54842 Federal Register / Vol. 78, No. 173 / Friday, September 6, 2013 / Proposed Rules 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 405, 410, 412, 416, 419, 

475, 476, 486, and 495 

[CMS–1601–CN] 

RIN 0938–AR54 

Medicare and Medicaid Programs: 

Hospital Outpatient Prospective 

Payment and Ambulatory Surgical 

Center Payment Systems and Quality 

Reporting Programs; Hospital ValueBased Purchasing Program; Organ 

Procurement Organizations; Quality 

Improvement Organizations; Electronic 

Health Records (EHR) Incentive 

Program; Provider Reimbursement 

Determinations and Appeals; 

Correction and Limited Extension of 

Comment Period 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Correction and limited 

extension of comment period for 

proposed rule. 

SUMMARY: This document corrects 

technical errors that appeared in the 

proposed rule published in the Federal 

Register on July 19, 2013, entitled 

‘‘Medicare and Medicaid Programs: 

Hospital Outpatient Prospective 

Payment and Ambulatory Surgical 

Center Payment Systems and Quality 

Reporting Programs; Hospital ValueBased Purchasing Program; Organ 

Procurement Organizations; Quality 

Improvement Organizations; Electronic 

Health Records (EHR) Incentive 

Program; Provider Reimbursement 

Determinations and Appeals.’’ 

This document extends the comment 

period for 10 days for the technical 

corrections set forth in this correcting 

document. 

DATES: Comment Period: The comment 

period, for the technical corrections set 

forth in this correcting document, is 

extended to 5 p.m. E.S.T. on September 

16, 2013. 

FOR FURTHER INFORMATION CONTACT: 

Erick Chuang, (410) 786–1816. 

SUPPLEMENTARY INFORMATION: 

I. Background 

In FR. Doc. 2013–16555 of July 19, 

2013 (78 FR 43534), (hereinafter referred 

to as the CY 2014 OPPS/ASC proposed 

rule), there were a number of technical 

errors that are discussed in the 

Summary of Errors, and further 

identified and corrected in the 

Correction of Errors sections. The CY 

2014 OPPS/ASC proposed rule proposes 

to revise the Medicare hospital 

outpatient prospective payment system 

(OPPS) and the Medicare ambulatory 

surgical center (ASC) payment system 

for calendar year (CY) 2014 to 

implement applicable statutory 

requirements and policy changes. In the 

CY 2014 OPPS/ASC proposed rule, we 

described proposed changes to the 

amounts and factors used to determine 

the payment rates for Medicare services 

paid under the OPPS and ASC payment 

system. 

Since the publication of the CY 2014 

OPPS/ASC proposed rule, we have 

reviewed the data on which the CY 2014 

proposed OPPS and ASC payment rates 

were developed, and discovered that in 

the process of applying our established 

and proposed methodologies to develop 

the CY 2014 proposed OPPS and ASC 

payment rates, specific cost estimation 

errors occurred in the OPPS modeling 

process. The errors resulting from the 

cost modeling used to develop the CY 

2014 proposed OPPS payment rates are 

isolated to a few specific ambulatory 

payment classifications (APCs). 

However, because the OPPS is a budget 

neutral payment system, there is a 

resulting impact on other proposed 

OPPS payment rates. The technical 

errors corrected in this document do not 

implicate any of the proposed 

methodologies or other proposed 

policies described in the CY 2014 

OPPS/ASC proposed rule. 

In the CY 2014 OPPS/ASC proposed 

rule, we proposed to continue our 

policy of basing the ASC relative 

payment weights and rates on APC 

groups and the OPPS relative payment 

weights, and because this document 

corrects technical errors related to cost 

modeling conducted in developing the 

proposed OPPS relative payment 

weights, the proposed CY 2014 ASC 

relative payment weights are being 

corrected. As we noted previously, the 

technical errors corrected in this 

document do not implicate any of the 

proposed methodologies or other 

proposed policies described in the CY 

2014 OPPS/ASC proposed rule. 

II. Limited Extension of Comment 

Period 

We are extending the comment 

period, for the limited purpose of 

providing the public an opportunity to 

comment on the technical corrections 

noted in this correcting document, for 

an additional 10 days, to September 16, 

2013. 

III. Summary of Errors and Corrections 

Posted on the CMS Web Site 

A. Outpatient Prospective Payment 

System Payment System Corrections 

In the CY 2014 OPPS/ASC proposed 

rule, we announced a number of 

proposals that would affect the CY 2014 

OPPS. One of the policy changes we 

proposed was a reconfiguration of how 

the visit APCs would be coded and paid 

in the CY 2014 OPPS (78 FR 43614). 

Separately, for the CY 2014 OPPS, we 

proposed to package certain clinical 

diagnostic laboratory tests that were 

previously paid to hospitals at the 

Clinical Lab Fee Schedule payment 

rates (78 FR 43572). Following the 

standard methodology we use to 

develop OPPS payment rates described 

in the proposed rule, we modeled the 

relevant data to develop the proposed 

new visit APCs (78 FR 43615 through 

43616). Subsequently, in reviewing how 

the cost modeling occurred in 

developing the proposed new visit APCs 

contained in the CY 2014 OPPS/ASC 

proposed rule, we discovered that a 

programming error caused the packaged 

costs associated with the CY 2014 

clinical diagnostic laboratory test 

packaging proposal to be excluded. To 

accurately reflect the interaction of 

these two CY 2014 OPPS proposed 

policies, in this correcting document, 

we have fixed this programming issue 

and developed proposed APC relative 

payment weights for the following 

proposed new visit APCs: 0634 

(Hospital Clinic Visits), 0635 (Type A 

Emergency Visits), and 0636 (Type B 

Emergency Visits). 

