Monday, 

November 21, 2005 

Part II 

Department of 

Health and Human 

Services 

Centers for Medicare & Medicaid Services 

42 CFR Part 405, et al. 

Medicare Program; Revisions to Payment 

Policies Under the Physician Fee 

Schedule for Calendar Year 2006 and 

Certain Provisions Related to the 

Competitive Acquisition Program of 

Outpatient Drugs and Biologicals Under 

Part B; Final Rule 

70116 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 405, 410, 411, 413, 414, 

424, and 426 

[CMS–1502–FC and CMS–1325–F] 

RINs 0938–AN84 and 0938–AN58 

Medicare Program; Revisions to 

Payment Policies Under the Physician 

Fee Schedule for Calendar Year 2006 

and Certain Provisions Related to the 

Competitive Acquisition Program of 

Outpatient Drugs and Biologicals 

Under Part B 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule with comment. 

SUMMARY: This rule addresses Medicare 

Part B payment policy, including the 

physician fee schedule that are 

applicable for calendar year (CY) 2006; 

and finalizes certain provisions of the 

interim final rule to implement the 

Competitive Acquisition Program (CAP) 

for Part B Drugs. It also revises Medicare 

Part B payment and related policies 

regarding: Physician work; practice 

expense (PE) and malpractice relative 

value units (RVUs); Medicare telehealth 

services; multiple diagnostic imaging 

procedures; covered outpatient drugs 

and biologicals; supplemental payments 

to Federally Qualified Health Centers 

(FQHCs); renal dialysis services; 

coverage for glaucoma screening 

services; National Coverage Decision 

(NCD) timeframes; and physician 

referrals for nuclear medicine services 

and supplies to health care entities with 

which they have financial relationships. 

In addition, the rule finalizes the 

interim RVUs for CY 2005 and issues 

interim RVUs for new and revised 

procedure codes for CY 2006. This rule 

also updates the codes subject to the 

physician self-referral prohibition and 

discusses payment policies relating to 

teaching anesthesia services, therapy 

caps, private contracts and opt-out, and 

chiropractic and oncology 

demonstrations. 

As required by the statute, it also 

announces that the physician fee 

schedule update for CY 2006 is ¥4.4 

percent, the initial estimate for the 

sustainable growth rate for CY 2006 is 

1.7 percent and the conversion factor for 

CY 2006 is $36.1770. 

DATES: Effective Date: These regulations 

are effective on January 1, 2006. 

Comment Date: To be assured 

consideration, comments must be 

received at one of the addresses 

provided below, no later than 5 p.m. on 

January 3, 2006. 

ADDRESSES: In commenting, please refer 

to file code CMS–1502–FC. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (no duplicates, please): 

1. Electronically. You may submit 

electronic comments on specific issues 

in this regulation to http:// 

www.cms.hhs.gov/regulations/ 

ecomments. (Attachments should be in 

Microsoft Word, WordPerfect, or Excel; 

however, we prefer Microsoft Word.) 

2. By regular mail. You may mail 

written comments (one original and two 

copies) to the following address ONLY: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–1502– 

FC, P.O. Box 8017, Baltimore, MD 

21244–8017. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments (one 

original and two copies) to the following 

address ONLY: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–1502– 

FC, Mail Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments (one original 

and two copies) before the close of the 

comment period to one of the following 

addresses. If you intend to deliver your 

comments to the Baltimore address, 

please call telephone number (410) 786– 

7197 in advance to schedule your 

arrival with one of our staff members. 

Room 445–G, Hubert H. Humphrey 

Building, 200 Independence Avenue, 

SW., Washington, DC 20201; or 7500 

Security Boulevard, Baltimore, MD 

21244–1850. 

(Because access to the interior of the 

HHH Building is not readily available to 

persons without Federal Government 

identification, commenters are 

encouraged to leave their comments in 

the CMS drop slots located in the main 

lobby of the building. A stamp-in clock 

is available for persons wishing to retain 

a proof of filing by stamping in and 

retaining an extra copy of the comments 

being filed.) 

Comments mailed to the addresses 

indicated as appropriate for hand or 

courier delivery may be delayed and 

received after the comment period. 

Submission of comments on 

paperwork requirements. You may 

submit comments on this document’s 

paperwork requirements by mailing 

your comments to the addresses 

provided at the end of the ‘‘Collection 

of Information Requirements’’ section in 

this document. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: Pam 

West (410) 786–2302 (for issues related 

to practice expense). 

Rick Ensor (410) 786–5617 (for issues 

related to the nonphysician workpool 

and supplemental survey data). 

Stephanie Monroe (410) 786–6864 (for 

issues related to the geographic 

practice cost index and malpractice 

RVUs). 

Craig Dobyski (410) 786–4584 (for issues 

related to list of telehealth services). 

Ken Marsalek (410) 786–4502 (for issues 

related to multiple procedure 

reduction for diagnostic imaging 

services and payment for teaching 

anesthesiologists). 

Henry Richter (410) 786–4562 (for 

issues related to payments for end 

stage renal disease facilities). 

Angela Mason (410) 786–7452 or 

Catherine Jansto (410) 786–7762 (for 

issues related to payment for covered 

outpatient drugs and biologicals). 

Fred Grabau (410) 786–0206 (for issues 

related to private contracts and opt 

out provision). 

David Worgo (410) 786–5919 (for issues 

related to Federally Qualified Health 

Centers). 

Dorothy Shannon (410) 786–3396 (for 

issues related to the outpatient 

therapy cap). 

Vadim Lubarsky (410) 786–0840 (for 

issues related to National Coverage 

Decision timeframes). 

Bill Larson (410) 786–7176 (for issues 

related to coverage of screening for 

glaucoma). 

Lia Prela (410) 786–0548 (for issues 

related to the competitive acquisition 

program (CAP) for part B drugs). 

Diane Milstead (410) 786–3355 or 

Gaysha Brooks (410) 786–9649 (for all 

other issues). 

SUPPLEMENTARY INFORMATION: 

Submitting Comments: We welcome 

comments from the public on the 

following issues: interim RVUs for 

selected procedure codes identified in 

Addendum C; and the physician self 

referral designated health services listed 

in tables 32 and 33. You can assist us 

by referencing the file code CMS–1502- 

FC and the specific ‘‘issue identifier’’ 

that precedes the section on which you 

choose to comment. 

Inspection of Public Comments: All 

comments received before the close of 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70117 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. CMS posts all comments 

received before the close of the 

comment period on its public web site 

as soon as possible after they are 

received. Hard copy comments received 

timely will 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. 

This Federal Register document is 

also available from the Federal Register 

online database through GPO Access a 

service of the U.S. Government Printing 

Office. The web site address is: http:// 

www.access.gpo.gov/nara/index.html. 

Information on the physician fee 

schedule can be found on the CMS 

homepage. You can access this data by 

using the following directions: 

1. Go to the CMS homepage (http:// 

www.cms.hhs.gov). 

2. Place your cursor over the word 

‘‘Professionals’’ in the blue areas near 

the top of the page. Select ‘‘physicians’’

from the drop-down menu. 

3. Under ‘‘Billing/Payment’’ select 

‘‘Physician Fee Schedule’’. 

To assist readers in referencing 

sections contained in this preamble, we 

are providing the following table of 

contents. Some of the issues discussed 

in this preamble affect the payment 

policies, but do not require changes to 

the regulations in the Code of Federal 

Regulations. Information on the 

regulation’s impact appears throughout 

the preamble and is not exclusively in 

section VI. 

Table of Contents 

I. Background 

A. Introduction 

B. Development of the Relative Value 

System 

C. Components of the Fee Schedule 

Payment Amounts 

D. Most Recent Changes the Fee Schedule 

II. Provisions of the Final Rule 

A. Resource-Based Practice Expense 

Relative Value Units (PE RVUs) 

1. Current Methodology 

2. PE Proposals for CY 2006 

3. PE Recommendations on CPEP Inputs 

for CY 2006 

4. Payment for Splint and Cast Supplies 

5. Miscellaneous PE Issues 

B. Geographic Practice Cost Indices (GPCIs) 

C. Malpractice RVUs 

1. Five Percent Specialty Threshold 

2. Specialty Crosswalk Issues 

3. Cardiac Catheterization and Angioplasty 

Exception 

4. Dominant Specialty for Low-Volume 

Codes 

5. Collection of Premium Data 

D. Medicare Telehealth Services 

1. Requests for Adding Services to the List 

of Medicare Telehealth Services 

2. Definition of an Originating Site 

3. Other Issues 

E. Contractor Pricing of Unlisted Therapy 

Modalities and Procedures 

F. Payment for Teaching Anesthesiologists 

G. End Stage Renal Disease (ESRD) Related 

Provisions 

1. Revised Pricing Methodology for 

Separately Billable Drugs and Biologicals 

Furnished by ESRD Facilities. 

2. Adjustment to Account for Changes in 

the Pricing of Separately Billable Drugs 

and Biologicals, and the Estimated 

Increase in Expenditures for Drugs and 

Biologicals 

3. Revisions to Geographic Designations 

and Wage Indexes Applied to the ESRD 

Composite Payment Rate 

4. Miscellaneous Comments on ESRD 

Issues 

5. Revisions to the Composite Payment 

Rate Exceptions Process 

H. Payment for Covered Outpatient Drugs 

and Biologicals 

1. ASP issues 

2. Payment for Drugs Furnished During CY 

2006 in Connection With the Furnishing 

of Renal Dialysis Services if Separately 

Billed by Renal Dialysis Facilities 

3. Clotting Factor Furnishing Fee 

4. Payment for Inhalation Drugs and 

Dispensing Fee 

5. Supplying Fee 

6. Competitive Acquisition of Outpatient 

Drugs And Biologicals Under Part B 

I. Private Contracts and Opt-out Provision 

J. Multiple Procedure Payment Reduction 

for Diagnostic Imaging 

K. Therapy Cap 

L. Chiropractic Demonstration Discussion 

M. Supplemental Payments to FQHCs 

Subcontracting with Medicare 

Advantage Plans 

N. National Coverage Decisions 

Timeframes 

O. Coverage of Screening for Glaucoma 

P. Additional Issues 

1. Corrections to Conditions for Medicare 

Payment (§ 424.22) 

2. Chemotherapy Demonstration Project 

III. Refinement of RVUs for CY 2006 and 

Response to Public Comments on Interim 

RVUs for 2005 

A. Summary of Issues Discussed Related to 

the Adjustment of RVUs 

B. Process for Establishing Work RVUs for 

the 2005 PFS 

C. Work RVU Refinements of Interim RVUs 

1. Methodology (Includes Table titled 

‘‘Work Relative Value Unit Refinements 

of the 2004 Interim and Related Relative 

Value Units’’) 

2. Interim 2005 Codes 

D. Establishment of Interim Work RVUs for 

New and Revised Physician’s Current 

Procedural Terminology (CPT) Codes 

and New Healthcare Common Procedure 

Coding System Codes (HCPCS) for 2006 

(Includes Table titled ‘‘American 

Medical Association Specialty Relative 

Value Update Committee and Health 

Care Professionals Advisory Committee 

Recommendations and CMS’s Decisions 

for New and Revised 2006 CPT Codes’’) 

E. Discussion of Codes for Which There 

Were No RUC Recommendations or for 

Which the RUC Recommendations Were 

Not Accepted 

F. Establishment of Interim PE RVUs for 

New and Revised Physician’s Current 

Procedural Terminology (CPT) Codes 

and New Healthcare Common Procedure 

Coding System (HCPCS) Codes for 2006 

IV. Five-Year Refinement of RVUs -Status 

update 

V. Physician Self-Referral Prohibition: 

Nuclear Medicine and Annual Update to 

the List of CPT/HCPCS Codes 

A. General 

B. Nuclear Medicine 

1. Response to Comments 

2. Revisions to the List of Codes Identifying 

Nuclear Medicine Services 

C. Annual Update to the Code List 

1. Response to Comments 

2. Revisions Effective for 2006 

VI. Physician Fee Schedule Update for CY 

2006 

A. Physician Fee Schedule Update 

B. The Percentage Change in the Medicare 

Economic Index (MEI) 

C. The Update Adjustment Factor 

VII. Allowed Expenditures for Physicians’

Services and the Sustainable Growth 

Rate 

A. Medicare Sustainable Growth Rate 

B. Physicians’ Services 

C. Preliminary Estimate of the SGR for 

2006 

D. Revised Sustainable Growth Rate for 

2005 

E. Final Sustainable Growth Rate for 2004 

F. Calculation of 2006, 2005, and 2004 

Sustainable Growth Rates 

VIII. Anesthesia and Physician Fee Schedule 

Conversion Factors for CY 2006 

A. Physician Fee Schedule Conversion 

Factor 

B. Anesthesia Fee Schedule Conversion 

Factor 

IX. Telehealth Originating Site Facility Fee 

Payment Amount Update 

X. Provisions of the Final Rule 

XI. Waiver of Proposed Rulemaking 

XII. Collection of Information Requirements 

XIII. Response to Comments 

XIV. Regulatory Impact Analysis 

Addendum A—Explanation and Use of 

Addendum B. 

Addendum B—Relative Value Units and 

Related Information 

Addendum C—Codes with Interim RVUs 

Addendum D—2006 Geographic Practice 

Cost Indices by Medicare Carrier and 

Locality 

Addendum E–2006 GAFs 

Addendum F—CAP: Revised Single Drug 

Category List 

Addendum G—CAP: Revised New Drugs for 

CAP Bidding for 2006 

Addendum H—List of CPT/HCPCS Codes 

Used to Describe Certain Designated 

Health Services Under Section 1877 of 

the Social Security Act 

70118 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

In addition, because of the many 

organizations and terms to which we 

refer by acronym in this proposed final 

rule with comment, we are listing these 

acronyms and their corresponding terms 

in alphabetical order below: 

AADA American Academy of 

Dermatology Association 

AAH American Association for 

Homecare 

ABN Advanced Beneficiary Notice 

ACC American College of Cardiology 

ACG American College of 

Gastroenterology 

ACR American College of Radiology 

AFROC Association of Freestanding 

Radiation Oncology Centers 

AGA American Gastroenterological 

Association 

AMA American Medical Association 

AMP Average manufacturer price 

AOAO American Osteopathic 

Academy of Orthopedics 

ASA American Society of 

Anesthesiologists 

ASGE American Society of 

Gastrointestinal Endoscopy 

ASP Average sales price 

ASTRO American Society for 

Therapeutic Radiation Oncology 

AUA American Urological Association 

AWP Average wholesale price 

BBA Balanced Budget Act of 1997 

BBRA Balanced Budget Refinement 

Act of 1999 

BIPA Benefits Improvement and 

Protection Act of 2000 

BLS Bureau of Labor Statistics 

BMI Body mass index 

BNF Budget neutrality factor 

BSA Body surface area 

CAP Competitive Acquisition Program 

CBSA Core-Based Statistical Area 

CF Conversion factor 

CFR Code of Federal Regulations 

CMA California Medical Association 

CMS Centers for Medicare & Medicaid 

Services 

CNS Clinical nurse specialist 

COBC Coordination of Benefits 

Contractor 

CPEP Clinical Practice Expert Panel 

CPI Consumer Price Index 

CPO Care Plan Oversight 

CPT (Physicians’) Current Procedural 

Terminology (4th Edition, 2002, 

copyrighted by the American 

Medical Association) 

CRNA Certified Registered Nurse 

Anesthetist 

CT Computed tomography 

CTA Computed tomographic 

angiography 

CY Calendar year 

DAW Dispense as written 

DHS Designated health services 

DME Durable medical equipment 

DMERC Durable Medical Equipment 

Regional Carrier 

DSMT Diabetes outpatient selfmanagement training services 

EAC Estimated acquisition cost 

ECP External counterpulsation 

E/M Evaluation and management 

EPO Erythopoeitin 

ESRD End stage renal disease 

FAX Facsimile 

FDA Food and Drug Administration 

FI Fiscal intermediary 

FQHC Federally qualified health 

center 

FR Federal Register 

GAF Geographic adjustment factor 

GAO Government Accountability 

Office 

GPCI Geographic practice cost index 

GPOs Group Purchasing Organizations 

HCPAC Health Care Professional 

Advisory Committee 

HCPCS Healthcare Common Procedure 

Coding System 

HHA Home health agency 

HHS (Department of) Health and 

Human Services 

HIC Health Insurance Number 

HIPAA Health Insurance Portability 

and Accountability Act of 1996, 

Public Law 104–191 

HOCM High Osmolar Contrast Media 

HPSA Health professional shortage 

area 

HRSA Health Resources and Services 

Administration (HHS) 

IDTFs Independent diagnostic testing 

facilities 

IPF Inpatient psychiatric facility 

IPPS Inpatient prospective payment 

system 

IRF Inpatient rehabilitation facility 

ISO Insurance Services Office 

IVIG Intravenous immune globulin 

JCAAI Joint Council of Allergy, 

Asthma, and Immunology 

JUA Joint underwriting association 

LCD Local coverage determination 

LTCH Long-term care hospital 

LOCM Low Osmolar Contrast Media 

MA Medicare Advantage 

MCAC Medicare Coverage Advisory 

Committee 

MCG Medical College of Georgia 

MedPAC Medicare Payment Advisory 

Commission 

MEI Medicare Economic Index 

MMA Medicare Prescription Drug, 

Improvement, and Modernization 

Act of 2003 

MNT Medical nutrition therapy 

MRA Magnetic resonance angiography 

MRI Magnetic resonance imaging 

MSA Metropolitan statistical area 

MSN Medicare summary notice 

NCD National coverage determination 

NCQDIS National Coalition of Quality 

Diagnostic Imaging Services 

NDC National drug code 

NECMA New England County 

Metropolitan Area 

NECTA New England City and Town 

Area 

NP Nurse practitioner 

NPP Nonphysician practitioners 

NPWP Nonphysician work pool 

OBRA Omnibus Budget Reconciliation 

Act 

OIG Office of Inspector General 

OMB Office of Management and 

Budget 

OPPS Outpatient prospective payment 

system 

OT Occupational therapy 

PA Physician assistant 

PC Professional component 

PE Practice Expense 

PEAC Practice Expense Advisory 

Committee 

PERC Practice Expense Review 

Committee 

PET Positron emission tomography 

PFS Physician Fee Schedule 

PLI Professional liability insurance 

PPAC Practicing Physicians Advisory 

Council 

PIN Provider identification number 

PPI Producer price index 

PPO Preferred provider organization 

PPS Prospective payment system 

PRA Paperwork Reduction Act 

PT Physical therapy 

RFA Regulatory Flexibility Act 

RIA Regulatory impact analysis 

RN Registered nurse 

RUC (AMA’s Specialty Society) 

Relative (Value) Update Committee 

RVU Relative value unit 

SGR Sustainable growth rate 

SMS (AMA’s) Socioeconomic 

Monitoring System 

SNF Skilled nursing facility 

SNM Society for Nuclear Medicine 

TA Technology assessment 

TC Technical component 

TEB Thoracic electrical bioimpedance 

tPA Tissue-type plasminogen activator 

UAF Update adjustment factor 

UPIN Unique provider identification 

number 

WAC Wholesale acquisition cost 

WAMP Widely available market price 

I. Background 

A. Introduction 

Since January 1, 1992, Medicare has 

paid for physicians’ services under 

section 1848 of the Social Security Act 

(the Act), ‘‘Payment for Physicians‘

Services.’’ The Act requires that 

payments under the physician fee 

schedule (PFS) be based on national 

uniform relative value units (RVUs) 

based on the resources used in 

furnishing a service. Section 1848(c) of 

the Act requires that national RVUs be 

established for physician work, practice 

expense (PE), and malpractice expense. 

Prior to the establishment of the 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70119 

resource-based relative value system, 

Medicare payment for physicians’

services was based on reasonable 

charges. 

Section 1848(c)(2)(B)(ii)(II) of the Act 

provides that adjustments in RVUs may 

not cause total physician fee schedule 

payments to differ by more than $20 

million from what they would have 

been had the adjustments not been 

made. If adjustments to RVUs cause 

expenditures to change by more than 

$20 million, we must make adjustments 

to ensure that they do not increase or 

decrease by more than $20 million. 

B. Development of the Relative Value 

System 

1. Work RVUs 

The concepts and methodology 

underlying the PFS were enacted as part 

of the Omnibus Budget Reconciliation 

Act (OBRA) of 1989, Public Law 101–

239, and OBRA 1990, (Public Law 101–

508). The final rule published 

November 25, 1991 (56 FR 59502) set 

forth the fee schedule for payment for 

physicians’ services beginning January 

1, 1992. Initially, only the physician 

work RVUs were resource-based, and 

the PE and malpractice RVUs were 

based on average allowable charges. 

The physician work RVUs established 

for the implementation of the fee 

schedule in January 1992 were 

developed with extensive input from 

the physician community. A research 

team at the Harvard School of Public 

Health developed the original physician 

work RVUs for most codes in a 

cooperative agreement with the 

Department of Health and Human 

Services (HHS). In constructing the 

code-specific vignettes for the original 

physician work RVUs, Harvard worked 

with panels of experts, both inside and 

outside the government, and obtained 

input from numerous physician 

specialty groups. 

Section 1848(b)(2)(A) of the Act 

specifies that the RVUs for radiology 

services are based on a relative value 

scale we adopted under section 

1834(b)(1)(A) of the Act, (the American 

College of Radiology (ACR) relative 

value scale), which we integrated into 

the overall PFS. Section 1848(b)(2)(B) of 

the Act specifies that the RVUs for 

anesthesia services are based on RVUs 

from a uniform relative value guide. We 

established a separate conversion factor 

(CF) for anesthesia services, and we 

continue to utilize time units as a basis 

for determining payment for these 

services. As a result, there is a separate 

payment methodology for anesthesia 

services. 

We establish physician work RVUs for 

new and revised codes based on 

recommendations received from the 

American Medical Association’s (AMA) 

Specialty Society Relative Value Update 

Committee (RUC). 

2. Practice Expense Relative Value Units 

(PE RVUs) 

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 physician’s service 

beginning in 1998. We were to consider 

the staff, equipment, and supplies used 

in the provision of various medical and 

surgical services. The legislation 

specifically required that, in 

implementing the new system of PE 

RVUs, we apply the same budgetneutrality provisions that are applicable 

to other adjustments under the 

physician fee schedule. 

Section 4505(a) of the Balanced 

Budget Act of 1997 (BBA) (Pub. L. 105–

33), amended section 1848(c)(2)(C)(ii) of 

the Act to delay 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 charge-based PE 

RVUs to resource-based RVUs. 

We established the resource-based PE 

RVUs for each physician’s service in a 

final rule, published November 2, 1998 

(63 FR 58814), effective for services 

furnished in 1999. Based on the 

requirement to transition to a resourcebased system for PE over a 4-year 

period, resource-based PE RVUs did not 

become fully effective until 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. The CPEP data were 

collected from panels of physicians, 

practice administrators, and 

nonphysicians (for example, registered 

nurses) nominated by physician 

specialty societies and other groups. 

The CPEP panels identified the direct 

inputs required for each physician’s 

service in both the office setting and 

out-of-office setting. The AMA’s SMS 

data provided aggregate specialtyspecific information on hours worked 

and PEs. 

Separate PE RVUs are established for 

procedures that can be performed in 

both a nonfacility setting, such as a 

physician’s office, and a facility setting, 

such as a hospital outpatient 

department. The difference between the 

facility and nonfacility RVUs reflects 

the fact that a facility receives separate 

payment from Medicare for its costs of 

providing the service, apart from 

payment under the PFS. The nonfacility 

RVUs reflect all of the direct and 

indirect PEs of providing a particular 

service outside a facility setting. 

Section 212 of the Medicare, 

Medicaid and State Child Health 

Insurance Program Balanced Budget 

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

106–113) directed 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 the 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. 

As discussed in the January 7, 2004 

physician fee schedule final rule (69 FR 

1092), section 303(a)(1)(B) of MMA 

amended section 1848(c)(2) of the Act 

by adding new subparagraph (H), 

‘‘Adjustments in Practice Expense 

Relative Value Units for Certain Drug 

Administration Services beginning in 

2004’’. Subparagraph (H)(i) requires the 

Secretary to determine the practice 

expense RVUs for 2004 using practice 

expense surveys submitted to the 

Secretary as of January 1, 2003 by a 

physician specialty organization in 

accordance with section 212 of the 

Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act 

(BBRA) of 1999 if the survey: (1) Covers 

practice expenses for oncology drug 

administration services; and (2) meets 

criteria established by the Secretary for 

acceptance of such surveys. Consistent 

with section 1848(c)(2)(H)(i) of the Act, 

in January 7, 2005 final rule, we 

announced we would use the ASCO 

survey to determine the practice 

expense RVUs for physician fee 

schedule services furnished on or after 

January 1, 2004 because it: (1) Was 

submitted prior to January 1, 2003; (2) 

includes expenses for drug 

administration services; and (3) meets 

criteria we have established for use of 

surveys. 

70120 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

3. Resource-Based Malpractice RVUs 

Section 4505(f) of the BBA amended 

section 1848(c) of the Act to require us 

to implement resource-based 

malpractice RVUs for services furnished 

on or after 2000. The resource-based 

malpractice RVUs were implemented in 

the PFS final rule published November 

2, 1999 (64 FR 59380). The malpractice 

RVUs are based on malpractice 

insurance premium data collected from 

commercial and physician-owned 

insurers from all the States, the District 

of Columbia, and Puerto Rico. 

4. Refinements to the RVUs 

Section 1848(c)(2)(B)(i) of the Act 

requires that we review all RVUs no less 

often than every five years. The first 5- 

year review of the physician work RVUs 

went into effect in 1997, published on 

November 22, 1996 (61 FR 59489). The 

second 5-year review went into effect in 

2002, published on November 1, 2001 

(66 FR 55246). The next 5-year review 

is scheduled to go into effect in 2007. 

In 1999, the AMA’s RUC established 

the Practice Expense Advisory 

Committee (PEAC) for the purpose of 

refining the direct PE inputs. Through 

March of 2004, the PEAC provided 

recommendations to CMS for over 7,600 

codes (all but a few hundred of the 

codes currently listed in the AMA’s 

Current Procedural Terminology (CPT) 

codes). 

In the November 15, 2004, PFS final 

rule (69 FR 66236), hereinafter referred 

to as the CY 2005 final rule, we 

implemented the first 5-year review of 

the malpractice RVUs (69 FR 66263). 

5. Adjustments to RVUS Are Budget 

Neutral 

Section 1848(c)(2)(B)(ii)(II) of the Act 

provides that adjustments in RVUs for a 

year may not cause total PFS payments 

to differ by more than $20 million from 

what they would have been if the 

adjustments were not made. In 

accordance with section 

1848(c)(2)(B)(ii)(II) of the Act, if 

adjustments to RVUs cause 

expenditures to change by more than 

$20 million, we make adjustments to 

ensure that expenditures do not increase 

or decrease by more than $20 million. 

C. Components of the Fee Schedule 

Payment Amounts 

Under the formula set forth in section 

1848(b)(1) of the Act, the payment 

amount for each service paid under the 

physician fee schedule is the product of 

three factors: (1) A nationally uniform 

relative value unit (RVU) for the service; 

(2) a geographic adjustment factor (GAF) 

for each physician fee schedule area; 

and (3) a nationally uniform conversion 

factor (CF) for the service. The CF 

converts the relative values into 

payment amounts. 

For each physician fee schedule 

service, there are 3 relative values: (1) 

An RVU for physician work; (2) an RVU 

for practice expense; and (3) an RVU for 

malpractice expense. For each of these 

components of the fee schedule, there is 

a geographic practice cost index (GPCI) 

for each fee schedule area. 

To calculate the payment for every 

physician service, the components of 

the fee schedule (physician work, PE, 

and malpractice RVUs) are adjusted by 

a geographic practice cost index (GPCI). 

The GPCIs reflect the relative costs of 

physician work, PEs, and malpractice 

insurance in an area compared to the 

national average costs for each 

component. 

Payments are converted to dollar 

amounts through the application of a 

CF, which is calculated by the Office of 

the Actuary and is updated annually for 

inflation. 

The general formula for calculating 

the Medicare fee schedule amount for a 

given service and fee schedule area can 

be expressed as: 

Payment = [(RVU work × GPCI work) + 

(RVU PE × GPCI PE) + (RVU malpractice 

× GPCI malpractice)] × CF. 

The CF for calendar year (CY) 2005 

appears in section VI, Physician Fee 

Schedule Update for CY 2006. The 

RVUs for CY 2006 are in Addendum B. 

The GPCIs for CY 2006 can be found in 

Addendum D. 

Section 1848(e) of the Act requires us 

to develop GAFs for all physician fee 

schedule areas. The total GAF for a fee 

schedule area is equal to a weighted 

average of the individual GPCIs for each 

of the three components of the service. 

However, in accordance with the 

statute, the GAF for the physician’s 

work reflects one-quarter of the relative 

cost of physician’s work compared to 

the national average. 

D. Most Recent Changes to the Fee 

Schedule 

In the CY 2005 final rule (69 FR 

66236), we refined the resource-based 

PE RVUs and made other changes and 

clarifications to Medicare Part B 

payment policy. These included: 

• Supplemental survey data for PE; 

• Updated GPCIs for physician work 

and PE; 

• Updated malpractice RVUs; 

• Revised requirements for 

supervision of therapy assistants; 

• Revised payment rules for low 

osmolar contrast media (LOCM); 

• Payment policies for physicians and 

practitioners managing dialysis patients; 

• Clarification of care plan oversight 

(CPO) requirements; 

• Requirements for supervision of 

diagnostic psychological testing 

services; 

• Clarifications to the policies 

affecting therapy services provided 

incident to a physician’s service; 

• Requirements for assignment of 

Medicare claims; 

• Additions to the list of telehealth 

services; 

• Changes to payments for drug 

administration services; and 

• Several coding issues. 

The CY 2005 final rule (69 FR 66236) 

also addressed the following provisions 

of the Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003 (MMA) (Pub. L. 108–173): 

• Coverage of an initial preventive 

physical examination. 

• Coverage of cardiovascular 

screening blood tests. 

• Coverage of diabetes screening tests. 

• Incentive payment improvements 

for physicians in physician shortage 

areas. 

• Changes to payment for covered 

outpatient drugs and biologicals and 

drug administration services. 

• Changes to payment for renal 

dialysis services. 

• Coverage of routine costs associated 

with certain clinical trials of category A 

devices as defined by the Food and Drug 

Administration. 

• Coverage of hospice consultation 

service. 

• Indexing the Part B deductible to 

inflation. 

• Extension of coverage of 

intravenous immune globulin (IVIG) for 

the treatment in the home of primary 

immune deficiency diseases. 

• Revisions to reassignment 

provisions. 

• Payment for diagnostic 

mammograms. 

• Coverage of religious nonmedical 

health care institution items and 

services to the beneficiary’s home. 

In addition, the CY 2005 PFS final 

rule finalized the calendar year (CY) 

2004 interim RVUs for new and revised 

codes in effect during CY 2004 and 

issued interim RVUs for new and 

revised procedure codes for CY 2005; 

updated the codes subject to the 

physician self-referral prohibition; 

discussed payment for set up of portable 

x-ray equipment; discussed the third 5- 

year refinement of work RVUs; and 

solicited comments on potentially 

misvalued work RVUs. 

In accordance with section 

1848(d)(1)(E) of the Act, we also 

announced that the PFS update for CY 

2005 would be 1.5 percent; the initial 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70121 

estimate for the sustainable growth rate 

for CY 2005 was 4.3; and the CF for CY 

2005 would be $37.8975. 

II. Provisions of the Final Rule 

In response to the August 8, 2005 

proposed rule (70 FR 45764), we 

received approximately 15,000 

comments. We received comments from 

individual physicians, health care 

workers, professional associations and 

societies, and beneficiaries. The 

majority of the comments addressed the 

proposals related to PE and the negative 

update to the PFS, GPCIs, and Teaching 

Anesthesiology. 

The proposed rule discussed policies 

that affected the RVUs on which 

payment for certain services would be 

based and other changes to Medicare 

Part B payment policy. We also 

discussed changes related to payment 

for covered outpatient drugs and 

biologicals; supplemental payments to 

federally qualified health centers 

(FQHCs); payment for renal dialysis 

services; the national coverage decision 

(NCD) process; coverage of screening for 

glaucoma; private contracts; and 

physician referrals for nuclear medicine 

services and supplies to health care 

entities with which they have financial 

relationships. RVU changes 

implemented through this final rule 

with comment are subject to the $20 

million limitation on annual 

adjustments contained in section 

1848(c)(2)(B)(ii)(II) of the Act. 

After reviewing the comments and 

determining the policies we would 

implement, we have estimated the costs 

and savings of these policies and 

discuss in detail the effects of these 

changes in the Regulatory Impact 

Analysis in section XIV. 

For the convenience of the reader, the 

headings for the policy issues 

correspond to the headings used in the 

August 8, 2005 proposed rule. More 

detailed background information for 

each issue can be found in the August 

8, 2005 proposed rule. 

A. Resource Based Practice Expense 

(PE) RVUs 

Based on section 1848(c)(1)(B) of the 

Act, PEs are the portion of the resources 

used in furnishing the service that 

reflects the general categories of 

physician and practitioner expenses 

(such as office rent and wages of 

personnel, but excluding malpractice 

expenses). 

Section 121 of the Social Security 

Amendments of 1994 (Pub. L. 103–432), 

enacted on October 31, 1994, required 

us to develop a methodology for a 

resource-based system for determining 

PE RVUs for each physician’s service. 

Up until that point, physicians’ PEs 

were based on historical allowed 

charges. This legislation stated that the 

revised PE methodology must consider 

the staff, equipment, and supplies used 

in the provision of various medical and 

surgical services in various settings 

beginning in 1998. The Secretary has 

interpreted this to mean that Medicare 

payments for each service would be 

based on the relative PE resources 

typically involved with performing the 

service. 

The initial implementation of 

resource-based PE RVUs was delayed 

until January 1, 1999, by section 4505(a) 

of the BBA. In addition, section 4505(b) 

of the BBA required the new payment 

methodology be phased-in over 4 years, 

effective for services furnished in CY 

1999, and fully effective in CY 2002. 

The first step toward implementation 

called for by the statute was to adjust 

the PE values for certain services for CY 

1998. Section 4505(d) of BBA required 

that, in developing the resource-based 

PE RVUs, the Secretary must: 

• Use, to the maximum extent 

possible, generally accepted cost 

accounting principles that recognize all 

staff, equipment, supplies, and 

expenses, not solely those that can be 

linked to specific procedures. 

• Develop a refinement method to be 

used during the transition. 

• Consider, in the course of notice 

and comment rulemaking, impact 

projections that compare new proposed 

payment amounts to data on actual 

physician PEs. 

Beginning in CY 1999, Medicare 

began the 4 year transition to resourcebased PE RVUs. In CY 2002, the 

resource-based PE RVUs were fully 

transitioned. 

1. Current Methodology 

The following sections discuss the 

current PE methodology. 

a. Data Sources 

There are two primary data sources 

used to calculate PEs. The AMA’s SMS 

survey data are used to develop the PEs 

per hour for each specialty. The second 

source of data used to calculate PEs was 

originally developed by the CPEP. The 

CPEP data include the supplies, 

equipment, and staff times specific to 

each procedure. 

The AMA developed the SMS survey 

in 1981 and discontinued it in 1999. 

Beginning in 2002, we incorporated the 

1999 SMS survey data into our 

calculation of the PE RVUs, using a 5- 

year average of SMS survey data. (See 

Revisions to Payment Policies and FiveYear Review of and Adjustments to the 

Relative Value Units Under the 

Physician Fee Schedule for CY 2002 

final rule, published November 1, 2001 

(66 FR 55246).) The SMS PE survey data 

are adjusted to a common year, 1995. 

The SMS data provide the following six 

categories of PE costs: 

• Clinical payroll expenses, which 

are payroll expenses (including fringe 

benefits) for clinical nonphysician 

personnel. 

• Administrative payroll expenses, 

which are payroll expenses (including 

fringe benefits) for nonphysician 

personnel involved in administrative, 

secretarial or clerical activities. 

• Office expenses, which include 

expenses for rent, mortgage interest, 

depreciation on medical buildings, 

utilities and telephones. 

• Medical material and supply 

expenses, which include expenses for 

drugs, x-ray films, and disposable 

medical products. 

• Medical equipment expenses, 

which include depreciation expenses, 

leases, and rent of medical equipment 

used in the diagnosis or treatment of 

patients. 

• All other expenses, including 

expenses for legal services, accounting, 

office management, professional 

association memberships, and any 

professional expenses not mentioned 

above. 

In accordance with section 212 of the 

BBRA, we established a process to 

supplement the SMS data for a specialty 

with data collected by entities and 

organizations other than the AMA (that 

is, the specialty itself). (See the Criteria 

for Submitting Supplemental Practice 

Expense Survey Data interim final rule 

with comment period, published on 

May 3, 2000 (65 FR 25664).) Originally, 

the deadline to submit supplementary 

survey data was through August 1, 2001. 

This deadline was extended in the 

November 1, 2001 final rule through 

August 1, 2003. (See the Revisions to 

Payment Policies and Five-Year Review 

of and Adjustments to the Relative 

Value Units Under the Physician Fee 

Schedule for CY 2002 final rule, 

published on November 1, 2001 (66 FR 

55246).) Then, to ensure maximum 

opportunity for specialties to submit 

supplementary survey data, we 

extended the deadline to submit surveys 

until March 1, 2005. (See the Revisions 

to Payment Policies Under the 

Physician Fee Schedule for CY 2002 

final rule, published on November 7, 

2003 (68 FR 63196).) 

The CPEPs consisted of panels of 

physicians, practice administrators, and 

nonphysicians (registered nurses, for 

example) who were nominated by 

physician specialty societies and other 

groups. There were 15 CPEPs consisting 

70122 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

of 180 members from more than 61 

specialties and subspecialties. 

Approximately 50 percent of the 

panelists were physicians. 

The CPEPs identified specific inputs 

involved in each physician service 

provided in an office or facility setting. 

The inputs identified were the quantity 

and type of nonphysician labor, medical 

supplies, and medical equipment. 

In 1999, the AMA’s Multi-specialty 

Relative Value Update Committee (RUC) 

established the PEAC. Since 1999, and 

until March 2004, the PEAC, a multispecialty committee, reviewed the 

original CPEP inputs and provided us 

with recommendations for refining 

these direct PE inputs for existing CPT 

codes. Through its last meeting in 

March 2004, the PEAC provided 

recommendations which we have 

reviewed and accepted for over 7,600 

codes. As a result of this scrutiny by the 

PEAC, the current CPEP/RUC inputs 

differ markedly from those originally 

recommended by the CPEPs. The PEAC 

has now been replaced by the Practice 

Expense Review Committee (PERC), 

which acts to assist the RUC in 

recommending PE inputs. 

b. Allocation of Practice Expenses to 

Services 

In order to establish PE RVUs for 

specific services, it is necessary to 

establish the direct and indirect PE 

associated with each service. Our 

current approach is to allocate aggregate 

specialty practice costs to specific 

procedures and, thus, it is often referred 

to as a ‘‘top-down’’ approach. The 

specialty PEs are derived from the 

AMA’s SMS survey and supplementary 

survey data. The PEs for a given 

specialty are allocated to the services 

performed by that specialty on the basis 

of the CPEP/RUC data and work RVUs 

assigned to each CPT code. The specific 

process is detailed as follows: 

Step 1—Calculation of the SMS Cost 

Pool for Each Specialty 

The six SMS cost categories can be 

described as either direct or indirect 

expenses. The three direct expense 

categories include clinical labor, 

medical supplies and medical 

equipment. Indirect expenses include 

administrative labor, office expense, and 

all other expenses. We combine these 

indirect expenses into a single category. 

The SMS cost pool for each specialty is 

calculated as follows: 

• The specialty PE per hour (PE/HR) 

for each of the three direct and one 

indirect cost categories from the SMS is 

calculated by dividing the aggregate PE 

per specialty by the specialty’s total 

hours spent in patient care activities 

(also determined by the SMS survey). 

The PE/HR is divided by 60 to obtain 

the PE per minute (PE/MIN). 

• Each specialty’s PE pools (for each 

of the three direct and one indirect cost 

categories) are created by multiplying 

the PE/MIN for the specialty by the total 

time the specialty spent treating 

Medicare patients for all procedures 

(determined using Medicare utilization 

data). Physician time on a procedurespecific level is available through RUC 

surveys of new or revised codes and 

through surveys conducted as part of 

the 5-year review process. For codes 

that the RUC has not yet reviewed, the 

original data from the Harvard resourcebased RVU system survey is used. 

Physician time includes time spent on 

the case before, during, and after the 

procedure. The physician procedure 

time is multiplied by the frequency that 

each procedure is performed on 

Medicare patients by the specialty. 

• The total specialty-specific SMS PE 

for each cost category is the sum, for 

each direct and indirect cost category, of 

all of the procedure-specific total PEs. 

Table 1 illustrates an example of the 

calculation of the total SMS cost pools 

for the three direct and one indirect cost 

categories discussed in step 1. For this 

specialty, PE/HR for clinical payroll 

expenses is $9.30 per hour. The hourly 

rate is divided by 60 minutes to obtain 

the clinical payroll per minute for the 

specialty. 

The total clinical payroll for 

providing hypothetical procedure 00001 

for this specialty of $3,633,465 is the 

result of taking the clinical payroll per 

minute of $0.16; multiplying this by the 

physician time for procedure 00001 (56 

minutes); and multiplying the result by 

the number of times this procedure was 

provided to Medicare patients by this 

specialty (418,602). The total amount 

spent on clinical payroll in this 

specialty is $667,457,018. This amount 

is calculated by summing the clinical 

payroll expenses of procedure 00001 

and all of the other services provided by 

this specialty. 

Step 2—Calculation of CPEP Cost Pool 

CPEP data provide expenditure 

amounts for the direct expense 

categories (clinical labor, supplies, and 

equipment cost) at the procedure level. 

Multiplying the CPEP procedure-level 

PEs for each of these three categories by 

the number of times the specialty 

provided the procedure, produces a 

total category cost, per procedure, for 

that specialty. The sum of the total 

expenses from each procedure results in 

the total CPEP category cost for the 

specialty. 


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For example, in Table 2, using CPEP 

data, the clinical labor cost of procedure 

00001 is $65.23. Under the methodology 

described above in this step, this is 

multiplied by the number of services for 

the specialty (418,602), to yield the total 

CPEP data clinical labor cost of the 

procedure: $27,305,408. In this 

example, the clinical labor cost for all 

other services performed by this 

specialty is $831,618,600. Therefore, the 

entire clinical labor CPEP expense pool 

for the specialty is $858,924,008. Step 2 

is repeated to calculate the CPEP supply 

and equipment costs. 

Step 3—Calculation and Application of 

Scaling Factors 

This step ensures that the total of the 

CPEP costs across all procedures 

performed by the specialty equates with 

the total direct costs for the specialty as 

reflected by the SMS data. To 

accomplish this, the CPEP data are 

scaled to SMS data by means of a 

scaling factor so that the total CPEP 

costs for each specialty equals the total 

SMS cost for the specialty. (The scaling 

factor is calculated by dividing the 

specialty’s SMS pool by the specialty’s 

CPEP pool.) 

The unscaled CPEP cost per 

procedure value, at the direct cost level, 

is then multiplied by the respective 

specialty scalar to yield the scaled CPEP 

procedure value. The sum of the scaled 

CPEP direct cost pool expenditures 

equals the total scaled direct expense for 

the specific procedure at the specialty 

level. 

In the Step 3 example shown in Table 

3, the SMS total clinical labor costs for 

the specialty is $667,457,018. This 

amount divided by the CPEP total 

clinical labor amount of $858,924,008 

yields a scaling factor of 0.78. The CPEP 

clinical labor cost for hypothetical 

procedure 00001 is $65.23. Multiplying 

the 0.78 scaling factor for clinical labor 

costs by $65.23 yields the scaled clinical 

labor cost amount of $50.69. Individual 

scaling factors must also be calculated 

for supply and equipment expenses. 

The sum of the scaled direct cost values, 

$50.69, $43.90, and $139.45, 

respectively, equals the total scaled 

direct expense of $234.04. 

TABLE 3.—CALCULATION AND APPLICATION OF SCALING FACTORS

Standard methodology Clinical/Labor Supplies Equipment 

Total Scaled direct 

expense 

(Sum of A, B, and 

C) 

(A) (B) (C) (D) 

(a) Total—SMS Pool .......................................................... $667,457,018 $344,493,945 $531,094,831 

(b) Total—CPEP Pool ........................................................ 858,924,008 411,894,617 5,929,275,023 

(c) Scaling Factor .............................................................. 0 .78 52 .49 1,556 .86 

Unscaled Value 

(e) CPT 00001—Scaled Value .......................................... 50 .69 43 .90 139 .45 $234.04 

(c) = (a)/(b) 

(e) = (c)*(d) 

Step 4—Calculation of Indirect 

Expenses 

Indirect PEs cannot be directly 

attributed to a specific service because 

they are incurred by the practice as a 

whole. Indirect costs include rent, 

utilities, office equipment and supplies, 

and accounting and legal fees. There is 

not a single, universally accepted 

approach for allocating indirect practice 

costs to individual procedure codes. 

Rather allocation involves judgment in 

identifying the base or bases that are the 

best measures of a practice’s indirect 

costs. 

To allocate the indirect PEs to a 

specific service, we use the following 

methodology: 

• The total scaled direct expenses and 

the converted work RVU (the work RVU 

for the service is multiplied by 

$34.5030, the 1995 CF) are added 

together, and then multiplied by the 

number of services provided by the 

specialty to Medicare patients. 

• The total indirect PEs per specialty 

are calculated by summing the indirect 

expenses for all other procedures 

provided by that specialty. 

For example, in Table 4, the physician 

work RVU for procedure 00001 is 2.36. 

Multiplying the work RVU by the 1995 

CF of $34.5030 equals $81.43. The 

physician work value is added to the 

scaled total direct expense from Step 3 


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70124 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

($234.04). The total of $314.47 is a 

proxy for the indirect PE for the 

specialty attributed to this procedure. 

The total indirect expenses are then 

multiplied by the number of times 

procedure 00001 is provided by the 

specialty (418,602), to calculate total 

indirect expenses for this procedure of 

$132,055,728. The process is repeated 

across all procedures performed by the 

specialty, and the indirect expenses for 

each service are summed to arrive at the 

total specialty indirect PE pool of 

$6,745,545,434. 

TABLE 4.—CALCULATION OF INDIRECT EXPENSE

Standard Methodology Physician Work* Total direct 

expense Total 

(A) (B) (C) 

(a) CPT 00001 ......................................................................................................... $81.43 $234.04 $315 .47 

(b) Allowed Services ................................................................................................ .............................. .............................. 418,602 

(c) Subtotal .............................................................................................................. .............................. .............................. 132,055,728 

(d) All Other Services .............................................................................................. .............................. .............................. 6,613,489,706 

(e) Total Indirect Expense ....................................................................................... .............................. .............................. 6,745,545,434 

* Calculated by multiplying work RVU of 2.36 by 1995 CF of $34.5030. 

Step 5—Calculation and Application of 

Indirect Scaling Factors 

Similar to the direct costs, the indirect 

costs are scaled to ensure that the total 

across all procedures performed by the 

specialty equates with the total indirect 

costs for the specialty as reflected by the 

SMS data. To accomplish this, the 

indirect costs calculated in Step 4 

(Table 4) are scaled to SMS data. The 

calculation of the indirect scaling 

factors is as follows: 

• The specialty’s total SMS indirect 

expense pool is divided by the 

specialty’s total indirect expense pool 

calculated in Step 4 (Table 4), to yield 

the indirect expense scaling factor. 

• The unscaled indirect expense 

amount, at the procedure level, is 

multiplied by the specialty’s scaling 

factor to calculate the procedure’s 

scaled indirect expenses. 

• The sum of the scaled indirect 

expense amount and the procedure’s 

direct expenses yields the total PEs for 

the specialty for this procedure. 

In table 5, to calculate the indirect 

scaling factor for hypothetical procedure 

00001, divide the total SMS indirect 

pool, $3,337,285,089 (calculated in Step 

1-Table 1)), by the total indirect expense 

for the specialty across all procedures of 

$6,745,545,434. This results in a scaling 

factor of 0.49. Next, the unscaled 

indirect cost of $315.47 is multiplied by 

the 0.49 scaling factor, resulting in 

scaled indirect cost of $156.07. To 

calculate the total PEs for the specialty 

for procedure 00001, the scaled direct 

and indirect expenses are added, 

totaling $390.12. 

TABLE 5.—CALCULATION OF INDIRECT SCALING FACTORS AND TOTAL PRACTICE EXPENSES

Standard methodology Indirect costs Direct cost 

Specialty specific 

practice expenses 

(Sum of A, B) 

(A) (B) (C) 

(a) Total—SMS Indirect Expense ............................................................................ $3,337,285,089 

(b) Total Indirect Expense for all Procedures (from Step 4) ................................... 6,745,545,434 

(c) Scaling Factor .................................................................................................... 0 .49 

(d) CPT 00001—Unscaled Value ............................................................................ 315 .47 

(e) CPT 00001—Scaled Value ................................................................................ 156 .07 $234.04 $390.12 

Step 6—Weighted Average of RVUs for 

Procedures Performed by More Than 

One Specialty 

For codes that are performed by more 

than one specialty, a weighted-average 

PE is calculated based on Medicare 

frequency data of all specialties 

performing the procedure as shown in 

Table 6. 

TABLE 6.—WEIGHT AVERAGING FOR ALL SPECIALTIES

Standard methodology Practice expense 

value 

Percent of total allowed services 

(A) (B) 

(a) Specialty Total Practice Expense .......................................................................................................... $390.12 83 

(b) Weighted Avg.—All Other Specialties ................................................................................................... 929.87 17 

(c) Weighted Avg.—All Specialties .............................................................................................................. 481.70 100 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70125 

Step 7—Budget Neutrality and Final 

RVU Calculation 

The total scaled direct and indirect 

inputs are then adjusted by a budget 

neutrality factor (BNF) to calculate 

RVUs. Section 1848(c)(2)(B)(ii)(II) of the 

Act provides that adjustments in RVUs 

may not cause total PFS payments to 

differ by more than $20 million from 

what they would have been if the 

adjustments were not made. Budget 

neutrality for the upcoming year is 

determined relative to the sum of PE 

RVUs for the current year. Although the 

PE RVUs for any particular code may 

vary from year-to-year, the sum of PE 

RVUs across all codes is set equal to the 

current year. The BNF is equal to the 

sum of the current year’s PE RVUs, 

divided by the sum of the direct and 

indirect inputs across all codes for the 

upcoming year. The BNF is applied to 

(multiplied by) the scaled direct and 

indirect expenses for each code to set 

the PE RVU for the upcoming year. 

In Table 7, the sum of the scaled 

direct and indirect expenses for 

hypothetical code 00001 ($481.70) is 

multiplied by the BNF (0.02 in this 

example) to yield a PE RVU of 10.60. 

TABLE 7.—CALCULATE PE RVU 

Total scaled direct 

and indirect inputs 

Budget neutrality 

factor Final PE RVU 

(A) (B) (C) 

(a) Code 00001 .......................................................................................................... $481.70 0.02 10.60 

c. Other Methodological Issues: 

Nonphysician Work Pool (NPWP) 

As an interim measure, until we could 

further analyze the effect of the topdown methodology on the Medicare 

payment for services with no physician 

work (including the technical 

components (TCs) of radiation oncology, 

radiology and other diagnostic tests), we 

created a separate PE pool for these 

services. However, any specialty society 

could request that its services be 

removed from the nonphysician work 

pool (NPWP). We have removed some 

services from the NPWP if we find that 

the requesting specialty provides the 

service the majority of the time. 

NPWP Step 1—Calculation of the SMS 

Cost Pool for Each Code 

This step parallels the calculations 

described above for the standard ‘‘topdown’’ PE allocation methodology. For 

codes in the NPWP, the direct and 

indirect SMS costs are set equal to the 

weighted average of the PE/HR for the 

specialties that provide the services in 

the pool. Clinical staff time is 

substituted for physician time in the 

calculation. The clinical staff time for 

the code is from CPEP data. Otherwise, 

the calculation is similar to the method 

described previously for codes with 

physician time. 

The following example in Table 8 

illustrates this calculation for 

hypothetical code 00002. In this 

example, the average clinical payroll 

PE/HR for all specialties in the NPWP 

is $12.30 and the clinical staff time for 

code 00002 is 116 minutes. 

NPWP Step 2—Calculation of ChargeBased PE RVU Cost Pool 

The NPWP calculation uses the 1998 

(charge-based) PE RVU value for the 

code, multiplied by the 1995 CF (25.74 

× $34.503 = $888.11). The percentage of 

clinical labor, supplies and equipment 

are the percentage that each PE category 

represents for all physicians relative to 

the total PE for all physicians 

(calculated from the SMS data) as 

shown in Table 9. 


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NPWP Step 3—Calculation and 

Application of Scaling Factors 

After the total cost pools for each code 

in the NPWP are calculated, the steps to 

ensure the total charge-based PEs for the 

procedure do not exceed the total SMS 

PEs for the procedure (scaling) are the 

same as those described previously for 

codes with physician work. 

In Table 10, the SMS total clinical 

labor costs are $2,499,159. This amount 

divided by the charge-based total 

clinical labor amount of $16,613,742 

yields a scaling factor of 0.15. The 

charge-based clinical labor cost for 

hypothetical procedure 00002 is 

$158.08 (from NPWP Step 2—Table 9). 

Multiplying the 0.15 scaling factor for 

clinical labor costs by $158.08 yields the 

scaled clinical labor cost amount of 

$23.78. Individual scaling factors must 

be calculated for both supply and 

equipment expenses. The sum of the 

scaled direct cost values, $23.78, $32.57 

and $2.72, respectively, equals the total 

scaled direct expense of $59.07. 

TABLE 10.—CALCULATION AND APPLICATION OF DIRECT COST SCALING FACTORS

NPWP methodology Clinical Supplies Equipment 

Total scaled 

direct expense 

(Sum of A, B, 

and C) 

(A) (B) (C) (D) 

(a) Total—NPWP Specialty Pool ............................................... $2,499,159 $1,503,559 $650,188 

(b) Total NPWP Charge-based Pool ......................................... 16,613,742 4,386,775 9,986,912 

(c) Scaling Factor ...................................................................... 0 .15 0 .34 0 .06 

(d) CPT 00002—Unscaled Value .............................................. 158 .08 95 .03 41 .74 

(e) CPT 00002—Scaled Value .................................................. 23 .78 32 .57 2 .72 $59.07 

NPWP Step 4—Calculation of Indirect 

Expenses 

Because codes in the NPWP do not 

have work RVUs, indirect expenses are 

set equal to direct expenses (for codes 

with physician work, indirect expenses 

equal the sum of the scaled direct 

expenses and the converted work RVU). 

This amount is then multiplied by the 

number of times the procedure is 

performed. 

In Table 11, the scaled total direct 

expense from NPWP Step 3 (Table 10) 

($59.07) is also the proxy for the total 

indirect expense attributed to the 

procedure. The total indirect expense is 

multiplied by the number of services 

(105,095), to calculate total indirect cost 

for this procedure of $6,207,961. 

TABLE 11.—CALCULATION OF INDIRECT EXPENSES

NPWP methodology Physician work * Total direct 

expense Total 

(A) (B) (C) 

(a) CPT 00002 ............................................................................................................... ............................ $59.07 $59 .07 

(b) Allowed Services—NPWP ....................................................................................... ............................ ............................ 105,095 

(c) Total NPWP Indirect Expense ................................................................................. ............................ ............................ $6,207,961 

NPWP Step 5—Calculation and 

Application of Indirect Scaling Factors 

Similar to the direct costs, the indirect 

costs are scaled to ensure that the total 

of the charge-based PE costs across all 

procedures equates with the total 

indirect costs as reflected by the SMS 

data for the code. To accomplish this, 

the charge-based indirect PEs are scaled 

to the SMS indirect PEs. 

In Table 12, to calculate the indirect 

scaling factor for hypothetical procedure 

00002, the total SMS indirect PE, 

$9,407,404 (from NPWP Step 1—Table 

8), is divided by the total charge-based 

indirect expense of $6,207,961 (from 

NPWP Step 4—Table 11). This results in 

a scaling factor of 1.51. Next, the 


ER21NO05.005</GPH>
Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70127 

unscaled indirect charge-based cost for 

procedure 00002 of $59.07 (from NPWP 

Step 4—Table 11) is multiplied by the 

1.51 scaling factor, resulting in scaled 

indirect costs for this procedure of 

$89.19. 

TABLE 12.—CALCULATION AND APPLICATION OF INDIRECT COST SCALING FACTORS

Standard methodology Indirect costs Direct cost 

Specialty specific 

PE RVU 

(Sum of A and B) 

(A) (B) (C) 

(a) Total—NPWP ‘‘SMS’’ Pool ................................................................................ $9,407,404 

(b) Total NPWP Indirect Expense ........................................................................... 6,207,961 

(c) Scaling Factor .................................................................................................... 1 .51 

(d) CPT 00002—Unscaled Value ............................................................................ 59 .07 

(e) CPT 00002—Scaled Value ................................................................................ 89 .19 $59.07 $148.26 

NPWP Step 6—Budget Neutrality and 

Final RVU Calculation 

Similar to the calculation for codes 

with physician work, the BNF is applied 

to (multiplied by) the scaled direct and 

indirect expenses for each code to set 

the PE RVU for the upcoming year. 

In Table 13, the sum of the scaled 

direct and indirect expenses for 

hypothetical code 00002 ($148.26) is 

multiplied by the BNF (0.022 in this 

example) to yield a PE RVU of 3.26. 

TABLE 13.—BUDGET NEUTRALITY AND FINAL RVU CALCULATION

Total scaled direct 

and indirect inputs 

Budget neutrality 

factor Final PE RVU 

Code 00002 ............................................................................................................... $148.26 0.022 2.96 

d. Facility/Nonfacility Costs 

Procedures that can be performed in 

a physician’s office as well as in a 

hospital have two PE RVUs; facility and 

nonfacility. The nonfacility setting 

includes physicians’ offices, patients’

homes, freestanding imaging centers, 

and independent pathology labs. 

Facility settings include hospitals, 

ambulatory surgery centers, and skilled 

nursing facilities (SNFs). The 

methodology for calculating the PE RVU 

is the same for both facility and 

nonfacility RVUs, but each is calculated 

independently to yield two separate PE 

RVUs. Because the PEs for services 

provided in a facility setting are 

generally included in the payment to 

the facility (rather than the payment to 

the physician under the fee schedule), 

the PE RVUs are generally lower for 

services provided in the facility setting. 

2. PE Proposals for CY 2006 

The following discussions outline the 

specific PE related proposals for CY 

2006. 

a. Supplemental PE Surveys 

The following discussions outline the 

criteria for supplemental survey 

submission as well as information we 

have received for approval. 

(1) Survey Criteria and Submission 

Dates 

In accordance with section 212 of the 

BBRA, we established criteria to 

evaluate survey data collected by 

organizations to supplement the SMS 

survey data normally used in the 

calculation of the PE component of the 

PFS. In the final rule published 

November 7, 2003 (68 FR 63196), we 

provided that, beginning in 2004, 

supplemental survey data had to be 

submitted by March 1 to be considered 

for use in computing PE RVUs for the 

following year. This allows us to 

publish our decisions regarding survey 

data in the proposed rule and provides 

the opportunity for public comment on 

these results before implementation. 

To continue to ensure the maximum 

opportunity for specialties to submit 

supplemental PE data, we extended 

until 2005 the period that we would 

accept survey data that meet the criteria 

set forth in the November 2000 PFS 

final rule. The deadline for submission 

of supplemental data to be considered 

in CY 2006 was March 1, 2005. 

(2) Submission of Supplemental Survey 

Data 

The following discussion outlines the 

survey data submitted for CY 2004 and 

CY 2005. 

(a) Surveys Submitted in 2004 

As discussed in the August 8, 2005 

PFS proposed rule (70 FR 45774), we 

had received surveys by March 1, 2004 

from the American College of 

Cardiology (ACC), the ACR, and the 

American Society for Therapeutic 

Radiation Oncology (ASTRO). The data 

submitted by the ACC and the ACR met 

our criteria. However, as requested by 

the ACC and the ACR, we deferred 

using their data until issues related to 

the NPWP could be addressed. In the 

August 8, 2005 proposed rule, we 

proposed to use the ACC and ACR 

survey data in the calculation of PE 

RVUs for CY 2006, but only as specified 

in the proposals relating to a revised 

methodology for establishing direct PE 

RVUs. 

The survey data from ASTRO did not 

meet the precision criteria established 

for supplemental surveys, therefore, we 

indicated we would not use it in the 

calculation of PE RVUs for CY 2005. 

However, we proposed to use these data 

to blend with data submitted by the 

Association of Freestanding Radiation 

Oncology Centers (AFROC) for CY 2006, 

as described below. 

(b) Surveys Submitted in 2005 

In 2005 we received surveys from the 

AFROC, the American Urological 

Association (AUA), the American 

Academy of Dermatology Association 

(AADA), the Joint Council of Allergy, 

Asthma, and Immunology (JCAAI), the 

National Coalition of Quality Diagnostic 

Imaging Services (NCQDIS) and a joint 

survey from the American 

Gastroenterological Association (AGA), 

the American Society of Gastrointestinal 

Endoscopy (ASGE), and the American 

College of Gastroenterology (ACG). 

70128 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

As explained in the August 8, 2005 

proposed rule, we contract with the 

Lewin Group to evaluate whether the 

supplemental survey data that are 

submitted meet our criteria and to make 

recommendations to us regarding their 

suitability for use in calculating PE 

RVUs. (The Lewin Group report on the 

2005 submissions is available on the 

CMS Web site at http:// 

www.cms.hhs.gov/physicians/pfs/.) The 

report indicated that, except for the 

survey from NCQDIS, all met our 

criteria and we are proposing to accept 

these surveys. The survey data 

submitted by the NCQDIS on 

independent diagnostic testing facilities 

(IDTFs) did not meet the precision 

criterion of a 90 percent confidence 

interval with a range of plus or minus 

15 percent of the mean (that is, 1.645 

times the standard error of the mean, 

divided by the mean, is equal to or less 

than 15 percent of the mean). For the 

NCQDIS survey, the precision level was 

calculated at 16.3 percent of the mean 

PE/HR (weighted by the number of 

physicians in the practice). However, 

the Lewin Group has recommended that 

we accept the data from NCQDIS. The 

Lewin Group points out that PE data for 

IDTFs do not currently exist, and 

suggests that the need for data for the 

specialty should be weighed against the 

precision requirement. 

We proposed not to accept the 

NCQDIS data to calculate the PE RVUs 

for services provided by IDTFs. As just 

noted, the NCQDIS data did not meet 

our precision requirements. We 

established the minimum precision 

standards because we believe it is 

necessary to ensure that the data used 

are valid and reliable, and the consistent 

application of the precision criteria is 

the best way to accomplish that 

objective. 

Section 303(a)(1) of the MMA added 

section 1848(c)(2)(I) of the Act to require 

us to use survey data that include 

expenses for the administration of drugs 

and biologicals submitted by a specialty 

group for which at least 40 percent of 

the Part B payments are attributable to 

the administration of drugs in 2002 to 

adjust PE RVUs for drug administration 

services. The provision applies to 

surveys received by March 1, 2005 for 

determining the CY 2006 PE RVUs. 

Section 303(a)(1) of the MMA also 

amended section 1848(c)(2)(B)(iv)(II) of 

the Act to provide an exemption from 

budget neutrality for any additional 

expenditures resulting from the use of 

this survey data to adjust PE RVUs for 

drug administration services. In the 

Changes to Medicare Payment for Drugs 

and Physician Fee Schedule Payments 

for CY 2004 interim final rule published 

January 7, 2004 (69 FR 1084), we stated 

that the specialty of urology meets the 

above criteria, along with gynecology 

and rheumatology (69 FR 1094). 

Because we proposed to accept the new 

survey data from the AUA, we are 

required to exempt from the budget 

neutrality adjustment any impacts of 

accepting these data for purposes of 

calculating PE RVUs for drug 

administration services. 

In addition, Lewin recommended 

blending the radiation oncology data 

from this year’s AFROC survey data 

with last year’s ASTRO survey data to 

calculate the PE/HR. According to the 

Lewin Group, the goal of the AFROC 

survey was to represent the population 

of freestanding radiation oncology 

centers only. In order to develop an 

overall average for the radiation 

oncology PE pool, the Lewin Group 

recommended we use the AFROC 

survey for freestanding radiation 

oncology centers, and the hospital-based 

subset of last year’s ASTRO survey. 

Consistent with that recommendation, 

we proposed to use the new PE/HR 

calculated in this manner for radiation 

oncology. 

As discussed in the August 8, 2005 

PFS proposed rule and also in the 

preamble of this final rule with 

comment, we proposed to revise our 

methodology to calculate direct PE 

RVUs from the current top-down cost 

allocation methodology to a bottom-up 

methodology. Although we would 

continue to use the SMS data and the 

incorporated supplemental survey data 

for indirect PEs, we did not extend the 

deadline for submitting supplemental 

survey data but rather requested 

comments on the most appropriate way 

to proceed to ensure the indirect PEs per 

hour are accurate and consistent across 

specialties. 

b. Revisions to the PE Methodology 

As discussed in the August 8, 2005 

proposed rule, since 1997, when we first 

proposed a resource-based PE 

methodology, we have had several 

major goals for this payment system and 

have encouraged the maximum input 

from the medical community regarding 

our PE data and methodology. 

We also have had the following three 

specific goals for the resource-based PE 

methodology itself, which have also 

been supported in numerous comments 

we have received from the medical 

community: 

• To ensure that the PE payments 

reflect, to the greatest extent possible, 

the actual relative resources required for 

each of the services on the PFS. This 

could only be accomplished by using 

the best available data to calculate the 

PE RVUs. 

• To develop a payment system for 

PE that is understandable and at least 

somewhat intuitive, so that specialties 

could generally predict the impacts of 

changes in the PE data. 

• To stabilize the PE payments so that 

there are not large fluctuations in the 

payment for given procedures from 

year-to-year. 

As we explained in the August 8, 

2005 proposed rule, we believe that we 

have consistently made a good faith 

effort to ensure fairness in our PE 

payment system by using the best data 

available at any one time. The change 

from the originally proposed ‘‘bottomup’’ to the ‘‘top-down’’ methodology 

came about because of a concern that 

the resource input data developed in 

1995 by the CPEP were less reliable than 

the aggregate specialty cost data derived 

from the SMS process. The adoption of 

the top-down approach necessitated the 

creation of the NPWP. The NPWP is a 

separate pool created to allocate PEs for 

codes that have only a technical (rather 

than professional) component, or codes 

that are not performed by physicians. 

However, the situation has now 

changed. As we explained in the August 

8, 2005 proposed rule, refinement of the 

original CPEP data is complete and the 

refined PE inputs now, in general, 

accurately capture the relative direct 

costs of performing PFS services. Also, 

the major specialties comprising the 

NPWP (radiology, radiation oncology, 

and cardiology) submitted supplemental 

survey data that we proposed to accept, 

which would eliminate the need to treat 

these technical services outside the PE 

methodology applied to other services. 

Due to the ongoing refinement by the 

RUC of the direct PE inputs, we had 

expected that the PE RVUs would 

necessarily fluctuate from year-to-year. 

However, it became apparent that 

certain aspects of our methodology 

exacerbated the yearly fluctuations. The 

services priced by the NPWP 

methodology have proven to be 

especially vulnerable to any change in 

the pool’s composition. With the 

CPEP/RUC refinement of existing 

services virtually complete, we 

indicated this was an opportunity for us 

to propose a way to provide stability to 

the PE RVUs. 

Therefore, consistent with our goals of 

using the most appropriate data, 

simplifying our methodology, and 

increasing the stability of the payment 

system, we proposed the following 

changes to our PE methodology and also 

requested suggestions that would assist 

us in further refinement of the indirect 

PE methodology. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70129 

(1) Use a Bottom-up Methodology To 

Calculate Direct PE Costs 

Instead of using the top-down 

approach to calculate the direct PE 

RVUs, where the aggregate CPEP/RUC 

costs for each specialty are scaled to 

match the aggregate SMS costs, we 

proposed to adopt a bottom-up method 

of determining the relative direct costs 

for each service. Under this method, the 

direct costs would be determined by 

summing the costs of the resources—the 

clinical staff, equipment and supplies—

typically required to provide the 

service. The costs of the resources, in 

turn, would be calculated from the 

refined CPEP/RUC inputs in our PE 

database. 

(2) Eliminate the Nonphysician Work 

Pool (NPWP) 

Since we proposed to incorporate new 

survey data for the major specialties that 

comprise the NPWP, we proposed to 

eliminate the pool and calculate the PE 

RVUs for the services currently in the 

pool by the same methodology used for 

all other services. This would allow the 

use of the refined CPEP/RUC data to 

price the direct costs of individual 

services, rather than utilizing the pre1998 charge-based PE RVUs. 

(3) Utilize the Current Indirect PE RVUs, 

Except for Those Services Affected by 

the Accepted Supplemental Survey Data 

As described previously, the SMS and 

supplemental survey data are the source 

for the specialty-specific aggregate 

indirect costs used in our PE 

calculations. We then allocate to 

particular codes on the basis of the 

direct costs allocated to a code and the 

work RVUs. Although we now believe 

the CPEP/RUC data are preferable to the 

SMS data for determining direct costs, 

we have no information that would 

indicate that the current indirect PE 

methodology is inaccurate. We also are 

not aware of any alternative approaches 

or data sources that we could use to 

calculate more appropriately the 

indirect PE, other than the new 

supplemental survey data, which we 

proposed to incorporate into our PE 

calculations. Therefore, we proposed to 

use the current indirect PEs in our 

calculation incorporating the new 

survey data into the codes performed by 

the specialities submitting the surveys. 

We specifically requested suggestions 

that would assist us in further 

refinement of the indirect PE 

methodology. For example, we noted in 

the proposed rule that we are 

considering whether we should 

continue to accept supplementary 

survey data or whether it would be 

preferable and feasible to have an SMStype survey of only indirect costs for all 

specialties; or whether a more formulabased methodology independent of the 

SMS data should be adopted, perhaps 

using the specialty-specific indirect-tototal cost percentage as a basis of the 

calculation. 

(4) Transition the Resulting Revised PE 

RVUs Over a 4-Year Period 

We are concerned that, when 

combined with an expected negative 

update factor for CY 2006, the shifts in 

some of the PE RVUs resulting from our 

proposals could cause some measure of 

financial stress on medical practices. 

Therefore, we proposed to transition the 

proposed PE changes over a 4-year 

period. This would also give ample 

opportunity for us, as well as the 

medical specialties and the RUC, to 

identify any anomalies in the PE data, 

to make any further appropriate 

revisions, and to collect additional data, 

as needed prior to the full 

implementation of the proposed PE 

changes. 

During this transition period, the PE 

RVUs would be calculated on the basis 

of a blend of RVUs calculated using our 

proposed methodology described above 

(weighted by 25 percent during CY 

2006, 50 percent during CY 2007, 75 

percent during CY 2008, and 100 

percent thereafter), and the current CY 

2005 PE RVUs for each existing code. 

Now that the direct PE inputs have 

been refined, we believe that the 

CPEP/RUC direct input data are 

generally superior to the specialtyspecific SMS PE/HR data for the 

purposes of determining the typical 

direct PE resources required to perform 

each service on the PFS. First, we have 

received recommendations on the 

procedure-specific inputs from the 

multi-specialty PEAC that were based 

on presentations from the relevant 

specialties after being closely 

scrutinized by the PEAC using 

standards and packages agreed to by all 

involved specialties. Second, the refined 

CPEP/RUC data are more current than 

the SMS data for the majority of 

specialties. Third, for direct costs, it 

appears more accurate to assume that 

the costs of the clinical staff, supplies 

and equipment are the same for a given 

service, regardless of the specialty that 

is performing it. This assumption does 

not hold true under the top-down direct 

cost methodology, where the specialtyspecific scaling factors create widely 

differing costs for the same service. 

We also would argue that the 

proposed methodology is less confusing 

and more intuitive than the current 

approach. For instance, the NPWP 

would be eliminated and all services 

would be priced using one 

methodology, eliminating the 

complicated calculations needed to 

price NPWP services. Also, any 

revisions made to the direct inputs 

would now have predictable results. 

Changes in the direct practice inputs for 

a service would proportionately change 

the PE RVUs for that service without 

significantly affecting the PE RVUs for 

unrelated services. 

In addition, the proposed 

methodology would create a system that 

would be significantly more stable from 

year-to-year than the current approach. 

We recognized that there are still some 

outstanding issues that need further 

consideration, as well as input from the 

medical community. For example, 

although we believe that the elimination 

of the NPWP would be, on the whole, 

a positive step, some practitioner 

services, such as audiology and medical 

nutrition therapy (MNT), would be 

significantly impacted by the proposed 

change. In addition, there are still 

services, such as the end stage renal 

disease (ESRD) visit codes, for which we 

have no direct input information. Also, 

as mentioned above, we do not have 

current SMS or supplementary survey 

data to calculate the indirect costs for 

most specialties. Further, we do not yet 

have accurate utilization for the new 

drug administration codes that were 

created in response to the MMA 

provision on drug administration. 

Therefore, we did not propose to change 

the RVUs for these services at this time, 

but to include them under our proposed 

methodology in next year’s rule when 

we have appropriate data. The proposed 

transition period would give us the 

opportunity to work with the affected 

specialties to collect the needed survey 

or other data or to determine whether 

further revisions to our PE methodology 

are needed. 

We requested comments on these 

proposed changes, particularly those 

concerning additional modifications to 

the indirect PE methodology that might 

help us further our intended goals. 

Comment: There were 3 main 

concerns raised in comments we 

received on our overall proposed PE 

methodology which included: (1) Many 

of the proposed decreases appeared 

anomalous and were not explained; (2) 

there was insufficient information given 

to allow specialties to review and 

analyze the proposal and its impact; and 

(3) the use of the new PE data from the 

seven accepted supplementary surveys 

caused an inequitable redistribution of 

PE RVUs. As a result of these concerns, 

many commenters also requested a 

70130 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

delay in the implementation of our 

proposed methodology. 

The following are examples of the 

comments detailing the above concerns. 

The AMA and the RUC agreed with 

the goals that we have set for an 

accurate, intuitive and stable 

methodology to use for the calculation 

of PE RVUs. The RUC added that it 

looks forward to helping us meet these 

goals. However, the AMA urged us to 

provide more information, such as 

examples of how the new values were 

calculated, the PE/HR and source of the 

data for each specialty and the budget 

neutrality adjuster applied at the end of 

the process, so that the medical 

community would have the opportunity 

to review the values and impact of the 

proposal. 

Medicare Payment Advisory 

Commission (MedPAC) stated its 

agreement with the concerns regarding 

the current PE methodology that 

motivated us to propose a change, but 

did request that we assess the impact of 

proposed changes by groups of 

services—evaluation and management 

services, major procedures, other 

procedures, laboratory tests and imaging 

services, as well as by physician 

specialty group. 

A specialty society representing 

obstetrics and gynecology commended 

the goal of the new methodology, but 

suggested we offer two or more 

examples of how PE is calculated, 

starting with the inputs that are used 

and moving through the process of 

developing the final PE RVUs for those 

codes. 

An optometric association expressed 

regret that the proposed rule does not 

provide service-specific examples of 

how PE RVUs would be calculated 

using the current and proposed 

methodologies because this made it 

difficult to provide detailed comments 

on the proposal. Therefore, the 

commenter concluded that we should 

issue a final with a comment period. 

Two emergency medicine societies also 

requested the same service-specific 

examples. 

An ophthalmology society was 

troubled by our failure to make the 

indirect cost data used in determining 

the rates of change in PE values 

available to all specialties for review 

and by the lack of analysis explaining 

the significant impacts caused by the 

acceptance of the supplemental survey 

data. 

A specialty society representing 

cardiology urged us to provide more 

data and a more detailed explanation of 

the methodology, along with examples 

of how RVUs for specific codes were 

determined, so that stakeholders can 

gain a thorough understanding of our 

proposal. 

A dermatology association 

commented that it is pleased that we 

want to transition to a bottom-up 

approach. The association believes that 

this will result in a more easily 

understood and stable payment system, 

but it would be helpful to have more 

information in the final rule on the 

calculation of PE values under the new 

methodology. For example, the 

association asks for clarification of why 

the PE RVUs for several dermatology 

procedures decreased. 

A specialty society representing 

physical medicine expressed concern 

regarding a number of the results with 

respect to several physical medicine and 

rehabilitation codes and requested that 

we provide a more detailed description 

of the new methodology and address 

anomalies in the final rule. The 

commenter suggested that we establish 

a percentage decrease threshold that 

would trigger an opportunity for 

expedited review to determine whether 

the direct cost inputs are accurate. 

Four organizations representing 

radiation oncology submitted comments 

stating their concern that several 

radiation therapy codes, including those 

for intensity modulated radiation 

therapy, continuing medical physics 

consultation and brachytherapy, have 

inappropriate proposed reductions. Two 

of the commenters recommended that 

we examine the impact of the 

methodology on a code-specific basis 

and, if necessary, implement an 

adjustment factor that limits the 

reduction to no more than 15 percent of 

the 2005 global RVUs at the end of the 

4-year transition period. Comments 

from societies representing nuclear 

cardiology and echocardiography also 

supported a cap on the maximum 

reduction applied to any procedure that 

resulted from the decision to adopt the 

new methodology. 

A geriatrics society expressed concern 

that geriatrics will experience a 1 

percent reduction under the new 

methodology and stated that the 

transition period is critical, as it will 

lessen the impact of the proposed 

reduction. The society suggested that, 

during the transition period, we should 

work with stakeholders to explain the 

new methodology, to identify nonintuitive decreases in payment and to 

identify better ways to pay for indirect 

expenses. 

An association representing nursing 

facility medical directors expressed 

concern that the new methodology will 

reduce the PE RVUs for nearly all codes 

for nursing facility services. If we 

proceed with the changes, the 

association suggested that we provide a 

more detailed explanation of the new 

methodology in the final rule, with 

examples of the PE RVU calculations for 

specific services under the old and new 

methods. 

A consulting company expressed 

concern that we failed to make needed 

data available, such as the time file, 

utilization file and scaling factors and 

pools file. The commenter also 

requested that, in the future, we 

consider making available the same files 

we use to produce the PE RVUs, the 

assumptions used, such as crosswalks or 

projected utilization for new services 

and the data needed to evaluate the 

methodology used to go from the survey 

data to a PE/HR. 

The American Cancer Society 

expressed concern regarding the specific 

reductions in payment for screening 

mammography, pap smears, pelvic/ 

breast exams and flexible 

sigmoidoscopies which could 

potentially reduce access to cancer 

screenings. 

An oncology nursing society strongly 

urged us to include drug administration 

services in the phase-in of the new 

methodology and exempt them from 

budget neutrality requirements. A 

cancer and blood disorders center 

expressed the same concern and stated 

that this omission would skirt the MMA 

mandate to exempt from budget 

neutrality limits any 2006 fee schedule 

changes to drug administration codes. 

An association representing medical 

colleges noted that, together with the 

negative update, the decrease in revenue 

across faculty practice groups will 

exceed ¥6 percent. The association 

recommended that this warrants further 

review by the medical community and 

CMS should make public examples of 

how the new values were calculated, the 

actual new PE values for each code, the 

PE per hour and source of the data for 

each specialty and the budget neutrality 

adjuster applied as a final step. 

A medical technology company 

requested that we explain how we 

intend to scale PE when CPT codes, 

such as endogenous radiofrequency 

ablation procedures, include a vascular 

as well as a radiology imaging 

procedure. The commenter 

recommended we should calculate the 

costs according to the primary group 

furnishing the procedure. In addition, 

the commenter contended that a 

deflation factor should not be applied to 

new procedures that have been valued 

by the RUC and CMS in late 2004 for 

establishment of 2005 payment. 

Following are examples of the 

comments explicitly requesting delay. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70131 

A comment from specialty societies 

representing general surgeons, 

anesthesiology, ophthalmology, 

hematology, emergency medicine, 

neurosurgery, cataract surgery, thoracic 

surgery, orthopaedic surgery, 

otolaryngology and hand surgery, 

supported by a letter from a member of 

the Congress, stated agreement with our 

goals for a PE methodology. However, 

the commenters requested that the 

implementation of the new 

methodology and data be delayed for 1 

year, citing several concerns: First, 

commenters claimed that CMS did not 

provide sufficient data and information 

or time to allow adequate review of the 

validity of the new methodology, the 

supplementary survey data or the 

proposed impact. As a result, the 

comment argued that physicians have 

not had a reasonable opportunity to 

participate in the rule making process, 

in compliance with the Administrative 

Procedure Act. In addition, the 

comment cited the Practicing Physician 

Advisory Committee recommendation 

that we delay implementation of the 

new data and methodology for 1 year. 

An oncology society commented that 

a final decision on the proposed 

revision to the PE methodology should 

be deferred 1 year until information is 

available on how the proposal will 

affect drug administration services. A 

large provider of oncology services was 

also troubled by the decision to exclude 

drug administration services from 

revisions to the PE methodology. 

A psychological association stated 

that its primary concern is ‘‘the 

proposed rule’s lack of clarity regarding 

the impacts that the change in 

methodology will have on each health 

care specialty.’’ Because of the lack of 

this data, the Association requested a 1 

year delay for our proposal. 

A specialty society representing 

surgeons stated that the proposed 

methodology apparently created many 

aberrant PE RVUs and gave examples: 

Closely related procedures with 

proposed RVUs that are inconsistent 

with their actual costs; services that 

contribute significantly to the increases 

in volume and intensity noted by 

MedPAC all receive significant 

increases; within specialties that should 

benefit from the higher PE/HR in their 

surveys, there are increases and 

decreases that cannot be explained; E/M 

services will be increased in the office 

setting, but decreased in the hospital 

setting. The college recommends that 

we withdraw the current proposal and 

republish it in a future PFS rule that 

includes a detailed description of the 

methodology. 

Two specialty societies representing 

thoracic and chest physicians expressed 

concern with the significant shifts in the 

PE that would necessitate a 4-year 

transition and suggested that there 

should be no change in PE until all 

specialties can complete supplemental 

PE surveys. 

A specialty society representing spine 

surgeons requested that we suspend the 

proposed PE changes until 2007, not 

because the methodology is flawed, but 

in order to allow all physicians an equal 

opportunity to submit data relevant to 

their specialties. 

A specialty society representing 

anesthesiologists contended that lack of 

information on data and methodology 

behind the PE changes requires a delay 

in implementation. The Society 

requested that we provide information 

that clearly breaks out the impact of the 

proposed changes by specialty on the 

indirect and direct PE payments. 

A medical group practice association 

fully supported the 4-year transition of 

the new PE values achieved under the 

new bottom-up calculation. However, 

because it believed that insufficient 

information has been made available, 

the association recommended that we 

delay implementation until the provider 

community has time to evaluate the 

methodology used to recalculate the PE 

RVUs. 

The following commenters requested 

a delay in calculating the PE RVUs for 

their own specific services under the 

new methodology. 

Several comments from a specialty 

society representing heart rhythm 

services, two manufacturers and a 

manufacturers association, as well as a 

provider of remote cardiac monitoring 

services expressed concern about the 

proposed cuts for remote cardiac 

monitoring services and requested that 

we not implement these proposed 

reductions, pending further study. 

Two societies representing audiology 

and speech language pathology, 

supported by a comment from two 

senators, expressed concern about the 

large reductions in payment for 

audiology services and urged us to 

impose a 1 year moratorium on the 

proposed reductions for these services 

so that an equitable methodology for 

their services can be developed. One 

commenter suggested that if we do not 

implement a moratorium on payment 

decreases for audiology services, we 

should consider an alternative, such as 

assigning proxy work RVUs for indirect 

PE using the otolaryngology PE/HR. 

The following commenters opposed 

any delay in implementing our 

proposed methodology. 

A gastroenterology association 

commented that, since all medical 

specialties had equal opportunity to 

conduct supplemental PE studies, there 

should not be a delay in the 

implementation of our proposed 

changes. 

A specialty society representing 

radiation oncology agreed that more 

information on the new methodology 

should be provided, but is opposed to 

any delay in the implementation of the 

proposed methodology as the transition 

provides sufficient opportunity for CMS 

to provide this information and resolve 

identified problems. 

A sonography society commented that 

we should not delay the implementation 

of the revised TC component services 

with a 4-year transition. An alternative 

to the zero-work pool has been many 

years in the making and we should fully 

implement the new values this year. 

An association representing urology 

disagrees with a 4-year phase in of the 

revised PE RVUs and strongly urged us 

to consider other options that will allow 

specialties with supplemental survey 

data to realize the full advantages of 

applying that data in 2006. The 

commenter claimed that a transition 

will allow specialties that did not 

conduct surveys to unfairly take a 

portion of the 4-year increases from 

specialties that did. 

A specialty society representing 

allergists expressed concern that the 

RVUs based on the new accepted data 

will be phased in over 4 years. The 

commenter contended that we have not 

provided any rationale for why we are 

breaking with past policy or why we 

have decided to phase-in the specialty 

survey data. The commenter is 

concerned in particular about the 

continued applicability of the old and 

incorrect scaling factors which result in 

the discounting of the specialty’s costs. 

A pharmaceuticals company 

requested that we consider an 

immediate 100 percent transition to the 

2009 proposed PE values for procedures 

like photodynamic therapy where 

access has been constrained due to the 

use of scaling factors. 

A society representing family 

physicians commented that the original 

legislation mandating resource-based PE 

was enacted in 1994 and that we 

delayed the initial implementation by a 

year before entering a 4-year transition 

under our current methodology. The 

commenter therefore encouraged us to 

shorten or eliminate the transition and 

finally complete the process of 

implementing resource-based PE. 

However a society representing 

internists supported our proposal to 

transition PE RVU changes resulting 

70132 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

from methodological changes in this 

proposed rule over a 4-year period. 

Response: We very much appreciate 

all the thoughtful and helpful comments 

we received on our proposal to revise 

our PE methodology. In addition, we are 

pleased that so many commenters stated 

their agreement with the goals that we 

outlined for our PE methodology in 

order to implement a payment system 

for physician and practitioner practice 

costs that is accurate, understandable, 

and stable. We also still believe, despite 

all the concerns pointed out by 

commenters, that the implementation of 

a methodology that bases the PE 

calculations on the latest available data, 

that uses the PEAC-refined CPEP data to 

create a bottom-up approach for direct 

costs and that values all services using 

the same method will help us achieve 

those goals. 

However, based on the comments we 

received, it appears that our PE proposal 

was not as clear and intuitive as we had 

intended. We continue to believe that 

the proposal for direct costs was 

straightforward; this proposal would do 

away with costs pools and scaling 

factors and merely add up the costs of 

the PEAC-refined input data assigned to 

each code to arrive at the direct PE 

RVUs (pre-PE budget neutrality). We 

had not anticipated that our indirect PE 

calculation would create difficulties 

since we intended that, except for those 

services for which the acceptance of the 

new supplementary survey data 

produced direct increases, to utilize the 

current indirect PE RVUs to develop the 

pre-PE budget neutrality indirect PE 

RVUs for 2006. However, due to an error 

in our indirect PE program, the indirect 

costs were not calculated as intended. 

As a result, almost all of the PE RVUs 

published in the August 8, 2005 

proposed rule were incorrect. 

Therefore, we are concerned that 

interested parties were not provided 

notice of the actual effect of the 

proposed changes in the PE RVU 

methodology and were not given the 

sufficient opportunity to submit 

meaningful comments on the proposal. 

As a result, we are withdrawing our 

entire PE methodology proposal and 

instead, with only three exceptions, we 

will use the current 2005 PE RVUs to 

value all services for CY 2006. First, as 

we usually do each year, we will value 

the work and PE on an interim basis for 

all codes that are new in 2006. Second, 

as required by section 1848(c)(2)(I) of 

the Act, we will apply the PE/HR data 

from the urology supplementary survey 

to the calculation of the PE RVUs for all 

the drug administration codes 

performed by urology. Third, we will 

apply the savings from the 

implementation of the multiple 

procedure payment reduction for certain 

imaging services across all the PE RVUs 

that are discussed later in the preamble 

of this rule. 

We understand that the withdrawal of 

this proposal will be welcomed by some 

and will be a disappointment to others, 

especially those specialties that 

undertook PE surveys that are not being 

used for 2006. We want to work with 

the medical community beginning now 

through the next proposed rule to 

exchange thoughts on all of the issues 

raised, to answer any questions and to 

provide additional data and corrected 

information. We hope to hold meetings 

on these topics early next year so that 

we can obtain maximum input from all 

interested parties to ensure that our next 

proposal does meet the goals we have 

set for our PE methodology. 

Acceptance of Supplementary Surveys 

for 2006 

Comment: Many commenters 

indicated their strong support for our 

proposal to accept the PE data from 7 

supplementary surveys. Several 

specialty societies representing 

radiation therapy expressed approval for 

the proposal to blend the survey data 

submitted by ASTRO and AFROC to 

calculate a revised PE/HR for radiation 

oncology services. A specialty society 

representing interventional radiology 

stated support for the proposed use of 

the ACR’s supplemental PE data for 

purposes of PE RVU determination. The 

ACC is pleased that we proposed to 

incorporate their supplemental PE 

survey data submitted for cardiology 

and other specialties that submitted data 

consistent with the acceptance criteria. 

The ACC commented that, given the 

rigorous and detailed analysis 

conducted by our contractor, these data 

are very likely superior to the SMS data 

that were used to calculate PE RVUs and 

that our acceptance of the supplemental 

PE data has been an important 

component of efforts to refine the 

resource-based PE RVUs. An 

echocardiography society and a 

commenter representing cardiovascular 

angiography also stated its support for 

use of the cardiology data. Two societies 

representing gastroenterology 

commented that they are pleased with 

our acceptance of the supplemental PE 

survey data for gastroenterology. The 

AUA strongly urged us to finalize our 

proposal to accept the AUA’s 

supplemental survey data, as they 

believe language in the section 

303(a)(1)(I) of the MMA requires us to 

accept supplemental data submitted by 

urology. In addition, the AUA stated 

that we are required by the MMA to 

update the 2006 PE RVUs for urology 

drug administration, applying the 

exemption from budget neutrality. A 

commenter representing prosthetic 

urology also agreed that we should use 

the urology supplemental data to 

allocate the indirect PE costs to each 

urology procedure. 

However, other commenters had 

concerns with the proposal. An 

otolaryngology specialty society 

questioned the validity of the dramatic 

increases in the PE/HR for the 

specialties that have submitted surveys 

because this could create a two-tiered 

system between those specialties that 

have submitted surveys and those 

which have not. Therefore, the society 

recommended that use of this new PE 

data be delayed until such time as a 

multispecialty PE survey can be 

conducted. A comment from an 

occupational therapy association 

recognized the need to use SMS 

aggregate data in the indirect 

calculations, but questioned the impact 

on specialties who did not participate in 

the survey and suggested that the 

transition period be used to examine the 

atypical impact of this change. Two 

thoracic surgery groups commented that 

the PE fluctuations and disparities 

caused by the acceptance of these 

surveys are counter-intuitive and 

advantage those for whom we have 

accepted data at the expense of those 

from whom we have not. The specialty 

society representing surgeons stated that 

the dramatic increase in the proposed 

PE/HR figures could cause significant 

distortions in the relativity of PE 

payments across specialties and urged 

that we delay implementation of the 

new data until a multi-specialty PE 

survey, similar to the AMA’s SMS 

survey can be conducted. However, the 

society also recommended that we use 

the urology PE/HR data because it 

would be required by the MMA. A 

provider group representing remote 

cardiac services recommended that we 

should refrain from incorporating any 

additional survey data until all 

supplemental data is submitted. 

Conversely, a society representing 

echocardiographers stated that it is 

crucial for us to use the submitted 

survey meeting our criteria in order to 

retain the type of trust necessary for 

physician specialty groups to conduct 

this type of survey in the future. The 

commenters from the gastroenterology 

groups stated that use of these data 

should not be transitioned, but should 

be treated consistently with the manner 

in which all other supplemental data 

have been treated. Further, the 

commenter contended that, even if we 

agree to a delay in the implementation 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70133 

of our proposed methodology, the 

accepted supplemental PE/HR data 

should be implemented immediately for 

both direct and indirect expenses. 

Response: We understand the 

considerable effort, time and money 

expended by the specialty societies that 

submitted surveys that met our criteria 

and are aware that there will be 

considerable disappointment that the 

new data will not be used for 2006. We 

also understand the concern of those 

specialties that have not undertaken a 

supplementary survey that now fear that 

they could be relatively disadvantaged if 

the accepted surveys are used. We 

would point out that for the last five 

years there has been an equal 

opportunity for all specialties to submit 

supplementary data and it could be 

presumed that those specialties that did 

not avail themselves of the opportunity 

believed the effort was not worth the 

probable result. In addition, all 

specialties had the opportunity to 

comment on our proposed criteria for 

acceptance of survey data and the 

medical community at large did not 

comment that the criteria needed to be 

more stringent. However, we will not be 

using the accepted supplementary data 

in our indirect PE calculations for 2006, 

with the exception of the urology PE/HR 

data that we are applying to the drug 

administration codes performed by 

urology as required by section 

1848(c)(2)(I) of the Act. We are not using 

the other accepted supplementary PE 

data because, as explained above, we are 

not adopting the proposed changes to 

our PE methodology, we did not 

propose to use the survey data for 

calculating the direct PE RVUs and the 

use of the survey data would have 

caused significant changes in the PE 

RVUs for which there would have been 

no opportunity for comment. 

Comment: We also received several 

comments with specific concerns 

regarding our handling of the submitted 

PE survey data. A specialty society 

representing radiation oncology asserted 

that the approach to blending survey 

data has inadvertently lowered the 

values for certain radiation oncology 

services by under-weighting the PE 

expenses for freestanding facilities from 

the AFROC survey and by 

overestimating the hours in the 

denominator of the PE/HR calculation. 

In addition, three commenters 

questioned an apparent discrepancy 

with the PE/HR for radiology, radiation 

oncology and cardiology recommended 

by the Lewin Group and the PE/HR in 

the proposed rule and the subsequent 

correction notice. The commenters 

requested a clarification on how we 

applied the deflators in order to ensure 

that all specialties submitting surveys 

were evaluated in the same way. A 

comment from specialty societies 

representing most major surgical groups, 

as well as emergency medicine and 

anesthesia, contended that over the 

years we have treated supplemental 

survey data with different standards and 

have blended some while not blending 

others. A medical technology company 

requested that we explain how the data 

were evaluated, especially because we 

did not accept some recommendations 

presented by the Lewin Group. 

Response: Because we are not 

utilizing the new supplementary data 

for indirect PE calculations for 2006, we 

plan to discuss all of these issues with 

the relevant specialties in order to 

determine if adjustments are needed to 

our calculations of the PE/HR data. 

However, we do not believe that we 

have treated supplemental data with 

different standards, but would request 

specific information from the 

commenters. Currently, we are not using 

any blended data for any supplementary 

survey that we have accepted and used. 

Although we rely heavily on the 

analysis and evaluation of the survey 

data done by the Lewin Group, we are 

responsible for the final decision on 

whether or not to accept the data from 

a given survey. The Lewin Group did 

recommend that we accept the data 

from the NCQDIS survey, which did not 

meet our precision criteria, because we 

currently have no survey data for them. 

However, we believe that it is more 

equitable to apply the same standards to 

all who submit surveys and we 

proposed not to accept the survey data 

at this time. 

Comment: The NCQDIS expressed 

concern that we did not accept their PE 

survey data for diagnostic imaging 

services in IDTFs because the precision 

criteria was not met. NCQDIS pointed 

out that the Lewin Group recommended 

that we accept the data in spite of the 

precision level because PE data for 

IDTFs do not currently exist. The 

commenter stated that, after further 

analysis of the data, NCQDIS 

determined that inclusion of one 

inaccurate record skewed the findings 

outside the acceptable precision range. 

Therefore, NCQDIS recommended that 

we accept the revised analysis from the 

Lewin Group that includes updated PE 

information for the record in question 

and that we allow the updated data to 

be used in development of PE RVUs for 

2006. The NCQDIS recommendation 

was supported by a comment from a 

society representing diagnostic medical 

sonography that contended that no 

alternative data is available for these 

entities and the current PE data used 

understates their PE. 

Response: There have been further 

discussions between NCQDIS and our 

contractor. We will be discussing this 

with the specialty in order to resolve the 

issue for a future proposal. 

Comment: A nuclear medicine society 

stated that it cannot respond to our use 

of the radiology and cardiology surveys 

because it has not seen the data as it 

relates to nuclear medicine. The 

commenter requested that we make the 

nuclear medicine supplementary survey 

information and impact available. A 

specialty society representing radiation 

oncology expressed the belief that the 

new survey data do not reflect the costs 

of brachytherapy because providers of 

this service were not adequately 

represented in the sample. 

Response: We would be willing to 

discuss the societies’ concerns to 

determine an appropriate resolution. 

Comment: A long term care 

association urged us to use the data 

from the ACR supplementary survey as 

the PE/HR proxy for the portable x-ray 

set-up code (Q0092) to prevent 

inconsistencies in the application of the 

new payment methodology. 

Response: We do not believe it would 

be appropriate to use the same indirect 

costs associated with a free-standing 

radiology center, which incurs costs for 

such requirements as lead shielding and 

structural reinforcements for heavy 

equipment, as the costs for setting up a 

portable x-ray machine. Therefore, we 

will not apply the data from the 

radiology supplementary survey to the 

calculations of the PE RVUs for Q0092. 

Comment: Because we had proposed 

to accept the supplementary survey data 

for radiology, radiation oncology and 

cardiology, the specialties that make up 

the bulk of the NPWP, we also proposed 

eliminating the pool and pricing all of 

the services in the NPWP under the new 

proposed PE methodology. We received 

comments from several organizations 

including those representing diagnostic 

sonography, urology, medical 

physicists, allergy geriatrics and a blood 

disorder center supporting this 

proposal. However, the specialty society 

representing audiology urged that, 

before we dismantle the protection 

provided by the NPWP, a reasonable 

formula should be developed to fairly 

and adequately reimburse audiologists 

for their services. The societies 

representing audiology, speech language 

pathology and medical nutrition all 

commented that we should assign work 

RVUs to their services, rather than 

treating their professional work as PE. 

Response: We are pleased that most 

commenters approved of our proposal to 

70134 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

eliminate the NPWP. However, because 

we will not be using the accepted new 

supplementary survey data in the 

calculation of PE RVUs for 2006, we 

believe it would be more equitable to 

defer the elimination of the pool as well. 

Therefore, we will not be implementing 

this proposal for 2006. This will also 

give us the additional time to work with 

audiology and other specialties to 

ensure that our future proposal will be 

equitable to all. Because we are 

maintaining the NPWP for 2006, we are 

deferring our decision regarding work 

RVUs for audiology, speech language 

pathology and medical nutrition 

pending further discussions with the 

specialties. 

Bottom-up for Direct PE 

Comment: We received many 

comments on our proposal to value the 

direct PE for all services by the bottomup method, using the PEAC refined 

staff, supply and equipment costs 

associated with each procedure as the 

basis for calculating the direct PE RVUs. 

Almost all of these comments favored 

our proposal to modify our PE 

methodology. This support was 

expressed whether the commenter also 

requested a delay in the implementation 

of our proposed methodology or 

recommended immediate 

implementation with no transitioning of 

the new PE RVUs. Commenters who 

were pleased with the resulting PE 

RVUs and those concerned with specific 

reductions also showed support. Below 

are some specific examples of the 

supporting comments. 

Two comments from specialty 

societies representing family physicians 

and internists agreed that the bottom-up 

approach will produce a more accurate, 

intuitive and stable PE methodology. 

One of the commenters contended that 

the proposed methodology would be 

more accurate because the bottom-up 

methodology assumes that the costs of 

the clinical labor, supplies and 

equipment are the same for a given 

service, regardless of the specialty 

performing it. 

A urological association supported 

switching to a bottom-up methodology 

for calculating PE RVUs and believed it 

meets our stated goals of using the most 

appropriate data, simplifying the PE 

methodology and increasing the 

stability of the PE payments. 

A major oncology center applauded 

our decision to implement a bottom-up 

approach because of the inequities that 

result when PE RVUs are set using a 

top-down approach which allows the 

frequent ‘‘leakage’’ of a specialty’s costs 

to other specialties. This rationale was 

also stated by a society representing 

anesthesiologists and by a patient 

advocate foundation. 

An oncology nursing society 

commented it has long advocated a 

bottom-up modification to help ensure 

that PE payments reflect the actual 

relative resources required for each 

service provided by oncology nurses. 

An organization representing allergy 

supported our proposal to change to a 

bottom-up methodology for determining 

PE values because this is a more rational 

approach. This view was shared in a 

comment from a physical medicine and 

rehabilitation society, which added that 

a bottom-up approach would result in a 

more direct relationship between PE 

RVUs and direct costs. 

A spine society commented that it 

welcomed the change to a ‘‘bottom-up 

methodology because any movement in 

the direction of stability and uniformity 

will have positive effects across 

providers.’’

A specialty society representing 

neurology supported the proposed 

change to a bottom-up methodology for 

calculating direct costs. The society 

asserted that the top-down method is 

flawed as it unfairly raises the expenses 

for high-end procedures. The 

commenter also stated that the excellent 

work of the PEAC, and now the PERC, 

has produced reliable data for all the 

codes, making CPEP complete for all the 

codes and must be given primacy in any 

method we would chose to implement. 

Two radiation therapy societies stated 

their strong support of the proposed 

bottom-up methodology and the 

proposed implementation for January 1, 

2006. One society commented that 

eliminating the scaling factors, at least 

for direct costs, is a step in the right 

direction toward a simpler and more 

transparent PE methodology. 

A respiratory care association stated 

support for our proposed bottom-up 

approach because this methodology 

would minimize aberrations that might 

inadvertently appear in the calculations, 

providing a more accurate 

representation of direct PE incurred by 

pulmonary physicians. 

A psychological association 

commented that the refinements 

approved by the PEAC may allow CMS 

to utilize a more simplified PE 

methodology which will make PE more 

understandable. 

An organization representing 

radiology contended that using the 

bottom-up methodology seems to be a 

simpler and easier way to make the 

transition with minimal impact. A 

medical sonography society stated that 

our efforts to help ensure a more 

accurate payment for healthcare services 

and create more year-to-year stability 

are to be commended. 

An occupational therapy association 

and a physical therapy association both 

agreed that the bottom-up method 

would be a preferable methodology. 

First, because it would rely on actual 

inputs from the specialties providing 

each service and second because it 

would create a more stable and 

predictable system and would reflect 

the actual relative resources required for 

each service. 

A specialty society representing 

hematology agreed that the top-down 

method for calculating the direct PE is 

extremely complex and not at all 

intuitive and stated that the bottom-up 

method will simplify the system and 

reduce the complexity of the 

calculations. 

Other organizations that supported 

the adoption of the bottom-up approach 

to valuing direct costs included 

specialty societies representing 

podiatry, prosthetic urology, geriatrics, 

infectious diseases, chest physicians, a 

pharmaceutical company, and medical 

group practices. 

Response: We are very pleased that so 

many in the medical community 

approve of the concept of using a 

bottom-up methodology to value the 

direct PE RVUs. We believe, along with 

these commenters, that the use of the 

bottom-up approach in the future would 

allow us to calculate more accurately 

the relative direct costs for each service 

in the PFS. The bottom-up approach 

would be simple to understand—we 

merely sum the costs of the PEACrefined clinical staff, supply and 

equipment inputs that are assigned to 

each service. The bottom-up approach 

would be intuitive—any change in 

direct inputs would lead to a 

commensurate change in the direct PE 

RVUs. The bottom-up methodology 

should also be more stable—with no 

cost pools or scaling factors to 

complicate the computation, direct PE 

RVUs for a service would only change 

if there was a revision to the inputs 

assigned. It was the hard work put forth 

by the AMA, the PEAC, the RUC and 

specialty societies in refining the CPEP 

inputs that made it possible to propose 

using a bottom-up methodology. 

However, for reasons discussed in this 

section, we are not implementing the 

bottom-up methodology for direct costs 

for 2006. However, we will be working 

with the RUC and the medical 

community to ensure that the inputs 

assigned to each service are correct and 

that the overall methodology works as 

intended so that we can propose this 

improvement in the future. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70135 

Comment: Several commenters 

expressed concern regarding the future 

refinement of the direct PE inputs that 

would ensure that a bottom-up 

methodology continues to lead to 

appropriate PE RVUs. A radiation 

oncology specialty society 

recommended that the bottom-up 

methodology be reviewed to ensure that 

the full input amounts are recognized 

accurately. A specialty society 

representing podiatry commented that 

the codes refined in the early stages of 

the PEAC may have inputs not 

consistent with codes refined later and 

that they should be looked at again by 

PEAC or PERC. The specialty society 

representing allergy suggested that there 

needs to be a continuing mechanism, 

such as the PEAC and PERC, for 

addressing changes in PE. A physical 

medicine society asserted that it is 

essential that we establish a system for 

updating or revising direct cost inputs 

based on new data or changes in 

technology. A thoracic medicine society 

supported the bottom-up methodology 

for creating direct PE inputs with 

continued refinement by the PEAC or 

the PERC. A pharmaceutical company 

supported the bottom-up method of 

determining the relative direct costs of 

each service, but requested that we 

establish a system to accept and review 

external data during the notice and 

comment period to update the direct 

cost inputs as needed. A specialty 

society representing prosthetic urology 

recommended that we adopt the bottomup method and establish a method to 

review external data to ensure that the 

inputs are updated appropriately. 

Response: We agree with the 

commenters that there needs to be a 

continuing review process for the direct 

PE inputs to reflect changes in practice 

or new technology. In addition, it will 

be necessary to ensure that the clinical 

staff time standards and supply and 

equipment packages that have been 

developed through the refinement 

process are applied appropriately to all 

services. We are hopeful that the RUC 

will continue to play a role in this 

further review and will be discussing 

this with RUC staff. In addition, we will 

continue to encourage input from the 

medical community in general regarding 

the accuracy of the direct inputs and 

their pricing. 

Comment: There were a few specific 

concerns raised by commenters 

regarding the bottom-up methodology. 

A specialty society representing 

radiation oncology stated that the 

bottom-up methodology may be 

unintentionally compressing higher-cost 

technology. A health care provider 

supported the bottom-up approach 

conceptually, but expressed concerns 

that aggregate budget neutrality would 

be more difficult to control using a 

bottom-up approach than using the topdown. A medical group practice 

association, as well as a large multispecialty clinic, had concerns that the 

RUC recommendations we have 

accepted for new technical procedures 

have, because of budget neutrality, 

eroded the value attributed to cognitive 

services. MedPAC had concerns about 

dealing with overvalued services and 

with the assumptions we use to allocate 

the cost of equipment to a specific 

service. For example, MedPAC 

questioned whether our assumption of 

50 percent utilization for all equipment 

is valid. 

Response: We are not sure how the 

bottom-up methodology would 

compress higher cost technology, but 

would be willing to discuss this with 

the commenter as we develop our next 

proposal. For budget neutrality, we are 

not certain that it is harder to control 

under a bottom-up approach; it would 

depend on which data source—the 

aggregate SMS-type data or the PEACrefined input data—produces the most 

accurate estimate of direct costs. We 

understand, in a budget neutral system, 

the concern about the effect that adding 

inputs for expensive technology has on 

cognitive services, but under a bottomup methodology there would not be the 

issue of scaling factors exaggerating this 

effect. We would like very much to 

discuss the issue raised by MedPAC as 

we endeavor to improve our PE 

methodology. 

Future Indirect PE Refinement 

Comment: Although we did not 

propose any major change to the 

indirect PE methodology, other than 

incorporating the new PE survey data, 

we did indicate our interest in receiving 

suggestions on ways to continue to 

refine the indirect PE calculations. Most 

commenters focused on the need for us 

to acquire up-to-date survey information 

for all specialties so that the PE data for 

all specialties is as current as possible. 

Specialty societies representing 

infectious disease physicians, 

orthopaedists, remote cardiac services, 

chest physicians and physical medicine 

commented that we should extend the 

deadline to allow specialty societies to 

conduct supplemental PE surveys. A 

commenter representing 

otolaryngologists stated this would not 

be a preferred option since the high cost 

involved with conducting surveys 

would disadvantage smaller specialties. 

Other specialty societies representing 

cataract surgeons, anesthesiologists, 

emergency medicine and otolaryngology 

recommended that an unbiased SMStype survey that cuts across all 

specialties would be most appropriate 

for use in the future, instead of having 

data from different time periods. In 

arguing for this multi-specialty 

approach, an emergency medicine 

association commented that, as 

MedPAC reports have indicated, only 

specialty societies who are likely to gain 

ground have incentive to produce new 

surveys. The specialty society 

representing otolaryngology cited the 

discussion in the Lewin Group report, 

‘‘Recommendations Regarding 

Supplemental Practice Expense Data 

Submitted for 2006,’’ that suggests that 

the increase in the surveyed PE/HR 

could indicate a ‘‘secular trend in rising 

physician PEs,’’ and the need for a 

multi-specialty PE survey. The 

commenter also suggested that a 

universal survey could be paid for by 

using funds reallocated from the 

oncology demonstration. A specialty 

society representing spine surgeons 

commented that all physicians should 

have the opportunity to submit data 

relevant to their specialties because it 

would be unfair to reduce PE 

reimbursement for providers such as 

neurosurgeons and orthopedic surgeons 

without allowing those providers that 

opportunity to submit accurate data. 

The society suggested that, as we have 

established a model for survey data, we 

could allow societies to survey their 

membership and submit the results, 

either directly to CMS or through the 

RUC. An association representing 

medical group practices recommended 

that a comprehensive study be initiated 

to accurately balance the relativity of 

overhead costs of practice for each 

service on a nationwide basis and that 

this include the costs of information 

technology (IT) implementation. An 

emergency medicine commenter 

recommended including survey 

questions on uncompensated care. 

Response: We agree with all the 

commenters that, for the PE RVUs to 

reflect accurately the relative indirect 

costs for all services, it would be most 

preferable to have current data for all 

specialties. However, section 212 of the 

BBRA required that we establish a 

process to use data developed by 

entities and organizations to 

supplement the data we normally 

collect in determining the PE 

component. We established this process 

and set criteria and a timeline for 

submission of this data. Although we 

twice extended the period during which 

we would accept these supplemental 

data, we are not proposing to extend 

this period beyond this year. We believe 

70136 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

that there has been sufficient time for 

individual specialties that had sufficient 

member support to do a survey, and that 

had reason to believe that the results of 

a survey would be helpful, to submit 

supplementary PE data to us. Therefore, 

we agree with the commenters who 

suggest that a multi-specialty survey 

done for a uniform time period would 

be most helpful. We are now planning 

to work with the AMA and the medical 

community to develop a strategy for 

funding and fielding a multi-specialty 

indirect PE survey that will help ensure 

that our PE methodology treats all 

specialties equitably. 

Comment: Several commenters 

offered the following suggestions for 

revisions to the indirect methodology. 

Comments from two associations 

representing speech language 

pathologists and audiologists argued 

that the current method of assigning 

indirect costs to their services results in 

a gross underestimation of these costs 

for both audiology and speech-language 

pathology services. One association 

suggested an alternative method of 

basing indirect costs on the ratio of the 

refined direct costs to the total costs for 

all physicians or for otolaryngologists. 

A specialty society representing 

allergy expressed concern that the 

indirect costs of an allergy practice are 

not properly accounted for in the 

current methodology because most 

either are not assigned work RVUs or 

have very low work RVUs, but may have 

high actual indirect costs. The society 

recommended that we should either 

establish a mechanism for adjusting the 

indirect PE when the existing formula 

yields an inequitable result, or revise 

the direct costs to include 

administrative staff time. 

A comment from a manufacturer 

stated that we should not use the ‘‘All 

Physician’’ indirect cost data for IDTFs 

and recommended using the radiology 

PE/HR figure for IDTF radiological 

services and the cardiology PE/HR for 

IDTF cardiology services, with the 

exception of the cardiac remote 

monitoring services which should be 

paid at current levels, pending the 

collection of additional data. 

A comment from a clinical oncology 

society recommended that any revision 

in the methodology for direct costs 

should be accompanied by a revision in 

the methodology for allocating indirect 

costs. The society stated that both the 

Lewin Group and the Government 

Accountability Office have found that 

the current methodology for indirect 

costs is biased against services that lack 

a physician work component. 

A family physician association 

questioned why we use physician work, 

rather than physician time, in our 

formula for allocating indirect expenses. 

The commenter stated that there is no 

evidence that PE would vary with 

physician intensity and recommended 

that we use physician time rather than 

work in the allocation of indirect 

expenses. 

A group representing cardiac services 

providers recommended that if and 

when the new methodology is applied 

to remote cardiac monitoring, indirect 

costs for these services should be based 

on a survey of their group and not on 

the ‘‘All Physician’’ average PE/HR, 

which fails to reflect the actual practice 

costs incurred. The group also 

recommended that we allocated indirect 

costs solely on the basis of direct costs, 

without regard to physician work. 

Response: We thank all the above 

commenters for their suggestions on 

improvements to our indirect PE 

methodology. We will certainly 

consider all of the above 

recommendations, as we work with the 

medical community to develop our next 

proposal for indirect PE. 

Comment: The American College of 

Surgeons recommends that we convene 

a multi-stakeholder process to address 

indirect PE methodological issues so 

that we can make further changes before 

final implementation of our new 

methodology. 

Response: As we have mentioned 

previously, we agree wholeheartedly 

with the above recommendation. We 

plan to initiate an open process with the 

medical community to exchange ideas, 

answer questions and provide 

information regarding changes to all 

aspects of our PE methodology before 

publication of the next PFS proposed 

rule. We recognize that in any payment 

system based on costs, indirect costs are 

always the most difficult to allocate 

fairly and accurately. Therefore, we will 

welcome all suggestions, including 

those recommended, to improve our 

indirect PE methodology. 

Other Issues 

Comment: A group representing 

community cancer centers requested 

that we review the PE RVUs for drug 

administration services as soon as the 

needed data are available to ensure that 

they accurately reflect all the costs 

associated with these services. The 

National Patient Advocate Foundation 

agreed because of concern that use of 

the current indirect PE RVUs will not be 

sufficient to reimburse oncologists for 

drug administration costs. 

Response: We should have the 

utilization data needed for the 2006 

proposed rule and plan to include the 

drug administration services in 

whatever PE methodology is proposed. 

Comment: Several commenters 

recommended that we maintain budget 

neutrality for PE RVU changes by 

adjusting the CF proportionately, rather 

than decreasing only PE RVUs. 

Response: Though there could be 

operational difficulties with adjusting 

the CF to account for PE budget 

neutrality, we would like to solicit 

comments on how best to reflect the 

budget neutrality for PE. 

3. PE Recommendations on CPEP Inputs 

for CY 2006 

Since 1999, the PEAC, an advisory 

committee of the AMA’s RUC, provided 

us with recommendations for refining 

the direct PE inputs (clinical staff, 

supplies, and equipment) for existing 

CPT codes. The PEAC held its last 

meeting in March 2004 and the AMA 

established a new committee, the PERC, 

to assist the RUC in recommending PE 

inputs. 

With the PERC’s assistance, the RUC 

completed refinement of approximately 

200 remaining codes at its meetings 

held in September 2004 and February 

2005. A list of these codes appeared in 

Addendum C of proposed rule. 

We reviewed the RUC-submitted PE 

recommendations and proposed to 

adopt nearly all of them. We worked 

with the AMA staff to correct any 

typographical errors and to make certain 

that the recommendations are in line 

with previously accepted standards. 

As stated in the proposed rule, we 

revised the PE database to reflect these 

RUC recommendations which can be 

found on our web site. (See the 

‘‘Supplementary Information’’ section of 

this rule for directions on accessing our 

web site.) 

We disagreed with the RUC’s 

recommendation for clinical labor time 

for CPT code 36522, Extracorporeal 

Photopheresis. In the CY 2005 final rule 

(69 FR 66236), we assigned, on an 

interim basis, 223 minutes of total 

clinical labor for the service period 

based on the typical treatment time of 

approximately 4 hours. The RUC, 

however, recommended 122 minutes 

total clinical labor time for the service 

period, which allowed for 90 minutes of 

nurse ‘‘intra service’’ time for the 

performance of the procedure (the 

society originally proposed 180 

minutes). We believe that 135 minutes 

is a more appropriate estimation of the 

clinical staff time actually needed for 

the intra time, as it more closely 

approximates the time assigned to the 

other procedures in this family of codes, 

including CPT codes 36514, 36515, and 

36516. Therefore, we proposed a total 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70137 

clinical labor time of 167 minutes for 

the service period. We did not receive 

specific comments for this revision and 

are finalizing this change to the clinical 

labor time. While we have made the 

change in the PE database, the PE RVUs 

for 2006 will not reflect the adjustment 

due to the decision concerning the PE 

methodology to maintain all PE RVUs at 

the 2005 level as discussed previously. 

The RUC also recommended that no 

inputs be assigned to several codes 

because the services were not performed 

in the office setting. However, our 

utilization data shows that 4 of these 

codes (CPT codes 15852, 76975, 78350, 

and 86585) are currently priced in the 

office and are performed with sufficient 

frequency in the office to warrant this. 

Therefore, we proposed not to accept 

the RUC recommendations for these 

services at this time, but requested 

comments from the relevant specialties 

as to whether the recommendations 

should be accepted. 

Comment: We received comments 

from one specialty society disagreeing 

with the RUC’s recommendation for 

CPT 78350, single photon bone 

densitometry, as they believe this 

procedure is being performed in the 

office. They expressed their intentions 

to work with CMS as they develop 

appropriate PE inputs for this procedure 

in the nonfacility setting. The specialty 

society also expressed their agreement 

with the RUC’s recommendation to 

eliminate the nonfacility PE RVUs for 

76975 because virtually all of these 

exams are performed in the facility 

setting. In addition, a national 

organization representing medical 

directors of respiratory care, supported 

the retention of nonfacility PE RVUs for 

CPT 86585, TB tine test, because they 

believe it to be a legitimate office-based 

procedure. We did not receive 

comments on the appropriateness of 

nonfacility RVUs for CPT 15852. 

Response: We will maintain the 

nonfacility setting PE RVUs for 78350 

and look forward to working with the 

specialty society in their initiative to 

develop inputs for this procedure. We 

will remove the PE inputs for the 

nonfacility setting for CPT codes 76976 

and 15852, although for the 2006 PFS 

these codes will reflect the 2005 PE 

RVU amounts. CPT 86585 has been 

deleted from CPT 2006 and will not 

appear on Addendum B. 

4. Payment for Splint and Cast Supplies 

In the Physician Fee Schedule (CY 

2000); Payment Policies and Relative 

Value Unit Adjustment final rule, 

published November 2, 1999 (64 FR 

59379) and the Physician Fee Schedule 

(CY 2002); Payment Policies and 

Relative Value Units Five-Year Review 

and Adjustments final rule, published 

November 1, 2000 (66 FR 55245), we 

removed cast and splint supplies from 

the PE database for the CPT codes for 

fracture management and cast/strapping 

application procedures. Because casting 

supplies could be separately billed 

using Healthcare Common Procedure 

Coding System (HCPCS) codes that were 

established for payment of these 

supplies under section 1861(s)(5) of the 

Act, we did not want to make duplicate 

payment under the PFS for these items. 

However, in limiting payment of these 

supplies to the HCPCS codes Q4001 

through Q4051, we unintentionally 

prohibited remuneration for these 

supplies when they are not used for 

reduction of a fracture or dislocation, 

but rather, are provided (and covered) as 

incident to a physician’s service under 

section 1861(s)(2)(A) of the Act. 

Because these casting supplies are 

covered in sections 1861(s)(5) or 

1861(s)(2)(A) of the Act, we proposed to 

eliminate the separate HCPCS codes for 

these casting supplies and to again 

include these supplies in the PE 

database. This would allow for payment 

for these supplies whether based on 

section 1861(s)(5) or 1861(s)(2)(A) of the 

Act, while ensuring that no duplicate 

payments are made. In addition, by 

bundling the cost of the cast and splint 

supplies into the PE component of the 

applicable procedure codes under the 

PFS, physicians would no longer need 

to bill Q-codes in addition to the 

procedure codes to be paid for these 

materials. 

Because these supplies were removed 

from the PE database prior to the 

refinement of these services by the 

PEAC, we proposed to add back the 

original CPEP supply data for casts and 

splints to each applicable CPT code and 

we requested that the relevant medical 

societies review the ‘‘Direct Practice 

Expense Inputs’’ on our web site and 

provide us with feedback regarding the 

appropriateness of the type and amount 

of casting and splinting supplies. We 

also requested specific information 

about the amount of casting supplies 

needed for the 10-day and 90-day global 

procedures, because these supplies may 

not be required at each follow-up visit; 

therefore, the number of follow-up visits 

may not reflect the typical number of 

cast changes required for each service. 

We reincorporated the following cast 

and splint supplies as direct inputs: 

fiberglass roll, 3 inch and 4 inch; cast 

padding, 4 inch; webril (now designated 

as cast padding, 3 inch); cast shoe; 

stockingnet/stockinette, 4 inch and 6 

inch; dome paste bandage; cast sole; 

elastoplast roll; fiberglass splint; ace 

wrap, 6 inch; and kerlix (now 

designated as bandage, kerlix, sterile, 

4.5 inch) and malleable arch bars. The 

cast and splint supplies were added, 

where applicable, to the following CPT 

codes: 23500 through 23680, 24500 

through 24685, 25500 through 25695, 

26600 through 26785, 27500 through 

27566, 27750 through 27848, 28400 

through 28675, and 29000 through 

29750. 

Because we proposed to pay for splint 

and cast through the PE component of 

the PFS, we would no longer make 

separate payment for these items using 

the HCPCS Q-codes. 

Comment: We received a comment on 

behalf of the American Osteopathic 

Academy of Orthopedics (AOAO) that 

provided specific information for the 

type and number of casts needed for the 

10 or 90-day global period for each code 

in the relevant fracture management 

series. The AOAO also noted the type 

and amount of casting supplies, 

including stockinette, cast padding, 

fiberglass and post-op cast shoe, as 

appropriate. 

We also received a comment from the 

RUC expressing their appreciation for 

the proposal to make coding and billing 

for fracture management and casting/ 

strapping supplies easier by reducing 

the number of codes for physicians to 

submit. In addition, the RUC expressed 

interest in reviewing the data submitted 

in response to our proposal so that the 

resulting casts and strapping PE inputs 

can ‘‘enjoy the same level of scrutiny 

and cross-specialty refinement that all 

of the other PE inputs have’’. 

Other specialty societies supported 

our proposal to include casting material 

in the fracture care codes and the 

elimination of the Q codes. However, 

some of these societies expressed 

concerns about bundling all of the 

necessary casting/strapping supplies for 

the global period into the fracture 

management codes. These commenters 

related that only the initial cast/ 

strapping supplies should be bundled 

into the relevant fracture care code 

series and that physicians should be 

able to continue to submit separate 

claims for the CPT codes for the 

application of casts and strapping 

procedures during the global period. 

Many commenters, primarily from 

orthopedic practices, expressed concern 

about the proposal, but misunderstood 

that this proposal was separate from the 

anticipated negative update for 2006 

based on the SGR methodology. 

Response: We thank AOAO for 

submitting the information we 

requested in the proposed rule. The 

society submitted a clear, 

70138 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

comprehensive and beautifully prepared 

spreadsheet detailing each CPT code in 

the various fracture management series. 

We commend them on their efforts to 

submit such a thorough and meticulous 

document in response to our proposed 

rule request. 

For the 2006 fee schedule, based on 

the decision concerning PE 

methodology to maintain all PE RVUs at 

the 2005 level previously discussed, we 

have removed the CPEP inputs for casts 

and splints from the PE database and 

CMS will retain use of the Q-code fee 

schedule as done in the past. In 

addition, we will use the interim time 

period before the notice of proposed 

rulemaking for the 2007 fee schedule to 

work with the affected specialties and 

the RUC to clarify issues related to 

Medicare payment policy and establish 

more appropriate amounts of casting/ 

strapping materials for the relevant 

series of fracture management codes and 

the casts and strapping application 

codes. Due to the temporary status and 

intended limited use of the Q-code fee 

schedule, it is our intention to resolve 

these important payment issues in the 

near future. A detailed discussion of the 

SGR and the update for 2006 is found 

later in this final rule with comment. 

5. Miscellaneous PE Issues 

In this section, we discuss our 

specific proposals related to PE inputs. 

a. Supply Items for CPT Code 95015 

We proposed to change the supply 

inputs for CPT code 95015, 

intracutaneous (intradermal) tests, 

sequential and incremental, with drugs, 

biologicals or venoms, immediate type 

reaction, specify number of tests, based 

on comments received from the JCAAI. 

JCAAI reported that ‘‘venom’’ is the 

most typical test substance used when 

performing this service and that 

‘‘antigen’’, currently listed in the PE 

database, is never used. They also 

suggested that the appropriate venom 

quantity should be 0.3 ml (instead of the 

0.1 ml listed for CY 2005) because of the 

necessity to use all 5 venoms (honey 

bee, yellow jacket, yellow hornet, white 

face hornet and wasp) to perform this 

sensitivity testing; that is, 1 ml of each 

venom type for a total of 5 ml of venom. 

The diluted venoms are sequentially 

administered until sensitivity is shown, 

beginning with the lowest concentration 

of venom and subsequently 

administering increasing concentrations 

of each venom. We accepted the 

specialty’s argument and proposed to 

change the test substance in CPT code 

95015 to venom, at $10.70 (from single 

antigen, at $5.18) and the quantity to 0.3 

ml (from 0.1 ml). 

Comment: JCAAI expressed their 

appreciation for our proposal to change 

the supply item input for CPT 95015 

from 0.1 ml antigen to .3 ml of venom. 

Response: The appropriate changes 

have been made to our PE database. 

However, as discussed above, because 

we are making only limited, necessary 

changes to PE RVUs for the 2006 PFS, 

the PE RVUs for this code will continue 

to reflect the 2005 PE RVU amounts. 

b. Flow Cytometry Services 

In the CY 2005 final rule (69 FR 

66236), we solicited comments on the 

interim RVUs and PE inputs for new 

and revised codes, including flow 

cytometry services. Based on comments 

received and additional discussions 

with representatives from the society 

representing independent laboratories, 

we proposed to revise the PE inputs for 

the flow cytometry CPT codes 88184 

and 88185. 

Based on information from the 

specialty society, we proposed to 

change the direct inputs used for PE as 

follows: 

• Clinical Labor: Change the staff type 

in the service (intra) period in both CPT 

codes 88184 and 88185 to 

cytotechnologist, at $0.45 per minute 

(currently lab technician, at $0.33 per 

minute). 

• Supplies: Change the antibody cost 

for both CPT codes 88184 and 88185 to 

$8.50 (from $3.544). 

• Equipment: Add a computer, 

printer, slide strainer, biohazard hood, 

and FACS wash assistant to CPT code 

88184. Add a computer and printer to 

the equipment for CPT code 88185. 

Comment: We received comments 

from several organizations including 

those representing professional services 

in clinical laboratories, manufacturers, 

clinical laboratories, and clinical 

pathologists. These commenters all 

supported our proposal to revise the PE 

inputs outlined above for the flow 

cytometry CPT codes 88184 and 88185. 

Response: We appreciate the support 

extended to us by these national 

organizations in regards to the revision 

of direct inputs for the CPT codes for 

flow cytometry. The PE changes have 

been made, as indicated above, to the 

database. However, because we are 

making only limited, necessary changes 

to PE RVUs for the 2006 PFS, the PE 

RVUs for these codes will continue to 

reflect the 2005 PE RVU amounts. 

c. Low Osmolar Contrast Media (LOCM) 

and High Osmolar Contrast Media 

(HOCM) 

HOCM and LOCM are used to 

enhance images produced by various 

types of diagnostic radiological 

procedures. In the CY 2005 final rule 

(69 FR 66356), we eliminated the 

criteria for the payment of LOCM that 

had been included at § 414.38. Effective 

April 1, 2005, providers can receive 

separate payment for LOCM when used 

with procedures requiring contrast 

media through the use of separate Qcodes. Payment for HOCM is currently 

included as part of the PE component 

under the PFS. We proposed, effective 

January 1, 2006, to no longer include 

payment for HOCM under the PFS and 

to establish Q-codes for the separate 

payment of HOCM. 

As noted in the proposed rule we 

reviewed the PE database and proposed 

to remove the following two supply 

items which we have identified as 

HOCM from the PE database: 

• Conray inj. iothalamate 43 

percent(supply item #SH026, deleted 

from 64 procedures). 

• Diatrizoate sodium 50 percent 

(supply item #SH0238, deleted from 74 

procedures). 

We also identified 5 CPT codes 

(specifically CPT codes 42550, 70370, 

93508, 93510 and 93526) that included 

omnipaque as a supply item, and 

proposed to remove this supply item 

from these 5 CPT codes since 

omnipaque is actually a type of LOCM. 

Comment: We received several 

comments from organizations 

representing radiology physicians and 

manufacturers on our proposal to delete 

HOCM from the PE database. The 

commenters supported our proposal for 

separate payment for both HOCM and 

LOCM to ensure beneficiaries access to 

all the various types of medical 

imagining contrast media. The 

commenter representing the 

manufacturers requested that we notify 

carriers that separate payment for LOCM 

and HOCM is available. 

Response: We thank the organizations 

for their comments in support of our 

proposal which would permit separate 

payment for HOCM in 2006. We have 

removed HOCM from the direct inputs 

in the PE database and also deleted 

LOCM from the 5 procedures as noted 

above. However, because we are not 

implementing the bottom-up 

methodology which utilizes the direct 

inputs to determine the PE RVUs, these 

imaging codes will again be valued in 

the NPWP where the PE RVUs are 

established using an appropriate 

crosswalked charge-based RVU 

containing HOCM as an inherent supply 

cost. We will delay separate payment for 

HOCM until such time the direct inputs 

are used to determine PE RVUs. For 

2006, the PE RVUs will be retained at 

the 2005 level. We remind the 

commenters that the average sales price 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70139 

(ASP) quarterly values are published on 

our Web site at the following address: 

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

drugs/asp.asp. 

d. Imaging Rooms 

We include standardized ‘‘rooms’’ for 

certain services in our PE equipment 

database, rather than listing each item 

separately. We received pricing 

information from the ACR for the 

following rooms that are included in the 

database. We accepted most of the 

proposed items that met the $500 

threshold for equipment and proposed 

to include the items in each specific 

room, as follows: 

• Basic Radiology Room: $127,750 (xray machine @ $125,550 and camera 

@ $2,200). The recommended viewbox 

was not included because most codes 

assigned this room have also been 

assigned an alternator (automated film 

viewer) or a 4-panel viewbox. 

• Radiographic-Flouroscopic Room: 

$367,664 (Radiographic machine 

@ $365,464 and camera @ $2,200). The 

recommended viewbox was not 

included because most codes assigned 

this room have also been assigned an 

alternator (automated film viewer) or a 

4-panel viewbox. 

• Mammography Room: $168,214 

(mammography unit @ $124,900; 

reporting system @ $16,690; 

mammography phantom @ $674; 

densitometer 

@ $3,660; sensitometer @ $2,750; 

desktop PC for monitoring 

@ $1,840; and processor @ $17,700. 

Separately listed equipment items 

(densitometer, mammography reporting 

system, sensitometer, mammography 

phantom, desktop computer, and the 

film processor) that duplicated items 

included in the mammography room 

were removed from the codes assigned 

the room, eliminating the reporting 

system, sensitometer and phantom from 

the PE database. 

• Computed tomography (CT) Room: 

$1,284,000 (16-slice CT scanner with 

power injector and monitoring system) 

• Magnetic Resonance Imaging (MRI) 

Room: $1,605,000 (1.5T MR scanner 

with power injector and monitoring 

system) 

Comment: We received comments 

from one specialty society requesting 

that we add 4 cassettes to the 

composition and cost of the 

mammography room although each 

cassette does not meet the $500 

equipment threshold. Another 

commenter representing a large 

radiology group practice agreed that our 

cost allowance for the mammography 

room was appropriate for the standard 

analog mammography room. However, 

this commenter asked us to develop a 

separately identified cost for a digital 

mammography room, costing 

approximately 3 to 4 times as much as 

the analog room, citing this digital 

system provides better diagnostic 

services. 

Response: We appreciate the 

comments regarding the cost and 

composition of the mammography 

room. We are sympathetic to the 

commenter’s request for the creation of 

a separate digital mammography room. 

However, the direct PE inputs for labor, 

supplies and equipment that are 

included in physicians’ services reflect 

the costs involved in the typical 

procedure or service provided in the 

nonfacility setting. We believe that the 

mammography room we proposed 

represents the equipment used to 

provide the typical mammography 

service and was based on information 

provided by the specialty society. 

We disagree with the specialty society 

in regards to adding the cost of the 4 

cassettes to the room’s price. The 

threshold for the inclusion of equipment 

for PE purposes remains at $500. For 

this reason, we will finalize the value of 

the mammography room as proposed, at 

$168,214. 

In addition we will finalize the 

proposed values for all of the above 

imaging rooms in this final rule with 

comment. However, because we are 

adopting only limited, necessary 

changes to PE RVUs for CY 2006, and 

will continue to utilize the NPWP to 

value these services, the RVUs will 

remain the same as those for 2005. 

e. Equipment Pricing for Select Services 

and Procedures From the CY 2005 Final 

Rule (69 FR 66236) 

In the August 8, 2005 proposed rule, 

we presented information on pricing of 

equipment for select services and 

procedures based on specialty 

information and stated we would be 

accepting the prices. The specific 

equipment was as follows: 

• Equipment pricing for certain 

radiology services received from the 

ACR were presented in table 15 of the 

proposed rule. 

• Equipment pricing on the 

Ultrasound color Doppler transducers 

and vaginal probe received from the 

American College of Obstetrics and 

Gynecology was presented. 

• For CPT 36522, extracorporeal 

photopheresis, we discussed equipment 

pricing information specific to this 

procedure. 

• Pricing of EMG botox machine used 

in CPT code 92265 as presented by the 

American Academy of Ophthalmology. 

No comments were received on these 

items, therefore, the prices discussed in 

the proposed rule will be used in the PE 

database. However, we will continue to 

use the 2005 PE RVUs for each of these 

codes for CY 2006. 

f. Supply Item for In Situ Hybridization 

Codes (CPT 88365, 88367, and 88368) 

As discussed in the August 8, 2005 

proposed rule, we received comments in 

response to the CY 2005 final rule from 

the College of American Pathologists 

regarding the number of DNA probes 

assigned to the in situ hybridization 

codes, CPT codes 88365, 88367, and 

88368. Currently, CPT codes 88365 and 

88368 have 1.5 probes assigned, while 

CPT code 88367 has only 0.75 of a probe 

assigned. The College of American 

Pathologists requested that we assign 

1.5 probes to CPT code 88367, and 

provided justification for this request. 

We accepted the College of American 

Pathologists’ rationale and proposed to 

change the probe quantity for CPT code 

88367 to 1.5. 

Comment: A society representing 

clinical pathologists supports the 

proposed change to the probe quantity 

for CPT 88367. 

Response: We have entered the 

number of probes, at 1.5, to our PE 

database. This change will not be 

expressed in the 2006 PE RVUs because 

as discussed above, we will retain the 

2005 PE RVUs. 

g. Supply Item for Percutaneous 

Vertebroplasty Procedures (CPT Codes 

22520 and 22525) 

The Society for Interventional 

Radiology (SIR) provided us with 

documentation for the price of the 

vertebroplasty kit used in CPT codes 

22520 and 22525. We proposed to 

accept a new price of $696 for this 

supply, currently listed as $660.50, a 

placeholder price from the CY 2005 

final rule. 

Comment: Commenters supported the 

proposed $696 cost estimate for the 

vertebroplasty kit. 

Response: We are finalizing our 

proposal to value the vertebroplasty kit 

price at $696 in the supply database, 

although, as discussed previously, this 

will not be reflected in the 2006 PE 

RVUs because we will retain the 2005 

PE RVUs. 

h. Clinical Labor for G-codes Related to 

Home Health and Hospice Physician 

Supervision, Certification and 

Recertification 

As discussed in the August 8, 2005 

PFS proposed rule, 4 G-codes related to 

home health and hospice physician 

supervision, certification and 

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recertification, G0179, 180, 181, and 

182, are incorrectly valued for clinical 

labor. These codes are cross-walked 

from CPT codes 99375 and 99378, 

which underwent PEAC refinement in 

January 2003 for the 2004 fee schedule. 

However, we did not apply the new 

refinements to these specific G-codes. 

This was an oversight on our part and 

we proposed to revise the PE database 

to reflect the new values in the 2006 

physician fee schedule. 

Comment: Commenters, including 

those representing the specialty 

societies for home care physicians and 

internists, expressed concern about the 

decrease in PE RVUs for the G-codes for 

hospice and home health supervision 

and care plan oversight services. One 

commenter requested that we elaborate 

on the sequence of events that lead to 

this decrease. 

Response: We appreciate the concern 

expressed by the commenters and are 

providing additional information 

outlining the reason for this change. For 

the 2001 PFS, these G-codes were 

created in order to provide payment for 

these specific services. Changes made to 

the CPT codes (CPT codes 99375 and 

99378) for 2001 did not enable us to 

recognize the CPT codes for Medicare 

payment purposes. Therefore, the PE 

inputs that had been applied to these 

CPT codes were cross-walked and used 

to establish the PE RVUS for the G codes 

that we established for these services. 

Subsequent to this, the CPT codes 

underwent refinement by the PEAC at 

its January 2003 meeting where a 

majority of the other E/M services were 

refined. CMS accepted these PE 

recommendations from the PEAC that 

included only a total of 36 minutes for 

clinical labor. The PEAC 

recommendations did not include 

supplies and equipment because they 

did not believe these were utilized in 

the typical services represented by these 

codes. These PE inputs were intended to 

be crosswalked to the G-codes for 2004, 

however, due to an oversight, this did 

not occur. We apologize to the 

specialties that this refinement was not 

done in a timely manner. Thus, we are 

finalizing the direct inputs for these Gcodes in this rule and have changed the 

PE database accordingly. However in 

2006, the PE RVUs for these 4 G-codes 

will remain at the 2005 level, as 

explained above. 

i. Programmers for Implantable 

Neurostimulators and Intrathecal Drug 

Infusion Pumps 

Subsequent to the CY 2005 final rule, 

we received comments from a 

manufacturer of programmers for 

implantable neurostimulators and 

intrathecal drug infusion pumps. The 

commenter indicated that the 

equipment costs for these programmers 

are not a direct expense for the 

physicians performing the programming 

of these devices and that the 

manufacturer furnishes these devices 

without cost because the programming 

device is considered a ‘‘necessary, 

ancillary item to the neurostimulator 

and drug pump and can only be used to 

program these devices.’’ Therefore, we 

proposed to remove the 2 programmers 

from the PE database: EQ208 for 

medication pump from 2 codes (CPT 

62367 and 62368) and EQ209 for the 

neurostimulator from 8 codes (CPT 

95970–97979). We also requested 

comments from the specialty societies 

performing these services as to whether 

this reflects typical practice. 

Comment: Several commenters 

disagreed with this proposal indicating 

that not all programmers are provided 

without cost. Specifically, for the one 

manufacturer, the practice of providing 

physicians with these programmers free 

of charge is just a recent occurrence. In 

addition, one commenter informed us 

that there are other PE items that are not 

accounted for, including a printer, for 

62367 and 62368. The RUC commented 

that several specialty societies 

conducted an email-based survey 

finding that the majority of the 

respondents reported paying for these 

programmers. The RUC asked us to 

reconsider our decision to delete the 

programmers from the PE direct inputs 

because it was based solely on the 

recommendation of one manufacturer. 

Response: We are sympathetic to the 

commenters’ concerns about the 

programmers used by pain medicine 

physicians. We have carefully reviewed 

our decision to delete the programmers 

from the PE database in light of the 

comments we received. Therefore, based 

on the uncertainty as to which brand 

product is typical, the survey results 

presented to us by the RUC, and the life, 

7 years, of each programmer, we have 

determined that we will retain these 

programmers in the database. In 

addition, we have added ‘‘with printer’’

to the description of EQ208 to match 

that of EQ209 in order to assuage the 

commenter’s concern that the price 

listed in the database, $1975, correctly 

reflects the cost of both the programmer 

and the printer. Because the PE RVUs 

for 2005 contained the price for these 

programmers, the PE RVUs for 2006 will 

continue to reflect their costs. 

j. Pricing of New Supply and Equipment 

Items 

As part of the CY 2005 final rule 

process, we reviewed and updated the 

prices for equipment items in our PE 

database and assigned a unique 

identifier to each equipment item with 

the first 2 elements corresponding to 

one of 7 categories. It was brought to our 

attention that we assigned the same 

category identifier (ELXXX) for both 

‘‘lanes/rooms’’ as well as ‘‘laboratory 

equipment’’. To correct this, we 

proposed assigning laboratory 

equipment items the new category 

identifier ‘‘EPXXX’’, but the specific 

numbers associated with each item 

would remain the same. In addition, 

supply items were reviewed and 

updated in the rulemaking process for 

the 2004 PFS. During subsequent 

meetings of both the PEAC (now 

referred to as the PERC) and the RUC, 

supply and equipment items were 

added that were not included in the 

pricing updates. In the proposed rule we 

included 2 tables (Table 16: Proposed 

Practice Expense Supply Items and 

Table 17: Proposed Practice Expense 

Equipment Items) that listed the 

additional supply and equipment items 

for 2006 and the proposed associated 

prices that we would use in the PE 

calculation. The listing of new supplies 

and equipment in the proposed rule 

does not guarantee that the price listed 

for each item has been accepted. Rather, 

the new supply and equipment tables 

are to make specialties aware of the 

descriptors and assigned supply or 

equipment codes that can be used in 

future proposals to the RUC and 

HCPAC. As discussed below, the 

addition of an item to the tables for new 

supplies or equipment does not 

preclude the inclusion of the same item 

on the tables that require more detailed 

information and documentation from 

the specialty organization. 

k. Supply and Equipment Items Needing 

Specialty Input 

We also identified certain supply and 

equipment items for which we were 

unable to verify the pricing information, 

reflected in Table 18: Supply Items 

Needing Specialty Input for Pricing and 

Table 19: Equipment Items Needing 

Specialty Input for Pricing of the 

proposed rule. We stated that the items 

listed in these tables represent the 

outstanding items from last year and 

new items added from the RUC 

recommendations. Therefore, we 

requested that commenters, particularly 

specialty organizations, provide pricing 

information on items in these tables 

along with documentation to support 

the recommended price. 

Tables 14 and 15 reflect the comments 

and documentation we received for each 

item. Specialty societies are asked to 

review these supplies and equipment, as 

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appropriate, to assure that the item 

status is accurate and forward any 

necessary documentation. We would 

also like to reinforce the types of 

documents that meet the acceptable 

category. The following list includes 

examples of acceptable documentation: 

• Photocopy or actual vendor catalog 

listing, indicating price, accessories or 

components (if applicable), available 

quantity, company name, brand name, 

and catalog date. Scanned versions, if 

readable, can also be emailed. 

• Photocopy of web page with 

specific supply or equipment including 

the necessary information listed in 

above bullet. 

• Photocopy of invoice indicating the 

price paid for specific supply or 

equipment, as well as the specific 

contents of kit, pack or tray for supplies 

and component or accessory parts for 

the equipment item. 

• Letter, FAX or e-mail from 

manufacturer, vendor or distributor 

noting the ASP of the supply or 

equipment. The description of the item 

must list all contents, accessories or 

component parts that are included in 

the price. 

The following information is not 

considered acceptable documentation, 

including: 

• Web site addresses. 

• Vendor, manufacturer, or 

distributor phone number and address. 

• Approximated values. 

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l. Additional PE Issues Raised by 

Commenters 

Comment: We received a comment 

from an equipment distributor and 

multiple comments from physicians 

asking us to add more clinical labor, 

supplies and equipment to CPT codes 

78481 and 78483 for cardiac blood pool 

imaging using the first pass technique. 

The commenters emphasized that the 

labor costs are understated, and that 

additional supplies and equipment are 

necessary to perform these services. In 

particular, the commenters requested 

we add a nuclear medicine gamma 

camera to the equipment inputs or 

cross-walk the equipment listed for CPT 

78465. The distributor presented supply 

and equipment tables for both codes, 

using direct PE inputs currently listed 

in the PE database, most of these are 

found in the PE for CPT 78465. 

Response: The direct inputs for these 

‘‘First Pass’’ services were presented by 

the specialty society to the PEAC at its 

January 2004 meeting. The RUC 

forwarded the PEAC’s recommendations 

to CMS for consideration during the 

rulemaking process for the 2004 fee 

schedule at which time these 

recommendations were accepted. We do 

not believe that we are in a position to 

make the type of changes to the PE 

inputs for these 2 codes that the 

commenters have requested. We 

recommend that the commenters and 

the specialty society whose members 

perform these procedures, work together 

so that necessary changes can be 

considered through the usual RUC 

process. 

Comment: We received comments 

from a specialty society and a 

manufacturer asking us to replace a 

supply item, a Tesio type dual catheter, 

with the Lifesite system in CPT 36566—

a procedure described as the insertion of 

tunneled catheter with subcutaneous 

port(s). The specialty society explained 

that when the RUC valued this service 

in 2003, the incorrect catheter was 

included with their PE 

recommendations. The manufacturer 

asks for our assistance in correcting a 

‘‘clerical error’’ in our database. The 

commenters explain that CPT codes 

36565 and CPT 36566 are nearly 

identical in procedure, although CPT 

36566 requires the insertion of 

‘‘subcutaneous port(s)’’ and that the 

Tesio-type catheter, priced at $355, is 

currently listed for both of these 

procedures. The Lifesite system, 

containing a subcutaneous port, is 

priced at $1750. Both commenters noted 

that 2 Lifesite systems are necessary to 

perform this procedure instead of one 

for a total supply cost of $3500. 

Response: We appreciate the 

commenters concerns about the specific 

supplies they believe are needed to 

perform this service. The work and PE 

values for CPT 36566 were forwarded by 

the RUC and accepted in our final rule, 

for the 2004 fee schedule. We believe 

that the RUC is the appropriate avenue 

to address correction of inputs to the PE 

database, particularly due to the 

expensive nature of this replacement, 

and are not revising the PE database to 

reflect this price change. 

Comment: A specialty society 

commented that it believes the 

nonfacility PE RVUs were mistakenly 

deleted from CPT codes 59812, 59840, 

and 59841. The specialty also requested 

that nonfacility PE RVUs be added for 

CPT 58558. 

Response: We have reviewed the 

specialty’s request regarding nonfacility 

PE RVUs for the 4 codes noted above. 

The ‘‘NA’’ indicator for PE RVUs in the 

nonfacility setting is listed incorrectly 

for CPT codes 59840 and 59841 in 

Addendum B of our proposed rule. Both 

of these CPT codes should have PE 

RVUs listed in the nonfacility setting. 

The specialty society is mistaken, 

however, regarding the appropriateness 

of nonfacility PE RVUs for CPT 59812 

and 58558. These codes have both 

undergone refinement by the PEAC at 

least once and the recommendations 

forwarded by the RUC clearly indicated 

that these procedures were not valued 

in the nonfacilty setting. We have 

changed our database, as appropriate, to 

reflect the changes for CPT 59840 and 

59812. 

Comment: We received comments 

from a specialty organization citing that 

the total RVUs for CPT 19298 are too 

low in comparison to those for CPT 

19296—both new CPT codes for CY 

2005. The specialty believes this 

difference is likely due to the supply PE 

inputs necessary to perform each 

procedure. The specialty states that the 

catheter supply expenses should be 

similar between the 2 services, yet the 

nonfacility PE RVUs for CPT 19298 

(39.56) are significantly lower than 

those listed for CPT 19296 (117.96). The 

specialty stated that while the average 

number of catheters used for CPT 19298 

is 25, ranging from 15–30, this cost 

should be comparable to the catheter 

required for CPT 19296. Finally, the 

specialty requests that we crosswalk the 

total RVUs for the nonfacility setting 

from CPT 19296 to CPT 19298 for 2006 

while they gather detailed information 

to present to us. 

Response: We have researched the 

specialty’s concern about the supply 

cost differences between the 2 new CPT 

codes for 2005. Whereas the specialty 

contends that the catheter expenses are 

similar, or only somewhat greater for 

CPT 19296, we found that the 

differences between these 2 supply costs 

is significant. The mammosite tray, 

containing the catheter used for CPT 

19296, is priced at $2,550 while the 

button-end implant catheters used for 

CPT 19298 are priced at $18.50 each. 

The PE database indicates that the RUCrecommended typical procedure would 

require 30 such catheters, opposed to 25 

noted by the specialty, for a total cost of 

$555. Consequently, we will not change 

the PE RVUs for either procedure, 

although we remain puzzled as to the 

commenters’ specific concerns. We look 

forward to the specialty’s clarification 

regarding this issue and would urge 

them to address their concerns through 

the usual RUC process. We would also 

like to remind commenters that interim 

RVUs are published, for new and 

revised CPT codes, in our final rule each 

year and are subject to a 60-day 

comment period at that time. We 

encourage commenters to observe and 

utilize the respective comment periods 

during our annual rulemaking process 

in order that we may respond timely to 

issues and concerns. 

Comment: We received many 

comments regarding the use of ‘‘NA’’ in 

Addendum B when used for the 

‘‘Nonfacility PE RVUs’’ column, the 

‘‘Facility PE RVUs’’ column, and the 

occasional code with NA noted in both 

PE RVU columns. These commenters 

asked us to provide a clear definition of 

how the service is paid when the NA is 

affixed to either PE RVU column in 

Addendum B which our rule for 2005 

fee schedule had PE RVUs listed for the 

nonfacility. One commenter stated that 

private payors believe that payment is 

not made when the NA indicator is 

listed in Addendum B. 

Response: We appreciate the 

commenters remarks regarding the 

uncertainty involved with interpreting 

Addendum B, particular regarding the 

use of the ‘‘NA’’ indicator for the PE 

RVUs nonfacility and facility columns. 

Due to the confusion expressed by the 

commenters surrounding the NA 

designations, we have added 

explanations to Addendum A in order 

to assist the readers of Addendum B. We 

are also including these definitions here 

because of this issue’s importance. The 

following 2 explanations also appear in 

Addendum A of this rule: 

• An ‘‘NA’’ in the ‘‘Non-facility PE 

RVUs’’ column of Addendum B means 

that CMS has not developed a PE RVU 

in the nonfacility setting for the service 

because it is typically performed in the 

hospital (that is, for example, an open 

heart surgery is generally performed in 

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the hospital setting and not a 

physician’s office). 

• Services that have an ‘‘NA’’ in the 

‘‘Facility PE RVUs’’ column of 

Addendum B are typically not paid 

using the PFS when provided in a 

facility setting. These services (which 

include ‘‘incident to’’ services and the 

technical portion of a diagnostic tests) 

are generally paid under either the 

outpatient hospital prospective payment 

system or bundled into the hospital 

inpatient prospective payment system 

payment. 

Comment: Other commenters, 

including specialty organizations, 

device manufacturers and physicians, 

noted that CMS had either mistakenly 

removed PE RVUs in the nonfacility 

setting or that we had made a decision 

to stop paying for services where, in 

Addendum B, an ‘‘NA’’ appeared in the 

proposed rule in the PE RVUs 

nonfacility column. Another commenter 

believes that a series of codes for E/M 

services were incorrectly marked as 

‘‘NA’’ in the facility setting. These 

commenters requested that the PE RVUs 

be restored to these codes. 

Response: We apologize to those 

commenters who found that where, due 

to the use of a new PE methodology, 

some of the codes listed in Addendum 

B of the proposed rule were mistakenly 

marked with an ‘‘NA’’ in either the 

nonfacility or facility PE RVU column 

when the service is actually valued in 

this setting and PE RVUs were listed 

previously. These mistakes were 

corrected for Addendum B in this final 

rule with comment. Most of the 

commenters requesting the restoration 

of ‘‘missing’’ PE RVUs in the nonfacility 

setting, though, were mistaken because, 

in fact, we have not developed 

nonfacility PE RVUs for these services 

and Addendum B continues to properly 

reflect the ‘‘NA’’ for the nonfacility PE 

RVU column. 

Comment: Several commenters asked 

us to create PE RVUs for their services 

by cross-walking the direct inputs from 

other services. 

Response: All of the requests we 

received to establish PE RVUs in the 

nonfacility setting were for services that 

the PEAC/RUC had either refined or 

developed without recommendations 

for PE nonfacility inputs. We would like 

to remind the specialty organizations 

that the RUC has a long standing 

process for the establishment and 

refinement of PE inputs and encourage 

all organizations to follow this process. 

Comment: A manufacturer requested 

that we add 15 minutes of clinical labor 

and a tilt table to the PE database for 

CPT codes 36475 and 36476—both new 

codes for CPT 2005. 

Response: We agree that the tilt table, 

for Trendelenberg, is needed for these 

procedures and are adding this 

equipment, for the respective service 

period minutes for each code. However, 

the commenter’s request for additional 

clinical labor is not timely because the 

RVUs for these new codes were 

published as interim in the CY 2005 

PFS final rule with comment at that 

time. As stated in the response above, 

we remind commenters to observe and 

utilize the comment period for new and 

revised codes at the time they are issued 

in our final rule or utilize the 

established RUC process, as appropriate. 

Comment: We received a comment 

from an organization representing 

radiation oncology informing us that 

equipment for CPT codes 77333 and 

77470 was missing. 

Response: For CPT 77470, we disagree 

with the commenter that this service 

should be assigned equipment. At the 

January 2004 PEAC meeting, this code 

was valued specifically to compensate 

for the clinical labor costs involved with 

certain high-intensity radiation 

procedures, such as combined 

chemotherapy and radiation treatment. 

CPT 77470 was valued to be billed once 

throughout the course of treatment, that 

is typically comprised of 25 fractions. 

On the other hand, we agree with the 

commenter that the lack of equipment 

for CPT codes 77333 and CPT 77332 

appears to be an oversight. We believe 

that the PEAC, at their September 2002 

meeting, when considering equipment 

inputs for CPT code 77334, intended to 

cross-walk this equipment to the other 

2 codes in the family, CPT code 77332 

and 77333. Therefore, we are adding 

this equipment to 77332 and 77333, on 

an interim basis, and have changed the 

PE database to reflect this addition for 

the correlating service period time for 

each service. However, as explained 

above, because these codes will be 

valued in the NPWP and the 2005 PE 

RVUs will be retained in 2006, this 

addition will be transparent until such 

time as the direct inputs are used to 

establish the PE RVUs for the NPWP 

services. 

Comment: We received comments 

from several organizations, a specialty 

society, device manufacturers, IDTFs 

and physicians regarding concerns 

about the remote cardiac event 

monitoring services, including CPT 

codes 93012, 93226, 93232, 93271, 

93733 and 93736, based on the 

significant reduction in PE RVUs for 

these services published in our 

proposed rule using the bottom-up 

methodology and the elimination of the 

NPWP. Two of these services, CPT 

codes 93012 and 90271, were reviewed 

by the RUC in April 2005 and forwarded 

as part of the PERC/RUC 

recommendations in the proposed rule. 

The commenters noted that these 

services are typically provided by IDTFs 

that are equipped for continuous 

monitoring capabilities 24 hours a day, 

7 days a week and require highly 

trained staff to perform the monitoring 

of transmissions. The commenters all 

agreed that the uniqueness of these 

services makes a poor fit with the usual 

accounting for direct practice expenses 

in the physician office. A specialty 

society requested CMS to work with the 

involved provider community, that is, 

the specialty IDTFs, to ensure that the 

direct and indirect costs of providing 

these services are adequately reflected 

in the nonfacility PE RVUs. 

Response: We are pleased that the 

commenters are in agreement that these 

cardiac event monitoring services may 

not fit the usual PE model. We are also 

happy that the specialty society has 

requested our assistance to work with 

the specialized provider community in 

order to ensure more appropriate PE 

inputs for these services. We look 

forward to working with the provider 

organizations before the issuance of our 

next proposed rule. 

Comment: A manufacturer requested 

that we increase the work and PE values 

for G0166, external counterpulsation 

(ECP), because of the significant 

decrease in PE RVUs for the nonfacility 

setting in the proposed rule. 

Specifically, the commenter asked that 

the labor time be increased to include 

pre and post service time in addition to 

the 60 minutes allotted for actual ECP 

treatment time. 

Response: We agree with the 

commenter that the 60 minutes is 

inadequate to account for the other 

activities that the RN performs in 

relationship to each ECP service. We 

have assigned some of the standardized 

times for the activities previously 

identified by the PEAC as appropriate to 

this service, as follows: 3 minutes for 

meet and greet; 2 minutes to prepare the 

room; 2 minutes to position the patient; 

3 minutes for vitals; and 3 minutes for 

cleaning the room. This extra 13 

minutes has been added to the service 

period in the PE database yielding a 

total of 73 minutes for the ECP service—

although, as discussed previously, this 

increase will not take effect in 2006 

because, with limited exceptions, we 

will retain the 2005 PE RVU values for 

existing codes. 

Comment: Many commenters, 

including physicians and a device 

manufacturer, requested that we 

increase labor, supplies, and equipment 

PE values for CPT code 93701, thoracic 

70150 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

electrical bioimpedance (TEB). Their 

concerns arose from the proposed 

reduction in PE RVUs in the proposed 

rule for this service. Some of the 

commenters told us that the average cost 

of the equipment from one manufacturer 

is $38,000, the electrodes are 10.95 

($8.95 with discount) and that the labor 

time for the TEB procedure ranges from 

15–20 minutes. The commenters 

requested that we adjust the PE values 

accordingly. 

Response: We are sympathetic to the 

commenters concerns regarding the 

decrease in PE RVUs reflected in the 

proposed rule that reflected both the 

elimination of the NPWP and the 

bottom-up methodology. For the labor 

time request, the PE database does 

contain 20 minutes, although this time 

was incorrectly cross-walked to the 

equipment time. We apologize to the 

commenters regarding this error, and 

have changed the equipment time to 20 

minutes, from 10, in the database. We 

disagree with the commenters about the 

inaccuracy of the equipment cost. 

During the rulemaking process for the 

CY 2005 fee schedule, at which time we 

revalued all equipment in the PE 

database, we identified 2 different 

brands of equipment used for the TEB 

service. When the 2 prices are averaged 

(using $38,000 as noted above by the 

commenters), the cost of the TEB 

equipment is $28,625 which is the price 

listed in the database. We also repriced 

our supply database during rulemaking 

for the 2004 fee schedule. The TEB 

electrodes or sensors are listed at $9.95 

in the database and that amount is based 

solely on a phone quote from the 

commenting manufacturer. TEB sensors 

from the other equipment manufacturer 

range from $4.43 to $6.00 for each 

patient application. Based on current 

valuation of the supplies and equipment 

in the PE database, we are not changing 

the price of equipment or supplies for 

the TEB service. 

m. Additional PE Issues Raised by 

Commenters 

Comment: We received 2 comments 

from specialty organizations requesting 

CMS to re-evaluate the lack of physician 

work value for the 3 G-codes (G0237, 

G0238, and G0239) CMS created to 

describe services to improve respiratory 

function to reflect the physician’s work 

in overseeing these incident to services. 

The commenters contend that the 

addition of CPT 99755, assistive 

technology assessment, in 2004 created 

a rank-order anomaly for the respiratory 

function G-codes. The commenters 

requested that CMS ask the RUC to 

evaluate the work for these G-codes. 

Response: We disagree with the 

commenter’s contention that a rank 

order anomaly exists between the 

respiratory function G-codes and CPT 

97755. We were clear when we created 

these codes during rulemaking for the 

2002 fee schedule that the G-codes 

would make billing of CPT codes 

97000–97799 inappropriate for 

professionals involved in treating 

respiratory conditions, unless these 

services are delivered by physical 

therapists (PTs) and occupational 

therapists (OTs) and meet other 

requirements for physical and 

occupational therapy services. We also 

disagree that these services are always 

provided incident to a physician’s 

service because in the CORF setting, 

where respiratory therapy services are 

statutorily delineated as a CORF service, 

the physician’s direct supervision is not 

a requirement and the incident to 

provisions do not apply. The G-codes 

enable us to distinguish CORF 

respiratory therapy and incident to 

services from the services provided by 

PTs and OTs under the therapy benefit. 

Consequently, these G-codes cannot be 

used to bill for services provided under 

the physical and occupational benefit 

category at section 1861(P) of the Act 

and, as such, cannot create a rank order 

anomaly with the 97000 series of CPT 

codes. Although we have not assigned 

any work values for this final rule with 

comment, we are still considering the 

merits of this request and are happy to 

meet with the commenters prior to the 

issuance of our next proposed rule to 

discuss this issue in greater detail. We 

remind the specialty societies that they 

can make requests to the RUC to review 

the G-codes with respect to work values. 

However, we believe the appropriate 

review entity would be the HCPAC. 

Comment: Several commenters 

expressed their concern regarding the 

high-priced supply items in our practice 

expense database. In their comments, 

the RUC requested that we consider a 

different approach for payment of highpriced disposable medical supplies, 

particularly with respect to new 

technology supply items—where prices 

commonly decrease within 6–12 months 

after being distributed into a wider 

market—as these services move into the 

physician’s office. As an alternative, the 

RUC strongly encourages CMS to review 

and re-price medical supplies, priced at 

or above $200, on an annual basis. 

Another commenter noted that our 

listed price of $677 for the endovenous 

laser kit used for CPT 36478 is 

apparently in error because it is readily 

available at $250–$350 and listed four 

suppliers who distribute this supply in 

the noted price range. 

Response: We appreciate comments 

and remarks. The RUC’s comments 

regarding high cost medical supplies 

and the need to review these prices on 

a more frequent basis than every 5 years. 

Because we are committed to ensuring 

that the prices for supplies and 

equipment in the PE database are 

accurate, we also want to account in 

some way for the volatile nature of 

prices for new technology. We will 

consider options for revaluing these 

high cost ‘‘new tech’’ supply items and 

include a discussion of this issue in the 

next proposed rule 

Comment: We received a comment 

from an organization representing 

services of audiologists noting that the 

salary for audiologists and the 

equipment for their services are too low 

or out of date. 

Response: During the rulemaking 

process for the 2005 fee schedule, we 

revalued all equipment in the PE 

database, and requested specialty input 

at that time. To the extent that there 

have been changes since last year, we 

recommend that the organization utilize 

the establish RUC process. We would 

also encourage the commenter to supply 

us with updated salary information so 

that we may better address their other 

concern. 

Revisions to CPT Code Series 21076 

Through 21087 

We also want to note that, at the 

request of the RUC, we have been 

working directly with representatives of 

maxillofacial prosthetics to refine the PE 

inputs for the CPT code series 21076 

through 21087. They have submitted 

spreadsheets to us for labor, supplies 

and equipment, and much of this 

information has been entered in the PE 

database although, as discussed above, 

the 2005 PE RVUs will be retained for 

2006. We will continue to work with the 

specialty to refine these inputs, 

verifying prices and quantities, prior to 

the issuance of our next proposed rule. 

B. Geographic Practice Cost Indices 

(GPCIs) 

Section 1848(e)(1)(A) of the Act 

requires us to develop separate GPCIs to 

measure resource cost differences 

among localities compared to the 

national average for each of the three fee 

schedule components. While requiring 

that the PE and malpractice GPCIs 

reflect the full relative cost differences, 

section 1848(e)(1)(A)(iii) of the Act 

requires that the physician work GPCIs 

reflect only one-quarter of the relative 

cost differences compared to the 

national average. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70151 

As discussed in the August 8, 2005 

proposed rule (70 FR 45783), section 

1848(e)(1)(E) of the Act, as amended by 

section 412 of the MMA, established a 

floor of 1.0 for the work GPCI for any 

locality where the GPCI would 

otherwise fall below 1.0. This 1.0 work 

GPCI floor was used for purposes of 

payment for services furnished on or 

after January 1, 2004 and before January 

1, 2007. This 1.0 floor will remain in 

effect in 2006. 

Section 602 of the MMA added 

section 1848(e)(1)(G) of the Act, which 

sets a floor of 1.67 for the work, PE, and 

malpractice GPCIs for services furnished 

in Alaska between January 1, 2004 and 

December 31, 2005 for any locality 

where the GPCI would otherwise fall 

below 1.67. Effective January 1, 2006, 

this provision will end. In the proposed 

rule, we indicated the 2006 GPCIs for 

Alaska will be 1.017 for physician work, 

1.103 for PE, and 1.029 for malpractice. 

Payment Localities 

In the August 8, 2005 proposed rule 

(70 FR 45783), we stated that we look 

for the support of a State medical 

society as the impetus for changes to 

existing payment localities. Because the 

GPCIs for each locality are calculated 

using the average of the county-specific 

data from all of the counties in the 

locality, removing high-cost counties 

from a locality will result in lower 

GPCIs for the remaining counties. 

Because of this redistributive impact, 

we have refrained, in the past, from 

making changes to payment localities 

unless the State medical association 

provides evidence that any proposed 

change has Statewide support. 

After the publication of the CY 2005 

final rule, the California Medical 

Association (CMA) submitted a proposal 

for a demonstration project that was the 

same as its proposal submitted in 

response to the August 5, 2004 PFS 

proposed rule. The CMS proposed 

removing ten counties from the existing 

‘‘Rest of California’’ payment locality 

and creating ten new payment localities. 

Additionally, reductions to the 

payments to the Rest of California 

locality, would be balanced by payment 

contributions from the other payment 

localities in the State. 

There were several aspects of the 

proposal that made implementation 

problematic for us under our 

demonstration authority. For example, 

physicians whose payments would 

decrease under the demonstration could 

challenge the validity of a new locality 

configuration established without 

providing them the opportunity to 

comment through the regulatory process 

(as is our normal process for making 

locality changes). In particular, 

physicians who are not members of 

county medical societies or the CMA, or 

did not agree to participate in the 

proposed demonstration may have 

challenged its implementation. 

Also, the Medicare PFS currently uses 

identical GPCIs to pay for services 

provided in an area by both physicians 

and nonphysician providers (such as 

podiatrists, optometrists, physical 

therapists, and nurse practitioner). 

Changing the locality configuration for 

medical doctors and doctors of 

osteopathic medicine, but not for other 

professionals, would have some 

peculiar results that were not addressed 

in the CMA proposal. For example, in 

areas where the GPCIs would be 

reduced under the demonstration, some 

practitioners not participating under the 

demonstration (such as physical 

therapists) could be paid more than 

physicians in the same locality. 

Conversely, where the GPCIs would be 

increased under the demonstration, 

there would likely be complaints from 

the nonphysician practitioners not 

included in the demonstration. 

Nonetheless, we do recognize the 

potential impact of wide variations in 

the practice costs within a single 

payment locality. In the CY 2005 final 

rule, we noted that we received many 

comments from physicians and 

individuals in Santa Cruz County 

expressing the opinion that Santa Cruz 

County should be removed from the 

Rest of California payment locality and 

placed in its own payment locality. The 

county-specific GAF of Santa Cruz 

County is 10 percent higher than the 

Rest of California locality GAF. Santa 

Cruz County is adjacent to Santa Clara 

County and San Mateo County. Santa 

Clara and San Mateo Counties have two 

of the highest GAFs in the nation. The 

published 2006 GAF for the Rest of 

California payment locality is 24 

percent less than the GAFs of Santa 

Clara and San Mateo. 

Sonoma County is also part of the 

Rest of California payment locality. The 

county-specific GAF of Sonoma County 

is 8 percent higher than the Rest of 

California locality GAF. Sonoma County 

is bordered by Marin County and Napa 

County. Using published 2006 values, 

the payment locality that includes 

Marin and Napa counties has the fourth 

highest GAF in the nation, and is 13 

percent higher than the GAF of the Rest 

of California payment locality. 

We recognize that changing 

demographics over time may lead to 

significant payment disparities in 

particular circumstances. We rely upon 

State medical societies to identify and 

propose consensus approaches to 

resolving these disparities, because 

there are redistributive impacts in the 

‘‘budget neutral’’ process within a State 

when new localities are created (or 

existing ones reconfigured). Yet we also 

recognize our responsibility for 

establishing fee schedule areas. In the 

proposed rule, to assure the maximum 

opportunity for public discussion and 

comment to identify a consensus 

approach, we listed alternative locality 

configurations that we had examined, 

including: 

• The CMA demonstration approach 

comparing county-specific GAFs to the 

payment locality GAF, and designating 

any county with a county-specific GAF 

at least 5 percent higher than its locality 

GAF as a new locality; 

• An approach that sorts counties by 

descending GAFs and compares the 

highest county to the second highest 

county. If the difference between these 

two counties is 5 percent or less, they 

are included in the same locality. The 

third highest county GAF is then 

compared to the highest county GAF 

and so on, until the next county GAF is 

not within 5 percent of the highest 

county GAF. At that point, the county 

GAF that is more than 5 percent lower 

than the highest county GAF becomes 

the comparison for the next lowest 

county GAF, to create a second locality. 

This process is repeated down 

throughout all of the counties; 

• An approach that compares the 

county with the highest GAF to the 

Statewide average, removing counties 

that are 5 percent or more than the 

Statewide average; and 

• An approach that bases GPCI 

payment localities on Metropolitan 

Statistical Areas as defined by the Office 

of Management and Budget. 

However, because these 

reconfigurations would result in 

significant redistributions across most 

California counties, we simply proposed 

the approach that would have the least 

impact on other counties. We proposed 

that Santa Cruz and Sonoma Counties 

(the two counties with the most 

significant disparity between the 

assigned Rest of California GAF and the 

county-specific GAF) be removed from 

the Rest of California payment locality 

and that each would be its own payment 

locality. We invited and received 

comments regarding this proposal and 

possible alternative approaches to 

address this issue. We were particularly 

interested in whether the CMA 

supported this approach. Those 

comments and our responses are 

discussed below. 

The issue of payment locality 

designation in light of changing 

economic and population trends will be 

70152 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

of importance to us for the foreseeable 

future. We also indicated in the 

proposed rule that we are interested in 

other solutions to the problem, and with 

any ideas or suggestions that will help 

resolve the problems associated with the 

designation and revision of payment 

localities. We would use those ideas and 

suggestions in developing any future 

proposal that would be subject to 

comment through the rulemaking 

process. 

Comment: Numerous comments from 

the beneficiaries and health care 

providers in Santa Cruz and Sonoma 

Counties, and from several members of 

the Congress, including a U.S. Senator 

from California, supported our proposed 

change. These comments focused on the 

high costs of practicing in Santa Cruz 

and Sonoma Counties and were 

appreciative of the proposal. Most 

supporters referred to studies that have 

shown the high costs of working in 

Santa Cruz and Sonoma Counties have 

resulted in physicians restricting their 

practices or withdrawing from practice 

altogether. According to the 

commenters, this has made it more 

difficult for Medicare beneficiaries to 

find doctors in those counties. These 

commenters feel that our proposed 

change will encourage physicians to 

continue to treat Medicare patients in 

their Santa Cruz and Sonoma County 

practices. 

Response: These two counties 

currently have the most significant 

disparities between their present GAFs 

and their county-specific GAFs. They 

are also bordered by counties with 

significantly higher GAFs. As we stated 

earlier in this section and in the 

proposed rule, we have received many 

comments in the past expressing 

concern that these disparities have led 

some practitioners to relocate their 

practices out of these counties, creating 

potential access problems. 

The proposal was an attempt to 

balance the interests of physicians and 

nonphysician practitioners and their 

patients in Santa Cruz and Sonoma 

Counties with the interests of providers 

and patients in the other counties in the 

Rest of California. We noted in the 

proposed rule that the 2006 Rest of 

California GAF would be 1.011, 

compared to the 2005 GAF of 1.012. 

Absent this proposal, the 2006 Rest of 

California GAF would be 1.017 (2006 is 

the second year of the transition to the 

new GPCIs and GAFs incorporating 

updated data). 

Comment: We also received 

comments opposing the proposal from 

numerous providers and medical 

associations in the current Rest of 

California payment locality. In addition, 

several members of the Congress wrote 

letters opposing the proposed change. 

The CMA pointed to the fact, which 

is the result of the budget neutrality 

requirement for administrative actions 

to modify GPCIs, that the Rest of 

California locality would be negatively 

impacted. The CMA also notes that the 

proposal does not address the other 

localities it identified in its 

demonstration proposal. These views 

were echoed by the other commenters 

objecting to the proposal. 

Response: It is indicative of the 

difficult nature of this issue that many 

of the same commenters who expressed 

disappointment that our proposal did 

not address all of the other counties that 

CMA identified in its demonstration 

proposal were also concerned that the 

proposal would simultaneously result in 

a reduction of the GPCIs for the Rest of 

California payment locality. Under our 

current statutory authority, it is well 

known that changes to the payment 

localities must be implemented in a 

budget neutral manner. Therefore, it is 

not possible to fully meet both 

objectives without legislation to provide 

additional funding for physician 

payments in California. 

While we appreciate the situation of 

practitioners in Santa Cruz and Sonoma 

Counties as described above, we also 

acknowledge the concerns of those in 

the Rest of California payment locality 

about the negative payment impact of 

removing the GPCI data for Santa Cruz 

and Sonoma Counties, and the lack of 

support from the CMA for an 

administrative solution to these 

payment concerns. As we mentioned 

earlier in this section, our proposal was 

designed to balance these two interests. 

As we have stated repeatedly in the 

past, we believe payment locality 

reconfigurations should be supported 

broadly across the State. It was our 

belief that the proposal we presented, 

which actually would have had the 

smallest possible negative impact on the 

Rest of California’s GAF, might meet 

that criterion. However, based on the 

comments we received opposing the 

proposal, particularly those from the 

CMA, it is apparent that this proposed 

change is not acceptable to the majority 

of commenters at this time. 

Comment: The CMA indicated that it 

supports a nationwide legislative 

solution that would provide additional 

funding for physicians in counties 

adversely affected by locality 

reconfigurations. The CMA states ‘‘this 

is the only GPCI solution that we are 

supporting at this time.’’

The Medicare Payment Advisory 

Commission (MedPAC) comments that 

the locality boundaries have not had a 

complete review since 1997 and that 

economic and population trends are 

likely to have changed since that time. 

MedPAC is studying these issues, and 

encourages CMS to do so as well, with 

the goal of revisiting the boundaries of 

all payment localities nationwide. 

We also received a comment from a 

member of the Congress urging us to 

conduct a national examination of the 

definitions of payment localities. The 

commenter recommended that we 

propose a method to reconfigure 

payment localities to be effective 

January 1, 2008. The commenter also 

recommended that we develop a process 

for periodically reviewing payment 

localities. 

Response: As we stated earlier in this 

section and in the proposed rule, we are 

interested in all ideas that will help 

resolve the problems associated with the 

designation and revision of payment 

localities. Clearly, as illustrated by the 

situation discussed earlier in this 

section, one of the most significant 

issues to be addressed is the 

redistributive nature of changes to the 

payment localities in a budget neutral 

context. 

There are currently 89 separate 

payment localities. Of these, 34 are 

Statewide localities. Our last 

comprehensive evaluation of the 

definition and composition of the 

payment localities was discussed in the 

July 2, 1996 proposed rule (61 FR 

34615) and the November 22, 1996 final 

rule (61 FR 59494). The localities 

existing at that time, which were 

developed by the local Medicare 

contractors, served as building blocks 

for the current localities (at the time, 

there were 210 separate localities, 22 of 

them were Statewide localities). 

We stated at the time that our major 

goals were to simplify payment areas 

and payment differences among 

adjacent geographic areas while 

maintaining accuracy in tracking input 

price differences among areas. There is 

an inherent trade-off between these two 

goals. Thus, at one extreme is a set of 

Statewide localities with no intra-state 

geographic adjustments; very simple, 

but less descriptive of input price 

differences. At the other extreme is a 

separate locality for each county; 

maximum input price adjustment for 

geographic variation, but operationally 

very cumbersome, expensive to develop 

and maintain, and potentially very 

confusing for providers. 

We do not disagree with the view that 

a comprehensive evaluation of the 

current payment localities is due, and 

we look forward to working 

cooperatively with MedPAC in that 

regard. We are examining all viable 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70153 

options that will meet the general 

objectives discussed above. We would 

note, however, that our goals for this 

analysis are very similar to those we 

expressed in 1996. 

Comment: A private insurer is 

opposed to our proposal because it 

increases the number of payment 

localities which increases commercial 

payer administrative costs. The insurer 

suggests we reduce the number of 

California payment localities from 10 to 

3. 

Response: While we appreciate and, 

as a matter of general policy, agree that 

it would be preferable to minimize the 

number of separate payment localities 

wherever possible, we do not believe 

that reducing the number of payment 

localities would resolve the issues 

discussed above. 

Comment: We received comments 

from a medical clinic in Wisconsin and 

a research and management 

organization in Colorado. These 

commenters stated that CMS is using 

improper data to create the GPCIs. The 

commenters suggest we change the wage 

proxy categories to include physicians 

and remove physician work from the 

GPCI calculation. They further state that 

‘‘Medicare payments are a primary 

stimulus in attracting greater numbers of 

physicians to high payment localities’’. 

The commenters also suggest we look 

for alternative data sources for rent data. 

Response: The CY 2005 final rule 

contained responses to commenters 

raising the same issues related to the 

data used to calculate the GPCIs as those 

noted above (69 FR 66260). Because the 

data used to calculate the GPCIs was not 

part of the proposed rule, we refer the 

commenter to that document rather than 

repeat that discussion here. We also 

note that we continue to evaluate other 

potential sources of data to use to 

calculate the GPCIs. 

We are disappointed that there was 

limited support for the proposal to 

create new, separate payment localities 

for Santa Cruz and Sonoma Counties. As 

we noted above, the proposal was 

designed to balance concerns of 

practitioners in higher-cost Santa Cruz 

and Sonoma Counties with the concerns 

of those in the Rest of California 

payment locality about the negative 

payment impact resulting from removal 

of the GPCI data for Santa Cruz and 

Sonoma counties from the Rest of 

California GPCI calculation. Because of 

the nearly complete lack of support for 

this proposal outside the two positively 

impacted counties, we have decided to 

withdraw this proposal at this time. As 

noted above, we intend to work with 

MedPAC and other interested parties 

toward a more comprehensive 

evaluation of potential refinements of 

the payment localities. 

Under section 1848(e)(1)(E) of the Act, 

the floor of 1.67 for the work, PE, and 

malpractice GPCIs for services furnished 

in Alaska ends as of January 1, 2006. 

Therefore, as of that date, the GPCIs for 

Alaska will be 1.017 for physician work, 

1.103 for PE, and 1.029 for malpractice 

costs. 

C. Malpractice Relative Value Units 

(RVUs) 

We discussed several proposed 

technical changes and other issues 

related to the calculation of the 

malpractice RVUs in the proposed rule. 

These are summarized below, along 

with discussions of the comments we 

received and our responses. 

1. Five Percent Specialty Threshold 

We are concerned that the malpractice 

RVUs could be inappropriately inflated 

or deflated due to irregular data based 

upon incorrectly reported specialty 

classifications and have examined the 

impact of establishing a minimum 

percentage threshold for any procedure 

performed by any specialty before the 

risk factor of that specialty is included 

in the malpractice RVU calculation of a 

particular code. We proposed excluding 

data for any specialty that performs less 

than 5 percent of a particular service or 

procedure from the malpractice RVU 

calculation for that service or procedure 

and discussed the code-specific impact 

of implementing this proposed 

threshold. Our assumption was that the 

infrequent instances of these specialties 

in our data represent aberrant 

occurrences and removing the 

associated risk factor from the 

malpractice RVU calculation would 

improve the accuracy and stability of 

the RVUs. This was based on our belief 

that removing data attributable to 

specialties that occur in our data less 

than 5 percent of the time would most 

appropriately balance the objective to 

identify irregular data (claims with a 

specialty identified that is highly 

unlikely to have performed a particular 

procedure) while including specialties 

that perform a procedure a small 

percentage (but at least 5 percent)of the 

time. 

We excluded evaluation and 

management (E&M) services from the 

analysis. Medicare claims data show 

that E&M services are performed by 

virtually all physician specialties. 

Therefore, in the case of E&M codes, it 

is likely that even the low relative 

percentages of performance by some 

specialties would accurately represent 

the provision of the service by those 

specialties. 

For all services other than E&M 

services, we stated our belief that 

removing data attributable to specialties 

that occur in our data less than 5 

percent of the time would most 

appropriately balance the objective to 

identify irregular data (claims with a 

specialty identified that is highly 

unlikely to have performed a particular 

procedure) while including specialties 

that perform a procedure a small 

percentage of the time. The higher the 

threshold, the more likely it would 

result in the removal of data for 

specialties actually performing the 

procedure, while a lower threshold 

would be more likely to fail to remove 

some irregular data, particularly for lowvolume codes (fewer than 100 

occurrences, where each claim 

represents 1 or more percentage points). 

The overall impact of removing the 

risk factor for specialties that occur less 

than 5 percent of the time in our data 

for a procedure is minimal. There is no 

impact on the malpractice RVUs for 

over 5,280 codes, and there is an impact 

of less than 1 percent on the malpractice 

RVUs for over 1,300 additional codes. 

Only 16 codes decrease by at least 0.1 

RVUs, with the biggest decrease being a 

negative 0.28 impact on the malpractice 

RVU for CPT code 17108, Destruction of 

skin lesions, from a current RVU of 0.82 

to a proposed RVU of 0.54. 

Conversely, there are 219 codes for 

which RVUs increase by at least 0.1, the 

largest increase being a positive 0.81 

RVU increase for CPT code 61583, 

Craniofacial approach, skull, from a 

current RVU of 8.32 to a proposed RVU 

of 9.13. Among codes whose 

malpractice RVUs would increase under 

our proposal, 646 have increases of less 

than 1 percent. The impact analysis 

section of this proposed rule examines 

the effects of this proposed change by 

specialty. 

Comment: Numerous commenters 

supported the 5 percent specialty 

threshold. Several commenters 

suggested that we apply the threshold to 

the E&M codes. 

Response: We appreciate the 

commenters’ support of this change to 

our methodology. Regarding the 

exclusion of E&M codes from our 

analysis, we note our rationale as stated 

above in this section. The comments we 

received did not address our concern 

that all specialties use these codes. 

Therefore, we still believe it is 

appropriate not to apply the 5 percent 

specialty threshold to the E&M codes. 

Comment: We received a comment 

recommending the threshold be lowered 

to 1 percent. The commenter is 

concerned that a 5 percent threshold 

inappropriately removes some 

70154 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

specialties actually performing 

interventional radiology services. The 

example of CPT code 35476 

(percutaneous venous angioplasty) was 

provided. The commenter noted that 

CMS’s proposed 5 percent threshold 

removed the risk factors for general 

surgeons and vascular surgeons, 

resulting in a decrease in the 

malpractice RVUs for this code. The 

commenter states this was contrary to 

our objective to remove irregular data 

because both of these specialties 

actually perform this procedure, and 

that a 1 percent threshold would better 

retain those specialties actually 

providing the service while still 

removing irregular data. 

Response: In the case of CPT code 

35476, the risk factors for the two 

specialties that were removed resulted 

in a decrease in the RVUs for this code; 

however, we review these data on a 

regular basis and if, in the future, the 

data support it, we will change the 

RVUs accordingly. We note that the 

majority of commenters supported a 5 

percent threshold as reasonable. We do 

not believe a 1 percent threshold, as 

suggested by the commenter, is 

reasonable as this threshold would not 

be an effective screen for claims with a 

specialty identified that is highly 

unlikely to have performed a particular 

procedure. However, we will continue 

to assess whether a different threshold 

may ensure irregular data are removed 

without also removing data for 

specialties that actually perform the 

service. 

2. Specialty Crosswalk Issues 

Malpractice insurers generally use 

five-digit codes developed by the 

Insurance Services Office (ISO), an 

advisory body serving property and 

casualty insurers, to classify physician 

specialties into different risk classes for 

premium rating purposes. ISO codes 

classify physicians not only by 

specialty, but in many cases also by 

whether or not the specialty performs 

surgical procedures. A given specialty 

could thus have two ISO codes, one for 

use in rating a member of that specialty 

who performs surgical procedures and 

another for rating a member who does 

not perform surgery. 

Medicare uses its own system of 

specialty classification for payment and 

data purposes. Therefore, to calculate 

the malpractice RVUs, it was necessary 

to map Medicare specialties to ISO 

codes and insurer risk classes, and in 

some instances to crosswalk unassigned 

specialties to the most approximate 

existing ISO codes and risk classes. 

We stated in the CY 2005 final rule 

that we would continue to work with 

the AMA RUC’s Professional Liability 

Insurance (PLI) Workgroup to address 

any potential inconsistencies that may 

still exist in our methodology. Based 

upon this commitment, the RUC PLI 

Workgroup forwarded various 

recommendations for our consideration. 

The RUC developed its 

recommendations based upon 

comments submitted to them by 

physician specialty organizations. 

As discussed in the August 8, 2005 

proposed rule, the Workgroup believes 

the risk factors assigned to certain 

professions overestimate the insurance 

premiums for these professions and, 

based on its recommendations, we 

proposed revising the risk factor for the 

following specialties to a risk factor of 

1.00: clinical psychology; licensed 

clinical social work; psychology; 

occupational therapy; opticians and 

optometrists; chiropractic and physical 

therapy. We invited comment from 

representatives of the affected 

specialties and others regarding the 

appropriateness of this proposal, as well 

as other specialty crosswalks and 

suggestions for reliable sources of actual 

malpractice premium data for 

nonphysician groups. 

The RUC PLI Workgroup also 

believed that a number of professions 

that were assigned to the average for all 

physicians risk factor should be 

removed from the calculation of 

malpractice RVUs altogether and 

recommended excluding data from the 

following professions: Certified clinical 

nurse specialist; clinical laboratory; 

multispecialty clinic or group practice; 

nurse practitioner; physician assistant; 

and physiological laboratory 

(independent). We agreed with this 

recommendation and proposed to 

establish malpractice RVUs based upon 

the mix of specialties exclusive of the 

above specialties and professions. 

The PLI Workgroup also made 

recommendations for changing the 

crosswalks for risk factors for the 

following specialties which we did not 

accept: Certified registered nurse 

anesthetists; colorectal surgeons; 

gynecologists; and oncologists. We did 

not propose changes to the current 

crosswalks for these specialties and 

professions because we believe the 

current crosswalks we are using for 

these specialties appropriately reflect 

the types of services they provide. 

Comment: One commenter objected to 

our proposed change in the crosswalk to 

the lowest current risk factor of 1.00 for 

opticians and optometrists. The 

commenter stated that the 

recommendation from the RUC was not 

based on examination of the premium 

data or any other objective evidence. 

However, another commenter supported 

the proposal to crosswalk optometrists 

and opticians to the lowest current risk 

factor of 1.00, arguing this more 

appropriately reflects the actual level of 

risk assumed during the performance of 

procedures. 

A commenter objected to the 

proposed crosswalk change to 1.00 for 

clinical psychologists, licensed clinical 

social workers, and psychologists 

because the commenter believes that the 

malpractice insurance costs for these 

nonphysician practitioners are well 

below those paid by psychiatrists. 

Response: The proposed changes to 

the risk adjustment factor crosswalks 

were based on our agreement with the 

RUC PLI Workgroup’s assertion that 

these nonphysician professionals incur 

costs most similar to the lowest cost 

physician specialty. Because we do not 

have actual premium data for these 

professional groups, it is necessary to 

select an appropriate crosswalk 

category. We proposed to change the 

crosswalks for these specialties because, 

absent actual premium data, we agree 

with the RUC that these groups very 

likely do not incur malpractice costs on 

par with the average physician 

specialty. 

In its comments, the RUC points out 

that each of the professions for which 

we proposed to change the malpractice 

crosswalk is represented on the RUC’s 

Health Care Professional Advisory 

Committee (HCPAC). The HCPAC 

agreed that these professions should 

review their premium data and report 

back to the HCPAC at its September 29, 

2005 meeting. Subsequently, on October 

6, 2005 (after the close of the public 

comment period), the RUC submitted 

the results of these reviews. 

The RUC submitted to us after the 

close of the public comment period 

malpractice insurance premium data 

from many of these nonphysician 

professional groups. Because these data 

were received after the close of the 

comment period, and we believe it is 

important to allow the affected 

specialties the opportunity to comment 

on changes to the crosswalks, we are not 

incorporating these data in this final 

rule with comment. However, we would 

note that the data suggest that the 

annual premiums paid by these groups 

are below the average amounts paid by 

allergists and immunologists, the lowest 

premium cost physician specialties. 

We plan to continue to examine this 

issue in conjunction with the RUC’s PLI 

Workgroup before the 2007 proposed 

rule. Based on the fact that commenters 

did not provide any alternative data to 

suggest the crosswalks we proposed 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70155 

were inappropriate, we will adopt our 

proposals for 2006 without change. 

Comment: One commenter supported 

our proposal to change the crosswalk for 

services of occupational therapists to 

1.00, but suggests that the crosswalk 

should not be to allergy and 

immunology. Instead, the commenter 

recommended a crosswalk to physical 

medicine and rehabilitation. 

Response: We appreciate the 

commenter’s support of our proposal. 

With regard to the commenter’s 

recommendation to crosswalk to the 

specialty of physical medicine and 

rehabilitation, we would note that the 

risk factor for this specialty is 1.26 

rather than 1.00. As noted above, 

because the comments we received did 

not contain any alternative data to 

suggest the crosswalks we proposed 

were inappropriate, we are adopting our 

proposals for 2006. 

Comment: Several commenters urged 

us to reconsider our proposal to not 

accept the RUC PLI’s recommendations 

to crosswalk: the specialty of 

gynecologist/oncologist to surgical 

oncology; certified registered nurse 

anesthetists (CRNAs) to anesthesiology; 

and, colorectal surgery to general 

surgery. 

Commenters also suggested separate 

surgical and nonsurgical risk factors for 

urology, and that hand surgery be 

crosswalked to orthopedic surgery 

(without spine). 

Response: With respect to the 

commenters’ recommendation to 

crosswalk gynecologist/oncologist to 

surgical oncology, the commenters did 

not substantially justify the argument 

that the professional liability premiums 

of the specialty are similar to those of 

surgical oncologists; however, we will 

analyze the data for this suggestion for 

possible future consideration. 

Commenters noted that CRNAs are 

currently crosswalked to general 

surgery, which means that CRNAs have 

a higher risk factor than 

anesthesiologists. These commenters 

recommended that CRNAs be 

crosswalked to anesthesiology and we 

accept this recommendation. 

For the request to crosswalk colorectal 

surgery to general surgery, the specialty 

of colorectal surgery was not 

crosswalked. Instead, we used actual 

premium liability insurance data 

collected for this specialty. 

Consequently, we disagree that this 

specialty should be crosswalked to 

another specialty. As stated previously 

and in the proposed rule, we only 

crosswalked specialties for which no 

premium data were collected. 

With regard to the comments 

regarding separate surgical and 

nonsurgical risk factors for urology, we 

would be interested in further 

information regarding the 

appropriateness of this change. 

For the request to crosswalk hand 

surgery to orthopedic surgery, we note 

that, similar to colorectal surgery above, 

we used actual premium liability 

insurance data collected for this 

specialty. Consequently, we disagree 

that this specialty should be 

crosswalked to another specialty. 

Comment: The RUC supported our 

proposal to remove the risk adjustment 

data for the following professions and 

providers: certified clinical nurse 

specialist; clinical laboratory; 

multispecialty clinic or group practice; 

nurse practitioners, physician assistants; 

and physiological laboratory 

(independent). 

Response: We appreciate these 

supportive comments for this proposed 

change. 

3. Cardiac Catheterization and 

Angioplasty Exception 

In the November 2, 1999 final PFS 

rule (64 FR 59384), we applied surgical 

risk factors to the following cardiology 

catheterization and angioplasty codes: 

92980 to 92998 and 93501 to 93536. 

This exception was established because 

these procedures are quite invasive and 

more akin to surgical than nonsurgical 

procedures. 

In the CY 2005 (69 FR 66275), we 

discussed changes to the list of codes 

that would fall under the exception. In 

response to a request from the RUC’s 

PLI Workgroup, we proposed to add the 

following CPT codes to the existing list 

of codes under the exception: 92975; 

92980 to 92998; and 93617 to 93641. 

Comment: Several commenters 

supported the changes made for the 

cardiac catheterization and angioplasty 

exception. 

Response: We appreciate the 

supportive comments for this proposed 

change. 

4. Dominant Specialty for Low-Volume 

Codes 

The final recommendation from the 

PLI Workgroup was to use the dominant 

specialty approach for services or 

procedures with fewer than 100 

occurrences, and to apply this approach 

to the list of 1,844 services supplied by 

the workgroup. The PLI Workgroup 

worked in conjunction with various 

specialty organizations to identify the 

dominant specialty that performs each 

service. 

We did not propose to adopt this 

methodology and noted that low volume 

procedures or services are not 

necessarily performed by only one 

specialty. As noted previously, we 

would distinguish between excluding 

data presumed to be erroneous from 

data reflecting utilization by specialties 

that perform a service but are not the 

dominant specialty. However, we 

acknowledge that there may be 

instances where irregular data exist that 

would not be identified and removed by 

our proposed 5 percent threshold 

discussed previously. We will continue 

to work with the RUC PLI Workgroup 

examine this issue in the future. 

Comment: Numerous commenters 

opposed our policy to use actual 

specialty data rather than dominant 

specialties and suggested that we adopt 

the RUC recommendations. 

Response: As we stated in the PFS 

proposed rule (70 FR 45786), we believe 

that basing payment on all specialties 

that perform a particular service ensures 

that the actual professional liability 

insurance costs of all specialties are 

included in the calculation of the 

malpractice RVUs. Therefore, we do not 

believe it would be appropriate, even for 

these low-volume services, to include 

only the dominant specialty if other 

specialties regularly provide the service. 

5. Collection of Premium Data 

Although this issue was not part of 

the proposed rule, many commenters 

suggested that we use alternative 

sources for our premium data. 

Comment: Some commenters 

suggested we used data supplied by the 

Physicians Insurers Association of 

America (PIAA) or directly from 

physician providers. 

Response: We are currently 

investigating the usefulness of the PIAA 

data and once our evaluation of the data 

is complete we will make a decision. 

We are not considering using physician 

provider self-reported premium costs. 

Final Decision 

We are implementing the proposed 5 

percent threshold and specialty 

crosswalk changes discussed in the 

proposed rule. After considering all of 

the other comments received, we are not 

making other changes to the calculation 

of the malpractice RVUs. 

D. Medicare Telehealth Services 

1. Requests for Adding Services to the 

List of Medicare Telehealth Services 

As discussed in the August 8, 2005 

PFS proposed rule (70 FR 45786), 

section 1834(m) of the Act defines 

telehealth services as professional 

consultations, office and other 

outpatient visits, and office psychiatry 

services identified as of July 1, 2000 by 

CPT codes 99241 through 99275, 99201 

70156 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

through 99215, 90804 through 90809, 

and 90862. In addition, the statute 

requires us to establish a process for 

adding services to or deleting services 

from the list of telehealth services on an 

annual basis. 

In the December 31, 2002 Federal 

Register (67 FR 79988), we established 

a process for adding or deleting services 

to the list of Medicare telehealth 

services. This process provides the 

public an ongoing opportunity to submit 

requests for adding services. We assign 

any request to make additions to the list 

of Medicare telehealth services to one of 

the following categories: 

• Category #1: Services that are 

similar to office and other outpatient 

visits, consultations, and office 

psychiatry services. In reviewing these 

requests, we look for similarities 

between the proposed 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. 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 

use of a telecommunications system to 

deliver the service produces similar 

diagnostic findings or therapeutic 

interventions as compared with the 

face-to-face ‘‘hands on’’ delivery of the 

same service. Requestors should submit 

evidence showing that the use of a 

telecommunications system does not 

affect the diagnosis or treatment plan as 

compared to a face-to-face delivery of 

the requested service. 

Since establishing the process, we 

have added the psychiatric diagnostic 

interview examination and ESRD 

services with 2 to 3 visits per month and 

4 or more visits per month to the list of 

Medicare telehealth services (although 

we require at least one in-person visit a 

month by a physician, clinical nurse 

specialist, nurse practitioner, or 

physician assistant to examine the 

vascular access site). 

Requests for adding services to the list 

of Medicare telehealth services must be 

submitted and received no later than 

December 31st of each year to be 

considered for the next proposed rule. 

For example, requests submitted before 

the end of CY 2004 are considered for 

the CY 2006 proposed rule. For more 

information on submitting a request for 

an addition to the list of Medicare 

telehealth services, visit our web site at 

www.cms.hhs.gov/physicians/ 

telehealth. 

We received the following public 

requests for additional approved 

services in CY 2004: (1) Individual 

medical nutritional therapy (MNT) as 

described by HCPCS codes G0270, 

97802 and 97803; (2) group MNT 

(HCPCS codes G0271 and 97804); (3) 

individual diabetes outpatient selfmanagement training (DSMT) services 

(HCPCS code G0108); (4) Group DSMT 

(HCPCS code G0109); and (5) 

modification of the definition of an 

interactive telecommunications system 

for purposes of furnishing a telehealth 

service. 

After reviewing the public requests, 

we proposed to add individual MNT as 

represented by HCPCS codes G0270, 

97802 and 97803 to the list of Medicare 

telehealth services. We also proposed to 

add individual MNT to the list of 

Medicare telehealth services at § 410.78 

and § 414.65. Moreover, because a 

certified registered dietitian or other 

nutrition professional are the only 

practitioners permitted by law to 

furnish MNT, we proposed to revise 

§ 410.78 to add a registered dietitian and 

nutrition professional as defined in 

§ 410.134 to the list of practitioners who 

may furnish and receive payment for a 

telehealth service. 

We did not propose to add any 

additional services to the list of 

Medicare telehealth services or to make 

any changes to the definition of an 

interactive telecommunications system 

for CY 2006. 

For further information on our 

proposals, see the Federal Register 

dated August 8, 2005 (70 FR 45786). 

Individual MNT 

Comment: Many commenters 

supported our proposal to approve 

individual MNT for telehealth and to 

add a registered dietitian and nutrition 

professional to the list of practitioners 

authorized to furnish and receive 

payment for Medicare telehealth 

services. Commenters stated that adding 

MNT to the list of Medicare telehealth 

services would improve access and 

services for patients in remote areas 

where traditional MNT services may not 

be readily available. For example, a 

State dietetic association mentioned that 

in many cases, patients need to drive for 

more than an hour to receive MNT 

services and that the ability to furnish 

individual MNT as a telehealth service 

will provide great benefit to rural 

Medicare beneficiaries. Furthermore, a 

renal association stated that limited 

access to nutritional therapists is 

problematic for patients with stage 3 

and 4 kidney disease who are located in 

rural or isolated areas. The commenter 

explained that nutritional counseling is 

an important tool for helping 

beneficiaries improve their nutritional 

status and in controlling levels of key 

electrolytes such as potassium and 

phosphorous. Several MNT practices 

also urged us to adopt our proposal to 

approve individual MNT for telehealth. 

Another commenter supported the 

addition of individual MNT, however 

stated that more conclusive data 

regarding efficacy is needed before 

further expansion. 

Response: We agree with the 

commenters that approving individual 

MNT for telehealth would help provide 

greater access to registered dietitians 

and other nutritional professionals for 

beneficiaries in rural and or isolated 

areas. 

Comment: A few commenters believe 

that MNT should not be approved as a 

Medicare telehealth service. For 

instance, a certified diabetes educator 

(CDE) stated that it would be very 

difficult to accurately assess cognitive 

and literacy levels, emotional state and 

motivation without seeing the patient. 

The commenter also believes that faceto-face interaction for assessment, 

establishment of goals, and reviewing 

written materials is essential. The 

commenter expressed support for using 

telehealth to furnish MNT in very 

limited circumstances, for example if 

there was no access to an educator 

within 50 miles or if the patient was 

homebound. One commenter contends 

that it would be difficult to assess a 

patient’s understanding of the dietary 

prescription, nutrient content of each 

food group, portion control and 

information provided by food labels, 

especially for beneficiaries who cannot 

read and or have a vision impairment 

that prevents them from reading fine 

print. Moreover, another commenter 

believes that individual MNT includes 

skill-based training beyond an 

individual assessment, not unlike 

teaching insulin administration or blood 

glucose monitoring. The commenter 

stated that the skills taught in MNT 

cannot be verbally assessed through 

distance education. 

Response: As discussed in the 

proposed rule, we believe that 

individual MNT is similar in nature to 

an office or other outpatient visit (which 

is defined in the law as a Medicare 

telehealth service). We believe that the 

components of an E/M office visit 

involve a similar level of patient 

counseling for following a treatment 

plan as compared to individual MNT. 

We also believe that a registered 

dietitian at the distant site, along with 

an appropriate medical professional 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70157 

with the beneficiary at the originating 

site, could adequately assess and adjust 

to the beneficiary’s ability to understand 

and follow his or her nutritional plan. 

We do not agree with the commenter 

that the same level of physical, skillbased training that is required in an 

individual DSMT session, (for example, 

teaching a Medicare beneficiary the 

skills necessary for the self-injection of 

insulin), is a requirement for individual 

MNT. 

Comment: One commenter requested 

that we clarify whether we would pay 

a physician practice for individual MNT 

furnished as a telehealth service when 

a registered dietitian or other nutrition 

professional reassigns his or her right to 

bill for payment to the physician 

practice as an employer. 

Response: As discussed in the CMS 

claims processing manual (Pub. 100–04, 

chapter 1, section 30.2.6), if the 

employer/employee reassignment 

exception is met, and the person 

furnishing the service and the entity 

wishing to bill are both enrolled in 

Medicare and each have their own 

billing number, then we could make 

payment to the physician practice for 

the MNT service. 

Group Medical Nutritional Therapy 

(MNT) and Diabetes Self-Management 

Training Services (DSMT) 

Comment: Some commenters agreed 

with our proposal not to add DSMT to 

the list of Medicare telehealth services. 

For instance, one commenter wrote that 

DSMT can not be done as a telehealth 

service because in-person interaction 

with the client is crucial for assessing 

the skill development necessary for 

managing diabetes. Additionally, two 

certified diabetic educators (CDE) stated 

that DSMT can not be adequately 

furnished as a telehealth service and 

agreed with our proposal not to add 

DSMT to the list of Medicare telehealth 

services. Furthermore, another 

commenter stated that face-to-face 

interaction for assessment, 

establishment of goals, and reviewing 

written materials is essential for DSMT. 

Response: As discussed in the 

proposed rule, we believe that DSMT is 

not similar to the current list of 

Medicare telehealth services and 

requires conclusive evidence showing 

that the use of a telecommunications 

system is an adequate substitute for the 

in-person delivery of DSMT. 

Comment: A few commenters believe 

group MNT and group DSMT are similar 

in nature to the current list of Medicare 

telehealth services and therefore should 

be approved for telehealth under 

category 1 criteria. The commenters 

contend that the same presentation 

material, text books, manuals, DVD’s 

and on site support staff are used 

whether group DSMT or group MNT is 

furnished in-person or through an 

interactive audio and video 

telecommunications system. The 

commenters stated that the practitioner 

would conduct the same training 

session for a telehealth service as they 

would in-person, and they believe that 

the interactive differences between 

group MNT and group DSMT and the 

current Medicare telehealth services 

should not be used as a basis for 

denying these services. The commenters 

believe that the criteria for approving 

group MNT and group DSMT should be 

based on whether the use of a 

telecommunications system is 

equivalent to the in-person delivery of 

the requested service. Moreover, 

commenters argue that no group 

services would ever be approved if we 

base approval upon whether the 

interactive dynamic of the requested 

service is similar to existing telehealth 

services and requested us to add group 

MNT and group DSMT as a precedent 

by which other future group service 

requests could be measured. 

Response: Category 1 requests are 

reviewed to ensure that the roles of, and 

interaction among, the beneficiary and 

physician (or other practitioner) of the 

requested service are similar to the 

current telehealth services, for example 

office and other outpatient visits and 

consultation services. In other words, 

the roles of, and interaction among, the 

beneficiary and physician (or 

practitioner) is the criterion used to 

determine whether the requested service 

is similar to the current telehealth 

services. 

Since the interactive dynamic of 

group MNT and group DSMT is not 

similar to the current list of telehealth 

services, the request to add these 

services was assigned to category 2. For 

category 2 services, we assess whether 

the use of an interactive audio and 

video telecommunications system to 

deliver the requested service is 

equivalent to the in-person delivery of 

the service. To that end, we review any 

comparative analyses submitted by the 

requestor illustrating that the use of a 

telecommunications system is an 

adequate substitute for the in-person 

delivery of the requested service. If the 

requestor were to submit studies 

indicating that beneficiaries receiving 

group MNT and group DSMT 

comprehend and apply the training 

material as well by telehealth as in 

person, we would reconsider approving 

group MNT and group DSMT for 

telehealth. 

Comment: The same group of 

commenters also believe that individual 

DSMT is similar to the existing list of 

telehealth services and should be 

approved as a category 1 request. The 

commenters contend that a telepresenter 

would be able to facilitate the ‘‘hands 

on’’ aspects of training a patient how to 

inject insulin. For example, a 

telepresenter with a patient at the 

originating site (who is not a certified 

CDE) could assist with filling syringes, 

mixing doses, and showing the injection 

site location through illustration or 

pointing to areas on the body. 

Commenters also argue that the use of 

a large video monitor to show gradient 

markings on a syringe could be 

beneficial for patients with poor vision. 

Response: As discussed in the 

proposed rule, we considered 

individual DSMT as a category 2 request 

because the components included in 

training a Medicare beneficiary to 

administer insulin injections are 

typically not part of the services 

currently on the list of telehealth 

services. We did not propose to add 

individual DSMT because the requestors 

did not submit any comparative 

analyses illustrating that the use of an 

interactive audio and video 

telecommunications system is an 

adequate substitute for individual 

DSMT furnished in-person. 

Comment: Several commenters 

submitted summaries of studies and or 

articles regarding group psychiatry, 

individual psychotherapy, and 

medication management furnished as 

telehealth services. Additionally, an 

individual practitioner mentioned a 

study that compared diabetes education 

furnished through telemedicine with 

diabetes education furnished in-person. 

Response: For category 2 services, we 

require evidence showing that the 

requested telehealth service is 

equivalent to the in-person delivery of 

the same service. The articles regarding 

mental health services and 

pharmacologic management do not 

address whether the use of a 

telecommunications system is an 

adequate substitute for the in-person 

delivery of MNT or DSMT. 

Additionally, individual psychotherapy 

and pharmacologic management are 

already on the list of Medicare 

telehealth services. 

The comparison study regarding 

diabetes education focused on certain 

aspects of individual DSMT (but, as 

noted below, not on training patients to 

inject insulin), and therefore is 

irrelevant to the request to add group 

DSMT. The study conclusions 

mentioned that the ‘‘diabetes nurse 

educator was even successful in 

70158 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

teaching insulin administration via 

telemedicine to a patient who had very 

high blood glucose levels’’. However, 

training patients on the selfadministration of injectable drugs 

(which typically occurs during an 

individual training session) was not the 

focus of this study and no conclusive 

evidence was provided showing that 

insulin administration can routinely be 

taught as a telehealth service. 

Comment: Some commenters 

suggested that we approve the majority 

of DSMT for telehealth and require 

selected aspects of the training such as 

the instruction of insulin injections to 

be furnished in person by a CDE. For 

instance, one CDE stated that the use of 

telehealth would not be appropriate for 

teaching selected skills (such as the 

administration of self-injectable drugs, 

glucometer testing, or insulin pump 

therapy), and should not replace the 

initial assessment or all follow-up visits. 

Some CDE’s and DSMT programs stated 

that a combination of in-person and 

telehealth training works well for their 

patients. However, commenters stated 

that the majority of the curriculum for 

an American Diabetes Association 

(ADA) recognized DSMT program can 

be successfully provided as a telehealth 

service. For instance, a CDE stated that 

curriculum components such as 

nutritional management, foot care, 

ketone testing, sick day management, 

use of a supplemental insulin scale, and 

treatment of hypoglycemia or 

hyperglycemia could be furnished as a 

telehealth service. 

Response: DSMT is furnished either 

as an individual or group service as 

described by HCPCS codes G0108 and 

G0109 respectively. As many 

commenters mentioned, teaching a 

patient how to inject insulin is typically 

furnished as part of an individual DSMT 

session rather than in a group setting. 

Additionally, as discussed at 

§ 410.141(c)(1), Medicare payment for 

initial DSMT may not exceed 10 hours 

of beneficiary training in which 9 hours 

of the training are usually furnished as 

a group service. Since teaching a patient 

how to inject insulin is typically an 

integral component of an individual 

training session, and comprises only 1 

hour of a maximum of 10 hours of 

initial training, we do not believe that 

it would be appropriate to carve out 

selected skill-based training from an 

individual DSMT service. 

We agree that skill-based training 

such as teaching patients how to inject 

insulin would be difficult to accomplish 

without the physical in-person presence 

of the teaching practitioner and believe 

this is not a common aspect of the 

current list of telehealth services. Given 

that teaching patients the skills required 

for insulin injection and blood glucose 

monitoring are typically furnished 

during an individual DSMT session we 

assigned the request to add individual 

DSMT to category 2. Moreover, as 

discussed previously, since the 

interactive dynamic of group DSMT is 

not similar to the current list of 

telehealth services, it does not meet the 

criteria for category 1. Therefore, we 

require evidence showing that the use of 

an interactive audio and video 

telecommunications system in 

furnishing DSMT is an adequate 

substitute for DSMT furnished inperson. 

Comment: Some commenters believed 

that we compared group MNT to group 

psychiatric therapy or mental health 

counseling. The commenters suggest 

this is not a fair comparison because 

patients participating in a group MNT 

session typically do not discuss specific 

personal health information with the 

nutrition professional because the group 

‘‘therapy’’ is a discussion of nutrition 

and is centered on a specific medical 

disease topic (for example, diabetes). 

Commenters contend that in the case of 

group MNT, the dietitian presents 

educational material to many 

beneficiaries at once and that the level 

of intense personal interaction found in 

group mental health services is not 

necessary in group MNT. 

Response: As discussed previously, 

we compared the roles of, and 

interaction among, the beneficiary and 

physician (or other practitioner) in 

furnishing MNT and DSMT to the 

existing telehealth services. We did not 

compare group MNT to group 

psychiatric therapy or to group mental 

health counseling. 

Comment: A few commenters stated 

that furnishing MNT for a diabetic 

patient is intended to be an adjunct to 

DSMT. For example, one group of 

commenters stated that without 

receiving DSMT, patients would not 

have an overall understanding of 

diabetes, how the disease develops and 

changes, and would not be taught 

additional methods for controlling 

glucose beyond those presented in 

MNT. 

Response: Approving individual MNT 

for telehealth is one step along the way 

to helping more beneficiaries gain 

access to a collaborative skill-based 

DSMT program. As discussed earlier, 

we believe there should be conclusive 

evidence showing that DSMT can be as 

effective when furnished as a telehealth 

service as in a face-to-face encounter 

before we approve this service for 

telehealth. 

Additionally, we conduct and sponsor 

a number of innovative demonstration 

projects to test and measure the effect of 

potential program changes. Our 

demonstrations study the likely impact 

of new methods of service delivery, 

coverage of new types of service, and 

new payment approaches on 

beneficiaries, providers, health plans, 

states, and the Medicare Trust Funds. 

We would encourage the commenters to 

take advantage of other programs that 

the agency has set up to increase 

medical quality and reduce cost. For 

more information on demonstration 

projects visit our web site at 

www.cms.hhs.gov/researchers/demos. 

Comment: A few commenters 

requested that we pay for DSMT 

education provided to patients over the 

phone. One commenter submitted 

several studies and articles regarding 

telephone-based interventions for 

diabetes care, (for example, telephone 

counseling). 

Response: Patient education provided 

over the phone is beyond the scope of 

this provision. Telephone calls do not 

meet the definition of an interactive 

telecommunications system and are not 

on the list of Medicare telehealth 

services. Additionally, as discussed in 

the Medicare benefits policy manual, 

publication 100–2, chapter 15, section 

30, no separate payment is made for 

phone calls under the Medicare 

program. 

Comment: One commenter requested 

us to recognize CDE’s as a Medicare 

practitioner and allow them to bill the 

Medicare program directly. 

Response: The statute does not permit 

a CDE to bill and receive direct payment 

for Medicare services. The statute 

defines a certified DSMT provider as a 

physician, other individual, or entity 

who, in addition to providing DSMT 

services, provides other items or 

services for which direct payment may 

be made. We do not have the statutory 

authority to establish a separate CDE 

benefit category. 

Definition of an Interactive 

Telecommunications System 

We received many comments 

regarding the use of an interactive audio 

and one-way video telecommunications 

system for delivering a Medicare 

telehealth consultation. Several 

commenters expressed qualified support 

for the use of an interactive audio and 

one-way video telecommunication for 

purposes of furnishing a telehealth 

consultation. For instance, some 

commenters believe that allowing oneway video would be appropriate in 

situations when it enables the 

consulting physician to add value to the 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70159 

diagnosis and decision making 

capabilities of the patient care team at 

the originating site which includes, at a 

minimum, a treating physician; and 

where observation of the consulting 

physician by the patient is either 

unnecessary or not possible (for 

example, when the patient is 

unconscious). 

Some commenters also suggested that 

we allow one-way video specifically for 

assessing suitability for stroke 

thrombolytic tissue-type plasminogen 

activator (tPA) therapy and compared 

the remote evaluation of a stroke patient 

for purposes of determining tPA 

treatment to a confirmatory 

consultation. For instance, the treating 

physician at the originating site would 

make a determination regarding the use 

of tPA and request a consultation to 

confirm his or her decision to use tPA 

therapy. Another commenter, who 

currently provides stroke consultation 

as a Medicare telehealth service, 

believes this service is an outpatient or 

inpatient consultation (where the 

neurologist at the distant site 

determines the treatment plan rather 

than offering a second or third opinion). 

The commenter also explained that they 

use an interactive audio and video 

telecommunications system that allows 

two-way real time video interaction 

between the consulting physician at the 

distant site and the originating site 

medical team. 

One organization stated that payment 

should be made for physicians’ services 

that are safe, effective, medically 

appropriate, and provided under 

accepted standards of medical practice. 

The commenter believes that the critical 

factor in determining whether to pay for 

a service should be medical necessity 

rather than the technology used to 

furnish the service. The commenter also 

compared the use of one-way video and 

two-way audio to a physician furnishing 

a visit to a blind patient. The 

commenter contends that we would not 

deny payment for a face-to-face 

consultation on the basis that the 

patient could not see the physician, and 

therefore we should not deny a 

telehealth consultation on the same 

basis. 

Another commenter requested that we 

allow the use of one-way video 

equipment for delivering infectious 

disease telehealth consultations for ICU 

patients. The commenter explained that 

the hospital ICU is currently equipped 

with a one-way video, two-way audio 

telecommunications system and 

contends that moving interactive audio 

and video teleconferencing equipment 

to the ICU patient is very cumbersome 

and is only possible if appropriate 

technical staff are available. 

We received a few comments 

regarding the added clinical value of 

two-way video versus one-way video 

and whether one-way video is 

appropriate for a broad range of 

specialty consultations. One commenter 

made the point that two-way video 

would allow the patient to see the 

physician or practitioner at the distant 

site when a greater degree of interaction 

is necessary. One organization believes 

that two-way video may add value to a 

telehealth consultation by allowing the 

patient and presenting practitioner (if 

necessary) to see the body language and 

other non-verbal communication of the 

physician or practitioner at the distant 

site. However, the commenter stated 

that payment should not be denied for 

using a one-way video 

telecommunications system. Another 

commenter supported using one-way 

video in limited emergent 

circumstances, but also stated that 

additional research should be 

conducted to determine whether the use 

of one-way video is appropriate for a 

broad range of specialty consultations. 

Some commenters did not support the 

use of one-way video for furnishing a 

telehealth consultation. For instance, 

one commenter stated that face-to-face 

(interactive video) is a better method for 

obtaining patient compliance and 

results in a higher level of patient 

confidence with the health care team. 

Response: We appreciate the 

comments on the use of an interactive 

audio and one-way video 

telecommunications system for 

purposes of furnishing a telehealth 

consultation. We intend to consider the 

suggestions raised by the commenters as 

we continue to evaluate conditions of 

payment for Medicare telehealth 

services. We continue to believe that the 

interaction between the consulting 

physician and the clinical staff at the 

originating site is important and it is not 

clear to us that one-way video is as 

effective in that regard as two-way 

video. With regard to the commenter 

who stated that the critical factor in 

determining whether to pay for a 

telehealth service should be based on 

medical necessity, we believe that the 

method used to furnish the service, for 

example the use of an appropriate 

telecommunications system, is just as 

critical as whether the service itself is 

medically necessary. 

2. Definition of an Originating Site 

As discussed in the August 8, 2005 

proposed rule, section 418 of the MMA 

required the Health Resources Services 

Administration (HRSA) within HHS, in 

consultation with CMS, to conduct an 

evaluation of demonstration projects 

under which SNFs, as defined in section 

1819(a) of the Act, are treated as 

originating sites for Medicare telehealth 

services. The MMA also required HRSA 

to submit a report to the Congress that 

would include recommendations on 

‘‘mechanisms to ensure that permitting 

a SNF to serve as an originating site for 

the use of telehealth services or any 

other service delivered via a 

telecommunications system does not 

serve as a substitute for in-person visits 

furnished by a physician, or for inperson visits furnished by a PA, NP or 

CNS, as is otherwise required by the 

Secretary.’’ We indicated that this report 

was currently under development and 

that if the Secretary concludes in the 

report that it is advisable to include a 

SNF as a Medicare telehealth originating 

site under section 1834(m) of the Act, 

we would consider the 

recommendations of the report to 

determine whether to add SNFs to the 

list of approved originating sites. We 

also solicited comments on this topic. 

Comment: We received many 

comments supporting the use of 

telehealth in a SNF. The commenters 

noted that adding a SNF to the 

definition of an originating site would 

provide increased access to specialty 

physicians and practitioners, most 

notably mental health services, and 

decrease unnecessary travel for both the 

beneficiary and nursing facility staff. 

For example, one mental health 

practitioner stated that research studies 

indicate a critical shortage of 

psychiatrists in non-MSA areas and a 

lack of appropriate mental health care in 

rural SNF’s as compared to their urban 

counterparts. As such, the commenter 

believes that many rural SNFs do not 

provide professional psychiatric or 

mental health care and that telehealth is 

one method that could be used to meet 

the mental health needs of the rural SNF 

population. Furthermore, the 

commenter stated that the lack of 

appropriate mental health care results in 

higher rates of psychiatric 

hospitalizations and the inability to 

effectively manage medications. 

Another commenter believes that 

allowing telehealth services to be 

furnished in a SNF would increase 

access to follow-up care and would 

result in cost savings. For example, the 

commenter contends that addressing 

acute medical conditions earlier before 

they develop into a crisis could save 

money by reducing transportation costs 

and decrease the number of hospital 

admissions. The commenter also 

mentioned that traveling and waiting in 

an unfamiliar waiting room is often 

70160 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

confusing and uncomfortable for the 

patient. The use of telehealth for SNF 

residents could result in less travel 

hardships for both the patient and SNF 

staff. 

Response: We appreciate the 

comments regarding the addition of 

SNFs to the definition of an originating 

site. At this time the telehealth report to 

the Congress, as required by section 418 

of the MMA, is under development 

within HHS. As discussed previously, 

we have the authority to approve 

telehealth furnished in a SNF if the 

Secretary concludes in the report that it 

is advisable to include a SNF as a 

Medicare telehealth originating site 

under section 1834(m) of the Act. 

Comment: A few commenters 

requested us to add other facilities in 

addition to a SNF to the definition of an 

originating site. For example, one 

organization requested that we expand 

the definition of an originating site to 

include domiciliary care facilities and 

other congregate-living arrangements if 

SNFs are approved as an originating 

site. Another commenter requested that 

we expand the definition of an 

originating site to allow all community 

hospitals regardless of their location (for 

purposes of furnishing a telehealth 

consultation for stroke patients). The 

commenter noted that a timely 

evaluation of a stroke patient is crucial 

for effective stroke treatment and argued 

that beyond three hours after onset, 

resuscitation of injured brain cells 

becomes increasingly unlikely. The 

commenter contends that timely access 

to a critical care neurologist remains a 

concern for the majority of community 

hospitals. Moreover, a national society 

of nephrology requested that we add a 

dialysis facility to the list of originating 

sites. 

Response: The statute defines an 

originating site facility as a physician’s 

or practitioner’s office, hospital, critical 

access hospital, rural health clinic, or 

FQHC. Additionally, the statute only 

permits telehealth services to be 

furnished at an originating site located 

in a rural health professional shortage 

area as defined in section 332(a)(1)(A) of 

the Public Health Service Act or within 

a county that is not included in a 

metropolitan statistical area. We do not 

have the legislative authority (except for 

SNFs as indicated previously) to expand 

the definition of an originating site 

facility or to allow telehealth services to 

be furnished in a hospital regardless of 

geographic location. 

3. Other Issues 

Comment: One association urged us to 

pay for asynchronous ‘‘store and 

forward’’ dermatology consultations. 

The commenter explained that a store 

and forward consultation involves the 

transmission of dermatological 

photographs and other medical 

information to the consulting 

practitioner without interaction between 

the patient and practitioner at the 

distant site; the patient is not present for 

the consultation. The commenter 

contends that store and forward 

consultation is more convenient for the 

patient, originating site and consulting 

physician. 

Response: Medicare telehealth 

services include office and other 

outpatient visits (99201 through 99215), 

professional consultations (99241 

through 99275), individual 

psychotherapy (90804 through 90809), 

pharmacologic management (90862), 

psychiatric diagnostic interview 

examination (90801), and ESRD-related 

services included in the MCP (except for 

one visit per month to examine the 

access site). As a condition of payment 

under Medicare, these services require 

an in-person patient encounter. We 

believe that the patient’s presence, and 

the use of an interactive audio and 

video telecommunications system 

permitting the distant site practitioner 

to interact with the patient, provides a 

reasonable substitute for an in-person 

encounter. The statute provides for the 

use of asynchronous, store and forward 

technologies for delivering telehealth 

services only for Federal telemedicine 

demonstration programs conducted in 

Alaska or Hawaii. We do not have the 

authority to expand the use of store and 

forward technology in delivering 

telehealth services. 

Comment: Two commenters urged us 

to consider adding speech-language 

pathologist and audiologists as 

practitioners allowed to furnish and 

receive payment for telehealth services 

and noted that we have not submitted 

the telehealth report to the Congress on 

additional sites, geographic areas and 

practitioners that may be appropriate for 

Medicare telehealth payment. The 

commenters also mentioned that the 

American Speech-Hearing Association 

(ASHA) previously submitted a request 

for consideration in the CY 2005 

physician rule to add various speech 

and audiology services to the list of 

Medicare telehealth services. The 

commenters believe that we have not 

responded specifically to ASHA’s 

request to approve speech and 

audiology services for telehealth. 

Response: The report to the Congress 

(as required by section 223(d) of the 

Medicare, Medicaid and State Child 

Health Insurance Program Benefits 

Improvement and Protection Act of 

2000 (BIPA) (Pub. L. 106–554)) on 

additional sites and settings, 

practitioners, and geographic areas that 

may be appropriate for Medicare 

telehealth payment is under 

development. We are considering the 

suggestions raised by the commenter as 

we formulate our recommendations to 

the Congress. Moreover, since speech 

language pathologists and audiologists 

are not permitted under current law to 

provide and receive payment for 

Medicare telehealth services at the 

distant site, we can not fully consider 

ASHA’s request to add speech and 

audiology services to the list of 

Medicare telehealth services. 

Comment: One commenter requested 

that we replace the term face-to-face 

with ‘‘in-person’’. The commenter 

believes that the term ‘‘in-person’’ is a 

better description of an encounter where 

the patient and practitioner are in the 

physical presence of each other. 

Response: The commenter’s 

suggestion to use the term ‘‘in-person’’

to describe an encounter where the 

physician or practitioner and the 

beneficiary are physically in the same 

room has been noted. We will consider 

the commenter’s suggestion as we 

discuss Medicare telehealth payment 

policy. 

Result of Evaluation of Comments 

We will add individual MNT as 

represented by HCPCS codes G0270, 

97802 and 97803 to the list of Medicare 

telehealth services. We also will add 

individual MNT to the list of Medicare 

telehealth services at § 410.78 and 

§ 414.65. Moreover, since a certified 

registered dietitian or other nutrition 

professional are the only practitioners 

permitted by statute to furnish MNT, we 

will revise § 410.78 to add a registered 

dietitian and nutrition professional as 

defined in § 410.134 to the list of 

practitioners that may furnish and 

receive payment for a telehealth service. 

E. Contractor Pricing of Unlisted 

Therapy Modalities and Procedures 

We recognize that there may be 

services or procedures performed that 

have no specific CPT codes assigned. In 

these situations, it is appropriate to use 

one of the CPT codes designated for 

reporting unlisted procedures. These 

unlisted codes do not typically have 

RVUs assigned to them. 

For services coded using these 

unlisted codes, the provider includes a 

description of the specific procedure(s) 

that was furnished. The contractor uses 

this information to determine an 

appropriate valuation. 

As explained in the August 8, 2005 

PFS proposed rule (70 FR 45788), 

currently, there are two unlisted CPT 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70161 

codes with assigned RVUs, CPT 97039, 

Unlisted modality (specify and time if 

constant attendance), and 97139 

Unlisted therapeutic procedure. 

To make the pricing methodology 

consistent with our policy for other 

unlisted services, and to more 

appropriately match payments with the 

actual resources expended to deliver the 

services provided, we proposed to have 

our contractors value CPT codes 97039 

and 97139. 

We received several comments on this 

proposal and provide the following 

summary of the comments and our 

response below. 

Comment: Two commenters were 

opposed to the proposal. These 

commenters stated they were concerned 

that contractor pricing would create 

inconsistencies in the payment for these 

services or would lower payment 

resulting in the services no longer being 

provided, potentially increasing the 

administrative burden and resulting in 

delayed payments. One of these 

commenters suggested that we work 

with interested specialties to better 

understand the services billed under 

these codes. Another commenter 

expressed concern that obtaining new 

CPT codes requires a good deal of 

research and investigation to ensure 

accurate payment. 

Other commenters supported this 

proposed change, indicating that 

because these codes are used for widely 

different services they should be 

evaluated separately and there is no 

basis for assigning the code a set fee 

schedule rate. 

Response: While it is true that having 

these codes priced by the contractors 

may result in some increase in 

administrative burden and impact the 

timeliness of payments, it will not 

necessarily result in lower payments. 

Our goal is to ensure appropriate 

payment for the actual services 

provided and we believe that our 

contractors will work with the provider 

community to make certain that this 

occurs. To the extent that providers 

believe that new codes are needed they 

might want to work with the specialty 

organizations to achieve this objective. 

Final Decision: We are finalizing our 

proposal and our contractors will value 

CPT codes 97039 and 97139. We are 

assigning a status indicator of ‘‘C’’ to 

these two CPT codes. 

F. Payment for Teaching 

Anesthesiologists 

In the August 8, 2005 PFS proposed 

rule (70 FR 45789), we summarized the 

current policy for the payment for 

services provided by teaching 

anesthesiologists, including the 

revisions to the policy published 

November 7, 2003 (68 FR 63196 through 

63395), where we revised § 414.46 of 

our regulations to allow teaching 

anesthesiologists to bill in a similar 

manner to teaching certified registered 

nurse anesthetists (CRNAs) for the 

teaching anesthesiologist’s involvement 

in two concurrent cases involving 

residents. This policy took effect for 

services furnished on or after January 1, 

2004 and was intended as an alternative 

to the ‘‘medical direction’’ payment 

policy applicable to concurrent cases 

involving teaching anesthesiologists and 

residents. 

As noted in the August 8, 2005 

proposed rule, despite the higher level 

of payment available under this policy, 

the American Society of 

Anesthesiologists (ASA) has informed 

us that it is not aware of any teaching 

anesthesia programs that have arranged 

their practices to meet the conditions 

necessary to bill under the revised 

policy. The ASA suggests that the 

teaching physician regulations for 

teaching anesthesiologists should be 

similar to those for teaching surgeons 

for overlapping complex surgery 

procedures. The ASA thinks that 

anesthesia is similar to complex surgery 

in terms of critical periods, overlap, and 

availability of teaching physicians. 

However, as we noted in the August 8, 

2005 proposed rule, the critical portions 

of the teaching anesthesia service and 

the critical portions of the teaching 

surgeon service are not the same. The 

ASA believes that inadequate payment 

levels have contributed to the loss of 

teaching anesthesiologists and an 

inability to recruit new faculty. 

In the August 8, 2005 proposed rule, 

we requested comments on a teaching 

physician policy for anesthesiologists 

that could build on the policy 

announced in the November 7, 2003 

PFS final rule, but could provide the 

appropriate revisions that would allow 

it to be more flexible for teaching 

anesthesia programs. We also indicated 

we would be interested in receiving data 

and studies relevant to this issue as well 

as any offsetting savings that could be 

made to account for any potential costs 

that could be incurred if there was a 

policy change. 

Discussion of Comments Received 

As discussed previously in this 

section, we did not present a formal 

proposal, but asked for comments from 

interested stakeholders on these issues. 

While we have not fully analyzed all the 

relevant information and data, we have 

been provided anecdotal evidence that 

some anesthesiologists may be leaving 

academic practice for better 

compensated positions in private 

practice. While we recognize that 

Medicare payment policies are an 

important consideration in these 

decisions, they are not the only factor. 

In contrast, as pointed out by a 

commenter, there has been an increase 

in the number of nurse anesthesia 

programs from 83 programs in 2000 to 

105 programs projected for 2006. The 

number of nurse anesthesia graduates 

has surged from 1075 nurse anesthetists 

in 2000 to 2035 projected for 2006. 

Despite these increases, nurse 

anesthesia programs had reported 

similar financial problems, such as 

levels of teachers’ salaries, in recruiting 

faculty to teaching nurse anesthetists. 

In terms of anesthesia manpower, we 

did not receive any information from 

surgical groups indicating difficulty in 

getting anesthesiologists or CRNAs to 

provide anesthesia services. 

Additionally, we did not receive any 

comments identifying areas of offsetting 

savings that might be used to fund any 

change in the teaching anesthesia 

payment policy. 

We will continue to review the 

information and relevant data presented 

by the commenters and consult with the 

stakeholders before we move forward 

with any proposal. 

G. End Stage Renal Disease (ESRD) 

Related Provisions 

On August 8, 2005, we published the 

Revisions to Payment Policies Under the 

Physician Fee Schedule for CY 2006 

proposed rule in the Federal Register 

(70 FR 45789), revising payments to 

ESRD facilities under the provisions of 

the MMA. The proposed rule 

implements section 1881(b) of the Act, 

as amended by section 623 of the MMA, 

which directs the Secretary to make a 

number of revisions to the composite 

rate payment system, as well as 

payment for separately billable drugs 

furnished by ESRD facilities. 

Under section 1881(b)(12) of the Act, 

the add-on adjustment must reflect both 

the effect of the new payment 

methodology and estimate growth in 

ESRD drug expenditures. We proposed 

an add-on adjustment of 8.1 percent to 

the composite payment rate to account 

for the difference between previous 

payments for separately billed drugs 

and biologicals and the revised pricing 

that will take effect January 1, 2006. 

We updated that add-on adjustment to 

reflect estimated growth in ESRD drug 

expenditures of 0.7 percent. We 

combined the add-on adjustment of 8.1 

percent that reflects the payment 

methodology we will be using for ESRD 

drugs with the 0.7 percent increase for 

expenditures in 2006 to produce one 

70162 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

proposed drug add-on adjustment for 

CY 2006 of 8.9 percent. 

Following publication of the proposed 

rule, it came to our attention that 3 

codes had been omitted in our analysis 

of drug payments and utilization for the 

top ten ESRD drugs that affected our 

calculation of the proposed add-on 

adjustment. On September 1, 2005, we 

issued a correction notice on the CMS 

Web site, to correct our omission of the 

3 J Codes in the estimation of the market 

shares for the top ten ESRD drugs used 

in our calculation of the proposed drug 

add-on adjustment for 2006. The 

‘‘Correction to the Proposed ESRD Drug 

Add-on Adjustment: Revised Table 22’’

is available at http://www.cms.hhs.gov/ 

providers/esrd/ 

090105_ESRD_Correction.pdf. The 

corrected table shows the revised 

weights compared to the weights 

included in the proposed rule and 

resulted in a revised proposed total drug 

add-on adjustment to the composite 

payment rate of 11.3 percent for 2006. 

We also proposed to revise the drug 

pricing for ESRD drugs to ASP+6 

percent for the top ten drugs furnished 

by independent facilities and EPO 

furnished by hospital-based facilities. 

In addition, section 1881(b)(12) of the 

Act as amended by section 623 of the 

MMA provided authority to the 

Secretary to revise the geographic index 

applied to the composite payment rate 

and phase in any changes to the index 

over a multi-year period. Accordingly, 

we proposed to revise the geographic 

classifications and wage indexes 

currently in effect for adjusting 

composite rate payments and to 

implement these changes over a 2-year 

transition period. 

We also proposed to revise the 

regulations applicable to the composite 

rate exceptions process to reflect section 

623 of the MMA provisions that restricts 

exceptions to pediatric facilities. 

No changes to the current case-mix 

adjustments were proposed. 

We received a total of 37 comments 

from the ESRD community that 

represented major organizations, 

pharmaceutical companies, 

beneficiaries, and concerned 

individuals. The comments and 

responses are summarized in the 

following sections. 

1. Revised Pricing Methodology for 

Separately Billable Drugs and 

Biologicals Furnished by ESRD 

Facilities 

In the August 8, 2005 proposed rule, 

we proposed that payment for drugs 

furnished in connection with renal 

dialysis services and separately billed 

by independent renal dialysis facilities 

would be based on payment amounts 

determined under section 1847A of the 

Act which are 106 percent of the ASP. 

We proposed to update the payment 

allowances quarterly, based on the ASP 

reported to us by drug manufacturers. 

We also proposed to pay for EPO in 

hospital-based facilities at the ASP+6 

percent. We stated that we are interested 

in moving to the ASP+6 percent 

methodology for all separately billed 

drugs and solicited comments on a drug 

add-on estimation methodology that 

would allow us pay hospital-based 

facilities ASP+6 percent for all 

separately billable drugs. 

In this final rule with comment, we 

are implementing payment of ASP+6 

percent for all ESRD drugs furnished by 

both independent and hospital-based 

ESRD facilities. A discussion of the final 

drug payment methodology and related 

comments and responses can be found 

in section II.H.2. 

2. Adjustment to Account for Changes 

in the Pricing of Separately Billable 

Drugs and Biologicals, and the 

Estimated Increase in Expenditures for 

Drugs and Biologicals 

Section 1881(b)(12) of the Act, as 

added by section 623(d) of the MMA, 

contains two provisions that describe 

how the drug add-on adjustment will be 

implemented in the ESRD payment 

system. First, the add-on adjustment 

must reflect the difference between the 

payment methodology for separately 

billed drugs under the drug price in 

effect in CY 2004 and current drug 

pricing and, second, the aggregate 

payments for CY 2005 must equal 

aggregate payments absent this MMA 

provision. 

Prior to 2005, separately billable 

ESRD drugs and biologicals other than 

EPO furnished in independent facilities 

were paid under the average wholesale 

price (AWP) methodology. In 2005, 

section 1881(b)(13)(A)(ii) of the Act 

required that we pay the acquisition 

cost for separately billable ESRD drugs 

(including EPO) as determined by the 

Office of the Inspector General (OIG). If 

the OIG did not determine an 

acquisition cost for a separately billable 

drug or biological, then the Secretary 

was given discretion to determine the 

payment rate. In the CY 2005 final rule 

(69 FR 66322–66323), we described the 

methodology that we used for 

developing the drug add-on adjustment 

to the composite rate to account for the 

difference between estimated drug 

payments under the AWP payment 

system and the acquisition costs as 

determined by the OIG. This adjustment 

was developed so that aggregate 

spending for composite rates plus 

separately billed drugs would remain 

budget neutral for CY 2005. 

Section 1881(b)(12) of the Act, as 

added by section 623 (d) of the MMA, 

also contains two provisions related to 

adjustments to payments for drugs and 

biologicals for CY 2006. Section 

1881(b)(12)(C)(ii) of the Act requires 

that we recalculate the 2005 add-on 

adjustment to reflect the difference 

between estimated payments using the 

AWP payment methodology and the 

payment methodology for 2006 which 

we proposed to be ASP+6 percent. 

In addition, section 1881(b)(12)(F) of 

the Act requires that, beginning in 2006, 

we establish an annual update 

adjustment to reflect estimated growth 

in expenditures for separately billable 

drugs and biologicals furnished by 

ESRD facilities. This update would be 

applied only to the drug add-on portion 

of the composite payment rate. In order 

to meet both requirements, we proposed 

to develop the CY 2006 drug add-on 

adjustment in two steps. 

First, we proposed to recalculate the 

CY 2005 add-on adjustment to reflect 

the difference in drug payments using 

95 percent AWP pricing and payments 

using ASP+6 pricing. The result of this 

calculation would replace the current 

8.7 percent adjustment and would be 

budget neutral to CY 2005 payments. 

Next, we proposed to develop a 

proposed annual update methodology 

that we would first use in CY 2006 to 

reflect the estimated growth in drug 

expenditures each year. As stated 

previously, this update would be 

applied only to the drug add-on portion 

of the composite payment rate. For 

specific details regarding the proposed 

adjustments, see the August 8, 2005 

Federal Register (70 FR 45793 through 

45800). 

As noted previously, we issued a 

correction to the proposed ESRD drug 

add-on adjustment contained in the 

proposed rule. In this notice we 

acknowledged that our estimation of the 

market shares for the top ten ESRD 

drugs that we used in the calculation of 

the proposed drug add-on for 2006 was 

incorrect. After further analysis of the 

2003 expenditure data used to assign 

weights to the top ten ESRD drugs, we 

determined that our data did not 

account for 3 new ‘‘J’’ codes that were 

implemented in 2003. As a result, the 

weights for Iron Sucrose, Sodium Ferric 

Gluconate and Paricalcitol were 

understated. 

In addition, we noted that the weight 

for EPO incorrectly included 

expenditures for hospital-based 

facilities. Since the purpose of the 

weighting was to allocate the drug 

spread to all other drugs paid using the 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70163 

proposed ASP+6 percent pricing, 

hospital-based data should not have 

been included because we paid for other 

hospital-based drugs based on cost. 

Table 16 shows the revised weights 

compared to the weights included in the 

proposed rule. 

TABLE 16.—REVISED TO REFLECT CORRECTION

Drugs Published proposed weights 

Revised proposed 

weights 

Epogen ......................................................................................................................................................... 78.83 69.33 

Calcitriol ....................................................................................................................................................... 0.13 0.84 

Doxercalciferol ............................................................................................................................................. 1.74 1.48 

Iron dextran .................................................................................................................................................. 0.38 0.23 

Iron sucrose ................................................................................................................................................. 0.71 7.03 

Levocarnitine ................................................................................................................................................ 0.89 0.77 

Paricalcitol .................................................................................................................................................... 17.37 14.61 

Sodium ferric glut ......................................................................................................................................... 0.53 4.96 

Alteplase, Recombinant ............................................................................................................................... 0.18 0.56 

Vancomycin ................................................................................................................................................. 0.24 0.19 

We note that as a result of these data 

corrections, the top ten drugs account 

for 98 percent of total ESRD drug 

expenditures, rather than 92 percent as 

stated in the proposed rule. 

Using these revised weights, the 

proposed recalculated 2005 drug add-on 

adjustment was corrected to 10.4 

percent, and the proposed 2006 update 

was corrected to 0.8 percent. The 

corrected total drug add-on adjustment 

proposed for 2006 was 11.3 percent. 

The proposed rule also discussed a 

method to estimate the drug spread 

applicable to hospital-based facilities for 

non-EPO drugs if we decided to 

implement ASP+6 percent pricing for 

all hospital-based drugs. This 

methodology would use the weighted 

average drug spread percent for 

independent facilities to estimate the 

drug spread for non-EPO drugs 

furnished by hospital-based ESRD 

facilities. 

The following sections discuss the 

comments we received on these issues 

and provide a detailed description of 

the final drug add-on adjustment to the 

ESRD composite payment rate that will 

be implemented January 1, 2006. 

Comment: We received a number of 

comments advocating that drug 

payments to hospital based facilities 

should be the same as to independent 

facilities. However, most of these 

comments raised no concerns regarding 

our proposed methodology for 

computing the drug spread applicable to 

hospital-based facilities. Two comments 

specifically supported our proposal to 

use the drug pricing drug spread from 

independent facilities to estimate the 

spread for hospital-based facilities. Two 

comments stated we should follow 

MedPAC’s suggestion that we collect 

data to estimate hospital-based facilities’

cost and Medicare payment per unit for 

ESRD drugs, but did not raise concerns 

with our proposed alternative method 

for estimating the drug spread 

applicable to hospital-based facilities if 

we implemented ASP+6 percent 

pricing. MedPAC recommended that we 

use the same methodology to pay for all 

drugs (regardless of setting) and 

suggested that we could use dosing data 

from independent facilities to estimate 

ASP+6 payments for hospital-based 

facilities to compute the drug spread 

related to hospital-based facility drug 

payments. 

Response: Given both the MedPAC 

recommendation that ASP should be the 

basis of payment for all separately 

billable ESRD drugs and the overall 

support for providing consistent drug 

payments for both hospital-based and 

independent facilities, we have decided, 

in light of section 1881(b)(13)(A)(iii) of 

the Act, to implement ASP+6 percent 

pricing for hospital-based facilities 

beginning January 1, 2006. See section 

II.H.2 for a more detailed discussion of 

this issue. We are adopting the 

methodology outlined in the proposed 

rule to determine the drug spread 

applicable to hospital-based facilities 

and to calculate a drug add-on 

adjustment. We are also adopting the 

proposed methodology which would 

permit us to implement a change in 

payment to ASP+6 percent for all nonEPO drugs provided by hospital-based 

ESRD facilities. 

While we agree that the ideal 

approach would be to collect data from 

hospital-based facilities, this data 

collection would significantly delay 

implementation of a consistent ESRD 

drug payment policy. Absent the 

collection of data, we believe that using 

the estimation methodology described 

in the proposed rule brings us closer to 

the actual price of hospital drugs 

(ASP+6 percent) than does the policy of 

continuing to rely on reasonable costs. 

In response to MedPAC’s suggestion, 

we did an analysis of drug dosing units 

from the billing data of independent 

facilities and were unable to determine 

accurate monthly average units from 

those bills, because facilities do not bill 

individual line items by date of service. 

As a result, the average monthly dose 

we computed for some drugs was 

significantly below the FDA expected 

monthly dose. In other words, the 

average monthly dose for the top ten 

ESRD drugs from independent facility 

data that we could use as a proxy for 

pricing the hospital-based bills was 

problematic. We believe the statute 

contemplates a single payment 

approach for separately billable ESRD 

drugs. Therefore, using our estimation 

proposal is a start towards MedPAC’s 

principle that the same prices should be 

paid for the same services across all 

settings which we believe is consistent 

with the statute. Furthermore, moving to 

ASP+6 percent pricing for hospitalbased facilities evens out the effect of 

the drug add-on adjustment between 

independent and hospital-based 

facilities. 

Therefore, we have computed the 

drug spread for non-EPO hospital based 

drugs using the weighted average drug 

spread percentage from independent 

facilities. We applied that percentage to 

the total hospital-based drug payments 

in order to estimate the amount of the 

drug spread as a result of revising the 

drug pricing methodology to ASP+6 

percent for hospital-based facilities. 

We believe this method provides a 

reasonable estimation of the drug spread 

because, as explained previously, all 

drugs in both settings are based on 

ASP+6 pricing. Moreover, we believe 

that the benefits of implementing a 

consistent drug payment methodology 

outweighs any potential drawbacks that 

may result from estimating the drug 

spread without more precise data. We 

intend to pursue options for obtaining 

additional data to more accurately 

70164 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

compute and update the drug add-on 

adjustment. Once more complete 

hospital-based ESRD drug data become 

available, we will re-examine the 

computation of the drug add-on 

adjustment and make any necessary 

revisions to our estimations. 

Comment: We received comments 

from two associations representing 

ESRD facilities that expressed concern 

about our interpretation of the statutory 

provision related to the drug add-on 

adjustment. These comments presented 

legal arguments challenging our 

decision to apply a single drug add-on 

adjustment that is applicable to both 

hospital-based and independent ESRD 

facilities. Both comments indicated that 

as long as separate drug payment 

methodologies are in place for hospitalbased facilities and independent 

facilities, the statutory text, structure, 

and legislative history requires that we 

establish distinct drug add-on 

adjustments. Another commenter 

recommended that the add-on 

adjustment should be directly linked to 

hospital-based and independent 

facilities based on the actual loss of 

revenue due to changes in 

reimbursement for separately billed 

drugs. 

Response: We continue to believe that 

our interpretation of this statutory 

provision represents the best reading of 

the statute as we explained, for reasons, 

discussed, in the CY 2005 final rule (see 

69 FR 66319 through 66320). 

Accordingly, rather than adopting 

separate add-on adjustments for 

independent and hospital-based ESRD 

facilities, we are addressing the 

payment inequities expressed in the 

comments and pointed out in the 

MedPAC report that result from 

differential drug payment 

methodologies for hospital-based and 

independent facilities. As discussed 

previously, we are implementing a 

consistent drug payment methodology 

for all ESRD provider settings. In this 

way, we believe we have resolved the 

concerns expressed by these 

commenters in a manner consistent 

with the statute. 

a. Recalculation of the CY 2005 Drug 

Add-on Adjustment 

For CY 2006, we proposed to use the 

same method that we used to develop 

the drug add-on adjustment for CY 2005 

to recalculate the 2005 adjustment to 

reflect the proposed revision to the 

ESRD drug payment methodology from 

acquisition costs to ASP+6 percent. That 

is, we proposed to calculate the spread 

based on the difference in aggregate 

payments between estimated payment 

based on AWP pricing and estimated 

payment based on ASP+6 pricing. 

Although we proposed to use pricing 

data from the second quarter of CY 

2005, we indicated that all of the data 

used to develop the proposed add-on 

adjustment would be updated for the 

final rule with comment, as more 

current data would be available. 

(1) Historical Drug Expenditure Data 

To develop the drug add-on 

adjustment for this final rule with 

comment, we used historical total 

aggregate payments for separately billed 

ESRD drugs for calendar years 2001, 

2002, 2003, and 2004. For EPO, these 

payments were broken down according 

to type of ESRD facility (hospital-based 

versus independent). We also used the 

number of dialysis treatments 

performed by these two types of 

facilities over the same period. 

(2) ASP+6 Percent Prices 

In the proposed rule we used the 

ASP+6 percent prices for the second 

quarter of CY 2005. However, we 

indicated that we would use all four 

quarters of CY 2005 prices to develop 

the CY 2005 ASP payments. 

Comment: One commenter raised 

concerns regarding using four quarters 

of the ASP to determine an annual 

average. This commenter indicated that 

the most recent available quarter, 

specifically, the fourth quarter ASP 

prices of any CY represents the ASP for 

the entire year. This commenter 

recommended that, instead of using all 

four quarter of CY 2005, we use only the 

fourth quarter of CY 2005 ASP to 

calculate the difference in the aggregate 

payments based on 95 percent AWP 

pricing and the estimated payment 

based on ASP+6 percent. 

Response: We do not agree with this 

recommendation and have used the 

average of ASP prices in all four 

quarters of 2005 to calculate the add-on 

adjustment. The fourth quarter of the 

ASP represents only the most current 

ASP prices, and does not represent an 

aggregate annual average. Therefore, our 

calculation for ASP+6 percent includes 

not only the most current quarter (that 

is, the fourth quarter ASP) but also the 

previous three quarters of ASP pricing 

data for 2005). We believe this 

calculation provides the most accurate 

estimation of 2005 actual ASP+6 

percent payments. 

We used four quarters of 2005 ASP+6 

percent prices for the drugs listed in 

Table 17. We averaged these to develop 

prices representing the average 2005 

ASP payments. 

TABLE 17 

Drug 

Average sales 

price plus 6% 

2005 

Epogen ........................... $9.30 

Calcitriol .......................... 0.75 

Doxercalciferol ................ 2.19 

Iron dextran .................... 11.21 

Iron sucrose .................... 0.36 

Levocarnitine .................. 12.30 

Paricalcitol ...................... 3.92 

Sodium ferric glut ........... 4.74 

Alteplase, Recombinant .. 30.61 

Vancomycin .................... 2.95 

(3) Estimated Medicare Payments Using 

95 Percent of AWP 

In the proposed rule, we used the first 

quarter 2005 AWP prices and updated 

them to the second quarter by applying, 

for drugs other than EPO, an estimated 

AWP quarterly growth of approximately 

0.74 percent. In order to estimate AWP 

payments for this final rule with 

comment, we used 4 quarters of 2005 

AWP prices and averaged them to 

obtain prices representative of 2005 

payment amounts. This methodology 

was not applied to the price for Epogen 

since payment was maintained at $10.00 

per thousand units prior to MMA (see 

Table 18). 

TABLE 18 

Drugs 

2005 average estimated medicare 

payments using 

95% of AWP 

Epogen ........................... $10.00 

Calcitriol .......................... 1.36 

Doxercalciferol ................ 3.98 

Iron dextran .................... 17.91 

Iron sucrose .................... 0.65 

Levocarnitine .................. 36.48 

Paricalcitol ...................... 5.32 

Sodium ferric glut ........... 8.17 

Alteplase, Recombinant .. 31.89 

Vancomycin .................... 3.79 

(4) Dialysis Treatments 

In the proposed rule, using the most 

complete data available at the time, we 

estimated total dialysis treatments for 

2005 at 34.5 million. 

Comment: We received comments 

suggesting that our estimate of dialysis 

treatments was overstated. 

Response: Using more recent data that 

has become available since we issued 

the proposed rule, we increased our 

projection of total number of dialysis 

treatments based on actuarially 

projected growth in the number of ESRD 

beneficiaries. Since Medicare covers a 

maximum of three treatments per week, 

utilization growth is limited, and, 

therefore, any increase in the number of 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70165 

treatments should be due to beneficiary 

enrollment. The actual 2004 data we 

used in this final rule with comment, 

showed higher treatment counts than 

we had projected for 2004 in the 

proposed rule. Therefore, for CY 2005, 

we estimate there will be a total of 34.7 

million treatments performed. 

(5) Drug Payments 

In the proposed rule, we updated drug 

payments for both EPO and non-EPO 

drugs using the estimated trend factor 

for EPO of 9.0 percent. We proposed 

using the EPO 9.0 percent trend factor 

for all drugs (not just for EPO) because 

EPO constitutes the largest proportion of 

drugs furnished by ESRD facilities and 

because we determined that the 

extremely varied growth in spending for 

non-EPO drugs between 2000 and 2003 

prohibited a reliable trend analysis. As 

we indicated we would do in the 

proposed rule, we used later 2004 drug 

payment data for the final rule with 

comment and trended those data 

forward to 2005. 

Comment: We received a number of 

comments concerning our use of the 

EPO trend factor to update drug 

payments to 2005. These comments 

expressed concern that this resulted in 

understating the growth in ESRD drug 

payments. We also received comments 

that we should correlate the growth of 

EPO and other separately billable ESRD 

drugs. 

Response: Since we now have 2004 

data, we have modified the trend factor 

to more accurately reflect the growth in 

drug payments. In addition, we have 

calculated trend factors for non-EPO 

drugs independently of those for EPO. 

We updated the total aggregate EPO 

drug payments for both hospital-based 

and independent facilities by using 

historical trend factors using data from 

2001 through 2004. For CY 2005, the CY 

2004 payment level was increased by a 

trend factor of 11.0 percent. 

Similarly, we updated the aggregate 

spending for separately billable drugs, 

other than EPO, for both hospital-based 

and independent facilities by using a 

historical trend factor of 15 percent. 

In addition, we deducted 50 cents for 

each administration of EPO from the 

total EPO spending for both hospitalbased and independent facilities to 

account for payment for syringes that 

were included in the EPO payments 

prior to the implementation of the MMA 

drug payment provisions. 

In the proposed rule, we estimated the 

cost of syringes at $1.6 million for 

hospital-based facilities and $26.8 

million for independent facilities. 

Comment: We received comments 

that the proposed $26.8 million dollars 

estimated for syringe payments to 

independent facilities was too high, 

because the estimated number of 

administrations of EPO exceeded the 

number of treatments. 

Response: We have re-estimated the 

syringe payments to take into account 

problems we encountered related to the 

administrations field on the dialysis 

bills. Thus for the final rule with 

comment, we are calculating syringe 

payments as 50 cents multiplied by 90 

percent of estimated treatments for 

2005. The 90 percent represents the 

percent of dialysis patients that receive 

EPO. Since we only pay for one 

administration per treatment we applied 

this 90 percent to total treatments in 

order to estimate the number of EPO 

administrations. 

Using this methodology, for CY 2005, 

we estimate payments for these syringes 

will amount to $1.8 million for hospitalbased facilities and $13.8 million for 

independent facilities. 

For CY 2005, we estimate that total 

spending for separately billable drugs 

will reach $462 million for drugs 

provided in hospital-based facilities 

($217 million for EPO and $245 million 

for other drugs), and $3.102 billion for 

drugs provided in independent facilities 

($2.082 billion for EPO and $1.019 

billion for other drugs). 

Comment: One comment indicated 

that we were eliminating separate 

payments for syringes. 

Response: We believe the commenter 

misunderstood our payment policy. We 

currently pay separately for syringes 

used to administer ESRD drugs, and will 

continue to do so. We began paying 

separately for the syringes associated 

with administration of EPO when EPO 

payment was revised from payment at 

$10 per 1,000 units in 2005. While the 

previous $10 payment included 

payment for syringes, the new payment 

methodology does not. We have not 

modified our approach to paying for 

syringes in general, but now also pay 

separately for syringes associated with 

the administration of EPO. 

(6) Add-On Calculation and Budget 

Neutrality 

In the August 8, 2005 proposed rule 

(70 FR 45789), we acknowledged a 

mistake in our calculation of the 

proposed drug add-on adjustment. The 

proposed 2005 recalculated add-on 

adjustment was 10.4 percent. In 

addition, we indicated in the proposed 

rule that we intended to include more 

recent 2004 billing data in the 

calculation of the final drug add-on 

adjustment. 

Comment: We received a number of 

comments commending us for 

responding to industry concerns by 

making the corrections to the proposed 

add-on calculation and urging us to use 

the most accurate, up-to-date data and 

trends available to compute the 2005 

budget-neutral add-on adjustment. 

Response: We have taken these 

comments into consideration and have 

updated all of the data and assumptions 

used to calculate the add-on adjustment 

as described below. 

For each of the top ten drugs, we 

calculated the percent by which ASP+6 

percent is projected to be less than 

payment amounts under the 95 percent 

of AWP pricing system for 2005. We 

then calculated a weighted average of 

the percentages by which ASP+6 

percent would be below 95 percent of 

AWP payment amounts, for the top 10 

ESRD drugs for independent facilities. 

We weighted these percentages by using 

the 2005 estimated Medicare payment 

amounts for the top ten drugs. This 

procedure resulted in a weighted 

average payment difference of 16 

percent. 

TABLE 19 

Drugs 

2005 estimated 

medicare payment 

weights as a 

percentage of total 

drug 

expenditures 

Percent by which 

ASP+6% prices 

are below 95% of 

AWP prices 

Epogen ......................................................................................................................................................... 67.96 7.03 

Calcitriol ....................................................................................................................................................... 0.45 44.74 

Doxercalciferol ............................................................................................................................................. 3.62 44.94 

Iron dextran .................................................................................................................................................. 0.11 37.40 

Iron sucrose ................................................................................................................................................. 7.79 44.50 

70166 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

TABLE 19—Continued 

Drugs 

2005 estimated 

medicare payment 

weights as a 

percentage of total 

drug 

expenditures 

Percent by which 

ASP+6% prices 

are below 95% of 

AWP prices 

Levocarnitine ................................................................................................................................................ 1.11 66.27 

Paricalcitol .................................................................................................................................................... 13.38 26.44 

Sodium ferric glut ......................................................................................................................................... 4.64 41.96 

Alteplase, Recombinant ............................................................................................................................... 0.75 4.00 

Vancomycin ................................................................................................................................................. 0.20 22.20 

Since we estimate that these 10 drugs 

represent nearly 98 percent of total 2005 

drug payments to both hospital-based 

and independent facilities, we applied 

the weighted average to 100 percent or 

all of aggregate drug spending 

projections for hospital-based and 

independent facilities, producing a 

projected difference of $585 million (the 

sum of $76 million for hospital-based 

and $509 for independent facilities). 

Since we do not currently have reliable 

data on dosing units from hospitalbased bills, we believe it is reasonable, 

as discussed above, to proxy the drug 

spread for hospital-based facilities using 

the spread for independent facilities. 

The weighted average is applied to 100 

percent of drug spending projections for 

hospital-based and independent 

facilities. 

Distributing the total 2005 figure of 

$585 million over a total projected 34.7 

million treatments results in a revised 

2005 add-on to the per treatment 

composite rate of 13.1 percent. This 

compares to the proposed adjustment of 

10.4 percent. By making this adjustment 

to the composite rate, we estimate that 

the aggregate payments to ESRD 

facilities would be budget neutral for 

drug payments for 2005, as required by 

the MMA. We note that, beginning 

January 1, 2006, this 13.1 percent 

adjustment replaces the 8.7 percent 

adjustment currently in effect for CY 

2005. 

b. Calculation of the Proposed CY 2006 

Inflation Update to the Drug Add-On 

Adjustment 

The proposed rule described the 

approach we proposed to use to update 

the drug add-on adjustment to account 

for the estimated growth in drug 

expenditures between 2005 and 2006. 

Based on the most recent, complete data 

that was available at the time, we 

proposed a 2006 inflation adjustment of 

0.8 percent to the drug add-on to the 

composite payment to reflect the 

estimated growth in drug expenditures 

between 2005 and 2006. While we 

received no comments specific to the 

add-on inflation adjustment, we did 

receive comment about our growth 

projections used to calculate the 

adjustment. Those comments were 

addressed in the previous section. 

(1) Drug Payments and Dialysis 

Treatments 

Similar to the above mentioned 

process, we updated the total aggregate 

EPO drug spending for hospital-based 

and independent facilities using 

historical trend factors. For 2006, the 

EPO payment level was increased from 

2005 by a trend factor of 11.0 percent. 

We also updated aggregate spending for 

separately billable drugs, other than 

EPO, for both hospital-based and 

independent facilities by a trend factor 

of 15 percent. This procedure resulted 

in projected drug expenditures of $523 

million for drugs provided in hospital 

based facilities ($240 million for EPO 

and $283 million for other drugs) and 

$3.481 billion for drugs provided in 

independent facilities ($2.306 billion for 

EPO and $1.175 billion for other drugs). 

These numbers include an estimated 

reduction for the 50 cent payment for 

syringes of $1.9 million for hospitalbased facilities and $14.1 million for 

independent facilities. We also updated 

the projected number of dialysis 

treatments using actuarial enrollment 

projections. This resulted in total of 35.6 

million treatments for 2006. 

(2) Adjustment to Composite Rate AddOn 

The proposed computation of the 

2006 inflation adjustment to the 

composite rate was 0.8 percent. We have 

updated our projected inflation 

adjustment for the drug add-on and 

have included data for non-EPO 

hospital-based drugs into the 

computation. 

Since EPO is updated at an average 

trend of 11 percent and other separately 

billable drugs are updated by a trend 

factor of 15 percent, for both hospitalbased and independent facilities, for 

2006 we computed a combined 

weighted average growth in total drug 

expenditures of 12.3 percent, based on 

the relative proportions of EPO and nonEPO drugs. We then applied the 12.3 

percent projected growth in aggregate 

drug expenditures between 2005 and 

2006 to the 2005 drug add-on figure of 

$585 million. This resulted in a 

projected incremental increase in the 

drug spread for 2006 of $72 million ($9 

million for drugs furnished by hospitalbased facilities and $63 million for 

drugs furnished by independent 

facilities). We distributed the $72 

million over 35.6 million projected 

treatments, resulting in a 1.4 percent 

increase to the 2005 composite payment 

rate. 

