19992 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Care Financing Administration

[BPD–846–PN]

RIN 0938–AH38

Medicare Program; Five-Year Review

of Work Relative Value Units Under the

Physician Fee Schedule

AGENCY: Health Care Financing

Administration (HCFA), HHS.

ACTION: Proposed notice.

SUMMARY: This proposed notice

discusses changes to work relative value

units (RVUs) affecting payment for

physician services. Section

1848(c)(2)(B)(i) of the Social Security

Act requires that we review all work

RVUs no less often than every 5 years.

Since we implemented the physician fee

schedule effective for services furnished

beginning January 1, 1992, we have

initiated the 5-year review of work

RVUs that will be effective for services

furnished beginning January 1, 1997.

DATES: Comments will be considered if

we receive them at the appropriate

address, as provided below, no later

than 5 p.m. on July 2, 1996.

ADDRESSES: Mail written comments (1

original and 3 copies) to the following

address: Health Care Financing

Administration, Department of Health

and Human Services, Attention: BPD–

846–PN, P.O. Box 7519, Baltimore, MD

21207–0519.

If you prefer, you may deliver your

written comments (1 original and 3

copies) to one of the following

addresses:

Room 309–G, Hubert H. Humphrey

Building, 200 Independence Avenue

SW., Washington, DC 20201, or

Room C5–09–26, 7500 Security

Boulevard, Baltimore, MD 21244–

1850.

Because of staffing and resource

limitations, we cannot accept comments

by facsimile (FAX) transmission. In

commenting, please refer to file code

BPD–846–PN. Comments received

timely will be available for public

inspection as they are received,

generally beginning approximately 3

weeks after publication of a document,

in Room 309–G of the Department’s

offices at 200 Independence Avenue

SW., Washington, DC, on Monday

through Friday of each week from 8:30

a.m. to 5 p.m. (phone: (202) 690–7890).

Copies: To order copies of the Federal

Register containing this document, send

your request to: New Orders,

Superintendent of Documents, P.O. Box

371954, Pittsburgh, PA 15250–7954.

Specify the date of the issue requested

and enclose a check or money order

payable to the Superintendent of

Documents, or enclose your Visa or

Master Card number and expiration

date. Credit card orders can also be

placed by calling the order desk at (202)

512–1800 or by faxing to (202) 512–

2250. The cost for each copy is $8. As

an alternative, you can view and

photocopy the Federal Register

document at most libraries designated

as Federal Depository Libraries and at

many other public and academic

libraries throughout the country that

receive the Federal Register.

This Federal Register document is

also available from the Federal Register

online database through GPO Access, a

service of the U.S. Government Printing

Office. Free public access is available on

a Wide Area Information Server (WAIS)

through the Internet and via

asynchronous dial-in. Internet users can

access the database by using the World

Wide Web; the Superintendent of

Documents home page address is http:/

/www.access.gpo.gov/sulldocs/, by

using local WAIS client software, or by

telnet to swais.access.gpo.gov, then

login as guest (no password required).

Dial-in users should use

communications software and modem

to call (202) 512–1661; type swais, then

login as guest (no password required).

For general information about GPO

Access, contact the GPO Access User

Support Team by sending Internet email to help@eids05.eids gpo.gov; by

faxing to (202) 512–1262; or by calling

(202) 512–1530 between 7 a.m. and 5

p.m. Eastern time, Monday through

Friday, except for Federal holidays.

FOR FURTHER INFORMATION CONTACT:

Elizabeth Holland, (410) 786–1309.

SUPPLEMENTARY INFORMATION: To assist

readers in referencing sections

contained in this proposed notice, we

are providing the following table of

contents.

Table of Contents

I. Background

A. Legislative Requirements

B. Published Changes to the Physician Fee

Schedule

C. Summary of the Development of

Physician Work Relative Value Units

D. Scope of the Review

II. Discussion of Comments and Decisions

A. Review of Comments (Includes Table

1—Five-Year Review of Work Relative

Value Units)

B. Discussion of Comments by Clinical

Area

1. Integumentary System

2. Orthopaedic Surgery

3. Otolaryngology and Maxillofacial

Surgery

4. Podiatry

5. Cardiology and Interventional Radiology

6. General Surgery, Colon and Rectal

Surgery, and Gastroenterology

7. Urology

8. Gynecology

9. Neurosurgery

10. Ophthalmology

11. Imaging

12. Cardiothoracic and Vascular Surgery

13. Pathology and Laboratory Procedures

14. Psychiatry

15. Other Medical and Therapeutic

Services

16. Speech/Language/Hearing

C. Other Comments

1. Evaluation and Management Services

(Includes Table 2—Evaluation and

Management Codes; Five-Year Review—

Proposed Relative Value Units)

2. Review of Studies by Abt Associates,

Inc.

3. Pediatrics

4. Anesthesia

5. Codes Without Work Relative Value

Units

6. Codes Referred to the Physicians’

Current Procedural Terminology

Editorial Panel (Includes Table 3—Codes

Referred to the Physicians’ Current

Procedural Terminology Editorial Panel)

7. Potentially Overvalued Services

D. Other Issues

1. Budget Neutrality

2. Calculation of Practice Expense and

Malpractice Expense Relative Value

Units

3. Impact of Work Relative Value Unit

Changes for Evaluation and Management

Services on Work Relative Value Units

for Global Surgical Services

4. Proposal for Future Review

5. Nature and Format of Comments on

Work Relative Value Units

III. Collection of Information Requirements

IV. Response to Comments

V. Regulatory Impact Analysis

A. Regulatory Flexibility Act

B. Effects on Physician Payments

1. Impact Estimation Methodology

2. Overall Fee Schedule Impact

3. Specialty Level Effect (Includes Table

4—Five-Year Review Impact on

Medicare Payments by Specialty)

C. Rural Hospital Impact Statement

Addendum—Codes Subject to Comment

In addition, because of the many

organizations and terms to which we refer by

acronym in this proposed notice, we are

listing these acronyms and their

corresponding terms in alphabetical order

below:

AMA American Medical Association

CPT [Physicians’] Current Procedural

Terminology [4th Edition, 1996,

copyrighted by the American Medical

Association]

HCFA Health Care Financing Administration

HCPCS HCFA Common Procedure Coding

System

IWPUT Intraservice work per unit time

RUC [American Medical Association

Specialty Society] Relative [Value]

Update Committee

RVU Relative value unit
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I. Background

A. Legislative Requirements

The Medicare program was

established in 1965 by the addition of

title XVIII to the Social Security Act (the

Act). Since January 1, 1992, Medicare

pays for physician services under

section 1848 of the Act, ‘‘Payment for

Physicians’ Services.’’ This section

contains three major elements: (1) A fee

schedule for the payment of physician

services; (2) a Medicare volume

performance standard for the rates of

increase in Medicare expenditures for

physician services; and (3) limits on the

amounts that nonparticipating

physicians can charge beneficiaries. The

Act requires that payments under the

fee schedule 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, and malpractice expense.

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

provides that adjustments in RVUs

because of changes resulting from a

review of those 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 this

tolerance is exceeded, we must make

adjustments to preserve budget

neutrality.

B. Published Changes to the Physician

Fee Schedule

We published a final rule on

November 25, 1991 (56 FR 59502) to

implement section 1848 of the Act by

establishing a fee schedule for physician

services furnished on or after January 1,

1992. In the November 1991 final rule

(56 FR 59511), we stated our intention

to update RVUs for new and revised

codes in the American Medical

Association’s (AMA’s) Physicians’

Current Procedural Terminology (CPT)

through an ‘‘interim RVU’’ process

every year. The updates to the RVUs

and fee schedule policies follow:

• September 15, 1992, as a correction

notice for the 1992 physician fee

schedule (57 FR 42491).

• November 25, 1992, as a final notice

with comment period on new and

revised RVUs only for the 1993

physician fee schedule (57 FR 55914).

• June 7, 1993, as a correction notice

for the 1993 physician fee schedule (58

FR 31964).

• December 2, 1993, as a final rule

with comment period (58 FR 63626)

announcing revised payment policies

and RVUs for 1994. (We solicited

comments on new and revised RVUs

only. There were two correction notices

published for the 1994 physician fee

schedule (July 15, 1994, 59 FR 36069)

and (August 4, 1994, 59 FR 39828).)

• December 8, 1994, as a final rule

with comment period (59 FR 63410) to

revise the geographic adjustment factor

values, fee schedule payment areas, and

payment policies and RVUs for 1995.

The final rule also discussed the process

for periodic review and adjustment of

RVUs not less frequently than every 5

years as required by section

1848(c)(2)(B)(i) of the Act. (There were

two correction notices published for the

1995 physician fee schedule (January 3,

1995, 60 FR 46) and (July 18, 1995, 60

FR 36733).)

• December 8, 1995, as a final rule

with comment period (60 FR 63124) to

revise various policies affecting

payment for physician services

including Medicare payment for

physician services in teaching settings,

the RVUs for certain existing procedure

codes, and to establish interim RVUs for

new and revised procedure codes. The

rule also included the final revised 1996

geographic practice cost indices.

This proposed notice updates

information in the final Federal Register

documents listed above. It discusses

changes to work RVUs affecting

payment for physician services. Section

1848(c)(2)(B)(i) of the Act requires that

we review all work RVUs no less often

than every 5 years. Since we

implemented the physician fee schedule

effective for services furnished

beginning January 1, 1992, we have

initiated the 5-year review of work

RVUs that will be effective for services

furnished beginning January 1, 1997.

C. Summary of the Development of

Physician Work Relative Value Units

Development of the concepts and

methodology underlying the physician

fee schedule has been under way for a

number of years. Based on

Congressional mandates contained in

the Consolidated Omnibus Budget

Reconciliation Act of 1985 (Public Law

99–272), the Omnibus Budget

Reconciliation Act of 1986 (Public Law

99–509), and the Omnibus Budget

Reconciliation Act of 1987 (Public Law

100–203), we began our effort to

develop a physician fee schedule based

on a relative value scale. We were

assisted in this task by a number of

experts inside and outside of

government, including the research

team at the Harvard University School

of Public Health. The Harvard research

team produced ‘‘A National Study of

Resource-Based Relative Value Scales

for Physician Services’’ (September

1988) and ‘‘A National Study of

Resource-Based Relative Value Scales

for Physician Services Phase II’’

(November 1990) under a cooperative

agreement with us. Harvard’s Phase III

final report was completed in December

of 1991.