As a result of the proposed coding 

and payment changes to the visit APCs, 

we proposed a new composite APC 

8009 (Extended Assessment and 

Management Composite) for the CY 

2014 OPPS (78 FR 43562 through 

43563). Additionally, we proposed to 

expand the line item trim to also 

include clinical diagnostic laboratory 

tests that did not receive payment in the 

claims year in our cost modeling 

process for the CY 2014 OPPS (78 FR 

43551). Upon reviewing the cost data 

used to develop this proposed APC, we 

discovered that the line item trim was 

not correctly applied to the proposed 

new composite APC 8009 in our cost 

modeling process. In this correcting 

document, we are correctly applying the 

proposed line item trim for clinical 

diagnostic laboratory tests that did not 

receive payment in the claims year in 

estimating the costs associated with 

proposed new composite APC 8009. 

For the CY 2014 OPPS, we proposed 

to recognize the CPT codes for 

stereotactic radiosurgery (77371, 77372, 


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and 77373) while no longer recognizing 

the G-codes that had previously been 

used to identify certain stereotactic 

radiosurgery services (G0173, G0251, 

G0339, and G0340) (78 FR 43593 

through 43594). However, following our 

established and proposed 

methodologies, in developing the 

estimated costs on which the proposed 

CY 2014 OPPS payment rates were 

based, we neglected to include the data 

from those G-codes in calculating the 

proposed geometric mean costs of the 

stereotactic radiosurgery APCs. In this 

correcting document, we have included 

the claims data from those G-codes in 

calculating the proposed APC relative 

payment weights for the proposed 

stereotactic radiosurgery APCs 0066 

(Level I Stereotactic Radiosurgery) and 

0067 (Level II Stereotactic 

Radiosurgery). 

In our review, we also discovered an 

error with the calculation of the 

proposed CY 2014 budget neutrality 

adjustment factor used to calculate the 

proposed CY 2014 cancer hospital 

payment adjustment. As noted in the CY 

2014 OPPS/ASC proposed rule, the 

proposed CY 2014 budget neutrality 

adjustment factor is calculated by 

comparing the estimated total CY 2014 

OPPS payments including the proposed 

CY 2014 cancer hospital payment 

adjustment to the estimated total CY 

2014 OPPS payments using the CY 2013 

cancer hospital payment adjustment. 

We miscalculated the proposed CY 2014 

cancer hospital adjustment payment 

weights for purposes of this comparison 

when converting estimated CY 2014 

cancer hospital adjustment payments 

into payment weights. Correctly 

developing this proposed CY 2014 

cancer hospital adjustment payment 

weight for this comparison requires a 

corresponding correction to the 

proposed budget neutrality adjustment 

associated with the proposed CY 2014 

cancer hospital payment adjustment 

from the 1.0001 published in the CY 

2014 OPPS/ASC proposed rule (78 FR 

43577) to 1.0003. As a result of the 

correction to the proposed CY 2014 

cancer hospital payment adjustment for 

budget neutrality, the proposed CY 2014 

OPPS conversion factor is also corrected 

in this correcting document from the 

$72.728 published in the CY 2014 

OPPS/ASC proposed rule (78 FR 43578) 

to $72.743. 

While the technical corrections 

described previously are generally 

isolated to specific APCs, because the 

OPPS is a budget neutral payment 

system, we recalculated the proposed 

CY 2014 budget neutral weight scaler. 

As discussed in the CY 2014 OPPS/ASC 

proposed rule, the budget neutral 

weight scaler is calculated by comparing 

aggregate CY 2013 OPPS payment 

weight to unscaled aggregate CY 2014 

OPPS payment weight. As a result of the 

technical corrections previously 

described, several of the estimated costs 

on which the proposed unscaled CY 

2014 payment weights are developed 

require correlating corrections. Those 

corrections to the proposed payment 

weights then affect the proposed 

aggregate unscaled CY 2014 OPPS 

payment weights which are then used to 

determine the appropriate proposed 

budget neutrality adjustment. Using the 

corrected proposed unscaled relative 

payment weights, the proposed CY 2014 

budget neutrality weight scaler changes 

from 1.2143 as originally proposed (see 

78 FR 43576) to 1.3315. 

As previously stated, the technical 

corrections discussed previously result 

in corrections to the proposed OPPS 

relative payment weights and the 

proposed CY 2014 OPPS conversion 

factor, both of which are used to 

calculate the proposed CY 2014 OPPS 

payment rates. Outlier payments are 

made based on the relationship between 

APC payments and estimated cost, so 

corrections to the proposed APC 

payment rates would affect the 

appropriate fixed-dollar outlier 

threshold applied to achieve the 

estimated OPPS outlier spending target 

of 1.0 percent (78 FR 43583 through 

43584). Using the corrected proposed 

CY 2014 OPPS relative payment weights 

and conversion factor, the proposed CY 

2014 OPPS/ASC fixed-dollar outlier 

threshold changes from $2,775, as 

originally proposed (see 78 FR 43583 

through 43584), to $2,900. 

We are also making technical 

corrections to Table 39—Estimated 

Impact of the Proposed CY 2014 

Changes for the Hospital Outpatient 

Prospective Payments System (78 FR 

43692) and the correlating preamble 

language (78 FR 43689). As noted 

previously, because the OPPS is a 

budget neutral system, and while the 

impact of the technical corrections 

discussed previously on APC payment 

is generally concentrated within specific 

APCs that were modified for significant 

proposals in CY 2014, there are 

resulting technical corrections necessary 

with respect to all other proposed CY 

2014 OPPS payment weights and rates 

within the system. The corrections to 

this impact table (78 FR 43692) relative 

to the impact table originally published 

in the CY 2014 OPPS/ASC proposed 

rule correspond to the case mix of 

services furnished by providers and 

how they are affected by the technical 

corrections in this document. 