Comment: We received a number of 

comments regarding an annual update 

factor. Several comments recommended 

that we should provide an annual 

update to the composite rate. The 

specific recommendation suggested an 

annual market basket update in the 

composite rate equivalent to the 

MedPAC recommendation of an 

increase to the composite payment rate 

of 2.5 percent in 2006. The comments 

further acknowledged that the creation 

of an annual market basket update 

requires Congressional action. 

Response: Because Congressional 

action is required, there is no specific 

provision in the current statute or 

regulations for an annual update for the 

composite payment rate based on the 

ESRD market basket rate of increase. 

However, the statute does, in effect, 

provide for an annual update to the drug 

add-on to the composite payment rate. 

As discussed previously, the statute 

requires that we annually update the 

amount of the drug spread included in 

the composite payment rate, based on 

the projected growth in drug 

expenditure between 2005 and 2006. 

We are providing an inflation 

adjustment to the composite payment 

rate of 1.4 percent. Even though this 

inflation adjustment is part of the 

overall add-on adjustment, the overall 

effect for 2006 is equal to an update of 

1.4 percent. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70167 

In addition, we note that as part of our 

work on the development of a fully 

bundled prospective payment system 

(PPS) for ESRD facilities, we will be 

developing an update framework that 

would include an ESRD market basket 

factor. We expect to include a 

discussion of this update framework as 

part of a Report to Congress on a fully 

bundled PPS for outpatient ESRD 

facilities. This report is still under 

development. 

Comment: One comment stated that 

the add-on adjustment to the composite 

rate should be reflected as an absolute 

dollar amount rather than a percentage, 

stating that there is no logical reason 

why the drug add-on component should 

be adjusted by a wage index. 

Response: Section 1881(b)(12)(A) of 

the Act which was added by the MMA, 

required the establishment of a ‘‘casemix adjusted prospective payment 

system for dialysis services’’ that 

included: (1) The composite rate; (2) 

case-mix adjustment for a limited 

number of patient characteristics; and 

(3) a drug add-on adjustment to the 

composite rate to account for the 

difference in drug payments compared 

to the previous drug pricing 

methodology. Section 1881(b)(12)(D) 

requires that payments under this 

system be adjusted by a geographic 

index. Therefore, we are required to 

apply the wage index to all components 

of the case-mix adjusted composite rate 

system. 

c. Drug Add-On Adjustment for 2006 

With the CY 2005 add-on to the per 

treatment composite rate being 13.1 

percent and the additional increment for 

expenditures in CY 2006 being 1.4 

percent, the combined drug add-on 

adjustment for 2006 is 14.7 percent 

(1.131 × 1.014). 

3. Revisions to Geographic Designations 

and Wage Indexes Applied to the ESRD 

Composite Payment Rate 

Section 1881(b)(12)(D) of the Act, as 

added by section 623(d) of the MMA, 

gave the Secretary the discretionary 

authority to revise the current wage 

index incorporated in the ESRD 

composite payment rates. That 

provision also requires that any revised 

wage index be phased in over a 

multiyear period. We proposed to adopt 

OMB’s revised geographic definitions 

(announced in OMB Bulletin No. 03–04, 

issued June 6, 2003) to determine urban 

and rural locales for purposes of 

calculating ESRD composite payment 

rates, beginning January 1, 2006. In 

conjunction with using OMB’s 

geographic designations, we proposed to 

recalculate the ESRD wage index based 

on acute care hospital wage and 

employment data for FY 2002, as 

reported to us in connection with 

development of the wage index used in 

the inpatient hospital prospective 

payment system (IPPS). We also 

proposed to update the labor portion of 

the ESRD composite rate to which the 

wage index is applied. Below we 

discuss comments we received on these 

proposals and our final determinations 

regarding CY 2006 revisions to the wage 

index adjustment as it is applied to the 

ESRD composite payment rate. 

a. Use of Revised OMB Geographic Area 

Designations To Determine Urban and 

Rural Locales for ESRD Composite 

Payment Rates 

In the August 8, 2005 proposed rule, 

we proposed to use OMB’s revised corebased statistical area (CBSA)-based 

definitions for Metropolitan Statistical 

Areas, New England County 

Metropolitan Areas, and Micropolitan 

Statistical Areas, announced in OMB 

Bulletin 03–04 (June 6, 2003) as the 

basis for revising the urban/rural locales 

and corresponding wage index values 

reflected in the composite payment 

rates. The definitions we proposed are 

the same urban and rural definitions 

used for the Medicare IPPS, but without 

regard to geographic reclassifications 

authorized under section 1886(d)(8) and 

(d)(10) of the Act. In conjunction with 

adopting OMB’s geographic 

classifications, we proposed replacing 

the current weighted wage index based 

on a 60/40 blend of Bureau of Labor 

Statistics (BLS) and hospital wage index 

values with one developed exclusively 

from acute care hospital wage and 

employment data obtained from the 

Medicare hospital cost reports. We 

proposed to update the wage index 

annually. For a full discussion of our 

proposals, see the August 8, 2005 

proposed rule (70 FR 45793 through 

45800). The following section contains 

a summary of the comments that we 

received on the proposed wage index 

revisions. 

Comment: Several commenters, 

generally those representing 

independent ESRD facilities located in 

rural areas, opposed implementation of 

the CBSA based wage index. The 

commenters expressed concern that the 

proposed wage index would jeopardize 

beneficiary access to care, and left little 

protection for rural facilities. Some 

commenters pointed out the amount of 

the reduction in composite payments 

that specific providers would incur 

based on the proposed urban/rural 

definitions and revised wage index 

values. 

Response: The current urban/rural 

definitions reflected in the composite 

payment rates have been in effect for 

over 20 years, and needed to be 

updated. By revising those definitions to 

conform with the latest available OMB 

geographic designations as explained in 

the August 8, 2005 proposed rule, we 

believe that we are complying with the 

express intent of the Congress 

permitting revision of those 

designations, as set forth in section 

1881(b)(12)(D) of the Act. While our 

authority to revise the current ESRD 

wage index is discretionary, we believe 

this revision is essential if the 

composite rates are to reflect accurately 

the costs of providing ESRD services. 

None of the commenters proposed an 

alternative to our proposed geographic 

classification system. Because we must 

have a national classification system 

built on clear objective standards, we 

are adopting the CBSA based urban/ 

rural definitions, as described in our 

proposed rule. As to commenters’

concerns about any reductions in the 

base composite payment rates, we have 

taken these concerns into consideration 

and have adopted a transition policy 

concerning the wage index. We address 

commenter’s comments and provide a 

more detailed discussion of our 

transition policy in section II.3.c. of this 

final rule with comment. 

Comment: While several commenters 

supported the implementation of the 

new CBSA based wage index, they 

expressed concern over the potential 

impact on independent ESRD facilities, 

particularly those located in rural areas. 

The most frequent recommendations to 

reduce the impact of any payment 

reductions were to extend the proposed 

transition period from 2 to 5 years, and 

provide annual updates of the wage 

index in each of those years. 

Response: We agree that the new 

CBSA based wage index should be 

revised periodically to account for not 

only changes in labor market 

conditions, but also any future revisions 

in the definitions of the Metropolitan 

Statistical Areas and other geographic 

designations which may be announced 

by OMB. We will revise the ESRD wage 

index annually using the most recent 

Medicare cost report data as is used in 

the Medicare hospital IPPS. We also 

agree that the proposed transition 

period of 2 years may not be sufficiently 

long to provide ESRD facilities with 

enough time to adapt to the new wage 

index and have extended the transition 

period to 4 years. For a more complete 

discussion of our policies to help ESRD 

facilities adapt to the OMB geographic 

designations and wage index revisions 

70168 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

we have adopted for ESRD purposes 

(see section C of this preamble). 

Comment: Several commenters 

endorsed our adoption of the proposed 

wage index based on the revised OMB 

definitions. However, the commenters 

were critical of what they perceived to 

be a lack of transparency in the data and 

methodology used to develop the new 

wage index, especially the budget 

neutrality adjustment. The commenters 

requested that we provide the data and 

methodology used to calculate the new 

wage index values and BNF. 

Response: For purposes of adjusting 

the labor-related portion of the CY 2006 

ESRD composite rate, we are using the 

most recent hospital wage data 

applicable to FY 2006 payments as 

discussed previously in this section. We 

start with the wage index used by the 

Skilled Nursing Home Prospective 

Payment System (SNF PPS) and 

multiply this index by a numeric factor, 

which is the budget neutrality 

adjustment. We use the SNF PPS wage 

index because we believe it reflects the 

most recent data, and is consistent with 

all other non-acute care facility payment 

systems. 

As explained earlier in this section, 

we begin with the same wage index 

values as those used by the SNF and 

multiply those values by the BNF (See 

Tables 21 and 22). The methodology for 

creating this wage index BNF is 

explained in further detail below. 

The wage index measures relative 

differences in the average hourly wage 

for the hospitals in each labor market 

area compared to the national average 

hourly wage. As stated previously, for 

ESRD payment purposes the wage index 

values are based on wage data as 

reported by hospitals on their Medicare 

cost reports. The wage data used to 

construct the wage index are updated 

annually, based on the most current 

data available. Accordingly, 2002 wage 

data were used to construct the wage 

index values used in this final rule with 

comment and 2003 wage data will be 

used to construct the wage index that 

we intend to use for the ESRD 

composite rate for CY 2007. 

For each geographic area, wage data 

for all providers in that area are 

combined. The sum of all wages for all 

providers in that geographic area is 

divided by the total hours for all 

providers in that geographic area. The 

result is the average hourly rate for that 

geographic area. This data can be found 

at the following link: http:// 

www.cms.hhs.gov/providers/hipps/ 

ippswage.asp. 

The data will be found under the 

section labeled, ‘‘FY 2006 Wage Index 

Public Use Files’’, and contains average 

hourly rate data and wage index. The 

index is computed by dividing the 

average hourly rate for each geographic 

area within the CBSA by the national 

average hourly wage. 

As we noted earlier, for the ESRD 

wage index we are using hospital wage 

data without regard to any approved 

geographic reclassification authorized 

under sections 1886(d)(8) and (d)(10) of 

the Act or other provision that only 

applies to hospitals paid under the 

IPPS. For purposes of the ESRD wage 

index methodology, the data we use is 

pre-reclassified, pre-floor hospital data 

and unadjusted by occupational mix. 

The final step is to multiply each 

wage index value by the wage index 

budget neutrality factor (BNF) (see 

section 4 for details about this 

adjustment). 

Comment: One commenter strongly 

objected to our proposed 

implementation of the CBSA based 

wage index. The commenter maintained 

that we have failed to examine the 

entire dialysis patient delivery system 

taken as a whole. Specifically, we have 

not recognized that rural facilities 

generally have lower utilization, and 

consequently higher costs per treatment, 

especially for overhead and supplies, 

compared to urban facilities. The 

commenter offered three options for 

consideration-the establishment of one 

composite rate for all dialysis facilities, 

the creation of a special composite rate 

adjustment factor that compensates 

rural facilities for their higher overhead 

costs due to lower utilization, or the 

creation of an explicit exception for 

higher rural facility overhead costs. 

Response: We recognize that large 

chain dialysis providers operate with 

the benefit of economies of scale, and 

may be better able to adapt to the impact 

of policy changes to the composite 

payment rates. However, we have no 

evidence to indicate that rural facilities 

have higher overhead and supply costs 

per treatment. Payments to rural 

facilities are lower compared to urban 

facilities because rural facility 

composite rate costs, including labor 

costs, are generally lower. We do not 

believe our use of a CBSA-based wage 

index would change our conclusion, 

however, as noted below, we will 

continue to monitor provider cost data. 

Moreover, section 623(b) of the MMA 

and section 422(a)(2) of BIPA prohibit 

the granting of new exceptions for the 

composite rate, except for pediatric 

ESRD facilities. 

b. Revised Labor-Related Portion 

The current composite rate wage 

index is applied to two different laborrelated shares, 40.65 percent for 

independent facilities and 36.78 percent 

for hospital-based facilities. Given the 

age of the cost data used to develop 

these shares, we proposed revising the 

labor-related portion of the composite 

rate based on the ESRD composite rate 

market basket contained in our May 

2003 Report to Congress on developing 

a bundled outpatient ESRD payment 

system. We proposed the use of a single 

labor-related share of 53.711 percent 

that would apply to both hospital-based 

and independent facilities. This 

proportion was based on the sum of the 

labor-related categories of costs that 

comprise the ESRD market basket. (70 

FR 45796 through 45798). We received 

the following comments on this 

proposal. 

Comment: One commenter criticized 

our use of the ESRD composite rate 

market basket developed from CY 1997 

data to revise the labor related-portion 

of composite rate costs subject to wage 

index adjustment. The commenter 

maintained that the use of more recent 

cost report data to develop a revised 

labor-related share would be more 

reflective of current economic realities. 

Another commenter recommended that 

we use the hospital market basket, 

which was developed from fiscal year 

2002 data, instead. The commenter 

reasoned that the hospital market basket 

would be a more appropriate measure, 

not only because it reflects more recent 

data, but also because ESRD facilities 

compete with hospitals for labor and 

use the same vendors for supplies. 

Response: Calendar year 1997 was the 

most recent year for which relatively 

complete data were available when the 

ESRD composite rate market basket was 

developed in 2003. Until the ESRD 

market basket is rebased to incorporate 

later data, we believe it is proper to use 

the 1997-based ESRD composite rate 

market basket to determine the laborrelated share because it reflects the cost 

structures of ESRD facilities serving 

Medicare beneficiaries. We will 

continue to evaluate the available data 

on ESRD facilities and expect to 

periodically rebase the ESRD market 

basket when appropriate. 

We disagree with the commenter’s 

recommendation to use the 2002-based 

hospital market basket to determine the 

labor-related share for ESRD facilities. 

We believe the 1997-based ESRD market 

basket best reflects the types of medical 

services and cost structures used by 

ESRD facilities. This is consistent with 

other payment systems that use 

individually tailored market baskets to 

determine their labor-related share. 

Comment: One commenter attempted 

to replicate the basic composite 

payment rate (that is, the payment rate 

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prior to application of the drug add on 

and patient specific case-mix 

adjustments) for the Orlando, Florida 

MSA. The commenter inquired whether 

the proposed revised wage index for 

each urban/rural area is applied to 40 

percent or 100 percent of the wage 

adjustment reflected in the current 

composite payment rates. 

Response: The published wage index 

applicable to each urban/rural area is 

neither applied to 40 percent nor 100 

percent of the composite payment rate’s 

current wage adjustment. We currently 

multiply the current wage index by one 

of two different labor-related portions of 

the composite payment rates, depending 

on the type of ESRD facility. The 

portion is 40.65 percent for independent 

facilities and 36.78 percent for hospitalbased facilities. However, the composite 

rate wage index itself is a blend of two 

separate wage index values. Of the 

current measure, 40 percent, is based on 

the hospital wage index calculated from 

fiscal year 1986 data, and 60 percent is 

based on the hospital wage index 

calculated from 1980 BLS data. 

However, in our August 8, 2005 

proposed rule, we proposed making the 

labor-related portion the same for both 

hospital-based and independent ESRD 

facilities. That proportion (53.711 

percent) was developed from the laborrelated components of the ESRD 

composite rate market basket. Moreover, 

the proposed wage index is not a 

blended measure. It was developed 

exclusively from hospital wage and 

employment data for fiscal year 2002 

obtained from the Medicare hospital 

cost reports. We proposed to apply the 

proposed wage index values to 100 

percent of the 53.711 percent laborrelated share. The revised labor-related 

shares applicable to hospital-based and 

independent ESRD facilities were 

contained in Table 26 of our proposed 

rule. Using data contained in Table 26 

in our proposed rule, we calculated that 

the basic composite payment rate for 

hospital-based ESRD facilities in the 

Orlando MSA would have been $71.12 

× 0.9677 + $61.29 or $130.11. For 

independent facilities the rate would 

have been $68.94 × 0.9677 + $59.41 or 

$126.12. 

c. Adoption of Floor/Ceiling Wage Index 

Values and Transition Policies for 

Implementation of Revised Wage Index 

The wage index values in the current 

composite payment rates reflect a floor 

of 0.90 and a cap of 1.30. In the August 

8, 2005 rule, we proposed eliminating 

the cap because of the effect it has had 

on restricting payments in high wage 

areas. While we stated that we would 

like to remove the floor as well, we were 

concerned that its immediate 

elimination could adversely affect 

beneficiary access to dialysis. To 

mitigate any potential adverse impact, 

we proposed a gradual reduction in the 

floor to 0.85 for 2006 and 0.80 in 2007, 

with a reevaluation of continued need 

for the floor in 2008. 

We also proposed a 2-year transition 

for implementation of the new 

composite payment rates, but only for 

those facilities whose CBSA based 

payment decreased. Under the proposed 

transition, facilities would be paid the 

higher of the new wage adjusted 

composite rate, or a 50–50 blend of the 

current wage adjusted rate and the new 

wage adjusted rate (70 FR 45798 

through 45799). We received the 

following comments regarding the 

proposed ceiling and floor wage index 

values and the 2-year transition period. 

Comment: Several commenters 

representing facilities whose payment 

rates would increase as a result of the 

revised urban/rural definitions and 

wage index values, endorsed the 

immediate introduction of the new basic 

composite payment rates. Other 

commenters either supported the 

proposed 2-year transition period, or 

recommended longer transitions of 

varying duration to mitigate further the 

impact of reduced composite payments. 

Response: Most commenters endorsed 

our proposal to provide for a transition 

period to mitigate the impact of the 

revised CBSA based composite payment 

rates, but believed that a 2-year 

transition was too short. The 

recommended transition periods, 

generally ranged from 3 to 5 years, with 

several commenters supporting a 

transition period of 5 years. We agree 

that a longer transition period is 

appropriate to allow ESRD facilities 

sufficient time to adjust to the new 

CBSA based wage index, and have 

selected 4 years as a reasonable 

compromise among the recommended 

alternatives. While a 4-year transition is 

longer than the transition in other 

payment systems, we believe it is 

justified in the case of ESRD facilities 

because the wage data currently used for 

the wage index is over 20 years old. 

Thus, facilities need more than the 

usual transition. However, we will 

apply the 4-year transition period to all 

ESRD facilities, those whose base 

composite payment rates compared to 

those currently in effect increase as well 

as decrease. This represents a change 

from our proposed policy of applying a 

transition period only to those facilities 

whose composite payment rates 

decreased. We believe that a transition 

period of 4 years applied to all ESRD 

facilities achieves a reasonable balance 

between cushioning the impact for 

providers whose CBSA based composite 

payment rates decrease, and 

implementing the CBSA based wage 

index as quickly as possible. 

Comment: We received several 

comments on our proposal to reduce 

gradually the wage index floor from its 

current level of 0.90, to 0.85 in 2006 and 

0.80 in 2007. The comments included 

keeping the floor at 0.90, maintaining 

the floor at 0.90 but simultaneously 

increasing the ceiling from its current 

level of 1.30 to 1.40, and phasing out the 

floor as proposed, but also extending the 

phase out to the wage index ceiling as 

well. 

Response: We recognize that only 

immediate elimination of the 0.90 floor 

could substantially reduce composite 

payments in locales where prevailing 

labor costs are lower. Although ESRD 

facilities in areas with wage levels 

below 0.90 have benefited from the 

application of the floor, we are 

concerned that its sudden elimination 

could adversely affect ESRD beneficiary 

access to care. 

In the August 8, 2005 rule, we 

proposed lifting the wage index cap of 

1.30 entirely in 2006 because it has 

restricted payments in areas with high 

labor costs. Under our proposal ESRD 

facilities whose base composite 

payment rate increased would receive 

the full payment amount per treatment 

without regard to the cap. 

We have carefully reconsidered our 

proposal in light of concerns over the 

potential impact of the use of new 

CBSA-based geographic designations 

and wage index values on ESRD 

facilities that will experience a decrease 

in their composite payments. We 

believe that it would be more consistent 

and equitable for all ESRD facilities if 

we phased out the wage index floor and 

eliminated the ceiling. Accordingly, we 

are implementing a 4-year transition 

period that will apply to all ESRD 

facilities, those experiencing either an 

increase or decrease in their base 

composite payment rate for 2006. 

Although the present wage index ceiling 

of 1.30 will be eliminated in 2006, 

facilities whose payments have been 

restricted by the ceiling would not 

receive 100 percent of their otherwise 

applicable base composite payment per 

treatment without the ceiling until 2009. 

This occurs as a result of blending the 

proportion of old MSA and new CBSA 

based wage adjusted composite rates 

over the 4-year transition period as 

shown in Table 20. By applying blended 

shares during the 4-year transition 

period to all ESRD facilities, we believe 

we can achieve a balance between our 

goals of preserving access to care in low 

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wage areas and the ultimate elimination 

of constraints on the wage index. The 

wage index floors, caps, and blended 

shares of the base composite payment 

rates applicable to all ESRD facilities for 

CYs 2006 through 2009 are detailed in 

Table 20. 

TABLE 20.—WAGE INDEX TRANSITION BLEND

CY payment Floor Ceiling Old MSA New CBSA 

2006 ......................... 0.85 * ......................................................... None .......................................................... 75 25 

2007 ......................... 0.80 * ......................................................... None .......................................................... 50 50 

2008 ......................... Reassess ................................................... None .......................................................... 25 75 

2009 ......................... Reassess ................................................... None .......................................................... 0 100 

* Each wage index floor is multiplied by a budget neutrality adjustment factor. For CY 2006 the budget neutrality adjustment is 1.045287 resulting in an actual wage index floor of .8885. 

We plan to reassess the continuing 

application of the wage index floor in 

connection with the 2008 update to the 

composite payment rates. 

An example of how the base 

composite payment rates would be 

blended during the 4 year transition 

period to reflect the old MSA and new 

CBSA based geographic designating 

follows. 

Assume an ESRD facility whose base 

composite payment rate (that is, without 

regard to any case-mix adjustments) is 

$135.00 per treatment in 2005. Based on 

the new CBSA wage index designations, 

its base composite payment rate is 

$145.00 for 2006. This facility’s blended 

rate during each year of the 4 year 

transition period would be as follows: 

CY 2006—.75 × $135.00 + .25 × $145.00 

= $137.50 

CY 2007—.50 × $135.00 + .50 × $145.00 

= $140.00 

CY 2008—.25 × $135.00 + .75 × $145.00 

= $142.00 

CY 2009—0 × $135.00 + 1.0 × $145.00 

= $145.00 

Of course, this hypothetical assumes 

that the calculated rate of $145.00 for 

2006 will not change in 2007 and the 

following years. In actuality, it would 

because of annual revisions to the wage 

index. However, the example serves to 

illustrate how the new CBSA-based 

composite payment rates will be 

phased-in during the 4 year transition 

period, regardless of whether an ESRD 

facility’s base composite payment 

increases or decreases in 2006 compared 

to 2005. 

Comment: One commenter endorsed 

our proposed elimination of the wage 

index cap, but was concerned that 

isolated rural ESRD facilities, whose 

wage levels are generally lower than 

those prevailing in urban locales, could 

be adversely affected, even with the 

proposed floor wage index values. The 

commenter recommended that these 

facilities continue to be permitted to 

receive the isolated essential facility 

exception to their otherwise applicable 

composite payment rate under 

§ 413.186. 

Response: ESRD facilities which have 

been granted exceptions to their 

composite payment rates, including 

those granted under the authority of 

§ 413.186, have the option of either 

retaining their exceptions, or becoming 

subject to the case-mix adjusted 

composite payments, at any time. 

Beyond this option, we have no 

discretion to grant new exceptions 

under § 413.186. Section 422(a)(2) of 

BIPA, as amended by section 623(b) of 

the MMA, eliminated the granting of 

new exceptions to the composite 

payment rates except for ESRD facilities 

qualifying as pediatric facilities. We 

believe that the wage index floors of 

0.85 for 2006 and 0.80 for 2007, the 

extension of the transition period from 

2 to 4 years, and affording facilities the 

option of retaining previously granted 

exceptions, should help cushion any 

potential adverse impact to ESRD 

facilities located in isolated rural areas. 

Comment: Several commenters 

expressed particular concern over the 

relatively large reduction in payment 

rates for dialysis facilities in certain 

rural areas and in certain States. While 

most of these locales were unspecified, 

some commenters used Ohio out as an 

example, noting that implementation of 

the revised wage index would reduce 

payment rates in Ohio by more than 

$14.00 per treatment. The commenters 

requested that we provide a State 

specific impact analysis, delay 

implementation of the proposed revised 

composite payment rates for a 6-month 

period, and engage in dialysis 

community discussions to determine 

whether changes to the proposed wage 

index floor values and modification of 

the proposed 2-year transition period, 

would be necessary. 

Response: We strive to engage in 

discussions with the dialysis 

community concerning ESRD payment 

policies, such as our open door forums 

where the dialysis community can 

provide input to CMS on ESRD issues. 

Moreover, as noted previously, based in 

part on the comments received we are 

implementing revisions to our proposed 

policies regarding continuation of the 

wage index floor and ceiling, and the 

duration of the transition period. These 

changes should lessen the impact of our 

adoption of CBSA-based geographic 

designations and revised wage index 

values for ESRD services. We believe 

that no 6-month delay in implementing 

the revised composite payment rates is 

necessary. To respond to the 

commenter’s suggestion that we provide 

a State-specific impact analysis, we 

have provided this information in Table 

52. We are extending the proposed 2- 

year transition to a 4-year transition to 

allow affected facilities to adjust to the 

revised wage indices. 

Comment: We received several 

comments which endorsed a phase in of 

the new CBSA based wage index based 

on a 50/50 split, similar to the wage 

index adopted in connection with the 

FY 2006 SNF PPS. 

Response: The FY 2006 SNF PPS, 

published in the Federal Register on 

August 4, 2005 (70 FR 45026), adopted 

a wage index consisting of a blend of 50 

percent of the FY 2006 MSA-based wage 

index, and 50 percent of the FY 2006 

CBSA-based wage index, both of which 

were developed from FY 2002 hospital 

wage data (70 FR 45041). This blended 

wage index is effective for a 1 year 

period. As the current ESRD wage index 

is obsolete, we see no reason to use it 

as a part of a blended measure which 

would then reflect an outdated wage 

index as part of a transition mechanism. 

4. ESRD Wage Index Budget Neutrality 

Section 623(d) of MMA added section 

1881(b)(12)(E)(i) to the Act which 

requires that any revisions to the ESRD 

composite rate payment system as a 

result of the MMA provision (including 

the geographic adjustment) be made in 

a budget neutral manner. This means 

that aggregate payments to ESRD 

facilities in CY 2006 should be the same 

aggregate payments that would have 

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been made if we had not made any 

changes to the geographic adjusters. We 

proposed to apply a budget neutrality 

adjustment factor directly to the revised 

ESRD wage index values, rather than 

applying the adjustment to the base 

composite payment rates. We believe 

this is the simplest approach since it 

allows us to maintain a base composite 

rate for hospital-based facilities and one 

for independent facilities during the 

transition from the current wage 

adjustments to the revised wage 

adjustments. The proposed budget 

neutrality adjustment was 1.023024. 

For CY 2006, we will apply the 

budget neutrality adjustment factor 

directly to the revised ESRD wage index 

values. Since we will be transitioning to 

the new wage index over a 4-year 

period, the computation of the 

adjustment factor varies slightly from 

our proposal. However, the basic 

method and concept is still the same as 

we proposed. 

In order to compute the proposed 

wage index BNF, we used treatment 

counts from CY 2004 billing data and 

facility-specific CY 2005 composite 

payment rates. For purposes of adjusting 

the labor-related portion of the CY 2006 

ESRD composite rate, we are using the 

most recent hospital wage data 

applicable to FY 2006 payments as 

discussed previously in this section. 

Using treatment counts from the 2004 

claims and facility-specific CY 2005 

composite payment rates, we computed 

the estimated dollar amount each ESRD 

provider would have received had there 

been no changes to the ESRD wage 

index. This becomes the target amount 

of expenditures for all ESRD facilities. 

Then we computed the estimated dollar 

amount that would have been paid to 

the same ESRD facilities using the 

revised ESRD wage index (including the 

4-year transition). In the first year of the 

transition, ESRD facilities receive 25 

percent of the CBSA wage adjusted 

composite rate and 75 percent of the 

current composite rate. This becomes 

the first year new amount of 

expenditures for all ESRD facilities. 

After comparing these two dollar 

amounts (target amount divided by first 

year new amount), we calculate an 

adjustment factor that, when multiplied 

by the ESRD wage index, will result in 

the target amount of expenditures for all 

ESRD facilities. Since the ESRD wage 

index is only applied to the laborrelated portion of the composite rate 

payment, we computed the adjustment 

based on that proportion (53.711 

percent). We apply the estimated budget 

neutrality adjustment factor to the 

revised wage index values for CY 2006 

to ensure that estimated aggregate 

payments to ESRD facilities would 

remain budget neutral. The final wage 

index BNF adjustment factor is 

1.045287. 

Applying this budget neutrality to the 

wage index floor of 0.8500, results in a 

wage index floor for 2006 of 0.8885. 

As stated earlier, the data used to 

compute the BNF are the wage index 

values in Table 21 and 22, the 2004 100 

percent Outpatient Standard Analytic 

File (SAF) Claims, and geographic 

location information for each facility 

which may be found through Dialysis 

Facility Compare. 

Comment: Several commenters 

requested that we provide the data and 

methodology used to compute the wage 

index BNF. 

Response: The purpose of the wage 

index BNF is to achieve budget 

neutrality as required by section 623(d) 

of the MMA, which added section 

1881(b)(12)(E)(i) to the Act. That 

provision of the Act requires that any 

revisions to the ESRD composite rate 

payment system (including the 

geographic adjustment) must be made in 

a budget neutral manner. This means 

that aggregate payments to ESRD 

facilities in CY 2006 should be the same 

as aggregate payments that would have 

been made if we had not made any 

changes to the geographic adjusters. The 

methodology for computing the wage 

index BNF is described earlier in this 

section. 

The data used to compute the BNF are 

the wage index values in Tables 21 and 

22, the 2004 100 percent Outpatient 

Standard Analytic File (SAF) Claims, 

and geographic location information for 

each provider which may be found 

through Dialysis Facility Compare. 

Dialysis Facility Compare can be found 

by going to the following link: http:// 

www.medicare/Download/ 

DOWNLOADDB.asp. 

d. Wage Index Table 

The following two tables show the 

ESRD wage indexes for urban areas 

(Table 21) and rural areas (Table 22). 

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4. Miscellaneous Comments on ESRD 

Issues 

We propose to make no changes to the 

existing case-mix adjustment system. 

We proposed to maintain the existing 

system as established in the CY 2005 

final rule (69 FR 66238) and 

implemented on April 1, 2005. 

Comment: One commenter 

recommended that we stop the 

implementation of the basic case-mix 

adjustment. The commenter was critical 

of the case-mix adjustment because this 

commenter could not calculate the 

impact on their payment of one of the 

case-mix variables, specifically, weight. 

This commenter did not want to report 

weight as a case-mix variable because of 

the fluctuations in this variable, that is, 

weight changes. 

Response: Section 623(d)(1) of the 

MMA added section 1881(b)(12)(A) of 

the Act requiring that the outpatient 

dialysis services included in the 

composite rate be case-mix adjusted. 

Case-mix variables are characteristics of 

the patients served that enable payment 

systems to reflect the resources needed 

by patients. The statute required 

adjustments to the composite payment 

rate for a limited number of patient 

characteristics. We implemented the 

case-mix adjustments required by the 

statute in April 2005, using research on 

case-mix variables to support our 

selection of a limited number of casemix adjusters. A report on that research, 

entitled, ‘‘Methodology for Developing a 

Basic Case-mix Adjustment for the 

Medicare ESRD Prospective Payment 

System’’ is available on 

www.sph.umich.edu/kecc. The selected 

case-mix adjusters are age, low body 

mass index (BMI), and body surface area 

(BSA). BSA and low BMI were selected 

because they are a better predictor of 

cost of care than using weight alone. 

Height and weight are the case-mix 

variables that we use to calculate BMI 

and BSA adjusters. For this reason, and 

because we think that facilities should 

be easily able to report a case-mix 

variable that should be part of each 

patient’s ongoing care plan, we will 

continue to require reporting of the 

patient’s weight for purposes of 

calculating the case-mix adjusters. 

Comment: There were several 

comments recommending that we 

explore the option of adding variables to 

the existing basic case-mix adjustments. 

Commenters recommended including 

variables that measured improved 

survival rates, creating a new code for 

ESRD patients with diabetes, and 

adding measures that reflect 

improvements in the quality of life for 

ESRD patients. Comments indicated that 

the current case-mix adjustments do not 

adequately compensate providers for 

resources used or the intensity of care 

that is required to provide services to 

the frail elderly, and patients with 

ambulatory limitations or selected 

comorbid conditions. In addition, 

commenters recommended that we 

should consider a variable that adjusts 

for time in treatment; specifically 

recommending that we consider the 

potential predictive power of a variable 

that exported the interval following the 

initial 6 months of ESRD treatments 

because the intensity of care and 

resources could increase. 

Response: We indicated in the 

proposed rule that we anticipated 

maintaining the basic case-mix 

adjustment as established in the CY 

2005 final rule (69 FR 66238) and 

implemented on April 1, 2005. 

Although we understand the comments 

that we explore additional case-mix 

variables, we do not currently have the 

data that would be necessary to analyze 

the current case-mix adjustment 

variables and refine the basic system. 

Therefore, we believe that it is 

premature at this time to add additional 

variables to the basic case-mix 

adjustment system. Several of the 

variables recommended, including 

intensity of care, survival rates and 

quality of life improvement, are 

excellent recommendations as variables 

for exploration. 

As we stated in the CY 2005 final 

rule, the basic case-mix system is 

adjusts for a limited number of patient 

characteristics, consistent with the 

provisions of section 1881(b)(12)(A) of 

the Act as added by section 623 of the 

MMA. The MMA legislation anticipated 

that work would continue toward the 

development of a more fully bundled 

case-mix payment system for ESRD. We 

are continuing to work towards a more 

fully bundled case-mix system through 

ongoing research and development of a 

demonstration project required by the 

MMA. 

We have a contract with the 

University of Michigan to continue the 

research that was initiated in 2001 to 

explore a number of variables that could 

be predictive of resource use in a fully 

bundled case-mix adjusted system. This 

research will include exploring the 

predictive potential of variables 

available from existing data sources, 

including assessing the potential impact 

of comorbid conditions to predict 

payments. Several of the suggestions, 

specifically, survival rates, assessing 

improvements in the quality of life for 

ESRD patients, developing frailty/ 

ambulatory limitation measures, require 

the construction of classification 

measures of functioning for disability 

and health. These are beyond the scope 

of our existing research efforts; however, 

over time, HHS may include efforts to 

develop classifications of functioning 

for disability and health measures, as 

well as add quality measurements as 

part of our payment systems. 

In addition, we will be assessing the 

data submitted under the existing basic 

case-mix system. As the analysis of this 

data progresses, we will consider 

potential refinements to the basic casemix system. 

We are also working on a 

demonstration project that will assess 

the use of a fully case-mix adjusted 

payment system. Both the 

demonstration and the ongoing research 

will examine the impact of comorbid 

conditions on case-mix and payment. 

Regarding the comment that we 

should create a reimbursement code for 

ESRD patients with diabetes, we note 

that we did analyze comorbid 

conditions as part of the research for the 

basic case-mix system. At that time 

diabetes was not found to be a 

significant predictor. In addition, our 

staff found that the reporting of 

comorbid conditions, including 

diabetes, was frequently limited. 

Therefore, as part of our training effort, 

we have encouraged facilities to report 

all comorbid conditions, and plan to use 

the reported data in our ongoing 

research related to refining the basic 

case-mix system. Thus, we will 

continue to assess the impact of diabetes 

as a case-mix variable and a predictor of 

resource use, but we will not be 

requesting, at this time, the creation of 

a new code for diabetic ESRD patients 

for payment. 

Comment: One commenter expressed 

concern regarding the reporting of 

height and weight for individuals who 

are double amputees. The comments 

indicated because of the case-mix 

adjustments for these individuals, the 

average reimbursement was reduced by 

an average of $20 per treatment even 

though these patients generally require 

the same or additional treatment 

because they could be in a wheel chair 

or possibly transported by stretcher. 

Response: We concur that there may 

be issues surrounding the reporting of 

the height and weight variables 

associated with double amputees. We 

have explored a number of reporting 

options for these patients in an attempt 

to resolve both clinical and operational 

issues related to the reporting of these 

values. We agree that requiring that the 

height for double amputees be measured 

‘‘as they present’’ may not accurately 

measure the necessary dialysis dose, we 

also believe that the reported weight for 

70214 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

these patients would require adjusting if 

we instructed facilities to report height 

‘‘pre-amputation.’’

Based on the available literature 

related to height and weight 

measurements for double amputees, we 

believe there is sufficient data from 

which to appropriately adjust weight if 

height is reported pre-amputation. We 

relied on the methodology in the KDOQI ‘‘Guidelines for Peritoneal 

Dialysis Adequacy.’’ Appendix E, 

Guideline 9 contains instructions 

related to adjustments to weight for 

amputees. Based on those guidelines, 

we are adopting the following formula 

for adjusting weight using the 

adjustment factor for below the knee 

(BKA) double amputees which is the 

most common type of double 

amputation: 

Pre-Amputation Weight = Actual 

Weight × 1.15 

Therefore, for dialysis treatments 

provided on or after January 1, 2006, we 

will revise our claims processing 

instructions related to the reporting of 

height and weight for double amputee 

dialysis patients. Height would be 

reported ‘‘pre-amputation’’ and weight 

would be adjusted by 1.15 to reflect the 

‘‘pre-amputation’’ weight. 

Comment: We received a number of 

comments from ESRD patients 

expressing concern regarding the impact 

that any reductions in payment could 

have on their care. One ESRD patient 

expressed concern that if there were 

payment cuts, the facilities could be 

adversely impacted resulting in 

facilities closing. 

Response: The intent of the changes 

in payments to ESRD facilities was to 

appropriately pay facilities based on the 

characteristics of the patients they treat, 

as well as the wage levels for the areas 

in which they are located. We note that 

all of the changes in payments as a 

result of the MMA legislation were done 

in a budget neutral manner. That is, 

aggregate payments to ESRD facilities 

remain constant. While the result of the 

changes we have made to the wage 

adjustment will result in redistributing 

payments to individual facilities, these 

changes more accurately pay facilities 

based on local wage levels. We 

understand the concerns expressed by 

these patients and have provided for a 

transition from the old, outdated wage 

adjustment to the revised adjustment to 

help mitigate any adverse impact to 

individual facilities. In addition, we 

have provided a 1.4 percent increase to 

the payment facilities receive for 2006 

based on the projected increase in drug 

expenditure between 2005 and 2006. 

5. Revisions to the Composite Payment 

Rate Exceptions Process 

In response to the changes made by 

section 422 of BIPA and section 623 of 

MMA, in the August 8, 2005 proposed 

rule (70 FR 45840 through 45842), we 

proposed changes to the existing 

regulations at § 413.180 through 

§ 413.192 (42 CFR Part 413, Subpart H) 

regarding criteria and application 

procedures for requesting an exception 

to the ESRD composite rate payment. 

We also proposed to revise § 413.170(b) 

to specify that subpart H provides 

procedures and criteria under which 

only a pediatric ESRD facility as 

specified in the statute may receive an 

exception. 

a. Pediatric ESRD Facility Exception 

Existing exception rates are protected 

under section 422(a)(2)(C) of BIPA. The 

‘‘protection’’ clause for existing 

exception rates provides that exception 

rates in effect on December 1, 2000 (or 

approved based on an application by 

July 1, 2001) remain in effect as long as 

the facility’s exception rate is higher 

than the updated composite rate. 

Pediatric ESRD facility exception rates 

granted under the provisions of section 

623 of the MMA (hereinafter referred to 

as ‘‘pediatric facility exception rates’’) 

are not subject to the ‘‘protection’’

clause for existing exception rates. 

However, we proposed to change our 

regulations to continue pediatric facility 

exception rates in the same way as 

existing nonpediatric exception rates. 

Specifically, we proposed that both 

nonpediatric and pediatric facility 

exception rates would remain in effect 

until the facility notifies its fiscal 

intermediary that it wishes to give up its 

rate because its case-mix adjusted 

composite rate is higher. As section 

422(a)(2)(B) of BIPA allows existing 

nonpediatric exception rates to continue 

in effect as long as the exception rate 

exceeds the facility’s updated composite 

payment rate, we expected that each 

facility would compare its existing 

exception rates to its basic case-mix 

adjusted composite rates to determine 

which is the higher rate. We believe the 

determination as to whether an ESRD 

facility’s exception rate per treatment 

will exceed its average case-mix 

adjusted composite rate per treatment is 

best left to the affected entity. 

In the past, an ESRD facility could 

request an exception to its prospective 

composite payment rate within 180 days 

of the effective date of its new 

composite rate (s) or the date on which 

we opened a specific exception 

window. We proposed to revise 

§ 413.180(d) to remove the requirement 

that an application for an exception 

must be filed within the 180-day 

window because we believe that the 

small volume of applications will make 

it feasible for us to accept applications 

on a rolling basis. Therefore, we 

proposed to revise § 413.180(d) to state 

that a pediatric ESRD facility may 

request an exception to its composite 

payment rate at any time after it has 

been in operation for at least 12 

consecutive months. For a full 

discussion of our proposal, see the 

August 8, 2005 proposed rule (70 FR 

45840 through 45842). We received the 

following comments on these issues: 

Comment: Several commenters asked 

for clarification that CMS will continue 

to recognize the exceptions status of non 

pediatric ESRD facilities. The 

commenters stated that the proposed 

rule presents conflicting statements 

about the continuing validity of these 

exceptions. 

Response: We agree, and we are 

revising proposed § 413.180(i) to 

include the statement that ‘‘ESRD 

facilities electing to retain their 

nonpediatric or pediatric exception 

rates (including self-dialysis training) do 

not need to notify their intermediaries.’’

An ESRD facility may notify its fiscal 

intermediary at any time if it wishes to 

give up its nonpediatric or pediatric 

exception rate. Thirty days after written 

notice is received by the intermediary, 

the facility will become subject to the 

new basic case-mix adjusted composite 

payment rate methodology. A facility’s 

decision to give up its exception rate 

can not be subsequently rescinded or 

reversed. 

Comment: One commenter is 

concerned that the composite rate as 

modified by the MMA will be 

maintained for patients under age 18 in 

many facilities that do not qualify for a 

pediatric exception because the 

pediatric population is below 50 percent 

of all patients dialyzed. Patients under 

age 18 require additional resources. The 

commenter recommends that a facility 

should qualify for a pediatric exception 

if 25 percent of its patients are under 21 

years of age. 

Response: Section 623 of the MMA 

amended BIPA to allow a pediatric 

ESRD facility that did not have an 

approved exception rate as of October 1, 

2002, to file for an exception to its 

updated prospective payment rate. To 

apply for the exception rate, the MMA 

requires that the pediatric facility has to 

demonstrate that at least 50 percent of 

its patients are individuals under 18 

years of age. 

We believe the statute is very specific 

regarding the criteria a pediatric ESRD 

facility must satisfy in order to apply for 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70215 

an exception rate. We have incorporated 

these statutory provisions in our 

proposed regulatory changes to 

§ 413.170, § 413.182, and § 413.184. 

However, we note, that regardless of 

whether the pediatric exception is 

available to a facility, pediatric ESRD 

patients (defined as those under the age 

of 18) receive a specific case-mix 

adjustment factor when the composite 

payment rate is determined. None of the 

other case-mix adjustors that apply to 

nonpediatric patients (that is, the five 

age groups, low BMI, and BSA) is 

applicable to pediatric ESRD patients. 

Comment: We received two comments 

supporting the proposed change to 

allow pediatric ESRD facilities to file an 

exception at anytime after it is in 

operation for at least 12 consecutive 

months. 

Response: Previously, a pediatric 

ESRD facility that has been denied its 

exception would have to wait until a 

subsequent exception request. We have 

revised § 413.180(d) to provide that a 

pediatric ESRD facility that has been 

denied an exception may immediately 

file another exception request. However, 

a subsequent exception request must 

address the deficiencies cited in our 

determination letter. 

b. Pediatric Facility Exception Request 

Process 

Section 422 of BIPA prohibited CMS 

from providing exceptions to ESRD 

facilities on or after December 31, 2000. 

Section 623 of the MMA amended BIPA 

by restoring the exception process, but 

only for pediatric facilities that that did 

not have an approved exception rate as 

of October 1, 2002. To file for an 

exception, the pediatric facility would 

have to demonstrate that at least 50 

percent of its patients are individuals 

under 18 years of age. Since the MMA 

restored the exception process only for 

pediatric facilities, we proposed to 

remove existing exception criteria that 

are not applicable to the newly defined 

pediatric facilities, including exceptions 

for isolated essential facilities, 

extraordinary circumstances, and 

frequency of dialysis as specified in 

regulations at § 413.182(b), (c), and (e). 

However, we proposed to retain the 

exception criterion for self-dialysis 

training costs under § 413.182(d) 

because some pediatric facilities may 

qualify for an exception on that basis. 

For a full discussion of our proposal, see 

the August 8, 2005 proposed rule (70 FR 

45841). The comments received on 

these issues and our response to those 

comments are as follows: 

Comment: Several commenters asked 

that we retain the exceptions process for 

all five previous exception criteria in 

order to preserve access to care for 

dialysis patients and to foster evolution 

in the patterns of dialysis care. 

Commenters pointed out that the recent 

experience with Hurricane Katrina 

underscores the need for an exception 

process to provide for continuity of 

dialysis care during extraordinary 

circumstances. Commenters included a 

recommendation that self-dialysis and 

more frequent dialysis should be 

preserved as exception options, noting 

that patients with congestive heart 

failure may require four dialysis 

treatments per week, and this is a 

growing segment of the ESRD 

population. Finally, the commenters 

stated that the exception for isolated 

essential facilities should be retained 

because of the potential impact on 

access to care resulting from the 

proposed changes in the composite 

payment rate wage index and 

reimbursement for ESRD drugs. 

Response: We have determined that 

pediatric facilities would not qualify for 

an exception under most of the existing 

exception criteria because of the 

uniqueness of their patient population 

(at least 50 percent under age 18). In the 

past, ESRD facilities with high 

percentages of pediatric patients only 

qualified for exceptions under the 

‘‘atypical patient mix’’ criterion 

specified at § 413.182(a) and § 413.184. 

We have, therefore, proposed to replace 

the ‘‘atypical patient mix’’ criteria with 

a more specific ‘‘pediatric patient mix’’

criteria and to retain this exception at 

proposed §§ 413.182 and 413.184. We 

proposed to eliminate the exception 

criteria that we believe do not apply to 

facilities with large numbers of pediatric 

patients (that is, exceptions on the basis 

of isolated essential facilities, 

extraordinary circumstances, and 

frequency of dialysis). Based on our 

experience in granting ESRD exceptions, 

we do not believe that a situation exists 

where any newly defined pediatric 

facility with the required volume of 

pediatric patients would qualify for an 

exception under the isolated essential 

facilities criterion. Further, we note that 

previous exception requests for 

‘‘frequency of dialysis’’ were granted to 

ESRD facilities that dialyzed their 

patients less frequently than 3 times a 

week and not more frequently as 

suggested by the commenter. However, 

we proposed to retain the exception 

criterion for self-dialysis training costs 

under § 413.182(d) because we have 

found that some pediatric facilities may 

qualify for an exception on that basis. 

With respect to Hurricane Katrina, we 

have taken into consideration that, in 

this type of emergency (an extraordinary 

circumstance), alternatives exist to 

ensure that ESRD patients will have 

continuing access to services in other 

ESRD facilities. Any ESRD facility that 

has adequate treatment capacity, and is 

located close to a displaced patient’s 

home, would be glad to offer its dialysis 

services. However, if there are no 

remaining ESRD facilities nearby to 

voluntarily accept displaced patients, 

dialysis service will be made available 

to these patients that have been 

temporarily relocated to a local shelter 

or to another town. Displaced patients 

relocated to another town that are 

healthy enough to drive or to be driven 

to a dialysis facility, will receive 

dialysis services there. Displaced 

patients in temporary shelters will 

receive dialysis from providers or 

suppliers that will send the necessary 

equipment, personnel, and supplies to 

the shelter. 

We are finalizing the changes to 

§ 413.180 through § 413.192 as 

proposed. However, we have added 

language to § 413.180 regarding the 

intermediary notification discussed 

above. In addition, we are adding a 

technical clarification to proposed 

§ 413.170 to cross-reference § 413.184 

which specifies pediatric patient-mix 

requirements that pediatric ESRD 

facilities must meet to qualify for an 

exception. 

H. Payment for Covered Outpatient 

Drugs and Biologicals 

Medicare Part B covers a limited 

number of prescription drugs and 

biologicals. For the purposes of this 

rule, the term ‘‘drugs’’ will hereafter 

refer to both drugs and biologicals. 

Medicare Part B covered drugs not paid 

on a cost or prospective payment basis 

generally fall into three categories: 

• Drugs furnished incident to a 

physician’s service. 

• DME drugs. 

• Drugs specifically covered by 

statute (immunosuppressive drugs, for 

example). 

Beginning in CY 2005, the vast 

majority of Medicare Part B drugs not 

paid on a cost or prospective payment 

basis are paid under the ASP 

methodology. The ASP methodology is 

based on data submitted to us quarterly 

by manufacturers. In addition to the 

payment for the drug, Medicare 

currently pays a dispensing fee for 

inhalation drugs, a furnishing fee for 

blood clotting factors, and a supplying 

fee for certain Part B drugs. 

In this section of the preamble we 

discuss the August 8, 2005 (70 FR 

45843) proposed changes and issues 

related to the determination of the 

payment amounts for covered Part B 

drugs and the separate payments 

70216 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

allowable for dispensing inhalation 

drugs, furnishing blood clotting factor, 

and supplying certain other Part B 

drugs. We also discussed proposed 

changes in how manufacturers calculate 

the ASP and in the ASP data reported 

to us. 

1. ASP Issues 

Section 303(c) of the MMA amended 

Title XVIII of the Act by adding new 

section 1847A. This new section 

establishes the use of the ASP 

methodology for payment for most 

drugs and biologicals not paid on a cost 

or prospective payment basis furnished 

on or after January 1, 2005. The ASP 

reporting requirements are set forth in 

section 1927(b) of the Act. 

Manufacturers must submit ASP data to 

us quarterly. The manufacturers’

submissions are due to us not later than 

30 days after the last day of each 

calendar quarter. The methodology for 

developing Medicare drug payment 

allowances based on the manufacturers’

submitted ASP data is specified in the 

regulations in part 414, subpart K. Based 

on the data we receive, we update the 

Part B drug payment amounts quarterly. 

In this section of the preamble, we 

discuss: Our proposed changes related 

to the methodology manufacturers use 

to calculate the ASP and apply the 

estimate of lagged price concessions in 

the ASP calculation; the reporting of 

ASP data; the weighting methodology 

we follow to establish the Medicare 

payment amounts using the ASP data; 

the comments received and our 

responses; and our final policy with 

respect to these issues. 

a. Estimation Methodology for Lagged 

Price Concessions 

Section 1847A(c)(5)(A) of the Act 

states that the ASP is to be calculated by 

the manufacturer on a quarterly basis. 

As a part of that calculation, 

manufacturers are to take into account 

price concessions such as—

• Volume discounts. 

• Prompt pay discounts. 

• Cash discounts. 

• Free goods that are contingent on 

any purchase requirement. 

• Chargebacks. 

• Rebates (other than rebates under 

the Medicaid drug rebate program). 

If the data on these price concessions 

are lagged, then the manufacturer is 

required to estimate costs attributable to 

these price concessions. Specifically, 

the manufacturer sums the price 

concessions for the most recent 12- 

month period available associated with 

all sales subject to the ASP reporting 

requirements. The manufacturer then 

calculates a percentage using this 

summed amount as the numerator and 

the corresponding total sales data as the 

denominator. This results in a 12-month 

rolling average price concession 

percentage that is applied to the total in 

dollars for the sales subject to the ASP 

reporting requirement for the quarter 

being submitted to determine the price 

concession estimate for the quarter. The 

methodology is specified in 

§ 414.804(a)(3). 

We identified a refinement of the ASP 

calculation and lagged price concession 

estimation methodology related to 

chargebacks that we believe improves 

the accuracy of the estimate. As a result, 

we proposed to clarify the ASP 

calculation in the August 8, 2005 

proposed rule (70 FR 5843). 

b. Price Concessions: Wholesaler 

Chargebacks 

Wholesaler chargebacks are a type of 

price concession, generally paid on a 

lagged basis, that apply to sales to 

customers (for example, physicians) via 

a wholesaler (or distributor). Wholesaler 

chargeback arrangements may vary in 

scope and complexity. Under the 

current estimation methodology for 

lagged price concessions, total lagged 

price concessions, including lagged 

wholesaler chargebacks, for the 12- 

month period are divided by total sales 

for that same period to determine a ratio 

that is applied to the total sales for the 

reporting period. The ratio of lagged 

price concessions to sales is calculated 

over all sales, both indirect sales (sales 

to wholesalers and distributors and 

other similar entities that sells to others 

in the distribution chain) and direct 

sales (sales directly from manufacturer 

to providers, such as hospitals or 

HMOs). To the extent that the 

relationship between total dollars for 

indirect sales and total dollars for all 

sales is different for the reporting 

quarter and the 12-month period used, 

the current ratio methodology for 

estimating lagged price concessions may 

overstate or understate wholesaler 

chargebacks expected for the reporting 

period. A more accurate estimation of 

lagged price concessions would 

minimize the effect of quarter to quarter 

variations in the relationship between 

indirect sales and all sales. As a result, 

we proposed to revise § 414.804 to 

require manufacturers to calculate the 

ASP for direct sales independently from 

the ASP for all other sales subject to the 

ASP reporting requirement (indirect 

sales). Then, the manufacturer would 

calculate a weighted average of the 

direct sales ASP and the indirect sales 

ASP to submit to us. 

We believed that the weighted average 

of direct sales ASP and indirect sales 

ASP would improve the overall 

accuracy of the ASP calculation, 

particularly for NDCs with significant 

fluctuations in the percentage of sales 

that are direct sales. 

We proposed conforming changes to 

§ 414.804 for the methodology for 

calculating the lagged price concessions 

percentage. We also proposed to revise 

the regulation to clarify that the 

estimation ratio methodology relates to 

lagged price concessions and also define 

‘‘direct sales’’ and ‘‘indirect sales’’ in 

§ 414.802. In addition, we requested 

comments about the advisability and 

potential effects of requiring 

manufacturers to calculate the ASP for 

direct sales, including price 

concessions, independently from the 

ASP for indirect sales and then 

calculating a weighted average of these 

ASPs to submit to us, as well as the 

proposed definitions of direct sales and 

indirect sales. 

Comment: We received many 

comments on our proposed refinement 

to the ASP calculation. Nearly all of 

these commenters opposed this 

proposal and many asked for 

clarification of the proposed 

terminology. 

All but one of the comments received 

from drug manufacturers stated that the 

proposed change to the ASP calculation 

would require significant modifications 

to manufacturers’ accounting and 

reporting data systems while resulting 

in minimal change or benefit to the 

ASP-based payment. Many commenters 

stated that the proposed modification to 

the ASP calculation would not result in 

more accurate payments. Further, 

comments from groups representing 

drug and biological manufacturers 

stated that they do not believe the 

proposed methodology will have a 

material impact on the overall ASP or 

the accuracy of the calculation. Many of 

the commenters opposing the proposal 

stated that the expense and burden of 

implementing the proposed change to 

the ASP calculation would be 

unjustified because direct and indirect 

sales and price concessions for a given 

product are stable over time, 

particularly for generic products, and 

further breakdown of the calculation 

would not have a significant impact on 

the ASP calculation. Many commenters 

also noted that implementing the 

proposed weighted average approach 

would increase both the complexity of 

the ASP calculation and the potential 

for calculation error. 

We received comments from 

manufacturers of oncology, inhalation, 

contrast media, and other drugs and 

biologicals that included estimates of 

the potential impacts of the proposed 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70217 

modification to the ASP calculation for 

a limited number of NDCs chosen as 

examples. These estimates ranged from 

a slight decrease (less than one half of 

a percent) to a 4.3 percent increase in 

the overall ASP for the NDC. One 

manufacturer estimated that sales would 

have to vary 20 percent from the 12- 

month lag period to change the ASP by 

more than 1 percent. Notwithstanding 

the potential change in the overall ASP, 

all but one manufacturer, which reports 

ASP for a single product, recommended 

that we not adopt the proposed change. 

However, some of these commenters 

suggested that the weighted average 

approach be voluntary or applicable 

only in cases where significant 

fluctuations exist in the proportion of 

sales that are direct and indirect and 

there is a compelling need to apply the 

proposed methodology. Other 

commenters from the manufacturing 

community were concerned about 

consistency across manufacturers and 

recommended that we not leave it up to 

each manufacturer to choose whether to 

use the proposed methodology or not. 

One commenter suggested that the 

proposed methodology be mandatory for 

a manufacturer that has at least one 

NDC with direct sales of 33 percent or 

more of gross sales for the prior year. 

The manufacturer would then be 

required to calculate the ASP for all of 

its NDCs using the proposed 

methodology. 

Several commenters expressed 

concern that the proposed definitions of 

direct and indirect sales were unclear 

and required further clarification to 

ensure consistent application across 

manufacturers. Several commenters 

noted that our use of the term supplier 

was confusing; that it was unclear 

whether GPO sales would be considered 

direct or indirect; and it was unclear 

how utilization rebates to PBMs should 

be categorized. Several commenters 

noted that certain purchasers (for 

example, specialty pharmacies) may 

purchase both directly and indirectly 

during a given reporting period. 

Similarly, we received a comment from 

a drug manufacturer requesting greater 

clarification on how to allocate price 

concessions across direct and indirect 

sales when a customer purchases under 

both of these channels. Several 

manufacturers noted that their current 

data systems were not capable of 

capturing data at the level of detail 

necessary to accurately segregate sales 

into the direct and indirect categories. 

Other commenters noted that, in 

general, manufacturers do not track 

price concessions associated with direct 

or indirect sales. As a result, several 

commenters recommended that, if the 

proposed methodology is adopted, we 

implement the change prospectively to 

allow for a phase-in period and to delay 

implementation until April 2006 or later 

to provide time for systems changes to 

be implemented and tested. 

We received a few comments from 

drug manufacturers expressing their 

belief that other market issues cause 

fluctuation in the ASP, and that it 

would be more beneficial to receive 

guidance on how to resolve these issues. 

A few commenters were concerned 

with the time frame for implementation 

of the proposed modification of the ASP 

calculation. These commenters 

recommended that we consider delaying 

implementation until after a trial period 

or at least until April 2006. 

We also received comments from 

providers who have experienced 

difficulty acquiring drugs at or below 

the payment amount. These 

commenters, as well as comments from 

physician organizations, support 

changes to the ASP calculation insofar 

as they will result in more appropriate 

reimbursements for Part B drugs. 

Response: Our goal is to ensure 

continued beneficiary access to care 

through implementation of accurate and 

sufficient payment systems. To this end, 

we proposed to refine the ASP 

calculation because the weighted 

average of direct sales ASP and indirect 

sales ASP could potentially improve the 

overall accuracy of the ASP calculation. 

We greatly appreciate the efforts 

undertaken by commenters to examine 

the potential impacts of the proposed 

method on the overall ASP calculation. 

Based on the comments received, we 

find compelling the commenters’

concerns about the challenges and 

increased burden associated with 

calculating the ASP independently for 

direct and indirect sales and then 

calculating the weighted average ASP. 

Although we continue to have interest 

in the potential impacts of quarter to 

quarter variations in estimates of price 

concessions, we will not adopt the 

proposed change at this time. 

In reaching our decision, we noted 

that all of the drug manufacturers that 

submitted comments reported that the 

impact of the proposed refinement of 

the ASP calculation would be minimal 

or not material. We note that these 

commenters are in a position to assess 

the impacts of the proposed 

methodology on their customers and to 

weigh the potential benefits and 

burdens inherent with the proposed 

change. In all but one case (a 

manufacturer which reports ASP for 

only one product), they did not support 

the proposal because they believe the 

burden would outweigh the benefit. 

Among the comments received that 

specified potential percentage changes 

in the overall ASP, a range of potential 

impacts was reported. One of the 

examples submitted suggested that the 

impact could extend to upwards of a 4 

percent increase in the ASP for an NDC, 

while another example showed a slight 

decrease. We cannot determine whether 

the reported examples are representative 

of other or all NDCs subject to the ASP 

reporting requirements. 

We also noted the concerns expressed 

by manufacturers regarding the 

significant additional burdens 

associated with the proposed 

methodology, the potential for 

inconsistent application of the proposed 

methodology across manufacturers, and 

the potential effects of the proposed 

methodology on manufacturers’

systems. In addition, we carefully 

considered the comments from the 

physician community in support of 

refinements to the ASP calculation that 

would increase payments. 

Although we are not implementing 

the proposed refinement to the ASP 

calculation at this time, we will 

continue to work with manufacturer to 

better understand the instances in 

which the proposed methodology may 

benefit the program and the potential for 

appropriate use of that methodology for 

certain or all NDCs, and whether such 

an approach would be sustainable. 

We did not receive any comments on 

our proposal to revise the regulations at 

§ 414.804 to clarify that the estimation 

ratio methodology published on 

September 16, 2004 (69 FR 55763), 

relates to lagged price concessions; 

therefore, we will implement the 

revised regulatory language as proposed. 

c. Determining the Payment Amount 

Based on ASP Data 

As explained in the August 8, 2005 

proposed rule (70 FR 45844) in response 

to inquiries we have received related to 

the formula we use to calculate the 

payment amount for each billing code 

we posted information on our web site 

(http://www.questions.cms.hhs.gov) 

earlier this year. We included this 

information (which follows) in the 

proposed rule to ensure greater public 

access to this information. 

• For each billing code, we calculate 

a weighted ASP using the ASP data 

submitted by manufacturers. 

• Manufacturers submit ASP data at 

the 11-digit NDC level. 

• Manufacturers submit the number 

of units of the 11-digit NDC sold and the 

ASP for those units. 

70218 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

• We convert the manufacturers’ ASP 

for each NDC into the ASP per billing 

unit by dividing the manufacturer’s ASP 

for that NDC by the number of billing 

units in that NDC. For example, a 

manufacturer sells a box of 4 vials of a 

drug. Each vial contains 20 milligrams 

(mg). The billing code is per 10 mg. The 

conversion formula is: manufacturer’s 

ASP/[(4 vials × 20 mg)/10 mg = 8 

billable units per NDC]. 

• Then, the ASP per billing unit and 

the number of units (11-digit NDCs) sold 

for each NDC assigned to the Billing 

Code are used to calculate a weighted 

ASP for the billing code. We sum the 

ASP per billing unit times the number 

of 11-digit NDCs sold for each NDC 

assigned to the billing code, and then 

divide by the total number of NDCs 

sold. The ASP per billing unit for each 

NDC is weighted equally regardless of 

package size. 

Comment: Several manufacturers and 

other commenters representing the 

manufacturing community 

recommended that the formula be 

revised so that the payment limit is 

calculated based on the weighted ASP 

of the number of billing units sold 

rather than the number of NDCs sold. 

These commenters noted that products 

are available in different package sizes 

and that a billing code may encompass 

multiple NDCs. As a result, these 

commenters contend that weighting the 

ASP payment amount by NDCs sold 

does not reflect the true weighted 

average price per billing unit. Several 

commenters, including manufacturers 

and their trade associations, noted that 

altering the formula to weight by the 

number of billing units sold may 

increase or decrease the overall ASP. 

Nonetheless, these commenters 

recommend adoption of their 

recommended alternative formula. One 

commenter suggested that the 

alternative formula be adopted along 

with an exception process that would be 

applicable to billing codes that 

represent therapies of differing weights 

or dosage. We also received comments 

from manufacturers that supported 

continued use of the current formula. 

Response: In establishing the formula 

used to calculate the payment amounts 

based on the manufacturers’ ASP data, 

we considered various approaches, 

including the alternative approach 

recommended by some commenters. For 

the initial implementation of the ASP 

methodology, we operationalized the 

calculation of ASP by weighting the 

formula by the number of NDCs sold. As 

we gain more experience with the ASP 

data and other sources of information 

become available about the purchasing 

patterns of providers and their 

acquisition costs, we may consider 

altering the methodology or establishing 

exceptions, if we find good reason to do 

so. If we decided such a change is 

warranted, we would implement the 

change at the next quarterly update. 

Comment: Although not directly 

related to the formula used to calculate 

the ASP payment amounts, we received 

several comments from oncology 

physician practices and other 

commenters related to the adequacy of 

the ASP+6 percent payment 

methodology and other topics. We 

received several comments from 

oncology and other providers 

contending that the Medicare payment 

amount does not always cover their 

acquisition costs for certain drugs. A 

mid-sized oncology practice reported 

that it is unable to obtain nearly half of 

the drugs it administers at a price below 

the Medicare reimbursement rate. This 

commenter believes that larger practices 

may not face drug acquisition costs that 

exceed ASP+6 percent. One oncology 

practice reported that the ASP+6 

percent payment would cover its drug 

costs if beneficiaries could always afford 

their cost sharing amounts. A large 

oncology practice stated that its average 

Medicare reimbursement, which is 2 

percent more than its acquisition costs, 

was insufficient and would cause it to 

discontinue treatment for beneficiaries. 

On the topic of price concessions, 

several commenters, including a drug 

manufacturer, suggested that prompt 

pay and other discounts given to 

wholesalers and distributors should not 

be included in the calculation of the 

manufacturers’ ASP so that the payment 

amounts would be increased. 

Response: It is true for all payment 

systems based on averages that the 

payment amount may not equal a 

specific provider’s cost for every 

service. Section 1847A of the Act 

specifies that the Medicare payment is 

at 106 percent of ASP for the majority 

of Part B drugs and biologicals not paid 

on a cost or prospective payment basis. 

The statute requires use of the ASP+6 

percent payment methodology except in 

limited instances. Although several 

commenters (most of which represent 

oncology practices) reported that the 

ASP+6 percent methodology was 

insufficient to cover their drug 

acquisition costs for certain drugs, these 

commenters also acknowledged that the 

Medicare payment exceeds their drug 

acquisition costs for other drugs. This is 

consistent with the findings of recent 

studies by the General Accountability 

Office (GAO) (GAO–05–142R), Office of 

Inspector General (OIG) (‘‘Adequacy of 

Medicare Part B Drug Reimbursement to 

Physician Practices for the Treatment of 

Cancer Patients’’, (A–06–05–00024), and 

MedPAC (October 6, 2005, public 

meeting report on oncology site visits). 

These studies have found that 

physicians generally can obtain 

oncology drugs for prices below 

Medicare reimbursement. 

We did not propose a change to the 

price concessions manufacturers must 

include in the ASP calculation. Section 

1847A(c)(3) of the Act specifically 

identifies prompt pay discounts as a 

type of price concession that must be 

included in the manufacturer’s 

calculation of the ASP. 

Comment: We received comments 

from a few drug manufacturers 

requesting clarification and more 

detailed guidance on the treatment of 

administrative fees, service fees, and 

data fees in the ASP calculation. 

Response: These issues are beyond 

the scope of this rule. We will continue 

to work with manufacturers to more 

fully understand these issues. We 

expect to publish a final rule on the ASP 

reporting requirements and will 

consider these comments in the course 

of preparing that rule. 

Comment: We received comments 

from oncology practices, ESRD facilities 

and retail pharmacies, as well as IVIG 

manufacturers and stakeholders, 

indicating that manufacturer price 

increases are not reflected timely in the 

ASP+6 percent payment amounts due to 

the necessary lag time for calculating 

the rates and updating the payment 

systems. One commenter suggested that 

we implement a ‘‘true up’’ mechanism 

that immediately reconciles the historic 

reimbursement rate to reflect 

manufacturer price increases. Several 

IVIG stakeholders suggested that we 

issue payment rates on a retroactive 

basis. 

Response: Section 1847A(c)(5)(B) 

specifies a prospective update in the 

payment amounts. We agree with the 

commenters’ observations that there is a 

necessary time frame after the close of 

a calendar quarter for manufacturers to 

calculate and submit the ASP data to 

CMS, for CMS to prepare and issue the 

payment rates, and for the claims 

processing contractors to implement the 

updated payment files. As we stated in 

the CY 2005 final rule (69 FR 66300), we 

implement these new prices through 

program instructions or otherwise at the 

first opportunity after we receive the 

data, which is the calendar quarter after 

receipt. 

Comment: Several commenters, 

including patient and industry 

representatives and physicians as well 

as manufacturers, requested that we take 

steps to improve the availability of IVIG. 

Many of these commenters noted their 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70219 

ongoing collaboration with the 

Congress, HHS, CMS and others to 

better understand the market forces and 

dynamics influencing the current IVIG 

situation. These commenters reported 

that numerous patients and physician 

practices have been adversely impacted 

by the change in reimbursement to the 

ASP+6 percent methodology. These 

impacts include postponed infusions, 

increasing intervals between infusions, 

having to receive treatment in the 

hospital setting rather than in the 

physician office, possible unintended 

reactions as a result of switching brands 

of IVIG, and increased level of effort to 

obtain product and schedule services. 

Several commenters restated 

suggestions previously communicated 

to us, including concerns about our 

proposed changes for IVIG 

reimbursement in the outpatient setting. 

Comments from an industry group 

referenced its new study that it is 

conducting to help clarify the 

marketplace and provide insight into 

the costs for providing IVIG services. 

The study will examine IVIG acquisition 

costs and related services. Citing the 

adverse effects of patients migrating 

from physician offices to hospitals for 

treatment, several commenters 

requested that we consider an interim 

add-on payment for the complex 

activities related to furnishing IVIG 

until the industry study is completed. 

These commenters noted that the addon payment would ensure that 

providers are paid sufficiently for IVIG 

under Part B so that their provision of 

IVIG remains viable and beneficiaries’

access to IVIG is not reduced. 

Response: We will continue to work 

with the IVIG community, 

manufacturers, the Congress, and other 

entities to seek better understanding of 

the supply and market issues 

influencing the current IVIG market. We 

look forward to learning of the 

industry’s study findings as that work 

progresses. We have discussed the 

accuracy of the ASP data with the 

manufacturers and have been assured by 

these manufacturers that their ASPs 

have been developed in accordance 

with applicable guidance and that the 

resulting price reflects the current IVIG 

market in aggregate. At the same time, 

the IVIG manufacturers’ association, the 

Plasma Protein Therapeutics 

Association, reports that the overall 

supply of IVIG is adequate and has 

improved in the past several months. 

However, based on the comments 

received and our ongoing work with 

manufacturers, patient groups, and 

other stakeholders, we continue to be 

concerned about reports of patients 

experiencing difficulties in accessing 

timely IVIG treatments and reports of 

providers experiencing difficulties in 

obtaining adequate amounts of IVIG 

products on a consistent basis to meet 

their patients’ needs in the current 

marketplace. Most brands of IVIG have 

been put on allocation by manufacturers 

and some manufacturers have reported 

allocating products to a smaller number 

of distributors and reducing the size of 

inventories. In addition, there have been 

reports of diversion of products to the 

secondary market and secondary 

distributors raising prices markedly. 

The Secretary’s Advisory Committee on 

Blood Safety and Availability has 

recommended immediate steps be taken 

to ensure access to IVIG so that patients’

needs are being met. However, the 

complexity of the IVIG marketplace 

makes it unclear what particular 

systematic approaches would be most 

effective in addressing the many 

individual circumstances that have been 

shared with us while not exacerbating 

what appears to be a temporary 

disruption in the marketplace. 

IVIG is a complicated biological 

product that is purified from human 

plasma obtained from human plasma 

donors. Its purification is a complex 

process that occurs along a very long 

timeline, and only a small number of 

manufacturers provide commercially 

available products. Historically, 

numerous factors, including decreased 

manufacturing capacity, increased 

usage, more sophisticated processing 

steps, and low demand for byproducts 

from IVIG fractionation have affected 

the supply of IVIG. For CY 2006, there 

are 2 HCPCS codes that describe all 

IVIG products, based on their 

lyophilized versus liquid preparation. 

The recent patterns of utilization of 

IVIG also are unusual in comparison 

with most other drugs and biologicals. 

Different IVIG products are FDAapproved in a number of therapeutic 

areas for various specific conditions 

which include: anti-infective therapy 

(bone marrow transplant); immune 

globulin replacement therapy (primary 

immune deficiencies and chronic 

lymphocytic leukemia); antiinflammatory therapy (Kawasaki 

disease); and immunomodulation 

therapy (idiopathic thrombocytopenic 

purpura). IVIG therapy, which has been 

available for about 25 years, was 

initially reserved for the treatment of 

these FDA-approved indications. More 

recently, IVIG has been increasingly 

used off-label so that off-label uses now 

significantly exceed on-label uses. Many 

of these off-label uses are for 

autoimmune, neurological, or systemic 

inflammatory conditions. Some off-label 

uses of IVIG are supported by a robust 

evidence base, while for other medical 

conditions the evidence has not 

demonstrated that IVIG infusions are of 

significant therapeutic benefit. There are 

also new emerging indications for IVIG 

treatment, including those based on 

recommendations from various 

professional associations and advisory 

groups. In addition, despite the growing 

uses of IVIG there are definite risks 

associated with IVIG treatment, 

including both early inflammatory 

reactions and more rare but serious 

renal and thromboembolic 

complications, as well as the inherent 

risk associated with receipt of any 

biological product even with the 

ongoing improvements in the safety of 

these types of products. 

Medicare currently has one national 

coverage determination in place since 

CY 2002 regarding IVIG infusions to 

treat autoimmune blistering diseases, 

and there are numerous local coverage 

policies that describe Medicare coverage 

for specific off-label indications. In the 

context of these national and local 

coverage policies, IVIG use in hospital 

outpatient departments has climbed 

steeply over the most recent years for 

which data are available, from about 

40,000 infusion days in CY 2002, to 

60,000 days in CY 2003, and again to 

over 70,000 days in CY 2004. The 

infusion of IVIG in physician offices 

increased from about 2.3 million grams 

in CY 2003 to 4.0 million grams in CY 

2004. In the face of growing demand for 

IVIG in the absence of significant 

changes in the prevalence of medical 

conditions for which there is high 

quality evidence regarding the 

effectiveness of IVIG therapy, we are 

concerned that all patients with medical 

need for IVIG continue to have access to 

this expensive and valuable therapy. 

Over the upcoming year, we will be 

using our historical claims databases to 

study the epidemiology of IVIG 

treatment of Medicare beneficiaries in 

outpatient settings. We expect that the 

health system as a whole should 

encourage an accountable and 

scientifically-grounded use of IVIG, and 

we welcome discussions with industry, 

providers, and other interested entities 

regarding efforts to ensure that IVIG is 

responsibly utilized for evidence-based 

clinical indications so that optimal 

benefit is obtained. 

Commenters have indicated to us that 

the infusion of IVIG in physician offices 

is more complex and resource intensive, 

particularly during the actual infusion, 

than many other types of infusions 

currently reported using the same drug 

administration CPT codes. They have 

described the specific resources 

70220 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

required for initiating and monitoring 

infusions of IVIG for patients under 

various clinical circumstances. We 

encourage commenters to discuss their 

concerns with the CPT Editorial Panel 

to assess whether alternative coding or 

additional CPT guidance would be 

appropriate. In addition, they may wish 

to discuss their resource concerns with 

the AMA/Specialty Society RVS Update 

Committee that provides advice 

regarding the resources associated with 

physician services. 

Based on the potential access 

concerns, the growing demand for IVIG, 

and the unique features of IVIG detailed 

above, as we seek to gain improved 

understanding of the contemporary 

volatile IVIG marketplace, we will 

employ a two-pronged approach during 

CY 2006 to help ensure the availability 

of IVIG to physicians and hospital 

outpatient departments who care for 

Medicare beneficiaries and will be paid 

ASP+6 percent for the IVIG products. 

First, in addition to the ongoing 

monitoring and outreach activities 

within the HHS, the Office of the 

Inspector General (OIG) is studying the 

availability and pricing of IVIG as part 

of its monitoring of market prices 

pursuant to section 1847A(d)(2)(A) of 

the Act. We expect the OIG’s work to 

provide a significant contribution to the 

analysis of the current situation with 

respect to the specific activities of 

manufacturers and distributors that may 

be contributing to possible access 

problems for IVIG as we move to the 

ASP methodology in both physician 

office and hospital outpatient settings. 

We hope to understand those particular 

market behaviors that may have led to 

such public alarm about the availability 

of IVIG and the adequacy of our 

payment rate of ASP+6 percent, 

concerns that have been particularly 

strong and persistent for IVIG in 

comparison with other drugs paid under 

the same ASP methodology. 

Second, we will provide additional 

payment in CY 2006. Presently the IVIG 

marketplace is a dynamic one, where a 

significant portion of IVIG products 

previously available in CY 2005 are 

being discontinued and other products 

are expected to enter the market over 

the next year. In light of this temporary 

market instability, we understand that 

manufacturers have continued 

allocation procedures aimed at 

stabilizing the supply of IVIG. Even so, 

we understand that providers may face 

purchasing whichever brand of IVIG is 

available, even if it is not a brand the 

patient is known to tolerate. Many 

patients treated with IVIG receive 

regular infusions on a predictable 

schedule. To meet this need, physicians’

office staff must conduct significant 

preadministration services prior to IVIG 

infusions to monitor and manage their 

inventory, locate available IVIG 

products, reschedule infusions 

according to product availability and 

patients’ needs, and implement 

physicians’ determinations regarding 

whether the available formulations are 

appropriate for patients and whether 

specific dosing adjustments are 

required. Product-specific factors must 

be evaluated in light of patients’ clinical 

indications for the IVIG infusions, their 

underlying medical conditions, and 

their past reactions to various IVIG 

products, and office staff must locate 

appropriate doses of IVIG products in 

light of these considerations. If the 

appropriate IVIG product formulations 

were more widely and reliably 

available, we do not believe that routine 

IVIG infusions would require these 

extensive preadministration-related 

services prior to each infusion. 

To continue to ensure appropriate 

patient access to IVIG in CY 2006 during 

this short-term period of market 

instability for IVIG, beginning for dates 

of service on or after January 1, 2006 

through December 31, 2006, we will 

temporarily allow a separate payment to 

physicians to reflect the substantial 

additional resources that are associated 

with locating and acquiring adequate 

IVIG product and preparing for an office 

infusion of IVIG in the current 

environment. We expect that making 

separate payment for these additional 

necessary services will help insure that 

physicians are able to continue to 

provide IVIG infusions to their patients 

who depend upon them. We will also 

provide an additional payment to 

hospital outpatient departments for 

these special services, to ensure that 

patients continue to have access to IVIG 

infusions in the most medically 

appropriate settings, without 

undesirable shifts in sites of service for 

their care. 

Because the resources associated with 

the preadministration-related services 

for intravenous infusion of 

immunoglobulin are not accounted for 

in the physician office practice expense 

associated with the CY 2006 drug 

administration codes that will be billed 

for IVIG infusions, we are creating a 

temporary G-code to describe these 

additional preadministration services 

related to the intravenous infusion of 

immunoglobulin. We have established 

the following G-code for physician 

office billing for CY 2006: 

G0332; Preadministration-related 

services for intravenous infusion of 

immunoglobulin, per infusion encounter 

(This service is to be billed in 

conjunction with administration of 

immunoglobulin). 

Physicians may bill this service once 

per day in association with a patient 

encounter for administration of IVIG, in 

addition to billing for the appropriate 

drug administration service(s) and for 

appropriate units of the HCPCS code 

that describes the IVIG product infused. 

In addition, physicians may also bill for 

any significant and separately 

identifiable evaluation and management 

(E/M) service they perform at a level 2 

through 5 in association with the 

infusion encounter, appending modifier 

–25 to the E/M service. We have 

established the payment level for this 

service in physician offices by crosswalking the RVUs for the new G-code to 

the practice expense RVUs of 1.90 for 

G0319, ESRD related services during the 

course of treatment, for patients 20 years 

of age and over; with 1 face-to-face 

physician visit per month. We do not 

believe there is increased 

preadministration physician work 

associated with preparation for 

intravenous infusion of 

immunoglobulin, so we have not 

allocated the physician work RVUs 

assigned to G0319 to G0332. Physician 

work associated with preparation for the 

intravenous infusion of 

immunoglobulin is already included in 

the physician work allocated to the drug 

administration services associated with 

the infusion and to the evaluation and 

management services (including the preand post-work already included in the 

relative values for evaluation and 

management services) provided to 

patients receiving intravenous 

immunoglobulin treatments. However, 

we think G0332 requires additional 

resources from the physician practice, 

particularly clinical labor, that are 

comparable to the practice expense for 

the ESRD management code. We expect 

that in many cases IVIG infusions will 

be provided once per month, with 

activities in preparation for the infusion, 

including consulting with patients and 

distributors, conducted over the course 

of a month as are the ESRD related 

services described by G0319. In 

addition, preparation for the IVIG 

infusion will generally not require a 

face-to-face visit with the patient prior 

to the infusion, so we have selected the 

ESRD related services G code that 

includes only one physician visit for the 

practice expense crosswalk. 

We believe that this temporary 

separate payment provided through 

G0332 in CY 2006 for the physician 

office and hospital outpatient resources 

associated with additional IVIG 

preadministration-related services due 

to the present significant fluctuations in 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70221 

the IVIG marketplace will ensure that 

Medicare beneficiaries depending on 

IVIG experience no adverse health 

consequences from the market 

instability for IVIG products. In the 

meantime, we will continue to evaluate 

the market factors affecting the pricing 

and availability of IVIG products in the 

context of our ASP+6 percent payment 

methodology and our separate payment 

for G0332 in CY 2006. We expect that 

in CY 2006 with continued collection of 

updated ASP data for IVIG; improved 

understanding of the IVIG marketplace; 

more focused attention on the medical 

necessity of the utilization of IVIG; 

ongoing collaboration between CMS, the 

IVIG community, manufacturers, 

providers, and other interested entities; 

and this temporary separate payment for 

hospital and physician office resources 

required for the intensive 

preadministration services related to 

IVIG infusion, the IVIG marketplace 

should stabilize over the upcoming year. 

Substantial preadministration-related 

services for IVIG infusions should no 

longer be required of physician offices 

and hospital outpatient departments 

that provide IVIG infusions to patients 

who need them. Therefore, this 

additional payment for G0332 is 

effective for CY 2006 only. Thus, we 

will be closely monitoring this issue 

once again in the context of our 

rulemaking for CY 2007. 

Comment: Several commenters 

representing providers of community 

cancer care and manufacturers noted 

that physicians do not receive separate 

payment for pharmaceutical 

management and related pharmacy and 

handling costs (such as drug inventory, 

disposal of toxic waste, and spillage and 

breakage), and that in the 2006 proposed 

rule for HOPD we proposed a 2 percent 

add-on payment to the ASP+6 percent 

payment for drugs. These commenters 

stated the costs for handling 

pharmaceuticals are similar across 

settings and that physicians should 

receive the same add-on. 

Response: The costs for handling 

pharmaceuticals are paid through the PE 

RVUs for the drug administration code. 

d. Reporting WAC 

As explained in the August 8, 2005 

proposed rule (70 FR 45844) we have 

provided information on our web site 

(http://www.questions.cms.hhs.gov) 

concerning reporting WAC. We state 

that manufacturers must report the 

WAC for a single source drug or 

biological if it is less than the ASP for 

a quarter and in cases where the ASP 

during the first quarter of sales is 

unavailable. Upon further review, we 

have determined that the WAC must be 

reported each quarter if required for 

payment to be made under section 

1847A of the Act, in addition to the 

ASP, if available. 

Section 1927(b)(3)(A)(iii) of the Act 

specifies the ASP data manufacturers 

must report. Section 

1927(b)(3)(A)(iii)(II) of the Act specifies 

that the manufacturer must report the 

WAC, if it is required in order for 

payment to be made under section 

1847A of the Act. Under section 1847A 

of the Act, the payment is based on 

WAC (as opposed to ASP) in the 

following cases: 

• For a single source drug or 

biological, when the WAC-based 

calculated payment is less than the 

ASP-based calculated payment for all 

NDCs assigned to such drug or 

biological product. (See section 

1847A(b)(4) of the Act.) 

• During an initial period in which 

data on the prices for sales for the drug 

or biological is not sufficiently available 

from the manufacturer to compute an 

ASP. (See section 1847A(c)(4) of the 

Act.) 

In these instances, we must make the 

determination of whether the payment 

amount is based on ASP or WAC. 

Therefore, WAC is required for payment 

in all of these instances. 

As explained in the August 8, 2005 

proposed rule (70 FR 45844), we had 

previously published a template which 

manufacturers must use to report ASP 

data to us; however, the WAC was not 

included in that template. Therefore, 

because of the requirement to report the 

WAC and the confusion manufacturers 

have experienced in submitting the 

WAC data we proposed, in a separate 

information collection notice published 

August 19, 2005 (70 FR 48770), to revise 

the reporting template to include a place 

to report WAC. 

To clarify the instances when 

manufacturers are required to report the 

WAC, in the August 8, 2005 proposed 

rule (70 FR 45844), we stated that 

manufacturers are required to report 

quarterly both the ASP and the WAC for 

NDCs assigned to a single source drug 

or biological billing code. Manufacturers 

are also required to report the WAC for 

use in determining the payment during 

the initial period under section 

1847A(c)(4) of the Act. That is, the WAC 

is reported for the reporting period prior 

to reporting the ASP based on a full 

quarter of sales. 

Because the WAC could change 

during a reporting period, we proposed 

that in reporting the WAC, 

manufacturers would be required to 

report the WAC in effect on the last day 

of the reporting period. 

Comment: Some commenters noted 

that requiring manufacturers to report 

WAC for all single source drugs each 

quarter encompasses the requirement 

for manufacturers to report WAC for 

new drugs during the initial period. 

Separately specifying these instances in 

the preamble led some commenters to 

request clarification of how the 

proposed policy differs from the 

existing requirements posted on our 

web site. Several manufacturers 

requested that we clarify in the final 

rule with comment that the WAC in 

effect on the last day of the reporting 

period is the value to be submitted for 

that reporting period. 

Response: We agree with the 

commenters who noted that new drugs 

are a subset of single source drugs. We 

separately specified the requirements 

for reporting WAC in these two 

instances so that manufacturers would 

be aware of the reporting requirement 

and because we have discussed these 

instances separately in past rulemaking. 

The proposed change is different from 

existing guidance previously posted on 

our web site in that we clarify that 

submission of the WAC in these 

instances is always necessary for 

payment to be made. The manufacturer 

does not decide if the WAC is to be 

submitted and the WAC is not 

submitted only if it is less than the ASP 

as previously posted on our web site. 

We interpret section 

1927(b)(3)(A)(iii)(II) of the Act to apply 

to all NDCs of single source drugs. 

Final Decision 

Manufacturers must report WAC for 

all single source drugs (including new 

drugs) each reporting period. In 

submitting the WAC, manufacturers 

must report the WAC in effect on the 

last day of the reporting period. We will 

update our web site to include this 

decision. 

e. Revised Format for Submitting ASP 

Data 

The August 8, 2005 proposed rule (70 

FR 45845) included a discussion of the 

format manufacturers are required to 

use to report the ASP data to us. 

However, as discussed above, the 

current template does not provide 

adequate instructions for manufacturers 

to report both the ASP and the WAC. 

Therefore, we published a separate 

information collection notice on August 

19, 2005 (70 FR 48770) and proposed to 

revise the ASP reporting format to 

accommodate submission of both, the 

ASP and the WAC as well as collect the 

following additional information: 

• Drug name. 

70222 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

• Package size (strength of product, 

volume per item, and number of items 

per NDC). 

• Expiration date for last lot 

manufactured. 

• Date the NDC was first marketed 

(for products first marketed on or after 

October 1, 2005). 

• Date of first sale for products first 

sold on or after October 1, 2005. 

Comment: We received several 

comments in response to the proposed 

rule related to our separate information 

collection notice on the proposed 

changes to the ASP reporting format 

(CMS–10110; see 70 FR 48770). The 

commenters generally supported 

inclusion of the WAC and drug name 

within the reporting format. Some 

commenters expressed concerns related 

to the level of burden that would be 

necessary to report some of the 

proposed additional data elements, 

particularly the date the NDC was first 

marketed. Some commenters suggested 

refinements to the definitions of the 

proposed data elements and the 

frequency of their collection. In 

addition, commenters suggested that we 

consider using data elements collected 

by Medicaid in lieu of the proposed data 

elements pertaining to first marketing 

date, first date of sale, and expiration 

date. In addition, commenters stated 

that they were uncertain when the 

proposed changes to the reporting 

requirements would be effective. 

Response: We appreciate receiving the 

comments on the proposed additional 

data elements and the proposed 

revisions to Addendum A used to report 

ASP data. To be considered timely, 

comments on the proposed modification 

to ASP reporting format must have been 

mailed within 60 days of that notice (by 

October 18, 2005). All timely comments 

were not available for consideration at 

the time of the preparation of this final 

rule with comment. Changes to the ASP 

information collection (CMS–10110; 

OMB control number 0938–0921), if 

adopted by CMS and approved by the 

OMB, would be effective as of the 

approval date of the information 

collection submission Manufacturers 

would begin reporting the additional 

data elements with the next reporting 

deadline. 

f. Limitations on ASP 

Section 1847A(d)(1) of the Act states 

that ‘‘the Inspector General of HHS shall 

conduct studies, which may include 

surveys to determine the widely 

available market prices (WAMP) of 

drugs and biologicals to which this 

section applies, as the Inspector 

General, in consultation with the 

Secretary determines to be appropriate.’’

Section 1847A(d)(2) of the Act states 

that ‘‘Based upon such studies and other 

data for drugs and biologicals, the 

Inspector General shall compare the 

ASP under this section for drugs and 

biologicals with—

• The widely available market price 

(WAMP) for these drugs and biologicals 

(if any); and 

• The average manufacturer price 

(AMP) (as determined under section 

1927(k)(1) of the Act for such drugs and 

biologicals.’’

Section 1847A(d)(3)(A) of the Act 

states that ‘‘The Secretary may disregard 

the ASP for a drug or biological that 

exceeds the WAMP or the AMP for such 

drug or biological by the applicable 

threshold percentage (as defined in 

subparagraph (B)).’’ The applicable 

threshold is specified as 5 percent for 

CY 2005. For CY 2006 and subsequent 

years, section 1847A(d)(3)(B) of the Act 

establishes that the applicable threshold 

is ‘‘the percentage applied under this 

subparagraph subject to such 

adjustment as the Secretary may specify 

for the WAMP or the AMP, or both.’’

For CY 2006, we proposed to specify 

an applicable threshold percentage of 5 

percent for both the WAMP and AMP. 

We did not receive the OIG’s final report 

in time for consideration before 

developing the proposed rule. Thus, we 

believe that continuing the CY 2005 

threshold percentage applicable to both 

the WAMP and AMP is most 

appropriate. 

Comment: One commenter stated its 

support of credible drug rates that are 

based upon widely accepted health care 

industry standards, and that are 

established using methodologies that are 

clear and readily understood by persons 

with health care industry knowledge. In 

this context, the commenter expressed 

concern about how well the terms 

WAMP and AMP are understood across 

the health care industry. Several 

commenters supported our proposal to 

retain 5 percent as the applicable 

threshold for 2006, while strongly 

urging that we not implement the 

provisions relating to substitution of the 

ASP until notice and comment 

rulemaking is conducted. Many 

commenters referred to the language in 

the Conference Report accompanying 

the MMA that discusses rulemaking in 

connection with this issue and 

requested that we follow the intent of 

that language and provide the public the 

opportunity to evaluate the validity of 

the processes used and the data 

obtained by OIG. 

Response: We appreciate the 

commenter’s acknowledgement that we 

are required to specify the threshold 

percentage applicable in 2006. Section 

1847A(d)(3)(B)(i) of the Act specified 

the applicable threshold percentage for 

2005. Section 1847A(d)(1) of the Act 

requires that the OIG conduct studies to 

determine the WAMPs, and the OIG 

began its study activities shortly after 

the passage of the MMA. Upon 

completion, the OIG’s findings and 

methodology will be available to the 

public. We are aware of the Conference 

Report language; however, given the 

statutory requirements in section 

1847A(d), we do not believe rulemaking 

is appropriate at this time. 

Final Decision 

We will establish 5 percent as the 

applicable threshold for 2006. 

2. Payment for Drugs Furnished During 

CY 2006 in Connection With the 

Furnishing of Renal Dialysis Services if 

Separately Billed by Renal Dialysis 

Facilities 

Section 1881(b)(13)(A)(iii) of the Act 

indicates that payment for a drug 

furnished during CY 2006 and 

subsequent years in connection with the 

furnishing of renal dialysis services, if 

separately billed by renal dialysis 

facilities, will be based on the 

acquisition cost of the drug as 

determined by the OIG report to the 

Secretary as required by section 623(c) 

of the MMA or, the amount determined 

under section 1847A of the Act for the 

drug, as the Secretary may specify. In 

the report entitled, ‘‘Medicare 

Reimbursement for Existing End Stage 

Renal Disease Drugs,’’ the OIG obtained 

the drug acquisition costs for the top 10 

ESRD drugs for the 4 largest ESRD 

chains as well as a sampling of the 

remaining independent facilities. Based 

on the information obtained from this 

report, for CY 2005, payment for the top 

10 ESRD drugs billed by freestanding 

facilities and payment for EPO billed by 

hospital-based facilities was based on 

acquisition costs as determined by the 

OIG. Due to the lag in the data obtained 

by the OIG, we updated the acquisition 

costs for the top 10 ESRD drugs to 2005 

by the PPI. The separately billable ESRD 

drugs not contained in the OIG report 

were paid at the ASP+6 percent for 

freestanding facilities. The payment 

allowances for these remaining drugs 

were updated on a quarterly basis 

during 2005. 

Section 1881(b)(13)(A)(iii) of the Act 

gives the Secretary the authority to 

establish the payment amounts for 

separately billable ESRD drugs 

beginning in 2006 based on acquisition 

costs or the amount determined under 

section 1847A of the Act. As discussed 

in the proposed rule, we do not believe 

that it is appropriate to continue to use 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70223 

2002 acquisition costs updated by the 

PPI for another year as the basis for 

payment. The acquisition costs are 

based on 2002 data which, despite 

updates by the PPI do not necessarily 

reflect current market conditions. Thus, 

the chances increase that Medicare 

payments will either overpay or 

underpay for drugs resulting in 

payments that are inconsistent with the 

goal of making accurate payments for 

drugs. We also considered whether 

actual acquisition cost data could be 

periodically updated. However, we do 

not believe that it would be feasible to 

base Medicare payments over the long 

term on continually acquiring data on 

actual acquisition costs from ESRD 

facilities. This approach would provide 

incentives for manufacturers and 

facilities to increase acquisition costs 

without constraint. It also would not 

necessarily provide data regarding 

current market rates. Therefore, we 

proposed that the payment methodology 

for all ESRD drugs when separately 

billed by freestanding ESRD facilities 

during CY 2006 be the amount 

determined under section 1847A of the 

Act. This payment amount is the ASP+6 

percent rate. 

Based on an analysis of the 2002 

acquisition costs for the top 10 

separately billable ESRD drugs, when 

updated by the PPI for CY 2006, it is our 

contention that relying on 2002 

acquisition cost data updated for a 

number of years as would be necessary 

to establish a payment amount for 2006 

is not the most appropriate option for 

determining Medicare payment rates 

when other drug-specific pricing is 

available. Further, we contend that 

relying on the ASP+6 percent as the 

payment rate for all separately billable 

ESRD drugs when billed by freestanding 

ESRD facilities for CY 2006 is a more 

reliable indicator of the market 

transaction prices for these drugs. The 

ASP is reflective of manufacturer sales 

for specific drug products and is more 

indicative of market and sales trends for 

those specific products than the 2002 

OIG acquisition cost data. 

We also note MedPAC’s 

recommendation in its June 2005 report 

that the ASP be the basis of payment for 

all separately billable ESRD drugs 

provided by both freestanding and 

hospital-based facilities in CY 2006 

(MedPAC, ‘‘Report to the Congress: 

Issues in a Modernized Medicare 

Program,’’ June 2005). In making this 

recommendation, MedPAC states that 

the ASP data are more current (updated 

quarterly) and more likely to reflect 

actual transaction prices when 

compared with acquisition cost data 

which are not regularly collected by the 

OIG or CMS. Furthermore, the report 

indicated that utilizing the same 

payment policy for both freestanding 

and hospital-based facilities would 

ensure uniformity across the various 

settings irrespective of the site of care. 

In addition, MedPAC recommends in its 

report that we obtain, ‘‘* * * data to 

estimate hospitals’’ costs and Medicare’s 

payment per unit for these drugs. No 

published source identifies the unit 

payment for these drugs because 

Medicare pays hospitals their 

reasonable costs.’’ MedPAC further 

states: ‘‘We attempted to calculate the 

unit payment from 2003 claims data, but 

the accuracy of the data fields we 

needed to make this calculation was 

unclear, particularly the number of 

units furnished and Medicare’s payment 

to the hospital.’’ MedPAC also 

recommends that CMS or the OIG 

collect acquisition cost data periodically 

in the future to gauge the appropriate 

percentage of ASP for the payment 

amount. 

We acknowledged MedPAC’s 

recommendations regarding uniformity 

across the various settings irrespective 

of the site of care and believe it is more 

appropriate to pay for separately billed 

drugs furnished in hospital-based 

facilities under the ASP+6 percent 

methodology rather than on a 

reasonable cost basis. 

Therefore, for CY 2006, we proposed 

that payment for a drug furnished in 

connection with renal dialysis services 

and separately billed by freestanding 

renal dialysis facilities and EPO billed 

by hospital-based facilities be based on 

section 1847A of the Act. We proposed 

to update the payment allowances 

quarterly based on the ASP reported to 

us by drug manufacturers. We sought 

comment on our proposed decision to 

revise the payment methodology for 

separately billable ESRD drugs and 

about the potential method we have 

discussed in other sections of this final 

rule with comment which would permit 

us to pay hospital-based facilities under 

the ASP+6 percent methodology for 

2006. We also sought comment on how 

this proposed decision could affect 

beneficiaries’ or providers’ access to 

these drugs. 

We received numerous comments 

regarding our proposal to pay for drugs 

furnished in connection with renal 

dialysis services and separately billed 

by free-standing renal dialysis facilities 

as well as EPO billed by hospital-based 

facilities at the ASP+6 percent payment 

methodology. We also received 

comments on our proposal to continue 

to pay hospital-based facilities 

reasonable cost for separately billable 

ESRD drugs. Those comments and 

responses are provided below. 

Comment: Several commenters agreed 

with our proposal to use the ASP+6 

percent methodology as the basis for 

payment for drugs furnished in 

connection with renal dialysis services 

and separately billed by free-standing 

renal dialysis facilities as well as EPO 

billed by hospital-based facilities and 

our decision to update the payment 

allowances on a quarterly basis. These 

commenters viewed the ASP+6 percent 

payment methodology as superior to the 

average acquisition payment 

methodology as the ASP+6 percent 

methodology enables payment to reflect 

the actual market transaction prices for 

ESRD drugs. Commenters stated that 

reliance on the ASP+6 percent 

methodology will lead to a more 

uniform payment policy across care 

settings. These commenters strongly 

recommended that we finalize our 

proposal to pay all ESRD drugs when 

separately billed by freestanding ESRD 

facilities, as well as EPO when 

furnished in hospital-based facilities at 

ASP+6 percent. It was noted that the 

ASP+6 percent methodology is easier 

for us to administer as we already 

collect and update ASP data on a 

quarterly basis. Other commenters were 

cautious in regards to the ASP system, 

indicating that although the shift from 

average acquisition cost to ASP+6 

percent appeared rational, the ASP 

would be largely influenced by the 

lower large provider price. As a result, 

the ASP prices would not reflect the 

acquisition costs for all providers. Small 

dialysis facilities would be unable to 

purchase ESRD drugs at the proposed 

prices and would be at risk of being 

paid well below their acquisition costs, 

as they lack the same buying power or 

economics of scale that larger facilities 

possess. Some commenters focused on 

statements we made in the past in 

which we stated that we expected 

smaller providers to join buying groups 

in order to reduce acquisition costs. 

These commenters stated that although 

almost all small dialysis providers 

belong to such buying groups, such 

arrangements have not reduced the 

disparity between the large providers’

acquisition prices and the small 

providers’ acquisition prices. 

Commenters suggested that this ‘‘market 

dynamic’’ with extremely different 

buying power among providers does not 

exist in any other market where we have 

established drug payment policies. 

Response: We agree with the 

commenters who suggested that we 

establish the 2006 payment rates for 

drug furnished in connection with renal 

dialysis services and separately billed 

70224 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

by freestanding renal dialysis facilities 

and EPO billed by hospital-based 

facilities using the ASP, rather than use 

the 2002 average acquisition costs 

updated by the PPI. We also agree for 

2006 to apply the quarterly update of 

ASP data to payment for drugs 

furnished by freestanding renal dialysis 

facilities and EPO billed by hospitalbased facilities. 

After consideration of the feasibility 

of continuing to use 2002 acquisition 

costs updated by the PPI for another 

year, we have determined that the 

ASP+6 percent methodology is the most 

accurate measure for paying for EPO 

furnished in hospital-based facilities 

and for separately billable ESRD drugs 

provided in freestanding dialysis 

facilities. 

Implemented in 2005 by the MMA of 

2003, the ASP methodology is based on 

data submitted by manufacturers of 

Medicare Part B drugs. The ASP for all 

drug products included within the same 

billing and payment code is the volumeweighted average of the manufacturers’

ASPs reported to us across all the NDCs 

assigned to the billing or payment code. 

Therefore, the ASP is a more accurate 

indicator of market trends for specific 

drugs. 

We do not agree with commenters 

who suggest that varying buying power 

only exists among providers of ESRD 

drugs. Other purchasers of Part B drugs 

have expressed concerns to us regarding 

a variation in buying power. We will 

continue to support groups representing 

Medicare Part B drug purchasers, 

especially small and rural purchasers, to 

help them identify the most favorable 

drug prices possible. 

Comment: Many commenters 

requested that if we implemented the 

ASP-based methodology for separately 

billable ESRD drugs, we should utilize 

the most recently available ASP data 

and update that data quarterly. These 

commenters expressed concern about 

the significant lag time apparent in the 

current ASP methodology, indicating 

the lag time results in a decrease in 

payment that no dialysis facility has the 

ability to make up. Commenters 

encouraged us to provide retrospective 

payments to dialysis facilities, 

particularly small or independent 

dialysis providers to prevent such 

facilities from reducing services or from 

closing. One large drug manufacturer 

suggested that we consider an 

alternative drug payment option for 

small providers and we assure that these 

providers are not negatively affected by 

changes in the payment policy for 

drugs. Commenters suggested that we 

utilize a methodology that uses average 

acquisition price for small providers as 

the marker for ESRD drug 

reimbursement, citing section 

1881(b)(13)(A)(ii) of the Act as the 

authority. Under this system, we would 

collect acquisition cost data from small 

providers, update the data for the 

current year and establish payment rates 

on these acquisition costs. Other 

commenters suggested that we consider 

establishing an exception process 

whereby rural or inner city ESRD 

facilities could request an alternate 

payment based on their actual drug 

acquisition costs as a result of unique 

economic circumstances. Some 

commenters suggested that we exclude 

EPO from the ASP payment 

methodology, stating that EPO has only 

one manufacturer and accounts for a 

large proportion of drug payment to 

independent dialysis facilities. Some 

commenters suggested that contracts of 

large providers are able to influence the 

ASP for EPO and for these providers; 

the acquisition price will be close to 

ASP. The inclusion of EPO in the ASP 

methodology will create disparity in 

patient care. 

Response: In response to concerns 

regarding the significant lag time 

apparent in the ASP methodology, the 

ASP methodology is based on ASPs 

reported by manufacturers quarterly. 

Manufacturers must report to us no later 

than 30 days after the close of the 

quarter. We implement these new prices 

through program instructions or 

otherwise at the first opportunity after 

we receive the data, which is the 

calendar quarter after receipt. 

We do not agree with commenters 

who suggested that we permit small, 

rural, or inner city ESRD facilities to 

request an alternate payment based on 

their actual drug acquisition costs, or 

that we exclude EPO from the ASP 

payment methodology. We do not have 

that authority. Section 

1881(b)(13)(A)(iii) of the Social Security 

Act states that the Secretary chooses the 

methodology to determine payment 

rates for all drugs separately billed by 

ESRD facilities. The language refers to 

the choice of acquisition costs as 

determined by the Inspector General of 

the ASP rates. Section 1881(b)(13)(A)(ii) 

does not provide authority for 

individual providers to choose whether 

to be paid on the basis of costs or the 

ASP method. 

Comment: Several organizations 

stated that payment differences should 

be eliminated for separately billable 

drugs furnished in independent and 

hospital-based facilities and the ASP 

payment methodology should be used 

for all drugs provided in hospital-based 

facilities. One commenter agreed with 

our concerns regarding the lack of 

available data from hospital claims and 

recommended that the Secretary collect 

data on the acquisition cost and 

payment per unit for drugs furnished by 

hospital-based providers, or consider 

using the unit dosing information 

obtained from claims submitted by 

freestanding dialysis facilities and 

consult with clinical experts regarding 

the appropriateness of the dose data. 

Response: We agree with commenters 

who suggested that we utilize the same 

payment methodology for separately 

billable drugs furnished in independent 

facilities and hospital-based facilities. 

For reasons discussed in the ESRD 

section of this final rule with comment, 

we believe it is appropriate to 

implement the ASP payment 

methodology for all drugs provided in 

hospital-based facilities. 

Comment: Prompt pay discounts are 

included in the calculation of the ASP; 

however, commenters stated that small 

customers do not normally receive such 

discounts. Rather, these customers are 

charged an additional service fee to the 

price of the product. Thus, by including 

prompt pay discounts in the calculation 

of the ASP, the ASP is lowered, but the 

small providers are not privy to such 

discounts. Commenter also stated that 

sales to cutomers outside of 

independent dialysis facilities are 

included in the calculation of the ASP 

and thus, contribute to the difference 

between manufacturer-provided ASPs 

and provider acquisition costs. They 

stated that we have established a 

distinct methodology for drug payment 

for hospital-based dialysis facilities, and 

therefore, it is inappropriate to include 

such customers in the ASP payment 

system for independent dialysis 

facilities. 

Response: In the calculation of the 

ASP, as specified in Section 

1847A(c)(3), a manufacturer should 

include volume discounts, prompt pay 

discounts, cash discounts, free goods 

that are contingent on any purchase 

requirements, chargebacks, and rebates 

(other than rebates under the Medicaid 

rebate statute). We lack the statutory 

authority to permit manufacturers to 

exclude prompt pay discounts from the 

calculation of the ASP. Further, the 

statute does not permit the exclusion of 

or differentiation by classes of trade in 

the calculation of the ASP payment 

rates, except for the specific statutory 

exceptions described in the Medicaid 

best price calculation under sections 

1927(c)(1)(C)(i) and 1927(c)(1)(C)(ii)(III) 

of the Act. 

Comment: Several commenters stated 

that the ASP methodology does not take 

into consideration provider costs for 

storage, handling, and wastage. Small 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70225 

1 GAO, ‘‘Medicare Payment for Covered 

Outpatient Drugs Exceed Providers’ Costs,’’

September 2001. OIG, ‘‘Excessive Medicare 

Reimbursement for Albuterol,’’ March 2002. 2Muse & Associates Report for the American 

Assoication for Homecare, ‘‘The Cost of Delivering 

Inhalation Drug Services to Medicare 

Beneficiaries,’’ August 2004. 3 GAO, ‘‘Appropriate Dispensing Fee Needed for 

Suppliers of Inhalation Therapy Drugs,’’ GAO–050–

72, October 2004. 

providers will be disadvantaged as they 

have less efficient and more costly 

systems for storage and handling. 

Response: The ASP+6 percent 

payment methodology was not intended 

to cover the handling and storage of 

drugs. 

3. Clotting Factor Furnishing Fee 

Section 303(e)(1) of the MMA added 

section 1842(o)(5) of the Act which 

requires the Secretary, beginning in CY 

2005, to pay a furnishing fee in an 

amount the Secretary determines to be 

appropriate to hemophilia treatment 

centers and homecare companies for the 

items and services associated with the 

furnishing of blood clotting factor. In 

the CY 2005 final rule (69 FR 66236), we 

established a furnishing fee of $0.14 per 

unit of clotting factor for CY 2005. 

Section 1842(o)(5) of the Act specifies 

that the furnishing fee for clotting factor 

for years after CY 2005 will be equal to 

the fee for the previous year increased 

by the percentage increase in the 

consumer price index (CPI) for medical 

care for the 12-month period ending 

with June of the previous year. The 

percent increase for the 12 months 

ending June 2005 is 4.2 percent. 

Consequently, the furnishing fee will be 

$0.146 per unit clotting factor for CY 

2006. While the furnishing fee payment 

rate is calculated at 3 digits, the actual 

amount paid to providers and suppliers 

is rounded to 2 digits. The requests to 

publish the 2006 furnishing fee in the 

final rule with comment were the only 

comments we received on the clotting 

factor section in the proposed rule. 

4. Payment for Inhalation Drugs and 

Dispensing Fee 

Medicare Part B pays for inhalation 

drugs administered via a nebulizer, a 

covered item of DME. Beginning in CY 

2006, coverage for inhalation drugs 

administered through metered dose 

inhalers will generally be available 

through the Medicare Part D benefit. 

This represents an important expansion 

in the options available to beneficiaries 

for inhalation drug coverage under 

Medicare. We expect that both modes of 

inhalation drug delivery will play an 

important role in the Medicare program 

in the years to come. 

Prior to CY 2004, most Medicare Part 

B covered drugs, including inhalation 

drugs administered by a nebulizer 

(hereafter referred to as inhalation 

drugs), were paid at 95 percent of the 

AWP. Numerous studies by the OIG and 

GAO indicated that 95 percent of AWP 

substantially exceeded suppliers’

acquisition costs for Medicare Part B 

drugs, particularly for the high volume 

inhalation drugs, albuterol and 

ipratropium bromide.1 The MMA 

changed the Medicare payment 

methodology for many Part B covered 

drugs, including inhalation drugs. As an 

interim step, in CY 2004, Medicare paid 

a reduced percentage of AWP, 80 

percent of AWP in the case of albuterol 

and ipratropium bromide. Beginning 

with CY 2005, Medicare paid for 

inhalation drugs at 106 percent of the 

average sales price (ASP+6 percent). 

In addition to making payment for the 

drug itself, Medicare also pays a 

dispensing fee to suppliers of inhalation 

drugs. Prior to CY 2005, Medicare paid 

a monthly $5 dispensing fee for each 

covered inhalation drug or combination 

of drugs used. In the August 5, 2004 

proposed rule (69 FR 47488), we sought 

comment on an appropriate dispensing 

fee level to cover the shipping, 

handling, compounding, and other 

pharmacy activities required to get these 

medications to beneficiaries. We 

received many comments asserting that 

a substantial fee was needed to 

compensate suppliers for a wide range 

of costs associated with dispensing 

drugs to beneficiaries, with many citing 

a 2004 report prepared by a consultant 

for the American Association for 

Homecare (AAH) that recommended a 

$68 fee.2 The 2004 AAH report provided 

information for 10 cost categories: 

clinical intake; establishing/revising the 

plan of care; delivery of services; 

compliance monitoring/refill calls; 

billing/collections; other direct costs; 

patient education; caregiver training; 

care coordination; and in-home visits. In 

addition, as discussed in the August 8, 

2005, proposed rule, a 2004 study by the 

GAO showed substantial variation in 

supplier costs of dispensing inhalation 

drugs.3 With the wide variation in the 

reported costs and services provided by 

inhalation drug suppliers suggested by 

the comments and the GAO study, we 

stated in the CY 2005 final rule (69 FR 

66338) that we would establish an 

interim dispensing fee for inhalation 

drugs applicable for CY 2005 and 

reconsider the issue for CY 2006. The 

2005 dispensing fee for a 30-day supply 

of inhalation drugs was based on the 

industry recommended $68 fee from the 

2004 AAH study, excluding certain 

costs that Medicare generally does not 

reimburse regardless of the Medicare 

Part B benefit category (that is, sales and 

marketing, bad debt, and an explicit 

profit margin). The resulting fee 

established for a 30-day supply of 

inhalation drugs was $57 for CY 2005. 

Because the 2004 AAH study did not 

establish a fee for a 90-day supply, we 

applied the methodology used in the 

2004 GAO report to convert the 30-day 

fee to a 90-day fee. Accordingly, the 

2005 fee established for a 90-day supply 

was $80. In establishing the dispensing 

fee rates for 2005, we indicated in the 

CY 2005 final rule that although the 

AAH study contained costs related to 

services that may be of potential benefit 

to our beneficiaries, we were concerned 

that these services may be outside the 

scope of a dispensing fee. We indicated 

that we would consider this issue 

further in order to establish an 

appropriate dispensing fee for CY 2006. 

As discussed in the August 8, 2005 

proposed rule (70 FR 45847), we 

indicated that we intend to establish a 

dispensing fee amount for 2006 that is 

appropriate to cover the costs of those 

services that fall within the scope of a 

dispensing fee. Furthermore, we 

indicated that we thought this fee 

amount likely would be lower than the 

current fee of $57 per 30-day period in 

2005. In the proposed rule we solicited 

public comments and information on a 

number of issues including the 

following: 

• What services appropriately fall 

within the scope of a dispensing fee; the 

cost of providing those services; and, 

whether any of the services being 

provided by inhalation drug suppliers 

may be covered through another part of 

the Medicare program, such as the PFS 

or the DME benefit. 

• An appropriate dispensing fee level 

for 2006 as well as data and information 

on the various services inhalation drug 

suppliers are currently providing to 

Medicare beneficiaries and the 

associated costs, and typical dispensing 

costs for an efficient, high-quality 

supplier. 

• The extent to which inhalation drug 

suppliers have utilized the newly 

available 90-day scripts in order to 

reduce unit shipping costs and any 

reasons as to why 90-day supplies may 

not have been utilized. 

• How revised guidelines regarding 

the timeframe for delivery of refills has 

affected the need for overnight delivery 

services as well as the extent to which 

suppliers have shifted their shipping to 

ground services. 

• Comments on the potential impact 

on beneficiaries and providers of 

possible changes to the inhalation drug 

dispensing fee in 2006, as well as the 

70226 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

4Muse Associates Report Prepared for the 

American Association for Homecare, ‘‘Examination 

of Inhalation Drug Services to Medicare 

Beneficiaries Under the Average Sales Price 

Reimbursement Methodology In Response to the 

CMS Notice of Proposed Rule Making (CMS–1502–

P),’’ September 2005. 

impact of the new drug benefit on 

inhalation drug access. 

Comment: Many commenters 

suggested that dispensing inhalation 

drugs to Medicare beneficiaries involves 

a wide range of services that should be 

compensated through the dispensing 

fee. A number of commenters referenced 

a 2005 report by an industry consultant 

sponsored by the AAH.4 The 2005 AAH 

report indicated that suppliers provide 

services in seven broad categories: 

Intake; compounding, dispensing, and 

pharmacy assessment; delivery, set-up, 

and patient education; follow-up and 

compliance monitoring; quality 

assurance, accreditation, licensing, and 

regulatory compliance; Medicare billing 

and compliance; and other direct and 

indirect costs and expenses. Within 

these seven categories, the 2005 AAH 

report indicated that there were ‘‘117 

discrete services’’ provided to or on 

behalf of Medicare beneficiaries. The 

2005 report surveyed 82 homecare 

pharmacies. The vast majority of survey 

respondents thought the 117 discrete 

services outlined by the consultant fell 

within the scope of a dispensing fee, 

and the vast majority of respondents 

indicated they were providing these 

services. Several commenters suggested 

that the survey demonstrated there was 

widespread agreement that the standard 

of care for inhalation drug suppliers 

involved a wide range of services. In 

addition, one commenter asserted that 

the 117 services identified in the 2005 

AAH report encompassed all of the 

functions identified in the 2004 AAH 

report prepared by the same consultant, 

which formed the basis of the 2005 fee. 

Response: We established the interim 

dispensing fee for 2005 based on cost 

data from the 2004 AAH report. That 

report provided cost data for 10 service 

categories: Clinical intake; establishing/ 

revising the plan of care; delivery of 

services; compliance monitoring/refill 

calls; billing/collections; other direct 

costs; patient education; caregiver 

training; care-coordination; and in-home 

visits. In using this data to establish the 

2005 fee in the CY 2005 final rule, we 

indicated that we were concerned that 

some of the services in the industry cost 

data may be outside the scope of a 

dispensing fee and we would revisit this 

issue further in order to establish an 

appropriate dispensing fee for CY 2006. 

As discussed in the August 8, 2005, 

proposed rule, we continue to have 

concerns with respect to what services 

should be included within the 

dispensing fee payment. 

Authority for a dispensing fee for 

inhalation drugs is based on section 

1842(o)(2) of the Act, which provides 

that if payment is made to a licensed 

pharmacy for a drug or biological under 

Medicare Part B, the Secretary may pay 

a dispensing fee (less the applicable 

deductible and coinsurance) to the 

pharmacy. The statute did not define 

the term dispensing fee or set 

parameters as to what activities should 

be included within the scope of that 

definition. However, as discussed 

below, we do not believe the Congress 

intended us to adopt the broad reading 

of dispensing fee suggested by 

commenters. 

We are not persuaded by suggestions 

that Medicare should broadly define the 

definition of dispensing fees for 

inhalation drugs to include pharmacy 

care management services such as 

patient education, caregiver training, 

care coordination, and in-home visits. A 

number of commenters suggested the 

dispensing fee be based on the total 

costs of supplying inhalation drugs 

indicated by the 2004 AAH report data. 

That data indicated that suppliers 

expend on average 63.5 minutes per 

new patient and 50 minutes per 

established patient per month on patient 

education, caregiver training, care 

coordination, and in-home visits. Such 

services represent pharmacy care 

management services, which (if 

included in dispensing fee payments) 

would extend the definition of 

dispensing fee beyond what we believe 

should be reasonably included within 

the scope this benefit. As an initial 

matter, we do not believe that there is 

any indication that the Congress 

intended these care management 

activities to be included in the 

definition of dispensing fees. Where the 

Congress wished for us to cover the 

costs of such training and management 

services under Medicare, it specifically 

directed us to do so (for example, by 

amending the statute to recognize 

diabetes outpatient self management 

training under Medicare Part B and 

medication therapy management 

programs under Medicare Part D (see 

sections 1861(qq) and 1860D–4(c) of the 

Social Security Act). Therefore, in 

accordance with our interpretation of 

the statute, we do not believe it is 

reasonable for us to define the term 

dispensing fee under Medicare Part B to 

include the costs of such services. 

In addition, we also believe that the 

inclusion of beneficiary education and 

training about use of nebulizers would 

raise duplicate payment issues. Payment 

for DME is based on fee schedule 

amounts which include, in part, 

amounts for training beneficiaries on the 

use of nebulizer equipment. Thus, the 

equipment supplier is responsible for 

educating the beneficiary on the use of 

the DME or ensuring that ‘‘another 

qualified party’’ has done so as specified 

in § 424.57(c)(12). In addition, under the 

physician fee schedule Medicare makes 

a separate payment for beneficiary 

training by a physician or physician’s 

staff regarding use of a nebulizer (CPT 

code 94664, demonstration and/or 

evaluation of patient utilization of an 

aerosol generator, nebulizer, metered 

dose inhaler or IPPB device). We believe 

that physicians can play an important 

role in beneficiary training concerning 

the use of nebulizers, as they are 

ultimately responsible for directing 

beneficiary care, and determining what 

drug treatment regimen is most effective 

for an individual patient. Accordingly, 

because payment for education, 

training, and management concerning 

use of nebulizer equipment may be 

separately recognized under Medicare, 

we are concerned that the inclusion of 

such services within the definition of 

dispensing fee would increase the 

potential for double billing. 

We are also not persuaded by 

commenters’ suggestions that the 2005 

AAH report demonstrates that the 

standard of care for supplying 

inhalation drugs includes a broad range 

of services. The 2005 AAH report 

presented results from a survey of 

homecare companies, in which the 

companies were asked whether 117 

activities or overhead items should be 

included in the dispensing fee and 

whether the companies currently 

provide or undertake each activity/item 

(although the frequency and extent to 

which each activity/item was provided 

was not asked). The 2005 report 

identified services provided but failed 

to provide any information on the 

proportion of beneficiaries actually 

receiving various services (for example, 

patient education, caregiver training, inhome visits). It also did not provide any 

information on the cost of various 

services (other than delivery), or the 

amount of time involved in providing 

these services to the typical beneficiary. 

Consequently, the 2005 AAH report fails 

to demonstrate that the 117 activities/ 

overhead items outlined in the 2005 

report translate into an average of 63.5 

minutes per new patient and 50 minutes 

per established patient each month for 

the care management services of patient 

education, caregiver training, in-home 

visits, and care coordination in the 2004 

AAH report. Since the 2005 report did 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70227 

5Office of the Inspector General, ‘‘Review of 

Services Provided by Inhalation Drug Suppliers,’’

September 2005, OEI–01–05–00090. 

not include information on costs, the 

2004 AAH report is the only 

information we have on average cost 

and time per activity. However, even the 

2004 AAH report does not contain 

information on the proportion of 

beneficiaries that actually receive the 

care management services. Accordingly, 

given the data identified in the reports, 

we are not persuaded by the AAH 

reports that the standard of care for 

supplying inhalation drugs includes 

extensive care management services for 

patient education, caregiver training, inhome visits, and care coordination. 

Furthermore, a September 2005 OIG 

study entitled ‘‘Review of Services 

Provided by Inhalation Drug 

Suppliers’’ 5 found little evidence that 

inhalation drug suppliers provide care 

management services to many 

beneficiaries. The OIG report sought to 

ascertain the nature and extent of 

services provided by inhalation drug 

suppliers. The OIG examined services 

such as clinical intake, revising the plan 

of care, patient/caregiver education, 

responding to patient/caregiver 

inquiries about the drug, contacting the 

physician’s office, contacting a patient 

for a refill, reviewing medication 

compliance, and other certain services. 

The OIG did not focus on certain core 

activities such as filling prescriptions, 

delivery, and billing that they indicated 

were necessary for suppliers to dispense 

drugs and receive reimbursement. They 

also indicated that they excluded 

equipment related services because 

Medicare pays suppliers separately for 

equipment. 

The OIG report concluded that 

beneficiaries receive few services from 

their inhalation drug supplier beyond 

calls to ask if they need a drug refill. 

The OIG report found that among 

beneficiaries with at least 2 months of 

claims in 2003, 16 percent received no 

services (that is, no educational 

services, refill calls, or other adjunct 

services the OIG examined) from their 

inhalation drug supplier during the 

entire year. The OIG found that refill 

calls accounted for the majority of 

services provided by inhalation drug 

suppliers. In addition, the OIG found 

that only 16 percent of beneficiaries 

received an educational service from 

their drug supplier, 8 percent made a 

non-billing inquiry to their drug 

supplier, 8 percent received an in-home 

visit, 5 percent had a care plan revision, 

and 3 percent received a respiratory 

assessment from their drug supplier at 

least once during 2003. Furthermore, 

the OIG report indicated that only 27 

percent of beneficiaries had their 

medication compliance reviewed by 

drug supplier at least once in 2003, with 

89 percent of these reviews occurring 

during refill calls. Accordingly, in light 

of the OIG findings regarding services 

actually provided, we remain 

unconvinced regarding the standard of 

care contentions set forth in comments 

concerning the 2004 and 2005 AAH 

reports. 

As mentioned previously, we do not 

believe it is appropriate to include care 

management services such as patient 

education, caregiver training, care 

coordination, and in-home visits in the 

inhalation drug dispensing fee. 

Furthermore, the OIG found that few 

care management services were actually 

provided to a typical beneficiary. While 

it is possible that some types of care 

management services may be of 

potential benefit to some beneficiaries, 

at this time there is not clear evidence 

that such services are widely provided 

to beneficiaries nor have there been 

studies evaluating the effect of such 

services on beneficiary outcomes. Given 

such concerns, we do not believe it is 

appropriate for us to define dispensing 

fee under Medicare Part B to include 

care management services. However, we 

believe it is very important that the 

Medicare program support better patient 

care outcomes, particularly for 

beneficiaries with chronic respiratory 

conditions. We plan to explore how the 

Medicare program can engage 

physicians and their partners on issues 

of quality and performance to foster 

high quality of care for Medicare 

beneficiaries using respiratory drugs. 

For example, we believe there may be 

an opportunity under our demonstration 

authority to implement a demonstration 

program to test whether care 

management and care coordination 

services by physicians and their 

partners can improve health outcomes 

and reduce Medicare costs for 

beneficiaries who use inhalation drugs. 

Comment: Some commenters 

criticized the OIG report as being too 

narrow in scope. A few commenters 

suggested that the OIG study excluded 

many essential services such as drug 

deliveries and billing activity that 

account for the bulk of services and 

costs. Another commenter suggested 

that the study did not capture all the 

services inhalation drug suppliers 

provide, including many that are 

required by State and Federal 

regulations (for example, Food and Drug 

Administration and State Pharmacy 

Boards), and standards of care for 

pharmacy practice. The commenters 

also criticized the OIG report for 

excluding billing services and not taking 

into account the substantial amounts of 

time spent doing the following: 

Collecting and processing the relevant 

billing information from the beneficiary 

and beneficiary’s physician, which the 

commenter indicated often requires 

multiple on-site visits to doctors offices; 

verifying eligibility and processing 

reimbursement from secondary insurers 

responsible for payment of coinsurance; 

and researching and on-site verification 

of beneficiary financial and living 

circumstances in order to validate a 

waiver of coinsurance for hardship. The 

commenters also criticized the OIG 

report for not taking into account nonpayment of coinsurance by Medicaid, 

the costs of Medicare billing 

requirements, and costs of oversight by 

multiple carriers. Furthermore, several 

commenters suggested that the OIG 

study undercounted services because 

the OIG survey instrument requested 

documentation for each service 

provided and the report focused on 

documented services. Some commenters 

suggested that this approach left out 

those services for which suppliers did 

not have documentation, either because 

they had discarded the documentation 

after it was no longer useful or because 

they had not documented services since 

there was no requirement to do so. 

Some commenters indicated that the 

mandatory refill calls require two 

telephone contacts on average before 

contact is made with the beneficiary. 

One commenter indicated that it 

maintains documentation of failed call 

attempts only for several months, and is 

not required to maintain long-term 

documentation of repeated calls and 

visits to patient homes and physicians’

offices to gather documentation and 

information. In addition, one 

commenter noted that the OIG report 

expanded the categories of services it 

analyzed in its report based on 

information submitted by respondents 

in the survey instrument’s ‘‘other’’

category. The commenter believed that 

this meant participants in the OIG 

report may not have always been 

explicitly asked about certain types of 

services. This commenter also criticized 

the OIG report for not conducting field 

work to observe the activities of 

inhalation drug suppliers, and indicated 

its belief that the GAO and 2004 AAH 

report included a more thorough 

analysis. Another commenter stated that 

the OIG report does not address the 

issue that the costs of dispensing drugs 

are higher than the current $57 fee for 

high quality suppliers in compliance 

with applicable requirements. 

Furthermore, the commenter stated that 

70228 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

the service levels suggested in the OIG 

report are not representative of high 

quality suppliers. The commenter also 

stated that the behavior of noncompliant 

suppliers should not serve as a basis for 

reducing the fee because they contend 

the various services are required to 

comply with the regulations of 

Medicare, other government entities, 

and accrediting or quality assurance 

organizations. 

Response: We do not find the 

criticisms of the OIG report persuasive. 

While a number of commenters 

criticized the methodology and findings 

of the OIG study, we believe that the 

results of the OIG study are credible. 

The OIG study examined the extent to 

which certain services such as patient/ 

caregiver education, responding to 

patient/caregiver inquiries about drugs, 

revising the plan of care, contacting the 

physician’s office, contacting a patient 

for a refill, reviewing medication 

compliance, and certain other services 

were actually being provided to 

beneficiaries by inhalation drug 

suppliers. The OIG failed to find 

evidence that many beneficiaries 

received such services from their 

inhalation drug suppliers, with the 

exception of drug refill calls. 

Although some commenters criticized 

the OIG report for not including core 

dispensing activities such as filling the 

prescription and billing, the OIG report 

indicated that it did not focus on those 

activities because it did not have cause 

to question that they are necessary to 

dispense drugs and be reimbursed. The 

OIG instead focused on those services 

where less was known about the extent 

to which the services were actually 

being provided to beneficiaries. The OIG 

report examined a set of services that 

accounted for 60 percent of costs 

included in the 2004 AAH data. In 

addition, some costs cited by one 

commenter as being improperly 

excluded from the OIG study, such as 

non-payment of coinsurance by 

Medicaid, costs associated with waivers 

of coinsurance for indigent 

beneficiaries, and assessment of the 

beneficiary’s situation for coinsurance 

waiver, are not generally reimbursed 

under Medicare Part B as a matter of 

general policy. 

We are not persuaded by those 

commenters who suggested that the OIG 

study should be disregarded because the 

OIG undercounted the number of 

services suppliers actually provide due 

to the OIG’s focus on documented 

services. Although the OIG focused its 

analysis on documented services, the 

OIG report indicated that if they had 

included undocumented services 

reported by suppliers in their analysis, 

the average number of services per 

beneficiary would still have been low 

(increasing from an average of 1.2 to 

1.59 services per beneficiary per 

month). In addition, if various services 

are essential to dispensing these drugs 

to beneficiaries as some have suggested, 

we would have expected that suppliers 

would have documented the content 

and frequency of the services in patient 

records in order to track patient progress 

and maintain continuity of care. 

Furthermore, although some contend 

that the OIG study suggests that some 

suppliers are non-compliant in their 

provision of required services, as 

commenters pointed out, the OIG study 

did not generally collect information on 

the core services required to furnish 

inhalation drugs, with the exception of 

refill recalls. The OIG report found that 

not all beneficiaries who should have 

received a refill call actually got one. 

We plan to study the issue of refill call 

compliance further, and we believe it is 

important to reflect the costs of refills 

call in the dispensing fee. 

In terms of the comment that the OIG 

study added several service categories 

based on information submitted by 

commenters, the survey instrument 

included an ‘‘other’’ category under 

which suppliers could report any 

services that were not captured by the 

categories provided. We do not view the 

opportunity for suppliers to elaborate on 

the types of services provided to be a 

weakness but rather a strength of the 

study. Although the OIG study was 

criticized by some for not conducting 

field work, the OIG adopted a 

methodology that was designed to 

provide information on a representative 

sample of beneficiaries receiving 

inhalation drugs. 

While the OIG report does not provide 

information on supplier costs, that was 

not the objective of the OIG study. The 

OIG report provides information on the 

percent of beneficiaries that received 

various services from their drug 

suppliers, and as a result, and we 

believe it offers helpful information in 

our consideration of the inhalation drug 

dispensing fee. 

Comment: We received a number of 

comments recommending either an 

increase or no reduction in the 

dispensing fee for 2006. Several 

commenters suggested the 2005 AAH 

report provided an appropriate fee for 

2006. For that report, a consultant 

surveyed homecare pharmacies about 

what fee level they thought was 

appropriate for 2006. Survey 

respondents on average suggested a fee 

of $66.55 for a 30-day supply and a fee 

of $138.80 a 90-day supply. Suggested 

fees from other commenters ranged from 

$57 to $68, with a few commenters 

suggesting an inflation adjustment on 

top of those levels. One insurer 

commented that the current dispensing 

fee appears high. 

Some commenters provided cost 

information as part of their contention 

that the fee should not be reduced or 

should be increased. One large supplier 

indicated that its costs were about $75 

per beneficiary for a 30-day period, with 

the 3 cost categories accounting for the 

largest share being delivery, setup, and 

patient education ($20); clinical intake 

($15); and compounding, dispensing, 

and assessment ($14). Another supplier 

indicated its costs broke out as follows: 

delivery, set-up, and patient education 

(27.3 percent); compounding, 

dispensing, pharmacy assessment (19.0 

percent); patient intake (17.8 percent); 

follow-up and compliance monitoring 

(11.6 percent); quality assurance, 

accreditation, licensing and regulatory 

compliance (9.1 percent), other direct 

and indirect costs (4.2 percent). The 

supplier indicated that its costs were 

largely for salaries, freight and other 

delivery charges, and business 

infrastructure. 

A number of commenters stated that 

the dispensing fee should not be based 

on retail pharmacy costs, stating that 

retail pharmacies do not provide the 

array of services that homecare 

pharmacies do. One retail pharmacy 

clarified its comments from the prior 

year cited in the proposed rule. By 

suggesting a fee of 5 to 6 times the 

current fee last year, the retail pharmacy 

said they meant 5 to 6 times the $10 

proposed supplying fee (for 

immunosuppressive, oral anticancer, 

and oral anti-emetic drugs) for 2005 

(that is, $50 to $60). In addition, a 

respiratory company stated that a 

comment received on the August 5, 

2004 proposed rule from another retail 

pharmacy, which was cited in the 

August 8, 2005 proposed rule, may have 

been intended to mean $25 per 

prescription rather than $25 per 30-day 

period. Also, the commenter stated that 

the prior cost data was irrelevant 

because it preceded experience with the 

ASP system. Comments from retail 

pharmacies and a pharmacy association 

indicated support for the dispensing fee 

level urged by the 2005 AAH report. 

A number of commenters stated there 

would be adverse effects on beneficiary 

access to inhalation drugs if the fee were 

reduced. Some suppliers asserted that 

they would reduce the services offered 

to beneficiaries or cease supplying 

inhalation drugs to Medicare 

beneficiaries. A number of commenters 

pointed to the 2005 AAH survey, which 

indicated that 45 percent of providers 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70229 

would not accept Medicare patients if 

the dispensing fee were reduced more 

than a nominal amount, while 50 

percent indicated they would reduce 

services provided to beneficiaries, and 

2.5 percent indicated they would close. 

One commenter maintained that some 

providers had already closed or are 

seeking acquisition by other companies 

under current reimbursement rates. 

Another commenter speculated that a 

reduction in the dispensing fee would 

cause a shift away from small home care 

pharmacies to retail pharmacies, and 

asserted that these pharmacies would 

have to gear up by increasing 

inventories or directing patients to their 

mail order pharmacies. Some 

commenters suggested that a fee 

reduction could lead to adverse health 

effect for beneficiaries, reduced quality, 

or use of more intensive Medicare 

services. Others raised concerns that a 

reduction could create adverse 

incentives for substituting MDIs for 

nebulizers, even for patients where 

nebulizers are the preferred delivery 

mechanism. 

Some commenters suggested that it is 

premature to reduce the dispensing fee. 

Some of these commenters asserted that 

CMS did not provide any new cost data 

in the proposed rule that would warrant 

a reduction. Several commenters stated 

costs had increased due to higher fuel 

prices, unforeseen natural disasters, and 

wage inflation. Several commenters 

pointed to the 2005 AAH study which 

indicated that the average cost of 

shipping increased from $12.13 in 2004 

to $14.41 in 2005. One commenter 

indicated that its overnight shipping 

costs were between $27 to $40 per 

shipment. Another commenter cited a 

12.5 percent increase in the fuel 

surcharge cap for one large shipping 

company, which they indicated would 

cause their delivery costs to increase an 

additional 4 percent on top of prior 

increases. One commenter indicated 

that its cost per shipment had increased 

by $0.40 due to increased fuel costs in 

2005, and it expected additional future 

increases. In urging an increase in the 

fee to take into account inflation, 

another commenter mentioned that it 

had consolidated the number of 

pharmacies it operated to increase 

efficiency, but indicated that the 

number of costs that could be reduced 

was limited. Another commenter stated 

that we should not reduce the fee 

because the agency indicated in a 

October 8, 2004 letter to GAO that a fee 

of $55 to $64 was a reasonable range for 

a 2005 fee. Other commenters asserted 

that experience with the ASP system 

and the current dispensing fee is too 

limited to conclude there are 

overpayments. One commenter stated 

that the payment reduction in 2005 was 

greater than the Congressional Budget 

Office or the CMS Actuaries Office had 

projected prior to passage of the 

Medicare Modernization Act. This 

commenter suggested actual levels in 

2005 claims data be compared to 

original estimates before taking any 

action. 

Response: As noted previously, we 

established the 2005 dispensing fee 

using data from the 2004 AAH report. 

That report included costs for a wide 

range of services beyond basic 

dispensing, such as patient education, 

caregiver training, care coordination, 

and in-home visits. As discussed 

previously, we believe these activities 

represent care management services that 

should not fall within the scope of a 

dispensing fee. Furthermore, the 

September 2005 OIG report found little 

evidence that many beneficiaries receive 

these care management services. 

Consequently, we are establishing a 

dispensing fee for 2006 using the 2004 

AAH cost data excluding separable costs 

for care management services. We 

believe this interpretation represents an 

appropriate reading of the statute. Based 

on the 2004 AAH data for homecare 

pharmacies, excluding costs for care 

coordination, in-home visits, patient 

education, and caregiver training (as 

well as sales, marketing, bad debt and 

profit which were also excluded last 

year because Medicare does not 

generally reimburse those costs with 

respect to Part B services), we are 

establishing a dispensing fee of $33 for 

a 30-day supply of inhalation drugs. 

Because greater levels of effort may be 

involved in dispensing inhalation drugs 

when a patient begins these drugs for 

the first time, we have decided to 

maintain the current $57 dispensing fee 

for the first 30-day period in which an 

individual uses inhalation drugs as a 

Medicare beneficiary. Thus, beginning 

in 2006, we will pay a dispensing fee of 

$57 for the first month an individual 

uses inhalation drugs as a Medicare 

beneficiary, and $33 for a 30-day supply 

of inhalation drugs for all other months. 

Although some commenters urged an 

inflation adjustment, we do not believe 

it is warranted for 2006 because we do 

not believe it is clear that total 

dispensing costs have increased since 

the 2004 industry cost data was 

collected. Although data from the 2004 

industry report may not reflect wage 

inflation or increased delivery costs due 

to fuel price increases, it would also not 

include any efficiencies that providers 

may have achieved as they have 

adjusted to the new payment system in 

2005. The 2005 AAH report did not 

provide updated cost data for the 

service categories included in the 2004 

AAH report. Given that the 2004 AAH 

cost data would not reflect inflationary 

pressures, nor increased efficiencies in 

business operations, it is uncertain 

whether an upward or downward 

adjustment to the 2004 cost data should 

be made. As a result, we believe it is 

best to use the 2004 AAH data as is. We 

will consider the appropriateness of an 

inflation adjustment for the future. 

Regarding concerns raised by some 

commenters about beneficiary access, 

we believe, as discussed previously, that 

the fee level we are establishing is 

appropriate to cover suppliers’

dispensing costs, and beneficiaries will 

maintain good access to inhalation 

drugs. The fee amount is based on the 

2004 AAH cost data for clinical intake, 

establishing/revising the plan of care, 

delivery of services, refill calls/ 

compliance monitoring, billing/ 

collections, ‘‘other’’ direct costs, and 

indirect costs, excluding sales, 

marketing, bad debt, and profit which 

are not reimbursed by Medicare. Having 

based the 2006 dispensing fee on 

industry cost data for those activities 

that we believe fall within the scope of 

a dispensing fee, we believe the fees are 

appropriate to cover providers’ costs 

and will not impair access. In addition, 

we will continue to monitor access to 

care. 

Regarding concerns raised by some 

commenters about CMS lowering the fee 

without the benefit of new cost data, we 

believe it is our fiduciary responsibility 

to establish an appropriate payment for 

2006. As discussed previously, our 

decision is based on our determination 

that certain services should not fall 

within the scope of the dispensing fee 

and the OIG report which found that 

these services are furnished infrequently 

to beneficiaries. We believe our decision 

to lower the fee for 2006 is consistent 

with our October 8, 2004 letter to the 

GAO, in which we stated that a 

dispensing fee in the range of $55 to $64 

would be appropriate for the interim 

2005 fee. Regarding the comment that 

the savings from the ASP system are 

greater for inhalation drugs than the 

savings projected by CBO or the CMS 

actuaries prior to enactment of the 

MMA, we recognize the concerns 

regarding the shift from a payment 

system based on AWP; however, we do 

not believe such concerns are an 

appropriate consideration in 

determining the dispensing fee for 2006. 

Medicare does not generally establish 

payment rates based on budget 

projections. Rather, we use the most 

reliable cost data available to establish 

70230 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

a payment rate that is consistent with 

the statute and appropriate for Medicare 

covered services. 

Comment: In response to our request 

for comments on providers’ experience 

with the dispensing fee for a 90-day 

supply, we received a number of 

comments. One commenter pointed to 

the 2005 AAH survey, which found that 

most respondents (77 percent) do not 

provide a 90-day supply, and among 

those that do it represents 3 percent of 

their business. Reasons cited by survey 

respondents for non-use of a 90-day 

supply included—(1) 30-day supply 

promotes more contact with patients 

and compliance monitoring; (2) patient 

prescriptions often change; and (3) 

many suppliers believed the 90-day 

dispensing fee ($80 in 2005) was not 

adequate to cover costs. Less than 1 

percent indicated they do not provide a 

90-day supply because it is less 

profitable than a 30-day supply. A few 

other commenters raised concerns about 

the 90-day dispensing fee and provided 

similar reasons for non-use of the 90- 

day supply as the 2005 AAH survey. In 

addition, one commenter cited 

Medicare’s refund requirements for 

unused drugs as being another reason 

for non-use of the 90-day supply. 

However, one commenter suggested that 

the 90-day supply is not used because 

it receives less reimbursement overall 

than using the 30-day supply. A 

physician specialty group supported the 

90-day prescription because it reduces 

paperwork and redundant efforts by 

patients, physicians, and DME 

suppliers. 

Response: We agree with the 

physician specialty group that 

dispensing a 90-day supply has merit; 

thus, we have continued the 90-day 

dispensing fee for 2006. As cited by 

respondents to the 2005 AAH study, a 

30-day supply may be most appropriate 

for certain beneficiaries such as those 

with changing prescriptions. However, 

for those situations where it is 

medically appropriate, we believe it is 

important to have a 90-day option 

available. 

In the CY 2005 final rule, we 

calculated the 90-day dispensing fee by 

taking direct costs for the 30-day fee and 

tripling indirect costs (which was based 

on the methodology used in the October 

2004 GAO report). However, as 

discussed, some commenters voiced 

concern about the adequacy of the 2005 

90-day dispensing fee. Some 

commenters supported the 

reimbursement amounts suggested by 

respondents in the 2005 AAH survey. In 

that survey, respondents suggested an 

average fee for a 90-day supply 

($138.80) that was roughly twice the 

amount they suggested for a 30-day 

supply ($66.55). For 2006 using a 2 to 

1 ratio for the 90-day versus 30-day fee 

would yield a 90-day fee about 40 

percent higher than our previous 

methodology. We believe it is important 

that adequate reimbursement be 

available for the 90-day option, as well 

as, the 30-day option. Therefore, using 

the 2 to 1 ratio recommended by 

commenters for the 90-day versus 30- 

day supply payment rates, we are 

establishing a fee of $66 for a 90-day 

supply of inhalation drugs for 2006. 

Although we established two levels of 

dispensing fees for a 30-day supply, an 

initial 30-day fee of $57 and a 30-day fee 

of $33 for all other months, we do not 

believe a higher initial fee is warranted 

for a 90-day supply given that we do not 

believe a 90-day supply is generally 

used when a beneficiary first begins 

inhalation drugs. A number of 

commenters noted that the 90-day 

supply is not well-suited for patients 

whose prescriptions are likely to 

change. We recognize that beneficiaries 

who begin using inhalation drugs for the 

first time are more likely than 

established patients to experience 

changes in drugs or dosages, or to 

discontinue use altogether. Accordingly, 

we do not believe it is appropriate to 

encourage use of a 90-day supply when 

a beneficiary first begins using 

inhalation drugs by establishing a 

higher initial 90-day fee. Consequently, 

given such concerns, we have not 

provided two levels of dispensing fees 

with the 90-day option. 

Comment: Some commenters noted 

that refill calls are a service required by 

Medicare. 

Response: We agree that Medicare 

requires that a supplier confirm that a 

beneficiary needs a refill before sending 

a new shipment, and we have included 

the costs of refill calls from the 2004 

AAH report within the dispensing fee. 

Comment: A few commenters 

suggested that many of the activities 

they carry out are required to maintain 

compliance with FDA, Medicare, and 

State regulations, and with standards 

imposed by accrediting bodies such as 

JCAHO. Some commenters noted that 

CMS has issued draft supplier quality 

standards, and that they are required to 

provide certain services as part of those 

standards. The commenters suggested 

that the dispensing fee should 

accommodate their costs in these areas. 

Response: With the exception of 

certain guidelines concerning 

compounding, we do not believe that 

the requirements applicable to 

inhalation drug suppliers are in general 

substantially different from the 

requirements applicable to pharmacies 

dispensing other drugs. Furthermore, 

we view costs such as regulatory 

compliance and quality assurance as 

part of overhead, which we have 

included in the dispensing fee based on 

the 2004 AAH cost data for overhead 

and other direct costs. We also do not 

believe that the costs associated with 

regulatory requirements applicable to 

equipment suppliers should be 

compensated through the inhalation 

drug dispensing fee. The Medicare 

program makes separate payments to 

equipment suppliers for rental/purchase 

of nebulizers and maintenance, and 

regulatory requirements applicable to 

equipment suppliers would be covered 

through the basic payment rates for the 

equipment, not the Medicare payment 

rate for drugs or dispensing. 

Regarding the draft supplier quality 

standards that have been released for 

comment, we note that the agency has 

adopted a two-step process for 

developing those standards. An initial 

document with draft quality standards 

for suppliers of several types of durable 

medical equipment has been released 

for public comment. We expect to 

release a second document that will 

clarify which quality standards apply to 

inhalation drug suppliers. We expect 

that the standards applying to 

inhalation drug suppliers will be 

consistent with accepted quality 

standards for pharmacies. Furthermore, 

the standards will establish minimum 

requirements for being a supplier, 

which we consider to be part of the 

standard cost of doing business that is 

covered through our basic payment 

rates. As with conditions of 

participations (COP) for providers, we 

do not increase our payment rate as a 

result of a change in COP requirements. 

Comment: One commenter stated that 

section 1842(b)(3) of the Act requires 

Medicare payments be reasonable. The 

commenter asserted that the agency has 

established in § 405.502(a) criteria for 

determining what is reasonable, and 

stated that Medicare has a history of 

recognizing and reimbursing services 

related to patient care. 

Response: We recognize the 

commenter’s concern regarding the 

reasonableness of Medicare payments. 

We have based the dispensing fee 

payment rates on industry cost data 

from the 2004 AAH report, which was 

submitted as part of comments by AAH 

on the CY 2005 proposed rule, and used 

in the CY 2005 final rule, to establish 

the 2005 dispensing fee. To establish the 

2006 dispensing fee, we have used the 

2004 AAH cost data excluding those 

services that fall outside the scope of a 

dispensing fee. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70231 

Comment: Some commenters cited 

Medicare’s drug payment rates (ASP+6 

percent) as a reason the dispensing fee 

should remain the same or be increased. 

One homecare pharmacy indicated that 

it could not obtain drugs at ASP+6 

percent. A few commenters stated that 

their costs exceed reimbursement for 

drugs in cases where a physician writes 

brand medically necessary and the drug 

is in a billing code that contains both 

brand and generic drugs. An inhalation 

drug supplier indicated that for three 

inhalation drugs its acquisition costs 

exceeded Medicare reimbursement. 

Some commenters indicated Medicare 

drug payments (ASP+6 percent) were 

inadequate for a variety of reasons such 

as exclusion of wholesaler markup from 

ASP, the lag time between sales for a 

quarter and the inclusion of such 

information in the Medicare ASP+6 

drug payment rates, volatility in ASP+6 

reimbursement from quarter to quarter, 

and class of trade differences in pricing. 

One commenter suggested that Medicare 

had addressed concerns about the 

adequacy of ASP+6 percent 

reimbursement for oncology patients by 

implementing the Demonstration of 

Improved Quality of Care for Cancer 

Patients Undergoing Chemotherapy. 

They also suggested that the ASP+6 

percent cap on reimbursement for the 

upcoming Part B drug competitive 

acquisition program (CAP) was a reason 

for its delay, because they asserted 

vendors did not want to commit to a 

program where ASP+6 percent was the 

reimbursement limit. The commenter 

stated that the issues it has encountered 

with ASP+6 percent are similar to the 

issues faced by oncologists and vendors 

under CAP program and therefore 

should be addressed through the 

inhalation drug dispensing fee. 

In addition, a few commenters 

suggested that Medicare payments for 

equipment were inadequate, 

necessitating a substantial dispensing 

fee. 

Response: Although some 

commenters stated that the dispensing 

fee should account for drug acquisition 

costs in excess of the ASP+6 percent 

payment, we disagree. Section 1847A of 

the Act specifies that the Medicare 

payment for inhalation drugs is at 106 

percent of the ASP. We believe the 

Congress established the ASP based 

payment for inhalation drugs and 

separate authority for dispensing of 

these drugs for good reason, namely to 

pay appropriately for each service and 

to eliminate cross subsidization of 

services. Similarly, we believe payment 

for nebulizer equipment is a distinct 

policy separate from the dispensing fee, 

and one should not cross subsidize the 

other. In establishing the dispensing fee 

of $33 for a 30-day supply of inhalation 

drugs (and higher first month payment), 

we are focusing on what we believe is 

the appropriate scope and payment for 

the dispensing fee. 

Although one commenter suggested 

that we had addressed perceived issues 

about ASP+6 percent payment adequacy 

by implementing the Demonstration of 

Improved Quality of Care for Cancer 

Patients Undergoing Chemotherapy, we 

disagree. The purpose of the 

demonstration program is to promote 

improvements in quality by measuring 

patient outcomes in several areas of 

concern often cited by patients 

undergoing chemotherapy, which can 

then be traced to treatments and 

outcomes. In addition, we believe that 

the commenter’s statement that the 

change in the timeframe for 

implementation of the Medicare Part B 

drug CAP was a result of the ASP+6 

percent cap on vendor reimbursement is 

not accurate and not related to the 

inhalation drug dispensing fee. 

Comment: A few commenters 

expressed concern that the 30-day 

dispensing fee is the same regardless of 

the number of prescriptions dispensed. 

They noted that if a prescription is 

changed in the middle of the 30-day 

period they do not receive an additional 

fee. They suggested CMS consider a per 

script fee. 

Response: The dispensing fee amount 

we have established is based on the 

2004 AAH report data, which presented 

average costs for a month. 

Consequently, we believe our payment 

rate should be adequate to cover 

situations where multiple prescriptions 

are provided. We will consider the 

suggestion of a per script fee in future 

rulemaking, as necessary. 

Comment: Several commenters 

indicated that our revised guidelines 

concerning the timeframe for shipping 

refills had not reduced their need to use 

of overnight shipping. An industry 

association indicated that several factors 

often force overnight shipping such as 

hospitals giving beneficiaries only a one 

or two dose supply and beneficiaries 

waiting until they are out of medication 

to reorder. The 2005 AAH survey 

indicated that the percent of shipments 

that were overnight increased slightly 

from 56.3 percent in 2004 to 56.9 

percent in 2005. One commenter 

indicated that 60 percent of its 

shipments occur on an overnight basis 

because of several factors such as 

needing multiple calls to reach a 

beneficiary and new prescriptions 

reportedly needing to be shipped 

overnight. The commenter urged us to 

permit refill calls as needed to be ready 

to ship refill orders at least 7 days before 

the patient’s medication runs out. The 

commenter believes that this would 

allow for ground shipping in most cases, 

including refill dates that fall on 

weekends and 3-day holidays. One 

commenter suggested that the 30-day 

dispensing fee reimbursement guideline 

had reduced the amount of drugs that 

they could ship in a month, 

necessitating more use of overnight 

shipping. In addition, one commenter 

asserted if beneficiaries come in for a 

refill before the end of the month, then 

the pharmacy would receive no fee. 

While most commenters indicated that 

the revised delivery timeframes had not 

had a substantial impact on their 

delivery practices, one commenter 

indicated that 70 percent of its shipment 

through the third quarter of 2005 were 

ground deliveries, and they hoped to 

transition an additional 20 percent of 

shipments to ground delivery in the 

fourth quarter of 2005 as a result of 

Medicare’s extension of the patient 

notification and shipment window. 

Response: In the CY 2005 final rule, 

we made several administrative changes 

aimed at reducing inhalation drug 

supplier costs, including providing 

more flexible refill timeframes. We 

currently allow refills to be sent up to 

approximately 5 days before the end of 

the current usage period. To further 

facilitate the use of ground delivery, we 

are in the process of working to expand 

this timeframe to allow refills to be sent 

up to 7 days before the end of the 

current usage period. Under this new 

delivery timeframe, we will allow a 

dispensing fee to be paid up to 7 days 

before the end of current usage period, 

with up to 12 months of dispensing fees 

payable per year per beneficiary. 

In addition, we note that for 2006, we 

are establishing a dispensing fee of $57 

for the first month an individual uses 

inhalation drugs as a Medicare 

beneficiary because greater levels of 

effort may be involved in dispensing 

inhalation drugs when a patient begins 

these drugs for the first time, for 

example, following hospital discharge. 

Comment: Many commenters 

responded to our request for comments 

on the impact of Medicare Part D 

coverage of metered dose inhalers on 

beneficiary access to care. A number of 

commenters asserted that they did not 

believe there would be a substantial 

shift to MDIs when they become 

covered under Medicare Part D. One 

commenter said that MDIs are not a 

substitute for nebulizers, as many 

patients require nebulizers due to 

inability to use MDIs properly, or 

physicians’ experience has shown 

nebulizers are more effective than MDIs. 

70232 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

Another commenter said that although 

research has not been able to 

demonstrate the superiority of 

nebulizers to MDIs, nebulizers are the 

standard of care for COPD and chronic 

lung diseases in the moderate to severe 

stages. Other reasons commenters cited 

for their belief that there would not be 

a substantial shift to MDIs include: 

Physician inability to properly train 

patients on MDIs; patient familiarity 

with nebulizer use gained during 

hospital stays; research suggesting 

patient preference for nebulizers; 

potential use of nebulizers and MDIs by 

the same patient; and potential 

differences in cost-sharing across 

Medicare Part B and Part D. However, 

one physician specialty group said that 

it anticipates many Medicare 

beneficiaries will migrate to MDIs, and 

those that remain on nebulizers will be 

more frail and in need of more 

personalized service. 

Response: We believe expansion of 

Medicare coverage of inhalation drugs 

to include MDIs under Medicare Part D 

will provide additional options for 

treatment and positively impact access 

to care. As we indicated in the proposed 

rule, we recognize that nebulizers are 

required by many beneficiaries because 

of their individual circumstances. We 

believe that physicians will choose the 

treatment option that best meets a 

beneficiary’s needs, and both nebulizers 

and MDIs will play an important role in 

the Medicare program in the years to 

come. 

Comment: A health professional 

association asserted that individuals 

that provide patient education on use of 

nebulizers, MDIs, and dry powder 

inhalers (DPIs) should be qualified by 

virtue of education, training, and 

competency testing. It also urged CMS 

to pay a separate education fee to 

physicians when prescribing an MDI or 

dry powder inhaler. The commenter 

also proposed various levels of fees for 

initial and follow-up services. 

Another commenter raised concerns 

about what it asserts is a trend toward 

drop shipping respiratory related 

devices. The commenter expressed 

concern that contact between a 

respiratory patient and provider may 

disappear, raising potential concerns 

about correct usage of the respiratory 

device. 

Response: We agree that it is 

important that beneficiaries are properly 

trained in the use of nebulizers. The 

Medicare program provides that 

equipment suppliers either directly 

train the beneficiary in the use of the 

nebulizer or ensure that the beneficiary 

has been trained by other qualified 

individuals (§ 424.57(c)(12)). In 

addition, under the physician fee 

schedule, Medicare will pay physicians 

to train the beneficiary in the use of a 

nebulizer, MDI, or inhalation device 

(CPT code 94664, demonstration and/or 

evaluation of patient utilization of an 

aerosol generator, nebulizer, metered 

dose inhaler or IPPB device). 

Comment: One commenter stated that 

CMS evaded its notice and comment 

rulemaking obligations under the 

Administrative Procedures Act (APA) to 

collect meaningful data in support of an 

appropriate dispensing fee. The 

commenter urged us to publish data in 

a subsequent rule, and seek comment, 

before publishing a final payment rate 

for 2006. 

Response: In the August 8, 2005 

proposed rule, we identified and 

reviewed available studies and data on 

the cost of providing inhalation drugs, 

sought comment as well as additional 

data and information concerning an 

appropriate payment amount and scope, 

and indicated that we thought it likely 

that the payment amount for 2006 

would be lower than the current 

amount. Furthermore, in establishing 

the 2006 dispensing fee, we analyzed 

the available studies and data in 

response to comments received on the 

proposed rule and based on that 

analysis have continued to use the 2004 

AAH data that was identified in the 

proposed rule and also used to establish 

the 2005 fee. Furthermore, as discussed 

previously, it is our opinion that the 

rates established in this rule are 

appropriate in light of the statute and 

our understanding of Congressional 

intent. We believe, therefore, this met 

our obligations under the APA. 

Comment: One commenter took issue 

with our description in the proposed 

rule of inhalation drugs as supplies. 

Response: Medicare coverage of 

inhalation drugs is derived from their 

use in covered nebulizers. For Medicare 

coverage purposes, they are considered 

covered supplies. 

Comment: A few commenters 

expressed concern about precedents 

Medicare Part B will set for Medicare 

Part D. They asserted that 90-day scripts 

are not appropriate for nursing home 

patients. 

Response: The Medicare Part B policy 

concerning a 90-day dispensing fee does 

not carry over to Medicare Part D. 

Comment: Although the assignment of 

benefits form (AOB) has been 

eliminated, one commenter noted that 

the requirement to obtain a payment 

authorization signed by the beneficiary 

before submitting the claim diminishes 

the benefit of eliminating the AOB. The 

commenter urged CMS to eliminate the 

requirement for signed payment 

authorization for providers and those 

reimbursed based on assignment only. 

Response: We thank the commenter 

for the comment. CMS is reviewing the 

beneficiary signature requirement for 

claims submission in light of the 

elimination of the AOB form in 

instances of mandatory assignment. 

However, CMS currently requires a 

beneficiary signature for claims 

submission. 

Comment: One drug manufacturer 

suggested that compounding that 

attempts to mimic production of 

commercially available products 

threatens patient safety. The commenter 

urged CMS to structure the dispensing 

fee to reduce the likelihood of 

inappropriate compounding. The 

commenter also suggested code 

modifiers for pharmacy-compounded 

medications to help identify their 

occurrence. Another drug manufacturer 

suggested that reducing the dispensing 

fee could spur suppliers to provide 

compounded versions of commercially 

available products without physician or 

patient authorization. The commenter 

suggested that we review supplier 

documentation to ensure compounded 

solutions are only furnished where 

documentation supports medical 

necessity of a customized product. 

Response: The inclusion of costs for 

pharmacy compounding in the 

dispensing fee is not in any way an 

endorsement of compounding that is 

inconsistent with FDA guidelines. 

Furthermore, Medicare expects that 

pharmacies comply with FDA 

guidelines irrespective of the dispensing 

fee payment amount established. We 

understand the concerns the 

commenters raised and will consider 

the issues further. 

Comment: One commenter urged us 

to require code modifiers for claims 

associated with patient compounding of 

inhalation drugs. The commenter asserts 

that when a physician writes a 

prescription for a compounded drug, the 

inhalation drug supplier has an 

incentive to dispense the drugs 

separately in order to obtain two 

dispensing fees. The commenter asserts 

that implementing the modifiers would 

allow us to pay only one dispensing fee, 

instead of two, under these 

circumstances. 

Response: Medicare pays only one 

dispensing fee per 30-day (or 90-day) 

period, regardless of the number of 

drugs dispensed. As a result, these 

modifiers would not affect Medicare 

expenditures. 

Comment: We received some 

comments in response to our request for 

information about why there is 

substantial variation in costs across 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70233 

suppliers. A few commenters suggested 

that many beneficiaries receive services 

from small providers who may have 

higher costs. 

Response: We appreciate the 

comments. We note that the GAO 

report, which showed wide cost 

variation, found that larger suppliers 

did not necessarily have lower costs 

than small suppliers. We continue to 

believe that this is an issue that might 

benefit from further study. 

5. Supplying Fee 

Section 303(e)(2) of the MMA added 

section 1842(o)(6) of the Act which 

requires the Secretary to pay a 

supplying fee (less applicable 

deductible and coinsurance) to 

pharmacies for certain Medicare Part B 

drugs and biologicals, as determined 

appropriate by the Secretary. The types 

of Medicare Part B drugs and biologicals 

eligible for a supplying fee are 

immunosuppressive drugs described in 

section 1861(s)(2)(J) of the Act, oral 

anticancer chemotherapeutic drugs 

described in section 1861(s)(2)(Q) of the 

Act, and oral anti-emetic drugs used as 

part of an anticancer chemotherapeutic 

regimen described in section 

1861(s)(2)(T) of the Act. 

Beginning with CY 2005, Medicare 

established a supplying fee of $24 per 

prescription for these categories of 

drugs, with a higher fee of $50 for the 

initial oral immunosuppressive 

prescription supplied in the first month 

after a transplant. When multiple drugs 

are supplied to a beneficiary, a separate 

supplying fee is paid for each 

prescription, except when different 

strengths of the same drug are supplied 

on a single day. When we established 

the $24 supplying fee in the CY 2005 

final rule (69 FR 66236), we indicated 

that we were establishing a rate higher 

than that of other payers due to the 

additional costs associated with 

Medicare Part B’s lack of online claims 

adjudication. 

As part of the August 8, 2005 

proposed rule (70 FR 45848), we 

proposed changes to the supplying fee 

for multiple prescriptions supplied 

during the same month. We proposed to 

continue paying $24 for the first 

prescription supplied during a month 

(or $50 for the first oral 

immunosuppressive prescription 

supplied in the first month after a 

transplant) and a supplying fee of $8 for 

each additional prescription the 

pharmacy supplied to the beneficiary 

during the same month. Each pharmacy 

supplying these drugs to a beneficiary 

during a month would be entitled to one 

$24 supplying fee per beneficiary during 

that month. In making this proposal, we 

indicated that when a pharmacy 

supplies multiple drugs to a beneficiary 

during the same month, many of which 

are likely to be supplied on the same 

day, we were concerned that we were 

overpaying for the costs associated with 

our lack of online claims adjudication. 

Furthermore, we indicated that we 

believe that the $24 supplying fee for 

the first prescription would adequately 

compensate a supplier for the billing 

costs associated with the lack of on-line 

claims adjudication, and that the cost of 

supplying additional prescriptions in 

the same month should be comparable 

to that of other payers. 

We also proposed to expand the 

circumstances under which we pay 

supplying fees for multiple 

prescriptions filled on the same day. 

Currently, we pay a supplying fee for 

each prescription supplied on the same 

day as long as the prescriptions are for 

different drugs. We proposed to pay a 

supplying fee for each prescription, 

even if the prescriptions are for different 

strengths of the same drug. 

We requested comments about the 

appropriateness of our proposed 

supplying fee for multiple prescriptions 

supplied during a single month along 

with data and information about the 

incremental costs of supplying 

additional prescriptions to a Medicare 

beneficiary during a single month. We 

also asked for comments about how 

pharmacy costs and reimbursement for 

supplying oral drugs under Medicare 

compares to that of other payers. 

We received numerous comments 

regarding our supplying fee proposals. 

Those comments and responses are 

provided below. 

Comment: Numerous commenters 

were supportive of our proposal to 

expand the circumstances under which 

we pay a supplying fee to include 

paying separate fees when multiple 

strengths of the same drug are supplied 

on the same day. However, many 

commenters expressed concern about 

our proposal to pay a supplying fee of 

$24 to a pharmacy for the first 

prescription and $8 for all subsequent 

prescriptions supplied in a 30-day 

period. Commenters generally urged no 

reduction in the supplying fee when 

multiple prescriptions are provided in 

the same month, and a few urged a 

payment increase. In opposing the $8 

subsequent fee, some commenters stated 

that the agency had included no new 

cost data in the proposed rule to support 

a reduction. At the same time, some 

commenters provided cost information 

as part of their comments. 

A few commenters indicated that the 

cost of supplying a drug for an insurer 

with online claims adjudication had 

increased from $8 (as cited in the 

proposed rule) to $9 to $10 based on 

new studies. An association 

representing chain drug stores provided 

information from a few large chains 

indicating that the average cost to 

supply a Medicare Part B prescription 

was between $19 and $21, noting that 

small chains or independent pharmacies 

may have higher costs. The association 

asserted that the current $24 fee was 

reasonable considering the fact that 

Medicare currently does not pay 

separate supplying fees for different 

strengths of the same drug supplied on 

the same day. The association urged us 

to consider an increase in the $24 fee to 

take into account inflation, and an 

increase in the $50 fee for the first 

prescription after a transplant to 

compensate for the intense patient 

monitoring that the association 

indicated was needed. A large chain 

pharmacy indicated its average cost of 

supplying a Medicare prescription was 

$19.02, which included $5.54 for bad 

debt. 

An association for specialty transplant 

pharmacies submitted data suggesting 

that Medicare’s reimbursement 

(combined payment for the drug and 

supplying fee) to these pharmacies for 2 

large volume immunosuppressive drugs 

is comparable or lower than that of 

Medicaid or private payers. This 

association pointed to a 2004 report 

prepared by a consultant, which 

indicated that specialty pharmacy costs 

for immunosuppressive drugs for 

Medicare patients averaged about $35. 

This association also indicated that 

transplant pharmacies have higher costs 

because they offer more extensive 

services, routinely stock specialty 

medicines and maintain regular and 

consistent contact with their Medicare 

clients. The association suggested that 

these services should be compensated 

through the supplying fee. In addition, 

this association also claimed that chain 

pharmacy data collected in a similar 

manner to the specialty pharmacy data 

yield costs of $21. The group asserted 

that the chain costs appear lower than 

the specialty pharmacy costs in part 

because chains supply items such as 

diabetic test-strips, which they indicate 

cost less to supply. 

In opposing a reduction in the 

supplying fee for subsequent 

prescriptions in a month, a number of 

commenters took issue with the 

rationale provided in the proposed rule 

for the reduction, saying that there are 

not economies of scale in processing 

Medicare claims when multiple 

prescriptions are provided in the same 

month. Many commenters outlined 

costs associated with billing Medicare. 

70234 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

Because of the lack of online claims 

adjudication, some stated that there was 

more bad debt associated with Medicare 

Part B claims. Other commenters 

indicated that it takes longer to process 

a Medicare claim because of the 

requirement of a signed order from the 

physician as well as the lack of online 

claims adjudication. Some commenters 

indicated that without online claims 

adjudication, pharmacies must call the 

DMERC to check the beneficiary’s 

deductible as well as verify whether the 

beneficiary is still enrolled in traditional 

Medicare as opposed to Medicare 

Advantage. Other commenters indicated 

that the lack of online claims 

adjudication and automatic cross over 

claims means that they may have to 

refund a beneficiary’s coinsurance if it 

is later determined that the beneficiary 

has supplemental insurance. Other 

billing activities and requirements that 

commenters cited as creating added 

costs include: contracting with a special 

entity to convert Medicare Part B claims 

from the NCPDP format to ANSI X837; 

working with physicians to determine 

whether oral anticancer or anti-emetic 

drugs are being prescribed for Medicare 

Part B covered indications; having to 

submit the unique physician identifying 

number (UPIN) on the claim; and 

Medicare’s requirement that the date of 

service and date of prescription be the 

same. 

Although most commenters did not 

support the proposal for a reduced fee 

when multiple prescriptions are 

supplied in a month, one health insurer 

commented that the current supplying 

fee payment amounts appear high, and 

put upward pressure on commercial 

rates. 

Response: As we indicated in the CY 

2005 final rule (69 FR 66236), we 

recognize that the cost of supplying 

Medicare Part B drugs is somewhat 

higher than that of other payers because 

of the lack of on-line claims 

adjudication for Medicare Part B claims. 

We believe it is appropriate for 

Medicare’s supplying fee to compensate 

for the Medicare billing costs associated 

with the lack of online claims 

adjudication. However, as we indicated 

last year, we do not believe the 

supplying fee for these drugs should be 

higher than other payers for reasons 

other than the lack of on-line claims 

adjudication. 

The comments included information 

on the costs of supplying Medicare Part 

B drugs for some chain pharmacies. One 

chain reported Medicare costs of $14.48 

($19.02 – $5.54 non-reimbursed bad 

debt). A retail pharmacy association 

commented that a few chains had 

indicated that their costs of supplying a 

Medicare Part B prescription were 

between $19–$21 per prescription 

(without indicating whether bad debt 

was included). Furthermore, as we 

indicated in the August 14, 2004 final 

rule (69 FR 66236), our analysis of data 

from a 2004 survey of specialty 

pharmacies yields a supplying fee in the 

range of $13–$27 depending on the 

proportion of personnel costs assumed 

to be associated with Medicare billing. 

This range was developed by using a 

figure of $5 or $10 for the payment rates 

of payers with on-line adjudication, and 

adding to that Medicare claims 

processing costs from the specialty 

pharmacy data ($8), and a portion of 

personnel costs from the specialty 

pharmacy data (total was $9) assumed to 

be related to Medicare billing. This 

results in supplying fee between $13 ($5 

+ $8) and $27 ($10 + $8 + $9), 

depending on the portion of personnel 

costs associated with Medicare billings. 

Based on this information from chains 

and specialty pharmacies, we agree that 

an $8 fee for subsequent prescriptions is 

too low. However, as discussed in more 

detail subsequently, our analysis of the 

cost information from the comments has 

led us to believe that a subsequent 

prescription supplying fee that is 

slightly lower than $24 would be 

appropriate. Based on our analysis, we 

believe that a $24 fee for the first 

prescription in a 30-day period, and a 

$16 fee per prescription for all 

subsequent prescriptions in the 30-day 

period would be consistent with the 

cost information included in the 

comments. Under this fee structure, 

reimbursement to a pharmacy for the 

supplying fee would average $24 for a 

patient with 1 prescription in a 30-day 

period, $20 per prescription for patients 

with 2 prescriptions, $18.67 per 

prescription for a patient with 3 

prescriptions, and $18 per prescription 

for a patient with 4 prescriptions, for 

example. Our claims data currently 

indicate that beneficiaries receiving 

immunosuppressive, oral anticancer, or 

oral anti-emetic drugs under Medicare 

Part B average 2.2 prescriptions per 

month, with a majority receiving 4 or 

fewer. We believe average supplying fee 

payments ranging from $18 to $24 are 

consistent with the chain drug store 

costs indicated in the comments and 

falls within the mid-range of the 

potential supply fee amounts we 

calculated based on the specialty 

pharmacy data survey. 

Because we continue to believe that 

there are some economies of scale for 

Medicare billing costs when multiple 

prescriptions are supplied in the same 

month, particularly when they are billed 

on the same claim form, we believe it is 

appropriate to pay a higher fee for the 

first prescription in a 30-day period, and 

the somewhat lower fee for all 

subsequent prescriptions in the 30-day 

period. For example, several activities 

related to Medicare billing that 

commenters cited as being costly 

including calling the DMERC to verify 

the beneficiary’s Medicare fee for 

service eligibility, locating the 

physician’s UPIN to include on the 

Medicare Part B claim form, handling 

coinsurance refunds for crossover 

claims, and completing other 

information on the claim form would 

only have to be performed once, rather 

than twice, when multiple prescriptions 

are submitted on the same claim. 

Moreover, following through on our 

proposal to expand payment of the 

supplying fee to include paying separate 

fees when multiple strengths of the 

same drug are supplied on the same 

day, we believe it is important that the 

subsequent prescription supplying fee 

reflect lower incremental costs. 

Consequently, beginning in 2006, we 

are establishing a supplying fee of $24 

for the first prescription in a 30-day 

period, and $16 for each subsequent 

prescription in the period. Each 

pharmacy will be eligible for one $24 

fee per beneficiary per 30-day period. 

As mentioned previously, beginning in 

2006 we are also expanding the 

circumstances under which we pay the 

supplying fee to include paying separate 

fees for different strengths of the same 

drug that are a supplied on the same 

day. We are not altering the current 

policy of paying a $50 supplying fee for 

the first immunosuppressive 

prescription after a transplant. If a 

supplier receives a $50 supplying fee for 

the initial prescription after a 

transplant, a supplying fee of $16 will 

be paid for all subsequent prescriptions, 

after the initial prescription, furnished 

by that supplier to the beneficiary 

during that 30-day period. 

We are making conforming changes to 

§ 414.1001(b) to reflect this policy 

concerning subsequent prescriptions 

supplied during the same 30-day period 

as the initial immunosuppressive 

prescription after a transplant. 

Comment: A number of commenters 

expressed concerns about beneficiary 

access if the supplying fee were 

reduced. Some suggested that 

pharmacies may stop providing these 

drugs to beneficiaries if the supplying 

fee is lowered. Others believe that a 

reduction in the fee could lead specialty 

pharmacies to stop providing support 

services to transplant patients, which 

they assert could adversely impact 

transplant success for some patients. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70235 

Response: We believe the supplying 

fee payment amounts we have 

established are appropriate based on the 

cost information available from the 

comments, and beneficiaries will 

continue to have good access to these 

drugs. Furthermore, we note that the 

reduction in Medicare payments 

resulting from the supplying fee changes 

are expected to represent at most 1 

percent of Medicare total payments to 

pharmacies for these drugs. 

Comment: Some commenters 

expressed concern about the reduction 

in reimbursement that would result 

from the subsequent prescription 

supplying fee in certain situations (for 

example, for drugs that have a 3-week 

prescription cycle or for patients with 3 

prescriptions per month). 

Response: Under the supplying fee 

rates established for 2006, Medicare 

reimbursement for the supplying fee 

would in the majority of cases average 

from $24 (patient with 1 Medicare Part 

B prescription) to $18 (patient with 4 

Medicare Part B prescriptions). As 

mentioned previously, we believe this 

range of average reimbursement is 

consistent with the chain pharmacy cost 

information in the comments and falls 

near the mid-range of the potential 

supplying fee payment amounts we 

calculated based on the 2004 survey 

data for specialty pharmacies. 

Furthermore, we believe the supplying 

fee payment rates appropriately reflect 

the potential for economies of scale 

when multiple prescriptions are 

supplied in the same month. 

Comment: A few commenters stated 

that a lower subsequent prescription fee 

may encourage pharmacies to send 

patients to affiliate locations in order to 

receive the $24 fee. 

Response: We disagree. As mentioned 

previously, we believe that the 

supplying fee payment rates established 

are adequate to cover pharmacies’

supplying costs based on the cost 

information included in the comments. 

We do not believe that these 

reimbursement changes would spur 

pharmacies to take actions that would 

cause inconvenience to the beneficiaries 

they serve. 

Comment: Some commenters 

maintained Medicare’s drug payment 

rates (the average sales price + 6 

percent) were below their acquisition 

costs for certain drugs, and stated that 

the current $24 per prescription 

supplying fee should be unchanged or 

increased to compensate for this. 

Response: Although some 

commenters stated that the supplying 

fee should account for drug acquisition 

costs in excess of the ASP+6 percent 

payment, we disagree. Section 1847A of 

the Act specifies that the Medicare 

payment for these drugs is at 106 

percent of the ASP. We believe the 

Congress established the ASP based 

payment for these drugs and separate 

payment for the supplying of these 

drugs for good reason, namely to pay 

appropriately for each distinct service. 

In expanding the circumstances under 

which we pay a supplying fee and 

establishing the supplying fee payment 

amounts ($24 for the first prescription 

in a 30-day period and $16 for all 

subsequent prescriptions in a 30-day 

period, as well as the $50 fee for first 

immunosuppressive prescription after a 

transplant), we are focusing on the 

appropriate scope and payment for the 

supplying fee. 

Comment: A few commenters 

suggested that for 2006 the current 

supplying fee payment amounts ($50 for 

initial prescription after a transplant, 

and $24 per prescription otherwise) be 

increased for inflation or to ensure 

adequate reimbursement for services 

provided by suppliers. 

Response: We believe that the 

supplying fee payment amounts we 

have established for 2006 are consistent 

with the cost information from the 

comments this year. We will consider 

an inflation adjustment for the future. 

Comment: Some commenters raised 

concern that if a beneficiary sought a 

refill before the end of the month, the 

pharmacy would not be eligible for a 

$24 fee for that refill. 

Response: We understand the 

commenters’ concern. We are taking 

several steps to address this potential 

issue. First, we have decided to use a 

30-day period rather than a calendar 

month as the basis for determining 

whether a $24 or $16 supplying fee is 

payable. Thus, we will pay a $24 

supplying fee for the first prescription 

supplied by a pharmacy in a 30-day 

period (or a $50 supplying fee for the 

first immunosuppressive prescription 

after a transplant), and a $16 supplying 

fee for each subsequent prescription 

supplied by that pharmacy to the 

beneficiary in the 30-day period. We 

believe using a 30-day period avoids 

arbitrary fluctuations in payment that 

might otherwise occur as a result of 

variation in the number of days per 

month. In addition, in our instructions 

to implement the 2006 supplying fee, 

we will allow a $24 supplying fee to be 

paid for a refill prescription up to 7 days 

before the end of the 30-day period for 

which the last $24 supplying fee was 

paid to that pharmacy, with up to 

twelve $24 supplying fees payable per 

beneficiary per year. 

Comment: A number of commenters 

expressed concern that the assignment 

of benefits (AOB) forms, which the 

August 14, 2004 final rule indicated 

would be eliminated, has not yet been 

eliminated. 

Response: The requirement that a 

pharmacy obtain an AOB form when 

supplying drugs to a beneficiary was 

eliminated for dates of services on or 

after January 1, 2005. Because of 

technical issues, the claims processing 

contractors did not immediately 

implement this change. We published a 

change request in August 2005 

clarifying that the requirement for an 

AOB form was eliminated effective 

January 1, 2005 for pharmacies 

supplying Medicare Part B drugs to 

beneficiaries (as well as in other 

circumstances where assignment is 

mandatory). This change request will be 

implemented on November 14, 2005. 

The change request can be found at: 

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

pm_trans/R643CP.pdf. 

Comment: Several commenters 

expressed concern that the DMERC 

Information Form (DIF), which the 

August 14, 2004 final rule indicated 

would be eliminated, had not been 

eliminated yet. A commenter also 

mentioned some suppliers having 

difficulty with the rejection of claims for 

immunosuppressives for ‘‘DIFs not on 

file,’’ when they are on file. In addition, 

one commenter urged us to not only 

eliminate the DIF, but also to eliminate 

the requirement that pharmacies collect 

and submit the DIF information with 

each claim. The commenter suggests 

that most of this information can be 

obtained by information submitted to 

Medicare by the transplant facility or 

transplant physician, and the 

requirement for pharmacies to submit 

the information is duplicative. 

Response: The elimination of the DIF 

will be implemented with the quarterly 

systems release that occurs April 2006. 

A number of systems issues makes the 

elimination of the DIF more involved 

than anticipated. We regret the delay in 

the elimination of this requirement, and 

remain committed to implementing the 

change in April 2006. Regarding the 

other issues concerning the DIF raised 

in the comments, these billing issues are 

outside the scope of this final rule; 

however, we encourage commenters to 

continue to bring these concerns to our 

attention. 

Comment: A specialty pharmacy 

group indicated that some pharmacies 

had encountered situations where 

Medicaid or other third party payers 

were not covering the beneficiary’s 

coinsurance on the supplying fee. The 

commenter requested that the final rule 

include an explanation of these parties’

70236 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

responsibilities concerning beneficiary 

coinsurance on the supplying fee. 

Response: The supplying fee is 

covered under Medicare Part B. Like all 

other Medicare Part B benefit categories, 

standardized Medigap plans are 

responsible for paying all (plans A–J) or 

a specified proportion (plans K and L) 

of a beneficiary’s Part B coinsurance 

once the Part B deductible has been met. 

With some exceptions, State Medicaid 

programs are responsible for beneficiary 

cost-sharing for the supplying fee for 

beneficiaries who are dually eligible for 

both Medicare and Medicaid. State 

Medicaid programs can limit 

coinsurance payments to the extent that 

any payment, when combined with 

Medicare payments, equals the amount 

of reimbursement payable under the 

State Medicaid program. A State 

Medicaid program may deem a 

pharmacy to be paid in full even if it has 

received either no coinsurance payment 

or a reduced payment from the State. 

Beneficiaries have no liability beyond 

the State’s payment amount as set forth 

in section 1902(n)(2) of the Act. 

Comment: One commenter suggested 

that physicians be allowed to bill for the 

supplying fee for immunosuppressive, 

oral anti-cancer, and oral anti-emetic 

drugs. The commenter suggested we 

could define a pharmacy, for the 

purposes of the supplying fee, to 

include physicians acting as 

pharmacists. As another approach, they 

suggested we could use our inherent 

reasonableness authority to extend the 

supplying fee to physicians. 

Response: As we indicated in the CY 

2005 final rule, given our understanding 

of Congressional intent, we do not 

believe it would be appropriate to pay 

a supplying fee to physicians. In 

addition, at this time, we do not have 

sufficient data to determine if our 

inherent reasonableness authority 

would apply in this instance. 

Comment: A specialty pharmacy 

group requested that we include 

clarification in the final rule concerning 

whether temporary billing codes for the 

supplying fee G0369 and G0370 will be 

replaced with permanent codes. 

Response: Effective January 2006, we 

intend to replace the G-codes for the 

supplying fee with Q-codes. 

6. Competitive Acquisition of 

Outpatient Drugs and Biologicals Under 

Part B 

In this section of the preamble, we 

discuss the Competitive Acquisition 

Program (CAP) for Part B drugs; 

summarize the requirements established 

in the July 6, 2005 interim final rule 

with comment titled ‘‘Competitive 

Acquisition of Outpatient Drugs and 

Biologicals Under Medicare Part B’’ (70 

FR 39022); respond to comments on 

selected issues in that rule and finalize 

the associated policies; and discuss the 

next steps in the implementation of the 

CAP program. We are addressing the 

issue of inclusion of CAP drug units in 

the ASP calculation in separate 

rulemaking. 

General Overview of CAP 

Section 303(d) of the MMA amended 

the Act by adding a new section 1847B, 

which establishes a program for the 

acquisition of and payment for 

competitively biddable Part B covered 

drugs and biologicals furnished on or 

after January 1, 2006. Implementation of 

the CAP will provide physicians with a 

choice between—

• Obtaining these drugs from entities 

selected to participate in the CAP in a 

competitive bidding process; or 

• Acquiring and billing for Part B 

covered drugs under the ASP drug 

payment methodology. 

In our July 6, 2005 interim final rule 

with comment, we finalized provisions 

set forth in the Competitive Acquisition 

of Outpatient Drugs and Biologicals 

Under Part B proposed rule published 

on March 4, 2005 in the Federal 

Register (70 FR 10746), but also 

provided the public an additional 

opportunity to comment on the final 

provisions established for the CAP. We 

codified the requirements and 

provisions for the CAP in regulations at 

42 CFR part 414, subpart K, with 

§ 414.906 through § 414.920 containing 

requirements for payment under the 

CAP as follows: 

• Section 414.906 (Competitive 

acquisition program as the basis for 

payment). This section specifies how 

payment for CAP drugs is determined, 

including vendor responsibilities for 

billing, shipment and delivery; 

computation of the payment amount; 

substitution of CAP drugs and resupply 

of a participating CAP physician’s drug 

inventory. 

• Section 414.908 (Competitive 

acquisition program). This section 

specifies the process for a physician to 

select an approved CAP vendor and the 

responsibilities of a participating CAP 

physician, including the specific 

information that must be included on 

the prescription order as well as 

notification and the timeframe for 

submission of claims. This section also 

specifies the process for selecting 

approved CAP vendors, as well as 

factors that are considered in the 

selection process such as exclusion 

under section 1128 of the Act from 

participation in Medicare or other 

Federal health care programs. 

• Section 414.910 (Bidding process). 

This section outlines the specific 

criteria for submission of a bidding 

price for a CAP drug, and specifies what 

costs should be included in the bid 

price. 

• Section 414.912 (Conflicts of 

interest). This section discusses 

requirements and standards for conflict 

of interest that applicants that bid to 

participate and approved CAP vendors 

must meet. 

• Section 414.914 (Terms of 

contract). This section outlines the 

contract provisions between CMS and 

the approved CAP vendor including 

contract length and termination, and 

specific requirements the approved CAP 

vendor must comply with. 

• Section 414.916 (Dispute 

resolution for vendors and 

beneficiaries). This section discusses the 

process available to an approved CAP 

vendor and beneficiaries for resolution 

of denied drug claims, outlining the 

steps, timeframes and requirements that 

must be met. 

• Section 414.917 (Dispute 

resolution and process for suspension or 

termination of approved CAP contract). 

This section discusses the process 

available to participating CAP 

physicians for resolution of quality or 

service issues concerning an approved 

CAP vendor, including steps and 

timeframes that are to be followed. 

• Section 414.918 (Assignment) and 

§ 414.920 (Judicial review). Application 

of assignment and administrative and 

judicial review for the CAP are 

discussed in these sections of the 

regulation, respectively. 

In the July 6, 2005, interim final rule 

with comment for the CAP published as 

CMS 1325–IFC, we also defined terms 

used for the CAP in § 414.902. We also 

established that for initial 

implementation, the competitive 

acquisition area, in which approved 

CAP vendors supply drugs, will be on 

a national level and include all 50 

States, the District of Columbia, Puerto 

Rico, and the U.S. territories. In 

addition, we established a single drug 

category consisting of approximately 

180 drugs commonly provided 

‘‘incident to’’ a physician’s service and 

included these in the addenda to the 

July 6, 2005 interim final rule with 

comment. These drugs represent about 

40 percent of the approximately 440 

drugs that may be billed ‘‘incident to’’

physician services and about 85 percent 

of physicians’ Part B drugs by billed 

charges, as reflected in our Part B billing 

data. 

Effective August 3, 2005, we 

suspended the vendor bidding process 

that began with publication of the July 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70237 

6, 2005 interim final rule with comment 

to allow us more time to fully review 

public comments on the interim final 

rule with comment and also to further 

refine the bidding process. We provided 

notification of the suspension on the 

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

providers/drugs/compbid/ and through 

the pharmacy and physician Listservs. 

We also announced the suspension of 

the bid process in the Competitive 

Acquisition of Outpatient Drugs and 

Biologicals Under Part B: Interpretation 

and Correction interim final rule with 

comment, published on September 6, 

2005 in the Federal Register (70 FR 

52930). In that document, we stated we 

would publish a final rule for 

implementing the CAP after we 

analyzed the additional comments on 

the July 6, 2005 interim final rule with 

comment and determined the best 

manner for improving the efficiency of 

the CAP and increasing potential 

participation of both vendors and 

physicians in the program. We also 

indicated that we would announce the 

dates for the new vendor bidding period 

as well as a special physician election 

period with the publication of the final 

rule. As noted earlier in this section of 

the preamble and as discussed in more 

detail below, in this final rule with 

comment, we are addressing certain 

issues raised by commenters responding 

to the July 6, 2005 interim final rule 

with comment. We believe it is critical 

to address these specific concerns we 

have identified through review of the 

comments and finalize or clarify 

specific policy issues raised to allow us 

to effectively implement the CAP. Other 

issues raised by commenters that are not 

addressed in this final rule with 

comment will be addressed in future 

rulemaking, once we have fully 

reviewed all of the comments not 

addressed in this rulemaking. Specific 

information concerning implementation 

of the CAP, including vendor bidding 

and physician election are discussed 

later in this section. 

Analysis of and Response to Public 

Comments 

We received a total of 225 timely 

comments in response to the July 6, 

2005 interim final rule with comment 

(70 FR 39022). Commenters included 

trade associations, medical societies and 

organizations, a health insurance 

company, pharmaceutical 

manufacturers and wholesalers, 

specialty pharmacies and pharmacy 

benefits management groups, as well as 

practitioners, private citizens and 

patient advocates, and a member of the 

Congress. All public comments were 

reviewed and grouped by related topics 

and focused on various aspects of the 

CAP interim final rule with comment. In 

this final rule with comment, we are 

responding to comments related to 

certain aspects of the CAP, and making 

modifications to the regulation text 

where necessary so that an improved 

implementation can be achieved. We 

will be responding to the remaining 

comments and issues raised in future 

rulemaking after we have had the 

opportunity to fully review those 

comments and issues. The specific areas 

being addressed are discussed below. 

a. Design of the Program 

In this section, we discuss the policy 

and process for changes to the original 

CAP Single Drug Category List 

(Addendum A) and changes in the 

original New Drugs for the CAP Bidding 

for 2006 (Addendum B). These changes 

are reflected in Addendum F and 

Addendum G of this final rule with 

comment. We also clarify issues related 

to drugs included in the CAP and 

updated certain requirements for 

bidding. We discuss the process for 

when and how an approved CAP vendor 

may request that we approve a change 

to its CAP drug list. Finally we discuss 

CAP drug weighting for the single drug 

category. 

(1) Changes to the List of Drugs 

Supplied Under the CAP 

The CAP is intended to provide 

beneficiaries with access to Medicare 

Part B drugs and maintain physician 

flexibility when prescribing 

medications. In the July 6, 2005 interim 

final rule with comment, we described 

how the single drug category list was 

developed and how newer agents and 

substitute products could be 

incorporated into the CAP. In this 

section of the preamble, we will 

respond to comments relating to drugs 

supplied under the CAP. 

We developed the single drug 

category list by developing criteria 

based on Part B drug utilization. This 

list was published in Addendum A of 

the July 6, 2005 interim final rule with 

comment and contains the majority of 

drugs that a prospective CAP vendor 

will bid on. Newer drugs without 

utilization data were listed in 

Addendum B—New Drugs for CAP 

Bidding in 2006 in the July 6, 2005 

interim final rule with comment. 

Development of these lists began with 

the statutory definition of competitively 

biddable drugs and biologicals (section 

1847B(a)(2) of the Act) and then the 

application of specific steps described 

in the July 6, 2005 interim final rule 

with comment (70 FR 39030) to narrow 

the list of possible drugs based on 

utilization and other factors, as 

described in the interim final rule with 

comment, that we believe made 

inclusion of the drug in the CAP drug 

category appropriate for the initial 

implementation stage of the CAP. 

Section 1847B(a)(1)(B) of the Act 

requires that the Secretary establish 

categories of drugs that will be included 

under the CAP, and requires the 

Secretary to phase-in the program with 

respect to these categories. The statute 

also defines ‘‘competitively biddable 

drugs and biologicals’’ for the purposes 

of the CAP by referring to section 

1842(o)(1)(C) of the Act. 

Relying on our authority to phase in 

the CAP drug categories as appropriate, 

we narrowed our focus to drugs 

furnished ‘‘incident to’’ a physician’s 

service. In response to comments, and 

in an effort to offer the CAP to as many 

physicians as possible, we chose not to 

phase-in the CAP on the basis of drugs 

typically used by any one particular 

specialty; however, we realized that 

certain types of drugs may be better 

suited for inclusion in early stages of the 

CAP than others. During our review of 

comments on the July 6, 2005 interim 

final rule with comment and subsequent 

review of the single drug category list 

published in Addendum A, we became 

aware of supply issues with one specific 

drug. These issues have prompted us to 

make changes to the Single Drug 

Category List in Addendum A of the 

interim final rule with comment 

(included with this rule as Addendum 

F). We have deleted a HCPCS code 

(J1710) for a drug that is being phased 

out of the market and revised the 

addenda that comprise the CAP drug 

category to account for upcoming 

changes to HCPCS codes. Also, before 

the CAP is implemented, several new 

permanent HCPCS codes will be 

approved and several others modified. 

A number of these newly approved 

codes would have been included in the 

CAP drug category identified in our July 

6, 2005 interim final rule with 

comment, had permanent HCPCS codes 

been available at that time. Therefore, 

we are amending the list of drugs 

published in the New Drugs for CAP 

Bidding for 2006 in Addendum B of the 

interim final rule with comment to 

account for drugs in the new HCPCS 

codes, and to account for HCPCS codes 

that appeared in Addendum A of the 

July 6, 2005 interim final rule with 

comment that have since been split into 

separate HCPCS codes for which we are 

unable to calculate new weights. 

Updated lists of drugs that are included 

in the initial CAP drug category appear 

70238 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

in Addendum F and Addendum G of 

this rule. 

(a) Changes to the Single Drug Category 

List—Addendum A of the July 6, 2005 

Interim Final Rule With Comment 

The July 6, 2005 interim final rule 

with comment discussed criteria for 

developing the Single Drug Category 

List (Addendum A of the interim final 

rule with comment). In the following 

section, we describe factors that led us 

to revise this list. 

After suspending the bidding process, 

we reviewed the drugs included in the 

Single Drug Category List that was 

published in Addendum A of the July 

6, 2005 interim final rule with comment 

(70 FR 39101). During this process, we 

found that the brand name product 

under HCPCS code J1710 

(hydrocortisone sodium phosphate 

injection) was withdrawn from the 

market and that generic products for 

this code are not reliably available. This 

drug’s weight in the CAP’s Single Drug 

Category List as published in 

Addendum A is 0.000060285401. 

Because of the availability issue 

associated with this drug we will 

remove J1710 from the Single Drug 

Category List and recalculate weights for 

the remaining drugs. The impact on 

other drugs’ weights will be minimal 

because of J1710’s very low weight. 

Yearly updates to the HCPCS codes 

also impacted the CAP drug lists in 

several ways. One code J7051 Sterile 

saline or water up to 5cc (CAP weight 

= 0.006953978284) was modified to 

A4218 Sterile saline or water, metered 

dose dispenser, 10 ml. ‘‘A codes’’ are 

primarily medical and surgical supplies, 

and we believe that the change reflects 

usage that is primarily through a means 

other than incident to a physician’s 

service. Therefore, we will remove this 

code from the Single Drug Category list 

and recalculate weights for the 

remaining drugs. 

Revisions to the Single Drug list also 

reflect modifications to several HCPCS 

codes. These modifications will not 

affect the weighting calculation because 

they are either changes in names or 

consolidation of multiple codes into 

one. The previous codes’ utilization 

data will be used in the updated 

calculation. Table 23 illustrates the 

affected HCPCS codes. 

TABLE 23 

New HCPCS code New description Old HCPCS code 

J0881 ....................................... Injection, darbepoetin alfa, 1 microgram (non-esrd use) ....................................................... J0880 

Q0137 

J0885 ....................................... Injection, epoetin alfa, (for non-esrd use), 1000 units ............................................................ Q0136 

J7318 ....................................... Hyaluronan (Sodium Hyaluronate) or derivative, intra-articular injection, 1 mg .................... J7317 

J7320 

The changes to the HCPCS codes also 

affected iron dextran. A discussion of 

iron dextran’s removal from the single 

drug category list and the addition of 

the two new iron dextran HCPCS codes 

to the Revised New Drugs for CAP 

Bidding For 2006 appears in the 

following section. 

(b) Changes to New Drugs for CAP 

Bidding for 2006—Addendum B of July 

6, 2005 Interim Final Rule With 

Comment (See Addendum G in This 

Final Rule With Comment) 

Addendum B, published in the July 6, 

2005 interim final rule with comment 

(70 FR 39102), was developed in 

response to comments on the proposed 

rule that urged us to provide a means to 

include newer drugs. We are updating 

Addendum B with drugs that have been 

recently assigned new HCPCS codes, 

and drugs that were previously listed in 

Addendum A of the July 6, 2005 interim 

final rule with comment, but because of 

HCPCS code changes, cannot be reweighted. These changes appear in 

Addendum G of this rule. Further 

details are provided below. 

Comment: We received numerous 

comments asking that individual drugs 

that were recently approved and 

introduced to the United States market 

be included in the CAP. Improving the 

selection of products that could be 

supplied through the CAP was 

commonly given as a reason for the 

request. 

Response: We agree that it is desirable 

for the CAP to include a wide variety of 

drugs and to maintain the flexibility to 

adapt to a rapidly changing 

marketplace. Therefore, we are adding 

additional procedures to the CAP that 

will allow approved CAP vendors to 

adjust and update their drug lists. These 

changes are described below. 

In the July 6, 2005 interim final rule 

with comment, we stated that we 

intended to provide the physician with 

choice and flexibility within groups of 

drugs that might be used by different 

specialties for the treatment of various 

conditions. The drugs available under 

the CAP are intended to accommodate 

a variety of physician practice patterns 

and a variety of specialties. As 

discussed in other sections of this rule, 

the CAP also seeks to provide access to 

new drug therapies. 

As a part of the annual HCPCS code 

update, several new permanent HCPCS 

codes were issued. Billing with these 

codes will begin on January 1, 2006. In 

order to keep the CAP list of drugs as 

comprehensive and complete as 

possible, we have updated the New 

Drugs for CAP Bidding that was 

originally published in Addendum B of 

the July 6, 2005 interim final rule with 

comment to account for the coding 

changes. This list of newly issued 

HCPCS codes provided us with an 

opportunity to add drugs to the CAP 

drug category; the additions include 

several recently approved drugs. 

Examination of the new HCPCS codes 

also revealed that several codes for 

drugs listed in Addendum A of the July 

6, 2005 interim final rule with comment 

had undergone modification. For 

example, beginning in January 2006, the 

HCPCS code for iron dextran will be 

split into two codes, and the HCPCS 

code for darbepoetin alfa when used for 

non-end stage renal disease will be 

revised. 

We are unable to recalculate the 

weights for these split HCPCS codes 

because it is not possible to estimate the 

new codes’ utilization. Therefore, we 

are including these drugs in a revised 

version of Addendum B—New Drugs for 

CAP Bidding 2006, which was 

published in the July 6, 2005 in the 

interim final rule with comment. The 

list of New Drugs for CAP Bidding 2006 

is now Addendum G of this rule. We 

believe this change is appropriate 

because we had already decided to 

include these drugs in the CAP drug 

category, and adding them to 

Addendum G will avoid a recalculation 

of the other CAP drugs’ weights based 

on an imprecise estimate of utilization. 

Addenda F and G published in this final 

rule with comment supersede Addenda 

A and B from the July 6, 2005 interim 

final rule with comment. Note that 

HCPCS code modifications as they 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70239 

relate to the Single Drug Category list 

were discussed in section II.H.6.a.(1).(a) 

of this final rule with comment. 

In order to be included in Addendum 

G—Revised List of New Drugs for CAP 

Bidding for 2006, we determined that a 

drug must not appear in the Revised 

Single Drug Category List (Addendum F 

of this rule) and must meet at least one 

of the following three criteria: 

• Criterion 1: The drug must have 

been listed in Addendum B of the July 

6, 2005 interim final rule with 

comment, ‘‘New drugs for CAP Bidding 

for 2006’’. 

• Criterion 2: The drug must have a 

new J or Q HCPCS code effective 

January 1, 2006, and meet the three 

following conditions: 

+ Be administered incident to a 

physician’s service. 

+ Have had a previous C, S or ‘‘NOC’’

(Not Otherwise Classified or 

Miscellaneous) code. 

+ Have one national published ASP 

payment price and not meet either of 

the following two conditions: 

++ Be primarily billed through the 

DME process. 

++ Be primarily used as a diagnostic 

agent. 

• Criterion 3: The drug must be listed 

in Addendum A—Single Drug Category 

List published in the July 6, 2005 

interim final rule with comment, but 

had its HCPCS code terminated effective 

January 1, 2006 and split into J or Q 

Codes that become effective January 1, 

2006. 

Criterion 1 describes drugs listed in 

Addendum B of the July 6, 2005 interim 

final rule with comment. Tables 24 and 

25 list drugs that meet criteria 2 and 3. 

Table 24 lists drugs that will have new 

HCPCS codes beginning January 1, 2006 

and Table 25 is a list of drugs that were 

previously included in Addendum A 

but whose HCPCS codes were split. 

Combining these three lists will yield 

Addendum G—Revised New Drugs for 

CAP Bidding for 2006, which is 

published in this rule. 

TABLE 24.—CAP DRUGS WITH NEW

HCPCS CODES EFFECTIVE JANUARY 1, 2006 

HCPCS 

(effective 

1/1/2006) 

Long description 

J0128 ........ Abarelix injection. 

J0180 ........ Agalsidase beta injection. 

J0878 ........ Daptomycin injection. 

J1931 ........ Laronidase injection. 

J2357 ........ Omalizumab injection. 

J2469 ........ Palonosetron HCl. 

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

J9035 ........ Bevacizumab injection. 

J9041 ........ Bortezomib injection. 

TABLE 24.—CAP DRUGS WITH NEW

HCPCS CODES EFFECTIVE JANUARY 1, 2006—Continued 

HCPCS 

(effective 

1/1/2006) 

Long description 

J9055 ........ Cetuximab injection. 

J9305 ........ Pemetrexed injection. 

J9264 ........ Paclitaxel protein bound particles. 

J2503 ........ Pegaptanib. 

J0278 ........ Amikacin. 

J9225 ........ Histrelin implant. 

TABLE 25.—HCPCS CODES FROM

ADDENDUM A THAT HAVE BEEN SPLIT

HCPCS 

(effective 

1/1/ 

2006) 

2006 Long 

description 

Discontinued 

HCPCS 

J1751 .. Iron Dextran 

165.

J1750 

J1752 .. Iron Dextran 

267.

J1750 

The drugs identified in Addendum G 

will be bid and paid for as described in 

the July 6, 2005 interim final rule with 

comment (70 FR 39072). In the July 6, 

2005 interim final rule with comment, 

we stated that we will require that 

prospective vendors include bids for all 

of these drugs in their submissions and 

provide these drugs to physicians who 

elect to participate in the CAP. 

However, we will not incorporate the 

bids for these drugs into the composite 

bid methodology, because we lack 

sufficient utilization data to compute 

appropriate weights for these drugs. 

Instead, we will consider these bids 

separately from, but parallel to, 

evaluation of the composite bid for the 

other drugs for which we have adequate 

utilization data. Specifically, we will 

require bidders to submit a separate bid 

for each drug in the list. We will also 

impose a ceiling on acceptable bids. As 

in the case of the composite bids, that 

ceiling will be tied to the ASP payment 

methodology. Specifically, we will not 

accept any bid for a drug listed in 

Addendum G that is higher than 106 

percent of the ASP for that drug (as 

determined at the time when the 

bidding begins). In order to be eligible 

for selection as an approved CAP 

vendor, a bidder must meet all of the 

criteria outlined in § 414.908 of the 

regulation text and must submit 

acceptable bids on each of the drugs 

listed in Addenda F and G of this final 

rule with comment. 

(c) Process for Adding NDCs Within a 

HCPCS Code in an Approved CAP 

Vendor’s Drug List 

We acknowledge that given the 3-year 

CAP contract duration, some changes to 

the approved CAP vendors’ CAP drug 

lists are anticipated during the life of 

the contract. In the July 6, 2005 interim 

final rule with comment (70 FR 39075), 

we described a mechanism where 

approved CAP vendors could request 

CMS approval to add new drugs to their 

CAP drug lists once the drug had a 

permanent HCPCS code. We also 

described a mechanism (70 FR 39044 

and § 414.906(f)(2)(i)) where, if a 

particular NDC becomes unavailable or 

goes through a period of short supply an 

approved CAP vendor could substitute 

a different NDC within the HCPCS code 

for the NDC currently supplied by the 

approved CAP vendor for an extended 

period of time (2 weeks or longer) if the 

approved CAP vendor identifies the 

replacement product, CMS approval for 

the substitution is obtained, and all 

participating CAP physicians who have 

selected the approved CAP vendor are 

notified of the change. 

Comment: Numerous commenters 

recommended that we develop a 

mechanism to allow approved CAP 

vendors to add drug products (identified 

by an NDC) to those already supplied 

within a HCPCS code during the CAP 

contract period. Potential vendors 

indicated in their comments that they 

would like the flexibility to add NDCs 

because, as experience with the CAP 

grows, they may encounter situations 

where the addition of certain drugs 

supplied under a HCPCS code may 

improve beneficiary access, reduce 

waste, and improve the vendor’s cost 

efficiency. 

Response: We agree that additional 

mechanisms to expand an approved 

CAP vendor’s drug list at the NDC level 

are desirable. The current requirements 

state that an approved CAP vendor must 

offer at least one NDC within each 

HCPCS code in the CAP drug category. 

We encourage potential vendors to bid 

more than the minimum of one NDC per 

HCPCS code. However, we also 

understand that, as the 3-year contract 

period progresses, opportunities to 

modify the initial list of NDCs supplied 

under a HCPCS code will occur. 

Examples of these opportunities could 

include introduction of a new package 

size, the introduction of a new 

manufacturer’s products (including new 

multisource products), and price 

changes in existing NDCs. 

We believe that in order for an 

approved CAP vendor to continue to 

meet participating CAP physicians’

70240 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

needs, it is in the approved CAP 

vendor’s best interest to provide and 

maintain a satisfactory range of 

products, and to improve the range of 

available products as experience with 

the program increases. We agree that a 

mechanism to increase the number of 

CAP drugs offered by an approved CAP 

vendor is expected to improve access to 

Part B drugs and to improve prescribing 

flexibility for physicians who obtain 

drugs through the CAP. We believe that 

the process to add NDCs to the existing 

list of NDCs supplied by an approved 

CAP vendor is appropriate, provided 

that the additions to the approved CAP 

vendor’s list undergo an approval 

process. 

In the July 6, 2005 interim final rule 

with comment, in § 414.906(f)(2), we 

stated that the designated carrier’s 

medical director will approve long-term 

substitutions to the list of drugs 

supplied by an approved CAP vendor 

‘‘on behalf of CMS.’’ As described in the 

following sections of this rule and based 

on comments on the interim final rule 

with comment, we have expanded this 

request and approval process for 

incorporating changes into the list of 

drugs supplied by the CAP vendor to 

include new NDCs, and new HCPCS 

codes. In addition, beginning in 2007, 

approved CAP vendors will be able to 

request approval to add newly approved 

drugs to their CAP drug list before the 

drug is assigned a HCPCS code. 

In order to provide flexibility for 

managing this task and consistency for 

these processes, we are amending 

§ 414.906 to allow CMS or its designee 

to approve long-term substitutions and 

additions to approved CAP vendors’

CAP drug lists. We are also revising 

§ 414.906(f)(4)(iii) to specify that 

substitutions that are due to a drug 

shortage, or other exigent circumstance, 

may become effective immediately 

provided that the approved CAP 

vendor’s participating CAP physicians 

are notified of the substitution 

immediately following CMS approval. 

We are modeling the process of 

adding new NDCs within a HCPCS code 

on the substitution mechanism 

described in the July 6, 2005 interim 

final rule with comment (70 FR 39044) 

and specified in § 414.906(f). We note 

that because this is a mechanism for the 

addition of drugs to an approved CAP 

vendor’s CAP drug list, the approved 

CAP vendor will be required to continue 

supplying all NDCs from its most 

recently updated CAP drug list. (The 

substitution process should be used if 

the approved CAP vendor is seeking 

approval to remove an NDC from its 

CAP drug list and replace it with 

another NDC.) In order to add a new 

NDC within a HCPCS code being offered 

in the approved CAP vendor’s CAP drug 

list, the approved CAP vendor must 

make a written request to CMS or its 

designee. Requests for approval must 

include a rationale and discussion of 

impact on the CAP, including safety, 

waste, and potential for cost savings. 

The requests will be reviewed and, if 

approved, changes will become effective 

as of the beginning of the next quarter. 

Like the substitution procedure, the 

addition of new NDCs to an approved 

CAP vendor’s CAP drug list will not 

affect the CAP payment amount for that 

particular HCPCS, as the payment 

amount will have been set during the 

initial bidding (or approval process for 

adding an additional HCPCS code) and, 

if applicable, updated as outlined in 

§ 414.906. This application process is 

reflected in the amended 

§ 414.906(f)(2)(ii). 

Participating CAP physicians who 

have selected the approved CAP vendor 

must be notified of additions to the 

approved CAP vendor’s CAP drug list at 

least on a quarterly basis (at least 30 

days or earlier before the approved 

changes are due to take effect). Both the 

approved CAP drug vendor and CMS (or 

its designee) will be responsible for 

maintaining this information and 

disseminating it. Approved CAP 

vendors must provide direct (for 

example, mail or e-mail) notification of 

updates to the participating CAP 

physicians enrolled with them on a 

quarterly basis. The entire list of drugs 

supplied by the approved CAP vendor 

should be disseminated at least once 

yearly; and approved CAP vendors must 

make a complete list that incorporates 

the most recent updates available to 

participating CAP physicians on an 

ongoing basis. We will post the updated 

drug lists on our web site. The approved 

CAP vendor may also post the complete, 

updated, and approved list on its web 

site. We have added these requirements 

to new § 414.914(f)(15). We will issue 

additional instructions for this process 

at a later date. 

(d) Process for Expediting the Addition 

of Newly Approved Drugs to the CAP 

(‘‘NOC’’ Codes) 

The July 6, 2005 interim final rule 

with comment outlined a process that 

approved CAP vendors can use to add 

new drugs to the list of drugs supplied 

under the CAP once the new drug has 

been assigned a permanent HCPCS 

code, provided the drug would have 

been properly assigned to the single 

drug category and that CMS determines 

that the drug is appropriate for 

inclusion. This mechanism was 

intended to provide an opportunity for 

vendors to supply drugs that were 

introduced too late to be incorporated 

into the Addendum B—New Drugs for 

CAP bidding for 2006 published in the 

July 6, 2005 interim final rule with 

comment. 

Comment: Several commenters have 

requested that we develop a process to 

further expedite the addition of newly 

approved or marketed drugs to an 

approved CAP vendor’s drug list. 

Commenters stated that access to newly 

approved drugs should be immediate. 

These commenters further stated that 

participating CAP physicians should not 

have to go outside of the CAP to acquire 

new drugs. Several commenters 

suggested a mechanism that uses the 

miscellaneous (‘‘NOC’’) HCPCS codes 

for physicians and vendors to bill CAP 

drugs that do not have a permanent 

HCPCS code. Certain commenters also 

suggested that approved CAP vendors 

be required to offer the new drugs as 

soon as they are on the market. 

Response: We agree with the 

commenters that the earlier addition of 

newly approved or newly marketed 

drugs to the CAP is desirable, to the 

extent these drugs are appropriate for 

inclusion in the CAP. The tight 

timeframe for CAP implementation and 

the requirement for additional system 

changes prevent us from implementing 

the process suggested by the 

commenters at this time. In 2007, 

approved CAP vendors will be able to 

request CMS approval to add new drugs 

without a permanent HCPCS code to 

their CAP drug lists. This process will 

be similar to the process established in 

the July 6, 2005 interim final rule with 

comment that allows approved CAP 

vendors to add new drugs that are 

assigned a permanent HCPCS code to 

their CAP drug lists. Approved CAP 

vendors will submit a request to add 

these drugs, and CMS or its designee 

will determine whether the particular 

drugs are appropriate for inclusion in 

the CAP using a process that parallels 

the development of the Single Drug 

Category List and the List of New Drugs 

for CAP bidding for 2006. Updates to 

the approved CAP vendors’ CAP drug 

lists will be made on a quarterly basis; 

we anticipate that all approved CAP 

vendors’ updates will be posted on the 

CMS Web site simultaneously. 

Payment for new CAP drugs approved 

for inclusion in the approved CAP 

vendor’s CAP drug list before they are 

assigned a HCPCS code would be at the 

price published in the ASP’s ‘‘not 

otherwise classified’’ (NOC) price file 

consistent with the next quarterly 

update. And we note that these drugs 

would be considered for inclusion in 

the CAP only if CMS is able to identify 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70241 

a single ASP payment amount for the 

drug. At a future date, we will issue 

additional guidance to approved CAP 

vendors on the application procedures 

for requesting approval to add these 

changes to the approved CAP vendor’s 

CAP drug list, and we will issue 

additional guidance to participating 

CAP physicians on how to order these 

particular drugs once they are added to 

the approved CAP vendor’s CAP drug 

list. 

We do not believe that requiring 

approved CAP vendors to add all new 

drugs to their CAP lists is advisable. 

Instead, we believe that a request and 

approval process as described for other 

changes to an approved CAP vendor’s 

drug list would be appropriate because 

it would allow for flexibility while 

ensuring that only those that are 

appropriate for inclusion in the CAP are 

added to an approved CAP vendor’s 

CAP drug list. As discussed in the July 

6, 2005 interim final rule with comment 

(70 FR 39027 through 39031) some 

drugs may not be good candidates for 

the CAP, for instance, some new drugs 

are not typically administered ‘‘incident 

to’’ a physician’s services, some new 

drugs may have very low utilization, 

and some may have special storage, 

distribution, or handling requirements 

that would make these drugs 

inappropriate for inclusion in the CAP. 

The existing procedures for adding new 

NDCs within the HCPCS codes that are 

on an approved CAP vendor’s CAP drug 

list, and the new procedures for adding 

new HCPCS codes to an approved CAP 

vendor’s CAP drug list also rely on 

approved CAP vendors’ voluntary 

requests and our approval of these 

requests. Simply put, we want to 

expand the number of CAP drugs that 

approved CAP vendors offer, but we do 

not believe that all new drugs should be 

added to the CAP, or that addition of 

certain drugs should be mandatory, 

especially at the beginning of this 

program. As we gain experience with 

the program we may consider other 

approaches to the addition of drugs that 

a vendor supplies under the CAP. 

Beginning in 2007, approved CAP 

vendors will be able to request approval 

to add new ‘‘NOC’’ drugs to their CAP 

drug lists. The procedures will parallel 

those for addition of new HCPCS codes 

and new NDCs within a HCPCS code, as 

specified in § 414.906(f)(2)(iv). In each 

case, the approved CAP vendor must 

make a written request to CMS (or its 

designee). Requests for approval must 

include a rationale and discussion of 

impact on the CAP, including safety, 

waste, and potential for cost savings. 

The requests will be reviewed and, if 

approved, changes will become effective 

on a quarterly basis. 

We remind physicians that an 

approved CAP vendor’s CAP drug list is 

subject to change over the contract 

period. Upon electing to participate in 

the CAP and selecting an approved CAP 

vendor, participating CAP physicians 

are agreeing to accept, in most cases, the 

particular NDCs listed and shipped by 

the selected approved CAP vendor for 

the duration of the participating CAP 

physician’s election period with the 

approved CAP vendor. By electing to 

participate with a particular approved 

CAP vendor, the participating CAP 

physician also is agreeing to accept the 

approved changes to the approved CAP 

vendor’s CAP drug list and drugs 

supplied under the updated and 

approved lists. We believe that the 

changes in the approved CAP vendor’s 

CAP drug list will improve (or at least 

maintain) a participating CAP 

physician’s selection of available drugs 

and will likewise improve (or maintain) 

Medicare beneficiaries’ access to drugs 

supplied under the CAP. We are 

revising § 414.908(a)(3)(vi) to state this 

requirement. 

We remind physicians that routine 

orders for CAP drugs should be placed 

at the HCPCS level, unless the 

participating CAP physician determines 

that a particular product that is on the 

approved CAP vendor’s CAP drug list is 

medically necessary for a patient. In this 

case, a participating CAP physician may 

order that specific NDC from the 

approved CAP vendor under the 

‘‘furnish as written’’ process. 

Documentation of medical necessity in 

the medical record is also required; this 

information may be subject to medical 

review. We are revising 

§ 414.908(a)(3)(vii) to reflect this 

requirement. 

(e) Process for Adding Drugs With a 

New HCPCS Code to the CAP 

In the July 6, 2005 interim final rule 

with comment (70 FR 39075), we stated 

that we would allow approved CAP 

vendors to petition CMS to add drugs 

with a new HCPCS code to their CAP 

drug lists; however, we did not include 

regulation text to implement this 

section. In order to implement this 

process we are amending regulation text 

at § 414.906(f)(2)(iii). 

(f) Process for Adding Single Indication 

Orphan Drugs to the CAP 

Table 26 is a brief summary of 

methods that an approved vendor may 

use to amend the list of drugs it supplies 

under the CAP. Please note that all of 

these methods require approval from 

CMS or its designee. 

Comment: We received several 

comments from manufacturers 

requesting inclusion of their single 

indication orphan drugs in the CAP. 

Most commenters stated that these low 

volume products were quite suitable for 

the CAP because availability through 

the CAP would minimize the associated 

administrative burden for physicians 

who choose to administer them. 

Inclusion of one product (thyrotropin 

alfa) was also requested by a number of 

physicians who treat patients with 

thyroid cancer and by patients who had 

been treated for thyroid cancer. One 

manufacturer specifically requested that 

its orphan drug (azacitidine) not be 

included in the CAP, citing concern 

about timely access to the drug. 

Response: We appreciate the 

comments that we received regarding 

single indication orphan drugs. 

Improving access to Part B drugs is a 

desirable quality for this program. For 

example, we have endeavored to 

improve access by allowing the addition 

of new NDCs and new HCPCS codes to 

a drug vendor’s list. During this initial 

stage of the CAP, as described in the 

July 6, 2005 interim final rule with 

comment (70 FR 39032), we also have 

sought to strike a balance that would 

allow for a sufficiently sized market 

volume for approved CAP vendors, 

while making the CAP a meaningful 

alternative for most physician 

specialties. In order to decrease the 

inventory burden for approved CAP 

vendors, we wanted to minimize the 

number of drugs included in the CAP 

drug category that are billed in very low 

volumes, so we applied dollar value 

thresholds to the CAP. 

As noted by commenters, the addition 

of the single indication orphan drugs to 

the CAP drug category may decrease 

administrative burden on the 

participating CAP physicians, and we 

agree that a decreased burden is 

desirable. We are persuaded by the 

number of commenters that asked us to 

include single indication orphan drugs 

in the CAP drug category that a 

mechanism for their addition to an 

approved CAP vendor’s CAP drug list is 

desirable. However, for the reasons that 

prompted us not to include single 

indication orphan drugs in the initial 

drug category (as described in the July 

6, 2005 interim final rule with 

comment), we continue to believe that 

we should not require approved CAP 

vendors to supply these drugs. 

Therefore, we are specifying that 

approved CAP vendors may request 

CMS approval to add single indication 

orphan drugs (as described in the July 

6, 2005 interim final rule with 

comment) to their CAP drug lists. The 

70242 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

single indication drugs covered by this 

provision are the following: J0205, 

J0256. J9300, J1785, J2355, J3240, J7513, 

J9010, J9015, J9017, J9160, J9216 and 

their successor codes. Payment for 

single indication orphan drugs that 

vendors voluntarily add to the CAP will 

be based on ASP+6 percent. 

TABLE 26.—METHODS FOR CHANGING AN APPROVED CAP VENDOR’S CAP DRUG LIST

Description Regulation text 

Substitution: Approved CAP vendor may request approval to replace one or more NDCs in a HCPCS code supplied by 

the approved CAP vendor with one or more other NDCs.

§ 414.906(f)(2)(i). 

Add newly issued HCPCS Codes: Approved CAP vendor may request that CMS allow it to supply additional HCPCS 

codes under the CAP.

§ 414.906(f)(2)(iii). 

Additional NDCs: Approved CAP vendor may request that CMS allow it to supply additional NDCs under a HCPCS code 

that the approved CAP vendor already supplies under the CAP.

§ 414.906(f)(2)(ii). 

Newly approved drugs without HCPCS codes (‘‘NOC’’ dugs’’): Beginning in 2007, approved CAP vendor may request 

that CMS allow it to supply a newly approved drug under the CAP before a permanent HCPCS code is assigned to 

the drug.

§ 414.906(f)(2)(iv). 

Single Indication Orphan Drugs: Approved CAP vendor may request that CMS allowed it to supply single indication orphan drugs under the CAP.§ 414.906(f)(2)(iii). 

(g) Other Issues Related to Drugs 

Supplied Under the CAP 

(i) Addition of Other Specific Drugs 

We received comments regarding the 

addition of low volume drugs, and 

dermal tissue biologicals to the CAP. 

Specific comments and responses for 

each type of drug follow. 

Comment: One commenter asked 

whether we would allow approved CAP 

vendors to voluntarily supply drugs 

with low utilization volumes through 

the CAP. The commenter was 

specifically referring to drugs that were 

not included in the CAP category 

because of utilization criteria described 

in the interim final rule with comment 

(70 FR 39031–39032). 

Response: Drugs included in the 

initial CAP drug category account for 

about 85 percent of Part B drugs billed 

by physicians. In other sections of this 

rule we have described methods that an 

approved CAP vendor may use to 

request the addition of new NDCs or 

new HCPCS codes to the CAP. Although 

we appreciate the request to add drugs 

with low utilization volumes to the CAP 

drug category, we believe it is 

appropriate to allow additions to an 

approved CAP vendor’s CAP drug list 

through the case-by-case approval 

process we have described above and 

specified in § 414.906. Once we gain 

experience with the CAP, we anticipate 

being able to consider broadening the 

scope of drugs included in future CAP 

drug categories. 

Comment: The manufacturers of two 

dermal tissue products expressed 

concern about language in the July 6, 

2005 interim final rule with comment 

that stated ‘‘tissues are not considered 

drug products.’’ One manufacturer 

asked that its product be included in the 

CAP, while the other stated other 

reasons for excluding its product were 

appropriate and did not ask that its 

product be included in the CAP. 

Response: We thank the commenters 

for providing us with the opportunity to 

clarify the discussion about dermal 

tissue found in the July 6, 2005 interim 

final rule with comment (70 FR 39031). 

During development of the criteria used 

to create Addendum A—Single Drug 

Category List of the July 6, 2005 interim 

final rule with comment, we attempted 

to allow for a sufficiently sized market 

for approved CAP vendors, while 

making the CAP a meaningful 

alternative for most physician 

specialties. The statement that the 

commenter references above was 

intended to explain why we did not 

include dermal tissue products in the 

initial CAP drug category and was not 

intended to reflect overall Medicare 

policy for dermal tissue products. We 

are not including tissues in the initial 

CAP drug category at this time because 

the products do not have sufficient 

documented utilization, and some 

products may require specialized 

handling. As we gain experience with 

the CAP, we anticipate reevaluating 

exclusion criteria applied to bidding for 

the initial phase of this program. 

(ii) Formularies and the CAP 

In the July 6, 2005 interim final rule 

with comment, we responded to 

comments on the subject of formularies. 

We respond to additional comments on 

the subject from the July 6, 2005 interim 

final rule with comment below. 

Comment: We received several 

comments that encouraged us to refrain 

from creating formularies in the CAP 

and to avoid situations where a 

formulary-like process could be created. 

Commenters raised concerns about a 

formulary’s likelihood to limit 

beneficiaries’ access to a wide selection 

of drugs and the impact on a physician’s 

choice in prescribing medications. 

Response: In the July 6, 2005 interim 

final rule, we stated that we were not 

accepting the recommendation that 

vendors be permitted to establish 

formularies because the statute 

expressly requires that for multiple 

source drugs, a competition be 

conducted for the acquisition of at least 

one drug per billing code within that 

category (70 FR 39034). We agree that in 

an effort to provide physicians with 

maximum flexibility in prescribing, we 

should avoid the use of formularies in 

the CAP. Furthermore, we believe that 

making the CAP less restrictive will 

increase physician interest and, 

therefore, improve vendor participation. 

In the July 6, 2005 interim final rule 

with comment (70 FR 39033 through 

39034 and 39068), we stated that ‘‘we 

do not expect there to be a creation of 

a drug formulary,’’ and we further 

discussed our belief that vendors would 

find it prudent to structure their bids in 

a way to supply more than one NDC per 

HCPCS code. We wish to emphasize 

that this is still our position on 

formularies in the CAP. It is our opinion 

that approved CAP vendors who offer 

more than one product per HCPCS code 

would be selected by a greater number 

of participating CAP physicians. 

(iii) Physicians Regulatory Issues Team 

Drugs 

The July 6, 2005 interim final rule 

with comment also discussed issues 

regarding drugs that have posed 

acquisition problems for some 

physicians under the ASP system. We 

received additional comments on this 

topic. 

Comment: Commenters asked 

whether drugs included on the 

Physicians Regulatory Issues Team 

(PRIT) list (drugs reported to be difficult 

for physicians to obtain for less than 

ASP+6 percent) have been included in 

the CAP. Commenters also asked that 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70243 

the PRIT list be made available to the 

public. 

Response: The PRIT is a group of CMS 

subject matter experts who work to 

reduce the regulatory burden on 

Medicare physicians. Since the 

inception of the ASP payment system, 

individual physicians have reported 

difficulty in acquiring certain drugs for 

less than ASP+6 percent. At the request 

of the Physicians Practice Advisory 

Committee, the PRIT began compiling 

reports of these situations. More 

information about the PRIT may be 

found at the following web site: 

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

prit/. 

Because the PRIT list is based on 

voluntary reporting, and information is 

received on an ad-hoc, 

nonrepresentative basis, the PRIT list 

may not fully describe overall drug 

pricing or availability patterns; 

therefore, we have chosen not to use the 

PRIT list as a specific criterion for the 

CAP. However, as stated in of the July 

6, 2006 interim final rule with comment 

(70 FR 39033), we did review drugs that 

had been associated with access 

problems under the ASP payment 

system during the development of the 

CAP single drug category and we have 

subsequently examined the PRIT list 

during the writing of this rule. We have 

found that the CAP includes most drugs 

reported to the PRIT. PRIT list drugs not 

in the CAP are drugs that were not 

included for specific reasons described 

in the July 6, 2005 interim final rule 

with comment, such as -single 

indication orphan drugs, drugs without 

permanent HCPCS codes, oral 

medications, and drugs with low 

utilization. 

(iv) Discussion of Intrathecal Pain 

Management 

The July 6, 2005 interim final rule 

with comment’s discussion of specific 

drugs contained a comment and 

response on ziconotide (Prialt). 

Comment: One commenter stated that, 

in our discussion of intrathecal pain 

management, we mischaracterized 

ziconotide as an opioid analgesic. The 

commenter points out our inconsistency 

in referring to ziconotide as an opioid, 

but following with a discussion that 

demonstrates understanding that 

ziconotide is not an opiate. The 

commenter asked if non-opiate pain 

medications administered intrathecally 

through an implanted pump or external 

infusion device would be suitable for 

inclusion in the CAP. The commenter 

also asked whether ziconotide could be 

added to Addendum B—New Drugs for 

CAP Bidding for 2006 of the drug 

bidding list if a permanent HCPCS code 

were assigned in the Fall of 2005. The 

commenter also noted that baclofen and 

clonidine, two other medications that 

can be administered intrathecally 

through a pump, are included in the 

CAP drug category. 

Response: We appreciate the 

opportunity to clarify our discussion. 

Ziconotide is not an opiate analgesic 

and it is not a controlled substance. 

Neither the comment nor the 

corresponding response were intended 

to describe ziconotide as an opioid or to 

limit the discussion to intrathecally 

administered opioids. 

Our response to the comment in the 

interim final rule with comment was 

intended to address two points. First, 

we did not consider opioids and 

ziconotide for inclusion into the bid list 

for different reasons. Opioids are 

controlled substances and are subject to 

extra record keeping requirements as 

stated in the July 6, 2005 interim final 

rule with comment (70 FR 39028); 

ziconotide was not included in the CAP 

drug category because it had not yet 

been assigned a HCPCS code. Second, 

we agreed in principle that opioid 

medications administered intrathecally 

through implanted variable-rate 

infusion devices could be included 

under the CAP, when they are 

administered by physicians in their 

offices incident to their services. 

Although we specifically referred to 

opioid medications in this discussion, 

the statement applies to non-opioid 

medications as well. However in the 

interim final rule with comment, we 

described our methodology for 

determining whether a drug would be 

included in the initial CAP drug 

category. (70 FR 39028 and 39031 

through 39032). 

Although ziconotide generally 

appears to meet the criteria for inclusion 

in the initial CAP drug category, we 

have become aware of an unresolved 

payment methodology issue with this 

drug resulting in the lack of a consistent 

ASP for ziconotide. It is important that 

drugs included in the CAP drug 

category have an ASP that we can 

determine, because a drug’s ASP is used 

to calculate the overall price ceiling for 

the composite bid and the maximum 

payment amount for CAP drugs not 

included in the composite bidding 

process. For this reason, we are not 

including this drug in the CAP at this 

time. 

(v) Leuprolide and Related Drugs 

During the development of the Single 

Drug Category List published in 

Addendum A of the July 6, 2005 interim 

final rule with comment, we chose not 

to include injectable forms of leuprolide 

acetate (J9217 and J9218) in the initial 

CAP drug category. We provide a 

discussion of local coverage 

determinations (LCDs) and LCA policy 

as it relates to the CAP in the July 6, 

2005 interim final rule with comment 

(70 FR 39039). We note that leuprolide 

acetate implant (J9219) remains in the 

CAP’s Single Drug Category List. 

Comment: We received several 

comments about leuprolide and other 

luteinizing hormone-releasing hormone 

(LHRH) analogues, which include 

goserelin, triptorelin, and histrelin. 

Commenters acknowledged the 

complexity of applying LCA policies to 

the CAP for both physicians and 

vendors. They also questioned whether 

all regions of the United States were 

subject to LCA policies for this 

leuprolide, and commenters expressed 

concern that the policies may extend to 

LHRH other than leuprolide and 

goserelin, such as histrelin and 

triptorelin. Two commenters suggested 

that the CAP not use LCA policies, and 

failing that the commenter suggested 

that drugs covered by LCA policies be 

‘‘carved out’’ of the CAP. Another 

commenter stated that LCA policies 

varied so much that not including 

leuprolide in the CAP drug category was 

an incomplete solution to the LCA issue 

because the entire group of LHRH 

analogues was in the process of 

becoming affected by LCAs, and that 

continuing price changes could not 

guarantee that goserelin would remain 

the least costly alternative drug among 

the LHRH analogues. 

Response: We appreciate the concerns 

raised by the commenters. However, we 

do not believe that we have the 

authority to specify that CAP prices 

supersede an LCA policy. As we stated 

in the July 6, 2005 interim final rule 

with comment, nothing in this rule is 

intended to disrupt the longstanding 

ability of contractors to apply an LCA 

policy under section 1862(a)(1)(A) of the 

Act. Section 1862(a)(1)(A) of the Act 

provides that notwithstanding any other 

provision in the Medicare statute (that 

is, including section 1847B of the Act), 

no payment may be made under Part A 

or Part B for any expenses incurred for 

items and services that are not 

medically necessary. As a result, if a 

carrier applies an LCA policy to a 

particular drug, a claim submitted to the 

carrier for that drug is subject to LCA. 

After considering the comments, we 

continue to believe that the decisions 

outlined in the July 6, 2005 interim final 

rule with comment pertaining to which 

drugs are included in the CAP drug 

category maintain a balance between 

physician access to LHRH analogues 

70244 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

and vendor risk associated with the 

application of LCAs for these drugs. 

(h) Drug Weighting 

In the July 6, 2005 interim final rule 

with comment (70 FR 39069), we 

finalized our proposal to employ a 

‘‘composite bid’’ for selecting bidders. 

The composite bid will be constructed 

by weighting each HCPCS bid by the 

HCPCS code’s share of volume 

(measured in HCPCS units) of drugs in 

our single drug category during the prior 

year. Within the single category, the 

drugs weights will sum to one. 

Comment: Some commenters 

suggested that instead of using only 

utilization data to derive weights, we 

should use both utilization and allowed 

charges data so that products with high 

utilization, but low charges, are not over 

weighted. 

Response: We appreciate the 

suggestion of an alternative weighting 

methodology, and we recognize that the 

weighting methodology could be 

developed in a number of ways. We are 

also aware that changing the weighting 

methodology from utilization volume to 

dollar volume could impact overall 

weighting. 

For the initial bidding cycle, we chose 

to use a relatively simple weighting 

methodology based on claims volume, 

but corrected for the appearance of 

multiple identical claim lines on a given 

day of service. We also believe that the 

creation of a single drug category further 

minimizes some effects associated with 

using utilization data as the only 

weighting parameter. We do not believe 

that a change in weighting methodology 

would result in significantly different 

weights than those derived under the 

current weighting methodology for the 

majority of drugs in the single drug 

category list. Therefore, we will 

implement CAP using the same 

weighting methodology described in the 

July 6, 2005 interim final rule with 

comment (70 FR 39069 through 39071) 

and will consider alternatives for future 

bidding cycles. 

Earlier in this section we have 

discussed the need to make changes to 

the Single Drug Category List published 

in Addendum A of the July 6 2005 

interim final rule with comment. The 

resulting change in the composition of 

the Single Drug List required us to 

recalculate the drug weights. A 

complete discussion of the reasons for 

this revision is included in section 

II.H.6.a.(1)(a), Changes to the Single 

Drug Category List—Addendum A of the 

July 6, 2005 interim final rule with 

comment. 

b. Vendor/Bidding Issues 

In this section we discuss issues 

related to vendor bidding such as drug 

quality, vendor subcontracting, 

confidentiality of the bids, vendor call 

center requirements, the inclusion of 

prompt pay discounts in vendor net 

acquisition costs, and the mechanics of 

the bidding process. 

(1) Quality/Product Integrity 

In the July 6, 2005 interim final rule 

with comment (70 FR 390660 through 

390662), we discussed product integrity 

and the requirement to comply with 

existing State and Federal laws 

regarding adulteration, misbranding, 

spoilage, contamination, expiration, and 

counterfeiting of products. We stated 

that although we do not propose to 

require applicants or potential CAP 

vendors to employ measures beyond 

those required for licensure and 

regulatory compliance, we believe these 

measures set a minimum standard, and 

we requested that applicants discuss 

any additional measures they have 

taken to ensure product integrity. We 

also provided examples of additional 

measures that pose minimal burden but 

enhance the ability to detect 

adulterated, misbranded, or counterfeit 

drugs. We further stated that the 

approved CAP vendor application 

process, the maintenance of appropriate 

licensure, and Medicare supplier status 

form the framework for product 

integrity. We also noted that potential 

CAP vendors are required to submit a 

compliance plan as part of the bidding 

process that contains policies and 

procedures for the prevention of fraud, 

waste, and abuse, and provides detailed 

information on steps to ensure product 

integrity as specified in § 414.914. 

Comment: Many commenters 

supported the steps outlined in the July 

6, 2005 interim final rule with comment 

to ensure quality and product integrity. 

There were some commenters, however, 

who expressed concern that the 

provisions in the interim final rule with 

comment will not be adequate to 

prevent fraud and abuse and ensure 

product integrity. One commenter 

believed that patient health and safety 

could be compromised by the 

imposition of a third party (the 

approved CAP vendor) for drug 

acquisition, preparation, and delivery. 

This commenter was also concerned 

about the possibility that certain drugs 

could be reconstituted in their vials by 

the approved CAP vendor. Another 

commenter suggested that the VerifiedAccredited Wholesale Distributors TM

Program could play a key role in 

adherence to quality and performance 

standards among approved CAP 

vendors. This is a program developed by 

the Task Force on Counterfeit Drugs and 

Wholesale Distributors that was 

convened in 2003 by the National 

Association of Boards of Pharmacy to 

ensure that a wholesale distribution 

facility is licensed and operating under 

best practices for drug distribution. 

Response: We appreciate and share 

the commenters’ concerns about 

ensuring quality and product integrity. 

However, we do not agree that the 

approved CAP vendor’s role in drug 

acquisition, preparation, and delivery 

will compromise patient health and 

safety. We addressed the issue of 

reconstituted vials in the July 6, 2005 

interim final rule with comment (70 FR 

39061) by stating that approved CAP 

vendors may split vial trays, but cannot 

ship opened vials. 

As we gain more experience with the 

CAP, we will explore the VerifiedAccredited Wholesale Distributors TM

Program and other options to further 

protect product integrity. 

Comments: Several commenters 

recommended that CMS establish 

standards and survey procedures for 

approved CAP vendors and their 

subcontractors to inspect the chain of 

custody of the drugs delivered to 

participating CAP physicians. These 

commenters also requested that CMS 

establish and disseminate information 

about the procedure that participating 

CAP physicians should follow to report 

a suspected delivery of counterfeit 

drugs, and suggested that a web-based 

quality reporting system be available on 

various aspects of the approved CAP 

vendor’s performance. These 

commenters also wanted clarification 

that one substantiated instance of 

purchase or distribution of a counterfeit 

drug by an approved CAP vendor will 

result in the automatic termination of 

the vendor’s Part B supplier contract 

and the CAP contract. 

Response: We continue to believe that 

existing Federal and State requirements, 

along with the specific requirements for 

approved CAP vendors outlined in the 

bidding and selection process, provide 

an adequate framework for protecting 

product integrity. Participating CAP 

Physicians should notify the approved 

CAP vendor immediately if there are 

any questions regarding the integrity of 

a CAP drug, and report any violations to 

the appropriate Federal and State 

authorities, as well as to the designated 

carrier’s dispute resolution staff. In 

addition, the designated carrier will act 

promptly to investigate CAP quality 

complaints under the process outlined 

for dispute resolution as described in 

§ 414.916. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70245 

As we gain experience with the CAP, 

we will assess whether additional steps 

are needed to ensure product quality. 

We are committed to ensuring that 

approved CAP vendors ship only high 

quality products and any reports of 

compromised quality will be addressed 

promptly. 

(2) Subcontracting 

In the July 6, 2005 interim final rule 

with comment (70 FR 39060, 39064, and 

39065), we stated that a vendor could 

subcontract with another entity as long 

as that entity met all of our approved 

CAP vendor requirements, is in 

compliance with all applicable laws and 

regulations, has a demonstrable record 

of integrity regarding fraud and abuse 

and conflict of interest, and has 

adequate administrative arrangements 

in place to ensure effective operations. 

Information on specific requirements for 

subcontractors was provided in the July 

6, 2005 interim final rule with comment 

and is a required part of the vendor’s 

CAP application. 

In § 414.914(f)(9), we also stated that 

it is the approved CAP vendor’s 

responsibility to determine that 

subcontractors remain compliant with 

these standards. It was further noted 

that we intend that subcontractors or 

other entities associated with furnishing 

CAP drugs under an approved CAP 

vendor’s contract maintain the same 

standards as the approved CAP vendor 

for the role that they play in supplying 

CAP drugs. 

Comment: Many commenters 

expressed support that we intend to 

hold any subcontractors to the same 

standards as the approved CAP vendors. 

However, some commenters requested 

clarification on certain aspects of 

subcontracts or requested more stringent 

requirements. Two commenters 

requested that approved CAP vendors 

include in their subcontractor 

agreements a covenant binding on the 

subcontractor to comply with all rules 

applicable to approved CAP vendors, 

including those rules regarding product 

integrity and drug pedigree, and that 

HHS be a third party beneficiary to 

these agreements with the right to 

enforce any of the provisions relating to 

CAP compliance. One commenter 

wanted assurance that a contract 

between a large distributor and a 

specialty pharmacy would not be 

considered a conflict of interest. 

Another commenter requested that we 

require full disclosure of a potential 

CAP vendor’s corporate relationships 

and specifically prohibit potential CAP 

vendor subsidiaries from bidding 

against their parent company or other 

subsidiaries with the same parent 

company. 

Response: We appreciate the 

commenters’ interest in maintaining 

quality of the CAP by ensuring integrity 

in all aspects of the approved CAP 

vendor and subcontractor relationship. 

We believe that we have stated clearly 

our intention to hold all subcontractors 

to the same rigorous standards that we 

require of approved CAP vendors. We 

also believe that we have the necessary 

authority to review, enforce, and take 

any needed action to ensure that quality 

and integrity of the subcontractor 

relationship is maintained. 

Because an approved CAP vendor is 

ultimately responsible for any activity of 

its subcontractor and risks termination 

of its CAP contract if quality or integrity 

are compromised, we believe that the 

approved CAP vendor will take 

adequate steps to ensure compliance 

with all requirements. Therefore, we 

will not require a binding covenant 

between approved CAP vendors and 

subcontractors, although we would 

expect that an approved CAP vendor 

may want to include this type of 

provision in its subcontracts for its own 

protection. 

Contracts between a distributor and a 

specialty pharmacy are not 

automatically problematic. However, 

these arrangements would be subject to 

the same requirements as specified in 

the CAP statute and regulations that 

apply to all other subcontracting 

arrangements. Approved CAP vendors 

may wish to consult with legal counsel 

to determine whether there exists 

unique circumstances that could present 

a conflict of interest. 

We also appreciate the commenters’

concern about corporate relationships 

and the possibility of a potential CAP 

vendor’s subsidiaries bidding against 

their parent company or other 

subsidiaries with the same parent 

company. However, because of the 

complexity of many corporate 

relationships, we believe that rejecting 

bids based on a test such as the 

commenter suggests could exclude some 

legitimate and qualified entities from 

participating in the CAP. We will not 

prohibit any qualified bidder from 

submitting a bid to be an approved CAP 

vendor, but we expect applicants to 

submit any relevant information, 

including information about their 

corporate relationships. We will review 

all this information as part of the 

application and bidding process 

described in this final rule with 

comment and the July 6, 2005 interim 

final rule with comment. 

(3) Confidentiality of the Bids (Potential 

CAP Vendor Information) 

In both the March 4, 2005 proposed 

rule (70 FR 10746) and the July 6, 2005 

interim final rule with comment (70 FR 

39065), we affirmed that all cost 

information will be confidential and not 

made available for public display, and 

that bid prices will be kept confidential 

in accordance with section 1927(b)(3)(D) 

of the Act. 

We also stated that section 

1847B(a)(1)(C) of the Act provides that, 

in implementing the CAP, the Secretary 

may waive provisions of the Federal 

Acquisition Regulation (FAR), ‘‘other 

than provisions relating to the 

confidentiality of information.’’ The 

confidentiality provisions of the FAR 

apply to the data submitted by bidders 

and potential CAP vendors under the 

CAP. 

However, we noted that what is 

confidential for FAR purposes may not 

necessarily be protected under the 

provisions of the Freedom of 

Information Act (FOIA), and that if a 

FOIA request is received for pricing 

information, the request will be 

processed in accordance with 5 U.S.C 

section 552(b) and 45 CFR part 5, 

subpart F to determine whether any of 

the FOIA’s exemptions to mandatory 

disclosure may apply to protect the 

information. 

Comment: One commenter expressed 

concern that drug pricing information 

may be subject to disclosure under 

FOIA and suggested that it is protected 

from disclosure under FOIA exemption 

(b)(4). This commenter also suggested 

that drug pricing information provided 

under the CAP be treated the same as 

the drug pricing information provided 

for Hospital Outpatient Prospective 

Payment System (OPPS) and the 

Medicare Part D prescription drug 

benefit. Another commenter wanted 

assurance that all potential CAP vendor 

cost data will be protected as 

proprietary and will remain confidential 

and unidentifiable by manufacturer or 

wholesaler. 

Response: We again affirm that, to the 

extent permitted by law, all cost 

information submitted during the 

bidding process and as part of the 

contract’s price adjustment process will 

remain confidential and not made 

available, and that potential CAP vendor 

pricing information will be kept 

confidential. The FAR directly 

addresses the government’s obligation to 

protect contractor information 

submitted in response to a solicitation 

for competitive bids. If a FOIA request 

is received seeking disclosure of a 

bidder’s pricing data, that request would 

70246 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

be forwarded to the CMS FOIA officer 

for review in accordance with FOIA 

requirements. To the extent allowed by 

Federal law, we will assert applicable 

FOIA exemptions to protect confidential 

cost and pricing information. The FOIA 

exemptions are set forth in Department 

of Health & Human Services Freedom of 

Information regulations at 45 CFR part 

5, subpart F. 

(4) Approved CAP Vendor 

Requirements/Call Center Hours of 

Operation 

In the July 6, 2005 interim final rule 

with comment (70 FR 39065), we stated 

that the approved CAP vendor would be 

required to—

• Maintain the operation of a 

grievance process so that participating 

CAP physician, beneficiary, and 

beneficiary caregiver complaints can be 

addressed; 

• Provide a prompt response to any 

inquiry as outlined in the vendor 

application form; 

• Maintain business hours on 

weekdays and weekends with staff 

available to provide customer assistance 

for the disabled, including the hearing 

impaired, and to Spanish speaking 

inquirers; and 

• Provide toll-free emergency 

assistance when the call center is 

closed. 

We also required that approved CAP 

vendors maintain a formal mechanism 

for responding to complaints from 

participating CAP physicians, 

beneficiaries, and their caregivers (if 

applicable) (70 FR 39065). Additionally, 

we stated that customer service is of 

primary importance and approved CAP 

vendors must demonstrate the ability to 

respond to inquiries on both weekdays 

and weekends (70 FR 39085). 

Comment: We received no objections 

to any of the requirements. A 

commenter noted that although vendors 

are required to have procedures to 

resolve complaints and inquiries about 

CAP drug shipments, there were no 

clear standards for systems or 

procedures that approved CAP vendors 

must maintain. This commenter 

supported the establishment of a call 

center or other patient support center to 

answer patients’ questions about billing, 

payment schedules, and other matters. 

Response: We believe that customer 

service is of primary importance and 

that approved CAP vendors must 

demonstrate the ability to respond 

promptly and satisfactorily to inquiries 

from providers, beneficiaries, and 

caregivers. We believe that approved 

CAP vendors should have the flexibility 

to develop standards and systems that 

meet our requirements. However, we 

note that an approved CAP vendor will 

be required to respond to inquiries from 

a wide variety of sources, including 

beneficiaries and physician office staff, 

and that inquiries could come from a 

variety of time zones. Therefore, we are 

finalizing this policy and revising 

§ 414.914 to reflect that an approved 

CAP vendor will be required to—

• Maintain the operation of a 

grievance process so that participating 

CAP physician, beneficiary, and 

beneficiary caregiver complaints can be 

addressed. 

• Respond within 2 business days to 

any inquiry, or sooner if the inquiry is 

related to drug quality. 

• Staff a toll-free line from 8:30 a.m. 

or earlier and until 5 p.m. or later for all 

time zones served in the continental 

United States by the approved CAP 

vendor on business days (Monday 

through Friday excluding Federal 

holidays) to provide customer 

assistance, and establish reasonable 

hours of operation for Hawaii, Alaska, 

Puerto Rico, and the other U.S. 

territories. 

• Staff a toll-free emergency line for 

weekend and evening access when the 

call center is closed, and determine 

which hours on Saturdays and Sundays 

the call center will be staffed and which 

hours a toll-free emergency line will be 

activated. 

• Include assistance for the disabled, 

the hearing impaired, and Spanish 

speaking inquirers in all customer 

service operations. 

We also recommend that all approved 

CAP vendors have arrangements in 

place to obtain translation services in 

other languages if serving a sizable 

population of beneficiaries or caregivers 

whose language is other than English or 

Spanish and who do not have access to 

translator assistance. 

When a beneficiary has a question 

about a coinsurance bill from an 

approved CAP vendor, the beneficiary is 

directed to contact the approved CAP 

vendor or his or her supplemental 

insurance provider (if applicable). If the 

beneficiary has no supplemental 

insurance, and believes he or she is not 

liable for the coinsurance bill, but is 

unable to resolve the situation on their 

own, the beneficiary may contact the 

designated carrier’s customer service 

staff for assistance. The dispute 

resolution process is described in 

§ 414.916(d) and in the July 6, 2005 

interim final rule with comment (70 FR 

39098). 

(5) Prompt Pay Discounts 

In the July 6, 2005 interim final rule 

with comment, we stated that prompt 

pay discounts should be disclosed by 

the approved CAP vendor and included 

in determining reasonable, net 

acquisition costs for purposes of section 

1847B(c)(7) of the Act, and that we were 

interested in receiving comments about 

how these discounts are arranged and 

whether they are indeed different from 

other price concessions and discount 

arrangements. 

Comment: Some commenters 

questioned the inclusion of prompt pay 

discounts in the determination of 

approved CAP vendors’ reasonable net 

acquisition costs. They argued that so 

long as prompt pay discounts truly 

represent the time value of money and 

the fair market value of the distribution 

and financial services that are provided 

and are not passed on to providers, they 

should not be included in the approved 

CAP vendor’s net acquisition costs. The 

commenters also raised issues with the 

treatment of prompt pay discounts 

under the ASP system. 

Response: We disagree that prompt 

payment discounts should be excluded 

from the determination of an approved 

CAP vendor’s reasonable, net 

acquisition costs. Section 1847B(c)(7) of 

the Act makes reference to an approved 

CAP vendor’s ‘‘reasonable, net 

acquisition costs’’. The statute’s use of 

the word ‘‘net’’ indicates these costs 

should reflect discounts the approved 

CAP vendor has received. Further, we 

believe it is appropriate that ‘‘net 

acquisition costs’’ be calculated in a 

manner consistent with the calculation 

of ASP. Prompt pay discounts are price 

concessions that must be included in a 

manufacturer’s calculation of ASP. 

Please see section II.H.1 of this 

preamble, ASP Issues, for further 

discussion of prompt pay discounts 

under the ASP payment methodology. 

(6) Bidding Process 

In the July 6, 2005 interim final rule 

with comment, we stated that the 

composite bid ceiling will be 

determined on the basis of ASP prices 

in effect during the quarter in which the 

bids are generated, and that the single 

price for each drug (HCPCS code) will 

be initially determined on the basis of 

the median of the bids submitted during 

the second quarter of CY 2005 for that 

drug. We further stated that the price of 

each drug will then be updated to the 

mid-point of CY 2006 (five quarter 

increase) Producer Price Index (PPI) for 

prescription preparations. 

Given the 6 month delay in 

implementation and the corresponding 

change in the bidding period, we will be 

making certain adjustments to the 

bidding process to account for more 

recent data. In general, we will retain 

the process described in the July 6, 2005 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70247 

interim final rule with comment 

(§ 414.904). However, we will require 

bidders to base their bid on the October 

ASP file which accounts for the most 

recent ASP data available and can be 

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

providers/drugs/asp. As a result of the 

use of the updated drug pricing data and 

the delay in the implementation, we 

will no longer need to update the bid 

price by 5 quarters of PPI. Instead, we 

will update prices by 4 quarters of PPI. 

This allows the data to be trended 

forward from the period in which 

bidding is conducted (the fourth quarter 

of CY 2005) to the period in which the 

single prices will actually be in effect 

(second half of CY 2006). Specifically, 

the price of each CAP drug will be 

updated to the mid-point of the 2006 

payment period on the basis of 

projecting the overall change in PPI 

prices for prescription preparations. 

Bidding for potential CAP vendors 

will commence upon publication of this 

final rule with comment. Bidders will 

have at least 30 days to submit an 

application. Upon publication of the 

final rule, CAP bidding forms and 

additional information regarding 

bidding timelines, and other related 

material, can be found at http:// 

www.cms.hhs.gov/providers/drugs/ 

compbid/bid_form_announ.asp. 

c. Operational Issues 

In this section, we address drug 

product waste and returns, and when 

unused portions of single-use drugs may 

be billable to Medicare under the CAP. 

We address billing issues and timing of 

claims processing and payment. We 

address comments regarding 

coinsurance and collection of Advanced 

Beneficiary Notice forms (ABNs) and 

arrangements between approved CAP 

vendors and participating CAP 

physicians for services relating to the 

CAP. 

We also address several CAP drugordering issues. We describe the 

resupply option and emergency use 

within the CAP. We clarify when a 

Medicare beneficiary’s height and 

weight are needed for ordering a CAP 

drug. We also clarify the ‘‘furnish as 

written’’ option. Finally, we address 

patient confidentiality. 

(1) Unused Drug Product (Waste and 

Returns) 

In the July 6, 2005 interim final rule 

with comment (70 FR 39062), we 

responded to commenters asking for 

specific guidance on how to manage 

drug waste and returns as follows: 

Although a variety of situations may 

create quantities of unused drugs at the 

place of administration, we believe the 

unused CAP drugs will come in the 

following 3 forms: 

• An unopened vial (or vial package) 

as shipped by the approved CAP 

vendor. 

• An opened vial (that may or may 

not be reconstituted or partly used). 

• A drug that has been removed from 

a vial or package and is in a syringe, IV 

bag, or other device or container used 

for drug administration. 

Unused quantities of a drug may 

increase the risk of waste, fraud and 

abuse, and attempts to use the excess 

drug may violate applicable pharmacy 

law or may compromise product 

integrity. We expect that approved CAP 

vendors will furnish drugs in a manner 

that will minimize unused drugs. We 

also expect that participating CAP 

physicians and approved CAP vendors 

will both make an effort to label, ship, 

and store CAP drugs in a manner that 

will allow the legally permissible reuse 

of an unopened and intact container of 

a CAP drug. Returns of unused products 

through a distribution system may be 

acceptable, but many States prohibit 

reusing drugs that have been dispensed 

by a pharmacy (For further information, 

see FDA Office of Regulatory Affairs 

(ORA) Compliance Policy Guides 

Manual Sec. 460.300, Return of Unused 

Prescription Drugs to Pharmacy Stock, 

CPG 7132.09). We are aware of 

situations when an approved CAP 

vendor may label a vendor-supplied 

outer container for prescriptions to keep 

the actual manufacturer’s packaging 

intact and unlabelled. We further expect 

approved CAP vendors to offer and ship 

units of a drug that match the 

beneficiary’s dosing requirements and 

HCPCS billing amount as closely as 

practical. In this way, a degree of waste 

will be prevented. Specific details, 

including how waste, returns, and their 

cost burden are handled, will depend on 

State law and regulation as well as the 

individual situations. Approved CAP 

vendors should establish policies on 

these issues (making sure that they 

comply with applicable laws and 

regulations) and make the policies 

available for physicians to review 

during the election period and through 

the term of the approved CAP vendor’s 

participation in the CAP. 

Approved CAP vendors will supply 

CAP drugs to participating CAP 

physicians’ offices in unopened vials. 

However, in situations where a CAP 

drug is dosed by body weight or BSA, 

the amount of drug in vials may not 

match the Medicare patient’s actual 

dose, and the approved CAP vendor will 

be forced to ship excess drug. In certain 

States, pharmacy law may prevent the 

use of excess CAP drug for another 

Medicare beneficiary if the order must 

be labeled as a prescription. The return 

process is guided by the following: 

• Federal Law and guidelines (such 

as the FDA/ORA CPG 460.300), State 

law, Medicare requirements (such as the 

Claims Processing Manual), drug 

stability, and appropriate standards 

(such as United States Pharmacopoeia 

Chapter 797, Pharmaceutical 

Compounding—Sterile Preparations) 

will be used to determine how an extra 

drug product(s) may be used for 

subsequent dosing on the same 

beneficiary or for use on another 

beneficiary. 

• If excess drug product remaining in 

a vial shipped by an approved CAP 

vendor must be returned, the approved 

CAP vendor is expected to accept excess 

CAP drugs for disposal and is expected 

to pay for shipping. The participating 

CAP physician is responsible for 

appropriately packing the drug. 

Consolidating shipping into larger and 

less frequent packages by the 

participating CAP physician would be 

encouraged. We do not intend for this 

process to be used as a vehicle for 

routine disposal of empty or nearly 

empty vials, disposal of any drug 

product not shipped by an approved 

CAP vendor, or disposal of drugs mixed 

in IV bags, syringes, associated needles 

and tubing, or other devices used in the 

administration of the drug product to a 

beneficiary. 

The approved CAP vendor bills 

Medicare only for the amount of CAP 

drug administered to the Medicare 

beneficiary and the beneficiary’s 

coinsurance amount will be calculated 

from the quantity of drug that is 

administered. Because the CAP statute 

authorizes us to pay the approved CAP 

vendor only upon administration of the 

CAP drug, any discarded drug (or drug 

that is considered waste) will not be 

eligible for payment. 

We also stated that the CAP dispute 

resolution process will be available to 

resolve any associated disputes. 

Comment: Most commenters objected 

to our payment policy for the unused 

portion of drugs. Most commenters 

perceived that the payment policy for 

the unused portion of a drug under the 

CAP was more restrictive than the 

payment policy for the unused portion 

of a drug under the ASP payment 

system. Many, but not all, commenters 

on this issue supported the general 

concept of payment for the unused 

portion of drugs contingent upon good 

faith efforts on the part of the 

participating CAP physician and 

approved CAP vendor to minimize 

unused drugs. However, some 

commenters indicated that payment to 

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the approved CAP vendor for the 

unused portion of CAP drugs should not 

be contingent on good faith efforts by 

the participating CAP physician, but 

only good faith efforts by the approved 

CAP vendor in furnishing the drug. 

Response: Under the ASP payment 

system, physicians may bill the program 

for the unused portion of a drug 

remaining in an opened single-use vial 

if the physician made good faith efforts 

to minimize the unused portion of the 

drug in how he or she scheduled 

patients and how he or she ordered, 

accepted, stored, and used the drug. 

This policy does not apply to the 

unused portion of drugs from multiple 

use vials. 

We expect that approved CAP 

vendors and participating CAP 

physicians will act and interact in a 

manner that will minimize unused 

drugs. Section 1847B(a)(3)(A)(iii) of the 

Act states that payment for CAP drugs 

is conditioned upon the administration 

of these drugs. We are clarifying that we 

consider the unused portion of a drug 

remaining in an opened single-use vial 

to be administered for the limited 

purpose of section 1847B(a)(3)(A)(iii)(II) 

of the Act, but only if the participating 

CAP physician has made good faith 

efforts to minimize the unused portion 

of the CAP drug in how he or she 

scheduled patients and how he or she 

ordered, accepted, stored, and used the 

drug, and only if the approved CAP 

vendor has made good faith efforts to 

minimize the unused portion of the 

drug in how it supplied the drug. This 

policy does not apply to the unused 

portion of drugs from multiple use vials. 

We disagree with commenters who 

indicated that payment for the unused 

portion of drugs should not be 

contingent on good faith efforts by the 

participating CAP physician, but only 

on good faith efforts by the approved 

CAP vendor in supplying the drug. The 

program should not pay for the unused 

portion of a drug resulting from 

circumstances that were avoidable 

through good faith efforts. However, in 

response to these comments, we are 

including a new obligation in 

participating CAP physicians’ CAP 

election agreement that requires the 

participating CAP physician to make 

good faith efforts to minimize the 

unused portion of CAP drugs in how he 

or she schedules patients and how he or 

she orders, accepts, stores, and uses the 

drugs. The requirement stated in the 

July 6, 2005 interim final rule with 

comment (70FR 39048) still applies, that 

when a participating CAP physician 

does not administer a CAP drug during 

the time frame specified on the 

prescription order, or administers a 

smaller amount of the drug than was 

originally ordered, the participating 

CAP physician must contact the 

approved CAP vendor to discuss what 

to do. If it is permissible under State 

law, and if the CAP drug is unopened 

and both the participating CAP 

physician and the approved CAP vendor 

are in agreement, then the participating 

CAP physician may retain the drug for 

administration to another Medicare 

beneficiary. However, before the drug 

could be administered to another 

Medicare beneficiary, the participating 

CAP physician would need to provide 

the approved CAP vendor with a new 

prescription order for the drug, and the 

approved CAP vendor would need to 

provide the participating CAP physician 

with a new beneficiary-specific 

prescription order number. 

If the unused portion of the CAP drug 

is from a single-use vial, and all of the 

other conditions are met, the approved 

CAP vendor may bill for the unused 

portion of the CAP drug in the singleuse vial. However, if the unused portion 

of the CAP drug is from a multi-use vial 

or an unopened vial, the participating 

CAP physician and approved CAP 

vendor must come to an arrangement on 

what to do with the unused CAP drug 

consistent with statute, the CAP 

regulations, and all applicable State and 

Federal laws and regulations. We note 

that unused CAP drugs are the property 

of the approved CAP vendor. 

Comment: Some commenters asked 

for clarification of wastage, spillage or 

spoilage. 

Response: Any drug or portion of a 

CAP drug that is not administered to a 

Medicare patient is considered wastage, 

spillage or spoilage. We note that if the 

other conditions described in the 

previous response are met, the unused 

portion of a CAP drug from a single-use 

vial is considered to have been 

administered for purposes of section 

1847B(a)(3)(A)(iii)(II) of the Act, and, 

therefore, would not be considered 

wastage, spillage, or spoilage. 