A model fee schedule was published

on September 4, 1990 as part of a notice

with comment period (55 FR 36178).

The addenda to the model fee schedule

notice provided preliminary estimates

of the RVUs associated with the

approximately 1,400 services studied as

part of the Harvard Phase I study. We

provided a 60-day public comment

period; comments received were

considered carefully and were helpful to

us in developing the proposed rule that

was published in the Federal Register

on June 5, 1991 (56 FR 25792).

Based primarily on Phase II and some

of Phase III of the Harvard study, the

proposed rule contained RVUs for more

than 4,000 services representing about

85 percent of Medicare payments. In

Phase II, 15 additional medical and

surgical specialties were studied that

were not studied in Phase I. In addition,

seven Phase I specialties were restudied,

with four of these restudies funded by

the specialty societies. Not only did

Phase II almost triple the number of

services for which RVUs had been

produced, but it refined the RVUs for

many of the original 1,400 services.

The final rule published on November

25, 1991 (56 FR 59502) was based

primarily on Phases II and III of the

Harvard study, which produced RVUs

for all but about 400 of the remaining

Medicare-covered services that required

work RVUs. In Phase III, most of the

extrapolated Phases I and II RVUs were

replaced by RVUs that were generated

by a small group survey process, and

many preservice and postservice work

estimates for Phases I and II work RVUs

were revised. A few early Phase III

results were available for inclusion in

the proposed rule; additional Phase III

results were provided to us in

installments throughout 1991. We

developed RVUs for roughly 400

services that had not been surveyed by

Harvard (generally low volume services

or nonphysician services or services that

were extrapolated by Harvard).

Physician work RVUs were reviewed

and developed by carrier medical

directors, initially through a survey

conducted by mail and subsequently

through group meetings to refine the

product of the survey process. Through

a consensus or Delphi-type process,

carrier medical directors rated physician

work for the remaining services. In

addition, a number of physician work

RVUs were refined based on

information provided as part of the
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comment process on the June 5, 1991

proposed rule.

The AMA Specialty Society Relative

Value Update Committee (RUC) was

formed in November 1991 and grew out

of a series of discussions between the

AMA and the major national medical

specialty societies. The RUC is

comprised of 26 members; 22 are

representatives of major specialty

societies. The remaining members

represent the AMA, the American

Osteopathic Association, and the CPT

Editorial Panel. The work of the RUC is

supported by the RUC Advisory

Committee made up of representatives

of 65 specialty societies in the AMA’s

House of Delegates.

The RUC currently makes

recommendations to us on the

assignment of RVUs for new and revised

CPT codes. As we discussed in our

December 8, 1994 final rule with

comment period, we shared comments

we received on the 1995 work RVUs

with the RUC (59 FR 63453). However,

we retained the responsibility for

analyzing the comments and developing

this proposed notice.

D. Scope of the Review

We initiated the 5-year review by

soliciting public comments on all work

RVUs for approximately 7,000 CPT/

HCPCS (HCFA Common Procedure

Coding System) codes published in our

December 8, 1994 final rule (59 FR

63410). We reviewed all timely

comments received during the comment

period for our December 8, 1994 final

rule. We excluded two major areas of

comments from the 5-year review. The

first excluded area was comments that

addressed work RVUs that were

considered interim for 1995. We

considered these comments as a part of

our annual review process, the results of

which we published in the December 8,

1995 final rule (60 FR 63124). The

second major area we excluded was

comments that addressed practice

expense and malpractice expense RVUs.

As we stated in the December 8, 1994

final rule (59 FR 63454), the scope of the

5-year review is limited to work RVUs.

Three specialty societies (the

American Academy of Orthopaedic

Surgeons, the American Society of

Anesthesiologists, and the American

Academy of Otolaryngology - Head and

Neck Surgery, Inc.) submitted studies

conducted for them by Abt Associates,

Inc., which spanned all of the more than

2,000 codes used by physicians in those

specialties. We referred these studies to

the RUC. The American Academy of

Pediatrics submitted comments

asserting that the physician work

involved in furnishing 480 services to

pediatric patients is different than the

physician work involved in furnishing

the same services to adult patients.

After a preliminary screening, we

referred approximately 3,500 codes to

the RUC for its review. The codes

included those found in public

comments (700 codes), the American

Academy of Pediatrics— comments (480

codes); three special studies by Abt

Associates, Inc. (about 2,000 codes); and

those we identified as potentially

misvalued (300 codes).

II. Discussion of Comments and

Decisions

A. Review of Comments

During the comment period for our

December 8, 1994 final rule (59 FR

63410), we received more than 500

public comments on approximately

1,100 codes. After review by our

medical staff, we forwarded comments

on approximately 700 codes for

consideration by the RUC. Comments

that we did not forward are listed in

Table 1 and are identified by a code that

explains our rejection of the comment.

In addition, we forwarded comments on

approximately 300 codes identified by

us as potentially misvalued.

Comments that we did not refer to the

RUC generally fall into several

categories:

• Comments that do not pertain to

work RVUs or that are not sufficiently

descriptive to be helpful in

understanding why the existing RVUs

are incorrect.

• Comments on services for which we

have not assigned work RVUs because

we have determined that the codes do

not represent physician services or, in a

few instances, because they represent

either ‘‘bundled’’ or noncovered

services.

• Comments that are similar to, or

duplicate, other comments which we

referred to the RUC.

The process for evaluating codes

included in the 5-year review involved

the same basic methodology as the

process for the annual physician fee

schedule update, with some important

changes. Because the 5-year review

involved evaluating the physician work

of established codes with established

work RVUs, we needed compelling

arguments to support changes in the

assignment of work RVUs. To gather

evidence to support these arguments, in

addition to comparing the total

physician work involved in the services

under review to key reference services,

we asked commenters to provide a

detailed comparison of the preservice,

intraservice, and postservice time

involved in the key reference services

selected. For this purpose, for surgical

procedures, we further divided

postservice time into time on the day of

the procedure, time in the intensive care

unit, hospital visits, and office or other

outpatient visits following discharge.

We also requested comments

regarding other elements of physician

work, in addition to time, and the extent

to which the service had changed over

the last 5 years. We considered the

commenters’ statements regarding the

complexity of each nontemporal

component for the services under

review and the services used as key

references. The nontemporal

components of work are the physician’s

mental effort and judgment, technical

skill and physical effort, and stress

resulting from the risk of mortality or

iatrogenic harm to the patient. We also

considered whether the service had

changed over the past 5 years as the

result of one of the following

conditions: new technology that had

become more familiar to physicians, the

service having been furnished to

patients who had more or less complex

medical conditions, or a change in the

site where the service had usually been

furnished.

The public comments addressed

many CPT codes for evaluation and

management services. Because we

introduced the new codes for these

services simultaneously with the

Medicare physician fee schedule in

1992 and because we have not revised

them during the annual update process,

their inclusion in the 5-year review

presents the first opportunity for

evaluating their relative physician work.

In the public comments addressing

these services, the major primary care

specialty societies stated that the

services had become more difficult than

they were when the original Harvard

resource-based relative value scale

surveys were conducted in the late

1980’s, due to factors such as decreasing

lengths of hospital stay, increasing

complexity of patients in inpatient and

outpatient settings, documentation and

case management requirements, and a

better educated patient population that

expects more information from

physicians.

For more than 1,000 codes included

in the 5-year review, we divided the

CPT codes into clinical groups and

another group containing all the codes

identified by the RUC as potentially

overvalued services. (Additional codes

from the Abt Associates, Inc. studies

and from the American Academy of

Pediatrics’ comments are discussed in

sections II.C.2. and II.C.3. of this notice,

respectively.) In addition, the AMA is

submitting approximately 65 CPT codes
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to its CPT Editorial Panel. The RUC was

unable to recommend work RVUs for

these codes because the services were

not clearly described or could vary

widely from patient to patient. We will

address these codes in a future annual

update of the physician fee schedule.

The following is a categorization of our

decisions and how they relate to the

comments received from the public

(including medical specialty societies)

and the RUC:

• For 28 percent of the codes, we are

proposing to increase the work RVUs.

• For 61 percent of the codes, we are

proposing to maintain the current work

RVUs. We are also proposing to

maintain the values for the anesthesia

codes.

• For 11 percent of the codes, we are

proposing to decrease the work RVUs.

Our proposed work RVUs agree with

the RUC recommendations for 93

percent of the codes. Table 1—Five-Year

Review of Work Relative Value Units

Table 1 lists the codes reviewed

during the 5-year review. This table

includes the following information:

• CPT/HCPCS (HCFA Common

Procedure Coding System) code. This is

the CPT or alphanumeric HCPCS code

for a service.

• Modifier. A modifier -26 is shown if

the work RVUs represent the

professional component of the service.

• Description. This is an abbreviated

version of the narrative description of

the code.

• 1995 work RVUs. The work RVUs

that appeared in the December 8, 1994

final rule are shown for each reviewed

code.

• Requested work RVUs. This column

identifies the work RVUs requested by

commenters. We received more than

one comment on some codes, and, in a

few of these cases, the commenters

requested different RVUs. If the

comment was sent to the RUC, the table

lists the RVUs sent to the RUC. The

letters ‘‘CPT’’ indicate that the

commenter requested that the code be

referred to the CPT Editorial Panel. For

some codes, we received no specific

RVU recommendations. Some of these

codes are included in the review

because of rank order anomaly issues

within a family of codes. An asterisk

indicates a code identified by the RUC

as potentially overvalued. The RVUs

shown have not been adjusted for

budget neutrality.

• RUC recommendation. This column

identifies the work RVUs recommended

by the RUC. A letter in this column

indicates that the comment was rejected

and not sent to the RUC. An ‘‘A’’

indicates that the comment was covered

by another comment. A ‘‘B’’ indicates

that the comment was not helpful. A

‘‘C’’ indicates that no change was

requested. A ‘‘D’’ indicates a

misinterpretation of the code. An ‘‘E’’

indicates that the comment was

withdrawn by the commenter. The

letters ‘‘CPT’’ indicate that the RUC has

referred this code to the CPT Editorial

Panel for further clarification. A ‘‘Z’’

indicates that these services have no

physician work and were not subject to

the 5-year review. For a general

discussion of these codes, see section

II.C.5. (codes without work relative

value units). The letters ‘‘POS’’ indicate

that the code is potentially overvalued.

