

0 

52v

3 

Effective 

Clinical 

Care 

HIV/AIDS: Pneumocystis Jiroveci 

Pneumonia (PCP) Prophylaxis: Percentage 

of patients aged 6 weeks and older with a 

diagnosis of HIV/AIDS who were prescribed 

Pneumocystis Jiroveci Pneumonia (PCP) 

prophylaxis 

NCQA X MU2 
CMS-1612-FC 779

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

AQ

A 

Ad

opt

ed/

176 

Effective 

Clinical 

Care 

Rheumatoid Arthritis (RA): Tuberculosis 

Screening: Percentage of patients aged 18 

years and older with a diagnosis of 

rheumatoid arthritis (RA) who have 

documentation of a tuberculosis (TB) 

screening performed and results interpreted 

within 6 months prior to receiving a first 

course of therapy using a biologic diseasemodifying anti-rheumatic drug (DMARD) 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures 

AC 

Rheumat

ology 

 X AQA 

AQ

A 

Ad

opt

ed/

177 

Effective 

Clinical 

Care 

Rheumatoid Arthritis (RA): Periodic 

Assessment of Disease Activity: Percentage 

of patients aged 18 years and older with a 

diagnosis of rheumatoid arthritis (RA) who 

have an assessment and classification of 

disease activity within 12 months 

While several comments were concerned 

AC 

Rheumat

ology 

 X AQA 
CMS-1612-FC 780

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures 

AQ

A 

Ad

opt

ed/

179 

Effective 

Clinical 

Care 

Rheumatoid Arthritis (RA): Assessment 

and Classification of Disease Prognosis: 

Percentage of patients aged 18 years and 

older with a diagnosis of rheumatoid arthritis 

(RA) who have an assessment and 

classification of disease prognosis at least 

once within 12 months 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures 

AC 

Rheumat

ology 

 X AQA 

AQ

A 

Ad

opt

ed 

/18

0 

Effective 

Clinical 

Care 

Rheumatoid Arthritis (RA): 

Glucocorticoid Management: Percentage of 

patients aged 18 years and older with a 

diagnosis of rheumatoid arthritis (RA) who 

have been assessed for glucocorticoid use 

and, for those on prolonged doses of 

prednisone ≥ 10 mg daily (or equivalent) 

with improvement or no change in disease 

activity, documentation of glucocorticoid 

management plan within 12 months 

While several comments were concerned 

AC 

Rheumat

ology 

 X AQA 
CMS-1612-FC 781

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures 

039

9 

/18

3 

Community

/ 

Population 

Health 

Hepatitis C: Hepatitis A Vaccination in 

Patients with Hepatitis C Virus (HCV): 

Percentage of patients aged 18 years and 

older with a diagnosis of chronic hepatitis C 

who have received at least one injection of 

hepatitis A vaccine, or who have documented 

immunity to hepatitis A 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

AGA X 

038

6 

/19

4 

Effective 

Clinical 

Care 

Oncology: Cancer Stage Documented: 

Percentage of patients, regardless of age, 

with a diagnosis of cancer who are seen in 

the ambulatory setting who have a baseline 

American Joint Committee on Cancer 

(AJCC) cancer stage or documentation that 

the cancer is metastatic in the medical record 

at least once during the 12 month reporting 

period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

AMAPCPI 

ASCO X 
CMS-1612-FC 782

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS as part of its goal to lower the data 

error rate and decrease provider burden. Note 

that this measure is no longer part of a 

measures group as well. 

002

2/2

38 

156

v3 

Patient 

Safety 

Use of High-Risk Medications in the 

Elderly: Percentage of patients 66 years of 

age and older who were ordered high-risk 

medications. Two rates are reported 

a. Percentage of patients who were ordered at 

least one high-risk medication. 

b. Percentage of patients who were ordered at 

least two different high-risk medications 

No comments were received regarding this 

measure. CMS is finalizing its proposal to 

add registry as a reporting option for this 

measure in 2015 PQRS.

NCQA X X MU2 

007

5/2

41 

182

v4 

Effective 

Clinical 

Care 

Ischemic Vascular Disease (IVD): 

Complete Lipid Profile and LDL-C 

Control (<100 mg/dL): Percentage of 

patients 18 years of age and older who were 

discharged alive for acute myocardial 

infarction (AMI), coronary artery bypass 

graft (CABG) or percutaneous coronary 

interventions (PCI) in the 12 months prior to 

the measurement period, or who had an 

active diagnosis of ischemic vascular disease 

(IVD) during the measurement period, and 

who had each of the following during the 

measurement period: a complete lipid profile 

and LDL-C was adequately controlled (< 100 

mg/dL) 

CMS is finalizing its proposal to change the 

reporting option of PQRS #241 to EHR-only 

reporting as part of its efforts to align with 

the EHR Incentive Program when PQRS 

would otherwise propose to remove this 

measure from PQRS 2015. PQRS will keep 

this measure as EHR reportable until the 

EHR Incentive Program can change this 

measure.

NCQA X 

MU2 

Million 

Hearts 

N/

A 

/32

Effective 

Clinical 

Care 

Pediatric Kidney Disease: Adequacy of 

Volume Management: Percentage of 

calendar months within a 12-month period 

RPA X 
CMS-1612-FC 783

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

7 during which patients aged 17 years and 

younger with a diagnosis of End Stage Renal 

Disease (ESRD) undergoing maintenance 

hemodialysis in an outpatient dialysis facility 

have an assessment of the adequacy of 

volume management from a nephrologist 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS as part of its goal to lower the data 

error rate and decrease provider burden.

166

7 

/32

8 

Effective 

Clinical 

Care 

Pediatric Kidney Disease: ESRD Patients 

Receiving Dialysis: Hemoglobin Level < 

10g/dL: Percentage of calendar months 

within a 12-month period during which 

patients aged 17 years and younger with a 

diagnosis of End Stage Renal Disease 

(ESRD) receiving hemodialysis or peritoneal 

dialysis have a hemoglobin level < 10 g/dL 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that not all eligible professionals have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. CMS appreciates the 

commenters’ concerns and believes that 

removal of the claims-based reporting option 

will not negatively impact a significant 

number of providers reporting these 

measures. Therefore, CMS is finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015. 

RPA X 

208

2 

/33

8 

Effective 

Clinical 

Care 

HIV Viral Load Suppression: The 

percentage of patients, regardless of age, 

with a diagnosis of HIV with a HIV viral 

load less than 200 copies/mL at last viral 

load test during the measurement year 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

HRSA X 
CMS-1612-FC 784

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

208

3 

/33

9 

Effective 

Clinical 

Care 

Prescription of HIV Antiretroviral 

Therapy: Percentage of patients, regardless 

of age, with a diagnosis of HIV prescribed 

antiretroviral therapy for the treatment of 

HIV infection during the measurement year 

While several comments were concerned 

with the removal of reporting options for 

some measures, CMS is finalizing its 

proposal to make this individual measure 

reportable via measures groups-only to lessen 

the burden of eligible professionals reporting 

individual measures based on the current 

requirement of nine measures over three 

domains. While removing reporting options 

could be seen as increasing burden for 

eligible professionals, as they have fewer 

choices to report this measure, we do not 

believe this is the case with reporting via 

measures groups. For example, an individual 

eligible professional reporting via a measures 

group only need to report on a minimum of 6 

measures rather than a minimum of 9 

measures covering 3 NQS domains, as is the 

case with reporting individual measures

HRSA X 

207

9 

/34

0 

Efficiency 

and Cost 

Reduction 

HIV Medical Visit Frequency: Percentage 

of patients, regardless of age with a diagnosis 

of HIV who had at least one medical visit in 

each 6 month period of the 24 month 

measurement period, with a minimum of 60 

days between medical visits 

This measure was included on this table in 

error in the proposed rule. There are no 

changes proposed for this measure in 2015 

PQRS. This measure was reportable through 

measure groups only in PQRS 2014 and will 

continue to be similarly reportable in PQRS 

2015. 

HRSA X 

071

0/ 

370

159

v3 

Effective 

Clinical 

Care 

Depression Remission at Twelve Months: 

Adult patients age 18 and older with major 

depression or dysthymia and an initial PHQ9 score > 9 who demonstrate remission at 

MNCM X X MU2 
CMS-1612-FC 785

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

twelve months defined as PHQ-9 score less 

than 5. This measure applies to both patients 

with newly diagnosed and existing 

depression whose current PHQ-9 score 

indicates a need for treatment 

CMS did not receive any comments 

regarding the proposal to add registry as a 

reporting option for this measure. As such, 

CMS is finalizing this proposal for 2015 

PQRS. 

Measures Not Finalized as Proposed 

008

6/0

12 

143

v3 

Effective 

Clinical 

Care 

Primary Open-Angle Glaucoma (POAG): 

Optic Nerve Evaluation: Percentage of 

patients aged 18 years and older with a 

diagnosis of primary open-angle glaucoma 

(POAG) who have an optic nerve head 

evaluation during one or more office visits 

within 12 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AMAPCPI 

NCQA 

X X X MU2 

008

9/0

19 

142

v3 

Effective 

Clinical 

Care 

Diabetic Retinopathy: Communication 

with the Physician Managing Ongoing 

Diabetes Care: Percentage of patients aged 

18 years and older with a diagnosis of 

diabetic retinopathy who had a dilated 

macular or fundus exam performed with 

documented communication to the physician 

who manages the ongoing care of the patient 

with diabetes mellitus regarding the findings 

of the macular or fundus exam at least once 

within 12 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

AMAPCPI 

NCQA 

X X X MU2 
CMS-1612-FC 786

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

004

5/0

24 

Communica

tion and 

Care 

Coordinatio

n 

Osteoporosis: Communication with the 

Physician Managing On-going Care PostFracture of Hip, Spine or Distal Radius 

for Men and Women Aged 50 Years and 

Older: Percentage of patients aged 50 years 

and older treated for a hip, spine or distal 

radial fracture with documentation of 

communication with the physician managing 

the patient’s on-going care that a fracture 

occurred and that the patient was or should 

be tested or treated for osteoporosis 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Furthermore, this 

measure is a preventive care measure. 

Therefore, CMS is not finalizing its proposal 

to remove the claims-based reporting option 

for this measure in 2015 PQRS. However, 

CMS is moving away from claims-based 

measures and therefore may reconsider the 

reporting options for this measure in future 

program years. 

AMAPCPI 

NCQA 

X X 

004

6/0

39 

Effective 

Clinical 

Care 

Screening or Therapy for Osteoporosis for 

Women Aged 65 Years and Older: 

Percentage of female patients aged 65 years 

and older who have a central dual-energy Xray absorptiometry (DXA) measurement 

ordered or performed at least once since age 

60 or pharmacologic therapy prescribed 

within 12 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

AMAPCPI 

NCQA 

X X X 
CMS-1612-FC 787

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS identified this measure as a broadly 

applicable, preventive care measure. 

Therefore, CMS is not finalizing its proposal 

to remove the claims-based reporting option 

for this measure in 2015 PQRS. However, 

CMS is moving away from claims-based 

measures and therefore may reconsider the 

reporting options for this measure in future 

program years. 

004

8/0

40 

Effective 

Clinical 

Care 

Osteoporosis: Management Following 

Fracture of Hip, Spine or Distal Radius 

for Men and Women Aged 50 Years and 

Older: Percentage of patients aged 50 years 

and older with fracture of the hip, spine, or 

distal radius who had a central dual-energy 

X-ray absorptiometry (DXA) measurement 

ordered or performed or pharmacologic 

therapy prescribed 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AMAPCPI 

NCQA 

X X 

009

7/0

46 

Communica

tion and 

Care 

Coordinatio

n 

Medication Reconciliation: Percentage of 

patients aged 18 years and older discharged 

from any inpatient facility (for example, 

hospital, skilled nursing facility, or 

rehabilitation facility) and seen within 30 

days following discharge in the office by the 

physician, prescribing practitioner, registered 

nurse, or clinical pharmacist providing ongoing care who had a reconciliation of the 

discharge medications with the current 

medication list in the outpatient medical 

record documented. This measure is reported 

as two rates stratified by age group: 

Reporting Age Criteria 1: 18-64 years of age 

Reporting Age Criteria 2: 65 years and older 

AMAPCPI 

NCQA 

X X 
CMS-1612-FC 788

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

010

0/0

50 

Person and 

CaregiverCentered 

Experience 

and 

Outcomes 

Urinary Incontinence: Plan of Care for 

Urinary Incontinence in Women Aged 65 

Years and Older: Percentage of female 

patients aged 65 years and older with a 

diagnosis of urinary incontinence with a 

documented plan of care for urinary 

incontinence at least once within 12 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Furthermore, CMS 

identified this measure as a preventive care 

measure. Therefore, CMS is not finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS. However, CMS is moving away from 

claims-based measures and therefore may 

reconsider the reporting options for this 

measure in future program years.

NCQA 

AMAPCPI X X 

009

0/0

54 

Effective 

Clinical 

Care 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed for 

Non-Traumatic Chest Pain: Percentage of 

patients aged 40 years and older with an 

emergency department discharge diagnosis 

of non-traumatic chest pain who had a 12-

lead electrocardiogram (ECG) performed 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

AMAPCPI 

NCQA 

X X 
CMS-1612-FC 789

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

038

7/0

71 

140

v3 

Effective 

Clinical 

Care 

Breast Cancer: Hormonal Therapy for 

Stage IC - IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) 

Positive Breast Cancer: Percentage of 

female patients aged 18 years and older with 

Stage IC through IIIC, ER or PR positive 

breast cancer who were prescribed tamoxifen 

or aromatase inhibitor (AI) during the 12-

month reporting period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AMAPCPI 

ASCO 

NCCN 

X X X X MU2 

038

5/0

72 

141

v3 

Effective 

Clinical 

Care 

Colon Cancer: Chemotherapy for AJCC 

Stage III Colon Cancer Patients: 

Percentage of patients aged 18 through 80 

years with AJCC Stage III colon cancer who 

are referred for adjuvant chemotherapy, 

prescribed adjuvant chemotherapy, or have 

previously received adjuvant chemotherapy 

within the 12-month reporting period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

AMAPCPI 

ASCO 

NCCN 

X X X X MU2 
CMS-1612-FC 790

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

N/

A/1

12 

Effective 

Clinical 

Care 

Breast Cancer Screening: Percentage of 

women 50 through 74 years of age who had a 

mammogram to screen for breast cancer 

within 27 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS identified this as a broadly applicable, 

preventive care measure. Therefore, CMS is 

not finalizing its proposal to remove the 

claims-based reporting option for this 

measure in 2015 PQRS. However, CMS is 

moving away from claims-based measures 

and therefore may reconsider the reporting 

options for this measure in future program 

years.

NCQA X X X X X MU2 

003

4 

/11

3 

130

v3 

Effective 

Clinical 

Care 

Colorectal Cancer Screening: Percentage 

of patients 50 through 75 years of age who 

had appropriate screening for colorectal 

cancer 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS identified this as a broadly applicable, 

preventive care measure. Therefore, CMS is 

not finalizing its proposal to remove the 

claims-based reporting option for this 

measure in 2015 PQRS. However, CMS is 

moving away from claims-based measures 

and therefore may reconsider the reporting 

options for this measure in future program 

years. 

NCQA X X X X X MU2 
CMS-1612-FC 791

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

005

5 

/11

7 

131

v3 

Effective 

Clinical 

Care 

Diabetes: Eye Exam: Percentage of patients 

18 through 75 years of age with a diagnosis 

of diabetes (type 1 and type 2) who had a 

retinal or dilated eye exam by an eye care 

professional in the measurement period or a 

negative retinal or dilated eye exam (negative 

for retinopathy) in the year prior to the 

measurement period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. In addition, many 

commenters supported the inclusion of the 

measure within the Shared Savings Program 

Diabetes Composite, but requested testing of 

the Composite measure and submission to 

NQF. Some commenters did not support the 

addition of a process measure to the Shared 

Savings Program measure set and questioned 

the measure’s link to improving outcomes. 

Therefore, CMS is not finalizing its proposal 

to remove the claims-based reporting option 

for this measure in 2015 PQRS. However, 

CMS is moving away from claims-based 

measures and therefore may reconsider the 

reporting options for this measure in future 

program years. CMS will finalize adding the 

measure to the Shared Savings Program 

Diabetes Composite due to its clinical 

importance, alignment with PQRS, and 

stakeholder support.

NCQA X X X X X ACO 

MU2 

006

2 

/11

9 

134

v3 

Effective 

Clinical 

Care 

Diabetes: Medical Attention for 

Nephropathy: The percentage of patients 

18-75 years of age with diabetes who had a 

nephropathy screening test or evidence of 

nephropathy during the measurement period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

NCQA X X X X MU2 
CMS-1612-FC 792

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

claims-based option. Furthermore, CMS 

identified this measure as a preventive care 

measure. Therefore, CMS is not finalizing its 

proposal to remove the claims-based 

reporting option for this measure in 2015 

PQRS. However, CMS is moving away from 

claims-based measures and therefore may 

reconsider the reporting options for this 

measure in future program years.

056

3 

/14

1 

Communica

tion and 

Care 

Coordinatio

n 

Primary Open-Angle Glaucoma (POAG): 

Reduction of Intraocular Pressure (IOP) 

by 15% OR Documentation of a Plan of 

Care: Percentage of patients aged 18 years 

and older with a diagnosis of primary openangle glaucoma (POAG) whose glaucoma 

treatment has not failed (the most recent IOP 

was reduced by at least 15% from the preintervention level) OR if the most recent IOP 

was not reduced by at least 15% from the 

pre-intervention level, a plan of care was 

documented within 12 months 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AAO X X 

005

6 

/16

3 

123

v3 

Effective 

Clinical 

Care 

Diabetes: Foot Exam: Percentage of 

patients aged 18-75 years of age with 

diabetes who had a foot exam during the 

measurement period 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Furthermore, CMS 

NCQA X X X X ACO 

MU2 
CMS-1612-FC 793

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

identified this as a preventive care measure. 

Therefore, CMS is not finalizing its proposal 

to remove the claims-based reporting option 

for this measure in 2015 PQRS. However, 

CMS is moving away from claims-based 

measures and therefore may reconsider the 

reporting options for this measure in future 

program years.

065

9 

/18

5 

Communica

tion and 

Care 

Coordinatio

n 

Colonoscopy Interval for Patients with a 

History of Adenomatous Polyps – 

Avoidance of Inappropriate Use: 

Percentage of patients aged 18 years and 

older receiving a surveillance colonoscopy 

with a history of a prior adenomatous 

polyp(s) in previous colonoscopy findings, 

who had an interval of 3 or more years since 

their last colonoscopy 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AGA 

ASGE 

ACG X X 

006

8/2

04 

164

v3 

Effective 

Clinical 

Care 

Ischemic Vascular Disease (IVD): Use of 

Aspirin or Another Antithrombotic: 

Percentage of patients 18 years of age and 

older who were discharged alive for acute 

myocardial infarction (AMI), coronary artery 

bypass graft (CABG) or percutaneous 

coronary interventions (PCI) in the 12 

months prior to the measurement period, or 

who had an active diagnosis of ischemic 

vascular disease (IVD) during the 

measurement period and who had 

documentation of use of aspirin or another 

antithrombotic during the measurement 

period 

Commenters expressed concern with 

maintaining this measure in PQRS for EHR 

reporting only for the “sake of alignment 

with the EHR Incentive Program especially 

in the face of changing [clinical] evidence.” 

However, due to CMS’s desire to maintain 

NCQA X X X X 

MU2 

Million 

Hearts 
CMS-1612-FC 794

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

alignment with the EHR Incentive Program, 

CMS will not make changes to EHR 

measures until the EHR Incentive Program is 

able to change this measure. 

commentsfrombut CMS is not finalizing its 

proposal to remove the claims, registry and 

GPRO reporting options for this measure. 

This measure will continue to be reportable 

through claims, registry, GPRO (including 

the Shared Savings Program), as well as 

EHR in PQRS 2015. However, CMS is 

moving away from claims-based measures 

and therefore may reconsider the reporting 

options for this measure in future program 

years. 

040

9 

/20

5 

Effective 

Clinical 

Care 

HIV/AIDS: Sexually Transmitted Disease 

Screening for Chlamydia, Gonorrhea, and 

Syphilis: Percentage of patients aged 13 

years and older with a diagnosis of 

HIV/AIDS for whom chlamydia, gonorrhea 

and syphilis screenings were performed at 

least once since the diagnosis of HIV 

infection 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years.

NCQA 

AMAPCPI X X 

065

1 

/25

4 

Effective 

Clinical 

Care 

Ultrasound Determination of Pregnancy 

Location for Pregnant Patients with 

Abdominal Pain: Percentage of pregnant 

female patients aged 14 to 50 who present to 

the emergency department (ED) with a chief 

complaint of abdominal pain or vaginal 

bleeding who receive a trans-abdominal or 

trans-vaginal ultrasound to determine 

pregnancy location 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

ACEP X X 
CMS-1612-FC 795

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

065

2 

/25

5 

Effective 

Clinical 

Care 

Rh Immunoglobulin (Rhogam) for RhNegative Pregnant Women at Risk of Fetal 

Blood Exposure: Percentage of Rh-negative 

pregnant women aged 14-50 years at risk of 

fetal blood exposure who receive RhImmunoglobulin (Rhogam) in the emergency 

department (ED) 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

ACEP X X 

N/

A 

/26

8 

Effective 

Clinical 

Care 

Epilepsy: Counseling for Women of 

Childbearing Potential with Epilepsy: All 

female patients of childbearing potential (12-

44 years old) diagnosed with epilepsy who 

were counseled about epilepsy and how its 

treatment may affect contraception and 

pregnancy at least once a year 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

AAN X X 
CMS-1612-FC 796

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

N/

A/2

70 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Corticosteroid Sparing 

Therapy: Percentage of patients aged 18 

years and older with a diagnosis of 

inflammatory bowel disease who have been 

managed by corticosteroids greater than or 

equal to 10 mg/day of prednisone equivalents 

for 60 or greater consecutive days or a single 

prescription equating to 600mg prednisone or 

greater for all fills that have been prescribed 

corticosteroid sparing therapy in the last 

reporting year 

Commenters requested this IBD measure and 

others noted in this table be reportable 

through registry in addition to the IBD 

Measure Group to better support providers 

reporting these measures. CMS agrees, and 

for this reason CMS is finalizing this 

measure with modifications as reportable in 

2015 PQRS through registry and measure 

group.

AGA X X 

N/

A/2

71 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Corticosteroid Related 

Iatrogenic Injury – Bone Loss Assessment: 

Percentage of patients aged 18 years and 

older with an inflammatory bowel disease 

encounter who were prescribed prednisone 

equivalents greater than or equal to 10 

mg/day for 60 or greater consecutive days or 

a single prescription equating to 600mg 

prednisone or greater for all fills and were 

documented for risk of bone loss once during 

the reporting year or the previous calendar 

year 

Commenters requested this IBD measure and 

others noted in this table be reportable 

through registry in addition to the IBD 

Measure Group to better support providers 

reporting these measures. CMS agrees, and 

for this reason CMS is finalizing this 

measure with modifications as reportable in 

2015 PQRS through registry and measure 

group.

AGA X X 

N/

A/2

74 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Testing for Latent Tuberculosis (TB) 

Before Initiating Anti-TNF (Tumor 

Necrosis Factor) Therapy: Percentage of 

AGA X X 
CMS-1612-FC 797

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

patients aged 18 years and older with a 

diagnosis of inflammatory bowel disease for 

whom a tuberculosis (TB) screening was 

performed and results interpreted within six 

months prior to receiving a first course of 

anti-TNF (tumor necrosis factor) therapy 

Commenters requested this IBD measure and 

others noted in this table be reportable 

through registry in addition to the IBD 

Measure Group to better support providers 

reporting these measures. CMS agrees, and 

for this reason CMS is finalizing this 

measure with modifications as reportable in 

2015 PQRS through registry and measure 

group.

N/

A/2

75 

Effective 

Clinical 

Care 

Inflammatory Bowel Disease (IBD): 

Assessment of Hepatitis B Virus (HBV) 

Status Before Initiating Anti-TNF (Tumor 

Necrosis Factor) Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of inflammatory bowel disease 

(IBD) who had Hepatitis B Virus (HBV) 

status assessed and results interpreted within 

one year prior to receiving a first course of 

anti-TNF (tumor necrosis factor) therapy 

Commenters requested this IBD measure and 

others noted in this table be reportable 

through registry in addition to the IBD 

Measure Group to better support providers 

reporting these measures. CMS agrees, and 

for this reason CMS is finalizing this 

measure with modifications as reportable in 

2015 PQRS through registry and measure 

group.

AGA X X 

065

8 

/32

0 

Communica

tion and 

Care 

Coordinatio

n 

Appropriate Follow-Up Interval for 

Normal Colonoscopy in Average Risk 

Patients: Percentage of patients aged 50 

years and older receiving a screening 

colonoscopy without biopsy or polypectomy 

who had a recommended follow-up interval 

of at least 10 years for repeat colonoscopy 

documented in their colonoscopy report 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

AGA 

ASGE 

ACG X X 
CMS-1612-FC 798

NQF/ PQRS CMS E-Measure ID 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward Claims 

CSV Registry EHR GPRO (Web Interface) Measures Groups Other Quality Reporting Programs 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

152

5 

/32

6 

Effective 

Clinical 

Care 

Atrial Fibrillation and Atrial Flutter: 

Chronic Anticoagulation Therapy: 

Percentage of patients aged 18 and older with 

a diagnosis of nonvalvular atrial fibrillation 

(AF) or atrial flutter whose assessment of the 

specified thromboembolic risk factors 

indicate one or more high-risk factors or 

more than one moderate risk factor, as 

determined by CHADS2 risk stratification, 

who were prescribed warfarin OR another 

oral anticoagulant drug that is FDA approved 

for the prevention of thromboembolism 

Several commenters were concerned with 

CMS’ proposal to eliminate the claims-based 

reporting option for various measures, noting 

that eligible professionals who may have 

reported on these measures do not have the 

resources to implement registry or EHR 

reporting and will no longer be able to 

participate in PQRS. Upon further review, 

CMS agrees that a significant number of 

providers that report this measure will be 

negatively impacted by the removal of the 

claims-based option. Therefore, CMS is not 

finalizing its proposal to remove the claimsbased reporting option for this measure in 

2015 PQRS. However, CMS is moving away 

from claims-based measures and therefore 

may reconsider the reporting options for this 

measure in future program years. 

AMAPCPI 

ACCF 

AHA 

X X 

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is 

due to the timing of measure specification preparation and the measure versions used by the various reporting options/methods. 

Please refer to the measure specifications that apply for each of the reporting options/methods for specific measure details. 

d. PQRS Measures Groups 

Section 414.90(b) defines a measures group as a subset of four or more PQRS measures that have 

a particular clinical condition or focus in common. The denominator definition and coding of the 

measures group identifies the condition or focus that is shared across the measures within a particular 

measures group. 
CMS-1612-FC 799

In the CY 2014 PFS proposed rule, we proposed (78 FR 43448) to increase the number of 

measures that may be included in a measures group from a minimum of 4 measures to a minimum of 6. 

We proposed increasing the minimum number of measures that may be contained in a measures group in 

accordance with increasing the number of individual measures to be reported via claims and registry. 

However, we did not finalize this proposal, stating that, although we still plan to increase the minimum 

number of measures in a measures group in the future, we would work with the measure developers and 

owners of these measures groups appropriately to add measures to measures groups that only contain four 

measures within the measures group (78 FR 74730). For CY 2015, we again we proposed to modify 

§414.90(b) to define a measures group as a subset of six or more PQRS measures that have a particular 

clinical condition or focus in common (79 FR 40457). We solicited and received the following public 

comment on this proposal: 

Comment: Several commenters opposed this proposal. Commenters noted that CMS did not 

work with the measure group developers and owners to create the proposed measures groups that consist 

of at least 6 measures and were concerned that the additional measures in the proposed measures groups 

were arbitrarily added and not relevant to the measures already contained in the measures group. 

Response: While we understand the commenters’ concerns that the additional measures may not 

be relevant to the measure group topic or condition, we note that we have performed clinical analyses to 

ensure that the added measures relate to the measure group topics and conditions. The addition of 

measures within the measures groups was not arbitrary. While some of the measures did not address the 

specific topic or condition depicted, we added measures within the measures groups that we believed 

were clinically relevant to report, as we believe these measures address topics and clinical 

conditions that are accepted in the clinical community as critical to monitor. For example, in 

most instances, we added measures from the cross-cutting measures set such as Tobacco 

Screening and Cessation and Medication Reconciliation. With respect to the concern that 

measures developers and measure owners were not consulted when developing our proposal to 

add measures to the measures groups, we will continue to work with the measure developers and 
CMS-1612-FC 800

owners to address any concerns they may have with the final measures groups and address 

changes when needed through future rulemaking. Based on the reasons stated here and in the 

proposed rule, we are finalizing our proposal to modify §414.90(b) to define a measures group as 

a subset of six or more PQRS measures that have a particular clinical condition or focus in 

common. 

In addition, we proposed to add two new measures groups that will be available for 

reporting in the PQRS beginning in 2015: the Sinusitis and Acute Otitis Externa (AOE) measures 

groups (79 FR 40457). 

Furthermore, we proposed to remove the following measures groups (79 FR 40457): 

● Perioperative care measures group; 

● Back pain measures group; 

● Cardiovascular prevention measures group; 

● Ischemic Vascular Disease (IVD) measures group; 

● Sleep Apnea measures group; and 

● Chronic obstructive pulmonary disease (COPD) measures group. 

We received the following comments on our proposals related to our proposals related to 

either the proposed addition or removal of the following measures groups: 

Comments on the proposed removal of the Perioperative Care Measures Group: Several 

commenters requested that CMS retain the Perioperative Care Measures Group and the related 

individual measures noting the following: “there is a bias in measuring that improves 

performance; (2) there are few measures applicable to surgeons it will be much harder to 

participate in PQRS without the perioperative measures.” 

Response: While there has been evidence to suggest there may be a bias in measuring 

that improves performance, there is an equal amount of evidence to the contrary that suggest this 
CMS-1612-FC 801

bias is not impactful. Additionally, we believe that there are a number of broadly applicable 

measures that these specialty surgeons can report. For these reasons, we are finalizing our 

proposal to remove the Perioperative Care Measure Group from reporting in 2015 PQRS. 

Comments on the proposed removal of the Back Pain Measures Group: Several 

commenters were concerned with the proposal to remove the Back Pain measures group, noting 

it would negatively impact physician anesthesiologists’, pain medicine physicians’ and physical 

therapists’ ability to report. Other commenters supported the removal of some of the Back Pain 

measure group measures such as “Back Pain: Initial Visit” and “Back Pain: Physical Exam.” 

Response: The measures in this measure group reflect clinical concepts that do not add 

clinical value to PQRS. Specifically, the measures in this group are entirely clinical process 

measures that do not meaningfully contribute to improved patient outcomes, and CMS believes 

that removal of this measure group will not negatively impact physician anesthesiologists’, pain 

medicine physicians’, and physical therapists’ ability to report. For these reasons, we are 

finalizing our proposal to remove the Back Pain Measure Group from reporting in 2015 PQRS. 

Comments on the proposed removal of the Cardiovascular Prevention Measures Group: 

We proposed to remove the cardiovascular prevention measures group because a number of 

individual measures contained in this measures group are proposed to be removed from all PQRS 

program reporting options with the exception of EHR reporting. No comments were received 

about the removal of this measure group. For these reasons, we are finalizing our proposal to 

remove the Cardiovascular Prevention Measure Group from reporting in 2015 PQRS. 

Comments on the proposed removal of the Ischemic Vascular Disease Measures Group: 

We proposed to remove the cardiovascular prevention measures group because a number of 

individual measures contained in this measures group are proposed to be removed from all PQRS 

program reporting options with the exception of EHR reporting. No comments were received 
CMS-1612-FC 802

about the removal of this measure group. For these reasons, we are finalizing our proposal to 

remove the Ischemic Vascular Disease Measure Group from reporting in 2015 PQRS. 

Comments on the proposed addition of the Acute Otitis Externa (AOE) Measures Group: 

One commenter supported the addition of this measure group. 

Response: We did not receive any dissenting comments. For these reasons, we are 

finalizing our proposal to include the AOE measure group for reporting in 2015 PQRS. 

Comments on the proposed removal of the Chronic Obstructive Pulmonary Disorder 

(COPD) Measures Group: We initially proposed to remove this measure group contingent on the 

measure steward not being able to maintain certain measures contained in this measures group 

(79 FR 40457). A new steward has been identified for the measures at risk, and for this reason 

we are not finalizing our proposal to remove this measures group in 2015. 

Comments on the proposed removal of the Sleep Apnea Measures Group: We initially 

proposed to remove this measures group contingent on the measure steward not being able to 

maintain certain measures contained in this measures group. A new steward has been identified 

for the measures at risk, and for this reason we are not finalizing our proposal to remove this 

measures group in 2015. 

Comments on the proposed Rheumatoid Arthritis Measures Group: Commenters 

disagreed with CMS's proposal to add the Preventive Care and Screening: Influenza 

Immunization (PQRS #110) and Preventive Care and Screening: Tobacco Use: Screening and 

Cessation Intervention (PQRS #226) measures to the Rheumatoid Arthritis Measures Group for 

CY 2015. Commenters did not believe these measures provide substantial value to the specific 

clinical focus of this measures group. Instead, commenters recommend the addition of crosscutting measure Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow 

(PQRS #128) and Pain Assessment and Follow-up (PQRS #131) to achieve the goal of six 
CMS-1612-FC 803

measures while retaining clinical relevance. CMS agrees with commenters’ suggestions and thus 

is not finalizing the proposal to add PQRS #110 and #226 to this measure group, but rather will 

add PQRS #128 and #131 to better support the clinical purpose of this measure group while 

meeting the six measure minimum requirement. 

Tables 57 through 79 specify our final measures groups in light of the reasons stated in 

the proposed rule and the comments received. Please note that some measures groups were not 

addressed above. With respect to the measures groups that were not addressed above, we did not 

receive any comments on these proposed measures groups and are therefore finalizing the 

respective measures groups as proposed. 

 
CMS-1612-FC 804

TABLE 57: Asthma Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0047/053 

Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting:

Percentage of patients aged 5 through 64 years with a diagnosis of persistent asthma who 

were prescribed long-term control medication 

AMA-PCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an influenza 

immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin / mineral / dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user

AMA-PCPI 

N/A/402 

Tobacco Use and Help with Quitting Among Adolescents: Percentage of adolescents 13 to 

20 years of age with a primary care visit during the measurement period for whom tobacco 

use status was documented and received help quitting if identified as a tobacco user.

NCQA / NCIQM 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 

Plan: Percentage of patients aged 18 years and older with a BMI documented during the 

current encounter or during the previous six months AND with a BMI outisde of normal 

parameters, a follow-up plan is documented during the encounter or during the previous six 

months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2 ; Age 18 – 64 years 

BMI ≥ 18.5 and < 25 kg/m2

CMS/QIP 

TABLE 58: Acute Otitis Externa (AOE) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0653/091 Acute Otitis Externa (AOE): Topical Therapy: Percentage of patients aged 2 years and 

older with a diagnosis of AOE who were prescribed topical preparations AMA-PCPI 

0654/093 

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of 

Inappropriate Use: Percentage of patients aged 2 years and older with a diagnosis of AOE 

who were not prescribed systemic antimicrobial therapy

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin / mineral / dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0420/131 

Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older 

with documentation of a pain assessment using a standardized tool(s) on each visit AND 

documentation of a follow-up plan when pain is present

CMS/QIP 

0101/154 Falls: Risk Assessment: Percentage of patients aged 65 years and older with a history of 

falls who had a risk assessment for falls completed within 12 months AMA-PCPI 

0101/155 Falls: Plan of Care: Percentage of patients aged 65 years and older with a history of falls 

who had a plan of care for falls documented within 12 months AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/317 

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up 

Documented: Percentage of patients aged 18 years and older seen during the reporting 

period who were screened for high blood pressure AND a recommended follow-up plan is 

documented based on the current blood pressure (BP) reading as indicated 

CMS/QIP 

 
CMS-1612-FC 805

TABLE 59: Cataracts Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route of administration 

CMS/QIP 

0565/191 

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery:

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract 

who had cataract surgery and no significant ocular conditions impacting the visual outcome 

of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved 

within 90 days following the cataract surgery 

AMA-PCPI/NCQA 

0564/192 

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring 

Additional Surgical Procedures: Percentage of patients aged 18 years and older with a 

diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list 

of surgical procedures in the 30 days following cataract surgery which would indicate the 

occurrence of any of the following major complications: retained nuclear fragments, 

endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence 

AMA-PCPI/NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/303 

Cataracts: Improvement in Patient’s Visual Function within 90 Days Following 

Cataract Surgery: Percentage of patients aged 18 years and older in sample who had 

cataract surgery and had improvement in visual function achieved within 90 days following 

the cataract surgery, based on completing a pre-operative and post-operative visual function 

survey 

AAO 

N/A/304 

Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery: Percentage 

of patients aged 18 years and older in sample who had cataract surgery and were satisfied 

with their care within 90 days following the cataract surgery, based on completion of the 

Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey 

AAO 

N/A/388 

Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior 

Capsule Requiring Unplanned Vsitrectomy): Rupture of the posterior capsule during 

anterior segment surgery requiring vsitrectomy 

AAEECE/ACHS 

N/A/389 Cataract Surgery: Difference Between Planned and Final Refraction: Percentage of 

patients who achieve planned refraction within +-1,0 D AAEECE/ACHS 

 
CMS-1612-FC 806

TABLE 60: Chronic Kidney Disease (CKD) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or 

surrogate decision maker documented in the medical record or documentation in the medical 

record that an advance care plan was discussed but the patient did not wish or was not able to 

name a surrogate decision maker or provide an advance care plan 

AMAPCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an influenza 

immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

1668/121 

Adult Kidney Disease: Laboratory Testing (Lipid Profile): Percentage of patients aged 18 

years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving 

Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within 

a 12-month period 

AMA-PCPI 

N/A/122 

Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for those 

patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 

5, not receiving Renal Replacement Therapy [RRT]) and proteinuria with a blood pressure < 

140/90 mmHg OR ≥ 140/90 mmHg with a documented plan of care 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a list of 

current medications using all immediate resources available on the date of the encounter. This list 

must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary 

(nutritional) supplements AND must contain the medications’ name, dosage, frequency and route 

of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more times 

within 24 months AND who received cessation counseling intervention if identified as a tobacco 

user 

AMA-PCPI 

 
CMS-1612-FC 807

TABLE 61: Chronic Obstructive Pulmonary Disorder (COPD) Measures Group for 2015 and 

Beyond 

(Please note that CMS initially proposed to remove this measure group contingent on the measure steward not being 

able to maintain certain measures contained in this measures group. A new steward has been identified for the 

measures at risk and for this reason CMS is not finalizing its proposal to remove this measures group in 2015.) 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or 

surrogate decision maker documented in the medical record or documentation in the medical 

record that an advance care plan was discussed but the patient did not wish or was not able to 

name a surrogate decision maker or provide an advance care plan 

AMAPCPI/NCQA 

0091/051 

Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of 

patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results 

documented 

AMA-PCPI 

0102/052 

Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy:

Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an 

FEV1/FVC less than 60% and have symptoms who were prescribed an inhaled bronchodilator 

AMA-PCPI 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an influenza 

immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and 

older who have ever received a pneumococcal vaccine NCQA 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a list of 

current medications using all immediate resources available on the date of the encounter. This list 

must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary 

(nutritional) supplements AND must contain the medications’ name, dosage, frequency and route 

of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more times 

within 24 months AND who received cessation counseling intervention if identified as a tobacco 

user 

AMA-PCPI 

 
CMS-1612-FC 808

TABLE 62: Coronary Artery Bypass Graft (CABG) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0134/043 

Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in 

Patients with Isolated CABG Surgery: Percentage of patients aged 18 years and older 

undergoing isolated CABG surgery who received an IMA graft 

STS 

0236/044 

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with 

Isolated CABG Surgery: Percentage of isolated Coronary Artery Bypass Graft (CABG) 

surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours 

prior to surgical incision 

CMS/QIP 

0129/164 

Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients 

aged 18 years and older undergoing isolated CABG surgery who require postoperative 

intubation > 24 hours 

STS 

0130/165 

Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate:

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, 

within 30 days postoperatively, develop deep sternal wound infection involving muscle, 

bone, and/or mediastinum requiring operative intervention 

STS 

0131/166 

Coronary Artery Bypass Graft (CABG): Stroke: Percentage of patients aged 18 years and 

older undergoing isolated CABG surgery who have a postoperative stroke (that is, any 

confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the 

brain) that did not resolve within 24 hours 

STS 

0114/167 

Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure: Percentage of 

patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing 

renal failure) who develop postoperative renal failure or require dialysis 

STS 

0115/168 

Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration: Percentage of patients 

aged 18 years and older undergoing isolated CABG surgery who require a return to the 

operating room (OR) during the current hospitalization for mediastinal bleeding with or 

without tamponade, graft occlusion, valve dysfunction, or other cardiac reason. 

Please note that CMS had proposed to remove this measure from the program and thus this 

measure group as a result in the NPRM. However, as noted above in Table 55, CMS is not 

finalizing its proposal to remove this measure, and as such, the measure is not being removed 

from this measure group either.

STS 

 
CMS-1612-FC 809

TABLE 63: Coronary Artery Disease (CAD) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0067/006 

Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12 month period 

who were prescribed aspirin or clopidogrel 

AMAPCPI/ACCF/AHA 

0070/007 

Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction 

(MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%: Percentage of patients aged 

18 years and older with a diagnosis of coronary artery disease seen within a 12 month period 

who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker 

therapy

AMA-PCPI 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 

Plan: Percentage of patients aged 18 years and older with a BMI documented during the 

current encounter or during the previous six months AND with a BMI outside of normal 

parameters, a follow-up plan is documented during the encounter or during the previous six 

months of the encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2

; Age 18 – 64 years 

BMI ≥ 18.5 and < 25 kg/m2

CMS/QIP 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/242 

Coronary Artery Disease (CAD): Symptom Management: Percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12 month period 

with results of an evaluation of level of activity and an assessment of whether anginal 

symptoms are present or absent with appropriate management of anginal symptoms within a 

12 month period 

AMAPCPI/ACCF/AHA 

 
CMS-1612-FC 810

TABLE 64: Dementia Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or 

surrogate decision maker documented in the medical record or documentation in the medical 

record that an advance care plan was discussed but the patient did not wish or was not able to 

name a surrogate decision maker or provide an advance care plan 

AMA-PCPI/NCQA 

N/A/280 

Dementia: Staging of Dementia: Percentage of patients, regardless of age, with a diagnosis 

of dementia whose severity of dementia was classified as mild, moderate or severe at least 

once within a 12 month period 

AMA-PCPI 

N/A/281 

Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a 

diagnosis of dementia for whom an assessment of cognition is performed and the results 

reviewed at least once within a 12 month period 

AMA-PCPI 

N/A/282 

Dementia: Functional Status Assessment: Percentage of patients, regardless of age, with a 

diagnosis of dementia for whom an assessment of functional status is performed and the 

results reviewed at least once within a 12 month period 

AMA-PCPI 

N/A/283 

Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of 

age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric 

symptoms is performed and results reviewed at least once in a 12 month period 

AMA-PCPI 

N/A/284 

Dementia: Management of Neuropsychiatric Symptoms: Percentage of patients, 

regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric 

symptoms who received or were recommended to receive an intervention for 

neuropsychiatric symptoms within a 12 month period 

AMA-PCPI 

N/A/285 

Dementia: Screening for Depressive Symptoms: Percentage of patients, regardless of age, 

with a diagnosis of dementia who were screened for depressive symptoms within a 12 month 

period 

AMA-PCPI 

N/A/286 

Dementia: Counseling Regarding Safety Concerns: Percentage of patients, regardless of 

age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for 

counseling regarding safety concerns within a 12 month period 

AMA-PCPI 

N/A/287 

Dementia: Counseling Regarding Risks of Driving: Percentage of patients, regardless of 

age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the 

risks of driving and the alternatives to driving at least once within a 12 month period 

AMA-PCPI 

N/A/288 

Dementia: Caregiver Education and Support: Percentage of patients, regardless of age, 

with a diagnosis of dementia whose caregiver(s) were provided with education on dementia 

disease management and health behavior changes AND referred to additional sources for 

support within a 12 month period 

AMA-PCPI 

TABLE 65: Diabetes Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0059/001 Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-75 years of age with 

diabetes who had hemoglobin A1c > 9.0% during the measurement period NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an influenza 

immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

0055/117 

Diabetes: Eye Exam: Percentage of patients 18 through 75 years of age with a diagnosis of 

diabetes (type 1 and type 2) who had a retinal or dilated eye exam in the measurement period 

or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the 

measurement period 

NCQA 

0062/119 

Diabetes: Medical Attention for Neuropathy: The percentage of patients 18-75 years of 

age with diabetes who had a nephropathy screening test or evidence of nephropathy during 

the measurement period 

NCQA 

0056/163 Diabetes: Foot Exam: Percentage of patients aged 18-75 years of age with diabetes who had 

a foot exam during the measurement period NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

 
CMS-1612-FC 811

TABLE 66: General Surgery Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/354 Anastomotic Leak Intervention: Percentage of patients aged 18 years and older who 

required an anastomotic leak intervention following gastric bypass or colectomy surgery ACS 

N/A/355 

Unplanned Reoperation within the 30 Day Postoperative Period: Percentage of patients 

aged 18 years and older who had any unplanned reoperation within the 30 day postoperative 

period 

ACS 

N/A/356 

Unplanned Hospital Readmission within 30 Days of Principal Procedure: Percentage of 

patients aged 18 years and older who had an unplanned hospital readmission within 30 days 

of principal procedure 

ACS 

N/A/357 Surgical Site Infection (SSI): Percentage of patients aged 18 years and older who had a 

surgical site infection (SSI) ACS 

N/A/358 

Patient-Centered Surgical Risk Assessment and Communication: Percentage of patients 

who underwent a non-emergency surgery who had their personalized risks of postoperative 

complications assessed by their surgical team prior to surgery using a clinical data-based, 

patient-specific risk calculator and who received personal discussion of those risks with the 

surgeon 

ACS 

TABLE 67: Heart Failure (HF) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0081/005 

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin 

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD):

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a 

current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE 

inhibitor or ARB therapy either within a 12 month period when seen in the outpatient 

setting OR at each hospital discharge 

AMAPCPI/ACCF/AHA 

0083/008 

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction 

(LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure 

(HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were 

prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient 

setting OR at each hospital discharge 

AMAPCPI/ACCF/AHA 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan 

or surrogate decision maker documented in the medical record or documentation in the 

medical record that an advance care plan was discussed but the patient did not wish or was 

not able to name a surrogate decision maker or provide an advance care plan 

AMA-PCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an 

influenza immunization OR who reported previous receipt of an influenza immunization.

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin / mineral / dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified 

as a tobacco user 

AMA-PCPI 

 
CMS-1612-FC 812

TABLE 68: Hepatitis C Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0395/084 

Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment: Percentage 

of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started 

antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C 

virus (HCV) RNA testing was performed within 12 months prior to initiation of antiviral 

treatment 

AMA-PCPI 

0396/085 

Hepatitis C: HCV Genotype Testing Prior to Treatment: Percentage of patients aged 18 

years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within 

the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was 

performed within 12 months prior to initiation of antiviral treatment 

AMA-PCPI 

0398/087 

Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 

Weeks After Initiation of Treatment: Percentage of patients aged 18 years and older with 

a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom 

quantitative hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after 

the initiation of antiviral treatment 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0399/183 

Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV):

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who 

have received at least one injection of hepatitis A vaccine, or who have documented 

immunity to hepatitis A 

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/401 

Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis:

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C 

cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for 

hepatocellular carcinoma (HCC) at least once within the 12 month reporting period 

AGA/AASLD/AMAPCPI 

N/A/390 

Discussion and Shared Decision Making Surrounding Treatment Options: Percentage 

of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or 

other qualified healthcare professional reviewed the range of treatment options appropriate 

to their genotype and demonstrated a shared decision making approach with the patient. To 

meet the measure, there must be documentation in the patient record of a discussion 

between the physician or other qualified healthcare professional and the patient that includes 

all of the following: treatment choices appropriate to genotype, risks and benefits, evidence 

of effectiveness, and patient preferences toward treatment 

AGA/AASLD/AMAPCPI 

 
CMS-1612-FC 813

TABLE 69: HIV/AIDS Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or 

surrogate decision maker documented in the medical record or documentation in the medical 

record that an advance care plan was discussed but the patient did not wish or was not able to 

name a surrogate decision maker or provide an advance care plan 

AMA-PCPI/NCQA 

0418/134 

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan: 

Percentage of patients aged 12 years and older screened for clinical depression on the date of 

the encounter using an age appropriate standardized depression screening tool AND if 

positive, a follow-up plan is documented on the date of the positive screen 

CMS/QIP 

0405/160 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients 

aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis 

Jiroveci Pneumonia (PCP) prophylaxis 

NCQA 

0409/205 

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and 

Syphilis: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for 

whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the 

diagnosis of HIV infection 

AMA-PCPI/NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user

AMA-PCPI 

2082/338 

HIV Viral Load Suppression: The percentage of patients, regardless of age, with a diagnosis 

of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the 

measurement year 

HRSA 

2083/339 

Prescription of HIV Antiretroviral Therapy: Percentage of patients, regardless of age, with 

a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during 

the measurement year 

HRSA 

2079/340 

HIV Medical Visit Frequency: Percentage of patients, regardless of age with a diagnosis of 

HIV who had at least one medical visit in each 6 month period of the 24 month measurement 

period, with a minimum of 60 days between medical visits 

HRSA 

 
CMS-1612-FC 814

TABLE 70: Inflammatory Bowel Disease (IBD) Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an 

influenza immunization OR who reported previous receipt of an influenza immunization

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age 

and older who have ever received a pneumococcal vaccine NCQA 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified 

as a tobacco user 

AMA-PCPI 

N/A/270 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing 

Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory 

bowel disease who have been managed by corticosteroids greater than or equal to 10 

mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription 

equating to 600 mg prednisone or greater for all fills that have been prescribed 

corticosteroid sparing therapy in the last reporting year 

AGA 

N/A/271 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related 

Iatrogenic Injury – Bone Loss Assessment: Percentage of patients aged 18 years and 

older with an inflammatory bowel disease encounter who were prescribed prednisone 

equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a 

single prescription equating to 600 mg prednisone or greater for all fills and were 

documented for risk of bone loss once during the reporting year or the previous calendar 

year 

AGA 

N/A/274 

Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before 

Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 

years and older with a diagnosis of inflammatory bowel disease for whom a tuberculosis 

(TB) screening was performed and results interpreted within 6 months prior to receiving a 

first course of anti-TNF (tumor necrosis factor) therapy 

AGA 

N/A/275 

Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status 

Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients 

aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had 

Hepatitis B Virus (HBV) status assessed and results interpreted within 1 year prior to 

receiving a first course of anti-TNF (tumor necrosis factor) therapy 

AGA 

 
CMS-1612-FC 815

TABLE 71: Oncology Measures Group for 2015 and Beyond 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0387/071 

Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer: Percentage of 

female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive 

breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-

month reporting period 

AMAPCPI/ASCO/NCC

N 

0385/072 

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients: Percentage 

of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for 

adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received 

adjuvant chemotherapy within the 12-month reporting period 

AMAPCPI/ASCO/NCC

N 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an 

influenza immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting 

a list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0384/143 

Oncology: Medical and Radiation – Pain Intensity Quantified: Percentage of patients, 

regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or 

radiation therapy in which pain intensity is quantified 

AMA-PCPI 

0383/144 

Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of visits for 

patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or 

radiation therapy who report having pain with a documented plan of care to address pain 

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified 

as a tobacco user 

AMA-PCPI 

 
CMS-1612-FC 816

TABLE 72: Optimizing Patient Exposure to Ionizing Radiation Measures Group for 2015 and 

Beyond 

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/359 

Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized 

Nomenclature for Computed Tomography (CT) Imaging Description: Percentage of 

computed tomography (CT) imaging reports for all patients, regardless of age, with the 

imaging study named according to a standardized nomenclature and the standardized 

nomenclature is used in institution’s computer systems 

AMA-PCPI 

N/A/360 

Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose 

Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear 

Medicine Studies: Percentage of computed tomography (CT) and cardiac nuclear medicine 

(myocardial perfusion studies) imaging reports for all patients, regardless of age, that 

document a count of known previous CT (any type of CT) and cardiac nuclear medicine 

(myocardial perfusion) studies that the patient has received in the 12-month period prior to 

the current study 

AMA-PCPI 

N/A/361 

Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose 

Index Registry: Percentage of total computed tomography (CT) studies performed for all 

patients, regardless of age, that are reported to a radiation dose index registry AND that 

include at a minimum selected data elements 

AMA-PCPI 

N/A/362 

Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) 

Images Available for Patient Follow-up and Comparison Purposes: Percentage of final 

reports for computed tomography (CT) studies performed for all patients, regardless of age, 

which document that Digital Imaging and Communications in Medicine (DICOM) format 

image data are available to non-affiliated external entities on a secure, media free, 

reciprocally searchable basis with patient authorization for at least a 12-month period after 

the study 

AMA-PCPI 

N/A/363 

Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed 

Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared 

Archive: Percentage of final reports of computed tomography (CT) studies performed for all 

patients, regardless of age, which document that a search for Digital Imaging and 

Communications in Medicine (DICOM) format images was conducted for prior patient CT 

imaging studies completed at non-affiliated external healthcare facilities or entities within the 

past 12-months and are available through a secure, authorized, media free, shared archive 

prior to an imaging study being performed 

AMA-PCPI 

N/A/364 

Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT 

Imaging for Incidentally Detected Pulmonary Nodules According to Recommended 

Guidelines: Percentage of final reports for CT imaging studies of the thorax for patients aged 

18 years and older with documented follow-up recommendations for incidentally detected 

pulmonary nodules (for example, follow-up CT imaging studies needed or that no follow-up 

is needed) based at a minimum on nodule size AND patient risk factors 

AMA-PCPI 

 
CMS-1612-FC 817

TABLE 73: Parkinson’s Disease Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0326/047 

Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or 

surrogate decision maker documented in the medical record or documentation in the medical 

record that an advance care plan was discussed but the patient did not wish or was not able to 

name a surrogate decision maker or provide an advance care plan 

AMA-PCPI/NCQA 

N/A/289 

Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review: All patients with a 

diagnosis of Parkinson’s disease who had an annual assessment including a review of current 

medications (for example, medications that can produce Parkinson-like signs or symptoms) 

and a review for the presence of atypical features (for example, falls at presentation and early 

in the disease course, poor response to levodopa, symmetry at onset, rapid progression [to 

Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least annually 

AAN 

N/A/290 

Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment: All patients 

with a diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or 

disturbances (for example, psychosis, depression, anxiety disorder, apathy, or impulse control 

disorder) at least annually 

AAN 

N/A/291 

Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment: All patients 

with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or 

dysfunction at least annually 

AAN 

N/A/292 

Parkinson’s Disease: Querying about Sleep Disturbances: All patients with a diagnosis of 

Parkinson’s disease (or caregivers, as appropriate) who were queried about sleep disturbances 

at least annually 

AAN 

N/A/293 

Parkinson’s Disease: Rehabilitative Therapy Options: All patients with a diagnosis of 

Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options 

(for example, physical, occupational, or speech therapy) discussed at least annually 

AAN 

N/A/294 

Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options 

Reviewed: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as 

appropriate) who had the Parkinson’s disease treatment options (for example, nonpharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at 

least once annually 

AAN 

 
CMS-1612-FC 818

TABLE 74: Preventive Care Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0046/039 

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older:

Percentage of female patients aged 65 years and older who have a central dual-energy Xray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or 

pharmacologic therapy prescribed within 12 months 

AMAPCPI/NCQA 

N/A/48 

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in 

Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older 

who were assessed for the presence or absence of urinary incontinence within 12 months 

AMAPCPI/NCQA 

0041/110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older seen for a visit between October 1 and March 31 who received an 

influenza immunization OR who reported previous receipt of an influenza immunization 

AMA-PCPI 

0043/111 Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age 

and older who have ever received a pneumococcal vaccine NCQA 

N/A/112 Breast Cancer Screening: Percentage of women 50 through 74 years of age who had a 

mammogram to screen for breast cancer within 27 months NCQA 

0034/113 Colorectal Cancer Screening: Percentage of patients 50 through 75 years of age who had 

appropriate screening for colorectal cancer NCQA 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 

Plan: Percentage of patients aged 18 years and older with a BMI documented during the 

current encounter or during the previous six months AND with a BMI outside of normal 

parameters, a follow-up plan is documented during the encounter or during the previous six 

months of the current encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2

; Age 18 – 64 years 

BMI ≥ 18.5 and < 25 kg/m2

CMS/QIP 

0418/134 

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up 

Plan: Percentage of patients aged 12 years and older screened for clinical depression on the 

date of the encounter using an age appropriate standardized depression screening tool AND 

if positive, a follow-up plan is documented on the date of the positive screen 

CMS/QIP 

AQA 

Adopted/173 

Preventive Care and Screening: Unhealthy Alcohol Use – Screening: Percentage of 

patients aged 18 years and older who were screened for unhealthy alcohol use at least once 

within 24 months using a systematic screening method** 

Please note that CMS had proposed to remove this measure from the program and thus this 

measure group as a result in the NPRM. However, as noted above in Table 55, CMS is not 

finalizing its proposal to remove this measure, and as such, the measure is not being 

removed from this measure group either.

AMA-PCPI 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified 

as a tobacco user 

AMA-PCPI 

 
CMS-1612-FC 819

TABLE 75: Rheumatoid Arthritis (RA) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0054/108 

Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) 

Therapy: Percentage of patients aged 18 years and older who were diagnosed with RA and 

were prescribed, dispensed, or administered at least one ambulatory prescription for a diseasemodifying anti-rheumatic drug (DMARD) 

NCQA 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: 

Percentage of patients aged 18 years and older with a BMI documented during the current 

encounter or during the previous six months AND with a BMI outside of normal parameters, 

a follow-up plan is documented during the encounter or during the previous six months of the 

current encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2

; Age 18 – 64 years 

BMI ≥ 18.5 and < 25 kg/m2

CMS/QIP 

0420/131 

Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older 

with documentation of a pain assessment using a standardized tool(s) on each visit AND 

documentation of a follow-up plan when pain is present

CMS/QIP 

N/A/176 

Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 years 

and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a 

tuberculosis (TB) screening performed and results interpreted within 6 months prior to 

receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug 

(DMARD) 

AMA-PCPI 

 N/A/177 

Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of 

patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an 

assessment and classification of disease activity within 12 months 

AMA-PCPI 

N/A/178 

Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 

years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status 

assessment was performed at least once within 12 months

AMA-PCPI 

N/A/179 

Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis:

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) 

who have an assessment and classification of disease prognosis at least once within 12 

months 

AMA-PCPI 

N/A/180 

Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 18 

years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for 

glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or 

equivalent) with improvement or no change in disease activity, documentation of 

glucocorticoid management plan within 12 months 

AMA-PCPI 

 
CMS-1612-FC 820

TABLE 76: Sinusitis Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting 

a list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0420/131 

Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older 

with documentation of a pain assessment using a standardized tool(s) on each visit AND 

documentation of a follow-up plan when pain is present

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified 

as a tobacco user 

AMA-PCPI 

N/A/331 

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use):

Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who 

were prescribed an antibiotic within 7 days of diagnosis or within 10 days after onset of 

symptoms 

AMA-PCPI 

N/A/332 

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients 

with Acute Bacterial Sinusitis: Percentage of patients aged 18 years and older with a 

diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without 

clavulante, as a first line antibiotic at the time of diagnosis 

AMA-PCPI 

N/A/333 

Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse): Percentage 

of patients aged 18 years and older with a diagnosis of acute sinusitis who had a 

computerized tomography (CT) scan of the paranasal sinuses ordered at the time of 

diagnosis or received within 28 days after date of diagnosis 

AMA-PCPI 

 
CMS-1612-FC 821

TABLE 77: Sleep Apnea Measures Group for 2015 and Beyond 

(Please note that CMS initially proposed to remove this measure group contingent on the measure steward not being 

able to maintain certain measures contained in this measures group. A new steward has been identified for the 

measures at risk and for this reason CMS is not finalizing its proposal to remove this measures group in 2015.) 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0421/128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 

Plan: Percentage of patients aged 18 years and older with a BMI documented during the 

current encounter or during the previous six months AND with a BMI outside of normal 

parameters, a follow-up plan is documented during the encounter or during the previous six 

months of the current encounter 

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2; Age 18 – 64 years 

BMI ≥ 18.5 and < 25 kg/m2

CMS/QIP 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/276 

Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 

years and older with a diagnosis of obstructive sleep apnea that includes documentation of an 

assessment of sleep symptoms, including presence or absence of snoring and daytime 

sleepiness 

AMA-PCPI/NCQA 

N/A/277 

Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 

years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index 

(AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis 

AMA-PCPI/NCQA 

N/A/278 

Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 

18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were 

prescribed positive airway pressure therapy 

AMA-PCPI/NCQA 

N/A/279 

Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy:

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep 

apnea who were prescribed positive airway pressure therapy who had documentation that 

adherence to positive airway pressure therapy was objectively measured 

AMA-PCPI/NCQA 

 
CMS-1612-FC 822

TABLE 78: Total Knee Replacement (TKR) Measures Group for 2015 and Beyond

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0419/130 

Documentation of Current Medications in the Medical Record: Percentage of visits for 

patients aged 18 years and older for which the eligible professional attests to documenting a 

list of current medications using all immediate resources available on the date of the 

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and 

vitamin / mineral / dietary (nutritional) supplements AND must contain the medications’ 

name, dosage, frequency and route of administration 

CMS/QIP 

0028/226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

Percentage of patients 18 years and older who were screened for tobacco use one or more 

times within 24 months AND who received cessation counseling intervention if identified as 

a tobacco user 

AMA-PCPI 

N/A/350 

Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Nonsurgical) Therapy: Percentage of patients regardless of age or gender undergoing a total 

knee replacement with documented shared decision-making with discussion of conservative 

(non-surgical) therapy (or example, NSAIDS, analgesics, weight loss, exercise, injections) 

prior to the procedure 

AAHKS 

N/A/351 

Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk 

Evaluation: Percentage of patients regardless of age or gender undergoing a total knee 

replacement who are evaluated for the presence or absence of venous thromboembolic and 

cardiovascular risk factors within 30 days prior to the procedure(for example, history of Deep 

Vein Thrombosis, Pulmonary Embolism, Myocardial Infarction, Arrhythmia and Stroke) and 

Stroke 

AAHKS 

N/A/352 

Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet:

Percentage of patients regardless of age undergoing a total knee replacement who had the 

prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet 

AAHKS 

N/A/353 

Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report:

Percentage of patients regardless of age or gender undergoing total knee replacement whose 

operative report identifies the prosthetic implant specifications including the prosthetic 

implant manufacturer, the brand name of the prosthetic implant and the size of prosthetic 

implant 

AAHKS 

e. Measures Available for Reporting in the GPRO Web Interface 

We finalized the measures that are available for reporting in the GPRO web interface for 2014 

and beyond in the CY 2013 PFS final rule (77 FR 69269). However, we proposed to remove and add 

measures in the GPRO web interface measure set as reflected in Tables 47 and 48 in the CY 2015 PFS 

proposed rule for 2015 and beyond (79 FR 40468). Specifically, Table 47 specified the measures we 

proposed to remove for reporting from the GPRO web interface, and Table 48 specified the measures we 

proposed to add for reporting in the GPRO web interface. CMS proposed to adopt Depression Remission 

at Twelve Months (NQF #0710) in the 2015 GPRO Web Interface reporting option for ACOs and group 

practices (79 FR 40469). This measure is currently reportable in the PQRS program through the EHR 

reporting option only and has not been tested using claims level data or sampling 

methodology. Depression Remission at Twelve Months (NQF #0710) requires a look-back period and a 

look-forward period possibly spanning multiple calendar years. Additionally, this measure requires 
CMS-1612-FC 823

utilization of a PHQ-9 depression screening tool with a score greater than 9 and a diagnosis of 

depression/dysthymia to identify the beginning of the episode (initial patient population). Successful 

completion of the quality action for this measure looks for a PHQ-9 score of less than 5 at the twelve 

month mark (plus or minus 30 days) from the initial onset of the episode. CMS solicited comments 

regarding these proposals, and the comments are addressed in Tables 79 and 80. 
CMS-1612-FC 824

TABLE 79: Measures Being Removed from the Group Practice Reporting Option Web Interface 

Beginning in 2015 and Beyond 

NQF/ 

PQRS 

GPRO 

Module 

NQS 

Domai

n 

Measure and Title Description¥

Measure 

Steward 

Other Quality 

Reporting 

Programs 

Measures Finalized as Proposed 

0097/ 

046 

Care 

Coordinatio

n/ 

Patient 

Safety 

Patient 

Safety 

Medication Reconciliation: Percentage of patients aged 65 

years and older discharged from any inpatient facility (for 

example, hospital, skilled nursing facility, or rehabilitation 

facility) and seen within 30 days following discharge in the 

office by the physician, prescribing practitioner, registered nurse, 

or clinical pharmacist providing on-going care who had a 

reconciliation of the discharge medications with the current 

medication list in the outpatient medical record documented 

Several commenters agreed with CMS’ proposal to remove this 

measure, noting “full medication reconciliation should be done at 

least annually with all patients.” However, other commenters 

disagreed, indicating this measure “specifically evaluates the 

medication reconciliation during a time period when patients are 

most vulnerable during a time of transitions of care that may 

result in adverse consequences to the patient including 

preventable readmission to the hospital.” However, CMS 

continues to believe NQF #0419 Documentation of Medications 

in the Medical Record is a more robust and broadly applicable 

measure. Furthermore, there have been implementation issues 

with this measure in the web interface, despite CMS believing 

this is a valuable measure. Finally, CMS is continuing to work to 

align the GPRO with the EHR Incentive Programs, and NQF 

#0419 is in the Incentive Program, whereas PQRS #046 is not. 

For these reasons, CMS is finalizing its proposal to remove this 

measure from reporting through the GPRO WI in 2015 PQRS 

and the Shared Savings Program. 

AMAPCPI/NCQ

A 

0074/ 

197 

Coronary 

Artery 

Disease 

Effectiv

e 

Clinical 

Care 

Coronary Artery Disease (CAD): Lipid Control: Percentage 

of patients aged 18 years and older with a diagnosis of coronary 

artery disease seen within a 12 month period who have a LDL-C 

result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 

mg/dL and have a documented plan of care to achieve LDL-C < 

100 mg/dL, including at a minimum the prescription of a statin 

While some commenters disagreed with CMS’s proposal to 

remove this measure “unless or until new measures that are more 

consistent with new and existing guidelines are put in place to 

replace them”, several commenters supported the proposal to 

retire this and the two other lipid control measures listed as a 

result of new clinical guidelines released in 2013 by the 

American College of Cardiology and American Heart 

Association. For this reason, CMS is finalizing its proposal to 

remove this measure from reporting in 2015 PQRS and the 

Shared Savings Program.

AMAPCPI/ 

ACCF/ 

AHA 
CMS-1612-FC 825 NQF/ PQRS 

GPRO 

Module 

NQS 

Domai

n 

Measure and Title Description¥

Measure 

Steward 

Other Quality 

Reporting 

Programs 

0729/ 

319 

Diabetes 

Mellitus 

Effectiv

e 

Clinical 

Care 

Diabetes Composite: Optimal Diabetes Care: Patients ages 18 

through 75 with a diagnosis of diabetes, who meet all the 

numerator targets of this composite measure: 

● Diabetes Mellitus: High Blood Pressure Control. 

● Diabetes Mellitus: Low Density Lipoprotein (LDL-C) 

Control. 

● Diabetes Mellitus: Hemoglobin A1c Control (< 8%). 

● Diabetes Mellitus: Tobacco Non-Use 

CMS proposed retiring 4 components of the 5 part diabetes 

composite measure as noted above. Specifically, commenters: 

● Disagreed with removing the blood pressure component, 

noting “important that diabetic patients have their blood pressure 

and cholesterol monitored in order to prevent co-morbidities; if 

assessing quality of their care is folded into the general Medicare 

patient population, the focus on their care and desirable health 

care outcomes is effectively “watered down.” However, other 

commenters supported this change noting “a measure that is 

based on a specific A1c level is no longer an accurate measure of 

a physician’s ability to provide high quality care for their 

patients.” CMS agrees this measure may no longer be the best 

measure of quality care in this area. Further, CMS continues to 

believe this measure is somewhat duplicative of the measure 

Controlling High Blood Pressure (NQF #0018) and that the 

diabetes measure may capture a subpopulation of the broader 

Controlling High Blood Pressure measure. 

● Agreed with removing the LDL component as a result of 

new clinical guidelines released in 2013 by the American 

College of Cardiology and American Heart Association 

(https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000

437738.63853.7a.full.pdf). 

 ● Agreed with removing the Hemoglobin A1c Control 

(<8%) component, noting it is “too restrictive for a small cohort 

of patients and not restrictive enough for the majority of 

patients.” 

 ● Disagreed with removing the Tobacco Non-Use 

component, noting “this outcome based measure (as opposed to 

the screening and counseling measure) is not only a critical 

measure for diabetic best management, but removing it is 

stepping away from a known shared goal of moving towards 

outcome based measures.” However, other commenters 

supported this change nothing that this measure, in addition to 

other measures, “were either duplicative of other measures or the 

guidelines for the measure have been changed.” CMS continues 

to believe this component is somewhat duplicative of the 

Tobacco Screening and Cessation Counseling measure (NQF 

0028) and NQF 0028 is more broadly applicable. 

For these reasons, CMS is finalizing its proposal to remove these 

four components of the diabetes composite measure from 

reporting in 2015 PQRS and the Shared Savings Program. 

MNCM 
CMS-1612-FC 826 NQF/ PQRS 

GPRO 

Module 

NQS 

Domai

n 

Measure and Title Description¥

Measure 

Steward 

Other Quality 

Reporting 

Programs 

0075/ 

241 

Ischemic 

Vascular 

Disease 

Effectiv

e 

Clinical 

Care 

Ischemic Vascular Disease (IVD): Complete Lipid Profile 

and LDL-C Control (< 100 mg/dL): Percentage of patients 18 

years of age and older who were discharged alive for acute 

myocardial infarction (AMI), coronary artery bypass graft 

(CABG) or percutaneous coronary interventions (PCI) in the 12 

months prior to the measurement period, or who had an active 

diagnosis of ischemic vascular disease (IVD) during the 

measurement period, and who had each of the following during 

the measurement period: a complete lipid profile and LDL-C was 

adequately controlled (< 100 mg/dL)

Commenters supported the proposal to retire this lipid control 

related measure because of the new clinical guidelines for statin 

treatment, as discussed for other LDL measures in this table. For 

this reason, CMS is finalizing its proposal to remove this 

measure from reporting in 2015 PQRS and the Shared Savings 

Program. 

NCQA MU2 

Millio

n 

Hearts 

Measures Not Finalized as Proposed 

0068/ 

204 

Ischemic 

Vascular 

Disease 

Effectiv

e 

Clinical 

Care 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another 

Antithrombotic: Percentage of patients 18 years of age and 

older who were discharged alive for acute myocardial infarction 

(AMI), coronary artery bypass graft (CABG) or percutaneous 

coronary interventions (PCI) in the 12 months prior to the 

measurement period, or who had an active diagnosis of ischemic 

vascular disease (IVD) during the measurement period and who 

had documentation of use of aspirin or another antithrombotic 

during the measurement period

CMS received comments about this measure being proposed for 

removal from the Web Interface for PQRS and the Shared 

Savings Program. Some commenters requested clarification of 

CMS’s previous concern that the measure may not align with 

current guidelines when proposing its removal. After reviewing 

the measure further, we have determined the measure does not 

conflict with current guidelines the updated ATP-4 cholesterol 

guidelines, which have gone away from focusing on specific 

LDL targets, but do not impact this measure as previously 

thought. This measure is also a core measure for the Million 

Hearts Initiative. It is CMS’s intent to maintain alignment with 

other quality reporting programs and HHS Initiatives. CMS also 

received comments supporting the removal of the measure from 

the Shared Savings Program, but requesting clarification of 

guideline changes impacting the measureTherefore, CMS will 

maintain alignment with the Million Hearts program and for this 

reason CMS is retaining this measure and it will be available for 

reporting through the GPRO WI in 2015 PQRS and the Shared 

Savings Program. 

NCQA MU2 

Millio

n 

Hearts 
CMS-1612-FC 827 NQF/ PQRS 

GPRO 

Module 

NQS 

Domai

n 

Measure and Title Description¥

Measure 

Steward 

Other Quality 

Reporting 

Programs 

0729/ 

319 

Diabetes 

Mellitus 

Effectiv

e 

Clinical 

Care 

Diabetes Composite: Optimal Diabetes Care: Patients ages 18 

through 75 with a diagnosis of diabetes, who meet all the 

numerator targets of this composite measure: 

 ● Diabetes Mellitus: Daily Oral Aspirin or Antiplatelet 

Medication Use for Patients with Diabetes and Ischemic 

Vascular Disease

CMS did not originally propose to remove this measure. 

However, this measure was reported in the PQRS as a 

component of the diabetes composite reportable via the GPRO 

Web Interface. We note that, while we did not originally 

propose to remove this measure, we proposed to remove all of 

the other components of the diabetes composite of which this 

measure was a part. Specifically, we proposed to remove the 

following components of the diabetes composite: 

• Diabetes Mellitus: High Blood Pressure Control. 

• Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control. 

• Diabetes Mellitus: Hemoglobin A I c Control ( < 8% ). 

• Diabetes Mellitus: Tobacco Non-Use 

Since we proposed to remove all other components of the 

diabetes composite listed above, we believe the public could 

reasonably foresee that we would remove this measure from the 

PQRS and Shared Savings Program measure set if all other 

components of the diabetes composite were removed. In 

addition, CMS believes the Daily Oral Aspirin component of this 

measure may be somewhat duplicative of PQRS #204 (Ischemic 

Vascular Disease (IVD): Use of Aspirin or Another 

Antithrombotic). Therefore, we are removing this measure from 

the PQRS measure set. 

To maintain alignment with PQRS and reduce reporting burden 

for ACOs, we are also removing this measure from the Shared 

Savings Program measure set. CMS believes that removing this 

measure will reduce burden on ACOs and allow them to improve 

their performance on the diabetes composite by reducing the 

number of measures included in the composite. 

Therefore, for the reasons stated above, we are removing this 

measure from the PQRS and Shared Savings Program measure 

set beginning in 2015 

MNCM 
CMS-1612-FC 828

TABLE 80: New Measures That Will Be Available for Reporting by the Group Practice Reporting 

Option Web Interface Beginning in 2015 and Beyond 

f. The Clinician Group (CG) Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

Survey 

In the CY 

NQF/ 

PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other

Quality 

Reportin

g 

Program

Measures Finalized as Proposed 

0059/ 

001 

Diabetes 

Mellitus 

Effective 

Clinical 

Care 

Diabetes: Hemoglobin A1c Poor Control: Percentage of 

patients 18-75 years of age with diabetes who had hemoglobin 

A1c > 9.0% during the measurement period 

The Shared Savings Program and PQRS received many 

comments supporting removal of the Diabetes: Hemogolobin 

A1c control (<8 percent) (ACO-22), since <8 percent seems 

restrictive. CMS received some comments suggesting we move 

toward more outcome measures than process measures. CMS is 

finalizing its proposal to include this measure in the new 

Diabetes Management (DM) composite as a more appropriate 

A1c component for reporting in 2015 PQRS and the Shared 

Savings Program. This measure, Hemogolobin A1c Poor 

Control is being finalized because it addresses a clinically 

important area for diabetic patients and replaces the previous 

measure in the DM composite. 

NCQA MU2 

0055/

117 

Diabetes 

Mellitus 

Effective 

Clinical 

Care 

Diabetes: Eye Exam: Percentage of patients 18 through 75 

years of age with a diagnosis of diabetes (type 1 and type 2) 

who had a retinal or dilated eye exam by an eye care 

professional in the measurement period or a negative retinal or 

dilated eye exam (negative for retinopathy) in the year prior to 

the measurement period 

Several commenters supported the addition of this measure to 

the GPRO WI for PQRS and the Shared Savings Program, 

noting eye exams are an important part of quality care for 

diabetic patients. CMS also received some comments 

suggesting that we not finalize additional process measures and 

questioning the improvement to outcomes, noting while “foot 

and eye exams are an important part of good diabetes care, we 

recommend that they not replace the current outcomes measures 

in the Diabetes Composite measure set.” CMS agrees foot and 

eye exams are a valuable addition that reflect good diabetes 

care. Please see Table 79 for additional discussion of the 

rationale for the removal of the previous diabetes composite. 

CMS is finalizing its proposal to include this measure in the 

new Diabetes Management composite in the GPRO WI for 

reporting in 2015 PQRS and Shared Savings Program due to the 

clinical importance of the measure and alignment of programs.

NCQA MU2 
CMS-1612-FC 829 NQF/ PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other

Quality 

Reportin

g 

Program

0419/

130 

Care 

Coordinati

on/ 

Patient 

Safety 

Patient 

Safety 

Documentation of Current Medications in the Medical 

Record: Percentage of visits for patients aged 18 years and 

older for which the eligible professional attests to documenting 

a list of current medications using all immediate resources 

available on the date of the encounter. This list must include 

ALL known prescriptions, over-the-counters, herbals, and 

vitamin/mineral/dietary (nutritional) supplements AND must

contain the medications’ name, dosage, frequency and route of 

administration 

While some commenters disagreed with the addition of this 

measure, others suggested medication reconciliation should be 

performed at all office visits and not just those visits occurring 

after an inpatient discharge. Furthermore, the steward of CARE1 (PQRS #46) Medication Reconciliation: Reconciliation After 

Discharge from an Inpatient Facility indicated this measure is 

not appropriate for the GPRO WI reporting mechanism. Some 

commenters recommended limiting documentation of current 

medications to only the last visit due to potential reporting 

burden. 

We disagree with the commenters who disagree with the 

addition of this measure. We believe this measure adequately 

captures an important aspect of patient safety – the need to 

understand a patient’s current medications. We believe 

documenting current medications is key to determining the most 

appropriate care for a patient. With respect to the commenters 

who believed that medication reconciliation should be 

performed on all office visits, please note that the title and 

description of the measure does not limit this measure to 

documentation after an inpatient discharge. With respect to a 

measure steward’s concern that this measure is not appropriate 

for the GPRO WI reporting mechanism, we disagree with the 

measure steward. As we note above, we believe this measure is 

appropriate for the GPRO WI as it captures an important aspect 

of patient safety. 

Based on the comments received and for the reasons stated 

above, CMS is finalizing its proposal to replace PQRS #46 with 

PQRS #130 Documentation of Current Medications in the 

Medical Record for reporting in the GPRO WI in 2015 PQRS 

and Shared Savings Program and will consider reporting burden 

in finalizing specifications for GPRO reporting. 

CMS/QI

P 

MU2 
CMS-1612-FC 830 NQF/ PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other

Quality 

Reportin

g 

Program

0710/

370 

Mental 

Health 

Effective 

Clinical 

Care 

Depression Remission at Twelve Months: Adult patients age 

18 and older with major depression or dysthymia and an initial 

PHQ-9 score > 9 who demonstrate remission at twelve months 

defined as PHQ-9 score less than 5. This measure applies to 

both patients with newly diagnosed and existing depression 

whose current PHQ-9 score indicates a need for treatment. 

Several commenters for PQRS and the Shared Savings Program 

expressed concern over use of the PHQ-9, indicating not all 

practices use this tool. CMS appreciates commenter feedback 

and concerns regarding issues with the use of PHQ-9. CMS 

recognizes there may be EPs reporting who do not currently use 

this tool and because of the look back period may not be able to 

implement this tool in time for the next reporting period, and as 

such CMS is considered adjustments to how this measure will 

be reported, specifically for the Shared Savings Program. CMS 

continues to believe this Depression Remission measure 

represents an important outcome. Depression management is 

particularly important due the effects on patient adherence with 

treatment for other chronic conditions. For these reasons, CMS 

is finalizing its proposal to make this measure reportable 

through the GPRO WI in 2015 PQRS and the Shared Savings 

Program. Given the comments and concerns raised regarding 

the use of the PHQ-9 tool and providing ACOs with time to 

make necessary adjustments for implementation, the measure 

will be designated as pay-for-reporting under the Shared 

Savings Program for all 3 years of an ACO’s first agreement 

period, as specified in the program’s final measure set.

MNCM MU2 

Measures Not Finalized as Proposed 

0067/

006 

Coronary 

Artery 

Disease 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): Antiplatelet Therapy:

Percentage of patients aged 18 years and older with a diagnosis 

of coronary artery disease (CAD) seen within a 12 month period 

who were prescribed aspirin or clopidogrel. 