Comment: One commenter indicated 

that totally unopened or unused vials or 

packages ordered by the participating 

CAP physician should be purchased by 

the participating CAP physician for his 

or her own inventory. 

Response: We expect participating 

CAP physicians will make good faith 

efforts to minimize unused CAP drugs. 

One of the goals of the CAP program is 

to allow physicians a choice between 

obtaining CAP drugs from approved 

CAP vendors selected in a competitive 

bidding process or acquiring and billing 

for Part B covered drugs under the ASP 

drug payment methodology. We do not 

believe that requiring participating CAP 

physicians to purchase totally unopened 

or unused vials or packages for their 

own inventory is consistent with this 

goal. 

Comment: One commenter stated that 

many neurology practices that 

administer botox infusions split vials of 

the medication between two patients in 

cases where the patient does not need 

the full vial. The commenter indicated 

that the interim final rule with comment 

would prohibit this practice. 

Response: We indicated in the interim 

final rule with comment that unused 

quantities of a drug may increase the 

risk of waste, fraud and abuse, and 

attempts to use the excess drug may 

violate pharmacy law and may 

compromise product integrity. However, 

we also indicated that specific details 

will depend on State law and regulation 

as well as the individual situations. 

Approved CAP vendors will establish 

policies on these issues (making sure 

that they comply with applicable laws 

and regulations) and make the policies 

available for physicians to review 

during the election period and through 

approved CAP vendor’s participation in 

the CAP. Note also our policy regarding 

unused portions of a CAP drug from a 

single-use vial, which is described 

above. 

(2) Timing of Approved CAP Vendor 

Billing/Payment of Claims 

In the July 6, 2005 interim final rule 

with comment, we stated the 

participating CAP physician must file 

his or her drug administration claim 

within 14 days of administration (70 FR 

39050 and 39095), and that the 

approved CAP vendor could not bill the 

beneficiary for drug product 

coinsurance until the claims matched 

and the approved CAP vendor received 

payment from the designated carrier (70 

FR 39052 and 39097). 

Comment: Potential vendors have 

proposed ways to shorten the time 

frame of the approved CAP vendor’s 

payment window. One suggested that 

approved CAP vendors should be 

permitted to bill and be paid for drugs 

upon delivery to a participating CAP 

physician. Another suggested that the 

participating CAP physician be deemed 

to have ‘‘purchased’’ the drug if the 

participating CAP physician has not 

filed his or her claim within 14 days of 

delivery. These potential vendors are 

concerned about the viability of the CAP 

from a cash flow perspective. 

Response: In most cases, assuming the 

participating CAP physician and the 

approved CAP vendor have promptly 

and properly submitted their claims, the 

approved CAP vendor should be paid by 

CMS within two to three weeks from the 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70249 

date of drug administration. The 

anticipated sequence of events for the 

majority of CAP claims that are in 

compliance with local coverage 

determinations (LCDs) is described in 

the timeline in Diagram 1. 

This timeline (diagram 1) is offered as 

an illustration of how the approved CAP 

vendor’s drug claim and the 

participating CAP physician’s 

administration claim would travel 

through the Medicare claims processing 

system using the month of October as an 

example. The claims depicted here are 

assumed to have passed ‘‘front end 

edits’’ and been considered ‘‘clean 

claims.’’

BILLING CODE 4120–01–U 

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BILLING CODE 4120–01–C 


ER21NO05.053</GPH>
Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70251 

In the July 6, 2005 interim final rule 

with comment, we asked the approved 

CAP vendor to submit its drug claim to 

the designated carrier no earlier than the 

first day of the anticipated week of 

administration as indicated on the drug 

order (70 FR 39040). After performing 

initial ‘‘front end’’ edits to validate the 

claim, the designated carrier will 

forward the approved CAP vendor’s 

claim to the CMS central claims 

processing system. If there is not an 

immediate match between the approved 

CAP vendor’s drug product claim and 

the participating CAP physician’s drug 

administration claim in the CMS central 

claims system on the day the approved 

CAP vendor’s claim is received, then the 

approved CAP vendor’s claim goes into 

a recycling phase and will be reviewed 

for a match regularly thereafter. Section 

1842(c)(3)(A) of the Act requires that no 

payment on an electronic claim shall be 

issued in less than 13 days. We add one 

day for mailroom and check handling 

and refer to this 14-day period as the 

‘‘payment floor.’’ The payment floor 

clock starts on the day the approved 

CAP vendor’s claim is received by the 

designated carrier as long as the claim 

passes all edits and is classified as a 

‘‘clean claim’’. 

In the July 6, 2005 interim final rule 

with comment, we stated that 

participating CAP physicians are 

required to file their claims for drug 

administration services within 14 days 

of the date of administration (70 FR 

39050). Statistics obtained from 

Medicare claims filing data indicate that 

75 percent of physician claims are filed 

within 14 days of the date of service, 

and that 95.6 percent of all Part B claims 

are considered clean when first filed. 

Within 3 days of receipt of a 

participating CAP physician’s clean 

claim that has not been suspended for 

medical review, the CMS central claims 

processing system will generate a match 

between the participating CAP 

physician’s claim and the approved 

CAP vendor’s claim and permit 

payment of the approved drug vendor’s 

drug product claim, provided the 14-day 

payment floor has been satisfied. 

In the July 6, 2005 interim final rule 

with comment, we stated that drug 

administration claims will undergo 

electronic medical review for 

compliance with LCDs (70 FR 39038). 

Historically, approximately 5 percent of 

Part B drug claims are suspended for 

manual review, and approximately 7 

percent of all claims (that is, not just 

those for Part B drugs) are denied. We 

expect that a small number of CAP drug 

claims will be reviewed for off-label use. 

As for the 20 percent coinsurance 

portion of the bill, about 80 percent of 

Medicare beneficiaries have a 

supplemental insurance policy that 

covers the beneficiary’s cost sharing 

obligation. Approved CAP vendors will 

know which beneficiaries have a 

supplemental policy because that 

information is required to be included 

on the prescription order. Approved 

CAP vendors will also be able to verify 

the beneficiary’s supplemental coverage 

by contacting the supplemental insurer. 

If the supplemental insurer has an 

arrangement with CMS as part of the 

automatic coordination of benefits 

process, the approved CAP vendor’s 

claim will automatically cross over to 

the supplemental insurer after Medicare 

has paid its 80 percent share of the 

claim. In addition, under the mandatory 

Medigap crossover process, claims will 

be forwarded to the supplemental 

insurers for their use calculating their 

financial liability after Medicare if the 

approved CAP vendor properly coded 

the claim with the trading partner (for 

example, supplemental insurers) 

information. In both of these situations, 

after the supplemental insurer receives 

the claim it will issue applicable 

payment to the approved CAP vendor. 

When an approved CAP vendor has 

supplied a CAP drug for administration 

to a beneficiary without supplemental 

insurance, the approved CAP vendor 

may bill the beneficiary upon receipt of 

Medicare’s payment from the designated 

carrier or upon administration of the 

drug, if the approved CAP vendor has 

received notice of administration from 

the participating CAP physician. The 

approved CAP vendor may enter into a 

voluntary arrangement with a 

participating CAP physician to receive 

notification that the drug has been 

administered. The approved CAP 

vendor may also enter into a voluntary 

arrangement with the participating CAP 

physician to arrange for the collection of 

the beneficiary’s coinsurance after the 

drug is administered, or to deliver 

information and notices on 

coninsurance assistance. 

(3) Arrangements Between Approved 

CAP Vendors and Participating CAP 

Physicians for the Collection of 

Coinsurance and ABNs 

In the July 6, 2005 interim final rule 

with comment, we stated that nothing in 

the CAP statute or regulations 

prohibited an approved CAP vendor and 

a participating CAP physician from 

entering into an agreement governing 

their arrangements for the provision of 

CAP drugs or other items or services (70 

FR 39050). We added that parties to 

these agreements must ensure that the 

arrangements do not violate the 

physician self-referral (‘‘Stark’’) 

prohibition (section 1877 of the Act), 

the Federal anti-kickback statute 

(section 1128B(b) of the Act), or any 

other Federal or State law or regulation 

governing billing or claims submission. 

Comment: Some commenters 

requested that we state explicitly that 

approved CAP vendors and 

participating CAP physicians are 

allowed to enter into these 

arrangements. They suggested that drug 

industry relationships commonly 

include supplier/physician 

arrangements. These commenters 

believed that approved CAP vendor/ 

participating CAP physician 

arrangements will promote more 

participation in the CAP, stimulate 

greater cooperation between the parties, 

and generate fiscal efficiencies. 

Physician and manufacturer 

commenters requested that we 

implement the CAP with safeguards that 

preserve the participating CAP 

physician’s prescribing authority in the 

presence of these arrangements. They 

asked us to ensure that approved CAP 

vendors have no incentive and no 

regulatory pathway by which to restrict, 

limit, or change a participating CAP 

physician’s access to specific drug and 

biological therapy. 

Response: We are stating explicitly 

that nothing in the CAP statute or 

regulations prohibits approved CAP 

vendors and participating CAP 

physicians from entering into voluntary 

written arrangements that include—

• An arrangement between a 

participating CAP physician and an 

approved CAP vendor to notify the 

approved CAP vendor after the CAP 

drug has been administered to the 

beneficiary; 

• An arrangement between a 

participating CAP physician and an 

approved CAP vendor to communicate 

with the beneficiary about coinsurance 

for CAP drugs on behalf of the approved 

CAP vendor; 

• An arrangement between a 

participating CAP physician and an 

approved CAP vendor to issue an ABN 

on behalf of the approved CAP vendor; 

• An arrangement between a 

participating CAP physician and an 

approved CAP vendor to collect 

applicable coinsurance and deductible 

on behalf of the approved CAP vendor 

from the beneficiary with no 

supplemental insurance coverage after 

the drug has been administered; and 

• Any other appropriate and legal 

arrangement between a participating 

CAP physician and an approved CAP 

vendor. (We note that the provisions of 

§ 414.914(h) also allow the participating 

CAP physician and the approved CAP 

vendor to enter into an arrangement for 

70252 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

the participating CAP physician to 

deliver notices related to the vendor’s 

coinsurance assistance program.) 

We will not dictate the breadth of use 

or the specific obligations contained in 

these arrangements, other than to note 

that they must comply with applicable 

law and to prohibit approved CAP 

vendors from coercing participating 

CAP physicians into entering any of 

these arrangements, as noted below. All 

written arrangements between approved 

CAP vendors and participating CAP 

physicians must comply with the 

requirements discussed below. 

These arrangements should be 

carefully scrutinized by the parties to 

ensure that these arrangements are not 

disguised payments for referrals for 

items or services payable by a Federal 

health care program. These 

arrangements are subject to the 

physician self-referral (‘‘Stark’’) 

prohibition, the Federal anti-kickback 

statute or any other Federal or State law 

or regulation governing billing or claims 

submission. Arrangements should be at 

fair market value for actual services 

provided and should not take into 

account the volume or value of referrals. 

Percentage compensation arrangements 

or per item arrangements for billing and 

collection services between 

participating CAP physicians and 

approved CAP vendors would be highly 

suspect under the fraud and abuse laws. 

Approved CAP vendors who enter 

into these arrangements with 

participating CAP physicians remain 

subject to liability for improper waivers 

of deductibles and coinsurance, 

including violations of the Federal antikickback statute and liability under 

section 1128A(a)(5) of the Act. Costsharing waivers are permitted under 

certain conditions for financially needy 

beneficiaries as specified in section 

1128A(i)(6) of the Act. Parties should 

monitor these arrangements to ensure 

that waivers are made appropriately and 

create safeguards to ensure that these 

arrangements are not used by approved 

CAP vendors or participating CAP 

physicians as inappropriate marketing 

tools. 

A participating CAP physician’s 

decision to enter into an arrangement 

with an approved CAP vendor must be 

completely voluntary. An approved 

CAP vendor may not refuse to do 

business with a participating CAP 

physician because the participating CAP 

physician has declined to enter into an 

arrangement with the approved CAP 

vendor. Approved CAP vendors must 

accept all participating CAP physicians 

who choose to enroll with that approved 

CAP vendor. 

Comment: Some commenters 

proposed that approved CAP vendors 

should have authority to obtain 

beneficiary credit card authorization 

before shipping drugs for them. One 

commenter suggested that Medicare 

withhold the approved CAP vendor’s 20 

percent coinsurance from the 

participating CAP physician’s drug 

administration claim payment. The 

participating CAP physician would then 

collect both the administration 

coinsurance together with the drug 

product coinsurance from the 

beneficiary and/or the beneficiary’s 

supplemental insurer. The approved 

CAP vendor would be paid the full 

amount. 

Response: The CAP statute requires 

that we develop a process for the 

sharing of information between the 

participating CAP physician and the 

approved CAP vendor related to the 

payment of deductible and coinsurance 

(section 1847B(a)(3)(C) of the Act). In 

the July 6, 2005 interim final rule with 

comment, we interpreted this to mean 

beneficiary contact information, 

Medicare information, and third party 

insurance information (70 FR 39041). In 

the interim final rule with comment, we 

stated that we will not ask the 

participating CAP physician to collect 

the beneficiary’s credit card information 

and share it with the approved CAP 

vendor because this information is not 

necessary to complete the drug ordering 

process, nor is it part of any 

supplemental insurance coverage that 

the beneficiary may have. We maintain 

that position in this final rule with 

comment. We do not ask the 

participating CAP physician to collect 

and forward credit card information to 

a third party supplier in any other 

Medicare setting. The beneficiary will 

have supplemental insurance 

approximately 80 percent of the time, 

rendering beneficiary payment 

information unnecessary in most cases. 

We do not believe it is appropriate to 

require participating CAP physicians to 

secure drug coinsurance payment 

information from beneficiaries with no 

supplemental insurance, since 

provisions of section 1847B(a)(3)(A)(ii) 

of the Act make the collection of 

coinsurance the responsibility of the 

approved CAP vendor. However, as 

discussed previously, the participating 

CAP physician and the approved CAP 

vendor may enter into a voluntary 

arrangement, whereby the participating 

CAP physician, on the approved CAP 

vendor’s behalf, would collect 

coinsurance from beneficiaries with no 

supplemental insurance coverage. 

(4) Resupply Option/Definition of 

Emergency 

As stated in the July 6, 2005 interim 

final rule with comment (70 FR 39037 

and 39047), the four criteria that govern 

the resupply option are contained in 

section 1847B(a)(5) of the Act, which 

says that a participating CAP physician 

may acquire drugs under the CAP to 

resupply his or her private inventory if 

all of the following requirements are 

met: 

• The drugs were required 

immediately. 

• The participating CAP physician 

could not have anticipated the need for 

the drugs. 

• The approved CAP vendor could 

not have delivered the drugs in a timely 

manner. 

• The participating CAP physician 

administered the drugs in an emergency 

situation. 

As we also stated in the July 6, 2005 

interim final rule with comment, these 

criteria are set forth in the CAP statute, 

and, therefore, we do not have the 

authority to change them, or to allow 

that some of them be optional. 

In the July 6, 2005 interim final rule 

with comment, we defined ‘‘delivery in 

a timely manner’’ for the resupply 

provisions of the CAP as the ability to 

meet emergency delivery standards for 

timely delivery as defined in § 414.902. 

We also defined ‘‘emergency situation’’

for the purposes of the resupply 

provisions of the CAP in § 414.902 as an 

unforeseen occurrence or situation 

determined by the participating CAP 

physician, in his or her clinical 

judgment, to require prompt action or 

attention for purposes of permitting the 

participating CAP physician to use a 

drug from his or her own stock, if the 

other requirements of § 414.906(e) are 

met. 

In the July 6, 2005 interim final rule 

with comment, we stated that we 

anticipated that the local carrier would, 

at times, conduct a post-payment review 

of claims for emergency drug 

replacement in order to determine 

whether participating CAP physicians 

were complying with conditions for 

emergency drug replacement. The local 

carrier would use the emergency 

replacement modifier code to identify 

claims for emergency drug replacement 

for random post-payment review. 

Comment: Numerous commenters 

expressed concern that the emergency 

resupply provisions were too restrictive 

and would have a negative impact on 

patient care. These commenters stated 

that, particularly for oncology treatment, 

health status changes are common, 

resulting in frequent changes in drug 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70253 

dosage or medication(s). These 

commenters believe that the 

requirements regarding emergency 

resupply would result in delayed 

treatment for patients already ill, and 

increase the burden on the patient and 

their caregivers. The impact on people 

in rural areas who may live several 

hours from where they receive treatment 

was mentioned by many commenters, 

and it was suggested that the patient’s 

driving distance be considered in the 

ability of a participating CAP physician 

to provide drugs out of office supply 

and be resupplied by the approved CAP 

vendor. One commenter also noted that 

acute and infectious disease patients 

could be at risk if there was any delay 

in treatment. 

Some commenters expressed concern 

that participating CAP physicians who 

use the emergency resupply option 

might be subjected to unwarranted 

audits. Others expressed concern that 

frequent use of the emergency resupply 

option would result in adverse 

consequences for the participating CAP 

physician. There were also questions 

about the approved CAP vendor’s ability 

to withhold shipment if the approved 

CAP vendor did not agree that an 

emergency existed or if they believe the 

drug that was used in the emergency 

situation would not be covered. 

Response: As stated in the July 6, 

2005 interim final rule with comment, 

we believe that the definition of 

emergency used in this situation should 

be one that enables the participating 

CAP physician to use his or her clinical 

judgment to determine when his or her 

patient needs immediate treatment. We 

have defined emergency for purposes of 

this provision as a situation determined 

by the participating CAP physician’s 

clinical judgment to be an unforeseen 

situation that requires prompt action or 

attention. If the approved CAP vendor’s 

emergency delivery timeframe would 

result in delivery of the drug after the 

time necessary to meet the patient’s 

clinical need, it would be considered 

that the CAP drug could not have been 

delivered in a timely manner. 

We are firm in our view that the 

determination of clinical need rests with 

the participating CAP physician and we 

leave it to the participating CAP 

physician to determine the scope of the 

clinical need. As previously stated, the 

participating CAP physician will assess 

whether all of the criteria are applicable 

and will document the patient’s medical 

record accordingly. However, we do not 

believe that driving distance in itself 

should be a determining factor in the 

use of the emergency supply provision. 

Rather, the participating CAP physician 

should evaluate the entire clinical 

situation of the patient and make an 

appropriate determination based on all 

relevant information. 

Approved CAP vendors do not have 

the authority to override a participating 

CAP physician’s determination of what 

constitutes an emergency situation for 

purposes of the resupply provision. 

Policies regarding the shipment of CAP 

drugs are the same for the emergency 

resupply provision as they are for 

routine ordering and shipping of CAP 

drugs and for the ‘‘furnish as written’’

procedures. In all of these cases, the 

approved CAP vendor is required to 

deliver CAP drug(s) upon receipt of a 

prescription order, ensuring that the 

participating CAP physician’s judgment 

about the appropriate treatment is the 

final determining factor in the decisionmaking process. The same principle 

applies to the emergency replacement 

process. If a participating CAP 

physician orders a CAP drug to resupply 

inventory on the basis of an emergency 

administration, the approved CAP 

vendor must ship it, unless the 

conditions of § 414.914(h) are met. 

As stated in the July 6, 2005 interim 

final rule with comment, we anticipate 

that at times the local carrier would 

conduct a post payment review of 

emergency drug replacement in order to 

determine whether participating CAP 

physicians were complying with 

conditions for emergency drug 

replacement. We acknowledge that there 

may be some participating CAP 

physicians that may have legitimate 

reasons for more frequent use of the 

emergency resupply option. The post 

payment review process will also 

provide us with information on 

participating CAP physicians’ use of the 

emergency resupply provision and help 

to distinguish between appropriate and 

inappropriate use of this provision. As 

we gain more experience with the CAP, 

we will assess whether the emergency 

resupply provision is working as 

intended, and whether further 

refinement is necessary. 

(5) Order Form Information on Patient’s 

Height and Weight 

In the July 6, 2005 interim final rule 

with comment (70 FR 39095), we stated 

that the participating CAP physician 

would agree to provide specific 

information to the approved CAP 

vendor from whom he or she has elected 

to receive drugs information. The 

specific information required included 

the Medicare beneficiary’s height and 

weight. We also stated that abbreviated 

information could be sent for repeat 

patient orders. We received comments 

regarding the patient’s height and 

weight. 

Comment: Some commenters stated 

that including the patient’s height and 

weight on the CAP order form should 

not be required. 

Response: It is possible for an 

approved CAP vendor to be a 

wholesaler distributor, a specialty 

pharmacy or a combination of both. 

State and Federal laws that govern 

specialty pharmacy operations may be 

different from those that govern 

wholesale distributor operations. For 

example, State laws, regulations, and 

recognized professional practice 

standards may require that specialty 

pharmacy services be provided by a 

qualified pharmacist. If the approved 

CAP vendor is a specialty pharmacy or 

distributor with an arrangement with a 

specialty pharmacy to supply drugs to a 

participating CAP physician, then 

information on patient height and 

weight may be required in order for a 

pharmacist to check a dispensed dose. 

If the approved CAP vendor operates 

solely as a drug wholesaler this 

information may not be necessary. To 

reflect the different requirements that 

may apply to different potential types of 

approved CAP vendors, we are 

amending § 414.908(a)(3)(v)(M) to 

specify that height and weight should be 

provided only if necessary. 

(6) Furnish as Written 

In the July 6, 2005 interim final rule 

with comment (70 FR 39043), we stated 

that we would allow the participating 

CAP physician to obtain a drug and bill 

Medicare under the ASP system using 

the ‘‘furnish as written’’ (FAW) option 

when medical necessity requires that a 

specific formulation of a drug be 

furnished to the patient, and that 

formulation is not provided by the 

approved CAP vendor. Documentation 

of the medical necessity must be 

maintained in the Medicare patient’s 

medical record. The participating CAP 

physician would use a FAW modifier to 

identify that he or she was allowed to 

bill Medicare under the ASP system in 

this limited circumstance. 

Comment: One commenter stated the 

examples given under the description of 

FAW were very narrow and would keep 

a participating CAP physician from 

using the FAW option proactively. 

Response: If the approved CAP 

vendor does not carry a specific NDC 

that is medically necessary for a patient, 

the participating CAP physician may 

purchase the drug, bill for it and use the 

FAW modifier on the drug claim. In this 

situation, the local carrier will pay the 

participating CAP physician under the 

ASP payment system. We remind 

physicians that the FAW process 

70254 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

requires documentation of medical 

necessity. 

Although the July 6, 2005 interim 

final rule with comment contained 

several examples of when the FAW 

process may be used, we did not intend 

to imply that these were exhaustive. The 

examples were meant to be illustrative, 

and were not meant to exclude other 

situations where FAW could 

legitimately be used in order to furnish 

a patient with the most appropriate 

therapy. Rather, we wished to indicate 

two points—(1) Participating CAP 

physicians who use FAW must 

appropriately document clinical 

judgment in support of the use of FAW; 

and (2) FAW is not intended to provide 

participating CAP physicians with an 

‘‘end run’’ around their decision to 

participate in the CAP. The CAP is in no 

way intended to bar access to a 

medically necessary therapy. However, 

where medical necessity is served by 

the drug formulation supplied by the 

approved CAP vendor, coverage is 

available only if the participating CAP 

physician obtains the drug from the 

approved CAP vendor. 

We again remind physicians that 

routine orders for CAP drugs should be 

placed at the HCPCS level. Specific 

products not on an approved CAP 

vendor’s drug list that are medically 

necessary for the beneficiary may be 

obtained through the ASP system. 

Please note that the approved CAP 

vendor has the ability to request CMS 

approval to add new drugs to its CAP 

drug list. This process was discussed in 

the July 6, 2005 interim final rule with 

comment (70 FR 39075) and further 

described previously in this section. 

(7) Patient Data Confidentiality 

In the July 6, 2005 interim final rule 

with comment (70 FR 39065), we stated 

that approved CAP vendors would be 

required to comply with the HIPAA 

Administrative Simplification Rules, 

including the Privacy Rule. 

Comment: One commenter requested 

that CMS explicitly prohibit approved 

CAP vendors from using, sharing, or 

selling patient information for any 

purpose other than that which is strictly 

related to fulfilling CAP orders. Another 

commenter wanted assurance that 

approved CAP vendor subcontractors 

would be subject to the same 

confidentiality requirements as the 

approved CAP vendor. 

Response: We concur with the 

commenters that patient information 

must be protected from misuse, and 

believe that this requirement is 

adequately addressed by the 

requirement that approved CAP vendors 

comply with the HIPAA Privacy and 

Security rules. We also note that 

subcontractors are held to the same 

requirements and standards as the 

approved CAP vendor, including those 

pertaining to confidentiality. 

d. Beneficiary Issues 

In this section we discuss the policy 

permitting an approved CAP vendor to 

stop supplying drugs for a beneficiary 

who is not meeting their coinsurance 

obligations. 

We also discuss the ABN process as 

it pertains to the CAP. Finally, we 

respond to comments about the 

financial liability of a Medicare/ 

Medicaid dual eligible beneficiary who 

receives a CAP drug. 

(1) Coinsurance 

In the July 6, 2005 interim final rule 

with comment, we specified 

requirements at § 414.914(g) to include 

a provision requiring approved CAP 

vendors to provide information on 

sources of cost-sharing assistance 

available to beneficiaries on request (70 

FR 39096). We noted that routine waiver 

of deductibles and coinsurance could 

violate the Federal anti-kickback statute, 

as well as, the civil prohibition on 

offering inducements to beneficiaries at 

section 1128A(a)(5) of the Act (70 FR 

39050). However, cost-sharing waivers 

are permitted under certain conditions 

for beneficiaries who are experiencing 

financial hardship. 

We also stated in the July 6, 2005 

interim final rule with comment that we 

would not require an approved CAP 

vendor to continue to supply CAP drugs 

for beneficiaries who do not pay their 

deductible or coinsurance. Rather, we 

would allow the approved CAP vendor 

to refuse to make further shipments to 

the participating CAP physician for that 

beneficiary as long as the requirements 

of § 414.914(h) are met. In instances 

where a beneficiary failed to meet his or 

her obligation to pay coinsurance or 

deductible for a CAP drug, and the 

approved CAP vendor refused to 

continue providing the drug, we stated 

that we would permit the participating 

CAP physician to opt out of that drug 

category for the CAP. 

Comment: Commenters from the 

community of potential CAP vendors 

expressed support for the approved CAP 

vendor’s right to refuse to ship drugs for 

beneficiaries who do not meet their 

deductible and coinsurance obligations. 

They recommend removal of the 

requirement that the approved CAP 

vendor wait up to 60 days before 

discontinuing shipment of drugs on 

behalf of beneficiaries who do not meet 

their coinsurance obligations. The 

commenters offer that their exposure for 

additional uncollected coinsurance 

during the waiting period represents a 

risk so great that it renders participation 

in CAP untenable, and they should be 

permitted to collect coinsurance 

amounts on the day they ship the drugs. 

Physicians and some drug 

manufacturers commented that the 45 to 

60 day waiting period is too short, 

suggesting the period after the vendor’s 

referral to a specific, bona fide 

charitable organization should be 

extended to permit the beneficiary 

sufficient time to apply for the aid, and 

the charitable organization time to 

process the request. A longer period was 

requested for cognitively impaired 

beneficiaries. 

Response: Approved CAP vendors 

who become concerned about additional 

drug coinsurance exposure during the 

waiting period may make reasonable 

contact with the beneficiary for 

assurance that he or she is making 

timely and meaningful efforts to secure 

additional sources of funding. The 

additional 15-day waiting period after 

the specific, bona fide charitable 

organization referral represents a safety 

valve, and is not suggested as the 

starting point for the beneficiary’s effort 

to secure alternative funding. The 

regulatory time periods set up a 

framework for an enforceable remedy. 

However, in light of the comments, and 

to reflect our policy change that an 

approved CAP vendor may make an 

arrangement with a participating CAP 

physician to collect coinsurance on its 

behalf, we are making modifications to 

§ 414.914(h) to reflect that the 45-day 

period will begin on the date that the 

bill for coinsurance is delivered to the 

beneficiary whether it is mailed by the 

approved CAP vendor or delivered by 

the participating CAP physician on the 

behalf of the approved CAP vendor. We 

are also clarifying that the delivery of 

the coinsurance bill need not be 

subsequent to Medicare payment if the 

approved CAP vendor has received 

notice of drug administration from the 

participating CAP physician and the 

beneficiary lacks supplemental 

insurance. Because we believe the 

regulatory provision with this technical 

modification appropriately balances the 

interests of all involved, we are not 

going to change the length of the waiting 

period in § 414.904(h). 

Comment: Some physician 

commenters have indicated that they 

waive coinsurance for indigent 

beneficiaries in some cases and expect 

that vendors should do likewise as a 

matter of routine. 

Response: Approved CAP vendors 

and participating CAP physicians must 

conduct their business in compliance 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70255 

with the requirements of sections 

1128A(a)(5) and 1128A(i)(6) of the Act. 

In the July 6, 2005 interim final rule 

with comment (70 FR 39053) we stated 

that we were modifying the program 

requirements at § 414.914(g) to include 

a provision requiring approved CAP 

vendors to provide information on 

sources of cost-sharing assistance 

available to beneficiaries on request. It 

is important to note that routine waiver 

of deductibles and coinsurance can 

violate the Federal anti-kickback statute, 

as well as the civil prohibition on 

offering inducements to beneficiaries at 

section 1128A(a)(5) of the Act. However, 

cost-sharing waivers are permitted 

under certain conditions for 

beneficiaries who are experiencing 

financial hardship. The assistance 

offered by the approved CAP vendor 

must take the form of one of the 

following: A referral to a bona fide and 

independent charitable organization, 

implementation of a reasonable 

payment plan, or a full or partial waiver 

of the cost-sharing amount based on the 

individual financial need of the patient, 

provided that the waiver meets all of the 

requirements in § 1003.101(1) 

(Definition of ‘‘Remuneration’’). The 

availability of waivers may not be 

advertised or be made as part of a 

solicitation; however, approved CAP 

vendors may inform beneficiaries 

generally of the various categories of 

assistance noted in the preceding 

sentence. In no event may the approved 

CAP vendor include or make any 

statements or representations that 

promise or guarantee that beneficiaries 

will receive cost-sharing waivers. We 

will evaluate the procedures that 

applicant vendors propose to implement 

to make cost-sharing assistance referrals 

as part of the approved CAP vendor 

application review process. 

Comment: Some physician 

commenters opposed the vendor’s right 

to refuse further shipment because they 

believe it will fall to the physician to 

communicate to the beneficiary that his 

or her drugs are not being delivered, 

even though the decision to refuse 

shipment was the approved CAP 

vendor’s. 

Response: We understand the 

commenters’ concern. However, when 

notifying the beneficiary of the 

approved CAP vendor’s refusal to ship 

CAP drugs, the participating CAP 

physician need not justify the approved 

CAP vendor’s decision. Instead, the 

participating CAP physician need only 

direct the beneficiary to the approved 

CAP vendor’s grievance process. We 

believe it is the responsibility of the 

approved CAP vendor to notify the 

beneficiary about the conditions 

(specified in § 414.914(h)) under which 

the approved CAP vendor could 

permissibly cease delivery of CAP drugs 

for a beneficiary. 

Comment: A few physician 

commenters expressed concern that an 

approved CAP vendor could use the 

refusal to ship for nonpayment of 

coinsurance as a way to influence the 

participating CAP physician’s treatment 

plan, such as forcing the participating 

CAP physician to admit the beneficiary 

to a hospital. 

Response: In order to preserve the 

flexibility of the participating CAP 

physician as required by the statute we 

have significantly limited the instances 

in which an approved CAP vendor can 

refuse to ship. However, we have a very 

specific process to provide the approved 

CAP vendor with some economic 

protection, and we will monitor the 

instances where an approved CAP 

vendor refuses to ship for nonpayment 

of coinsurance to ensure it is not being 

abused. The participating CAP 

physician may seek assistance from the 

CAP designated carrier in working out 

disputes where the participating CAP 

physician believes the approved CAP 

vendor is abusing the process under 

§ 414.917. 

Comment: One physician group 

commented that the regulation should 

be revised to require that the approved 

CAP vendor must provide information 

on cost sharing assistance to needy 

beneficiaries. The commenter stated that 

because the regulation at § 414.914(g)(3) 

and § 414.914(h)(3) state that the 

approved CAP vendor may inform 

beneficiaries that they generally make 

available categories of assistance such as 

referral to a bona fide charitable 

organization, implementation of a 

payment plan, or a full or partial waiver 

of the cost sharing amount that they 

were not required to do so. 

Response: In the July 6, 2005 interim 

final rule with comment (70 FR 39086), 

we stated that the approved CAP vendor 

would be required on request, to 

provide information to beneficiaries on 

sources of coinsurance assistance. The 

regulations at § 414.914(g) state that the 

‘‘approved CAP vendor must provide 

assistance to beneficiaries experiencing 

financial difficulty in paying their cost 

sharing amounts * * *’’ However, 

§ 414.914(g)(3) and § 414.914(h)(3) state 

that approved CAP vendors may inform 

beneficiaries that they generally make 

cost sharing assistance available. It was 

our intention as reflected in the 

language in the preamble and 

§ 414.914(g) and § 414.914(h)(3) to 

require approved CAP vendors to have 

a cost sharing assistance program 

available if the beneficiary expressed a 

need for one. 

Section 14.914(g)(3) and 

§ 414.914(h)(3) were intended to convey 

that approved CAP vendors may 

generally inform beneficiaries of the 

existence of this program rather than 

waiting for the beneficiary to request 

assistance. It was not our intention to 

convey that the approved CAP vendor 

had the option not to provide this 

assistance. In order to resolve any 

confusion we are revising 

§ 414.914(g)(3) and § 414.914(h)(3) to 

reflect our original intent. The revision 

now reads, ‘‘Approved CAP vendors 

must inform beneficiaries,’’ that they 

generally make available the categories 

of assistance described in paragraphs 

§ 414.914(g)(1), (g)(2), and (g)(3) of this 

section.’’

Comment: One manufacturer 

commented that the vendor should be 

required to document ‘‘reasonable 

collection efforts’’ before being allowed 

to cut off a beneficiary. 

Response: Because approximately 80 

percent of beneficiaries have a Medicare 

supplemental policy that includes 

coverage for Part B cost sharing, their 

coinsurance and deductible payments 

should be made automatically in most 

cases by their supplemental insurer 

under the coordination of benefits 

process. Some beneficiaries without 

supplemental insurance may have 

difficulty making their coinsurance and 

deductible payments at times, and may 

seek assistance from the approved CAP 

vendor or some other third party. As we 

stated previously in this final rule and 

in the July 6, 2005 interim final rule 

with comment and consistent with the 

requirements of section 1128A(a)(5) of 

the Act and § 414.914(g) of the 

regulations, at the time of billing, the 

approved CAP vendor must inform the 

beneficiary generally of the types of 

cost-sharing assistance that may be 

available. If the beneficiary is unable to 

pay the coinsurance or deductible, he or 

she may request assistance from the 

approved CAP vendor as described 

above. The approved CAP vendor has an 

obligation to provide the information 

requested, and to take one of the actions 

specified in § 414.914(g). However, if 

the beneficiary has not requested 

financial assistance and if after a period 

of 45 days from delivery date of the 

approved CAP vendor’s bill to the 

beneficiary whether by the approved 

CAP vendor or by the participating CAP 

physician on the behalf of the approved 

CAP vendor, the beneficiary’s 

coinsurance obligation remains unpaid, 

the approved CAP vendor may refuse to 

make further shipments of drugs to the 

participating CAP physician for that 

70256 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

beneficiary. (We note that these 

provisions assume that the approved 

CAP vendor bills the beneficiary after 

payment is received from Medicare and 

his or her supplemental insurance 

provider (if applicable).) 

If the beneficiary requests cost-sharing 

assistance and the approved CAP 

vendor refers the beneficiary to a bona 

fide independent charitable 

organization for assistance or offers a 

payment plan, the approved vendor 

must wait an additional 15 days from 

the date of delivery (which would be the 

postmark date when mailed and 

received date when hand delivered) of 

the approved CAP vendor’s response to 

the beneficiary’s request for cost-sharing 

assistance. If at the end of the 15-day 

time period, the approved CAP vendor 

has not received a cost-sharing payment 

(either from the charitable organization 

or from the beneficiary under the 

payment plan), the approved CAP 

vendor may refuse to ship additional 

drugs to the physician on behalf of that 

beneficiary. Further, if the approved 

CAP vendor implements a reasonable 

payment plan, it must continue to ship 

CAP drugs for the beneficiary, so long 

as the beneficiary remains in 

compliance with the payment plan. 

Finally, if the approved CAP vendor 

waives the cost-sharing in accordance 

with section 1128A(i)(6)(A) of the Act 

and § 1003.101 and § 414.914(g)(3) of 

the regulations, it may not refuse to ship 

CAP drugs for the beneficiary. At this 

time, we believe that sufficient 

safeguards are built into the system to 

protect the beneficiary. Beneficiaries 

who believe that the approved CAP 

vendor is not adhering to these 

standards may use the vendor’s 

grievance process. If that does not 

resolve the issue to their satisfaction 

they may request assistance from the 

designated carrier under the dispute 

resolution process. We will monitor the 

implementation of this provision to see 

whether a requirement that the 

approved CAP vendor document 

collection efforts should be 

implemented at a later date. 

Comment: A beneficiary advocacy 

group requested that the approved CAP 

vendor be required to assess the 

beneficiary’s financial condition and 

waive coinsurance for beneficiaries who 

meet a prescribed poverty test. 

Response: Any beneficiary who is 

unable to meet his or her cost-sharing 

obligations is free to request assistance 

from the approved CAP vendor. We 

assume that if the approved CAP vendor 

administers its own plan rather than 

referring the beneficiary to a charitable 

organization for assistance, it will 

develop eligibility guidelines for the 

plan. We do not require any provider to 

waive coinsurance on a routine basis. 

(2) Advance Beneficiary Notices (ABNs) 

In the July 6, 2005 interim final rule 

with comment, we stated that the 

approved CAP vendor could issue an 

ABN to the beneficiary if the approved 

CAP vendor and the participating CAP 

physician did not agree about whether 

the drug administration service claim 

would be paid as a medically necessary 

service (70 FR 39058). We also stated 

that the approved CAP vendor may ask 

the participating CAP physician to 

deliver an ABN. If the participating CAP 

physician agrees to do so, he or she will 

describe both the administration of the 

drug and the drug product on the ABN, 

together with the estimated cost for each 

that the beneficiary must pay if he or 

she receives the drug and Medicare does 

not pay. We also noted that if the 

participating CAP physician declined to 

issue the ABN, then the approved CAP 

vendor could issue the ABN to the 

beneficiary before the drug was 

administered. In the July 6, 2005 interim 

final rule with comment, we used the 

phrase ‘‘signed ABN’’ where we meant 

to say ‘‘enforceable ABN’’ (70 FR 39039 

and 39051). We wish to clarify this 

point because there are circumstances 

under which an ABN issued via 

telephone can be enforced. The 

requirements for delivery of ABNs can 

be found in the Medicare Claims 

Processing Manual, Pub. 100–4, Chapter 

30, Section 40.3.4. These requirements 

may be accessed electronically at http:// 

cms.hhs.gov/manuals/104_claims/ 

clm104c30.pdf. 

Comment: Some physicians 

commented that an obligation to collect 

an ABN on behalf of the approved CAP 

vendor represented an unwelcomed 

administrative burden. Others expressed 

concern that approved CAP vendors 

would overuse the ABN process, issuing 

ABNs even when the approved CAP 

vendor had no reasonable belief that the 

physician’s drug administration claim 

or the vendor’s claim for the drug would 

be denied. A commenter stated that it 

would be a logical anomaly for the 

approved CAP vendor to ask a 

participating CAP physician to collect 

an ABN in cases where the physician 

believes the drug administration 

services and, consequently, the drug 

product will be covered. The 

commenter believes this puts the 

participating CAP physician in an 

untenable situation and will serve to 

confuse the beneficiary unnecessarily. 

Commenters from the community of 

potential vendors requested that we 

allow the approved CAP vendor to 

refuse to ship the CAP drug if the 

approved CAP vendor believes the 

applicable coverage policy prohibits 

payment and the participating CAP 

physician refuses to collect an ABN for 

the CAP drug on behalf of the vendor, 

suggesting that, in this case, the 

participating CAP physician should be 

allowed to use the furnish as written 

process. One commenter requested that 

we allow the approved CAP vendor to 

terminate CAP business with a 

participating CAP physician who 

refused to issue an ABN on behalf of the 

approved CAP vendor when the 

underlying claim was not paid. 

Response: In response to the 

commenters’ concerns, we reemphasize 

that the participating CAP physician’s 

decision to issue an ABN on behalf of 

the approved CAP vendor is completely 

voluntary. An approved CAP vendor is 

always free to contact the beneficiary 

and issue an ABN on its own. Because 

the participating CAP physician’s 

decision to issue an ABN is voluntary, 

the approved CAP vendor may not 

penalize the participating CAP 

physician who refuses to do so by 

refusing to ship the drug or attempting 

in some other way to force the 

participating CAP physician to obtain it. 

We note that, approved CAP vendors 

will have a disincentive to abuse the 

ABN process. Should an approved CAP 

vendor issue an ABN that is not 

consistent with CMS requirements, and 

the claim for the drug is denied and 

appealed to an Administrative Law 

Judge (ALJ), the ALJ could review the 

case and determine that the use of the 

ABN was inappropriate or invalid, 

thereby shifting liability to the approved 

CAP vendor. In addition, if an approved 

CAP vendor frequently seeks ABNs in 

cases where the participating CAP 

physician’s local carrier routinely 

determines a particular drug to be 

covered, the approved CAP vendor may 

not be seen as a good business partner 

by the participating CAP physician and 

could lose his or her business at the 

next CAP election period. After careful 

consideration of the comments we have 

received, and balancing all the policy 

implications we have decided to 

maintain the policy with respect to 

ABNs set forth in the July 6, 2005 

interim final rule with comment. 

(3) Dual Eligibles 

In the July 6, 2005 interim final rule 

with comment, we addressed the 

situation of beneficiaries who are dually 

eligible for the Medicare and Medicaid 

programs. We stated that Medicaid 

coinsurance payments would vary by 

State and that we had no authority to 

change the coinsurance amount based 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70257 

on who was responsible for payment of 

the coinsurance (70 FR 39054). 

Comment: Several commenters 

requested that we specifically state that 

dual eligible, Medicare/Medicaid 

beneficiaries may not be held 

responsible for more coinsurance than 

what the Medicaid State Agency pays. 

They have asked us to make clear that 

approved CAP vendors may not balance 

bill the beneficiary for that portion of 

the 20 percent Medicare coinsurance 

that is above the given State’s Medicaid 

upper payment limit. 

Response: State Medicaid programs 

can limit coinsurance payments to the 

extent that any payment for a covered 

Medicaid benefit, when combined with 

Medicare payments, equals the amount 

of reimbursement payable under the 

Medicaid program. A State Medicaid 

program may deem an approved CAP 

vendor to be paid in full even if it has 

received either no coinsurance payment 

or a reduced payment from the State. 

Dual eligible beneficiaries have no 

liability for a covered Medicaid benefit 

beyond the State’s payment amount as 

set forth in section 1902(n)(2) of the Act. 

e. Physician Election Issues and 

Education 

In the July, 6, 2005 interim final rule 

with comment (70 FR 39079), we stated 

that section 1847B(a)(1)(A) of the Act 

specifies that each physician be given 

the opportunity annually to elect to 

participate in the CAP. Physicians who 

do not elect to participate in the CAP 

would continue to buy the drugs they 

provide to beneficiaries ‘‘incident to’’

their service and bill the Medicare 

program for them under section 1847A 

of the Act, the ASP system. Section 

1847B(a)(5)(A) of the Act requires that 

we develop a process that physicians 

who wish to participate in the CAP may 

use to select an approved CAP vendor. 

This election is to occur on an annual 

basis. The statute requires that we 

coordinate this process with the 

Medicare Participating Physician 

Process described in section 1842(h) of 

the Act. Additionally, we stated that 

physicians who elect to participate in 

the CAP would be required to complete 

a CAP election agreement and would 

agree to the participating CAP physician 

requirements as established in the July 

6, 2005 interim final rule with comment 

(70 FR 39079 through 39083). 

In the July 6, 2005 interim final rule 

with comment, we also stated that the 

participating CAP physician election 

process would operate from October 1 to 

November 15 of each calendar year. In 

the September 6, 2005 interim final rule 

with comment interpretation and 

correction notice (70 FR 52930), we 

announced a delay in CAP 

implementation to approximately July 1, 

2006. We anticipate that the bidding for 

the initial round of CAP will commence 

upon the publication of this rule. Thus, 

for this first CAP year the participating 

CAP physician election process will 

occur for approximately 6 weeks in 

early to mid-spring. Exact dates and 

election procedures will be announced 

on our web site. Later in 2006, we will 

conduct the annual participating CAP 

physician election for CY 2007. The 

election period for 2007 will occur from 

October 1, 2006 to November 15, 2006, 

with subsequent annual participating 

CAP physician election periods running 

from October 1 to November 15 of each 

calendar year thereafter. 

In the July 6, 2005 interim final rule 

with comment, we stated that 

participating CAP physicians who wish 

to continue their participation in the 

CAP into subsequent years would do so 

by executing an abbreviated agreement, 

which would, if applicable, indicate a 

preference to change approved CAP 

vendors or, if applicable, CAP drug 

category. We also described specific 

instances in which participating CAP 

physicians will be permitted to select 

another approved CAP vendor or leave 

the CAP mid-year. These instances are 

when the selected approved CAP 

vendor ceases to participate in the CAP 

because its contract is terminated or 

suspended or if the participating CAP 

physician leaves the group practice that 

had selected the given approved CAP 

vendor or relocates to another 

competitive area (if multiple CAP 

competitive areas are implemented). 

Additionally, physicians newly enrolled 

in Medicare have 90 days from the date 

of enrollment to elect to participate in 

the CAP. The election process was 

summarized in the July 6, 2005 interim 

final rule with comment (70 FR 39083). 

We also stated that when a physician 

bills as a member of a group using the 

group’s Provider Identification Number 

(PIN), he or she must follow the group’s 

election to participate or not to 

participate in the CAP. Thus, members 

of a group practice would elect to 

participate in the CAP as a group when 

billing under the group PIN. We also 

stated that if a group practice physician 

maintains a separate solo practice, he or 

she could make a separate 

determination of whether to participate 

in the CAP for the solo practice if using 

his or her individual PIN for the solo 

practice. 

(1) Group vs. Individual Participation in 

CAP 

We received several comments on the 

CAP participation of physicians who are 

in a group practice. 

Comment: Several commenters 

suggest that when a physician is part of 

a group practice that the choice to elect 

the CAP should be made by the 

individual physician or by the 

physician specialty. Commenters sought 

clarification on the ability of physicians 

to be able to make their own, 

independent decisions related to the 

CAP so as not to affect the continuity of 

the group practices. One commenter 

specifically sought clarification on 

whether a physician within a group 

practice could opt out of CAP while his 

partners within the group opted in. The 

commenter believed that the language 

allows one physician within a group to 

continue with the ‘‘buy and bill’’

method while the others within the 

group opt to elect the CAP as long as the 

physician bills all of his or her 

professional services rendered to group 

patients under his or her own 

individual PIN. 

Response: In the July 6, 2005 interim 

final rule with comment (70 FR 39082), 

we stated that we were required to 

coordinate the selection of the approved 

CAP vendor with agreements entered 

into under section 1842(h) of the Act 

(agreements to become a Medicare 

participating physician). The Medicare 

participating physician enrollment 

process coordinates the Medicare 

payment for the health care services 

delivered to a Medicare beneficiary. 

When payments for services are made to 

a health care provider, they are made 

based on the PIN. In order for a 

physician to ‘‘buy and bill’’ separately 

from the group he or she must not have 

reassigned his or her benefits to the 

group. By reassigning his or her benefits 

to the group practice, the physician will 

be billing Medicare using the group’s 

PIN. Thus, the group will make the 

choice about whether to participate in 

the CAP. 

Comment: Another commenter sought 

clarification on whether a nonparticipating physician who joined the 

CAP will be able to accept assignment 

for CAP drug administration. 

Response: When a Medicare 

physician is a non-participating 

physician, he or she may still accept 

assignment on a case-by-case basis for 

his or her services. However, he or she 

must agree to accept assignment for all 

Medicare Part B drug payment as 

specified in section 1842(o)(3)(A) of the 

Act. If the non-participating physician 

elects to participate in the CAP he or 

70258 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

she will no longer be billing Medicare 

for the Part B drugs that he or she 

obtains through CAP, but he or she will 

still be able to bill Medicare for the 

administration of those drugs. Thus, if 

a non-participating physician elects to 

participate in the CAP, he or she must 

agree to accept assignment for drug 

administration for all CAP drugs to 

allow for the Medicare beneficiary’s and 

approved CAP vendor’s appeal rights. 

(2) Practitioners in CAP-Clarification 

In the July, 6, 2005 interim final rule 

with comment, we stated that 

physicians would have a choice to 

participate in the CAP or continue to 

buy the drugs they provide to 

beneficiaries ‘‘incident to’’ their service 

and bill the Medicare program for them 

under the ASP system as specified in 

section 1847A of the Act. We would like 

to clarify that for the purposes of the 

CAP, a physician includes all 

practitioners that meet the definition of 

a ‘‘physician’’ in section 1861(r) of the 

Act. 

(3) Physician Choice of Approved CAP 

Vendor 

Comment: One commenter believes 

that approved CAP vendors will be 

entirely dependent on physicians for 

various actions including—filing claims, 

appealing a denial, obtaining 

beneficiary information, and, where 

necessary, obtaining an ABN. The 

commenter asserts that approved CAP 

vendors should be allowed the right to 

decline to work with a participating 

CAP physician who has—

• Previously failed to pay for drugs 

on a timely basis. 

• Materially breached his or her 

contractual obligations to the approved 

CAP vendor or his or her CAP election 

agreement with CMS. 

• Acted in a manner that obstructs 

the purpose or intent of the CAP, or 

otherwise hinders its effectiveness. 

• Otherwise acted in bad faith. 

The commenter is concerned that as 

long as a participating CAP physician is 

not currently suspended, the 

participating CAP physician may select 

any approved CAP vendor he or she 

wishes, including an approved CAP 

vendor that might have generated a 

suspension request for that participating 

CAP physician. The commenter further 

asserts that because of the critical 

reliance of approved CAP vendors on 

participating CAP physician’s 

compliance with CAP requirements that 

in the event of the participating CAP 

physician’s noncompliance the 

approved CAP vendors should have the 

right not to work with a participating 

CAP physician if it has a reasonable 

basis for concern. The commenter also 

believes it is important for the approved 

CAP vendor to have some recourse 

when it will potentially be selling drug 

products to the physician, and, thus, 

potentially be owed significant amounts 

by a physician in certain situations. 

Response: The commenter’s reference 

to a vendor ‘‘selling’’ drugs to a 

physician appears to be expressing 

concern about an approved CAP 

vendor’s relationship with a 

participating CAP physician outside the 

scope of the CAP. These relationships 

are beyond the scope of this rule. 

Currently, physicians purchase the 

drugs they administer to their Medicare 

beneficiary patients and are reimbursed 

for those drugs through the ASP 

payment system. The CAP is an 

alternative way for physicians to obtain 

drugs. In the CAP, the participating CAP 

physician does not purchase CAP drugs, 

but rather orders them. Because 

participating CAP physicians will not 

own the CAP drugs they order from the 

approved CAP vendor, the approved 

CAP vendor will not be ‘‘selling’’ the 

drug to the participating CAP physician. 

Instead, the approved CAP vendor will 

ship CAP drugs to the participating CAP 

physician and bill Medicare for them 

upon administration. In addition, as we 

have stated in this final rule with 

comment and the July 6, 2005 interim 

final rule with comment, an approved 

CAP vendor must accept any 

participating CAP physician who selects 

it. However, in developing the CAP, we 

recognized that the approved CAP 

vendor, as the owner of the CAP drugs, 

would have significant financial risk. 

We developed a dispute resolution 

process to assist the approved CAP 

vendor if there were occurrences of 

participating CAP physician 

noncompliance within the program. In 

the July 6, 2005 interim final rule with 

comment (70 FR 39054), we detailed the 

dispute resolution process for 

addressing participating CAP 

physician’s non-compliance with CAP 

obligations. We believe the dispute 

resolution process is the appropriate 

forum for addressing these concerns. 

(4) Participating CAP Physician Mid 

Year Opt-Out 

In this section, we discuss the 

comments received concerning the 

ability of a participating CAP physician 

to opt-out of the CAP prior to the end 

of the year and our responses to those 

comments. 

Comment: We received a number of 

comments requesting that participating 

CAP physicians have the ability to optout of CAP for any approved CAP 

vendor issues, including quality and 

delivery issues. 

Response: We understand the 

commenters’ concerns. We believe that 

we have provided for a sound method 

to ensure the quality of the CAP and to 

resolve these issues. As discussed in the 

July 6, 2005 interim final rule with 

comment (70 FR 39058), we established 

financial and quality standards to 

ensure that we choose reputable and 

experienced vendors to participate in 

the CAP. 

Participating CAP physicians will 

have the option of changing approved 

CAP vendors or opting out of the CAP 

program on an annual basis. We also 

provided the circumstances, as specified 

in § 414.908(a)(2), under which a 

participating CAP physician may choose 

a different approved CAP vendor midyear or opt-out of the CAP. These 

circumstances are: (1) If the selected 

approved CAP vendor ceases to 

participate in the CAP; (2) if the 

participating CAP physician leaves the 

group practice that had selected the 

approved CAP vendor; (3) if the 

participating CAP physician relocates to 

another competitive acquisition area 

(once multiple CAP competitive areas 

are developed); or, (4) for other exigent 

circumstances defined by CMS. We 

identified a separate exigent 

circumstance relating to instances in 

which an approved CAP vendor 

declines to ship CAP drugs (when the 

conditions of § 414.914(h) are met) in 

§ 414.908(a)(5). We note that in all these 

cases, while there is only one drug 

category for CAP, the participating CAP 

physician would be allowed to opt-out 

of the CAP altogether. 

In the July 6, 2005 interim final rule 

with comment, we also discussed how 

the participating CAP physician would 

use the approved CAP vendor’s 

grievance process for drug quality and 

service issues and turn to the designated 

carrier for assistance in developing 

solutions (70 FR 39057). If a 

participating CAP physician is 

dissatisfied with the drug quality or 

drug delivery performance of an 

approved CAP vendor, we expect the 

participating CAP physician to attempt 

to resolve the issue with the approved 

CAP vendor informally, and then to use 

the approved CAP vendor’s grievance 

procedure. The next step is to ask for 

the designated carrier’s assistance in 

developing a solution with cooperation 

from both parties. The designated 

carrier will act promptly to investigate 

quality and service issues. If these are 

not resolved, the designated carrier may 

recommend to CMS the suspension or 

termination of the approved CAP 

vendor’s contract. We will act on that 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70259 

recommendation after gathering any 

necessary, or additional information 

from the participating CAP physician 

and approved CAP vendor. If the 

approved CAP vendor is suspended 

from the program, that vendor will be 

unable to participate in the CAP for the 

remainder of that year. The ultimate 

sanction for service and quality issues is 

termination of the approved CAP 

vendor’s 3-year contract upon 

exhaustion of the reconsideration 

process as specified in § 414.917. If the 

approved CAP vendor contract is 

suspended or terminated, the 

participating CAP physician would be 

able to choose another approved CAP 

vendor or leave the CAP altogether. 

(5) Participating CAP Physician Opt-Out 

for Non-Payment of Coinsurance 

In the July 6, 2005 interim final rule 

with comment (70 FR 39053), we stated 

that in instances where a beneficiary has 

failed to meet his or her obligation to 

pay the coinsurance or the deductible 

for a drug, the conditions of § 414.914(h) 

were met, and the approved CAP vendor 

has refused to continue shipping CAP 

drugs to the participating CAP 

physician for the beneficiary, we will 

permit the participating CAP physician 

to opt-out of that drug category for the 

CAP. We noted that for the initial 

implementation of the CAP, there is 

only one CAP drug category. Thus, a 

participating CAP physician exercising 

this option will be opting out of the 

entire CAP program until the next 

opportunity to elect to participate. 

We are making a technical change to 

§ 414.908(a)(5) to state that if the 

approved CAP vendor refuses to ship to 

the participating CAP physician because 

the conditions of § 414.914(h) have been 

met; the participating CAP physician 

can withdraw from the applicable CAP 

drug category for the remainder of the 

year immediately upon notice to CMS 

and to the approved CAP vendor. We 

note again, that for the initial 

implementation of the CAP, there is 

only one CAP drug category. Thus, a 

participating CAP physician exercising 

this option will, in effect, be opting out 

of the entire CAP program until the next 

opportunity to elect to participate. 

Comment: We received numerous 

comments on the exigent circumstance 

that allows a participating CAP 

physician to opt-out of CAP if an 

approved CAP vendor were to stop 

providing a drug to a Medicare 

beneficiary due to non-payment of the 

coinsurance to the approved CAP 

vendor. Commenters requested that we 

allow the participating CAP physician 

to opt-out of CAP for only that one 

Medicare beneficiary allowing the 

participating CAP physician to continue 

in CAP for the other Medicare 

beneficiaries. 

Response: We do not believe that 

allowing a participating CAP physician 

to opt-out of CAP on a beneficiary-bybeneficiary basis is consistent with the 

CAP statute. When a physician elects to 

obtain drugs through the CAP that 

physician will no longer be able to bill 

Medicare for drugs under the ASP 

methodology that is available from the 

approved CAP vendor unless permitted 

under the ‘‘furnish as written’’ option. 

The approved CAP vendor will bill 

Medicare for the CAP drugs 

administered by the participating CAP 

physician. Therefore, if an approved 

CAP vendor has refused to ship the CAP 

drug as specified in § 415.914(h), we 

will permit the participating CAP 

physician to opt-out of CAP for that 

category. However, we note that for the 

initial implementation of CAP there is 

only one drug category. 

(6) Physician Education 

In the July 6, 2005 interim final rule 

with comment, we stated that we would 

instruct the Medicare carriers to use 

various communication channels at the 

local and national levels to disseminate 

information about the CAP and assist 

approved CAP vendors and 

participating CAP physicians in 

understanding the Medicare program’s 

operations, policy, and billing and 

administration procedures regarding the 

CAP in conjunction with use (70 FR 

39084). The Medicare carriers will be 

instructed to use data analyses in 

tailoring their outreach and educational 

efforts for potential vendors and 

physicians regarding identified areas of 

confusion about the CAP. Additionally, 

we specified that the Medicare carriers 

would be instructed to use mass media, 

as well as educational and outreach 

products, services, forums, and 

partnerships in an effort to disseminate 

information about, and provide 

assistance regarding, the CAP to 

potential vendors and healthcare 

practitioner communities. We stated 

that the goal of our outreach and 

education would be to ensure that those 

who provide services to Medicare 

beneficiaries receive the information 

they need to understand the Medicare 

program so that they can administer it 

and bill it correctly. 

Comment: There were comments 

requesting assistance and education for 

the CAP. One commenter was 

concerned with the availability of 

assistance and education to the 

participating CAP physician discussed 

in the July 6, 2005 interim final rule 

with comment. The commenter asserted 

that we have not elaborated on how 

physicians would be able to obtain 

education and assistance on CAP 

throughout the year. The commenter 

believed that physicians will have 

questions related to the CAP processes 

or other technical aspects not clear at 

the beginning of the program. The 

commenter also believed that we might 

make changes during the course of the 

year once the program is implemented 

and improvements are instituted. The 

commenter encouraged us to anticipate 

the need for on-going, real-time 

assistance to the participating CAP 

physician utilizing the CAP, particularly 

in the first year and implement a 

proactive education strategy. Another 

commenter requested that given the 

short time frame allowed for the CAP 

election, we ensure that physicians are 

properly educated and informed about 

CAP before they make an election. They 

suggested that we require approved CAP 

vendors to provide participating CAP 

physicians with a disclosure form and 

to certify that they have accurately 

disclosed all program features including 

administrative requirements, technical/ 

software requirements, penalties, 

restrictions on delivery and transporting 

of drugs. 

Response: The commenter is correct 

to note that there will be changes in the 

CAP during the course of the year. As 

we previously discussed, approved CAP 

vendors will have the opportunity to 

request approval to change their drug 

lists in several ways. Physicians should 

be aware of this before electing to 

participate in the CAP, but CMS and 

approved CAP vendors will inform 

participating CAP physicians of these 

and other changes on a timely basis, as 

described in a previous section of this 

preamble. 

In the July 6, 2005 interim final rule 

with comment, we stated that we would 

post on our Web site, the approved CAP 

vendors we have selected for the CAP, 

their categories of drugs (and specific 

NDCs), and the geographic areas within 

which they would operate (70 FR 

39081). (See http://www.cms.hhs.gov/ 

providers/drugs/compbid/). We stated 

that we would publicize the 

participating CAP physician election 

information on our Web site, listservs, 

Medicare fee-for-service contractors’

Web sites, and newsletters. We stated 

our intention to coordinate with 

physician specialty organizations to 

inform their members that the 

participating CAP physician election 

information is available. We also stated 

that we would provide a CAP fact sheet 

so that the carriers can disseminate it to 

their physicians and that there would be 

an education campaign to inform 

70260 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

physicians about the CAP Web site and 

the election process. We described our 

plan to make available, the participating 

CAP physician election agreement forms 

with instruction on how to download, 

complete, and sign them and return 

them to the local carrier. The local 

carrier will note the physician’s 

decision to participate in the CAP, the 

approved CAP vendor and the selected 

categories of drugs (when multiple 

categories of drugs become available). 

The local carrier will forward 

information from the participating CAP 

physician election agreement to the CAP 

designated carrier. The designated 

carrier will compile a master list of all 

participating CAP physicians’ approved 

CAP vendor and drug category 

selections. In addition, the designated 

carrier will notify each approved CAP 

vendor of the participating CAP 

physicians who have elected to enroll 

with that approved CAP vendor. 

Throughout the year we will continue 

to provide participating CAP physician 

assistance through the participating 

CAP physician’s local carrier and the 

designated carrier. Both the 

participating CAP physician’s local 

carrier and the designated carrier will 

have toll free numbers for participating 

CAP physicians to use in requesting 

assistance. 

f. Brief Summary of Comments We Are 

Not Addressing 

In response to the July 6, 2005 interim 

final rule with comment, we received 

comments on a wide variety of issues 

related to the CAP. This final rule with 

comment addresses those issues that are 

most urgent to begin CAP 

implementation. Other issues raised in 

the comments will be fully considered 

and addressed at a later time. 

Among the comments we are not 

addressing at this time are comments 

related to rural operational issues, the 

impact of CAP delivery times on 

satellite clinics, restrictions on 

transporting drugs, the 14 day 

participating CAP physician billing 

requirement, impact on clinical 

research, and licensure requirements for 

CAP pharmacies and distributors. 

I. Private Contracts and Opt-Out 

Provision 

Section 4507 of the BBA of 1997 

amended section 1802 of the Act to 

permit certain physicians and 

practitioners to opt-out of Medicare if 

certain conditions were met, and to 

provide through private contracts 

services that would otherwise be 

covered by Medicare. 

When a physician or practitioner fails 

to maintain the conditions necessary for 

opt-out and does not take good faith 

efforts to correct his or her failure to 

maintain opt-out, current regulations at 

§ 405.435(b) specify the consequences to 

that physician or practitioner for the 

remainder of that physician’s or 

practitioner’s 2-year opt-out period. 

However, § 405.435(b) describes a 

situation where the Medicare carrier 

notifies the physician or practitioner 

that he or she is violating the 

regulations and the statute. As 

explained in the August 8, 2005 

proposed rule, the current regulations 

do not address the consequences to 

physicians and practitioners in 

situations when a condition resulting in 

failure to maintain opt-out occurs 

during the 2-year opt-out period, but a 

Medicare carrier does not discover or 

give notice of a physician’s or 

practitioner’s failure to maintain opt-out 

during the 2-year opt-out period. We 

proposed to amend § 405.435 in order to 

clarify that the consequences specified 

in § 405.435(b) for the failure on the part 

of a physician or practitioner to 

maintain opt-out will apply regardless 

of whether or when a carrier notifies a 

physician or practitioner of the failure 

to maintain opt-out. We also proposed 

to add a new paragraph (d) to clarify 

that in situations where a violation of 

§ 405.435(a) is not discovered by the 

carrier during the 2-year opt-out period 

when the violation actually occurred, 

then the requirements of § 405.435(b)(1) 

through (b)(8) would be applicable from 

the date that the first violation of 

§ 405.435(a) occurred until the end of 

the opt-out period during which the 

violation occurred (unless the physician 

or practitioner takes good faith efforts to 

restore opt-out conditions, for example, 

by refunding the amounts in excess of 

the charge limits to beneficiaries with 

whom he or she did not sign a private 

contract). These good faith efforts must 

be made within 45 days of any notice 

by the carrier that the physician or 

practitioner has failed to maintain optout (where the carrier discovers the 

failure after the 2-year opt-out period 

has expired), or within 45 days after the 

physician or practitioner has discovered 

the failure to maintain opt-out, 

whichever is earlier. 

Comment: One commenter stated that 

having physicians suffer regulatory 

consequences for failure to maintain 

opt-out status, even when they are not 

notified of their status, would be unfair 

and discouraging. They recommended 

that Medicare carriers be required to 

notify physicians of their opt-out status 

60 days before any actions are taken 

against them. 

Response: The revision to § 405.435 

does not instruct Medicare carriers to 

take action against physicians without 

sufficient notice to the physician. In 

situations where a physician or 

practitioner fails to maintain opt-out 

and the carrier discovers that violation 

either during the physician’s or 

practitioner’s opt-out period or after it 

expires, carriers will notify the 

physician or practitioner of the violation 

and the physician or practitioner will 

have 45 days from the date of the 

carrier’s notice to correct that violation. 

Similarly, in the situation where the 

physician or practitioner discovers that 

he or she has failed to maintain opt-out, 

the physician or practitioner will be on 

notice that unless he or she takes 

corrective action within 45 days the 

provisions of § 405.435(b)(1)–(b)(8) are 

applicable. We do not agree with the 

commenter’s suggestion that the 45-day 

period for taking corrective action 

should begin in all cases until the 

carrier sends a notice, that is, including 

situations in which the physician or 

practitioner discovers the failure to 

maintain opt-out. If physicians and 

practitioners were permitted to 

intentionally violate their opt-out 

responsibilities, or ignore unintentional 

violations that they discovered 

subsequently, until the carrier notifies 

the physician or practitioner of the 

violation, harm to both beneficiaries and 

the program could result. For example, 

beneficiaries could enter into private 

contracts that do not meet the notice 

requirements of § 405.415 or the 

Medicare program could make mistaken 

payments due to the physician or 

practitioner billing Medicare in 

violation of § 405.425. In order to 

minimize these harms when a physician 

or practitioner discovers a failure to 

maintain opt-out, we believe the 45-day 

period should begin on the date the 

failure to maintain opt-out is 

discovered, not at some later date when 

a carrier discovers the failure and gives 

notice. 

Comment: One commenter stated that 

the proposed rule would establish 

regulations that address situations 

where a physician or practitioner that 

has opted out of the Medicare program 

fails to maintain the requirements of 

their status. In particular, the proposed 

regulatory language would provide 

physicians or practitioners that have 

opted out of the Medicare program 45 

days to correct the violation. The 

commenter believes these regulations 

are reasonable as proposed. However, 

the commenter urges the agency to 

establish standardized language for the 

violation notice and clear guidelines for 

carriers to execute timely notice of optout violation. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70261 

Response: The CMS Internet-Only 

Manual (Publication 100–2, chapter 15, 

section 40.12) currently provides 

Medicare’s carriers with standardized 

guidelines regarding the notice to 

physicians and practitioners, and the 

actions to take, in cases of failure to 

maintain opt out status. 

We are finalizing our proposed 

changes to § 405.435 (b) and adding new 

paragraph (d) as proposed. 

J. Multiple Procedure Payment 

Reduction for Diagnostic Imaging 

As explained in the August 8, 2005 

proposed rule (70 FR 45849), diagnostic 

imaging procedures are priced in the 

following three ways: 

• The professional component (PC) 

represents the physician work, that is, 

the interpretation. 

• The technical component (TC) 

represents PE, that is, clinical staff, 

supplies, and equipment. 

• The global service represents both 

PC and TC. 

Under the resource-based PE 

methodology, specific PE inputs of 

clinical labor, supplies, and equipment 

are used to calculate PE RVUs for each 

individual service. We do not believe 

these same inputs are needed to perform 

subsequent procedures. When multiple 

images are taken in a single session, 

most of the clinical labor activities and 

most supplies are not performed or 

furnished twice. In addition, equipment 

time and indirect costs are allocated 

based on clinical labor time; therefore, 

these inputs should be reduced 

accordingly. Excluding these PE inputs, 

which we believe are duplicative, 

supports a 50 percent reduction in the 

payment for the TC of subsequent 

procedures. A reduction of 50 percent is 

also currently used in the multiple 

procedure payment reduction for 

surgery, which has been a longstanding 

policy. 

Therefore, we proposed extending the 

multiple procedure payment reduction 

to the TC of specific procedures listed 

in Table 29 of the August 8, 2005 

proposed rule (70 FR 45850). Table 29 

identified 11 families of imaging 

procedures by imaging modality 

(ultrasound, CT and computed 

tomographic angiography (CTA), MRI 

and magnetic resonance angiography 

(MRA)), and contiguous body area (for 

example, CT and CTA of Chest/Thorax/ 

Abdomen/Pelvis). We proposed 

applying the reduction only to 

procedures involving contiguous body 

areas within a family of codes, not 

across families, and to those multiple 

procedures that were provided in one 

session. We also proposed only to apply 

the multiple procedure payment 

reduction to the TC of certain 

procedures because, while we believe 

there may be some reduction in 

physician work associated with the 

performance of multiple diagnostic 

imaging procedures on contiguous body 

areas, we have no specific plans to 

extend the proposal to the PC. In 

addition, since the global service 

payment equals the combined PC and 

TC components, when the global service 

code is billed for these procedures, the 

TC would be reduced to the same as 

above, but the PC would be paid in full. 

We proposed making full payment for 

the TC of the highest priced procedure 

and payment at 50 percent of the TC for 

each additional procedure. 

Comment: Several commenters 

supported our proposal, and described 

it as appropriate, reasonable, justified, 

rational, and consistent with the private 

sector. One commenter suggested 

extending the proposal to the 

professional component. Two other 

commenters stated that it should not be 

applied to the professional component. 

One commenter suggested applying the 

reduction to noncontiguous body areas 

imaged using the same modality. 

Another commenter indicated an 

understanding of the rationale for the 

proposal but did not want it extended 

to traditional radiographs. 

Response: We appreciate the 

commenters’ support. We currently 

have no plans to extend our proposal to 

incorporate the commenters’

suggestions (that is, to include 

noncontiguous body areas, other 

radiologic examinations, or the 

professional component of imaging 

services). We are not certain whether 

and to what degree a multiple procedure 

payment reduction policy would be 

appropriate in these types of situations. 

Comment: Several commenters 

opposed our proposal on the basis that 

diagnostic imaging is not comparable to 

surgery. For example, they noted that 

diagnostic imaging is not paid as part of 

a global package of services; its pre and 

post activities and resources are 

typically not as extensive as those 

required for surgery, and so should 

comprise a much smaller portion of the 

payment than for surgery; and it is 

highly capital intensive compared to 

surgery. One commenter stated that 

nuclear medicine procedures were 

inappropriately discounted and should 

not serve as precedent for discounting 

diagnostic imaging procedures. 

Response: We agree that diagnostic 

imaging procedures are not comparable 

to surgical procedures and did not base 

the development of the multiple 

imaging procedure payment reduction 

policy on specific comparisons with the 

reductions applicable to multiple 

surgical procedures. Instead, with 

findings from the MedPAC 

recommendation about a multiple 

imaging procedure reduction, detailed 

information regarding current imaging 

reduction payment policies in the 

private insurance industry, and our 

analysis of PE data, we believe that the 

rationale for the proposed reduction is 

sound. The 50 percent reduction was 

specifically founded upon wellestablished and professionally accepted 

data we examined from the PEAC, as 

described below, and was not based 

simply on the fact that a 50 percent 

reduction is applied to multiple surgical 

procedures. In addition, the reduction 

for six nuclear medicine procedures has 

been in effect for 11 years. During that 

time, we have received no evidence to 

indicate that it is not appropriate. 

Nevertheless, we did not base our 

multiple imaging procedure reduction 

policy on comparisons with nuclear 

medicine procedures. 

Comment: Numerous commenters 

agreed that some clinical labor 

activities, supplies, and equipment are 

not duplicated for subsequent 

procedures. Other commenters 

indicated exactly the opposite (that is, 

that these items, including some portion 

of scanning time, are duplicated). In 

addition, some commenters indicated 

that where equipment adjustments are 

required between studies, clinical labor 

time could actually increase when 

multiple imaging procedures are 

performed on the same patient during a 

single session. 

The majority of commenters agreed 

that there are some efficiencies when 

multiple procedures are performed but 

disagreed that all the activities we listed 

above are never duplicated. Therefore, 

they disagreed that the efficiencies 

achieved in subsequent procedures 

support a 50 percent reduction. Many 

commenters indicated that a 50 percent 

reduction is arbitrary and that we 

provided no supporting data. Several 

commenters suggested that the 

reduction should be somewhere 

between 5 and 25 percent. The ACR 

offered several suggestions on the 

relative level of reduction among 

families of procedures, for example, that 

the reduction for the procedures in 

family four should be less than for 

family two; and that the reduction for 

procedures in family seven should be 

less than for family two, but greater than 

for family four. However, they provided 

no specific percentages for the 

reductions in each family. 

A few commenters recommended 

varying the percentage reduction by 

modality because efficiencies are not 

70262 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

uniform across all families of 

procedures. Two commenters indicated 

that the proposal was inconsistent with 

the mandate to make resource-based PE 

payments. Specific comments included 

the following: 

• For ultrasound procedures, all 

clinical labor activities except for 

greeting the patient, are duplicated. 

• For some CTs, repositioning the 

patient is necessary. Some CTs require 

multi-phasic contrast injections that are 

separately scanned. 

• For CTs, MRIs and MRAs, the 

number of prior exams for review before 

the studies are performed has increased 

significantly. 

• Some CTs, CTAs, MRIs, and MRAs 

require more images, slices or pulse 

sequences. 

• For brain MRIs and neck MRAs, it 

is necessary to remove the patient; 

change from a head coil to a 

neurovascular coil; retune the coil; enter 

multiple new scan parameters; 

reposition the patient; and run a new set 

of pulse sequences. The patient often 

requests a break between procedures. 

Several commenters recommended 

delaying implementation of the 

proposal for 1 year pending further 

study. Their reasons included: 

postponing until the PE inputs are fully 

implemented and clearly defined; 

deferring until the entire PFS 

methodology is reassessed; and delaying 

until MedPAC’s other imaging study 

recommendations are implemented. 

Two commenters suggested that we 

phase-in the reduction. The ACR offered 

to work with CMS to reexamine the 

procedures subject to the reduction; 

reconfigure the families of procedures; 

and, determine appropriate reductions 

based on modality family. 

Response: We indicated in the 

proposed rule that the following 

activities are not duplicated for 

subsequent procedures: 

• Greeting the patient. 

• Positioning and escorting the 

patient. 

• Providing education and obtaining 

consent. 

• Retrieving prior exams. 

• Setting up the IV. 

• Preparing and cleaning the room. 

In addition, we consider supplies, 

with the exception of film, are not 

duplicated for subsequent procedures. 

Therefore, the 50 percent reduction for 

subsequent procedures is based on 

eliminating the time for the clinical 

labor activities noted above, plus 

supplies, with the exception of film. We 

do not assume any reduction in 

procedure (scanning) time or equipment 

for subsequent procedures. However, as 

noted in the proposed rule, equipment, 

time, and indirect costs are allocated 

based on clinical labor time; therefore, 

these inputs were reduced accordingly. 

The 50 percent reduction was 

determined based on the examination of 

multiple pairs of procedure codes from 

the families representing all modalities 

(that is, ultrasound, CT/CTA, and 

MRI/MRA studies) that were frequently 

performed on a single day based on 

historical claims data. Using PE input 

data provided by the RUC, we factored 

out the clinical staff minutes for the 

activities we indicated are not 

duplicated for subsequent procedures, 

and the supplies, other than film, which 

we consider are not duplicated for 

subsequent procedures. As noted 

previously, equipment time and indirect 

costs are allocated based on clinical 

labor time; therefore, these inputs were 

reduced accordingly. Removing the PE 

inputs for activities that are not 

duplicated, and adjusting the equipment 

time and indirect costs for the 

individual pairs of procedures studied, 

supports payment reductions ranging 

from 40 to 59 percent for the subsequent 

services. Because we found a relatively 

narrow range of percentage payment 

reductions across modalities and 

families, and taking into consideration 

that we did not eliminate any 

duplicative image acquisition time for 

subsequent procedures in our analysis, 

we decided that an across-the-board 

reduction for all 11 families of 50 

percent (which is approximately the 

midpoint of the range established 

through our analysis) was both justified 

and conservative. We believe this 

payment reduction policy represents an 

appropriate reduction for the typical 

delivery of multiple imaging services in 

all 11 families. Because the reduction is 

based on eliminating the specific 

practice expense inputs that are not 

duplicated, we believe the proposal is 

consistent with the resource-based 

practice expense methodology. 

While various alternative reduction 

percentages were suggested, no 

evidence was presented to support 

specific alternative percentages. 

However, we recognize that many 

commenters raised significant 

objections and we appreciate their 

comments indicating their specific 

concerns regarding the appropriate 

reductions for each family and specific 

combinations of services within 

families. 

To allow for a transition of the 

changes in payments for these services 

attributable to this reduction policy, and 

provide a further opportunity for 

comment, we have decided to phase-in 

the policy over 2 years. We will 

implement a 25 percent payment 

reduction in CY 2006 and a 50 percent 

reduction for all 11 families in CY 2007 

for all code families, unless we find 

upon further review during the 

upcoming year that modifications to this 

policy are appropriate. To enhance our 

review, we are soliciting, from providers 

of diagnostic imaging services, 

comprehensive data regarding the 

efficiencies associated with different 

combinations of imaging services in the 

11 families. We welcome the 

opportunity to have other discussions 

with the physician community on these 

issues. 

Comment: One commenter noted that 

a patient having both a pelvic and 

transvaginal ultrasound often needs a 

break between procedures and requires 

repositioning, along with the use of a 

different probe for the second study. 

The commenter also noted that breast 

and pelvic ultrasounds are often 

performed in different locations and by 

different physicians. 

Response: The commenter has raised 

some serious questions concerning 

whether any payment reduction is 

appropriate for the procedures 

indicated. Therefore, we have decided 

to delete transvaginal ultrasound and 

ultrasound of the breast(s) (CPT codes 

76830 and 76645, respectively) from the 

list of procedures in family one subject 

to the payment reduction, pending 

further study. We believe there may be 

common clinical scenarios where these 

services are provided in combination 

with other ultrasound studies where 

payment reduction may not be 

appropriate. These typical efficiencies 

associated with these services when 

provided in combination with other 

studies in family one require further 

study. 

Comment: Many commenters asked 

how ‘‘single session’’ is defined and 

what mechanism will be used to 

distinguish single and multiple 

sessions. One commenter indicated that 

multiple procedures are frequently 

performed in separate rooms within the 

radiology department or in different 

areas within the hospital. In these cases, 

the patient must be transported from 

one room to another and the process 

restarted. One commenter noted the 

potential for abuse by self-referring 

physicians writing separate 

prescriptions for studies on different 

days. Another commenter indicated that 

the proposal will force providers to 

schedule further studies on additional 

days. 

Response: We consider a single 

session to be one encounter where a 

patient could receive one or more 

radiological studies. If more than one of 

the imaging services in a single family 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70263 

is provided to the patient during one 

encounter, then this would constitute a 

single session and the lower-priced 

procedure(s) would be reduced. On the 

other hand, if a patient has a separate 

encounter on the same day for a 

medically necessary reason and receives 

a second imaging service from the same 

family, we consider these multiple 

studies in the same family on the same 

day to be provided in separate sessions. 

In the latter case, we have established 

that the physician should use modifier 

-59 to indicate multiple sessions, and 

that the multiple procedure reduction 

does not apply. Medicare carriers will 

establish edits to ensure that separate 

sessions are not inappropriately 

scheduled for contiguous body area 

imaging in attempts to bypass the 

reduction. Use of the modifier where 

not medically necessary in order to 

bypass the payment reduction 

constitutes fraud. 

Comment: One commenter suggested 

that the proposal required multiple 

body area imaging whenever a 

procedure in a particular family was 

performed, resulting in unnecessary 

imaging. Another commenter stated that 

grouping procedures to justify lower 

reimbursement provides no medical or 

monetary benefit and is detrimental to 

patient care. 

Response: It appears the commenters 

have misinterpreted our proposal. The 

proposal in no way requires the 

performance of unnecessary multiple 

imaging procedures when only a single 

study is medically necessary. The 

families of procedures are based on 

claims data indicating that these 

procedures are often done in 

combination, most likely in a single 

session. We believe that the payment 

reduction for the lower-priced imaging 

procedures from one family performed 

on contiguous body areas provides the 

most appropriate payments for the 

services provided. 

Comment: A few commenters 

recommended that we apply the budget 

neutrality adjustment only to PE RVUs 

and not to work RVUs. 

Response: The commenters are correct 

that, because the payment reduction 

applies only to PE RVUs, the savings 

should likewise only apply to PE RVUs. 

We agree with this comment and have 

made the necessary adjustment. 

Comment: One commenter indicated 

that we should request a statutory 

change to exempt the proposal from 

budget neutrality. 

Response: We believe it is up to the 

Congress to decide whether it wants to 

make adjustments to the application of 

budget neutrality. We have no plans to 

request this change. 

Final Decision 

We have revised our proposal as 

follows: 

• Phase in the payment reduction, 

with a 25 percent reduction in CY 2006 

and a 50 percent reduction in CY 2007. 

Our review of the multiple imaging 

payment reduction policy will be 

ongoing. 

• Deleting CPT codes 76830 and 

76645 from the list of procedures in 

family one subject to the reduction, 

pending further study. 

• Applying the budget neutrality 

adjustment only to PE RVUs, rather than 

to both work and PE RVUs. 

An example of the current and CY 

2006 payments is summarized in Table 

26, and the revised lists of procedures 

subject to the reduction, are set forth in 

Table 27: 

TABLE 26.—EXAMPLE OF PAYMENTS

Procedure 1 

74183 

Procedure 2 

72196 

Current total 

payment 

CY 2006 total 

payment CY 2006 payment calculation 

PC ............................ $117.00 $90.00 $207.00 $207.00 no reduction. 

TC ............................ 978.00 529.00 1,507.00 1,374.75 978 + (.75 × $529). 

Global ....................... 1,095.00 619.00 1,714.00 1,581.75 $207 + $978 + (0.75 × $529). 

BILLING CODE 4120–01–U 

70264 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 


ER21NO05.054</GPH>
Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70265 

BILLING CODE 4120–01–C 


ER21NO05.055</GPH>
70266 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

K. Therapy Cap 

As discussed in the August 8, 2005 

proposed rule, section 1833(g)(1) of the 

Act applies an annual, per beneficiary 

combined cap on outpatient physical 

therapy and speech-language pathology 

services, and a similar separate cap on 

outpatient occupational therapy services 

under Medicare Part B. While Section 

624 of the MMA placed a moratorium 

on the application of these caps from 

December 8, 2003 through December 31, 

2005, the caps will become effective 

again beginning January 1, 2006. (The 

caps were last implemented from 

September 1, 2003 through December 7, 

2003.) Section 1833(g)(2) of the Act 

provides that, for 1999 through 2001, 

the caps were $1500, and for years after 

2001, the caps are equal to the 

preceding year’s cap increased by the 

percentage increase in the MEI (except 

that if an increase for a year is not a 

multiple of $10, it is rounded to the 

nearest multiple of $10). 

All of the comments we received 

questioned the use of therapy caps as a 

way to ensure beneficiaries get needed 

service while constraining the growth in 

spending. The large majority also 

pointed out the negative effects the 

therapy caps had on beneficiaries and 

providers when they were last 

implemented. However, most of the 

commenters recognized that we do not 

have the authority to change the caps. 

Commenters also wrote in support of an 

extended moratorium; separating 

physical therapy and speech-language 

pathology into two caps; a conditionbased payment system; a pay-forperformance system; and a 

demonstration to assess one or more 

alternative limitation methods. 

We will implement therapy caps on 

January 1, 2006 according to the statute. 

We note that significant progress has 

been made toward the challenging goal 

of establishing a payment policy ‘‘based 

on the classification individuals’’ as 

required by the Congress in the BBA 

section 4541(d)(2) and again in the 

BBRA section 221(c)(2)(B). First, in 

order to evaluate Medicare payments for 

therapy services, we developed a 

method of identifying therapy services 

and their individual costs on Medicare 

claim lines. Then, we identified 

classification groups and conducted 

initial analyses of the type and amount 

of treatment utilized by each group. 

These 21 classification groups consisted 

of patients whose conditions were 

similar based on ICD–9 diagnosis codes, 

utilization patterns, published research 

and clinical opinion that indicated they 

may have similar health risk and require 

similar level of care and expenditures 

for service. For example, spinal cord 

injury, hip fracture, and 

musculoskeletal disorders form 

classifications that include many similar 

diagnoses. This demonstrated that if the 

expected need for service can be 

determined for subsets of each 

classification group, system edits that 

limit spending based on expected needs 

are feasible and would result in cost 

savings. To implement a payment 

method based on the conditions 

described by classification groups, 

additional information is needed on the 

claim about the patient’s need for 

therapy services. Indicators or 

measurements that represent need, such 

as severity and acuity of a patient’s 

condition, are not available on the 

current Medicare claim form and are not 

consistently gathered or reported by 

therapists. In order to be useful, these 

factors must be obtained from a 

sufficiently large database of patients to 

predict patients’ needs with statistical 

validity and reliability. We currently 

have studies underway to extend the 

progress made in prior studies to 

explore the potential for using patient 

condition information to predict therapy 

needs and likely outcomes. We expect 

these studies to be completed in 2006. 

After issuance of this rule, we will 

issue instructions to contractors related 

to the implementation of therapy caps. 

We will consider comments received in 

response to the August 8, 2005 proposed 

rule as we develop those instructions. 

Since 2003, we have maintained, and 

we recently updated, a web site that 

describes therapy caps. We encourage 

providers and beneficiaries to review 

that information at www.cms.hhs.gov/ 

medlearn/therapy (Therapy Cap Status). 

Based on the formula established in 

1883(g)(2) of the Act, the therapy caps 

will be implemented January 1, 2006. 

The dollar amount for the therapy caps 

for CY 2006 is $1,740. 

L. Chiropractic Demonstration 

Discussion 

Section 1861(r)(5) of the Act limits 

current Medicare coverage for 

chiropractic treatment by means of the 

manual manipulation of the spine for 

the purpose of correcting a subluxation, 

defined generally as a malfunction of 

the spine. Specifically, Medicare covers 

three CPT Codes provided by 

chiropractors: 98940 (manipulative 

treatment, 1–2 regions of the spine); 

98941 (manipulative treatment, 3–4 

regions of the spine); and 98942 

(manipulative treatment, 5 regions of 

the spine). Treatment must be provided 

for an active subluxation only, and not 

for prevention or maintenance. 

Additionally, treatment of the 

subluxation must be related to a 

neuromusculoskeletal condition where 

there is a reasonable expectation of 

recovery or functional improvement. 

In the August 8, 2005 proposed rule, 

we included a discussion of the 2-year 

demonstration authorized by Section 

651 of the MMA to evaluate the 

feasibility and advisability of covering 

additional chiropractic services under 

Medicare. These services extend beyond 

the current coverage for manipulation to 

care for neuromusculoskeletal 

conditions typical among eligible 

beneficiaries, and cover diagnostic and 

other services that a chiropractor is 

legally authorized to perform by the 

State or jurisdiction in which the 

treatment is provided. Physician 

approval will not be required for these 

services. The demonstration is being 

conducted in four sites, two rural and 

two urban. One site of each area type 

must be a health professional shortage 

area (HPSA). The demonstration must 

also be budget neutral. The statute 

requires the Secretary to ensure that 

aggregate payments made under the 

Medicare program do not exceed those 

that would be paid in the absence of this 

demonstration. 

Ensuring budget neutrality requires 

that the Secretary develop a strategy for 

recouping funds should the 

demonstration result in costs higher 

than would occur in the absence of the 

demonstration. In this case, we would 

make adjustments in the national 

chiropractor fee schedule to recover the 

costs of the demonstration in excess of 

the amount estimated to yield budget 

neutrality. We will assess budget 

neutrality by determining the change in 

costs based on a pre/post comparison of 

costs and the rate of change for specific 

diagnoses that are treated by 

chiropractors and physicians in the 

demonstration sites and control sites. 

We will not limit our analysis to 

reviewing only chiropractor claims, 

because the costs of the expanded 

chiropractor services may have an 

impact on other Medicare costs. 

Any needed reduction would be made 

in the CY 2010 and CY 2011 fee 

schedules as it will take approximately 

2 years to complete the claims analysis. 

If we determine that the adjustment for 

budget neutrality is greater than 2 

percent of spending for the chiropractor 

fee schedule codes (comprised of the 3 

currently covered CPT codes 98940, 

98941 and 98942), we will implement 

the adjustment over a 2-year period. 

However, if the adjustment is less than 

2 percent of spending under the 

chiropractor fee schedule codes, we will 

implement the adjustment over a 1-year 

period. We will include the detailed 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70267 

analysis of budget neutrality and any 

proposed offset in the CY 2009 Federal 

Register publication of the PFS. 

We also noted in the proposed rule 

that PT services performed by 

chiropractors under the demonstration 

will be included under the PT cap 

described in section II.K. of the 

preamble to this final rule with 

comment. These services are included 

under the cap because chiropractors are 

subject to the same rules as medical 

doctors for therapy services under the 

demonstration. 

The following is a summary of the 

comments received and our responses. 

Comment: Several commenters 

expressed concern regarding specific 

aspects of the demonstration project, 

including PT services being provided by 

chiropractors and including the PT 

services provided by chiropractors 

under the demonstration under the 

therapy cap. 

Response: A discussion of the 

chiropractic demonstration was 

included in the PFS proposed rule 

because of the potential for a budget 

neutrality adjustment that will be 

discussed in the CY 2009 Federal 

Register publication of the PFS. Issues 

concerning the demonstration project 

itself were outside the scope of the 

proposed rule. We are including PT 

services provided by chiropractors 

under the therapy cap because under 

the demonstration, we are subjecting 

chiropractors to the same rules as 

physicians for therapy services. 

Comment: One commenter suggested 

that in the calculation of the budget 

neutrality of the demonstration project 

that the therapy rendered by the 

chiropractors or their therapists is a 

‘‘trade off’’ of associated costs that 

would have required evaluation, order 

and recertification by a medical doctor. 

They also suggested that the 

management of neuromuscular 

conditions is more efficient when all 

contributing factors are identified and 

addressed simultaneously by the 

combined skills of each specialty. The 

patient would normally learn to 

function more rapidly through 

concurrent multidisciplinary 

management than with any limited 

single approach. In addition, the 

commenters noted that to accurately 

assess the demonstration a variety of 

variables, such as medical services that 

were not required or services directly 

replaced by another provider, need to be 

considered. 

Response: Section 651(a)(1) specified 

that the chiropractic services provided 

under the demonstration should include 

diagnostic and other services that a 

chiropractor is legally authorized to 

perform by the State or jurisdiction in 

which the treatment is provided. There 

is no requirement for concurrent 

multidisciplinary management of 

neuromuscular conditions. We 

recognize that covering additional 

services by chiropractors could have an 

impact on currently covered Medicare 

services. For this reason, we plan to 

assess budget neutrality by examining 

the total Medicare costs for specific 

diagnoses, and not just the chiropractor 

costs. As we noted previously, we will 

provide a detailed analysis of budget 

neutrality and any proposed offset in 

the CY 2009 Federal Register 

publication of the PFS. 

Comment: Commenters requested that 

we clarify plans for making reductions 

to maintain budget neutrality and 

identify claims we will analyze. The 

commenters also requested that we 

provide information on how this will 

impact the SGR, particularly if the 

chiropractic demonstration results in 

increased spending on physicians’

services, since this could result in 

reductions in reimbursement for all 

physicians, not just chiropractors. 

Another commenter opposed the 

application of any adjustments to the 

national chiropractic fee schedule 

instead of an adjustment to the overall 

fee schedule. This commenter believes 

that the totality of funds under part B 

and not subset of services within it 

should finance the demonstration 

program and that this is reflected in 

section 651(f)(A)of the MMA. 

Response: Section 651(f)(A) requires 

that ‘‘* * * the Secretary shall ensure 

that the aggregate payment made by the 

Secretary under the Medicare program 

do not exceed the amount which the 

Secretary would have paid under the 

Medicare program if the demonstrations 

projects under this section were not 

implemented.’’ The legislation does not 

specify a specific methodology for 

ensuring budget neutrality. Our 

methodology meets the legislative 

intent, and appropriately impacts the 

profession that is directly affected by 

the demonstration. 

Because the demonstration is located 

in only four sites in which the 

expansion of services is permitted, we 

anticipate that the impact on the SGR 

would be negligible. 

M. Supplemental Payments to Federally 

Qualified Health Centers (FQHCs) 

Subcontracting With Medicare 

Advantage (MA) Plans 

Section 237 of the MMA amended 

section 1833(a)(3) of Act to provide 

supplemental payments to FQHCs that 

contract with Medicare Advantage (MA) 

organizations to cover the difference, if 

any, between the payment received by 

the FQHC for treating enrollees in MA 

plans offered by the MA organization 

and the payment that the FQHC is 

entitled to receive under the cost-based 

all-inclusive payment rate as set forth in 

part 405, subpart X. The supplemental 

payment for covered Medicare FQHC 

services furnished to MA enrollees 

augments the direct payments made by 

MA plans to FQHCs for covered 

Medicare FQHC services. 

In order to implement this new 

payment provision, we must determine 

whether the Medicare cost-based 

payments to which the FQHC would be 

entitled exceed the amount of payments 

received by the center from the MA 

organization and, if so, pay the 

difference to the FQHC. 

The proposed supplemental payment 

for FQHC covered services rendered to 

MA enrollees is equal to the difference 

between 100 percent of the FQHC’s allinclusive cost-based per-visit rate and 

the average per-visit rate received by the 

FQHC from the MA plan in which the 

enrollee is enrolled, less any amount the 

FQHC may charge as described in 

section 1857(e)(3)(B) of the Act. 

A supplemental payment will be 

made every time a face-to-face 

encounter occurs between an MA 

enrollee and any one of the FQHC’s core 

practitioners: physician, nurse 

practitioner, physician assistant, clinical 

nurse midwife, clinical psychologist, or 

clinical social worker. The 

supplemental payment is made directly 

to each FQHC through the Medicare 

Fiscal Intermediary (FI). 

In the August 8, 2005 proposed rule, 

we proposed conforming changes to our 

regulations to add § 405.2469 to provide 

a supplemental payment, based on a 

per-visit calculation, to FQHCs under 

contract (directly or indirectly) with MA 

organizations. 

We received comments on the portion 

of the proposed rule addressing the 

FQHC supplemental payment provision 

of section 237 of the MMA. A summary 

of those comments and our responses 

follows: 

Comment: One commenter asked how 

the Medicare contractor will know the 

amount the health plan paid when 

FQHCs bill the Medicare contractor for 

the supplemental payment. 

Response: The Medicare contractor 

will know the amount paid by the MA 

plan based on the required MA payment 

estimate furnished by the FQHC to the 

contractor. The payment amount 

difference between the interim FQHC 

all-inclusive cost based rate and the 

average interim MA rate will be 

reported on the FQHC claim form every 

time the FQHC submits a bill to the 

70268 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

contractor to collect an FQHC 

supplemental payment. The Medicare 

contractor will pay FQHCs the 

difference between the interim FQHC 

all-inclusive rate and the interim MA 

rate on a per-visit basis. 

Comment: A commenter requested 

clarification regarding cost sharing rules 

for MA enrollees as referenced in 

§ 405.2469(a)(ii), which stipulates that 

FQHCs may charge Medicare patients as 

described in section 1857(e)(3)(B) of the 

Act. 

Response: Section 1857(e)(3)(B) of the 

Act provides that a FQHC must accept 

the MA payment and the Federal 

supplemental payment (that is, the 

payment decribed in section 

1833(a)(3)(B)) as payment in full for 

services covered by the agreement, 

except that the FQHC may collect any 

amount of cost-sharing permitted under 

the MA contract, so long as the amounts 

of any deductible, coinsurance, or copayment comply with the requirements 

under section 1854(e) of the Act. In 

general, an MA plan offered by an MA 

organization satisfies section 1854(e) of 

the Act beginning in 2006 if the 

monthly basic MA premium and the 

actuarial value of the cost sharing 

charged to enrollees for services covered 

under Parts A and B of original 

Medicare do not exceed the actuarial 

value of cost sharing charged to 

beneficiaries in original Medicare. MA 

plans must also disclose cost sharing 

amounts to their members. 

Comment: Two commenters urged us 

to deduct from the supplemental 

payment calculation only the amount of 

cost-sharing actually collected by the 

FQHC. Furthermore, the commenters 

asked that we recognize any uncollected 

cost-sharing amounts as ‘‘bad debt’’ on 

the FQHC cost report. 

Response: The supplemental payment 

calculation shall deduct the cost sharing 

amounts set forth in the formal contract 

between the FQHC and MA plan, not 

the actual amounts collected by the 

FQHC. Section 1833(a)(1)(B) states that 

the supplemental payment is to be 

calculated net of any amount the FQHC 

‘‘may charge’’ as described in section 

1857(e)(3)(B) of the Act. Thus the 

language of the statute plainly states 

that the supplemental payment is to be 

based on what the FQHC could charge 

as cost sharing, not cost sharing 

amounts that the FQHC actually 

collects. 

Rules regarding what may constitute 

‘‘bad debt’’ for purposes of a FQHC’s 

cost report are beyond the scope of this 

final rule with comment. Furthermore, 

the rules we are finalizing pertain to 

section 237 of the MMA which 

addresses a supplemental payment to 

FQHCs that contract, directly or 

indirectly, with an MA organization. 

Thus, arrangements pertaining to ‘‘bad 

debt’’ for uncollected cost sharing owed 

by an MA plan enrollee, if any, would 

be governed by the contract between the 

FQHC and the MA organization. 

Comment: A commenter questioned 

whether the upper payment limit would 

apply in determining the supplemental 

payment. 

Response: For FQHCs operating below 

the FQHC national payment limit, we 

will use their actual per-visit allinclusive rate to determine the FQHC 

supplemental. For FQHCs operating at 

or above the national payment limit, we 

will use the applicable national FQHC 

urban or rural upper limit to calculate 

the FQHC supplemental payment. The 

amount of the supplemental payment 

will be the amount by which the 

original FQHC payment exceeds the MA 

plan payment. Section 237 of the MMA 

clearly requires the use of a cost-based 

rate or based on other tests of 

reasonableness as the Secretary may 

prescribe in regulations. The 

longstanding national FQHC payment 

limit is an integral part of the FQHC 

payment methodology as set forth in 

regulations. 

Comment: A commenter questioned 

whether the provider types listed on 

page 45853 (Proposed Payment 

Methodology Section) of the August 8, 

2005 proposed rule is broader than the 

original FQHC benefit. 

Response: In the proposed rule, we 

explained that an FQHC supplemental 

payment is made only when a face-toface encounter occurs between a core 

FQHC practitioner and an MA enrollee. 

This list of core FQHC practitioners is 

identical to the practitioner list for the 

original FQHC Medicare benefit. 

Furthermore, these FQHC practitioners 

must meet all applicable qualification 

requirements as set forth in section 405 

and 491 of the CFR in order to qualify 

for the supplemental payment. 

Comment: A commenter requested 

that we amend the regulatory definition 

of eligible centers for the FQHC 

supplemental payments to allow 

payments for health centers for the 

homeless. The preamble of the proposed 

rule states that eligible FQHCs include 

all centers receiving grants under 

Section 330 except those centers that 

receive funds pursuant to Section 330(h) 

of the Public Health Service Act (that is, 

Health Care for the Homeless grantees). 

The commenter specifically requested 

that we recognize these centers for 

supplemental payments, or at a 

minimum, be prepared to do so as soon 

as legislation is passed. 

Response: We currently do not have 

the statutory authority to recognize as 

Medicare FQHCs any entity that does 

not meet statutory requirements for 

designation as an FQHC. Consequently, 

we cannot provide centers that are not 

FQHCs with Medicare FQHC 

supplemental payments for treating MA 

enrollees. If changes were made to the 

statute, we would implement 

regulations, as necessary, consistent 

with statutory requirements. 

Comment: A commenter asked for 

clarification regarding the statement in 

the rule that FQHCs under contract 

(indirectly or directly) with MA 

organizations are eligible for 

supplemental payments. The 

commenter requested specific 

confirmation that the term ‘‘indirect’’ is 

intended to include arrangements under 

which the health center contracts with 

another organization, which in turn, 

contracts with the MA organization in 

order to provide Medicare services. 

Response: We interpreted section 237 

of the MMA to mean that any Medicare 

FQHC furnishing covered FQHC 

services to MA plan enrollees would be 

eligible for supplemental payments 

regardless of whether they have a direct 

contract with an MA organization or 

contract with another entity (for 

example, a medical group) that has a 

direct contract with the MA 

organization to treat its enrollees. 

Comment: A commenter asked 

whether a health center with an MA 

contract can bill Medicare directly on a 

fee-for-service basis if the center 

provides services to plan enrollees that 

are not FQHC services. For example, can 

they directly bill for services the FQHC 

could otherwise bill as Part B services 

if it were not providing the service to an 

MA plan enrollee? A commenter 

requested clarification whether a health 

center will be allowed to bill original 

Medicare for extended hours of 

operation not included under the 

center’s MA arrangement. Another 

commenter asked whether a health 

center that utilizes a specialist, who is 

not included in the MA plan’s specialty 

panel, to provide an FQHC core service 

will be permitted to bill Medicare for 

these services. 

Response: The FQHC should bill 

original Medicare only for covered 

services rendered to original Medicare 

beneficiaries that are ‘‘not’’ enrolled in 

an MA plan. In accordance with section 

1851(i) of the Act, with limited 

exceptions, only the MA organization is 

entitled to receive Medicare payments 

for services furnished to its enrollees. 

Therefore, FQHCs under direct or 

indirect contract with an MA 

organization must look to the MA 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70269 

organization for payment. The 

additional payment permitted by 

section 1833(a)(3)(B) of the Act applies 

only to FQHC services described in 

section 1832(a)(2)(D)(ii) of the Act. 

Comment: A commenter questioned 

whether services not covered under 

original Medicare, but offered and paid 

for by the MA plan, such as dental, are 

included in determining the CMS wraparound payment to the center. 

Response: Only services meeting the 

definition of an FQHC service as 

defined under section 1832(a)(2)(D) of 

the Act are included in the 

determination of the FQHC 

supplemental payment. Thus, services 

other than those defined under section 

1832(a)(2)(D), such as dental services, 

are not included in the determination of 

the supplemental payment. 

Comment: A commenter requested 

that we modify our proposed FQHC 

supplemental payment methodology to 

include Medicare FQHC covered 

services that are not necessarily 

performed as a face-to-face encounter. 

Response: All covered Medicare 

FQHCs services are eligible for 

supplemental payments regardless of 

whether these services trigger a billable 

FQHC visit. For purposes of 

consistency, we adopt the longstanding 

FQHC visit definition under original 

Medicare, which would provide a 

supplemental payment every time there 

is a face-to-face encounter between an 

MA enrollee and one or more of the 

following FQHC covered core 

practitioners: physicians, nurse 

practitioners, physician assistants, 

clinical nurse midwives, clinical 

psychologists, or clinical social workers. 

The costs of services incidental to the 

professional services of the above core 

FQHC practitioners would be bundled 

into the calculation of the supplemental 

payment. In light of the fact that all 

incidental services and costs are 

recognized, we believe that the use of 

the FQHC encounter definition for the 

supplemental payment provision is 

reasonable and appropriate. 

Comment: A commenter requested 

clarification regarding the interim rate 

that should be utilized for these health 

centers in light of the fact that centers 

have yet to have their annual 

reconciliation from 2004 performed. 

Response: The interim rate for MA 

payments will be based on estimates 

from the contracting FQHC until actual 

MA payments and visits are captured on 

the FQHC cost report. We will use these 

estimates until actual MA payments and 

visits are captured on the FQHC cost 

reports. At that point, payments will be 

adjusted accordingly. 

Comment: A commenter asked for 

clarification regarding which fiscal year 

would apply to the rate calculation 

methodology for services rendered on or 

after January 1, 2006—the Federal fiscal 

year, the health center, or the MA plan. 

Furthermore, clarification was requested 

regarding the transition process for 

reconciling differences between centers’

fiscal year and the MA contract year. 

Response: The FQHC supplemental 

payment calculation shall be based on 

the FQHC’s cost report year. For the 

initial year, if the MA plan’s contract 

year and the FQHC’s fiscal year do not 

coincide, the FQHC supplemental 

payment calculation shall be based on a 

weighted average of MA payments 

based on the number of MA visits 

expected in each respective MA contract 

year. In subsequent FQHC cost report 

years, actual MA payments and visits 

will be used to calculate final FQHC 

supplemental payments as well as the 

interim supplemental payments for the 

following year. Since actual payments 

and visits already reflect the differences 

between the FQHC fiscal year and the 

MA contract year, no transition process 

is necessary. 

Comment: A commenter requested 

clarification whether payments will be 

aggregated across multiple MA plans or 

whether the payments will be plan 

specific. 

Response: In cases where an FQHC 

has multiple arrangements in place with 

different MA plans, payments will be 

aggregated across multiple plans to 

determine final Medicare program 

liability. In other words, at cost 

settlement MA payments will be 

aggregated for all MA enrollees treated 

by the FQHC. 

Comment: A commenter expressed 

concern that the required detailed MA 

payment estimates from FQHCs will 

result in a significant increase in 

administrative time. In light of this new 

requirement, they suggested that we 

develop standard forms and information 

requests to ease the burden as much as 

possible. 

Response: Each eligible FQHC seeking 

the supplemental payment is required to 

submit (for the first two rate years) to 

the Medicare Fiscal Intermediary (FI) an 

estimate of the average MA payments 

(per-visit basis) for covered FQHC 

services provided to MA enrollees. 

Every eligible FQHC seeking the 

supplemental payment is required to 

submit a documented estimate of its 

average per-visit payment for MA 

enrollees in each MA plan offered by 

the MA organization and any other 

information as may be required to 

enable the FI to accurately establish an 

interim supplemental payment. 

Expected payments from the MA 

organization would be used only until 

actual MA revenue and visits collected 

on the FQHC’s cost report can be used 

to establish the amount of the 

supplemental payment. Until we modify 

the FQHC cost report form to identify 

and capture MA payments and visits, 

each eligible FQHC requesting 

supplemental payments will be required 

to submit estimates to CMS. 

Comment: A commenter urged us to 

calculate and provide supplemental 

payments on a per-visit basis to ensure 

adequate cash flow to contracting 

FQHCs. 

Response: Under the proposed rule, 

we added § 405.2469 to specify that the 

FQHC supplemental payment 

methodology is on a per-visit basis. 

Comment: A commenter requested 

timely annual system reviews of cost 

reports to ensure that the health centers 

are provided with a continuous cash 

flow of Medicare funding. 

Response: The Medicare contractors 

responsible for processing FQHC claims 

and reviewing cost reports will use all 

available resources for timely cost report 

settlement. 

Comment: A commenter requests that 

we provide guidance under this rule 

regarding the methods of enforcing the 

statutory requirement that MA plan 

payments to contracting FQHCs must be 

comparable to other contracting health 

care providers furnishing similar 

services. 

Response: Generally, we will examine 

contracts and attendant fee schedules 

between MA organizations and FQHCs 

and between MA organizations and 

other providers to ensure that payment 

levels for similar services are 

comparable. 

Comment: A commenter requested 

clarification regarding how our crossover system will work for MA enrollees 

who are dually-eligible for the Medicare 

and Medicaid programs. They asked if 

claims for dually-eligible patients will 

be forwarded to the Medicaid agency by 

the MA plan or by CMS. 

Response: Our crossover processes do 

not apply to MA claims but rather to 

claims that are processed under original 

Medicare, fee-for-service contractor 

operations. Therefore, claims for 

persons who have enrolled in an MA 

plan will not be crossed over by CMS. 

The MA plan would need to coordinate 

with Medicaid. 

Comment: A commenter expressed 

concern about the appeals process for 

circumstances under which the MA 

plan denies a claim, which would result 

in our denial of the supplemental 

payment. They asked what procedures 

70270 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

the health center should follow when 

faced with this situation. 

Response: If an FQHC signs a waiver 

of liability, the FQHC may utilize the 

MA appeals process at 42 CFR part 422, 

subpart M to contest an MA 

organization’s payment denial. If the 

MA organization’s claim denial is 

overturned upon appeal, CMS will make 

a supplemental payment to a FQHC. 

Comment: A commenter requested 

that we work with MA plans on 

establishing an expedited credentialing 

process to ensure that all health center 

providers are credentialed on a timely 

basis, preferably prior to January 1, 

2006. 

Response: The requirements related to 

credentialing MA plan providers are 

found in subpart E the Part 422. Note 

that with limited exceptions, the 

credentialing process that MA 

organizations follow for providers is at 

the MA organization’s discretion (see 

§ 422.204). 

Comment: A commenter requested 

clarification that supplemental 

payments are available for Medicarecovered services provided by FQHCs 

under non-traditional managed care 

approaches, such as Preferred Provider 

Organization (PPOs). 

Response: FQHCs contracting with 

any MA organization are eligible for 

supplemental payments. MA 

organizations can offer various types of 

MA plans, including PPOs. 

We are revising § 405.2469 as 

proposed with one change, the first use 

of the term ‘‘Medicare Advantage plans’’

is revised to read ‘‘Medicare Advantage 

organizations.’’

N. National Coverage Decisions 

Timeframes 

We have established requirements 

concerning the administrative review of 

local coverage determinations (LCDs) 

and National Coverage Determinations 

(NCDs) at 42 CFR part 426, with subpart 

C specifically addressing the general 

provisions for the review of LCDs and 

NCDs. We are updating these 

requirements as they apply to NCDs to 

reflect changes in the statute. 

Under our existing regulations in part 

426, Subpart C, the Departmental 

Appeals Board may stay the 

adjudicatory proceedings in certain 

circumstances to allow CMS to consider 

significant new evidence that is 

submitted in the context of a challenge 

to an NCD. Our previous regulations at 

§ 426.340(e), permitted a brief stay of 

the adjudicatory proceedings (not more 

than 90 days), for CMS to complete its 

reconsideration of the NCD. Those 

timeframes, although short, were 

consistent with the previous process for 

making NCDs that did not require 

publication of a proposed decision 

memorandum and an opportunity for 

public comment on the proposed 

decision memorandum. 

As discussed in the August 8, 2005 

proposed rule (70 FR 45853), based on 

the provisions of section 731 of the 

MMA of 2003, we proposed to amend 

§ 426.340 to state that if the CMS 

informs the Board that a revision or 

reconsideration was or will be initiated, 

then the Board will stay the proceedings 

and set appropriate timeframes by 

which the revision or reconsideration 

will be completed, that reflects 

sufficient time for the publication of a 

proposed determination, a 30-day 

public comment period, and time for 

CMS to prepare a final determination 

that responds to public comments as 

specified in section 1862(l) of the Act. 

We also proposed to eliminate the 

reference to the 90-day reconsideration 

period in § 426.340(e)(3) for NCD 

appeals to reflect the new timeframes in 

the MMA. 

Comment: We received 7 comments 

regarding the proposed NCD 

timeframes. All commenters supported 

the change. However, a few commenters 

raised concerns about the delays 

regarding a specific NCD that was 

initiated before the December 8, 2003 

effective date for the statutory change. 

Response: We will finalize the 

changes to § 426.340 as proposed with 

minor technical edits, and will continue 

to work diligently to assure that all 

NCDs submitted after the December 8, 

2003 effective date for the statutory 

change are developed within the set 

timeframes. 

O. Coverage of Screening for Glaucoma 

On January 1, 2002, we implemented 

regulations at § 410.23(a)(2), Conditions 

for and limitations on coverage of 

screening for glaucoma, requiring that 

the term ‘‘eligible beneficiary’’ be 

defined to include individuals in the 

following high risk categories: 

Individuals with diabetes mellitus; 

individuals with a family history of 

glaucoma; or African-Americans age 50 

and over. As discussed in the August 8, 

2005 proposed rule (70 FR 45853) based 

on our review of the current medical 

literature, we believe that there are other 

beneficiaries who are at risk for 

glaucoma and should be included in the 

definition of eligible beneficiary for 

purposes of the glaucoma screening 

benefit. 

We believe the evidence is adequate 

to conclude that Hispanic persons age 

65 and older are at high risk and could 

benefit from glaucoma screening. 

Therefore in § 410.23(a)(2), we 

proposed to revise the definition of an 

eligible beneficiary to include Hispanic 

Americans age 65 and over. In view of 

the possibility that it may be 

appropriate to include other individuals 

in the definition of those at ‘‘high risk’’

for glaucoma, we also requested 

comments on this issue, including 

documentation from the peer-reviewed 

medical literature in support of 

suggested changes. 

We received seven comments on the 

proposal to expand coverage of the 

glaucoma screening benefit to include 

Hispanic Americans within the category 

of those individuals at ‘‘high risk’’ for 

glaucoma. The following is a summary 

of the comments received and our 

responses. 

Comment: One commenter stated that 

it might be appropriate to include other 

individuals (and not only HispanicAmericans over age 65) in the definition 

of those at ‘‘high risk’’ for glaucoma. 

The commenter cited the Los Angeles 

Latino Eye Study and the research 

conducted by the Eye Diseases 

Prevalence Research Group as 

illustrating a sharp rise in the 

prevalence of glaucoma among 

Hispanic-Americans beginning at age 60 

(Archives of Ophthalmology 2004; 

122:532–538). The commenter indicated 

that according to the latter research, the 

risk of developing glaucoma among 

Hispanics between the ages 50–59 is 

2.92 percent, and that this number 

increases significantly to 7.36 percent 

for Hispanics between the ages 60–69. 

In view of this increase in the 

prevalence of glaucoma in the Hispanic 

population between the ages 60–69, the 

commenter recommended that CMS 

reduce the proposed screening coverage 

age from 65 to 60 years of age, 

suggesting that this lowering of the age 

would allow for medical intervention at 

an earlier stage during this critical 

period for glaucoma development. 

Response: We note that the 

commenter relied on the results of a 

major study (See the Archives 

Ophthalmology 2004; 122:532–538) in 

offering their suggestion for revising the 

proposal. That, in turn, relied on the 

results of another major study (See 

Archives of Ophthalmology 2001; 

119:1819–1826) for data on incidence 

and prevalence of primary open angle 

glaucoma in Hispanic-Americans. The 

latter study (Quigley, et al.) contains a 

graph on page 1822 which, in addition 

to stating the same data that the 

commenter referenced, shows an 

acceleration in prevalence of open angle 

glaucoma in Hispanic-Americans as 

compared to White persons beginning at 

age 65. This study by Quigley et al. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70271 

yields data supporting a higher 

incidence of open angle glaucoma in 

Hispanics as compared to Whites 

beginning at age 65 (Quigley, HA et al). 

The prevalence of glaucoma in a 

population based study of Hispanic 

subjects: proyecto VER. (Annals of 

Ophthalmology 2001; 119:1819–1825). 

Though they are not statistically 

significant in that age group, the data 

strongly favors our conclusion. 

However, for ages under 65 years, the 

evidence is poor for any differences in 

these 2 groups for an incidence of open 

angle glaucoma. Therefore, we have 

chosen a coverage baseline for the 

glaucoma screening benefit of age 65 

and older for Hispanic-Americans. 

Comment: One commenter stated that 

they did not support the proposal to 

expand the definition of those 

individuals at ‘‘high risk’’ for glaucoma 

because they do not believe there is 

sufficient evidence in the medical 

literature to recommend for or against 

screening adults for glaucoma, 

including Hispanic-Americans age 65 

and older. The commenter cited the 

United States Preventive Services Task 

Force (USPSTF) recommendation that 

concluded that there is insufficient 

evidence to recommend for or against 

screening adults for glaucoma. The 

commenter also noted that while the 

USPSFT clinical considerations section 

of its recommendation states that 

increased ocular pressure, family 

history, older age, and being of AfricanAmerican descent place an individual at 

risk for glaucoma, it makes no mention 

of Hispanic-Americans. Therefore, the 

commenter concluded that CMS should 

not make any changes to the current 

definition. 

Response: As stated previously, the 

articles in Archives of Ophthalmology, 

show that the prevalence of glaucoma in 

Hispanics begins to increase at age 65 

markedly when compared to Whites. 

While the USPSTF concluded that there 

is insufficient evidence to recommend 

either for or against screening any adult 

for glaucoma, section 1861(s)(2)(K) of 

the Act mandates coverage of screening 

for glaucoma for individuals determined 

to be at high risk for glaucoma, 

individuals with a family history of 

glaucoma and individuals with diabetes. 

Based on our review of the two 

published studies, we believe that the 

evidence is adequate to conclude that 

Hispanics age 65 and older meet the 

definition of individuals at high risk for 

glaucoma and could benefit from 

glaucoma screening. Further, since 

glaucoma is prevalent in Hispanics, we 

would rather be inclusive rather than 

exclusive for the screening benefit. 

Comment: Two commenters urge 

CMS to help educate providers and 

Hispanic beneficiaries to ensure that 

they are aware of the benefits associated 

with the new coverage when it is 

included in the final rule. 

Response: We agree and will release 

appropriate manual and transmittal 

instructions and information from our 

educational components for the medical 

community, including a MedLearn 

Matters article and fact sheets. We also 

encourage the medical community to 

join this effort in educating physicians 

and beneficiaries by distributing their 

own communications, bulletins, or 

other publications. In addition, we have 

specifically included information on the 

expanded glaucoma screening benefit in 

the 2006 English and Spanish versions 

of the Medicare and You Handbook, 

and we plan to revise the booklet, 

Medicare’s Preventive Services, and the 

bilingual brochure for Hispanic 

beneficiaries, to reflect the expanded 

benefit as well. 

Comment: One commenter expressed 

concern that at the present time, if a 

glaucoma screening is performed and a 

disease or condition other than 

glaucoma is discovered the screening 

examination will no longer be 

considered to be a covered service, 

which may leave providers open to 

additional financial liability unless they 

ensure that the patient sign an ABN. 

The commenter recommends that 

Medicare should cover screening 

examinations without regard to the 

diagnosis that is determined as a result 

of the screening in a particular case. 

Response: The availability of coverage 

under the screening benefit does not 

depend on whether or not a disease 

condition is discovered during the 

annual screening examination. Medicare 

covers the screening examination 

regardless of the findings at the time of 

the screening examination, but if the 

provider decides to perform and bill 

Medicare for the more comprehensive 

eye exam, the cost of the screening 

examination is considered bundled into 

the Medicare payment for the more 

expensive comprehensive eye 

examination. For example, if a disease, 

cataract, or a macular degeneration 

condition is discovered at the time of 

the glaucoma screening, the provider 

may decide to perform a medically 

necessary comprehensive eye 

examination and bill Medicare Part B 

for that more expensive covered service. 

In this example, it would be 

inappropriate for the provider to bill 

Medicare for the less expensive 

glaucoma screening service as well as 

the more comprehensive and expensive 

service because it would be duplicative 

for Medicare to pay for both services. In 

this situation, the only eye service that 

may be billed Medicare is the 

comprehensive eye examination and it 

would be presumed that the glaucoma 

screening service is bundled into the 

Medicare payment for the 

comprehensive eye service. 

Comment: One commenter suggested 

that CMS work with the Secretary of 

HHS to add on beneficiary eligibility for 

all Medicare covered screening tests to 

the ASC X12N 270/271 eligibility 

transaction. 

Response: This issue does not fall 

within the scope of the Medicare PFS 

regulations; and therefore, we are 

unable to address it in this final rule 

with comment. 

Comment: Two commenters 

expressed concern about the statement 

in the Regulatory Impact Analysis (70 

FR 45870) of the proposed rule that 

stated that the expansion of the benefit 

to include Hispanic persons age 65 and 

older ‘‘is not expected to have a 

significant cost impact on the Medicare 

program.’’ The commenters urge CMS to 

make available to the public it’s 

calculation of the impact on spending 

that would result from the proposed 

increase in glaucoma screening coverage 

and to reflect these spending increases 

in the SGR, including increases due to 

the initial test and all related and 

follow-up care. 

Response: Based on the projected 

utilization of the expanded glaucoma 

screening coverage to include Hispanic 

persons age 65 and older, we estimated 

in the proposed rule that the expanded 

benefit would result in an increase in 

Medicare payments to ophthalmologists 

or optometrists who will provide these 

screening tests and related follow-up 

tests and treatment. However, we noted 

that this change was not expected to 

have a significant cost impact on the 

Medicare program. Based on Medicare 

Part B carrier claims processing data, we 

estimate that the program paid for about 

1,100 glaucoma screening services in CY 

2004 at a cost of about $47,000 for the 

same time period. While it is not 

possible to predict how many HispanicAmericans might take advantage of the 

new coverage that will be available to 

them, judging from the impact of the 

present glaucoma screening benefit on 

the Medicare costs in CY 2004, we do 

not believe the expansion will have a 

significant impact on program costs in 

CY 2005 and subsequent years. 

Comment: One commenter suggested 

that CMS seek to improve its coverage 

web site in the future to reflect all 

changes being considered by the 

agency—both regulatory and NCD 

developments—that relate to Medicare 

70272 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

coverage of various preventive services. 

The commenter stated that providing 

references to all matters affecting 

Medicare coverage in one place would 

provide the pubic with a better 

understanding of the extent of the 

agency’s efforts in this area. 

Response: We note that the regulation 

and the NCD processes are two separate 

methods specified in the Medicare 

statute for developing and publishing 

national coverage policies. However, we 

plan to review the commenter’s 

suggestion for providing references on 

the CMS Coverage web site to all 

matters—both regulatory and NCD 

developments—affecting Medicare 

coverage in the preventive services area. 

Final Decision 

We are revising the definition of an 

eligible beneficiary who is at ‘‘high risk’’

for glaucoma to include HispanicAmericans age 65 and older as 

proposed. 

P. Additional Issues 

1. Corrections to Conditions for 

Medicare Payment (§ 424.22) 

Two typographical errors in 42 CFR 

424.22 were discovered. First, 

§ 424.22(d) erroneously refers to the 

definition of ‘‘financial relationship’’ in 

‘‘§ 411.351’’ instead of ‘‘§ 411.354’’. In 

addition, footnote 1 of § 424.22(a)(1)(iv) 

contains an error in the spelling of the 

word ‘‘hospital.’’ Therefore, we are 

revising § 424.22 to correct these errors. 

2. Chemotherapy Demonstration Project 

CMS seeks to encourage quality care 

in all facets of cancer treatment and care 

by encouraging best clinical practices 

and quality care. In the CY 2005 final 

rule, we announced the initiation of a 1 

year demonstration project for CY 2005 

for office-based oncology services. The 

authority for this demonstration is based 

on sections 402(a)(1)(B) and 402(b) of 

the Social Security Act Amendments of 

1967 (Pub. L. 90–248). These provisions 

allow the Secretary to develop and 

engage in experiments and 

demonstration projects to provide 

incentives for economy while 

maintaining or improving quality in the 

provision of health services. 

This CY 2005 project focused on three 

areas of concern often cited by patients 

undergoing chemotherapy: controlling 

pain; minimizing nausea and vomiting; 

and reducing fatigue. Participating 

practitioners are reporting standardized 

assessments of patient symptoms at the 

time of chemotherapy encounters. We 

are collecting data based on these 

assessments over the course of 

chemotherapy treatment to trace 

changes in patient symptoms, quality of 

life, and medical responses associated 

with standardized physician assessment 

of these important areas. 

To facilitate the collection of 

information, we established new Billing 

Codes, that is, G–codes, to be reported 

by practitioners in the demonstration. 

The codes correspond to four patient 

assessment levels for each of the three 

patient symptom areas: Nausea and 

vomiting; pain; and fatigue. These 

levels, based on the Rotterdam scale, 

have already proven effective in 

measuring patient symptoms associated 

with cancer care, are easily understood 

by patients, and are in widespread use. 

Practices reporting data on all three 

factors to Medicare qualify for an 

additional payment of $130 per 

encounter. By billing the designated 

codes, the practitioner self–enrolls in 

the project. 

Although we did not include a 

discussion item or demonstration 

proposal in the August 8, 2005, 

proposed physician fee schedule rule, 

we did release a fact sheet on August 1, 

2005, titled, ‘‘Demonstration of 

Improved Quality of Care for Cancer 

Patients Undergoing Chemotherapy’’

which was posted on our web site. The 

fact sheet provided background on the 

demonstration project, shared 

preliminary data on the results of the 

demonstration, and indicated that we 

would continue to consult with its 

stakeholders about the merits of the 

program and the utility of the data 

captured. 

We received comments on the 

proposed rule on the demonstration 

itself and the specific items in the fact 

sheet. Some commenters pointed out 

what they perceived as limitations of 

the demonstration itself, such as the 

application of the Part B coinsurance to 

the demonstration codes. Almost all 

commenters urged CMS to extend the 

demonstration project in its current 

form or revise it to capture better data 

on quality and outcomes. Several 

commenters favored extending the 

demonstration to services provided by 

other physician specialties, such as 

rheumatology, gastroenterology, 

urology, or infectious disease; or to 

those services currently not included in 

the framework of the demonstration, 

such as chemotherapy administration to 

hospital outpatients or chemotherapy 

services provided through oral anticancer drugs. 

One major specialty group opposed 

the continuation of the demonstration 

project stating that it is inconsistent 

with current efforts to build evidencebased medicine into the delivery of high 

quality care to Medicare patients. 

Following extensive discussions with 

various groups representing the interests 

of oncologists and advocates for patient 

care, we have decided to retain the 

demonstration project for one more 

year, but we will revise the G-codes for 

reporting in order to take a further step 

toward encouraging quality care and 

promoting best clinical practices that 

should lead to improved patient 

outcomes. We will eliminate the CY 

2005 G-codes specific to the assessment 

of patient symptoms, while maintaining 

our focus on quality cancer care, 

including the management of 

debilitating symptoms, to assure the 

best possible quality of life for cancer 

patients. 

Reconfiguration of the Demonstration 

for CY 2006 

The new 1 year oncology 

demonstration, applicable to services 

furnished in CY 2006, will build on the 

use of G codes to gather more specific 

information relevant to the quality of 

care for cancer patients, their 

treatments, and the spectrum of care 

they receive from their doctors, and 

whether or not the care follows clinical 

guidelines. The project will emphasize 

evidence-based practice guidelines that 

have been shown to lead to better 

patient outcomes as the source for 

standard of care, permitting us to 

monitor and encourage quality care to 

cancer patients. Reporting will no 

longer be specific to chemotherapy 

administration services, but instead will 

be associated with physician E/M visits 

for established patients with cancer, 

visits that are frequent and essential to 

assuring quality of care and life for 

patients. 

The demonstration is available to 

office-based hematologists/oncologists 

who provide an E/M service of level 2, 

3, 4, or 5 to an established patient, when 

the service is delivered to a patient with 

a primary diagnosis of cancer belonging 

to one of the following major diagnostic 

categories: 

• Breast cancer (invasive). 

• Colon cancer. 

• Rectal cancer. 

• Prostate cancer. 

• Lung cancer (either non-small cell 

or small cell). 

• Stomach cancer. 

• Esophageal cancer. 

• Pancreatic cancer. 

• Ovarian cancer. 

• Non-Hodgkins Lymphoma. 

• Chronic myelogenous leukemia. 

• Multiple myeloma. 

• Cancer of the head and neck. 

E/M services furnished by 

hematologists/oncologists for patients 

with other cancers as the principal 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70273 

diagnosis will not qualify under the 

demonstration. 

We are establishing a 2006 payment 

amount of $23 for the 1 year oncology 

demonstration payment. To qualify for 

the $23 oncology demonstration 

payment, the physician must submit 

one G-code from each of the following 

three categories when an E/M service of 

level 2, 3, 4, or 5 is billed: (1) The 

primary focus of the E/M service; (2) the 

current disease state; and (3) whether 

current management adheres to clinical 

guidelines. 

We will inform the public on more 

details of this demonstration through a 

fact sheet and information on our Web 

site at www.cms.hhs.gov/. 

III. Refinement of Relative Value Units 

for Calendar Year 2006 and Response 

to Public Comments on Interim Relative 

Value Units for 2005 

[If you choose to comment on issues 

in this section, please include the 

caption ‘‘Interim Relative Value Units’’

at the beginning of your comments.] 

A. Summary of Issues Discussed Related 

to the Adjustment of Relative Value 

Units 

Section III.B. and III.C. of this final 

rule with comment describes the 

methodology used to review the 

comments received on the RVUs for 

physician work and the process used to 

establish RVUs for new and revised CPT 

codes. Changes to codes on the PFS 

reflected in Addendum B are effective 

for services furnished beginning January 

1, 2006. 

B. Process for Establishing Work 

Relative Value Units for the 2005 

Physician Fee Schedule 

Our CY 2005 final rule (69 FR 66236) 

contained the work RVUs for Medicare 

payment for existing procedure codes 

under the PFS and interim RVUs for 

new and revised codes beginning 

January 1, 2005. We considered the 

RVUs for the interim codes to be subject 

to public comment under the annual 

refinement process. In this section, we 

summarize the refinements to the 

interim work RVUs published in the CY 

2005 final rule and our establishment of 

the work RVUs for new and revised 

codes for the 2006 PFS. 

C. Work Relative Value Unit 

Refinements of Interim Relative Value 

Units 

1. Methodology (Includes Table Titled 

‘‘Work Relative Value Unit Refinements 

of the 2004 Interim and Related Relative 

Value Units’’) 

Although the RVUs in the CY 2005 

PFS final rule were used to calculate 

2005 payment amounts, we considered 

the RVUs for the new or revised codes 

to be interim. We accepted comments 

for a period of 60 days. We received 

substantive comments for 7 CPT codes 

with interim work RVUs. 

To evaluate these comments, we used 

a process similar to the process used 

since 1997. (See the October 31, 1997 

final rule (62 FR 59084) for the 

discussion of refinement of CPT codes 

with interim work RVUs.) We convened 

a multispecialty panel of physicians to 

assist us in the review of the comments. 

The comments that we did not submit 

to panel review are discussed at the end 

of this section, as well as those that 

were reviewed by the panel, which are 

contained in Table 28, Codes Reviewed 

Under the Refinement Process. We 

invited representatives from the 

organizations from which we received 

substantive comments to attend a panel 

for discussion of the code on which they 

had commented. The panel was 

moderated by our medical staff, and 

consisted of the following voting 

members: 

• One or two clinicians representing 

the commenting organization. 

• One primary care clinician 

nominated by the American Academy of 

Family Physicians. 

• Three carrier medical directors. 

• Two clinicians with practices in 

related specialties who were expected to 

have knowledge of the service under 

review. 

The panel discussed the work 

involved in the procedure under review 

in comparison to the work associated 

with other services under the PFS. We 

assembled a set of 75 reference services 

and asked the panel members to 

compare the clinical aspects of the work 

of the service a commenter believed was 

incorrectly valued to one or more of the 

reference services. In compiling the set, 

we attempted to include: (1) Services 

that are commonly performed whose 

work RVUs are not controversial; (2) 

services that span the entire spectrum 

from the easiest to the most difficult; 

and (3) at least three services performed 

by each of the major specialties so that 

each specialty would be represented. 

The intent of the panel process was to 

capture each participant’s independent 

judgment based on the discussion and 

his or her clinical experience. Following 

the discussion, each participant rated 

the work for the procedure. Ratings 

were individual and confidential, and 

there was no attempt to achieve 

consensus among the panel members. 

We then analyzed the ratings based on 

a presumption that the interim RVUs 

were correct. To overcome this 

presumption, the inaccuracy of the 

interim RVUs had to be apparent to the 

broad range of physicians participating 

in each panel. 

Ratings of work were analyzed for 

consistency among the groups 

represented on each panel. In addition, 

we used statistical tests to determine 

whether there was enough agreement 

among the groups of the panel and 

whether the agreed-upon RVUs were 

significantly different from the interim 

RVUs published in Addendum C of the 

final rule. We did not modify the RVUs 

unless there was a clear indication for 

a change. If there was agreement across 

groups for change, but the groups did 

not agree on what the new RVUs should 

be, we eliminated the outlier group and 

looked for agreement among the 

remaining groups as the basis for new 

RVUs. We used the same methodology 

in analyzing the ratings that we first 

used in the refinement process for the 

1993 PFS. The statistical tests were 

described in detail in the November 25, 

1992 final rule (57 FR 55938). Our 

decision to convene multispecialty 

panels of physicians and to apply the 

statistical tests we described was based 

on our need to balance the interests of 

those who commented on the work 

RVUs against the redistributive effects 

that would occur in other specialties. 

Table 28 lists those interim codes 

reviewed under the refinement panel 

process described in this section. This 

table includes the following 

information: 

• CPT Code. This is the CPT code for 

a service. 

• Description. This is an abbreviated 

version of the narrative description of 

the code. 

• 2005 Work RVU. The work RVUs 

that appeared in the CY 2005 final rule 

are shown for each reviewed code. 

• Requested Work RVU. This column 

identifies the work RVUs requested by 

commenters. 

• 2006 Work RVU. This column 

contains the final RVUs for physician 

work. 

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TABLE 28.—CODES REVIEWED UNDER THE REFINEMENT PANEL PROCESS

CPT code* Mod Descriptor 2005 work RVU Requested 

work RVU 

2006 work 

RVU 

97605 ................ .................... Neg press wound tx, < 50 cm ................................................... Bundled ............ 0.55 0.55 

97606 ................ .................... Neg press wound tx, > 50 cm ................................................... Bundled ............ 0.60 0.60 

* All CPT codes and descriptions copyright 2005 AMA. All rights reserved and applicable FARS/DFARS clauses apply. 

2. Interim 2005 Codes 

CPT codes 97605 Negative pressure 

wound therapy (e.g., vacuum assisted 

drainage collection), 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 

and 97606 Negative pressure wound 

therapy (e.g., vacuum assisted drainage 

collection), including topical 

application(s), wound assessment, and 

instruction(s) for ongoing care, per 

session; total wound(s) surface area 

greater than 50 square centimeters. 

The RUC HCPAC review board 

recommended 0.55 work RVUs for CPT 

code 97605 and 0.60 work RVUs for 

CPT code 97606, which we did not 

accept. We disagreed with their 

recommendation that these services 

contained physician work and did not 

assign work RVUs. Further, when the 

negative pressure wound therapy 

service does not encompass selective 

debridement, we consider the service to 

represent a dressing change and will not 

make separate payment. When the 

negative pressure wound therapy 

service includes the need for selective 

debridement, we consider the services 

represented by CPT codes 97605 and 

97606 to be bundled into CPT codes 

97597 or 97598. We assigned a status 

indicator of ‘‘B’’ to CPT code 97605 and 

97606, meaning that we would not make 

separate payment for these services. 

Comment: Commenters disagreed 

with our decision not to accept the RUC 

HCPAC recommended work RVU of 

0.55 for CPT code 97605 and 0.60 work 

RVU for CPT code 97606 and with our 

decision not to make separate payment 

for these services. Based on these 

comments, we referred these codes to 

the multispecialty validation panel for 

review. 

Response: As a result of the statistical 

analysis of the 2005 multispecialty 

validation panel ratings, we have 

assigned 0.55 work RVUs to CPT code 

97605 and 0.60 work RVUs to CPT code 

97606. 

CPT codes 32855 Backbench standard 

preparation of cadaver donor lung 

allograft prior to transplantation, 

including dissection of allograft from 

surrounding soft tissues to prepare 

pulmonary venous/atrial cuff, 

pulmonary artery, and bronchus; 

unilateral; 32856 Backbench standard 

preparation of cadaver donor lung 

allograft prior to transplantation, 

including dissection of allograft from 

surrounding soft tissues to prepare 

pulmonary venous/atrial cuff, 

pulmonary artery, and bronchus; 

bilateral; 33933 Backbench standard 

preparation of cadaver donor heart/lung 

allograft prior to transplantation, 

including dissection of allograft from 

surrounding soft tissues to prepare 

aorta, superior vena cava, inferior vena 

cava, and trachea for implantation; 

Backbench standard preparation of 

cadaver donor heart allograft prior to 

transplantation, including dissection of 

allograft from surrounding soft tissues 

to prepare aorta, superior vena cava, 

inferior vena cava, pulmonary artery, 

and left atrium for implantation; 44715 

Backbench standard preparation of 

cadaver or living donor intestine 

allograft prior to transplantation, 

including mobilization and fashioning 

of the superior mesenteric artery and 

vein; 47143 Backbench standard 

preparation of cadaver donor whole 

liver graft prior to allotransplantation, 

including cholecystectomy, if necessary, 

and dissection and removal of 

surrounding soft tissues to prepare the 

vena cava, portal vein, hepatic artery, 

and common bile duct for implantation; 

without trisegment or lobe split; 47144 

Backbench standard preparation of 

cadaver donor whole liver graft prior to 

allotransplantation, including 

cholecystectomy, if necessary, and 

dissection and removal of surrounding 

soft tissues to prepare the vena cava, 

portal vein, hepatic artery, and common 

bile duct for implantation; with 

trisegment split of whole liver graft into 

two partial liver grafts (ie, left lateral 

segment (segments II and III) and right 

trisegment (segments I and IV through 

VIII)); 47145 Backbench standard 

preparation of cadaver donor whole 

liver graft prior to allotransplantation, 

including cholecystectomy, if necessary, 

and dissection and removal of 

surrounding soft tissues to prepare the 

vena cava, portal vein, hepatic artery, 

and common bile duct for implantation; 

with lobe split of whole liver graft into 

two partial liver grafts (ie, left lobe 

(segments II, III, and IV) and right lobe 

(segments I and V through VIII)); 48551 

Backbench standard preparation of 

cadaver donor pancreas allograft prior 

to transplantation, including dissection 

of allograft from surrounding soft 

tissues, splenectomy, duodenotomy, 

ligation of bile duct, ligation of 

mesenteric vessels, and Y-graft arterial 

anastomoses from iliac artery to 

superior mesenteric artery and to 

splenic artery; 50323 Backbench 

standard preparation of cadaver donor 

renal allograft prior to transplantation, 

including dissection and removal of 

perinephric fat, diaphragmatic and 

retroperitoneal attachments, excision of 

adrenal gland, and preparation of 

ureter(s), renal vein(s), and renal 

artery(s), ligating branches, as 

necessary; and 50325 Backbench 

standard preparation of living donor 

renal allograft (open or laparoscopic) 

prior to transplantation, including 

dissection and removal of perinephric 

fat and preparation of ureter(s), renal 

vein(s), and renal artery(s), ligating 

branches, as necessary. These codes, all 

of which were approved in 2004 for 

inclusion in the 2005 CPT, were 

designated by us as carrier-priced. 

Comment: Commenters believed these 

codes describe services which are not 

payable under the Medicare PFS 

because they are hospital organ 

acquisition costs reimbursed under Part 

A of Medicare. The commenters 

requested that we change the 

designation of the standard backbench 

services from carrier priced to 

‘‘excluded by law’’, to be consistent 

with deceased donor procurement codes 

thereby indicating that they are not 

included in the definition of physician 

services for PFS purposes. Commenters 

also requested that we clarify that these 

services are included in the definition of 

hospital organ acquisition costs. 

Response: The backbench standard 

preparation codes describe procedures 

that are performed by physicians to 

prepare donor organs for implantation. 

The procedure is usually performed at 

the same hospital by the same surgical 

transplant team where the recipient 

transplant operation occurs, often in the 

same or adjacent operating room. It is 

usually completed shortly prior to or 

during the recipient transplant 

operation (especially for the heart and 

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lung) although more time is available to 

complete the transplant operations for 

the liver, kidney, and pancreas. This 

procedure is a necessary component for 

completion of the recipient transplant 

operation. With the exception of living 

donors, these services are rarely 

rendered at the hospital where the 

donor organs are procured. Hospital 

organ acquisition costs primarily consist 

of charges for services rendered by the 

hospital, Organ Procurement 

Organization (OPO), and the physicians 

related to retrieving the cadaveric donor 

organs at the ‘‘donor hospital’’ location. 

By virtue of its proximate timing and 

spatial association with the recipient 

transplant operation, this group of 

backbench standard preparation 

procedures are similar to other 

transplant surgery procedures that are 

performed by physicians and paid 

under the Medicare PFS. Therefore, we 

do not see how they would be 

considered as hospital organ acquisition 

costs (as suggested by the commenter). 

Since the codes for these backbench 

procedures do not represent deceased 

donor procurement codes, they would 

not appropriately be designated as 

‘‘excluded by law’’ as requested by the 

commenter. It would be more 

appropriate to pay for these services 

under the PFS. 

In the specific case of living donors, 

both the ‘‘donor hospital’’ and the 

‘‘recipient hospital’’ are obviously the 

same, although both operations are 

performed simultaneously by different 

surgical teams. In these cases, the 

backbench standard preparation 

procedures may be performed by 

physician members of either the donor 

team, the recipient team, or even a third 

surgical team. 

It is recognized that on occasion a 

donor organ will not be used for 

transplant at the facility where the 

backbench standard preparation 

procedure is performed (often because 

the intended recipient is found to be 

medically unsuitable after completion of 

the backbench work). In these 

situations, the donor organ may be sent 

to a different facility for another 

potential transplant recipient. Even in 

these situations, the physician 

performing the backbench procedure 

has no particular association with the 

initial donor procurement operation, the 

OPO, or the ‘‘donor hospital’’ site. 

Therefore, this physician’s work is still 

a physician service that should be paid 

under the Medicare PFS. 

CPT codes 36475 Endovenous 

ablation therapy of incompetent vein, 

extremity, inclusive of all imaging 

guidance and monitoring, percutaneous, 

radiofrequency; first vein treated and 

36476 Endovenous ablation therapy of 

incompetent vein, extremity, inclusive 

of all imaging guidance and monitoring, 

percutaneous, radiofrequency; second 

and subsequent veins treated in a single 

extremity, each through separate access 

sites. We accepted the RUC 

recommendation of 6.72 work RVUs for 

36475 and 3.38 work RVUs for 36476. 

Comment: We received a comment 

expressing concerns that we assigned 

endovenous radiofrequency (RF) 

ablation procedures (CPT code 36475 

and 36476) the same work RVUs as were 

assigned to endovenous laser 

procedures (CPT codes 36478 and 

36479). The commenter strongly urged 

us to reevaluate the work RVUs for RF 

ablation procedures. The commenter 

also noted that the vignette developed 

for the RF procedure was used for the 

laser procedure with one modification—

the word radiofrequency was changed to 

‘‘laser’’ and as a result, the vignette for 

the laser procedure was inaccurate, 

misleading, and created the impression 

that the work for the laser procedure is 

as intense as the work for the RF 

procedure. The commenter believed the 

mistaken description likely blurred the 

distinctions between the two procedures 

in terms of work and procedure time. 

The commenter also believed the flawed 

survey is evidence that the work RVUs 

for RF procedures were not appropriate 

and should be reexamined. 

Response: We believe the RUC 

appropriately valued these codes based 

upon the information that was provided 

to them during the RUC survey process 

and suggest the commenter contact the 

specialty society to have these codes 

reexamined by the RUC. 

In the CY 2005 final rule (69 FR 

66370), we also responded to the RUC 

recommendations on the PE inputs for 

the new and revised CPT codes for 

2005. Comments received on the PE 

inputs were addressed earlier in this 

preamble in the PE proposals for CY 

2006 with the exception of comments 

received on CPT codes 36475 and 

36476. As noted in the previous 

discussion concerning refinement of 

interim work RVUs, the commenter 

indicated the vignette was incorrect and 

therefore we believe the concerns about 

PE should also be handled through the 

RUC process by the specialty society. 

D. Establishment of Interim Work 

Relative Value Units for New and 

Revised Physician’s Current Procedural 

Terminology (CPT) Codes and New 

Healthcare Common Procedure Coding 

System Codes (HCPCS) for 2006 

(Includes Table titled ‘‘American 

Medical Association Specialty Relative 

Value Update Committee and Health 

Care Professionals Advisory Committee 

Recommendations and CMS’s Decisions 

for New and Revised 2006 CPT Codes’’) 

One aspect of establishing RVUs for 

2006 was to assign interim work RVUs 

for all new and revised CPT codes. As 

described in our November 25, 1992 

notice on the 1993 PFS (57 FR 55951) 

and in section III.B. of the November 22, 

1996 final rule (61 FR 59505), we 

established a process, based on 

recommendations received from the 

AMA’s RUC, for establishing interim 

work RVUs for new and revised codes. 

This year we received work RVU 

recommendations for 175 new and 

revised CPT codes from the RUC. Our 

staff and medical officers reviewed the 

RUC recommendations by comparing 

them to our reference set or to other 

comparable services for which work 

RVUs had previously been established. 

We also considered the relationships 

among the new and revised codes for 

which we received RUC 

recommendations and agreed with the 

majority of the relative relationships 

reflected in the RUC values. In some 

instances, although we agreed with the 

relationships, we nonetheless revised 

the work RVUs to achieve work 

neutrality within families of codes. That 

is, the work RVUs were adjusted so that 

the sum of the new or revised work 

RVUs (weighted by projected frequency 

of use) for a family will be the same as 

the sum of the current work RVUs 

(weighted by projected frequency of use) 

for the family of codes. We reviewed all 

the RUC recommendations and accepted 

approximately 94 percent of the RUC 

recommended values. For 

approximately 6 percent of the 

recommendations, we agreed with the 

relativity established by the RUC, but 

needed to adjust work RVUs to retain 

budget neutrality. 

We received 9 recommendations from 

the Health Care Professional Advisory 

Committee (HCPAC). We agreed with 

seven of these recommendations and 

disagreed with two of them. 

Table 29, titled ‘‘AMA RUC and 

HCPAC Recommendations and CMS 

Decisions for New and Revised 2006 

CPT Codes,’’ lists the new or revised 

CPT codes, and their associated work 

RVUs, that will be interim in 2006. This 

70276 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

table includes the following 

information: 

• A ‘‘#’’ identifies a new code for 

2006. 

• CPT code. This is the CPT code for 

a service. 

• Modifier. A ‘‘26’’ in this column 

indicates that the work RVUs are for the 

professional component of the code. 

• Description. This is an abbreviated 

version of the narrative description of 

the code. 

• RUC recommendations. This 

column identifies the work RVUs 

recommended by the RUC. 

• HCPAC recommendations. This 

column identifies the work RVUs 

recommended by the HCPAC. 

• CMS decision. This column 

indicates whether we agreed or we 

disagreed with the RUC 

recommendation. Codes for which we 

did not accept the RUC 

recommendation are discussed in 

greater detail following this table. An 

‘‘(a)’’ indicates that no RUC 

recommendation was provided. 

• 2006 Work RVUs. This column 

establishes the interim 2006 work RVUs 

for physician work. 

BILLING CODE 4120–01–U 

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BILLING CODE 4120–01–C 

Table 30, which is titled ‘‘AMA RUC 

ANESTHESIA RECOMMENDATIONS 

AND CMS DECISIONS FOR NEW AND 

REVISED 2006 CPT CODES’’, lists the 

new or revised CPT codes for anesthesia 

and their base units that will be interim 

in 2006. This table includes the 

following information: 

• CPT code. This is the CPT code for 

a service. 

• Description. This is an abbreviated 

version of the narrative description of 

the code. 

• RUC recommendations. This 

column identifies the base units 

recommended by the RUC. 

• CMS decision. This column 

indicates whether we agreed or we 

disagreed with the RUC 

recommendation. Codes for which we 

did not accept the RUC 

recommendation are discussed in 

greater detail following this table. 

• 2006 Base Units. This column 

establishes the 2006 base units for these 

services. 


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TABLE 30.—AMA RUC ANESTHESIA RECOMMENDATIONS AND CMS DECISIONS FOR NEW AND REVISED CPT CODES

* CPT CODE Description RUC recommendation CMS decision 2006 base 

units 

#01965 .............. ANESTH, INC/MISSED AB PROC ............................................................ 4.00 Agree ................ 4.00 

#01966 .............. ANESTH, INDUCED AB PROCEDURE .................................................... 4.00 Agree ................ 4.00 

*All CPT codes copyright 2005 AMA. 

# New CPT code. 

E. Discussion of Codes for Which There 

Were No RUC Recommendations or for 

Which the RUC Recommendations Were 

Not Accepted 

The following is a summary of our 

rationale for not accepting particular 

RUC work RVUs, base unit 

recommendations, or for accepting RUC 

recommendations with an intention to 

continue to monitor and reexamine the 

code(s) in the near future. It is arranged 

by type of service in CPT order. This 

summary refers only to work RVUs or 

Base Units. 

New and Revised Codes for 2006 

CPT codes 61630 Balloon angioplasty, 

intracranial (e.g., atherosclerotic 

stenosis), percutaneous; 61635 

Transcatheter placement of 

intravascular stent(s), intracranial (e.g., 

athersosclerotic stenosis), including 

balloon angioplasty if performed; 61640 

Balloon dilatation of intracranial 

vasospasm, percutaneous, initial vessel; 

61641 Balloon dilatation of intracranial 

vasospasm, percutaneous, initial vessel; 

each additional vessel in same vascular 

family; and 61642 Balloon dilatation of 

intracranial vasospasm, percutaneous, 

initial vessel; each additional vessel in 

different vascular family.—The RUC 

recommended 21.08 work RVUs for 

61630, 23.08 work RVUs for 61635, 

12.32 work RVUs for 61640, 4.33 work 

RVUs for 61641 and 8.66 work RVUs for 

61642. We are assigning a status 

indicator of N for these services because 

they are noncovered under Medicare 

due to a National Coverage Decision. 

CPT codes 76376 3D rendering with 

interpretation and reporting of 

computed tomography, magnetic 

resonance imaging, ultrasound or other 

tomographic modality; not requiring 

image post-processing on an 

independent workstation and 76377 3D 

rendering with interpretation and 

reporting of computed tomography, 

magnetic resonance imaging, 

ultrasound or other tomographic 

modality; requiring image post 

processing on an independent 

workstation.—The CPT Editorial Panel 

created CPT codes 76376 and 76377 to 

describe the new technology of 

volumetric acquisition of advanced 

cross-sectional imaging. The RUC 

recommended 0.20 work RVUs for CPT 

code 76376 and 0.79 work RVUs for 

CPT code 76377. These services were 

previously reported using CPT code 

76375 Coronal, sagittal, multiplanar, 

oblique, 3-dimensional and/or 

holographic reconstruction of computed 

tomography, magnetic resonance 

imaging, or other tomography modality. 

—According to the specialty society of 

the services reported for 76375, 80 to 90 

percent reflected two-dimensional 

multiplanar reformatting and only 10 to 

20 percent reflected three-dimensional 

rendering described in codes 76376 and 

76377. Although we are accepting the 

utilization crosswalks recommended by 

the specialty society and the work RVUs 

recommended by the RUC, we will 

continue to evaluate the work and 

utilization associated with these 

services over the next year and 

reexamine these codes in the future. 

CPT code 88334 Pathology 

consultation during surgery; cytologic 

examination (e.g., touch prep, squash 

prep), each additional site.—The RUC 

recommended a work RVU of 0.80 for 

this service based on a comparison of 

this procedure to CPT code 88332 

Pathology consultation during surgery; 

each additional tissue block, with frozen 

section(s). The RUC reviewed the 

specialty society’s survey data and 

noted that the surveyed code 88334, 

when compared to the reference code 

88332 has higher intensity/complexity 

measures and an additional five minutes 

of intra-service time, 20 minutes and 15 

minutes, respectively. Although 88334 

has an additional five minutes of intraservice time, we believe that 88334 is 

very similar in work to 88332 and, 

therefore, should be valued the same. 

We have assigned 0.59 work RVUs to 

88334. 

CPT codes 88384 Array-based 

evaluation of multiple molecular 

probes; 11 through 50 probes, 88385 

Array-based evaluation of multiple 

molecular probes; 51 through 250 

probes and 88386 Array-based 

evaluation of multiple molecular 

probes; 251 through 500 probes.—The 

RUC recommended that the base code 

(88384) be carrier priced and 

recommended 1.50 work RVUs for 

88385 and 1.88 work RVUs for 88386. 

We will allow the base code to be carrier 

priced and are accepting the RUC 

recommended values for 88385 and 

88386. We will continue to evaluate the 

work and utilization associated with all 

of these services over the next year and 

reexamine these codes in the future. 

CPT code 90773 Therapeutic, 

prophylactic or diagnostic injection 

(specify substance or drug); intraarterial.—We did not receive a final 

RUC recommendation for this code. 

This code replaces CPT code 90783 

Therapeutic, prophylactic or diagnostic 

injection (specify material injected); 

intra-arterial, which has been deleted 

and was assigned 0.17 work RVUs. On 

an interim basis, we have assigned 0.17 

work RVUs to 90773 since it replaces 

90783. 

CPT code 92630 Auditory 

rehabilitation, pre-lingual hearing loss 

and 92633 Auditory rehabilitation, postlingual hearing loss.—CPT codes 92630 

and 92633 represent speech language 

pathology and audiology services. These 

CPT codes describe rehabilitative or 

therapeutic services. When speechlanguage pathologists (SLPs) provide 

these services, they may bill for them by 

using CPT code 92507 Treatment of 

speech, language, voice, 

communication, and/or auditory 

processing disorder; individual, as 

appropriate. According to the Medicare 

statute, section 1861(ll)(2) of the Act, 

audiologists are recognized for purposes 

of providing diagnostic testing services 

to Medicare beneficiaries. Therefore, we 

will not recognize CPT codes 92630 and 

92633 under Medicare and have 

assigned a status indicator of I because 

these services represent therapeutic 

services rather than diagnostic tests. 

CPT code 95251 Ambulatory 

continuous glucose monitoring of 

interstitial tissue fluid via a 

subcutaneous sensor for up to 72 hours; 

physician interpretation and report.—

The RUC recommended a work RVU of 

0.85 for this service. We disagree with 

the RUC’s recommendation because we 

believe the work for this service is 

similar to CPT code 93268 Patient 

demand single or multiple event 

recording with presymptom memory 

loop, 24-hour attended monitoring, per 

30 day period of time; includes 

70282 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

transmission, physician review and 

interpretation, which involves the 

review of data over a 30 day period. 

Therefore, we have assigned 0.52 work 

RVUs to 95251. 

CPT codes 95873 Electrical 

stimulation for guidance in conjunction 

with chemodenervation (List separately 

in addition to code for primary 

procedure) and 95874 (Needle 

electromyography for guidance in 

conjunction with chemodenervation 

(List separately in addition to code for 

primary procedure).—The RUC 

recommended a work RVU of 0.56 for 

CPT codes 95873 and 95874. The RUC 

examined reference code 95860 (Needle 

electromyography; one extremity with or 

without related paraspinal areas) and 

determined that the intensity for the 

new procedures and the reference 

procedure were the same so a proper 

value for both new codes should be 

based on the ratio of time with the 

reference code. We believe that the work 

involved with 95873 and 95874 is very 

similar to 95870 and therefore should be 

valued the same. We have assigned 0.37 

work RVUs to CPT codes 95873 and 

95874. 

CPT codes 96116 Neurobehavioral 

status exam (clinical assessment of 

thinking, reasoning and judgment, e.g., 

acquired knowledge, attention, 

language, memory, planning and 

problem solving, and visual spatial 

abilities); per hour of the psychologist’s 

or physician’s time, both face-to-face 

time with the patient and time 

preparing the report and 96118 

Neuropsychological testing (e.g., 

Halstead-Reitan Neuropsychological 

Battery, Wechsler Memory Scales and 

Wisconsin Card Sorting Test); per hour 

of the psychologist’s or physician’s time, 

both face-to-face time with the patient 

and time preparing the report.—The 

HCPAC recommended 2.05 work RVUs 

for CPT codes 96116 and 96118. We 

disagree with the HCPAC’s 

recommendation and believe the 

physician work associated with these 

services is similar to 96101, as reflected 

by the technical skill, judgment and 

complexity of these services. Therefore, 

we have assigned 1.86 work RVUs to 

96116 and 96118. 

CPT codes 98960 Education and 

training for patient self-management by 

a qualified, nonphysician health care 

professional using a standardized 

curriculum, face-to-face with the patient 

(could include caregiver/family) each 30 

minutes; individual patient; 98961 

Education and training for patient selfmanagement by a qualified, 

nonphysician health care professional 

using a standardized curriculum, faceto-face with the patient (could include 

caregiver/family) each 30 minutes; 2–4 

patients; and 98962 Education and 

training for patient self-management by 

a qualified, nonphysician health care 

professional using a standardized 

curriculum, face-to-face with the patient 

(could include caregiver/family) each 30 

minutes; 5–8 patients.—We are 

assigning a status indicator of N for 

these services because they are 

noncovered under Medicare. 

CPT codes 99143 Moderate sedation 

services (other than those services 

described by codes 00100–01999) 

provided by the same physician 

performing the diagnostic or therapeutic 

service that the sedation supports, 

requiring the presence of an 

independent trained observer to assist 

in the monitoring of the patient’s level 

of consciousness and physiological 

status, under 5 years of age; first 30 

minutes intra-service time, 99144 

Moderate sedation services (other than 

those services described by codes 

00100–01999) provided by the same 

physician performing the diagnostic or 

therapeutic service that the sedation 

supports, requiring the presence of an 

independent trained observer to assist 

in the monitoring of the patient’s level 

of consciousness and physiological 

status, age 5 years or older; first 30 

minutes intra-service time, 99145 

Moderate sedation services (other than 

those services described by codes 

00100–01999) provided by the same 

physician performing the diagnostic or 

therapeutic service that the sedation 

supports, requiring the presence of an 

independent trained observer to assist 

in the monitoring of the patient’s level 

of consciousness and physiological 

status, age 5 years or older; each 

additional 15 minutes intra-service 

time, 99148 Moderate sedation services 

(other than those services described by 

codes 00100–01999) provided by a 

physician other than the health care 

professional performing the diagnostic 

or therapeutic service that the sedation 

supports, under 5 years of age; first 30 

minutes intra-service time, 99149 

Moderate sedation services (other than 

those services described by codes 

00100–01999) provided by a physician 

other than the health care professional 

performing the diagnostic or therapeutic 

service that the sedation supports, age 5 

years or older; first 30 minutes intraservice time, 99150 Moderate sedation 

services (other than those services 

described by codes 00100–01999) 

provided by a physician other than the 

health care professional performing the 

diagnostic or therapeutic service that 

the sedation supports, each additional 

15 minutes intra-service time.—The CPT 

Editorial Panel created six new codes to 

accurately report 2 separate families of 

moderate sedation. One family describes 

the provision of moderate sedation 

services by the physician who is 

performing the diagnostic or therapeutic 

service and supervising an independent 

trained observer while the other family 

describes moderate sedation services 

performed by a physician (other than an 

anesthesiologist) other than the 

physician performing a diagnostic or 

therapeutic service. These new codes 

replace CPT codes 99141 Sedation with 

or without analgesia (conscious 

sedation); intravenous, intra-muscular 

or inhalation and 99142 Sedation with 

or without analgesia (conscious 

sedation); oral, rectal and/or intranasal, 

which were bundled under the PFS. The 

RUC recommended 0.70 work RVUs for 

99143, 0.66 work RVUs for 99144, 0.23 

work RVUs for 99145, 1.75 work RVUs 

for 99148, 1.65 work RVUs for 99149 

and 0.47 work RVUs for 99150. We are 

uncertain whether the RUC assigned 

values are appropriate and have carrier 

priced these codes in order to gather 

information for utilization and proper 

pricing. 

F. Establishment of Interim PE RVUs 

for New and Revised Physician’s 

Current Procedural Terminology (CPT) 

Codes and New Healthcare Common 

Procedure Coding System (HCPCS) 

Codes for 2006. 

We have developed a process for 

establishing interim PE RVUs for new 

and revised codes that is similar to that 

used for work RVUs. Under this process, 

the RUC recommends the PE direct 

inputs (the staff time, supplies and 

equipment) associated with each new 

code. We then review the 

recommendations in a manner similar to 

our evaluation of the recommended 

work RVUs. The RUC recommendations 

on the PE inputs for the new and 

revised 2006 codes were submitted to us 

as interim recommendations. 

We have accepted, in the interim, the 

PE recommendations submitted by the 

RUC for the codes listed in the table 

titled ‘‘AMA RUC and HCPAC RVU 

Recommendations and CMS Decisions 

for New and Revised 2006 CPT Codes.’’

CPT code 28890 Extracorporeal shock 

wave, high energy, performed by a 

physician, requiring anesthesia other 

than local, including ultrasound 

guidance, involving the plantar fascia.—

We accepted the work RVUs for CPT 

28890. However, we disagree with the 

RUC’s recommendation to value this 

procedure only in the facility setting. 

We believe that this procedure is being 

performed in the nonfacility setting and 

are assigning the following PE inputs 

based on information that the RUC 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70283 

provided for informational purposes: (a) 

Total clinical labor time of 133 minutes 

consisting of 16 minutes for pre-service, 

36 minutes for the service period, and 

81 minutes for the post-service period; 

(b) supplies consist of 4 multispecialty 

supply packages (1 each for the 

procedure and each of the 3 post visits), 

1 fenestrated drape, 3 18–24 gauge 

needles, 1 10cc syringe, 5cc of lidocaine 

1 percent, 5cc of marcaine 0.5 percent, 

and 2 alcohol swabs; and (c) equipment 

includes ESW machine used for the 

procedure for 36 minutes and a power 

table and an exam lamp each for 117 

minutes (includes the 36 minute 

procedure and 81 minutes for the post 

visits). 

CPT 89049 Caffeine halothane 

contracture test (CHCT) for malignant 

hyperthermia susceptibility, including 

interpretation and report.—While we 

accepted the work RVUs for this 

procedure, we disagreed with a PE 

recommendation regarding 30 minutes 

clinical labor—provided by a staff blend 

comprised of a combination laboratory 

technician and histotechnologist—that 

was requested to prepare the registry 

report. Because we do not pay for the 

clinical labor necessary to prepare 

registry reports in any other procedure 

codes, we have deleted the 30 minutes 

report preparation time from the total 

service period time in the practice labor 

expense database. The net result for the 

clinical labor service period is 274 

minutes for CPT 89049. 

IV. Five-Year Refinement of RVUs— 

Status Update 

In the CY 2005 final rule (69 FR 

66236), we solicited comments on the 

work RVUs that may be inappropriately 

valued. Since we recognized that this 

process generally elicits comments 

focusing on undervalued codes, we also 

indicated that we would identify codes 

(especially high-volume codes across 

specialties) that: 

• Are valued as being performed in 

the inpatient setting, but that are now 

predominantly performed on an 

outpatient basis; and 

• Were not reviewed by the RUC, 

(that is, Harvard RVUs are still being 

used, or there is no information). 

We received comments on potentially 

misvalued services from approximately 

35 specialty organizations and 

individuals involving over 500 codes. 

We shared these comments with the 

RUC and also identified approximately 

160 additional codes for review. As 

explained in the CY 2005 final rule (69 

FR 66236), we proposed to utilize a 

process similar to that established for 

the assignment of RVUs for new and 

revised CPT codes where the RUC 

makes recommendations on work RVUs 

for services. This process was used 

during the last 5-year review, and we 

believe that it was beneficial. The RUC’s 

perspective is helpful because of its 

experience in recommending RVUs for 

new and revised CPT codes since we 

implemented the PFS. Furthermore, the 

RUC, by virtue of its multispecialty 

membership and consultation with 

approximately 65 specialty societies, 

involves the medical community in the 

refinement process. 

We will consider all comments on all 

work RVUs in the development of a 

proposed rule that we will publish 

2006. In that rule, we will propose the 

revisions to work RVUs that we believe 

are needed. We will then review and 

analyze the comments received in 

response to our proposed revisions and 

publish our decisions in the final rule 

for CY 2007. 

V. Physician Self-Referral Prohibition: 

Nuclear Medicine and Annual Update 

to the List of CPT/HCPCS Codes 

A. General 

Section 1877 of the Act prohibits a 

physician from referring a Medicare 

beneficiary for certain designated health 

services (DHS) to a health care 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. 

As specified in our regulations at 

§ 411.351, the following services are 

DHS: 

• Clinical laboratory services. 

• Physical therapy, occupational 

therapy, and speech-language pathology 

services. 

• Radiology and certain other imaging 

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. 

B. Nuclear Medicine 

In the August 8, 2005 rule, we 

proposed to include diagnostic and 

therapeutic nuclear medicine 

procedures under the DHS categories for 

radiology and certain other imaging 

services and radiation therapy services 

and supplies, respectively. The DHS 

categories of radiology and certain other 

imaging services and radiation therapy 

services and supplies are defined by a 

list of CPT and HCPCS codes that is 

updated annually and posted on our 

web site. In the August 8, 2005 

proposed rule (70 FR 45764), we stated 

that we would revise the list of CPT and 

HCPCS codes (List of CPT/HCPCS 

Codes) that identifies the items and 

services that are included in each of 

these DHS categories. Addendum G of 

the proposed rule set forth a list of 

codes for all diagnostic nuclear 

medicine procedures, all therapeutic 

nuclear medicine procedures, and the 

radiopharmaceuticals used in diagnostic 

and therapeutic nuclear medicine 

procedures. Additionally, we stated our 

intention to include diagnostic nuclear 

medicine services on the revised List of 

CPT/HCPCS Codes under ‘‘Radiology 

and Certain Other Imaging Services’’

and to include therapeutic nuclear 

medicine services on the revised List of 

CPT/HCPCS Codes under ‘‘Radiation 

Therapy Services and Supplies’’. We 

stated that some radiopharmaceuticals 

may be included in both categories. 

We requested comments concerning 

whether the list was accurate and 

complete. In addition, we requested 

comments as to whether, or how, to 

minimize the impact on physicians who 

are currently parties to arrangements 

that involve nuclear medicine services 

and supplies (that is, by specifying a 

delayed effective date or by 

grandfathering certain arrangements). 

1. Response to Comments 

We received many comments in 

response to our proposal to add 

diagnostic and therapeutic nuclear 

medicine services and supplies to the 

list of designated health services subject 

to the physician self-referral 

prohibition. Comments were submitted 

by or on behalf of numerous specialty 

societies, individual physicians, 

physician group practices, 

manufacturers, hospitals, the AMA and 

other trade associations, diagnostic 

imaging centers, and the Medicare 

Payment Advisory Commission 

(MedPAC). We received a few general 

comments, but the vast majority of 

comments centered on five specific 

issues. We address the comments in the 

following order: 

• General Comments. 

• Authority to Include Nuclear 

Medicine Services and Supplies as 

Designated Health Services. 

• Overutilization or Abuse. 

• Beneficiary Access to Care. 

70284 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

• Quality of Care. 

• Grandfathering Existing 

Arrangements or Delaying the Effective 

Date. 

a. General Comments 

Comment: One commenter questioned 

how our proposal would affect a 

physician’s ability to refer patients to a 

positron emission tomography (PET) 

center that purchases 

radiopharmaceuticals (which are DHS 

under our proposal) from a company 

with which the referring physician has 

a financial relationship. 

Response: The effect of this final rule 

with comment on a physician who has 

a financial relationship with a company 

that produces and supplies 

radiopharmaceuticals for PET scanning 

will depend on the nature of the 

physician’s financial relationship with 

the supplying company and the 

supplying company’s financial 

relationship with the PET center to 

which the physician wishes to refer. 

Depending on the facts, the arrangement 

described by the commenter could 

constitute an indirect compensation 

arrangement (as defined in 

§ 411.354(c)(2). If an indirect 

compensation arrangement exists 

between the referring physician and the 

PET center, the physician may not refer 

to the PET center unless the 

arrangement complies with the indirect 

compensation arrangement exception at 

§ 411.357(p). 

Comment: One commenter expressed 

concern about our proposal and 

requested that we maintain the ability of 

radiation oncologists to order, perform 

and use as needed, diagnostic and 

therapeutic nuclear medicine services 

for radiation treatment planning and 

treatment delivery. 

Response: We do not believe this final 

rule with comment will prohibit a 

radiation oncologist from ordering or 

performing diagnostic and therapeutic 

nuclear medicine services for purposes 

of radiation treatment planning and 

delivery. A ‘‘referral’’ does not include 

the request by a radiation oncologist for 

radiation therapy, including therapeutic 

nuclear medicine, if the request results 

from a consultation initiated by another 

physician and the services are furnished 

by or under the supervision of the 

radiation oncologist, or under the 

supervision of another radiation 

oncologist in the same group practice. In 

the March 26, 2004 final rule (69 FR 

16065), we stated that the radiation 

oncologist exception in the definition of 

‘‘referral’’ would also protect ‘‘necessary 

and integral ancillary services 

requested, and appropriately 

supervised, by the radiation oncologist.’’

We believe that diagnostic nuclear 

medicine procedures that are necessary 

and integral to the provision of radiation 

therapy fall within the scope of this 

protection. Accordingly, we are 

modifying the definition of ‘‘Referral’’ in 

§ 411.351. 

Comment: Two commenters suggested 

that the in-office ancillary services 

exception be modified or amended to 

prevent referring physicians from 

circumventing the physician selfreferral law and its provisions. 

Response: We understand the 

commenter’s viewpoint, but the 

commenter’s request goes beyond the 

scope of this rulemaking. We believe the 

in-office ancillary services exception 

strikes an appropriate balance between 

preventing program abuse without 

unduly interfering with the practice of 

medicine. However, we will continue to 

monitor the potential for abuse with 

respect to existing exceptions. 

Comment: One commenter requested 

that we create a new exception for a 

physician’s investment or ownership in 

a health care entity which provides 

nuclear medicine services and supplies, 

if the physician who refers patients to 

these entities directly supervises (onsite) the technicians or other personnel 

performing the nuclear medicine 

procedures on patients referred by that 

physician. 

Response: Under section 1877(b)(4) of 

the Act, we may create a regulatory 

exception only if we determine that the 

exception would pose no risk of 

program or patient abuse. The 

commenter seems to believe that the 

potential for program and patient abuse 

would be eliminated by having an 

owner physician on-site when a 

technician performs a nuclear medicine 

procedure that the physician has 

ordered. We do not see how this 

requirement would eliminate the risk of 

overutilization or other program or 

patient abuse that arises when a 

physician self-refers to an entity with 

which he or she has a financial 

relationship. 

b. Authority To Include Nuclear 

Medicine Services and Supplies as a 

Designated Health Services (DHS) 

The physician self-referral statute, at 

section 1877(h)(6) of the Act, includes 

within the list of DHS, ‘‘radiology 

services, including magnetic resonance 

imaging, computerized axial 

tomography, and ultrasound services,’’

and ‘‘radiation therapy services and 

supplies.’’ We proposed to include 

diagnostic and therapeutic nuclear 

medicine as DHS because we believe 

they are within the statute’s meaning of 

radiology services and radiation therapy 

services and supplies. We did not 

receive any comments disputing the 

assertion that therapeutic nuclear 

medicine services are radiation therapy 

services and supplies. However, 

regarding diagnostic nuclear medicine 

services, we received some comments 

that disagreed with our interpretation of 

the statute as well as some that agreed 

with our interpretation. 

Comment: Three commenters noted 

that we proposed to include diagnostic 

nuclear medicine procedures within our 

definition of ‘‘radiology and certain 

other imaging services’’ in § 405.351. 

These commenters stated that ‘‘other 

imaging services’’ does not appear in the 

statute, and they asserted that the 

Congress rejected virtually identical (in 

their view) statutory phrasing. The 

commenters noted that when the 

Congress initially included radiology as 

a DHS in the Omnibus Budget 

Reconciliation Act of 1993, the language 

read ‘‘radiology and other diagnostic 

services’’ and that the Congress 

amended the statute in the Social 

Security Amendments of 1994 to delete 

the phrase ‘‘and other diagnostic 

services.’’ The commenters also asserted 

that if the Congress had meant to 

include nuclear medicine within the 

DHS category of radiology, it would 

have specifically mentioned diagnostic 

nuclear medicine, as it did magnetic 

resonance imaging (MRIs), 

computerized axial tomography (CT 

scans), and ultrasound services. 

Response: We are including 

diagnostic nuclear imaging services in 

our definition of ‘‘radiology and certain 

other imaging services’’ because we 

believe they are radiology services 

within the meaning of section 

1877(h)(6)(D) of the Act. We disagree 

with the commenter’s assertion that we 

lack statutory authority to include 

certain imaging services in the DHS 

category described at section 

1877(h)(6)(D) of the Act. We believe that 

the Congress meant to include all forms 

of radiology, that is, those that have 

traditionally been considered to be 

radiology, as well as certain other 

imaging services, such as ultrasound 

that may or may or not be considered to 

be radiology in the traditional sense. 

Further, we believe the Congress meant 

to include all forms of radiology, 

regardless of whether the particular 

form existed or was covered by 

Medicare on the date the statutory 

language was enacted or became 

effective. We believe that, by describing 

the DHS category as ‘‘[r]adiology 

services, including [MRI, CAT scans], 

and ultrasound services,’’ the Congress 

merely provided examples (rather than 

an exhaustive list) of some of the most 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70285 

common forms of radiology other than 

x-rays. 

Comment: Three commenters stated 

that nuclear medicine should not be 

considered a DHS because it is 

clinically and technically distinct from 

the services that the Congress 

enumerated when it defined the scope 

of radiology services. The commenters 

noted that the American Board of 

Nuclear Medicine defines nuclear 

medicine as ‘‘the medical specialty that 

employs radionuclides to evaluate 

metabolic, physiologic and pathologic 

conditions of the body for purposes of 

diagnosis, therapy and research.’’

According to the commenters, the 

introduction of radiolabeled, 

biologically active compounds into 

patients distinguishes nuclear medicine 

from radiology, which may involve the 

administration of biologically inert 

contrast agents, such as barium sulfate, 

iodine or gadolinium. One of these 

commenters stated that the mere use of 

radioactive material does not render a 

service radiology because radioactive 

materials are used in non-radiology 

services such as the performance of 

radioimmunoassay and irradiation of 

blood products. 

Response: We are not persuaded that 

the common definitions of ‘‘radiology’’

cited in our proposed rule (70 FR 

45854–55) are incorrect or do not 

include diagnostic nuclear imaging. As 

we stated in the proposed rule (70 FR 

45855–56), radiology is ‘‘that branch of 

the health sciences dealing with 

radioactive substances and radiant 

energy and with the diagnosis and 

treatment of disease by means of both 

ionizing (that is, x-rays) and nonionizing (that is, ultrasound) 

radiations.’’ (quoting Dorland’s 

Illustrated Medical Dictionary). We 

noted in the proposed rule (70 FR 

45855–56) that, ‘‘[i]n more recent years, 

radiology has come also to embrace 

diagnosis by a method of organ scanning 

with the use of radioactive isotopes and 

non-ionizing radiation, such as 

ultrasound and nuclear magnetic 

resonance.’’ (quoting Encyclopaedia 

Britannica outline). Diagnostic nuclear 

medicine services involve the use of 

radioactive substances and ionizing 

radiation for purposes of diagnosis. Like 

the other services the Congress 

identified in describing ‘‘radiology 

services,’’ the final product is an image 

used for purposes of diagnosis. We 

believe that the Congress intended to 

include as ‘‘radiology services’’ all 

forms of radiological imaging, regardless 

of whether exposure to radioactive 

materials or radiation is achieved 

through ingestion or eternal application 

and regardless of whether the form of 

radiation is ionizing or non-ionizing. 

We also note that certain professional 

medical organizations such as the AMA 

and the ACR consider diagnostic 

nuclear imaging to be a subspecialty of 

radiology. 

We agree that the use of radioactive 

substances to perform a particular 

service does not, by itself, render that 

service ‘‘radiology’’ within the meaning 

of section 1877(h)(6)(D). We are not 

including as ‘‘radiology and certain 

other imaging services’’ any diagnostic 

nuclear medicine services that are not 

imaging services. We note that 

radioimmunoassay is a clinical 

laboratory service for purposes of 

section 1877, and irradiation of blood 

products is not a DHS. 

Comment: We received several 

comments addressing whether nuclear 

medicine is a subspecialty of radiology. 

MedPAC stated that it strongly supports 

the proposal to include nuclear 

medicine services in the definition of 

‘‘radiology and certain other imaging 

services.’’ MedPAC further stated its 

belief that the proposal is justified 

because physician groups such as the 

ACR and the AMA consider nuclear 

medicine to be a subspecialty of 

radiology. (We note that although the 

AMA objected to our proposal on the 

grounds that overutilization has not 

been shown for nuclear medicine 

services, the AMA did not assert that 

diagnostic nuclear medicine is not a 

subspecialty of radiology.) Another 

commenter stated that it is reasonable to 

include nuclear medicine as a DHS, but 

took exception to our statement in the 

proposed rule that diagnostic nuclear 

medicine is a subset of radiology. This 

commenter stated that the Nuclear 

Regulatory Commission (NRC) 

recognizes multiple alternative 

pathways to becoming a medical 

authorized user of isotopes in addition 

to certification from the American Board 

of Radiology. The commenter also noted 

that many different subspecialties, in 

addition to radiology, are recognized 

stakeholders with voting rights at the 

NRC Advisory Committee on the 

Medical Use of Isotopes. Two other 

commenters stated that according to the 

American Board of Medical Specialties, 

nuclear medicine and radiology are 

separate medical specialties, and that 

each is one of only 26 distinct medical 

disciplines subject to Primary Board 

Certification. These commenters stated 

that, although it is true that some 

nuclear medicine training is 

incorporated into the diagnostic 

radiology training program, and that the 

American Board of Radiology does 

include questions on nuclear medicine 

in its certification examination, 

physicians become eligible to take the 

American Board of Nuclear Medicine 

examination only after successfully 

completing a nuclear medicine 

residency program. Finally, one 

commenter objected to the proposal to 

include nuclear medicine as a DHS 

insofar as the proposal relates to the 

subspecialty of nuclear cardiology. 

According to this commenter, nuclear 

cardiology is the science of performing 

cardiac stress testing with the 

interpretation of nuclear images for 

purposes of determining a patient’s 

diagnosis and prognosis; therefore, 

nuclear cardiology is not simply the 

interpretation of images, which the 

commenter stated is the case in nuclear 

medicine. The commenter asserted that 

the great majority of physicians certified 

by the Certification Board of Nuclear 

Cardiology are cardiologists rather than 

radiologists. 

Response: We recognize that there is 

some difference of opinion, including 

among competing certification 

organizations, as to whether nuclear 

medicine is a subspecialty of radiology 

or whether it: (1) Is a subspecialty of 

both radiology and some other area of 

medicine; or (2) has achieved some type 

of independent status. However, even if 

nuclear medicine has achieved some 

type of independent status, it, 

nevertheless, is a form of radiology (as 

that term is commonly defined) and that 

therapeutic nuclear medicine is a form 

of radiation therapy. Likewise, the fact 

that cardiologists have found nuclear 

imaging to be particularly useful for 

evaluating heart disease and have 

developed a subspecialty in nuclear 

cardiology does not alter the essential 

fact that nuclear imaging employs 

radioactive material and is a form of 

radiology. 

Comment: One commenter stated that 

our January 4, 2001 final rule clearly 

and permanently established the 

principle that nuclear medicine services 

are not radiology services. The 

commenter believes that the January 

2001 rule fairly interpreted the law and 

that it is inappropriate to change the 

regulation in the absence of specific 

direction from the Congress in the form 

of a statutory change. 

Response: We disagree with the 

commenter’s belief that our regulations 

remain fixed for all time absent a change 

in the statute. As stated in the August 

8, 2005 proposed rule, we believe that 

a better reading of the statute is that the 

radiology and radiation therapy DHS 

categories, as set forth in section 

1877(h)(6) of the Act, encompass 

diagnostic and therapeutic nuclear 

medicine services, respectively. 

Therefore, we believe it is appropriate to 

70286 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

amend our regulations to include 

diagnostic and therapeutic nuclear 

medicine services within the respective 

DHS categories of radiology services and 

radiation therapy services and supplies. 

c. Overutilization or Abuse 

In the August 8, 2005 proposed rule, 

we cited several studies that suggest that 

a physician’s referral patterns and 

utilization of nuclear medicine services 

and supplies closely correlate to 

whether the physician has a financial 

interest in the entity providing the 

services and supplies. We received 

several comments representing 

divergent views as to whether nuclear 

medicine services and supplies are at 

risk for abuse and overutilization when 

physicians have financial interests in 

the entities that provide the services and 

supplies. 

Comment: One commenter supported 

our proposal to include nuclear 

medicine as a DHS and believed that 

there has been significant 

overutilization and abuse of this 

imaging modality in his State. The 

commenter believes that the problems 

have become more acute with the 

proliferation of PET and PET/CT 

imaging centers set up as joint ventures 

between select groups of referring 

physicians and venture capitalists in the 

State and requested that we prohibit 

these types of ventures. 

Response: We welcome the 

commenter’s observations regarding the 

impact on the utilization of PET and 

PET/CT imaging when physicians enter 

into arrangements with non-physician 

investors to own these imaging centers. 

Inclusion of nuclear medicine services 

and supplies as DHS likely will have an 

impact on these ventures (and 

potentially the utilization of PET and 

PET/CT imaging). However, whether or 

not PET joint ventures are abusive is not 

a determinative factor in our decision to 

include diagnostic and therapeutic 

nuclear medicine as DHS. Rather, our 

decision is based on our belief that these 

services and supplies properly are 

categorized as ‘‘radiology and certain 

other imaging services’’ and ‘‘radiation 

therapy services and supplies’’ within 

the meaning of the statute. 

Comment: One commenter provided a 

summary of the findings from its own 

clinical and financial database regarding 

the incidence of physician self-referral 

for nuclear medicine services. The 

commenter asserted that the data show 

that self-referring providers are much 

more likely to order these types of 

services than those who do not selfrefer. 

Response: We appreciate the 

commenter’s willingness to share its 

data regarding the incidence of 

physician self-referral for one specific 

type of nuclear imaging service (nuclear 

cardiology). The commenter’s findings 

are consistent with the information we 

already have, including the studies cited 

in the August 8, 2005 proposed rule, 

that nuclear medicine services and 

supplies pose the same risk of abuse 

that the Congress intended to eliminate 

for other types of radiology, imaging and 

radiation therapy services and supplies. 

Comment: Two commenters 

supported the expansion of the 

physician self-referral provisions to 

include nuclear medicine services and 

supplies. One of the commenters stated 

his or her belief that the proliferation of 

imaging units in non-hospital 

environments has contributed 

significantly to the increase in 

diagnostic imaging costs. This 

commenter urged that, although the 

advancement of PET technology has 

proven to be a clinically effective 

diagnostic imaging tool, the physician 

self-referral law should have equal 

extension and universal application to 

all imaging providers. The other 

commenter stated that recent studies of 

the effects of physician self-referral have 

shown that, when physicians have an 

investment interest in imaging 

equipment and have the opportunity to 

self-refer, their utilization is 

significantly higher than among 

physicians who refer their patients to a 

provider in which the referring 

physician has no financial interest. This 

commenter added that nuclear medicine 

services and supplies should have been 

included in the original listing, because 

the potential for abuse is no different 

than for CT scans or MRI scans. Both 

this commenter and MedPAC contend 

that our policy change will help limit 

referrals for nuclear medicine services 

that are based on financial, rather than 

clinical, reasons. 

Response: We believe that the 

position advocated by these commenters 

is consistent with the studies we cited 

in the August 8, 2005 proposed rule. As 

we stated in the proposed rule, although 

we believe that diagnostic and 

therapeutic nuclear medicine services 

are radiology and radiation therapy 

services and supplies within the 

meaning of the statute, we would 

resolve any doubt as to this matter in 

favor of including them as DHS. After 

careful review of the information 

available to us currently, we believe it 

is appropriate to include diagnostic and 

therapeutic nuclear medicine services 

and supplies as DHS. 

Comment: One commenter asserted 

that the risk of anti-competitive 

behavior would increase by limiting the 

parties that may provide nuclear 

medicine services, which is contrary to 

our rationale of protecting against abuse 

and ensuring quality patient care. In 

contrast, MedPAC referred to the 1994 

GAO report (GAO/HEHS–95–2) and 

supported the inclusion of nuclear 

medicine as DHS. MedPAC contended 

that physician self-referral to nuclear 

medicine facilities undermines fair 

competition among these facilities 

because physician investors have a 

financial incentive to refer patients to 

the facility they own. 

Response: We agree with MedPAC 

regarding potential anti-competitive 

behavior. Moreover, we do not agree 

with the other commenter’s assertion 

that the inclusion of nuclear medicine 

services and supplies as DHS would 

limit the types of entities that may 

provide nuclear medicine services. 

Rather, the inclusion of these services 

and supplies as DHS merely limits the 

type of investors in the entities 

providing nuclear medicine services 

and supplies (that is, except for 

investors in either rural providers (as 

defined at § 411.356(c)(1) or entities that 

furnish the services in compliance with 

the in-office ancillary services 

exception, our proposal would limit 

physician investors to those who will 

not refer patients to the entity). 

Comment: Several commenters 

asserted (but did not provide data or 

other proof) that nuclear medicine 

services are not at risk for the kind of 

overutilization that the physician selfreferral law is designed to prevent. 

Other commenters disagreed with the 

proposal to include nuclear medicine 

services and supplies (and, in 

particular, nuclear cardiology) as DHS. 

The commenters stated that it is not 

possible to know if the rise in utilization 

of nuclear medicine services is due to 

abuse and believed that we must show 

evidence that these services are 

currently being abused before including 

nuclear medicine services and supplies 

as DHS. 

Response: In the August 8, 2005 

proposed rule, we referenced several 

studies concerning overutilization and 

increases in imaging services being 

performed in physician offices. We 

received comments, both data-driven 

and anecdotal, to support our belief that 

nuclear medicine services are subject to 

overutilization when physician selfinterest is present, as is the case in 

many (but not all) office-based (or nonhospital) imaging procedures. We must 

emphasize, however, that our decision 

to include nuclear medicine as a DHS is 

based upon our current knowledge of 

nuclear medicine. We believe it is 

appropriate to interpret the DHS 

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categories described in section 

1877(h)(6)(D) and (E) of the Act to 

include diagnostic nuclear medicine 

services and supplies and therapeutic 

nuclear medicine services and supplies, 

respectively. 

Although we are conscious of a 

possible correlation between increased 

utilization and a showing of abuse, in 

the January 4, 2001 final rule with 

comment (66 FR 860), we stated that we 

did not believe the Congress intended 

us to review every possible service 

within a DHS category to determine its 

potential for overutilization. The 

Congress has already made the 

determination that the services in each 

of the eleven DHS categories are 

potentially subject to overutilization or 

other abuse. The risk of abuse and the 

potential for anti-competitive behavior 

inherent in physician self-referrals for 

nuclear medicine services simply 

provide additional support in favor of 

including nuclear medicine as DHS. 

Comment: One commenter claimed 

that the increase in utilization of 

nuclear imaging services and supplies is 

due, at least in part, to the shift in site 

of service from the hospital setting to 

the physician office as well as a change 

in the standard of care in the treatment 

of patients due to improved technology 

and its applications. The commenter 

asserted that physician self-referral does 

not appear to be the primary driver of 

growth in imaging services, citing a 

study that shows that access to imaging 

technology, even in the absence of 

financial incentives, will result in 

increased utilization. The commenter 

contended that ‘‘eliminating the ability 

of specialty physicians to perform and 

interpret imaging tests in their offices is 

not protection against the growth in 

utilization.’’

Response: We are aware of the 

apparent shift in the site of service. 

However, we do not believe that the 

change in site of service accounts for all, 

or even most, of the increase in 

Medicare payments for nuclear 

medicine services. In fact, in its March 

2005 ‘‘Report to the Congress: Medicare 

Payment Policy’’, MedPAC indicated 

that about 80 percent of the increase in 

the volume and intensity of imaging 

services, including nuclear medicine, 

between 1999 and 2002, was unrelated 

to any shift in service setting. We 

disagree with the commenter that 

inclusion of nuclear medicine services 

and supplies as DHS necessarily will 

prohibit physicians from performing 

and interpreting imaging tests in their 

offices. Certain arrangements and 

referrals may qualify for protection 

under existing provisions of the 

physician self-referral law and 

regulations (for example, the in-office 

ancillary services exception). In 

addition, even if we assume the 

commenter’s sources are correct and 

utilization will increase with access to 

technology regardless of financial 

incentives for the referring physician, 

this does not affect the definition of 

radiology and radiation therapy, nor 

does it affect the proper inclusion of 

nuclear medicine services and supplies 

in these categories of DHS. We also note 

that, even if not the main ‘‘driver’’ of 

overutilization, self-interested referrals 

that cause any overutilization are 

problematic. 

d. Beneficiary Access 

We received numerous comments 

regarding the impact of our provision on 

beneficiary access to care. Our 

responses to these comments follow. 

Comment: Several commenters 

expressed concern that our proposal 

would limit beneficiary access to 

nuclear medicine services. The AMA 

expressed concern about the potential 

impact of our proposal with regard to 

disruption of patient care, as well as 

access to these services. One of the 

commenters believes that our proposal 

will have a negative impact on the 

availability of PET scans, which 

constitute an important share of 

Medicare-covered nuclear imaging. In 

addition, another commenter raised 

concerns about where physicians would 

send patients for PET/CT scans. 

Response: We recognize that the 

inclusion of nuclear medicine as a DHS 

may cause some changes in physician 

ownership of, or investment interests in 

PET centers; however, we do not agree 

with the commenters’ assertions that 

our proposal would disrupt patient care 

and limit access to nuclear medicine 

services such as PET scans. We believe 

that most patients will continue to 

receive nuclear medicine services in the 

same location or vicinity where those 

services had been provided before. We 

see no reason why other providers or 

entities in the vicinity of existing PET 

centers would not be available or 

become available to furnish these 

services should a physician choose to 

divest any ownership or investment 

interest in an entity that furnishes 

nuclear medicine services. 

Alternatively, by restructuring their 

arrangements to comply with an 

existing exception, physicians may be 

able to continue referring patients to the 

same location for nuclear medicine 

services. In other words, whereas this 

rule may affect a physician’s ability to 

refer to a PET center with which he or 

she has a financial relationship, there 

should be either alternative entities 

available to provide the services in the 

same setting or alternative business 

structures that would permit the 

physician to continue furnishing the 

services to his or her own patients. 

Other commenters, such as MedPAC, 

have also noted that there are a large 

number and variety of settings in which 

nuclear medicine services are available 

(such as hospitals, freestanding centers 

that are not owned by physicians, and 

physician offices). Therefore, we believe 

there would be no decrease in 

beneficiary access to care. Nevertheless, 

we have taken steps, as described in our 

discussion of the delayed effective date, 

to minimize any potential disruption of 

patient care or access to these services. 

Comment: One commenter stated that 

there were not many PET scanners in 

the State of Oklahoma, and thus, 

patients would have to travel long 

distances for testing. 

Response: We do not believe that this 

regulatory change will cause any 

significant disruption in patient care. 

The only referrals for PET scans that our 

proposal would prohibit are those made 

by physicians whose financial 

relationship with the entity furnishing 

the PET scans does not satisfy an 

exception such as the in-office ancillary 

services exception or the rural provider 

exception. If the financial relationship is 

an ownership interest in a non-rural 

provider, the physician may: (1) Divest 

the interest; (2) restructure the financial 

relationship so that it complies with an 

exception; or (3) maintain the interest 

and refer his or her patients to another 

entity for PET scans. If the physician 

chooses to divest or appropriately 

restructure his interest in the PET 

center, the physician’s subsequent 

referrals to the PET center would not be 

prohibited under section 1877 of the 

Act, provided that the physician has no 

other financial relationship with the 

entity that fails to comply with an 

exception. We believe that the rural 

provider exception will ensure that 

beneficiaries in rural areas have 

continued access to nuclear medicine 

services. 

Comment: One commenter expressed 

concern that if PET services are 

reclassified as DHS, physicians will be 

prevented from performing this service 

in mobile coaches due to the exclusion 

of mobile settings from the in-office 

ancillary exception. The commenter 

contended that beneficiary access will 

be limited where physicians cannot 

afford to operate PET services at fixed 

locations. The commenter requested 

that the final rule exclude PET services 

from DHS, or, in the alternative, create 

an exemption for physician ownership 

arrangements of PET units that contain 

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certain intrinsic checks against overutilization. 

Response: The commenter is correct 

that nuclear medicine services such as 

PET furnished in mobile coaches would 

not satisfy the ‘‘same building’’ element 

of the in-office ancillary services 

exception. However, if the entity 

furnishing the mobile services furnishes 

at least 75 percent of all the DHS it 

furnishes is to residents of a rural area 

(as defined in § 411.356(c)(c)(1)), it 

could meet the requirements of the rural 

provider exception. The commenter did 

not specify the nature of any intrinsic 

checks against overutilization and as we 

noted in Phase I (66 FR 861), medical 

necessity reviews and other efforts may 

not be sufficient to control 

overutilization. The statute permits us 

to create an exception only when there 

is no risk of fraud or program abuse. We 

have concluded that internal controls or 

medical necessity reviews are not 

necessarily effective controls on overutilization, unfair competition, or other 

abuse. Therefore, we decline to adopt 

the requested exception. Additionally, 

we do not agree with the commenter’s 

assertion that where physicians cannot 

afford to operate PET centers at fixed 

locations, the result will be to limit 

access to beneficiaries. As we have 

noted above, PET services are furnished 

in various settings other than physicianowned entities. Therefore, we do not 

believe our proposal will have a 

negative impact on beneficiary access. 

e. Quality of Care 

Comment: Two physicians disagreed 

with the proposal to include nuclear 

medicine services because they believed 

that the inclusion of nuclear medicine 

would reduce quality of care to patients. 

One of the physicians expressed specific 

concern about the timeliness of 

diagnosis and initiation of therapy. The 

physician recommended that we 

disseminate evidence-based guidelines 

on the appropriate use of nuclear 

medicine procedures for diagnosis and 

treatment, and measurement of the 

quality of the service provided. 

Additionally, the commenter suggested 

that Medicare reimbursement should be 

site-neutral, ownership-neutral, and 

based on the clinical appropriateness, 

safety, and quality of the service 

provided. 

Response: We do not believe that the 

inclusion of nuclear medicine as a DHS 

would reduce quality of care. We have 

no data, and the commenter furnished 

no data or anecdotal evidence, to 

support the physician’s contention that 

nuclear medicine facilities owned by 

non-physicians furnish lower quality of 

care, as may be evidenced by delays in 

diagnosis and the initiation of 

treatment. Regarding the commenter’s 

other recommendations, this regulation 

is not the appropriate vehicle for 

addressing the development of 

evidence-based guidelines, 

measurement of the quality of the 

service, and changes in Medicare 

reimbursement. 

Comment: One commenter stated that 

the increased referrals and physician 

investment may not be attributable to 

financial incentives but rather may be 

attributable to improved services and 

diagnosis achieved by utilizing better 

equipment. The commenter expressed 

concern that the adoption of this 

provision could have a negative impact 

on the future provision of quality health 

care as physicians may hesitate to invest 

in new technology or services. The 

commenter contended that patient care 

has improved due to physician 

investment in entities providing nuclear 

medicine and PET services. Specifically, 

the commenter stated that the ability to 

invest in new technology has led to 

improved diagnostic and treatment 

ability, and lower costs and improved 

patient care. 

In addition, the commenter stated that 

physician investment has led to 

increased access to these services. 

According to the commenter, nuclear 

medicine and PET scan services require 

more expensive equipment than 

traditional radiology services and 

therefore physician investment in this 

equipment fills a necessary gap where 

large care providers have been unable to 

afford such equipment or choose not to 

acquire such equipment. 

Response: We recognize that in some 

instances, new technology has led to 

improved diagnostic and treatment 

lower costs, and improved patient care; 

however, this final rule with comment 

does not prevent physicians from 

furnishing nuclear medicine services or 

utilizing better nuclear medicine 

equipment. Rather, and consistent with 

the purposes of the statute, the 

provisions of this final rule with 

comment restrict the circumstances 

under which physicians can financially 

benefit from DHS they order. Moreover, 

we believe that many non-physician 

owned entities will invest in new 

technology or new services and that 

quality of care will not be affected 

because most physicians will continue 

to refer patients for medically necessary 

services even where there is no 

potential for personal profit. Finally, we 

note that the commenters offered no 

evidence to support their claim that 

physician ownership of nuclear 

medicine facilities results in improved 

quality of care. 

Comment: Some commenters opposed 

our proposal as it related to nuclear 

cardiology services, which the 

commenters asserted are integral to the 

diagnosis of heart disease and are 

performed primarily by cardiologists. 

One commenter stated that our proposal 

would prevent cardiologists from 

referring their patients for these 

services, thus causing primary care 

practitioners to refer these same patients 

directly to radiologists for nuclear 

testing, effectively bypassing a 

cardiologist’s input on the appropriate 

approach to cardiac testing. The 

commenter asserted that nuclear 

medicine services performed in 

hospitals will be interpreted by 

radiologists who do not possess the 

specialized skills of cardiologists, and 

that our proposal would, therefore, 

negatively affect patient care. 

Response: We are not persuaded by 

the commenters’ concerns. First, our 

proposal would not prohibit a 

cardiologist from referring patients for 

nuclear medicine services; it would 

merely prohibit the physician from 

referring patients for these services to 

entities with which the physician has a 

financial relationship if that financial 

relationship does not comply with an 

existing exception. Second, we do not 

believe that patient care would be 

negatively affected if a cardiologist had 

to refer patients to a hospital for nuclear 

cardiology tests that would be 

interpreted by a radiologist. We are not 

convinced that cardiologists are the only 

individuals qualified to interpret these 

tests. Moreover, we believe that 

hospitals have every incentive to ensure 

that such tests are interpreted by 

qualified physicians (including 

cardiologists, if necessary). 

Comment: Another commenter 

suggested that the inclusion of nuclear 

medicine as a DHS will limit the 

development of diagnostic testing 

facilities and thereby make the hospital 

setting the only permissible setting for 

nuclear cardiology. 

Response: We do not agree that the 

effect of this rule will be to make the 

hospital setting the only permissible 

setting for nuclear cardiology. 

Physician-owned diagnostic testing 

facilities are not prohibited if the 

physician owners do not refer patients 

to the facilities or if the financial 

relationship complies with another 

exception, such as the rural provider or 

in-office ancillary services exceptions. 

Additionally, as MedPAC noted, there 

are numerous other types of nonhospital entities or non-physician 

owned entities that currently furnish 

these services. 

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f. Grandfathering Existing Arrangements 

or Delaying the Effective Date 

In the August 8, 2005 proposed rule, 

we requested comments as to whether, 

or how, to minimize the impact on 

physicians who are currently parties to 

arrangements that involve nuclear 

medicine services and supplies (that is, 

by grandfathering certain arrangements, 

or by specifying a delayed effective 

date). Most commenters addressed this 

aspect of the proposed rule and either 

requested that current financial 

arrangements be grandfathered or 

recommended a delay in the effective 

date of our proposal. 

Comment: Many commenters 

supported a delayed effective date for 

our proposal. Commenters suggested 

various lengths of delay in 

implementing our proposal. Several 

commenters favored delaying the 

effective date for three to six months. 

One of the commenters suggested that 

physicians should have at least five 

years to divest themselves of existing 

ownership or investment interests. This 

commenter believed that this would be 

the minimum period for physicians to 

recover a fair share of their capital 

investments and dispose of their assets 

without having to resort to ‘‘bargain 

basement’’ sales. The Society of Nuclear 

Medicine strongly encouraged a phasedin implementation over two to three 

years to decrease the chances that 

patient access would be compromised. 

The ACR recommended an effective 

date of January 1, 2006 with a 1-year 

‘‘grace period’’ prior to enforcement. 

Response: We have carefully 

considered the impact of our proposal 

on both beneficiaries and physicians. 

We have also considered our duty to 

implement the statute. Given our 

conclusion that nuclear medicine 

services and supplies are radiology and 

radiation therapy services and supplies, 

we do not believe we can delay the 

effective date beyond a reasonable 

period of time. After weighing these 

considerations, we have decided to 

delay the effective date of this 

regulatory change until January 1, 2007. 

We believe this delay provides adequate 

notice to the general public and a 

reasonable length of time for physicians 

to divest any existing ownership 

interests or to restructure their financial 

relationships with nuclear medicine 

entities so that they comply with a 

statutory or regulatory exception (if that 

is the course of action they choose to 

take), without unduly delaying our 

statutory duty to implement the statute. 

We are aware that many of the financial 

arrangements concerning nuclear 

medicine entities are complex and 

involve ownership, investment, and 

leasing arrangements. Accordingly, we 

are rejecting commenters’ suggestions 

for a shorter or longer delay in 

implementation as being impractical or 

unreasonable. 

Comment: Many commenters 

recommended that current financial 

arrangements be grandfathered and that 

the process be clearly implemented with 

as little administrative burden as 

possible. For example, some 

commenters urged us to grandfather 

existing PET joint ventures. The AMA 

stated its belief that CMS has the 

authority to implement a grandfather 

clause, and urged us to use it to avoid 

‘‘fire sales’’ wherein physicians may not 

be able to recover the initial costs of 

their investment due to much greater 

supply than demand. Another 

commenter expressed a similar belief 

that the sales prices will reflect the 

forced nature of an immediate need to 

sell and be significantly below the 

prices that could be obtained in the 

absence of a grandfather provision. The 

commenter stated that ‘‘even if CMS 

allowed a three to five year period to 

divest, investors may still not receive 

the full value of their investment.’’ A 

physician stated that he and other 

physicians took risk by investing in 

nuclear medicine entities and believed 

that they should not have to divest their 

interest. Therefore, the physician 

advocated that we grandfather existing 

establishments and present ownership 

structures. Another commenter 

suggested that we grandfather financial 

relationships that were established prior 

to the effective date of the proposed 

rule. 

A few commenters objected to 

grandfathering for several reasons 

including—(1) There was no precedent 

for grandfathering; (2) the statute does 

not permit grandfathering; and (3) to do 

so would negate the intent of the 

proposal. 

Response: After reconsidering the 

issue, we question whether we have the 

authority to grandfather existing 

arrangements. Grandfathering existing 

arrangements would essentially require 

the creation of a new exception for 

physician financial relationships with 

certain nuclear medicine facilities. We 

have authority to create exceptions only 

for arrangements that pose no risk of 

patient or program abuse. We believe 

that physician self-referrals for 

diagnostic and therapeutic nuclear 

medicine services and supplies pose a 

risk of abuse, and we do not believe this 

risk is mitigated or eliminated simply 

because financial relationship was 

acquired before a particular date. 

Therefore, we have decided not to 

grandfather existing financial 

relationships between physicians and 

nuclear medicine facilities. However, 

we believe our decision to specify a 

delayed effective date will provide 

physicians with sufficient time to divest 

their ownership interests or to 

restructure appropriately existing 

financial arrangements. 

2. Revisions to the List of Codes 

Identifying Nuclear Medicine Services 

We have carefully reviewed the list of 

codes identifying nuclear medicine 

services and supplies (Nuclear Medicine 

Code List), as published in Addendum 

G of the August 8, 2005 PFS proposed 

rule. We have identified various 

additions and deletions. 

Table 31 reflects the addition of new 

CPT and HCPCS codes that become 

effective January 1, 2006 or that became 

effective since the publication of the 

proposed rule. Table 31 also reflects the 

addition of codes that will be 

recognized by Medicare for payment 

purposes effective January 1, 2006. 

Table 31 reflects the deletions 

necessary to conform the Nuclear 

Medicine Code List to the most recent 

publications of CPT and HCPCS codes. 

We have also deleted all C codes listed 

in the proposed rule because these are 

hospital outpatient services and are thus 

included in a different DHS category. 

Table 31 identifies the nuclear 

medicine codes that will be included 

(effective January 1, 2007) in the DHS 

categories of radiology and certain other 

imaging services and radiation therapy 

services and supplies. 

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C. Annual Update to the Code List 

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 

publications. The DHS categories 

defined and updated in this manner are: 

• Clinical laboratory services. 

• Physical therapy, occupational 

therapy, and speech-language pathology 

services. 

• Radiology and certain other imaging 

services. 

• Radiation therapy services and 

supplies. 

The updated Code List appears as 

Addendum H in this PFS final rule with 

comment and is available on our Web 

site at http://cms.hhs.gov/medlearn/ 

refphys.asp. We also include in the 

Code List those items and services that 

may qualify for either of the following 

two exceptions to the physician selfreferral 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 Code List was last updated in the 

CY 2005 PFS final rule (69 FR 66236). 

The updated all-inclusive Code List 

effective January 1, 2006 (except as 

otherwise noted for specific nuclear 

medicine codes) is presented in 

Addendum H of this final rule with 

comment. 

1. Response to Comments 

We received the following comment: 

Comment: One commenter suggested 

incorporating the Code List in the 

National Physician Fee Relative Value 

File as discussed in the CY 2005 PFS 

final rule (69 FR 66373). 

Response: We have decided not to 

incorporate the Code List into the 

National Physician Fee Relative Value 

File as suggested by the commenter. 

That file is updated quarterly and would 

entail a quarterly update to the PFS. In 

discussions with the commenter (an 

association representing medical group 

practices), we learned that its primary 

goal was to have the Code List in a 

format that could be downloaded. The 

previous Code Lists were generally 

posted on our web site as PDF files that 

could not be downloaded. Therefore, we 

will be posting the updated Code List on 

our physician self-referral Web site in 

an Excel spreadsheet that may be 

downloaded. 

2. Revisions Effective for 2006 

Tables 32 and 33, in this section, 

identify the additions and deletions, 

respectively, to the comprehensive Code 

List published in Addendum L of the 

CY 2005 PFS final rule. Tables 32 and 

33 also identify the additions and 

deletions to the lists of codes used to 

identify the items and services that may 

qualify for the exceptions in 

§ 411.355(g) (regarding EPO and other 

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 for the 

codes listed in Tables 32 and 33, if we 

receive them by the date specified in the 

DATES section of this final rule with 

comment. We will not consider any 

comment that advocates a substantive 

change to any of the DHS defined in 

§ 411.351. 

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The additions specified in Table 32 

generally reflect new CPT and HCPCS 

codes that become effective January 1, 

2006 or that became effective since our 

last update. Table 32 also reflects the 

addition of codes that will be 

recognized by Medicare for payment 

purposes effective January 1, 2006. It 

does not reflect the addition of the 

nuclear medicine codes that were 

discussed in section V.B.2 of this 

preamble. For the convenience of 

physicians and DHS entities, nuclear 

medicine codes appear on Addendum H 

with an asterisk to indicate that they 

will become effective on January 1, 2007 

for physician self-referral purposes. 

As a result of reviewing nuclear 

medicine codes as set forth in the CPT, 

we are adding CPT 78267 and 78268 for 

urea breath tests and analyses to the 

DHS category of clinical laboratory 

services. Although these codes appear 

under the nuclear medicine subheading 

in the CPT, they do not represent 

imaging services. Therefore, we do not 

consider CPT 78267 and 78268 

radiology or other imaging services. We 

are adding these codes to the Code List 

under the clinical laboratory services 

category. This is consistent with our 

payment policy, since these codes are 

reimbursed under the clinical laboratory 

fee schedule. We note that there are 

other tests involving the use of 

radiopharmaceuticals (for example, CPT 

83519) that are identified by the Code 

List as clinical laboratory services. 

Additionally, we are adding CPT code 

92506 for the evaluation of speech, 

language, voice, communication, and/or 

auditory processing. We had deleted 

this code in the Phase II physician selfreferral interim final rule published on 

March 26, 2004 (69 FR 16054) because 

it represented an audiology service. 

However, Medicare does not provide 

reimbursement for CPT code 92506 as 

an audiology service. Under Medicare, 

that code is only reimbursed as a 

speech-language pathology service and 

therefore must be added to the Code 

List. 

VI. Physician Fee Schedule Update for 

CY 2006 

A. Physician Fee Schedule Update 

The PFS update is determined using 

a formula specified by statute. Under 

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is equal to the product of 1 plus the 

percentage increase in the Medicare 

Economic Index (MEI) (divided by 100) 

and 1 plus the update adjustment factor 

(UAF). For CY 2006, the MEI is equal to 

2.8 percent (1.028). The UAF is ¥7.0 

percent (0.930). The product of the MEI 

(1.028) and the UAF (0.930), equals the 

CY 2006 update of ¥4.4 percent 

(0.95604). 

Our calculations of these figures are 

explained in this section. 

B. The Percentage Change in the 

Medicare Economic Index (MEI) 

The MEI measures the weightedaverage 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 2000 base year weights, is 

comprised of two broad categories: 

physician’s own time and physician’s 

PE. 

The physician’s 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 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 and other nonlabor 

inputs. The physician’s PE component 

also includes the following categories of 

nonlabor inputs: Office expense; 

medical materials and supplies; 

professional liability insurance; medical 

equipment; and other expenses. The 

components are adjusted to reflect 

productivity growth in physicians’

offices by the 10-year moving average of 

productivity in the private nonfarm 

business sector. Table 34 presents a 

listing of the MEI cost categories with 

associated weights and percent changes 

for price proxies for the 2006 update. 

For CY 2006, the increase in the MEI is 

2.8 percent, which includes a 1.0 

percent productivity offset based on the 

10-year moving average of multifactor 

productivity. This is the result of a 3.2 

percent increase in physician’s own 

time and a 4.4 percent increase in 

physician’s PE. Within the physician’s 

PE, the largest increase occurred in 

professional liability insurance, which 

increased 13.7 percent. 

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C. The Update Adjustment Factor 

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. Allowed expenditures are equal 

to actual expenditures in a base period 

updated each year by the sustainable 

growth rate (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. 

1. Calculation Under Current Law 

Under section 1848(d)(4)(B) of the 

Act, the UAF for a year beginning with 

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—

+ 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. Section 

1848(f)(3) specifies that the SGR (and, in 

turn, allowed expenditures) for the 

upcoming CY (2006 in this case), the 

current CY (2005) and the preceding CY 

(2004) are to be determined on the basis 

of the best data available as of 

September 1 of the current year. 

Allowed expenditures are initially 

estimated and subsequently revised 

twice. The second revision occurs after 

the CY has ended (that is, we are 

making the final revision to 2004 

allowed expenditures in this final rule 

with comment). Once the SGR and 

allowed expenditures for a year have 

been revised twice, they are final. 

Table 35 shows annual and 

cumulative allowed expenditures for 

physicians’ services from April 1, 1996 

through the end of the current CY, 

including the transition period to a CY 

system that occurred in 1999. Also 

shown is the SGR corresponding with 

each period. The calculation of the SGR 

is discussed in detail below. 

BILLING CODE 4120–01–P 

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ER21NO05.069</GPH>
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BILLING CODE 4120–01–C 


ER21NO05.070</GPH>
70304 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

Consistent with section 1848(d)(4)(E) 

of the Act, Table 35 includes our final 

revision of allowed expenditures for 

2004, a recalculation of allowed 

expenditures for 2005, and our initial 

estimate of allowed expenditures for 

2006. To determine the UAF for 2006, 

the statute requires that we use allowed 

and actual expenditures from April 1, 

1996 through December 31, 2005 and 

the 2006 SGR. Consistent with section 

1848(d)(4)(E) of the Act, we will be 

making further revisions to the 2005 and 

2006 SGRs and 2005 and 2006 allowed 

expenditures. Because we have 

incomplete actual expenditure data for 

2005, 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 Table 35 in 

the statutory formula illustrated below: 

UAF T et Actual

Actual

T et Actual = − × + arg − − . arg 05 05 / /

05

4 96 12 05 4 75 / / . 96 12 05

05 06

33 −

×

×

Actual SGR

UAF = Update Adjustment Factor 

Target05 = Allowed Expenditures for 

2005 or $80.4 billion 

Actual05 = Estimated Actual 

Expenditures for 2005 = $93.3 

billion 

Target 4/96–12/05 = Allowed Expenditures 

from 4/1/1996–12/31/2005 = $611.8 

billion 

Actual 4/96–12/05 = Estimated Actual 

Expenditures from 4/1/1996–12/31/ 

2005 = $642.5 billion 

SGR06 = 1.7 percent (1.017) 

$. $.

$ . . $ .$ .$. . . . 80 4 93 393 3

75 611 8 642 5

93 3 1 017

33 0 210 − × + −

×

× =−

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 ¥0.070 

or greater than 0.03. Since ¥0.210 is 

less than ¥0.070, the UAF for 2005 will 

be ¥0.070. 

Section 1848(d)(4)(A)(ii) of the Act 

indicates that 1 should be added to the 

UAF determined under section 

1848(d)(4)(B) of the Act. Thus, adding 1 

to ¥0.070 makes the UAF equal to 

0.930. 

VII. Allowed Expenditures for 

Physicians’ Services and the 

Sustainable Growth Rate 

A. Medicare Sustainable Growth Rate 

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 

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-forservice beneficiaries; 

(3) The estimated projected growth in 

real gross domestic product (GDP) 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 publish SGRs for 3 

different time periods, no later than 

November 1 of each year, using the best 

data available as of September 1 of each 

year. Under section 1848(f)(3)(C)(i) of 

the Act, the SGR is estimated and 

subsequently revised twice (beginning 

with the FY and CY 2000 SGRs) based 

on later data. (There were also 

provisions in the Act to adjust the FY 

1998 and FY 1999 SGRs. 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 making our 

preliminary estimate of the 2006 SGR, a 

revision to the 2005 SGR, and our final 

revision to the 2004 SGR. 

B. 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 

Federal Register (66 FR 55316) on 

November 1, 2001. We defined 

physicians’ services to include many of 

the medical and other health services 

listed in section 1861(s) of the Act. For 

purposes of determining allowed 

expenditures, actual expenditures, and 

SGRs, we have 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): 

• Physicians’ services. 

• Services and supplies furnished 

incident to physicians’ services. 

• Outpatient physical therapy 

services and outpatient occupational 

therapy services. 

• Antigens prepared by, or under the 

direct supervision of, a physician. 

• Services of physician assistants, 

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. 


ER21NO05.000</MATH> ER21NO05.001</MATH>
Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70305 

6Fisher, Elliott S., MD, MPH; David E. Wennberg, 

MD, MPH; Therese A. Stukel, Ph.D.; Daniel J. 

Gottlieb, MS; F.L. Lucas, Ph.D.; and Etoile L. 

Pinder, MS, ‘‘The Implications of Regional 

Variations in Medicare Spending. Part 1: The 

Content, Quality, and Accessibility of Care,’’ in The 

Annals of Internal Medicine, February 18, 2003, Vol 

138, Issue 4. 

• Screening mammography, 

screening pap smears, and screening 

pelvic exams. 

• Diabetes outpatient selfmanagement training services. 

• Medical nutrition therapy 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 exam. 

• Cardiovascular screening blood 

tests. 

• Diabetes screening tests. 

• Telehealth services. 

• Physician work and resources to 

establish and document the need for a 

power mobility device (see 70 FR 

50940). 

Telehealth services and the power 

mobility device related services have 

been added because they meet the 

statutory criteria for services to be 

included in the SGR (that is, these 

services are commonly performed or 

furnished by a physician or in a 

physician’s office). 

We appreciate the tremendous 

number of comments we received 

expressing concern about the negative 

update for 2006. Those comments are 

summarized below, along with our 

responses. 

Comment: Commenters noted that 

physicians’ costs are rising, while fees 

are being cut. The cumulative impact of 

the projected reductions from 2006 to 

2012 will be about ¥27 percent, while 

the MEI increase over this same period 

is projected to be 19 percent. 

Commenters predict that, based on the 

MEI alone, payments should increase by 

3.5 percent in 2006. Instead, payments 

are being reduced. Because commercial 

insurance carriers base their payment 

updates upon Medicare’s PFS, the 

overall negative impact is compounded. 

Many comments predict that costs to 

provide care will soon exceed 

reimbursement. The result will be that 

patient quality of care will be 

compromised, with doctors taking 

drastic measures to cut costs of health 

care delivery to remain solvent. 

Eventually, physicians will be unable to 

absorb the losses, and they will refuse 

or limit Medicare patients, resulting in 

reduced access to care. Costs will shift 

to inpatient settings, which will be more 

costly for Medicare, less efficient in 

delivering care, and yield worse health 

outcomes for beneficiaries. 

Commenters recommend that the SGR 

be replaced with an appropriate 

inflation rate (for example, the projected 

change in prices or the MEI). Updates 

should be linked to changes in the 

actual costs of medical practice. 

Response: We are fully cognizant of 

the potential implications of seven years 

of negative physician updates, remain 

concerned regarding those trends, and 

are closely monitoring physicians’

participation in the Medicare program, 

as well as beneficiaries’ access to care. 

At the same time, simply increasing 

spending by adding larger updates into 

the current volume-based payment 

system that is already experiencing 

increases of 12 to 13 percent or more per 

year would have an adverse effect from 

the standpoint both Medicare’s finances 

and beneficiary premiums and costsharing, and therefore would not 

promote better quality care. 

However, it is clear, under our current 

system, that there is much potential for 

physicians to improve the value of our 

health care spending. Under the current 

system, there are substantial variations 

in resources and in spending growth for 

the same medical condition in different 

practices and in different parts of the 

country, without apparent differences in 

quality and outcomes, and without a 

clear basis in existing medical evidence. 

A study published in 2003 looked at 

regional variations in the number of 

services received by Medicare patients 

who were hospitalized for hip fractures, 

colorectal cancer, and acute myocardial 

infarction.6 The researchers found that 

patients in higher spending areas 

received approximately 60 percent more 

care, but that quality of care in those 

regions was no better on most measures 

and was even worse for several 

preventive care measures. Further, there 

are many examples of steps that 

physicians can take to improve quality 

while helping to keep overall costs 

down (for example, management of 

diabetic patients may result in reduced 

hospital admissions). 

Because it is critical for CMS payment 

systems to support better outcomes for 

our beneficiaries while safeguarding 

Medicare’s finances, we are working 

closely and collaboratively with medical 

professionals and the Congress to 

consider changes to increase the 

effectiveness of the payment 

methodology Medicare uses to 

compensate physicians for providing 

services to Medicare beneficiaries. We 

are engaging physicians on issues of 

quality and performance with the goal 

of supporting the most effective clinical 

and financial approaches to achieve 

better health outcomes for Medicare 

beneficiaries. We are committed to 

developing reporting and payment 

systems that enable us to support and 

reward quality, and to improve care 

without increasing overall Medicare 

costs. When clear, valid and widely 

accepted quality measures are in place, 

pay-for-performance is a tool that can 

enable our reimbursement methodology 

to better support efforts to improve 

quality and to avoid unnecessary costs. 

Currently, hospitals and physicians 

are paid under separate systems. Under 

these systems, physicians do not receive 

credit for avoiding unnecessary 

hospitalizations by providing better care 

to their patients. However, in our 

physician group practice demonstration 

project, physicians could receive 

performance-based payments derived 

from savings from preventing chronic 

disease complications, avoiding 

hospitalizations, and improving quality 

of care. 

The evidence is increasing that when 

healthcare providers are given 

incentives for achieving higher quality 

care, they respond by taking a range of 

steps from the simple to the high-tech 

to improve care and reduce costs (for 

example, by avoiding unnecessary 

hospital care). This is not surprising, as 

our health professionals are dedicated, 

and they want to do everything in their 

power to get the best care to their 

patients. So when we support high 

quality care, we enable professionals to 

do what they do best. 

We have seen this approach work 

first-hand with hospital payments 

where we have tied the annual hospital 

payment update to quality measure 

reporting. It has had a positive impact 

on the availability of quality 

information, with about 98 percent of 

the hospitals subject to this provision 

reporting quality data. 

Reporting clinically valid quality 

measures is an important step toward 

achieving major improvements in 

quality. If you cannot measure 

something, it is hard to take steps to 

improve it. We have been working hard 

in close collaboration with health 

professionals and other stakeholders to 

promote the development of better 

measures for reporting on the quality of 

care. 

Comment: Most commenters support 

the overall development of measures 

related to the quality and efficiency of 

care furnished by physicians, but many 

70306 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

are concerned that the promotion of 

high quality health care is incompatible 

with the current SGR system. Any 

performance measures may involve 

additional services or administrative 

actions, and will exacerbate the 

problems with the current volume-based 

update formula. Some commenters note 

that many electronic health record 

systems with decision support tools 

specifically prompt physicians to 

perform additional diagnostic tests and 

screenings, which, in turn, could offset 

any projected savings. Overall, pay-forperformance will drive spending over 

the target, negatively impacting future 

updates, and thereby penalizing 

physicians for participating in pay-forperformance. 

Commenters also expressed the 

concern that health information 

technology systems, a key component of 

many pay for performance programs, 

will be unaffordable to physicians 

facing payment cuts. 

Response: Medicare needs to 

encourage and reward efficiency and 

high quality care, and not simply pay 

for more services, regardless of the 

quality of those services or of the impact 

that those services have on patient 

health. 

Currently, the physician payment 

system does not always recognize 

clinically appropriate care. For example, 

Medicare will pay for a duplicate x-ray 

or blood test right before surgery if a 

hospital does not coordinate care 

adequately with the physician’s office. 

The physician payment system should 

support, encourage, and provide an 

incentive for physicians to improve 

quality and reduce unnecessary 

Medicare costs by avoiding unnecessary 

services (like duplicate tests). 

Another way the current physician 

payment system fails to encourage 

clinically appropriate care is the way in 

which it tends to steer patient care 

decisions. Oncologists, for example, are 

paid less for transitioning a terminal 

patient to palliative care and focusing 

on quality of life issues, than for 

recommending and providing intensive 

procedures, even if the side effects of 

those procedures are significant and the 

benefits negligible. In addition, the 

current payment system does not 

reward physicians who actively prevent 

readmissions for patients with heart 

failure or diabetes. 

Linking a portion of Medicare 

payments to valid measures of quality 

and effective use of resources could give 

physicians more direct incentives to 

implement the innovative ideas and 

approaches that actually result in 

improvements in both the value and 

quality of care that people with 

Medicare receive. 

We have been working on the 

technical methods for supporting 

effective, simple, and least burdensome 

reporting and payment based on these 

measures. In the years ahead, it is 

expected that electronic record systems 

can be developed that would provide 

information that is needed to measure 

and report on quality while fully 

protecting patient confidentiality. 

However, while electronic health 

records would greatly facilitate the 

accurate and efficient use of information 

on quality measures and quality 

improvement, progress on supporting 

quality improvement should not be 

delayed until electronic health records 

are widely used. Indeed, taking steps 

now to promote quality reporting and 

improvement also could promote the 

adoption of and investment by 

physicians in electronic records, which 

would facilitate more efficient quality 

reporting and quality improvement 

activities. In the short term, there is 

considerable evidence that information 

on a broad range of quality measures 

can be obtained adequately via 

information transmitted on existing 

claims. Steps will be taken to ensure 

patient confidentiality when obtaining 

these quality measures. 

In addition, we believe that several 

Federal government actions are creating 

favorable market conditions for the 

adoption of health information 

technology. First, HHS, through the 

Office of the National Coordinator for 

Health Information Technology, is 

leading a public-private partnership to 

reduce the risk of Health Information 

Technology investment by: harmonizing 

health information standards; certifying 

health IT products to ensure consistency 

with standards; addressing variations in 

privacy and security policies that can 

pose challenges to interoperability; and, 

developing an architecture for 

nationwide sharing of electronic health 

information. Second, two recently 

proposed rules discussed an exception 

to the Stark statute and a safe harbor to 

the anti-kickback statute for eprescribing technology and electronic 

health records, which would create 

opportunities for physicians to acquire 

health information technology free or at 

a reduced cost. 

In January 2006, we will start the 

process of collecting quality information 

on services provided by physicians in 

certain specialties and subspecialties 

through the voluntary reporting of GCodes for quality indicators. The Gcodes were established by Medicare to 

supplement claims data with clinical 

data pertinent to a variety of quality 

measures, without the burdens of chart 

abstraction. Those quality measures 

have been achieved through a process of 

study and consensus with input from 

physicians and others. 

Comment: Commenters suggested that 

we should assume the leadership in 

pushing the Congress to enact 

legislation preventing a negative update 

for 2006, and to replace the SGR with 

a more sustainable system. They stated 

that it would be a show of good faith 

and leadership for CMS to take the 

administrative action to remove drugs 

from the SGR and levels of allowed 

expenditures retroactively to 1996, even 

prior to legislative action. The 

commenters opined that if CMS makes 

the administrative changes now, worth 

about $111 billion, then the legislative 

price tag will drop and will increase the 

likelihood of Congressional action to fix 

the SGR permanently. 

Response: We are concerned about the 

projections of seven years of negative 

updates to physician payments and are 

closely monitoring the current volumebased payment system for physicians’

services. The CMS Office of the Actuary 

(OACT) estimated under its Mid-Session 

Baseline that removing drugs from the 

SGR and allowed expenditures 

retroactively to 1996 would cost $111 

billion. We note that our current 

estimate is that removing drugs 

prospectively would not provide relief 

to the negative updates projected for 

2006 and the succeeding several years. 

OACT estimates removing drugs 

prospectively would cost an additional 

$36 billion over 10 years. These changes 

would also have significant impacts on 

beneficiary premiums. Consequently, 

while we have carefully reviewed our 

authority to make this administrative 

change, we also have been working with 

the Congress and health professional 

organizations on payment reforms that 

would improve the effectiveness of the 

payment methodology for physicians 

without increasing overall Medicare 

costs. 

Comment: Many commenters 

indicated that they support removing 

the costs of Part B covered drugs from 

the calculation of the SGR, and 

provided or referenced legal opinions 

and Congressional support for this view. 

Some commented that they find no 

basis in the statute for ever including 

drugs in the definition of physicians’

services, and CMS is therefore obligated 

to remove them retroactively from the 

SGR. 

Commenters contend that the rapid 

increase in the price of drugs is a major 

contributor to increased spending on 

physician-administered drugs. 

Therefore, it is not logical to include 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70307 

drugs in calculating the target, because 

the growth in expenditures on these 

drugs is not controlled by physicians 

and reduced payments to physicians 

will not affect future spending on Part 

B drugs provided incident to 

physicians’ services. 

Some commenters noted that 

including drugs in the SGR has not led 

to controls on drug spending and, as a 

result, removing them would not lead to 

increased spending on drugs. These 

commenters opined that spending on 

drugs is rising far more rapidly than 

spending on physicians’ and other 

practitioners’ services. According to 

these commenters, in 1996 drugs 

represented 3.7 percent of the physician 

spending portion of the SGR 

calculation, but in 2004, drugs 

represented 9.8 percent. 

Commenters stated that growth in 

Medicare spending on drugs is driven 

primarily by the introduction of 

expensive new drugs to the Medicare 

population and extensive marketing 

(including direct-to-consumer 

advertising), and that prices are set by 

drug companies that are not impacted 

by negative updates to the Medicare 

physician fee schedule. 

Some commenters indicated that the 

increase in drug spending is due to 

government policies that encourage the 

rapid development of drugs. 

Response: The statute provides the 

Secretary with clear authority to specify 

the services that are included in the 

SGR. Section 1848(f)(4)(A) of the Act 

indicates that the term ‘‘physicians 

services’’ includes other items and 

services specified by the Secretary that 

are commonly performed or furnished 

by a physician or in a physician’s office. 

We disagree with the comments 

suggesting that the Secretary does not 

have the authority to include drugs in 

the definition of physicians’ services for 

purposes of determining allowed 

expenditures, actual expenditures, and 

the SGR. We define ‘‘physicians’

services’’ to include many of the 

medical and other health services listed 

in section 1861(s) of the Act that meet 

the criterion of being commonly 

performed by a physician or furnished 

in a physicians’ office. Because 

‘‘incident to’’ drugs covered under 

1861(s) of the Act are commonly 

furnished in physicians’ offices, we 

include these items in the calculation of 

the SGR and allowed expenditures. 

We have indicated in the past that 

retrospective removal of drugs from the 

SGR is statutorily difficult. For example, 

the statute requires the estimated SGR 

be refined twice based on actual data. 

We do not see a legal basis to reestimate the SGR and allowed 

expenditures for a year after it has been 

estimated and revised twice. Further, as 

noted previously, our current estimate is 

that removing drugs retroactively from 

the SGR would not result in a positive 

update for 2006 or the succeeding few 

years. 

Comment: CMS has clearly excluded 

drugs from physicans’ services for 

purposes of administering other 

Medicare payment provisions. For 

example, in the December 13, 2002 

Inherent Reasonableness rule (67 FR 

76684), CMS applied inherent 

reasonableness to certain Part B items 

and services other than physicians’

services as defined and paid for under 

section 1848 of the Act, stating that 

drugs are paid under section 1842(o) of 

the Act and not section 1848 of the Act. 

In response to comments, CMS asserted 

that the inherent reasonableness 

provision should therefore be applied to 

drugs administered in physicians’

offices. 

Response: As we pointed out in the 

December 13, 2002 Federal Register, the 

statute specifies that inherent 

reasonableness applies to certain Part B 

items and services other than 

physicians’ services as defined and paid 

for under section 1848 of the Act. Drugs 

are paid under section 1842(o) of the 

Act and not section 1848 of the Act. The 

application of inherent reasonableness 

to payments for drugs relates to the 

payment methodology for drugs, not to 

whether they are physicians’ services. 

Accordingly, our decision to permit the 

application of inherent reasonableness 

to compute the payment amounts for 

Part B drugs is not inconsistent with our 

determination that it is appropriate to 

include drugs furnished incident to a 

physician’s services in the definition of 

physicians’ services for purposes of 

computing the SGR and actual and 

allowed expenditures under the 

physician fee schedule. 

Comment: We received many 

comments criticizing the ability of the 

current SGR methodology to 

appropriately reflect many factors 

affecting physician spending. For 

example, malpractice insurance 

continues to escalate; there is a general 

increase in overhead and inflation; and 

there are additional expenses associated 

with regulatory compliance for which 

the SGR is not adjusted. The SGR does 

not account for trends in utilization 

attributable to important technological 

improvements, improved quality of 

care, and efficiency in the health care 

system overall. 

Also, commenters stated that payment 

updates under the SGR formula are tied 

to GDP, which bears little relationship 

to patients’ health care needs or 

physicians’ practice costs because 

medical needs of individual patients are 

not related to the overall economy. 

Patients’ needs do not diminish in 

slower economies, and are therefore 

wholly unrelated to measures of GDP. In 

addition, Medicare patients have more 

chronic diseases and require more 

medications, tests, counseling, and 

education than the average health care 

consumer; therefore, the time required 

to see a Medicare patient is 

disproportionately high relative to the 

Medicare payment received. 

Commenters are concerned that services 

to Medicare beneficiaries are not 

adequately reflected in GDP because 

they are disproportionately more 

expensive than services provided to the 

rest of the population. 

Commenters believe that reliance on 

GDP makes the SGR an inherently 

unstable system, and unnecessarily 

detracts from an appropriate focus on an 

analysis of actual data regarding the 

increasing costs of providing 

physicians’ services to Medicare 

beneficiaries. The formula fails to 

consider the growth in beneficiary 

population and utilization factors 

unrelated to economic trends. The GDP 

is a factor beyond physicians’ control 

and it is inappropriate to use it as a 

means to control growth in Medicare 

spending. 

Response: Under section 1848(d)(4) of 

the Act, the PFS update is equal to the 

product of the percentage increase in 

the MEI and the UAF. The UAF is 

determined by comparing allowed and 

actual expenditures from prior years 

and the current year, and adjusting the 

update to account for the difference. 

The SGR is used to calculate allowed 

expenditures, and the GDP is one of the 

components used to calculate the SGR. 

Change in enrollment in fee-for-service 

Medicare is one of the factors used in 

computing the SGR. (See section 

1848(f)(2)(B) of the Act.) 

The percentage change in the MEI is 

one of the key components used to 

update the PFS CF. In accounting for the 

weighted average price change for 

various inputs involved with producing 

physicians’ services, the MEI measures 

inflation in physician practice costs and 

general wage levels. Elements of the 

MEI include measures of physicians’

PEs, including nonphysician employee 

compensation, office expenses, medical 

material and supplies, professional 

liability insurance, and medical 

equipment. As noted above in this 

section, professional liability insurance 

experienced the largest percentage 

increase of any component of the MEI 

for 2006. 

70308 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

The GDP is a general measure of 

economic growth. It is not intended to 

reflect factors specific to operating a 

medical practice because these are 

captured in the MEI. Currently, the 

statute requires that we use the GDP as 

a component of the SGD, which is then 

used to calculate the target level of 

expenditures. 

We disagree with the comment that 

use of GDP makes the SGR inherently 

unstable. The SGR is based on the 10 

year average of GDP, so year-to-year 

changes are averaged over a significant 

period, modulating any fluctuations 

from one year to the next. 

Comment: Some commenters stated 

that physicians are penalized with pay 

cuts when Medicare spending on 

physicians’ services exceeds the SGR 

spending target, yet the SGR is not 

adjusted to take into account many 

factors beyond physicians’ control, 

including government policies that, 

although good for patients, promote 

Medicare spending on physicians’

services. Specifically, governmentinduced increases in spending on 

physicians’ services should be 

accurately reflected in the SGR target. 

The impact of these government policies 

on spending for physicians’ services is 

ignored or underestimated in 

calculating the target. New government 

policies often result not only in direct 

expenditures, but can also lead to 

ancillary new expenditures that are not 

appropriately reflected in the target. For 

example, new preventive benefits can 

lead to additional physician services, 

such as office visits. CMS has not 

provided details as to how its estimates 

of costs for new benefits are calculated 

under section 1848(f)(2)(D) of the Act, 

making it impossible to judge the 

accuracy of its target adjustments. 

Commenters also contend there have 

been a number of regulatory changes 

that encouraged growth in spending on 

physicians’ services by shifting services 

from facilities to physicians’ offices. 

Services previously provided by 

facilities (and not included in the 

calculation of actual and allowed 

expenditures in the base year) are now 

provided in physicians’ offices, and are 

not reflected in the current level of 

allowed expenditures. For example, the 

growth in therapy services was 

influenced by the elimination of costbased reimbursement to many facilities. 

This led many rehabilitation agencies to 

terminate their provider numbers and 

enroll as physical therapists in private 

practice. It also provided incentives for 

hospitals to discharge patients sooner, 

leading to increased therapy services 

paid under the physician fee schedule. 

Commenters urge CMS to adjust for 

other spending increases attributable to 

quality improvement programs that 

trigger physicians’ services. 

Commenters provided examples of 

increased administrative demands and 

costs being imposed upon physicians 

through Federal program requirements 

including: transition of new and dually 

eligible beneficiaries into Medicare Part 

D drug plans; electronic prescribing; 

national demonstration on pay for 

performance; and Medicare policies on 

competitive acquisition for outpatient 

drugs and biologicals under Part B. 

Response: As described previously, 

the calculation of the SGR is determined 

by statute. Policy changes due to statute 

or regulation are required to be 

accounted for in the SGR calculation. 

For example, past changes that were 

expected to result in increased spending 

for therapy were reflected in prior years’

SGR calculations. (See the CY 2002 

Final Rule (66 FR 55320).) Similarly, 

last year we made an adjustment to the 

SGR to account for increased Medicare 

spending for physicians’ services as a 

result of the MMA provisions providing 

for Medicare coverage of an initial 

preventive physical examination, 

cardiovascular, and diabetes screening 

tests. (See the CY 2005 Final Rule (69 

FR 66388).) Based on subsequent data, 

we will revise these estimates and 

adjust the SGR as discussed in section 

F. of this preamble. 

Comment: We received many public 

comments that argued for adjusting the 

SGR for changes in expenditures 

resulting from national coverage 

determinations (NCDs). According to 

these comments, any changes in 

national Medicare coverage policy, such 

as a Program Memorandum or an NCD, 

constitute regulatory changes for 

purposes of computing the SGR. The 

commenters indicate that, because the 

statute provides the authority to adjust 

the SGR for statutory or regulatory 

changes, any new coverage initiative 

should be taken into account in 

determining the SGR. 

Commenters noted that CMS has 

previously stated that it is very difficult 

to estimate any costs or savings 

associated with specific coverage 

decisions. Additionally, CMS has stated 

that adjustments to the target for NCDs 

would likely be of such a small 

magnitude that it would have little 

effect on future projected updates. 

Commenters noted that CMS adjusts 

Medicare Advantage payments to 

account for NCDs, so clearly CMS has 

some means to estimate the costs of 

NCDs. Some commenters contracted 

with a private research firm to estimate 

the costs of several NCDs, to illustrate 

that it is possible to make such 

estimates and to provide a sense of their 

magnitude. These studies indicated that 

although certain individual NCDs do 

not significantly increase Medicare 

spending, some NCDs do have a 

significant impact. Furthermore, even if 

individually, the impacts of new NCDs 

are relatively minor, taken in the 

aggregate, even those NCDs with 

marginal impact contribute to rising 

utilization. 

Response: The large majority of 

Medicare spending is for services that 

are covered at local carrier discretion. 

While we may establish national 

coverage (or noncoverage) for a new 

item or service with a defined statutory 

benefit category, the NCD does not 

necessarily increase Medicare spending 

to the extent that the service has or 

would have been covered at local carrier 

discretion in the absence of a NCD. 

Because Medicare would cover these 

services without an NCD, it is unclear 

whether there are any additional costs 

associated with the NCDs. We may also 

issue an NCD to clarify Medicare 

coverage for existing items or services. 

This decision may establish national 

policy that replaces differing local 

practices. In these cases, there may not 

have been consistency among Medicare 

carriers as to whether an item or service 

qualified for coverage based on existing 

statute or regulation. Thus, our NCD 

would replace differing local practices 

with a national determination which, 

based on existing law and regulations, 

clarifies Medicare coverage for an item 

or service. Spending may or may not 

increase or decrease depending upon 

the degree to which the particular item 

or service is currently being covered by 

Medicare carriers and whether the 

decision is to establish coverage or 

noncoverage of the item or service. As 

a result, at this time, we do not intend 

to make any adjustment to the SGR to 

account for new NCDs. We will examine 

this issue further, for example, to 

determine the impact of new NCDs on 

Medicare spending for physicians’

services above and beyond what would 

happen with LCDs, though we expect 

that these NCDs would have, at most, a 

limited impact. 

Comment: In response to the 

discussion in the proposed rule about 

substantial growth in Medicare 

spending in certain areas, commenters 

suggested that growth may be due to 

previously unmet needs that are only 

now being met. The commenters 

pointed out that nothing in the data 

presented suggested that the increased 

levels of service were inappropriate. 

Some commenters noted that since the 

introduction of the SGR methodology 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70309 

many procedures have begun to move 

from settings, such as outpatient 

facilities, to physicians’ offices. As a 

result, the full cost of these procedures 

is not reflected in either the SGR or 

allowed expenditures. Commenters 

believe CMS must recognize this shift in 

site of service and make appropriate 

adjustments to the target. 

Response: We are taking collaborative 

steps to better understand these trends, 

including what changes in utilization 

are likely to be associated with 

important health improvements and 

which have limited or questionable 

health benefits. We have been reviewing 

the technical aspects of this situation in 

detail with health policy experts as well 

as the AMA and various specialty 

societies. Generally, our analysis 

indicates that while there are some 

identifiable factors that have 

contributed to higher spending, these 

factors do not account for a substantial 

part of the growth in spending on 

physicians’ services. Major contributors 

to the rapid increase in spending are 

more frequent and more intensive 

following visits, more frequent and 

more complex imaging, more frequent 

and more intensive minor procedures 

such as physical therapy, more frequent 

and more complex laboratory tests, and 

increased use of drugs in physicians’

offices. There is also a lot of evidence 

of much variation in the use of these 

services without much evidence of 

impact on health outcomes. This 

variation reinforces our commitment to 

continuing to develop better evidence 

on what additional spending is effective 

as well as to moving our payment 

system toward recognizing better quality 

care. Moreover, the statute does not 

provide a mechanism for us to recognize 

additional expenditures on physicians’

services resulting from changes in 

medical practice that are not also 

changes in law and regulation. As a 

result, we do not see any legal basis to 

make adjustment to the SGR to reflect 

the additional expenditures associated 

with these factors. 

C. Preliminary Estimate of the SGR for 

2006 

Our preliminary estimate of the 2006 

SGR is 1.7 percent. We first estimated 

the 2006 SGR in March and made the 

estimate available to the Medicare 

Payment Advisory Commission and on 

our web site. Table 36 shows that March 

2005 and our current estimates of the 

factors included in the 2006 SGR. 

TABLE 36.—2006 SGR CALCULATION

Statutory factors March estimate Current estimate 

Fees ................................................................................... 2.8 percent (1.028) ........................................................... 2.7 percent (1.027). 

Enrollment ......................................................................... ¥2.5 percent (0.975) ....................................................... ¥3.1 percent (0.969). 

Real Per Capita GDP ........................................................ 2.3 percent (1.023) ........................................................... 2.2 percent (1.022). 

Law and Regulation .......................................................... 0.0 percent (1.000) ........................................................... 0.0 percent (1.000). 

Total ........................................................................... 2.5 percent (1.025) ........................................................... 1.7 percent (1.017) 

Note: Consistent with section 1848(f)(2) of 

the Act, the statutory factors are multiplied, 

not added, to produce the total (that is, 1.027 

× 0.969 × 1.022 × 1.000 = 1.017). A more 

detailed explanation of each figure is 

provided in section VII.F.1 of this preamble. 

D. Revised Sustainable Growth Rate for 

2005 

Our current estimate of the 2005 SGR 

is 4.6 percent. Table 37 shows our 

preliminary estimate of the 2005 SGR 

that was published in the CY 2005 Final 

Rule (69 FR 66386) and our current 

estimate. 

TABLE 37.—2005 SGR CALCULATION

Statutory factors Estimate from CY 2005 Final Rule Current estimate 

Fees ................................................................................... 1.3 percent (1.013) ........................................................... 0.8 percent (1.008). 

Enrollment ......................................................................... ¥0.3 percent (0.997) ....................................................... 0.3 percent (1.003). 

Real Per Capita GDP ........................................................ 2.2 percent (1.022) ........................................................... 2.2 percent (1.022). 

Law and Regulation .......................................................... 1.0 percent (1.010) ........................................................... 1.2 percent (1.010). 

Total ........................................................................... 4.3 percent (1.043) ........................................................... 4.6 percent (1.046). 

A more detailed explanation of each 

figure is provided in section VII.F.2 of 

this preamble. 

E. Final Sustainable Growth Rate for 

2004 

The SGR for 2004 is 6.6 percent. Table 

38 shows our preliminary estimate of 

the 2004 SGR from the CY 2004 Final 

Rule (68 FR 63249), our revised estimate 

from the CY 2005 Final Rule (69 FR 

66387) and the final figures determined 

using the latest available data. 

TABLE 38.—2004 SGR CALCULATION

Statutory factors Estimate from CY 2004 Final Rule Estimate from CY 2005 Final Rule Final 

Fees ................................................... 2.7 percent (1.027) ........................... 1.4 percent (1.014) ........................... 1.3 percent (1.013). 

Enrollment .......................................... 1.7 percent (1.017) ........................... 1.7 percent (1.017) ........................... 1.3 percent (1.013). 

Real Per Capita GDP ........................ 2.8 percent (1.028) ........................... 2.2 percent (1.022) ........................... 2.1 percent (1.021). 

Law and Reg ...................................... 0.0 percent (1.000) ........................... 1.5 percent (1.015) ........................... 1.7 percent (1.017). 

Total ............................................ 7.4 percent (1.074) ........................... 7.0 percent (1.070) ........................... 6.6 percent (1.066). 

70310 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

A more detailed explanation of each 

figure is provided in section VII.F.3. 

F. Calculation of 2006, 2005, and 2004 

Sustainable Growth Rates 

1. Detail on the 2006 SGR 

All of the figures used to determine 

the 2006 SGR are estimates that will be 

revised based on subsequent data. Any 

differences between these estimates and 

the actual measurement of these figures 

will be included in future revisions of 

the SGR and allowed expenditures and 

incorporated into subsequent PFS 

updates. 

• Factor 1—Changes in Fees for 

Physicians’ Services (Before Applying 

Legislative Adjustments) for 2006 

This factor is calculated as a 

weighted-average of the 2006 fee 

increases 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 83.1 percent of total 

allowed charges included in the SGR in 

2006 and are updated using the MEI. 

The MEI for 2006 is 2.8 percent. 

Diagnostic laboratory tests are estimated 

to represent approximately 7.2 percent 

of Medicare allowed charges included 

in the SGR for 2006. Medicare payments 

for these tests are updated by the 

Consumer Price Index for Urban Areas 

(CPI–U). However, section 629 of the 

MMA specifies that diagnostic 

laboratory services will receive an 

update of 0.0 percent from 2004 through 

2008. 

Drugs are estimated to represent 9.7 

percent of Medicare allowed charges 

included in the SGR in 2006. Sections 

303 and 304 of the MMA require 

Medicare to pay for most drugs at 106 

percent of ASP beginning January 1, 

2005. We estimated a weighted-average 

change in fees for drugs included in the 

SGR (using the ASP plus 6 percent 

pricing methodology) of 4.1 percent for 

2006. Table 39 shows the weightedaverage of the MEI, laboratory and drug 

price changes for 2006. 

TABLE 39 

Weight Update 

Physician ...................... 0.831 2.8 

Laboratory ..................... 0.072 0.0 

Drugs ............................ 0.097 4.1 

Weighted-average ........ 1.000 2.7 

We estimate that the weighted-average 

increase in fees for physicians’ services 

in 2006 under the SGR (before applying 

any legislative adjustments) will be 2.7 

percent. 

• Factor 2—The Percentage Change in 

the Average Number of Part B Enrollees 

From 2005 to 2006 

This factor is our estimate of the 

percent change in the average number of 

fee-for-service enrollees from 2005 to 

2006. Services provided to Medicare 

Advantage (MA) plan enrollees are 

outside the scope of the SGR and are 

excluded from this estimate. OACT 

estimates that the average number of 

Medicare Part B fee-for-service enrollees 

will decrease by ¥3.1 percent from 

2005 to 2006. Table 40 illustrates how 

this figure was determined. 

TABLE 40 

2005 2006 

Overall ..................................................................................... 39.536 million ......................................................................... 40.059 million. 

Medicare Advantage (MA) ...................................................... 5.070 million ........................................................................... 6.654 million. 

Net .......................................................................................... 34.466 million ......................................................................... 33.405 million. 

Percent Increase ..................................................................... ................................................................................................ ¥3.1 percent. 

An important factor affecting fee-forservice 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 

calendar year, 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 2006 becomes 

known. 

• Factor 3—Estimated Real Gross 

Domestic Product Per Capita Growth in 

2006 

We estimate that the growth in real 

GDP per capita from 2005 to 2006 will 

be 2.2 percent (based on the 10-year 

average GDP over the ten years of 1997–

2006). Our past experience indicates 

that there have also been changes in 

estimates of real per capita GDP growth 

made before the year begins and the 

actual change in GDP 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 2006. 

• Factor 4—Percentage Change in 

Expenditures for Physicians’ Services 

Resulting From Changes in Statute or 

Regulations in 2006 Compared With 

2005 

The statutory and regulatory 

provisions that will affect expenditures 

in CY 2006 relative to CY 2005 are 

estimated to have an impact on 

expenditures of less than 0.05 percent. 

These provisions include the expiration 

of the temporary higher payments to 

physicians in Alaska, the new powered 

wheelchair code for physicians, and the 

impact of the new IVIG service 

discussed elsewhere in this final rule 

with comment. 

2. Detail on the 2005 SGR 

A more detailed discussion of our 

revised estimates of the four elements of 

the 2005 SGR follows. 

• Factor 1—Changes in Fees for 

Physicians’ Services (Before Applying 

Legislative Adjustments) for 2005 

This factor was calculated as a 

weighted-average of the 2005 fee 

increases that apply for the different 

types of services included in the 

definition of physicians’ services for the 

SGR. 

We estimate that services paid using 

the PFS account for approximately 84.3 

percent of total allowed charges 

included in the SGR in 2005. These 

services were updated using the 2005 

MEI of 3.1 percent. We estimate that 

diagnostic laboratory tests represent 

approximately 7.0 percent of total 

allowed charges included in the SGR in 

2005. Medicare payments for these tests 

are updated by the CPI–U. However, 

section 629 of the MMA specifies that 

diagnostic laboratory services will 

receive an update of 0.0 percent from 

2004 through 2008. 

We estimate that drugs represent 8.7 

percent of Medicare allowed charges 

included in the SGR in 2005. Sections 

303 and 304 of the MMA require 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70311 

Medicare to pay for most drugs at 106 

percent of ASP beginning January 1, 

2005. We now estimate a weightedaverage change in fees for drugs 

included in the SGR of ¥21.1 percent 

for 2005. The estimated weightedaverage change in the CY 2005 Final 

Rule was ¥14.7 percent. The decline in 

the estimate is due to updated ASP data. 

Table 41 shows the weighted-average of 

the MEI, laboratory and drug price 

changes for 2005. 

TABLE 41 

Weight Update 

Physician .......... 0.843 3.1 

Laboratory ......... 0.070 0.0 

Drugs ................ 0.087 ¥21.1 

Weighted-average ................ 1.000 0.8 

After taking into account the elements 

described in Table 41, we estimate that 

the weighted-average increase in fees for 

physicians’ services in 2005 under the 

SGR (before applying any legislative 

adjustments) will be 0.8 percent. Our 

estimate of this factor in the CY 2005 

Final Rule was 1.3 percent. The 

reduction from 1.3 percent to our 

current estimate of 0.8 percent is 

primarily due to application of the drug 

pricing changes required by sections 

303 and 304 of the MMA. 

• Factor 2—The Percentage Change in 

the Average Number of Part B Enrollees 

From 2004 to 2005 

OACT estimates that the average 

number of Medicare Part B fee-forservice enrollees (excluding 

beneficiaries enrolled in M+C plans) 

increased by 0.3 percent in 2005. Table 

42 illustrates how we determined this 

figure. 

TABLE 42 

2004 2005 

Overall ..................................................................................... 39.048 million ......................................................................... 39.536 million. 

Medicare+Choice .................................................................... 4.683 million ........................................................................... 5.070 million. 

Net .......................................................................................... 34.366 million ......................................................................... 34.466 million. 

Percent Increase ..................................................................... ................................................................................................ 0.3 percent. 

OACT’s estimate of the 0.3 percent 

change in the number of fee-for-service 

enrollees, net of M+C enrollment for 

2005 compared to 2004, is greater than 

our original estimate of ¥0.3 percent in 

the CY 2005 Final Rule (69 FR 66388). 

While our current projection based on 

data from 8 months of 2005 is greater 

than our original estimate of ¥0.3 

percent when we had no data, it is still 

possible that our final estimate of this 

figure will be different once we have 

complete information on 2005 fee-forservice enrollment. 

• Factor 3—Estimated Real Gross 

Domestic Product Per Capita Growth in 

2005 

We estimate that the growth in real 

GDP per capita will be 2.2 percent for 

2005 (based on the 10-year average GDP 

over the ten years of 1996–2005). 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 2005 economic performance becomes 

available to us in 2006. 

• Factor 4—Percentage Change in 

Expenditures for Physicians’ Services 

Resulting From Changes in Statute or 

Regulations in 2005 Compared With 

2004 

There are a number of statutory 

provisions that affect the 2005 SGR. As 

mentioned previously in the preamble, 

sections 303 and 304 of the MMA 

changed Medicare payment for drugs. 

These provisions also changed Medicare 

payments for the administration of 

drugs. Section 303(a)(1) of the MMA 

amended section 1848(c)(2) of the Act to 

require the Secretary to make a number 

of changes that increased Medicare 

payment for drug administration 

beginning January 1, 2004. These 

changes permanently increased 

Medicare payments for drug 

administration by a weighted-average of 

110 percent. Section 303(a)(4) of the 

MMA required an additional 

transitional adjustment (temporary 

increase) to Medicare’s payment for 

drug administration of 32 percent for 

2004 and 3 percent for 2005. The change 

in the transitional adjustment of 32 

percent for 2004 to 3 percent for 2005 

would reduce Medicare payments for 

drug administration between 2004 and 

2005. However, some of this reduction 

will be lessened because we also 

adopted changes to the codes and 

payment amounts for drug 

administration based on 

recommendations from the AMA’s CPT 

Editorial Panel and Relative Value 

Update Committee (RUC), under the 

authority of section 1848(c)(2)(J) of the 

Act. We further increased PFS payments 

by paying separately for injections 

provided on the same day as another 

PFS service. We estimate that changes to 

our policy on injections and the changes 

to our drug administration payments 

taken together increased physician 

spending by 0.8 percent. 

There are several other statutory 

provisions that are estimated to increase 

Medicare spending for physicians’

services under the SGR. Section 413(a) 

of the MMA establishes a 5 percent 

increase in the PFS payment for services 

provided in physician scarcity areas. 

Section 413(b) of the MMA improves 

the procedures for paying the 10 percent 

PFS bonus payment for services 

provided in health professional shortage 

areas. We estimate that the provisions of 

section 413 of the MMA will increase 

Medicare PFS payments by 0.1 percent. 

Sections 611 through 613 of the MMA 

provide Medicare coverage for an initial 

preventive physical examination, 

cardiovascular and diabetes screening 

tests. We estimate that new Medicare 

coverage for these preventive services 

will increase spending for physicians’

services under the SGR by 0.3 percent. 

Taken together, we estimate that all of 

the statutory provisions for 2005 will 

increase Medicare spending for 

physicians’ services by 1.2 percent. 

3. Detail on the 2004 SGR 

A more detailed discussion of our 

final revised estimates of the four 

elements of the 2004 SGR follows. 

• Factor 1—Changes in Fees for 

Physicians’ Services (Before Applying 

Legislative Adjustments) for 2004 

This factor was calculated as a 

weighted-average of the 2004 fee 

increases that apply for the different 

types of services included in the 

definition of physicians’ services for the 

SGR. 

Services paid using the PFS 

accounted for approximately 83.3 

70312 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

percent of total Medicare allowed 

charges included in the SGR for 2004 

and are updated using the MEI. The MEI 

for 2004 was 2.9 percent. Diagnostic 

laboratory tests represented 

approximately 6.8 percent of total 2004 

Medicare allowed charges included in 

the SGR and are updated by the CPI–U. 

However, section 629 of the MMA 

specifies that diagnostic laboratory 

services will receive an update of 0.0 

percent from 2004 through 2008. Drugs 

represented approximately 9.9 percent 

of total Medicare allowed charges 

included in the SGR for 2004. 

Historically, Medicare paid for drugs 

under section 1842(o) of the Act at 95 

percent of average wholesale price 

(AWP). However, with some exceptions, 

sections 303 and 304 of the MMA 

generally require Medicare to pay for 

drugs at 85 percent of the AWP 

determined as of April 1, 2003, or a 

specified percentage of AWP based on 

studies by the Government 

Accountability Office and the Office of 

the Inspector General in 2004. We 

implemented section 303 and 304 of the 

MMA in an interim final rule making 

changes to the PFS for 2004, which 

appeared in the Federal Register on 

January 7, 2004 (see 69 FR 1086). Taking 

sections 303 and 304 of the MMA into 

account, we estimate a weighted-average 

change in fees for drugs included in the 

SGR of ¥11.5 percent for 2004. Table 43 

shows the weighted-average of the MEI, 

laboratory, and drug price increases for 

2004. 

TABLE 43 

Weight Update 

Physician .......... 0.833 2.9 

Laboratory ......... 0.068 0.0 

Drugs ................ 0.099 ¥11.5 

TABLE 43—Continued 

Weight Update 

Weighted-average ................ 1.000 1.3 

After taking into account the elements 

described in Table 43, we estimate that 

the weighted-average increase in fees for 

physicians’ services in 2004 under the 

SGR (before applying any legislative 

adjustments) was 1.3 percent. 

• Factor 2—The Percentage Change in 

the Average Number of Part B Enrollees 

From 2003 to 2004 

We estimate the increase in the 

number of fee-for-service enrollees 

(excluding beneficiaries enrolled in 

M+C plans) from 2003 to 2004 was 1.3 

percent. Our calculation of this factor is 

based on complete data from 2004. 

Table 44 illustrates the calculation of 

this factor. 

TABLE 44 

2003 2004 

Overall ..................................................................................... 38.465 million ......................................................................... 39.048 million. 

Medicare+Choice .................................................................... 4.655 million ........................................................................... 4.683 million. 

Net .......................................................................................... 33.810 million ......................................................................... 34.366 million. 

Percent Increase ..................................................................... ................................................................................................ 1.3 percent. 

• Factor 3—Estimated Real Gross 

Domestic Product Per Capita Growth in 

2004 

We estimate that the growth in real 

per capita GDP was 2.1 percent in 2004 

(based on the 10-year average GDP over 

the ten years of 1995–2004). This figure 

is a final one based on complete data for 

2004. 

• Factor 4—Percentage Change in 

Expenditures for Physicians’ Services 

Resulting From Changes in Statute or 

Regulations in 2004 Compared With 

2003 

There are four statutory provisions 

that increased 2004 Medicare spending 

relative to 2003. Section 412 of the 

MMA established a floor of 1.0 on 

adjustments to the physician work 

relative value unit for the GPCI for the 

years 2004 through 2006. Section 602 of 

the MMA increased the GPCIs for work, 

PE, and malpractice in Alaska to 1.67. 

We estimate that sections 412 and 602 

of the MMA increased 2004 Medicare 

spending included in the SGR by 0.6 

percent. Sections 303 and 304 of the 

MMA increased Medicare’s payments 

for drug administration in 2004. It 

further exempted the increases in 

payment from the budget neutrality 

provisions of section 1848(c)(2) of the 

Act. We estimate the section 303 and 

304 provisions increased spending for 

physicians’ services by 1.0 percent in 

2004. Taken together, we estimate that 

statutory provisions increased 2004 

spending for physicians’ services by 1.7 

percent (after accounting for rounding). 

VIII. Anesthesia and Physician Fee 

Schedule Conversion Factors (CF) for 

CY 2006 

The 2006 PFS CF will be $36.1770. 

The 2006 national average anesthesia CF 

is $16.9591. 

A. Physician Fee Schedule Conversion 

Factor 

Under section 1848(d)(1)(A) of the 

Act, the PFS CF is equal to the CF for 

the previous year multiplied by the 

update determined under section 

1848(d)(4) of the Act. 

Under section 1848(c)(2) of the Act, 

adjustments to RVUs may not cause the 

amount of expenditures to differ by 

more than $20 million from the amount 

of expenditures that would have 

resulted without such adjustments. As 

described earlier, we are implementing 

several changes to the work RVUs that 

would result in a change in 

expenditures that would exceed $20 

million if we made no offsetting 

adjustments to either the conversion 

factor or RVUs. 

With respect to the work RVUs, our 

policy has been to meet the budgetneutrality requirements in the statute by 

making an adjustment to the conversion 

factor. That is, we estimate the aggregate 

number of work RVUs that will be paid 

under current and revised policy in CY 

2006. We apply a uniform adjustment 

factor to the conversion factor to make 

the aggregate payments under the 

revised work RVUs equal the aggregate 

payments under the current work RVUs. 

As a result of the 2006 work RVU 

changes described earlier, we will be 

making an adjustment of .9985 percent 

to the conversion factor to meet the 

budget neutrality requirements in the 

statute. Note that this adjustment is also 

being applied to the anesthesia fee 

schedule as shown in table 46. 

We illustrate the calculation for the 

2006 PFS CF in Table 45. 

TABLE 45 

2005 Conversion Factor .... $37.8975. 

2006 Update ...................... ¥4.4 percent. 

2006 Adjustment for Work 

RVU Changes.