• HCFA Decision. This column

indicates whether we agreed with the

RUC recommendation (‘‘agreed’’); we

are proposing work RVUs that are

higher than the RUC recommendation

(‘‘increased’’); or we are proposing work

RVUs that are less than the RUC

recommendation (‘‘decreased’’). Codes

for which we did not accept the RUC

recommendation are discussed in

greater detail following Table 1. An (a)

in this column indicates that in the

absence of a RUC recommendation we

are proposing to maintain the present

work RVUs. A (b) in this column

indicates that this code is being

considered in the 1996 refinement

process.

• Proposed work RVUs. This column

contains the proposed RVUs for

physician work. The absence of

proposed work RVUs indicates that

comments on these codes were rejected

or withdrawn and the work RVUs for

these codes are not changing as a result

of the 5-year review. The work RVUs

shown have not been adjusted for

budget neutrality.

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B. Discussion of Comments by Clinical

Area

1. Integumentary System

Comment: Numerous specialty

societies surveyed and commented on

the CPT codes for the integumentary

system that they believed were

undervalued or overvalued. In several

instances, specialty societies were

responding to reductions proposed by

other commenters. The specialty

societies’ recommendations were

supported with survey data and

arguments that were based on changes

in the patient population, changes in

technology, and rank-order anomalies.

Survey samples were of sufficient size

to validate the results. Additionally,

specialty societies made cross-specialty

comparisons to similar procedures. The

comparisons gave support to arguments

and survey data.

RUC Evaluation/Recommendation:

Generally, the RUC found the data,

comparisons, and arguments

convincing. The RUC looked for

compelling evidence that the procedure

had changed, the patient population had

changed, or the code had been originally

undervalued or overvalued. When the

RUC recommended different work

RVUs, it typically attempted to

reconcile new survey data and rationale

with Harvard data, producing final

recommended work RVUs. In all, the

RUC recommended that the work RVUs

for 6 codes be reduced in value, for 15

codes be increased in value, and for 35

codes be maintained at the current

value.

HCFA Decision: We agree with the

RUC on most of its findings, but we

have rejected the RUC recommendations

for the following eight integumentary

system codes:

CPT codes 15570 through 15576

(Formation of direct or tubed pedicle,

with or without transfer).

There are four codes in this family

that are used to report the formation of

direct or tubed pedicles in different

body areas. We received a comment that

all of these codes are undervalued when

compared to the corresponding adjacent

flap codes, CPT code 14001 with 7.78

work RVUs, CPT code 14021 with 9.37

work RVUs, and CPT code 14040 with

7.18 work RVUs.

In its recommendation to us, the RUC

indicated that several old codes, CPT

codes 15500 through 15515, which were

valued by Harvard, were deleted in 1992

and replaced with CPT codes 15570

through 15576. The RUC also noted that

the new codes are misvalued and that

no explanation had been received

describing how the work RVUs of these

codes were determined. The current

survey results show median work RVUs

of 9.85 and a median intraservice time

of 105 minutes for CPT code 15570;

median work RVUs of 9.63 and a

median intraservice time of 90 minutes

for CPT code 15572; median work RVUs

of 10.50 and a median intraservice time

of 120 minutes for CPT code 15574; and

median work RVUs of 8.50 and a

median intraservice time of 90 minutes

for CPT code 15576. These results agree

with the Harvard data for the original

codes, CPT codes 15500 through 15515.

Based on the survey results and the lack

of rationale for the current work RVUs,

the RUC recommended that the codes be

valued at the same level established by

Harvard for the original deleted codes.

We have not accepted the RUC

recommendations for two reasons. First,

the RUC’s understanding of the source

of the work RVUs for the current codes

is incorrect and second, we believe the

vignettes that were surveyed may have

led to an overestimation of the work.

These four codes first appeared in

CPT 1992, following a revision of this

section of CPT. The codes do not

correspond directly to the deleted codes

(CPT codes 15500 through 15515) cited

by the RUC because other codes (CPT

codes 15540 through 15555 and 15700

through 15730) also were deleted and

crosswalked to the new codes. Because

we viewed the coding change as

significant, we did not accept the work

RVUs developed by Harvard for CPT

codes 15500 through 15515 as a valid

basis for the new codes. We proposed

work RVUs for the current CPT codes

15540 through 15555 in the November

25, 1991 final rule for the 1992

physician fee schedule (56 FR 59502).

Because the comments that we received

suggested that the proposed work RVUs

were too low, we referred the codes to

one of the multispecialty refinement

panels that met in May 1992. Based on

the ratings of that panel, no changes

were made in the work RVUs, and they

became final work RVUs effective

January 1, 1993.

The vignettes that were surveyed by

the RUC describe patient problems and

services that we believe may have led to

an overestimation of the work involved

in the formation of direct or tubed

pedicles. For example, the vignette for

CPT code 15574 reads:

A 56-year-old hunter sustains a gun shot

injury to his left hand. He is brought to the

hospital and initial debridement, fracture

stabilization and temporary wound cover is

accomplished with dressing changes. A

tailored groin flap is planned for coverage of

the dorsal defect. At operation, a random

patterned groin flap is elevated. The hand is,

again, thoroughly debrided and lavaged, and

the groin flap is placed. The abdominal

wound is closed by primary advancement of

the abdominal skin. The postoperative care is

routine until either further delay or

separation occurs.

The preservice work is described as

including an assessment of the patient

in the emergency room. The intraservice

work is described as including the

creation of a special dressing to

maintain the relative positions of the

hand, the flap, and the abdominal wall.

We are concerned that the survey

respondents may have considered the

work of debridement, fracture

stabilization, initial emergency room

evaluation, and immobilization of the

hand, flap, and abdomen in their

estimates of work. If so, the work RVUs

are excessive because those other

services can be reported and paid

separately. Therefore, we are

maintaining the current work RVUs.

CPT code 15580 (Cross finger flap,

including free graft to donor site).

We received a comment that this code

is undervalued when compared to CPT

code 15240 (Skin full graft procedure)

and CPT code 15100 (Skin split graft

procedure). It was argued that the

current work RVUs do not account for

the intraservice time and work involved

in harvesting and applying the skin

graft. Survey data showed a median

intraservice time of 90 minutes and

median work RVUs of 9.00. The RUC

recommended that the work RVUs be

increased based on the survey results

and its conclusion that the comparison

to skin graft procedures was

appropriate.

We have not proposed a change in the

work RVUs for this code because we are

concerned that CPT is not clear

regarding the separate reporting of a

graft to the donor site, and the vignette

may have led to an overestimation of

work. There is a note in the introductory

paragraphs for the flap codes that states:

‘‘Repair of donor site requiring skin graft

or local flaps is considered an

additional separate procedure.’’ This

contradicts the terminology of CPT code

15580 and could be a source of

confusion.

The vignette that was used in the survey

reads: A 36-year-old laborer sustains an

avulsion injury of the volar aspect of the

middle of phalanx of the left index finger in

a grinding machine. The profundus tendon is

intact and the neurovascular bundles are

intact. At operation, a cross finger pedicle

flap from the dorsum of the adjacent left

middle phalanx is elevated and rotated

downward and placed on the volar aspect of

the adjacent finger. The donor site defect was

reconstructed with a full thickness skin graft

harvested from the left groin. Both the

pedicle and the skin graft were sewn in

place. The postoperative care is routine for

that of a split thickness skin graft.
20020 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

The preservice work is described as

including an assessment of the patient

in the emergency room. The description

of the intraservice work includes

thorough debridement and

immobilization of the fingers in a

specially constructed dressing to

remove tension from the flap by

preventing motion.

We are concerned that the survey

respondents may have considered the

work of debridement, initial emergency

room evaluation, and immobilization of

the fingers in their estimates of work. If

so, the work RVUs are excessive because

the other services can be reported

separately. Therefore, we are

maintaining the current work RVUs.

CPT codes 17000, 17001, and 17002

(Destruction by any method of benign

facial or premalignant lesions in any

location).

An individual who underwent the

destruction of skin lesions commented

that the physician charges for these

procedures were excessive. He stated

that the application of liquid nitrogen is

not time consuming and is an

insignificant cost and that the physician

work involved is minimal and does not

require great skill. We forwarded the

comment to the RUC. The specialty

society recommended to the RUC that

the work RVUs for these codes be

maintained.

The RUC responded by indicating that

the intention of the RUC and the 5-year

review is to examine work RVUs. The

RUC concluded that the comment we

forwarded was based on charges the

commenter incurred, a matter which is

not directly related to the mission of the

RUC. Therefore, the RUC recommended

that the current work RVUs be

maintained.

We acknowledge that part of the

individual’s comments related to the

charges he incurred. However, we

believe that the commenter raised a

legitimate concern about the amount of

physician work when he made reference

to the amount of time, physician

involvement, and skill required to

destroy a skin lesion. Therefore, we

reexamined the work RVUs assigned to

these codes and concluded they are too

high when compared to other services

on the fee schedule. CPT code 17000

(Destruction of a single benign facial or

premalignant lesion) currently has work

RVUs that are approximately 3.5 times

higher than the work RVUs assigned to

the destruction of a second similar

lesion (CPT code 17001). There are no

other services with such a variance. A

more appropriate valuation of CPT code

17000 would set the initial lesion

destruction at about twice the level of

the work RVUs for a subsequent lesion.

Therefore, we are proposing 0.36 work

RVUs. This downward revaluation of

CPT code 17000 is supported by

comparing the proposed work RVUs to

the following reference services: CPT

code 11700 (Debridement of nails), with

0.32 work RVUs, and CPT code 11050

(Paring of skin lesion), with 0.43 work

RVUs. These services are comparable to

CPT code 17000 in terms of setup time,

procedure time, risk, and aftercare.

We also believe that CPT code 17001

(Destruction of second and third benign

facial or premalignant lesion, each) and

CPT code 17002 (Destruction of over

three lesions, each additional lesion) are

overvalued. We propose to reduce the

work RVUs of these codes to 0.14. The

proposed work RVUs for these codes

would maintain approximately the same

ratio to CPT code 17101, with 0.11 work

RVUs, and CPT code 17102, also with

0.11 work RVUs, as CPT code 17000,

with 0.64 work RVUs, now has to CPT

code 17100, with 0.53 work RVUs, that

is, about 1.2. In other words, we believe

the current relative relationship of work

RVUs for the destruction of benign

facial or premalignant lesions (CPT code

17000) to the work RVU for the

destruction of benign lesions in areas

other than the face (CPT code 17100) is

correct but the work RVUs are too high.