B. Ambulatory Surgical Center Payment 

System Corrections 

ASC payment rates are based on the 

OPPS relative payment weights for the 

majority of items and services that are 

provided at ASCs. Therefore, 

corrections to the proposed CY 2014 

OPPS relative payment weights also 

have an impact on the proposed CY 

2014 ASC relative payment weights and 

ASC payment rates. Due to the 

corrections made to the proposed CY 

2014 OPPS relative payment weights, 

we recalculated the proposed CY 2014 

budget neutral ASC weight scaler (see 

78 FR 43640 and 43641). Using the 

proposed corrected scaled CY 2014 

OPPS relative weights, the proposed CY 

2014 budget neutrality ASC weight 

scaler changes from 0.8961, as originally 

proposed (78 FR 43641), to 0.9102. The 

corrected proposed CY 2014 ASC 

relative payment weights and the 

proposed CY 2014 budget neutral ASC 

weight scaler have no impact on the 

proposed CY 2014 ASC conversion 

factor. 

C. Summary of Errors in and 

Corrections to Addenda Posted on the 

CMS Web Site 

1. Outpatient Prospective Payment 

System Payment System Addenda 

We are making several minor 

technical corrections to the OPPS 

addenda. We are correcting the OPPS 

status indicators for CPT codes 93619, 

93620 and 93650 to ‘‘J1’’ to accurately 

reflect our CY 2014 proposal to establish 

APC 0085 as a comprehensive APC. We 

are also correcting the displayed 

assignment of CPT code 33233 to APC 

0106 to fix a discrepancy between our 

addenda and the cost statistics files we 

make available to the public. As a result 

of these corrections, Addendum A, B, C, 

and M will also be corrected. 

To view the corrected proposed CY 

2014 OPPS payment rates that result 

from the corrected geometric mean costs 

and other technical corrections, we refer 

readers to the Addenda and supporting 

files that are posted on the CMS Web 

site at: http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/

HospitalOutpatientPPS/index.html. 

Select ‘‘CMS–1601–CN’’ from the list of 

regulations. All corrected Addenda for 

this correcting document are contained 

in the zipped folder entitled, ‘‘2014 

OPPS NPRM Addenda’’ at the bottom of 

the page for CMS–1601–CN. The 

corrected CY 2014 OPPS file of 

geometric mean costs is found under 

supporting documentation for CMS– 

1601–CN. 


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2. Ambulatory Surgical Center Payment 

System Addenda 

To view the corrected proposed CY 

2014 ASC payment rates that result from 

the corrected proposed CY 2014 ASC 

relative payment weights, see the ASC 

addenda that are posted on the CMS 

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

Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/ASCRegulations-and-Notices.html. Select 

‘‘CMS–1601–CN’’ from the list of 

regulations. All corrected ASC addenda 

for this correcting document are 

contained in the zipped folder entitled 

‘‘Addendum AA, BB, DD1, DD2, and 

EE’’ at the bottom of the page for CMS– 

1601–CN. 

IV. Waiver of 60-Day Comment Period 

We ordinarily permit a 60-day 

comment period on notices of proposed 

rulemaking in the Federal Register, as 

provided in section 1871(b)(1) of the 

Act. However, this period may be 

shortened, as provided under section 

1871(b)(2)(C) of the Act, when the 

Secretary finds good cause that a 60-day 

comment period would be 

impracticable, unnecessary, or contrary 

to the public interest and incorporates a 

statement of the finding and its reasons 

in the rule issued. Because the 

corrections in this document do not 

make any changes to the substantive 

policies proposed in the CY 2014 OPPS/ 

ASC proposed rule, but merely correct 

underlying data errors that impact 

certain components of the payment 

systems to conform to the proposed 

policies clearly intended in the 

preamble of the proposed rule, this 

correcting document does not constitute 

agency rulemaking, and therefore the 

60-day comment period does not apply. 

In addition, we believe it is important 

for the public to have the corrected 

information as soon as possible and find 

no reason to delay dissemination of it. 

For the reasons stated previously, we 

find it both unnecessary and contrary to 

the public interest to undertake further 

notice and comment procedures with 

respect to this correcting document. 

V. Correction of Errors 

In FR Doc. 2013–16555 of July 19, 

2013 (78 FR 43534), make the following 

corrections: 

■ 1. On page 43562, third column, first 

full paragraph, in line 4, the figure 

‘‘$1,357’’ is corrected to read ‘‘$1,348’’. 

■ 2. On page 43571, 

■ a. Table 8—CY 2013 Separate 

Payment Versus CY 2014 Proposed 

Packaged Payment For MPI, the table is 

corrected to read as follows: 

TABLE 8—CY 2013 SEPARATE PAYMENT VERSUS CY 2014 PROPOSED PACKAGED PAYMENT FOR MPI 

Service or supply 

CY 2013 Separate payment for 

MPI components 

CY 2013 Separate payment for 

MPI components 

CY 2013 Separate payment for 

MPI components 

CY 2013 Separate payment for 

MPI components 

CY 2014 Proposed packaged 

payment for MPI 

78452 .................................................................... $680 ................. $680 ................. $680 ................. $680 ................. $1,216 

93017 .................................................................... $177 ................. $177 ................. $177 ................. $177 ................. PÖ

Exercise or Stress Agent ¥ .................................... Exercise—$0 .... J1245–P ........... J2785–$215 ...... J0152–$219* .... P 

Radiopharmaceutical ............................................ P ....................... P ....................... P ....................... P ....................... P 

Total ............................................................... $857 ................. $857 ................. $1,072 .............. $1,076 .............. $1,216 

P = Packaged. 

ÖThe stress test described by CPT code 93017 is proposed to be conditionally packaged as a result of the proposal described below to conditionally package ancillary services. ¥April 2013 ASP Drug Pricing File. 

* 70 kg patient. 

■ b. First column, first paragraph, in 

line 4, the figure ‘‘14’’ is corrected to 

read ‘‘12’’. 

■ 3. On page 43576, third column, 

second full paragraph, in line 17, the 

figure ‘‘1.2143’’ is corrected to read 

‘‘1.3315’’. 

■ 4. On page 43577, third column, third 

full paragraph, in line 27, the figure 

‘‘1.0001’’ is corrected to read ‘‘1.0003’’. 