.9985. 

2006 Conversion Factor .... $36.1770. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70313 

B. Anesthesia Fee Schedule Conversion 

Factor 

Anesthesia services do not have RVUs 

like other PFS services. Therefore, we 

account for any necessary RVU 

adjustments through an adjustment to 

the anesthesia fee schedule CF to 

simulate changes to RVUs. We modeled 

the resource-based practice expense 

methodology using imputed anesthesia 

RVUs that were made comparable to 

other physician fee schedule services. 

As a result of modeling practice expense 

changes, we are incorporating a 1.00039 

adjustment to the anesthesia fee 

schedule conversion factor. We used the 

following figures to determine the 

anesthesia fee schedule CF (see Table 

46). 

TABLE 46 

2005 Anesthesia Conversion Factor $17.7594. 

2006 Update ¥4.4 percent. 

2006 Adjustment for Work 

RVU Changes 

.9985. 

2006 Adjustment for PE 

Changes 

1.00039. 

2006 Anesthesia Conversion Factor $16.9591. 

IX. Telehealth Originating Site Facility 

Fee Payment Amount Update 

Section 1834(m) of the Act establishes 

the payment amount for the Medicare 

telehealth originating site facility fee for 

telehealth services provided from 

October 1, 2001 through December 31 

2002, at $20. For telehealth services 

provided 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 2006 is 2.8 

percent. 

Therefore, for CY 2006, the payment 

amount for HCPCS code ‘‘Q3014, 

telehealth originating site facility fee’’ is 

80 percent of the lesser of the actual 

charge or $22.47. The Medicare 

telehealth originating site facility fee 

and MEI increase by the applicable time 

period is shown in Table 47. 

TABLE 47 

Facility fee MEI increase 

(percent) 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 

X. Provisions of the Final Rule With 

Comment 

The provisions of this final rule with 

comment restate the provisions of the 

August 2005 proposed rule, except as 

noted elsewhere in the preamble. 

XI. Waiver of Proposed Rulemaking 

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 substances 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. 

As discussed in sections III. and V. of 

this final rule with comment, we utilize 

HCPCS codes for Medicare payment 

purposes. The HCPCS is a national drug 

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 

codes, it is impracticable for CMS 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 provided to Medicare beneficiaries 

by physicians during the CY in which 

they become effective. Moreover, 

regulations implementing HIPAA (42 

CFR parts 160 and 162) reguire that the 

HCPCS be used to report health care 

services, including services paid under 

the PFS. We also assign interim RVUs 

to any new codes based on a review of 

the RUC recommendations for valuing 

these services. By reviewing these RUC 

recommendations for the new 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 providing the services. 

If we did not assign RVUs to new codes 

on an interim basis, the alternative 

would be to either not pay for these 

services during the initial CY or have 

each carrier 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. 

For the reasons outlined above, we 

find 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. We are providing a 

60-day public comment period. 

XII. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

of 1995, we are required to provide 60- 

70314 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

day notice in the Federal Register and 

solicit public comment before a 

collection of information requirement is 

submitted to the Office of Management 

and Budget (OMB) for review and 

approval. In order to fairly evaluate 

whether an information collection 

should be approved by OMB, section 

3506(c)(2)(A) of the Paperwork 

Reduction Act of 1995 requires that we 

solicit comment on the following issues: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

We are soliciting public comment on 

each of these issues for the following 

sections of this document that contain 

information collection requirements: 

Section 413.180 Procedures for 

Requesting Exceptions to Payment Rates 

Paragraph (b) specifies the criteria for 

a pediatric ESRD facility requesting an 

exception to payment rates. 

Paragraph (e) outlines the 

documentation that a pediatric ESRD 

facility must submit to CMS when 

requesting an exception to its payment 

rates. Paragraph (i) discusses the period 

of approval for payment exception 

requests. A prospective exception 

payment rate approved by CMS applies 

for the period from the date the 

complete exception request was filed 

with its intermediary until thirty days 

after the intermediary’s receipt of the 

facility’s letter notifying the 

intermediary of the facility’s request to 

give up its exception rate. 

The burden associated with the 

requirements in paragraph (e) is the 

time and effort required by the facility 

to prepare and submit the exception 

request to CMS. The burden associated 

with the requirement in paragraph (i) is 

the time and effort required by the 

facility to draft and mail the letter that 

notifies the intermediary of the facilities 

request to give up its exception rate. 

The collection requirement in this 

section has not changed. While this 

requirement is subject to the PRA, this 

requirement is currently approved in 

OMB No. 0938–0296. 

Section 413.184 Payment Exception: 

Pediatric Patient Mix 

Paragraph (b) specifies the 

documentation requirements that a 

pediatric ESRD facility must meet in 

order to qualify for an exception to its 

prospective payment rate based on its 

pediatric patient mix. In addition to the 

other qualifications specified in this 

section, this section states that a facility 

must submit a listing of all outpatient 

dialysis patients (including all home 

patients) treated during the most 

recently completed and filed cost report. 

The burden associated with this 

requirement is the time and effort for 

the facility to submit a listing of all 

outpatient dialysis patients (including 

all home patients) treated during the 

most recently completed and filed cost 

report. 

The collection requirement in this 

section has not changed. While this 

requirement is subject to the PRA, this 

requirement is currently approved in 

OMB No. 0938–0296. 

Section 413.186 Payment Exception: 

Self-Dialysis Training Costs in Pediatric 

Facilities 

In summary, this section outlines the 

requirements a pediatric ESRD facility 

must meet to qualify for an exception to 

the prospective payment rate based on 

self-dialysis training costs. Paragraph (e) 

states that a facility must provide 

specific information to support its 

exception request. Paragraph (f) states 

that in addition to the other 

qualifications outlined in this section, 

pediatric ESRD facility must submit 

with its exception request a list of 

patients, by modality, trained during the 

most recent cost report period, in order 

to justify its accelerated training 

exception request. 

The burden associated with these 

requirements is the time and effort for 

the facility to prepare and submit the 

required information to support its 

exception request, and the time and 

effort for the pediatric ESRD facility to 

prepare and submit with its exception 

request a list of patients, by modality, 

trained during the most recent cost 

report period. 

The collection requirements in this 

section have not changed. While these 

requirements are subject to the PRA, 

they are currently approved in OMB 

No.0938–0296. 

Section 414.804 Basis of Payment 

In summary, this section requires 

manufacturers to report ASP data to 

CMS. This section details the process a 

manufacturer must follow to calculate 

the ASP. The ASP reporting 

requirements are discussed in further 

detail in the interim final rule with 

comment, Medicare Program; 

Manufacturer Submission of 

Manufacturer’s Average Sales Price 

(ASP) Data for Medicare Part B Drugs 

and Biologicals, that published on April 

2, 2004 in the Federal Register 

(69FR17935–17941). 

The burden associated with these 

requirements is the time and effort 

required by manufacturers of Medicare 

Part B Drugs and biologicals to prepare 

and submit to the required ASP data to 

CMS. 

While these requirements are subject 

to the PRA, the requirements are 

currently approved in OMB No. 0938–

0921, with a current expiration date of 

September 30, 2007. 

We intend to revise this information 

collection to include adequate 

instructions for manufacturers to report 

the ASP, the WAC, and other data 

elements. These revisions will be 

addressed in detail in a revised 

information collection request in 

accordance with the Paperwork 

Reduction Act of 1995. 

We have submitted a copy of this 

proposed rule to OMB for its review of 

the information collection requirements 

described above. These requirements are 

not effective until they have been 

approved by OMB. 

If you comment on these information 

collection and recordkeeping 

requirements, please mail copies 

directly to the following: 

Centers for Medicare & Medicaid 

Services, Office of Strategic Operations 

and Regulatory Affairs, Regulations 

Development Group, Attn: Jim 

Wickliffe, [CMS–1502–P], Room C4–26–

05, 7500 Security Boulevard, Baltimore, 

MD 21244–1850; and 

Office of Information and Regulatory 

Affairs, Office of Management and 

Budget, Room 10235, New Executive 

Office Building, Washington, DC 20503, 

Attn: Brenda Aguilar, CMS Desk Officer, 

CMS–1502–P, 

Brenda.Aguilar@omb.eop.gov. Fax (202) 

395–6974. 

XIII. Response to Comments 

Because of the large number of public 

comments we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document, we will 

respond to the comments in the 

preamble to that document. 

XIV. Regulatory Impact Analysis 

We have examined the impact of this 

rule as required by Executive Order 

12866 (September 1993, Regulatory 

Planning and Review), the Regulatory 

Flexibility Act (RFA) (September 19, 

1980 Pub. L. 96–354), section 1102(b) of 

the Social Security Act, the Unfunded 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70315 

Mandates Reform Act of 1995 (Pub. L. 

104–4), and Executive Order 13132. 

Executive Order 12866 (as amended 

by Executive Order 13258, which 

merely reassigns responsibilities of 

duties) directs agencies to assess all 

costs and benefits of available regulatory 

alternatives and, when 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 

must be prepared for final rules with 

economically significant effects (that is, 

a final rule that would have an annual 

effect on the economy of $100 million 

or more in any one year, or would 

adversely affect in a material way the 

economy, a sector of the economy, 

productivity, competition, jobs, the 

environment, public health or safety, or 

State, local, or tribal governments or 

communities). As indicated in more 

detail below, we estimate that the PFS 

provisions included in this final rule 

with comment will redistribute more 

than $100 million in one year. We are 

considering this final rule with 

comment to be economically significant 

because its provisions are estimated to 

result in an increase, decrease or 

aggregate redistribution of Medicare 

spending that will exceed $100 million. 

Therefore, this final rule with comment 

is a major rule and we have prepared a 

regulatory impact analysis. 

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. 

Section 1102(b) of the Act requires us 

to prepare a regulatory impact analysis 

for any rule that may have a significant 

impact on the operations of a substantial 

number of small rural hospitals. This 

analysis must conform to the provisions 

of section 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 a Metropolitan 

Statistical Area and has fewer than 100 

beds. We have determined that this final 

rule with comment would have minimal 

impact on small hospitals located in 

rural areas. Of 227 hospital-based ESRD 

facilities located in rural areas, only 40 

are affiliated with hospitals with fewer 

than 100 beds. 

For purposes of the RFA, physicians, 

nonphysician practitioners, and 

suppliers are considered small 

businesses if they generate revenues of 

$6 million or less. Approximately 95 

percent of physicians are considered to 

be small entities. There are about 

875,000 physicians, other practitioners 

and medical suppliers that receive 

Medicare payment under the PFS. 

For purposes of the RFA, 

approximately 90 percent of suppliers of 

durable medical equipment (DME) and 

prosthetic devices are considered small 

businesses according to the Small 

Business Administration’s (SBA) size 

standards. We estimate that 106,000 

entities bill Medicare for durable 

medical equipment, prosthetics, 

orthotics, and supplies (DMEPOS) each 

year. Total annual estimated Medicare 

revenues for DME suppliers exceed 

approximately $8.5 billion in 2004. Of 

this amount, approximately $1.4 billion 

were for nebulizer drugs in 2004. The 

vast majority, 95 percent, of retail 

pharmacy companies are small 

businesses as measured by the SBA size 

standard. Approximately, 16,000 

pharmacies billed Medicare for 

immunosuppressive, oral anti-cancer, or 

oral anti-emetic drugs in 2004. 

Pharmacies received Medicare revenues 

for those drugs of approximately $350 

million in 2004. 

In addition, most ESRD facilities are 

considered small entities, either based 

on nonprofit status or by having 

revenues of $29 million or less in any 

year. We consider a substantial number 

of entities to be affected if the final rule 

is estimated to impact more than 5 

percent of the total number of small 

entities. Based on our analysis of the 

957 nonprofit ESRD facilities 

considered small entities in accordance 

with the above definitions, we estimate 

that the combined impact of the changes 

to payment for renal dialysis services 

included in this final rule with 

comment would have a 1.5 percent 

decrease in payments relative to current 

payments. 

The impact of the CAP provisions 

included in this final rule with 

comment on an individual physician is 

dependent on whether the drugs they 

provide to Medicare beneficiaries are 

included in the list of CAP drugs and 

whether the physician chooses to obtain 

drugs administered to Medicare 

beneficiaries through the CAP. 

In addition, the CAP provisions in 

this rule will have a potential impact on 

entities, either existing or formed 

specifically for this purpose, that are 

involved in the dispensing or 

distribution of drugs. The impact is 

dependent on the ability of potential 

vendors to successfully compete on a 

national level and receive approval as a 

vendor under the CAP. 

The analysis and discussion provided 

in this section, as well as elsewhere in 

this final rule with comment, complies 

with the RFA requirements. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

rule that may result in expenditures in 

any year by State, local, or tribal 

governments, in the aggregate, or by the 

private sector, of $120 million. Medicare 

beneficiaries are considered to be part of 

the private sector for this purpose. 

We have examined this final rule with 

comment in accordance with Executive 

Order 13132 and have determined that 

this regulation would not have any 

significant impact on the rights, roles, or 

responsibilities of State, local, or tribal 

governments. A discussion concerning 

the impact of this rule on beneficiaries 

is found later in this section. 

We have prepared the following 

analysis, which, together with the 

information provided in the rest of this 

preamble, meets all assessment 

requirements. It explains the rationale 

for and purposes of the rule; details the 

costs and benefits of the rule; analyzes 

alternatives; and presents the measures 

we plan to use to minimize the burden 

on small entities. As indicated 

elsewhere in this final rule with 

comment, we are making a variety of 

changes to our regulations, payments, or 

payment policies to ensure that our 

payment systems reflect changes in 

medical practice and the relative value 

of services. We provide information for 

each of the policy changes in the 

relevant sections of this final rule with 

comment. We are unaware of any 

relevant Federal rules that duplicate, 

overlap or conflict with this rule. The 

relevant sections of this final rule with 

comment contain a description of 

significant alternatives if applicable. 

A. Resource-Based Work and PE RVUs 

Under section 1848(c)(2) of the Act, 

adjustments to RVUs may not cause the 

amount of expenditures to differ by 

more than $20 million from the amount 

of expenditures that would have 

resulted without such adjustments. We 

are implementing several changes that 

would result in a change in 

expenditures that would exceed $20 

million if we made no offsetting 

adjustments to either the CF or RVUs. 

With respect to the work RVUs, our 

policy has been to meet the budgetneutrality requirements in the statute by 

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making an adjustment to the CF. That is, 

we estimate the aggregate number of 

work RVUs that will be paid under 

current and revised policy in CY 2006. 

We apply a uniform adjustment factor to 

the CF to make the aggregate payments 

under the revised work RVUs equal the 

aggregate payments under the current 

work RVUs. As a result of the 2006 work 

RVU changes described earlier, we will 

be making an adjustment of ¥0.6 

percent to the CF to meet the budget 

neutrality requirements in the statute. 

For PE RVUs, our policy has been to 

meet the budget-neutrality requirements 

in the statute by incorporating a 

rescaling adjustment in the PE 

methodologies. That is, we estimate the 

aggregate number of PE RVUs that will 

be paid under current and revised 

policy in CY 2006. We apply a uniform 

adjustment factor to make the aggregate 

number of revised PE RVUs equal the 

number estimated that would be paid 

under current policy. While we are 

continuing to apply this policy for 

general changes in coding and RVUs, we 

are increasing aggregate PFS payments 

to account for the higher payments for 

drug administration services resulting 

from the incorporation of the survey 

data submitted by the AUA. These 

increases in payment are being made 

under the authority of section 

1848(c)(2)(J) of the Act that exempts the 

changes in payments for drug 

administration from the budget 

neutrality requirements of section 

1848(c)(2)(B)(iv) of the Act. 

As described earlier, we will base PE 

payments in 2006 on the current 2005 

PE RVUs to the extent practicable after 

making changes required by law, such 

as the incorporation of the urology 

survey for the drug administration 

codes. In the situation where a code is 

new in 2006 and we do not have 2005 

PE RVUs, we created new PE RVUs to 

use as the basis for 2006 payments. 

Table 49, Impact of CY 2006 RVU 

Changes, Multiple Imaging Discount, 

and Conversion Factor Update on Total 

Medicare Allowed Charges by Specialty, 

shows the percentage impact by 

specialty of the PE changes in 

combination with other changes being 

implemented. 

The ¥4 percent decrease in payment 

for clinical psychology shown in the PE 

refinements column in Table 49 is 

attributable to the deletion of several 

codes and creation of new codes for 

certain psychological testing services. 

The deleted codes had reflected the 

practitioner’s work in the PE RVUs. As 

indicated in Table 29 of section III.D., 

we accepted the recommendation of the 

RUC’s HCPAC for work RVUs for the 

new codes. Thus, there is a shift in 

payment from the PE RVUs to the work 

RVUs for these psychological testing 

codes. We note that the increase in the 

payment in the work RVUs exceeds the 

decrease in payment in the PE RVUs, 

causing an overall net increase in 

payments to clinical psychologists of 2 

percent as a result of the shift from the 

PE RVUs to the work RVUs for these 

new codes. While not included in table 

49, we estimate that temporary payment 

associated with IVIG described 

previously will result in approximately 

$10 million in additional CY 2006 

allowed charges under the PFS. 

B. Malpractice RVUs 

As discussed in section II C. of this 

final rule with comment, we are making 

technical changes to the calculation of 

the malpractice RVUs. We are removing 

the malpractice data for specialties that 

occur less than 5 percent of the time in 

our data for a procedure code; adopting 

several changes to the crosswalks used 

to assign risk factors to specialties for 

which we did not otherwise have data; 

using the lowest risk factor of 1.00 for 

clinical psychology, licensed clinical 

social work, chiropractors, and physical 

therapists; and adding cardiology 

catheterization and angioplasty codes to 

the list of codes for which we apply 

surgical rather than nonsurgical risk 

adjustment factors. Table 49 shows the 

combined impact of these changes. The 

impact of these methodological changes 

in the calculation of resource-based 

malpractice expense RVUs is negligible 

as malpractice RVUs account for less 

than 4 percent of total payments. 

C. Multiple Imaging Procedures 

As discussed in section II.J of this 

final rule with comment, we are 

reducing payments for TCs of certain 

multiple imaging procedures performed 

in the same session within the same 

imaging families. In order to calculate 

the impact of this change, we examined 

2004 PFS carrier claims processed 

through March 31, 2005. We extracted 

all claims that were billed on the same 

day, for the same beneficiary, at the 

same provider, for multiple diagnostic 

imaging procedures within the same 

family of codes. For each subset of 

claims, the procedures were arrayed 

based on the pricing of the TC of these 

services. In the proposed rule, we 

simulated the effect of the multiple 

procedure payment reduction by 

accounting for 100 percent of the 

highest priced TC, and 50 percent of all 

other TCs. In this final rule with 

comment, we simulated the effect of the 

multiple procedure payment reduction 

by accounting for 100 percent of the 

highest priced TC, and 25 percent of all 

other TCs. This change is the result of 

public comments described more fully 

in section II.J. of this rule. Note that if 

the procedure was billed globally, the 

professional component was always 

calculated at 100 percent of the 

professional component (modifier-26) 

value. 

The simulated total allowed charges 

for each family of codes includes all 

global, technical, and professional 

utilization for the family of codes (for 

example, the sum of claims where the 

multiple procedure payment reduction 

would have been in effect, in addition 

to claims that would not have been 

subject to the multiple procedure 

payment reduction). These simulated 

totals were then compared to the actual 

allowed charges for each family of codes 

within the same time period to calculate 

the impacts of the change. 

Table 48 shows the actual 2004 

allowed charges by family of imaging 

procedures and lists the percentage 

impact by family if this policy had been 

in effect. Family 2 has the largest ¥9.5 

percent impact, while Family 11 has the 

smallest ¥0.7 percent impact. 

TABLE 48.—IMPACT OF MULTIPLE PROCEDURE REDUCTION FOR DIAGNOSTIC IMAGING BY FAMILY OF IMAGING SERVICES

Family Description of family of imaging procedures 

2004 Medicare 

allowed 

charges 

($ in millions) 

Percentage 

impact 

01 ...................... Ultrasound (Chest/Abdomen/Pelvis—Non-Obstetrical) ............................................................ $138 ¥3.4 

02 ...................... CT and CTA (Chest/Thorax/Abd/Pelvis) .................................................................................. 563 ¥9.5 

03 ...................... CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck) ................................................................. 97 ¥1.3 

04 ...................... MRI and MRA (Chest/Abd/Pelvis) ............................................................................................ 105 ¥2.4 

05 ...................... MRI and MRA (Head/Brain/Neck) ............................................................................................ 532 ¥3.1 

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TABLE 48.—IMPACT OF MULTIPLE PROCEDURE REDUCTION FOR DIAGNOSTIC IMAGING BY FAMILY OF IMAGING SERVICES—

Continued 

Family Description of family of imaging procedures 

2004 Medicare 

allowed 

charges 

($ in millions) 

Percentage 

impact 

06 ...................... MRI and MRA (spine) ............................................................................................................... 540 ¥2.2 

07 ...................... CT (spine) ................................................................................................................................. 24 ¥2.1 

08 ...................... MRI and MRA (lower extremities) ............................................................................................ 166 ¥1.6 

09 ...................... CT and CTA (lower extremities) ............................................................................................... 5 ¥1.0 

10 ...................... MR and MRI (upper extremities and joints) ............................................................................. 107 ¥1.4 

11 ...................... CT and CTA (upper extremities) .............................................................................................. 2 ¥0.7 

Total for all procedures subject to multiple imaging reductions ............................................... 2,276 ¥4.2 

Using the same data, we also 

summarized the dollar value of the 

reductions by specialty. Specialtyspecific percentage impacts were 

calculated by comparing each 

specialty’s 2004 allowed charges for all 

Medicare allowed services to the 

reduced allowed charges that would 

have occurred had this policy been in 

effect. As expected, the most significant 

impacts occur among radiologists, who 

would experience a ¥1 percent impact. 

Diagnostic testing facilities also 

experience a ¥1 percent impact. Most 

other specialties experience a very small 

(0.1 percent) payment increase as a 

result of the budget neutrality 

adjustment. (Because this multiple 

procedure reduction adjustment would 

otherwise reduce overall payments by 

0.1 percent, it is necessary to include a 

budget neutrality adjustment to the PE 

RVUs, resulting in positive impacts for 

most specialties.) Table 49 shows the 

percentage impact by specialty in 

combination with other changes being 

implemented. 

D. Combined Impacts 

Our estimates of changes in Medicare 

revenues for PFS services compare 

payment rates for 2006 with payment 

rates for 2005 using 2004 Medicare 

utilization for both years. We are using 

2004 Medicare claims processed and 

paid through June 30, 2005, that we 

estimate are 98.5 percent complete, and 

have adjusted the figures to reflect a full 

year of data. Thus, because we are using 

a single year of utilization, the estimated 

changes in revenues reflect payment 

changes only between 2005 and 2006. 

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 than those 

shown here. The payment impacts 

reflect averages for each specialty based 

on Medicare utilization. The payment 

impact for an individual physician 

would be different from the average, 

based on the mix of services the 

physician provides. 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 80 percent of their 

Medicare revenues from clinical 

laboratory services that are not paid 

under the PFS. Table 49 shows only the 

payment impact on PFS services. 

Table 49 shows the specialty level 

impact on payment of the work RVU 

changes, practice expense RVU changes, 

malpractice RVU changes, and multiple 

imaging payment changes being 

implemented for CY 2006. The column 

labeled ‘‘Final Rule Impacts’’ shows the 

combined effect of the changes in 

payment attributable to the work RVU 

changes, practice expense RVUs, 

malpractice RVUs, and the multiple 

imaging policy. The column labeled 

‘‘Impact of Update and Drug Admin. 

Transition shows the impact of these 

changes, and reflects the expiration of 

the transitional adjustment required by 

section 303 of the MMA for drug 

administration services. This 

adjustment was set at 32 percent for 

2004 and 3 percent for 2005. In 

addition, this column reflects a ¥4.4 

percent payment update to the CF 

described in section VI. of this final rule 

with comment and the budget neutrality 

scaler required by the changes in the 

work RVUs. 

BILLING CODE 4120–01–U 

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ER21NO05.071</GPH>
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BILLING CODE 4120–01–C 

Table 50 shows the impact on total 

payments for selected high-volume 

procedures of all of the changes 

previously discussed. We selected these 

procedures because they are the most 

commonly provided by a broad 

spectrum of physician specialties. There 

are separate columns that show the 

change in the facility rates and the 

nonfacility rates. For an explanation of 

facility and nonfacility PE refer to 

section II.A. in the preamble of this final 

rule with comment. 

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In the CY 2005 final rule, we showed 

the combined impact of PFS and drug 

payment changes on the total revenues 

for specialties that perform a significant 

volume of drug administration services. 

(69 FR 66406) Although we have not 

performed a similar combined impact 

analysis this year for all of the 

specialties considered last year, we have 

undertaken a similar analysis of 

hematology/oncology. In last year’s final 

rule, we announced a 1 year 

demonstration to collect information 

about symptoms for cancer patients 

receiving chemotherapy (69 FR 66308). 

In this final rule with comment, we are 

announcing a new demonstration 

project again focused on improving the 

quality of care provided to beneficiaries 

stricken with cancer. Although both of 

these demonstrations are implemented 

through the Secretary’s authority under 

sections 402(a)(1)(B) and 402(b) of the 

Social Security Act Amendments of 

1967 (Pub. L. 90–248), we discussed the 

impacts of the additional payments from 

the 2005 demonstration in last year’s 

final rule impact analysis. Therefore, we 

are also including an analysis of the 


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impact on payments to oncologists as 

the 2005 demonstration project ends 

and the new demonstration project 

begins. 

We have updated the analysis from 

the proposed rule using more recent 

data. As indicated in Table 51, PFS 

services account for approximately 25 

percent of Medicare revenues for 

oncologists. The current demonstration 

accounts for approximately 3 percent of 

Medicare revenues for oncologists. If we 

assume no growth in the volume of PFS 

services, the combined 2006 impact of 

changes in Medicare payments for all 

PFS and demonstration services 

provided by oncologists is –10 percent. 

We estimate that approximately 70 

percent of total Medicare revenues for 

oncologists are attributed to drugs. If we 

again assume no growth in the volume 

of PFS services and additionally assume 

no growth in Medicare Part B drug 

spending (price or volume), we project 

total Medicare revenues to oncologists 

would decline by –3 percent. 

If we assume historical growth for the 

volume of PFS services and continue to 

assume no growth in Medicare Part B 

drug spending, we estimate total 

Medicare revenues to oncologists would 

remain unchanged between 2005 and 

2006. 

If we assure historical growth for the 

volume of PFS services and for the 

volume of Medicare Part B drugs, we 

estimate total Medicare revenues to 

oncologists would increase by 6 percent 

between 2005 and 2006. 

We estimate that the revised 

chemotherapy demonstration project 

discussed earlier will result in 

additional allowed charges to 

oncologists of approximately $150 

million in CY 2006. 

E. Medicare Telehealth Services 

In section II.D. of this final rule with 

comment, we are adding individual 

medical nutrition therapy, as 

represented by HCPCS codes G0270, 

97802, and 97803, to the list of 

telehealth services. We believe that this 

change will have little effect on 

Medicare expenditures. 

F. Contractor Pricing of CPT Codes 

97039 and 97139 

As discussed earlier in the preamble 

of this final rule with comment (section 

II.E.), we will have the contractors value 

CPT codes 97039 and 97139. This will 

make the pricing methodology for these 

services consistent with our policy for 

other unlisted services and should not 

have a significant impact on Medicare 

expenditures. 

G. ESRD–MMA Related Provisions 

The ESRD related provisions in this 

final rule with comment are discussed 

in section II.G. To understand the 

impact of the changes affecting 

payments to different categories of 

ESRD facilities, it is necessary to 

compare estimated payments under the 

current payment system (current 

payments) to estimated payments under 

the revisions to the composite rate 

payment system as set forth in this final 

rule with comment (final payments). To 

estimate the impact among various 

classes of ESRD facilities, it is 

imperative that the estimates of current 

payments and final payments contain 

similar inputs. Therefore, we simulated 

payments only for those ESRD facilities 

for which we are able to calculate both 

current 2005 payments and final 2006 

payments. 

Due to data limitations, we are unable 

to estimate current and final payments 

for 171 facilities that bill for ESRD 

dialysis treatments. ESRD providers 

were grouped into the categories based 

on characteristics provided in the 

Online Survey and Certification and 

Reporting (OSCAR) file and the most 

recent cost report data from the 

Healthcare Cost Report Information 

System (HCRIS). We also used the June 

2005 update of CY 2004 Standard 

Analytical File (SAF) claims as a basis 

for Medicare dialysis treatments and 

separately billable drugs and 

biologicals. As we stated in the 

proposed rule, this is an updated 

version of the 2004 SAF file compared 

to the December 2004 version of the file 

we used in the proposed rule. 

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Table 52 shows the impact of CY 2006 

changes to payments to hospital based 

and independent ESRD facilities. We 

have included both composite rate 

payments as well as payments for 

separately billable drugs and biologicals 

because both are affected by the CY 

2006 changes. The first column of Table 

52 identifies the type of ESRD provider, 

the second column indicates the 

number of ESRD facilities for each type, 

and the third column indicates the 

number of dialysis treatments. 

The fourth column shows the effect of 

changes to the ESRD wage index as it 

affects the composite rate payments to 

ESRD facilities. Composite rate 


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payments account for about 60 percent 

of revenues to ESRD facilities. The 

fourth column compares aggregate wage 

adjusted composite rate payments using 

the revised ESRD wage index compared 

to the current ESRD wage adjusted 

composite rate payments. Since CY 

2006 is the first year of the 4-year 

transition to the revised ESRD wage 

index, ESRD facilities receive 25 percent 

of the revised CBSA-based wage 

adjusted composite rate and 75 percent 

of the current composite rate. The 

overall effect to all ESRD providers in 

aggregate is zero because the CY 2006 

ESRD wage index has been multiplied 

by a BNF to comply with the statutory 

requirement that any wage index 

revisions be done in a manner that 

results in the same aggregate amount of 

expenditures as would have been made 

without any changes in the wage index. 

The percent changes shown in the fifth 

and sixth columns are the result of the 

increase to the drug add-on and the 

changes in drug prices which are 

explained in section XIV.G. of this final 

rule with comment. 

The fifth column shows the effect of 

the changes in drug payments to ESRD 

providers between CY 2006 and CY 

2005. Drug payments account for about 

40 percent of revenues to ESRD 

providers. Current payments for drugs 

represent 2005 Medicare reimbursement 

using AAP prices for the top ten drugs 

(as discussed earlier in this preamble). 

Current Medicare spending for the top 

ten drugs is estimated using 2005 AAP 

prices times actual drug utilization from 

2004 claims. (EPO units are estimated 

using payments because the units field 

on bills represents the number of EPO 

administrations rather than the number 

of EPO units). Spending for CY 2006 is 

estimated by using the average of the 

four quarters of 2005 ASP +6 percent for 

the top ten drugs times actual drug 

utilization from 2004 claims. The prices 

for these top ten drugs are discussed 

earlier in this preamble and the average 

of the four quarters of 2005 are shown 

in Table 52. We did not have hospitalbased facilities utilization data for top 

ten drugs other than EPO. Therefore, we 

needed a proxy to estimate CY 2006 

payments to hospital-based facilities 

under ASP +6 pricing. We estimated 

these drugs by using the weighted 

spread of the difference between ASP +6 

and AWP prices from independent 

facilities and applying it to payments to 

hospital-based facilities for top ten 

drugs other than EPO. 

Payment for drugs in 2006 also 

includes the 14.7 percent drug add-on to 

the composite rate. This amount is 

computed by multiplying the wage 

adjusted composite rate for each 

provider and the dialysis treatments 

from 2004 claims. Column 5 is 

computed by comparing spending under 

the CY 2006 payment for drugs (4 

quarter average of 2005 ASP +6) 

including the 14.7 percent drug add-on 

amount to spending under current 

payments for drugs with the current 

drug add-on of 8.7 percent. 

We did not simulate any case mix in 

this impact table (Table 52) because 

2004 claims data do not include the new 

data fields (height and weight) that are 

needed to calculate case mix. These data 

fields were not required to be reported 

by providers until January 1, 2005. 

However, we have not made any 

changes to case mix for CY 2006. 

Column 6 shows the overall effect of 

all changes in drug and composite rate 

payments to ESRD providers. The 

overall effect is measured as the 

difference between CY 2006 payment 

with all MMA changes in this final rule 

with comment and current payment. CY 

2006 payment is computed by 

multiplying the composite rate for each 

provider (with both the CY 2006 ESRD 

wage index and the 14.7 percent drug 

add-on) times dialysis treatments from 

2004. In addition, the CY 2006 payment 

includes payments for separately 

billable drugs under the ASP +6 drug 

pricing using a 4 quarter average of 2005 

ASP +6. Current payment is the current 

wage adjusted composite rate for each 

provider times dialysis treatments from 

2004 claims plus current AAP priced 

drug payments for separately billable 

drugs with the current 8.7 percent drug 

add-on. 

The overall impact on ESRD providers 

in the aggregate is 1.2 percent increase. 

At first it may not seem obvious how the 

growth rates in columns 4 and 5 

combine to result in the overall growth 

effect in column 6. While the wage 

index changes are budget neutral in 

aggregate, the drug payments to all 

ESRD providers have increased by 2.9 

percent. Since drug payments to ESRD 

providers account for about 40 percent 

of revenues and the composite payment 

rate payment account for the other 60 

percent of revenues, the 2.9 percent 

growth in drugs combined with the 

budget neutral composite rate payments 

result in the overall 1.2 percent growth 

in payment to all ESRD providers. 

Some commenters expressed concern 

regarding the reduction in payment 

rates for dialysis facilities in certain 

States and requested that we provide a 

State-specific impact analysis. Table 53 

lists the impact for each State. 

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H. Payment for Covered Outpatient 

Drugs and Biologicals, and CAP 

Provisions 

As discussed in section II.H of this 

final rule with comment, the changes to 

the supplying fee for 

immunosuppressive, oral anticancer, 

and oral anti-emetic drugs are estimated 

to reduce total Federal expenditures by 

$2 million in 2006, and $14 million over 

the 5-year period, CY 2006 to 2010. The 

changes to the inhalation drug 

dispensing fee are expected to reduce 

total Federal expenditures by $120 

million in 2006, and $720 million over 

the 5-year period, CY 2006 to 2010. 

For the CAP provisions contained in 

this final rule with comment, the 

purpose of the CAP program is to 

provide choices to physicians and 

potentially achieve budgetary savings to 

Medicare and beneficiaries through a 

competitive bidding approach to 

determining Medicare payment rates for 

selected drugs. In addition the CAP will 

provide physicians with an alternative 

way to obtain these selected drugs that 

they use for treating their Medicare 

beneficiaries in their offices. As 

discussed in the July 6, 2005 interim 

final rule (70 FR 39091), we have 

estimated the impact of the costs of 

furnishing or administering drugs 

through the CAP on the Medicare 

program and expect it to be negligible, 

at the beginning until participating CAP 

physicians, approved CAP vendors and 

CMS gain more experience with the 

program. During the first year, we 

anticipate no significant additional cost 

savings or increases associated with the 

CAP, relative to the ASP payment 

system. The CAP program will provide 

alternatives to physicians who do not 

wish to purchase drugs directly or 

collect coinsurance. 

I. Private Contracts and Opt-Out 

Provision 

The changes discussed in section II.I. 

of this final rule with comment, with 

respect to private contracts and the optout provision, are estimated to have no 

significant impact on Medicare 

expenditures. However, we believe the 

changes will clarify that the 

consequences for the failure to maintain 

opt-out will apply regardless of whether 

the physician or practitioner was 

notified by the carrier. 

J. FQHC Supplemental Payment 

Provision 

Section 237 of the MMA amended 

section 1833(a)(3) of Act to provide 

supplemental payments to FQHCs that 

contract with Medicare Advantage (MA) 

organizations to cover the difference, if 

any, between the payment received by 

the health center for treating MA 

enrollees and the payment to which the 

FQHC would be entitled to receive 

under its cost-based all-inclusive 

payment rate. We estimate that this new 

MMA payment provision for FQHC 

services will not increase Medicare 

payments. In other words, this MMA 

provision will have no budgetary impact 

on the Medicare trust fund due to the 

fact that a supplemental payment will 

only be made when the MA payment to 

the health center is less than its original 

FQHC cost based rate. Consequently, no 

additional Medicare expenditures will 

be needed to pay the center up to what 

it would have received under original 

Medicare. 

K. National Coverage Decisions 

Timeframes 

The changes to § 426.340 discussed in 

section II.N. of this final rule with 

comment, are made in order to conform 

certain timeframes in the regulation to 

meet legislative changes made by the 

MMA of 2003. These changes to the 

regulation meet Congressional intent in 

the development of NCDs, and conform 

the regulation to the overall NCD 

process. There are no budget 

implications as a result of these 

changes. 

L. Coverage of Screening for Glaucoma 

As discussed in section II.O. of the 

preamble to this final rule with 

comment, we are expanding the 

definition of an eligible beneficiary 

under the glaucoma screening benefit to 

include Hispanic Americans age 65 and 

over, effective January 1, 2006, subject 

to certain frequency and other 

limitations on coverage. At present, 

§ 410.23(a)(2) (Conditions for and 

limitations on coverage of screening for 

glaucoma) defines the term ‘‘eligible 

beneficiary’’ to include individuals in 

the following high risk categories: 

• Individual with diabetes mellitus. 

• Individual with a family history of 

glaucoma. 

• African-Americans age 50 and over. 

Based on the projected utilization of 

these screening services and related 

medically necessary follow-up tests and 

treatment that may be required for the 

additional beneficiaries screened, we 

estimate that this expanded benefit will 

result in an increase in Medicare 

payments to ophthalmologists or 

optometrists who will provide these 

screening tests and related follow-up 

tests and treatment. However, as 

discussed in earlier in section II.O. this 

is not expected to have a significant cost 

impact on the Medicare program. 

M. Physician Referral for Nuclear 

Medicine Services 

As discussed earlier in section V., we 

are revising the regulations at 411.351 to 

include all diagnostic and therapeutic 

nuclear medicine services and supplies 

furnished or referred on or after January 

1, 2007, in the definitions of ‘‘radiology 

and certain other imaging services’’ and 

‘‘radiation therapy services and 

supplies,’’ respectively. 

As stated in the proposed rule, the 

inclusion of nuclear medicine as a 

designated health service (DHS) 

primarily would affect physicians and 

health care entities that furnish these 

types of items and services to Medicare 

beneficiaries. We are unable to quantify 

the number of physicians who have 

either an ownership or an investment 

interest in entities that furnish nuclear 

medicine services and/or supplies. Even 

if we assume that a substantial number 

of physicians have ownership or 

investment interests in these types of 

entities, we believe that, in general, the 

economic impact on these physicians 

would not necessarily be substantial, for 

the reasons stated below. 

Physician owners/investors of entities 

that furnish nuclear medicine services 

and supplies in a manner that satisfies 

the requirements of the in-office 

ancillary services exception would not 

be affected by this proposed rule. 

Similarly, a physician’s ownership of, or 

investment in, a rural provider of 

nuclear medicine services and supplies 

would not be affected by this rule if the 

financial relationship complies with the 

rural provider exception at 

§ 411.356(c)(1), which allows a 

physician to own and refer to an entity 

at least 75 percent of all DHS that it 

furnishes to residents of a rural area, as 

defined in the physician self-referral 

statute. We also do not know the extent 

to which equipment (such as a PET 

scanner) that was purchased by an 

entity in which a physician has an 

ownership or investment interest will be 

fully depreciated (or mostly so) or 

functionally obsolete by the time this 

rule is effective. 

Although the impact on an individual 

physician may be significant, we do not 

believe that physicians, in general, will 

be significantly affected if they are 

required to stop making referrals to an 

entity in which they have an ownership 

interest. We believe that the majority of 

physicians receive most of their income 

from the services they personally 

provide, and not from nuclear medicine 

services performed by entities that they 

own or invest in. In addition, we 

assume that, unless the physician 

established the entity to serve only his 

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or her patients, the entity receives 

referrals from other physicians. Thus, 

the physician may still receive a return 

on the ownership or investment. 

Likewise, we do not believe that a 

physician’s divestiture of his or her 

ownership interest would necessarily 

have a significant economic effect. We 

assume, that, from an economic 

standpoint, most physicians invest in 

entities because they are income 

producing. If an investment is 

successful, a physician should have 

little difficulty finding new investors 

willing to acquire the physician’s 

investment. We are unable to quantify 

the number of physicians who would 

wish to divest his or her ownership 

interest as a result of this rule, nor are 

we able to ascertain the degree to which 

these physicians would sell their 

ownership interests at a loss or profit. 

We believe the cost of divestiture will 

vary from situation to situation. Also, 

since the rule is not effective until 

January 1, 2007, this will give those 

physicians who wish to divest 

additional time to find a suitable buyer 

and will allow those physicians an 

additional year in which to depreciate 

their nuclear medicine equipment. 

We expect that this change may result 

in savings to both the Medicare and 

Medicaid programs by minimizing anticompetitive business arrangements as 

well as financial incentives that 

encourage over-utilization of costly 

nuclear medicine services. We cannot 

gauge with any certainty the extent of 

these savings to either program at this 

time. 

N. Alternatives Considered 

This final rule with comment contains 

a range of policies, including some 

which are related to specific MMA 

provisions. The preamble provides 

descriptions of the statutory provisions 

that are addressed, identifies those 

policies when discretion has been 

exercised, presents rationale for our 

decisions and, where relevant, 

alternatives that were considered. 

We considered making our proposal 

to include diagnostic and therapeutic 

nuclear medicine services and supplies 

as a DHS effective immediately; 

however, we are persuaded that 

delaying the effective date until January 

1, 2007 would be less disruptive to 

physicians who may choose to divest 

their investment and to beneficiaries 

who may need to receive services and 

supplies at another location. 

O. Impact on Beneficiaries 

There are a number of changes made 

in this final rule with comment that 

would have an effect on beneficiaries. In 

general, we believe these changes will 

improve beneficiary access to services 

that are currently covered or will 

expand the Medicare benefit package to 

include new services. 

As explained in more detail below, 

the regulatory provisions may affect 

beneficiary liability in some cases. Any 

changes in aggregate beneficiary liability 

from a particular provision will be a 

function of the coinsurance (20 percent 

if applicable for the particular provision 

after the beneficiary has met the 

deductible) and the effect of the 

aggregate cost (savings) of the provision 

on the calculation of the Medicare Part 

B premium rate (generally 25 percent of 

the provision’s cost or savings). 

To illustrate this point, under this 

final rule with comment the 2006 

national payment amount in the 

nonfacility setting for CPT code 99203, 

as shown in Table 50, is $92.61 which 

means that, in 2006, the beneficiary 

coinsurance for this service would be 

$18.52. 

In addition, as with the 2005 

chemotherapy demonstration project, 

the Medicare beneficiaries, or their 

supplemental insurers, who receive 

office-based cancer treatment, will be 

liable for the 20 percent Part B 

coinsurance on the G codes billed under 

the 2006 oncology demonstration. The 

service linking the payment of the 

demonstration fee has changed from a 

chemotherapy infusion or push service 

in 2005 to an established office visit of 

level 2, 3, 4, or 5 in 2006. The 

demonstration fee payment will be 

lower per unit of service for the 

Medicare beneficiary in 2006 than 2005 

thus, we expect that the coinsurance 

liability for a Medicare beneficiary will 

be reduced. However, the total impact 

on a beneficiary will depend upon the 

specific services received during 2006. 

Very few of the changes we are 

making impact overall payments and 

therefore will affect Medicare 

beneficiaries’ coinsurance liability. 

Changes discussed above that do affect 

overall spending would similarly 

impact beneficiaries’ coinsurance. 

For example, we have tried to ensure 

that the rule concerning physician selfreferral for nuclear medicine services 

would not adversely impact the medical 

care of Medicare or Medicaid patients. 

We recognize that our proposal may 

have an impact on current arrangements 

under which patients are receiving 

medical care, and that some financial 

arrangements may have to be 

restructured for patients to continue 

receiving medically necessary nuclear 

medicine services and supplies at the 

same location or from the same entity. 

Therefore, we are delaying the effective 

date of this provision until January 1, 

2007. Implementation of this rule is 

consistent with the statutory intent of 

section 1877(h) of the Act. This final 

rule with comment may help minimize 

anti-competitive behavior that can affect 

where a beneficiary receives health care 

services. It may also reduce the 

potential for overutilization, and thus, 

decrease the number of unnecessary 

tests or procedures to which Medicare 

and Medicaid patients are subjected. 

With respect to the CAP provisions, 

we do not expect, during the first year 

of the program, that there will be an 

appreciable difference to the 

beneficiaries if their drugs were to be 

administered by a physician 

participating in the CAP or purchasing 

them and being reimbursed for them 

within the ASP payment system. At 

least initially, until approved CAP 

vendors, participating CAP physicians, 

and CMS gain more experience with 

this new program, we do not anticipate 

there would be any significant 

additional costs or savings to a 

beneficiary whose physician 

participates in the CAP. The CAP 

should be largely transparent to the 

beneficiary population. The only change 

should be the entity that bills the 

beneficiary for the coinsurance. 

We also do not believe that 

beneficiaries would experience drug 

access issues as a result of 

implementation of the CAP. However, 

we intend to monitor beneficiary access 

closely and may propose additional 

changes to our payment system in the 

future, if necessary. 

P. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 54 we have 

prepared an accounting statement 

showing the classification of the 

expenditures associated with the 

provisions of this final rule with 

comment. Table 54 includes the impact 

of the changes in this rule on providers 

and suppliers and encompasses the 

¥4.4 percent negative update to the PFS 

based on the statutory SGR formula. 

Expenditures are classified as 

transfers to Medicare providers or 

suppliers (that is, ESRD facilities and 

physicians, other practitioners and 

medical suppliers, including CAP 

vendors, that receive payment under the 

PFS or Medicare Part B). 

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TABLE 54.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM CY 2005 TO THE CY 2006 

[In millions] 

Category Transfers 

Annualized Monetized Transfers .............................................................. Negative transfer—Estimated decrease in expenditures $2668. 

From Whom To Whom? ........................................................................... Federal Government To ESRD Medicare Providers; physicians, other 

practitioners and suppliers, including CAP vendors that receive payment under the Medicare Physician Fee Schedule; and Medicare 

Suppliers billing for Part B drugs. 

In accordance with the provisions of 

Executive Order 12866, this final rule 

with comment was reviewed by the 

Office of Management and Budget. 

List of Subjects 

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 record keeping 

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 424 

Emergency medical services, Health 

facilities, Health professions, Medicare, 

Reporting and recordkeeping 

requirements. 

42 CFR Part 426 

Administrative practice and 

procedure, Medicare, Reporting and 

recordkeeping requirements. 

■ For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR 

chapter IV as set forth below: 

PART 405—FEDERAL HEALTH 

INSURANCE FOR THE AGED AND 

DISABLED 

■ 1. The authority citation for part 405 

continues to read as follows: 

Authority: Secs. 1102, 1861, 1862(a), 1871, 

1874, 1881, and 1886(k) of the Social 

Security Act (42 U.S.C. 1302, 1395x, 

1395y(a), 1395hh, 1395kk, 1395rr, and 

1395ww(k)), and sec. 353 of the Public 

Health Service Act (42 U.S.C. 263a). 

Subpart D—Private Contracts 

■ 2. Section 405.435 is amended by—

■ A. Revising paragraph (b) introductory 

text. 

■ B. Adding paragraph (d). 

The revision and addition read as 

follows: 

§ 405.435 Failure to maintain opt-out. 

* * * * * 

(b) If a physician or practitioner fails 

to maintain opt-out in accordance with 

paragraph (a) of this section, then, for 

the remainder of the opt-out period, 

except as provided by paragraph (d) of 

this section—

* * * * * 

(d) If a physician or practitioner 

demonstrates that he or she has taken 

good faith efforts to maintain opt-out 

(including by refunding amounts in 

excess of the charge limits to 

beneficiaries with whom he or she did 

not sign a private contract) within 45 

days of a notice from the carrier of a 

violation of paragraph (a) of this section, 

then the requirements of paragraphs 

(b)(1) through (b)(8) of this section are 

not applicable. In situations where a 

violation of paragraph (a) of this section 

is not discovered by the carrier during 

the 2-year opt-out period when the 

violation actually occurred, then the 

requirements of paragraphs (b)(1) 

through (b)(8) of this section are 

applicable from the date that the first 

violation of paragraph (a) of this section 

occurred until the end of the opt-out 

period during which the violation 

occurred (unless the physician or 

practitioner takes good faith efforts, 

within 45 days of any notice from the 

carrier that the physician or practitioner 

failed to maintain opt-out, or within 45 

days of the physician’s or practitioner’s 

discovery of the failure to maintain optout, whichever is earlier, to correct his 

or her violations of paragraph (a) of this 

section. Good faith efforts include, but 

are not limited to, refunding any 

amounts collected in excess of the 

charge limits to beneficiaries with 

whom he or she did not sign a private 

contract. 

Subpart X—Rural Health Clinic and 

Federally Qualified Health Center 

Services 

■ 3. Add § 405.2469 to read as follows: 

§ 405.2469 Federally Qualified Health 

Centers supplemental payments. 

Federally Qualified Health Centers 

under contract (directly or indirectly) 

with Medicare Advantage organizations 

are eligible for supplemental payments 

for covered Federally Qualified Health 

Center services furnished to enrollees in 

Medicare Advantage plans offered by 

the Medicare Advantage organization to 

cover the difference, if any, between 

their payments from the Medicare 

Advantage plan and what they would 

receive under the cost-based Federally 

Qualified Health Center payment 

system. 

(a) Calculation of supplemental 

payment. (1) The supplemental payment 

for Federally Qualified Health Center 

covered services provided to Medicare 

patients enrolled in Medicare 

Advantage plans is based on —

(i) The difference between payments 

received by the center from the 

Medicare Advantage plan as determined 

on a per visit basis; 

(ii) The Federally Qualified Health 

Center’s all-inclusive cost-based per 

visit rate as set forth in this subpart; 

(iii) Less any amount the FQHC may 

charge as described in section 

1857(e)(3)(B) of the Act. 

(2) Any financial incentives provided 

to Federally Qualified Health Centers 

under their Medicare Advantage 

contracts, such as risk pool payments, 

bonuses, or withholds, are prohibited 

from being included in the calculation 

of supplemental payments due to the 

Federally Qualified Health Center. 

70330 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

(b) Per visit supplemental payment. A 

supplemental payment required under 

this section is made to the Federally 

Qualified Health Center when a covered 

face-to-face encounter occurs between a 

Medicare Advantage enrollee and a 

practitioner as set forth in § 405.2463. 

PART 410—SUPPLEMENTARY 

MEDICAL INSURANCE (SMI) 

BENEFITS 

■ 4. The authority citation for part 410 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

Subpart B—Medical and Other Health 

Services 

■ 5. Section 410.23 is amended by—

■ A. Revising paragraphs (a)(2)(i) 

through (iii). 

■ B. Adding a new paragraph (a)(2)(iv). 

The revision and addition read as 

follows: 

§ 410.23 Screening for glaucoma: 

Conditions for and limitations on coverage. 

(a) * * * 

(2) * * * 

(i) Individual with diabetes mellitus. 

(ii) Individual with a family history of 

glaucoma. 

(iii) African-Americans age 50 and 

over. 

(iv) Hispanic-Americans age 65 and 

over. 

* * * * * 

■ 6. Section 410.78 is amended by—

■ A. Revising paragraph (b) introductory 

text. 

■ B. Adding paragraph (b)(2)(viii). 

The revision and addition read as 

follows: 

§ 410.78 Telehealth services 

* * * * * 

(b) General rule. Medicare Part B pays 

for office and other outpatient visits, 

professional consultation, psychiatric 

diagnostic interview examination, 

individual psychotherapy, 

pharmacologic management, end stage 

renal disease related services included 

in the monthly capitation payment 

(except for one visit per month to 

examine the access site), and individual 

medical nutrition therapy furnished by 

an interactive telecommunications 

system if the following conditions are 

met: 

* * * * * 

(2) * * * 

(viii) A registered dietitian or 

nutrition professional as described in 

§ 410.134. 

* * * * * 

PART 411—EXCLUSIONS FROM 

MEDICARE AND LIMITATIONS ON 

MEDICARE PAYMENT 

■ 7. The authority citation for part 411 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

Subpart J—Financial Relationships 

Between Physicians and Entities 

Furnishing Designated Health Services 

■ 8. Section 411.351 is amended by —

■ A. Revising the definition of 

‘‘Radiation therapy services and 

supplies’’. 

■ B. Revising the definition of 

‘‘Radiology and certain other imaging 

services’’. 

■ C. Revising the introductory text of 

paragraph (2) of the definition of 

‘‘Referral’’. 

The revisions read as follows: 

§ 411.351 Definitions. 

* * * * * 

Radiation therapy services and 

supplies means those particular services 

and supplies, including (effective 

January 1, 2007) therapeutic nuclear 

medicine services and supplies, so 

identified on the List of CPT/HCPCS 

Codes. All services and supplies so 

identified on the List of CPT/HCPCS 

Codes are radiation therapy services and 

supplies for purposes of this subpart. 

Any service or supply not specifically 

identified as radiation therapy services 

or supplies on the List of CPT/HCPCS 

Codes is not a radiation therapy service 

or supply for purposes of this subpart. 

The list of codes identifying radiation 

therapy services and supplies is based 

on section 1861(s)(4) of the Act and 

§ 410.35 of this chapter. 

Radiology and certain other imaging 

services means those particular services 

so identified on the List of CPT/HCPCS 

Codes. All services so identified on the 

List of CPT/HCPCS Codes are radiology 

and certain other imaging services for 

purposes of this subpart. Any service 

not specifically identified as radiology 

and certain other imaging services on 

the List of CPT/HCPCS Codes is not a 

radiology or certain other imaging 

service for purposes of this subpart. The 

list of codes identifying radiology and 

certain other imaging services includes 

the professional and technical 

components of any diagnostic test or 

procedure using x-rays, ultrasound, 

computerized axial tomography, 

magnetic resonance imaging, nuclear 

medicine (effective January 1, 2007), or 

other imaging services. All codes 

identified as radiology and certain other 

imaging services are covered under 

section 1861(s)(3) of the Act and 

§ 410.32 and § 410.34 of this chapter, 

but do not include—

(1) X-ray, fluoroscopy, or ultrasound 

procedures that require the insertion of 

a needle, catheter, tube, or probe 

through the skin or into a body orifice; 

and 

(2) Radiology procedures that are 

integral to the performance of a 

nonradiological medical procedure and 

performed—

(i) During the nonradiological medical 

procedure; or 

(ii) Immediately following the 

nonradiological medical procedure 

when necessary to confirm placement of 

an item placed during the 

nonradiological medical procedure. 

Referral—

* * * * * 

(2) Does not include a request by a 

pathologist for clinical diagnostic 

laboratory tests and pathological 

examination services, by a radiologist 

for diagnostic radiology services, and by 

a radiation oncologist for radiation 

therapy or ancillary services necessary 

for, and integral to, the provision of 

radiation therapy, if—

* * * * * 

PART 413—PRINCIPLES OF 

REASONABLE COST 

REIMBURSEMENT; PAYMENT FOR 

END-STAGE RENAL DISEASE 

SERVICES; PROSPECTIVELY 

DETERMINED PAYMENT RATES FOR 

SKILLED NURSING FACILITIES 

■ 9. The authority citation for part 413 

continues to read as follows: 

Authority: Secs. 1102, 1812(d), 1814(b), 

1815, 1833(a), (i), and (n), 1871, 1881, 1883, 

and 1886 of the Social Security Act (42 

U.S.C. 1302, 1395D(D), 1395f(b), 1395g, 

13951(a), (i), and (n), 1395hh, 1395rr, 1395tt, 

and 1395ww). 

Subpart H—Payment for End-Stage 

Renal Disease (ESRD) Services and 

Organ Procurement Costs 

■ 10. Section 413.170 is amended by 

revising paragraph (b) to read as follows: 

§ 413.170 Scope. 

* * * * * 

(b) Providing procedures and criteria 

under which a pediatric ESRD facility 

(an ESRD facility with at least a 50 

percent pediatric patient mix as 

specified in § 413.184 of this subpart) 

may receive an exception to the 

prospective payment rates; and 

* * * * * 

■ 11. Section 413.174 is amended by—

■ A. Revising paragraph (f). 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70331 

■ B. Removing paragraph (g). 

The revision reads as follows: 

§ 413.174 Prospective rates for hospitalbased and independent ESRD facilities. 

* * * * * 

(f) Additional payment for separately 

billable drugs. CMS makes an additional 

payment for certain drugs furnished to 

ESRD patients by a Medicare-approved 

ESRD facility. CMS makes this payment 

directly to the ESRD facility. Payment 

for these drugs is made—

(1) Only on an assignment basis, 

directly to the facility which must 

accept, as payment in full, the amount 

that CMS determines; 

(2) Subject to the Part B deductible 

and coinsurance; 

(3) Effective January 1, 2006, to 

hospital-based ESRD facilities in 

accordance with the methodology 

specified in § 414.904 of this 

subchapter. 

(4) To independent ESRD facilities in 

accordance with the methodology 

specified in § 405.517 of this 

subchapter. 

■ 12. Section 413.180 is amended by—

■ A. Revising paragraphs (b) and (d) 

■ B. Removing paragraphs (e) and (k). 

■ C. Redesignating paragraphs (f) 

through (j) as paragraphs (e) through (i). 

■ D. Revising newly redesignated 

paragraph (i). 

■ E. Redesignating paragraphs (l) and 

(m) as paragraphs (j) and (k). 

■ F. Revising newly redesignated 

paragraph (k). 

The revisions read as follows: 

§ 413.180 Procedures for requesting 

exceptions to payment rates. 

* * * * * 

(b) Criteria for requesting an 

exception. If a pediatric ESRD facility 

projects on the basis of prior year costs 

and utilization trends that it has an 

allowable cost per treatment higher than 

its prospective rate set under § 413.174, 

and if these excess costs are attributable 

to one or more of the factors in 

§ 413.182, the facility may request, in 

accordance with paragraph (e) of this 

section, that CMS approve an exception 

to that rate and set a higher prospective 

payment rate. 

* * * * * 

(d) Payment rate exception request. 

Effective October 1, 2002, CMS may 

approve exceptions to a pediatric ESRD 

facility’s updated prospective payment 

rate, if the pediatric ESRD facility did 

not have an approved exception rate as 

of October 1, 2002. A pediatric ESRD 

facility may request an exception to its 

payment rate at any time after it is in 

operation for at least 12 consecutive 

months. 

* * * * * 

(i) Period of approval: Payment 

exception request. A prospective 

exception payment rate approved by 

CMS applies for the period from the 

date the complete exception request was 

filed with its intermediary until 30 days 

after the intermediary’s receipt of the 

facility’s letter notifying the 

intermediary of the facility’s request to 

give up its exception rate and be subject 

to the basic case-mix adjusted 

composite payment rate methodology. 

ESRD facilities electing to retain their 

nonpediatric or pediatric exception 

rates (including self-dialysis training) do 

not need to notify their intermediaries. 

Once a facility notifies its fiscal 

intermediary in writing that it cannot 

retain its current exception rate, that 

decision cannot be subsequently 

reversed. 

* * * * * 

(k) Criteria for refiling a denied 

exception request. A pediatric ESRD 

facility that was denied an exception 

request may immediately file another 

exception request. Any subsequent 

exception request must address and 

document the issues cited in CMS’

denial letter. 

■ 13. Section 413.182 is revised to read 

as follows: 

§ 413.182 Criteria for approval of 

exception requests. 

(a) CMS may approve exceptions to a 

pediatric ESRD facility’s prospective 

payment rate if the pediatric ESRD 

facility did not have an approved 

exception rate as of October 1, 2002. 

(b) The pediatric ESRD facility must 

demonstrate, by convincing objective 

evidence, that its total per treatment 

costs are reasonable and allowable 

under the relevant cost reimbursement 

principles of part 413 and that its per 

treatment costs in excess of its payment 

rate are directly attributable to any of 

the following criteria: 

(1) Pediatric patient mix, as specified 

in § 413.184. 

(2) Self-dialysis training costs in 

pediatric facilities, as specified in 

§ 413.186. 

■ 14. Section 413.184 is amended by 

revising paragraphs (a) and (b)(1) to read 

as follows: 

§ 413.184 Payment exception: Pediatric 

patient mix. 

(a) Qualifications. To qualify for an 

exception to its prospective payment 

rate based on its pediatric patient mix 

a facility must demonstrate that—

(1) At least 50 percent of its patients 

are individuals under 18 years of age; 

(2) Its nursing personnel costs are 

allocated properly between each mode 

of care; 

(3) The additional nursing hours per 

treatment are not the result of an excess 

number of employees; 

(4) Its pediatric patients require a 

significantly higher staff-to-patient ratio 

than typical adult patients; and 

(5) These services, procedures, or 

supplies and their per treatment costs 

are clearly prudent and reasonable 

when compared to those of pediatric 

facilities with a similar patient mix. 

(b) Documentation. (1) A pediatric 

ESRD facility must submit a listing of all 

outpatient dialysis patients (including 

all home patients) treated during the 

most recently completed and filed cost 

report (in accordance with cost 

reporting requirements under § 413.198) 

showing—

(i) Age of patients and percentage of 

patients under the age of 18; 

(ii) Individual patient diagnosis; 

(iii) Home patients and ages; 

(iv) In-facility patients, staff-assisted, 

or self-dialysis; 

(v) Diabetic patients; and 

(vi) Patients isolated because of 

contagious disease. 

* * * * * 

§ 413.186 [Removed] 

■ 15. Section 413.186 is removed. 

§ 413.188 [Removed] 

■ 16. Section 413.188 is removed. 

§ 414.190 [Redesignated as § 413.186] 

■ 17. Redesignate § 413.190 as § 413.186 

and revise the newly designated 

§ 413.186 to read as follows: 

§ 413.186 Payment exception: Self-dialysis 

training costs in pediatric facilities. 

(a) Qualification. To qualify for an 

exception to the prospective payment 

rate based on self-dialysis training costs, 

the pediatric ESRD facility must 

establish that it incurs per treatment 

costs for furnishing self-dialysis and 

home dialysis training that exceed the 

facility’s payment rate for the training 

sessions. 

(b) Justification. To justify its 

exception request, a facility must—

(1) Separately identify those elements 

contributing to its costs in excess of the 

composite training rate; and 

(2) Demonstrate that its per treatment 

costs are reasonable and allowable. 

(c) Criteria for determining proper 

cost reporting. CMS considers the 

pediatric ESRD facility’s total costs, cost 

finding and apportionment, including 

its allocation of costs, to determine if 

costs are properly reported by treatment 

modality. 

(d) Limitation of exception requests. 

Exception requests for a higher training 

rate are limited to those cost 

70332 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

components relating to training such as 

technical staff, medical supplies, and 

the special costs of education (manuals 

and education materials). These 

requests may include overhead and 

other indirect costs to the extent that 

these costs are directly attributable to 

the additional training costs. 

(e) Documentation. The pediatric 

ESRD facility must provide the 

following information to support its 

exception request: 

(1) A copy of the facility’s training 

program. 

(2) Computation of the facility’s cost 

per treatment for maintenance sessions 

and training sessions including an 

explanation of the cost difference 

between the two modalities. 

(3) Class size and patients’ training 

schedules. 

(4) Number of training sessions 

required, by treatment modality, to train 

patients. 

(5) Number of patients trained for the 

current year and the prior 2 years on a 

monthly basis. 

(6) Projection for the next 12 months 

of future training candidates. 

(7) The number and qualifications of 

staff at training sessions. 

(f) Accelerated training exception. (1) 

A pediatric ESRD facility may bill 

Medicare for a dialysis training session 

only when a patient receives a dialysis 

treatment (normally 3 times a week for 

hemodialysis). Continuous cycling 

peritoneal dialysis (CCPD) and 

continuous ambulatory peritoneal 

dialysis (CAPD) are daily treatment 

modalities; ESRD facilities are paid the 

equivalent of three hemodialysis 

treatments for each week that CCPD and 

CAPD treatments are provided. 

(2) If a pediatric ESRD facility elects 

to train all its patients using a particular 

treatment modality more often than 

during each dialysis treatment and, as a 

result, the number of billable training 

dialysis sessions is less than the number 

of actual training sessions, the facility 

may request a composite rate exception, 

limited to the lesser of the—

(i) Facility’s projected training cost 

per treatment; or 

(ii) Cost per treatment the facility 

receives in training a patient if it had 

trained patients only during a dialysis 

treatment, that is, three times per week. 

(3) An ESRD facility may bill a 

maximum of 25 training sessions per 

patient for hemodialysis training and 15 

sessions for CCPD and CAPD training. 

(4) In computing the payment amount 

under an accelerated training exception, 

CMS uses a minimum number of 

training sessions per patient (15 for 

hemodialysis and 5 for CAPD and 

CCPD) when the facility actually 

provides fewer than the minimum 

number of training sessions. 

(5) To justify an accelerated training 

exception request, an ESRD facility 

must document that a significant 

number of training sessions for a 

particular modality are provided during 

a shorter but more condensed period. 

(6) The facility must submit with the 

exception request a list of patients, by 

modality, trained during the most recent 

cost report period. The list must include 

each beneficiary’s—

(i) Name; 

(ii) Age; and 

(iii) Training status (completed, not 

completed, being retrained, or in the 

process of being trained). 

(7) The total treatments from the 

patient list must be the same as the total 

treatments reported on the cost report 

filed with the request. 

§ 413.192 [Removed] 

■ 18. Section 413.192 is removed. 

PART 414—PAYMENT FOR PART B 

MEDICAL AND OTHER HEALTH 

SERVICES 

■ 19. The authority citation for part 414 

continues to read as follows: 

Authority: Secs. 1102, 1871, and 1881(b)(1) 

of the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395rr(b)(1)). 

Subpart B—Physicians and Other 

Practitioners 

■ 20. Section 414.65 is amended by 

revising paragraph (a)(1) to read as 

follows:. 

§ 414.65 Payment for telehealth services 

(a) * * * 

(1) The Medicare payment amount for 

office or other outpatient visits, 

consultation, individual psychotherapy, 

psychiatric diagnostic interview 

examination, pharmacologic 

management, end stage renal disease 

related services included in the monthly 

capitation payment (except for one visit 

per month to examine the access site), 

and individual medical nutrition 

therapy furnished via an interactive 

telecommunications system is equal to 

the current fee schedule amount 

applicable for the service of the 

physician or practitioner. 

* * * * * 

Subpart J—Submission of 

Manufacture’s Average Sales Price 

Data 

■ 21. Section 414.804(a) is amended by 

revising paragraph (a)(3)(iv) to read as 

follows: 

§ 414.804 Basis of payment. 

(a) * * * 

(3) * * * 

(iv) Example. The total lagged price 

concessions (discounts, rebates, etc.) 

over the most recent 12-month period 

available associated with direct sales for 

National Drug Code 12345–6789–01 

subject to the ASP reporting 

requirement equal $200,000. The total 

in dollars for the sales subject to the 

average sales price reporting 

requirement for the same period equals 

$600,000. The lagged price concessions 

percentage for this period equals 

200,000/600,000 = .33333. The total in 

dollars for the direct sales subject to the 

average sales price reporting 

requirement for the quarter being 

reported equals $50,000 for 10,000 units 

sold. Assuming no non-lagged price 

concessions apply, the manufacturer’s 

average sales price calculation for this 

National Drug Code for this quarter is: 

$50,000¥(0.33333 × $50,000) = $33,334 

(net total sales amount); $33,334/10,000 

= $3.33 (average sales price). 

* * * * * 

■ 22. Section 414.904 is amended by—

■ A. Revising paragraph (a) introductory 

text. 

■ B. Adding a new paragraph (d)(2)(iii). 

■ C. Revising paragraphs (d)(3) and 

(e)(2). 

The revisions and additions read as 

follows: 

§ 414.904 Basis of payment 

(a) Method of payment. Payment for a 

drug furnished on or after January 1, 

2005 is based on the lesser of—

* * * * * 

(d) * * * 

(2) * * * 

(iii) Effective for drugs and biologicals 

furnished in 2006, the payment for such 

drugs and biologicals furnished in 

connection with renal dialysis services 

and separately billed by freestanding 

and hospital-based renal dialysis 

facilities not paid on a cost basis is 106 

percent of the average sales price. 

(3) Widely available market price and 

average manufacturer price. If the 

Inspector General finds that the average 

sales price exceeds the widely available 

market price or the average 

manufacturer price by 5 percent or more 

in calendar year 2006, the payment limit 

in the quarter following the transmittal 

of this information to the Secretary is 

the lesser of the widely available market 

price or 103 percent of the average 

manufacturer price. 

(e) * * * 

(2) Infusion drugs furnished through a 

covered item of durable medical 

equipment. The payment limit for an 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70333 

infusion drug furnished through a 

covered item of durable medical 

equipment is calculated using 95 

percent of the average wholesale price 

in effect on October 1, 2003 and is not 

updated in 2006. 

* * * * * 

■ 23. Section 414.906 is amended by 

revising paragraph (f) to read as follows: 

§ 414.906 Competitive acquisition program 

as the basis for payment. 

* * * * * 

(f) Substitution or addition of drugs 

on an approved CAP vendor’s CAP drug 

list. (1) Short-term substitution of a CAP 

drug. On an occasional basis (for a 

period of time less than 2 weeks), an 

approved CAP vendor may agree to 

furnish a substitute NDC within a 

HCPCS code on the approved CAP 

vendor’s CAP drug list if the approved 

CAP vendor—

(i) Is willing to accept the payment 

amount that was established for the 

HCPCS code under this section; and 

(ii) Obtains the participating CAP 

physician’s prior approval. 

(2) Long-term substitution or addition 

of a CAP drug. An approved CAP 

vendor may submit a request, as 

specified in paragraph (f)(3) of this 

section, for approval to substitute an 

NDC supplied by the approved CAP 

vendor for another NDC within the same 

HCPCS code or to add an NDC to the 

approved CAP vendor’s drug list, if at 

least one of the following criteria is met: 

(i) Proposed substitution of an NDC 

for a period of 2 weeks or longer. 

(ii) Proposed addition of one or more 

NDCs within a HCPCS code included in 

the CAP drug category specified by CMS 

or on the approved CAP vendor’s 

approved CAP drug list. 

(iii) Proposed addition of—

(A) One or more newly issued HCPCS 

codes; or 

(B) One of the following single 

indication orphan drug J codes or their 

updates: J0205, J0256, J9300, J1785, 

J2355, J3240, J7513, J9010, J9015, J9017, 

J9160, J9216. 

(iv) Beginning January 1, 2007, the 

proposed addition of a drug(s) that has 

not yet been assigned a HCPCS code, 

but for which a HCPCS code must be 

established. 

(3) Requesting the addition or 

substitution of CAP drug. An approved 

CAP vendor that meets the one of the 

criteria specified in paragraph (f)(2) 

must submit a written request to CMS 

or its designee. The request must—

(i) Specify the NDC(s) and the 

respective HCPCS code that is to be 

added or substituted. 

(ii) Address the rationale for the 

substitution or addition of the NDC(s) or 

the addition of the HCPCS code(s) as 

applicable; and 

(iii) Address the impact of the 

substitution of the NDC(s) or the 

addition of the NDC(s) or HCPCS 

code(s), or both on—

(A) Patient and drug safety; 

(B) Drug waste; and 

(C) The potential for cost savings. 

(4) Approval of a request(s). CMS or 

its designee notifies the approved CAP 

vendor of its decision. 

(i) Except as specified in paragraph 

(f)(4)(ii) of this section, an approved 

request is effective at the beginning of 

the next calendar quarter. 

(ii) Approved substitutions for request 

based on a drug shortage or other 

exigent circumstance may become 

effective immediately provided that—

(A) CMS approves the immediate 

substitution; and 

(B) The approved CAP vendor’s 

notifies its CAP participating physicians 

of the substitution immediately 

following CMS approval. 

(5) Payment for an approved drug 

change(s). The payment for— (i) 

Substituted or added CAP drugs that are 

within a HCPCS code for which 

payment is computed under paragraph 

(c)(1) of this section is the single 

payment for that HCPCS code, as 

determined and updated in accordance 

with paragraph (c)(1) of this section; or 

(ii) Added CAP drugs that are not 

within a HCPCS code for which 

payment is computed under paragraph 

(c)(1) of this section is specified under 

paragraph (c)(2) of this section. 

■ 24. Section 414.908 is amended by—

■ A. Revising paragraphs (a)(3)(v)(M). 

■ B. Redesignating paragraphs (a)(3)(vi) 

through (a)(3) (xii) as (a)(3)(viii) through 

(a)(3)(xiv). 

■ C. Adding new paragraphs (a)(3)(vi) 

and (a)(3)(vii). 

■ D. Revising paragraph (a)(5). 

The revisions and additions read as 

follows: 

§ 414.908 Competitive acquisition 

program. 

(a) * * * 

(3) * * * 

(v) * * * 

(M) Additional patient information: 

date of birth, allergies, height/weight, 

ICD–9–CM (if necessary). 

(vi) Agrees to accept the particular 

National Drug Codes (NDCs) supplied 

by the approved CAP vendor for the 

duration of the participating CAP 

physician’s enrollment with the 

approved CAP vendor, subject to 

paragraphs (a)(3)(vii) and (a)(3)(xiv) of 

this section. By electing to participate 

with an approved CAP vendor, the 

participating CAP physician also agrees 

to accept the changes to the approved 

CAP vendor’s CAP drug list that have 

been approved in accordance with 

§ 414.906(f). 

(vii) Agrees to place routine orders for 

CAP drugs at the HCPCs level, except 

when medical necessity requires a 

particular formulation on the approved 

CAP vendor’s CAP drug list. Medical 

necessity must be documented. When 

the conditions of this paragraph are met, 

the participating CAP physician may 

submit a prescription order to the 

approved CAP vendor that specifies the 

NDC. 

* * * * * 

(5) Additional opt out provision. In 

addition to the circumstances listed in 

paragraph (a)(2) of this section, if the 

approved CAP vendor refuses to ship to 

the participating CAP physician because 

the conditions of § 414.914(h) were met, 

the physician can withdraw from the 

CAP category for the remainder of the 

year immediately upon notice to CMS 

and the approved CAP vendor. 

* * * * * 

■ 25. Section 414.914 is amended by—

■ A. Redesignating paragraphs (f)(9) 

through (f)(11) as paragraphs (f)(14) 

through (f)(16). 

■ B. Redesignating (f)(5) through (f)(8) 

as paragraphs (f)(9) through (f)(12) and 

paragraphs. 

■ C. Adding new paragraphs (f)(5) 

through (f)(8) and (f)(13). 

■ D. Revising paragraph (g)(3). 

■ E. Revising paragraphs (h)(1) through 

(h)(3), (h)(5) and (h)(6), and (h)(8). 

The revisions and additions read as 

follows: 

§ 414.914 Terms of contract. 

* * * * * 

(f) * * * 

(5) Respond within 2 business days to 

any inquiry, or sooner if the inquiry is 

related to drug quality; 

(6) Staff a toll-free telephone line from 

8:30 a.m. or earlier and until 5 p.m. or 

later for all time zones served in the 

continental United States by the CAP 

vendor on business days (Monday 

through Friday excluding Federal 

holidays) to provide customer 

assistance, and establish reasonable 

hours of operation for Hawaii, Alaska, 

Puerto Rico, and the other U.S. 

territories; 

(7) Staff an emergency toll-free 

telephone line for weekend and evening 

access when the call center is closed, 

and determine what hours on Saturday 

and Sunday the call center is staffed and 

which hours a toll-free emergency line 

is activated; and 

(8) Include assistance for the disabled, 

the hearing impaired, and SpanishVerDate Aug<31>2005 14:28 Nov 18, 2005 Jkt 208001 PO 00000 Frm 00219 Fmt 4701 Sfmt 4700 E:\FR\FM\21NOR2.SGM 21NOR2
70334 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

speaking inquirers in all customer 

service operations. 

* * * * * 

(13) Provide direct notification to 

participating CAP physicians enrolled 

with them of updates to the approved 

CAP vendor’s CAP drug list on a 

quarterly basis. Changes must be 

disseminated at least 30 days before the 

approved changes are due to take effect, 

unless immediate notification as 

described in § 414.906(f)(4) is required. 

The approved CAP vendor’s entire CAP 

drug list must be disseminated at least 

once yearly; and approved CAP vendors 

must make a complete list that 

incorporates the most recent updates 

available to physicians on an ongoing 

basis. CMS posts on its web site the 

updated CAP drug lists for each 

approved CAP vendor. 

* * * * * 

(g) * * * 

(3) A full or partial waiver of the costsharing amount after determining in 

good faith that the individual is in 

financial need or the failure of 

reasonable collection efforts, provided 

that the waiver meets all of the 

requirements of section 1128A(i)(6)(A) 

of the Act and the corresponding 

regulations at paragraph (1) of the 

definition of ‘‘Remuneration’’ in 

§ 1003.101 of this title. The availability 

of waivers may not be advertised or be 

made as part of a solicitation. Approved 

CAP vendors must inform beneficiaries 

that they generally make available the 

categories of assistance described in 

paragraphs (g)(1), (g)(2), and (g)(3) of 

this section. In no event may the 

approved CAP vendor include or make 

any statements or representations that 

promise or guarantee that beneficiaries 

receive cost-sharing waivers. 

(h) * * * 

(1) Subsequent to receipt of final 

payment by Medicare, or the 

verification of drug administration by 

the participating CAP physician, the 

approved CAP vendor must bill any 

applicable supplemental insurance 

policies. 

(2) If a balance remains, after the 

supplemental insurer pays their share of 

the bill, or if there is no supplemental 

insurance, the approved CAP vendor 

may bill the beneficiary. 

(3) At the time of billing the 

beneficiary, or the participating CAP 

physician’s presentation of the bill on 

behalf of the approved CAP vendor, the 

approved CAP vendor must inform the 

beneficiary of any types of cost-sharing 

assistance that may be available 

consistent with the requirements of 

section 1128A(a)(5) of the Act and 

§ 414.914(g). 

(4) * * * 

(5) For purposes of paragraph (h) 

delivery means postmark date, or the 

date the coinsurance bill or notice was 

presented to the beneficiary by the 

participating CAP physician on behalf 

of the approved CAP vendor. 

(i) Except as specified in paragraph 

(h)(5)(ii), if after 45 days from delivery 

of the approved CAP vendor’s bill to the 

beneficiary, the beneficiary’s costsharing obligation remains unpaid, the 

approved CAP vendor may refuse 

further shipments to the participating 

CAP physician for that beneficiary. 

(ii) If the beneficiary has requested 

cost-sharing assistance within 45 days 

of receiving delivery of the approved 

CAP vendor’s bill, provisions of 

paragraphs (h)(6), (h)(7), or (h)(8) of this 

section, apply. 

(6) If the approved CAP vendor 

implements a reasonable payment plan, 

as specified in § 414.914(g)(2), the 

approved CAP vendor must continue to 

ship CAP drugs for the beneficiary, as 

long as the beneficiary remains in 

compliance with the payment plan and 

makes an initial payment under the plan 

within 15 days after the delivery of the 

approved CAP vendor’s written notice 

to the beneficiary offering the payment 

plan. 

(7) * * * 

(8) If the approved CAP vendor refers 

the beneficiary to a bona fide and 

independent charity in accordance with 

§ 414.914(g)(1), the approved CAP 

vendor may refuse to ship drugs if the 

past due balance is not paid 15 days 

after the date of delivery of the 

approved CAP vendor’s written notice 

to the beneficiary containing the referral 

for cost-sharing assistance. 

* * * * * 

Subpart L—Supplying and Dispensing 

Fees 

■ 26. Section 414.1001 is revised to read 

as follows: 

§ 414.1001 Basis of payment. 

(a) Supplying fees. Beginning in CY 

2006—

(1) A supplying fee of $24 is paid to 

a pharmacy for the first prescription of 

drugs and biologicals described in 

sections 1861(s)(2)(J), 1861(s)(2)(Q), and 

1861(s)(2)(T) of the Act, that the 

pharmacy provided to a beneficiary 

during a 30-day period. 

(2) A supplying fee of $16 is paid to 

a pharmacy for each prescription 

following the first prescription (as 

specified in paragraph (a)(1) of this 

section) of drugs and biologicals 

described in sections 1861(s)(2)(J), 

1861(s)(2)(Q), and 1861(s)(2)(T) of the 

Act, that the pharmacy provided to a 

beneficiary during a 30-day period. 

(3) A separate supplying fee is paid to 

a pharmacy for each prescription of 

drugs and biologicals described in 

sections 1861(s)(2)(J), 1861(s)(2)(Q), and 

1861(s)(2)(T) of the Act. 

(b) Supplying fees following 

transplant. Beginning CY 2006—(1) A 

supplying fee of $50 is paid to 

pharmacy for the initial supplied 

prescription of drugs and biologicals 

described in section 1861(s)(2)(J) of the 

Act, that the pharmacy provided to a 

patient during the first 30-day period 

following a transplant. 

(2) A supplying fee of $16 is paid to 

a pharmacy for each prescription 

following an initial prescription after a 

transplant (as specified in paragraph 

(b)(1) of this section) of drugs and 

biologicals describe in section 

1861(s)(2)(J) of the Act, that the 

pharmacy provided to a beneficiary 

during a 30-day period. 

(c) 30-day dispensing fees. Beginning 

CY 2006—(1) A dispensing fee of $57 is 

paid to a supplier to the extent that the 

prescription is for the initial dispensed 

30-day supply of inhalation drugs 

furnished through durable medical 

equipment covered under section 

1861(n) of the Act, regardless of the 

number of partial shipments of that 30- 

day supply. 

(2) Except for supplied inhalation 

drugs that meet criteria described in 

paragraph (c)(1) of this section, a 

dispensing fee of $33 is paid for each 

dispensed 30-day supply of inhalation 

drugs furnished through durable 

medical equipment covered under 

section 1861(n) of the Act, regardless of 

the number of partial shipments of that 

30-day supply. 

(d) 90-day dispensing fee. Beginning 

CY 2006, a dispensing fee of $66 is paid 

to a supplier for each dispensed 90-day 

supply of inhalation drugs furnished 

through durable medical equipment 

covered under section 1861(n) of the 

Act, regardless of the number of partial 

shipments of that 90-day supply. 

PART 424—CONDITIONS FOR 

MEDICARE PAYMENT 

■ 27. The authority citation for part 424 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

§ 424.22 [Amended] 

■ 28. In § 424.22—

■ A. The footnote for paragraph 

(a)(1)(iv), the term ‘‘hosptial’’ is 

removed and the term ‘‘hospital’’ is 

added in its place. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70335 

■ B. Paragraph (d), remove the reference 

to ‘‘§ 411.351’’ and add in its place the 

reference ‘‘§ 411.354’’. 

PART 426—REVIEW OF NATIONAL 

COVERAGE DETERMINATIONS AND 

LOCAL COVERAGE 

DETERMINATIONS 

■ 29. The authority citation for part 426 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

■ 30. The heading for Part 426 is revised 

to read as set forth above. 

Subpart C—General Provisions for the 

Review of LCDs and NCDs 

■ 31. Section 426.340 is amended by 

revising paragraphs (e)(2) and (f)(2) to 

read as follows: 

§ 426.340 Procedures for review of new 

evidence. 

* * * * * 

(e) * * * 

(2) Sets a reasonable timeframe—

(i) For LCDs, of not more than 90 

days, by which the contractor completes 

the reconsideration; or 

(ii) For NCDs, in compliance with the 

timeframes specified in section 1862(1) 

of the Act, by which CMS completes the 

reconsideration. 

(f) * * * 

(2) Does not meet—

(i) For LCDs, the 90-day 

reconsideration timeframe; or 

(ii) For NCDs, the reconsideration 

timeframe specified by the Board, in 

compliance with section 1862(1) of the 

Act. 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: October 26, 2005. 

Mark B. McClellan, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Approved: November 1, 2005. 

Michael O. Leavitt, 

Secretary. 

Note: These addenda will not appear in the 

Code of Federal Regulations. 

Addendum A: Explanation and Use of 

Addenda B 

The addenda on the following pages 

provides various data pertaining to the 

Medicare fee schedule for physicians’

services furnished in 2006. Addendum 

B contains the RVUs for work, nonfacility PE, facility PE, and malpractice 

expense, and other information for all 

services included in the PFS. 

In previous years, we have listed 

many services in Addendum B that are 

not paid under the PFS. To avoid 

publishing as many pages of codes for 

these services, we are not including 

clinical laboratory codes and most 

alpha-numeric codes (Healthcare 

Common Procedure Coding System 

(HCPCS) codes not included in CPT) in 

Addendum B. 

Addendum B—2006 Relative Value 

Units and Related Information Used in 

Determining Medicare Payments for 

2006 

This addendum contains the 

following information for each CPT 

code and alphanumeric HCPCS code, 

except for: alphanumeric codes 

beginning with B (enteral and parenteral 

therapy), E (durable medical 

equipment), K (temporary codes for 

nonphysicians’ services or items), or L 

(orthotics); and codes for 

anesthesiology. 

Please also note the following: 

• An ‘‘NA’’ in the ‘‘Non-facility PE 

RVUs’’ column of Addendum B means 

that CMS has not developed a PE RVU 

in the non-facility setting for the service 

because it is typically performed in the 

hospital (for example, an open heart 

surgery is generally performed in the 

hospital setting and not a physician’s 

office). 

• Services that have an ‘‘NA’’ in the 

‘‘Facility PE RVUs’’ column of 

Addendum B are typically not paid 

using the PFS when provided in a 

facility setting. These services (which 

include ‘‘incident to’’ services and the 

technical portion of diagnostic tests) are 

generally paid under either the 

outpatient hospital prospective payment 

system or bundled into the hospital 

inpatient prospective payment system 

payment. 

1. CPT/HCPCS code. This is the CPT 

or alphanumeric HCPCS number for the 

service. Alphanumeric HCPCS codes are 

included at the end of this addendum. 

2. Modifier. A modifier is shown if 

there is a technical component (modifier 

TC) and a professional component (PC) 

(modifier –26) for the service. If there is 

a PC and a TC for the service, 

Addendum B contains three entries for 

the code. A code for: the global values 

(both professional and technical); 

modifier –26 (PC); and, modifier TC. 

The global service is not designated by 

a modifier, and physicians must bill 

using the code without a modifier if the 

physician furnishes both the PC and the 

TC of the service. 

Modifier –53 is shown for a 

discontinued procedure. There will be 

RVUs for the code (CPT code 45378) 

with this modifier. 

3. Status indicator. This indicator 

shows whether the CPT/HCPCS code is 

in the PFS and whether it is separately 

payable if the service is covered. 

A = Active code. These codes are 

separately payable under the PFS if 

covered. There will be RVUs for codes 

with this status. The presence of an ‘‘A’’

indicator does not mean that Medicare 

has made a national coverage 

determination regarding the service. 

Carriers remain responsible for coverage 

decisions in the absence of a national 

Medicare policy. 

B = Bundled code. Payments for 

covered services are always bundled 

into payment for other services 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 incident (an 

example is a telephone call from a 

hospital nurse regarding care of a 

patient). 

C = Carrier-priced code. Carriers will 

establish RVUs and payment amounts 

for these services, generally on an 

individual case basis following review 

of documentation, such as an operative 

report. 

D = Deleted/discontinued code. These 

codes are deleted effective with the 

beginning of the CY and are always 

subject to a 90 day grace period. 

E = Excluded from the PFS by 

regulation. These codes are for items 

and services that CMS choses to exclude 

from the PFS payment by regulation. No 

RVUs are shown, and no payment may 

be made under the PFS for these codes. 

Payment for them, when covered, 

continues under reasonable charge 

procedures. 

F = Deleted/discontinued codes. 

(Code not subject to a 90-day grace 

period.) These codes are deleted 

effective with the beginning of the CY 

and are never subject to a grace period. 

This indicator is no longer effective 

with the 2006 PFS as of January 1, 2006. 

G = Code not valid for Medicare 

purposes. Medicare does not recognize 

codes assigned this status. Medicare 

uses another code for reporting of, and 

payment for, these services. (Code 

subject to a 90 day grace period.) This 

indicator is no longer effective with the 

2006 PFS as of January 1, 2006. 

H = Deleted modifier. For 2000 and 

later years, either the TC or PC 

component shown for the code has been 

deleted and the deleted component is 

shown in the data base with the H status 

indicator. 

I = Not valid for Medicare purposes. 

Medicare uses another code for the 

70336 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

reporting of, and the payment for these 

services. (Code not subject to a 90-day 

grace period.) 

N = Noncovered service. These codes 

are noncovered services. Medicare 

payment may not be made for these 

codes. If RVUs are shown, they are not 

used for Medicare payment. 

P = Bundled or excluded code. There 

are no RVUs for these services. No 

separate payment is made for them 

under the PFS. 

—If the item or service is covered as 

incident to a physician’s service and 

is furnished on the same day as a 

physician’s service, payment for it is 

bundled into the payment for the 

physician’s service to which it is 

incident (an example is an elastic 

bandage furnished by a physician 

incident to a physician’s service). 

—If the item or service is covered as 

other than incident to a physician’s 

service, it is excluded from the PFS 

(for example, colostomy supplies) and 

is paid under the other payment 

provisions of the Act. 

R = Restricted coverage. Special 

coverage instructions apply. If the 

service is covered and no RVUs are 

shown, it is carrier-priced. 

T = There are RVUs for these services, 

but they are only paid if there are no 

other services payable under the PFS 

billed on the same date by the same 

provider. If any other services payable 

under the PFS are billed on the same 

date by the same provider, these 

services are bundled into the service(s) 

for which payment is made. 

X = Exclusion by law. These codes 

represent an item or service that is not 

within the definition of ‘‘physicians’

services’’ for PFS payment purposes. No 

RVUs are shown for these codes, and no 

payment may be made under the PFS. 

(Examples are ambulance services and 

clinical diagnostic laboratory services.) 

4. Description of code. This is an 

abbreviated version of the narrative 

description of the code. 

5. Physician work RVUs. These are the 

RVUs for the physician work for this 

service in 2006. Codes that are not used 

for Medicare payment are identified 

with a ‘‘+.’’

6. Non-facility practice expense 

RVUs. These are the resource-based PE 

RVUs for non-facility settings. 

7. Facility practice expense RVUs. 

These are the resource-based PE RVUs 

for facility settings. 

8. Malpractice expense RVUs. These 

are the RVUs for the malpractice 

expense for the service for 2006. 

9. Non-facility total. This is the sum 

of the work, non-facility practice 

expense, and malpractice expense 

RVUs. 

10. Facility total. This is the sum of 

the work, facility PE, and malpractice 

expense RVUs. 

11. Global period. This indicator 

shows the number of days in the global 

period for the code (0, 10, or 90 days). 

An explanation of the alpha codes 

follows: 

MMM = The code describes a service 

furnished in uncomplicated maternity 

cases including antepartum care, 

delivery, and postpartum care. The 

usual global surgical concept does not 

apply. See the 1999 Physicians’ Current 

Procedural Terminology for specific 

definitions. 

XXX = The global concept does not 

apply. 

YYY = The global period is to be set 

by the carrier (for example, unlisted 

surgery codes). 

ZZZ = Code related to another service 

that is always included in the global 

period of the other service. (Note: 

Physician work and PE are associated 

with intra service time and in some 

instances the post service time.) 

70337 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

0001F .... .......... I Heart failure assessed ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0003T .... .......... C Cervicography .................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0005F .... .......... I Osteoarthritis assessed ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0008T .... .......... C Upper gi endoscopy w/suture ............................ 0.00 0.00 0.00 0.00 0.00 .00 XXX 

0016T .... .......... C Thermotx choroid vasc lesion ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0017T .... .......... C Photocoagulat macular drusen .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0018T .... .......... C Transcranial magnetic stimul ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0019T .... .......... C Extracorp shock wv tx,ms nos ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0021T .... .......... C Fetal oximetry, trnsvag/cerv ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0024T .... .......... C Transcath cardiac reduction ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0026T .... .......... C Measure remnant lipoproteins ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0027T .... .......... C Endoscopic epidural lysis ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0028T .... .......... C Dexa body composition study ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0029T .... .......... C Magnetic tx for incontinence .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0030T .... .......... C Antiprothrombin antibody ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0031T .... .......... C Speculoscopy ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0032T .... .......... C Speculoscopy w/direct sample ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0041T .... .......... C Detect ur infect agnt w/cpas .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0042T .... .......... C Ct perfusion w/contrast, cbf ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0043T .... .......... C Co expired gas analysis ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0044T .... .......... C Whole body photography ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0045T .... .......... C Whole body photography ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0046T .... .......... C Cath lavage, mammary duct(s ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0047T .... .......... C Cath lavage, mammary duct(s) .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0048T .... .......... C Implant ventricular device .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0049T .... .......... C External circulation assist ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0050T .... .......... C Removal circulation assist .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0051T .... .......... C Implant total heart system .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0052T .... .......... C Replace component heart syst .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0053T .... .......... C Replace component heart syst .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0054T .... .......... C Bone surgery using computer ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0055T .... .......... C Bone surgery using computer ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0056T .... .......... C Bone surgery using computer ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0058T .... .......... C Cryopreservation, ovary tiss ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0059T .... .......... C Cryopreservation, oocyte ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0060T .... .......... C Electrical impedance scan ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0061T .... .......... C Destruction of tumor, breast ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0062T .... .......... C Rep intradisc annulus;1 lev ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0063T .... .......... C Rep intradisc annulus;>1lev ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0064T .... .......... C Spectroscop eval expired gas ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0065T .... .......... C Ocular photoscreen bilat .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0066T .... 26 ..... N Ct colonography;screen ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0066T .... TC .... N Ct colonography;screen ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0066T .... .......... N Ct colonography;screen ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0067T .... 26 ..... C Ct colonography;dx ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0067T .... TC .... C Ct colonography;dx ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0067T .... .......... C Ct colonography;dx ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0068T .... .......... C Interp/rept heart sound ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0069T .... .......... C Analysis only heart sound .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0070T .... .......... C Interp only heart sound ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0071T .... .......... C U/s leiomyomata ablate <200 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0072T .... .......... C U/s leiomyomata ablate >200 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0073T .... .......... A Delivery, comp imrt ............................................ 0.00 18.07 NA 0.13 18.20 NA XXX 

0074T .... .......... N Online physician e/m .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0075T .... 26 ..... C Perq stent/chest vert art ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0075T .... TC .... C Perq stent/chest vert art ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0075T .... .......... C Perq stent/chest vert art ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0076T .... 26 ..... C S&i stent/chest vert art ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0076T .... TC .... C S&i stent/chest vert art ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0076T .... .......... C S&i stent/chest vert art ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0077T .... .......... C Cereb therm perfusion probe ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0078T .... .......... C Endovasc aort repr w/device .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0079T .... .......... C Endovasc visc extnsn repr ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0080T .... .......... C Endovasc aort repr rad s&i ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0081T .... .......... C Endovasc visc extnsn s&i .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0082T .... .......... C Stereotactic rad delivery ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0083T .... .......... C Stereotactic rad tx mngmt .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0084T .... .......... C Temp prostate urethral stent .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0085T .... .......... C Breath test heart reject ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0086T .... .......... C L ventricle fill pressure ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0087T .... .......... C Sperm eval hyaluronan ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0088T .... .......... C Rf tongue base vol reduxn ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0089T .... .......... C Actigraphy testing, 3-day .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0090T .... .......... C Cervical artific disc ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0091T .... .......... C Lumbar artific disc .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70338 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

0092T .... .......... C Artific disc addl ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0093T .... .......... C Cervical artific diskectomy .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0094T .... .......... C Lumbar artific diskectomy .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0095T .... .......... C Artific diskectomy addl ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0096T .... .......... C Rev cervical artific disc ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0097T .... .......... C Rev lumbar artific disc ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0098T .... .......... C Rev artific disc addl ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0099T .... .......... C Implant corneal ring ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0100T .... .......... C Prosth retina receive&gen .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0101T .... .......... C Extracorp shockwv tx,hi enrg ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0102T .... .......... C Extracorp shockwv tx,anesth ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0103T .... .......... C Holotranscobalamin ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0104T .... .......... C At rest cardio gas rebreathe .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0105T .... .......... C Exerc cardio gas rebreathe ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0106T .... .......... C Touch quant sensory test ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0107T .... .......... C Vibrate quant sensory test ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0108T .... .......... C Cool quant sensory test ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0109T .... .......... C Heat quant sensory test ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0110T .... .......... C Nos quant sensory test ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0111T .... .......... C Rbc membranes fatty acids ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0115T .... .......... C Med tx mngmt 15 min ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0116T .... .......... C Med tx mngmt subsqt ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0117T .... .......... C Med tx mngmt addl 15 min ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0120T .... .......... C Fibroadenoma cryoablate, ea ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0123T .... .......... C Scleral fistulization .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0124T .... .......... C Conjunctival drug placement .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0126T .... .......... C Chd risk imt study .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0130T .... .......... C Chron care drug investigatn ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0133T .... .......... C Esophageal implant injexn ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0135T .... .......... C Perq cryoablate renal tumor ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0137T .... .......... C Prostate saturation sampling .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0140T .... .......... C Exhaled breath condensate ph .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0141T .... .......... C Perq islet transplant ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0142T .... .......... C Open islet transplant .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0143T .... .......... C Laparoscopic islet transplnt ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0144T .... .......... C CT heart wo dye; qual calc ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0145T .... .......... C CT heart w/wo dye funct .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0146T .... .......... C CCTA w/wo dye ................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0147T .... .......... C CCTA w/wo, quan calcium ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0148T .... .......... C CCTA w/wo, strxr ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0149T .... .......... C CCTA w/wo, strxr quan calc .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0150T .... .......... C CCTA w/wo, disease strxr .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0151T .... .......... C CT heart funct add-on ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0152T .... .......... C Computer chest add-on ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0153T .... .......... C Implant aneur sensor add-on ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0154T .... .......... C Implant aneur sensor study ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0500F .... .......... I Initial prenatal care visit ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0501F .... .......... I Prenatal flow sheet ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0502F .... .......... I Subsequent prenatal care .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

0503F .... .......... I Postpartum care visit .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1000F .... .......... I Tobacco use, smoking, assess .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1001F .... .......... I Tobacco use, non-smoking ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

10021 .... .......... A Fna w/o image .................................................... 1.27 2.16 0.54 0.10 3.53 1.91 XXX 

10022 .... .......... A Fna w/image ....................................................... 1.27 2.55 0.42 0.08 3.90 1.77 XXX 

1002F .... .......... I Assess anginal symptom/level ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1003F .... .......... I Level of activity assess ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

10040 .... .......... A Acne surgery ...................................................... 1.18 1.01 0.79 0.05 2.24 2.02 010 

1004F .... .......... I Clin symp vol ovrld assess ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1005F .... .......... I Asthma symptoms evaluate ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

10060 .... .......... A Drainage of skin abscess ................................... 1.17 1.21 0.93 0.12 2.50 2.22 010 

10061 .... .......... A Drainage of skin abscess ................................... 2.40 1.83 1.50 0.26 4.49 4.16 010 

1006F .... .......... I Osteoarthritis assess .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1007F .... .......... I Anti-inflm/anlgsc otc assess ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

10080 .... .......... A Drainage of pilonidal cyst ................................... 1.17 3.11 1.11 0.11 4.39 2.39 010 

10081 .... .......... A Drainage of pilonidal cyst ................................... 2.45 4.08 1.50 0.24 6.77 4.19 010 

1008F .... .......... I Gi/renal risk assess ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

10120 .... .......... A Remove foreign body ......................................... 1.22 2.18 0.97 0.12 3.52 2.31 010 

10121 .... .......... A Remove foreign body ......................................... 2.69 3.52 1.79 0.33 6.54 4.81 010 

10140 .... .......... A Drainage of hematoma/fluid ............................... 1.53 1.78 1.29 0.19 3.50 3.01 010 

10160 .... .......... A Puncture drainage of lesion ............................... 1.20 1.60 1.08 0.14 2.94 2.42 010 

10180 .... .......... A Complex drainage, wound ................................. 2.25 2.99 1.99 0.35 5.59 4.59 010 

11000 .... .......... A Debride infected skin .......................................... 0.60 0.58 0.22 0.07 1.25 0.89 000 

11001 .... .......... A Debride infected skin add-on ............................. 0.30 0.23 0.11 0.04 0.57 0.45 ZZZ 

11004 .... .......... A Debride genitalia & perineum ............................. 10.31 NA 3.91 0.67 NA 14.89 000 

11005 .... .......... A Debride abdom wall ........................................... 13.75 NA 5.58 0.96 NA 20.29 000 

70339 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

11006 .... .......... A Debride genit/per/abdom wall ............................ 12.61 NA 4.86 1.28 NA 18.75 000 

11008 .... .......... A Remove mesh from abd wall ............................. 5.00 NA 2.03 0.61 NA 7.64 ZZZ 

11010 .... .......... A Debride skin, fx .................................................. 4.19 6.89 2.63 0.66 11.74 7.48 010 

11011 .... .......... A Debride skin/muscle, fx ...................................... 4.94 8.18 2.35 0.74 13.86 8.03 000 

11012 .... .......... A Debride skin/muscle/bone, fx ............................. 6.87 12.14 3.85 1.16 20.17 11.88 000 

11040 .... .......... A Debride skin, partial ........................................... 0.50 0.52 0.21 0.06 1.08 0.77 000 

11041 .... .......... A Debride skin, full ................................................. 0.82 0.66 0.33 0.10 1.58 1.25 000 

11042 .... .......... A Debride skin/tissue ............................................. 1.12 0.97 0.44 0.13 2.22 1.69 000 

11043 .... .......... A Debride tissue/muscle ........................................ 2.38 3.39 2.60 0.32 6.09 5.30 010 

11044 .... .......... A Debride tissue/muscle/bone ............................... 3.06 4.46 3.76 0.43 7.95 7.25 010 

11055 .... .......... R Trim skin lesion .................................................. 0.43 0.56 0.17 0.05 1.04 0.65 000 

11056 .... .......... R Trim skin lesions, 2 to 4 ..................................... 0.61 0.64 0.23 0.07 1.32 0.91 000 

11057 .... .......... R Trim skin lesions, over 4 .................................... 0.79 0.74 0.30 0.10 1.63 1.19 000 

11100 .... .......... A Biopsy, skin lesion .............................................. 0.81 1.25 0.37 0.03 2.09 1.21 000 

11101 .... .......... A Biopsy, skin add-on ............................................ 0.41 0.33 0.19 0.02 0.76 0.62 ZZZ 

11200 .... .......... A Removal of skin tags .......................................... 0.77 1.04 0.76 0.04 1.85 1.57 010 

11201 .... .......... A Remove skin tags add-on .................................. 0.29 0.16 0.12 0.02 0.47 0.43 ZZZ 

11300 .... .......... A Shave skin lesion ............................................... 0.51 0.99 0.21 0.03 1.53 0.75 000 

11301 .... .......... A Shave skin lesion ............................................... 0.85 1.11 0.38 0.04 2.00 1.27 000 

11302 .... .......... A Shave skin lesion ............................................... 1.05 1.30 0.46 0.05 2.40 1.56 000 

11303 .... .......... A Shave skin lesion ............................................... 1.24 1.58 0.52 0.07 2.89 1.83 000 

11305 .... .......... A Shave skin lesion ............................................... 0.67 0.85 0.27 0.07 1.59 1.01 000 

11306 .... .......... A Shave skin lesion ............................................... 0.99 1.10 0.42 0.07 2.16 1.48 000 

11307 .... .......... A Shave skin lesion ............................................... 1.14 1.29 0.49 0.07 2.50 1.70 000 

11308 .... .......... A Shave skin lesion ............................................... 1.41 1.45 0.59 0.13 2.99 2.13 000 

11310 .... .......... A Shave skin lesion ............................................... 0.73 1.11 0.32 0.04 1.88 1.09 000 

11311 .... .......... A Shave skin lesion ............................................... 1.05 1.23 0.49 0.05 2.33 1.59 000 

11312 .... .......... A Shave skin lesion ............................................... 1.20 1.42 0.55 0.06 2.68 1.81 000 

11313 .... .......... A Shave skin lesion ............................................... 1.62 1.81 0.72 0.10 3.53 2.44 000 

11400 .... .......... A Exc tr-ext b9+marg 0.5 < cm ............................. 0.85 2.00 0.88 0.06 2.91 1.79 010 

11401 .... .......... A Exc tr-ext b9+marg 0.6-1 cm ............................. 1.23 2.06 1.02 0.10 3.39 2.35 010 

11402 .... .......... A Exc tr-ext b9+marg 1.1-2 cm ............................. 1.51 2.23 1.08 0.13 3.87 2.72 010 

11403 .... .......... A Exc tr-ext b9+marg 2.1-3 cm ............................. 1.79 2.40 1.32 0.17 4.36 3.28 010 

11404 .... .......... A Exc tr-ext b9+marg 3.1-4 cm ............................. 2.06 2.71 1.40 0.21 4.98 3.67 010 

11406 .... .......... A Exc tr-ext b9+marg > 4.0 cm ............................. 2.76 3.07 1.65 0.32 6.15 4.73 010 

11420 .... .......... A Exc h-f-nk-sp b9+marg 0.5 < ............................. 0.98 1.77 0.93 0.09 2.84 2.00 010 

11421 .... .......... A Exc h-f-nk-sp b9+marg 0.6-1 ............................. 1.42 2.07 1.11 0.13 3.62 2.66 010 

11422 .... .......... A Exc h-f-nk-sp b9+marg 1.1-2 ............................. 1.63 2.26 1.33 0.16 4.05 3.12 010 

11423 .... .......... A Exc h-f-nk-sp b9+marg 2.1-3 ............................. 2.01 2.59 1.45 0.20 4.80 3.66 010 

11424 .... .......... A Exc h-f-nk-sp b9+marg 3.1-4 ............................. 2.43 2.81 1.60 0.25 5.49 4.28 010 

11426 .... .......... A Exc h-f-nk-sp b9+marg > 4 cm .......................... 3.77 3.49 2.11 0.44 7.70 6.32 010 

11440 .... .......... A Exc face-mm b9+marg 0.5 < cm ....................... 1.06 2.21 1.31 0.08 3.35 2.45 010 

11441 .... .......... A Exc face-mm b9+marg 0.6-1 cm ........................ 1.48 2.34 1.49 0.13 3.95 3.10 010 

11442 .... .......... A Exc face-mm b9+marg 1.1-2 cm ........................ 1.72 2.55 1.57 0.16 4.43 3.45 010 

11443 .... .......... A Exc face-mm b9+marg 2.1-3 cm ........................ 2.29 2.92 1.82 0.22 5.43 4.33 010 

11444 .... .......... A Exc face-mm b9+marg 3.1-4 cm ........................ 3.14 3.48 2.19 0.30 6.92 5.63 010 

11446 .... .......... A Exc face-mm b9+marg > 4 cm .......................... 4.48 4.05 2.78 0.43 8.96 7.69 010 

11450 .... .......... A Removal, sweat gland lesion ............................. 2.73 5.04 2.03 0.34 8.11 5.10 090 

11451 .... .......... A Removal, sweat gland lesion ............................. 3.94 6.62 2.55 0.53 11.09 7.02 090 

11462 .... .......... A Removal, sweat gland lesion ............................. 2.51 5.12 2.02 0.32 7.95 4.85 090 

11463 .... .......... A Removal, sweat gland lesion ............................. 3.94 6.84 2.69 0.54 11.32 7.17 090 

11470 .... .......... A Removal, sweat gland lesion ............................. 3.25 5.07 2.27 0.40 8.72 5.92 090 

11471 .... .......... A Removal, sweat gland lesion ............................. 4.40 6.72 2.77 0.58 11.70 7.75 090 

11600 .... .......... A Exc tr-ext mlg+marg 0.5 < cm ........................... 1.31 2.64 0.97 0.10 4.05 2.38 010 

11601 .... .......... A Exc tr-ext mlg+marg 0.6-1 cm ............................ 1.80 2.71 1.22 0.12 4.63 3.14 010 

11602 .... .......... A Exc tr-ext mlg+marg 1.1-2 cm ............................ 1.95 2.83 1.26 0.12 4.90 3.33 010 

11603 .... .......... A Exc tr-ext mlg+marg 2.1-3 cm ............................ 2.19 3.08 1.33 0.16 5.43 3.68 010 

11604 .... .......... A Exc tr-ext mlg+marg 3.1-4 cm ............................ 2.40 3.38 1.39 0.20 5.98 3.99 010 

11606 .... .......... A Exc tr-ext mlg+marg > 4 cm .............................. 3.42 4.07 1.74 0.36 7.85 5.52 010 

11620 .... .......... A Exc h-f-nk-sp mlg+marg 0.5 < ........................... 1.19 2.60 0.95 0.09 3.88 2.23 010 

11621 .... .......... A Exc h-f-nk-sp mlg+marg 0.6-1 ............................ 1.76 2.71 1.24 0.12 4.59 3.12 010 

11622 .... .......... A Exc h-f-nk-sp mlg+marg 1.1-2 ............................ 2.09 2.97 1.39 0.14 5.20 3.62 010 

11623 .... .......... A Exc h-f-nk-sp mlg+marg 2.1-3 ............................ 2.61 3.34 1.58 0.20 6.15 4.39 010 

11624 .... .......... A Exc h-f-nk-sp mlg+marg 3.1-4 ............................ 3.06 3.75 1.78 0.27 7.08 5.11 010 

11626 .... .......... A Exc h-f-nk-sp mlg+mar > 4 cm .......................... 4.29 4.64 2.40 0.45 9.38 7.14 010 

11640 .... .......... A Exc face-mm malig+marg 0.5 < ......................... 1.35 2.66 1.11 0.11 4.12 2.57 010 

11641 .... .......... A Exc face-mm malig+marg 0.6-1 ......................... 2.16 3.03 1.53 0.16 5.35 3.85 010 

11642 .... .......... A Exc face-mm malig+marg 1.1-2 ......................... 2.59 3.41 1.71 0.19 6.19 4.49 010 

11643 .... .......... A Exc face-mm malig+marg 2.1-3 ......................... 3.10 3.81 1.97 0.26 7.17 5.33 010 

11644 .... .......... A Exc face-mm malig+marg 3.1-4 ......................... 4.02 4.69 2.46 0.37 9.08 6.85 010 

11646 .... .......... A Exc face-mm mlg+marg > 4 cm ......................... 5.94 5.77 3.48 0.61 12.32 10.03 010 

11719 .... .......... R Trim nail(s) ......................................................... 0.17 0.25 0.07 0.02 0.44 0.26 000 

11720 .... .......... A Debride nail, 1-5 ................................................. 0.32 0.34 0.12 0.04 0.70 0.48 000 

11721 .... .......... A Debride nail, 6 or more ...................................... 0.54 0.44 0.21 0.07 1.05 0.82 000 

11730 .... .......... A Removal of nail plate ......................................... 1.13 1.03 0.43 0.14 2.30 1.70 000 

70340 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

11732 .... .......... A Remove nail plate, add-on ................................. 0.57 0.44 0.22 0.07 1.08 0.86 ZZZ 

11740 .... .......... A Drain blood from under nail ............................... 0.37 0.55 0.35 0.04 0.96 0.76 000 

11750 .... .......... A Removal of nail bed ........................................... 1.86 2.17 1.76 0.22 4.25 3.84 010 

11752 .... .......... A Remove nail bed/finger tip ................................. 2.67 3.00 3.00 0.35 6.02 6.02 010 

11755 .... .......... A Biopsy, nail unit .................................................. 1.31 1.57 0.77 0.14 3.02 2.22 000 

11760 .... .......... A Repair of nail bed ............................................... 1.58 2.63 1.79 0.21 4.42 3.58 010 

11762 .... .......... A Reconstruction of nail bed ................................. 2.89 2.89 2.35 0.36 6.14 5.60 010 

11765 .... .......... A Excision of nail fold, toe ..................................... 0.69 1.79 0.76 0.08 2.56 1.53 010 

11770 .... .......... A Removal of pilonidal lesion ................................ 2.61 3.49 1.50 0.33 6.43 4.44 010 

11771 .... .......... A Removal of pilonidal lesion ................................ 5.73 5.66 3.32 0.74 12.13 9.79 090 

11772 .... .......... A Removal of pilonidal lesion ................................ 6.97 7.52 5.08 0.89 15.38 12.94 090 

11900 .... .......... A Injection into skin lesions ................................... 0.52 0.65 0.21 0.02 1.19 0.75 000 

11901 .... .......... A Added skin lesions injection ............................... 0.80 0.66 0.35 0.03 1.49 1.18 000 

11920 .... .......... R Correct skin color defects .................................. 1.61 3.71 1.09 0.24 5.56 2.94 000 

11921 .... .......... R Correct skin color defects .................................. 1.93 3.97 1.27 0.29 6.19 3.49 000 

11922 .... .......... R Correct skin color defects .................................. 0.49 1.14 0.25 0.07 1.70 0.81 ZZZ 

11950 .... .......... R Therapy for contour defects ............................... 0.84 1.14 0.39 0.06 2.04 1.29 000 

11951 .... .......... R Therapy for contour defects ............................... 1.19 1.49 0.51 0.11 2.79 1.81 000 

11952 .... .......... R Therapy for contour defects ............................... 1.69 1.86 0.68 0.16 3.71 2.53 000 

11954 .... .......... R Therapy for contour defects ............................... 1.85 2.45 0.90 0.25 4.55 3.00 000 

11960 .... .......... A Insert tissue expander(s) .................................... 9.07 NA 10.42 1.31 NA 20.80 090 

11970 .... .......... A Replace tissue expander .................................... 7.05 NA 6.15 1.05 NA 14.25 090 

11971 .... .......... A Remove tissue expander(s) ............................... 2.13 9.14 3.80 0.32 11.59 6.25 090 

11975 .... .......... N Insert contraceptive cap ..................................... +1.48 1.42 0.57 0.17 3.07 2.22 XXX 

11976 .... .......... R Removal of contraceptive cap ............................ 1.78 1.72 0.68 0.21 3.71 2.67 000 

11977 .... .......... N Removal/reinsert contra cap .............................. +3.30 2.28 1.26 0.37 5.95 4.93 XXX 

11980 .... .......... A Implant hormone pellet(s) .................................. 1.48 1.08 0.54 0.13 2.69 2.15 000 

11981 .... .......... A Insert drug implant device .................................. 1.48 1.70 0.68 0.12 3.30 2.28 XXX 

11982 .... .......... A Remove drug implant device ............................. 1.78 1.95 0.83 0.17 3.90 2.78 XXX 

11983 .... .......... A Remove/insert drug implant ............................... 3.30 2.29 1.47 0.23 5.82 5.00 XXX 

12001 .... .......... A Repair superficial wound(s) ................................ 1.70 1.99 0.77 0.15 3.84 2.62 010 

12002 .... .......... A Repair superficial wound(s) ................................ 1.86 2.05 0.90 0.17 4.08 2.93 010 

12004 .... .......... A Repair superficial wound(s) ................................ 2.24 2.33 1.01 0.21 4.78 3.46 010 

12005 .... .......... A Repair superficial wound(s) ................................ 2.86 2.83 1.20 0.27 5.96 4.33 010 

12006 .... .......... A Repair superficial wound(s) ................................ 3.66 3.40 1.51 0.35 7.41 5.52 010 

12007 .... .......... A Repair superficial wound(s) ................................ 4.11 3.83 1.82 0.45 8.39 6.38 010 

12011 .... .......... A Repair superficial wound(s) ................................ 1.76 2.14 0.78 0.16 4.06 2.70 010 

12013 .... .......... A Repair superficial wound(s) ................................ 1.99 2.28 0.93 0.18 4.45 3.10 010 

12014 .... .......... A Repair superficial wound(s) ................................ 2.46 2.58 1.06 0.23 5.27 3.75 010 

12015 .... .......... A Repair superficial wound(s) ................................ 3.19 3.14 1.25 0.29 6.62 4.73 010 

12016 .... .......... A Repair superficial wound(s) ................................ 3.92 3.56 1.52 0.37 7.85 5.81 010 

12017 .... .......... A Repair superficial wound(s) ................................ 4.70 NA 1.90 0.47 NA 7.07 010 

12018 .... .......... A Repair superficial wound(s) ................................ 5.52 NA 2.26 0.64 NA 8.42 010 

12020 .... .......... A Closure of split wound ........................................ 2.62 3.83 1.93 0.30 6.75 4.85 010 

12021 .... .......... A Closure of split wound ........................................ 1.84 1.83 1.41 0.24 3.91 3.49 010 

12031 .... .......... A Layer closure of wound(s) .................................. 2.15 2.29 0.96 0.17 4.61 3.28 010 

12032 .... .......... A Layer closure of wound(s) .................................. 2.47 3.85 1.80 0.16 6.48 4.43 010 

12034 .... .......... A Layer closure of wound(s) .................................. 2.92 3.20 1.45 0.25 6.37 4.62 010 

12035 .... .......... A Layer closure of wound(s) .................................. 3.42 5.21 2.16 0.39 9.02 5.97 010 

12036 .... .......... A Layer closure of wound(s) .................................. 4.04 5.57 2.55 0.55 10.16 7.14 010 

12037 .... .......... A Layer closure of wound(s) .................................. 4.66 6.11 2.97 0.66 11.43 8.29 010 

12041 .... .......... A Layer closure of wound(s) .................................. 2.37 2.55 1.13 0.19 5.11 3.69 010 

12042 .... .......... A Layer closure of wound(s) .................................. 2.74 3.27 1.46 0.17 6.18 4.37 010 

12044 .... .......... A Layer closure of wound(s) .................................. 3.14 3.22 1.60 0.27 6.63 5.01 010 

12045 .... .......... A Layer closure of wound(s) .................................. 3.63 5.28 2.29 0.41 9.32 6.33 010 

12046 .... .......... A Layer closure of wound(s) .................................. 4.24 6.52 2.76 0.54 11.30 7.54 010 

12047 .... .......... A Layer closure of wound(s) .................................. 4.64 6.36 3.09 0.58 11.58 8.31 010 

12051 .... .......... A Layer closure of wound(s) .................................. 2.47 3.28 1.45 0.20 5.95 4.12 010 

12052 .... .......... A Layer closure of wound(s) .................................. 2.77 3.23 1.43 0.17 6.17 4.37 010 

12053 .... .......... A Layer closure of wound(s) .................................. 3.12 3.25 1.53 0.23 6.60 4.88 010 

12054 .... .......... A Layer closure of wound(s) .................................. 3.45 3.57 1.63 0.30 7.32 5.38 010 

12055 .... .......... A Layer closure of wound(s) .................................. 4.42 4.49 2.13 0.45 9.36 7.00 010 

12056 .... .......... A Layer closure of wound(s) .................................. 5.23 6.77 3.06 0.59 12.59 8.88 010 

12057 .... .......... A Layer closure of wound(s) .................................. 5.95 6.15 3.76 0.56 12.66 10.27 010 

13100 .... .......... A Repair of wound or lesion .................................. 3.12 4.06 2.31 0.26 7.44 5.69 010 

13101 .... .......... A Repair of wound or lesion .................................. 3.91 4.67 2.69 0.26 8.84 6.86 010 

13102 .... .......... A Repair wound/lesion add-on .............................. 1.24 1.17 0.57 0.13 2.54 1.94 ZZZ 

13120 .... .......... A Repair of wound or lesion .................................. 3.30 4.15 2.35 0.26 7.71 5.91 010 

13121 .... .......... A Repair of wound or lesion .................................. 4.32 4.86 2.80 0.25 9.43 7.37 010 

13122 .... .......... A Repair wound/lesion add-on .............................. 1.44 1.51 0.63 0.15 3.10 2.22 ZZZ 

13131 .... .......... A Repair of wound or lesion .................................. 3.78 4.37 2.69 0.26 8.41 6.73 010 

13132 .... .......... A Repair of wound or lesion .................................. 5.94 5.92 4.17 0.32 12.18 10.43 010 

13133 .... .......... A Repair wound/lesion add-on .............................. 2.19 1.66 1.03 0.18 4.03 3.40 ZZZ 

13150 .... .......... A Repair of wound or lesion .................................. 3.80 4.88 2.77 0.34 9.02 6.91 010 

13151 .... .......... A Repair of wound or lesion .................................. 4.44 4.81 3.15 0.31 9.56 7.90 010 

70341 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

13152 .... .......... A Repair of wound or lesion .................................. 6.32 6.05 4.05 0.40 12.77 10.77 010 

13153 .... .......... A Repair wound/lesion add-on .............................. 2.38 1.94 1.14 0.24 4.56 3.76 ZZZ 

13160 .... .......... A Late closure of wound ........................................ 10.46 NA 7.18 1.54 NA 19.18 090 

14000 .... .......... A Skin tissue rearrangement ................................. 5.88 7.87 5.48 0.59 14.34 11.95 090 

14001 .... .......... A Skin tissue rearrangement ................................. 8.46 9.44 7.09 0.82 18.72 16.37 090 

14020 .... .......... A Skin tissue rearrangement ................................. 6.58 8.63 6.55 0.64 15.85 13.77 090 

14021 .... .......... A Skin tissue rearrangement ................................. 10.04 10.01 8.30 0.81 20.86 19.15 090 

14040 .... .......... A Skin tissue rearrangement ................................. 7.86 8.83 7.22 0.62 17.31 15.70 090 

14041 .... .......... A Skin tissue rearrangement ................................. 11.47 10.62 8.70 0.73 22.82 20.90 090 

14060 .... .......... A Skin tissue rearrangement ................................. 8.49 8.81 7.45 0.68 17.98 16.62 090 

14061 .... .......... A Skin tissue rearrangement ................................. 12.27 11.63 9.53 0.76 24.66 22.56 090 

14300 .... .......... A Skin tissue rearrangement ................................. 11.74 11.16 9.20 1.16 24.06 22.10 090 

14350 .... .......... A Skin tissue rearrangement ................................. 9.60 NA 7.16 1.34 NA 18.10 090 

15000 .... .......... A Wound prep, 1st 100 sq cm ............................... 3.99 3.80 2.19 0.54 8.33 6.72 000 

15001 .... .......... A Wound prep, addl 100 sq cm ............................. 1.00 1.35 0.41 0.14 2.49 1.55 ZZZ 

15040 .... .......... A Harvest cultured skin graft ................................. 2.00 4.57 1.13 0.24 6.81 3.37 000 

15050 .... .......... A Skin pinch graft .................................................. 4.29 6.93 5.12 0.57 11.79 9.98 090 

15100 .... .......... A Skin splt grft, trnk/arm/leg .................................. 9.04 12.62 7.84 1.28 22.94 18.16 090 

15101 .... .......... A Skin splt grft t/a/l, add-on ................................... 1.72 3.74 1.17 0.24 5.70 3.13 ZZZ 

15110 .... .......... A Epidrm autogrft trnk/arm/leg ............................... 9.50 10.70 7.02 1.31 21.51 17.83 090 

15111 .... .......... A Epidrm autogrft t/a/l add-on ............................... 1.85 1.29 0.79 0.26 3.40 2.90 ZZZ 

15115 .... .......... A Epidrm a-grft face/nck/hf/g ................................. 9.81 9.25 7.37 1.15 20.21 18.33 090 

15116 .... .......... A Epidrm a-grft f/n/hf/g addl .................................. 2.50 1.58 1.12 0.33 4.41 3.95 ZZZ 

15120 .... .......... A Skn splt a-grft fac/nck/hf/g ................................. 9.82 10.75 7.80 1.16 21.73 18.78 090 

15121 .... .......... A Skn splt a-grft f/n/hf/g add .................................. 2.67 4.51 1.85 0.36 7.54 4.88 ZZZ 

15130 .... .......... A Derm autograft, trnk/arm/leg .............................. 7.00 9.89 6.36 0.97 17.86 14.33 090 

15131 .... .......... A Derm autograft t/a/l add-on ................................ 1.50 1.07 0.64 0.21 2.78 2.35 ZZZ 

15135 .... .......... A Derm autograft face/nck/hf/g .............................. 10.50 9.90 8.15 1.23 21.63 19.88 090 

15136 .... .......... A Derm autograft, f/n/hf/g add ............................... 1.50 0.89 0.67 0.20 2.59 2.37 ZZZ 

15150 .... .......... A Cult epiderm grft t/arm/leg ................................. 8.25 8.48 6.46 1.14 17.87 15.85 090 

15151 .... .......... A Cult epiderm grft t/a/l addl .................................. 2.00 1.31 0.85 0.28 3.59 3.13 ZZZ 

15152 .... .......... A Cult epiderm graft t/a/l +% ................................. 2.50 1.56 1.06 0.35 4.41 3.91 ZZZ 

15155 .... .......... A Cult epiderm graft, f/n/hf/g ................................. 9.00 7.84 6.98 1.05 17.89 17.03 090 

15156 .... .......... A Cult epidrm grft f/n/hfg add ................................ 2.75 1.56 1.24 0.36 4.67 4.35 ZZZ 

15157 .... .......... A Cult epiderm grft f/n/hfg +% ............................... 3.00 1.78 1.35 0.39 5.17 4.74 ZZZ 

15170 .... .......... A Acell graft trunk/arms/legs .................................. 5.00 3.84 2.37 0.55 9.39 7.92 090 

15171 .... .......... A Acell graft t/arm/leg add-on ................................ 1.55 0.68 0.62 0.19 2.42 2.36 ZZZ 

15175 .... .......... A Acellular graft, f/n/hf/g ........................................ 7.00 5.44 4.01 0.82 13.26 11.83 090 

15176 .... .......... A Acell graft, f/n/hf/g add-on .................................. 2.45 1.11 0.99 0.29 3.85 3.73 ZZZ 

15200 .... .......... A Skin full graft, trunk ............................................ 8.02 9.43 6.22 0.98 18.43 15.22 090 

15201 .... .......... A Skin full graft trunk add-on ................................. 1.32 2.57 0.62 0.19 4.08 2.13 ZZZ 

15220 .... .......... A Skin full graft sclp/arm/leg .................................. 7.86 9.21 6.70 0.84 17.91 15.40 090 

15221 .... .......... A Skin full graft add-on .......................................... 1.19 2.33 0.56 0.16 3.68 1.91 ZZZ 

15240 .... .......... A Skin full grft face/genit/hf .................................... 9.03 10.23 7.97 0.92 20.18 17.92 090 

15241 .... .......... A Skin full graft add-on .......................................... 1.86 2.45 0.91 0.23 4.54 3.00 ZZZ 

15260 .... .......... A Skin full graft een & lips ..................................... 10.04 10.24 8.60 0.69 20.97 19.33 090 

15261 .... .......... A Skin full graft add-on .......................................... 2.23 2.70 1.40 0.21 5.14 3.84 ZZZ 

15300 .... .......... A Apply skinallogrft, t/arm/lg .................................. 3.99 3.21 2.24 0.49 7.69 6.72 090 

15301 .... .......... A Apply sknallogrft t/a/l addl .................................. 1.00 0.47 0.40 0.14 1.61 1.54 ZZZ 

15320 .... .......... A Apply skin allogrft f/n/hf/g ................................... 4.70 3.63 2.54 0.58 8.91 7.82 090 

15321 .... .......... A Aply sknallogrft f/n/hfg add ................................. 1.50 0.69 0.59 0.21 2.40 2.30 ZZZ 

15330 .... .......... A Aply acell alogrft t/arm/leg .................................. 3.99 3.20 2.23 0.49 7.68 6.71 090 

15331 .... .......... A Aply acell grft t/a/l add-on .................................. 1.00 0.46 0.40 0.14 1.60 1.54 ZZZ 

15335 .... .......... A Apply acell graft, f/n/hf/g .................................... 4.50 3.48 2.45 0.55 8.53 7.50 090 

15336 .... .......... A Aply acell grft f/n/hf/g add .................................. 1.43 0.69 0.57 0.20 2.32 2.20 ZZZ 

15340 .... .......... A Apply cult skin substitute .................................... 3.72 4.01 2.76 0.41 8.14 6.89 010 

15341 .... .......... A Apply cult skin sub add-on ................................. 0.50 0.61 0.20 0.06 1.17 0.76 ZZZ 

15360 .... .......... A Apply cult derm sub, t/a/l ................................... 3.87 4.48 3.09 0.43 8.78 7.39 090 

15361 .... .......... A Aply cult derm sub t/a/l add ............................... 1.15 0.58 0.46 0.14 1.87 1.75 ZZZ 

15365 .... .......... A Apply cult derm sub f/n/hf/g ............................... 4.15 4.56 3.20 0.46 9.17 7.81 090 

15366 .... .......... A Apply cult derm f/hf/g add .................................. 1.45 0.70 0.58 0.17 2.32 2.20 ZZZ 

15400 .... .......... A Apply skin xenograft, t/a/l ................................... 3.99 4.02 4.02 0.47 8.48 8.48 090 

15401 .... .......... A Apply skn xenogrft t/a/l add ............................... 1.00 1.90 0.44 0.14 3.04 1.58 ZZZ 

15420 .... .......... A Apply skin xgraft, f/n/hf/g .................................... 4.50 4.79 3.80 0.52 9.81 8.82 090 

15421 .... .......... A Apply skn xgrft f/n/hf/g add ................................ 1.50 1.32 0.62 0.21 3.03 2.33 ZZZ 

15430 .... .......... A Apply acellular xenograft .................................... 5.75 6.92 6.63 0.66 13.33 13.04 090 

15431 .... .......... C Apply acellular xgraft add ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

15570 .... .......... A Form skin pedicle flap ........................................ 9.20 11.33 6.78 1.34 21.87 17.32 090 

15572 .... .......... A Form skin pedicle flap ........................................ 9.26 9.52 6.47 1.20 19.98 16.93 090 

15574 .... .......... A Form skin pedicle flap ........................................ 9.87 10.71 7.81 1.20 21.78 18.88 090 

15576 .... .......... A Form skin pedicle flap ........................................ 8.68 9.78 6.90 0.87 19.33 16.45 090 

15600 .... .......... A Skin graft ............................................................ 1.91 7.62 3.07 0.27 9.80 5.25 090 

15610 .... .......... A Skin graft ............................................................ 2.42 4.70 3.43 0.35 7.47 6.20 090 

15620 .... .......... A Skin graft ............................................................ 2.94 7.80 3.89 0.35 11.09 7.18 090 

15630 .... .......... A Skin graft ............................................................ 3.27 7.06 4.16 0.34 10.67 7.77 090 

70342 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

15650 .... .......... A Transfer skin pedicle flap ................................... 3.96 7.16 4.22 0.42 11.54 8.60 090 

15732 .... .......... A Muscle-skin graft, head/neck ............................. 17.81 18.09 12.25 1.99 37.89 32.05 090 

15734 .... .......... A Muscle-skin graft, trunk ...................................... 17.76 18.16 12.41 2.61 38.53 32.78 090 

15736 .... .......... A Muscle-skin graft, arm ........................................ 16.25 18.28 11.25 2.45 36.98 29.95 090 

15738 .... .......... A Muscle-skin graft, leg ......................................... 17.89 18.02 11.75 2.65 38.56 32.29 090 

15740 .... .......... A Island pedicle flap graft ...................................... 10.23 10.16 8.28 0.63 21.02 19.14 090 

15750 .... .......... A Neurovascular pedicle graft ............................... 11.39 NA 9.07 1.42 NA 21.88 090 

15756 .... .......... A Free myo/skin flap microvasc ............................ 35.18 NA 20.62 4.61 NA 60.41 090 

15757 .... .......... A Free skin flap, microvasc ................................... 35.18 NA 21.65 3.89 NA 60.72 090 

15758 .... .......... A Free fascial flap, microvasc ............................... 35.05 NA 21.63 4.23 NA 60.91 090 

15760 .... .......... A Composite skin graft .......................................... 8.73 10.05 7.28 0.85 19.63 16.86 090 

15770 .... .......... A Derma-fat-fascia graft ......................................... 7.51 NA 6.70 1.05 NA 15.26 090 

15775 .... .......... R Hair transplant punch grafts ............................... 3.95 4.24 1.30 0.52 8.71 5.77 000 

15776 .... .......... R Hair transplant punch grafts ............................... 5.53 5.37 2.81 0.72 11.62 9.06 000 

15780 .... .......... A Abrasion treatment of skin ................................. 7.28 11.55 8.27 0.67 19.50 16.22 090 

15781 .... .......... A Abrasion treatment of skin ................................. 4.84 6.93 5.38 0.34 12.11 10.56 090 

15782 .... .......... A Abrasion treatment of skin ................................. 4.31 9.88 6.57 0.34 14.53 11.22 090 

15783 .... .......... A Abrasion treatment of skin ................................. 4.28 6.89 4.19 0.28 11.45 8.75 090 

15786 .... .......... A Abrasion, lesion, single ...................................... 2.03 3.36 1.32 0.11 5.50 3.46 010 

15787 .... .......... A Abrasion, lesions, add-on ................................... 0.33 1.09 0.16 0.04 1.46 0.53 ZZZ 

15788 .... .......... R Chemical peel, face, epiderm ............................ 2.09 6.73 3.09 0.11 8.93 5.29 090 

15789 .... .......... R Chemical peel, face, dermal .............................. 4.91 8.11 4.81 0.20 13.22 9.92 090 

15792 .... .......... R Chemical peel, nonfacial .................................... 1.86 7.11 4.46 0.13 9.10 6.45 090 

15793 .... .......... A Chemical peel, nonfacial .................................... 3.73 6.30 4.39 0.19 10.22 8.31 090 

15819 .... .......... A Plastic surgery, neck .......................................... 9.37 NA 7.20 0.97 NA 17.54 090 

15820 .... .......... A Revision of lower eyelid ..................................... 5.14 6.99 5.58 0.40 12.53 11.12 090 

15821 .... .......... A Revision of lower eyelid ..................................... 5.71 7.37 5.73 0.45 13.53 11.89 090 

15822 .... .......... A Revision of upper eyelid ..................................... 4.44 5.85 4.50 0.37 10.66 9.31 090 

15823 .... .......... A Revision of upper eyelid ..................................... 7.04 7.87 6.45 0.50 15.41 13.99 090 

15824 .... .......... R Removal of forehead wrinkles ............................ 0.00 0.00 0.00 0.00 0.00 0.00 000 

15825 .... .......... R Removal of neck wrinkles .................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15826 .... .......... R Removal of brow wrinkles .................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15828 .... .......... R Removal of face wrinkles ................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

15829 .... .......... R Removal of skin wrinkles ................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

15831 .... .......... A Excise excessive skin tissue .............................. 12.38 NA 8.18 1.75 NA 22.31 090 

15832 .... .......... A Excise excessive skin tissue .............................. 11.57 NA 8.36 1.66 NA 21.59 090 

15833 .... .......... A Excise excessive skin tissue .............................. 10.62 NA 8.23 1.49 NA 20.34 090 

15834 .... .......... A Excise excessive skin tissue .............................. 10.83 NA 7.71 1.61 NA 20.15 090 

15835 .... .......... A Excise excessive skin tissue .............................. 11.65 NA 7.56 1.60 NA 20.81 090 

15836 .... .......... A Excise excessive skin tissue .............................. 9.33 NA 6.80 1.34 NA 17.47 090 

15837 .... .......... A Excise excessive skin tissue .............................. 8.42 8.57 7.39 1.18 18.17 16.99 090 

15838 .... .......... A Excise excessive skin tissue .............................. 7.12 NA 6.08 0.58 NA 13.78 090 

15839 .... .......... A Excise excessive skin tissue .............................. 9.37 8.85 6.41 1.22 19.44 17.00 090 

15840 .... .......... A Graft for face nerve palsy .................................. 13.24 NA 10.00 1.32 NA 24.56 090 

15841 .... .......... A Graft for face nerve palsy .................................. 23.23 NA 15.03 2.54 NA 40.80 090 

15842 .... .......... A Flap for face nerve palsy ................................... 37.90 NA 22.98 4.93 NA 65.81 090 

15845 .... .......... A Skin and muscle repair, face ............................. 12.55 NA 9.33 0.81 NA 22.69 090 

15850 .... .......... B Removal of sutures ............................................ +0.78 1.56 0.30 0.05 2.39 1.13 XXX 

15851 .... .......... A Removal of sutures ............................................ 0.86 1.68 0.31 0.06 2.60 1.23 000 

15852 .... .......... A Dressing change not for burn ............................ 0.86 1.85 0.33 0.09 2.80 1.28 000 

15860 .... .......... A Test for blood flow in graft ................................. 1.95 0.83 0.78 0.27 3.05 3.00 000 

15876 .... .......... R Suction assisted lipectomy ................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15877 .... .......... R Suction assisted lipectomy ................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15878 .... .......... R Suction assisted lipectomy ................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15879 .... .......... R Suction assisted lipectomy ................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

15920 .... .......... A Removal of tail bone ulcer ................................. 7.94 NA 5.57 1.04 NA 14.55 090 

15922 .... .......... A Removal of tail bone ulcer ................................. 9.89 NA 7.23 1.42 NA 18.54 090 

15931 .... .......... A Remove sacrum pressure sore .......................... 9.23 NA 5.70 1.25 NA 16.18 090 

15933 .... .......... A Remove sacrum pressure sore .......................... 10.83 NA 7.87 1.52 NA 20.22 090 

15934 .... .......... A Remove sacrum pressure sore .......................... 12.67 NA 8.06 1.78 NA 22.51 090 

15935 .... .......... A Remove sacrum pressure sore .......................... 14.55 NA 10.35 2.09 NA 26.99 090 

15936 .... .......... A Remove sacrum pressure sore .......................... 12.36 NA 8.24 1.76 NA 22.36 090 

15937 .... .......... A Remove sacrum pressure sore .......................... 14.19 NA 9.85 2.06 NA 26.10 090 

15940 .... .......... A Remove hip pressure sore ................................. 9.33 NA 6.19 1.31 NA 16.83 090 

15941 .... .......... A Remove hip pressure sore ................................. 11.41 NA 9.48 1.66 NA 22.55 090 

15944 .... .......... A Remove hip pressure sore ................................. 11.44 NA 8.62 1.65 NA 21.71 090 

15945 .... .......... A Remove hip pressure sore ................................. 12.67 NA 9.67 1.84 NA 24.18 090 

15946 .... .......... A Remove hip pressure sore ................................. 21.54 NA 14.41 3.16 NA 39.11 090 

15950 .... .......... A Remove thigh pressure sore .............................. 7.53 NA 5.43 1.04 NA 14.00 090 

15951 .... .......... A Remove thigh pressure sore .............................. 10.70 NA 7.88 1.49 NA 20.07 090 

15952 .... .......... A Remove thigh pressure sore .............................. 11.37 NA 7.77 1.60 NA 20.74 090 

15953 .... .......... A Remove thigh pressure sore .............................. 12.61 NA 9.02 1.79 NA 23.42 090 

15956 .... .......... A Remove thigh pressure sore .............................. 15.50 NA 10.80 2.21 NA 28.51 090 

15958 .... .......... A Remove thigh pressure sore .............................. 15.46 NA 11.07 2.25 NA 28.78 090 

15999 .... .......... C Removal of pressure sore .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

70343 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

16000 .... .......... A Initial treatment of burn(s) .................................. 0.89 0.86 0.26 0.08 1.83 1.23 000 

16020 .... .......... A Dress/debrid p-thick burn, s ............................... 0.80 1.29 0.58 0.08 2.17 1.46 000 

16025 .... .......... A Dress/debrid p-thick burn, m .............................. 1.85 1.77 0.96 0.19 3.81 3.00 000 

16030 .... .......... A Dress/debrid p-thick burn, l ................................ 2.08 2.18 1.12 0.24 4.50 3.44 000 

16035 .... .......... A Incision of burn scab, initi .................................. 3.74 NA 1.58 0.46 NA 5.78 090 

16036 .... .......... A Escharotomy; add’l incision ................................ 1.50 NA 0.60 0.20 NA 2.30 ZZZ 

17000 .... .......... A Destroy benign/premlg lesion ............................. 0.60 0.97 0.54 0.03 1.60 1.17 010 

17003 .... .......... A Destroy lesions, 2-14 ......................................... 0.15 0.11 0.07 0.01 0.27 0.23 ZZZ 

17004 .... .......... A Destroy lesions, 15 or more ............................... 2.79 2.31 1.59 0.11 5.21 4.49 010 

17106 .... .......... A Destruction of skin lesions ................................. 4.58 4.61 3.34 0.35 9.54 8.27 090 

17107 .... .......... A Destruction of skin lesions ................................. 9.15 7.22 5.47 0.63 17.00 15.25 090 

17108 .... .......... A Destruction of skin lesions ................................. 13.18 9.29 7.68 0.54 23.01 21.40 090 

17110 .... .......... A Destruct lesion, 1-14 .......................................... 0.65 1.62 0.70 0.05 2.32 1.40 010 

17111 .... .......... A Destruct lesion, 15 or more ................................ 0.92 1.67 0.81 0.05 2.64 1.78 010 

17250 .... .......... A Chemical cautery, tissue .................................... 0.50 1.22 0.34 0.06 1.78 0.90 000 

17260 .... .......... A Destruction of skin lesions ................................. 0.91 1.28 0.67 0.04 2.23 1.62 010 

17261 .... .......... A Destruction of skin lesions ................................. 1.17 1.61 0.83 0.05 2.83 2.05 010 

17262 .... .......... A Destruction of skin lesions ................................. 1.58 1.89 1.02 0.06 3.53 2.66 010 

17263 .... .......... A Destruction of skin lesions ................................. 1.79 2.06 1.09 0.07 3.92 2.95 010 

17264 .... .......... A Destruction of skin lesions ................................. 1.94 2.23 1.12 0.08 4.25 3.14 010 

17266 .... .......... A Destruction of skin lesions ................................. 2.34 2.51 1.22 0.09 4.94 3.65 010 

17270 .... .......... A Destruction of skin lesions ................................. 1.32 1.70 0.87 0.05 3.07 2.24 010 

17271 .... .......... A Destruction of skin lesions ................................. 1.49 1.78 0.98 0.06 3.33 2.53 010 

17272 .... .......... A Destruction of skin lesions ................................. 1.77 2.00 1.11 0.07 3.84 2.95 010 

17273 .... .......... A Destruction of skin lesions ................................. 2.05 2.21 1.21 0.08 4.34 3.34 010 

17274 .... .......... A Destruction of skin lesions ................................. 2.59 2.57 1.44 0.10 5.26 4.13 010 

17276 .... .......... A Destruction of skin lesions ................................. 3.20 2.95 1.68 0.16 6.31 5.04 010 

17280 .... .......... A Destruction of skin lesions ................................. 1.17 1.61 0.81 0.05 2.83 2.03 010 

17281 .... .......... A Destruction of skin lesions ................................. 1.72 1.91 1.09 0.07 3.70 2.88 010 

17282 .... .......... A Destruction of skin lesions ................................. 2.04 2.16 1.24 0.08 4.28 3.36 010 

17283 .... .......... A Destruction of skin lesions ................................. 2.64 2.55 1.49 0.11 5.30 4.24 010 

17284 .... .......... A Destruction of skin lesions ................................. 3.21 2.93 1.76 0.13 6.27 5.10 010 

17286 .... .......... A Destruction of skin lesions ................................. 4.43 3.68 2.45 0.23 8.34 7.11 010 

17304 .... .......... A 1 stage mohs, up to 5 spec ............................... 7.59 8.26 3.57 0.30 16.15 11.46 000 

17305 .... .......... A 2 stage mohs, up to 5 spec ............................... 2.85 3.90 1.34 0.11 6.86 4.30 000 

17306 .... .......... A 3 stage mohs, up to 5 spec ............................... 2.85 3.92 1.35 0.11 6.88 4.31 000 

17307 .... .......... A Mohs addl stage up to 5 spec ........................... 2.85 3.57 1.36 0.11 6.53 4.32 000 

17310 .... .......... A Mohs any stage > 5 spec each .......................... 0.95 1.62 0.46 0.03 2.60 1.44 ZZZ 

17340 .... .......... A Cryotherapy of skin ............................................ 0.76 0.37 0.36 0.05 1.18 1.17 010 

17360 .... .......... A Skin peel therapy ............................................... 1.43 1.44 0.87 0.06 2.93 2.36 010 

17380 .... .......... R Hair removal by electrolysis ............................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

17999 .... .......... C Skin tissue procedure ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

19000 .... .......... A Drainage of breast lesion ................................... 0.84 1.99 0.31 0.08 2.91 1.23 000 

19001 .... .......... A Drain breast lesion add-on ................................. 0.42 0.25 0.14 0.04 0.71 0.60 ZZZ 

19020 .... .......... A Incision of breast lesion ..................................... 3.56 6.35 2.68 0.45 10.36 6.69 090 

19030 .... .......... A Injection for breast x-ray .................................... 1.53 2.87 0.50 0.09 4.49 2.12 000 

19100 .... .......... A Bx breast percut w/o image ............................... 1.27 2.09 0.42 0.16 3.52 1.85 000 

19101 .... .......... A Biopsy of breast, open ....................................... 3.18 4.51 1.92 0.39 8.08 5.49 010 

19102 .... .......... A Bx breast percut w/image .................................. 2.00 3.84 0.66 0.14 5.98 2.80 000 

19103 .... .......... A Bx breast percut w/device .................................. 3.69 11.52 1.23 0.30 15.51 5.22 000 

19110 .... .......... A Nipple exploration ............................................... 4.29 5.81 2.87 0.57 10.67 7.73 090 

19112 .... .......... A Excise breast duct fistula ................................... 3.66 6.08 2.69 0.48 10.22 6.83 090 

19120 .... .......... A Removal of breast lesion ................................... 5.55 4.55 3.07 0.73 10.83 9.35 090 

19125 .... .......... A Excision, breast lesion ....................................... 6.05 4.79 3.29 0.80 11.64 10.14 090 

19126 .... .......... A Excision, addl breast lesion ............................... 2.93 NA 1.00 0.38 NA 4.31 ZZZ 

19140 .... .......... A Removal of breast tissue ................................... 5.13 7.16 3.40 0.69 12.98 9.22 090 

19160 .... .......... A Partial mastectomy ............................................. 5.98 NA 3.43 0.79 NA 10.20 090 

19162 .... .......... A P-mastectomy w/ln removal ............................... 13.51 NA 6.35 1.79 NA 21.65 090 

19180 .... .......... A Removal of breast .............................................. 8.79 NA 5.03 1.18 NA 15.00 090 

19182 .... .......... A Removal of breast .............................................. 7.72 NA 4.76 1.04 NA 13.52 090 

19200 .... .......... A Removal of breast .............................................. 15.47 NA 7.98 1.92 NA 25.37 090 

19220 .... .......... A Removal of breast .............................................. 15.70 NA 8.25 2.07 NA 26.02 090 

19240 .... .......... A Removal of breast .............................................. 15.98 NA 8.22 2.12 NA 26.32 090 

19260 .... .......... A Removal of chest wall lesion ............................. 15.42 NA 11.18 2.13 NA 28.73 090 

19271 .... .......... A Revision of chest wall ........................................ 18.87 NA 18.00 2.62 NA 39.49 090 

19272 .... .......... A Extensive chest wall surgery .............................. 21.52 NA 18.98 2.99 NA 43.49 090 

19290 .... .......... A Place needle wire, breast ................................... 1.27 2.86 0.42 0.07 4.20 1.76 000 

19291 .... .......... A Place needle wire, breast ................................... 0.63 1.21 0.21 0.04 1.88 0.88 ZZZ 

19295 .... .......... A Place breast clip, percut ..................................... 0.00 2.70 NA 0.01 2.71 NA ZZZ 

19296 .... .......... A Place po breast cath for rad .............................. 3.63 125.75 1.53 0.36 129.74 5.52 000 

19297 .... .......... A Place breast cath for rad .................................... 1.72 NA 0.64 0.17 NA 2.53 ZZZ 

19298 .... .......... A Place breast rad tube/caths ............................... 6.00 42.28 2.42 0.43 48.71 8.85 000 

19316 .... .......... A Suspension of breast ......................................... 10.67 NA 7.53 1.64 NA 19.84 090 

19318 .... .......... A Reduction of large breast ................................... 15.60 NA 11.20 2.92 NA 29.72 090 

19324 .... .......... A Enlarge breast .................................................... 5.84 NA 4.90 0.84 NA 11.58 090 

70344 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

19325 .... .......... A Enlarge breast with implant ................................ 8.44 NA 6.54 1.33 NA 16.31 090 

19328 .... .......... A Removal of breast implant ................................. 5.67 NA 5.03 0.91 NA 11.61 090 

19330 .... .......... A Removal of implant material .............................. 7.58 NA 6.05 1.26 NA 14.89 090 

19340 .... .......... A Immediate breast prosthesis .............................. 6.32 NA 3.12 1.06 NA 10.50 ZZZ 

19342 .... .......... A Delayed breast prosthesis .................................. 11.18 NA 8.95 1.83 NA 21.96 090 

19350 .... .......... A Breast reconstruction ......................................... 8.91 13.88 7.19 1.41 24.20 17.51 090 

19355 .... .......... A Correct inverted nipple(s) ................................... 7.56 10.28 4.71 0.92 18.76 13.19 090 

19357 .... .......... A Breast reconstruction ......................................... 18.13 NA 15.66 2.93 NA 36.72 090 

19361 .... .......... A Breast reconstruction ......................................... 19.23 NA 12.47 2.92 NA 34.62 090 

19364 .... .......... A Breast reconstruction ......................................... 40.94 NA 23.61 6.22 NA 70.77 090 

19366 .... .......... A Breast reconstruction ......................................... 21.25 NA 11.61 3.24 NA 36.10 090 

19367 .... .......... A Breast reconstruction ......................................... 25.69 NA 16.74 4.03 NA 46.46 090 

19368 .... .......... A Breast reconstruction ......................................... 32.37 NA 18.97 5.52 NA 56.86 090 

19369 .... .......... A Breast reconstruction ......................................... 29.78 NA 18.45 4.50 NA 52.73 090 

19370 .... .......... A Surgery of breast capsule .................................. 8.04 NA 6.92 1.29 NA 16.25 090 

19371 .... .......... A Removal of breast capsule ................................ 9.34 NA 7.84 1.62 NA 18.80 090 

19380 .... .......... A Revise breast reconstruction .............................. 9.13 NA 7.72 1.44 NA 18.29 090 

19396 .... .......... A Design custom breast implant ............................ 2.17 1.08 0.99 0.30 3.55 3.46 000 

19499 .... .......... C Breast surgery procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

20000 .... .......... A Incision of abscess ............................................. 2.12 2.70 1.74 0.25 5.07 4.11 010 

20005 .... .......... A Incision of deep abscess .................................... 3.41 3.50 2.26 0.46 7.37 6.13 010 

2000F .... .......... I Blood pressure measure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

2001F .... .......... I Weight record ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

2002F .... .......... I Clin sign vol ovrld assess .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

2003F .... .......... I Auscultation heart perform ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

2004F .... .......... I Initial exam involved joints ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

20100 .... .......... A Explore wound, neck .......................................... 10.06 NA 4.47 1.21 NA 15.74 010 

20101 .... .......... A Explore wound, chest ......................................... 3.22 5.94 1.62 0.44 9.60 5.28 010 

20102 .... .......... A Explore wound, abdomen .................................. 3.93 7.48 1.91 0.49 11.90 6.33 010 

20103 .... .......... A Explore wound, extremity ................................... 5.29 8.60 3.40 0.75 14.64 9.44 010 

20150 .... .......... A Excise epiphyseal bar ........................................ 13.67 NA 7.05 2.03 NA 22.75 090 

20200 .... .......... A Muscle biopsy ..................................................... 1.46 3.04 0.75 0.23 4.73 2.44 000 

20205 .... .......... A Deep muscle biopsy ........................................... 2.35 3.90 1.19 0.33 6.58 3.87 000 

20206 .... .......... A Needle biopsy, muscle ....................................... 0.99 6.52 0.63 0.07 7.58 1.69 000 

20220 .... .......... A Bone biopsy, trocar/needle ................................ 1.27 4.57 0.79 0.08 5.92 2.14 000 

20225 .... .......... A Bone biopsy, trocar/needle ................................ 1.87 24.52 1.13 0.22 26.61 3.22 000 

20240 .... .......... A Bone biopsy, excisional ...................................... 3.23 NA 2.56 0.44 NA 6.23 010 

20245 .... .......... A Bone biopsy, excisional ...................................... 7.77 NA 6.59 1.31 NA 15.67 010 

20250 .... .......... A Open bone biopsy .............................................. 5.02 NA 3.51 1.02 NA 9.55 010 

20251 .... .......... A Open bone biopsy .............................................. 5.55 NA 4.17 1.15 NA 10.87 010 

20500 .... .......... A Injection of sinus tract ........................................ 1.23 2.27 1.53 0.12 3.62 2.88 010 

20501 .... .......... A Inject sinus tract for x-ray ................................... 0.76 2.92 0.25 0.04 3.72 1.05 000 

20520 .... .......... A Removal of foreign body .................................... 1.85 2.92 1.77 0.21 4.98 3.83 010 

20525 .... .......... A Removal of foreign body .................................... 3.49 9.17 2.63 0.51 13.17 6.63 010 

20526 .... .......... A Ther injection, carp tunnel .................................. 0.94 0.97 0.52 0.13 2.04 1.59 000 

20550 .... .......... A Inj tendon sheath/ligament ................................. 0.75 0.71 0.23 0.09 1.55 1.07 000 

20551 .... .......... A Inj tendon origin/insertion ................................... 0.75 0.68 0.33 0.08 1.51 1.16 000 

20552 .... .......... A Inj trigger point, 1/2 muscl .................................. 0.66 0.72 0.20 0.05 1.43 0.91 000 

20553 .... .......... A Inject trigger points, =/> 3 .................................. 0.75 0.82 0.22 0.04 1.61 1.01 000 

20600 .... .......... A Drain/inject, joint/bursa ....................................... 0.66 0.65 0.35 0.08 1.39 1.09 000 

20605 .... .......... A Drain/inject, joint/bursa ....................................... 0.68 0.76 0.36 0.08 1.52 1.12 000 

20610 .... .......... A Drain/inject, joint/bursa ....................................... 0.79 0.95 0.42 0.11 1.85 1.32 000 

20612 .... .......... A Aspirate/inj ganglion cyst ................................... 0.70 0.71 0.36 0.10 1.51 1.16 000 

20615 .... .......... A Treatment of bone cyst ...................................... 2.28 3.52 1.85 0.20 6.00 4.33 010 

20650 .... .......... A Insert and remove bone pin ............................... 2.23 2.37 1.55 0.31 4.91 4.09 010 

20660 .... .......... A Apply, rem fixation device .................................. 2.51 3.06 1.61 0.59 6.16 4.71 000 

20661 .... .......... A Application of head brace .................................. 4.88 NA 4.92 1.14 NA 10.94 090 

20662 .... .......... A Application of pelvis brace ................................. 6.06 NA 5.54 0.56 NA 12.16 090 

20663 .... .......... A Application of thigh brace ................................... 5.42 NA 4.84 0.94 NA 11.20 090 

20664 .... .......... A Halo brace application ........................................ 8.05 NA 7.06 1.74 NA 16.85 090 

20665 .... .......... A Removal of fixation device ................................. 1.31 2.16 1.35 0.19 3.66 2.85 010 

20670 .... .......... A Removal of support implant ............................... 1.74 11.57 2.11 0.28 13.59 4.13 010 

20680 .... .......... A Removal of support implant ............................... 3.34 8.81 3.73 0.56 12.71 7.63 090 

20690 .... .......... A Apply bone fixation device ................................. 3.51 NA 2.52 0.59 NA 6.62 090 

20692 .... .......... A Apply bone fixation device ................................. 6.40 NA 3.78 1.05 NA 11.23 090 

20693 .... .......... A Adjust bone fixation device ................................ 5.85 NA 5.46 0.98 NA 12.29 090 

20694 .... .......... A Remove bone fixation device ............................. 4.15 7.16 4.05 0.71 12.02 8.91 090 

20802 .... .......... A Replantation, arm, complete .............................. 41.09 NA 21.01 3.81 NA 65.91 090 

20805 .... .......... A Replant forearm, complete ................................. 49.93 NA 34.41 4.84 NA 89.18 090 

20808 .... .......... A Replantation hand, complete ............................. 61.56 NA 42.34 6.86 NA 110.76 090 

20816 .... .......... A Replantation digit, complete ............................... 30.89 NA 37.90 4.52 NA 73.31 090 

20822 .... .......... A Replantation digit, complete ............................... 25.55 NA 34.69 4.18 NA 64.42 090 

20824 .... .......... A Replantation thumb, complete ........................... 30.89 NA 36.65 4.61 NA 72.15 090 

20827 .... .......... A Replantation thumb, complete ........................... 26.37 NA 36.58 3.66 NA 66.61 090 

20838 .... .......... A Replantation foot, complete ............................... 41.35 NA 22.34 1.12 NA 64.81 090 

70345 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

20900 .... .......... A Removal of bone for graft .................................. 5.57 8.45 5.69 0.94 14.96 12.20 090 

20902 .... .......... A Removal of bone for graft .................................. 7.54 NA 6.90 1.30 NA 15.74 090 

20910 .... .......... A Remove cartilage for graft .................................. 5.33 NA 5.20 0.71 NA 11.24 090 

20912 .... .......... A Remove cartilage for graft .................................. 6.34 NA 5.81 0.69 NA 12.84 090 

20920 .... .......... A Removal of fascia for graft ................................. 5.30 NA 4.23 0.66 NA 10.19 090 

20922 .... .......... A Removal of fascia for graft ................................. 6.60 7.56 4.88 0.70 14.86 12.18 090 

20924 .... .......... A Removal of tendon for graft ............................... 6.47 NA 5.90 1.04 NA 13.41 090 

20926 .... .......... A Removal of tissue for graft ................................. 5.52 NA 4.76 0.87 NA 11.15 090 

20930 .... .......... B Spinal bone allograft .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

20931 .... .......... A Spinal bone allograft .......................................... 1.81 NA 0.93 0.43 NA 3.17 ZZZ 

20936 .... .......... B Spinal bone autograft ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

20937 .... .......... A Spinal bone autograft ......................................... 2.79 NA 1.45 0.54 NA 4.78 ZZZ 

20938 .... .......... A Spinal bone autograft ......................................... 3.02 NA 1.56 0.64 NA 5.22 ZZZ 

20950 .... .......... A Fluid pressure, muscle ....................................... 1.26 6.86 0.99 0.20 8.32 2.45 000 

20955 .... .......... A Fibula bone graft, microvasc .............................. 39.15 NA 24.34 4.89 NA 68.38 090 

20956 .... .......... A Iliac bone graft, microvasc ................................. 39.21 NA 24.81 7.01 NA 71.03 090 

20957 .... .......... A Mt bone graft, microvasc .................................... 40.59 NA 18.99 7.05 NA 66.63 090 

20962 .... .......... A Other bone graft, microvasc ............................... 39.21 NA 26.60 6.55 NA 72.36 090 

20969 .... .......... A Bone/skin graft, microvasc ................................. 43.85 NA 26.71 4.79 NA 75.35 090 

20970 .... .......... A Bone/skin graft, iliac crest .................................. 43.00 NA 25.45 6.60 NA 75.05 090 

20972 .... .......... A Bone/skin graft, metatarsal ................................ 42.93 NA 20.64 5.30 NA 68.87 090 

20973 .... .......... A Bone/skin graft, great toe ................................... 45.69 NA 25.23 5.54 NA 76.46 090 

20974 .... .......... A Electrical bone stimulation ................................. 0.62 0.69 0.54 0.11 1.42 1.27 000 

20975 .... .......... A Electrical bone stimulation ................................. 2.60 NA 1.71 0.51 NA 4.82 000 

20979 .... .......... A Us bone stimulation ............................................ 0.62 0.80 0.34 0.09 1.51 1.05 000 

20982 .... .......... A Ablate, bone tumor(s) perq ................................ 7.27 109.86 2.98 0.69 117.82 10.94 000 

20999 .... .......... C Musculoskeletal surgery ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

21010 .... .......... A Incision of jaw joint ............................................. 10.12 NA 7.11 1.11 NA 18.34 090 

21015 .... .......... A Resection of facial tumor ................................... 5.28 NA 5.02 0.70 NA 11.00 090 

21025 .... .......... A Excision of bone, lower jaw ............................... 10.04 12.28 9.38 1.32 23.64 20.74 090 

21026 .... .......... A Excision of facial bone(s) ................................... 4.84 7.88 6.34 0.60 13.32 11.78 090 

21029 .... .......... A Contour of face bone lesion ............................... 7.70 9.40 7.03 0.94 18.04 15.67 090 

21030 .... .......... A Excise max/zygoma b9 tumor ............................ 4.49 6.35 5.04 0.54 11.38 10.07 090 

21031 .... .......... A Remove exostosis, mandible ............................. 3.24 5.18 3.63 0.48 8.90 7.35 090 

21032 .... .......... A Remove exostosis, maxilla ................................. 3.24 5.36 3.52 0.47 9.07 7.23 090 

21034 .... .......... A Excise max/zygoma mlg tumor .......................... 16.15 15.97 12.70 1.71 33.83 30.56 090 

21040 .... .......... A Excise mandible lesion ....................................... 4.49 6.41 4.73 0.54 11.44 9.76 090 

21044 .... .......... A Removal of jaw bone lesion ............................... 11.84 NA 9.40 1.12 NA 22.36 090 

21045 .... .......... A Extensive jaw surgery ........................................ 16.15 NA 12.39 1.52 NA 30.06 090 

21046 .... .......... A Remove mandible cyst complex ........................ 12.98 NA 11.93 1.85 NA 26.76 090 

21047 .... .......... A Excise lwr jaw cyst w/repair ............................... 18.72 NA 13.48 2.12 NA 34.32 090 

21048 .... .......... A Remove maxilla cyst complex ............................ 13.48 NA 12.17 1.76 NA 27.41 090 

21049 .... .......... A Excis uppr jaw cyst w/repair .............................. 17.97 NA 13.06 1.59 NA 32.62 090 

21050 .... .......... A Removal of jaw joint ........................................... 10.75 NA 9.47 1.47 NA 21.69 090 

21060 .... .......... A Remove jaw joint cartilage ................................. 10.21 NA 8.63 1.38 NA 20.22 090 

21070 .... .......... A Remove coronoid process ................................. 8.19 NA 7.12 1.27 NA 16.58 090 

21076 .... .......... A Prepare face/oral prosthesis .............................. 13.40 12.39 10.03 1.99 27.78 25.42 010 

21077 .... .......... A Prepare face/oral prosthesis .............................. 33.70 31.42 26.08 4.55 69.67 64.33 090 

21079 .... .......... A Prepare face/oral prosthesis .............................. 22.31 21.56 17.20 3.15 47.02 42.66 090 

21080 .... .......... A Prepare face/oral prosthesis .............................. 25.06 24.56 19.42 3.74 53.36 48.22 090 

21081 .... .......... A Prepare face/oral prosthesis .............................. 22.85 22.36 17.54 3.20 48.41 43.59 090 

21082 .... .......... A Prepare face/oral prosthesis .............................. 20.84 19.40 15.78 3.11 43.35 39.73 090 

21083 .... .......... A Prepare face/oral prosthesis .............................. 19.27 18.84 14.47 2.88 40.99 36.62 090 

21084 .... .......... A Prepare face/oral prosthesis .............................. 22.48 22.50 17.75 2.18 47.16 42.41 090 

21085 .... .......... A Prepare face/oral prosthesis .............................. 8.99 8.31 6.80 1.27 18.57 17.06 010 

21086 .... .......... A Prepare face/oral prosthesis .............................. 24.88 23.81 19.49 3.71 52.40 48.08 090 

21087 .... .......... A Prepare face/oral prosthesis .............................. 24.88 23.35 19.25 3.44 51.67 47.57 090 

21088 .... .......... C Prepare face/oral prosthesis .............................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

21089 .... .......... C Prepare face/oral prosthesis .............................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

21100 .... .......... A Maxillofacial fixation ........................................... 4.21 11.56 4.75 0.34 16.11 9.30 090 

21110 .... .......... A Interdental fixation .............................................. 5.20 9.59 8.38 0.72 15.51 14.30 090 

21116 .... .......... A Injection, jaw joint x-ray ...................................... 0.81 4.34 0.33 0.06 5.21 1.20 000 

21120 .... .......... A Reconstruction of chin ........................................ 4.92 10.61 7.51 0.60 16.13 13.03 090 

21121 .... .......... A Reconstruction of chin ........................................ 7.63 9.76 7.84 0.90 18.29 16.37 090 

21122 .... .......... A Reconstruction of chin ........................................ 8.51 NA 8.64 1.07 NA 18.22 090 

21123 .... .......... A Reconstruction of chin ........................................ 11.14 NA 10.83 1.40 NA 23.37 090 

21125 .... .......... A Augmentation, lower jaw bone ........................... 10.60 55.38 8.34 0.79 66.77 19.73 090 

21127 .... .......... A Augmentation, lower jaw bone ........................... 11.10 42.92 9.48 1.52 55.54 22.10 090 

21137 .... .......... A Reduction of forehead ........................................ 9.81 NA 7.75 1.32 NA 18.88 090 

21138 .... .......... A Reduction of forehead ........................................ 12.17 NA 9.56 1.74 NA 23.47 090 

21139 .... .......... A Reduction of forehead ........................................ 14.59 NA 11.09 1.18 NA 26.86 090 

21141 .... .......... A Reconstruct midface, lefort ................................ 18.07 NA 13.69 2.35 NA 34.11 090 

21142 .... .......... A Reconstruct midface, lefort ................................ 18.78 NA 12.86 2.38 NA 34.02 090 

21143 .... .......... A Reconstruct midface, lefort ................................ 19.55 NA 14.35 1.66 NA 35.56 090 

21145 .... .......... A Reconstruct midface, lefort ................................ 19.91 NA 13.94 2.84 NA 36.69 090 

70346 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

21146 .... .......... A Reconstruct midface, lefort ................................ 20.68 NA 15.37 3.09 NA 39.14 090 

21147 .... .......... A Reconstruct midface, lefort ................................ 21.74 NA 15.09 1.84 NA 38.67 090 

21150 .... .......... A Reconstruct midface, lefort ................................ 25.20 NA 16.81 2.55 NA 44.56 090 

21151 .... .......... A Reconstruct midface, lefort ................................ 28.26 NA 23.02 2.30 NA 53.58 090 

21154 .... .......... A Reconstruct midface, lefort ................................ 30.47 NA 23.19 2.48 NA 56.14 090 

21155 .... .......... A Reconstruct midface, lefort ................................ 34.40 NA 23.96 6.64 NA 65.00 090 

21159 .... .......... A Reconstruct midface, lefort ................................ 42.32 NA 29.16 8.18 NA 79.66 090 

21160 .... .......... A Reconstruct midface, lefort ................................ 46.37 NA 27.55 4.13 NA 78.05 090 

21172 .... .......... A Reconstruct orbit/forehead ................................. 27.76 NA 13.79 3.55 NA 45.10 090 

21175 .... .......... A Reconstruct orbit/forehead ................................. 33.12 NA 17.84 4.83 NA 55.79 090 

21179 .... .......... A Reconstruct entire forehead ............................... 22.22 NA 14.17 2.80 NA 39.19 090 

21180 .... .......... A Reconstruct entire forehead ............................... 25.15 NA 15.42 3.48 NA 44.05 090 

21181 .... .......... A Contour cranial bone lesion ............................... 9.89 NA 7.48 1.32 NA 18.69 090 

21182 .... .......... A Reconstruct cranial bone ................................... 32.14 NA 19.17 2.80 NA 54.11 090 

21183 .... .......... A Reconstruct cranial bone ................................... 35.26 NA 20.89 4.47 NA 60.62 090 

21184 .... .......... A Reconstruct cranial bone ................................... 38.18 NA 22.00 5.70 NA 65.88 090 

21188 .... .......... A Reconstruction of midface .................................. 22.43 NA 18.92 1.69 NA 43.04 090 

21193 .... .......... A Reconst lwr jaw w/o graft ................................... 17.12 NA 12.69 2.23 NA 32.04 090 

21194 .... .......... A Reconst lwr jaw w/graft ...................................... 19.81 NA 13.79 2.02 NA 35.62 090 

21195 .... .......... A Reconst lwr jaw w/o fixation ............................... 17.21 NA 14.86 1.64 NA 33.71 090 

21196 .... .......... A Reconst lwr jaw w/fixation .................................. 18.88 NA 15.74 2.07 NA 36.69 090 

21198 .... .......... A Reconstr lwr jaw segment .................................. 14.14 NA 12.74 1.44 NA 28.32 090 

21199 .... .......... A Reconstr lwr jaw w/advance .............................. 15.98 NA 9.14 1.39 NA 26.51 090 

21206 .... .......... A Reconstruct upper jaw bone .............................. 14.08 NA 12.67 1.33 NA 28.08 090 

21208 .... .......... A Augmentation of facial bones ............................. 10.21 22.39 9.61 1.09 33.69 20.91 090 

21209 .... .......... A Reduction of facial bones ................................... 6.71 10.83 8.09 0.90 18.44 15.70 090 

21210 .... .......... A Face bone graft .................................................. 10.21 24.94 9.38 1.30 36.45 20.89 090 

21215 .... .......... A Lower jaw bone graft .......................................... 10.75 42.00 9.39 1.53 54.28 21.67 090 

21230 .... .......... A Rib cartilage graft ............................................... 10.75 NA 8.06 1.29 NA 20.10 090 

21235 .... .......... A Ear cartilage graft ............................................... 6.71 9.87 6.43 0.61 17.19 13.75 090 

21240 .... .......... A Reconstruction of jaw joint ................................. 14.03 NA 12.08 2.24 NA 28.35 090 

21242 .... .......... A Reconstruction of jaw joint ................................. 12.93 NA 11.54 1.78 NA 26.25 090 

21243 .... .......... A Reconstruction of jaw joint ................................. 20.76 NA 17.48 3.25 NA 41.49 090 

21244 .... .......... A Reconstruction of lower jaw ............................... 11.84 NA 12.13 1.25 NA 25.22 090 

21245 .... .......... A Reconstruction of jaw ......................................... 11.84 14.44 9.88 1.19 27.47 22.91 090 

21246 .... .......... A Reconstruction of jaw ......................................... 12.45 NA 9.07 1.35 NA 22.87 090 

21247 .... .......... A Reconstruct lower jaw bone ............................... 22.60 NA 17.40 2.83 NA 42.83 090 

21248 .... .......... A Reconstruction of jaw ......................................... 11.46 12.17 9.43 1.55 25.18 22.44 090 

21249 .... .......... A Reconstruction of jaw ......................................... 17.49 16.77 12.73 2.48 36.74 32.70 090 

21255 .... .......... A Reconstruct lower jaw bone ............................... 16.69 NA 16.18 2.38 NA 35.25 090 

21256 .... .......... A Reconstruction of orbit ....................................... 16.17 NA 11.85 1.50 NA 29.52 090 

21260 .... .......... A Revise eye sockets ............................................ 16.50 NA 12.80 0.97 NA 30.27 090 

21261 .... .......... A Revise eye sockets ............................................ 31.44 NA 24.30 3.42 NA 59.16 090 

21263 .... .......... A Revise eye sockets ............................................ 28.38 NA 19.13 2.62 NA 50.13 090 

21267 .... .......... A Revise eye sockets ............................................ 18.87 NA 19.83 1.70 NA 40.40 090 

21268 .... .......... A Revise eye sockets ............................................ 24.44 NA 20.27 3.65 NA 48.36 090 

21270 .... .......... A Augmentation, cheek bone ................................ 10.21 11.68 7.27 0.72 22.61 18.20 090 

21275 .... .......... A Revision, orbitofacial bones ............................... 11.22 NA 8.18 1.29 NA 20.69 090 

21280 .... .......... A Revision of eyelid ............................................... 6.02 NA 5.94 0.42 NA 12.38 090 

21282 .... .......... A Revision of eyelid ............................................... 3.48 NA 4.49 0.26 NA 8.23 090 

21295 .... .......... A Revision of jaw muscle/bone ............................. 1.53 NA 2.54 0.16 NA 4.23 090 

21296 .... .......... A Revision of jaw muscle/bone ............................. 4.24 NA 4.92 0.34 NA 9.50 090 

21299 .... .......... C Cranio/maxillofacial surgery ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

21300 .... .......... A Treatment of skull fracture ................................. 0.72 2.37 0.26 0.13 3.22 1.11 000 

21310 .... .......... A Treatment of nose fracture ................................. 0.58 2.29 0.15 0.05 2.92 0.78 000 

21315 .... .......... A Treatment of nose fracture ................................. 1.51 4.24 1.89 0.14 5.89 3.54 010 

21320 .... .......... A Treatment of nose fracture ................................. 1.85 3.92 1.62 0.18 5.95 3.65 010 

21325 .... .......... A Treatment of nose fracture ................................. 3.76 NA 8.64 0.31 NA 12.71 090 

21330 .... .......... A Treatment of nose fracture ................................. 5.37 NA 9.73 0.56 NA 15.66 090 

21335 .... .......... A Treatment of nose fracture ................................. 8.60 NA 9.65 0.74 NA 18.99 090 

21336 .... .......... A Treat nasal septal fracture ................................. 5.71 NA 9.64 0.55 NA 15.90 090 

21337 .... .......... A Treat nasal septal fracture ................................. 2.70 6.14 3.58 0.28 9.12 6.56 090 

21338 .... .......... A Treat nasoethmoid fracture ................................ 6.45 NA 14.06 0.82 NA 21.33 090 

21339 .... .......... A Treat nasoethmoid fracture ................................ 8.08 NA 13.94 0.96 NA 22.98 090 

21340 .... .......... A Treatment of nose fracture ................................. 10.75 NA 8.42 1.15 NA 20.32 090 

21343 .... .......... A Treatment of sinus fracture ................................ 12.93 NA 15.51 1.47 NA 29.91 090 

21344 .... .......... A Treatment of sinus fracture ................................ 19.69 NA 16.55 2.43 NA 38.67 090 

21345 .... .......... A Treat nose/jaw fracture ...................................... 8.15 9.87 7.19 0.92 18.94 16.26 090 

21346 .... .......... A Treat nose/jaw fracture ...................................... 10.59 NA 12.24 1.21 NA 24.04 090 

21347 .... .......... A Treat nose/jaw fracture ...................................... 12.67 NA 16.24 1.47 NA 30.38 090 

21348 .... .......... A Treat nose/jaw fracture ...................................... 16.66 NA 11.14 2.48 NA 30.28 090 

21355 .... .......... A Treat cheek bone fracture .................................. 3.76 6.25 3.49 0.34 10.35 7.59 010 

21356 .... .......... A Treat cheek bone fracture .................................. 4.14 7.14 4.56 0.46 11.74 9.16 010 

21360 .... .......... A Treat cheek bone fracture .................................. 6.45 NA 5.95 0.74 NA 13.14 090 

21365 .... .......... A Treat cheek bone fracture .................................. 14.93 NA 10.86 1.69 NA 27.48 090 

70347 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

21366 .... .......... A Treat cheek bone fracture .................................. 17.74 NA 11.36 2.49 NA 31.59 090 

21385 .... .......... A Treat eye socket fracture ................................... 9.15 NA 8.30 0.97 NA 18.42 090 

21386 .... .......... A Treat eye socket fracture ................................... 9.15 NA 7.09 0.97 NA 17.21 090 

21387 .... .......... A Treat eye socket fracture ................................... 9.69 NA 8.98 1.08 NA 19.75 090 

21390 .... .......... A Treat eye socket fracture ................................... 10.11 NA 7.82 0.90 NA 18.83 090 

21395 .... .......... A Treat eye socket fracture ................................... 12.66 NA 9.05 1.44 NA 23.15 090 

21400 .... .......... A Treat eye socket fracture ................................... 1.40 2.62 1.88 0.15 4.17 3.43 090 

21401 .... .......... A Treat eye socket fracture ................................... 3.26 8.01 3.50 0.38 11.65 7.14 090 

21406 .... .......... A Treat eye socket fracture ................................... 7.00 NA 6.10 0.73 NA 13.83 090 

21407 .... .......... A Treat eye socket fracture ................................... 8.60 NA 6.88 0.94 NA 16.42 090 

21408 .... .......... A Treat eye socket fracture ................................... 12.36 NA 8.91 1.44 NA 22.71 090 

21421 .... .......... A Treat mouth roof fracture ................................... 5.13 9.36 8.33 0.73 15.22 14.19 090 

21422 .... .......... A Treat mouth roof fracture ................................... 8.31 NA 8.10 0.99 NA 17.40 090 

21423 .... .......... A Treat mouth roof fracture ................................... 10.38 NA 9.35 1.27 NA 21.00 090 

21431 .... .......... A Treat craniofacial fracture .................................. 7.04 NA 9.55 0.70 NA 17.29 090 

21432 .... .......... A Treat craniofacial fracture .................................. 8.60 NA 8.08 0.81 NA 17.49 090 

21433 .... .......... A Treat craniofacial fracture .................................. 25.31 NA 16.45 2.78 NA 44.54 090 

21435 .... .......... A Treat craniofacial fracture .................................. 17.22 NA 12.74 1.98 NA 31.94 090 

21436 .... .......... A Treat craniofacial fracture .................................. 28.00 NA 18.27 3.09 NA 49.36 090 

21440 .... .......... A Treat dental ridge fracture .................................. 2.70 7.12 6.18 0.38 10.20 9.26 090 

21445 .... .......... A Treat dental ridge fracture .................................. 5.37 9.78 8.39 0.78 15.93 14.54 090 

21450 .... .......... A Treat lower jaw fracture ..................................... 2.97 7.40 6.89 0.33 10.70 10.19 090 

21451 .... .......... A Treat lower jaw fracture ..................................... 4.86 9.38 8.42 0.63 14.87 13.91 090 

21452 .... .......... A Treat lower jaw fracture ..................................... 1.98 13.06 4.62 0.27 15.31 6.87 090 

21453 .... .......... A Treat lower jaw fracture ..................................... 5.53 10.77 10.76 0.74 17.04 17.03 090 

21454 .... .......... A Treat lower jaw fracture ..................................... 6.45 NA 6.28 0.82 NA 13.55 090 

21461 .... .......... A Treat lower jaw fracture ..................................... 8.08 24.53 12.70 0.98 33.59 21.76 090 

21462 .... .......... A Treat lower jaw fracture ..................................... 9.78 27.69 12.75 1.27 38.74 23.80 090 

21465 .... .......... A Treat lower jaw fracture ..................................... 11.89 NA 9.84 1.50 NA 23.23 090 

21470 .... .......... A Treat lower jaw fracture ..................................... 15.32 NA 12.05 1.96 NA 29.33 090 

21480 .... .......... A Reset dislocated jaw .......................................... 0.61 1.78 0.19 0.06 2.45 0.86 000 

21485 .... .......... A Reset dislocated jaw .......................................... 3.98 8.24 7.68 0.51 12.73 12.17 090 

21490 .... .......... A Repair dislocated jaw ......................................... 11.84 NA 9.72 1.96 NA 23.52 090 

21495 .... .......... A Treat hyoid bone fracture ................................... 5.68 NA 8.44 0.46 NA 14.58 090 

21497 .... .......... A Interdental wiring ................................................ 3.85 8.47 7.66 0.50 12.82 12.01 090 

21499 .... .......... C Head surgery procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

21501 .... .......... A Drain neck/chest lesion ...................................... 3.80 6.44 3.83 0.43 10.67 8.06 090 

21502 .... .......... A Drain chest lesion ............................................... 7.11 NA 5.65 0.97 NA 13.73 090 

21510 .... .......... A Drainage of bone lesion ..................................... 5.73 NA 5.68 0.80 NA 12.21 090 

21550 .... .......... A Biopsy of neck/chest .......................................... 2.06 3.59 1.72 0.16 5.81 3.94 010 

21555 .... .......... A Remove lesion, neck/chest ................................ 4.34 5.53 3.20 0.56 10.43 8.10 090 

21556 .... .......... A Remove lesion, neck/chest ................................ 5.56 NA 4.11 0.65 NA 10.32 090 

21557 .... .......... A Remove tumor, neck/chest ................................ 8.87 NA 5.37 1.08 NA 15.32 090 

21600 .... .......... A Partial removal of rib .......................................... 6.88 NA 5.75 0.99 NA 13.62 090 

21610 .... .......... A Partial removal of rib .......................................... 14.59 NA 8.89 3.07 NA 26.55 090 

21615 .... .......... A Removal of rib .................................................... 9.86 NA 6.70 1.45 NA 18.01 090 

21616 .... .......... A Removal of rib and nerves ................................. 12.02 NA 8.04 1.86 NA 21.92 090 

21620 .... .......... A Partial removal of sternum ................................. 6.78 NA 5.99 0.98 NA 13.75 090 

21627 .... .......... A Sternal debridement ........................................... 6.80 NA 6.32 1.02 NA 14.14 090 

21630 .... .......... A Extensive sternum surgery ................................. 17.35 NA 11.87 2.58 NA 31.80 090 

21632 .... .......... A Extensive sternum surgery ................................. 18.11 NA 11.14 2.65 NA 31.90 090 

21685 .... .......... A Hyoid myotomy & suspension ............................ 12.98 NA 10.00 1.06 NA 24.04 090 

21700 .... .......... A Revision of neck muscle .................................... 6.18 NA 4.45 0.32 NA 10.95 090 

21705 .... .......... A Revision of neck muscle/rib ............................... 9.59 NA 5.60 1.43 NA 16.62 090 

21720 .... .......... A Revision of neck muscle .................................... 5.67 2.47 2.47 0.91 9.05 9.05 090 

21725 .... .......... A Revision of neck muscle .................................... 6.98 NA 5.46 1.21 NA 13.65 090 

21740 .... .......... A Reconstruction of sternum ................................. 16.48 NA 8.54 2.36 NA 27.38 090 

21742 .... .......... C Repair stern/nuss w/o scope .............................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

21743 .... .......... C Repair sternum/nuss w/scope ............................ 0.00 0.00 0.00 0.00 0.00 0.00 090 

21750 .... .......... A Repair of sternum separation ............................. 10.75 NA 6.13 1.63 NA 18.51 090 

21800 .... .......... A Treatment of rib fracture .................................... 0.96 NA 1.34 0.09 NA 2.39 090 

21805 .... .......... A Treatment of rib fracture .................................... 2.75 NA 3.21 0.38 NA 6.34 090 

21810 .... .......... A Treatment of rib fracture(s) ................................ 6.85 NA 4.98 0.94 NA 12.77 090 

21820 .... .......... A Treat sternum fracture ........................................ 1.28 1.83 1.77 0.16 3.27 3.21 090 

21825 .... .......... A Treat sternum fracture ........................................ 7.40 NA 6.41 1.11 NA 14.92 090 

21899 .... .......... C Neck/chest surgery procedure ........................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

21920 .... .......... A Biopsy soft tissue of back .................................. 2.06 3.29 1.47 0.14 5.49 3.67 010 

21925 .... .......... A Biopsy soft tissue of back .................................. 4.48 5.18 3.25 0.60 10.26 8.33 090 

21930 .... .......... A Remove lesion, back or flank ............................. 4.99 5.73 3.41 0.66 11.38 9.06 090 

21935 .... .......... A Remove tumor, back .......................................... 17.93 NA 9.65 2.47 NA 30.05 090 

22010 .... .......... A I&d, p-spine, c/t/cerv-thor ................................... 11.05 NA 8.91 1.73 NA 21.69 090 

22015 .... .......... A I&d, p-spine, l/s/ls ............................................... 10.94 NA 8.85 1.71 NA 21.50 090 

22100 .... .......... A Remove part of neck vertebra ........................... 9.72 NA 7.55 2.13 NA 19.40 090 

22101 .... .......... A Remove part, thorax vertebra ............................ 9.80 NA 7.77 1.90 NA 19.47 090 

22102 .... .......... A Remove part, lumbar vertebra ........................... 9.80 NA 8.13 1.87 NA 19.80 090 

70348 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

22103 .... .......... A Remove extra spine segment ............................ 2.34 NA 1.21 0.44 NA 3.99 ZZZ 

22110 .... .......... A Remove part of neck vertebra ........................... 12.72 NA 9.19 2.76 NA 24.67 090 

22112 .... .......... A Remove part, thorax vertebra ............................ 12.79 NA 9.30 2.52 NA 24.61 090 

22114 .... .......... A Remove part, lumbar vertebra ........................... 12.79 NA 9.28 2.63 NA 24.70 090 

22116 .... .......... A Remove extra spine segment ............................ 2.32 NA 1.17 0.50 NA 3.99 ZZZ 

22210 .... .......... A Revision of neck spine ....................................... 23.78 NA 15.45 5.44 NA 44.67 090 

22212 .... .......... A Revision of thorax spine ..................................... 19.39 NA 13.31 3.90 NA 36.60 090 

22214 .... .......... A Revision of lumbar spine .................................... 19.42 NA 13.85 3.91 NA 37.18 090 

22216 .... .......... A Revise, extra spine segment .............................. 6.03 NA 3.14 1.29 NA 10.46 ZZZ 

22220 .... .......... A Revision of neck spine ....................................... 21.34 NA 13.66 5.06 NA 40.06 090 

22222 .... .......... A Revision of thorax spine ..................................... 21.49 NA 11.16 4.12 NA 36.77 090 

22224 .... .......... A Revision of lumbar spine .................................... 21.49 NA 14.26 4.18 NA 39.93 090 

22226 .... .......... A Revise, extra spine segment .............................. 6.03 NA 3.10 1.29 NA 10.42 ZZZ 

22305 .... .......... A Treat spine process fracture .............................. 2.05 2.32 1.93 0.39 4.76 4.37 090 

22310 .... .......... A Treat spine fracture ............................................ 2.61 2.81 2.36 0.50 5.92 5.47 090 

22315 .... .......... A Treat spine fracture ............................................ 8.83 9.71 7.35 1.85 20.39 18.03 090 

22318 .... .......... A Treat odontoid fx w/o graft ................................. 21.47 NA 13.42 5.28 NA 40.17 090 

22319 .... .......... A Treat odontoid fx w/graft .................................... 23.96 NA 14.75 6.03 NA 44.74 090 

22325 .... .......... A Treat spine fracture ............................................ 18.27 NA 12.11 3.87 NA 34.25 090 

22326 .... .......... A Treat neck spine fracture ................................... 19.56 NA 12.74 4.42 NA 36.72 090 

22327 .... .......... A Treat thorax spine fracture ................................. 19.17 NA 12.40 3.98 NA 35.55 090 

22328 .... .......... A Treat each add spine fx ..................................... 4.60 NA 2.27 0.94 NA 7.81 ZZZ 

22505 .... .......... A Manipulation of spine ......................................... 1.87 NA 0.94 0.36 NA 3.17 010 

22520 .... .......... A Percut vertebroplasty thor .................................. 8.90 61.84 5.11 1.71 72.45 15.72 010 

22521 .... .......... A Percut vertebroplasty lumb ................................ 8.33 56.13 4.96 1.60 66.06 14.89 010 

22522 .... .......... A Percut vertebroplasty add’l ................................. 4.30 NA 1.68 0.82 NA 6.80 ZZZ 

22523 .... .......... A Percut kyphoplasty, thor ..................................... 8.94 NA 5.92 1.43 NA 16.29 010 

22524 .... .......... A Percut kyphoplasty, lumbar ................................ 8.54 NA 5.71 1.36 NA 15.61 010 

22525 .... .......... A Percut kyphoplasty, add-on ................................ 4.47 NA 2.28 0.72 NA 7.47 ZZZ 

22532 .... .......... A Lat thorax spine fusion ....................................... 23.96 NA 14.86 4.34 NA 43.16 090 

22533 .... .......... A Lat lumbar spine fusion ...................................... 23.09 NA 13.63 3.15 NA 39.87 090 

22534 .... .......... A Lat thor/lumb, add’l seg ...................................... 5.99 NA 3.04 1.25 NA 10.28 ZZZ 

22548 .... .......... A Neck spine fusion ............................................... 25.78 NA 15.85 5.59 NA 47.22 090 

22554 .... .......... A Neck spine fusion ............................................... 18.59 NA 12.38 4.45 NA 35.42 090 

22556 .... .......... A Thorax spine fusion ............................................ 23.42 NA 14.77 4.34 NA 42.53 090 

22558 .... .......... A Lumbar spine fusion ........................................... 22.25 NA 13.33 3.15 NA 38.73 090 

22585 .... .......... A Additional spinal fusion ...................................... 5.52 NA 2.80 1.25 NA 9.57 ZZZ 

22590 .... .......... A Spine & skull spinal fusion ................................. 20.48 NA 13.36 4.78 NA 38.62 090 

22595 .... .......... A Neck spinal fusion .............................................. 19.36 NA 12.87 4.40 NA 36.63 090 

22600 .... .......... A Neck spine fusion ............................................... 16.12 NA 11.22 3.72 NA 31.06 090 

22610 .... .......... A Thorax spine fusion ............................................ 16.00 NA 11.44 3.52 NA 30.96 090 

22612 .... .......... A Lumbar spine fusion ........................................... 20.97 NA 14.24 4.46 NA 39.67 090 

22614 .... .......... A Spine fusion, extra segment .............................. 6.43 NA 3.36 1.38 NA 11.17 ZZZ 

22630 .... .......... A Lumbar spine fusion ........................................... 20.81 NA 13.64 4.72 NA 39.17 090 

22632 .... .......... A Spine fusion, extra segment .............................. 5.22 NA 2.67 1.16 NA 9.05 ZZZ 

22800 .... .......... A Fusion of spine ................................................... 18.22 NA 12.81 3.75 NA 34.78 090 

22802 .... .......... A Fusion of spine ................................................... 30.83 NA 19.65 6.15 NA 56.63 090 

22804 .... .......... A Fusion of spine ................................................... 36.22 NA 22.76 6.98 NA 65.96 090 

22808 .... .......... A Fusion of spine ................................................... 26.23 NA 16.35 4.92 NA 47.50 090 

22810 .... .......... A Fusion of spine ................................................... 30.22 NA 18.41 5.13 NA 53.76 090 

22812 .... .......... A Fusion of spine ................................................... 32.65 NA 20.12 5.28 NA 58.05 090 

22818 .... .......... A Kyphectomy, 1-2 segments ................................ 31.78 NA 18.92 6.45 NA 57.15 090 

22819 .... .......... A Kyphectomy, 3 or more ...................................... 36.39 NA 20.11 7.65 NA 64.15 090 

22830 .... .......... A Exploration of spinal fusion ................................ 10.83 NA 7.98 2.29 NA 21.10 090 

22840 .... .......... A Insert spine fixation device ................................. 12.52 NA 6.51 2.78 NA 21.81 ZZZ 

22841 .... .......... B Insert spine fixation device ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

22842 .... .......... A Insert spine fixation device ................................. 12.56 NA 6.52 2.74 NA 21.82 ZZZ 

22843 .... .......... A Insert spine fixation device ................................. 13.44 NA 6.62 2.85 NA 22.91 ZZZ 

22844 .... .......... A Insert spine fixation device ................................. 16.42 NA 8.78 3.18 NA 28.38 ZZZ 

22845 .... .......... A Insert spine fixation device ................................. 11.94 NA 6.09 2.85 NA 20.88 ZZZ 

22846 .... .......... A Insert spine fixation device ................................. 12.40 NA 6.35 2.95 NA 21.70 ZZZ 

22847 .... .......... A Insert spine fixation device ................................. 13.78 NA 7.04 2.99 NA 23.81 ZZZ 

22848 .... .......... A Insert pelv fixation device ................................... 5.99 NA 3.19 1.15 NA 10.33 ZZZ 

22849 .... .......... A Reinsert spinal fixation ....................................... 18.48 NA 11.76 3.89 NA 34.13 090 

22850 .... .......... A Remove spine fixation device ............................ 9.51 NA 7.01 2.04 NA 18.56 090 

22851 .... .......... A Apply spine prosth device .................................. 6.70 NA 3.37 1.49 NA 11.56 ZZZ 

22852 .... .......... A Remove spine fixation device ............................ 9.00 NA 6.81 1.89 NA 17.70 090 

22855 .... .......... A Remove spine fixation device ............................ 15.11 NA 9.69 3.51 NA 28.31 090 

22899 .... .......... C Spine surgery procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

22900 .... .......... A Remove abdominal wall lesion .......................... 5.79 NA 3.23 0.76 NA 9.78 090 

22999 .... .......... C Abdomen surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

23000 .... .......... A Removal of calcium deposits ............................. 4.35 8.55 4.43 0.68 13.58 9.46 090 

23020 .... .......... A Release shoulder joint ........................................ 8.92 NA 7.58 1.54 NA 18.04 090 

23030 .... .......... A Drain shoulder lesion ......................................... 3.42 7.41 2.91 0.57 11.40 6.90 010 

23031 .... .......... A Drain shoulder bursa .......................................... 2.74 7.88 2.73 0.46 11.08 5.93 010 

70349 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

23035 .... .......... A Drain shoulder bone lesion ................................ 8.60 NA 8.29 1.47 NA 18.36 090 

23040 .... .......... A Exploratory shoulder surgery ............................. 9.19 NA 7.88 1.60 NA 18.67 090 

23044 .... .......... A Exploratory shoulder surgery ............................. 7.11 NA 6.45 1.24 NA 14.80 090 

23065 .... .......... A Biopsy shoulder tissues ..................................... 2.27 2.49 1.62 0.20 4.96 4.09 010 

23066 .... .......... A Biopsy shoulder tissues ..................................... 4.15 7.69 3.99 0.63 12.47 8.77 090 

23075 .... .......... A Removal of shoulder lesion ................................ 2.39 3.67 1.79 0.34 6.40 4.52 010 

23076 .... .......... A Removal of shoulder lesion ................................ 7.62 NA 5.57 1.13 NA 14.32 090 

23077 .... .......... A Remove tumor of shoulder ................................. 16.07 NA 10.24 2.33 NA 28.64 090 

23100 .... .......... A Biopsy of shoulder joint ...................................... 6.02 NA 5.67 1.04 NA 12.73 090 

23101 .... .......... A Shoulder joint surgery ........................................ 5.57 NA 5.35 0.96 NA 11.88 090 

23105 .... .......... A Remove shoulder joint lining .............................. 8.22 NA 7.14 1.42 NA 16.78 090 

23106 .... .......... A Incision of collarbone joint .................................. 5.95 NA 5.72 0.99 NA 12.66 090 

23107 .... .......... A Explore treat shoulder joint ................................ 8.61 NA 7.41 1.49 NA 17.51 090 

23120 .... .......... A Partial removal, collar bone ............................... 7.10 NA 6.48 1.23 NA 14.81 090 

23125 .... .......... A Removal of collar bone ...................................... 9.38 NA 7.58 1.62 NA 18.58 090 

23130 .... .......... A Remove shoulder bone, part .............................. 7.54 NA 7.15 1.30 NA 15.99 090 

23140 .... .......... A Removal of bone lesion ..................................... 6.88 NA 5.24 1.08 NA 13.20 090 

23145 .... .......... A Removal of bone lesion ..................................... 9.08 NA 7.46 1.49 NA 18.03 090 

23146 .... .......... A Removal of bone lesion ..................................... 7.82 NA 7.13 1.35 NA 16.30 090 

23150 .... .......... A Removal of humerus lesion ............................... 8.47 NA 6.94 1.32 NA 16.73 090 

23155 .... .......... A Removal of humerus lesion ............................... 10.33 NA 8.35 1.80 NA 20.48 090 

23156 .... .......... A Removal of humerus lesion ............................... 8.67 NA 7.40 1.50 NA 17.57 090 

23170 .... .......... A Remove collar bone lesion ................................. 6.85 NA 6.04 1.12 NA 14.01 090 

23172 .... .......... A Remove shoulder blade lesion ........................... 6.89 NA 6.30 1.01 NA 14.20 090 

23174 .... .......... A Remove humerus lesion .................................... 9.50 NA 8.38 1.65 NA 19.53 090 

23180 .... .......... A Remove collar bone lesion ................................. 8.52 NA 9.02 1.47 NA 19.01 090 

23182 .... .......... A Remove shoulder blade lesion ........................... 8.14 NA 8.57 1.37 NA 18.08 090 

23184 .... .......... A Remove humerus lesion .................................... 9.37 NA 9.34 1.63 NA 20.34 090 

23190 .... .......... A Partial removal of scapula .................................. 7.23 NA 6.19 1.17 NA 14.59 090 

23195 .... .......... A Removal of head of humerus ............................. 9.80 NA 7.75 1.70 NA 19.25 090 

23200 .... .......... A Removal of collar bone ...................................... 12.06 NA 8.75 1.93 NA 22.74 090 

23210 .... .......... A Removal of shoulder blade ................................ 12.47 NA 9.02 2.02 NA 23.51 090 

23220 .... .......... A Partial removal of humerus ................................ 14.54 NA 10.85 2.48 NA 27.87 090 

23221 .... .......... A Partial removal of humerus ................................ 17.71 NA 11.75 3.05 NA 32.51 090 

23222 .... .......... A Partial removal of humerus ................................ 23.88 NA 15.83 3.94 NA 43.65 090 

23330 .... .......... A Remove shoulder foreign body .......................... 1.85 3.69 1.89 0.24 5.78 3.98 010 

23331 .... .......... A Remove shoulder foreign body .......................... 7.37 NA 6.81 1.27 NA 15.45 090 

23332 .... .......... A Remove shoulder foreign body .......................... 11.60 NA 9.35 2.02 NA 22.97 090 

23350 .... .......... A Injection for shoulder x-ray ................................. 1.00 3.47 0.33 0.06 4.53 1.39 000 

23395 .... .......... A Muscle transfer,shoulder/arm ............................. 16.82 NA 12.90 2.93 NA 32.65 090 

23397 .... .......... A Muscle transfers ................................................. 16.11 NA 11.40 2.73 NA 30.24 090 

23400 .... .......... A Fixation of shoulder blade .................................. 13.52 NA 10.10 2.29 NA 25.91 090 

23405 .... .......... A Incision of tendon & muscle ............................... 8.36 NA 6.94 1.45 NA 16.75 090 

23406 .... .......... A Incise tendon(s) & muscle(s) ............................. 10.77 NA 8.36 1.87 NA 21.00 090 

23410 .... .......... A Repair rotator cuff, acute ................................... 12.43 NA 9.43 2.16 NA 24.02 090 

23412 .... .......... A Repair rotator cuff, chronic ................................. 13.29 NA 9.92 2.31 NA 25.52 090 

23415 .... .......... A Release of shoulder ligament ............................ 9.96 NA 8.01 1.73 NA 19.70 090 

23420 .... .......... A Repair of shoulder .............................................. 13.28 NA 10.87 2.31 NA 26.46 090 

23430 .... .......... A Repair biceps tendon ......................................... 9.97 NA 8.12 1.73 NA 19.82 090 

23440 .... .......... A Remove/transplant tendon ................................. 10.46 NA 8.28 1.82 NA 20.56 090 

23450 .... .......... A Repair shoulder capsule .................................... 13.38 NA 9.87 2.32 NA 25.57 090 

23455 .... .......... A Repair shoulder capsule .................................... 14.35 NA 10.47 2.49 NA 27.31 090 

23460 .... .......... A Repair shoulder capsule .................................... 15.35 NA 11.40 2.66 NA 29.41 090 

23462 .... .......... A Repair shoulder capsule .................................... 15.28 NA 10.78 2.59 NA 28.65 090 

23465 .... .......... A Repair shoulder capsule .................................... 15.83 NA 11.21 2.76 NA 29.80 090 

23466 .... .......... A Repair shoulder capsule .................................... 14.20 NA 11.40 2.46 NA 28.06 090 

23470 .... .......... A Reconstruct shoulder joint .................................. 17.12 NA 12.29 2.98 NA 32.39 090 

23472 .... .......... A Reconstruct shoulder joint .................................. 21.07 NA 14.45 3.66 NA 39.18 090 

23480 .... .......... A Revision of collar bone ....................................... 11.16 NA 8.80 1.94 NA 21.90 090 

23485 .... .......... A Revision of collar bone ....................................... 13.41 NA 9.92 2.33 NA 25.66 090 

23490 .... .......... A Reinforce clavicle ............................................... 11.84 NA 8.72 1.47 NA 22.03 090 

23491 .... .......... A Reinforce shoulder bones .................................. 14.19 NA 10.74 2.46 NA 27.39 090 

23500 .... .......... A Treat clavicle fracture ......................................... 2.08 2.88 2.53 0.30 5.26 4.91 090 

23505 .... .......... A Treat clavicle fracture ......................................... 3.68 4.42 3.85 0.61 8.71 8.14 090 

23515 .... .......... A Treat clavicle fracture ......................................... 7.40 NA 6.57 1.28 NA 15.25 090 

23520 .... .......... A Treat clavicle dislocation .................................... 2.16 2.86 2.75 0.34 5.36 5.25 090 

23525 .... .......... A Treat clavicle dislocation .................................... 3.59 4.55 3.95 0.46 8.60 8.00 090 

23530 .... .......... A Treat clavicle dislocation .................................... 7.30 NA 5.95 1.20 NA 14.45 090 

23532 .... .......... A Treat clavicle dislocation .................................... 8.00 NA 6.99 1.38 NA 16.37 090 

23540 .... .......... A Treat clavicle dislocation .................................... 2.23 2.87 2.37 0.29 5.39 4.89 090 

23545 .... .......... A Treat clavicle dislocation .................................... 3.25 4.20 3.37 0.35 7.80 6.97 090 

23550 .... .......... A Treat clavicle dislocation .................................... 7.23 NA 6.39 1.25 NA 14.87 090 

23552 .... .......... A Treat clavicle dislocation .................................... 8.44 NA 7.34 1.46 NA 17.24 090 

23570 .... .......... A Treat shoulder blade fx ...................................... 2.23 3.02 2.90 0.36 5.61 5.49 090 

23575 .... .......... A Treat shoulder blade fx ...................................... 4.05 4.89 4.32 0.59 9.53 8.96 090 

70350 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

23585 .... .......... A Treat scapula fracture ........................................ 8.95 NA 7.66 1.54 NA 18.15 090 

23600 .... .......... A Treat humerus fracture ....................................... 2.93 4.56 3.56 0.48 7.97 6.97 090 

23605 .... .......... A Treat humerus fracture ....................................... 4.86 6.17 5.12 0.84 11.87 10.82 090 

23615 .... .......... A Treat humerus fracture ....................................... 9.34 NA 8.86 1.62 NA 19.82 090 

23616 .... .......... A Treat humerus fracture ....................................... 21.24 NA 14.18 3.69 NA 39.11 090 

23620 .... .......... A Treat humerus fracture ....................................... 2.40 3.62 2.99 0.40 6.42 5.79 090 

23625 .... .......... A Treat humerus fracture ....................................... 3.92 4.95 4.29 0.67 9.54 8.88 090 

23630 .... .......... A Treat humerus fracture ....................................... 7.34 NA 6.65 1.27 NA 15.26 090 

23650 .... .......... A Treat shoulder dislocation .................................. 3.38 3.78 2.77 0.30 7.46 6.45 090 

23655 .... .......... A Treat shoulder dislocation .................................. 4.56 NA 4.18 0.69 NA 9.43 090 

23660 .... .......... A Treat shoulder dislocation .................................. 7.48 NA 6.40 1.29 NA 15.17 090 

23665 .... .......... A Treat dislocation/fracture .................................... 4.46 5.35 4.73 0.71 10.52 9.90 090 

23670 .... .......... A Treat dislocation/fracture .................................... 7.89 NA 6.85 1.36 NA 16.10 090 

23675 .... .......... A Treat dislocation/fracture .................................... 6.04 6.85 5.85 1.01 13.90 12.90 090 

23680 .... .......... A Treat dislocation/fracture .................................... 10.04 NA 8.13 1.75 NA 19.92 090 

23700 .... .......... A Fixation of shoulder ............................................ 2.52 NA 2.18 0.44 NA 5.14 010 

23800 .... .......... A Fusion of shoulder joint ...................................... 14.14 NA 10.44 2.35 NA 26.93 090 

23802 .... .......... A Fusion of shoulder joint ...................................... 16.58 NA 10.20 2.70 NA 29.48 090 

23900 .... .......... A Amputation of arm & girdle ................................ 19.69 NA 11.74 3.18 NA 34.61 090 

23920 .... .......... A Amputation at shoulder joint .............................. 14.59 NA 9.95 2.46 NA 27.00 090 

23921 .... .......... A Amputation follow-up surgery ............................. 5.48 NA 5.09 0.78 NA 11.35 090 

23929 .... .......... C Shoulder surgery procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

23930 .... .......... A Drainage of arm lesion ....................................... 2.94 6.34 2.32 0.43 9.71 5.69 010 

23931 .... .......... A Drainage of arm bursa ....................................... 1.79 5.93 2.18 0.28 8.00 4.25 010 

23935 .... .......... A Drain arm/elbow bone lesion ............................. 6.08 NA 5.93 1.05 NA 13.06 090 

24000 .... .......... A Exploratory elbow surgery .................................. 5.81 NA 5.43 0.97 NA 12.21 090 

24006 .... .......... A Release elbow joint ............................................ 9.30 NA 7.77 1.50 NA 18.57 090 

24065 .... .......... A Biopsy arm/elbow soft tissue ............................. 2.08 3.22 1.75 0.17 5.47 4.00 010 

24066 .... .......... A Biopsy arm/elbow soft tissue ............................. 5.20 8.96 4.14 0.80 14.96 10.14 090 

24075 .... .......... A Remove arm/elbow lesion .................................. 3.91 7.37 3.41 0.56 11.84 7.88 090 

24076 .... .......... A Remove arm/elbow lesion .................................. 6.29 NA 4.87 0.95 NA 12.11 090 

24077 .... .......... A Remove tumor of arm/elbow .............................. 11.74 NA 7.76 1.72 NA 21.22 090 

24100 .... .......... A Biopsy elbow joint lining ..................................... 4.92 NA 4.53 0.85 NA 10.30 090 

24101 .... .......... A Explore/treat elbow joint ..................................... 6.12 NA 5.95 1.03 NA 13.10 090 

24102 .... .......... A Remove elbow joint lining .................................. 8.02 NA 6.88 1.33 NA 16.23 090 

24105 .... .......... A Removal of elbow bursa .................................... 3.60 NA 4.40 0.61 NA 8.61 090 

24110 .... .......... A Remove humerus lesion .................................... 7.38 NA 6.68 1.28 NA 15.34 090 

24115 .... .......... A Remove/graft bone lesion .................................. 9.62 NA 7.23 1.67 NA 18.52 090 

24116 .... .......... A Remove/graft bone lesion .................................. 11.79 NA 9.10 2.05 NA 22.94 090 

24120 .... .......... A Remove elbow lesion ......................................... 6.64 NA 5.94 1.10 NA 13.68 090 

24125 .... .......... A Remove/graft bone lesion .................................. 7.88 NA 6.18 1.06 NA 15.12 090 

24126 .... .......... A Remove/graft bone lesion .................................. 8.30 NA 7.04 1.16 NA 16.50 090 

24130 .... .......... A Removal of head of radius ................................. 6.24 NA 6.04 1.04 NA 13.32 090 

24134 .... .......... A Removal of arm bone lesion .............................. 9.72 NA 8.88 1.64 NA 20.24 090 

24136 .... .......... A Remove radius bone lesion ............................... 7.98 NA 7.24 1.38 NA 16.60 090 

24138 .... .......... A Remove elbow bone lesion ................................ 8.04 NA 7.80 1.34 NA 17.18 090 

24140 .... .......... A Partial removal of arm bone ............................... 9.17 NA 9.13 1.51 NA 19.81 090 

24145 .... .......... A Partial removal of radius .................................... 7.57 NA 8.08 1.25 NA 16.90 090 

24147 .... .......... A Partial removal of elbow ..................................... 7.53 NA 8.62 1.30 NA 17.45 090 

24149 .... .......... A Radical resection of elbow ................................. 14.18 NA 11.65 2.34 NA 28.17 090 

24150 .... .......... A Extensive humerus surgery ................................ 13.25 NA 10.02 2.32 NA 25.59 090 

24151 .... .......... A Extensive humerus surgery ................................ 15.56 NA 11.54 2.59 NA 29.69 090 

24152 .... .......... A Extensive radius surgery .................................... 10.04 NA 7.75 1.48 NA 19.27 090 

24153 .... .......... A Extensive radius surgery .................................... 11.52 NA 5.59 0.74 NA 17.85 090 

24155 .... .......... A Removal of elbow joint ....................................... 11.71 NA 8.42 1.92 NA 22.05 090 

24160 .... .......... A Remove elbow joint implant ............................... 7.82 NA 6.91 1.30 NA 16.03 090 

24164 .... .......... A Remove radius head implant ............................. 6.22 NA 5.79 1.03 NA 13.04 090 

24200 .... .......... A Removal of arm foreign body ............................. 1.76 3.42 1.63 0.20 5.38 3.59 010 

24201 .... .......... A Removal of arm foreign body ............................. 4.55 9.84 4.24 0.72 15.11 9.51 090 

24220 .... .......... A Injection for elbow x-ray ..................................... 1.31 3.64 0.44 0.08 5.03 1.83 000 

24300 .... .......... A Manipulate elbow w/anesth ................................ 3.74 NA 5.73 0.65 NA 10.12 090 

24301 .... .......... A Muscle/tendon transfer ....................................... 10.18 NA 8.20 1.66 NA 20.04 090 

24305 .... .......... A Arm tendon lengthening ..................................... 7.44 NA 6.73 1.15 NA 15.32 090 

24310 .... .......... A Revision of arm tendon ...................................... 5.97 NA 5.60 0.96 NA 12.53 090 

24320 .... .......... A Repair of arm tendon ......................................... 10.54 NA 7.55 1.73 NA 19.82 090 

24330 .... .......... A Revision of arm muscles .................................... 9.59 NA 7.90 1.60 NA 19.09 090 

24331 .... .......... A Revision of arm muscles .................................... 10.63 NA 8.70 1.77 NA 21.10 090 

24332 .... .......... A Tenolysis, triceps ................................................ 7.44 NA 6.79 1.23 NA 15.46 090 

24340 .... .......... A Repair of biceps tendon ..................................... 7.88 NA 7.00 1.36 NA 16.24 090 

24341 .... .......... A Repair arm tendon/muscle ................................. 7.89 NA 7.94 1.36 NA 17.19 090 

24342 .... .......... A Repair of ruptured tendon .................................. 10.60 NA 8.54 1.85 NA 20.99 090 

24343 .... .......... A Repr elbow lat ligmnt w/tiss ............................... 8.64 NA 8.17 1.43 NA 18.24 090 

24344 .... .......... A Reconstruct elbow lat ligmnt .............................. 13.98 NA 11.55 2.36 NA 27.89 090 

24345 .... .......... A Repr elbw med ligmnt w/tissu ............................ 8.64 NA 8.04 1.44 NA 18.12 090 

24346 .... .......... A Reconstruct elbow med ligmnt ........................... 13.98 NA 11.37 2.33 NA 27.68 090 

70351 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

24350 .... .......... A Repair of tennis elbow ....................................... 5.24 NA 5.60 0.87 NA 11.71 090 

24351 .... .......... A Repair of tennis elbow ....................................... 5.90 NA 5.94 1.02 NA 12.86 090 

24352 .... .......... A Repair of tennis elbow ....................................... 6.42 NA 6.20 1.10 NA 13.72 090 

24354 .... .......... A Repair of tennis elbow ....................................... 6.47 NA 6.17 1.07 NA 13.71 090 

24356 .... .......... A Revision of tennis elbow .................................... 6.67 NA 6.33 1.11 NA 14.11 090 

24360 .... .......... A Reconstruct elbow joint ...................................... 12.32 NA 9.50 2.05 NA 23.87 090 

24361 .... .......... A Reconstruct elbow joint ...................................... 14.06 NA 10.61 2.18 NA 26.85 090 

24362 .... .......... A Reconstruct elbow joint ...................................... 14.97 NA 10.07 2.60 NA 27.64 090 

24363 .... .......... A Replace elbow joint ............................................ 18.46 NA 13.75 3.01 NA 35.22 090 

24365 .... .......... A Reconstruct head of radius ................................ 8.38 NA 7.22 1.41 NA 17.01 090 

24366 .... .......... A Reconstruct head of radius ................................ 9.12 NA 7.56 1.52 NA 18.20 090 

24400 .... .......... A Revision of humerus .......................................... 11.04 NA 8.88 1.92 NA 21.84 090 

24410 .... .......... A Revision of humerus .......................................... 14.80 NA 10.34 2.57 NA 27.71 090 

24420 .... .......... A Revision of humerus .......................................... 13.42 NA 10.57 2.17 NA 26.16 090 

24430 .... .......... A Repair of humerus .............................................. 12.79 NA 9.77 2.21 NA 24.77 090 

24435 .... .......... A Repair humerus with graft .................................. 13.15 NA 10.91 2.27 NA 26.33 090 

24470 .... .......... A Revision of elbow joint ....................................... 8.73 NA 7.74 1.48 NA 17.95 090 

24495 .... .......... A Decompression of forearm ................................. 8.11 NA 8.77 1.18 NA 18.06 090 

24498 .... .......... A Reinforce humerus ............................................. 11.90 NA 9.29 2.06 NA 23.25 090 

24500 .... .......... A Treat humerus fracture ....................................... 3.21 4.86 3.69 0.50 8.57 7.40 090 

24505 .... .......... A Treat humerus fracture ....................................... 5.16 6.62 5.41 0.89 12.67 11.46 090 

24515 .... .......... A Treat humerus fracture ....................................... 11.63 NA 9.41 2.02 NA 23.06 090 

24516 .... .......... A Treat humerus fracture ....................................... 11.63 NA 9.14 2.02 NA 22.79 090 

24530 .... .......... A Treat humerus fracture ....................................... 3.49 5.22 4.05 0.57 9.28 8.11 090 

24535 .... .......... A Treat humerus fracture ....................................... 6.86 7.86 6.64 1.18 15.90 14.68 090 

24538 .... .......... A Treat humerus fracture ....................................... 9.42 NA 8.73 1.64 NA 19.79 090 

24545 .... .......... A Treat humerus fracture ....................................... 10.44 NA 8.47 1.82 NA 20.73 090 

24546 .... .......... A Treat humerus fracture ....................................... 15.67 NA 11.35 2.73 NA 29.75 090 

24560 .... .......... A Treat humerus fracture ....................................... 2.80 4.49 3.20 0.44 7.73 6.44 090 

24565 .... .......... A Treat humerus fracture ....................................... 5.55 6.63 5.54 0.93 13.11 12.02 090 

24566 .... .......... A Treat humerus fracture ....................................... 7.78 NA 8.18 1.30 NA 17.26 090 

24575 .... .......... A Treat humerus fracture ....................................... 10.64 NA 8.42 1.86 NA 20.92 090 

24576 .... .......... A Treat humerus fracture ....................................... 2.86 4.77 3.72 0.46 8.09 7.04 090 

24577 .... .......... A Treat humerus fracture ....................................... 5.78 6.95 5.86 0.95 13.68 12.59 090 

24579 .... .......... A Treat humerus fracture ....................................... 11.58 NA 8.86 2.02 NA 22.46 090 

24582 .... .......... A Treat humerus fracture ....................................... 8.54 NA 9.14 1.48 NA 19.16 090 

24586 .... .......... A Treat elbow fracture ........................................... 15.19 NA 11.26 2.64 NA 29.09 090 

24587 .... .......... A Treat elbow fracture ........................................... 15.14 NA 11.05 2.52 NA 28.71 090 

24600 .... .......... A Treat elbow dislocation ...................................... 4.22 4.87 3.51 0.50 9.59 8.23 090 

24605 .... .......... A Treat elbow dislocation ...................................... 5.41 NA 5.38 0.89 NA 11.68 090 

24615 .... .......... A Treat elbow dislocation ...................................... 9.41 NA 7.84 1.60 NA 18.85 090 

24620 .... .......... A Treat elbow fracture ........................................... 6.97 NA 6.27 1.07 NA 14.31 090 

24635 .... .......... A Treat elbow fracture ........................................... 13.17 NA 14.09 2.28 NA 29.54 090 

24640 .... .......... A Treat elbow dislocation ...................................... 1.20 1.85 0.80 0.12 3.17 2.12 010 

24650 .... .......... A Treat radius fracture ........................................... 2.16 3.79 2.76 0.35 6.30 5.27 090 

24655 .... .......... A Treat radius fracture ........................................... 4.39 5.97 4.80 0.70 11.06 9.89 090 

24665 .... .......... A Treat radius fracture ........................................... 8.13 NA 7.53 1.41 NA 17.07 090 

24666 .... .......... A Treat radius fracture ........................................... 9.48 NA 8.09 1.62 NA 19.19 090 

24670 .... .......... A Treat ulnar fracture ............................................. 2.54 4.12 3.08 0.41 7.07 6.03 090 

24675 .... .......... A Treat ulnar fracture ............................................. 4.71 6.02 4.98 0.81 11.54 10.50 090 

24685 .... .......... A Treat ulnar fracture ............................................. 8.79 NA 7.54 1.52 NA 17.85 090 

24800 .... .......... A Fusion of elbow joint .......................................... 11.18 NA 8.77 1.63 NA 21.58 090 

24802 .... .......... A Fusion/graft of elbow joint .................................. 13.67 NA 10.41 2.37 NA 26.45 090 

24900 .... .......... A Amputation of upper arm ................................... 9.59 NA 7.08 1.53 NA 18.20 090 

24920 .... .......... A Amputation of upper arm ................................... 9.53 NA 6.96 1.61 NA 18.10 090 

24925 .... .......... A Amputation follow-up surgery ............................. 7.06 NA 6.10 1.14 NA 14.30 090 

24930 .... .......... A Amputation follow-up surgery ............................. 10.23 NA 7.26 1.67 NA 19.16 090 

24931 .... .......... A Amputate upper arm & implant .......................... 12.70 NA 5.74 1.89 NA 20.33 090 

24935 .... .......... A Revision of amputation ....................................... 15.54 NA 8.04 2.13 NA 25.71 090 

24940 .... .......... C Revision of upper arm ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 090 

24999 .... .......... C Upper arm/elbow surgery ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

25000 .... .......... A Incision of tendon sheath ................................... 3.37 NA 6.89 0.55 NA 10.81 090 

25001 .... .......... A Incise flexor carpi radialis ................................... 3.37 NA 4.24 0.55 NA 8.16 090 

25020 .... .......... A Decompress forearm 1 space ............................ 5.91 NA 9.59 0.93 NA 16.43 090 

25023 .... .......... A Decompress forearm 1 space ............................ 12.94 NA 14.98 2.03 NA 29.95 090 

25024 .... .......... A Decompress forearm 2 spaces .......................... 9.49 NA 7.49 1.36 NA 18.34 090 

25025 .... .......... A Decompress forearm 2 spaces .......................... 16.52 NA 10.00 1.82 NA 28.34 090 

25028 .... .......... A Drainage of forearm lesion ................................. 5.24 NA 8.18 0.81 NA 14.23 090 

25031 .... .......... A Drainage of forearm bursa ................................. 4.13 NA 7.94 0.63 NA 12.70 090 

25035 .... .......... A Treat forearm bone lesion .................................. 7.35 NA 13.63 1.24 NA 22.22 090 

25040 .... .......... A Explore/treat wrist joint ....................................... 7.17 NA 7.32 1.15 NA 15.64 090 

25065 .... .......... A Biopsy forearm soft tissues ................................ 1.99 3.23 1.91 0.15 5.37 4.05 010 

25066 .... .......... A Biopsy forearm soft tissues ................................ 4.12 NA 7.08 0.64 NA 11.84 090 

25075 .... .......... A Removal forearm lesion subcu .......................... 3.73 NA 5.91 0.55 NA 10.19 090 

25076 .... .......... A Removal forearm lesion deep ............................ 4.91 NA 9.57 0.74 NA 15.22 090 

70352 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

25077 .... .......... A Remove tumor, forearm/wrist ............................. 9.75 NA 12.12 1.42 NA 23.29 090 

25085 .... .......... A Incision of wrist capsule ..................................... 5.49 NA 7.14 0.85 NA 13.48 090 

25100 .... .......... A Biopsy of wrist joint ............................................ 3.89 NA 5.29 0.59 NA 9.77 090 

25101 .... .......... A Explore/treat wrist joint ....................................... 4.68 NA 5.91 0.75 NA 11.34 090 

25105 .... .......... A Remove wrist joint lining .................................... 5.84 NA 7.32 0.92 NA 14.08 090 

25107 .... .......... A Remove wrist joint cartilage ............................... 6.42 NA 8.36 0.99 NA 15.77 090 

25110 .... .......... A Remove wrist tendon lesion ............................... 3.91 NA 7.07 0.62 NA 11.60 090 

25111 .... .......... A Remove wrist tendon lesion ............................... 3.38 NA 4.71 0.53 NA 8.62 090 

25112 .... .......... A Reremove wrist tendon lesion ............................ 4.52 NA 5.27 0.70 NA 10.49 090 

25115 .... .......... A Remove wrist/forearm lesion .............................. 8.81 NA 14.07 1.31 NA 24.19 090 

25116 .... .......... A Remove wrist/forearm lesion .............................. 7.10 NA 13.18 1.11 NA 21.39 090 

25118 .... .......... A Excise wrist tendon sheath ................................ 4.36 NA 5.76 0.68 NA 10.80 090 

25119 .... .......... A Partial removal of ulna ....................................... 6.03 NA 7.62 0.96 NA 14.61 090 

25120 .... .......... A Removal of forearm lesion ................................. 6.09 NA 12.12 1.00 NA 19.21 090 

25125 .... .......... A Remove/graft forearm lesion .............................. 7.47 NA 12.88 1.06 NA 21.41 090 

25126 .... .......... A Remove/graft forearm lesion .............................. 7.54 NA 13.05 1.27 NA 21.86 090 

25130 .... .......... A Removal of wrist lesion ...................................... 5.25 NA 6.44 0.80 NA 12.49 090 

25135 .... .......... A Remove & graft wrist lesion ............................... 6.88 NA 7.53 1.02 NA 15.43 090 

25136 .... .......... A Remove & graft wrist lesion ............................... 5.96 NA 6.61 1.03 NA 13.60 090 

25145 .... .......... A Remove forearm bone lesion ............................. 6.36 NA 12.09 1.01 NA 19.46 090 

25150 .... .......... A Partial removal of ulna ....................................... 7.08 NA 8.23 1.14 NA 16.45 090 

25151 .... .......... A Partial removal of radius .................................... 7.38 NA 12.76 1.18 NA 21.32 090 

25170 .... .......... A Extensive forearm surgery ................................. 11.07 NA 15.19 1.77 NA 28.03 090 

25210 .... .......... A Removal of wrist bone ....................................... 5.94 NA 6.81 0.88 NA 13.63 090 

25215 .... .......... A Removal of wrist bones ...................................... 7.88 NA 8.78 1.19 NA 17.85 090 

25230 .... .......... A Partial removal of radius .................................... 5.22 NA 6.16 0.79 NA 12.17 090 

25240 .... .......... A Partial removal of ulna ....................................... 5.16 NA 6.97 0.81 NA 12.94 090 

25246 .... .......... A Injection for wrist x-ray ....................................... 1.45 3.45 0.48 0.09 4.99 2.02 000 

25248 .... .......... A Remove forearm foreign body ........................... 5.13 NA 8.54 0.72 NA 14.39 090 

25250 .... .......... A Removal of wrist prosthesis ............................... 6.59 NA 6.12 1.01 NA 13.72 090 

25251 .... .......... A Removal of wrist prosthesis ............................... 9.56 NA 7.94 1.26 NA 18.76 090 

25259 .... .......... A Manipulate wrist w/anesthes .............................. 3.74 NA 5.74 0.62 NA 10.10 090 

25260 .... .......... A Repair forearm tendon/muscle ........................... 7.79 NA 13.35 1.19 NA 22.33 090 

25263 .... .......... A Repair forearm tendon/muscle ........................... 7.81 NA 13.30 1.18 NA 22.29 090 

25265 .... .......... A Repair forearm tendon/muscle ........................... 9.87 NA 14.35 1.47 NA 25.69 090 

25270 .... .......... A Repair forearm tendon/muscle ........................... 5.99 NA 12.06 0.95 NA 19.00 090 

25272 .... .......... A Repair forearm tendon/muscle ........................... 7.03 NA 12.83 1.11 NA 20.97 090 

25274 .... .......... A Repair forearm tendon/muscle ........................... 8.74 NA 13.66 1.36 NA 23.76 090 

25275 .... .......... A Repair forearm tendon sheath ........................... 8.49 NA 7.60 1.31 NA 17.40 090 

25280 .... .......... A Revise wrist/forearm tendon .............................. 7.21 NA 12.67 1.08 NA 20.96 090 

25290 .... .......... A Incise wrist/forearm tendon ................................ 5.28 NA 15.03 0.82 NA 21.13 090 

25295 .... .......... A Release wrist/forearm tendon ............................ 6.54 NA 12.19 1.00 NA 19.73 090 

25300 .... .......... A Fusion of tendons at wrist .................................. 8.79 NA 8.47 1.26 NA 18.52 090 

25301 .... .......... A Fusion of tendons at wrist .................................. 8.39 NA 8.08 1.29 NA 17.76 090 

25310 .... .......... A Transplant forearm tendon ................................. 8.13 NA 13.07 1.21 NA 22.41 090 

25312 .... .......... A Transplant forearm tendon ................................. 9.56 NA 13.98 1.41 NA 24.95 090 

25315 .... .......... A Revise palsy hand tendon(s) ............................. 10.18 NA 14.44 1.58 NA 26.20 090 

25316 .... .......... A Revise palsy hand tendon(s) ............................. 12.31 NA 16.27 1.74 NA 30.32 090 

25320 .... .......... A Repair/revise wrist joint ...................................... 10.75 NA 11.42 1.61 NA 23.78 090 

25332 .... .......... A Revise wrist joint ................................................ 11.39 NA 9.20 1.83 NA 22.42 090 

25335 .... .......... A Realignment of hand .......................................... 12.86 NA 11.62 1.92 NA 26.40 090 

25337 .... .......... A Reconstruct ulna/radioulnar ............................... 10.15 NA 11.11 1.61 NA 22.87 090 

25350 .... .......... A Revision of radius ............................................... 8.77 NA 14.01 1.46 NA 24.24 090 

25355 .... .......... A Revision of radius ............................................... 10.15 NA 14.65 1.73 NA 26.53 090 

25360 .... .......... A Revision of ulna .................................................. 8.42 NA 13.91 1.41 NA 23.74 090 

25365 .... .......... A Revise radius & ulna .......................................... 12.38 NA 15.69 2.15 NA 30.22 090 

25370 .... .......... A Revise radius or ulna ......................................... 13.34 NA 16.12 2.28 NA 31.74 090 

25375 .... .......... A Revise radius & ulna .......................................... 13.02 NA 16.47 2.26 NA 31.75 090 

25390 .... .......... A Shorten radius or ulna ........................................ 10.38 NA 14.62 1.65 NA 26.65 090 

25391 .... .......... A Lengthen radius or ulna ..................................... 13.63 NA 16.60 2.21 NA 32.44 090 

25392 .... .......... A Shorten radius & ulna ........................................ 13.93 NA 16.01 2.10 NA 32.04 090 

25393 .... .......... A Lengthen radius & ulna ...................................... 15.85 NA 17.63 2.76 NA 36.24 090 

25394 .... .......... A Repair carpal bone, shorten ............................... 10.38 NA 8.08 1.59 NA 20.05 090 

25400 .... .......... A Repair radius or ulna .......................................... 10.90 NA 15.23 1.82 NA 27.95 090 

25405 .... .......... A Repair/graft radius or ulna ................................. 14.36 NA 17.32 2.32 NA 34.00 090 

25415 .... .......... A Repair radius & ulna .......................................... 13.33 NA 16.56 2.17 NA 32.06 090 

25420 .... .......... A Repair/graft radius & ulna .................................. 16.31 NA 18.32 2.61 NA 37.24 090 

25425 .... .......... A Repair/graft radius or ulna ................................. 13.19 NA 21.45 2.08 NA 36.72 090 

25426 .... .......... A Repair/graft radius & ulna .................................. 15.80 NA 16.60 2.54 NA 34.94 090 

25430 .... .......... A Vasc graft into carpal bone ................................ 9.24 NA 7.36 1.27 NA 17.87 090 

25431 .... .......... A Repair nonunion carpal bone ............................. 10.42 NA 8.42 1.90 NA 20.74 090 

25440 .... .......... A Repair/graft wrist bone ....................................... 10.42 NA 9.43 1.63 NA 21.48 090 

25441 .... .......... A Reconstruct wrist joint ........................................ 12.88 NA 10.03 2.07 NA 24.98 090 

25442 .... .......... A Reconstruct wrist joint ........................................ 10.83 NA 8.91 1.53 NA 21.27 090 

25443 .... .......... A Reconstruct wrist joint ........................................ 10.37 NA 8.80 1.37 NA 20.54 090 

70353 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

25444 .... .......... A Reconstruct wrist joint ........................................ 11.13 NA 9.06 1.71 NA 21.90 090 

25445 .... .......... A Reconstruct wrist joint ........................................ 9.68 NA 8.01 1.55 NA 19.24 090 

25446 .... .......... A Wrist replacement .............................................. 16.53 NA 11.95 2.47 NA 30.95 090 

25447 .... .......... A Repair wrist joint(s) ............................................ 10.35 NA 8.68 1.61 NA 20.64 090 

25449 .... .......... A Remove wrist joint implant ................................. 14.47 NA 10.70 2.21 NA 27.38 090 

25450 .... .......... A Revision of wrist joint ......................................... 7.86 NA 10.22 1.36 NA 19.44 090 

25455 .... .......... A Revision of wrist joint ......................................... 9.48 NA 10.89 0.96 NA 21.33 090 

25490 .... .......... A Reinforce radius ................................................. 9.53 NA 13.77 1.43 NA 24.73 090 

25491 .... .......... A Reinforce ulna .................................................... 9.95 NA 14.50 1.60 NA 26.05 090 

25492 .... .......... A Reinforce radius and ulna .................................. 12.31 NA 15.34 2.14 NA 29.79 090 

25500 .... .......... A Treat fracture of radius ....................................... 2.45 3.58 2.72 0.35 6.38 5.52 090 

25505 .... .......... A Treat fracture of radius ....................................... 5.20 6.56 5.44 0.90 12.66 11.54 090 

25515 .... .......... A Treat fracture of radius ....................................... 9.17 NA 7.48 1.59 NA 18.24 090 

25520 .... .......... A Treat fracture of radius ....................................... 6.25 6.88 6.08 1.08 14.21 13.41 090 

25525 .... .......... A Treat fracture of radius ....................................... 12.22 NA 10.02 2.12 NA 24.36 090 

25526 .... .......... A Treat fracture of radius ....................................... 12.96 NA 13.54 2.19 NA 28.69 090 

25530 .... .......... A Treat fracture of ulna .......................................... 2.09 3.77 2.87 0.34 6.20 5.30 090 

25535 .... .......... A Treat fracture of ulna .......................................... 5.13 6.03 5.31 0.89 12.05 11.33 090 

25545 .... .......... A Treat fracture of ulna .......................................... 8.89 NA 7.68 1.53 NA 18.10 090 

25560 .... .......... A Treat fracture radius & ulna ............................... 2.44 3.70 2.61 0.35 6.49 5.40 090 

25565 .... .......... A Treat fracture radius & ulna ............................... 5.62 6.72 5.44 0.93 13.27 11.99 090 

25574 .... .......... A Treat fracture radius & ulna ............................... 7.00 NA 7.22 1.21 NA 15.43 090 

25575 .... .......... A Treat fracture radius/ulna ................................... 10.43 NA 9.54 1.81 NA 21.78 090 

25600 .... .......... A Treat fracture radius/ulna ................................... 2.63 4.10 2.98 0.42 7.15 6.03 090 

25605 .... .......... A Treat fracture radius/ulna ................................... 5.80 7.25 6.24 1.00 14.05 13.04 090 

25611 .... .......... A Treat fracture radius/ulna ................................... 7.76 NA 8.99 1.34 NA 18.09 090 

25620 .... .......... A Treat fracture radius/ulna ................................... 8.54 NA 7.28 1.42 NA 17.24 090 

25622 .... .......... A Treat wrist bone fracture .................................... 2.61 4.28 3.11 0.41 7.30 6.13 090 

25624 .... .......... A Treat wrist bone fracture .................................... 4.52 6.32 5.08 0.76 11.60 10.36 090 

25628 .... .......... A Treat wrist bone fracture .................................... 8.42 NA 7.84 1.37 NA 17.63 090 

25630 .... .......... A Treat wrist bone fracture .................................... 2.88 4.19 2.95 0.45 7.52 6.28 090 

25635 .... .......... A Treat wrist bone fracture .................................... 4.38 5.96 3.91 0.74 11.08 9.03 090 

25645 .... .......... A Treat wrist bone fracture .................................... 7.24 NA 6.65 1.20 NA 15.09 090 

25650 .... .......... A Treat wrist bone fracture .................................... 3.05 4.32 3.18 0.45 7.82 6.68 090 

25651 .... .......... A Pin ulnar styloid fracture .................................... 5.35 NA 5.50 0.86 NA 11.71 090 

25652 .... .......... A Treat fracture ulnar styloid ................................. 7.59 NA 7.02 1.21 NA 15.82 090 

25660 .... .......... A Treat wrist dislocation ........................................ 4.75 NA 4.72 0.58 NA 10.05 090 

25670 .... .......... A Treat wrist dislocation ........................................ 7.91 NA 7.01 1.28 NA 16.20 090 

25671 .... .......... A Pin radioulnar dislocation ................................... 5.99 NA 6.17 1.00 NA 13.16 090 

25675 .... .......... A Treat wrist dislocation ........................................ 4.66 5.67 4.66 0.62 10.95 9.94 090 

25676 .... .......... A Treat wrist dislocation ........................................ 8.03 NA 7.32 1.34 NA 16.69 090 

25680 .... .......... A Treat wrist fracture ............................................. 5.98 NA 4.75 0.78 NA 11.51 090 

25685 .... .......... A Treat wrist fracture ............................................. 9.77 NA 7.82 1.60 NA 19.19 090 

25690 .... .......... A Treat wrist dislocation ........................................ 5.49 NA 5.52 0.88 NA 11.89 090 

25695 .... .......... A Treat wrist dislocation ........................................ 8.33 NA 7.11 1.32 NA 16.76 090 

25800 .... .......... A Fusion of wrist joint ............................................ 9.75 NA 9.12 1.57 NA 20.44 090 

25805 .... .......... A Fusion/graft of wrist joint .................................... 11.26 NA 10.28 1.80 NA 23.34 090 

25810 .... .......... A Fusion/graft of wrist joint .................................... 10.55 NA 9.93 1.67 NA 22.15 090 

25820 .... .......... A Fusion of hand bones ........................................ 7.44 NA 7.87 1.22 NA 16.53 090 

25825 .... .......... A Fuse hand bones with graft ............................... 9.26 NA 9.26 1.41 NA 19.93 090 

25830 .... .......... A Fusion, radioulnar jnt/ulna .................................. 10.04 NA 14.45 1.55 NA 26.04 090 

25900 .... .......... A Amputation of forearm ........................................ 9.00 NA 12.60 1.30 NA 22.90 090 

25905 .... .......... A Amputation of forearm ........................................ 9.11 NA 12.33 1.40 NA 22.84 090 

25907 .... .......... A Amputation follow-up surgery ............................. 7.79 NA 11.79 1.10 NA 20.68 090 

25909 .... .......... A Amputation follow-up surgery ............................. 8.95 NA 12.31 1.44 NA 22.70 090 

25915 .... .......... A Amputation of forearm ........................................ 17.05 NA 18.93 2.93 NA 38.91 090 

25920 .... .......... A Amputate hand at wrist ...................................... 8.67 NA 7.87 1.35 NA 17.89 090 

25922 .... .......... A Amputate hand at wrist ...................................... 7.41 NA 7.07 1.12 NA 15.60 090 

25924 .... .......... A Amputation follow-up surgery ............................. 8.45 NA 8.11 1.32 NA 17.88 090 

25927 .... .......... A Amputation of hand ............................................ 8.79 NA 11.71 1.27 NA 21.77 090 

25929 .... .......... A Amputation follow-up surgery ............................. 7.58 NA 5.89 1.14 NA 14.61 090 

25931 .... .......... A Amputation follow-up surgery ............................. 7.80 NA 11.49 1.15 NA 20.44 090 

25999 .... .......... C Forearm or wrist surgery .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

26010 .... .......... A Drainage of finger abscess ................................ 1.54 5.58 1.63 0.18 7.30 3.35 010 

26011 .... .......... A Drainage of finger abscess ................................ 2.19 8.84 2.33 0.33 11.36 4.85 010 

26020 .... .......... A Drain hand tendon sheath .................................. 4.66 NA 5.37 0.73 NA 10.76 090 

26025 .... .......... A Drainage of palm bursa ...................................... 4.81 NA 5.13 0.76 NA 10.70 090 

26030 .... .......... A Drainage of palm bursa(s) ................................. 5.92 NA 5.74 0.92 NA 12.58 090 

26034 .... .......... A Treat hand bone lesion ...................................... 6.22 NA 6.37 1.01 NA 13.60 090 

26035 .... .......... A Decompress fingers/hand .................................. 9.50 NA 7.89 1.47 NA 18.86 090 

26037 .... .......... A Decompress fingers/hand .................................. 7.24 NA 6.34 1.13 NA 14.71 090 

26040 .... .......... A Release palm contracture .................................. 3.33 NA 4.06 0.53 NA 7.92 090 

26045 .... .......... A Release palm contracture .................................. 5.55 NA 5.66 0.93 NA 12.14 090 

26055 .... .......... A Incise finger tendon sheath ................................ 2.69 14.39 3.95 0.43 17.51 7.07 090 

26060 .... .......... A Incision of finger tendon ..................................... 2.81 NA 3.52 0.45 NA 6.78 090 

70354 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

26070 .... .......... A Explore/treat hand joint ...................................... 3.68 NA 3.37 0.48 NA 7.53 090 

26075 .... .......... A Explore/treat finger joint ..................................... 3.78 NA 3.79 0.53 NA 8.10 090 

26080 .... .......... A Explore/treat finger joint ..................................... 4.23 NA 4.86 0.66 NA 9.75 090 

26100 .... .......... A Biopsy hand joint lining ...................................... 3.66 NA 4.14 0.54 NA 8.34 090 

26105 .... .......... A Biopsy finger joint lining ..................................... 3.70 NA 4.24 0.59 NA 8.53 090 

26110 .... .......... A Biopsy finger joint lining ..................................... 3.52 NA 4.05 0.53 NA 8.10 090 

26115 .... .......... A Removal hand lesion subcut .............................. 3.85 13.13 4.78 0.59 17.57 9.22 090 

26116 .... .......... A Removal hand lesion, deep ............................... 5.52 NA 6.02 0.84 NA 12.38 090 

26117 .... .......... A Remove tumor, hand/finger ................................ 8.54 NA 7.08 1.26 NA 16.88 090 

26121 .... .......... A Release palm contracture .................................. 7.53 NA 6.98 1.17 NA 15.68 090 

26123 .... .......... A Release palm contracture .................................. 9.28 NA 8.88 1.43 NA 19.59 090 

26125 .... .......... A Release palm contracture .................................. 4.60 NA 2.45 0.70 NA 7.75 ZZZ 

26130 .... .......... A Remove wrist joint lining .................................... 5.41 NA 5.36 0.94 NA 11.71 090 

26135 .... .......... A Revise finger joint, each ..................................... 6.95 NA 6.48 1.07 NA 14.50 090 

26140 .... .......... A Revise finger joint, each ..................................... 6.16 NA 6.06 0.92 NA 13.14 090 

26145 .... .......... A Tendon excision, palm/finger ............................. 6.31 NA 6.07 0.97 NA 13.35 090 

26160 .... .......... A Remove tendon sheath lesion ........................... 3.15 12.41 4.13 0.49 16.05 7.77 090 

26170 .... .......... A Removal of palm tendon, each .......................... 4.76 NA 4.95 0.69 NA 10.40 090 

26180 .... .......... A Removal of finger tendon ................................... 5.17 NA 5.43 0.78 NA 11.38 090 

26185 .... .......... A Remove finger bone ........................................... 5.24 NA 6.05 0.81 NA 12.10 090 

26200 .... .......... A Remove hand bone lesion ................................. 5.50 NA 5.37 0.88 NA 11.75 090 

26205 .... .......... A Remove/graft bone lesion .................................. 7.69 NA 6.91 1.20 NA 15.80 090 

26210 .... .......... A Removal of finger lesion .................................... 5.14 NA 5.44 0.79 NA 11.37 090 

26215 .... .......... A Remove/graft finger lesion ................................. 7.09 NA 6.33 0.98 NA 14.40 090 

26230 .... .......... A Partial removal of hand bone ............................. 6.32 NA 5.93 1.01 NA 13.26 090 

26235 .... .......... A Partial removal, finger bone ............................... 6.18 NA 5.83 0.95 NA 12.96 090 

26236 .... .......... A Partial removal, finger bone ............................... 5.31 NA 5.34 0.81 NA 11.46 090 

26250 .... .......... A Extensive hand surgery ...................................... 7.54 NA 6.45 1.07 NA 15.06 090 

26255 .... .......... A Extensive hand surgery ...................................... 12.41 NA 9.40 1.68 NA 23.49 090 

26260 .... .......... A Extensive finger surgery ..................................... 7.02 NA 6.20 1.01 NA 14.23 090 

26261 .... .......... A Extensive finger surgery ..................................... 9.08 NA 6.19 1.14 NA 16.41 090 

26262 .... .......... A Partial removal of finger ..................................... 5.66 NA 5.35 0.88 NA 11.89 090 

26320 .... .......... A Removal of implant from hand ........................... 3.97 NA 4.32 0.59 NA 8.88 090 

26340 .... .......... A Manipulate finger w/anesth ................................ 2.50 NA 4.89 0.39 NA 7.78 090 

26350 .... .......... A Repair finger/hand tendon .................................. 5.98 NA 14.65 0.93 NA 21.56 090 

26352 .... .......... A Repair/graft hand tendon ................................... 7.67 NA 15.40 1.13 NA 24.20 090 

26356 .... .......... A Repair finger/hand tendon .................................. 8.06 NA 18.42 1.21 NA 27.69 090 

26357 .... .......... A Repair finger/hand tendon .................................. 8.57 NA 15.68 1.33 NA 25.58 090 

26358 .... .......... A Repair/graft hand tendon ................................... 9.13 NA 16.69 1.38 NA 27.20 090 

26370 .... .......... A Repair finger/hand tendon .................................. 7.10 NA 15.15 1.12 NA 23.37 090 

26372 .... .......... A Repair/graft hand tendon ................................... 8.75 NA 16.58 1.40 NA 26.73 090 

26373 .... .......... A Repair finger/hand tendon .................................. 8.15 NA 16.09 1.23 NA 25.47 090 

26390 .... .......... A Revise hand/finger tendon ................................. 9.18 NA 13.32 1.40 NA 23.90 090 

26392 .... .......... A Repair/graft hand tendon ................................... 10.24 NA 16.77 1.57 NA 28.58 090 

26410 .... .......... A Repair hand tendon ............................................ 4.62 NA 11.97 0.73 NA 17.32 090 

26412 .... .......... A Repair/graft hand tendon ................................... 6.30 NA 13.31 0.97 NA 20.58 090 

26415 .... .......... A Excision, hand/finger tendon .............................. 8.33 NA 11.81 0.98 NA 21.12 090 

26416 .... .......... A Graft hand or finger tendon ................................ 9.36 NA 14.63 0.79 NA 24.78 090 

26418 .... .......... A Repair finger tendon ........................................... 4.24 NA 12.36 0.67 NA 17.27 090 

26420 .... .......... A Repair/graft finger tendon .................................. 6.76 NA 13.67 1.07 NA 21.50 090 

26426 .... .......... A Repair finger/hand tendon .................................. 6.14 NA 13.20 0.95 NA 20.29 090 

26428 .... .......... A Repair/graft finger tendon .................................. 7.20 NA 13.90 1.09 NA 22.19 090 

26432 .... .......... A Repair finger tendon ........................................... 4.01 NA 10.29 0.64 NA 14.94 090 

26433 .... .......... A Repair finger tendon ........................................... 4.55 NA 10.82 0.72 NA 16.09 090 

26434 .... .......... A Repair/graft finger tendon .................................. 6.08 NA 11.57 0.93 NA 18.58 090 

26437 .... .......... A Realignment of tendons ..................................... 5.81 NA 11.60 0.89 NA 18.30 090 

26440 .... .......... A Release palm/finger tendon ............................... 5.01 NA 13.47 0.75 NA 19.23 090 

26442 .... .......... A Release palm & finger tendon ........................... 8.15 NA 15.99 1.20 NA 25.34 090 

26445 .... .......... A Release hand/finger tendon ............................... 4.30 NA 13.18 0.65 NA 18.13 090 

26449 .... .......... A Release forearm/hand tendon ............................ 6.99 NA 15.82 1.06 NA 23.87 090 

26450 .... .......... A Incision of palm tendon ...................................... 3.66 NA 7.35 0.59 NA 11.60 090 

26455 .... .......... A Incision of finger tendon ..................................... 3.63 NA 7.30 0.58 NA 11.51 090 

26460 .... .......... A Incise hand/finger tendon ................................... 3.45 NA 7.16 0.55 NA 11.16 090 

26471 .... .......... A Fusion of finger tendons .................................... 5.72 NA 11.27 0.88 NA 17.87 090 

26474 .... .......... A Fusion of finger tendons .................................... 5.31 NA 11.42 0.76 NA 17.49 090 

26476 .... .......... A Tendon lengthening ............................................ 5.17 NA 10.96 0.79 NA 16.92 090 

26477 .... .......... A Tendon shortening ............................................. 5.14 NA 11.09 0.81 NA 17.04 090 

26478 .... .......... A Lengthening of hand tendon .............................. 5.79 NA 11.87 0.90 NA 18.56 090 

26479 .... .......... A Shortening of hand tendon ................................. 5.73 NA 11.59 0.92 NA 18.24 090 

26480 .... .......... A Transplant hand tendon ..................................... 6.68 NA 15.08 1.02 NA 22.78 090 

26483 .... .......... A Transplant/graft hand tendon ............................. 8.28 NA 15.54 1.26 NA 25.08 090 

26485 .... .......... A Transplant palm tendon ..................................... 7.69 NA 15.40 1.15 NA 24.24 090 

26489 .... .......... A Transplant/graft palm tendon ............................. 9.54 NA 12.09 1.26 NA 22.89 090 

26490 .... .......... A Revise thumb tendon ......................................... 8.40 NA 12.86 1.21 NA 22.47 090 

26492 .... .......... A Tendon transfer with graft .................................. 9.61 NA 13.64 1.40 NA 24.65 090 

70355 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

26494 .... .......... A Hand tendon/muscle transfer ............................. 8.46 NA 13.01 1.28 NA 22.75 090 

26496 .... .......... A Revise thumb tendon ......................................... 9.58 NA 13.27 1.45 NA 24.30 090 

26497 .... .......... A Finger tendon transfer ........................................ 9.56 NA 13.61 1.41 NA 24.58 090 

26498 .... .......... A Finger tendon transfer ........................................ 13.98 NA 16.21 2.10 NA 32.29 090 

26499 .... .......... A Revision of finger ............................................... 8.97 NA 13.08 1.35 NA 23.40 090 

26500 .... .......... A Hand tendon reconstruction ............................... 5.95 NA 11.47 0.90 NA 18.32 090 

26502 .... .......... A Hand tendon reconstruction ............................... 7.13 NA 12.05 1.13 NA 20.31 090 

26504 .... .......... A Hand tendon reconstruction ............................... 7.46 NA 12.62 1.24 NA 21.32 090 

26508 .... .......... A Release thumb contracture ................................ 6.00 NA 11.71 0.98 NA 18.69 090 

26510 .... .......... A Thumb tendon transfer ....................................... 5.42 NA 11.37 0.79 NA 17.58 090 

26516 .... .......... A Fusion of knuckle joint ....................................... 7.14 NA 12.27 1.10 NA 20.51 090 

26517 .... .......... A Fusion of knuckle joints ...................................... 8.82 NA 13.54 1.41 NA 23.77 090 

26518 .... .......... A Fusion of knuckle joints ...................................... 9.01 NA 13.43 1.35 NA 23.79 090 

26520 .... .......... A Release knuckle contracture .............................. 5.29 NA 13.93 0.80 NA 20.02 090 

26525 .... .......... A Release finger contracture ................................. 5.32 NA 14.01 0.81 NA 20.14 090 

26530 .... .......... A Revise knuckle joint ........................................... 6.68 NA 6.16 1.04 NA 13.88 090 

26531 .... .......... A Revise knuckle with implant ............................... 7.90 NA 7.14 1.17 NA 16.21 090 

26535 .... .......... A Revise finger joint ............................................... 5.23 NA 3.75 0.71 NA 9.69 090 

26536 .... .......... A Revise/implant finger joint .................................. 6.36 NA 9.68 0.96 NA 17.00 090 

26540 .... .......... A Repair hand joint ................................................ 6.42 NA 11.90 0.99 NA 19.31 090 

26541 .... .......... A Repair hand joint with graft ................................ 8.61 NA 13.43 1.28 NA 23.32 090 

26542 .... .......... A Repair hand joint with graft ................................ 6.77 NA 12.06 1.02 NA 19.85 090 

26545 .... .......... A Reconstruct finger joint ...................................... 6.91 NA 12.17 1.05 NA 20.13 090 

26546 .... .......... A Repair nonunion hand ........................................ 8.91 NA 15.07 1.44 NA 25.42 090 

26548 .... .......... A Reconstruct finger joint ...................................... 8.02 NA 12.89 1.20 NA 22.11 090 

26550 .... .......... A Construct thumb replacement ............................ 21.21 NA 17.63 2.45 NA 41.29 090 

26551 .... .......... A Great toe-hand transfer ...................................... 46.51 NA 32.53 7.96 NA 87.00 090 

26553 .... .......... A Single transfer, toe-hand .................................... 46.20 NA 22.75 2.41 NA 71.36 090 

26554 .... .......... A Double transfer, toe-hand .................................. 54.87 NA 37.64 9.41 NA 101.92 090 

26555 .... .......... A Positional change of finger ................................. 16.61 NA 18.23 2.48 NA 37.32 090 

26556 .... .......... A Toe joint transfer ................................................ 47.19 NA 33.42 2.57 NA 83.18 090 

26560 .... .......... A Repair of web finger ........................................... 5.37 NA 9.83 0.85 NA 16.05 090 

26561 .... .......... A Repair of web finger ........................................... 10.90 NA 12.38 1.45 NA 24.73 090 

26562 .... .......... A Repair of web finger ........................................... 14.98 NA 17.19 2.23 NA 34.40 090 

26565 .... .......... A Correct metacarpal flaw ..................................... 6.73 NA 12.04 1.00 NA 19.77 090 

26567 .... .......... A Correct finger deformity ...................................... 6.81 NA 11.98 1.04 NA 19.83 090 

26568 .... .......... A Lengthen metacarpal/finger ................................ 9.07 NA 15.47 1.49 NA 26.03 090 

26580 .... .......... A Repair hand deformity ........................................ 18.15 NA 13.68 2.28 NA 34.11 090 

26587 .... .......... A Reconstruct extra finger ..................................... 14.03 NA 9.24 1.53 NA 24.80 090 

26590 .... .......... A Repair finger deformity ....................................... 17.93 NA 13.98 2.77 NA 34.68 090 

26591 .... .......... A Repair muscles of hand ..................................... 3.25 NA 9.65 0.48 NA 13.38 090 

26593 .... .......... A Release muscles of hand ................................... 5.30 NA 11.16 0.78 NA 17.24 090 

26596 .... .......... A Excision constricting tissue ................................ 8.94 NA 8.85 1.43 NA 19.22 090 

26600 .... .......... A Treat metacarpal fracture ................................... 1.96 3.62 2.66 0.30 5.88 4.92 090 

26605 .... .......... A Treat metacarpal fracture ................................... 2.85 4.57 3.66 0.49 7.91 7.00 090 

26607 .... .......... A Treat metacarpal fracture ................................... 5.35 NA 6.29 0.87 NA 12.51 090 

26608 .... .......... A Treat metacarpal fracture ................................... 5.35 NA 6.27 0.88 NA 12.50 090 

26615 .... .......... A Treat metacarpal fracture ................................... 5.32 NA 5.32 0.86 NA 11.50 090 

26641 .... .......... A Treat thumb dislocation ...................................... 3.93 4.58 3.54 0.39 8.90 7.86 090 

26645 .... .......... A Treat thumb fracture ........................................... 4.40 5.18 4.20 0.67 10.25 9.27 090 

26650 .... .......... A Treat thumb fracture ........................................... 5.71 NA 6.71 0.94 NA 13.36 090 

26665 .... .......... A Treat thumb fracture ........................................... 7.59 NA 6.63 0.90 NA 15.12 090 

26670 .... .......... A Treat hand dislocation ........................................ 3.68 4.27 2.95 0.39 8.34 7.02 090 

26675 .... .......... A Treat hand dislocation ........................................ 4.63 5.49 4.48 0.77 10.89 9.88 090 

26676 .... .......... A Pin hand dislocation ........................................... 5.51 NA 6.71 0.91 NA 13.13 090 

26685 .... .......... A Treat hand dislocation ........................................ 6.97 NA 6.16 1.09 NA 14.22 090 

26686 .... .......... A Treat hand dislocation ........................................ 7.93 NA 6.92 1.24 NA 16.09 090 

26700 .... .......... A Treat knuckle dislocation .................................... 3.68 3.77 2.87 0.35 7.80 6.90 090 

26705 .... .......... A Treat knuckle dislocation .................................... 4.18 5.35 4.31 0.66 10.19 9.15 090 

26706 .... .......... A Pin knuckle dislocation ....................................... 5.11 NA 5.10 0.81 NA 11.02 090 

26715 .... .......... A Treat knuckle dislocation .................................... 5.73 NA 5.53 0.91 NA 12.17 090 

26720 .... .......... A Treat finger fracture, each .................................. 1.66 2.79 2.06 0.24 4.69 3.96 090 

26725 .... .......... A Treat finger fracture, each .................................. 3.33 4.78 3.51 0.53 8.64 7.37 090 

26727 .... .......... A Treat finger fracture, each .................................. 5.22 NA 6.25 0.84 NA 12.31 090 

26735 .... .......... A Treat finger fracture, each .................................. 5.97 NA 5.57 0.95 NA 12.49 090 

26740 .... .......... A Treat finger fracture, each .................................. 1.94 3.14 2.71 0.31 5.39 4.96 090 

26742 .... .......... A Treat finger fracture, each .................................. 3.84 5.00 3.89 0.58 9.42 8.31 090 

26746 .... .......... A Treat finger fracture, each .................................. 5.80 NA 5.58 0.91 NA 12.29 090 

26750 .... .......... A Treat finger fracture, each .................................. 1.70 2.49 2.02 0.22 4.41 3.94 090 

26755 .... .......... A Treat finger fracture, each .................................. 3.10 4.43 3.01 0.42 7.95 6.53 090 

26756 .... .......... A Pin finger fracture, each ..................................... 4.38 NA 5.74 0.71 NA 10.83 090 

26765 .... .......... A Treat finger fracture, each .................................. 4.16 NA 4.40 0.66 NA 9.22 090 

26770 .... .......... A Treat finger dislocation ....................................... 3.02 3.44 2.42 0.27 6.73 5.71 090 

26775 .... .......... A Treat finger dislocation ....................................... 3.70 5.21 3.82 0.54 9.45 8.06 090 

26776 .... .......... A Pin finger dislocation .......................................... 4.79 NA 6.02 0.77 NA 11.58 090 

70356 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

26785 .... .......... A Treat finger dislocation ....................................... 4.20 NA 4.54 0.68 NA 9.42 090 

26820 .... .......... A Thumb fusion with graft ...................................... 8.25 NA 13.29 1.30 NA 22.84 090 

26841 .... .......... A Fusion of thumb ................................................. 7.12 NA 13.27 1.18 NA 21.57 090 

26842 .... .......... A Thumb fusion with graft ...................................... 8.23 NA 13.41 1.32 NA 22.96 090 

26843 .... .......... A Fusion of hand joint ............................................ 7.60 NA 12.39 1.15 NA 21.14 090 

26844 .... .......... A Fusion/graft of hand joint ................................... 8.72 NA 13.40 1.33 NA 23.45 090 

26850 .... .......... A Fusion of knuckle ............................................... 6.96 NA 12.24 1.06 NA 20.26 090 

26852 .... .......... A Fusion of knuckle with graft ............................... 8.45 NA 12.93 1.22 NA 22.60 090 

26860 .... .......... A Fusion of finger joint ........................................... 4.68 NA 11.22 0.73 NA 16.63 090 

26861 .... .......... A Fusion of finger jnt, add-on ................................ 1.74 NA 0.93 0.27 NA 2.94 ZZZ 

26862 .... .......... A Fusion/graft of finger joint .................................. 7.36 NA 12.38 1.10 NA 20.84 090 

26863 .... .......... A Fuse/graft added joint ........................................ 3.89 NA 2.12 0.56 NA 6.57 ZZZ 

26910 .... .......... A Amputate metacarpal bone ................................ 7.59 NA 11.25 1.16 NA 20.00 090 

26951 .... .......... A Amputation of finger/thumb ................................ 4.58 NA 10.18 0.71 NA 15.47 090 

26952 .... .......... A Amputation of finger/thumb ................................ 6.30 NA 11.69 0.95 NA 18.94 090 

26989 .... .......... C Hand/finger surgery ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

26990 .... .......... A Drainage of pelvis lesion .................................... 7.47 NA 7.23 1.22 NA 15.92 090 

26991 .... .......... A Drainage of pelvis bursa .................................... 6.67 11.19 5.45 1.11 18.97 13.23 090 

26992 .... .......... A Drainage of bone lesion ..................................... 13.00 NA 10.41 2.16 NA 25.57 090 

27000 .... .......... A Incision of hip tendon ......................................... 5.61 NA 5.30 0.98 NA 11.89 090 

27001 .... .......... A Incision of hip tendon ......................................... 6.93 NA 6.11 1.24 NA 14.28 090 

27003 .... .......... A Incision of hip tendon ......................................... 7.33 NA 6.50 1.12 NA 14.95 090 

27005 .... .......... A Incision of hip tendon ......................................... 9.65 NA 7.84 1.72 NA 19.21 090 

27006 .... .......... A Incision of hip tendons ....................................... 9.67 NA 8.00 1.69 NA 19.36 090 

27025 .... .......... A Incision of hip/thigh fascia .................................. 11.14 NA 8.57 1.84 NA 21.55 090 

27030 .... .......... A Drainage of hip joint ........................................... 12.99 NA 9.67 2.26 NA 24.92 090 

27033 .... .......... A Exploration of hip joint ........................................ 13.37 NA 9.95 2.32 NA 25.64 090 

27035 .... .......... A Denervation of hip joint ...................................... 16.66 NA 11.26 2.15 NA 30.07 090 

27036 .... .......... A Excision of hip joint/muscle ................................ 12.86 NA 10.03 2.26 NA 25.15 090 

27040 .... .......... A Biopsy of soft tissues ......................................... 2.87 5.25 2.02 0.27 8.39 5.16 010 

27041 .... .......... A Biopsy of soft tissues ......................................... 9.88 NA 6.66 1.35 NA 17.89 090 

27047 .... .......... A Remove hip/pelvis lesion ................................... 7.44 7.13 4.78 1.03 15.60 13.25 090 

27048 .... .......... A Remove hip/pelvis lesion ................................... 6.24 NA 4.81 0.92 NA 11.97 090 

27049 .... .......... A Remove tumor, hip/pelvis ................................... 13.64 NA 8.42 2.06 NA 24.12 090 

27050 .... .......... A Biopsy of sacroiliac joint ..................................... 4.35 NA 4.43 0.60 NA 9.38 090 

27052 .... .......... A Biopsy of hip joint ............................................... 6.22 NA 5.90 1.08 NA 13.20 090 

27054 .... .......... A Removal of hip joint lining .................................. 8.53 NA 7.36 1.47 NA 17.36 090 