Additionally, we are concerned that

there is an inconsistency in the current

CPT coding for these two groups of

codes. For benign non-facial lesion

destruction, CPT code 17104 is only

reported once for any number of lesions

numbering 15 or more. There is not

currently a parallel code for benign

facial or premalignant lesions, and there

is no limitation on the number of times

CPT code 17002 can be reported for

lesions removed during a single visit.

Also, we did not receive comments on

all of the destruction codes so we have

not addressed in this notice other

destruction of skin lesion codes that

appear to be overvalued. We plan to

address our concerns regarding the

coding and work RVUs for those

services in the future.

2. Orthopaedic Surgery

Originally, the American Academy of

Orthopaedic Surgeons submitted a

study of 1,300 orthopaedic services

conducted by Abt Associates, Inc. for

review during the 5-year review. In

addition, the American Academy of

Orthopaedic Surgeons submitted

detailed comments on 41 procedures.

The Abt study involved a combination

of a telephone survey of randomly

selected orthopaedic surgeons and

multiple consensus panels comprised of

orthopaedic subspecialists and

generalists. The American Academy of

Orthopaedic Surgeons considered the

work RVUs that resulted from the study

to be much more appropriately aligned

than the current work RVUs. In

addition, the American Academy of

Orthopaedic Surgeons believed that the

work RVUs in the current scale are

compressed at both the low and the high

end, whereas the Abt values expand the

scale in both directions.

The American Academy of

Orthopaedic Surgeons stated that the

Harvard study underestimated the

intraservice work of many of the

services its members furnish. The

commenter was particularly concerned

that the work RVUs for many of the

services are based on a survey of general

orthopaedic surgeons with little or no

experience performing highly

specialized services normally provided

by subspecialists within orthopaedic

surgery, such as pediatric orthopaedic

surgeons. For example, Harvard

included general orthopaedic surgeons

in the survey for CPT code 28262

(Capsulotomy, midfoot; extensive,

including posterior talotibial

capsulotomy and tendon(s) lengthening

as for resistant clubfoot deformity)

while the American Academy of

Orthopaedic Surgeons surveyed

pediatric orthopaedic surgeons with

much more experience performing the

procedure. The American Academy of

Orthopaedic Surgeons’ survey

confirmed that the Harvard study had

underestimated intraservice time.

The RUC reviewed the methodology

used by Abt and concluded that the

RUC should consider a survey of

representative codes using Abt’s

methodology to validate the relationship

of the Abt-developed work RVUs to

RUC-developed work RVUs. Instead, the

American Academy of Orthopaedic

Surgeons elected to withdraw the Abt

study and the comments on 41 codes.

The American Academy of Orthopaedic

Surgeons also elected to conduct a

survey of the work involved in 83 codes

that it believed were misvalued in

accordance with the RUC process. The

American Academy of Orthopaedic

Surgeons involved 11 national

orthopaedic subspecialty organizations

in this survey.

The RUC reviewed and recommended

increases in work RVUs for 37 of the 83

codes presented by the American

Academy of Orthopaedic Surgeons. The

RUC reviewed an additional 15 services

based on comments from the American

Academy of Pediatrics, the American

Society of Plastic and Reconstructive

Surgeons, and other commenters. In

general, the RUC did not accept

recommendations for increased work

RVUs when the American Academy of
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20021

Orthopaedic Surgeons’ survey time data

were similar to Harvard data or when

the reference services cited were not

appropriate. The RUC recommended

increased work RVUs to correct rankorder anomalies in codes for which the

American Academy of Orthopaedic

Surgeons’ surveys confirm that the

intraservice time for the procedure was

underestimated in the Harvard study

and the patient population had changed

in the past 5 years.

The RUC also reviewed and

recommended decreases for 10 of the 12

following orthopaedic services, which

the RUC identified as potentially

overvalued based on special analyses of

trends in claims data and the intensity

(work per unit of time) of the

intraservice work. This intensity of

intraservice work is expressed as

IWPUT, which is an acronym for

intraservice work per unit time.

CPT

code Descriptor

25065 Biopsy, soft tissue of forearm and/or

wrist; superficial.

26992 Incision, deep, with opening of bone

cortex (e.g., for osteomyelitis or

bone abscess), pelvis and/or hip

joint.

27001 Tenotomy, adductor of hip, subcutaneous, open.

27003 Tenotomy, adductor, subcutaneous,

open, with obturator neurectomy.

27006 Tenotomy, adductors of hip, subcutaneous, open (separate procedure).

27040 Biopsy, soft tissue of pelvis and hip

area; superficial.

27090 Removal of hip prosthesis (separate

procedure).

27265 Closed treatment of post hip

arthroplasty dislocation; without

anesthesia.

27266 Closed treatment of post hip

arthroplasty dislocation; requiring

regional or general anesthesia.

27323 Biopsy, soft tissue of thigh or knee

area; superficial.

27550 Closed treatment of knee dislocation; without anesthesia.

64763 Transection or avulsion of obturator

nerve, extrapelvic, with or without

adductor tenotomy.

The description of, and rationale for,

these decreases is included in section

II.C.7. of this notice, which contains the

discussion of the entire group of

services identified as potentially

overvalued.

HCFA Decision: We have accepted all

of the RUC recommendations for the

orthopaedic surgery codes.

3. Otolaryngology and Maxillofacial

Surgery

The American Academy of

Otolaryngology—Head and Neck

Surgery, Inc. submitted a study

conducted for it by Abt Associates, Inc.

that covered 800 codes, 417 of which

are considered to be primary

otolaryngology codes, and 100 of which

were discussed in detailed comments

for the 5-year review. The 100 codes

represent approximately 10 percent of

the universe of otolaryngolog—head and

neck surgery services. The comments

reflect the opinions of about 40

American Academy of Otolaryngology—

Head and Neck Surgery, Inc. members

with expertise in the services chosen.

The American Academy of Oral and

Maxillofacial Surgeons and the

American Society of Plastic and

Reconstructive Surgeons, Inc. also

submitted comments and presented

recommendations to the RUC for some

of the codes discussed in this section.

The RUC reviewed the methodology

used by Abt and concluded that the

RUC should consider a survey of

representative codes using RUC

methodology to validate the relationship

of the Abt-developed work RVUs to the

RUC-developed work RVUs. The

American Academy of Otolaryngology—

Head and Neck Surgery, Inc. surveyed

and submitted recommendations for 53

codes using the RUC methodology. The

survey response rate was low for many

of the codes for which we originally

received comments during the public

comment phase and, therefore, the

American Academy of Otolaryngology—

Head and Neck Surgery, Inc. chose to

withdraw these codes from the RUC

review.

The RUC was concerned by the lack

of compelling evidence for changing

many of the services presented by the

American Academy of Otolaryngology—

Head and Neck Surgery, Inc. and

recommended that their current work

RVUs be maintained. The RUC

identified several problems with these

services: Survey results for preservice

and postservice time appeared to be

overstated; inappropriate reference

services with different global periods

were used; the only arguments were that

the patient population presented

increased risk of HIV and hepatitis to

the physician, the patients had previous

radiation treatment, and acceptable

vocal cord capability is now more

important to patients. In addition,

commenters made many

recommendations to increase the

current work RVUs, but the American

Academy of Otolaryngology—Head and

Neck Surgery, Inc. data were very

similar to the Harvard time data. The

RUC also did not find the argument that

the IWPUT was understated, without

any other evidence, a compelling reason

to increase the work RVUs.

The RUC recommended increased

work RVUs for 30 codes to correct rankorder anomalies, address problems

when American Academy of

Otolaryngology—Head and Neck

Surgery, Inc. surveys confirm that the

intraservice time for the procedure was

underestimated in the Harvard study,

and when the patient population had

changed in the past 5 years making the

services more complex.

HCFA decision: We have accepted the

RUC recommendations for work RVUs

for 24 of the codes but have rejected its

recommendations for the following 6

codes: CPT code 21025 (Excision of

bone, lower jaw).

The current work RVUs are 5.03. A

commenter recommended an increase to

8.98 work RVUs since this code is

similar to CPT code 24134 (Removal of

arm bone lesion). The RUC noted that a

rank anomaly exists between this

service and CPT code 21030 (Excision of

benign tumor or cyst of facial bone other

than mandible) and CPT code 21041

(Excision of benign cyst or tumor of

mandible; complex). The American

Academy of Oral and Maxillofacial

Surgeons’ survey median for

intraservice time is 120 minutes, which

is significantly higher than CPT code

21041 and reference service CPT code

24134. Thus, the RUC recommended

that the American Academy of Oral and

Maxillofacial Surgeons’ survey median

of 8.92 work RVUs be adopted.

We believe that the surveyed vignette

does not represent the typical patient,

and it includes services for which other

codes can be reported. The vignette

describes a patient with intraoral and

extraoral swelling and suppuration from

multiple fistulae. Dissection of the

inferior alveolar nerve is required and

hyperbaric oxygen is initiated. We

believe this vignette describes a patient

with much more extensive infection

than the typical patient. It is also our

view that CPT code 21030, which has

7.05 work RVUs, is more difficult than

this procedure. Therefore, we are

retaining the current 5.03 work RVUs

for CPT code 21025. CPT codes 31531,

31536, 31541, 31561, and 31571

(Operative laryngoscopies).

We received comments that CPT

codes 31541, 31561, and 31571 are

undervalued because of increased

patient complexity and greater emphasis

on acceptable vocal results. The RUC

did not find those arguments

compelling enough to suggest a change

in work RVUs.

However, the RUC identified rank

order anomalies in the work RVUs for

direct laryngoscopies and the

corresponding procedures using an

operating microscope. Among the five
20022 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

pairs of procedures, the difference in

work RVUs for use of the operating

microscope varies from ¥0.57 to +0.34

work RVUs. The RUC recommended

retaining the 1995 work RVUs for the

direct laryngoscopies (CPT codes 31530,

31535, 31540, 31560, and 31570) and

adding a constant 0.40 work RVUs to

arrive at the work RVUs for the

corresponding procedures using an

operating microscope (CPT codes 31531,

31536, 31541, 31561, and 31571).

We disagree with the concept of

increasing the work RVUs for

procedures using an operating

microscope and believe that the work

RVUs for a procedure generally should

be the same, regardless of the technique

used. For example, the destruction of

skin lesions (CPT codes 17000 through

17105) are valued the same regardless of

the method of destruction. Therefore,

we have established work RVUs that are

the same for both codes in a pair.