■ 5. On page 43578, 

■ a. First column, 

■ (1) First full paragraph, 

■ (a) In line 13, the figure ‘‘1.0001’’ is 

corrected to read ‘‘1.0003’’. 

■ (b) In line 18, the figure ‘‘$72.728’’ is 

corrected to read ‘‘$72.743’’. 

■ (2) Second full paragraph, in line 34, 

the figure ‘‘$71.273’’ is corrected to read 

‘‘$71.288’’. 

■ b. Second column, first paragraph, 

■ (1) In line 3, the figure ‘‘$72.728’’ is 

corrected to read ‘‘$72.743’’. 

■ (2) In line 16, the figure ‘‘$71.273’’ is 

corrected to read ‘‘$71.288’’. 

■ 6. On page 43584, 

■ a. First column, under the heading ‘‘2. 

Proposed Outlier Calculation’’, second 

paragraph, in line 11, the figure 

‘‘$2,775’’ is corrected to read ‘‘$2,900’’. 

■ b. Third column, first partial 

paragraph, 

■ (1) In line 8, the figure ‘‘$2,775’’ is 

corrected to read ‘‘$2,900’’. 

■ (2) In line 21, the figure ‘‘$2,775’’ is 

corrected to read ‘‘$2,900’’. 

■ 7. On page 43586, 

■ a. First column, in the fourth full 

paragraph, 

■ (1) In line 17, the figure ‘‘$345.75’’ is 

corrected to read ‘‘$340.56’’. 

■ (2) In line 21, the figure ‘‘$338.84’’ is 

corrected to read ‘‘$333.75’’. 

■ (3) In line 30, the figure ‘‘$272.96’’ is 

corrected to read ‘‘$268.87’’ and the 

figure ‘‘$345.75’’ is corrected to read 

‘‘$340.56’’. 

■ (4) In line 33, the figure ‘‘$267.51’’ is 

corrected to read ‘‘$263.49’’. 

■ (5) In line 34, the figure ‘‘$338.84’’ is 

corrected to read ‘‘$333.75’’. 

■ (6) In line 37, the figure ‘‘$138.30’’ is 

corrected to read ‘‘$133.50’’ and 

‘‘$345.75’’ is corrected to read 

‘‘$340.56’’. 

■ b. Second column, first partial 

paragraph, 

■ (1) In line 2, the figure ‘‘$135.54’’ is 

corrected to read ‘‘$133.50’’. 

■ (2) In line 3, the figure ‘‘$338.84’’ is 

corrected to read ‘‘$333.75’’. 

■ (3) In line 6, the figure ‘‘$411.26’’ is 

corrected to read ‘‘$405.09’’ and 

‘‘$272.96’’ is corrected to read 

‘‘$268.87’’. 

■ (4) In line 7, the figure ‘‘$138.30’’ is 

corrected to read ‘‘$136.22’’. 

■ (5) In line 9, the figure ‘‘$403.05’’ is 

corrected to read ‘‘$396.99’’ and 

‘‘$267.51’’ is corrected to read 

‘‘$263.49’’. 

■ (6) In line 10, the figure ‘‘$135.54’’ is 

corrected to read ‘‘$133.50’’. 

■ c. Third column, under the heading 

‘‘3. Proposed Calculation of an Adjusted 

Copayment Amount for an APC Group’’, 

second full paragraph, 

■ (1) In line 6, the figure ‘‘$69.15’’ is 

corrected to read ‘‘$68.12’’. 

■ (2) In line 8, the figure ‘‘$345.75’’ is 

corrected to read ‘‘$340.56’’. 

■ 8. On page 43590, Table 14—New 

Category III CPT Codes Implemented In 


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July 2013, the fifth column titled, ‘‘Proposed CY 2014 Payment Rate’’ is 

corrected to read as follows: 

TABLE 14—NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2013 

CY 2013 

CPT Code CY 2013 Long descriptor 

Proposed CY 

2014 status 

indicator 

Proposed CY 

2014 APC 

Proposed CY 

2014 payment 

rate 

0329T .......... Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report.E N/A N/A 

0330T .......... Tear film imaging, unilateral or bilateral, with interpretation and report ............ S 0230 $51.05 

0331T .......... Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment.S 0398 391.36 

0332T .......... Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT.S 0398 391.36 

0333T .......... Visual evoked potential, screening of visual acuity, automated ........................ E N/A N/A 

0334T .......... Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally 

invasive (indirect visualization), includes obtaining and applying autograft 

or allograft (structural or morselized), when performed, includes image 

guidance when performed (that is, CT or fluoroscopic).

T 0208 4,108.96 

■ 9. On page 43630, Table 34–New 

Level II HCPCS Codes for Covered 

Surgical Procedures or Covered 

Ancillary Services Implemented in July 

2013, the table is corrected to read as 

follows: 

TABLE 34—NEW LEVEL II HCPCS CODES FOR COVERED SURGICAL PROCEDURES OR COVERED ANCILLARY SERVICES

IMPLEMENTED IN JULY 2013 

CY 2013 

HCPCS Code CY 2013 Long descriptor 

Proposed CY 

2014 payment 

indicator 

Proposed CY 

2014 payment 

rate 

C9131 ............. Injection, ado-trastuzumab emtansine, 1 mg ............................................................................. K2 $29.40 

C9736 ............. Laparoscopy, surgical, radiofrequency ablation of uterine fibroid(s), including intraoperative 

guidance and monitoring, when performed.

G2 2,010.57 

Q2033 ............. Influenza Vaccine, Recombinant Himagglutinin Antigens, for Intramuscular Use (Flublok) ..... L1 N/A 

Q2050 * ........... Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 mg .................. K2 545.44 

Q2051 * ........... Injection, Zoledronic Acid, Not Otherwise Specified, 1 mg ........................................................ K2 196.42 

* Note: HCPCS code Q2050 replaced code J9002 and HCPCS code Q2051 replaced HCPCS codes J3487 and J3488 beginning July 1, 2013. 