27060 .... .......... A Removal of ischial bursa .................................... 5.42 NA 4.38 0.80 NA 10.60 090 

27062 .... .......... A Remove femur lesion/bursa ............................... 5.36 NA 5.21 0.93 NA 11.50 090 

27065 .... .......... A Removal of hip bone lesion ............................... 5.89 NA 5.46 1.01 NA 12.36 090 

27066 .... .......... A Removal of hip bone lesion ............................... 10.31 NA 8.46 1.79 NA 20.56 090 

27067 .... .......... A Remove/graft hip bone lesion ............................ 13.81 NA 10.69 1.84 NA 26.34 090 

27070 .... .......... A Partial removal of hip bone ................................ 10.70 NA 9.16 1.74 NA 21.60 090 

27071 .... .......... A Partial removal of hip bone ................................ 11.44 NA 10.15 1.92 NA 23.51 090 

27075 .... .......... A Extensive hip surgery ......................................... 34.95 NA 19.26 5.64 NA 59.85 090 

27076 .... .......... A Extensive hip surgery ......................................... 22.09 NA 14.55 3.70 NA 40.34 090 

27077 .... .......... A Extensive hip surgery ......................................... 39.94 NA 22.73 6.12 NA 68.79 090 

27078 .... .......... A Extensive hip surgery ......................................... 13.42 NA 9.97 2.22 NA 25.61 090 

27079 .... .......... A Extensive hip surgery ......................................... 13.73 NA 9.57 1.94 NA 25.24 090 

27080 .... .......... A Removal of tail bone .......................................... 6.38 NA 4.84 0.93 NA 12.15 090 

27086 .... .......... A Remove hip foreign body ................................... 1.87 4.56 1.83 0.25 6.68 3.95 010 

27087 .... .......... A Remove hip foreign body ................................... 8.53 NA 6.68 1.35 NA 16.56 090 

27090 .... .......... A Removal of hip prosthesis .................................. 11.13 NA 8.81 1.94 NA 21.88 090 

27091 .... .......... A Removal of hip prosthesis .................................. 22.11 NA 14.03 3.84 NA 39.98 090 

27093 .... .......... A Injection for hip x-ray .......................................... 1.30 4.47 0.48 0.13 5.90 1.91 000 

27095 .... .......... A Injection for hip x-ray .......................................... 1.50 5.74 0.52 0.14 7.38 2.16 000 

27096 .... .......... A Inject sacroiliac joint ........................................... 1.40 4.36 0.33 0.08 5.84 1.81 000 

27097 .... .......... A Revision of hip tendon ....................................... 8.79 NA 6.43 1.57 NA 16.79 090 

27098 .... .......... A Transfer tendon to pelvis ................................... 8.82 NA 7.04 0.95 NA 16.81 090 

27100 .... .......... A Transfer of abdominal muscle ............................ 11.06 NA 8.69 1.85 NA 21.60 090 

27105 .... .......... A Transfer of spinal muscle ................................... 11.75 NA 9.19 1.72 NA 22.66 090 

27110 .... .......... A Transfer of iliopsoas muscle .............................. 13.24 NA 9.14 2.18 NA 24.56 090 

27111 .... .......... A Transfer of iliopsoas muscle .............................. 12.13 NA 9.16 1.94 NA 23.23 090 

27120 .... .......... A Reconstruction of hip socket .............................. 17.98 NA 11.87 3.08 NA 32.93 090 

27122 .... .......... A Reconstruction of hip socket .............................. 14.96 NA 11.07 2.61 NA 28.64 090 

27125 .... .......... A Partial hip replacement ...................................... 14.67 NA 10.65 2.54 NA 27.86 090 

27130 .... .......... A Total hip arthroplasty .......................................... 20.09 NA 13.34 3.50 NA 36.93 090 

27132 .... .......... A Total hip arthroplasty .......................................... 23.27 NA 15.68 4.04 NA 42.99 090 

27134 .... .......... A Revise hip joint replacement .............................. 28.48 NA 17.84 4.94 NA 51.26 090 

27137 .... .......... A Revise hip joint replacement .............................. 21.14 NA 13.97 3.67 NA 38.78 090 

27138 .... .......... A Revise hip joint replacement .............................. 22.14 NA 14.43 3.84 NA 40.41 090 

27140 .... .......... A Transplant femur ridge ....................................... 12.22 NA 9.44 2.11 NA 23.77 090 

27146 .... .......... A Incision of hip bone ............................................ 17.40 NA 12.17 2.96 NA 32.53 090 

27147 .... .......... A Revision of hip bone .......................................... 20.55 NA 13.29 3.57 NA 37.41 090 

27151 .... .......... A Incision of hip bones .......................................... 22.48 NA 7.97 3.91 NA 34.36 090 

70357 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

27156 .... .......... A Revision of hip bones ......................................... 24.59 NA 16.11 4.21 NA 44.91 090 

27158 .... .......... A Revision of pelvis ............................................... 19.71 NA 11.00 3.16 NA 33.87 090 

27161 .... .......... A Incision of neck of femur .................................... 16.68 NA 12.14 2.94 NA 31.76 090 

27165 .... .......... A Incision/fixation of femur .................................... 17.88 NA 12.95 3.10 NA 33.93 090 

27170 .... .......... A Repair/graft femur head/neck ............................. 16.05 NA 11.33 2.81 NA 30.19 090 

27175 .... .......... A Treat slipped epiphysis ...................................... 8.45 NA 6.69 1.46 NA 16.60 090 

27176 .... .......... A Treat slipped epiphysis ...................................... 12.03 NA 9.04 2.22 NA 23.29 090 

27177 .... .......... A Treat slipped epiphysis ...................................... 15.06 NA 10.92 2.61 NA 28.59 090 

27178 .... .......... A Treat slipped epiphysis ...................................... 11.97 NA 8.44 2.08 NA 22.49 090 

27179 .... .......... A Revise head/neck of femur ................................ 12.96 NA 10.02 2.25 NA 25.23 090 

27181 .... .......... A Treat slipped epiphysis ...................................... 14.66 NA 10.23 1.57 NA 26.46 090 

27185 .... .......... A Revision of femur epiphysis ............................... 9.17 NA 7.54 2.39 NA 19.10 090 

27187 .... .......... A Reinforce hip bones ........................................... 13.52 NA 10.35 2.37 NA 26.24 090 

27193 .... .......... A Treat pelvic ring fracture .................................... 5.55 5.10 5.10 0.96 11.61 11.61 090 

27194 .... .......... A Treat pelvic ring fracture .................................... 9.64 NA 7.67 1.65 NA 18.96 090 

27200 .... .......... A Treat tail bone fracture ....................................... 1.84 2.23 2.16 0.28 4.35 4.28 090 

27202 .... .......... A Treat tail bone fracture ....................................... 7.03 NA 16.91 1.06 NA 25.00 090 

27215 .... .......... A Treat pelvic fracture(s) ....................................... 10.03 NA 7.10 1.97 NA 19.10 090 

27216 .... .......... A Treat pelvic ring fracture .................................... 15.17 NA 9.62 2.63 NA 27.42 090 

27217 .... .......... A Treat pelvic ring fracture .................................... 14.09 NA 10.17 2.41 NA 26.67 090 

27218 .... .......... A Treat pelvic ring fracture .................................... 20.12 NA 11.43 3.48 NA 35.03 090 

27220 .... .......... A Treat hip socket fracture .................................... 6.17 5.74 5.65 1.07 12.98 12.89 090 

27222 .... .......... A Treat hip socket fracture .................................... 12.68 NA 10.00 2.19 NA 24.87 090 

27226 .... .......... A Treat hip wall fracture ........................................ 14.89 NA 7.83 2.48 NA 25.20 090 

27227 .... .......... A Treat hip fracture(s) ............................................ 23.41 NA 15.44 4.05 NA 42.90 090 

27228 .... .......... A Treat hip fracture(s) ............................................ 27.12 NA 17.67 4.66 NA 49.45 090 

27230 .... .......... A Treat thigh fracture ............................................. 5.49 5.53 5.11 0.95 11.97 11.55 090 

27232 .... .......... A Treat thigh fracture ............................................. 10.66 NA 7.19 1.85 NA 19.70 090 

27235 .... .......... A Treat thigh fracture ............................................. 12.14 NA 9.48 2.11 NA 23.73 090 

27236 .... .......... A Treat thigh fracture ............................................. 15.58 NA 11.08 2.71 NA 29.37 090 

27238 .... .......... A Treat thigh fracture ............................................. 5.51 NA 5.15 0.89 NA 11.55 090 

27240 .... .......... A Treat thigh fracture ............................................. 12.48 NA 9.50 2.16 NA 24.14 090 

27244 .... .......... A Treat thigh fracture ............................................. 15.92 NA 11.33 2.77 NA 30.02 090 

27245 .... .......... A Treat thigh fracture ............................................. 20.28 NA 13.78 3.52 NA 37.58 090 

27246 .... .......... A Treat thigh fracture ............................................. 4.70 4.47 4.43 0.81 9.98 9.94 090 

27248 .... .......... A Treat thigh fracture ............................................. 10.43 NA 8.23 1.81 NA 20.47 090 

27250 .... .......... A Treat hip dislocation ........................................... 6.94 NA 4.63 0.62 NA 12.19 090 

27252 .... .......... A Treat hip dislocation ........................................... 10.37 NA 7.45 1.66 NA 19.48 090 

27253 .... .......... A Treat hip dislocation ........................................... 12.90 NA 9.81 2.24 NA 24.95 090 

27254 .... .......... A Treat hip dislocation ........................................... 18.23 NA 12.05 3.17 NA 33.45 090 

27256 .... .......... A Treat hip dislocation ........................................... 4.11 3.53 2.09 0.46 8.10 6.66 010 

27257 .... .......... A Treat hip dislocation ........................................... 5.21 NA 2.82 0.69 NA 8.72 010 

27258 .... .......... A Treat hip dislocation ........................................... 15.41 NA 10.90 2.64 NA 28.95 090 

27259 .... .......... A Treat hip dislocation ........................................... 21.52 NA 14.16 3.74 NA 39.42 090 

27265 .... .......... A Treat hip dislocation ........................................... 5.04 NA 4.80 0.63 NA 10.47 090 

27266 .... .......... A Treat hip dislocation ........................................... 7.48 NA 6.36 1.29 NA 15.13 090 

27275 .... .......... A Manipulation of hip joint ..................................... 2.27 NA 2.11 0.39 NA 4.77 010 

27280 .... .......... A Fusion of sacroiliac joint ..................................... 13.37 NA 10.29 2.53 NA 26.19 090 

27282 .... .......... A Fusion of pubic bones ........................................ 11.32 NA 8.02 1.86 NA 21.20 090 

27284 .... .......... A Fusion of hip joint ............................................... 23.41 NA 14.80 3.92 NA 42.13 090 

27286 .... .......... A Fusion of hip joint ............................................... 23.41 NA 15.84 3.12 NA 42.37 090 

27290 .... .......... A Amputation of leg at hip ..................................... 23.25 NA 14.10 3.43 NA 40.78 090 

27295 .... .......... A Amputation of leg at hip ..................................... 18.62 NA 11.34 2.95 NA 32.91 090 

27299 .... .......... C Pelvis/hip joint surgery ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

27301 .... .......... A Drain thigh/knee lesion ....................................... 6.48 10.10 5.15 1.04 17.62 12.67 090 

27303 .... .......... A Drainage of bone lesion ..................................... 8.27 NA 7.00 1.43 NA 16.70 090 

27305 .... .......... A Incise thigh tendon & fascia ............................... 5.91 NA 5.20 1.01 NA 12.12 090 

27306 .... .......... A Incision of thigh tendon ...................................... 4.61 NA 4.73 0.85 NA 10.19 090 

27307 .... .......... A Incision of thigh tendons .................................... 5.79 NA 5.40 1.04 NA 12.23 090 

27310 .... .......... A Exploration of knee joint ..................................... 9.26 NA 7.60 1.61 NA 18.47 090 

27315 .... .......... A Partial removal, thigh nerve ............................... 6.96 NA 4.96 1.09 NA 13.01 090 

27320 .... .......... A Partial removal, thigh nerve ............................... 6.29 NA 5.25 1.06 NA 12.60 090 

27323 .... .......... A Biopsy, thigh soft tissues ................................... 2.28 3.52 1.89 0.24 6.04 4.41 010 

27324 .... .......... A Biopsy, thigh soft tissues ................................... 4.89 NA 4.19 0.75 NA 9.83 090 

27327 .... .......... A Removal of thigh lesion ...................................... 4.46 6.01 3.73 0.64 11.11 8.83 090 

27328 .... .......... A Removal of thigh lesion ...................................... 5.56 NA 4.38 0.84 NA 10.78 090 

27329 .... .......... A Remove tumor, thigh/knee ................................. 14.12 NA 9.05 2.14 NA 25.31 090 

27330 .... .......... A Biopsy, knee joint lining ..................................... 4.96 NA 4.58 0.86 NA 10.40 090 

27331 .... .......... A Explore/treat knee joint ...................................... 5.87 NA 5.54 1.02 NA 12.43 090 

27332 .... .......... A Removal of knee cartilage ................................. 8.26 NA 7.14 1.43 NA 16.83 090 

27333 .... .......... A Removal of knee cartilage ................................. 7.29 NA 6.69 1.26 NA 15.24 090 

27334 .... .......... A Remove knee joint lining .................................... 8.69 NA 7.43 1.51 NA 17.63 090 

27335 .... .......... A Remove knee joint lining .................................... 9.99 NA 8.24 1.74 NA 19.97 090 

27340 .... .......... A Removal of kneecap bursa ................................ 4.17 NA 4.57 0.72 NA 9.46 090 

27345 .... .......... A Removal of knee cyst ......................................... 5.91 NA 5.64 1.00 NA 12.55 090 

70358 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

27347 .... .......... A Remove knee cyst .............................................. 5.77 NA 5.44 0.98 NA 12.19 090 

27350 .... .......... A Removal of kneecap .......................................... 8.16 NA 7.26 1.41 NA 16.83 090 

27355 .... .......... A Remove femur lesion ......................................... 7.64 NA 6.79 1.32 NA 15.75 090 

27356 .... .......... A Remove femur lesion/graft ................................. 9.47 NA 7.87 1.65 NA 18.99 090 

27357 .... .......... A Remove femur lesion/graft ................................. 10.51 NA 8.73 1.95 NA 21.19 090 

27358 .... .......... A Remove femur lesion/fixation ............................. 4.73 NA 2.53 0.82 NA 8.08 ZZZ 

27360 .... .......... A Partial removal, leg bone(s) ............................... 10.48 NA 9.58 1.83 NA 21.89 090 

27365 .... .......... A Extensive leg surgery ......................................... 16.25 NA 11.71 2.79 NA 30.75 090 

27370 .... .......... A Injection for knee x-ray ....................................... 0.96 3.73 0.32 0.08 4.77 1.36 000 

27372 .... .......... A Removal of foreign body .................................... 5.06 10.08 4.70 0.84 15.98 10.60 090 

27380 .... .......... A Repair of kneecap tendon .................................. 7.15 NA 7.30 1.24 NA 15.69 090 

27381 .... .......... A Repair/graft kneecap tendon .............................. 10.32 NA 9.12 1.79 NA 21.23 090 

27385 .... .......... A Repair of thigh muscle ....................................... 7.75 NA 7.65 1.36 NA 16.76 090 

27386 .... .......... A Repair/graft of thigh muscle ............................... 10.54 NA 9.54 1.85 NA 21.93 090 

27390 .... .......... A Incision of thigh tendon ...................................... 5.32 NA 5.12 0.92 NA 11.36 090 

27391 .... .......... A Incision of thigh tendons .................................... 7.19 NA 6.58 1.23 NA 15.00 090 

27392 .... .......... A Incision of thigh tendons .................................... 9.19 NA 7.61 1.57 NA 18.37 090 

27393 .... .......... A Lengthening of thigh tendon .............................. 6.38 NA 5.85 1.10 NA 13.33 090 

27394 .... .......... A Lengthening of thigh tendons ............................. 8.49 NA 7.24 1.47 NA 17.20 090 

27395 .... .......... A Lengthening of thigh tendons ............................. 11.71 NA 9.35 2.04 NA 23.10 090 

27396 .... .......... A Transplant of thigh tendon ................................. 7.85 NA 7.02 1.34 NA 16.21 090 

27397 .... .......... A Transplants of thigh tendons .............................. 11.26 NA 9.07 1.82 NA 22.15 090 

27400 .... .......... A Revise thigh muscles/tendons ........................... 9.01 NA 7.27 1.31 NA 17.59 090 

27403 .... .......... A Repair of knee cartilage ..................................... 8.32 NA 7.20 1.44 NA 16.96 090 

27405 .... .......... A Repair of knee ligament ..................................... 8.64 NA 7.51 1.51 NA 17.66 090 

27407 .... .......... A Repair of knee ligament ..................................... 10.26 NA 8.34 1.78 NA 20.38 090 

27409 .... .......... A Repair of knee ligaments ................................... 12.88 NA 9.98 2.24 NA 25.10 090 

27412 .... .......... A Autochondrocyte implant knee ........................... 23.23 NA 14.84 4.35 NA 42.42 090 

27415 .... .......... A Osteochondral knee allograft ............................. 18.49 NA 12.59 4.35 NA 35.43 090 

27418 .... .......... A Repair degenerated kneecap ............................. 10.83 NA 8.93 1.88 NA 21.64 090 

27420 .... .......... A Revision of unstable kneecap ............................ 9.82 NA 8.13 1.71 NA 19.66 090 

27422 .... .......... A Revision of unstable kneecap ............................ 9.77 NA 8.14 1.70 NA 19.61 090 

27424 .... .......... A Revision/removal of kneecap ............................. 9.80 NA 8.11 1.70 NA 19.61 090 

27425 .... .......... A Lat retinacular release open .............................. 5.21 NA 5.54 0.90 NA 11.65 090 

27427 .... .......... A Reconstruction, knee .......................................... 9.35 NA 7.82 1.63 NA 18.80 090 

27428 .... .......... A Reconstruction, knee .......................................... 13.98 NA 11.27 2.42 NA 27.67 090 

27429 .... .......... A Reconstruction, knee .......................................... 15.50 NA 12.45 2.70 NA 30.65 090 

27430 .... .......... A Revision of thigh muscles .................................. 9.66 NA 8.02 1.69 NA 19.37 090 

27435 .... .......... A Incision of knee joint .......................................... 9.48 NA 8.50 1.69 NA 19.67 090 

27437 .... .......... A Revise kneecap .................................................. 8.45 NA 7.26 1.49 NA 17.20 090 

27438 .... .......... A Revise kneecap with implant ............................. 11.21 NA 8.56 1.95 NA 21.72 090 

27440 .... .......... A Revision of knee joint ......................................... 10.41 NA 6.01 1.81 NA 18.23 090 

27441 .... .......... A Revision of knee joint ......................................... 10.80 NA 6.73 1.88 NA 19.41 090 

27442 .... .......... A Revision of knee joint ......................................... 11.87 NA 8.94 2.09 NA 22.90 090 

27443 .... .......... A Revision of knee joint ......................................... 10.91 NA 8.75 1.90 NA 21.56 090 

27445 .... .......... A Revision of knee joint ......................................... 17.65 NA 12.39 3.08 NA 33.12 090 

27446 .... .......... A Revision of knee joint ......................................... 15.82 NA 11.30 2.80 NA 29.92 090 

27447 .... .......... A Total knee arthroplasty ....................................... 21.45 NA 14.64 3.79 NA 39.88 090 

27448 .... .......... A Incision of thigh .................................................. 11.04 NA 8.62 1.94 NA 21.60 090 

27450 .... .......... A Incision of thigh .................................................. 13.96 NA 10.61 2.42 NA 26.99 090 

27454 .... .......... A Realignment of thigh bone ................................. 17.53 NA 12.54 3.12 NA 33.19 090 

27455 .... .......... A Realignment of knee .......................................... 12.80 NA 9.91 2.24 NA 24.95 090 

27457 .... .......... A Realignment of knee .......................................... 13.43 NA 9.95 2.34 NA 25.72 090 

27465 .... .......... A Shortening of thigh bone .................................... 13.85 NA 10.25 2.47 NA 26.57 090 

27466 .... .......... A Lengthening of thigh bone ................................. 16.31 NA 11.86 2.77 NA 30.94 090 

27468 .... .......... A Shorten/lengthen thighs ..................................... 18.94 NA 12.39 3.30 NA 34.63 090 

27470 .... .......... A Repair of thigh .................................................... 16.05 NA 11.82 2.79 NA 30.66 090 

27472 .... .......... A Repair/graft of thigh ............................................ 17.69 NA 12.72 3.07 NA 33.48 090 

27475 .... .......... A Surgery to stop leg growth ................................. 8.63 NA 7.23 1.36 NA 17.22 090 

27477 .... .......... A Surgery to stop leg growth ................................. 9.84 NA 7.75 1.73 NA 19.32 090 

27479 .... .......... A Surgery to stop leg growth ................................. 12.78 NA 9.67 2.78 NA 25.23 090 

27485 .... .......... A Surgery to stop leg growth ................................. 8.83 NA 7.42 1.53 NA 17.78 090 

27486 .... .......... A Revise/replace knee joint ................................... 19.24 NA 13.53 3.36 NA 36.13 090 

27487 .... .......... A Revise/replace knee joint ................................... 25.23 NA 16.60 4.39 NA 46.22 090 

27488 .... .......... A Removal of knee prosthesis ............................... 15.72 NA 11.73 2.74 NA 30.19 090 

27495 .... .......... A Reinforce thigh ................................................... 15.53 NA 11.44 2.71 NA 29.68 090 

27496 .... .......... A Decompression of thigh/knee ............................. 6.10 NA 5.62 0.99 NA 12.71 090 

27497 .... .......... A Decompression of thigh/knee ............................. 7.16 NA 5.45 1.15 NA 13.76 090 

27498 .... .......... A Decompression of thigh/knee ............................. 7.98 NA 5.97 1.24 NA 15.19 090 

27499 .... .......... A Decompression of thigh/knee ............................. 8.99 NA 6.84 1.47 NA 17.30 090 

27500 .... .......... A Treatment of thigh fracture ................................. 5.91 6.14 5.00 1.02 13.07 11.93 090 

27501 .... .......... A Treatment of thigh fracture ................................. 5.91 5.81 5.40 1.03 12.75 12.34 090 

27502 .... .......... A Treatment of thigh fracture ................................. 10.56 NA 8.13 1.78 NA 20.47 090 

27503 .... .......... A Treatment of thigh fracture ................................. 10.56 NA 8.31 1.84 NA 20.71 090 

27506 .... .......... A Treatment of thigh fracture ................................. 17.42 NA 12.82 3.03 NA 33.27 090 

70359 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

27507 .... .......... A Treatment of thigh fracture ................................. 13.97 NA 9.87 2.42 NA 26.26 090 

27508 .... .......... A Treatment of thigh fracture ................................. 5.82 6.48 5.50 0.97 13.27 12.29 090 

27509 .... .......... A Treatment of thigh fracture ................................. 7.70 NA 7.98 1.34 NA 17.02 090 

27510 .... .......... A Treatment of thigh fracture ................................. 9.12 NA 7.35 1.53 NA 18.00 090 

27511 .... .......... A Treatment of thigh fracture ................................. 13.62 NA 11.23 2.37 NA 27.22 090 

27513 .... .......... A Treatment of thigh fracture ................................. 17.89 NA 13.92 3.12 NA 34.93 090 

27514 .... .......... A Treatment of thigh fracture ................................. 17.27 NA 13.39 3.00 NA 33.66 090 

27516 .... .......... A Treat thigh fx growth plate ................................. 5.36 6.37 5.53 0.81 12.54 11.70 090 

27517 .... .......... A Treat thigh fx growth plate ................................. 8.77 NA 7.47 1.22 NA 17.46 090 

27519 .... .......... A Treat thigh fx growth plate ................................. 15.00 NA 11.62 2.55 NA 29.17 090 

27520 .... .......... A Treat kneecap fracture ....................................... 2.86 4.55 3.45 0.47 7.88 6.78 090 

27524 .... .......... A Treat kneecap fracture ....................................... 9.99 NA 8.25 1.74 NA 19.98 090 

27530 .... .......... A Treat knee fracture ............................................. 3.77 5.33 4.43 0.65 9.75 8.85 090 

27532 .... .......... A Treat knee fracture ............................................. 7.29 7.38 6.47 1.26 15.93 15.02 090 

27535 .... .......... A Treat knee fracture ............................................. 11.48 NA 10.14 2.00 NA 23.62 090 

27536 .... .......... A Treat knee fracture ............................................. 15.63 NA 11.64 2.73 NA 30.00 090 

27538 .... .......... A Treat knee fracture(s) ......................................... 4.86 6.15 5.21 0.84 11.85 10.91 090 

27540 .... .......... A Treat knee fracture ............................................. 13.08 NA 9.54 2.27 NA 24.89 090 

27550 .... .......... A Treat knee dislocation ........................................ 5.75 6.03 4.94 0.76 12.54 11.45 090 

27552 .... .......... A Treat knee dislocation ........................................ 7.89 NA 6.97 1.36 NA 16.22 090 

27556 .... .......... A Treat knee dislocation ........................................ 14.39 NA 11.68 2.50 NA 28.57 090 

27557 .... .......... A Treat knee dislocation ........................................ 16.74 NA 13.16 2.97 NA 32.87 090 

27558 .... .......... A Treat knee dislocation ........................................ 17.69 NA 13.08 3.08 NA 33.85 090 

27560 .... .......... A Treat kneecap dislocation .................................. 3.81 4.85 3.19 0.40 9.06 7.40 090 

27562 .... .......... A Treat kneecap dislocation .................................. 5.78 NA 4.78 0.94 NA 11.50 090 

27566 .... .......... A Treat kneecap dislocation .................................. 12.21 NA 9.35 2.12 NA 23.68 090 

27570 .... .......... A Fixation of knee joint .......................................... 1.74 NA 1.78 0.30 NA 3.82 010 

27580 .... .......... A Fusion of knee .................................................... 19.34 NA 14.84 3.37 NA 37.55 090 

27590 .... .......... A Amputate leg at thigh ......................................... 12.01 NA 6.69 1.74 NA 20.44 090 

27591 .... .......... A Amputate leg at thigh ......................................... 12.66 NA 8.67 2.02 NA 23.35 090 

27592 .... .......... A Amputate leg at thigh ......................................... 10.00 NA 6.19 1.45 NA 17.64 090 

27594 .... .......... A Amputation follow-up surgery ............................. 6.91 NA 5.18 1.02 NA 13.11 090 

27596 .... .......... A Amputation follow-up surgery ............................. 10.58 NA 6.83 1.57 NA 18.98 090 

27598 .... .......... A Amputate lower leg at knee ............................... 10.51 NA 7.04 1.65 NA 19.20 090 

27599 .... .......... C Leg surgery procedure ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

27600 .... .......... A Decompression of lower leg ............................... 5.64 NA 4.54 0.86 NA 11.04 090 

27601 .... .......... A Decompression of lower leg ............................... 5.63 NA 4.86 0.80 NA 11.29 090 

27602 .... .......... A Decompression of lower leg ............................... 7.34 NA 5.14 1.10 NA 13.58 090 

27603 .... .......... A Drain lower leg lesion ......................................... 4.93 7.51 4.17 0.74 13.18 9.84 090 

27604 .... .......... A Drain lower leg bursa ......................................... 4.46 6.10 3.97 0.69 11.25 9.12 090 

27605 .... .......... A Incision of achilles tendon .................................. 2.87 7.70 2.33 0.41 10.98 5.61 010 

27606 .... .......... A Incision of achilles tendon .................................. 4.13 NA 3.37 0.69 NA 8.19 010 

27607 .... .......... A Treat lower leg bone lesion ................................ 7.96 NA 6.19 1.31 NA 15.46 090 

27610 .... .......... A Explore/treat ankle joint ...................................... 8.33 NA 7.02 1.40 NA 16.75 090 

27612 .... .......... A Exploration of ankle joint .................................... 7.32 NA 6.11 1.13 NA 14.56 090 

27613 .... .......... A Biopsy lower leg soft tissue ............................... 2.17 3.24 1.81 0.20 5.61 4.18 010 

27614 .... .......... A Biopsy lower leg soft tissue ............................... 5.65 7.15 4.45 0.78 13.58 10.88 090 

27615 .... .......... A Remove tumor, lower leg ................................... 12.54 NA 9.42 1.83 NA 23.79 090 

27618 .... .......... A Remove lower leg lesion .................................... 5.08 6.03 4.00 0.72 11.83 9.80 090 

27619 .... .......... A Remove lower leg lesion .................................... 8.39 9.54 5.97 1.25 19.18 15.61 090 

27620 .... .......... A Explore/treat ankle joint ...................................... 5.97 NA 5.48 0.97 NA 12.42 090 

27625 .... .......... A Remove ankle joint lining ................................... 8.29 NA 6.48 1.28 NA 16.05 090 

27626 .... .......... A Remove ankle joint lining ................................... 8.90 NA 6.94 1.48 NA 17.32 090 

27630 .... .......... A Removal of tendon lesion .................................. 4.79 7.58 4.39 0.74 13.11 9.92 090 

27635 .... .......... A Remove lower leg bone lesion ........................... 7.77 NA 6.76 1.31 NA 15.84 090 

27637 .... .......... A Remove/graft leg bone lesion ............................ 9.84 NA 8.31 1.66 NA 19.81 090 

27638 .... .......... A Remove/graft leg bone lesion ............................ 10.55 NA 8.31 1.84 NA 20.70 090 

27640 .... .......... A Partial removal of tibia ....................................... 11.35 NA 10.34 1.88 NA 23.57 090 

27641 .... .......... A Partial removal of fibula ..................................... 9.23 NA 8.36 1.46 NA 19.05 090 

27645 .... .......... A Extensive lower leg surgery ............................... 14.15 NA 12.08 2.41 NA 28.64 090 

27646 .... .......... A Extensive lower leg surgery ............................... 12.64 NA 11.06 2.05 NA 25.75 090 

27647 .... .......... A Extensive ankle/heel surgery ............................. 12.22 NA 7.63 1.75 NA 21.60 090 

27648 .... .......... A Injection for ankle x-ray ...................................... 0.96 3.53 0.33 0.08 4.57 1.37 000 

27650 .... .......... A Repair achilles tendon ........................................ 9.68 NA 7.53 1.59 NA 18.80 090 

27652 .... .......... A Repair/graft achilles tendon ............................... 10.31 NA 8.05 1.71 NA 20.07 090 

27654 .... .......... A Repair of achilles tendon ................................... 10.00 NA 7.16 1.58 NA 18.74 090 

27656 .... .......... A Repair leg fascia defect ..................................... 4.56 8.55 3.78 0.69 13.80 9.03 090 

27658 .... .......... A Repair of leg tendon, each ................................. 4.97 NA 4.57 0.79 NA 10.33 090 

27659 .... .......... A Repair of leg tendon, each ................................. 6.80 NA 5.66 1.09 NA 13.55 090 

27664 .... .......... A Repair of leg tendon, each ................................. 4.58 NA 4.56 0.76 NA 9.90 090 

27665 .... .......... A Repair of leg tendon, each ................................. 5.39 NA 4.98 0.89 NA 11.26 090 

27675 .... .......... A Repair lower leg tendons ................................... 7.17 NA 5.75 1.11 NA 14.03 090 

27676 .... .......... A Repair lower leg tendons ................................... 8.41 NA 6.77 1.37 NA 16.55 090 

27680 .... .......... A Release of lower leg tendon .............................. 5.73 NA 5.12 0.93 NA 11.78 090 

27681 .... .......... A Release of lower leg tendons ............................ 6.81 NA 5.93 1.15 NA 13.89 090 

70360 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

27685 .... .......... A Revision of lower leg tendon .............................. 6.49 7.31 5.48 0.97 14.77 12.94 090 

27686 .... .......... A Revise lower leg tendons ................................... 7.45 NA 6.51 1.24 NA 15.20 090 

27687 .... .......... A Revision of calf tendon ....................................... 6.23 NA 5.33 1.00 NA 12.56 090 

27690 .... .......... A Revise lower leg tendon ..................................... 8.70 NA 6.37 1.33 NA 16.40 090 

27691 .... .......... A Revise lower leg tendon ..................................... 9.95 NA 7.78 1.64 NA 19.37 090 

27692 .... .......... A Revise additional leg tendon .............................. 1.87 NA 0.93 0.32 NA 3.12 ZZZ 

27695 .... .......... A Repair of ankle ligament .................................... 6.50 NA 5.89 1.05 NA 13.44 090 

27696 .... .......... A Repair of ankle ligaments .................................. 8.26 NA 6.45 1.28 NA 15.99 090 

27698 .... .......... A Repair of ankle ligament .................................... 9.35 NA 6.96 1.47 NA 17.78 090 

27700 .... .......... A Revision of ankle joint ........................................ 9.28 NA 5.70 1.30 NA 16.28 090 

27702 .... .......... A Reconstruct ankle joint ....................................... 13.65 NA 10.49 2.37 NA 26.51 090 

27703 .... .......... A Reconstruction, ankle joint ................................. 15.85 NA 11.26 2.76 NA 29.87 090 

27704 .... .......... A Removal of ankle implant ................................... 7.61 NA 5.61 1.27 NA 14.49 090 

27705 .... .......... A Incision of tibia ................................................... 10.36 NA 8.19 1.80 NA 20.35 090 

27707 .... .......... A Incision of fibula ................................................. 4.36 NA 4.95 0.76 NA 10.07 090 

27709 .... .......... A Incision of tibia & fibula ...................................... 9.94 NA 8.15 1.73 NA 19.82 090 

27712 .... .......... A Realignment of lower leg ................................... 14.23 NA 10.77 2.47 NA 27.47 090 

27715 .... .......... A Revision of lower leg .......................................... 14.37 NA 10.80 2.49 NA 27.66 090 

27720 .... .......... A Repair of tibia ..................................................... 11.77 NA 9.43 2.04 NA 23.24 090 

27722 .... .......... A Repair/graft of tibia ............................................. 11.80 NA 9.16 2.05 NA 23.01 090 

27724 .... .......... A Repair/graft of tibia ............................................. 18.17 NA 12.40 3.16 NA 33.73 090 

27725 .... .......... A Repair of lower leg ............................................. 15.57 NA 11.94 2.71 NA 30.22 090 

27727 .... .......... A Repair of lower leg ............................................. 13.99 NA 10.37 2.43 NA 26.79 090 

27730 .... .......... A Repair of tibia epiphysis ..................................... 7.40 NA 6.44 1.72 NA 15.56 090 

27732 .... .......... A Repair of fibula epiphysis ................................... 5.31 NA 4.94 0.77 NA 11.02 090 

27734 .... .......... A Repair lower leg epiphyses ................................ 8.47 NA 6.30 1.35 NA 16.12 090 

27740 .... .......... A Repair of leg epiphyses ..................................... 9.29 NA 8.01 1.62 NA 18.92 090 

27742 .... .......... A Repair of leg epiphyses ..................................... 10.28 5.58 5.58 1.79 17.65 17.65 090 

27745 .... .......... A Reinforce tibia .................................................... 10.05 NA 8.19 1.75 NA 19.99 090 

27750 .... .......... A Treatment of tibia fracture .................................. 3.19 4.77 3.86 0.55 8.51 7.60 090 

27752 .... .......... A Treatment of tibia fracture .................................. 5.83 6.67 5.69 1.01 13.51 12.53 090 

27756 .... .......... A Treatment of tibia fracture .................................. 6.77 NA 6.48 1.17 NA 14.42 090 

27758 .... .......... A Treatment of tibia fracture .................................. 11.65 NA 9.21 2.03 NA 22.89 090 

27759 .... .......... A Treatment of tibia fracture .................................. 13.74 NA 10.34 2.38 NA 26.46 090 

27760 .... .......... A Treatment of ankle fracture ................................ 3.01 4.69 3.60 0.48 8.18 7.09 090 

27762 .... .......... A Treatment of ankle fracture ................................ 5.24 6.35 5.29 0.85 12.44 11.38 090 

27766 .... .......... A Treatment of ankle fracture ................................ 8.35 NA 7.24 1.44 NA 17.03 090 

27780 .... .......... A Treatment of fibula fracture ................................ 2.65 4.19 3.22 0.41 7.25 6.28 090 

27781 .... .......... A Treatment of fibula fracture ................................ 4.39 5.51 4.65 0.73 10.63 9.77 090 

27784 .... .......... A Treatment of fibula fracture ................................ 7.10 NA 6.49 1.23 NA 14.82 090 

27786 .... .......... A Treatment of ankle fracture ................................ 2.84 4.47 3.34 0.46 7.77 6.64 090 

27788 .... .......... A Treatment of ankle fracture ................................ 4.44 5.66 4.66 0.74 10.84 9.84 090 

27792 .... .......... A Treatment of ankle fracture ................................ 7.65 NA 6.98 1.32 NA 15.95 090 

27808 .... .......... A Treatment of ankle fracture ................................ 2.83 4.81 3.71 0.46 8.10 7.00 090 

27810 .... .......... A Treatment of ankle fracture ................................ 5.12 6.26 5.16 0.82 12.20 11.10 090 

27814 .... .......... A Treatment of ankle fracture ................................ 10.66 NA 8.58 1.85 NA 21.09 090 

27816 .... .......... A Treatment of ankle fracture ................................ 2.89 4.39 3.42 0.43 7.71 6.74 090 

27818 .... .......... A Treatment of ankle fracture ................................ 5.49 6.39 5.18 0.82 12.70 11.49 090 

27822 .... .......... A Treatment of ankle fracture ................................ 10.98 NA 10.68 1.91 NA 23.57 090 

27823 .... .......... A Treatment of ankle fracture ................................ 12.98 NA 11.50 2.25 NA 26.73 090 

27824 .... .......... A Treat lower leg fracture ...................................... 2.89 4.07 3.57 0.45 7.41 6.91 090 

27825 .... .......... A Treat lower leg fracture ...................................... 6.18 6.62 5.40 1.02 13.82 12.60 090 

27826 .... .......... A Treat lower leg fracture ...................................... 8.53 NA 8.85 1.47 NA 18.85 090 

27827 .... .......... A Treat lower leg fracture ...................................... 14.04 NA 12.80 2.43 NA 29.27 090 

27828 .... .......... A Treat lower leg fracture ...................................... 16.21 NA 13.97 2.81 NA 32.99 090 

27829 .... .......... A Treat lower leg joint ............................................ 5.48 NA 6.80 0.95 NA 13.23 090 

27830 .... .......... A Treat lower leg dislocation ................................. 3.78 4.40 3.86 0.54 8.72 8.18 090 

27831 .... .......... A Treat lower leg dislocation ................................. 4.55 NA 4.47 0.73 NA 9.75 090 

27832 .... .......... A Treat lower leg dislocation ................................. 6.48 NA 6.19 1.03 NA 13.70 090 

27840 .... .......... A Treat ankle dislocation ....................................... 4.57 NA 3.77 0.46 NA 8.80 090 

27842 .... .......... A Treat ankle dislocation ....................................... 6.20 NA 5.13 1.00 NA 12.33 090 

27846 .... .......... A Treat ankle dislocation ....................................... 9.78 NA 7.95 1.70 NA 19.43 090 

27848 .... .......... A Treat ankle dislocation ....................................... 11.18 NA 9.74 1.94 NA 22.86 090 

27860 .... .......... A Fixation of ankle joint ......................................... 2.34 NA 1.99 0.39 NA 4.72 010 

27870 .... .......... A Fusion of ankle joint, open ................................. 13.89 NA 10.55 2.36 NA 26.80 090 

27871 .... .......... A Fusion of tibiofibular joint ................................... 9.16 NA 7.60 1.59 NA 18.35 090 

27880 .... .......... A Amputation of lower leg ..................................... 11.83 NA 7.15 1.75 NA 20.73 090 

27881 .... .......... A Amputation of lower leg ..................................... 12.32 NA 8.87 1.98 NA 23.17 090 

27882 .... .......... A Amputation of lower leg ..................................... 8.93 NA 6.50 1.29 NA 16.72 090 

27884 .... .......... A Amputation follow-up surgery ............................. 8.20 NA 5.77 1.22 NA 15.19 090 

27886 .... .......... A Amputation follow-up surgery ............................. 9.31 NA 6.53 1.40 NA 17.24 090 

27888 .... .......... A Amputation of foot at ankle ................................ 9.66 NA 7.52 1.51 NA 18.69 090 

27889 .... .......... A Amputation of foot at ankle ................................ 9.97 NA 6.49 1.46 NA 17.92 090 

27892 .... .......... A Decompression of leg ........................................ 7.38 NA 5.61 1.10 NA 14.09 090 

27893 .... .......... A Decompression of leg ........................................ 7.34 NA 5.48 1.10 NA 13.92 090 

70361 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

27894 .... .......... A Decompression of leg ........................................ 10.47 NA 7.79 1.65 NA 19.91 090 

27899 .... .......... C Leg/ankle surgery procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

28001 .... .......... A Drainage of bursa of foot ................................... 2.73 2.99 1.96 0.33 6.05 5.02 010 

28002 .... .......... A Treatment of foot infection ................................. 4.61 5.00 3.78 0.61 10.22 9.00 010 

28003 .... .......... A Treatment of foot infection ................................. 8.40 6.25 5.24 1.12 15.77 14.76 090 

28005 .... .......... A Treat foot bone lesion ........................................ 8.67 NA 6.06 1.16 NA 15.89 090 

28008 .... .......... A Incision of foot fascia ......................................... 4.44 4.56 3.21 0.57 9.57 8.22 090 

28010 .... .......... A Incision of toe tendon ......................................... 2.84 2.38 2.38 0.36 5.58 5.58 090 

28011 .... .......... A Incision of toe tendons ....................................... 4.13 NA 3.31 0.59 NA 8.03 090 

28020 .... .......... A Exploration of foot joint ...................................... 5.00 6.03 4.14 0.72 11.75 9.86 090 

28022 .... .......... A Exploration of foot joint ...................................... 4.66 5.21 3.86 0.62 10.49 9.14 090 

28024 .... .......... A Exploration of toe joint ....................................... 4.37 5.23 3.93 0.58 10.18 8.88 090 

28030 .... .......... A Removal of foot nerve ........................................ 6.14 NA 3.66 0.74 NA 10.54 090 

28035 .... .......... A Decompression of tibia nerve ............................ 5.08 5.87 4.10 0.70 11.65 9.88 090 

28043 .... .......... A Excision of foot lesion ........................................ 3.53 3.82 3.18 0.46 7.81 7.17 090 

28045 .... .......... A Excision of foot lesion ........................................ 4.71 5.39 3.61 0.63 10.73 8.95 090 

28046 .... .......... A Resection of tumor, foot ..................................... 10.16 8.79 6.49 1.36 20.31 18.01 090 

28050 .... .......... A Biopsy of foot joint lining .................................... 4.24 4.90 3.60 0.60 9.74 8.44 090 

28052 .... .......... A Biopsy of foot joint lining .................................... 3.93 4.92 3.44 0.53 9.38 7.90 090 

28054 .... .......... A Biopsy of toe joint lining ..................................... 3.44 4.73 3.24 0.46 8.63 7.14 090 

28060 .... .......... A Partial removal, foot fascia ................................. 5.22 5.49 3.88 0.70 11.41 9.80 090 

28062 .... .......... A Removal of foot fascia ....................................... 6.51 6.53 4.02 0.83 13.87 11.36 090 

28070 .... .......... A Removal of foot joint lining ................................. 5.09 5.23 3.82 0.73 11.05 9.64 090 

28072 .... .......... A Removal of foot joint lining ................................. 4.57 5.54 4.31 0.68 10.79 9.56 090 

28080 .... .......... A Removal of foot lesion ....................................... 3.57 5.12 3.69 0.47 9.16 7.73 090 

28086 .... .......... A Excise foot tendon sheath .................................. 4.77 8.00 4.69 0.76 13.53 10.22 090 

28088 .... .......... A Excise foot tendon sheath .................................. 3.85 5.77 3.90 0.61 10.23 8.36 090 

28090 .... .......... A Removal of foot lesion ....................................... 4.40 5.15 3.46 0.59 10.14 8.45 090 

28092 .... .......... A Removal of toe lesions ....................................... 3.63 5.23 3.53 0.49 9.35 7.65 090 

28100 .... .......... A Removal of ankle/heel lesion ............................. 5.65 7.98 4.70 0.82 14.45 11.17 090 

28102 .... .......... A Remove/graft foot lesion .................................... 7.72 NA 5.96 1.14 NA 14.82 090 

28103 .... .......... A Remove/graft foot lesion .................................... 6.49 NA 4.62 0.91 NA 12.02 090 

28104 .... .......... A Removal of foot lesion ....................................... 5.11 5.50 3.93 0.70 11.31 9.74 090 

28106 .... .......... A Remove/graft foot lesion .................................... 7.15 NA 4.44 0.97 NA 12.56 090 

28107 .... .......... A Remove/graft foot lesion .................................... 5.55 6.54 4.21 0.74 12.83 10.50 090 

28108 .... .......... A Removal of toe lesions ....................................... 4.15 4.60 3.26 0.53 9.28 7.94 090 

28110 .... .......... A Part removal of metatarsal ................................. 4.07 5.23 3.23 0.54 9.84 7.84 090 

28111 .... .......... A Part removal of metatarsal ................................. 5.00 6.29 3.66 0.67 11.96 9.33 090 

28112 .... .......... A Part removal of metatarsal ................................. 4.48 5.82 3.58 0.61 10.91 8.67 090 

28113 .... .......... A Part removal of metatarsal ................................. 4.78 6.07 4.32 0.63 11.48 9.73 090 

28114 .... .......... A Removal of metatarsal heads ............................ 9.78 11.65 8.39 1.42 22.85 19.59 090 

28116 .... .......... A Revision of foot .................................................. 7.74 6.81 5.18 1.03 15.58 13.95 090 

28118 .... .......... A Removal of heel bone ........................................ 5.95 6.26 4.35 0.84 13.05 11.14 090 

28119 .... .......... A Removal of heel spur ......................................... 5.38 5.44 3.73 0.70 11.52 9.81 090 

28120 .... .......... A Part removal of ankle/heel ................................. 5.39 7.30 4.42 0.77 13.46 10.58 090 

28122 .... .......... A Partial removal of foot bone ............................... 7.28 6.85 5.28 0.98 15.11 13.54 090 

28124 .... .......... A Partial removal of toe ......................................... 4.80 5.00 3.66 0.60 10.40 9.06 090 

28126 .... .......... A Partial removal of toe ......................................... 3.51 4.22 3.00 0.45 8.18 6.96 090 

28130 .... .......... A Removal of ankle bone ...................................... 8.10 NA 6.73 1.26 NA 16.09 090 

28140 .... .......... A Removal of metatarsal ....................................... 6.90 7.24 4.77 0.92 15.06 12.59 090 

28150 .... .......... A Removal of toe ................................................... 4.08 4.84 3.29 0.53 9.45 7.90 090 

28153 .... .......... A Partial removal of toe ......................................... 3.65 4.32 2.69 0.47 8.44 6.81 090 

28160 .... .......... A Partial removal of toe ......................................... 3.73 4.57 3.34 0.49 8.79 7.56 090 

28171 .... .......... A Extensive foot surgery ........................................ 9.59 NA 5.44 1.33 NA 16.36 090 

28173 .... .......... A Extensive foot surgery ........................................ 8.79 7.61 5.21 1.12 17.52 15.12 090 

28175 .... .......... A Extensive foot surgery ........................................ 6.04 5.72 3.71 0.73 12.49 10.48 090 

28190 .... .......... A Removal of foot foreign body ............................. 1.96 3.40 1.48 0.22 5.58 3.66 010 

28192 .... .......... A Removal of foot foreign body ............................. 4.63 5.49 3.65 0.61 10.73 8.89 090 

28193 .... .......... A Removal of foot foreign body ............................. 5.72 5.62 3.93 0.73 12.07 10.38 090 

28200 .... .......... A Repair of foot tendon ......................................... 4.59 5.10 3.56 0.61 10.30 8.76 090 

28202 .... .......... A Repair/graft of foot tendon ................................. 6.83 7.23 4.50 0.91 14.97 12.24 090 

28208 .... .......... A Repair of foot tendon ......................................... 4.36 4.82 3.31 0.58 9.76 8.25 090 

28210 .... .......... A Repair/graft of foot tendon ................................. 6.34 6.23 4.03 0.81 13.38 11.18 090 

28220 .... .......... A Release of foot tendon ....................................... 4.52 4.68 3.43 0.57 9.77 8.52 090 

28222 .... .......... A Release of foot tendons ..................................... 5.61 5.25 4.13 0.69 11.55 10.43 090 

28225 .... .......... A Release of foot tendon ....................................... 3.65 4.29 2.91 0.46 8.40 7.02 090 

28226 .... .......... A Release of foot tendons ..................................... 4.52 4.80 3.75 0.58 9.90 8.85 090 

28230 .... .......... A Incision of foot tendon(s) .................................... 4.23 4.68 3.68 0.55 9.46 8.46 090 

28232 .... .......... A Incision of toe tendon ......................................... 3.38 4.53 3.32 0.44 8.35 7.14 090 

28234 .... .......... A Incision of foot tendon ........................................ 3.36 4.68 3.36 0.44 8.48 7.16 090 

28238 .... .......... A Revision of foot tendon ...................................... 7.72 7.26 4.94 1.06 16.04 13.72 090 

28240 .... .......... A Release of big toe .............................................. 4.35 4.64 3.49 0.58 9.57 8.42 090 

28250 .... .......... A Revision of foot fascia ........................................ 5.91 5.64 4.14 0.82 12.37 10.87 090 

28260 .... .......... A Release of midfoot joint ..................................... 7.95 6.34 5.00 1.14 15.43 14.09 090 

28261 .... .......... A Revision of foot tendon ...................................... 11.71 8.63 7.32 1.57 21.91 20.60 090 

70362 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

28262 .... .......... A Revision of foot and ankle ................................. 15.81 13.59 10.94 2.59 31.99 29.34 090 

28264 .... .......... A Release of midfoot joint ..................................... 10.33 7.75 7.30 1.54 19.62 19.17 090 

28270 .... .......... A Release of foot contracture ................................ 4.75 4.90 3.74 0.62 10.27 9.11 090 

28272 .... .......... A Release of toe joint, each .................................. 3.79 4.19 2.86 0.46 8.44 7.11 090 

28280 .... .......... A Fusion of toes ..................................................... 5.18 6.26 4.49 0.73 12.17 10.40 090 

28285 .... .......... A Repair of hammertoe ......................................... 4.58 4.87 3.43 0.59 10.04 8.60 090 

28286 .... .......... A Repair of hammertoe ......................................... 4.55 4.80 3.26 0.57 9.92 8.38 090 

28288 .... .......... A Partial removal of foot bone ............................... 4.73 5.95 4.89 0.65 11.33 10.27 090 

28289 .... .......... A Repair hallux rigidus ........................................... 7.03 8.00 5.78 1.02 16.05 13.83 090 

28290 .... .......... A Correction of bunion ........................................... 5.65 6.27 4.73 0.82 12.74 11.20 090 

28292 .... .......... A Correction of bunion ........................................... 7.03 7.48 5.55 0.91 15.42 13.49 090 

28293 .... .......... A Correction of bunion ........................................... 9.14 10.77 6.12 1.13 21.04 16.39 090 

28294 .... .......... A Correction of bunion ........................................... 8.55 7.45 4.72 1.09 17.09 14.36 090 

28296 .... .......... A Correction of bunion ........................................... 9.17 8.17 5.43 1.19 18.53 15.79 090 

28297 .... .......... A Correction of bunion ........................................... 9.17 8.97 6.27 1.32 19.46 16.76 090 

28298 .... .......... A Correction of bunion ........................................... 7.93 7.23 5.01 1.05 16.21 13.99 090 

28299 .... .......... A Correction of bunion ........................................... 10.56 8.79 6.08 1.37 20.72 18.01 090 

28300 .... .......... A Incision of heel bone .......................................... 9.53 NA 7.05 1.54 NA 18.12 090 

28302 .... .......... A Incision of ankle bone ........................................ 9.54 NA 6.90 1.42 NA 17.86 090 

28304 .... .......... A Incision of midfoot bones ................................... 9.15 7.96 5.75 1.27 18.38 16.17 090 

28305 .... .......... A Incise/graft midfoot bones .................................. 10.48 NA 6.74 1.27 NA 18.49 090 

28306 .... .......... A Incision of metatarsal ......................................... 5.85 6.85 4.18 0.84 13.54 10.87 090 

28307 .... .......... A Incision of metatarsal ......................................... 6.32 11.05 5.30 0.90 18.27 12.52 090 

28308 .... .......... A Incision of metatarsal ......................................... 5.28 5.76 3.69 0.70 11.74 9.67 090 

28309 .... .......... A Incision of metatarsals ....................................... 12.76 NA 7.97 2.04 NA 22.77 090 

28310 .... .......... A Revision of big toe ............................................. 5.42 5.76 3.56 0.70 11.88 9.68 090 

28312 .... .......... A Revision of toe ................................................... 4.54 5.45 3.64 0.63 10.62 8.81 090 

28313 .... .......... A Repair deformity of toe ....................................... 5.00 5.29 4.84 0.73 11.02 10.57 090 

28315 .... .......... A Removal of sesamoid bone ............................... 4.85 4.90 3.34 0.63 10.38 8.82 090 

28320 .... .......... A Repair of foot bones ........................................... 9.17 NA 6.73 1.43 NA 17.33 090 

28322 .... .......... A Repair of metatarsals ......................................... 8.33 9.20 6.35 1.27 18.80 15.95 090 

28340 .... .......... A Resect enlarged toe tissue ................................ 6.97 6.46 4.25 0.84 14.27 12.06 090 

28341 .... .......... A Resect enlarged toe ........................................... 8.40 6.95 4.82 1.01 16.36 14.23 090 

28344 .... .......... A Repair extra toe(s) ............................................. 4.25 5.76 3.64 0.51 10.52 8.40 090 

28345 .... .......... A Repair webbed toe(s) ......................................... 5.91 6.21 4.69 0.80 12.92 11.40 090 

28360 .... .......... A Reconstruct cleft foot ......................................... 13.32 NA 10.52 2.28 NA 26.12 090 

28400 .... .......... A Treatment of heel fracture .................................. 2.16 3.64 3.06 0.35 6.15 5.57 090 

28405 .... .......... A Treatment of heel fracture .................................. 4.56 4.84 4.63 0.73 10.13 9.92 090 

28406 .... .......... A Treatment of heel fracture .................................. 6.30 NA 6.81 1.11 NA 14.22 090 

28415 .... .......... A Treat heel fracture .............................................. 15.95 NA 13.32 2.66 NA 31.93 090 

28420 .... .......... A Treat/graft heel fracture ...................................... 16.62 NA 12.95 2.80 NA 32.37 090 

28430 .... .......... A Treatment of ankle fracture ................................ 2.09 3.40 2.57 0.31 5.80 4.97 090 

28435 .... .......... A Treatment of ankle fracture ................................ 3.39 3.89 3.75 0.55 7.83 7.69 090 

28436 .... .......... A Treatment of ankle fracture ................................ 4.70 NA 5.93 0.81 NA 11.44 090 

28445 .... .......... A Treat ankle fracture ............................................ 15.60 NA 11.06 2.58 NA 29.24 090 

28450 .... .......... A Treat midfoot fracture, each ............................... 1.90 3.12 2.48 0.28 5.30 4.66 090 

28455 .... .......... A Treat midfoot fracture, each ............................... 3.09 3.43 3.43 0.44 6.96 6.96 090 

28456 .... .......... A Treat midfoot fracture ......................................... 2.68 NA 4.16 0.44 NA 7.28 090 

28465 .... .......... A Treat midfoot fracture, each ............................... 7.00 NA 6.33 1.10 NA 14.43 090 

28470 .... .......... A Treat metatarsal fracture .................................... 1.99 3.13 2.45 0.30 5.42 4.74 090 

28475 .... .......... A Treat metatarsal fracture .................................... 2.97 3.34 3.22 0.44 6.75 6.63 090 

28476 .... .......... A Treat metatarsal fracture .................................... 3.37 NA 4.99 0.54 NA 8.90 090 

28485 .... .......... A Treat metatarsal fracture .................................... 5.70 NA 5.46 0.83 NA 11.99 090 

28490 .... .......... A Treat big toe fracture .......................................... 1.09 2.02 1.64 0.14 3.25 2.87 090 

28495 .... .......... A Treat big toe fracture .......................................... 1.58 2.18 2.07 0.20 3.96 3.85 090 

28496 .... .......... A Treat big toe fracture .......................................... 2.33 8.27 3.20 0.36 10.96 5.89 090 

28505 .... .......... A Treat big toe fracture .......................................... 3.80 8.12 3.91 0.56 12.48 8.27 090 

28510 .... .......... A Treatment of toe fracture ................................... 1.09 1.53 1.53 0.14 2.76 2.76 090 

28515 .... .......... A Treatment of toe fracture ................................... 1.46 1.90 1.90 0.18 3.54 3.54 090 

28525 .... .......... A Treat toe fracture ................................................ 3.32 7.53 3.44 0.49 11.34 7.25 090 

28530 .... .......... A Treat sesamoid bone fracture ............................ 1.06 1.44 1.44 0.14 2.64 2.64 090 

28531 .... .......... A Treat sesamoid bone fracture ............................ 2.35 7.28 2.07 0.34 9.97 4.76 090 

28540 .... .......... A Treat foot dislocation .......................................... 2.04 2.41 2.41 0.26 4.71 4.71 090 

28545 .... .......... A Treat foot dislocation .......................................... 2.45 2.35 2.35 0.37 5.17 5.17 090 

28546 .... .......... A Treat foot dislocation .......................................... 3.20 6.93 4.39 0.52 10.65 8.11 090 

28555 .... .......... A Repair foot dislocation ........................................ 6.29 9.93 5.69 1.04 17.26 13.02 090 

28570 .... .......... A Treat foot dislocation .......................................... 1.66 2.43 2.34 0.23 4.32 4.23 090 

28575 .... .......... A Treat foot dislocation .......................................... 3.31 3.73 3.73 0.56 7.60 7.60 090 

28576 .... .......... A Treat foot dislocation .......................................... 4.16 NA 4.18 0.69 NA 9.03 090 

28585 .... .......... A Repair foot dislocation ........................................ 7.98 7.34 5.85 1.25 16.57 15.08 090 

28600 .... .......... A Treat foot dislocation .......................................... 1.89 2.82 2.69 0.27 4.98 4.85 090 

28605 .... .......... A Treat foot dislocation .......................................... 2.71 3.13 3.13 0.40 6.24 6.24 090 

28606 .... .......... A Treat foot dislocation .......................................... 4.89 NA 4.70 0.82 NA 10.41 090 

28615 .... .......... A Repair foot dislocation ........................................ 7.76 NA 8.06 1.30 NA 17.12 090 

28630 .... .......... A Treat toe dislocation ........................................... 1.70 1.57 1.00 0.20 3.47 2.90 010 

70363 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

28635 .... .......... A Treat toe dislocation ........................................... 1.91 2.03 1.53 0.26 4.20 3.70 010 

28636 .... .......... A Treat toe dislocation ........................................... 2.77 3.88 2.63 0.43 7.08 5.83 010 

28645 .... .......... A Repair toe dislocation ......................................... 4.21 4.96 3.28 0.57 9.74 8.06 090 

28660 .... .......... A Treat toe dislocation ........................................... 1.23 1.26 0.79 0.13 2.62 2.15 010 

28665 .... .......... A Treat toe dislocation ........................................... 1.92 NA 1.43 0.26 NA 3.61 010 

28666 .... .......... A Treat toe dislocation ........................................... 2.66 5.90 2.59 0.43 8.99 5.68 010 

28675 .... .......... A Repair of toe dislocation .................................... 2.92 7.16 3.36 0.45 10.53 6.73 090 

28705 .... .......... A Fusion of foot bones .......................................... 18.77 NA 12.47 3.08 NA 34.32 090 

28715 .... .......... A Fusion of foot bones .......................................... 13.08 NA 9.78 2.16 NA 25.02 090 

28725 .... .......... A Fusion of foot bones .......................................... 11.59 NA 8.26 1.86 NA 21.71 090 

28730 .... .......... A Fusion of foot bones .......................................... 10.74 NA 8.50 1.70 NA 20.94 090 

28735 .... .......... A Fusion of foot bones .......................................... 10.83 NA 7.84 1.68 NA 20.35 090 

28737 .... .......... A Revision of foot bones ....................................... 9.63 NA 6.82 1.47 NA 17.92 090 

28740 .... .......... A Fusion of foot bones .......................................... 8.01 10.89 6.48 1.22 20.12 15.71 090 

28750 .... .......... A Fusion of big toe joint ......................................... 7.29 11.94 6.68 1.13 20.36 15.10 090 

28755 .... .......... A Fusion of big toe joint ......................................... 4.73 6.12 3.76 0.65 11.50 9.14 090 

28760 .... .......... A Fusion of big toe joint ......................................... 7.74 7.99 5.53 1.05 16.78 14.32 090 

28800 .... .......... A Amputation of midfoot ........................................ 8.20 NA 5.81 1.15 NA 15.16 090 

28805 .... .......... A Amputation thru metatarsal ................................ 8.38 NA 5.66 1.18 NA 15.22 090 

28810 .... .......... A Amputation toe & metatarsal .............................. 6.20 NA 4.48 0.86 NA 11.54 090 

28820 .... .......... A Amputation of toe ............................................... 4.40 7.57 3.79 0.61 12.58 8.80 090 

28825 .... .......... A Partial amputation of toe .................................... 3.58 7.01 3.49 0.50 11.09 7.57 090 

28890 .... .......... A High energy eswt, plantar f ................................ 3.30 5.73 2.09 0.41 9.44 5.80 090 

28899 .... .......... C Foot/toes surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

29000 .... .......... A Application of body cast ..................................... 2.25 2.97 1.74 0.41 5.63 4.40 000 

29010 .... .......... A Application of body cast ..................................... 2.06 3.29 1.78 0.45 5.80 4.29 000 

29015 .... .......... A Application of body cast ..................................... 2.41 2.98 1.60 0.28 5.67 4.29 000 

29020 .... .......... A Application of body cast ..................................... 2.11 3.19 1.41 0.28 5.58 3.80 000 

29025 .... .......... A Application of body cast ..................................... 2.40 3.15 1.86 0.44 5.99 4.70 000 

29035 .... .......... A Application of body cast ..................................... 1.77 3.62 1.58 0.28 5.67 3.63 000 

29040 .... .......... A Application of body cast ..................................... 2.22 2.47 1.51 0.36 5.05 4.09 000 

29044 .... .......... A Application of body cast ..................................... 2.12 3.98 1.91 0.35 6.45 4.38 000 

29046 .... .......... A Application of body cast ..................................... 2.41 3.24 2.10 0.42 6.07 4.93 000 

29049 .... .......... A Application of figure eight ................................... 0.89 1.30 0.53 0.13 2.32 1.55 000 

29055 .... .......... A Application of shoulder cast ............................... 1.78 2.99 1.47 0.30 5.07 3.55 000 

29058 .... .......... A Application of shoulder cast ............................... 1.31 1.56 0.72 0.17 3.04 2.20 000 

29065 .... .......... A Application of long arm cast ............................... 0.87 1.33 0.75 0.15 2.35 1.77 000 

29075 .... .......... A Application of forearm cast ................................ 0.77 1.26 0.68 0.13 2.16 1.58 000 

29085 .... .......... A Apply hand/wrist cast ......................................... 0.87 1.28 0.63 0.14 2.29 1.64 000 

29086 .... .......... A Apply finger cast ................................................. 0.62 0.96 0.49 0.07 1.65 1.18 000 

29105 .... .......... A Apply long arm splint .......................................... 0.87 1.23 0.51 0.12 2.22 1.50 000 

29125 .... .......... A Apply forearm splint ........................................... 0.59 1.02 0.39 0.07 1.68 1.05 000 

29126 .... .......... A Apply forearm splint ........................................... 0.77 1.21 0.46 0.07 2.05 1.30 000 

29130 .... .......... A Application of finger splint .................................. 0.50 0.47 0.17 0.06 1.03 0.73 000 

29131 .... .......... A Application of finger splint .................................. 0.55 0.74 0.24 0.03 1.32 0.82 000 

29200 .... .......... A Strapping of chest .............................................. 0.65 0.72 0.34 0.04 1.41 1.03 000 

29220 .... .......... A Strapping of low back ......................................... 0.64 0.72 0.39 0.04 1.40 1.07 000 

29240 .... .......... A Strapping of shoulder ......................................... 0.71 0.85 0.36 0.06 1.62 1.13 000 

29260 .... .......... A Strapping of elbow or wrist ................................ 0.55 0.74 0.32 0.05 1.34 0.92 000 

29280 .... .......... A Strapping of hand or finger ................................ 0.51 0.80 0.32 0.03 1.34 0.86 000 

29305 .... .......... A Application of hip cast ........................................ 2.03 3.35 1.77 0.35 5.73 4.15 000 

29325 .... .......... A Application of hip casts ...................................... 2.32 3.54 1.96 0.40 6.26 4.68 000 

29345 .... .......... A Application of long leg cast ................................ 1.40 1.77 1.06 0.24 3.41 2.70 000 

29355 .... .......... A Application of long leg cast ................................ 1.53 1.71 1.12 0.26 3.50 2.91 000 

29358 .... .......... A Apply long leg cast brace ................................... 1.43 2.07 1.09 0.25 3.75 2.77 000 

29365 .... .......... A Application of long leg cast ................................ 1.18 1.66 0.95 0.20 3.04 2.33 000 

29405 .... .......... A Apply short leg cast ............................................ 0.86 1.22 0.71 0.14 2.22 1.71 000 

29425 .... .......... A Apply short leg cast ............................................ 1.01 1.23 0.74 0.15 2.39 1.90 000 

29435 .... .......... A Apply short leg cast ............................................ 1.18 1.56 0.93 0.20 2.94 2.31 000 

29440 .... .......... A Addition of walker to cast ................................... 0.57 0.69 0.27 0.08 1.34 0.92 000 

29445 .... .......... A Apply rigid leg cast ............................................. 1.78 1.81 0.96 0.27 3.86 3.01 000 

29450 .... .......... A Application of leg cast ........................................ 2.08 1.47 1.09 0.27 3.82 3.44 000 

29505 .... .......... A Application, long leg splint ................................. 0.69 1.18 0.45 0.08 1.95 1.22 000 

29515 .... .......... A Application lower leg splint ................................. 0.73 0.87 0.46 0.09 1.69 1.28 000 

29520 .... .......... A Strapping of hip .................................................. 0.54 0.85 0.47 0.03 1.42 1.04 000 

29530 .... .......... A Strapping of knee ............................................... 0.57 0.79 0.33 0.05 1.41 0.95 000 

29540 .... .......... A Strapping of ankle and/or ft ................................ 0.51 0.42 0.31 0.06 0.99 0.88 000 

29550 .... .......... A Strapping of toes ................................................ 0.47 0.42 0.28 0.06 0.95 0.81 000 

29580 .... .......... A Application of paste boot .................................... 0.57 0.65 0.35 0.07 1.29 0.99 000 

29590 .... .......... A Application of foot splint ..................................... 0.76 0.51 0.29 0.09 1.36 1.14 000 

29700 .... .......... A Removal/revision of cast .................................... 0.57 0.89 0.28 0.08 1.54 0.93 000 

29705 .... .......... A Removal/revision of cast .................................... 0.76 0.82 0.38 0.13 1.71 1.27 000 

29710 .... .......... A Removal/revision of cast .................................... 1.34 1.53 0.70 0.20 3.07 2.24 000 

29715 .... .......... A Removal/revision of cast .................................... 0.94 1.17 0.40 0.09 2.20 1.43 000 

29720 .... .......... A Repair of body cast ............................................ 0.68 1.16 0.39 0.12 1.96 1.19 000 

70364 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

29730 .... .......... A Windowing of cast .............................................. 0.75 0.81 0.35 0.12 1.68 1.22 000 

29740 .... .......... A Wedging of cast ................................................. 1.12 1.15 0.49 0.18 2.45 1.79 000 

29750 .... .......... A Wedging of clubfoot cast .................................... 1.26 1.06 0.58 0.21 2.53 2.05 000 

29799 .... .......... C Casting/strapping procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

29800 .... .......... A Jaw arthroscopy/surgery .................................... 6.42 NA 6.99 0.99 NA 14.40 090 

29804 .... .......... A Jaw arthroscopy/surgery .................................... 8.13 NA 7.64 1.38 NA 17.15 090 

29805 .... .......... A Shoulder arthroscopy, dx ................................... 5.88 NA 5.69 1.02 NA 12.59 090 

29806 .... .......... A Shoulder arthroscopy/surgery ............................ 14.35 NA 11.19 2.49 NA 28.03 090 

29807 .... .......... A Shoulder arthroscopy/surgery ............................ 13.88 NA 11.02 2.41 NA 27.31 090 

29819 .... .......... A Shoulder arthroscopy/surgery ............................ 7.61 NA 6.81 1.32 NA 15.74 090 

29820 .... .......... A Shoulder arthroscopy/surgery ............................ 7.06 NA 6.24 1.22 NA 14.52 090 

29821 .... .......... A Shoulder arthroscopy/surgery ............................ 7.71 NA 6.82 1.33 NA 15.86 090 

29822 .... .......... A Shoulder arthroscopy/surgery ............................ 7.42 NA 6.71 1.28 NA 15.41 090 

29823 .... .......... A Shoulder arthroscopy/surgery ............................ 8.16 NA 7.24 1.41 NA 16.81 090 

29824 .... .......... A Shoulder arthroscopy/surgery ............................ 8.24 NA 7.55 1.42 NA 17.21 090 

29825 .... .......... A Shoulder arthroscopy/surgery ............................ 7.61 NA 6.78 1.32 NA 15.71 090 

29826 .... .......... A Shoulder arthroscopy/surgery ............................ 8.98 NA 7.55 1.55 NA 18.08 090 

29827 .... .......... A Arthroscop rotator cuff repr ................................ 15.34 NA 11.56 2.66 NA 29.56 090 

29830 .... .......... A Elbow arthroscopy .............................................. 5.75 NA 5.36 0.99 NA 12.10 090 

29834 .... .......... A Elbow arthroscopy/surgery ................................. 6.27 NA 5.85 1.08 NA 13.20 090 

29835 .... .......... A Elbow arthroscopy/surgery ................................. 6.47 NA 5.90 1.13 NA 13.50 090 

29836 .... .......... A Elbow arthroscopy/surgery ................................. 7.54 NA 6.81 1.22 NA 15.57 090 

29837 .... .......... A Elbow arthroscopy/surgery ................................. 6.86 NA 6.15 1.19 NA 14.20 090 

29838 .... .......... A Elbow arthroscopy/surgery ................................. 7.70 NA 6.91 1.30 NA 15.91 090 

29840 .... .......... A Wrist arthroscopy ............................................... 5.53 NA 5.34 0.84 NA 11.71 090 

29843 .... .......... A Wrist arthroscopy/surgery .................................. 6.00 NA 5.64 0.92 NA 12.56 090 

29844 .... .......... A Wrist arthroscopy/surgery .................................. 6.36 NA 5.84 1.04 NA 13.24 090 

29845 .... .......... A Wrist arthroscopy/surgery .................................. 7.51 NA 6.49 0.99 NA 14.99 090 

29846 .... .......... A Wrist arthroscopy/surgery .................................. 6.74 NA 6.07 1.07 NA 13.88 090 

29847 .... .......... A Wrist arthroscopy/surgery .................................. 7.07 NA 6.21 1.08 NA 14.36 090 

29848 .... .......... A Wrist endoscopy/surgery .................................... 5.43 NA 5.62 0.86 NA 11.91 090 

29850 .... .......... A Knee arthroscopy/surgery .................................. 8.18 NA 5.05 1.25 NA 14.48 090 

29851 .... .......... A Knee arthroscopy/surgery .................................. 13.08 NA 9.82 2.34 NA 25.24 090 

29855 .... .......... A Tibial arthroscopy/surgery .................................. 10.60 NA 8.79 1.84 NA 21.23 090 

29856 .... .......... A Tibial arthroscopy/surgery .................................. 14.12 NA 10.70 2.39 NA 27.21 090 

29860 .... .......... A Hip arthroscopy, dx ............................................ 8.04 NA 6.97 1.36 NA 16.37 090 

29861 .... .......... A Hip arthroscopy/surgery ..................................... 9.14 NA 7.36 1.59 NA 18.09 090 

29862 .... .......... A Hip arthroscopy/surgery ..................................... 9.89 NA 8.58 1.62 NA 20.09 090 

29863 .... .......... A Hip arthroscopy/surgery ..................................... 9.89 NA 8.53 1.42 NA 19.84 090 

29866 .... .......... A Autgrft implnt, knee w/scope .............................. 13.88 NA 11.38 2.39 NA 27.65 090 

29867 .... .......... A Allgrft implnt, knee w/scope ............................... 17.00 NA 13.26 2.78 NA 33.04 090 

29868 .... .......... A Meniscal trnspl, knee w/scpe ............................. 23.59 NA 16.84 4.35 NA 44.78 090 

29870 .... .......... A Knee arthroscopy, dx ......................................... 5.06 NA 4.90 0.85 NA 10.81 090 

29871 .... .......... A Knee arthroscopy/drainage ................................ 6.54 NA 5.89 1.14 NA 13.57 090 

29873 .... .......... A Knee arthroscopy/surgery .................................. 5.99 NA 6.59 1.04 NA 13.62 090 

29874 .... .......... A Knee arthroscopy/surgery .................................. 7.04 NA 6.09 1.11 NA 14.24 090 

29875 .... .......... A Knee arthroscopy/surgery .................................. 6.30 NA 5.87 1.09 NA 13.26 090 

29876 .... .......... A Knee arthroscopy/surgery .................................. 7.91 NA 7.04 1.37 NA 16.32 090 

29877 .... .......... A Knee arthroscopy/surgery .................................. 7.34 NA 6.76 1.28 NA 15.38 090 

29879 .... .......... A Knee arthroscopy/surgery .................................. 8.03 NA 7.14 1.39 NA 16.56 090 

29880 .... .......... A Knee arthroscopy/surgery .................................. 8.49 NA 7.38 1.47 NA 17.34 090 

29881 .... .......... A Knee arthroscopy/surgery .................................. 7.75 NA 6.98 1.34 NA 16.07 090 

29882 .... .......... A Knee arthroscopy/surgery .................................. 8.64 NA 7.26 1.50 NA 17.40 090 

29883 .... .......... A Knee arthroscopy/surgery .................................. 11.03 NA 9.09 1.92 NA 22.04 090 

29884 .... .......... A Knee arthroscopy/surgery .................................. 7.32 NA 6.72 1.27 NA 15.31 090 

29885 .... .......... A Knee arthroscopy/surgery .................................. 9.08 NA 7.99 1.58 NA 18.65 090 

29886 .... .......... A Knee arthroscopy/surgery .................................. 7.53 NA 6.87 1.30 NA 15.70 090 

29887 .... .......... A Knee arthroscopy/surgery .................................. 9.03 NA 7.95 1.57 NA 18.55 090 

29888 .... .......... A Knee arthroscopy/surgery .................................. 13.88 NA 10.23 2.41 NA 26.52 090 

29889 .... .......... A Knee arthroscopy/surgery .................................. 15.98 NA 12.47 2.78 NA 31.23 090 

29891 .... .......... A Ankle arthroscopy/surgery .................................. 8.39 NA 7.53 1.39 NA 17.31 090 

29892 .... .......... A Ankle arthroscopy/surgery .................................. 8.99 NA 7.76 1.41 NA 18.16 090 

29893 .... .......... A Scope, plantar fasciotomy .................................. 5.21 6.30 4.00 0.63 12.14 9.84 090 

29894 .... .......... A Ankle arthroscopy/surgery .................................. 7.20 NA 5.49 1.15 NA 13.84 090 

29895 .... .......... A Ankle arthroscopy/surgery .................................. 6.98 NA 5.49 1.11 NA 13.58 090 

29897 .... .......... A Ankle arthroscopy/surgery .................................. 7.17 NA 5.90 1.17 NA 14.24 090 

29898 .... .......... A Ankle arthroscopy/surgery .................................. 8.31 NA 6.21 1.28 NA 15.80 090 

29899 .... .......... A Ankle arthroscopy/surgery .................................. 13.89 NA 10.57 2.40 NA 26.86 090 

29900 .... .......... A Mcp joint arthroscopy, dx ................................... 5.41 NA 5.88 0.94 NA 12.23 090 

29901 .... .......... A Mcp joint arthroscopy, surg ................................ 6.12 NA 6.28 1.06 NA 13.46 090 

29902 .... .......... A Mcp joint arthroscopy, surg ................................ 6.69 NA 6.56 1.12 NA 14.37 090 

29999 .... .......... C Arthroscopy of joint ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

30000 .... .......... A Drainage of nose lesion ..................................... 1.43 4.08 1.39 0.12 5.63 2.94 010 

3000F .... .......... I Blood press </= 140/90 mmhg ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

30020 .... .......... A Drainage of nose lesion ..................................... 1.43 3.28 1.47 0.12 4.83 3.02 010 

70365 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

3002F .... .......... I Blood pressure > 140/90 mmhg ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

30100 .... .......... A Intranasal biopsy ................................................ 0.94 1.98 0.82 0.07 2.99 1.83 000 

30110 .... .......... A Removal of nose polyp(s) .................................. 1.63 3.25 1.57 0.14 5.02 3.34 010 

30115 .... .......... A Removal of nose polyp(s) .................................. 4.34 NA 5.78 0.41 NA 10.53 090 

30117 .... .......... A Removal of intranasal lesion .............................. 3.16 13.18 4.64 0.26 16.60 8.06 090 

30118 .... .......... A Removal of intranasal lesion .............................. 9.68 NA 9.22 0.78 NA 19.68 090 

30120 .... .......... A Revision of nose ................................................. 5.26 6.51 6.02 0.52 12.29 11.80 090 

30124 .... .......... A Removal of nose lesion ...................................... 3.10 NA 3.62 0.25 NA 6.97 090 

30125 .... .......... A Removal of nose lesion ...................................... 7.15 NA 8.34 0.63 NA 16.12 090 

30130 .... .......... A Excise inferior turbinate ...................................... 3.37 NA 5.61 0.31 NA 9.29 090 

30140 .... .......... A Resect inferior turbinate ..................................... 3.42 NA 6.21 0.35 NA 9.98 090 

30150 .... .......... A Partial removal of nose ...................................... 9.13 NA 11.04 0.93 NA 21.10 090 

30160 .... .......... A Removal of nose ................................................ 9.57 NA 10.24 0.88 NA 20.69 090 

30200 .... .......... A Injection treatment of nose ................................. 0.78 1.62 0.74 0.06 2.46 1.58 000 

30210 .... .......... A Nasal sinus therapy ............................................ 1.08 2.11 1.31 0.09 3.28 2.48 010 

30220 .... .......... A Insert nasal septal button ................................... 1.54 4.24 1.53 0.12 5.90 3.19 010 

30300 .... .......... A Remove nasal foreign body ............................... 1.04 4.64 1.92 0.08 5.76 3.04 010 

30310 .... .......... A Remove nasal foreign body ............................... 1.96 NA 3.11 0.16 NA 5.23 010 

30320 .... .......... A Remove nasal foreign body ............................... 4.51 NA 7.06 0.39 NA 11.96 090 

30400 .... .......... R Reconstruction of nose ...................................... 9.82 NA 15.53 1.04 NA 26.39 090 

30410 .... .......... R Reconstruction of nose ...................................... 12.96 NA 18.42 1.42 NA 32.80 090 

30420 .... .......... R Reconstruction of nose ...................................... 15.86 NA 17.96 1.46 NA 35.28 090 

30430 .... .......... R Revision of nose ................................................. 7.20 NA 16.06 0.77 NA 24.03 090 

30435 .... .......... R Revision of nose ................................................. 11.69 NA 19.41 1.22 NA 32.32 090 

30450 .... .......... R Revision of nose ................................................. 18.62 NA 21.95 1.96 NA 42.53 090 

30460 .... .......... A Revision of nose ................................................. 9.95 NA 9.97 1.03 NA 20.95 090 

30462 .... .......... A Revision of nose ................................................. 19.54 NA 20.30 2.53 NA 42.37 090 

30465 .... .......... A Repair nasal stenosis ......................................... 11.62 NA 12.00 1.06 NA 24.68 090 

30520 .... .......... A Repair of nasal septum ...................................... 5.69 NA 6.68 0.46 NA 12.83 090 

30540 .... .......... A Repair nasal defect ............................................ 7.74 NA 9.30 0.67 NA 17.71 090 

30545 .... .......... A Repair nasal defect ............................................ 11.36 NA 11.93 1.70 NA 24.99 090 

30560 .... .......... A Release of nasal adhesions ............................... 1.26 4.78 2.14 0.10 6.14 3.50 010 

30580 .... .......... A Repair upper jaw fistula ..................................... 6.68 7.79 5.81 0.89 15.36 13.38 090 

30600 .... .......... A Repair mouth/nose fistula .................................. 6.01 7.54 5.03 0.70 14.25 11.74 090 

30620 .... .......... A Intranasal reconstruction .................................... 5.96 NA 8.86 0.57 NA 15.39 090 

30630 .... .......... A Repair nasal septum defect ............................... 7.11 NA 7.97 0.61 NA 15.69 090 

30801 .... .......... A Ablate inf turbinate, superf ................................. 1.09 4.14 1.93 0.09 5.32 3.11 010 

30802 .... .......... A Cauterization, inner nose ................................... 2.03 4.62 2.37 0.16 6.81 4.56 010 

30901 .... .......... A Control of nosebleed .......................................... 1.21 1.36 0.32 0.11 2.68 1.64 000 

30903 .... .......... A Control of nosebleed .......................................... 1.54 2.72 0.50 0.13 4.39 2.17 000 

30905 .... .......... A Control of nosebleed .......................................... 1.97 3.52 0.76 0.17 5.66 2.90 000 

30906 .... .......... A Repeat control of nosebleed .............................. 2.45 3.90 1.20 0.20 6.55 3.85 000 

30915 .... .......... A Ligation, nasal sinus artery ................................ 7.19 NA 6.71 0.58 NA 14.48 090 

30920 .... .......... A Ligation, upper jaw artery ................................... 9.82 NA 9.00 0.80 NA 19.62 090 

30930 .... .......... A Ther fx, nasal inf turbinate ................................. 1.26 NA 1.62 0.12 NA 3.00 010 

30999 .... .......... C Nasal surgery procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

31000 .... .......... A Irrigation, maxillary sinus .................................... 1.15 2.85 1.40 0.09 4.09 2.64 010 

31002 .... .......... A Irrigation, sphenoid sinus ................................... 1.91 NA 3.25 0.15 NA 5.31 010 

31020 .... .......... A Exploration, maxillary sinus ................................ 2.94 8.55 5.20 0.29 11.78 8.43 090 

31030 .... .......... A Exploration, maxillary sinus ................................ 5.91 11.53 6.68 0.60 18.04 13.19 090 

31032 .... .......... A Explore sinus, remove polyps ............................ 6.56 NA 7.25 0.59 NA 14.40 090 

31040 .... .......... A Exploration behind upper jaw ............................. 9.41 NA 9.85 0.87 NA 20.13 090 

31050 .... .......... A Exploration, sphenoid sinus ............................... 5.27 NA 6.37 0.49 NA 12.13 090 

31051 .... .......... A Sphenoid sinus surgery ...................................... 7.10 NA 8.26 0.62 NA 15.98 090 

31070 .... .......... A Exploration of frontal sinus ................................. 4.27 NA 5.95 0.38 NA 10.60 090 

31075 .... .......... A Exploration of frontal sinus ................................. 9.15 NA 9.76 0.75 NA 19.66 090 

31080 .... .......... A Removal of frontal sinus .................................... 11.40 NA 13.57 1.23 NA 26.20 090 

31081 .... .......... A Removal of frontal sinus .................................... 12.73 NA 14.04 2.46 NA 29.23 090 

31084 .... .......... A Removal of frontal sinus .................................... 13.49 NA 13.54 1.19 NA 28.22 090 

31085 .... .......... A Removal of frontal sinus .................................... 14.18 NA 14.00 1.72 NA 29.90 090 

31086 .... .......... A Removal of frontal sinus .................................... 12.84 NA 13.32 1.07 NA 27.23 090 

31087 .... .......... A Removal of frontal sinus .................................... 13.08 NA 12.57 1.44 NA 27.09 090 

31090 .... .......... A Exploration of sinuses ........................................ 9.52 NA 12.59 0.94 NA 23.05 090 

31200 .... .......... A Removal of ethmoid sinus .................................. 4.96 NA 9.24 0.29 NA 14.49 090 

31201 .... .......... A Removal of ethmoid sinus .................................. 8.36 NA 9.20 0.82 NA 18.38 090 

31205 .... .......... A Removal of ethmoid sinus .................................. 10.22 NA 11.91 0.67 NA 22.80 090 

31225 .... .......... A Removal of upper jaw ........................................ 19.20 NA 17.87 1.59 NA 38.66 090 

31230 .... .......... A Removal of upper jaw ........................................ 21.91 NA 19.42 1.77 NA 43.10 090 

31231 .... .......... A Nasal endoscopy, dx .......................................... 1.10 3.39 0.88 0.09 4.58 2.07 000 

31233 .... .......... A Nasal/sinus endoscopy, dx ................................ 2.18 4.31 1.48 0.20 6.69 3.86 000 

31235 .... .......... A Nasal/sinus endoscopy, dx ................................ 2.64 4.92 1.72 0.26 7.82 4.62 000 

31237 .... .......... A Nasal/sinus endoscopy, surg ............................. 2.98 5.21 1.89 0.28 8.47 5.15 000 

31238 .... .......... A Nasal/sinus endoscopy, surg ............................. 3.26 5.25 2.10 0.27 8.78 5.63 000 

31239 .... .......... A Nasal/sinus endoscopy, surg ............................. 8.69 NA 8.02 0.62 NA 17.33 010 

31240 .... .......... A Nasal/sinus endoscopy, surg ............................. 2.61 NA 1.74 0.24 NA 4.59 000 

70366 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

31254 .... .......... A Revision of ethmoid sinus .................................. 4.64 NA 2.86 0.45 NA 7.95 000 

31255 .... .......... A Removal of ethmoid sinus .................................. 6.95 NA 4.12 0.73 NA 11.80 000 

31256 .... .......... A Exploration maxillary sinus ................................. 3.29 NA 2.12 0.33 NA 5.74 000 

31267 .... .......... A Endoscopy, maxillary sinus ................................ 5.45 NA 3.30 0.55 NA 9.30 000 

31276 .... .......... A Sinus endoscopy, surgical ................................. 8.84 NA 5.13 0.92 NA 14.89 000 

31287 .... .......... A Nasal/sinus endoscopy, surg ............................. 3.91 NA 2.46 0.39 NA 6.76 000 

31288 .... .......... A Nasal/sinus endoscopy, surg ............................. 4.57 NA 2.82 0.46 NA 7.85 000 

31290 .... .......... A Nasal/sinus endoscopy, surg ............................. 17.21 NA 12.08 1.40 NA 30.69 010 

31291 .... .......... A Nasal/sinus endoscopy, surg ............................. 18.16 NA 12.51 1.68 NA 32.35 010 

31292 .... .......... A Nasal/sinus endoscopy, surg ............................. 14.74 NA 10.64 1.21 NA 26.59 010 

31293 .... .......... A Nasal/sinus endoscopy, surg ............................. 16.19 NA 11.41 1.28 NA 28.88 010 

31294 .... .......... A Nasal/sinus endoscopy, surg ............................. 19.03 NA 12.91 1.53 NA 33.47 010 

31299 .... .......... C Sinus surgery procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

31300 .... .......... A Removal of larynx lesion .................................... 14.27 NA 15.02 1.17 NA 30.46 090 

31320 .... .......... A Diagnostic incision, larynx .................................. 5.25 NA 10.33 0.46 NA 16.04 090 

31360 .... .......... A Removal of larynx .............................................. 17.05 NA 16.77 1.38 NA 35.20 090 

31365 .... .......... A Removal of larynx .............................................. 24.12 NA 20.42 1.97 NA 46.51 090 

31367 .... .......... A Partial removal of larynx .................................... 21.83 NA 21.95 1.78 NA 45.56 090 

31368 .... .......... A Partial removal of larynx .................................... 27.05 NA 25.56 2.20 NA 54.81 090 

31370 .... .......... A Partial removal of larynx .................................... 21.35 NA 22.32 1.74 NA 45.41 090 

31375 .... .......... A Partial removal of larynx .................................... 20.18 NA 20.44 1.63 NA 42.25 090 

31380 .... .......... A Partial removal of larynx .................................... 20.18 NA 20.66 1.70 NA 42.54 090 

31382 .... .......... A Partial removal of larynx .................................... 20.49 NA 21.67 1.67 NA 43.83 090 

31390 .... .......... A Removal of larynx & pharynx ............................. 27.49 NA 24.45 2.23 NA 54.17 090 

31395 .... .......... A Reconstruct larynx & pharynx ............................ 31.04 NA 28.38 2.48 NA 61.90 090 

31400 .... .......... A Revision of larynx ............................................... 10.29 NA 13.81 0.83 NA 24.93 090 

31420 .... .......... A Removal of epiglottis .......................................... 10.20 NA 9.57 0.83 NA 20.60 090 

31500 .... .......... A Insert emergency airway .................................... 2.33 NA 0.55 0.17 NA 3.05 000 

31502 .... .......... A Change of windpipe airway ................................ 0.65 0.31 0.28 0.05 1.01 0.98 000 

31505 .... .......... A Diagnostic laryngoscopy .................................... 0.61 1.45 0.61 0.05 2.11 1.27 000 

31510 .... .......... A Laryngoscopy with biopsy .................................. 1.92 3.31 1.25 0.16 5.39 3.33 000 

31511 .... .......... A Remove foreign body, larynx ............................. 2.16 3.13 1.06 0.19 5.48 3.41 000 

31512 .... .......... A Removal of larynx lesion .................................... 2.07 3.21 1.36 0.18 5.46 3.61 000 

31513 .... .......... A Injection into vocal cord ..................................... 2.10 NA 1.46 0.17 NA 3.73 000 

31515 .... .......... A Laryngoscopy for aspiration ............................... 1.80 3.55 1.06 0.14 5.49 3.00 000 

31520 .... .......... A Dx laryngoscopy, newborn ................................. 2.56 NA 1.56 0.20 NA 4.32 000 

31525 .... .......... A Dx laryngoscopy excl nb .................................... 2.63 3.65 1.66 0.21 6.49 4.50 000 

31526 .... .......... A Dx laryngoscopy w/oper scope .......................... 2.57 NA 1.72 0.21 NA 4.50 000 

31527 .... .......... A Laryngoscopy for treatment ............................... 3.27 NA 1.88 0.26 NA 5.41 000 

31528 .... .......... A Laryngoscopy and dilation ................................. 2.37 NA 1.46 0.19 NA 4.02 000 

31529 .... .......... A Laryngoscopy and dilation ................................. 2.68 NA 1.71 0.22 NA 4.61 000 

31530 .... .......... A Laryngoscopy w/fb removal ............................... 3.38 NA 1.96 0.29 NA 5.63 000 

31531 .... .......... A Laryngoscopy w/fb & op scope .......................... 3.58 NA 2.28 0.29 NA 6.15 000 

31535 .... .......... A Laryngoscopy w/biopsy ...................................... 3.16 NA 2.00 0.26 NA 5.42 000 

31536 .... .......... A Laryngoscopy w/bx & op scope ......................... 3.55 NA 2.26 0.29 NA 6.10 000 

31540 .... .......... A Laryngoscopy w/exc of tumor ............................ 4.12 NA 2.55 0.33 NA 7.00 000 

31541 .... .......... A Larynscop w/tumr exc + scope .......................... 4.52 NA 2.79 0.37 NA 7.68 000 

31545 .... .......... A Remove vc lesion w/scope ................................ 6.30 NA 3.48 0.37 NA 10.15 000 

31546 .... .......... A Remove vc lesion scope/graft ............................ 9.73 NA 4.98 0.78 NA 15.49 000 

31560 .... .......... A Laryngoscop w/arytenoidectom .......................... 5.45 NA 3.16 0.43 NA 9.04 000 

31561 .... .......... A Larynscop, remve cart + scop ............................ 5.99 NA 3.38 0.49 NA 9.86 000 

31570 .... .......... A Laryngoscope w/vc inj ........................................ 3.86 5.69 2.39 0.31 9.86 6.56 000 

31571 .... .......... A Laryngoscop w/vc inj + scope ............................ 4.26 NA 2.61 0.35 NA 7.22 000 

31575 .... .......... A Diagnostic laryngoscopy .................................... 1.10 1.91 0.89 0.09 3.10 2.08 000 

31576 .... .......... A Laryngoscopy with biopsy .................................. 1.97 3.67 1.29 0.14 5.78 3.40 000 

31577 .... .......... A Remove foreign body, larynx ............................. 2.47 3.77 1.53 0.21 6.45 4.21 000 

31578 .... .......... A Removal of larynx lesion .................................... 2.84 4.29 1.52 0.23 7.36 4.59 000 

31579 .... .......... A Diagnostic laryngoscopy .................................... 2.26 3.79 1.48 0.18 6.23 3.92 000 

31580 .... .......... A Revision of larynx ............................................... 12.36 NA 15.96 1.00 NA 29.32 090 

31582 .... .......... A Revision of larynx ............................................... 21.59 NA 25.87 1.75 NA 49.21 090 

31584 .... .......... A Treat larynx fracture ........................................... 19.61 NA 18.20 1.71 NA 39.52 090 

31587 .... .......... A Revision of larynx ............................................... 11.97 NA 9.29 0.97 NA 22.23 090 

31588 .... .......... A Revision of larynx ............................................... 13.09 NA 13.65 1.06 NA 27.80 090 

31590 .... .......... A Reinnervate larynx ............................................. 6.96 NA 15.58 0.84 NA 23.38 090 

31595 .... .......... A Larynx nerve surgery ......................................... 8.33 NA 10.58 0.68 NA 19.59 090 

31599 .... .......... C Larynx surgery procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

31600 .... .......... A Incision of windpipe ............................................ 7.17 NA 3.20 0.80 NA 11.17 000 

31601 .... .......... A Incision of windpipe ............................................ 4.44 NA 2.41 0.40 NA 7.25 000 

31603 .... .......... A Incision of windpipe ............................................ 4.14 NA 1.71 0.44 NA 6.29 000 

31605 .... .......... A Incision of windpipe ............................................ 3.57 NA 1.19 0.40 NA 5.16 000 

31610 .... .......... A Incision of windpipe ............................................ 8.75 NA 8.28 0.79 NA 17.82 090 

31611 .... .......... A Surgery/speech prosthesis ................................. 5.63 NA 7.08 0.46 NA 13.17 090 

31612 .... .......... A Puncture/clear windpipe ..................................... 0.91 1.10 0.35 0.08 2.09 1.34 000 

31613 .... .......... A Repair windpipe opening .................................... 4.58 NA 6.01 0.42 NA 11.01 090 

31614 .... .......... A Repair windpipe opening .................................... 7.11 NA 8.74 0.58 NA 16.43 090 

70367 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

31615 .... .......... A Visualization of windpipe .................................... 2.09 2.60 1.20 0.16 4.85 3.45 000 

31620 .... .......... A Endobronchial us add-on ................................... 1.40 5.66 0.55 0.11 7.17 2.06 ZZZ 

31622 .... .......... A Dx bronchoscope/wash ...................................... 2.78 5.67 1.06 0.18 8.63 4.02 000 

31623 .... .......... A Dx bronchoscope/brush ..................................... 2.88 6.44 1.05 0.13 9.45 4.06 000 

31624 .... .......... A Dx bronchoscope/lavage .................................... 2.88 5.79 1.05 0.13 8.80 4.06 000 

31625 .... .......... A Bronchoscopy w/biopsy(s) ................................. 3.36 5.83 1.21 0.18 9.37 4.75 000 

31628 .... .......... A Bronchoscopy/lung bx, each .............................. 3.80 7.04 1.30 0.18 11.02 5.28 000 

31629 .... .......... A Bronchoscopy/needle bx, each .......................... 4.09 14.29 1.40 0.16 18.54 5.65 000 

31630 .... .......... A Bronchoscopy dilate/fx repr ................................ 3.81 NA 1.72 0.32 NA 5.85 000 

31631 .... .......... A Bronchoscopy, dilate w/stent ............................. 4.36 NA 1.77 0.34 NA 6.47 000 

31632 .... .......... A Bronchoscopy/lung bx, add’l .............................. 1.03 0.81 0.31 0.18 2.02 1.52 ZZZ 

31633 .... .......... A Bronchoscopy/needle bx add’l ........................... 1.32 0.92 0.40 0.16 2.40 1.88 ZZZ 

31635 .... .......... A Bronchoscopy w/fb removal ............................... 3.67 6.13 1.43 0.24 10.04 5.34 000 

31636 .... .......... A Bronchoscopy, bronch stents ............................. 4.30 NA 1.77 0.31 NA 6.38 000 

31637 .... .......... A Bronchoscopy, stent add-on .............................. 1.58 NA 0.56 0.13 NA 2.27 ZZZ 

31638 .... .......... A Bronchoscopy, revise stent ................................ 4.88 NA 1.98 0.22 NA 7.08 000 

31640 .... .......... A Bronchoscopy w/tumor excise ........................... 4.93 NA 2.08 0.46 NA 7.47 000 

31641 .... .......... A Bronchoscopy, treat blockage ............................ 5.02 NA 1.89 0.35 NA 7.26 000 

31643 .... .......... A Diag bronchoscope/catheter .............................. 3.49 NA 1.23 0.20 NA 4.92 000 

31645 .... .......... A Bronchoscopy, clear airways ............................. 3.16 5.15 1.12 0.16 8.47 4.44 000 

31646 .... .......... A Bronchoscopy, reclear airway ............................ 2.72 4.87 1.00 0.14 7.73 3.86 000 

31656 .... .......... A Bronchoscopy, inj for x-ray ................................ 2.17 7.31 0.83 0.15 9.63 3.15 000 

31700 .... .......... A Insertion of airway catheter ................................ 1.34 2.16 0.68 0.08 3.58 2.10 000 

31708 .... .......... A Instill airway contrast dye ................................... 1.41 2.04 0.46 0.07 3.52 1.94 000 

31710 .... .......... A Insertion of airway catheter ................................ 1.30 NA 0.41 0.12 NA 1.83 000 

31715 .... .......... A Injection for bronchus x-ray ................................ 1.11 NA 0.34 0.07 NA 1.52 000 

31717 .... .......... A Bronchial brush biopsy ....................................... 2.12 8.27 0.79 0.14 10.53 3.05 000 

31720 .... .......... A Clearance of airways .......................................... 1.06 0.33 0.33 0.07 1.46 1.46 000 

31725 .... .......... A Clearance of airways .......................................... 1.96 0.65 0.58 0.14 2.75 2.68 000 

31730 .... .......... A Intro, windpipe wire/tube .................................... 2.85 2.20 1.00 0.21 5.26 4.06 000 

31750 .... .......... A Repair of windpipe ............................................. 13.00 NA 17.60 1.05 NA 31.65 090 

31755 .... .......... A Repair of windpipe ............................................. 15.91 NA 24.59 1.29 NA 41.79 090 

31760 .... .......... A Repair of windpipe ............................................. 22.32 NA 10.74 2.94 NA 36.00 090 

31766 .... .......... A Reconstruction of windpipe ................................ 30.38 NA 13.69 4.52 NA 48.59 090 

31770 .... .......... A Repair/graft of bronchus ..................................... 22.48 NA 10.27 2.83 NA 35.58 090 

31775 .... .......... A Reconstruct bronchus ........................................ 23.50 NA 11.82 3.01 NA 38.33 090 

31780 .... .......... A Reconstruct windpipe ......................................... 17.69 NA 11.08 1.65 NA 30.42 090 

31781 .... .......... A Reconstruct windpipe ......................................... 23.49 NA 12.16 2.24 NA 37.89 090 

31785 .... .......... A Remove windpipe lesion .................................... 17.20 NA 10.21 1.59 NA 29.00 090 

31786 .... .......... A Remove windpipe lesion .................................... 23.94 NA 13.13 3.29 NA 40.36 090 

31800 .... .......... A Repair of windpipe injury .................................... 7.42 NA 9.27 0.79 NA 17.48 090 

31805 .... .......... A Repair of windpipe injury .................................... 13.11 NA 7.23 1.82 NA 22.16 090 

31820 .... .......... A Closure of windpipe lesion ................................. 4.48 5.68 3.66 0.38 10.54 8.52 090 

31825 .... .......... A Repair of windpipe defect .................................. 6.80 7.68 5.39 0.53 15.01 12.72 090 

31830 .... .......... A Revise windpipe scar ......................................... 4.49 5.78 3.99 0.44 10.71 8.92 090 

31899 .... .......... C Airways surgical procedure ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

32000 .... .......... A Drainage of chest ............................................... 1.54 3.06 0.48 0.08 4.68 2.10 000 

32002 .... .......... A Treatment of collapsed lung ............................... 2.19 3.22 1.06 0.12 5.53 3.37 000 

32005 .... .......... A Treat lung lining chemically ................................ 2.19 6.47 0.70 0.23 8.89 3.12 000 

32019 .... .......... A Insert pleural catheter ........................................ 4.17 20.02 1.65 0.42 24.61 6.24 000 

32020 .... .......... A Insertion of chest tube ........................................ 3.97 NA 1.35 0.43 NA 5.75 000 

32035 .... .......... A Exploration of chest ............................................ 8.66 NA 5.87 1.26 NA 15.79 090 

32036 .... .......... A Exploration of chest ............................................ 9.67 NA 6.45 1.43 NA 17.55 090 

32095 .... .......... A Biopsy through chest wall .................................. 8.35 NA 5.38 1.22 NA 14.95 090 

32100 .... .......... A Exploration/biopsy of chest ................................ 15.22 NA 7.84 2.23 NA 25.29 090 

32110 .... .......... A Explore/repair chest ........................................... 22.97 NA 10.76 3.21 NA 36.94 090 

32120 .... .......... A Re-exploration of chest ...................................... 11.52 NA 7.09 1.63 NA 20.24 090 

32124 .... .......... A Explore chest free adhesions ............................. 12.70 NA 7.23 1.89 NA 21.82 090 

32140 .... .......... A Removal of lung lesion(s) .................................. 13.91 NA 7.70 1.96 NA 23.57 090 

32141 .... .......... A Remove/treat lung lesions .................................. 13.98 NA 7.57 2.00 NA 23.55 090 

32150 .... .......... A Removal of lung lesion(s) .................................. 14.13 NA 7.62 2.00 NA 23.75 090 

32151 .... .......... A Remove lung foreign body ................................. 14.19 NA 8.02 2.03 NA 24.24 090 

32160 .... .......... A Open chest heart massage ................................ 9.29 NA 5.28 1.31 NA 15.88 090 

32200 .... .......... A Drain, open, lung lesion ..................................... 15.27 NA 8.63 2.13 NA 26.03 090 

32201 .... .......... A Drain, percut, lung lesion ................................... 3.99 20.76 1.30 0.24 24.99 5.53 000 

32215 .... .......... A Treat chest lining ................................................ 11.31 NA 6.92 1.68 NA 19.91 090 

32220 .... .......... A Release of lung .................................................. 23.96 NA 12.99 3.56 NA 40.51 090 

32225 .... .......... A Partial release of lung ........................................ 13.94 NA 7.67 2.06 NA 23.67 090 

32310 .... .......... A Removal of chest lining ...................................... 13.42 NA 7.41 1.99 NA 22.82 090 

32320 .... .......... A Free/remove chest lining .................................... 23.96 NA 12.19 3.51 NA 39.66 090 

32400 .... .......... A Needle biopsy chest lining ................................. 1.76 2.13 0.55 0.10 3.99 2.41 000 

32402 .... .......... A Open biopsy chest lining .................................... 7.55 NA 5.12 1.07 NA 13.74 090 

32405 .... .......... A Biopsy, lung or mediastinum .............................. 1.93 0.67 0.63 0.11 2.71 2.67 000 

32420 .... .......... A Puncture/clear lung ............................................ 2.18 NA 0.68 0.12 NA 2.98 000 

32440 .... .......... A Removal of lung ................................................. 24.96 NA 12.93 3.68 NA 41.57 090 

70368 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

32442 .... .......... A Sleeve pneumonectomy ..................................... 26.20 NA 14.80 3.84 NA 44.84 090 

32445 .... .......... A Removal of lung ................................................. 25.05 NA 14.10 3.71 NA 42.86 090 

32480 .... .......... A Partial removal of lung ....................................... 23.71 NA 12.09 3.49 NA 39.29 090 

32482 .... .......... A Bilobectomy ........................................................ 24.96 NA 12.95 3.66 NA 41.57 090 

32484 .... .......... A Segmentectomy .................................................. 20.66 NA 11.41 3.03 NA 35.10 090 

32486 .... .......... A Sleeve lobectomy ............................................... 23.88 NA 13.28 3.51 NA 40.67 090 

32488 .... .......... A Completion pneumonectomy .............................. 25.67 NA 13.82 3.80 NA 43.29 090 

32491 .... .......... R Lung volume reduction ....................................... 21.22 NA 12.66 2.98 NA 36.86 090 

32500 .... .......... A Partial removal of lung ....................................... 21.97 NA 12.39 3.25 NA 37.61 090 

32501 .... .......... A Repair bronchus add-on ..................................... 4.68 NA 1.54 0.65 NA 6.87 ZZZ 

32503 .... .......... A Resect apical lung tumor ................................... 30.00 NA 15.11 4.37 NA 49.48 090 

32504 .... .......... A Resect apical lung tum/chest ............................. 34.80 NA 16.72 5.07 NA 56.59 090 

32540 .... .......... A Removal of lung lesion ....................................... 14.62 NA 9.66 2.07 NA 26.35 090 

32601 .... .......... A Thoracoscopy, diagnostic ................................... 5.45 NA 2.36 0.80 NA 8.61 000 

32602 .... .......... A Thoracoscopy, diagnostic ................................... 5.95 NA 2.53 0.87 NA 9.35 000 

32603 .... .......... A Thoracoscopy, diagnostic ................................... 7.80 NA 3.04 1.14 NA 11.98 000 

32604 .... .......... A Thoracoscopy, diagnostic ................................... 8.77 NA 3.46 1.25 NA 13.48 000 

32605 .... .......... A Thoracoscopy, diagnostic ................................... 6.92 NA 2.91 1.00 NA 10.83 000 

32606 .... .......... A Thoracoscopy, diagnostic ................................... 8.39 NA 3.34 1.22 NA 12.95 000 

32650 .... .......... A Thoracoscopy, surgical ...................................... 10.73 NA 6.78 1.58 NA 19.09 090 

32651 .... .......... A Thoracoscopy, surgical ...................................... 12.89 NA 7.25 1.86 NA 22.00 090 

32652 .... .......... A Thoracoscopy, surgical ...................................... 18.63 NA 10.17 2.72 NA 31.52 090 

32653 .... .......... A Thoracoscopy, surgical ...................................... 12.85 NA 6.99 1.88 NA 21.72 090 

32654 .... .......... A Thoracoscopy, surgical ...................................... 12.42 NA 7.55 1.63 NA 21.60 090 

32655 .... .......... A Thoracoscopy, surgical ...................................... 13.08 NA 7.26 1.89 NA 22.23 090 

32656 .... .......... A Thoracoscopy, surgical ...................................... 12.89 NA 7.96 1.89 NA 22.74 090 

32657 .... .......... A Thoracoscopy, surgical ...................................... 13.63 NA 7.70 1.99 NA 23.32 090 

32658 .... .......... A Thoracoscopy, surgical ...................................... 11.61 NA 7.37 1.69 NA 20.67 090 

32659 .... .......... A Thoracoscopy, surgical ...................................... 11.57 NA 7.47 1.62 NA 20.66 090 

32660 .... .......... A Thoracoscopy, surgical ...................................... 17.40 NA 9.51 2.08 NA 28.99 090 

32661 .... .......... A Thoracoscopy, surgical ...................................... 13.23 NA 7.81 1.92 NA 22.96 090 

32662 .... .......... A Thoracoscopy, surgical ...................................... 16.42 NA 8.85 2.17 NA 27.44 090 

32663 .... .......... A Thoracoscopy, surgical ...................................... 18.44 NA 10.79 2.72 NA 31.95 090 

32664 .... .......... A Thoracoscopy, surgical ...................................... 14.18 NA 7.65 2.32 NA 24.15 090 

32665 .... .......... A Thoracoscopy, surgical ...................................... 15.52 NA 8.15 2.15 NA 25.82 090 

32800 .... .......... A Repair lung hernia .............................................. 13.67 NA 7.43 1.98 NA 23.08 090 

32810 .... .......... A Close chest after drainage ................................. 13.03 NA 7.54 1.93 NA 22.50 090 

32815 .... .......... A Close bronchial fistula ........................................ 23.12 NA 11.00 3.27 NA 37.39 090 

32820 .... .......... A Reconstruct injured chest ................................... 21.45 NA 12.20 2.52 NA 36.17 090 

32850 .... .......... X Donor pneumonectomy ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

32851 .... .......... A Lung transplant, single ....................................... 38.57 NA 27.74 5.56 NA 71.87 090 

32852 .... .......... A Lung transplant with bypass .............................. 41.74 NA 33.26 6.00 NA 81.00 090 

32853 .... .......... A Lung transplant, double ...................................... 47.74 NA 31.84 7.05 NA 86.63 090 

32854 .... .......... A Lung transplant with bypass .............................. 50.90 NA 34.83 7.20 NA 92.93 090 

32855 .... .......... C Prepare donor lung, single ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

32856 .... .......... C Prepare donor lung, double ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

32900 .... .......... A Removal of rib(s) ................................................ 20.24 NA 9.91 2.93 NA 33.08 090 

32905 .... .......... A Revise & repair chest wall ................................. 20.72 NA 10.16 3.15 NA 34.03 090 

32906 .... .......... A Revise & repair chest wall ................................. 26.73 NA 12.09 3.97 NA 42.79 090 

32940 .... .......... A Revision of lung .................................................. 19.40 NA 9.50 2.88 NA 31.78 090 

32960 .... .......... A Therapeutic pneumothorax ................................ 1.84 1.74 0.56 0.16 3.74 2.56 000 

32997 .... .......... A Total lung lavage ................................................ 5.99 NA 1.92 0.55 NA 8.46 000 

32999 .... .......... C Chest surgery procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

33010 .... .......... A Drainage of heart sac ......................................... 2.24 NA 0.78 0.14 NA 3.16 000 

33011 .... .......... A Repeat drainage of heart sac ............................ 2.24 NA 0.81 0.15 NA 3.20 000 

33015 .... .......... A Incision of heart sac ........................................... 6.79 NA 4.96 0.65 NA 12.40 090 

33020 .... .......... A Incision of heart sac ........................................... 12.59 NA 6.80 1.79 NA 21.18 090 

33025 .... .......... A Incision of heart sac ........................................... 12.07 NA 6.37 1.80 NA 20.24 090 

33030 .... .......... A Partial removal of heart sac ............................... 18.68 NA 9.55 2.83 NA 31.06 090 

33031 .... .......... A Partial removal of heart sac ............................... 21.76 NA 10.06 3.13 NA 34.95 090 

33050 .... .......... A Removal of heart sac lesion .............................. 14.34 NA 7.86 2.14 NA 24.34 090 

33120 .... .......... A Removal of heart lesion ..................................... 24.52 NA 11.61 3.69 NA 39.82 090 

33130 .... .......... A Removal of heart lesion ..................................... 21.36 NA 10.14 3.00 NA 34.50 090 

33140 .... .......... A Heart revascularize (tmr) .................................... 19.97 NA 10.91 2.85 NA 33.73 090 

33141 .... .......... A Heart tmr w/other procedure .............................. 4.83 NA 1.58 0.69 NA 7.10 ZZZ 

33200 .... .......... A Insertion of heart pacemaker ............................. 12.46 NA 6.86 1.70 NA 21.02 090 

33201 .... .......... A Insertion of heart pacemaker ............................. 10.16 NA 6.60 1.36 NA 18.12 090 

33206 .... .......... A Insertion of heart pacemaker ............................. 6.66 NA 4.47 0.52 NA 11.65 090 

33207 .... .......... A Insertion of heart pacemaker ............................. 8.03 NA 4.67 0.59 NA 13.29 090 

33208 .... .......... A Insertion of heart pacemaker ............................. 8.12 NA 4.78 0.56 NA 13.46 090 

33210 .... .......... A Insertion of heart electrode ................................ 3.30 NA 1.25 0.18 NA 4.73 000 

33211 .... .......... A Insertion of heart electrode ................................ 3.39 NA 1.31 0.21 NA 4.91 000 

33212 .... .......... A Insertion of pulse generator ............................... 5.51 NA 3.37 0.43 NA 9.31 090 

33213 .... .......... A Insertion of pulse generator ............................... 6.36 NA 3.73 0.45 NA 10.54 090 

33214 .... .......... A Upgrade of pacemaker system .......................... 7.74 NA 4.90 0.58 NA 13.22 090 

70369 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

33215 .... .......... A Reposition pacing-defib lead .............................. 4.75 NA 3.19 0.37 NA 8.31 090 

33216 .... .......... A Insert lead pace-defib, one ................................ 5.77 NA 4.21 0.36 NA 10.34 090 

33217 .... .......... A Insert lead pace-defib, dual ................................ 5.74 NA 4.24 0.39 NA 10.37 090 

33218 .... .......... A Repair lead pace-defib, one ............................... 5.43 NA 4.31 0.37 NA 10.11 090 

33220 .... .......... A Repair lead pace-defib, dual .............................. 5.51 NA 4.28 0.37 NA 10.16 090 

33222 .... .......... A Revise pocket, pacemaker ................................. 4.95 NA 4.30 0.42 NA 9.67 090 

33223 .... .......... A Revise pocket, pacing-defib ............................... 6.45 NA 4.60 0.45 NA 11.50 090 

33224 .... .......... A Insert pacing lead & connect ............................. 9.04 NA 4.01 0.54 NA 13.59 000 

33225 .... .......... A L ventric pacing lead add-on .............................. 8.33 NA 3.26 0.45 NA 12.04 ZZZ 

33226 .... .......... A Reposition l ventric lead ..................................... 8.68 NA 3.83 0.59 NA 13.10 000 

33233 .... .......... A Removal of pacemaker system .......................... 3.29 NA 3.28 0.22 NA 6.79 090 

33234 .... .......... A Removal of pacemaker system .......................... 7.81 NA 4.92 0.56 NA 13.29 090 

33235 .... .......... A Removal pacemaker electrode .......................... 9.39 NA 6.83 0.73 NA 16.95 090 

33236 .... .......... A Remove electrode/thoracotomy ......................... 12.58 NA 7.45 1.68 NA 21.71 090 

33237 .... .......... A Remove electrode/thoracotomy ......................... 13.69 NA 7.80 1.59 NA 23.08 090 

33238 .... .......... A Remove electrode/thoracotomy ......................... 15.20 NA 8.22 2.02 NA 25.44 090 

33240 .... .......... A Insert pulse generator ........................................ 7.59 NA 4.59 0.41 NA 12.59 090 

33241 .... .......... A Remove pulse generator .................................... 3.24 NA 2.97 0.18 NA 6.39 090 

33243 .... .......... A Remove eltrd/thoracotomy ................................. 22.61 NA 11.49 2.09 NA 36.19 090 

33244 .... .......... A Remove eltrd, transven ...................................... 13.74 NA 8.92 0.99 NA 23.65 090 

33245 .... .......... A Insert epic eltrd pace-defib ................................. 14.28 NA 7.92 2.01 NA 24.21 090 

33246 .... .......... A Insert epic eltrd/generator .................................. 20.68 NA 10.31 2.63 NA 33.62 090 

33249 .... .......... A Eltrd/insert pace-defib ........................................ 14.21 NA 8.38 0.77 NA 23.36 090 

33250 .... .......... A Ablate heart dysrhythm focus ............................ 21.82 NA 11.05 3.18 NA 36.05 090 

33251 .... .......... A Ablate heart dysrhythm focus ............................ 24.84 NA 11.69 3.59 NA 40.12 090 

33253 .... .......... A Reconstruct atria ................................................ 31.01 NA 13.86 4.52 NA 49.39 090 

33261 .... .......... A Ablate heart dysrhythm focus ............................ 24.84 NA 11.80 3.45 NA 40.09 090 

33282 .... .......... A Implant pat-active ht record ............................... 4.16 NA 4.03 0.23 NA 8.42 090 

33284 .... .......... A Remove pat-active ht record .............................. 2.50 NA 3.54 0.14 NA 6.18 090 

33300 .... .......... A Repair of heart wound ........................................ 17.89 NA 9.26 2.65 NA 29.80 090 

33305 .... .......... A Repair of heart wound ........................................ 21.41 NA 10.64 3.12 NA 35.17 090 

33310 .... .......... A Exploratory heart surgery ................................... 18.48 NA 9.61 2.58 NA 30.67 090 

33315 .... .......... A Exploratory heart surgery ................................... 22.34 NA 10.91 3.27 NA 36.52 090 

33320 .... .......... A Repair major blood vessel(s) ............................. 16.76 NA 8.24 2.07 NA 27.07 090 

33321 .... .......... A Repair major vessel ........................................... 20.17 NA 9.81 2.90 NA 32.88 090 

33322 .... .......... A Repair major blood vessel(s) ............................. 20.59 NA 10.39 2.85 NA 33.83 090 

33330 .... .......... A Insert major vessel graft ..................................... 21.40 NA 10.29 2.81 NA 34.50 090 

33332 .... .......... A Insert major vessel graft ..................................... 23.92 NA 10.54 3.02 NA 37.48 090 

33335 .... .......... A Insert major vessel graft ..................................... 29.96 NA 13.37 4.27 NA 47.60 090 

33400 .... .......... A Repair of aortic valve ......................................... 28.46 NA 15.71 4.10 NA 48.27 090 

33401 .... .......... A Valvuloplasty, open ............................................ 23.87 NA 13.54 3.56 NA 40.97 090 

33403 .... .......... A Valvuloplasty, w/cp bypass ................................ 24.85 NA 14.34 3.54 NA 42.73 090 

33404 .... .......... A Prepare heart-aorta conduit ............................... 28.50 NA 14.58 4.32 NA 47.40 090 

33405 .... .......... A Replacement of aortic valve ............................... 34.95 NA 18.34 5.31 NA 58.60 090 

33406 .... .......... A Replacement of aortic valve ............................... 37.44 NA 19.18 5.43 NA 62.05 090 

33410 .... .......... A Replacement of aortic valve ............................... 32.41 NA 16.63 4.68 NA 53.72 090 

33411 .... .......... A Replacement of aortic valve ............................... 36.20 NA 18.79 5.46 NA 60.45 090 

33412 .... .......... A Replacement of aortic valve ............................... 41.94 NA 20.46 6.37 NA 68.77 090 

33413 .... .......... A Replacement of aortic valve ............................... 43.43 NA 20.87 6.51 NA 70.81 090 

33414 .... .......... A Repair of aortic valve ......................................... 30.30 NA 14.17 4.56 NA 49.03 090 

33415 .... .......... A Revision, subvalvular tissue ............................... 27.11 NA 12.05 4.13 NA 43.29 090 

33416 .... .......... A Revise ventricle muscle ..................................... 30.30 NA 13.54 4.56 NA 48.40 090 

33417 .... .......... A Repair of aortic valve ......................................... 28.49 NA 13.65 4.09 NA 46.23 090 

33420 .... .......... A Revision of mitral valve ...................................... 22.67 NA 9.59 1.81 NA 34.07 090 

33422 .... .......... A Revision of mitral valve ...................................... 25.90 NA 13.69 3.93 NA 43.52 090 

33425 .... .......... A Repair of mitral valve ......................................... 26.96 NA 13.09 4.06 NA 44.11 090 

33426 .... .......... A Repair of mitral valve ......................................... 32.95 NA 17.18 5.01 NA 55.14 090 

33427 .... .......... A Repair of mitral valve ......................................... 39.94 NA 19.42 6.07 NA 65.43 090 

33430 .... .......... A Replacement of mitral valve ............................... 33.45 NA 17.34 5.08 NA 55.87 090 

33460 .... .......... A Revision of tricuspid valve ................................. 23.56 NA 11.33 3.44 NA 38.33 090 

33463 .... .......... A Valvuloplasty, tricuspid ....................................... 25.58 NA 12.95 3.86 NA 42.39 090 

33464 .... .......... A Valvuloplasty, tricuspid ....................................... 27.29 NA 13.56 4.14 NA 44.99 090 

33465 .... .......... A Replace tricuspid valve ...................................... 28.75 NA 13.00 4.38 NA 46.13 090 

33468 .... .......... A Revision of tricuspid valve ................................. 30.07 NA 13.69 4.06 NA 47.82 090 

33470 .... .......... A Revision of pulmonary valve .............................. 20.78 NA 10.72 1.03 NA 32.53 090 

33471 .... .......... A Valvotomy, pulmonary valve .............................. 22.22 NA 9.78 3.38 NA 35.38 090 

33472 .... .......... A Revision of pulmonary valve .............................. 22.22 NA 11.89 3.54 NA 37.65 090 

33474 .... .......... A Revision of pulmonary valve .............................. 23.01 NA 10.91 3.21 NA 37.13 090 

33475 .... .......... A Replacement, pulmonary valve .......................... 32.95 NA 15.41 4.92 NA 53.28 090 

33476 .... .......... A Revision of heart chamber ................................. 25.73 NA 11.99 2.41 NA 40.13 090 

33478 .... .......... A Revision of heart chamber ................................. 26.70 NA 13.09 3.88 NA 43.67 090 

33496 .... .......... A Repair, prosth valve clot .................................... 27.21 NA 12.78 4.12 NA 44.11 090 

33500 .... .......... A Repair heart vessel fistula .................................. 25.51 NA 11.49 3.86 NA 40.86 090 

33501 .... .......... A Repair heart vessel fistula .................................. 17.75 NA 8.30 1.90 NA 27.95 090 

33502 .... .......... A Coronary artery correction ................................. 21.01 NA 11.10 2.99 NA 35.10 090 

70370 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

33503 .... .......... A Coronary artery graft .......................................... 21.75 NA 9.76 1.77 NA 33.28 090 

33504 .... .......... A Coronary artery graft .......................................... 24.62 NA 11.84 3.35 NA 39.81 090 

33505 .... .......... A Repair artery w/tunnel ........................................ 26.80 NA 12.94 2.18 NA 41.92 090 

33506 .... .......... A Repair artery, translocation ................................ 35.45 NA 14.60 4.65 NA 54.70 090 

33507 .... .......... A Repair art, intramural ......................................... 30.00 NA 13.68 4.05 NA 47.73 090 

33508 .... .......... A Endoscopic vein harvest .................................... 0.31 NA 0.10 0.04 NA 0.45 ZZZ 

33510 .... .......... A CABG, vein, single ............................................. 28.96 NA 16.38 4.40 NA 49.74 090 

33511 .... .......... A CABG, vein, two ................................................. 29.96 NA 17.12 4.55 NA 51.63 090 

33512 .... .......... A CABG, vein, three .............................................. 31.75 NA 17.65 4.66 NA 54.06 090 

33513 .... .......... A CABG, vein, four ................................................ 31.95 NA 17.83 4.87 NA 54.65 090 

33514 .... .......... A CABG, vein, five ................................................. 32.70 NA 18.10 4.76 NA 55.56 090 

33516 .... .......... A Cabg, vein, six or more ...................................... 34.95 NA 18.85 5.11 NA 58.91 090 

33517 .... .......... A CABG, artery-vein, single ................................... 2.57 NA 0.84 0.39 NA 3.80 ZZZ 

33518 .... .......... A CABG, artery-vein, two ...................................... 4.84 NA 1.58 0.73 NA 7.15 ZZZ 

33519 .... .......... A CABG, artery-vein, three .................................... 7.11 NA 2.33 1.04 NA 10.48 ZZZ 

33521 .... .......... A CABG, artery-vein, four ...................................... 9.39 NA 3.08 1.37 NA 13.84 ZZZ 

33522 .... .......... A CABG, artery-vein, five ...................................... 11.65 NA 3.82 1.77 NA 17.24 ZZZ 

33523 .... .......... A Cabg, art-vein, six or more ................................ 13.93 NA 4.54 2.12 NA 20.59 ZZZ 

33530 .... .......... A Coronary artery, bypass/reop ............................. 5.85 NA 1.92 0.88 NA 8.65 ZZZ 

33533 .... .......... A CABG, arterial, single ......................................... 29.96 NA 16.51 4.55 NA 51.02 090 

33534 .... .......... A CABG, arterial, two ............................................ 32.15 NA 17.76 4.69 NA 54.60 090 

33535 .... .......... A CABG, arterial, three .......................................... 34.45 NA 18.18 5.01 NA 57.64 090 

33536 .... .......... A Cabg, arterial, four or more ................................ 37.44 NA 18.34 5.42 NA 61.20 090 

33542 .... .......... A Removal of heart lesion ..................................... 28.81 NA 13.03 4.37 NA 46.21 090 

33545 .... .......... A Repair of heart damage ..................................... 36.72 NA 15.67 5.19 NA 57.58 090 

33548 .... .......... A Restore/remodel, ventricle ................................. 37.97 NA 19.35 5.51 NA 62.83 090 

33572 .... .......... A Open coronary endarterectomy ......................... 4.44 NA 1.45 0.65 NA 6.54 ZZZ 

33600 .... .......... A Closure of valve ................................................. 29.47 NA 12.55 4.41 NA 46.43 090 

33602 .... .......... A Closure of valve ................................................. 28.50 NA 12.48 3.81 NA 44.79 090 

33606 .... .......... A Anastomosis/artery-aorta ................................... 30.69 NA 13.71 4.40 NA 48.80 090 

33608 .... .......... A Repair anomaly w/conduit .................................. 31.04 NA 14.14 4.73 NA 49.91 090 

33610 .... .......... A Repair by enlargement ....................................... 30.56 NA 13.64 4.55 NA 48.75 090 

33611 .... .......... A Repair double ventricle ...................................... 33.95 NA 14.17 4.36 NA 52.48 090 

33612 .... .......... A Repair double ventricle ...................................... 34.95 NA 15.19 5.28 NA 55.42 090 

33615 .... .......... A Repair, modified fontan ...................................... 33.95 NA 13.18 4.31 NA 51.44 090 

33617 .... .......... A Repair single ventricle ........................................ 36.94 NA 16.04 5.64 NA 58.62 090 

33619 .... .......... A Repair single ventricle ........................................ 44.93 NA 20.86 6.44 NA 72.23 090 

33641 .... .......... A Repair heart septum defect ................................ 21.36 NA 9.60 3.22 NA 34.18 090 

33645 .... .......... A Revision of heart veins ....................................... 24.78 NA 11.80 3.78 NA 40.36 090 

33647 .... .......... A Repair heart septum defects .............................. 28.69 NA 13.81 3.31 NA 45.81 090 

33660 .... .......... A Repair of heart defects ....................................... 29.96 NA 13.52 4.48 NA 47.96 090 

33665 .... .......... A Repair of heart defects ....................................... 28.56 NA 13.87 3.99 NA 46.42 090 

33670 .... .......... A Repair of heart chambers .................................. 34.95 NA 13.21 4.64 NA 52.80 090 

33681 .... .......... A Repair heart septum defect ................................ 30.56 NA 14.72 4.44 NA 49.72 090 

33684 .... .......... A Repair heart septum defect ................................ 29.61 NA 13.66 3.38 NA 46.65 090 

33688 .... .......... A Repair heart septum defect ................................ 30.57 NA 10.50 4.72 NA 45.79 090 

33690 .... .......... A Reinforce pulmonary artery ................................ 19.52 NA 10.19 1.96 NA 31.67 090 

33692 .... .......... A Repair of heart defects ....................................... 30.70 NA 13.96 4.57 NA 49.23 090 

33694 .... .......... A Repair of heart defects ....................................... 33.95 NA 14.26 5.26 NA 53.47 090 

33697 .... .......... A Repair of heart defects ....................................... 35.95 NA 14.91 4.08 NA 54.94 090 

33702 .... .......... A Repair of heart defects ....................................... 26.50 NA 12.60 3.67 NA 42.77 090 

33710 .... .......... A Repair of heart defects ....................................... 29.67 NA 14.00 4.42 NA 48.09 090 

33720 .... .......... A Repair of heart defect ........................................ 26.52 NA 12.32 3.83 NA 42.67 090 

33722 .... .......... A Repair of heart defect ........................................ 28.37 NA 13.89 1.30 NA 43.56 090 

33730 .... .......... A Repair heart-vein defect(s) ................................. 34.20 NA 14.16 5.01 NA 53.37 090 

33732 .... .......... A Repair heart-vein defect ..................................... 28.12 NA 13.42 3.67 NA 45.21 090 

33735 .... .......... A Revision of heart chamber ................................. 21.36 NA 8.98 1.91 NA 32.25 090 

33736 .... .......... A Revision of heart chamber ................................. 23.48 NA 11.88 3.08 NA 38.44 090 

33737 .... .......... A Revision of heart chamber ................................. 21.73 NA 10.96 3.24 NA 35.93 090 

33750 .... .......... A Major vessel shunt ............................................. 21.38 NA 10.24 1.16 NA 32.78 090 

33755 .... .......... A Major vessel shunt ............................................. 21.76 NA 8.83 3.25 NA 33.84 090 

33762 .... .......... A Major vessel shunt ............................................. 21.76 NA 10.18 3.13 NA 35.07 090 

33764 .... .......... A Major vessel shunt & graft ................................. 21.76 NA 10.25 3.00 NA 35.01 090 

33766 .... .......... A Major vessel shunt ............................................. 22.73 NA 11.70 3.69 NA 38.12 090 

33767 .... .......... A Major vessel shunt ............................................. 24.46 NA 11.75 3.81 NA 40.02 090 

33768 .... .......... A Cavopulmonary shunting .................................... 8.00 NA 2.67 1.19 NA 11.86 ZZZ 

33770 .... .......... A Repair great vessels defect ............................... 36.94 NA 14.72 5.72 NA 57.38 090 

33771 .... .......... A Repair great vessels defect ............................... 34.60 NA 12.42 5.66 NA 52.68 090 

33774 .... .......... A Repair great vessels defect ............................... 30.93 NA 14.70 4.80 NA 50.43 090 

33775 .... .......... A Repair great vessels defect ............................... 32.15 NA 15.03 4.98 NA 52.16 090 

33776 .... .......... A Repair great vessels defect ............................... 33.99 NA 15.85 5.07 NA 54.91 090 

33777 .... .......... A Repair great vessels defect ............................... 33.41 NA 15.66 5.47 NA 54.54 090 

33778 .... .......... A Repair great vessels defect ............................... 39.94 NA 16.94 6.18 NA 63.06 090 

33779 .... .......... A Repair great vessels defect ............................... 36.16 NA 15.41 2.91 NA 54.48 090 

33780 .... .......... A Repair great vessels defect ............................... 41.69 NA 19.14 3.67 NA 64.50 090 

70371 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

33781 .... .......... A Repair great vessels defect ............................... 36.40 NA 13.37 5.95 NA 55.72 090 

33786 .... .......... A Repair arterial trunk ............................................ 38.94 NA 16.76 5.69 NA 61.39 090 

33788 .... .......... A Revision of pulmonary artery ............................. 26.58 NA 11.98 4.02 NA 42.58 090 

33800 .... .......... A Aortic suspension ............................................... 16.22 NA 8.13 2.45 NA 26.80 090 

33802 .... .......... A Repair vessel defect ........................................... 17.63 NA 9.25 2.26 NA 29.14 090 

33803 .... .......... A Repair vessel defect ........................................... 19.57 NA 9.79 3.19 NA 32.55 090 

33813 .... .......... A Repair septal defect ........................................... 20.62 NA 10.94 3.12 NA 34.68 090 

33814 .... .......... A Repair septal defect ........................................... 25.73 NA 12.68 3.84 NA 42.25 090 

33820 .... .......... A Revise major vessel ........................................... 16.27 NA 8.38 2.34 NA 26.99 090 

33822 .... .......... A Revise major vessel ........................................... 17.29 NA 8.98 2.67 NA 28.94 090 

33824 .... .......... A Revise major vessel ........................................... 19.49 NA 10.01 2.88 NA 32.38 090 

33840 .... .......... A Remove aorta constriction ................................. 20.60 NA 10.32 2.15 NA 33.07 090 

33845 .... .......... A Remove aorta constriction ................................. 22.09 NA 11.38 3.21 NA 36.68 090 

33851 .... .......... A Remove aorta constriction ................................. 21.24 NA 10.71 3.17 NA 35.12 090 

33852 .... .......... A Repair septal defect ........................................... 23.67 NA 11.39 2.15 NA 37.21 090 

33853 .... .......... A Repair septal defect ........................................... 31.67 NA 14.86 4.47 NA 51.00 090 

33860 .... .......... A Ascending aortic graft ........................................ 37.94 NA 16.50 5.74 NA 60.18 090 

33861 .... .......... A Ascending aortic graft ........................................ 41.94 NA 17.76 6.35 NA 66.05 090 

33863 .... .......... A Ascending aortic graft ........................................ 44.93 NA 18.74 6.57 NA 70.24 090 

33870 .... .......... A Transverse aortic arch graft ............................... 43.93 NA 18.43 6.60 NA 68.96 090 

33875 .... .......... A Thoracic aortic graft ........................................... 33.01 NA 14.13 4.88 NA 52.02 090 

33877 .... .......... A Thoracoabdominal graft ..................................... 42.54 NA 16.36 5.92 NA 64.82 090 

33880 .... .......... A Endovasc taa repr incl subcl .............................. 33.00 NA 13.51 2.74 NA 49.25 090 

33881 .... .......... A Endovasc taa repr w/o subcl .............................. 28.00 NA 11.99 2.32 NA 42.31 090 

33883 .... .......... A Insert endovasc prosth, taa ................................ 20.00 NA 9.21 2.10 NA 31.31 090 

33884 .... .......... A Endovasc prosth, taa, add-on ............................ 8.20 NA 2.58 0.86 NA 11.64 ZZZ 

33886 .... .......... A Endovasc prosth, delayed .................................. 17.00 NA 8.25 1.79 NA 27.04 090 

33889 .... .......... A Artery transpose/endovas taa ............................ 15.92 NA 5.19 2.17 NA 23.28 000 

33891 .... .......... A Car-car bp grft/endovas taa ............................... 20.00 NA 6.98 2.72 NA 29.70 000 

33910 .... .......... A Remove lung artery emboli ................................ 24.55 NA 11.46 3.69 NA 39.70 090 

33915 .... .......... A Remove lung artery emboli ................................ 20.99 NA 9.66 1.44 NA 32.09 090 

33916 .... .......... A Surgery of great vessel ...................................... 25.79 NA 11.37 3.66 NA 40.82 090 

33917 .... .......... A Repair pulmonary artery ..................................... 24.46 NA 12.22 3.69 NA 40.37 090 

33920 .... .......... A Repair pulmonary atresia ................................... 31.90 NA 13.86 4.37 NA 50.13 090 

33922 .... .......... A Transect pulmonary artery ................................. 23.48 NA 10.93 3.09 NA 37.50 090 

33924 .... .......... A Remove pulmonary shunt .................................. 5.49 NA 1.85 0.82 NA 8.16 ZZZ 

33925 .... .......... A Rpr pul art unifocal w/o cpb ............................... 29.50 NA 14.70 4.60 NA 48.80 090 

33926 .... .......... A Repr pul art, unifocal w/cpb ............................... 42.00 NA 17.73 6.20 NA 65.93 090 

33930 .... .......... X Removal of donor heart/lung .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

33933 .... .......... C Prepare donor heart/lung ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

33935 .... .......... R Transplantation, heart/lung ................................. 60.87 NA 28.85 9.03 NA 98.75 090 

33940 .... .......... X Removal of donor heart ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

33944 .... .......... C Prepare donor heart ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

33945 .... .......... R Transplantation of heart ..................................... 42.04 NA 21.45 6.24 NA 69.73 090 

33960 .... .......... A External circulation assist ................................... 19.33 NA 4.92 2.66 NA 26.91 000 

33961 .... .......... A External circulation assist ................................... 10.91 NA 3.62 0.88 NA 15.41 ZZZ 

33967 .... .......... A Insert ia percut device ........................................ 4.84 NA 1.85 0.35 NA 7.04 000 

33968 .... .......... A Remove aortic assist device .............................. 0.64 NA 0.23 0.07 NA 0.94 000 

33970 .... .......... A Aortic circulation assist ....................................... 6.74 NA 2.29 0.82 NA 9.85 000 

33971 .... .......... A Aortic circulation assist ....................................... 9.68 NA 6.02 1.25 NA 16.95 090 

33973 .... .......... A Insert balloon device .......................................... 9.75 NA 3.32 1.26 NA 14.33 000 

33974 .... .......... A Remove intra-aortic balloon ............................... 14.39 NA 7.90 1.73 NA 24.02 090 

33975 .... .......... A Implant ventricular device .................................. 20.97 NA 6.30 3.06 NA 30.33 XXX 

33976 .... .......... A Implant ventricular device .................................. 22.97 NA 7.57 3.25 NA 33.79 XXX 

33977 .... .......... A Remove ventricular device ................................. 19.26 NA 11.10 2.80 NA 33.16 090 

33978 .... .......... A Remove ventricular device ................................. 21.70 NA 11.78 3.30 NA 36.78 090 

33979 .... .......... A Insert intracorporeal device ................................ 45.93 NA 14.96 6.95 NA 67.84 XXX 

33980 .... .......... A Remove intracorporeal device ........................... 56.17 NA 25.31 8.56 NA 90.04 090 

33999 .... .......... C Cardiac surgery procedure ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

34001 .... .......... A Removal of artery clot ........................................ 12.89 NA 6.73 1.84 NA 21.46 090 

34051 .... .......... A Removal of artery clot ........................................ 15.19 NA 7.80 2.20 NA 25.19 090 

34101 .... .......... A Removal of artery clot ........................................ 9.99 NA 5.37 1.41 NA 16.77 090 

34111 .... .......... A Removal of arm artery clot ................................. 9.99 NA 5.37 1.40 NA 16.76 090 

34151 .... .......... A Removal of artery clot ........................................ 24.96 NA 10.43 3.55 NA 38.94 090 

34201 .... .......... A Removal of artery clot ........................................ 10.01 NA 5.43 1.45 NA 16.89 090 

34203 .... .......... A Removal of leg artery clot .................................. 16.48 NA 8.08 2.35 NA 26.91 090 

34401 .... .......... A Removal of vein clot ........................................... 24.96 NA 10.69 3.09 NA 38.74 090 

34421 .... .......... A Removal of vein clot ........................................... 11.98 NA 6.31 1.55 NA 19.84 090 

34451 .... .......... A Removal of vein clot ........................................... 26.96 NA 11.47 3.83 NA 42.26 090 

34471 .... .......... A Removal of vein clot ........................................... 10.16 NA 5.32 1.18 NA 16.66 090 

34490 .... .......... A Removal of vein clot ........................................... 9.85 NA 5.44 1.41 NA 16.70 090 

34501 .... .......... A Repair valve, femoral vein ................................. 15.98 NA 8.51 2.34 NA 26.83 090 

34502 .... .......... A Reconstruct vena cava ....................................... 26.91 NA 12.33 3.62 NA 42.86 090 

34510 .... .......... A Transposition of vein valve ................................ 18.92 NA 9.44 2.32 NA 30.68 090 

34520 .... .......... A Cross-over vein graft .......................................... 17.92 NA 8.47 2.28 NA 28.67 090 

70372 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

34530 .... .......... A Leg vein fusion ................................................... 16.62 NA 8.63 1.73 NA 26.98 090 

34800 .... .......... A Endovas aaa repr w/sm tube ............................. 20.72 NA 9.19 2.45 NA 32.36 090 

34802 .... .......... A Endovas aaa repr w/2-p part ............................. 22.97 NA 9.81 2.32 NA 35.10 090 

34803 .... .......... A Endovas aaa repr w/3-p part ............................. 24.00 NA 10.24 2.00 NA 36.24 090 

34804 .... .......... A Endovas aaa repr w/1-p part ............................. 22.97 NA 9.83 2.29 NA 35.09 090 

34805 .... .......... A Endovas aaa repr w/long tube ........................... 21.85 NA 9.67 2.00 NA 33.52 090 

34808 .... .......... A Endovas iliac a device addon ............................ 4.12 NA 1.37 0.59 NA 6.08 ZZZ 

34812 .... .......... A Xpose for endoprosth, femorl ............................. 6.74 NA 2.24 1.18 NA 10.16 000 

34813 .... .......... A Femoral endovas graft add-on ........................... 4.79 NA 1.57 0.67 NA 7.03 ZZZ 

34820 .... .......... A Xpose for endoprosth, iliac ................................ 9.74 NA 3.24 1.50 NA 14.48 000 

34825 .... .......... A Endovasc extend prosth, init .............................. 11.98 NA 6.16 1.28 NA 19.42 090 

34826 .... .......... A Endovasc exten prosth, add’l ............................. 4.12 NA 1.37 0.44 NA 5.93 ZZZ 

34830 .... .......... A Open aortic tube prosth repr .............................. 32.54 NA 13.73 4.54 NA 50.81 090 

34831 .... .......... A Open aortoiliac prosth repr ................................ 35.29 NA 11.76 4.88 NA 51.93 090 

34832 .... .......... A Open aortofemor prosth repr ............................. 35.29 NA 14.66 4.84 NA 54.79 090 

34833 .... .......... A Xpose for endoprosth, iliac ................................ 11.98 NA 4.44 1.69 NA 18.11 000 

34834 .... .......... A Xpose, endoprosth, brachial .............................. 5.34 NA 2.20 0.76 NA 8.30 000 

34900 .... .......... A Endovasc iliac repr w/graft ................................. 16.36 NA 7.60 1.99 NA 25.95 090 

35001 .... .......... A Repair defect of artery ....................................... 19.61 NA 9.58 2.80 NA 31.99 090 

35002 .... .......... A Repair artery rupture, neck ................................ 20.97 NA 9.72 2.99 NA 33.68 090 

35005 .... .......... A Repair defect of artery ....................................... 18.09 NA 8.87 1.76 NA 28.72 090 

35011 .... .......... A Repair defect of artery ....................................... 17.97 NA 8.00 2.54 NA 28.51 090 

35013 .... .......... A Repair artery rupture, arm .................................. 21.97 NA 9.70 3.09 NA 34.76 090 

35021 .... .......... A Repair defect of artery ....................................... 19.62 NA 9.44 2.86 NA 31.92 090 

35022 .... .......... A Repair artery rupture, chest ............................... 23.15 NA 9.88 3.16 NA 36.19 090 

35045 .... .......... A Repair defect of arm artery ................................ 17.54 NA 7.52 2.44 NA 27.50 090 

35081 .... .......... A Repair defect of artery ....................................... 27.97 NA 11.49 4.00 NA 43.46 090 

35082 .... .......... A Repair artery rupture, aorta ................................ 38.44 NA 15.33 5.42 NA 59.19 090 

35091 .... .......... A Repair defect of artery ....................................... 35.35 NA 13.60 5.12 NA 54.07 090 

35092 .... .......... A Repair artery rupture, aorta ................................ 44.93 NA 17.68 6.38 NA 68.99 090 

35102 .... .......... A Repair defect of artery ....................................... 30.71 NA 12.39 4.47 NA 47.57 090 

35103 .... .......... A Repair artery rupture, groin ................................ 40.44 NA 15.89 5.74 NA 62.07 090 

35111 .... .......... A Repair defect of artery ....................................... 24.96 NA 10.49 3.46 NA 38.91 090 

35112 .... .......... A Repair artery rupture,spleen .............................. 29.96 NA 11.99 4.07 NA 46.02 090 

35121 .... .......... A Repair defect of artery ....................................... 29.96 NA 12.40 4.29 NA 46.65 090 

35122 .... .......... A Repair artery rupture, belly ................................ 34.95 NA 13.84 4.74 NA 53.53 090 

35131 .... .......... A Repair defect of artery ....................................... 24.96 NA 10.77 3.79 NA 39.52 090 

35132 .... .......... A Repair artery rupture, groin ................................ 29.96 NA 12.41 4.29 NA 46.66 090 

35141 .... .......... A Repair defect of artery ....................................... 19.97 NA 8.94 2.89 NA 31.80 090 

35142 .... .......... A Repair artery rupture, thigh ................................ 23.27 NA 10.39 3.35 NA 37.01 090 

35151 .... .......... A Repair defect of artery ....................................... 22.61 NA 10.01 3.23 NA 35.85 090 

35152 .... .......... A Repair artery rupture, knee ................................ 25.58 NA 11.40 3.60 NA 40.58 090 

35180 .... .......... A Repair blood vessel lesion ................................. 13.60 NA 6.96 1.00 NA 21.56 090 

35182 .... .......... A Repair blood vessel lesion ................................. 29.96 NA 12.83 4.35 NA 47.14 090 

35184 .... .......... A Repair blood vessel lesion ................................. 17.97 NA 8.31 2.52 NA 28.80 090 

35188 .... .......... A Repair blood vessel lesion ................................. 14.26 NA 7.65 2.15 NA 24.06 090 

35189 .... .......... A Repair blood vessel lesion ................................. 27.96 NA 11.98 4.00 NA 43.94 090 

35190 .... .......... A Repair blood vessel lesion ................................. 12.73 NA 6.49 1.79 NA 21.01 090 

35201 .... .......... A Repair blood vessel lesion ................................. 16.12 NA 8.01 2.33 NA 26.46 090 

35206 .... .......... A Repair blood vessel lesion ................................. 13.23 NA 6.57 1.86 NA 21.66 090 

35207 .... .......... A Repair blood vessel lesion ................................. 10.13 NA 7.37 1.48 NA 18.98 090 

35211 .... .......... A Repair blood vessel lesion ................................. 22.09 NA 10.64 3.19 NA 35.92 090 

35216 .... .......... A Repair blood vessel lesion ................................. 18.72 NA 9.00 2.64 NA 30.36 090 

35221 .... .......... A Repair blood vessel lesion ................................. 24.35 NA 9.96 3.36 NA 37.67 090 

35226 .... .......... A Repair blood vessel lesion ................................. 14.48 NA 7.45 2.01 NA 23.94 090 

35231 .... .......... A Repair blood vessel lesion ................................. 19.97 NA 9.79 2.88 NA 32.64 090 

35236 .... .......... A Repair blood vessel lesion ................................. 17.08 NA 7.90 2.42 NA 27.40 090 

35241 .... .......... A Repair blood vessel lesion ................................. 23.09 NA 11.15 3.52 NA 37.76 090 

35246 .... .......... A Repair blood vessel lesion ................................. 26.41 NA 11.45 3.85 NA 41.71 090 

35251 .... .......... A Repair blood vessel lesion ................................. 30.15 NA 11.82 4.12 NA 46.09 090 

35256 .... .......... A Repair blood vessel lesion ................................. 18.33 NA 8.37 2.62 NA 29.32 090 

35261 .... .......... A Repair blood vessel lesion ................................. 17.77 NA 8.03 2.60 NA 28.40 090 

35266 .... .......... A Repair blood vessel lesion ................................. 14.89 NA 7.02 2.09 NA 24.00 090 

35271 .... .......... A Repair blood vessel lesion ................................. 22.09 NA 10.54 3.15 NA 35.78 090 

35276 .... .......... A Repair blood vessel lesion ................................. 24.21 NA 11.23 3.48 NA 38.92 090 

35281 .... .......... A Repair blood vessel lesion ................................. 27.96 NA 11.73 3.96 NA 43.65 090 

35286 .... .......... A Repair blood vessel lesion ................................. 16.14 NA 8.07 2.34 NA 26.55 090 

35301 .... .......... A Rechanneling of artery ....................................... 18.67 NA 8.45 2.67 NA 29.79 090 

35311 .... .......... A Rechanneling of artery ....................................... 26.96 NA 11.77 3.41 NA 42.14 090 

35321 .... .......... A Rechanneling of artery ....................................... 15.98 NA 7.40 2.24 NA 25.62 090 

35331 .... .......... A Rechanneling of artery ....................................... 26.16 NA 11.26 3.82 NA 41.24 090 

35341 .... .......... A Rechanneling of artery ....................................... 25.07 NA 10.89 3.77 NA 39.73 090 

35351 .... .......... A Rechanneling of artery ....................................... 22.97 NA 9.62 3.34 NA 35.93 090 

35355 .... .......... A Rechanneling of artery ....................................... 18.47 NA 8.10 2.66 NA 29.23 090 

35361 .... .......... A Rechanneling of artery ....................................... 28.16 NA 11.73 4.14 NA 44.03 090 

70373 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

35363 .... .......... A Rechanneling of artery ....................................... 30.15 NA 12.62 4.32 NA 47.09 090 

35371 .... .......... A Rechanneling of artery ....................................... 14.70 NA 6.97 2.13 NA 23.80 090 

35372 .... .......... A Rechanneling of artery ....................................... 17.97 NA 8.06 2.62 NA 28.65 090 

35381 .... .......... A Rechanneling of artery ....................................... 15.79 NA 7.83 2.25 NA 25.87 090 

35390 .... .......... A Reoperation, carotid add-on ............................... 3.19 NA 1.06 0.46 NA 4.71 ZZZ 

35400 .... .......... A Angioscopy ......................................................... 3.00 NA 1.11 0.43 NA 4.54 ZZZ 

35450 .... .......... A Repair arterial blockage ..................................... 10.05 NA 3.57 1.25 NA 14.87 000 

35452 .... .......... A Repair arterial blockage ..................................... 6.90 NA 2.61 0.94 NA 10.45 000 

35454 .... .......... A Repair arterial blockage ..................................... 6.03 NA 2.32 0.87 NA 9.22 000 

35456 .... .......... A Repair arterial blockage ..................................... 7.34 NA 2.77 1.04 NA 11.15 000 

35458 .... .......... A Repair arterial blockage ..................................... 9.48 NA 3.48 1.26 NA 14.22 000 

35459 .... .......... A Repair arterial blockage ..................................... 8.62 NA 3.18 1.21 NA 13.01 000 

35460 .... .......... A Repair venous blockage ..................................... 6.03 NA 2.28 0.83 NA 9.14 000 

35470 .... .......... A Repair arterial blockage ..................................... 8.62 89.12 3.36 0.69 98.43 12.67 000 

35471 .... .......... A Repair arterial blockage ..................................... 10.05 100.55 3.96 0.67 111.27 14.68 000 

35472 .... .......... A Repair arterial blockage ..................................... 6.90 64.54 2.75 0.58 72.02 10.23 000 

35473 .... .......... A Repair arterial blockage ..................................... 6.03 60.01 2.43 0.51 66.55 8.97 000 

35474 .... .......... A Repair arterial blockage ..................................... 7.35 87.98 2.90 0.57 95.90 10.82 000 

35475 .... .......... R Repair arterial blockage ..................................... 9.48 56.26 3.57 0.62 66.36 13.67 000 

35476 .... .......... A Repair venous blockage ..................................... 6.03 44.86 2.36 0.34 51.23 8.73 000 

35480 .... .......... A Atherectomy, open ............................................. 11.06 NA 4.05 1.28 NA 16.39 000 

35481 .... .......... A Atherectomy, open ............................................. 7.60 NA 2.88 1.13 NA 11.61 000 

35482 .... .......... A Atherectomy, open ............................................. 6.64 NA 2.57 0.89 NA 10.10 000 

35483 .... .......... A Atherectomy, open ............................................. 8.09 NA 3.03 1.15 NA 12.27 000 

35484 .... .......... A Atherectomy, open ............................................. 10.42 NA 3.78 1.27 NA 15.47 000 

35485 .... .......... A Atherectomy, open ............................................. 9.48 NA 3.54 1.35 NA 14.37 000 

35490 .... .......... A Atherectomy, percutaneous ............................... 11.06 NA 4.71 0.71 NA 16.48 000 

35491 .... .......... A Atherectomy, percutaneous ............................... 7.60 NA 3.30 0.74 NA 11.64 000 

35492 .... .......... A Atherectomy, percutaneous ............................... 6.64 NA 3.20 0.43 NA 10.27 000 

35493 .... .......... A Atherectomy, percutaneous ............................... 8.09 NA 3.81 0.56 NA 12.46 000 

35494 .... .......... A Atherectomy, percutaneous ............................... 10.42 NA 4.47 0.59 NA 15.48 000 

35495 .... .......... A Atherectomy, percutaneous ............................... 9.48 NA 4.40 0.69 NA 14.57 000 

35500 .... .......... A Harvest vein for bypass ..................................... 6.44 NA 2.03 0.93 NA 9.40 ZZZ 

35501 .... .......... A Artery bypass graft ............................................. 19.16 NA 8.48 2.80 NA 30.44 090 

35506 .... .......... A Artery bypass graft ............................................. 19.64 NA 9.49 2.86 NA 31.99 090 

35507 .... .......... A Artery bypass graft ............................................. 19.64 NA 9.45 2.84 NA 31.93 090 

35508 .... .......... A Artery bypass graft ............................................. 18.62 NA 9.47 2.77 NA 30.86 090 

35509 .... .......... A Artery bypass graft ............................................. 18.04 NA 8.79 2.61 NA 29.44 090 

35510 .... .......... A Artery bypass graft ............................................. 22.97 NA 10.20 2.11 NA 35.28 090 

35511 .... .......... A Artery bypass graft ............................................. 21.17 NA 9.38 2.90 NA 33.45 090 

35512 .... .......... A Artery bypass graft ............................................. 22.47 NA 10.03 2.11 NA 34.61 090 

35515 .... .......... A Artery bypass graft ............................................. 18.62 NA 9.31 2.77 NA 30.70 090 

35516 .... .......... A Artery bypass graft ............................................. 16.30 NA 6.82 2.33 NA 25.45 090 

35518 .... .......... A Artery bypass graft ............................................. 21.17 NA 9.00 3.02 NA 33.19 090 

35521 .... .......... A Artery bypass graft ............................................. 22.17 NA 9.86 3.12 NA 35.15 090 

35522 .... .......... A Artery bypass graft ............................................. 21.73 NA 9.78 2.11 NA 33.62 090 

35525 .... .......... A Artery bypass graft ............................................. 20.60 NA 9.40 2.11 NA 32.11 090 

35526 .... .......... A Artery bypass graft ............................................. 29.91 NA 12.54 3.62 NA 46.07 090 

35531 .... .......... A Artery bypass graft ............................................. 36.15 NA 14.51 5.16 NA 55.82 090 

35533 .... .......... A Artery bypass graft ............................................. 27.96 NA 11.75 3.84 NA 43.55 090 

35536 .... .......... A Artery bypass graft ............................................. 31.65 NA 12.98 4.61 NA 49.24 090 

35541 .... .......... A Artery bypass graft ............................................. 25.76 NA 11.23 3.70 NA 40.69 090 

35546 .... .......... A Artery bypass graft ............................................. 25.50 NA 10.89 3.69 NA 40.08 090 

35548 .... .......... A Artery bypass graft ............................................. 21.54 NA 9.45 2.97 NA 33.96 090 

35549 .... .......... A Artery bypass graft ............................................. 23.31 NA 10.40 3.29 NA 37.00 090 

35551 .... .......... A Artery bypass graft ............................................. 26.63 NA 11.52 3.74 NA 41.89 090 

35556 .... .......... A Artery bypass graft ............................................. 21.73 NA 9.75 3.09 NA 34.57 090 

35558 .... .......... A Artery bypass graft ............................................. 21.17 NA 9.57 2.99 NA 33.73 090 

35560 .... .......... A Artery bypass graft ............................................. 31.95 NA 13.35 4.74 NA 50.04 090 

35563 .... .......... A Artery bypass graft ............................................. 24.16 NA 10.55 3.51 NA 38.22 090 

35565 .... .......... A Artery bypass graft ............................................. 23.17 NA 10.16 3.29 NA 36.62 090 

35566 .... .......... A Artery bypass graft ............................................. 26.88 NA 11.41 3.82 NA 42.11 090 

35571 .... .......... A Artery bypass graft ............................................. 24.02 NA 10.87 3.42 NA 38.31 090 

35572 .... .......... A Harvest femoropopliteal vein .............................. 6.81 NA 2.25 0.99 NA 10.05 ZZZ 

35583 .... .......... A Vein bypass graft ............................................... 22.34 NA 10.18 3.16 NA 35.68 090 

35585 .... .......... A Vein bypass graft ............................................... 28.35 NA 12.25 4.01 NA 44.61 090 

35587 .... .......... A Vein bypass graft ............................................... 24.71 NA 11.48 3.51 NA 39.70 090 

35600 .... .......... A Harvest artery for cabg ...................................... 4.94 NA 1.62 0.73 NA 7.29 ZZZ 

35601 .... .......... A Artery bypass graft ............................................. 17.47 NA 8.64 2.49 NA 28.60 090 

35606 .... .......... A Artery bypass graft ............................................. 18.68 NA 9.04 2.69 NA 30.41 090 

35612 .... .......... A Artery bypass graft ............................................. 15.74 NA 7.90 2.08 NA 25.72 090 

35616 .... .......... A Artery bypass graft ............................................. 15.68 NA 8.12 2.19 NA 25.99 090 

35621 .... .......... A Artery bypass graft ............................................. 19.97 NA 8.70 2.91 NA 31.58 090 

35623 .... .......... A Bypass graft, not vein ........................................ 23.96 NA 10.52 3.45 NA 37.93 090 

35626 .... .......... A Artery bypass graft ............................................. 27.71 NA 12.00 4.07 NA 43.78 090 

70374 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

35631 .... .......... A Artery bypass graft ............................................. 33.95 NA 13.87 4.95 NA 52.77 090 

35636 .... .......... A Artery bypass graft ............................................. 29.46 NA 12.33 4.09 NA 45.88 090 

35641 .... .......... A Artery bypass graft ............................................. 24.53 NA 11.09 3.53 NA 39.15 090 

35642 .... .......... A Artery bypass graft ............................................. 17.95 NA 8.71 2.27 NA 28.93 090 

35645 .... .......... A Artery bypass graft ............................................. 17.44 NA 8.29 2.49 NA 28.22 090 

35646 .... .......... A Artery bypass graft ............................................. 30.95 NA 13.14 4.43 NA 48.52 090 

35647 .... .......... A Artery bypass graft ............................................. 27.96 NA 11.80 3.98 NA 43.74 090 

35650 .... .......... A Artery bypass graft ............................................. 18.97 NA 8.38 2.71 NA 30.06 090 

35651 .... .......... A Artery bypass graft ............................................. 25.00 NA 10.75 3.35 NA 39.10 090 

35654 .... .......... A Artery bypass graft ............................................. 24.96 NA 10.68 3.52 NA 39.16 090 

35656 .... .......... A Artery bypass graft ............................................. 19.50 NA 8.62 2.79 NA 30.91 090 

35661 .... .......... A Artery bypass graft ............................................. 18.97 NA 8.95 2.71 NA 30.63 090 

35663 .... .......... A Artery bypass graft ............................................. 21.97 NA 10.00 3.10 NA 35.07 090 

35665 .... .......... A Artery bypass graft ............................................. 20.97 NA 9.47 3.00 NA 33.44 090 

35666 .... .......... A Artery bypass graft ............................................. 22.16 NA 10.67 3.15 NA 35.98 090 

35671 .... .......... A Artery bypass graft ............................................. 19.30 NA 9.39 2.77 NA 31.46 090 

35681 .... .......... A Composite bypass graft ..................................... 1.60 NA 0.53 0.23 NA 2.36 ZZZ 

35682 .... .......... A Composite bypass graft ..................................... 7.19 NA 2.39 1.03 NA 10.61 ZZZ 

35683 .... .......... A Composite bypass graft ..................................... 8.49 NA 2.83 1.20 NA 12.52 ZZZ 

35685 .... .......... A Bypass graft patency/patch ................................ 4.04 NA 1.35 0.58 NA 5.97 ZZZ 

35686 .... .......... A Bypass graft/av fist patency ............................... 3.34 NA 1.13 0.47 NA 4.94 ZZZ 

35691 .... .......... A Arterial transposition ........................................... 18.02 NA 8.42 2.58 NA 29.02 090 

35693 .... .......... A Arterial transposition ........................................... 15.34 NA 7.74 2.21 NA 25.29 090 

35694 .... .......... A Arterial transposition ........................................... 19.13 NA 8.62 2.69 NA 30.44 090 

35695 .... .......... A Arterial transposition ........................................... 19.13 NA 8.57 2.73 NA 30.43 090 

35697 .... .......... A Reimplant artery each ........................................ 3.00 NA 1.02 0.41 NA 4.43 ZZZ 

35700 .... .......... A Reoperation, bypass graft .................................. 3.08 NA 1.02 0.44 NA 4.54 ZZZ 

35701 .... .......... A Exploration, carotid artery .................................. 8.49 NA 5.16 1.12 NA 14.77 090 

35721 .... .......... A Exploration, femoral artery ................................. 7.17 NA 4.44 1.03 NA 12.64 090 

35741 .... .......... A Exploration popliteal artery ................................. 7.99 NA 4.67 1.12 NA 13.78 090 

35761 .... .......... A Exploration of artery/vein ................................... 5.36 NA 4.02 0.75 NA 10.13 090 

35800 .... .......... A Explore neck vessels ......................................... 7.01 NA 4.66 0.95 NA 12.62 090 

35820 .... .......... A Explore chest vessels ........................................ 12.86 NA 7.22 1.94 NA 22.02 090 

35840 .... .......... A Explore abdominal vessels ................................ 9.76 NA 5.30 1.34 NA 16.40 090 

35860 .... .......... A Explore limb vessels .......................................... 5.54 NA 4.04 0.78 NA 10.36 090 

35870 .... .......... A Repair vessel graft defect .................................. 22.14 NA 9.79 3.00 NA 34.93 090 

35875 .... .......... A Removal of clot in graft ...................................... 10.11 NA 5.20 1.41 NA 16.72 090 

35876 .... .......... A Removal of clot in graft ...................................... 16.97 NA 7.53 2.39 NA 26.89 090 

35879 .... .......... A Revise graft w/vein ............................................. 15.98 NA 7.71 2.27 NA 25.96 090 

35881 .... .......... A Revise graft w/vein ............................................. 17.97 NA 8.69 2.55 NA 29.21 090 

35901 .... .......... A Excision, graft, neck ........................................... 8.18 NA 5.32 1.15 NA 14.65 090 

35903 .... .......... A Excision, graft, extremity .................................... 9.38 NA 6.17 1.30 NA 16.85 090 

35905 .... .......... A Excision, graft, thorax ......................................... 31.20 NA 13.22 4.43 NA 48.85 090 

35907 .... .......... A Excision, graft, abdomen .................................... 34.95 NA 14.20 4.91 NA 54.06 090 

36000 .... .......... A Place needle in vein ........................................... 0.18 0.57 0.05 0.01 0.76 0.24 XXX 

36002 .... .......... A Pseudoaneurysm injection trt ............................. 1.96 2.87 0.97 0.17 5.00 3.10 000 

36005 .... .......... A Injection ext venography .................................... 0.95 7.67 0.31 0.05 8.67 1.31 000 

36010 .... .......... A Place catheter in vein ......................................... 2.43 19.36 0.79 0.20 21.99 3.42 XXX 

36011 .... .......... A Place catheter in vein ......................................... 3.14 27.90 1.06 0.27 31.31 4.47 XXX 

36012 .... .......... A Place catheter in vein ......................................... 3.51 19.00 1.19 0.23 22.74 4.93 XXX 

36013 .... .......... A Place catheter in artery ...................................... 2.52 21.42 0.69 0.25 24.19 3.46 XXX 

36014 .... .......... A Place catheter in artery ...................................... 3.02 20.18 1.03 0.19 23.39 4.24 XXX 

36015 .... .......... A Place catheter in artery ...................................... 3.51 23.73 1.19 0.21 27.45 4.91 XXX 

36100 .... .......... A Establish access to artery .................................. 3.02 12.11 1.11 0.26 15.39 4.39 XXX 

36120 .... .......... A Establish access to artery .................................. 2.01 10.73 0.65 0.14 12.88 2.80 XXX 

36140 .... .......... A Establish access to artery .................................. 2.01 12.81 0.64 0.16 14.98 2.81 XXX 

36145 .... .......... A Artery to vein shunt ............................................ 2.01 12.59 0.66 0.11 14.71 2.78 XXX 

36160 .... .......... A Establish access to aorta ................................... 2.52 13.52 0.84 0.26 16.30 3.62 XXX 

36200 .... .......... A Place catheter in aorta ....................................... 3.02 16.56 1.01 0.24 19.82 4.27 XXX 

36215 .... .......... A Place catheter in artery ...................................... 4.67 27.11 1.61 0.27 32.05 6.55 XXX 

36216 .... .......... A Place catheter in artery ...................................... 5.27 29.16 1.80 0.31 34.74 7.38 XXX 

36217 .... .......... A Place catheter in artery ...................................... 6.29 55.60 2.18 0.44 62.33 8.91 XXX 

36218 .... .......... A Place catheter in artery ...................................... 1.01 5.10 0.34 0.07 6.18 1.42 ZZZ 

36245 .... .......... A Place catheter in artery ...................................... 4.67 32.18 1.68 0.31 37.16 6.66 XXX 

36246 .... .......... A Place catheter in artery ...................................... 5.27 30.05 1.83 0.38 35.70 7.48 XXX 

36247 .... .......... A Place catheter in artery ...................................... 6.29 49.65 2.15 0.47 56.41 8.91 XXX 

36248 .... .......... A Place catheter in artery ...................................... 1.01 4.05 0.34 0.07 5.13 1.42 ZZZ 

36260 .... .......... A Insertion of infusion pump .................................. 9.70 NA 4.89 1.29 NA 15.88 090 

36261 .... .......... A Revision of infusion pump .................................. 5.44 NA 3.67 0.70 NA 9.81 090 

36262 .... .......... A Removal of infusion pump ................................. 4.01 NA 2.76 0.54 NA 7.31 090 

36299 .... .......... C Vessel injection procedure ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

36400 .... .......... A Bl draw < 3 yrs fem/jugular ................................ 0.38 0.28 0.09 0.03 0.69 0.50 XXX 

36405 .... .......... A Bl draw < 3 yrs scalp vein .................................. 0.31 0.26 0.08 0.03 0.60 0.42 XXX 

36406 .... .......... A Bl draw < 3 yrs other vein .................................. 0.18 0.28 0.05 0.01 0.47 0.24 XXX 

36410 .... .......... A Non-routine bl draw > 3 yrs ............................... 0.18 0.29 0.05 0.01 0.48 0.24 XXX 

70375 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

36415 .... .......... X Routine venipuncture ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

36416 .... .......... B Capillary blood draw ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

36420 .... .......... A Vein access cutdown < 1 yr ............................... 1.01 0.34 0.27 0.07 1.42 1.35 XXX 

36425 .... .......... A Vein access cutdown > 1 yr ............................... 0.76 NA 0.22 0.06 NA 1.04 XXX 

36430 .... .......... A Blood transfusion service ................................... 0.00 1.01 NA 0.06 1.07 NA XXX 

36440 .... .......... A Bl push transfuse, 2 yr or < ............................... 1.03 NA 0.29 0.10 NA 1.42 XXX 

36450 .... .......... A Bl exchange/transfuse, nb .................................. 2.23 NA 0.71 0.21 NA 3.15 XXX 

36455 .... .......... A Bl exchange/transfuse non-nb ........................... 2.43 NA 1.01 0.15 NA 3.59 XXX 

36460 .... .......... A Transfusion service, fetal ................................... 6.58 NA 2.25 0.79 NA 9.62 XXX 

36468 .... .......... R Injection(s), spider veins .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

36469 .... .......... R Injection(s), spider veins .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

36470 .... .......... A Injection therapy of vein ..................................... 1.09 2.69 0.73 0.12 3.90 1.94 010 

36471 .... .......... A Injection therapy of veins ................................... 1.57 3.08 0.96 0.19 4.84 2.72 010 

36475 .... .......... A Endovenous rf, 1st vein ..................................... 6.72 51.54 2.54 0.37 58.63 9.63 000 

36476 .... .......... A Endovenous rf, vein add-on ............................... 3.38 7.90 1.14 0.18 11.46 4.70 ZZZ 

36478 .... .......... A Endovenous laser, 1st vein ................................ 6.72 46.91 2.54 0.37 54.00 9.63 000 

36479 .... .......... A Endovenous laser vein addon ............................ 3.38 8.01 1.14 0.18 11.57 4.70 ZZZ 

36481 .... .......... A Insertion of catheter, vein ................................... 6.98 5.75 2.60 0.55 13.28 10.13 000 

36500 .... .......... A Insertion of catheter, vein ................................... 3.51 NA 1.37 0.20 NA 5.08 000 

36510 .... .......... A Insertion of catheter, vein ................................... 1.09 3.90 0.61 0.10 5.09 1.80 000 

36511 .... .......... A Apheresis wbc .................................................... 1.74 NA 0.73 0.08 NA 2.55 000 

36512 .... .......... A Apheresis rbc ..................................................... 1.74 NA 0.74 0.08 NA 2.56 000 

36513 .... .......... A Apheresis platelets ............................................. 1.74 NA 0.73 0.17 NA 2.64 000 

36514 .... .......... A Apheresis plasma ............................................... 1.74 17.02 0.71 0.08 18.84 2.53 000 

36515 .... .......... A Apheresis, adsorp/reinfuse ................................. 1.74 66.49 0.66 0.08 68.31 2.48 000 

36516 .... .......... A Apheresis, selective ........................................... 1.22 84.29 0.48 0.08 85.59 1.78 000 

36522 .... .......... A Photopheresis ..................................................... 1.67 32.46 0.96 0.13 34.26 2.76 000 

36540 .... .......... B Collect blood venous device .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

36550 .... .......... A Declot vascular device ....................................... 0.00 0.39 NA 0.37 0.76 NA XXX 

36555 .... .......... A Insert non-tunnel cv cath .................................... 2.68 5.77 0.80 0.11 8.56 3.59 000 

36556 .... .......... A Insert non-tunnel cv cath .................................... 2.50 5.64 0.74 0.19 8.33 3.43 000 

36557 .... .......... A Insert tunneled cv cath ....................................... 5.09 21.20 2.66 0.57 26.86 8.32 010 

36558 .... .......... A Insert tunneled cv cath ....................................... 4.79 21.10 2.56 0.57 26.46 7.92 010 

36560 .... .......... A Insert tunneled cv cath ....................................... 6.24 29.76 3.04 0.57 36.57 9.85 010 

36561 .... .......... A Insert tunneled cv cath ....................................... 5.99 29.67 2.96 0.57 36.23 9.52 010 

36563 .... .......... A Insert tunneled cv cath ....................................... 6.19 26.82 2.99 0.84 33.85 10.02 010 

36565 .... .......... A Insert tunneled cv cath ....................................... 5.99 24.77 2.96 0.57 31.33 9.52 010 

36566 .... .......... A Insert tunneled cv cath ....................................... 6.49 25.57 3.12 0.57 32.63 10.18 010 

36568 .... .......... A Insert picc cath ................................................... 1.92 7.55 0.58 0.11 9.58 2.61 000 

36569 .... .......... A Insert picc cath ................................................... 1.82 7.36 0.57 0.19 9.37 2.58 000 

36570 .... .......... A Insert picvad cath ............................................... 5.31 33.27 2.73 0.57 39.15 8.61 010 

36571 .... .......... A Insert picvad cath ............................................... 5.29 33.34 2.72 0.57 39.20 8.58 010 

36575 .... .......... A Repair tunneled cv cath ..................................... 0.67 4.06 0.26 0.20 4.93 1.13 000 

36576 .... .......... A Repair tunneled cv cath ..................................... 3.19 6.96 1.85 0.19 10.34 5.23 010 

36578 .... .......... A Replace tunneled cv cath ................................... 3.49 11.16 2.31 0.19 14.84 5.99 010 

36580 .... .......... A Replace cvad cath .............................................. 1.31 6.96 0.41 0.19 8.46 1.91 000 

36581 .... .......... A Replace tunneled cv cath ................................... 3.43 19.55 1.93 0.19 23.17 5.55 010 

36582 .... .......... A Replace tunneled cv cath ................................... 5.19 26.09 2.87 0.19 31.47 8.25 010 

36583 .... .......... A Replace tunneled cv cath ................................... 5.24 26.11 2.89 0.19 31.54 8.32 010 

36584 .... .......... A Replace picc cath ............................................... 1.20 6.99 0.55 0.19 8.38 1.94 000 

36585 .... .......... A Replace picvad cath ........................................... 4.79 27.90 2.74 0.19 32.88 7.72 010 

36589 .... .......... A Removal tunneled cv cath .................................. 2.27 2.25 1.39 0.24 4.76 3.90 010 

36590 .... .......... A Removal tunneled cv cath .................................. 3.30 3.38 1.72 0.44 7.12 5.46 010 

36595 .... .......... A Mech remov tunneled cv cath ............................ 3.59 17.30 1.45 0.21 21.10 5.25 000 

36596 .... .......... A Mech remov tunneled cv cath ............................ 0.75 3.70 0.50 0.05 4.50 1.30 000 

36597 .... .......... A Reposition venous catheter ................................ 1.21 2.41 0.44 0.07 3.69 1.72 000 

36598 .... .......... T Inj w/fluor, eval cv device ................................... 0.74 2.65 2.65 0.05 3.44 3.44 000 

36600 .... .......... A Withdrawal of arterial blood ............................... 0.32 0.49 0.09 0.02 0.83 0.43 XXX 

36620 .... .......... A Insertion catheter, artery .................................... 1.15 NA 0.23 0.07 NA 1.45 000 

36625 .... .......... A Insertion catheter, artery .................................... 2.11 NA 0.53 0.26 NA 2.90 000 

36640 .... .......... A Insertion catheter, artery .................................... 2.10 NA 1.04 0.21 NA 3.35 000 

36660 .... .......... A Insertion catheter, artery .................................... 1.40 NA 0.44 0.14 NA 1.98 000 

36680 .... .......... A Insert needle, bone cavity .................................. 1.20 NA 0.49 0.11 NA 1.80 000 

36800 .... .......... A Insertion of cannula ............................................ 2.43 NA 1.81 0.25 NA 4.49 000 

36810 .... .......... A Insertion of cannula ............................................ 3.96 NA 1.68 0.45 NA 6.09 000 

36815 .... .......... A Insertion of cannula ............................................ 2.62 NA 1.17 0.35 NA 4.14 000 

36818 .... .......... A Av fuse, uppr arm, cephalic ............................... 11.52 NA 6.05 1.89 NA 19.46 090 

36819 .... .......... A Av fuse, uppr arm, basilic .................................. 13.98 NA 6.39 1.95 NA 22.32 090 

36820 .... .......... A Av fusion/forearm vein ....................................... 13.98 NA 6.40 1.94 NA 22.32 090 

36821 .... .......... A Av fusion direct any site ..................................... 8.92 NA 4.66 1.23 NA 14.81 090 

36822 .... .......... A Insertion of cannula(s) ........................................ 5.41 NA 4.39 0.79 NA 10.59 090 

36823 .... .......... A Insertion of cannula(s) ........................................ 20.97 NA 9.40 2.88 NA 33.25 090 

36825 .... .......... A Artery-vein autograft ........................................... 9.83 NA 5.06 1.35 NA 16.24 090 

36830 .... .......... A Artery-vein nonautograft ..................................... 11.98 NA 5.25 1.66 NA 18.89 090 

36831 .... .......... A Open thrombect av fistula .................................. 7.99 NA 3.95 1.09 NA 13.03 090 

70376 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

36832 .... .......... A Av fistula revision, open ..................................... 10.48 NA 4.73 1.44 NA 16.65 090 

36833 .... .......... A Av fistula revision ............................................... 11.93 NA 5.22 1.65 NA 18.80 090 

36834 .... .......... A Repair A-V aneurysm ......................................... 9.92 NA 4.80 1.37 NA 16.09 090 

36835 .... .......... A Artery to vein shunt ............................................ 7.14 NA 4.33 0.98 NA 12.45 090 

36838 .... .......... A Dist revas ligation, hemo .................................... 20.60 NA 9.41 3.01 NA 33.02 090 

36860 .... .......... A External cannula declotting ................................ 2.01 1.78 0.68 0.11 3.90 2.80 000 

36861 .... .......... A Cannula declotting .............................................. 2.52 NA 1.49 0.27 NA 4.28 000 

36870 .... .......... A Percut thrombect av fistula ................................ 5.15 53.18 3.16 0.29 58.62 8.60 090 

37140 .... .......... A Revision of circulation ........................................ 23.56 NA 10.51 2.01 NA 36.08 090 

37145 .... .......... A Revision of circulation ........................................ 24.57 NA 10.89 3.25 NA 38.71 090 

37160 .... .......... A Revision of circulation ........................................ 21.57 NA 9.28 2.81 NA 33.66 090 

37180 .... .......... A Revision of circulation ........................................ 24.57 NA 10.32 3.34 NA 38.23 090 

37181 .... .......... A Splice spleen/kidney veins ................................. 26.64 NA 11.03 3.40 NA 41.07 090 

37182 .... .......... A Insert hepatic shunt (tips) ................................... 16.97 NA 6.08 1.00 NA 24.05 000 

37183 .... .......... A Remove hepatic shunt (tips) .............................. 7.99 NA 3.02 0.47 NA 11.48 000 

37184 .... .......... A Prim art mech thrombectomy ............................. 8.66 71.90 3.36 0.55 81.11 12.57 000 

37185 .... .......... A Prim art m-thrombect add-on ............................. 3.28 22.95 1.11 0.21 26.44 4.60 ZZZ 

37186 .... .......... A Sec art m-thrombect add-on .............................. 4.92 49.53 1.66 0.32 54.77 6.90 ZZZ 

37187 .... .......... A Venous mech thrombectomy ............................. 8.03 70.38 3.15 0.51 78.92 11.69 000 

37188 .... .......... A Venous m-thrombectomy add-on ....................... 5.71 62.15 2.37 0.37 68.23 8.45 000 

37195 .... .......... C Thrombolytic therapy, stroke .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

37200 .... .......... A Transcatheter biopsy .......................................... 4.55 NA 1.50 0.27 NA 6.32 000 

37201 .... .......... A Transcatheter therapy infuse ............................. 4.99 NA 2.55 0.33 NA 7.87 000 

37202 .... .......... A Transcatheter therapy infuse ............................. 5.67 NA 3.04 0.43 NA 9.14 000 

37203 .... .......... A Transcatheter retrieval ....................................... 5.02 32.97 2.04 0.29 38.28 7.35 000 

37204 .... .......... A Transcatheter occlusion ..................................... 18.11 NA 5.92 1.48 NA 25.51 000 

37205 .... .......... A Transcath iv stent, percut ................................... 8.27 NA 3.76 0.60 NA 12.63 000 

37206 .... .......... A Transcath iv stent/perc addl ............................... 4.12 NA 1.43 0.31 NA 5.86 ZZZ 

37207 .... .......... A Transcath iv stent, open ..................................... 8.27 NA 3.17 1.17 NA 12.61 000 

37208 .... .......... A Transcath iv stent/open addl .............................. 4.12 NA 1.38 0.59 NA 6.09 ZZZ 

37209 .... .......... A Change iv cath at thromb tx ............................... 2.27 NA 0.74 0.15 NA 3.16 000 

37215 .... .......... R Transcath stent, cca w/eps ................................ 18.71 NA 9.12 1.09 NA 28.92 090 

37216 .... .......... R Transcath stent, cca w/o eps ............................. 17.98 NA 8.84 1.04 NA 27.86 090 

37250 .... .......... A Iv us first vessel add-on ..................................... 2.10 NA 0.75 0.21 NA 3.06 ZZZ 

37251 .... .......... A Iv us each add vessel add-on ............................ 1.60 NA 0.55 0.19 NA 2.34 ZZZ 

37500 .... .......... A Endoscopy ligate perf veins ............................... 10.98 NA 6.87 1.54 NA 19.39 090 

37501 .... .......... C Vascular endoscopy procedure .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

37565 .... .......... A Ligation of neck vein .......................................... 10.86 NA 5.64 1.33 NA 17.83 090 

37600 .... .......... A Ligation of neck artery ........................................ 11.23 NA 6.65 1.41 NA 19.29 090 

37605 .... .......... A Ligation of neck artery ........................................ 13.09 NA 6.92 1.98 NA 21.99 090 

37606 .... .......... A Ligation of neck artery ........................................ 6.27 NA 4.57 1.23 NA 12.07 090 

37607 .... .......... A Ligation of a-v fistula .......................................... 6.15 NA 3.57 0.85 NA 10.57 090 

37609 .... .......... A Temporal artery procedure ................................. 3.00 4.51 1.97 0.36 7.87 5.33 010 

37615 .... .......... A Ligation of neck artery ........................................ 5.72 NA 4.12 0.68 NA 10.52 090 

37616 .... .......... A Ligation of chest artery ....................................... 16.47 NA 8.10 2.32 NA 26.89 090 

37617 .... .......... A Ligation of abdomen artery ................................ 22.03 NA 9.20 2.97 NA 34.20 090 

37618 .... .......... A Ligation of extremity artery ................................. 4.83 NA 3.62 0.67 NA 9.12 090 

37620 .... .......... A Revision of major vein ........................................ 10.54 NA 5.73 0.91 NA 17.18 090 

37650 .... .......... A Revision of major vein ........................................ 7.79 NA 4.69 1.01 NA 13.49 090 

37660 .... .......... A Revision of major vein ........................................ 20.97 NA 9.08 2.48 NA 32.53 090 

37700 .... .......... A Revise leg vein ................................................... 3.72 NA 2.80 0.53 NA 7.05 090 

37718 .... .......... A Ligate/strip short leg vein ................................... 6.76 NA 4.07 0.14 NA 10.97 090 

37722 .... .......... A Ligate/strip long leg vein .................................... 7.79 NA 4.42 0.86 NA 13.07 090 

37735 .... .......... A Removal of leg veins/lesion ............................... 10.51 NA 5.52 1.48 NA 17.51 090 

37760 .... .......... A Ligation, leg veins, open .................................... 10.45 NA 5.36 1.44 NA 17.25 090 

37765 .... .......... A Phleb veins - extrem - to 20 .............................. 7.34 NA 4.63 0.48 NA 12.45 090 

37766 .... .......... A Phleb veins - extrem 20+ ................................... 9.29 NA 5.34 0.48 NA 15.11 090 

37780 .... .......... A Revision of leg vein ............................................ 3.83 NA 2.86 0.53 NA 7.22 090 

37785 .... .......... A Ligate/divide/excise vein .................................... 3.83 5.21 2.73 0.54 9.58 7.10 090 

37788 .... .......... A Revascularization, penis .................................... 21.98 NA 9.11 2.25 NA 33.34 090 

37790 .... .......... A Penile venous occlusion ..................................... 8.33 NA 4.38 0.59 NA 13.30 090 

37799 .... .......... C Vascular surgery procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

38100 .... .......... A Removal of spleen, total .................................... 14.48 NA 6.19 1.91 NA 22.58 090 

38101 .... .......... A Removal of spleen, partial ................................. 15.29 NA 6.54 2.04 NA 23.87 090 

38102 .... .......... A Removal of spleen, total .................................... 4.79 NA 1.64 0.63 NA 7.06 ZZZ 

38115 .... .......... A Repair of ruptured spleen .................................. 15.80 NA 6.66 2.08 NA 24.54 090 

38120 .... .......... A Laparoscopy, splenectomy ................................. 16.97 NA 7.40 2.24 NA 26.61 090 

38129 .... .......... C Laparoscope proc, spleen .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

38200 .... .......... A Injection for spleen x-ray .................................... 2.64 NA 0.89 0.14 NA 3.67 000 

38204 .... .......... B Bl donor search management ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38205 .... .......... R Harvest allogenic stem cells .............................. 1.50 NA 0.67 0.07 NA 2.24 000 

38206 .... .......... R Harvest auto stem cells ...................................... 1.50 NA 0.67 0.07 NA 2.24 000 

38207 .... .......... I Cryopreserve stem cells ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38208 .... .......... I Thaw preserved stem cells ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38209 .... .......... I Wash harvest stem cells .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70377 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

38210 .... .......... I T-cell depletion of harvest .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38211 .... .......... I Tumor cell deplete of harvst .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38212 .... .......... I Rbc depletion of harvest .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38213 .... .......... I Platelet deplete of harvest ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38214 .... .......... I Volume deplete of harvest ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38215 .... .......... I Harvest stem cell concentrte .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

38220 .... .......... A Bone marrow aspiration ..................................... 1.08 3.73 0.52 0.05 4.86 1.65 XXX 

38221 .... .......... A Bone marrow biopsy .......................................... 1.37 3.94 0.65 0.07 5.38 2.09 XXX 

38230 .... .......... R Bone marrow collection ...................................... 4.53 NA 3.23 0.48 NA 8.24 010 

38240 .... .......... R Bone marrow/stem transplant ............................ 2.24 NA 1.03 0.11 NA 3.38 XXX 

38241 .... .......... R Bone marrow/stem transplant ............................ 2.24 NA 1.04 0.11 NA 3.39 XXX 

38242 .... .......... A Lymphocyte infuse transplant ............................ 1.71 NA 0.78 0.08 NA 2.57 000 

38300 .... .......... A Drainage, lymph node lesion ............................. 1.99 4.31 2.06 0.25 6.55 4.30 010 

38305 .... .......... A Drainage, lymph node lesion ............................. 5.99 NA 4.45 0.88 NA 11.32 090 

38308 .... .......... A Incision of lymph channels ................................. 6.44 NA 3.75 0.85 NA 11.04 090 

38380 .... .......... A Thoracic duct procedure .................................... 7.45 NA 5.70 0.74 NA 13.89 090 

38381 .... .......... A Thoracic duct procedure .................................... 12.86 NA 6.90 1.84 NA 21.60 090 

38382 .... .......... A Thoracic duct procedure .................................... 10.06 NA 5.77 1.37 NA 17.20 090 

38500 .... .......... A Biopsy/removal, lymph nodes ............................ 3.74 3.70 2.09 0.49 7.93 6.32 010 

38505 .... .......... A Needle biopsy, lymph nodes .............................. 1.14 2.06 0.78 0.09 3.29 2.01 000 

38510 .... .......... A Biopsy/removal, lymph nodes ............................ 6.42 5.56 3.49 0.72 12.70 10.63 010 

38520 .... .......... A Biopsy/removal, lymph nodes ............................ 6.66 NA 4.06 0.84 NA 11.56 090 

38525 .... .......... A Biopsy/removal, lymph nodes ............................ 6.06 NA 3.30 0.80 NA 10.16 090 

38530 .... .......... A Biopsy/removal, lymph nodes ............................ 7.97 NA 4.40 1.12 NA 13.49 090 

38542 .... .......... A Explore deep node(s), neck ............................... 5.90 NA 4.49 0.60 NA 10.99 090 

38550 .... .......... A Removal, neck/armpit lesion .............................. 6.91 NA 3.92 0.88 NA 11.71 090 

38555 .... .......... A Removal, neck/armpit lesion .............................. 14.12 NA 8.55 1.75 NA 24.42 090 

38562 .... .......... A Removal, pelvic lymph nodes ............................ 10.47 NA 5.79 1.20 NA 17.46 090 

38564 .... .......... A Removal, abdomen lymph nodes ...................... 10.81 NA 5.26 1.32 NA 17.39 090 

38570 .... .......... A Laparoscopy, lymph node biop .......................... 9.24 NA 3.98 1.13 NA 14.35 010 

38571 .... .......... A Laparoscopy, lymphadenectomy ........................ 14.66 NA 5.66 1.15 NA 21.47 010 

38572 .... .......... A Laparoscopy, lymphadenectomy ........................ 16.57 NA 7.09 1.90 NA 25.56 010 

38589 .... .......... C Laparoscope proc, lymphatic ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

38700 .... .......... A Removal of lymph nodes, neck .......................... 8.23 NA 6.25 0.72 NA 15.20 090 

38720 .... .......... A Removal of lymph nodes, neck .......................... 13.59 NA 9.38 1.20 NA 24.17 090 

38724 .... .......... A Removal of lymph nodes, neck .......................... 14.52 NA 9.86 1.28 NA 25.66 090 

38740 .... .......... A Remove armpit lymph nodes ............................. 10.01 NA 4.95 1.32 NA 16.28 090 

38745 .... .......... A Remove armpit lymph nodes ............................. 13.08 NA 6.09 1.73 NA 20.90 090 

38746 .... .......... A Remove thoracic lymph nodes ........................... 4.88 NA 1.61 0.72 NA 7.21 ZZZ 

38747 .... .......... A Remove abdominal lymph nodes ....................... 4.88 NA 1.67 0.64 NA 7.19 ZZZ 

38760 .... .......... A Remove groin lymph nodes ............................... 12.93 NA 6.14 1.71 NA 20.78 090 

38765 .... .......... A Remove groin lymph nodes ............................... 19.95 NA 8.83 2.47 NA 31.25 090 

38770 .... .......... A Remove pelvis lymph nodes .............................. 13.21 NA 5.76 1.40 NA 20.37 090 

38780 .... .......... A Remove abdomen lymph nodes ........................ 16.57 NA 8.22 1.88 NA 26.67 090 

38790 .... .......... A Inject for lymphatic x-ray .................................... 1.29 7.37 0.76 0.13 8.79 2.18 000 

38792 .... .......... A Identify sentinel node ......................................... 0.52 NA 0.44 0.06 NA 1.02 000 

38794 .... .......... A Access thoracic lymph duct ............................... 4.44 NA 3.46 0.32 NA 8.22 090 

38999 .... .......... C Blood/lymph system procedure .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

39000 .... .......... A Exploration of chest ............................................ 6.09 NA 4.66 0.89 NA 11.64 090 

39010 .... .......... A Exploration of chest ............................................ 11.77 NA 7.56 1.75 NA 21.08 090 

39200 .... .......... A Removal chest lesion ......................................... 13.60 NA 7.55 2.02 NA 23.17 090 

39220 .... .......... A Removal chest lesion ......................................... 17.39 NA 9.39 2.45 NA 29.23 090 

39400 .... .......... A Visualization of chest ......................................... 5.60 NA 4.86 0.82 NA 11.28 010 

39499 .... .......... C Chest procedure ................................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

39501 .... .......... A Repair diaphragm laceration .............................. 13.17 NA 6.47 1.77 NA 21.41 090 

39502 .... .......... A Repair paraesophageal hernia ........................... 16.31 NA 7.16 2.16 NA 25.63 090 

39503 .... .......... A Repair of diaphragm hernia ............................... 94.86 NA 33.47 10.95 NA 139.28 090 

39520 .... .......... A Repair of diaphragm hernia ............................... 16.08 NA 8.06 2.23 NA 26.37 090 

39530 .... .......... A Repair of diaphragm hernia ............................... 15.39 NA 7.15 2.10 NA 24.64 090 

39531 .... .......... A Repair of diaphragm hernia ............................... 16.40 NA 7.40 2.21 NA 26.01 090 

39540 .... .......... A Repair of diaphragm hernia ............................... 13.30 NA 6.24 1.79 NA 21.33 090 

39541 .... .......... A Repair of diaphragm hernia ............................... 14.39 NA 6.60 1.92 NA 22.91 090 

39545 .... .......... A Revision of diaphragm ....................................... 13.35 NA 7.56 1.83 NA 22.74 090 

39560 .... .......... A Resect diaphragm, simple .................................. 11.98 NA 6.30 1.59 NA 19.87 090 

39561 .... .......... A Resect diaphragm, complex ............................... 17.47 NA 9.36 2.44 NA 29.27 090 

39599 .... .......... C Diaphragm surgery procedure ........................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

4000F .... .......... I Tobacco use txmnt counseling .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4001F .... .......... I Tobacco use txmnt, pharmacol .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4002F .... .......... I Statin therapy, rx ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4003F .... .......... I Pt ed write/oral, pts w/ hf ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4006F .... .......... I Beta-blocker therapy rx ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4009F .... .......... I Ace inhibitor therapy rx ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4011F .... .......... I Oral antiplatelet therapy rx ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4012F .... .......... I Warfarin therapy rx ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4014F .... .......... I Written discharge instr prvd ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70378 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

4015F .... .......... I Persist asthma medicine ctrl .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4016F .... .......... I Anti-inflm/anlgsc agent rx ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4017F .... .......... I Gi prophylaxis for nsaid rx ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

4018F .... .......... I Therapy exercise joint rx .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

40490 .... .......... A Biopsy of lip ........................................................ 1.22 1.63 0.61 0.05 2.90 1.88 000 

40500 .... .......... A Partial excision of lip .......................................... 4.27 6.91 4.34 0.38 11.56 8.99 090 

40510 .... .......... A Partial excision of lip .......................................... 4.69 6.63 4.02 0.49 11.81 9.20 090 

40520 .... .......... A Partial excision of lip .......................................... 4.66 7.56 4.12 0.52 12.74 9.30 090 

40525 .... .......... A Reconstruct lip with flap ..................................... 7.54 NA 6.32 0.85 NA 14.71 090 

40527 .... .......... A Reconstruct lip with flap ..................................... 9.12 NA 7.37 0.97 NA 17.46 090 

40530 .... .......... A Partial removal of lip .......................................... 5.39 7.83 4.59 0.55 13.77 10.53 090 

40650 .... .......... A Repair lip ............................................................ 3.63 6.81 3.30 0.38 10.82 7.31 090 

40652 .... .......... A Repair lip ............................................................ 4.25 7.76 4.27 0.52 12.53 9.04 090 

40654 .... .......... A Repair lip ............................................................ 5.30 8.62 4.94 0.60 14.52 10.84 090 

40700 .... .......... A Repair cleft lip/nasal ........................................... 12.77 NA 9.10 0.95 NA 22.82 090 

40701 .... .......... A Repair cleft lip/nasal ........................................... 15.83 NA 11.36 1.65 NA 28.84 090 

40702 .... .......... A Repair cleft lip/nasal ........................................... 13.02 NA 8.27 1.23 NA 22.52 090 

40720 .... .......... A Repair cleft lip/nasal ........................................... 13.53 NA 9.92 1.79 NA 25.24 090 

40761 .... .......... A Repair cleft lip/nasal ........................................... 14.70 NA 10.30 1.93 NA 26.93 090 

40799 .... .......... C Lip surgery procedure ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

40800 .... .......... A Drainage of mouth lesion ................................... 1.17 2.97 1.78 0.13 4.27 3.08 010 

40801 .... .......... A Drainage of mouth lesion ................................... 2.53 4.03 2.75 0.31 6.87 5.59 010 

40804 .... .......... A Removal, foreign body, mouth ........................... 1.24 3.40 1.86 0.11 4.75 3.21 010 

40805 .... .......... A Removal, foreign body, mouth ........................... 2.69 4.49 2.82 0.32 7.50 5.83 010 

40806 .... .......... A Incision of lip fold ............................................... 0.31 1.84 0.50 0.04 2.19 0.85 000 

40808 .... .......... A Biopsy of mouth lesion ....................................... 0.96 2.66 1.48 0.10 3.72 2.54 010 

40810 .... .......... A Excision of mouth lesion .................................... 1.31 2.89 1.66 0.13 4.33 3.10 010 

40812 .... .......... A Excise/repair mouth lesion ................................. 2.31 3.73 2.41 0.28 6.32 5.00 010 

40814 .... .......... A Excise/repair mouth lesion ................................. 3.41 4.95 3.90 0.41 8.77 7.72 090 

40816 .... .......... A Excision of mouth lesion .................................... 3.66 5.18 4.01 0.40 9.24 8.07 090 

40818 .... .......... A Excise oral mucosa for graft .............................. 2.41 5.18 3.98 0.21 7.80 6.60 090 

40819 .... .......... A Excise lip or cheek fold ...................................... 2.41 4.09 3.10 0.29 6.79 5.80 090 

40820 .... .......... A Treatment of mouth lesion ................................. 1.28 3.94 2.45 0.11 5.33 3.84 010 

40830 .... .......... A Repair mouth laceration ..................................... 1.76 3.73 2.10 0.19 5.68 4.05 010 

40831 .... .......... A Repair mouth laceration ..................................... 2.46 4.67 3.06 0.30 7.43 5.82 010 

40840 .... .......... R Reconstruction of mouth .................................... 8.72 9.81 6.99 1.08 19.61 16.79 090 

40842 .... .......... R Reconstruction of mouth .................................... 8.72 10.09 6.80 1.08 19.89 16.60 090 

40843 .... .......... R Reconstruction of mouth .................................... 12.08 11.98 7.83 1.39 25.45 21.30 090 

40844 .... .......... R Reconstruction of mouth .................................... 15.99 15.81 11.59 1.99 33.79 29.57 090 

40845 .... .......... R Reconstruction of mouth .................................... 18.55 17.11 13.25 2.00 37.66 33.80 090 

40899 .... .......... C Mouth surgery procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

41000 .... .......... A Drainage of mouth lesion ................................... 1.30 2.32 1.41 0.12 3.74 2.83 010 

41005 .... .......... A Drainage of mouth lesion ................................... 1.26 3.34 1.72 0.12 4.72 3.10 010 

41006 .... .......... A Drainage of mouth lesion ................................... 3.24 4.80 3.18 0.35 8.39 6.77 090 

41007 .... .......... A Drainage of mouth lesion ................................... 3.10 5.15 3.03 0.31 8.56 6.44 090 

41008 .... .......... A Drainage of mouth lesion ................................... 3.36 4.69 3.21 0.42 8.47 6.99 090 

41009 .... .......... A Drainage of mouth lesion ................................... 3.58 4.98 3.58 0.47 9.03 7.63 090 

41010 .... .......... A Incision of tongue fold ........................................ 1.06 3.43 1.60 0.07 4.56 2.73 010 

41015 .... .......... A Drainage of mouth lesion ................................... 3.95 5.42 4.15 0.46 9.83 8.56 090 

41016 .... .......... A Drainage of mouth lesion ................................... 4.06 5.63 4.23 0.53 10.22 8.82 090 

41017 .... .......... A Drainage of mouth lesion ................................... 4.06 5.65 4.31 0.53 10.24 8.90 090 

41018 .... .......... A Drainage of mouth lesion ................................... 5.09 6.15 4.58 0.68 11.92 10.35 090 

41100 .... .......... A Biopsy of tongue ................................................ 1.63 2.43 1.42 0.15 4.21 3.20 010 

41105 .... .......... A Biopsy of tongue ................................................ 1.42 2.31 1.32 0.13 3.86 2.87 010 

41108 .... .......... A Biopsy of floor of mouth ..................................... 1.05 2.08 1.13 0.10 3.23 2.28 010 

41110 .... .......... A Excision of tongue lesion ................................... 1.51 2.99 1.64 0.13 4.63 3.28 010 

41112 .... .......... A Excision of tongue lesion ................................... 2.73 4.48 3.23 0.28 7.49 6.24 090 

41113 .... .......... A Excision of tongue lesion ................................... 3.19 4.75 3.48 0.34 8.28 7.01 090 

41114 .... .......... A Excision of tongue lesion ................................... 8.46 NA 7.21 0.83 NA 16.50 090 

41115 .... .......... A Excision of tongue fold ....................................... 1.74 3.30 1.86 0.18 5.22 3.78 010 

41116 .... .......... A Excision of mouth lesion .................................... 2.44 4.36 2.81 0.23 7.03 5.48 090 

41120 .... .......... A Partial removal of tongue ................................... 9.76 NA 15.35 0.79 NA 25.90 090 

41130 .... .......... A Partial removal of tongue ................................... 11.13 NA 16.24 0.93 NA 28.30 090 

41135 .... .......... A Tongue and neck surgery .................................. 23.06 NA 23.29 1.88 NA 48.23 090 

41140 .... .......... A Removal of tongue ............................................. 25.46 NA 26.75 2.26 NA 54.47 090 

41145 .... .......... A Tongue removal, neck surgery .......................... 30.01 NA 30.63 2.54 NA 63.18 090 

41150 .... .......... A Tongue, mouth, jaw surgery .............................. 23.01 NA 24.78 1.94 NA 49.73 090 

41153 .... .......... A Tongue, mouth, neck surgery ............................ 23.73 NA 25.09 2.00 NA 50.82 090 

41155 .... .......... A Tongue, jaw, & neck surgery ............................. 27.68 NA 26.88 2.33 NA 56.89 090 

41250 .... .......... A Repair tongue laceration .................................... 1.91 2.75 1.18 0.18 4.84 3.27 010 

41251 .... .......... A Repair tongue laceration .................................... 2.27 3.28 1.55 0.22 5.77 4.04 010 

41252 .... .......... A Repair tongue laceration .................................... 2.97 3.90 2.26 0.29 7.16 5.52 010 

41500 .... .......... A Fixation of tongue ............................................... 3.70 NA 7.47 0.30 NA 11.47 090 

41510 .... .......... A Tongue to lip surgery ......................................... 3.41 NA 7.95 0.20 NA 11.56 090 

41520 .... .......... A Reconstruction, tongue fold ............................... 2.73 4.63 3.63 0.27 7.63 6.63 090 

70379 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

41599 .... .......... C Tongue and mouth surgery ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

41800 .... .......... A Drainage of gum lesion ...................................... 1.17 2.60 1.28 0.12 3.89 2.57 010 

41805 .... .......... A Removal foreign body, gum ............................... 1.24 2.68 2.22 0.13 4.05 3.59 010 

41806 .... .......... A Removal foreign body,jawbone .......................... 2.69 3.59 3.04 0.37 6.65 6.10 010 

41820 .... .......... R Excision, gum, each quadrant ............................ 0.00 0.00 0.00 0.00 0.00 0.00 000 

41821 .... .......... R Excision of gum flap ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

41822 .... .......... R Excision of gum lesion ....................................... 2.31 3.90 1.88 0.31 6.52 4.50 010 

41823 .... .......... R Excision of gum lesion ....................................... 3.30 5.58 4.02 0.47 9.35 7.79 090 

41825 .... .......... A Excision of gum lesion ....................................... 1.31 3.07 2.25 0.15 4.53 3.71 010 

41826 .... .......... A Excision of gum lesion ....................................... 2.31 2.44 2.11 0.30 5.05 4.72 010 

41827 .... .......... A Excision of gum lesion ....................................... 3.41 5.53 3.67 0.35 9.29 7.43 090 

41828 .... .......... R Excision of gum lesion ....................................... 3.09 3.81 2.97 0.44 7.34 6.50 010 

41830 .... .......... R Removal of gum tissue ...................................... 3.34 4.97 3.63 0.44 8.75 7.41 010 

41850 .... .......... R Treatment of gum lesion .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

41870 .... .......... R Gum graft ........................................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

41872 .... .......... R Repair gum ......................................................... 2.59 5.03 3.47 0.30 7.92 6.36 090 

41874 .... .......... R Repair tooth socket ............................................ 3.09 4.85 3.18 0.45 8.39 6.72 090 

41899 .... .......... C Dental surgery procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

42000 .... .......... A Drainage mouth roof lesion ................................ 1.23 2.57 1.25 0.12 3.92 2.60 010 

42100 .... .......... A Biopsy roof of mouth .......................................... 1.31 2.09 1.36 0.13 3.53 2.80 010 

42104 .... .......... A Excision lesion, mouth roof ................................ 1.64 2.55 1.55 0.16 4.35 3.35 010 

42106 .... .......... A Excision lesion, mouth roof ................................ 2.10 3.23 2.45 0.25 5.58 4.80 010 

42107 .... .......... A Excision lesion, mouth roof ................................ 4.43 5.73 3.96 0.44 10.60 8.83 090 

42120 .... .......... A Remove palate/lesion ......................................... 6.16 NA 11.80 0.52 NA 18.48 090 

42140 .... .......... A Excision of uvula ................................................ 1.62 3.73 2.10 0.13 5.48 3.85 090 

42145 .... .......... A Repair palate, pharynx/uvula ............................. 8.04 NA 7.51 0.65 NA 16.20 090 

42160 .... .......... A Treatment mouth roof lesion .............................. 1.80 4.26 2.30 0.17 6.23 4.27 010 

42180 .... .......... A Repair palate ...................................................... 2.50 3.08 2.11 0.21 5.79 4.82 010 

42182 .... .......... A Repair palate ...................................................... 3.82 3.88 3.04 0.40 8.10 7.26 010 

42200 .... .......... A Reconstruct cleft palate ...................................... 11.98 NA 10.24 1.27 NA 23.49 090 

42205 .... .......... A Reconstruct cleft palate ...................................... 13.27 NA 10.10 1.58 NA 24.95 090 

42210 .... .......... A Reconstruct cleft palate ...................................... 14.48 NA 11.49 2.16 NA 28.13 090 

42215 .... .......... A Reconstruct cleft palate ...................................... 8.81 NA 9.10 1.31 NA 19.22 090 

42220 .... .......... A Reconstruct cleft palate ...................................... 7.01 NA 6.80 0.73 NA 14.54 090 

42225 .... .......... A Reconstruct cleft palate ...................................... 9.53 NA 17.11 0.86 NA 27.50 090 

42226 .... .......... A Lengthening of palate ......................................... 9.99 NA 14.74 1.01 NA 25.74 090 

42227 .... .......... A Lengthening of palate ......................................... 9.51 NA 15.59 0.98 NA 26.08 090 

42235 .... .......... A Repair palate ...................................................... 7.86 NA 11.89 0.72 NA 20.47 090 

42260 .... .......... A Repair nose to lip fistula .................................... 9.79 10.22 7.08 1.26 21.27 18.13 090 

42280 .... .......... A Preparation, palate mold .................................... 1.54 1.97 1.14 0.19 3.70 2.87 010 

42281 .... .......... A Insertion, palate prosthesis ................................ 1.93 2.64 1.88 0.17 4.74 3.98 010 

42299 .... .......... C Palate/uvula surgery ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

42300 .... .......... A Drainage of salivary gland ................................. 1.93 2.83 1.82 0.16 4.92 3.91 010 

42305 .... .......... A Drainage of salivary gland ................................. 6.06 NA 4.73 0.51 NA 11.30 090 

42310 .... .......... A Drainage of salivary gland ................................. 1.56 2.27 1.54 0.13 3.96 3.23 010 

42320 .... .......... A Drainage of salivary gland ................................. 2.35 3.28 2.10 0.21 5.84 4.66 010 

42330 .... .......... A Removal of salivary stone .................................. 2.21 3.15 1.85 0.19 5.55 4.25 010 

42335 .... .......... A Removal of salivary stone .................................. 3.31 4.91 3.15 0.29 8.51 6.75 090 

42340 .... .......... A Removal of salivary stone .................................. 4.59 6.06 3.94 0.42 11.07 8.95 090 

42400 .... .......... A Biopsy of salivary gland ..................................... 0.78 1.65 0.72 0.06 2.49 1.56 000 

42405 .... .......... A Biopsy of salivary gland ..................................... 3.29 4.01 2.46 0.28 7.58 6.03 010 

42408 .... .......... A Excision of salivary cyst ..................................... 4.53 5.93 3.62 0.45 10.91 8.60 090 

42409 .... .......... A Drainage of salivary cyst .................................... 2.81 4.53 2.77 0.27 7.61 5.85 090 

42410 .... .......... A Excise parotid gland/lesion ................................ 9.33 NA 6.24 0.91 NA 16.48 090 

42415 .... .......... A Excise parotid gland/lesion ................................ 16.86 NA 10.89 1.43 NA 29.18 090 

42420 .... .......... A Excise parotid gland/lesion ................................ 19.56 NA 12.41 1.65 NA 33.62 090 

42425 .... .......... A Excise parotid gland/lesion ................................ 13.00 NA 8.63 1.05 NA 22.68 090 

42426 .... .......... A Excise parotid gland/lesion ................................ 21.23 NA 13.05 1.80 NA 36.08 090 

42440 .... .......... A Excise submaxillary gland .................................. 6.96 NA 4.80 0.59 NA 12.35 090 

42450 .... .......... A Excise sublingual gland ...................................... 4.61 5.92 4.26 0.42 10.95 9.29 090 

42500 .... .......... A Repair salivary duct ............................................ 4.29 5.70 4.19 0.41 10.40 8.89 090 

42505 .... .......... A Repair salivary duct ............................................ 6.17 7.14 5.38 0.55 13.86 12.10 090 

42507 .... .......... A Parotid duct diversion ......................................... 6.10 NA 6.55 0.49 NA 13.14 090 

42508 .... .......... A Parotid duct diversion ......................................... 9.09 NA 8.36 1.04 NA 18.49 090 

42509 .... .......... A Parotid duct diversion ......................................... 11.52 NA 10.22 0.93 NA 22.67 090 

42510 .... .......... A Parotid duct diversion ......................................... 8.14 NA 7.81 0.66 NA 16.61 090 

42550 .... .......... A Injection for salivary x-ray .................................. 1.25 3.22 0.41 0.07 4.54 1.73 000 

42600 .... .......... A Closure of salivary fistula ................................... 4.81 6.60 4.13 0.43 11.84 9.37 090 

42650 .... .......... A Dilation of salivary duct ...................................... 0.77 1.10 0.71 0.07 1.94 1.55 000 

42660 .... .......... A Dilation of salivary duct ...................................... 1.13 1.35 0.85 0.09 2.57 2.07 000 

42665 .... .......... A Ligation of salivary duct ..................................... 2.53 4.18 2.60 0.23 6.94 5.36 090 

42699 .... .......... C Salivary surgery procedure ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

42700 .... .......... A Drainage of tonsil abscess ................................. 1.62 2.66 1.70 0.13 4.41 3.45 010 

42720 .... .......... A Drainage of throat abscess ................................ 5.41 4.84 3.80 0.44 10.69 9.65 010 

42725 .... .......... A Drainage of throat abscess ................................ 10.70 NA 8.24 0.91 NA 19.85 090 

70380 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

42800 .... .......... A Biopsy of throat .................................................. 1.39 2.19 1.40 0.11 3.69 2.90 010 

42802 .... .......... A Biopsy of throat .................................................. 1.54 4.77 2.07 0.12 6.43 3.73 010 

42804 .... .......... A Biopsy of upper nose/throat ............................... 1.24 3.75 1.74 0.10 5.09 3.08 010 

42806 .... .......... A Biopsy of upper nose/throat ............................... 1.58 4.08 1.94 0.13 5.79 3.65 010 

42808 .... .......... A Excise pharynx lesion ........................................ 2.30 3.10 1.94 0.19 5.59 4.43 010 

42809 .... .......... A Remove pharynx foreign body ........................... 1.81 2.34 1.33 0.16 4.31 3.30 010 

42810 .... .......... A Excision of neck cyst .......................................... 3.25 5.73 3.55 0.29 9.27 7.09 090 

42815 .... .......... A Excision of neck cyst .......................................... 7.06 NA 6.43 0.61 NA 14.10 090 

42820 .... .......... A Remove tonsils and adenoids ............................ 3.90 NA 3.30 0.31 NA 7.51 090 

42821 .... .......... A Remove tonsils and adenoids ............................ 4.28 NA 3.51 0.35 NA 8.14 090 

42825 .... .......... A Removal of tonsils .............................................. 3.41 NA 3.18 0.25 NA 6.84 090 

42826 .... .......... A Removal of tonsils .............................................. 3.37 NA 3.04 0.27 NA 6.68 090 

42830 .... .......... A Removal of adenoids ......................................... 2.57 NA 2.57 0.20 NA 5.34 090 

42831 .... .......... A Removal of adenoids ......................................... 2.71 NA 2.85 0.22 NA 5.78 090 

42835 .... .......... A Removal of adenoids ......................................... 2.30 NA 2.47 0.21 NA 4.98 090 

42836 .... .......... A Removal of adenoids ......................................... 3.18 NA 2.97 0.26 NA 6.41 090 

42842 .... .......... A Extensive surgery of throat ................................ 8.75 NA 11.02 0.71 NA 20.48 090 

42844 .... .......... A Extensive surgery of throat ................................ 14.29 NA 16.28 1.16 NA 31.73 090 

42845 .... .......... A Extensive surgery of throat ................................ 24.25 NA 23.25 1.98 NA 49.48 090 

42860 .... .......... A Excision of tonsil tags ........................................ 2.22 NA 2.41 0.18 NA 4.81 090 

42870 .... .......... A Excision of lingual tonsil ..................................... 5.39 NA 8.59 0.44 NA 14.42 090 

42890 .... .......... A Partial removal of pharynx ................................. 12.92 NA 14.19 1.05 NA 28.16 090 

42892 .... .......... A Revision of pharyngeal walls ............................. 15.81 NA 17.22 1.28 NA 34.31 090 

42894 .... .......... A Revision of pharyngeal walls ............................. 22.85 NA 22.08 1.86 NA 46.79 090 

42900 .... .......... A Repair throat wound ........................................... 5.24 NA 3.67 0.50 NA 9.41 010 

42950 .... .......... A Reconstruction of throat ..................................... 8.09 NA 11.90 0.72 NA 20.71 090 

42953 .... .......... A Repair throat, esophagus ................................... 8.95 NA 17.38 0.88 NA 27.21 090 

42955 .... .......... A Surgical opening of throat .................................. 7.38 NA 10.70 0.80 NA 18.88 090 

42960 .... .......... A Control throat bleeding ....................................... 2.33 NA 1.97 0.19 NA 4.49 010 

42961 .... .......... A Control throat bleeding ....................................... 5.58 NA 4.97 0.45 NA 11.00 090 

42962 .... .......... A Control throat bleeding ....................................... 7.13 NA 5.93 0.58 NA 13.64 090 

42970 .... .......... A Control nose/throat bleeding .............................. 5.42 NA 4.19 0.39 NA 10.00 090 

42971 .... .......... A Control nose/throat bleeding .............................. 6.20 NA 5.13 0.51 NA 11.84 090 

42972 .... .......... A Control nose/throat bleeding .............................. 7.19 NA 5.72 0.62 NA 13.53 090 

42999 .... .......... C Throat surgery procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

43020 .... .......... A Incision of esophagus ........................................ 8.08 NA 5.43 0.87 NA 14.38 090 

43030 .... .......... A Throat muscle surgery ....................................... 7.68 NA 5.51 0.70 NA 13.89 090 

43045 .... .......... A Incision of esophagus ........................................ 20.09 NA 10.73 2.58 NA 33.40 090 

43100 .... .......... A Excision of esophagus lesion ............................. 9.18 NA 6.24 0.93 NA 16.35 090 

43101 .... .......... A Excision of esophagus lesion ............................. 16.22 NA 7.90 2.31 NA 26.43 090 

43107 .... .......... A Removal of esophagus ...................................... 39.94 NA 18.31 5.22 NA 63.47 090 

43108 .... .......... A Removal of esophagus ...................................... 34.14 NA 14.25 4.07 NA 52.46 090 

43112 .... .......... A Removal of esophagus ...................................... 43.43 NA 19.42 5.79 NA 68.64 090 

43113 .... .......... A Removal of esophagus ...................................... 35.22 NA 15.15 4.42 NA 54.79 090 

43116 .... .......... A Partial removal of esophagus ............................ 31.17 NA 16.74 3.05 NA 50.96 090 

43117 .... .......... A Partial removal of esophagus ............................ 39.94 NA 17.32 5.17 NA 62.43 090 

43118 .... .......... A Partial removal of esophagus ............................ 33.15 NA 13.82 4.10 NA 51.07 090 

43121 .... .......... A Partial removal of esophagus ............................ 29.15 NA 13.71 3.90 NA 46.76 090 

43122 .... .......... A Partial removal of esophagus ............................ 39.94 NA 17.44 5.40 NA 62.78 090 

43123 .... .......... A Partial removal of esophagus ............................ 33.15 NA 14.14 4.15 NA 51.44 090 

43124 .... .......... A Removal of esophagus ...................................... 27.28 NA 13.12 3.73 NA 44.13 090 

43130 .... .......... A Removal of esophagus pouch ........................... 11.73 NA 7.58 1.16 NA 20.47 090 

43135 .... .......... A Removal of esophagus pouch ........................... 16.08 NA 8.11 2.33 NA 26.52 090 

43200 .... .......... A Esophagus endoscopy ....................................... 1.59 4.14 1.07 0.13 5.86 2.79 000 

43201 .... .......... A Esoph scope w/submucous inj ........................... 2.09 4.64 1.10 0.15 6.88 3.34 000 

43202 .... .......... A Esophagus endoscopy, biopsy .......................... 1.89 5.56 0.94 0.15 7.60 2.98 000 

43204 .... .......... A Esoph scope w/sclerosis inj ............................... 3.76 NA 1.52 0.30 NA 5.58 000 

43205 .... .......... A Esophagus endoscopy/ligation ........................... 3.78 NA 1.52 0.28 NA 5.58 000 

43215 .... .......... A Esophagus endoscopy ....................................... 2.60 NA 1.20 0.22 NA 4.02 000 

43216 .... .......... A Esophagus endoscopy/lesion ............................. 2.40 NA 1.06 0.20 NA 3.66 000 

43217 .... .......... A Esophagus endoscopy ....................................... 2.90 6.97 1.19 0.26 10.13 4.35 000 

43219 .... .......... A Esophagus endoscopy ....................................... 2.80 NA 1.35 0.24 NA 4.39 000 

43220 .... .......... A Esoph endoscopy, dilation ................................. 2.10 NA 0.97 0.17 NA 3.24 000 

43226 .... .......... A Esoph endoscopy, dilation ................................. 2.34 NA 1.03 0.19 NA 3.56 000 

43227 .... .......... A Esoph endoscopy, repair ................................... 3.59 NA 1.45 0.28 NA 5.32 000 

43228 .... .......... A Esoph endoscopy, ablation ................................ 3.76 NA 1.55 0.34 NA 5.65 000 

43231 .... .......... A Esoph endoscopy w/us exam ............................ 3.19 NA 1.31 0.23 NA 4.73 000 

43232 .... .......... A Esoph endoscopy w/us fn bx ............................. 4.47 NA 1.82 0.34 NA 6.63 000 

43234 .... .......... A Upper GI endoscopy, exam ............................... 2.01 5.34 0.87 0.17 7.52 3.05 000 

43235 .... .......... A Uppr gi endoscopy, diagnosis ............................ 2.39 5.18 1.02 0.19 7.76 3.60 000 

43236 .... .......... A Uppr gi scope w/submuc inj ............................... 2.92 6.42 1.22 0.21 9.55 4.35 000 

43237 .... .......... A Endoscopic us exam, esoph .............................. 3.98 NA 1.59 0.43 NA 6.00 000 

43238 .... .......... A Uppr gi endoscopy w/us fn bx ........................... 5.02 NA 1.97 0.43 NA 7.42 000 

43239 .... .......... A Upper GI endoscopy, biopsy .............................. 2.87 5.73 1.19 0.22 8.82 4.28 000 

43240 .... .......... A Esoph endoscope w/drain cyst .......................... 6.85 NA 2.61 0.56 NA 10.02 000 

70381 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

43241 .... .......... A Upper GI endoscopy with tube .......................... 2.59 NA 1.10 0.21 NA 3.90 000 

43242 .... .......... A Uppr gi endoscopy w/us fn bx ........................... 7.30 NA 2.74 0.53 NA 10.57 000 

43243 .... .......... A Upper gi endoscopy & inject .............................. 4.56 NA 1.80 0.33 NA 6.69 000 

43244 .... .......... A Upper GI endoscopy/ligation .............................. 5.04 NA 1.97 0.37 NA 7.38 000 

43245 .... .......... A Uppr gi scope dilate strictr ................................. 3.18 NA 1.30 0.26 NA 4.74 000 

43246 .... .......... A Place gastrostomy tube ...................................... 4.32 NA 1.69 0.34 NA 6.35 000 

43247 .... .......... A Operative upper GI endoscopy .......................... 3.38 NA 1.37 0.27 NA 5.02 000 

43248 .... .......... A Uppr gi endoscopy/guide wire ............................ 3.15 NA 1.31 0.23 NA 4.69 000 

43249 .... .......... A Esoph endoscopy, dilation ................................. 2.90 NA 1.21 0.22 NA 4.33 000 

43250 .... .......... A Upper GI endoscopy/tumor ................................ 3.20 NA 1.31 0.26 NA 4.77 000 

43251 .... .......... A Operative upper GI endoscopy .......................... 3.69 NA 1.48 0.29 NA 5.46 000 

43255 .... .......... A Operative upper GI endoscopy .......................... 4.81 NA 1.89 0.35 NA 7.05 000 

43256 .... .......... A Uppr gi endoscopy w/stent ................................. 4.34 NA 1.71 0.32 NA 6.37 000 

43257 .... .......... A Uppr gi scope w/thrml txmnt .............................. 5.50 NA 2.21 0.36 NA 8.07 000 

43258 .... .......... A Operative upper GI endoscopy .......................... 4.54 NA 1.79 0.33 NA 6.66 000 

43259 .... .......... A Endoscopic ultrasound exam ............................. 5.19 NA 2.00 0.35 NA 7.54 000 

43260 .... .......... A Endo cholangiopancreatograph ......................... 5.95 NA 2.29 0.43 NA 8.67 000 

43261 .... .......... A Endo cholangiopancreatograph ......................... 6.26 NA 2.40 0.46 NA 9.12 000 

43262 .... .......... A Endo cholangiopancreatograph ......................... 7.38 NA 2.79 0.54 NA 10.71 000 

43263 .... .......... A Endo cholangiopancreatograph ......................... 7.28 NA 2.77 0.54 NA 10.59 000 

43264 .... .......... A Endo cholangiopancreatograph ......................... 8.89 NA 3.32 0.65 NA 12.86 000 

43265 .... .......... A Endo cholangiopancreatograph ......................... 10.00 NA 3.70 0.73 NA 14.43 000 

43267 .... .......... A Endo cholangiopancreatograph ......................... 7.38 NA 2.79 0.54 NA 10.71 000 

43268 .... .......... A Endo cholangiopancreatograph ......................... 7.38 NA 2.89 0.54 NA 10.81 000 

43269 .... .......... A Endo cholangiopancreatograph ......................... 8.20 NA 3.08 0.60 NA 11.88 000 

43271 .... .......... A Endo cholangiopancreatograph ......................... 7.38 NA 2.79 0.54 NA 10.71 000 

43272 .... .......... A Endo cholangiopancreatograph ......................... 7.38 NA 2.79 0.54 NA 10.71 000 

43280 .... .......... A Laparoscopy, fundoplasty .................................. 17.22 NA 7.29 2.27 NA 26.78 090 

43289 .... .......... C Laparoscope proc, esoph ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

43300 .... .......... A Repair of esophagus .......................................... 9.13 NA 6.39 1.12 NA 16.64 090 

43305 .... .......... A Repair esophagus and fistula ............................ 17.36 NA 10.72 1.54 NA 29.62 090 

43310 .... .......... A Repair of esophagus .......................................... 25.35 NA 11.09 3.60 NA 40.04 090 

43312 .... .......... A Repair esophagus and fistula ............................ 28.38 NA 11.92 4.00 NA 44.30 090 

43313 .... .......... A Esophagoplasty congenital ................................ 45.21 NA 18.86 5.45 NA 69.52 090 

43314 .... .......... A Tracheo-esophagoplasty cong ........................... 50.19 NA 19.24 6.63 NA 76.06 090 

43320 .... .......... A Fuse esophagus & stomach .............................. 19.90 NA 9.23 2.73 NA 31.86 090 

43324 .... .......... A Revise esophagus & stomach ........................... 20.54 NA 8.79 2.75 NA 32.08 090 

43325 .... .......... A Revise esophagus & stomach ........................... 20.03 NA 8.81 2.59 NA 31.43 090 

43326 .... .......... A Revise esophagus & stomach ........................... 19.71 NA 9.32 2.84 NA 31.87 090 

43330 .... .......... A Repair of esophagus .......................................... 19.74 NA 8.55 2.62 NA 30.91 090 

43331 .... .......... A Repair of esophagus .......................................... 20.10 NA 9.81 2.93 NA 32.84 090 

43340 .... .......... A Fuse esophagus & intestine ............................... 19.58 NA 8.99 2.45 NA 31.02 090 

43341 .... .......... A Fuse esophagus & intestine ............................... 20.82 NA 10.04 2.91 NA 33.77 090 

43350 .... .......... A Surgical opening, esophagus ............................. 15.76 NA 8.46 1.42 NA 25.64 090 

43351 .... .......... A Surgical opening, esophagus ............................. 18.32 NA 9.82 2.46 NA 30.60 090 

43352 .... .......... A Surgical opening, esophagus ............................. 15.24 NA 8.40 2.05 NA 25.69 090 

43360 .... .......... A Gastrointestinal repair ........................................ 35.65 NA 15.11 4.96 NA 55.72 090 

43361 .... .......... A Gastrointestinal repair ........................................ 40.44 NA 16.93 4.49 NA 61.86 090 

43400 .... .......... A Ligate esophagus veins ..................................... 21.17 NA 9.46 1.95 NA 32.58 090 

43401 .... .......... A Esophagus surgery for veins ............................. 22.06 NA 9.51 3.04 NA 34.61 090 

43405 .... .......... A Ligate/staple esophagus .................................... 19.98 NA 9.61 2.83 NA 32.42 090 

43410 .... .......... A Repair esophagus wound .................................. 13.45 NA 7.65 1.71 NA 22.81 090 

43415 .... .......... A Repair esophagus wound .................................. 24.96 NA 11.77 3.52 NA 40.25 090 

43420 .... .......... A Repair esophagus opening ................................ 14.33 NA 7.42 1.43 NA 23.18 090 

43425 .... .......... A Repair esophagus opening ................................ 21.00 NA 10.00 3.02 NA 34.02 090 

43450 .... .......... A Dilate esophagus ................................................ 1.38 2.64 0.69 0.11 4.13 2.18 000 

43453 .... .......... A Dilate esophagus ................................................ 1.51 6.08 0.73 0.11 7.70 2.35 000 

43456 .... .......... A Dilate esophagus ................................................ 2.57 13.78 1.10 0.20 16.55 3.87 000 

43458 .... .......... A Dilate esophagus ................................................ 3.06 6.67 1.28 0.24 9.97 4.58 000 

43460 .... .......... A Pressure treatment esophagus .......................... 3.79 NA 1.49 0.31 NA 5.59 000 

43496 .... .......... C Free jejunum flap, microvasc ............................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

43499 .... .......... C Esophagus surgery procedure ........................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

43500 .... .......... A Surgical opening of stomach .............................. 11.03 NA 4.98 1.45 NA 17.46 090 

43501 .... .......... A Surgical repair of stomach ................................. 20.01 NA 8.32 2.64 NA 30.97 090 

43502 .... .......... A Surgical repair of stomach ................................. 23.10 NA 9.48 3.09 NA 35.67 090 

43510 .... .......... A Surgical opening of stomach .............................. 13.06 NA 6.60 1.48 NA 21.14 090 

43520 .... .......... A Incision of pyloric muscle ................................... 9.98 NA 5.27 1.36 NA 16.61 090 

43600 .... .......... A Biopsy of stomach .............................................. 1.91 NA 0.66 0.14 NA 2.71 000 

43605 .... .......... A Biopsy of stomach .............................................. 11.96 NA 5.30 1.58 NA 18.84 090 

43610 .... .......... A Excision of stomach lesion ................................. 14.58 NA 6.16 1.93 NA 22.67 090 

43611 .... .......... A Excision of stomach lesion ................................. 17.81 NA 7.58 2.35 NA 27.74 090 

43620 .... .......... A Removal of stomach .......................................... 29.99 NA 11.82 3.95 NA 45.76 090 

43621 .... .......... A Removal of stomach .......................................... 30.68 NA 12.00 4.03 NA 46.71 090 

43622 .... .......... A Removal of stomach .......................................... 32.48 NA 12.62 4.29 NA 49.39 090 

43631 .... .......... A Removal of stomach, partial .............................. 22.56 NA 9.18 2.98 NA 34.72 090 

70382 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

43632 .... .......... A Removal of stomach, partial .............................. 22.56 NA 9.18 2.98 NA 34.72 090 

43633 .... .......... A Removal of stomach, partial .............................. 23.07 NA 9.35 3.05 NA 35.47 090 

43634 .... .......... A Removal of stomach, partial .............................. 25.08 NA 10.11 3.32 NA 38.51 090 

43635 .... .......... A Removal of stomach, partial .............................. 2.06 NA 0.70 0.27 NA 3.03 ZZZ 

43640 .... .......... A Vagotomy & pylorus repair ................................. 16.99 NA 7.27 2.25 NA 26.51 090 

43641 .... .......... A Vagotomy & pylorus repair ................................. 17.24 NA 7.38 2.24 NA 26.86 090 

43644 .... .......... A Lap gastric bypass/roux-en-y ............................. 27.83 NA 11.24 3.15 NA 42.22 090 

43645 .... .......... A Lap gastr bypass incl smll i ................................ 29.96 NA 12.04 3.53 NA 45.53 090 

43651 .... .......... A Laparoscopy, vagus nerve ................................. 10.13 NA 4.77 1.33 NA 16.23 090 

43652 .... .......... A Laparoscopy, vagus nerve ................................. 12.13 NA 5.77 1.55 NA 19.45 090 

43653 .... .......... A Laparoscopy, gastrostomy ................................. 7.72 NA 4.19 1.01 NA 12.92 090 

43659 .... .......... C Laparoscope proc, stom ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

43750 .... .......... A Place gastrostomy tube ...................................... 4.48 NA 2.20 0.43 NA 7.11 010 

43752 .... .......... A Nasal/orogastric w/stent ..................................... 0.81 0.28 0.26 0.02 1.11 1.09 000 

43760 .... .......... A Change gastrostomy tube .................................. 1.10 2.09 0.45 0.09 3.28 1.64 000 

43761 .... .......... A Reposition gastrostomy tube .............................. 2.01 1.17 0.66 0.13 3.31 2.80 000 

43770 .... .......... A Lap, place gastr adjust band .............................. 16.71 NA 7.73 2.18 NA 26.62 090 

43771 .... .......... A Lap, revise adjust gast band .............................. 19.50 NA 8.61 2.54 NA 30.65 090 

43772 .... .......... A Lap, remove adjust gast band ........................... 15.00 NA 6.44 1.92 NA 23.36 090 

43773 .... .......... A Lap, change adjust gast band ............................ 19.50 NA 8.61 2.55 NA 30.66 090 

43774 .... .......... A Lap remov adj gast band/port ............................ 15.00 NA 6.58 1.84 NA 23.42 090 

43800 .... .......... A Reconstruction of pylorus ................................... 13.67 NA 5.91 1.81 NA 21.39 090 

43810 .... .......... A Fusion of stomach and bowel ............................ 14.63 NA 6.19 1.93 NA 22.75 090 

43820 .... .......... A Fusion of stomach and bowel ............................ 15.35 NA 6.42 2.03 NA 23.80 090 

43825 .... .......... A Fusion of stomach and bowel ............................ 19.19 NA 8.03 2.53 NA 29.75 090 

43830 .... .......... A Place gastrostomy tube ...................................... 9.52 NA 4.85 1.25 NA 15.62 090 

43831 .... .......... A Place gastrostomy tube ...................................... 7.83 NA 4.52 1.03 NA 13.38 090 

43832 .... .......... A Place gastrostomy tube ...................................... 15.58 NA 6.86 1.97 NA 24.41 090 

43840 .... .......... A Repair of stomach lesion ................................... 15.54 NA 6.78 2.05 NA 24.37 090 

43842 .... .......... A V-band gastroplasty ........................................... 18.44 NA 7.81 2.44 NA 28.69 090 

43843 .... .......... A Gastroplasty w/o v-band .................................... 18.62 NA 7.78 2.45 NA 28.85 090 

43845 .... .......... A Gastroplasty duodenal switch ............................ 31.00 10.80 10.80 4.05 45.85 45.85 090 

43846 .... .......... A Gastric bypass for obesity .................................. 24.01 NA 10.05 3.18 NA 37.24 090 

43847 .... .......... A Gastric bypass incl small i ................................. 26.88 NA 10.92 3.55 NA 41.35 090 

43848 .... .......... A Revision gastroplasty ......................................... 29.35 NA 11.84 3.87 NA 45.06 090 

43850 .... .......... A Revise stomach-bowel fusion ............................ 24.68 NA 9.84 3.27 NA 37.79 090 

43855 .... .......... A Revise stomach-bowel fusion ............................ 26.12 NA 10.35 3.46 NA 39.93 090 

43860 .... .......... A Revise stomach-bowel fusion ............................ 24.96 NA 9.99 3.30 NA 38.25 090 

43865 .... .......... A Revise stomach-bowel fusion ............................ 26.48 NA 10.53 3.50 NA 40.51 090 

43870 .... .......... A Repair stomach opening .................................... 9.68 NA 4.52 1.27 NA 15.47 090 

43880 .... .......... A Repair stomach-bowel fistula ............................. 24.61 NA 9.92 3.26 NA 37.79 090 

43886 .... .......... A Revise gastric port, open ................................... 4.00 NA 3.14 0.25 NA 7.39 090 

43887 .... .......... A Remove gastric port, open ................................. 3.95 NA 2.78 0.51 NA 7.24 090 

43888 .... .......... A Change gastric port, open .................................. 5.80 NA 3.77 0.70 NA 10.27 090 

43999 .... .......... C Stomach surgery procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

44005 .... .......... A Freeing of bowel adhesion ................................. 16.21 NA 6.73 2.14 NA 25.08 090 

44010 .... .......... A Incision of small bowel ....................................... 12.50 NA 5.46 1.64 NA 19.60 090 

44015 .... .......... A Insert needle cath bowel .................................... 2.62 NA 0.88 0.35 NA 3.85 ZZZ 

44020 .... .......... A Explore small intestine ....................................... 13.97 NA 5.95 1.85 NA 21.77 090 

44021 .... .......... A Decompress small bowel ................................... 14.06 NA 5.98 1.86 NA 21.90 090 

44025 .... .......... A Incision of large bowel ....................................... 14.26 NA 6.04 1.89 NA 22.19 090 

44050 .... .......... A Reduce bowel obstruction .................................. 14.01 NA 5.97 1.85 NA 21.83 090 

44055 .... .......... A Correct malrotation of bowel .............................. 21.97 NA 8.75 2.90 NA 33.62 090 

44100 .... .......... A Biopsy of bowel .................................................. 2.01 NA 0.71 0.17 NA 2.89 000 

44110 .... .......... A Excise intestine lesion(s) .................................... 11.79 NA 5.24 1.55 NA 18.58 090 

44111 .... .......... A Excision of bowel lesion(s) ................................. 14.27 NA 6.12 1.86 NA 22.25 090 

44120 .... .......... A Removal of small intestine ................................. 16.97 NA 7.09 2.24 NA 26.30 090 

44121 .... .......... A Removal of small intestine ................................. 4.44 NA 1.52 0.58 NA 6.54 ZZZ 

44125 .... .......... A Removal of small intestine ................................. 17.51 NA 7.27 2.26 NA 27.04 090 

44126 .... .......... A Enterectomy w/o taper, cong ............................. 35.45 NA 14.15 4.68 NA 54.28 090 

44127 .... .......... A Enterectomy w/taper, cong ................................ 40.94 NA 15.76 5.75 NA 62.45 090 

44128 .... .......... A Enterectomy cong, add-on ................................. 4.44 NA 1.53 0.61 NA 6.58 ZZZ 

44130 .... .......... A Bowel to bowel fusion ........................................ 14.47 NA 6.23 1.87 NA 22.57 090 

44132 .... .......... R Enterectomy, cadaver donor .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44133 .... .......... R Enterectomy, live donor ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44135 .... .......... R Intestine transplnt, cadaver ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44136 .... .......... R Intestine transplant, live ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44137 .... .......... C Remove intestinal allograft ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44139 .... .......... A Mobilization of colon ........................................... 2.23 NA 0.76 0.28 NA 3.27 ZZZ 

44140 .... .......... A Partial removal of colon ..................................... 20.97 NA 8.67 2.70 NA 32.34 090 

44141 .... .......... A Partial removal of colon ..................................... 19.48 NA 10.07 2.52 NA 32.07 090 

44143 .... .......... A Partial removal of colon ..................................... 22.96 NA 10.71 3.04 NA 36.71 090 

44144 .... .......... A Partial removal of colon ..................................... 21.50 NA 9.64 2.85 NA 33.99 090 

44145 .... .......... A Partial removal of colon ..................................... 26.38 NA 10.83 3.28 NA 40.49 090 

44146 .... .......... A Partial removal of colon ..................................... 27.50 NA 12.89 3.40 NA 43.79 090 

70383 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

44147 .... .......... A Partial removal of colon ..................................... 20.68 NA 8.71 2.55 NA 31.94 090 

44150 .... .......... A Removal of colon ............................................... 23.91 NA 12.05 3.03 NA 38.99 090 

44151 .... .......... A Removal of colon/ileostomy ............................... 26.84 NA 13.43 3.48 NA 43.75 090 

44152 .... .......... A Removal of colon/ileostomy ............................... 27.79 NA 11.62 3.51 NA 42.92 090 

44153 .... .......... A Removal of colon/ileostomy ............................... 30.54 NA 14.41 3.54 NA 48.49 090 

44155 .... .......... A Removal of colon/ileostomy ............................... 27.82 NA 13.34 3.27 NA 44.43 090 

44156 .... .......... A Removal of colon/ileostomy ............................... 30.74 NA 15.07 3.94 NA 49.75 090 

44160 .... .......... A Removal of colon ............................................... 18.59 NA 7.76 2.36 NA 28.71 090 

44180 .... .......... A Lap, enterolysis .................................................. 14.42 NA 6.25 1.85 NA 22.52 090 

44186 .... .......... A Lap, jejunostomy ................................................ 9.77 NA 4.80 1.27 NA 15.84 090 

44187 .... .......... A Lap, ileo/jejuno-stomy ........................................ 15.93 NA 8.29 1.95 NA 26.17 090 

44188 .... .......... A Lap, colostomy ................................................... 17.61 NA 8.87 2.23 NA 28.71 090 

44202 .... .......... A Lap, enterectomy ................................................ 22.01 NA 8.95 2.84 NA 33.80 090 

44203 .... .......... A Lap resect s/intestine, addl ................................ 4.44 NA 1.50 0.57 NA 6.51 ZZZ 

44204 .... .......... A Laparo partial colectomy .................................... 25.04 NA 9.98 3.10 NA 38.12 090 

44205 .... .......... A Lap colectomy part w/ileum ............................... 22.20 NA 8.87 2.74 NA 33.81 090 

44206 .... .......... A Lap part colectomy w/stoma .............................. 26.96 NA 11.28 3.45 NA 41.69 090 

44207 .... .......... A L colectomy/coloproctostomy ............................. 29.96 NA 11.51 3.66 NA 45.13 090 

44208 .... .......... A L colectomy/coloproctostomy ............................. 31.95 NA 13.17 3.87 NA 48.99 090 

44210 .... .......... A Laparo total proctocolectomy ............................. 27.96 NA 11.90 3.41 NA 43.27 090 

44211 .... .......... A Laparo total proctocolectomy ............................. 34.95 NA 14.71 4.16 NA 53.82 090 

44212 .... .......... A Laparo total proctocolectomy ............................. 32.45 NA 13.72 3.77 NA 49.94 090 

44213 .... .......... A Lap, mobil splenic fl add-on ............................... 3.50 NA 1.22 0.44 NA 5.16 ZZZ 

44227 .... .......... A Lap, close enterostomy ...................................... 26.50 NA 10.65 3.37 NA 40.52 090 

44238 .... .......... C Laparoscope proc, intestine ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

44300 .... .......... A Open bowel to skin ............................................ 12.09 NA 5.50 1.60 NA 19.19 090 

44310 .... .......... A Ileostomy/jejunostomy ........................................ 15.93 NA 6.71 1.98 NA 24.62 090 

44312 .... .......... A Revision of ileostomy ......................................... 8.01 NA 4.00 0.92 NA 12.93 090 

44314 .... .......... A Revision of ileostomy ......................................... 15.03 NA 6.57 1.74 NA 23.34 090 

44316 .... .......... A Devise bowel pouch ........................................... 21.06 NA 8.56 2.37 NA 31.99 090 

44320 .... .......... A Colostomy ........................................................... 17.61 NA 7.67 2.25 NA 27.53 090 

44322 .... .......... A Colostomy with biopsies ..................................... 11.96 NA 8.59 1.54 NA 22.09 090 

44340 .... .......... A Revision of colostomy ........................................ 7.71 NA 4.27 0.99 NA 12.97 090 

44345 .... .......... A Revision of colostomy ........................................ 15.41 NA 6.90 1.96 NA 24.27 090 

44346 .... .......... A Revision of colostomy ........................................ 16.96 NA 7.40 2.12 NA 26.48 090 

44360 .... .......... A Small bowel endoscopy ..................................... 2.59 NA 1.10 0.19 NA 3.88 000 

44361 .... .......... A Small bowel endoscopy/biopsy .......................... 2.87 NA 1.20 0.21 NA 4.28 000 

44363 .... .......... A Small bowel endoscopy ..................................... 3.49 NA 1.38 0.27 NA 5.14 000 

44364 .... .......... A Small bowel endoscopy ..................................... 3.73 NA 1.49 0.27 NA 5.49 000 

44365 .... .......... A Small bowel endoscopy ..................................... 3.31 NA 1.36 0.24 NA 4.91 000 

44366 .... .......... A Small bowel endoscopy ..................................... 4.40 NA 1.74 0.32 NA 6.46 000 

44369 .... .......... A Small bowel endoscopy ..................................... 4.51 NA 1.74 0.33 NA 6.58 000 

44370 .... .......... A Small bowel endoscopy/stent ............................. 4.79 NA 1.98 0.37 NA 7.14 000 

44372 .... .......... A Small bowel endoscopy ..................................... 4.40 NA 1.74 0.35 NA 6.49 000 

44373 .... .......... A Small bowel endoscopy ..................................... 3.49 NA 1.42 0.27 NA 5.18 000 

44376 .... .......... A Small bowel endoscopy ..................................... 5.25 NA 2.03 0.42 NA 7.70 000 

44377 .... .......... A Small bowel endoscopy/biopsy .......................... 5.52 NA 2.14 0.40 NA 8.06 000 

44378 .... .......... A Small bowel endoscopy ..................................... 7.12 NA 2.70 0.52 NA 10.34 000 

44379 .... .......... A S bowel endoscope w/stent ............................... 7.46 NA 2.92 0.62 NA 11.00 000 

44380 .... .......... A Small bowel endoscopy ..................................... 1.05 NA 0.55 0.08 NA 1.68 000 

44382 .... .......... A Small bowel endoscopy ..................................... 1.27 NA 0.63 0.12 NA 2.02 000 

44383 .... .......... A Ileoscopy w/stent ................................................ 2.94 NA 1.27 0.21 NA 4.42 000 

44385 .... .......... A Endoscopy of bowel pouch ................................ 1.82 3.36 0.75 0.15 5.33 2.72 000 

44386 .... .......... A Endoscopy, bowel pouch/biop ........................... 2.12 6.66 0.88 0.20 8.98 3.20 000 

44388 .... .......... A Colonoscopy ....................................................... 2.82 5.09 1.15 0.26 8.17 4.23 000 

44389 .... .......... A Colonoscopy with biopsy .................................... 3.13 6.64 1.27 0.27 10.04 4.67 000 

44390 .... .......... A Colonoscopy for foreign body ............................ 3.82 7.13 1.49 0.32 11.27 5.63 000 

44391 .... .......... A Colonoscopy for bleeding ................................... 4.31 8.75 1.69 0.34 13.40 6.34 000 

44392 .... .......... A Colonoscopy & polypectomy .............................. 3.81 6.60 1.49 0.34 10.75 5.64 000 

44393 .... .......... A Colonoscopy, lesion removal ............................. 4.83 6.92 1.87 0.42 12.17 7.12 000 

44394 .... .......... A Colonoscopy w/snare ......................................... 4.42 7.83 1.72 0.38 12.63 6.52 000 

44397 .... .......... A Colonoscopy w/stent .......................................... 4.70 NA 1.80 0.39 NA 6.89 000 

44500 .... .......... A Intro, gastrointestinal tube .................................. 0.49 NA 0.16 0.03 NA 0.68 000 

44602 .... .......... A Suture, small intestine ........................................ 16.01 NA 6.41 2.11 NA 24.53 090 

44603 .... .......... A Suture, small intestine ........................................ 18.63 NA 7.29 2.41 NA 28.33 090 

44604 .... .......... A Suture, large intestine ........................................ 16.01 NA 6.47 2.11 NA 24.59 090 

44605 .... .......... A Repair of bowel lesion ........................................ 19.50 NA 8.41 2.51 NA 30.42 090 

44615 .... .......... A Intestinal stricturoplasty ...................................... 15.91 NA 6.69 2.06 NA 24.66 090 

44620 .... .......... A Repair bowel opening ........................................ 12.18 NA 5.34 1.51 NA 19.03 090 

44625 .... .......... A Repair bowel opening ........................................ 15.03 NA 6.32 1.85 NA 23.20 090 

44626 .... .......... A Repair bowel opening ........................................ 25.32 NA 9.84 3.26 NA 38.42 090 

44640 .... .......... A Repair bowel-skin fistula .................................... 21.62 NA 8.59 2.77 NA 32.98 090 

44650 .... .......... A Repair bowel fistula ............................................ 22.54 NA 8.91 2.92 NA 34.37 090 

44660 .... .......... A Repair bowel-bladder fistula ............................... 21.33 NA 8.36 2.13 NA 31.82 090 

44661 .... .......... A Repair bowel-bladder fistula ............................... 24.77 NA 9.58 2.80 NA 37.15 090 

70384 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

44680 .... .......... A Surgical revision, intestine ................................. 15.38 NA 6.46 1.99 NA 23.83 090 

44700 .... .......... A Suspend bowel w/prosthesis .............................. 16.09 NA 6.68 1.83 NA 24.60 090 

44701 .... .......... A Intraop colon lavage add-on .............................. 3.10 NA 1.06 0.37 NA 4.53 ZZZ 

44715 .... .......... C Prepare donor intestine ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

44720 .... .......... A Prep donor intestine/venous .............................. 5.00 NA 1.71 0.37 NA 7.08 XXX 

44721 .... .......... A Prep donor intestine/artery ................................. 7.00 NA 2.40 0.97 NA 10.37 XXX 

44799 .... .......... C Unlisted procedure intestine ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

44800 .... .......... A Excision of bowel pouch .................................... 11.21 NA 5.40 1.47 NA 18.08 090 

44820 .... .......... A Excision of mesentery lesion ............................. 12.07 NA 5.50 1.59 NA 19.16 090 

44850 .... .......... A Repair of mesentery ........................................... 10.72 NA 5.01 1.39 NA 17.12 090 

44899 .... .......... C Bowel surgery procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

44900 .... .......... A Drain app abscess, open ................................... 10.12 NA 4.70 1.33 NA 16.15 090 

44901 .... .......... A Drain app abscess, percut ................................. 3.37 27.97 1.11 0.22 31.56 4.70 000 

44950 .... .......... A Appendectomy .................................................... 9.99 NA 4.32 1.31 NA 15.62 090 

44955 .... .......... A Appendectomy add-on ....................................... 1.53 NA 0.54 0.20 NA 2.27 ZZZ 

44960 .... .......... A Appendectomy .................................................... 12.32 NA 5.35 1.63 NA 19.30 090 

44970 .... .......... A Laparoscopy, appendectomy ............................. 8.69 NA 4.09 1.14 NA 13.92 090 

44979 .... .......... C Laparoscope proc, app ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

45000 .... .......... A Drainage of pelvic abscess ................................ 4.51 NA 2.97 0.52 NA 8.00 090 

45005 .... .......... A Drainage of rectal abscess ................................ 1.99 4.06 1.58 0.25 6.30 3.82 010 

45020 .... .......... A Drainage of rectal abscess ................................ 4.71 NA 3.28 0.55 NA 8.54 090 

45100 .... .......... A Biopsy of rectum ................................................ 3.67 NA 2.37 0.44 NA 6.48 090 

45108 .... .......... A Removal of anorectal lesion ............................... 4.75 NA 2.78 0.59 NA 8.12 090 

45110 .... .......... A Removal of rectum ............................................. 27.96 NA 12.43 3.35 NA 43.74 090 

45111 .... .......... A Partial removal of rectum ................................... 16.46 NA 7.18 2.06 NA 25.70 090 

45112 .... .......... A Removal of rectum ............................................. 30.49 NA 11.79 3.42 NA 45.70 090 

45113 .... .......... A Partial proctectomy ............................................. 30.53 NA 12.63 3.48 NA 46.64 090 

45114 .... .......... A Partial removal of rectum ................................... 27.28 NA 10.90 3.35 NA 41.53 090 

45116 .... .......... A Partial removal of rectum ................................... 24.54 NA 10.05 2.87 NA 37.46 090 

45119 .... .......... A Remove rectum w/reservoir ............................... 30.79 NA 12.49 3.35 NA 46.63 090 

45120 .... .......... A Removal of rectum ............................................. 24.56 NA 10.15 2.89 NA 37.60 090 

45121 .... .......... A Removal of rectum and colon ............................ 27.00 NA 11.13 3.24 NA 41.37 090 

45123 .... .......... A Partial proctectomy ............................................. 16.68 NA 6.87 1.85 NA 25.40 090 

45126 .... .......... A Pelvic exenteration ............................................. 45.09 NA 19.26 4.32 NA 68.67 090 

45130 .... .......... A Excision of rectal prolapse ................................. 16.42 NA 6.78 1.79 NA 24.99 090 

45135 .... .......... A Excision of rectal prolapse ................................. 19.25 NA 8.43 2.35 NA 30.03 090 

45136 .... .......... A Excise ileoanal reservior .................................... 27.26 NA 12.55 2.81 NA 42.62 090 

45150 .... .......... A Excision of rectal stricture .................................. 5.66 NA 2.97 0.61 NA 9.24 090 

45160 .... .......... A Excision of rectal lesion ..................................... 15.30 NA 6.66 1.67 NA 23.63 090 

45170 .... .......... A Excision of rectal lesion ..................................... 11.47 NA 5.25 1.35 NA 18.07 090 

45190 .... .......... A Destruction, rectal tumor .................................... 9.73 NA 4.63 1.13 NA 15.49 090 

45300 .... .......... A Proctosigmoidoscopy dx .................................... 0.38 1.53 0.28 0.04 1.95 0.70 000 

45303 .... .......... A Proctosigmoidoscopy dilate ................................ 0.44 18.73 0.33 0.05 19.22 0.82 000 

45305 .... .......... A Proctosigmoidoscopy w/bx ................................. 1.01 2.64 0.50 0.11 3.76 1.62 000 

45307 .... .......... A Proctosigmoidoscopy fb ..................................... 0.94 3.04 0.48 0.11 4.09 1.53 000 

45308 .... .......... A Proctosigmoidoscopy removal ........................... 0.83 2.00 0.44 0.09 2.92 1.36 000 

45309 .... .......... A Proctosigmoidoscopy removal ........................... 2.01 2.82 0.84 0.22 5.05 3.07 000 

45315 .... .......... A Proctosigmoidoscopy removal ........................... 1.40 2.87 0.63 0.15 4.42 2.18 000 

45317 .... .......... A Proctosigmoidoscopy bleed ............................... 1.50 2.44 0.66 0.15 4.09 2.31 000 

45320 .... .......... A Proctosigmoidoscopy ablate .............................. 1.58 2.92 0.71 0.16 4.66 2.45 000 

45321 .... .......... A Proctosigmoidoscopy volvul ............................... 1.17 NA 0.56 0.13 NA 1.86 000 

45327 .... .......... A Proctosigmoidoscopy w/stent ............................. 1.65 NA 0.69 0.16 NA 2.50 000 

45330 .... .......... A Diagnostic sigmoidoscopy .................................. 0.96 2.28 0.50 0.08 3.32 1.54 000 

45331 .... .......... A Sigmoidoscopy and biopsy ................................ 1.15 3.08 0.59 0.09 4.32 1.83 000 

45332 .... .......... A Sigmoidoscopy w/fb removal ............................. 1.79 5.01 0.80 0.16 6.96 2.75 000 

45333 .... .......... A Sigmoidoscopy & polypectomy .......................... 1.79 4.88 0.80 0.15 6.82 2.74 000 

45334 .... .......... A Sigmoidoscopy for bleeding ............................... 2.73 NA 1.14 0.20 NA 4.07 000 

45335 .... .......... A Sigmoidoscopy w/submuc inj ............................. 1.46 3.22 0.69 0.11 4.79 2.26 000 

45337 .... .......... A Sigmoidoscopy & decompress ........................... 2.36 NA 1.00 0.21 NA 3.57 000 

45338 .... .......... A Sigmoidoscopy w/tumr remove .......................... 2.34 5.23 1.00 0.19 7.76 3.53 000 

45339 .... .......... A Sigmoidoscopy w/ablate tumr ............................ 3.14 3.47 1.28 0.26 6.87 4.68 000 

45340 .... .......... A Sig w/balloon dilation ......................................... 1.89 6.19 0.83 0.15 8.23 2.87 000 

45341 .... .......... A Sigmoidoscopy w/ultrasound .............................. 2.60 NA 1.07 0.19 NA 3.86 000 

45342 .... .......... A Sigmoidoscopy w/us guide bx ............................ 4.05 NA 1.54 0.30 NA 5.89 000 

45345 .... .......... A Sigmoidoscopy w/stent ....................................... 2.92 NA 1.16 0.23 NA 4.31 000 

45355 .... .......... A Surgical colonoscopy ......................................... 3.51 NA 1.38 0.36 NA 5.25 000 

45378 .... 53 ..... A Diagnostic colonoscopy ...................................... 0.96 2.28 0.50 0.08 3.32 1.54 000 

45378 .... .......... A Diagnostic colonoscopy ...................................... 3.69 6.16 1.47 0.30 10.15 5.46 000 

45379 .... .......... A Colonoscopy w/fb removal ................................. 4.68 7.68 1.82 0.39 12.75 6.89 000 

45380 .... .......... A Colonoscopy and biopsy .................................... 4.43 7.21 1.74 0.35 11.99 6.52 000 

45381 .... .......... A Colonoscopy, submucous inj ............................. 4.19 7.13 1.65 0.30 11.62 6.14 000 

45382 .... .......... A Colonoscopy/control bleeding ............................ 5.68 9.97 2.19 0.41 16.06 8.28 000 

45383 .... .......... A Lesion removal colonoscopy .............................. 5.86 7.94 2.23 0.48 14.28 8.57 000 

45384 .... .......... A Lesion remove colonoscopy ............................... 4.69 6.82 1.83 0.38 11.89 6.90 000 

45385 .... .......... A Lesion removal colonoscopy .............................. 5.30 7.82 2.04 0.42 13.54 7.76 000 

70385 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

45386 .... .......... A Colonoscopy dilate stricture ............................... 4.57 12.44 1.79 0.39 17.40 6.75 000 

45387 .... .......... A Colonoscopy w/stent .......................................... 5.90 NA 2.34 0.48 NA 8.72 000 

45391 .... .......... A Colonoscopy w/endoscope us ........................... 5.09 NA 1.98 0.42 NA 7.49 000 

45392 .... .......... A Colonoscopy w/endoscopic fnb .......................... 6.54 NA 2.49 0.42 NA 9.45 000 

45395 .... .......... A Lap, removal of rectum ...................................... 30.50 NA 13.71 3.62 NA 47.83 090 

45397 .... .......... A Lap, remove rectum w/pouch ............................. 34.00 NA 14.30 3.66 NA 51.96 090 

45400 .... .......... A Laparoscopic proctopexy ................................... 18.06 NA 7.85 2.02 NA 27.93 090 

45402 .... .......... A Lap proctopexy w/sig resect .............................. 25.04 NA 10.01 2.81 NA 37.86 090 

45499 .... .......... C Laparoscope proc, rectum ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

45500 .... .......... A Repair of rectum ................................................. 7.28 NA 3.54 0.75 NA 11.57 090 

45505 .... .......... A Repair of rectum ................................................. 7.57 NA 3.86 0.86 NA 12.29 090 

45520 .... .......... A Treatment of rectal prolapse .............................. 0.55 1.64 0.37 0.05 2.24 0.97 000 

45540 .... .......... A Correct rectal prolapse ....................................... 16.25 NA 6.81 1.84 NA 24.90 090 

45541 .... .......... A Correct rectal prolapse ....................................... 13.38 NA 5.96 1.55 NA 20.89 090 

45550 .... .......... A Repair rectum/remove sigmoid .......................... 22.97 NA 9.24 2.61 NA 34.82 090 

45560 .... .......... A Repair of rectocele ............................................. 10.56 NA 5.06 1.13 NA 16.75 090 

45562 .... .......... A Exploration/repair of rectum ............................... 15.36 NA 7.00 1.83 NA 24.19 090 

45563 .... .......... A Exploration/repair of rectum ............................... 23.43 NA 10.54 3.10 NA 37.07 090 

45800 .... .......... A Repair rect/bladder fistula .................................. 17.74 NA 7.44 1.85 NA 27.03 090 

45805 .... .......... A Repair fistula w/colostomy ................................. 20.75 NA 9.53 2.02 NA 32.30 090 

45820 .... .......... A Repair rectourethral fistula ................................. 18.45 NA 7.64 1.58 NA 27.67 090 

45825 .... .......... A Repair fistula w/colostomy ................................. 21.22 NA 9.84 2.31 NA 33.37 090 

45900 .... .......... A Reduction of rectal prolapse .............................. 2.61 NA 1.50 0.30 NA 4.41 010 

45905 .... .......... A Dilation of anal sphincter .................................... 2.30 NA 1.43 0.27 NA 4.00 010 

45910 .... .......... A Dilation of rectal narrowing ................................ 2.80 NA 1.66 0.30 NA 4.76 010 

45915 .... .......... A Remove rectal obstruction ................................. 3.14 4.33 2.10 0.30 7.77 5.54 010 

45990 .... .......... A Surg dx exam, anorectal .................................... 1.80 NA 0.79 0.17 NA 2.76 000 

45999 .... .......... C Rectum surgery procedure ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

46020 .... .......... A Placement of seton ............................................ 2.90 2.34 1.86 0.31 5.55 5.07 010 

46030 .... .......... A Removal of rectal marker ................................... 1.23 1.35 0.71 0.14 2.72 2.08 010 

46040 .... .......... A Incision of rectal abscess ................................... 4.95 5.51 3.59 0.62 11.08 9.16 090 

46045 .... .......... A Incision of rectal abscess ................................... 4.31 NA 2.90 0.54 NA 7.75 090 

46050 .... .......... A Incision of anal abscess ..................................... 1.19 2.55 0.84 0.14 3.88 2.17 010 

46060 .... .......... A Incision of rectal abscess ................................... 5.68 NA 3.25 0.67 NA 9.60 090 

46070 .... .......... A Incision of anal septum ...................................... 2.71 NA 1.84 0.36 NA 4.91 090 

46080 .... .......... A Incision of anal sphincter ................................... 2.49 2.37 1.13 0.30 5.16 3.92 010 

46083 .... .......... A Incise external hemorrhoid ................................. 1.40 2.53 0.92 0.15 4.08 2.47 010 

46200 .... .......... A Removal of anal fissure ..................................... 3.41 3.86 2.87 0.39 7.66 6.67 090 

46210 .... .......... A Removal of anal crypt ........................................ 2.67 5.12 2.63 0.31 8.10 5.61 090 

46211 .... .......... A Removal of anal crypts ...................................... 4.24 5.42 3.51 0.48 10.14 8.23 090 

46220 .... .......... A Removal of anal tag ........................................... 1.56 2.30 0.95 0.17 4.03 2.68 010 

46221 .... .......... A Ligation of hemorrhoid(s) ................................... 2.04 2.65 1.75 0.23 4.92 4.02 010 

46230 .... .......... A Removal of anal tags ......................................... 2.57 3.08 1.29 0.30 5.95 4.16 010 

46250 .... .......... A Hemorrhoidectomy ............................................. 3.88 5.32 2.62 0.48 9.68 6.98 090 

46255 .... .......... A Hemorrhoidectomy ............................................. 4.59 5.85 2.84 0.58 11.02 8.01 090 

46257 .... .......... A Remove hemorrhoids & fissure .......................... 5.39 NA 2.88 0.64 NA 8.91 090 