4. Podiatry

The American Podiatric Medical

Association submitted comments on

services that its members frequently

perform that may be inappropriately

valued. The organization’s comments

were based on surveys of the members

of the organization representing the

spectrum of foot and ankle services, as

well as geographic diversity. In

addition, the organization relied on data

from two previous national surveys on

preservice and intraservice care

prepared by the American Podiatric

Medical Association for the Physician

Payment Review Commission.

The American Podiatric Medical

Association submitted

recommendations to the RUC for review

in two formats: surveyed services with

completed summary of recommendation

forms and a letter detailing rationale for

those services they did not survey. The

Association also commented on 13

codes that it considers to be overvalued.

RUC Evaluation/Recommendation:

The RUC’s position was that the

American Podiatric Medical Association

had not provided compelling evidence

for changing the work RVUs for any of

the services for which no survey was

conducted. Neither did the RUC find

surveys that only confirmed the Harvard

survey times to be sufficient evidence to

justify change. However, the survey data

for CPT codes 28113 and 28288 and

HCPCS code M0101 persuaded the RUC

to recommend increases in the work

RVUs for these services. The RUC also

did not concur with the American

Podiatric Medical Association’s

comment about overvalued procedures

and recommended that the current work

RVUs be maintained.

HCFA Decision: We have accepted all

but one of the RUC’s 20

recommendations for podiatry (19

resulting from the American Podiatric

Medical Association’s comments and

one to maintain a rank order between

codes): HCPCS code M0101 (Cutting or

removal of corns).

The current work RVUs are 0.37. A

commenter recommended that we

increase the work RVUs to 0.70 based

on the view that this service is

significantly more difficult than the

work for CPT code 11050 (Paring or

curettement of benign hyperkeratotic

skin lesion with or without chemical

cauterization (such as verrucae or clavi)

not extending through the stratum

corneum (e.g., callus or wart) with or

without local anesthesia; single lesion),

which is valued at 0.43 work RVUs, and

CPT code 11700 (Debridement of nails,

manual; five or less), which is valued at

0.32 work RVUs. The preservice work is

slightly greater than reference

procedures CPT codes 11050 and 11700,

but the intraservice work was reported

by a survey as 250 percent greater than

either reference procedure. The

commenter stated that the technical

skill for these services is similar;

however, physical effort is much greater

for HCPCS code M0101. The RUC

agreed that HCPCS code M0101

involves more work than treating 2 skin

lesions and trimming 10 toenails and

that this service is undervalued. It

proposed 0.45 work RVUs. We disagree

with these proposed work RVUs. The

description of this service is ‘‘cutting or

removal of corns, calluses and/or

trimming of nails, application of skin

creams and other hygienic and

preventive maintenance care (excludes

debridement of nail(s).’’

We believe that the service most

reported by this code is trimming of

nails, which is of less intensity than the

work associated with cutting or removal

of corns and calluses. The typical

service involves the less intense

portions of this complex definition. The

surveys conducted by the American

Podiatric Medical Association used

vignettes of patients with circulatory

impairment and neurologic deficit

accompanying systemic disease. The

existence of these comorbid conditions

may not accurately reflect the work

RVUs for the typical patient. Although

current Medicare coverage is restricted

to the more difficult patients with

coexisting disease, we base the work

RVUs on the typical patient. The RUC

survey methodology is based on

vignettes that are intended to describe

the typical patient and service. In this

case, we believe the vignette describes

an unusual or atypical patient which

results in an RVU recommendation that

exceeds the current work RVUs. We

believe that the usual service of

trimming of nails is less work than the

paring or curettement of other less

common procedures such as benign

hyperkeratotic skin lesions and,

therefore, have decided to maintain the

current 0.37 work RVUs.

5. Cardiology and Interventional

Radiology

The RUC considered comments

submitted by the Society of

Cardiovascular and Interventional

Radiology, the Society of Critical Care

Medicine, and the American College of

Cardiology on 25 cardiology and

interventional radiology procedures.

The Society of Cardiovascular and

Interventional Radiology reported to the

RUC that it did not conduct a RUC

survey. The Society of Cardiovascular

and Interventional Radiology sent a

survey containing all of the

interventional radiology codes to 60

interventional radiologists that asked

the physicians to evaluate the 1995

work RVUs for each code and select

those codes that they believed were

misvalued. For the codes selected, the

respondents were instructed to indicate

which CPT code they believed more

accurately described the service in

terms of time and intensity. These

responses were evaluated by a small

working group formed by the Society of

Cardiovascular and Interventional

Radiology consisting of physicians that

are familiar with CPT, work RVUs, and

the RUC process. Those codes that were

identified by the working group as

misvalued were the codes upon which

that society commented. In its

comments to us and during the RUC

presentation, the Society of

Cardiovascular and Interventional

Radiology mentioned that the physician

work for vascular ultrasound studies is

equal to all other diagnostic ultrasound

services, including those in the

abdomen, chest, pelvis,

retroperitoneum, and heart. The work

RVU recommendations are based on

work RVUs for either ‘‘limited’’ or

‘‘complete’’ ultrasound examinations in

those areas.

HCFA Decision: We have accepted all

but two of the RUC recommendations

for the cardiology and interventional

radiology codes: CPT codes 93307 and

93312, both for echo exam of heart.

CPT code 93307 (Echocardiography,

real-time with image documentation

(2D) with or without M-Mode recording;

complete).

We received a comment that the field

of echocardiography has changed

significantly in the past 5 years, in both
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20023

clinical utility and diagnostic

complexity. Although the technical

innovations of the past 5 years have

made this an easier service to perform,

the patients that require this service are

more complex, which has resulted in an

increased amount of physician work.

The physicians are viewing and making

judgments on constantly moving

objects, which increases the possibility

of misinterpretation. Often this service

is furnished in acute care settings or

emergency situations, which increase

physician stress. The information

derived from this study is used in the

development of critical management

decisions. The risk of misdiagnosis, in

both emergent and nonemergent

situations, can lead to potentially fatal

events.

The current work RVUs for

echocardiography are 0.78. The RUC

agreed that the code is undervalued

based on the amount of physician work

that is required to perform this study

and the increased amount of

information that can now be derived

from echocardiography. However, the

RUC believed that the specialty society

recommendation of 1.48 work RVUs

was too high and recommended the

Harvard value for this procedure, which

was 1.06 work RVUs.

We do not agree that

echocardiography is undervalued. We

believe that technical innovations have

made physician interpretations of

echocardiograms less difficult than in

the past. We also believe that some of

the work that is being reported as

physician work is actually the work of

technicians. For example, the

description of intraservice work

provided to the RUC implies that

physicians review entire tapes and

analyze and measure the structure and

dynamics of the chambers, valves, and

great vessels. It is our understanding

that much of this information is

prepared by technicians for subsequent

review by physicians. We consider the

work of technicians to be a practice

expense that is reflected in the practice

expense RVUs, not the physician work

RVUs. We also question whether the

vignette surveyed by the specialty

society, which describes an

echocardiogram performed on an

acutely ill patient in need of emergency

echocardiography, represents the typical

patient requiring echocardiography.

Medicare claims data from calendar year

1995 indicate that 50 percent of claims

for CPT code 93307 are billed with

place of service as office or outpatient

hospital and 49 percent are billed with

place of service as inpatient hospital.

This suggests that the typical patient is

not critically ill or that there is a

bimodal distribution of patients.

CPT code 93312 (Echocardiography,

real-time with image documentation

(2D) (with or without M-Mode

recording), transesophageal; including

probe placement, image acquisition,

interpretation and report).

We received a comment that

transesophageal echocardiography is

undervalued in comparison to other

services that require similar physician

work effort and that performance of this

procedure requires considerable mental

effort. As described above in the

discussion of CPT code 93307, the heart

is constantly moving, increasing the

possibility of misinterpretation, which

could lead to misdiagnosis. There is an

added technical skill required by the

physician to insert the probe into the

esophagus and the stomach of a

critically ill patient. This procedure is

often performed in the emergency

setting while the patient is under

conscious sedation. As a point of

reference, the RUC reviewed Harvard

Phase III data that show 2.76 work RVUs

(adjusted to be on a scale equivalent to

1995 work RVUs) for upper

gastrointestinal endoscopy (CPT code

43235), the reference code being used in

this comparison. These work RVUs are

higher than both the existing 1.57 work

RVUs and the 2.39 work RVUs

recommended by the specialty society.

The RUC agreed with the specialty

society rationale and recommended an

increase to 2.39 work RVUs.

For reasons similar to those described

above for CPT code 93307, we do not

believe that transesophageal

echocardiography is undervalued. This

service was considered by a refinement

panel in 1993, and, based on the ratings

of the panel, the RVUs were not

increased. We do not find the new

evidence submitted by the RUC to be

sufficient to warrant an increase in

RVUs.

6. General Surgery, Colon and Rectal

Surgery, and Gastroenterology

The review of general surgery

procedures primarily addressed

comments submitted by the American

College of Surgeons on codes identified

as misvalued through a study conducted

by Abt Associates, Inc. Although this

study identified many procedures as

potentially misvalued, the American

College of Surgeons’ comments selected

only 30 codes for review, based on the

magnitude of the potential change and

their frequency and expenditures. The

American College of Surgeons

recommended both increases and

decreases.

The American Society of General

Surgeons also submitted comments on a

number of procedures, including several

general surgery procedures, and their

suggestions were consistent with some

of those made by the American College

of Surgeons.

The American Society of Colon and

Rectal Surgeons submitted comments

indicating that the partial colectomy

codes and hemorrhoidectomy codes

should be reviewed to place them in a

more correct rank-order from least to

most difficult. Other commenters also

identified rank-order problems in these

families and further identified three

overvalued procedures. The American

Society of General Surgeons

recommended that the work RVUs for

several colon and rectal procedures be

increased.

Comments were submitted by the

American College of Gastroenterology

and another commenter on several

gastroenterology codes.

Of the 30 codes on which the

American College of Surgeons

commented, the RUC recommended

adopting most of the recommended

decreases and a few of the

recommended increases, based on

results from a survey of 175 surgeons,

comparisons to the final Harvard study

results, comparisons to key reference

services, and analysis of Medicare

claims data.

The current work RVUs for several of

the codes identified by the American

Society of General Surgeons, however,

are based on recent RUC

recommendations, and, in the absence

of new evidence, the RUC did not

believe reconsideration was warranted

for these codes.