■ 10. On page 43631, Table 35–New 

Category III CPT Codes Implemented in 

July 2013 as ASC Covered Ancillary 

Services, the table is corrected to read 

as follows: 

TABLE 35—NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2013 AS ASC COVERED ANCILLARY SERVICES

CY 2013 CPT 

Code CY 2013 Long descriptor 

Proposed CY 

2014 payment 

indicator 

Proposed CY 

2014 payment 

rate 

0331T .............. Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment Z2 $212.14 

0332T .............. Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; 

with tomographic SPECT.

Z2 $212.14 

■ 11. On page 43641, first column, first 

partial paragraph, in line 12, the figure 

‘‘0.8961’’ is corrected to read ‘‘0.9102’’. 

■ 12. On page 43652, third column, first 

partial paragraph, 

■ a. In line 6, the figure ‘‘$71.273’’ is 

corrected to read ‘‘$71.288’’. 

■ b. In line 7, the figure ‘‘$72.728’’ is 

corrected to read ‘‘$72.743’’. 

■ 13. On pages 43692 through 43693, 

Table 39—Estimated Impact of the 

Proposed CY 2014 Changes for the 

Hospital Outpatient Prospective 

Payment System, the table is corrected 

to read as follows: 


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54846 Federal Register / Vol. 78, No. 173 / Friday, September 6, 2013 / Proposed Rules 

TABLE 39—ESTIMATED IMPACT OF THE PROPOSED CY 2014 CHANGES FOR THE HOSPITAL OUTPATIENT PROSPECTIVE

PAYMENT SYSTEM

Number of 

hospitals 

APC recalibration 

(all changes) (%) 

New wage index 

and provider 

adjustments (%) 

Combined cols 

2,3 with market 

basket update 

Column 4 with 

frontier wage 

index adjustment 

(%) 

All proposed 

changes (%) 

(1) (2) (3) (4) (5) (6) 

ALL FACILITIES * ............ 3,953 0.0 0.0 1.8 1.9 1.8 

ALL HOSPITALS ............. 3,791 0.0 0.0 1.8 1.9 1.8 

(excludes hospitals permanently held harmless 

and CMHCs) 

URBAN HOSPITALS ....... 2,859 0.0 0.0 1.9 2.0 1.9 

LARGE URBAN (GT 

1 MILL.) ................. 1,566 0.3 0.2 2.3 2.3 2.3 

OTHER URBAN (LE 

1 MILL.) ................. 1,293 ¥0.3 ¥0.1 1.4 1.7 1.5 

RURAL HOSPITALS ........ 932 ¥0.3 ¥0.3 1.3 1.5 1.4 

SOLE COMMUNITY 389 0.3 ¥0.3 1.9 2.3 1.9 

OTHER RURAL ........ 543 ¥0.8 ¥0.2 0.8 0.9 0.8 

BEDS (URBAN) 

0–99 BEDS ............... 959 0.1 0.1 1.9 2.1 2.0 

100–199 BEDS ......... 831 ¥0.2 ¥0.1 1.5 1.6 1.6 

200–299 BEDS ......... 454 ¥0.4 0.0 1.4 1.6 1.5 

300–499 BEDS ......... 407 0.1 0.0 1.9 2.1 2.0 

500 + BEDS .............. 208 0.4 0.2 2.4 2.4 2.4 

BEDS (RURAL) 

0–49 BEDS ............... 352 ¥0.7 ¥0.6 0.6 0.8 0.6 

50–100 BEDS ........... 342 0.4 ¥0.1 2.1 2.4 2.2 

101–149 BEDS ......... 133 ¥0.6 ¥0.5 0.8 1.0 0.9 

150–199 BEDS ......... 61 ¥1.0 ¥0.1 0.7 1.1 0.7 

200 + BEDS .............. 44 ¥0.3 ¥0.2 1.3 1.3 1.5 

VOLUME (URBAN) 

LT 5,000 Lines .......... 485 ¥0.5 0.2 1.5 1.7 1.6 

5,000–10,999 Lines .. 109 0.3 –0.1 1.9 2.4 1.4 

11,000–20,999 Lines 132 0.1 0.0 1.9 2.1 1.9 

21,000–42,999 Lines 262 ¥0.1 ¥0.2 1.5 1.6 1.6 

42,999–89,999 Lines 517 0.2 0.1 2.1 2.1 2.1 

GT 89,999 Lines ....... 1,354 0.0 0.0 1.9 2.0 1.9 

VOLUME (RURAL) 

LT 5,000 Lines .......... 31 0.1 ¥0.4 1.5 6.1 1.6 

5,000–10,999 Lines .. 34 2.1 ¥0.5 3.3 3.4 3.4 

11,000–20,999 Lines 67 1.8 ¥0.7 2.8 3.0 2.7 

21,000–42,999 Lines 182 0.8 ¥0.3 2.3 2.9 2.2 

GT 42,999 Lines ....... 618 ¥0.4 ¥0.2 1.2 1.4 1.3 

REGION (URBAN) 

NEW ENGLAND ....... 150 1.1 0.6 3.5 3.5 3.4 

MIDDLE ATLANTIC .. 342 0.2 0.7 2.7 2.7 2.7 

SOUTH ATLANTIC ... 432 ¥0.5 ¥0.3 1.0 1.0 1.1 

EAST NORTH CENT. 459 ¥0.1 ¥0.2 1.5 1.5 1.5 

EAST SOUTH CENT. 172 ¥0.5 ¥0.3 1.0 1.0 1.1 

WEST NORTH 

CENT. .................... 193 1.7 ¥0.3 3.1 4.3 3.3 

WEST SOUTH 

CENT. .................... 487 ¥1.1 ¥0.2 0.6 0.6 0.7 

MOUNTAIN ............... 194 0.5 ¥0.3 2.0 2.3 2.0 

PACIFIC .................... 385 0.3 0.6 2.7 2.7 2.6 

PUERTO RICO ......... 45 4.2 0.6 6.6 6.6 7.0 

REGION (RURAL) 