46258 .... .......... A Remove hemorrhoids & fistula ........................... 5.72 NA 3.28 0.68 NA 9.68 090 

46260 .... .......... A Hemorrhoidectomy ............................................. 6.36 NA 3.19 0.76 NA 10.31 090 

46261 .... .......... A Remove hemorrhoids & fissure .......................... 7.07 NA 3.61 0.79 NA 11.47 090 

46262 .... .......... A Remove hemorrhoids & fistula ........................... 7.49 NA 3.74 0.83 NA 12.06 090 

46270 .... .......... A Removal of anal fistula ....................................... 3.71 5.00 2.84 0.46 9.17 7.01 090 

46275 .... .......... A Removal of anal fistula ....................................... 4.55 4.64 2.98 0.52 9.71 8.05 090 

46280 .... .......... A Removal of anal fistula ....................................... 5.97 NA 3.26 0.66 NA 9.89 090 

46285 .... .......... A Removal of anal fistula ....................................... 4.08 3.77 2.75 0.44 8.29 7.27 090 

46288 .... .......... A Repair anal fistula .............................................. 7.12 NA 3.68 0.79 NA 11.59 090 

46320 .... .......... A Removal of hemorrhoid clot ............................... 1.61 2.13 0.85 0.18 3.92 2.64 010 

46500 .... .......... A Injection into hemorrhoid(s) ................................ 1.61 2.12 1.15 0.16 3.89 2.92 010 

46505 .... .......... A Chemodenervation anal musc ........................... 2.86 3.05 1.97 0.14 6.05 4.97 010 

46600 .... .......... A Diagnostic anoscopy .......................................... 0.50 1.56 0.34 0.05 2.11 0.89 000 

46604 .... .......... A Anoscopy and dilation ........................................ 1.31 9.15 0.62 0.12 10.58 2.05 000 

46606 .... .......... A Anoscopy and biopsy ......................................... 0.81 3.79 0.43 0.09 4.69 1.33 000 

46608 .... .......... A Anoscopy, remove for body ............................... 1.51 4.41 0.65 0.16 6.08 2.32 000 

46610 .... .......... A Anoscopy, remove lesion ................................... 1.32 4.04 0.61 0.15 5.51 2.08 000 

46611 .... .......... A Anoscopy ............................................................ 1.81 3.34 0.78 0.19 5.34 2.78 000 

46612 .... .......... A Anoscopy, remove lesions ................................. 2.34 5.20 0.98 0.28 7.82 3.60 000 

46614 .... .......... A Anoscopy, control bleeding ................................ 2.01 2.33 0.84 0.20 4.54 3.05 000 

46615 .... .......... A Anoscopy ............................................................ 2.68 2.49 1.07 0.33 5.50 4.08 000 

46700 .... .......... A Repair of anal stricture ....................................... 9.12 NA 4.21 0.94 NA 14.27 090 

46705 .... .......... A Repair of anal stricture ....................................... 6.89 NA 3.69 0.91 NA 11.49 090 

46706 .... .......... A Repr of anal fistula w/glue ................................. 2.39 NA 1.25 0.28 NA 3.92 010 

46710 .... .......... A Repr per/vag pouch sngl proc ............................ 16.00 NA 7.77 1.38 NA 25.15 090 

46712 .... .......... A Repr per/vag pouch dbl proc ............................. 34.00 NA 15.08 3.66 NA 52.74 090 

46715 .... .......... A Rep perf anoper fistu ......................................... 7.19 NA 3.58 0.92 NA 11.69 090 

46716 .... .......... A Rep perf anoper/vestib fistu ............................... 15.05 NA 7.99 1.58 NA 24.62 090 

46730 .... .......... A Construction of absent anus .............................. 26.71 NA 12.05 2.46 NA 41.22 090 

70386 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

46735 .... .......... A Construction of absent anus .............................. 32.12 NA 13.58 3.20 NA 48.90 090 

46740 .... .......... A Construction of absent anus .............................. 29.96 NA 13.26 2.41 NA 45.63 090 

46742 .... .......... A Repair of imperforated anus .............................. 35.75 NA 17.43 3.19 NA 56.37 090 

46744 .... .......... A Repair of cloacal anomaly .................................. 52.55 NA 21.17 6.38 NA 80.10 090 

46746 .... .......... A Repair of cloacal anomaly .................................. 58.13 NA 25.21 7.68 NA 91.02 090 

46748 .... .......... A Repair of cloacal anomaly .................................. 64.11 NA 23.70 3.36 NA 91.17 090 

46750 .... .......... A Repair of anal sphincter ..................................... 10.23 NA 5.06 1.10 NA 16.39 090 

46751 .... .......... A Repair of anal sphincter ..................................... 8.76 NA 5.43 0.94 NA 15.13 090 

46753 .... .......... A Reconstruction of anus ...................................... 8.28 NA 3.85 0.94 NA 13.07 090 

46754 .... .......... A Removal of suture from anus ............................. 2.20 3.60 1.67 0.19 5.99 4.06 010 

46760 .... .......... A Repair of anal sphincter ..................................... 14.41 NA 7.10 1.59 NA 23.10 090 

46761 .... .......... A Repair of anal sphincter ..................................... 13.82 NA 6.02 1.43 NA 21.27 090 

46762 .... .......... A Implant artificial sphincter ................................... 12.69 NA 5.53 1.24 NA 19.46 090 

46900 .... .......... A Destruction, anal lesion(s) .................................. 1.91 2.59 1.27 0.17 4.67 3.35 010 

46910 .... .......... A Destruction, anal lesion(s) .................................. 1.86 2.91 1.06 0.19 4.96 3.11 010 

46916 .... .......... A Cryosurgery, anal lesion(s) ................................ 1.86 3.16 1.39 0.11 5.13 3.36 010 

46917 .... .......... A Laser surgery, anal lesions ................................ 1.86 9.15 1.12 0.21 11.22 3.19 010 

46922 .... .......... A Excision of anal lesion(s) ................................... 1.86 3.28 1.07 0.22 5.36 3.15 010 

46924 .... .......... A Destruction, anal lesion(s) .................................. 2.76 8.71 1.35 0.26 11.73 4.37 010 

46934 .... .......... A Destruction of hemorrhoids ................................ 3.50 5.08 2.96 0.32 8.90 6.78 090 

46935 .... .......... A Destruction of hemorrhoids ................................ 2.43 3.47 1.21 0.23 6.13 3.87 010 

46936 .... .......... A Destruction of hemorrhoids ................................ 3.68 4.88 2.50 0.34 8.90 6.52 090 

46937 .... .......... A Cryotherapy of rectal lesion ............................... 2.69 2.78 1.22 0.14 5.61 4.05 010 

46938 .... .......... A Cryotherapy of rectal lesion ............................... 4.65 4.00 3.06 0.58 9.23 8.29 090 

46940 .... .......... A Treatment of anal fissure ................................... 2.32 2.00 1.09 0.23 4.55 3.64 010 

46942 .... .......... A Treatment of anal fissure ................................... 2.04 1.84 1.02 0.19 4.07 3.25 010 

46945 .... .......... A Ligation of hemorrhoids ...................................... 1.84 3.27 2.48 0.19 5.30 4.51 090 

46946 .... .......... A Ligation of hemorrhoids ...................................... 2.58 3.73 2.40 0.27 6.58 5.25 090 

46947 .... .......... A Hemorrhoidopexy by stapling ............................. 5.20 NA 2.72 0.75 NA 8.67 090 

46999 .... .......... C Anus surgery procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

47000 .... .......... A Needle biopsy of liver ......................................... 1.90 3.08 0.63 0.12 5.10 2.65 000 

47001 .... .......... A Needle biopsy, liver add-on ............................... 1.90 NA 0.65 0.25 NA 2.80 ZZZ 

47010 .... .......... A Open drainage, liver lesion ................................ 15.99 NA 8.41 1.80 NA 26.20 090 

47011 .... .......... A Percut drain, liver lesion ..................................... 3.69 NA 1.21 0.22 NA 5.12 000 

47015 .... .......... A Inject/aspirate liver cyst ...................................... 15.09 NA 7.50 1.83 NA 24.42 090 

47100 .... .......... A Wedge biopsy of liver ......................................... 11.65 NA 6.05 1.53 NA 19.23 090 

47120 .... .......... A Partial removal of liver ....................................... 35.45 NA 15.18 4.65 NA 55.28 090 

47122 .... .......... A Extensive removal of liver .................................. 55.05 NA 21.50 7.19 NA 83.74 090 

47125 .... .......... A Partial removal of liver ....................................... 49.12 NA 19.56 6.45 NA 75.13 090 

47130 .... .......... A Partial removal of liver ....................................... 53.27 NA 21.02 6.94 NA 81.23 090 

47133 .... .......... X Removal of donor liver ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

47135 .... .......... R Transplantation of liver ....................................... 81.40 NA 31.59 9.93 NA 122.92 090 

47136 .... .......... R Transplantation of liver ....................................... 68.50 NA 27.09 8.41 NA 104.00 090 

47140 .... .......... A Partial removal, donor liver ................................ 54.92 NA 22.33 5.17 NA 82.42 090 

47141 .... .......... A Partial removal, donor liver ................................ 67.40 NA 26.98 5.17 NA 99.55 090 

47142 .... .......... A Partial removal, donor liver ................................ 74.89 NA 29.55 5.17 NA 109.61 090 

47143 .... .......... C Prep donor liver, whole ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

47144 .... .......... C Prep donor liver, 3-segment ............................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

47145 .... .......... C Prep donor liver, lobe split ................................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

47146 .... .......... A Prep donor liver/venous ..................................... 6.00 NA 2.06 0.83 NA 8.89 XXX 

47147 .... .......... A Prep donor liver/arterial ...................................... 7.00 NA 2.40 0.97 NA 10.37 XXX 

47300 .... .......... A Surgery for liver lesion ....................................... 15.06 NA 7.24 1.98 NA 24.28 090 

47350 .... .......... A Repair liver wound ............................................. 19.53 NA 8.89 2.58 NA 31.00 090 

47360 .... .......... A Repair liver wound ............................................. 26.88 NA 11.60 3.37 NA 41.85 090 

47361 .... .......... A Repair liver wound ............................................. 47.05 NA 18.56 5.85 NA 71.46 090 

47362 .... .......... A Repair liver wound ............................................. 18.48 NA 8.74 2.50 NA 29.72 090 

47370 .... .......... A Laparo ablate liver tumor rf ................................ 19.66 NA 8.15 2.55 NA 30.36 090 

47371 .... .......... A Laparo ablate liver cryosurg ............................... 19.66 NA 8.16 2.60 NA 30.42 090 

47379 .... .......... C Laparoscope procedure, liver ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

47380 .... .......... A Open ablate liver tumor rf .................................. 22.97 NA 9.38 2.86 NA 35.21 090 

47381 .... .......... A Open ablate liver tumor cryo .............................. 23.24 NA 9.61 2.84 NA 35.69 090 

47382 .... .......... A Percut ablate liver rf ........................................... 15.17 NA 6.09 0.96 NA 22.22 010 

47399 .... .......... C Liver surgery procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

47400 .... .......... A Incision of liver duct ........................................... 32.44 NA 13.47 3.07 NA 48.98 090 

47420 .... .......... A Incision of bile duct ............................................ 19.85 NA 8.78 2.62 NA 31.25 090 

47425 .... .......... A Incision of bile duct ............................................ 19.80 NA 8.83 2.61 NA 31.24 090 

47460 .... .......... A Incise bile duct sphincter .................................... 18.01 NA 8.38 2.20 NA 28.59 090 

47480 .... .......... A Incision of gallbladder ........................................ 10.80 NA 5.92 1.42 NA 18.14 090 

47490 .... .......... A Incision of gallbladder ........................................ 7.22 NA 5.58 0.43 NA 13.23 090 

47500 .... .......... A Injection for liver x-rays ...................................... 1.96 NA 0.64 0.12 NA 2.72 000 

47505 .... .......... A Injection for liver x-rays ...................................... 0.76 NA 0.25 0.04 NA 1.05 000 

47510 .... .......... A Insert catheter, bile duct ..................................... 7.82 NA 5.02 0.46 NA 13.30 090 

47511 .... .......... A Insert bile duct drain ........................................... 10.48 NA 5.09 0.62 NA 16.19 090 

47525 .... .......... A Change bile duct catheter .................................. 5.54 15.13 2.81 0.33 21.00 8.68 010 

47530 .... .......... A Revise/reinsert bile tube ..................................... 5.84 33.88 3.72 0.37 40.09 9.93 090 

70387 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

47550 .... .......... A Bile duct endoscopy add-on ............................... 3.02 NA 1.02 0.40 NA 4.44 ZZZ 

47552 .... .......... A Biliary endoscopy thru skin ................................ 6.03 NA 2.38 0.42 NA 8.83 000 

47553 .... .......... A Biliary endoscopy thru skin ................................ 6.34 NA 2.07 0.37 NA 8.78 000 

47554 .... .......... A Biliary endoscopy thru skin ................................ 9.05 NA 3.36 0.96 NA 13.37 000 

47555 .... .......... A Biliary endoscopy thru skin ................................ 7.55 NA 2.47 0.45 NA 10.47 000 

47556 .... .......... A Biliary endoscopy thru skin ................................ 8.55 NA 2.79 0.50 NA 11.84 000 

47560 .... .......... A Laparoscopy w/cholangio ................................... 4.88 NA 1.67 0.65 NA 7.20 000 

47561 .... .......... A Laparo w/cholangio/biopsy ................................. 5.17 NA 1.92 0.66 NA 7.75 000 

47562 .... .......... A Laparoscopic cholecystectomy .......................... 11.07 NA 4.99 1.46 NA 17.52 090 

47563 .... .......... A Laparo cholecystectomy/graph .......................... 11.92 NA 5.31 1.58 NA 18.81 090 

47564 .... .......... A Laparo cholecystectomy/explr ............................ 14.21 NA 5.96 1.88 NA 22.05 090 

47570 .... .......... A Laparo cholecystoenterostomy .......................... 12.56 NA 5.38 1.65 NA 19.59 090 

47579 .... .......... C Laparoscope proc, biliary ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

47600 .... .......... A Removal of gallbladder ...................................... 13.56 NA 6.14 1.79 NA 21.49 090 

47605 .... .......... A Removal of gallbladder ...................................... 14.67 NA 6.51 1.94 NA 23.12 090 

47610 .... .......... A Removal of gallbladder ...................................... 18.79 NA 7.94 2.48 NA 29.21 090 

47612 .... .......... A Removal of gallbladder ...................................... 18.75 NA 7.89 2.47 NA 29.11 090 

47620 .... .......... A Removal of gallbladder ...................................... 20.61 NA 8.53 2.73 NA 31.87 090 

47630 .... .......... A Remove bile duct stone ..................................... 9.10 NA 4.89 0.65 NA 14.64 090 

47700 .... .......... A Exploration of bile ducts ..................................... 15.60 NA 7.42 2.06 NA 25.08 090 

47701 .... .......... A Bile duct revision ................................................ 27.77 NA 11.50 3.67 NA 42.94 090 

47711 .... .......... A Excision of bile duct tumor ................................. 23.00 NA 9.94 3.04 NA 35.98 090 

47712 .... .......... A Excision of bile duct tumor ................................. 30.19 NA 12.44 3.92 NA 46.55 090 

47715 .... .......... A Excision of bile duct cyst .................................... 18.77 NA 8.44 2.48 NA 29.69 090 

47716 .... .......... A Fusion of bile duct cyst ...................................... 16.42 NA 7.83 2.14 NA 26.39 090 

47720 .... .......... A Fuse gallbladder & bowel ................................... 15.89 NA 7.48 2.10 NA 25.47 090 

47721 .... .......... A Fuse upper gi structures .................................... 19.09 NA 8.57 2.52 NA 30.18 090 

47740 .... .......... A Fuse gallbladder & bowel ................................... 18.45 NA 8.38 2.41 NA 29.24 090 

47741 .... .......... A Fuse gallbladder & bowel ................................... 21.31 NA 9.30 2.82 NA 33.43 090 

47760 .... .......... A Fuse bile ducts and bowel ................................. 25.81 NA 10.86 3.41 NA 40.08 090 

47765 .... .......... A Fuse liver ducts & bowel .................................... 24.84 NA 10.81 3.29 NA 38.94 090 

47780 .... .......... A Fuse bile ducts and bowel ................................. 26.46 NA 11.22 3.49 NA 41.17 090 

47785 .... .......... A Fuse bile ducts and bowel ................................. 31.13 NA 12.93 4.09 NA 48.15 090 

47800 .... .......... A Reconstruction of bile ducts ............................... 23.27 NA 10.07 3.07 NA 36.41 090 

47801 .... .......... A Placement, bile duct support .............................. 15.15 NA 8.16 1.16 NA 24.47 090 

47802 .... .......... A Fuse liver duct & intestine .................................. 21.52 NA 9.68 2.85 NA 34.05 090 

47900 .... .......... A Suture bile duct injury ........................................ 19.87 NA 8.88 2.64 NA 31.39 090 

47999 .... .......... C Bile tract surgery procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

48000 .... .......... A Drainage of abdomen ......................................... 28.03 NA 11.52 3.47 NA 43.02 090 

48001 .... .......... A Placement of drain, pancreas ............................ 35.40 NA 13.90 4.68 NA 53.98 090 

48005 .... .......... A Resect/debride pancreas ................................... 42.11 NA 16.59 5.54 NA 64.24 090 

48020 .... .......... A Removal of pancreatic stone ............................. 15.68 NA 7.31 2.12 NA 25.11 090 

48100 .... .......... A Biopsy of pancreas, open .................................. 12.21 NA 5.60 1.62 NA 19.43 090 

48102 .... .......... A Needle biopsy, pancreas .................................... 4.67 7.97 1.95 0.28 12.92 6.90 010 

48120 .... .......... A Removal of pancreas lesion ............................... 15.83 NA 6.86 2.09 NA 24.78 090 

48140 .... .......... A Partial removal of pancreas ............................... 22.91 NA 9.55 3.02 NA 35.48 090 

48145 .... .......... A Partial removal of pancreas ............................... 23.98 NA 9.84 3.17 NA 36.99 090 

48146 .... .......... A Pancreatectomy .................................................. 26.36 NA 12.00 3.49 NA 41.85 090 

48148 .... .......... A Removal of pancreatic duct ............................... 17.31 NA 7.61 2.29 NA 27.21 090 

48150 .... .......... A Partial removal of pancreas ............................... 47.93 NA 19.54 6.30 NA 73.77 090 

48152 .... .......... A Pancreatectomy .................................................. 43.68 NA 18.23 5.78 NA 67.69 090 

48153 .... .......... A Pancreatectomy .................................................. 47.82 NA 19.58 6.29 NA 73.69 090 

48154 .... .......... A Pancreatectomy .................................................. 44.03 NA 18.26 5.82 NA 68.11 090 

48155 .... .......... A Removal of pancreas ......................................... 24.60 NA 11.68 3.26 NA 39.54 090 

48160 .... .......... N Pancreas removal/transplant .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

48180 .... .......... A Fuse pancreas and bowel .................................. 24.68 NA 10.17 3.27 NA 38.12 090 

48400 .... .......... A Injection, intraop add-on ..................................... 1.95 NA 0.64 0.15 NA 2.74 ZZZ 

48500 .... .......... A Surgery of pancreatic cyst ................................. 15.26 NA 7.34 2.02 NA 24.62 090 

48510 .... .......... A Drain pancreatic pseudocyst .............................. 14.29 NA 7.45 1.82 NA 23.56 090 

48511 .... .......... A Drain pancreatic pseudocyst .............................. 3.99 20.95 1.31 0.24 25.18 5.54 000 

48520 .... .......... A Fuse pancreas cyst and bowel .......................... 15.57 NA 6.71 2.05 NA 24.33 090 

48540 .... .......... A Fuse pancreas cyst and bowel .......................... 19.69 NA 8.12 2.60 NA 30.41 090 

48545 .... .......... A Pancreatorrhaphy ............................................... 18.15 NA 7.99 2.37 NA 28.51 090 

48547 .... .......... A Duodenal exclusion ............................................ 25.79 NA 10.50 3.41 NA 39.70 090 

48550 .... .......... X Donor pancreatectomy ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

48551 .... .......... C Prep donor pancreas .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

48552 .... .......... A Prep donor pancreas/venous ............................. 4.30 NA 1.46 0.31 NA 6.07 XXX 

48554 .... .......... R Transpl allograft pancreas .................................. 34.12 NA 18.30 4.18 NA 56.60 090 

48556 .... .......... A Removal, allograft pancreas .............................. 15.69 NA 8.08 2.07 NA 25.84 090 

48999 .... .......... C Pancreas surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

49000 .... .......... A Exploration of abdomen ..................................... 11.66 NA 5.39 1.52 NA 18.57 090 

49002 .... .......... A Reopening of abdomen ...................................... 10.47 NA 5.02 1.37 NA 16.86 090 

49010 .... .......... A Exploration behind abdomen ............................. 12.26 NA 5.91 1.51 NA 19.68 090 

49020 .... .......... A Drain abdominal abscess ................................... 22.81 NA 10.21 2.84 NA 35.86 090 

49021 .... .......... A Drain abdominal abscess ................................... 3.37 21.11 1.11 0.20 24.68 4.68 000 

70388 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

49040 .... .......... A Drain, open, abdom abscess ............................. 13.50 NA 6.43 1.69 NA 21.62 090 

49041 .... .......... A Drain, percut, abdom abscess ........................... 3.99 19.57 1.31 0.24 23.80 5.54 000 

49060 .... .......... A Drain, open, retrop abscess ............................... 15.84 NA 7.44 1.74 NA 25.02 090 

49061 .... .......... A Drain, percut, retroper absc ............................... 3.69 19.68 1.21 0.22 23.59 5.12 000 

49062 .... .......... A Drain to peritoneal cavity ................................... 11.34 NA 5.44 1.39 NA 18.17 090 

49080 .... .......... A Puncture, peritoneal cavity ................................. 1.35 3.99 0.46 0.08 5.42 1.89 000 

49081 .... .......... A Removal of abdominal fluid ................................ 1.26 2.59 0.43 0.09 3.94 1.78 000 

49085 .... .......... A Remove abdomen foreign body ......................... 12.12 NA 5.51 1.62 NA 19.25 090 

49180 .... .......... A Biopsy, abdominal mass .................................... 1.73 3.11 0.57 0.10 4.94 2.40 000 

49200 .... .......... A Removal of abdominal lesion ............................. 10.23 NA 5.03 1.24 NA 16.50 090 

49201 .... .......... A Remove abdom lesion, complex ........................ 14.82 NA 7.04 1.87 NA 23.73 090 

49215 .... .......... A Excise sacral spine tumor .................................. 33.45 NA 14.08 4.37 NA 51.90 090 

49220 .... .......... A Multiple surgery, abdomen ................................. 14.86 NA 6.64 1.88 NA 23.38 090 

49250 .... .......... A Excision of umbilicus .......................................... 8.34 NA 4.27 1.08 NA 13.69 090 

49255 .... .......... A Removal of omentum ......................................... 11.12 NA 5.62 1.43 NA 18.17 090 

49320 .... .......... A Diag laparo separate proc .................................. 5.09 NA 2.64 0.65 NA 8.38 010 

49321 .... .......... A Laparoscopy, biopsy .......................................... 5.39 NA 2.65 0.70 NA 8.74 010 

49322 .... .......... A Laparoscopy, aspiration ..................................... 5.69 NA 3.00 0.71 NA 9.40 010 

49323 .... .......... A Laparo drain lymphocele .................................... 9.47 NA 4.50 1.20 NA 15.17 090 

49329 .... .......... C Laparo proc, abdm/per/oment ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

49400 .... .......... A Air injection into abdomen .................................. 1.88 3.08 0.62 0.15 5.11 2.65 000 

49419 .... .......... A Insrt abdom cath for chemotx ............................ 6.64 NA 3.57 0.81 NA 11.02 090 

49420 .... .......... A Insert abdom drain, temp ................................... 2.22 NA 1.09 0.21 NA 3.52 000 

49421 .... .......... A Insert abdom drain, perm ................................... 5.53 NA 3.16 0.74 NA 9.43 090 

49422 .... .......... A Remove perm cannula/catheter ......................... 6.24 NA 2.90 0.83 NA 9.97 010 

49423 .... .......... A Exchange drainage catheter .............................. 1.46 14.11 0.52 0.09 15.66 2.07 000 

49424 .... .......... A Assess cyst, contrast inject ................................ 0.76 3.72 0.29 0.04 4.52 1.09 000 

49425 .... .......... A Insert abdomen-venous drain ............................ 11.35 NA 5.61 1.54 NA 18.50 090 

49426 .... .......... A Revise abdomen-venous shunt .......................... 9.62 NA 4.77 1.28 NA 15.67 090 

49427 .... .......... A Injection, abdominal shunt ................................. 0.89 NA 0.30 0.07 NA 1.26 000 

49428 .... .......... A Ligation of shunt ................................................. 6.05 NA 3.93 0.80 NA 10.78 010 

49429 .... .......... A Removal of shunt ............................................... 7.39 NA 3.43 1.02 NA 11.84 010 

49491 .... .......... A Rpr hern preemie reduc ..................................... 11.11 NA 5.06 1.40 NA 17.57 090 

49492 .... .......... A Rpr ing hern premie, blocked ............................. 14.01 NA 6.12 1.80 NA 21.93 090 

49495 .... .......... A Rpr ing hernia baby, reduc ................................ 5.88 NA 2.96 0.74 NA 9.58 090 

49496 .... .......... A Rpr ing hernia baby, blocked ............................. 8.78 NA 4.28 1.07 NA 14.13 090 

49500 .... .......... A Rpr ing hernia, init, reduce ................................. 5.47 NA 3.12 0.71 NA 9.30 090 

49501 .... .......... A Rpr ing hernia, init blocked ................................ 8.87 NA 4.21 1.12 NA 14.20 090 

49505 .... .......... A Prp i/hern init reduc >5 yr .................................. 7.59 NA 3.75 1.03 NA 12.37 090 

49507 .... .......... A Prp i/hern init block >5 yr ................................... 9.56 NA 4.46 1.27 NA 15.29 090 

49520 .... .......... A Rerepair ing hernia, reduce ............................... 9.62 NA 4.44 1.28 NA 15.34 090 

49521 .... .......... A Rerepair ing hernia, blocked .............................. 11.95 NA 5.25 1.59 NA 18.79 090 

49525 .... .......... A Repair ing hernia, sliding ................................... 8.56 NA 4.08 1.13 NA 13.77 090 

49540 .... .......... A Repair lumbar hernia .......................................... 10.37 NA 4.75 1.37 NA 16.49 090 

49550 .... .......... A Rpr rem hernia, init, reduce ............................... 8.62 NA 4.13 1.14 NA 13.89 090 

49553 .... .......... A Rpr fem hernia, init blocked ............................... 9.43 NA 4.42 1.24 NA 15.09 090 

49555 .... .......... A Rerepair fem hernia, reduce .............................. 9.02 NA 4.27 1.20 NA 14.49 090 

49557 .... .......... A Rerepair fem hernia, blocked ............................. 11.13 NA 4.99 1.47 NA 17.59 090 

49560 .... .......... A Rpr ventral hern init, reduc ................................ 11.55 NA 5.15 1.52 NA 18.22 090 

49561 .... .......... A Rpr ventral hern init, block ................................. 14.23 NA 6.07 1.88 NA 22.18 090 

49565 .... .......... A Rerepair ventrl hern, reduce .............................. 11.55 NA 5.23 1.52 NA 18.30 090 

49566 .... .......... A Rerepair ventrl hern, block ................................. 14.38 NA 6.14 1.90 NA 22.42 090 

49568 .... .......... A Hernia repair w/mesh ......................................... 4.88 NA 1.67 0.64 NA 7.19 ZZZ 

49570 .... .......... A Rpr epigastric hern, reduce ................................ 5.68 NA 3.17 0.75 NA 9.60 090 

49572 .... .......... A Rpr epigastric hern, blocked .............................. 6.72 NA 3.47 0.88 NA 11.07 090 

49580 .... .......... A Rpr umbil hern, reduc < 5 yr .............................. 4.10 NA 2.60 0.54 NA 7.24 090 

49582 .... .......... A Rpr umbil hern, block < 5 yr .............................. 6.64 NA 3.47 0.88 NA 10.99 090 

49585 .... .......... A Rpr umbil hern, reduc > 5 yr .............................. 6.22 NA 3.30 0.82 NA 10.34 090 

49587 .... .......... A Rpr umbil hern, block > 5 yr .............................. 7.55 NA 3.74 0.99 NA 12.28 090 

49590 .... .......... A Repair spigelian hernia ...................................... 8.53 NA 4.09 1.13 NA 13.75 090 

49600 .... .......... A Repair umbilical lesion ....................................... 10.94 NA 5.34 1.32 NA 17.60 090 

49605 .... .......... A Repair umbilical lesion ....................................... 75.89 NA 28.58 9.36 NA 113.83 090 

49606 .... .......... A Repair umbilical lesion ....................................... 18.57 NA 7.70 2.45 NA 28.72 090 

49610 .... .......... A Repair umbilical lesion ....................................... 10.48 NA 5.21 1.07 NA 16.76 090 

49611 .... .......... A Repair umbilical lesion ....................................... 8.91 NA 6.99 0.78 NA 16.68 090 

49650 .... .......... A Laparo hernia repair initial ................................. 6.26 NA 3.20 0.93 NA 10.39 090 

49651 .... .......... A Laparo hernia repair recur ................................. 8.23 NA 4.05 1.14 NA 13.42 090 

49659 .... .......... C Laparo proc, hernia repair .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

49900 .... .......... A Repair of abdominal wall .................................... 12.26 NA 6.24 1.62 NA 20.12 090 

49904 .... .......... A Omental flap, extra-abdom ................................. 19.97 NA 15.25 2.69 NA 37.91 090 

49905 .... .......... A Omental flap, intra-abdom .................................. 6.54 NA 2.30 0.75 NA 9.59 ZZZ 

49906 .... .......... C Free omental flap, microvasc ............................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

49999 .... .......... C Abdomen surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

50010 .... .......... A Exploration of kidney .......................................... 10.96 NA 5.23 0.93 NA 17.12 090 

50020 .... .......... A Renal abscess, open drain ................................ 14.64 NA 7.76 1.34 NA 23.74 090 

70389 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

50021 .... .......... A Renal abscess, percut drain .............................. 3.37 21.71 1.10 0.20 25.28 4.67 000 

50040 .... .......... A Drainage of kidney ............................................. 14.92 NA 6.82 1.03 NA 22.77 090 

50045 .... .......... A Exploration of kidney .......................................... 15.44 NA 6.61 1.24 NA 23.29 090 

50060 .... .......... A Removal of kidney stone .................................... 19.27 NA 7.84 1.36 NA 28.47 090 

50065 .... .......... A Incision of kidney ................................................ 20.76 NA 6.09 1.59 NA 28.44 090 

50070 .... .......... A Incision of kidney ................................................ 20.29 NA 8.23 1.44 NA 29.96 090 

50075 .... .......... A Removal of kidney stone .................................... 25.30 NA 9.92 1.80 NA 37.02 090 

50080 .... .......... A Removal of kidney stone .................................... 14.69 NA 6.29 1.04 NA 22.02 090 

50081 .... .......... A Removal of kidney stone .................................... 21.77 NA 8.78 1.54 NA 32.09 090 

50100 .... .......... A Revise kidney blood vessels .............................. 16.07 NA 7.80 2.06 NA 25.93 090 

50120 .... .......... A Exploration of kidney .......................................... 15.89 NA 6.78 1.21 NA 23.88 090 

50125 .... .......... A Explore and drain kidney ................................... 16.50 NA 6.98 1.43 NA 24.91 090 

50130 .... .......... A Removal of kidney stone .................................... 17.26 NA 7.18 1.22 NA 25.66 090 

50135 .... .......... A Exploration of kidney .......................................... 19.15 NA 7.79 1.33 NA 28.27 090 

50200 .... .......... A Biopsy of kidney ................................................. 2.63 NA 1.29 0.16 NA 4.08 000 

50205 .... .......... A Biopsy of kidney ................................................. 11.29 NA 5.02 1.30 NA 17.61 090 

50220 .... .......... A Remove kidney, open ........................................ 17.12 NA 7.25 1.35 NA 25.72 090 

50225 .... .......... A Removal kidney open, complex ......................... 20.20 NA 8.16 1.50 NA 29.86 090 

50230 .... .......... A Removal kidney open, radical ............................ 22.04 NA 8.59 1.55 NA 32.18 090 

50234 .... .......... A Removal of kidney & ureter ............................... 22.37 NA 8.85 1.59 NA 32.81 090 

50236 .... .......... A Removal of kidney & ureter ............................... 24.82 NA 10.27 1.76 NA 36.85 090 

50240 .... .......... A Partial removal of kidney .................................... 21.97 NA 9.03 1.55 NA 32.55 090 

50250 .... .......... A Cryoablate renal mass open .............................. 19.97 NA 9.18 1.39 NA 30.54 090 

50280 .... .......... A Removal of kidney lesion ................................... 15.65 NA 6.70 1.19 NA 23.54 090 

50290 .... .......... A Removal of kidney lesion ................................... 14.71 NA 6.47 1.41 NA 22.59 090 

50300 .... .......... X Remove cadaver donor kidney .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

50320 .... .......... A Remove kidney, living donor .............................. 22.18 NA 10.68 2.35 NA 35.21 090 

50323 .... .......... C Prep cadaver renal allograft ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

50325 .... .......... C Prep donor renal graft ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

50327 .... .......... A Prep renal graft/venous ...................................... 4.00 NA 1.35 0.29 NA 5.64 XXX 

50328 .... .......... A Prep renal graft/arterial ...................................... 3.50 NA 1.18 0.26 NA 4.94 XXX 

50329 .... .......... A Prep renal graft/ureteral ..................................... 3.34 NA 1.13 0.25 NA 4.72 XXX 

50340 .... .......... A Removal of kidney .............................................. 12.13 NA 6.51 1.65 NA 20.29 090 

50360 .... .......... A Transplantation of kidney ................................... 31.48 NA 15.51 3.81 NA 50.80 090 

50365 .... .......... A Transplantation of kidney ................................... 36.75 NA 18.24 4.42 NA 59.41 090 

50370 .... .......... A Remove transplanted kidney .............................. 13.70 NA 7.16 1.67 NA 22.53 090 

50380 .... .......... A Reimplantation of kidney .................................... 20.73 NA 12.05 2.50 NA 35.28 090 

50382 .... .......... A Change ureter stent, percut ............................... 5.50 36.22 1.87 0.34 42.06 7.71 000 

50384 .... .......... A Remove ureter stent, percut .............................. 5.00 35.32 1.71 0.31 40.63 7.02 000 

50387 .... .......... A Change ext/int ureter stent ................................. 2.00 18.26 0.67 0.12 20.38 2.79 000 

50389 .... .......... A Remove renal tube w/fluoro ............................... 1.10 12.78 0.37 0.07 13.95 1.54 000 

50390 .... .......... A Drainage of kidney lesion ................................... 1.96 NA 0.64 0.12 NA 2.72 000 

50391 .... .......... A Instll rx agnt into rnal tub ................................... 1.96 1.58 0.63 0.14 3.68 2.73 000 

50392 .... .......... A Insert kidney drain .............................................. 3.37 NA 1.52 0.20 NA 5.09 000 

50393 .... .......... A Insert ureteral tube ............................................. 4.15 NA 1.79 0.25 NA 6.19 000 

50394 .... .......... A Injection for kidney x-ray .................................... 0.76 2.69 0.66 0.05 3.50 1.47 000 

50395 .... .......... A Create passage to kidney .................................. 3.37 NA 1.50 0.21 NA 5.08 000 

50396 .... .......... A Measure kidney pressure ................................... 2.09 NA 1.08 0.13 NA 3.30 000 

50398 .... .......... A Change kidney tube ........................................... 1.46 16.36 0.52 0.09 17.91 2.07 000 

50400 .... .......... A Revision of kidney/ureter .................................... 19.47 NA 7.89 1.38 NA 28.74 090 

50405 .... .......... A Revision of kidney/ureter .................................... 23.89 NA 9.05 1.78 NA 34.72 090 

50500 .... .......... A Repair of kidney wound ..................................... 19.54 NA 8.40 2.01 NA 29.95 090 

50520 .... .......... A Close kidney-skin fistula ..................................... 17.20 NA 7.44 1.49 NA 26.13 090 

50525 .... .......... A Repair renal-abdomen fistula ............................. 22.24 NA 9.02 1.83 NA 33.09 090 

50526 .... .......... A Repair renal-abdomen fistula ............................. 23.98 NA 9.88 1.96 NA 35.82 090 

50540 .... .......... A Revision of horseshoe kidney ............................ 19.90 NA 8.34 1.36 NA 29.60 090 

50541 .... .......... A Laparo ablate renal cyst ..................................... 15.98 NA 6.50 1.13 NA 23.61 090 

50542 .... .......... A Laparo ablate renal mass .................................. 19.97 NA 8.15 1.39 NA 29.51 090 

50543 .... .......... A Laparo partial nephrectomy ............................... 25.46 NA 10.22 1.80 NA 37.48 090 

50544 .... .......... A Laparoscopy, pyeloplasty ................................... 22.37 NA 8.54 1.58 NA 32.49 090 

50545 .... .......... A Laparo radical nephrectomy ............................... 23.96 NA 9.21 1.70 NA 34.87 090 

50546 .... .......... A Laparoscopic nephrectomy ................................ 20.45 NA 8.38 1.57 NA 30.40 090 

50547 .... .......... A Laparo removal donor kidney ............................ 25.46 NA 11.13 2.76 NA 39.35 090 

50548 .... .......... A Laparo remove w/ureter ..................................... 24.36 NA 9.20 1.72 NA 35.28 090 

50549 .... .......... C Laparoscope proc, renal .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

50551 .... .......... A Kidney endoscopy .............................................. 5.59 4.15 1.98 0.40 10.14 7.97 000 

50553 .... .......... A Kidney endoscopy .............................................. 5.98 4.37 2.18 0.39 10.74 8.55 000 

50555 .... .......... A Kidney endoscopy & biopsy ............................... 6.52 4.82 2.34 0.45 11.79 9.31 000 

50557 .... .......... A Kidney endoscopy & treatment .......................... 6.61 4.59 2.30 0.47 11.67 9.38 000 

50561 .... .......... A Kidney endoscopy & treatment .......................... 7.58 5.09 2.65 0.54 13.21 10.77 000 

50562 .... .......... A Renal scope w/tumor resect .............................. 10.90 NA 4.32 0.73 NA 15.95 090 

50570 .... .......... A Kidney endoscopy .............................................. 9.53 NA 3.22 0.68 NA 13.43 000 

50572 .... .......... A Kidney endoscopy .............................................. 10.33 NA 3.51 0.85 NA 14.69 000 

50574 .... .......... A Kidney endoscopy & biopsy ............................... 11.00 NA 3.75 0.77 NA 15.52 000 

50575 .... .......... A Kidney endoscopy .............................................. 13.96 NA 4.64 0.99 NA 19.59 000 

70390 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

50576 .... .......... A Kidney endoscopy & treatment .......................... 10.97 NA 3.67 0.78 NA 15.42 000 

50580 .... .......... A Kidney endoscopy & treatment .......................... 11.84 NA 3.97 0.83 NA 16.64 000 

50590 .... .......... A Fragmenting of kidney stone .............................. 9.08 12.43 4.12 0.65 22.16 13.85 090 

50592 .... .......... A Perc rf ablate renal tumor .................................. 6.75 149.45 2.99 0.43 156.63 10.17 010 

50600 .... .......... A Exploration of ureter ........................................... 15.82 NA 6.68 1.13 NA 23.63 090 

50605 .... .......... A Insert ureteral support ........................................ 15.44 NA 6.75 1.45 NA 23.64 090 

50610 .... .......... A Removal of ureter stone ..................................... 15.90 NA 6.98 1.43 NA 24.31 090 

50620 .... .......... A Removal of ureter stone ..................................... 15.14 NA 6.35 1.07 NA 22.56 090 

50630 .... .......... A Removal of ureter stone ..................................... 14.92 NA 6.29 1.09 NA 22.30 090 

50650 .... .......... A Removal of ureter ............................................... 17.38 NA 7.24 1.23 NA 25.85 090 

50660 .... .......... A Removal of ureter ............................................... 19.52 NA 7.97 1.38 NA 28.87 090 

50684 .... .......... A Injection for ureter x-ray ..................................... 0.76 4.98 0.47 0.05 5.79 1.28 000 

50686 .... .......... A Measure ureter pressure .................................... 1.51 3.45 0.82 0.11 5.07 2.44 000 

50688 .... .......... A Change of ureter tube/stent ............................... 1.17 NA 1.06 0.07 NA 2.30 010 

50690 .... .......... A Injection for ureter x-ray ..................................... 1.16 1.83 0.72 0.07 3.06 1.95 000 

50700 .... .......... A Revision of ureter ............................................... 15.19 NA 7.13 1.27 NA 23.59 090 

50715 .... .......... A Release of ureter ................................................ 18.87 NA 8.76 2.13 NA 29.76 090 

50722 .... .......... A Release of ureter ................................................ 16.33 NA 7.82 1.90 NA 26.05 090 

50725 .... .......... A Release/revise ureter ......................................... 18.46 NA 8.06 1.52 NA 28.04 090 

50727 .... .......... A Revise ureter ...................................................... 8.17 NA 4.28 0.61 NA 13.06 090 

50728 .... .......... A Revise ureter ...................................................... 12.00 NA 5.57 1.00 NA 18.57 090 

50740 .... .......... A Fusion of ureter & kidney ................................... 18.39 NA 7.75 1.96 NA 28.10 090 

50750 .... .......... A Fusion of ureter & kidney ................................... 19.48 NA 8.00 1.38 NA 28.86 090 

50760 .... .......... A Fusion of ureters ................................................ 18.39 NA 7.69 1.55 NA 27.63 090 

50770 .... .......... A Splicing of ureters .............................................. 19.48 NA 7.99 1.45 NA 28.92 090 

50780 .... .......... A Reimplant ureter in bladder ................................ 18.33 NA 7.60 1.51 NA 27.44 090 

50782 .... .......... A Reimplant ureter in bladder ................................ 19.51 NA 8.79 1.61 NA 29.91 090 

50783 .... .......... A Reimplant ureter in bladder ................................ 20.52 NA 8.23 1.98 NA 30.73 090 

50785 .... .......... A Reimplant ureter in bladder ................................ 20.49 NA 8.31 1.45 NA 30.25 090 

50800 .... .......... A Implant ureter in bowel ....................................... 14.50 NA 6.48 1.19 NA 22.17 090 

50810 .... .......... A Fusion of ureter & bowel .................................... 20.02 NA 9.11 2.31 NA 31.44 090 

50815 .... .......... A Urine shunt to intestine ...................................... 19.90 NA 8.46 1.54 NA 29.90 090 

50820 .... .......... A Construct bowel bladder .................................... 21.86 NA 8.66 1.89 NA 32.41 090 

50825 .... .......... A Construct bowel bladder .................................... 28.14 NA 11.15 2.07 NA 41.36 090 

50830 .... .......... A Revise urine flow ................................................ 31.23 NA 12.20 2.37 NA 45.80 090 

50840 .... .......... A Replace ureter by bowel .................................... 19.97 NA 8.44 1.47 NA 29.88 090 

50845 .... .......... A Appendico-vesicostomy ...................................... 20.86 NA 8.92 1.57 NA 31.35 090 

50860 .... .......... A Transplant ureter to skin .................................... 15.34 NA 6.63 1.29 NA 23.26 090 

50900 .... .......... A Repair of ureter .................................................. 13.60 NA 6.15 1.14 NA 20.89 090 

50920 .... .......... A Closure ureter/skin fistula ................................... 14.31 NA 6.58 1.01 NA 21.90 090 

50930 .... .......... A Closure ureter/bowel fistula ................................ 18.69 NA 7.98 1.28 NA 27.95 090 

50940 .... .......... A Release of ureter ................................................ 14.49 NA 6.41 1.26 NA 22.16 090 

50945 .... .......... A Laparoscopy ureterolithotomy ............................ 16.97 NA 7.05 1.36 NA 25.38 090 

50947 .... .......... A Laparo new ureter/bladder ................................. 24.46 NA 9.71 2.16 NA 36.33 090 

50948 .... .......... A Laparo new ureter/bladder ................................. 22.47 NA 8.71 1.70 NA 32.88 090 

50949 .... .......... C Laparoscope proc, ureter ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

50951 .... .......... A Endoscopy of ureter ........................................... 5.83 4.30 2.06 0.41 10.54 8.30 000 

50953 .... .......... A Endoscopy of ureter ........................................... 6.23 4.41 2.37 0.43 11.07 9.03 000 

50955 .... .......... A Ureter endoscopy & biopsy ................................ 6.74 6.43 2.69 0.48 13.65 9.91 000 

50957 .... .......... A Ureter endoscopy & treatment ........................... 6.78 4.57 2.38 0.48 11.83 9.64 000 

50961 .... .......... A Ureter endoscopy & treatment ........................... 6.04 4.37 2.19 0.41 10.82 8.64 000 

50970 .... .......... A Ureter endoscopy ............................................... 7.13 NA 2.47 0.52 NA 10.12 000 

50972 .... .......... A Ureter endoscopy & catheter ............................. 6.88 NA 2.47 0.49 NA 9.84 000 

50974 .... .......... A Ureter endoscopy & biopsy ................................ 9.16 NA 3.11 0.64 NA 12.91 000 

50976 .... .......... A Ureter endoscopy & treatment ........................... 9.03 NA 3.07 0.66 NA 12.76 000 

50980 .... .......... A Ureter endoscopy & treatment ........................... 6.84 NA 2.38 0.48 NA 9.70 000 

51000 .... .......... A Drainage of bladder ............................................ 0.78 1.95 0.24 0.05 2.78 1.07 000 

51005 .... .......... A Drainage of bladder ............................................ 1.02 4.71 0.34 0.10 5.83 1.46 000 

51010 .... .......... A Drainage of bladder ............................................ 3.52 5.62 1.88 0.28 9.42 5.68 010 

51020 .... .......... A Incise & treat bladder ......................................... 6.70 NA 3.86 0.47 NA 11.03 090 

51030 .... .......... A Incise & treat bladder ......................................... 6.76 NA 3.98 0.58 NA 11.32 090 

51040 .... .......... A Incise & drain bladder ........................................ 4.39 NA 2.77 0.31 NA 7.47 090 

51045 .... .......... A Incise bladder/drain ureter ................................. 6.76 NA 3.93 0.52 NA 11.21 090 

51050 .... .......... A Removal of bladder stone .................................. 6.91 NA 3.65 0.49 NA 11.05 090 

51060 .... .......... A Removal of ureter stone ..................................... 8.84 NA 4.51 0.62 NA 13.97 090 

51065 .... .......... A Remove ureter calculus ..................................... 8.84 NA 4.36 0.63 NA 13.83 090 

51080 .... .......... A Drainage of bladder abscess ............................. 5.95 NA 3.55 0.43 NA 9.93 090 

51500 .... .......... A Removal of bladder cyst .................................... 10.12 NA 5.01 1.03 NA 16.16 090 

51520 .... .......... A Removal of bladder lesion ................................. 9.28 NA 4.68 0.69 NA 14.65 090 

51525 .... .......... A Removal of bladder lesion ................................. 13.95 NA 6.14 0.99 NA 21.08 090 

51530 .... .......... A Removal of bladder lesion ................................. 12.36 NA 5.76 1.05 NA 19.17 090 

51535 .... .......... A Repair of ureter lesion ........................................ 12.55 NA 6.12 1.23 NA 19.90 090 

51550 .... .......... A Partial removal of bladder .................................. 15.64 NA 6.74 1.31 NA 23.69 090 

51555 .... .......... A Partial removal of bladder .................................. 21.20 NA 8.68 1.69 NA 31.57 090 

51565 .... .......... A Revise bladder & ureter(s) ................................. 21.59 NA 8.98 1.63 NA 32.20 090 

70391 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

51570 .... .......... A Removal of bladder ............................................ 24.20 NA 9.76 1.71 NA 35.67 090 

51575 .... .......... A Removal of bladder & nodes ............................. 30.40 NA 12.05 2.16 NA 44.61 090 

51580 .... .......... A Remove bladder/revise tract .............................. 31.03 NA 12.52 2.24 NA 45.79 090 

51585 .... .......... A Removal of bladder & nodes ............................. 35.18 NA 13.73 2.48 NA 51.39 090 

51590 .... .......... A Remove bladder/revise tract .............................. 32.61 NA 12.64 2.27 NA 47.52 090 

51595 .... .......... A Remove bladder/revise tract .............................. 37.08 NA 14.16 2.59 NA 53.83 090 

51596 .... .......... A Remove bladder/create pouch ........................... 39.46 NA 15.26 2.77 NA 57.49 090 

51597 .... .......... A Removal of pelvic structures .............................. 38.29 NA 14.86 2.81 NA 55.96 090 

51600 .... .......... A Injection for bladder x-ray .................................. 0.88 5.06 0.29 0.06 6.00 1.23 000 

51605 .... .......... A Preparation for bladder xray .............................. 0.64 6.07 0.35 0.04 6.75 1.03 000 

51610 .... .......... A Injection for bladder x-ray .................................. 1.05 2.29 0.60 0.07 3.41 1.72 000 

51700 .... .......... A Irrigation of bladder ............................................ 0.88 1.60 0.28 0.06 2.54 1.22 000 

51701 .... .......... A Insert bladder catheter ....................................... 0.50 1.58 0.19 0.04 2.12 0.73 000 

51702 .... .......... A Insert temp bladder cath .................................... 0.50 2.09 0.24 0.04 2.63 0.78 000 

51703 .... .......... A Insert bladder cath, complex .............................. 1.47 2.74 0.56 0.10 4.31 2.13 000 

51705 .... .......... A Change of bladder tube ..................................... 1.02 2.28 0.61 0.07 3.37 1.70 010 

51710 .... .......... A Change of bladder tube ..................................... 1.49 3.34 0.77 0.11 4.94 2.37 010 

51715 .... .......... A Endoscopic injection/implant .............................. 3.73 3.91 1.35 0.29 7.93 5.37 000 

51720 .... .......... A Treatment of bladder lesion ............................... 1.96 1.75 0.69 0.14 3.85 2.79 000 

51725 .... 26 ..... A Simple cystometrogram ...................................... 1.51 0.49 0.49 0.12 2.12 2.12 000 

51725 .... TC .... A Simple cystometrogram ...................................... 0.00 5.11 NA 0.04 5.15 NA 000 

51725 .... .......... A Simple cystometrogram ...................................... 1.51 5.60 NA 0.16 7.27 NA 000 

51726 .... 26 ..... A Complex cystometrogram .................................. 1.71 0.56 0.56 0.13 2.40 2.40 000 

51726 .... TC .... A Complex cystometrogram .................................. 0.00 6.96 NA 0.05 7.01 NA 000 

51726 .... .......... A Complex cystometrogram .................................. 1.71 7.52 NA 0.18 9.41 NA 000 

51736 .... 26 ..... A Urine flow measurement .................................... 0.61 0.20 0.20 0.05 0.86 0.86 000 

51736 .... TC .... A Urine flow measurement .................................... 0.00 0.38 NA 0.01 0.39 NA 000 

51736 .... .......... A Urine flow measurement .................................... 0.61 0.58 NA 0.06 1.25 NA 000 

51741 .... 26 ..... A Electro-uroflowmetry, first ................................... 1.14 0.37 0.37 0.09 1.60 1.60 000 

51741 .... TC .... A Electro-uroflowmetry, first ................................... 0.00 0.42 NA 0.02 0.44 NA 000 

51741 .... .......... A Electro-uroflowmetry, first ................................... 1.14 0.79 NA 0.11 2.04 NA 000 

51772 .... 26 ..... A Urethra pressure profile ..................................... 1.61 0.55 0.55 0.15 2.31 2.31 000 

51772 .... TC .... A Urethra pressure profile ..................................... 0.00 5.04 NA 0.05 5.09 NA 000 

51772 .... .......... A Urethra pressure profile ..................................... 1.61 5.59 NA 0.20 7.40 NA 000 

51784 .... 26 ..... A Anal/urinary muscle study .................................. 1.53 0.50 0.50 0.12 2.15 2.15 000 

51784 .... TC .... A Anal/urinary muscle study .................................. 0.00 3.49 NA 0.04 3.53 NA 000 

51784 .... .......... A Anal/urinary muscle study .................................. 1.53 3.99 NA 0.16 5.68 NA 000 

51785 .... 26 ..... A Anal/urinary muscle study .................................. 1.53 0.50 0.50 0.11 2.14 2.14 000 

51785 .... TC .... A Anal/urinary muscle study .................................. 0.00 3.95 NA 0.04 3.99 NA 000 

51785 .... .......... A Anal/urinary muscle study .................................. 1.53 4.45 NA 0.15 6.13 NA 000 

51792 .... 26 ..... A Urinary reflex study ............................................ 1.10 0.41 0.41 0.07 1.58 1.58 000 

51792 .... TC .... A Urinary reflex study ............................................ 0.00 5.60 NA 0.13 5.73 NA 000 

51792 .... .......... A Urinary reflex study ............................................ 1.10 6.01 NA 0.20 7.31 NA 000 

51795 .... 26 ..... A Urine voiding pressure study ............................. 1.53 0.50 0.50 0.12 2.15 2.15 000 

51795 .... TC .... A Urine voiding pressure study ............................. 0.00 6.81 NA 0.10 6.91 NA 000 

51795 .... .......... A Urine voiding pressure study ............................. 1.53 7.31 NA 0.22 9.06 NA 000 

51797 .... 26 ..... A Intraabdominal pressure test .............................. 1.60 0.53 0.53 0.12 2.25 2.25 000 

51797 .... TC .... A Intraabdominal pressure test .............................. 0.00 5.27 NA 0.05 5.32 NA 000 

51797 .... .......... A Intraabdominal pressure test .............................. 1.60 5.80 NA 0.17 7.57 NA 000 

51798 .... .......... A Us urine capacity measure ................................ 0.00 0.34 NA 0.08 0.42 NA XXX 

51800 .... .......... A Revision of bladder/urethra ................................ 17.39 NA 7.58 1.32 NA 26.29 090 

51820 .... .......... A Revision of urinary tract ..................................... 17.86 NA 8.30 1.74 NA 27.90 090 

51840 .... .......... A Attach bladder/urethra ........................................ 10.69 NA 5.58 1.06 NA 17.33 090 

51841 .... .......... A Attach bladder/urethra ........................................ 13.01 NA 6.39 1.24 NA 20.64 090 

51845 .... .......... A Repair bladder neck ........................................... 9.72 NA 4.75 0.79 NA 15.26 090 

51860 .... .......... A Repair of bladder wound .................................... 12.00 NA 5.77 1.16 NA 18.93 090 

51865 .... .......... A Repair of bladder wound .................................... 15.02 NA 6.69 1.23 NA 22.94 090 

51880 .... .......... A Repair of bladder opening .................................. 7.65 NA 3.96 0.72 NA 12.33 090 

51900 .... .......... A Repair bladder/vagina lesion .............................. 12.95 NA 6.08 1.21 NA 20.24 090 

51920 .... .......... A Close bladder-uterus fistula ............................... 11.79 NA 5.65 1.18 NA 18.62 090 

51925 .... .......... A Hysterectomy/bladder repair .............................. 15.56 NA 8.63 2.03 NA 26.22 090 

51940 .... .......... A Correction of bladder defect ............................... 28.39 NA 12.11 2.14 NA 42.64 090 

51960 .... .......... A Revision of bladder & bowel .............................. 22.98 NA 9.66 1.63 NA 34.27 090 

51980 .... .......... A Construct bladder opening ................................. 11.34 NA 5.39 0.86 NA 17.59 090 

51990 .... .......... A Laparo urethral suspension ................................ 12.48 NA 6.16 1.39 NA 20.03 090 

51992 .... .......... A Laparo sling operation ........................................ 13.99 NA 6.22 1.41 NA 21.62 090 

51999 .... .......... C Laparoscope proc, bladder ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

52000 .... .......... A Cystoscopy ......................................................... 2.01 3.31 0.76 0.14 5.46 2.91 000 

52001 .... .......... A Cystoscopy, removal of clots ............................. 5.44 5.08 1.87 0.39 10.91 7.70 000 

52005 .... .......... A Cystoscopy & ureter catheter ............................. 2.37 5.58 0.89 0.17 8.12 3.43 000 

52007 .... .......... A Cystoscopy and biopsy ...................................... 3.02 16.49 1.15 0.22 19.73 4.39 000 

52010 .... .......... A Cystoscopy & duct catheter ............................... 3.02 10.78 1.15 0.21 14.01 4.38 000 

52204 .... .......... A Cystoscopy ......................................................... 2.37 14.55 0.90 0.17 17.09 3.44 000 

52214 .... .......... A Cystoscopy and treatment ................................. 3.70 38.21 1.33 0.26 42.17 5.29 000 

52224 .... .......... A Cystoscopy and treatment ................................. 3.14 36.56 1.15 0.22 39.92 4.51 000 

70392 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

52234 .... .......... A Cystoscopy and treatment ................................. 4.62 NA 1.66 0.33 NA 6.61 000 

52235 .... .......... A Cystoscopy and treatment ................................. 5.44 NA 1.94 0.39 NA 7.77 000 

52240 .... .......... A Cystoscopy and treatment ................................. 9.71 NA 3.31 0.69 NA 13.71 000 

52250 .... .......... A Cystoscopy and radiotracer ............................... 4.49 NA 1.65 0.32 NA 6.46 000 

52260 .... .......... A Cystoscopy and treatment ................................. 3.91 NA 1.42 0.28 NA 5.61 000 

52265 .... .......... A Cystoscopy and treatment ................................. 2.94 13.38 1.11 0.22 16.54 4.27 000 

52270 .... .......... A Cystoscopy & revise urethra .............................. 3.36 11.06 1.24 0.24 14.66 4.84 000 

52275 .... .......... A Cystoscopy & revise urethra .............................. 4.69 15.60 1.66 0.33 20.62 6.68 000 

52276 .... .......... A Cystoscopy and treatment ................................. 4.99 NA 1.79 0.35 NA 7.13 000 

52277 .... .......... A Cystoscopy and treatment ................................. 6.16 NA 2.23 0.44 NA 8.83 000 

52281 .... .......... A Cystoscopy and treatment ................................. 2.80 7.11 1.08 0.20 10.11 4.08 000 

52282 .... .......... A Cystoscopy, implant stent .................................. 6.39 NA 2.24 0.45 NA 9.08 000 

52283 .... .......... A Cystoscopy and treatment ................................. 3.73 3.95 1.38 0.26 7.94 5.37 000 

52285 .... .......... A Cystoscopy and treatment ................................. 3.60 4.02 1.33 0.26 7.88 5.19 000 

52290 .... .......... A Cystoscopy and treatment ................................. 4.58 NA 1.65 0.32 NA 6.55 000 

52300 .... .......... A Cystoscopy and treatment ................................. 5.30 NA 1.91 0.38 NA 7.59 000 

52301 .... .......... A Cystoscopy and treatment ................................. 5.50 NA 1.99 0.46 NA 7.95 000 

52305 .... .......... A Cystoscopy and treatment ................................. 5.30 NA 1.86 0.38 NA 7.54 000 

52310 .... .......... A Cystoscopy and treatment ................................. 2.81 4.70 1.03 0.20 7.71 4.04 000 

52315 .... .......... A Cystoscopy and treatment ................................. 5.20 8.69 1.84 0.37 14.26 7.41 000 

52317 .... .......... A Remove bladder stone ....................................... 6.71 29.02 2.29 0.48 36.21 9.48 000 

52318 .... .......... A Remove bladder stone ....................................... 9.18 NA 3.10 0.65 NA 12.93 000 

52320 .... .......... A Cystoscopy and treatment ................................. 4.69 NA 1.63 0.33 NA 6.65 000 

52325 .... .......... A Cystoscopy, stone removal ................................ 6.15 NA 2.12 0.44 NA 8.71 000 

52327 .... .......... A Cystoscopy, inject material ................................ 5.18 31.90 1.82 0.37 37.45 7.37 000 

52330 .... .......... A Cystoscopy and treatment ................................. 5.03 38.93 1.76 0.36 44.32 7.15 000 

52332 .... .......... A Cystoscopy and treatment ................................. 2.83 5.76 1.05 0.21 8.80 4.09 000 

52334 .... .......... A Create passage to kidney .................................. 4.82 NA 1.74 0.35 NA 6.91 000 

52341 .... .......... A Cysto w/ureter stricture tx .................................. 5.99 NA 2.22 0.43 NA 8.64 000 

52342 .... .......... A Cysto w/up stricture tx ........................................ 6.49 NA 2.35 0.46 NA 9.30 000 

52343 .... .......... A Cysto w/renal stricture tx .................................... 7.19 NA 2.59 0.51 NA 10.29 000 

52344 .... .......... A Cysto/uretero, stricture tx ................................... 7.69 NA 2.80 0.55 NA 11.04 000 

52345 .... .......... A Cysto/uretero w/up stricture ............................... 8.19 NA 2.96 0.58 NA 11.73 000 

52346 .... .......... A Cystouretero w/renal strict ................................. 9.22 NA 3.29 0.65 NA 13.16 000 

52351 .... .......... A Cystouretero & or pyeloscope ............................ 5.85 NA 2.15 0.41 NA 8.41 000 

52352 .... .......... A Cystouretero w/stone remove ............................ 6.87 NA 2.51 0.49 NA 9.87 000 

52353 .... .......... A Cystouretero w/lithotripsy ................................... 7.96 NA 2.86 0.57 NA 11.39 000 

52354 .... .......... A Cystouretero w/biopsy ........................................ 7.33 NA 2.68 0.52 NA 10.53 000 

52355 .... .......... A Cystouretero w/excise tumor .............................. 8.81 NA 3.15 0.63 NA 12.59 000 

52400 .... .......... A Cystouretero w/congen repr ............................... 9.67 NA 3.74 0.68 NA 14.09 090 

52402 .... .......... A Cystourethro cut ejacul duct .............................. 5.27 NA 1.70 0.40 NA 7.37 000 

52450 .... .......... A Incision of prostate ............................................. 7.63 NA 3.68 0.54 NA 11.85 090 

52500 .... .......... A Revision of bladder neck .................................... 8.46 NA 3.93 0.60 NA 12.99 090 

52510 .... .......... A Dilation prostatic urethra .................................... 6.71 NA 3.12 0.48 NA 10.31 090 

52601 .... .......... A Prostatectomy (TURP) ....................................... 12.35 NA 5.11 0.87 NA 18.33 090 

52606 .... .......... A Control postop bleeding ..................................... 8.12 NA 3.56 0.57 NA 12.25 090 

52612 .... .......... A Prostatectomy, first stage ................................... 7.97 NA 3.74 0.56 NA 12.27 090 

52614 .... .......... A Prostatectomy, second stage ............................. 6.83 NA 3.35 0.48 NA 10.66 090 

52620 .... .......... A Remove residual prostate .................................. 6.60 NA 2.99 0.47 NA 10.06 090 

52630 .... .......... A Remove prostate regrowth ................................. 7.25 NA 3.20 0.51 NA 10.96 090 

52640 .... .......... A Relieve bladder contracture ............................... 6.61 NA 2.97 0.47 NA 10.05 090 

52647 .... .......... A Laser surgery of prostate ................................... 10.34 74.15 4.54 0.73 85.22 15.61 090 

52648 .... .......... A Laser surgery of prostate ................................... 11.19 NA 4.80 0.79 NA 16.78 090 

52700 .... .......... A Drainage of prostate abscess ............................ 6.79 NA 3.19 0.48 NA 10.46 090 

53000 .... .......... A Incision of urethra ............................................... 2.28 NA 1.54 0.16 NA 3.98 010 

53010 .... .......... A Incision of urethra ............................................... 3.63 NA 2.92 0.24 NA 6.79 090 

53020 .... .......... A Incision of urethra ............................................... 1.77 3.01 0.67 0.13 4.91 2.57 000 

53025 .... .......... A Incision of urethra ............................................... 1.13 3.74 0.51 0.08 4.95 1.72 000 

53040 .... .......... A Drainage of urethra abscess .............................. 6.39 NA 3.44 0.45 NA 10.28 090 

53060 .... .......... A Drainage of urethra abscess .............................. 2.63 2.09 1.37 0.28 5.00 4.28 010 

53080 .... .......... A Drainage of urinary leakage ............................... 6.28 NA 5.97 0.52 NA 12.77 090 

53085 .... .......... A Drainage of urinary leakage ............................... 10.25 NA 7.42 0.92 NA 18.59 090 

53200 .... .......... A Biopsy of urethra ................................................ 2.59 1.32 0.98 0.20 4.11 3.77 000 

53210 .... .......... A Removal of urethra ............................................. 12.55 NA 5.85 0.89 NA 19.29 090 

53215 .... .......... A Removal of urethra ............................................. 15.56 NA 6.64 1.10 NA 23.30 090 

53220 .... .......... A Treatment of urethra lesion ................................ 6.99 NA 3.72 0.49 NA 11.20 090 

53230 .... .......... A Removal of urethra lesion .................................. 9.57 NA 4.72 0.73 NA 15.02 090 

53235 .... .......... A Removal of urethra lesion .................................. 10.12 NA 4.91 0.72 NA 15.75 090 

53240 .... .......... A Surgery for urethra pouch .................................. 6.44 NA 3.53 0.52 NA 10.49 090 

53250 .... .......... A Removal of urethra gland ................................... 5.88 NA 3.30 0.49 NA 9.67 090 

53260 .... .......... A Treatment of urethra lesion ................................ 2.98 2.25 1.42 0.25 5.48 4.65 010 

53265 .... .......... A Treatment of urethra lesion ................................ 3.12 2.72 1.42 0.24 6.08 4.78 010 

53270 .... .......... A Removal of urethra gland ................................... 3.09 2.21 1.54 0.30 5.60 4.93 010 

53275 .... .......... A Repair of urethra defect ..................................... 4.52 NA 2.26 0.32 NA 7.10 010 

53400 .... .......... A Revise urethra, stage 1 ...................................... 12.75 NA 6.04 0.98 NA 19.77 090 

70393 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

53405 .... .......... A Revise urethra, stage 2 ...................................... 14.46 NA 6.33 1.10 NA 21.89 090 

53410 .... .......... A Reconstruction of urethra ................................... 16.42 NA 7.07 1.16 NA 24.65 090 

53415 .... .......... A Reconstruction of urethra ................................... 19.38 NA 7.35 1.37 NA 28.10 090 

53420 .... .......... A Reconstruct urethra, stage 1 .............................. 14.06 NA 6.30 0.96 NA 21.32 090 

53425 .... .......... A Reconstruct urethra, stage 2 .............................. 15.96 NA 6.90 1.13 NA 23.99 090 

53430 .... .......... A Reconstruction of urethra ................................... 16.32 NA 7.01 1.15 NA 24.48 090 

53431 .... .......... A Reconstruct urethra/bladder ............................... 19.86 NA 8.07 1.41 NA 29.34 090 

53440 .... .......... A Male sling procedure .......................................... 13.60 NA 5.99 0.96 NA 20.55 090 

53442 .... .......... A Remove/revise male sling .................................. 11.55 NA 5.45 0.82 NA 17.82 090 

53444 .... .......... A Insert tandem cuff .............................................. 13.38 NA 5.89 0.94 NA 20.21 090 

53445 .... .......... A Insert uro/ves nck sphincter ............................... 14.04 NA 7.10 0.99 NA 22.13 090 

53446 .... .......... A Remove uro sphincter ........................................ 10.21 NA 5.23 0.72 NA 16.16 090 

53447 .... .......... A Remove/replace ur sphincter ............................. 13.47 NA 6.44 0.95 NA 20.86 090 

53448 .... .......... A Remov/replc ur sphinctr comp ........................... 21.12 NA 9.07 1.50 NA 31.69 090 

53449 .... .......... A Repair uro sphincter ........................................... 9.69 NA 4.73 0.68 NA 15.10 090 

53450 .... .......... A Revision of urethra ............................................. 6.13 NA 3.30 0.43 NA 9.86 090 

53460 .... .......... A Revision of urethra ............................................. 7.11 NA 3.70 0.50 NA 11.31 090 

53500 .... .......... A Urethrlys, transvag w/ scope .............................. 12.19 NA 6.22 0.90 NA 19.31 090 

53502 .... .......... A Repair of urethra injury ...................................... 7.62 NA 3.99 0.62 NA 12.23 090 

53505 .... .......... A Repair of urethra injury ...................................... 7.62 NA 3.87 0.54 NA 12.03 090 

53510 .... .......... A Repair of urethra injury ...................................... 10.09 NA 5.17 0.74 NA 16.00 090 

53515 .... .......... A Repair of urethra injury ...................................... 13.29 NA 5.94 1.05 NA 20.28 090 

53520 .... .......... A Repair of urethra defect ..................................... 8.67 NA 4.48 0.61 NA 13.76 090 

53600 .... .......... A Dilate urethra stricture ........................................ 1.21 1.14 0.43 0.09 2.44 1.73 000 

53601 .... .......... A Dilate urethra stricture ........................................ 0.98 1.27 0.37 0.07 2.32 1.42 000 

53605 .... .......... A Dilate urethra stricture ........................................ 1.28 NA 0.41 0.09 NA 1.78 000 

53620 .... .......... A Dilate urethra stricture ........................................ 1.62 2.00 0.59 0.11 3.73 2.32 000 

53621 .... .......... A Dilate urethra stricture ........................................ 1.35 2.08 0.49 0.10 3.53 1.94 000 

53660 .... .......... A Dilation of urethra ............................................... 0.71 1.31 0.31 0.05 2.07 1.07 000 

53661 .... .......... A Dilation of urethra ............................................... 0.72 1.30 0.29 0.05 2.07 1.06 000 

53665 .... .......... A Dilation of urethra ............................................... 0.76 NA 0.25 0.06 NA 1.07 000 

53850 .... .......... A Prostatic microwave thermotx ............................ 9.44 94.33 3.95 0.67 104.44 14.06 090 

53852 .... .......... A Prostatic rf thermotx ........................................... 9.87 89.03 4.38 0.70 99.60 14.95 090 

53853 .... .......... A Prostatic water thermother ................................. 5.23 55.50 2.86 0.37 61.10 8.46 090 

53899 .... .......... C Urology surgery procedure ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

54000 .... .......... A Slitting of prepuce .............................................. 1.54 2.92 0.93 0.11 4.57 2.58 010 

54001 .... .......... A Slitting of prepuce .............................................. 2.19 3.19 1.11 0.15 5.53 3.45 010 

54015 .... .......... A Drain penis lesion ............................................... 5.31 NA 2.56 0.38 NA 8.25 010 

54050 .... .......... A Destruction, penis lesion(s) ................................ 1.24 1.66 1.03 0.08 2.98 2.35 010 

54055 .... .......... A Destruction, penis lesion(s) ................................ 1.22 1.57 0.80 0.08 2.87 2.10 010 

54056 .... .......... A Cryosurgery, penis lesion(s) .............................. 1.24 1.69 1.13 0.06 2.99 2.43 010 

54057 .... .......... A Laser surg, penis lesion(s) ................................. 1.24 2.22 0.83 0.09 3.55 2.16 010 

54060 .... .......... A Excision of penis lesion(s) ................................. 1.93 3.11 1.06 0.13 5.17 3.12 010 

54065 .... .......... A Destruction, penis lesion(s) ................................ 2.42 2.64 1.23 0.13 5.19 3.78 010 

54100 .... .......... A Biopsy of penis ................................................... 1.90 2.81 0.82 0.10 4.81 2.82 000 

54105 .... .......... A Biopsy of penis ................................................... 3.49 4.29 1.94 0.25 8.03 5.68 010 

54110 .... .......... A Treatment of penis lesion ................................... 10.11 NA 4.76 0.72 NA 15.59 090 

54111 .... .......... A Treat penis lesion, graft ..................................... 13.55 NA 5.78 0.96 NA 20.29 090 

54112 .... .......... A Treat penis lesion, graft ..................................... 15.84 NA 6.81 1.11 NA 23.76 090 

54115 .... .......... A Treatment of penis lesion ................................... 6.14 4.38 3.46 0.43 10.95 10.03 090 

54120 .... .......... A Partial removal of penis ..................................... 9.96 NA 4.68 0.68 NA 15.32 090 

54125 .... .......... A Removal of penis ............................................... 13.51 NA 5.84 0.95 NA 20.30 090 

54130 .... .......... A Remove penis & nodes ...................................... 20.11 NA 8.19 1.52 NA 29.82 090 

54135 .... .......... A Remove penis & nodes ...................................... 26.32 NA 10.19 1.87 NA 38.38 090 

54150 .... .......... A Circumcision ....................................................... 1.81 4.36 0.70 0.16 6.33 2.67 000 

54152 .... .......... A Circumcision ....................................................... 2.31 NA 1.20 0.19 NA 3.70 010 

54160 .... .......... A Circumcision ....................................................... 2.48 4.15 1.09 0.19 6.82 3.76 010 

54161 .... .......... A Circumcision ....................................................... 3.27 NA 1.56 0.23 NA 5.06 010 

54162 .... .......... A Lysis penil circumic lesion .................................. 3.00 4.66 1.44 0.21 7.87 4.65 010 

54163 .... .......... A Repair of circumcision ........................................ 3.00 NA 2.01 0.21 NA 5.22 010 

54164 .... .......... A Frenulotomy of penis .......................................... 2.50 NA 1.84 0.18 NA 4.52 010 

54200 .... .......... A Treatment of penis lesion ................................... 1.06 1.80 0.97 0.08 2.94 2.11 010 

54205 .... .......... A Treatment of penis lesion ................................... 7.92 NA 4.69 0.56 NA 13.17 090 

54220 .... .......... A Treatment of penis lesion ................................... 2.42 3.85 0.95 0.17 6.44 3.54 000 

54230 .... .......... A Prepare penis study ........................................... 1.34 1.08 0.63 0.09 2.51 2.06 000 

54231 .... .......... A Dynamic cavernosometry ................................... 2.04 1.37 0.87 0.16 3.57 3.07 000 

54235 .... .......... A Penile injection ................................................... 1.19 0.96 0.58 0.08 2.23 1.85 000 

54240 .... 26 ..... A Penis study ......................................................... 1.31 0.43 0.43 0.11 1.85 1.85 000 

54240 .... TC .... A Penis study ......................................................... 0.00 0.60 NA 0.06 0.66 NA 000 

54240 .... .......... A Penis study ......................................................... 1.31 1.03 NA 0.17 2.51 NA 000 

54250 .... 26 ..... A Penis study ......................................................... 2.22 0.71 0.71 0.16 3.09 3.09 000 

54250 .... TC .... A Penis study ......................................................... 0.00 0.20 NA 0.02 0.22 NA 000 

54250 .... .......... A Penis study ......................................................... 2.22 0.91 NA 0.18 3.31 NA 000 

54300 .... .......... A Revision of penis ................................................ 10.39 NA 5.58 0.76 NA 16.73 090 

54304 .... .......... A Revision of penis ................................................ 12.47 NA 6.34 0.88 NA 19.69 090 

70394 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

54308 .... .......... A Reconstruction of urethra ................................... 11.81 NA 5.97 0.84 NA 18.62 090 

54312 .... .......... A Reconstruction of urethra ................................... 13.55 NA 7.00 1.24 NA 1.79 090 

54316 .... .......... A Reconstruction of urethra ................................... 16.79 NA 7.96 1.21 NA 25.96 090 

54318 .... .......... A Reconstruction of urethra ................................... 11.23 NA 5.80 1.39 NA 18.42 090 

54322 .... .......... A Reconstruction of urethra ................................... 12.99 NA 6.47 0.92 NA 20.38 090 

54324 .... .......... A Reconstruction of urethra ................................... 16.29 NA 7.97 1.14 NA 25.40 090 

54326 .... .......... A Reconstruction of urethra ................................... 15.70 NA 7.79 1.11 NA 24.60 090 

54328 .... .......... A Revise penis/urethra .......................................... 15.63 NA 7.26 0.98 NA 23.87 090 

54332 .... .......... A Revise penis/urethra .......................................... 17.05 NA 7.74 1.21 NA 26.00 090 

54336 .... .......... A Revise penis/urethra .......................................... 20.01 NA 10.31 2.20 NA 32.52 090 

54340 .... .......... A Secondary urethral surgery ................................ 8.90 NA 5.04 0.63 NA 14.57 090 

54344 .... .......... A Secondary urethral surgery ................................ 15.92 NA 7.76 1.54 NA 25.22 090 

54348 .... .......... A Secondary urethral surgery ................................ 17.12 NA 8.36 1.23 NA 26.71 090 

54352 .... .......... A Reconstruct urethra/penis .................................. 24.70 NA 11.20 2.24 NA 38.14 090 

54360 .... .......... A Penis plastic surgery .......................................... 11.91 NA 6.04 0.84 NA 18.79 090 

54380 .... .......... A Repair penis ....................................................... 13.16 NA 6.62 0.93 NA 20.71 090 

54385 .... .......... A Repair penis ....................................................... 15.37 NA 8.27 0.86 NA 24.50 090 

54390 .... .......... A Repair penis and bladder ................................... 21.58 NA 9.43 1.54 NA 32.55 090 

54400 .... .......... A Insert semi-rigid prosthesis ................................ 8.98 NA 4.35 0.64 NA 13.97 090 

54401 .... .......... A Insert self-contd prosthesis ................................ 10.26 NA 5.74 0.73 NA 16.73 090 

54405 .... .......... A Insert multi-comp penis pros .............................. 13.41 NA 5.93 0.95 NA 20.29 090 

54406 .... .......... A Remove muti-comp penis pros .......................... 12.08 NA 5.43 0.86 NA 18.37 090 

54408 .... .......... A Repair multi-comp penis pros ............................ 12.73 NA 5.74 0.90 NA 19.37 090 

54410 .... .......... A Remove/replace penis prosth ............................ 15.48 NA 6.63 1.10 NA 23.21 090 

54411 .... .......... A Remov/replc penis pros, comp .......................... 15.98 NA 7.05 1.13 NA 24.16 090 

54415 .... .......... A Remove self-contd penis pros ........................... 8.19 NA 4.20 0.58 NA 12.97 090 

54416 .... .......... A Remv/repl penis contain pros ............................ 10.85 NA 5.38 0.77 NA 17.00 090 

54417 .... .......... A Remv/replc penis pros, compl ............................ 14.17 NA 6.18 1.00 NA 21.35 090 

54420 .... .......... A Revision of penis ................................................ 11.40 NA 5.58 0.81 NA 17.79 090 

54430 .... .......... A Revision of penis ................................................ 10.13 NA 5.11 0.72 NA 15.96 090 

54435 .... .......... A Revision of penis ................................................ 6.11 NA 3.62 0.43 NA 10.16 090 

54440 .... .......... C Repair of penis ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

54450 .... .......... A Preputial stretching ............................................. 1.12 0.95 0.44 0.08 2.15 1.64 000 

54500 .... .......... A Biopsy of testis ................................................... 1.31 0.61 0.56 0.10 2.02 1.97 000 

54505 .... .......... A Biopsy of testis ................................................... 3.45 NA 1.92 0.27 NA 5.64 010 

54512 .... .......... A Excise lesion testis ............................................. 8.57 NA 4.13 0.67 NA 13.37 090 

54520 .... .......... A Removal of testis ................................................ 5.22 NA 2.79 0.50 NA 8.51 090 

54522 .... .......... A Orchiectomy, partial ........................................... 9.49 NA 4.87 0.89 NA 15.25 090 

54530 .... .......... A Removal of testis ................................................ 8.57 NA 4.24 0.66 NA 13.47 090 

54535 .... .......... A Extensive testis surgery ..................................... 12.14 NA 5.55 0.95 NA 18.64 090 

54550 .... .......... A Exploration for testis ........................................... 7.77 NA 3.81 0.59 NA 12.17 090 

54560 .... .......... A Exploration for testis ........................................... 11.11 NA 5.16 0.90 NA 17.17 090 

54600 .... .......... A Reduce testis torsion .......................................... 7.00 NA 3.55 0.51 NA 11.06 090 

54620 .... .......... A Suspension of testis ........................................... 4.89 NA 2.44 0.37 NA 7.70 010 

54640 .... .......... A Suspension of testis ........................................... 6.89 NA 3.74 0.62 NA 11.25 090 

54650 .... .......... A Orchiopexy (Fowler-Stephens) ........................... 11.43 NA 5.41 1.16 NA 18.00 090 

54660 .... .......... A Revision of testis ................................................ 5.10 NA 3.00 0.44 NA 8.54 090 

54670 .... .......... A Repair testis injury .............................................. 6.40 NA 3.54 0.47 NA 10.41 090 

54680 .... .......... A Relocation of testis(es) ....................................... 12.63 NA 6.16 1.16 NA 19.95 090 

54690 .... .......... A Laparoscopy, orchiectomy ................................. 10.94 NA 4.94 1.02 NA 16.90 090 

54692 .... .......... A Laparoscopy, orchiopexy ................................... 12.86 NA 5.44 1.30 NA 19.60 090 

54699 .... .......... C Laparoscope proc, testis .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

54700 .... .......... A Drainage of scrotum ........................................... 3.42 NA 1.94 0.28 NA 5.64 010 

54800 .... .......... A Biopsy of epididymis .......................................... 2.33 0.94 0.90 0.23 3.50 3.46 000 

54820 .... .......... A Exploration of epididymis ................................... 5.13 NA 2.94 0.40 NA 8.47 090 

54830 .... .......... A Remove epididymis lesion ................................. 5.37 NA 3.02 0.41 NA 8.80 090 

54840 .... .......... A Remove epididymis lesion ................................. 5.19 NA 2.78 0.37 NA 8.34 090 

54860 .... .......... A Removal of epididymis ....................................... 6.31 NA 3.31 0.45 NA 10.07 090 

54861 .... .......... A Removal of epididymis ....................................... 8.89 NA 4.31 0.63 NA 13.83 090 

54900 .... .......... A Fusion of spermatic ducts .................................. 13.18 NA 5.80 0.93 NA 19.91 090 

54901 .... .......... A Fusion of spermatic ducts .................................. 17.91 NA 7.53 1.82 NA 27.26 090 

55000 .... .......... A Drainage of hydrocele ........................................ 1.43 2.07 0.65 0.11 3.61 2.19 000 

55040 .... .......... A Removal of hydrocele ........................................ 5.35 NA 2.90 0.43 NA 8.68 090 

55041 .... .......... A Removal of hydroceles ....................................... 7.73 NA 3.97 0.60 NA 12.30 090 

55060 .... .......... A Repair of hydrocele ............................................ 5.51 NA 3.08 0.46 NA 9.05 090 

55100 .... .......... A Drainage of scrotum abscess ............................ 2.13 3.68 1.56 0.17 5.98 3.86 010 

55110 .... .......... A Explore scrotum ................................................. 5.69 NA 3.13 0.43 NA 9.25 090 

55120 .... .......... A Removal of scrotum lesion ................................. 5.08 NA 2.95 0.39 NA 8.42 090 

55150 .... .......... A Removal of scrotum ........................................... 7.21 NA 3.84 0.56 NA 11.61 090 

55175 .... .......... A Revision of scrotum ............................................ 5.23 NA 3.01 0.37 NA 8.61 090 

55180 .... .......... A Revision of scrotum ............................................ 10.70 NA 5.37 0.90 NA 16.97 090 

55200 .... .......... A Incision of sperm duct ........................................ 4.23 12.35 2.38 0.33 16.91 6.94 090 

55250 .... .......... A Removal of sperm duct(s) .................................. 3.29 11.50 2.22 0.25 15.04 5.76 090 

55300 .... .......... A Prepare, sperm duct x-ray ................................. 3.50 NA 1.31 0.25 NA 5.06 000 

55400 .... .......... A Repair of sperm duct .......................................... 8.48 NA 4.06 0.64 NA 13.18 090 

70395 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

55450 .... .......... A Ligation of sperm duct ........................................ 4.11 7.01 1.87 0.29 11.41 6.27 010 

55500 .... .......... A Removal of hydrocele ........................................ 5.58 NA 3.09 0.55 NA 9.22 090 

55520 .... .......... A Removal of sperm cord lesion ........................... 6.02 NA 3.25 0.75 NA 10.02 090 

55530 .... .......... A Revise spermatic cord veins .............................. 5.65 NA 3.01 0.45 NA 9.11 090 

55535 .... .......... A Revise spermatic cord veins .............................. 6.55 NA 3.40 0.47 NA 10.42 090 

55540 .... .......... A Revise hernia & sperm veins ............................. 7.66 NA 3.80 0.94 NA 12.40 090 

55550 .... .......... A Laparo ligate spermatic vein .............................. 6.56 NA 3.30 0.57 NA 10.43 090 

55559 .... .......... C Laparo proc, spermatic cord .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

55600 .... .......... A Incise sperm duct pouch .................................... 6.37 NA 3.33 0.62 NA 10.32 090 

55605 .... .......... A Incise sperm duct pouch .................................... 7.95 NA 4.29 0.64 NA 12.88 090 

55650 .... .......... A Remove sperm duct pouch ................................ 11.78 NA 5.28 0.92 NA 17.98 090 

55680 .... .......... A Remove sperm pouch lesion ............................. 5.18 NA 2.97 0.47 NA 8.62 090 

55700 .... .......... A Biopsy of prostate .............................................. 1.57 4.20 0.64 0.11 5.88 2.32 000 

55705 .... .......... A Biopsy of prostate .............................................. 4.56 NA 2.30 0.32 NA 7.18 010 

55720 .... .......... A Drainage of prostate abscess ............................ 7.63 NA 3.82 0.95 NA 12.40 090 

55725 .... .......... A Drainage of prostate abscess ............................ 8.67 NA 4.49 0.70 NA 13.86 090 

55801 .... .......... A Removal of prostate ........................................... 17.77 NA 7.62 1.34 NA 26.73 090 

55810 .... .......... A Extensive prostate surgery ................................. 22.55 NA 8.95 1.60 NA 33.10 090 

55812 .... .......... A Extensive prostate surgery ................................. 27.47 NA 10.99 2.04 NA 40.50 090 

55815 .... .......... A Extensive prostate surgery ................................. 30.41 NA 11.90 2.16 NA 44.47 090 

55821 .... .......... A Removal of prostate ........................................... 14.23 NA 6.21 1.01 NA 21.45 090 

55831 .... .......... A Removal of prostate ........................................... 15.60 NA 6.66 1.10 NA 23.36 090 

55840 .... .......... A Extensive prostate surgery ................................. 22.66 NA 9.29 1.61 NA 33.56 090 

55842 .... .......... A Extensive prostate surgery ................................. 24.34 NA 9.85 1.72 NA 35.91 090 

55845 .... .......... A Extensive prostate surgery ................................. 28.51 NA 10.94 2.02 NA 41.47 090 

55859 .... .......... A Percut/needle insert, pros .................................. 12.50 NA 5.85 0.89 NA 19.24 090 

55860 .... .......... A Surgical exposure, prostate ............................... 14.43 NA 6.41 1.02 NA 21.86 090 

55862 .... .......... A Extensive prostate surgery ................................. 18.36 NA 7.85 1.49 NA 27.70 090 

55865 .... .......... A Extensive prostate surgery ................................. 22.84 NA 9.27 1.63 NA 33.74 090 

55866 .... .......... A Laparo radical prostatectomy ............................. 30.69 NA 11.73 2.16 NA 44.58 090 

55870 .... .......... A Electroejaculation ............................................... 2.58 1.53 1.08 0.16 4.27 3.82 000 

55873 .... .......... A Cryoablate prostate ............................................ 19.44 NA 8.96 1.38 NA 29.78 090 

55899 .... .......... C Genital surgery procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

55970 .... .......... N Sex transformation, M to F ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

55980 .... .......... N Sex transformation, F to M ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

56405 .... .......... A I & D of vulva/perineum ..................................... 1.44 1.33 1.14 0.17 2.94 2.75 010 

56420 .... .......... A Drainage of gland abscess ................................ 1.39 2.28 1.04 0.16 3.83 2.59 010 

56440 .... .......... A Surgery for vulva lesion ..................................... 2.84 NA 1.71 0.34 NA 4.89 010 

56441 .... .......... A Lysis of labial lesion(s) ....................................... 1.97 1.82 1.41 0.20 3.99 3.58 010 

56501 .... .......... A Destroy, vulva lesions, sim ................................ 1.53 1.79 1.24 0.18 3.50 2.95 010 

56515 .... .......... A Destroy vulva lesion/s compl ............................. 2.76 2.55 1.82 0.33 5.64 4.91 010 

56605 .... .......... A Biopsy of vulva/perineum ................................... 1.10 1.07 0.46 0.13 2.30 1.69 000 

56606 .... .......... A Biopsy of vulva/perineum ................................... 0.55 0.49 0.22 0.07 1.11 0.84 ZZZ 

56620 .... .......... A Partial removal of vulva ...................................... 7.46 NA 4.80 0.90 NA 13.16 090 

56625 .... .......... A Complete removal of vulva ................................ 8.39 NA 5.33 1.02 NA 14.74 090 

56630 .... .......... A Extensive vulva surgery ..................................... 12.34 NA 6.85 1.49 NA 20.68 090 

56631 .... .......... A Extensive vulva surgery ..................................... 16.18 NA 8.83 1.95 NA 26.96 090 

56632 .... .......... A Extensive vulva surgery ..................................... 20.26 NA 9.54 2.38 NA 32.18 090 

56633 .... .......... A Extensive vulva surgery ..................................... 16.45 NA 8.61 1.97 NA 27.03 090 

56634 .... .......... A Extensive vulva surgery ..................................... 17.85 NA 9.45 2.16 NA 29.46 090 

56637 .... .......... A Extensive vulva surgery ..................................... 21.94 NA 11.09 2.60 NA 35.63 090 

56640 .... .......... A Extensive vulva surgery ..................................... 22.14 NA 10.64 2.88 NA 35.66 090 

56700 .... .......... A Partial removal of hymen ................................... 2.52 NA 1.84 0.30 NA 4.66 010 

56720 .... .......... A Incision of hymen ............................................... 0.68 NA 0.51 0.08 NA 1.27 000 

56740 .... .......... A Remove vagina gland lesion .............................. 4.56 NA 2.57 0.56 NA 7.69 010 

56800 .... .......... A Repair of vagina ................................................. 3.88 NA 2.20 0.44 NA 6.52 010 

56805 .... .......... A Repair clitoris ...................................................... 18.83 NA 9.44 2.14 NA 30.41 090 

56810 .... .......... A Repair of perineum ............................................. 4.12 NA 2.30 0.49 NA 6.91 010 

56820 .... .......... A Exam of vulva w/scope ...................................... 1.50 1.31 0.65 0.18 2.99 2.33 000 

56821 .... .......... A Exam/biopsy of vulva w/scope ........................... 2.05 1.76 0.91 0.25 4.06 3.21 000 

57000 .... .......... A Exploration of vagina .......................................... 2.97 NA 1.72 0.31 NA 5.00 010 

57010 .... .......... A Drainage of pelvic abscess ................................ 6.02 NA 3.81 0.71 NA 10.54 090 

57020 .... .......... A Drainage of pelvic fluid ....................................... 1.50 0.94 0.59 0.18 2.62 2.27 000 

57022 .... .......... A I & d vaginal hematoma, pp ............................... 2.56 NA 1.49 0.26 NA 4.31 010 

57023 .... .......... A I & d vag hematoma, non-ob ............................. 4.74 NA 2.58 0.58 NA 7.90 010 

57061 .... .......... A Destroy vag lesions, simple ............................... 1.25 1.65 1.12 0.15 3.05 2.52 010 

57065 .... .......... A Destroy vag lesions, complex ............................ 2.61 2.30 1.67 0.31 5.22 4.59 010 

57100 .... .......... A Biopsy of vagina ................................................. 1.20 1.08 0.48 0.14 2.42 1.82 000 

57105 .... .......... A Biopsy of vagina ................................................. 1.69 1.80 1.42 0.20 3.69 3.31 010 

57106 .... .......... A Remove vagina wall, partial ............................... 6.35 NA 4.19 0.73 NA 11.27 090 

57107 .... .......... A Remove vagina tissue, part ............................... 22.97 NA 10.49 2.71 NA 36.17 090 

57109 .... .......... A Vaginectomy partial w/nodes ............................. 26.96 NA 11.27 3.21 NA 41.44 090 

57110 .... .......... A Remove vagina wall, complete .......................... 14.27 NA 7.29 1.73 NA 23.29 090 

57111 .... .......... A Remove vagina tissue, compl ............................ 26.96 NA 12.65 3.17 NA 42.78 090 

57112 .... .......... A Vaginectomy w/nodes, compl ............................ 28.96 NA 12.13 3.07 NA 44.16 090 

70396 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

57120 .... .......... A Closure of vagina ............................................... 7.40 NA 4.61 0.89 NA 12.90 090 

57130 .... .......... A Remove vagina lesion ........................................ 2.43 2.16 1.54 0.29 4.88 4.26 010 

57135 .... .......... A Remove vagina lesion ........................................ 2.67 2.27 1.65 0.31 5.25 4.63 010 

57150 .... .......... A Treat vagina infection ......................................... 0.55 1.10 0.21 0.07 1.72 0.83 000 

57155 .... .......... A Insert uteri tandems/ovoids ................................ 6.26 NA 4.57 0.43 NA 11.26 090 

57160 .... .......... A Insert pessary/other device ................................ 0.89 1.01 0.34 0.10 2.00 1.33 000 

57170 .... .......... A Fitting of diaphragm/cap ..................................... 0.91 1.48 0.33 0.11 2.50 1.35 000 

57180 .... .......... A Treat vaginal bleeding ........................................ 1.58 2.17 1.26 0.19 3.94 3.03 010 

57200 .... .......... A Repair of vagina ................................................. 3.93 NA 2.90 0.46 NA 7.29 090 

57210 .... .......... A Repair vagina/perineum ..................................... 5.16 NA 3.44 0.62 NA 9.22 090 

57220 .... .......... A Revision of urethra ............................................. 4.30 NA 3.11 0.51 NA 7.92 090 

57230 .... .......... A Repair of urethral lesion ..................................... 5.63 NA 3.41 0.54 NA 9.58 090 

57240 .... .......... A Repair bladder & vagina .................................... 6.06 NA 3.82 0.62 NA 10.50 090 

57250 .... .......... A Repair rectum & vagina ..................................... 5.52 NA 3.58 0.65 NA 9.75 090 

57260 .... .......... A Repair of vagina ................................................. 8.26 NA 4.84 0.97 NA 14.07 090 

57265 .... .......... A Extensive repair of vagina .................................. 11.32 NA 6.05 1.32 NA 18.69 090 

57267 .... .......... A Insert mesh/pelvic flr addon ............................... 4.88 NA 1.98 0.64 NA 7.50 ZZZ 

57268 .... .......... A Repair of bowel bulge ........................................ 6.75 NA 4.20 0.79 NA 11.74 090 

57270 .... .......... A Repair of bowel pouch ....................................... 12.09 NA 6.26 1.42 NA 19.77 090 

57280 .... .......... A Suspension of vagina ......................................... 15.02 NA 7.38 1.67 NA 24.07 090 

57282 .... .......... A Colpopexy, extraperitoneal ................................. 6.86 NA 4.51 1.02 NA 12.39 090 

57283 .... .......... A Colpopexy, intraperitoneal .................................. 10.84 NA 5.93 1.02 NA 17.79 090 

57284 .... .......... A Repair paravaginal defect .................................. 12.68 NA 7.16 1.41 NA 21.25 090 

57287 .... .......... A Revise/remove sling repair ................................. 10.69 NA 5.49 0.90 NA 17.08 090 

57288 .... .......... A Repair bladder defect ......................................... 13.00 NA 5.92 1.12 NA 20.04 090 

57289 .... .......... A Repair bladder & vagina .................................... 11.56 NA 6.05 1.21 NA 18.82 090 

57291 .... .......... A Construction of vagina ....................................... 7.94 NA 4.93 0.93 NA 13.80 090 

57292 .... .......... A Construct vagina with graft ................................ 13.07 NA 6.95 1.58 NA 21.60 090 

57295 .... .......... A Change vaginal graft .......................................... 7.45 NA 4.44 0.91 NA 12.80 090 

57300 .... .......... A Repair rectum-vagina fistula .............................. 7.60 NA 4.29 0.87 NA 12.76 090 

57305 .... .......... A Repair rectum-vagina fistula .............................. 13.75 NA 6.28 1.72 NA 21.75 090 

57307 .... .......... A Fistula repair & colostomy .................................. 15.91 NA 7.01 2.01 NA 24.93 090 

57308 .... .......... A Fistula repair, transperine .................................. 9.93 NA 5.10 1.14 NA 16.17 090 

57310 .... .......... A Repair urethrovaginal lesion .............................. 6.77 NA 3.84 0.54 NA 11.15 090 

57311 .... .......... A Repair urethrovaginal lesion .............................. 7.97 NA 4.12 0.65 NA 12.74 090 

57320 .... .......... A Repair bladder-vagina lesion ............................. 8.00 NA 4.37 0.69 NA 13.06 090 

57330 .... .......... A Repair bladder-vagina lesion ............................. 12.33 NA 5.72 1.06 NA 19.11 090 

57335 .... .......... A Repair vagina ..................................................... 18.70 NA 9.05 1.91 NA 29.66 090 

57400 .... .......... A Dilation of vagina ................................................ 2.27 NA 1.11 0.26 NA 3.64 000 

57410 .... .......... A Pelvic examination ............................................. 1.75 2.02 0.89 0.18 3.95 2.82 000 

57415 .... .......... A Remove vaginal foreign body ............................ 2.17 NA 1.42 0.24 NA 3.83 010 

57420 .... .......... A Exam of vagina w/scope .................................... 1.60 1.35 0.67 0.19 3.14 2.46 000 

57421 .... .......... A Exam/biopsy of vag w/scope ............................. 2.20 1.85 0.96 0.27 4.32 3.43 000 

57425 .... .......... A Laparoscopy, surg, colpopexy ........................... 15.73 NA 6.65 1.75 NA 24.13 090 

57452 .... .......... A Exam of cervix w/scope ..................................... 1.50 1.28 0.76 0.18 2.96 2.44 000 

57454 .... .......... A Bx/curett of cervix w/scope ................................ 2.33 1.64 1.15 0.28 4.25 3.76 000 

57455 .... .......... A Biopsy of cervix w/scope .................................... 1.99 1.72 0.87 0.24 3.95 3.10 000 

57456 .... .......... A Endocerv curettage w/scope .............................. 1.85 1.65 0.82 0.22 3.72 2.89 000 

57460 .... .......... A Bx of cervix w/scope, leep ................................. 2.83 5.86 1.38 0.34 9.03 4.55 000 

57461 .... .......... A Conz of cervix w/scope, leep ............................. 3.43 6.12 1.47 0.41 9.96 5.31 000 

57500 .... .......... A Biopsy of cervix .................................................. 0.97 2.55 0.63 0.12 3.64 1.72 000 

57505 .... .......... A Endocervical curettage ....................................... 1.14 1.46 1.10 0.14 2.74 2.38 010 

57510 .... .......... A Cauterization of cervix ........................................ 1.90 1.56 1.04 0.23 3.69 3.17 010 

57511 .... .......... A Cryocautery of cervix ......................................... 1.90 1.83 1.37 0.23 3.96 3.50 010 

57513 .... .......... A Laser surgery of cervix ....................................... 1.90 1.72 1.40 0.23 3.85 3.53 010 

57520 .... .......... A Conization of cervix ............................................ 4.03 3.94 2.88 0.49 8.46 7.40 090 

57522 .... .......... A Conization of cervix ............................................ 3.35 3.16 2.46 0.41 6.92 6.22 090 

57530 .... .......... A Removal of cervix ............................................... 4.78 NA 3.39 0.58 NA 8.75 090 

57531 .... .......... A Removal of cervix, radical .................................. 27.96 NA 13.20 3.34 NA 44.50 090 

57540 .... .......... A Removal of residual cervix ................................. 12.20 NA 6.25 1.49 NA 19.94 090 

57545 .... .......... A Remove cervix/repair pelvis ............................... 13.01 NA 6.69 1.52 NA 21.22 090 

57550 .... .......... A Removal of residual cervix ................................. 5.52 NA 3.83 0.67 NA 10.02 090 

57555 .... .......... A Remove cervix/repair vagina .............................. 8.94 NA 5.09 1.09 NA 15.12 090 

57556 .... .......... A Remove cervix, repair bowel .............................. 8.36 NA 4.86 0.92 NA 14.14 090 

57700 .... .......... A Revision of cervix ............................................... 3.54 NA 3.11 0.41 NA 7.06 090 

57720 .... .......... A Revision of cervix ............................................... 4.12 NA 3.11 0.49 NA 7.72 090 

57800 .... .......... A Dilation of cervical canal .................................... 0.77 0.76 0.47 0.09 1.62 1.33 000 

57820 .... .......... A D & c of residual cervix ...................................... 1.67 1.47 1.14 0.20 3.34 3.01 010 

58100 .... .......... A Biopsy of uterus lining ........................................ 1.53 1.32 0.72 0.18 3.03 2.43 000 

58110 .... .......... A Bx done w/colposcopy add-on ........................... 0.77 0.55 0.31 0.09 1.41 1.17 ZZZ 

58120 .... .......... A Dilation and curettage ........................................ 3.27 2.31 1.88 0.39 5.97 5.54 010 

58140 .... .......... A Myomectomy abdom method ............................. 14.58 NA 7.12 1.81 NA 23.51 090 

58145 .... .......... A Myomectomy vag method .................................. 8.03 NA 4.80 0.97 NA 13.80 090 

58146 .... .......... A Myomectomy abdom complex ........................... 18.97 NA 9.03 2.32 NA 30.32 090 

58150 .... .......... A Total hysterectomy ............................................. 15.22 NA 7.50 1.84 NA 24.56 090 

70397 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

58152 .... .......... A Total hysterectomy ............................................. 20.57 NA 9.88 2.47 NA 32.92 090 

58180 .... .......... A Partial hysterectomy ........................................... 15.27 NA 7.47 1.64 NA 24.38 090 

58200 .... .......... A Extensive hysterectomy ..................................... 21.56 NA 10.02 2.54 NA 34.12 090 

58210 .... .......... A Extensive hysterectomy ..................................... 28.81 NA 13.23 3.37 NA 45.41 090 

58240 .... .......... A Removal of pelvis contents ................................ 38.33 NA 17.66 4.22 NA 60.21 090 

58260 .... .......... A Vaginal hysterectomy ......................................... 12.96 NA 6.71 1.57 NA 21.24 090 

58262 .... .......... A Vag hyst including t/o ......................................... 14.75 NA 7.40 1.79 NA 23.94 090 

58263 .... .......... A Vag hyst w/t/o & vag repair ................................ 16.04 NA 7.90 1.94 NA 25.88 090 

58267 .... .......... A Vag hyst w/urinary repair ................................... 17.01 NA 8.39 2.06 NA 27.46 090 

58270 .... .......... A Vag hyst w/enterocele repair ............................. 14.24 NA 7.08 1.73 NA 23.05 090 

58275 .... .......... A Hysterectomy/revise vagina ............................... 15.74 NA 7.79 1.91 NA 25.44 090 

58280 .... .......... A Hysterectomy/revise vagina ............................... 16.98 NA 8.27 2.06 NA 27.31 090 

58285 .... .......... A Extensive hysterectomy ..................................... 22.23 NA 9.97 2.70 NA 34.90 090 

58290 .... .......... A Vag hyst complex ............................................... 18.97 NA 9.15 2.29 NA 30.41 090 

58291 .... .......... A Vag hyst incl t/o, complex .................................. 20.76 NA 9.90 2.52 NA 33.18 090 

58292 .... .......... A Vag hyst t/o & repair, compl .............................. 22.05 NA 10.39 2.67 NA 35.11 090 

58293 .... .......... A Vag hyst w/uro repair, compl ............................. 23.03 NA 10.68 2.78 NA 36.49 090 

58294 .... .......... A Vag hyst w/enterocele, compl ............................ 20.25 NA 9.58 2.39 NA 32.22 090 

58300 .... .......... N Insert intrauterine device .................................... +1.01 1.42 0.38 0.12 2.55 1.51 XXX 

58301 .... .......... A Remove intrauterine device ............................... 1.27 1.32 0.48 0.15 2.74 1.90 000 

58321 .... .......... A Artificial insemination .......................................... 0.92 1.15 0.37 0.10 2.17 1.39 000 

58322 .... .......... A Artificial insemination .......................................... 1.10 1.20 0.42 0.13 2.43 1.65 000 

58323 .... .......... A Sperm washing ................................................... 0.23 0.53 0.09 0.03 0.79 0.35 000 

58340 .... .......... A Catheter for hysterography ................................ 0.88 3.17 0.65 0.09 4.14 1.62 000 

58345 .... .......... A Reopen fallopian tube ........................................ 4.65 NA 2.44 0.41 NA 7.50 010 

58346 .... .......... A Insert heyman uteri capsule ............................... 6.74 NA 3.93 0.56 NA 11.23 090 

58350 .... .......... A Reopen fallopian tube ........................................ 1.01 1.49 0.92 0.12 2.62 2.05 010 

58353 .... .......... A Endometr ablate, thermal ................................... 3.55 35.76 2.06 0.43 39.74 6.04 010 

58356 .... .......... A Endometrial cryoablation .................................... 6.36 61.61 2.70 0.82 68.79 9.88 010 

58400 .... .......... A Suspension of uterus ......................................... 6.35 NA 3.94 0.75 NA 11.04 090 

58410 .... .......... A Suspension of uterus ......................................... 12.71 NA 6.45 1.45 NA 20.61 090 

58520 .... .......... A Repair of ruptured uterus ................................... 11.90 NA 6.05 1.47 NA 19.42 090 

58540 .... .......... A Revision of uterus .............................................. 14.62 NA 6.97 1.78 NA 23.37 090 

58545 .... .......... A Laparoscopic myomectomy ................................ 14.58 NA 7.20 1.77 NA 23.55 090 

58546 .... .......... A Laparo-myomectomy, complex .......................... 18.97 NA 8.94 2.30 NA 30.21 090 

58550 .... .......... A Laparo-asst vag hysterectomy ........................... 14.17 NA 7.31 1.72 NA 23.20 090 

58552 .... .......... A Laparo-vag hyst incl t/o ...................................... 15.98 NA 8.03 1.72 NA 25.73 090 

58553 .... .......... A Laparo-vag hyst, complex .................................. 18.97 NA 8.94 2.30 NA 30.21 090 

58554 .... .......... A Laparo-vag hyst w/t/o, compl ............................. 21.97 NA 10.42 2.27 NA 34.66 090 

58555 .... .......... A Hysteroscopy, dx, sep proc ................................ 3.33 2.20 1.55 0.40 5.93 5.28 000 

58558 .... .......... A Hysteroscopy, biopsy ......................................... 4.74 NA 2.18 0.57 NA 7.49 000 

58559 .... .......... A Hysteroscopy, lysis ............................................. 6.16 NA 2.74 0.74 NA 9.64 000 

58560 .... .......... A Hysteroscopy, resect septum ............................. 6.99 NA 3.09 0.84 NA 10.92 000 

58561 .... .......... A Hysteroscopy, remove myoma ........................... 9.99 NA 4.29 1.21 NA 15.49 000 

58562 .... .......... A Hysteroscopy, remove fb ................................... 5.20 NA 2.36 0.63 NA 8.19 000 

58563 .... .......... A Hysteroscopy, ablation ....................................... 6.16 56.35 2.76 0.74 63.25 9.66 000 

58565 .... .......... A Hysteroscopy, sterilization .................................. 7.02 49.70 3.91 1.19 57.91 12.12 090 

58578 .... .......... C Laparo proc, uterus ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

58579 .... .......... C Hysteroscope procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

58600 .... .......... A Division of fallopian tube .................................... 5.59 NA 3.34 0.66 NA 9.59 090 

58605 .... .......... A Division of fallopian tube .................................... 4.99 NA 3.12 0.59 NA 8.70 090 

58611 .... .......... A Ligate oviduct(s) add-on ..................................... 1.45 NA 0.57 0.18 NA 2.20 ZZZ 

58615 .... .......... A Occlude fallopian tube(s) ................................... 3.89 NA 2.71 0.47 NA 7.07 010 

58660 .... .......... A Laparoscopy, lysis .............................................. 11.27 NA 5.27 1.40 NA 17.94 090 

58661 .... .......... A Laparoscopy, remove adnexa ............................ 11.03 NA 5.13 1.34 NA 17.50 010 

58662 .... .......... A Laparoscopy, excise lesions .............................. 11.77 NA 5.80 1.43 NA 19.00 090 

58670 .... .......... A Laparoscopy, tubal cautery ................................ 5.59 NA 3.28 0.67 NA 9.54 090 

58671 .... .......... A Laparoscopy, tubal block ................................... 5.59 NA 3.28 0.68 NA 9.55 090 

58672 .... .......... A Laparoscopy, fimbrioplasty ................................. 12.86 NA 6.20 1.60 NA 20.66 090 

58673 .... .......... A Laparoscopy, salpingostomy .............................. 13.72 NA 6.59 1.69 NA 22.00 090 

58679 .... .......... C Laparo proc, oviduct-ovary ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

58700 .... .......... A Removal of fallopian tube .................................. 12.03 NA 6.00 1.51 NA 19.54 090 

58720 .... .......... A Removal of ovary/tube(s) ................................... 11.34 NA 5.79 1.39 NA 18.52 090 

58740 .... .......... A Revise fallopian tube(s) ...................................... 13.98 NA 7.15 1.71 NA 22.84 090 

58750 .... .......... A Repair oviduct .................................................... 14.82 NA 7.38 1.84 NA 24.04 090 

58752 .... .......... A Revise ovarian tube(s) ....................................... 14.82 NA 6.96 1.80 NA 23.58 090 

58760 .... .......... A Remove tubal obstruction .................................. 13.11 NA 6.73 1.79 NA 21.63 090 

58770 .... .......... A Create new tubal opening .................................. 13.95 NA 6.92 1.73 NA 22.60 090 

58800 .... .......... A Drainage of ovarian cyst(s) ................................ 4.13 3.65 2.91 0.43 8.21 7.47 090 

58805 .... .......... A Drainage of ovarian cyst(s) ................................ 5.87 NA 3.51 0.69 NA 10.07 090 

58820 .... .......... A Drain ovary abscess, open ................................ 4.21 NA 3.30 0.52 NA 8.03 090 

58822 .... .......... A Drain ovary abscess, percut .............................. 10.11 NA 5.23 1.16 NA 16.50 090 

58823 .... .......... A Drain pelvic abscess, percut .............................. 3.37 21.38 1.12 0.24 24.99 4.73 000 

58825 .... .......... A Transposition, ovary(s) ....................................... 10.96 NA 5.81 1.32 NA 18.09 090 

58900 .... .......... A Biopsy of ovary(s) .............................................. 5.98 NA 3.58 0.69 NA 10.25 090 

70398 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

58920 .... .......... A Partial removal of ovary(s) ................................. 11.34 NA 5.59 1.43 NA 18.36 090 

58925 .... .......... A Removal of ovarian cyst(s) ................................ 11.34 NA 5.70 1.41 NA 18.45 090 

58940 .... .......... A Removal of ovary(s) ........................................... 7.28 NA 4.11 0.91 NA 12.30 090 

58943 .... .......... A Removal of ovary(s) ........................................... 18.40 NA 8.67 2.22 NA 29.29 090 

58950 .... .......... A Resect ovarian malignancy ................................ 16.90 NA 8.42 2.04 NA 27.36 090 

58951 .... .......... A Resect ovarian malignancy ................................ 22.35 NA 10.47 2.63 NA 35.45 090 

58952 .... .......... A Resect ovarian malignancy ................................ 24.97 NA 11.78 3.02 NA 39.77 090 

58953 .... .......... A Tah, rad dissect for debulk ................................ 31.95 NA 14.58 3.83 NA 50.36 090 

58954 .... .......... A Tah rad debulk/lymph remove ........................... 34.95 NA 15.75 4.17 NA 54.87 090 

58956 .... .......... A Bso, omentectomy w/tah .................................... 20.78 NA 10.34 4.00 NA 35.12 090 

58960 .... .......... A Exploration of abdomen ..................................... 14.63 NA 7.37 1.79 NA 23.79 090 

58970 .... .......... A Retrieval of oocyte ............................................. 3.52 2.32 1.49 0.43 6.27 5.44 000 

58974 .... .......... C Transfer of embryo ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

58976 .... .......... A Transfer of embryo ............................................. 3.82 2.69 1.83 0.47 6.98 6.12 000 

58999 .... .......... C Genital surgery procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

59000 .... .......... A Amniocentesis, diagnostic .................................. 1.30 2.08 0.67 0.31 3.69 2.28 000 

59001 .... .......... A Amniocentesis, therapeutic ................................ 3.00 NA 1.41 0.71 NA 5.12 000 

59012 .... .......... A Fetal cord puncture, prenatal ............................. 3.44 NA 1.54 0.82 NA 5.80 000 

59015 .... .......... A Chorion biopsy ................................................... 2.20 1.55 1.04 0.52 4.27 3.76 000 

59020 .... 26 ..... A Fetal contract stress test .................................... 0.66 0.26 0.26 0.16 1.08 1.08 000 

59020 .... TC .... A Fetal contract stress test .................................... 0.00 0.52 NA 0.10 0.62 NA 000 

59020 .... .......... A Fetal contract stress test .................................... 0.66 0.78 NA 0.26 1.70 NA 000 

59025 .... 26 ..... A Fetal non-stress test ........................................... 0.53 0.21 0.21 0.13 0.87 0.87 000 

59025 .... TC .... A Fetal non-stress test ........................................... 0.00 0.23 NA 0.02 0.25 NA 000 

59025 .... .......... A Fetal non-stress test ........................................... 0.53 0.44 NA 0.15 1.12 NA 000 

59030 .... .......... A Fetal scalp blood sample ................................... 1.99 NA 0.77 0.47 NA 3.23 000 

59050 .... .......... A Fetal monitor w/report ........................................ 0.89 NA 0.35 0.21 NA 1.45 XXX 

59051 .... .......... A Fetal monitor/interpret only ................................ 0.74 NA 0.29 0.17 NA 1.20 XXX 

59070 .... .......... A Transabdom amnioinfus w/us ............................ 5.24 5.16 2.32 0.28 10.68 7.84 000 

59072 .... .......... A Umbilical cord occlud w/us ................................. 8.99 NA 3.13 0.16 NA 12.28 000 

59074 .... .......... A Fetal fluid drainage w/us .................................... 5.24 4.58 2.32 0.28 10.10 7.84 000 

59076 .... .......... A Fetal shunt placement, w/us .............................. 8.99 NA 3.13 0.16 NA 12.28 000 

59100 .... .......... A Remove uterus lesion ........................................ 12.33 NA 6.47 2.94 NA 21.74 090 

59120 .... .......... A Treat ectopic pregnancy ..................................... 11.47 NA 6.26 2.72 NA 20.45 090 

59121 .... .......... A Treat ectopic pregnancy ..................................... 11.65 NA 6.34 2.78 NA 20.77 090 

59130 .... .......... A Treat ectopic pregnancy ..................................... 14.20 NA 4.80 3.38 NA 22.38 090 

59135 .... .......... A Treat ectopic pregnancy ..................................... 13.86 NA 7.24 3.30 NA 24.40 090 

59136 .... .......... A Treat ectopic pregnancy ..................................... 13.16 NA 6.62 3.13 NA 22.91 090 

59140 .... .......... A Treat ectopic pregnancy ..................................... 5.45 2.22 2.22 1.29 8.96 8.96 090 

59150 .... .......... A Treat ectopic pregnancy ..................................... 11.65 NA 6.01 2.78 NA 20.44 090 

59151 .... .......... A Treat ectopic pregnancy ..................................... 11.47 NA 6.07 2.73 NA 20.27 090 

59160 .... .......... A D & c after delivery ............................................ 2.71 3.30 2.14 0.64 6.65 5.49 010 

59200 .... .......... A Insert cervical dilator .......................................... 0.79 1.19 0.30 0.19 2.17 1.28 000 

59300 .... .......... A Episiotomy or vaginal repair ............................... 2.41 2.18 0.96 0.57 5.16 3.94 000 

59320 .... .......... A Revision of cervix ............................................... 2.48 NA 1.24 0.59 NA 4.31 000 

59325 .... .......... A Revision of cervix ............................................... 4.06 NA 1.90 0.88 NA 6.84 000 

59350 .... .......... A Repair of uterus .................................................. 4.94 NA 1.88 1.17 NA 7.99 000 

59400 .... .......... A Obstetrical care .................................................. 23.03 NA 15.36 5.48 NA 43.87 MMM 

59409 .... .......... A Obstetrical care .................................................. 13.48 NA 5.32 3.21 NA 22.01 MMM 

59410 .... .......... A Obstetrical care .................................................. 14.76 NA 6.32 3.51 NA 24.59 MMM 

59412 .... .......... A Antepartum manipulation ................................... 1.71 NA 0.81 0.40 NA 2.92 MMM 

59414 .... .......... A Deliver placenta .................................................. 1.61 NA 0.64 0.38 NA 2.63 MMM 

59425 .... .......... A Antepartum care only ......................................... 4.80 4.21 1.86 1.14 10.15 7.80 MMM 

59426 .... .......... A Antepartum care only ......................................... 8.27 7.56 3.23 1.97 17.80 13.47 MMM 

59430 .... .......... A Care after delivery .............................................. 2.13 1.23 0.94 0.50 3.86 3.57 MMM 

59510 .... .......... A Cesarean delivery .............................................. 26.18 NA 17.31 6.23 NA 49.72 MMM 

59514 .... .......... A Cesarean delivery only ....................................... 15.95 NA 6.23 3.79 NA 25.97 MMM 

59515 .... .......... A Cesarean delivery .............................................. 17.34 NA 7.85 4.12 NA 29.31 MMM 

59525 .... .......... A Remove uterus after cesarean ........................... 8.53 NA 3.31 1.94 NA 13.78 ZZZ 

59610 .... .......... A Vbac delivery ...................................................... 24.58 NA 15.91 5.85 NA 46.34 MMM 

59612 .... .......... A Vbac delivery only .............................................. 15.04 NA 6.07 3.58 NA 24.69 MMM 

59614 .... .......... A Vbac care after delivery ..................................... 16.32 NA 6.95 3.88 NA 27.15 MMM 

59618 .... .......... A Attempted vbac delivery ..................................... 27.74 NA 18.28 6.59 NA 52.61 MMM 

59620 .... .......... A Attempted vbac delivery only ............................. 17.50 NA 6.78 4.16 NA 28.44 MMM 

59622 .... .......... A Attempted vbac after care .................................. 18.90 NA 8.66 4.49 NA 32.05 MMM 

59812 .... .......... A Treatment of miscarriage ................................... 4.00 NA 2.55 0.95 NA 7.50 090 

59820 .... .......... A Care of miscarriage ............................................ 4.00 4.43 3.57 0.95 9.38 8.52 090 

59821 .... .......... A Treatment of miscarriage ................................... 4.46 4.28 3.41 1.06 9.80 8.93 090 

59830 .... .......... A Treat uterus infection ......................................... 6.10 NA 3.99 1.44 NA 11.53 090 

59840 .... .......... R Abortion .............................................................. 3.01 NA 2.13 0.71 NA 5.85 010 

59841 .... .......... R Abortion .............................................................. 5.23 3.50 2.98 1.24 9.97 9.45 010 

59850 .... .......... R Abortion .............................................................. 5.90 NA 3.26 1.28 NA 10.44 090 

59851 .... .......... R Abortion .............................................................. 5.92 NA 3.75 1.28 NA 10.95 090 

59852 .... .......... R Abortion .............................................................. 8.23 NA 5.05 1.80 NA 15.08 090 

59855 .... .......... R Abortion .............................................................. 6.11 NA 3.55 1.45 NA 11.11 090 

70399 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

59856 .... .......... R Abortion .............................................................. 7.47 NA 4.07 1.78 NA 13.32 090 

59857 .... .......... R Abortion .............................................................. 9.28 NA 4.72 2.01 NA 16.01 090 

59866 .... .......... R Abortion (mpr) .................................................... 3.99 NA 1.90 0.87 NA 6.76 000 

59870 .... .......... A Evacuate mole of uterus .................................... 6.00 NA 4.49 1.42 NA 11.91 090 

59871 .... .......... A Remove cerclage suture .................................... 2.13 1.75 1.13 0.50 4.38 3.76 000 

59897 .... .......... C Fetal invas px w/us ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

59898 .... .......... C Laparo proc, ob care/deliver .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

59899 .... .......... C Maternity care procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

60000 .... .......... A Drain thyroid/tongue cyst ................................... 1.76 1.93 1.71 0.15 3.84 3.62 010 

60001 .... .......... A Aspirate/inject thyriod cyst ................................. 0.97 1.41 0.33 0.07 2.45 1.37 000 

60100 .... .......... A Biopsy of thyroid ................................................. 1.56 1.40 0.53 0.10 3.06 2.19 000 

60200 .... .......... A Remove thyroid lesion ........................................ 9.54 NA 6.00 1.01 NA 16.55 090 

60210 .... .......... A Partial thyroid excision ....................................... 10.86 NA 5.65 1.23 NA 17.74 090 

60212 .... .......... A Partial thyroid excision ....................................... 16.01 NA 7.69 1.94 NA 25.64 090 

60220 .... .......... A Partial removal of thyroid ................................... 11.88 NA 6.16 1.32 NA 19.36 090 

60225 .... .......... A Partial removal of thyroid ................................... 14.17 NA 7.42 1.64 NA 23.23 090 

60240 .... .......... A Removal of thyroid ............................................. 16.04 NA 7.60 1.85 NA 25.49 090 

60252 .... .......... A Removal of thyroid ............................................. 20.54 NA 10.12 2.29 NA 32.95 090 

60254 .... .......... A Extensive thyroid surgery ................................... 26.95 NA 14.18 2.60 NA 43.73 090 

60260 .... .......... A Repeat thyroid surgery ....................................... 17.44 NA 8.67 1.93 NA 28.04 090 

60270 .... .......... A Removal of thyroid ............................................. 20.24 NA 10.48 2.32 NA 33.04 090 

60271 .... .......... A Removal of thyroid ............................................. 16.80 NA 8.60 1.74 NA 27.14 090 

60280 .... .......... A Remove thyroid duct lesion ................................ 5.86 NA 4.67 0.54 NA 11.07 090 

60281 .... .......... A Remove thyroid duct lesion ................................ 8.52 NA 5.85 0.73 NA 15.10 090 

60500 .... .......... A Explore parathyroid glands ................................ 16.21 NA 7.42 2.00 NA 25.63 090 

60502 .... .......... A Re-explore parathyroids ..................................... 20.32 NA 9.38 2.53 NA 32.23 090 

60505 .... .......... A Explore parathyroid glands ................................ 21.46 NA 10.95 2.64 NA 35.05 090 

60512 .... .......... A Autotransplant parathyroid ................................. 4.44 NA 1.62 0.53 NA 6.59 ZZZ 

60520 .... .......... A Removal of thymus gland .................................. 16.78 NA 8.31 2.19 NA 27.28 090 

60521 .... .......... A Removal of thymus gland .................................. 18.84 NA 9.57 2.81 NA 31.22 090 

60522 .... .......... A Removal of thymus gland .................................. 23.06 NA 11.29 3.26 NA 37.61 090 

60540 .... .......... A Explore adrenal gland ........................................ 17.00 NA 7.60 1.74 NA 26.34 090 

60545 .... .......... A Explore adrenal gland ........................................ 19.85 NA 8.55 2.07 NA 30.47 090 

60600 .... .......... A Remove carotid body lesion ............................... 17.90 NA 10.99 2.19 NA 31.08 090 

60605 .... .......... A Remove carotid body lesion ............................... 20.21 NA 12.29 2.49 NA 34.99 090 

60650 .... .......... A Laparoscopy adrenalectomy .............................. 19.97 NA 8.00 2.28 NA 30.25 090 

60659 .... .......... C Laparo proc, endocrine ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

60699 .... .......... C Endocrine surgery procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

61000 .... .......... A Remove cranial cavity fluid ................................ 1.58 NA 0.95 0.13 NA 2.66 000 

61001 .... .......... A Remove cranial cavity fluid ................................ 1.49 NA 1.06 0.16 NA 2.71 000 

61020 .... .......... A Remove brain cavity fluid ................................... 1.51 NA 1.34 0.34 NA 3.19 000 

61026 .... .......... A Injection into brain canal .................................... 1.69 NA 1.39 0.33 NA 3.41 000 

61050 .... .......... A Remove brain canal fluid ................................... 1.51 NA 1.27 0.11 NA 2.89 000 

61055 .... .......... A Injection into brain canal .................................... 2.10 NA 1.42 0.17 NA 3.69 000 

61070 .... .......... A Brain canal shunt procedure .............................. 0.89 NA 1.01 0.17 NA 2.07 000 

61105 .... .......... A Twist drill hole .................................................... 5.13 NA 3.94 1.32 NA 10.39 090 

61107 .... .......... A Drill skull for implantation ................................... 4.99 NA 2.54 1.29 NA 8.82 000 

61108 .... .......... A Drill skull for drainage ........................................ 10.17 NA 7.16 2.63 NA 19.96 090 

61120 .... .......... A Burr hole for puncture ........................................ 8.75 NA 6.01 2.09 NA 16.85 090 

61140 .... .......... A Pierce skull for biopsy ........................................ 15.88 NA 9.91 4.11 NA 29.90 090 

61150 .... .......... A Pierce skull for drainage .................................... 17.54 NA 10.40 4.31 NA 32.25 090 

61151 .... .......... A Pierce skull for drainage .................................... 12.40 NA 7.83 3.00 NA 23.23 090 

61154 .... .......... A Pierce skull & remove clot ................................. 14.97 NA 9.51 4.20 NA 28.68 090 

61156 .... .......... A Pierce skull for drainage .................................... 16.30 NA 9.86 4.22 NA 30.38 090 

61210 .... .......... A Pierce skull, implant device ................................ 5.83 NA 2.92 1.50 NA 10.25 000 

61215 .... .......... A Insert brain-fluid device ...................................... 4.88 NA 4.01 1.26 NA 10.15 090 

61250 .... .......... A Pierce skull & explore ........................................ 10.40 NA 6.87 2.76 NA 20.03 090 

61253 .... .......... A Pierce skull & explore ........................................ 12.34 NA 7.74 2.61 NA 22.69 090 

61304 .... .......... A Open skull for exploration .................................. 21.93 NA 12.87 5.61 NA 40.41 090 

61305 .... .......... A Open skull for exploration .................................. 26.57 NA 15.35 6.07 NA 47.99 090 

61312 .... .......... A Open skull for drainage ...................................... 24.53 NA 15.08 6.34 NA 45.95 090 

61313 .... .......... A Open skull for drainage ...................................... 24.89 NA 14.84 6.43 NA 46.16 090 

61314 .... .......... A Open skull for drainage ...................................... 24.19 NA 13.07 6.26 NA 43.52 090 

61315 .... .......... A Open skull for drainage ...................................... 27.64 NA 16.06 7.14 NA 50.84 090 

61316 .... .......... A Implt cran bone flap to abdo .............................. 1.39 NA 0.60 0.35 NA 2.34 ZZZ 

61320 .... .......... A Open skull for drainage ...................................... 25.58 NA 14.79 6.60 NA 46.97 090 

61321 .... .......... A Open skull for drainage ...................................... 28.46 NA 16.17 7.12 NA 51.75 090 

61322 .... .......... A Decompressive craniotomy ................................ 29.46 NA 15.71 7.61 NA 52.78 090 

61323 .... .......... A Decompressive lobectomy ................................. 30.95 NA 16.13 8.01 NA 55.09 090 

61330 .... .......... A Decompress eye socket ..................................... 23.29 NA 13.76 2.31 NA 39.36 090 

61332 .... .......... A Explore/biopsy eye socket ................................. 27.24 NA 15.64 4.82 NA 47.70 090 

61333 .... .......... A Explore orbit/remove lesion ................................ 27.91 NA 15.62 3.91 NA 47.44 090 

61334 .... .......... A Explore orbit/remove object ............................... 18.24 NA 10.66 1.74 NA 30.64 090 

61340 .... .......... A Subtemporal decompression .............................. 18.63 NA 11.15 4.83 NA 34.61 090 

61343 .... .......... A Incise skull (press relief) .................................... 29.73 NA 16.85 7.62 NA 54.20 090 

70400 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

61345 .... .......... A Relieve cranial pressure ..................................... 27.16 NA 15.43 7.02 NA 49.61 090 

61440 .... .......... A Incise skull for surgery ....................................... 26.59 NA 14.24 6.88 NA 47.71 090 

61450 .... .......... A Incise skull for surgery ....................................... 25.91 NA 14.32 5.77 NA 46.00 090 

61458 .... .......... A Incise skull for brain wound ............................... 27.25 NA 15.55 7.01 NA 49.81 090 

61460 .... .......... A Incise skull for surgery ....................................... 28.35 NA 16.46 6.02 NA 50.83 090 

61470 .... .......... A Incise skull for surgery ....................................... 26.02 NA 13.89 5.88 NA 45.79 090 

61480 .... .......... A Incise skull for surgery ....................................... 26.45 NA 15.31 6.71 NA 48.47 090 

61490 .... .......... A Incise skull for surgery ....................................... 25.62 NA 14.36 6.90 NA 46.88 090 

61500 .... .......... A Removal of skull lesion ...................................... 17.89 NA 10.83 4.10 NA 32.82 090 

61501 .... .......... A Remove infected skull bone ............................... 14.82 NA 9.23 3.21 NA 27.26 090 

61510 .... .......... A Removal of brain lesion ..................................... 28.41 NA 16.74 7.33 NA 52.48 090 

61512 .... .......... A Remove brain lining lesion ................................. 35.04 NA 19.73 9.05 NA 63.82 090 

61514 .... .......... A Removal of brain abscess .................................. 25.22 NA 14.47 6.52 NA 46.21 090 

61516 .... .......... A Removal of brain lesion ..................................... 24.57 NA 14.30 6.33 NA 45.20 090 

61517 .... .......... A Implt brain chemotx add-on ............................... 1.38 NA 0.64 0.35 NA 2.37 ZZZ 

61518 .... .......... A Removal of brain lesion ..................................... 37.26 NA 21.15 9.62 NA 68.03 090 

61519 .... .......... A Remove brain lining lesion ................................. 41.33 NA 22.71 10.60 NA 74.64 090 

61520 .... .......... A Removal of brain lesion ..................................... 54.76 NA 30.41 11.18 NA 96.35 090 

61521 .... .......... A Removal of brain lesion ..................................... 44.41 NA 24.28 11.36 NA 80.05 090 

61522 .... .......... A Removal of brain abscess .................................. 29.41 NA 16.46 7.60 NA 53.47 090 

61524 .... .......... A Removal of brain lesion ..................................... 27.82 NA 15.71 7.14 NA 50.67 090 

61526 .... .......... A Removal of brain lesion ..................................... 52.09 NA 29.57 7.05 NA 88.71 090 

61530 .... .......... A Removal of brain lesion ..................................... 43.79 NA 25.12 6.13 NA 75.04 090 

61531 .... .......... A Implant brain electrodes ..................................... 14.61 NA 9.15 3.78 NA 27.54 090 

61533 .... .......... A Implant brain electrodes ..................................... 19.68 NA 11.56 5.10 NA 36.34 090 

61534 .... .......... A Removal of brain lesion ..................................... 20.94 NA 12.12 5.42 NA 38.48 090 

61535 .... .......... A Remove brain electrodes ................................... 11.61 NA 7.44 3.01 NA 22.06 090 

61536 .... .......... A Removal of brain lesion ..................................... 35.47 NA 19.84 9.18 NA 64.49 090 

61537 .... .......... A Removal of brain tissue ..................................... 24.96 NA 14.78 6.92 NA 46.66 090 

61538 .... .......... A Removal of brain tissue ..................................... 26.77 NA 15.35 6.92 NA 49.04 090 

61539 .... .......... A Removal of brain tissue ..................................... 32.03 NA 17.81 8.30 NA 58.14 090 

61540 .... .......... A Removal of brain tissue ..................................... 29.96 NA 17.29 8.30 NA 55.55 090 

61541 .... .......... A Incision of brain tissue ....................................... 28.81 NA 16.25 6.58 NA 51.64 090 

61542 .... .......... A Removal of brain tissue ..................................... 30.97 NA 17.87 8.01 NA 56.85 090 

61543 .... .......... A Removal of brain tissue ..................................... 29.18 NA 16.43 7.54 NA 53.15 090 

61544 .... .......... A Remove & treat brain lesion .............................. 25.46 NA 13.86 5.95 NA 45.27 090 

61545 .... .......... A Excision of brain tumor ...................................... 43.73 NA 24.28 10.60 NA 78.61 090 

61546 .... .......... A Removal of pituitary gland ................................. 31.25 NA 17.54 7.65 NA 56.44 090 

61548 .... .......... A Removal of pituitary gland ................................. 21.50 NA 12.82 3.42 NA 37.74 090 

61550 .... .......... A Release of skull seams ...................................... 14.63 NA 6.95 0.98 NA 22.56 090 

61552 .... .......... A Release of skull seams ...................................... 19.53 NA 9.14 1.06 NA 29.73 090 

61556 .... .......... A Incise skull/sutures ............................................. 22.23 NA 11.39 4.64 NA 38.26 090 

61557 .... .......... A Incise skull/sutures ............................................. 22.35 NA 13.66 5.78 NA 41.79 090 

61558 .... .......... A Excision of skull/sutures ..................................... 25.54 NA 14.23 1.36 NA 41.13 090 

61559 .... .......... A Excision of skull/sutures ..................................... 32.74 NA 19.37 8.48 NA 60.59 090 

61563 .... .......... A Excision of skull tumor ....................................... 26.79 NA 15.28 5.15 NA 47.22 090 

61564 .... .......... A Excision of skull tumor ....................................... 33.78 NA 18.33 8.75 NA 60.86 090 

61566 .... .......... A Removal of brain tissue ..................................... 30.95 NA 17.82 6.92 NA 55.69 090 

61567 .... .......... A Incision of brain tissue ....................................... 35.45 NA 20.73 6.52 NA 62.70 090 

61570 .... .......... A Remove foreign body, brain ............................... 24.56 NA 13.95 5.86 NA 44.37 090 

61571 .... .......... A Incise skull for brain wound ............................... 26.35 NA 15.18 6.77 NA 48.30 090 

61575 .... .......... A Skull base/brainstem surgery ............................. 34.31 NA 19.69 5.32 NA 59.32 090 

61576 .... .......... A Skull base/brainstem surgery ............................. 52.35 NA 34.83 5.56 NA 92.74 090 

61580 .... .......... A Craniofacial approach, skull ............................... 30.30 NA 25.65 3.36 NA 59.31 090 

61581 .... .......... A Craniofacial approach, skull ............................... 34.55 NA 23.51 3.91 NA 61.97 090 

61582 .... .......... A Craniofacial approach, skull ............................... 31.61 NA 27.38 7.19 NA 66.18 090 

61583 .... .......... A Craniofacial approach, skull ............................... 36.16 NA 25.18 9.18 NA 70.52 090 

61584 .... .......... A Orbitocranial approach/skull ............................... 34.60 NA 24.59 8.16 NA 67.35 090 

61585 .... .......... A Orbitocranial approach/skull ............................... 38.55 NA 26.57 7.01 NA 72.13 090 

61586 .... .......... A Resect nasopharynx, skull ................................. 25.06 NA 22.65 4.36 NA 52.07 090 

61590 .... .......... A Infratemporal approach/skull .............................. 41.72 NA 28.70 5.29 NA 75.71 090 

61591 .... .......... A Infratemporal approach/skull .............................. 43.61 NA 29.61 5.64 NA 78.86 090 

61592 .... .......... A Orbitocranial approach/skull ............................... 39.58 NA 26.58 10.04 NA 76.20 090 

61595 .... .......... A Transtemporal approach/skull ............................ 29.53 NA 22.41 3.97 NA 55.91 090 

61596 .... .......... A Transcochlear approach/skull ............................ 35.58 NA 24.51 3.39 NA 63.48 090 

61597 .... .......... A Transcondylar approach/skull ............................ 37.90 NA 23.06 8.81 NA 69.77 090 

61598 .... .......... A Transpetrosal approach/skull ............................. 33.36 NA 23.30 5.68 NA 62.34 090 

61600 .... .......... A Resect/excise cranial lesion ............................... 25.81 NA 19.83 3.78 NA 49.42 090 

61601 .... .......... A Resect/excise cranial lesion ............................... 27.85 NA 20.55 6.61 NA 55.01 090 

61605 .... .......... A Resect/excise cranial lesion ............................... 29.29 NA 22.02 2.85 NA 54.16 090 

61606 .... .......... A Resect/excise cranial lesion ............................... 38.77 NA 25.22 8.94 NA 72.93 090 

61607 .... .......... A Resect/excise cranial lesion ............................... 36.22 NA 23.85 6.88 NA 66.95 090 

61608 .... .......... A Resect/excise cranial lesion ............................... 42.04 NA 26.66 10.72 NA 79.42 090 

61609 .... .......... A Transect artery, sinus ......................................... 9.88 NA 4.86 2.55 NA 17.29 ZZZ 

61610 .... .......... A Transect artery, sinus ......................................... 29.63 NA 13.18 7.66 NA 50.47 ZZZ 

70401 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

61611 .... .......... A Transect artery, sinus ......................................... 7.41 NA 3.83 1.88 NA 13.12 ZZZ 

61612 .... .......... A Transect artery, sinus ......................................... 27.84 NA 13.35 4.30 NA 45.49 ZZZ 

61613 .... .......... A Remove aneurysm, sinus ................................... 40.80 NA 26.34 8.42 NA 75.56 090 

61615 .... .......... A Resect/excise lesion, skull ................................. 32.02 NA 22.79 4.72 NA 59.53 090 

61616 .... .......... A Resect/excise lesion, skull ................................. 43.27 NA 28.73 8.24 NA 80.24 090 

61618 .... .......... A Repair dura ......................................................... 16.96 NA 10.47 3.71 NA 31.14 090 

61619 .... .......... A Repair dura ......................................................... 20.68 NA 12.28 3.94 NA 36.90 090 

61623 .... .......... A Endovasc tempory vessel occl ........................... 9.95 NA 4.09 1.05 NA 15.09 000 

61624 .... .......... A Transcath occlusion, cns .................................... 20.12 NA 6.91 1.95 NA 28.98 000 

61626 .... .......... A Transcath occlusion, non-cns ............................ 16.60 NA 5.53 1.24 NA 23.37 000 

61630 .... .......... N Intracranial angioplasty ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

61635 .... .......... N Intracran angioplsty w/stent ............................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

61640 .... .......... N Dilate ic vasospasm, init .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

61641 .... .......... N Dilate ic vasospasm add-on ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

61642 .... .......... N Dilate ic vasospasm add-on ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

61680 .... .......... A Intracranial vessel surgery ................................. 30.66 NA 17.48 7.93 NA 56.07 090 

61682 .... .......... A Intracranial vessel surgery ................................. 61.48 NA 32.30 15.85 NA 109.63 090 

61684 .... .......... A Intracranial vessel surgery ................................. 39.75 NA 22.06 10.28 NA 72.09 090 

61686 .... .......... A Intracranial vessel surgery ................................. 64.39 NA 34.82 16.66 NA 115.87 090 

61690 .... .......... A Intracranial vessel surgery ................................. 29.27 NA 16.77 6.92 NA 52.96 090 

61692 .... .......... A Intracranial vessel surgery ................................. 51.79 NA 27.55 13.39 NA 92.73 090 

61697 .... .......... A Brain aneurysm repr, complx ............................. 50.44 NA 28.09 12.81 NA 91.34 090 

61698 .... .......... A Brain aneurysm repr, complx ............................. 48.34 NA 26.77 12.50 NA 87.61 090 

61700 .... .......... A Brain aneurysm repr, simple .............................. 50.44 NA 27.88 12.98 NA 91.30 090 

61702 .... .......... A Inner skull vessel surgery .................................. 48.34 NA 26.11 10.76 NA 85.21 090 

61703 .... .......... A Clamp neck artery .............................................. 17.44 NA 10.49 4.05 NA 31.98 090 

61705 .... .......... A Revise circulation to head .................................. 36.15 NA 19.31 8.84 NA 64.30 090 

61708 .... .......... A Revise circulation to head .................................. 35.25 NA 15.19 2.50 NA 52.94 090 

61710 .... .......... A Revise circulation to head .................................. 29.63 NA 13.68 4.51 NA 47.82 090 

61711 .... .......... A Fusion of skull arteries ....................................... 36.28 NA 19.86 9.39 NA 65.53 090 

61720 .... .......... A Incise skull/brain surgery .................................... 16.74 NA 10.00 2.78 NA 29.52 090 

61735 .... .......... A Incise skull/brain surgery .................................... 20.40 NA 12.20 2.72 NA 35.32 090 

61750 .... .......... A Incise skull/brain biopsy ..................................... 18.17 NA 10.64 4.71 NA 33.52 090 

61751 .... .......... A Brain biopsy w/ct/mr guide ................................. 17.59 NA 10.85 4.55 NA 32.99 090 

61760 .... .......... A Implant brain electrodes ..................................... 22.24 NA 8.74 5.40 NA 36.38 090 

61770 .... .......... A Incise skull for treatment .................................... 21.41 NA 12.29 3.54 NA 37.24 090 

61790 .... .......... A Treat trigeminal nerve ........................................ 10.84 NA 5.93 2.81 NA 19.58 090 

61791 .... .......... A Treat trigeminal tract .......................................... 14.59 NA 8.94 3.39 NA 26.92 090 

61793 .... .......... A Focus radiation beam ......................................... 17.21 NA 10.15 4.45 NA 31.81 090 

61795 .... .......... A Brain surgery using computer ............................ 4.03 NA 2.04 0.79 NA 6.86 ZZZ 

61850 .... .......... A Implant neuroelectrodes ..................................... 12.37 NA 7.69 3.21 NA 23.27 090 

61860 .... .......... A Implant neuroelectrodes ..................................... 20.84 NA 12.09 4.94 NA 37.87 090 

61863 .... .......... A Implant neuroelectrode ....................................... 18.97 NA 11.80 5.41 NA 36.18 090 

61864 .... .......... A Implant neuroelectrde, addl ................................ 4.49 NA 2.29 5.41 NA 12.19 ZZZ 

61867 .... .......... A Implant neuroelectrode ....................................... 31.29 NA 18.07 5.41 NA 54.77 090 

61868 .... .......... A Implant neuroelectrde, add’l ............................... 7.91 NA 4.02 5.41 NA 17.34 ZZZ 

61870 .... .......... A Implant neuroelectrodes ..................................... 14.92 NA 9.73 3.86 NA 28.51 090 

61875 .... .......... A Implant neuroelectrodes ..................................... 15.04 NA 8.59 2.94 NA 26.57 090 

61880 .... .......... A Revise/remove neuroelectrode .......................... 6.28 NA 4.58 1.66 NA 12.52 090 

61885 .... .......... A Insrt/redo neurostim 1 array ............................... 5.84 NA 5.32 1.59 NA 12.75 090 

61886 .... .......... A Implant neurostim arrays .................................... 7.99 NA 6.37 1.96 NA 16.32 090 

61888 .... .......... A Revise/remove neuroreceiver ............................ 5.06 NA 3.68 1.33 NA 10.07 010 

62000 .... .......... A Treat skull fracture ............................................. 12.51 NA 5.53 1.06 NA 19.10 090 

62005 .... .......... A Treat skull fracture ............................................. 16.15 NA 8.82 3.86 NA 28.83 090 

62010 .... .......... A Treatment of head injury .................................... 19.78 NA 11.74 5.12 NA 36.64 090 

62100 .... .......... A Repair brain fluid leakage .................................. 22.00 NA 12.82 4.83 NA 39.65 090 

62115 .... .......... A Reduction of skull defect .................................... 21.63 NA 11.67 5.49 NA 38.79 090 

62116 .... .......... A Reduction of skull defect .................................... 23.55 NA 13.40 6.09 NA 43.04 090 

62117 .... .......... A Reduction of skull defect .................................... 26.56 NA 15.41 4.52 NA 46.49 090 

62120 .... .......... A Repair skull cavity lesion .................................... 23.31 NA 18.53 2.99 NA 44.83 090 

62121 .... .......... A Incise skull repair ............................................... 21.55 NA 15.49 4.16 NA 41.20 090 

62140 .... .......... A Repair of skull defect ......................................... 13.49 NA 8.34 3.46 NA 25.29 090 

62141 .... .......... A Repair of skull defect ......................................... 14.89 NA 9.07 3.75 NA 27.71 090 

62142 .... .......... A Remove skull plate/flap ...................................... 10.77 NA 7.01 2.72 NA 20.50 090 

62143 .... .......... A Replace skull plate/flap ...................................... 13.03 NA 8.06 3.36 NA 24.45 090 

62145 .... .......... A Repair of skull & brain ........................................ 18.79 NA 10.92 4.49 NA 34.20 090 

62146 .... .......... A Repair of skull with graft .................................... 16.10 NA 9.66 3.61 NA 29.37 090 

62147 .... .......... A Repair of skull with graft .................................... 19.31 NA 11.33 4.31 NA 34.95 090 

62148 .... .......... A Retr bone flap to fix skull ................................... 2.00 NA 0.86 0.48 NA 3.34 ZZZ 

62160 .... .......... A Neuroendoscopy add-on .................................... 3.00 NA 1.53 0.77 NA 5.30 ZZZ 

62161 .... .......... A Dissect brain w/scope ........................................ 19.97 NA 12.13 5.17 NA 37.27 090 

62162 .... .......... A Remove colloid cyst w/scope ............................. 25.21 NA 14.89 5.89 NA 45.99 090 

62163 .... .......... A Neuroendoscopy w/fb removal ........................... 15.48 NA 9.95 4.00 NA 29.43 090 

62164 .... .......... A Remove brain tumor w/scope ............................ 27.46 NA 14.99 5.36 NA 47.81 090 

62165 .... .......... A Remove pituit tumor w/scope ............................. 21.97 NA 13.42 3.00 NA 38.39 090 

70402 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

62180 .... .......... A Establish brain cavity shunt ............................... 21.03 NA 12.32 4.97 NA 38.32 090 

62190 .... .......... A Establish brain cavity shunt ............................... 11.05 NA 7.10 2.79 NA 20.94 090 

62192 .... .......... A Establish brain cavity shunt ............................... 12.23 NA 7.64 3.01 NA 22.88 090 

62194 .... .......... A Replace/irrigate catheter .................................... 5.02 NA 2.44 0.92 NA 8.38 010 

62200 .... .......... A Establish brain cavity shunt ............................... 18.29 NA 10.87 4.64 NA 33.80 090 

62201 .... .......... A Brain cavity shunt w/scope ................................ 14.84 NA 9.47 3.67 NA 27.98 090 

62220 .... .......... A Establish brain cavity shunt ............................... 12.98 NA 8.00 3.34 NA 24.32 090 

62223 .... .......... A Establish brain cavity shunt ............................... 12.85 NA 8.26 3.13 NA 24.24 090 

62225 .... .......... A Replace/irrigate catheter .................................... 5.40 NA 4.10 1.39 NA 10.89 090 

62230 .... .......... A Replace/revise brain shunt ................................. 10.52 NA 6.50 2.70 NA 19.72 090 

62252 .... 26 ..... A Csf shunt reprogram .......................................... 0.74 0.37 0.37 0.19 1.30 1.30 XXX 

62252 .... TC .... A Csf shunt reprogram .......................................... 0.00 1.10 NA 0.02 1.12 NA XXX 

62252 .... .......... A Csf shunt reprogram .......................................... 0.74 1.47 NA 0.21 2.42 NA XXX 

62256 .... .......... A Remove brain cavity shunt ................................. 6.59 NA 4.70 1.71 NA 13.00 090 

62258 .... .......... A Replace brain cavity shunt ................................. 14.52 NA 8.74 3.73 NA 26.99 090 

62263 .... .......... A Epidural lysis mult sessions ............................... 6.13 12.73 3.20 0.41 19.27 9.74 010 

62264 .... .......... A Epidural lysis on single day ............................... 4.42 7.75 1.42 0.27 12.44 6.11 010 

62268 .... .......... A Drain spinal cord cyst ......................................... 4.73 11.56 2.15 0.43 16.72 7.31 000 

62269 .... .......... A Needle biopsy, spinal cord ................................. 5.01 14.72 1.98 0.37 20.10 7.36 000 

62270 .... .......... A Spinal fluid tap, diagnostic ................................. 1.13 3.00 0.56 0.08 4.21 1.77 000 

62272 .... .......... A Drain cerebro spinal fluid ................................... 1.35 3.62 0.71 0.18 5.15 2.24 000 

62273 .... .......... A Inject epidural patch ........................................... 2.15 2.72 0.71 0.13 5.00 2.99 000 

62280 .... .......... A Treat spinal cord lesion ...................................... 2.63 6.95 1.01 0.30 9.88 3.94 010 

62281 .... .......... A Treat spinal cord lesion ...................................... 2.66 5.67 0.89 0.19 8.52 3.74 010 

62282 .... .......... A Treat spinal canal lesion .................................... 2.33 8.38 0.92 0.17 10.88 3.42 010 

62284 .... .......... A Injection for myelogram ...................................... 1.54 4.97 0.68 0.13 6.64 2.35 000 

62287 .... .......... A Percutaneous diskectomy .................................. 8.07 NA 5.57 0.58 NA 14.22 090 

62290 .... .......... A Inject for spine disk x-ray ................................... 3.00 7.15 1.38 0.23 10.38 4.61 000 

62291 .... .......... A Inject for spine disk x-ray ................................... 2.91 5.95 1.23 0.26 9.12 4.40 000 

62292 .... .......... A Injection into disk lesion ..................................... 7.85 NA 4.48 0.82 NA 13.15 090 

62294 .... .......... A Injection into spinal artery .................................. 11.81 NA 5.60 1.24 NA 18.65 090 

62310 .... .......... A Inject spine c/t .................................................... 1.91 4.82 0.65 0.12 6.85 2.68 000 

62311 .... .......... A Inject spine l/s (cd) ............................................. 1.54 4.93 0.59 0.09 6.56 2.22 000 

62318 .... .......... A Inject spine w/cath, c/t ........................................ 2.04 5.74 0.65 0.12 7.90 2.81 000 

62319 .... .......... A Inject spine w/cath l/s (cd) ................................. 1.87 4.99 0.61 0.11 6.97 2.59 000 

62350 .... .......... A Implant spinal canal cath ................................... 6.86 NA 3.95 1.02 NA 11.83 090 

62351 .... .......... A Implant spinal canal cath ................................... 9.99 NA 7.14 2.24 NA 19.37 090 

62355 .... .......... A Remove spinal canal catheter ............................ 5.44 NA 3.17 0.71 NA 9.32 090 

62360 .... .......... A Insert spine infusion device ................................ 2.62 NA 2.69 0.34 NA 5.65 090 

62361 .... .......... A Implant spine infusion pump .............................. 5.41 NA 3.93 0.80 NA 10.14 090 

62362 .... .......... A Implant spine infusion pump .............................. 7.03 NA 4.37 1.18 NA 12.58 090 

62365 .... .......... A Remove spine infusion device ........................... 5.41 NA 3.59 0.86 NA 9.86 090 

62367 .... .......... A Analyze spine infusion pump ............................. 0.48 0.61 0.10 0.03 1.12 0.61 XXX 

62368 .... .......... A Analyze spine infusion pump ............................. 0.75 0.69 0.17 0.06 1.50 0.98 XXX 

63001 .... .......... A Removal of spinal lamina ................................... 15.80 NA 9.54 3.76 NA 29.10 090 

63003 .... .......... A Removal of spinal lamina ................................... 15.93 NA 9.89 3.72 NA 29.54 090 

63005 .... .......... A Removal of spinal lamina ................................... 14.90 NA 10.00 3.34 NA 28.24 090 

63011 .... .......... A Removal of spinal lamina ................................... 14.50 NA 8.29 3.37 NA 26.16 090 

63012 .... .......... A Removal of spinal lamina ................................... 15.38 NA 10.15 3.48 NA 29.01 090 

63015 .... .......... A Removal of spinal lamina ................................... 19.32 NA 11.90 4.75 NA 35.97 090 

63016 .... .......... A Removal of spinal lamina ................................... 19.17 NA 11.81 4.58 NA 35.56 090 

63017 .... .......... A Removal of spinal lamina ................................... 15.92 NA 10.42 3.63 NA 29.97 090 

63020 .... .......... A Neck spine disk surgery ..................................... 14.79 NA 9.70 3.71 NA 28.20 090 

63030 .... .......... A Low back disk surgery ....................................... 11.98 NA 8.44 3.00 NA 23.42 090 

63035 .... .......... A Spinal disk surgery add-on ................................ 3.15 NA 1.59 0.79 NA 5.53 ZZZ 

63040 .... .......... A Laminotomy, single cervical ............................... 18.78 NA 11.53 4.67 NA 34.98 090 

63042 .... .......... A Laminotomy, single lumbar ................................ 17.44 NA 11.37 4.25 NA 33.06 090 

63043 .... .......... C Laminotomy, add’l cervical ................................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

63044 .... .......... C Laminotomy, add’l lumbar .................................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

63045 .... .......... A Removal of spinal lamina ................................... 16.48 NA 10.38 3.98 NA 30.84 090 

63046 .... .......... A Removal of spinal lamina ................................... 15.78 NA 10.21 3.55 NA 29.54 090 

63047 .... .......... A Removal of spinal lamina ................................... 14.59 NA 9.92 3.23 NA 27.74 090 

63048 .... .......... A Remove spinal lamina add-on ........................... 3.26 NA 1.66 0.72 NA 5.64 ZZZ 

63050 .... .......... A Cervical laminoplasty ......................................... 20.75 NA 11.87 4.66 NA 37.28 090 

63051 .... .......... A C-laminoplasty w/graft/plate ............................... 24.25 NA 13.51 4.66 NA 42.42 090 

63055 .... .......... A Decompress spinal cord ..................................... 21.96 NA 13.17 5.27 NA 40.40 090 

63056 .... .......... A Decompress spinal cord ..................................... 20.33 NA 12.60 4.75 NA 37.68 090 

63057 .... .......... A Decompress spine cord add-on ......................... 5.25 NA 2.64 1.22 NA 9.11 ZZZ 

63064 .... .......... A Decompress spinal cord ..................................... 24.57 NA 14.46 5.69 NA 44.72 090 

63066 .... .......... A Decompress spine cord add-on ......................... 3.26 NA 1.66 0.69 NA 5.61 ZZZ 

63075 .... .......... A Neck spine disk surgery ..................................... 19.38 NA 12.12 4.62 NA 36.12 090 

63076 .... .......... A Neck spine disk surgery ..................................... 4.04 NA 2.06 0.96 NA 7.06 ZZZ 

63077 .... .......... A Spine disk surgery, thorax ................................. 21.41 NA 12.83 3.98 NA 38.22 090 

63078 .... .......... A Spine disk surgery, thorax ................................. 3.28 NA 1.64 0.66 NA 5.58 ZZZ 

63081 .... .......... A Removal of vertebral body ................................. 23.69 NA 14.36 5.54 NA 43.59 090 

70403 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

63082 .... .......... A Remove vertebral body add-on .......................... 4.36 NA 2.23 1.02 NA 7.61 ZZZ 

63085 .... .......... A Removal of vertebral body ................................. 26.88 NA 15.51 4.48 NA 46.87 090 

63086 .... .......... A Remove vertebral body add-on .......................... 3.19 NA 1.59 0.59 NA 5.37 ZZZ 

63087 .... .......... A Removal of vertebral body ................................. 35.52 NA 19.51 6.20 NA 61.23 090 

63088 .... .......... A Remove vertebral body add-on .......................... 4.32 NA 2.18 0.82 NA 7.32 ZZZ 

63090 .... .......... A Removal of vertebral body ................................. 28.12 NA 16.08 4.21 NA 48.41 090 

63091 .... .......... A Remove vertebral body add-on .......................... 3.03 NA 1.46 0.48 NA 4.97 ZZZ 

63101 .... .......... A Removal of vertebral body ................................. 31.95 NA 19.33 5.69 NA 56.97 090 

63102 .... .......... A Removal of vertebral body ................................. 31.95 NA 19.33 5.69 NA 56.97 090 

63103 .... .......... A Remove vertebral body add-on .......................... 4.82 NA 2.51 0.69 NA 8.02 ZZZ 

63170 .... .......... A Incise spinal cord tract(s) ................................... 19.80 NA 11.89 4.86 NA 36.55 090 

63172 .... .......... A Drainage of spinal cyst ....................................... 17.63 NA 10.67 4.48 NA 32.78 090 

63173 .... .......... A Drainage of spinal cyst ....................................... 21.96 NA 12.84 5.68 NA 40.48 090 

63180 .... .......... A Revise spinal cord ligaments ............................. 18.24 NA 11.01 3.95 NA 33.20 090 

63182 .... .......... A Revise spinal cord ligaments ............................. 20.47 NA 10.98 5.30 NA 36.75 090 

63185 .... .......... A Incise spinal column/nerves ............................... 15.02 NA 8.11 2.79 NA 25.92 090 

63190 .... .......... A Incise spinal column/nerves ............................... 17.42 NA 10.16 3.24 NA 30.82 090 

63191 .... .......... A Incise spinal column/nerves ............................... 17.51 NA 10.50 6.34 NA 34.35 090 

63194 .... .......... A Incise spinal column & cord ............................... 19.16 NA 11.74 3.26 NA 34.16 090 

63195 .... .......... A Incise spinal column & cord ............................... 18.81 NA 11.07 4.87 NA 34.75 090 

63196 .... .......... A Incise spinal column & cord ............................... 22.27 NA 13.42 5.76 NA 41.45 090 

63197 .... .......... A Incise spinal column & cord ............................... 21.08 NA 12.24 5.36 NA 38.68 090 

63198 .... .......... A Incise spinal column & cord ............................... 25.34 NA 8.45 6.43 NA 40.22 090 

63199 .... .......... A Incise spinal column & cord ............................... 26.85 NA 15.07 1.40 NA 43.32 090 

63200 .... .......... A Release of spinal cord ....................................... 19.15 NA 11.32 4.96 NA 35.43 090 

63250 .... .......... A Revise spinal cord vessels ................................. 40.70 NA 19.98 9.01 NA 69.69 090 

63251 .... .......... A Revise spinal cord vessels ................................. 41.14 NA 22.65 10.41 NA 74.20 090 

63252 .... .......... A Revise spinal cord vessels ................................. 41.13 NA 22.29 10.64 NA 74.06 090 

63265 .... .......... A Excise intraspinal lesion ..................................... 21.53 NA 12.80 5.43 NA 39.76 090 

63266 .... .......... A Excise intraspinal lesion ..................................... 22.27 NA 13.21 5.54 NA 41.02 090 

63267 .... .......... A Excise intraspinal lesion ..................................... 17.92 NA 11.10 4.37 NA 33.39 090 

63268 .... .......... A Excise intraspinal lesion ..................................... 18.49 NA 10.39 3.69 NA 32.57 090 

63270 .... .......... A Excise intraspinal lesion ..................................... 26.76 NA 15.50 6.82 NA 49.08 090 

63271 .... .......... A Excise intraspinal lesion ..................................... 26.88 NA 15.61 6.90 NA 49.39 090 

63272 .... .......... A Excise intraspinal lesion ..................................... 25.28 NA 14.72 6.18 NA 46.18 090 

63273 .... .......... A Excise intraspinal lesion ..................................... 24.25 NA 14.37 5.74 NA 44.36 090 

63275 .... .......... A Biopsy/excise spinal tumor ................................. 23.64 NA 13.80 5.80 NA 43.24 090 

63276 .... .......... A Biopsy/excise spinal tumor ................................. 23.41 NA 13.71 5.83 NA 42.95 090 

63277 .... .......... A Biopsy/excise spinal tumor ................................. 20.80 NA 12.55 5.01 NA 38.36 090 

63278 .... .......... A Biopsy/excise spinal tumor ................................. 20.53 NA 12.42 4.55 NA 37.50 090 

63280 .... .......... A Biopsy/excise spinal tumor ................................. 28.31 NA 16.35 7.27 NA 51.93 090 

63281 .... .......... A Biopsy/excise spinal tumor ................................. 28.01 NA 16.21 7.17 NA 51.39 090 

63282 .... .......... A Biopsy/excise spinal tumor ................................. 26.35 NA 15.36 6.76 NA 48.47 090 

63283 .... .......... A Biopsy/excise spinal tumor ................................. 24.96 NA 14.69 6.26 NA 45.91 090 

63285 .... .......... A Biopsy/excise spinal tumor ................................. 35.95 NA 19.99 9.18 NA 65.12 090 

63286 .... .......... A Biopsy/excise spinal tumor ................................. 35.58 NA 19.95 9.21 NA 64.74 090 

63287 .... .......... A Biopsy/excise spinal tumor ................................. 36.64 NA 20.47 9.39 NA 66.50 090 

63290 .... .......... A Biopsy/excise spinal tumor ................................. 37.32 NA 20.64 9.02 NA 66.98 090 

63295 .... .......... A Repair of laminectomy defect ............................ 5.25 NA 2.15 1.03 NA 8.43 ZZZ 

63300 .... .......... A Removal of vertebral body ................................. 24.39 NA 14.33 5.97 NA 44.69 090 

63301 .... .......... A Removal of vertebral body ................................. 27.56 NA 15.59 5.39 NA 48.54 090 

63302 .... .......... A Removal of vertebral body ................................. 27.77 NA 15.89 5.53 NA 49.19 090 

63303 .... .......... A Removal of vertebral body ................................. 30.45 NA 16.95 4.68 NA 52.08 090 

63304 .... .......... A Removal of vertebral body ................................. 30.28 NA 17.31 6.41 NA 54.00 090 

63305 .... .......... A Removal of vertebral body ................................. 31.98 NA 18.09 5.71 NA 55.78 090 

63306 .... .......... A Removal of vertebral body ................................. 32.17 NA 17.84 8.33 NA 58.34 090 

63307 .... .......... A Removal of vertebral body ................................. 31.58 NA 16.85 4.46 NA 52.89 090 

63308 .... .......... A Remove vertebral body add-on .......................... 5.24 NA 2.61 1.29 NA 9.14 ZZZ 

63600 .... .......... A Remove spinal cord lesion ................................. 14.00 NA 5.41 1.52 NA 20.93 090 

63610 .... .......... A Stimulation of spinal cord ................................... 8.72 59.85 2.26 0.86 69.43 11.84 000 

63615 .... .......... A Remove lesion of spinal cord ............................. 16.26 NA 9.29 2.84 NA 28.39 090 

63650 .... .......... A Implant neuroelectrodes ..................................... 6.73 NA 3.18 0.53 NA 10.44 090 

63655 .... .......... A Implant neuroelectrodes ..................................... 10.27 NA 6.91 2.43 NA 19.61 090 

63660 .... .......... A Revise/remove neuroelectrode .......................... 6.15 NA 3.62 0.78 NA 10.55 090 

63685 .... .......... A Insrt/redo spine n generator ............................... 7.03 NA 4.15 1.05 NA 12.23 090 

63688 .... .......... A Revise/remove neuroreceiver ............................ 5.38 NA 3.56 0.89 NA 9.83 090 

63700 .... .......... A Repair of spinal herniation ................................. 16.51 NA 10.33 3.52 NA 30.36 090 

63702 .... .......... A Repair of spinal herniation ................................. 18.45 NA 11.06 4.12 NA 33.63 090 

63704 .... .......... A Repair of spinal herniation ................................. 21.15 NA 12.95 4.57 NA 38.67 090 

63706 .... .......... A Repair of spinal herniation ................................. 24.07 NA 13.61 6.23 NA 43.91 090 

63707 .... .......... A Repair spinal fluid leakage ................................. 11.24 NA 7.72 2.51 NA 21.47 090 

63709 .... .......... A Repair spinal fluid leakage ................................. 14.30 NA 9.42 3.09 NA 26.81 090 

63710 .... .......... A Graft repair of spine defect ................................ 14.05 NA 9.06 3.40 NA 26.51 090 

63740 .... .......... A Install spinal shunt .............................................. 11.34 NA 7.36 2.93 NA 21.63 090 

63741 .... .......... A Install spinal shunt .............................................. 8.24 NA 4.76 1.66 NA 14.66 090 

70404 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

63744 .... .......... A Revision of spinal shunt ..................................... 8.09 NA 5.27 1.89 NA 15.25 090 

63746 .... .......... A Removal of spinal shunt ..................................... 6.42 NA 3.78 1.53 NA 11.73 090 

64400 .... .......... A N block inj, trigeminal ......................................... 1.11 1.90 0.43 0.07 3.08 1.61 000 

64402 .... .......... A N block inj, facial ................................................ 1.25 1.61 0.60 0.09 2.95 1.94 000 

64405 .... .......... A N block inj, occipital ........................................... 1.32 1.46 0.46 0.08 2.86 1.86 000 

64408 .... .......... A N block inj, vagus ............................................... 1.41 1.58 0.85 0.10 3.09 2.36 000 

64410 .... .......... A N block inj, phrenic ............................................. 1.43 2.51 0.46 0.09 4.03 1.98 000 

64412 .... .......... A N block inj, spinal accessor ............................... 1.18 2.66 0.43 0.08 3.92 1.69 000 

64413 .... .......... A N block inj, cervical plexus ................................. 1.40 1.85 0.50 0.08 3.33 1.98 000 

64415 .... .......... A N block inj, brachial plexus ................................ 1.48 2.81 0.46 0.09 4.38 2.03 000 

64416 .... .......... A N block cont infuse, b plex ................................. 3.49 NA 0.79 0.31 NA 4.59 010 

64417 .... .......... A N block inj, axillary ............................................. 1.44 3.04 0.49 0.11 4.59 2.04 000 

64418 .... .......... A N block inj, suprascapular .................................. 1.32 2.63 0.44 0.07 4.02 1.83 000 

64420 .... .......... A N block inj, intercost, sng ................................... 1.18 3.89 0.42 0.08 5.15 1.68 000 

64421 .... .......... A N block inj, intercost, mlt .................................... 1.68 6.10 0.52 0.11 7.89 2.31 000 

64425 .... .......... A N block inj, ilio-ing/hypogi .................................. 1.75 1.65 0.54 0.13 3.53 2.42 000 

64430 .... .......... A N block inj, pudendal .......................................... 1.46 2.52 0.55 0.10 4.08 2.11 000 

64435 .... .......... A N block inj, paracervical ..................................... 1.45 2.53 0.69 0.16 4.14 2.30 000 

64445 .... .......... A N block inj, sciatic, sng ...................................... 1.48 2.68 0.50 0.10 4.26 2.08 000 

64446 .... .......... A N blk inj, sciatic, cont inf .................................... 3.25 NA 1.00 0.20 NA 4.45 010 

64447 .... .......... A N block inj fem, single ........................................ 1.50 NA 0.43 0.09 NA 2.02 000 

64448 .... .......... A N block inj fem, cont inf ..................................... 3.00 NA 0.81 0.18 NA 3.99 010 

64449 .... .......... A N block inj, lumbar plexus .................................. 3.00 NA 0.96 0.15 NA 4.11 010 

64450 .... .......... A N block, other peripheral .................................... 1.27 1.24 0.48 0.13 2.64 1.88 000 

64470 .... .......... A Inj paravertebral c/t ............................................ 1.85 7.25 0.71 0.11 9.21 2.67 000 

64472 .... .......... A Inj paravertebral c/t add-on ................................ 1.29 2.34 0.34 0.08 3.71 1.71 ZZZ 

64475 .... .......... A Inj paravertebral l/s ............................................. 1.41 6.90 0.63 0.10 8.41 2.14 000 

64476 .... .......... A Inj paravertebral l/s add-on ................................ 0.98 2.13 0.24 0.07 3.18 1.29 ZZZ 

64479 .... .......... A Inj foramen epidural c/t ...................................... 2.20 7.51 0.89 0.12 9.83 3.21 000 

64480 .... .......... A Inj foramen epidural add-on ............................... 1.54 2.85 0.47 0.10 4.49 2.11 ZZZ 

64483 .... .......... A Inj foramen epidural l/s ....................................... 1.90 7.91 0.83 0.11 9.92 2.84 000 

64484 .... .......... A Inj foramen epidural add-on ............................... 1.33 3.29 0.37 0.08 4.70 1.78 ZZZ 

64505 .... .......... A N block, spenopalatine gangl ............................. 1.36 1.24 0.66 0.10 2.70 2.12 000 

64508 .... .......... A N block, carotid sinus s/p ................................... 1.12 3.33 0.74 0.07 4.52 1.93 000 

64510 .... .......... A N block, stellate ganglion ................................... 1.22 3.46 0.51 0.07 4.75 1.80 000 

64517 .... .......... A N block inj, hypogas plxs ................................... 2.20 2.73 0.87 0.11 5.04 3.18 000 

64520 .... .......... A N block, lumbar/thoracic ..................................... 1.35 5.15 0.55 0.08 6.58 1.98 000 

64530 .... .......... A N block inj, celiac pelus ..................................... 1.58 4.46 0.65 0.10 6.14 2.33 000 

64550 .... .......... A Apply neurostimulator ......................................... 0.18 0.28 0.05 0.01 0.47 0.24 000 

64553 .... .......... A Implant neuroelectrodes ..................................... 2.31 2.84 1.86 0.18 5.33 4.35 010 

64555 .... .......... A Implant neuroelectrodes ..................................... 2.27 3.11 1.19 0.19 5.57 3.65 010 

64560 .... .......... A Implant neuroelectrodes ..................................... 2.36 2.64 1.28 0.22 5.22 3.86 010 

64561 .... .......... A Implant neuroelectrodes ..................................... 6.73 30.14 2.78 0.51 37.38 10.02 010 

64565 .... .......... A Implant neuroelectrodes ..................................... 1.76 3.29 1.26 0.13 5.18 3.15 010 

64573 .... .......... A Implant neuroelectrodes ..................................... 7.49 NA 5.26 1.60 NA 14.35 090 

64575 .... .......... A Implant neuroelectrodes ..................................... 4.34 NA 2.68 0.61 NA 7.63 090 

64577 .... .......... A Implant neuroelectrodes ..................................... 4.61 NA 3.29 1.04 NA 8.94 090 

64580 .... .......... A Implant neuroelectrodes ..................................... 4.11 NA 3.56 0.36 NA 8.03 090 

64581 .... .......... A Implant neuroelectrodes ..................................... 13.48 NA 5.39 1.05 NA 19.92 090 

64585 .... .......... A Revise/remove neuroelectrode .......................... 2.06 11.31 2.14 0.20 13.57 4.40 010 

64590 .... .......... A Insrt/redo perph n generator .............................. 2.40 7.16 2.29 0.19 9.75 4.88 010 

64595 .... .......... A Revise/remove neuroreceiver ............................ 1.73 10.42 1.93 0.19 12.34 3.85 010 

64600 .... .......... A Injection treatment of nerve ............................... 3.44 9.38 1.65 0.34 13.16 5.43 010 

64605 .... .......... A Injection treatment of nerve ............................... 5.60 9.58 2.19 0.79 15.97 8.58 010 

64610 .... .......... A Injection treatment of nerve ............................... 7.15 8.89 3.72 1.58 17.62 12.45 010 

64612 .... .......... A Destroy nerve, face muscle ............................... 1.96 2.49 1.32 0.11 4.56 3.39 010 

64613 .... .......... A Destroy nerve, neck muscle ............................... 1.96 2.94 1.22 0.11 5.01 3.29 010 

64614 .... .......... A Destroy nerve, extrem musc .............................. 2.20 3.23 1.31 0.10 5.53 3.61 010 

64620 .... .......... A Injection treatment of nerve ............................... 2.84 5.07 1.33 0.20 8.11 4.37 010 

64622 .... .......... A Destr paravertebrl nerve l/s ................................ 3.00 7.78 1.37 0.18 10.96 4.55 010 

64623 .... .......... A Destr paravertebral n add-on ............................. 0.99 2.97 0.22 0.06 4.02 1.27 ZZZ 

64626 .... .......... A Destr paravertebrl nerve c/t ............................... 3.28 7.80 1.97 0.20 11.28 5.45 010 

64627 .... .......... A Destr paravertebral n add-on ............................. 1.16 4.54 0.27 0.07 5.77 1.50 ZZZ 

64630 .... .......... A Injection treatment of nerve ............................... 3.00 2.74 1.41 0.22 5.96 4.63 010 

64640 .... .......... A Injection treatment of nerve ............................... 2.76 4.19 1.85 0.29 7.24 4.90 010 

64650 .... .......... A Chemodenerv eccrine glands ............................ 0.70 0.87 0.30 0.06 1.63 1.06 000 

64653 .... .......... A Chemodenerv eccrine glands ............................ 0.88 0.92 0.38 0.08 1.88 1.34 000 

64680 .... .......... A Injection treatment of nerve ............................... 2.62 6.73 1.43 0.18 9.53 4.23 010 

64681 .... .......... A Injection treatment of nerve ............................... 3.54 9.32 2.07 0.28 13.14 5.89 010 

64702 .... .......... A Revise finger/toe nerve ...................................... 4.22 NA 3.87 0.61 NA 8.70 090 

64704 .... .......... A Revise hand/foot nerve ...................................... 4.56 NA 3.32 0.61 NA 8.49 090 

64708 .... .......... A Revise arm/leg nerve ......................................... 6.11 NA 4.87 0.96 NA 11.94 090 

64712 .... .......... A Revision of sciatic nerve .................................... 7.74 NA 4.97 0.95 NA 13.66 090 

64713 .... .......... A Revision of arm nerve(s) .................................... 10.98 NA 5.89 1.82 NA 18.69 090 

64714 .... .......... A Revise low back nerve(s) ................................... 10.31 NA 4.21 1.19 NA 15.71 090 

70405 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

64716 .... .......... A Revision of cranial nerve .................................... 6.30 NA 5.99 0.63 NA 12.92 090 

64718 .... .......... A Revise ulnar nerve at elbow .............................. 5.98 NA 6.01 1.05 NA 13.04 090 

64719 .... .......... A Revise ulnar nerve at wrist ................................ 4.84 NA 4.53 0.77 NA 10.14 090 

64721 .... .......... A Carpal tunnel surgery ......................................... 4.28 NA 5.38 0.73 NA 10.39 090 

64722 .... .......... A Relieve pressure on nerve(s) ............................. 4.69 NA 3.05 0.48 NA 8.22 090 

64726 .... .......... A Release foot/toe nerve ....................................... 4.17 NA 2.80 0.54 NA 7.51 090 

64727 .... .......... A Internal nerve revision ........................................ 3.10 NA 1.50 0.48 NA 5.08 ZZZ 

64732 .... .......... A Incision of brow nerve ........................................ 4.40 NA 3.51 0.98 NA 8.89 090 

64734 .... .......... A Incision of cheek nerve ...................................... 4.91 NA 4.06 0.89 NA 9.86 090 

64736 .... .......... A Incision of chin nerve ......................................... 4.59 NA 4.03 0.52 NA 9.14 090 

64738 .... .......... A Incision of jaw nerve .......................................... 5.72 NA 4.62 1.08 NA 11.42 090 

64740 .... .......... A Incision of tongue nerve ..................................... 5.58 NA 5.13 0.69 NA 11.40 090 

64742 .... .......... A Incision of facial nerve ....................................... 6.21 NA 4.71 0.73 NA 11.65 090 

64744 .... .......... A Incise nerve, back of head ................................. 5.23 NA 3.78 1.16 NA 10.17 090 

64746 .... .......... A Incise diaphragm nerve ...................................... 5.92 NA 4.51 0.82 NA 11.25 090 

64752 .... .......... A Incision of vagus nerve ...................................... 7.05 NA 4.29 0.93 NA 12.27 090 

64755 .... .......... A Incision of stomach nerves ................................ 13.50 NA 5.65 1.83 NA 20.98 090 

64760 .... .......... A Incision of vagus nerve ...................................... 6.95 NA 3.46 0.81 NA 11.22 090 

64761 .... .......... A Incision of pelvis nerve ....................................... 6.40 NA 3.53 0.53 NA 10.46 090 

64763 .... .......... A Incise hip/thigh nerve ......................................... 6.92 NA 5.21 0.94 NA 13.07 090 

64766 .... .......... A Incise hip/thigh nerve ......................................... 8.66 NA 5.26 1.06 NA 14.98 090 

64771 .... .......... A Sever cranial nerve ............................................ 7.34 NA 5.57 1.23 NA 14.14 090 

64772 .... .......... A Incision of spinal nerve ...................................... 7.20 NA 4.93 1.40 NA 13.53 090 

64774 .... .......... A Remove skin nerve lesion .................................. 5.16 NA 3.84 0.74 NA 9.74 090 

64776 .... .......... A Remove digit nerve lesion .................................. 5.11 NA 3.69 0.76 NA 9.56 090 

64778 .... .......... A Digit nerve surgery add-on ................................. 3.11 NA 1.50 0.46 NA 5.07 ZZZ 

64782 .... .......... A Remove limb nerve lesion .................................. 6.22 NA 3.78 0.86 NA 10.86 090 

64783 .... .......... A Limb nerve surgery add-on ................................ 3.71 NA 1.84 0.51 NA 6.06 ZZZ 

64784 .... .......... A Remove nerve lesion ......................................... 9.81 NA 6.61 1.38 NA 17.80 090 

64786 .... .......... A Remove sciatic nerve lesion .............................. 15.44 NA 9.86 2.60 NA 27.90 090 

64787 .... .......... A Implant nerve end .............................................. 4.29 NA 2.13 0.58 NA 7.00 ZZZ 

64788 .... .......... A Remove skin nerve lesion .................................. 4.60 NA 3.47 0.73 NA 8.80 090 

64790 .... .......... A Removal of nerve lesion .................................... 11.29 NA 7.22 2.10 NA 20.61 090 

64792 .... .......... A Removal of nerve lesion .................................... 14.90 NA 8.85 2.48 NA 26.23 090 

64795 .... .......... A Biopsy of nerve .................................................. 3.01 NA 1.56 0.52 NA 5.09 000 

64802 .... .......... A Remove sympathetic nerves .............................. 9.14 NA 5.14 1.29 NA 15.57 090 

64804 .... .......... A Remove sympathetic nerves .............................. 14.62 NA 7.18 2.14 NA 23.94 090 

64809 .... .......... A Remove sympathetic nerves .............................. 13.65 NA 5.78 1.50 NA 20.93 090 

64818 .... .......... A Remove sympathetic nerves .............................. 10.28 NA 5.30 1.33 NA 16.91 090 

64820 .... .......... A Remove sympathetic nerves .............................. 10.35 NA 7.14 1.49 NA 18.98 090 

64821 .... .......... A Remove sympathetic nerves .............................. 8.74 NA 7.36 1.24 NA 17.34 090 

64822 .... .......... A Remove sympathetic nerves .............................. 8.74 NA 7.25 1.30 NA 17.29 090 

64823 .... .......... A Remove sympathetic nerves .............................. 10.35 NA 8.15 1.57 NA 20.07 090 

64831 .... .......... A Repair of digit nerve ........................................... 9.43 NA 7.09 1.41 NA 17.93 090 

64832 .... .......... A Repair nerve add-on .......................................... 5.65 NA 2.94 0.85 NA 9.44 ZZZ 

64834 .... .......... A Repair of hand or foot nerve .............................. 10.17 NA 7.11 1.54 NA 18.82 090 

64835 .... .......... A Repair of hand or foot nerve .............................. 10.92 NA 7.71 1.73 NA 20.36 090 

64836 .... .......... A Repair of hand or foot nerve .............................. 10.92 NA 7.68 1.67 NA 20.27 090 

64837 .... .......... A Repair nerve add-on .......................................... 6.25 NA 3.24 0.97 NA 10.46 ZZZ 

64840 .... .......... A Repair of leg nerve ............................................. 13.00 NA 8.27 1.37 NA 22.64 090 

64856 .... .......... A Repair/transpose nerve ...................................... 13.78 NA 9.21 2.12 NA 25.11 090 

64857 .... .......... A Repair arm/leg nerve .......................................... 14.47 NA 9.66 2.21 NA 26.34 090 

64858 .... .......... A Repair sciatic nerve ............................................ 16.47 NA 10.80 3.33 NA 30.60 090 

64859 .... .......... A Nerve surgery ..................................................... 4.25 NA 2.20 0.67 NA 7.12 ZZZ 

64861 .... .......... A Repair of arm nerves ......................................... 19.21 NA 11.80 4.08 NA 35.09 090 

64862 .... .......... A Repair of low back nerves ................................. 19.41 NA 11.96 4.31 NA 35.68 090 

64864 .... .......... A Repair of facial nerve ......................................... 12.53 NA 8.79 1.26 NA 22.58 090 

64865 .... .......... A Repair of facial nerve ......................................... 15.22 NA 13.56 1.50 NA 30.28 090 

64866 .... .......... A Fusion of facial/other nerve ................................ 15.72 NA 13.20 2.04 NA 30.96 090 

64868 .... .......... A Fusion of facial/other nerve ................................ 14.02 NA 11.46 1.43 NA 26.91 090 

64870 .... .......... A Fusion of facial/other nerve ................................ 15.97 NA 8.75 1.30 NA 26.02 090 

64872 .... .......... A Subsequent repair of nerve ................................ 1.99 NA 1.08 0.29 NA 3.36 ZZZ 

64874 .... .......... A Repair & revise nerve add-on ............................ 2.98 NA 1.53 0.42 NA 4.93 ZZZ 

64876 .... .......... A Repair nerve/shorten bone ................................. 3.37 NA 1.75 0.47 NA 5.59 ZZZ 

64885 .... .......... A Nerve graft, head or neck .................................. 17.50 NA 11.63 1.63 NA 30.76 090 

64886 .... .......... A Nerve graft, head or neck .................................. 20.72 NA 13.58 2.08 NA 36.38 090 

64890 .... .......... A Nerve graft, hand or foot .................................... 15.13 NA 10.02 2.29 NA 27.44 090 

64891 .... .......... A Nerve graft, hand or foot .................................... 16.12 NA 7.60 1.63 NA 25.35 090 

64892 .... .......... A Nerve graft, arm or leg ....................................... 14.63 NA 8.89 2.47 NA 25.99 090 

64893 .... .......... A Nerve graft, arm or leg ....................................... 15.58 NA 9.89 2.61 NA 28.08 090 

64895 .... .......... A Nerve graft, hand or foot .................................... 19.22 NA 9.68 2.57 NA 31.47 090 

64896 .... .......... A Nerve graft, hand or foot .................................... 20.46 NA 11.01 3.16 NA 34.63 090 

64897 .... .......... A Nerve graft, arm or leg ....................................... 18.21 NA 10.72 2.54 NA 31.47 090 

64898 .... .......... A Nerve graft, arm or leg ....................................... 19.47 NA 11.82 2.77 NA 34.06 090 

64901 .... .......... A Nerve graft add-on ............................................. 10.20 NA 5.28 1.37 NA 16.85 ZZZ 

70406 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

64902 .... .......... A Nerve graft add-on ............................................. 11.81 NA 5.98 1.55 NA 19.34 ZZZ 

64905 .... .......... A Nerve pedicle transfer ........................................ 14.00 NA 8.51 2.00 NA 24.51 090 

64907 .... .......... A Nerve pedicle transfer ........................................ 18.80 NA 12.56 3.16 NA 34.52 090 

64999 .... .......... C Nervous system surgery .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

65091 .... .......... A Revise eye .......................................................... 6.45 NA 8.37 0.32 NA 15.14 090 

65093 .... .......... A Revise eye with implant ..................................... 6.86 NA 8.74 0.34 NA 15.94 090 

65101 .... .......... A Removal of eye .................................................. 7.02 NA 9.55 0.35 NA 16.92 090 

65103 .... .......... A Remove eye/insert implant ................................. 7.56 NA 9.76 0.37 NA 17.69 090 

65105 .... .......... A Remove eye/attach implant ................................ 8.48 NA 10.49 0.42 NA 19.39 090 

65110 .... .......... A Removal of eye .................................................. 13.93 NA 13.71 0.81 NA 28.45 090 

65112 .... .......... A Remove eye/revise socket ................................. 16.36 NA 16.18 1.30 NA 33.84 090 

65114 .... .......... A Remove eye/revise socket ................................. 17.50 NA 16.39 1.02 NA 34.91 090 

65125 .... .......... A Revise ocular implant ......................................... 3.12 8.83 3.61 0.19 12.14 6.92 090 

65130 .... .......... A Insert ocular implant ........................................... 7.14 NA 9.19 0.35 NA 16.68 090 

65135 .... .......... A Insert ocular implant ........................................... 7.32 NA 9.34 0.36 NA 17.02 090 

65140 .... .......... A Attach ocular implant .......................................... 8.01 NA 9.90 0.40 NA 18.31 090 

65150 .... .......... A Revise ocular implant ......................................... 6.25 NA 7.99 0.31 NA 14.55 090 

65155 .... .......... A Reinsert ocular implant ...................................... 8.65 NA 10.51 0.50 NA 19.66 090 

65175 .... .......... A Removal of ocular implant ................................. 6.27 NA 8.50 0.31 NA 15.08 090 

65205 .... .......... A Remove foreign body from eye .......................... 0.71 0.64 0.29 0.03 1.38 1.03 000 

65210 .... .......... A Remove foreign body from eye .......................... 0.84 0.81 0.38 0.04 1.69 1.26 000 

65220 .... .......... A Remove foreign body from eye .......................... 0.71 0.64 0.28 0.05 1.40 1.04 000 

65222 .... .......... A Remove foreign body from eye .......................... 0.93 0.89 0.38 0.04 1.86 1.35 000 

65235 .... .......... A Remove foreign body from eye .......................... 7.56 NA 6.76 0.37 NA 14.69 090 

65260 .... .......... A Remove foreign body from eye .......................... 10.94 NA 9.68 0.57 NA 21.19 090 

65265 .... .......... A Remove foreign body from eye .......................... 12.57 NA 10.65 0.62 NA 23.84 090 

65270 .... .......... A Repair of eye wound .......................................... 1.90 5.24 1.39 0.09 7.23 3.38 010 

65272 .... .......... A Repair of eye wound .......................................... 3.81 7.73 3.30 0.19 11.73 7.30 090 

65273 .... .......... A Repair of eye wound .......................................... 4.35 NA 3.59 0.22 NA 8.16 090 

65275 .... .......... A Repair of eye wound .......................................... 5.33 6.33 3.95 0.26 11.92 9.54 090 

65280 .... .......... A Repair of eye wound .......................................... 7.65 NA 6.25 0.38 NA 14.28 090 

65285 .... .......... A Repair of eye wound .......................................... 12.88 NA 9.24 0.64 NA 22.76 090 

65286 .... .......... A Repair of eye wound .......................................... 5.50 11.17 4.63 0.27 16.94 10.40 090 

65290 .... .......... A Repair of eye socket wound .............................. 5.40 NA 4.75 0.31 NA 10.46 090 

65400 .... .......... A Removal of eye lesion ........................................ 6.05 8.35 6.14 0.30 14.70 12.49 090 

65410 .... .......... A Biopsy of cornea ................................................ 1.47 2.12 0.97 0.07 3.66 2.51 000 

65420 .... .......... A Removal of eye lesion ........................................ 4.16 8.88 4.45 0.21 13.25 8.82 090 

65426 .... .......... A Removal of eye lesion ........................................ 5.24 10.20 4.93 0.25 15.69 10.42 090 

65430 .... .......... A Corneal smear .................................................... 1.47 1.29 0.98 0.07 2.83 2.52 000 

65435 .... .......... A Curette/treat cornea ........................................... 0.92 1.00 0.71 0.04 1.96 1.67 000 

65436 .... .......... A Curette/treat cornea ........................................... 4.18 4.10 3.68 0.21 8.49 8.07 090 

65450 .... .......... A Treatment of corneal lesion ............................... 3.27 4.08 3.95 0.16 7.51 7.38 090 

65600 .... .......... A Revision of cornea ............................................. 3.39 5.02 3.36 0.17 8.58 6.92 090 

65710 .... .......... A Corneal transplant .............................................. 12.33 NA 11.23 0.61 NA 24.17 090 

65730 .... .......... A Corneal transplant .............................................. 14.23 NA 12.05 0.70 NA 26.98 090 

65750 .... .......... A Corneal transplant .............................................. 14.98 NA 12.00 0.74 NA 27.72 090 

65755 .... .......... A Corneal transplant .............................................. 14.87 NA 11.92 0.73 NA 27.52 090 

65760 .... .......... N Revision of cornea ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

65765 .... .......... N Revision of cornea ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

65767 .... .......... N Corneal tissue transplant ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

65770 .... .......... A Revise cornea with implant ................................ 17.53 NA 13.24 0.87 NA 31.64 090 

65771 .... .......... N Radial keratotomy .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

65772 .... .......... A Correction of astigmatism .................................. 4.28 5.55 4.14 0.21 10.04 8.63 090 

65775 .... .......... A Correction of astigmatism .................................. 5.78 NA 5.97 0.28 NA 12.03 090 

65780 .... .......... A Ocular reconst, transplant .................................. 10.23 NA 10.32 0.44 NA 20.99 090 

65781 .... .......... A Ocular reconst, transplant .................................. 17.64 NA 13.71 0.44 NA 31.79 090 

65782 .... .......... A Ocular reconst, transplant .................................. 14.98 NA 12.02 0.44 NA 27.44 090 

65800 .... .......... A Drainage of eye .................................................. 1.91 1.80 1.18 0.09 3.80 3.18 000 

65805 .... .......... A Drainage of eye .................................................. 1.91 2.18 1.19 0.09 4.18 3.19 000 

65810 .... .......... A Drainage of eye .................................................. 4.86 NA 4.71 0.24 NA 9.81 090 

65815 .... .......... A Drainage of eye .................................................. 5.04 10.03 4.82 0.25 15.32 10.11 090 

65820 .... .......... A Relieve inner eye pressure ................................ 8.12 NA 9.08 0.40 NA 17.60 090 

65850 .... .......... A Incision of eye .................................................... 10.50 NA 8.46 0.52 NA 19.48 090 

65855 .... .......... A Laser surgery of eye .......................................... 3.84 4.32 3.11 0.19 8.35 7.14 010 

65860 .... .......... A Incise inner eye adhesions ................................ 3.54 4.05 2.51 0.18 7.77 6.23 090 

65865 .... .......... A Incise inner eye adhesions ................................ 5.59 NA 5.64 0.28 NA 11.51 090 

65870 .... .......... A Incise inner eye adhesions ................................ 6.26 NA 6.43 0.31 NA 13.00 090 

65875 .... .......... A Incise inner eye adhesions ................................ 6.53 NA 6.81 0.32 NA 13.66 090 

65880 .... .......... A Incise inner eye adhesions ................................ 7.08 NA 7.05 0.35 NA 14.48 090 

65900 .... .......... A Remove eye lesion ............................................. 10.91 NA 10.28 0.54 NA 21.73 090 

65920 .... .......... A Remove implant of eye ...................................... 8.39 NA 8.19 0.41 NA 16.99 090 

65930 .... .......... A Remove blood clot from eye .............................. 7.43 NA 6.85 0.37 NA 14.65 090 

66020 .... .......... A Injection treatment of eye ................................... 1.59 3.13 1.44 0.08 4.80 3.11 010 

66030 .... .......... A Injection treatment of eye ................................... 1.25 2.97 1.28 0.06 4.28 2.59 010 

66130 .... .......... A Remove eye lesion ............................................. 7.68 9.65 5.63 0.38 17.71 13.69 090 

70407 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

66150 .... .......... A Glaucoma surgery .............................................. 8.29 NA 9.43 0.46 NA 18.18 090 

66155 .... .......... A Glaucoma surgery .............................................. 8.28 NA 9.38 0.41 NA 18.07 090 

66160 .... .......... A Glaucoma surgery .............................................. 10.15 NA 10.22 0.50 NA 20.87 090 

66165 .... .......... A Glaucoma surgery .............................................. 8.00 NA 9.27 0.40 NA 17.67 090 

66170 .... .......... A Glaucoma surgery .............................................. 12.14 NA 12.26 0.60 NA 25.00 090 

66172 .... .......... A Incision of eye .................................................... 15.02 NA 15.24 0.74 NA 31.00 090 

66180 .... .......... A Implant eye shunt ............................................... 14.53 NA 10.79 0.71 NA 26.03 090 

66185 .... .......... A Revise eye shunt ................................................ 8.13 NA 7.40 0.40 NA 15.93 090 

66220 .... .......... A Repair eye lesion ............................................... 7.76 NA 7.12 0.40 NA 15.28 090 

66225 .... .......... A Repair/graft eye lesion ....................................... 11.03 NA 8.76 0.55 NA 20.34 090 

66250 .... .......... A Follow-up surgery of eye .................................... 5.97 11.72 5.50 0.30 17.99 11.77 090 

66500 .... .......... A Incision of iris ..................................................... 3.70 NA 4.65 0.18 NA 8.53 090 

66505 .... .......... A Incision of iris ..................................................... 4.07 NA 5.00 0.20 NA 9.27 090 

66600 .... .......... A Remove iris and lesion ....................................... 8.67 NA 8.24 0.43 NA 17.34 090 

66605 .... .......... A Removal of iris ................................................... 12.77 NA 10.05 0.77 NA 23.59 090 

66625 .... .......... A Removal of iris ................................................... 5.12 NA 4.74 0.26 NA 10.12 090 

66630 .... .......... A Removal of iris ................................................... 6.15 NA 5.73 0.31 NA 12.19 090 

66635 .... .......... A Removal of iris ................................................... 6.24 NA 5.76 0.31 NA 12.31 090 

66680 .... .......... A Repair iris & ciliary body .................................... 5.43 NA 5.29 0.27 NA 10.99 090 

66682 .... .......... A Repair iris & ciliary body .................................... 6.20 NA 6.63 0.31 NA 13.14 090 

66700 .... .......... A Destruction, ciliary body ..................................... 4.77 5.26 3.94 0.24 10.27 8.95 090 

66710 .... .......... A Ciliary transsleral therapy ................................... 4.77 5.18 3.85 0.23 10.18 8.85 090 

66711 .... .......... A Ciliary endoscopic ablation ................................ 6.60 NA 6.49 0.30 NA 13.39 090 

66720 .... .......... A Destruction, ciliary body ..................................... 4.77 5.81 4.73 0.26 10.84 9.76 090 

66740 .... .......... A Destruction, ciliary body ..................................... 4.77 5.10 3.98 0.23 10.10 8.98 090 

66761 .... .......... A Revision of iris .................................................... 4.06 5.61 4.32 0.20 9.87 8.58 090 

66762 .... .......... A Revision of iris .................................................... 4.57 5.67 4.30 0.23 10.47 9.10 090 

66770 .... .......... A Removal of inner eye lesion .............................. 5.17 6.10 4.81 0.26 11.53 10.24 090 

66820 .... .......... A Incision, secondary cataract ............................... 3.88 NA 5.83 0.19 NA 9.90 090 

66821 .... .......... A After cataract laser surgery ................................ 2.35 4.10 3.63 0.11 6.56 6.09 090 

66825 .... .......... A Reposition intraocular lens ................................. 8.22 NA 9.09 0.40 NA 17.71 090 

66830 .... .......... A Removal of lens lesion ....................................... 8.19 NA 6.97 0.36 NA 15.52 090 

66840 .... .......... A Removal of lens material ................................... 7.90 NA 6.88 0.39 NA 15.17 090 

66850 .... .......... A Removal of lens material ................................... 9.10 NA 7.66 0.45 NA 17.21 090 

66852 .... .......... A Removal of lens material ................................... 9.96 NA 8.12 0.49 NA 18.57 090 

66920 .... .......... A Extraction of lens ................................................ 8.85 NA 7.32 0.44 NA 16.61 090 

66930 .... .......... A Extraction of lens ................................................ 10.16 NA 8.16 0.49 NA 18.81 090 

66940 .... .......... A Extraction of lens ................................................ 8.92 NA 7.62 0.43 NA 16.97 090 

66982 .... .......... A Cataract surgery, complex ................................. 13.48 NA 9.89 0.63 NA 24.00 090 

66983 .... .......... A Cataract surg w/iol, 1 stage ............................... 8.98 NA 6.13 0.14 NA 15.25 090 

66984 .... .......... A Cataract surg w/iol, 1 stage ............................... 10.21 NA 7.44 0.39 NA 18.04 090 

66985 .... .......... A Insert lens prosthesis ......................................... 8.38 NA 7.47 0.36 NA 16.21 090 

66986 .... .......... A Exchange lens prosthesis .................................. 12.26 NA 9.20 0.60 NA 22.06 090 

66990 .... .......... A Ophthalmic endoscope add-on .......................... 1.51 NA 0.69 0.07 NA 2.27 ZZZ 

66999 .... .......... C Eye surgery procedure ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

67005 .... .......... A Partial removal of eye fluid ................................ 5.69 NA 4.87 0.28 NA 10.84 090 

67010 .... .......... A Partial removal of eye fluid ................................ 6.86 NA 5.43 0.34 NA 12.63 090 

67015 .... .......... A Release of eye fluid ........................................... 6.91 NA 6.47 0.34 NA 13.72 090 

67025 .... .......... A Replace eye fluid ................................................ 6.83 9.25 6.24 0.34 16.42 13.41 090 

67027 .... .......... A Implant eye drug system .................................... 10.83 NA 8.02 0.54 NA 19.39 090 

67028 .... .......... A Injection eye drug ............................................... 2.52 2.71 1.46 0.12 5.35 4.10 000 

67030 .... .......... A Incise inner eye strands ..................................... 4.83 NA 5.87 0.24 NA 10.94 090 

67031 .... .......... A Laser surgery, eye strands ................................ 3.66 4.61 3.65 0.18 8.45 7.49 090 

67036 .... .......... A Removal of inner eye fluid ................................. 11.87 NA 9.15 0.58 NA 21.60 090 

67038 .... .......... A Strip retinal membrane ....................................... 21.21 NA 15.53 1.04 NA 37.78 090 

67039 .... .......... A Laser treatment of retina .................................... 14.50 NA 12.22 0.71 NA 27.43 090 

67040 .... .......... A Laser treatment of retina .................................... 17.20 NA 13.72 0.85 NA 31.77 090 

67101 .... .......... A Repair detached retina ....................................... 7.52 9.15 6.55 0.37 17.04 14.44 090 

67105 .... .......... A Repair detached retina ....................................... 7.40 8.10 6.17 0.37 15.87 13.94 090 

67107 .... .......... A Repair detached retina ....................................... 14.82 NA 11.33 0.73 NA 26.88 090 

67108 .... .......... A Repair detached retina ....................................... 20.79 NA 14.46 1.02 NA 36.27 090 

67110 .... .......... A Repair detached retina ....................................... 8.80 10.26 7.41 0.44 19.50 16.65 090 

67112 .... .......... A Rerepair detached retina .................................... 16.83 NA 11.84 0.83 NA 29.50 090 

67115 .... .......... A Release encircling material ................................ 4.98 NA 5.09 0.25 NA 10.32 090 

67120 .... .......... A Remove eye implant material ............................ 5.97 8.60 5.55 0.29 14.86 11.81 090 

67121 .... .......... A Remove eye implant material ............................ 10.65 NA 8.55 0.53 NA 19.73 090 

67141 .... .......... A Treatment of retina ............................................. 5.19 5.87 4.87 0.26 11.32 10.32 090 

67145 .... .......... A Treatment of retina ............................................. 5.36 5.74 4.94 0.27 11.37 10.57 090 

67208 .... .......... A Treatment of retinal lesion ................................. 6.69 6.14 5.53 0.33 13.16 12.55 090 

67210 .... .......... A Treatment of retinal lesion ................................. 8.81 6.59 5.90 0.44 15.84 15.15 090 

67218 .... .......... A Treatment of retinal lesion ................................. 18.50 NA 12.19 0.92 NA 31.61 090 

67220 .... .......... A Treatment of choroid lesion ............................... 13.11 10.45 9.04 0.65 24.21 22.80 090 

67221 .... .......... R Ocular photodynamic ther .................................. 4.00 4.34 1.81 0.20 8.54 6.01 000 

67225 .... .......... A Eye photodynamic ther add-on .......................... 0.47 0.25 0.21 0.02 0.74 0.70 ZZZ 

67227 .... .......... A Treatment of retinal lesion ................................. 6.57 6.60 5.54 0.33 13.50 12.44 090 

70408 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

67228 .... .......... A Treatment of retinal lesion ................................. 12.72 11.51 8.56 0.63 24.86 21.91 090 

67250 .... .......... A Reinforce eye wall .............................................. 8.65 NA 9.20 0.47 NA 18.32 090 

67255 .... .......... A Reinforce/graft eye wall ...................................... 8.89 NA 9.92 0.44 NA 19.25 090 

67299 .... .......... C Eye surgery procedure ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

67311 .... .......... A Revise eye muscle ............................................. 6.64 NA 6.04 0.37 NA 13.05 090 

67312 .... .......... A Revise two eye muscles .................................... 8.53 NA 6.77 0.43 NA 15.73 090 

67314 .... .......... A Revise eye muscle ............................................. 7.51 NA 6.57 0.39 NA 14.47 090 

67316 .... .......... A Revise two eye muscles .................................... 9.65 NA 7.52 0.49 NA 17.66 090 

67318 .... .......... A Revise eye muscle(s) ......................................... 7.84 NA 6.95 0.41 NA 15.20 090 

67320 .... .......... A Revise eye muscle(s) add-on ............................ 4.32 NA 1.96 0.22 NA 6.50 ZZZ 

67331 .... .......... A Eye surgery follow-up add-on ............................ 4.05 NA 1.84 0.21 NA 6.10 ZZZ 

67332 .... .......... A Rerevise eye muscles add-on ............................ 4.48 NA 2.03 0.23 NA 6.74 ZZZ 

67334 .... .......... A Revise eye muscle w/suture .............................. 3.97 NA 1.80 0.20 NA 5.97 ZZZ 

67335 .... .......... A Eye suture during surgery .................................. 2.49 NA 1.12 0.13 NA 3.74 ZZZ 

67340 .... .......... A Revise eye muscle add-on ................................. 4.92 NA 2.21 0.25 NA 7.38 ZZZ 

67343 .... .......... A Release eye tissue ............................................. 7.34 NA 6.53 0.37 NA 14.24 090 

67345 .... .......... A Destroy nerve of eye muscle ............................. 2.96 2.59 2.02 0.17 5.72 5.15 010 

67350 .... .......... A Biopsy eye muscle ............................................. 2.87 NA 1.88 0.15 NA 4.90 000 

67399 .... .......... C Eye muscle surgery procedure .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

67400 .... .......... A Explore/biopsy eye socket ................................. 9.75 NA 11.29 0.56 NA 21.60 090 

67405 .... .......... A Explore/drain eye socket .................................... 7.92 NA 9.80 0.44 NA 18.16 090 

67412 .... .......... A Explore/treat eye socket ..................................... 9.49 NA 10.96 0.48 NA 20.93 090 

67413 .... .......... A Explore/treat eye socket ..................................... 9.99 NA 10.80 0.50 NA 21.29 090 

67414 .... .......... A Explr/decompress eye socket ............................ 11.11 NA 12.07 0.65 NA 23.83 090 

67415 .... .......... A Aspiration, orbital contents ................................. 1.76 NA 0.76 0.09 NA 2.61 000 

67420 .... .......... A Explore/treat eye socket ..................................... 20.03 NA 17.44 1.15 NA 38.62 090 

67430 .... .......... A Explore/treat eye socket ..................................... 13.37 NA 14.93 0.86 NA 29.16 090 

67440 .... .......... A Explore/drain eye socket .................................... 13.07 NA 14.30 0.70 NA 28.07 090 

67445 .... .......... A Explr/decompress eye socket ............................ 14.40 NA 13.95 0.90 NA 29.25 090 

67450 .... .......... A Explore/biopsy eye socket ................................. 13.49 NA 14.73 0.68 NA 28.90 090 

67500 .... .......... A Inject/treat eye socket ........................................ 0.79 0.67 0.29 0.05 1.51 1.13 000 

67505 .... .......... A Inject/treat eye socket ........................................ 0.82 0.69 0.31 0.05 1.56 1.18 000 

67515 .... .......... A Inject/treat eye socket ........................................ 0.61 0.59 0.38 0.03 1.23 1.02 000 

67550 .... .......... A Insert eye socket implant ................................... 10.17 NA 11.33 0.72 NA 22.22 090 

67560 .... .......... A Revise eye socket implant ................................. 10.58 NA 11.40 0.60 NA 22.58 090 

67570 .... .......... A Decompress optic nerve .................................... 13.56 NA 13.62 0.68 NA 27.86 090 

67599 .... .......... C Orbit surgery procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

67700 .... .......... A Drainage of eyelid abscess ................................ 1.35 6.04 1.27 0.07 7.46 2.69 010 

67710 .... .......... A Incision of eyelid ................................................. 1.02 5.39 1.21 0.05 6.46 2.28 010 

67715 .... .......... A Incision of eyelid fold .......................................... 1.22 5.39 1.29 0.06 6.67 2.57 010 

67800 .... .......... A Remove eyelid lesion ......................................... 1.38 1.62 1.04 0.07 3.07 2.49 010 

67801 .... .......... A Remove eyelid lesions ....................................... 1.88 1.97 1.26 0.09 3.94 3.23 010 

67805 .... .......... A Remove eyelid lesions ....................................... 2.22 2.53 1.65 0.11 4.86 3.98 010 

67808 .... .......... A Remove eyelid lesion(s) ..................................... 3.79 NA 3.78 0.19 NA 7.76 090 

67810 .... .......... A Biopsy of eyelid .................................................. 1.48 3.34 0.68 0.06 4.88 2.22 000 

67820 .... .......... A Revise eyelashes ............................................... 0.89 0.60 0.56 0.04 1.53 1.49 000 

67825 .... .......... A Revise eyelashes ............................................... 1.38 1.74 1.41 0.07 3.19 2.86 010 

67830 .... .......... A Revise eyelashes ............................................... 1.70 5.55 1.50 0.08 7.33 3.28 010 

67835 .... .......... A Revise eyelashes ............................................... 5.55 NA 4.63 0.28 NA 10.46 090 

67840 .... .......... A Remove eyelid lesion ......................................... 2.04 5.49 1.65 0.10 7.63 3.79 010 

67850 .... .......... A Treat eyelid lesion .............................................. 1.69 3.38 1.47 0.07 5.14 3.23 010 

67875 .... .......... A Closure of eyelid by suture ................................ 1.35 3.31 0.94 0.07 4.73 2.36 000 

67880 .... .......... A Revision of eyelid ............................................... 3.79 6.63 3.81 0.19 10.61 7.79 090 

67882 .... .......... A Revision of eyelid ............................................... 5.06 7.65 4.82 0.25 12.96 10.13 090 

67900 .... .......... A Repair brow defect ............................................. 6.13 9.09 5.27 0.38 15.60 11.78 090 

67901 .... .......... A Repair eyelid defect ........................................... 7.39 NA 5.42 0.54 NA 13.35 090 

67902 .... .......... A Repair eyelid defect ........................................... 9.35 NA 5.48 0.60 NA 15.43 090 

67903 .... .......... A Repair eyelid defect ........................................... 6.36 9.59 5.53 0.47 16.42 12.36 090 

67904 .... .......... A Repair eyelid defect ........................................... 6.25 9.66 5.25 0.41 16.32 11.91 090 

67906 .... .......... A Repair eyelid defect ........................................... 6.78 5.39 5.04 0.46 12.63 12.28 090 

67908 .... .......... A Repair eyelid defect ........................................... 5.12 6.65 5.36 0.28 12.05 10.76 090 

67909 .... .......... A Revise eyelid defect ........................................... 5.39 8.05 4.96 0.31 13.75 10.66 090 

67911 .... .......... A Revise eyelid defect ........................................... 5.26 NA 4.79 0.31 NA 10.36 090 

67912 .... .......... A Correction eyelid w/implant ................................ 5.67 18.98 5.55 0.28 24.93 11.50 090 

67914 .... .......... A Repair eyelid defect ........................................... 3.67 6.36 3.06 0.19 10.22 6.92 090 

67915 .... .......... A Repair eyelid defect ........................................... 3.18 6.00 2.81 0.16 9.34 6.15 090 

67916 .... .......... A Repair eyelid defect ........................................... 5.30 8.07 4.77 0.28 13.65 10.35 090 

67917 .... .......... A Repair eyelid defect ........................................... 6.01 8.48 5.08 0.36 14.85 11.45 090 

67921 .... .......... A Repair eyelid defect ........................................... 3.39 6.21 2.90 0.17 9.77 6.46 090 

67922 .... .......... A Repair eyelid defect ........................................... 3.06 5.93 2.76 0.15 9.14 5.97 090 

67923 .... .......... A Repair eyelid defect ........................................... 5.87 8.14 4.98 0.30 14.31 11.15 090 

67924 .... .......... A Repair eyelid defect ........................................... 5.78 8.95 4.69 0.30 15.03 10.77 090 

67930 .... .......... A Repair eyelid wound ........................................... 3.60 5.73 2.18 0.19 9.52 5.97 010 

67935 .... .......... A Repair eyelid wound ........................................... 6.21 8.54 4.42 0.39 15.14 11.02 090 

67938 .... .......... A Remove eyelid foreign body .............................. 1.33 5.40 1.26 0.06 6.79 2.65 010 

70409 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

67950 .... .......... A Revision of eyelid ............................................... 5.81 8.66 5.23 0.36 14.83 11.40 090 

67961 .... .......... A Revision of eyelid ............................................... 5.68 8.71 5.04 0.33 14.72 11.05 090 

67966 .... .......... A Revision of eyelid ............................................... 6.56 9.16 5.58 0.37 16.09 12.51 090 

67971 .... .......... A Reconstruction of eyelid ..................................... 9.78 NA 7.30 0.53 NA 17.61 090 

67973 .... .......... A Reconstruction of eyelid ..................................... 12.85 NA 9.34 0.75 NA 22.94 090 

67974 .... .......... A Reconstruction of eyelid ..................................... 12.82 NA 9.26 0.75 NA 22.83 090 

67975 .... .......... A Reconstruction of eyelid ..................................... 9.12 NA 6.97 0.50 NA 16.59 090 

67999 .... .......... C Revision of eyelid ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

68020 .... .......... A Incise/drain eyelid lining ..................................... 1.37 1.41 1.21 0.06 2.84 2.64 010 

68040 .... .......... A Treatment of eyelid lesions ................................ 0.85 0.71 0.43 0.04 1.60 1.32 000 

68100 .... .......... A Biopsy of eyelid lining ........................................ 1.35 3.26 0.95 0.07 4.68 2.37 000 

68110 .... .......... A Remove eyelid lining lesion ............................... 1.77 4.11 1.65 0.09 5.97 3.51 010 

68115 .... .......... A Remove eyelid lining lesion ............................... 2.36 5.98 1.92 0.12 8.46 4.40 010 

68130 .... .......... A Remove eyelid lining lesion ............................... 4.92 8.74 4.61 0.24 13.90 9.77 090 

68135 .... .......... A Remove eyelid lining lesion ............................... 1.84 1.82 1.65 0.09 3.75 3.58 010 

68200 .... .......... A Treat eyelid by injection ..................................... 0.49 0.54 0.33 0.02 1.05 0.84 000 

68320 .... .......... A Revise/graft eyelid lining .................................... 5.36 11.31 5.54 0.27 16.94 11.17 090 

68325 .... .......... A Revise/graft eyelid lining .................................... 7.35 NA 6.56 0.44 NA 14.35 090 

68326 .... .......... A Revise/graft eyelid lining .................................... 7.14 NA 6.43 0.35 NA 13.92 090 

68328 .... .......... A Revise/graft eyelid lining .................................... 8.17 NA 7.31 0.54 NA 16.02 090 

68330 .... .......... A Revise eyelid lining ............................................ 4.82 9.44 4.73 0.24 14.50 9.79 090 

68335 .... .......... A Revise/graft eyelid lining .................................... 7.18 NA 6.40 0.36 NA 13.94 090 

68340 .... .......... A Separate eyelid adhesions ................................. 4.16 8.90 4.11 0.21 13.27 8.48 090 

68360 .... .......... A Revise eyelid lining ............................................ 4.36 8.06 4.19 0.22 12.64 8.77 090 

68362 .... .......... A Revise eyelid lining ............................................ 7.33 NA 6.42 0.36 NA 14.11 090 

68371 .... .......... A Harvest eye tissue, alograft ............................... 4.89 NA 4.74 0.44 NA 10.07 010 

68399 .... .......... C Eyelid lining surgery ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

68400 .... .......... A Incise/drain tear gland ........................................ 1.69 5.92 1.83 0.08 7.69 3.60 010 

68420 .... .......... A Incise/drain tear sac ........................................... 2.30 6.21 2.11 0.11 8.62 4.52 010 

68440 .... .......... A Incise tear duct opening ..................................... 0.94 2.09 1.27 0.05 3.08 2.26 010 

68500 .... .......... A Removal of tear gland ........................................ 11.00 NA 9.76 0.55 NA 21.31 090 

68505 .... .......... A Partial removal, tear gland ................................. 10.92 NA 10.68 0.55 NA 22.15 090 

68510 .... .......... A Biopsy of tear gland ........................................... 4.60 7.35 2.10 0.23 12.18 6.93 000 

68520 .... .......... A Removal of tear sac ........................................... 7.50 NA 7.44 0.37 NA 15.31 090 

68525 .... .......... A Biopsy of tear sac .............................................. 4.42 NA 2.03 0.22 NA 6.67 000 

68530 .... .......... A Clearance of tear duct ........................................ 3.65 8.19 2.65 0.18 12.02 6.48 010 

68540 .... .......... A Remove tear gland lesion .................................. 10.58 NA 9.42 0.52 NA 20.52 090 

68550 .... .......... A Remove tear gland lesion .................................. 13.24 NA 11.38 0.80 NA 25.42 090 

68700 .... .......... A Repair tear ducts ................................................ 6.59 NA 6.00 0.32 NA 12.91 090 

68705 .... .......... A Revise tear duct opening ................................... 2.06 4.18 1.80 0.10 6.34 3.96 010 

68720 .... .......... A Create tear sac drain ......................................... 8.95 NA 7.88 0.44 NA 17.27 090 

68745 .... .......... A Create tear duct drain ........................................ 8.62 NA 7.88 0.52 NA 17.02 090 

68750 .... .......... A Create tear duct drain ........................................ 8.65 NA 8.29 0.43 NA 17.37 090 

68760 .... .......... A Close tear duct opening ..................................... 1.73 3.55 1.63 0.09 5.37 3.45 010 

68761 .... .......... A Close tear duct opening ..................................... 1.36 2.28 1.32 0.06 3.70 2.74 010 

68770 .... .......... A Close tear system fistula .................................... 7.01 3.19 3.19 0.35 10.55 10.55 090 

68801 .... .......... A Dilate tear duct opening ..................................... 0.94 1.95 1.48 0.05 2.94 2.47 010 

68810 .... .......... A Probe nasolacrimal duct ..................................... 1.90 3.67 2.68 0.10 5.67 4.68 010 

68811 .... .......... A Probe nasolacrimal duct ..................................... 2.35 NA 2.42 0.13 NA 4.90 010 

68815 .... .......... A Probe nasolacrimal duct ..................................... 3.20 8.26 2.82 0.17 11.63 6.19 010 

68840 .... .......... A Explore/irrigate tear ducts .................................. 1.25 1.60 1.12 0.06 2.91 2.43 010 

68850 .... .......... A Injection for tear sac x-ray ................................. 0.80 0.88 0.68 0.04 1.72 1.52 000 

68899 .... .......... C Tear duct system surgery .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

69000 .... .......... A Drain external ear lesion .................................... 1.45 2.89 1.36 0.12 4.46 2.93 010 

69005 .... .......... A Drain external ear lesion .................................... 2.11 2.94 1.84 0.17 5.22 4.12 010 

69020 .... .......... A Drain outer ear canal lesion ............................... 1.48 4.00 2.07 0.12 5.60 3.67 010 

69090 .... .......... N Pierce earlobes .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

69100 .... .......... A Biopsy of external ear ........................................ 0.81 1.71 0.39 0.03 2.55 1.23 000 

69105 .... .......... A Biopsy of external ear canal .............................. 0.85 2.35 0.77 0.07 3.27 1.69 000 

69110 .... .......... A Remove external ear, partial .............................. 3.43 6.76 4.48 0.30 10.49 8.21 090 

69120 .... .......... A Removal of external ear ..................................... 4.04 NA 6.20 0.38 NA 10.62 090 

69140 .... .......... A Remove ear canal lesion(s) ............................... 7.96 NA 13.32 0.65 NA 21.93 090 

69145 .... .......... A Remove ear canal lesion(s) ............................... 2.62 5.80 3.31 0.21 8.63 6.14 090 

69150 .... .......... A Extensive ear canal surgery ............................... 13.41 NA 13.44 1.22 NA 28.07 090 

69155 .... .......... A Extensive ear/neck surgery ................................ 20.77 NA 19.60 1.92 NA 42.29 090 

69200 .... .......... A Clear outer ear canal ......................................... 0.77 2.39 0.55 0.06 3.22 1.38 000 

69205 .... .......... A Clear outer ear canal ......................................... 1.20 NA 1.36 0.10 NA 2.66 010 

69210 .... .......... A Remove impacted ear wax ................................ 0.61 0.63 0.23 0.05 1.29 0.89 000 

69220 .... .......... A Clean out mastoid cavity .................................... 0.83 2.37 0.73 0.07 3.27 1.63 000 

69222 .... .......... A Clean out mastoid cavity .................................... 1.40 3.86 2.07 0.12 5.38 3.59 010 

69300 .... .......... R Revise external ear ............................................ 6.35 NA 4.23 0.72 NA 11.30 YYY 

69310 .... .......... A Rebuild outer ear canal ...................................... 10.77 NA 16.33 0.85 NA 27.95 090 

69320 .... .......... A Rebuild outer ear canal ...................................... 16.93 NA 21.90 1.37 NA 40.20 090 

69399 .... .......... C Outer ear surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

69400 .... .......... A Inflate middle ear canal ...................................... 0.83 2.17 0.67 0.07 3.07 1.57 000 

70410 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

69401 .... .......... A Inflate middle ear canal ...................................... 0.63 1.24 0.65 0.05 1.92 1.33 000 

69405 .... .......... A Catheterize middle ear canal ............................. 2.63 3.51 2.32 0.21 6.35 5.16 010 

69420 .... .......... A Incision of eardrum ............................................. 1.33 3.16 1.59 0.11 4.60 3.03 010 

69421 .... .......... A Incision of eardrum ............................................. 1.73 NA 2.17 0.15 NA 4.05 010 

69424 .... .......... A Remove ventilating tube ..................................... 0.85 2.19 0.68 0.07 3.11 1.60 000 

69433 .... .......... A Create eardrum opening .................................... 1.52 3.10 1.64 0.13 4.75 3.29 010 

69436 .... .......... A Create eardrum opening .................................... 1.96 NA 2.30 0.19 NA 4.45 010 

69440 .... .......... A Exploration of middle ear ................................... 7.56 NA 8.80 0.61 NA 16.97 090 

69450 .... .......... A Eardrum revision ................................................ 5.56 NA 7.05 0.45 NA 13.06 090 

69501 .... .......... A Mastoidectomy ................................................... 9.06 NA 9.03 0.73 NA 18.82 090 

69502 .... .......... A Mastoidectomy ................................................... 12.36 NA 11.62 1.00 NA 24.98 090 

69505 .... .......... A Remove mastoid structures ............................... 12.97 NA 17.24 1.05 NA 31.26 090 

69511 .... .......... A Extensive mastoid surgery ................................. 13.50 NA 17.52 1.09 NA 32.11 090 

69530 .... .......... A Extensive mastoid surgery ................................. 19.16 NA 21.69 1.54 NA 42.39 090 

69535 .... .......... A Remove part of temporal bone .......................... 36.09 NA 32.05 2.92 NA 71.06 090 

69540 .... .......... A Remove ear lesion ............................................. 1.20 3.75 1.98 0.10 5.05 3.28 010 

69550 .... .......... A Remove ear lesion ............................................. 10.97 NA 14.90 0.89 NA 26.76 090 

69552 .... .......... A Remove ear lesion ............................................. 19.43 NA 20.73 1.59 NA 41.75 090 

69554 .... .......... A Remove ear lesion ............................................. 33.11 NA 30.42 2.91 NA 66.44 090 

69601 .... .......... A Mastoid surgery revision .................................... 13.22 NA 12.71 1.07 NA 27.00 090 

69602 .... .......... A Mastoid surgery revision .................................... 13.56 NA 13.27 1.10 NA 27.93 090 

69603 .... .......... A Mastoid surgery revision .................................... 14.00 NA 18.41 1.14 NA 33.55 090 

69604 .... .......... A Mastoid surgery revision .................................... 14.00 NA 13.73 1.14 NA 28.87 090 

69605 .... .......... A Mastoid surgery revision .................................... 18.46 NA 21.01 1.50 NA 40.97 090 

69610 .... .......... A Repair of eardrum .............................................. 4.42 5.57 3.28 0.36 10.35 8.06 010 

69620 .... .......... A Repair of eardrum .............................................. 5.88 11.15 6.31 0.48 17.51 12.67 090 

69631 .... .......... A Repair eardrum structures ................................. 9.85 NA 11.23 0.80 NA 21.88 090 

69632 .... .......... A Rebuild eardrum structures ................................ 12.73 NA 13.51 1.03 NA 27.27 090 

69633 .... .......... A Rebuild eardrum structures ................................ 12.08 NA 13.09 0.98 NA 26.15 090 

69635 .... .......... A Repair eardrum structures ................................. 13.31 NA 16.79 1.08 NA 31.18 090 

69636 .... .......... A Rebuild eardrum structures ................................ 15.20 NA 19.36 1.23 NA 35.79 090 

69637 .... .......... A Rebuild eardrum structures ................................ 15.09 NA 19.28 1.22 NA 35.59 090 

69641 .... .......... A Revise middle ear & mastoid ............................. 12.69 NA 12.82 1.03 NA 26.54 090 

69642 .... .......... A Revise middle ear & mastoid ............................. 16.81 NA 16.33 1.36 NA 34.50 090 

69643 .... .......... A Revise middle ear & mastoid ............................. 15.30 NA 14.86 1.24 NA 31.40 090 

69644 .... .......... A Revise middle ear & mastoid ............................. 16.94 NA 20.46 1.37 NA 38.77 090 

69645 .... .......... A Revise middle ear & mastoid ............................. 16.36 NA 20.08 1.33 NA 37.77 090 

69646 .... .......... A Revise middle ear & mastoid ............................. 17.96 NA 20.82 1.46 NA 40.24 090 

69650 .... .......... A Release middle ear bone ................................... 9.65 NA 9.94 0.78 NA 20.37 090 

69660 .... .......... A Revise middle ear bone ..................................... 11.88 NA 11.21 0.96 NA 24.05 090 

69661 .... .......... A Revise middle ear bone ..................................... 15.72 NA 14.74 1.27 NA 31.73 090 

69662 .... .......... A Revise middle ear bone ..................................... 15.42 NA 13.79 1.25 NA 30.46 090 

69666 .... .......... A Repair middle ear structures .............................. 9.74 NA 10.00 0.79 NA 20.53 090 

69667 .... .......... A Repair middle ear structures .............................. 9.75 NA 10.01 0.79 NA 20.55 090 

69670 .... .......... A Remove mastoid air cells ................................... 11.49 NA 11.74 0.93 NA 24.16 090 

69676 .... .......... A Remove middle ear nerve .................................. 9.51 NA 10.78 0.81 NA 21.10 090 

69700 .... .......... A Close mastoid fistula .......................................... 8.22 NA 9.27 0.67 NA 18.16 090 

69710 .... .......... N Implant/replace hearing aid ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

69711 .... .......... A Remove/repair hearing aid ................................. 10.42 NA 10.82 0.83 NA 22.07 090 

69714 .... .......... A Implant temple bone w/stimul ............................ 13.98 NA 12.70 1.13 NA 27.81 090 

69715 .... .......... A Temple bne implnt w/stimulat ............................ 18.22 NA 15.07 1.48 NA 34.77 090 

69717 .... .......... A Temple bone implant revision ............................ 14.96 NA 14.51 0.90 NA 30.37 090 

69718 .... .......... A Revise temple bone implant ............................... 18.47 NA 15.34 3.21 NA 37.02 090 

69720 .... .......... A Release facial nerve ........................................... 14.36 NA 14.56 1.16 NA 30.08 090 

69725 .... .......... A Release facial nerve ........................................... 25.34 NA 20.19 2.44 NA 47.97 090 

69740 .... .......... A Repair facial nerve ............................................. 15.94 NA 13.45 1.27 NA 30.66 090 

69745 .... .......... A Repair facial nerve ............................................. 16.66 NA 15.01 1.14 NA 32.81 090 

69799 .... .......... C Middle ear surgery procedure ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

69801 .... .......... A Incise inner ear ................................................... 8.55 NA 9.49 0.69 NA 18.73 090 

69802 .... .......... A Incise inner ear ................................................... 13.08 NA 12.36 1.06 NA 26.50 090 

69805 .... .......... A Explore inner ear ................................................ 13.80 NA 11.91 1.12 NA 26.83 090 

69806 .... .......... A Explore inner ear ................................................ 12.33 NA 11.07 1.00 NA 24.40 090 

69820 .... .......... A Establish inner ear window ................................ 10.32 NA 11.25 0.90 NA 22.47 090 

69840 .... .......... A Revise inner ear window .................................... 10.24 NA 13.21 0.79 NA 24.24 090 

69905 .... .......... A Remove inner ear ............................................... 11.08 NA 11.38 0.90 NA 23.36 090 

69910 .... .......... A Remove inner ear & mastoid ............................. 13.61 NA 11.95 1.07 NA 26.63 090 

69915 .... .......... A Incise inner ear nerve ........................................ 21.20 NA 16.51 1.69 NA 39.40 090 

69930 .... .......... A Implant cochlear device ..................................... 16.78 NA 14.79 1.36 NA 32.93 090 

69949 .... .......... C Inner ear surgery procedure .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

69950 .... .......... A Incise inner ear nerve ........................................ 25.60 NA 18.95 2.28 NA 46.83 090 

69955 .... .......... A Release facial nerve ........................................... 27.00 NA 21.44 2.48 NA 50.92 090 

69960 .... .......... A Release inner ear canal ..................................... 27.00 NA 20.11 2.17 NA 49.28 090 

69970 .... .......... A Remove inner ear lesion .................................... 29.99 NA 23.34 2.41 NA 55.74 090 

69979 .... .......... C Temporal bone surgery ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

69990 .... .......... R Microsurgery add-on .......................................... 3.46 NA 1.80 0.89 NA 6.15 ZZZ 

70411 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

70010 .... 26 ..... A Contrast x-ray of brain ....................................... 1.19 0.39 0.39 0.05 1.63 1.63 XXX 

70010 .... TC .... A Contrast x-ray of brain ....................................... 0.00 4.34 NA 0.22 4.56 NA XXX 

70010 .... .......... A Contrast x-ray of brain ....................................... 1.19 4.73 NA 0.27 6.19 NA XXX 

70015 .... 26 ..... A Contrast x-ray of brain ....................................... 1.19 0.39 0.39 0.08 1.66 1.66 XXX 

70015 .... TC .... A Contrast x-ray of brain ....................................... 0.00 1.35 NA 0.08 1.43 NA XXX 

70015 .... .......... A Contrast x-ray of brain ....................................... 1.19 1.74 NA 0.16 3.09 NA XXX 

70030 .... 26 ..... A X-ray eye for foreign body ................................. 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70030 .... TC .... A X-ray eye for foreign body ................................. 0.00 0.42 NA 0.02 0.44 NA XXX 

70030 .... .......... A X-ray eye for foreign body ................................. 0.17 0.48 NA 0.03 0.68 NA XXX 

70100 .... 26 ..... A X-ray exam of jaw .............................................. 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

70100 .... TC .... A X-ray exam of jaw .............................................. 0.00 0.52 NA 0.02 0.54 NA XXX 

70100 .... .......... A X-ray exam of jaw .............................................. 0.18 0.58 NA 0.03 0.79 NA XXX 

70110 .... 26 ..... A X-ray exam of jaw .............................................. 0.25 0.08 0.08 0.01 0.34 0.34 XXX 

70110 .... TC .... A X-ray exam of jaw .............................................. 0.00 0.62 NA 0.04 0.66 NA XXX 

70110 .... .......... A X-ray exam of jaw .............................................. 0.25 0.70 NA 0.05 1.00 NA XXX 

70120 .... 26 ..... A X-ray exam of mastoids ..................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

70120 .... TC .... A X-ray exam of mastoids ..................................... 0.00 0.62 NA 0.04 0.66 NA XXX 

70120 .... .......... A X-ray exam of mastoids ..................................... 0.18 0.68 NA 0.05 0.91 NA XXX 

70130 .... 26 ..... A X-ray exam of mastoids ..................................... 0.34 0.11 0.11 0.02 0.47 0.47 XXX 

70130 .... TC .... A X-ray exam of mastoids ..................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

70130 .... .......... A X-ray exam of mastoids ..................................... 0.34 0.89 NA 0.07 1.30 NA XXX 

70134 .... 26 ..... A X-ray exam of middle ear ................................... 0.34 0.11 0.11 0.02 0.47 0.47 XXX 

70134 .... TC .... A X-ray exam of middle ear ................................... 0.00 0.73 NA 0.05 0.78 NA XXX 

70134 .... .......... A X-ray exam of middle ear ................................... 0.34 0.84 NA 0.07 1.25 NA XXX 

70140 .... 26 ..... A X-ray exam of facial bones ................................ 0.19 0.06 0.06 0.01 0.26 0.26 XXX 

70140 .... TC .... A X-ray exam of facial bones ................................ 0.00 0.62 NA 0.04 0.66 NA XXX 

70140 .... .......... A X-ray exam of facial bones ................................ 0.19 0.68 NA 0.05 0.92 NA XXX 

70150 .... 26 ..... A X-ray exam of facial bones ................................ 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

70150 .... TC .... A X-ray exam of facial bones ................................ 0.00 0.78 NA 0.05 0.83 NA XXX 

70150 .... .......... A X-ray exam of facial bones ................................ 0.26 0.86 NA 0.06 1.18 NA XXX 

70160 .... 26 ..... A X-ray exam of nasal bones ................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70160 .... TC .... A X-ray exam of nasal bones ................................ 0.00 0.52 NA 0.02 0.54 NA XXX 

70160 .... .......... A X-ray exam of nasal bones ................................ 0.17 0.58 NA 0.03 0.78 NA XXX 

70170 .... 26 ..... A X-ray exam of tear duct ..................................... 0.30 0.10 0.10 0.01 0.41 0.41 XXX 

70170 .... TC .... A X-ray exam of tear duct ..................................... 0.00 0.95 NA 0.06 1.01 NA XXX 

70170 .... .......... A X-ray exam of tear duct ..................................... 0.30 1.05 NA 0.07 1.42 NA XXX 

70190 .... 26 ..... A X-ray exam of eye sockets ................................ 0.21 0.07 0.07 0.01 0.29 0.29 XXX 

70190 .... TC .... A X-ray exam of eye sockets ................................ 0.00 0.62 NA 0.04 0.66 NA XXX 

70190 .... .......... A X-ray exam of eye sockets ................................ 0.21 0.69 NA 0.05 0.95 NA XXX 

70200 .... 26 ..... A X-ray exam of eye sockets ................................ 0.28 0.09 0.09 0.01 0.38 0.38 XXX 

70200 .... TC .... A X-ray exam of eye sockets ................................ 0.00 0.78 NA 0.05 0.83 NA XXX 

70200 .... .......... A X-ray exam of eye sockets ................................ 0.28 0.87 NA 0.06 1.21 NA XXX 

70210 .... 26 ..... A X-ray exam of sinuses ....................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70210 .... TC .... A X-ray exam of sinuses ....................................... 0.00 0.62 NA 0.04 0.66 NA XXX 

70210 .... .......... A X-ray exam of sinuses ....................................... 0.17 0.68 NA 0.05 0.90 NA XXX 

70220 .... 26 ..... A X-ray exam of sinuses ....................................... 0.25 0.08 0.08 0.01 0.34 0.34 XXX 

70220 .... TC .... A X-ray exam of sinuses ....................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

70220 .... .......... A X-ray exam of sinuses ....................................... 0.25 0.86 NA 0.06 1.17 NA XXX 

70240 .... 26 ..... A X-ray exam, pituitary saddle .............................. 0.19 0.06 0.06 0.01 0.26 0.26 XXX 

70240 .... TC .... A X-ray exam, pituitary saddle .............................. 0.00 0.42 NA 0.02 0.44 NA XXX 

70240 .... .......... A X-ray exam, pituitary saddle .............................. 0.19 0.48 NA 0.03 0.70 NA XXX 

70250 .... 26 ..... A X-ray exam of skull ............................................ 0.24 0.08 0.08 0.01 0.33 0.33 XXX 

70250 .... TC .... A X-ray exam of skull ............................................ 0.00 0.62 NA 0.04 0.66 NA XXX 

70250 .... .......... A X-ray exam of skull ............................................ 0.24 0.70 NA 0.05 0.99 NA XXX 

70260 .... 26 ..... A X-ray exam of skull ............................................ 0.34 0.11 0.11 0.02 0.47 0.47 XXX 

70260 .... TC .... A X-ray exam of skull ............................................ 0.00 0.89 NA 0.06 0.95 NA XXX 

70260 .... .......... A X-ray exam of skull ............................................ 0.34 1.00 NA 0.08 1.42 NA XXX 

70300 .... 26 ..... A X-ray exam of teeth ............................................ 0.10 0.05 0.05 0.01 0.16 0.16 XXX 

70300 .... TC .... A X-ray exam of teeth ............................................ 0.00 0.26 NA 0.02 0.28 NA XXX 

70300 .... .......... A X-ray exam of teeth ............................................ 0.10 0.31 NA 0.03 0.44 NA XXX 

70310 .... 26 ..... A X-ray exam of teeth ............................................ 0.16 0.08 0.08 0.01 0.25 0.25 XXX 

70310 .... TC .... A X-ray exam of teeth ............................................ 0.00 0.42 NA 0.02 0.44 NA XXX 

70310 .... .......... A X-ray exam of teeth ............................................ 0.16 0.50 NA 0.03 0.69 NA XXX 

70320 .... 26 ..... A Full mouth x-ray of teeth .................................... 0.22 0.08 0.08 0.01 0.31 0.31 XXX 

70320 .... TC .... A Full mouth x-ray of teeth .................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

70320 .... .......... A Full mouth x-ray of teeth .................................... 0.22 0.86 NA 0.06 1.14 NA XXX 

70328 .... 26 ..... A X-ray exam of jaw joint ...................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

70328 .... TC .... A X-ray exam of jaw joint ...................................... 0.00 0.49 NA 0.02 0.51 NA XXX 

70328 .... .......... A X-ray exam of jaw joint ...................................... 0.18 0.55 NA 0.03 0.76 NA XXX 

70330 .... 26 ..... A X-ray exam of jaw joints ..................................... 0.24 0.08 0.08 0.01 0.33 0.33 XXX 

70330 .... TC .... A X-ray exam of jaw joints ..................................... 0.00 0.84 NA 0.05 0.89 NA XXX 

70330 .... .......... A X-ray exam of jaw joints ..................................... 0.24 0.92 NA 0.06 1.22 NA XXX 

70332 .... 26 ..... A X-ray exam of jaw joint ...................................... 0.54 0.20 0.20 0.02 0.76 0.76 XXX 

70332 .... TC .... A X-ray exam of jaw joint ...................................... 0.00 2.11 NA 0.12 2.23 NA XXX 

70332 .... .......... A X-ray exam of jaw joint ...................................... 0.54 2.31 NA 0.14 2.99 NA XXX 

70412 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

70336 .... 26 ..... A Magnetic image, jaw joint ................................... 1.48 0.49 0.49 0.07 2.04 2.04 XXX 

70336 .... TC .... A Magnetic image, jaw joint ................................... 0.00 11.23 NA 0.59 11.82 NA XXX 

70336 .... .......... A Magnetic image, jaw joint ................................... 1.48 11.72 NA 0.66 13.86 NA XXX 

70350 .... 26 ..... A X-ray head for orthodontia ................................. 0.17 0.07 0.07 0.01 0.25 0.25 XXX 

70350 .... TC .... A X-ray head for orthodontia ................................. 0.00 0.38 NA 0.02 0.40 NA XXX 

70350 .... .......... A X-ray head for orthodontia ................................. 0.17 0.45 NA 0.03 0.65 NA XXX 

70355 .... 26 ..... A Panoramic x-ray of jaws ..................................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

70355 .... TC .... A Panoramic x-ray of jaws ..................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

70355 .... .......... A Panoramic x-ray of jaws ..................................... 0.20 0.64 NA 0.05 0.89 NA XXX 

70360 .... 26 ..... A X-ray exam of neck ............................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70360 .... TC .... A X-ray exam of neck ............................................ 0.00 0.42 NA 0.02 0.44 NA XXX 

70360 .... .......... A X-ray exam of neck ............................................ 0.17 0.48 NA 0.03 0.68 NA XXX 

70370 .... 26 ..... A Throat x-ray & fluoroscopy ................................. 0.32 0.10 0.10 0.01 0.43 0.43 XXX 

70370 .... TC .... A Throat x-ray & fluoroscopy ................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

70370 .... .......... A Throat x-ray & fluoroscopy ................................. 0.32 1.41 NA 0.08 1.81 NA XXX 

70371 .... 26 ..... A Speech evaluation, complex .............................. 0.84 0.28 0.28 0.04 1.16 1.16 XXX 

70371 .... TC .... A Speech evaluation, complex .............................. 0.00 2.11 NA 0.12 2.23 NA XXX 

70371 .... .......... A Speech evaluation, complex .............................. 0.84 2.39 NA 0.16 3.39 NA XXX 

70373 .... 26 ..... A Contrast x-ray of larynx ...................................... 0.44 0.14 0.14 0.02 0.60 0.60 XXX 

70373 .... TC .... A Contrast x-ray of larynx ...................................... 0.00 1.79 NA 0.11 1.90 NA XXX 

70373 .... .......... A Contrast x-ray of larynx ...................................... 0.44 1.93 NA 0.13 2.50 NA XXX 

70380 .... 26 ..... A X-ray exam of salivary gland ............................. 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70380 .... TC .... A X-ray exam of salivary gland ............................. 0.00 0.67 NA 0.04 0.71 NA XXX 

70380 .... .......... A X-ray exam of salivary gland ............................. 0.17 0.73 NA 0.05 0.95 NA XXX 

70390 .... 26 ..... A X-ray exam of salivary duct ............................... 0.38 0.12 0.12 0.02 0.52 0.52 XXX 

70390 .... TC .... A X-ray exam of salivary duct ............................... 0.00 1.79 NA 0.11 1.90 NA XXX 

70390 .... .......... A X-ray exam of salivary duct ............................... 0.38 1.91 NA 0.13 2.42 NA XXX 

70450 .... 26 ..... A Ct head/brain w/o dye ........................................ 0.85 0.28 0.28 0.04 1.17 1.17 XXX 

70450 .... TC .... A Ct head/brain w/o dye ........................................ 0.00 4.73 NA 0.25 4.98 NA XXX 

70450 .... .......... A Ct head/brain w/o dye ........................................ 0.85 5.01 NA 0.29 6.15 NA XXX 

70460 .... 26 ..... A Ct head/brain w/dye ........................................... 1.13 0.37 0.37 0.05 1.55 1.55 XXX 

70460 .... TC .... A Ct head/brain w/dye ........................................... 0.00 5.68 NA 0.30 5.98 NA XXX 

70460 .... .......... A Ct head/brain w/dye ........................................... 1.13 6.05 NA 0.35 7.53 NA XXX 

70470 .... 26 ..... A Ct head/brain w/o & w/dye ................................. 1.27 0.42 0.42 0.06 1.75 1.75 XXX 

70470 .... TC .... A Ct head/brain w/o & w/dye ................................. 0.00 7.09 NA 0.37 7.46 NA XXX 

70470 .... .......... A Ct head/brain w/o & w/dye ................................. 1.27 7.51 NA 0.43 9.21 NA XXX 

70480 .... 26 ..... A Ct orbit/ear/fossa w/o dye .................................. 1.28 0.42 0.42 0.06 1.76 1.76 XXX 

70480 .... TC .... A Ct orbit/ear/fossa w/o dye .................................. 0.00 4.73 NA 0.25 4.98 NA XXX 

70480 .... .......... A Ct orbit/ear/fossa w/o dye .................................. 1.28 5.15 NA 0.31 6.74 NA XXX 

70481 .... 26 ..... A Ct orbit/ear/fossa w/dye ..................................... 1.38 0.45 0.45 0.06 1.89 1.89 XXX 

70481 .... TC .... A Ct orbit/ear/fossa w/dye ..................................... 0.00 5.68 NA 0.30 5.98 NA XXX 

70481 .... .......... A Ct orbit/ear/fossa w/dye ..................................... 1.38 6.13 NA 0.36 7.87 NA XXX 

70482 .... 26 ..... A Ct orbit/ear/fossa w/o&w/dye ............................. 1.45 0.48 0.48 0.06 1.99 1.99 XXX 

70482 .... TC .... A Ct orbit/ear/fossa w/o&w/dye ............................. 0.00 7.09 NA 0.37 7.46 NA XXX 

70482 .... .......... A Ct orbit/ear/fossa w/o&w/dye ............................. 1.45 7.57 NA 0.43 9.45 NA XXX 

70486 .... 26 ..... A Ct maxillofacial w/o dye ..................................... 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

70486 .... TC .... A Ct maxillofacial w/o dye ..................................... 0.00 4.73 NA 0.25 4.98 NA XXX 

70486 .... .......... A Ct maxillofacial w/o dye ..................................... 1.14 5.10 NA 0.30 6.54 NA XXX 

70487 .... 26 ..... A Ct maxillofacial w/dye ......................................... 1.30 0.43 0.43 0.06 1.79 1.79 XXX 

70487 .... TC .... A Ct maxillofacial w/dye ......................................... 0.00 5.68 NA 0.30 5.98 NA XXX 

70487 .... .......... A Ct maxillofacial w/dye ......................................... 1.30 6.11 NA 0.36 7.77 NA XXX 

70488 .... 26 ..... A Ct maxillofacial w/o & w/dye .............................. 1.42 0.46 0.46 0.06 1.94 1.94 XXX 

70488 .... TC .... A Ct maxillofacial w/o & w/dye .............................. 0.00 7.09 NA 0.37 7.46 NA XXX 

70488 .... .......... A Ct maxillofacial w/o & w/dye .............................. 1.42 7.55 NA 0.43 9.40 NA XXX 

70490 .... 26 ..... A Ct soft tissue neck w/o dye ................................ 1.28 0.42 0.42 0.06 1.76 1.76 XXX 

70490 .... TC .... A Ct soft tissue neck w/o dye ................................ 0.00 4.73 NA 0.25 4.98 NA XXX 

70490 .... .......... A Ct soft tissue neck w/o dye ................................ 1.28 5.15 NA 0.31 6.74 NA XXX 

70491 .... 26 ..... A Ct soft tissue neck w/dye ................................... 1.38 0.45 0.45 0.06 1.89 1.89 XXX 

70491 .... TC .... A Ct soft tissue neck w/dye ................................... 0.00 5.68 NA 0.30 5.98 NA XXX 

70491 .... .......... A Ct soft tissue neck w/dye ................................... 1.38 6.13 NA 0.36 7.87 NA XXX 

70492 .... 26 ..... A Ct sft tsue nck w/o & w/dye ............................... 1.45 0.47 0.47 0.06 1.98 1.98 XXX 

70492 .... TC .... A Ct sft tsue nck w/o & w/dye ............................... 0.00 7.09 NA 0.37 7.46 NA XXX 

70492 .... .......... A Ct sft tsue nck w/o & w/dye ............................... 1.45 7.56 NA 0.43 9.44 NA XXX 

70496 .... 26 ..... A Ct angiography, head ......................................... 1.75 0.57 0.57 0.08 2.40 2.40 XXX 

70496 .... TC .... A Ct angiography, head ......................................... 0.00 10.63 NA 0.58 11.21 NA XXX 

70496 .... .......... A Ct angiography, head ......................................... 1.75 11.20 NA 0.66 13.61 NA XXX 

70498 .... 26 ..... A Ct angiography, neck ......................................... 1.75 0.57 0.57 0.08 2.40 2.40 XXX 

70498 .... TC .... A Ct angiography, neck ......................................... 0.00 10.63 NA 0.58 11.21 NA XXX 

70498 .... .......... A Ct angiography, neck ......................................... 1.75 11.20 NA 0.66 13.61 NA XXX 

70540 .... 26 ..... A Mri orbit/face/neck w/o dye ................................ 1.35 0.44 0.44 0.06 1.85 1.85 XXX 

70540 .... TC .... A Mri orbit/face/neck w/o dye ................................ 0.00 11.23 NA 0.39 11.62 NA XXX 

70540 .... .......... A Mri orbit/face/neck w/o dye ................................ 1.35 11.67 NA 0.45 13.47 NA XXX 

70542 .... 26 ..... A Mri orbit/face/neck w/dye ................................... 1.62 0.53 0.53 0.07 2.22 2.22 XXX 

70542 .... TC .... A Mri orbit/face/neck w/dye ................................... 0.00 13.48 NA 0.47 13.95 NA XXX 

70542 .... .......... A Mri orbit/face/neck w/dye ................................... 1.62 14.01 NA 0.54 16.17 NA XXX 

70413 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

70543 .... 26 ..... A Mri orbt/fac/nck w/o & w/dye .............................. 2.15 0.71 0.71 0.10 2.96 2.96 XXX 

70543 .... TC .... A Mri orbt/fac/nck w/o & w/dye .............................. 0.00 24.95 NA 0.84 25.79 NA XXX 

70543 .... .......... A Mri orbt/fac/nck w/o & w/dye .............................. 2.15 25.66 NA 0.94 28.75 NA XXX 

70544 .... 26 ..... A Mr angiography head w/o dye ........................... 1.20 0.40 0.40 0.05 1.65 1.65 XXX 

70544 .... TC .... A Mr angiography head w/o dye ........................... 0.00 11.23 NA 0.59 11.82 NA XXX 

70544 .... .......... A Mr angiography head w/o dye ........................... 1.20 11.63 NA 0.64 13.47 NA XXX 

70545 .... 26 ..... A Mr angiography head w/dye ............................... 1.20 0.39 0.39 0.05 1.64 1.64 XXX 

70545 .... TC .... A Mr angiography head w/dye ............................... 0.00 11.23 NA 0.59 11.82 NA XXX 

70545 .... .......... A Mr angiography head w/dye ............................... 1.20 11.62 NA 0.64 13.46 NA XXX 

70546 .... 26 ..... A Mr angiograph head w/o&w/dye ........................ 1.80 0.59 0.59 0.08 2.47 2.47 XXX 

70546 .... TC .... A Mr angiograph head w/o&w/dye ........................ 0.00 22.47 NA 0.59 23.06 NA XXX 

70546 .... .......... A Mr angiograph head w/o&w/dye ........................ 1.80 23.06 NA 0.67 25.53 NA XXX 

70547 .... 26 ..... A Mr angiography neck w/o dye ............................ 1.20 0.39 0.39 0.05 1.64 1.64 XXX 

70547 .... TC .... A Mr angiography neck w/o dye ............................ 0.00 11.23 NA 0.59 11.82 NA XXX 

70547 .... .......... A Mr angiography neck w/o dye ............................ 1.20 11.62 NA 0.64 13.46 NA XXX 

70548 .... 26 ..... A Mr angiography neck w/dye ............................... 1.20 0.39 0.39 0.05 1.64 1.64 XXX 

70548 .... TC .... A Mr angiography neck w/dye ............................... 0.00 11.23 NA 0.59 11.82 NA XXX 

70548 .... .......... A Mr angiography neck w/dye ............................... 1.20 11.62 NA 0.64 13.46 NA XXX 

70549 .... 26 ..... A Mr angiograph neck w/o&w/dye ......................... 1.80 0.59 0.59 0.08 2.47 2.47 XXX 

70549 .... TC .... A Mr angiograph neck w/o&w/dye ......................... 0.00 22.47 NA 0.59 23.06 NA XXX 

70549 .... .......... A Mr angiograph neck w/o&w/dye ......................... 1.80 23.06 NA 0.67 25.53 NA XXX 

70551 .... 26 ..... A Mri brain w/o dye ................................................ 1.48 0.49 0.49 0.07 2.04 2.04 XXX 

70551 .... TC .... A Mri brain w/o dye ................................................ 0.00 11.23 NA 0.59 11.82 NA XXX 

70551 .... .......... A Mri brain w/o dye ................................................ 1.48 11.72 NA 0.66 13.86 NA XXX 

70552 .... 26 ..... A Mri brain w/dye ................................................... 1.78 0.59 0.59 0.08 2.45 2.45 XXX 

70552 .... TC .... A Mri brain w/dye ................................................... 0.00 13.48 NA 0.70 14.18 NA XXX 

70552 .... .......... A Mri brain w/dye ................................................... 1.78 14.07 NA 0.78 16.63 NA XXX 

70553 .... 26 ..... A Mri brain w/o & w/dye ........................................ 2.36 0.78 0.78 0.10 3.24 3.24 XXX 

70553 .... TC .... A Mri brain w/o & w/dye ........................................ 0.00 24.95 NA 1.31 26.26 NA XXX 

70553 .... .......... A Mri brain w/o & w/dye ........................................ 2.36 25.73 NA 1.41 29.50 NA XXX 

70557 .... 26 ..... A Mri brain w/o dye ................................................ 2.90 1.13 1.13 0.08 4.11 4.11 XXX 

70557 .... TC .... C Mri brain w/o dye ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70557 .... .......... C Mri brain w/o dye ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70558 .... 26 ..... A Mri brain w/dye ................................................... 3.20 1.24 1.24 0.10 4.54 4.54 XXX 

70558 .... TC .... C Mri brain w/dye ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70558 .... .......... C Mri brain w/dye ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70559 .... 26 ..... A Mri brain w/o & w/dye ........................................ 3.20 1.24 1.24 0.12 4.56 4.56 XXX 

70559 .... TC .... C Mri brain w/o & w/dye ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70559 .... .......... C Mri brain w/o & w/dye ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

71010 .... 26 ..... A Chest x-ray ......................................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

71010 .... TC .... A Chest x-ray ......................................................... 0.00 0.47 NA 0.02 0.49 NA XXX 

71010 .... .......... A Chest x-ray ......................................................... 0.18 0.53 NA 0.03 0.74 NA XXX 

71015 .... 26 ..... A Chest x-ray ......................................................... 0.21 0.07 0.07 0.01 0.29 0.29 XXX 

71015 .... TC .... A Chest x-ray ......................................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

71015 .... .......... A Chest x-ray ......................................................... 0.21 0.59 NA 0.03 0.83 NA XXX 

71020 .... 26 ..... A Chest x-ray ......................................................... 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

71020 .... TC .... A Chest x-ray ......................................................... 0.00 0.62 NA 0.04 0.66 NA XXX 

71020 .... .......... A Chest x-ray ......................................................... 0.22 0.69 NA 0.05 0.96 NA XXX 

71021 .... 26 ..... A Chest x-ray ......................................................... 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

71021 .... TC .... A Chest x-ray ......................................................... 0.00 0.73 NA 0.05 0.78 NA XXX 

71021 .... .......... A Chest x-ray ......................................................... 0.27 0.82 NA 0.06 1.15 NA XXX 

71022 .... 26 ..... A Chest x-ray ......................................................... 0.31 0.10 0.10 0.01 0.42 0.42 XXX 

71022 .... TC .... A Chest x-ray ......................................................... 0.00 0.73 NA 0.05 0.78 NA XXX 

71022 .... .......... A Chest x-ray ......................................................... 0.31 0.83 NA 0.06 1.20 NA XXX 

71023 .... 26 ..... A Chest x-ray and fluoroscopy .............................. 0.38 0.13 0.13 0.01 0.52 0.52 XXX 

71023 .... TC .... A Chest x-ray and fluoroscopy .............................. 0.00 0.78 NA 0.05 0.83 NA XXX 

71023 .... .......... A Chest x-ray and fluoroscopy .............................. 0.38 0.91 NA 0.06 1.35 NA XXX 

71030 .... 26 ..... A Chest x-ray ......................................................... 0.31 0.10 0.10 0.01 0.42 0.42 XXX 

71030 .... TC .... A Chest x-ray ......................................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

71030 .... .......... A Chest x-ray ......................................................... 0.31 0.88 NA 0.06 1.25 NA XXX 

71034 .... 26 ..... A Chest x-ray and fluoroscopy .............................. 0.46 0.16 0.16 0.02 0.64 0.64 XXX 

71034 .... TC .... A Chest x-ray and fluoroscopy .............................. 0.00 1.44 NA 0.08 1.52 NA XXX 

71034 .... .......... A Chest x-ray and fluoroscopy .............................. 0.46 1.60 NA 0.10 2.16 NA XXX 

71035 .... 26 ..... A Chest x-ray ......................................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

71035 .... TC .... A Chest x-ray ......................................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

71035 .... .......... A Chest x-ray ......................................................... 0.18 0.58 NA 0.03 0.79 NA XXX 

71040 .... 26 ..... A Contrast x-ray of bronchi .................................... 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

71040 .... TC .... A Contrast x-ray of bronchi .................................... 0.00 1.46 NA 0.08 1.54 NA XXX 

71040 .... .......... A Contrast x-ray of bronchi .................................... 0.58 1.65 NA 0.11 2.34 NA XXX 

71060 .... 26 ..... A Contrast x-ray of bronchi .................................... 0.74 0.24 0.24 0.03 1.01 1.01 XXX 

71060 .... TC .... A Contrast x-ray of bronchi .................................... 0.00 2.21 NA 0.13 2.34 NA XXX 

71060 .... .......... A Contrast x-ray of bronchi .................................... 0.74 2.45 NA 0.16 3.35 NA XXX 

71090 .... 26 ..... A X-ray & pacemaker insertion .............................. 0.54 0.21 0.21 0.02 0.77 0.77 XXX 

71090 .... TC .... A X-ray & pacemaker insertion .............................. 0.00 1.68 NA 0.11 1.79 NA XXX 

71090 .... .......... A X-ray & pacemaker insertion .............................. 0.54 1.89 NA 0.13 2.56 NA XXX 

70414 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

71100 .... 26 ..... A X-ray exam of ribs .............................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

71100 .... TC .... A X-ray exam of ribs .............................................. 0.00 0.57 NA 0.04 0.61 NA XXX 

71100 .... .......... A X-ray exam of ribs .............................................. 0.22 0.64 NA 0.05 0.91 NA XXX 

71101 .... 26 ..... A X-ray exam of ribs/chest .................................... 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

71101 .... TC .... A X-ray exam of ribs/chest .................................... 0.00 0.67 NA 0.04 0.71 NA XXX 

71101 .... .......... A X-ray exam of ribs/chest .................................... 0.27 0.76 NA 0.05 1.08 NA XXX 

71110 .... 26 ..... A X-ray exam of ribs .............................................. 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

71110 .... TC .... A X-ray exam of ribs .............................................. 0.00 0.78 NA 0.05 0.83 NA XXX 

71110 .... .......... A X-ray exam of ribs .............................................. 0.27 0.87 NA 0.06 1.20 NA XXX 

71111 .... 26 ..... A X-ray exam of ribs/chest .................................... 0.32 0.10 0.10 0.01 0.43 0.43 XXX 

71111 .... TC .... A X-ray exam of ribs/chest .................................... 0.00 0.89 NA 0.06 0.95 NA XXX 

71111 .... .......... A X-ray exam of ribs/chest .................................... 0.32 0.99 NA 0.07 1.38 NA XXX 

71120 .... 26 ..... A X-ray exam of breastbone .................................. 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

71120 .... TC .... A X-ray exam of breastbone .................................. 0.00 0.65 NA 0.04 0.69 NA XXX 

71120 .... .......... A X-ray exam of breastbone .................................. 0.20 0.72 NA 0.05 0.97 NA XXX 

71130 .... 26 ..... A X-ray exam of breastbone .................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

71130 .... TC .... A X-ray exam of breastbone .................................. 0.00 0.71 NA 0.04 0.75 NA XXX 

71130 .... .......... A X-ray exam of breastbone .................................. 0.22 0.78 NA 0.05 1.05 NA XXX 

71250 .... 26 ..... A Ct thorax w/o dye ............................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

71250 .... TC .... A Ct thorax w/o dye ............................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

71250 .... .......... A Ct thorax w/o dye ............................................... 1.16 6.31 NA 0.36 7.83 NA XXX 

71260 .... 26 ..... A Ct thorax w/dye .................................................. 1.24 0.41 0.41 0.05 1.70 1.70 XXX 

71260 .... TC .... A Ct thorax w/dye .................................................. 0.00 7.09 NA 0.37 7.46 NA XXX 

71260 .... .......... A Ct thorax w/dye .................................................. 1.24 7.50 NA 0.42 9.16 NA XXX 

71270 .... 26 ..... A Ct thorax w/o & w/dye ........................................ 1.38 0.45 0.45 0.06 1.89 1.89 XXX 

71270 .... TC .... A Ct thorax w/o & w/dye ........................................ 0.00 8.88 NA 0.46 9.34 NA XXX 

71270 .... .......... A Ct thorax w/o & w/dye ........................................ 1.38 9.33 NA 0.52 11.23 NA XXX 

71275 .... 26 ..... A Ct angiography, chest ........................................ 1.92 0.63 0.63 0.09 2.64 2.64 XXX 

71275 .... TC .... A Ct angiography, chest ........................................ 0.00 12.42 NA 0.39 12.81 NA XXX 

71275 .... .......... A Ct angiography, chest ........................................ 1.92 13.05 NA 0.48 15.45 NA XXX 

71550 .... 26 ..... A Mri chest w/o dye ............................................... 1.46 0.48 0.48 0.06 2.00 2.00 XXX 

71550 .... TC .... A Mri chest w/o dye ............................................... 0.00 11.23 NA 0.45 11.68 NA XXX 

71550 .... .......... A Mri chest w/o dye ............................................... 1.46 11.71 NA 0.51 13.68 NA XXX 

71551 .... 26 ..... A Mri chest w/dye .................................................. 1.73 0.57 0.57 0.08 2.38 2.38 XXX 

71551 .... TC .... A Mri chest w/dye .................................................. 0.00 13.48 NA 0.52 14.00 NA XXX 

71551 .... .......... A Mri chest w/dye .................................................. 1.73 14.05 NA 0.60 16.38 NA XXX 

71552 .... 26 ..... A Mri chest w/o & w/dye ........................................ 2.26 0.74 0.74 0.10 3.10 3.10 XXX 

71552 .... TC .... A Mri chest w/o & w/dye ........................................ 0.00 24.95 NA 0.68 25.63 NA XXX 

71552 .... .......... A Mri chest w/o & w/dye ........................................ 2.26 25.69 NA 0.78 28.73 NA XXX 

71555 .... 26 ..... R Mri angio chest w or w/o dye ............................. 1.81 0.60 0.60 0.08 2.49 2.49 XXX 

71555 .... TC .... R Mri angio chest w or w/o dye ............................. 0.00 11.23 NA 0.59 11.82 NA XXX 

71555 .... .......... R Mri angio chest w or w/o dye ............................. 1.81 11.83 NA 0.67 14.31 NA XXX 

72010 .... 26 ..... A X-ray exam of spine ........................................... 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

72010 .... TC .... A X-ray exam of spine ........................................... 0.00 1.02 NA 0.06 1.08 NA XXX 

72010 .... .......... A X-ray exam of spine ........................................... 0.45 1.17 NA 0.08 1.70 NA XXX 

72020 .... 26 ..... A X-ray exam of spine ........................................... 0.15 0.05 0.05 0.01 0.21 0.21 XXX 

72020 .... TC .... A X-ray exam of spine ........................................... 0.00 0.42 NA 0.02 0.44 NA XXX 