The RUC agreed with most of the

changes recommended by the American

Society of Colon and Rectal Surgeons

based on the evidence provided by the

Society.

The RUC did not believe compelling

new evidence had been provided to

support either an increase or a decrease

in the work RVUs for the

gastroenterology codes on which the

American College of Gastroenterology

commented. The RUC has previously

reviewed most work RVUs for the

gastroenterology procedures and has

recently considered the evidence for

adjusting these work RVUs and did not

find the evidence to be persuasive.

HCFA Decision: We have accepted all

but one of the RUC recommendations

for general surgery, colon and rectal

surgery, and gastroenterology codes:

CPT code 43830 (Place gastrostomy

tube).

The current work RVUs are 4.84. A

commenter noted that an anomaly exists
20024 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

between CPT code 43750 (Place

gastrotomy tube), which is assigned 5.71

work RVUs, and CPT code 43830 since

the latter procedure is more complex.

The commenter recommended 7.50

work RVUs. The RUC noted that the

Harvard data indicate that the IWPUT

for CPT code 43750 is 0.082, while it is

0.059 for CPT code 43830. Since CPT

code 43830 is much more complex than

CPT code 43750, the IWPUT is the

reverse of the appropriate relationship.

The RUC recommended 7.50 work

RVUs for CPT code 43830.

We relied on Harvard work RVUs to

reestablish the proper relationship by

accepting the decrease recommended by

the RUC for CPT code 43750 and

increasing CPT code 43830 to 6.52 work

RVUs. We rejected the RUC

recommendation of 7.50 work RVUs for

CPT code 43830 as too high since this

recommendation would value

placement of a gastronomy tube higher

than CPT code 49507 (Repair of an

inguinal hernia), which is assigned 7.40

work RVUs and appear to approximate

the work of placing a gastrostomy tube.

7. Urology

Commenters advocated reductions in

about 40 urology-related CPT codes. In

most cases, commenters based their

rationale on comparisons to crossspecialty procedures. Work RVUs were

reduced to the level of the work RVUs

of the cross-specialty procedure. The

commenters also attempted to link the

reduction of one code in a family to

other codes in an effort to maintain the

reduction of work RVUs throughout the

family. Typically, the response of the

American Urological Association was to

survey the code and to refute the crossspecialty link established by the

commenters. The rationale established

by the American Urological Association

was generally compelling in that it was

based on anatomical, technical, and

patient-population differences that

proved the cross-specialty comparisons

to be faulty. Usually, the American

Urological Association’s arguments

were supported by survey data that

validated their claims when compared

to Harvard data. In many instances,

surveyed intraservice time was greater

than the Harvard data showed, and

work RVUs turned out to be greater than

established 1995 work RVUs.

RUC Evaluation/Recommendation:

The RUC examined the American

Urological Association’s arguments

against the cross-specialty links and

proposed work RVU reductions. They

evaluated the aspects of the arguments

and typically came to the conclusion

that the reference procedures chosen for

comparison by the commenters were

inappropriate. The RUC also analyzed

survey data to determine if time and

complexity measures were sufficient to

support the arguments of the American

Urological Association. The RUC also

looked at time and complexity gains to

ascertain if increased work RVUs were

necessary. The basis for many of the

comments was comparison between

urology codes and codes in other

specialties. As part of its review, the

RUC compared several urology codes to

other procedures on its multiple points

of comparison reference set based on the

IWPUT. The urology codes proved to be

well within expected levels. For

example, CPT code 50010 (Exploration

of kidney) has an IWPUT of 0.094,

which compares to CPT code 93510

(Left heart catheterization), with an

IWPUT of 0.099; CPT code 26531

(Revise knuckle with implant), with an

IWPUT of 0.090; CPT code 66984

(Remove cataract, insert lens), with an

IWPUT of 0.121; or CPT code 61700

(Inner skull vessel surgery), with an

IWPUT of 0.088. CPT code 54200

(Treatment of penis lesion) has an

IWPUT of 0.038, which compares to

CPT code 11642 (Removal of skin

lesion), with an IWPUT of 0.047; CPT

code 45110 (Removal of rectum), with

an IWPUT of 0.061; or CPT code 46260

(Hemorrhoidectomy), with an IWPUT of

0.049. Generally, the RUC found that the

recommended reductions were not

appropriate, but that rationale and data

were also not sufficiently compelling to

support specialty-recommended

increased work RVUs. As a result, the

RUC recommended that 37 of the 46

codes be maintained at 1995 levels.

HCFA Decision: We have accepted all

but three of the RUC recommendations

for the urology codes: CPT code 50205

(Biopsy of kidney).

The current work RVUs are 12.69. A

commenter recommended a decrease to

6.75 work RVUs since the procedure

requires no more work, time, or effort

than CPT code 47100 (Wedge biopsy of

liver), which is assigned 6.75 work

RVUs. In addition, the commenter

argued, this procedure is incorrectly

valued relative to kidney exploration;

the biopsy should be lower than an

exploration. The RUC noted that most

renal biopsies are not open but

percutaneous procedures; however, CPT

code 50205 is an open procedure.

Survey data show median intraservice

time of 75 minutes and median work

RVUs of 18.50. Although the American

Urological Association recommended

increasing the work RVUs up to the

survey median, the RUC found no

compelling evidence to increase the

work RVUs.

We rejected the RUC recommendation

to retain the current work RVUs and

have assigned 10.50 work RVUs, a value

slightly greater than CPT code 50010

(Exploration of the kidney) to reflect the

added work of the open procedure

biopsy.

CPT code 50590 (Lithotripsy,

extracorporeal shock wave).

The current work RVUs are 9.62. A

commenter recommended a reduction to

6.54 work RVUs based on an argument

that this is not a surgical procedure. The

commenter compared the intraservice

work to 1 hour of critical care. The

proposed work RVUs also include two

hospital visits (CPT codes 99221 and

99231) and 2.5 level-three office visits

(CPT 99213). The RUC believed that this

procedure is similar to a surgical

procedure in that anesthesia is used and

a urologist is always present. The RUC

concluded that the current work RVUs

should not be reduced based on its

analysis of survey data showing a

median intraservice time of 80 minutes.

We disagree with the RUC

recommendation to maintain the 9.62

work RVUs. We believe the intraservice

intensity of extracorporeal shock wave

lithotripsy is more comparable to

evaluation and management services

than traditional surgical services. For

example, the current 9.62 work RVUs

are higher than those for an exploratory

laparotomy (CPT code 49000), with 8.99

work RVUs. We have assigned 7.13

work RVUs to CPT code 50590 based on

90 minutes of critical care (CPT codes

99291 and 99292), with work RVUs of

3.64 and 1.84, respectively, and three

mid-level office visits (CPT code 99213),

with 0.55 work RVUs.

CPT code 51741 (Electrouroflowmetry, first).

The current work RVUs are 1.57. A

commenter recommended a reduction to

1.14 work RVUs to bring the code into

correct alignment with the family of

codes. The RUC recommended no

change in the current work RVUs. We

believe that a reduction in work RVUs

to 1.14 is appropriate to maintain the

proper relationship to CPT code 51736

(Urine flow measurement), which the

RUC reduced from 0.84 work RVUs to

0.61 work RVUs.

8. Gynecology

Comment: The American College of

Obstetricians and Gynecologists has had

significant and longstanding concerns

about the accuracy of the work RVUs

assigned for obstetric and gynecologic

services. The American College of

Obstetricians and Gynecologists

believed that the work RVUs for services

furnished to women have been

historically undervalued when
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20025

compared to similar services on men or

on similar anatomical structures. The

American College of Obstetricians and

Gynecologists presented survey data

and arguments for 45 codes, 44 of which

recommended increased work RVUs. In

addition to providing survey data, the

American College of Obstetricians and

Gynecologists developed rationales

based on a ‘‘building block’’ method

using survey data on service

characteristics and work RVUs of

established codes. The building block

method also uses preservice,

postservice, and intraservice work

intervals to assign physician work RVUs

to the individual components of the

global surgical services package.

Appropriate work RVUs for preservice

and postservice intervals for the

evaluation and management services

were selected based on length of time,

number of visits, clinical setting, and

judgment of level of care required.

Using this method, the American

College of Obstetricians and

Gynecologists was able to arrive at work

RVU estimates for surgical codes with a

variety of global periods.

The survey data in almost every case

supported an increase in work RVUs.

The surveys had a minimum survey

sample size of 100 and response rates in

excess of 30 percent. The surveyed

intraservice times were consistently

substantially greater than Harvard

intraservice times. The work RVUs that

were derived from a survey were in

every case greater than the established

work RVUs. When the building block

method was used, it produced results

that confirmed the survey data and

argued for increased work RVUs. The

American College of Obstetricians and

Gynecologists used cross-specialty

comparisons to validate both survey

data and its building block method.

Cross-specialty comparisons were

especially convincing when direct

parallels could be drawn to similar

services on men or similar procedures to

manage like disease in different organs.

RUC Evaluation/Recommendation:

The RUC found the multiple

independent points of validation

convincing. The survey, building block,

and cross-specialty comparisons

typically supported the claim for

increased work RVUs. Generally, the

RUC was skeptical of the building block

approach. The RUC believed that there

was too much room for subjective

selection of the type and level of

evaluation and management services.

The RUC also recognized that double

counting and overestimation of work

components may yield results for which

the sum of the parts exceeds the whole.

Typically, the RUC accepted the lowest

work RVU increase generated by the

three methods.

HCFA Decision: We have accepted all

of the RUC recommendations for the

gynecology codes.

9. Neurosurgery

Comment: The American Association

of Neurological Surgeons/Congress of

Neurological Surgeons submitted

comments identifying 73 misvalued

services, both undervalued and

overvalued. The comments presented a

detailed history of the work RVUs for

neurosurgery, identifying several

problems in the methodology and

results of the original Harvard study,

particularly in the change from

intraoperative work to total work in the

cross-specialty linkage process and in

review by refinement panels. The

commenter attributed the basic problem

to the Harvard cross-specialty linkage

process, arguing that it caused

distortions and compressions of work

RVUs within the neurosurgery services.

Although this was corrected to some

degree in Phase III of the Harvard study,

the 1992 refinement panels did not

accept many of the final Harvard

numbers for neurosurgical procedures.