Commenters agreed with the addition of this measure, but 

recommended testing the composite and maintaining as only 

pay-for-reporting for the Shared Savings Program. Other 

commenters did not agree with including this measure due to 

concerns that the composite has not been reviewed by NQF and 

has not been tested before implementation. CMS agrees this 

measure needs to be tested as part of the composite prior to 

implementation and as such, CMS is not finalizing its proposal 

to include this measure for reporting in for the PQRS GPRO 

web interface and Shared Savings Program. 

AMAPCPI/ 

ACCF/ 

AHA 

MU2 

0070/

007 

Coronary 

Artery 

Disease 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): Beta-Blocker Therapy – 

Prior Myocardial Infarction (MI) or Left Ventricular 

Systolic Dysfunction (LVEF < 40%): Percentage of patients 

aged 18 years and older with a diagnosis of coronary artery 

disease seen within a 12 month period who also have prior MI 

OR a current or LVEF < 40% who were prescribed beta-blocker 

therapy 

Some commenters agreed with the addition of this measure 

while others did not agree with including this measure and 

suggested testing and submission to NQF. We also believe this 

measure is topped out. Therefore, CMS is not finalizing its 

proposal to include this measure for reporting for the PQRS and 

Shared Savings Program GPRO web interface.

AMAPCPI/ 

ACCF/ 

AHA 

MU2 
CMS-1612-FC 831 NQF/ PQRS 

GPRO 

Module 

NQS 

Domain Measure and Title Description¥

Measure 

Steward 

Other

Quality 

Reportin

g 

Program

0056/

163 

Diabetes 

Mellitus 

Effective 

Clinical 

Care 

Diabetes: Foot Exam: Percentage of patients aged 18-75 years 

of age with diabetes who had a foot exam during the 

measurement period 

While several commenters supported the addition of this 

measure, many commenters did not support the inclusion of this 

process measure and suggested further testing of the composite 

as well as identifying the link to improved outcomes. 

Furthermore, CMS believes the measures that are being 

finalized for the Diabetes Composite represent a robust, 

outcome focused set of measures with room for quality 

improvement. Therefore, CMS is not finalizing its proposal to 

make this measure reportable through the GPRO WI in 2015 

PQRS and the Shared Savings Program. 

NCQA MU2 

N/A/

242 

Coronary 

Artery 

Disease 

Effective 

Clinical 

Care 

Coronary Artery Disease (CAD): Symptom Management: 

Percentage of patients aged 18 years and older with a diagnosis 

of coronary artery disease (CAD) seen within a 12 month period 

with results of an evaluation of level of activity and an 

assessment of whether anginal symptoms are present or absent 

with appropriate management of anginal symptoms within a 12 

month period 

Some commenters agreed with CMS’ proposal to include this 

measure in the GPRO WI. However, most commenters did not 

support including the measure due to lack of NQF endorsement 

and the reporting burden/challenges if the measure is finalized. 

Due to the comments received not supporting the measure due 

to reporting burden, CMS is not finalizing its proposal to 

include this measure for reporting in 2015 PQRS and Shared 

Savings Program GPRO web interface.

AMAPCPI/ 

ACCF/ 

AHA 

0729/ 

319 

Diabetes 

Mellitus 

Effective 

Clinical 

Care 

Diabetes Composite: Optimal Diabetes Care: Patients ages 

18 through 75 with a diagnosis of diabetes, who meet all the 

numerator targets of this composite measure: 

 ● Diabetes Mellitus: Daily Oral Aspirin or Antiplatelet 

Medication Use for Patients with Diabetes and Ischemic 

Vascular Disease

As discussed in Table 79 above, CMS believes the Daily Oral 

Aspirin component of this measure may be somewhat 

duplicative of PQRS #204, ACO-30 (Ischemic Vascular 

Disease (IVD): Use of Aspirin or Another Antithrombotic). 

Furthermore, upon further review and with CMS’s intent to 

maintain alignment with other quality reporting programs and 

limit the number of potentially duplicative measures that may 

cause additional reporting burden, CMS is removing this 

measure from the PQRS and Shared Savings Program measure 

sets. 

MNCM 

 

f. The Clinician Group (CG) Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

Survey 

In the CY 2014 PFS final rule with comment period, we finalized the CG-CAHPS survey 

available for reporting under the PQRS for 2014 and beyond (78 FR 74750 through 74751), to which we 
CMS-1612-FC 832

are now referring as the CAHPS for PQRS. Please note that, in the CY 2014 PFS final rule with 

comment period, we classified the CAHPS for PQRS survey under the care coordination and 

communication NQS domain. We noted that this was an error on our part, as the CAHPS for PQRS 

survey has typically been classified under the Person and Caregiver-Centered Experience and Outcomes 

domain as the CAHPS for PQRS survey assesses beneficiary experience of care and outcomes. 

Therefore, as we indicated in Table 21 of the CY 2015 proposed rule, we proposed to reclassify the 

CAHPS for PQRS survey under the Person and Caregiver-Centered Experience and Outcomes domain. 

We invited public comment on this proposal. Please note that the comments on this proposal are 

addressed in Table 54, where the domain change for CAHPS for PQRS as well as other PQRS measures 

is indicated. 

6. Statutory Requirements and Other Considerations for the Selection of PQRS Quality Measures for 

Meeting the Criteria for Satisfactory Participation in a QCDR for 2014 and Beyond for Individual 

Eligible Professionals 

For the measures which eligible professionals participating in a QCDR must report, section 

1848(m)(3)(D) of the Act, as amended and added by section 601(b) of the ATRA, provides that the 

Secretary shall treat eligible professionals as satisfactorily submitting data on quality measures if they 

satisfactorily participate in a QCDR. Section 1848(m)(3)(E) of the Act, as added by section 601(b) of the 

ATRA, provides some flexibility with regard to the types of measures applicable to satisfactory 

participation in a QCDR, by specifying that for measures used by a QCDR, sections 1890(b)(7) and 

1890A(a) of the Act shall not apply, and measures endorsed by the entity with a contract with the 

Secretary under section 1890(a) of the Act may be used. 

In the CY 2014 PFS final rule with comment period, we finalized requirements related to the 

parameters for the measures that would have to be reported to CMS by a QCDR for the purpose of its 

individual eligible professionals meeting the criteria for satisfactory participation under the PQRS (78 FR 

74751 through 74753). Although we did not propose to remove any of the requirements we finalized 

related to these parameters, we proposed to modify the following parameters we finalized in the CY 2014 
CMS-1612-FC 833

PFS final rule with comment period related to measures that may be reported by a QCDR (79 FR 40472 

through 40473): 

● The QCDR must have at least 1 outcome measure available for reporting, which is a measure 

that assesses the results of health care that are experienced by patients (that is, patients’ clinical events; 

patients’ recovery and health status; patients’ experiences in the health system; and efficiency/cost). 

As we proposed that for an eligible professional to meet the criterion for satisfactory participation 

in a QCDR for the 2017 PQRS payment adjustment, the eligible professional must report on at least 3 

outcome measures or, in lieu of 3 outcome measures, at least 2 outcome measures and 1 resource use, 

patient experience of care, or efficiency/appropriate use measure, we modified this requirement to 

conform to this satisfactory participation criterion. Therefore, we proposed that a QCDR must have at 

least 3 outcome measures available for reporting, which is a measure that assesses the results of health 

care that are experienced by patients (that is, patients’ clinical events; patients’ recovery and health status; 

patients’ experiences in the health system; and efficiency/cost). In lieu of having 3 outcome measures 

available for reporting, the QCDR must have at least 2 outcome measures available for reporting and at 

least 1 resource use, patient experience of care, or efficiency/appropriate use measure (79 FR 40473). We 

solicited and received the following comments on this proposal: 

Comment: As the majority of commenters opposed our proposal to require the reporting of 3 

outcomes measures to meet the criteria for satisfactory participation for the 2017 PQRS payment 

adjustment, for the same reasons, the majority of commenters also opposed our proposal to require that a 

QCDR must have at least 3 outcome measures available for reporting, or, in lieu of 3 outcome measures, 

a QCDR have at least 2 outcome measures available for reporting and at least 1 resource use, patient 

experience of care, or efficiency/appropriate use measure. The commenters believed this proposed 

requirement was overly burdensome for QCDRs. 

Response: We responded to the commenters’ concerns regarding our proposal to require the 

reporting of 3 outcomes measures to meet the criteria for satisfactory participation for the 2017 PQRS 

payment adjustment at III.K.3.a. For the same reasons discussed in that section, we are modifying our 

proposal to require that a QCDR must have at least 3 outcome measures available for reporting, or, in lieu 
CMS-1612-FC 834

of 3 outcome measures, a QCDR have at least 2 outcome measures available for reporting and at least 1 

resource use, patient experience of care, or efficiency/appropriate use measure. To correspond with the 

final criteria for the satisfactory participation for the 2017 PQRS payment adjustment, for 2015 and 

beyond, we are modifying this proposal to require that a QCDR have at least 2 outcome measures 

available for reporting. An outcomes measure is a measure that assesses the results of health care that are 

experienced by patients (that is, patients’ clinical events; patients’ recovery and health status; patients’ 

experiences in the health system; and efficiency/cost). In lieu of having 2 outcomes measures available 

for reporting, the QCDR must at least have 1 outcome measure available for reporting and at least 1 

resource use, patient experience of care, efficiency/appropriate use measure, or patient safety measure. 

We believe this is an appropriate modification, as QCDRs that only have the ability to report 1 outcome 

measure may still report 1 outcome measure as long as the QCDR has another measure (resource use, 

patient experience of care, efficiency/appropriate use measure, or patient safety measure) in another 

domain available for reporting. 

We proposed to define resource use, patient experience of care, or efficiency/appropriate use 

measures in the following manner (79 FR 40473): 

● A resource use measure is a measure that is a comparable measure of actual dollars or 

standardized units of resources applied to the care given to a specific population or event, such as a 

specific diagnosis, procedure, or type of medical encounter. We did not receive any comments on this 

proposed definition of a resource use measure. As such, we are finalizing this definition of a resource use 

measure as proposed. 

● A patient experience of care measure is a measure of person- or family-reported experiences 

(outcomes) of being engaged as active members of the health care team and in collaborative partnerships 

with providers and provider organizations. We did not receive any comments on this proposed definition 

of a patient experience of care measure. As such, we are finalizing this definition of a patient experience 

of care measure as proposed. 

● An efficiency/appropriate use measure is a measure of the appropriate use of health care 

services (such as diagnostics or therapeutics) based upon evidence-based guidelines of care, or for which 
CMS-1612-FC 835

the potential for harm exceeds the possible benefits of care. We did not receive any comments this 

proposed definition of an efficiency/appropriate use measure. As such, we are finalizing this definition of 

an efficiency/appropriate use measure as proposed. 

Please note that, for purposes of meeting the criteria for satisfactory participation in a QCDR, we 

allow QCDRs to report on any measure if it meets the measure parameters we finalize. We noted that we 

would allow and encourage the reporting of the Consumer Assessment of Healthcare Providers Surgical 

Care Survey (S-CAHPS) through a QCDR. 

Finally, in the CY 2014 PFS final rule with comment period, we stated that a QCDR must 

provide to CMS descriptions and narrative specifications for the measures for which it will report to CMS 

by no later than March 31, 2014. In keeping with this timeframe, we proposed that a QCDR must provide 

to CMS descriptions for the measures for which it will report to CMS for a particular year by no later than 

March 31 of the applicable reporting period for which the QCDR wishes to submit quality measures data. 

We solicited and received the following comments on this proposal: 

Comment: Commenters believed that it was reasonable to require a QCDR to provide to CMS 

descriptions and narrative specifications for the measures for which it will report to CMS by no later than 

March 31, 2014. 

Response: We appreciate the commenters’ feedback. Based on the comments received, we are 

finalizing our proposal to require that a QCDR must provide to CMS descriptions for the measures for 

which it will report to CMS for a particular year by no later than March 31 of the applicable reporting 

period for which the QCDR wishes to submit quality measures data. For example, if a QCDR wishes to 

submit quality measures data for the 2017 PQRS payment adjustment (the 12-month reporting period of 

which occurs in 2015), the QCDR must provide to CMS descriptions for the measures for which it will 

report to CMS by no later than March 31, 2015. The descriptions must include: name/title of measures, 

NQF # (if NQF-endorsed), descriptions of the denominator, numerator, and when applicable, denominator 

exceptions and denominator exclusions of the measure. The narrative specifications provided must be 

similar to the narrative specifications we provide in our measures list, available at 
CMS-1612-FC 836

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaimsRegistry_Mea

sureSpecs_SupportingDocs_12132013.zip. 

Related to this proposal, we proposed that, 15 days following CMS approval of these measure 

specifications, the QCDR must publicly post the measures specifications for the measures it intends to 

report for the PQRS using any public format it prefers. Immediately following posting of the measures 

specification information, the QCDR must provide CMS with the link to where this information is posted. 

CMS will then post this information when it provides its list of QCDRs for the year. We believe 

providing this information will further aid in creating transparency of reporting. We solicited and 

received the following comment on this proposal: 

Comment: Some commenters supported this proposal, as the commenters believe it was 

reasonable to require that this information be made available to the public. The commenters supported 

our proposal to defer to the QCDR in terms of what platform and in what manner this data may be made 

available to the public. Some commenters opposed this proposal based on their concerns that the public 

reporting requirement was overly burdensome and urged CMS to delay requiring the posting of measures 

data until the measures have been tested for validity and reliability. The commenters believed that CMS 

should not make substantial changes in the QCDR requirements, as the QCDR option is new and the 

entities need time to familiarize themselves with the QCDR option before new requirements are 

established. One commenter preferred public reporting of QCDR quality measures data through a single 

site so that information would be easily accessible and people seeking this information would not be 

forced to look through multiple sites. 

Response: With respect to the commenters who opposed this proposal and urged us not to make 

additional changes to the QCDR option while entities become more familiar with this option, we 

understand the commenters’ concerns. However, we believe that transparency of data is a key component 

of a QCDR option. Furthermore, in the CY 2014 PFS final rule, while we did not finalize our proposal 

that a QCDR have a plan to publicly report quality measures data, we noted that we encouraged QCDRs 

“to move towards the public reporting of quality measures data” and stated that “[w]e plan to establish 

such a requirement in the future and will revisit this proposed requirement as part of CY 2015 
CMS-1612-FC 837

rulemaking” (78 FR 74471). Therefore, we believe that QCDRs were on notice that we would finalize a 

requirement to make quality measures data available to the public. With respect to the commenter that 

preferred this information to be posted on a single site, we note that the Physician Compare website will 

provide quality measures data information on eligible professionals participating in QCDRs. Therefore, 

while the QCDRs are free to provide this information elsewhere, the Physician Compare website will 

serve as a point where all information will be accessible. Based on the reasons we stated above and in the 

proposed rule, we are finalizing our proposal to require that, 15 days following CMS approval of these 

measure specifications, a QCDR must publicly post the measures specifications for the measures it 

intends to report for the PQRS using any public format it prefers. Immediately following posting of the 

measures specification information, the QCDR must provide CMS with the link to where this information 

is posted. CMS will then post this information when it provides its list of QCDRs for the year. 

7. Informal Review 

In the CY 2013 PFS final rule with comment period (77 FR 69289), we established that “an 

eligible professional electing to utilize the informal review process must request an informal review by 

February 28 of the year in which the payment adjustment is being applied. For example, if an eligible 

professional requests an informal review related to the 2015 payment adjustment, the eligible professional 

would be required to submit his/her request for an informal review by February 28, 2015.” As stated in 

the CY 2013 PFS final rule with comment period, we believed this deadline provided ample time for 

eligible professionals and group practices after their respective claims begin to be adjusted due to the 

payment adjustment. However, because PQRS data is used to establish the quality composite of the VM, 

we believe it is necessary to expand the informal review process to allow for some limited corrections of 

the PQRS data to be made. Therefore, we proposed to modify the payment adjustment informal review 

deadline to within 30 days of the release of the feedback reports. For example, if the feedback reports for 

the 2016 payment adjustment (based on data collected for 2014 reporting periods) were released on 

August 31, 2015, an eligible professional or group practice would be required to submit a request for an 

informal review by September 30, 2015. We believe that by being able to notify eligible professionals 

and group practices of CMS’ decision on the informal review request much earlier than we would have 
CMS-1612-FC 838

been able to do with the previous informal review request deadline we can provide a brief period for an 

eligible or group practice to make some limited corrections to its PQRS data. This resubmitted data could 

then be used to make corrections to the VM calculations, when appropriate. 

The PQRS regulations at §414.90(m)(1) currently require an eligible professional or group 

practice to submit an informal review request to CMS within 90 days of the release of the feedback 

reports. Therefore, we proposed to revise §414.90(m)(1) to require the request of the informal review 

within 30 days of release of the feedback reports. 

Regarding the eligible professional’s or group practice’s ability to provide additional information 

to assist in the informal review process, we proposed to provide the following limitations as to what 

information might be taken into consideration: 

● CMS would only allow resubmission of data that was submitted using a third-party vendor 

using the qualified registry, EHR data submission vendor, or QCDR reporting mechanisms. Therefore, 

CMS would not allow resubmission of data submitted via claims, direct EHR, or the GPRO web interface 

reporting mechanisms. We are limiting resubmission to third-party vendors, because we believe that 

third-party vendors are more easily able to detect errors than direct users. 

● CMS would only allow resubmission of data that was already previously submitted to CMS. 

Submission of new data – such as new measures data not previously submitted or new data for eligible 

professionals for which data was not submitted during the original submission period – would not be 

accepted. 

● For any given resubmission period, CMS would only accept data that was previously 

submitted for the reporting periods for which the corresponding informal review period applies. For 

example, the resubmission period immediately following the informal review period for the 2017 PQRS 

payment adjustment would only allow resubmission for data previously submitted for the 2017 PQRS 

payment adjustment reporting periods occurring in 2015. 

As such, we proposed to add §414.90(m)(3) to reflect this proposal as follows: (3) If, during the 

informal review process, CMS finds errors in data that was submitted using a third-party vendor using 

either the qualified registry, EHR data submission vendor, or QCDR reporting mechanisms, CMS may 
CMS-1612-FC 839

allow for the resubmission of data to correct these errors. (i) CMS will not allow resubmission of data 

submitted via claims, direct EHR, and the GPRO web interface reporting mechanisms. (ii) CMS will 

only allow resubmission of data that was already previously submitted to CMS. (iii) CMS will only 

accept data that was previously submitted for the reporting periods for which the corresponding informal 

review period applies. 

We invited public comment on these proposals. The following is summary of the comments we 

received regarding on these proposals. 

Comment: Several commenters opposed our proposal to change the amount of time an eligible 

professional or group practice would have to submit an informal review request to 30 days. One 

commenter stated that it was necessary to have a longer timeframe, as accessing PQRS feedback reports 

can be extremely cumbersome and time-intensive. The commenters believed that 30 days was an 

insufficient amount of time to access, analyze, and identify errors in the PQRS feedback reports. Some of 

these commenters urged CMS to extend the request period to 60 or 90 days in lieu of 30 days. 

Response: We understand that this provides eligible professionals and group practices with a 

much shorter timeline with which to submit an informal review request. We also understand the 

commenters’ concerns regarding having to access and analyze the feedback reports as well as submitting 

an informal review request within 30 days. As we stated in the proposed rule, it is necessary to shorten 

the timeline in order to be allow for the resubmission of data, if applicable to the eligible professional or 

group practice. However, given these concerns, we will increase the amount of time in which eligible 

professionals and group practices may submit an informal review request. In order to finalize our 

proposal to allow for the resubmission of data, it is necessary to receive all informal review requests 

within 60 days of the release of the feedback reports. At this time, we believe the 60-day deadline still 

provides us with enough time to allow for the resubmission of data. However, should we find that more 

time is needed to process resubmissions, we reserve the right to propose further changes to this deadline 

in future rulemaking. Therefore, for the reasons stated above and in the proposed rule, we are finalizing 

our proposal to modify §414.90(m)(1) to indicate the payment adjustment informal review deadline to 

within 60 days of the release of the feedback reports beginning in 2015. 
CMS-1612-FC 840

Comment: Several commenters generally supported our proposal to allow for resubmission of 

data. 

Response: We appreciate the commenters’ support for this proposal. Based on the support for 

this proposal and for the reasons we stated in the proposed rule, we are finalizing our proposal to allow 

for resubmission of data as proposed. As we proposed, we are providing the following limitations as to 

what information might be taken into consideration: 

● CMS would only allow resubmission of data that was submitted by a third-party vendor on 

behalf of an eligible professional or group practice using the qualified registry, EHR data submission 

vendor, or QCDR reporting mechanisms. Therefore, CMS would not allow resubmission of data 

submitted via claims, direct EHR, or the GPRO web interface reporting mechanisms. We are limiting 

resubmission to third-party vendors, because we believe that third-party vendors are more easily able to 

detect errors than direct users. 

● CMS would only allow resubmission of data that was already previously submitted to CMS. 

Submission of new data – such as new measures data not previously submitted or new data for eligible 

professionals for which data was not submitted during the original submission period – would not be 

accepted. 

● For any given resubmission period, CMS would only accept data that was previously 

submitted for the reporting periods for which the corresponding informal review period applies. For 

example, the resubmission period immediately following the informal review period for the 2017 PQRS 

payment adjustment would only allow resubmission for data previously submitted for the 2017 PQRS 

payment adjustment reporting periods occurring in 2015. 

Because of the comments received and for the reasons stated above and in the proposed rule, we 

are finalizing our proposal to modify the payment adjustment informal review deadline to within 60 days 

of the release of the feedback reports. In addition, to allow resubmission of data, we are finalizing our 

proposal, as proposed, to add §414.90(m)(3) as follows: (3) If, during the informal review process, CMS 

finds errors in data that was submitted using a third-party vendor using either the qualified registry, EHR 

data submission vendor, or QCDR reporting mechanisms, CMS may allow for the resubmission of data to 
CMS-1612-FC 841

correct these errors. (i) CMS will not allow resubmission of data submitted via claims, direct EHR, and 

the GPRO web interface reporting mechanisms. (ii) CMS will only allow resubmission of data that was 

already previously submitted to CMS. (iii) CMS will only accept data that was previously submitted for 

the reporting periods for which the corresponding informal review period applies. 

L. Electronic Health Record (EHR) Incentive Program 

The HITECH Act (Title IV of Division B of the ARRA, together with Title XIII of 

Division A of the ARRA) authorizes incentive payments under Medicare and Medicaid for the 

adoption and meaningful use of certified EHR technology (CEHRT). Section 1848(o)(2)(B)(iii) 

of the Act requires that in selecting CQMs for eligible professionals (EPs) to report under the 

EHR Incentive Program, and in establishing the form and manner of reporting, the Secretary 

shall seek to avoid redundant or duplicative reporting otherwise required. As such, we have 

taken steps to establish alignments among various quality reporting and payment programs that 

include the submission of CQMs. 

For CY 2012 and subsequent years, §495.8(a)(2)(ii) requires an EP to successfully report 

the clinical quality measures selected by CMS to CMS or the states, as applicable, in the form 

and manner specified by CMS or the states, as applicable. 

In the CY 2014 PFS final rule with comment period (78 FR 74756), we finalized our 

proposal to require EPs who seek to report CQMs electronically under the Medicare EHR 

Incentive Program to use the most recent version of the electronic specifications for the CQMs 

and have CEHRT that is tested and certified to the most recent version of the electronic 

specifications for the CQMs. We noted it is important for EPs to electronically report the most 

recent versions of the electronic specifications for the CQMs as updated measure versions 

correct minor inaccuracies found in prior measure versions. We stated that to ensure that 

CEHRT products can successfully transmit CQM data using the most recent version of the 
CMS-1612-FC 842

electronic specifications for the CQMs, it is important that the product be tested and certified to 

the most recent version of the electronic specifications for the CQMs. 

Since finalizing this proposal, we have received feedback from stakeholders regarding the 

difficulty and expense of having to test and recertify CEHRT products to the most recent version 

of the electronic specifications for the CQMs. Although we still believe EPs should test and 

certify their products to the most recent version of the electronic specifications for the CQMs 

when feasible, we understand the burdens associated with this requirement. Therefore, to 

eliminate this added burden, we proposed that, beginning in CY 2015, EPs would not be required 

to ensure that their CEHRT products are recertified to the most recent version of the electronic 

specifications for the CQMs. Please note that, although we are not requiring recertification, EPs 

must still report the most recent version of the electronic specifications for the CQMs. 

In the CY 2014 PFS final rule with comment period, we established the requirement that 

EPs who seek to report CQMs electronically under the Medicare EHR Incentive Program must 

use the most recent version of the electronic specifications for the CQMs (78 FR 74756). We 

solicited and received the following public comments on these proposals: 

Comment: The majority of commenters supported our proposal not to require EPs to 

recertify their EHR products to the most recent version of the eCQMs. One commenter opposed 

this proposal, stating that if we did not require recertification some products run the risk of not 

being able to perform critical Stage 2 functions such as secure messaging between patients and 

providers, offering patients the ability to view, download, and transmit their own health 

information, and improving care transitions with a summary of care record for transitions and 

referrals. 

Response: We appreciate the commenters’ support for this proposal. With respect to the 

commenter who opposed this proposal, we agree that it is important to recertify as frequently as 
CMS-1612-FC 843

possible for the reasons the commenter stated. However, at this time, we understand that 

requiring recertification to the most recent version of the electronic specifications for the CQMs, 

which could occur annually, may be overly burdensome and time-consuming for providers. 

Please note that this proposal was limited to EPs and not intended to apply to eligible hospitals 

(EHs) or critical access hospitals. Based on the comments received and for the reasons stated in 

the proposed rule, we are finalizing our proposal that, beginning in CY 2015, EPs are not 

required to ensure that their CEHRT products are recertified to the most recent version of the 

electronic specifications for the CQMs. Although we are not requiring recertification, EPs must 

still report the most recent version of the electronic specifications for the CQMs. 

Additionally, we noted in the proposed rule that, with respect to the following measure 

CMS140v2, Breast Cancer Hormonal Therapy for Stage IC–IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF 0387), a substantive 

error was discovered in the June 2013 version of this electronically specified clinical quality 

measure (79 FR 40474). If an EP chooses to report this measure electronically under the EHR 

Incentive Program in CY 2014, the prior, December 2012 version of the measure, which is 

CMS140v1, must be used (78 FR 74757). In the proposed rule (79 FR 40474), we stated that 

because a more recent and corrected version of this measure has been developed, we will require 

the reporting of the most recent, updated version of the measure Breast Cancer Hormonal 

Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast 

Cancer (NQF 0387), if an EP chooses to report the measure electronically in CY 2015. 

In the EHR Incentive Program Stage 2 final rule, we established CQM reporting options 

for the Medicare EHR Incentive Program for CY 2014 and subsequent years that include one 

individual reporting option that aligns with the PQRS’s EHR reporting option (77 FR 54058) and 

two group reporting options that align with the PQRS GPRO and Medicare Shared Savings 
CMS-1612-FC 844

Program (MSSP) and Pioneer ACOs (77 FR 54076 to 54078). In the CY 2014 PFS final rule 

with comment period, we finalized two additional aligned options for EPs to report CQMs for 

the Medicare EHR Incentive Program for CY 2014 and subsequent years with the intention of 

minimizing the reporting burden on EPs (78 FR 74753 through 74757). One of the aligned 

options finalized in the CY 2014 PFS final rule with comment period (78 FR 74754 through 

74755) is a reporting option for CQMs for the Medicare EHR Incentive Program under which 

EPs can submit CQM information using qualified clinical data registries, according the definition 

and requirements for qualified clinical data registries established under the PQRS. 

The second aligned option finalized in the CY 2014 PFS final rule with comment period 

(78 FR 74755 through 74756) is a group reporting option for CQMs for the Medicare EHR 

Incentive Program beginning in CY 2014 under which EPs who are part of a Comprehensive 

Primary Care (CPC) initiative practice site that successfully reports at least nine electronically 

specified CQMs across three domains for the relevant reporting period in accordance with the 

requirements established for the CPC initiative and using CEHRT would satisfy the CQM 

reporting component of meaningful use for the Medicare EHR Incentive Program. If a CPC 

practice site is not successful in reporting, EPs who are part of the site would still have the 

opportunity to report CQMs in accordance with the requirements established for the Medicare 

EHR Incentive Program in the Stage 2 final rule. Additionally, only those EPs who are beyond 

their first year of demonstrating meaningful use may use this CPC group reporting option. The 

CPC practice sites must submit the CQM data in the form and manner required by the CPC 

initiative. Therefore, whether CPC required electronic submission or attestation of CQMs, the 

CPC practice site must submit the CQM data in the form and manner required by the CPC 

initiative. 
CMS-1612-FC 845

The CPC initiative, under the authority of section 3021 of the Affordable Care Act, is a 

multi-payer initiative fostering collaboration between public and private health care payers to 

strengthen primary care. Under this initiative, we will pay participating primary care practices a 

care management fee to support enhanced, coordinated services. Simultaneously, participating 

commercial, state, and other federal insurance plans are also offering enhanced support to 

primary care practices that provide high-quality primary care. There are approximately 483 CPC 

practice sites across 7 health care markets in the U.S. More details on the CPC initiative can be 

found at http://innovation.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html. 

Under the CPC initiative, CPC practice sites are required to report to CMS a subset of the 

CQMs that were selected in the EHR Incentive Program Stage 2 final rule for EPs to report 

under the EHR Incentive Program beginning in CY 2014 (for a list of CQMs that were selected 

in the EHR Incentive Program Stage 2 final rule for EPs to report under the EHR Incentive 

Program beginning in CY 2014, see 77 FR 54069 through 54075). We proposed to retain the 

group reporting option for CPC practice sites as finalized in the CY 2014 PFS final rule, but to 

relax the requirement for the CQMs to cover three domains. Instead, we proposed that, for CY 

2015 only, under this group reporting option, the CPC practice site must report a minimum of 

nine CQMs from the CPC subset, and the nine CQMs reported must cover at least 2 domains, 

although we strongly encouraged practice sites to report across more domains if 

feasible. Although the requirement to report across three domains is important because the 

domains are linked to the National Quality Strategy and used throughout CMS quality programs, 

the CPC practice sites are required to report from a limited number of CQMs that were selected 

for the EHR Incentive Program and are focused on a primary care population. Therefore, these 

CPC practice sites may not have measures to select from that cover three domains. Additionally, 
CMS-1612-FC 846

CPC practice sites are assessed for quality performance on measures other than electronically 

specified CQMs which do cover other National Quality Strategy domains. We invited public 

comment on this proposal. 

The following is a summary of the comments we received regarding our proposal on the 

group reporting option for CPC practice sites. 

Comment: A few commenters indicated general support for relaxing the domain 

requirement for the primary care physicians, indicating providers should be able to select the 

measures most applicable to their population. 

Response: We appreciate the support for this proposal. The CPC CQM set targets a 

primary care patient population and therefore is appropriate for reporting by CPC practice sites 

in the model. 

Comment: One commenter opposed relaxing the reporting requirements for CPC 

practice sites to only report 2 domains instead of 3. The commenter indicated consumers and 

purchasers want to see measures across these domains reported electronically. The commenter 

believed CPC practice sites have sufficient measures to choose from to report 9 measures that 

cover 3 domains. 

Response: The CPC initiative is a model tested by the Center for Medicare and Medicaid 

Innovation. As such, CPC includes specific quality measure reporting requirements for each 

CPC practice site to be eligible to participate in any Medicare shared savings, which is a 

component of the model. The quality reporting requirements include reporting on a subset of the 

CQMs selected for the EHR Incentive Program beginning in CY 2014. 

The CPC measure subset includes a total of 11 measures, of which 7 fall in the clinical 

process/effectiveness domain, 3 in the population health domain, and 1 in the safety domain. We 

proposed to reduce the number of domains required to at least 2 domains to allow CPC practice 
CMS-1612-FC 847

sites that would be unable to obtain in their EHR the one safety CQM in the CPC measure subset 

to meet the MU CQM requirement. This would provide CPC practice sites an opportunity to 

successfully report to the CPC model and satisfy the CQM reporting component of meaningful 

use, so they would not have to report quality measures twice to both CPC and the Medicare EHR 

Incentive Program. 

After consideration of the comments received, and for the reasons stated previously, we are 

finalizing the proposal to reduce the required number of domains for CY 2015 only as proposed. 
CMS-1612-FC 848

M. Medicare Shared Savings Program 

Under section 1899 of the Act, CMS has established the Medicare Shared Savings 

program (Shared Savings Program) to facilitate coordination and cooperation among providers to 

improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate 

of growth in health care costs. Eligible groups of providers and suppliers, including physicians, 

hospitals, and other health care providers, may participate in the Shared Savings Program by 

forming or participating in an Accountable Care Organization (ACO). The final rule 

implementing the Shared Savings Program appeared in the November 2, 2011 Federal Register 

(Medicare Shared Savings Program: Accountable Care Organizations Final Rule (76 FR 67802)). 

Section 1899(b)(3)(A) of the Act requires the Secretary to determine appropriate 

measures to assess the quality of care furnished by ACOs, such as measures of clinical processes 

and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization 

such as rates of hospital admission for ambulatory sensitive conditions. Section 1899(b)(3)(B) of 

the Act requires ACOs to submit data in a form and manner specified by the Secretary on 

measures that the Secretary determines necessary for ACOs to report to evaluate the quality of 

care furnished by ACOs. Section 1899(b)(3)(C) of the Act requires the Secretary to establish 

quality performance standards to assess the quality of care furnished by ACOs, and to seek to 

improve the quality of care furnished by ACOs over time by specifying higher standards, new 

measures, or both for the purposes of assessing the quality of care. Additionally, section 

1899(b)(3)(D) of the Act gives the Secretary authority to incorporate reporting requirements and 

incentive payments related to the PQRS, EHR Incentive Program and other similar initiatives 

under section 1848 of the Act. Finally, section 1899(d)(1)(A) of the Act states that an ACO is 
CMS-1612-FC 849

eligible to receive payment for shared savings, if they are generated, only after meeting the 

quality performance standards established by the Secretary. 

In the November 2011 final rule establishing the Shared Savings Program, we established 

the quality performance standards that ACOs must meet to be eligible to share in savings that are 

generated (76 FR 67870 through 67904). Quality performance measures are submitted by ACOs 

through a CMS web interface, currently the group practice reporting option (GPRO) web 

interface, calculated by CMS from internal and claims data, and collected through a patient and 

caregiver experience of care survey. 

Consistent with the directive under section 1899(b)(3)(C) of the Act, we believe the 

existing Shared Savings Program regulations incorporate a built in mechanism for encouraging 

ACOs to improve care over the course of their 3-year agreement period, and to reward quality 

improvement over time. During the first year of the agreement period, ACOs can qualify for the 

maximum sharing rate by completely and accurately reporting all quality measures. After that, 

ACOs must meet certain thresholds of performance, which are currently phased in over the 

course of the ACO’s first agreement period, and are rewarded for improved performance on a 

sliding scale in which higher levels of quality performance translate to higher rates of shared 

savings (or, for ACOs subject to performance-based risk that demonstrate losses, lower rates of 

shared losses). In this way, the quality performance standard increases over the course of the 

ACO’s agreement period. 

Additionally, we have made an effort to align quality performance measures, submission 

methods, and incentives under the Shared Savings Program with the PQRS. Eligible 

professionals participating in an ACO may qualify for the PQRS incentive payment under the 
CMS-1612-FC 850

Shared Savings Program or avoid the downward PQRS payment adjustment when the ACO 

satisfactorily reports the ACO GPRO measures on their behalf using the GPRO web interface. 

Since the November 2011 final rule establishing the Shared Savings Program was issued, 

we have revisited certain aspects of the quality performance standard in the annual PFS 

rulemaking out of a desire to ensure thoughtful alignment with the agency’s other quality 

incentive programs that are addressed in that rule. Specifically, we have updated our rules to 

align with PQRS and the EHR Incentive Program, and addressed issues related to benchmarking 

and scoring ACO quality performance (77 FR 69301 through 69304; 78 FR 74757 through 

74764). This year, as part of the CY 2015 Physician Fee Schedule proposed rule, we addressed 

several issues related to the Shared Savings Program quality performance standard and alignment 

with other CMS quality initiatives. Specifically, we revisited the current quality performance 

standard, proposed changes to the quality measures, and sought comment on future quality 

performance measures. We also proposed to modify the timeframe between updates to the 

quality performance benchmarks, to establish an additional incentive to reward ACO quality 

improvement, and to make several technical corrections to the regulations in subpart F of Part 

425. 

1. Existing Quality Measures and Performance Standard 

 As discussed previously, section1899(b)(3)(C) of the Act states that the Secretary may 

establish quality performance standards to assess the quality of care furnished by ACOs and 

“seek to improve the quality of care furnished by ACOs over time by specifying higher 

standards, new measures, or both....” In the November 2011 Shared Savings Program final rule, 

we established a quality performance standard that consists of 33 measures. These measures are 

submitted by the ACO through the GPRO web interface, calculated by CMS from administrative 
CMS-1612-FC 851

and claims data, and collected via a patient experience of care survey based on the Clinician and 

Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. 

Although the patient experience of care survey used for the Shared Savings Program includes the 

core CG-CAHPS modules, this patient experience of care survey also includes some additional 

modules. Therefore, we will refer to the patient experience of care survey that is used under the 

Shared Savings Program as CAHPS for ACOs. The measures span four domains, including 

patient experience of care, care coordination/patient safety, preventive health, and at-risk 

population. The measures collected through the GPRO web interface are also used to determine 

whether eligible professionals participating in an ACO qualify for the 2013 and 2014 PQRS 

incentive payment or avoid the PQRS payment adjustment for 2015 and subsequent years. 

Eligible professionals in an ACO may qualify for the PQRS incentive payment or avoid the 

downward PQRS payment adjustment when the ACO satisfactorily reports all of the ACO 

GPRO measures on their behalf using the GPRO web interface. 

In selecting the 33 measure set, we balanced a wide variety of important considerations. 

Given that many ACOs were expected to be newly formed organizations, in the November 2011 

Shared Savings Program final rule (76 FR 67886), we concluded that ACO quality measures 

should focus on discrete processes and short-term measurable outcomes derived from 

administrative claims and limited medical record review facilitated by a CMS-provided web 

interface to lessen the burden of reporting. Because of the focus on Medicare FFS beneficiaries, 

our measure selection emphasized prevention and management of chronic diseases that have 

high impact on these beneficiaries such as heart disease, diabetes mellitus, and chronic 

obstructive pulmonary disease. We believed that the quality measures used in the Shared 

Savings Program should be tested, evidence-based, target conditions of high cost and high 
CMS-1612-FC 852

prevalence in the Medicare FFS population, reflect priorities of the National Quality Strategy, 

address the continuum of care to reflect the requirement that ACOs accept accountability for 

their patient populations, and align with existing quality programs and value-based purchasing 

initiatives. 

At this time, we continue to believe it is most appropriate to focus on quality measures 

that directly assess the overall quality of care furnished to FFS beneficiaries. The set of 33 

measures that we adopted in the November 2011 Shared Savings Program final rule includes 

measures addressing patient experience, outcomes, and evidence-based care processes. Thus far, 

we have not included any specific measures addressing high cost services or utilization since we 

believe that the potential to earn shared savings offers an important and direct incentive for 

ACOs to address utilization issues in a way that is most appropriate for their organization, patient 

population, and local healthcare environment. We note that while the quality performance 

standard is limited to these 33 measures, the performance of ACOs is measured on many more 

metrics and ACOs are informed of their performance in these areas. For example, an assessment 

of an ACO’s utilization of certain resources is provided to the ACO via quarterly reports that 

contain information such as the utilization of emergency services or the utilization of CTs and 

MRIs. 

 As we have stated previously (76 FR 67872), our principal goal in selecting quality 

measures for ACOs was to identify measures of success in the delivery of high-quality health 

care at the individual and population levels. We believe endorsed measures have been tested, 

validated, and clinically accepted, and therefore, selected the 33 measures with a preference for 

NQF-endorsed measures. However, the statute does not limit us to using endorsed measures in 

the Shared Savings Program. As a result we also exercised our discretion to include certain 
CMS-1612-FC 853

measures that we believe to be high impact but that are not currently endorsed, for example, 

ACO#11, Percent of PCPs Who Successfully Qualify for an EHR Incentive Program Payment. 

In selecting the final set of 33 measures, we sought to include both process and outcome 

measures, including patient experience of care (76 FR 67873). Because ACOs are charged with 

improving and coordinating care and delivering high quality care, but also need time to form, 

acquire infrastructure and develop clinical care processes, we continue to believe it is important 

to have a combination of both process and outcomes measures. We note, however, that as other 

CMS quality reporting programs, such as PQRS, move to more outcomes-based measures and 

fewer process measures over time, we may also revise the quality performance standard for the 

Shared Savings Program to incorporate more outcomes-based measures over time. 

Therefore, we viewed the 33 measures adopted in the November 2011 Shared Savings 

Program final rule as a starting point for ACO quality measurement. As we stated in that rule 

(67 FR 67891), we plan to modify the measures in future reporting cycles to reflect changes in 

practice and improvements in quality of care and to continue aligning with other quality 

reporting programs and will add and/or retire measures as appropriate through the rulemaking 

process. In addition, we are working with the measures community to ensure that the 

specifications for the measures used under the Shared Savings Program are up-to-date. We note 

that we must balance the timing of the release of specifications so they are as up-to-date as 

possible, while also giving ACOs sufficient time to review specifications. Our intention is to 

issue the specifications annually, prior to the start of the reporting period for which they will 

apply. 

In the November 2011 Shared Savings Program final rule (76 FR 67873), we combined 

care coordination and patient safety into a single domain to better align with the National Quality 
CMS-1612-FC 854

Strategy and to emphasize the importance of ambulatory patient safety and care coordination. 

We also intended to continue exploring ways to best capture ACO care coordination metrics and 

noted that we would consider adding new care coordination measures for future years (67 FR 

67877). 

2. Changes to the Quality Measures Used in Establishing Quality Performance Standards that 

ACOs must meet to be Eligible for Shared Savings 

a. Background and Proposal. 

Since the November 2011 Shared Savings Program final rule, we have continued to 

review the quality measures used for the Shared Savings Program to ensure that they are up to 

date with current clinical practice and are aligned with the GPRO web interface reporting for 

PQRS. Based on these reviews, in the CY 2015 Physician Fee Schedule proposed rule, we 

proposed a number of measure additions, deletions and other revisions that we believed would be 

appropriate for the Shared Savings Program. An overview of changes we proposed is provided 

in Table 50 of the proposed rule (79 FR 40479 through 40481) which lists the measures that we 

proposed would be used to assess ACO quality under the Shared Savings Program starting in 

2015. To summarize, we proposed to add 12 new measures and retire eight measures. We also 

proposed to rename the EHR measure in order to reflect the transition from an incentive payment 

to a payment adjustment under the EHR Incentive Program and to revise the component 

measures within the Diabetes and CAD composites. In total, we proposed to use 37 measures for 

establishing the quality performance standard that ACOs must meet to be eligible for shared 

savings. Although the total number of measures would increase from the current 33 measures to 

37 measures under this proposal, we stated we did not anticipate that this would increase the 

reporting burden on ACOs because the increased number of measures is accounted for by 
CMS-1612-FC 855

measures that would be calculated by CMS using administrative claims data or from a patient 

survey. The total number of measures that the ACO would need to directly report through the 

CMS website interface would actually decrease by one, in addition to removing redundancy in 

measures reported. 

Finally, as part of the proposed changes, we proposed to replace the current five 

component diabetes composite measure with a new four component diabetes composite measure. 

In addition, we proposed to replace the current two component coronary artery disease composite 

measure with a new four component coronary artery disease composite measure. Under this 

proposal, 21 measures would be reported by ACOs through the GPRO web interface and scored 

as 15 measures. 

Below, we summarize and group comments received on these proposals by first 

responding to general comments on our proposals and then by the method of data submission for 

the measure as listed in Table 50 of the proposed rule (79 FR 40479 through 40481) (that is, 

survey, claims, EHR incentive program, and the CMS web interface). In order to align the 

measures submitted through the CMS web interface with the PQRS and VM programs, we 

discuss specific comments in response to the proposed changes to the measures submitted 

through the CMS web interface with the comments received for these same measures for the 

PQRS and the VM programs. See Tables 79 and 80 in section III.K., for a discussion of and 

response to these comments. 

General Comment: In addition to the comments that focus on individual measures, we 

received many general comments about the quality performance measures used in the Shared 

Savings Program. For example, we received many comments supporting the alignment between 

ACO, PQRS and VM quality measures and an increased focus on outcomes-based quality 
CMS-1612-FC 856

measures. Some commenters objected to the net increase in measures, believing there is 

underlying burden for providers even for claims-based measures. Additionally, many ACOs did 

not support the proposed new measures, suggesting, for example, they would be unnecessary 

because of the incentives inherent to the Shared Savings Program, or that, in general, the new 

proposed measures are inadequately defined, tested or benchmarked. These ACOs believed that 

many of the proposed new measures address clinical issues beyond an ACO’s control and 

therefore should not be added. Other concerns about the new measures were that they would 

require substantial change in clinical practice, would substantially add to the reporting burden, 

and/or are questionably related to improving care quality and/or patient outcomes. 

Other commenters supported adding the new measures. One commenter, for example, 

stated that “the expanded measures are important utilization and management measures that our 

developing ACO would have likely considered and built into our ACO Cost, Utilization, and 

Risk dashboard anyway. From a clinical and system standpoint, these additions are key 

components of better managing avoidable utilization and costs. They are measures we would 

want to know regardless of the Proposed Rule.” MedPAC suggested that CMS move quality 

measurement for ACOs, MA plans, and FFS Medicare in the direction of a small set of 

population-based outcome measures, such as potentially preventable inpatient hospital 

admissions, emergency department visits, and readmissions. 

Response: We continue to believe it is appropriate to add, remove, and modify quality 

measures for the Shared Savings Program to reflect changes in clinical practice and for other 

program needs. We want to minimize any additional burdens this could create for ACOs and 

their ACO participants and ACO providers/suppliers. Therefore, we agree with the comments in 

support of the alignment between ACO, PQRS and VM for the quality measures submitted 
CMS-1612-FC 857

through the CMS web interface, and an increased focus on outcomes-based quality measures. 

We disagree with those ACOs that suggested certain proposed new measures would be 

unnecessary because of the incentives inherent to the Shared Savings Program. Instead, we 

agree with the commenter who noted that such measures can be important utilization and 

management tools that many ACOs may consider and build into their own internal monitoring 

systems as a way to help manage avoidable utilization and costs. Further, we believe certain 

proposed new measures highlight the value of discussions with patients about their care. 

b. Survey based measure: 

● CAHPS Stewardship of Patient Resources. This measure is one of the unscored 

survey measures currently collected in addition to the seven scored survey measures that are 

already part of the current set of 33 measures under the Shared Savings Program. Information on 

the unscored survey measure modules is currently shared with the ACOs for informational 

purposes only. The Stewardship of Patient Resources measure asks the patient whether the care 

team talked with the patient about prescription medicine costs. The measure exhibited high 

reliability during the first two administrations of the CAHPS survey, and during testing, the 

beneficiaries that participated in cognitive testing said that prescription drug costs were 

important to them. We proposed to add Stewardship of Patient Resources as a scored measure in 

the patient experience domain because we believe, based on testing, that this is an important 

factor for measuring a beneficiary’s engagement and experience with healthcare providers. We 

also proposed that the measure would be phased into pay for performance as we plan to do for 

other new measures, using a similar process to the phase in that was used for the scored measure 

modules in the survey that are currently used to assess ACO quality performance. 

Comment: Some commenters supported the proposed addition of this measure, agreeing 
CMS-1612-FC 858

that discussing the cost of medications is important to assess the possibility that medication costs 

may be a barrier to care or that the measure may be an indicator of a patient’s satisfaction with 

the care he or she is receiving. Other commenters questioned how this discussion leads to a plan 

of action or a modified plan of treatment to improve care if the patient is unable to pay for the 

medication. These commenters asked us to further explain how we envision this measure 

improving patient care. Some believe it would be reasonable to include this measure under pay 

for reporting, but that additional discussions with the community would be needed in order to 

establish an appropriate benchmark for this measure, as this is a relatively new measure. Some 

thought that physician discussions with patients regarding medication cost would be appropriate 

for “high tier,” costly medications, but would be of questionable value relative to measuring 

patient-centered, quality care delivery for more frequently prescribed, lower cost, generic 

medications and/or the extent to which patients take medications as prescribed. Some 

commenters suggested that it would be unnecessary and/or burdensome to add this measure. For 

example, commenters indicated that physicians do not and cannot know the co-pays for each 

drug under each insurance plan and product and that there would be tremendous patient 

dissatisfaction when inaccurate pricing or cost information is provided to the patient by the 

provider. Some commenters believe this measure is unnecessary since encouraging adherence to 

medications is a key strategy for ACOs to reduce avoidable costs, and inability to afford 

medications is a key barrier to adherence, so ACOs already have an incentive to discuss the cost 

of medications with their patients. 

Response: This measure asks patients whether any health care provider spoke to them 

about their prescription medication costs and does not require that physicians know the co-pays 

for each drug under each insurance plan and product. Additionally, discussing this topic with 
CMS-1612-FC 859

beneficiaries can lead a clinician to understand whether and how the beneficiary may struggle 

with payment for medications, a factor that can affect adherence to prescribed regimens. We can 

therefore envision a scenario where, once the issue is identified, a clinician participating in an 

ACO could inform and educate the beneficiary about less expensive options, such as the use of 

generic medications, or about available community resources, as part of the ACO’s care 

coordination processes required under §425.112(b)(4). This in turn could directly improve the 

quality of care the beneficiary receives by improving medication adherence and leading to 

greater beneficiary engagement. Because this measure is already part of the CAHPS survey, we 

do not believe it will increase reporting burden for the ACO. The CAHPS survey question is 

available in the CAHPS Survey for ACOs Quality Assurance Guidelines on the CAHPS for 

ACOs website. As discussed below, because this is a new measure, the measure will be pay-forreporting for the first two reporting periods it is in use for all ACOs, regardless of the phase-in 

schedule to pay-for-performance, in order to provide time for the development of an appropriate 

benchmark. 

Final Decision: We are finalizing our proposed addition of the CAHPS: Stewardship of 

Patient Resources measure. After the measure has been used in the program under pay for 

reporting for two reporting periods, it will be pay-for-reporting for the first performance year of 

an ACO’s first agreement period and pay-for-performance for the ACO’s second and third 

performance years. We continue to believe that it is important for physicians and others to 

discuss the beneficiary’s perspective on the cost of medications because is important to assess 

the possibility that medication costs may be a barrier to care. The measure exhibited high 

reliability during the first two administrations of the CAHPS survey, and during testing, the 
CMS-1612-FC 860

beneficiaries that participated in cognitive testing said that prescription drug costs were 

important to them. 

c. Claims Based Measures to be Computed by CMS 

● Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM). We 

proposed to add a 30-day all cause skilled nursing facility (SNF) readmission measure. CMS is 

the measure steward for this claims-based measure, which is under review at NQF under NQF 

#2510. This measure estimates the risk-standardized rate of all-cause, unplanned, hospital 

readmissions for patients who have been admitted to a SNF within 30 days of discharge from a 

prior inpatient admission to a hospital, CAH, or a psychiatric hospital. The measure is based on 

data for 12 months of SNF admissions. We believe this measure would help fill a gap in the 

current Shared Savings Program measure set and would provide a focus on an area where ACOs 

are targeting care redesign. ACOs and their ACO participants often include post-acute care 

(PAC) settings and the addition of this measure would enhance the participation of and 

alignment with these facilities. Even when the ACO does not include post-acute facilities 

formally as part of its organization, ACO providers/suppliers furnish other services that have the 

potential to affect PAC outcomes. Thus, this measure would emphasize the importance of 

coordinating the care of beneficiaries across these sites of care. Additionally, because this 

measure would be calculated from claims, there would not be a burden on ACOs to collect this 

information. 

Comment: A number of commenters supported including the measure and/or the concept 

to align the incentives of ACOs and SNFs to lower their readmission rates. Some provided 

suggestions to further refine the measure, such as to use a risk-adjusted measure of potentially 

avoidable readmissions for SNFs. Although MedPAC recommended that CMS consider a risk-
CMS-1612-FC 861

adjusted, potentially avoidable readmission measure for SNFs, they did support the addition of a 

SNF readmission measure because of the importance of post-acute care management and care 

transitions between settings in improving beneficiary care. Another commenter supported the 

measure but encouraged delay until such time as Medicare readmission policy links a portion of 

SNF payments to their readmission rates so that SNFs would bear risk/penalty equal to that of 

other providers in order to incent readmissions reduction. Some commenters believe that it is 

unnecessary and duplicative to add this quality measure since it is an inherent part of the Shared 

Savings Program that an ACO will be penalized through a reduction in shared savings if it has a 

high rate of readmissions. They also argue that ACOs that use SNFs for higher-acuity patients 

could see an increase in SNF readmission rates and thus be inappropriately penalized. A 

commenter suggested ACO scores will be inappropriately affected when beneficiaries return to 

an ACO participant hospital after being discharged to a SNF that is not participating in the ACO. 

In such cases, an ACO may be unable to achieve the same level of collaboration needed to affect 

change as compared to ACOs that include one or more SNFs as ACO participants or ACO 

providers/suppliers. Concern was also expressed regarding the ability of ACOs to consistently 

monitor psychiatric hospital discharges since federal laws limit the use and disclosure of 

documentation regarding drug and substance abuse as well as mental health therapies. These 

commenters recommend removing psychiatric hospital admissions from this measure since 

ACOs currently do not receive mental health claims data and should not be held accountable for 

measures for which they are not able to collect and monitor data over the performance period. 

Operational concerns were also raised including data lags and that ACOs can only derive raw 

admissions/readmission rates from the monthly claims files and the commenters believe these 

rates are not useful for improving performance against benchmarks unless CMS provides the 
CMS-1612-FC 862

algorithm to apply the appropriate risk adjustment. These commenters indicate that ACOs face 

significant challenges in monitoring performance when reliable risk-adjusted rates of admissions 

and readmissions are not provided on a regular basis. 

Response: We appreciate the numerous thoughtful comments. We disagree with 

commenters that this measure is unnecessary and duplicative because we continue to believe that 

including this measure would reinforce the importance of coordinating the care of beneficiaries 

across hospital and SNF sites of care. We have previously expressed our expectation that ACOs 

coordinate the care of beneficiaries across these sites regardless of whether there are any postacute care (PAC) providers participating in the ACO (§425.112(b)(4)). Even when the ACO 

does not include post-acute facilities formally as ACO participants or ACO providers/suppliers, 

ACO providers/suppliers furnish other services that have the potential to affect PAC outcomes. 

Thus, this measure would emphasize the importance of coordinating the care of beneficiaries 

across these sites of care. Additionally, because this measure is calculated from claims, there 

would not be a reporting burden on ACOs to collect this information. We appreciate the 

recommendations that we use a risk-adjusted, potentially avoidable SNF readmission measure, 

however, there is currently no such measure available for use. We note that the SNF 30-day allcause readmission measure does exclude planned readmissions using a similar methodology to 

ACO-8 Risk-Standardized, All Condition Readmission. Unplanned readmission rates do provide 

ACOs with useful information to better coordinate care and work toward reducing the risk of 

readmissions for all patients, including patients coming from a SNF. Further, contrary to the 

assertion of some commenters, we note that the HIPAA Privacy Rule generally provides the 

same protections for mental health information as it does for all protected health information 

(with the exception of psychotherapy notes). See the Department’s guidance on the HIPAA 
CMS-1612-FC 863

Privacy Rule and sharing information related to mental health, available at 

http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html. Thus, ACOs that 

request claims data under §425.704 for purposes of their own health care operations or the health 

care operations of their covered entity ACO participants and ACO providers/suppliers, in 

accordance with HIPAA requirements, already receive information about mental health therapies 

as part of those data sets. 

Final Decision: We are finalizing our proposal to add this 30-day all-cause SNF 

readmission measure. After the measure has been used in the program under pay for reporting 

for two reporting periods, the measure will be pay-for-reporting in the first two performance 

years of an ACO’s first agreement period and will transition to pay-for-performance in the final 

year of the ACO’s agreement period. We believe this measure will help fill a gap in the current 

Shared Savings Program measure set and will provide a focus on an area where ACOs are 

targeting care redesign. 

● All-Cause Unplanned Admissions for Patients with Diabetes Mellitus (DM), Heart 

Failure (HF) and Multiple Chronic Conditions. We proposed to add three new measures to the 

Care Coordination/Patient Safety domain. The three new measures are for: all-cause unplanned 

Admissions for Patients with Diabetes Mellitus (DM), all-cause unplanned Admissions for 

Patients with Heart Failure (HF) and all-cause unplanned Admissions for Patients with Multiple 

Chronic Conditions (MCC). These three measures are under development through a CMS 

contract with Yale New Haven Health Services Corporation/Center for Outcomes Research and 

Evaluation (CORE) to develop quality measures specifically for ACO patients with heart failure, 

diabetes, and multiple chronic conditions. We believe that these measures are important to 

promote and assess ACO quality as it relates to chronic condition inpatient admission because 
CMS-1612-FC 864

these chronic conditions are major causes for unplanned admissions and the addition of these 

measures will support the ACOs’ efforts to improve care coordination for these chronic 

conditions. These measures are claims-based, and therefore, we do not expect that they would 

impose any additional burden on ACOs. 

The following is a summary of the comments we received regarding our proposal to add 

these three new claims-based measures for All-Cause Unplanned Admissions for Patients with 

DM, HF and MCC. 

Comment: We received a wide variety of comments in response to the proposal to add 

these claims-based measures. Many commenters supported the use of claims-based outcome 

measures to reduce reporting burden for providers, however, concerns were raised regarding the 

lack of NQF endorsement. Some commenters supported adding one or more of these measures, 

agreeing that chronic condition inpatient admissions are major causes for unplanned admissions 

and that the addition of one or more of these measures would support the ACOs’ efforts to 

improve care coordination. For example, a few commenters supported the addition of a measure 

for All Cause Unplanned Admission for Patients with Multiple Chronic Conditions as all efforts 

to manage chronic disease may help lead to better patient outcomes and control cost. Another 

commenter supported the measures but preferred collapsing them into one measure of potentially 

avoidable hospitalizations, because of concern that the proposed condition-specific measures will 

be statistically unreliable and subject to random variation that will limit their usefulness in 

distinguishing ACOs’ actual performance. In addition, some commenters urged CMS to ensure 

the measures are adjusted for planned readmissions, unrelated readmissions and sociodemographic status. Other commenters supported applying these measures in the Shared 

Savings Program as pay for reporting only at this time since these measures are still under 
CMS-1612-FC 865

development, accepted target rates are not available and the measures are not yet endorsed by 

NQF. Commenters requested additional definition of what “other multiple chronic conditions” 

would be measured. MedPAC supported an increase of outcome measures. Finally, some 

commenters believe it is not possible to comment on measures that are still under development, 

and questioned the added benefit of including these measures since ACOs have an inherent 

incentive to avoid or reduce unplanned hospital admissions. 

Response: We continue to believe that these measures are important to promote and 

assess ACO quality because these chronic conditions are major causes for unplanned admissions 

and the addition of these measures will support the ACOs’ efforts to improve care coordination 

for beneficiaries with these chronic conditions. These measures are claims-based, and therefore, 

we do not expect that they would impose any additional reporting burden on ACOs. Many 

concerns were raised regarding the lack of NQF endorsement, but CMS intends on submitting all 

three measures to NQF for review in the future. Draft measure specifications were made 

available to the public during the measure development comment period during the spring and 

summer of 2014. CMS will provide final measure specifications to the public when available 

(typically in the early part of the performance year). The MCC measure cohort definition aligns 

with the NQF MCC Measurement Framework, which defines patients with MCCs as people 

“having two or more concurrent chronic conditions that...act together to significantly increase 

the complexity of management, and affect functional roles and health outcomes, compromise life 

expectancy, or hinder self-management.”11 The MCC measure cohort of chronic conditions 

 

11 National Quality Forum (NQF). Multiple Chronic Conditions Measurement Framework. 2012; 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=71227
CMS-1612-FC 866

includes conditions such as, but not limited to, Acute Myocardial Infarction, Stroke, and Chronic 

Obstructive Pulmonary Disease. 

 Final Decision: After considering the comments received in response to our proposal to 

add these three measures, we will add the All-Cause Unplanned Admissions for Patients with 

MCC, HF, and DM measures as pay-for-reporting for two performance years. After this time, 

the measure will be pay-for-reporting for the first two performance years for new ACOs in their 

first agreement period before transitioning to pay for performance in performance year three. 

We believe that it is important to include these measures in the Shared Savings Program measure 

set since they were specifically developed for ACO populations and move the quality 

performance standard under the Shared Savings Program toward more outcome-based measures. 

DM, HF, and MCCs affect a large volume of Medicare beneficiaries and can result in high costs 

due to poorly coordinated care. As a result, these chronic conditions are a focus of many ACO 

care redesign activities. Finally, these measures are claims-based and therefore do not impose an 

additional burden on ACOs for data reporting. 

d. Measure submitted through the EHR incentive program: 

● Percent of PCPs who Successfully Meet Meaningful Use Requirements. 

Because downward adjustments to Medicare payments will begin in 2015 under the EHR 

Incentive Program, we proposed to modify the name and specifications for ACO #11 Percent of 

PCPs who Successfully Qualify for an EHR Incentive Program Payment so that it more 

accurately depicts successful use and adoption of EHR technology in the coming years. We note 

this measure would continue to be doubly weighted. 

Comment: We received a range of comments regarding this proposal. Some agreed that 

it is necessary to rename the measure given that the EHR Incentive Program begins its transition 
CMS-1612-FC 867

to a payment adjustment effective in 2015. Some of the commenters, while agreeing with the 

proposed change, also provided additional specification suggestions such as to exclude certain 

physicians, such as hospitalists, from the denominator of this measure, stating that hospitalists 

are not PCPs when providing observation services. Another commenter requested that CMS 

clarify “the interaction of the Medicaid Meaningful Use program and the MSSP” and “the impact 

to non-PCP EPs”. Another commenter requested that CMS make the list of EPs available to 

ACOs intermittently throughout the performance year to aid ACOs in ensuring that all EPs attest 

in a timely manner. A commenter questioned why this measure in its current form is limited 

only to PCPs, as opposed to all EPs that are ACO providers/suppliers. Others were concerned 

that there appeared to be no opportunity to exclude physicians such as those who retired, died, 

moved out the country, from the denominator of this measure. Finally, there were a number of 

commenters that suggested the measure should be dropped and not renamed, since it is a process 

measure and the commenters believe that this measure has no direct relationship to the quality of 

patient care. 

Response: We continue to believe, as do a number of commenters, that this is an 

important measure that should be retained and renamed given that downward adjustments to 

Medicare payments will begin in 2015 under the EHR Incentive Program. We appreciate the 

suggestions from commenters that agree with the proposed change and provided additional 

specification suggestions. We are not persuaded by commenters that suggest this measure 

should be removed from the quality performance standard for the Shared Savings Program. On 

the contrary, we believe the measure directly supports the adoption and meaningful use of 

certified EHR technology, which is an important tool to support change in the health care 

delivery system including the steps being taken by ACOs to improve the quality and efficiency 
CMS-1612-FC 868

of care. The measure specifications will continue to align with the EHR Incentive Program 

definitions of hospital-based providers and will exclude observation services, accordingly. The 

measure specifications include Medicare and Medicaid eligible PCPs. Practitioners other than 

PCPs are not included in the measure at this time in efforts to focus on the meaningful use of 

certified EHRs in the provision of primary care services. This measure aligns with other HHS 

initiatives that support the adoption and meaningful use of certified EHR technology. For 

example, the HHS Office of the National Coordinator for Health Information Technology and 

CMS are managing $27 billion in funding from the American Recovery and Reinvestment Act of 

2009 and other sources to promote the adoption of electronic health records (EHR) in hospitals 

and doctor’s offices12. More than 75 percent of eligible health care professionals, and over 90 

percent of eligible hospitals, have already qualified for EHR incentive payments for using 

certified EHR technology. Retaining this measure in the quality performance standard for the 

Shared Savings Program will help provide an additional and appropriate incentive to reinforce 

the adoption and meaningful use of certified EHR technology. Finally, performance on this 

measure is determined using EHR Incentive Program data and due to the EHR Incentive 

Program timelines and data collection, CMS will not be able to provide lists of EPs to ACOs 

throughout the performance year. 

Final Decision: After consideration of the comments received, we are finalizing the 

proposal to modify the name and specifications of ACO-11 to the Percent of PCPs who 

successfully meet MU requirements. 

e. Measures submitted through the CMS web interface 

 

12 http://www.hhs.gov/news/press/2014pres/09/20140916a.html 
CMS-1612-FC 869

To align with PQRS, we proposed to add several measures submitted through the CMS 

web interface that we believed were appropriate for the ACO quality performance standard. The 

measures we proposed to add were: 

● Depression Remission at Twelve Months (NQF #0710). 

● Diabetes Measures for Foot Exam and Eye Exam (NQF #0056 and #0055). 

● Coronary Artery Disease (CAD): Symptom Management. 

● Coronary Artery Disease (CAD): Beta Blocker Therapy—Prior Myocardial Infarction 

(MI) or Left Ventricular Systolic Dysfunction (LVEF<40%) (NQF #0070). 

● Coronary Artery Disease (CAD): Antiplatelet Therapy (NQF #0067). 

● Documentation of Current Medications in the Medical Record (NQF #0419). 

Additionally, we identified a number of the existing measures submitted through the 

CMS web interface that have not kept up with clinical best practice, are redundant with other 

measures that make up the quality performance standard, or that could be replaced by similar 

measures that are more appropriate for ACO quality reporting. For the reasons specified in the 

proposed rule, we proposed to no longer collect data on the following measures, and these 

measures would no longer be used for establishing the quality performance standards that ACOs 

must meet to be eligible to share in savings: 

● ACO #12, Medication Reconciliation after Discharge from an Inpatient Facility. 

● ACO #22, Diabetes Composite measure: Hemoglobin A1c control (<8 percent). 

● ACO #23, Diabetes Composite: Low Density Lipoprotein (<100) (NQF #0729). 

● ACO #24, Diabetes Composite: Blood Pressure (<140/90) (NQF #0729). 

● ACO #25, Diabetes Composite: Tobacco Non-use (NQF #0729). 
CMS-1612-FC 870

● ACO #29, Ischemic Vascular Disease: Complete Lipid Profile and LDL Control (<100 

mg/dl) (NQF #0075). 

● ACO #30, Ischemic Vascular Disease: Use of Aspirin or another Antithrombotic (NQF 

#0068). 

● ACO #32, Coronary Artery Disease (CAD) Composite: Drug Therapy for Lowering 

LDL Cholesterol (NQF #74). 

Finally, given these proposed changes, we also proposed updates and revisions to the 

Diabetes and CAD Composite measures. We proposed that the Diabetes Composite include the 

following measures: 

● ACO #26: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for 

Patients with Diabetes Mellitus and Ischemic Vascular Disease. 

● ACO #27: Diabetes: Hemoglobin A1c Poor Control. 

● ACO #41: Diabetes: Foot Exam. 

● ACO #42: Diabetes: Eye Exam. 

We further proposed that the CAD Composite include the following measures: 

● ACO #33: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor 

Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%). 

● ACO #43: Antiplatelet Therapy. 

● ACO #44: Symptom Management. 

● ACO #45: Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left 

Ventricular Systolic Dysfunction (LVEF<40%). 

We solicited comment on these composite measures and whether there are any concerns 

regarding the calculation of a composite score. Given the general concerns around composite 
CMS-1612-FC 871

measures and their use, we also solicited comment on how we combine and incorporate 

component measure scoring for the composite. 

Comment: Most commenters supported the proposed removal and replacement of 

measures that may not align with current clinical guidelines or that appear to overlap with other 

measures currently in the measure set. At least one commenter specifically opposed removal of 

ACO #30, Ischemic Vascular Disease: Use of Aspirin or another Antithrombotic (NQF #0068) 

and the LDL measures, stating that there is disagreement on guidelines among professional 

organizations. Others expressed concern about the number of proposed changes that will require 

ACOs, in turn, to make changes to their internal processes and their EHRs to facilitate data 

collection. Some commenters raised general clinical or other methodological concerns about 

individual proposed measures submitted through the CMS web interface. Our detailed responses 

to those comments can be found in Table 79 of section III.K. of this final rule with comment 

period. 

We do, however, wish to note some specific comments relevant to our final policy 

decisions with respect to the quality performance measures used in the Shared Savings Program: 

(1) Commenters noted that the Patient Health Questionnaire 9 (PHQ-9) is specified for use in the 

Depression Remission measure (proposed ACO # 40), and that this tool is only one of several 

options available to practitioners. These commenters suggested not adding this measure until 

ACOs have had the opportunity to uniformly phase in the use of the PHQ-9 in order to meet the 

measure specification requirements. Additionally, commenters suggested that their ability to 

perform well on this measure may be limited if they cannot access the PHQ-9 score data from 

mental health care providers. (2) Many commenters did not support the proposed addition of the 

CAD: Symptom Management measure (proposed ACO # 44), stating they believe the measure 
CMS-1612-FC 872

lack primary care focus and that there are potential challenges in data collection. CMS also 

received a comment supporting the proposed addition of the CAD: Antiplatelet Therapy measure 

(proposed ACO # 43), however, this commenter recommended that if added, the measure only 

be used for pay-for-reporting. (3) Some commenters did not support the retirement of the 4 

Diabetes Composite measures and 1 CAD Composite measure proposed to be removed due to 

the resources already invested in reporting these 5 measures. (4) CMS received comments 

suggesting that the quality performance standard under the Shared Savings Program should focus 

on broader categories of measures (such as preventive health measures) that are generalizable 

across providers and care settings, rather than measures that target specific providers or care 

settings. 

Response: We continue to believe that the quality performance measures used in the 

Shared Savings Program should reflect current clinical guidelines. We appreciate the 

commenters’ agreement with our proposed changes to remove and replace measures that are not 

in adherence with current clinical guidelines. In response to comments, included in Table 79 in 

section III.K , we will retain ACO #30, Ischemic Vascular Disease: Use of Aspirin or another 

Antithrombotic (NQF #0068). We note that we erroneously made the assertion that this measure 

conflicts with current clinical guidelines. Therefore, due to the clinical importance of the 

measure, the measurement gap it addresses, and its alignment with the Million Hearts Campaign 

and PQRS, we will retain this measure. 

Given the concerns raised by commenters, included in Table 80 of section III.K, 

regarding our proposal to use PHQ-9 for the Depression Remission measure, we will not finalize 

our proposal that the measure would be phased-in to pay-for-performance during the second and 

third performance years of an ACO’s first agreement period. We will, however, finalize our 
CMS-1612-FC 873

proposal to use the measure to assess ACO quality, but only as pay-for-reporting for all three 

performance years of an ACO’s first agreement period. We believe this approach will provide 

flexibility for ACOs to continue to use tools other than the PHQ-9, while providing the 

opportunity for ACOs to begin adopting this tool without harming their ability to achieve full 

points on the measure. Additionally, as noted above, the HIPAA Privacy Rule generally 

provides the same protections for mental health information as it does for all protected health 

information (with the exception of psychotherapy notes). We therefore do not believe there 

would be any unusual impediments to accessing the information required for reporting of this 

particular measure. 

After consideration of the comments received and in order to align with the final 

measures that will be used in the PQRS program, we will not finalize the CAD: Symptom 

Management (proposed ACO – 44) and CAD: Antiplatelet Therapy (proposed ACO – 43) 

measures for the Shared Savings Program. See section III.K, Table 79, for comment discussion 

and response. 

We believe it is important to make changes in the measures used to assess ACO quality to 

address the statutory mandate in section 1899(b)(3)(A) of the Act which requires the Secretary to 

determine appropriate measures to assess the quality of care furnished by the ACO, reflect 

current clinical practice, promote high quality care, and alignment with PQRS and National 

Quality Strategy. We therefore disagree with commenters that internal operational challenges 

that arise from changes in the measure set outweigh the benefit of such changes. 

After considering the comments received regarding the proposed new measures, we are 

finalizing our proposal to add the following new measures that will be submitted by the ACO 

through the CMS web interface: 
CMS-1612-FC 874

• Documentation of Current Medications in the Medical Record (NQF #0419). 

• Depression Remission at Twelve Months (NQF #0710). 

• Diabetes Measures for Eye Exam (NQF #0055). 

 For the reasons stated in section III.K., we decline to finalize our proposals to add the 

following measures: 

• Diabetes: Foot Exam (NQF #0056) 

• CAD: Antiplatelet Therapy (NQF #0067) 

• CAD: Symptom Management 

• CAD: Beta-Blocker Therapy – Prior Myocardial Infarction or Left Ventricular Systolic 

Dysfunction (LVSD) (NQF #0070) 

 We are not finalizing our proposal to add the CAD: Antiplatelet Therapy (NQF #0067) 

measure and instead will keep the measure it was designed to replace, ACO #30, Ischemic 

Vascular Disease: Use of Aspirin or another Antithrombotic (NQF #0068) because we have 

determined that it does not conflict with clinical guidelines, remains clinically important, 

addresses a measurement gap, and aligns with the Million Hearts Campaign and PQRS. We 

believe that retention of this measure in lieu of the proposed Antiplatelet Therapy measure will 

additionally reduce burden on ACOs that would otherwise need to revise their data collection 

processes to accommodate this change. 

 Additionally, we are finalizing our proposal to remove certain measures from the ACO 

quality performance standard including the following: 

● ACO #12, Medication Reconciliation after Discharge from an Inpatient Facility 

● ACO #22, Diabetes Composite measure: Hemoglobin A1c control (<8 percent). 

● ACO #23, Diabetes Composite: Low Density Lipoprotein (<100) (NQF #0729). 
CMS-1612-FC 875

● ACO #24, Diabetes Composite: Blood Pressure (<140/90) (NQF #0729). 

● ACO #25, Diabetes Composite: Tobacco Non-use (NQF #0729). 

● ACO #29, Ischemic Vascular Disease: Complete Lipid Profile and LDL Control (<100 

mg/dl) (NQF #0075). 

● ACO #32, Coronary Artery Disease (CAD) Composite: Drug Therapy for Lowering 

LDL Cholesterol (NQF #74). 

Finally, given these changes, we are revising the Diabetes Composite to include the 

following measures: 

● ACO #27: Diabetes: Hemoglobin A1c Poor Control (NQF #0059). 

● ACO #42: Diabetes: Eye Exam (NQF #0055). 

 Although not previously proposed, in order to align with PQRS and in response to 

commenter concerns about using this measure outside the composite, we are removing ACO 

#26, Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes 

Mellitus and Ischemic Vascular Disease. While we believe the measure may be valid apart from 

the composite, we are swayed by the concerns raised by commenters as discussed in Table 79 in 

section III.K. We believe removing ACO-26 is consistent with our proposals to align with the 

PQRS program and remove redundancy of measures within the Shared Savings Program 

measure set. In addition, we believe removing this measure will reduce reporting burden for 

ACOs and may also help to improve performance on the diabetes composite. We also note that 

the removal of this measure would additionally alleviate some redundancy with ACO #30 

Ischemic Vascular Disease: Use of Aspirin or another Antithrombotic (NQF #0068) which we 

are retaining for the reasons discussed above. 

 The CAD Composite will be removed since there is only one CAD measure remaining. 
CMS-1612-FC 876

We believe that the final measure set as adopted in this final rule is appropriate for 

purposes of the ACO quality performance standard and in order to align with changes being 

made to the PQRS for the reasons specified above and in Tables 79 and 80 in section III.K. 

Additionally, we believe that our final decision to remove certain measures will improve 

alignment with best practices and reduce reporting burden for ACOs. 

f. Summary of Changes to the ACO Quality Measures 

We are finalizing the ACO quality performance measures as follows. In total, we will 

use 33 measures to establish the quality performance standards that ACOs must meet to be 

eligible for shared savings. Although the number of measures in the measure set remains at 33, 

we are reducing the number of measures reported through the CMS web interface by 5 to reduce 

burden. In addition, as discussed in section III.K., we are also reducing the number of patients 

ACOs are required to report on for each measure. This change will also reduce the burden of 

quality reporting for ACOs. The new measures will be pay for reporting for the first two 

performance years for all ACOs. After this initial period, the measures will be phased in to payfor-performance over the course of an ACO’s first agreement period with the exception of 

Depression Remission at 12 Months which will stay at pay-for-reporting for all three 

performance years. 

Specifically, we are finalizing the following changes to the Shared Savings Program 

quality measure set (see Table 81 for a list of the final measures and for further details of phase 

in to pay-for-performance during the agreement period): 

● Add the CAHPS: Stewardship of Patient Resources measure as pay-for-reporting in the 

first performance year of an ACO’s first agreement period and pay-for-performance in the 

second and third performance years. 
CMS-1612-FC 877

● Add SNF 30-Day All-Cause Readmission measure and All-Cause Unplanned 

Admissions measures for Patients with Multiple Clinical Conditions, Heart Failure, and Diabetes 

as pay-for-reporting for the first two years of an ACO’s first agreement period before 

transitioning to pay for performance in performance year three. 

● Add Depression Remission at 12 Months (NQF #0710) measure as pay-for-reporting 

for all three performance years of an ACO’s first agreement period. 

● Replace ACO-12 Medication Reconciliation (NQF #0097) with “Documentation of 

Current Medications in the Medical Record” (NQF #0419). 

● Add Diabetes: Eye Exam (NQF #0055) 

● Modify name and specifications of ACO-11 from Percent of PCPS who successfully 

Qualify for an EHR Incentive Program Payment to the Percent of PCPs who Successfully Meet 

MU Requirements. 

In addition, we are finalizing the retirement of 6 of the 7 measures we proposed to delete 

because they do not align with updated clinical guidelines or are similar to existing measures 

(ACO-22, 23, 24, 25, 29, and 32). We are not finalizing our proposal to remove ACO-30 

Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic and are removing ACO26 Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes 

Mellitus and Ischemic Vascular Disease due to comments received and for the reasons discussed 

above and in section III.K, Table 79. 

 We are also not finalizing the following proposed measures, but instead will continue to 

consider them for the future given the measurement gaps and high-cost, high-volume conditions 

these measures address for the quality performance standard as discussed in Table 79 in section 

III.K: 
CMS-1612-FC 878

• Diabetes: Foot Exam (NQF #0056) 

• CAD: Antiplatelet therapy (NQF #0067) 

• CAD: Symptom management 

• CAD: Beta-blocker therapy – prior Myocardial Infarction (MI) or LVSD (NQF #0070) 

As a result, we will no longer have a CAD composite in the measure set and will only have 1 

CAD measure in the Clinical Care in the At-Risk Population domain (ACO# 33: AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – 

Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%)). 