72020 .... .......... A X-ray exam of spine ........................................... 0.15 0.47 NA 0.03 0.65 NA XXX 

72040 .... 26 ..... A X-ray exam of neck spine .................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72040 .... TC .... A X-ray exam of neck spine .................................. 0.00 0.60 NA 0.04 0.64 NA XXX 

72040 .... .......... A X-ray exam of neck spine .................................. 0.22 0.67 NA 0.05 0.94 NA XXX 

72050 .... 26 ..... A X-ray exam of neck spine .................................. 0.31 0.10 0.10 0.01 0.42 0.42 XXX 

72050 .... TC .... A X-ray exam of neck spine .................................. 0.00 0.89 NA 0.06 0.95 NA XXX 

72050 .... .......... A X-ray exam of neck spine .................................. 0.31 0.99 NA 0.07 1.37 NA XXX 

72052 .... 26 ..... A X-ray exam of neck spine .................................. 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

72052 .... TC .... A X-ray exam of neck spine .................................. 0.00 1.13 NA 0.06 1.19 NA XXX 

72052 .... .......... A X-ray exam of neck spine .................................. 0.36 1.25 NA 0.08 1.69 NA XXX 

72069 .... 26 ..... A X-ray exam of trunk spine .................................. 0.22 0.08 0.08 0.01 0.31 0.31 XXX 

72069 .... TC .... A X-ray exam of trunk spine .................................. 0.00 0.49 NA 0.02 0.51 NA XXX 

72069 .... .......... A X-ray exam of trunk spine .................................. 0.22 0.57 NA 0.03 0.82 NA XXX 

72070 .... 26 ..... A X-ray exam of thoracic spine ............................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72070 .... TC .... A X-ray exam of thoracic spine ............................. 0.00 0.65 NA 0.04 0.69 NA XXX 

72070 .... .......... A X-ray exam of thoracic spine ............................. 0.22 0.72 NA 0.05 0.99 NA XXX 

72072 .... 26 ..... A X-ray exam of thoracic spine ............................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72072 .... TC .... A X-ray exam of thoracic spine ............................. 0.00 0.73 NA 0.05 0.78 NA XXX 

72072 .... .......... A X-ray exam of thoracic spine ............................. 0.22 0.80 NA 0.06 1.08 NA XXX 

72074 .... 26 ..... A X-ray exam of thoracic spine ............................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72074 .... TC .... A X-ray exam of thoracic spine ............................. 0.00 0.91 NA 0.06 0.97 NA XXX 

72074 .... .......... A X-ray exam of thoracic spine ............................. 0.22 0.98 NA 0.07 1.27 NA XXX 

72080 .... 26 ..... A X-ray exam of trunk spine .................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72080 .... TC .... A X-ray exam of trunk spine .................................. 0.00 0.67 NA 0.04 0.71 NA XXX 

72080 .... .......... A X-ray exam of trunk spine .................................. 0.22 0.74 NA 0.05 1.01 NA XXX 

72090 .... 26 ..... A X-ray exam of trunk spine .................................. 0.28 0.09 0.09 0.01 0.38 0.38 XXX 

72090 .... TC .... A X-ray exam of trunk spine .................................. 0.00 0.67 NA 0.04 0.71 NA XXX 

72090 .... .......... A X-ray exam of trunk spine .................................. 0.28 0.76 NA 0.05 1.09 NA XXX 

70415 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

72100 .... 26 ..... A X-ray exam of lower spine ................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72100 .... TC .... A X-ray exam of lower spine ................................. 0.00 0.67 NA 0.04 0.71 NA XXX 

72100 .... .......... A X-ray exam of lower spine ................................. 0.22 0.74 NA 0.05 1.01 NA XXX 

72110 .... 26 ..... A X-ray exam of lower spine ................................. 0.31 0.10 0.10 0.01 0.42 0.42 XXX 

72110 .... TC .... A X-ray exam of lower spine ................................. 0.00 0.91 NA 0.06 0.97 NA XXX 

72110 .... .......... A X-ray exam of lower spine ................................. 0.31 1.01 NA 0.07 1.39 NA XXX 

72114 .... 26 ..... A X-ray exam of lower spine ................................. 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

72114 .... TC .... A X-ray exam of lower spine ................................. 0.00 1.19 NA 0.06 1.25 NA XXX 

72114 .... .......... A X-ray exam of lower spine ................................. 0.36 1.31 NA 0.08 1.75 NA XXX 

72120 .... 26 ..... A X-ray exam of lower spine ................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

72120 .... TC .... A X-ray exam of lower spine ................................. 0.00 0.89 NA 0.06 0.95 NA XXX 

72120 .... .......... A X-ray exam of lower spine ................................. 0.22 0.96 NA 0.07 1.25 NA XXX 

72125 .... 26 ..... A Ct neck spine w/o dye ........................................ 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

72125 .... TC .... A Ct neck spine w/o dye ........................................ 0.00 5.93 NA 0.31 6.24 NA XXX 

72125 .... .......... A Ct neck spine w/o dye ........................................ 1.16 6.31 NA 0.36 7.83 NA XXX 

72126 .... 26 ..... A Ct neck spine w/dye ........................................... 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

72126 .... TC .... A Ct neck spine w/dye ........................................... 0.00 7.09 NA 0.37 7.46 NA XXX 

72126 .... .......... A Ct neck spine w/dye ........................................... 1.22 7.49 NA 0.42 9.13 NA XXX 

72127 .... 26 ..... A Ct neck spine w/o & w/dye ................................ 1.27 0.42 0.42 0.06 1.75 1.75 XXX 

72127 .... TC .... A Ct neck spine w/o & w/dye ................................ 0.00 8.88 NA 0.46 9.34 NA XXX 

72127 .... .......... A Ct neck spine w/o & w/dye ................................ 1.27 9.30 NA 0.52 11.09 NA XXX 

72128 .... 26 ..... A Ct chest spine w/o dye ....................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

72128 .... TC .... A Ct chest spine w/o dye ....................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

72128 .... .......... A Ct chest spine w/o dye ....................................... 1.16 6.31 NA 0.36 7.83 NA XXX 

72129 .... 26 ..... A Ct chest spine w/dye .......................................... 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

72129 .... TC .... A Ct chest spine w/dye .......................................... 0.00 7.09 NA 0.37 7.46 NA XXX 

72129 .... .......... A Ct chest spine w/dye .......................................... 1.22 7.49 NA 0.42 9.13 NA XXX 

72130 .... 26 ..... A Ct chest spine w/o & w/dye ............................... 1.27 0.42 0.42 0.06 1.75 1.75 XXX 

72130 .... TC .... A Ct chest spine w/o & w/dye ............................... 0.00 8.88 NA 0.46 9.34 NA XXX 

72130 .... .......... A Ct chest spine w/o & w/dye ............................... 1.27 9.30 NA 0.52 11.09 NA XXX 

72131 .... 26 ..... A Ct lumbar spine w/o dye .................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

72131 .... TC .... A Ct lumbar spine w/o dye .................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

72131 .... .......... A Ct lumbar spine w/o dye .................................... 1.16 6.31 NA 0.36 7.83 NA XXX 

72132 .... 26 ..... A Ct lumbar spine w/dye ....................................... 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

72132 .... TC .... A Ct lumbar spine w/dye ....................................... 0.00 7.09 NA 0.37 7.46 NA XXX 

72132 .... .......... A Ct lumbar spine w/dye ....................................... 1.22 7.49 NA 0.42 9.13 NA XXX 

72133 .... 26 ..... A Ct lumbar spine w/o & w/dye ............................. 1.27 0.42 0.42 0.06 1.75 1.75 XXX 

72133 .... TC .... A Ct lumbar spine w/o & w/dye ............................. 0.00 8.88 NA 0.46 9.34 NA XXX 

72133 .... .......... A Ct lumbar spine w/o & w/dye ............................. 1.27 9.30 NA 0.52 11.09 NA XXX 

72141 .... 26 ..... A Mri neck spine w/o dye ...................................... 1.60 0.53 0.53 0.07 2.20 2.20 XXX 

72141 .... TC .... A Mri neck spine w/o dye ...................................... 0.00 11.23 NA 0.59 11.82 NA XXX 

72141 .... .......... A Mri neck spine w/o dye ...................................... 1.60 11.76 NA 0.66 14.02 NA XXX 

72142 .... 26 ..... A Mri neck spine w/dye ......................................... 1.92 0.64 0.64 0.09 2.65 2.65 XXX 

72142 .... TC .... A Mri neck spine w/dye ......................................... 0.00 13.48 NA 0.70 14.18 NA XXX 

72142 .... .......... A Mri neck spine w/dye ......................................... 1.92 14.12 NA 0.79 16.83 NA XXX 

72146 .... 26 ..... A Mri chest spine w/o dye ..................................... 1.60 0.53 0.53 0.07 2.20 2.20 XXX 

72146 .... TC .... A Mri chest spine w/o dye ..................................... 0.00 12.48 NA 0.64 13.12 NA XXX 

72146 .... .......... A Mri chest spine w/o dye ..................................... 1.60 13.01 NA 0.71 15.32 NA XXX 

72147 .... 26 ..... A Mri chest spine w/dye ........................................ 1.92 0.63 0.63 0.09 2.64 2.64 XXX 

72147 .... TC .... A Mri chest spine w/dye ........................................ 0.00 13.48 NA 0.70 14.18 NA XXX 

72147 .... .......... A Mri chest spine w/dye ........................................ 1.92 14.11 NA 0.79 16.82 NA XXX 

72148 .... 26 ..... A Mri lumbar spine w/o dye ................................... 1.48 0.49 0.49 0.07 2.04 2.04 XXX 

72148 .... TC .... A Mri lumbar spine w/o dye ................................... 0.00 12.48 NA 0.64 13.12 NA XXX 

72148 .... .......... A Mri lumbar spine w/o dye ................................... 1.48 12.97 NA 0.71 15.16 NA XXX 

72149 .... 26 ..... A Mri lumbar spine w/dye ...................................... 1.78 0.60 0.60 0.08 2.46 2.46 XXX 

72149 .... TC .... A Mri lumbar spine w/dye ...................................... 0.00 13.48 NA 0.70 14.18 NA XXX 

72149 .... .......... A Mri lumbar spine w/dye ...................................... 1.78 14.08 NA 0.78 16.64 NA XXX 

72156 .... 26 ..... A Mri neck spine w/o & w/dye ............................... 2.57 0.85 0.85 0.11 3.53 3.53 XXX 

72156 .... TC .... A Mri neck spine w/o & w/dye ............................... 0.00 24.95 NA 1.31 26.26 NA XXX 

72156 .... .......... A Mri neck spine w/o & w/dye ............................... 2.57 25.80 NA 1.42 29.79 NA XXX 

72157 .... 26 ..... A Mri chest spine w/o & w/dye .............................. 2.57 0.84 0.84 0.11 3.52 3.52 XXX 

72157 .... TC .... A Mri chest spine w/o & w/dye .............................. 0.00 24.95 NA 1.31 26.26 NA XXX 

72157 .... .......... A Mri chest spine w/o & w/dye .............................. 2.57 25.79 NA 1.42 29.78 NA XXX 

72158 .... 26 ..... A Mri lumbar spine w/o & w/dye ............................ 2.36 0.78 0.78 0.10 3.24 3.24 XXX 

72158 .... TC .... A Mri lumbar spine w/o & w/dye ............................ 0.00 24.95 NA 1.31 26.26 NA XXX 

72158 .... .......... A Mri lumbar spine w/o & w/dye ............................ 2.36 25.73 NA 1.41 29.50 NA XXX 

72159 .... 26 ..... N Mr angio spine w/o&w/dye ................................. +1.80 0.69 0.69 0.10 2.59 2.59 XXX 

72159 .... TC .... N Mr angio spine w/o&w/dye ................................. +0.00 12.27 12.27 0.64 12.91 12.91 XXX 

72159 .... .......... N Mr angio spine w/o&w/dye ................................. +1.80 12.96 12.96 0.74 15.50 15.50 XXX 

72170 .... 26 ..... A X-ray exam of pelvis .......................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

72170 .... TC .... A X-ray exam of pelvis .......................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

72170 .... .......... A X-ray exam of pelvis .......................................... 0.17 0.58 NA 0.03 0.78 NA XXX 

72190 .... 26 ..... A X-ray exam of pelvis .......................................... 0.21 0.07 0.07 0.01 0.29 0.29 XXX 

72190 .... TC .... A X-ray exam of pelvis .......................................... 0.00 0.67 NA 0.04 0.71 NA XXX 

72190 .... .......... A X-ray exam of pelvis .......................................... 0.21 0.74 NA 0.05 1.00 NA XXX 

70416 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

72191 .... 26 ..... A Ct angiograph pelv w/o&w/dye .......................... 1.81 0.60 0.60 0.08 2.49 2.49 XXX 

72191 .... TC .... A Ct angiograph pelv w/o&w/dye .......................... 0.00 12.06 NA 0.39 12.45 NA XXX 

72191 .... .......... A Ct angiograph pelv w/o&w/dye .......................... 1.81 12.66 NA 0.47 14.94 NA XXX 

72192 .... 26 ..... A Ct pelvis w/o dye ................................................ 1.09 0.36 0.36 0.05 1.50 1.50 XXX 

72192 .... TC .... A Ct pelvis w/o dye ................................................ 0.00 5.93 NA 0.31 6.24 NA XXX 

72192 .... .......... A Ct pelvis w/o dye ................................................ 1.09 6.29 NA 0.36 7.74 NA XXX 

72193 .... 26 ..... A Ct pelvis w/dye ................................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

72193 .... TC .... A Ct pelvis w/dye ................................................... 0.00 6.86 NA 0.36 7.22 NA XXX 

72193 .... .......... A Ct pelvis w/dye ................................................... 1.16 7.24 NA 0.41 8.81 NA XXX 

72194 .... 26 ..... A Ct pelvis w/o & w/dye ......................................... 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

72194 .... TC .... A Ct pelvis w/o & w/dye ......................................... 0.00 8.51 NA 0.43 8.94 NA XXX 

72194 .... .......... A Ct pelvis w/o & w/dye ......................................... 1.22 8.91 NA 0.48 10.61 NA XXX 

72195 .... 26 ..... A Mri pelvis w/o dye .............................................. 1.46 0.48 0.48 0.06 2.00 2.00 XXX 

72195 .... TC .... A Mri pelvis w/o dye .............................................. 0.00 11.23 NA 0.45 11.68 NA XXX 

72195 .... .......... A Mri pelvis w/o dye .............................................. 1.46 11.71 NA 0.51 13.68 NA XXX 

72196 .... 26 ..... A Mri pelvis w/dye .................................................. 1.73 0.57 0.57 0.08 2.38 2.38 XXX 

72196 .... TC .... A Mri pelvis w/dye .................................................. 0.00 13.48 NA 0.52 14.00 NA XXX 

72196 .... .......... A Mri pelvis w/dye .................................................. 1.73 14.05 NA 0.60 16.38 NA XXX 

72197 .... 26 ..... A Mri pelvis w/o & w/dye ....................................... 2.26 0.74 0.74 0.10 3.10 3.10 XXX 

72197 .... TC .... A Mri pelvis w/o & w/dye ....................................... 0.00 24.95 NA 0.92 25.87 NA XXX 

72197 .... .......... A Mri pelvis w/o & w/dye ....................................... 2.26 25.69 NA 1.02 28.97 NA XXX 

72198 .... 26 ..... A Mr angio pelvis w/o & w/dye .............................. 1.80 0.59 0.59 0.08 2.47 2.47 XXX 

72198 .... TC .... A Mr angio pelvis w/o & w/dye .............................. 0.00 11.23 NA 0.59 11.82 NA XXX 

72198 .... .......... A Mr angio pelvis w/o & w/dye .............................. 1.80 11.82 NA 0.67 14.29 NA XXX 

72200 .... 26 ..... A X-ray exam sacroiliac joints ............................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

72200 .... TC .... A X-ray exam sacroiliac joints ............................... 0.00 0.52 NA 0.02 0.54 NA XXX 

72200 .... .......... A X-ray exam sacroiliac joints ............................... 0.17 0.58 NA 0.03 0.78 NA XXX 

72202 .... 26 ..... A X-ray exam sacroiliac joints ............................... 0.19 0.06 0.06 0.01 0.26 0.26 XXX 

72202 .... TC .... A X-ray exam sacroiliac joints ............................... 0.00 0.62 NA 0.04 0.66 NA XXX 

72202 .... .......... A X-ray exam sacroiliac joints ............................... 0.19 0.68 NA 0.05 0.92 NA XXX 

72220 .... 26 ..... A X-ray exam of tailbone ....................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

72220 .... TC .... A X-ray exam of tailbone ....................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

72220 .... .......... A X-ray exam of tailbone ....................................... 0.17 0.63 NA 0.05 0.85 NA XXX 

72240 .... 26 ..... A Contrast x-ray of neck spine .............................. 0.91 0.29 0.29 0.04 1.24 1.24 XXX 

72240 .... TC .... A Contrast x-ray of neck spine .............................. 0.00 4.76 NA 0.25 5.01 NA XXX 

72240 .... .......... A Contrast x-ray of neck spine .............................. 0.91 5.05 NA 0.29 6.25 NA XXX 

72255 .... 26 ..... A Contrast x-ray, thorax spine ............................... 0.91 0.27 0.27 0.04 1.22 1.22 XXX 

72255 .... TC .... A Contrast x-ray, thorax spine ............................... 0.00 4.34 NA 0.22 4.56 NA XXX 

72255 .... .......... A Contrast x-ray, thorax spine ............................... 0.91 4.61 NA 0.26 5.78 NA XXX 

72265 .... 26 ..... A Contrast x-ray, lower spine ................................ 0.83 0.25 0.25 0.04 1.12 1.12 XXX 

72265 .... C ...... A Contrast x-ray, lower spine ................................ 0.00 4.08 NA 0.22 4.30 NA XXX 

72265 .... .......... A Contrast x-ray, lower spine ................................ 0.83 4.33 NA 0.26 5.42 NA XXX 

72270 .... 26 ..... A Contrast x-ray, spine .......................................... 1.33 0.42 0.42 0.06 1.81 1.81 XXX 

72270 .... TC .... A Contrast x-ray, spine .......................................... 0.00 6.12 NA 0.33 6.45 NA XXX 

72270 .... .......... A Contrast x-ray, spine .......................................... 1.33 6.54 NA 0.39 8.26 NA XXX 

72275 .... 26 ..... A Epidurography .................................................... 0.76 0.20 0.20 0.04 1.00 1.00 XXX 

72275 .... TC .... A Epidurography .................................................... 0.00 2.11 NA 0.22 2.33 NA XXX 

72275 .... .......... A Epidurography .................................................... 0.76 2.31 NA 0.26 3.33 NA XXX 

72285 .... 26 ..... A X-ray c/t spine disk ............................................. 1.16 0.36 0.36 0.07 1.59 1.59 XXX 

72285 .... TC .... A X-ray c/t spine disk ............................................. 0.00 8.40 NA 0.43 8.83 NA XXX 

72285 .... .......... A X-ray c/t spine disk ............................................. 1.16 8.76 NA 0.50 10.42 NA XXX 

72295 .... 26 ..... A X-ray of lower spine disk .................................... 0.83 0.27 0.27 0.06 1.16 1.16 XXX 

72295 .... TC .... A X-ray of lower spine disk .................................... 0.00 7.88 NA 0.40 8.28 NA XXX 

72295 .... .......... A X-ray of lower spine disk .................................... 0.83 8.15 NA 0.46 9.44 NA XXX 

73000 .... 26 ..... A X-ray exam of collar bone .................................. 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73000 .... TC .... A X-ray exam of collar bone .................................. 0.00 0.52 NA 0.02 0.54 NA XXX 

73000 .... .......... A X-ray exam of collar bone .................................. 0.16 0.57 NA 0.03 0.76 NA XXX 

73010 .... 26 ..... A X-ray exam of shoulder blade ............................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73010 .... TC .... A X-ray exam of shoulder blade ............................ 0.00 0.52 NA 0.02 0.54 NA XXX 

73010 .... .......... A X-ray exam of shoulder blade ............................ 0.17 0.58 NA 0.03 0.78 NA XXX 

73020 .... 26 ..... A X-ray exam of shoulder ...................................... 0.15 0.05 0.05 0.01 0.21 0.21 XXX 

73020 .... TC .... A X-ray exam of shoulder ...................................... 0.00 0.47 NA 0.02 0.49 NA XXX 

73020 .... .......... A X-ray exam of shoulder ...................................... 0.15 0.52 NA 0.03 0.70 NA XXX 

73030 .... 26 ..... A X-ray exam of shoulder ...................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

73030 .... TC .... A X-ray exam of shoulder ...................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

73030 .... .......... A X-ray exam of shoulder ...................................... 0.18 0.63 NA 0.05 0.86 NA XXX 

73040 .... 26 ..... A Contrast x-ray of shoulder .................................. 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

73040 .... TC .... A Contrast x-ray of shoulder .................................. 0.00 2.11 NA 0.12 2.23 NA XXX 

73040 .... .......... A Contrast x-ray of shoulder .................................. 0.54 2.29 NA 0.14 2.97 NA XXX 

73050 .... 26 ..... A X-ray exam of shoulders .................................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

73050 .... TC .... A X-ray exam of shoulders .................................... 0.00 0.67 NA 0.04 0.71 NA XXX 

73050 .... .......... A X-ray exam of shoulders .................................... 0.20 0.74 NA 0.05 0.99 NA XXX 

73060 .... 26 ..... A X-ray exam of humerus ...................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73060 .... TC .... A X-ray exam of humerus ...................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

73060 .... .......... A X-ray exam of humerus ...................................... 0.17 0.63 NA 0.05 0.85 NA XXX 

70417 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

73070 .... 26 ..... A X-ray exam of elbow .......................................... 0.15 0.05 0.05 0.01 0.21 0.21 XXX 

73070 .... TC .... A X-ray exam of elbow .......................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

73070 .... .......... A X-ray exam of elbow .......................................... 0.15 0.57 NA 0.03 0.75 NA XXX 

73080 .... 26 ..... A X-ray exam of elbow .......................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73080 .... TC .... A X-ray exam of elbow .......................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

73080 .... .......... A X-ray exam of elbow .......................................... 0.17 0.63 NA 0.05 0.85 NA XXX 

73085 .... 26 ..... A Contrast x-ray of elbow ...................................... 0.54 0.19 0.19 0.02 0.75 0.75 XXX 

73085 .... TC .... A Contrast x-ray of elbow ...................................... 0.00 2.11 NA 0.12 2.23 NA XXX 

73085 .... .......... A Contrast x-ray of elbow ...................................... 0.54 2.30 NA 0.14 2.98 NA XXX 

73090 .... 26 ..... A X-ray exam of forearm ....................................... 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73090 .... TC .... A X-ray exam of forearm ....................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

73090 .... .......... A X-ray exam of forearm ....................................... 0.16 0.57 NA 0.03 0.76 NA XXX 

73092 .... 26 ..... A X-ray exam of arm, infant .................................. 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73092 .... TC .... A X-ray exam of arm, infant .................................. 0.00 0.49 NA 0.02 0.51 NA XXX 

73092 .... .......... A X-ray exam of arm, infant .................................. 0.16 0.54 NA 0.03 0.73 NA XXX 

73100 .... 26 ..... A X-ray exam of wrist ............................................ 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73100 .... TC .... A X-ray exam of wrist ............................................ 0.00 0.49 NA 0.02 0.51 NA XXX 

73100 .... .......... A X-ray exam of wrist ............................................ 0.16 0.54 NA 0.03 0.73 NA XXX 

73110 .... 26 ..... A X-ray exam of wrist ............................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73110 .... TC .... A X-ray exam of wrist ............................................ 0.00 0.53 NA 0.02 0.55 NA XXX 

73110 .... .......... A X-ray exam of wrist ............................................ 0.17 0.59 NA 0.03 0.79 NA XXX 

73115 .... 26 ..... A Contrast x-ray of wrist ........................................ 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

73115 .... TC .... A Contrast x-ray of wrist ........................................ 0.00 1.58 NA 0.10 1.68 NA XXX 

73115 .... .......... A Contrast x-ray of wrist ........................................ 0.54 1.76 NA 0.12 2.42 NA XXX 

73120 .... 26 ..... A X-ray exam of hand ............................................ 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73120 .... TC .... A X-ray exam of hand ............................................ 0.00 0.49 NA 0.02 0.51 NA XXX 

73120 .... .......... A X-ray exam of hand ............................................ 0.16 0.54 NA 0.03 0.73 NA XXX 

73130 .... 26 ..... A X-ray exam of hand ............................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73130 .... TC .... A X-ray exam of hand ............................................ 0.00 0.53 NA 0.02 0.55 NA XXX 

73130 .... .......... A X-ray exam of hand ............................................ 0.17 0.59 NA 0.03 0.79 NA XXX 

73140 .... 26 ..... A X-ray exam of finger(s) ...................................... 0.13 0.04 0.04 0.01 0.18 0.18 XXX 

73140 .... TC .... A X-ray exam of finger(s) ...................................... 0.00 0.42 NA 0.02 0.44 NA XXX 

73140 .... .......... A X-ray exam of finger(s) ...................................... 0.13 0.46 NA 0.03 0.62 NA XXX 

73200 .... 26 ..... A Ct upper extremity w/o dye ................................ 1.09 0.36 0.36 0.05 1.50 1.50 XXX 

73200 .... TC .... A Ct upper extremity w/o dye ................................ 0.00 4.97 NA 0.25 5.22 NA XXX 

73200 .... .......... A Ct upper extremity w/o dye ................................ 1.09 5.33 NA 0.30 6.72 NA XXX 

73201 .... 26 ..... A Ct upper extremity w/dye ................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

73201 .... TC .... A Ct upper extremity w/dye ................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

73201 .... .......... A Ct upper extremity w/dye ................................... 1.16 6.31 NA 0.36 7.83 NA XXX 

73202 .... 26 ..... A Ct uppr extremity w/o&w/dye ............................. 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

73202 .... TC .... A Ct uppr extremity w/o&w/dye ............................. 0.00 7.44 NA 0.39 7.83 NA XXX 

73202 .... .......... A Ct uppr extremity w/o&w/dye ............................. 1.22 7.84 NA 0.44 9.50 NA XXX 

73206 .... 26 ..... A Ct angio upr extrm w/o&w/dye ........................... 1.81 0.59 0.59 0.08 2.48 2.48 XXX 

73206 .... TC .... A Ct angio upr extrm w/o&w/dye ........................... 0.00 10.99 NA 0.39 11.38 NA XXX 

73206 .... .......... A Ct angio upr extrm w/o&w/dye ........................... 1.81 11.58 NA 0.47 13.86 NA XXX 

73218 .... 26 ..... A Mri upper extremity w/o dye ............................... 1.35 0.44 0.44 0.06 1.85 1.85 XXX 

73218 .... TC .... A Mri upper extremity w/o dye ............................... 0.00 11.23 NA 0.39 11.62 NA XXX 

73218 .... .......... A Mri upper extremity w/o dye ............................... 1.35 11.67 NA 0.45 13.47 NA XXX 

73219 .... 26 ..... A Mri upper extremity w/dye .................................. 1.62 0.54 0.54 0.07 2.23 2.23 XXX 

73219 .... TC .... A Mri upper extremity w/dye .................................. 0.00 13.48 NA 0.47 13.95 NA XXX 

73219 .... .......... A Mri upper extremity w/dye .................................. 1.62 14.02 NA 0.54 16.18 NA XXX 

73220 .... 26 ..... A Mri uppr extremity w/o&w/dye ............................ 2.15 0.71 0.71 0.10 2.96 2.96 XXX 

73220 .... TC .... A Mri uppr extremity w/o&w/dye ............................ 0.00 24.95 NA 0.84 25.79 NA XXX 

73220 .... .......... A Mri uppr extremity w/o&w/dye ............................ 2.15 25.66 NA 0.94 28.75 NA XXX 

73221 .... 26 ..... A Mri joint upr extrem w/o dye .............................. 1.35 0.44 0.44 0.06 1.85 1.85 XXX 

73221 .... TC .... A Mri joint upr extrem w/o dye .............................. 0.00 11.23 NA 0.39 11.62 NA XXX 

73221 .... .......... A Mri joint upr extrem w/o dye .............................. 1.35 11.67 NA 0.45 13.47 NA XXX 

73222 .... 26 ..... A Mri joint upr extrem w/dye .................................. 1.62 0.53 0.53 0.07 2.22 2.22 XXX 

73222 .... TC .... A Mri joint upr extrem w/dye .................................. 0.00 13.48 NA 0.47 13.95 NA XXX 

73222 .... .......... A Mri joint upr extrem w/dye .................................. 1.62 14.01 NA 0.54 16.17 NA XXX 

73223 .... 26 ..... A Mri joint upr extr w/o&w/dye ............................... 2.15 0.71 0.71 0.10 2.96 2.96 XXX 

73223 .... TC .... A Mri joint upr extr w/o&w/dye ............................... 0.00 24.95 NA 0.84 25.79 NA XXX 

73223 .... .......... A Mri joint upr extr w/o&w/dye ............................... 2.15 25.66 NA 0.94 28.75 NA XXX 

73225 .... 26 ..... N Mr angio upr extr w/o&w/dye ............................. +1.73 0.67 0.67 0.10 2.50 2.50 XXX 

73225 .... TC .... N Mr angio upr extr w/o&w/dye ............................. +0.00 11.04 11.04 0.59 11.63 11.63 XXX 

73225 .... .......... N Mr angio upr extr w/o&w/dye ............................. +1.73 11.71 11.71 0.69 14.13 14.13 XXX 

73500 .... 26 ..... A X-ray exam of hip ............................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73500 .... TC .... A X-ray exam of hip ............................................... 0.00 0.47 NA 0.02 0.49 NA XXX 

73500 .... .......... A X-ray exam of hip ............................................... 0.17 0.53 NA 0.03 0.73 NA XXX 

73510 .... 26 ..... A X-ray exam of hip ............................................... 0.21 0.07 0.07 0.01 0.29 0.29 XXX 

73510 .... TC .... A X-ray exam of hip ............................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

73510 .... .......... A X-ray exam of hip ............................................... 0.21 0.64 NA 0.05 0.90 NA XXX 

73520 .... 26 ..... A X-ray exam of hips ............................................. 0.26 0.09 0.09 0.01 0.36 0.36 XXX 

73520 .... TC .... A X-ray exam of hips ............................................. 0.00 0.67 NA 0.04 0.71 NA XXX 

73520 .... .......... A X-ray exam of hips ............................................. 0.26 0.76 NA 0.05 1.07 NA XXX 

70418 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

73525 .... 26 ..... A Contrast x-ray of hip ........................................... 0.54 0.18 0.18 0.03 0.75 0.75 XXX 

73525 .... TC .... A Contrast x-ray of hip ........................................... 0.00 2.11 NA 0.12 2.23 NA XXX 

73525 .... .......... A Contrast x-ray of hip ........................................... 0.54 2.29 NA 0.15 2.98 NA XXX 

73530 .... 26 ..... A X-ray exam of hip ............................................... 0.29 0.10 0.10 0.01 0.40 0.40 XXX 

73530 .... TC .... A X-ray exam of hip ............................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

73530 .... .......... A X-ray exam of hip ............................................... 0.29 0.62 NA 0.03 0.94 NA XXX 

73540 .... 26 ..... A X-ray exam of pelvis & hips ............................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

73540 .... TC .... A X-ray exam of pelvis & hips ............................... 0.00 0.57 NA 0.04 0.61 NA XXX 

73540 .... .......... A X-ray exam of pelvis & hips ............................... 0.20 0.64 NA 0.05 0.89 NA XXX 

73542 .... 26 ..... A X-ray exam, sacroiliac joint ................................ 0.59 0.16 0.16 0.03 0.78 0.78 XXX 

73542 .... TC .... A X-ray exam, sacroiliac joint ................................ 0.00 2.11 NA 0.12 2.23 NA XXX 

73542 .... .......... A X-ray exam, sacroiliac joint ................................ 0.59 2.27 NA 0.15 3.01 NA XXX 

73550 .... 26 ..... A X-ray exam of thigh ............................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73550 .... TC .... A X-ray exam of thigh ............................................ 0.00 0.57 NA 0.04 0.61 NA XXX 

73550 .... .......... A X-ray exam of thigh ............................................ 0.17 0.63 NA 0.05 0.85 NA XXX 

73560 .... 26 ..... A X-ray exam of knee, 1 or 2 ................................ 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73560 .... TC .... A X-ray exam of knee, 1 or 2 ................................ 0.00 0.52 NA 0.02 0.54 NA XXX 

73560 .... .......... A X-ray exam of knee, 1 or 2 ................................ 0.17 0.58 NA 0.03 0.78 NA XXX 

73562 .... 26 ..... A X-ray exam of knee, 3 ........................................ 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

73562 .... TC .... A X-ray exam of knee, 3 ........................................ 0.00 0.57 NA 0.04 0.61 NA XXX 

73562 .... .......... A X-ray exam of knee, 3 ........................................ 0.18 0.63 NA 0.05 0.86 NA XXX 

73564 .... 26 ..... A X-ray exam, knee, 4 or more ............................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

73564 .... TC .... A X-ray exam, knee, 4 or more ............................. 0.00 0.62 NA 0.04 0.66 NA XXX 

73564 .... .......... A X-ray exam, knee, 4 or more ............................. 0.22 0.69 NA 0.05 0.96 NA XXX 

73565 .... 26 ..... A X-ray exam of knees .......................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73565 .... TC .... A X-ray exam of knees .......................................... 0.00 0.49 NA 0.02 0.51 NA XXX 

73565 .... .......... A X-ray exam of knees .......................................... 0.17 0.55 NA 0.03 0.75 NA XXX 

73580 .... 26 ..... A Contrast x-ray of knee joint ................................ 0.54 0.17 0.17 0.03 0.74 0.74 XXX 

73580 .... TC .... A Contrast x-ray of knee joint ................................ 0.00 2.63 NA 0.14 2.77 NA XXX 

73580 .... .......... A Contrast x-ray of knee joint ................................ 0.54 2.80 NA 0.17 3.51 NA XXX 

73590 .... 26 ..... A X-ray exam of lower leg ..................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73590 .... TC .... A X-ray exam of lower leg ..................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

73590 .... .......... A X-ray exam of lower leg ..................................... 0.17 0.58 NA 0.03 0.78 NA XXX 

73592 .... 26 ..... A X-ray exam of leg, infant .................................... 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73592 .... TC .... A X-ray exam of leg, infant .................................... 0.00 0.49 NA 0.02 0.51 NA XXX 

73592 .... .......... A X-ray exam of leg, infant .................................... 0.16 0.54 NA 0.03 0.73 NA XXX 

73600 .... 26 ..... A X-ray exam of ankle ........................................... 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73600 .... TC .... A X-ray exam of ankle ........................................... 0.00 0.49 NA 0.02 0.51 NA XXX 

73600 .... .......... A X-ray exam of ankle ........................................... 0.16 0.54 NA 0.03 0.73 NA XXX 

73610 .... 26 ..... A X-ray exam of ankle ........................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73610 .... TC .... A X-ray exam of ankle ........................................... 0.00 0.53 NA 0.02 0.55 NA XXX 

73610 .... .......... A X-ray exam of ankle ........................................... 0.17 0.59 NA 0.03 0.79 NA XXX 

73615 .... 26 ..... A Contrast x-ray of ankle ....................................... 0.54 0.18 0.18 0.03 0.75 0.75 XXX 

73615 .... TC .... A Contrast x-ray of ankle ....................................... 0.00 2.11 NA 0.12 2.23 NA XXX 

73615 .... .......... A Contrast x-ray of ankle ....................................... 0.54 2.29 NA 0.15 2.98 NA XXX 

73620 .... 26 ..... A X-ray exam of foot .............................................. 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73620 .... TC .... A X-ray exam of foot .............................................. 0.00 0.49 NA 0.02 0.51 NA XXX 

73620 .... .......... A X-ray exam of foot .............................................. 0.16 0.54 NA 0.03 0.73 NA XXX 

73630 .... 26 ..... A X-ray exam of foot .............................................. 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

73630 .... TC .... A X-ray exam of foot .............................................. 0.00 0.53 NA 0.02 0.55 NA XXX 

73630 .... .......... A X-ray exam of foot .............................................. 0.17 0.59 NA 0.03 0.79 NA XXX 

73650 .... 26 ..... A X-ray exam of heel ............................................. 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

73650 .... TC .... A X-ray exam of heel ............................................. 0.00 0.47 NA 0.02 0.49 NA XXX 

73650 .... .......... A X-ray exam of heel ............................................. 0.16 0.52 NA 0.03 0.71 NA XXX 

73660 .... 26 ..... A X-ray exam of toe(s) .......................................... 0.13 0.04 0.04 0.01 0.18 0.18 XXX 

73660 .... TC .... A X-ray exam of toe(s) .......................................... 0.00 0.42 NA 0.02 0.44 NA XXX 

73660 .... .......... A X-ray exam of toe(s) .......................................... 0.13 0.46 NA 0.03 0.62 NA XXX 

73700 .... 26 ..... A Ct lower extremity w/o dye ................................. 1.09 0.36 0.36 0.05 1.50 1.50 XXX 

73700 .... TC .... A Ct lower extremity w/o dye ................................. 0.00 4.97 NA 0.25 5.22 NA XXX 

73700 .... .......... A Ct lower extremity w/o dye ................................. 1.09 5.33 NA 0.30 6.72 NA XXX 

73701 .... 26 ..... A Ct lower extremity w/dye .................................... 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

73701 .... TC .... A Ct lower extremity w/dye .................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

73701 .... .......... A Ct lower extremity w/dye .................................... 1.16 6.31 NA 0.36 7.83 NA XXX 

73702 .... 26 ..... A Ct lwr extremity w/o&w/dye ................................ 1.22 0.40 0.40 0.05 1.67 1.67 XXX 

73702 .... TC .... A Ct lwr extremity w/o&w/dye ................................ 0.00 7.44 NA 0.39 7.83 NA XXX 

73702 .... .......... A Ct lwr extremity w/o&w/dye ................................ 1.22 7.84 NA 0.44 9.50 NA XXX 

73706 .... 26 ..... A Ct angio lwr extr w/o&w/dye .............................. 1.90 0.62 0.62 0.08 2.60 2.60 XXX 

73706 .... TC .... A Ct angio lwr extr w/o&w/dye .............................. 0.00 10.99 NA 0.39 11.38 NA XXX 

73706 .... .......... A Ct angio lwr extr w/o&w/dye .............................. 1.90 11.61 NA 0.47 13.98 NA XXX 

73718 .... 26 ..... A Mri lower extremity w/o dye ............................... 1.35 0.44 0.44 0.06 1.85 1.85 XXX 

73718 .... TC .... A Mri lower extremity w/o dye ............................... 0.00 11.23 NA 0.39 11.62 NA XXX 

73718 .... .......... A Mri lower extremity w/o dye ............................... 1.35 11.67 NA 0.45 13.47 NA XXX 

73719 .... 26 ..... A Mri lower extremity w/dye .................................. 1.62 0.53 0.53 0.07 2.22 2.22 XXX 

73719 .... TC .... A Mri lower extremity w/dye .................................. 0.00 13.48 NA 0.47 13.95 NA XXX 

73719 .... .......... A Mri lower extremity w/dye .................................. 1.62 14.01 NA 0.54 16.17 NA XXX 

70419 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

73720 .... 26 ..... A Mri lwr extremity w/o&w/dye .............................. 2.15 0.70 0.70 0.10 2.95 2.95 XXX 

73720 .... TC .... A Mri lwr extremity w/o&w/dye .............................. 0.00 24.95 NA 0.84 25.79 NA XXX 

73720 .... .......... A Mri lwr extremity w/o&w/dye .............................. 2.15 25.65 NA 0.94 28.74 NA XXX 

73721 .... 26 ..... A Mri jnt of lwr extre w/o dye ................................. 1.35 0.44 0.44 0.06 1.85 1.85 XXX 

73721 .... TC .... A Mri jnt of lwr extre w/o dye ................................. 0.00 11.23 NA 0.39 11.62 NA XXX 

73721 .... .......... A Mri jnt of lwr extre w/o dye ................................. 1.35 11.67 NA 0.45 13.47 NA XXX 

73722 .... 26 ..... A Mri joint of lwr extr w/dye ................................... 1.62 0.53 0.53 0.07 2.22 2.22 XXX 

73722 .... TC .... A Mri joint of lwr extr w/dye ................................... 0.00 13.48 NA 0.47 13.95 NA XXX 

73722 .... .......... A Mri joint of lwr extr w/dye ................................... 1.62 14.01 NA 0.54 16.17 NA XXX 

73723 .... 26 ..... A Mri joint lwr extr w/o&w/dye ............................... 2.15 0.71 0.71 0.10 2.96 2.96 XXX 

73723 .... TC .... A Mri joint lwr extr w/o&w/dye ............................... 0.00 24.95 NA 0.84 25.79 NA XXX 

73723 .... .......... A Mri joint lwr extr w/o&w/dye ............................... 2.15 25.66 NA 0.94 28.75 NA XXX 

73725 .... 26 ..... R Mr ang lwr ext w or w/o dye .............................. 1.82 0.60 0.60 0.08 2.50 2.50 XXX 

73725 .... TC .... R Mr ang lwr ext w or w/o dye .............................. 0.00 11.23 NA 0.59 11.82 NA XXX 

73725 .... .......... R Mr ang lwr ext w or w/o dye .............................. 1.82 11.83 NA 0.67 14.32 NA XXX 

74000 .... 26 ..... A X-ray exam of abdomen ..................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

74000 .... TC .... A X-ray exam of abdomen ..................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

74000 .... .......... A X-ray exam of abdomen ..................................... 0.18 0.58 NA 0.03 0.79 NA XXX 

74010 .... 26 ..... A X-ray exam of abdomen ..................................... 0.23 0.08 0.08 0.01 0.32 0.32 XXX 

74010 .... TC .... A X-ray exam of abdomen ..................................... 0.00 0.57 NA 0.04 0.61 NA XXX 

74010 .... .......... A X-ray exam of abdomen ..................................... 0.23 0.65 NA 0.05 0.93 NA XXX 

74020 .... 26 ..... A X-ray exam of abdomen ..................................... 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

74020 .... TC .... A X-ray exam of abdomen ..................................... 0.00 0.62 NA 0.04 0.66 NA XXX 

74020 .... .......... A X-ray exam of abdomen ..................................... 0.27 0.71 NA 0.05 1.03 NA XXX 

74022 .... 26 ..... A X-ray exam series, abdomen ............................. 0.32 0.10 0.10 0.01 0.43 0.43 XXX 

74022 .... TC .... A X-ray exam series, abdomen ............................. 0.00 0.73 NA 0.05 0.78 NA XXX 

74022 .... .......... A X-ray exam series, abdomen ............................. 0.32 0.83 NA 0.06 1.21 NA XXX 

74150 .... 26 ..... A Ct abdomen w/o dye .......................................... 1.19 0.39 0.39 0.05 1.63 1.63 XXX 

74150 .... TC .... A Ct abdomen w/o dye .......................................... 0.00 5.68 NA 0.30 5.98 NA XXX 

74150 .... .......... A Ct abdomen w/o dye .......................................... 1.19 6.07 NA 0.35 7.61 NA XXX 

74160 .... 26 ..... A Ct abdomen w/dye ............................................. 1.27 0.42 0.42 0.06 1.75 1.75 XXX 

74160 .... TC .... A Ct abdomen w/dye ............................................. 0.00 6.86 NA 0.36 7.22 NA XXX 

74160 .... .......... A Ct abdomen w/dye ............................................. 1.27 7.28 NA 0.42 8.97 NA XXX 

74170 .... 26 ..... A Ct abdomen w/o & w/dye ................................... 1.40 0.46 0.46 0.06 1.92 1.92 XXX 

74170 .... TC .... A Ct abdomen w/o & w/dye ................................... 0.00 8.51 NA 0.43 8.94 NA XXX 

74170 .... .......... A Ct abdomen w/o & w/dye ................................... 1.40 8.97 NA 0.49 10.86 NA XXX 

74175 .... 26 ..... A Ct angio abdom w/o & w/dye ............................. 1.90 0.62 0.62 0.08 2.60 2.60 XXX 

74175 .... TC .... A Ct angio abdom w/o & w/dye ............................. 0.00 12.06 NA 0.39 12.45 NA XXX 

74175 .... .......... A Ct angio abdom w/o & w/dye ............................. 1.90 12.68 NA 0.47 15.05 NA XXX 

74181 .... 26 ..... A Mri abdomen w/o dye ......................................... 1.46 0.48 0.48 0.06 2.00 2.00 XXX 

74181 .... TC .... A Mri abdomen w/o dye ......................................... 0.00 11.23 NA 0.45 11.68 NA XXX 

74181 .... .......... A Mri abdomen w/o dye ......................................... 1.46 11.71 NA 0.51 13.68 NA XXX 

74182 .... 26 ..... A Mri abdomen w/dye ............................................ 1.73 0.57 0.57 0.08 2.38 2.38 XXX 

74182 .... TC .... A Mri abdomen w/dye ............................................ 0.00 13.48 NA 0.52 14.00 NA XXX 

74182 .... .......... A Mri abdomen w/dye ............................................ 1.73 14.05 NA 0.60 16.38 NA XXX 

74183 .... 26 ..... A Mri abdomen w/o & w/dye ................................. 2.26 0.74 0.74 0.10 3.10 3.10 XXX 

74183 .... TC .... A Mri abdomen w/o & w/dye ................................. 0.00 24.95 NA 0.92 25.87 NA XXX 

74183 .... .......... A Mri abdomen w/o & w/dye ................................. 2.26 25.69 NA 1.02 28.97 NA XXX 

74185 .... 26 ..... R Mri angio, abdom w orw/o dye ........................... 1.80 0.59 0.59 0.08 2.47 2.47 XXX 

74185 .... TC .... R Mri angio, abdom w orw/o dye ........................... 0.00 11.23 NA 0.59 11.82 NA XXX 

74185 .... .......... R Mri angio, abdom w orw/o dye ........................... 1.80 11.82 NA 0.67 14.29 NA XXX 

74190 .... 26 ..... A X-ray exam of peritoneum .................................. 0.48 0.16 0.16 0.02 0.66 0.66 XXX 

74190 .... TC .... A X-ray exam of peritoneum .................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

74190 .... .......... A X-ray exam of peritoneum .................................. 0.48 1.47 NA 0.09 2.04 NA XXX 

74210 .... 26 ..... A Contrst x-ray exam of throat .............................. 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

74210 .... TC .... A Contrst x-ray exam of throat .............................. 0.00 1.19 NA 0.06 1.25 NA XXX 

74210 .... .......... A Contrst x-ray exam of throat .............................. 0.36 1.31 NA 0.08 1.75 NA XXX 

74220 .... 26 ..... A Contrast x-ray, esophagus ................................. 0.46 0.15 0.15 0.02 0.63 0.63 XXX 

74220 .... TC .... A Contrast x-ray, esophagus ................................. 0.00 1.19 NA 0.06 1.25 NA XXX 

74220 .... .......... A Contrast x-ray, esophagus ................................. 0.46 1.34 NA 0.08 1.88 NA XXX 

74230 .... 26 ..... A Cine/vid x-ray, throat/esoph ............................... 0.53 0.17 0.17 0.02 0.72 0.72 XXX 

74230 .... TC .... A Cine/vid x-ray, throat/esoph ............................... 0.00 1.31 NA 0.07 1.38 NA XXX 

74230 .... .......... A Cine/vid x-ray, throat/esoph ............................... 0.53 1.48 NA 0.09 2.10 NA XXX 

74235 .... 26 ..... A Remove esophagus obstruction ......................... 1.19 0.39 0.39 0.05 1.63 1.63 XXX 

74235 .... TC .... C Remove esophagus obstruction ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74235 .... .......... C Remove esophagus obstruction ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74240 .... 26 ..... A X-ray exam, upper gi tract ................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74240 .... TC .... A X-ray exam, upper gi tract ................................. 0.00 1.46 NA 0.08 1.54 NA XXX 

74240 .... .......... A X-ray exam, upper gi tract ................................. 0.69 1.69 NA 0.11 2.49 NA XXX 

74241 .... 26 ..... A X-ray exam, upper gi tract ................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74241 .... TC .... A X-ray exam, upper gi tract ................................. 0.00 1.49 NA 0.08 1.57 NA XXX 

74241 .... .......... A X-ray exam, upper gi tract ................................. 0.69 1.72 NA 0.11 2.52 NA XXX 

74245 .... 26 ..... A X-ray exam, upper gi tract ................................. 0.91 0.30 0.30 0.04 1.25 1.25 XXX 

74245 .... TC .... A X-ray exam, upper gi tract ................................. 0.00 2.39 NA 0.13 2.52 NA XXX 

74245 .... .......... A X-ray exam, upper gi tract ................................. 0.91 2.69 NA 0.17 3.77 NA XXX 

70420 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

74246 .... 26 ..... A Contrst x-ray uppr gi tract .................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74246 .... TC .... A Contrst x-ray uppr gi tract .................................. 0.00 1.64 NA 0.10 1.74 NA XXX 

74246 .... .......... A Contrst x-ray uppr gi tract .................................. 0.69 1.87 NA 0.13 2.69 NA XXX 

74247 .... 26 ..... A Contrst x-ray uppr gi tract .................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74247 .... TC .... A Contrst x-ray uppr gi tract .................................. 0.00 1.68 NA 0.11 1.79 NA XXX 

74247 .... .......... A Contrst x-ray uppr gi tract .................................. 0.69 1.91 NA 0.14 2.74 NA XXX 

74249 .... 26 ..... A Contrst x-ray uppr gi tract .................................. 0.91 0.30 0.30 0.04 1.25 1.25 XXX 

74249 .... TC .... A Contrst x-ray uppr gi tract .................................. 0.00 2.58 NA 0.14 2.72 NA XXX 

74249 .... .......... A Contrst x-ray uppr gi tract .................................. 0.91 2.88 NA 0.18 3.97 NA XXX 

74250 .... 26 ..... A X-ray exam of small bowel ................................. 0.47 0.15 0.15 0.02 0.64 0.64 XXX 

74250 .... TC .... A X-ray exam of small bowel ................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

74250 .... .......... A X-ray exam of small bowel ................................. 0.47 1.46 NA 0.09 2.02 NA XXX 

74251 .... 26 ..... A X-ray exam of small bowel ................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74251 .... TC .... A X-ray exam of small bowel ................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

74251 .... .......... A X-ray exam of small bowel ................................. 0.69 1.54 NA 0.10 2.33 NA XXX 

74260 .... 26 ..... A X-ray exam of small bowel ................................. 0.50 0.16 0.16 0.02 0.68 0.68 XXX 

74260 .... TC .... A X-ray exam of small bowel ................................. 0.00 1.49 NA 0.08 1.57 NA XXX 

74260 .... .......... A X-ray exam of small bowel ................................. 0.50 1.65 NA 0.10 2.25 NA XXX 

74270 .... 26 ..... A Contrast x-ray exam of colon ............................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

74270 .... TC .... A Contrast x-ray exam of colon ............................. 0.00 1.70 NA 0.11 1.81 NA XXX 

74270 .... .......... A Contrast x-ray exam of colon ............................. 0.69 1.93 NA 0.14 2.76 NA XXX 

74280 .... 26 ..... A Contrast x-ray exam of colon ............................. 0.99 0.32 0.32 0.04 1.35 1.35 XXX 

74280 .... TC .... A Contrast x-ray exam of colon ............................. 0.00 2.24 NA 0.13 2.37 NA XXX 

74280 .... .......... A Contrast x-ray exam of colon ............................. 0.99 2.56 NA 0.17 3.72 NA XXX 

74283 .... 26 ..... A Contrast x-ray exam of colon ............................. 2.02 0.66 0.66 0.09 2.77 2.77 XXX 

74283 .... TC .... A Contrast x-ray exam of colon ............................. 0.00 2.57 NA 0.14 2.71 NA XXX 

74283 .... .......... A Contrast x-ray exam of colon ............................. 2.02 3.23 NA 0.23 5.48 NA XXX 

74290 .... 26 ..... A Contrast x-ray, gallbladder ................................. 0.32 0.10 0.10 0.01 0.43 0.43 XXX 

74290 .... TC .... A Contrast x-ray, gallbladder ................................. 0.00 0.73 NA 0.05 0.78 NA XXX 

74290 .... .......... A Contrast x-ray, gallbladder ................................. 0.32 0.83 NA 0.06 1.21 NA XXX 

74291 .... 26 ..... A Contrast x-rays, gallbladder ............................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

74291 .... TC .... A Contrast x-rays, gallbladder ............................... 0.00 0.42 NA 0.02 0.44 NA XXX 

74291 .... .......... A Contrast x-rays, gallbladder ............................... 0.20 0.49 NA 0.03 0.72 NA XXX 

74300 .... 26 ..... A X-ray bile ducts/pancreas ................................... 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

74300 .... TC .... C X-ray bile ducts/pancreas ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74300 .... .......... C X-ray bile ducts/pancreas ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74301 .... 26 ..... A X-rays at surgery add-on ................................... 0.21 0.07 0.07 0.01 0.29 0.29 ZZZ 

74301 .... TC .... C X-rays at surgery add-on ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

74301 .... .......... C X-rays at surgery add-on ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

74305 .... 26 ..... A X-ray bile ducts/pancreas ................................... 0.42 0.14 0.14 0.02 0.58 0.58 XXX 

74305 .... TC .... A X-ray bile ducts/pancreas ................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

74305 .... .......... A X-ray bile ducts/pancreas ................................... 0.42 0.92 NA 0.07 1.41 NA XXX 

74320 .... 26 ..... A Contrast x-ray of bile ducts ................................ 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

74320 .... TC .... A Contrast x-ray of bile ducts ................................ 0.00 3.16 NA 0.17 3.33 NA XXX 

74320 .... .......... A Contrast x-ray of bile ducts ................................ 0.54 3.34 NA 0.19 4.07 NA XXX 

74327 .... 26 ..... A X-ray bile stone removal .................................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

74327 .... TC .... A X-ray bile stone removal .................................... 0.00 1.77 NA 0.11 1.88 NA XXX 

74327 .... .......... A X-ray bile stone removal .................................... 0.70 2.00 NA 0.14 2.84 NA XXX 

74328 .... 26 ..... A X-ray bile duct endoscopy .................................. 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

74328 .... TC .... A X-ray bile duct endoscopy .................................. 0.00 3.16 NA 0.17 3.33 NA XXX 

74328 .... .......... A X-ray bile duct endoscopy .................................. 0.70 3.39 NA 0.20 4.29 NA XXX 

74329 .... 26 ..... A X-ray for pancreas endoscopy ........................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

74329 .... TC .... C X-ray for pancreas endoscopy ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74329 .... .......... C X-ray for pancreas endoscopy ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74330 .... 26 ..... A X-ray bile/panc endoscopy ................................. 0.90 0.29 0.29 0.04 1.23 1.23 XXX 

74330 .... TC .... A X-ray bile/panc endoscopy ................................. 0.00 3.16 NA 0.17 3.33 NA XXX 

74330 .... .......... A X-ray bile/panc endoscopy ................................. 0.90 3.45 NA 0.21 4.56 NA XXX 

74340 .... 26 ..... A X-ray guide for GI tube ...................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

74340 .... TC .... A X-ray guide for GI tube ...................................... 0.00 2.63 NA 0.14 2.77 NA XXX 

74340 .... .......... A X-ray guide for GI tube ...................................... 0.54 2.81 NA 0.16 3.51 NA XXX 

74350 .... 26 ..... A X-ray guide, stomach tube ................................. 0.76 0.25 0.25 0.03 1.04 1.04 XXX 

74350 .... TC .... A X-ray guide, stomach tube ................................. 0.00 3.16 NA 0.17 3.33 NA XXX 

74350 .... .......... A X-ray guide, stomach tube ................................. 0.76 3.41 NA 0.20 4.37 NA XXX 

74355 .... 26 ..... A X-ray guide, intestinal tube ................................ 0.76 0.25 0.25 0.03 1.04 1.04 XXX 

74355 .... TC .... A X-ray guide, intestinal tube ................................ 0.00 2.63 NA 0.14 2.77 NA XXX 

74355 .... .......... A X-ray guide, intestinal tube ................................ 0.76 2.88 NA 0.17 3.81 NA XXX 

74360 .... 26 ..... A X-ray guide, GI dilation ...................................... 0.54 0.19 0.19 0.02 0.75 0.75 XXX 

74360 .... TC .... A X-ray guide, GI dilation ...................................... 0.00 3.16 NA 0.17 3.33 NA XXX 

74360 .... .......... A X-ray guide, GI dilation ...................................... 0.54 3.35 NA 0.19 4.08 NA XXX 

74363 .... 26 ..... A X-ray, bile duct dilation ....................................... 0.88 0.29 0.29 0.04 1.21 1.21 XXX 

74363 .... TC .... C X-ray, bile duct dilation ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74363 .... .......... C X-ray, bile duct dilation ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74400 .... 26 ..... A Contrst x-ray, urinary tract ................................. 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

74400 .... TC .... A Contrst x-ray, urinary tract ................................. 0.00 1.68 NA 0.11 1.79 NA XXX 

74400 .... .......... A Contrst x-ray, urinary tract ................................. 0.49 1.84 NA 0.13 2.46 NA XXX 

70421 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

74410 .... 26 ..... A Contrst x-ray, urinary tract ................................. 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

74410 .... TC .... A Contrst x-ray, urinary tract ................................. 0.00 1.96 NA 0.11 2.07 NA XXX 

74410 .... .......... A Contrst x-ray, urinary tract ................................. 0.49 2.12 NA 0.13 2.74 NA XXX 

74415 .... 26 ..... A Contrst x-ray, urinary tract ................................. 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

74415 .... TC .... A Contrst x-ray, urinary tract ................................. 0.00 2.13 NA 0.12 2.25 NA XXX 

74415 .... .......... A Contrst x-ray, urinary tract ................................. 0.49 2.29 NA 0.14 2.92 NA XXX 

74420 .... 26 ..... A Contrst x-ray, urinary tract ................................. 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

74420 .... TC .... A Contrst x-ray, urinary tract ................................. 0.00 2.63 NA 0.14 2.77 NA XXX 

74420 .... .......... A Contrst x-ray, urinary tract ................................. 0.36 2.75 NA 0.16 3.27 NA XXX 

74425 .... 26 ..... A Contrst x-ray, urinary tract ................................. 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

74425 .... TC .... A Contrst x-ray, urinary tract ................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

74425 .... .......... A Contrst x-ray, urinary tract ................................. 0.36 1.43 NA 0.09 1.88 NA XXX 

74430 .... 26 ..... A Contrast x-ray, bladder ....................................... 0.32 0.10 0.10 0.02 0.44 0.44 XXX 

74430 .... TC .... A Contrast x-ray, bladder ....................................... 0.00 1.05 NA 0.06 1.11 NA XXX 

74430 .... .......... A Contrast x-ray, bladder ....................................... 0.32 1.15 NA 0.08 1.55 NA XXX 

74440 .... 26 ..... A X-ray, male genital tract ..................................... 0.38 0.12 0.12 0.02 0.52 0.52 XXX 

74440 .... TC .... A X-ray, male genital tract ..................................... 0.00 1.13 NA 0.06 1.19 NA XXX 

74440 .... .......... A X-ray, male genital tract ..................................... 0.38 1.25 NA 0.08 1.71 NA XXX 

74445 .... 26 ..... A X-ray exam of penis ........................................... 1.14 0.37 0.37 0.07 1.58 1.58 XXX 

74445 .... TC .... A X-ray exam of penis ........................................... 0.00 1.13 NA 0.06 1.19 NA XXX 

74445 .... .......... A X-ray exam of penis ........................................... 1.14 1.50 NA 0.13 2.77 NA XXX 

74450 .... 26 ..... A X-ray, urethra/bladder ........................................ 0.33 0.11 0.11 0.02 0.46 0.46 XXX 

74450 .... TC .... A X-ray, urethra/bladder ........................................ 0.00 1.46 NA 0.08 1.54 NA XXX 

74450 .... .......... A X-ray, urethra/bladder ........................................ 0.33 1.57 NA 0.10 2.00 NA XXX 

74455 .... 26 ..... A X-ray, urethra/bladder ........................................ 0.33 0.11 0.11 0.02 0.46 0.46 XXX 

74455 .... TC .... A X-ray, urethra/bladder ........................................ 0.00 1.58 NA 0.10 1.68 NA XXX 

74455 .... .......... A X-ray, urethra/bladder ........................................ 0.33 1.69 NA 0.12 2.14 NA XXX 

74470 .... 26 ..... A X-ray exam of kidney lesion ............................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

74470 .... TC .... A X-ray exam of kidney lesion ............................... 0.00 1.25 NA 0.07 1.32 NA XXX 

74470 .... .......... A X-ray exam of kidney lesion ............................... 0.54 1.43 NA 0.09 2.06 NA XXX 

74475 .... 26 ..... A X-ray control, cath insert .................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

74475 .... TC .... A X-ray control, cath insert .................................... 0.00 4.08 NA 0.22 4.30 NA XXX 

74475 .... .......... A X-ray control, cath insert .................................... 0.54 4.26 NA 0.24 5.04 NA XXX 

74480 .... 26 ..... A X-ray control, cath insert .................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

74480 .... TC .... A X-ray control, cath insert .................................... 0.00 4.08 NA 0.22 4.30 NA XXX 

74480 .... .......... A X-ray control, cath insert .................................... 0.54 4.26 NA 0.24 5.04 NA XXX 

74485 .... 26 ..... A X-ray guide, GU dilation ..................................... 0.54 0.17 0.17 0.03 0.74 0.74 XXX 

74485 .... TC .... A X-ray guide, GU dilation ..................................... 0.00 3.16 NA 0.17 3.33 NA XXX 

74485 .... .......... A X-ray guide, GU dilation ..................................... 0.54 3.33 NA 0.20 4.07 NA XXX 

74710 .... 26 ..... A X-ray measurement of pelvis ............................. 0.34 0.11 0.11 0.02 0.47 0.47 XXX 

74710 .... TC .... A X-ray measurement of pelvis ............................. 0.00 1.05 NA 0.06 1.11 NA XXX 

74710 .... .......... A X-ray measurement of pelvis ............................. 0.34 1.16 NA 0.08 1.58 NA XXX 

74740 .... 26 ..... A X-ray, female genital tract .................................. 0.38 0.13 0.13 0.02 0.53 0.53 XXX 

74740 .... TC .... A X-ray, female genital tract .................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

74740 .... .......... A X-ray, female genital tract .................................. 0.38 1.44 NA 0.09 1.91 NA XXX 

74742 .... 26 ..... A X-ray, fallopian tube ........................................... 0.61 0.20 0.20 0.03 0.84 0.84 XXX 

74742 .... TC .... C X-ray, fallopian tube ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74742 .... .......... C X-ray, fallopian tube ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

74775 .... 26 ..... A X-ray exam of perineum ..................................... 0.62 0.21 0.21 0.03 0.86 0.86 XXX 

74775 .... TC .... A X-ray exam of perineum ..................................... 0.00 1.46 NA 0.08 1.54 NA XXX 

74775 .... .......... A X-ray exam of perineum ..................................... 0.62 1.67 NA 0.11 2.40 NA XXX 

75552 .... 26 ..... A Heart mri for morph w/o dye .............................. 1.60 0.53 0.53 0.07 2.20 2.20 XXX 

75552 .... TC .... A Heart mri for morph w/o dye .............................. 0.00 11.23 NA 0.59 11.82 NA XXX 

75552 .... .......... A Heart mri for morph w/o dye .............................. 1.60 11.76 NA 0.66 14.02 NA XXX 

75553 .... 26 ..... A Heart mri for morph w/dye ................................. 2.00 0.65 0.65 0.07 2.72 2.72 XXX 

75553 .... TC .... A Heart mri for morph w/dye ................................. 0.00 11.23 NA 0.59 11.82 NA XXX 

75553 .... .......... A Heart mri for morph w/dye ................................. 2.00 11.88 NA 0.66 14.54 NA XXX 

75554 .... 26 ..... A Cardiac MRI/function .......................................... 1.83 0.64 0.64 0.07 2.54 2.54 XXX 

75554 .... TC .... A Cardiac MRI/function .......................................... 0.00 11.23 NA 0.59 11.82 NA XXX 

75554 .... .......... A Cardiac MRI/function .......................................... 1.83 11.87 NA 0.66 14.36 NA XXX 

75555 .... 26 ..... A Cardiac MRI/limited study .................................. 1.74 0.64 0.64 0.07 2.45 2.45 XXX 

75555 .... TC .... A Cardiac MRI/limited study .................................. 0.00 11.23 NA 0.59 11.82 NA XXX 

75555 .... .......... A Cardiac MRI/limited study .................................. 1.74 11.87 NA 0.66 14.27 NA XXX 

75556 .... .......... N Cardiac MRI/flow mapping ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75600 .... 26 ..... A Contrast x-ray exam of aorta ............................. 0.49 0.19 0.19 0.02 0.70 0.70 XXX 

75600 .... TC .... A Contrast x-ray exam of aorta ............................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75600 .... .......... A Contrast x-ray exam of aorta ............................. 0.49 12.83 NA 0.67 13.99 NA XXX 

75605 .... 26 ..... A Contrast x-ray exam of aorta ............................. 1.14 0.40 0.40 0.05 1.59 1.59 XXX 

75605 .... TC .... A Contrast x-ray exam of aorta ............................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75605 .... .......... A Contrast x-ray exam of aorta ............................. 1.14 13.04 NA 0.70 14.88 NA XXX 

75625 .... 26 ..... A Contrast x-ray exam of aorta ............................. 1.14 0.38 0.38 0.06 1.58 1.58 XXX 

75625 .... TC .... A Contrast x-ray exam of aorta ............................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75625 .... .......... A Contrast x-ray exam of aorta ............................. 1.14 13.02 NA 0.71 14.87 NA XXX 

75630 .... 26 ..... A X-ray aorta, leg arteries ..................................... 1.79 0.61 0.61 0.11 2.51 2.51 XXX 

75630 .... TC .... A X-ray aorta, leg arteries ..................................... 0.00 13.17 NA 0.69 13.86 NA XXX 

70422 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

75630 .... .......... A X-ray aorta, leg arteries ..................................... 1.79 13.78 NA 0.80 16.37 NA XXX 

75635 .... 26 ..... A Ct angio abdominal arteries ............................... 2.40 0.79 0.79 0.11 3.30 3.30 XXX 

75635 .... TC .... A Ct angio abdominal arteries ............................... 0.00 15.96 NA 0.39 16.35 NA XXX 

75635 .... .......... A Ct angio abdominal arteries ............................... 2.40 16.75 NA 0.50 19.65 NA XXX 

75650 .... 26 ..... A Artery x-rays, head & neck ................................ 1.49 0.49 0.49 0.07 2.05 2.05 XXX 

75650 .... TC .... A Artery x-rays, head & neck ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75650 .... .......... A Artery x-rays, head & neck ................................ 1.49 13.13 NA 0.72 15.34 NA XXX 

75658 .... 26 ..... A Artery x-rays, arm ............................................... 1.31 0.47 0.47 0.07 1.85 1.85 XXX 

75658 .... TC .... A Artery x-rays, arm ............................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75658 .... .......... A Artery x-rays, arm ............................................... 1.31 13.11 NA 0.72 15.14 NA XXX 

75660 .... 26 ..... A Artery x-rays, head & neck ................................ 1.31 0.44 0.44 0.06 1.81 1.81 XXX 

75660 .... TC .... A Artery x-rays, head & neck ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75660 .... .......... A Artery x-rays, head & neck ................................ 1.31 13.08 NA 0.71 15.10 NA XXX 

75662 .... 26 ..... A Artery x-rays, head & neck ................................ 1.66 0.59 0.59 0.06 2.31 2.31 XXX 

75662 .... TC .... A Artery x-rays, head & neck ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75662 .... .......... A Artery x-rays, head & neck ................................ 1.66 13.23 NA 0.71 15.60 NA XXX 

75665 .... 26 ..... A Artery x-rays, head & neck ................................ 1.31 0.44 0.44 0.09 1.84 1.84 XXX 

75665 .... TC .... A Artery x-rays, head & neck ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75665 .... .......... A Artery x-rays, head & neck ................................ 1.31 13.08 NA 0.74 15.13 NA XXX 

75671 .... 26 ..... A Artery x-rays, head & neck ................................ 1.66 0.55 0.55 0.07 2.28 2.28 XXX 

75671 .... TC .... A Artery x-rays, head & neck ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75671 .... .......... A Artery x-rays, head & neck ................................ 1.66 13.19 NA 0.72 15.57 NA XXX 

75676 .... 26 ..... A Artery x-rays, neck ............................................. 1.31 0.44 0.44 0.07 1.82 1.82 XXX 

75676 .... TC .... A Artery x-rays, neck ............................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75676 .... .......... A Artery x-rays, neck ............................................. 1.31 13.08 NA 0.72 15.11 NA XXX 

75680 .... 26 ..... A Artery x-rays, neck ............................................. 1.66 0.55 0.55 0.07 2.28 2.28 XXX 

75680 .... TC .... A Artery x-rays, neck ............................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75680 .... .......... A Artery x-rays, neck ............................................. 1.66 13.19 NA 0.72 15.57 NA XXX 

75685 .... 26 ..... A Artery x-rays, spine ............................................ 1.31 0.43 0.43 0.06 1.80 1.80 XXX 

75685 .... TC .... A Artery x-rays, spine ............................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75685 .... .......... A Artery x-rays, spine ............................................ 1.31 13.07 NA 0.71 15.09 NA XXX 

75705 .... 26 ..... A Artery x-rays, spine ............................................ 2.18 0.73 0.73 0.13 3.04 3.04 XXX 

75705 .... TC .... A Artery x-rays, spine ............................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75705 .... .......... A Artery x-rays, spine ............................................ 2.18 13.37 NA 0.78 16.33 NA XXX 

75710 .... 26 ..... A Artery x-rays, arm/leg ......................................... 1.14 0.39 0.39 0.07 1.60 1.60 XXX 

75710 .... TC .... A Artery x-rays, arm/leg ......................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75710 .... .......... A Artery x-rays, arm/leg ......................................... 1.14 13.03 NA 0.72 14.89 NA XXX 

75716 .... 26 ..... A Artery x-rays, arms/legs ..................................... 1.31 0.43 0.43 0.07 1.81 1.81 XXX 

75716 .... TC .... A Artery x-rays, arms/legs ..................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75716 .... .......... A Artery x-rays, arms/legs ..................................... 1.31 13.07 NA 0.72 15.10 NA XXX 

75722 .... 26 ..... A Artery x-rays, kidney .......................................... 1.14 0.40 0.40 0.05 1.59 1.59 XXX 

75722 .... TC .... A Artery x-rays, kidney .......................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75722 .... .......... A Artery x-rays, kidney .......................................... 1.14 13.04 NA 0.70 14.88 NA XXX 

75724 .... 26 ..... A Artery x-rays, kidneys ......................................... 1.49 0.56 0.56 0.05 2.10 2.10 XXX 

75724 .... TC .... A Artery x-rays, kidneys ......................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75724 .... .......... A Artery x-rays, kidneys ......................................... 1.49 13.20 NA 0.70 15.39 NA XXX 

75726 .... 26 ..... A Artery x-rays, abdomen ...................................... 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

75726 .... TC .... A Artery x-rays, abdomen ...................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75726 .... .......... A Artery x-rays, abdomen ...................................... 1.14 13.01 NA 0.70 14.85 NA XXX 

75731 .... 26 ..... A Artery x-rays, adrenal gland ............................... 1.14 0.37 0.37 0.06 1.57 1.57 XXX 

75731 .... TC .... A Artery x-rays, adrenal gland ............................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75731 .... .......... A Artery x-rays, adrenal gland ............................... 1.14 13.01 NA 0.71 14.86 NA XXX 

75733 .... 26 ..... A Artery x-rays, adrenals ....................................... 1.31 0.44 0.44 0.06 1.81 1.81 XXX 

75733 .... TC .... A Artery x-rays, adrenals ....................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75733 .... .......... A Artery x-rays, adrenals ....................................... 1.31 13.08 NA 0.71 15.10 NA XXX 

75736 .... 26 ..... A Artery x-rays, pelvis ............................................ 1.14 0.38 0.38 0.06 1.58 1.58 XXX 

75736 .... TC .... A Artery x-rays, pelvis ............................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75736 .... .......... A Artery x-rays, pelvis ............................................ 1.14 13.02 NA 0.71 14.87 NA XXX 

75741 .... 26 ..... A Artery x-rays, lung .............................................. 1.31 0.43 0.43 0.06 1.80 1.80 XXX 

75741 .... TC .... A Artery x-rays, lung .............................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75741 .... .......... A Artery x-rays, lung .............................................. 1.31 13.07 NA 0.71 15.09 NA XXX 

75743 .... 26 ..... A Artery x-rays, lungs ............................................ 1.66 0.54 0.54 0.07 2.27 2.27 XXX 

75743 .... TC .... A Artery x-rays, lungs ............................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75743 .... .......... A Artery x-rays, lungs ............................................ 1.66 13.18 NA 0.72 15.56 NA XXX 

75746 .... 26 ..... A Artery x-rays, lung .............................................. 1.14 0.38 0.38 0.05 1.57 1.57 XXX 

75746 .... TC .... A Artery x-rays, lung .............................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75746 .... .......... A Artery x-rays, lung .............................................. 1.14 13.02 NA 0.70 14.86 NA XXX 

75756 .... 26 ..... A Artery x-rays, chest ............................................ 1.14 0.45 0.45 0.04 1.63 1.63 XXX 

75756 .... TC .... A Artery x-rays, chest ............................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75756 .... .......... A Artery x-rays, chest ............................................ 1.14 13.09 NA 0.69 14.92 NA XXX 

75774 .... 26 ..... A Artery x-ray, each vessel ................................... 0.36 0.12 0.12 0.02 0.50 0.50 ZZZ 

75774 .... TC .... A Artery x-ray, each vessel ................................... 0.00 12.64 NA 0.65 13.29 NA ZZZ 

75774 .... .......... A Artery x-ray, each vessel ................................... 0.36 12.76 NA 0.67 13.79 NA ZZZ 

75790 .... 26 ..... A Visualize A-V shunt ............................................ 1.84 0.60 0.60 0.09 2.53 2.53 XXX 

75790 .... TC .... A Visualize A-V shunt ............................................ 0.00 1.35 NA 0.08 1.43 NA XXX 

70423 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

75790 .... .......... A Visualize A-V shunt ............................................ 1.84 1.95 NA 0.17 3.96 NA XXX 

75801 .... 26 ..... A Lymph vessel x-ray, arm/leg .............................. 0.81 0.27 0.27 0.08 1.16 1.16 XXX 

75801 .... TC .... A Lymph vessel x-ray, arm/leg .............................. 0.00 5.43 NA 0.29 5.72 NA XXX 

75801 .... .......... A Lymph vessel x-ray, arm/leg .............................. 0.81 5.70 NA 0.37 6.88 NA XXX 

75803 .... 26 ..... A Lymph vessel x-ray,arms/legs ............................ 1.17 0.38 0.38 0.05 1.60 1.60 XXX 

75803 .... TC .... A Lymph vessel x-ray,arms/legs ............................ 0.00 5.43 NA 0.29 5.72 NA XXX 

75803 .... .......... A Lymph vessel x-ray,arms/legs ............................ 1.17 5.81 NA 0.34 7.32 NA XXX 

75805 .... 26 ..... A Lymph vessel x-ray, trunk .................................. 0.81 0.27 0.27 0.05 1.13 1.13 XXX 

75805 .... TC .... A Lymph vessel x-ray, trunk .................................. 0.00 6.12 NA 0.33 6.45 NA XXX 

75805 .... .......... A Lymph vessel x-ray, trunk .................................. 0.81 6.39 NA 0.38 7.58 NA XXX 

75807 .... 26 ..... A Lymph vessel x-ray, trunk .................................. 1.17 0.38 0.38 0.05 1.60 1.60 XXX 

75807 .... TC .... C Lymph vessel x-ray, trunk .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75807 .... .......... C Lymph vessel x-ray, trunk .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75809 .... 26 ..... A Nonvascular shunt, x-ray ................................... 0.47 0.15 0.15 0.02 0.64 0.64 XXX 

75809 .... TC .... A Nonvascular shunt, x-ray ................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

75809 .... .......... A Nonvascular shunt, x-ray ................................... 0.47 0.93 NA 0.07 1.47 NA XXX 

75810 .... 26 ..... A Vein x-ray, spleen/liver ....................................... 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

75810 .... TC .... A Vein x-ray, spleen/liver ....................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75810 .... .......... A Vein x-ray, spleen/liver ....................................... 1.14 13.01 NA 0.70 14.85 NA XXX 

75820 .... 26 ..... A Vein x-ray, arm/leg ............................................. 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

75820 .... TC .... A Vein x-ray, arm/leg ............................................. 0.00 0.95 NA 0.06 1.01 NA XXX 

75820 .... .......... A Vein x-ray, arm/leg ............................................. 0.70 1.18 NA 0.09 1.97 NA XXX 

75822 .... 26 ..... A Vein x-ray, arms/legs ......................................... 1.06 0.35 0.35 0.05 1.46 1.46 XXX 

75822 .... TC .... A Vein x-ray, arms/legs ......................................... 0.00 1.48 NA 0.08 1.56 NA XXX 

75822 .... .......... A Vein x-ray, arms/legs ......................................... 1.06 1.83 NA 0.13 3.02 NA XXX 

75825 .... 26 ..... A Vein x-ray, trunk ................................................. 1.14 0.37 0.37 0.07 1.58 1.58 XXX 

75825 .... TC .... A Vein x-ray, trunk ................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75825 .... .......... A Vein x-ray, trunk ................................................. 1.14 13.01 NA 0.72 14.87 NA XXX 

75827 .... 26 ..... A Vein x-ray, chest ................................................ 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

75827 .... TC .... A Vein x-ray, chest ................................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75827 .... .......... A Vein x-ray, chest ................................................ 1.14 13.01 NA 0.70 14.85 NA XXX 

75831 .... 26 ..... A Vein x-ray, kidney ............................................... 1.14 0.37 0.37 0.06 1.57 1.57 XXX 

75831 .... TC .... A Vein x-ray, kidney ............................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75831 .... .......... A Vein x-ray, kidney ............................................... 1.14 13.01 NA 0.71 14.86 NA XXX 

75833 .... 26 ..... A Vein x-ray, kidneys ............................................. 1.49 0.49 0.49 0.09 2.07 2.07 XXX 

75833 .... TC .... A Vein x-ray, kidneys ............................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75833 .... .......... A Vein x-ray, kidneys ............................................. 1.49 13.13 NA 0.74 15.36 NA XXX 

75840 .... 26 ..... A Vein x-ray, adrenal gland ................................... 1.14 0.38 0.38 0.07 1.59 1.59 XXX 

75840 .... TC .... A Vein x-ray, adrenal gland ................................... 0.00 12.64 NA 0.65 13.29 NA XXX 

75840 .... .......... A Vein x-ray, adrenal gland ................................... 1.14 13.02 NA 0.72 14.88 NA XXX 

75842 .... 26 ..... A Vein x-ray, adrenal glands ................................. 1.49 0.48 0.48 0.07 2.04 2.04 XXX 

75842 .... TC .... A Vein x-ray, adrenal glands ................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75842 .... .......... A Vein x-ray, adrenal glands ................................. 1.49 13.12 NA 0.72 15.33 NA XXX 

75860 .... 26 ..... A Vein x-ray, neck ................................................. 1.14 0.39 0.39 0.04 1.57 1.57 XXX 

75860 .... TC .... A Vein x-ray, neck ................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75860 .... .......... A Vein x-ray, neck ................................................. 1.14 13.03 NA 0.69 14.86 NA XXX 

75870 .... 26 ..... A Vein x-ray, skull .................................................. 1.14 0.39 0.39 0.05 1.58 1.58 XXX 

75870 .... TC .... A Vein x-ray, skull .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75870 .... .......... A Vein x-ray, skull .................................................. 1.14 13.03 NA 0.70 14.87 NA XXX 

75872 .... 26 ..... A Vein x-ray, skull .................................................. 1.14 0.37 0.37 0.14 1.65 1.65 XXX 

75872 .... TC .... A Vein x-ray, skull .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75872 .... .......... A Vein x-ray, skull .................................................. 1.14 13.01 NA 0.79 14.94 NA XXX 

75880 .... 26 ..... A Vein x-ray, eye socket ........................................ 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

75880 .... TC .... A Vein x-ray, eye socket ........................................ 0.00 0.95 NA 0.06 1.01 NA XXX 

75880 .... .......... A Vein x-ray, eye socket ........................................ 0.70 1.18 NA 0.09 1.97 NA XXX 

75885 .... 26 ..... A Vein x-ray, liver .................................................. 1.44 0.47 0.47 0.06 1.97 1.97 XXX 

75885 .... TC .... A Vein x-ray, liver .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75885 .... .......... A Vein x-ray, liver .................................................. 1.44 13.11 NA 0.71 15.26 NA XXX 

75887 .... 26 ..... A Vein x-ray, liver .................................................. 1.44 0.47 0.47 0.06 1.97 1.97 XXX 

75887 .... TC .... A Vein x-ray, liver .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75887 .... .......... A Vein x-ray, liver .................................................. 1.44 13.11 NA 0.71 15.26 NA XXX 

75889 .... 26 ..... A Vein x-ray, liver .................................................. 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

75889 .... TC .... A Vein x-ray, liver .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75889 .... .......... A Vein x-ray, liver .................................................. 1.14 13.01 NA 0.70 14.85 NA XXX 

75891 .... 26 ..... A Vein x-ray, liver .................................................. 1.14 0.37 0.37 0.05 1.56 1.56 XXX 

75891 .... TC .... A Vein x-ray, liver .................................................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75891 .... .......... A Vein x-ray, liver .................................................. 1.14 13.01 NA 0.70 14.85 NA XXX 

75893 .... 26 ..... A Venous sampling by catheter ............................. 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

75893 .... TC .... A Venous sampling by catheter ............................. 0.00 12.64 NA 0.65 13.29 NA XXX 

75893 .... .......... A Venous sampling by catheter ............................. 0.54 12.82 NA 0.67 14.03 NA XXX 

75894 .... 26 ..... A X-rays, transcath therapy ................................... 1.31 0.43 0.43 0.08 1.82 1.82 XXX 

75894 .... TC .... A X-rays, transcath therapy ................................... 0.00 24.20 NA 1.27 25.47 NA XXX 

75894 .... .......... A X-rays, transcath therapy ................................... 1.31 24.63 NA 1.35 27.29 NA XXX 

75896 .... 26 ..... A X-rays, transcath therapy ................................... 1.31 0.45 0.45 0.05 1.81 1.81 XXX 

75896 .... TC .... A X-rays, transcath therapy ................................... 0.00 21.05 NA 1.10 22.15 NA XXX 

70424 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

75896 .... .......... A X-rays, transcath therapy ................................... 1.31 21.50 NA 1.15 23.96 NA XXX 

75898 .... 26 ..... A Follow-up angiography ....................................... 1.65 0.55 0.55 0.07 2.27 2.27 XXX 

75898 .... TC .... A Follow-up angiography ....................................... 0.00 1.05 NA 0.06 1.11 NA XXX 

75898 .... .......... A Follow-up angiography ....................................... 1.65 1.60 NA 0.13 3.38 NA XXX 

75900 .... 26 ..... A Intravascular cath exchange .............................. 0.49 0.16 0.16 0.03 0.68 0.68 XXX 

75900 .... TC .... C Intravascular cath exchange .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75900 .... .......... C Intravascular cath exchange .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75901 .... 26 ..... A Remove cva device obstruct .............................. 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

75901 .... TC .... A Remove cva device obstruct .............................. 0.00 1.31 NA 0.83 2.14 NA XXX 

75901 .... .......... A Remove cva device obstruct .............................. 0.49 1.47 NA 0.85 2.81 NA XXX 

75902 .... 26 ..... A Remove cva lumen obstruct .............................. 0.39 0.13 0.13 0.02 0.54 0.54 XXX 

75902 .... TC .... A Remove cva lumen obstruct .............................. 0.00 1.31 NA 0.83 2.14 NA XXX 

75902 .... .......... A Remove cva lumen obstruct .............................. 0.39 1.44 NA 0.85 2.68 NA XXX 

75940 .... 26 ..... A X-ray placement, vein filter ................................ 0.54 0.18 0.18 0.04 0.76 0.76 XXX 

75940 .... TC .... A X-ray placement, vein filter ................................ 0.00 12.64 NA 0.65 13.29 NA XXX 

75940 .... .......... A X-ray placement, vein filter ................................ 0.54 12.82 NA 0.69 14.05 NA XXX 

75945 .... 26 ..... A Intravascular us .................................................. 0.40 0.14 0.14 0.04 0.58 0.58 XXX 

75945 .... TC .... A Intravascular us .................................................. 0.00 4.57 NA 0.24 4.81 NA XXX 

75945 .... .......... A Intravascular us .................................................. 0.40 4.71 NA 0.28 5.39 NA XXX 

75946 .... 26 ..... A Intravascular us add-on ...................................... 0.40 0.14 0.14 0.05 0.59 0.59 ZZZ 

75946 .... TC .... C Intravascular us add-on ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75946 .... .......... C Intravascular us add-on ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75952 .... 26 ..... A Endovasc repair abdom aorta ............................ 4.49 1.49 1.49 0.43 6.41 6.41 XXX 

75952 .... TC .... C Endovasc repair abdom aorta ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75952 .... .......... C Endovasc repair abdom aorta ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75953 .... 26 ..... A Abdom aneurysm endovas rpr ........................... 1.36 0.45 0.45 0.13 1.94 1.94 XXX 

75953 .... TC .... C Abdom aneurysm endovas rpr ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75953 .... .......... C Abdom aneurysm endovas rpr ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75954 .... 26 ..... A Iliac aneurysm endovas rpr ................................ 2.25 0.78 0.78 0.15 3.18 3.18 XXX 

75954 .... TC .... C Iliac aneurysm endovas rpr ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75954 .... .......... C Iliac aneurysm endovas rpr ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75956 .... 26 ..... A Xray, endovasc thor ao repr .............................. 7.00 2.71 2.71 0.69 10.40 10.40 XXX 

75956 .... TC .... C Xray, endovasc thor ao repr .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75956 .... .......... C Xray, endovasc thor ao repr .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75957 .... 26 ..... A Xray, endovasc thor ao repr .............................. 6.00 2.32 2.32 0.59 8.91 8.91 XXX 

75957 .... TC .... C Xray, endovasc thor ao repr .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75957 .... .......... C Xray, endovasc thor ao repr .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75958 .... 26 ..... A Xray, place prox ext thor ao ............................... 4.00 1.55 1.55 0.39 5.94 5.94 XXX 

75958 .... TC .... C Xray, place prox ext thor ao ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75958 .... .......... C Xray, place prox ext thor ao ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75959 .... 26 ..... A Xray, place dist ext thor ao ................................ 3.50 1.36 1.36 0.34 5.20 5.20 XXX 

75959 .... TC .... C Xray, place dist ext thor ao ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75959 .... .......... C Xray, place dist ext thor ao ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75960 .... 26 ..... A Transcath iv stent rs&i ....................................... 0.82 0.28 0.28 0.05 1.15 1.15 XXX 

75960 .... TC .... A Transcath iv stent rs&i ....................................... 0.00 14.94 NA 0.77 15.71 NA XXX 

75960 .... .......... A Transcath iv stent rs&i ....................................... 0.82 15.22 NA 0.82 16.86 NA XXX 

75961 .... 26 ..... A Retrieval, broken catheter .................................. 4.24 1.39 1.39 0.18 5.81 5.81 XXX 

75961 .... TC .... A Retrieval, broken catheter .................................. 0.00 10.53 NA 0.55 11.08 NA XXX 

75961 .... .......... A Retrieval, broken catheter .................................. 4.24 11.92 NA 0.73 16.89 NA XXX 

75962 .... 26 ..... A Repair arterial blockage ..................................... 0.54 0.18 0.18 0.03 0.75 0.75 XXX 

75962 .... TC .... A Repair arterial blockage ..................................... 0.00 15.79 NA 0.83 16.62 NA XXX 

75962 .... .......... A Repair arterial blockage ..................................... 0.54 15.97 NA 0.86 17.37 NA XXX 

75964 .... 26 ..... A Repair artery blockage, each ............................. 0.36 0.12 0.12 0.03 0.51 0.51 ZZZ 

75964 .... TC .... A Repair artery blockage, each ............................. 0.00 8.41 NA 0.43 8.84 NA ZZZ 

75964 .... .......... A Repair artery blockage, each ............................. 0.36 8.53 NA 0.46 9.35 NA ZZZ 

75966 .... 26 ..... A Repair arterial blockage ..................................... 1.31 0.46 0.46 0.06 1.83 1.83 XXX 

75966 .... TC .... A Repair arterial blockage ..................................... 0.00 15.79 NA 0.83 16.62 NA XXX 

75966 .... .......... A Repair arterial blockage ..................................... 1.31 16.25 NA 0.89 18.45 NA XXX 

75968 .... 26 ..... A Repair artery blockage, each ............................. 0.36 0.13 0.13 0.02 0.51 0.51 ZZZ 

75968 .... TC .... A Repair artery blockage, each ............................. 0.00 8.41 NA 0.43 8.84 NA ZZZ 

75968 .... .......... A Repair artery blockage, each ............................. 0.36 8.54 NA 0.45 9.35 NA ZZZ 

75970 .... 26 ..... A Vascular biopsy .................................................. 0.83 0.28 0.28 0.04 1.15 1.15 XXX 

75970 .... TC .... A Vascular biopsy .................................................. 0.00 11.57 NA 0.60 12.17 NA XXX 

75970 .... .......... A Vascular biopsy .................................................. 0.83 11.85 NA 0.64 13.32 NA XXX 

75978 .... 26 ..... A Repair venous blockage ..................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

75978 .... TC .... A Repair venous blockage ..................................... 0.00 15.79 NA 0.83 16.62 NA XXX 

75978 .... .......... A Repair venous blockage ..................................... 0.54 15.97 NA 0.85 17.36 NA XXX 

75980 .... 26 ..... A Contrast xray exam bile duct ............................. 1.44 0.47 0.47 0.06 1.97 1.97 XXX 

75980 .... TC .... A Contrast xray exam bile duct ............................. 0.00 5.43 NA 0.29 5.72 NA XXX 

75980 .... .......... A Contrast xray exam bile duct ............................. 1.44 5.90 NA 0.35 7.69 NA XXX 

75982 .... 26 ..... A Contrast xray exam bile duct ............................. 1.44 0.47 0.47 0.06 1.97 1.97 XXX 

75982 .... TC .... C Contrast xray exam bile duct ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75982 .... .......... C Contrast xray exam bile duct ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75984 .... 26 ..... A Xray control catheter change ............................. 0.72 0.23 0.23 0.03 0.98 0.98 XXX 

75984 .... TC .... A Xray control catheter change ............................. 0.00 1.96 NA 0.11 2.07 NA XXX 

70425 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

75984 .... .......... A Xray control catheter change ............................. 0.72 2.19 NA 0.14 3.05 NA XXX 

75989 .... 26 ..... A Abscess drainage under x-ray ........................... 1.19 0.39 0.39 0.05 1.63 1.63 XXX 

75989 .... TC .... A Abscess drainage under x-ray ........................... 0.00 3.16 NA 0.17 3.33 NA XXX 

75989 .... .......... A Abscess drainage under x-ray ........................... 1.19 3.55 NA 0.22 4.96 NA XXX 

75992 .... 26 ..... A Atherectomy, x-ray exam ................................... 0.54 0.19 0.19 0.03 0.76 0.76 XXX 

75992 .... TC .... A Atherectomy, x-ray exam ................................... 0.00 15.79 NA 0.83 16.62 NA XXX 

75992 .... .......... A Atherectomy, x-ray exam ................................... 0.54 15.98 NA 0.86 17.38 NA XXX 

75993 .... 26 ..... A Atherectomy, x-ray exam ................................... 0.36 0.13 0.13 0.02 0.51 0.51 ZZZ 

75993 .... TC .... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75993 .... .......... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75994 .... 26 ..... A Atherectomy, x-ray exam ................................... 1.31 0.46 0.46 0.07 1.84 1.84 XXX 

75994 .... TC .... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75994 .... .......... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75995 .... 26 ..... A Atherectomy, x-ray exam ................................... 1.31 0.47 0.47 0.05 1.83 1.83 XXX 

75995 .... TC .... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75995 .... .......... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

75996 .... 26 ..... A Atherectomy, x-ray exam ................................... 0.36 0.12 0.12 0.02 0.50 0.50 ZZZ 

75996 .... TC .... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75996 .... .......... C Atherectomy, x-ray exam ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

75998 .... 26 ..... A Fluoroguide for vein device ................................ 0.38 0.13 0.13 0.01 0.52 0.52 ZZZ 

75998 .... TC .... A Fluoroguide for vein device ................................ 0.00 1.31 NA 0.10 1.41 NA ZZZ 

75998 .... .......... A Fluoroguide for vein device ................................ 0.38 1.44 NA 0.11 1.93 NA ZZZ 

76000 .... 26 ..... A Fluoroscope examination ................................... 0.17 0.05 0.05 0.01 0.23 0.23 XXX 

76000 .... TC .... A Fluoroscope examination ................................... 0.00 1.31 NA 0.07 1.38 NA XXX 

76000 .... .......... A Fluoroscope examination ................................... 0.17 1.36 NA 0.08 1.61 NA XXX 

76001 .... 26 ..... A Fluoroscope exam, extensive ............................ 0.67 0.22 0.22 0.05 0.94 0.94 XXX 

76001 .... TC .... A Fluoroscope exam, extensive ............................ 0.00 2.63 NA 0.14 2.77 NA XXX 

76001 .... .......... A Fluoroscope exam, extensive ............................ 0.67 2.85 NA 0.19 3.71 NA XXX 

76003 .... 26 ..... A Needle localization by x-ray ............................... 0.54 0.17 0.17 0.02 0.73 0.73 XXX 

76003 .... TC .... A Needle localization by x-ray ............................... 0.00 1.31 NA 0.07 1.38 NA XXX 

76003 .... .......... A Needle localization by x-ray ............................... 0.54 1.48 NA 0.09 2.11 NA XXX 

76005 .... 26 ..... A Fluoroguide for spine inject ................................ 0.60 0.15 0.15 0.03 0.78 0.78 XXX 

76005 .... TC .... A Fluoroguide for spine inject ................................ 0.00 1.31 NA 0.07 1.38 NA XXX 

76005 .... .......... A Fluoroguide for spine inject ................................ 0.60 1.46 NA 0.10 2.16 NA XXX 

76006 .... .......... A X-ray stress view ................................................ 0.41 0.18 0.18 0.06 0.65 0.65 XXX 

76010 .... 26 ..... A X-ray, nose to rectum ......................................... 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

76010 .... TC .... A X-ray, nose to rectum ......................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

76010 .... .......... A X-ray, nose to rectum ......................................... 0.18 0.58 NA 0.03 0.79 NA XXX 

76012 .... 26 ..... A Percut vertebroplasty fluor ................................. 1.31 0.47 0.47 0.10 1.88 1.88 XXX 

76012 .... TC .... C Percut vertebroplasty fluor ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76012 .... .......... C Percut vertebroplasty fluor ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76013 .... 26 ..... A Percut vertebroplasty, ct .................................... 1.38 0.48 0.48 0.07 1.93 1.93 XXX 

76013 .... TC .... C Percut vertebroplasty, ct .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76013 .... .......... C Percut vertebroplasty, ct .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76020 .... 26 ..... A X-rays for bone age ........................................... 0.19 0.06 0.06 0.01 0.26 0.26 XXX 

76020 .... TC .... A X-rays for bone age ........................................... 0.00 0.52 NA 0.02 0.54 NA XXX 

76020 .... .......... A X-rays for bone age ........................................... 0.19 0.58 NA 0.03 0.80 NA XXX 

76040 .... 26 ..... A X-rays, bone evaluation ..................................... 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

76040 .... TC .... A X-rays, bone evaluation ..................................... 0.00 0.78 NA 0.05 0.83 NA XXX 

76040 .... .......... A X-rays, bone evaluation ..................................... 0.27 0.87 NA 0.06 1.20 NA XXX 

76061 .... 26 ..... A X-rays, bone survey ........................................... 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

76061 .... TC .... A X-rays, bone survey ........................................... 0.00 1.00 NA 0.06 1.06 NA XXX 

76061 .... .......... A X-rays, bone survey ........................................... 0.45 1.15 NA 0.08 1.68 NA XXX 

76062 .... 26 ..... A X-rays, bone survey ........................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

76062 .... TC .... A X-rays, bone survey ........................................... 0.00 1.44 NA 0.08 1.52 NA XXX 

76062 .... .......... A X-rays, bone survey ........................................... 0.54 1.62 NA 0.10 2.26 NA XXX 

76065 .... 26 ..... A X-rays, bone evaluation ..................................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

76065 .... TC .... A X-rays, bone evaluation ..................................... 0.00 0.73 NA 0.05 0.78 NA XXX 

76065 .... .......... A X-rays, bone evaluation ..................................... 0.70 0.96 NA 0.08 1.74 NA XXX 

76066 .... 26 ..... A Joint survey, single view .................................... 0.31 0.10 0.10 0.02 0.43 0.43 XXX 

76066 .... TC .... A Joint survey, single view .................................... 0.00 1.11 NA 0.06 1.17 NA XXX 

76066 .... .......... A Joint survey, single view .................................... 0.31 1.21 NA 0.08 1.60 NA XXX 

76070 .... 26 ..... A Ct bone density, axial ......................................... 0.25 0.08 0.08 0.01 0.34 0.34 XXX 

76070 .... TC .... A Ct bone density, axial ......................................... 0.00 2.96 NA 0.16 3.12 NA XXX 

76070 .... .......... A Ct bone density, axial ......................................... 0.25 3.04 NA 0.17 3.46 NA XXX 

76071 .... 26 ..... A Ct bone density, peripheral ................................ 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

76071 .... TC .... A Ct bone density, peripheral ................................ 0.00 2.96 NA 0.05 3.01 NA XXX 

76071 .... .......... A Ct bone density, peripheral ................................ 0.22 3.03 NA 0.06 3.31 NA XXX 

76075 .... 26 ..... A Dxa bone density, axial ...................................... 0.30 0.10 0.10 0.01 0.41 0.41 XXX 

76075 .... TC .... A Dxa bone density, axial ...................................... 0.00 3.10 NA 0.17 3.27 NA XXX 

76075 .... .......... A Dxa bone density, axial ...................................... 0.30 3.20 NA 0.18 3.68 NA XXX 

76076 .... 26 ..... A Dxa bone density/peripheral .............................. 0.22 0.08 0.08 0.01 0.31 0.31 XXX 

76076 .... TC .... A Dxa bone density/peripheral .............................. 0.00 0.75 NA 0.05 0.80 NA XXX 

76076 .... .......... A Dxa bone density/peripheral .............................. 0.22 0.83 NA 0.06 1.11 NA XXX 

76077 .... 26 ..... A Dxa bone density/v-fracture ............................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

70426 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

76077 .... TC .... A Dxa bone density/v-fracture ............................... 0.00 0.75 NA 0.05 0.80 NA XXX 

76077 .... .......... A Dxa bone density/v-fracture ............................... 0.17 0.81 NA 0.06 1.04 NA XXX 

76078 .... 26 ..... A Radiographic absorptiometry ............................. 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

76078 .... TC .... A Radiographic absorptiometry ............................. 0.00 0.75 NA 0.05 0.80 NA XXX 

76078 .... .......... A Radiographic absorptiometry ............................. 0.20 0.82 NA 0.06 1.08 NA XXX 

76080 .... 26 ..... A X-ray exam of fistula .......................................... 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

76080 .... TC .... A X-ray exam of fistula .......................................... 0.00 1.05 NA 0.06 1.11 NA XXX 

76080 .... .......... A X-ray exam of fistula .......................................... 0.54 1.23 NA 0.08 1.85 NA XXX 

76082 .... 26 ..... A Computer mammogram add-on ......................... 0.06 0.02 0.02 0.01 0.09 0.09 ZZZ 

76082 .... TC .... A Computer mammogram add-on ......................... 0.00 0.42 NA 0.01 0.43 NA ZZZ 

76082 .... .......... A Computer mammogram add-on ......................... 0.06 0.44 NA 0.02 0.52 NA ZZZ 

76083 .... 26 ..... A Computer mammogram add-on ......................... 0.06 0.02 0.02 0.01 0.09 0.09 ZZZ 

76083 .... TC .... A Computer mammogram add-on ......................... 0.00 0.42 NA 0.01 0.43 NA ZZZ 

76083 .... .......... A Computer mammogram add-on ......................... 0.06 0.44 NA 0.02 0.52 NA ZZZ 

76086 .... 26 ..... A X-ray of mammary duct ...................................... 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

76086 .... TC .... A X-ray of mammary duct ...................................... 0.00 2.63 NA 0.14 2.77 NA XXX 

76086 .... .......... A X-ray of mammary duct ...................................... 0.36 2.75 NA 0.16 3.27 NA XXX 

76088 .... 26 ..... A X-ray of mammary ducts .................................... 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

76088 .... TC .... A X-ray of mammary ducts .................................... 0.00 3.67 NA 0.19 3.86 NA XXX 

76088 .... .......... A X-ray of mammary ducts .................................... 0.45 3.82 NA 0.21 4.48 NA XXX 

76090 .... 26 ..... A Mammogram, one breast ................................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

76090 .... TC .... A Mammogram, one breast ................................... 0.00 1.05 NA 0.06 1.11 NA XXX 

76090 .... .......... A Mammogram, one breast ................................... 0.70 1.28 NA 0.09 2.07 NA XXX 

76091 .... 26 ..... A Mammogram, both breasts ................................ 0.87 0.28 0.28 0.04 1.19 1.19 XXX 

76091 .... TC .... A Mammogram, both breasts ................................ 0.00 1.31 NA 0.07 1.38 NA XXX 

76091 .... .......... A Mammogram, both breasts ................................ 0.87 1.59 NA 0.11 2.57 NA XXX 

76092 .... 26 ..... A Mammogram, screening ..................................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

76092 .... TC .... A Mammogram, screening ..................................... 0.00 1.23 NA 0.07 1.30 NA XXX 

76092 .... .......... A Mammogram, screening ..................................... 0.70 1.46 NA 0.10 2.26 NA XXX 

76093 .... 26 ..... A Magnetic image, breast ...................................... 1.63 0.53 0.53 0.07 2.23 2.23 XXX 

76093 .... TC .... A Magnetic image, breast ...................................... 0.00 17.67 NA 0.92 18.59 NA XXX 

76093 .... .......... A Magnetic image, breast ...................................... 1.63 18.20 NA 0.99 20.82 NA XXX 

76094 .... 26 ..... A Magnetic image, both breasts ............................ 1.63 0.53 0.53 0.07 2.23 2.23 XXX 

76094 .... TC .... A Magnetic image, both breasts ............................ 0.00 23.98 NA 1.24 25.22 NA XXX 

76094 .... .......... A Magnetic image, both breasts ............................ 1.63 24.51 NA 1.31 27.45 NA XXX 

76095 .... 26 ..... A Stereotactic breast biopsy .................................. 1.59 0.52 0.52 0.09 2.20 2.20 XXX 

76095 .... TC .... A Stereotactic breast biopsy .................................. 0.00 7.18 NA 0.37 7.55 NA XXX 

76095 .... .......... A Stereotactic breast biopsy .................................. 1.59 7.70 NA 0.46 9.75 NA XXX 

76096 .... 26 ..... A X-ray of needle wire, breast ............................... 0.56 0.18 0.18 0.02 0.76 0.76 XXX 

76096 .... TC .... A X-ray of needle wire, breast ............................... 0.00 1.31 NA 0.07 1.38 NA XXX 

76096 .... .......... A X-ray of needle wire, breast ............................... 0.56 1.49 NA 0.09 2.14 NA XXX 

76098 .... 26 ..... A X-ray exam, breast specimen ............................ 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

76098 .... TC .... A X-ray exam, breast specimen ............................ 0.00 0.42 NA 0.02 0.44 NA XXX 

76098 .... .......... A X-ray exam, breast specimen ............................ 0.16 0.47 NA 0.03 0.66 NA XXX 

76100 .... 26 ..... A X-ray exam of body section ............................... 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

76100 .... TC .... A X-ray exam of body section ............................... 0.00 1.25 NA 0.07 1.32 NA XXX 

76100 .... .......... A X-ray exam of body section ............................... 0.58 1.44 NA 0.10 2.12 NA XXX 

76101 .... 26 ..... A Complex body section x-ray ............................... 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

76101 .... TC .... A Complex body section x-ray ............................... 0.00 1.42 NA 0.08 1.50 NA XXX 

76101 .... .......... A Complex body section x-ray ............................... 0.58 1.61 NA 0.11 2.30 NA XXX 

76102 .... 26 ..... A Complex body section x-rays ............................. 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

76102 .... TC .... A Complex body section x-rays ............................. 0.00 1.74 NA 0.11 1.85 NA XXX 

76102 .... .......... A Complex body section x-rays ............................. 0.58 1.93 NA 0.14 2.65 NA XXX 

76120 .... 26 ..... A Cine/video x-rays ................................................ 0.38 0.13 0.13 0.02 0.53 0.53 XXX 

76120 .... TC .... A Cine/video x-rays ................................................ 0.00 1.05 NA 0.06 1.11 NA XXX 

76120 .... .......... A Cine/video x-rays ................................................ 0.38 1.18 NA 0.08 1.64 NA XXX 

76125 .... 26 ..... A Cine/video x-rays add-on ................................... 0.27 0.09 0.09 0.01 0.37 0.37 ZZZ 

76125 .... TC .... A Cine/video x-rays add-on ................................... 0.00 0.78 NA 0.05 0.83 NA ZZZ 

76125 .... .......... A Cine/video x-rays add-on ................................... 0.27 0.87 NA 0.06 1.20 NA ZZZ 

76140 .... .......... I X-ray consultation ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76150 .... .......... A X-ray exam, dry process .................................... 0.00 0.42 NA 0.02 0.44 NA XXX 

76350 .... .......... C Special x-ray contrast study ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76355 .... 26 ..... A Ct scan for localization ....................................... 1.21 0.40 0.40 0.05 1.66 1.66 XXX 

76355 .... TC .... A Ct scan for localization ....................................... 0.00 8.28 NA 0.42 8.70 NA XXX 

76355 .... .......... A Ct scan for localization ....................................... 1.21 8.68 NA 0.47 10.36 NA XXX 

76360 .... 26 ..... A Ct scan for needle biopsy .................................. 1.16 0.38 0.38 0.05 1.59 1.59 XXX 

76360 .... TC .... A Ct scan for needle biopsy .................................. 0.00 8.28 NA 0.42 8.70 NA XXX 

76360 .... .......... A Ct scan for needle biopsy .................................. 1.16 8.66 NA 0.47 10.29 NA XXX 

76362 .... 26 ..... A Ct guide for tissue ablation ................................ 3.99 1.30 1.30 0.18 5.47 5.47 XXX 

76362 .... TC .... A Ct guide for tissue ablation ................................ 0.00 8.28 NA 1.46 9.74 NA XXX 

76362 .... .......... A Ct guide for tissue ablation ................................ 3.99 9.58 NA 1.64 15.21 NA XXX 

76370 .... 26 ..... A Ct scan for therapy guide ................................... 0.85 0.28 0.28 0.04 1.17 1.17 XXX 

76370 .... TC .... A Ct scan for therapy guide ................................... 0.00 2.96 NA 0.16 3.12 NA XXX 

76370 .... .......... A Ct scan for therapy guide ................................... 0.85 3.24 NA 0.20 4.29 NA XXX 

76376 .... 26 ..... A 3d render w/o postprocess ................................. 0.20 0.07 0.07 0.02 0.29 0.29 XXX 

70427 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

76376 .... TC .... A 3d render w/o postprocess ................................. 0.00 3.43 NA 0.08 3.51 NA XXX 

76376 .... .......... A 3d render w/o postprocess ................................. 0.20 3.50 NA 0.10 3.80 NA XXX 

76377 .... 26 ..... A 3d rendering w/postprocess ............................... 0.79 0.27 0.27 0.08 1.14 1.14 XXX 

76377 .... TC .... A 3d rendering w/postprocess ............................... 0.00 3.43 NA 0.31 3.74 NA XXX 

76377 .... .......... A 3d rendering w/postprocess ............................... 0.79 3.70 NA 0.39 4.88 NA XXX 

76380 .... 26 ..... A CAT scan follow-up study .................................. 0.98 0.32 0.32 0.04 1.34 1.34 XXX 

76380 .... TC .... A CAT scan follow-up study .................................. 0.00 3.51 NA 0.18 3.69 NA XXX 

76380 .... .......... A CAT scan follow-up study .................................. 0.98 3.83 NA 0.22 5.03 NA XXX 

76390 .... 26 ..... N Mr spectroscopy ................................................. +1.40 0.47 0.47 0.07 1.94 1.94 XXX 

76390 .... TC .... N Mr spectroscopy ................................................. +0.00 11.04 11.04 0.59 11.63 11.63 XXX 

76390 .... .......... N Mr spectroscopy ................................................. +1.40 11.51 11.51 0.66 13.57 13.57 XXX 

76393 .... 26 ..... A Mr guidance for needle place ............................ 1.50 0.50 0.50 0.09 2.09 2.09 XXX 

76393 .... TC .... A Mr guidance for needle place ............................ 0.00 11.23 NA 0.55 11.78 NA XXX 

76393 .... .......... A Mr guidance for needle place ............................ 1.50 11.73 NA 0.64 13.87 NA XXX 

76394 .... 26 ..... A Mri for tissue ablation ......................................... 4.24 1.38 1.38 0.24 5.86 5.86 XXX 

76394 .... TC .... A Mri for tissue ablation ......................................... 0.00 11.23 NA 1.57 12.80 NA XXX 

76394 .... .......... A Mri for tissue ablation ......................................... 4.24 12.61 NA 1.81 18.66 NA XXX 

76400 .... 26 ..... A Magnetic image, bone marrow ........................... 1.60 0.52 0.52 0.07 2.19 2.19 XXX 

76400 .... TC .... A Magnetic image, bone marrow ........................... 0.00 11.23 NA 0.59 11.82 NA XXX 

76400 .... .......... A Magnetic image, bone marrow ........................... 1.60 11.75 NA 0.66 14.01 NA XXX 

76496 .... 26 ..... C Fluoroscopic procedure ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76496 .... TC .... C Fluoroscopic procedure ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76496 .... .......... C Fluoroscopic procedure ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76497 .... 26 ..... C Ct procedure ....................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76497 .... TC .... C Ct procedure ....................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76497 .... .......... C Ct procedure ....................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76498 .... 26 ..... C Mri procedure ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76498 .... TC .... C Mri procedure ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76498 .... .......... C Mri procedure ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76499 .... 26 ..... C Radiographic procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76499 .... TC .... C Radiographic procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76499 .... .......... C Radiographic procedure ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76506 .... 26 ..... A Echo exam of head ............................................ 0.63 0.24 0.24 0.06 0.93 0.93 XXX 

76506 .... TC .... A Echo exam of head ............................................ 0.00 1.42 NA 0.08 1.50 NA XXX 

76506 .... .......... A Echo exam of head ............................................ 0.63 1.66 NA 0.14 2.43 NA XXX 

76510 .... 26 ..... A Ophth us, b & quant a ........................................ 1.55 0.68 0.68 0.03 2.26 2.26 XXX 

76510 .... TC .... A Ophth us, b & quant a ........................................ 0.00 2.19 NA 0.07 2.26 NA XXX 

76510 .... .......... A Ophth us, b & quant a ........................................ 1.55 2.87 NA 0.10 4.52 NA XXX 

76511 .... 26 ..... A Ophth us, quant a only ....................................... 0.94 0.40 0.40 0.03 1.37 1.37 XXX 

76511 .... TC .... A Ophth us, quant a only ....................................... 0.00 2.04 NA 0.07 2.11 NA XXX 

76511 .... .......... A Ophth us, quant a only ....................................... 0.94 2.44 NA 0.10 3.48 NA XXX 

76512 .... 26 ..... A Ophth us, b w/non-quant a ................................ 0.94 0.42 0.42 0.02 1.38 1.38 XXX 

76512 .... TC .... A Ophth us, b w/non-quant a ................................ 0.00 1.82 NA 0.10 1.92 NA XXX 

76512 .... .......... A Ophth us, b w/non-quant a ................................ 0.94 2.24 NA 0.12 3.30 NA XXX 

76513 .... 26 ..... A Echo exam of eye, water bath ........................... 0.66 0.29 0.29 0.02 0.97 0.97 XXX 

76513 .... TC .... A Echo exam of eye, water bath ........................... 0.00 1.52 NA 0.10 1.62 NA XXX 

76513 .... .......... A Echo exam of eye, water bath ........................... 0.66 1.81 NA 0.12 2.59 NA XXX 

76514 .... 26 ..... A Echo exam of eye, thickness ............................. 0.17 0.08 0.08 0.01 0.26 0.26 XXX 

76514 .... TC .... A Echo exam of eye, thickness ............................. 0.00 0.05 NA 0.01 0.06 NA XXX 

76514 .... .......... A Echo exam of eye, thickness ............................. 0.17 0.13 NA 0.02 0.32 NA XXX 

76516 .... 26 ..... A Echo exam of eye .............................................. 0.54 0.24 0.24 0.01 0.79 0.79 XXX 

76516 .... TC .... A Echo exam of eye .............................................. 0.00 1.22 NA 0.07 1.29 NA XXX 

76516 .... .......... A Echo exam of eye .............................................. 0.54 1.46 NA 0.08 2.08 NA XXX 

76519 .... 26 ..... A Echo exam of eye .............................................. 0.54 0.24 0.24 0.01 0.79 0.79 XXX 

76519 .... TC .... A Echo exam of eye .............................................. 0.00 1.31 NA 0.07 1.38 NA XXX 

76519 .... .......... A Echo exam of eye .............................................. 0.54 1.55 NA 0.08 2.17 NA XXX 

76529 .... 26 ..... A Echo exam of eye .............................................. 0.57 0.24 0.24 0.02 0.83 0.83 XXX 

76529 .... TC .... A Echo exam of eye .............................................. 0.00 1.13 NA 0.08 1.21 NA XXX 

76529 .... .......... A Echo exam of eye .............................................. 0.57 1.37 NA 0.10 2.04 NA XXX 

76536 .... 26 ..... A Us exam of head and neck ................................ 0.56 0.18 0.18 0.02 0.76 0.76 XXX 

76536 .... TC .... A Us exam of head and neck ................................ 0.00 1.42 NA 0.08 1.50 NA XXX 

76536 .... .......... A Us exam of head and neck ................................ 0.56 1.60 NA 0.10 2.26 NA XXX 

76604 .... 26 ..... A Us exam, chest, b-scan ..................................... 0.55 0.18 0.18 0.02 0.75 0.75 XXX 

76604 .... TC .... A Us exam, chest, b-scan ..................................... 0.00 1.31 NA 0.07 1.38 NA XXX 

76604 .... .......... A Us exam, chest, b-scan ..................................... 0.55 1.49 NA 0.09 2.13 NA XXX 

76645 .... 26 ..... A Us exam, breast(s) ............................................. 0.54 0.18 0.18 0.02 0.74 0.74 XXX 

76645 .... TC .... A Us exam, breast(s) ............................................. 0.00 1.05 NA 0.06 1.11 NA XXX 

76645 .... .......... A Us exam, breast(s) ............................................. 0.54 1.23 NA 0.08 1.85 NA XXX 

76700 .... 26 ..... A Us exam, abdom, complete ............................... 0.81 0.27 0.27 0.04 1.12 1.12 XXX 

76700 .... TC .... A Us exam, abdom, complete ............................... 0.00 1.98 NA 0.11 2.09 NA XXX 

76700 .... .......... A Us exam, abdom, complete ............................... 0.81 2.25 NA 0.15 3.21 NA XXX 

76705 .... 26 ..... A Echo exam of abdomen ..................................... 0.59 0.19 0.19 0.03 0.81 0.81 XXX 

76705 .... TC .... A Echo exam of abdomen ..................................... 0.00 1.42 NA 0.08 1.50 NA XXX 

76705 .... .......... A Echo exam of abdomen ..................................... 0.59 1.61 NA 0.11 2.31 NA XXX 

76770 .... 26 ..... A Us exam abdo back wall, comp ......................... 0.74 0.24 0.24 0.03 1.01 1.01 XXX 

70428 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

76770 .... TC .... A Us exam abdo back wall, comp ......................... 0.00 1.98 NA 0.11 2.09 NA XXX 

76770 .... .......... A Us exam abdo back wall, comp ......................... 0.74 2.22 NA 0.14 3.10 NA XXX 

76775 .... 26 ..... A Us exam abdo back wall, lim ............................. 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

76775 .... TC .... A Us exam abdo back wall, lim ............................. 0.00 1.42 NA 0.08 1.50 NA XXX 

76775 .... .......... A Us exam abdo back wall, lim ............................. 0.58 1.61 NA 0.11 2.30 NA XXX 

76778 .... 26 ..... A Us exam kidney transplant ................................. 0.74 0.24 0.24 0.03 1.01 1.01 XXX 

76778 .... TC .... A Us exam kidney transplant ................................. 0.00 1.98 NA 0.11 2.09 NA XXX 

76778 .... .......... A Us exam kidney transplant ................................. 0.74 2.22 NA 0.14 3.10 NA XXX 

76800 .... 26 ..... A Us exam, spinal canal ........................................ 1.13 0.34 0.34 0.05 1.52 1.52 XXX 

76800 .... TC .... A Us exam, spinal canal ........................................ 0.00 1.42 NA 0.08 1.50 NA XXX 

76800 .... .......... A Us exam, spinal canal ........................................ 1.13 1.76 NA 0.13 3.02 NA XXX 

76801 .... 26 ..... A Ob us < 14 wks, single fetus ............................. 0.99 0.34 0.34 0.04 1.37 1.37 XXX 

76801 .... TC .... A Ob us < 14 wks, single fetus ............................. 0.00 2.11 NA 0.12 2.23 NA XXX 

76801 .... .......... A Ob us < 14 wks, single fetus ............................. 0.99 2.45 NA 0.16 3.60 NA XXX 

76802 .... 26 ..... A Ob us < 14 wks, add’l fetus ............................... 0.83 0.29 0.29 0.04 1.16 1.16 ZZZ 

76802 .... TC .... A Ob us < 14 wks, add’l fetus ............................... 0.00 1.05 NA 0.12 1.17 NA ZZZ 

76802 .... .......... A Ob us < 14 wks, add’l fetus ............................... 0.83 1.34 NA 0.16 2.33 NA ZZZ 

76805 .... 26 ..... A Ob us >/= 14 wks, sngl fetus ............................. 0.99 0.34 0.34 0.04 1.37 1.37 XXX 

76805 .... TC .... A Ob us >/= 14 wks, sngl fetus ............................. 0.00 2.11 NA 0.12 2.23 NA XXX 

76805 .... .......... A Ob us >/= 14 wks, sngl fetus ............................. 0.99 2.45 NA 0.16 3.60 NA XXX 

76810 .... 26 ..... A Ob us >/= 14 wks, addl fetus ............................. 0.98 0.34 0.34 0.04 1.36 1.36 ZZZ 

76810 .... TC .... A Ob us >/= 14 wks, addl fetus ............................. 0.00 1.05 NA 0.22 1.27 NA ZZZ 

76810 .... .......... A Ob us >/= 14 wks, addl fetus ............................. 0.98 1.39 NA 0.26 2.63 NA ZZZ 

76811 .... 26 ..... A Ob us, detailed, sngl fetus ................................. 1.90 0.71 0.71 0.09 2.70 2.70 XXX 

76811 .... TC .... A Ob us, detailed, sngl fetus ................................. 0.00 3.54 NA 0.43 3.97 NA XXX 

76811 .... .......... A Ob us, detailed, sngl fetus ................................. 1.90 4.25 NA 0.52 6.67 NA XXX 

76812 .... 26 ..... A Ob us, detailed, addl fetus ................................. 1.78 0.66 0.66 0.08 2.52 2.52 ZZZ 

76812 .... TC .... A Ob us, detailed, addl fetus ................................. 0.00 1.05 NA 0.41 1.46 NA ZZZ 

76812 .... .......... A Ob us, detailed, addl fetus ................................. 1.78 1.71 NA 0.49 3.98 NA ZZZ 

76815 .... 26 ..... A Ob us, limited, fetus(s) ....................................... 0.65 0.23 0.23 0.03 0.91 0.91 XXX 

76815 .... TC .... A Ob us, limited, fetus(s) ....................................... 0.00 1.42 NA 0.08 1.50 NA XXX 

76815 .... .......... A Ob us, limited, fetus(s) ....................................... 0.65 1.65 NA 0.11 2.41 NA XXX 

76816 .... 26 ..... A Ob us, follow-up, per fetus ................................. 0.85 0.32 0.32 0.04 1.21 1.21 XXX 

76816 .... TC .... A Ob us, follow-up, per fetus ................................. 0.00 1.11 NA 0.06 1.17 NA XXX 

76816 .... .......... A Ob us, follow-up, per fetus ................................. 0.85 1.43 NA 0.10 2.38 NA XXX 

76817 .... 26 ..... A Transvaginal us, obstetric .................................. 0.75 0.26 0.26 0.03 1.04 1.04 XXX 

76817 .... TC .... A Transvaginal us, obstetric .................................. 0.00 1.52 NA 0.06 1.58 NA XXX 

76817 .... .......... A Transvaginal us, obstetric .................................. 0.75 1.78 NA 0.09 2.62 NA XXX 

76818 .... 26 ..... A Fetal biophys profile w/nst ................................. 1.05 0.39 0.39 0.05 1.49 1.49 XXX 

76818 .... TC .... A Fetal biophys profile w/nst ................................. 0.00 1.61 NA 0.10 1.71 NA XXX 

76818 .... .......... A Fetal biophys profile w/nst ................................. 1.05 2.00 NA 0.15 3.20 NA XXX 

76819 .... 26 ..... A Fetal biophys profil w/o nst ................................ 0.77 0.28 0.28 0.03 1.08 1.08 XXX 

76819 .... TC .... A Fetal biophys profil w/o nst ................................ 0.00 1.61 NA 0.10 1.71 NA XXX 

76819 .... .......... A Fetal biophys profil w/o nst ................................ 0.77 1.89 NA 0.13 2.79 NA XXX 

76820 .... 26 ..... A Umbilical artery echo .......................................... 0.50 0.19 0.19 0.03 0.72 0.72 XXX 

76820 .... TC .... A Umbilical artery echo .......................................... 0.00 1.61 NA 0.12 1.73 NA XXX 

76820 .... .......... A Umbilical artery echo .......................................... 0.50 1.80 NA 0.15 2.45 NA XXX 

76821 .... 26 ..... A Middle cerebral artery echo ............................... 0.70 0.27 0.27 0.03 1.00 1.00 XXX 

76821 .... TC .... A Middle cerebral artery echo ............................... 0.00 1.61 NA 0.12 1.73 NA XXX 

76821 .... .......... A Middle cerebral artery echo ............................... 0.70 1.88 NA 0.15 2.73 NA XXX 

76825 .... 26 ..... A Echo exam of fetal heart .................................... 1.67 0.60 0.60 0.07 2.34 2.34 XXX 

76825 .... TC .... A Echo exam of fetal heart .................................... 0.00 1.98 NA 0.11 2.09 NA XXX 

76825 .... .......... A Echo exam of fetal heart .................................... 1.67 2.58 NA 0.18 4.43 NA XXX 

76826 .... 26 ..... A Echo exam of fetal heart .................................... 0.83 0.29 0.29 0.03 1.15 1.15 XXX 

76826 .... TC .... A Echo exam of fetal heart .................................... 0.00 0.71 NA 0.05 0.76 NA XXX 

76826 .... .......... A Echo exam of fetal heart .................................... 0.83 1.00 NA 0.08 1.91 NA XXX 

76827 .... 26 ..... A Echo exam of fetal heart .................................... 0.58 0.21 0.21 0.02 0.81 0.81 XXX 

76827 .... TC .... A Echo exam of fetal heart .................................... 0.00 1.72 NA 0.12 1.84 NA XXX 

76827 .... .......... A Echo exam of fetal heart .................................... 0.58 1.93 NA 0.14 2.65 NA XXX 

76828 .... 26 ..... A Echo exam of fetal heart .................................... 0.56 0.22 0.22 0.03 0.81 0.81 XXX 

76828 .... TC .... A Echo exam of fetal heart .................................... 0.00 1.11 NA 0.08 1.19 NA XXX 

76828 .... .......... A Echo exam of fetal heart .................................... 0.56 1.33 NA 0.11 2.00 NA XXX 

76830 .... 26 ..... A Transvaginal us, non-ob ..................................... 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

76830 .... TC .... A Transvaginal us, non-ob ..................................... 0.00 1.52 NA 0.10 1.62 NA XXX 

76830 .... .......... A Transvaginal us, non-ob ..................................... 0.69 1.75 NA 0.13 2.57 NA XXX 

76831 .... 26 ..... A Echo exam, uterus ............................................. 0.72 0.25 0.25 0.03 1.00 1.00 XXX 

76831 .... TC .... A Echo exam, uterus ............................................. 0.00 1.52 NA 0.10 1.62 NA XXX 

76831 .... .......... A Echo exam, uterus ............................................. 0.72 1.77 NA 0.13 2.62 NA XXX 

76856 .... 26 ..... A Us exam, pelvic, complete ................................. 0.69 0.23 0.23 0.03 0.95 0.95 XXX 

76856 .... TC .... A Us exam, pelvic, complete ................................. 0.00 1.52 NA 0.10 1.62 NA XXX 

76856 .... .......... A Us exam, pelvic, complete ................................. 0.69 1.75 NA 0.13 2.57 NA XXX 

76857 .... 26 ..... A Us exam, pelvic, limited ..................................... 0.38 0.12 0.12 0.02 0.52 0.52 XXX 

76857 .... TC .... A Us exam, pelvic, limited ..................................... 0.00 1.71 NA 0.06 1.77 NA XXX 

76857 .... .......... A Us exam, pelvic, limited ..................................... 0.38 1.83 NA 0.08 2.29 NA XXX 

76870 .... 26 ..... A Us exam, scrotum .............................................. 0.64 0.21 0.21 0.03 0.88 0.88 XXX 

70429 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

76870 .... TC .... A Us exam, scrotum .............................................. 0.00 1.52 NA 0.10 1.62 NA XXX 

76870 .... .......... A Us exam, scrotum .............................................. 0.64 1.73 NA 0.13 2.50 NA XXX 

76872 .... 26 ..... A Us, transrectal .................................................... 0.69 0.22 0.22 0.04 0.95 0.95 XXX 

76872 .... TC .... A Us, transrectal .................................................... 0.00 2.03 NA 0.10 2.13 NA XXX 

76872 .... .......... A Us, transrectal .................................................... 0.69 2.25 NA 0.14 3.08 NA XXX 

76873 .... 26 ..... A Echograp trans r, pros study .............................. 1.55 0.50 0.50 0.09 2.14 2.14 XXX 

76873 .... TC .... A Echograp trans r, pros study .............................. 0.00 2.11 NA 0.16 2.27 NA XXX 

76873 .... .......... A Echograp trans r, pros study .............................. 1.55 2.61 NA 0.25 4.41 NA XXX 

76880 .... 26 ..... A Us exam, extremity ............................................ 0.59 0.19 0.19 0.03 0.81 0.81 XXX 

76880 .... TC .... A Us exam, extremity ............................................ 0.00 1.42 NA 0.08 1.50 NA XXX 

76880 .... .......... A Us exam, extremity ............................................ 0.59 1.61 NA 0.11 2.31 NA XXX 

76885 .... 26 ..... A Us exam infant hips, dynamic ............................ 0.74 0.24 0.24 0.03 1.01 1.01 XXX 

76885 .... TC .... A Us exam infant hips, dynamic ............................ 0.00 1.52 NA 0.10 1.62 NA XXX 

76885 .... .......... A Us exam infant hips, dynamic ............................ 0.74 1.76 NA 0.13 2.63 NA XXX 

76886 .... 26 ..... A Us exam infant hips, static ................................. 0.62 0.20 0.20 0.03 0.85 0.85 XXX 

76886 .... TC .... A Us exam infant hips, static ................................. 0.00 1.42 NA 0.08 1.50 NA XXX 

76886 .... .......... A Us exam infant hips, static ................................. 0.62 1.62 NA 0.11 2.35 NA XXX 

76930 .... 26 ..... A Echo guide, cardiocentesis ................................ 0.67 0.25 0.25 0.02 0.94 0.94 XXX 

76930 .... TC .... A Echo guide, cardiocentesis ................................ 0.00 1.52 NA 0.10 1.62 NA XXX 

76930 .... .......... A Echo guide, cardiocentesis ................................ 0.67 1.77 NA 0.12 2.56 NA XXX 

76932 .... 26 ..... A Echo guide for heart biopsy ............................... 0.67 0.25 0.25 0.02 0.94 0.94 XXX 

76932 .... TC .... A Echo guide for heart biopsy ............................... 0.00 1.52 NA 0.10 1.62 NA XXX 

76932 .... .......... A Echo guide for heart biopsy ............................... 0.67 1.77 NA 0.12 2.56 NA XXX 

76936 .... 26 ..... A Echo guide for artery repair ............................... 1.99 0.66 0.66 0.13 2.78 2.78 XXX 

76936 .... TC .... A Echo guide for artery repair ............................... 0.00 6.31 NA 0.34 6.65 NA XXX 

76936 .... .......... A Echo guide for artery repair ............................... 1.99 6.97 NA 0.47 9.43 NA XXX 

76937 .... 26 ..... A Us guide, vascular access ................................. 0.30 0.10 0.10 0.03 0.43 0.43 ZZZ 

76937 .... TC .... A Us guide, vascular access ................................. 0.00 0.38 NA 0.10 0.48 NA ZZZ 

76937 .... .......... A Us guide, vascular access ................................. 0.30 0.48 NA 0.13 0.91 NA ZZZ 

76940 .... 26 ..... A Us guide, tissue ablation .................................... 2.00 0.65 0.65 0.31 2.96 2.96 XXX 

76940 .... TC .... A Us guide, tissue ablation .................................... 0.00 1.52 NA 0.29 1.81 NA XXX 

76940 .... .......... A Us guide, tissue ablation .................................... 2.00 2.17 NA 0.60 4.77 NA XXX 

76941 .... 26 ..... A Echo guide for transfusion ................................. 1.34 0.47 0.47 0.07 1.88 1.88 XXX 

76941 .... TC .... A Echo guide for transfusion ................................. 0.00 1.53 NA 0.08 1.61 NA XXX 

76941 .... .......... A Echo guide for transfusion ................................. 1.34 2.00 NA 0.15 3.49 NA XXX 

76942 .... 26 ..... A Echo guide for biopsy ........................................ 0.67 0.22 0.22 0.03 0.92 0.92 XXX 

76942 .... TC .... A Echo guide for biopsy ........................................ 0.00 2.82 NA 0.10 2.92 NA XXX 

76942 .... .......... A Echo guide for biopsy ........................................ 0.67 3.04 NA 0.13 3.84 NA XXX 

76945 .... 26 ..... A Echo guide, villus sampling ................................ 0.67 0.22 0.22 0.03 0.92 0.92 XXX 

76945 .... TC .... A Echo guide, villus sampling ................................ 0.00 1.53 NA 0.08 1.61 NA XXX 

76945 .... .......... A Echo guide, villus sampling ................................ 0.67 1.75 NA 0.11 2.53 NA XXX 

76946 .... 26 ..... A Echo guide for amniocentesis ............................ 0.38 0.14 0.14 0.02 0.54 0.54 XXX 

76946 .... TC .... A Echo guide for amniocentesis ............................ 0.00 1.52 NA 0.10 1.62 NA XXX 

76946 .... .......... A Echo guide for amniocentesis ............................ 0.38 1.66 NA 0.12 2.16 NA XXX 

76948 .... 26 ..... A Echo guide, ova aspiration ................................. 0.38 0.13 0.13 0.02 0.53 0.53 XXX 

76948 .... TC .... A Echo guide, ova aspiration ................................. 0.00 1.52 NA 0.10 1.62 NA XXX 

76948 .... .......... A Echo guide, ova aspiration ................................. 0.38 1.65 NA 0.12 2.15 NA XXX 

76950 .... 26 ..... A Echo guidance radiotherapy .............................. 0.58 0.19 0.19 0.03 0.80 0.80 XXX 

76950 .... TC .... A Echo guidance radiotherapy .............................. 0.00 1.31 NA 0.07 1.38 NA XXX 

76950 .... .......... A Echo guidance radiotherapy .............................. 0.58 1.50 NA 0.10 2.18 NA XXX 

76965 .... 26 ..... A Echo guidance radiotherapy .............................. 1.34 0.43 0.43 0.08 1.85 1.85 XXX 

76965 .... TC .... A Echo guidance radiotherapy .............................. 0.00 5.59 NA 0.29 5.88 NA XXX 

76965 .... .......... A Echo guidance radiotherapy .............................. 1.34 6.02 NA 0.37 7.73 NA XXX 

76970 .... 26 ..... A Ultrasound exam follow-up ................................. 0.40 0.13 0.13 0.02 0.55 0.55 XXX 

76970 .... TC .... A Ultrasound exam follow-up ................................. 0.00 1.05 NA 0.06 1.11 NA XXX 

76970 .... .......... A Ultrasound exam follow-up ................................. 0.40 1.18 NA 0.08 1.66 NA XXX 

76975 .... 26 ..... A GI endoscopic ultrasound .................................. 0.81 0.28 0.28 0.04 1.13 1.13 XXX 

76975 .... TC .... A GI endoscopic ultrasound .................................. 0.00 1.52 NA 0.10 1.62 NA XXX 

76975 .... .......... A GI endoscopic ultrasound .................................. 0.81 1.80 NA 0.14 2.75 NA XXX 

76977 .... 26 ..... A Us bone density measure .................................. 0.05 0.02 0.02 0.01 0.08 0.08 XXX 

76977 .... TC .... A Us bone density measure .................................. 0.00 0.82 NA 0.05 0.87 NA XXX 

76977 .... .......... A Us bone density measure .................................. 0.05 0.84 NA 0.06 0.95 NA XXX 

76986 .... 26 ..... A Ultrasound guide intraoper ................................. 1.20 0.40 0.40 0.13 1.73 1.73 XXX 

76986 .... TC .... A Ultrasound guide intraoper ................................. 0.00 2.63 NA 0.14 2.77 NA XXX 

76986 .... .......... A Ultrasound guide intraoper ................................. 1.20 3.03 NA 0.27 4.50 NA XXX 

76999 .... 26 ..... C Echo examination procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76999 .... TC .... C Echo examination procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

76999 .... .......... C Echo examination procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77261 .... .......... A Radiation therapy planning ................................ 1.39 0.51 0.51 0.07 1.97 1.97 XXX 

77262 .... .......... A Radiation therapy planning ................................ 2.11 0.75 0.75 0.11 2.97 2.97 XXX 

77263 .... .......... A Radiation therapy planning ................................ 3.14 1.11 1.11 0.16 4.41 4.41 XXX 

77280 .... 26 ..... A Set radiation therapy field .................................. 0.70 0.22 0.22 0.04 0.96 0.96 XXX 

77280 .... TC .... A Set radiation therapy field .................................. 0.00 3.48 NA 0.18 3.66 NA XXX 

77280 .... .......... A Set radiation therapy field .................................. 0.70 3.70 NA 0.22 4.62 NA XXX 

77285 .... 26 ..... A Set radiation therapy field .................................. 1.05 0.34 0.34 0.05 1.44 1.44 XXX 

70430 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

77285 .... TC .... A Set radiation therapy field .................................. 0.00 5.59 NA 0.30 5.89 NA XXX 

77285 .... .......... A Set radiation therapy field .................................. 1.05 5.93 NA 0.35 7.33 NA XXX 

77290 .... 26 ..... A Set radiation therapy field .................................. 1.56 0.50 0.50 0.08 2.14 2.14 XXX 

77290 .... TC .... A Set radiation therapy field .................................. 0.00 6.53 NA 0.35 6.88 NA XXX 

77290 .... .......... A Set radiation therapy field .................................. 1.56 7.03 NA 0.43 9.02 NA XXX 

77295 .... 26 ..... A Set radiation therapy field .................................. 4.56 1.46 1.46 0.23 6.25 6.25 XXX 

77295 .... TC .... A Set radiation therapy field .................................. 0.00 28.01 NA 1.48 29.49 NA XXX 

77295 .... .......... A Set radiation therapy field .................................. 4.56 29.47 NA 1.71 35.74 NA XXX 

77299 .... 26 ..... C Radiation therapy planning ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77299 .... TC .... C Radiation therapy planning ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77299 .... .......... C Radiation therapy planning ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77300 .... 26 ..... A Radiation therapy dose plan .............................. 0.62 0.20 0.20 0.03 0.85 0.85 XXX 

77300 .... TC .... A Radiation therapy dose plan .............................. 0.00 1.34 NA 0.07 1.41 NA XXX 

77300 .... .......... A Radiation therapy dose plan .............................. 0.62 1.54 NA 0.10 2.26 NA XXX 

77301 .... 26 ..... A Radiotherapy dose plan, imrt ............................. 7.99 2.57 2.57 0.40 10.96 10.96 XXX 

77301 .... TC .... A Radiotherapy dose plan, imrt ............................. 0.00 28.01 NA 1.48 29.49 NA XXX 

77301 .... .......... A Radiotherapy dose plan, imrt ............................. 7.99 30.58 NA 1.88 40.45 NA XXX 

77305 .... 26 ..... A Teletx isodose plan simple ................................. 0.70 0.23 0.23 0.04 0.97 0.97 XXX 

77305 .... TC .... A Teletx isodose plan simple ................................. 0.00 1.87 NA 0.11 1.98 NA XXX 

77305 .... .......... A Teletx isodose plan simple ................................. 0.70 2.10 NA 0.15 2.95 NA XXX 

77310 .... 26 ..... A Teletx isodose plan intermed ............................. 1.05 0.34 0.34 0.05 1.44 1.44 XXX 

77310 .... TC .... A Teletx isodose plan intermed ............................. 0.00 2.34 NA 0.13 2.47 NA XXX 

77310 .... .......... A Teletx isodose plan intermed ............................. 1.05 2.68 NA 0.18 3.91 NA XXX 

77315 .... 26 ..... A Teletx isodose plan complex .............................. 1.56 0.50 0.50 0.08 2.14 2.14 XXX 

77315 .... TC .... A Teletx isodose plan complex .............................. 0.00 2.67 NA 0.14 2.81 NA XXX 

77315 .... .......... A Teletx isodose plan complex .............................. 1.56 3.17 NA 0.22 4.95 NA XXX 

77321 .... 26 ..... A Special teletx port plan ....................................... 0.95 0.30 0.30 0.05 1.30 1.30 XXX 

77321 .... TC .... A Special teletx port plan ....................................... 0.00 4.05 NA 0.21 4.26 NA XXX 

77321 .... .......... A Special teletx port plan ....................................... 0.95 4.35 NA 0.26 5.56 NA XXX 

77326 .... 26 ..... A Brachytx isodose calc simp ................................ 0.93 0.30 0.30 0.05 1.28 1.28 XXX 

77326 .... TC .... A Brachytx isodose calc simp ................................ 0.00 2.37 NA 0.13 2.50 NA XXX 

77326 .... .......... A Brachytx isodose calc simp ................................ 0.93 2.67 NA 0.18 3.78 NA XXX 

77327 .... 26 ..... A Brachytx isodose calc interm ............................. 1.39 0.44 0.44 0.07 1.90 1.90 XXX 

77327 .... TC .... A Brachytx isodose calc interm ............................. 0.00 3.48 NA 0.18 3.66 NA XXX 

77327 .... .......... A Brachytx isodose calc interm ............................. 1.39 3.92 NA 0.25 5.56 NA XXX 

77328 .... 26 ..... A Brachytx isodose plan compl ............................. 2.09 0.67 0.67 0.11 2.87 2.87 XXX 

77328 .... TC .... A Brachytx isodose plan compl ............................. 0.00 4.97 NA 0.25 5.22 NA XXX 

77328 .... .......... A Brachytx isodose plan compl ............................. 2.09 5.64 NA 0.36 8.09 NA XXX 

77331 .... 26 ..... A Special radiation dosimetry ................................ 0.87 0.28 0.28 0.04 1.19 1.19 XXX 

77331 .... TC .... A Special radiation dosimetry ................................ 0.00 0.50 NA 0.02 0.52 NA XXX 

77331 .... .......... A Special radiation dosimetry ................................ 0.87 0.78 NA 0.06 1.71 NA XXX 

77332 .... 26 ..... A Radiation treatment aid(s) .................................. 0.54 0.17 0.17 0.03 0.74 0.74 XXX 

77332 .... TC .... A Radiation treatment aid(s) .................................. 0.00 1.34 NA 0.07 1.41 NA XXX 

77332 .... .......... A Radiation treatment aid(s) .................................. 0.54 1.51 NA 0.10 2.15 NA XXX 

77333 .... 26 ..... A Radiation treatment aid(s) .................................. 0.84 0.27 0.27 0.04 1.15 1.15 XXX 

77333 .... TC .... A Radiation treatment aid(s) .................................. 0.00 1.90 NA 0.11 2.01 NA XXX 

77333 .... .......... A Radiation treatment aid(s) .................................. 0.84 2.17 NA 0.15 3.16 NA XXX 

77334 .... 26 ..... A Radiation treatment aid(s) .................................. 1.24 0.40 0.40 0.06 1.70 1.70 XXX 

77334 .... TC .... A Radiation treatment aid(s) .................................. 0.00 3.26 NA 0.17 3.43 NA XXX 

77334 .... .......... A Radiation treatment aid(s) .................................. 1.24 3.66 NA 0.23 5.13 NA XXX 

77336 .... .......... A Radiation physics consult ................................... 0.00 2.99 NA 0.16 3.15 NA XXX 

77370 .... .......... A Radiation physics consult ................................... 0.00 3.50 NA 0.18 3.68 NA XXX 

77399 .... 26 ..... C External radiation dosimetry ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77399 .... TC .... C External radiation dosimetry ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77399 .... .......... C External radiation dosimetry ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77401 .... .......... A Radiation treatment delivery .............................. 0.00 1.78 NA 0.11 1.89 NA XXX 

77402 .... .......... A Radiation treatment delivery .............................. 0.00 1.78 NA 0.11 1.89 NA XXX 

77403 .... .......... A Radiation treatment delivery .............................. 0.00 1.78 NA 0.11 1.89 NA XXX 

77404 .... .......... A Radiation treatment delivery .............................. 0.00 1.78 NA 0.11 1.89 NA XXX 

77406 .... .......... A Radiation treatment delivery .............................. 0.00 1.78 NA 0.11 1.89 NA XXX 

77407 .... .......... A Radiation treatment delivery .............................. 0.00 2.10 NA 0.12 2.22 NA XXX 

77408 .... .......... A Radiation treatment delivery .............................. 0.00 2.10 NA 0.12 2.22 NA XXX 

77409 .... .......... A Radiation treatment delivery .............................. 0.00 2.10 NA 0.12 2.22 NA XXX 

77411 .... .......... A Radiation treatment delivery .............................. 0.00 2.10 NA 0.12 2.22 NA XXX 

77412 .... .......... A Radiation treatment delivery .............................. 0.00 2.34 NA 0.13 2.47 NA XXX 

77413 .... .......... A Radiation treatment delivery .............................. 0.00 2.34 NA 0.13 2.47 NA XXX 

77414 .... .......... A Radiation treatment delivery .............................. 0.00 2.34 NA 0.13 2.47 NA XXX 

77416 .... .......... A Radiation treatment delivery .............................. 0.00 2.34 NA 0.13 2.47 NA XXX 

77417 .... .......... A Radiology port film(s) ......................................... 0.00 0.59 NA 0.04 0.63 NA XXX 

77418 .... .......... A Radiation tx delivery, imrt ................................... 0.00 18.07 NA 0.13 18.20 NA XXX 

77421 .... 26 ..... A Stereoscopic x-ray guidance .............................. 0.39 0.13 0.13 0.02 0.54 0.54 XXX 

77421 .... TC .... A Stereoscopic x-ray guidance .............................. 0.00 3.36 NA 0.10 3.46 NA XXX 

77421 .... .......... A Stereoscopic x-ray guidance .............................. 0.39 3.49 NA 0.12 4.00 NA XXX 

77422 .... .......... A Neutron beam tx, simple .................................... 0.00 1.71 NA 0.13 1.84 NA XXX 

77423 .... .......... A Neutron beam tx, complex ................................. 0.00 2.26 NA 0.13 2.39 NA XXX 

70431 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

77427 .... .......... A Radiation tx management, x5 ............................ 3.31 1.06 1.06 0.17 4.54 4.54 XXX 

77431 .... .......... A Radiation therapy management ......................... 1.81 0.68 0.68 0.09 2.58 2.58 XXX 

77432 .... .......... A Stereotactic radiation trmt .................................. 7.92 2.91 2.91 0.41 11.24 11.24 XXX 

77470 .... 26 ..... A Special radiation treatment ................................ 2.09 0.67 0.67 0.11 2.87 2.87 XXX 

77470 .... TC .... A Special radiation treatment ................................ 0.00 11.18 NA 0.59 11.77 NA XXX 

77470 .... .......... A Special radiation treatment ................................ 2.09 11.85 NA 0.70 14.64 NA XXX 

77499 .... 26 ..... C Radiation therapy management ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77499 .... TC .... C Radiation therapy management ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77499 .... .......... C Radiation therapy management ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77520 .... .......... C Proton trmt, simple w/o comp ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77522 .... .......... C Proton trmt, simple w/comp ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77523 .... .......... C Proton trmt, intermediate .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77525 .... .......... C Proton treatment, complex ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77600 .... 26 ..... R Hyperthermia treatment ...................................... 1.56 0.50 0.50 0.08 2.14 2.14 XXX 

77600 .... TC .... R Hyperthermia treatment ...................................... 0.00 3.06 NA 0.16 3.22 NA XXX 

77600 .... .......... R Hyperthermia treatment ...................................... 1.56 3.56 NA 0.24 5.36 NA XXX 

77605 .... 26 ..... R Hyperthermia treatment ...................................... 2.09 0.66 0.66 0.16 2.91 2.91 XXX 

77605 .... TC .... R Hyperthermia treatment ...................................... 0.00 4.07 NA 0.22 4.29 NA XXX 

77605 .... .......... R Hyperthermia treatment ...................................... 2.09 4.73 NA 0.38 7.20 NA XXX 

77610 .... 26 ..... R Hyperthermia treatment ...................................... 1.56 0.51 0.51 0.08 2.15 2.15 XXX 

77610 .... TC .... R Hyperthermia treatment ...................................... 0.00 3.06 NA 0.16 3.22 NA XXX 

77610 .... .......... R Hyperthermia treatment ...................................... 1.56 3.57 NA 0.24 5.37 NA XXX 

77615 .... 26 ..... R Hyperthermia treatment ...................................... 2.09 0.66 0.66 0.11 2.86 2.86 XXX 

77615 .... TC .... R Hyperthermia treatment ...................................... 0.00 4.07 NA 0.22 4.29 NA XXX 

77615 .... .......... R Hyperthermia treatment ...................................... 2.09 4.73 NA 0.33 7.15 NA XXX 

77620 .... 26 ..... R Hyperthermia treatment ...................................... 1.56 0.52 0.52 0.20 2.28 2.28 XXX 

77620 .... TC .... R Hyperthermia treatment ...................................... 0.00 3.06 NA 0.16 3.22 NA XXX 

77620 .... .......... R Hyperthermia treatment ...................................... 1.56 3.58 NA 0.36 5.50 NA XXX 

77750 .... 26 ..... A Infuse radioactive materials ............................... 4.90 1.58 1.58 0.25 6.73 6.73 090 

77750 .... TC .... A Infuse radioactive materials ............................... 0.00 1.33 NA 0.07 1.40 NA 090 

77750 .... .......... A Infuse radioactive materials ............................... 4.90 2.91 NA 0.32 8.13 NA 090 

77761 .... 26 ..... A Apply intrcav radiat simple ................................. 3.80 1.09 1.09 0.19 5.08 5.08 090 

77761 .... TC .... A Apply intrcav radiat simple ................................. 0.00 2.51 NA 0.14 2.65 NA 090 

77761 .... .......... A Apply intrcav radiat simple ................................. 3.80 3.60 NA 0.33 7.73 NA 090 

77762 .... 26 ..... A Apply intrcav radiat interm ................................. 5.71 1.84 1.84 0.29 7.84 7.84 090 

77762 .... TC .... A Apply intrcav radiat interm ................................. 0.00 3.62 NA 0.19 3.81 NA 090 

77762 .... .......... A Apply intrcav radiat interm ................................. 5.71 5.46 NA 0.48 11.65 NA 090 

77763 .... 26 ..... A Apply intrcav radiat compl .................................. 8.56 2.75 2.75 0.43 11.74 11.74 090 

77763 .... TC .... A Apply intrcav radiat compl .................................. 0.00 4.50 NA 0.23 4.73 NA 090 

77763 .... .......... A Apply intrcav radiat compl .................................. 8.56 7.25 NA 0.66 16.47 NA 090 

77776 .... 26 ..... A Apply interstit radiat simpl .................................. 4.65 0.95 0.95 0.44 6.04 6.04 090 

77776 .... TC .... A Apply interstit radiat simpl .................................. 0.00 2.19 NA 0.13 2.32 NA 090 

77776 .... .......... A Apply interstit radiat simpl .................................. 4.65 3.14 NA 0.57 8.36 NA 090 

77777 .... 26 ..... A Apply interstit radiat inter ................................... 7.47 2.38 2.38 0.39 10.24 10.24 090 

77777 .... TC .... A Apply interstit radiat inter ................................... 0.00 4.24 NA 0.22 4.46 NA 090 

77777 .... .......... A Apply interstit radiat inter ................................... 7.47 6.62 NA 0.61 14.70 NA 090 

77778 .... 26 ..... A Apply interstit radiat compl ................................. 11.17 3.58 3.58 0.57 15.32 15.32 090 

77778 .... TC .... A Apply interstit radiat compl ................................. 0.00 5.14 NA 0.27 5.41 NA 090 

77778 .... .......... A Apply interstit radiat compl ................................. 11.17 8.72 NA 0.84 20.73 NA 090 

77781 .... 26 ..... A High intensity brachytherapy .............................. 1.66 0.53 0.53 0.08 2.27 2.27 090 

77781 .... TC .... A High intensity brachytherapy .............................. 0.00 20.36 NA 1.06 21.42 NA 090 

77781 .... .......... A High intensity brachytherapy .............................. 1.66 20.89 NA 1.14 23.69 NA 090 

77782 .... 26 ..... A High intensity brachytherapy .............................. 2.49 0.80 0.80 0.13 3.42 3.42 090 

77782 .... TC .... A High intensity brachytherapy .............................. 0.00 20.36 NA 1.06 21.42 NA 090 

77782 .... .......... A High intensity brachytherapy .............................. 2.49 21.16 NA 1.19 24.84 NA 090 

77783 .... 26 ..... A High intensity brachytherapy .............................. 3.72 1.19 1.19 0.19 5.10 5.10 090 

77783 .... TC .... A High intensity brachytherapy .............................. 0.00 20.36 NA 1.06 21.42 NA 090 

77783 .... .......... A High intensity brachytherapy .............................. 3.72 21.55 NA 1.25 26.52 NA 090 

77784 .... 26 ..... A High intensity brachytherapy .............................. 5.60 1.80 1.80 0.29 7.69 7.69 090 

77784 .... TC .... A High intensity brachytherapy .............................. 0.00 20.36 NA 1.06 21.42 NA 090 

77784 .... .......... A High intensity brachytherapy .............................. 5.60 22.16 NA 1.35 29.11 NA 090 

77789 .... 26 ..... A Apply surface radiation ....................................... 1.12 0.37 0.37 0.06 1.55 1.55 000 

77789 .... TC .... A Apply surface radiation ....................................... 0.00 0.45 NA 0.02 0.47 NA 000 

77789 .... .......... A Apply surface radiation ....................................... 1.12 0.82 NA 0.08 2.02 NA 000 

77790 .... 26 ..... A Radiation handling .............................................. 1.05 0.34 0.34 0.05 1.44 1.44 XXX 

77790 .... TC .... A Radiation handling .............................................. 0.00 0.50 NA 0.02 0.52 NA XXX 

77790 .... .......... A Radiation handling .............................................. 1.05 0.84 NA 0.07 1.96 NA XXX 

77799 .... 26 ..... C Radium/radioisotope therapy ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77799 .... TC .... C Radium/radioisotope therapy ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

77799 .... .......... C Radium/radioisotope therapy ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78000 .... 26 ..... A Thyroid, single uptake ........................................ 0.19 0.06 0.06 0.01 0.26 0.26 XXX 

78000 .... TC .... A Thyroid, single uptake ........................................ 0.00 0.97 NA 0.06 1.03 NA XXX 

78000 .... .......... A Thyroid, single uptake ........................................ 0.19 1.03 NA 0.07 1.29 NA XXX 

78001 .... 26 ..... A Thyroid, multiple uptakes ................................... 0.26 0.09 0.09 0.01 0.36 0.36 XXX 

78001 .... TC .... A Thyroid, multiple uptakes ................................... 0.00 1.31 NA 0.07 1.38 NA XXX 

70432 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78001 .... .......... A Thyroid, multiple uptakes ................................... 0.26 1.40 NA 0.08 1.74 NA XXX 

78003 .... 26 ..... A Thyroid suppress/stimul ..................................... 0.33 0.11 0.11 0.01 0.45 0.45 XXX 

78003 .... TC .... A Thyroid suppress/stimul ..................................... 0.00 0.97 NA 0.06 1.03 NA XXX 

78003 .... .......... A Thyroid suppress/stimul ..................................... 0.33 1.08 NA 0.07 1.48 NA XXX 

78006 .... 26 ..... A Thyroid imaging with uptake .............................. 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

78006 .... TC .... A Thyroid imaging with uptake .............................. 0.00 2.39 NA 0.13 2.52 NA XXX 

78006 .... .......... A Thyroid imaging with uptake .............................. 0.49 2.55 NA 0.15 3.19 NA XXX 

78007 .... 26 ..... A Thyroid image, mult uptakes .............................. 0.50 0.17 0.17 0.02 0.69 0.69 XXX 

78007 .... TC .... A Thyroid image, mult uptakes .............................. 0.00 2.58 NA 0.14 2.72 NA XXX 

78007 .... .......... A Thyroid image, mult uptakes .............................. 0.50 2.75 NA 0.16 3.41 NA XXX 

78010 .... 26 ..... A Thyroid imaging .................................................. 0.39 0.13 0.13 0.02 0.54 0.54 XXX 

78010 .... TC .... A Thyroid imaging .................................................. 0.00 1.83 NA 0.11 1.94 NA XXX 

78010 .... .......... A Thyroid imaging .................................................. 0.39 1.96 NA 0.13 2.48 NA XXX 

78011 .... 26 ..... A Thyroid imaging with flow ................................... 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

78011 .... TC .... A Thyroid imaging with flow ................................... 0.00 2.42 NA 0.13 2.55 NA XXX 

78011 .... .......... A Thyroid imaging with flow ................................... 0.45 2.57 NA 0.15 3.17 NA XXX 

78015 .... 26 ..... A Thyroid met imaging ........................................... 0.67 0.23 0.23 0.03 0.93 0.93 XXX 

78015 .... TC .... A Thyroid met imaging ........................................... 0.00 2.58 NA 0.14 2.72 NA XXX 

78015 .... .......... A Thyroid met imaging ........................................... 0.67 2.81 NA 0.17 3.65 NA XXX 

78016 .... 26 ..... A Thyroid met imaging/studies .............................. 0.82 0.28 0.28 0.03 1.13 1.13 XXX 

78016 .... TC .... A Thyroid met imaging/studies .............................. 0.00 3.49 NA 0.18 3.67 NA XXX 

78016 .... .......... A Thyroid met imaging/studies .............................. 0.82 3.77 NA 0.21 4.80 NA XXX 

78018 .... 26 ..... A Thyroid met imaging, body ................................. 0.86 0.30 0.30 0.04 1.20 1.20 XXX 

78018 .... TC .... A Thyroid met imaging, body ................................. 0.00 5.44 NA 0.29 5.73 NA XXX 

78018 .... .......... A Thyroid met imaging, body ................................. 0.86 5.74 NA 0.33 6.93 NA XXX 

78020 .... 26 ..... A Thyroid met uptake ............................................ 0.60 0.21 0.21 0.02 0.83 0.83 ZZZ 

78020 .... TC .... A Thyroid met uptake ............................................ 0.00 1.31 NA 0.14 1.45 NA ZZZ 

78020 .... .......... A Thyroid met uptake ............................................ 0.60 1.52 NA 0.16 2.28 NA ZZZ 

78070 .... 26 ..... A Parathyroid nuclear imaging .............................. 0.82 0.28 0.28 0.04 1.14 1.14 XXX 

78070 .... TC .... A Parathyroid nuclear imaging .............................. 0.00 4.28 NA 0.11 4.39 NA XXX 

78070 .... .......... A Parathyroid nuclear imaging .............................. 0.82 4.56 NA 0.15 5.53 NA XXX 

78075 .... 26 ..... A Adrenal nuclear imaging .................................... 0.74 0.26 0.26 0.03 1.03 1.03 XXX 

78075 .... TC .... A Adrenal nuclear imaging .................................... 0.00 5.44 NA 0.29 5.73 NA XXX 

78075 .... .......... A Adrenal nuclear imaging .................................... 0.74 5.70 NA 0.32 6.76 NA XXX 

78099 .... 26 ..... C Endocrine nuclear procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78099 .... TC .... C Endocrine nuclear procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78099 .... .......... C Endocrine nuclear procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78102 .... 26 ..... A Bone marrow imaging, ltd .................................. 0.55 0.19 0.19 0.02 0.76 0.76 XXX 

78102 .... TC .... A Bone marrow imaging, ltd .................................. 0.00 2.05 NA 0.12 2.17 NA XXX 

78102 .... .......... A Bone marrow imaging, ltd .................................. 0.55 2.24 NA 0.14 2.93 NA XXX 

78103 .... 26 ..... A Bone marrow imaging, mult ............................... 0.75 0.26 0.26 0.03 1.04 1.04 XXX 

78103 .... TC .... A Bone marrow imaging, mult ............................... 0.00 3.18 NA 0.17 3.35 NA XXX 

78103 .... .......... A Bone marrow imaging, mult ............................... 0.75 3.44 NA 0.20 4.39 NA XXX 

78104 .... 26 ..... A Bone marrow imaging, body .............................. 0.80 0.27 0.27 0.03 1.10 1.10 XXX 

78104 .... TC .... A Bone marrow imaging, body .............................. 0.00 4.08 NA 0.22 4.30 NA XXX 

78104 .... .......... A Bone marrow imaging, body .............................. 0.80 4.35 NA 0.25 5.40 NA XXX 

78110 .... 26 ..... A Plasma volume, single ....................................... 0.19 0.07 0.07 0.01 0.27 0.27 XXX 

78110 .... TC .... A Plasma volume, single ....................................... 0.00 0.95 NA 0.06 1.01 NA XXX 

78110 .... .......... A Plasma volume, single ....................................... 0.19 1.02 NA 0.07 1.28 NA XXX 

78111 .... 26 ..... A Plasma volume, multiple .................................... 0.22 0.08 0.08 0.01 0.31 0.31 XXX 

78111 .... TC .... A Plasma volume, multiple .................................... 0.00 2.58 NA 0.14 2.72 NA XXX 

78111 .... .......... A Plasma volume, multiple .................................... 0.22 2.66 NA 0.15 3.03 NA XXX 

78120 .... 26 ..... A Red cell mass, single ......................................... 0.23 0.08 0.08 0.01 0.32 0.32 XXX 

78120 .... TC .... A Red cell mass, single ......................................... 0.00 1.74 NA 0.11 1.85 NA XXX 

78120 .... .......... A Red cell mass, single ......................................... 0.23 1.82 NA 0.12 2.17 NA XXX 

78121 .... 26 ..... A Red cell mass, multiple ...................................... 0.32 0.11 0.11 0.01 0.44 0.44 XXX 

78121 .... TC .... A Red cell mass, multiple ...................................... 0.00 2.92 NA 0.14 3.06 NA XXX 

78121 .... .......... A Red cell mass, multiple ...................................... 0.32 3.03 NA 0.15 3.50 NA XXX 

78122 .... 26 ..... A Blood volume ...................................................... 0.45 0.16 0.16 0.02 0.63 0.63 XXX 

78122 .... TC .... A Blood volume ...................................................... 0.00 4.61 NA 0.24 4.85 NA XXX 

78122 .... .......... A Blood volume ...................................................... 0.45 4.77 NA 0.26 5.48 NA XXX 

78130 .... 26 ..... A Red cell survival study ....................................... 0.61 0.21 0.21 0.03 0.85 0.85 XXX 

78130 .... TC .... A Red cell survival study ....................................... 0.00 2.86 NA 0.14 3.00 NA XXX 

78130 .... .......... A Red cell survival study ....................................... 0.61 3.07 NA 0.17 3.85 NA XXX 

78135 .... 26 ..... A Red cell survival kinetics .................................... 0.64 0.22 0.22 0.03 0.89 0.89 XXX 

78135 .... TC .... A Red cell survival kinetics .................................... 0.00 4.88 NA 0.25 5.13 NA XXX 

78135 .... .......... A Red cell survival kinetics .................................... 0.64 5.10 NA 0.28 6.02 NA XXX 

78140 .... 26 ..... A Red cell sequestration ........................................ 0.61 0.20 0.20 0.03 0.84 0.84 XXX 

78140 .... TC .... A Red cell sequestration ........................................ 0.00 3.94 NA 0.21 4.15 NA XXX 

78140 .... .......... A Red cell sequestration ........................................ 0.61 4.14 NA 0.24 4.99 NA XXX 

78185 .... 26 ..... A Spleen imaging ................................................... 0.40 0.14 0.14 0.02 0.56 0.56 XXX 

78185 .... TC .... A Spleen imaging ................................................... 0.00 2.37 NA 0.13 2.50 NA XXX 

78185 .... .......... A Spleen imaging ................................................... 0.40 2.51 NA 0.15 3.06 NA XXX 

78190 .... 26 ..... A Platelet survival, kinetics .................................... 1.09 0.39 0.39 0.08 1.56 1.56 XXX 

78190 .... TC .... A Platelet survival, kinetics .................................... 0.00 5.73 NA 0.30 6.03 NA XXX 

70433 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78190 .... .......... A Platelet survival, kinetics .................................... 1.09 6.12 NA 0.38 7.59 NA XXX 

78191 .... 26 ..... A Platelet survival .................................................. 0.61 0.20 0.20 0.03 0.84 0.84 XXX 

78191 .... TC .... A Platelet survival .................................................. 0.00 7.36 NA 0.37 7.73 NA XXX 

78191 .... .......... A Platelet survival .................................................. 0.61 7.56 NA 0.40 8.57 NA XXX 

78195 .... 26 ..... A Lymph system imaging ...................................... 1.20 0.41 0.41 0.06 1.67 1.67 XXX 

78195 .... TC .... A Lymph system imaging ...................................... 0.00 4.08 NA 0.22 4.30 NA XXX 

78195 .... .......... A Lymph system imaging ...................................... 1.20 4.49 NA 0.28 5.97 NA XXX 

78199 .... 26 ..... C Blood/lymph nuclear exam ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78199 .... TC .... C Blood/lymph nuclear exam ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78199 .... .......... C Blood/lymph nuclear exam ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78201 .... 26 ..... A Liver imaging ...................................................... 0.44 0.15 0.15 0.02 0.61 0.61 XXX 

78201 .... TC .... A Liver imaging ...................................................... 0.00 2.37 NA 0.13 2.50 NA XXX 

78201 .... .......... A Liver imaging ...................................................... 0.44 2.52 NA 0.15 3.11 NA XXX 

78202 .... 26 ..... A Liver imaging with flow ....................................... 0.51 0.17 0.17 0.02 0.70 0.70 XXX 

78202 .... TC .... A Liver imaging with flow ....................................... 0.00 2.89 NA 0.14 3.03 NA XXX 

78202 .... .......... A Liver imaging with flow ....................................... 0.51 3.06 NA 0.16 3.73 NA XXX 

78205 .... 26 ..... A Liver imaging (3D) .............................................. 0.71 0.24 0.24 0.03 0.98 0.98 XXX 

78205 .... TC .... A Liver imaging (3D) .............................................. 0.00 5.93 NA 0.31 6.24 NA XXX 

78205 .... .......... A Liver imaging (3D) .............................................. 0.71 6.17 NA 0.34 7.22 NA XXX 

78206 .... 26 ..... A Liver image (3d) with flow .................................. 0.96 0.33 0.33 0.04 1.33 1.33 XXX 

78206 .... TC .... A Liver image (3d) with flow .................................. 0.00 5.93 NA 0.11 6.04 NA XXX 

78206 .... .......... A Liver image (3d) with flow .................................. 0.96 6.26 NA 0.15 7.37 NA XXX 

78215 .... 26 ..... A Liver and spleen imaging ................................... 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

78215 .... TC .... A Liver and spleen imaging ................................... 0.00 2.95 NA 0.14 3.09 NA XXX 

78215 .... .......... A Liver and spleen imaging ................................... 0.49 3.11 NA 0.16 3.76 NA XXX 

78216 .... 26 ..... A Liver & spleen image/flow .................................. 0.57 0.19 0.19 0.02 0.78 0.78 XXX 

78216 .... TC .... A Liver & spleen image/flow .................................. 0.00 3.49 NA 0.18 3.67 NA XXX 

78216 .... .......... A Liver & spleen image/flow .................................. 0.57 3.68 NA 0.20 4.45 NA XXX 

78220 .... 26 ..... A Liver function study ............................................ 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

78220 .... TC .... A Liver function study ............................................ 0.00 3.73 NA 0.19 3.92 NA XXX 

78220 .... .......... A Liver function study ............................................ 0.49 3.89 NA 0.21 4.59 NA XXX 

78223 .... 26 ..... A Hepatobiliary imaging ......................................... 0.84 0.28 0.28 0.04 1.16 1.16 XXX 

78223 .... TC .... A Hepatobiliary imaging ......................................... 0.00 3.67 NA 0.19 3.86 NA XXX 

78223 .... .......... A Hepatobiliary imaging ......................................... 0.84 3.95 NA 0.23 5.02 NA XXX 

78230 .... 26 ..... A Salivary gland imaging ....................................... 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

78230 .... TC .... A Salivary gland imaging ....................................... 0.00 2.19 NA 0.13 2.32 NA XXX 

78230 .... .......... A Salivary gland imaging ....................................... 0.45 2.34 NA 0.15 2.94 NA XXX 

78231 .... 26 ..... A Serial salivary imaging ....................................... 0.52 0.18 0.18 0.02 0.72 0.72 XXX 

78231 .... TC .... A Serial salivary imaging ....................................... 0.00 3.18 NA 0.17 3.35 NA XXX 

78231 .... .......... A Serial salivary imaging ....................................... 0.52 3.36 NA 0.19 4.07 NA XXX 

78232 .... 26 ..... A Salivary gland function exam ............................. 0.47 0.16 0.16 0.02 0.65 0.65 XXX 

78232 .... TC .... A Salivary gland function exam ............................. 0.00 3.55 NA 0.18 3.73 NA XXX 

78232 .... .......... A Salivary gland function exam ............................. 0.47 3.71 NA 0.20 4.38 NA XXX 

78258 .... 26 ..... A Esophageal motility study .................................. 0.74 0.25 0.25 0.03 1.02 1.02 XXX 

78258 .... TC .... A Esophageal motility study .................................. 0.00 2.89 NA 0.14 3.03 NA XXX 

78258 .... .......... A Esophageal motility study .................................. 0.74 3.14 NA 0.17 4.05 NA XXX 

78261 .... 26 ..... A Gastric mucosa imaging ..................................... 0.69 0.24 0.24 0.03 0.96 0.96 XXX 

78261 .... TC .... A Gastric mucosa imaging ..................................... 0.00 4.11 NA 0.22 4.33 NA XXX 

78261 .... .......... A Gastric mucosa imaging ..................................... 0.69 4.35 NA 0.25 5.29 NA XXX 

78262 .... 26 ..... A Gastroesophageal reflux exam .......................... 0.68 0.23 0.23 0.03 0.94 0.94 XXX 

78262 .... TC .... A Gastroesophageal reflux exam .......................... 0.00 4.26 NA 0.22 4.48 NA XXX 

78262 .... .......... A Gastroesophageal reflux exam .......................... 0.68 4.49 NA 0.25 5.42 NA XXX 

78264 .... 26 ..... A Gastric emptying study ....................................... 0.78 0.26 0.26 0.03 1.07 1.07 XXX 

78264 .... TC .... A Gastric emptying study ....................................... 0.00 4.14 NA 0.22 4.36 NA XXX 

78264 .... .......... A Gastric emptying study ....................................... 0.78 4.40 NA 0.25 5.43 NA XXX 

78267 .... .......... X Breath tst attain/anal c-14 .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78268 .... .......... X Breath test analysis, c-14 ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78270 .... 26 ..... A Vit B-12 absorption exam ................................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

78270 .... TC .... A Vit B-12 absorption exam ................................... 0.00 1.55 NA 0.10 1.65 NA XXX 

78270 .... .......... A Vit B-12 absorption exam ................................... 0.20 1.62 NA 0.11 1.93 NA XXX 

78271 .... 26 ..... A Vit b-12 absrp exam, int fac ............................... 0.20 0.07 0.07 0.01 0.28 0.28 XXX 

78271 .... TC .... A Vit b-12 absrp exam, int fac ............................... 0.00 1.64 NA 0.10 1.74 NA XXX 

78271 .... .......... A Vit b-12 absrp exam, int fac ............................... 0.20 1.71 NA 0.11 2.02 NA XXX 

78272 .... 26 ..... A Vit B-12 absorp, combined ................................. 0.27 0.09 0.09 0.01 0.37 0.37 XXX 

78272 .... TC .... A Vit B-12 absorp, combined ................................. 0.00 2.33 NA 0.13 2.46 NA XXX 

78272 .... .......... A Vit B-12 absorp, combined ................................. 0.27 2.42 NA 0.14 2.83 NA XXX 

78278 .... 26 ..... A Acute GI blood loss imaging .............................. 0.99 0.33 0.33 0.04 1.36 1.36 XXX 

78278 .... TC .... A Acute GI blood loss imaging .............................. 0.00 4.88 NA 0.25 5.13 NA XXX 

78278 .... .......... A Acute GI blood loss imaging .............................. 0.99 5.21 NA 0.29 6.49 NA XXX 

78282 .... 26 ..... A GI protein loss exam .......................................... 0.38 0.13 0.13 0.02 0.53 0.53 XXX 

78282 .... TC .... C GI protein loss exam .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78282 .... .......... C GI protein loss exam .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78290 .... 26 ..... A Meckel’s divert exam .......................................... 0.68 0.23 0.23 0.03 0.94 0.94 XXX 

78290 .... TC .... A Meckel’s divert exam .......................................... 0.00 3.06 NA 0.16 3.22 NA XXX 

78290 .... .......... A Meckel’s divert exam .......................................... 0.68 3.29 NA 0.19 4.16 NA XXX 

70434 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78291 .... 26 ..... A Leveen/shunt patency exam .............................. 0.88 0.30 0.30 0.04 1.22 1.22 XXX 

78291 .... TC .... A Leveen/shunt patency exam .............................. 0.00 3.07 NA 0.16 3.23 NA XXX 

78291 .... .......... A Leveen/shunt patency exam .............................. 0.88 3.37 NA 0.20 4.45 NA XXX 

78299 .... 26 ..... C GI nuclear procedure ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78299 .... TC .... C GI nuclear procedure ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78299 .... .......... C GI nuclear procedure ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78300 .... 26 ..... A Bone imaging, limited area ................................ 0.62 0.21 0.21 0.03 0.86 0.86 XXX 

78300 .... TC .... A Bone imaging, limited area ................................ 0.00 2.49 NA 0.14 2.63 NA XXX 

78300 .... .......... A Bone imaging, limited area ................................ 0.62 2.70 NA 0.17 3.49 NA XXX 

78305 .... 26 ..... A Bone imaging, multiple areas ............................. 0.83 0.28 0.28 0.04 1.15 1.15 XXX 

78305 .... TC .... A Bone imaging, multiple areas ............................. 0.00 3.67 NA 0.19 3.86 NA XXX 

78305 .... .......... A Bone imaging, multiple areas ............................. 0.83 3.95 NA 0.23 5.01 NA XXX 

78306 .... 26 ..... A Bone imaging, whole body ................................. 0.86 0.29 0.29 0.04 1.19 1.19 XXX 

78306 .... TC .... A Bone imaging, whole body ................................. 0.00 4.28 NA 0.22 4.50 NA XXX 

78306 .... .......... A Bone imaging, whole body ................................. 0.86 4.57 NA 0.26 5.69 NA XXX 

78315 .... 26 ..... A Bone imaging, 3 phase ...................................... 1.02 0.34 0.34 0.04 1.40 1.40 XXX 

78315 .... TC .... A Bone imaging, 3 phase ...................................... 0.00 4.79 NA 0.25 5.04 NA XXX 

78315 .... .......... A Bone imaging, 3 phase ...................................... 1.02 5.13 NA 0.29 6.44 NA XXX 

78320 .... 26 ..... A Bone imaging (3D) ............................................. 1.04 0.36 0.36 0.04 1.44 1.44 XXX 

78320 .... TC .... A Bone imaging (3D) ............................................. 0.00 5.93 NA 0.31 6.24 NA XXX 

78320 .... .......... A Bone imaging (3D) ............................................. 1.04 6.29 NA 0.35 7.68 NA XXX 

78350 .... 26 ..... A Bone mineral, single photon .............................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

78350 .... TC .... A Bone mineral, single photon .............................. 0.00 0.75 NA 0.05 0.80 NA XXX 

78350 .... .......... A Bone mineral, single photon .............................. 0.22 0.82 NA 0.06 1.10 NA XXX 

78351 .... .......... N Bone mineral, dual photon ................................. +0.30 1.72 0.12 0.01 2.03 0.43 XXX 

78399 .... 26 ..... C Musculoskeletal nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78399 .... TC .... C Musculoskeletal nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78399 .... .......... C Musculoskeletal nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78414 .... 26 ..... A Non-imaging heart function ................................ 0.45 0.16 0.16 0.02 0.63 0.63 XXX 

78414 .... TC .... C Non-imaging heart function ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78414 .... .......... C Non-imaging heart function ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78428 .... 26 ..... A Cardiac shunt imaging ....................................... 0.78 0.29 0.29 0.03 1.10 1.10 XXX 

78428 .... TC .... A Cardiac shunt imaging ....................................... 0.00 2.26 NA 0.13 2.39 NA XXX 

78428 .... .......... A Cardiac shunt imaging ....................................... 0.78 2.55 NA 0.16 3.49 NA XXX 

78445 .... 26 ..... A Vascular flow imaging ........................................ 0.49 0.17 0.17 0.02 0.68 0.68 XXX 

78445 .... TC .... A Vascular flow imaging ........................................ 0.00 1.87 NA 0.11 1.98 NA XXX 

78445 .... .......... A Vascular flow imaging ........................................ 0.49 2.04 NA 0.13 2.66 NA XXX 

78456 .... 26 ..... A Acute venous thrombus image .......................... 1.00 0.34 0.34 0.04 1.38 1.38 XXX 

78456 .... TC .... A Acute venous thrombus image .......................... 0.00 3.99 NA 0.29 4.28 NA XXX 

78456 .... .......... A Acute venous thrombus image .......................... 1.00 4.33 NA 0.33 5.66 NA XXX 

78457 .... 26 ..... A Venous thrombosis imaging ............................... 0.77 0.26 0.26 0.03 1.06 1.06 XXX 

78457 .... TC .... A Venous thrombosis imaging ............................... 0.00 2.67 NA 0.14 2.81 NA XXX 

78457 .... .......... A Venous thrombosis imaging ............................... 0.77 2.93 NA 0.17 3.87 NA XXX 

78458 .... 26 ..... A Ven thrombosis images, bilat ............................. 0.90 0.32 0.32 0.04 1.26 1.26 XXX 

78458 .... TC .... A Ven thrombosis images, bilat ............................. 0.00 4.03 NA 0.21 4.24 NA XXX 

78458 .... .......... A Ven thrombosis images, bilat ............................. 0.90 4.35 NA 0.25 5.50 NA XXX 

78459 .... 26 ..... A Heart muscle imaging (PET) .............................. 1.50 0.57 0.57 0.05 2.12 2.12 XXX 

78459 .... TC .... C Heart muscle imaging (PET) .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78459 .... .......... C Heart muscle imaging (PET) .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78460 .... 26 ..... A Heart muscle blood, single ................................. 0.86 0.29 0.29 0.04 1.19 1.19 XXX 

78460 .... TC .... A Heart muscle blood, single ................................. 0.00 2.37 NA 0.13 2.50 NA XXX 

78460 .... .......... A Heart muscle blood, single ................................. 0.86 2.66 NA 0.17 3.69 NA XXX 

78461 .... 26 ..... A Heart muscle blood, multiple .............................. 1.23 0.43 0.43 0.05 1.71 1.71 XXX 

78461 .... TC .... A Heart muscle blood, multiple .............................. 0.00 4.73 NA 0.25 4.98 NA XXX 

78461 .... .......... A Heart muscle blood, multiple .............................. 1.23 5.16 NA 0.30 6.69 NA XXX 

78464 .... 26 ..... A Heart image (3d), single ..................................... 1.09 0.38 0.38 0.04 1.51 1.51 XXX 

78464 .... TC .... A Heart image (3d), single ..................................... 0.00 7.09 NA 0.37 7.46 NA XXX 

78464 .... .......... A Heart image (3d), single ..................................... 1.09 7.47 NA 0.41 8.97 NA XXX 

78465 .... 26 ..... A Heart image (3d), multiple .................................. 1.46 0.52 0.52 0.05 2.03 2.03 XXX 

78465 .... TC .... A Heart image (3d), multiple .................................. 0.00 11.82 NA 0.62 12.44 NA XXX 

78465 .... .......... A Heart image (3d), multiple .................................. 1.46 12.34 NA 0.67 14.47 NA XXX 

78466 .... 26 ..... A Heart infarct image ............................................. 0.69 0.24 0.24 0.03 0.96 0.96 XXX 

78466 .... TC .... A Heart infarct image ............................................. 0.00 2.63 NA 0.14 2.77 NA XXX 

78466 .... .......... A Heart infarct image ............................................. 0.69 2.87 NA 0.17 3.73 NA XXX 

78468 .... 26 ..... A Heart infarct image (ef) ...................................... 0.80 0.27 0.27 0.03 1.10 1.10 XXX 

78468 .... TC .... A Heart infarct image (ef) ...................................... 0.00 3.67 NA 0.19 3.86 NA XXX 

78468 .... .......... A Heart infarct image (ef) ...................................... 0.80 3.94 NA 0.22 4.96 NA XXX 

78469 .... 26 ..... A Heart infarct image (3D) ..................................... 0.92 0.31 0.31 0.03 1.26 1.26 XXX 

78469 .... TC .... A Heart infarct image (3D) ..................................... 0.00 5.24 NA 0.28 5.52 NA XXX 

78469 .... .......... A Heart infarct image (3D) ..................................... 0.92 5.55 NA 0.31 6.78 NA XXX 

78472 .... 26 ..... A Gated heart, planar, single ................................. 0.98 0.34 0.34 0.04 1.36 1.36 XXX 

78472 .... TC .... A Gated heart, planar, single ................................. 0.00 5.53 NA 0.30 5.83 NA XXX 

78472 .... .......... A Gated heart, planar, single ................................. 0.98 5.87 NA 0.34 7.19 NA XXX 

78473 .... 26 ..... A Gated heart, multiple .......................................... 1.47 0.51 0.51 0.06 2.04 2.04 XXX 

78473 .... TC .... A Gated heart, multiple .......................................... 0.00 8.28 NA 0.42 8.70 NA XXX 

70435 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78473 .... .......... A Gated heart, multiple .......................................... 1.47 8.79 NA 0.48 10.74 NA XXX 

78478 .... 26 ..... A Heart wall motion add-on ................................... 0.62 0.23 0.23 0.02 0.87 0.87 XXX 

78478 .... TC .... A Heart wall motion add-on ................................... 0.00 1.56 NA 0.10 1.66 NA XXX 

78478 .... .......... A Heart wall motion add-on ................................... 0.62 1.79 NA 0.12 2.53 NA XXX 

78480 .... 26 ..... A Heart function add-on ......................................... 0.62 0.22 0.22 0.02 0.86 0.86 XXX 

78480 .... TC .... A Heart function add-on ......................................... 0.00 1.56 NA 0.10 1.66 NA XXX 

78480 .... .......... A Heart function add-on ......................................... 0.62 1.78 NA 0.12 2.52 NA XXX 

78481 .... 26 ..... A Heart first pass, single ....................................... 0.98 0.36 0.36 0.03 1.37 1.37 XXX 

78481 .... TC .... A Heart first pass, single ....................................... 0.00 5.24 NA 0.28 5.52 NA XXX 

78481 .... .......... A Heart first pass, single ....................................... 0.98 5.60 NA 0.31 6.89 NA XXX 

78483 .... 26 ..... A Heart first pass, multiple .................................... 1.47 0.54 0.54 0.05 2.06 2.06 XXX 

78483 .... TC .... A Heart first pass, multiple .................................... 0.00 7.89 NA 0.41 8.30 NA XXX 

78483 .... .......... A Heart first pass, multiple .................................... 1.47 8.43 NA 0.46 10.36 NA XXX 

78491 .... 26 ..... A Heart image (pet), single .................................... 1.50 0.59 0.59 0.06 2.15 2.15 XXX 

78491 .... TC .... C Heart image (pet), single .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78491 .... .......... C Heart image (pet), single .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78492 .... 26 ..... A Heart image (pet), multiple ................................. 1.87 0.74 0.74 0.07 2.68 2.68 XXX 

78492 .... TC .... C Heart image (pet), multiple ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78492 .... .......... C Heart image (pet), multiple ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78494 .... 26 ..... A Heart image, spect ............................................. 1.19 0.42 0.42 0.05 1.66 1.66 XXX 

78494 .... TC .... A Heart image, spect ............................................. 0.00 7.09 NA 0.30 7.39 NA XXX 

78494 .... .......... A Heart image, spect ............................................. 1.19 7.51 NA 0.35 9.05 NA XXX 

78496 .... 26 ..... A Heart first pass add-on ....................................... 0.50 0.18 0.18 0.02 0.70 0.70 ZZZ 

78496 .... TC .... A Heart first pass add-on ....................................... 0.00 7.09 NA 0.30 7.39 NA ZZZ 

78496 .... .......... A Heart first pass add-on ....................................... 0.50 7.27 NA 0.32 8.09 NA ZZZ 

78499 .... 26 ..... C Cardiovascular nuclear exam ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78499 .... TC .... C Cardiovascular nuclear exam ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78499 .... .......... C Cardiovascular nuclear exam ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78580 .... 26 ..... A Lung perfusion imaging ...................................... 0.74 0.25 0.25 0.03 1.02 1.02 XXX 

78580 .... TC .... A Lung perfusion imaging ...................................... 0.00 3.44 NA 0.18 3.62 NA XXX 

78580 .... .......... A Lung perfusion imaging ...................................... 0.74 3.69 NA 0.21 4.64 NA XXX 

78584 .... 26 ..... A Lung V/Q image single breath ........................... 0.99 0.33 0.33 0.04 1.36 1.36 XXX 

78584 .... TC .... A Lung V/Q image single breath ........................... 0.00 3.21 NA 0.17 3.38 NA XXX 

78584 .... .......... A Lung V/Q image single breath ........................... 0.99 3.54 NA 0.21 4.74 NA XXX 

78585 .... 26 ..... A Lung V/Q imaging .............................................. 1.09 0.36 0.36 0.05 1.50 1.50 XXX 

78585 .... TC .... A Lung V/Q imaging .............................................. 0.00 5.66 NA 0.30 5.96 NA XXX 

78585 .... .......... A Lung V/Q imaging .............................................. 1.09 6.02 NA 0.35 7.46 NA XXX 

78586 .... 26 ..... A Aerosol lung image, single ................................. 0.40 0.13 0.13 0.02 0.55 0.55 XXX 

78586 .... TC .... A Aerosol lung image, single ................................. 0.00 2.60 NA 0.14 2.74 NA XXX 

78586 .... .......... A Aerosol lung image, single ................................. 0.40 2.73 NA 0.16 3.29 NA XXX 

78587 .... 26 ..... A Aerosol lung image, multiple .............................. 0.49 0.17 0.17 0.02 0.68 0.68 XXX 

78587 .... TC .... A Aerosol lung image, multiple .............................. 0.00 2.81 NA 0.14 2.95 NA XXX 

78587 .... .......... A Aerosol lung image, multiple .............................. 0.49 2.98 NA 0.16 3.63 NA XXX 

78588 .... 26 ..... A Perfusion lung image ......................................... 1.09 0.36 0.36 0.05 1.50 1.50 XXX 

78588 .... TC .... A Perfusion lung image ......................................... 0.00 3.21 NA 0.18 3.39 NA XXX 

78588 .... .......... A Perfusion lung image ......................................... 1.09 3.57 NA 0.23 4.89 NA XXX 

78591 .... 26 ..... A Vent image, 1 breath, 1 proj .............................. 0.40 0.13 0.13 0.02 0.55 0.55 XXX 

78591 .... TC .... A Vent image, 1 breath, 1 proj .............................. 0.00 2.86 NA 0.14 3.00 NA XXX 

78591 .... .......... A Vent image, 1 breath, 1 proj .............................. 0.40 2.99 NA 0.16 3.55 NA XXX 

78593 .... 26 ..... A Vent image, 1 proj, gas ...................................... 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

78593 .... TC .... A Vent image, 1 proj, gas ...................................... 0.00 3.46 NA 0.18 3.64 NA XXX 

78593 .... .......... A Vent image, 1 proj, gas ...................................... 0.49 3.62 NA 0.20 4.31 NA XXX 

78594 .... 26 ..... A Vent image, mult proj, gas ................................. 0.53 0.18 0.18 0.02 0.73 0.73 XXX 

78594 .... TC .... A Vent image, mult proj, gas ................................. 0.00 4.99 NA 0.25 5.24 NA XXX 

78594 .... .......... A Vent image, mult proj, gas ................................. 0.53 5.17 NA 0.27 5.97 NA XXX 

78596 .... 26 ..... A Lung differential function .................................... 1.27 0.42 0.42 0.05 1.74 1.74 XXX 

78596 .... TC .... A Lung differential function .................................... 0.00 7.09 NA 0.37 7.46 NA XXX 

78596 .... .......... A Lung differential function .................................... 1.27 7.51 NA 0.42 9.20 NA XXX 

78599 .... 26 ..... C Respiratory nuclear exam .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78599 .... TC .... C Respiratory nuclear exam .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78599 .... .......... C Respiratory nuclear exam .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78600 .... 26 ..... A Brain imaging, ltd static ...................................... 0.44 0.15 0.15 0.02 0.61 0.61 XXX 

78600 .... TC .... A Brain imaging, ltd static ...................................... 0.00 2.89 NA 0.14 3.03 NA XXX 

78600 .... .......... A Brain imaging, ltd static ...................................... 0.44 3.04 NA 0.16 3.64 NA XXX 

78601 .... 26 ..... A Brain imaging, ltd w/flow .................................... 0.51 0.17 0.17 0.02 0.70 0.70 XXX 

78601 .... TC .... A Brain imaging, ltd w/flow .................................... 0.00 3.41 NA 0.18 3.59 NA XXX 

78601 .... .......... A Brain imaging, ltd w/flow .................................... 0.51 3.58 NA 0.20 4.29 NA XXX 

78605 .... 26 ..... A Brain imaging, complete ..................................... 0.53 0.18 0.18 0.02 0.73 0.73 XXX 

78605 .... TC .... A Brain imaging, complete ..................................... 0.00 3.41 NA 0.18 3.59 NA XXX 

78605 .... .......... A Brain imaging, complete ..................................... 0.53 3.59 NA 0.20 4.32 NA XXX 

78606 .... 26 ..... A Brain imaging, compl w/flow .............................. 0.64 0.21 0.21 0.03 0.88 0.88 XXX 

78606 .... TC .... A Brain imaging, compl w/flow .............................. 0.00 3.88 NA 0.21 4.09 NA XXX 

78606 .... .......... A Brain imaging, compl w/flow .............................. 0.64 4.09 NA 0.24 4.97 NA XXX 

78607 .... 26 ..... A Brain imaging (3D) ............................................. 1.23 0.43 0.43 0.05 1.71 1.71 XXX 

78607 .... TC .... A Brain imaging (3D) ............................................. 0.00 6.57 NA 0.35 6.92 NA XXX 

70436 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78607 .... .......... A Brain imaging (3D) ............................................. 1.23 7.00 NA 0.40 8.63 NA XXX 

78608 .... 26 ..... A Brain imaging (PET) ........................................... 1.50 0.51 0.51 0.06 2.07 2.07 XXX 

78608 .... TC .... C Brain imaging (PET) ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78608 .... .......... C Brain imaging (PET) ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78609 .... 26 ..... A Brain imaging (PET) ........................................... 1.50 0.51 0.51 0.06 2.07 2.07 XXX 

78609 .... TC .... C Brain imaging (PET) ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78609 .... .......... C Brain imaging (PET) ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78610 .... 26 ..... A Brain flow imaging only ...................................... 0.30 0.11 0.11 0.01 0.42 0.42 XXX 

78610 .... TC .... A Brain flow imaging only ...................................... 0.00 1.58 NA 0.10 1.68 NA XXX 

78610 .... .......... A Brain flow imaging only ...................................... 0.30 1.69 NA 0.11 2.10 NA XXX 

78615 .... 26 ..... A Cerebral vascular flow image ............................. 0.42 0.15 0.15 0.02 0.59 0.59 XXX 

78615 .... TC .... A Cerebral vascular flow image ............................. 0.00 3.86 NA 0.21 4.07 NA XXX 

78615 .... .......... A Cerebral vascular flow image ............................. 0.42 4.01 NA 0.23 4.66 NA XXX 

78630 .... 26 ..... A Cerebrospinal fluid scan ..................................... 0.68 0.23 0.23 0.03 0.94 0.94 XXX 

78630 .... TC .... A Cerebrospinal fluid scan ..................................... 0.00 5.05 NA 0.27 5.32 NA XXX 

78630 .... .......... A Cerebrospinal fluid scan ..................................... 0.68 5.28 NA 0.30 6.26 NA XXX 

78635 .... 26 ..... A CSF ventriculography ......................................... 0.61 0.23 0.23 0.02 0.86 0.86 XXX 

78635 .... TC .... A CSF ventriculography ......................................... 0.00 2.55 NA 0.14 2.69 NA XXX 

78635 .... .......... A CSF ventriculography ......................................... 0.61 2.78 NA 0.16 3.55 NA XXX 

78645 .... 26 ..... A CSF shunt evaluation ......................................... 0.57 0.19 0.19 0.02 0.78 0.78 XXX 

78645 .... TC .... A CSF shunt evaluation ......................................... 0.00 3.44 NA 0.18 3.62 NA XXX 

78645 .... .......... A CSF shunt evaluation ......................................... 0.57 3.63 NA 0.20 4.40 NA XXX 

78647 .... 26 ..... A Cerebrospinal fluid scan ..................................... 0.90 0.31 0.31 0.04 1.25 1.25 XXX 

78647 .... TC .... A Cerebrospinal fluid scan ..................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

78647 .... .......... A Cerebrospinal fluid scan ..................................... 0.90 6.24 NA 0.35 7.49 NA XXX 

78650 .... 26 ..... A CSF leakage imaging ......................................... 0.61 0.21 0.21 0.03 0.85 0.85 XXX 

78650 .... TC .... A CSF leakage imaging ......................................... 0.00 4.65 NA 0.24 4.89 NA XXX 

78650 .... .......... A CSF leakage imaging ......................................... 0.61 4.86 NA 0.27 5.74 NA XXX 

78660 .... 26 ..... A Nuclear exam of tear flow .................................. 0.53 0.18 0.18 0.02 0.73 0.73 XXX 

78660 .... TC .... A Nuclear exam of tear flow .................................. 0.00 2.13 NA 0.12 2.25 NA XXX 

78660 .... .......... A Nuclear exam of tear flow .................................. 0.53 2.31 NA 0.14 2.98 NA XXX 

78699 .... 26 ..... C Nervous system nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78699 .... TC .... C Nervous system nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78699 .... .......... C Nervous system nuclear exam ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78700 .... 26 ..... A Kidney imaging, static ........................................ 0.45 0.15 0.15 0.02 0.62 0.62 XXX 

78700 .... TC .... A Kidney imaging, static ........................................ 0.00 3.06 NA 0.16 3.22 NA XXX 

78700 .... .......... A Kidney imaging, static ........................................ 0.45 3.21 NA 0.18 3.84 NA XXX 

78701 .... 26 ..... A Kidney imaging with flow .................................... 0.49 0.16 0.16 0.02 0.67 0.67 XXX 

78701 .... TC .... A Kidney imaging with flow .................................... 0.00 3.57 NA 0.18 3.75 NA XXX 

78701 .... .......... A Kidney imaging with flow .................................... 0.49 3.73 NA 0.20 4.42 NA XXX 

78704 .... 26 ..... A Imaging renogram .............................................. 0.74 0.25 0.25 0.03 1.02 1.02 XXX 

78704 .... TC .... A Imaging renogram .............................................. 0.00 3.96 NA 0.21 4.17 NA XXX 

78704 .... .......... A Imaging renogram .............................................. 0.74 4.21 NA 0.24 5.19 NA XXX 

78707 .... 26 ..... A Kidney flow/function image ................................ 0.96 0.32 0.32 0.04 1.32 1.32 XXX 

78707 .... TC .... A Kidney flow/function image ................................ 0.00 4.48 NA 0.23 4.71 NA XXX 

78707 .... .......... A Kidney flow/function image ................................ 0.96 4.80 NA 0.27 6.03 NA XXX 

78708 .... 26 ..... A Kidney flow/function image ................................ 1.21 0.41 0.41 0.05 1.67 1.67 XXX 

78708 .... TC .... A Kidney flow/function image ................................ 0.00 4.48 NA 0.23 4.71 NA XXX 

78708 .... .......... A Kidney flow/function image ................................ 1.21 4.89 NA 0.28 6.38 NA XXX 

78709 .... 26 ..... A Kidney flow/function image ................................ 1.41 0.47 0.47 0.06 1.94 1.94 XXX 

78709 .... TC .... A Kidney flow/function image ................................ 0.00 4.48 NA 0.23 4.71 NA XXX 

78709 .... .......... A Kidney flow/function image ................................ 1.41 4.95 NA 0.29 6.65 NA XXX 

78710 .... 26 ..... A Kidney imaging (3D) ........................................... 0.66 0.22 0.22 0.03 0.91 0.91 XXX 

78710 .... TC .... A Kidney imaging (3D) ........................................... 0.00 5.93 NA 0.31 6.24 NA XXX 

78710 .... .......... A Kidney imaging (3D) ........................................... 0.66 6.15 NA 0.34 7.15 NA XXX 

78715 .... 26 ..... A Renal vascular flow exam .................................. 0.30 0.11 0.11 0.01 0.42 0.42 XXX 

78715 .... TC .... A Renal vascular flow exam .................................. 0.00 1.58 NA 0.10 1.68 NA XXX 

78715 .... .......... A Renal vascular flow exam .................................. 0.30 1.69 NA 0.11 2.10 NA XXX 

78725 .... 26 ..... A Kidney function study ......................................... 0.38 0.13 0.13 0.02 0.53 0.53 XXX 

78725 .... TC .... A Kidney function study ......................................... 0.00 1.79 NA 0.11 1.90 NA XXX 

78725 .... .......... A Kidney function study ......................................... 0.38 1.92 NA 0.13 2.43 NA XXX 

78730 .... 26 ..... A Urinary bladder retention .................................... 0.36 0.12 0.12 0.02 0.50 0.50 XXX 

78730 .... TC .... A Urinary bladder retention .................................... 0.00 1.46 NA 0.08 1.54 NA XXX 

78730 .... .......... A Urinary bladder retention .................................... 0.36 1.58 NA 0.10 2.04 NA XXX 

78740 .... 26 ..... A Ureteral reflux study ........................................... 0.57 0.19 0.19 0.03 0.79 0.79 XXX 

78740 .... TC .... A Ureteral reflux study ........................................... 0.00 2.13 NA 0.12 2.25 NA XXX 

78740 .... .......... A Ureteral reflux study ........................................... 0.57 2.32 NA 0.15 3.04 NA XXX 

78760 .... 26 ..... A Testicular imaging .............................................. 0.66 0.22 0.22 0.03 0.91 0.91 XXX 

78760 .... TC .... A Testicular imaging .............................................. 0.00 2.69 NA 0.14 2.83 NA XXX 

78760 .... .......... A Testicular imaging .............................................. 0.66 2.91 NA 0.17 3.74 NA XXX 

78761 .... 26 ..... A Testicular imaging/flow ....................................... 0.71 0.24 0.24 0.03 0.98 0.98 XXX 

78761 .... TC .... A Testicular imaging/flow ....................................... 0.00 3.21 NA 0.17 3.38 NA XXX 

78761 .... .......... A Testicular imaging/flow ....................................... 0.71 3.45 NA 0.20 4.36 NA XXX 

78799 .... 26 ..... C Genitourinary nuclear exam ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78799 .... TC .... C Genitourinary nuclear exam ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70437 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

78799 .... .......... C Genitourinary nuclear exam ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78800 .... 26 ..... A Tumor imaging, limited area .............................. 0.66 0.22 0.22 0.04 0.92 0.92 XXX 

78800 .... TC .... A Tumor imaging, limited area .............................. 0.00 3.41 NA 0.18 3.59 NA XXX 

78800 .... .......... A Tumor imaging, limited area .............................. 0.66 3.63 NA 0.22 4.51 NA XXX 

78801 .... 26 ..... A Tumor imaging, mult areas ................................ 0.79 0.27 0.27 0.05 1.11 1.11 XXX 

78801 .... TC .... A Tumor imaging, mult areas ................................ 0.00 4.23 NA 0.22 4.45 NA XXX 

78801 .... .......... A Tumor imaging, mult areas ................................ 0.79 4.50 NA 0.27 5.56 NA XXX 

78802 .... 26 ..... A Tumor imaging, whole body ............................... 0.86 0.29 0.29 0.04 1.19 1.19 XXX 

78802 .... TC .... A Tumor imaging, whole body ............................... 0.00 5.55 NA 0.30 5.85 NA XXX 

78802 .... .......... A Tumor imaging, whole body ............................... 0.86 5.84 NA 0.34 7.04 NA XXX 

78803 .... 26 ..... A Tumor imaging (3D) ........................................... 1.09 0.38 0.38 0.05 1.52 1.52 XXX 

78803 .... TC .... A Tumor imaging (3D) ........................................... 0.00 6.57 NA 0.35 6.92 NA XXX 

78803 .... .......... A Tumor imaging (3D) ........................................... 1.09 6.95 NA 0.40 8.44 NA XXX 

78804 .... 26 ..... A Tumor imaging, whole body ............................... 1.07 0.37 0.37 0.04 1.48 1.48 XXX 

78804 .... TC .... A Tumor imaging, whole body ............................... 0.00 11.09 NA 0.30 11.39 NA XXX 

78804 .... .......... A Tumor imaging, whole body ............................... 1.07 11.46 NA 0.34 12.87 NA XXX 

78805 .... 26 ..... A Abscess imaging, ltd area .................................. 0.73 0.25 0.25 0.03 1.01 1.01 XXX 

78805 .... TC .... A Abscess imaging, ltd area .................................. 0.00 3.41 NA 0.18 3.59 NA XXX 

78805 .... .......... A Abscess imaging, ltd area .................................. 0.73 3.66 NA 0.21 4.60 NA XXX 

78806 .... 26 ..... A Abscess imaging, whole body ............................ 0.86 0.29 0.29 0.04 1.19 1.19 XXX 

78806 .... TC .... A Abscess imaging, whole body ............................ 0.00 6.45 NA 0.35 6.80 NA XXX 

78806 .... .......... A Abscess imaging, whole body ............................ 0.86 6.74 NA 0.39 7.99 NA XXX 

78807 .... 26 ..... A Nuclear localization/abscess .............................. 1.09 0.39 0.39 0.04 1.52 1.52 XXX 

78807 .... TC .... A Nuclear localization/abscess .............................. 0.00 6.57 NA 0.35 6.92 NA XXX 

78807 .... .......... A Nuclear localization/abscess .............................. 1.09 6.96 NA 0.39 8.44 NA XXX 

78811 .... 26 ..... A Tumor imaging (pet), limited .............................. 1.54 0.53 0.53 0.11 2.18 2.18 XXX 

78811 .... TC .... C Tumor imaging (pet), limited .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78811 .... .......... C Tumor imaging (pet), limited .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78812 .... 26 ..... A Tumor image (pet)/skul-thigh ............................. 1.93 0.66 0.66 0.11 2.70 2.70 XXX 

78812 .... TC .... C Tumor image (pet)/skul-thigh ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78812 .... .......... C Tumor image (pet)/skul-thigh ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78813 .... 26 ..... A Tumor image (pet) full body ............................... 2.00 0.69 0.69 0.11 2.80 2.80 XXX 

78813 .... TC .... C Tumor image (pet) full body ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78813 .... .......... C Tumor image (pet) full body ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78814 .... 26 ..... A Tumor image pet/ct, limited ................................ 2.20 0.76 0.76 0.11 3.07 3.07 XXX 

78814 .... TC .... C Tumor image pet/ct, limited ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78814 .... .......... C Tumor image pet/ct, limited ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78815 .... 26 ..... A Tumorimage pet/ct skul-thigh ............................. 2.44 0.84 0.84 0.11 3.39 3.39 XXX 

78815 .... TC .... C Tumorimage pet/ct skul-thigh ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78815 .... .......... C Tumorimage pet/ct skul-thigh ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78816 .... 26 ..... A Tumor image pet/ct full body ............................. 2.50 0.86 0.86 0.11 3.47 3.47 XXX 

78816 .... TC .... C Tumor image pet/ct full body ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78816 .... .......... C Tumor image pet/ct full body ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78890 .... 26 ..... B Nuclear medicine data proc ............................... +0.05 0.02 0.02 0.01 0.08 0.08 XXX 

78890 .... TC .... B Nuclear medicine data proc ............................... +0.00 1.31 NA 0.06 1.37 NA XXX 

78890 .... .......... B Nuclear medicine data proc ............................... +0.05 1.33 NA 0.07 1.45 NA XXX 

78891 .... 26 ..... B Nuclear med data proc ....................................... +0.10 0.04 0.04 0.01 0.15 0.15 XXX 

78891 .... TC .... B Nuclear med data proc ....................................... +0.00 2.63 NA 0.13 2.76 NA XXX 

78891 .... .......... B Nuclear med data proc ....................................... +0.10 2.67 NA 0.14 2.91 NA XXX 

78999 .... 26 ..... C Nuclear diagnostic exam .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78999 .... TC .... C Nuclear diagnostic exam .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

78999 .... .......... C Nuclear diagnostic exam .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79005 .... 26 ..... A Nuclear rx, oral admin ........................................ 1.80 0.60 0.60 0.08 2.48 2.48 XXX 

79005 .... TC .... A Nuclear rx, oral admin ........................................ 0.00 2.63 NA 0.14 2.77 NA XXX 

79005 .... .......... A Nuclear rx, oral admin ........................................ 1.80 3.23 NA 0.22 5.25 NA XXX 

79101 .... 26 ..... A Nuclear rx, iv admin ........................................... 1.96 0.67 0.67 0.08 2.71 2.71 XXX 

79101 .... TC .... A Nuclear rx, iv admin ........................................... 0.00 2.63 NA 0.14 2.77 NA XXX 

79101 .... .......... A Nuclear rx, iv admin ........................................... 1.96 3.30 NA 0.22 5.48 NA XXX 

79200 .... 26 ..... A Nuclear rx, intracav admin ................................. 1.99 0.69 0.69 0.09 2.77 2.77 XXX 

79200 .... TC .... A Nuclear rx, intracav admin ................................. 0.00 2.63 NA 0.14 2.77 NA XXX 

79200 .... .......... A Nuclear rx, intracav admin ................................. 1.99 3.32 NA 0.23 5.54 NA XXX 

79300 .... 26 ..... A Nuclr rx, interstit colloid ...................................... 1.60 0.56 0.56 0.13 2.29 2.29 XXX 

79300 .... TC .... C Nuclr rx, interstit colloid ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79300 .... .......... C Nuclr rx, interstit colloid ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79403 .... 26 ..... A Hematopoietic nuclear tx .................................... 2.25 0.89 0.89 0.10 3.24 3.24 XXX 

79403 .... TC .... A Hematopoietic nuclear tx .................................... 0.00 4.28 NA 0.14 4.42 NA XXX 

79403 .... .......... A Hematopoietic nuclear tx .................................... 2.25 5.17 NA 0.24 7.66 NA XXX 

79440 .... 26 ..... A Nuclear rx, intra-articular .................................... 1.99 0.72 0.72 0.08 2.79 2.79 XXX 

79440 .... TC .... A Nuclear rx, intra-articular .................................... 0.00 2.63 NA 0.14 2.77 NA XXX 

79440 .... .......... A Nuclear rx, intra-articular .................................... 1.99 3.35 NA 0.22 5.56 NA XXX 

79445 .... 26 ..... A Nuclear rx, intra-arterial ...................................... 2.40 0.82 0.82 0.12 3.34 3.34 XXX 

79445 .... TC .... C Nuclear rx, intra-arterial ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79445 .... .......... C Nuclear rx, intra-arterial ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79999 .... 26 ..... C Nuclear medicine therapy .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

79999 .... TC .... C Nuclear medicine therapy .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70438 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

79999 .... .......... C Nuclear medicine therapy .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

80500 .... .......... A Lab pathology consultation ................................ 0.37 0.21 0.16 0.01 0.59 0.54 XXX 

80502 .... .......... A Lab pathology consultation ................................ 1.33 0.54 0.54 0.04 1.91 1.91 XXX 

83020 .... 26 ..... A Hemoglobin electrophoresis ............................... 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

83912 .... 26 ..... A Genetic examination ........................................... 0.37 0.12 0.12 0.01 0.50 0.50 XXX 

84165 .... 26 ..... A Protein e-phoresis, serum .................................. 0.37 0.14 0.14 0.01 0.52 0.52 XXX 

84166 .... 26 ..... A Protein e-phoresis/urine/csf ................................ 0.37 0.14 0.14 0.01 0.52 0.52 XXX 

84181 .... 26 ..... A Western blot test ................................................ 0.37 0.14 0.14 0.01 0.52 0.52 XXX 

84182 .... 26 ..... A Protein, western blot test ................................... 0.37 0.16 0.16 0.02 0.55 0.55 XXX 

85060 .... .......... A Blood smear interpretation ................................. 0.45 0.18 0.18 0.02 0.65 0.65 XXX 

85097 .... .......... A Bone marrow interpretation ................................ 0.94 1.92 0.41 0.04 2.90 1.39 XXX 

85390 .... 26 ..... A Fibrinolysins screen ............................................ 0.37 0.13 0.13 0.01 0.51 0.51 XXX 

85396 .... .......... A Clotting assay, whole blood ............................... 0.37 NA 0.16 0.04 NA 0.57 XXX 

85576 .... 26 ..... A Blood platelet aggregation ................................. 0.37 0.16 0.16 0.01 0.54 0.54 XXX 

86077 .... .......... A Physician blood bank service ............................. 0.94 0.39 0.39 0.03 1.36 1.36 XXX 

86078 .... .......... A Physician blood bank service ............................. 0.94 0.46 0.40 0.03 1.43 1.37 XXX 

86079 .... .......... A Physician blood bank service ............................. 0.94 0.45 0.41 0.03 1.42 1.38 XXX 

86255 .... 26 ..... A Fluorescent antibody, screen ............................. 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

86256 .... 26 ..... A Fluorescent antibody, titer .................................. 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

86320 .... 26 ..... A Serum immunoelectrophoresis ........................... 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

86325 .... 26 ..... A Other immunoelectrophoresis ............................ 0.37 0.13 0.13 0.01 0.51 0.51 XXX 

86327 .... 26 ..... A Immunoelectrophoresis assay ............................ 0.42 0.18 0.18 0.02 0.62 0.62 XXX 

86334 .... 26 ..... A Immunofix e-phoresis, serum ............................. 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

86335 .... 26 ..... A Immunfix e-phorsis/urine/csf .............................. 0.37 0.14 0.14 0.01 0.52 0.52 XXX 

86485 .... .......... C Skin test, candida ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

86490 .... .......... A Coccidioidomycosis skin test ............................. 0.00 0.29 NA 0.02 0.31 NA XXX 

86510 .... .......... A Histoplasmosis skin test ..................................... 0.00 0.32 NA 0.02 0.34 NA XXX 

86580 .... .......... A TB intradermal test ............................................. 0.00 0.25 NA 0.02 0.27 NA XXX 

87164 .... 26 ..... A Dark field examination ........................................ 0.37 0.12 0.12 0.01 0.50 0.50 XXX 

87207 .... 26 ..... A Smear, special stain ........................................... 0.37 0.16 0.16 0.01 0.54 0.54 XXX 

88104 .... 26 ..... A Cytopathology, fluids .......................................... 0.56 0.24 0.24 0.02 0.82 0.82 XXX 

88104 .... TC .... A Cytopathology, fluids .......................................... 0.00 0.61 NA 0.02 0.63 NA XXX 

88104 .... .......... A Cytopathology, fluids .......................................... 0.56 0.85 NA 0.04 1.45 NA XXX 

88106 .... 26 ..... A Cytopathology, fluids .......................................... 0.56 0.24 0.24 0.02 0.82 0.82 XXX 

88106 .... TC .... A Cytopathology, fluids .......................................... 0.00 1.11 NA 0.02 1.13 NA XXX 

88106 .... .......... A Cytopathology, fluids .......................................... 0.56 1.35 NA 0.04 1.95 NA XXX 

88107 .... 26 ..... A Cytopathology, fluids .......................................... 0.76 0.33 0.33 0.03 1.12 1.12 XXX 

88107 .... TC .... A Cytopathology, fluids .......................................... 0.00 1.21 NA 0.02 1.23 NA XXX 

88107 .... .......... A Cytopathology, fluids .......................................... 0.76 1.54 NA 0.05 2.35 NA XXX 

88108 .... 26 ..... A Cytopath, concentrate tech ................................ 0.56 0.24 0.24 0.02 0.82 0.82 XXX 

88108 .... TC .... A Cytopath, concentrate tech ................................ 0.00 0.97 NA 0.02 0.99 NA XXX 

88108 .... .......... A Cytopath, concentrate tech ................................ 0.56 1.21 NA 0.04 1.81 NA XXX 

88112 .... 26 ..... A Cytopath, cell enhance tech ............................... 1.18 0.51 0.51 0.02 1.71 1.71 XXX 

88112 .... TC .... A Cytopath, cell enhance tech ............................... 0.00 1.46 NA 0.02 1.48 NA XXX 

88112 .... .......... A Cytopath, cell enhance tech ............................... 1.18 1.97 NA 0.04 3.19 NA XXX 

88125 .... 26 ..... A Forensic cytopathology ...................................... 0.26 0.11 0.11 0.01 0.38 0.38 XXX 

88125 .... TC .... A Forensic cytopathology ...................................... 0.00 0.16 NA 0.01 0.17 NA XXX 

88125 .... .......... A Forensic cytopathology ...................................... 0.26 0.27 NA 0.02 0.55 NA XXX 

88141 .... .......... A Cytopath, c/v, interpret ....................................... 0.42 0.15 0.15 0.02 0.59 0.59 XXX 

88160 .... 26 ..... A Cytopath smear, other source ............................ 0.50 0.21 0.21 0.02 0.73 0.73 XXX 

88160 .... TC .... A Cytopath smear, other source ............................ 0.00 0.62 NA 0.02 0.64 NA XXX 

88160 .... .......... A Cytopath smear, other source ............................ 0.50 0.83 NA 0.04 1.37 NA XXX 

88161 .... 26 ..... A Cytopath smear, other source ............................ 0.50 0.21 0.21 0.02 0.73 0.73 XXX 

88161 .... TC .... A Cytopath smear, other source ............................ 0.00 0.73 NA 0.02 0.75 NA XXX 

88161 .... .......... A Cytopath smear, other source ............................ 0.50 0.94 NA 0.04 1.48 NA XXX 

88162 .... 26 ..... A Cytopath smear, other source ............................ 0.76 0.33 0.33 0.03 1.12 1.12 XXX 

88162 .... TC .... A Cytopath smear, other source ............................ 0.00 0.69 NA 0.02 0.71 NA XXX 

88162 .... .......... A Cytopath smear, other source ............................ 0.76 1.02 NA 0.05 1.83 NA XXX 

88172 .... 26 ..... A Cytopathology eval of fna .................................. 0.60 0.26 0.26 0.02 0.88 0.88 XXX 

88172 .... TC .... A Cytopathology eval of fna .................................. 0.00 0.47 NA 0.02 0.49 NA XXX 

88172 .... .......... A Cytopathology eval of fna .................................. 0.60 0.73 NA 0.04 1.37 NA XXX 

88173 .... 26 ..... A Cytopath eval, fna, report ................................... 1.39 0.59 0.59 0.05 2.03 2.03 XXX 

88173 .... TC .... A Cytopath eval, fna, report ................................... 0.00 1.55 NA 0.02 1.57 NA XXX 

88173 .... .......... A Cytopath eval, fna, report ................................... 1.39 2.14 NA 0.07 3.60 NA XXX 

88182 .... 26 ..... A Cell marker study ............................................... 0.77 0.33 0.33 0.03 1.13 1.13 XXX 

88182 .... TC .... A Cell marker study ............................................... 0.00 1.65 NA 0.04 1.69 NA XXX 

88182 .... .......... A Cell marker study ............................................... 0.77 1.98 NA 0.07 2.82 NA XXX 

88184 .... .......... A Flowcytometry/ tc, 1 marker ............................... 0.00 1.32 NA 0.02 1.34 NA XXX 

88185 .... .......... A Flowcytometry/tc, add-on ................................... 0.00 0.64 NA 0.02 0.66 NA ZZZ 

88187 .... .......... A Flowcytometry/read, 2-8 ..................................... 1.36 0.45 0.45 0.01 1.82 1.82 XXX 

88188 .... .......... A Flowcytometry/read, 9-15 ................................... 1.69 0.57 0.57 0.01 2.27 2.27 XXX 

88189 .... .......... A Flowcytometry/read, 16 & > ............................... 2.23 0.75 0.75 0.01 2.99 2.99 XXX 

88199 .... 26 ..... C Cytopathology procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88199 .... TC .... C Cytopathology procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88199 .... .......... C Cytopathology procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70439 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

88291 .... .......... A Cyto/molecular report ......................................... 0.52 0.17 0.17 0.02 0.71 0.71 XXX 

88299 .... .......... C Cytogenetic study ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88300 .... 26 ..... A Surgical path, gross ........................................... 0.08 0.03 0.03 0.01 0.12 0.12 XXX 

88300 .... TC .... A Surgical path, gross ........................................... 0.00 0.42 NA 0.01 0.43 NA XXX 

88300 .... .......... A Surgical path, gross ........................................... 0.08 0.45 NA 0.02 0.55 NA XXX 

88302 .... 26 ..... A Tissue exam by pathologist ............................... 0.13 0.06 0.06 0.01 0.20 0.20 XXX 

88302 .... TC .... A Tissue exam by pathologist ............................... 0.00 0.97 NA 0.02 0.99 NA XXX 

88302 .... .......... A Tissue exam by pathologist ............................... 0.13 1.03 NA 0.03 1.19 NA XXX 

88304 .... 26 ..... A Tissue exam by pathologist ............................... 0.22 0.09 0.09 0.01 0.32 0.32 XXX 

88304 .... TC .... A Tissue exam by pathologist ............................... 0.00 1.23 NA 0.02 1.25 NA XXX 

88304 .... .......... A Tissue exam by pathologist ............................... 0.22 1.32 NA 0.03 1.57 NA XXX 

88305 .... 26 ..... A Tissue exam by pathologist ............................... 0.75 0.33 0.33 0.03 1.11 1.11 XXX 

88305 .... TC .... A Tissue exam by pathologist ............................... 0.00 1.58 NA 0.04 1.62 NA XXX 

88305 .... .......... A Tissue exam by pathologist ............................... 0.75 1.91 NA 0.07 2.73 NA XXX 

88307 .... 26 ..... A Tissue exam by pathologist ............................... 1.59 0.68 0.68 0.06 2.33 2.33 XXX 

88307 .... TC .... A Tissue exam by pathologist ............................... 0.00 2.48 NA 0.06 2.54 NA XXX 

88307 .... .......... A Tissue exam by pathologist ............................... 1.59 3.16 NA 0.12 4.87 NA XXX 

88309 .... 26 ..... A Tissue exam by pathologist ............................... 2.28 0.97 0.97 0.08 3.33 3.33 XXX 

88309 .... TC .... A Tissue exam by pathologist ............................... 0.00 3.43 NA 0.06 3.49 NA XXX 

88309 .... .......... A Tissue exam by pathologist ............................... 2.28 4.40 NA 0.14 6.82 NA XXX 

88311 .... 26 ..... A Decalcify tissue .................................................. 0.24 0.10 0.10 0.01 0.35 0.35 XXX 

88311 .... TC .... A Decalcify tissue .................................................. 0.00 0.13 NA 0.01 0.14 NA XXX 

88311 .... .......... A Decalcify tissue .................................................. 0.24 0.23 NA 0.02 0.49 NA XXX 

88312 .... 26 ..... A Special stains ..................................................... 0.54 0.23 0.23 0.02 0.79 0.79 XXX 

88312 .... TC .... A Special stains ..................................................... 0.00 1.29 NA 0.01 1.30 NA XXX 

88312 .... .......... A Special stains ..................................................... 0.54 1.52 NA 0.03 2.09 NA XXX 

88313 .... 26 ..... A Special stains ..................................................... 0.24 0.10 0.10 0.01 0.35 0.35 XXX 

88313 .... TC .... A Special stains ..................................................... 0.00 1.15 NA 0.01 1.16 NA XXX 

88313 .... .......... A Special stains ..................................................... 0.24 1.25 NA 0.02 1.51 NA XXX 

88314 .... 26 ..... A Histochemical stain ............................................ 0.45 0.19 0.19 0.02 0.66 0.66 XXX 

88314 .... TC .... A Histochemical stain ............................................ 0.00 1.88 NA 0.02 1.90 NA XXX 

88314 .... .......... A Histochemical stain ............................................ 0.45 2.07 NA 0.04 2.56 NA XXX 

88318 .... 26 ..... A Chemical histochemistry .................................... 0.42 0.18 0.18 0.02 0.62 0.62 XXX 

88318 .... TC .... A Chemical histochemistry .................................... 0.00 1.47 NA 0.01 1.48 NA XXX 

88318 .... .......... A Chemical histochemistry .................................... 0.42 1.65 NA 0.03 2.10 NA XXX 

88319 .... 26 ..... A Enzyme histochemistry ...................................... 0.53 0.22 0.22 0.02 0.77 0.77 XXX 

88319 .... TC .... A Enzyme histochemistry ...................................... 0.00 3.20 NA 0.02 3.22 NA XXX 

88319 .... .......... A Enzyme histochemistry ...................................... 0.53 3.42 NA 0.04 3.99 NA XXX 

88321 .... .......... A Microslide consultation ....................................... 1.30 0.79 0.56 0.05 2.14 1.91 XXX 

88323 .... 26 ..... A Microslide consultation ....................................... 1.35 0.57 0.57 0.05 1.97 1.97 XXX 

88323 .... TC .... A Microslide consultation ....................................... 0.00 1.21 NA 0.02 1.23 NA XXX 

88323 .... .......... A Microslide consultation ....................................... 1.35 1.78 NA 0.07 3.20 NA XXX 

88325 .... .......... A Comprehensive review of data .......................... 2.22 2.94 0.95 0.07 5.23 3.24 XXX 

88329 .... .......... A Path consult introp ............................................. 0.67 0.65 0.29 0.02 1.34 0.98 XXX 

88331 .... 26 ..... A Path consult intraop, 1 bloc ............................... 1.19 0.51 0.51 0.04 1.74 1.74 XXX 

88331 .... TC .... A Path consult intraop, 1 bloc ............................... 0.00 0.59 NA 0.04 0.63 NA XXX 

88331 .... .......... A Path consult intraop, 1 bloc ............................... 1.19 1.10 NA 0.08 2.37 NA XXX 

88332 .... 26 ..... A Path consult intraop, add’l .................................. 0.59 0.25 0.25 0.02 0.86 0.86 XXX 

88332 .... TC .... A Path consult intraop, add’l .................................. 0.00 0.21 NA 0.02 0.23 NA XXX 

88332 .... .......... A Path consult intraop, add’l .................................. 0.59 0.46 NA 0.04 1.09 NA XXX 

88333 .... 26 ..... A Intraop cyto path consult, 1 ................................ 1.20 0.53 0.53 0.04 1.77 1.77 XXX 

88333 .... TC .... A Intraop cyto path consult, 1 ................................ 0.00 0.55 NA 0.04 0.59 NA XXX 

88333 .... .......... A Intraop cyto path consult, 1 ................................ 1.20 1.08 NA 0.08 2.36 NA XXX 

88334 .... 26 ..... A Intraop cyto path consult, 2 ................................ 0.59 0.26 0.26 0.02 0.87 0.87 XXX 

88334 .... TC .... A Intraop cyto path consult, 2 ................................ 0.00 0.34 NA 0.02 0.36 NA XXX 

88334 .... .......... A Intraop cyto path consult, 2 ................................ 0.59 0.60 NA 0.04 1.23 NA XXX 

88342 .... 26 ..... A Immunohistochemistry ........................................ 0.85 0.36 0.36 0.03 1.24 1.24 XXX 

88342 .... TC .... A Immunohistochemistry ........................................ 0.00 1.10 NA 0.02 1.12 NA XXX 

88342 .... .......... A Immunohistochemistry ........................................ 0.85 1.46 NA 0.05 2.36 NA XXX 

88346 .... 26 ..... A Immunofluorescent study ................................... 0.86 0.36 0.36 0.03 1.25 1.25 XXX 

88346 .... TC .... A Immunofluorescent study ................................... 0.00 1.21 NA 0.02 1.23 NA XXX 

88346 .... .......... A Immunofluorescent study ................................... 0.86 1.57 NA 0.05 2.48 NA XXX 

88347 .... 26 ..... A Immunofluorescent study ................................... 0.86 0.35 0.35 0.03 1.24 1.24 XXX 

88347 .... TC .... A Immunofluorescent study ................................... 0.00 0.91 NA 0.02 0.93 NA XXX 

88347 .... .......... A Immunofluorescent study ................................... 0.86 1.26 NA 0.05 2.17 NA XXX 

88348 .... 26 ..... A Electron microscopy ........................................... 1.51 0.64 0.64 0.06 2.21 2.21 XXX 

88348 .... TC .... A Electron microscopy ........................................... 0.00 8.74 NA 0.07 8.81 NA XXX 

88348 .... .......... A Electron microscopy ........................................... 1.51 9.38 NA 0.13 11.02 NA XXX 

88349 .... 26 ..... A Scanning electron microscopy ........................... 0.76 0.33 0.33 0.03 1.12 1.12 XXX 

88349 .... TC .... A Scanning electron microscopy ........................... 0.00 3.24 NA 0.06 3.30 NA XXX 

88349 .... .......... A Scanning electron microscopy ........................... 0.76 3.57 NA 0.09 4.42 NA XXX 

88355 .... 26 ..... A Analysis, skeletal muscle ................................... 1.85 0.79 0.79 0.07 2.71 2.71 XXX 

88355 .... TC .... A Analysis, skeletal muscle ................................... 0.00 8.00 NA 0.06 8.06 NA XXX 

88355 .... .......... A Analysis, skeletal muscle ................................... 1.85 8.79 NA 0.13 10.77 NA XXX 

88356 .... 26 ..... A Analysis, nerve ................................................... 3.02 1.26 1.26 0.12 4.40 4.40 XXX 

70440 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

88356 .... TC .... A Analysis, nerve ................................................... 0.00 2.93 NA 0.07 3.00 NA XXX 

88356 .... .......... A Analysis, nerve ................................................... 3.02 4.19 NA 0.19 7.40 NA XXX 

88358 .... 26 ..... A Analysis, tumor ................................................... 0.95 0.40 0.40 0.10 1.45 1.45 XXX 

88358 .... TC .... A Analysis, tumor ................................................... 0.00 0.44 NA 0.07 0.51 NA XXX 

88358 .... .......... A Analysis, tumor ................................................... 0.95 0.84 NA 0.17 1.96 NA XXX 

88360 .... 26 ..... A Tumor immunohistochem/manual ...................... 1.10 0.47 0.47 0.06 1.63 1.63 XXX 

88360 .... TC .... A Tumor immunohistochem/manual ...................... 0.00 1.26 NA 0.02 1.28 NA XXX 

88360 .... .......... A Tumor immunohistochem/manual ...................... 1.10 1.73 NA 0.08 2.91 NA XXX 

88361 .... 26 ..... A Tumor immunohistochem/comput ...................... 1.18 0.49 0.49 0.10 1.77 1.77 XXX 

88361 .... TC .... A Tumor immunohistochem/comput ...................... 0.00 2.54 NA 0.07 2.61 NA XXX 

88361 .... .......... A Tumor immunohistochem/comput ...................... 1.18 3.03 NA 0.17 4.38 NA XXX 

88362 .... 26 ..... A Nerve teasing preparations ................................ 2.17 0.92 0.92 0.09 3.18 3.18 XXX 

88362 .... TC .... A Nerve teasing preparations ................................ 0.00 3.78 NA 0.06 3.84 NA XXX 

88362 .... .......... A Nerve teasing preparations ................................ 2.17 4.70 NA 0.15 7.02 NA XXX 

88365 .... 26 ..... A Insitu hybridization (fish) .................................... 1.20 0.51 0.51 0.03 1.74 1.74 XXX 

88365 .... TC .... A Insitu hybridization (fish) .................................... 0.00 1.62 NA 0.02 1.64 NA XXX 

88365 .... .......... A Insitu hybridization (fish) .................................... 1.20 2.13 NA 0.05 3.38 NA XXX 

88367 .... 26 ..... A Insitu hybridization, auto .................................... 1.30 0.54 0.54 0.06 1.90 1.90 XXX 

88367 .... TC .... A Insitu hybridization, auto .................................... 0.00 3.50 NA 0.06 3.56 NA XXX 

88367 .... .......... A Insitu hybridization, auto .................................... 1.30 4.04 NA 0.12 5.46 NA XXX 

88368 .... 26 ..... A Insitu hybridization, manual ................................ 1.40 0.60 0.60 0.06 2.06 2.06 XXX 

88368 .... TC .... A Insitu hybridization, manual ................................ 0.00 1.80 NA 0.06 1.86 NA XXX 

88368 .... .......... A Insitu hybridization, manual ................................ 1.40 2.40 NA 0.12 3.92 NA XXX 

88371 .... 26 ..... A Protein, western blot tissue ................................ 0.37 0.13 0.13 0.01 0.51 0.51 XXX 

88372 .... 26 ..... A Protein analysis w/probe .................................... 0.37 0.16 0.16 0.01 0.54 0.54 XXX 

88380 .... 26 ..... C Microdissection ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88380 .... TC .... C Microdissection ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88380 .... .......... C Microdissection ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88384 .... 26 ..... C Eval molecular probes, 11-50 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88384 .... TC .... C Eval molecular probes, 11-50 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88384 .... .......... C Eval molecular probes, 11-50 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88385 .... 26 ..... A Eval molecul probes, 51-250 ............................. 1.50 0.65 0.65 0.06 2.21 2.21 XXX 

88385 .... TC .... C Eval molecul probes, 51-250 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88385 .... .......... C Eval molecul probes, 51-250 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88386 .... 26 ..... A Eval molecul probes, 251-500 ........................... 1.88 0.82 0.82 0.08 2.78 2.78 XXX 

88386 .... TC .... C Eval molecul probes, 251-500 ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88386 .... .......... C Eval molecul probes, 251-500 ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88399 .... 26 ..... C Surgical pathology procedure ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88399 .... TC .... C Surgical pathology procedure ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88399 .... .......... C Surgical pathology procedure ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

89049 .... .......... A Chct for mal hyperthermia .................................. 1.40 3.56 0.27 0.06 5.02 1.73 XXX 

89060 .... 26 ..... A Exam,synovial fluid crystals ............................... 0.37 0.16 0.16 0.01 0.54 0.54 XXX 

89100 .... .......... A Sample intestinal contents ................................. 0.60 1.84 0.21 0.03 2.47 0.84 XXX 

89105 .... .......... A Sample intestinal contents ................................. 0.50 2.23 0.17 0.02 2.75 0.69 XXX 

89130 .... .......... A Sample stomach contents .................................. 0.45 1.75 0.13 0.02 2.22 0.60 XXX 

89132 .... .......... A Sample stomach contents .................................. 0.19 1.55 0.06 0.01 1.75 0.26 XXX 

89135 .... .......... A Sample stomach contents .................................. 0.79 1.90 0.25 0.04 2.73 1.08 XXX 

89136 .... .......... A Sample stomach contents .................................. 0.21 1.74 0.09 0.01 1.96 0.31 XXX 

89140 .... .......... A Sample stomach contents .................................. 0.94 2.09 0.27 0.04 3.07 1.25 XXX 

89141 .... .......... A Sample stomach contents .................................. 0.85 2.80 0.33 0.03 3.68 1.21 XXX 

89220 .... .......... A Sputum specimen collection .............................. 0.00 0.43 NA 0.02 0.45 NA XXX 

89230 .... .......... A Collect sweat for test .......................................... 0.00 0.11 NA 0.02 0.13 NA XXX 

89240 .... .......... C Pathology lab procedure .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90281 .... .......... I Human ig, im ...................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90283 .... .......... I Human ig, iv ....................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90287 .... .......... I Botulinum antitoxin ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90288 .... .......... I Botulism ig, iv ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90291 .... .......... I Cmv ig, iv ........................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90296 .... .......... E Diphtheria antitoxin ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90371 .... .......... E Hep b ig, im ........................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90375 .... .......... E Rabies ig, im/sc .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90376 .... .......... E Rabies ig, heat treated ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90378 .... .......... X Rsv ig, im, 50mg ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90379 .... .......... I Rsv ig, iv ............................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90384 .... .......... I Rh ig, full-dose, im ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90385 .... .......... E Rh ig, minidose, im ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90386 .... .......... I Rh ig, iv .............................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90389 .... .......... I Tetanus ig, im ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90393 .... .......... E Vaccina ig, im ..................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90396 .... .......... E Varicella-zoster ig, im ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90399 .... .......... I Immune globulin ................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90465 .... .......... A Immune admin 1 inj, < 8 yrs .............................. 0.17 0.31 NA 0.01 0.49 NA XXX 

90466 .... .......... A Immune admin addl inj, < 8 y ............................ 0.15 0.13 NA 0.01 0.29 NA ZZZ 

90467 .... .......... R Immune admin o or n, < 8 yrs ........................... 0.17 0.17 0.09 0.01 0.35 0.27 XXX 

90468 .... .......... R Immune admin o/n, addl < 8 y ........................... 0.15 0.11 0.06 0.01 0.27 0.22 ZZZ 

70441 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

90471 .... .......... A Immunization admin ........................................... 0.17 0.31 NA 0.01 0.49 NA XXX 

90472 .... .......... A Immunization admin, each add .......................... 0.15 0.13 NA 0.01 0.29 NA ZZZ 

90473 .... .......... R Immune admin oral/nasal ................................... 0.17 0.19 0.07 0.01 0.37 0.25 XXX 

90474 .... .......... R Immune admin oral/nasal addl ........................... 0.15 0.10 0.06 0.01 0.26 0.22 ZZZ 

90476 .... .......... E Adenovirus vaccine, type 4 ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90477 .... .......... E Adenovirus vaccine, type 7 ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90581 .... .......... E Anthrax vaccine, sc ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90585 .... .......... E Bcg vaccine, percut ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90586 .... .......... E Bcg vaccine, intravesical .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90632 .... .......... E Hep a vaccine, adult im ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90633 .... .......... E Hep a vacc, ped/adol, 2 dose ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90634 .... .......... E Hep a vacc, ped/adol, 3 dose ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90636 .... .......... E Hep a/hep b vacc, adult im ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90645 .... .......... E Hib vaccine, hboc, im ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90646 .... .......... E Hib vaccine, prp-d, im ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90647 .... .......... E Hib vaccine, prp-omp, im ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90648 .... .......... E Hib vaccine, prp-t, im ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90649 .... .......... E H papilloma vacc 3 dose im ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90655 .... .......... X Flu vaccine no preserv 6-35m ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90656 .... .......... X Flu vaccine no preserv 3 & > ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90657 .... .......... X Flu vaccine, 6-35 mo, im .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90658 .... .......... X Flu vaccine age 3 & over, im ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90660 .... .......... X Flu vaccine, nasal .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90665 .... .......... E Lyme disease vaccine, im .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90669 .... .......... N Pneumococcal vacc, ped <5 .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90675 .... .......... E Rabies vaccine, im ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90676 .... .......... E Rabies vaccine, id .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90680 .... .......... E Rotovirus vacc 3 dose, oral ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90690 .... .......... E Typhoid vaccine, oral ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90691 .... .......... E Typhoid vaccine, im ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90692 .... .......... E Typhoid vaccine, h-p, sc/id ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90693 .... .......... E Typhoid vaccine, akd, sc .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90698 .... .......... E Dtap-hib-ip vaccine, im ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90700 .... .......... E Dtap vaccine, < 7 yrs, im ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90701 .... .......... E Dtp vaccine, im ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90702 .... .......... E Dt vaccine < 7, im .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90703 .... .......... E Tetanus vaccine, im ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90704 .... .......... E Mumps vaccine, sc ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90705 .... .......... E Measles vaccine, sc ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90706 .... .......... E Rubella vaccine, sc ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90707 .... .......... E Mmr vaccine, sc ................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90708 .... .......... E Measles-rubella vaccine, sc ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90710 .... .......... E Mmrv vaccine, sc ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90712 .... .......... E Oral poliovirus vaccine ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90713 .... .......... E Poliovirus, ipv, sc/im ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90714 .... .......... E Td vaccine no prsrv >/= 7 im ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90715 .... .......... E Tdap vaccine >7 im ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90716 .... .......... E Chicken pox vaccine, sc .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90717 .... .......... E Yellow fever vaccine, sc ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90718 .... .......... E Td vaccine > 7, im .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90719 .... .......... E Diphtheria vaccine, im ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90720 .... .......... E Dtp/hib vaccine, im ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90721 .... .......... E Dtap/hib vaccine, im ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90723 .... .......... I Dtap-hep b-ipv vaccine, im ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90725 .... .......... E Cholera vaccine, injectable ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90727 .... .......... E Plague vaccine, im ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90732 .... .......... X Pneumococcal vaccine ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90733 .... .......... E Meningococcal vaccine, sc ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90734 .... .......... E Meningococcal vaccine, im ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90735 .... .......... E Encephalitis vaccine, sc ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90736 .... .......... E Zoster vacc, sc ................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90740 .... .......... X Hepb vacc, ill pat 3 dose im .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90743 .... .......... X Hep b vacc, adol, 2 dose, im ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90744 .... .......... X Hepb vacc ped/adol 3 dose im .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90746 .... .......... X Hep b vaccine, adult, im .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90747 .... .......... X Hepb vacc, ill pat 4 dose im .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90748 .... .......... I Hep b/hib vaccine, im ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90749 .... .......... E Vaccine toxoid .................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90760 .... .......... A Hydration iv infusion, init .................................... 0.17 1.43 1.43 0.07 1.67 1.67 XXX 

90761 .... .......... A Hydrate iv infusion, add-on ................................ 0.09 0.40 0.40 0.04 0.53 0.53 ZZZ 

90765 .... .......... A Ther/proph/diag iv inf, init ................................... 0.21 1.76 1.76 0.07 2.04 2.04 XXX 

90766 .... .......... A Ther/proph/dg iv inf, add-on ............................... 0.18 0.46 0.46 0.04 0.68 0.68 ZZZ 

90767 .... .......... A Tx/proph/dg addl seq iv inf ................................. 0.19 0.89 0.89 0.04 1.12 1.12 ZZZ 

90768 .... .......... A Ther/diag concurrent inf ..................................... 0.17 0.44 0.44 0.04 0.65 0.65 ZZZ 

90772 .... .......... A Ther/proph/diag inj, sc/im ................................... 0.17 0.31 0.31 0.01 0.49 0.49 XXX 

70442 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

90773 .... .......... A Ther/proph/diag inj, ia ........................................ 0.17 0.32 0.32 0.02 0.51 0.51 XXX 

90774 .... .......... A Ther/proph/diag inj, iv push ................................ 0.18 1.30 1.30 0.04 1.52 1.52 XXX 

90775 .... .......... A Ther/proph/diag inj add-on ................................. 0.10 0.57 0.57 0.04 0.71 0.71 ZZZ 

90779 .... .......... C Ther/prop/diag inj/inf proc .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90801 .... .......... A Psy dx interview ................................................. 2.80 1.17 0.93 0.06 4.03 3.79 XXX 

90802 .... .......... A Intac psy dx interview ......................................... 3.01 1.20 0.98 0.07 4.28 4.06 XXX 

90804 .... .......... A Psytx, office, 20-30 min ...................................... 1.21 0.49 0.38 0.03 1.73 1.62 XXX 

90805 .... .......... A Psytx, off, 20-30 min w/e&m .............................. 1.37 0.50 0.42 0.03 1.90 1.82 XXX 

90806 .... .......... A Psytx, off, 45-50 min .......................................... 1.86 0.70 0.60 0.04 2.60 2.50 XXX 

90807 .... .......... A Psytx, off, 45-50 min w/e&m .............................. 2.02 0.70 0.63 0.05 2.77 2.70 XXX 

90808 .... .......... A Psytx, office, 75-80 min ...................................... 2.79 1.03 0.90 0.06 3.88 3.75 XXX 

90809 .... .......... A Psytx, off, 75-80, w/e&m .................................... 2.95 1.00 0.92 0.07 4.02 3.94 XXX 

90810 .... .......... A Intac psytx, off, 20-30 min .................................. 1.32 0.51 0.42 0.04 1.87 1.78 XXX 

90811 .... .......... A Intac psytx, 20-30, w/e&m .................................. 1.48 0.57 0.46 0.04 2.09 1.98 XXX 

90812 .... .......... A Intac psytx, off, 45-50 min .................................. 1.97 0.79 0.64 0.04 2.80 2.65 XXX 

90813 .... .......... A Intac psytx, 45-50 min w/e&m ............................ 2.13 0.77 0.67 0.05 2.95 2.85 XXX 

90814 .... .......... A Intac psytx, off, 75-80 min .................................. 2.90 1.10 0.98 0.06 4.06 3.94 XXX 

90815 .... .......... A Intac psytx, 75-80 w/e&m ................................... 3.06 1.05 0.95 0.07 4.18 4.08 XXX 

90816 .... .......... A Psytx, hosp, 20-30 min ...................................... 1.25 NA 0.46 0.03 NA 1.74 XXX 

90817 .... .......... A Psytx, hosp, 20-30 min w/e&m .......................... 1.41 NA 0.46 0.03 NA 1.90 XXX 

90818 .... .......... A Psytx, hosp, 45-50 min ...................................... 1.89 NA 0.69 0.04 NA 2.62 XXX 

90819 .... .......... A Psytx, hosp, 45-50 min w/e&m .......................... 2.05 NA 0.65 0.05 NA 2.75 XXX 

90821 .... .......... A Psytx, hosp, 75-80 min ...................................... 2.83 NA 1.01 0.06 NA 3.90 XXX 

90822 .... .......... A Psytx, hosp, 75-80 min w/e&m .......................... 2.99 NA 0.95 0.08 NA 4.02 XXX 

90823 .... .......... A Intac psytx, hosp, 20-30 min .............................. 1.36 NA 0.48 0.03 NA 1.87 XXX 

90824 .... .......... A Intac psytx, hsp 20-30 w/e&m ............................ 1.52 NA 0.49 0.04 NA 2.05 XXX 

90826 .... .......... A Intac psytx, hosp, 45-50 min .............................. 2.01 NA 0.72 0.05 NA 2.78 XXX 

90827 .... .......... A Intac psytx, hsp 45-50 w/e&m ............................ 2.16 NA 0.68 0.05 NA 2.89 XXX 

90828 .... .......... A Intac psytx, hosp, 75-80 min .............................. 2.94 NA 1.06 0.06 NA 4.06 XXX 

90829 .... .......... A Intac psytx, hsp 75-80 w/e&m ............................ 3.10 NA 0.98 0.07 NA 4.15 XXX 

90845 .... .......... A Psychoanalysis ................................................... 1.79 0.58 0.55 0.04 2.41 2.38 XXX 

90846 .... .......... R Family psytx w/o patient ..................................... 1.83 0.65 0.65 0.04 2.52 2.52 XXX 

90847 .... .......... R Family psytx w/patient ........................................ 2.21 0.82 0.76 0.05 3.08 3.02 XXX 

90849 .... .......... R Multiple family group psytx ................................. 0.59 0.27 0.24 0.02 0.88 0.85 XXX 

90853 .... .......... A Group psychotherapy ......................................... 0.59 0.25 0.23 0.01 0.85 0.83 XXX 

90857 .... .......... A Intac group psytx ................................................ 0.63 0.29 0.25 0.01 0.93 0.89 XXX 

90862 .... .......... A Medication management .................................... 0.95 0.40 0.32 0.02 1.37 1.29 XXX 

90865 .... .......... A Narcosynthesis ................................................... 2.84 1.36 0.91 0.12 4.32 3.87 XXX 

90870 .... .......... A Electroconvulsive therapy .................................. 1.88 1.94 0.59 0.04 3.86 2.51 000 

90875 .... .......... N Psychophysiological therapy .............................. +1.20 0.90 0.46 0.04 2.14 1.70 XXX 

90876 .... .......... N Psychophysiological therapy .............................. +1.90 1.16 0.73 0.05 3.11 2.68 XXX 

90880 .... .......... A Hypnotherapy ..................................................... 2.19 1.04 0.69 0.05 3.28 2.93 XXX 

90882 .... .......... N Environmental manipulation ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90885 .... .......... B Psy evaluation of records ................................... +0.97 0.37 0.37 0.02 1.36 1.36 XXX 

90887 .... .......... B Consultation with family ..................................... +1.48 0.82 0.56 0.04 2.34 2.08 XXX 

90889 .... .......... B Preparation of report .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90899 .... .......... C Psychiatric service/therapy ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90901 .... .......... A Biofeedback train, any meth .............................. 0.41 0.65 0.14 0.02 1.08 0.57 000 

90911 .... .......... A Biofeedback peri/uro/rectal ................................. 0.89 1.56 0.31 0.06 2.51 1.26 000 

90918 .... .......... I ESRD related services, month ........................... +11.16 6.13 6.13 0.36 17.65 17.65 XXX 

90919 .... .......... I ESRD related services, month ........................... +8.53 4.01 4.01 0.29 12.83 12.83 XXX 

90920 .... .......... I ESRD related services, month ........................... +7.26 3.76 3.76 0.23 11.25 11.25 XXX 

90921 .... .......... I ESRD related services, month ........................... +4.46 2.45 2.45 0.14 7.05 7.05 XXX 

90922 .... .......... I ESRD related services, day ............................... +0.37 0.21 0.21 0.01 0.59 0.59 XXX 

90923 .... .......... I Esrd related services, day .................................. +0.28 0.13 0.13 0.01 0.42 0.42 XXX 

90924 .... .......... I Esrd related services, day .................................. +0.24 0.12 0.12 0.01 0.37 0.37 XXX 

90925 .... .......... I Esrd related services, day .................................. +0.15 0.08 0.08 0.01 0.24 0.24 XXX 

90935 .... .......... A Hemodialysis, one evaluation ............................ 1.22 NA 0.67 0.04 NA 1.93 000 

90937 .... .......... A Hemodialysis, repeated eval .............................. 2.11 NA 0.97 0.07 NA 3.15 000 

90940 .... .......... X Hemodialysis access study ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90945 .... .......... A Dialysis, one evaluation ..................................... 1.28 NA 0.69 0.04 NA 2.01 000 

90947 .... .......... A Dialysis, repeated eval ....................................... 2.16 NA 0.99 0.07 NA 3.22 000 

90989 .... .......... X Dialysis training, complete ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90993 .... .......... X Dialysis training, incompl .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

90997 .... .......... A Hemoperfusion ................................................... 1.84 NA 0.66 0.06 NA 2.56 000 

90999 .... .......... C Dialysis procedure .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91000 .... 26 ..... A Esophageal intubation ........................................ 0.73 0.25 0.25 0.03 1.01 1.01 000 

91000 .... TC .... A Esophageal intubation ........................................ 0.00 0.08 NA 0.01 0.09 NA 000 

91000 .... .......... A Esophageal intubation ........................................ 0.73 0.33 NA 0.04 1.10 NA 000 

91010 .... 26 ..... A Esophagus motility study ................................... 1.25 0.44 0.44 0.06 1.75 1.75 000 

91010 .... TC .... A Esophagus motility study ................................... 0.00 3.98 NA 0.06 4.04 NA 000 

91010 .... .......... A Esophagus motility study ................................... 1.25 4.42 NA 0.12 5.79 NA 000 

91011 .... 26 ..... A Esophagus motility study ................................... 1.50 0.53 0.53 0.07 2.10 2.10 000 

91011 .... TC .... A Esophagus motility study ................................... 0.00 4.71 NA 0.06 4.77 NA 000 

91011 .... .......... A Esophagus motility study ................................... 1.50 5.24 NA 0.13 6.87 NA 000 

70443 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

91012 .... 26 ..... A Esophagus motility study ................................... 1.46 0.51 0.51 0.06 2.03 2.03 000 

91012 .... TC .... A Esophagus motility study ................................... 0.00 5.26 NA 0.07 5.33 NA 000 

91012 .... .......... A Esophagus motility study ................................... 1.46 5.77 NA 0.13 7.36 NA 000 

91020 .... 26 ..... A Gastric motility studies ....................................... 1.44 0.49 0.49 0.07 2.00 2.00 000 

91020 .... TC .... A Gastric motility studies ....................................... 0.00 4.04 NA 0.06 4.10 NA 000 

91020 .... .......... A Gastric motility studies ....................................... 1.44 4.53 NA 0.13 6.10 NA 000 

91022 .... 26 ..... A Duodenal motility study ...................................... 1.44 0.51 0.51 0.07 2.02 2.02 000 

91022 .... TC .... A Duodenal motility study ...................................... 0.00 3.90 NA 0.06 3.96 NA 000 

91022 .... .......... A Duodenal motility study ...................................... 1.44 4.41 NA 0.13 5.98 NA 000 

91030 .... 26 ..... A Acid perfusion of esophagus .............................. 0.91 0.32 0.32 0.04 1.27 1.27 000 

91030 .... TC .... A Acid perfusion of esophagus .............................. 0.00 2.12 NA 0.02 2.14 NA 000 

91030 .... .......... A Acid perfusion of esophagus .............................. 0.91 2.44 NA 0.06 3.41 NA 000 

91034 .... 26 ..... A Gastroesophageal reflux test ............................. 0.97 0.34 0.34 0.06 1.37 1.37 000 

91034 .... TC .... A Gastroesophageal reflux test ............................. 0.00 4.91 NA 0.06 4.97 NA 000 

91034 .... .......... A Gastroesophageal reflux test ............................. 0.97 5.25 NA 0.12 6.34 NA 000 

91035 .... 26 ..... A G-esoph reflx tst w/electrod ............................... 1.59 0.56 0.56 0.06 2.21 2.21 000 

91035 .... TC .... A G-esoph reflx tst w/electrod ............................... 0.00 10.27 NA 0.06 10.33 NA 000 

91035 .... .......... A G-esoph reflx tst w/electrod ............................... 1.59 10.83 NA 0.12 12.54 NA 000 

91037 .... 26 ..... A Esoph imped function test .................................. 0.97 0.34 0.34 0.06 1.37 1.37 000 

91037 .... TC .... A Esoph imped function test .................................. 0.00 2.60 NA 0.06 2.66 NA 000 

91037 .... .......... A Esoph imped function test .................................. 0.97 2.94 NA 0.12 4.03 NA 000 

91038 .... 26 ..... A Esoph imped funct test > 1h .............................. 1.10 0.39 0.39 0.06 1.55 1.55 000 

91038 .... TC .... A Esoph imped funct test > 1h .............................. 0.00 1.84 NA 0.06 1.90 NA 000 

91038 .... .......... A Esoph imped funct test > 1h .............................. 1.10 2.23 NA 0.12 3.45 NA 000 

91040 .... 26 ..... A Esoph balloon distension tst .............................. 0.97 0.34 0.34 0.06 1.37 1.37 000 

91040 .... TC .... A Esoph balloon distension tst .............................. 0.00 10.82 NA 0.06 10.88 NA 000 

91040 .... .......... A Esoph balloon distension tst .............................. 0.97 11.16 NA 0.12 12.25 NA 000 

91052 .... 26 ..... A Gastric analysis test ........................................... 0.79 0.28 0.28 0.03 1.10 1.10 000 

91052 .... TC .... A Gastric analysis test ........................................... 0.00 2.18 NA 0.02 2.20 NA 000 

91052 .... .......... A Gastric analysis test ........................................... 0.79 2.46 NA 0.05 3.30 NA 000 

91055 .... 26 ..... A Gastric intubation for smear ............................... 0.94 0.27 0.27 0.05 1.26 1.26 000 

91055 .... TC .... A Gastric intubation for smear ............................... 0.00 2.68 NA 0.02 2.70 NA 000 

91055 .... .......... A Gastric intubation for smear ............................... 0.94 2.95 NA 0.07 3.96 NA 000 

91060 .... 26 ..... A Gastric saline load test ....................................... 0.45 0.14 0.14 0.03 0.62 0.62 000 

91060 .... TC .... A Gastric saline load test ....................................... 0.00 1.83 NA 0.02 1.85 NA 000 

91060 .... .......... A Gastric saline load test ....................................... 0.45 1.97 NA 0.05 2.47 NA 000 

91065 .... 26 ..... A Breath hydrogen test .......................................... 0.20 0.07 0.07 0.01 0.28 0.28 000 

91065 .... TC .... A Breath hydrogen test .......................................... 0.00 1.39 NA 0.02 1.41 NA 000 

91065 .... .......... A Breath hydrogen test .......................................... 0.20 1.46 NA 0.03 1.69 NA 000 

91100 .... .......... A Pass intestine bleeding tube .............................. 1.08 2.80 0.28 0.07 3.95 1.43 000 

91105 .... .......... A Gastric intubation treatment ............................... 0.37 2.11 0.09 0.03 2.51 0.49 000 

91110 .... 26 ..... A Gi tract capsule endoscopy ................................ 3.64 1.28 1.28 0.09 5.01 5.01 XXX 

91110 .... TC .... A Gi tract capsule endoscopy ................................ 0.00 20.96 NA 0.07 21.03 NA XXX 

91110 .... .......... A Gi tract capsule endoscopy ................................ 3.64 22.24 NA 0.16 26.04 NA XXX 

91120 .... 26 ..... A Rectal sensation test .......................................... 0.97 0.34 0.34 0.07 1.38 1.38 XXX 

91120 .... TC .... A Rectal sensation test .......................................... 0.00 10.67 NA 0.04 10.71 NA XXX 

91120 .... .......... A Rectal sensation test .......................................... 0.97 11.01 NA 0.11 12.09 NA XXX 

91122 .... 26 ..... A Anal pressure record .......................................... 1.77 0.60 0.60 0.13 2.50 2.50 000 

91122 .... TC .... A Anal pressure record .......................................... 0.00 4.51 NA 0.08 4.59 NA 000 

91122 .... .......... A Anal pressure record .......................................... 1.77 5.11 NA 0.21 7.09 NA 000 

91123 .... .......... B Irrigate fecal impaction ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91132 .... 26 ..... A Electrogastrography ........................................... 0.52 0.18 0.18 0.02 0.72 0.72 XXX 

91132 .... TC .... C Electrogastrography ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91132 .... .......... C Electrogastrography ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91133 .... 26 ..... A Electrogastrography w/test ................................. 0.66 0.23 0.23 0.03 0.92 0.92 XXX 

91133 .... TC .... C Electrogastrography w/test ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91133 .... .......... C Electrogastrography w/test ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91299 .... 26 ..... C Gastroenterology procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91299 .... TC .... C Gastroenterology procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91299 .... .......... C Gastroenterology procedure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92002 .... .......... A Eye exam, new patient ....................................... 0.88 0.97 0.34 0.02 1.87 1.24 XXX 

92004 .... .......... A Eye exam, new patient ....................................... 1.67 1.70 0.68 0.04 3.41 2.39 XXX 

92012 .... .......... A Eye exam established pat .................................. 0.67 1.03 0.29 0.02 1.72 0.98 XXX 

92014 .... .......... A Eye exam & treatment ....................................... 1.10 1.41 0.47 0.03 2.54 1.60 XXX 

92015 .... .......... N Refraction ........................................................... +0.38 1.49 0.15 0.01 1.88 0.54 XXX 

92018 .... .......... A New eye exam & treatment ............................... 2.50 NA 1.07 0.07 NA 3.64 XXX 

92019 .... .......... A Eye exam & treatment ....................................... 1.31 NA 0.56 0.03 NA 1.90 XXX 

92020 .... .......... A Special eye evaluation ....................................... 0.37 0.34 0.16 0.01 0.72 0.54 XXX 

92060 .... 26 ..... A Special eye evaluation ....................................... 0.69 0.29 0.29 0.02 1.00 1.00 XXX 

92060 .... TC .... A Special eye evaluation ....................................... 0.00 0.44 NA 0.01 0.45 NA XXX 

92060 .... .......... A Special eye evaluation ....................................... 0.69 0.73 NA 0.03 1.45 NA XXX 

92065 .... 26 ..... A Orthoptic/pleoptic training ................................... 0.37 0.15 0.15 0.01 0.53 0.53 XXX 

92065 .... TC .... A Orthoptic/pleoptic training ................................... 0.00 0.38 NA 0.01 0.39 NA XXX 

92065 .... .......... A Orthoptic/pleoptic training ................................... 0.37 0.53 NA 0.02 0.92 NA XXX 

92070 .... .......... A Fitting of contact lens ......................................... 0.70 1.07 0.32 0.02 1.79 1.04 XXX 

70444 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

92081 .... 26 ..... A Visual field examination(s) ................................. 0.36 0.15 0.15 0.01 0.52 0.52 XXX 

92081 .... TC .... A Visual field examination(s) ................................. 0.00 0.79 NA 0.01 0.80 NA XXX 

92081 .... .......... A Visual field examination(s) ................................. 0.36 0.94 NA 0.02 1.32 NA XXX 

92082 .... 26 ..... A Visual field examination(s) ................................. 0.44 0.19 0.19 0.01 0.64 0.64 XXX 

92082 .... TC .... A Visual field examination(s) ................................. 0.00 1.04 NA 0.01 1.05 NA XXX 

92082 .... .......... A Visual field examination(s) ................................. 0.44 1.23 NA 0.02 1.69 NA XXX 

92083 .... 26 ..... A Visual field examination(s) ................................. 0.50 0.22 0.22 0.01 0.73 0.73 XXX 

92083 .... TC .... A Visual field examination(s) ................................. 0.00 1.21 NA 0.01 1.22 NA XXX 

92083 .... .......... A Visual field examination(s) ................................. 0.50 1.43 NA 0.02 1.95 NA XXX 

92100 .... A ...... Serial tonometry exam(s) ................................... 0.92 1.35 0.36 0.02 2.29 1.30 XXX 

92120 .... .......... A Tonography & eye evaluation ............................ 0.81 1.07 0.32 0.02 1.90 1.15 XXX 

92130 .... .......... A Water provocation tonography ........................... 0.81 1.28 0.37 0.02 2.11 1.20 XXX 

92135 .... 26 ..... A Opthalmic dx imaging ......................................... 0.35 0.15 0.15 0.01 0.51 0.51 XXX 

92135 .... TC .... A Opthalmic dx imaging ......................................... 0.00 0.64 NA 0.01 0.65 NA XXX 

92135 .... .......... A Opthalmic dx imaging ......................................... 0.35 0.79 NA 0.02 1.16 NA XXX 

92136 .... 26 ..... A Ophthalmic biometry .......................................... 0.54 0.24 0.24 0.01 0.79 0.79 XXX 

92136 .... TC .... A Ophthalmic biometry .......................................... 0.00 1.41 NA 0.07 1.48 NA XXX 

92136 .... .......... A Ophthalmic biometry .......................................... 0.54 1.65 NA 0.08 2.27 NA XXX 

92140 .... .......... A Glaucoma provocative tests ............................... 0.50 0.99 0.21 0.01 1.50 0.72 XXX 

92225 .... .......... A Special eye exam, initial .................................... 0.38 0.22 0.16 0.01 0.61 0.55 XXX 

92226 .... .......... A Special eye exam, subsequent .......................... 0.33 0.21 0.14 0.01 0.55 0.48 XXX 

92230 .... .......... A Eye exam with photos ........................................ 0.60 1.53 0.20 0.02 2.15 0.82 XXX 

92235 .... 26 ..... A Eye exam with photos ........................................ 0.81 0.37 0.37 0.02 1.20 1.20 XXX 

92235 .... TC .... A Eye exam with photos ........................................ 0.00 2.25 NA 0.06 2.31 NA XXX 

92235 .... .......... A Eye exam with photos ........................................ 0.81 2.62 NA 0.08 3.51 NA XXX 

92240 .... 26 ..... A Icg angiography .................................................. 1.10 0.50 0.50 0.03 1.63 1.63 XXX 

92240 .... TC .... A Icg angiography .................................................. 0.00 5.62 NA 0.06 5.68 NA XXX 

92240 .... .......... A Icg angiography .................................................. 1.10 6.12 NA 0.09 7.31 NA XXX 

92250 .... 26 ..... A Eye exam with photos ........................................ 0.44 0.19 0.19 0.01 0.64 0.64 XXX 

92250 .... TC .... A Eye exam with photos ........................................ 0.00 1.34 NA 0.01 1.35 NA XXX 

92250 .... .......... A Eye exam with photos ........................................ 0.44 1.53 NA 0.02 1.99 NA XXX 

92260 .... .......... A Ophthalmoscopy/dynamometry .......................... 0.20 0.26 0.09 0.01 0.47 0.30 XXX 

92265 .... 26 ..... A Eye muscle evaluation ....................................... 0.81 0.28 0.28 0.04 1.13 1.13 XXX 

92265 .... TC .... A Eye muscle evaluation ....................................... 0.00 1.21 NA 0.02 1.23 NA XXX 

92265 .... .......... A Eye muscle evaluation ....................................... 0.81 1.49 NA 0.06 2.36 NA XXX 

92270 .... 26 ..... A Electro-oculography ............................................ 0.81 0.33 0.33 0.03 1.17 1.17 XXX 

92270 .... TC .... A Electro-oculography ............................................ 0.00 1.20 NA 0.02 1.22 NA XXX 

92270 .... .......... A Electro-oculography ............................................ 0.81 1.53 NA 0.05 2.39 NA XXX 

92275 .... 26 ..... A Electroretinography ............................................ 1.01 0.43 0.43 0.03 1.47 1.47 XXX 

92275 .... TC .... A Electroretinography ............................................ 0.00 1.51 NA 0.02 1.53 NA XXX 

92275 .... .......... A Electroretinography ............................................ 1.01 1.94 NA 0.05 3.00 NA XXX 