Even the final Harvard data contain

errors in data on postservice work, and

the study often does not assume any

intensive care unit visits when at least

several would be furnished by the

neurosurgeon.

Most of the arguments presented

focus on the nontemporal components

of physician work, described as

‘‘intensity.’’ The commenters explained

that the current work RVUs do not

accurately reflect the varying levels of

intensity for different neurosurgical

procedures, nor within the different

components of each service. To identify

the specific codes that are misvalued in

the current scale, the American

Association of Neurological Surgeons/

Congress of Neurological Surgeons

conducted a survey in 1994. This

organization surveyed a representative

sample of 200 neurosurgeons to evaluate

in detail the time and intensity of the

key reference services for neurosurgery

in accordance with our discussion of the

nature and format of comments on work

RVUs that appeared in our December 8,

1994 final rule (59 FR 63454 to 63455).

The survey did not ask physicians to

reevaluate the total work RVUs for these

procedures. The time data gathered from

this study, which included detailed

operative logs on over 1,500

neurosurgical patients, were found to

correspond closely to the final Harvard

Phase III data, and the American

Association of Neurological Surgeons/

Congress of Neurological Surgeons

concluded that the survey validated the

Harvard results for this component of

work. The study also attempted to

directly measure mental effort and

judgment, technical skill and physical

effort, and psychological stress, rather

than calculating it as a ratio of work to

time. This allowed for more variation

within each component of intensity and

greater precision in calculating work

RVUs. This research confirmed the

problems initially identified by the

American Association of Neurological

Surgeons/Congress of Neurological

Surgeons that, for some of the most

complex procedures, preservice and

postservice work were underestimated

by 30 to 40 percent.

The focus of the American

Association of Neurological Surgeons/

Congress of Neurological Surgeons’

comments was on appropriately valuing

the codes within neurosurgery by

adjusting the rank-orders upwards and

downwards. To develop its

recommendations to the RUC, the

American Association of Neurological

Surgeons/Congress of Neurological

Surgeons conducted a second survey in

1995, which led the RUC to make some

adjustments in the recommended work

RVUs. In addition, the American

Association of Neurological Surgeons/

Congress of Neurological Surgeons

identified five more misvalued codes

that had not been mentioned in its

original comments.

RUC Evaluation/Recommendation:

The RUC evaluated the approach used

to calculate the recommended work

RVUs and considered it to be

reasonable. There was some discussion

of ‘‘lumping’’ vs. ‘‘splitting,’’ because

the American Association of

Neurological Surgeons/Congress of

Neurological Surgeons’ methodology of

measuring intensity ‘‘splits’’ it out from

overall work. On the other hand, the

time periods used by the American

Association of Neurological Surgeons/

Congress of Neurological Surgeons were

the same as those used by Harvard, and

the time estimates were based on

objective data, not on surgeons’

opinions about how much time they

spend doing each component of work.

In fact, for a number of the services

studied by the American Association of

Neurological Surgeons/Congress of

Neurological Surgeons, the resulting

work RVUs tended to validate the final

work RVUs from the Harvard study. For

example, CPT code 61480 (Craniectomy,

suboccipital; for mesencephalic

tractotomy or pedunculotomy) currently

has 16.77 work RVUs, but the final

Harvard work RVUs for the service are

25.55, and the neurosurgery study
20026 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

produced a recommended 25.03 work

RVUs.

The effort appeared to the RUC more

as an attempt to bring a higher degree

of precision to the work RVUs for

neurosurgery than to split work into

more components in order to inflate the

work RVUs. The recommended

reductions in some higher frequency

codes bolstered this perception (for

example, CPT code 63030 (Laminotomy

(hemilaminectomy), with

decompression of nerve root(s),

including partial facetectomy,

foraminotomy and/or excision of

herniated intervertebral disk; one

interspace, lumbar) was reduced from

12.11 to 11.10 work RVUs and had a

frequency of 29,103 in 1994). In

addition, a number of very low

frequency services, including some

pediatric codes, were included in the

analysis and recommendations (for

example, CPT code 61480 (Craniectomy,

suboccipital; for mesencephalic

tractotomy or pedunculotomy), which

had zero claims in 1994). Services that

are both highly specialized and very

infrequently furnished may not have

received sufficient attention in the

Harvard study.

To evaluate the results of this

approach, the RUC workgroup, which

included a general surgeon, an

ophthalmologist, and a psychiatrist, first

selected a number of the codes and

calculated two ratios: (1) recommended

total work RVUs/intraservice time, and

(2) recommended total work RVUs/total

time. The results of this analysis were

very consistent with one another and

with other codes with work RVUs, with

nearly all of the codes having a ratio of

work RVUs to total time of about 0.05

and ratios of work RVUs to intraservice

work time of 0.10 to 0.14. The highest

intraservice work ratio was 0.178 for

CPT code 61700 (Surgery of intracranial

aneurysm, intracranial approach;

carotid circulation), with 48.30

recommended work RVUs. The results

were considered appropriate because of

the extremely complex and difficult

nature of the service, when compared

both to other codes within the family of

intracranial vascular codes and to other

major neurosurgical services.

The RUC then selected several of the

codes for comparison with codes on the

multiple points of comparison with

which they were familiar:

• CPT code 61682 (Surgery of

intracranial arteriovenous malformation;

supratentorial, complex), with 59.47

recommended work RVUs, was

compared with CPT code 33870

(Transverse aortic arch graft), which has

37.74 work RVUs. This service involves

the surgical efforts to obliterate and

remove a congenital vascular

malformation from within the brain,

frequently deep within a cerebral

hemisphere. Many of the issues that

contribute to the high complexity of

CPT code 61700 also apply to this

service, although preservice and

postservice work complexity is

somewhat lower. This service requires

420 minutes of intraoperative time,

however, compared to 270 minutes for

CPT code 61700.

• CPT code 67107 (Repair of retinal

detachment), with 13.99 work RVUs,

was compared to CPT code 61875

(Implantation of neurostimulator

electrodes), with 13.79 recommended

work RVUs. The intraservice work ratio

for retinal detachment is 0.13 and the

total work ratio is 0.049; for the

neurosurgery code the intraservice work

ratio is 0.115 and the total work ratio is

0.04. The ratio comparisons and the

work and time involved in each service

appear to be correct. CPT code 67107

involves 107 minutes of intraoperative

time, and CPT code 61875 involves 120

minutes of intraoperative time. The final

Harvard work RVUs for CPT code 61875

are 14.06.

• The comparison of CPT code 61702

(Surgery of intracranial aneurysm), with

46.31 recommended work RVUs, to CPT

code 48150 (Partial removal of

pancreas), with 42.53 work RVUs, also

seems correct, since CPT code 61702

involves surgery of a vertebral or basilar

artery aneurysm and has the same high

levels of mental effort, technical skill,

and stress/risk outlined above for CPT

code 61700.

The RUC concluded that the

neurosurgery study produced work RVU

recommendations that are considerably

more precise than the current work

RVUs for these services.

Three of the codes surveyed by the

American Association of Neurological

Surgeons/Congress of Neurological

Surgeons were also the subject of other

comments and were therefore reviewed

individually by the RUC:

• For CPT code 61791 (Creation of

lesion by stereotactic method,

percutaneous, by neurolytic agent (e.g.,

alcohol, thermal, electrical,

radiofrequency); trigeminal medullary

tract) with 7.29 work RVUs, the

commenters recommended an increase

to 13.29 work RVUs because the service

is substantially more difficult than CPT

code 61790, which is the same service

performed on the gasserian ganglion,

with 10.31 work RVUs. The RUC

recommended a somewhat higher

increase to 13.99 work RVUs rather than

the 13.29 work RVUs recommended by

commenters. The Harvard work RVUs

for this service are 14.28.

• For CPT code 62290 (Injection

procedure for diskography, each level;

lumbar), with 3.58 work RVUs, we

received a comment recommending a

reduction to 2.05 work RVUs, which

would be 25 percent more than the work

RVUs for CPT code 62289 (Injection of

substance other than anesthetic,

antispasmodic, contrast, or neurolytic

solutions; lumbar or caudal epidural

(separate procedure)). The American

Association of Neurological Surgeons/

Congress of Neurological Surgeons

argued that CPT code 62289 is a poor

reference for CPT code 62290 because

the techniques are not very comparable

and the targets and risks are different.

The RUC agreed with this argument.

The American Association of

Neurological Surgeons/Congress of

Neurological Surgeons stated that CPT

code 62291 (Injection procedure for

diskography, each level; cervical), with

2.91 work RVUs, is a better reference.

The specialty society stated that CPT

code 62290 should be reduced from 3.58

to 3.00 work RVUs to allow for the fact

that lumbar diskography is inherently

more difficult than cervical diskography

and still maintain the correct rank-order

of the current work RVUs.

• For CPT code 64443 (Injection,

anesthetic agent; paravertebral facet

joint nerve, lumbar, each additional

level), with 1.35 work RVUs,

commenters recommended the code be

valued at 50 percent of CPT code 64442

(Injection, anesthetic agent;

paravertebral facet joint nerve, lumbar,

single level) because it is an add-on

code and does not involve preservice

and postservice work. Although the

general rule is that about 50 percent of

the work is intraservice work and 50

percent is preservice and postservice

work, this, however, does not hold true

for many minor procedures. In fact, the

work RVUs for CPT code 64443 were

already reduced significantly when the

global period was changed in 1994. For

these two codes (CPT code 64442 and

CPT code 64443), the ratio is

approximately 61 percent. The RUC

recommended, therefore, that the work

RVUs for CPT code 64443 be reduced to

0.98 from 1.35, but not to 0.78, as

recommended by the commenter.

The RUC believed it is important to

add all of the codes identified by the

American Association of Neurological

Surgeons/Congress of Neurological

Surgeons to the 5-year review in order

to have correct rank-ordering of codes

across neurosurgical procedures. In

addition, the RUC considered

recommending that all the neurosurgery

codes in the 5-year review be rescaled

so that the net effect of the changes in

work RVUs would be zero to make the
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20027

changes work-neutral. Although the

American Association of Neurological

Surgeons/Congress of Neurological

Surgeons recommended changes in a

very large number of codes, the overall

impact of the recommendations is

relatively small. An AMA analysis using

1994 frequency data found that

acceptance of the recommended

changes would only increase Medicare

expenditures by about $3.8 million. The

RUC recommended, therefore, that all

the suggested changes be adopted

without any rescaling.