An overview of the changes we are finalizing is provided in Table 81, which lists the 

measures that will be used to assess ACO quality under the Shared Savings Program starting 

with the 2015 performance year. 
CMS-1612-FC 879

TABLE 81: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet f

Domain ACO Measure # Measure Title New Measure NQF #/Measure Steward Method of Data Submission 

Pa

PY

AIM: Better Care for Individuals 

Patient/Caregiver 

Experience 

ACO - 1 CAHPS: Getting Timely Care, Appointments, and Information NQF #0005, AHRQ Survey R 

ACO - 2 CAHPS: How Well Your Doctors Communicate NQF #0005 AHRQ Survey R ACO - 3 CAHPS: Patients' Rating of Doctor NQF #0005 AHRQ Survey R ACO - 4 CAHPS: Access to Specialists NQF #N/A CMS/AHRQ Survey R ACO - 5 CAHPS: Health Promotion and Education NQF #N/A CMS/AHRQ Survey R 

ACO – 6 CAHPS: Shared Decision Making NQF #N/A CMS/AHRQ Survey R ACO – 7 CAHPS: Health Status/Functional Status NQF #N/A CMS/AHRQ Survey R 

ACO - 34 CAHPS: Stewardship of Patient Resources X NQF #N/A CMS/AHRQ Survey R 

Care Coordination/ 

Safety 

ACO - 8 

Risk-Standardized, All Condition Readmission Adapted NQF 

#1789 CMS 

Claims R 

ACO - 35 

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) X 

NQF #TBD CMS Claims R 

ACO - 36 All-Cause Unplanned Admissions for Patients with Diabetes X NQF#TBD CMS Claims R 

ACO -37 All-Cause Unplanned Admissions for Patients with Heart Failure X NQF#TBD CMS Claims R ACO -38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions X NQF#TBD CMS Claims R 

ACO - 9 

Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) 

Adapted NQF #0275 AHRQ Claims R 

ACO - 10 

Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) 

Adapted NQF #0277 AHRQ 

Claims R 

ACO - 11 

Percent of PCPs who Successfully Meet Meaningful Use Requirements 

NQF #N/A CMS 

EHR Incentive 

Program 

Reporting 

R 
CMS-1612-FC 880

Domain ACO Measure # Measure Title New Measure NQF #/Measure Steward Method of Data Submission 

Pa

PY

ACO -39 Documentation of Current Medications in the Medical Record X NQF #0419 CMS CMS Web Interface R 

ACO - 13 Falls: Screening for Future Fall Risk NQF #0101 NCQA CMS Web Interface R 

AIM: Better Health for Populations 

Preventive Health 

ACO - 14 Preventive Care and Screening: Influenza Immunization NQF #0041 AMA-PCPI CMS Web Interface R 

ACO – 15 Pneumonia Vaccination Status for Older Adults NQF #0043 NCQA CMS Web Interface R ACO – 16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up NQF #0421 CMS CMS Web Interface R ACO – 17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention NQF #0028 AMA-PCPI CMS Web Interface R ACO – 18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan NQF #0418 CMS CMS Web Interface R ACO – 19 Colorectal Cancer Screening NQF #0034 NCQA CMS Web Interface R ACO – 20 Breast Cancer Screening NQF #NA NCQA CMS Web Interface R 

ACO - 21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented CMS CMS Web Interface R 

Clinical Care for At Risk 

Population - Depression ACO – 40 Depression Remission at Twelve Months X NQF #0710 MNCM CMS Web Interface R 

Clinical Care for At Risk 

Population - Diabetes 

Diabetes Composite (All or Nothing Scoring): 

ACO - 27: Diabetes Mellitus: Hemoglobin A1c Poor Control ACO - 41: Diabetes: Eye Exam 

CMS Composite 

ACO -27 

NQF #0059 NCQA (individual component) 

CMS Web 

Interface R 

ACO - 41 X 

NQF #0055 NCQA (individual component) 

CMS Web 

Interface R 

Clinical Care for At Risk 

Population - 

Hypertension 

ACO - 28 

Hypertension (HTN): Controlling High Blood Pressure 

NQF #0018 NCQA 

CMS Web 

Interface R 

Clinical Care for At Risk 

Population - Ischemic 

Vascular Disease 

ACO-30 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 

NQF #0068 NCQA 

CMS Web 

Interface R 

Clinical Care for At Risk 

Population - 

Heart Failure 

ACO - 31 

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 

NQF #0083 AMA-PCPI 

CMS Web 

Interface R 
CMS-1612-FC 881

Domain ACO Measure # Measure Title New Measure NQF #/Measure Steward Method of Data Submission 

Pa

PY

Clinical Care for At Risk 

Population – Coronary 

Artery Disease 

ACO - 33 

Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 

NQF # 0066 ACC 

CMS Web 

Interface 

R 
CMS-1612-FC 882

The current quality scoring methodology is explained in the regulations at §425.502 and 

in the preamble to the November 2011 final rule (76 FR 67895 through 67900). As a result of 

the additions, deletions, and revisions to the quality measure set being made in this final rule, 

each of the four domains will include the following number of quality measures (See Table 82 

for details.): 

• Patient/Caregiver Experience of Care – 8 measures 

• Care Coordination/Patient Safety – 10 measures 

• Preventive Health – 8 measures 

• At Risk Population – 6 measures (including 5 individual measures and a 2-

component diabetes composite measure) 

Table 82 provides a summary of the number of measures by domain and the total points 

and domain weights that will be used for scoring purposes under these changes. Otherwise, the 

current methodology for calculating an ACO’s overall quality performance score will continue to 

apply. Table 83 provides the measures that are retired/replaced. 

TABLE 82: Number of Measures and Total Points for Each Domain within the Quality 

Performance Standard 

 Domain Number of 

Individual Measures

Total Measures for 

Scoring Purposes

Total Possible Points Domain Weight

Patient/Caregiver 

Experience 

8 8 individual survey 

module measures 

16 25% 

Care Coordination/ 

Patient Safety 

10 10 measures. Note 

that the EHR measure 

is double-weighted (4 

points) 

22 25% 

Preventive Health 8 8 measures 16 25% 

At-Risk Population 7 5 individual 

measures, plus a 2-

component diabetes 

composite measure, 

scored as one. 

12 25% 

Total in all Domains 33 32 66 100% 

 
CMS-1612-FC 883

TABLE 83: Shared Savings Program Measures Retired/Replaced 

Notes Domain Measure Title NQF 

Measure #/ 

Measure 

Steward 

Method of 

Data 

Submission 

Pay for Performance Phase In 

R = Reporting P=Performance 

Performance Performance 

Performance 

 Year 1 Year 2 Year 3 

ACO 

#12 

Replaced 

Care 

Coordination/ 

Patient Safety 

Medication 

Reconciliation: 

Reconciliation After 

Discharge from an 

Inpatient Facility 

NQF #97

AMAPCPI/NCQA 

GPRO Web 

Interface 

R P P 

ACO 

#22 

Retired 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Hemoglobin A1c Control 

(<8 percent) 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P 

ACO 

#23 

Retired 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Low Density Lipoprotein 

(<100) 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P 

ACO 

#24 

Retired -

Redunda

nt 

Measure 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Blood Pressure <140/90 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P

ACO 

#25 

Retired - 

Redunda

nt 

measure 

At Risk 

Population - 

Diabetes 

Diabetes Composite (All 

or Nothing Scoring): 

Tobacco Non Use 

NQF #0729 

MN 

Community 

Measurement 

GPRO Web 

Interface 

R P P

ACO # 

26 

Retired - 

redundan

t 

measure 

At Risk 

Population – 

Diabetes 

 Diabetes Composite: 

Daily Aspirin or 

Antiplatelet Medication 

Use for Patients with 

Diabetes Mellitus and 

Ischemic Vascular 

Disease

 GPRO Web 

Interface 

R P P

ACO 

#29 

Retired 

At Risk 

Population – 

Ischemic 

Vascular 

Disease 

Ischemic Vascular 

Disease (IVD): Complete 

Lipid Profile and LDL 

Control <100 mg/dl 

NQF #75 

NCQA 

GPRO Web 

Interface 

R P P

ACO 

#32 

Retired 

At Risk 

Population – 

Coronary 

Artery 

Disease 

Coronary Artery Disease 

(CAD) Composite: All or 

Nothing Scoring:

Drug Therapy for 

Lowering LDLCholesterol 

NQF #74 

CMS 

(composite) / 

AMA-PCPI 

(individual 

component) 

GPRO Web 

Interface 

R R P

We believe that these modifications to the quality measure set for the Shared Savings 

Program will further enhance the quality of care patients receive from ACO participants and 
CMS-1612-FC 884

ACO providers/suppliers, better reflect clinical practice guidelines, streamline measures 

reporting, and enhance alignment with PQRS and the EHR Incentive Program. 

g. Effective date and phase in of quality measures. 

Proposal: We proposed that these measures changes would become effective beginning 

with the 2015 reporting period, and the 2015 performance year (PY). We also proposed that all 

quality measures would be phased in for ACOs with 2015 start dates according to the phase-in 

schedule in Table 81. We proposed that ACOs with start dates before 2015 would be responsible 

only for complete and accurate reporting of the new measures for the 2015 performance year and 

then responsible for either reporting or performance on measures according to the phase in 

schedule. 

Comment: Most commenters did not separately provide comments on this specific 

proposal regarding the effective date for measure changes but addressed the general issue as part 

of their comments on individual measures or related issues, especially with respect to the 

effective date for benchmarking purposes. However, a number of commenters disagreed with 

the proposal to move certain new measures to pay for performance after only one year of pay for 

reporting. They suggested that an additional year of pay for reporting would be needed in order 

to adequately and fairly set benchmarks for pay for performance, especially for measures that 

have not been previously tested in any large scale health system and may be newly or not yet 

accredited by the National Quality Forum (NQF). 

Response: We are finalizing our proposal that quality measures will become effective for 

the Shared Savings Program quality performance standard beginning in 2015 and the phase-in 

schedule indicated in Table 81. Additionally, we are convinced by commenters that believe that 

an additional year of pay for reporting is needed by CMS and ACOs to fully implement new 

measures. Therefore, each new measure will be pay-for-reporting for its first two reporting 
CMS-1612-FC 885

periods in use. This additional time will help to ensure that ACOs have adequate time to phase 

in their own care processes and infrastructure before they are held accountable for performance 

and that CMS has adequate data to set benchmarks for new measures before they transition to 

pay for performance according to the phase-in schedule in Table 81. In other words, the phase-in 

schedule indicated in Table 81 applies to a measure after it has been pay-for-reporting for the 

first two reporting periods it is in use. In this case, the new measures we are finalizing will be 

pay-for-reporting for the 2015 and 2016 reporting periods, which will take precedence over the 

phase-in schedule for ACOs that are currently participating in the Shared Savings Program. 

Using new measures as pay-for-reporting for the first two reporting periods they are in use will 

provide adequate time and data necessary to set the benchmarks for the 2017 reporting period 

when the measures will transition to pay for performance under the phase in schedule indicated 

in Table 81. 

For example, assume a new measure is scheduled to phase in with reporting in PY1, 

reporting in PY2, and performance in PY3. Further assume that an ACO with a 2014 start date 

will be in its second performance year (PY2) when the measure becomes effective. In this 

example, according to the performance year phase-in schedule, the ACO would be responsible 

for complete and accurate reporting of the new measure in PY2 and for performance on the 

measure in PY3. However, because the measure is new and will be pay-for-reporting for the 

2015 and 2016 reporting periods, this overrides the phase-in schedule because we would not 

have benchmark information for this ACO’s PY3. In this example, if the ACO renews its 

participation agreement for a new agreement period then the ACO would be responsible for 

performance on the measure in PY1 of its new agreement period, because the measure was 

scheduled to be pay-for-performance in PY3 of the previous agreement period. If we change the 

assumptions in the example to an ACO with a start date of 2015, under the phase-in schedule the 
CMS-1612-FC 886

ACO would be responsible for performance in PY3 which corresponds with the 2017 reporting 

period, the first year in which the measure is available to be used for pay-for-performance. In 

other words, each new measure is pay-for-reporting until it is possible to use it as pay-forperformance, and whether the ACO is subject to pay-for-performance at that time is determined 

by the phase-in schedule in Table 81. 

We are also revising §425.502(a)(4) to provide that the quality performance standard for 

a newly introduced measure is set at the level of complete and accurate reporting for the first two 

reporting periods for which reporting of the measure is required. For subsequent reporting 

periods, the quality performance standard for the measure will be assessed according to the 

phase-in schedule for the measure. 

h. Aligning with PQRS sampling methodology 

Proposal: As noted in the November 2011 Shared Savings Program final rule 

(76 FR 67900), the Shared Savings Program uses the same sampling method used by PQRS 

GPRO. Specifically, the sample for the ACO GPRO must consist of at least 411 assigned 

beneficiaries per measure set/domain. If the pool of eligible, assigned beneficiaries is less than 

411, the ACO must report on 100 percent, or all, of the assigned beneficiaries sampled. In the 

proposed rule, we stated that to the extent that PQRS modifies and finalizes changes in the 

reporting requirements for group practices reporting via the GPRO web interface, we proposed to 

make similar modifications to ACO reporting through the GPRO web interface. Specifically, as 

discussed in section III.K. of this final rule with comment period, we proposed to reduce the 

GPRO web interface minimum reporting requirements for PQRS reporting from 411 to 248 

consecutively ranked and assigned patients for each measure or 100 percent of the sample for 

each measure if there are less than 248 patients in a given sample. We proposed that the reduced 

sample for each measure for reporting through the GPRO web interface would also apply to 
CMS-1612-FC 887

ACOs. We stated that we believe that a reduction in the number of sampled beneficiaries would 

reduce reporting burden for ACOs while maintaining high statistical validity and reliability in 

results. 

Comment: We received relatively few comments on this proposal, but most of those that 

commented supported the proposal. A majority of commenters also supported the PQRS 

proposal to reduce the reported sample size for groups of 100 or more EPs, and agreed that this 

smaller sample size would reduce reporting burden (please refer to section III.K.). However, a 

few commenters were concerned that a sample size of 248 may not adequately or accurately 

represent the diversity of an ACO’s providers and suppliers, especially for larger ACOs. These 

ACOs can include mixed models of employed and independent-affiliated provider practices. 

Therefore, these commenters support reducing the sample size requirement only for smaller 

ACOs, such as those ACOs with 5,000 to 10,000 assigned beneficiaries. Alternatively, these 

commenters request that ACOs be given the option to continue to report a larger sample size if 

they prefer. A commenter also asked that CMS publish results that support the statistical validity 

and reliability of the proposed reduction of the sample from 411 to 248. 

Response: Specific responses to comments on this proposal can be found in section 

III.K.4.a. of this final rule with comment period. We appreciate the comments from stakeholders 

that support the proposal to reduce the sample size and agree that this change will reduce 

reporting burden for ACOs. Moreover, commenters agreed that a reduction in the sample size to 

248 would continue to be statistically valid and reliable. As discussed in section III.K.4.a, our 

internal assessments performed for PQRS confirm this conclusion. Additionally, we clarify that 

the GPRO web interface tool will continue to contain an oversample of 616 patients at it has 

previously, however, the number required for reporting is being reduced from 411 to 248. 

Because we have concluded that a sample of 248 is statistically valid and reliable, we disagree 
CMS-1612-FC 888

that the reduced sample size will not adequately represent the diversity of the ACO’s providers 

and suppliers. Further, we do not have a mechanism that would allow us to deviate from the 

established methodology used by the GPRO web interface, and therefore cannot offer an option 

at this time for ACOs to choose to be assessed on more than 248 patients. As noted above, the 

tool oversamples up to 616 patients, and ACOs may choose, but are not required, to report on all 

616. We oversample to allow ACOs to include beneficiaries for quality reporting to replace 

beneficiaries ACOs are unable to report on, due to exclusions, so they can complete the 

minimum required number of patients. However, in accordance with the methodology 

previously adopted under PQRS, the ACO would only be assessed based on reporting for 248 

patients using the existing sampling methodology that otherwise has been previously established. 

In order to align with the policy being finalized for PQRS, we are reducing the required 

number of consecutively ranked patients reported for each measure module through the CMS 

web interface from 411 to 248. Because ACOs report using the same web interface tool used by 

PQRS, this reduction in the required sample size for reporting will reduce burden, while ensuring 

statistical validity and reliability is maintained. It also ensures consistency and equal treatment 

for all groups reporting through the GPRO web interface. 

3. Request for Comments for Future Quality Measures 

In the proposed rule (79 FR 40483), we indicated that in addition to the changes to the 

current set of measures for the Shared Savings Program discussed above, we were interested in 

public comment on additional measures that we may consider in future rulemaking. We 

particularly welcomed comments regarding the following issues: 

● Gaps in measures and additional specific measures: We solicited comments on 

specific measures or measure groups that may be considered in future rulemaking to fill in gaps 

that may exist for assessing ACO quality performance. 
CMS-1612-FC 889

● Caregiver experience of care: We solicited comment on additional specific caregiver 

experience of care measures that might be considered in future rulemaking. 

● Alignment with Value-Based Payment Modifier (VM) measures: We solicited 

comment on whether there are synergies that can be created by aligning the ACO quality 

measure set with the measures used under the VM. Although we did not propose any changes to 

align with the measures used under the VM, we did seek comment on whether the VM 

composites should be considered in the future as a replacement for the two ACO claims-based 

ambulatory sensitive conditions admissions (ASCA) measures. 

● Specific measures to assess care in the frail elderly population: We welcomed 

comments with suggestions of new measures of the quality of care furnished to the frail elderly 

population that we may consider adopting in future rulemaking. 

● Utilization: We welcomed comments on whether it is sufficient for utilization 

information to be included in the aggregate quarterly reports to ACOs or whether utilization 

measures should also be used to assess the ACO’s quality performance as an added incentive to 

provide more efficient care. If commenters were interested in having utilization measures 

included in the quality performance standard, we welcomed specific comments on what 

utilization measures would be most appropriate for future consideration and suggestions for how 

to risk adjust these measures. 

● Health outcomes: We welcomed suggestions as to whether and when it would be 

appropriate to include a self-reported health and functional status measure in the quality 

performance standard. We specifically welcomed comments on the appropriateness of using a 

tool such the Health Outcomes Survey for health plans which assesses changes in the physical 

and mental health of individual beneficiaries over time. We also welcomed suggestions for 

alternatives to self-reported measures that may be considered in the future. 
CMS-1612-FC 890

● Measures for retirement: We solicited input from commenters on any measures that 

should be considered for retirement in future rulemaking. We welcomed comments on whether 

to continue to require ‘topped out” measures be included as pay for reporting measures. In 

addition, we noted that we were proposing changes to the benchmarking methodology for topped 

out measures. 

● Additional public health measures: In the proposed rule, we noted that we may 

propose to include an additional preventive health measure in the quality measure set under the 

Shared Savings Program in future rulemaking. Specifically, we indicated that we were 

considering adding “Preventive Care and Screening: Unhealthy Alcohol Use: Screening and 

Brief Counseling” (NQF #2152). This measure would reflect screening of Medicare 

beneficiaries covered under the existing Medicare benefit referred to as the “Screening and 

Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse” benefit. We 

welcomed comments on the potential addition of this measure and noted that we would consider 

any comments received in developing any future proposal with respect to this measure. 

Comment: Commenters identified a wide variety of specific measure gap areas that we 

should address, such as COPD, care coordination, medication management and adherence, 

preventive care/adult immunizations, pain, malnutrition, wounds, bladder control, outcome 

measures and cost/efficiency/utilization related measures. Some commenters provided 

suggestions for specific measures that we should consider in future rulemaking while other 

commenters provided more general suggestions about the types of additional measures that we 

should consider. For example, some commenters suggested that quality measures should be 

primarily designed to protect beneficiaries from inappropriate reductions in services by ACOs. 

Other commenters noted that to improve care for beneficiaries, the measures should focus on 

areas where: (a) CMS believes Medicare beneficiaries are receiving poor care today; and (b) it is 
CMS-1612-FC 891

feasible for an ACO to make changes in care that would improve care in those areas using the 

limited resources available in the Shared Savings Program. Others opposed utilization measures, 

believing these types of measures are not necessary within the Shared Savings Program because 

of the inherent incentive for ACOs participating in the program to reduce unnecessary services 

and achieve savings. A commenter supported adding public health measures “...to help 

overcome the difficulties inherent in procedure-based measures that capture limited volumes of 

experience in rural settings.” This commenter provided additional suggestions, such as that we 

exercise caution in interpreting results from self-reported measures, because of a tendency of 

rural respondents to understate the true burden of chronic illness and travel. Another commenter 

emphasized that measure development should not entirely focus on outcomes measures because 

process measures can also improve outcomes. Some measures without clear clinical evidence 

(that is, lacking NQF endorsement) should be avoided. Furthermore, survey measures should be 

minimal (and not heavily weighted) due to subjectivity, cost of collection, and risk of inaccurate 

representation based on response rate. This commenter also recommended that the number of 

measures required to be reported should be realistic and CMS should move toward the use of 

composites and outcome measures. Refining the measurement strategy in this way over time 

will allow for ACOs to mature in function, which takes a few years, and CMS should structure 

measure selection and performance measurement to reflect growth from fledgling ACO to a 

mature ACO. CMS should set up data reporting to be automated as much as possible. Finally, a 

commenter suggested that complementing the measurement strategy should be a forum for 

communication among ACO participants to share best practices and lessons learned. Comments 

regarding “topped out” measures for retirement are included in the discussion below regarding 

the adjustment of the benchmarks for “topped out” measures. 

Response: We appreciate receiving the many thoughtful suggestions. We will consider 
CMS-1612-FC 892

these suggestions further as we develop any future proposals for additional measures for the 

Shared Savings Program, which we would implement through rulemaking. 

4. Electronic Reporting of Quality Measure Data 

We believe that certified EHR technology used in a meaningful way is one piece of a 

broader health information technology infrastructure needed to reform the health care system and 

improve health care quality, efficiency, and patient safety. Through our programs such as the 

Medicare and Medicaid EHR Incentive Programs and the Stage 2 meaningful use (MU) 

requirements we seek to expand the meaningful use of certified EHR technology (CEHRT). 

Adoption of CEHRT by ACO participants and ACO providers/suppliers may help support efforts 

to achieve improvements in patient care and quality, including reductions in medical errors, 

increased access to and availability of records and data, improved clinical decision support, and 

the convenience of electronic prescribing. Additionally, we believe that the potential for the 

Shared Savings Program to achieve its goals could be further advanced by direct EHR-based 

quality data reporting by ACOs and their ACO participants and ACO providers/suppliers. This 

could help reinforce the use of CEHRT, reduce errors in quality measure submission, and 

achieve data submission efficiencies. We believe ACOs and their providers should be leaders in 

encouraging EHR adoption and should be using CEHRT to improve quality of care and patient 

safety and to reduce errors. 

 Furthermore, beginning in 2015, eligible professionals that do not successfully 

demonstrate meaningful use of CEHRT will be subject to a downward payment adjustment 

under Medicare that starts at -1 percent and increases each year that an eligible professional does 

not demonstrate meaningful use, to a maximum of -5 percent. A final rule establishing the 

requirements of Stage 2 of the Medicare EHR Incentive Program appeared in the September 4, 

2012 Federal Register (Medicare and Medicaid Programs; Electronic Health Record Incentive 
CMS-1612-FC 893

Program—Stage 2 Final Rule) (77 FR 53968). Included in this final rule are the meaningful use 

and other requirements that apply for the payment adjustments under Medicare for covered 

professional services provided by eligible professionals failing to demonstrate meaningful use of 

CEHRT, including the CQM reporting component of meaningful use. As previously discussed 

in section III.M.2, we are finalizing a proposal to revise the name and the specifications for the 

quality measure regarding EHR adoption to take the changing incentives into account. 

Specifically, we are changing the name of ACO #11 from “Percent of PCPs Who Successfully 

Qualify for an EHR Incentive Program Payment” to “Percent of PCPs Who Successfully Meet 

Meaningful Use Requirements” to more accurately reflect what is being measured. 

 Additionally, under a group reporting option established for the Medicare EHR Incentive 

Program (77 FR 54076 through 54078), EPs participating in an ACO under the Shared Savings 

Program who extract the data necessary for the ACO to satisfy the quality reporting requirements 

of the Shared Savings Program from CEHRT would satisfy the CQM reporting component of 

meaningful use as a group for the Medicare EHR Incentive Program. In addition to submitting 

CQMs as part of an ACO, EPs have to individually satisfy the other objectives and associated 

measures for their respective stage of meaningful use. 

 However, we clarified that if an EP intends to use this group reporting option to meet the 

CQM reporting component of meaningful use, then the EP would have to extract all of its CQM 

data from a CEHRT and report it to the ACO (in a form and manner specified by the ACO) in 

order for the EP to potentially qualify for the Medicare EHR Incentive Program. The ACO must 

also report the GPRO web interface measures and satisfy the reporting requirements under the 

Shared Savings Program in order to its EPs to satisfy the CQM reporting component of 

meaningful use for the Medicare EHR Incentive Program. 
CMS-1612-FC 894

 Although these group reporting requirements were established under the Medicare EHR 

Incentive Program, the Shared Savings Program regulations were not amended to reflect these 

reporting requirements. Therefore, we proposed to amend the regulations governing the Shared 

Savings Program to align with the requirements previously adopted under the Medicare EHR 

Incentive Program in order to provide that EPs participating in an ACO under the Shared 

Savings Program can satisfy the CQM reporting component of meaningful use for the Medicare 

EHR Incentive Program when the ACO reports GPRO web interface measures by adding new 

paragraph (d) to §425.506. We proposed that this new paragraph would provide that EPs 

participating in an ACO under the Shared Savings Program satisfy the CQM reporting 

component of meaningful use for the Medicare EHR Incentive Program when: (1) the eligible 

professional extracts data necessary for the ACO to satisfy its quality reporting requirements 

from CEHRT; and (2) the ACO satisfactorily reports the ACO GPRO measures through a CMS 

web interface. 

Although we did not propose any new requirements regarding EHR based reporting 

under the Shared Savings Program, we welcomed suggestions and comments about issues which 

we would consider in developing any future proposals. We especially solicited comment on the 

feasibility of an ACO to be a convener and submitter of quality measures through an EHR or 

alternative method of electronically reporting quality measures to us. We indicated our interest 

in the opportunities and barriers to ACO EHR quality measure reporting, as well as ways to 

overcome any barriers. We also welcomed suggestions on alternative ways that we might 

implement EHR-based reporting of quality measures in the Shared Savings Program, such as 

directly from EHRs or via data submission vendors. We solicited comment on whether EHR 

reporting should be a requirement for all Shared Savings Program ACOs or if the requirement 

for EHR reporting should be phased in gradually, for instance through a separate risk track or by 
CMS-1612-FC 895

the establishment of a “core and menu” quality measure set approach in which we would 

establish a core set of required quality measures and then supplement these required measures 

with a menu of additional measures (such as EHR-based reporting) from which an ACO could 

choose. This approach could provide ACOs with additional flexibility and allow them to report 

on quality measures that better reflect any special services they provide. As an alternative, we 

also solicited comment on whether ACO providers/suppliers could use a local registry-like 

version of the GPRO web interface to capture relevant clinical information and to monitor 

performance on all Medicare patients throughout the year and to more easily report quality data 

to CMS annually. 

Comment: We received a wide variety of suggestions from ACOs and other 

stakeholders. Most ACOs support CMS’s decision not to propose any new requirements at this 

time regarding EHR based reporting, and they agree with aligning the Shared Savings Program 

with the EHR Incentive Program whereby EPs participating in an ACO can satisfy the CQM 

reporting component of meaningful use when the EP extracts data necessary for the ACO to 

satisfy its quality reporting requirements using a CEHRT and the ACO satisfactorily reports the 

GPRO measures through the CMS web interface. Some commenters believe the technical and 

operational barriers outlined in the proposed rule were severely understated. Healthcare 

Information and Management Systems Society (HIMSS) considered requiring EHR-based 

reporting of quality measures in the Shared Savings Program to be premature. Commenters 

raised concerns that the current lack of interoperability capabilities for ACOs that are formed by 

disparate organizations, often hospitals and physician groups coming together, but using 

differing EHR platforms that do not communicate electronic data sufficiently to centralize data 

for quality reporting would limit the ability of ACOs to successfully report quality through an 

EHR. They state it will take significant resources and time to ensure that interoperability is 
CMS-1612-FC 896

achieved. Rather than requiring EHR-based reporting, some commenters suggested that CMS 

should give providers the option to report through EHRs. 

Response: We appreciate the comments recommending that we not establish any new 

requirements at this time regarding EHR based reporting under the Shared Savings Program. We 

also appreciate the comments supporting aligning the Shared Savings Program with the EHR 

Incentive Program whereby EP participating in an ACO can satisfy the CQM reporting 

component of meaningful use when the EP extracts data necessary for the ACO to satisfy its 

GPRO reporting requirement using a CEHRT and the ACO satisfactorily reports the GPRO 

measures through the CMS web interface. 

We will continue to work toward electronic reporting of quality measures, keeping in 

mind the unique relationship ACOs have with their ACO participants and ACO 

providers/suppliers. We understand and appreciate the feedback from those stakeholders who 

raised important concerns about the readiness of ACOs and EHR systems to report quality 

electronically under the Shared Savings Program. We will use the information provided by 

commenters to work with ACOs and other stakeholders to develop possible ways to encourage 

EHR adoption taking into account input from ACOs on challenges for ACO electronic collection 

and submission of measures. In addition, we will consider the input we have received from 

stakeholders when deciding what additional requirements should be proposed in future 

rulemaking to encourage EHR adoption and use by ACOs and their ACO participants and ACO 

providers/suppliers. 

After consideration of the comments received regarding this proposal, we are finalizing 

our proposal to codify in the Shared Savings Program rules for 2015 and beyond that an eligible 

professional that is an ACO provider/supplier can satisfy the CQM reporting component of 

meaningful use when the eligible professional extracts data from CEHRT necessary for the ACO 
CMS-1612-FC 897

to satisfy its quality reporting requirements under the Shared Savings Program and the ACO 

reports the GPRO measures through the CMS web interface. This policy will be codified at § 

425.506(d) of the Shared Savings Program regulations. We emphasize that if an EP intends to 

use this group reporting option to meet the CQM reporting component of meaningful use, then 

the EP would have to extract all its CQM data from a CEHRT and report it to the ACO (in a 

form and manner specified by the ACO) in order for the EP to potentially qualify for the 

Medicare EHR Incentive Program. The ACO must also report the GPRO measures through the 

CMS web interface in order for its EPs to satisfy the CQM reporting component of meaningful 

use for the Medicare EHR Incentive Program. 

Although this amendment to the regulations will align the Medicare Shared Savings 

Program regulations with the existing requirements under the Medicare EHR Incentive Program, 

we intend to take steps in the future to better align and integrate EHR use into quality reporting 

under the Shared Savings Program. 

5. Quality Performance Benchmarks 

a. Overview of Current Requirements 

Section 1899(b)(3)(C) of the Act directs the Secretary to “establish quality performance 

standards to assess the quality of care furnished by ACOs” and to “seek to improve the quality of 

care furnished by ACOs over time by specifying higher standards, new measures, or both for 

purposes of assessing such quality of care.” Under the current Shared Savings Program 

regulations at §425.502, the following requirements with regard to establishing a quality 

performance benchmark for measures apply: (1) during the first performance year of an ACO’s 

agreement period, the quality performance standard is set at the level of complete and accurate 

reporting; (2) during subsequent performance years, the quality performance standard will be 

phased in such that ACOs will be assessed on their performance on certain measures (see Table 1 
CMS-1612-FC 898

of the November 2011 Shared Savings Program final rule (76 FR 67889 through 67890), for 

details of the transition for each of the 33 measures); (3) we designate a quality performance 

benchmark and minimum attainment level for each measure, and establish a point scale for the 

level of achievement on each measure; and (4) we define quality performance benchmarks using 

FFS Medicare data or using flat percentages when the 60th percentile is equal to or greater than 

80.00 percent. 

Section 425.502(b)(2) governs the data that CMS uses to establish the quality 

performance benchmarks for quality performance measures under the Shared Savings Program. 

Consistent with section 1899(b)(3)(C) of the Act, which requires CMS to seek to improve the 

quality of care furnished by ACOs participating in the Shared Savings Program over time, 

§425.500(b)(3) states that in establishing the measures to assess the quality of care furnished by 

an ACO, CMS seeks to improve the quality of care furnished by ACOs over time by specifying 

higher standards, new measures, or both. 

Subsequently, we discussed several issues related to the establishment of quality 

performance benchmarks in the CY 2014 PFS final rule with comment period 

(78 FR 74759 through 74764). In that rule (78 FR 74760), we finalized a proposal to combine 

all available Medicare FFS quality data, including data gathered under PQRS (through both the 

GPRO web interface tool and other quality reporting mechanisms) and other relevant FFS 

quality data reported to CMS (including data submitted by Shared Savings Program and Pioneer 

ACOs) to set the quality performance benchmarks for 2014 and subsequent reporting periods. In 

establishing this policy, we determined that it was appropriate to use all FFS data rather than 

only ACO data, at least in the early years of the program, to avoid the possibility of punishing 

high performers where performance is generally high among all ACOs. We did not finalize a 

proposal to use Medicare Advantage (MA) data alone or in combination with FFS data in the 
CMS-1612-FC 899

short-term. Instead, we stated in the CY 2014 PFS final rule with comment period 

(78 FR 74760) that we intended to revisit the policy of using MA data in future rulemaking when 

we have more experience setting benchmarks for ACOs. 

Additionally, in the CY 2014 PFS final rule with comment period, we retained the ability 

to use flat percentages to set benchmarks when many reporters demonstrate high achievement on 

a measure, so that ACOs with high performance on a measure are not penalized (78 FR 74760). 

More specifically, we will now use all available FFS data to calculate benchmarks, including 

ACO data, except where performance at the 60th percentile is equal to or greater than 80 percent 

for individual measures. In these cases, a flat percentage will be used to set the benchmark for 

the measure. This policy allows ACOs with high scores to earn maximum or near maximum 

quality points while still allowing room for improvement and rewarding that improvement in 

subsequent years. 

As previously discussed, the first performance year of an ACO’s agreement period is pay 

for reporting only, so ACOs earn their maximum sharing rate for completely and accurately 

reporting all 33 quality measures. Quality performance benchmarks are released in 

subregulatory guidance prior to the start of the quality reporting period for which they apply so 

that as we phase in measures to pay for performance, ACOs are aware of the actual performance 

rates they will need to achieve to earn the maximum quality points under each domain. In the 

November 2011 Shared Savings Program final rule, we indicated our intent to gradually raise the 

minimum attainment level to continue to incentivize quality improvement over time and noted 

that we would do so through future rulemaking after providing sufficient advance notice with a 

comment period to allow for industry input (76 FR 67898). In the CY 2014 PFS final rule with 

comment period, we reiterated our policy of setting quality performance benchmarks prior to the 

reporting year for which they would apply (78 FR 74759). Specifically, we use data submitted in 
CMS-1612-FC 900

2013 for the 2012 reporting period to set the quality performance benchmarks for the 2014 

reporting period. However, we recognize that in the first few years of the Shared Savings 

Program, we will only have a limited amount of data for some measures, which may cause the 

benchmarks for these measures to fluctuate, possibly making it difficult for ACOs to improve 

upon their previous year’s performance. Stakeholders have also told us that they prefer to have a 

stable benchmark target so that they can be rewarded for quality improvement from one year to 

the next. Therefore, instead of modifying quality performance benchmarks annually, in the CY 

2014 PFS final rule with comment period (78 FR 74761) we stated that we would set the 

benchmarks for the 2014 reporting year in advance using data submitted during 2013 for the 

2012 reporting year, and continue to use that benchmark for 2 reporting years (specifically, the 

2014 and 2015 reporting years). We further indicated our intention to revisit this issue in future 

rulemaking to allow for public comment on the appropriate number of years that a benchmark 

should apply before it is updated. 

b. Revisions for Benchmarking Measures That Are “Topped Out” 

 In the discussion of measures in the CY 2015 Physician Fee Schedule proposed rule, we 

indicated that some measures may be topped out, meaning that all but a very few organizations 

achieve near perfect performance on the measure. Since publication of the quality performance 

benchmarks for the 2014 and 2015 quality reporting years, a number of ACOs have noted that 

using available national FFS data has resulted in some benchmarks where the 80th or 90th 

percentiles approach 100 percent performance on the measure. Stakeholders have suggested it is 

unreasonable to hold organizations, especially very large organizations such as ACOs to this 

high standard and that it may be easier for smaller and medium size physician practices to 

achieve higher levels of performance given their smaller patient populations. We believe these 

concerns have merit because we have looked at the FFS data submitted to CMS and agree it is 
CMS-1612-FC 901

possible that smaller practices or practices with smaller populations may be able to achieve these 

higher levels of performance more easily than larger practices or organizations with larger 

patient populations. Therefore, we proposed certain modifications to our benchmarking 

methodology to address the way that such “topped out” measures are treated for purposes of 

evaluating an ACO’s performance. Specifically, when the national FFS data results in the 90th 

percentile for a measure are greater than or equal to 95 percent, we would use flat percentages 

for the measure, similar to our policy under §425.502(b)(2)(ii) of using flat percentages when the 

60th percentile is greater than 80 percent to address clustered measures. We believe this 

approach would address concerns about how topped out measures affect the quality performance 

standard while continuing to reward high performance, and being readily understandable to all. 

We proposed to revise §425.502(b)(2)(ii) to reflect this policy. We invited comments on this 

proposal. We also invited comments on other potential approaches for addressing topped out 

measures. We indicated that we would use any comments received to help develop any future 

proposals regarding topped out measures. For example, we welcomed comments on whether we 

should drop topped out measures from the measures set, fold them into composites, or retain 

them but make them pay for reporting only. 

Comment: Commenters were generally in agreement with our proposal to use flat 

percentages for topped out measures, which is consistent with our policy of using flat 

percentages when the 60th percentile is greater than 80 percent to address clustered measures. 

We received a wide variety of responses to our request for comment on what should be done 

with topped out measures through future rulemaking. Many commenters supported retaining 

such measures with the view that quality measures are intended to protect Medicare beneficiaries 

from receiving inappropriate care. If all but a few organizations achieve near perfect 

performance, the commenters believe it would be important to retain that measure to encourage 
CMS-1612-FC 902

better performance from the low performing organizations, and to prevent backsliding by the 

high performers. Other commenters, including MedPAC, suggested removing topped out 

measures to reduce reporting burden. Others suggested that topped out measures could be 

dropped or moved from being process-based to clinical outcome-based and be folded into 

composites to prevent “back sliding,” or that they could be considered “deemed met” without a 

reporting requirement but available for audit if so chosen. 

Response: We appreciate the commenters’ support for the proposal to use flat 

percentages when the national FFS data results in the 90th percentile performing at greater than 

or equal to 95 percent. We also appreciate the additional suggestions regarding treatment of 

topped out measures and intend to consider this issue further in future rulemaking. 

Final Decision: After consideration of the comments received on this issue, we are 

finalizing our proposal to use flat percentages when the national FFS data results in the 90th 

percentile for a measure are greater than or equal to 95 percent. We are also finalizing our 

proposed revisions to §425.502(b)(2)(ii) to reflect this policy. Although this final policy is 

similar to our current policy for setting benchmarks based on flat percentages when the 60th

percentile is equal to or greater than 80.00 percent, we clarify that this methodology would apply 

to all measures, including measures whose performance rates are calculated as ratios, for 

example, measures such as the ACO Ambulatory Sensitive Conditions Admissions and the All 

Condition Readmission measure. We believe it is appropriate to apply this methodology to all 

topped out measures, including measures whose performance rates are calculated as ratios. 

Measures calculated and reported as ratios may also become topped out and we believe it is 

important to keep a consistent approach for addressing all Shared Savings Program measures that 

become topped out. 
CMS-1612-FC 903

c. Quality Performance Standard for Measures that Apply to ACOs that Enter a Second or 

Subsequent Participation Agreement 

 As discussed previously, during an ACO’s first participation agreement period, the 

quality performance standard during the first performance year is initially set at the level of 

complete and accurate reporting, and then, during performance years 2 and 3 within the ACO’s 

first agreement period, the quality performance standard is phased in such that the ACO is 

assessed on its performance on selected measures. We did not directly indicate the quality 

performance standard that would apply if an ACO were to subsequently enter into a second or 

subsequent participation agreement. However, §425.502(a)(1) provides that during the first 

performance year of an ACO’s agreement period, CMS will define the quality performance 

standard at the level of complete and accurate reporting of all quality measures. As drafted, this 

regulation could be read to imply that the quality performance standard for ACOs in the first 

performance year of a subsequent agreement period would also be set at the standard of full and 

accurate reporting. We do not believe it is appropriate for an ACO in a second or subsequent 

agreement period to report quality measures on a pay-for-reporting basis if they have previously 

reported these measures in a prior agreement period. The ACO would have gained experience 

reporting the quality measures during the earlier agreement period, and as a result, we do not 

believe it would be necessary to provide any further transition period. Rather, we believe it 

would be appropriate to assess the ACO’s actual performance on measures that have been 

designated as pay for performance during all 3 years of the second or subsequent participation 

agreement period. 

 Accordingly, we proposed to revise our regulations to expressly provide that during a 

second or subsequent participation agreement period, the ACO would continue to be assessed on 

its performance on each measure that has been designated as pay for performance. That is, the 
CMS-1612-FC 904

ACO would continue to be assessed on the quality performance standard that would otherwise 

apply to an ACO if it were in the third performance year of the first agreement period. We will 

do this by modifying §425.502(a)(1) and (a)(2) to indicate that the performance standard will be 

set at the level of complete and accurate reporting of all quality measures only for the first 

performance year of an ACO’s first agreement period, and that during subsequent agreement 

periods, pay for performance will apply for all three performance years. 

 Comment: We received relatively few comments on this proposal. A number of those 

that responded supported the proposal. A few were hesitant to support it, suggesting that a 

performance standard for a quality measure should not be continued into a second or a 

subsequent participation agreement period if there have been any significant changes in the 

measure set and/or in the specifications used to calculate performance on the measures. In such 

cases, those measures that have changed should follow the same schedule as would apply to an 

ACO in its first agreement period. Another example of a concern these commenters raised is if 

an ACO with a 2013 start date (three year agreement for 2013 through 2015) chooses to sign a 

subsequent three year agreement (for 2016 through 2018), that requires it to accept risk, then the 

ACO would possibly be facing new benchmarks beginning in PY 2016 and would not be 

afforded a one year pay for reporting transition period to gain experience with the new 

benchmarks. 

 Response: We appreciate the comments in support of this proposal. We believe that 

concerns that were expressed by some commenters about changes in the measure set are 

addressed through the phase-in schedule for new measures, as outlined in Table 81, and our 

policy, finalized above, that all new measures will be pay-for-reporting for all ACOs for the first 

two reporting periods in which they are in use, regardless of the phase-in schedule. This will 

permit time for CMS to gather data for benchmarking and publish benchmarks prior to the start 
CMS-1612-FC 905

of the third reporting period in which a new measure is in use. This two year grace period will 

also permit ACOs to become accustomed to the measure before it becomes pay-for-performance. 

So in the example given by the commenter, the ACO with a 2013 start date would not be subject 

to pay-for-performance in its first year of the subsequent agreement period (starting in 2016) for 

any of the new measures finalized in this rule. The first opportunity for the new measures to be 

used as pay-for-performance would be for the 2017 reporting period, which would correspond to 

this ACO’s second performance year of its subsequent agreement period. Because the ACO 

would be in its subsequent agreement period, all measures would be pay-for-performance at that 

time, with the exception of measures that remain pay-for-reporting in all years, according to the 

phase-in schedule indicated in Table 81. For example, the Depression Remission at 12 Months 

measure (ACO# 40) is pay-for-reporting for all three years of an ACO’s first agreement period. 

In a subsequent agreement period, ACOs will continue to be assessed on this measure as pay-forreporting, which corresponds to the level of performance required in PY3 of the first agreement 

period. 

 Final Decision: We are finalizing our proposal to modify §425.502(a) to indicate that for 

ACOs in a second or subsequent agreement period, all measures will be pay for performance for 

all three performance years unless the measure is designated as pay-for-reporting for all three 

years, as indicated in Table 81. We clarify that, as discussed in more detail above, this policy 

applies only to measures that have been in use for two years or more, for which benchmarks are 

available, and thus, would not apply to new measures, which are designated as pay-for-reporting 

during the first two reporting periods they are in use. 

d. Timing for Updating Benchmarks 

 As discussed in the CY 2014 PFS final rule with comment (78 FR 74761), we have 

further considered suggestions from ACOs regarding the appropriate number of years that a 
CMS-1612-FC 906

benchmark should apply before it is updated. ACOs suggested that there be a longer period of 

time to gain experience with the performance measure, before the benchmark is further updated. 

ACOs also indicated that it would be desirable to set and leave benchmarks static for additional 

performance years so that they have a quality improvement target to strive for that does not 

change frequently. ACOs believe that a stable benchmark would enhance their ability to be 

rewarded for quality improvement, as well as quality achievement, from one year to the next. 

We recognize, however, that there could be some concerns about lengthening the period between 

updates to the quality performance benchmarks. The current benchmarks as discussed 

previously, for example, are based on a combination of all available Medicare FFS quality data, 

including data gathered under PQRS, the Shared Savings Program and Pioneer ACO Model, but 

not MA quality data. To the extent that the benchmarks are based on quality data reported by a 

large number of ACOs and other FFS entities, we believe it is reasonable to use them to assess 

the quality performance of ACOs. Furthermore, as discussed in the 2014 PFS final rule with 

comment period (78 FR 74761), we are also persuaded that we should establish a longer period 

between updates to the benchmarks in order to provide ACOs with a more stable target for 

measuring quality improvement. In the absence of this stability, it could be very difficult to 

assess quality improvement from year to year. 

 In the 2014 PFS final rule with comment period, we noted that we intended to address the 

number of years between updates to the benchmarks again in future rulemaking in order to allow 

for public comment. Therefore, we considered how long benchmarks should be in place before 

they are updated. We considered a range of options, from setting benchmarks every 2 years to 

setting benchmarks every 5 years. For example, we considered the option of setting benchmarks 

every 3 years. However, we note that ACO agreement periods are 3 years long and a new cohort 

of ACOs enters the program each year. As a result, setting benchmarks every 3 years might 
CMS-1612-FC 907

advantage some ACOs over others, particularly ACOs that have an agreement period during 

which benchmarks are not updated. Therefore, we proposed to update benchmarks every 2 

years. We believe 2 years is an appropriate amount of time because the Shared Savings Program 

is relatively new and we do not have extensive experience in setting benchmarks under the 

Shared Savings Program. Updating the benchmarks every 2 years would enable us to be more 

flexible and give us the ability to make adjustments more frequently if appropriate. We note, 

however, that we may revisit this policy as more ACOs enter the program, more FFS data is 

collected which could help us better understand to what extent benchmarks should vary from 

year to year, or if we make any future proposals regarding the use of MA quality data for setting 

benchmarks. 

 Accordingly, we proposed to revise §425.502(b) to add a new paragraph (b)(4)(i), which 

would provide that CMS will update benchmarks every 2 years. To illustrate this proposed 

policy, the existing quality performance benchmarks, which are based on data submitted in 2013 

for the 2012 reporting period would apply for a total of 2 performance years (the 2014 and 2015 

performance years) after which we would reset the benchmarks for all ACOs based on data for 

the 2014 reporting period that is reported during 2015. These updated benchmarks would apply 

for the 2016 and 2017 performance years. This timeline is summarized in Table 85. Under this 

proposal, ACOs would have a stable target for quality achievement for 2 years, which should 

improve the opportunity for ACOs to be rewarded for improvement from year to year compared 

to that benchmark. We also proposed to revise §425.502(b) to add a new paragraph (b)(4)(ii), 

which would provide that for measures introduced in the first year of the 2-year benchmarking 

cycle, the benchmark will be established in the second year and updated along with the other 

measures at the start of the next 2-year benchmarking cycle. 
CMS-1612-FC 908

 We solicited comment on this proposal. We specifically solicited comment on the 

appropriate number of years that a benchmark should remain stable before it is updated. We also 

welcomed comments about when annual updates might be appropriate such as when there is a 

substantive specification change to a measure between years. For instance, the age range used 

for the breast cancer screening measure is different in 2014 than in 2013, or when the measure 

owner modifies or retires a measure. Additionally, although we proposed to retain our current 

policy of using the most recent available data to set the quality performance benchmarks, we also 

solicited comment on whether data from other reporting periods should also be considered in 

establishing benchmarks that will apply for 2 performance years. Specifically, we sought input 

on whether data from multiple years should be used to help provide more stable benchmarks. 

For example, should data submitted for the 2013 and 2014 reporting periods be combined to set 

benchmarks for the 2016 and 2017 performance years? 

Comment: We received a wide range of comments in response to this proposal. In 

general most commenters supported setting benchmarks for at least two years but many, 

including some ACOs, supported a longer period of at least three years to align with the Shared 

Savings Program agreement period to provide more stability for ACOs. There were some 

commenters that suggested more frequent adjustment of benchmarks under certain situations, 

suggesting that more frequent benchmark updates may be necessary whenever there are 

substantive specification changes for a measure, such as changes in the dominator or frequency. 

For example, a commenter stated that even slight modifications to a measure specification could 

eliminate any opportunity to establish a valid benchmark and that CMS must therefore consider 

establishing new benchmarks when even “non-substantive” changes are made to measure. A 

commenter suggested that instead of the proposed two year interval, benchmarks should be 

adjusted annually if there is a statistically significant performance change across all 
CMS-1612-FC 909

organizations. Some commenters suggested the use of multiple years of data to set benchmarks, 

suggesting, for example, that some measures could be susceptible to year specific events that 

could skew results. 

Response: We are finalizing our proposal to set benchmarks for two years to provide 

ACOs with stable quality improvement targets. We believe that setting benchmarks for two 

years provides ACOs with stable quality improvement targets while not advantaging some ACOs 

over others by setting them for three years. We also agree with commenters who suggested the 

use of multiple years of data to set benchmarks to reduce the effect that year to year variation 

might have on the benchmarks. Therefore, we will use up to 3 years of FFS data to set 

benchmarks, if available. This should provide sufficient stability to minimize year to year 

variation while also representing reasonably current practices, if the data is available. The use of 

multiple years of FFS data to set benchmarks will apply to all newly established benchmarks, 

but will not affect existing benchmarks, which apply to the 2014 and 2015 performance years. 

 We are finalizing our proposal to set benchmarks for two years to provide ACOs with 

stable targets for quality improvement. In addition, we will use up to three years of FFS data to 

set benchmarks, if available. The use of multiple years of FFS data to set benchmarks will apply 

to all newly established benchmarks, but will not affect existing benchmarks, which apply to the 

2014 and 2015 performance years. We are finalizing our proposal to revise §425.502(b) to add a 

new paragraph (b)(4)(i) providing that CMS will update benchmarks every 2 years. In light of 

our decision to set the quality performance standard for a newly introduced measure at the level 

of complete and accurate reporting for the first two reporting periods for which the measure is in 

use, we are revising proposed §425.502(b)(4)(ii) to provide that for newly introduced measures 

that transition to pay for performance in the second year of the 2-year benchmarking cycle, the 

benchmark will be established in that year and updated along with the other measures at the start 
CMS-1612-FC 910

of the next 2-year benchmarking cycle. For example, if a new measure is scheduled to become 

pay for performance in 2017 after being used for pay-for-reporting for 2015 and 2016, it will be 

set for the 2017 performance year and subsequently reset at the beginning of the next 2-year 

benchmarking cycle (2018-2019). In other words, such a measure would have its benchmark set 

for a single year before phasing into the biennial benchmarking schedule outlined in Table 84. 

TABLE 84: Timeline for Setting and Updating Quality Performance Benchmarks 

Reporting period for data 

used to set benchmark 

Year data is analyzed, and 

benchmark is published 

Performance year and reporting period to 

which benchmark applies 

2012 2013 2014 & 2015 

2012, 2013, 2014 2015 2016 & 2017 

2014, 2015, 2016 2017 2018 & 2019 

 

6. Rewarding Quality Improvement 

a. Current Approach to Rewarding ACOs for Both Quality Attainment and Quality 

Improvement 

 ACOs must meet a CMS-specified quality performance standard in order to be eligible to 

share in savings. The Shared Savings Program quality performance standard currently consists 

of a set of quality measures spanning four domains that are collected via the patient and 

caregiver experience of care survey, calculated by CMS from internal administrative and claims 

data, and submitted by the ACO through the CMS web interface. The four domains include 

patient/caregiver experience of care, care coordination/patient safety, preventive health, and atrisk populations. The measures collected through the CMS web interface are also used to 

determine whether eligible professionals that bill through the TIN of an ACO participant qualify 

for the PQRS incentive payment or avoid the downward PQRS payment adjustment. Eligible 

professionals that bill through the TIN of an ACO participant may qualify for the PQRS 

incentive payment or avoid the downward PQRS payment adjustment when the ACO 

satisfactorily reports the ACO GPRO quality measures on their behalf. 
CMS-1612-FC 911

 Under current policy, the quality performance standard is defined at the level of full and 

complete reporting for the first performance year of an ACO’s agreement period. After that, an 

ACO must meet certain thresholds of performance and is rewarded on a sliding scale in which 

higher levels of quality performance translate to higher rates of shared savings. This scale, 

therefore, rewards improvement over time, since higher performance translates to higher shared 

savings. For example, an ACO that performs at the 80th percentile one year and then at the 90th

percentile the next year would receive a higher level of shared savings in its second year than its 

first year, based on its improved quality performance. In this way, ACOs are rewarded for both 

attainment and improvement. This is particularly true when benchmarks are stable for more than 

one year, as discussed earlier in this section. 

We recognize that rewards for both quality attainment, as well as quality improvement 

are not always built in to pay-for-performance initiatives. For example, in HVBP (Hospital 

Value-Based Purchasing) hospitals are scored based on the higher of their achievement or 

improvement on specified quality measures, with some hospitals receiving incentive payments if 

their overall performance is high enough relative to their peers. In the November 2011 final rule 

establishing the Shared Savings Program (76 FR 67897), we indicated in response to comments 

that we believe the approach of offering more points for better quality performance also offers an 

implicit incentive for continuous quality improvements, since it incorporates a sliding scale in 

which higher levels of quality performance translate to higher sharing rates. We believed that 

high performing ACOs should do well under this approach since it recognizes and provides 

incentives for ACOs to maintain high quality performance in order to maximize their share of 

savings and minimize their share of losses. 
CMS-1612-FC 912

b. Additional Rewards for Quality Improvement 

 ACOs and other stakeholders have suggested that the current quality points scale 

described above does not adequately reward ACOs for both quality attainment and improvement. 

They request that we further strengthen the incentives for quality improvement by including an 

additional explicit reward for those ACOs that improve from one year to the next. 

 As discussed previously, the existing quality performance standard includes a sliding 

point scale that rewards ACOs for certain levels of attainment. In addition, we note that under 

the final policy discussed above in which we will establish a stable quality performance 

benchmark for a period of 2 years, there should be an even greater opportunity for every ACO to 

demonstrate improvement and be rewarded for that improvement from year to year. However, 

we were persuaded by suggestions from stakeholders that an additional, more explicit reward 

should be included for ACOs that improve their quality scores from year to year. Therefore, we 

proposed to revise our existing quality scoring strategy to explicitly recognize and reward ACOs 

that make year-to-year improvements in their quality performance scores on individual measures. 

 To develop such an approach, we looked to the MA program, which has already 

successfully developed and implemented a formula for measuring quality improvement. The 

MA five star rating program computes an improvement change score which is defined as the 

score for a measure in a performance year minus the score in the previous performance year. 

The MA five star rating program then measures each plan’s net quality improvement by 

calculating the total number of significantly improved quality measures and subtracting the total 

number of significantly declined quality measures. This is an approach that we believed was 

also appropriate for measuring quality improvement for ACOs. (For more details on the formula 

for calculating the MA quality improvement measure, see the discussion in “Medicare 2014 Part 

C & D Star Rating Technical Notes”, Attachment I, page 80, which can be downloaded from the 
CMS-1612-FC 913

CMS website at http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html.) 

 We continue to believe it is important to recognize that the Shared Savings Program is 

not a managed care program. Unlike MA, this program’s design retains FFS flexibility and the 

freedom of choice available to beneficiaries under Medicare Parts A and B which generally 

necessitates different program requirements. However, in this case we believe there would be 

significant advantages for the Shared Savings Program to adopt the formula for a quality 

improvement measure that MA has already developed and implemented rather than attempt to 

develop a new formula for a quality improvement measure. In particular, the MA measure 

formula has already been fully developed and vetted with stakeholders, in the context of the MA 

program, with detailed operational specifications and previously shared with the public. 

 In addition, we believe it is important to add a quality improvement measure to the 

Shared Savings Program in a manner that would minimize disruption for ACOs. We believe it 

would be undesirable for both ACOs and the program if the quality improvement measure were 

added in a way that required extensive revisions to the current quality measurement 

methodology, for example, reweighting of the four quality measure domains. Therefore, we 

proposed to add a quality improvement measure to award bonus points for quality improvement 

to each of the existing four quality measure domains. For each quality measure domain, we 

proposed to award an ACO up to two additional bonus points for quality performance 

improvement on the quality measures within the domain. These bonus points would be added to 

the total points that the ACO achieved within each of the four domains. Under this proposal, the 

total possible points that could be achieved in a domain, including up to 2 bonus points, could 

not exceed the current maximum total points achievable within the domain. 
CMS-1612-FC 914

 ACOs would achieve bonus points for this quality improvement measure in a domain if 

they achieve statistically significant levels of quality improvement for measures within the 

domain, as discussed below. Otherwise, the current methodology for calculating the ACO’s 

overall quality performance score would continue to apply (see §425.502(e) and 76 FR 67895 

through 67900). Additional details about the proposal to incorporate bonus points into the 

quality performance scoring methodology are discussed in the CY 2015 Physician Fee Schedule 

proposed rule (79 FR 40490 through 40492). Highlights of the methodology we proposed are as 

follows.: 

 The quality improvement measure scoring for a domain would be based on the ACO’s 

net improvement in quality for the other measures in the domain. The calculation of the quality 

improvement measure for each domain would generally be based on the formula used for the 

MA five star rating program, as follows: 

Improvement Change Score = score for a measure in performance year minus score in 

previous performance year. 

In general, for a measure to be eligible to be included for purposes of determining quality 

improvement and awarding bonus points in a domain for a performance year, the measure must 

be a measure for which an ACO was scored in both the performance year and the immediately 

preceding performance year. Measures that were not scored in both the performance year and 

the immediately preceding performance year, for example, new measures, would not be included 

in the assessment of improvement. Otherwise, for purposes of determining quality improvement 

and awarding bonus points, we would include all of the individual measures within the domain, 

including both pay-for-reporting measures and pay-for-performance measures. In determining 

improvement, the actual performance score achieved by the ACO on the measure would be used, 

not the score used to determine shared savings. In other words, we would calculate a 
CMS-1612-FC 915

performance score for each measure, regardless of whether it is pay for reporting or pay for 

performance, and include the score in the report we provide to the ACO. For example, all 

measures are pay for reporting in the first year of an ACO’s first agreement period, but even 

though the ACO will receive full credit for all reported measures, its actual performance on those 

measures will also be scored and provided to the ACO for informational purposes. We believe it 

is appropriate to use these actual performance scores to assess improvement on a measure from 

year to year, regardless of whether the measure is designated as a pay for reporting or a pay for 

performance measure in that performance year because the performance scores achieved by the 

ACO provide the best indication of the actual change in quality performance by the ACO. 

If the ACO is in its first performance year of its first agreement period, then it would not 

be possible, of course, to measure quality improvement. Therefore, for these ACOs the existing 

scoring methodology would continue to apply and no bonus points would be awarded. If an 

ACO in its second or subsequent performance year does not experience an improvement nor a 

decline in quality performance for any of the selected measures compared to its previous 

reporting period, or it experiences an improvement for some measures but has an equal or greater 

number of measures where quality performance has declined, then the ACO would likewise not 

be awarded any bonus points. If an ACO renews a participation agreement, then the 

measurement of quality improvement would be based on a comparison between performance in 

the first year of the new agreement period and performance in the 3rd year of the previous 

agreement period. 

 For each qualifying measure, we would determine whether there was a significant 

improvement or decline between the two performance years by applying a common standard 

statistical test. (See the discussion of the t-test for calculating the MA quality improvement 

measure in “Medicare 2014 Part C & D Star Rating Technical Notes”, Attachment I, page 80, 
CMS-1612-FC 916

which can be downloaded from the CMS website at http://www.cms.gov/Medicare/PrescriptionDrug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html). Statistical significance 

testing in this case assesses how unlikely it is that differences as big as those observed would be 

due to chance when the performance is actually the same. The test recognizes and appropriately 

adjusts measures at both high and low levels of performance for statistically significant levels of 

change. Under this methodology, we can be reasonably certain, at a 95 percent level of 

confidence, that statistically significant differences in an ACO’s quality measure performance for 

a year compared to the previous year are real and not simply due to random variation in measure 

sampling. 

 The awarding of bonus points would be based on an ACO’s net improvement within a 

domain, and would be calculated by determining the total number of significantly improved 

measures and subtracting the total number of significantly declined measures. Up to 2 bonus 

points would be awarded on a sliding scale based on the ACO’s net improvement for the domain 

compared to the total number of individual measures in the domain. 

 Consistent with our current quality methodology, the total points earned for measures in 

each domain, including any quality improvement points, would be summed and divided by the 

total points available for that domain to produce an overall domain score of the percentage of 

points earned versus points available. The percentage score for each domain will be averaged 

together to generate a final overall quality performance score and sharing rate for each ACO that 

will be used to determine the amount of shared savings or, if applicable the amount of losses it 

owes, consistent with the requirements under §425.502(e). 

 In developing this proposal to award bonus points for quality improvement, we 

considered several alternative options. Specifically, we considered whether it would be more 

appropriate not to award bonus points but instead to include a computed quality improvement 
CMS-1612-FC 917

measure that would be incorporated into the current scoring methodology just as any other 

measure would be added. Under this alternative approach, we would increase the total possible 

points that could be awarded in a domain. However, we did not propose that approach because 

we believe that awarding bonus points would provide the desired incentive, would be more 

understandable and less disruptive, and would not require extensive changes to the quality 

performance standard. By awarding bonus points we also avoid the need to develop ways to 

avoid unfairly penalizing new ACOs. Similarly, ACOs that have already achieved a very high 

level of quality for an individual measure may not be able to achieve further statistically 

significant improvement for the measure. Such ACOs could otherwise be disadvantaged if they 

were not able to earn performance points for a new quality improvement measure added to the 

total measures in the domain. We believe our quality improvement proposal mitigates these 

concerns because the measure recognizes incremental improvement at higher levels of 

performance and does not impose any penalty on ACOs that have already achieved a high level 

of performance. 

 We also considered whether we should provide an even greater additional incentive by 

increasing the total possible bonus points, perhaps up to 4 points to provide a higher incentive for 

greater levels of quality improvement. However, we did not propose that option because we 

were concerned that awarding 4 points for the quality improvement measure could overweight 

the additional incentive for quality improvement given that the program already rewards higher 

performance with a greater share of any savings. 

 In addition, we had some concerns about whether it would be appropriate to use the “pay 

for reporting” data reported to us, given that this information does not affect an ACO’s quality 

performance score in the first performance year. Therefore, we considered whether the quality 

improvement score should apply only to those ACOs that have completed at least two 
CMS-1612-FC 918

performance years. Under this alternative approach, ACOs would have an opportunity to be 

assessed based on their actual quality measure performance before being assessed on their 

quality improvement scores. We did not select this approach because we wanted to provide an 

incentive that would apply as soon as possible in the agreement period. Furthermore, as noted 

earlier, we believe it would be appropriate to include pay-for-reporting measures for purposes of 

awarding bonus points since under §425.500(f) ACOs are required to report pay-for-reporting 

measures completely, accurately, and timely. 

 We proposed to add a new paragraph (e)(4) to §425.502 to incorporate this process for 

calculating bonus points for quality improvement into the quality performance scoring 

methodology. We solicited comments on this proposal and welcomed comments on the 

alternative approaches discussed in the proposed rule. We also solicited comments on whether 

there are other alternative approaches to explicitly rewarding quality improvement for ACOs, 

and whether the implicit reward for quality improvement provided under the current regulations 

is sufficient. 

 We also welcomed any suggestions on how the Shared Savings Program might integrate 

elements of other quality improvement methodologies such as those employed by HVBP or MA. 

Such comments would be considered in developing possible future proposals to further align 

with other Medicare quality improvement programs. 

Comment: Commenters were supportive of explicitly recognizing and rewarding ACOs 

that make year to year improvements in the manner proposed. Many commenters, however, felt 

that our proposal did not go far enough and recommended instead that CMS award up to four 

bonus points (rather than two) for quality improvement in each of the existing four quality 

measure domains, or permit bonus points in one domain to influence the weighting of the 

domain. These commenters pointed out that the proposal to award up to two bonus points would 
CMS-1612-FC 919

increase the overall quality performance score for an ACO by at most 14 percent. Some 

commenters suggested additional approaches, such as awarding an additional 10 percent of 

shared savings for those ACOs that score in the top 10 percent on quality measures. Another 

example is a suggestion that ACOs be allowed to retain 50% of their share of savings regardless 

of the MSR if their overall quality score improves year-over-year. 

Response: We appreciate the overall support from commenters who generally agreed 

with the proposal to offer an additional and explicit reward for improving quality performance in 

the Shared Savings Program. This additional reward would complement and reinforce our 

current quality performance scoring system that implicitly takes into account improvements over 

prior performance and rewards ACOs with a greater share in savings for greater quality 

performance. We believe that adding an explicit incentive places even greater emphasis on 

quality improvement, encouraging all ACOs to continue to improve quality for their patient 

populations over time, in addition to maintaining existing high quality levels. The success of the 

Shared Savings Program is dependent in large part on ACOs further improving the quality of the 

care they provide, not merely maintaining current levels of quality. Further, we believe that the 

suggestions from some commenters to increase the additional quality improvement award to up 

to four bonus points have merit. Although we proposed the improvement measure to increase 

the domain score by up to 2 points, similar to other measures in the domain, we agree with 

commenters that increasing this to four bonus points would not appear to overweight the 

additional incentive since the additional bonus points can only increase a quality score by at most 

25 percent overall. (That is, 4 bonus points per domain times 4 domains equals 16, which when 

divided by the 66 total points possible equals approximately 25 percent). Additionally, we have 

at least one measure (ACO #11, Percent of PCPs who Successfully Qualify for an EHR Incentive 

Program Payment) that is doubly weighted at 4 points in order to emphasize the importance of 
CMS-1612-FC 920

adoption of EHR meaningful use. Permitting the quality improvement measure to be double 

weighted would similarly emphasize the importance of quality improvement, further 

encouraging ACOs to improve overall quality for their patient populations over time. 

 Final Decision: We are finalizing our proposal to provide an additional quality 

improvement reward for Shared Savings Program ACOs who demonstrate quality improvement 

on measures in a domain. We believe that this additional and explicit reward for quality 

improvement would complement and reinforce our current quality performance approach. 

Specifically, for each quality measure domain, we will award an ACO up to four additional 

bonus points for quality performance improvement on the quality measures within the domain. 

These bonus points would be added to the total points that the ACO achieves within each of the 

four domains. The total possible points that can be achieved in a domain, including up to 4 

bonus points, could not exceed the maximum total points achievable within the domain. For 

example, as shown in Table 82, the total possible points for the patient/caregiver experience 

domain, which has eight individual measures, is 16 total possible points. Under this new policy 

that we are finalizing to provide for quality improvement bonus points, the maximum possible 

points within this domain will remain 16. If an ACO scores 12 points and is awarded four 

additional bonus points for quality improvement then the ACO’s total points for this domain 

would be 16. However, if instead this same ACO had scored 13 points, then this ACO’s total 

points after adding the bonus points would still not exceed 16. Table 82, which shows the 

number of points available per domain under the revised quality performance standard, reflects 

the current quality measure scoring methodology which will continue. Consistent with our 

current quality scoring methodology, the total points earned for measures in each domain, 

including any quality improvement bonus points up to the total possible points for the domain, 

would be summed and divided by the total points available for that domain to produce an overall 
CMS-1612-FC 921

domain score of the percentage of points earned versus points available. The percentage score 

for each domain will be averaged together to generate a final overall quality performance score 

and sharing rate for each ACO that will be used to determine the percentage of savings it shares 

or, if applicable, the percentage of losses it owes, consistent with the methodology established 

under §425.502(e). 

 The calculation of the quality improvement measure for each domain would generally be 

based on the formula used for the MA five star rating program, as follows: 

Improvement Change Score = score for a measure in performance year minus score in previous 

performance year. 

 For each qualifying measure, we will determine whether there was a significant 

improvement or decline between the two performance years by applying a “t-test” which is a 

common standard statistical test, at a 95 percent level of confidence. (See the discussion of the ttest for calculating the MA quality improvement measure in “Medicare 2014 Part C & D Star 

Rating Technical Notes”, Attachment I, page 80, which can be downloaded from the CMS 

website at http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html). This test assesses how unlikely it 

is that differences as big as those observed would be due to chance when the performance is 

actually the same. 

 The bonus points, up to a maximum of 4 points, will be awarded in direct proportion to 

the ACO’s net improvement for the domain to the total number of individual measures in the 

domain. For example, there are eight individual measures for the patient/caregiver experience of 

care domain. If an ACO achieves a significant quality increase in all eight measures then the 

ACO would be awarded the maximum of four bonus points for this domain. However, if the 

ACO achieved a significant quality increase in only one of the eight measures in this domain and 
CMS-1612-FC 922

no significant quality decline on any of the measures then the ACO would be awarded bonus 

points for quality improvement in the domain that is 1/8 times 4 = 0.50. The total points that the 

ACO could achieve in this domain could still not exceed the current maximum of 16 points 

shown in Table 82. We are also finalizing our proposal to add a new paragraph (4) to 

§425.502(e) to incorporate the new bonus points scoring methodology, but are revising the 

proposed language in order to reflect our decision to award up to 4 bonus points per domain. 

7. Technical Corrections 

 Currently §425.502(d)(2)(ii) states that ACOs must score above the minimum attainment 

level determined by CMS on 70 percent of the measures in each domain. If an ACO fails to 

achieve the minimum attainment level on at least 70 percent of the measures in a domain, CMS 

will take the actions described in §425.216(c). We note that §425.216, which addresses the 

actions we may take prior to termination of an ACO from the Shared Savings Program does not 

include a paragraph (c). To encompass all of the actions we may take prior to termination, we 

believe the correct reference should be to §425.216 generally, and therefore, proposed to make a 

technical correction to §425.502(d)(2)(ii) to eliminate the specific reference to paragraph (c) of 

§425.216. We also proposed to correct a typographical error in this provision by revising 

“actions describe” to read “actions described.” 

 In addition, we also proposed to make a technical correction to §425.502(a)(2). This 

provision currently states that ACOs will be assessed on performance based on the minimum 

attainment level for certain measures. However, as explained above and in the November 2011 

Shared Savings Program final rule (76 FR 67895 through 67896), ACO performance on a 

measure is assessed not only based on the minimum attainment level for the measure but also 

based upon the quality performance benchmark that has been established for that measure. This 

methodology for calculating the performance score for a measure is codified in the regulations at 
CMS-1612-FC 923

§425.502(c). Accordingly, we proposed to amend §425.502(a)(2) to state that ACO performance 

will be assessed based on the quality performance benchmark and minimum attainment level for 

certain measures. 

 We requested comments on these proposed technical corrections. 

 We received no objections to correcting the typographical errors and making these 

other minor technical corrections and are finalizing them as proposed. 
CMS-1612-FC 924

N. Value-Based Payment Modifier and Physician Feedback Program 

1. Overview 

Section 1848(p) of the Act requires that we establish a value-based payment modifier 

(VM) and apply it to specific physicians and groups of physicians the Secretary determines 

appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, 

2017. On or after January 1, 2017, section 1848(p)(7) of the Act provides the Secretary 

discretion to apply the VM to eligible professionals as defined in section 1848(k)(3)(B) of the 

Act. Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral. The VM program 

continues CMS’s initiative to increase the transparency of health care quality information and to 

assist providers and beneficiaries in improving medical decision-making and health care 

delivery.13

2. Governing Principles for VM Implementation. 

In the CY 2013 PFS final rule with comment period, we discussed the goals of the VM 

and also established that specific principles should govern the implementation of the VM (77 FR 

69307). We refer readers to that rule for a detailed discussion and list those principles here for 

reference. 

● A focus on measurement and alignment. Measures for the VM should consistently 

reflect differences in performance among groups or solo practitioners, reflect the diversity of 

services furnished, and be consistent with the National and CMS Quality Strategies and other 

CMS quality initiatives, including the PQRS, the Shared Savings Program, and the Medicare 

EHR Incentive Program. 

 

13 Kate Goodrich, et al. “A History and a Vision for CMS Quality Measurement Programs”. Joint Comm’n J. 

Quality & Patient Safety. 2012. 38,465, available at

http://www.ingentaconnect.com/content/jcaho/jcjqs/2012/00000038/00000010/art00006. 
CMS-1612-FC 925

● A focus on physician and eligible professional choice. Physicians and other 

nonphysician eligible professionals should be able to choose the level (individual or group) at 

which their quality performance will be assessed, reflecting eligible professionals’ choice over 

their practice configurations. The choice of level should align with the requirements of other 

physician quality reporting programs. 

● A focus on shared accountability. The VM can facilitate shared accountability by 

assessing performance at the group level and by focusing on the total costs of care, not just the 

costs of care furnished by an individual professional. 

● A focus on actionable information. The Quality and Resource Use Reports (QRURs) 

should provide meaningful and actionable information to help groups and solo practitioners 

identify clinical, efficiency and effectiveness areas where they are doing well, as well as areas in 

which performance could be improved by providing groups and solo practitioners with QRURs 

on the quality and cost of care they furnish to their patients. 

● A focus on a gradual implementation. The VM should focus initially on identifying 

high and low performing groups and solo practitioners. As we gain more experience with 

physician measurement tools and methodologies, we can broaden the scope of measures 

assessed, refine physician peer groups, create finer payment distinctions, and provide greater 

payment incentives for high performance. 

3. Overview of Existing Policies for the Physician VM. 

In the CY 2013 PFS final rule with comment period (77 FR 69310), we finalized policies 

to phase-in the VM by applying it beginning January 1, 2015, to Medicare PFS payments to 

physicians in groups of 100 or more eligible professionals. A summary of the existing policies 

that we finalized for the CY 2015 VM can be found in the CY 2014 PFS proposed rule (78 FR 

43486 through 43488). Subsequently, in the CY 2014 PFS final rule with comment period (78 
CMS-1612-FC 926

FR 74765 through 74787), we finalized policies to continue the phase-in of the VM by applying 

it starting January 1, 2016 to payments under the Medicare PFS for physicians in groups of 10 or 

more eligible professionals. 

4. Provisions of This Final Rule With Comment Period 

As a general summary, we proposed the following VM policies in the CY 2015 PFS 

proposed rule: 

● To apply the VM to all physicians and nonphysician eligible professionals in groups 

with two or more eligible professionals and to solo practitioners starting in CY 2017. 

● To make quality–tiering mandatory for groups and solo practitioners within Category 

1 for the CY 2017 VM. Where solo practitioners and groups with two to nine eligible 

professionals would be subject only to any upward or neutral adjustment determined under the 

quality-tiering methodology. 

● To tailor the application of the VM to physicians and nonphysician eligible 

professionals participating in the Medicare Shared Savings Program (Shared Savings Program), 

the Pioneer ACO Model, the CPC Initiative, or other similar Innovation Center models or CMS 

initiatives starting in CY 2017. 

● To clarify the exclusion of non-assigned claims for non-participating providers from 

the VM. 

● To increase the amount of payment at risk under the VM from 2.0 percent in CY 2016 

to 4.0 percent in CY 2017. 

● To align the quality measures and quality reporting mechanisms for the VM with those 

available to groups and individuals under the PQRS during the CY 2015 performance period. 

● To expand the current informal inquiry process to allow additional corrections for the 

CY 2015 payment adjustment period. 
CMS-1612-FC 927

● To address the concerns raised by NQF regarding the per capita cost measures in the 

cost composite. 

In this final rule with comment period, we discuss the proposed policies, the comments 

received, our responses to the comments, and a brief statement of our final policy. 

Comment: We received some comments on the VM in general that were not related to 

any specific proposal that we made in the proposed rule. Several commenters suggested that the 

CMS- hierarchical condition categories (HCC) Risk Adjustment methodology used in the total 

per capita cost measures for the VM does not accurately capture the additional costs associated 

with treating the sickest beneficiaries. Some of these commenters stated that groups that work 

exclusively in post-acute and long-term care settings would be unable to perform well on cost 

measures under the current methodology. Commenters suggested that we should include the 

place of service where the beneficiary received care in our methodology to set cost benchmarks 

such that groups would be compared against other groups that treat beneficiaries who are also 

receiving care in that type of location. 

Another commenter suggested that we add an additional adjustment for SNF CPT codes 

to account for higher costs of beneficiaries in this location. One commenter suggested that CMS 

exclude beneficiaries who receive a major organ transplant from our cost and quality measures 

because he believes that prospective HCC risk adjustment would not account for these added 

costs in the performance period. Another commenter stated that beneficiaries who receive care 

at home typically have high HCC scores and higher costs. This commenter suggested that CMS 

should consider exempting practices from the VM who treat a high number of beneficiaries with 

the highest HCC scores or those with more than a certain number of chronic conditions or 

activities of daily living dependencies, change the risk adjustment methodology to include the 

frailty adjuster used in the PACE program, or add “recognition of savings from expected costs.” 
CMS-1612-FC 928

Response: We appreciate the concerns raised by commenters and agree that it is 

important to make adjustments for differences in beneficiary characteristics that impact health 

and cost outcomes and are outside of the control of the provider. We continue to believe that our 

current methodology of using HCC scores that include adjustments for Medicare and Medicaid 

eligibility status in addition to diagnoses, and truncating costs at the 99th percentile for the 

highest cost beneficiaries, help address these concerns. While, the VM program does not, in the 

aggregate, adjust costs using an institutional risk score, the Medicare Spending per Beneficiary 

measure that will be used as part of the cost composite in 2014 does adjust costs based on 

whether a beneficiary recently required long-term institutional care as well as for whether a 

beneficiary is new to the Medicare program. We addressed the idea of adjusting cost measures 

for differences in site of service, as it pertained to hospitals, in the FY 2012 IPPS Final Rule (76 

FR 51825). We continue to believe that such adjustments would undermine the ability of our 

measures to meaningfully capture differences in Medicare spending. To address concerns 

regarding specialties that might routinely treat more complex and consequently more costly 

beneficiaries, we finalized in the CY 2013 PFS final rule with comment period that we would 

apply a specialty adjustment to all cost measures used in the VM (78 FR 74776). This enables 

groups’ costs to be compared to similarly-comprised groups, based on specialty. In 2011, an 

independent analysis concluded that this risk-adjustment methodology is effective at predicting 

actual costs, even for beneficiaries with serious or multiple chronic illnesses.14 Moreover, the 

academic literature notes the multi-variant nature of care quality and the importance of defining 

measures across rather than simply within care settings.15

 

14 Gregory C. Pope, et al. “Evaluation of the CMS-HCC Risk Adjustment Model: Final Report.” (March 2011). 

15 Tracy E. Spinks, et al. Delivering high-quality cancer care: The critical role of quality measurement. Healthcare. 

2014. 2,53-62. 
CMS-1612-FC 929

We note that high costs within the post-acute and long-term care settings present a unique 

opportunity for these providers to improve performance on cost and quality measures. While we 

continue to encourage providers to report quality measures for patients in these settings and to 

use the information contained in their QRUR to improve and achieve high levels of performance, 

we will continue to monitor these groups and solo practitioners’ performance under the VM and 

continue to explore potential risk adjustment refinements.. 

a. Group Size 

As noted in section III.N.1, section 1848(p)(4)(B)(iii)(II) of the Act requires the Secretary 

to apply the VM to items and services furnished under the PFS beginning not later than January 

1, 2017, for all physicians and groups of physicians. Therefore, we proposed to apply the VM in 

CY 2017 and each subsequent calendar year payment adjustment period to physicians in groups 

of physicians with two or more eligible professionals and to physicians who are solo 

practitioners (79 FR 40493-40495). For purposes of the VM, we defined a physician, a group of 

physicians, and an eligible professional in the CY 2013 PFS final rule with comment period (77 

FR 69307-69310). We proposed to define a “solo practitioner” at §414.1205 as a single Tax 

Identification Number (TIN) with one eligible professional who is identified by an individual 

National Provider Identifier (NPI) billing under that TIN. We noted that this proposal to apply 

the VM to all solo practitioner physicians and all groups of physicians would complete our 

phase-in of the VM as required by the Act. 

In the proposed rule, we stated our belief that we can validly and reliably apply the VM 

to groups with two or more eligible professionals and to solo practitioners (79 FR 40494). We 

noted that we conducted statistical reliability analysis on the PQRS quality measures and the VM 

cost measures reported in the 2010 and 2011 group and individual Quality and Resource Use 

Reports (QRURs) (78 FR 43500 through 43502) and found that 98 percent of the PQRS 
CMS-1612-FC 930

measures included in the analysis, which were substantially similar to the PQRS measures that 

will be assessed during performance period CY 2015 for purposes of the VM, were highly 

reliable. As stated in the proposed rule, we believe that these results suggest that we can reliably 

apply these measures to solo practitioners and groups (79 FR 40494). In section III.N.4.h, we 

discuss the reliability of the all-cause readmission measure and the policy we are finalizing to 

address reliability concerns regarding that measure. 

In Table 55 of the proposed rule, we presented the number of groups, eligible 

professionals, physicians, and nonphysician eligible professionals in groups of various sizes 

based on an analysis of CY 2012 claims with a 90-day run-out period (79 FR 40494). We 

estimated that our proposals to apply the VM to all groups with two or more eligible 

professionals and to all solo practitioners in CY 2017 would affect approximately 83,500 groups 

and 210,000 solo practitioners (as identified by their TINs). We further estimated that the groups 

consist of approximately 815,000 physicians and 315,000 nonphysician eligible professionals (79 

FR 40493). 

For this final rule with comment period, we have updated Table 55 from the proposed 

rule, using CY 2013 claims with a 90-day claim run-out period and including TINs that 

participated in the Shared Savings Program, the Pioneer ACO Model, or the Comprehensive 

Primary Care Initiative in 2013. Table 86 shows the number of groups, eligible professionals, 

physicians, and nonphysician eligible professionals in groups of various sizes. We note that the 

number of eligible professionals includes other practitioners, such as physician assistants and 

nurse practitioners, in addition to physicians. We estimate that final policy to apply the VM to 

all physicians in groups with two or more eligible professionals and to all physicians who are 

solo practitioners in CY 2017 would affect approximately 900,000 physicians. 