NEW ENGLAND ....... 25 2.7 0.6 5.1 5.1 5.0 

MIDDLE ATLANTIC .. 68 ¥1.3 ¥0.3 0.3 0.3 0.3 

SOUTH ATLANTIC ... 158 ¥1.0 ¥0.4 0.4 0.4 0.5 

EAST NORTH CENT. 124 ¥0.9 ¥0.4 0.5 0.5 0.6 

EAST SOUTH CENT. 170 ¥0.9 ¥0.6 0.3 0.3 0.5 

WEST NORTH 

CENT. .................... 99 1.0 ¥0.1 2.7 3.9 2.8 

WEST SOUTH 

CENT. .................... 196 ¥0.7 ¥0.4 0.7 0.8 0.9 

MOUNTAIN ............... 63 0.4 0.2 2.5 4.0 2.0 

PACIFIC .................... 29 2.4 0.7 4.9 5.0 5.0 

TEACHING STATUS 

NON–TEACHING ..... 2,792 ¥0.5 ¥0.1 1.2 1.3 1.3 

MINOR ...................... 686 ¥0.2 0.0 1.6 1.9 1.7 


ehiers on DSK2VPTVN1PROD with PROPOSALS-1
Federal Register / Vol. 78, No. 173 / Friday, September 6, 2013 / Proposed Rules 54847 

TABLE 39—ESTIMATED IMPACT OF THE PROPOSED CY 2014 CHANGES FOR THE HOSPITAL OUTPATIENT PROSPECTIVE

PAYMENT SYSTEM—Continued 

Number of 

hospitals 

APC recalibration 

(all changes) (%) 

New wage index 

and provider 

adjustments (%) 

Combined cols 

2,3 with market 

basket update 

Column 4 with 

frontier wage 

index adjustment 

(%) 

All proposed 

changes (%) 

(1) (2) (3) (4) (5) (6) 

MAJOR ..................... 313 1.2 0.2 3.2 3.2 3.1 

DSH PATIENT PERCENT 

0 ................................ 12 ¥1.3 ¥0.1 0.4 0.4 0.2 

GT 0–0.10 ................. 349 0.1 0.1 2.0 2.1 2.0 

0.10–0.16 .................. 334 0.0 0.1 1.9 2.1 2.0 

0.16–0.23 .................. 680 0.0 0.0 1.8 2.0 1.9 

0.23–0.35 .................. 1,045 0.0 0.0 1.8 1.9 1.8 

GE 0.35 ..................... 831 ¥0.1 0.0 1.7 1.7 1.7 

DSH NOT AVAILABLE ** .................. 540 1.7 0.0 3.5 3.5 3.2 

URBAN TEACHING/DSH 

TEACHING & DSH ... 909 0.4 0.1 2.3 2.5 2.3 

NO TEACHING/DSH 1,429 ¥0.6 0.0 1.2 1.3 1.3 

NO TEACHING/NO 

DSH ....................... 12 ¥1.3 ¥0.1 0.4 0.4 0.2 

DSH NOT AVAILABLE ** .................. 509 1.6 0.1 3.5 3.6 3.2 

TYPE OF OWNERSHIP 

VOLUNTARY ............ 2,004 0.1 0.1 2.0 2.2 2.1 

PROPRIETARY ........ 1,250 ¥0.5 ¥0.1 1.2 1.3 1.2 

GOVERNMENT ........ 537 ¥0.3 ¥0.2 1.3 1.3 1.4 

CMHCs ............................. 100 ¥7.1 ¥0.2 ¥5.6 ¥5.5 ¥5.2 

Column (1) shows total hospitals and/or CMHCs. 

Column (2) includes all CY 2014 OPPS proposals and compares those to the CY 2013 OPPS (which includes outpatient lab services previously paid at CLFS rates). 

Column (3) shows the budget neutral impact of updating the wage index by applying the FY 2014 hospital inpatient wage index. The proposed 

rural adjustment continues our current policy of 7.1 percent so the budget neutrality factor is 1. Similarly, the differential in estimated cancer hospital payments for the proposed adjustment is minimal and thus results in a budget neutrality factor of 1.0003. 

Column (4) shows the impact of all budget neutrality adjustments and the proposed addition of the 1.8 percent OPD fee schedule update factor (2.5 percent reduced by 0.4 percentage points for the proposed productivity adjustment and further reduced by 0.3 percentage point in order 

to satisfy statutory requirements set forth in the Affordable Care Act). 

Column (5) shows the non-budget neutral impact of applying the frontier State wage adjustment. 

Column (6) shows the additional adjustments to the conversion factor resulting from a change in the pass-through estimate, adding estimated 

outlier payments, and applying payment wage indexes. 

* These 3,953 providers include children and cancer hospitals, which are held harmless to pre-BBA amounts, and CMHCs. Payments for lab 

services at CLFS rates, which we are proposing to package in the CY 2014 OPPS, are included in the columns where appropriate. 

** Complete DSH numbers are not available for providers that are not paid under IPPS, including rehabilitation, psychiatric, and long-term care 

hospitals. 

■ 14. On page 43696, 

■ a. First column, first full paragraph, in 

line 9, the figure ‘‘0.8961’’ is corrected 

to read ‘‘0.9102’’. 

■ b. Third column, 

(1) Fourth paragraph, in line 8, the 

phrase ‘‘a 1 percent increase’’ is 

corrected to read ‘‘no change’’. 

■ (2) Fifth paragraph, in line 13, the 

phrase ‘‘7 percent’’ is corrected to read 

‘‘8 percent’’. 