92283 .... 26 ..... A Color vision examination .................................... 0.17 0.07 0.07 0.01 0.25 0.25 XXX 

92283 .... TC .... A Color vision examination .................................... 0.00 0.77 NA 0.01 0.78 NA XXX 

92283 .... .......... A Color vision examination .................................... 0.17 0.84 NA 0.02 1.03 NA XXX 

92284 .... 26 ..... A Dark adaptation eye exam ................................. 0.24 0.08 0.08 0.01 0.33 0.33 XXX 

92284 .... TC .... A Dark adaptation eye exam ................................. 0.00 1.81 NA 0.01 1.82 NA XXX 

92284 .... .......... A Dark adaptation eye exam ................................. 0.24 1.89 NA 0.02 2.15 NA XXX 

92285 .... 26 ..... A Eye photography ................................................ 0.20 0.09 0.09 0.01 0.30 0.30 XXX 

92285 .... TC .... A Eye photography ................................................ 0.00 0.90 NA 0.01 0.91 NA XXX 

92285 .... .......... A Eye photography ................................................ 0.20 0.99 NA 0.02 1.21 NA XXX 

92286 .... 26 ..... A Internal eye photography ................................... 0.66 0.29 0.29 0.02 0.97 0.97 XXX 

92286 .... TC .... A Internal eye photography ................................... 0.00 2.77 NA 0.02 2.79 NA XXX 

92286 .... .......... A Internal eye photography ................................... 0.66 3.06 NA 0.04 3.76 NA XXX 

92287 .... .......... A Internal eye photography ................................... 0.81 2.39 0.31 0.02 3.22 1.14 XXX 

92310 .... .......... N Contact lens fitting .............................................. +1.17 1.12 0.45 0.04 2.33 1.66 XXX 

92311 .... .......... A Contact lens fitting .............................................. 1.08 1.09 0.35 0.03 2.20 1.46 XXX 

92312 .... .......... A Contact lens fitting .............................................. 1.26 1.08 0.50 0.03 2.37 1.79 XXX 

92313 .... .......... A Contact lens fitting .............................................. 0.92 1.06 0.29 0.02 2.00 1.23 XXX 

92314 .... .......... N Prescription of contact lens ................................ +0.69 0.94 0.27 0.01 1.64 0.97 XXX 

92315 .... .......... A Prescription of contact lens ................................ 0.45 0.85 0.16 0.01 1.31 0.62 XXX 

92316 .... .......... A Prescription of contact lens ................................ 0.68 0.91 0.29 0.02 1.61 0.99 XXX 

92317 .... .......... A Prescription of contact lens ................................ 0.45 0.94 0.15 0.01 1.40 0.61 XXX 

92325 .... .......... A Modification of contact lens ................................ 0.00 0.40 NA 0.01 0.41 NA XXX 

92326 .... .......... A Replacement of contact lens .............................. 0.00 1.63 NA 0.06 1.69 NA XXX 

92340 .... .......... N Fitting of spectacles ........................................... +0.37 0.70 0.14 0.01 1.08 0.52 XXX 

92341 .... .......... N Fitting of spectacles ........................................... +0.47 0.74 0.18 0.01 1.22 0.66 XXX 

92342 .... .......... N Fitting of spectacles ........................................... +0.53 0.76 0.21 0.01 1.30 0.75 XXX 

92352 .... .......... B Special spectacles fitting .................................... +0.37 0.68 0.14 0.01 1.06 0.52 XXX 

92353 .... .......... B Special spectacles fitting .................................... +0.50 0.73 0.19 0.02 1.25 0.71 XXX 

92354 .... .......... B Special spectacles fitting .................................... +0.00 8.89 NA 0.10 8.99 NA XXX 

92355 .... .......... B Special spectacles fitting .................................... +0.00 4.34 NA 0.01 4.35 NA XXX 

92358 .... .......... B Eye prosthesis service ....................................... +0.00 0.97 NA 0.05 1.02 NA XXX 

92370 .... .......... N Repair & adjust spectacles ................................ +0.32 0.55 0.13 0.02 0.89 0.47 XXX 

92371 .... .......... B Repair & adjust spectacles ................................ +0.00 0.62 NA 0.02 0.64 NA XXX 

92499 .... 26 ..... C Eye service or procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70445 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

92499 .... TC .... C Eye service or procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92499 .... .......... C Eye service or procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92502 .... .......... A Ear and throat examination ................................ 1.51 NA 1.11 0.05 NA 2.67 000 

92504 .... .......... A Ear microscopy examination .............................. 0.18 0.50 0.09 0.01 0.69 0.28 XXX 

92506 .... .......... A Speech/hearing evaluation ................................. 0.86 2.60 0.40 0.03 3.49 1.29 XXX 

92507 .... .......... A Speech/hearing therapy ..................................... 0.52 1.11 0.23 0.02 1.65 0.77 XXX 

92508 .... .......... A Speech/hearing therapy ..................................... 0.26 0.51 0.12 0.01 0.78 0.39 XXX 

92511 .... .......... A Nasopharyngoscopy ........................................... 0.84 3.32 0.78 0.03 4.19 1.65 000 

92512 .... .......... A Nasal function studies ........................................ 0.55 1.14 0.18 0.02 1.71 0.75 XXX 

92516 .... .......... A Facial nerve function test ................................... 0.43 1.20 0.22 0.01 1.64 0.66 XXX 

92520 .... .......... A Laryngeal function studies ................................. 0.75 0.51 0.39 0.03 1.29 1.17 XXX 

92526 .... .......... A Oral function therapy .......................................... 0.55 1.64 0.20 0.02 2.21 0.77 XXX 

92531 .... .......... B Spontaneous nystagmus study .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92532 .... .......... B Positional nystagmus test .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92533 .... .......... B Caloric vestibular test ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92534 .... .......... B Optokinetic nystagmus test ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92541 .... 26 ..... A Spontaneous nystagmus test ............................. 0.40 0.19 0.19 0.02 0.61 0.61 XXX 

92541 .... TC .... A Spontaneous nystagmus test ............................. 0.00 0.84 NA 0.02 0.86 NA XXX 

92541 .... .......... A Spontaneous nystagmus test ............................. 0.40 1.03 NA 0.04 1.47 NA XXX 

92542 .... 26 ..... A Positional nystagmus test .................................. 0.33 0.16 0.16 0.01 0.50 0.50 XXX 

92542 .... TC .... A Positional nystagmus test .................................. 0.00 0.98 NA 0.02 1.00 NA XXX 

92542 .... .......... A Positional nystagmus test .................................. 0.33 1.14 NA 0.03 1.50 NA XXX 

92543 .... 26 ..... A Caloric vestibular test ......................................... 0.10 0.05 0.05 0.01 0.16 0.16 XXX 

92543 .... TC .... A Caloric vestibular test ......................................... 0.00 0.52 NA 0.01 0.53 NA XXX 

92543 .... .......... A Caloric vestibular test ......................................... 0.10 0.57 NA 0.02 0.69 NA XXX 

92544 .... 26 ..... A Optokinetic nystagmus test ................................ 0.26 0.12 0.12 0.01 0.39 0.39 XXX 

92544 .... TC .... A Optokinetic nystagmus test ................................ 0.00 0.78 NA 0.02 0.80 NA XXX 

92544 .... .......... A Optokinetic nystagmus test ................................ 0.26 0.90 NA 0.03 1.19 NA XXX 

92545 .... 26 ..... A Oscillating tracking test ...................................... 0.23 0.11 0.11 0.01 0.35 0.35 XXX 

92545 .... TC .... A Oscillating tracking test ...................................... 0.00 0.69 NA 0.02 0.71 NA XXX 

92545 .... .......... A Oscillating tracking test ...................................... 0.23 0.80 NA 0.03 1.06 NA XXX 

92546 .... 26 ..... A Sinusoidal rotational test .................................... 0.29 0.13 0.13 0.01 0.43 0.43 XXX 

92546 .... TC .... A Sinusoidal rotational test .................................... 0.00 1.86 NA 0.02 1.88 NA XXX 

92546 .... .......... A Sinusoidal rotational test .................................... 0.29 1.99 NA 0.03 2.31 NA XXX 

92547 .... .......... A Supplemental electrical test ............................... 0.00 0.08 NA 0.06 0.14 NA ZZZ 

92548 .... 26 ..... A Posturography .................................................... 0.50 0.26 0.26 0.02 0.78 0.78 XXX 

92548 .... TC .... A Posturography .................................................... 0.00 2.00 NA 0.13 2.13 NA XXX 

92548 .... .......... A Posturography .................................................... 0.50 2.26 NA 0.15 2.91 NA XXX 

92551 .... .......... N Pure tone hearing test, air ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92552 .... .......... A Pure tone audiometry, air ................................... 0.00 0.44 NA 0.04 0.48 NA XXX 

92553 .... .......... A Audiometry, air & bone ...................................... 0.00 0.66 NA 0.06 0.72 NA XXX 

92555 .... .......... A Speech threshold audiometry ............................ 0.00 0.38 NA 0.04 0.42 NA XXX 

92556 .... .......... A Speech audiometry, complete ............................ 0.00 0.57 NA 0.06 0.63 NA XXX 

92557 .... .......... A Comprehensive hearing test .............................. 0.00 1.19 NA 0.12 1.31 NA XXX 

92559 .... .......... N Group audiometric testing .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92560 .... .......... N Bekesy audiometry, screen ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92561 .... .......... A Bekesy audiometry, diagnosis ........................... 0.00 0.72 NA 0.06 0.78 NA XXX 

92562 .... .......... A Loudness balance test ....................................... 0.00 0.41 NA 0.04 0.45 NA XXX 

92563 .... .......... A Tone decay hearing test .................................... 0.00 0.38 NA 0.04 0.42 NA XXX 

92564 .... .......... A Sisi hearing test .................................................. 0.00 0.47 NA 0.05 0.52 NA XXX 

92565 .... .......... A Stenger test, pure tone ...................................... 0.00 0.40 NA 0.04 0.44 NA XXX 

92567 .... .......... A Tympanometry .................................................... 0.00 0.52 NA 0.06 0.58 NA XXX 

92568 .... .......... A Acoustic refl threshold tst ................................... 0.00 0.38 NA 0.04 0.42 NA XXX 

92569 .... .......... A Acoustic reflex decay test .................................. 0.00 0.41 NA 0.04 0.45 NA XXX 

92571 .... .......... A Filtered speech hearing test ............................... 0.00 0.39 NA 0.04 0.43 NA XXX 

92572 .... .......... A Staggered spondaic word test ........................... 0.00 0.09 NA 0.01 0.10 NA XXX 

92573 .... .......... A Lombard test ...................................................... 0.00 0.35 NA 0.04 0.39 NA XXX 

92575 .... .......... A Sensorineural acuity test .................................... 0.00 0.30 NA 0.02 0.32 NA XXX 

92576 .... .......... A Synthetic sentence test ...................................... 0.00 0.44 NA 0.05 0.49 NA XXX 

92577 .... .......... A Stenger test, speech .......................................... 0.00 0.72 NA 0.07 0.79 NA XXX 

92579 .... .......... A Visual audiometry (vra) ...................................... 0.00 0.73 NA 0.06 0.79 NA XXX 

92582 .... .......... A Conditioning play audiometry ............................. 0.00 0.73 NA 0.06 0.79 NA XXX 

92583 .... .......... A Select picture audiometry ................................... 0.00 0.89 NA 0.08 0.97 NA XXX 

92584 .... .......... A Electrocochleography ......................................... 0.00 2.48 NA 0.21 2.69 NA XXX 

92585 .... 26 ..... A Auditor evoke potent, compre ............................ 0.50 0.21 0.21 0.03 0.74 0.74 XXX 

92585 .... TC .... A Auditor evoke potent, compre ............................ 0.00 1.86 NA 0.14 2.00 NA XXX 

92585 .... .......... A Auditor evoke potent, compre ............................ 0.50 2.07 NA 0.17 2.74 NA XXX 

92586 .... .......... A Auditor evoke potent, limit .................................. 0.00 1.86 NA 0.14 2.00 NA XXX 

92587 .... 26 ..... A Evoked auditory test ........................................... 0.13 0.06 0.06 0.01 0.20 0.20 XXX 

92587 .... TC .... A Evoked auditory test ........................................... 0.00 1.31 NA 0.11 1.42 NA XXX 

92587 .... .......... A Evoked auditory test ........................................... 0.13 1.37 NA 0.12 1.62 NA XXX 

92588 .... 26 ..... A Evoked auditory test ........................................... 0.36 0.16 0.16 0.01 0.53 0.53 XXX 

92588 .... TC .... A Evoked auditory test ........................................... 0.00 1.47 NA 0.13 1.60 NA XXX 

92588 .... .......... A Evoked auditory test ........................................... 0.36 1.63 NA 0.14 2.13 NA XXX 

92590 .... .......... N Hearing aid exam, one ear ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70446 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

92591 .... .......... N Hearing aid exam, both ears .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92592 .... .......... N Hearing aid check, one ear ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92593 .... .......... N Hearing aid check, both ears ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92594 .... .......... N Electro hearng aid test, one ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92595 .... .......... N Electro hearng aid tst, both ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92596 .... .......... A Ear protector evaluation ..................................... 0.00 0.59 NA 0.06 0.65 NA XXX 

92597 .... .......... A Oral speech device eval ..................................... 0.86 1.69 0.45 0.03 2.58 1.34 XXX 

92601 .... .......... A Cochlear implt f/up exam < 7 ............................. 0.00 3.51 NA 0.07 3.58 NA XXX 

92602 .... .......... A Reprogram cochlear implt < 7 ............................ 0.00 2.39 NA 0.07 2.46 NA XXX 

92603 .... .......... A Cochlear implt f/up exam 7 > ............................. 0.00 2.15 NA 0.07 2.22 NA XXX 

92604 .... .......... A Reprogram cochlear implt 7 > ............................ 0.00 1.35 NA 0.07 1.42 NA XXX 

92605 .... .......... B Eval for nonspeech device rx ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92606 .... .......... B Non-speech device service ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92607 .... .......... A Ex for speech device rx, 1hr .............................. 0.00 3.09 NA 0.05 3.14 NA XXX 

92608 .... .......... A Ex for speech device rx addl ............................. 0.00 0.55 NA 0.05 0.60 NA XXX 

92609 .... .......... A Use of speech device service ............................ 0.00 1.59 NA 0.04 1.63 NA XXX 

92610 .... .......... A Evaluate swallowing function ............................. 0.00 3.44 NA 0.08 3.52 NA XXX 

92611 .... .......... A Motion fluoroscopy/swallow ................................ 0.00 3.44 NA 0.08 3.52 NA XXX 

92612 .... .......... A Endoscopy swallow tst (fees) ............................. 1.27 2.75 0.66 0.04 4.06 1.97 XXX 

92613 .... .......... A Endoscopy swallow tst (fees) ............................. 0.71 0.40 0.39 0.05 1.16 1.15 XXX 

92614 .... .......... A Laryngoscopic sensory test ................................ 1.27 2.51 0.66 0.04 3.82 1.97 XXX 

92615 .... .......... A Eval laryngoscopy sense tst .............................. 0.63 0.35 0.35 0.05 1.03 1.03 XXX 

92616 .... .......... A Fees w/laryngeal sense test .............................. 1.88 3.40 0.99 0.06 5.34 2.93 XXX 

92617 .... .......... A Interprt fees/laryngeal test .................................. 0.79 0.44 0.44 0.05 1.28 1.28 XXX 

92620 .... .......... A Auditory function, 60 min ................................... 0.00 1.14 NA 0.06 1.20 NA XXX 

92621 .... .......... A Auditory function, + 15 min ................................ 0.00 0.25 NA 0.06 0.31 NA ZZZ 

92625 .... .......... A Tinnitus assessment ........................................... 0.00 1.12 NA 0.06 1.18 NA XXX 

92626 .... .......... A Eval aud rehab status ........................................ 0.00 0.55 NA 0.06 0.61 NA XXX 

92627 .... .......... A Eval aud status rehab add-on ............................ 0.00 0.55 NA 0.06 0.61 NA XXX 

92630 .... .......... I Aud rehab pre-ling hear loss .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92633 .... .......... I Aud rehab postling hear loss ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92700 .... .......... C Ent procedure/service ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92950 .... .......... A Heart/lung resuscitation cpr ............................... 3.79 4.21 0.97 0.28 8.28 5.04 000 

92953 .... .......... A Temporary external pacing ................................ 0.23 NA 0.07 0.02 NA 0.32 000 

92960 .... .......... A Cardioversion electric, ext .................................. 2.25 6.33 1.17 0.07 8.65 3.49 000 

92961 .... .......... A Cardioversion, electric, int .................................. 4.59 NA 2.09 0.29 NA 6.97 000 

92970 .... .......... A Cardioassist, internal .......................................... 3.51 NA 1.06 0.16 NA 4.73 000 

92971 .... .......... A Cardioassist, external ......................................... 1.77 NA 0.85 0.06 NA 2.68 000 

92973 .... .......... A Percut coronary thrombectomy .......................... 3.28 NA 1.29 0.23 NA 4.80 ZZZ 

92974 .... .......... A Cath place, cardio brachytx ............................... 3.00 NA 1.18 0.21 NA 4.39 ZZZ 

92975 .... .......... A Dissolve clot, heart vessel ................................. 7.24 NA 2.82 0.50 NA 10.56 000 

92977 .... .......... A Dissolve clot, heart vessel ................................. 0.00 8.07 NA 0.46 8.53 NA XXX 

92978 .... 26 ..... A Intravasc us, heart add-on ................................. 1.80 0.71 0.71 0.06 2.57 2.57 ZZZ 

92978 .... TC .... A Intravasc us, heart add-on ................................. 0.00 4.57 NA 0.24 4.81 NA ZZZ 

92978 .... .......... A Intravasc us, heart add-on ................................. 1.80 5.28 NA 0.30 7.38 NA ZZZ 

92979 .... 26 ..... A Intravasc us, heart add-on ................................. 1.44 0.56 0.56 0.06 2.06 2.06 ZZZ 

92979 .... TC .... A Intravasc us, heart add-on ................................. 0.00 2.30 NA 0.13 2.43 NA ZZZ 

92979 .... .......... A Intravasc us, heart add-on ................................. 1.44 2.86 NA 0.19 4.49 NA ZZZ 

92980 .... .......... A Insert intracoronary stent ................................... 14.82 NA 6.07 1.03 NA 21.92 000 

92981 .... .......... A Insert intracoronary stent ................................... 4.16 NA 1.63 0.29 NA 6.08 ZZZ 

92982 .... .......... A Coronary artery dilation ...................................... 10.96 NA 4.54 0.76 NA 16.26 000 

92984 .... .......... A Coronary artery dilation ...................................... 2.97 NA 1.16 0.21 NA 4.34 ZZZ 

92986 .... .......... A Revision of aortic valve ...................................... 21.77 NA 11.86 1.51 NA 35.14 090 

92987 .... .......... A Revision of mitral valve ...................................... 22.67 NA 12.25 1.59 NA 36.51 090 

92990 .... .......... A Revision of pulmonary valve .............................. 17.31 NA 9.82 1.20 NA 28.33 090 

92992 .... .......... C Revision of heart chamber ................................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

92993 .... .......... C Revision of heart chamber ................................. 0.00 0.00 0.00 0.00 0.00 0.00 090 

92995 .... .......... A Coronary atherectomy ........................................ 12.07 NA 4.97 0.84 NA 17.88 000 

92996 .... .......... A Coronary atherectomy add-on ........................... 3.26 NA 1.27 0.10 NA 4.63 ZZZ 

92997 .... .......... A Pul art balloon repr, percut ................................ 11.98 NA 4.83 0.40 NA 17.21 000 

92998 .... .......... A Pul art balloon repr, percut ................................ 5.99 NA 2.21 0.28 NA 8.48 ZZZ 

93000 .... .......... A Electrocardiogram, complete .............................. 0.17 0.51 NA 0.03 0.71 NA XXX 

93005 .... .......... A Electrocardiogram, tracing ................................. 0.00 0.45 NA 0.02 0.47 NA XXX 

93010 .... .......... A Electrocardiogram report .................................... 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

93012 .... .......... A Transmission of ecg ........................................... 0.00 6.03 NA 0.18 6.21 NA XXX 

93014 .... .......... A Report on transmitted ecg .................................. 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

93015 .... .......... A Cardiovascular stress test .................................. 0.75 1.96 NA 0.14 2.85 NA XXX 

93016 .... .......... A Cardiovascular stress test .................................. 0.45 0.17 0.17 0.02 0.64 0.64 XXX 

93017 .... .......... A Cardiovascular stress test .................................. 0.00 1.68 NA 0.11 1.79 NA XXX 

93018 .... .......... A Cardiovascular stress test .................................. 0.30 0.11 0.11 0.01 0.42 0.42 XXX 

93024 .... 26 ..... A Cardiac drug stress test ..................................... 1.17 0.45 0.45 0.04 1.66 1.66 XXX 

93024 .... TC .... A Cardiac drug stress test ..................................... 0.00 1.12 NA 0.08 1.20 NA XXX 

93024 .... .......... A Cardiac drug stress test ..................................... 1.17 1.57 NA 0.12 2.86 NA XXX 

93025 .... 26 ..... A Microvolt t-wave assess ..................................... 0.75 0.29 0.29 0.03 1.07 1.07 XXX 

93025 .... TC .... A Microvolt t-wave assess ..................................... 0.00 7.32 NA 0.11 7.43 NA XXX 

70447 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

93025 .... .......... A Microvolt t-wave assess ..................................... 0.75 7.61 NA 0.14 8.50 NA XXX 

93040 .... .......... A Rhythm ECG with report .................................... 0.16 0.20 NA 0.02 0.38 NA XXX 

93041 .... .......... A Rhythm ECG, tracing ......................................... 0.00 0.15 NA 0.01 0.16 NA XXX 

93042 .... .......... A Rhythm ECG, report ........................................... 0.16 0.05 0.05 0.01 0.22 0.22 XXX 

93224 .... .......... A ECG monitor/report, 24 hrs ................................ 0.52 3.62 NA 0.24 4.38 NA XXX 

93225 .... .......... A ECG monitor/record, 24 hrs ............................... 0.00 1.24 NA 0.08 1.32 NA XXX 

93226 .... .......... A ECG monitor/report, 24 hrs ................................ 0.00 2.19 NA 0.14 2.33 NA XXX 

93227 .... .......... A ECG monitor/review, 24 hrs ............................... 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

93230 .... .......... A ECG monitor/report, 24 hrs ................................ 0.52 3.90 NA 0.26 4.68 NA XXX 

93231 .... .......... A Ecg monitor/record, 24 hrs ................................. 0.00 1.52 NA 0.11 1.63 NA XXX 

93232 .... .......... A ECG monitor/report, 24 hrs ................................ 0.00 2.19 NA 0.13 2.32 NA XXX 

93233 .... .......... A ECG monitor/review, 24 hrs ............................... 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

93235 .... .......... A ECG monitor/report, 24 hrs ................................ 0.45 2.79 NA 0.16 3.40 NA XXX 

93236 .... .......... A ECG monitor/report, 24 hrs ................................ 0.00 2.63 NA 0.14 2.77 NA XXX 

93237 .... .......... A ECG monitor/review, 24 hrs ............................... 0.45 0.16 0.16 0.02 0.63 0.63 XXX 

93268 .... .......... A ECG record/review ............................................. 0.52 7.46 NA 0.28 8.26 NA XXX 

93270 .... .......... A ECG recording .................................................... 0.00 1.24 NA 0.08 1.32 NA XXX 

93271 .... .......... A Ecg/monitoring and analysis .............................. 0.00 6.03 NA 0.18 6.21 NA XXX 

93272 .... .......... A Ecg/review, interpret only ................................... 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

93278 .... 26 ..... A ECG/signal-averaged ......................................... 0.25 0.10 0.10 0.01 0.36 0.36 XXX 

93278 .... TC .... A ECG/signal-averaged ......................................... 0.00 1.15 NA 0.11 1.26 NA XXX 

93278 .... .......... A ECG/signal-averaged ......................................... 0.25 1.25 NA 0.12 1.62 NA XXX 

93303 .... 26 ..... A Echo transthoracic .............................................. 1.30 0.48 0.48 0.04 1.82 1.82 XXX 

93303 .... TC .... A Echo transthoracic .............................................. 0.00 3.87 NA 0.23 4.10 NA XXX 

93303 .... .......... A Echo transthoracic .............................................. 1.30 4.35 NA 0.27 5.92 NA XXX 

93304 .... 26 ..... A Echo transthoracic .............................................. 0.75 0.28 0.28 0.02 1.05 1.05 XXX 

93304 .... TC .... A Echo transthoracic .............................................. 0.00 1.95 NA 0.13 2.08 NA XXX 

93304 .... .......... A Echo transthoracic .............................................. 0.75 2.23 NA 0.15 3.13 NA XXX 

93307 .... 26 ..... A Echo exam of heart ............................................ 0.92 0.35 0.35 0.03 1.30 1.30 XXX 

93307 .... TC .... A Echo exam of heart ............................................ 0.00 3.87 NA 0.23 4.10 NA XXX 

93307 .... .......... A Echo exam of heart ............................................ 0.92 4.22 NA 0.26 5.40 NA XXX 

93308 .... 26 ..... A Echo exam of heart ............................................ 0.53 0.20 0.20 0.02 0.75 0.75 XXX 

93308 .... TC .... A Echo exam of heart ............................................ 0.00 1.95 NA 0.13 2.08 NA XXX 

93308 .... .......... A Echo exam of heart ............................................ 0.53 2.15 NA 0.15 2.83 NA XXX 

93312 .... 26 ..... A Echo transesophageal ........................................ 2.20 0.79 0.79 0.08 3.07 3.07 XXX 

93312 .... TC .... A Echo transesophageal ........................................ 0.00 3.79 NA 0.29 4.08 NA XXX 

93312 .... .......... A Echo transesophageal ........................................ 2.20 4.58 NA 0.37 7.15 NA XXX 

93313 .... .......... A Echo transesophageal ........................................ 0.95 NA 0.21 0.06 NA 1.22 XXX 

93314 .... 26 ..... A Echo transesophageal ........................................ 1.25 0.47 0.47 0.04 1.76 1.76 XXX 

93314 .... TC .... A Echo transesophageal ........................................ 0.00 3.79 NA 0.29 4.08 NA XXX 

93314 .... .......... A Echo transesophageal ........................................ 1.25 4.26 NA 0.33 5.84 NA XXX 

93315 .... 26 ..... A Echo transesophageal ........................................ 2.78 1.01 1.01 0.09 3.88 3.88 XXX 

93315 .... TC .... C Echo transesophageal ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93315 .... .......... C Echo transesophageal ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93316 .... .......... A Echo transesophageal ........................................ 0.95 NA 0.24 0.05 NA 1.24 XXX 

93317 .... 26 ..... A Echo transesophageal ........................................ 1.83 0.67 0.67 0.08 2.58 2.58 XXX 

93317 .... TC .... C Echo transesophageal ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93317 .... .......... C Echo transesophageal ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93318 .... 26 ..... A Echo transesophageal intraop ........................... 2.20 0.48 0.48 0.14 2.82 2.82 XXX 

93318 .... TC .... C Echo transesophageal intraop ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93318 .... .......... C Echo transesophageal intraop ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93320 .... 26 ..... A Doppler echo exam, heart .................................. 0.38 0.15 0.15 0.01 0.54 0.54 ZZZ 

93320 .... TC .... A Doppler echo exam, heart .................................. 0.00 1.71 NA 0.12 1.83 NA ZZZ 

93320 .... .......... A Doppler echo exam, heart .................................. 0.38 1.86 NA 0.13 2.37 NA ZZZ 

93321 .... 26 ..... A Doppler echo exam, heart .................................. 0.15 0.06 0.06 0.01 0.22 0.22 ZZZ 

93321 .... TC .... A Doppler echo exam, heart .................................. 0.00 1.11 NA 0.08 1.19 NA ZZZ 

93321 .... .......... A Doppler echo exam, heart .................................. 0.15 1.17 NA 0.09 1.41 NA ZZZ 

93325 .... 26 ..... A Doppler color flow add-on .................................. 0.07 0.03 0.03 0.01 0.11 0.11 ZZZ 

93325 .... TC .... A Doppler color flow add-on .................................. 0.00 2.91 NA 0.21 3.12 NA ZZZ 

93325 .... .......... A Doppler color flow add-on .................................. 0.07 2.94 NA 0.22 3.23 NA ZZZ 

93350 .... 26 ..... A Echo transthoracic .............................................. 1.48 0.57 0.57 0.05 2.10 2.10 XXX 

93350 .... TC .... A Echo transthoracic .............................................. 0.00 1.77 NA 0.13 1.90 NA XXX 

93350 .... .......... A Echo transthoracic .............................................. 1.48 2.34 NA 0.18 4.00 NA XXX 

93501 .... 26 ..... A Right heart catheterization ................................. 3.02 1.15 1.15 0.21 4.38 4.38 000 

93501 .... TC .... A Right heart catheterization ................................. 0.00 16.95 NA 1.05 18.00 NA 000 

93501 .... .......... A Right heart catheterization ................................. 3.02 18.10 NA 1.26 22.38 NA 000 

93503 .... .......... A Insert/place heart catheter ................................. 2.91 NA 0.68 0.20 NA 3.79 000 

93505 .... 26 ..... A Biopsy of heart lining .......................................... 4.37 1.68 1.68 0.30 6.35 6.35 000 

93505 .... TC .... A Biopsy of heart lining .......................................... 0.00 1.99 NA 0.16 2.15 NA 000 

93505 .... .......... A Biopsy of heart lining .......................................... 4.37 3.67 NA 0.46 8.50 NA 000 

93508 .... 26 ..... A Cath placement, angiography ............................ 4.09 2.09 2.09 0.28 6.46 6.46 000 

93508 .... TC .... A Cath placement, angiography ............................ 0.00 12.64 NA 0.65 13.29 NA 000 

93508 .... .......... A Cath placement, angiography ............................ 4.09 14.73 NA 0.93 19.75 NA 000 

93510 .... 26 ..... A Left heart catheterization .................................... 4.32 2.18 2.18 0.30 6.80 6.80 000 

93510 .... TC .... A Left heart catheterization .................................... 0.00 37.06 NA 2.31 39.37 NA 000 

70448 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

93510 .... .......... A Left heart catheterization .................................... 4.32 39.24 NA 2.61 46.17 NA 000 

93511 .... 26 ..... A Left heart catheterization .................................... 5.02 2.45 2.45 0.35 7.82 7.82 000 

93511 .... TC .... A Left heart catheterization .................................... 0.00 36.07 NA 2.24 38.31 NA 000 

93511 .... .......... A Left heart catheterization .................................... 5.02 38.52 NA 2.59 46.13 NA 000 

93514 .... 26 ..... A Left heart catheterization .................................... 7.04 3.13 3.13 0.49 10.66 10.66 000 

93514 .... TC .... C Left heart catheterization .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93514 .... .......... R Left heart catheterization .................................... 7.04 39.09 39.09 2.74 48.87 48.87 000 

93524 .... 26 ..... A Left heart catheterization .................................... 6.94 3.18 3.18 0.48 10.60 10.60 000 

93524 .... TC .... A Left heart catheterization .................................... 0.00 47.14 NA 2.95 50.09 NA 000 

93524 .... .......... A Left heart catheterization .................................... 6.94 50.32 NA 3.43 60.69 NA 000 

93526 .... 26 ..... A Rt & Lt heart catheters ....................................... 5.98 2.82 2.82 0.42 9.22 9.22 000 

93526 .... TC .... A Rt & Lt heart catheters ....................................... 0.00 48.43 NA 3.04 51.47 NA 000 

93526 .... .......... A Rt & Lt heart catheters ....................................... 5.98 51.25 NA 3.46 60.69 NA 000 

93527 .... 26 ..... A Rt & Lt heart catheters ....................................... 7.27 3.32 3.32 0.51 11.10 11.10 000 

93527 .... TC .... A Rt & Lt heart catheters ....................................... 0.00 47.14 NA 2.95 50.09 NA 000 

93527 .... .......... A Rt & Lt heart catheters ....................................... 7.27 50.46 NA 3.46 61.19 NA 000 

93528 .... 26 ..... A Rt & Lt heart catheters ....................................... 8.99 4.04 4.04 0.62 13.65 13.65 000 

93528 .... TC .... A Rt & Lt heart catheters ....................................... 0.00 47.14 NA 2.95 50.09 NA 000 

93528 .... .......... A Rt & Lt heart catheters ....................................... 8.99 51.18 NA 3.57 63.74 NA 000 

93529 .... 26 ..... A Rt, lt heart catheterization .................................. 4.79 2.28 2.28 0.33 7.40 7.40 000 

93529 .... TC .... A Rt, lt heart catheterization .................................. 0.00 47.14 NA 2.95 50.09 NA 000 

93529 .... .......... A Rt, lt heart catheterization .................................. 4.79 49.42 NA 3.28 57.49 NA 000 

93530 .... 26 ..... A Rt heart cath, congenital .................................... 4.22 1.94 1.94 0.29 6.45 6.45 000 

93530 .... TC .... A Rt heart cath, congenital .................................... 0.00 16.95 NA 1.05 18.00 NA 000 

93530 .... .......... A Rt heart cath, congenital .................................... 4.22 18.89 NA 1.34 24.45 NA 000 

93531 .... 26 ..... A R & l heart cath, congenital ............................... 8.34 3.59 3.59 0.58 12.51 12.51 000 

93531 .... TC .... A R & l heart cath, congenital ............................... 0.00 48.43 NA 3.04 51.47 NA 000 

93531 .... .......... A R & l heart cath, congenital ............................... 8.34 52.02 NA 3.62 63.98 NA 000 

93532 .... 26 ..... A R & l heart cath, congenital ............................... 9.99 4.26 4.26 0.69 14.94 14.94 000 

93532 .... TC .... C R & l heart cath, congenital ............................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93532 .... .......... C R & l heart cath, congenital ............................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93533 .... 26 ..... A R & l heart cath, congenital ............................... 6.69 2.80 2.80 0.47 9.96 9.96 000 

93533 .... TC .... C R & l heart cath, congenital ............................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93533 .... .......... C R & l heart cath, congenital ............................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93539 .... .......... A Injection, cardiac cath ........................................ 0.40 NA 0.16 0.01 NA 0.57 000 

93540 .... .......... A Injection, cardiac cath ........................................ 0.43 NA 0.17 0.01 NA 0.61 000 

93541 .... .......... A Injection for lung angiogram ............................... 0.29 NA 0.11 0.01 NA 0.41 000 

93542 .... .......... A Injection for heart x-rays .................................... 0.29 NA 0.11 0.01 NA 0.41 000 

93543 .... .......... A Injection for heart x-rays .................................... 0.29 NA 0.11 0.01 NA 0.41 000 

93544 .... .......... A Injection for aortography .................................... 0.25 NA 0.10 0.01 NA 0.36 000 

93545 .... .......... A Inject for coronary x-rays ................................... 0.40 NA 0.16 0.01 NA 0.57 000 

93555 .... 26 ..... A Imaging, cardiac cath ......................................... 0.81 0.32 0.32 0.03 1.16 1.16 XXX 

93555 .... TC .... A Imaging, cardiac cath ......................................... 0.00 6.29 NA 0.34 6.63 NA XXX 

93555 .... .......... A Imaging, cardiac cath ......................................... 0.81 6.61 NA 0.37 7.79 NA XXX 

93556 .... 26 ..... A Imaging, cardiac cath ......................................... 0.83 0.32 0.32 0.03 1.18 1.18 XXX 

93556 .... TC .... A Imaging, cardiac cath ......................................... 0.00 9.92 NA 0.51 10.43 NA XXX 

93556 .... .......... A Imaging, cardiac cath ......................................... 0.83 10.24 NA 0.54 11.61 NA XXX 

93561 .... 26 ..... A Cardiac output measurement ............................. 0.50 0.16 0.16 0.02 0.68 0.68 000 

93561 .... TC .... A Cardiac output measurement ............................. 0.00 0.52 NA 0.06 0.58 NA 000 

93561 .... .......... A Cardiac output measurement ............................. 0.50 0.68 NA 0.08 1.26 NA 000 

93562 .... 26 ..... A Cardiac output measurement ............................. 0.16 0.05 0.05 0.01 0.22 0.22 000 

93562 .... TC .... A Cardiac output measurement ............................. 0.00 0.32 NA 0.04 0.36 NA 000 

93562 .... .......... A Cardiac output measurement ............................. 0.16 0.37 NA 0.05 0.58 NA 000 

93571 .... 26 ..... A Heart flow reserve measure ............................... 1.80 0.68 0.68 0.06 2.54 2.54 ZZZ 

93571 .... TC .... A Heart flow reserve measure ............................... 0.00 4.57 NA 0.24 4.81 NA ZZZ 

93571 .... .......... A Heart flow reserve measure ............................... 1.80 5.25 NA 0.30 7.35 NA ZZZ 

93572 .... 26 ..... A Heart flow reserve measure ............................... 1.44 0.50 0.50 0.04 1.98 1.98 ZZZ 

93572 .... TC .... C Heart flow reserve measure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93572 .... .......... C Heart flow reserve measure ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93580 .... .......... A Transcath closure of asd .................................... 17.97 NA 7.40 1.25 NA 26.62 000 

93581 .... .......... A Transcath closure of vsd .................................... 24.39 NA 9.42 1.71 NA 35.52 000 

93600 .... 26 ..... A Bundle of His recording ...................................... 2.12 0.83 0.83 0.16 3.11 3.11 000 

93600 .... TC .... A Bundle of His recording ...................................... 0.00 1.96 NA 0.13 2.09 NA 000 

93600 .... .......... A Bundle of His recording ...................................... 2.12 2.79 NA 0.29 5.20 NA 000 

93602 .... 26 ..... A Intra-atrial recording ........................................... 2.12 0.82 0.82 0.17 3.11 3.11 000 

93602 .... TC .... A Intra-atrial recording ........................................... 0.00 1.11 NA 0.07 1.18 NA 000 

93602 .... .......... A Intra-atrial recording ........................................... 2.12 1.93 NA 0.24 4.29 NA 000 

93603 .... 26 ..... A Right ventricular recording ................................. 2.12 0.81 0.81 0.18 3.11 3.11 000 

93603 .... TC .... A Right ventricular recording ................................. 0.00 1.68 NA 0.11 1.79 NA 000 

93603 .... .......... A Right ventricular recording ................................. 2.12 2.49 NA 0.29 4.90 NA 000 

93609 .... 26 ..... A Map tachycardia, add-on .................................... 4.99 1.96 1.96 0.35 7.30 7.30 ZZZ 

93609 .... TC .... A Map tachycardia, add-on .................................... 0.00 2.73 NA 0.17 2.90 NA ZZZ 

93609 .... .......... A Map tachycardia, add-on .................................... 4.99 4.69 NA 0.52 10.20 NA ZZZ 

93610 .... 26 ..... A Intra-atrial pacing ................................................ 3.02 1.16 1.16 0.24 4.42 4.42 000 

93610 .... TC .... A Intra-atrial pacing ................................................ 0.00 1.35 NA 0.10 1.45 NA 000 

70449 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

93610 .... .......... A Intra-atrial pacing ................................................ 3.02 2.51 NA 0.34 5.87 NA 000 

93612 .... 26 ..... A Intraventricular pacing ........................................ 3.02 1.16 1.16 0.25 4.43 4.43 000 

93612 .... TC .... A Intraventricular pacing ........................................ 0.00 1.61 NA 0.11 1.72 NA 000 

93612 .... .......... A Intraventricular pacing ........................................ 3.02 2.77 NA 0.36 6.15 NA 000 

93613 .... .......... A Electrophys map 3d, add-on .............................. 6.99 NA 2.77 0.49 NA 10.25 ZZZ 

93615 .... 26 ..... A Esophageal recording ........................................ 0.99 0.27 0.27 0.03 1.29 1.29 000 

93615 .... TC .... A Esophageal recording ........................................ 0.00 0.32 NA 0.02 0.34 NA 000 

93615 .... .......... A Esophageal recording ........................................ 0.99 0.59 NA 0.05 1.63 NA 000 

93616 .... 26 ..... A Esophageal recording ........................................ 1.49 0.43 0.43 0.09 2.01 2.01 000 

93616 .... TC .... C Esophageal recording ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 000 

93616 .... .......... C Esophageal recording ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 000 

93618 .... 26 ..... A Heart rhythm pacing ........................................... 4.25 1.67 1.67 0.30 6.22 6.22 000 

93618 .... TC .... A Heart rhythm pacing ........................................... 0.00 3.97 NA 0.24 4.21 NA 000 

93618 .... .......... A Heart rhythm pacing ........................................... 4.25 5.64 NA 0.54 10.43 NA 000 

93619 .... 26 ..... A Electrophysiology evaluation .............................. 7.31 3.19 3.19 0.51 11.01 11.01 000 

93619 .... TC .... A Electrophysiology evaluation .............................. 0.00 7.72 NA 0.47 8.19 NA 000 

93619 .... .......... A Electrophysiology evaluation .............................. 7.31 10.91 NA 0.98 19.20 NA 000 

93620 .... 26 ..... A Electrophysiology evaluation .............................. 11.57 4.85 4.85 0.80 17.22 17.22 000 

93620 .... TC .... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

93620 .... .......... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 000 

93621 .... 26 ..... A Electrophysiology evaluation .............................. 2.10 0.82 0.82 0.15 3.07 3.07 ZZZ 

93621 .... TC .... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93621 .... .......... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93622 .... 26 ..... A Electrophysiology evaluation .............................. 3.10 1.21 1.21 0.22 4.53 4.53 ZZZ 

93622 .... TC .... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93622 .... .......... C Electrophysiology evaluation .............................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93623 .... 26 ..... A Stimulation, pacing heart .................................... 2.85 1.11 1.11 0.20 4.16 4.16 ZZZ 

93623 .... TC .... C Stimulation, pacing heart .................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93623 .... .......... C Stimulation, pacing heart .................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93624 .... 26 ..... A Electrophysiologic study ..................................... 4.80 2.20 2.20 0.33 7.33 7.33 000 

93624 .... TC .... A Electrophysiologic study ..................................... 0.00 1.99 NA 0.13 2.12 NA 000 

93624 .... .......... A Electrophysiologic study ..................................... 4.80 4.19 NA 0.46 9.45 NA 000 

93631 .... 26 ..... A Heart pacing, mapping ....................................... 7.59 2.78 2.78 0.97 11.34 11.34 000 

93631 .... TC .... C Heart pacing, mapping ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93631 .... .......... C Heart pacing, mapping ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

93640 .... 26 ..... A Evaluation heart device ...................................... 3.51 1.36 1.36 0.24 5.11 5.11 000 

93640 .... TC .... A Evaluation heart device ...................................... 0.00 7.19 NA 0.42 7.61 NA 000 

93640 .... .......... A Evaluation heart device ...................................... 3.51 8.55 NA 0.66 12.72 NA 000 

93641 .... 26 ..... A Electrophysiology evaluation .............................. 5.92 2.32 2.32 0.41 8.65 8.65 000 

93641 .... TC .... A Electrophysiology evaluation .............................. 0.00 7.19 NA 0.42 7.61 NA 000 

93641 .... .......... A Electrophysiology evaluation .............................. 5.92 9.51 NA 0.83 16.26 NA 000 

93642 .... 26 ..... A Electrophysiology evaluation .............................. 4.88 2.22 2.22 0.15 7.25 7.25 000 

93642 .... TC .... A Electrophysiology evaluation .............................. 0.00 7.19 NA 0.42 7.61 NA 000 

93642 .... .......... A Electrophysiology evaluation .............................. 4.88 9.41 NA 0.57 14.86 NA 000 

93650 .... .......... A Ablate heart dysrhythm focus ............................ 10.49 NA 4.44 0.73 NA 15.66 000 

93651 .... .......... A Ablate heart dysrhythm focus ............................ 16.23 NA 6.34 1.13 NA 23.70 000 

93652 .... .......... A Ablate heart dysrhythm focus ............................ 17.65 NA 6.90 1.23 NA 25.78 000 

93660 .... 26 ..... A Tilt table evaluation ............................................ 1.89 0.74 0.74 0.06 2.69 2.69 000 

93660 .... TC .... A Tilt table evaluation ............................................ 0.00 1.68 NA 0.02 1.70 NA 000 

93660 .... .......... A Tilt table evaluation ............................................ 1.89 2.42 NA 0.08 4.39 NA 000 

93662 .... 26 ..... A Intracardiac ecg (ice) .......................................... 2.80 1.11 1.11 0.09 4.00 4.00 ZZZ 

93662 .... TC .... C Intracardiac ecg (ice) .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93662 .... .......... C Intracardiac ecg (ice) .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

93668 .... .......... N Peripheral vascular rehab .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93701 .... 26 ..... A Bioimpedance, thoracic ...................................... 0.17 0.07 0.07 0.01 0.25 0.25 XXX 

93701 .... TC .... A Bioimpedance, thoracic ...................................... 0.00 0.91 NA 0.01 0.92 NA XXX 

93701 .... .......... A Bioimpedance, thoracic ...................................... 0.17 0.98 NA 0.02 1.17 NA XXX 

93720 .... .......... A Total body plethysmography .............................. 0.17 0.76 NA 0.07 1.00 NA XXX 

93721 .... .......... A Plethysmography tracing .................................... 0.00 0.71 NA 0.06 0.77 NA XXX 

93722 .... .......... A Plethysmography report ..................................... 0.17 0.05 0.05 0.01 0.23 0.23 XXX 

93724 .... 26 ..... A Analyze pacemaker system ............................... 4.88 1.92 1.92 0.15 6.95 6.95 000 

93724 .... TC .... A Analyze pacemaker system ............................... 0.00 3.97 NA 0.24 4.21 NA 000 

93724 .... .......... A Analyze pacemaker system ............................... 4.88 5.89 NA 0.39 11.16 NA 000 

93727 .... .......... A Analyze ilr system .............................................. 0.52 0.20 0.20 0.02 0.74 0.74 XXX 

93731 .... 26 ..... A Analyze pacemaker system ............................... 0.45 0.17 0.17 0.01 0.63 0.63 XXX 

93731 .... TC .... A Analyze pacemaker system ............................... 0.00 0.49 NA 0.04 0.53 NA XXX 

93731 .... .......... A Analyze pacemaker system ............................... 0.45 0.66 NA 0.05 1.16 NA XXX 

93732 .... 26 ..... A Analyze pacemaker system ............................... 0.92 0.35 0.35 0.03 1.30 1.30 XXX 

93732 .... TC .... A Analyze pacemaker system ............................... 0.00 0.51 NA 0.04 0.55 NA XXX 

93732 .... .......... A Analyze pacemaker system ............................... 0.92 0.86 NA 0.07 1.85 NA XXX 

93733 .... 26 ..... A Telephone analy, pacemaker ............................. 0.17 0.07 0.07 0.01 0.25 0.25 XXX 

93733 .... TC .... A Telephone analy, pacemaker ............................. 0.00 0.73 NA 0.06 0.79 NA XXX 

93733 .... .......... A Telephone analy, pacemaker ............................. 0.17 0.80 NA 0.07 1.04 NA XXX 

93734 .... 26 ..... A Analyze pacemaker system ............................... 0.38 0.15 0.15 0.01 0.54 0.54 XXX 

93734 .... TC .... A Analyze pacemaker system ............................... 0.00 0.35 NA 0.02 0.37 NA XXX 

70450 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

93734 .... .......... A Analyze pacemaker system ............................... 0.38 0.50 NA 0.03 0.91 NA XXX 

93735 .... 26 ..... A Analyze pacemaker system ............................... 0.74 0.28 0.28 0.02 1.04 1.04 XXX 

93735 .... TC .... A Analyze pacemaker system ............................... 0.00 0.44 NA 0.04 0.48 NA XXX 

93735 .... .......... A Analyze pacemaker system ............................... 0.74 0.72 NA 0.06 1.52 NA XXX 

93736 .... 26 ..... A Telephonic analy, pacemaker ............................ 0.15 0.06 0.06 0.01 0.22 0.22 XXX 

93736 .... TC .... A Telephonic analy, pacemaker ............................ 0.00 0.63 NA 0.06 0.69 NA XXX 

93736 .... .......... A Telephonic analy, pacemaker ............................ 0.15 0.69 NA 0.07 0.91 NA XXX 

93740 .... 26 ..... B Temperature gradient studies ............................ +0.16 0.04 0.04 0.01 0.21 0.21 XXX 

93740 .... TC .... B Temperature gradient studies ............................ +0.00 0.15 NA 0.01 0.16 NA XXX 

93740 .... .......... B Temperature gradient studies ............................ +0.16 0.19 NA 0.02 0.37 NA XXX 

93741 .... 26 ..... A Analyze ht pace device sngl .............................. 0.80 0.31 0.31 0.03 1.14 1.14 XXX 

93741 .... TC .... A Analyze ht pace device sngl .............................. 0.00 0.67 NA 0.04 0.71 NA XXX 

93741 .... .......... A Analyze ht pace device sngl .............................. 0.80 0.98 NA 0.07 1.85 NA XXX 

93742 .... 26 ..... A Analyze ht pace device sngl .............................. 0.91 0.36 0.36 0.03 1.30 1.30 XXX 

93742 .... TC .... A Analyze ht pace device sngl .............................. 0.00 0.67 NA 0.04 0.71 NA XXX 

93742 .... .......... A Analyze ht pace device sngl .............................. 0.91 1.03 NA 0.07 2.01 NA XXX 

93743 .... 26 ..... A Analyze ht pace device dual .............................. 1.03 0.40 0.40 0.03 1.46 1.46 XXX 

93743 .... TC .... A Analyze ht pace device dual .............................. 0.00 0.73 NA 0.04 0.77 NA XXX 

93743 .... .......... A Analyze ht pace device dual .............................. 1.03 1.13 NA 0.07 2.23 NA XXX 

93744 .... 26 ..... A Analyze ht pace device dual .............................. 1.18 0.46 0.46 0.04 1.68 1.68 XXX 

93744 .... TC .... A Analyze ht pace device dual .............................. 0.00 0.67 NA 0.04 0.71 NA XXX 

93744 .... .......... A Analyze ht pace device dual .............................. 1.18 1.13 NA 0.08 2.39 NA XXX 

93745 .... 26 ..... C Set-up cardiovert-defibrill ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93745 .... TC .... C Set-up cardiovert-defibrill ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93745 .... .......... C Set-up cardiovert-defibrill ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93760 .... .......... N Cephalic thermogram ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93762 .... .......... N Peripheral thermogram ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93770 .... 26 ..... B Measure venous pressure .................................. +0.16 0.05 0.05 0.01 0.22 0.22 XXX 

93770 .... TC .... B Measure venous pressure .................................. +0.00 0.03 NA 0.01 0.04 NA XXX 

93770 .... .......... B Measure venous pressure .................................. +0.16 0.08 NA 0.02 0.26 NA XXX 

93784 .... .......... A Ambulatory BP monitoring ................................. 0.38 1.55 NA 0.03 1.96 NA XXX 

93786 .... .......... A Ambulatory BP recording ................................... 0.00 0.91 NA 0.01 0.92 NA XXX 

93788 .... .......... A Ambulatory BP analysis ..................................... 0.00 0.51 NA 0.01 0.52 NA XXX 

93790 .... .......... A Review/report BP recording ............................... 0.38 0.13 0.13 0.01 0.52 0.52 XXX 

93797 .... .......... A Cardiac rehab ..................................................... 0.18 0.30 0.07 0.01 0.49 0.26 000 

93798 .... .......... A Cardiac rehab/monitor ........................................ 0.28 0.46 0.11 0.01 0.75 0.40 000 

93799 .... 26 ..... C Cardiovascular procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93799 .... TC .... C Cardiovascular procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93799 .... .......... C Cardiovascular procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

93875 .... 26 ..... A Extracranial study ............................................... 0.22 0.08 0.08 0.01 0.31 0.31 XXX 

93875 .... TC .... A Extracranial study ............................................... 0.00 2.26 NA 0.11 2.37 NA XXX 

93875 .... .......... A Extracranial study ............................................... 0.22 2.34 NA 0.12 2.68 NA XXX 

93880 .... 26 ..... A Extracranial study ............................................... 0.60 0.20 0.20 0.04 0.84 0.84 XXX 

93880 .... TC .... A Extracranial study ............................................... 0.00 5.37 NA 0.35 5.72 NA XXX 

93880 .... .......... A Extracranial study ............................................... 0.60 5.57 NA 0.39 6.56 NA XXX 

93882 .... 26 ..... A Extracranial study ............................................... 0.40 0.14 0.14 0.04 0.58 0.58 XXX 

93882 .... TC .... A Extracranial study ............................................... 0.00 3.37 NA 0.22 3.59 NA XXX 

93882 .... .......... A Extracranial study ............................................... 0.40 3.51 NA 0.26 4.17 NA XXX 

93886 .... 26 ..... A Intracranial study ................................................ 0.94 0.37 0.37 0.06 1.37 1.37 XXX 

93886 .... TC .... A Intracranial study ................................................ 0.00 6.39 NA 0.39 6.78 NA XXX 

93886 .... .......... A Intracranial study ................................................ 0.94 6.76 NA 0.45 8.15 NA XXX 

93888 .... 26 ..... A Intracranial study ................................................ 0.62 0.23 0.23 0.05 0.90 0.90 XXX 

93888 .... TC .... A Intracranial study ................................................ 0.00 4.02 NA 0.27 4.29 NA XXX 

93888 .... .......... A Intracranial study ................................................ 0.62 4.25 NA 0.32 5.19 NA XXX 

93890 .... 26 ..... A Tcd, vasoreactivity study .................................... 1.00 0.40 0.40 0.06 1.46 1.46 XXX 

93890 .... TC .... A Tcd, vasoreactivity study .................................... 0.00 4.51 NA 0.39 4.90 NA XXX 

93890 .... .......... A Tcd, vasoreactivity study .................................... 1.00 4.91 NA 0.45 6.36 NA XXX 

93892 .... 26 ..... A Tcd, emboli detect w/o inj .................................. 1.15 0.46 0.46 0.06 1.67 1.67 XXX 

93892 .... TC .... A Tcd, emboli detect w/o inj .................................. 0.00 4.71 NA 0.39 5.10 NA XXX 

93892 .... .......... A Tcd, emboli detect w/o inj .................................. 1.15 5.17 NA 0.45 6.77 NA XXX 

93893 .... 26 ..... A Tcd, emboli detect w/inj ..................................... 1.15 0.46 0.46 0.06 1.67 1.67 XXX 

93893 .... TC .... A Tcd, emboli detect w/inj ..................................... 0.00 4.58 NA 0.39 4.97 NA XXX 

93893 .... .......... A Tcd, emboli detect w/inj ..................................... 1.15 5.04 NA 0.45 6.64 NA XXX 

93922 .... 26 ..... A Extremity study ................................................... 0.25 0.08 0.08 0.02 0.35 0.35 XXX 

93922 .... TC .... A Extremity study ................................................... 0.00 2.61 NA 0.13 2.74 NA XXX 

93922 .... .......... A Extremity study ................................................... 0.25 2.69 NA 0.15 3.09 NA XXX 

93923 .... 26 ..... A Extremity study ................................................... 0.45 0.15 0.15 0.04 0.64 0.64 XXX 

93923 .... TC .... A Extremity study ................................................... 0.00 3.89 NA 0.22 4.11 NA XXX 

93923 .... .......... A Extremity study ................................................... 0.45 4.04 NA 0.26 4.75 NA XXX 

93924 .... 26 ..... A Extremity study ................................................... 0.50 0.17 0.17 0.05 0.72 0.72 XXX 

93924 .... TC .... A Extremity study ................................................... 0.00 4.63 NA 0.25 4.88 NA XXX 

93924 .... .......... A Extremity study ................................................... 0.50 4.80 NA 0.30 5.60 NA XXX 

93925 .... 26 ..... A Lower extremity study ........................................ 0.58 0.20 0.20 0.04 0.82 0.82 XXX 

93925 .... TC .... A Lower extremity study ........................................ 0.00 6.60 NA 0.35 6.95 NA XXX 

93925 .... .......... A Lower extremity study ........................................ 0.58 6.80 NA 0.39 7.77 NA XXX 

70451 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

93926 .... 26 ..... A Lower extremity study ........................................ 0.39 0.13 0.13 0.04 0.56 0.56 XXX 

93926 .... TC .... A Lower extremity study ........................................ 0.00 3.93 NA 0.23 4.16 NA XXX 

93926 .... .......... A Lower extremity study ........................................ 0.39 4.06 NA 0.27 4.72 NA XXX 

93930 .... 26 ..... A Upper extremity study ........................................ 0.46 0.16 0.16 0.04 0.66 0.66 XXX 

93930 .... TC .... A Upper extremity study ........................................ 0.00 5.21 NA 0.37 5.58 NA XXX 

93930 .... .......... A Upper extremity study ........................................ 0.46 5.37 NA 0.41 6.24 NA XXX 

93931 .... 26 ..... A Upper extremity study ........................................ 0.31 0.10 0.10 0.03 0.44 0.44 XXX 

93931 .... TC .... A Upper extremity study ........................................ 0.00 3.39 NA 0.24 3.63 NA XXX 

93931 .... .......... A Upper extremity study ........................................ 0.31 3.49 NA 0.27 4.07 NA XXX 

93965 .... 26 ..... A Extremity study ................................................... 0.35 0.12 0.12 0.02 0.49 0.49 XXX 

93965 .... TC .... A Extremity study ................................................... 0.00 2.68 NA 0.12 2.80 NA XXX 

93965 .... .......... A Extremity study ................................................... 0.35 2.80 NA 0.14 3.29 NA XXX 

93970 .... 26 ..... A Extremity study ................................................... 0.68 0.23 0.23 0.06 0.97 0.97 XXX 

93970 .... TC .... A Extremity study ................................................... 0.00 5.03 NA 0.40 5.43 NA XXX 

93970 .... .......... A Extremity study ................................................... 0.68 5.26 NA 0.46 6.40 NA XXX 

93971 .... 26 ..... A Extremity study ................................................... 0.45 0.15 0.15 0.03 0.63 0.63 XXX 

93971 .... TC .... A Extremity study ................................................... 0.00 3.45 NA 0.27 3.72 NA XXX 

93971 .... .......... A Extremity study ................................................... 0.45 3.60 NA 0.30 4.35 NA XXX 

93975 .... 26 ..... A Vascular study .................................................... 1.80 0.60 0.60 0.13 2.53 2.53 XXX 

93975 .... TC .... A Vascular study .................................................... 0.00 7.05 NA 0.43 7.48 NA XXX 

93975 .... .......... A Vascular study .................................................... 1.80 7.65 NA 0.56 10.01 NA XXX 

93976 .... 26 ..... A Vascular study .................................................... 1.21 0.40 0.40 0.05 1.66 1.66 XXX 

93976 .... TC .... A Vascular study .................................................... 0.00 3.94 NA 0.30 4.24 NA XXX 

93976 .... .......... A Vascular study .................................................... 1.21 4.34 NA 0.35 5.90 NA XXX 

93978 .... 26 ..... A Vascular study .................................................... 0.65 0.22 0.22 0.06 0.93 0.93 XXX 

93978 .... TC .... A Vascular study .................................................... 0.00 4.30 NA 0.37 4.67 NA XXX 

93978 .... .......... A Vascular study .................................................... 0.65 4.52 NA 0.43 5.60 NA XXX 

93979 .... 26 ..... A Vascular study .................................................... 0.44 0.15 0.15 0.03 0.62 0.62 XXX 

93979 .... TC .... A Vascular study .................................................... 0.00 3.07 NA 0.24 3.31 NA XXX 

93979 .... .......... A Vascular study .................................................... 0.44 3.22 NA 0.27 3.93 NA XXX 

93980 .... 26 ..... A Penile vascular study ......................................... 1.25 0.41 0.41 0.08 1.74 1.74 XXX 

93980 .... TC .... A Penile vascular study ......................................... 0.00 2.45 NA 0.34 2.79 NA XXX 

93980 .... .......... A Penile vascular study ......................................... 1.25 2.86 NA 0.42 4.53 NA XXX 

93981 .... 26 ..... A Penile vascular study ......................................... 0.44 0.14 0.14 0.02 0.60 0.60 XXX 

93981 .... TC .... A Penile vascular study ......................................... 0.00 2.74 NA 0.31 3.05 NA XXX 

93981 .... .......... A Penile vascular study ......................................... 0.44 2.88 NA 0.33 3.65 NA XXX 

93990 .... 26 ..... A Doppler flow testing ............................................ 0.25 0.09 0.09 0.03 0.37 0.37 XXX 

93990 .... TC .... A Doppler flow testing ............................................ 0.00 3.91 NA 0.23 4.14 NA XXX 

93990 .... .......... A Doppler flow testing ............................................ 0.25 4.00 NA 0.26 4.51 NA XXX 

94010 .... 26 ..... A Breathing capacity test ....................................... 0.17 0.05 0.05 0.01 0.23 0.23 XXX 

94010 .... TC .... A Breathing capacity test ....................................... 0.00 0.62 NA 0.02 0.64 NA XXX 

94010 .... .......... A Breathing capacity test ....................................... 0.17 0.67 NA 0.03 0.87 NA XXX 

94014 .... .......... A Patient recorded spirometry ............................... 0.52 0.76 NA 0.03 1.31 NA XXX 

94015 .... .......... A Patient recorded spirometry ............................... 0.00 0.59 NA 0.01 0.60 NA XXX 

94016 .... .......... A Review patient spirometry .................................. 0.52 0.17 0.17 0.02 0.71 0.71 XXX 

94060 .... 26 ..... A Evaluation of wheezing ...................................... 0.31 0.09 0.09 0.01 0.41 0.41 XXX 

94060 .... TC .... A Evaluation of wheezing ...................................... 0.00 0.98 NA 0.06 1.04 NA XXX 

94060 .... .......... A Evaluation of wheezing ...................................... 0.31 1.07 NA 0.07 1.45 NA XXX 

94070 .... 26 ..... A Evaluation of wheezing ...................................... 0.60 0.18 0.18 0.03 0.81 0.81 XXX 

94070 .... TC .... A Evaluation of wheezing ...................................... 0.00 0.64 NA 0.10 0.74 NA XXX 

94070 .... .......... A Evaluation of wheezing ...................................... 0.60 0.82 NA 0.13 1.55 NA XXX 

94150 .... 26 ..... B Vital capacity test ............................................... +0.07 0.03 0.03 0.01 0.11 0.11 XXX 

94150 .... TC .... B Vital capacity test ............................................... +0.00 0.44 NA 0.01 0.45 NA XXX 

94150 .... .......... B Vital capacity test ............................................... +0.07 0.47 NA 0.02 0.56 NA XXX 

94200 .... 26 ..... A Lung function test (MBC/MVV) .......................... 0.11 0.03 0.03 0.01 0.15 0.15 XXX 

94200 .... TC .... A Lung function test (MBC/MVV) .......................... 0.00 0.41 NA 0.02 0.43 NA XXX 

94200 .... .......... A Lung function test (MBC/MVV) .......................... 0.11 0.44 NA 0.03 0.58 NA XXX 

94240 .... 26 ..... A Residual lung capacity ....................................... 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94240 .... TC .... A Residual lung capacity ....................................... 0.00 0.58 NA 0.05 0.63 NA XXX 

94240 .... .......... A Residual lung capacity ....................................... 0.26 0.66 NA 0.06 0.98 NA XXX 

94250 .... 26 ..... A Expired gas collection ........................................ 0.11 0.03 0.03 0.01 0.15 0.15 XXX 

94250 .... TC .... A Expired gas collection ........................................ 0.00 0.61 NA 0.01 0.62 NA XXX 

94250 .... .......... A Expired gas collection ........................................ 0.11 0.64 NA 0.02 0.77 NA XXX 

94260 .... 26 ..... A Thoracic gas volume .......................................... 0.13 0.04 0.04 0.01 0.18 0.18 XXX 

94260 .... TC .... A Thoracic gas volume .......................................... 0.00 0.54 NA 0.04 0.58 NA XXX 

94260 .... .......... A Thoracic gas volume .......................................... 0.13 0.58 NA 0.05 0.76 NA XXX 

94350 .... 26 ..... A Lung nitrogen washout curve ............................. 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94350 .... TC .... A Lung nitrogen washout curve ............................. 0.00 0.68 NA 0.04 0.72 NA XXX 

94350 .... .......... A Lung nitrogen washout curve ............................. 0.26 0.76 NA 0.05 1.07 NA XXX 

94360 .... 26 ..... A Measure airflow resistance ................................ 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94360 .... TC .... A Measure airflow resistance ................................ 0.00 0.62 NA 0.06 0.68 NA XXX 

94360 .... .......... A Measure airflow resistance ................................ 0.26 0.70 NA 0.07 1.03 NA XXX 

94370 .... 26 ..... A Breath airway closing volume ............................ 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94370 .... TC .... A Breath airway closing volume ............................ 0.00 0.64 NA 0.02 0.66 NA XXX 

94370 .... .......... A Breath airway closing volume ............................ 0.26 0.72 NA 0.03 1.01 NA XXX 

70452 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

94375 .... 26 ..... A Respiratory flow volume loop ............................. 0.31 0.09 0.09 0.01 0.41 0.41 XXX 

94375 .... TC .... A Respiratory flow volume loop ............................. 0.00 0.51 NA 0.02 0.53 NA XXX 

94375 .... .......... A Respiratory flow volume loop ............................. 0.31 0.60 NA 0.03 0.94 NA XXX 

94400 .... 26 ..... A CO2 breathing response curve .......................... 0.40 0.12 0.12 0.03 0.55 0.55 XXX 

94400 .... TC .... A CO2 breathing response curve .......................... 0.00 0.72 NA 0.06 0.78 NA XXX 

94400 .... .......... A CO2 breathing response curve .......................... 0.40 0.84 NA 0.09 1.33 NA XXX 

94450 .... 26 ..... A Hypoxia response curve ..................................... 0.40 0.12 0.12 0.02 0.54 0.54 XXX 

94450 .... TC .... A Hypoxia response curve ..................................... 0.00 0.73 NA 0.02 0.75 NA XXX 

94450 .... .......... A Hypoxia response curve ..................................... 0.40 0.85 NA 0.04 1.29 NA XXX 

94452 .... 26 ..... A Hast w/report ...................................................... 0.31 0.09 0.09 0.02 0.42 0.42 XXX 

94452 .... TC .... A Hast w/report ...................................................... 0.00 0.93 NA 0.02 0.95 NA XXX 

94452 .... .......... A Hast w/report ...................................................... 0.31 1.02 NA 0.04 1.37 NA XXX 

94453 .... 26 ..... A Hast w/oxygen titrate .......................................... 0.40 0.12 0.12 0.02 0.54 0.54 XXX 

94453 .... TC .... A Hast w/oxygen titrate .......................................... 0.00 1.39 NA 0.02 1.41 NA XXX 

94453 .... .......... A Hast w/oxygen titrate .......................................... 0.40 1.51 NA 0.04 1.95 NA XXX 

94620 .... 26 ..... A Pulmonary stress test/simple ............................. 0.64 0.20 0.20 0.03 0.87 0.87 XXX 

94620 .... TC .... A Pulmonary stress test/simple ............................. 0.00 2.30 NA 0.10 2.40 NA XXX 

94620 .... .......... A Pulmonary stress test/simple ............................. 0.64 2.50 NA 0.13 3.27 NA XXX 

94621 .... 26 ..... A Pulm stress test/complex ................................... 1.42 0.44 0.44 0.06 1.92 1.92 XXX 

94621 .... TC .... A Pulm stress test/complex ................................... 0.00 1.77 NA 0.10 1.87 NA XXX 

94621 .... .......... A Pulm stress test/complex ................................... 1.42 2.21 NA 0.16 3.79 NA XXX 

94640 .... .......... A Airway inhalation treatment ................................ 0.00 0.30 NA 0.02 0.32 NA XXX 

94642 .... .......... C Aerosol inhalation treatment .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94656 .... .......... A Initial ventilator mgmt ......................................... 1.22 1.16 0.32 0.06 2.44 1.60 XXX 

94657 .... .......... A Continued ventilator mgmt ................................. 0.83 0.98 0.25 0.04 1.85 1.12 XXX 

94660 .... .......... A Pos airway pressure, CPAP ............................... 0.76 0.65 0.23 0.04 1.45 1.03 XXX 

94662 .... .......... A Neg press ventilation, cnp .................................. 0.76 NA 0.23 0.03 NA 1.02 XXX 

94664 .... .......... A Evaluate pt use of inhaler .................................. 0.00 0.31 NA 0.04 0.35 NA XXX 

94667 .... .......... A Chest wall manipulation ..................................... 0.00 0.52 NA 0.05 0.57 NA XXX 

94668 .... .......... A Chest wall manipulation ..................................... 0.00 0.45 NA 0.02 0.47 NA XXX 

94680 .... 26 ..... A Exhaled air analysis, o2 ..................................... 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94680 .... TC .... A Exhaled air analysis, o2 ..................................... 0.00 1.79 NA 0.06 1.85 NA XXX 

94680 .... .......... A Exhaled air analysis, o2 ..................................... 0.26 1.87 NA 0.07 2.20 NA XXX 

94681 .... 26 ..... A Exhaled air analysis, o2/co2 .............................. 0.20 0.06 0.06 0.01 0.27 0.27 XXX 

94681 .... TC .... A Exhaled air analysis, o2/co2 .............................. 0.00 2.47 NA 0.12 2.59 NA XXX 

94681 .... .......... A Exhaled air analysis, o2/co2 .............................. 0.20 2.53 NA 0.13 2.86 NA XXX 

94690 .... 26 ..... A Exhaled air analysis ........................................... 0.07 0.02 0.02 0.01 0.10 0.10 XXX 

94690 .... TC .... A Exhaled air analysis ........................................... 0.00 1.98 NA 0.04 2.02 NA XXX 

94690 .... .......... A Exhaled air analysis ........................................... 0.07 2.00 NA 0.05 2.12 NA XXX 

94720 .... 26 ..... A Monoxide diffusing capacity ............................... 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94720 .... TC .... A Monoxide diffusing capacity ............................... 0.00 0.92 NA 0.06 0.98 NA XXX 

94720 .... .......... A Monoxide diffusing capacity ............................... 0.26 1.00 NA 0.07 1.33 NA XXX 

94725 .... 26 ..... A Membrane diffusion capacity ............................. 0.26 0.08 0.08 0.01 0.35 0.35 XXX 

94725 .... TC .... A Membrane diffusion capacity ............................. 0.00 2.84 NA 0.12 2.96 NA XXX 

94725 .... .......... A Membrane diffusion capacity ............................. 0.26 2.92 NA 0.13 3.31 NA XXX 

94750 .... 26 ..... A Pulmonary compliance study ............................. 0.23 0.07 0.07 0.01 0.31 0.31 XXX 

94750 .... TC .... A Pulmonary compliance study ............................. 0.00 1.27 NA 0.04 1.31 NA XXX 

94750 .... .......... A Pulmonary compliance study ............................. 0.23 1.34 NA 0.05 1.62 NA XXX 

94760 .... .......... T Measure blood oxygen level .............................. 0.00 0.04 NA 0.02 0.06 NA XXX 

94761 .... .......... T Measure blood oxygen level .............................. 0.00 0.07 NA 0.06 0.13 NA XXX 

94762 .... .......... A Measure blood oxygen level .............................. 0.00 0.47 NA 0.10 0.57 NA XXX 

94770 .... 26 ..... A Exhaled carbon dioxide test ............................... 0.15 0.04 0.04 0.01 0.20 0.20 XXX 

94770 .... TC .... A Exhaled carbon dioxide test ............................... 0.00 0.71 NA 0.07 0.78 NA XXX 

94770 .... .......... A Exhaled carbon dioxide test ............................... 0.15 0.75 NA 0.08 0.98 NA XXX 

94772 .... 26 ..... C Breath recording, infant ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94772 .... TC .... C Breath recording, infant ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94772 .... .......... C Breath recording, infant ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94799 .... 26 ..... C Pulmonary service/procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94799 .... TC .... C Pulmonary service/procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

94799 .... .......... C Pulmonary service/procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95004 .... .......... A Percut allergy skin tests ..................................... 0.00 0.10 NA 0.01 0.11 NA XXX 

95010 .... .......... A Percut allergy titrate test .................................... 0.15 0.32 0.06 0.01 0.48 0.22 XXX 

95015 .... .......... A Id allergy titrate-drug/bug ................................... 0.15 0.14 0.06 0.01 0.30 0.22 XXX 

95024 .... .......... A Id allergy test, drug/bug ..................................... 0.00 0.15 NA 0.01 0.16 NA XXX 

95027 .... .......... A Id allergy titrate-airborne .................................... 0.00 0.15 NA 0.01 0.16 NA XXX 

95028 .... .......... A Id allergy test-delayed type ................................ 0.00 0.23 NA 0.01 0.24 NA XXX 

95044 .... .......... A Allergy patch tests .............................................. 0.00 0.20 NA 0.01 0.21 NA XXX 

95052 .... .......... A Photo patch test ................................................. 0.00 0.25 NA 0.01 0.26 NA XXX 

95056 .... .......... A Photosensitivity tests .......................................... 0.00 0.17 NA 0.01 0.18 NA XXX 

95060 .... .......... A Eye allergy tests ................................................. 0.00 0.35 NA 0.02 0.37 NA XXX 

95065 .... .......... A Nose allergy test ................................................ 0.00 0.20 NA 0.01 0.21 NA XXX 

95070 .... .......... A Bronchial allergy tests ........................................ 0.00 2.29 NA 0.02 2.31 NA XXX 

95071 .... .......... A Bronchial allergy tests ........................................ 0.00 2.93 NA 0.02 2.95 NA XXX 

95075 .... .......... A Ingestion challenge test ..................................... 0.95 0.82 0.38 0.03 1.80 1.36 XXX 

95078 .... .......... A Provocative testing ............................................. 0.00 0.25 NA 0.02 0.27 NA XXX 

70453 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

95115 .... .......... A Immunotherapy, one injection ............................ 0.00 0.39 NA 0.02 0.41 NA XXX 

95117 .... .......... A Immunotherapy injections .................................. 0.00 0.50 NA 0.02 0.52 NA XXX 

95120 .... .......... I Immunotherapy, one injection ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95125 .... .......... I Immunotherapy, many antigens ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95130 .... .......... I Immunotherapy, insect venom ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95131 .... .......... I Immunotherapy, insect venoms ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95132 .... .......... I Immunotherapy, insect venoms ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95133 .... .......... I Immunotherapy, insect venoms ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95134 .... .......... I Immunotherapy, insect venoms ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95144 .... .......... A Antigen therapy services .................................... 0.06 0.19 0.02 0.01 0.26 0.09 XXX 

95145 .... .......... A Antigen therapy services .................................... 0.06 0.32 0.02 0.01 0.39 0.09 XXX 

95146 .... .......... A Antigen therapy services .................................... 0.06 0.44 0.03 0.01 0.51 0.10 XXX 

95147 .... .......... A Antigen therapy services .................................... 0.06 0.42 0.02 0.01 0.49 0.09 XXX 

95148 .... .......... A Antigen therapy services .................................... 0.06 0.58 0.03 0.01 0.65 0.10 XXX 

95149 .... .......... A Antigen therapy services .................................... 0.06 0.80 0.03 0.01 0.87 0.10 XXX 

95165 .... .......... A Antigen therapy services .................................... 0.06 0.19 0.02 0.01 0.26 0.09 XXX 

95170 .... .......... A Antigen therapy services .................................... 0.06 0.13 0.03 0.01 0.20 0.10 XXX 

95180 .... .......... A Rapid desensitization ......................................... 2.01 2.04 0.93 0.04 4.09 2.98 XXX 

95199 .... .......... C Allergy immunology services .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95250 .... .......... A Glucose monitoring, cont ................................... 0.00 4.11 NA 0.01 4.12 NA XXX 

95251 .... .......... A Gluc monitor, cont, phys i&r ............................... 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

95805 .... 26 ..... A Multiple sleep latency test .................................. 1.88 0.66 0.66 0.09 2.63 2.63 XXX 

95805 .... TC .... A Multiple sleep latency test .................................. 0.00 16.65 NA 0.34 16.99 NA XXX 

95805 .... .......... A Multiple sleep latency test .................................. 1.88 17.31 NA 0.43 19.62 NA XXX 

95806 .... 26 ..... A Sleep study, unattended .................................... 1.66 0.54 0.54 0.08 2.28 2.28 XXX 

95806 .... TC .... A Sleep study, unattended .................................... 0.00 2.80 NA 0.31 3.11 NA XXX 

95806 .... .......... A Sleep study, unattended .................................... 1.66 3.34 NA 0.39 5.39 NA XXX 

95807 .... 26 ..... A Sleep study, attended ........................................ 1.66 0.53 0.53 0.08 2.27 2.27 XXX 

95807 .... TC .... A Sleep study, attended ........................................ 0.00 11.35 NA 0.42 11.77 NA XXX 

95807 .... .......... A Sleep study, attended ........................................ 1.66 11.88 NA 0.50 14.04 NA XXX 

95808 .... 26 ..... A Polysomnography, 1-3 ....................................... 2.65 0.92 0.92 0.13 3.70 3.70 XXX 

95808 .... TC .... A Polysomnography, 1-3 ....................................... 0.00 12.31 NA 0.42 12.73 NA XXX 

95808 .... .......... A Polysomnography, 1-3 ....................................... 2.65 13.23 NA 0.55 16.43 NA XXX 

95810 .... 26 ..... A Polysomnography, 4 or more ............................. 3.52 1.18 1.18 0.17 4.87 4.87 XXX 

95810 .... TC .... A Polysomnography, 4 or more ............................. 0.00 16.36 NA 0.42 16.78 NA XXX 

95810 .... .......... A Polysomnography, 4 or more ............................. 3.52 17.54 NA 0.59 21.65 NA XXX 

95811 .... 26 ..... A Polysomnography w/cpap .................................. 3.79 1.27 1.27 0.18 5.24 5.24 XXX 

95811 .... TC .... A Polysomnography w/cpap .................................. 0.00 17.97 NA 0.43 18.40 NA XXX 

95811 .... .......... A Polysomnography w/cpap .................................. 3.79 19.24 NA 0.61 23.64 NA XXX 

95812 .... 26 ..... A Eeg, 41-60 minutes ............................................ 1.08 0.45 0.45 0.06 1.59 1.59 XXX 

95812 .... TC .... A Eeg, 41-60 minutes ............................................ 0.00 3.59 NA 0.11 3.70 NA XXX 

95812 .... .......... A Eeg, 41-60 minutes ............................................ 1.08 4.04 NA 0.17 5.29 NA XXX 

95813 .... 26 ..... A Eeg, over 1 hour ................................................ 1.73 0.70 0.70 0.09 2.52 2.52 XXX 

95813 .... TC .... A Eeg, over 1 hour ................................................ 0.00 4.33 NA 0.11 4.44 NA XXX 

95813 .... .......... A Eeg, over 1 hour ................................................ 1.73 5.03 NA 0.20 6.96 NA XXX 

95816 .... 26 ..... A Eeg, awake and drowsy ..................................... 1.08 0.46 0.46 0.06 1.60 1.60 XXX 

95816 .... TC .... A Eeg, awake and drowsy ..................................... 0.00 3.26 NA 0.10 3.36 NA XXX 

95816 .... .......... A Eeg, awake and drowsy ..................................... 1.08 3.72 NA 0.16 4.96 NA XXX 

95819 .... 26 ..... A Eeg, awake and asleep ...................................... 1.08 0.46 0.46 0.06 1.60 1.60 XXX 

95819 .... TC .... A Eeg, awake and asleep ...................................... 0.00 2.53 NA 0.10 2.63 NA XXX 

95819 .... .......... A Eeg, awake and asleep ...................................... 1.08 2.99 NA 0.16 4.23 NA XXX 

95822 .... 26 ..... A Eeg, coma or sleep only .................................... 1.08 0.46 0.46 0.06 1.60 1.60 XXX 

95822 .... TC .... A Eeg, coma or sleep only .................................... 0.00 4.15 NA 0.13 4.28 NA XXX 

95822 .... .......... A Eeg, coma or sleep only .................................... 1.08 4.61 NA 0.19 5.88 NA XXX 

95824 .... 26 ..... A Eeg, cerebral death only .................................... 0.74 0.31 0.31 0.04 1.09 1.09 XXX 

95824 .... TC .... C Eeg, cerebral death only .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95824 .... .......... C Eeg, cerebral death only .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95827 .... 26 ..... A Eeg, all night recording ...................................... 1.08 0.41 0.41 0.05 1.54 1.54 XXX 

95827 .... TC .... A Eeg, all night recording ...................................... 0.00 2.30 NA 0.14 2.44 NA XXX 

95827 .... .......... A Eeg, all night recording ...................................... 1.08 2.71 NA 0.19 3.98 NA XXX 

95829 .... 26 ..... A Surgery electrocorticogram ................................ 6.20 2.32 2.32 0.48 9.00 9.00 XXX 

95829 .... TC .... A Surgery electrocorticogram ................................ 0.00 28.77 NA 0.02 28.79 NA XXX 

95829 .... .......... A Surgery electrocorticogram ................................ 6.20 31.09 NA 0.50 37.79 NA XXX 

95830 .... .......... A Insert electrodes for EEG ................................... 1.70 3.30 0.73 0.11 5.11 2.54 XXX 

95831 .... .......... A Limb muscle testing, manual ............................. 0.28 0.46 0.13 0.01 0.75 0.42 XXX 

95832 .... .......... A Hand muscle testing, manual ............................. 0.29 0.33 0.12 0.02 0.64 0.43 XXX 

95833 .... .......... A Body muscle testing, manual ............................. 0.47 0.58 0.23 0.02 1.07 0.72 XXX 

95834 .... .......... A Body muscle testing, manual ............................. 0.60 0.63 0.28 0.03 1.26 0.91 XXX 

95851 .... .......... A Range of motion measurements ........................ 0.16 0.36 0.08 0.01 0.53 0.25 XXX 

95852 .... .......... A Range of motion measurements ........................ 0.11 0.26 0.05 0.01 0.38 0.17 XXX 

95857 .... .......... A Tensilon test ....................................................... 0.53 0.60 0.23 0.02 1.15 0.78 XXX 

95860 .... 26 ..... A Muscle test, one limb ......................................... 0.96 0.42 0.42 0.05 1.43 1.43 XXX 

95860 .... TC .... A Muscle test, one limb ......................................... 0.00 1.00 NA 0.02 1.02 NA XXX 

95860 .... .......... A Muscle test, one limb ......................................... 0.96 1.42 NA 0.07 2.45 NA XXX 

95861 .... 26 ..... A Muscle test, 2 limbs ........................................... 1.54 0.68 0.68 0.07 2.29 2.29 XXX 

70454 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

95861 .... TC .... A Muscle test, 2 limbs ........................................... 0.00 0.73 NA 0.06 0.79 NA XXX 

95861 .... .......... A Muscle test, 2 limbs ........................................... 1.54 1.41 NA 0.13 3.08 NA XXX 

95863 .... 26 ..... A Muscle test, 3 limbs ........................................... 1.87 0.80 0.80 0.09 2.76 2.76 XXX 

95863 .... TC .... A Muscle test, 3 limbs ........................................... 0.00 0.94 NA 0.06 1.00 NA XXX 

95863 .... .......... A Muscle test, 3 limbs ........................................... 1.87 1.74 NA 0.15 3.76 NA XXX 

95864 .... 26 ..... A Muscle test, 4 limbs ........................................... 1.99 0.87 0.87 0.09 2.95 2.95 XXX 

95864 .... TC .... A Muscle test, 4 limbs ........................................... 0.00 1.79 NA 0.12 1.91 NA XXX 

95864 .... .......... A Muscle test, 4 limbs ........................................... 1.99 2.66 NA 0.21 4.86 NA XXX 

95865 .... 26 ..... A Muscle test, larynx ............................................. 1.57 0.77 0.77 0.08 2.42 2.42 XXX 

95865 .... TC .... A Muscle test, larynx ............................................. 0.00 0.68 NA 0.03 0.71 NA XXX 

95865 .... .......... A Muscle test, larynx ............................................. 1.57 1.45 NA 0.11 3.13 NA XXX 

95866 .... 26 ..... A Muscle test, hemidiaphragm .............................. 1.25 0.56 0.56 0.07 1.88 1.88 XXX 

95866 .... TC .... A Muscle test, hemidiaphragm .............................. 0.00 0.20 NA 0.03 0.23 NA XXX 

95866 .... .......... A Muscle test, hemidiaphragm .............................. 1.25 0.76 NA 0.10 2.11 NA XXX 

95867 .... 26 ..... A Muscle test cran nerv unilat ............................... 0.79 0.35 0.35 0.03 1.17 1.17 XXX 

95867 .... TC .... A Muscle test cran nerv unilat ............................... 0.00 0.58 NA 0.04 0.62 NA XXX 

95867 .... .......... A Muscle test cran nerv unilat ............................... 0.79 0.93 NA 0.07 1.79 NA XXX 

95868 .... 26 ..... A Muscle test cran nerve bilat ............................... 1.18 0.51 0.51 0.05 1.74 1.74 XXX 

95868 .... TC .... A Muscle test cran nerve bilat ............................... 0.00 0.70 NA 0.05 0.75 NA XXX 

95868 .... .......... A Muscle test cran nerve bilat ............................... 1.18 1.21 NA 0.10 2.49 NA XXX 

95869 .... 26 ..... A Muscle test, thor paraspinal ............................... 0.37 0.16 0.16 0.02 0.55 0.55 XXX 

95869 .... TC .... A Muscle test, thor paraspinal ............................... 0.00 0.21 NA 0.02 0.23 NA XXX 

95869 .... .......... A Muscle test, thor paraspinal ............................... 0.37 0.37 NA 0.04 0.78 NA XXX 

95870 .... 26 ..... A Muscle test, nonparaspinal ................................ 0.37 0.16 0.16 0.02 0.55 0.55 XXX 

95870 .... TC .... A Muscle test, nonparaspinal ................................ 0.00 0.21 NA 0.02 0.23 NA XXX 

95870 .... .......... A Muscle test, nonparaspinal ................................ 0.37 0.37 NA 0.04 0.78 NA XXX 

95872 .... 26 ..... A Muscle test, one fiber ......................................... 1.50 0.63 0.63 0.08 2.21 2.21 XXX 

95872 .... TC .... A Muscle test, one fiber ......................................... 0.00 0.60 NA 0.05 0.65 NA XXX 

95872 .... .......... A Muscle test, one fiber ......................................... 1.50 1.23 NA 0.13 2.86 NA XXX 

95873 .... 26 ..... A Guide nerv destr, elec stim ................................ 0.37 0.16 0.16 0.02 0.55 0.55 ZZZ 

95873 .... TC .... A Guide nerv destr, elec stim ................................ 0.00 0.20 NA 0.02 0.22 NA ZZZ 

95873 .... .......... A Guide nerv destr, elec stim ................................ 0.37 0.36 NA 0.04 0.77 NA ZZZ 

95874 .... 26 ..... A Guide nerv destr, needle emg ........................... 0.37 0.17 0.17 0.02 0.56 0.56 ZZZ 

95874 .... TC .... A Guide nerv destr, needle emg ........................... 0.00 0.20 NA 0.02 0.22 NA ZZZ 

95874 .... .......... A Guide nerv destr, needle emg ........................... 0.37 0.37 NA 0.04 0.78 NA ZZZ 

95875 .... 26 ..... A Limb exercise test .............................................. 1.10 0.47 0.47 0.05 1.62 1.62 XXX 

95875 .... TC .... A Limb exercise test .............................................. 0.00 0.98 NA 0.06 1.04 NA XXX 

95875 .... .......... A Limb exercise test .............................................. 1.10 1.45 NA 0.11 2.66 NA XXX 

95900 .... 26 ..... A Motor nerve conduction test ............................... 0.42 0.18 0.18 0.02 0.62 0.62 XXX 

95900 .... TC .... A Motor nerve conduction test ............................... 0.00 1.08 NA 0.02 1.10 NA XXX 

95900 .... .......... A Motor nerve conduction test ............................... 0.42 1.26 NA 0.04 1.72 NA XXX 

95903 .... 26 ..... A Motor nerve conduction test ............................... 0.60 0.26 0.26 0.03 0.89 0.89 XXX 

95903 .... TC .... A Motor nerve conduction test ............................... 0.00 0.93 NA 0.02 0.95 NA XXX 

95903 .... .......... A Motor nerve conduction test ............................... 0.60 1.19 NA 0.05 1.84 NA XXX 

95904 .... 26 ..... A Sense nerve conduction test .............................. 0.34 0.15 0.15 0.02 0.51 0.51 XXX 

95904 .... TC .... A Sense nerve conduction test .............................. 0.00 0.94 NA 0.02 0.96 NA XXX 

95904 .... .......... A Sense nerve conduction test .............................. 0.34 1.09 NA 0.04 1.47 NA XXX 

95920 .... 26 ..... A Intraop nerve test add-on ................................... 2.11 0.93 0.93 0.16 3.20 3.20 ZZZ 

95920 .... TC .... A Intraop nerve test add-on ................................... 0.00 1.31 NA 0.07 1.38 NA ZZZ 

95920 .... .......... A Intraop nerve test add-on ................................... 2.11 2.24 NA 0.23 4.58 NA ZZZ 

95921 .... 26 ..... A Autonomic nerv function test .............................. 0.90 0.33 0.33 0.04 1.27 1.27 XXX 

95921 .... TC .... A Autonomic nerv function test .............................. 0.00 0.38 NA 0.02 0.40 NA XXX 

95921 .... .......... A Autonomic nerv function test .............................. 0.90 0.71 NA 0.06 1.67 NA XXX 

95922 .... 26 ..... A Autonomic nerv function test .............................. 0.96 0.40 0.40 0.05 1.41 1.41 XXX 

95922 .... TC .... A Autonomic nerv function test .............................. 0.00 0.38 NA 0.02 0.40 NA XXX 

95922 .... .......... A Autonomic nerv function test .............................. 0.96 0.78 NA 0.07 1.81 NA XXX 

95923 .... 26 ..... A Autonomic nerv function test .............................. 0.90 0.38 0.38 0.05 1.33 1.33 XXX 

95923 .... TC .... A Autonomic nerv function test .............................. 0.00 1.56 NA 0.02 1.58 NA XXX 

95923 .... .......... A Autonomic nerv function test .............................. 0.90 1.94 NA 0.07 2.91 NA XXX 

95925 .... 26 ..... A Somatosensory testing ....................................... 0.54 0.22 0.22 0.04 0.80 0.80 XXX 

95925 .... TC .... A Somatosensory testing ....................................... 0.00 0.91 NA 0.06 0.97 NA XXX 

95925 .... .......... A Somatosensory testing ....................................... 0.54 1.13 NA 0.10 1.77 NA XXX 

95926 .... 26 ..... A Somatosensory testing ....................................... 0.54 0.23 0.23 0.03 0.80 0.80 XXX 

95926 .... TC .... A Somatosensory testing ....................................... 0.00 0.91 NA 0.06 0.97 NA XXX 

95926 .... .......... A Somatosensory testing ....................................... 0.54 1.14 NA 0.09 1.77 NA XXX 

95927 .... 26 ..... A Somatosensory testing ....................................... 0.54 0.25 0.25 0.04 0.83 0.83 XXX 

95927 .... TC .... A Somatosensory testing ....................................... 0.00 0.91 NA 0.06 0.97 NA XXX 

95927 .... .......... A Somatosensory testing ....................................... 0.54 1.16 NA 0.10 1.80 NA XXX 

95928 .... 26 ..... A C motor evoked, uppr limbs ............................... 1.50 0.65 0.65 0.06 2.21 2.21 XXX 

95928 .... TC .... A C motor evoked, uppr limbs ............................... 0.00 2.38 NA 0.03 2.41 NA XXX 

95928 .... .......... A C motor evoked, uppr limbs ............................... 1.50 3.03 NA 0.09 4.62 NA XXX 

95929 .... 26 ..... A C motor evoked, lwr limbs ................................. 1.50 0.65 0.65 0.06 2.21 2.21 XXX 

95929 .... TC .... A C motor evoked, lwr limbs ................................. 0.00 2.57 NA 0.03 2.60 NA XXX 

95929 .... .......... A C motor evoked, lwr limbs ................................. 1.50 3.22 NA 0.09 4.81 NA XXX 

95930 .... 26 ..... A Visual evoked potential test ............................... 0.35 0.15 0.15 0.02 0.52 0.52 XXX 

70455 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

95930 .... TC .... A Visual evoked potential test ............................... 0.00 2.10 NA 0.01 2.11 NA XXX 

95930 .... .......... A Visual evoked potential test ............................... 0.35 2.25 NA 0.03 2.63 NA XXX 

95933 .... 26 ..... A Blink reflex test ................................................... 0.59 0.24 0.24 0.04 0.87 0.87 XXX 

95933 .... TC .... A Blink reflex test ................................................... 0.00 0.78 NA 0.06 0.84 NA XXX 

95933 .... .......... A Blink reflex test ................................................... 0.59 1.02 NA 0.10 1.71 NA XXX 

95934 .... 26 ..... A H-reflex test ........................................................ 0.51 0.22 0.22 0.02 0.75 0.75 XXX 

95934 .... TC .... A H-reflex test ........................................................ 0.00 0.21 NA 0.02 0.23 NA XXX 

95934 .... .......... A H-reflex test ........................................................ 0.51 0.43 NA 0.04 0.98 NA XXX 

95936 .... 26 ..... A H-reflex test ........................................................ 0.55 0.24 0.24 0.03 0.82 0.82 XXX 

95936 .... TC .... A H-reflex test ........................................................ 0.00 0.21 NA 0.02 0.23 NA XXX 

95936 .... .......... A H-reflex test ........................................................ 0.55 0.45 NA 0.05 1.05 NA XXX 

95937 .... 26 ..... A Neuromuscular junction test ............................... 0.65 0.27 0.27 0.08 1.00 1.00 XXX 

95937 .... TC .... A Neuromuscular junction test ............................... 0.00 0.34 NA 0.02 0.36 NA XXX 

95937 .... .......... A Neuromuscular junction test ............................... 0.65 0.61 NA 0.10 1.36 NA XXX 

95950 .... 26 ..... A Ambulatory eeg monitoring ................................ 1.51 0.64 0.64 0.08 2.23 2.23 XXX 

95950 .... TC .... A Ambulatory eeg monitoring ................................ 0.00 3.30 NA 0.43 3.73 NA XXX 

95950 .... .......... A Ambulatory eeg monitoring ................................ 1.51 3.94 NA 0.51 5.96 NA XXX 

95951 .... 26 ..... A EEG monitoring/videorecord .............................. 5.99 2.56 2.56 0.32 8.87 8.87 XXX 

95951 .... TC .... C EEG monitoring/videorecord .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95951 .... .......... C EEG monitoring/videorecord .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95953 .... 26 ..... A EEG monitoring/computer .................................. 3.08 1.29 1.29 0.17 4.54 4.54 XXX 

95953 .... TC .... A EEG monitoring/computer .................................. 0.00 6.35 NA 0.43 6.78 NA XXX 

95953 .... .......... A EEG monitoring/computer .................................. 3.08 7.64 NA 0.60 11.32 NA XXX 

95954 .... 26 ..... A EEG monitoring/giving drugs ............................. 2.45 1.04 1.04 0.13 3.62 3.62 XXX 

95954 .... TC .... A EEG monitoring/giving drugs ............................. 0.00 3.19 NA 0.06 3.25 NA XXX 

95954 .... .......... A EEG monitoring/giving drugs ............................. 2.45 4.23 NA 0.19 6.87 NA XXX 

95955 .... 26 ..... A EEG during surgery ............................................ 1.01 0.36 0.36 0.05 1.42 1.42 XXX 

95955 .... TC .... A EEG during surgery ............................................ 0.00 1.97 NA 0.17 2.14 NA XXX 

95955 .... .......... A EEG during surgery ............................................ 1.01 2.33 NA 0.22 3.56 NA XXX 

95956 .... 26 ..... A Eeg monitoring, cable/radio ............................... 3.08 1.30 1.30 0.16 4.54 4.54 XXX 

95956 .... TC .... A Eeg monitoring, cable/radio ............................... 0.00 14.15 NA 0.43 14.58 NA XXX 

95956 .... .......... A Eeg monitoring, cable/radio ............................... 3.08 15.45 NA 0.59 19.12 NA XXX 

95957 .... 26 ..... A EEG digital analysis ........................................... 1.98 0.85 0.85 0.11 2.94 2.94 XXX 

95957 .... TC .... A EEG digital analysis ........................................... 0.00 1.70 NA 0.12 1.82 NA XXX 

95957 .... .......... A EEG digital analysis ........................................... 1.98 2.55 NA 0.23 4.76 NA XXX 

95958 .... 26 ..... A EEG monitoring/function test ............................. 4.24 1.75 1.75 0.21 6.20 6.20 XXX 

95958 .... TC .... A EEG monitoring/function test ............................. 0.00 1.75 NA 0.13 1.88 NA XXX 

95958 .... .......... A EEG monitoring/function test ............................. 4.24 3.50 NA 0.34 8.08 NA XXX 

95961 .... 26 ..... A Electrode stimulation, brain ................................ 2.97 1.32 1.32 0.48 4.77 4.77 XXX 

95961 .... TC .... A Electrode stimulation, brain ................................ 0.00 1.31 NA 0.07 1.38 NA XXX 

95961 .... .......... A Electrode stimulation, brain ................................ 2.97 2.63 NA 0.55 6.15 NA XXX 

95962 .... 26 ..... A Electrode stim, brain add-on .............................. 3.21 1.39 1.39 0.32 4.92 4.92 ZZZ 

95962 .... TC .... A Electrode stim, brain add-on .............................. 0.00 1.31 NA 0.07 1.38 NA ZZZ 

95962 .... .......... A Electrode stim, brain add-on .............................. 3.21 2.70 NA 0.39 6.30 NA ZZZ 

95965 .... 26 ..... A Meg, spontaneous .............................................. 7.99 3.43 3.43 0.46 11.88 11.88 XXX 

95965 .... TC .... C Meg, spontaneous .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95965 .... .......... C Meg, spontaneous .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95966 .... 26 ..... A Meg, evoked, single ........................................... 3.99 1.71 1.71 0.19 5.89 5.89 XXX 

95966 .... TC .... C Meg, evoked, single ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95966 .... .......... C Meg, evoked, single ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95967 .... 26 ..... A Meg, evoked, each add’l .................................... 3.49 1.18 1.18 0.16 4.83 4.83 ZZZ 

95967 .... TC .... C Meg, evoked, each add’l .................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

95967 .... .......... C Meg, evoked, each add’l .................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

95970 .... .......... A Analyze neurostim, no prog ............................... 0.45 0.85 0.14 0.03 1.33 0.62 XXX 

95971 .... .......... A Analyze neurostim, simple ................................. 0.78 0.68 0.22 0.07 1.53 1.07 XXX 

95972 .... .......... A Analyze neurostim, complex .............................. 1.50 1.21 0.49 0.14 2.85 2.13 XXX 

95973 .... .......... A Analyze neurostim, complex .............................. 0.92 0.62 0.34 0.07 1.61 1.33 ZZZ 

95974 .... .......... A Cranial neurostim, complex ................................ 3.00 1.70 1.30 0.16 4.86 4.46 XXX 

95975 .... .......... A Cranial neurostim, complex ................................ 1.70 0.89 0.73 0.12 2.71 2.55 ZZZ 

95978 .... .......... A Analyze neurostim brain/1h ................................ 3.50 1.94 1.30 0.18 5.62 4.98 XXX 

95979 .... .......... A Analyz neurostim brain addon ........................... 1.64 0.87 0.69 0.08 2.59 2.41 ZZZ 

95990 .... .......... A Spin/brain pump refil & main .............................. 0.00 1.50 NA 0.06 1.56 NA XXX 

95991 .... .......... A Spin/brain pump refil & main .............................. 0.77 1.46 0.17 0.06 2.29 1.00 XXX 

95999 .... .......... C Neurological procedure ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

96000 .... .......... A Motion analysis, video/3d ................................... 1.80 NA 0.53 0.11 NA 2.44 XXX 

96001 .... .......... A Motion test w/ft press meas ............................... 2.15 NA 0.66 0.10 NA 2.91 XXX 

96002 .... .......... A Dynamic surface emg ........................................ 0.41 NA 0.15 0.02 NA 0.58 XXX 

96003 .... .......... A Dynamic fine wire emg ....................................... 0.37 NA 0.12 0.02 NA 0.51 XXX 

96004 .... .......... A Phys review of motion tests ............................... 2.14 0.94 0.94 0.11 3.19 3.19 XXX 

96101 .... .......... A Psycho testing by psych/phys ............................ 1.86 0.65 0.63 0.05 2.56 2.54 XXX 

96102 .... .......... A Psycho testing by technician .............................. 0.50 0.66 0.17 0.01 1.17 0.68 XXX 

96103 .... .......... A Psycho testing admin by comp .......................... 0.51 0.21 0.17 0.02 0.74 0.70 XXX 

96105 .... .......... A Assessment of aphasia ...................................... 0.00 1.77 NA 0.18 1.95 NA XXX 

96110 .... .......... A Developmental test, lim ...................................... 0.00 0.18 NA 0.18 0.36 NA XXX 

96111 .... .......... A Developmental test, extend ................................ 2.60 1.05 NA 0.18 3.83 NA XXX 

70456 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

96116 .... .......... A Neurobehavioral status exam ............................ 1.86 0.83 0.64 0.18 2.87 2.68 XXX 

96118 .... .......... A Neuropsych tst by psych/phys ........................... 1.86 1.39 0.63 0.18 3.43 2.67 XXX 

96119 .... .......... A Neuropsych testing by tech ................................ 0.55 1.02 0.19 0.18 1.75 0.92 XXX 

96120 .... .......... A Neuropsych tst admin w/comp ........................... 0.51 0.74 0.17 0.02 1.27 0.70 XXX 

96150 .... .......... A Assess hlth/behave, init ..................................... 0.50 0.18 0.18 0.01 0.69 0.69 XXX 

96151 .... .......... A Assess hlth/behave, subseq .............................. 0.48 0.18 0.17 0.01 0.67 0.66 XXX 

96152 .... .......... A Intervene hlth/behave, indiv ............................... 0.46 0.17 0.16 0.01 0.64 0.63 XXX 

96153 .... .......... A Intervene hlth/behave, group ............................. 0.10 0.04 0.03 0.01 0.15 0.14 XXX 

96154 .... .......... A Interv hlth/behav, fam w/pt ................................. 0.45 0.17 0.16 0.01 0.63 0.62 XXX 

96155 .... .......... N Interv hlth/behav fam no pt ................................ +0.44 0.18 0.17 0.02 0.64 0.63 XXX 

96401 .... .......... A Chemo, anti-neopl, sq/im ................................... 0.21 1.53 1.53 0.01 1.75 1.75 XXX 

96402 .... .......... A Chemo hormon antineopl sq/im ......................... 0.19 0.74 0.74 0.01 0.94 0.94 XXX 

96405 .... .......... A Chemo intralesional, up to 7 .............................. 0.52 2.78 0.24 0.03 3.33 0.79 000 

96406 .... .......... A Chemo intralesional over 7 ................................ 0.80 3.08 0.29 0.03 3.91 1.12 000 

96409 .... .......... A Chemo, iv push, sngl drug ................................. 0.24 2.93 2.93 0.06 3.23 3.23 XXX 

96411 .... .......... A Chemo, iv push, addl drug ................................. 0.20 1.61 1.61 0.06 1.87 1.87 ZZZ 

96413 .... .......... A Chemo, iv infusion, 1 hr ..................................... 0.28 4.20 4.20 0.08 4.56 4.56 XXX 

96415 .... .......... A Chemo, iv infusion, addl hr ................................ 0.19 0.77 0.77 0.07 1.03 1.03 ZZZ 

96416 .... .......... A Chemo prolong infuse w/pump .......................... 0.21 4.61 4.61 0.08 4.90 4.90 XXX 

96417 .... .......... A Chemo iv infus each addl seq ........................... 0.21 1.95 1.95 0.07 2.23 2.23 ZZZ 

96420 .... .......... A Chemo, ia, push tecnique .................................. 0.17 2.66 NA 0.08 2.91 NA XXX 

96422 .... .......... A Chemo ia infusion up to 1 hr ............................. 0.17 4.84 NA 0.08 5.09 NA XXX 

96423 .... .......... A Chemo ia infuse each addl hr ............................ 0.17 1.89 NA 0.02 2.08 NA ZZZ 

96425 .... .......... A Chemotherapy,infusion method ......................... 0.17 4.48 NA 0.08 4.73 NA XXX 

96440 .... .......... A Chemotherapy, intracavitary .............................. 2.37 8.04 1.23 0.17 10.58 3.77 000 

96445 .... .......... A Chemotherapy, intracavitary .............................. 2.20 8.05 1.18 0.14 10.39 3.52 000 

96450 .... .......... A Chemotherapy, into CNS ................................... 1.53 6.96 1.29 0.09 8.58 2.91 000 

96521 .... .......... A Refill/maint, portable pump ................................ 0.21 3.77 3.77 0.06 4.04 4.04 XXX 

96522 .... .......... A Refill/maint pump/resvr syst ............................... 0.21 2.65 2.65 0.06 2.92 2.92 XXX 

96523 .... .......... T Irrig drug delivery device .................................... 0.04 0.69 0.69 0.01 0.74 0.74 XXX 

96542 .... .......... A Chemotherapy injection ...................................... 0.75 4.24 0.66 0.07 5.06 1.48 XXX 

96549 .... .......... C Chemotherapy, unspecified ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

96567 .... .......... A Photodynamic tx, skin ........................................ 0.00 1.96 NA 0.04 2.00 NA XXX 

96570 .... .......... A Photodynamic tx, 30 min .................................... 1.10 NA 0.37 0.11 NA 1.58 ZZZ 

96571 .... .......... A Photodynamic tx, addl 15 min ............................ 0.55 NA 0.19 0.03 NA 0.77 ZZZ 

96900 .... .......... A Ultraviolet light therapy ....................................... 0.00 0.44 NA 0.02 0.46 NA XXX 

96902 .... .......... B Trichogram ......................................................... +0.41 0.18 0.16 0.01 0.60 0.58 XXX 

96910 .... .......... A Photochemotherapy with UV-B .......................... 0.00 0.99 NA 0.04 1.03 NA XXX 

96912 .... .......... A Photochemotherapy with UV-A .......................... 0.00 1.26 NA 0.05 1.31 NA XXX 

96913 .... .......... A Photochemotherapy, UV-A or B ......................... 0.00 1.68 NA 0.10 1.78 NA XXX 

96920 .... .......... A Laser tx, skin < 250 sq cm ................................. 1.15 2.54 0.56 0.02 3.71 1.73 000 

96921 .... .......... A Laser tx, skin 250-500 sq cm ............................. 1.17 2.61 0.57 0.03 3.81 1.77 000 

96922 .... .......... A Laser tx, skin > 500 sq cm ................................. 2.10 3.49 0.62 0.04 5.63 2.76 000 

96999 .... .......... C Dermatological procedure .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97001 .... .......... A Pt evaluation ....................................................... 1.20 0.75 0.45 0.05 2.00 1.70 XXX 

97002 .... .......... A Pt re-evaluation .................................................. 0.60 0.44 0.23 0.02 1.06 0.85 XXX 

97003 .... .......... A Ot evaluation ...................................................... 1.20 0.88 0.40 0.06 2.14 1.66 XXX 

97004 .... .......... A Ot re-evaluation .................................................. 0.60 0.67 0.19 0.02 1.29 0.81 XXX 

97005 .... .......... I Athletic train eval ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97006 .... .......... I Athletic train reeval ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97010 .... .......... B Hot or cold packs therapy .................................. +0.06 0.05 NA 0.01 0.12 NA XXX 

97012 .... .......... A Mechanical traction therapy ............................... 0.25 0.13 NA 0.01 0.39 NA XXX 

97014 .... .......... I Electric stimulation therapy ................................ +0.18 0.19 0.19 0.01 0.38 0.38 XXX 

97016 .... .......... A Vasopneumatic device therapy .......................... 0.18 0.18 NA 0.01 0.37 NA XXX 

97018 .... .......... A Paraffin bath therapy .......................................... 0.06 0.10 NA 0.01 0.17 NA XXX 

97022 .... .......... A Whirlpool therapy ............................................... 0.17 0.21 NA 0.01 0.39 NA XXX 

97024 .... .......... A Diathermy eg, microwave ................................... 0.06 0.07 NA 0.01 0.14 NA XXX 

97026 .... .......... A Infrared therapy .................................................. 0.06 0.06 NA 0.01 0.13 NA XXX 

97028 .... .......... A Ultraviolet therapy .............................................. 0.08 0.07 NA 0.01 0.16 NA XXX 

97032 .... .......... A Electrical stimulation ........................................... 0.25 0.16 NA 0.01 0.42 NA XXX 

97033 .... .......... A Electric current therapy ...................................... 0.26 0.27 NA 0.01 0.54 NA XXX 

97034 .... .......... A Contrast bath therapy ......................................... 0.21 0.15 NA 0.01 0.37 NA XXX 

97035 .... .......... A Ultrasound therapy ............................................. 0.21 0.10 NA 0.01 0.32 NA XXX 

97036 .... .......... A Hydrotherapy ...................................................... 0.28 0.32 NA 0.01 0.61 NA XXX 

97039 .... .......... C Physical therapy treatment ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97110 .... .......... A Therapeutic exercises ........................................ 0.45 0.27 NA 0.02 0.74 NA XXX 

97112 .... .......... A Neuromuscular reeducation ............................... 0.45 0.31 NA 0.01 0.77 NA XXX 

97113 .... .......... A Aquatic therapy/exercises .................................. 0.44 0.39 NA 0.01 0.84 NA XXX 

97116 .... .......... A Gait training therapy ........................................... 0.40 0.24 NA 0.01 0.65 NA XXX 

97124 .... .......... A Massage therapy ................................................ 0.35 0.23 NA 0.01 0.59 NA XXX 

97139 .... .......... C Physical medicine procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97140 .... .......... A Manual therapy ................................................... 0.43 0.25 NA 0.01 0.69 NA XXX 

97150 .... .......... A Group therapeutic procedures ........................... 0.27 0.18 NA 0.01 0.46 NA XXX 

97530 .... .......... A Therapeutic activities .......................................... 0.44 0.32 NA 0.01 0.77 NA XXX 

97532 .... .......... A Cognitive skills development .............................. 0.44 0.20 NA 0.01 0.65 NA XXX 

70457 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

97533 .... .......... A Sensory integration ............................................ 0.44 0.24 NA 0.01 0.69 NA XXX 

97535 .... .......... A Self care mngment training ................................ 0.45 0.33 NA 0.01 0.79 NA XXX 

97537 .... .......... A Community/work reintegration ............................ 0.45 0.26 NA 0.01 0.72 NA XXX 

97542 .... .......... A Wheelchair mngment training ............................ 0.45 0.28 NA 0.01 0.74 NA XXX 

97545 .... .......... R Work hardening .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97546 .... .......... R Work hardening add-on ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

97597 .... .......... A Active wound care/20 cm or < ........................... 0.58 0.66 NA 0.05 1.29 NA XXX 

97598 .... .......... A Active wound care > 20 cm ............................... 0.80 0.79 NA 0.05 1.64 NA XXX 

97602 .... .......... B Wound(s) care non-selective ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97605 .... .......... A Neg press wound tx, < 50 cm ............................ 0.55 0.34 0.22 0.02 0.91 0.79 XXX 

97606 .... .......... A Neg press wound tx, > 50 cm ............................ 0.60 0.90 0.41 0.03 1.53 1.04 XXX 

97750 .... .......... A Physical performance test .................................. 0.45 0.32 NA 0.02 0.79 NA XXX 

97755 .... .......... A Assistive technology assess .............................. 0.62 0.28 NA 0.02 0.92 NA XXX 

97760 .... .......... A Orthotic mgmt and training ................................. 0.45 0.34 0.20 0.03 0.82 0.68 XXX 

97761 .... .......... A Prosthetic training ............................................... 0.45 0.28 0.19 0.02 0.75 0.66 XXX 

97762 .... .......... A C/o for orthotic/prosth use .................................. 0.25 0.42 0.19 0.02 0.69 0.46 XXX 

97799 .... .......... C Physical medicine procedure ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

97802 .... .......... A Medical nutrition, indiv, in ................................... 0.00 0.47 NA 0.01 0.48 NA XXX 

97803 .... .......... A Med nutrition, indiv, subseq ............................... 0.00 0.47 NA 0.01 0.48 NA XXX 

97804 .... .......... A Medical nutrition, group ...................................... 0.00 0.18 NA 0.01 0.19 NA XXX 

97810 .... .......... N Acupunct w/o stimul 15 min ............................... +0.60 0.38 0.23 0.03 1.01 0.86 XXX 

97811 .... .......... N Acupunct w/o stimul addl 15m ........................... +0.50 0.25 0.19 0.03 0.78 0.72 ZZZ 

97813 .... .......... N Acupunct w/stimul 15 min .................................. +0.65 0.40 0.25 0.03 1.08 0.93 XXX 

97814 .... .......... N Acupunct w/stimul addl 15m .............................. +0.55 0.30 0.21 0.03 0.88 0.79 ZZZ 

98925 .... .......... A Osteopathic manipulation ................................... 0.45 0.32 0.14 0.02 0.79 0.61 000 

98926 .... .......... A Osteopathic manipulation ................................... 0.65 0.41 0.25 0.03 1.09 0.93 000 

98927 .... .......... A Osteopathic manipulation ................................... 0.87 0.50 0.29 0.03 1.40 1.19 000 

98928 .... .......... A Osteopathic manipulation ................................... 1.03 0.59 0.34 0.04 1.66 1.41 000 

98929 .... .......... A Osteopathic manipulation ................................... 1.19 0.67 0.37 0.05 1.91 1.61 000 

98940 .... .......... A Chiropractic manipulation ................................... 0.45 0.23 0.12 0.01 0.69 0.58 000 

98941 .... .......... A Chiropractic manipulation ................................... 0.65 0.30 0.17 0.01 0.96 0.83 000 

98942 .... .......... A Chiropractic manipulation ................................... 0.87 0.36 0.23 0.02 1.25 1.12 000 

98943 .... .......... N Chiropractic manipulation ................................... +0.40 0.24 0.16 0.01 0.65 0.57 XXX 

98960 .... .......... N Self-mgmt educ & train, 1 pt .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

98961 .... .......... N Self-mgmt educ/train, 2-4 pt ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

98962 .... .......... N Self-mgmt educ/train, 5-8 pt ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99000 .... .......... B Specimen handling ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99001 .... .......... B Specimen handling ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99002 .... .......... B Device handling .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99024 .... .......... B Postop follow-up visit ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99026 .... .......... N In-hospital on call service ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99027 .... .......... N Out-of-hosp on call service ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99050 .... .......... B Medical services after hrs .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99051 .... .......... B Med serv, eve/wkend/holiday ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99053 .... .......... B Med serv 10pm-8am, 24 hr fac .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99056 .... .......... B Med service out of office .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99058 .... .......... B Office emergency care ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99060 .... .......... B Out of office emerg med serv ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99070 .... .......... B Special supplies ................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99071 .... .......... B Patient education materials ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99075 .... .......... N Medical testimony ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99078 .... .......... B Group health education ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99080 .... .......... B Special reports or forms ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99082 .... .......... C Unusual physician travel .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99090 .... .......... B Computer data analysis ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99091 .... .......... B Collect/review data from pt ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99100 .... .......... B Special anesthesia service ................................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99116 .... .......... B Anesthesia with hypothermia ............................. 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99135 .... .......... B Special anesthesia procedure ............................ 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99140 .... .......... B Emergency anesthesia ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99143 .... .......... C Mod cs by same phys, < 5 yrs ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99144 .... .......... C Mod cs by same phys, 5 yrs + ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99145 .... .......... C Mod cs by same phys add-on ............................ 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99148 .... .......... C Mod cs diff phys < 5 yrs ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99149 .... .......... C Mod cs diff phys 5 yrs + ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99150 .... .......... C Mod cs diff phys add-on ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99170 .... .......... A Anogenital exam, child ....................................... 1.75 1.77 0.55 0.08 3.60 2.38 000 

99172 .... .......... N Ocular function screen ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99173 .... .......... N Visual acuity screen ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99175 .... .......... A Induction of vomiting .......................................... 0.00 1.39 NA 0.10 1.49 NA XXX 

99183 .... .......... A Hyperbaric oxygen therapy ................................ 2.34 3.25 0.72 0.16 5.75 3.22 XXX 

99185 .... .......... A Regional hypothermia ........................................ 0.00 0.64 NA 0.04 0.68 NA XXX 

99186 .... .......... A Total body hypothermia ...................................... 0.00 1.79 NA 0.45 2.24 NA XXX 

99190 .... .......... X Special pump services ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99191 .... .......... X Special pump services ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70458 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

99192 .... .......... X Special pump services ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99195 .... .......... A Phlebotomy ......................................................... 0.00 0.44 NA 0.02 0.46 NA XXX 

99199 .... .......... C Special service/proc/report ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99201 .... .......... A Office/outpatient visit, new ................................. 0.45 0.49 0.15 0.03 0.97 0.63 XXX 

99202 .... .......... A Office/outpatient visit, new ................................. 0.88 0.79 0.31 0.05 1.72 1.24 XXX 

99203 .... .......... A Office/outpatient visit, new ................................. 1.34 1.13 0.48 0.09 2.56 1.91 XXX 

99204 .... .......... A Office/outpatient visit, new ................................. 2.00 1.50 0.71 0.12 3.62 2.83 XXX 

99205 .... .......... A Office/outpatient visit, new ................................. 2.67 1.78 0.95 0.15 4.60 3.77 XXX 

99211 .... .......... A Office/outpatient visit, est ................................... 0.17 0.39 0.06 0.01 0.57 0.24 XXX 

99212 .... .......... A Office/outpatient visit, est ................................... 0.45 0.54 0.16 0.03 1.02 0.64 XXX 

99213 .... .......... A Office/outpatient visit, est ................................... 0.67 0.69 0.24 0.03 1.39 0.94 XXX 

99214 .... .......... A Office/outpatient visit, est ................................... 1.10 1.03 0.41 0.05 2.18 1.56 XXX 

99215 .... .......... A Office/outpatient visit, est ................................... 1.77 1.32 0.65 0.08 3.17 2.50 XXX 

99217 .... .......... A Observation care discharge ............................... 1.28 NA 0.53 0.06 NA 1.87 XXX 

99218 .... .......... A Observation care ................................................ 1.28 NA 0.44 0.06 NA 1.78 XXX 

99219 .... .......... A Observation care ................................................ 2.14 NA 0.72 0.10 NA 2.96 XXX 

99220 .... .......... A Observation care ................................................ 2.99 NA 1.03 0.14 NA 4.16 XXX 

99221 .... .......... A Initial hospital care ............................................. 1.28 NA 0.45 0.07 NA 1.80 XXX 

99222 .... .......... A Initial hospital care ............................................. 2.14 NA 0.74 0.10 NA 2.98 XXX 

99223 .... .......... A Initial hospital care ............................................. 2.99 NA 1.03 0.13 NA 4.15 XXX 

99231 .... .......... A Subsequent hospital care ................................... 0.64 NA 0.23 0.03 NA 0.90 XXX 

99232 .... .......... A Subsequent hospital care ................................... 1.06 NA 0.37 0.04 NA 1.47 XXX 

99233 .... .......... A Subsequent hospital care ................................... 1.51 NA 0.52 0.06 NA 2.09 XXX 

99234 .... .......... A Observ/hosp same date ..................................... 2.56 NA 0.89 0.13 NA 3.58 XXX 

99235 .... .......... A Observ/hosp same date ..................................... 3.41 NA 1.15 0.16 NA 4.72 XXX 

99236 .... .......... A Observ/hosp same date ..................................... 4.26 NA 1.44 0.19 NA 5.89 XXX 

99238 .... .......... A Hospital discharge day ....................................... 1.28 NA 0.54 0.05 NA 1.87 XXX 

99239 .... .......... A Hospital discharge day ....................................... 1.75 NA 0.73 0.07 NA 2.55 XXX 

99241 .... .......... A Office consultation .............................................. 0.64 0.64 0.22 0.05 1.33 0.91 XXX 

99242 .... .......... A Office consultation .............................................. 1.29 1.04 0.46 0.10 2.43 1.85 XXX 

99243 .... .......... A Office consultation .............................................. 1.72 1.39 0.63 0.13 3.24 2.48 XXX 

99244 .... .......... A Office consultation .............................................. 2.58 1.83 0.92 0.16 4.57 3.66 XXX 

99245 .... .......... A Office consultation .............................................. 3.42 2.28 1.24 0.21 5.91 4.87 XXX 

99251 .... .......... A Initial inpatient consult ........................................ 0.66 NA 0.24 0.05 NA 0.95 XXX 

99252 .... .......... A Initial inpatient consult ........................................ 1.32 NA 0.50 0.09 NA 1.91 XXX 

99253 .... .......... A Initial inpatient consult ........................................ 1.82 NA 0.68 0.11 NA 2.61 XXX 

99254 .... .......... A Initial inpatient consult ........................................ 2.64 NA 0.98 0.13 NA 3.75 XXX 

99255 .... .......... A Initial inpatient consult ........................................ 3.64 NA 1.35 0.18 NA 5.17 XXX 

99281 .... .......... A Emergency dept visit .......................................... 0.33 NA 0.09 0.02 NA 0.44 XXX 

99282 .... .......... A Emergency dept visit .......................................... 0.55 NA 0.14 0.04 NA 0.73 XXX 

99283 .... .......... A Emergency dept visit .......................................... 1.24 NA 0.31 0.09 NA 1.64 XXX 

99284 .... .......... A Emergency dept visit .......................................... 1.95 NA 0.47 0.14 NA 2.56 XXX 

99285 .... .......... A Emergency dept visit .......................................... 3.06 NA 0.72 0.23 NA 4.01 XXX 

99288 .... .......... B Direct advanced life support .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99289 .... .......... A Ped crit care transport ........................................ 4.79 NA 1.45 0.24 NA 6.48 XXX 

99290 .... .......... A Ped crit care transport addl ................................ 2.40 NA 0.81 0.12 NA 3.33 ZZZ 

99291 .... .......... A Critical care, first hour ........................................ 3.99 2.58 1.28 0.21 6.78 5.48 XXX 

99292 .... .......... A Critical care, add’l 30 min .................................. 2.00 0.90 0.64 0.11 3.01 2.75 ZZZ 

99293 .... .......... A Ped critical care, initial ....................................... 15.98 NA 4.76 1.12 NA 21.86 XXX 

99294 .... .......... A Ped critical care, subseq .................................... 7.99 NA 2.41 0.45 NA 10.85 XXX 

99295 .... .......... A Neonate crit care, initial ..................................... 18.46 NA 5.39 1.16 NA 25.01 XXX 

99296 .... .......... A Neonate critical care subseq .............................. 7.99 NA 2.55 0.32 NA 10.86 XXX 

99298 .... .......... A Ic for lbw infant < 1500 gm ................................ 2.75 NA 0.93 0.17 NA 3.85 XXX 

99299 .... .......... A Ic, lbw infant 1500-2500 gm ............................... 2.50 NA 0.86 0.16 NA 3.52 XXX 

99300 .... .......... A Ic, infant pbw 2501-5000 gm ............................. 2.40 NA 0.84 2.40 NA 5.64 XXX 

99304 .... .......... A Nursing facility care, init ..................................... 1.20 0.49 0.49 0.05 1.74 1.74 XXX 

99305 .... .......... A Nursing facility care, init ..................................... 1.61 0.63 0.63 0.07 2.31 2.31 XXX 

99306 .... .......... A Nursing facility care, init ..................................... 2.01 0.75 0.75 0.09 2.85 2.85 XXX 

99307 .... .......... A Nursing fac care, subseq ................................... 0.60 0.27 0.27 0.03 0.90 0.90 XXX 

99308 .... .......... A Nursing fac care, subseq ................................... 1.00 0.45 0.45 0.04 1.49 1.49 XXX 

99309 .... .......... A Nursing fac care, subseq ................................... 1.42 0.62 0.62 0.06 2.10 2.10 XXX 

99310 .... .......... A Nursing fac care, subseq ................................... 1.77 0.78 0.78 0.08 2.63 2.63 XXX 

99315 .... .......... A Nursing fac discharge day ................................. 1.13 0.45 0.45 0.05 1.63 1.63 XXX 

99316 .... .......... A Nursing fac discharge day ................................. 1.50 0.59 0.59 0.06 2.15 2.15 XXX 

99318 .... .......... A Annual nursing fac assessmnt ........................... 1.20 0.49 0.49 0.05 1.74 1.74 XXX 

99324 .... .......... A Domicil/r-home visit new pat .............................. 1.01 0.49 0.38 0.05 1.55 1.44 XXX 

99325 .... .......... A Domicil/r-home visit new pat .............................. 1.52 0.68 0.55 0.07 2.27 2.14 XXX 

99326 .... .......... A Domicil/r-home visit new pat .............................. 2.27 0.92 0.78 0.10 3.29 3.15 XXX 

99327 .... .......... A Domicil/r-home visit new pat .............................. 3.03 1.17 1.05 0.13 4.33 4.21 XXX 

99328 .... .......... A Domicil/r-home visit new pat .............................. 3.78 1.42 1.31 0.16 5.36 5.25 XXX 

99334 .... .......... A Domicil/r-home visit est pat ................................ 0.76 0.40 0.26 0.04 1.20 1.06 XXX 

99335 .... .......... A Domicil/r-home visit est pat ................................ 1.26 0.58 0.43 0.06 1.90 1.75 XXX 

99336 .... .......... A Domicil/r-home visit est pat ................................ 2.02 0.82 0.66 0.09 2.93 2.77 XXX 

99337 .... .......... A Domicil/r-home visit est pat ................................ 3.03 1.15 0.98 0.13 4.31 4.14 XXX 

99339 .... .......... B Domicil/r-home care supervis ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70459 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

99340 .... .......... I Domicil/r-home care supervis ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99341 .... .......... A Home visit, new patient ...................................... 1.01 0.48 NA 0.05 1.54 NA XXX 

99342 .... .......... A Home visit, new patient ...................................... 1.52 0.68 NA 0.07 2.27 NA XXX 

99343 .... .......... A Home visit, new patient ...................................... 2.27 0.94 NA 0.10 3.31 NA XXX 

99344 .... .......... A Home visit, new patient ...................................... 3.03 1.18 NA 0.13 4.34 NA XXX 

99345 .... .......... A Home visit, new patient ...................................... 3.78 1.43 NA 0.16 5.37 NA XXX 

99347 .... .......... A Home visit, est patient ........................................ 0.76 0.40 NA 0.04 1.20 NA XXX 

99348 .... .......... A Home visit, est patient ........................................ 1.26 0.58 NA 0.06 1.90 NA XXX 

99349 .... .......... A Home visit, est patient ........................................ 2.02 0.83 NA 0.09 2.94 NA XXX 

99350 .... .......... A Home visit, est patient ........................................ 3.03 1.18 NA 0.13 4.34 NA XXX 

99354 .... .......... A Prolonged service, office .................................... 1.77 0.77 0.66 0.08 2.62 2.51 ZZZ 

99355 .... .......... A Prolonged service, office .................................... 1.77 0.75 0.62 0.07 2.59 2.46 ZZZ 

99356 .... .......... A Prolonged service, inpatient ............................... 1.71 NA 0.62 0.07 NA 2.40 ZZZ 

99357 .... .......... A Prolonged service, inpatient ............................... 1.71 NA 0.63 0.08 NA 2.42 ZZZ 

99358 .... .......... B Prolonged serv, w/o contact ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99359 .... .......... B Prolonged serv, w/o contact ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99360 .... .......... X Physician standby services ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99361 .... .......... B Physician/team conference ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99362 .... .......... B Physician/team conference ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99371 .... .......... B Physician phone consultation ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99372 .... .......... B Physician phone consultation ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99373 .... .......... B Physician phone consultation ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99374 .... .......... B Home health care supervision ........................... +1.10 0.70 0.42 0.05 1.85 1.57 XXX 

99375 .... .......... I Home health care supervision ........................... +1.73 1.55 1.55 0.07 3.35 3.35 XXX 

99377 .... .......... B Hospice care supervision ................................... +1.10 0.70 0.42 0.05 1.85 1.57 XXX 

99378 .... .......... I Hospice care supervision ................................... +1.73 1.95 1.95 0.07 3.75 3.75 XXX 

99379 .... .......... B Nursing fac care supervision .............................. +1.10 0.70 0.42 0.04 1.84 1.56 XXX 

99380 .... .......... B Nursing fac care supervision .............................. +1.73 0.99 0.66 0.06 2.78 2.45 XXX 

99381 .... .......... N Prev visit, new, infant ......................................... +1.19 1.50 0.45 0.05 2.74 1.69 XXX 

99382 .... .......... N Prev visit, new, age 1-4 ..................................... +1.36 1.54 0.52 0.05 2.95 1.93 XXX 

99383 .... .......... N Prev visit, new, age 5-11 ................................... +1.36 1.48 0.52 0.05 2.89 1.93 XXX 

99384 .... .......... N Prev visit, new, age 12-17 ................................. +1.53 1.55 0.59 0.06 3.14 2.18 XXX 

99385 .... .......... N Prev visit, new, age 18-39 ................................. +1.53 1.55 0.59 0.06 3.14 2.18 XXX 

99386 .... .......... N Prev visit, new, age 40-64 ................................. +1.88 1.75 0.72 0.07 3.70 2.67 XXX 

99387 .... .......... N Prev visit, new, 65 & over .................................. +2.06 1.88 0.79 0.07 4.01 2.92 XXX 

99391 .... .......... N Prev visit, est, infant ........................................... +1.02 1.02 0.39 0.04 2.08 1.45 XXX 

99392 .... .......... N Prev visit, est, age 1-4 ....................................... +1.19 1.09 0.45 0.05 2.33 1.69 XXX 

99393 .... .......... N Prev visit, est, age 5-11 ..................................... +1.19 1.06 0.45 0.05 2.30 1.69 XXX 

99394 .... .......... N Prev visit, est, age 12-17 ................................... +1.36 1.13 0.52 0.05 2.54 1.93 XXX 

99395 .... .......... N Prev visit, est, age 18-39 ................................... +1.36 1.16 0.52 0.05 2.57 1.93 XXX 

99396 .... .......... N Prev visit, est, age 40-64 ................................... +1.53 1.25 0.59 0.06 2.84 2.18 XXX 

99397 .... .......... N Prev visit, est, 65 & over .................................... +1.71 1.36 0.66 0.06 3.13 2.43 XXX 

99401 .... .......... N Preventive counseling, indiv ............................... +0.48 0.62 0.19 0.01 1.11 0.68 XXX 

99402 .... .......... N Preventive counseling, indiv ............................... +0.98 0.87 0.37 0.02 1.87 1.37 XXX 

99403 .... .......... N Preventive counseling, indiv ............................... +1.46 1.09 0.56 0.04 2.59 2.06 XXX 

99404 .... .......... N Preventive counseling, indiv ............................... +1.95 1.32 0.75 0.05 3.32 2.75 XXX 

99411 .... .......... N Preventive counseling, group ............................. +0.15 0.18 0.06 0.01 0.34 0.22 XXX 

99412 .... .......... N Preventive counseling, group ............................. +0.25 0.25 0.10 0.01 0.51 0.36 XXX 

99420 .... .......... N Health risk assessment test ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99429 .... .......... N Unlisted preventive service ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99431 .... .......... A Initial care, normal newborn ............................... 1.17 NA 0.38 0.05 NA 1.60 XXX 

99432 .... .......... A Newborn care, not in hosp ................................. 1.26 0.93 0.40 0.07 2.26 1.73 XXX 

99433 .... .......... A Normal newborn care/hospital ........................... 0.62 NA 0.20 0.02 NA 0.84 XXX 

99435 .... .......... A Newborn discharge day hosp ............................ 1.50 NA 0.59 0.06 NA 2.15 XXX 

99436 .... .......... A Attendance, birth ................................................ 1.50 NA 0.47 0.06 NA 2.03 XXX 

99440 .... .......... A Newborn resuscitation ........................................ 2.93 NA 0.93 0.12 NA 3.98 XXX 

99450 .... .......... N Life/disability evaluation ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99455 .... .......... R Disability examination ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99456 .... .......... R Disability examination ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99499 .... .......... C Unlisted e&m service ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99500 .... .......... I Home visit, prenatal ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99501 .... .......... I Home visit, postnatal .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99502 .... .......... I Home visit, nb care ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99503 .... .......... I Home visit, resp therapy .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99504 .... .......... I Home visit mech ventilator ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99505 .... .......... I Home visit, stoma care ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99506 .... .......... I Home visit, im injection ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99507 .... .......... I Home visit, cath maintain ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99509 .... .......... I Home visit day life activity .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99510 .... .......... I Home visit, sing/m/fam couns ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99511 .... .......... I Home visit, fecal/enema mgmt ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99512 .... .......... I Home visit for hemodialysis ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99600 .... .......... I Home visit nos .................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99601 .... .......... I Home infusion/visit, 2 hrs ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99602 .... .......... I Home infusion, each add’l hr ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

70460 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

A4890 .... .......... R Repair/maint cont hemo equip ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0150 .... .......... R Comprehensve oral evaluation .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0240 .... .......... R Intraoral occlusal film ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0250 .... .......... R Extraoral first film ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0260 .... .......... R Extraoral ea additional film ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0270 .... .......... R Dental bitewing single film ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0272 .... .......... R Dental bitewings two films .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0274 .... .......... R Dental bitewings four films ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0277 .... .......... R Vert bitewings-sev to eight ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0416 .... .......... R Viral culture ........................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0421 .... .......... R Gen tst suscept oral disease ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0431 .... .......... R Diag tst detect mucos abnorm ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0460 .... .......... R Pulp vitality test .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0472 .... .......... R Gross exam, prep & report ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0473 .... .......... R Micro exam, prep & report ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0474 .... .......... R Micro w exam of surg margins ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0475 .... .......... R Decalcification procedure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0476 .... .......... R Spec stains for microorganis .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0477 .... .......... R Spec stains not for microorg .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0478 .... .......... R Immunohistochemical stains .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0479 .... .......... R Tissue in-situ hybridization ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0480 .... .......... R Cytopath smear prep & report ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0481 .... .......... R Electron microscopy diagnost ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0482 .... .......... R Direct immunofluorescence ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0483 .... .......... R Indirect immunofluorescence ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0484 .... .......... R Consult slides prep elsewher ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0485 .... .......... R Consult inc prep of slides ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D0502 .... .......... R Other oral pathology procedu ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D0999 .... .......... R Unspecified diagnostic proce ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D1510 .... .......... R Space maintainer fxd unilat ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D1515 .... .......... R Fixed bilat space maintainer .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D1520 .... .......... R Remove unilat space maintain ........................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D1525 .... .......... R Remove bilat space maintain ............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D1550 .... .......... R Recement space maintainer .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D2999 .... .......... R Dental unspec restorative pr .............................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D3460 .... .......... R Endodontic endosseous implan ......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D3999 .... .......... R Endodontic procedure ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4260 .... .......... R Osseous surgery per quadrant .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4263 .... .......... R Bone replce graft first site .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4264 .... .......... R Bone replce graft each add ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4268 .... .......... R Surgical revision procedure ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D4270 .... .......... R Pedicle soft tissue graft pr ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4271 .... .......... R Free soft tissue graft proc .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4273 .... .......... R Subepithelial tissue graft .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4355 .... .......... R Full mouth debridement ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D4381 .... .......... R Localized delivery antimicro ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5911 .... .......... R Facial moulage sectional .................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5912 .... .......... R Facial moulage complete ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5951 .... .......... R Feeding aid ......................................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5983 .... .......... R Radiation applicator ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5984 .... .......... R Radiation shield .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5985 .... .......... R Radiation cone locator ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D5987 .... .......... R Commissure splint .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D6920 .... .......... R Dental connector bar .......................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7111 .... .......... R Extraction coronal remnants .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7140 .... .......... R Extraction erupted tooth/exr ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7210 .... .......... R Rem imp tooth w mucoper flp ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7220 .... .......... R Impact tooth remov soft tiss ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7230 .... .......... R Impact tooth remov part bony ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7240 .... .......... R Impact tooth remov comp bony ......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7241 .... .......... R Impact tooth rem bony w/comp .......................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7250 .... .......... R Tooth root removal ............................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7260 .... .......... R Oral antral fistula closure ................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7261 .... .......... R Primary closure sinus perf ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7283 .... .......... R Place device impacted tooth .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7288 .... .......... R Brush biopsy ....................................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7291 .... .......... R Transseptal fiberotomy ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D7321 .... .......... R Alveoloplasty not w/extracts ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7511 .... .......... R Incision/drain abscess intra ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7521 .... .......... R Incision/drain abscess extra ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D7940 .... .......... R Reshaping bone orthognathic ............................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9110 .... .......... R Tx dental pain minor proc .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9230 .... .......... R Analgesia ............................................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9248 .... .......... R Sedation (non-iv) ................................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

D9630 .... .......... R Other drugs/medicaments .................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

70461 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

D9930 .... .......... R Treatment of complications ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9940 .... .......... R Dental occlusal guard ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9950 .... .......... R Occlusion analysis .............................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9951 .... .......... R Limited occlusal adjustment ............................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

D9952 .... .......... R Complete occlusal adjustment ........................... 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

G0008 ... .......... X Admin influenza virus vac .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0009 ... .......... X Admin pneumococcal vaccine ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0010 ... .......... X Admin hepatitis b vaccine .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0027 ... .......... X Semen analysis .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0101 ... .......... A CA screen;pelvic/breast exam ........................... 0.45 0.52 0.17 0.02 0.99 0.64 XXX 

G0102 ... .......... A Prostate ca screening; dre ................................. 0.17 0.39 0.06 0.01 0.57 0.24 XXX 

G0103 ... .......... X Psa, total screening ............................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0104 ... .......... A CA screen;flexi sigmoidscope ............................ 0.96 2.28 0.50 0.08 3.32 1.54 000 

G0105 ... 53 ..... A Colorectal scrn; hi risk ind .................................. 0.96 2.28 0.50 0.08 3.32 1.54 000 

G0105 ... .......... A Colorectal scrn; hi risk ind .................................. 3.69 6.16 1.47 0.30 10.15 5.46 000 

G0106 ... 26 ..... A Colon CA screen;barium enema ........................ 0.99 0.32 0.32 0.04 1.35 1.35 XXX 

G0106 ... TC .... A Colon CA screen;barium enema ........................ 0.00 2.24 NA 0.13 2.37 NA XXX 

G0106 ... .......... A Colon CA screen;barium enema ........................ 0.99 2.56 NA 0.17 3.72 NA XXX 

G0107 ... .......... X CA screen; fecal blood test ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0108 ... .......... A Diab manage trn per indiv .................................. 0.00 0.83 NA 0.01 0.84 NA XXX 

G0109 ... .......... A Diab manage trn ind/group ................................ 0.00 0.48 NA 0.01 0.49 NA XXX 

G0117 ... .......... T Glaucoma scrn hgh risk direc ............................ 0.45 0.72 0.19 0.01 1.18 0.65 XXX 

G0118 ... .......... T Glaucoma scrn hgh risk direc ............................ 0.17 0.53 0.06 0.01 0.71 0.24 XXX 

G0120 ... 26 ..... A Colon ca scrn; barium enema ............................ 0.99 0.32 0.32 0.04 1.35 1.35 XXX 

G0120 ... TC .... A Colon ca scrn; barium enema ............................ 0.00 2.24 NA 0.13 2.37 NA XXX 

G0120 ... .......... A Colon ca scrn; barium enema ............................ 0.99 2.56 NA 0.17 3.72 NA XXX 

G0121 ... 53 ..... A Colon ca scrn not hi rsk ind ............................... 0.96 2.28 0.50 0.08 3.32 1.54 000 

G0121 ... .......... A Colon ca scrn not hi rsk ind ............................... 3.69 6.16 1.47 0.30 10.15 5.46 000 

G0122 ... 26 ..... N Colon ca scrn; barium enema ............................ +0.99 0.38 0.38 0.05 1.42 1.42 XXX 

G0122 ... TC .... N Colon ca scrn; barium enema ............................ +0.00 2.20 2.20 0.13 2.33 2.33 XXX 

G0122 ... .......... N Colon ca scrn; barium enema ............................ +0.99 2.58 2.58 0.18 3.75 3.75 XXX 

G0123 ... .......... X Screen cerv/vag thin layer ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0124 ... .......... A Screen c/v thin layer by MD ............................... 0.42 0.15 0.15 0.02 0.59 0.59 XXX 

G0127 ... .......... R Trim nail(s) ......................................................... 0.17 0.25 0.07 0.01 0.43 0.25 000 

G0128 ... .......... R CORF skilled nursing service ............................. 0.08 0.03 0.03 0.01 0.12 0.12 XXX 

G0130 ... 26 ..... A Single energy x-ray study .................................. 0.22 0.07 0.07 0.01 0.30 0.30 XXX 

G0130 ... TC .... A Single energy x-ray study .................................. 0.00 0.80 NA 0.05 0.85 NA XXX 

G0130 ... .......... A Single energy x-ray study .................................. 0.22 0.87 NA 0.06 1.15 NA XXX 

G0141 ... .......... A Scr c/v cyto,autosys and md .............................. 0.42 0.15 0.15 0.02 0.59 0.59 XXX 

G0143 ... .......... X Scr c/v cyto,thinlayer,rescr ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0144 ... .......... X Scr c/v cyto,thinlayer,rescr ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0145 ... .......... X Scr c/v cyto,thinlayer,rescr ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0147 ... .......... X Scr c/v cyto, automated sys ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0148 ... .......... X Scr c/v cyto, autosys, rescr ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0166 ... .......... A Extrnl counterpulse, per tx ................................. 0.07 3.58 0.03 0.01 3.66 0.11 XXX 

G0168 ... .......... A Wound closure by adhesive ............................... 0.45 1.94 0.22 0.03 2.42 0.70 000 

G0173 ... .......... X Linear acc stereo radsur com ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0175 ... .......... X OPPS Service,sched team conf ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0176 ... .......... X OPPS/PHP;activity therapy ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0177 ... .......... X OPPS/PHP; train & educ serv ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0179 ... .......... A MD recertification HHA PT ................................. 0.45 1.03 NA 0.02 1.50 NA XXX 

G0180 ... .......... A MD certification HHA patient .............................. 0.67 1.26 NA 0.03 1.96 NA XXX 

G0181 ... .......... A Home health care supervision ........................... 1.73 1.48 NA 0.07 3.28 NA XXX 

G0182 ... .......... A Hospice care supervision ................................... 1.73 1.66 NA 0.07 3.46 NA XXX 

G0186 ... .......... C Dstry eye lesn,fdr vssl tech ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

G0202 ... 26 ..... A Screeningmammographydigital .......................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

G0202 ... TC .... A Screeningmammographydigital .......................... 0.00 2.55 NA 0.07 2.62 NA XXX 

G0202 ... .......... A Screeningmammographydigital .......................... 0.70 2.78 NA 0.10 3.58 NA XXX 

G0204 ... 26 ..... A Diagnosticmammographydigital ......................... 0.87 0.28 0.28 0.04 1.19 1.19 XXX 

G0204 ... TC .... A Diagnosticmammographydigital ......................... 0.00 2.51 NA 0.07 2.58 NA XXX 

G0204 ... .......... A Diagnosticmammographydigital ......................... 0.87 2.79 NA 0.11 3.77 NA XXX 

G0206 ... 26 ..... A Diagnosticmammographydigital ......................... 0.70 0.23 0.23 0.03 0.96 0.96 XXX 

G0206 ... TC .... A Diagnosticmammographydigital ......................... 0.00 2.03 NA 0.06 2.09 NA XXX 

G0206 ... .......... A Diagnosticmammographydigital ......................... 0.70 2.26 NA 0.09 3.05 NA XXX 

G0219 ... 26 ..... N PET img wholbod melano nonco ....................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0219 ... TC .... N PET img wholbod melano nonco ....................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0219 ... .......... N PET img wholbod melano nonco ....................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0235 ... 26 ..... N PET not otherwise specified .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0235 ... TC .... N PET not otherwise specified .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0235 ... .......... N PET not otherwise specified .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0237 ... .......... A Therapeutic procd strg endur ............................. 0.00 0.47 NA 0.02 0.49 NA XXX 

G0238 ... .......... A Oth resp proc, indiv ............................................ 0.00 0.49 NA 0.02 0.51 NA XXX 

G0239 ... .......... A Oth resp proc, group .......................................... 0.00 0.33 NA 0.02 0.35 NA XXX 

G0243 ... .......... X Multisour photon stero treat ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0245 ... .......... R Initial foot exam pt lops ...................................... 0.88 0.79 0.31 0.04 1.71 1.23 XXX 

70462 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

G0246 ... .......... R Followup eval of foot pt lop ................................ 0.45 0.54 0.16 0.02 1.01 0.63 XXX 

G0247 ... .......... R Routine footcare pt w lops ................................. 0.50 0.52 0.21 0.02 1.04 0.73 ZZZ 

G0248 ... .......... R Demonstrate use home inr mon ........................ 0.00 6.63 NA 0.01 6.64 NA XXX 

G0249 ... .......... R Provide test material,equipm .............................. 0.00 3.97 NA 0.01 3.98 NA XXX 

G0250 ... .......... R MD review interpret of test ................................. 0.18 0.06 0.06 0.01 0.25 0.25 XXX 

G0251 ... .......... E Linear acc based stero radio ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0255 ... 26 ..... N Current percep threshold tst .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0255 ... TC .... N Current percep threshold tst .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0255 ... .......... N Current percep threshold tst .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0257 ... .......... E Unsched dialysis ESRD pt hos .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0259 ... .......... E Inject for sacroiliac joint ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0260 ... .......... E Inj for sacroiliac jt anesth ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0265 ... .......... X Cryopresevation Freeze+stora ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0266 ... .......... X Thawing + expansion froz cel ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0267 ... .......... X Bone marrow or psc harvest .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0268 ... .......... A Removal of impacted wax md ............................ 0.61 0.63 0.24 0.02 1.26 0.87 000 

G0269 ... .......... B Occlusive device in vein art ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0270 ... .......... A MNT subs tx for change dx ................................ 0.00 0.47 NA 0.01 0.48 NA XXX 

G0271 ... .......... A Group MNT 2 or more 30 mins .......................... 0.00 0.18 NA 0.01 0.19 NA XXX 

G0275 ... .......... A Renal angio, cardiac cath .................................. 0.25 NA 0.10 0.01 NA 0.36 ZZZ 

G0278 ... .......... A Iliac art angio,cardiac cath ................................. 0.25 NA 0.10 0.01 NA 0.36 ZZZ 

G0281 ... .......... A Elec stim unattend for press .............................. 0.18 0.11 NA 0.01 0.30 NA XXX 

G0282 ... .......... N Elect stim wound care not pd ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0283 ... .......... A Elec stim other than wound ............................... 0.18 0.11 NA 0.01 0.30 NA XXX 

G0288 ... .......... A Recon, CTA for surg plan .................................. 0.00 10.64 NA 0.18 10.82 NA XXX 

G0289 ... .......... A Arthro, loose body + chondro ............................. 1.48 NA 0.80 0.26 NA 2.54 ZZZ 

G0290 ... .......... E Drug-eluting stents, single .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0291 ... .......... E Drug-eluting stents,each add ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0293 ... .......... E Non-cov surg proc,clin trial ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0294 ... .......... E Non-cov proc, clinical trial .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0295 ... .......... N Electromagnetic therapy onc .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0297 ... .......... X Insert single chamber/cd .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0298 ... .......... X Insert dual chamber/cd ....................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0299 ... .......... X Inser/repos single icd+leads ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0300 ... .......... X Insert reposit lead dual+gen ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0302 ... .......... X Pre-op service LVRS complete .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0303 ... .......... X Pre-op service LVRS 10-15dos ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0304 ... .......... X Pre-op service LVRS 1-9 dos ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0305 ... .......... X Post op service LVRS min 6 .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0306 ... .......... X CBC/diffwbc w/o platelet .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0307 ... .......... X CBC without platelet ........................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0308 ... .......... A ESRD related svc 4+mo < 2yrs ......................... 12.74 8.56 8.56 0.42 21.72 21.72 XXX 

G0309 ... .......... A ESRD related svc 2-3mo <2yrs ......................... 10.61 7.12 7.12 0.36 18.09 18.09 XXX 

G0310 ... .......... A ESRD related svc 1 vst <2yrs ............................ 8.49 5.70 5.70 0.28 14.47 14.47 XXX 

G0311 ... .......... A ESRD related svs 4+mo 2-11yr ......................... 9.73 4.73 4.73 0.34 14.80 14.80 XXX 

G0312 ... .......... A ESRD relate svs 2-3 mo 2-11y .......................... 8.11 3.93 3.93 0.29 12.33 12.33 XXX 

G0313 ... .......... A ESRD related svs 1 mon 2-11y ......................... 6.49 3.15 3.15 0.22 9.86 9.86 XXX 

G0314 ... .......... A ESRD related svs 4+ mo 12-19 ......................... 8.28 4.43 4.43 0.27 12.98 12.98 XXX 

G0315 ... .......... A ESRD related svs 2-3mo/12-19 ......................... 6.90 3.68 3.68 0.23 10.81 10.81 XXX 

G0316 ... .......... A ESRD related svs 1vis/12-19y ........................... 5.52 2.95 2.95 0.17 8.64 8.64 XXX 

G0317 ... .......... A ESRD related svs 4+mo 20+yrs ........................ 5.09 2.87 2.87 0.17 8.13 8.13 XXX 

G0318 ... .......... A ESRD related svs 2-3 mo 20+y ......................... 4.24 2.39 2.39 0.14 6.77 6.77 XXX 

G0319 ... .......... A ESRD related svs 1visit 20+y ............................ 3.39 1.91 1.91 0.11 5.41 5.41 XXX 

G0320 ... .......... A ESD related svs home undr 2 ............................ 10.61 7.12 7.12 0.36 18.09 18.09 XXX 

G0321 ... .......... A ESRDrelatedsvs home mo 2-11y ....................... 8.11 3.93 3.93 0.29 12.33 12.33 XXX 

G0322 ... .......... A ESRD related svs hom mo12-19 ....................... 6.90 3.68 3.68 0.23 10.81 10.81 XXX 

G0323 ... .......... A ESRD related svs home mo 20+ ....................... 4.24 2.39 2.39 0.14 6.77 6.77 XXX 

G0324 ... .......... A ESRD relate svs home/dy <2yr .......................... 0.35 0.24 0.24 0.01 0.60 0.60 XXX 

G0325 ... .......... A ESRD relate home/day/ 2-11yr .......................... 0.23 0.12 0.12 0.01 0.36 0.36 XXX 

G0326 ... .......... A ESRD relate home/dy 12-19yr ........................... 0.27 0.13 0.13 0.01 0.41 0.41 XXX 

G0327 ... .......... A ESRD relate home/dy 20+yrs ............................ 0.14 0.08 0.08 0.01 0.23 0.23 XXX 

G0328 ... .......... X Fecal blood scrn immunoassay ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0329 ... .......... A Electromagntic tx for ulcers ................................ 0.06 0.14 0.02 0.01 0.21 0.09 XXX 

G0337 ... .......... X Hospice evaluation preelecti .............................. +1.34 0.51 0.51 0.09 1.94 1.94 XXX 

G0339 ... .......... C Robot lin-radsurg com, first ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0340 ... .......... C Robt lin-radsurg fractx 2-5 ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0341 ... .......... A Percutaneous islet celltrans ............................... 6.98 5.75 2.60 0.48 13.21 10.06 000 

G0342 ... .......... A Laparoscopy islet cell trans ................................ 11.92 NA 5.31 1.46 NA 18.69 090 

G0343 ... .......... A Laparotomy islet cell transp ............................... 19.85 NA 8.78 2.06 NA 30.69 090 

G0344 ... .......... A Initial preventive exam ....................................... 1.34 1.13 0.48 0.10 2.57 1.92 XXX 

G0364 ... .......... A Bone marrow aspirate &biopsy .......................... 0.16 0.14 0.06 0.04 0.34 0.26 ZZZ 

G0365 ... 26 ..... A Vessel mapping hemo access ........................... 0.25 0.09 0.09 0.02 0.36 0.36 XXX 

G0365 ... TC .... A Vessel mapping hemo access ........................... 0.00 3.91 NA 0.23 4.14 NA XXX 

G0365 ... .......... A Vessel mapping hemo access ........................... 0.25 4.00 NA 0.25 4.50 NA XXX 

G0366 ... .......... A EKG for initial prevent exam .............................. 0.17 0.51 NA 0.03 0.71 NA XXX 

70463 

ADDENDUM B.—RELATIVE VALUE UNITS (RVUS) AND RELATED INFORMATION—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

G0367 ... .......... A EKG tracing for initial prev ................................. 0.00 0.45 NA 0.02 0.47 NA XXX 

G0368 ... .......... A EKG interpret & report preve ............................. 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

G0372 ... .......... A MD service required for PMD ............................ 0.17 0.39 0.06 0.01 0.57 0.24 XXX 

G0375 ... .......... A Smoke/tobacco counselng 3-10 ......................... 0.24 0.09 0.09 0.01 0.34 0.34 XXX 

G0376 ... .......... A Smoke/tobacco counseling >10 ......................... 0.48 0.18 0.17 0.01 0.67 0.66 XXX 

G0378 ... .......... X Hospital observation per hr ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G0379 ... .......... X Direct admit hospital observ ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G3001 ... .......... X Admin + supply, tositumomab ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9001 ... .......... X MCCD, initial rate ............................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9002 ... .......... X MCCD,maintenance rate .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9003 ... .......... X MCCD, risk adj hi, initial ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9004 ... .......... X MCCD, risk adj lo, initial ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9005 ... .......... X MCCD, risk adj, maintenance ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9006 ... .......... X MCCD, Home monitoring ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9007 ... .......... X MCCD, sch team conf ........................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9008 ... .......... X Mccd,phys coor-care ovrsght ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9009 ... .......... X MCCD, risk adj, level 3 ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9010 ... .......... X MCCD, risk adj, level 4 ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9011 ... .......... X MCCD, risk adj, level 5 ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9012 ... .......... X Other Specified Case Mgmt ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9013 ... .......... N ESRD demo bundle level I ................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9014 ... .......... N ESRD demo bundle-level II ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9016 ... .......... N Demo-smoking cessation coun .......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9017 ... .......... X Amantadine HCL 100mg oral ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9018 ... .......... X Zanamivir,inhalation pwd 10m ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9019 ... .......... X Oseltamivir phosphate 75mg ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9020 ... .......... X Rimantadine HCL 100mg oral ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9021 ... .......... X Chemo assess nausea vomit L1 ........................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9022 ... .......... X Chemo assess nausea vomit L2 ........................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9023 ... .......... X Chemo assess nausea vomit L3 ........................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9024 ... .......... X Chemo assess nausea vomit L4 ........................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9025 ... .......... X Chemo assessment pain level1 ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9026 ... .......... X Chemo assessment pain level2 ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9027 ... .......... X Chemo assessment pain level3 ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9028 ... .......... X Chemo assessment pain level4 ......................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9029 ... .......... X Chemo assess for fatigue L1 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9030 ... .......... X Chemo assess for fatigue L2 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9031 ... .......... X Chemo assess for fatigue L3 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9032 ... .......... X Chemo assess for fatigue L4 ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9033 ... .......... X Amantadine HCL oral brand .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9034 ... .......... X Zanamivir, inh pwdr, brand ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9035 ... .......... X Oseltamivir phosp, brand ................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9036 ... .......... X Rimantadine HCL, brand .................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9041 ... .......... X Low vision rehab occupationa ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9042 ... .......... X Low vision rehab orient/mobi ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9043 ... .......... X Low vision lowvision therapi ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

G9044 ... .......... X Low vision rehabilate teache .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

M0064 ... .......... A Visit for drug monitoring ..................................... 0.37 0.34 0.12 0.01 0.72 0.50 XXX 

P3001 .... .......... A Screening pap smear by phys ........................... 0.42 0.15 0.15 0.02 0.59 0.59 XXX 

Q0035 ... 26 ..... A Cardiokymography ............................................. 0.17 0.06 0.06 0.01 0.24 0.24 XXX 

Q0035 ... TC .... A Cardiokymography ............................................. 0.00 0.39 NA 0.02 0.41 NA XXX 

Q0035 ... .......... A Cardiokymography ............................................. 0.17 0.45 NA 0.03 0.65 NA XXX 

Q0091 ... .......... A Obtaining screen pap smear .............................. 0.37 0.67 0.14 0.02 1.06 0.53 XXX 

Q0092 ... .......... A Set up port xray equipment ................................ 0.00 0.32 NA 0.01 0.33 NA XXX 

Q3001 ... .......... C Brachytherapy Radioelements ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

Q3014 ... .......... X Telehealth facility fee ......................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

R0070 .... .......... C Transport portable x-ray ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

R0075 .... .......... C Transport port x-ray multipl ................................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

R0076 .... .......... B Transport portable EKG ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

V5299 .... .......... R Hearing service .................................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. 

2 Copyright 2005 American Dental Association. All rights reserved. 

3 +Indicates RVUs are not used for Medicare payment. 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. 2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM C.—CODES WITH INTERIM RVUS

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

15040 .... .......... A Harvest cultured skin graft ................................. 2.00 4.57 1.13 0.24 6.81 3.37 000 

15110 .... .......... A Epidrm autogrft trnk/arm/leg ............................... 9.50 10.70 7.02 1.31 21.51 17.83 090 

15111 .... .......... A Epidrm autogrft t/a/l add-on ............................... 1.85 1.29 0.79 0.26 3.40 2.90 ZZZ 

70464 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. 2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM C.—CODES WITH INTERIM RVUS—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

15115 .... .......... A Epidrm a-grft face/nck/hf/g ................................. 9.81 9.25 7.37 1.15 20.21 18.33 090 

15116 .... .......... A Epidrm a-grft f/n/hf/g addl .................................. 2.50 1.58 1.12 0.33 4.41 3.95 ZZZ 

15130 .... .......... A Derm autograft, trnk/arm/leg .............................. 7.00 9.89 6.36 0.97 17.86 14.33 090 

15131 .... .......... A Derm autograft t/a/l add-on ................................ 1.50 1.07 0.64 0.21 2.78 2.35 ZZZ 

15135 .... .......... A Derm autograft face/nck/hf/g .............................. 10.50 9.90 8.15 1.23 21.63 19.88 090 

15136 .... .......... A Derm autograft, f/n/hf/g add ............................... 1.50 0.89 0.67 0.20 2.59 2.37 ZZZ 

15150 .... .......... A Cult epiderm grft t/arm/leg ................................. 8.25 8.48 6.46 1.14 17.87 15.85 090 

15151 .... .......... A Cult epiderm grft t/a/l addl .................................. 2.00 1.31 0.85 0.28 3.59 3.13 ZZZ 

15152 .... .......... A Cult epiderm graft t/a/l +% ................................. 2.50 1.56 1.06 0.35 4.41 3.91 ZZZ 

15155 .... .......... A Cult epiderm graft, f/n/hf/g ................................. 9.00 7.84 6.98 1.05 17.89 17.03 090 

15156 .... .......... A Cult epidrm grft f/n/hfg add ................................ 2.75 1.56 1.24 0.36 4.67 4.35 ZZZ 

15157 .... .......... A Cult epiderm grft f/n/hfg +% ............................... 3.00 1.78 1.35 0.39 5.17 4.74 ZZZ 

15170 .... .......... A Acell graft trunk/arms/legs .................................. 5.00 3.84 2.37 0.55 9.39 7.92 090 

15171 .... .......... A Acell graft t/arm/leg add-on ................................ 1.55 0.68 0.62 0.19 2.42 2.36 ZZZ 

15175 .... .......... A Acellular graft, f/n/hf/g ........................................ 7.00 5.44 4.01 0.82 13.26 11.83 090 

15176 .... .......... A Acell graft, f/n/hf/g add-on .................................. 2.45 1.11 0.99 0.29 3.85 3.73 ZZZ 

15300 .... .......... A Apply skinallogrft, t/arm/lg .................................. 3.99 3.21 2.24 0.49 7.69 6.72 090 

15301 .... .......... A Apply sknallogrft t/a/l addl .................................. 1.00 0.47 0.40 0.14 1.61 1.54 ZZZ 

15320 .... .......... A Apply skin allogrft f/n/hf/g ................................... 4.70 3.63 2.54 0.58 8.91 7.82 090 

15321 .... .......... A Aply sknallogrft f/n/hfg add ................................. 1.50 0.69 0.59 0.21 2.40 2.30 ZZZ 

15330 .... .......... A Aply acell alogrft t/arm/leg .................................. 3.99 3.20 2.23 0.49 7.68 6.71 090 

15331 .... .......... A Aply acell grft t/a/l add-on .................................. 1.00 0.46 0.40 0.14 1.60 1.54 ZZZ 

15335 .... .......... A Apply acell graft, f/n/hf/g .................................... 4.50 3.48 2.45 0.55 8.53 7.50 090 

15336 .... .......... A Aply acell grft f/n/hf/g add .................................. 1.43 0.69 0.57 0.20 2.32 2.20 ZZZ 

15340 .... .......... A Apply cult skin substitute .................................... 3.72 4.01 2.76 0.41 8.14 6.89 010 

15341 .... .......... A Apply cult skin sub add-on ................................. 0.50 0.61 0.20 0.06 1.17 0.76 ZZZ 

15360 .... .......... A Apply cult derm sub, t/a/l ................................... 3.87 4.48 3.09 0.43 8.78 7.39 090 

15361 .... .......... A Aply cult derm sub t/a/l add ............................... 1.15 0.58 0.46 0.14 1.87 1.75 ZZZ 

15365 .... .......... A Apply cult derm sub f/n/hf/g ............................... 4.15 4.56 3.20 0.46 9.17 7.81 090 

15366 .... .......... A Apply cult derm f/hf/g add .................................. 1.45 0.70 0.58 0.17 2.32 2.20 ZZZ 

15420 .... .......... A Apply skin xgraft, f/n/hf/g .................................... 4.50 4.79 3.80 0.52 9.81 8.82 090 

15421 .... .......... A Apply skn xgrft f/n/hf/g add ................................ 1.50 1.32 0.62 0.21 3.03 2.33 ZZZ 

15430 .... .......... A Apply acellular xenograft .................................... 5.75 6.92 6.63 0.66 13.33 13.04 090 

15431 .... .......... C Apply acellular xgraft add ................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

22010 .... .......... A I&d, p-spine, c/t/cerv-thor ................................... 11.05 NA 8.91 1.73 NA 21.69 090 

22015 .... .......... A I&d, p-spine, l/s/ls ............................................... 10.94 NA 8.85 1.71 NA 21.50 090 

22523 .... .......... A Percut kyphoplasty, thor ..................................... 8.94 NA 5.92 1.43 NA 16.29 010 

22524 .... .......... A Percut kyphoplasty, lumbar ................................ 8.54 NA 5.71 1.36 NA 15.61 010 

22525 .... .......... A Percut kyphoplasty, add-on ................................ 4.47 NA 2.28 0.72 NA 7.47 ZZZ 

28890 .... .......... A High energy eswt, plantar f ................................ 3.30 5.73 2.09 0.41 9.44 5.80 090 

32503 .... .......... A Resect apical lung tumor ................................... 30.00 NA 15.11 4.37 NA 49.48 090 

32504 .... .......... A Resect apical lung tum/chest ............................. 34.80 NA 16.72 5.07 NA 56.59 090 

33507 .... .......... A Repair art, intramural ......................................... 30.00 NA 13.68 4.05 NA 47.73 090 

33548 .... .......... A Restore/remodel, ventricle ................................. 37.97 NA 19.35 5.51 NA 62.83 090 

33768 .... .......... A Cavopulmonary shunting .................................... 8.00 NA 2.67 1.19 NA 11.86 ZZZ 

33880 .... .......... A Endovasc taa repr incl subcl .............................. 33.00 NA 13.51 2.74 NA 49.25 090 

33881 .... .......... A Endovasc taa repr w/o subcl .............................. 28.00 NA 11.99 2.32 NA 42.31 090 

33883 .... .......... A Insert endovasc prosth, taa ................................ 20.00 NA 9.21 2.10 NA 31.31 090 

33884 .... .......... A Endovasc prosth, taa, add-on ............................ 8.20 NA 2.58 0.86 NA 11.64 ZZZ 

33886 .... .......... A Endovasc prosth, delayed .................................. 17.00 NA 8.25 1.79 NA 27.04 090 

33889 .... .......... A Artery transpose/endovas taa ............................ 15.92 NA 5.19 2.17 NA 23.28 000 

33891 .... .......... A Car-car bp grft/endovas taa ............................... 20.00 NA 6.98 2.72 NA 29.70 000 

33925 .... .......... A Rpr pul art unifocal w/o cpb ............................... 29.50 NA 14.70 4.60 NA 48.80 090 

33926 .... .......... A Repr pul art, unifocal w/cpb ............................... 42.00 NA 17.73 6.20 NA 65.93 090 

36598 .... .......... T Inj w/fluor, eval cv device ................................... 0.74 2.65 2.65 0.05 3.44 3.44 000 

37184 .... .......... A Prim art mech thrombectomy ............................. 8.66 71.90 3.36 0.55 81.11 12.57 000 

37185 .... .......... A Prim art m-thrombect add-on ............................. 3.28 22.95 1.11 0.21 26.44 4.60 ZZZ 

37186 .... .......... A Sec art m-thrombect add-on .............................. 4.92 49.53 1.66 0.32 54.77 6.90 ZZZ 

37187 .... .......... A Venous mech thrombectomy ............................. 8.03 70.38 3.15 0.51 78.92 11.69 000 

37188 .... .......... A Venous m-thrombectomy add-on ....................... 5.71 62.15 2.37 0.37 68.23 8.45 000 

37718 .... .......... A Ligate/strip short leg vein ................................... 6.76 NA 4.07 0.14 NA 10.97 090 

37722 .... .......... A Ligate/strip long leg vein .................................... 7.79 NA 4.42 0.86 NA 13.07 090 

43770 .... .......... A Lap, place gastr adjust band .............................. 16.71 NA 7.73 2.18 NA 26.62 090 

43771 .... .......... A Lap, revise adjust gast band .............................. 19.50 NA 8.61 2.54 NA 30.65 090 

43772 .... .......... A Lap, remove adjust gast band ........................... 15.00 NA 6.44 1.92 NA 23.36 090 

43773 .... .......... A Lap, change adjust gast band ............................ 19.50 NA 8.61 2.55 NA 30.66 090 

43774 .... .......... A Lap remov adj gast band/port ............................ 15.00 NA 6.58 1.84 NA 23.42 090 

43845 .... .......... A Gastroplasty duodenal switch ............................ 31.00 10.80 10.80 4.05 45.85 45.85 090 

43886 .... .......... A Revise gastric port, open ................................... 4.00 NA 3.14 0.25 NA 7.39 090 

43887 .... .......... A Remove gastric port, open ................................. 3.95 NA 2.78 0.51 NA 7.24 090 

43888 .... .......... A Change gastric port, open .................................. 5.80 NA 3.77 0.70 NA 10.27 090 

44180 .... .......... A Lap, enterolysis .................................................. 14.42 NA 6.25 1.85 NA 22.52 090 

44186 .... .......... A Lap, jejunostomy ................................................ 9.77 NA 4.80 1.27 NA 15.84 090 

44187 .... .......... A Lap, ileo/jejuno-stomy ........................................ 15.93 NA 8.29 1.95 NA 26.17 090 

44188 .... .......... A Lap, colostomy ................................................... 17.61 NA 8.87 2.23 NA 28.71 090 

70465 

——————————

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. 2 Copyright 2005 American Dental Association. All rights reserved. 

3+Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM C.—CODES WITH INTERIM RVUS—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

44213 .... .......... A Lap, mobil splenic fl add-on ............................... 3.50 NA 1.22 0.44 NA 5.16 ZZZ 

44227 .... .......... A Lap, close enterostomy ...................................... 26.50 NA 10.65 3.37 NA 40.52 090 

45395 .... .......... A Lap, removal of rectum ...................................... 30.50 NA 13.71 3.62 NA 47.83 090 

45397 .... .......... A Lap, remove rectum w/pouch ............................. 34.00 NA 14.30 3.66 NA 51.96 090 

45400 .... .......... A Laparoscopic proctopexy ................................... 18.06 NA 7.85 2.02 NA 27.93 090 

45402 .... .......... A Lap proctopexy w/sig resect .............................. 25.04 NA 10.01 2.81 NA 37.86 090 

45499 .... .......... C Laparoscope proc, rectum ................................. 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

45990 .... .......... A Surg dx exam, anorectal .................................... 1.80 NA 0.79 0.17 NA 2.76 000 

46505 .... .......... A Chemodenervation anal musc ........................... 2.86 3.05 1.97 0.14 6.05 4.97 010 

46710 .... .......... A Repr per/vag pouch sngl proc ............................ 16.00 NA 7.77 1.38 NA 25.15 090 

46712 .... .......... A Repr per/vag pouch dbl proc ............................. 34.00 NA 15.08 3.66 NA 52.74 090 

50250 .... .......... A Cryoablate renal mass open .............................. 19.97 NA 9.18 1.39 NA 30.54 090 

50382 .... .......... A Change ureter stent, percut ............................... 5.50 36.22 1.87 0.34 42.06 7.71 000 

50384 .... .......... A Remove ureter stent, percut .............................. 5.00 35.32 1.71 0.31 40.63 7.02 000 

50387 .... .......... A Change ext/int ureter stent ................................. 2.00 18.26 0.67 0.12 20.38 2.79 000 

50389 .... .......... A Remove renal tube w/fluoro ............................... 1.10 12.78 0.37 0.07 13.95 1.54 000 

50592 .... .......... A Perc rf ablate renal tumor .................................. 6.75 149.45 2.99 0.43 156.63 10.17 010 

51999 .... .......... C Laparoscope proc, bladder ................................ 0.00 0.00 0.00 0.00 0.00 0.00 YYY 

57295 .... .......... A Change vaginal graft .......................................... 7.45 NA 4.44 0.91 NA 12.80 090 

58110 .... .......... A Bx done w/colposcopy add-on ........................... 0.77 0.55 0.31 0.09 1.41 1.17 ZZZ 

61630 .... .......... N Intracranial angioplasty ...................................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

61635 .... .......... N Intracran angioplsty w/stent ............................... 0.00 0.00 0.00 0.00 0.00 0.00 090 

61640 .... .......... N Dilate ic vasospasm, init .................................... 0.00 0.00 0.00 0.00 0.00 0.00 000 

61641 .... .......... N Dilate ic vasospasm add-on ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

61642 .... .......... N Dilate ic vasospasm add-on ............................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

64650 .... .......... A Chemodenerv eccrine glands ............................ 0.70 0.87 0.30 0.06 1.63 1.06 000 

64653 .... .......... A Chemodenerv eccrine glands ............................ 0.88 0.92 0.38 0.08 1.88 1.34 000 

67901 .... .......... A Repair eyelid defect ........................................... 7.39 NA 5.42 0.54 NA 13.35 090 

67902 .... .......... A Repair eyelid defect ........................................... 9.35 NA 5.48 0.60 NA 15.43 090 

75956 .... 26 ..... A Xray, endovasc thor ao repr .............................. 7.00 2.71 2.71 0.69 10.40 10.40 XXX 

75957 .... 26 ..... A Xray, endovasc thor ao repr .............................. 6.00 2.32 2.32 0.59 8.91 8.91 XXX 

75958 .... 26 ..... A Xray, place prox ext thor ao ............................... 4.00 1.55 1.55 0.39 5.94 5.94 XXX 

75959 .... 26 ..... A Xray, place dist ext thor ao ................................ 3.50 1.36 1.36 0.34 5.20 5.20 XXX 

76376 .... 26 ..... A 3d render w/o postprocess ................................. 0.20 0.07 0.07 0.02 0.29 0.29 XXX 

76377 .... 26 ..... A 3d rendering w/postprocess ............................... 0.79 0.27 0.27 0.08 1.14 1.14 XXX 

77421 .... 26 ..... A Stereoscopic x-ray guidance .............................. 0.39 0.13 0.13 0.02 0.54 0.54 XXX 

77422 .... .......... A Neutron beam tx, simple .................................... 0.00 1.71 NA 0.13 1.84 NA XXX 

77423 .... .......... A Neutron beam tx, complex ................................. 0.00 2.26 NA 0.13 2.39 NA XXX 

88333 .... 26 ..... A Intraop cyto path consult, 1 ................................ 1.20 0.53 0.53 0.04 1.77 1.77 XXX 

88334 .... 26 ..... A Intraop cyto path consult, 2 ................................ 0.59 0.26 0.26 0.02 0.87 0.87 XXX 

88384 .... 26 ..... C Eval molecular probes, 11-50 ............................ 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

88385 .... 26 ..... A Eval molecul probes, 51-250 ............................. 1.50 0.65 0.65 0.06 2.21 2.21 XXX 

88386 .... 26 ..... A Eval molecul probes, 251-500 ........................... 1.88 0.82 0.82 0.08 2.78 2.78 XXX 

89049 .... .......... A Chct for mal hyperthermia .................................. 1.40 3.56 0.27 0.06 5.02 1.73 XXX 

90760 .... .......... A Hydration iv infusion, init .................................... 0.17 1.43 1.43 0.07 1.67 1.67 XXX 

90761 .... .......... A Hydrate iv infusion, add-on ................................ 0.09 0.40 0.40 0.04 0.53 0.53 ZZZ 

90765 .... .......... A Ther/proph/diag iv inf, init ................................... 0.21 1.76 1.76 0.07 2.04 2.04 XXX 

90766 .... .......... A Ther/proph/dg iv inf, add-on ............................... 0.18 0.46 0.46 0.04 0.68 0.68 ZZZ 

90767 .... .......... A Tx/proph/dg addl seq iv inf ................................. 0.19 0.89 0.89 0.04 1.12 1.12 ZZZ 

90768 .... .......... A Ther/diag concurrent inf ..................................... 0.17 0.44 0.44 0.04 0.65 0.65 ZZZ 

90772 .... .......... A Ther/proph/diag inj, sc/im ................................... 0.17 0.31 0.31 0.01 0.49 0.49 XXX 

90773 .... .......... A Ther/proph/diag inj, ia ........................................ 0.17 0.32 0.32 0.02 0.51 0.51 XXX 

90774 .... .......... A Ther/proph/diag inj, iv push ................................ 0.18 1.30 1.30 0.04 1.52 1.52 XXX 

90775 .... .......... A Ther/proph/diag inj add-on ................................. 0.10 0.57 0.57 0.04 0.71 0.71 ZZZ 

90779 .... .......... C Ther/prop/diag inj/inf proc .................................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

91022 .... 26 ..... A Duodenal motility study ...................................... 1.44 0.51 0.51 0.07 2.02 2.02 000 

92520 .... .......... A Laryngeal function studies ................................. 0.75 0.51 0.39 0.03 1.29 1.17 XXX 

92626 .... .......... A Eval aud rehab status ........................................ 0.00 0.55 NA 0.06 0.61 NA XXX 

92627 .... .......... A Eval aud status rehab add-on ............................ 0.00 0.55 NA 0.06 0.61 NA XXX 

92630 .... .......... I Aud rehab pre-ling hear loss .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

92633 .... .......... I Aud rehab postling hear loss ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

95251 .... .......... A Gluc monitor, cont, phys i&r ............................... 0.52 0.19 0.19 0.02 0.73 0.73 XXX 

95865 .... 26 ..... A Muscle test, larynx ............................................. 1.57 0.77 0.77 0.08 2.42 2.42 XXX 

95866 .... 26 ..... A Muscle test, hemidiaphragm .............................. 1.25 0.56 0.56 0.07 1.88 1.88 XXX 

95873 .... 26 ..... A Guide nerv destr, elec stim ................................ 0.37 0.16 0.16 0.02 0.55 0.55 ZZZ 

95874 .... 26 ..... A Guide nerv destr, needle emg ........................... 0.37 0.17 0.17 0.02 0.56 0.56 ZZZ 

96101 .... .......... A Psycho testing by psych/phys ............................ 1.86 0.65 0.63 0.05 2.56 2.54 XXX 

96102 .... .......... A Psycho testing by technician .............................. 0.50 0.66 0.17 0.01 1.17 0.68 XXX 

96103 .... .......... A Psycho testing admin by comp .......................... 0.51 0.21 0.17 0.02 0.74 0.70 XXX 

96116 .... .......... A Neurobehavioral status exam ............................ 1.86 0.83 0.64 0.18 2.87 2.68 XXX 

96118 .... .......... A Neuropsych tst by psych/phys ........................... 1.86 1.39 0.63 0.18 3.43 2.67 XXX 

96119 .... .......... A Neuropsych testing by tech ................................ 0.55 1.02 0.19 0.18 1.75 0.92 XXX 

96120 .... .......... A Neuropsych tst admin w/comp ........................... 0.51 0.74 0.17 0.02 1.27 0.70 XXX 

96401 .... .......... A Chemo, anti-neopl, sq/im ................................... 0.21 1.53 1.53 0.01 1.75 1.75 XXX 

96402 .... .......... A Chemo hormon antineopl sq/im ......................... 0.19 0.74 0.74 0.01 0.94 0.94 XXX 

70466 

ADDENDUM C.—CODES WITH INTERIM RVUS—Continued 

CPT 1

HCPCS2 Mod Status Description 

Physician 

work 

RVUs 3

NonFacility 

PE RVUs 

Facility 

PE RVUs 

Malpractice 

RVUs 

NonFacility 

Total 

Facility 

Total Global 

96409 .... .......... A Chemo, iv push, sngl drug ................................. 0.24 2.93 2.93 0.06 3.23 3.23 XXX 

96411 .... .......... A Chemo, iv push, addl drug ................................. 0.20 1.61 1.61 0.06 1.87 1.87 ZZZ 

96413 .... .......... A Chemo, iv infusion, 1 hr ..................................... 0.28 4.20 4.20 0.08 4.56 4.56 XXX 

96415 .... .......... A Chemo, iv infusion, addl hr ................................ 0.19 0.77 0.77 0.07 1.03 1.03 ZZZ 

96416 .... .......... A Chemo prolong infuse w/pump .......................... 0.21 4.61 4.61 0.08 4.90 4.90 XXX 

96417 .... .......... A Chemo iv infus each addl seq ........................... 0.21 1.95 1.95 0.07 2.23 2.23 ZZZ 

96450 .... .......... A Chemotherapy, into CNS ................................... 1.53 6.96 1.29 0.09 8.58 2.91 000 

96521 .... .......... A Refill/maint, portable pump ................................ 0.21 3.77 3.77 0.06 4.04 4.04 XXX 

96522 .... .......... A Refill/maint pump/resvr syst ............................... 0.21 2.65 2.65 0.06 2.92 2.92 XXX 

96523 .... .......... T Irrig drug delivery device .................................... 0.04 0.69 0.69 0.01 0.74 0.74 XXX 

96542 .... .......... A Chemotherapy injection ...................................... 0.75 4.24 0.66 0.07 5.06 1.48 XXX 

97760 .... .......... A Orthotic mgmt and training ................................. 0.45 0.34 0.20 0.03 0.82 0.68 XXX 

97761 .... .......... A Prosthetic training ............................................... 0.45 0.28 0.19 0.02 0.75 0.66 XXX 

97762 .... .......... A C/o for orthotic/prosth use .................................. 0.25 0.42 0.19 0.02 0.69 0.46 XXX 

98960 .... .......... N Self-mgmt educ & train, 1 pt .............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

98961 .... .......... N Self-mgmt educ/train, 2-4 pt ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

98962 .... .......... N Self-mgmt educ/train, 5-8 pt ............................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99143 .... .......... C Mod cs by same phys, < 5 yrs ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99144 .... .......... C Mod cs by same phys, 5 yrs + ........................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99145 .... .......... C Mod cs by same phys add-on ............................ 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99148 .... .......... C Mod cs diff phys < 5 yrs ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99149 .... .......... C Mod cs diff phys 5 yrs + ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99150 .... .......... C Mod cs diff phys add-on ..................................... 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ 

99300 .... .......... A Ic, infant pbw 2501-5000 gm ............................. 2.40 NA 0.84 2.40 NA 5.64 XXX 

99304 .... .......... A Nursing facility care, init ..................................... 1.20 0.49 0.49 0.05 1.74 1.74 XXX 

99305 .... .......... A Nursing facility care, init ..................................... 1.61 0.63 0.63 0.07 2.31 2.31 XXX 

99306 .... .......... A Nursing facility care, init ..................................... 2.01 0.75 0.75 0.09 2.85 2.85 XXX 

99307 .... .......... A Nursing fac care, subseq ................................... 0.60 0.27 0.27 0.03 0.90 0.90 XXX 

99308 .... .......... A Nursing fac care, subseq ................................... 1.00 0.45 0.45 0.04 1.49 1.49 XXX 

99309 .... .......... A Nursing fac care, subseq ................................... 1.42 0.62 0.62 0.06 2.10 2.10 XXX 

99310 .... .......... A Nursing fac care, subseq ................................... 1.77 0.78 0.78 0.08 2.63 2.63 XXX 

99318 .... .......... A Annual nursing fac assessmnt ........................... 1.20 0.49 0.49 0.05 1.74 1.74 XXX 

99324 .... .......... A Domicil/r-home visit new pat .............................. 1.01 0.49 0.38 0.05 1.55 1.44 XXX 

99325 .... .......... A Domicil/r-home visit new pat .............................. 1.52 0.68 0.55 0.07 2.27 2.14 XXX 

99326 .... .......... A Domicil/r-home visit new pat .............................. 2.27 0.92 0.78 0.10 3.29 3.15 XXX 

99327 .... .......... A Domicil/r-home visit new pat .............................. 3.03 1.17 1.05 0.13 4.33 4.21 XXX 

99328 .... .......... A Domicil/r-home visit new pat .............................. 3.78 1.42 1.31 0.16 5.36 5.25 XXX 

99334 .... .......... A Domicil/r-home visit est pat ................................ 0.76 0.40 0.26 0.04 1.20 1.06 XXX 

99335 .... .......... A Domicil/r-home visit est pat ................................ 1.26 0.58 0.43 0.06 1.90 1.75 XXX 

99336 .... .......... A Domicil/r-home visit est pat ................................ 2.02 0.82 0.66 0.09 2.93 2.77 XXX 

99337 .... .......... A Domicil/r-home visit est pat ................................ 3.03 1.15 0.98 0.13 4.31 4.14 XXX 

99339 .... .......... B Domicil/r-home care supervis ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

99340 .... .......... I Domicil/r-home care supervis ............................. 0.00 0.00 0.00 0.00 0.00 0.00 XXX 

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. 2 Copyright 2005 American Dental Association. All rights reserved. 

3 +Indicates RVUs are not used for Medicare payment. 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM D.—2006 GEOGRAPHIC PRACTICE COST INDICES BY MEDICARE CARRIER AND LOCALITY

Carrier Locality Locality Name Work 

GPCI 

PE 

GPCI 

MP 

GPCI 

00510 ....... 00 ............. Alabama .............................................................................................................................. 1.000 0.846 0.752 

00831 ....... 01 ............. Alaska .................................................................................................................................. 1.017 1.103 1.029 

00832 ....... 00 ............. Arizona ................................................................................................................................ 1.000 0.992 1.069 

00520 ....... 13 ............. Arkansas .............................................................................................................................. 1.000 0.831 0.438 

31140 ....... 03 ............. Marin/Napa/Solano, CA ....................................................................................................... 1.035 1.340 0.651 

31140 ....... 05 ............. San Francisco, CA .............................................................................................................. 1.060 1.543 0.651 

31140 ....... 06 ............. San Mateo, CA .................................................................................................................... 1.073 1.536 0.639 

31140 ....... 07 ............. Oakland/Berkley, CA ........................................................................................................... 1.054 1.371 0.651 

31140 ....... 09 ............. Santa Clara, CA .................................................................................................................. 1.083 1.540 0.604 

31146 ....... 17 ............. Ventura, CA ......................................................................................................................... 1.028 1.179 0.744 

31146 ....... 18 ............. Los Angeles, CA ................................................................................................................. 1.041 1.156 0.954 

31146 ....... 26 ............. Anaheim/Santa Ana, CA ..................................................................................................... 1.034 1.236 0.954 

31140 ....... 99 ............. Rest of California* ............................................................................................................... 1.007 1.053 0.733 

31146 ....... 99 ............. Rest of California* ............................................................................................................... 1.007 1.053 0.733 

00824 ....... 01 ............. Colorado .............................................................................................................................. 1.000 1.014 0.803 

00591 ....... 00 ............. Connecticut .......................................................................................................................... 1.038 1.170 0.900 

00903 ....... 01 ............. DC + MD/VA Suburbs ......................................................................................................... 1.048 1.250 0.926 

00902 ....... 01 ............. Delaware ............................................................................................................................. 1.012 1.018 0.892 

00590 ....... 03 ............. Fort Lauderdale, FL ............................................................................................................. 1.000 0.988 1.703 

00590 ....... 04 ............. Miami, FL ............................................................................................................................. 1.000 1.046 2.269 

00590 ....... 99 ............. Rest of Florida ..................................................................................................................... 1.000 0.934 1.272 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70467 

ADDENDUM D.—2006 GEOGRAPHIC PRACTICE COST INDICES BY MEDICARE CARRIER AND LOCALITY—Continued 

Carrier Locality Locality Name Work 

GPCI 

PE 

GPCI 

MP 

GPCI 

00511 ....... 01 ............. Atlanta, GA .......................................................................................................................... 1.010 1.089 0.966 

00511 ....... 99 ............. Rest of Georgia ................................................................................................................... 1.000 0.872 0.966 

00833 ....... 01 ............. Hawaii/Guam ....................................................................................................................... 1.005 1.111 0.800 

05130 ....... 00 ............. Idaho .................................................................................................................................... 1.000 0.868 0.459 

00952 ....... 12 ............. East St. Louis, IL ................................................................................................................. 1.000 0.939 1.750 

00952 ....... 15 ............. Suburban Chicago, IL ......................................................................................................... 1.018 1.115 1.652 

00952 ....... 16 ............. Chicago, IL .......................................................................................................................... 1.025 1.126 1.867 

00952 ....... 99 ............. Rest of Illinois ...................................................................................................................... 1.000 0.872 1.193 

00630 ....... 00 ............. Indiana ................................................................................................................................. 1.000 0.906 0.436 

00826 ....... 00 ............. Iowa ..................................................................................................................................... 1.000 0.868 0.589 

00650 ....... 00 ............. Kansas* ............................................................................................................................... 1.000 0.878 0.721 

00660 ....... 00 ............. Kentucky .............................................................................................................................. 1.000 0.854 0.873 

00528 ....... 01 ............. New Orleans, LA ................................................................................................................. 1.000 0.946 1.197 

00528 ....... 99 ............. Rest of Louisiana ................................................................................................................ 1.000 0.847 1.058 

31142 ....... 03 ............. Southern Maine ................................................................................................................... 1.000 1.013 0.637 

31142 ....... 99 ............. Rest of Maine ...................................................................................................................... 1.000 0.886 0.637 

00901 ....... 01 ............. Baltimore/Surr. Cntys, MD .................................................................................................. 1.012 1.078 0.947 

00901 ....... 99 ............. Rest of Maryland ................................................................................................................. 1.000 0.980 0.760 

31143 ....... 01 ............. Metropolitan Boston ............................................................................................................ 1.030 1.329 0.823 

31143 ....... 99 ............. Rest of Massachusetts ........................................................................................................ 1.007 1.103 0.823 

00953 ....... 01 ............. Detroit, MI ............................................................................................................................ 1.037 1.054 2.744 

00953 ....... 99 ............. Rest of Michigan ................................................................................................................. 1.000 0.921 1.518 

00954 ....... 00 ............. Minnesota ............................................................................................................................ 1.000 1.005 0.410 

00512 ....... 00 ............. Mississippi ........................................................................................................................... 1.000 0.839 0.722 

00740 ....... 02 ............. Metropolitan Kansas City, MO ............................................................................................ 1.000 0.975 0.946 

00523 ....... 01 ............. Metropolitan St. Louis, MO ................................................................................................. 1.000 0.955 0.941 

00523 ....... 99 ............. Rest of Missouri* ................................................................................................................. 1.000 0.802 0.892 

00740 ....... 99 ............. Rest of Missouri* ................................................................................................................. 1.000 0.802 0.892 

00751 ....... 01 ............. Montana ............................................................................................................................... 1.000 0.844 0.904 

00655 ....... 00 ............. Nebraska ............................................................................................................................. 1.000 0.875 0.454 

00834 ....... 00 ............. Nevada ................................................................................................................................ 1.003 1.043 1.068 

31144 ....... 40 ............. New Hampshire ................................................................................................................... 1.000 1.027 0.942 

00805 ....... 01 ............. Northern NJ ......................................................................................................................... 1.058 1.220 0.973 

00805 ....... 99 ............. Rest of New Jersey ............................................................................................................. 1.043 1.119 0.973 

00521 ....... 05 ............. New Mexico ......................................................................................................................... 1.000 0.887 0.895 

00801 ....... 99 ............. Rest of New York ................................................................................................................ 1.000 0.917 0.677 

00803 ....... 01 ............. Manhattan, NY .................................................................................................................... 1.065 1.298 1.504 

00803 ....... 02 ............. NYC Suburbs/Long I., NY ................................................................................................... 1.052 1.280 1.785 

00803 ....... 03 ............. Poughkpsie/N NYC Suburbs, NY ........................................................................................ 1.014 1.074 1.167 

14330 ....... 04 ............. Queens, NY ......................................................................................................................... 1.032 1.228 1.710 

05535 ....... 00 ............. North Carolina ..................................................................................................................... 1.000 0.920 0.640 

00820 ....... 01 ............. North Dakota ....................................................................................................................... 1.000 0.860 0.602 

00883 ....... 00 ............. Ohio ..................................................................................................................................... 1.000 0.933 0.976 

00522 ....... 00 ............. Oklahoma ............................................................................................................................ 1.000 0.854 0.382 

00835 ....... 01 ............. Portland, OR ........................................................................................................................ 1.002 1.057 0.441 

00835 ....... 99 ............. Rest of Oregon .................................................................................................................... 1.000 0.925 0.441 

00865 ....... 01 ............. Metropolitan Philadelphia, PA ............................................................................................. 1.016 1.104 1.386 

00865 ....... 99 ............. Rest of Pennsylvania .......................................................................................................... 1.000 0.902 0.806 

00973 ....... 20 ............. Puerto Rico .......................................................................................................................... 1.000 0.698 0.261 

00524 ....... 01 ............. Rhode Island ....................................................................................................................... 1.045 0.989 0.909 

00880 ....... 01 ............. South Carolina ..................................................................................................................... 1.000 0.893 0.394 

00820 ....... 02 ............. South Dakota ....................................................................................................................... 1.000 0.876 0.365 

05440 ....... 35 ............. Tennessee ........................................................................................................................... 1.000 0.879 0.631 

00900 ....... 09 ............. Brazoria, TX ........................................................................................................................ 1.020 0.961 1.298 

00900 ....... 11 ............. Dallas, TX ............................................................................................................................ 1.009 1.062 1.061 

00900 ....... 15 ............. Galveston, TX ...................................................................................................................... 1.000 0.952 1.298 

00900 ....... 18 ............. Houston, TX ........................................................................................................................ 1.016 1.014 1.297 

00900 ....... 20 ............. Beaumont, TX ..................................................................................................................... 1.000 0.860 1.298 

00900 ....... 28 ............. Fort Worth, TX ..................................................................................................................... 1.000 0.989 1.061 

00900 ....... 31 ............. Austin, TX ............................................................................................................................ 1.000 1.046 0.986 

00900 ....... 99 ............. Rest of Texas ...................................................................................................................... 1.000 0.865 1.138 

00823 ....... 09 ............. Utah ..................................................................................................................................... 1.000 0.937 0.662 

31145 ....... 50 ............. Vermont ............................................................................................................................... 1.000 0.968 0.514 

00973 ....... 50 ............. Virgin Islands ....................................................................................................................... 1.000 1.014 1.003 

00904 ....... 00 ............. Virginia ................................................................................................................................. 1.000 0.940 0.579 

00836 ....... 02 ............. Seattle (King Cnty), WA ...................................................................................................... 1.014 1.131 0.819 

00836 ....... 99 ............. Rest of Washington ............................................................................................................. 1.000 0.978 0.819 

00884 ....... 16 ............. West Virginia ....................................................................................................................... 1.000 0.819 1.547 

00951 ....... 00 ............. Wisconsin ............................................................................................................................ 1.000 0.918 0.790 

00825 ....... 21 ............. Wyoming .............................................................................................................................. 1.000 0.853 0.935 

For 2005 & 2006, if the work GPCI falls below a 1.0 index, the work GPCI equals 1.0. 

70468 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

* States are served by more than one carrier. 

ADDENDUM E.—2006 GAFS

Carrier Locality Locality name 2006 

GAF 

31140 ....... 09 ............. Santa Clara, CA ................................................................................................................................................... 1.265 

31140 ....... 06 ............. San Mateo, CA .................................................................................................................................................... 1.259 

31140 ....... 05 ............. San Francisco, CA ............................................................................................................................................... 1.256 

00803 ....... 01 ............. Manhattan, NY ..................................................................................................................................................... 1.184 

00803 ....... 02 ............. NYC Suburbs/Long I., NY ................................................................................................................................... 1.180 

31140 ....... 07 ............. Oakland/Berkley, CA ........................................................................................................................................... 1.177 

31140 ....... 03 ............. Marin/Napa/Solano, CA ....................................................................................................................................... 1.154 

31143 ....... 01 ............. Metropolitan Boston ............................................................................................................................................. 1.153 

14330 ....... 04 ............. Queens, NY ......................................................................................................................................................... 1.144 

00903 ....... 01 ............. DC + MD/VA Suburbs ......................................................................................................................................... 1.132 

00805 ....... 01 ............. Northern NJ ......................................................................................................................................................... 1.126 

31146 ....... 26 ............. Anaheim/Santa Ana, CA ...................................................................................................................................... 1.119 

00953 ....... 01 ............. Detroit, MI ............................................................................................................................................................ 1.111 

00952 ....... 16 ............. Chicago, IL ........................................................................................................................................................... 1.102 

00591 ....... 00 ............. Connecticut .......................................................................................................................................................... 1.091 

31146 ....... 18 ............. Los Angeles, CA .................................................................................................................................................. 1.088 

00952 ....... 15 ............. Suburban Chicago, IL .......................................................................................................................................... 1.085 

31146 ....... 17 ............. Ventura, CA ......................................................................................................................................................... 1.083 

00805 ....... 99 ............. Rest of New Jersey ............................................................................................................................................. 1.074 

00865 ....... 01 ............. Metropolitan Philadelphia, PA ............................................................................................................................. 1.069 

00590 ....... 04 ............. Miami, FL ............................................................................................................................................................. 1.069 

00836 ....... 02 ............. Seattle (King Cnty), WA ...................................................................................................................................... 1.058 

00831 ....... 01 ............. Alaska .................................................................................................................................................................. 1.055 

00803 ....... 03 ............. Poughkpsie/N NYC Suburbs, NY ........................................................................................................................ 1.046 

00833 ....... 01 ............. Hawaii/Guam ....................................................................................................................................................... 1.044 

00511 ....... 01 ............. Atlanta, GA .......................................................................................................................................................... 1.043 

31143 ....... 99 ............. Rest of Massachusetts ........................................................................................................................................ 1.042 

00901 ....... 01 ............. Baltimore/Surr. Cntys, MD ................................................................................................................................... 1.039 

00900 ....... 11 ............. Dallas, TX ............................................................................................................................................................ 1.034 

00900 ....... 18 ............. Houston, TX ......................................................................................................................................................... 1.026 

00834 ....... 00 ............. Nevada ................................................................................................................................................................. 1.023 

00590 ....... 03 ............. Fort Lauderdale, FL ............................................................................................................................................. 1.022 

00900 ....... 31 ............. Austin, TX ............................................................................................................................................................ 1.020 

31146 ....... 99 ............. Rest of California* ................................................................................................................................................ 1.017 

31140 ....... 99 ............. Rest of California* ................................................................................................................................................ 1.017 

31144 ....... 40 ............. New Hampshire ................................................................................................................................................... 1.010 

00902 ....... 01 ............. Delaware .............................................................................................................................................................. 1.010 

00973 ....... 50 ............. Virgin Islands ....................................................................................................................................................... 1.007 

00900 ....... 09 ............. Brazoria, TX ......................................................................................................................................................... 1.005 

00835 ....... 01 ............. Portland, OR ........................................................................................................................................................ 1.005 

00952 ....... 12 ............. East St. Louis, IL ................................................................................................................................................. 1.003 

00832 ....... 00 ............. Arizona ................................................................................................................................................................. 0.999 

00824 ....... 01 ............. Colorado .............................................................................................................................................................. 0.999 

00900 ....... 28 ............. Fort Worth, TX ..................................................................................................................................................... 0.998 

31142 ....... 03 ............. Southern Maine ................................................................................................................................................... 0.992 

00900 ....... 15 ............. Galveston, TX ...................................................................................................................................................... 0.991 

00740 ....... 02 ............. Metropolitan Kansas City, MO ............................................................................................................................. 0.987 

00953 ....... 99 ............. Rest of Michigan .................................................................................................................................................. 0.986 

00836 ....... 99 ............. Rest of Washington ............................................................................................................................................. 0.984 

00528 ....... 01 ............. New Orleans, LA ................................................................................................................................................. 0.984 

00901 ....... 99 ............. Rest of Maryland ................................................................................................................................................. 0.982 

00590 ....... 99 ............. Rest of Florida ..................................................................................................................................................... 0.982 

00954 ....... 00 ............. Minnesota ............................................................................................................................................................ 0.980 

00523 ....... 01 ............. Metropolitan St. Louis, MO .................................................................................................................................. 0.978 

00883 ....... 00 ............. Ohio ..................................................................................................................................................................... 0.970 

31145 ....... 50 ............. Vermont ............................................................................................................................................................... 0.968 

00823 ....... 09 ............. Utah ..................................................................................................................................................................... 0.960 

00904 ....... 00 ............. Virginia ................................................................................................................................................................. 0.958 

00951 ....... 00 ............. Wisconsin ............................................................................................................................................................. 0.956 

00952 ....... 99 ............. Rest of Illinois ...................................................................................................................................................... 0.952 

00801 ....... 99 ............. Rest of New York ................................................................................................................................................ 0.952 

05535 ....... 00 ............. North Carolina ...................................................................................................................................................... 0.951 

00900 ....... 20 ............. Beaumont, TX ...................................................................................................................................................... 0.951 

00865 ....... 99 ............. Rest of Pennsylvania ........................................................................................................................................... 0.950 

00900 ....... 99 ............. Rest of Texas ...................................................................................................................................................... 0.947 

00521 ....... 05 ............. New Mexico ......................................................................................................................................................... 0.947 

00835 ....... 99 ............. Rest of Oregon .................................................................................................................................................... 0.946 

00511 ....... 99 ............. Rest of Georgia ................................................................................................................................................... 0.943 

00740 ....... 99 ............. Rest of Missouri* ................................................................................................................................................. 0.910 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70469 

ADDENDUM E.—2006 GAFS—Continued 

Carrier Locality Locality name 2006 

GAF 

00884 ....... 16 ............. West Virginia ........................................................................................................................................................ 0.942 

00630 ....... 00 ............. Indiana ................................................................................................................................................................. 0.937 

31142 ....... 99 ............. Rest of Maine ...................................................................................................................................................... 0.936 

00650 ....... 00 ............. Kansas* ................................................................................................................................................................ 0.936 

00528 ....... 99 ............. Rest of Louisiana ................................................................................................................................................. 0.936 

00825 ....... 21 ............. Wyoming .............................................................................................................................................................. 0.934 

05440 ....... 35 ............. Tennessee ........................................................................................................................................................... 0.933 

00660 ....... 00 ............. Kentucky .............................................................................................................................................................. 0.932 

00880 ....... 01 ............. South Carolina ..................................................................................................................................................... 0.930 

00870 ....... 01 ............. Rhode Island ........................................................................................................................................................ 0.930 

00751 ....... 01 ............. Montana ............................................................................................................................................................... 0.928 

00826 ....... 00 ............. Iowa ..................................................................................................................................................................... 0.927 

00655 ....... 00 ............. Nebraska .............................................................................................................................................................. 0.925 

00820 ....... 01 ............. North Dakota ........................................................................................................................................................ 0.924 

00510 ....... 00 ............. Alabama ............................................................................................................................................................... 0.923 

05130 ....... 00 ............. Idaho .................................................................................................................................................................... 0.922 

00820 ....... 02 ............. South Dakota ....................................................................................................................................................... 0.922 

00512 ....... 00 ............. Mississippi ............................................................................................................................................................ 0.919 

00522 ....... 00 ............. Oklahoma ............................................................................................................................................................. 0.913 

00740 ....... 99 ............. Rest of Missouri* ................................................................................................................................................. 0.910 

00523 ....... 99 ............. Rest of Missouri* ................................................................................................................................................. 0.910 

00520 ....... 13 ............. Arkansas .............................................................................................................................................................. 0.905 

00973 ....... 20 ............. Puerto Rico .......................................................................................................................................................... 0.840 

* States are served by more than one carrier. 

ADDENDUM F.—REVISED SINGLE DRUG CATEGORY LIST

HCPCS Long description Recalculated 

weights 

J0150 ....... INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG ................................................................................. 0.00069828 

J0152 ....... INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG .................................................................................. 0.00458348 

J0170 ....... INJECTION, ADRENALIN, EPINEPHRINE, 1 ML AMPULE .................................................................................... 0.00007878 

J0207 ....... INJECTION, AMIFOSTINE, 500 MG ........................................................................................................................ 0.00016059 

J0215 ....... INJECTION, ALEFACEPT, 0.5 MG .......................................................................................................................... 0.00083178 

J0280 ....... INJECTION, AMINOPHYLLIN, 250 MG ................................................................................................................... 0.00081886 

J0290 ....... INJECTION, AMPICILLIN SODIUM, 500 MG .......................................................................................................... 0.00012626 

J0475 ....... INJECTION, BACLOFEN, 10 MG ............................................................................................................................. 0.00024582 

J0540 ....... INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 1,200,000 UNITS .......................... 0.00007191 

J0550 ....... INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 2,400,000 UNITS .......................... 0.00001826 

J0570 ....... INJECTION, PENICILLIN G BENZATHINE, 1,200,000 UNITS ............................................................................... 0.00004593 

J0585 ....... BOTULINUM TOXIN TYPE A, PER UNIT ................................................................................................................ 0.03734001 

J0587 ....... BOTULINUM TOXIN TYPE B, PER 100 UNITS ...................................................................................................... 0.00150333 

J0600 ....... INJECTION, EDETATE CALCIUM DISODIUM, 1000 MG ....................................................................................... 0.00004448 

J0637 ....... INJECTION, CASPOFUNGIN ACETATE, 5 MG ...................................................................................................... 0.00008462 

J0640 ....... INJECTION, LEUCOVORIN CALCIUM, PER 50 MG .............................................................................................. 0.01061886 

J0670 ....... INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML ............................................................................... 0.00038303 

J0690 ....... INJECTION, CEFAZOLIN SODIUM, 500 MG .......................................................................................................... 0.00042306 

J0692 ....... INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG ........................................................................................... 0.00024785 

J0696 ....... INJECTION, CEFTRIAXONE SODIUM, PER 250 MG ............................................................................................ 0.00667188 

J0698 ....... INJECTION, CEFOTAXIME SODIUM, PER GM ...................................................................................................... 0.00014842 

J0702 ....... INJECTION, BETAMETHASONE ACETATE & BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG ........... 0.00287002 

J0704 ....... INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG .................................................................. 0.00056918 

J0735 ....... INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG .............................................................................................. 0.00034065 

J0800 ....... INJECTION, CORTICOTROPIN, 40 UNITS ............................................................................................................. 0.00363050 

J0895 ....... INJECTION, DEFEROXAMINE MESYLATE, 500 MG ............................................................................................. 0.00024388 

J1000 ....... INJECTION, DEPO-ESTRADIOL CYPIONATE, 5 MG ............................................................................................ 0.00020962 

J1020 ....... INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG ................................................................................... 0.00127016 

J1030 ....... INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG ................................................................................... 0.00591680 

J1040 ....... INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG ................................................................................... 0.00526505 

J1051 ....... INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG .............................................................................. 0.00006510 

J1094 ....... INJECTION, DEXAMETHASONE ACETATE, 1 MG ................................................................................................ 0.00350405 

J1100 ....... INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG ............................................................................ 0.05478551 

J1190 ....... INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG ......................................................................... 0.00002438 

J1200 ....... INJECTION, DIPHENHYDRAMINE HCL, 50 MG .................................................................................................... 0.00215958 

J1212 ....... INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML ................................................................................... 0.00008455 

J1245 ....... INJECTION, DIPYRIDAMOLE, PER 10 MG ............................................................................................................ 0.00382235 

J1250 ....... INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG ............................................................................. 0.00053051 

J1260 ....... INJECTION, DOLASETRON MESYLATE, 10 MG ................................................................................................... 0.01732829 

J1335 ....... INJECTION, ERTAPENEM SODIUM, 500 MG ........................................................................................................ 0.00013230 

70470 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM F.—REVISED SINGLE DRUG CATEGORY LIST—Continued 

HCPCS Long description Recalculated 

weights 

J1440 ....... INJECTION, FILGRASTIM (G-CSF), 300 MCG ....................................................................................................... 0.00193096 

J1441 ....... INJECTION, FILGRASTIM (G-CSF), 480 MCG ....................................................................................................... 0.00406386 

J1450 ....... INJECTION FLUCONAZOLE, 200 MG .................................................................................................................... 0.00001605 

J1580 ....... INJECTION, GARAMYCIN, GENTAMICIN, 80 MG ................................................................................................. 0.00039839 

J1600 ....... INJECTION, GOLD SODIUM THIOMALATE, 50 MG .............................................................................................. 0.00005600 

J1626 ....... INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG ................................................................................ 0.01480082 

J1631 ....... INJECTION, HALOPERIDOL DECANOATE, PER 50 MG ...................................................................................... 0.00020651 

J1642 ....... INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS ...................................................... 0.06406943 

J1644 ....... INJECTION, HEPARIN SODIUM, PER 1000 UNITS ............................................................................................... 0.00353690 

J1645 ....... INJECTION, DALTEPARIN SODIUM, PER 2500 IU ............................................................................................... 0.00011497 

J1650 ....... INJECTION, ENOXAPARIN SODIUM, 10 MG ......................................................................................................... 0.00135285 

J1655 ....... INJECTION, TINZAPARIN SODIUM, 1000 IU ......................................................................................................... 0.00047054 

J1720 ....... INJECTION, HYDROCORTISONE SODIUM SUCCINATE, 100 MG ...................................................................... 0.00013295 

J1745 ....... INJECTION INFLIXIMAB, 10 MG ............................................................................................................................. 0.02755927 

J1750 ....... INJECTION, IRON DEXTRAN, 50 MG ..................................................................................................................... 0.00245914 

J1756 ....... INJECTION, IRON SUCROSE, 1 MG ...................................................................................................................... 0.01024469 

J1885 ....... INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG ................................................................................... 0.00329270 

J1940 ....... INJECTION, FUROSEMIDE, 20 MG ........................................................................................................................ 0.00065208 

J1956 ....... INJECTION, LEVOFLOXACIN, 250 MG .................................................................................................................. 0.00008608 

J2001 ....... INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG .............................................................. 0.00077337 

J2010 ....... INJECTION, LINCOMYCIN HCL, 300 MG ............................................................................................................... 0.00062307 

J2150 ....... INJECTION, MANNITOL, 25% IN 50 ML ................................................................................................................. 0.00029139 

J2260 ....... INJECTION, MILRINONE LACTATE, 5 MG ............................................................................................................. 0.00004947 

J2300 ....... INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG ................................................................................ 0.00026276 

J2325 ....... INJECTION, NESIRITIDE, 0.1 MG ........................................................................................................................... 0.00027338 

J2353 ....... INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG ................................... 0.00194628 

J2354 ....... INJECTION, OCTREOTIDE, NON-DEPOT SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG ......... 0.00008391 

J2405 ....... INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG ............................................................................. 0.01369661 

J2430 ....... INJECTION, PAMIDRONATE DISODIUM, PER 30 MG .......................................................................................... 0.00156404 

J2505 ....... INJECTION, PEGFILGRASTIM, 6 MG ..................................................................................................................... 0.00064954 

J2550 ....... INJECTION, PROMETHAZINE HCL, 50 MG ........................................................................................................... 0.00068512 

J2680 ....... INJECTION, FLUPHENAZINE DECANOATE, 25 MG ............................................................................................. 0.00015076 

J2765 ....... INJECTION, METOCLOPRAMIDE HCL, 10 MG ..................................................................................................... 0.00011107 

J2780 ....... INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG ........................................................................................... 0.00088333 

J2820 ....... INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG .............................................................................................. 0.00217374 

J2912 ....... INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML .............................................................................................. 0.00678337 

J2916 ....... INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG .......................... 0.00060984 

J2920 ....... INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, 40 MG ............................................................... 0.00031153 

J2930 ....... INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, 125 MG ............................................................. 0.00077009 

J2997 ....... INJECTION, ALTEPLASE RECOMBINANT, 1 MG .................................................................................................. 0.00012209 

J3260 ....... INJECTION, TOBRAMYCIN SULFATE, 80 MG ....................................................................................................... 0.00018247 

J3301 ....... INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG .................................................................................... 0.02161210 

J3302 ....... INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG ....................................................................................... 0.00172788 

J3303 ....... INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG ............................................................................... 0.00094370 

J3315 ....... INJECTION, TRIPTORELIN PAMOATE, 3.75 MG .................................................................................................. 0.00000712 

J3370 ....... INJECTION, VANCOMYCIN HCL, 500 MG ............................................................................................................. 0.00083980 

J3396 ....... INJECTION, VERTEPORFIN, 0.1 MG ..................................................................................................................... 0.05425250 

J3410 ....... INJECTION, HYDROXYZINE HCL, 25 MG .............................................................................................................. 0.00040904 

J3420 ....... INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG .................................................................. 0.01200091 

J3475 ....... INJECTION, MAGNESIUM SULFATE, PER 500 MG .............................................................................................. 0.00108238 

J3480 ....... INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ .............................................................................................. 0.00215178 

J3487 ....... INJECTION, ZOLEDRONIC ACID, 1 MG ................................................................................................................. 0.00335651 

J7030 ....... INFUSION, NORMAL SALINE SOLUTION , 1000 CC ............................................................................................ 0.00102582 

J7040 ....... INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) ............................................................... 0.00242568 

J7042 ....... 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) .......................................................................................... 0.00049750 

J7050 ....... INFUSION, NORMAL SALINE SOLUTION , 250 CC .............................................................................................. 0.00990901 

J7060 ....... 5% DEXTROSE/WATER (500 ML = 1 UNIT) .......................................................................................................... 0.00102607 

J7070 ....... INFUSION, D5W, 1000 CC ...................................................................................................................................... 0.00015855 

J7120 ....... RINGERS LACTATE INFUSION, 1000 CC .............................................................................................................. 0.00016938 

J7318 ....... HYALURONAN (SODIUM HYALURONATE) OR DERIVATIVE, INTRA-ARTICULAR INJECTION, 1 MG ............ 0.00340613 

J9000 ....... DOXORUBICIN HCL, 10 MG ................................................................................................................................... 0.00235266 

J9001 ....... DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG .......................................................... 0.00032456 

J9031 ....... BCG (INTRAVESICAL) PER INSTILLATION ........................................................................................................... 0.00049146 

J9040 ....... BLEOMYCIN SULFATE, 15 UNITS .......................................................................................................................... 0.00003718 

J9045 ....... CARBOPLATIN, 50 MG ............................................................................................................................................ 0.00568694 

J9050 ....... CARMUSTINE, 100 MG ........................................................................................................................................... 0.00000887 

J9060 ....... CISPLATIN, POWDER OR S0LUTION, PER 10 MG .............................................................................................. 0.00095159 

J9062 ....... CISPLATIN, 50 MG ................................................................................................................................................... 0.00025368 

J9065 ....... INJECTION, CLADRIBINE, PER 1 MG .................................................................................................................... 0.00008122 

J9070 ....... CYCLOPHOSPHAMIDE, 100 MG ............................................................................................................................ 0.00062537 

J9080 ....... CYCLOPHOSPHAMIDE, 200 MG ............................................................................................................................ 0.00004956 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70471 

ADDENDUM F.—REVISED SINGLE DRUG CATEGORY LIST—Continued 

HCPCS Long description Recalculated 

weights 

J9090 ....... CYCLOPHOSPHAMIDE, 500 MG ............................................................................................................................ 0.00008105 

J9091 ....... CYCLOPHOSPHAMIDE, 1.0 GRAM ........................................................................................................................ 0.00005036 

J9092 ....... CYCLOPHOSPHAMIDE, 2.0 GRAM ........................................................................................................................ 0.00000528 

J9093 ....... CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG ................................................................................................... 0.00092452 

J9094 ....... CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG ................................................................................................... 0.00009167 

J9095 ....... CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG ................................................................................................... 0.00017653 

J9096 ....... CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM ............................................................................................... 0.00013943 

J9097 ....... CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAM ............................................................................................... 0.00001356 

J9098 ....... CYTARABINE LIPOSOME, 10 MG .......................................................................................................................... 0.00000815 

J9100 ....... CYTARABINE, 100 MG ............................................................................................................................................ 0.00012978 

J9110 ....... CYTARABINE, 500 MG ............................................................................................................................................ 0.00002071 

J9130 ....... DACARBAZINE, 100 MG .......................................................................................................................................... 0.00009406 

J9140 ....... DACARBAZINE, 200 MG .......................................................................................................................................... 0.00007007 

J9150 ....... DAUNORUBICIN, 10 MG ......................................................................................................................................... 0.00000488 

J9170 ....... DOCETAXEL, 20 MG ............................................................................................................................................... 0.00256588 

J9178 ....... INJECTION, EPIRUBICIN HCL, 2 MG ..................................................................................................................... 0.00121617 

J9181 ....... ETOPOSIDE, 10 MG ................................................................................................................................................ 0.00230896 

J9182 ....... ETOPOSIDE, 100 MG .............................................................................................................................................. 0.00052981 

J9185 ....... FLUDARABINE PHOSPHATE, 50 MG ..................................................................................................................... 0.00030572 

J9190 ....... FLUOROURACIL, 500 MG ....................................................................................................................................... 0.00395219 

J9200 ....... FLOXURIDINE, 500 MG ........................................................................................................................................... 0.00000408 

J9201 ....... GEMCITABINE HCL, 200 MG .................................................................................................................................. 0.00494962 

J9202 ....... GOSERELIN ACETATE IMPLANT, PER 3.6 MG .................................................................................................... 0.00287887 

J9206 ....... IRINOTECAN, 20 MG ............................................................................................................................................... 0.00318310 

J9208 ....... IFOSFAMIDE, 1 GM ................................................................................................................................................. 0.00007873 

J9209 ....... MESNA, 200 MG ...................................................................................................................................................... 0.00036778 

J9211 ....... IDARUBICIN HYDROCHLORIDE, 5 MG .................................................................................................................. 0.00000318 

J9213 ....... INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS .............................................................................. 0.00008062 

J9214 ....... INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS .............................................................................. 0.00673538 

J9219 ....... LEUPROLIDE ACETATE IMPLANT, 65 MG ............................................................................................................ 0.00006510 

J9245 ....... INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG ......................................................................................... 0.00000158 

J9250 ....... METHOTREXATE SODIUM, 5 MG .......................................................................................................................... 0.00186241 

J9260 ....... METHOTREXATE SODIUM, 50 MG ........................................................................................................................ 0.00051323 

J9263 ....... INJECTION, OXALIPLATIN, 0.5 MG ........................................................................................................................ 0.07300568 

J9265 ....... PACLITAXEL, 30 MG ............................................................................................................................................... 0.00555323 

J9268 ....... PENTOSTATIN, PER 10 MG ................................................................................................................................... 0.00000643 

J9280 ....... MITOMYCIN, 5 MG ................................................................................................................................................... 0.00004067 

J9290 ....... MITOMYCIN, 20 MG ................................................................................................................................................. 0.00003473 

J9291 ....... MITOMYCIN, 40 MG ................................................................................................................................................. 0.00006128 

J9293 ....... INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG ............................................................................ 0.00025058 

J9310 ....... RITUXIMAB, 100 MG ................................................................................................................................................ 0.00408558 

J9320 ....... STREPTOZOCIN, 1 GM ........................................................................................................................................... 0.00000671 

J9340 ....... THIOTEPA, 15 MG ................................................................................................................................................... 0.00002446 

J9350 ....... TOPOTECAN, 4 MG ................................................................................................................................................. 0.00018223 

J9355 ....... TRASTUZUMAB, 10 MG .......................................................................................................................................... 0.00542012 

J9360 ....... VINBLASTINE SULFATE, 1 MG .............................................................................................................................. 0.00035725 

J9370 ....... VINCRISTINE SULFATE, 1 MG ............................................................................................................................... 0.00019702 

J9375 ....... VINCRISTINE SULFATE, 2 MG ............................................................................................................................... 0.00011487 

J9390 ....... VINORELBINE TARTRATE, PER 10 MG ................................................................................................................ 0.00110762 

J9395 ....... INJECTION, FULVESTRANT, 25 MG ...................................................................................................................... 0.00126358 

J9600 ....... PORFIMER SODIUM, 75 MG ................................................................................................................................... 0.00000030 

J0885 ....... INJECTION, EPOETIN ALPHA, (FOR NON ESRD USE), PER 1000 UNITS ........................................................ 0.25074794 

J0881 ....... INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE) ............................................................................ 0.15914222 

Q3025 ...... INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE .................................................... 0.00078070 

ADDENDUM G.—REVISED NEW DRUGS

FOR CAP BIDDING FOR 2006 

[Effective January 1, 2006] 

HCPCS Long description 

J0128 ..... Abarelix injection. 

J0180 ..... Agalsidase beta injection. 

J0278 ..... Amikacin. 

J0878 ..... Daptomycin injection. 

J1751 ..... Iron Dextran 165. 

J1752 ..... Iron Dextran 267. 

J1931 ..... Laronidase injection. 

J2357 ..... Omalizumab injection. 

ADDENDUM G.—REVISED NEW DRUGS

FOR CAP BIDDING FOR 2006—Continued 

[Effective January 1, 2006] 

HCPCS Long description 

J2469 ..... Palonosetron HCl. 

J2503 ..... Pegaptanib. 

J2794 ..... Risperidone, long acting. 

J9035 ..... Bevacizumab injection. 

J9041 ..... Bortezomib injection. 

J9055 ..... Cetuximab injection. 

J9225 ..... Histrelin implant. 

ADDENDUM G.—REVISED NEW DRUGS

FOR CAP BIDDING FOR 2006—Continued 

[Effective January 1, 2006] 

HCPCS Long description 

J9264 ..... Paclitaxel protein bound particles. 

J9305 ..... Pemetrexed injection. 

70472 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

CLINICAL LABORATORY SERVICES 

Include CPT codes for all clinical laboratory services in the 80000 series, except EXCLUDE CPT 

codes for the following blood component collection 

services: 

86890 ................... Autologous blood process 

86891 ................... Autologous blood, op salvage 

86927 ................... Plasma, fresh frozen 

86930 ................... Frozen blood prep 

86931 ................... Frozen blood thaw 

86932 ................... Frozen blood freeze/thaw 

86945 ................... Blood product/irradiation 

86950 ................... Leukacyte transfusion 

86965 ................... Pooling blood platelets 

86985 ................... Split blood or products 

Include the following CPT and HCPCS level 2 

codes for other clinical laboratory services: 

0026T ................... Measure remnant lipoproteins 

0030T ................... Antiprothrombin antibody 

0041T ................... Detect ur infect agnt w/cpas 

0043T ................... Co expired gas analysis 

0058T ................... Cryopreservation, ovary tiss 

0059T ................... Cryopreservation, oocyte 

0064T ................... Spectroscop eval expired gas 

0085T ................... Breath test heart reject 

0087T ................... Sperm eval hyaluronan 

0103T ................... Holotranscobalamin 

0104T ................... At rest cardio gas rebreathe 

0111T ................... RBC membranes fatty acids 

0140T ................... Exhaled breath condensate ph 

36415 ................... Routine venipuncture 

78267 ................... Breath test attain/anal c-14 

78268 ................... Breath test analysis c-14 

G0027 .................. Semen analysis 

G0103 .................. Psa, total screening 

G0107 .................. CA screen; fecal blood test 

G0123 .................. Screen cerv/vag thin layer 

G0124 .................. Screen c/v thin layer by MD 

G0141 .................. Scr c/v cyto,autosys and md 

G0143 .................. Scr c/v cyto,thinlayer,rescr 

G0144 .................. Scr c/v cyto,thinlayer,rescr 

G0145 .................. Scr c/v cyto,thinlayer,rescr 

G0147 .................. Scr c/v cyto, automated sys 

G0148 .................. Scr c/v cyto, autosys, rescr 

G0306 .................. CBC/diffwbc w/o platelet 

G0307 .................. CBC without platelet 

G0328 .................. Fecal blood scrn immunoassay 

P2028 ................... Cephalin floculation test 

P2029 ................... Congo red blood test 

P2033 ................... Blood thymol turbidity 

P2038 ................... Blood mucoprotein 

P3000 ................... Screen pap by tech w md supv 

P3001 ................... Screening pap smear by phys 

P9612 ................... Catheterize for urine spec 

P9615 ................... Urine specimen collect mult 

Q0111 .................. Wet mounts/ w preparations 

Q0112 .................. Potassium hydroxide preps 

Q0113 .................. Pinworm examinations 

Q0114 .................. Fern test 

Q0115 .................. Post-coital mucous exam 

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH-LANGUAGE PATHOLOGY 

Include the following CPT and HCPCS codes for 

the physical therapy/occupational therapy/speechlanguage pathology services: 

0019T ................... Extracorp shock wv tx,ms nos 

0029T ................... Magnetic tx for incontinence 

64550 ................... Apply neurostimulator 

90901 ................... Biofeedback train, any meth 

90911 ................... Biofeedback peri/uro/rectal 

92506 ................... Speech/hearing evaluation 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

92507 ................... Speech/hearing therapy 

92508 ................... Speech/hearing therapy 

92526 ................... Oral function therapy 

92597 ................... Oral speech device eval 

92607 ................... Ex for speech device rx, 1hr 

92608 ................... Ex for speech device rx addl 

92609 ................... Use of speech device service 

92610 ................... Evaluate swallowing function 

92611 ................... Motion fluoroscopy/swallow 

92612 ................... Endoscopy swallow tst (fees) 

92614 ................... Laryngoscopic sensory test 

92616 ................... Fees w/laryngeal sense test 

93797 ................... Cardiac rehab 

93798 ................... Cardiac rehab/monitor 

94667 ................... Chest wall manipulation 

94668 ................... Chest wall manipulation 

95831 ................... Limb muscle testing, manual 

95832 ................... Hand muscle testing, manual 

95833 ................... Body muscle testing, manual 

95834 ................... Body muscle testing, manual 

95851 ................... Range of motion measurements 

95852 ................... Range of motion measurements 

96000 ................... Motion analysis, video/3d 

96001 ................... Motion test w/ft press meas 

96002 ................... Dynamic surface emg 

96003 ................... Dynamic fine wire emg 

96105 ................... Assessment of aphasia 

96110 ................... Developmental test, lim 

96111 ................... Developmental test, extend 

97001 ................... Pt evaluation 

97002 ................... Pt re-evaluation 

97003 ................... Ot evaluation 

97004 ................... Ot re-evaluation 

97010 ................... Hot or cold packs therapy 

97012 ................... Mechanical traction therapy 

97016 ................... Vasopneumatic device therapy 

97018 ................... Paraffin bath therapy 

97022 ................... Whirlpool therapy 

97024 ................... Diathermy eg, microwave 

97026 ................... Infrared therapy 

97028 ................... Ultraviolet therapy 

97032 ................... Electrical stimulation 

97033 ................... Electric current therapy 

97034 ................... Contrast bath therapy 

97035 ................... Ultrasound therapy 

97036 ................... Hydrotherapy 

97039 ................... Physical therapy treatment 

97110 ................... Therapeutic exercises 

97112 ................... Neuromuscular reeducation 

97113 ................... Aquatic therapy/exercises 

97116 ................... Gait training therapy 

97124 ................... Massage therapy 

97139 ................... Physical medicine procedure 

97140 ................... Manual therapy 

97150 ................... Group therapeutic procedures 

97530 ................... Therapeutic activities 

97532 ................... Cognitive skills development 

97533 ................... Sensory integration 

97535 ................... Self care mngment training 

97537 ................... Community/work reintegration 

97542 ................... Wheelchair mngment training 

97545 ................... Work hardening 

97546 ................... Work hardening add-on 

97597 ................... Active wound care/20cm or < 

97598 ................... Active wound care > 20cm 

97602 ................... Wound(s) care nonselective 

97605 ................... Neg press wound tx, < 50 cm 

97606 ................... Neg press wound tx, > 50 cm 

97750 ................... Physical performance test 

97755 ................... Assistive technology assess 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

97760 ................... Orthotic mgmt and training 

97761 ................... Prosthetic training 

97762 ................... C/O for orthotic/prosth use 

97799 ................... Physical medicine procedure 

G0281 .................. Elec stim unattend for press 

G0283 .................. Elec stim other than wound 

G0329 .................. Electromagntic tx for ulcers 

RADIOLOGY AND CERTAIN OTHER IMAGING 

SERVICES 

Include the following CPT and HCPCS codes: 

0028T ................... Dexa body composition study 

0042T ................... Ct perfusion w/contrast, cbf 

0067T ................... Ct colonography;dx 

51798 ................... Us urine capacity measure 

70100 ................... X-ray exam of jaw 

70110 ................... X-ray exam of jaw 

70120 ................... X-ray exam of mastoids 

70130 ................... X-ray exam of mastoids 

70134 ................... X-ray exam of middle ear 

70140 ................... X-ray exam of facial bones 

70150 ................... X-ray exam of facial bones 

70160 ................... X-ray exam of nasal bones 

70190 ................... X-ray exam of eye sockets 

70200 ................... X-ray exam of eye sockets 

70210 ................... X-ray exam of sinuses 

70220 ................... X-ray exam of sinuses 

70240 ................... X-ray exam, pituitary saddle 

70250 ................... X-ray exam of skull 

70260 ................... X-ray exam of skull 

70300 ................... X-ray exam of teeth 

70310 ................... X-ray exam of teeth 

70320 ................... Full mouth x-ray of teeth 

70328 ................... X-ray exam of jaw joint 

70330 ................... X-ray exam of jaw joints 

70336 ................... Magnetic image, jaw joint 

70350 ................... X-ray head for orthodontia 

70355 ................... Panoramic x-ray of jaws 

70360 ................... X-ray exam of neck 

70370 ................... Throat x-ray & fluoroscopy 

70371 ................... Speech evaluation, complex 

70380 ................... X-ray exam of salivary gland 

70450 ................... Ct head/brain w/o dye 

70460 ................... Ct head/brain w/dye 

70470 ................... Ct head/brain w/o & w/dye 

70480 ................... Ct orbit/ear/fossa w/o dye 

70481 ................... Ct orbit/ear/fossa w/dye 

70482 ................... Ct orbit/ear/fossa w/o&w/dye 

70486 ................... Ct maxillofacial w/o dye 

70487 ................... Ct maxillofacial w/dye 

70488 ................... Ct maxillofacial w/o & w/dye 

70490 ................... Ct soft tissue neck w/o dye 

70491 ................... Ct soft tissue neck w/dye 

70492 ................... Ct sft tsue nck w/o & w/dye 

70496 ................... Ct angiography, head 

70498 ................... Ct angiography, neck 

70540 ................... Mri orbit/face/neck w/o dye 

70542 ................... Mri orbit/face/neck w/dye 

70543 ................... Mri orbt/fac/nck w/o & w/dye 

70544 ................... Mr angiography head w/o dye 

70545 ................... Mr angiography head w/dye 

70546 ................... Mr angiograph head w/o&w/dye 

70547 ................... Mr angiography neck w/o dye 

70548 ................... Mr angiography neck w/dye 

70549 ................... Mr angiograph neck w/o&w/dye 

70551 ................... Mri brain w/o dye 

70552 ................... Mri brain w/dye 

70553 ................... Mri brain w/o & w/dye 

71010 ................... Chest x-ray 

71015 ................... Chest x-ray 

71020 ................... Chest x-ray 

71021 ................... Chest x-ray 

71022 ................... Chest x-ray 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70473 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

71023 ................... Chest x-ray and fluoroscopy 

71030 ................... Chest x-ray 

71034 ................... Chest x-ray and fluoroscopy 

71035 ................... Chest x-ray 

71100 ................... X-ray exam of ribs 

71101 ................... X-ray exam of ribs/chest 

71110 ................... X-ray exam of ribs 

71111 ................... X-ray exam of ribs/chest 

71120 ................... X-ray exam of breastbone 

71130 ................... X-ray exam of breastbone 

71250 ................... Ct thorax w/o dye 

71260 ................... Ct thorax w/dye 

71270 ................... Ct thorax w/o & w/dye 

71275 ................... Ct angiography, chest 

71550 ................... Mri chest w/o dye 

71551 ................... Mri chest w/dye 

71552 ................... Mri chest w/o & w/dye 

71555 ................... Mri angio chest w or w/o dye 

72010 ................... X-ray exam of spine 

72020 ................... X-ray exam of spine 

72040 ................... X-ray exam of neck spine 

72050 ................... X-ray exam of neck spine 

72052 ................... X-ray exam of neck spine 

72069 ................... X-ray exam of trunk spine 

72070 ................... X-ray exam of thoracic spine 

72072 ................... X-ray exam of thoracic spine 

72074 ................... X-ray exam of thoracic spine 

72080 ................... X-ray exam of trunk spine 

72090 ................... X-ray exam of trunk spine 

72100 ................... X-ray exam of lower spine 

72110 ................... X-ray exam of lower spine 

72114 ................... X-ray exam of lower spine 

72120 ................... X-ray exam of lower spine 

72125 ................... Ct neck spine w/o dye 

72126 ................... Ct neck spine w/dye 

72127 ................... Ct neck spine w/o & w/dye 

72128 ................... Ct chest spine w/o dye 

72129 ................... Ct chest spine w/dye 

72130 ................... Ct chest spine w/o & w/dye 

72131 ................... Ct lumbar spine w/o dye 

72132 ................... Ct lumbar spine w/dye 

72133 ................... Ct lumbar spine w/o & w/dye 

72141 ................... Mri neck spine w/o dye 

72142 ................... Mri neck spine w/dye 

72146 ................... Mri chest spine w/o dye 

72147 ................... Mri chest spine w/dye 

72148 ................... Mri lumbar spine w/o dye 

72149 ................... Mri lumbar spine w/dye 

72156 ................... Mri neck spine w/o & w/dye 

72157 ................... Mri chest spine w/o & w/dye 

72158 ................... Mri lumbar spine w/o & w/dye 

72170 ................... X-ray exam of pelvis 

72190 ................... X-ray exam of pelvis 

72191 ................... Ct angiograph pelv w/o&w/dye 

72192 ................... Ct pelvis w/o dye 

72193 ................... Ct pelvis w/dye 

72194 ................... Ct pelvis w/o & w/dye 

72195 ................... Mri pelvis w/o dye 

72196 ................... Mri pelvis w/dye 

72197 ................... Mri pelvis w/o & w/dye 

72198 ................... Mr angio pelvis w/o & w/dye 

72200 ................... X-ray exam sacroiliac joints 

72202 ................... X-ray exam sacroiliac joints 

72220 ................... X-ray exam of tailbone 

73000 ................... X-ray exam of collar bone 

73010 ................... X-ray exam of shoulder blade 

73020 ................... X-ray exam of shoulder 

73030 ................... X-ray exam of shoulder 

73050 ................... X-ray exam of shoulders 

73060 ................... X-ray exam of humerus 

73070 ................... X-ray exam of elbow 

73080 ................... X-ray exam of elbow 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

73090 ................... X-ray exam of forearm 

73092 ................... X-ray exam of arm, infant 

73100 ................... X-ray exam of wrist 

73110 ................... X-ray exam of wrist 

73120 ................... X-ray exam of hand 

73130 ................... X-ray exam of hand 

73140 ................... X-ray exam of finger(s) 

73200 ................... Ct upper extremity w/o dye 

73201 ................... Ct upper extremity w/dye 

73202 ................... Ct uppr extremity w/o&w/dye 

73206 ................... Ct angio upr extrm w/o&w/dye 

73218 ................... Mri upper extremity w/o dye 

73219 ................... Mri upper extremity w/dye 

73220 ................... Mri uppr extremity w/o&w/dye 

73221 ................... Mri joint upr extrem w/o dye 

73222 ................... Mri joint upr extrem w/dye 

73223 ................... Mri joint upr extr w/o&w/dye 

73500 ................... X-ray exam of hip 

73510 ................... X-ray exam of hip 

73520 ................... X-ray exam of hips 

73540 ................... X-ray exam of pelvis & hips 

73550 ................... X-ray exam of thigh 

73560 ................... X-ray exam of knee, 1 or 2 

73562 ................... X-ray exam of knee, 3 

73564 ................... X-ray exam, knee, 4 or more 

73565 ................... X-ray exam of knees 

73590 ................... X-ray exam of lower leg 

73592 ................... X-ray exam of leg, infant 

73600 ................... X-ray exam of ankle 

73610 ................... X-ray exam of ankle 

73620 ................... X-ray exam of foot 

73630 ................... X-ray exam of foot 

73650 ................... X-ray exam of heel 

73660 ................... X-ray exam of toe(s) 

73700 ................... Ct lower extremity w/o dye 

73701 ................... Ct lower extremity w/dye 

73702 ................... Ct lwr extremity w/o&w/dye 

73706 ................... Ct angio lwr extr w/o&w/dye 

73718 ................... Mri lower extremity w/o dye 

73719 ................... Mri lower extremity w/dye 

73720 ................... Mri lwr extremity w/o&w/dye 

73721 ................... Mri jnt of lwr extre w/o dye 

73722 ................... Mri joint of lwr extr w/dye 

73723 ................... Mri joint lwr extr w/o&w/dye 

73725 ................... Mr ang lwr ext w or w/o dye 

74000 ................... X-ray exam of abdomen 

74010 ................... X-ray exam of abdomen 

74020 ................... X-ray exam of abdomen 

74022 ................... X-ray exam series, abdomen 

74150 ................... Ct abdomen w/o dye 

74160 ................... Ct abdomen w/dye 

74170 ................... Ct abdomen w/o & w/dye 

74175 ................... Ct angio abdom w/o & w/dye 

74181 ................... Mri abdomen w/o dye 

74182 ................... Mri abdomen w/dye 

74183 ................... Mri abdomen w/o & w/dye 

74185 ................... Mri angio, abdom w orw/o dye 

74210 ................... Contrst x-ray exam of throat 

74220 ................... Contrast x-ray, esophagus 

74230 ................... Cine/vid x-ray, throat/esoph 

74240 ................... X-ray exam, upper gi tract 

74241 ................... X-ray exam, upper gi tract 

74245 ................... X-ray exam, upper gi tract 

74246 ................... Contrst x-ray uppr gi tract 

74247 ................... Contrst x-ray uppr gi tract 

74249 ................... Contrst x-ray uppr gi tract 

74250 ................... X-ray exam of small bowel 

74290 ................... Contrast x-ray, gallbladder 

74291 ................... Contrast x-rays, gallbladder 

74710 ................... X-ray measurement of pelvis 

75552 ................... Heart mri for morph w/o dye 

75553 ................... Heart mri for morph w/dye 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

75554 ................... Cardiac MRI/function 

75555 ................... Cardiac MRI/limited study 

75635 ................... Ct angio abdominal arteries 

76000 ................... Fluoroscope examination 

76006 ................... X-ray stress view 

76010 ................... X-ray, nose to rectum 

76020 ................... X-rays for bone age 

76040 ................... X-rays, bone evaluation 

76061 ................... X-rays, bone survey 

76062 ................... X-rays, bone survey 

76065 ................... X-rays, bone evaluation 

76066 ................... Joint survey, single view 

76070 ................... Ct bone density, axial 

76071 ................... Ct bone density, peripheral 

76075 ................... Dxa bone density, axial 

76076 ................... Dxa bone density/peripheral 

76077 ................... Dxa bone density/v-fracture 

76078 ................... Radiographic absorptiometry 

76082 ................... Computer mammogram add-on 

76083 ................... Computer mammogram add-on 

76090 ................... Mammogram, one breast 

76091 ................... Mammogram, both breasts 

76092 ................... Mammogram, screening 

76093 ................... Magnetic image, breast 

76094 ................... Magnetic image, both breasts 

76100 ................... X-ray exam of body section 

76101 ................... Complex body section x-ray 

76102 ................... Complex body section x-rays 

76120 ................... Cine/video x-rays 

76125 ................... Cine/video x-rays add-on 

76150 ................... X-ray exam, dry process 

76370 ................... Ct scan for therapy guide 

76376 ................... 3d render w/o postprocess 

76377 ................... 3d rendering w/postprocess 

76380 ................... CAT scan follow-up study 

76400 ................... Magnetic image, bone marrow 

76499 ................... Radiographic procedure 

76506 ................... Echo exam of head 

76510 ................... Ophth us, b & quant a 

76511 ................... Ophth us, quant a only 

76512 ................... Ophth us, b w/non-quant a 

76513 ................... Echo exam of eye, water bath 

76514 ................... Echo exam of eye, thickness 

76516 ................... Echo exam of eye 

76519 ................... Echo exam of eye 

76536 ................... Us exam of head and neck 

76604 ................... Us exam, chest, b-scan 

76645 ................... Us exam, breast(s) 

76700 ................... Us exam, abdom, complete 

76705 ................... Echo exam of abdomen 

76770 ................... Us exam abdo back wall, comp 

76775 ................... Us exam abdo back wall, lim 

76778 ................... Us exam kidney transplant 

76800 ................... Us exam, spinal canal 

76801 ................... Ob us < 14 wks, single fetus 

76802 ................... Ob us < 14 wks, add’l fetus 

76805 ................... Ob us >/= 14 wks, sngl fetus 

76810 ................... Ob us >/= 14 wks, addl fetus 

76811 ................... Ob us, detailed, sngl fetus 

76812 ................... Ob us, detailed, addl fetus 

76815 ................... Ob us, limited, fetus(s) 

76816 ................... Ob us, follow-up, per fetus 

76818 ................... Fetal biophys profile w/nst 

76819 ................... Fetal biophys profil w/o nst 

76820 ................... Umbilical artery echo 

76821 ................... Middle cerebral artery echo 

76825 ................... Echo exam of fetal heart 

76826 ................... Echo exam of fetal heart 

76827 ................... Echo exam of fetal heart 

76828 ................... Echo exam of fetal heart 

76856 ................... Us exam, pelvic, complete 

76857 ................... Us exam, pelvic, limited 

70474 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

76870 ................... Us exam, scrotum 

76880 ................... Us exam, extremity 

76885 ................... Us exam infant hips, dynamic 

76886 ................... Us exam infant hips, static 

76970 ................... Ultrasound exam follow-up 

76977 ................... Us bone density measure 

76999 ................... Echo examination procedure 

78000* .................. Thyroid, single uptake 

78001* .................. Thyroid, multiple uptakes 

78003* .................. Thyroid suppress/stimul 

78006* .................. Thyroid imaging with uptake 

78007* .................. Thyroid image, mult uptakes 

78010* .................. Thyroid imaging 

78011* .................. Thyroid imaging with flow 

78015* .................. Thyroid met imaging 

78016* .................. Thyroid met imaging/studies 

78018* .................. Thyroid met imaging, body 

78020* .................. Thyroid met uptake 

78070* .................. Parathyroid nuclear imaging 

78075* .................. Adrenal nuclear imaging 

78099* .................. Endocrine nuclear procedure 

78102* .................. Bone marrow imaging, ltd 

78103* .................. Bone marrow imaging, mult 

78104* .................. Bone marrow imaging, body 

78110* .................. Plasma volume, single 

78111* .................. Plasma volume, multiple 

78120* .................. Red cell mass, single 

78121* .................. Red cell mass, multiple 

78122* .................. Blood volume 

78130* .................. Red cell survival study 

78135* .................. Red cell survival kinetics 

78140* .................. Red cell sequestration 

78185* .................. Spleen imaging 

78190* .................. Platelet survival, kinetics 

78191* .................. Platelet survival 

78195* .................. Lymph system imaging 

78199* .................. Blood/lymph nuclear exam 

78201* .................. Liver imaging 

78202* .................. Liver imaging with flow 

78205* .................. Liver imaging (3D) 

78206* .................. Liver image (3d) with flow 

78215* .................. Liver and spleen imaging 

78216* .................. Liver & spleen image/flow 

78220* .................. Liver function study 

78223* .................. Hepatobiliary imaging 

78230* .................. Salivary gland imaging 

78231* .................. Serial salivary imaging 

78232* .................. Salivary gland function exam 

78258* .................. Esophageal motility study 

78261* .................. Gastric mucosa imaging 

78262* .................. Gastroesophageal reflux exam 

78264* .................. Gastric emptying study 

78270* .................. Vit B-12 absorption exam 

78271* .................. Vit B-12 absrp exam, int fac 

78272* .................. Vit B-12 absorp, combined 

78278* .................. Acute GI blood loss imaging 

78282* .................. GI protein loss exam 

78290* .................. Meckel’s divert exam 

78291* .................. Leveen/shunt patency exam 

78299* .................. GI nuclear procedure 

78300* .................. Bone imaging, limited area 

78305* .................. Bone imaging, multiple areas 

78306* .................. Bone imaging, whole body 

78315* .................. Bone imaging, 3 phase 

78320* .................. Bone imaging (3D) 

78350 ................... Bone mineral, single photon 

78399* .................. Musculoskeletal nuclear exam 

78414* .................. Non-imaging heart function 

78428* .................. Cardiac shunt imaging 

78445* .................. Vascular flow imaging 

78456* .................. Acute venous thrombus image 

78457* .................. Venous thrombosis imaging 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

78458* .................. Ven thrombosis images, bilat 

78459* .................. Heart muscle imaging (PET) 

78460* .................. Heart muscle blood, single 

78461* .................. Heart muscle blood, multiple 

78464* .................. Heart image (3d), single 

78465* .................. Heart image (3d), multiple 

78466* .................. Heart infarct image 

78468* .................. Heart infarct image (ef) 

78469* .................. Heart infarct image (3D) 

78472* .................. Gated heart, planar, single 

78473* .................. Gated heart, multiple 

78478* .................. Heart wall motion add-on 

78480* .................. Heart function add-on 

78481* .................. Heart first pass, single 

78483* .................. Heart first pass, multiple 

78491* .................. Heart image (pet), single 

78492* .................. Heart image (pet), multiple 

78494* .................. Heart image, spect 

78496* .................. Heart first pass add-on 

78499* .................. Cardiovascular nuclear exam 

78580* .................. Lung perfusion imaging 

78584* .................. Lung V/Q image single breath 

78585* .................. Lung V/Q imaging 

78586* .................. Aerosol lung image, single 

78587* .................. Aerosol lung image, multiple 

78588* .................. Perfusion lung image 

78591* .................. Vent image, 1 breath, 1 proj 

78593* .................. Vent image, 1 proj, gas 

78594* .................. Vent image, mult proj, gas 

78596* .................. Lung differential function 

78599* .................. Respiratory nuclear exam 

78600* .................. Brain imaging, ltd static 

78601* .................. Brain imaging, ltd w/flow 

78605* .................. Brain imaging, complete 

78606* .................. Brain imaging, compl w/flow 

78607* .................. Brain imaging (3D) 

78608* .................. Brain imaging (PET) 

78609* .................. Brain imaging (PET) 

78610* .................. Brain flow imaging only 

78615* .................. Cerebral vascular flow image 

78630* .................. Cerebrospinal fluid scan 

78635* .................. CSF ventriculography 

78645* .................. CSF shunt evaluation 

78647* .................. Cerebrospinal fluid scan 

78650* .................. CSF leakage imaging 

78660* .................. Nuclear exam of tear flow 

78699* .................. Nervous system nuclear exam 

78700* .................. Kidney imaging, static 

78701* .................. Kidney imaging with flow 

78704* .................. Imaging renogram 

78707* .................. Kidney flow/function image 

78708* .................. Kidney flow/function image 

78709* .................. Kidney flow/function image 

78710* .................. Kidney imaging (3D) 

78715* .................. Renal vascular flow exam 

78725* .................. Kidney function study 

78730* .................. Urinary bladder retention 

78740* .................. Ureteral reflux study 

78760* .................. Testicular imaging 

78761* .................. Testicular imaging/flow 

78799* .................. Genitourinary nuclear exam 

78800* .................. Tumor imaging, limited area 

78801* .................. Tumor imaging, mult areas 

78802* .................. Tumor imaging, whole body 

78803* .................. Tumor imaging (3D) 

78804* .................. Tumor imaging, whole body 

78805* .................. Abscess imaging, ltd area 

78806* .................. Abscess imaging, whole body 

78807* .................. Nuclear localization/abscess 

78811* .................. Tumor imaging (pet), limited 

78812* .................. Tumor image (pet)/skul-thigh 

78813* .................. Tumor image (pet) full body 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

78814* .................. Tumor image pet/ct, limited 

78815* .................. Tumor image pet/ct skul-thigh 

78816* .................. Tumor image pet/ct full body 

78890* .................. Nuclear medicine data proc 

78891* .................. Nuclear med data proc 

78999* .................. Nuclear diagnostic exam 

91110 ................... Gi tract capsule endoscopy 

93303 ................... Echo transthoracic 

93304 ................... Echo transthoracic 

93307 ................... Echo exam of heart 

93308 ................... Echo exam of heart 

93320 ................... Doppler echo exam, heart [if 

used in conjunction with 93303- 

93308] 

93321 ................... Doppler echo exam, heart [if 

used in conjunction with 93303- 

93308] 

93325 ................... Doppler color flow add-on [if 

used in conjunction with 93303- 

93308] 

93875 ................... Extracranial study 

93880 ................... Extracranial study 

93882 ................... Extracranial study 

93886 ................... Intracranial study 

93888 ................... Intracranial study 

93890 ................... Tcd, vasoreactivity study 

93892 ................... Tcd, emboli detect w/o inj 

93922 ................... Extremity study 

93923 ................... Extremity study 

93924 ................... Extremity study 

93925 ................... Lower extremity study 

93926 ................... Lower extremity study 

93930 ................... Upper extremity study 

93931 ................... Upper extremity study 

93965 ................... Extremity study 

93970 ................... Extremity study 

93971 ................... Extremity study 

93975 ................... Vascular study 

93976 ................... Vascular study 

93978 ................... Vascular study 

93979 ................... Vascular study 

93980 ................... Penile vascular study 

93981 ................... Penile vascular study 

93990 ................... Doppler flow testing 

A4641* ................. Diagnostic imaging agent 

A4642* ................. Satumomab pendetide per 

dose 

A9500* ................. Technetium TC 99m sestamibi 

A9502* ................. Technetium TC99M tetrofosmin 

A9503* ................. Technetium TC 99m medronate 

A9504* ................. Technetium tc 99m apcitide 

A9505* ................. Thallous chloride TL 201/mci 

A9507* ................. Indium/111 capromab pendetid 

A9508* ................. Iobenguane sulfate I-131 

A9510* ................. Technetium TC99m Disofenin 

A9511* ................. Technetium TC 99m depreotide 

A9512* ................. Technetiumtc99mpertechnetate 

A9513* ................. Technetium tc-99m mebrofenin 

A9514* ................. Technetiumtc99m 

pyrophosphate 

A9515* ................. Technetium tc-99m pentetate 

A9516* ................. I-123 sodium iodide capsule 

A9519* ................. Technetiumtc-99mmacroag 

albu 

A9520* ................. Technetiumtc-99m sulfur clld 

A9521* ................. Technetiumtc-99m exametazine 

A9522* ................. Indium111ibritumomabtiuxetan 

A9524* ................. Iodinated I-131 serumalbumin 

A9526* ................. Ammonia N-13, per dose 

A9528* ................. Dx I131 so iodide cap millic 

A9529* ................. Dx I131 so iodide sol millic 

A9531* ................. Dx I131 so iodide microcurie 

Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 70475 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

A9533* ................. I-131 tositumomab diagnostic 

A9700* ................. Echocardiography contrast 

G0130 .................. Single energy x-ray study 

G0202 .................. Screeningmammographydigital 

G0204 .................. Diagnosticmammographydigital 

G0206 .................. Diagnosticmammographydigital 

G0288 .................. Recon, CTA for surg plan 

Q0092 .................. Set up port xray equipment 

Q3000* ................. Rubidium RB-82 

Q3002* ................. Gallium ga 67 

Q3003* ................. Technetium tc99m bicisate 

Q3004* ................. Xenon xe 133 

Q3005* ................. Technetium tc99m mertiatide 

Q3006* ................. Technetium tc99m glucepatate 

Q3007* ................. Sodium phosphate p32 

Q3008* ................. Indium 111-in pentetreotide 

Q3009* ................. Technetium tc99m oxidronate 

Q3010* ................. Technetium tc99mlabeledrbcs 

Q3011* ................. Chromic phosphate p32 

Q3012* ................. Cyanocobalamin cobalt co57 

Q9945* ................. LOCM<=149mg/ml iodine, 1 ml 

Q9946* ................. LOCM 150-199mg/ml iodine,1ml 

Q9947* ................. LOCM 200-249mg/ml iodine,1ml 

Q9948* ................. LOCM 250-299mg/ml/iodine,1ml 

Q9949* ................. LOCM 300-349mg/ml iodine,1ml 

Q9950* ................. LOCM 350-399mg/ml iodine,1ml 

Q9951* ................. LOCM>=400 mg/ml iodine,1ml 

Q9952* ................. Inj Gad-base MR contrast, ml 

Q9953* ................. Inj Fe-base MR contrast, ml 

Q9954* ................. Oral MR contrast, 100ml 

Q9955* ................. Inj perflexane lip micros, ml 

Q9956* ................. Inj octafluoropropane mic,ml 

Q9957* ................. Inj perflutren lip micros, ml 

R0070 ................... Transport portable x-ray 

R0075 ................... Transport port x-ray multipl 

RADIATION THERAPY SERVICES AND SUPPLIES 

Include the following CPT and HCPCS codes: 

0073T ................... Delivery, comp imrt 

0082T ................... Stereotactic rad delivery 

0083T ................... Stereotactic rad tx mngmt 

19296 ................... Place po breast cath for rad 

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

19298 ................... Place breast rad tube/caths 

31643 ................... Diag bronchoscope/catheter 

55859 ................... Percut/needle insert, pros 

57155 ................... Insert uteri tandems/ovoids 

58346 ................... Insert heyman uteri capsule 

61770 ................... Incise skull for treatment 

61793 ................... Focus radiation beam 

77261 ................... Radiation therapy planning 

77262 ................... Radiation therapy planning 

77263 ................... Radiation therapy planning 

77280 ................... Set radiation therapy field 

77285 ................... Set radiation therapy field 

77290 ................... Set radiation therapy field 

77295 ................... Set radiation therapy field 

77299 ................... Radiation therapy planning 

77300 ................... Radiation therapy dose plan 

77301 ................... Radiotherapy dose plan, imrt 

77305 ................... Teletx isodose plan simple 

77310 ................... Teletx isodose plan intermed 

77315 ................... Teletx isodose plan complex 

77321 ................... Special teletx port plan 

77326 ................... Brachytx isodose calc simp 

77327 ................... Brachytx isodose calc interm 

77328 ................... Brachytx isodose plan compl 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

77331 ................... Special radiation dosimetry 

77332 ................... Radiation treatment aid(s) 

77333 ................... Radiation treatment aid(s) 

77334 ................... Radiation treatment aid(s) 

77336 ................... Radiation physics consult 

77370 ................... Radiation physics consult 

77399 ................... External radiation dosimetry 

77401 ................... Radiation treatment 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 

77417 ................... Radiology port film(s) 

77418 ................... Radiation tx delivery, imrt 

77421 ................... Stereoscopic x-ray guidance 

77422 ................... Neutron beam tx, single 

77423 ................... Neutron beam tx, complex 

77427 ................... Radiation tx management, x5 

77431 ................... Radiation therapy management 

77432 ................... Stereotactic radiation trmt 

77470 ................... Special radiation treatment 

77499 ................... Radiation therapy management 

77520 ................... Proton trmt, simple w/o comp 

77522 ................... Proton trmt, simple w/comp 

77523 ................... Proton trmt, intermediate 

77525 ................... Proton treatment, complex 

77600 ................... Hyperthermia treatment 

77605 ................... Hyperthermia treatment 

77610 ................... Hyperthermia treatment 

77615 ................... Hyperthermia treatment 

77620 ................... Hyperthermia treatment 

77750 ................... Infuse radioactive materials 

77761 ................... Apply intrcav radiat simple 

77762 ................... Apply intrcav radiat interm 

77763 ................... Apply intrcav radiat compl 

77776 ................... Apply interstit radiat simpl 

77777 ................... Apply interstit radiat inter 

77778 ................... Apply interstit radiat compl 

77781 ................... High intensity brachytherapy 

77782 ................... High intensity brachytherapy 

77783 ................... High intensity brachytherapy 

77784 ................... High intensity brachytherapy 

77789 ................... Apply surface radiation 

77790 ................... Radiation handling 

77799 ................... Radium/radioisotope therapy 

79005* .................. Nuclear rx, oral admin 

79101* .................. Nuclear rx, iv admin 

79200* .................. Nuclear rx, intracav admin 

79300* .................. Nuclr rx, interstit colloid 

79403* .................. Hematopoietic nuclear tx 

79440* .................. Nuclear rx, intra-articular 

79445* .................. Nuclear rx, intra-arterial 

79999* .................. Nuclear medicine therapy 

92974 ................... Cath place, cardio brachytx 

A9517* ................. Th I131 so iodide cap millic 

A9523* ................. Yttrium90ibritumomabtiuxetan 

A9530* ................. Th I131 so iodide sol millic 

A9532* ................. I-125 serum albumin micro 

A9534* ................. I-131 tositumomab therapeut 

A9600* ................. Strontium-89 chloride 

A9605* ................. Samarium sm153 lexidronamm 

A9699* ................. Noc therapeutic radiopharm 

G0173 .................. Stereo radiosurgery,complete 

G0243 .................. Multisour photon stero treat 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

G0251 .................. Linear acc based stero radio 

G0339 .................. Robot lin-radsurg com, first 

G0340 .................. Robt lin-radsurg fractx 2-5 

Q3001* ................. Brachytherapy radioelements 

Q3007* ................. Sodium phosphate p32 

Q3011* ................. Chromic phosphate p32 

EPO AND OTHER DIALYSIS-RELATED DRUGS 

The physician self-referral prohibition does not 

apply to the following codes for EPO and other dialysis-related drugs furnished in or by an ESRD facility if the conditions in § 411.355(g) are satisfied: 

J0630 ................... Calcitonin salmon injection 

J0636 ................... Inj calcitriol per 0.1 mcg 

J0882 ................... Darbepoetin alfa, esrd use 

J0886 ................... Epoetin alfa, esrd 

J0895 ................... Deferoxamine mesylate inj 

J1270 ................... Injection, doxercalciferol 

J1751 ................... Iron dextran 165 injection 

J1752 ................... Iron dextran 267 injection 

J1756 ................... Iron sucrose injection 

J1955 ................... Inj levocarnitine per 1 gm 

J2501 ................... Paricalcitol 

J2916 ................... Na ferric gluconate complex 

J2993 ................... Reteplase injection 

J2995 ................... Inj streptokinase /250000 IU 

J2997 ................... Alteplase recombinant 

J3364 ................... Urokinase 5000 IU injection 

P9041 ................... Albumin (human),5%, 50ml 

P9045 ................... Albumin (human), 5%, 250ml 

P9046 ................... Albumin (human), 25%, 20ml 

P9047 ................... Albumin (human), 25%, 50ml 

PREVENTIVE SCREENING TESTS, 

IMMUNIZATIONS AND VACCINES 

The physician self-referral prohibition does not 

apply to the following tests if they are performed for 

screening purposes and satisfy the conditions in 

§ 411.355(h): 

76083 ................... Computer mammogram add-on 

76092 ................... Mammogram, screening 

80061 ................... Lipid panel [only when billed 

with one of the following ICD-9- 

CM codes: V81.0, V81.1, or 

V.81.2] 

82465 ................... Assay, bld/serum cholesterol 

[only when billed with one of 

the following ICD-9-CM codes: 

V81.0, V81.1, or V.81.2] 

82947 ................... Assay, glucose, blood quant 

[only when billed with ICD-9- 

CM code V77.1] 

82950 ................... Glucose test [only when billed 

with ICD-9-CM code V77.1] 

82951 ................... Glucose tolerance test (GTT) 

[only when billed with ICD-9- 

CM code V77.1] 

83718 ................... Assay of lipoprotein [only when 

billed with one of the following 

ICD-9-CM codes: V81.0, V81.1, 

or V.81.2] 

84478 ................... Assay of triglycerides [only 

when billed with one of the following ICD-9-CM codes: V81.0, 

V81.1, or V.81.2] 

G0103 .................. Psa, total screening 

G0107 .................. CA screen; fecal blood test 

G0123 .................. Screen cerv/vag thin layer 

G0124 .................. Screen c/v thin layer by MD 

G0141 .................. Scr c/v cyto,autosys and md 

G0143 .................. Scr c/v cyto,thinlayer,rescr 

G0144 .................. Scr c/v cyto,thinlayer,rescr 

G0145 .................. Scr c/v cyto,thinlayer,rescr 

70476 Federal Register / Vol. 70, No. 223 / Monday, November 21, 2005 / Rules and Regulations 

ADDENDUM H.—LIST OF CPT 1/ 

HCPCS CODES USED TO DESCRIBE

CERTAIN DESIGNATED HEALTH

SERVICE CATEGORIES 2 UNDER SECTION 1877 OF THE SOCIAL SECURITY

ACT—Continued 

[Effective Date: All codes are effective January 

1, 2006, except those followed by an asterisk. Codes followed by an asterisk will become effective on January 1, 2007.] 

G0147 .................. Scr c/v cyto, automated sys 

G0148 .................. Scr c/v cyto, autosys, rescr 

G0202 .................. Screening mammographydigital 

G0328 .................. Fecal blood scrn immunoassay 

P3000 ................... Screen pap by tech w md supv 

P3001 ................... Screening pap smear by phys 

The physician self-referral prohibition does not 

apply to the following immunization and vaccine 

codes if they satisfy the conditions in § 411.355(h): 

90655 ................... Flu vaccine no preserv 6-35m 

90656 ................... Flu vaccine no preserv 3 & > 

90657 ................... Flu vaccine, 6-35 mo, im 

90658 ................... Flu vaccine age 3 & over, im 

90732 ................... Pneumococcal vaccine 

90740 ................... Hepb vacc, ill pat 3 dose im 

90743 ................... Hep b vacc, adol, 2 dose, im 

90744 ................... Hepb vacc ped/adol 3 dose im 

90746 ................... Hep b vaccine, adult, im 

90747 ................... Hepb vacc, ill pat 4 dose im 

1 CPT codes and descriptions only are copyright 2005 American Medical Association. All 

rights are reserved and applicable FARS/ 

DFARS clauses apply. 2This list does not include codes for the following designated health service (DHS) categories: 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; and inpatient and outpatient hospital services. For 

the definitions of these DHS categories, refer 

to 42 CFR 411.351. For more information, refer 

to http://cms.hhs.gov/medlearn/refphys.asp. 

* Nuclear medicine services and supplies assigned an asterisk will be subject to the physician self-referral prohibition effective January 

1, 2007. 

[FR Doc. 05–22160 Filed 11–2–05; 5:07 pm] 

BILLING CODE 4120–01–P