 
CMS-1612-FC 931

TABLE 86: Eligible Professional/Physician Group Size Distribution (2013 claims) 

Group Size 

Number of 

Groups 

(TINs)* 

Eligible 

Professionals 

(EPs) 

Number of 

Physicians 

Number of 

Nonphysician 

EPs 

Percent of 

Physicians 

Percent of 

Nonphysician 

EPs 

100+ EPs 1,345 404,738 297,175 107,563 33% 30% 

50-99EPs 1,753 119,979 81,679 38,300 9% 11% 

25-49 EPs 3,926 134,038 90,141 43,897 10% 12% 

20-24 EPs 1,957 42,733 29,112 13,621 3% 4% 

10-19 EPs 8,697 117,164 78,893 38,271 9% 11% 

2-9 EPs 69,455 244,800 171,627 73,173 19% 20 

1 EP 205,084 205,084 159,770 45,314 18% 13 

Total 292,217 1,268,536 908,397 360,139 100% 100% 

*The number of groups (TINs) include TINs that have one or more EPs participating in the Shared Savings 

Program, the Pioneer ACO Model, or the Comprehensive Primary Care Initiative. 

 

In the proposed rule (79 FR 40494), we stated that in the CY 2014 PFS final rule with 

comment period, we finalized the proposal that if we are unable to attribute a sufficient number 

of beneficiaries to a group of physicians subject to the VM, and thus, are unable to calculate any 

of the cost measures with at least 20 cases, then the group’s cost composite score would be 

classified as ‘‘average’’ under the quality-tiering methodology (78 FR 74780 through 74781). 

However, we noted this policy was codified in § 414.1270(b)(5) as a group of physicians subject 

to the value-based payment modifier will receive a cost composite score that is classified as 

‘‘average’’ under §414.1275(b)(2) if such group does not have at least one cost measure with at 

least 20 cases. We stated that we believe the regulation text at §414.1270(b)(5) better reflects the 

intent of this policy, and accordingly, we proposed to clarify that the description of this policy in 

the preamble of the CY 2014 PFS final rule with comment period (78 FR 74780 through 74781) 

should be the same as the regulation text at §414.1270(b)(5). We also proposed to apply the 

same policy to groups and solo practitioners beginning in CY 2017. That is, a group or solo 
CMS-1612-FC 932

practitioner would receive a cost composite score that is classified as ‘‘average’’ under the 

quality-tiering methodology if the group or solo practitioner does not have at least one cost 

measure with at least 20 cases. We proposed to revise § 414.1270 accordingly. 

We proposed to revise §414.1210 to reflect that beginning in the CY 2017 payment 

adjustment period, the VM would be applied to physician and nonphysician eligible 

professionals in groups with two or more eligible professionals and to solo practitioners based on 

the performance period described at §414.1215 (79 FR 40495). Accordingly, we proposed to 

amend the regulations under subpart N to add references to solo practitioners. We solicited 

comments on all of these proposals. 

The following is summary of the comments we received on these proposals.

 Comment: We received one comment that supported our proposed definition of a “solo 

practitioner.” 

Response: We appreciate this comment and are finalizing the definition of a “solo 

practitioner” to mean, “a single Taxpayer Identification Number (TIN) with one eligible 

professional who is identified by an individual National Provider Identifier (NPI) billing under 

the TIN.” We are codifying this definition at §414.1205. 

Comment: Several commenters expressed concern that the cost measures potentially 

have little relevance to some provider groups and may leave some with an arbitrary label of 

“average” cost, if the minimum case number requirement for the cost measure is not met due to 

an insufficient number of beneficiaries being attributed to the group. 

Response: As we stated in the CY 2014 PFS final rule with comment period 

(78 FR 74780), we continue to believe that groups that are attributed fewer than the minimum 

case size of 20 beneficiaries would not allow for the calculation of reliable cost measures. We 

are concerned that not classifying the group as “average” when it has fewer than 20 attributed 
CMS-1612-FC 933

beneficiaries for at least one cost measure would increase the likelihood that its cost 

measures could fluctuate greatly from year to year. Therefore, we are finalizing our proposal 

that beginning in CY 2017 a group or solo practitioner will receive a cost composite score that is 

classified as “average” under the quality-tiering methodology if the group or solo practitioner 

does not have at least one cost measure with at least 20 cases and codifying the policy as 

proposed in §414.1270. We are also finalizing our proposal to clarify that the description of this 

policy in the preamble of the CY 2014 PFS final rule with comment period (78 FR 74780 

through 74781) for groups of physicians should be the same as the regulation text at 

§414.1270(b)(5). 

Comment: Several commenters, citing the Secretary’s statutory obligation, supported our 

proposal to apply the VM in the CY 2017 payment adjustment year to solo practitioner 

physicians and to groups of physicians with two or more eligible professionals. Other 

commenters opposed our proposed policy notwithstanding the statutory obligation to apply the 

VM to all physicians and groups of physicians beginning not later than January 1, 2017. 

Commenters stated that we should delay the application of the VM to all physicians, either 

through selective implementation or requesting that Congress amend the statute. Some 

commenters stated that, due to provider resource constraints, lack of access to adequate technical 

support, and potential lack of understanding of the information provided through the Physician 

Feedback Program, we should postpone the extension of the VM to smaller group practices and 

solo practitioners. Some commenters suggested that the VM would negatively impact 

physicians, especially given the proposed increase in the amount of payment at risk for CY 2017. 

Response: We disagree that the VM’s application to smaller groups and solo 

practitioners should be delayed. In addition to the statutory requirement to apply the VM to all 

physicians and groups of physicians beginning not later than January 1, 2017, the application of 
CMS-1612-FC 934

the VM to all physician groups and solo practitioners is essential to our ongoing efforts to 

encourage improvement in the quality and efficiency of care provided to Medicare beneficiaries 

and should not be delayed. The literature highlights that the majority of patients receive care in 

group practices with one or two physicians16 and that historically, smaller group practices have 

participated in quality improvement programs at lower rates than larger group practices.17 

Recent research also concludes that EHR-enabled small practices responded to incentives to 

improve quality of care on process and intermediate-outcome measures.18 For these reasons, we 

believe that the application of the VM to smaller group practices and solo practitioners has the 

potential to incentivize increased participation in quality reporting and quality improvement 

activities and that smaller groups and solo practitioners have the potential to perform well under 

the VM. 

The application of the VM to groups of two to nine eligible professionals and to solo 

practitioners in CY 2017 is consistent with our principle to focus on a gradual implementation of 

the VM. The financial impact of applying the VM to groups of two to nine eligible professionals 

and to solo practitioners will be eased since, we are finalizing a policy to hold them harmless 

from any downward payment adjustments under quality-tiering in CY 2017 (as discussed in 

section III.N.4.c.) and also finalizing a smaller downward payment adjustment under the VM for 

these groups and solo practitioners that are in Category 2 in CY 2017 (as discussed in section 

III.N.4.f below). Please note that in section III.N.4.b of this final rule with comment period, we 

are finalizing that the VM will apply to nonphysician eligible professionals in groups subject to 

the VM and to nonphysician eligible professionals who are solo practitioners beginning in the 

 

16 Sowmya R Rao, et al. Electronic health records in small physician practices: availability, use, and perceived 

benefits. J. Am. Med. Information Ass’n. 2011. 18, 271-275. 

17 Anne-Marie J. Audet, et al. Measure, Learn, And Improve: Physicians’ Involvement in Quality Improvement. 

Health Affairs. 2005. 24,843-853. 

18 Naomi S. Bardach, et al., Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With 

Electronic Health Records. J. Amer. Med. Ass’n. 2013. 310,1051-1059. 
CMS-1612-FC 935

CY 2018 payment adjustment period. 

Comment: Several commenters stated that CMS should ensure that the quality and cost 

measures are reliable and valid for small practices and solo practitioners before expanding the 

VM to all physicians. 

Response: Since the inception of the VM program, we have committed to establish a 

payment modifier that relies on a focused core set of measures appropriate to each specific 

provider category that reflects the level of care and the most important areas of service and 

measures for that provider (77 FR 69306). Analysis of the Physician Feedback Program 

confirms that the measures on which the VM is based are highly reliable, especially those that 

are self-reported.19 As stated in the proposed rule (79 FR 40494), we will be basing the quality 

of care composite on the PQRS measures selected, and reported on, by the groups (or the eligible 

professionals in the groups) and the solo practitioners, which enables us to recognize the 

diversity of reporting options for individuals and groups under the PQRS program and provide 

flexibility on the data they report for quality measures under the PQRS. This also allows these 

groups and solo practitioners the opportunity to choose measures that are relevant to their patient 

populations and consistent with clinical practice and high quality care. Moreover, our policy will 

mitigate any unintended consequences of the VM payment adjustment on smaller groups by 

holding harmless solo practitioner physicians and physicians in groups with two to nine eligible 

professionals from any downward payment adjustments under quality-tiering in CY 2017 (see 

section III.N.4.c of this final rule with comment period). 

We conducted an additional analysis of the cost measures for the VM, using our specialty 

benchmarking methodology and found the per capita cost measures to be reliable for solo 

 

19 Mathematica Policy Research, Experience Report for the Performance Year 2012 Quality and Resource Use 

Reports (January 8, 2014), available at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/2012-QRUR_Experience_Report.pdf. 
CMS-1612-FC 936

practitioners and groups of two or more eligible professionals. That analysis may be found at: 

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. 

Comment: Some commenters expressed concern about the VM’s impact on providers 

who treat high-cost patients and on certain specialties, such as anesthesiology, for which few 

quality measures are available. 

Response: The VM program continues to believe in the importance of stakeholder 

engagement for establishing quality metrics. To that end, we engage the National Quality Forum 

to pursue national endorsement of measures used in PQRS and the VM program. We are 

committed to using PQRS as the foundation for measurement of the performance rates for solo 

practitioner physicians and groups of physicians subject to the VM (77 FR 69314). Moreover, 

we recognized early in the VM program that the PQRS may not provide specialists and subspecialists the flexibility to report on measures that are relevant to their unique patient panels. 

As discussed later, in section III.N.4.h, in previous rulemakings, we have committed to 

expanding the specialty measures available in the PQRS in order to more accurately measure the 

performance on quality of care furnished by specialists. We also reaffirm our commitment to 

using measures of performance across specialties that are reliable and valid for the VM program 

(77 FR 69315; 78 FR 74773). 

Physicians have sufficient flexibility to choose the quality reporting method–PQRS 

GPRO web-interface, claims, registries, qualified clinical data registries, and EHR reporting 

mechanisms, as well as the measures on which to report information. The expansion of the 

GPRO to registries in 2013 and to EHRs in 2014 allowed sub-specialists to participate in PQRS 

as members of a group practice, such that the group could report data on measures of broad 

applicability (77 FR 69315). The claims-based outcome measures used in the VM afford groups 
CMS-1612-FC 937

and solo practitioners an additional opportunity to earn a quality composite score that is above 

average. Where a group or solo practitioner falls in Category 1 under the VM (that is, meets the 

criteria to avoid the CY 2017 PQRS payment adjustment), but the group or solo practitioner does 

not have at least 20 cases for each PQRS measure on which it reports as required for inclusion in 

the quality composite of the VM, the group or solo practitioner’s quality composite score would 

be based on the three claims-based outcome measures described at §414.1230, provided that the 

group or solo practitioner has at least 20 cases for at least one of the claims-based outcome 

measures. 

In addition, as discussed in section III.N.4.h of this final rule with comment period, 

eligible professionals and groups should note that PQRS has a Measure Applicability Validation 

(MAV) process. MAV determines PQRS incentive eligibility or potential applicability of the 

payment adjustment for eligible professionals and groups reporting less than nine measures 

across three domains or nine or more across less than three domains. We recommend that 

commenters refer to the Measure Application Validation (MAV) Process to alleviate concerns 

that lack of applicable measures would result in an automatic downward adjustment under the 

VM . http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013

.zip. Also, please refer to section III.K.2 of this final rule with comment period for the final 2017 

policies for MAV and the criteria for satisfactory reporting for the 2017 PQRS payment 

adjustment. 

Comment: Commenters cited that solo practitioners and groups with 2 to 24 eligible 

professionals, who received a QRUR in fall 2014, will have a short period of time to analyze 

their performance data and to prepare for the CY 2015 performance period. 

Response: On September 30, 2014, we made Quality and Resource Use Reports 
CMS-1612-FC 938

(QRURs) available to all group of physicians and physicians who are solo practitioners based on 

their performance in CY 2013. As we stated in the CY 2015 proposed rule (79 FR 40494-95), 

we believe that we have provided small groups and solo practitioners sufficient time to 

understand how the VM works and how to participate in the PQRS. We are sensitive to groups 

and solo practitioners who may need adequate lead time to understand the impact of the 

beneficiary attribution method used for the VM. At the time that we made our proposal to apply 

the VM to solo practitioners and groups of 2 to 25 EPs, available research suggested that the 

information provided in the QRURs is relevant to solo practitioners and groups for future quality 

improvement efforts. Published literature suggests that, of the beneficiaries assigned in one year 

to a group practice under the Shared Savings Program attribution rule, which is substantially 

similar to the one used in the VM program – 80 percent were assigned to that same group 

practice the following year.20 In response to commenters’ concerns, we also conducted an 

additional analysis using the VM attribution methodology and determined that, of the 

beneficiaries assigned to a given TIN for the five cost and 3 outcome measures included in the 

VM for 2017, approximately 76% were assigned to the same TIN for these measures, in both 

2012 and 2013. 

More importantly, we believe our final policy to hold harmless groups with two to nine 

eligible professionals and solo practitioners from any downward payment adjustments under 

quality-tiering in CY 2017 would likely mitigate unintended consequences that could occur (see 

section III.N.4.c of this final rule). We note that in the 2013 QRUR Experience Report, which 

will be released in the next few months, we will provide a detailed analysis of the impact of the 

2015 VM policies on groups of 100 or more eligible professionals subject to the VM in CY 

 

20 J. Michael McWilliams, et al. Outpatient Care Patterns and Organizational Accountability in Medicare. 2014. 

174,938-945. 
CMS-1612-FC 939

2015, including findings based on the data contained in the 2013 QRURs for all groups of 

physicians and solo practitioners. 

Comment: Several commenters believed that physicians had have little experience with 

the PQRS program and physicians generally do not understand the methodology used to 

calculate the VM and therefore urged CMS to increase its outreach and education efforts. One 

commenter urged CMS to publicly share the VM methodology, as well as the results of the 

reliability and validity testing of the measures used in the calculation of the VM. 

Response: In response to the comments about physicians not being familiar with the 

PQRS program or not understanding the methodology used to calculate the VM, we strongly 

encourage physicians to proactively educate themselves about the PQRS and VM programs by 

visiting the PQRS website http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html and VM/QRUR website 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/index.html. The PQRS website contains detailed 

information about how groups and individual eligible professionals can participate in the PQRS 

program, including information on how to avoid the PQRS payment adjustment. The 

VM/QRUR website (https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/index.html) contains information on the VM policies for 

each applicable payment adjustment year, including detailed information on the methodology 

used to calculate the CY 2015 VM shown in the CY 2013 QRURs and how to use the 

information contained in the QRURs. We note that we work with medical and specialty 

associations throughout the year to educate them about the PQRS and VM programs and the 

QRURs. Further outreach will be also be undertaken by our Quality Improvement Organizations 

(QIOs), who will provide technical assistance to physicians and groups of physicians in an effort 
CMS-1612-FC 940

to help them improve quality and consequently, performance under the VM program. 

As we expand the application of the VM to all physicians, we will continue to monitor 

the VM program and continue to examine the characteristic of those groups of physicians and 

solo practitioners that could be subject to an upward or downward payment adjustment under our 

quality-tiering methodology to determine whether our policies create anomalous effects in ways 

that do not reflect consistent differences in performance among physicians and physician groups. 

After considering the public comments, we are finalizing the proposal and regulation text 

at §414.1210(a)(3) that, beginning with the CY 2017 payment adjustment period, the VM will 

apply to physicians in groups with two or more eligible professionals and to physicians who are 

solo practitioners based on the performance period described at §414.1215. We are finalizing the 

definition of a “solo practitioner” at §414.1205 and amending the regulations under subpart N to 

add references to solo practitioners. We are also finalizing our proposal and the regulation text 

at § 414.1270(c)(5) that beginning in CY 2017 a group or solo practitioner will receive a cost 

composite score that is classified as “average” under the quality-tiering methodology if the group 

or solo practitioner does not have at least one cost measure with at least 20 cases. We are also 

finalizing our proposal to clarify that the description of this policy in the preamble of the CY 

2014 PFS final rule with comment period (78 FR 74780 through 74781) for groups of physicians 

should be the same as the regulation text at §414.1270(b)(5). 

b. Application of the VM to Nonphysician EPs 

As noted above, section 1848(p) of the Act requires that we establish the VM and apply it 

to items and services furnished under the PFS beginning on January 1, 2015, for specific 

physicians and groups of physicians the Secretary determines appropriate, and beginning not 

later than January 1, 2017, for all physicians and groups of physicians. Section 1848(p)(7) of the 

Act provides the Secretary discretion to apply the VM on or after January 1, 2017 to eligible 
CMS-1612-FC 941

professionals as defined in section 1848(k)(3)(B) of the Act. As previously finalized in the CY 

2013 PFS final rule with comment period, in payment adjustment years CY 2015 and CY 2016, 

we will apply the VM to Medicare payments for items and services billed under the PFS by 

physicians in groups (as identified by their Medicare-enrolled TIN) subject to the VM, but not to 

the other eligible professionals that also may bill under the TIN (77 FR 69312). We finalized in 

the CY 2013 PFS final rule with comment period (77 FR 69307 through 69310) that physicians, 

as defined in section 1861(r) of the Act, include doctors of medicine or osteopathy, doctors of 

dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, and 

chiropractors. 

In section III.N.4.a of this final rule with comment period, we finalized our proposal to 

apply the VM in the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period to physicians in groups of physicians with two or more eligible 

professionals and to physicians who are solo practitioners as required by section 

1848(p)(4)(B)(iii)(II) of the Act. 

In the CY 2015 PFS proposed rule, based on the Secretary’s discretion under section 

1848(p)(7) of the Act, we proposed to apply the VM beginning in the CY 2017 payment 

adjustment period to all of the eligible professionals in groups with two or more eligible 

professionals and to eligible professionals who are solo practitioners (79 FR 40495-40496). That 

is, we proposed to apply the VM beginning in CY 2017 to the items and services billed under the 

PFS by all of the physicians and nonphysician eligible professionals who bill under a group’s 

TIN. We proposed to apply the VM beginning in CY 2017 to groups that consist only of 

nonphysician eligible professionals (for example, groups with only nurse practitioners or 

physician assistants). We also proposed to modify the definition of “group of physicians” under 

§414.1205 to also include the term “group” to reflect these proposals. We also proposed to apply 
CMS-1612-FC 942

the VM beginning in CY 2017 to nonphysician eligible professionals who are solo practitioners. 

Additionally, we proposed that physicians and nonphysician eligible professionals would be 

subject to the same VM policies established in earlier rulemakings and under 42 CFR part 414, 

subpart N. For example, nonphysician eligible professionals would be subject to the same 

amount of payment at risk and quality-tiering policies as physicians. We proposed to modify the 

regulations under 42 CFR part 414, subpart N, accordingly. 

We finalized in the CY 2013 PFS final rule with comment period (77 FR 69307 through 

69310) that, for purposes of establishing group size, we will use the definition of an eligible 

professional as specified in section 1848(k)(3)(B) of the Act. This section defines an eligible 

professional as any of the following: (1) a physician; (2) a practitioner described in section 

1842(b)(18)(C) of the Act: physician assistant, nurse practitioner, clinical nurse specialist, 

certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical 

psychologist, registered dietician, or nutrition professional; (3) a physical or occupational 

therapist or a qualified speech-language pathologist; or (4) a qualified audiologist. 

Beginning CY 2017, under our proposal, the VM would apply to all of the eligible 

professionals, as specified in section 1848(k)(3)(B) of the Act, that bill under a group’s TIN 

based on the TIN’s performance during the applicable performance period. During the payment 

adjustment period, all of the nonphysician eligible professionals who bill under a group’s TIN 

would be subject to the same VM that would apply to the physicians who bill under that TIN. 

This proposal was consistent with our stated principle that the VM should focus on 

shared accountability (77 FR 69307). We continue to believe that the VM can facilitate shared 

accountability by assessing performance at the group practice level and by focusing on the total 

costs of care, not just the costs of care furnished by an individual physician. 
CMS-1612-FC 943

Moreover, section 1848(p)(5) of the Act requires us to, as appropriate, apply the VM “in 

a manner that promotes systems-based care.” We stated in the CY 2013 PFS proposed rule that, 

in this context, systems-based care is the processes and workflows that (1) make effective use of 

information technologies, (2) develop effective teams, (3) coordinate care across patient 

conditions, services, and settings over time, and (4) incorporate performance and outcome 

measurements for improvement and accountability.21 (77 FR 44996) We stated in the CY 2015 

PFS proposed rule, we believe that applying the VM to all of the eligible professionals in a 

group, rather than only the physicians in the group, would enhance the group’s ability and 

resources to redesign processes and workflows to achieve these objectives and furnish highquality and cost-effective clinical care with greater care coordination (79 FR 40496). 

As mentioned above, we also proposed to apply the VM to groups that consist only of 

nonphysician eligible professionals, as well as solo practitioners who are nonphysician eligible 

professionals beginning in CY 2017 (79 FR 40496). Consistent with the application of the VM 

to groups of physicians and groups that contain both physicians and nonphysician EPs, the 

quality of care composite for groups that consist only of nonphysician EPs and solo practitioner 

nonphysician EPs would be based on the quality data submitted under the PQRS at the group or 

individual level in accordance with our existing policy. To the extent we are able to attribute 

beneficiaries to these groups and solo practitioners under the attribution methodology proposed 

in section III.N.4.j of the proposed rule to calculate cost measures, we proposed to calculate the 

cost composite using those cost measures. If a cost composite could not be calculated for a 

group or solo practitioner, then we proposed to classify the group or solo practitioner’s cost 

 

21 Johnson JK, Miller SH, Horowitz SD. Systems-based practice: Improving the safety and quality of patient care by 

recognizing and improving the systems in which we work. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. 

Advances in Patient Safety: New Directions and Alternative Approaches, Vol 2: Culture and Redesign. AHRQ 

Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. p. 321-330. 
CMS-1612-FC 944

composite as “average” as specified in §414.1270. We solicited comments on all of our 

proposed policies for applying the VM to nonphysician eligible professionals beginning in CY 

2017. 

The following is summary of the comments we received on all of our proposed policies 

for applying the VM to nonphysician eligible professionals beginning in CY 2017. 

Comment: Several commenters supported our proposal to apply the VM to nonphysician 

eligible professionals beginning in CY 2017. These commenters stated that the proposal would 

support the goal of shared accountability and urged CMS to include their cost and quality data in 

the QRURs. Some of the commenters wanted nonphysician eligible professionals to be held 

harmless from any downward payment adjustments under the VM. 

Most of the commenters urged CMS to delay implementation of the VM for 

nonphysician eligible professionals and suggested that CMS adopt a phased approach that gives 

nonphysician eligible professionals more time to understand and prepare for the implementation 

of the VM. One commenter was specifically concerned about nonphysician eligible 

professionals who are solo practitioners or in groups with two to nine eligible professionals not 

having time to prepare for the implementation of the VM. Commenters expressed concern that 

nonphysician eligible professionals have not been sufficiently prepared for the VM because: 

prior PFS rules did not indicate that nonphysician eligible professionals may be included in the 

VM in the future; nonphysician eligible professional groups have not yet received a QRUR; 

nonphysician eligible professionals have not received targeted education regarding application of 

the VM to them; and the proposal does not allow nonphysician eligible professionals the same 

phased-in approach to the VM that CMS provided to physician groups. One commenter 

recommended that CMS not apply the VM to nonphysician eligible professionals until CMS 

adopts meaningful specialty designations. Other commenters indicated that some nonphysician 
CMS-1612-FC 945

eligible professionals groups will not be attributed cost measures since they do not bill evaluation 

and management codes. A few commenters were concerned about the low participation rates of 

nonphysician eligible professionals in the PQRS program. A few commenters proposed a 

phased-in approach for implementation of the VM for nonphysician eligible professionals, which 

they stated would be consistent with the implementation of the VM for physician groups. 

Response: We agree with the commenters that nonphysician eligible professionals would 

benefit from additional time to become familiar with participation in the PQRS program and the 

VM methodology. Therefore, we are not finalizing our proposal to apply the VM beginning in 

the CY 2017 payment adjustment period to nonphysician eligible professionals in groups with 

two or more eligible professionals and to nonphysician eligible professionals who are solo 

practitioners. Instead, we are finalizing that we will apply the 

VM beginning in the CY 2018 payment adjustment period to nonphysician eligible professionals 

in groups with two or more eligible professionals and to nonphysician eligible professionals who 

are solo practitioners. We added paragraph (a)(4) to §414.1210 to reflect this policy. We note 

that in the CY 2015 PFS proposed rule, we did not propose a performance period for the CY 

2018 payment adjustment period for the VM. The performance periods we have established in 

prior rulemaking for the VM have been two calendar years prior to the beginning of the payment 

adjustment year (for example, CY 2013 was the performance period for the VM applied in CY 

2015). We expect to propose the performance period for the CY 2018 payment adjustment 

period for the VM in the CY 2016 PFS proposed rule. 

We believe that delaying the implementation of the VM to nonphysician eligible 

professionals until CY 2018 is consistent with our stated objective to focus on gradual 

implementation of the VM. The delay would also provide additional time for nonphysician 

eligible professionals to learn about how to participate in the PQRS program and to become 
CMS-1612-FC 946

knowledgeable about the policies for calculating the VM. Information about the VM is 

available on the VM/QRUR website at http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeedbackProgram/index.html. 

Under our final policy, we will apply the VM beginning in CY 2018 to the items and 

services billed under the PFS by all of the physicians and nonphysician eligible professionals 

who bill under a group’s TIN. We are finalizing that we will apply the VM beginning in CY 

2018 to groups that consist only of nonphysician eligible professionals (for example, groups with 

only nurse practitioners or physician assistants). Beginning in CY 2018, the VM will apply to all 

of the eligible professionals, as specified in section 1848(k)(3)(B) of the Act, that bill under a 

group’s TIN based on the TIN’s performance during the applicable performance period. During 

the payment adjustment period, all of the nonphysician eligible professionals who bill under a 

group’s TIN will be subject to the same VM that will apply to the physicians who bill under that 

TIN. We are finalizing the proposed modification to the definition of “group of physicians” 

under §414.1205 to also include the term “group” to reflect these final policies. We are also 

finalizing the policy to apply the VM beginning in CY 2018 to nonphysician eligible 

professionals who are solo practitioners. 

Additionally, we are finalizing that beginning in CY 2018, physicians and nonphysician 

eligible professionals will be subject to the same VM policies established in earlier rulemakings 

and under subpart N. For example, nonphysician eligible professionals will be subject to the 

same amount of payment at risk and quality-tiering policies as physicians. We are finalizing the 

proposed modifications to the regulations under subpart N accordingly. 

However, since CY 2018 will be the first year that groups that consist only of 

nonphysician eligible professionals and solo practitioners who are nonphysician eligible 

professionals will be subject to the VM, we are finalizing a policy to hold these groups and solo 
CMS-1612-FC 947

practitioners harmless from downward adjustments under the quality-tiering methodology in CY 

2018. We will add regulation text under §414.1270 to reflect this policy when we establish the 

policies for the VM for the CY 2018 payment adjustment period in future rulemaking. 

 c. Approach to Setting the VM Adjustment Based on PQRS Participation 

In the CY 2014 PFS final rule with comment period (78 FR 74767-74768), we adopted a 

policy to categorize groups of physicians subject to the VM in CY 2016 based on a group’s 

participation in the PQRS. Specifically, we categorize groups of physicians eligible for the CY 

2016 VM into two categories. Category 1 includes groups of physicians that (a) meet the criteria 

for satisfactory reporting of data on PQRS quality measures through the GPRO for the CY 2016 

PQRS payment adjustment or (b) do not register to participate in the PQRS as a group practice in 

CY 2014 and that have at least 50 percent of the group’s eligible professionals meet the criteria 

for satisfactory reporting of data on PQRS quality measures as individuals for the CY 2016 

PQRS payment adjustment, or in lieu of satisfactory reporting, satisfactorily participate in a 

PQRS-qualified clinical data registry for the CY 2016 PQRS payment adjustment. For a group 

of physicians that is subject to the CY 2016 VM to be included in Category 1, the criteria for 

satisfactory reporting (or the criteria for satisfactory participation, if the PQRS-qualified clinical 

data registry reporting mechanism is selected) must be met during the CY 2014 reporting period 

for the PQRS CY 2016 payment adjustment. For the CY 2016 VM, Category 2 includes those 

groups of physicians that are subject to the CY 2016 VM and do not fall within Category 1. For 

those groups of physicians in Category 2, the VM for CY 2016 is -2.0 percent. 

We proposed to use a similar two-category approach for the CY 2017 VM based on 

participation in the PQRS by groups and solo practitioners (79 FR 40496). To continue to align 

the VM with the PQRS and accommodate the various ways in which EPs can participate in the 

PQRS, for purposes of the CY 2017 VM, we proposed that Category 1 would include those 
CMS-1612-FC 948

groups that meet the criteria for satisfactory reporting of data on PQRS quality measures via the 

GPRO (through use of the web-interface, EHR, or registry reporting mechanisms, as proposed in 

section III.K of the proposed rule) for the CY 2017 PQRS payment adjustment. Our proposed 

criteria for satisfactory reporting of data on PQRS quality measures via the GPRO for the PQRS 

payment adjustment for CY 2017 are described in section III.K of the proposed rule. We also 

proposed to include in Category 1 groups that do not register to participate in the PQRS as a 

group practice participating in the PQRS group practice reporting option (GPRO) in CY 2015 

and that have at least 50 percent of the group’s eligible professionals meet the criteria for 

satisfactory reporting of data on PQRS quality measures as individuals (through the use of 

claims, EHR, or registry reporting mechanism,) for the CY 2017 PQRS payment adjustment, or 

in lieu of satisfactory reporting, satisfactorily participate in a PQRS-qualified clinical data 

registry for the CY 2017 PQRS payment adjustment, all as proposed in section III.K of the 

proposed rule. We noted that these proposals are consistent with the policies for inclusion in 

Category 1 as established for the CY 2016 VM (78 FR 74767 through 74768). We would 

maintain the 50 percent threshold for the CY 2017 VM as we expand the application of the VM 

to all groups and solo practitioners in CY 2017. Our proposed criteria for satisfactory reporting 

by individual eligible professionals for the claims, EHR, and registry reporting mechanisms and 

for satisfactory participation in a qualified clinical data registry for the CY 2017 PQRS payment 

adjustment are described in section III.K of the proposed rule. Lastly, we proposed to include in 

Category 1 those solo practitioners that meet the criteria for satisfactory reporting of data on 

PQRS quality measures as individuals (through the use of claims, registry, or EHR reporting 

mechanism) for the CY 2017 PQRS payment adjustment, or in lieu of satisfactory reporting, 

satisfactorily participate in a PQRS-qualified clinical data registry for the CY 2017 PQRS 

payment adjustment, all as proposed in section III.K of the proposed rule. Category 2 would 
CMS-1612-FC 949

include those groups and solo practitioners that are subject to the CY 2017 VM and do not fall 

within Category 1. As discussed in the proposed rule (79 FR 40505), for CY 2017, we proposed 

to apply a -4.0 percent VM to groups with two or more eligible professionals and solo 

practitioners that fall in Category 2. We solicited comment on these proposals. 

The following is summary of the comments we received on these proposals. 

Comment: A number of commenters supported our proposal to continue to account for 

eligible professionals that participate in the PQRS as individuals in the determination of groups 

and solo practitioners that would be in Category 1. One commenter indicated that our proposals 

allow groups to have the flexibility to choose a PQRS reporting mechanism that best fits the 

practice. One commenter did not support the use of both group and individual reporting 

mechanisms to determine whether a group falls in Category 1, indicating that it makes 

comparisons among groups that choose to report as a group compared to a group whose eligible 

professionals report as individuals inequitable. 

Response: We appreciate commenters’ support for our proposal to provide a way to 

combine individually reported PQRS measures into a group score for purposes of the CY 2017 

VM. In response to the commenter’s concern about the use of the individual reporting 

mechanisms in the VM, we believe that the use of both the individually reported PQRS measures 

and the PQRS GPRO measures to calculate the quality composite of the VM recognizes 

recognize the diversity of physician practices and the various measures used to assess quality of 

care furnished by these practices. As we stated in the CY 2014 PFS final rule with comment 

period (78 FR 74767), one of the principles governing our implementation of the VM is to align 

program requirements to the extent possible. Thus, we expect to continue to align the VM with 

the PQRS program requirements and reporting mechanisms to ensure physicians and groups of 

physicians report data on quality measures that reflect their practice. 
CMS-1612-FC 950

Furthermore, we do not believe that comparing quality composite scores based on PQRS 

GPRO measures or individually reported PQRS measures would create inequities because a 

group’s performance reflects the underlying eligible professionals on whose behalf the group 

reports and the quality measure benchmarks are inclusive of data gathered through both PQRS 

GPRO and individually-reported PQRS measures. Lastly, we note that the inclusion of 

individual PQRS measure in the VM provides an additional mechanism and reduces additional 

reporting burden for groups that are subject to the VM and do not report under the PQRS as a 

group to avoid an automatic VM downward payment adjustment. 

After consideration of the comments received, and for the reasons stated previously, we 

are finalizing the two-category approach for the CY 2017 VM based on participation in the 

PQRS by groups and solo practitioners as proposed. For purposes of the CY 2017 VM, 

Category 1 will include those groups that meet the criteria for satisfactory reporting of data on 

PQRS quality measures via the GPRO (through use of the web-interface, EHR, or registry 

reporting mechanism, as finalized in section III.K of this final rule with comment period) for the 

CY 2017 PQRS payment adjustment. Our final criteria for satisfactory reporting of data on 

PQRS quality measures via the GPRO for the PQRS payment adjustment for CY 2017 are 

described in Table 51 in section III.K of this final rule with comment period. We also are 

finalizing to include in Category 1 groups that do not register to participate in the PQRS as a 

group practice participating in the PQRS GPRO in CY 2015 and that have at least 50 percent of 

the group’s eligible professionals meet the criteria for satisfactory reporting of data on PQRS 

quality measures as individuals (through the use of claims, EHR, or registry reporting 

mechanism) for the CY 2017 PQRS payment adjustment, or in lieu of satisfactory reporting, 

satisfactorily participate in a PQRS-qualified clinical data registry for the CY 2017 PQRS 

payment adjustment, all as finalized in Table 50 in section III.K of this final rule with comment 
CMS-1612-FC 951

period. Our final criteria for satisfactory reporting by individual eligible professionals for the 

claims, EHR, and registry reporting mechanisms and for satisfactory participation in a qualified 

clinical data registry for the CY 2017 PQRS payment adjustment are described in section III.K of 

this final rule with comment period. Lastly, we are finalizing to include in Category 1 those solo 

practitioners that meet the criteria for satisfactory reporting of data on PQRS quality measures as 

individuals (through the use of claims, registry, or EHR reporting mechanism) for the CY 2017 

PQRS payment adjustment, or in lieu of satisfactory reporting, satisfactorily participate in a 

PQRS-qualified clinical data registry for the CY 2017 PQRS payment adjustment, all as finalized 

in Table 50 in section III.K of this final rule with comment period. Category 2 will include those 

groups and solo practitioners that are subject to the CY 2017 VM and do not fall within Category 

1. We will continue to explore how to include additional data for specialists, including 

potentially incorporating Hospital VBP Program performance into the VM, as discussed in 

section III.N.4.k of this final rule with comment period. We would adopt any such changes 

through future notice and comment rulemaking. As discussed in section III.N.4.f of this final 

rule with comment period, for CY 2017, we are finalizing policies to (1) apply a -4.0 percent VM 

to groups with 10 or more eligible professionals that fall in Category 2, and (2) apply a -2.0 

percent VM to groups with two to nine eligible professionals and solo practitioners that fall in 

Category 2. 

For a group and a solo practitioner subject to the CY 2017 VM to be included in 

Category 1, the criteria for satisfactory reporting (or the criteria for satisfactory participation, in 

the case of solo practitioners and the 50 percent option described above for groups) must be met 

during the reporting periods occurring in CY 2015 for the CY 2017 PQRS payment adjustment. 

As noted in section III.5.g of this final rule with comment period earlier, CY 2015 is the 

performance period for the CY 2017 payment adjustment period for the VM. 
CMS-1612-FC 952

In the CY 2014 PFS final rule with comment period (78 FR 74768-74770), we finalized 

that the quality-tiering methodology will apply to all groups in Category 1 for the VM for CY 

2016, except that groups of physicians with between 10 and 99 eligible professionals would be 

subject only to upward or neutral adjustments derived under the quality-tiering methodology, 

while groups of physicians with 100 or more eligible professionals would be subject to upward, 

neutral, or downward adjustments derived under the quality-tiering methodology. In other 

words, we finalized that groups of physicians in Category 1 with between 10 and 99 eligible 

professionals would be held harmless from any downward adjustments derived from the qualitytiering methodology for the CY 2016 VM. 

For the CY 2017 VM, we proposed to continue a similar phase-in of the quality-tiering 

based on the number of eligible professionals in the group (79 FR 40497). We proposed to apply 

the quality-tiering methodology to all groups and solo practitioners in Category 1 for the VM for 

CY 2017, except that groups with two to nine eligible professionals and solo practitioners would 

be subject only to upward or neutral adjustments derived under the quality-tiering methodology, 

while groups with 10 or more eligible professionals would be subject to upward, neutral, or 

downward adjustments derived under the quality-tiering methodology. That is, we proposed that 

solo practitioners and groups with two to nine eligible professionals in Category 1 would be held 

harmless from any downward adjustments derived from the quality-tiering methodology for the 

CY 2017 VM. Accordingly, we proposed to revise §414.1270 to reflect these proposals. We 

believe this approach would reward groups and solo practitioners that provide high-quality/lowcost care, reduce program complexity, and would also fully engage groups and solo practitioners 

into the VM as we complete the phase-in of the VM in CY 2017. We solicited comments on 

these proposals. 
CMS-1612-FC 953

We stated in the CY 2015 PFS proposed rule (79 FR 40497) that we believe it is 

appropriate to hold groups with two to nine eligible professionals and solo practitioners in 

Category 1 harmless from any downward adjustments under the quality-tiering methodology, 

which is similar to the policy we apply to groups with between 10 and 99 eligible professionals 

during the first year the VM applies to them (CY 2016). We noted that we anticipate applying 

the CY 2018 VM with both upward and downward adjustments based on a performance period 

of CY 2016 to all groups and solo practitioners, and therefore, we would make proposals in 

future rulemaking accordingly. 

We stated that, for groups with between 10 and 99 eligible professionals, we believe it is 

appropriate to begin both the upward and the downward payment adjustments under the qualitytiering methodology for the CY 2017 VM. As stated in the CY 2014 PFS final rule with 

comment period (78 FR 74769), on September 16, 2013, we made available to all groups of 25 

or more eligible professionals an annual QRUR based on 2012 data to help groups estimate their 

quality and cost composites. As discussed in section III.N.4.a. of this final rule with comment 

period, in September 2014, we made available QRURs based on CY 2013 data to all groups of 

physicians and physicians who are solo practitioners. These QRURs contain performance 

information on the quality and cost measures used to calculate the quality and cost composites of 

the VM and show how all TINs fare under the policies established for the VM for the CY 2015 

payment adjustment period. As noted above, we are considering providing semi-annual QRURs 

with updated cost and resource use information to groups and solo practitioners. Then, during 

the summer of 2015, we intend to disseminate QRURs based on CY 2014 data to all groups and 

solo practitioners, and the reports would show how all TINs would fare under the policies 

established for the VM for the CY 2016 payment adjustment period. The QRURs will also 
CMS-1612-FC 954

include additional information about the TINs’ performance on the MSPB measure, individuallyreported PQRS measures, and the specialty-adjusted cost measures. 

Thus, we stated that we believe groups with between 10 and 99 eligible professionals will 

have adequate data to improve performance on the quality and cost measures that will be used to 

calculate the VM in CY 2017. As a result, we believe it is appropriate to apply both upward and 

downward adjustments under the quality-tiering methodology to groups with 10 or more eligible 

professionals in 2017. 

Based on an analysis of CY 2012 claims, we estimate that approximately 6 percent of all 

eligible professionals are in a Category 1 TIN that would be classified in tiers that would earn an 

upward adjustment by having a composite score that is at least 1 standard deviation away from 

the mean composite and it is statistically significant, approximately 11 percent of all eligible 

professionals are in a Category 1 TIN that would be classified in tiers that would receive a 

downward adjustment by having a composite score that is at least 1 standard deviation away 

from the mean composite and it is statistically significant, and approximately 83 percent of all 

eligible professionals are in a Category 1 TIN that would receive no payment adjustment in CY 

2017. These results suggest that our quality-tiering methodology identifies a small number of 

groups and solo practitioners that are outliers – both high and low performers – in terms of 

whose payments would be affected by the VM, thus limiting any widespread unintended 

consequences. 

We stated in the CY 2015 PFS proposed rule that we will continue to monitor the VM 

program and continue to examine the characteristics of those groups that could be subject to an 

upward or downward payment adjustment under our quality-tiering methodology to determine 

whether our policies create anomalous effects in ways that do not reflect consistent differences in 

performance among physicians and physician groups. 
CMS-1612-FC 955

The following is a summary of the comments we received on these proposals. 

Comment: Several commenters supported applying quality-tiering to all groups and solo 

practitioners. One commenter did not support the concept of quality-tiering and indicated that it 

should be voluntary for all practices. Most commenters strongly supported our proposal to hold 

harmless groups with two to nine eligible professionals and solo practitioners from downward 

payment adjustments in CY 2017, although one commenter suggested that CMS should apply 

downward adjustments to them. Some commenters supported our proposal to apply upward, 

neutral, or downward payment adjustment to physician groups with 10 or more eligible 

professionals. However, many commenters had concerns about applying the downward 

adjustment to groups with 10 or more eligible professionals, since we proposed a maximum 

downward adjustment of -4.0 percent. A commenter indicated that there is a substantial 

operational difference between large practices and small practices since larger practices have 

more resources and revenue and are better suited to absorb downward payment adjustments 

under the VM. Some commenters were concerned that implementation of the downward 

adjustment to smaller physician practices, particularly given that the downward adjustment is 

slated to be -4.0 percent in 2017, may negatively impact beneficiary access to care. Other 

comments stated that solo practitioners and groups with two to twenty-four eligible professionals 

would not have a QRUR until the fall 2014 and will have little time to analyze their performance 

data. A number of commenters recommended more intermediate, phased-in approach to the 

downward adjustment such as holding harmless groups with less than 25 eligible professionals, 

50 eligible professionals, or all groups regardless of size. Commenters suggested that we give 

only upward or neutral payment adjustments to all groups and solo practitioners or keep the CY 

2016 policies in place for the CY 2017 VM. One commenter suggested that physician groups be 

able to file for a hardship exception with CMS in the event they face a downward adjustment 
CMS-1612-FC 956

under the VM. One commenter suggested that the payment adjustments under quality-tiering 

apply to all groups regardless of size so that primary care physicians who practice in larger 

groups are not disadvantaged, while another suggested that CMS should not change the program 

in 2017. Some commenters requested demographic information about the outliers that would 

receive upward or downward adjustments based on quality-tiering. 

Response: We appreciate the commenters’ support of our proposal to apply the qualitytiering methodology to all groups and solo practitioners in Category 1 for the VM for CY 2017 

and to hold solo practitioners and groups with two to nine eligible professionals in Category 1 

harmless from any downward adjustments derived from the quality-tiering methodology for the 

CY 2017 VM. We disagree with commenters who suggested that we should not apply upward, 

neutral, or downward payment adjustments derived under the quality-tiering methodology to 

physician groups with 10 or more eligible professionals in CY 2017. For groups with 10 or more 

eligible professionals, we believe it is appropriate to apply both the upward and the downward 

payment adjustments under the quality-tiering methodology for the CY 2017 VM. As stated in 

the CY 2014 PFS final rule with comment period (78 FR 74769), on September 16, 2013, we 

made available to all groups of 25 or more eligible professionals an annual QRUR based on 2012 

data to help groups estimate their quality and cost composites. As discussed in section III.N.a. of 

this final rule with comment period, in September 2014, we made available QRURs based on CY 

2013 data to all groups of physicians and physicians who are solo practitioners. We believe that 

groups of 10 or more eligible professionals will have adequate data to improve performance on 

the quality and cost measures that will be used to calculate the VM in CY 2017. As a result, we 

believe it is appropriate to apply both upward and downward adjustments under the qualitytiering methodology to groups with 10 or more eligible professionals in 2017. 
CMS-1612-FC 957

With regard to the commenters’ concerns over the impact of the proposed maximum -4.0 

percent downward adjustments on small practices, as discussed in section III.N.4.f of this final 

rule with comment period, we are finalizing a policy to apply a -2.0 percent VM to groups with 

two to nine eligible professionals and solo practitioners that fall in Category 2. We believe the 

revised policy will alleviate some of the commenters’ concerns about the financial impact of 

applying quality-tiering to small groups and solo practitioners in CY 2017. 

With regard to the suggestion that physicians in groups of 10 to 24 eligible professionals 

have not had sufficient experience with the quality measures used in the VM, we note that on 

September 30, 2014, we made QRURs available to all group of physicians and physicians who 

are solo practitioners based on their performance in CY 2013. Each QRUR contains the group or 

solo practitioner’s performance information on the quality and cost measures used to calculate 

the quality and cost composites of the VM and show how the TIN would fare under the policies 

established for the VM for the CY 2015 payment adjustment period. As we stated in the CY 

2015 PFS proposed rule, we believe it is appropriate to hold groups with two to nine eligible 

professionals and solo practitioners in Category 1 harmless from any downward adjustments 

under the quality-tiering methodology, which is similar to the policy we apply to groups with 

between 10 and 99 eligible professionals during the first year the VM applies to them (CY 2016). 

For groups with between 10 and 99 eligible professionals, we believe it is appropriate to begin 

both the upward and the downward payment adjustments under the quality-tiering methodology 

for the CY 2017 VM. We believe that these groups have had sufficient time to understand how 

the VM works and how to participate in the PQRS. We note that the 2013 QRUR Experience 

Report, as described in section III.N.4.a of this final rule, will also contain additional information 

about the groups that were determined to have cost and/or quality performance that was 

significantly different than average, as determined under the policies established for the VM for 
CMS-1612-FC 958

the CY 2015 payment adjustment period. We reiterate our belief that the final policies will 

reward groups and solo practitioners that provide high-quality/low-cost care, reduce program 

complexity, and will also fully engage groups and solo practitioners into the VM as we complete 

the phase-in of the VM in CY 2017. 

After considering the public comments received, we are finalizing the application of the 

quality-tiering methodology to all groups and solo practitioners in Category 1 for the VM for CY 

2017, except that groups with two to nine eligible professionals and solo practitioners would be 

subject only to upward or neutral adjustments derived under the quality-tiering methodology, 

while groups with 10 or more eligible professionals would be subject to upward, neutral, or 

downward adjustments derived under the quality-tiering methodology. In other words, solo 

practitioners and groups with two to nine eligible professionals in Category 1 would be held 

harmless from any downward adjustments derived from the quality-tiering methodology for the 

CY 2017 VM. 

d. Application of the VM to Physicians and Nonphysician Eligible Professionals that Participate 

in the Shared Savings Program, the Pioneer ACO Model, the CPC Initiative, or Other Similar 

Innovation Center Models or CMS Initiatives 

We established a policy in the CY 2013 PFS final rule with comment period 

(77 FR 69313) to not apply the VM in CY 2015 and CY 2016 to groups of physicians that 

participate in the Shared Savings Program Accountable Care Organizations (ACOs), the Pioneer 

ACO Model, the Comprehensive Primary Care (CPC) Initiative, or other similar Innovation 

Center or CMS initiatives. We stated in the CY 2014 PFS final rule with comment period 

(78 FR 74766) that from an operational perspective, we will apply this policy to any group of 

physicians that otherwise would be subject to the VM, if one or more physician(s) in the group 
CMS-1612-FC 959

participate(s) in one of these programs or initiatives during the relevant performance period (CY 

2013 for the CY 2015 VM, and CY 2014 for the CY 2016 VM). 

Although section 1848(p)(4)(B)(iii)(I) of the Act gives the Secretary discretion to apply 

the VM beginning on January 1, 2015 to specific physicians and groups of physicians the 

Secretary determines appropriate, section 1848(p)(4)(B)(iii)(II) of the Act requires application of 

the VM beginning not later than January 1, 2017 to all physicians and groups of physicians. 

Therefore, as discussed in section III.N.4.a. of this final rule with comment period, we proposed 

to apply the VM to all physicians in groups with two or more eligible professionals and to solo 

practitioners who are physicians starting in CY 2017. In section III.N.4.b of this final rule with 

comment period, we discussed our proposal to also apply the VM starting in CY 2017 to all 

nonphysician eligible professionals in groups with two or more eligible professionals and to solo 

practitioners who are nonphysician eligible professionals. We describe in this section how we 

proposed to apply the VM beginning in the CY 2017 payment adjustment period to the 

physicians and nonphysician eligible professionals in groups, as well as those who are solo 

practitioners, participating in the Shared Savings Program, Pioneer ACO Model, the CPC 

Initiative, or other similar Innovation Center models or CMS initiatives. 

(1) Physicians and Nonphysician Eligible Professionals that Participate in ACOs under the 

Shared Savings Program 

 (a) Application of the VM to participants in the Shared Savings Program. Beginning 

with the CY 2017 payment adjustment period, we proposed to apply the VM to physicians and 

nonphysician eligible professionals in groups with two or more eligible professionals and to 

physicians and nonphysician eligible professionals who are solo practitioners participating in the 

Shared Savings Program (79 FR 40497). Groups and solo practitioners participate in the Shared 

Savings Program as part of an ACO as provided in section 1899 of the Act. Under the Shared 
CMS-1612-FC 960

Savings Program, an ACO may consist of multiple participating groups and solo practitioners (as 

identified by the ACO participants’ TINs). As of April 1, 2014, there are 338 ACOs 

participating in the Shared Savings Program. This number includes 31 ACOs that consist of only 

one ACO participant TIN. The ACO submits quality data on behalf of all the ACO participant 

TINs in that ACO under the Shared Savings Program. 

Comment: Many commenters suggested that we should continue to exempt Shared 

Savings Program participants from the VM. These commenters stated that because participants 

in the Shared Savings Program have already taken on accountability for quality improvement 

and cost reduction, it is unnecessary and confusing to apply the VM to these providers. Several 

commenters suggested that this option is available under the existing language of the statute or 

that, if CMS believes it does not have this authority, we should seek it from Congress. 

Commenters also expressed concern that applying the VM to participants in the Shared Savings 

Program would cause inappropriate comparisons of performance and create confusion by 

sending mixed signals about cost and quality benchmarks. Several of these commenters stated 

that organizations participating in Shared Savings Program and Pioneer ACOs are making 

significant investments and that they believe this further underscores the importance of allowing 

these groups to focus on one set of pay for performance metrics to avoid creating additional 

investment costs. A few commenters supported the application of the VM to Shared Savings 

Program participants because they believe that applying the VM broadly will encourage valuebased change. 

Response: We disagree with commenters who believe we should continue to exempt 

groups and solo practitioners who participate in the Shared Savings Program from the VM. We 

are required under section 1848(p)(4)(B)(iii)(II) of the Act to apply the VM to all physicians and 

groups of physicians no later than January 1, 2017, and we believe that alignment of these 
CMS-1612-FC 961

programs emphasizes the importance of quality reporting and quality measurement, for 

improvement of the quality of care provided to Medicare beneficiaries. We understand the 

concerns presented by the commenters regarding calculation of the cost and quality composites 

under the VM, and we address them below, in sections III.N.4.d.1(b) and (c) of this final rule 

with comment period. 

After considering the public comments on this proposal, we are finalizing our policy to 

apply the VM, beginning with the CY 2017 payment adjustment period, to physicians in groups 

with two or more eligible professionals and physicians who are solo practitioners that participate 

in an ACO under the Shared Savings Program. 

We note that, in response to commenters’ concerns, we are not finalizing the proposal to 

apply the VM to nonphysician eligible professionals in the CY 2017 payment adjustment period 

that participate in an ACO under the Shared Savings Program, consistent with the final policy 

for groups and solo practitioners that do not participate in the Shared Savings Program as 

discussed in section III.N.4.b of this final rule with comment period. Also, consistent with our 

policy discussed in section III.N.4.b to apply the VM beginning with the CY 2018 payment 

adjustment period to nonphysician eligible professionals who are not in an ACO under the 

Shared Savings Program, we will apply the VM beginning with the CY 2018 payment 

adjustment period to nonphysician eligible professionals in groups with two or more eligible 

professionals and nonphysician eligible professionals who are solo practitioners that participate 

in an ACO under the Shared Savings Program. We further note that, based in part on concerns 

identified by commenters, we are finalizing policies in sections III.N.4.d.1 (b) and (c) of this 

final rule with comment period that take into consideration a group or solo practitioner’s 

participation in an ACO under the Shared Savings Program during the performance period for 

the VM, rather than participation during the payment adjustment period for the VM as proposed. 
CMS-1612-FC 962

(b) Calculation of the cost composite of the VM for Shared Savings Program participants. 

Beginning with the CY 2017 payment adjustment period, we proposed to classify the cost 

composite for the VM as “average cost” for groups and solo practitioners (as identified by the 

ACO’s participant TINs) that participate in the Shared Savings Program during the payment 

adjustment period (for example, CY 2017) (79 FR 40498). We proposed to apply “average cost” 

to these groups and solo practitioners regardless of whether they participated in the Shared 

Savings Program during the performance period (for example, in CY 2015 for the CY 2017 

VM). We believe that it would not be appropriate to apply the quality-tiering methodology to 

calculate the cost composite for these groups and solo practitioners because of the differences in 

the methodology used to calculate the cost benchmarks under the Shared Savings Program and 

the VM. Under the Shared Savings Program, cost benchmarks are based on the actual historical 

Medicare fee-for-service expenditures for beneficiaries that would have been assigned to the 

ACO during the historical benchmark period, and are updated to reflect changes in national FFS 

spending; however, the cost benchmarks under the VM are based on national averages. We 

believe that these are significant differences in the methodology for calculating the cost 

benchmarks under the two programs. Consequently, we believe that any attempt to calculate the 

VM cost composite for groups and solo practitioners participating in the Shared Savings 

Program using the VM quality-tiering methodology would create two sets of standards for ACOs 

for their cost performance. We believe that having two sets of standards for participants in 

ACOs for cost performance would be inappropriate and confusing and could send conflicting 

messages and create conflicting incentives. We solicited comments on our proposals to classify 

the cost composite as “average cost” for groups and solo practitioners who participate in the 

Shared Savings Program during the payment adjustment period. 
CMS-1612-FC 963

For groups and solo practitioners who participate in the Shared Savings Program during 

the performance period (for example, CY 2015), but no longer participate in the Shared Savings 

Program during the payment adjustment period (for example, CY 2017), we proposed to apply 

the quality-tiering methodology to calculate the cost composite for the VM for the payment 

adjustment period based on the groups’ and solo practitioners’ performance on the cost 

measures, as identified under §414.1235, during the performance period (79 FR 40499). We 

stated that it would be appropriate to calculate their cost composite under the quality-tiering 

methodology because these groups and solo practitioners are no longer part of the Shared 

Savings Program during the payment adjustment period. 

Comment: As noted above, many commenters expressed concern that applying the VM 

to ACO participants in the Shared Savings Program would cause inappropriate comparisons of 

performance and create confusion by sending mixed signals about cost benchmarks. Several of 

these commenters who were opposed to the application of the VM to Shared Savings Program 

ACO participants suggested that we should continue to exempt Shared Savings Program 

participants from the VM, but stated that if we were to apply the VM to Shared Savings Program 

ACO participants, we should classify the cost composite as “average cost” because of the 

differing methodologies for assessing cost performance for the VM and the Shared Savings 

Programs. A few commenters stated that groups or solo practitioners participating in the Shared 

Savings Program should have their cost composite calculated without regard to participation in 

the Shared Savings Program and disagreed with our proposed policy because it limits the 

potential upward adjustment under the VM available to groups and solo practitioners 

participating in the Shared Savings Program. 

Response: We understand the concerns presented by these commenters that calculating a 

cost composite for these groups and solo practitioners could cause confusion and send mixed 
CMS-1612-FC 964

signals. The VM and Shared Savings Programs are sufficiently different such that it would be 

counterproductive at this point in the programs’ development to measure groups and solo 

practitioners using different cost measures under each program. To allow Shared Savings 

Program participants to focus their energy and resources on the Shared Savings Program targets 

for slowing expenditure growth, a different approach under the VM program for groups and 

physicians participating in the Shared Savings Program is appropriate. We will finalize our 

proposal to classify the cost composite for groups and solo practitioners participating in an ACO 

under the Shared Savings Program as “average cost” to avoid confusion and prevent conflicting 

incentives for these providers who have already committed to reducing cost growth through their 

participation in the Shared Savings Program. We plan to investigate the possibility of 

calculating a VM cost composite at the ACO level in the future, so that groups and solo 

practitioners in ACOs would have the opportunity to earn the full upward adjustment in the 

future, and we would address this issue in future rulemaking. 

Comment: We received several comments objecting to our proposal to take into account 

a group or solo practitioner’s participation in a Shared Savings Program ACO during the 

payment adjustment period for the VM. A few commenters did not support our proposal to 

apply “average cost” to groups and solo practitioners that join a Shared Savings Program ACO in 

the payment adjustment period, but were not in a Shared Savings Program ACO in the 

performance period. These commenters pointed out that this policy could discourage groups and 

solo practitioners from joining an ACO if it would mean they would not receive an earned 

upward adjustment in the payment adjustment period. One of these commenters suggested that 

groups or solo practitioners should be given the option to have their cost composite calculated 

under the quality-tiering methodology if they were not in an ACO in the performance period. 

Several commenters suggested that all groups and solo practitioners should be given the 
CMS-1612-FC 965

opportunity to “opt in” to having their cost composite calculated regardless of whether they were 

in an ACO in the performance period. Another commenter objected to our proposal to apply the 

quality-tiering methodology to calculate the cost composite for groups and solo practitioners that 

participate in the Shared Savings Program in the performance period but do not participate in the 

Shared Savings Program during the payment adjustment period. The commenter suggested that 

these groups should be classified as “average cost” because they would have been working 

toward ACO cost benchmarks during the performance year. 

Response: We are convinced by commenters who raised concerns with our proposal to 

consider a group or solo practitioner’s participation in a Shared Savings Program ACO during 

the payment adjustment period for the purpose of determining the applicability of the VM to the 

group or solo practitioner. We believe that commenters have accurately pointed out that Shared 

Savings Program ACO participants would be working toward a specified set of quality and cost 

metrics during the performance period, and that the performance period would therefore, best 

define their status as a Shared Savings Program participant for the purpose of determining the 

applicability of the VM during the associated payment adjustment period. We agree with the 

points raised in the comments about assessing a group or solo practitioner under the VM cost 

measures and benchmarks in the payment adjustment period if that group or solo practitioner was 

participating in an ACO under the Shared Savings Program in the performance period. A group 

or solo practitioner is unlikely to know two years in advance that it plans to leave an ACO, and 

we do not believe it would appropriate to assess the group or solo practitioner under a different 

set of cost measures than those that the group or solo practitioner had been working toward in the 

performance period as part of an ACO. As stated in our proposed rule (79 FR 40498), we believe 

that having two sets of standards for ACOs for cost performance would be inappropriate and 

confusing. We believe that the Shared Savings Program has the potential to reduce expenditure 
CMS-1612-FC 966

growth and improve quality and we do not want to discourage groups or solo practitioners from 

participating in that program (79 FR 40498). Consistent with that stated intent, and in light of the 

comments we received pointing out the potential conflict if we were to calculate a cost 

composite for groups and solo practitioners that participated in an ACO under the Shared 

Savings Program but did not participate in the payment adjustment period, we believe it is 

appropriate to apply “average cost” to all groups and solo practitioners that participate in an 

ACO under the Shared Savings Program in the performance period regardless of whether the 

group or solo practitioner remains in the ACO in the payment adjustment period. We do not, 

however, believe that it would be appropriate to use an “opt in” policy for groups or solo 

practitioners participating in Shared Savings Program ACOs. We believe that allowing groups 

and solo practitioners who participate in the Shared Savings Program in the performance period 

to “opt in” to having their cost composite calculated would conflict with our intent to avoid 

setting multiple financial benchmarks for these groups and solo practitioners. 

After considering the public comments received, we are finalizing our policy to classify 

the cost composite as “average cost” for groups and solo practitioners that participate in an ACO 

under the Shared Savings Program. Unlike our proposed policy, which considered participation 

in a Shared Savings Program ACO during the payment adjustment period for the VM (for 

example, CY 2017), we are finalizing a policy that, if a group or solo practitioner participates in 

a Shared Savings Program ACO during the applicable performance period (for example, the CY 

2015 performance period for the CY 2017 payment adjustment period), then that group or solo 

practitioner’s cost composite will be classified as “average cost,” regardless of whether the group 

or solo practitioner participates in a Shared Savings Program ACO during the payment 

adjustment period. In addition to addressing some of the concerns raised by commenters, we 

believe this final policy is consistent with our existing policy for CYs 2015 and 2016, under 
CMS-1612-FC 967

which a group’s participation in the Shared Savings Program during the performance period 

(CYs 2013 and 2014, respectively) is relevant for purposes of determining whether to exempt the 

group from application of the VM during the relevant payment adjustment period. Further, 

utilizing the performance period for the purpose of determining whether the group or solo 

practitioner is a Shared Savings Program ACO participant eliminates the need for us to calculate 

preliminary payment adjustment factors prior to the beginning of the payment adjustment period, 

and then recalculate the payment adjustment factors after the final ACO participation list is 

completed, as we had proposed to do (79 FR 40506). 

 As requested by commenters, this final policy is also simpler than our proposal, 

because it does not take into account a group’s status during the payment adjustment period. 

(c) Calculation of the quality composite under the VM for Shared Savings Program 

participants. Beginning with the CY 2017 payment adjustment period, we proposed to calculate 

the quality of care composite score for the VM for groups and solo practitioners who participate 

in an ACO under the Shared Savings Program in accordance with the following policies (79 FR 

40498-40499): 

● We proposed to calculate the quality of care composite score based on the qualitytiering methodology using quality data submitted by the ACO, as discussed in section III.N.4.h 

of this final rule with comment period, from the performance period and apply the same score to 

all of the groups and solo practitioners under the ACO during the payment adjustment period. In 

other words, using CY 2017 as an example, we proposed to calculate the quality of care 

composite score for the CY 2017 VM for all of the groups and solo practitioners participating in 

the ACO in CY 2017 based on the ACO’s CY 2015 quality data. We note that in section 

III.N.4.h of this final rule with comment period, we are finalizing our proposal to exclude the 

claims-based outcome measures identified under §414.1230 from the calculation of the quality of 
CMS-1612-FC 968

care composite score for groups and solo practitioners who participate in the Shared Savings 

Program as described in section III.N.4.d.1 of this final rule with comment period. 

● For groups and solo practitioners who participate in the ACO during the payment 

adjustment period (for example, CY 2017) and either did not participate in the Shared Savings 

Program or were part of a different ACO during the performance period (for example, CY 2015), 

we proposed to calculate the quality of care composite score based on the quality-tiering 

methodology using the quality data submitted by the ACO from the performance period. For 

example, if a group or solo practitioner is in ACO 1 during CY 2017, and either was not in the 

Shared Savings Program or was part of ACO 2 during CY 2015, we would use ACO 1’s quality 

data from CY 2015 to calculate the quality of care composite. This approach is consistent with 

our policy not to “track” or “carry” an individual professional’s performance from one TIN to 

another TIN (see 77 FR 69308 through 69310). In other words, if a professional changes groups 

from TIN A in the performance period to TIN B in the payment adjustment period, we would 

apply TIN B’s VM to the professional’s payments for items and services billed under TIN B 

during the payment adjustment period. 

● If the ACO did not exist during the performance period (for example, CY 2015), then 

we would not have the ACO’s quality data to use in the calculation of the quality of care 

composite score for the payment adjustment period (for example, CY 2017). Therefore, if the 

ACO exists during the payment adjustment period but did not exist during the performance 

period, we proposed to classify the quality of care composite for all groups and solo practitioners 

who participate in the ACO during the payment adjustment period as “average quality” for the 

payment adjustment period. We proposed to apply this policy to groups and solo practitioners 

regardless of their status during the performance period – in other words, regardless of whether 

they participated in the Shared Savings Program as part of a different ACO, or did not exist 
CMS-1612-FC 969

during the performance period (for example, a TIN forms or newly enrolls in Medicare after the 

end of the performance period). We believed this proposal was appropriate since we would not 

have the ACO’s quality data from the performance period to calculate a quality of care 

composite for all of the groups and solo practitioners participating in the ACO during the 

payment adjustment period. We noted that some of these groups and solo practitioners may have 

participated in the PQRS during the performance period; therefore, we would have quality data 

for those groups and solo practitioners. If they were part of a different ACO during the 

performance period, then we would also have that ACO’s quality data. We stated that we did 

not, however, believe that it would be appropriate to use the groups’ and solo practitioners’ 

PQRS or other ACO quality data from the performance period to calculate a quality of care 

composite because the groups and solo practitioners are part of a new ACO during the payment 

adjustment period. We stated our belief that this approach would be consistent with our policy 

not to “track” or “carry” an individual professional’s performance from one TIN to another TIN 

(see 77 FR 69308 through 69310). In this case, if a TIN’s status changes from the performance 

period to the payment adjustment period (that is, participating in ACO 2 or not participating in 

the Shared Savings Program in the performance period, to participating in ACO 1 in the payment 

adjustment period), then we proposed that we would not “track” or “carry” ACO 2’s quality data 

or the TIN’s PQRS quality data to determine the quality of care composite for groups and solo 

practitioners who participate in ACO 1. 

● For groups and solo practitioners who participate in the Shared Savings Program 

during the performance period (for example, CY 2015) but no longer participate in the Shared 

Savings Program during the payment adjustment period (for example, CY 2017), we proposed to 

classify the quality of care composite as “average quality” for the VM for the payment 

adjustment period. Since these groups and solo practitioners were part of an ACO during the 
CMS-1612-FC 970

performance period, we would have the ACO’s quality data from that period. We stated that we 

did not believe it would be appropriate to use the ACO’s quality data from the performance 

period to calculate a quality of care composite because the groups and solo practitioners are no 

longer part of the ACO during the payment adjustment period. We stated this approach is also 

consistent with our policy not to “track” or “carry” an individual professional’s performance 

from one TIN to another TIN (see 77 FR 69308 through 69310). Even though we proposed to 

classify the quality of care composite for these groups and solo practitioners as “average 

quality,” we solicited comments on whether we should use the ACO’s quality data from the 

performance period to calculate the quality composite for these groups and solo practitioners for 

the payment adjustment period. 

We solicited comments on all of our proposals to calculate the quality composite for 

groups and solo practitioners participating in the Shared Savings Program. We provided a 

summary of the proposals in the proposed rule in Table 56 using TIN A and ACO 1 and ACO 2 

as examples (79 FR 40499). 

Comment: As noted above, in the discussion of the cost composite, we received many 

comments stating that we should exempt groups and solo practitioners from the 2017 VM. Many 

commenters also suggested an “Innovation Pathway” approach for participants in the Shared 

Savings Program and Innovation Center initiatives. Under this suggested approach, groups and 

solo practitioners participating in the Shared Savings Program or other Innovation Center 

initiatives would receive “average cost” and “average quality” unless they opted to have their 

VM calculated. The reasoning behind this approach, provided by commenters, is to allow ACOs 

and the participating groups and solo practitioners to focus on one set of cost and quality 

benchmarks and avoid confusion predicted by some commenters. Many commenters also 

believe that applying the VM to these groups and solo practitioners could lead to “double 
CMS-1612-FC 971

counting” positive or negative performance. A few commenters stated that if we are to apply the 

VM to groups and solo practitioners in the Shared Savings Program, they should only be subject 

to a neutral or an upward adjustment. Some commenters supported our proposed policies related 

to cost and quality composites, and one commenter stated that if the VM is applied to these 

groups, they believed that only a quality composite should be calculated because they believe 

that ACOs are already rewarded for reducing costs. We also received comments on the specific 

quality measures and benchmarks that we proposed to use for the VM for groups and solo 

practitioners participating in the Shared Savings Program, which we address in section III.N.4.h 

of this final rule with comment period. 

Response: We appreciate commenters’ concern about the potential for conflicting 

incentives on cost and quality performance when applying the VM to Shared Savings Program 

participants given that these participants are already working toward a set of cost efficiency and 

quality improvement goals through the Shared Savings Program. We continue to believe, 

however, that it is appropriate to calculate a quality composite for groups and solo practitioners 

participating in the Shared Savings Program based on the ACO’s quality data. We appreciate the 

support of commenters who agreed that it is appropriate to calculate a quality composite for 

these groups and solo practitioners based on the ACO’s quality data. We disagree with 

commenters who believe it would be inappropriate to calculate a VM for groups and solo 

practitioners that participate in the Shared Savings Program because this could be seen as 

“double counting” performance. We believe that application of the VM to providers who 

participate in the Shared Savings Program reinforces the importance of quality improvement and 

quality reporting by offering participants in the Shared Savings Program an opportunity to earn 

an upward adjustment for improved performance. We agree with the commenter who stated if 

calculating a VM for Shared Savings Program participants, we should only calculate the quality 
CMS-1612-FC 972

composite. However, we would like to point out that the Shared Savings Program does also 

reward high quality care in addition to rewarding reductions in cost growth. Unlike the 

differences between the methodologies for evaluating costs under the Shared Savings Program 

and the VM, we do not believe that the differences between the quality methodologies for these 

two programs will create significant confusion or conflicting incentives. Because the GPRO web 

interface measures are consistent across the VM and Shared Savings Program, we believe that it 

will not create undue burden on ACO participants or cause significant confusion to calculate a 

quality composite for these groups and solo practitioners. More specifically, the cost measures 

and cost benchmarks used to determine the cost composite under the VM are different than the 

methodology used to calculate financial performance under the Shared Savings Program. In 

contrast, the GPRO web interface quality measures used in the Shared Savings Program are the 

same as those used to calculate the quality composite of the VM for groups that are not in Shared 

Savings Program ACOs that report through GPRO. Furthermore, ACOs in the Shared Savings 

Program report on quality measures on behalf of all the groups and solo practitioners that 

participate in the ACO, which allows us to calculate a single quality composite that can be 

applied to all participants. We do not have this same capability for the cost composite, which 

would need to be calculated separately for each group or solo practitioner and thus could create 

conflicting incentives and add more confusion. By calculating a quality composite for groups and 

solo practitioners that participate in ACOs under the Shared Savings Program we are providing 

an additional incentive to improve the quality of care for their beneficiaries. As stated in section 

III.N.4.d.1.b., where we discuss the calculation of the cost composite for Shared Savings 

Program ACO participants, we do not believe it would be appropriate to allow groups or solo 

practitioners to “opt in” to having their VM calculated based on the TIN’s, rather than the whole 

ACO’s, performance. Allowing groups or solo practitioners to “opt in” to having their own VM 
CMS-1612-FC 973

calculated could create conflicting incentives and competing priorities between the ACO’s goals 

and the specific group’s or solo practitioner’s goals. An “opt in” policy would result in Shared 

Savings Program ACO participants reporting quality data outside of the ACO, which is not 

consistent with the policies of the Shared Savings Program. 

Comment: As noted in the section III.N.4.d.1.b., we received a few comments related to 

scenarios in which a group or solo practitioner enters or leaves the Shared Savings Program. 

Commenters pointed out that applying an ACO’s quality performance to groups or solo 

practitioners that were not in the ACO in the performance period could discourage groups and 

solo practitioners from joining an ACO in the payment adjustment period if it would mean they 

would not receive an earned upward adjustment. One commenter indicated that it would not be 

fair to assess a group or solo practitioner that was in the Shared Savings Program in the 

performance period, but is not in the payment adjustment period, without consideration of the 

incentives in place in the performance period. This commenter, however, did not object to the 

application of “average quality” to groups and solo practitioners in this situation. We also 

received some general comments that the many different scenarios proposed were confusing and 

added additional complexity to the VM program. 

Response: We appreciate the comments that pointed out the potential problems with 

using participation during the payment adjustment period to determine the quality performance 

of groups and solo practitioners. As stated in the comments and responses in section 

III.N.4.d.1.b., we agree that using a group or solo practitioner’s status in the payment adjustment 

period could discourage future participation in the Shared Savings Program. Consistent with our 

response to the cost composite comments, we believe that it would be inappropriate to ignore the 

quality performance of a group or solo practitioner in the performance period because they 

choose to join an ACO in the payment adjustment period, as well as in the opposite scenario (if a 
CMS-1612-FC 974

group or solo practitioner participated in an ACO in the performance period and then left the 

ACO in the payment adjustment period). As discussed in our earlier response, we believe it 

would be appropriate to use the ACO’s quality performance because the group or solo 

practitioner was part of the ACO during the performance period and should be assessed based on 

the incentives that existed during the performance period. Our proposal to consider a group or 

solo practitioner’s participation in a Shared Savings Program ACO during the payment 

adjustment period was intended to be consistent with our existing policy to not “track” or “carry” 

an individual’s performance from one TIN to another from performance period to payment 

adjustment period. Given the comments we received on our proposals concerning the cost and 

quality composites for groups and solo practitioners that participate in an ACO under the Shared 

Savings Program, we agree that it is preferable to consider a group or solo practitioner’s 

participation in an ACO during the performance period to determine how the VM should be 

applied. Given that we would have ACO-level quality data available for group and solo 

practitioners that were in an ACO in the performance period, we believe this data should be used 

to calculate a quality composite for those groups and solo practitioners. This is consistent with 

the policy regarding the cost composite that we are finalizing in section III.N.4.d.1.b of this final 

rule with comment period, which focuses on the cost and quality performance incentives that 

existed for the group or solo practitioner in the performance period, not the payment adjustment 

period when applying the VM to groups and solo practitioners that are in the Shared Savings 

Program. As noted above, it is also consistent with the way in which we have determined 

participation in the Shared Savings Program for the 2015 and 2016 VM, based on whether the 

group or solo practitioner participated in the Shared Savings Program during the performance 

period. Further, as noted in the cost composite section III.N.4.d.1.b, utilizing the performance 

period for the purpose of determining whether the group or solo practitioner is a Shared Savings 
CMS-1612-FC 975

Program ACO participant eliminates the need for us to calculate preliminary payment adjustment 

factors prior to the beginning of the payment adjustment period, and then recalculate the 

payment adjustment factors after the final ACO participation list is completed, as we had 

proposed to do (79 FR 40506). We are also convinced by commenters who stated that our 

proposed policies were too complex. We believe that using a TIN’s participation in an ACO in 

the performance period to determine the cost composite, while considering the TIN’s status in 

the payment adjustment period to determine the quality composite, would add unnecessary 

complexity and inconsistency, especially as new ACOs continue to be established and existing 

ACOs expand. 

In the proposed rule (79 FR 40498), we stated that if a group or solo practitioner was in 

ACO 2 in the performance period and then joined ACO 1 in the payment adjustment period, we 

would use ACO 1’s quality performance to calculate the quality composite for that group or solo 

practitioner. Although we did not receive specific comments on this policy, we believe that 

based on the other comments received and the policy we are finalizing it would no longer be 

appropriate to use ACO 1’s quality data to calculate a quality composite for these groups and 

solo practitioners. Given that in all other scenarios, we are finalizing policies that we will 

consider the group or solo practitioner’s (as identified by taxpayer identification number (TIN)) 

status during the performance period, rather than the payment adjustment period to determine 

how the group’s or solo practitioner’s quality and cost composite should be calculated, we also 

believe this is the appropriate approach for groups and solo practitioners that move between 

ACOs. We have previously stated our rationale for using the performance period to determine a 

TIN’s association with an ACO and we believe that reasoning applies to this scenario as well. 

Furthermore, it would be unnecessarily complex to apply a different policy for groups and solo 

practitioners in this scenario (where the TIN is part of one ACO during the performance period 
CMS-1612-FC 976

and a different ACO during the payment adjustment period) than in the other scenarios 

previously discussed. 

After considering the public comments received, we are finalizing a policy to calculate a 

quality of care composite score based on the quality-tiering methodology using quality data 

submitted by a Shared Savings Program ACO during the performance period and apply the same 

quality composite to all of the groups and solo practitioners, as identified by TIN, under that 

ACO. Unlike our proposed policy, which considered whether a group or solo practitioner 

participates in a Shared Savings Program ACO during the payment adjustment period for the 

VM (for example, CY 2017), our final policy is if a group or solo practitioner participates in a 

Shared Savings Program ACO during the applicable performance period (for example, the CY 

2015 performance period for the CY 2017 payment adjustment period), then that group or solo 

practitioner’s quality composite is calculated using the ACO-level quality data from the 

performance period, regardless of whether the group or solo practitioner participates in a Shared 

Savings Program ACO during the payment adjustment period. The VM calculated under this 

policy will apply to all physicians billing under the group’s TIN in the CY 2017 payment 

adjustment period, and beginning in the CY 2018 payment adjustment period, to all physician 

and nonphysician eligible professionals billing under the group’s TIN, regardless of whether the 

professional was part of the group in the performance period. This is consistent with our policy 

for other groups subject to the VM, in that we will not “track” or “carry” an individual 

professional’s performance from one TIN to another TIN. 

Comment: Several commenters requested that we provide further guidance on how 

groups that leave the Shared Savings Program will be treated under the VM. Specifically one 

commenter suggested that we consider how we would apply the VM in situations in which an 

ACO dissolves mid-year and does not report quality data. The commenter stated that we should 
CMS-1612-FC 977

ensure that those groups and solo practitioners participating in the ACO are not subject to the 

automatic downward adjustment. 

Response: We appreciate commenters raising these questions and concerns. We did not 

specifically address in the proposed rule the scenario in which a Shared Savings Program ACO 

does not successfully report on quality as required under the Shared Savings Program during the 

performance period for the VM. We clarify that we intended to adopt for groups and solo 

practitioners that participate in a Shared Savings Program ACO the same policy that is generally 

applicable to groups and solo practitioners that fail to satisfactorily report or participate under 

PQRS and thus fall in Category 2 and are subject to an automatic downward adjustment under 

the VM in CY 2017 (79 FR 40496 – 40497). We are finalizing this policy for groups and solo 

practitioners that participate in a Shared Savings Program ACO under §414.1210(b)(2). 

Consistent with the application of the VM to other groups and solo practitioners that report under 

PQRS as described in section III.N.4.c, if the ACO does not successfully report quality data as 

required by the Shared Savings Program under §425.504, all groups and solo practitioners 

participating in the ACO will fall in Category 2 for the VM and therefore will be subject to a 

downward payment adjustment as described in section III.N.4.f. We also plan to issue programspecific guidance to provide participants with more information about how these various 

situations may be addressed. Our final policy focusing on the group or solo practitioner’s status 

in the performance period will simplify the operational issues related to determining the answers 

to these questions. 

(d) Treatment of groups with two to nine eligible professionals and solo practitioners in 

the Shared Savings Program. In section III.N.4.c of this final rule with comment period, we 

discussed our proposal to hold groups with two to nine eligible professionals and solo 
CMS-1612-FC 978

practitioners who are in Category 1 harmless from any downward adjustments under the qualitytiering methodology for the CY 2017 payment adjustment period. We proposed to also hold 

harmless from any downward adjustments groups with two to nine eligible professionals and 

solo practitioners who participate in ACOs under the Shared Savings Program during the CY 

2017 payment adjustment period based on their size during the performance period. We would 

follow our established process for determining group size, which is described at §414.1210(c). 

Therefore, to the extent that a quality of care composite can be calculated for an ACO, and the 

cost composite would be classified as “average cost,” groups with 10 or more eligible 

professionals participating in the Shared Savings Program would be subject to an upward, 

neutral, or downward payment adjustment in CY 2017, and groups with two to nine eligible 

professionals and solo practitioners would be subject to an upward or neutral payment 

adjustment in CY 2017. We also proposed that groups and solo practitioners participating in 

ACOs under the Shared Savings Program would be eligible for the additional upward payment 

adjustment of +1.0x for caring for high-risk beneficiaries, as proposed in section III.N.4.f. We 

proposed to modify §414.1210 to reflect these proposals. 

 Comment: We did not receive any comments on these proposals specific to the Shared 

Savings Program. General comments on these proposals are addressed in section III.N.4.c of this 

final rule with comment period. 