■ 15. On page 43697, Table 40— 

Estimated Impact of the Proposed CY 

2014 Update to the ASC Payment 

System on Aggregate CY 2014 Medicare 

Program Payments by Surgical Specialty 

or Ancillary Items and Services Group, 

the table is corrected to read as follows: 

TABLE 40—ESTIMATED IMPACT OF THE PROPOSED CY 2014 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE

CY 2014 MEDICARE PROGRAM PAYMENTS BY SURGICAL SPECIALTY OR ANCILLARY ITEMS AND SERVICES GROUP

Surgical specialty group (1) 

Estimated CY 

2013 ASC 

payments 

(in millions) (2) 

Estimated CY 

2014 percent 

change (3) 

Total ................................................................................................................................................................. $3,625 1% 

Eye and ocular adnexa .................................................................................................................................... 1,496 ¥3 

Digestive system .............................................................................................................................................. 743 8 

Nervous system ............................................................................................................................................... 540 0 

Musculoskeletal system ................................................................................................................................... 441 ¥1 

Genitourinary system ....................................................................................................................................... 159 5 

Integumentary system ..................................................................................................................................... 130 8 

Respiratory system .......................................................................................................................................... 46 7 

Cardiovascular system .................................................................................................................................... 32 ¥3 

Ancillary items and services ............................................................................................................................ 20 ¥12 


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54848 Federal Register / Vol. 78, No. 173 / Friday, September 6, 2013 / Proposed Rules 

TABLE 40—ESTIMATED IMPACT OF THE PROPOSED CY 2014 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE

CY 2014 MEDICARE PROGRAM PAYMENTS BY SURGICAL SPECIALTY OR ANCILLARY ITEMS AND SERVICES GROUP— 

Continued 

Surgical specialty group (1) 

Estimated CY 

2013 ASC 

payments 

(in millions) (2) 

Estimated CY 

2014 percent 

change (3) 

Auditory system ............................................................................................................................................... 12 4 

Hematologic & lymphatic systems ................................................................................................................... 5 17 

■ 16. On pages 43697 through 43698, 

Table 41—Estimated Impact of the 

Proposed CY 2014 Update to the ASC 

Payment System on Aggregate Payments 

for Selected Procedures, the table is 

corrected to read as follows: 

TABLE 41—ESTIMATED IMPACT OF THE PROPOSED CY 2014 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE

PAYMENTS FOR SELECTED PROCEDURES

CPT/HCPCS code * (1) Short descriptor (2) 

Estimated CY 

2013 ASC 

payments 

(in millions) (3) 

Estimated CY 

2014 percent 

change (4) 

66984 .............................. Cataract surg w/iol, 1 stage ............................................................................... $1,107 ¥3% 

43239 .............................. Upper GI endoscopy, biopsy .............................................................................. 163 13 

45380 .............................. Colonoscopy and biopsy .................................................................................... 154 7 

45385 .............................. Lesion removal colonoscopy .............................................................................. 98 7 

66982 .............................. Cataract surgery, complex ................................................................................. 89 ¥3 

45378 .............................. Diagnostic colonoscopy ...................................................................................... 80 7 

64483 .............................. Inj foramen epidural l/s ....................................................................................... 79 14 

62311 .............................. Inject spine l/s (cd) ............................................................................................. 71 14 

66821 .............................. After cataract laser surgery ................................................................................ 59 ¥1 

G0105 ............................. Colorectal scrn; hi risk ind .................................................................................. 42 1 

15823 .............................. Revision of upper eyelid ..................................................................................... 40 2 

64493 .............................. Inj paravert f jnt l/s 1 lev ..................................................................................... 40 14 

63650 .............................. Implant neuroelectrodes ..................................................................................... 39 3 

G0121 ............................. Colon ca scrn not hi rsk ind ............................................................................... 36 1 

29827 .............................. Arthroscop rotator cuff repr ................................................................................ 34 5 

64590 .............................. Insrt/redo pn/gastr stimul .................................................................................... 33 4 

64721 .............................. Carpal tunnel surgery ......................................................................................... 31 ¥1 

63685 .............................. Insrt/redo spine n generator ............................................................................... 31 4 

64636 ** .......................... Destroy l/s facet jnt addl ..................................................................................... 31 ¥100 

29881 .............................. Knee arthroscopy/surgery .................................................................................. 30 ¥3 

64635 .............................. Destroy lumb/sac facet jnt .................................................................................. 26 73 

29880 .............................. Knee arthroscopy/surgery .................................................................................. 25 ¥3 

43235 .............................. Uppr gi endoscopy diagnosis ............................................................................. 23 13 

45384 .............................. Lesion remove colonoscopy ............................................................................... 22 7 

52000 .............................. Cystoscopy ......................................................................................................... 21 5 

62310 .............................. Inject spine c/t .................................................................................................... 20 14 

29823 .............................. Shoulder arthroscopy/surgery ............................................................................ 19 5 

67042 .............................. Vit for macular hole ............................................................................................ 19 0 

28285 .............................. Repair of hammertoe .......................................................................................... 18 5 

50590 .............................. Fragmenting of kidney stone .............................................................................. 18 2 

* Note that HCPCS codes we are proposing to delete for CY 2014 are not displayed in this table. 

** The 100 decrease in estimated payment reflects our CY 2014 proposal to package the payment for CPT code 64636. 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program); (Catalog of Federal Domestic 

Assistance Program No. 93.773, Medicare— 

Hospital Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: September 4, 2013. 

Jennifer M. Cannistra, 

Executive Secretary to the Department, 

Department of Health and Human Services. 

[FR Doc. 2013–21849 Filed 9–5–13; 8:45 am] 

BILLING CODE 4120–01–P 


ehiers on DSK2VPTVN1PROD with PROPOSALS-1
Federal Register / Vol. 78, No. 173 / Friday, September 6, 2013 / Proposed Rules 54849 

DEPARTMENT OF TRANSPORTATION 

Pipeline and Hazardous Materials 

Safety Administration 

49 CFR Parts 173, 174, 178, 179, and 

180 

[Docket No. PHMSA–2012–0082 (HM–251)] 

RIN 2137–AE91 

Hazardous Materials: Rail Petitions 

and Recommendations To Improve the 

Safety of Railroad Tank Car 

Transportation (RRR) 

AGENCY: Pipeline and Hazardous 

Materials Safety Administration 

(PHMSA), DOT. 

ACTION: Advance Notice of Proposed 

Rulemaking (ANPRM). 

SUMMARY: PHMSA is considering 

revisions to the Hazardous Materials 

Regulations (HMR) to improve the 

regulations applicable to the 

transportation of hazardous materials by 

rail. The revisions are based on eight 

petitions received from the regulated 

community and four National 

Transportation Safety Board (NTSB) 

Recommendations which are referenced 

by a petition. In this ANPRM, we 

outline the petitions and NTSB 

recommendations, identify a 

preliminary estimate of costs and 

benefits from the petitions, pose several 

questions, and solicit comments and 

data from the public. Under Executive 

Order 13563, Federal agencies were 

asked to periodically review existing 

regulations. The questions posed in this 

ANPRM and responses by commenters 

will be used in conjunction with a 

retrospective review of existing 

requirements aimed to modify, 

streamline, expand, or repeal existing 

rules that are outmoded, ineffective, 

insufficient, or excessively burdensome. 

DATES: Comments must be received by 

November 5, 2013. 

ADDRESSES: You may submit comments 

identified by the docket number 

PHMSA–2012–0082 (HM–251) and the 

relevant petition number by any of the 

following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Fax: 1–202–493–2251. 

• Mail: Docket Management System; 

U.S. Department of Transportation, 

West Building, Ground Floor, Room 

W12–140, Routing Symbol M–30, 1200 

New Jersey Avenue SE., Washington, 

DC 20590. 

• Hand Delivery: To the Docket 

Management System; Room W12–140 

on the ground floor of the West 

Building, 1200 New Jersey Avenue SE., 

Washington, DC 20590, between 9 a.m. 

and 5 p.m., Monday through Friday, 

except Federal holidays. 

Instructions: All submissions must 

include the agency name and docket 

number for this notice at the beginning 

of the comment. To avoid duplication, 

please use only one of these four 

methods. All comments received will be 

posted without change to http://

www.regulations.gov and will include 

any personal information you provide. 

All comments received will be posted 

without change to the Federal Docket 

Management System (FDMS), including 

any personal information. 

Docket: For access to the dockets to 

read background documents or 

comments received, go to http://

www.regulations.gov or DOT’s Docket 

Operations Office located at U.S. 

Department of Transportation, West 

Building, Ground Floor, Room W12– 

140, Routing Symbol M–30, 1200 New 

Jersey Avenue SE., Washington, DC 

20590. 

Privacy Act: Anyone is able to search 

the electronic form of all comments 

received into any of our dockets by the 

name of the individual submitting the 

comments (or signing the comment, if 

submitted on behalf of an association, 

business, labor union, etc.). You may 

review DOT’s complete Privacy Act 

Statement in the Federal Register 

published on April 11, 2000 (Volume 

65, Number 70; Pages 19477–78) which 

may be viewed at: http://www.gpo.gov/ 

fdsys/pkg/FR-2000-04-11/pdf/00- 

8505.pdf. 

FOR FURTHER INFORMATION CONTACT: Karl 

Alexy, (202) 493–6245, Office of Safety 

Assurance and Compliance, Federal 

Railroad Administration or Ben Supko, 

(202) 366–8553, Standards and 

Rulemaking Division, Pipeline and 

Hazardous Materials Safety 

Administration, U.S. Department of 

Transportation, 1200 New Jersey Ave. 

SE., Washington, DC 20590–0001. 

SUPPLEMENTARY INFORMATION: 

Table of Contents 

I. Executive Summary 

II. Background 

III. Review of Amendments Considered 

A. Petition P–1507 

B. Petition P–1519 

C. Petition P–1547 

D. Petition P–1548 

E. Petition P–1577 

F. Petition P–1587 

G. Petition P–1595 

H. Petition P–1612 

IV. Regulatory Review and Notices 

A. Executive Order 12866, Executive Order 

13563, Executive Order 13610, and DOT 

Regulatory Policies and Procedures 

B. Executive Order 13132 

C. Executive Order 13175 

D. Regulatory Flexibility Act, Executive 

Order 13272, and DOT Policies and 

Procedures 

E. Paperwork Reduction Act 

F. Environmental Assessment 

G. Privacy Act 

H. International Trade Analysis 

I. Statutory/Legal Authority for This 

Rulemaking 

J. Regulation Identifier Number (RIN) 

I. Executive Summary 

PHMSA has received eight petitions 

for rulemaking and four NTSB 

recommendations proposing 

amendments to the Hazardous Materials 

Regulations (HMR; 49 CFR parts 171– 

180) applicable to the transportation of 

hazardous materials in commerce by 

rail. PHMSA is seeking public 

comments on whether the proposed 

amendments would enhance safety, 

revise, and clarify the HMR with regard 

to rail transport. Specifically, these 

amendments propose to: (1) Relax 

regulatory requirements to afford the 

Federal Railroad Administration (FRA) 

greater discretion to authorize the 

movement of non-conforming tank cars; 

(2) impose additional requirements that 

would correct an unsafe condition 

associated with pressure relief valves 

(PRV) on rail cars transporting carbon 

dioxide, refrigerated liquid; (3) relax 

regulatory requirements applicable to 

the repair and maintenance of DOT 

Specification 110, DOT Specification 

106, and ICC 27 tank car tanks (ton 

tanks); (4) relax regulatory requirement 

for the removal of rupture discs for 

inspection if the removal process would 

damage, change, or alter the intended 

operation of the device; and (5) impose 

additional requirements that would 

enhance the standards for DOT 

Specification 111 tank cars used to 

transport Packing Group (PG) I and II 

hazardous materials. The NTSB 

recommendations directly relate to the 

enhancement of DOT Specification 111 

tank cars. PHMSA looks forward to 

reviewing the public’s comments 

pertaining to the potential economic, 


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