Consistent with final policies in this final rule with comment period to use a group or solo 

practitioner’s status in the performance period to determine participation in the Shared Savings 

Program, we are finalizing a policy to hold harmless from any downward adjustments groups 

with two to nine eligible professionals and solo practitioners who participate in ACOs under the 

Shared Savings Program during the performance period (for example, the CY 2015 performance 
CMS-1612-FC 979

period for the CY 2017 payment adjustment period) based on their size during the performance 

period. 

We have modified §414.1210 to reflect these final policies for application of the VM 

beginning with the CY 2017 payment adjustment period to groups and solo practitioners that 

participate in an ACO under the Shared Savings Program ACO. 

 

(2) Physicians and Nonphysician Eligible Professionals that Participate in the Pioneer ACO 

Model, the Comprehensive Primary Care (CPC) Initiative, or Other Similar Innovation Center 

Models or CMS Initiatives 

Section 1115A of the Act authorizes the Innovation Center to test innovative payment 

and service delivery models to reduce Medicare, Medicaid, or Children’s Health Insurance 

Program (CHIP) expenditures, while preserving or enhancing the quality of care furnished to 

beneficiaries under those programs. Therefore, all models tested by the Innovation Center would 

be expected to assess participating entities (for example, providers, ACOs, states) based on 

quality and cost performance. As noted above, we established a policy in the CY 2013 PFS final 

rule with comment period (77 FR 69313) to not apply the VM in CY 2015 and CY 2016 to 

groups of physicians that are participating in the Pioneer ACO Model, the CPC Initiative, or in 

other Innovation Center initiatives or other CMS programs which also involve shared savings 

and where participants make substantial investments to report quality measures and to furnish 

higher quality, more efficient and effective healthcare. 

The Pioneer ACO Model and the CPC Initiative are scheduled to end on December 31, 

2016. Therefore, the relevant performance periods for consideration for participants in these 

initiatives are CY 2015 for the CY 2017 VM payment adjustment period and potentially CY 

2016 for the CY 2018 VM payment adjustment period. Under the Pioneer ACO Model, an ACO 
CMS-1612-FC 980

may consist of practitioners from multiple participating groups and solo practitioners (as 

identified by their individual TIN/NPI combination). Thus, a group practice may consist of one 

or more eligible professionals who participate in the Pioneer ACO Model and other eligible 

professionals who do not participate in the Pioneer ACO Model. In the case of the CPC 

Initiative, a practice site may participate in the model even if one or more other practice sites that 

use the same TIN does not participate. 

(a) Application of the VM to participants in the Pioneer ACO Model and CPC Initiative. 

Beginning with the CY 2017 payment adjustment period, we proposed to apply the VM to 

physicians and nonphysician eligible professionals in groups with two or more eligible 

professionals and to physicians and nonphysician eligible professionals who are solo 

practitioners who participate in the Pioneer ACO Model or the CPC Initiative during the relevant 

performance period in accordance with the policies described below (79 FR 40500). 

Comment: The majority of comments we received stated that CMS should not apply the 

VM to group practices and solo practitioners participating in the Pioneer ACO Model or CPC 

Initiative. These comments largely mirrored the comments summarized in section III.N.4.d.1.a 

of this final rule with comment period regarding the application of the VM to Shared Savings 

Program participants. A few commenters also suggested that the application of the VM to 

Innovation Center initiatives should be waived under section 1115A of the Act. Additionally, 

one organization expressed concern that the number of varying approaches to calculating the VM 

in our proposed rule would be too complex to implement and may not create equitable 

comparisons among Pioneer, CPC, other Innovation Center model participants, and other 

individuals and groups under the VM program. This commenter suggested that we exempt 

group practices and solo practitioners who participate in the Pioneer ACO Model until that 
CMS-1612-FC 981

model ends. As noted in section III.N.4.d.1.a, a few commenters supported the application of the 

VM to as many groups and solo practitioners as possible to encourage value-based change. 

Response: We are required to apply the VM to all physicians and groups of physicians 

beginning no later than January 1, 2017, and we believe that alignment of the VM program and 

the Pioneer ACO Model, CPC Initiative, and other similar models emphasizes the importance of 

quality reporting and quality measurement, for improvement of the quality of care provided to 

Medicare beneficiaries. We understand the concerns presented by these commenters and 

summarized in section III.N.4.d.1 regarding calculation of the cost and quality composites under 

the VM, and we address them below, in section III.N.4.d.2.b of this final rule with comment 

period. 

After considering the public comments on this proposal, we are finalizing a policy to 

apply the VM in the CY 2017 payment adjustment period, to physicians in groups with two or 

more eligible professionals in which at least one eligible professional participates in the Pioneer 

ACO Model or the CPC Initiative during the performance period, and to physicians who are solo 

practitioners that participate in the Pioneer ACO Model or the CPC Initiative during the 

performance period. 

We note that, in response to commenters’ concerns, we are not finalizing the proposal to 

apply the VM to nonphysician eligible professionals in the CY 2017 payment adjustment period 

that participate in the Pioneer ACO Model or CPC Initiative. This policy is consistent with the 

policy for the Shared Savings Program in the CY 2017 payment adjustment period described in 

section III.M.4.d.1 and for groups and solo practitioners that do not participate in these models or 

in the Shared Savings Program, as discussed in section III.N.4.b of this final rule with comment 

period. 
CMS-1612-FC 982

(b) Calculation of the cost and quality composite of the VM for Pioneer ACO and CPC 

Initiative participants. 

● For groups and solo practitioners who participate in the Pioneer ACO Model or the 

CPC Initiative during the performance period for the VM, we proposed policies for how we 

would calculate the cost and quality composites in a number of scenarios depending on whether 

or not all eligible professionals in the group participate in the model, whether or not the group or 

solo practitioner report through PQRS outside of the model, and if so, through which reporting 

mechanism, and whether or not the group or solo practitioner participate in the Shared Savings 

Program in the payment adjustment period. Additionally, we described several alternatives that 

we considered to the proposed policies. Specifically, we described two alternatives to Scenario 2 

described in the proposed rule (79 FR 40501). Under one alternative, for groups that have some 

eligible professionals participating in the model and some eligible professionals that are not 

participating in the model, we considered applying “average quality” without regard to any 

PQRS data reported outside of the model. Another alternative we considered was to apply 

‘‘average quality’’ to groups where less than 50 percent of all eligible professionals in the group 

meet the criteria for satisfactory reporting of data on PQRS quality measures as individuals or 

satisfactorily participate in a PQRS-qualified clinical data registry, because we would not have 

quality data for more than half of the group that we could use to calculate a quality composite. 

For a detailed description of these scenarios and proposed policies, as well as the alternatives 

considered, we refer readers to the proposed rule at 79 FR 40500-40504. We also provided a 

summary of these proposals, as Table 57 in the proposed rule (79 FR 40504). 

We solicited comments on these proposals and the alternatives considered. 

Comment: We received comments on our proposals for calculating the quality and cost 

composites for Pioneer ACO Model and CPC Initiative participants. As noted in section 
CMS-1612-FC 983

III.N.4.d.2.a of this final rule with comment period, most commenters did not support our 

proposal to apply the VM to Pioneer ACO and CPC participants in general. However, many of 

these commenters stated that if the VM were to be applied to these providers, then CMS should 

classify the cost and quality composites as average to avoid sending what they see as conflicting 

messages about cost and quality benchmarks. These commenters did not make any distinction 

between the reporting mechanism used when quality data is reported to PQRS outside of the 

model (for example, GPRO vs. individual reporting). Instead, they argued that we should apply 

average cost and average quality for all groups and solo practitioners participating in these 

models because they have already taken on accountability for cost and quality measures, and it 

would be confusing and unnecessary to hold them to a different set of measures or benchmarks. 

The “Innovation Pathway” suggestion referenced in the summary of comments on section 

III.N.4.d.1 was also recommended for groups and solo practitioners participating in the Pioneer 

Model and CPC Initiative. A few commenters suggested that providers participating in Pioneer 

or CPC should only be eligible for upward VM adjustments. Some commenters suggested that 

groups and solo practitioners should be able to opt-in to having their cost and quality composites 

calculated as described in the proposed rule. We also received a comment indicating that 

providers in the Pioneer and CPC models should have their VM calculated the same as any other 

TIN subject to the VM. 

Response: We are convinced by commenters who suggested that groups and solo 

practitioners in these models should be classified as “average cost” and “average quality.” In 

section III.N.4.d.1, we described our rationale for classifying the cost composite as “average” for 

groups and solo practitioners that participate in an ACO under the Shared Savings Program. 

Similar to the Shared Savings Program, the Pioneer ACO Model and CPC Initiative use a shared 

savings methodology that is significantly different than the cost measures and benchmarks used 
CMS-1612-FC 984

to calculate the cost composite under the VM program. Because of these significant differences, 

we are persuaded by commenters who stated that the calculating a cost composite for groups and 

solo practitioners in these models could create conflicting incentives. Moreover, it is challenging 

to meaningfully assess the quality performance of groups that participate in these models for 

purposes of calculating a quality composite for the VM given that for many of these groups, 

some eligible professionals in the group participate in these models while other eligible 

professionals within the same group do not participate (79 FR 40502). Although the Pioneer 

ACO Model uses the same set of quality measures as the Shared Savings Program, this quality 

data does not necessarily represent all eligible professionals in the group because some do not 

participate in the model. The CPC Initiative presents similar challenges because of groups in 

which only a subset of eligible professionals may be participating in the model. Because some 

of the groups with eligible professionals participating in these models could choose to report 

outside of the model through a PQRS reporting mechanism, we may have quality data for a 

subset of groups or for a subset of individuals within a group, depending on the reporting 

mechanism. The policies in our proposed rule indicated that we would make use of this quality 

data when available, however, as noted above, we also considered other options including 

applying “average quality” to certain groups. We agree that it is important for these participants 

to focus on the cost and quality measures within their respective models and are persuaded by the 

vast majority of commenters who indicated that these policies could create conflicting incentives 

for model participants and several commenters who stated that they were unnecessarily complex 

and likely to cause confusion. We do not agree with commenters who suggested giving 

groups and solo practitioners an opportunity to “opt-in” for the reasons stated in response to 

comments on section III.N.4.d.1. We appreciate the support of commenters who agreed that 

applying the VM to groups and solo practitioners in these initiatives would support the VM 
CMS-1612-FC 985

program goals of improving quality and cost efficiency. To the extent possible, we intend to 

provide QRURs showing cost and, where available, quality performance on VM measures, to 

these groups and solo practitioners to further support the goals of the VM program. 

Comment: We also received comments on our proposal to calculate the cost composite 

for groups and solo practitioners who are not in the Shared Savings Program or similar CMS 

initiative in the payment adjustment year. These commenters stated that groups and solo 

practitioners should be assessed based on the cost and quality incentives that were in place in the 

performance period, not the payment adjustment period. Under our proposed policies, we would 

calculate a cost composite for groups that participated in Pioneer or CPC in the performance 

period but did not participate in another similar initiative or the Shared Savings Program in the 

payment adjustment period. One commenter stated these groups and solo practitioners should be 

classified as average cost because at least a portion of their eligible professionals were operating 

under a different set of cost measures during the performance period. 

Response: As noted in section III.N.4.d.1, we are persuaded by commenters who 

suggested that taking into account the status of the group or solo practitioner in the payment 

adjustment period does not fully acknowledge the incentives that existed for the group or solo 

practitioner in the performance period and, consistent with the approach taken for Shared 

Savings Program participants, we are finalizing a policy that takes into account whether a group 

or solo practitioner participates in the Pioneer ACO Model or CPC Initiative during the 

performance period for the VM. As discussed above, we believe the differences in methodology 

between the VM cost measures and the methodologies used to determine shared savings under 

the Pioneer ACO Model and the CPC Initiative are significant and that it would be inappropriate 

to calculate a cost composite for these groups and solo practitioners. In the proposed rule (79 FR 

40502), we stated that for groups and solo practitioners that participate in the Pioneer ACO 
CMS-1612-FC 986

Model or CPC Initiative in the performance period and then participate in an ACO under the 

Shared Savings Program in the payment adjustment period, we would use the Shared Savings 

Program ACO’s quality data to calculate the quality composite, or classify the quality composite 

as average if the ACO did not exist in the performance period. We are modifying this policy such 

that groups or solo practitioners who participate in the Pioneer ACO Model or CPC Initiative in 

the performance period and then participate in an ACO under the Shared Savings Program in the 

payment adjustment period will also receive “average cost” and “average quality”. This is 

consistent with the policies we are finalizing for the groups and solo practitioners that participate 

in an ACO under the Shared Savings Program to consider the group or solo practitioner’s status 

during the performance period, in order to determine how the VM will be applied. 

 After considering the public comments, we are finalizing a policy that for solo 

practitioners and groups with at least one eligible professional participating in the Pioneer ACO 

Model or CPC Initiative during the performance period, we will classify the cost composite as 

“average cost” and the quality composite as “average quality” for the CY 2017 payment 

adjustment period. This policy is similar to the alternative to scenario 2 we considered in the 

proposed rule (79 FR 40501), though with a broader application to address commenters’ 

concerns about the level of complexity in the proposals. We are not finalizing our proposals 

regarding the requirements for groups and solo practitioners in the Pioneer ACO Model and CPC 

Initiative to avoid Category 2 and the downward payment adjustment. Instead, for the CY 2017 

payment adjustment period, the policy to classify the cost composite as “average cost” and the 

quality composite as “average quality” will apply to all solo practitioners who participate in the 

Pioneer ACO Model or the CPC Initiative in the performance period and all groups with at least 

one eligible professional who participates in the Pioneer ACO Model or the CPC Initiative in the 

performance period. Given the concerns about distracting from the goals of the models in which 
CMS-1612-FC 987

these groups and solo practitioners participate, the complexity of determining whether groups 

that have some eligible professionals in the model and some who are not in the model 

successfully reported quality performance data, and the commenters’ requests for a simpler 

policy, we believe this is an appropriate policy. 

The VM calculated under this policy will apply to all physicians billing under the group’s 

TIN in the CY 2017 payment adjustment period regardless of whether the physician was part of 

the group in the performance period. This is consistent with our policy for other groups subject 

to the VM, in that we will not “track” or “carry” an individual professional’s performance from 

one TIN to another TIN. 

(c) Treatment of groups of two to nine eligible professionals and solo practitioners that 

participate in the Pioneer ACO Model or CPC Initiative. 

In section III.N.4.c of this final rule with comment period, we discussed our proposal to 

hold groups with two to nine eligible professionals and solo practitioners who are in Category 1 

harmless from any downward adjustments under the quality-tiering methodology for the CY 

2017 payment adjustment period. We proposed to also hold harmless from any downward 

adjustments for CY 2017 groups with two to nine eligible professionals, where one or more 

eligible professionals participate in the Pioneer ACO Model or the CPC, and solo practitioners 

who participate in the Pioneer ACO Model or the CPC during the CY 2015 performance period 

based on their size during the performance period. We would follow our established process for 

determining group size, which is described at §414.1210(c). We also proposed that groups 

where one or more eligible professionals participate in the Pioneer ACO Model or the CPC 

during the performance period, and solo practitioners participating in the Pioneer ACO Model or 

the CPC during the performance period would be eligible for the additional upward payment 

adjustment of +1.0x for caring for high-risk beneficiaries, as proposed in section III.N.4.f below. 
CMS-1612-FC 988

Comment: We did not receive comments specific to this proposal. The comments we 

received on our general policy to hold harmless groups of two to nine eligible professionals and 

solo practitioners are discussed in III.N.4.a of this final rule with comment period. 

Given the modified policy we are finalizing for group practices and solo practitioners 

participating in the Pioneer ACO Model and CPC Initiative to classify the cost composite as 

“average cost” and the quality composite as “average quality,” these proposals are no longer 

relevant and will not be finalized. 

(d) In addition, beginning with the CY 2017 payment adjustment period, we proposed to 

apply the VM to physicians and nonphysician eligible professionals in groups with two or more 

eligible professionals and to physicians and nonphysician eligible professionals who are solo 

practitioners who participate in other similar Innovation Center models or CMS initiatives during 

the relevant performance period for the VM in accordance with the proposed policies described 

above for the Pioneer ACO Model and the CPC Initiative. We are unable to propose an 

exhaustive list of the models and initiatives that would fall under this category because many of 

them have not yet been developed. In addition, it is possible that the timeline for implementing 

some of these new models and initiatives may not coincide with the timeline for rulemaking for 

the VM. To address these issues, we proposed to rely on the following general criteria to 

determine whether a model or initiative would fall in this “other similar” category and thus 

would be subject to the policies described above for the Pioneer ACO Model and the CPC 

Initiative: (1) the model or initiative evaluates the quality of care and/or requires reporting on 

quality measures; (2) the model or initiative evaluates the cost of care and/or requires reporting 

on cost measures; (3) participants in the model or initiative receive payment based at least in part 

on their performance on quality measures and/or cost measures; (4) potential for conflict 

between the methodologies used for the VM and the methodologies used for the model or 
CMS-1612-FC 989

initiative; or (5) other relevant factors specific to a model or initiative. We noted that a model or 

initiative would not have to satisfy or address all of these criteria to be included in this “other 

similar” category. Rather, the criteria are intended to serve as a general framework for 

evaluating models and initiatives with regard to the application of the VM to groups and solo 

practitioners who participate (79 FR 40502). We solicited public comment on these or other 

appropriate criteria for determining which models or initiatives we should classify as “other 

similar” models, for the purposes of applying the policies for the Pioneer ACO Model and the 

CPC Initiative described above. 

Comment: We did not receive any comments on the criteria proposed to determine 

“other similar” models, though many of the comments received on our proposals related to the 

application of the VM to groups and solo practitioners participating in the Shared Savings 

Program, Pioneer ACO Model, or CPC Initiative. 

Response: As stated in our response to comments on the application of the VM to 

Pioneer ACO and CPC Initiative participants, we are convinced by commenters who suggested 

that we apply “average cost” and “average quality” to these groups and solo practitioners. We 

believe many of these “other similar” models would be testing new quality measures, reporting 

methods, or both, and we want to encourage innovation, including standing up new infrastructure 

to capture performance on quality measures that could be used in the VM program in the future. 

After consideration of the comments, we are finalizing our general criteria as proposed 

for determining if a model or initiative should be classified as an “other similar” model or 

initiative. We will apply the final policies adopted for applying the VM to groups and solo 

practitioners that participate in the Pioneer Model or the CPC Initiative to Innovation Center 

models and CMS initiatives that we determine are “similar” based on these criteria. 
CMS-1612-FC 990

We recognize that the policies we finalize for the Pioneer ACO Model and the CPC 

Initiative might not be applicable to all of the various models and initiatives that could be 

developed in future years. If we believe a different approach to applying the VM would be 

appropriate for a model or initiative, we intend to address it in future rulemaking. In addition, if 

we were to determine that a model or initiative falls under this “other similar” category based on 

the general criteria, we will provide notice to participants in the model or initiative through the 

methods of communication that are typically used for the model or initiative. 

Additionally, consistent with our final policies for the Pioneer ACO Model and CPC 

Initiative, Shared Savings Program, and groups and solo practitioners that do not participate in 

these programs or models, we will not apply the VM to nonphysician eligible professionals in 

similar Innovation Center models or CMS initiatives in the CY 2017 payment adjustment period. 

We modified §414.1210 to reflect all of these policies. 

In addition to the comments described above, we received a few comments that were 

outside the scope of what was proposed in this rule: 

Comment: One commenter stated that ACOs should have an opportunity to receive 

confidential reports on their performance on all Medicare FFS beneficiaries – not just MSSPattributed beneficiaries – through the Physician Feedback Program prior to application of the 

VM program. This commenter also stated that CMS should reduce the administrative burden 

associated with the “opt out” process for data sharing for Shared Savings Program ACOs. Other 

commenters stated that CMS should adjust the financial benchmarks for ACOs based on VM 

adjustments. 

Response: We appreciate the input from these commenters but believe these suggestions 

are outside the scope of this rule. Data sharing policies and financial benchmarking 

methodologies for the Medicare Shared Savings Program are described in the Final Rule for that 
CMS-1612-FC 991

program released in November 2011. The rule can be accessed 

http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf. Information on the Pioneer 

ACO Model, can be found here: http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/. 

e. Clarification Regarding Treatment of Non-assigned Claims for Non-Participating Physicians 

In the CY 2013 PFS final rule with comment period in which we established a number of 

key policies for the VM, we stated that we had received few comments on our proposal to apply 

the VM to the Medicare paid amounts for the items and services billed under the PFS so that 

beneficiary cost-sharing or coinsurance would not be affected (77 FR 69309). These 

commenters generally agreed with the proposal to apply the VM to the Medicare paid amounts 

for the items and services billed under the PFS at the TIN level so that beneficiary cost-sharing 

would not be affected. Therefore, we finalized this policy and accordingly established a 

definition of the VM at §414.1205 that was consistent with the proposal and the statutory 

requirement to provide for differential payment to a physician or a group of physicians under the 

fee schedule based upon the quality of care furnished compared to cost during a performance 

period. 

We continue to believe that it is important that beneficiary cost-sharing not be affected by 

the VM and that the VM should be applied to the amount that Medicare pays to physicians. 

However, in previous rulemaking, we did not directly address whether the VM would be applied 

to both assigned services for which Medicare makes payment to the physician, and to nonassigned services for which Medicare makes payment to the beneficiary. Participating 

physicians are those who have signed an agreement in accordance with section 1842(h)(1) of the 

Act to accept payment on an assignment-related basis for all items and services furnished to 

Medicare beneficiaries. In other words, participating physicians agree to accept the Medicare 

approved amount as payment in full and to charge the beneficiary only the Medicare deductible 
CMS-1612-FC 992

and coinsurance amount. In contrast, non-participating physicians have not signed an agreement 

to accept assignment for all services furnished to beneficiaries, but they can still choose to accept 

assignment for individual services. If they choose not to accept assignment for particular 

services, non-participating physicians can charge the beneficiary more than the Medicareapproved amount, up to a limit called the “limiting charge.” The limiting charge is defined at 

section 1848(g)(2)(C) of the Act as 115 percent of the recognized payment amount for 

nonparticipating physicians. In contrast, if a non-participating physician chooses to accept 

assignment for a service, they receive payment from Medicare at the approved amount for nonparticipating physicians, which is 95 percent of the fee schedule amount. Over 99 percent of 

Medicare physician services are billed on an assignment related basis by both participating and 

non-participating physicians and other suppliers, with the remainder billed as non-assigned 

services by non-participating physicians and other suppliers. 

For assigned claims, Medicare makes payment directly to the physician. In accordance 

with section 1848(p)(1) of the Act and the regulations at §414.1205 and §414.1210(a), the VM 

should be applied to assigned claims. However, for non-assigned claims, the limiting charge (the 

amount that the physician can bill a beneficiary for a non-assigned service) would not be affected 

if the VM were applied to the claim. This is so, because for non-assigned claims, application of 

the VM would not affect the limiting charge. Rather, Medicare makes payment for the nonassigned services directly to the beneficiary and the physician receives all payment for a nonassigned service directly from the beneficiary. If the VM were to be applied to non-assigned 

services, then the Medicare payment to a beneficiary would be increased when the VM is 

positive and decreased when the VM is negative. The application of the VM to non-assigned 

claims would therefore directly affect beneficiaries and not physicians, contrary to our intent as 

discussed in previous rulemaking (77 FR 69309). On that basis, we proposed to clarify that we 
CMS-1612-FC 993

would apply the VM only to assigned services and not to non-assigned services starting in CY 

2015 (79 FR 40504). We do not expect this proposed clarification, to not apply the VM to nonassigned claims, would be likely to affect a physician’s decision to participate in Medicare or to 

otherwise accept assignment for a particular claim. This is because the amount that a provider is 

entitled to receive from the beneficiary for non-assigned claims is not affected by whether or not 

the VM is applicable to non-assigned claims. Additionally, to the extent our proposal to expand 

application of the VM to nonphysician eligible professionals is finalized, we would likewise 

apply the VM only to services billed on an assignment-related basis and not to non-assigned 

services. We invited comments on this proposed clarification. 

The following is summary of the comments we received on this proposed clarification. 

Comment: We received relatively few comments on this technical issue. For those that 

did comment, nearly all agreed with the proposed clarification and agreed it is important that 

beneficiary cost-sharing not be affected by the VM, and that the VM should be applied to the 

amount that Medicare pays to physicians. Some commenters requested a similar policy be 

applied to the payment adjustments for PQRS and EHR Meaningful Use. A commenter opposed 

the proposed clarification, encouraging CMS to support non-participating providers by applying 

the value modifier adjustment to non-assigned claims at the group practice level (TIN), and to 

evaluate alternative solutions to paying providers other than at the claim level. 

Response: We appreciate receiving the comments that supported this technical 

clarification. However, we are unable to agree with the commenter that suggested an alternative 

approach to apply the VM to claims submitted by non-participating physicians. As explained 

above and in the proposal, the application of the VM to non-assigned claims by non-participating 

physicians would directly affect beneficiaries and not physicians, contrary to our intent. 

However, we further clarify that the VM will apply to all assigned claims, including those 
CMS-1612-FC 994

submitted by both participating and non-participating physicians, and nonphysician eligible 

professionals to the extent the VM is applied to them. Therefore, the VM will affect nonparticipating physicians to the extent that they submit assigned claims. 

 With regard to the comment that a similar policy for non-assigned claims be applied to 

the PQRS and EHR meaningful use adjustments, we believe the comment is outside of the scope 

of the proposed rule, although we note that the VM is quite different from the PQRS and EHRmeaningful use adjustments, which apply to the Medicare allowed amount rather than the 

Medicare paid amount. 

After considering the public comments, we are finalizing the proposed clarification to not 

apply the VM to non-assigned claims for non-participating physicians, and nonphysician eligible 

professionals to the extent the VM is applied to them. 

f. Payment Adjustment Amount 

Section 1848(p) of the Act does not specify the amount of payment that should be subject 

to the adjustment for the VM; however, section 1848(p)(4)(C) of the Act requires the VM be 

implemented in a budget neutral manner. Budget neutrality means that payments will increase 

for some groups and solo practitioners based on high performance and decrease for others based 

on low performance, but the aggregate expected amount of Medicare spending in any given year 

for physician and nonphysician eligible professional services paid under the Medicare PFS will 

not change as a result of application of the VM. 

In the CY 2014 PFS final rule with comment period (78 FR 74770-74771), we adopted a 

policy to apply a maximum downward adjustment of -2.0 percent for the CY 2016 VM for those 

groups of physicians with 10 or more eligible professionals that are in Category 2 and for groups 

of physicians with 100 or more eligible professionals that are in Category 1 and are classified as 

low quality/high cost groups. 
CMS-1612-FC 995

In the CY 2013 PFS final rule with comment period, we adopted a modest payment 

reduction of -1.0 percent for groups of physicians in Category 1 that elected quality tiering and 

were classified as low quality/high cost and for groups of physicians in Category 2 (77 FR 

69323-24). Although we received comments suggesting that larger payment adjustments (both 

upward and downward) would be necessary to more strongly encourage quality improvements, 

we finalized our proposed adjustments as we believed they better aligned with our goal to 

gradually phase in the VM. However, we noted that as we gained experience with our VM 

methodologies we would likely consider ways to increase the amount of payment at risk, as 

suggested by some commenters (77 FR 69324). 

We believe that we can increase the amount of payment at risk because we can reliably 

apply the VM to groups with two or more eligible professionals and to solo practitioners in CY 

2017 as discussed in section III.N.4.a of this final rule with comment period. Therefore, we 

proposed to increase the downward adjustment under the VM by doubling the amount of 

payment at risk from -2.0 percent in CY 2016 to -4.0 percent in CY 2017 (79 FR 40505-40506). 

That is, for CY 2017, we proposed to apply a -4.0 percent VM to groups with two or more 

eligible professionals and solo practitioners that fall in Category 2. In addition, we proposed to 

increase the maximum downward adjustment under the quality-tiering methodology in CY 2017 

to -4.0 percent for groups and solo practitioners classified as low quality/high cost and to set the 

adjustment to -2.0 percent for groups and solo practitioners classified as either low 

quality/average cost or average quality/high cost. However, as discussed in section III.N.4.c of 

this final rule with comment period, we proposed to hold solo practitioners and groups with two 

to nine eligible professionals that are in Category 1 harmless from any downward adjustments 

under the quality-tiering methodology in CY 2017. Consistent with our previous policy, we note 

that the estimated funds derived from the application of the downward adjustments to groups and 
CMS-1612-FC 996

solo practitioners in Category 1 and Category 2 would be available to all groups and solo 

practitioners eligible for VM upward payment adjustments. Accordingly, we also proposed to 

increase the maximum upward adjustment under the quality-tiering methodology in CY 2017 to 

+4.0x for groups and solo practitioners classified as high quality/low cost and to set the 

adjustment to +2.0x for groups and solo practitioners classified as either average quality/low cost 

or high quality/average cost (79 FR 40505). We also proposed to continue to provide an 

additional upward payment adjustment of +1.0x to groups and solo practitioners that care for 

high-risk beneficiaries (as evidenced by the average HCC risk score of the attributed beneficiary 

population). Lastly, we proposed to revise §414.1270 and §414.1275(c) and (d) to reflect the 

changes to the payment adjustments under the VM for the CY 2017 payment adjustment period. 

Table 87 shows the proposed quality-tiering payment adjustment amounts for CY 2017 (based 

on CY 2015 performance). We believe that the VM amount differentiates between cost and 

quality-tiers in a more meaningful way. We solicited comments on all of these proposals. 

TABLE 87: Proposed CY 2017 VM Payment Adjustment Amounts 

Cost/Quality Low Quality Average Quality High Quality 

Low Cost +0.0% +2.0x* +4.0x* 

Average Cost -2.0% +0.0% +2.0x* 

High Cost -4.0% -2.0% +0.0% 

* Groups and solo practitioners eligible for an additional +1.0x if reporting Physician Quality Reporting System 

quality measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores. 

The following is summary of the comments we received on all these proposals. 

Comment: The majority of the comments were opposed to our proposals to increase the 

downward payment adjustments from CY 2016 to CY 2017 for groups and solo practitioners that 

fall in Category 2 and those that are low quality/high cost under the quality-tiering methodology 

to -4.0 percent. Commenters expressed their belief that the changes are aggressive. Several 

commenters indicated that CY 2017 will be the first year that many physicians and all 
CMS-1612-FC 997

nonphysician eligible professionals will be subject to the VM, and therefore, recommended 

maintaining the maximum downward payment adjustment at -2.0 percent for Category 2 and 

those that are low quality/high cost under the quality-tiering methodology. Commenters 

indicated that many of these groups and solo practitioners have not yet received their QRURs; 

therefore, it would be premature to raise the adjustment amount until all groups and solo 

practitioners have applicable cost and quality metrics and have had an opportunity to participate 

in the PQRS and VM programs. Commenters indicated that CMS should not increase the 

amount of payment at risk under quality-tiering and for Category 2 without providing an 

opportunity for both providers and CMS to understand the implications of the current policies as 

no group has had experience with the VM since it will be implemented in CY 2015. Other 

commenters suggested that groups and solo practitioners will have little time to fully understand 

their baseline performance under the VM. They suggested by delaying the increase of the 

maximum penalty, CMS would gain experience with applying the VM to a broader variety of 

groups, and that groups and solo practitioners would increase their understanding of the 

methodology used to calculate the VM and review their QRURs. Few commenters suggested 

that if CMS is concerned about PQRS reporting, then it should separate the amount at risk for not 

reporting under the PQRS (Category 2) from the amount at risk under quality-tiering 

(Category 1) and that these adjustments should not be at the same level. 

Other commenters noted that the cumulative impact of penalties for PQRS, EHR, and the 

VM would add up to a potential -9.0 percent adjustment to Medicare payments and expressed 

that this cumulative impact would be overly burdensome. One commenter indicated that the 

proposed changes would occur in a post-sequester payment environment where providers already 

experience a -2.0 percent reduction in Medicare payment. Some commenters indicated it was 

unfair to hold solo practitioners and groups with two to nine eligible professionals at -4.0 percent 
CMS-1612-FC 998

for the first year of the VM when groups with of 10 to 99 eligible professionals and groups with 

100 or more eligible professionals EPs were at risk for only -2.0 percent and -1.0 percent 

respectively in their first year of the VM. These commenters suggested that we reduce their 

Category 2 downward payment adjustment for groups and solo practitioners during their first 

year in the VM. 

By contrast, some supported all of our VM payment adjustment proposals and expressed 

their belief that a -4.0 percent downward adjustment and +4.0x upward adjustment factor was not 

sufficient to incentivize physicians to improve quality. A few of these commenters suggested 

that the amount at risk should eventually be approximately 10.0 percent and that CMS should 

create a plan in the final rule to continually increase the weight of the VM over time. One 

commenter noted that there is evidence in the private sector that higher incentives and penalties 

have a great impact on quality improvement. 

Response: We acknowledge the commenters’ concerns about doubling the amount of 

payment at risk from -2.0 percent in CY 2016 to -4.0 percent in CY 2017 under the VM. 

However, the literature documents a positive correlation between physician participation in 

quality improvement activities and the extent of the payment adjustment.22 We agree with the 

commenters who suggested that smaller groups should be subject to a more gradual phase-in of 

the VM’s application to them, consistent with the experience of the larger groups. We 

acknowledge that our proposal would have held solo practitioners and groups with two to nine 

eligible professionals in Category 2 at risk for up to a -4.0 percent payment adjustment for the 

first year of the VM when groups with of 10 to 99 eligible professionals and groups with 100 or 

more eligible professionals EPs were at risk for only -2.0 percent and -1.0 percent respectively in 

 

22 Francois S. de Brantes & B. Guy D’Andrea. Physicians Respond to Pay-for-Performance Incentives: Larger 

Incentives Yield Greater Participation. Am. J. of Managed Care. 2009. 15,305-310. With regard to hospital 

participation, this correlation has been documented. Rachel M. Werner, et al. The Effect of Pay-For-Performance In 

Hospitals: Lessons for Quality Improvement. Health Affairs. 2011. 30,690-698.
CMS-1612-FC 999

the first year that the VM applied to them. In light of these comments, we agree that a smaller 

increase in the maximum amount of payment at risk for groups with two to nine eligible 

professionals and solo practitioners would be consistent with our stated focus on gradual 

implementation and would allow small groups and solo practitioners to gain more experience 

with the QRURs and the application of the VM. Therefore, we are finalizing -2.0 percent as the 

maximum amount of payment at risk in CY 2017 for groups with two to nine eligible 

professionals and solo practitioners. Specifically, in CY 2017, for groups with two to nine 

eligible professionals and solo practitioners, we will apply a -2.0 percent VM to a group or solo 

practitioner that falls in Category 2. We note that, as discussed in section III.N.4.c of this final 

rule with comment period, we are finalizing our proposal to hold solo practitioners and groups 

with two to nine eligible professionals that are in Category 1 harmless from any downward 

adjustments under the quality-tiering methodology in CY 2017, if classified as low quality/high 

cost, low quality/average cost, or average quality/high cost. Additionally, for groups with two to 

nine eligible professionals and solo practitioners, we are finalizing a policy to set the maximum 

upward adjustment under the quality-tiering methodology in CY 2017 to +2.0x if a group or solo 

practitioner is classified as high quality/low cost and set the adjustment to +1.0x if a group or 

solo practitioner is classified as either average quality/low cost or high quality/average cost. 

Table 88 shows the final quality-tiering payment adjustment amounts for CY 2017 (based on CY 

2015 performance) for groups with two to nine eligible professionals and solo practitioners. 

For groups with ten or more eligible professionals, we are finalizing the payment 

adjustments as proposed for CY 2017 (79 FR 40505-40506). As stated in the proposed rule (79 

FR 40505), we believe that we can increase the amount of payment at risk because groups of this 

size will have had sufficient experience with the VM prior to the CY 2017 payment adjustment 

period. By CY 2017, groups with 10 or more eligible professionals will have had at least one 
CMS-1612-FC 1000

year experience under the VM program. As stated in the CY 2014 PFS final rule with comment 

period (78 FR 74769), on September 16, 2013, we made available to all groups of 25 or more 

eligible professionals an annual QRUR based on 2012 data to help groups estimate their quality 

and cost composites. As discussed in section III.N.4.a. of this final rule with comment period, in 

September 2014, we made available QRURs based on CY 2013 data to all groups of physicians 

and physicians who are solo practitioners. We believe that groups of 10 or more eligible 

professionals will have had adequate data to improve performance on the quality and cost 

measures that will be used to calculate the VM in CY 2017. As a result, we believe it is 

appropriate to increase the amount of payment at risk for groups with ten or more eligible 

professionals in CY 2017. 

Consequently, for CY 2017, we will apply a -4.0 percent VM to groups with ten or more 

eligible professionals that fall in Category 2. In addition, we will set the maximum downward 

adjustment under the quality-tiering methodology in CY 2017 to -4.0 percent for groups with ten 

or more eligible professionals classified as low quality/high cost and set the adjustment to -2.0 

percent for groups with ten or more eligible professionals classified as either low quality/average 

cost or average quality/high cost. We will also set the maximum upward adjustment under the 

quality-tiering methodology in CY 2017 to +4.0x for groups with ten or more eligible 

professionals classified as high quality/low cost and set the adjustment to +2.0x for groups with 

ten or more eligible professionals classified as either average quality/low cost or high 

quality/average cost. Table 89 shows the final quality-tiering payment adjustment amounts for 

CY 2017 (based on CY 2015 performance) for groups with ten or more eligible professionals. 

We are also finalizing our proposal to continue to provide an additional upward payment 

adjustment of +1.0x to groups with two or more eligible professionals and solo practitioners that 
CMS-1612-FC 1001

care for high-risk beneficiaries (as evidenced by the average HCC risk score of the attributed 

beneficiary population). Lastly, we are finalizing the revisions at §414.1270(c) and 

§414.1275(c) and (d) to reflect the payment adjustments under the VM for the CY 2017 payment 

adjustment period. Tables 88 and 89 show the quality-tiering payment adjustment amounts for 

CY 2017 (based on CY 2015 performance). We believe that these final policies will alleviate 

commenters’ concern that our proposals were too aggressive for smaller groups and solo 

practitioners that are new to the VM in CY 2017, while continuing the gradual phase-in of the 

VM for groups with ten or more eligible professionals with an emphasis on the importance of 

reporting under the PQRS program and improving the quality and efficiency of services provided 

to Medicare beneficiaries. 

TABLE 88: Final CY 2017 VM Payment Adjustment Amounts for Groups with Two to 

Nine Eligible Professionals and Solo Practitioners 

Cost/Quality Low quality Average quality High quality 

Low cost +0.0% +1.0x* +2.0x* 

Average cost +0.0% +0.0% +1.0x* 

High cost +0.0% +0.0% +0.0% 

* Groups and solo practitioners eligible for an additional +1.0x if reporting measures and average beneficiary risk 

score is in the top 25 percent of all beneficiary risk scores, where ‘x’ represents the upward payment adjustment 

factor. 

TABLE 89: Final CY 2017 VM Payment Adjustment Amounts for Groups with Ten or 

More Eligible Professionals 

Cost/Quality Low quality Average quality High quality 

Low cost +0.0% +2.0x* +4.0x* 

Average cost -2.0% +0.0% +2.0x* 

High cost -4.0% -2.0% +0.0% 

* Groups eligible for an additional +1.0x if reporting measures and average beneficiary risk score is in the top 25 

percent of all beneficiary risk scores, where ‘x’ represents the upward payment adjustment factor. 

Consistent with the policy adopted in the CY 2013 PFS final rule with comment period 

(77 FR 69324 through 69325), the upward payment adjustment factor (“x” in Tables 88 and 89) 
CMS-1612-FC 1002

will be determined after the performance period has ended based on the aggregate amount of 

downward payment adjustments. We noted in the proposed rule that the estimated funds derived 

from the application of the downward adjustments to groups and solo practitioners in Category 1 

and Category 2 would be available to all groups and solo practitioners eligible for VM upward 

payment adjustments (79 FR 40504). 

In section III.N.4.d of the proposed rule (79 FR 40506), we discussed our proposal to 

apply the VM to physicians in groups with two or more eligible professionals and to physicians 

who are solo practitioners that participate in the Shared Savings Program during the payment 

adjustment period beginning with the CY 2017 payment adjustment period. We noted in the CY 

2015 PFS proposed rule that will have the final list of ACOs that will participate in the Shared 

Savings Program during the payment adjustment period and their participant TINs during the late 

fall prior to the beginning of the payment adjustment period (for example, the late fall of CY 

2016 prior to the CY 2017 payment adjustment period) (79 FR 40506). We also noted that this 

final list may not be available until after the beginning of the payment adjustment period. 

Therefore, we proposed to calculate preliminary payment adjustment factors (“x” in Table 87) 

prior to the beginning of the payment adjustment period, and subsequently finalize the payment 

adjustment factors after the final ACO participation list is completed. We note that the final 

payment adjustment factors may be updated depending on the outcome of the informal inquiry 

process described later at section III.N.4.i of this final rule with comment period. 

We did not receive any comments on these proposals. 

As discussed in section III.N.4.d of this final rule with comment period, we are finalizing 

a policy to use the performance period to determine which groups and solo practitioners 

participate in the Shared Savings Program for purposes of calculating their VM in CY 2017. 

Therefore, we are not finalizing our proposal to calculate preliminary payment adjustment 
CMS-1612-FC 1003

factors (“x” in Tables 88 and 89) prior to the beginning of the payment adjustment period, and 

then recalculating the payment adjustment factors after the final ACO participation list is 

completed. However, we are finalizing our proposal that we may update the payment adjustment 

factors, depending on the outcome of the informal inquiry process described later at section 

III.N.4.i of this final rule with comment period. 

g. Performance Period 

In the CY 2014 PFS final rule with comment period (78 FR 74771 through 74772), we 

adopted a policy that performance on quality and cost measures in CY 2015 will be used to 

calculate the VM that is applied to items and services for which payment is made under the PFS 

during CY 2017. Accordingly, we added a new paragraph (c) to §414.1215 to indicate that the 

performance period is CY 2015 for VM adjustments made in the CY 2017 payment adjustment 

period. 

h. Quality Measures 

 In the CY 2014 PFS final rule with comment period (78 FR 74773), we aligned 

our policies for the VM for CY 2016 with the PQRS group reporting mechanisms available to 

groups in CY 2014 and the PQRS reporting mechanisms available to individual eligible 

professionals in CY 2014, such that data that groups submit for quality reporting purposes 

through any of the PQRS group reporting mechanisms in CY 2014 and the data that individual 

eligible professionals submit through any of the individual PQRS reporting mechanisms in CY 

2014 will be used for calculating the quality composite under the quality-tiering approach for the 

VM for CY 2016. Moreover, all of the quality measures for which groups and individual eligible 

professionals are eligible to report under the PQRS in CY 2014 would be used to calculate the 

VM for a group for CY 2016 to the extent the group or individual eligible professionals in the 

group submits data on such measure in accordance with our 50 percent threshold policy (78 FR 
CMS-1612-FC 1004

74768). We also noted that, in accordance with 42 CFR 414.1230, three additional quality 

measures (outcome measures) for groups subject to the VM will continue to be included in the 

quality measures used for the VM in CY 2016. These measures are: (1) a composite of rates of 

potentially preventable hospital admissions for heart failure, chronic obstructive pulmonary 

disease, and diabetes; (2) a composite rate of potentially preventable hospital admissions for 

dehydration, urinary tract infections, and bacterial pneumonia; and (3) rates of an all-cause 

hospital readmissions measure (77 FR 69315). 

PQRS Reporting Mechanisms: It is important to continue to align the VM for CY 2017 

with the requirements of the PQRS, because quality reporting is a necessary component of 

quality improvement. We also seek not to place an undue burden on eligible professionals to 

report such data. Accordingly, for purposes of the VM for CY 2017, we proposed to continue to 

include in the VM all of the PQRS GPRO reporting mechanisms available to groups for the 

PQRS reporting periods in CY 2015 and all of the PQRS reporting mechanisms available to 

individual eligible professionals for the PQRS reporting periods in CY 2015. These reporting 

mechanisms were described in Tables 21 through 49 of the proposed rule (79 FR 40404). 

PQRS Quality Measures: We proposed to continue to use all of the quality measures that 

are available to be reported under these various PQRS reporting mechanisms to calculate a group 

or solo practitioner’s VM in CY 2017 to the extent that a group (or individual eligible 

professionals in the group, in the case of the “50 percent option”) or solo practitioner submits 

data on these measures. These PQRS quality measures were described in Tables 21 through 49 

of the proposed rule (79 FR 40404). 

We proposed that groups with two or more eligible professionals would be able to elect 

to include the patient experience of care measures collected through the PQRS CAHPS survey 
CMS-1612-FC 1005

for CY 2015 in their VM for CY 2017 (79 FR 40506). We also proposed to continue to include 

the three outcome measures in §414.1230 in the quality measures used for the VM in CY 2017. 

For groups that are assessed under the “50 percent option” for the CY 2017 VM, we proposed to 

calculate the group’s performance rate for each measure reported by at least one eligible 

professional in the group by combining the weighted average of the performance rates of those 

eligible professionals reporting the measure. We also proposed for groups that are assessed under 

the “50 percent option” for the CY 2017 VM to classify a group’s quality composite score as 

‘‘average’’ under the quality-tiering methodology, if all of the eligible professionals in the group 

satisfactorily participate in a PQRS qualified clinical data registry in CY 2015 and we are unable 

to receive quality performance data for those eligible professionals. We wish to clarify that in 

this proposal, the phrase “all of the eligible professionals in the group” refers to the at least 50 

percent of eligible professionals in the group who report as individuals under PQRS. In other 

words, we proposed for groups that are assessed under the “50 percent option” for the CY 2017 

VM, where all of the eligible professionals in the group who report as individuals under PQRS 

do so by satisfactorily participating in a PQRS qualified clinical data registry in CY 2015, and 

we are unable to receive quality performance data for those eligible professionals, then we would 

classify the group’s quality composite score as ‘‘average’’ under the quality-tiering 

methodology. If some EPs in the group report data using a qualified clinical data registry and we 

are unable to obtain the data, but other EPs in the group report data using the other PQRS 

reporting mechanisms for individuals, we would calculate the group’s score based on the 

reported performance data that we obtain through those other mechanisms (79 FR 40507). 

Although we finalized policies in the CY 2014 final rule with comment period that would 

allow groups assessed under the “50 percent option” to have data reported through a PQRS 

qualified clinical data registry in CY 2014 used for the purposes of their CY 2016 VM to the 
CMS-1612-FC 1006

extent performance data are available, we noted that we did not directly address the issue of how 

we would compute the national benchmarks for these measures. Under §414.1250, benchmarks 

for the quality of care measures for the VM are the national mean performance rate for a measure 

during the year prior to the performance period. In the CY 2013 PFS final rule (77 FR 69322), 

we finalized a policy that if a measure is new to the PQRS, we will be unable to calculate a 

benchmark and performance on that measure will therefore not be included in the quality 

composite. Consistent with these existing policies, we proposed to not include in the VM quality 

composite those measures reported through a PQRS qualified clinical data registry that are new 

to PQRS (in other words, measures that were not previously reported in PQRS) (79 FR 40507). 

This policy would apply beginning with the measures reported through a PQRS qualified clinical 

data registry in the CY 2014 performance period for the CY 2016 payment adjustment period. 

We welcomed public comment on this proposal. 

We noted that the PQRS administrative claims option described in §414.1230, is no 

longer available through PQRS (79 FR 40507). However, we are clarifying that the three 

claims-based outcome measures described in §414.1230, are still used in calculating the quality 

composite for purposes of the VM. We proposed to clarify that we calculate benchmarks for 

those outcome measures described in §414.1230 using the national mean for a measure's 

performance rate during the year prior to the performance period in accordance with our 

regulation at §414.1250(b) (79 FR 40507). We welcomed public comment on this proposal. 

The following is summary of the comments we received on these proposals. 

Comment: Several commenters supported the alignment of VM with PQRS requirements. 

Other commenters, however, raised concerns about the lack of applicable quality measures for 

multiple specialties and nonphysician eligible professionals, which they believe could result in 

an automatic downward payment adjustment for professionals who are unable to report. Several 
CMS-1612-FC 1007

commenters also suggested CMS should include measures in the VM only after physicians had 

reported on the measures under PQRS for at least a year. Several commenters supported our 

proposal to continue our existing VM benchmarking policy for measures that are new to PQRS 

or reported via a Qualified Clinical Data Registry (QCDR). Several commenters supported our 

proposal to allow optional reporting of patient experience of care measures for groups of two or 

more physicians. However several commenters urged us to consider additional patient 

experience measures that are relevant to beneficiaries using specific Medicare benefits. One 

commenter suggested that CAHPS data should be collected throughout the year, allowing 

providers to prioritize and monitor the effectiveness of improvement efforts, especially as patient 

experience of care data will be incorporated into the VM in CY 2017. One commenter suggested 

that the patient experience of care measures should be optional for quality tiering for the CY 

2017 VM, as the 2013 GPRO web participants are still awaiting the results of the survey 

administration. A number of commenters stated that CMS should not make patient experience 

measures a required component of the VM in the future. 

Response: PQRS measures are highly reliable measures for understanding the health and 

functional status of beneficiaries after treatment by a participating group or solo practitioner.23 

In previous rulemakings we have committed to expanding the specialty measures available in 

PQRS in order to more accurately measure the performance on quality of care furnished by 

specialists and we reaffirm our commitment to using measures of performance across specialties 

that are reliable and valid for the VM program (77 FR 69315; 78 FR 74773). Moreover, we 

believe group reporting can ameliorate the commenters’ concerns that the current set of PQRS 

measures does not capture all of the clinical care that some specialists and sub-specialists 

 

23 Mathematica Policy Research, “Experience Report for the Performance Year 2012 Quality and Resource Use 

Reports.” (January 8, 2014). 
CMS-1612-FC 1008

furnish. We also continue to believe that alignment with the PQRS program is an important goal 

for the VM, because it minimizes burden on providers and encourages widespread participation 

in quality reporting. 

As we stated in section III.N.4.a of this final rule with comment period, where a group or 

solo practitioner falls in Category 1 under the VM (that is, meets the criteria to avoid the CY 

2017 PQRS payment adjustment), but the group or solo practitioner does not have at least 20 

cases for each PQRS measure on which it reports as required for inclusion in the quality 

composite of the VM, the group or solo practitioner’s quality composite score would be based on 

the three claims-based outcome measures described at §414.1230, provided that the group or 

solo practitioner has at least 20 cases for at least one of the claims-based outcome measures. As 

discussed in section III.N.4.h of this final rule with comment period, eligible professionals and 

groups concerned about the lack of specialty measures to meet PQRS reporting requirements 

should note that PQRS has a Measure Applicability Validation (MAV) process. MAV 

determines PQRS incentive eligibility for eligible professionals and groups reporting less than 

nine measures across three domains or nine or more across less than three domains. We 

recommend that commenters refer to the Measure Application Validation (MAV) Process to 

alleviate concerns that lack of applicable measures would result in an automatic downward 

adjustment under the VM . http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/PQRS/Downloads/2014_PQRS_Claims_MeasureApplicabilityValidation_12132013

.zip. Also, please refer to section III.K.2 of this final rule with comment period for the final 2017 

policies for MAV and the criteria for satisfactory reporting for the 2017 PQRS payment 

adjustment. 

With regard to the commenters’ suggestion that the VM should include only measures on 
CMS-1612-FC 1009

which physicians have reported under PQRS for at least one year, we note that we are 

maintaining the policy set forth in §414.1250 that benchmarks for the quality of care measures 

are the national mean of a measure’s performance rate during the year prior to the performance 

period. Measures reported through a PQRS qualified clinical data registry that are new to PQRS 

would not be included in the quality composite for the VM because we would not be able to 

calculate benchmarks for them. We acknowledge the interest in ensuring that physicians report 

on measures for at least one year before they are included in the VM. Our current policy achieves 

that end by precluding the use of measures for which no benchmarking data is available. 

We acknowledge the comments suggesting that CMS expand the data collected on the patient 

experience of care (CAHPS) measures and note that we seek to align with the PQRS program in 

order to minimize reporting burden and align incentives across CMS incentive payment 

programs. We will consider these suggestions for any future refinements to the patient 

experience measures included in the PQRS program and the VM. CMS will provide survey 

results and post benchmarks for the patient experience of care measures; this data as well as the 

survey questions that can be accessed on the CMS website can be utilized to prioritize 

performance improvement efforts. We also acknowledge the commenters’ concerns with 

expansion of mandatory CAHPS inclusion in the VM and note that we would propose any such 

policy change through future notice and comment rulemaking. 

After consideration of the comments, we are finalizing our proposal to use all of the 

quality measures that are available to be reported under these various PQRS reporting 

mechanisms to calculate a group or solo practitioner’s VM in CY 2017, to the extent that a group 

(or individual eligible professionals in the group, in the case of the “50 percent option”) or solo 

practitioner submits data on these measures. We are finalizing our policy that groups with two 

or more eligible professionals can elect to include the patient experience of care measures 
CMS-1612-FC 1010

collected through the PQRS CAHPS survey for CY 2015 in their VM for CY 2017. We are 

finalizing our policy to continue to include the three outcome measures in §414.1230 in the 

quality measures used for the VM in CY 2017. We are finalizing our policy that for groups that 

are assessed under the “50 percent option” for the CY 2017 VM, we will calculate the group’s 

performance rate for each measure reported by at least one eligible professional in the group by 

combining the weighted average of the performance rates of those eligible professionals 

reporting the measure. 

We are finalizing our policy at §414.1270(c)(4) that, for groups that are assessed under 

the “50 percent option” for the CY 2017 VM, where all of the eligible professionals in the group 

who report as individuals under PQRS do so by satisfactorily participating in a PQRS qualified 

clinical data registry in CY 2015, and we are unable to receive quality performance data for 

those eligible professionals, then we will classify the group’s quality composite score as 

‘‘average’’ under the quality-tiering methodology. Because this is the same policy as for the CY 

2016 payment adjustment period, we are also making a conforming revision to §414.1270(b)(4). 

We are finalizing a policy that, for groups that are assessed under the “50 percent option” 

where some EPs in the group report data using a qualified clinical data registry and we are 

unable to obtain the data, but other EPs in the group report data using the other PQRS reporting 

mechanisms for individuals, then we will calculate the group’s score based on the reported 

performance data that we obtain through those other PQRS reporting mechanisms. We are 

finalizing a policy that, beginning with the CY 2014 performance period, measures reported 

through a PQRS qualified clinical data registry that are new to PQRS will not be included in the 

quality composite for the VM until such time as we have historical data to calculate benchmarks 

for them. Once we have historical data from measures submitted via QCDRs, the benchmark for 

quality of care measures will be the national mean for the measure’s performance rate during the 
CMS-1612-FC 1011

year prior to the performance period (§414.1250). We are finalizing our proposed clarification 

that we calculate benchmarks for the outcome measures described in §414.1230 using the 

national mean for a measure's performance rate during the year prior to the performance period 

in accordance with our regulation at §414.1250(b). Although we did not include proposed 

regulation text for this proposed clarification of our policy, we are finalizing revisions to 

regulation text at 414.1250(b) to reflect this final policy. 

Quality Measures for the Shared Savings Program: Starting with the CY 2017 payment 

adjustment period, as described in section III.M. of this final rule with comment period , we 

proposed to apply the value modifier to groups and solo practitioners participating in ACOs 

under the Shared Savings Program. To do so, we proposed quality measures and benchmarks for 

use with these groups and solo practitioners and solicited public comment on these proposals. 

We describe these proposals more fully below. 

With regard to quality measures, we noted that there is substantial overlap between those 

used to evaluate the ACOs under the Shared Savings Program and those used in the PQRS 

program and for the value modifier payment adjustment. For the CY 2017 payment adjustment 

period and subsequent payment adjustment periods, to determine a quality composite for the VM 

for groups and solo practitioners who participate in an ACO under the Shared Savings Program, 

we proposed to use the quality measures that are identical for the two programs. Specifically, for 

the CY 2017 payment adjustment period, we proposed to use the PQRS GPRO Web Interface 

measures and the outcome measure described at §414.1230(c) to determine a quality composite 

for groups and solo practitioners who participate in an ACO under the Shared Savings Program. 

Because the ACO GPRO Web Interface measures and PQRS GPRO Web Interface measures 

will be the same in CY 2015, we proposed to use the GPRO Web Interface measures reported by 

ACOs in determining the quality composite for groups and solo practitioners participating in 
CMS-1612-FC 1012

ACOs under the Shared Savings Program in CY 2017 (79 FR 40507). Utilizing these GPRO 

Web Interface measures in this regard further encourages successful quality reporting for Shared 

Savings Program ACOs. Additionally, we stated our belief that the all-cause hospital 

readmissions measure as calculated for ACOs under the Shared Savings Program is equivalent to 

the all-cause hospital readmissions measure we have adopted for the VM at §414.1230(c), and 

therefore, proposed use of that measure as calculated for ACOs in the Shared Savings Program 

for inclusion in the VM for the CY 2017 payment adjustment period (79 FR 40507). We note 

that the outcome measures described at §414.1230(a) and §414.1230(b) are not currently 

calculated for ACOs in the Shared Savings Program. These measures are: (1) a composite of 

rates of potentially preventable hospital admissions for heart failure, chronic obstructive 

pulmonary disease, and diabetes; and (2) a composite rate of potentially preventable hospital 

admissions for dehydration, urinary tract infections, and bacterial pneumonia. Because we have 

no experience with these measures in the Shared Savings Program, at this time, we did not 

propose to include these measures for groups and solo practitioners who participate in ACOs 

under that program. We proposed to modify the regulations at §412.1210 accordingly. 

The following is summary of the comments we received on these proposals. 

Comment: The majority of commenters opposed the proposals for two reasons. First, 

these commenters expressed their belief that the ACO would be required to report measures 

twice or report additional measures. Second, these commenters suggested that aligning the 

measures used in the Shared Savings Program and those in the VM program could lead to ACOs 

scoring well in one program while performing poorly in the other. Commenters believe that the 

VM and Shared Savings Program use different performance benchmarks and different 

approaches for determining good versus bad performance. 
CMS-1612-FC 1013

A few medical societies supported the proposals, recognizing CMS’s intent to align the 

measures and quality improvement goals of the Shared Savings Program and VM program. 

Several commenters suggested allowing groups that are new to GPRO Web Interface reporting 

to have at least one year to report measures before they are measured for performance. A few 

commenters recommended aligning the Shared Savings and the VM programs by removing the 

three claims-based outcome measures from the VM. 

Response: We disagree with the commenters’ suggestion that utilizing GPRO Web 

Interface measures to calculate Shared Savings Program ACO’s quality composites would cause 

them additional reporting burden, because the ACO GPRO Web-Interface measures and PQRS 

GPRO Web-Interface measures are the same. We believe, therefore, that utilizing the GPRO web 

interface measures for Shared Savings Program ACO quality composite calculation under the 

VM will further encourage successful quality reporting for ACOs in the Shared Savings Program 

and will not add burdensome reporting requirements. ACOs in the Shared Savings Program 

would not have to report measures twice for purposes of the VM. Moreover, the use of the 

GPRO Web Interface measures fosters alignment among the various CMS quality reporting 

programs. With regard to commenters’ suggestion that Shared Savings Program ACO 

participants might fare well on measures reported under the Shared Savings Program and poorly 

under the VM program, we do not believe this situation is likely to occur, because within the 

Shared Savings Program, ACOs will be measured against national benchmarks that are 

calculated using Medicare fee-for service data. The VM program also develops benchmarks 

using all available Medicare fee-for-service data. Although the benchmarking methodology 

differs in that the VM uses a national weighted mean and the Shared Savings Program use a 

decile distribution for measuring performance, we believe using the same data source enables a 

fair comparison for all groups and solo practitioners subject to the value modifier. 
CMS-1612-FC 1014

Further, we believe it is appropriate to use the Shared Savings Program ACOs’ all-cause 

readmission measure for calculating the VM for the CY 2017 payment adjustment period. As we 

stated in the proposed rule, we believe that the Shared Savings Program ACO all-cause 

readmission measure is equivalent to the all-cause hospital readmission measure adopted for the 

VM. The use of this measure will not impose any additional reporting burden on Shared Savings 

Program ACOs (79 FR 40508). 

After considering the public comments, we are finalizing a policy to use the ACO Group 

Practice Reporting Option (GRPO) Web Interface measures and the Shared Savings Program 

ACO all-cause readmission measure to calculate a quality composite score for groups and solo 

practitioners who participate in an ACO under the Shared Savings Program. 

To determine the standardized scores for these quality measures for use with those 

participating in ACOs under the Shared Savings Program, we proposed to apply the benchmark 

policy for quality measures for the VM as described under §414.1250. Under this policy, the 

VM benchmarks are the national mean for a measure’s performance rate based on data from one 

year prior to the performance period. We believe these are the appropriate benchmarks to use 

when determining the value modifier payment adjustment because they are the same benchmarks 

used to determine the value modifier payment adjustment for other groups and solo practitioners 

and they are similar to the benchmarks used under the Shared Savings Program. As stated above, 

within the Shared Savings Program, ACOs will be measured against national benchmarks that 

are calculated using Medicare fee-for service data and the VM program also develops 

benchmarks using all available Medicare fee-for-service data., We believe that use of the VM 

benchmarks creates a reasonable comparison among groups and solo practitioners and it is 

appropriate to evaluate those that participate in Shared Savings Program ACOs on the same basis 

as those that do not participate in the Shared Savings Program for the purpose of the value 
CMS-1612-FC 1015

modifier. We believe that the VM benchmarks are appropriate because they include all PQRS 

data available (77 FR 69322), including quality data used for the Shared Savings Program. . 

We stated that , while the Shared Savings Program develops benchmarks using all available 

Medicare fee-for-service data, we do not believe it is appropriate to use benchmarks from the 

Shared Savings Program to determine standardized scores for the quality composite of the value 

modifier payment adjustment. We do not think this enables a fair comparison among groups and 

solo practitioners subject to the value modifier because the Shared Savings Program benchmarks 

use gradients by decile (including the median) of national performance based on data two years 

prior to the performance period (78 FR 74759 through 74760). 

The following is summary of the comments we received on these proposals. 

Comment: A number of commenters opposed the proposal for the following reasons: the 

belief that a difference in performance benchmarks for the VM and Shared Savings Program 

could cause ACOs to score well in one program and perform poorly in the other; and the belief 

that the application of the VM benchmarking policy to the quality measures used by ACOs 

under the Shared Savings Program could introduce potential bias into the broader VM program. 

One commenter supported our proposal, noting that alignment of quality measures for the VM 

and Shared Savings Program would strengthen the benchmarks by establishing a larger pool of 

providers with comparable measures. 

Response: We appreciated the comments received. As stated above, with regard to the 

suggestion that Shared Savings Program ACO participants might fare well on measures reported 

under the Shared Savings Program and poorly under the VM program, we do not believe this 

situation is likely to occur, because the GPRO Web Interface measures used for the Shared 

Savings Program ACOs and the VM are the same and benchmarks used for performance 

measurement on use the same data source (fee-for-service Medicare data). We also do not 
CMS-1612-FC 1016

believe that introduction of SSP ACO data into the benchmarks would create a bias. We utilize 

national data for benchmarking, and we agree with the commenter who stated that this will 

strengthen the benchmarks by expanding the pool of participants. After consideration of the 

public comments received, we are finalizing the proposal to apply the benchmark policy for 

quality measures for the VM as described under §414.1250 to determine the standardized score 

for quality measures for groups and solo practitioners participating in ACOs under the Shared 

Savings Program. 

All-Cause Hospital Readmissions Measure: We finalized the inclusion of the all-cause 

hospital readmissions measure described at §414.1230(c) in the CY 2013 PFS final rule with 

comment (77 FR 69285). We subsequently investigated the reliability of this measure. We also 

have an existing policy at §414.1265, that a claims-based cost or quality measure must have a 

minimum of 20 cases, to be included in a composite score calculation. Furthermore, according 

to §414.1265(a), if a group has fewer than 20 cases for a measure in a performance period, that 

measure is excluded from its domain and the remaining measures in the domain are given equal 

weight. 

Based on 2012 data, we found that the average reliability for the all-cause hospital 

readmissions measure was below 0.4 when we examined groups with fewer than 200 cases but 

exceeded 0.4 for groups with 200 or more cases. Although we do not believe there is a universal 

consensus concerning a minimum reliability threshold, reliability scores in the 0.4 to 0.7 range 

are often considered moderate, and scores greater than 0.7 are considered high. In general, we 

found that the groups with at least 10 eligible professionals were more likely to have 200 or more 

cases as compared to groups with fewer eligible professionals. Thirty percent of groups with 10 

or more eligible professionals had 200 or more cases, as compared to 3 percent of groups with 1-
CMS-1612-FC 1017

9 eligible professionals. We found that the average reliability exceeded 0.4 for groups of all 

sizes (1 or more eligible professionals), with 200 or more cases. . 

After examining the reliability of the all-cause hospital readmissions measure data for 

2012 across all group sizes and considering its impacts on the cost composite of the VM as 

discussed below, we proposed to change the reliability policy (minimum number of cases) with 

respect to this measure. Specifically, beginning with the CY 2017 payment adjustment period, 

we proposed to change the reliability policy (minimum number of cases) with respect to the allcause hospital readmissions measure as described in §414.1230(c) from a minimum of 20 cases 

to a minimum of 200 cases for this measure to be included in the quality composite for the VM. 

For this measure only, we proposed to exclude the measure from the quality domain for a group 

or solo practitioner if the group or solo practitioner has fewer than 200 cases for the measure 

during the relevant performance period. In implementing this proposal, we noted that we would 

only apply it to the all-cause hospital readmissions measure as it is calculated for groups or solo 

practitioners who are not part of a Shared Savings Program ACO. In instances where we are 

including Shared Savings Program data for groups or solo practitioners who are part of a Shared 

Savings Program ACO, we would include their all-cause hospital readmissions measure as it is 

calculated for the Shared Savings Program. This approach to implementing this proposal is 

appropriate because the Shared Savings Program has taken into consideration the size of its 

groups in finalizing inclusion of this measure, and we value consistency with the Shared Savings 

Program’s reporting requirements for its participants, to the extent it is practicable. We would 

continue to include the measure in the VM quality domain for groups or solo practitioners who 

have 200 or more cases. We proposed to modify §414.1265 to reflect this proposal. We 

welcomed comments on this proposal. 
CMS-1612-FC 1018

We noted that, if we were to revise the minimum case size for the all-cause hospital 

readmissions measure for the quality composite of the VM, poor performance on controlling 

readmissions would continue to have an effect on the VM for groups with between 20 and 199 

cases through the cost composite of the VM. The Medicare Spending per Beneficiary (MSPB) 

measure, as finalized in the CY 2014 PFS final rule (78 FR 74775-74780), is a measure of all 

Medicare Part A and Part B payments during an episode spanning from 3 days prior to an index 

hospital admission through 30 days post-discharge with certain exclusions. Since all Part A and 

Part B spending is included in the 30 day post-discharge window, Medicare Part A payments for 

a readmission that are included in an MSPB episode will increase the MSPB amount relative to 

an MSPB episode without a readmission in the 30-day post-discharge window. Additionally, the 

cost of readmissions is incorporated as part of the 5 total per capita cost measures that comprise 

the remainder of the cost composite of the VM. The 5 total per capita cost measures are annual 

measures that include the costs of all Part A and Part B spending during the year, including the 

costs of readmissions. Therefore, readmission costs will have the effect of increasing total per 

capita cost spending for the groups attributed these patients’ costs. As a result, poor performance 

on controlling readmissions already will have an adverse effect on an attributed group’s cost 

composite of the VM, even if poor performance on the all-cause hospital readmissions measure 

would no longer be reflected in certain groups’ or solo practitioners’ quality composite of the 

VM due to having fewer than 200 all-cause hospital readmission cases. Even for those groups 

for which the all-cause hospital readmissions measure would be excluded from the quality 

composite calculations, groups would continue to have incentive to control readmissions, since 

doing so would reduce readmission costs, thereby improving performance on the paymentstandardized, risk-adjusted cost measures used for the cost composite of the VM. 

The following is summary of the comments we received on this proposal. 
CMS-1612-FC 1019

Comment: We received few comments on this proposal. Some commenters supported 

the inclusion of the all-cause readmission measure. One commenter supported the proposed 

change in the reliability policy for the hospital all-cause readmission measure, stating that this 

will provide valid and reliable estimates for hospital admissions to each group. Several 

commenters supported the need for reliable measures; however, one commenter expressed 

concern that even with an increased case minimum, the all-cause readmission measure was still 

not appropriate for physician accountability because the readmission costs are already included 

in the total per capita costs, the measure was not specified for group level measurement, and the 

measure was not supported by the Measures Application Partnership (MAP). This commenter 

stated that the all-cause readmission measure does not add value to the VM, further suggesting 

that if CMS chooses to keep the measure, then it should be adjusted for clinical and 

socioeconomic factors. Another commenter recommended CMS undertake an analysis to ensure 

this change would not result in disproportionate penalties for certain groups (such as surgeons) 

prior to finalizing this proposal. 

One commenter stated that this measure is not appropriate for physician practices because 

2012 data indicates that the measure could not meet a 0.4 percent reliability threshold at a 20-

case minimum. This commenter also questioned the justification for including a measure that 

will be applicable only to 30 percent of groups with 10 or more practitioners and three percent of 

smaller groups, even when the proposed minimum 200 case threshold is utilized. 

Response: We disagree with the commenters’ assessment of the reliability of the allcause hospital readmission measure, which quantifies the unplanned readmissions for any cause 

within 30 days from the date of discharge of an index admission. Our analysis of this measure 

based on 2012 data found that the average reliability exceeded 0.4 for groups with 200 or more 

cases included all group sizes (1 or more eligible professionals). We are committed to 
CMS-1612-FC 1020

monitoring this measure, as well as others to ensure that the minimum patient panel size is 

sufficient to meet the reliability standard for the VM program. With regard to concern that 

readmission costs are included in other spending measures, we disagree that this fact makes the 

all-cause hospital readmissions measure inappropriate for inclusion in the VM. The all-cause 

hospital readmissions measure is a measure of readmission rates, not of costs and we believe that 

readmission reduction is an important goal that we can emphasize through the VM. We note that 

the measure’s direction was supported by the MAP and also that the has been specified for 

groups. The group specifications may be found at: http://cms.gov/Medicare/Medicare-Fee-forService-Payment/sharedsavingsprogram/Downloads/ACO-8.pdf 

With regard to commenters’ concerns related to the issue of socioeconomic status 

adjustment, we continue to monitor activities at the National Quality Forum (NQF), such as the 

July 23, 2014 decision by the NQF Board in which the Board approved a trial period to test the 

impact of sociodemographic factor risk adjustment of performance measures (available at 

http://www.qualityforum.org/Press_Release/2014/NQF_Board_Approves_Trial_Risk_Adjustme

nt.aspx). While we continue to evaluate the appropriateness of applying different standards for 

the outcomes of patients of low socioeconomic status and the potential for an socioeconomic 

status adjustment to mask potential disparities or minimize incentives to improve the outcomes 

of economically disadvantaged populations, we would take any future decision by the NQF on 

this issue into consideration for any potential future refinements to this or any measure included 

in the VM. 

After consideration of the comments, we are finalizing the policy, beginning with the CY 

2017 payment adjustment period, to increase the case minimum from 20 cases to 200 cases for 

the all-cause hospital readmissions measure as described in §414.1230(c) to be included in the 

quality composite for the VM as proposed. Therefore, we are finalizing the proposal to exclude 
CMS-1612-FC 1021

the measure from the quality domain for a group or solo practitioner if the group or solo 

practitioner has fewer than 200 cases for the measure during the relevant performance period and 

all remaining measures in the domain will be given equal weight. We are codifying this change 

with a revision to the regulation at §414.1265. 

i. Expansion of the Informal Inquiry Process to Allow Corrections for the Value-Based 

Payment Modifier 

Section 1848(p)(10) of the Act provides that there shall be no administrative or judicial 

review under section 1869 of the Act, section 1878 of the Act, or otherwise of the following: 

● The establishment of the VM; 

● The evaluation of the quality of care composite, including the establishment of 

appropriate measures of the quality of care; 

● The evaluation of the cost composite, including the establishment of appropriate 

measures of costs; 

● The dates of implementation of the VM; 

● The specification of the initial performance period and any other performance period; 

● The application of the VM; and 

● The determination of costs. 

These statutory requirements regarding limitations of review are reflected in §414.1280. 

Despite the preclusion of administrative and judicial review, we previously indicated in the CY 

2013 PFS final rule with comment period (77 FR 69326) that we believed an informal review 

mechanism is appropriate for groups of physicians to review and to identify any possible errors 

prior to application of the VM, and we established an informal inquiry process at §414.1285. 

We stated that we intend to disseminate reports containing CY 2013 data in the fall of 2014 to 
CMS-1612-FC 1022

groups of physicians subject to the VM in 2015 and that we will make a help desk available to 

address questions related to the reports. 

We stated it would be appropriate to align with PQRS to consider requests for informal 

review of whether a group or solo practitioner successfully reported under the PQRS program 

and requests for reconsideration of PQRS data as described in section III.K, as well as to expand 

our current informal inquiry process to accept requests from groups and solo practitioners to 

review and correct certain other errors related to the VM, such as errors made by CMS in 

assessing the eligibility of a group or solo practitioner for the value modifier based on 

participation in a Shared Savings Program ACO, the Pioneer ACO Model, the CPC Initiative, or 

other similar Innovation Center models or CMS initiatives; computing standardized scores; 

computing domain scores; computing composite scores; or computing outcome or cost measures. 

We are working to develop and operationalize the necessary infrastructure to support such a 

corrections process, but at this time, we do not believe we would be able to implement the 

process until 2016 at the earliest. 

Therefore, for the CY 2015 payment adjustment period, to align with PQRS, we proposed 

to expand the informal inquiry process at §414.1285 to establish an initial corrections process 

that would allow for some limited corrections to be made (79 FR 40509). Specifically, under 

this initial corrections process, for the CY 2015 payment adjustment period, we proposed to 

establish a deadline of January 31, 2015 for a group to request correction of a perceived error 

made by CMS in the determination of its CY 2015 VM payment adjustment. Alternatively, we 

solicited comment on a deadline of no later than the end of February 2015 to align with the 

PQRS informal review process. We would then make a determination regarding the request. At 

this time, we do not anticipate it would be operationally feasible for us to fully evaluate errors 

with regard to quality measure data and accept data as described above under section III.K. for 
CMS-1612-FC 1023

the CY 2015 payment adjustment period, and thus we proposed to classify a TIN as “average 

quality” in the event we determine that we have made an error in the calculation of quality 

composite. We proposed to recompute a TIN’s cost composite in the event we determine that we 

have made an error in its calculation. We proposed to adjust a TIN’s quality-tier if we make 

corrections to a TIN’s quality and/or cost composites as a result of this initial corrections 

process. We noted that there would be no administrative or judicial review of the determinations 

resulting from this expanded informal inquiry process under section 1848(p)(10) of the Act. 

Starting with the CY 2016 payment adjustment period (which has a performance period 

of CY 2014), we proposed to continue the expanded informal inquiry process at §414.1285 as 

described above. However, in anticipation of having the necessary operational infrastructure to 

support the reconsideration of quality measure data, we proposed to establish a 30-day period 

that would start after the release of the QRURs for the applicable performance period for a group 

or solo practitioner to request correction of a perceived error made by CMS in the determination 

of the group or solo practitioner’s VM for that payment adjustment period. These QRURs 

contain performance information on the quality and cost measures used to calculate the quality 

and cost composites of the VM and will show how all TINs would fare under the policies 

established for the VM for the CY 2015 payment adjustment period. Similar to our proposal for 

the initial corrections process in CY 2015, we would then make a determination regarding the 

requests received. Since we anticipate it would be operationally feasible for us to fully evaluate 

errors with regard to quality measure data at that point, and accept data, consistent with PQRS 

policies, as described above under section III.K. for the CY 2016 payment adjustment period, we 

proposed to recompute a TIN’s quality composite and/or cost composite in the event we 

determine that we have made an error in the calculation. We noted that if the operational 

infrastructure is not available to allow this recomputation, we proposed to continue the approach 
CMS-1612-FC 1024

of the initial corrections process to classify a TIN as “average quality” in the event we determine 

that we have made an error in the calculation of the quality composite. We proposed to adjust a 

TIN’s quality-tier if we make a correction to a TIN’s quality and/or cost composites as a result of 

this corrections process. 

We welcomed comment on these proposals. 

The following is summary of the comments we received on both the initial corrections 

process in the CY 2015 payment adjustment period and the corrections process we proposed 

beginning with the CY 2016 payment adjustment period. 

Comment: Commenters supported implementing an expanded informal inquiry process 

to allow for corrections to the VM. However, almost all commenters requested later deadlines 

for submission of VM corrections. Specifically: 

● For 2015, most commenters supported establishing a deadline of no later than the end 

of February 2015, rather than January 31, to align with the PQRS informal review process. 

● For subsequent years, most commenters requested a longer period of 60 to 90 days 

(rather than 30 days) that would start after the release of the QRURs for the applicable 

performance period for a group or individual to request a correction of a perceived error related 

to the VM calculation. 

In addition, some commenters objected to the proposal for 2015 to classify a TIN as 

‘‘average quality’’ in the event we determined that we have made an error in the calculation of 

the quality composite. These commenters believe it would be inappropriate to deem a group 

“average quality” simply because CMS does not have the capacity to correct its own errors, 

especially if an “average quality” rating could potentially lead to penalties or lost incentive 

payments. Some commenters suggested that we consider requests for providers to resubmit 

their quality data. Other commenters asked that we provide additional clarification regarding 
CMS-1612-FC 1025

what situations will be considered in the informal review process. 

Response: We are persuaded by commenters who request that we establish later 

deadlines for the VM informal review process so that such deadlines are consistent with those of 

the PQRS informal review process. We agree with these comments since data reported under 

PQRS is an important component of the VM and that corrections to PQRS measure rates could 

affect the calculation of the VM payment adjustment amount. Therefore, for the CY 2015 

payment adjustment period, the deadline for submission of a request for VM informal review 

will be the end of February, 2015. Likewise, for subsequent payment adjustment years, we are 

persuaded by commenters that requested a longer period beyond 30 days, which would start after 

the release of the QRURs for the applicable performance period, for a group or individual to 

request a correction of a perceived error related to the VM calculation. However, we believe that 

60 days, not 90 days, would be a sufficient amount of time for providers to access their QRUR 

reports, review the information, which includes the VM payment adjustment amount that will 

apply for the subsequent payment adjustment year and make a decision whether or not to submit 

a VM correction request. Establishing a 60-day deadline enables us to make corrections prior to, 

or relatively soon after, the start of the applicable payment adjustment year. This helps reduce 

the number of claims that would need to subsequently be reprocessed during the applicable 

payment adjustment year. 

Finally, as we discussed in the proposal and above, it is not operationally feasible to fully 

evaluate errors with regard to quality measure data and accept data as described above under 

section III.K. for the CY 2015 payment adjustment period. Therefore, to minimize the impact on 

providers, we will classify a TIN as ‘‘average quality’’ in the event that we determine that we 

have made an error in the calculation of the quality composite. However, we understand the 

point made by a few commenters about this policy. It is possible that an “average quality” rating 
CMS-1612-FC 1026

for the CY 2015 payment adjustment period could potentially result in a higher or lower VM 

payment adjustment amount for an individual TIN than if the quality composite were 

recalculated. Therefore, we are working to develop the operational infrastructure to allow us to 

re-compute a TIN’s quality composite and accept data, consistent with PQRS quality data 

resubmission policies, as described above under section III.K. for the CY 2016 payment 

adjustment period in the event we determine that we have made an error in the calculation. 

After consideration of the public comments received: 

● For the CY 2015 payment adjustment period, we are: (1) finalizing a February 28, 

2015, deadline for a group to request correction of a perceived error made by CMS in the 

determination of its VM, and (2) finalizing a policy to classify a TIN as ‘‘average quality’’ in 

the event we determined that we have made an error in the calculation of the quality composite. 

● Beginning with the CY 2016 payment adjustment period, (1) we are finalizing a 

deadline of 60 days that would start after the release of the QRURs for the applicable 

performance period for a group or solo practitioner to request a correction of a perceived error 

related to the VM calculation, and (2) we will take steps to establish a process for accepting 

requests from providers to correct certain errors made by CMS or a third-party vendor (for 

example, registry). We intend to design this process as a means to re-compute a TIN’s quality 

composite and/or cost composite in the event we determine that we initially made an erroneous 

calculation. We note that if the operational infrastructure is not available to allow this recomputation, we will continue the approach for the CY 2015 payment adjustment period to 

classify a TIN as ‘‘average quality’’ in the event we determine that we have made an error in the 

calculation of the quality composite. 

For both the CY 2015 payment adjustment period and future adjustment periods, we will 

adjust a TIN’s quality-tier if we make a correction to a TIN’s quality and/or cost composites as a 
CMS-1612-FC 1027

result of this corrections process. We will provide additional operational details as necessary in 

sub-regulatory guidance. 

We further note that there is no administrative or judicial review of the determinations 

resulting from this expanded informal inquiry process under section 1848(p)(10) of the Act. 

j. Potential Methods to Address NQF Concerns Regarding the Total Per Capita Cost Measures 

In the CY 2013 PFS final rule with comment period (77 FR 69322), we established a 

policy to create a cost composite for each group subject to the VM that includes five paymentstandardized and risk-adjusted annual per capita cost measures. To calculate each group’s per 

capita cost measures, we first attribute beneficiaries to the group. We attribute beneficiaries 

using a two-step attribution methodology that is based on the assignment methodology used for 

the Shared Savings Program and the PQRS GPRO and that focuses on the delivery of primary 

care services (77 FR 69320) by both primary care physicians and specialists. 

In the CY 2014 PFS final rule with comment period (78 FR 74780), we finalized 

inclusion of the Medicare Spending Per Beneficiary (MSPB) measure as proposed in the cost 

composite beginning with the CY 2016 VM, with a CY 2014 performance period. As we 

proposed, we are using the MSPB amount as the measure’s performance rate rather than 

converting it to a ratio as is done under the Hospital Inpatient Quality Reporting (IQR) and VBP 

Programs. We finalized that the MSPB measure is added to the total per capita costs for all 

attributed beneficiaries domain and equally weighted with the total per capita cost measure in 

that domain. Additionally, we finalized that an MSPB episode is attributed to a single group of 

physicians that provides the plurality of Part B services (as measured by standardized allowed 

charges) during the index admission, for the purpose of calculating that group’s MSPB measure 

rate. Finally, we finalized a minimum of 20 MSPB episodes for inclusion of the MSPB measure 

in a physician group’s cost composite. 
CMS-1612-FC 1028

Additionally, in the CY 2014 PFS final rule with comment period (78 FR 74780), we 

finalized our proposal to use the specialty adjustment method to create the standardized score for 

each group’s cost measures beginning with the CY 2016 VM. That is, we refined our current 

peer group methodology to account for specialty mix using the specialty adjustment method. We 

also finalized our proposal to include this policy in our cost composite methodology. 

Additionally, we finalized our proposal to identify the specialty for each EP based on the 

specialty that is listed on the largest share of the EP’s Part B claims. 

As discussed in the CY 2014 PFS final rule with comment period (78 FR 74781), we 

submitted the total per capita cost measure for National Quality Forum (NQF) endorsement in 

January 2013. In the final voting in September 2013, the NQF Cost and Resource Use 

Committee narrowly voted against the measure by a count of 12 in support and 13 in opposition. 

We proposed to address two of the major concerns that Committee raised in its review of the 

measure. First, we proposed modifications to our two-step attribution methodology. Second, we 

proposed to reverse the current exclusion of certain Medicare beneficiaries during the 

performance period. We stated that these proposals would apply beginning with the CY 2017 

payment adjustment period for the VM and would apply to all five of the total per capita cost 

measures under §414.1235(a)(1) through (5) (79 FR 40510). The modifications to the two-step 

attribution methodology also would apply to the methodology used for attributing beneficiaries 

for the computation of claims based quality measures under §414.1230, except for participants in 

the Shared Savings Program as described later. 

The attribution methodology for the five total per capita cost measures and claims based 

quality measures in the VM, as finalized in the CY 2013 PFS final rule with comment period 

(77 FR 66318 through 66320), includes two steps. Before applying the two steps, however, we 

first identify all beneficiaries who have had at least one primary care service rendered by a 
CMS-1612-FC 1029

physician in the group. Primary care services include evaluation and management visits in 

office, other outpatient, skilled nursing facility, and home settings. After this “pre-step”, we 

assign, under Step 1, beneficiaries to the group practice who had a plurality of primary care 

services (as measured by allowed charges) rendered by primary care physicians in the group, 

which include Family Practice, Internal Medicine, General Practice, and Geriatric Medicine. If a 

beneficiary is non-assigned under Step 1, we proceed to Step 2, which is to assign beneficiaries 

to the group practice whose affiliated non-primary care physicians, nurse practitioners (NPs), 

physician assistants (PAs), and clinical nurse specialists (CNSs) together provided the plurality 

of primary care services (as measured by allowed charges), as long as at least one primary care 

service was provided by a non-primary care physician in the group. 

To address NQF concerns regarding the attribution methodology of the total per capita 

cost measure, we proposed two modifications to the two-step attribution methodology as applied 

to the five total per capita cost measures, as well as the claims based quality measures in the VM. 

NQF Committee members discussed how primary care services often are provided by NPs, PAs, 

or CNSs, but Step 1 of the attribution methodology assigns beneficiaries to the group who had a 

plurality of primary care services rendered by primary care physicians in the group. After further 

consideration, we agreed that it is appropriate to include NPs, PAs, and CNSs in Step 1 of the 

attribution method insofar as they provide primary care services. Consequently, we proposed to 

move these NPs, PAs, and CNSs from Step 2 of the attribution method to Step 1. This change 

would affect all five of the total per capita cost measures under §414.1235(a)(1) through (5) and 

the claims-based quality measures under §414.1230. 

Additionally, we proposed to remove the “pre-step” described above for the purposes of 

the value modifier. The “pre-step” was included in the Shared Savings Program assignment 

methodology to comply with the statutory requirement (77 FR 67851) that beneficiary 
CMS-1612-FC 1030

assignment be based upon the utilization of primary care services furnished by a physician. 

However, no such limitation exists for the VM. Consequently, we proposed to remove the “prestep” that identifies a pool of assignable beneficiaries that have had at least one primary care 

service furnished by a physician in the group. Removing the “pre-step” would result in 

streamlining the attribution process and attributing beneficiaries based on a plurality of primary 

care services according to Step 1 and Step 2. In addition, we believe that this proposal would 

help ensure that beneficiaries can be assigned to group practices made up of nonphysician 

eligible professionals because it would eliminate the criterion that a beneficiary have at least one 

primary care service furnished by a physician in the group practice. This change (removing the 

“pre-step”) would affect all five of the total per capita cost measures under §414.1235(a)(1) 

through (5) and the claims-based quality measures under §414.1230. 

The two-step attribution rule would remain intact after these two modifications, and the 

method would continue to be generally consistent with the method of assignment of beneficiaries 

under the Shared Savings Program, as specified under §414.1240. As discussed previously, the 

“pre-step” would be removed. We would assign, under Step 1, beneficiaries to the group who 

had a plurality of primary care services (as measured by allowed charges) rendered by primary 

care physicians, NPs, PAs, or CNSs in the group. If a beneficiary is non-assigned under Step 1, 

we still would proceed to Step 2, which would assign beneficiaries to the group practice whose 

affiliated non-primary care physicians provided the plurality of primary care services (as 

measured by allowed charges). We proposed these modifications only for groups and solo 

practitioners who are not participating in the Shared Savings Program. We noted that for groups 

and solo practitioners who participate in the Shared Savings Program, we would not remove the 

pre-step or change the attribution methodology for quality measures and cost measures, but 

would continue to rely on the methodology used by the Shared Savings Program to attribute 
CMS-1612-FC 1031

beneficiaries to ACOs in the Shared Savings Program. Because we are not applying these 

assignment changes to Shared Savings Program ACO participants, there is no need to recalculate 

Shared Savings Program assignment. 

One of the reasons we originally proposed this two-step attribution process for the total 

per capita cost measures and claims based quality measures was that it was aligned with the 

attribution methodologies used by the Shared Savings Program and also the PQRS GPRO web 

interface (77 FR 69318 through 69320). We recognize that these programs may seek to establish 

changes to their methodologies, and noted that for the purposes of the VM, we intended to retain 

the two-step beneficiary attribution methodology that was described in the CY 2013 PFS final 

rule with comment period (77 FR 69318 through 69320), subject to the changes proposed above. 

However, to address the concerns raised by NQF, we believe the proposed modification to the 

two-step beneficiary attribution method would more appropriately reflect the multiple ways in 

which primary care services are provided, which are not limited to physician groups. We 

welcomed comments on our proposed modification to the two-step attribution methodology as 

applied to the five total per capita cost measures under §414.1235(a)(1) through (a)(5) and to the 

claims-based quality measures under §414.1230 of the VM. 

The following is summary of the comments we received on our proposed modification to 

the two-step attribution methodology as applied to the five total per capita cost measures under 

§414.1235(a)(1) through (5) and to the claims-based quality measures under §414.1230 for the 

VM. 

Comment: Many commenters opposed our proposal to modify the two-step attribution 

methodology. The commenters stated that it would not be appropriate to include NPs, PAs and 

CNSs in the first step of the attribution methodology because these nonphysician practitioners 

are not necessarily practicing in a primary care setting. The commenters expressed concern that, 
CMS-1612-FC 1032

unlike for physicians, there is no specialty distinction on claims billed by NPs, PAs, or CNSs. 

Therefore, CMS would not be able to distinguish between those practitioners who are practicing 

in primary care settings and those who are in non-primary care settings. Commenters believe 

that moving NPs, PAs, and CNSs to the first step could result in beneficiaries being attributed to 

a specialty practice instead of a primary care practice. A few commenters stated that this would 

unfairly affect the cost measure calculations for specialist groups with large numbers of 

nonphysician practitioners. We did not receive any comments specifically opposing the removal 

of the “pre-step” from the methodology. Several commenters supported our proposal to modify 

the attribution methodology. The commenters stated that it is important to recognize the role of 

nonphysician practitioners in providing primary care to beneficiaries and that these changes 

create a methodology that more accurately reflects team-based approaches to care. 

Response: We appreciate the concerns raised by commenters about the potential impact 

that the lack of specialty designation for NPs, PAs, and CNSs could have on the cost and claims 

based quality measures. However, we do not believe that this is likely to occur. In an analysis of 

the impact of including NPs and PAs in step 1 of the attribution methodology using 2011 data for 

groups of twenty-five or more eligible professionals, we found that over 97 percent of 

beneficiaries were attributed to the same group that they had been attributed to under the current 

methodology. Although this analysis does not exactly replicate the changes we proposed, we 

believe it is a reasonable indication that the changes will not have the significant impact 

predicted by commenters. We are conducting additional analysis and will monitor the effect of 

these changes to ensure they are not having a disproportionately negative effect on a subset of 

provider types. We appreciate the support of and agree with commenters who believe it is 

important to recognize the role that many NPs, PAs, and CNSs play as primary care providers. 

The analysis referenced earlier also found that the inclusion of NPs and PAs in step 1 resulted in 
CMS-1612-FC 1033

an increase of 2.55 percent to the number of beneficiaries attributed to a group and the number of 

groups to which at least 20 beneficiaries were attributed increased by 3.4 percent. For these 

reasons, we agree with the NQF recommendation to include these nonphysician practitioners in 

the attribution methodology. Further, this attribution change will become even more important 

as we expand the application of the VM to smaller groups and solo practitioners, to increase the 

number of patients whom they can be assigned, to receive a cost composite that is other than 

“average” under the VM. 

We are finalizing our policy as proposed. Beginning in the CY 2017 payment adjustment 

period, we will move NPs, PAs, and CNSs from step 2 of the attribution method to step 1. 

Additionally we are removing the pre-step under which we first identify all beneficiaries who 

have had at least one primary care service rendered by a physician in the group. These changes 

apply to all five total per capita cost measures under §414.1235(a)(1) through (5) and the claimsbased quality measures under §414.1230. 

Second, NQF committee members raised concerns about the exclusion of certain 

beneficiaries in the methodology used for the total per capita cost measure. Committee members 

expressed concern that end-of-life costs were not being captured by the measure. We considered 

this argument and agreed that it is important to include certain beneficiaries with these costs 

during the performance period. As a result, we proposed to include certain part-year Medicare 

FFS beneficiaries. This change would affect all five of the total per capita cost measures under 

§414.1235(a)(1) through (a)(5). The change would provide a more complete assessment of end 

of life costs associated with the patients a physician group sees during the year (79 FR 40510). 

We proposed to continue excluding other part-year beneficiaries (those who spend part of 

the performance period in a Medicare Advantage (Part C) plan and those enrolled in Part A only 

or Part B only for part of the performance period and both Part A and Part B for the remainder of 
CMS-1612-FC 1034

the performance period) (79 FR 40511). Since 2012 we have applied the same attribution rule as 

that used for the Medicare Shared Savings Program and the PQRS GPRO Web Interface (77 FR 

69318-20). In this regard, excluding part-year Medicare Advantage enrollees would remain 

consistent with the Shared Savings Program and PQRS GPRO web interface reporting policy. If 

we were to include these part-year Medicare Advantage enrollees, we would need to determine a 

method to impute their costs for the portion of the performance period in which they were 

enrolled in FFS Medicare Parts A and B so that we could compare beneficiaries’ annual per 

capita costs appropriately. Similarly, Medicare Part A only or Medicare Part B only enrollees 

who were enrolled in both Part A and Part B for only part of the performance period would also 

require a method to impute their costs if they were no longer excluded. Furthermore, these Part 

A only or Part B only beneficiaries are excluded from the Shared Savings Program and PQRS 

GPRO methodology. 

We proposed including Medicare FFS beneficiaries who are newly enrolled to Medicare 

during the performance period and enrolled in both Part A and Part B while in Medicare FFS. 

Additionally, we noted that while the inclusion of new enrollees is inconsistent with GPRO’s 

methodology, it would be consistent with the Shared Savings Program’s methodology (79 FR 

40511). We welcomed comments on the inclusion of these part-year beneficiaries. We also 

welcomed comments on whether other part-year Medicare FFS beneficiaries (that is, those who 

are part-year Medicare Advantage enrollees or part-year Medicare Part A only or Part B only 

enrollees) should be included in the five total per capita cost measures under §414.1235(a)(1) 

through (5) in the VM. 

Comment: Some commenters opposed our proposal to include certain part-year 

Medicare FFS beneficiaries in the five total per capita cost measures because they believe the 

inclusion of these typically higher cost beneficiaries would inappropriately disadvantage groups 
CMS-1612-FC 1035

that treat a large percentage of beneficiaries at the end of life. We also received comments in 

support of our proposal to include certain part-year beneficiaries. These commenters stated that 

it is important to include as many Medicare beneficiaries in the cost measure calculations as 

feasible and especially important to capture the often significant costs incurred by beneficiaries 

at the end of life. One commenter suggested that we should develop an end of life specific cost 

and quality measure rather than including these costs in the per capita cost measures. We did not 

receive any comments in opposition to the inclusion of newly eligible beneficiaries in the five 

total per capita cost measures. One commenter indicated that they do not understand why we 

would exclude any of the part-year beneficiaries, stating that if we can impute costs for some 

part-year beneficiaries, we should be able to do so for all part-year beneficiaries. 

Response: We appreciate the support of commenters who supported our proposal to 

include some part-year beneficiaries in the five total per capita cost measures. Part-year 

beneficiaries include those who receive end-of-life care, which has been correlated with highcost episodes of care.24 However, analysis submitted to the Institute of Medicine produced an 

inconclusive causal relationship between the end of a beneficiary’s life and the cost of that 

care.25 Indeed, research refutes the assumption that Medicare beneficiaries near the end of life 

have substantially similar health statuses.26 Rather, prior diagnoses, a characteristic that we 

currently adjust for in the VM, accounts for a substantial percentage of the geographic variation 

in the end-of-life costs. In other words, we believe that the risk adjustment system under the VM 

program explains approximately the same extent of costs in the general Medicare population as it 

 

24 Congressional Budget Office, “High-Cost Medicare Beneficiaries.” Final Paper (May 2005), available at

http://www.cbo.gov/sites/default/files/05-03-medispending.pdf 25 Acumen, “Geographic Variation in Spending, Utilization and Quality: Medicare and Medicaid Beneficiaries” 

(May 2013), available at http://www.iom.edu/Reports/2013/~/media/Files/Report%20Files/2013/GeographicVariation/Sub-Contractor/Acumen-Medicare-Medicaid.pdf. 

26 Reschovsky JD, et al. “Geographic Variation in Fee-for-Service Medicare Beneficiaries’ Medical Costs Is Largely 

Explained by Disease Burden.” Med. Care Res. & Rev. 2013; XX,1-22. 
CMS-1612-FC 1036

does for the cohort of Medicare beneficiaries near the end of life.27 In response to concerns 

raised by commenters, we conducted additional analyses to ensure the inclusion of part-year 

beneficiaries does not inappropriately negatively impact certain groups or solo practitioners. This 

analysis, which we plan to post to the Value Modifier website in the near future, showed 

moderate reliability for the five per capita cost measures continued to be high with the inclusion 

of certain part-year beneficiaries. For example, for the overall per capita cost measure, 83 

percent of TINs had reliability equal to or higher than 0.4 when these part-year beneficiaries 

were included. We agree that it is important to capture as many beneficiaries and costs in these 

measures as is reasonably possible especially as the number of beneficiaries new to Medicare 

increases and we continue to agree with the NQF’s recommendation to capture end of life costs 

in our measures. We believe that the inclusion of newly eligible beneficiaries, who are typically 

much lower cost and a growing portion of the Medicare program, may offset some of the 

increased costs associated with beneficiaries at the end of life. We appreciate the suggestion to 

include cost and quality measures that specifically measure care at the end of life and will take 

this into consideration as we continue to develop the VM program. We also appreciate the 

comments in support of including other part-year beneficiaries in our measures and we will 

continue to look into this possibility. 

We are finalizing our policies as proposed. Beginning in the CY 2017 payment 

adjustment period, we will include certain part-year beneficiaries in the five total per capita cost 

measures under §414.1235(a)(1) through (5). These part-year beneficiaries include Medicare 

FFS beneficiaries who are at the end of life in the performance period and Medicare FFS 

beneficiaries who are newly enrolled in Medicare during the performance period and enrolled in 

 

27 Medicare decedents and Medicare survivors with similar diagnoses and utilization in the previous year had 

substantially similar cost profiles. Hogan C, et al. “Medicare Beneficiaries’ Costs of Care In the Last Year Of Life.” 

Health Affairs. 2001; 20, 188-195.
CMS-1612-FC 1037

both Part A and Part B while in Medicare FFS. 

In this final rule with comment period, we chose not to address the other concerns about 

the total per capita cost measures that were raised by NQF. First, we deferred addressing the 

issue of whether to incorporate socioeconomic status in our measures until after the NQF has 

finalized its guidance regarding risk adjustment for resource use measures. Second, we did not 

propose to include Part D data in the total per capita cost measures at this time due to the 

complexity of the issue and uncertainty of how to fairly and equitably incorporate the costs. 

Based on data compiled by the Medicare Payment Advisory Commission (MedPAC), we 

estimated that approximately 60 percent of Medicare FFS beneficiaries were enrolled in standalone Part D in 2013.28 A significant minority of beneficiaries has prescription drug coverage 

from a source that is outside of Medicare – such as through retiree coverage from a former 

employer – but for which Medicare does not have access to the data. Including Part D data 

would incorrectly indicate higher costs for these beneficiaries with Part D coverage relative to 

otherwise comparable beneficiaries without such coverage and for whom prescription drug costs 

cannot be measured directly by CMS. Before we are able to propose inclusion of Part D data, we 

would need to determine an approach to address this issue. We welcomed comments on 

suggested methods for including Part D data in the total per capita cost measures. 

Comment: Many commenters expressed concern that we are not currently including Part 

D expenditures in our cost measures. These commenters stated that the exclusion of Part D costs 

could push providers to prescribe Part D drugs even when the Part B drug is more appropriate for 

the patient. Additionally, commenter stated that they believe the exclusion of Part D unfairly 

 

28 Please see http://www.medpac.gov/documents/Mar14_EntireReport.pdf for underlying data. We estimated that 

there were 37.3 million Medicare FFS beneficiaries by subtracting the number of beneficiaries enrolled in Medicare 

Advantage (14.5 million) from the estimated total number of Medicare beneficiaries using data in table 13-1 (P. 

328). We estimated that there were 22.4 million beneficiaries with a stand-alone prescription drug plan, which 

represented 64 percent of the 35 million beneficiaries with Medicare Part D coverage (p. 355). 
CMS-1612-FC 1038

harms providers that see sicker patients because they believe that these patients are more likely 

to require Part B medications. Several commenters suggested that CMS either include Part D 

costs or exclude Part B drug costs. Others suggested excluding only those Part B costs for drugs 

that have a Part D equivalent or capping the Part B costs for certain high cost drugs. We did not 

receive any comments specifically recommending an approach for how Part D costs could be 

included in our cost measurement. 

Response: We appreciate the comments and understand the concerns raised in regard to 

exclusion of Part D costs. We remain committed to capturing a full picture of the total cost of 

care and to assessing cost in a fair and consistent manner. We are actively investigating options 

for operationally including Part D costs in our cost measures and would propose any viable 

options under future notice and comment rulemaking. 

Comment: We received many comments emphasizing the importance of including 

socioeconomic status in our measures. Commenters believe that this is critical to accurately 

comparing performance between providers that serve different populations. One commenter 

stated that socioeconomic status should be used in risk adjusting outcomes measures but should 

not be used in process measures. 

Response: As noted above, we will continue to consider whether it would be appropriate 

to apply a socioeconomic status adjustment to the measures included in the VM. In August 

2014, NQF released a report on this topic with recommendations for the development of 

socioeconomic risk adjustment methodologies29. Consistent with that report, we believe it is 

important to proceed cautiously on this question. We will take the recommendations in this 

 

29 National Quality Forum, “Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors.” Final 

Report (2014), available at 

http://www.qualityforum.org/Publications/2014/08/Risk_Adjustment_for_Socioeconomic_Status_or_Other_Sociode

mographic_Factors.aspx
CMS-1612-FC 1039

report into account as we consider potential future refinements to our risk adjustment 

methodologies. Any changes would be made through rulemaking. 

We also received the following comment, which we believe is outside of the scope of our 

proposals: 

Comment: One commenter stated that CMS should revise our attribution methodology to 

look at “allowed services,” rather than “allowed charges.” The commenter believes that by 

looking at “allowed charges” we may be inaccurately attributing beneficiaries to the provider 

that bills using higher level E&M codes, rather than the provider that sees the patient most often. 

Response: We believe that a focus on allowed charges is appropriate for attribution in Medicare 

payment measures, because the intent is to assess which eligible professional should be held 

accountable for the payments made. Further, the use of allowed charges in the scenario 

presented by the commenter would further incentivize providers to correctly code E&M services 

rendered. 

k. Discussion Regarding Treatment of Hospital-Based Physicians 

We considered including or allowing groups that include hospital-based physicians or 

solo practitioners who are hospital-based to elect the inclusion of Hospital Value-Based 

Purchasing (VBP) Program performance in their VM calculation in future years of the program. 

We stated that would include hospital performance for the hospital or hospitals in which they 

practice. We would propose such a change through future notice and comment rulemaking, 

taking into consideration public comment and any relevant empirical evidence available at that 

time. We considered this potential policy to expand the performance data included for hospitalbased physicians and to better align incentives for quality improvement and cost control across 

CMS programs. Such a policy would also address public comments we received on the CY 2014 

PFS proposed rule (78 FR 74775), suggesting that the Hospital VBP Program total performance 
CMS-1612-FC 1040

score for the hospital in which a specialist practices should be used in the VM. Commenters 

made this suggestion, noting that there were limited measures that apply to certain specialties 

and that those specialties may exercise wide influence over the quality of care provided in a 

hospital. We noted that a hospital’s final Hospital VBP Program performance for a given 

performance period would not be available to a group at the time that they registered for PQRS 

reporting, so if we were to establish a voluntary policy where groups could elect to include 

hospital performance, they would make the election to have that performance included in their 

VM for a payment adjustment period based on the hospital’s historic VBP Program performance 

which would be known to the TIN at the time of election. 

We sought public comment on the appropriate methodology to identify hospital-based 

groups and solo practitioners for the purpose of having Hospital VBP Program data included or 

allowing them to elect inclusion of Hospital VBP Program performance data in the VM at the 

TIN level (70 FR 40511-40512). We suggested that we could either allow self-nomination or set 

a threshold based on physician billing, in order to determine whether a given physician was 

hospital-based. We sought comment on whether we should set a threshold for a certain 

proportion of a group’s physicians that would have to meet the criteria, in order for hospital-level 

performance to be included in the group’s VM calculation. We also sought comment on whether 

to use a set of criteria to determine whether non-physician eligible professionals should be 

allowed to self-nominate or should automatically have hospital-level performance data included 

in the calculation of their VM. We requested public comment on potential methods for 

determining which hospital or hospitals’ Hospital VBP Program performance data should be 

included in a physician TIN’s VM and how to weight the hospitals, if more than one was 

included (79 FR 40512). We welcomed public comment on the approaches we considered, as 

well as alternative approaches for inclusion of all or part of the Hospital VBP Program TPS into 
CMS-1612-FC 1041

the VM. In the interest of aligning the HVBP and VM programs, we sought public comment on 

what criteria we should consider in selecting a subset of Hospital VBP Program measures or 

domains in the VM, if we were to adopt such a policy. Finally, we requested public comment on 

the most appropriate approach for including Hospital VBP Program performance into a TIN’s 

VM. 

Comment: Commenters generally supported including the Hospital VBP Program 

performance in the VM, suggesting that it be made voluntary for physicians who meet some 

threshold of services rendered in the hospital setting. Commenters stated that a 90 percent 

threshold would be too high. 

Response: We appreciate the comments and will take these into consideration as we 

continue to refine the VM program and improve the coordination between the HVBP and VM 

programs. We would propose any policy changes through future notice and comment 

rulemaking. 

5. Physician Feedback Program 

Section 1848(n) of the Act requires us to provide confidential reports to physicians (and, 

as determined appropriate by the Secretary, to groups of physicians) that measure the resources 

involved in furnishing care to Medicare FFS beneficiaries. Section 1848(n)(1)(A)(iii) of the Act 

also authorizes us to include information on the quality of care furnished to Medicare FFS 

beneficiaries. 

a. CY 2013 Quality and Resource Use Reports Based on CY 2013 Data and Disseminated in CY 

2014. 

In September 2014, we made available the QRURs based on CY 2013 data to all 

physicians (that is, TINs of any size) even though groups with fewer than 100 eligible 

professionals will not be subject to the VM in CY 2015. These reports provide clinically 
CMS-1612-FC 1042

meaningful and actionable information on several aspects of the performance of a group practice 

or solo practitioner. The reports present not only data assessing a group practice’s or solo 

practitioner’s performance on cost measures and information about the services and procedures 

contributing most to beneficiaries’ costs, but also provide data on their performance on quality 

measures they report under the PQRS as well as the three outcome measures under §414.1230. 

For groups of 100 or more eligible professionals that are subject to the VM starting in 2015, the 

QRURs provide information on how the group’s quality and cost performance affects their 

physicians’ Medicare payments in 2015. The reports also contain additional supplementary 

information on the specialty adjusted benchmarks; inclusion of the individual PQRS measures 

for informational purposes for EPs reporting PQRS measures as individuals; enhanced drill down 

tables; and a dashboard with key performance measures. The reports are based on the VM 

policies that were finalized in the CY 2013 PFS final rule (77 FR 69310) for physician payment 

adjustments under the VM beginning January 1, 2015, and they provide groups with an 

opportunity to see how the policies adopted will apply to them. 

b. Episode Costs and the Supplemental QRURs 

Section 1848(n)(9)(A) of the Act requires CMS to develop an episode grouper and 

include episode-based costs in the QRURs. An episode of care consists of medical and/or 

procedural services that address a specific medical condition or procedure that are delivered to a 

patient within a defined time period and are captured by claims data. An episode grouper 

organizes administrative claims data into episodes. 

We developed a prototype set of episodes that expands upon the set of episodes that were 

described in the CY 2014 PFS final rule with comment period (78 FR 74785). In summer 2014, 

we distributed Supplemental QRURs based on 2012 data to a greater number of groups (groups 
CMS-1612-FC 1043

with at least 100 EPs30EPs) that included a broader set of episodes than the 2011 Supplemental 

QRURs. In addition to the five clinical conditions in the 2011 Supplemental QRURs, the 2012 

Supplemental QRURs included: chronic congestive heart failure (CHF); chronic obstructive 

pulmonary disease (COPD)/asthma; acute COPD/asthma; permanent pacemaker system 

replacement/insertion; and bilateral cataract removal with lens implant. For the 2012 

Supplemental QRURs, we broke down these episode types into 20 subtypes altogether. In 

addition to these 20 episode subtypes, we included in the 2012 Supplemental QRURs 6 clinical 

episode-based measures that we are adapting from those considered for inclusion in the Hospital 

VBP program (79 FR 28122 through 28124). We described the 20 episode subtypes and six 

clinical episode-based measures in the proposed rule and sought comment on the three medical 

and three surgical episode measures that we included in the 2012 Supplemental QRURs. 

We did not receive any general comments on the three medical and three surgical episode 

measures that we included in the 2012 Supplemental QRURs. 

Attribution for the six clinical episode-based measures at the group level are the same as 

the rules used for comparable types of the 20 episode subtypes in the 2012 Supplemental QRURs 

as discussed above. Attribution rules varied depending on whether a clinical episode-based 

measure was one of the three surgical (or procedural) episodes or one of the three medical (or 

acute condition) episodes. Further details on attribution rules can be found in “Detailed Methods 

of the 2012 Medical Group Practice Supplemental Quality and Resource Use Reports (QRURs)” 

at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. 

 

30 For Supplemental QRUR purposes, groups were also included if they did not to participate in multiple 

accountable care organizations (ACOs) and did not to participate in more than one of the following initiatives in 

program year 2012: the Shared Savings Program, the Pioneer Accountable Care Organization (ACO) Model, or the 

Comprehensive Primary Care Initiative (CPCI). 
CMS-1612-FC 1044

Specifications for these six clinical episode-based measures, including the MS-DRG and 

procedure codes used to identify each of the episodes, and details of episode construction 

methodology, are available in “Detailed Methods of the 2012 Medical Group Practice 

Supplemental Quality and Resource Use Reports (QRURs)” at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. We 

welcomed public comments on these specifications and the construction of the six clinical 

episode-based measures that we included in the 2012 Supplemental QRURs. 

The following is summary of the comments we received on these specifications and the 

construction of the six clinical episode-based measures that we included in the 2012 

Supplemental QRURs. 

Comment: One commenter stated that because E&M services are used as the basis for 

attribution for acute and chronic episodes, they believe it is unlikely that most radiology groups 

would have a score calculated for these measures. The commenter also noted that certain 

procedural episode measures, not currently under consideration for inclusion in the VM, may be 

calculated for radiology groups. Another commenter stated that he believes there are 

inconsistencies and errors in the attribution methodology used for episode measures. 

Response: We understand the concerns of specialists, including radiology groups, about 

the challenge of identifying measures for which they would have a sufficient number of 

attributed beneficiaries to have the measures calculated. We will take these into consideration as 

we continue to refine the measures and consider them for future use in the VM. 

CMS’ episodes will continue to evolve over the coming years as more experience is 

gained. More information about the Supplemental QRURs can be found at 
CMS-1612-FC 1045

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html. 

We will continue to seek stakeholder input as we develop the episode framework. We 

considered proposing to add episode-based payment measures to the VM through future 

rulemaking for all 12 episode subtypes, or some subset of these episode subtypes, of the selected 

respiratory and selected heart conditions that have appeared in both the 2011 Supplemental 

QRURs and 2012 Supplemental QRURs. These 12 episode subtypes include: pneumonia (all), 

pneumonia without an inpatient hospitalization, pneumonia with an inpatient hospitalization, 

acute myocardial infarction (now called acute coronary syndrome or ACS), ACS without 

percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG), ACS with 

PCI, ACS with CABG, coronary artery disease (now called ischemic heart disease or IHD), IHD 

without ACS, IHD with ACS, CABG without preceding ACS, and PCI without preceding ACS. 

Additionally, we are considering proposing to add hospital episode-based payment measures to 

the VM at a later time, such as the six hospital episodes described above. We welcomed public 

comments on the specifications included on the website and the construction of the episodebased payment measures that we considered. 

The following is summary of the comments we received on the specifications included on 

the website and the construction of the episode-based payment measures that we considered. 

Comment: Several commenters supported our continued efforts to develop episodebased payment measures. Two of these commenters indicated that they believe these measures 

will support better coordination of care across settings. One commenter suggested that the 

development of episode measures should follow a similar process to that used for quality 

measures, including multi-stakeholder expert consensus, evidence-based medicine, and clinical 

guidelines, as appropriate. We received a few comments stating that the episode measures 
CMS-1612-FC 1046

should not be included in the VM at this time. Two commenters stated their belief that the 

episode measures are not currently tied to quality measures and suggested that we address that 

concern before incorporating the measures into the VM. Another commenter stated that they 

believe the episode measures are duplicative of the care already captured in the MSPB measure 

and expressed concern about the reliability of the measures. This commenter suggested that 

these measures should be removed from the supplemental QRURs until these reliability concerns 

are addressed. Another commenter suggested that CMS conduct a more thorough analysis of the 

attribution methodology used in the episode measures and that we narrow the scope of the 

conditions that are currently included in the episode measures before introducing them into the 

VM. 

Response: We appreciate the input of commenters. We share the commenters’ beliefs 

that coordination across care settings is an important factor in improving quality of care and cost 

performance. We understand the concerns raised about duplication across cost measures and will 

take that and the other feedback we received regarding attribution, tying the cost measures to 

quality measures and the vetting process for measures as we continue to refine the measures and 

consider them for future use in the VM. Developing a more robust set of cost measures for the 

VM remains an important goal. 

c. Future Plans for the Physician Feedback Reports 

In the proposed rule, we stated that we will continue to develop and refine the annual 

QRURs in an iterative manner and we will seek to further improve the reports by welcoming 

suggestions from our stakeholders. 

As noted previously, on September 30, 2014, we made available the QRURs based on 

CY 2013 data to all physicians (that is, TINs of any size) even though groups with fewer than 

100 eligible professionals will not be subject to the VM in CY 2015. These reports contain 
CMS-1612-FC 1047

performance on the quality and cost measures used to score the composites and additional 

information to help physicians coordinate care and improve the quality of care furnished. We 

also intend to provide semi-annual reports with updated cost and utilization data. We will again 

solicit feedback from physicians and continue to work with our partners to improve them. We 

note that physicians will have some time to determine the impact of our revised policies and 

revise their practices accordingly before the new policies impact them. We look forward to 

continue working with the physician community to improve the QRURs. 

We received the following general comments on the Physician Feedback Program: 

Comment: Many commenters stated their support for the Physician Feedback Program 

and applauded CMS’s efforts to improve the QRURs. Many commenters stated that we should 

provide QRURs to providers earlier in the year to give them more time to analyze the results and 

make adjustments prior to the following calendar year. Several commenters also suggested that 

QRURs should be distributed to all providers, including nonphysician eligible professionals. 

Some commenters suggested that CMS increase our education and outreach efforts to ensure that 

providers know how to access and use the QRURs. 

 Response: We appreciate commenters support for the Physician Feedback Program 

and we will take these comments into consideration as we continue to develop and improve the 

Physician Feedback Program. While it is not feasible to provide the annual QRURs earlier in the 

year while still allowing sufficient time for claims run out and reporting period, we are exploring 

how to provide semi-annual reports that will allow groups and solo practitioners to better track 

their performance on cost and utilization during the year.
CMS-1612-FC 1048

O. Establishment of the Federally Qualified Health Center Prospective Payment System 

(FQHC PPS) 

In the May 2, 2014 Federal Register, we published the final rule with comment period 

(79 FR 25436) entitled “Medicare Program; Prospective Payment System for Federally Qualified 

Health Centers; Changes to Contracting Policies for Rural Health Clinics; and Changes to 

Clinical Laboratory Improvement Amendments of 1998 Enforcement Actions for Proficiency 

Testing Referral; Final Rule” (herein, “FQHC PPS final rule”). This final rule with comment 

period implemented methodology and payment rates for federally qualified health center 

(FQHC) services under Medicare Part B beginning on October 1, 2014, in compliance with the 

statutory requirement of the Affordable Care Act, and contained other provisions. In this final 

rule with comment period, we invited comments on how payment for chronic care management 

(CCM) services could promote integrated and coordinated care in FQHCs and rural health clinics 

(RHCs). We also invited comments on the modification of our proposed policy to allow 

exceptions to the FQHC PPS per diem payment for subsequent illness or injury and mental 

health services furnished on the same day as a medical visit; the establishment of FQHC G-codes 

to report and bill FQHC visits to Medicare under the PPS; and the modification of our proposed 

approach to waiving coinsurance for preventive services when furnished with other services 

under the FQHC PPS. 

1. Promoting integrated and coordinated care in FQHCs and RHCs through payment for Chronic 

Care Management (CCM) services. 

 In the FQHC PPS final rule with comment period, we invited comments from FQHCs 

and RHCs on how payment for CCM services could help to promote integrated and coordinated 

care in FQHCs and RHCs. We cited the CCM information in the CY 2014 PFS final rule with 

comment period (78 FR 74230) for physicians billing under the PFS in 2015. We encouraged 
CMS-1612-FC 1049

FQHCs and RHCs to review this information and submit comments to us on how the CCM 

services payment could be adapted for FQHCs and RHCs to promote integrated and coordinated 

care. 

We received a few comments regarding how the CCM services payment could be 

adapted for FQHCs in CY 2015 to provide integrated and coordinated care in FQHCs. 

Commenters supported adopting the CCM provisions in FQHCs but had concerns about the 

unique challenges FQHCs would face implementing these provisions. The following is a 

summary of these comments. 

 Comment: Commenters stated that the seven initiatives outlined in the CY 2014 PFS 

final rule with comment period are viable in FQHCs, but noted that FQHCs would face unique 

challenges when implementing this provision. Commenters stated that the provisions requiring 

electronic exchange of information might prove difficult at this time since many FQHCs are 

using electronic health records but are still working on developing the interoperability with other 

providers. Commenters suggested the requirement to provide patients with secure messages via 

the internet would be difficult since many FQHC patients are at or below 200 percent of the 

federal poverty level (FPL) and do not have access to internet or email. For example, a 

commenter stated that 94 percent of all FQHC patients in one state were below 200 percent of 

the FPL in 2012. Commenters supported adopting these provisions for FQHCs and suggested 

that we implement requirements that do not place an undue burden on the health centers or the 

patient population. One commenter urged that the additional G-codes for CCM services be 

sufficient to cover the associated costs of documenting care coordination and another commenter 

expressed concern for appropriate payment and requested that we develop a risk-adjusted per 

patient per month CCM fee. 

 Response: We appreciate the comments and will take them into consideration. 
CMS-1612-FC 1050

2. Exceptions to the per diem FQHC PPS payment for subsequent illness or injury and mental 

health services furnished on the same day as a medical visit. 

FQHCs receive enhanced payment to reflect all costs associated with a visit in a single 

day by a Medicare beneficiary, regardless of the length or complexity of the visit or the number 

or type of practitioners seen. Under the all-inclusive rate (AIR) system, an exception to the one 

encounter payment per day policy was made for situations when a patient comes into the FQHC 

for a medically necessary visit, and after leaving the FQHC, has a medical issue that was not 

present at the visit earlier that day, such as an injury or unexpected onset of illness. In these 

situations, the FQHC has been paid separately for two visits on the same day for the same 

beneficiary. Under the AIR system, we also allowed separate payment for mental health services 

furnished on the same day as a medical visit, separate payment for diabetes self-management 

training/medical nutrition therapy (DSMT/MNT), and separate payment for the initial preventive 

physical exam (IPPE). 

In the FQHC PPS proposed rule, published in the September 23, 2013 Federal Register 

(78 FR 58386), we stated that 2011 Medicare FQHC claims data was reviewed to determine the 

frequency of FQHCs billing for more than one visit per day for a beneficiary, and we analyzed 

the potential financial impact on both FQHCs and on access to care if billing for more than 

1 visit per day for these situations was no longer permitted. We also considered several 

alternative options, such as an adjustment of the per visit rate when multiple visits occur in the 

same day, or the establishment of a separate per visit rate for subsequent visit due to illness or 

injury, mental health services, DSMT/MNT, or IPPE. 

An analysis of data from Medicare FQHC claims with dates of service between 

January 1, 2011 and June 30, 2012, indicated that multiple visits billed on the same day 

constituted less than 0.5 percent of all visits, even though the ability to do so has been in place 
CMS-1612-FC 1051

since 1992 for subsequent illness/injury, since 1996 for mental health services, and since 2007 

for DSMT/MNT. We concluded that even allowing for any underreporting in the data, 

eliminating the ability to bill for multiple visits on the same day would not significantly impact 

either the FQHC payment or a beneficiary’s access to care. Therefore, we proposed to revise 

§405.2463(b) to remove the exception to the single encounter payment per day for FQHCs paid 

under the proposed PPS, and we stated that this policy is consistent with an all-inclusive 

methodology and reasonable cost principles and would simplify billing and payment procedures. 

 In the FQHC PPS proposed rule, we solicited comments to address whether there are 

factors that we have not considered, particularly in regards to the provision of mental health 

services, and whether this change would impact access to these services or the integration of 

services in underserved communities. 

Although we did not receive any information that showed a direct link between multiple 

billing on the same day and increasing access to care, we modified our proposal in the final rule 

and stated that we will allow separate billing for subsequent illness or injury occurring on the 

same day as another medical visit. We also modified our proposal in the FQHC PPS final rule to 

allow separate billing for mental health services furnished on the same day as a medical visit, as 

the comments we received led us to conclude that this had the potential to increase access to 

care, even if the current claims data did not show that this option was being utilized. We invited 

comments on these modifications. 

We received many comments on the modifications to our proposed policy, which would 

allow an exception to the per diem PPS payment for subsequent injury or illness and for mental 

health services furnished on the same day as a medical visit. All of the commenters were 

supportive of this modification; however, most of the commenters requested additional 

exceptions to the per diem PPS payment. The following is a summary of these comments. 
CMS-1612-FC 1052

Comment: Most commenters strongly supported our decision to allow separate payment 

for subsequent injury or illness and mental health services furnished on the same day as a 

medical visit. Commenters stated that allowing separate payment for mental health services 

when primary care services are furnished would facilitate integrated and comprehensive health 

care to Medicare beneficiaries, and agreed with our assertion that separate payment for mental 

health services has the potential to increase access to mental health services in underserved areas. 

The commenters also stated that our modification demonstrated our commitment to the value of 

furnishing mental health services in FQHCs. 

Many of the commenters who supported our modification allowing subsequent injury or 

illness and mental health services to be billed separately when furnished on the same day as 

another billable visit also requested additional exceptions to the PPS per diem payment system. 

They noted that under the AIR payment system, DSMT/MNT services and the IPPE can be 

billed separately when furnished on the same day as another billable visit, and requested that 

these services also have an exception under the PPS. Commenters particularly emphasized the 

need for separate payment for DSMT/MNT services and suggested that not being able to bill 

separately for a DSMT/MNT visit that occurs on the same day as another billable medical visit 

would deter efficient provision of these services. 

Response: We appreciate the support for allowing an exception to the per diem payment 

when a subsequent injury or illness occurs and for mental health services furnished on the same 

day as a medical visit. 

Commenters are correct that IPPE and DSMT/MNT can be billed as a separate visit 

under the AIR payment system when furnished on the same day as another medical visit, and 

that we did not include IPPE or DSMT/MNT in the exceptions under the PPS. As explained in 

the FQHC PPS proposed rule, an analysis of claims data from FQHCs indicated that the 
CMS-1612-FC 1053

estimated cost per encounter was approximately 33 percent higher when a FQHC furnished care 

to a patient that was new to the FQHC or to a beneficiary receiving an IPPE or an annual 

wellness visit (AWV). If we allowed FQHCs to bill separately for an IPPE that occurred on the 

same day as another medical visit, we would be overpaying the FQHC for the cost of the IPPE. 

To accurately pay FQHCs for the costs of furnishing an IPPE, we added an adjustment factor of 

1.333 to the PPS rate when an IPPE is furnished at a FQHC. We also extended the adjustment 

factor to both initial and subsequent AWVs, in order to appropriately compensate FQHCs for the 

costs of furnishing these services. 

In the FQHC PPS proposed rule and final rules, we discussed that we did not include an 

exception to the per-diem payment for DSMT/MNT because an analysis of the claims and cost 

reporting data did not justify either a separate per-diem payment or an adjustment to the PPS 

rate. We also stated our belief that a DSMT/MNT visit is part of the broad category of primary 

care services that are included in the services of a FQHC and are part of the PPS per diem 

payment. We noted that visits with multiple practitioners that occur on the same day, including 

visits for different conditions or visits with a specialist physician, are not separately payable in a 

FQHC, and we do not believe that DSMT/MNT visits should be considered differently than 

other primary care services. 

Although the comments we received did not persuade us to allow DSMT/MNT to be 

billed separately in a FQHC when it occurs on the same day as another billable medical visit, or 

to add an adjustment to the PPS rate for DSMT/MNT when it is furnished on the same day as 

another billable visit, we believe it is a valuable service, particularly in FQHCs that serve areas 

with high rates of people with diabetes and related illnesses, and we encourage FQHCs to furnish 

this service as necessary. 

We are retaining §405.2463(c)(4)(i) and §405.2463(c)(4)(ii) as finalized in 79 FR 25478, 
CMS-1612-FC 1054

which states that for FQHCs billing under the PPS, Medicare pays for more than 1 visit per day 

when the patient (i) suffers an illness or injury subsequent to the first visit that requires additional 

diagnosis or treatment on the same day; or (ii) has a medical visit and a mental health visit on the 

same day. 

3. Establishment of FQHC G-codes to report and bill FQHC visits to Medicare under the PPS. 

In the FQHC PPS proposed rule (78 FR 58386), we cited section 1833(a)(1)(Z) of the Act 

and proposed that Medicare payment under the FQHC PPS would be 80 percent of the lesser of 

the provider’s actual charge or the PPS rate. Commenters were concerned that comparing actual 

charges with a bundled PPS rate would distort the true cost of services furnished and would 

result in FQHCs either being forced to increase their charges, or receive payment far below 

actual cost of furnishing services. In response to these comments, we established a new set of 

HCPCS G-codes to report an established Medicare patient visit, a new or initial patient visit, and 

an IPPE or AWV. 

We stated that a FQHC would set its charge for the specific payment codes based on its 

own determination of what would be appropriate for the services normally provided and the 

population served at that FQHC, and that the charge for a specific payment code would reflect 

the sum of regular rates charged to both beneficiaries and other paying patients for a typical 

bundle of services that would be furnished per diem to a Medicare beneficiary. We emphasized 

that the use of these payment codes does not dictate to providers how to set their charges, and 

that detailed HCPCS coding with the associated line item charges would continue to be required 

along with the payment codes when billing Medicare under the PPS. Medicare would pay 

FQHCs 80 percent of either the actual charge reported for the specific payment code or the PPS 

rate on each claim, whichever is lower. 

We stated that establishing HCPCS G-codes for FQHCs to report and bill for Medicare 
CMS-1612-FC 1055

visits would allow comparison between the PPS per diem rate and a FQHC’s charge for a per 

diem visit (as defined by the specific payment codes), and that this would be responsive to 

commenters’ concerns. As we did not propose the establishment of HCPCS G-codes in the 

proposed rule, nor did we receive public comments specifically requesting such codes, we 

invited comments on the establishment of G-codes for FQHCs to report and bill FQHC visits to 

Medicare under the FQHC PPS. 

We received several comments on the establishment of G-codes for FQHCs to report and 

bill FQHC visits to Medicare under the FQHC PPS. Most commenters favored using G-codes to 

report and bill FQHC visits under the PPS; however, commenters expressed concerns about the 

complexity and administrative burden of implementing these codes. The following is a summary 

of these comments. 

Comment: Commenters appreciated that we carefully considered the comments related 

to the Medicare claims payment process and prefer our development of FQHC payment G-codes 

to compare the FQHC PPS encounter-based rate with the FQHC’s actual charges. Commenters 

stated that the use of G-codes to implement the “lesser of” provision of the statute is a positive 

solution that allows for parity between the PPS payment rate and the actual charges being 

compared. Commenters stated that we resolved what they believe would have resulted in an 

“apples to oranges” comparison by implementing a system that compares the PPS per diem rate, 

defined by the specific payment HCPCS G-codes, to a FQHC’s actual charge for a per diem 

visit. 

Although many of the commenters were supportive of the establishment of G-codes for 

FQHCs to report and bill FQHC visits to Medicare under the FQHC PPS, many of these 

commenters stated that the process of developing charges for typical bundles of services will be 

complex for FQHCs. Commenters stated that FQHCs have had limited experience working with 
CMS-1612-FC 1056

payors who use a “lesser of” or “actual charges” payment methodology. Commenters 

acknowledged that Medicare regulations require that charges must be neutral among payors; 

however, given that other payors and paying patients would not be purchasing a precise bundle 

of services corresponding to the Medicare FQHC visit, commenters stated that the policy to 

develop G-codes charges is not straightforward. Commenters stated that the charges developed 

for the FQHC payment G-codes would not be used for any non-Medicare patient. Commenters 

also stated that it would be challenging for FQHCs to develop charges for a typical bundle of 

services and adhere to requirements under section 330 of the Public Health Service (PHS) Act, 

which requires FQHCs to develop charges consistent with locally prevailing rates that cover their 

reasonable costs of operation. Commenters stated that in developing actual charges, FQHCs 

would need to perfect their coding capabilities and appropriately capture the bundle of services 

they provide in the charges. Although some commenters emphasized the complexity of 

developing G-code charges, a few commenters appreciated that we did not establish precise 

methods for FQHCs to develop their own G-code charges. 

Response: We understand that developing G-codes for FQHC payment under the PPS is 

unfamiliar to FQHCs. To assist FQHCs in understanding the new payment system, we held two 

national training sessions which provided detailed examples of various billing scenarios. A 

transcript of the presentations and slides from the presentation are posted on our website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/index.html. 

Additional information is available in the “Medicare Benefit Policy Manual, Chapter 13 - Rural 

Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services,” and the 

“Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinic (RHC)/Federally 

Qualified Health Center (FQHC).” In the resources, we discuss the need for each FQHC to 

select a bundle of services that reflects a typical bundle of services that they would provide to a 
CMS-1612-FC 1057

new or established Medicare patient at their FQHC for medical and mental health services and 

IPPE and AWV. We also address how FQHCs set their own charges (which must be consistent 

with the requirements under section 330 of the PHS Act when applicable), and since charges 

must be the same for all patients, the charges for the services that are included in the bundle 

would be totaled to determine the G-code payment amount. We expect that once FQHCs set 

their charges and select the bundle of services that will be included in the FQHC G-codes, they 

will adapt well to the process. We would also note that other payors could choose to utilize the 

FQHC payment G-codes if they choose. 

Comment: Many commenters suggested that the use of FQHC payment G-codes would 

create an additional administrative burden for FQHCs’ coding and billing staff. Commenters 

stated that FQHCs will need to spend additional time explaining the charges on the Explanation 

of Benefits (EOB) to Medicare beneficiaries since there could be additional charges beyond what 

the beneficiary typically sees associated with a visit. Some commenters stated that using FQHC 

payment G-codes could artificially inflate FQHCs’ total gross charges, although others stated 

that some of the financial discrepancies in payment would be resolved once the FQHC receives 

payment. However, many commenters stated there would be an administrative burden to a 

FQHC in the short-term as it attempts to resolve balances and financial statements. 

Response: FQHCs may initially have to spend additional time explaining changes in 

charges and the patient’s EOB, and we encourage them to keep their patients informed of any 

changes. We also acknowledge that transitioning to a new payment system will require 

additional time and patience as all aspects of the billing system will need to be adapted. 

We noted in the FQHC PPS final rule that although FQHCs set their own charges, 

FQHCs that receive grant funding under section 330 of the PHS Act are required to maintain 

charges that are both consistent with locally prevailing rates or charges and are also reflective of 
CMS-1612-FC 1058

their reasonable costs of operation. Therefore, we do not expect that the FQHCs will use the 

payment G-codes to artificially inflate their charges. 

Comment: Several commenters were concerned that the use of G-codes would limit the 

definition or scope of a qualifying face-to-face visit. Commenters stated that we were limiting 

the scope of FQHC services by requiring that only certain HCPCS codes support the use of each 

FQHC payment G-code. Commenters stated that services described by codes other than 

evaluation and management (E/M) services also meet the definition of a face-to-face visit with a 

qualifying provider. The commenters recommended that for each qualifying visit, the FQHC 

should be able to enter the corresponding FQHC payment G-code to be eligible for payment. 

Response: We disagree that the new PPS may limit the scope of FQHC services. All 

services that qualified as a billable visit under the AIR payment system continue to qualify as a 

billable visit under the PPS. There has been no change to the scope of services that may be 

furnished in a FQHC and no change in the type of visits that qualify as a billable visit as a result 

of the new payment system. Since the previous payment system did not utilize HCPCS coding 

to determine payment, we anticipate the new payment system will be more transparent, as all 

services furnished must have the correct HCPCS codes for accurate payment, along with the 

appropriate G-code for payment. We would also note that in addition to E/M visits, there are 

many preventive services that can be billed as stand-alone visits in FQHCs under both the AIR 

and PPS payment systems. 

Comment: A few commenters suggested that we develop more G-codes to account for 

other types of services furnished in a FQHC and G-codes that address varying patient 

populations. One commenter suggested that we add an additional 10 to 15 HCPCS codes based 

on the historical claims data for FQHC visits. Another commenter suggested that due to the 

complex needs of their FQHC patient population, additional FQHC payment G-codes should 
CMS-1612-FC 1059

reflect multiple services, intensity, and cost of furnishing services to their complex patient 

population. 

Response: We stated in the FQHC PPS proposed and final rules that our goal for the 

FQHC PPS is to implement a system in accordance with the statute whereby FQHCs are fairly 

paid for the services they furnish to Medicare patients in the least burdensome manner possible, 

so that they may continue to furnish primary and preventive health services to the communities 

they serve. In developing the FQHC G-codes, we considered whether there should be fewer 

G-codes, or more G-codes, than the five that we ultimately proposed. The G-codes are designed 

to reflect a typical bundle of services that a FQHC furnishes to their Medicare patients, and we 

determined that having more G-codes would be burdensome without providing any advantage in 

payment accuracy. However, we will monitor the PPS system and will consider adding 

additional G-codes if necessary. 

Comment: A number of commenters requested clarification that the bundle of services 

taken into account in the G-code charge reflects the total bundle of services for a FQHC visit, 

rather than just the services furnished on that day. Some commenters also sought clarification on 

billing the professional component of a preventive service on a day subsequent to the day of the 

visit. These commenters are concerned whether under the new billing requirements for the 

FQHC PPS all services are meaningfully included in the encounter payment rate even when a 

component of the service is furnished on a different date than the actual visit. 

Response: The FQHC G-codes reflect the services that the FQHC typically furnishes to a 

Medicare patient that is either a new or established, medical or mental health patient or a patient 

receiving an IPPE or AWV. This may be the same bundle of services that are furnished to the 

patient on a particular day, but is not required to be the same services, as the patient may need 

more, fewer, or a different set of services on that particular day. 
CMS-1612-FC 1060

FQHCs may bill for services furnished incident to a visit on the same claim, even if they 

occur on a different day, as long as the services are furnished in a medically appropriate time 

frame. For example, if a patient has their blood drawn at the FQHC on a Monday, and sees the 

FQHC practitioner the following Wednesday, the FQHC would include the venipuncture on the 

same claim as the visit with the practitioner. 

The FQHC G-codes are defined in program instructions in accordance with statutory and 

regulatory requirements and will be implemented as described. 

4. Waiving coinsurance for preventive services when furnished with other services under the 

FQHC PPS. 

In the FQHC PPS proposed rule (78 FR 58386), we proposed that for FQHC claims that 

include a mix of preventive and non-preventive services, FQHCs would use payments under the 

PFS to determine the proportional amount of coinsurance that should be waived for payments 

based on the PPS encounter rate. Since Medicare payment under the FQHC PPS is required to 

be 80 percent of the lesser of the FQHC’s charges or the PPS rate, we proposed that we would 

continue to use FQHC-reported charges to determine the amount of coinsurance that should be 

waived for payments based on the FQHC’s charge, and that total payment to the FQHC, 

including both Medicare and beneficiary liability, would not exceed the lesser of the FQHC’s 

charge or the PPS rate. 

We acknowledged that our proposed approach for waiving coinsurance for preventive 

services when furnished with other services was complex and may be difficult for FQHCs to 

implement, and we invited public comment on how this proposal would impact a FQHC’s 

administrative procedures and billing practices. Commenters responded that the proposed 

system to calculate coinsurance was too complex and burdensome and requested that a 

simplified system be established. 
CMS-1612-FC 1061

In the final rule referenced above, we agreed with the commenters, and decided to retain 

the current method used under the AIR system for calculating coinsurance, with certain 

modifications. Under the new FQHC PPS, the dollar value of the FQHC’s reported line-item 

charge for the preventive service will be subtracted from the full payment amount, whether 

payment is based on the FQHC’s charge or the PPS rate. Medicare will pay the FQHC 100 

percent of the dollar value of the FQHC’s reported line-item charge for the preventive service, up 

to the total payment amount. Medicare also will pay a FQHC 80 percent of the remainder of the 

full payment amount, and beneficiary coinsurance would be assessed at 20 percent of the 

remainder of the full payment amount. If the reported line-item charge for the preventive service 

equals or exceeds the full payment amount, Medicare will pay 100 percent of the full payment 

amount and the beneficiary will not be responsible for any coinsurance. 

We believe that this revised methodology is responsive to commenters request for a 

simpler method of calculating coinsurance and will be more transparent to beneficiaries. We 

invited comments on this approach to waiving coinsurance for preventive services based on the 

dollar value of the FQHC’s reported line-item charge for preventive services. 

We received many comments on how our finalized policy for calculation of coinsurance 

for preventive services would affect a FQHC’s administrative procedures and billing practices. 

Most commenters appreciated that we are striving for policies that ease administrative burden; 

however, many of the commenters thought that our revised approach is still too complex and 

burdensome to implement. The following is a summary of these comments. 

Comment: Most commenters supported that we are striving for a waiver of coinsurance 

calculation that achieves greater simplicity and promotes fair payment under Medicare. A few 

commenters stated that our revised approach is a common sense and workable approach to 

applying this important provision. One commenter stated that this approach would allow for 
CMS-1612-FC 1062

FQHCs to assess coinsurance at the time services are furnished, potentially increase rates of 

collection, and reduce administrative burden. Commenters who supported the revised approach 

requested that we closely monitor how the waiver of coinsurance is calculated and determine if 

further modifications are needed in the future. Most commenters preferred the revised approach, 

but some expressed concern that it is still too complex and burdensome. Commenters stated that 

our methodology for the calculation of coinsurance waiver when the services include a mix of 

preventive and non-preventive services is too complex for the FQHC staff to accurately 

determine the coinsurance at the time services are furnished. Commenters suggested that 

FQHCs would be concerned with overcharging the patient and waive all coinsurance when a 

mixture of preventive and non-preventive services is furnished. Commenters acknowledged that 

FQHCs could bill the patient after the MAC issues a remittance advice, but the commenters 

stated that this would increase bad debt. One commenter stated that the revised approach creates 

an incentive for FQHCs to offer fewer services at each visit and request patients to return on 

different days for additional services that could have been furnished on the same day. 

Response: We appreciate that FQHCs want to accurately determine coinsurance amounts 

when there is a mix of preventive and non-preventive services furnished on the same day so that 

beneficiaries are neither overcharged nor undercharged. Since FQHCs set their own charges and 

develop their own G-codes, they should be able to accurately determine the coinsurance amount. 

We believe that the proposed method strikes the right balance between accuracy and simplicity, 

and we will make adjustment as necessary if problems arise. We also note that, under certain 

circumstances, FQHCs may waive coinsurance amounts for Medicare and Medicaid 

beneficiaries (see for example, section 1128B(b)(3)(D) of the Act and § 1001.952(k)(2) of the 

regulations). Also, most FQHCs are subject to the statutory and regulatory requirements of the 

Health Center Program (section 330 of the PHS Act; 42 CFR Part 51c; and 42 CFR 56.201 
CMS-1612-FC 1063

through 56.604), which, among other requirements, mandates that they may collect no more than 

a ‘‘nominal fee’’ from individuals whose annual income is at or below 100 percent of the Federal 

Poverty Level.” 

We are not clear why one commenter suggested that the method for calculating 

coinsurance could create an incentive for FQHCs to offer fewer services at each visit and request 

patients to return on different days for additional services that could have been furnished on the 

same day. However, as we stated in the FQHC PPS final rule, we expect FQHCs to act in the 

best interests of their patients, which includes scheduling visits in a manner that maximizes the 

health and safety of their patients. 

Comment: Some commenters stated that the complexity of our revised approach does 

not carry out Congressional intent to provide for complete waiver of coinsurance when covered 

preventive services are furnished. They stated that when Congress provided for a complete 

waiver of coinsurance for specific preventive services under section 4104 of the Affordable Care 

Act, it was intended to improve access to these services, and that requiring Medicare 

beneficiaries be liable for coinsurance when a mixture of preventive and non-preventive services 

are furnished does not remove barriers to these services. Commenters also stated that we lack 

“any specific statutory authorization to waive coinsurance for services provided under the FQHC 

PPS,” and therefore, CMS is not barred from implementing a complete waiver for coinsurance 

when a mixture of services are furnished. These commenters stated that a complete waiver of 

coinsurance for visits involving a preventive service is consistent with the regulation under 

§410.152(l), which states that Medicare Part B pays “100 percent of the Medicare payment 

amount established under the applicable payment methodology for the service setting for 

providers and suppliers of the following preventive services.” Commenters stated that a FQHC 

is a provider of such preventive services and that the FQHC PPS is an applicable payment 
CMS-1612-FC 1064

methodology. Commenters surmised that it is more consistent with the regulation to completely 

waive coinsurance for visits involving a mixture of preventive and non-preventive services rather 

than implement a partial coinsurance methodology. 

Response: We disagree with the commenters’ interpretation that the statutory and 

regulatory language cited provides us with the authority to waive coinsurance for all services 

when there is a mix of preventive and non-preventive services furnished during a FQHC 

encounter. The revised methodology for calculating coinsurance when there is a mix of 

preventive and non-preventive services on the claim was revised in response to commenters’ 

concerns that the methodology that was first proposed was overly complex and burdensome. We 

believe that the revised methodology is responsive to those concerns, and provides as much 

simplicity as possible while enabling FQHCs to comply with statutory requirements for the 

collection of coinsurance. 

We are retaining §405.2410(b)(2)(i), §405.2410(b)(2)(ii), and §405.2462(d) of the 

Medicare regulations as finalized in 79 FR 25475 and will use the current approach to waiving 

coinsurance for preventive services, whether total payment is based on the FQHC’s charge or the 

PPS rate, by subtracting the dollar value of the FQHC’s reported line-item charge for the 

preventive services from the full payment amount. 

5. Other Comments 

We received many comments requesting that we provide further information through 

subregulatory guidance to the stakeholder community regarding same-day visits, development of 

G-code charges, the calculation of coinsurance when a mixture of preventive and non-preventive 

services are furnished, what is considered the technical and the professional component of 

preventive services, billing procedures and processing of claims for same-day visits. Several 

commenters requested specific examples on calculating coinsurance when the claim contains a 
CMS-1612-FC 1065

mixture of preventive and non-preventive services. 

Response: The “Medicare Benefit Policy Manual, Chapter 13 - Rural Health Clinic 

(RHC) and Federally Qualified Health Center (FQHC) Services,” and the “Medicare Claims 

Processing Manual, Chapter 9 - Rural Health Clinic (RHC)/Federally Qualified Health Center 

(FQHC), ” are regularly updated and will address these topics. Additional information on the 

FQHC PPS is available on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/FQHCPPS/index.html. 

We received some comments that were not related to our specific proposals for the 

FQHC PPS. Although we appreciate the commenters’ feedback on billing for vaccines under 

Medicare part D, billing for costs relating to language assistance and other enabling services, 

adjustments to the California GAF, FQHC PPS rate risk adjusters, and the FQHC PPS 

implementation date, payment for furnishing services to dually eligible Medicare and Medicaid 

beneficiaries, these topics are beyond the scope of our specific proposals that we specified were 

subject to public comment in the FQHC PPS. 

6. Additional Technical Revisions 

a. SNF Consolidated Billing 

In this final rule with comment period, we are making a conforming technical revision in 

§411.15(p)(2) and §489.20(s). In the May 2, 2014, interim final rule (79 FR 25462), we updated 

§405.2411(b)(2) so that it reflects section 1888(e)(2)(A)(iv) of the Act (as amended by section 

410 of the MMA), which excludes certain RHC and FQHC practitioner services from 

consolidated billing and allows such services to be separately billable under Part B when 

furnished to a resident of a SNF during a covered Part A stay. This statutory provision was 

effective with services furnished on or after January 1, 2005 and was previously implemented 

through program instruction (CMS Pub 100–04, Medicare Claims Processing Manual, Chapter 6, 
CMS-1612-FC 1066

Section 20.1.1). 

However, in making this revision, we inadvertently neglected to make a conforming 

change in §411.15(p)(2), which enumerates the individual services that are excluded from the 

SNF consolidated billing provision, as well as in §489.20(s), which specifies compliance with 

consolidated billing as a requirement of the SNF’s Medicare provider agreement. Accordingly, 

we are now rectifying that omission. 

Regarding the technical corrections to parts 411 and 489 of the regulations discussed 

above, we note that we would ordinarily publish a notice of proposed rulemaking in the Federal 

Register to provide a period for public comment before revisions in the regulations text would 

take effect; however, we can waive this procedure if we find good cause that a notice and 

comment procedure is impracticable, unnecessary, or contrary to the public interest and 

incorporate a statement of the finding and its reasons in the notice issued. We find it 

unnecessary to undertake notice and comment rulemaking in connection with these particular 

revisions, as they merely provide technical corrections to the regulations, without making any 

substantive changes. Therefore, for good cause, we waive notice and comment procedures for 

the revisions that we are making to the regulations text in parts 411 and 489. 

b. Transitional Care Management 

In the May 2, 2014 final rule (79 FR 25436), we added transitional care management 

(TCM) to §405.2463(a)(1)(ii). To clarify that TCM does not necessarily require a face-to-face 

visit, we revised this section of the regulation for RHCs, but neglected to add the appropriate 

reference for FQHCs. Therefore, we are revising §405.2463(a)(2)(i), so that a FQHC visit 

includes a qualified TCM service. 
CMS-1612-FC 1067

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

1. General 

Section 1877 of the Act prohibits a physician from referring a Medicare beneficiary for 

certain designated health services (DHS) to an entity with which the physician (or a member of 

the physician's immediate family) has a financial relationship, unless an exception applies. 

Section 1877 of the Act also prohibits the DHS entity from submitting claims to Medicare or 

billing the beneficiary or any other entity for Medicare DHS that are furnished as a result of a 

prohibited referral. 

Section 1877(h)(6) of the Act and § 411.351 of our regulations specify that the following 

services are DHS: 

● Clinical laboratory services 

● Physical therapy services 

● Occupational therapy services 

● Outpatient speech-language pathology services 

● Radiology services 

● Radiation therapy services and supplies 

● Durable medical equipment and supplies 

● Parenteral and enteral nutrients, equipment, and supplies 

● Prosthetics, orthotics, and prosthetic devices and supplies 

● Home health services 

● Outpatient prescription drugs 

● Inpatient and outpatient hospital services 

2. Annual Update to the Code List 

a. Background 
CMS-1612-FC 1068

In §411.351, we specify that the entire scope of four DHS categories is defined in a list of 

CPT/HCPCS codes (the Code List), which is updated annually to account for changes in the 

most recent CPT and HCPCS Level II publications. The DHS categories defined and updated in 

this manner are: 

● Clinical laboratory services 

● Physical therapy, occupational therapy, and outpatient speech-language pathology 

services 

● Radiology and certain other imaging services 

● Radiation therapy services and supplies 

The Code List also identifies those items and services that may qualify for either of the 

following two exceptions to the physician self-referral prohibition: 

● EPO and other dialysis-related drugs furnished in or by an ESRD facility (§ 

411.355(g)) 

● Preventive screening tests, immunizations, or vaccines (§ 411.355(h)) 

The definition of DHS at §411.351 excludes services that are reimbursed by Medicare as 

part of a composite rate (unless the services are specifically identified as DHS and are 

themselves payable through a composite rate, such as home health and inpatient and outpatient 

hospital services). Effective January 1, 2011, EPO and dialysis-related drugs furnished in or by 

an ESRD facility (except drugs for which there are no injectable equivalents or other forms of 

administration), have been reimbursed under a composite rate known as the ESRD prospective 

payment system (ESRD PPS) (75 FR 49030). Accordingly, EPO and any dialysis-related drugs 

that are paid for under ESRD PPS are not DHS and are not listed among the drugs that could 

qualify for the exception at §411.355(g) for EPO and other dialysis-related drugs furnished by an 

ESRD facility. 
CMS-1612-FC 1069

Drugs for which there are no injectable equivalents or other forms of administration were 

scheduled to be paid under ESRD PPS beginning January 1, 2014 (75 FR 49044). However, on 

January 3, 2013, Congress enacted the American Taxpayer Relief Act of 2012 (ATRA), (Pub. 

L.112-240), which will delay payment of these drugs under ESRD PPS until January 1, 2016. In 

the meantime, such drugs furnished in or by an ESRD facility are not reimbursed as part of a 

composite rate and thus, are DHS. For purposes of the exception at §411.355(g) , only those 

drugs that are required for the efficacy of dialysis may be identified on the List of CPT/HCPCS 

Codes as eligible for the exception. As we have explained previously in the CY 2010 PFS final 

rule (75 FR 73583), we do not believe any of these drugs are required for the efficacy of dialysis. 

Therefore, we have not included any such drugs on the list of drugs that can qualify for the 

exception. 

The Code List was last updated in Addendum K of the CY 2014 PFS final rule with 

comment period. 

b. Response to Comments 

We received no public comments relating to the Code List that became effective 

January 1, 2014. 

c. Revisions Effective for 2015 

 The updated, comprehensive Code List effective January 1, 2015, is available on our 

Web site at http://www.cms.gov/Medicare/Fraud-andAbuse/PhysicianSelfReferral/List_of_Codes.html. 

Additions and deletions to the Code List conform it to the most recent publications of 

CPT and HCPCS Level II, and to changes in Medicare coverage policy and payment status. 

Tables 90 and 91 identify the additions and deletions, respectively, to the comprehensive 

Code List that become effective January 1, 2015. Tables 90 and 91 also identify the additions 
CMS-1612-FC 1070

and deletions to the list of codes used to identify the items and services that may qualify for the 

exception in §411.355(g) (regarding dialysis–related outpatient prescription drugs furnished in or 

by an ESRD facility) and in §411.355(h) (regarding preventive screening tests, immunizations, 

and vaccines). 

We will consider comments regarding the codes listed in Tables 90 and 91. Comments 

will be considered if we receive them by the date specified in the "DATES" section of this final 

rule with comment period. We will not consider any comment that advocates a substantive 

change to any of the DHS defined in §411.351. 

TABLE 90: Additions to the Physician Self-Referral List of CPT1/HCPCS Codes 

CLINICAL LABORATORY SERVICES 

0357T Cryopreservation oocyte(s) 

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND 

OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES 

97607 Neg press wnd tx </=50 sq cm 

97608 Neg press wound tx >50 cm 

RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES 

76641 Ultrasound breast complete 

76642 Ultrasound breast limited 

77061 Breast tomosynthesis uni 

77062 Breast tomosynthesis bi 

77063 Breast tomosynthesis bi 

77085 Dxa bone density study 

77086 Fracture assessment via dxa 

G0279 Tomosynthesis, mammo screen 

RADIATION THERAPY SERVICES AND SUPPLIES

A9606 Radium Ra223 dichloride ther 

C2644 Brachytx cesium-131 chloride 

77306 Telethx isodose plan simple 

77307 Telethx isodose plan cplx 

77316 Brachytx isodose plan simple 

77317 Brachytx isodose intermed 

77318 Brachytx isodose complex 
CMS-1612-FC 1071

77385 Ntsty modul rad tx dlvr smpl 

77386 Ntsty modul rad tx dlvr cplx 

G6001 Echo guidance radiotherapy 

G6002 Stereoscopic x-ray guidance 

G6003 Radiation treatment delivery 

G6004 Radiation treatment delivery 

G6005 Radiation treatment delivery 

G6006 Radiation treatment delivery 

G6007 Radiation treatment delivery 

G6008 Radiation treatment delivery 

G6009 Radiation treatment delivery 

G6010 Radiation treatment delivery 

G6011 Radiation treatment delivery 

G6012 Radiation treatment delivery 

G6013 Radiation treatment delivery 

G6014 Radiation treatment delivery 

G6015 Radiation tx delivery imrt 

G6016 Delivery comp imrt 

G6017 Intrafraction track motion 

DRUGS USED BY PATIENTS UNDERGOING DIALYSIS 

{No additions} 

PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND 

VACCINES 

90630 Flu vacc iiv4 no preserv id 

G0464 Colorec CA scr, sto bas DNA 1

CPT codes and descriptions only are copyright 2014 AMA. All rights are reserved and applicable FARS/DFARS 

clauses apply. 

 
CMS-1612-FC 1072

TABLE 91: Deletions from the Physician Self-Referral List of CPT1/HCPCS Codes 

CLINICAL LABORATORY SERVICES 

0059T Cryopreservation oocyte

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND 

OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES 

{No deletions} 

RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES 

74291 Contrast x-rays gallbladder 

76645 Us exam breast(s) 

77082 Dxa bone density vert fx 

RADIATION THERAPY SERVICES AND SUPPLIES 

0073T Delivery comp imrt 

0197T Intrafraction track motion 

77305 Teletx isodose plan simple 

77310 Teletx isodose plan intermed 

77315 Teletx isodose plan complex 

77326 Brachytx isodose calc simp 

77327 Brachytx isodose calc interm 

77328 Brachytx isodose plan compl 

77403 Radiation treatment delivery 

77404 Radiation treatment delivery 

77406 Radiation treatment delivery 

77408 Radiation treatment delivery 

77409 Radiation treatment delivery 

77411 Radiation treatment delivery 

77413 Radiation treatment delivery 

77414 Radiation treatment delivery 

77416 Radiation treatment delivery 

77418 Radiation tx delivery imrt 

77421 Stereoscopic x-ray guidance 

G0417 Sat biopsy prostate 21-40 

G0418 Sat biopsy prostate 41-60 

G0419 Sat biopsy prostate: >60 

DRUGS USED BY PATIENTS UNDERGOING DIALYSIS 

{No deletions}

PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND 

VACCINES 

{No deletions} 1 CPT codes and descriptions only are copyright 2014 AMA. All rights are reserved and applicable FARS/DFARS 

clauses apply.
CMS-1612-FC 1073

Q. Interim Final Revisions to the Electronic Health Record (EHR) Incentive Program 

1. Statutory Basis 

The American Recovery and Reinvestment Act of 2009 (Pub. L. 111–5) (ARRA) 

amended titles XVIII and XIX of the Act to authorize incentive payments to EPs, eligible 

hospitals, and critical access hospitals (CAHs), and Medicare Advantage (MA) organizations to 

promote the adoption and meaningful use of CEHRT. Sections 1848(o), 1853(l) and (m), 

1886(n), and 1814(l) of the Act provide the statutory basis for the Medicare incentive payments 

made to meaningful EHR users. These statutory provisions govern EPs, MA organizations (for 

certain qualifying EPs and hospitals that meaningfully use CEHRT), subsection (d) hospitals, 

and CAHs, respectively. Sections 1848(a)(7), 1853(l) and (m), 1886(b)(3)(B), and 1814(l) of the 

Act also establish downward payment adjustments, beginning with calendar or fiscal year 2015, 

for EPs, MA organizations, subsection (d) hospitals and CAHs that are not meaningful users of 

CEHRT for certain associated reporting periods. Sections 1903(a)(3)(F) and 1903(t) of the Act 

provide the statutory basis for Medicaid incentive payments, but do not provide for downward 

payment adjustments. 

Sections 1848(a)(7)(B), 1886(b)(3)(B)(ix)(II), and 1814(l)(4)(C) of the Act provide that 

the Secretary may, on a case-by-case basis, exempt an EP, eligible hospital, or CAH that is not a 

meaningful EHR user for an EHR reporting period for the year from the application of the 

payment adjustment if the Secretary determines that compliance with the requirement for being a 

meaningful EHR user would result in a significant hardship, such as in the case of an EP, eligible 

hospital, or CAH that practices or is located in a rural area without sufficient internet access. 

The exception is subject to annual renewal, but in no case may an exception be granted for more 

than 5 years. 

2. Provisions of the Interim Final Rule With Comment Period 
CMS-1612-FC 1074

a. Extreme and Uncontrollable Circumstances Hardship Exception 

In the September 4, 2014 Federal Register (79 FR 52910-52933) CMS and ONC 

published a final rule titled “Medicare and Medicaid Programs; Modifications to the Medicare 

and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and Other Changes 

to the EHR Incentive Program; and Health Information Technology: Revisions to the Certified 

EHR Technology Definition and EHR Certification Changes Related to Standards; Final Rule” 

(“2014 CEHRT Flexibility rule”). The final rule included policies allowing EPs, eligible 

hospitals, and CAHs that could not fully implement 2014 Edition CEHRT for an EHR reporting 

period in 2014 due to issues related to 2014 Edition CEHRT availability delays to continue to 

use 2011 Edition CEHRT or a combination of 2011 Edition and 2014 Edition CEHRT for the 

EHR reporting periods in CY 2014 and FY 2014, respectively. These CEHRT options applied 

only to those providers that could not fully implement 2014 Edition CEHRT to meet meaningful 

use for an EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability. The 

final rule also made changes to the attestation process to support these flexible options for 

CEHRT, although it did not alter the attestation or hardship exception application deadlines for 

2014. Therefore, for example, eligible hospitals that never successfully attested to meaningful 

use prior to FY 2014 were still required to attest by July 1, 2014, and eligible professionals who 

never successfully attested to meaningful use prior to CY 2014 were required to attest by 

October 1, 2014, for an EHR reporting period in FY 2014 or CY 2014, respectively, to avoid the 

Medicare payment adjustments in FY 2015 or CY 2015, respectively. To request a hardship 

exception from the Medicare payment adjustments in FY or CY 2015, applications were due 

from eligible professionals by July 1, 2014, eligible hospitals by April 1, 2014, and CAHs by 

November 30, 2015. In addition, throughout the course of the year, we continued to urge 

providers to purchase 2014 Edition CEHRT and not wait until the last minute to attest for the 
CMS-1612-FC 1075

EHR reporting period in 2014. 

 However, following publication of the 2014 CEHRT Flexibility rule, we became aware 

that providers were confused over their ability to use flexible options provided under the 2014 

CEHRT Flexibility rule, especially given the unchanged attestation deadlines. We received 

numerous letters from various health care associations, multiple questions from stakeholders on 

provider calls, and numerous e-mails from providers and EHR vendors, all expressing confusion 

and seeking clarification about whether they could use the flexible options provided under the 

2014 CEHRT Flexibility rule. Specifically, providers were unsure how they could use the 

flexible options given that the attestation deadlines for both eligible professionals (October 1, 

2014) and eligible hospitals (July 1, 2014) would have occurred on or before the effective date of 

the 2014 CEHRT Flexibility rule (October 1, 2014). Providers were extremely concerned that 

their inability to use the flexible options specified in the 2014 CEHRT Flexibility rule would 

subject them to a payment adjustment in 2015 under Medicare for failing to demonstrate 

meaningful use of CEHRT. This fear was compounded by the fact that the hardship exception 

application deadlines for both eligible professionals (July 1, 2014) and eligible hospitals (April 1, 

2014) had already passed. 

In particular, we became aware that eligible professionals who never successfully attested 

to meaningful use for the EHR Incentive Program were especially affected by this issue because 

they would not be able to use the flexibility options outlined in the 2014 CEHRT Flexibility rule 

before the October 1, 2014 deadline to avoid the payment adjustment in CY 2015, because these 

options could not be made available in the CMS Registration and Attestation System prior to the 

October 1, 2014 effective date of the 2014 CEHRT Flexibility rule. We also became aware that 

eligible professionals also faced uncertainty if they joined practices that were already using 2011 

Edition CEHRT and experienced delays in full implementation of 2014 Edition CEHRT. 
CMS-1612-FC 1076

Therefore, we understood that eligible professionals were concerned that the inability to attest by 

October 1, 2014 using the flexible options under the 2014 CEHRT Flexibility rule would 

potentially subject them to the payment adjustment in CY 2015 authorized under the Medicare 

EHR Incentive Program if they could not receive a hardship exception. 

Accordingly, to ensure that all providers can use the flexible options recently finalized 

under the 2014 CEHRT Flexibility rule for an EHR reporting period in 2014, and ensure that 

providers are not potentially subjected to the 2015 payment adjustment under the Medicare EHR 

Incentive Program, we are recognizing a hardship exception under the established category of 

“extreme and uncontrollable circumstances” under 42 CFR § 495.102(d)(4)(iii) for eligible 

professionals and § 412.64(d)(4)(ii)(B) for eligible hospitals, pursuant to the Secretary’s 

discretionary hardship exception authority. Under this IFC, we will consider that an extreme and 

uncontrollable circumstance hardship exists for an eligible professional or eligible hospital if two 

criteria are met. First, the provider must not have been able to fully implement the 2014 Edition 

CEHRT due to delays in 2014 Edition CEHRT availability. Second, the provider must not have 

been able to attest by their attestation deadline in 2014. For example, for eligible professionals, 

the eligible professional must not have been able to attest by October 1, 2014 using the flexibility 

options under the 2014 CEHRT Flexibility rule. For eligible hospitals, the eligible hospital must 

not have been able to attest by July 1, 2014 using the flexibility options under the 2014 CEHRT 

Flexibility rule. We will recognize an extreme and uncontrollable circumstance hardship 

exception under this IFC only for those providers meeting both these criteria and only for the 

2015 payment adjustment. 

 For CAHs, although we would recognize a hardship exception for CAHs under these 

circumstances, this exception would have little impact on CAHs because the hardship exception 

application deadline for CAHs for the 2015 payment adjustment does not occur until November 
CMS-1612-FC 1077

30, 2015. Accordingly, CAHs will have ample time to attest using the flexibility options under 

the 2014 CEHRT Flexibility rule and will not be impacted in the same manner as eligible 

hospitals or eligible professionals, whose attestation and hardship exception application 

deadlines have since passed. However, as explained below, to maximize flexibility in the 

hardship exception application submission process for all providers under the hardship exception 

categories, so that we avoid similar situations in the future, like the ones prompting this IFC, we 

are amending §413.70(a)(6) to allow CMS the flexibility to specify an alternate hardship 

exception application submission deadline for certain hardship categories other than November 

30th. 

b. Extension of Hardship Exception Application Deadline to November 30, 2014 for Eligible 

Professionals and Eligible Hospitals and Amendments to §§495.102, 412.64, and 413.70. 

Section 495.102(d)(4) provides the categories of hardship exceptions for EPs, including 

insufficient internet access, newly practicing EPs, extreme circumstances outside of an EP’s 

control, lack of control over the availability of CEHRT for EPs practicing in multiple locations, 

lack of face-to-face patient interactions and lack of need for follow-up care, and certain primary 

specialties. With the exception of the newly practicing EP hardship exception category, the EP 

is required to file a hardship exception application to CMS for the remaining hardship categories 

no later than July 1st of the year before the payment adjustment year. 

 Similar to eligible professionals, §412.64(d)(4) provides the categories of hardship 

exceptions for eligible hospitals, which include insufficient internet access, new eligible 

hospitals, and extreme and uncontrollable circumstances outside of an eligible hospital’s control. 

Under the hardship exception categories for insufficient internet access and extreme and 

uncontrollable circumstances, the eligible hospital is required to file a hardship exception 

application to CMS no later than April 1st of the year before the payment adjustment year. 
CMS-1612-FC 1078

Similar to eligible hospitals, §413.70(a)(6) provides the categories of hardship exceptions 

that CAHs could apply for, which include insufficient internet access, new CAHs, and extreme 

and uncontrollable circumstances outside of a CAH’s control. Under all hardship exception 

categories, the CAH is required to file a hardship exception application to CMS no later than 

November 30th after the close of the applicable EHR reporting period for a payment adjustment 

year to be considered for a hardship exception. 

For purposes of the 2015 payment adjustment under the Medicare EHR Incentive 

Program, the hardship exception application deadlines for both eligible hospitals and eligible 

professionals have ended. However, we need to accommodate the extreme and uncontrollable 

circumstance hardship exception recognized under this IFC. Therefore, for purposes of the 2015 

payment adjustment under the Medicare EHR Incentive Program, we are extending the hardship 

exception application submission deadline for both eligible hospitals and eligible professionals to 

November 30, 2014. We believe that extending the hardship exception application deadline to 

November 30, 2014 will allow ample time for those eligible hospitals and eligible professionals 

that could not fully implement 2014 Edition CEHRT due to 2014 Edition CEHRT availability 

delays and that could not attest by their applicable attestation deadline using the flexibility 

options provided in the 2014 CEHRT flexibility rule to file an application for the hardship 

exception recognized under this IFC. 

The extension of the hardship exception application submission deadline to November 

30, 2014, applies only to those providers who meet the criteria described under this IFC. We 

will not extend, reopen, or reconsider the hardship exception application deadline for the 2015 

payment adjustment for any other reason. Further, as explained above, because CAHs have still 

not reached their November 30, 2015 hardship exception application deadline, they are not 

affected in the same manner as eligible hospitals and eligible professionals, and are still eligible 
CMS-1612-FC 1079

to file a hardship exception application until November 30th under any of the categories 

specified under §413.70(a)(6). 

 Next, to extend the hardship exception application deadline to November 30, 2014, for 

eligible hospitals and eligible professionals, we must amend under this IFC the July 1st hardship 

exception application deadline for extreme and uncontrollable circumstances under 

§495.102(d)(4)(iii) for eligible professionals and the April 1st deadline under 

§412.64(d)(4)(ii)(B) for eligible hospitals. For eligible professionals, the new amendment to 

§495.102(d)(4)(iii) will include, following the July 1st hardship exception application submission 

deadline specified in the regulation, language that would enable CMS to specify a later deadline. 

For eligible hospitals, the new amendment to §412.64(d)(4)(ii)(B) will include, following the 

April 1st hardship exception application submission deadline specified in the regulation, language 

that would enable CMS to specify a later deadline. We are making these regulatory amendments 

under this IFC to allow eligible hospitals and eligible professionals to take advantage of the 

extreme and uncontrollable circumstances hardship exception outlined under this IFC. Without 

such changes, eligible hospitals and eligible professionals would be unable to apply for this 

hardship exception because the application deadlines have already passed. 

Finally, we note that, as with the circumstances described in this IFC that caused us to 

extend the deadline to November 30, 2014, there may be situations in the future that would 

warrant extending the July 1st deadline for eligible professionals, the April 1st deadline for 

eligible hospitals, and the November 30th deadline for CAHs. Accordingly, to ensure that we do 

not face similar timing constraints in the future and to reduce administrative burden on providers 

who wish to request a hardship exception, we are amending the regulation text for the other 

hardship exception categories to enable CMS to specify a later deadline for submission of 

hardship exception applications. 
CMS-1612-FC 1080

Specifically, for eligible professionals, in addition to the amendments we cited above for 

§495.102(d)(4)(iii) relating to the extreme and uncontrollable circumstances hardship exception 

category, we are also amending §495.102(d)(4)(i) (insufficient internet access) and (d)(4)(iv) 

(multiple locations/lack of face-to-face encounters and need for follow-up/certain primary 

specialties) to add similar language. 

 For eligible hospitals, in addition to the amendments we cited above for 

§412.64(d)(4)(ii)(B) relating to the extreme and uncontrollable circumstances hardship exception 

category, we are also amending §412.64(d)(4)(ii)(A) (lack of internet access) to add similar 

language. 

For CAHs, we are amending §413.70(a)(6)(ii) to add language similar to the language 

added to the regulation text for eligible professionals and eligible hospitals, as discussed above. 

We believe that the flexibility to specify a later hardship exception application submission 

deadline as set forth above will prevent situations such as the one addressed under this IFC 

where, for example, an unforeseen circumstance occurred, which could justify a hardship 

exception, but the hardship exception application submission deadline has passed. However, we 

emphasize that we do not intend to exercise this flexibility to extend the hardship exception 

application submission deadline frequently. Rather, to maintain the consistency needed for our 

operations, providers should expect to adhere to the dates specified in the regulation text and not 

rely on the possibility of changes to the hardship application submission period occurring on a 

frequent basis.
CMS-1612-FC 1081

IV. Collection of Information Requirements 

 Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in 

the Federal Register and solicit public comment before a collection of information requirement 

is submitted to the Office of Management and Budget (OMB) for review and approval. To fairly 

evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) 

of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following 

issues: 

● The need for the information collection and its usefulness in carrying out the proper 

functions of our agency. 

● The accuracy of our estimate of the information collection burden. 

● The quality, utility, and clarity of the information to be collected. 

● Recommendations to minimize the information collection burden on the affected 

public, including automated collection techniques. 

Unless noted otherwise, we used data from the U.S. Bureau of Labor Statistics for all 

salary estimates. The estimates include the cost of fringe benefits, calculated at 35 percent of 

salary, which is based on the Bureau’s June 2012 Employer Costs for Employee Compensation 

report. 

 In the CY 2015 PFS proposed rule (79 FR 40317), we solicited public comment on each 

of the section 3506(c)(2)(A)-required issues for the following information collection 

requirements (ICRs). 

A. Information Collection Requirements (ICRs) 

1. ICRs Regarding the Removal of Employment Requirements for Services Furnished Incident 

to Rural Health Clinics and Federally Qualified Health Center Visits 
CMS-1612-FC 1082

This provision removes the requirement that nonphysician RHC or FQHC practitioners 

be W-2 employees. This action does not require the modification of existing contracts or the 

creation of new contracts, nor does CMS collect any information on contracting. Consequently, 

the provision is not subject to the requirements under the Paperwork Reduction Act of 1995 (44 

U.S.C. 3501 et seq.). 

2. ICRs Regarding Access to Identifiable Data for the Center for Medicare and Medicaid 

Models 

This provision concerns the evaluation of models tested under, section 1115A of the Act. 

Section 1115(A)(d)(3) of the Act provides that the Paperwork Reduction Act (44 U.S.C. 3501 et 

seq.) shall not apply to the testing, evaluation or expansion of models under section 1115A of the 

Act. 

3. ICRs Regarding Local Coverage Determination Process for Clinical Diagnostic Laboratory 

Testing 

The proposed Clinical Diagnostic Laboratory LCD Process will not be finalized. 

Consequently, the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) and the LCD 

process do not apply to this final rule. 

4. ICRs Regarding the Solicitation of Comments on the Payment Policy for Substitute Physician 

Billing Arrangements 

The proposed rule solicited comment on substitute billing arrangements and did not set 

out any new or revised collection of information requirements. Consequently, the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501 et seq.) is not applicable. 

5. ICRs Regarding Reports of Payments or Other Transfers of Value and Physician Ownership 

and Investment Interests (§ 403.904(c)(8), (d)(3), and (g)) 
CMS-1612-FC 1083

With regard to the following provisions, no PRA-related comments were received. The 

proposed provisions are being adopted without change. 

In §403.904(c)(8), applicable manufacturers and applicable group purchasing 

organizations (GPOs) must report the marketed name and therapeutic area or product category of 

covered drugs, devices, biologicals and medical supplies. The amendment has non-measurable 

effect on current burden estimates since the manufacturers and GPOs are already required to 

report the marketed name for drugs and biologicals and report the marketed name, therapeutic 

area, or product category for devices and medical supplies. While the requirement has no burden 

implications, the provision will be submitted to OMB for approval under control number 0938-

1173 (CMS-10419). 

In §403.904(d)(3), applicable manufacturers and applicable GPOs must report the form 

of payment or other transfers of value as: cash or cash equivalent, in-kind items or services, 

stock, stock option, or any other ownership investment. The burden associated with this 

provision is the time and effort it will take each applicable manufacturer and applicable GPO to 

revise their reporting system to report the form of payment. 

The removal of §403.904(g) requires that applicable manufacturers and applicable GPOs 

of covered drugs, devices, biologicals, and medical supplies report annually to CMS all 

payments or other transfers of value provided as compensation for speaking at a continuing 

education program. The ongoing burden associated with this provision is the time and effort it 

will take each applicable manufacturer and applicable GPO to report payments or other transfers 

of value to CMS which were provided to physicians at a continuing education program. We 

estimate that it will take 1.0 hour to report payments or other transfers of value to CMS which 

were provided to physician at a continuing education program. 
CMS-1612-FC 1084

We estimate that it will take 1.0 hour to report payments or other transfers of value to 

CMS which were provided to physician covered recipients as compensation for speaking at a 

continuing education program and 0.5 hours to revise an applicable manufacturer or applicable 

GPO’s reporting system to report the form of payment. 

In deriving these figures, we used the following hourly labor rates and estimated the time 

to complete each task: $26.39/hr and 1.0 hours for support staff to report payments or other 

transfers of value to CMS which were provided to physician covered recipients as compensation 

for speaking at a continuing education program and $4+7.55/hr and 0.5 hours for support to 

revise their reporting system to report the form of payment. 

The preceding requirements and burden estimates will be added to the existing PRArelated requirements and burden estimates that have been approved by OMB under control 

number 0938-1173 (CMS-10419). 

6. ICRs Regarding Physician Payment, Efficiency, and Quality Improvements – Physician 

Quality Reporting System 

With regard to the following provisions, no PRA-related comments were received. The 

proposed provisions are being adopted without change. 

The annual burden estimate is calculated separately for the 2017 PQRS payment 

adjustment (the reporting periods of which occur in 2015): (1) individual eligible professionals 

and group practices using the claims (for eligible professionals only), (2) qualified registry and 

QCDR, (3) EHR-based reporting mechanisms, and (4) group practices using the group practice 

reporting option (GPRO). Please note that we are grouping group practices using the qualified 

registry and EHR-based reporting mechanisms with the burden estimate for individual eligible 

professionals using the qualified registry and EHR-based reporting mechanisms because we 

believe the criteria for satisfactory reporting for group practices using these 2 reporting 
CMS-1612-FC 1085

mechanisms under the GPRO are similar to the satisfactory reporting criteria for eligible 

professionals using these reporting mechanisms. 

a. Burden Estimate for PQRS Reporting by Individual Eligible Professionals: Reporting in 

General 

According to the 2012 Reporting Experience, “more than 1.2 million eligible 

professionals were eligible to participate in the 2012 PQRS, Medicare Shared Savings Program, 

and Pioneer ACO Model.”31 In this burden estimate, we assume that 1.2 million eligible 

professionals, the same number of eligible professionals eligible to participate in the PQRS in 

2012, will be eligible to participate in the PQRS. Historically, the PQRS has never experienced 

100 percent participation in reporting for the PQRS. Therefore, we believe that although 1.2 

million eligible professionals will be subject to the 2017 PQRS payment adjustment, not all 

eligible participants will report quality measures data for purposes of the 2017 PQRS payment 

adjustment. In this burden estimate, we will only provide burden estimates for the eligible 

professionals and group practices who attempt to submit quality measures data for purposes of 

the 2017 PQRS payment adjustment. 

In 2012, 435,871 eligible professionals (36 percent of eligible professionals, including 

those who belonged to group practices that reported under the GPRO and eligible professionals 

within an ACO that participated in the PQRS via the Shared Savings Program or Pioneer ACO 

model) participated in the PQRS, Medicare Shared Savings Program, or Pioneer ACO Model.32

 

We expect to see a significant increase in participation in reporting for the PQRS in 2015 than 

2012 as eligible professionals were not subject to a PQRS payment adjustment in 2012. Last 

year, we estimated that we would see a 50 percent participation rate in 2015. We still believe 

 

31 Centers for Medicare and Medicaid Services, 2012 Reporting Experience Including Trends (2007—2013): 

Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program, March 14, 2014, at xiii. 32 Id. at XV. 
CMS-1612-FC 1086

that a 14 percent increase in participation from 2012 is reasonable in 2015. Therefore, we 

estimate that 50 percent of eligible professionals (or approximately 600,000 eligible 

professionals) will report quality measures data for purposes of the 2017 PQRS payment 

adjustment. 

With respect to the PQRS, the burden associated with the requirements of this voluntary 

reporting initiative is the time and effort associated with individual eligible professionals 

identifying applicable quality measures for which they can report the necessary information, 

selecting a reporting option, and reporting the information on their selected measures or 

measures group to CMS using their selected reporting option. 

We believe the labor associated with eligible professionals and group practices reporting 

quality measures data in the PQRS is primarily handled by an eligible professional’s or group 

practice’s billing clerk or computer analyst trained to report quality measures data. Therefore, 

we will consider the hourly wage of a billing clerk and computer analyst in our estimates. For 

purposes of this burden estimate, we assume that a billing clerk will handle the administrative 

duties associated with participating in the PQRS. According to information published by the 

Bureau of Labor Statistics, available at http://www.bls.gov/oes/current/oes433021.htm, the mean 

hourly wage for a billing clerk is approximately $32.00/hour. Therefore, for purposes of 

handling administrative duties, we estimate an average labor cost of $32.00/hour. In addition, 

for purposes of this burden estimate, we assume that a computer analyst will engage in the duties 

associated with the reporting of quality measures. According to information published by the 

Bureau of Labor Statistics, available at http://www.bls.gov/oes/current/oes151121.htm, the mean 

hourly wage for a computer analyst is approximately $82.00/hour. Therefore, for purposes of 

reporting on quality measures, we estimate an average labor cost of $82.00/hour. 
CMS-1612-FC 1087

Please note that, in assessing PQRS-specific burden estimates, to account for benefits and 

overhead associated with labor in addition to the hourly wage costs described above, we are 

doubling the wage rates in our estimates. While we accounted for fringe benefits in the NPRM’s 

wage estimates, we did not double the wage rates in those estimates. 

For individual eligible professionals, the burden associated with the requirements of this 

reporting initiative is the time and effort associated with eligible professionals identifying 

applicable quality measures for which they can report the necessary information, collecting the 

necessary information, and reporting the information needed to report the eligible professional’s 

measures. We believe it is difficult to accurately quantify the burden because eligible 

professionals may have different processes for integrating the PQRS into their practice’s work 

flows. Moreover, the time needed for an eligible professional to review the quality measures and 

other information, select measures applicable to his or her patients and the services he or she 

furnishes to them, and incorporate the use of quality data codes into the office work flows is 

expected to vary along with the number of measures that are potentially applicable to a given 

professional’s practice. Since eligible professionals are generally required to report on at least 9 

measures covering at least 3 National Quality Strategy domains criteria for satisfactory reporting 

(or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) for the 2017 PQRS 

payment adjustment, we assume that each eligible professional reports on an average of 9 

measures for this burden analysis. 

For eligible professionals who are participating in PQRS for the first time, we will assign 

5 total hours as the amount of time needed for an eligible professional’s billing clerk to review 

the PQRS measures list, review the various reporting options, select the most appropriate 

reporting option, identify the applicable measures or measures groups for which they can report 

the necessary information, review the measure specifications for the selected measures or 
CMS-1612-FC 1088

measures groups, and incorporate reporting of the selected measures or measures groups into the 

office work flows. The measures list contains the measure title and brief summary information 

for the eligible professional to review. Assuming the eligible professional has received no 

training from his/her specialty society, we estimate it will take an eligible professional’s billing 

clerk up to 2 hours to review this list, review the reporting options, and select a reporting option 

and measures on which to report. If an eligible professional has received training, then we 

believe this would take less time. CMS believes 3 hours is plenty of time for an eligible 

professional to review the measure specifications of 9 measures or 1 measures group they select 

to report for purposes of participating in PQRS and to develop a mechanism for incorporating 

reporting of the selected measures or measures group into the office work flows. Therefore, we 

believe that the start-up cost for an eligible professional to report PQRS quality measures data is 

5 hours x $32/hour = $160. 

We continue to expect the ongoing costs associated with PQRS participation to decline 

based on an eligible professional’s familiarity with and understanding of the PQRS, experience 

with participating in the PQRS, and increased efforts by CMS and stakeholders to disseminate 

useful educational resources and best practices. 

We believe the burden associated with reporting the quality measures will vary 

depending on the reporting mechanism selected by the eligible professional. As such, we break 

down the burden estimates by eligible professionals and group practices participating in the 

GPRO according to the reporting mechanism used. 

b. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Claims-Based Reporting Mechanism 

According to the 2011 PQRS and eRx Experience Report, in 2011, 229,282 of the 

320,422 eligible professionals (or 72 percent) of eligible professionals used the claims-based 
CMS-1612-FC 1089

reporting mechanism. According to the 2012 Reporting Experience, 248,206 eligible 

professionals participated in the PQRS using the claims-based reporting mechanism in 2012.33

 

Preliminary estimates show that 252,567 eligible professionals participated in the PQRS using 

the claims-based reporting mechanism in 2013.34

According to the historical data cited above, while the claims-based reporting mechanism 

is still the most widely-used reporting mechanism, we are seeing a decline in the use of the 

claims-based reporting mechanism in the PQRS. While these eligible professionals continue to 

participate in the PQRS, these eligible professionals have started to shift towards the use of other 

reporting mechanisms – mainly the GPRO web interface (whether used by a PQRS GPRO or an 

ACO participating in the PQRS via the Medicare Shared Savings Program or the Pioneer ACO 

Model), registry, or the EHR-based reporting mechanisms. For purposes of this burden estimate, 

based on PQRS participation using the claims-based reporting mechanism in 2012 and 2013, we 

assume that approximately 250,000 eligible professionals will participate in the PQRS using the 

claims-based reporting mechanism. 

For the claims based reporting option, eligible professionals must gather the required 

information, select the appropriate quality data codes (QDCs), and include the appropriate QDCs 

on the claims they submit for payment. The PQRS will collect QDCs as additional (optional) 

line items on the existing HIPAA transaction 837 P and/or CMS form CMS-1500 (OMB control 

number 0938-0999). We do not anticipate any new forms and or any modifications to the 

existing transaction or form. We also do not anticipate changes to the 837 P or CMS-1500 for 

CY 2015. 

 

33 Id. at xvi. See Figure 4. 34 Id. 
CMS-1612-FC 1090

We estimate the cost for an eligible professional to review the list of quality measures or 

measures groups, identify the applicable measures or measures groups for which they can report 

the necessary information, incorporate reporting of the selected measures into the office work 

flows, and select a PQRS reporting option to be approximately $410 per eligible professional 

($82 per hour x 5 hours). 

Based on our experience with the Physician Voluntary Reporting Program (PVRP), we 

continue to estimate that the time needed to perform all the steps necessary to report each 

measure (that is, reporting the relevant quality data code(s) for 9 measures measure) would range 

from 15 seconds (0.25 minutes) to over 12 minutes for complicated cases and/or measures, with 

the median time being 1.75 minutes. To report 9 measures, we estimate that it will take 

approximately 2.25 minutes to 108 minutes to perform all of the necessary reporting steps. 

Per measure, at an average labor cost of $82/hour per practice, the cost associated with 

this burden will range from $0.34 to about $16.40 for more complicated cases and/or measures, 

with the cost for the median practice being $2.40. To report 9 measures, using an average labor 

cost of $82/hour, we estimated that the cost of reporting for an eligible professional via claims 

will range from $3.07 (2.25 minutes or 0.0375 hours x $82/hour) to $147.60 (108 minutes or 1.8 

hours x $82/hour) per reported case. 

The total estimated annual burden for this requirement will also vary along with the 

volume of claims on which quality data is reported. In previous years, when we required 

reporting on 80 percent of eligible cases for claims based reporting, we found that on average, 

the median number of reporting instances for each of the PQRS measures was 9. Since we 

reduced the required reporting rate by over one third to 50 percent, then for purposes of this 

burden analysis we assume that an eligible professional or eligible professional in a group 

practice will need to report each selected measure for 6 reporting instances. The actual number 
CMS-1612-FC 1091

of cases on which an eligible professional or group practice is required to report quality measures 

data will vary, however, with the eligible professional's or group practice’s patient population 

and the types of measures on which the eligible professional or group practice chooses to report 

(each measure's specifications includes a required reporting frequency). 

Based on these assumptions, we estimate that the total annual reporting burden per 

individual eligible professional associated with claims based reporting will range from 13.5 

minutes (0.25 minutes per measure x 9 measures x 6 cases per measure) to 648 minutes (12 

minutes per measure x 9 measures x 6 cases per measure), with the burden to the median practice 

being 94.5 minutes (1.75 minutes per measure x 9 measures x 6 cases). We estimate the total 

annual reporting cost per eligible professional or eligible professional in a group practice 

associated with claims based reporting will range from $18.36 ($0.34 per measure x 9 measures 

x 6 cases per measure) to $885.60 ($16.40 per measure x 9 measures x 6 cases per measure), 

with the cost to the median practice being $129.60 per eligible professional ($2.40 per measure x 

9 measures x 6 cases per measure). 

c. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Qualified Registry-based and QCDR-based Reporting Mechanisms 

In 2011, approximately 50,215 (or 16 percent) of the 320,422 eligible professionals 

participating in PQRS used the qualified registry-based reporting mechanism. According to the 

2012 Reporting Experience, 36,473 eligible professionals reported individual measures via the 

registry-based reporting mechanism, and 10,478 eligible professionals reporting measures groups 

via the registry-based reporting mechanism in 2012.35 Therefore, approximately 47,000 eligible 

professionals participated in the PQRS using the registry-based reporting mechanism in 2012. 

 

35 Id. at xvi. See Figure 4. 
CMS-1612-FC 1092

Please note that we currently have no data on participation in the PQRS via a QCDR as 2014 is 

the first year in which an eligible professional may participate in the PQRS via a QCDR. 

We believe that the rest of the eligible professionals not participating in other PQRS 

reporting mechanisms will use either the registry or QCDR reporting mechanisms for the 

following reasons: 

● The PQRS measures set is moving away from use of claims-based measures and 

moving towards the use of registry-based measures. 

● We believe the number of QCDR vendors will increase as the QCDR reporting 

mechanism evolves. 

Therefore, based on these assumptions, we expect to see a significant jump from 47,000 

eligible professionals to approximately 165,000 eligible professionals using either the registrybased reporting mechanism or QCDR in 2015. We believe the majority of these eligible 

professionals will participate in the PQRS using a QCDR, as we presume QCDRs will be larger 

entities with more members. 

For qualified registry based and QCDR-based reporting, there will be no additional time 

burden for eligible professionals or group practices to report data to a qualified registry as 

eligible professionals and group practices opting for qualified registry based reporting or use of a 

QCDR will more than likely already be reporting data to the qualified registry for other purposes 

and the qualified registry will merely be repackaging the data for use in the PQRS. Little, if any, 

additional data will need to be reported to the qualified registry or QCDR solely for purposes of 

participation in the PQRS. However, eligible professionals and group practices will need to 

authorize or instruct the qualified registry or QCDR to submit quality measures results and 

numerator and denominator data on quality measures to CMS on their behalf. We estimate that 
CMS-1612-FC 1093

the time and effort associated with this will be approximately 5 minutes per eligible professional 

or eligible professional within a group practice. 

Please note that, unlike the claims-based reporting mechanism that would require an 

eligible professional to report data to CMS on quality measures on multiple occasions, an 

eligible professional would not be required to submit this data to CMS, as the qualified registry 

or QCDR would perform this function on the eligible professional’s behalf. 

d. Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: EHR-Based Reporting Mechanism 

According to the 2011 PQRS and eRx Experience Report, in 2011, 560 (or less than 1 

percent) of the 320,422 eligible professionals participating in PQRS used the EHR-based 

reporting mechanism. In 2012 there was a sharp increase in reporting via the EHR-based 

reporting mechanism. Specifically, according to the 2012 Reporting Experience, in 2012, 19,817 

eligible professionals submitted quality data for the PQRS through a qualified EHR.36

 

We believe the number of eligible professionals and group practices using the EHR-based 

reporting mechanism will steadily increase as eligible professionals become more familiar with 

EHR products and more eligible professionals participate in programs encouraging the use of an 

EHR, such as the EHR Incentive Program. In particular, we believe eligible professionals will 

transition from using the claims-based to the EHR-based reporting mechanism. To account for 

this anticipated increase, we continue to estimate that approximately 50,000 eligible 

professionals, whether participating as an individual or part of a group practice under the GPRO, 

would use the EHR-based reporting mechanism in CY 2015. 

 

36 Id. at xv. 
CMS-1612-FC 1094

For EHR-based reporting, which includes EHR reporting via a direct EHR product and an 

EHR data submission vendor’s product, the eligible professional or group practice must review 

the quality measures on which we will be accepting PQRS data extracted from EHRs, select the 

appropriate quality measures, extract the necessary clinical data from his or her EHR, and submit 

the necessary data to the CMS-designated clinical data warehouse. 

For EHR based reporting for the PQRS, the individual eligible professional or group 

practice may either submit the quality measures data directly to CMS from their EHR or utilize 

an EHR data submission vendor to submit the data to CMS on the eligible professional’s or 

group practice’s behalf. To submit data to CMS directly from their EHR, the eligible 

professional or eligible professional in a group practice must have access to a CMS specified 

identity management system, such as IACS, which we believe takes less than 1 hour to obtain. 

Once an eligible professional or eligible professional in a group practice has an account for this 

CMS specified identity management system, he or she will need to extract the necessary clinical 

data from his or her EHR, and submit the necessary data to the CMS designated clinical data 

warehouse. With respect to submitting the actual data file for the respective reporting period, we 

believe that this will take an eligible professional or group practice no more than 2 hours, 

depending on the number of patients on which the eligible professional or group practice is 

submitting. We believe that once the EHR is programmed by the vendor to allow data 

submission to CMS, the burden to the eligible professional or group practice associated with 

submission of data on quality measures should be minimal as all of the information required to 

report the measure should already reside in the eligible professional's or group practice’s EHR. 

e. Burden Estimate for PQRS Reporting by Group Practices Using the GPRO Web Interface 

As we noted in last year’s estimate, according to the 2011 Experience Report, 

approximately 200 group practices participated in the GPRO in 2011. According to the 2012 
CMS-1612-FC 1095

Reporting Experience, 66 practices participated in the PQRS GPRO.37 In addition, 144 ACOs 

participated in the PQRS GPRO through either the Medicare Shared Savings Program (112 

ACOs) or Pioneer ACO Model (32 practices).38 These group practices encompass 134,510 

eligible professionals (or approximately 140,000 eligible professionals).39 Since it seems that 

roughly 200 group practices participated in the GPRO in 2011 and 2012, based on these 

numbers, we assume that 200 group practices (accounting for approximately 135,000 eligible 

professionals) will participate in the PQRS using the GPRO web interface in 2015. 

With respect to the process for group practices to be treated as satisfactorily submitting 

quality measures data under the PQRS, group practices interested in participating in the PQRS 

through the GPRO must complete a self-nomination process similar to the self-nomination 

process required of qualified registries. However, since a group practice using the GPRO web 

interface would not need to determine which measures to report under PQRS, we believe that the 

self-nomination process is handled by a group practice’s administrative staff. Therefore, we 

estimate that the self-nomination process for the group practices for the PQRS involves 

approximately 2 hours per group practice to review the PQRS GPRO and make the decision to 

participate as a group rather than individually and an additional 2 hours per group practice to 

draft the letter of intent for self-nomination, gather the requested TIN and NPI information, and 

provide this requested information. It is estimated that each self-nominated entity will also 

spend 2 hours undergoing the vetting process with CMS officials. We assume that the group 

practice staff involved in the group practice self-nomination process has an average practice 

labor cost of $32 per hour. Therefore, assuming the total burden hours per group practice 

associated with the group practice self-nomination process is 6 hours, we estimate the total cost 

 

37 Id. at xv. 38 Id. at xvi. 39 Id. at 18. 
CMS-1612-FC 1096

to a group practice associated with the group practice self-nomination process to be 

approximately $192 ($32 per hour x 6 hours per group practice). 

The burden associated with the group practice reporting requirements under the GPRO is 

the time and effort associated with the group practice submitting the quality measures data. For 

physician group practices, this would be the time associated with the physician group completing 

the web interface. We estimate that the time and effort associated with using the GPRO web 

interface will be comparable to the time and effort associated to using the PAT. As stated above, 

the information collection components of the PAT have been reviewed by OMB and are 

approved under control number 0938-0941(form CMS-10136) with an expiration date of July 31, 

2015, for use in the PGP, MCMP, and EHR demonstrations. As the GPRO was only recently 

implemented in 2010, it is difficult to determine the time and effort associated with the group 

practice submitting the quality measures data. As such, we will use the same burden estimate for 

group practices participating in the GPRO as we use for group practices participating in the PGP, 

MCMP, and EHR demonstrations. Since these changes will not have any impact on the 

information collection requirements associated with the PAT and we will be using the same data 

submission process used in the PGP demonstration, we estimate that the burden associated with a 

group practice completing data for PQRS under the web interface will be the same as for the 

group practice to complete the PAT for the PGP demonstration. In other words, we estimate 

that, on average, it will take each group practice 79 hours to submit quality measures data via the 

GPRO web interface at a cost of $82 per hour. Therefore, the total estimated annual cost per 

group practice is estimated to be approximately $6,478. 

7. ICRs Regarding the Medicare Shared Savings Program 
CMS-1612-FC 1097

Section 3022 of the Affordable Care Act exempts any collection of information 

associated with the Medicare Shared Savings Program from the requirements of the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

8. ICRs Regarding Interim Revisions to the Electronic Health Record (EHR) Incentive Program 

This rule does not impose new or alter existing reporting, recordkeeping, or third-party 

disclosure requirements. Consequently, it need not be reviewed by OMB under the authority of 

the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

9. ICRs Regarding the Extreme and Uncontrollable Circumstances Hardship Exception 

With regard to the hardship application, this rule will not impose any new or revised 

reporting, recordkeeping, or third-party disclosure requirements and therefore, does not require 

additional OMB review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 

3501 et seq.). The application’s information collection requirements and burden have been 

approved by OMB under OMB control number 0938-1158 (CMS-10336). 

B. Summary of Final Burden Estimates 

 Table 92 summarizes this rule’s requirements and burden estimates. 

 
CMS-1612-FC 1098

TABLE 92: Annual Recordkeeping and Reporting Requirements and Burden 

Regulation 

Section(s) 

OMB 

& 

CMS 

ID #s Respondents 

Responses 

(total) 

Burden 

(time) per 

Response 

Total 

Annual 

Burden 

(hours) 

Labor Cost 

of Reporting 

($/hr) 

Total Cost 

($) 

403.904(d)(3) 0938-

1173 

(CMS10419 

1,150 

(manufacturers) 

1,150 1.0 hr 

(reporting) 

1,150 26.39 30,349 

0.5 hr 

(system 

upgrades) 

575 47.55 27,341 

420 (GPOs) 

420 1.0 hr 

(reporting) 

420 26.39 11,084 

0.5 hr 

(system 

upgrades) 

210 47.55 9,986 

CY 2015 

PQRS (start 

up for first 

time 

participants) 

0938-

1059 

(CMS10276) 

164,000 164,000 5 hr 820,000 16.00 13,120,000 

CY 2015 

PQRS 

(ClaimsBased 

Reporting 

Mechanism) 

0938-

1059 

(CMS10276) 

250,000 250,000 

(preparation 

and 

reporting) 

5.2241 1,306,025 82.00 107,090,000 

CY 2015 

PQRS 

(Qualified 

Registrybased and 

QCDR-based 

Reporting 

Mechanisms) 

0938-

1059 

(CMS10276) 

165,000 165,000 5 min 13,750 N/A* N/A 

CY 2015 

PQRS (EHRBased 

Reporting 

Mechanism) 

0938-

1059 

(CMS10276) 

50,000 50,000 N/A** N/A N/A N/A 

CY 2015 

PQRS 

(Group 

Practices 

Using the 

GPRO Web 

Interface) 

0938-

1059 

(CMS10276) 

200 200 (selfnomination 

process) 

6 hr 17,000 192.00 1,334,000 

200 

(reporting) 

79 hr 

TOTAL 630,770 14,130,970 -- 2,159,130 -- 121,622,760 

*There is no set cost. As explained above, the cost will vary depending on the registry used. Additionally, many 

EPs and group practices using a registry or QCDR will most likely use a registry or QCDR for other purposes. 

**As explained above, the burden associated with the submission of data is minimal. 

C. Submission of PRA-Related Comments 
CMS-1612-FC 1099

 We have submitted a copy of this rule to OMB for its review of the rule’s information 

collection and recordkeeping requirements. These requirements are not effective until they have 

been approved by OMB. 

 To obtain copies of the supporting statement and any related forms for the paperwork 

collections referenced above, access CMS’ website at 

http://www.cms.hhs.gov/PaperworkReductionActof1995; email your request, including your 

address, phone number, OMB number, and CMS document identifier, to 

Paperwork@cms.hhs.gov; or call the Reports Clearance Office at 410–786–1326. 

 When commenting on the stated information collections, please reference the document 

identifier or OMB control number. To be assured consideration, comments and 

recommendations must be received by the OMB desk officer via one of the following 

transmissions: 

 Mail: OMB, Office of Information and Regulatory Affairs 

 Attention: CMS Desk Officer 

 Fax: (202) 395-5806 OR 

 E-mail: OIRA_submission@omb.eop.gov. 

 PRA-specific comments must be received by December 1, 2014[. 

V. 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 
CMS-1612-FC 1100

preamble, and, when we proceed with a subsequent document, we will respond to the comments 

in the preamble to that document. 
CMS-1612-FC 1101

VI. Waiver of Proposed Rulemaking and Waiver of Delay in Effective Date 

A. PFS provisions 

We ordinarily publish a notice of proposed rulemaking in the Federal Register and 

invite public comment on the proposed rule. The notice of proposed rulemaking includes a 

reference to the legal authority under which the rule is proposed, and the terms and substance of 

the proposed rule or a description of the subjects and issues involved. This procedure can be 

waived, however, if an agency finds good cause that a notice-and-comment procedure is 

impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the 

finding and its reasons in the rule issued. 

We utilize HCPCS codes for Medicare payment purposes. The HCPCS is a national 

coding system comprised of Level I (CPT) codes and Level II (HCPCS National Codes) that are 

intended to provide uniformity to coding procedures, services, and supplies across all types of 

medical providers and suppliers. Level I (CPT) codes are copyrighted by the AMA and consist 

of several categories, including Category I codes which are 5-digit numeric codes, and Category 

III codes which are temporary codes to track emerging technology, services, and procedures. 

The AMA issues an annual update of the CPT code set each Fall, with January 1 as the effective 

date for implementing the updated CPT codes. The HCPCS, including both Level I and Level II 

codes, is similarly updated annually on a CY basis. Annual coding changes are not available to 

the public until the Fall immediately preceding the annual January update of the PFS. Because 

of the timing of the release of these new and revised codes, it is impracticable for us to provide 

prior notice and solicit comment on these codes and the RVUs assigned to them in advance of 

publication of the final rule that implements the PFS. Yet, it is imperative that these coding 

changes be accounted for and recognized timely under the PFS for payment because services 

represented by these codes will be furnished to Medicare beneficiaries by physicians and 
CMS-1612-FC 1102

practitioners during the CY in which they become effective. Moreover, regulations 

implementing HIPAA (42 CFR parts 160 and 162) require that the HCPCS be used to report 

health care services, including services paid under the PFS. We assign interim RVUs to any new 

and revised codes based on a review of the RUC recommendations for valuing these services. 

We also assign interim RVUs to certain codes for which we did not receive specific RUC 

recommendations, but that are components of new combined codes. We set interim RVUs for 

the component codes in order to conform them to the value of the combined code. Finally, we 

assign interim RVUs to certain codes for which we received RUC recommendations for only one 

component (work or PE) but not both. By reviewing these RUC recommendations for the new 

and revised codes, we are able to assign RVUs to services based on input from the medical 

community and to establish payment for them, on an interim basis, that corresponds to the 

relative resources associated with furnishing the services. We are also able to determine, on an 

interim final basis, whether the codes will be subject to other payment policies. If we did not 

assign RVUs to new and revised codes on an interim basis, the alternative would be to either not 

pay for these services during the initial CY or have each Medicare contractor establish a payment 

rate for these new codes. We believe both of these alternatives are contrary to the public interest, 

particularly since the RUC process allows for an assessment of the valuation of these services by 

the medical community prior to our establishing payment for these codes on an interim basis. 

Therefore, we believe it would be contrary to the public interest to delay establishment of fee 

schedule payment amounts for these codes until notice and comment procedures could be 

completed. 

This final rule with comment period revises the process we will use to address new, 

revised in order to minimize the need to establish RVUs on an interim final basis beginning with 

rulemaking for CY 2017. However, for the reasons previously outlined in this section, we find 
CMS-1612-FC 1103

good cause to waive the notice of proposed rulemaking for the interim RVUs for selected 

procedure codes identified in Addendum C and to establish RVUs for these codes on an interim 

final basis for CY 2015. We are providing a 60-day public comment period. 

Section II.E. of this final rule with comment period discusses our review and decisions 

regarding the RUC recommendations. Similar to the RUC recommendations for new and revised 

codes previously discussed, due to the timing of the RUC recommendations for the services 

identified as potentially misvalued codes, it is impracticable for CMS to provide for notice and 

comment regarding specific revisions prior to publication of this final rule with comment period. 

We believe it is in the public interest to implement the revised RVUs for the codes that were 

identified as misvalued, and that have been reviewed and re-evaluated by the RUC, on an interim 

final basis for CY 2015. The revised RVUs for these codes will establish a more appropriate 

payment that better corresponds to the relative resources involved in furnishing these services. A 

delay in implementing revised values for these misvalued codes would not only perpetuate the 

known misvaluation for these services, it would also perpetuate distortion in the payment for 

other services under the PFS. Implementing the changes on an interim basis allows for a 

more equitable resource-based distribution of payments across all PFS services. We believe a 

delay in implementation of these revisions would be contrary to the public interest, particularly 

since the RUC process allows for an assessment of the valuation of these services by the medical 

community prior to the RUC’s recommendation to CMS. This final rule with comment period 

revises the process we will use to address misvalued codes in order to minimize the need to 

establish RVUs on an interim final basis beginning with rulemaking for CY 2017. However, for 

the reasons previously described, we find good cause to waive notice and comment procedures 

with respect to the misvalued codes and to revise RVUs for these codes on an interim final basis 

for CY 2015. We are providing a 60-day public comment period. 
CMS-1612-FC 1104

B. FQHC PPS Rates and Adjustments 

We ordinarily publish a notice of proposed rulemaking in the Federal Register and invite 

public comment on the proposed rule before publishing a final rule that responds to comments 

and sets forth final regulations that generally take effect at least 30 days later. This procedure 

can be waived, however, if an agency finds good cause that a notice-and-comment procedure is 

impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the 

finding and its reasons in the rule issued. 

In the May 2, 2014, interim final rule (79 FR 25462), we updated §405.2411(b)(2) so that 

it reflects section 1888(e)(2)(A)(iv) of the Act (as amended by section 410 of the MMA), which 

excludes certain RHC and FQHC practitioner services from consolidated billing and allows such 

services to be separately billable under Part B when furnished to a resident of a SNF during a 

covered Part A stay. 

However, in making this revision, we inadvertently neglected to make a conforming 

change in §411.15(p)(2), which enumerates the individual services that are excluded from the 

SNF consolidated billing provision, as well as in §489.20(s), which specifies compliance with 

consolidated billing as a requirement of the SNF’s Medicare provider agreement. Accordingly, 

we are now rectifying that omission in this final rule with comment period, by making a 

conforming technical revision in §411.15(p)(2) and §489.20(s). 

 These particular revisions merely provide technical corrections to the regulations, 

without making any substantive changes. Therefore, for good cause, we waive notice and 

comment procedures for the revisions to the regulations text in parts 411 and 489. 

C. Interim Final Revisions to the Electronic Health Record (EHR) Incentive Program 

We ordinarily publish a notice of proposed rulemaking in the Federal Register and 

invite public comment on the proposed rule. The notice of proposed rulemaking includes a 
CMS-1612-FC 1105

reference to the legal authority under which the rule is proposed, and the terms and substance of 

the proposed rule or a description of the subjects and issues involved. This procedure can be 

waived, however, if an agency finds good cause that a notice-and-comment procedure is 

impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the 

finding and its reasons in the rule issued. 

 With regard to the interim revisions to the Electronic Health Record (EHR) 

Incentive Program, we find good cause to waive the notice-and-comment procedure as contrary 

to the public interest. We believe that providing notice and a comment period would prevent us 

from providing relief from the circumstances outlined in section III.Q. A delay would interfere 

with the ability of eligible professionals and eligible hospitals to request a hardship exception for 

the extreme and uncontrollable circumstances specified under this IFC given that the hardship 

applications deadlines have since passed for both eligible professionals and eligible hospitals. 

Any delay to this IFC would potentially subject providers to the 2015 payment adjustment under 

the Medicare EHR Incentive Program and potentially decrease participation in the EHR 

Incentive Programs, thereby creating a negative impact to the forward movement of the EHR 

Incentive Programs. For these reasons, we find good cause to waive the notice of proposed 

rulemaking for these revisions to the EHR Incentive Program and to establish these revisions on 

an interim final basis. We are providing a 60-day public comment period. 

 We ordinarily provide a 60-day delay in the effective date of final rules after the date 

they are issued. The 60-day delay in effective date can be waived, however, if the agency finds 

for good cause that the delay is impracticable, unnecessary, or contrary to the public interest, and 

the agency incorporates a statement of the findings and its reasons in the rule issued. The 

delayed effective date may also be waived in the case of a substantive rule which grants or 

recognizes an exemption or relieves a restriction. For the reasons set forth below, we believe it 
CMS-1612-FC 1106

would be contrary to the public interest to delay the effective date of the interim final revisions to 

the EHR Incentive Program described in section III.Q of this final rule with comment period We 

also believe these interim final revisions relieve a restriction . 

 The IFC recognizes a hardship exception based on extreme and uncontrollable 

circumstances, which could potentially provide relief from the application of the 2015 payment 

adjustment under the Medicare EHR Incentive Program to certain providers. This IFC would 

also relieve a restriction by amending the existing deadlines in the regulation text for providers to 

apply for hardship exceptions from the payment adjustments. Unless these amendments to the 

deadlines are made effective immediately, eligible hospitals and eligible professionals would not 

have enough time to take advantage of the November 30th extended hardship exception 

application submission period specified in this IFC, given that their hardship exception 

application submission deadlines have since passed. We find good cause to waive the delayed 

effective date of the interim final revisions to the EHR Incentive Program and find that they 

relieve an existing restriction by changing the deadlines by which providers must apply for 

hardship exceptions. These provisions will be effective on [OFR—Insert date of filing for public 

inspection at OFR]. 
CMS-1612-FC 1107

VI. Regulatory Impact Analysis 

A. Statement of Need 

 This final rule with comment period is necessary to make payment and policy changes 

under the Medicare PFS and to make required statutory changes under the Pathway for SGR 

Reform Act of 2013 and the PAMA. This final rule with comment period also is necessary to 

make changes to Part B payment policy for clinical diagnostic lab tests and other Part B related 

policies. This rule also implements aspects of the data collection required under section 

1115A(b)(4) of the Act. 

B. Overall Impact 

We have examined the impact of this rule as required by Executive Order 12866 on 

Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving 

Regulation and Regulatory Review (February 2, 2013), the Regulatory Flexibility Act (RFA) 

(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, section 202 of 

the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 

13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of 

available regulatory alternatives and, if regulation is necessary, to select regulatory approaches 

that maximize net benefits (including potential economic, environmental, public health and 

safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be 

prepared for major rules with economically significant effects ($100 million or more in any 

1 year). We estimate, as discussed below in this section, that the PFS provisions included in this 

final rule with comment period will redistribute more than $100 million in 1 year. Therefore, we 

estimate that this rulemaking is "economically significant" as measured by the $100 million 
CMS-1612-FC 1108

threshold, and hence also a major rule under the Congressional Review Act. Accordingly, we 

have prepared a RIA that, to the best of our ability, presents the costs and benefits of the 

rulemaking. The RFA requires agencies to analyze options for regulatory relief of small entities. 

For purposes of the RFA, small entities include small businesses, nonprofit organizations, and 

small governmental jurisdictions. Most hospitals, practitioners and most other providers and 

suppliers are small entities, either by nonprofit status or by having annual revenues that qualify 

for small business status under the Small Business Administration standards. (For details see the 

SBA's website at http://www.sba.gov/content/table-small-business-size-standards (refer to the 

620000 series)). Individuals and States are not included in the definition of a small entity. 

The RFA requires that we analyze regulatory options for small businesses and other 

entities. We prepare a regulatory flexibility analysis unless we certify that a rule would not have 

a significant economic impact on a substantial number of small entities. The analysis must 

include a justification concerning the reason action is being taken, the kinds and number of small 

entities the rule affects, and an explanation of any meaningful options that achieve the objectives 

with less significant adverse economic impact on the small entities. 

Approximately 95 percent of practitioners, other providers and suppliers are considered 

to be small entities, based upon the SBA standards. There are over 1 million physicians, other 

practitioners, and medical suppliers that receive Medicare payment under the PFS. Because 

many of the affected entities are small entities, the analysis and discussion provided in this 

section as well as elsewhere in this final rule with comment period is intended to comply with 

the RFA requirements. 

In addition, section 1102(b) of the Act requires us to prepare an RIA if a rule may have a 

significant impact on the operations of a substantial number of small rural hospitals. This 
CMS-1612-FC 1109

analysis must conform to the provisions of section 604 of the RFA. For purposes of section 

1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a 

Metropolitan Statistical Area for Medicare payment regulations and has fewer than 100 beds. 

We are not preparing an analysis for section 1102(b) of the Act because we have determined, and 

the Secretary certifies, that this final rule with comment period would not have a significant 

impact on the operations of a substantial number of small rural hospitals. 

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies 

assess anticipated costs and benefits on State, local, or tribal governments or on the private sector 

before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 

dollars, updated annually for inflation. In 2014, that threshold is approximately $141 million. 

This final rule with comment period would impose no mandates on state, local, or tribal 

governments or on the private sector. 

Executive Order 13132 establishes certain requirements that an agency must meet when it 

promulgates a proposed rule (and subsequent final rule) that imposes substantial direct 

requirement costs on State and local governments, preempts State law, or otherwise has 

Federalism implications. Since this regulation does not impose any costs on State or local 

governments, the requirements of Executive Order 13132 are not applicable. 

We have prepared the following analysis, which together with the information provided 

in the rest of this preamble, meets all assessment requirements. The analysis explains the 

rationale for and purposes of this final rule with comment period; details the costs and benefits of 

the rule; analyzes alternatives; and presents the measures we would use to minimize the burden 

on small entities. As indicated elsewhere in this final rule with comment period, we are 

implementing a variety of changes to our regulations, payments, or payment policies to ensure 
CMS-1612-FC 1110

that our payment systems reflect changes in medical practice and the relative value of services, 

and to implement statutory provisions. We provide information for each of the policy changes in 

the relevant sections of this final rule with comment period. We are unaware of any relevant 

federal rules that duplicate, overlap, or conflict with this final rule with comment period. The 

relevant sections of this final rule with comment period contain a description of significant 

alternatives if applicable. 

C. Relative Value Unit (RVU) Impacts 

1. Resource-Based Work, PE, and Malpractice RVUs 

Section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or decreases in RVUs may 

not cause the amount of expenditures for the year to differ by more than $20 million from what 

expenditures would have been in the absence of these changes. If this threshold is exceeded, we 

make adjustments to preserve budget neutrality. 

Our estimates of changes in Medicare revenues for PFS services compare payment rates 

for CY 2014 with payment rates for CY 2015 using CY 2013 Medicare utilization as the basis 

for the comparison. The payment impacts reflect averages for each specialty based on Medicare 

utilization. The payment impact for an individual physician could vary from the average and 

would depend on the mix of services the physician furnishes. The average change in total 

revenues would be less than the impact displayed here because physicians furnish services to 

both Medicare and non-Medicare patients and specialties may receive substantial Medicare 

revenues for services that are not paid under the PFS. For instance, independent laboratories 

receive approximately 83 percent of their Medicare revenues from clinical laboratory services 

that are not paid under the PFS. 

We note that these impacts do not include the effect of the April 2015 conversion factor 
CMS-1612-FC 1111

changes under current law. The annual update to the PFS conversion factor is calculated based 

on a statutory formula that measures actual versus allowed or “target” expenditures, and applies 

a sustainable growth rate (SGR) calculation intended to control growth in aggregate Medicare 

expenditures for physicians’ services. This update methodology is typically referred to as the 

“SGR” methodology, although the SGR is only one component of the formula. Medicare PFS 

payments for services are not withheld if the percentage increase in actual expenditures exceeds 

the SGR. Rather, the PFS update, as specified in section 1848(d)(4) of the Act, is adjusted to 

eventually bring actual expenditures back in line with targets. If actual expenditures exceed 

allowed expenditures, the update is reduced. If actual expenditures are less than allowed 

expenditures, the update is increased. By law, we are required to apply these updates in 

accordance with sections 1848(d) and (f) of the Act, and any negative updates can only be 

averted by an Act of the Congress. Although the Congress has provided temporary relief from 

negative updates for every year since 2003, a long-term solution is critical. We are committed to 

working with the Congress to reform Medicare physician payments to provide predictable 

payments that incentivize quality and efficiency in a fiscally responsible way. We provide our 

most recent estimate of the SGR and physician update for CY 2015 on our website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/. 

Tables 93 shows the payment impact on PFS services. To the extent that there are 

year-to-year changes in the volume and mix of services provided by physicians, the actual 

impact on total Medicare revenues will be different from those shown in Table 93 (CY 2015 PFS 

Final Rule with Comment Period Estimated Impact on Total Allowed Charges by Specialty). 

The following is an explanation of the information represented in Table 93: 
CMS-1612-FC 1112

• Column A (Specialty): The Medicare specialty code as reflected in our 

physician/supplier enrollment files. 

• Column B (Allowed Charges): The aggregate estimated PFS allowed charges for the 

specialty based on CY 2013 utilization and CY 2014 rates. That is, allowed charges are 

the PFS amounts for covered services and include coinsurance and deductibles (which are 

the financial responsibility of the beneficiary). These amounts have been summed across 

all services furnished by physicians, practitioners, and suppliers within a specialty to 

arrive at the total allowed charges for the specialty. 

• Column C (Impact of Work RVU Changes): This column shows the estimated CY 2015 

impact on total allowed charges of the changes in the work RVUs, including the impact 

of changes due to new, revised, and misvalued codes. 

• Column D (Impact of PE RVU Changes): This column shows the estimated CY 2015 

impact on total allowed charges of the changes in the PE RVUs, including the impact of 

changes due to new, revised, and misvalued codes, the film-to-digital migration of 

imaging inputs, and other miscellaneous and minor provisions. 

• Column E (Impact of Malpractice (MP) Changes): This column shows the estimated CY 

2015 impact on total allowed charges of the changes in the MP RVUs, which are 

primarily driven by the required five year review and update of MP RVUs. 

• Column F (Cumulative Impact): This column shows the estimated CY 2015 combined 

impact on total allowed charges of all the changes in the previous columns. Column F 

may not equal the sum of columns C, D, and E due to rounding. 
CMS-1612-FC 1113

TABLE 93: CY 2015 PFS Final Rule with Comment Period Estimated Impact Table: 

Impacts of Work, Practice Expense, and Malpractice RVUs 

(A) 

 Specialty 

(B) 

Allowed 

Charges 

(mil) 

(C) 

Impact 

of Work 

RVU 

Changes

(D) 

Impact 

of PE 

RVU 

Changes

(E) 

Impact 

of MP 

RVU 

Changes 

(F) 

Combined 

Impact 

TOTAL $88,045 0% 0% 0% 0%

ALLERGY/IMMUNOLOGY $216 0% 0% 0% 0%

ANESTHESIOLOGY $1,993 0% 0% 0% 0%

AUDIOLOGIST $60 0% 0% 0% 0%

CARDIAC SURGERY $355 0% 0% -1% -1%

CARDIOLOGY $6,470 0% 0% 0% 0%

CHIROPRACTOR $812 0% 0% -1% -1%

CLINICAL PSYCHOLOGIST $704 0% -1% 0% -1%

CLINICAL SOCIAL WORKER $522 0% -1% 0% -1%

COLON AND RECTAL SURGERY $159 0% 0% 0% 0%

CRITICAL CARE $287 0% 0% 0% 0%

DERMATOLOGY $3,177 0% -1% 0% -2%

DIAGNOSTIC TESTING FACILITY $715 0% -2% 0% -2%

EMERGENCY MEDICINE $3,046 0% 0% 1% 1%

ENDOCRINOLOGY $457 0% 0% 0% 0%

FAMILY PRACTICE $6,107 1% 1% 0% 1%

GASTROENTEROLOGY $1,884 0% 0% 0% 0%

GENERAL PRACTICE $506 0% 0% 0% 0%

GENERAL SURGERY $2,245 0% 0% 0% 0%

GERIATRICS $227 1% 1% 0% 1%

HAND SURGERY $160 0% 0% 0% 0%

HEMATOLOGY/ONCOLOGY $1,811 0% 1% 0% 1%

INDEPENDENT LABORATORY $714 -1% 0% 0% -1%

INFECTIOUS DISEASE $652 0% 0% 0% 1%

INTERNAL MEDICINE $11,123 1% 1% 0% 1%

INTERVENTIONAL PAIN MGMT $678 0% 1% 0% 0%

INTERVENTIONAL RADIOLOGY $273 0% 1% 0% 0%

MULTISPECIALTY 

CLINIC/OTHER PHY $84 0% 0% 0% 0%

NEPHROLOGY $2,181 0% 0% 0% 0%

NEUROLOGY $1,513 0% 0% 0% 0%

NEUROSURGERY $740 0% 0% 1% 1%

NUCLEAR MEDICINE $49 0% 0% 0% 0%

NURSE ANES / ANES ASST $1,186 0% 0% 0% 0%

NURSE PRACTITIONER $2,224 0% 0% 0% 1%

OBSTETRICS/GYNECOLOGY $696 0% 0% 0% -1%

OPHTHALMOLOGY $5,685 0% 0% -2% -2%
CMS-1612-FC 1114

(A) 

 Specialty 

(B) 

Allowed 

Charges 

(mil) 

(C) 

Impact 

of Work 

RVU 

Changes

(D) 

Impact 

of PE 

RVU 

Changes

(E) 

Impact 

of MP 

RVU 

Changes 

(F) 

Combined 

Impact 

OPTOMETRY $1,163 0% 0% -1% -1%

ORAL/MAXILLOFACIAL 

SURGERY $45 0% 0% 0% 0%

ORTHOPEDIC SURGERY $3,672 0% 0% 0% -1%

OTHER $28 0% 0% -1% -1%

OTOLARNGOLOGY $1,174 0% 0% 0% 0%

PATHOLOGY $1,077 -1% 1% 0% 0%

PEDIATRICS $59 0% 0% 0% 0%

PHYSICAL MEDICINE $1,008 0% 0% 0% 0%

PHYSICAL/OCCUPATIONAL 

THERAPY $2,836 0% 0% 1% 1%

PHYSICIAN ASSISTANT $1,565 0% 0% 0% 0%

PLASTIC SURGERY $374 0% 0% -1% 0%

PODIATRY $2,001 0% 0% 0% 0%

PORTABLE X-RAY SUPPLIER $112 0% -2% 0% -2%

PSYCHIATRY $1,352 0% 0% 0% 0%

PULMONARY DISEASE $1,795 0% 0% 0% 0%

RADIATION ONCOLOGY $1,794 0% 0% 0% 0%

RADIATION THERAPY CENTERS $57 0% 0% 0% 1%

RADIOLOGY $4,523 0% -1% 0% -1%

RHEUMATOLOGY $541 0% 0% 0% -1%

THORACIC SURGERY $343 0% 0% -1% -1%

UROLOGY $1,838 0% 0% 0% 0%

VASCULAR SURGERY $978 0% 0% 0% 0%

Note: Table 93 shows only the payment impact on PFS services. These impacts use a constant conversion factor and 

thus do not include the effects of the April 2015 conversion factor change required under current law.

2. CY 2015 PFS Impact Discussion 

a. Work RVU Impacts 

The changes in work RVU impacts are almost entirely attributable to the payment for 

CCM services beginning in CY 2015. We finalized this separately billable CCM service in the 

CY 2014 final rule with comment period, effective beginning in CY 2015 (78 FR 74414 through 

74427). We are finalizing a payment rate for CCM services for CY 2015 (see section II.G. of this 
CMS-1612-FC 1115

final rule with comment period.) Payment for this service is expected to result in modest 

payment increases for family practice, internal medicine, and geriatrics. 

b. PE RVU Impacts 

Payment for CCM services also has a positive impact on the PE RVUs attributable to 

family practice, internal medicine, and geriatrics. The most widespread specialty impacts in PE 

RVUs are generally related implementing the RUC recommendation regarding the film-to-digital 

migration of imaging inputs, which primarily affects portable x-ray suppliers, diagnostic testing 

facilities, and interventional radiology. Other impacts result from adjustments of PE RVUs for 

services as discussed in section II.A. of this final rule with comment period. 

c. MP RVU Impacts 

The changes in MP RVUs are primarily attributable to the changes made as part of the 

statutorily required review of MP RVUs every five years as described in section II.C of this final 

rule with comment period. Of particular note are the impacts on the specialties of ophthalmology 

(-2 percent) and optometry (-1 percent). In the course of preparation of the proposed MP RVUs, 

we discovered that we had made an error in calculating the MP RVUs for ophthalmology codes 

in the last five year review CY that resulted in higher MP RVUs for ophthalmology and 

optometry for CY 2010 than would have resulted had the MP RVUs been calculated correctly. 

The MP RVUs have been at a level higher than they would have been had they been calculated 

correctly since CY 2010. 

d. Combined Impact 

 Column F of Table 93 displays the estimated CY 2015 combined impact on total allowed 

charges by specialty of all the RVU changes. These impacts are estimated prior to the 

application of the negative CF update effective April 1, 2015, applicable under the current 
CMS-1612-FC 1116

statute. 

Table 94 (Impact of Final rule with comment period on CY 2015 Payment for Selected 

Procedures) shows the estimated impact on total payments for selected high volume procedures 

of all of the changes discussed previously. We have included payment rates for the period of 

January 1, 2015 through March 31, 2015, as well as those for April 1, 2015 through December 

31, 2015. We selected these procedures for the sake of illustration from among the most 

commonly furnished by a broad spectrum of specialties. The change in both facility rates and the 

nonfacility rates are shown. For an explanation of facility and nonfacility PE, we refer readers to 

Addendum A of this final rule with comment period. 
CMS-1612-FC 1117

TABLE 94: Impact of Final Rule with Comment Period on CY 2014 Payment for Selected Pr

Facility Non-Fa

CPT/ 

 HCPCS 1

MOD Short Descriptor 

CY 20142

CY 2015 

Jan 1– 

March 313

% Change 

CY 2015 

April 1 – 

December 314

% Change 

CY 20142

CY 2015 

Jan 1– 

March 313

% Change 

11721 Debride nail 6 or more $25.43 $25.42 0% $20.04 -21% $45.14 $45.47 17000 Destruct premalg lesion $53.38 $53.70 1% $42.34 -21% $75.23 $66.95 -127130 Total hip arthroplasty $1,395.30 $1,399.11 0% $1,102.99 -21% NA NA N27244 Treat thigh fracture $1,262.04 $1,270.23 1% $1,001.38 -21% NA NA N27447 Total knee arthroplasty $1,394.58 $1,398.76 0% $1,102.08 -21% NA NA N33533 Cabg arterial single $1,956.28 $1,936.13 -1% $1,526.35 -22% NA NA N35301 Rechanneling of artery $1,200.42 $1,192.90 -1% $940.42 -22% NA NA N43239 Egd biopsy single/multiple $152.25 $152.16 0% $119.95 -21% $405.51 $409.92 66821 After cataract laser $324.55 $315.05 -3% $248.37 -23% $342.47 $333.67 -366984 Cataract surg w/iol 1 stage $673.11 $647.65 -4% $510.57 -24% NA NA N67210 Treatment of retinal lesion $523.37 $506.95 -3% $399.58 -24% $540.92 $524.49 -371010 Chest x-ray 1 view frontal NA NA NA NA NA $24.00 $22.55 -671010 26 Chest x-ray 1 view frontal $9.31 $9.31 0% $7.34 -21% $9.31 $9.31 077056 Mammogram both breasts NA NA NA NA NA $116.07 $116.00 077056 26 Mammogram both breasts $44.42 $44.39 0% $35.00 -21% $44.42 $44.39 077057 Mammogram screening NA NA NA NA NA $82.75 $82.70 077057 26 Mammogram screening $35.82 $35.80 0% $28.22 -21% $35.82 $35.80 077427 Radiation tx management $186.28 $186.17 0% $146.76 -21% $186.28 $186.17 088305 26 Tissue exam by $38.33 $39.02 2% $30.76 -20% $38.33 $39.02 290935 Hemodialysis one $73.44 $73.03 -1% $57.58 -22% NA NA N92012 Eye exam establish patient $54.81 $52.99 -3% $41.77 -24% $87.05 $85.57 -292014 Eye exam&tx estab pt $82.75 $80.55 -3% $63.50 -23% $126.10 $124.23 -93000 Electrocardiogram NA NA NA NA NA $16.84 $17.18 293010 Electrocardiogram report $8.60 $8.59 0% $6.77 -21% $8.60 $8.59 093015 Cardiovascular stress test NA NA NA NA NA $75.94 $76.97 
CMS-1612-FC 1118

Facility Non-Fa

CPT/ 

 HCPCS 1

MOD Short Descriptor 

CY 20142

CY 2015 

Jan 1– 

March 313

% Change 

CY 2015 

April 1 – 

December 314

% Change 

CY 20142

CY 2015 

Jan 1– 

March 313

% Change 

93307 26 Tte w/o doppler complete $45.85 $45.83 0% $36.13 -21% $45.85 $45.83 093458 26 L hrt artery/ventricle $325.63 $321.14 -1% $253.17 -22% $325.63 $321.14 -198941 Chiropract manj 3-4 $35.46 $35.09 -1% $27.66 -22% $41.55 $41.17 -99203 Office/outpatient visit new $77.02 $77.69 1% $61.25 -20% $108.18 $109.19 99213 Office/outpatient visit est $51.58 $51.20 -1% $40.36 -22% $73.08 $73.03 099214 Office/outpatient visit est $79.17 $78.76 -1% $62.09 -22% $107.83 $107.76 099222 Initial hospital care $138.63 $138.55 0% $109.23 -21% NA NA N99223 Initial hospital care $204.19 $204.07 0% $160.80 -21% NA NA N99231 Subsequent hospital care $39.41 $39.38 0% $31.05 -21% NA NA N99232 Subsequent hospital care $72.36 $73.03 1% $57.58 -20% NA NA N99233 Subsequent hospital care $104.24 $105.61 1% $83.26 -20% NA NA N99236 Observ/hosp same date $219.24 $219.82 0% $173.29 -21% NA NA N99239 Hospital discharge day $107.47 $108.12 1% $85.24 -21% NA NA N99283 Emergency dept visit $61.97 $62.29 1% $49.11 -21% NA NA N99284 Emergency dept visit $118.22 $119.22 1% $93.99 -20% NA NA N99291 Critical care first hour $224.61 $225.91 1% $178.09 -21% $274.76 $277.10 99292 Critical care addl 30 min $112.48 $113.13 1% $89.19 -21% $123.23 $124.23 99348 Home visit est patient NA NA NA NA NA $84.54 $84.13 099350 Home visit est patient NA NA NA NA NA $178.40 $177.93 0G0008 Immunization admin NA NA NA NA NA $25.08 $25.42 

1 CPT codes and descriptions are copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply

2 The CY 2014 conversion factor is 35.8228. 

3 Payments based on the CY 2015 conversion factor of 35.8013 effective January 1 – March 31. 

4 Payments based on the CY 2015 conversion factor of 28.2239 effective April 1.
CMS-1612-FC 1119

D. Effect of Changes to Medicare Telehealth Services Under the PFS 

 As discussed in section II.E. of this final rule with comment period, we are finalizing the 

addition of several new codes to the list of Medicare telehealth services. Although we expect 

these changes to increase access to care in rural areas, based on recent utilization of similar 

services already on the telehealth list, we estimate no significant impact on PFS expenditures 

from these additions. 

E. Geographic Practice Cost Indices (GPCIs) 

As discussed in section II.D of this final rule with comment period, we are required to 

review and revise the GPCIs at least every 3 years and phase in the adjustment over 2 years (if 

there has not been an adjustment in the past year). For CY 2015, we are not making any revisions 

related to the data or the methodologies used to calculate the GPCIs except in regard to the 

Virgin Islands locality discussed in section II.D. However, since the 1.0 work GPCI floor 

provided in section 1848(e)(1)(E) of the Act is set to expire on March 31, 2015, we have 

included two set of GPCIs and GAFs for CY 2015—one set for January 1, 2015 through March 

31, 2015 and another set for April 1, 2015 through December 31, 2015. The April 1, 2015 

through December 31, 2015 GPCIs and GAFs reflect the statutory expiration of the 1.0 work 

GPCI floor. 

F. Other Provisions of the Final Rule with Comment Period Regulation 

1. Ambulance Fee Schedule 

The statutory ambulance extender provisions are self-implementing. As a result, there 

are no policy proposals associated with these provisions or associated impact in this rule. We are 

finalizing our proposal to correct the dates in the Code of Federal Regulations (CFR) at 

§414.610(c)(1)(ii) and §414.610(c)(5)(ii) to conform the regulations to these self-implementing 

statutory provisions. 
CMS-1612-FC 1120

The geographic designations for approximately 92.02 percent of ZIP codes would be 

unchanged if we adopt OMB’s revised statistical area delineations and the updated RUCA codes. 

There are more ZIP codes that would change from rural to urban (3,038 or 7.08 percent) than 

from urban to rural (387 or 0.90 percent). The differences in the data provided in the proposed 

rule compared to the final rule are due to inclusion of the updated RUCA codes. In general, it is 

expected that ambulance providers and suppliers in 387 ZIP codes within 41 states may 

experience payment increases under the revised OMB delineations and the updated RUCA 

codes, as these areas have been redesignated from urban to rural. Ambulance providers and 

suppliers in 3, 038 ZIP codes within 46 states and Puerto Rico may experience payment 

decreases under the revised OMB delineations and the updated RUCA codes, as these areas have 

been redesignated from rural to urban. None of the current super rural areas will lose their status 

upon implementation of the revised OMB delineations and the updated RUCA codes. We 

estimate that the adoption of the revised OMB delineations and the updated RUCA codes would 

have a small fiscal impact on the Medicare program. 

2. Clinical Laboratory Fee Schedule 

 There is no impact because we are merely deleting language from the Code of Federal 

Regulations. 

3. Removal of Employment Requirements for Services Furnished “Incident to” RHC and 

FQHC Visits 

 The removal of employment requirements for services furnished “incident to” RHC and 

FQHC visits will provide RHCs and FQHCs with greater flexibility in meeting their staffing 

needs, which may result in increasing access to care in underserved areas. There is no cost to the 

federal government, and we cannot estimate a cost savings for RHCs or FQHCs. 

4. Access to Identifiable Data for the Center for Medicare and Medicaid Models 
CMS-1612-FC 1121

 Given that, in general, participants in Innovation Center models receive funding support 

to participate in model tests, we do not anticipate an impact. In those cases where there is a cost 

associated with the data reporting, such costs will vary by project, and thus cannot be laid out 

with specificity here. We do, however, expect the costs to be covered by payments associated 

with the model test. 

5. Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests 

 The Local Coverage Determination Process for Clinical Diagnostic Laboratory Tests will 

not be finalized. Therefore, there is no impact to CY 2015 physician payments under the PFS. 

6. Private Contracting/Opt Out 

 We corrected cross-references and outdated terminology in the regulations that we 

inadvertently neglected to revise, and changed the appeals process used for certain appeals 

relating to opt-out private contracting. We anticipate no or minimal impact as a result of these 

corrections. 

7. Payment Policy for Locum Tenens Physicians 

 We did not issue any new or revised requirements. There is no impact. 

8. Reports of Payments or Other Transfers of Value to Covered Recipients 

The changes to the Transparency Reports and Reporting of Physician Ownership or 

Investment Interests in section III.I of this final rule with comment period would not impact 

CY 2015 physician payments under the PFS. 

9. Physician Compare 

There will be no impact for the Physician Compare website because we are not collecting 

any new information specifically for the Physician Compare website. The information derived 

for Physician Compare comes from other programs that already collect data, including but not 

limited to the Physician Quality Reporting System (PQRS) and the Medicare Shared Savings 
CMS-1612-FC 1122

Program. 

10. Physician Quality Reporting System 

According to the 2012 Reporting Experience, “more than 1.2 million eligible 

professionals were eligible to participate in the 2012 PQRS, Medicare Shared Savings Program, 

and Pioneer ACO Model.”40 In this burden estimate, we assume that 1.2 million eligible 

professionals, the same number of eligible professionals eligible to participate in the PQRS in 

2012, will be eligible to participate in the PQRS. Since all eligible professionals are subject to 

the 2017 PQRS payment adjustment, we estimate that all 1.2 million eligible professionals will 

participate, (which includes, for the purposes of this discussion, being eligible for the 2017 

PQRS payment adjustment) in the PQRS in 2015 for purposes of meeting the criteria for 

satisfactory reporting (or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) 

for the 2017 PQRS payment adjustment. 

Historically, the PQRS has never experienced 100 percent participation in reporting for 

the PQRS. Therefore, we believe that although 1.2 million eligible professionals will be subject 

to the 2017 PQRS payment adjustment, not all eligible participants will actually report quality 

measures data for purposes of the 2017 PQRS payment adjustment. In this burden estimate, we 

will only provide burden estimates for the eligible professionals and group practices who attempt 

to submit quality measures data for purposes of the 2017 PQRS payment adjustment. In 2012, 

435,871 eligible professionals (36 percent) eligible professionals (including those who belonged 

to group practices that reported under the GPRO and eligible professionals within an ACO that 

participated in the PQRS via the Shared Savings Program or Pioneer ACO Model) participated in 

the PQRS, Medicare Shared Savings Program, or Pioneer ACO Model.41 We expect to see a 

 

40 Centers for Medicare and Medicaid Services, 2012 Reporting Experience Including Trends (2007—2013): 

Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program, March 14, 2014, at xiii. 41 Id. at XV. 
CMS-1612-FC 1123

significant increase in participation in reporting for the PQRS in 2015 than 2012 as eligible 

professionals were not subject to a PQRS payment adjustment in 2012. Last year (78 FR 74793), 

we estimated that we would see a 50 percent participation rate in 2015. We still believe that a 14 

percent increase in participation from 2012 is reasonable in 2015. Therefore, we estimate that 50 

percent of eligible professionals (or approximately 600,000 eligible professionals) will report 

quality measures data for purposes of the 2017 PQRS payment adjustment. 

For participation in the PQRS using the claims-based reporting mechanism, according to 

the 2011 PQRS and eRx Experience Report, in 2011, 229,282 of the 320,422 eligible 

professionals (or 72 percent) of eligible professionals used the claims-based reporting 

mechanism. According to the 2012 Reporting Experience, 248,206 eligible professionals 

participated in the PQRS using the claims-based reporting mechanism in 2012.42 Preliminary 

estimates show that 252,567 eligible professionals participated in the PQRS using the claimsbased reporting mechanism in 2013.43 According to the historical data cited above, although the 

claims-based reporting mechanism is still the most widely-used reporting mechanism, we are 

seeing a decline in the percentage of participants using the claims-based reporting mechanism in 

the PQRS. Although these eligible professionals continue to participate in the PQRS, these 

eligible professionals have started to shift towards the use of other reporting mechanisms – 

mainly the GPRO web interface (whether used by a PQRS GPRO or an ACO participating in the 

PQRS via the Medicare Shared Savings Program or Pioneer ACO model), registry, or the EHRbased reporting mechanisms. For purposes of this burden estimate, based on PQRS participation 

using the claims-based reporting mechanism in 2012 and 2013, we will assume that 

approximately 250,000 eligible professionals will participate in the PQRS using the claims-based 

 

42 Id. at xvi. See Figure 4. 43 Id. 
CMS-1612-FC 1124

reporting mechanism. 

For participation in the PQRS using a qualified registry or QCDR, in 2011, 

approximately 50,215 (or 16 percent) of the 320,422 eligible professionals participating in PQRS 

used the qualified registry-based reporting mechanism. According to the 2012 Reporting 

Experience, 36,473 eligible professionals reported individual measures via the registry-based 

reporting mechanism, and 10,478 eligible professionals reporting measures groups via the 

registry-based reporting mechanism in 2012.44 Therefore, approximately 47,000 eligible 

professionals participated in the PQRS using the registry-based reporting mechanism in 2012. 

Please note that we currently have no data on participation in the PQRS via a QCDR as 2014 is 

the first year in which an eligible professional may participate in the PQRS via a QCDR. We 

believe that the rest of the eligible professionals not participating in other PQRS reporting 

mechanisms will use either the registry or QCDR reporting mechanisms for the following 

reasons: (1) the PQRS measures set is moving away from use of claims-based measures and 

moving towards the use of registry-based measures; or (2) we believe the number of QCDR 

vendors will increase as the QCDR reporting mechanism evolves. Therefore, based on these 

assumptions, we expect to see a significant jump from 47,000 eligible professionals (the 

remaining number of eligible professionals not participating via the claims, EHR, or GPRO web 

interface reporting mechanisms) to approximately 165,000 eligible professionals using either the 

registry-based reporting mechanism or QCDR in 2015. We believe the majority of these eligible 

professionals will participate in the PQRS using a QCDR, as we presume QCDRs will be larger 

entities with more members. 

For participation in the PQRS using the EHR-based reporting mechanism, according to 

the 2011 PQRS and eRx Experience Report, in 2011, 560 (or less than 1 percent) of the 320,422 

 

44 Id. at xvi. See Figure 4. 
CMS-1612-FC 1125

eligible professionals participating in PQRS used the EHR-based reporting mechanism. 2012 

saw a sharp increase in reporting via the EHR-based reporting mechanism. Specifically, 

according to the 2012 Reporting Experience, in 2012, 19,817 eligible professionals submitted 

quality data for the PQRS through a qualified EHR.45 We believe the number of eligible 

professionals and group practices using the EHR-based reporting mechanism will steadily 

increase as eligible professionals become more familiar with EHR products and more eligible 

professionals participate in programs encouraging use of an EHR, such as the EHR Incentive 

Program. In particular, we believe eligible professionals will transition from using the claimsbased to the EHR-based reporting mechanisms. To account for this anticipated increase, we 

continue to estimate that approximately 50,000 eligible professionals, whether participating as an 

individual or part of a group practice under the GPRO, would use the EHR-based reporting 

mechanism in CY 2015. 

For participation in the PQRS using the GPRO web interface, as we noted in last year’s 

estimate, according to the 2011 Experience Report, approximately 200 group practices 

participated in the GPRO in 2011. According to the 2012 Reporting Experience, 66 practices 

participated in the PQRS GPRO.46 In addition, 144 ACOs participated in the PQRS GPRO 

through either the Medicare Shared Savings Program (112 ACOs) or Pioneer ACO Model (32 

practices).47 These group practices encompass 134,510 eligible professionals (or approximately 

140,000 eligible professionals).48 Since it seems that roughly 200 group practices participated in 

the GPRO in 2011 and 2012, based on these numbers, we will assume that 200 group practices 

 

45 Id. at xv. 46 Id. at xv. 47 Id. at xvi. 48 Id. at 18. 
CMS-1612-FC 1126

(accounting for approximately 135,000 eligible professionals) will participate in the PQRS using 

the GPRO web interface in 2015. 

Please note that, while we are finalizing the reporting of CAHPS survey measures using a 

CMS-certified survey vendor, we are not including this reporting mechanism in this impact 

statement as we believe that eligible professionals wishing to report CAHPS survey measures 

will do so for purposes other than the PQRS. 

(a) Assumptions for Burden Estimates 

For the PQRS, the burden associated with the requirements of this voluntary reporting 

initiative is the time and effort associated with individual eligible professionals identifying 

applicable quality measures for which they can report the necessary information, selecting a 

reporting option, and reporting the information on their selected measures or measures group to 

CMS using their selected reporting option. 

We believe the labor associated with eligible professionals and group practices reporting 

quality measures data in the PQRS is primarily handled by an eligible professional’s or group 

practice’s billing clerk or computer analyst trained to report quality measures data. Therefore, 

we will consider the hourly wage of a billing clerk and computer analyst in our estimates. For 

purposes of this burden estimate, we will assume that a billing clerk will handle the 

administrative duties associated with participating in the PQRS. According to information 

published by the Bureau of Labor Statistics, available at 

http://www.bls.gov/oes/2013/may/oes433021.htm, the mean hourly wage for a billing clerk is 

approximately $16.80/hour. Therefore, for purposes of handling administrative duties, we 

estimate an average labor cost of $16.00/hour. In addition, for purposes of this burden estimate, 

we will assume that a computer analyst will engage in the duties associated with the reporting of 

quality measures. According to information published by the Bureau of Labor Statistics, 
CMS-1612-FC 1127

available at http://www.bls.gov/oes/2013/may/oes151121.htm, the mean hourly wage for a 

computer analyst is approximately $41.00/hour. Therefore, for purposes of reporting on quality 

measures, we estimate an average labor cost of $41.00/hour. Please note that, in assessing the 

burden estimates below, to account for benefits and overhead associated with labor in addition to 

the hourly wage costs described above, we are doubling the wage rates in our estimates. 

For individual eligible professionals, the burden associated with the requirements of this 

reporting initiative is the time and effort associated with eligible professionals identifying 

applicable quality measures for which they can report the necessary information, collecting the 

necessary information, and reporting the information needed to report the eligible professional’s 

measures. We believe it is difficult to accurately quantify the burden because eligible 

professionals may have different processes for integrating the PQRS into their practice’s work 

flows. Moreover, the time needed for an eligible professional to review the quality measures and 

other information, select measures applicable to his or her patients and the services he or she 

furnishes to them, and incorporate the use of quality data codes into the office work flows is 

expected to vary along with the number of measures that are potentially applicable to a given 

professional’s practice. Since eligible professionals are generally required to report on at least 9 

measures covering at least 3 National Quality Strategy domains criteria for satisfactory reporting 

(or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) for the 2017 PQRS 

payment adjustment, we will assume that each eligible professional reports on an average of 9 

measures for this burden analysis. 

For eligible professionals who are participating in PQRS for the first time, we will assign 

5 total hours as the amount of time needed for an eligible professional’s billing clerk to review 

the PQRS Measures List, review the various reporting options, select the most appropriate 

reporting option, identify the applicable measures or measures groups for which they can report 
CMS-1612-FC 1128

the necessary information, review the measure specifications for the selected measures or 

measures groups, and incorporate reporting of the selected measures or measures groups into the 

office work flows. The measures list contains the measure title and brief summary information 

for the eligible professional to review. Assuming the eligible professional has received no 

training from his/her specialty society, we estimate it will take an eligible professional’s billing 

clerk up to 2 hours to review this list, review the reporting options, and select a reporting option 

and measures on which to report. If an eligible professional has received training, then we 

believe this would take less time. We believe 3 hours is plenty of time for an eligible 

professional to review the measure specifications of 9 measures or 1 measures group they select 

to report for purposes of participating in PQRS and to develop a mechanism for incorporating 

reporting of the selected measures or measures group into the office work flows. Therefore, we 

believe that the start-up cost for an eligible professional to report PQRS quality measures data is 

5 hours x $32/hour = $160. 

We believe the burden associated with actually reporting the quality measures will vary 

depending on the reporting mechanism selected by the eligible professional. As such, we break 

down the burden estimates by eligible professionals and group practices participating in the 

GPRO according to the reporting mechanism used. 

(b) Burden Estimate for PQRS Reporting by Individual Eligible Professionals: Claims-Based 

Reporting Mechanism 

For the claims-based reporting option, eligible professionals must gather the required 

information, select the appropriate quality data codes (QDCs), and include the appropriate QDCs 

on the claims they submit for payment. The PQRS will collects QDCs as additional (optional) 

line items on the existing HIPAA transaction 837-P and/or CMS Form 1500 (OCN: 0938-0999). 
CMS-1612-FC 1129

We do not anticipate any new forms and or any modifications to the existing transaction or form. 

We also do not anticipate changes to the 837-P or CMS Form 1500 for CY 2015. 

We estimate the cost for an eligible professional to review the list of quality measures or 

measures groups, identify the applicable measures or measures group for which they can report 

the necessary information, incorporate reporting of the selected measures into the office work 

flows, and select a PQRS reporting option to be approximately $410 per eligible professional 

($82 per hour x 5 hours). 

Based on our experience with the Physician Voluntary Reporting Program (PVRP), we 

continue to estimate that the time needed to perform all the steps necessary to report each 

measure (that is, reporting the relevant quality data code(s) for 9 measures measure) would range 

from 15 seconds (0.25 minutes) to over 12 minutes for complicated cases and/or measures, with 

the median time being 1.75 minutes. To report 9 measures, we estimate that it would take 

approximately 2.25 minutes to 108 minutes to perform all the steps necessary to report 9 

measures. 

Per measure, at an average labor cost of $82/hour per practice, the cost associated with 

this burden will range from $0.34 in labor to about $16.40 in labor time for more complicated 

cases and/or measures, with the cost for the median practice being $2.40. To report 9 measures, 

using an average labor cost of $82/hour, we estimated that the time cost of reporting for an 

eligible professional via claims would range from $3.07 (2.25 minutes or 0.0375 hours x 

$82/hour) to $147.60 (108 minutes or 1.8 hours x $82/hour) per reported case. 

The total estimated annual burden for this requirement will also vary along with the 

volume of claims on which quality data is reported. In previous years, when we required 

reporting on 80 percent of eligible cases for claims-based reporting, we found that on average, 

the median number of reporting instances for each of the PQRS measures was 9. Since we 
CMS-1612-FC 1130

reduced the required reporting rate by over one-third to 50 percent, then for purposes of this 

burden analysis we will assume that an eligible professional or eligible professional in a group 

practice will need to report each selected measure for 6 reporting instances. The actual number 

of cases on which an eligible professional or group practice is required to report quality measures 

data will vary, however, with the eligible professional's or group practice’s patient population 

and the types of measures on which the eligible professional or group practice chooses to report 

(each measure's specifications includes a required reporting frequency). 

Based on the assumptions discussed previously, we estimate the total annual reporting 

burden per individual eligible professional associated with claims-based reporting will range 

from 13.5 minutes (0.25 minutes per measure x 9 measures x 6 cases per measure) to 648 

minutes (12 minutes per measure x 9 measures x 6 cases per measure), with the burden to the 

median practice being 94.5 minutes (1.75 minutes per measure x 9 measures x 6 cases). We 

estimate the total annual reporting cost per eligible professional or eligible professional in a 

group practice associated with claims-based reporting will range from $18.36 ($0.34 per measure 

x 9 measures x 6 cases per measure) to $885.60 ($16.40 per measure x 9 measures x 6 cases per 

measure), with the cost to the median practice being $129.60 per eligible professional ($2.40 per 

measure x 9 measures x 6 cases per measure). 

(c) Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: Qualified Registry-based and QCDR-based Reporting Mechanisms 

For qualified registry-based and QCDR-based reporting, there will be no additional time 

burden for eligible professionals or group practices to report data to a qualified registry as 

eligible professionals and group practices opting for qualified registry-based reporting or use of a 

QCDR will more than likely already be reporting data to the qualified registry for other purposes 

and the qualified registry will merely be re-packaging the data for use in the PQRS. Little, if 
CMS-1612-FC 1131

any, additional data will need to be reported to the qualified registry or QCDR solely for 

purposes of participation in the PQRS. However, eligible professionals and group practices will 

need to authorize or instruct the qualified registry or QCDR to submit quality measures results 

and numerator and denominator data on quality measures to CMS on their behalf. We estimate 

that the time and effort associated with this will be approximately 5 minutes per eligible 

professional or eligible professional within a group practice. 

Based on the assumptions discussed above and in Part B of this supporting statement, 

Table 95 provides an estimate of the total annual burden hours and total annual cost burden 

associated with eligible professionals using the qualified registry-based or QCDR-based 

reporting mechanism. Please note that, unlike the claims-based reporting mechanism that would 

require an eligible professional to report data to us on quality measures on multiple occasions, an 

eligible professional would not be required to submit this data to us, as the qualified registry or 

QCDR would perform this function on the eligible professional’s behalf. 

(d) Burden Estimate for PQRS Reporting by Individual Eligible Professionals and Group 

Practices: EHR-Based Reporting Mechanism 

For EHR-based reporting, which includes EHR reporting via a direct EHR product and an 

EHR data submission vendor’s product, the eligible professional or group practice must review 

the quality measures on which we will be accepting PQRS data extracted from EHRs, select the 

appropriate quality measures, extract the necessary clinical data from his or her EHR, and submit 

the necessary data to the our designated clinical data warehouse. 

For EHR-based reporting for the PQRS, the individual eligible professional or group 

practice may either submit the quality measures data directly to us from their EHR or utilize an 

EHR data submission vendor to submit the data to us on the eligible professional’s or group 

practice’s behalf. To submit data to us directly from their EHR, the eligible professional or 
CMS-1612-FC 1132

eligible professional in a group practice must have access to our specified identity management 

system, such as IACS, which we believe takes less than 1 hour to obtain. Once an eligible 

professional or eligible professional in a group practice has an account for our specified identity 

management system, he or she will need to extract the necessary clinical data from his or her 

EHR, and submit the necessary data to the our designated clinical data warehouse. With respect 

to submitting the actual data file for the respective reporting period, we believe that this will take 

an eligible professional or group practice no more than 2 hours, depending on the number of 

patients on which the eligible professional or group practice is submitting. We believe that once 

the EHR is programmed by the vendor to allow data submission to us, the burden to the eligible 

professional or group practice associated with submission of data on quality measures should be 

minimal as all of the information required to report the measure should already reside in the 

eligible professional's or group practice’s EHR. 

(e) Burden Estimate for PQRS Reporting by Group Practices Using the GPRO Web Interface 

 With respect to the process for group practices to be treated as satisfactorily submitting 

quality measures data under the PQRS, group practices interested in participating in the PQRS 

through the group practice reporting option (GPRO) must complete a self-nomination process 

similar to the self-nomination process required of qualified registries. However, since a group 

practice using the GPRO web interface would not need to determine which measures to report 

under PQRS, we believe that the self-nomination process is handled by a group practice’s 

administrative staff. Therefore, we estimate that the self-nomination process for the group 

practices for the PQRS involves approximately 2 hours per group practice to review the PQRS 

GPRO and make the decision to participate as a group rather than individually and an additional 

2 hours per group practice to draft the letter of intent for self-nomination, gather the requested 

TIN and NPI information, and provide this requested information. It is estimated that each self-
CMS-1612-FC 1133

nominated entity will also spend 2 hours undergoing the vetting process with CMS officials. We 

assume that the group practice staff involved in the group practice self-nomination process has 

an average practice labor cost of $32 per hour. Therefore, assuming the total burden hours per 

group practice associated with the group practice self-nomination process is 6 hours, we estimate 

the total cost to a group practice associated with the group practice self-nomination process to be 

approximately $192 ($32 per hour x 6 hours per group practice). 

The burden associated with the group practice reporting requirements under the GPRO is 

the time and effort associated with the group practice submitting the quality measures data. For 

physician group practices, this would be the time associated with the physician group completing 

the web interface. We estimate that the time and effort associated with using the GPRO web 

interface will be comparable to the time and effort associated to using the PAT. As stated above, 

the information collection components of the PAT have been reviewed by OMB and was 

approved under OMB control number 0938-0941- Form 10136, with an expiration date of 

December 31, 2011 for use in the PGP, MCMP, and EHR demonstrations. As the GPRO was 

only recently implemented in 2010, it is difficult to determine the time and effort associated with 

the group practice submitting the quality measures data. As such, we will use the same burden 

estimate for group practices participating in the GPRO as we use for group practices 

participating in the PGP, MCMP, and EHR demonstrations. Since these changes will not have 

any impact on the information collection requirements associated with the PAT and we will be 

using the same data submission process used in the PGP demonstration, we estimate that the 

burden associated with a group practice completing data for PQRS under the web interface will 

be the same as for the group practice to complete the PAT for the PGP demonstration. In other 

words, we estimate that, on average, it will take each group practice 79 hours to submit quality 
CMS-1612-FC 1134

measures data via the GPRO web interface at a cost of $82 per hour. Therefore, the total 

estimated annual cost per group practice is estimated to be approximately $6,478. 

Tables 95 and 96 provide our total estimated costs for reporting in the PQRS for the 2017 

PQRS payment adjustment, the reporting periods of which occur in CY 2015. 

TABLE 95: Summary of Burden Estimates for Eligible Professionals and/or Group 

Practices using the Claims, Qualified registry, and EHR-based Reporting Mechanisms for 

the 2017 PQRS Payment Adjustment 

 Minimum 

Burden 

Estimate 

Maximum 

Burden 

Estimate 

Estimated Annual Burden Hours for Claims-based Reporting (for 

individual eligible professionals only) 1,306,025 3,948,920

Estimated Annual Burden Hours for Qualified registry-based or 

QCDR-based Reporting 1,333,695 1,333,695

Estimated Annual Burden Hours for EHR-based Reporting 

450,000 450,000

Estimated Total Annual Burden Hours for Eligible Professionals or 

Eligible Professionals in a Group Practice 3,089,720 5,732,615

Estimated Cost for Claims-based Reporting (for individual eligible 

professionals only) $107,090,000 $323,900,000

Estimated Cost for Qualified registry-based Reporting 

$109,362,000 $109,362,000

Estimated Cost for EHR-based Reporting 

$32,800,000 $32,800,000

Estimated Total Annual Cost for Eligible Professionals or Eligible 

Professionals in a Group Practice $249,252,000 $466,062,000

 
CMS-1612-FC 1135

TABLE 96: Estimated Costs of Group Practices using the GPRO Web Interface to 

Participate in the PQRS for the 2017 PQRS Payment Adjustment 

Maximum 

Burden 

Estimate 

Estimated # of Participating Group Practices 200 

Estimated # of Burden Hours Per Group Practice to Self-Nominate to Participate in 

PQRS and the Electronic Prescribing Incentive Program Under the Group Practice 

Reporting Option 

6 

Estimated # of Burden Hours Per Group Practice to Report Quality Measures 79 

Estimated Total Annual Burden Hours Per Group Practice 85 

Estimated Total Annual Burden Hours for Group Practices 17,000 

Estimated Cost Per Group Practice to Self-Nominate to Participate in PQRS for the 

Group Practice Reporting Option 

$192 

Estimated Cost Per Group Practice to Report Quality Measures $6,478 

Estimated Total Annual Cost Per Group Practice $6,670 

Annual Burden Cost for Group Practices $1,334,000

11. EHR Incentive Program 

 The changes to the EHR Incentive Program in section III.L of this final rule with 

comment period would not impact CY 2015 physician payments under the PFS. 

12. Medicare Shared Saving Program 

 The requirements for participating in the Medicare Shared Saving Program and the 

impacts of these requirements were established in the final rule implementing the Medicare 

Shared Savings Program that appeared in the Federal Register on November 2, 2011 

(76 FR 67802). The proposals for the Medicare Shared Savings Program set forth in the 

CY 2015 MPFS proposed rule revisited the current quality performance standard, proposed 

changes to the quality measures, proposed modifications to the timeframe between updates to the 

quality performance benchmarks, and proposed to establish an additional incentive to reward 

ACO quality improvement. Since the policies being adopted in this final rule with comment 

period do not increase the quality reporting burden for ACOs participating in the Shared Savings 

Program and their ACO participants and ACO providers/suppliers, there is no impact for these 

policies. 
CMS-1612-FC 1136

13. Value-Based Payment Modifier and the Physician Feedback Program 

 Section 1848(p) of the Act requires that we establish a VM and apply it to specific 

physicians and groups of physicians the Secretary determines appropriate starting January 1, 

2015 and to all physicians and groups of physicians by January 1, 2017. Section 1848(p)(4)(C) 

of the Act requires the VM to be budget neutral. Budget-neutrality means that, in aggregate, the 

increased payments to high performing physicians and groups of physicians equal the reduced 

payments to low performing physicians and groups of physicians. 

The changes to the VM in section III.N of this final rule with comment period will not 

impact CY 2015 physician payments under the PFS. We finalized the VM policies that would 

impact the CY 2015 physician payments under the PFS in the CY 2013 PFS final rule with 

comment period (77 FR 69306-69326). 

In the CY 2013 PFS final rule with comment period, we finalized policies to phase-in 

the VM by applying it starting January 1, 2015 to payments under the Medicare PFS for 

physicians in groups of 100 or more eligible professionals. We identify a group of physicians 

as a single taxpayer identification number (TIN). We apply the VM to the items and services 

billed by physicians under the TIN, not to other eligible professionals that also may bill under 

the TIN. We established CY 2013 as the performance period for the VM that will be applied to 

payments during CY 2015 (77 FR 69314). We also finalized that we will not apply the VM in 

CYs 2015 and 2016 to any group of physicians that is participating in the Medicare Shared 

Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care Initiative, or 

other similar Innovation Center or CMS initiatives (77 FR 69313). 

We finalized policies to determine the amount of the VM for CY 2015 by categorizing 

groups of physicians with 100 or more eligible professionals into two categories. Category 1 

includes groups of physicians that either (a) self-nominate for the PQRS as a group and report at 
CMS-1612-FC 1137

least one measure or (b) elect the PQRS Administrative Claims option as a group. Category 2 

includes groups that do not fall within either of the two subcategories (a) or (b) of Category 1. 

Groups within Category 1 may elect to have their VM for CY 2015 calculated using the qualitytiering methodology, which could result in an upward, neutral, or downward adjustment 

amount. The VM for groups of physicians in Category 1 that do not elect-quality tiering is 0.0 

percent, meaning that these groups will not receive a payment adjustment under the VM for CY 

2015. For the groups that are in Category 2, the VM for the CY 2015 payment adjustment 

period is -1.0 percent. 

 Under the quality-tiering approach, each group’s quality and cost composites are 

classified into high, average, and low categories depending upon whether the composites are at 

least one standard deviation above or below the mean. We compare the group’s quality of care 

composite classification with the cost composite classification to determine the VM adjustment 

for the CY 2015 payment adjustment period according to the amounts in Table 97. 

TABLE 97: 2015 Value-Based Payment Modifier Amounts under Quality-Tiering 

Cost/Quality Low Quality Average Quality High Quality 

Low Cost +0.0% +1.0x* +2.0x* 

Average Cost -0.5% +0.0% +1.0x* 

High Cost -1.0% -0.5% +0.0% 

* Groups of physicians eligible for an additional +1.0x if (1) reporting Physician Quality Reporting System quality 

measures through the GPRO web-interface or CMS-qualified registry, and (2) average beneficiary risk score is in 

the top 25 percent of all beneficiary risk scores. 

To ensure budget neutrality, we first aggregate the downward payment adjustments in 

Table 97 for those groups in Category 1 that have elected quality tiering with the -1.0 percent 

downward payment adjustments for groups of physicians subject to the VM that fall within 

Category 2. Using the aggregate downward payment adjustment amount, we then calculate the 

upward payment adjustment factor (x). These calculations will be done after the performance 

period has ended. 
CMS-1612-FC 1138

 In the proposed rule, we presented estimates on the number of eligible professionals and 

physician groups, by group size, based on CY 2012 claims data that were used to produce the 

2012 QRURs, which were available to groups of 25 or more eligible professionals on September 

16, 2013. The findings from the CY 2012 QRURs are available on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/2012-QRUR.html in a document titled “Experience Report 

for the Performance Year 2012 Quality and Resource Use Reports”. 

 On September 30, 2014, we made QRURs available to all groups of physicians and 

physicians who are solo practitioners based on their performance in CY 2013. We also 

completed the analysis of the impact of the VM in CY 2015 on physicians in groups with 100 or 

more eligible professionals based on their performance in CY 2013 and present a summary of the 

findings below. Please note that the impact of the policies for the CY 2017 VM finalized in this 

final rule with comment period will be discussed in the PFS rule for CY 2017. 

Based on the methodology codified in §414.1210(c), there are 1,010 groups of 100 or 

more eligible professionals (as identified by their Taxpayer Identification Numbers (TINs)) 

whose physicians’ payments under the Medicare PFS will be subject to the VM in the CY 2015 

payment adjustment period. Of these 1,010 groups subject to the CY 2015 VM, 706 groups met 

the criteria for inclusion in Category 1. As noted above, Category 1 for the CY 2015 VM 

includes groups of physicians that either (a) self-nominate for the PQRS as a group and report at 

least one measure or (b) elect the PQRS Administrative Claims option as a group. 

Of the 706 groups in Category 1, 133 groups elected in 2013 to have their CY 2015 VM 

calculated using the quality-tiering methodology; therefore, these groups will receive an upward, 

neutral, or downward adjustment in CY 2015 based on their performance on the quality and cost 

measures finalized for the CY 2015 VM in the CY 2013 PFS final rule with comment period (77 
CMS-1612-FC 1139

FR 69306-69326). We note that there were 21 groups for which we had insufficient data to 

calculate their quality or cost composite; therefore, these groups will receive a neutral adjustment 

to their payments in CY 2015. Of the 112 groups for which we were able to calculate both 

quality and cost composites, we found that 16 groups are in tiers that will result in an upward 

adjustment of +1.0x; 9 groups are in tiers that will result in a downward adjustment of between -

0.5 and -1.0 percent; and 87 groups are in tiers that will result in a neutral adjustment to their 

payments in CY 2015. Of the groups that are eligible for an upward adjustment, none of the 

groups are eligible to receive an additional +1.0x adjustment to their Medicare payments for 

treating high-risk beneficiaries. Table 98 shows the distribution of the 112 groups that elected 

quality-tiering into the various quality and cost tiers. Please note that CMS will announce the 

upward payment adjustment factor (x) in the Fall of 2014 on the CMS website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. 

TABLE 98: Distribution Using 2013 Data of Quality and Cost Tiers for Groups with 100 

or More Eligible Professionals that Elected Quality-Tiering for Which a Quality and Cost 

Composite Score Could Be Calculated (112 Groups) 

Cost/Quality Low Quality Average Quality High Quality 

Low Cost +0.0% 

(0) 

+1.0x 

(2) 

+2.0x 

(0) 

Average Cost -0.5% 

(5) 

+0.0% 

(87) 

+1.0x 

(14) 

High Cost -1.0% 

(2) 

-0.5% 

(2) 

+0.0% 

(0) 

 

 

Of the 706 groups in Category 1, 573 groups elected to not have their CY 2015 VM 

calculated using the quality-tiering methodology; therefore, their VM will be 0.0 percent, 

meaning that these groups will not receive a payment adjustment under the VM in CY 2015. 

Of the 1,010 groups subject to the CY 2015 VM, 304 groups met the criteria for inclusion 

in Category 2. As noted above, Category 2 includes groups that do not fall within either of the 
CMS-1612-FC 1140

two subcategories (a) or (b) of Category 1. There were 289 groups that did not self-nominate for 

the PQRS as a group, and 15 groups that self-nominated for the PQRS as a group, but did not 

report at least one measure. Groups in Category 2 will be subject to a -1.0 percent payment 

adjustment under the VM during the CY 2015 payment adjustment period. 

Please note that in CY 2015, only the physicians in groups with 100 or more eligible 

professionals that are in Category 1 and elected quality-tiering will be subject to upward, 

downward, or no payment adjustment under the VM according to Table 98. Additionally, 

physicians in groups with 100 or more eligible professionals that fall in Category 2 will be 

subject to the -1.0 percent VM in CY 2015. 

We note that in the 2013 QRUR Experience Report, which will be released in the next 

few months, we will provide a detailed analysis of the impact of the 2015 VM policies on groups 

of 100 or more eligible professionals subject to the VM in CY 2015, including findings based on 

the data contained in the 2013 QRURs for all groups of physicians and solo practitioners. 

14. Interim Revisions to the Electronic Health Record (EHR) Incentive Program 

 This interim final rule will allow us flexibility in setting the deadline for significant 

hardship exception applications. We refer readers to the impact analyses included in the final 

rule titled “Medicare and Medicaid Programs; Electronic Health Record Incentive Program—

Stage 2” (77 FR 53698 through 54162) and Medicare and Medicaid Programs; Modifications to 

the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs for 2014 and 

Other Changes to the EHR Incentive Program; and Health Information Technology; Revisions to 

the Certified EHR Technology Definition and EHR Certification Changes Related to Standards; 

Final Rule (79 FR 52911-52933). 

G. Alternatives Considered
CMS-1612-FC 1141

 This final rule with comment period contains a range of policies, including some 

provisions related to specific statutory provisions. The preceding preamble provides descriptions 

of the statutory provisions that are addressed, identifies those policies when discretion has been 

exercised, presents rationale for our final policies and, where relevant, alternatives that were 

considered. 

H. Impact on Beneficiaries 

There are a number of changes in this final rule with comment period that would have an 

effect on beneficiaries. In general, we believe that many of the changes, including the 

refinements of the PQRS with its focus on measuring, submitting, and analyzing quality data; 

establishing the basis for the value-based payment modifier to adjust physician payment 

beginning in CY 2015; improved accuracy in payment through revisions to the inputs used to 

calculate payments under the PFS; and revisions to payment for Part B drugs will have a positive 

impact and improve the quality and value of care provided to Medicare beneficiaries. 

 Most of the aforementioned policy changes could result in a change in beneficiary 

liability as relates to coinsurance (which is 20 percent of the fee schedule amount if applicable 

for the particular provision after the beneficiary has met the deductible). To illustrate this point, 

as shown in Table 94, the CY 2014 national payment amount in the nonfacility setting for CPT 

code 99203 (Office/outpatient visit, new) is $108.18, which means that in CY 2014 a beneficiary 

would be responsible for 20 percent of this amount, or $21.64. Based on this final rule with 

comment period, using the January 1 – March 31, 2015 CF of 35.8013, the CY 2015 national 

payment amount in the nonfacility setting for CPT code 99203, as shown in Table 94, is $109.19, 

which means that, in CY 2015, the beneficiary coinsurance for this service would be $21.84. In 

addition, we are finalizing a change in our definition of colorectal cancer screening test. As a 

result, beneficiary liability will not be applied to anesthesia billed in conjunction with a 
CMS-1612-FC 1142

colorectal cancer screening test. 

I. Accounting Statement 

As required by OMB Circular A-4 (available at 

http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 99 (Accounting Statement), 

we have prepared an accounting statement. This estimate includes growth in incurred benefits 

from CY 2014 to CY 2015 based on the FY 2015 President's Budget baseline. Note that 

subsequent legislation changed the updates for 2015 from those shown in the 2015 President’s 

Budget baseline. 

TABLE 99: Accounting Statement: Classification of Estimated Expenditures 

CATEGORY TRANSFERS 

CY 2015 Annualized Monetized Transfers Estimated decrease in expenditures of $14.7 billion 

for PFS conversion factor update. 

From Whom To Whom? Federal Government to physicians, other 

practitioners and providers and suppliers who receive 

payment under Medicare. 

CY 2015 Annualized Monetized Transfers Estimated increase in payment of $234 million. 

From Whom To Whom? Federal Government to eligible professionals who 

satisfactorily participate in the Physician Quality 

Reporting System (PQRS). 

TABLE 100: Accounting Statement: Classification of Estimated Costs, Transfer, and 

Savings 

Category Transfer 

CY 2015 Annualized Monetized 

Transfers of beneficiary cost 

coinsurance. 

$9 million 

From Whom to Whom? Beneficiaries to Federal Government 

J. Conclusion 

The analysis in the previous sections, together with the remainder of this preamble, 

provides an initial "Regulatory Flexibility Analysis." The previous analysis, together with the 

preceding portion of this preamble, provides a Regulatory Impact Analysis. 
CMS-1612-FC 1143

 In accordance with the provisions of Executive Order 12866, this regulation was 

reviewed by the Office of Management and Budget. 
CMS-1612-FC 1144

List of Subjects 

42 CFR Part 403 

Grant programs-health, Health insurance, Hospitals, Intergovernmental relations, 

Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 405 

Administrative practice and procedure, Health facilities, Health professions, Kidney 

diseases, Medical devices, Medicare, Reporting and recordkeeping requirements, Rural areas, 

X-rays. 

42 CFR Part 410 

Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting 

and recordkeeping requirements, Rural areas, X-rays. 

42 CFR Part 411 

Kidney diseases, Medicare, Physician Referral, Reporting and recordkeeping 

requirements. 

42 CFR Part 412 

Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, 

Reporting and recordkeeping requirements. 

42 CFR Part 413 

Health facilities, Kidney diseases, Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 414 

Administrative practice and procedure, Health facilities, Health professions, Kidney 

diseases, Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 425 
CMS-1612-FC 1145

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

and Reporting and recordkeeping requirements. 

42 CFR Part 489 

 Health facilities, Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 495 

Administrative practice and procedure, Electronic health records, Health facilities, Health 

professions, Health maintenance organizations (HMO), Medicaid, Medicare, Penalties, Privacy, 

Reporting and recordkeeping requirements. 

42 CFR Part 498 

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 
CMS-1612-FC 1146

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 

42 CFR chapter IV as set forth below:— 

PART 403—SPECIAL PROGRAMS AND PROJECTS 

1. The authority citation for part 403 continues to read as follows: 

Authority: 42 U.S.C. 1395b-3 and Secs. 1102 and 1871 of the Social Security Act (42 

U.S.C. 1302 and 1395hh). 

§403.902 [Amended] 

2. In §403.902, remove the definition of “Covered device”. 

3. Section 403.904 is amended by – 

A. Revising paragraphs (c)(8), (d)(3), and (d)(4). 

B. Adding paragraphs (d)(5) and (d)(6). 

C. Revising paragraph (f)(1)(iv). 

D. Removing paragraph (g). 

E. Redesignating paragraphs (h) and (i) as paragraphs (g) and (h), respectively. 

F. Amending newly redesignated paragraph (h)(2)(ii) by removing “paragraph (i)(2)(i) 

of this section” and adding in its place “paragraph (h)(2)(i) of this section”. 

G. Amending newly redesignated paragraph (h)(2)(iii) by removing “paragraph (i)(2)(ii) 

of this section” and adding in its place “paragraph (h)(2)(i) of this section”. 

The revisions and additions read as follows: 

§403.904 Reports of payments or other transfers of value to covered recipients. 

 * * * * * 

(c) * * * 

(8) Related covered drug, device, biological or medical supply. Report the marketed 

name of the related covered drugs, devices, biologicals, or medical supplies, and therapeutic area 
CMS-1612-FC 1147

or product category unless the payment or other transfer of value is not related to a particular 

covered drug, device, biological or medical supply. 

(i) For drugs and biologicals, if the marketed name has not yet been selected, applicable 

manufacturers must indicate the name registered on clinicaltrials.gov. 

(ii) Applicable manufacturers may report the marketed name and therapeutic area or 

product category for payments or other transfers of value related to a non-covered drug, device, 

biological, or medical supply. 

(iii) Applicable manufacturers must indicate if the related drug, device, biological, or 

medical supply is covered or non-covered. 

(iv) Applicable manufacturers must indicate if the payment or other transfer of value is 

not related to any covered or non-covered drug, device, biological or medical supply. 

 * * * * * 

(d) * * * 

(3) Stock. 

(4) Stock option. 

(5) Any other ownership interest. 

(6) Dividend, profit or other return on investment. 

 * * * * * 

 (f) * * * 

(1) * * *

 (iv) Name(s) of any related covered drugs, devices, biologicals, or medical supplies 

(subject to the requirements specified in paragraph (c)(8) of this section), for drugs and 

biologicals, the relevant National Drug Code(s), if any, for devices and medical supplies and 

report a therapeutic area or product category if a marketed name is not available. 
CMS-1612-FC 1148

 * * * * * 

§403.906 [Amended] 

4. In §403.906, amend paragraph (b)(6) by removing “§403.904(c) through (i)” and by 

adding in its place “§403.904(c) through (h).” 

5. New subpart K is added to part 403 to read as follows: 

Subpart K--Access to Identifiable Data for the Center for Medicare and Medicaid Models 

Sec. 

403.1100 Purpose and scope. 

403.1105 Definitions. 

403.1110 Evaluation of models. 

Subpart K--Access to Identifiable Data for the Center for Medicare and Medicaid Models 

§403.1100 Purpose and scope. 

 The regulations in this subpart implement section 1115A of the Act. The intent of that 

section is to enable CMS to test innovative payment and service delivery models to reduce 

program expenditures while preserving and/or enhancing the quality of care furnished to 

individuals under titles XVIII, XIX, and XXI of the Act. The Secretary is also required to 

conduct an evaluation of each model tested. 

§403.1105 Definitions. 

For purposes of this subpart-- 

Applicable titles means Titles XVIII, XIX, or XXI of the Act. 

§403.1110 Evaluation of models. 

(a) Evaluation. The Secretary conducts an evaluation of each model tested under section 

1115A of the Act. Such evaluation must include an analysis of the following: 
CMS-1612-FC 1149

(1) The quality of care furnished under the model, including the measurement of patientlevel outcomes and patient-centeredness criteria determined appropriate by the Secretary. 

(2) The changes in spending under the applicable titles by reason of the model. 

(b) Information. Any State or other entity participating in the testing of a model under 

section 1115A of the Act must collect and report such information, including “protected health 

information” as that term is defined at 45 CFR 160.103, as the Secretary determines is necessary 

to monitor and evaluate such model. Such data must be produced to the Secretary at the time 

and in the form and manner specified by the Secretary. 

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED 

6. The authority citation for part 405 continues to read as follows: 

Authority: Secs. 205(a), 1102, 1861, 1862(a), 1869, 1871, 1874, 1881, and 1886(k) of 

the Social Security Act (42 U.S.C. 405(a), 1302, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 

1395rr and 1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C. 263a). 

7. Section 405.400 is amended by revising the definition of “Emergency care services” to 

read as follows: 

§405.400 Definitions. 

 * * * * * 

Emergency care services means inpatient or outpatient hospital services that are 

necessary to prevent death or serious impairment of health and, because of the danger to life or 

health, require use of the most accessible hospital available and equipped to furnish those 

services. 

 * * * * * 

§405.420 [Amended] 
CMS-1612-FC 1150

8. In §405.420, amend paragraph (e), by removing the phrase “Medicare+Choice” and 

adding in its place the phrase “Medicare Advantage”.

§405.425 [Amended] 

9. In §405.425, amend paragraph (a) by removing the phrase “Medicare+Choice” and 

adding in its place the phrase “Medicare Advantage”. 

§405.450 [Amended] 

10. In §405.450, amend paragraph (a) by removing the reference “§405.803” and adding 

in its place the reference “§498.3(b) of this chapter” and amend paragraph (b) by removing the 

reference “§405.803” and adding in its place “§405.924”. 

§405.455 [Amended] 

11. In §405.455, remove the phrase “Medicare+Choice” and add in its place the phrase 

“Medicare Advantage” wherever it appears. 

12. Section 405.924 is amended by adding paragraph (b)(15) to read as follows: 

§405.924 Actions that are initial determinations. 

 * * * * * 

(b) * * * 

(15) A claim not payable to a beneficiary for the services of a physician who has optedout. 

 * * * * * 

13. Section 405.2413 is amended by— 

A. Amending paragraph (a)(4) by removing “;” and by adding in its place “; and”. 

B. Revising paragraph (a)(5). 

C. Removing paragraph (a)(6). 

The revision reads as follow: 

§405.2413 Services and supplies incident to a physician's services. 

 (a) * * * 
CMS-1612-FC 1151

(5) Furnished under the direct supervision of a physician. 

 * * * * * 

 14. Section 405.2415 is amended by— 

A. Revising the section heading and paragraph (a)(5). 

B. Removing paragraph (a)(6). 

The revision reads as follows: 

§405.2415 Services and supplies incident to nurse practitioner, physician assistant, or 

certified nurse-midwife services. 

(a) * * * 

(5) Furnished under the direct supervision of a nurse practitioner, physician assistant, or 

certified nurse- midwife. 

 * * * * * 

 15. Section 405.2452 is amended by— 

A. Amending paragraph (a)(4) by removing “;” and by adding in its place “; and”. 

B. Revising paragraph (a)(5). 

C. Removing paragraph (a)(6). 

The revision reads as follows: 

§405.2452 Services and supplies incident to clinical psychologist and clinical social worker 

services. 

 (a) * * * 

(5) Furnished under the direct supervision of a clinical psychologist or clinical social 

worker. 

 * * * * * 

16. Section 405.2463 is revised to read as follows: 
CMS-1612-FC 1152

§405.2463 What constitutes a visit. 

(a) Visit--General. (1) For RHCs, a visit is either of the following: 

(i) Face-to-face encounter between a RHC patient and one of the following: 

(A) Physician. 

(B) Physician assistant. 

(C) Nurse practitioner. 

(D) Certified nurse midwife. 

(E) Visiting registered professional or licensed practical nurse. 

(G) Clinical psychologist. 

(H) Clinical social worker. 

(ii) Qualified transitional care management service. 

(2) For FQHCs, a visit is either of the following: 

(i) A visit as described in paragraph (a)(1)(i) or (ii) of this section. 

(ii) A face-to-face encounter between a patient and either of the following: 

(A) A qualified provider of medical nutrition therapy services as defined in part 410, 

subpart G, of this chapter. 

(B) A qualified provider of outpatient diabetes self-management training services as 

defined in part 410, subpart H, of this chapter. 

(b) Visit--Medical. (1) A medical visit is a face-to-face encounter between a RHC or 

FQHC patient and one of the following: 

(i) Physician. 

(ii) Physician assistant. 

(iii) Nurse practitioner. 

(iv) Certified nurse midwife. 
CMS-1612-FC 1153

(v) Visiting registered professional or licensed practical nurse. 

(2) A medical visit for a FQHC patient may be either of the following: 

(i) Medical nutrition therapy visit. 

(ii) Diabetes outpatient self-management training visit. 

(3) Visit--Mental health. A mental health visit is a face-to-face encounter between a RHC 

or FQHC patient and one of the following: 

(i) Clinical psychologist. 

(ii) Clinical social worker. 

(iii) Other RHC or FQHC practitioner, in accordance with paragraph (b)(1) of this 

section, for mental health services. 

(c) Visit--Multiple. (1) For RHCs and FQHCs that are authorized to bill under the 

reasonable cost system, encounters with more than one health professional and multiple 

encounters with the same health professional that take place on the same day and at a single 

location constitute a single visit, except when the patient— 

(i) Suffers an illness or injury subsequent to the first visit that requires additional 

diagnosis or treatment on the same day; 

(ii) Has a medical visit and a mental health visit on the same day; or 

(iii) Has an initial preventive physical exam visit and a separate medical or mental health 

visit on the same day. 

(2) For RHCs and FQHCs that are authorized to bill under the reasonable cost system, 

Medicare pays RHCs and FQHCs for more than 1 visit per day when the conditions in paragraph 

(c)(1) of this section are met. 
CMS-1612-FC 1154

(3) For FQHCs that are authorized to bill under the reasonable cost system, Medicare 

pays for more than 1 visit per day when a DSMT or MNT visit is furnished on the same day as a 

visit described in paragraph (c)(1) of this section are met. 

(4) For FQHCs billing under the prospective payment system, Medicare pays for more 

than 1 visit per day when the patient— 

(i) Suffers an illness or injury subsequent to the first visit that requires additional 

diagnosis or treatment on the same day; or 

(ii) Has a medical visit and a mental health visit on the same day. 

PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 

17. The authority citation for part 410 continues to read as follows: 

Authority: Secs. 1102, 1834, 1871, 1881, and 1893 of the Social Security Act (42 

U.S.C. 1302. 1395m, 1395hh, and 1395ddd. 

18. Section 410.26 is amended by revising paragraphs (b)(5) and (b)(6) to read as 

follows: 

§410.26 Services and supplies incident to a physician's professional services: 

Conditions. 

* * * * * 

(b) * * * 

(5) In general, services and supplies must be furnished under the direct supervision of the 

physician (or other practitioner). Services and supplies furnished incident to transitional care 

management and chronic care management services can be furnished under general supervision 

of the physician (or other practitioner) when these services or supplies are provided by clinical 

staff. The physician (or other practitioner) supervising the auxiliary personnel need not be the 
CMS-1612-FC 1155

same physician (or other practitioner) upon whose professional service the incident to service is 

based. 

(6) Services and supplies must be furnished by the physician, practitioner with an 

incident to benefit, or auxiliary personnel. 

* * * * * 

19. Section 410.37 is amended by revising paragraph (a)(1)(iii) to read as follows: 

§410.37 Colorectal cancer screening tests: Conditions for and limitations on coverage.

 (a) * * * 

(1) * * * 

(iii) Screening colonoscopies, including anesthesia furnished in conjunction with the 

service. 

* * * * * 

20. Section 410.59 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.59 Outpatient occupational therapy services: Conditions.

* * * * * 

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of occupational therapy on a regular basis as an 

individual, in one of the following practice types: a solo practice, partnership, or group practice; 

or as an employee of one of these. 

* * * * * 

21. Section 410.60 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.60 Outpatient physical therapy services: Conditions.

* * * * * 
CMS-1612-FC 1156

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of physical therapy on a regular basis as an individual, 

in one of the following practice types: a solo practice, partnership, or group practice; or as an 

employee of one of these. 

* * * * * 

22. Section 410.62 is amended by revising paragraph (c)(1)(ii) to read as follows: 

§410.62 Outpatient speech-language pathology services: Conditions and exclusions. 

 * * * * * 

(c) * * * 

(1) * * * 

(ii) Engage in the private practice of speech-language pathology on a regular basis as an 

individual, in one of the following practice types: a solo practice, partnership, or group practice; 

or as an employee of one of these. 

* * * * * 

23. Section 410.78 is amended by revising paragraph (b) introductory text and paragraph 

(f) to read as follows: 

§410.78 Telehealth services. 

* * * * * 

(b) General rule. Medicare Part B pays for covered telehealth services included on the 

telehealth list when furnished by an interactive telecommunications system if the following 

conditions are met: 

* * * * * 
CMS-1612-FC 1157

(f) Process for adding or deleting services. Changes to the list of Medicare telehealth 

services are made through the annual physician fee schedule rulemaking process. A list of the 

services covered as telehealth services under this section is available on the CMS website. 

PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE 

PAYMENT 

24. The authority citation for part 411 continues to read as follows: 

Authority: Secs. 1102, 1860D-1 through 1860D-42, 1871, and 1877 of the Social 

Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn). 

25. Section 411.15 is amended by adding paragraph (p)(2)(xvii) to read as follows: 

§411.15 Particular services excluded from coverage. 

* * * * * 

(p) * * * 

(2) * * * 

(xvii) Those RHC and FQHC services that are described in §405.2411(b)(2) of this 

chapter. 

* * * * * 

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 

SERVICES 

26. The authority citation for part 412 continues to read as follows: 

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh), sec. 124 of Pub. L. 106-113 (113 Stat. 1501A-332), sec. 1206 of Pub. L. 113-67, and 

sec. 112 of Pub. L. 113-93. 

§412.64 [Amended]

27. In 412.64— 
CMS-1612-FC 1158

A. Amend paragraph (d)(4)(ii)(A) by removing the phrase “to April 1 of the year before 

the payment adjustment year” and adding in its place the phrase “to April 1 of the year before the 

payment adjustment year, or a later date specified by CMS”. 

B. Amend paragraph (d)(4)(ii)(A) by removing the phrase “by April 1 of the year before 

the applicable payment adjustment year” and adding in its place the phrase “by April 1 of the 

year before the applicable payment adjustment year, or a later date specified by CMS”. 

C. Amend paragraph (d)(4)(ii)(B)(1) by removing the phrase “April 1 of the year before 

the applicable payment adjustment year” and adding in its place the phrase “April 1 of the year 

before the applicable payment adjustment year, or a later date specified by CMS”. 

D. Amend paragraph (d)(4)(ii)(B)(2) by removing the phrase “April 1 of the year before 

the applicable payment adjustment year” and adding in its place the phrase “April 1 of the year 

before the applicable payment adjustment year, or a later date specified by CMS”. 

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT 

FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY 

DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITY SERVICES 

28. The authority citation for part 413 continues to read as follows: 

Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 

1881, 1883 and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 

1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. L. 

106-113 (113 Stat. 1501A-332), sec. 3201 of Pub. L. 112-96 (126 Stat. 156), and sec. 632 of 

Pub. L. 112-240 (126 Stat. 2354). 

§ 413.70 [Amended] 

29. Amend §413.70 by: 
CMS-1612-FC 1159

A. Amending paragraph (a)(6)(ii) introductory text by removing the phrase “no later than 

November 30 after the close of the applicable EHR reporting period” and adding in its place the 

phrase “ no later than November 30 after the close of the applicable EHR reporting period, or a 

later date specified by CMS ”. 

B. Amending paragraph (a)(6)(ii)(A) by removing the phrase “to November 30 after the 

end of the payment adjustment year” and adding in its place the phrase “to November 30 after 

the end of the payment adjustment year, or a later date specified by CMS”. 

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES 

30. The authority citation for part 414 continues to read as follows: 

Authority: Secs. 1102, 1871, and 1881(b)(l) of the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395rr(b)(l)). 

31. Section 414.24 is amended by— 

A. Revising the section heading, and paragraphs (a) and (b). 

B. Redesignating paragraph (c) as paragraph (d). 

C. Adding new paragraph (c). 

The revisions and addition read as follows: 

§414.24 Publication of RVUs and direct PE inputs. 

(a) Definitions. For purposes of this section, the following definitions apply: 

Existing code means a code that is not a new code under paragraph (c)(2) of this section, 

and includes codes for which the descriptor is revised and codes that are combinations or 

subdivisions of previously existing codes. 

New code means a code that describes a service that was not previously described or 

valued under the PFS using any other code or combination of codes. 
CMS-1612-FC 1160

(b) Revisions of RVUs and Direct PE Inputs. For valuations for calendar year 2017 and 

beyond, CMS publishes, through notice and comment rulemaking in the Federal Register

(including proposals in a proposed rule), changes in RVUs or direct PE inputs for existing codes. 

(c) Establishing RVUs and Direct PE inputs for new codes. 

(1) General rule. CMS establishes RVUs and direct PE inputs for new codes in the 

manner described in paragraph (b) of this section. 

(2) Exception for new codes for which CMS does not have sufficient information. When 

CMS determines for a new code that it does not have sufficient information to include proposed 

RVUs or direct PE inputs in the proposed rule, but that it is in the public interest for Medicare to 

use a new code during a payment year, CMS will publish in the Federal Register RVUs and 

direct PE inputs that are applicable on an interim basis subject to public comment. After 

considering public comments and other information on interim RVUs and PE inputs for the new 

code, CMS publishes in the Federal Register the final RVUs and PE inputs for the code. 

 * * * * * 

 32. Section 414.90 is amended by— 

A. In paragraph (b) by revising the definition of “Measures group”. 

B. In paragraphs (h)(5)(i)(B), (h)(5)(v), (j)(5)(i)(B) and (j)(5)(v) remove the phrase “CG 

CAHPS” and add in its place the phrase “CAHPS for PQRS”. 

C. In paragraphs (h)(4)(v) and (j)(4)(vi) remove the phrase “CAHPS” and add in its 

place the phrase “CAHPS for PQRS”. 

D. Redesignate paragraphs (j)(4) and (j)(5) as (j)(5) and (j)(6), respectively. 

E. Adding new paragraphs (j)(4), (j)(7), (k)(4) and (m)(3). 

F. Revising paragraph (m)(1). 

The revisions read as follows: 
CMS-1612-FC 1161

§414.90 Physician Quality Reporting System (PQRS). 

 * * * * * 

(b) * * * 

Measures group means a subset of six or more PQRS measures that have a particular 

clinical condition or focus in common. The denominator definition and coding of the measures 

group identifies the condition or focus that is shared across the measures within a particular 

measures group. 

 * * * * * 

(j) * * * 

(4) Satisfactory Reporting Criteria for Individual Eligible Professionals for the 2017 PQRS 

Payment Adjustment. An individual eligible professional who wishes to meet the criteria for 

satisfactory reporting for the 2017 PQRS payment adjustment must report information on PQRS 

quality measures identified by CMS in one of the following manners: 

(i) Via Claims. (A) For the 12-month 2017 PQRS payment adjustment reporting period--

(1)(i) Report at least 9 measures, covering at least 3 of the NQS domains and report each 

measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Of the 9 measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 

professional must report on at least 1 measure contained in the cross-cutting measure set 

specified by CMS. If less than 9 measures apply to the eligible professional, report up to 8 

measures and report each measure for at least 50 percent of the Medicare Part B FFS patients 

seen during the reporting period to which the measure applies. Measures with a 0 percent 

performance rate would not be counted. 

(ii) [Reserved] 
CMS-1612-FC 1162

(ii) Via Qualified Registry. (A) For the 12-month 2017 PQRS payment adjustment 

reporting period--

(1)(i) Report at least 9 measures, covering at least 3 of the NQS domains and report each 

measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Of the 9 measures reported, if the 

eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible 

professional must report on at least 1 measure contained in the cross-cutting measure set 

specified by CMS. If less than 9 measures apply to the eligible professional, report up to 8 

measures and report each measure for at least 50 percent of the Medicare Part B FFS patients 

seen during the reporting period to which the measure applies. 

(ii) Report at least 1 measures group and report each measures group for at least 20 

patients, a majority of which much be Medicare Part B FFS patients. 

(2) Measures with a 0 percent performance rate or measures groups containing a measure 

with a 0 percent performance rate will not be counted. 

(iii) Via EHR Direct Product. For the 12-month 2017 PQRS payment adjustment 

reporting period, report 9 measures covering at least 3 of the NQS domains. If an eligible 

professional's direct EHR product does not contain patient data for at least 9 measures covering 

at least 3 domains, then the eligible professional must report the measures for which there is 

Medicare patient data. An eligible professional must report on at least 1 measure for which there 

is Medicare patient data. 

(iv) Via EHR Data Submission Vendor. For the 12-month 2017 PQRS payment 

adjustment reporting period, report 9 measures covering at least 3 of the NQS domains. If an 

eligible professional's EHR data submission vendor product does not contain patient data for at 

least 9 measures covering at least 3 domains, then the eligible professional must report the 
CMS-1612-FC 1163

measures for which there is Medicare patient data. An eligible professional must report on at 

least 1 measure for which there is Medicare patient data. 

 * * * * * 

(7) Satisfactory reporting criteria for group practices for the 2017 PQRS payment 

adjustment. A group practice who wishes to meet the criteria for satisfactory reporting for the 

2017 PQRS payment adjustment must report information on PQRS quality measures identified 

by CMS in one of the following manners: 

(i) Via the GPRO web interface. For the 12-month 2017 PQRS payment adjustment 

reporting period, for a group practice of 25 to 99 eligible professionals, report on all measures 

included in the web interface and populate data fields for the first 248 consecutively ranked and 

assigned beneficiaries in the order in which they appear in the group's sample for each module or 

preventive care measure. If the pool of eligible assigned beneficiaries is less than 248, then 

report on 100 percent of assigned beneficiaries. A group practice must report on at least 1 

measure for which there is Medicare patient data. 

(ii) Via Qualified Registry. For a group practice of 2 to 99 eligible professionals, for the 

12-month 2017 PQRS payment adjustment reporting period, report at least 9 measures, covering 

at least 3 of the NQS domains and report each measure for at least 50 percent of the group 

practice's Medicare Part B FFS patients seen during the reporting period to which the measure 

applies; or if less than 9 measures covering at least 3 NQS domains apply to the eligible 

professional, then the group practice must report up to 8 measures for which there is Medicare 

patient data and report each measure for at least 50 percent of the group practice's Medicare Part 

B FFS patients seen during the reporting period to which the measure applies. Of the measures 

reported, if any eligible professional in the group practice sees at least 1 Medicare patient in a 

face-to-face encounter, the group practice must report on at least 1 measure contained in the 
CMS-1612-FC 1164

cross-cutting measure set specified by CMS. Measures with a 0 percent performance rate would 

not be counted; or 

(iii) Via EHR Direct Product. For a group practice of 2 to 99 eligible professionals, for 

the 12-month 2017 PQRS payment adjustment reporting period, report 9 measures covering at 

least 3 of the NQS domains. If a group practice's direct EHR product does not contain patient 

data for at least 9 measures covering at least 3 domains, then the group practice must report the 

measures for which there is Medicare patient data. A group practice must report on at least 1 

measure for which there is Medicare patient data. 

(iv) Via EHR Data Submission Vendor. For a group practice of 2 to 99 eligible 

professionals, for the 12-month 2017 PQRS payment adjustment reporting period, report 9 

measures covering at least 3 of the NQS domains. If a group practice's EHR data submission 

vendor product does not contain patient data for at least 9 measures covering at least 3 domains, 

then the group practice must report the measures for which there is Medicare patient data. A 

group practice must report on at least 1 measure for which there is Medicare patient data. 

(v) Via a Certified Survey Vendor in addition to a Qualified Registry. For a group 

practice of 2 or more eligible professionals, for the 12-month 2017 PQRS payment adjustment 

reporting period, report all CAHPS for PQRS survey measures via a CMS-certified survey 

vendor and report at least 6 additional measures covering at least 2 of the NQS domains using a 

qualified registry. If less than 6 measures apply to the group practice, the group practice must 

report up to 5 measures. Of the additional measures that must be reported in conjunction with 

reporting the CAHPS for PQRS survey measures, if any eligible professional in the group 

practice sees at least 1 Medicare patient in a face-to-face encounter, the group practice must 

report on at least 1 measure in the cross-cutting measure set specified by CMS. 
CMS-1612-FC 1165

(vi) Via a Certified Survey Vendor in addition a Direct EHR Product or EHR Data 

Submission Vendor. For a group practice of 2 or more eligible professionals, for the 12-month 

2017 PQRS payment adjustment reporting period, report all CAHPS for PQRS survey measures 

via a CMS-certified survey vendor and report at least 6 additional measures, outside of CAHPS 

for PQRS, covering at least 2 of the NQS domains using the direct EHR product that is CEHRT 

or EHR data submission vendor product that is CEHRT. If less than 6 measures apply to the 

group practice, the group practice must report up to 5 measures. Of the additional measures that 

must be reported in conjunction with reporting the CAHPS for PQRS survey measures, the group 

practice must report on at least 1 measure for which there is Medicare patient data. 

(vii) Via a Certified Survey Vendor in addition to the GPRO Web interface. (A) For a 

group practice of 25 or more eligible professionals, for the 12-month 2017 PQRS payment 

adjustment reporting period, report all CAHPS for PQRS survey measures via a CMS-certified 

survey vendor and report on all measures included in the GPRO web interface; AND populate 

data fields for the first 248 consecutively ranked and assigned beneficiaries in the order in which 

they appear in the group’s sample for each module or preventive care measure. If the pool of 

eligible assigned beneficiaries is less than 248, then the group practice would report on 100 

percent of assigned beneficiaries. A group practice must report on at least 1 measure for which 

there is Medicare patient data. 

(B) [Reserved] 

(k) * * * 

(4) Satisfactory participation criteria for individual eligible professionals for the 2017 

PQRS payment adjustment. An individual eligible professional who wishes to meet the criteria 

for satisfactory participation in a QCDR for the 2017 PQRS payment adjustment must report 

information on quality measures identified by the QCDR in one of the following manner: 
CMS-1612-FC 1166

(i) For the 12-month 2017 PQRS payment adjustment reporting period, report at least 9 

measures available for reporting under a QCDR covering at least 3 of the NQS domains, and 

report each measure for at least 50 percent of the eligible professional’s patients. Of these 

measures, report on at least 2 outcome measures, or, if 2 outcomes measures are not available, 

report on at least 2 outcome measures and at least 1 of the following types of measures – 

resource use, patient experience of care, efficiency/appropriate use or patient safety. 

(ii) [Reserved] 

 * * * * * 

(m) * * * 

(1) To request an informal review for reporting periods that occur prior to 2014, an 

eligible professional or group practice must submit a request to CMS within 90 days of the 

release of the feedback reports. To request an informal review for reporting periods that occur in 

2014 and subsequent years, an eligible professional or group practice must submit a request to 

CMS within 60 days of the release of the feedback reports. The request must be submitted in 

writing and summarize the concern(s) and reasons for requesting an informal review and may 

also include information to assist in the review. 

 * * * * * 

(3) If, during the informal review process, CMS finds errors in data that was submitted by 

a third-party vendor on behalf of an eligible professional or group practice using either the 

qualified registry, EHR data submission vendor, or QCDR reporting mechanisms, CMS may 

allow for the resubmission of data to correct these errors. 

(i) CMS will not allow resubmission of data submitted via claims, direct EHR, and the 

GPRO web interface reporting mechanisms. 
CMS-1612-FC 1167

(ii) CMS will only allow resubmission of data that was already previously submitted to 

CMS. 

(iii) CMS will only accept data that was previously submitted for the reporting periods 

for which the corresponding informal review period applies. 

 * * * * * 

§414.511 [Removed] 

33. Section §414.511 is removed. 

34. Section 414.610 is amended by revising paragraphs (c)(1)(ii) introductory text and 

(c)(5)(ii) to read as follows: 

§414.610 Basis of payment.

* * * * * 

(c) * * * 

(1) * * * 

(ii) For services furnished during the period July 1, 2008 through March 31, 2015, 

ambulance services originating in: 

* * * * * 

(5) * * * 

(ii) For services furnished during the period July 1, 2004 through March 31, 2015, the 

payment amount for the ground ambulance base rate is increased by 22.6 percent where the point 

of pickup is in a rural area determined to be in the lowest 25 percent of rural population arrayed 

by population density. The amount of this increase is based on CMS’s estimate of the ratio of 

the average cost per trip for the rural areas in the lowest quartile of population compared to the 

average cost per trip for the rural areas in the highest quartile of population. In making this 

estimate, CMS may use data provided by the GAO. 
CMS-1612-FC 1168

* * * * * 

35. Section 414.1200 is amended by revising paragraphs (a) and (b)(5) to read as 

follows: 

§414.1200 Basis and scope. 

(a) Basis. This subpart implements section 1848(p) of the Act by establishing a payment 

modifier that provides for differential payment starting in 2015 to a group of physicians and 

starting in 2017 to a group and a solo practitioner under the Medicare Physician Fee Schedule 

based on the quality of care furnished compared to cost during a performance period. 

(b) * * * 

(5) Additional measures for groups and solo practitioners. 

* * * * * 

36. Section 414.1205 is amended by— 

A. Revising the definitions of “Group of physicians” and “Value-based payment 

modifier.” 

B. Adding the definition of “Solo practitioner” in alphabetical order. 

The addition and revisions read as follows: 

§414.1205 Definitions. 

* * * * * 

Group of physicians (Group) means a single Taxpayer Identification Number (TIN) with 

2 or more eligible professionals, as identified by their individual National Provider Identifier 

(NPI), who have reassigned their Medicare billing rights to the TIN. 

* * * * * 
CMS-1612-FC 1169

Solo practitioner means a single Taxpayer Identification Number (TIN) with one eligible 

professional who is identified by an individual National Provider Identifier (NPI) billing under 

the TIN. 

* * * * * 

Value-based payment modifier means the percentage as determined under §414.1270 by 

which amounts paid to a group or solo practitioner under the Medicare Physician Fee Schedule 

established under section 1848 of the Act are adjusted based upon a comparison of the quality of 

care furnished to cost as determined by this subpart. 

37. Section 414.1210 is amended by— 

A. Adding paragraphs (a)(3), (a)(4), (b)(2), (b)(3), and (b)(4). 

B. Revising paragraph (c). 

The additions and revision reads as follows: 

§414.1210 Application of the value-based payment modifier.

(a) * * * 

(3) For the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period, to physicians in groups with 2 or more eligible professionals and to 

physicians who are solo practitioners based on the performance period for the payment 

adjustment period as described at §414.1215. 

(4) For the CY 2018 payment adjustment period and each subsequent calendar year 

payment adjustment period, to nonphysician eligible professionals in groups with 2 or more 

eligible professionals and to nonphysician eligible professionals who are solo practitioners based 

on the performance period for the payment adjustment period as described at §414.1215. 

(b) * * * 
CMS-1612-FC 1170

(2) Application of the value-based payment modifier to participants in the Shared Savings 

Program. 

(i) For the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period, the value-based payment modifier is applicable to physicians in 

groups with 2 or more eligible professionals and to physicians who are solo practitioners that 

participate in an ACO under the Shared Savings Program during the performance period for the 

payment adjustment period as described at §414.1215. The value-based payment modifier for a 

group or solo practitioner that participates in an ACO under the Shared Savings Program during 

the performance period is determined based on paragraphs (b)(2)(i)(A) through (D) of this 

section. 

(A) The cost composite is classified as “average” under §414.1275(b). 

(B) The quality composite score is calculated under §414.1260(a) using quality data 

reported by the ACO for the performance period through the ACO GPRO web interface as 

required under § 425.504(a)(1) or another mechanism specified by CMS and the ACO all-cause 

readmission measure. 

(C) For the CY 2017 payment adjustment period, the value-based payment modifier 

adjustment will be equal to the amount determined under § 414.1275 for the payment adjustment 

period, except that if the ACO does not successfully report quality data as described in paragraph 

(b)(2)(i)(B) of this section for the performance period, such adjustment will be equal to – 4% for 

groups with 10 or more eligible professionals and equal to – 2% for groups with two to nine 

eligible professionals and for solo practitioners. 

(D) The same value-based payment modifier adjustment will be applied in the payment 

adjustment period to all groups based on size as specified under § 414.1275 and solo 

practitioners that participated in the ACO during the performance period. 
CMS-1612-FC 1171

(ii) For the CY 2018 payment adjustment period and each subsequent calendar year 

payment adjustment period, the value-based payment modifier is applicable to nonphysician 

eligible professionals in groups with 2 or more eligible professionals and to nonphysician 

eligible professionals who are solo practitioners that participate in an ACO under the Shared 

Savings Program during the performance period for the payment adjustment period as described 

at §414.1215. The value-based payment modifier for nonphysician eligible professionals is 

determined in the same manner as for physicians as described under paragraphs (b)(2)(i)(A) 

through (D) of this section. 

 (3) Application of the value-based payment modifier to participants in the Pioneer ACO 

Model and the Comprehensive Primary Care Initiative. 

(i) For the CY 2017 payment adjustment period, the value-based payment modifier is 

applicable to physicians in groups with 2 or more eligible professionals and to physicians who 

are solo practitioners that participate in the Pioneer ACO Model or the Comprehensive Primary 

Care (CPC) Initiative during the performance period for the payment adjustment period as 

described at §414.1215. For purposes of the value-based payment modifier, a group or solo 

practitioner is considered to be participating in the Pioneer ACO Model or CPC Initiative if at 

least one eligible professional billing under the TIN in the performance period is participating in 

the Pioneer ACO Model or CPC Initiative in the performance period. The value-based payment 

modifier for groups and solo practitioners that participate in the Pioneer ACO Model or the CPC 

Initiative during the performance period is determined based on paragraphs (b)(3)(i)(A) through 

(C) of this section. 

(A) The cost composite is classified as “average” under §414.1275(b). 

(B) The quality composite is classified as “average” under §414.1275(b). 
CMS-1612-FC 1172

(C) The same value-based payment modifier adjustment will be applied in the payment 

adjustment period to all groups based on size as specified under § 414.1275 and solo 

practitioners that participated in the Pioneer ACO or CPC site during the performance period. 

 (4) Application of the value-based payment modifier to participants in other similar 

Innovation Center models or CMS initiatives. 

(i) For the CY 2017 payment adjustment period and each subsequent calendar year 

payment adjustment period, the value-based payment modifier is applicable to physicians in 

groups with 2 or more eligible professionals and to physicians who are solo practitioners that 

participate in other similar Innovation Center models or CMS initiatives during the performance 

period for the payment adjustment period as described at §414.1215. For purposes of the valuebased payment modifier, a group or solo practitioner is considered to be participating in a similar 

Innovation Center model or CMS initiative if at least one eligible professional billing under the 

TIN in the performance period is participating in the model or initiative in the performance 

period. The value-based payment modifier for groups and solo practitioners that participate in a 

similar Innovation Center model or CMS initiative is determined based on paragraphs 

(b)(3)(i)(A) through (C) of this section. 

(ii) [Reserved] 

 (c) Group size determination. The list of groups of physicians subject to the valuebased payment modifier for the CY 2015 payment adjustment period is based on a query of 

PECOS on October 15, 2013. For each subsequent calendar year payment adjustment period, the 

list of groups and solo practitioners subject to the value-based payment modifier is based on a 

query of PECOS that occurs within 10 days of the close of the Physician Quality Reporting 

System group registration process during the applicable performance period described at 

§414.1215. Groups are removed from the PECOS-generated list if, based on a claims analysis, 
CMS-1612-FC 1173

the group did not have the required number of eligible professionals, as defined in §414.1210(a), 

that submitted claims during the performance period for the applicable calendar year payment 

adjustment period. Solo practitioners are removed from the PECOS-generated list if, based on a 

claims analysis, the solo practitioner did not submit claims during the performance period for the 

applicable calendar year payment adjustment period. 

§414.1220 [Amended] 

38. In §414.1220, remove the phrase “Groups of physicians” and add in its place the 

phrase “Solo practitioners and groups”. 

39. Section 414.1225 is revised to read as follows: 

§414.1225 Alignment of Physician Quality Reporting System quality measures and quality 

measures for the value-based payment modifier. 

All of the quality measures for which solo practitioners and groups (or individual eligible 

professionals within such groups) are eligible to report under the Physician Quality Reporting 

System in a given calendar year are used to calculate the value-based payment modifier for the 

applicable payment adjustment period, as defined in §414.1215, to the extent a solo practitioner 

or a group (or individual eligible professionals within such group) submit data on such measures. 

40. Section 414.1230 is amended by revising the section heading and the introductory 

text to read as follows: 

§414.1230 Additional measures for groups and solo practitioners. 

The value-based payment modifier includes the following additional quality measures 

(outcome measures) as applicable for all groups and solo practitioners subject to the value-based 

payment modifier: 

* * * * * 

§414.1235 [Amended] 
CMS-1612-FC 1174

41. In §414.1235, amend paragraph (a) introductory text, by removing the phrase “of 

physicians subject” and add in its place the phrase “and solo practitioners subject”. 

42. Section 414.1240 is revised to read as follows: 

§414.1240 Attribution for quality of care and cost measures. 

(a) Beneficiaries are attributed to groups and solo practitioners subject to the value-based 

payment modifier using a method generally consistent with the method of assignment of 

beneficiaries under §425.402 of this chapter, for measures other than the Medicare Spending per 

Beneficiary measure. 

(b) For the Medicare Spending per Beneficiary (MSPB) measure, an MSPB episode is 

attributed to the group or the solo practitioner subject to the value-based payment modifier 

whose eligible professionals submitted the plurality of claims (as measured by allowable 

charges) under the group's or solo practitioner’s TIN for Medicare Part B services, rendered 

during an inpatient hospitalization that is an index admission for the MSPB measure during the 

applicable performance period described at §414.1215. 

§414.1245 [Amended] 

43. In §414.1245, amend the introductory text, by removing the phrase “of physicians 

subject” and add in its place the phrase “and solo practitioner subject”. 

44. Section 414.1250 is revised to read as follows: 

§414.1250 Benchmarks for quality of care measures. 

(a) The benchmark for quality of care measures reported through the PQRS using the 

claims, registries, EHR, or web interface is the national mean for that measure's performance rate 

(regardless of the reporting mechanism) during the year prior to the performance period. In 

calculating the national benchmark, solo practitioners’ and groups’ (or individual eligible 

professionals’ within such groups) performance rates are weighted by the number of 
CMS-1612-FC 1175

beneficiaries used to calculate the solo practitioners’ or groups’ (or individual eligible 

professionals’ within such groups) performance rate. 

 (b) The benchmark for each outcome measure under §414.1230, is the national mean for 

that measure’s performance rate during the year prior to the performance period. In calculating 

the national benchmark, solo practitioners’ and groups’ (or individual eligible professionals’ 

within such groups) performance rates are weighted by the number of beneficiaries used to 

calculate the solo practitioners’ or groups’ (or individual eligible professionals’ within such 

groups) performance rate. 

45. Section 414.1255 is amended by revising paragraphs (b) and (c) to read as follows: 

§414.1255 Benchmarks for cost measures. 

* * * * * 

(b) Beginning with the CY 2016 payment adjustment period, the cost measures of a 

group and solo practitioner subject to the value-based payment modifier are adjusted to account 

for the group's and solo practitioner’s specialty mix, by computing the weighted average of the 

national specialty-specific expected costs. Each national specialty-specific expected cost is 

weighted by the proportion of each specialty in the group, the number of eligible professionals of 

each specialty in the group, and the number of beneficiaries attributed to the group. 

(c) The national specialty-specific expected costs referenced in paragraph (b) of this 

section are derived by calculating, for each specialty, the average cost of beneficiaries attributed 

to groups and solo practitioners that include that specialty. 

46. Section 414.1265 is amended by revising the introductory text and paragraph (a) to 

read as follows: 

§414.1265 Reliability of measures. 
CMS-1612-FC 1176

To calculate a composite score for a quality measure or a cost measure, a group or solo 

practitioner subject to the value-based payment modifier must have 20 or more cases for that 

measure. 

 (a) In a performance period, if a group or solo practitioner has fewer than 20 cases for a 

measure, that measure is excluded from its domain and the remaining measures in the domain are 

given equal weight. 

(1) Starting with the CY 2017 payment adjustment period, the exception to this paragraph 

(a) is the all-cause hospital readmissions measure described at §414.1230(c). In a performance 

period, if a group or a solo practitioner has fewer than 200 cases for this all-cause hospital 

readmissions measure, that measure is excluded from its domain and the remaining measures in 

the domain are given equal weight. 

(2) [Reserved] 

* * * * * 

47. Section 414.1270 is amended by revising paragraph (b)(4) and adding paragraph (c) 

to read as follows: 

§414.1270 Determination and calculation of Value-Based Payment Modifier adjustments. 

* * * * * 

(b) * * * 

(4) If at least fifty percent of the eligible professionals in the group meet the criteria as 

individuals to avoid the PQRS payment adjustment for CY 2016 as specified by CMS, and all of 

those eligible professionals use a qualified clinical data registry and CMS is unable to receive 

quality performance data for them, the quality composite score for such group will be classified 

as “average” under § 414.1275(b)(1). 

* * * * * 
CMS-1612-FC 1177

(c) For the CY 2017 payment adjustment period: 

(1) A downward payment adjustment of −2.0 percent will be applied to a group with two 

to nine eligible professionals and a solo practitioner and a downward payment adjustment of -4.0 

percent will be applied to a group with 10 or more eligible professionals subject to the valuebased payment modifier if, during the applicable performance period as defined in §414.1215, 

the following apply: 

 (i) Such group does not self-nominate for the PQRS GPRO and meet the criteria as a 

group to avoid the PQRS payment adjustment for CY 2017 as specified by CMS; and 

(ii) Fifty percent of the eligible professionals in such group do not meet the criteria as 

individuals to avoid the PQRS payment adjustment for CY 2017 as specified by CMS; or 

(iii) Such solo practitioner does not meet the criteria as an individual to avoid the PQRS 

payment adjustment for CY 2017 as specified by CMS. 

(2) For a group comprised of 10 or more eligible professionals that is not included in 

paragraph (c)(1) of this section, the value-based payment modifier adjustment will be equal to 

the amount determined under §414.1275(c)(3)(i). 

(3) For a group comprised of between two to nine eligible professionals and a solo 

practitioner that are not included in paragraph (c)(1) of this section, the value-based payment 

modifier adjustment will be equal to the amount determined under §414.1275(c)(3)(ii). 

 (4) If at least fifty percent of the eligible professionals in the group meet the criteria as 

individuals to avoid the PQRS payment adjustment for CY 2017 as specified by CMS, and all of 

those eligible professionals use a qualified clinical data registry and CMS is unable to receive 

quality performance data for them, the quality composite score for such group will be classified 

as “average” under § 414.1275(b)(1). 
CMS-1612-FC 1178

(5) A group and a solo practitioner subject to the value-based payment modifier will 

receive a cost composite score that is classified as “average” under §414.1275(b)(2) if such 

group and solo practitioner do not have at least one cost measure with at least 20 cases. 

48. Section 414.1275 is amended by— 

A. Revising paragraph (a). 

B. Redesignating paragraphs (d) introductory text, (d)(1), and (d)(2) as paragraphs (d)(1) 

introductory text, (d)(1)(i), and (d)(1)(ii), respectively. 

C. Adding paragraphs (c)(3) and (d)(2). 

The revision and additions read as follows: 

§414.1275 Value-based payment modifier quality-tiering scoring methodology.

(a) The value-based payment modifier amount for a group and a solo practitioner subject 

to the value-based payment modifier is based upon a comparison of the composite of quality of 

care measures and a composite of cost measures. 

* * * * * 

(c) * * * 

(3) The following value-based payment modifier percentages apply to the CY 2017 

payment adjustment period: 

(i) For groups with 10 or more eligible professionals: 

CY 2017 VALUE-BASED PAYMENT MODIFIER AMOUNTS FOR THE QUALITY-TIERING 

APPROACH FOR GROUPS WITH 10 OR MORE ELIGIBLE PROFESSIONALS

Cost/Quality Low Quality Average 

Quality 

High Quality 

Low Cost +0.0% +2.0x* +4.0x* 

Average Cost -2.0% +0.0% +2.0x* 

High Cost -4.0% -2.0% +0.0% 

*Groups eligible for an additional +1.0x if reporting Physician Quality Reporting System quality measures and 

average beneficiary risk score is in the top 25 percent of all beneficiary risk scores, where ‘x’ represents the upward 

payment adjustment factor. 

(ii) For groups with two to nine eligible professionals and solo practitioners: 
CMS-1612-FC 1179

CY 2017 VALUE-BASED PAYMENT MODIFIER AMOUNTS FOR THE QUALITY-TIERING 

APPROACH FOR GROUPS WITH TWO TO NINE ELIGIBLE PROFESSIONALS AND SOLO 

PRACTITIONERS

Cost/Quality Low Quality Average 

Quality 

High Quality 

Low Cost +0.0% +1.0x* +2.0x* 

Average Cost +0.0% +0.0% +1.0x* 

High Cost +0.0% +0.0% +0.0% 

*Groups and solo practitioners eligible for an additional +1.0x if reporting Physician Quality Reporting System 

quality measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk scores, where ‘x’ 

represents the upward payment adjustment factor. 

 

(d) * * * 

(2) Groups and solo practitioners subject to the value-based payment modifier that have 

an attributed beneficiary population with an average risk score in the top 25 percent of the risk 

scores of beneficiaries nationwide and for the CY 2017 payment adjustment period are subject to 

the quality-tiering approach, receive a greater upward payment adjustment as follows: 

(i) Classified as high quality/low cost receive an upward adjustment of +5x (rather than 

+4x) if the group has 10 or more eligible professionals or +3x (rather than +2x) if a solo 

practitioner or the group has two to nine eligible professionals; and 

(ii) Classified as either high quality/average cost or average quality/low cost receive an 

upward adjustment of +3x (rather than +2x) if the group has 10 or more eligible professionals or 

+2x (rather than +1x) if a solo practitioner or the group has two to nine eligible professionals. 

§414.1285 [Amended] 

49. In §414.1285, remove the phrase “of physicians may” and add in its place the phrase 

“and a solo practitioner may”. 

PART 425--MEDICARE SHARED SAVINGS PROGRAM

50. The authority citation for part 425 continues to read as follows: 

Authority: Secs. 1102, 1106, 1871, and 1899 of the Social Security Act (42 U.S.C. 1302 

and 1395hh). 
CMS-1612-FC 1180

51. Section 425.308 is amended by revising paragraph (e) to read as follows: 

§425.308 Public reporting and transparency. 

* * * * * 

(e) Results of claims based measures. All quality measures will be reported on Physician 

Compare in the same way as for the group practices that report under the Physician Quality Reporting 

System. 

52. Section 425.502 is amended by--: 

A. In paragraph (a)(1), removing the phrase “of an ACO’s agreement, CMS” and adding 

in its place the phrase “of an ACO’s first agreement period, CMS” 

B. In paragraph (b)(2)(ii), removing the phrase “80.00 percent.” and adding in its place 

the phrase “80.00 percent, or when the 90th percentile is equal to or greater than 95 percent.” 

C. Revising paragraph (a)(2). 

D. Adding paragraphs (a)(3), (a)(4), (b)(4), and (e)(4). 

The revision and additions read as follows:

§425.502 Calculating the ACO quality performance score. 

(a) * * * 

(2) During subsequent performance years of the ACO’s first agreement period, the 

quality performance standard will be phased in such that the ACO must continue to report all 

measures but the ACO will be assessed on performance based on the quality performance 

benchmark and minimum attainment level of certain measures. 

(3) Under the quality performance standard for each performance year of an ACO’s 

subsequent agreement period, the ACO must continue to report on all measures but the ACO will 

be assessed on performance based on the quality performance benchmark and minimum 

attainment level of certain measures. 
CMS-1612-FC 1181

(4) The quality performance standard for a newly introduced measure is set at the level of 

complete and accurate reporting for the first two reporting periods for which reporting of the 

measure is required. For subsequent reporting periods, the quality performance standard for the 

measure will be assessed according to the phase-in schedule for the measure. 

(b) * * * 

(4)(i) CMS will update the quality performance benchmarks every 2 years. 

(ii) For newly introduced measures that transition to pay for performance in the second 

year of the 2-year benchmarking cycle, the benchmark will be established for that year and 

updated along with the other measures at the start of the next 2-year benchmarking cycle. 

(iii) CMS will use up to three years of data, as available, to set the benchmark for each 

quality measure. 

* * * * * 

(e) * * * 

(4)(i) ACOs that demonstrate quality improvement on established quality measures from 

year to year will be eligible for up to 4 bonus points per domain. 

(ii) Bonus points are awarded based on an ACO’s net improvement in measures within a 

domain, which is calculated by determining the total number of significantly improved measures 

and subtracting the total number of significantly declined measures. 

(iii) Up to four bonus points are awarded based on a comparison of the ACO’s net 

improvement in performance on the measures for the domain to the total number of individual 

measures in the domain. 

(iv) When bonus points are added to points earned for the quality measures in the 

domain, the total points received for the domain may not exceed the maximum total points for 

the domain in the absence of the quality improvement measure. 
CMS-1612-FC 1182

(v) If an ACO renews its participation agreement for a subsequent agreement period, 

quality improvement will be measured based on a comparison between performance in the first 

year of the new agreement period and performance in the third year of the previous agreement 

period. 

53. Section 425.506 is amended by revising the section heading and adding paragraph 

(d) to read as follows: 

§425.506 Incorporating reporting requirements related to adoption of Electronic health 

records technology. 

* * * * * * 

(d) Eligible professionals participating in an ACO under the Shared Savings Program 

satisfy the CQM reporting component of meaningful use for the Medicare EHR Incentive 

Program when the following occurs: 

(1) The eligible professional extracts data necessary for the ACO to satisfy the quality 

reporting requirements under this subpart from certified EHR technology. 

(2) The ACO reports the ACO GPRO measures through a CMS web interface. 

PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 

54. The authority citation for part 489 continues to read as follows: 

Authority: Secs. 1102, 1128I and 1871 of the Social Security Act (42 U.S.C. 1302, 

1320a-7j, and 1395hh). 

55. Section 489.20 is amended by adding paragraph (s)(17) to read as follows: 

§489.20 Basic commitments. 

* * * * * 

(s) * * * 

(17) Those RHC and FQHC services that are described in § 405.2411(b)(2) of this 
CMS-1612-FC 1183

chapter. 

* * * * * 

PART 495--STANDARDS FOR THE ELECTRONIC HEALTH RECORD 

TECHNOLOGY INCENTIVE PROGRAM 

56. The authority citation for part 495 continues to read as follows: 

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

§495.102 [Amended]

57. In 495.102— 

A. Amend paragraph (d)(4)(i) by removing the phrase in the first sentence “to July 1 of 

the year preceding the payment adjustment year” and adding in its place the phrase “to July 1 of 

the year preceding the payment adjustment year, or a later date specified by CMS”. 

B. Amend paragraph (d)(4)(i) by removing the phrase in the second sentence “no later 

than July 1 of the year before the applicable payment adjustment year” and adding in its place 

the phrase “no later than July 1 of the year before the applicable payment adjustment year, or a 

later date specified by CMS”. 

C. Amend paragraph (d)(4)(iii)(A) by removing the phrase in the second sentence “no 

later than July 1 of the year before the applicable payment adjustment year” and adding in its 

place the phrase “no later than July 1 of the year before the applicable payment adjustment year, 

or a later date specified by CMS”. 

D. Amend paragraph (d)(4)(iii)(B) by removing the phrase in the second sentence “by 

July 1 of the year before the applicable payment adjustment year” and adding in its place the 

phrase “by July 1 of the year before the applicable payment adjustment year, or a later date 

specified by CMS”. 
CMS-1612-FC 1184

E. Amend the introductory text of paragraph (d)(4)(iv) introductory text by removing the 

phrase “by July 1 of the year before the applicable payment adjustment year” and adding in its 

place the phrase “by July 1 of the year before the applicable payment adjustment year, or a later 

date specified by CMS”. 

PART 498—APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT 

PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS 

THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE 

MEDICAID PROGRAM 

58. The authority citation for part 498 continues to read as follows: 

Authority: Secs. 1102, 1128I and 1871 of the Social Security Act (42 U.S.C. 1302, 

1320a-7j, and 1395hh). 

59. Section 498.3 is amended by adding paragraph (b)(19) to read as follow: 

§498.3 Scope and applicability. 

 * * * * * 

(b) * * * 

(19) Whether a physician or practitioner has failed to properly opt-out, failed to maintain 

opt-out, failed to timely renew opt-out, failed to privately contract, or failed to properly terminate 

opt-out. 

 * * * * * 
CMS-1612-FC 

Dated: October 22, 2014. 

 _______________________________ 

Marilyn Tavenner, 

Administrator, 

 Centers for Medicare & Medicaid Services. 

Dated: October 28, 2014. 

 __________________________________ 

Sylvia M. Burwell, 

Secretary, 

Department of Health and Human Services. 

BILLING CODE 4120-01-P

[FR Doc. 2014-26183 Filed 10/31/2014 at 4:15 pm; Publication Date: 11/13/2014]