HCFA Decision: We have accepted all

but one of the RUC recommendations

for the neurosurgery codes: CPT code

61793 (Stereotactic focused proton

beam or gamma radiosurgery).

The RUC recommended an increase in

work RVUs from 16.70 to 17.88. We

disagree with this recommendation,

which is based in large part on a

calculation of the intraservice time

components by the American

Association of Neurological Surgeons

rather than on the surveyed time. The

calculated time was 210 minutes, while

the surveyed time was 120 minutes. We

are concerned that the calculated

intraservice time includes specific

elements that are described and

reported by codes in the radiation

oncology section of CPT. For example,

the calculated time includes 15 minutes

for ‘‘stereotactic images processed by

dose planning computer using dose

planning module for optimal

dosimetry’’ and 15 minutes for

‘‘planned dose tested in radiosurgical

device to assure correct targeting and

dosimetry.’’ In view of our concern, we

have decided to maintain the current

16.70 work RVUs.

10. Ophthalmology

The American Academy of

Ophthalmology and the American

Optometric Association responded to

comments requesting that the work

RVUs for 11 cataract-related codes be

reduced. In addition, the American

Academy of Ophthalmology surveyed

several codes and recommended work

RVU increases. Arguments supporting

increased work RVUs relied on surveys,

comparisons to cross-specialty codes,

and rationale claiming that procedures

have changed and now require adjusted

work RVUs. The response rates and

resulting samples were of sufficient size

to produce valid results.

Generally, the RUC found the data,

comparisons, and arguments

convincing. The RUC was looking for

compelling evidence that the procedure

had changed, the patient population had

changed, or the code had been originally

undervalued or overvalued. When the

RUC recommended different work

RVUs, it typically attempted to

reconcile new survey data and rationale

with Harvard data. This approach

produced final recommended work

RVUs below those recommended by the

specialty society. In all, the RUC

proposed that the work RVUs be

reduced for 7 codes, increased for 12

codes, and maintained at the current

value for 29 codes.

HCFA Decision: We have accepted all

but one of the RUC recommendations

for the ophthalmology codes: CPT code

66821 (Discission of secondary

membranous cataract (opacified

posterior lens capsule and/or anterior

hyaloid); laser surgery (e.g., YAG laser)

(one or more stages)).

We referred a comment to the RUC

which stated that this service is

overvalued and that the work RVUs

should be reduced to 2.30. The basis of

this recommendation was that the

technical skill and intensity of work for

CPT code 66821 are significantly lower

than for CPT code 66820 (Incision,

secondary cataract). In addition, the

intraservice time is less, and the number

of outpatient visits during the global

period are fewer.

The RUC reviewed the survey data

which showed a median intraservice

time of 11 minutes and median work

RVUs of 3.42. The intraservice skill and

complexity were considered to be

comparable to those of CPT code 66761

(Revision of iris) and CPT code 67031

(Laser surgery, eye strands). The RUC

concluded that the survey data and

comparisons were sufficiently

compelling to reject the commenter’s

recommended decrease in work RVUs.

The RUC recommended that the current

work RVUs be maintained.

We disagree. On a related matter, we

had forwarded a comment to the RUC

that the cataract codes were overvalued

because the procedures typically can be

performed in a shorter period of time

than the 54 minutes in the Harvard data.

However, we accepted the surveyed

median intraservice time of 50 minutes

presented to the RUC for cataract

surgery as the basis for not reducing the

work RVUs. Applying the intraservice

work intensity of the cataract procedure

(CPT code 66984) to the 11 minutes of

surveyed intraservice time for the YAG

laser procedure results in 2.15 work

RVUs, which we are proposing for CPT

code 66821. We believe this comparison

is appropriate because we do not believe

that the intensity of a YAG laser

procedure is greater than the intensity of

a cataract extraction.

For information on eye visit codes,

see the discussion of the evaluation and

management codes in section II.C.1. of

this notice.

11. Imaging

The RUC considered public

comments submitted by the American

College of Radiology, the American

College of Cardiology, and the Society

for Cardiovascular and Interventional

Radiology. The American College of

Radiology cited nine radiology codes

that it believed are misvalued. The

American College of Radiology noted

that a multidisciplinary approach was

used to identify these nine procedures.

Specifically, radiologists in each

specialty of radiology were asked to

review the procedures they perform and

determine whether or not the work

RVUs reflect the difficulty of the

procedure. A multidisciplinary panel of

radiologists and the American College of

Radiology Commission on Economics

then reviewed the selected procedures.

The panel determined that it could

present an adequate case for

reconsideration of the work RVUs for

these nine procedures.

We received many comments which

generally stated that radiology codes

were overvalued. The most common

reasons given were the following: Plain

film studies are relatively overvalued

compared to more complex radiographic

procedures; ultrasound studies are

overvalued; and the most common

computerized axial tomography and

magnetic resonance imaging studies are

overvalued. A comment also suggested

that plain film studies appeared

overvalued relative to evaluation and

management services. Other comments

suggested that simple planar procedures

such as aortography should be

decreased to equate the readings of

these films with equivalent noncontrast

studies; magnetic resonance imaging

should be revalued to reflect easier

interpretations with contrast material;

and both magnetic resonance imaging

and computerized axial tomography

scans should be similar for all anatomic

locations.

As part of its report outlining the

work RVU recommendations to the

RUC, the American College of Radiology

prepared a comprehensive rebuttal of

the comments. Specifically, the

American College of Radiology noted

that the current physician work RVUs

for plain film studies accurately reflect

the work involved in the procedure and,

therefore, should be maintained.

Contrary to the comments, the RUC

concluded, plain film studies are not

overvalued relative to more complex

radiographic studies. The American

College of Radiology survey data

supported the fact that the
20028 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

interpretation of plain film studies

requires more time than the evaluation

and management CPT code 99212

(Office/outpatient visit, established

patient) to which those studies were

most often compared.

The RUC also recommended that the

current work RVUs assigned to codes

involving the use of contrast material

should be retained since they require

more physician work than those not

involving the use of contrast. When

contrast is used, physicians must

interpret more images, with a

concomitant increase in work. Time

data and intensity analysis prepared by

the American College of Radiology

confirm the fact that the current work

RVUs for computerized axial

tomography scans reflect the physician

work involved. The American College of

Radiology also noted that the number of

images varies by the site that is being

imaged during a computerized axial

tomography scan, which rebuts the

commenters’ notion that the work RVUs

for this scan be the same regardless of

site. The American College of Radiology

reported that the presence of contrast

material increases the physician work of

magnetic resonance imaging since the

physician must visualize the anatomy in

greater detail, therefore, increasing the

complexity of the interpretation.

RUC Evaluation/Recommendation:

The RUC believed that extensive

evidence presented by the American

Society of Radiology compellingly

supported maintaining the current work

RVUs. The RUC agreed with all of the

recommended changes based on

evidence that was presented by the

American College of Radiology. For the

codes that were presented by the

Society for Cardiovascular and

Interventional Radiology, although the

RUC agreed that the services were

undervalued, the RUC did not believe

that the Society for Cardiovascular and

Interventional Radiology presented

compelling evidence for the requested

increases. Instead, the RUC suggested

increased work RVUs, but lower than

the specialty society recommended.

HCFA Decision: We have accepted all

of the RUC recommendations for the

imaging codes.

12. Cardiothoracic and Vascular Surgery

The American Society of General

Surgeons and the Society of Thoracic

Surgeons stated that the Harvard study

did not appropriately value lung

procedures. In particular, the

commenters stated that the Harvard

study had estimated, rather than

directly measured, preservice and

postservice times and that the current

RVUs do not reflect the physician work

involved in maintaining proper

hemodynamics during initiation of

anesthesia, stabilizing the patient for

transfer to the recovery room, and

accumulating sufficient evidence that

immediate reoperation or other

intervention for bleeding, impaired

circulation, or air leak is not needed.

The Society of Thoracic Surgeons also

commented on several cardiac

operations that it believed have become

more complex over time and

recommended slight increases in 11

coronary artery bypass graft procedures.

Generally, the RUC did not consider

evidence that the Society of Thoracic

Surgeons provided sufficiently

compelling to support increases in the

work RVUs for the thoracic procedures

identified in its comment. Also, the

RUC has already reviewed most of these

services, and any changes in work since

the Harvard study would have been

reflected in the RUC’s 1993

recommendations. However, the RUC

agreed that increases were warranted in

two of the cardiac surgery procedures,

CPT code 33426 (Repair of mitral valve)

and CPT code 33875 (Thoracic aorta

graft), which have become more

complex over the last 5 years.

The International Society for

Cardiovascular Surgery/The Society for

Vascular Surgery described a number of

problems in the current work RVUs for

vascular surgery procedures, many of

which are the result of the lack of any

distinct study of vascular surgical

procedures or vascular surgeons in the

Harvard study. This lack of a study

could have particularly deleterious

effects for the Medicare program

because Medicare patients account for

an exceptionally high percentage of total

patients seen by vascular surgeons. The

commenter stated, for example, that no

vascular surgeons were included in the

Harvard Technical Consulting Groups. It

also described errors in the Harvard

vignettes, which could have resulted

from the absence of vascular surgeons

on the Harvard Technical Consulting

Groups and led to incorrect data. The

commenter also noted that some

adjustments were made in these services

for the 1993 work RVUs based on an Abt

study, but that further refinements are

needed. Finally, the commenter

reported the results of an effort to obtain

intraoperative times from 10 hospitals

for 9 vascular procedures and 11 other

codes selected from the list of reference

procedures. This study found that,

while data on nonvascular surgeries

corresponded closely to existing

Harvard and RUC data for the services,

for vascular surgeries the current data

were 20 percent lower than the hospital

reported times. The American Society of

General Surgeons also commented on

two vascular surgical procedures, CPT

code 34201 (Removal of artery clot) and

CPT code 35654 (Artery bypass graft).

The RUC found that the International

Society for Cardiovascular Surgery/

Society for Vascular Surgery offered

compelling reasons to review the

current work RVUs for selected vascular

surgery procedures. The RUC did not

adopt the particular approaches or

proposed RVUs recommended by the

International Society for Cardiovascular

Surgery/Society for Vascular Surgery,

however.

The Society for Cardiovascular and

Interventional Radiology, the American

College of Surgeons, the American

Society of Hematology, the American

Thoracic Society, the International

Society for Cardiovascular Surgery/

Society for Vascular Surgery, and the

American Society of General Surgeons

commented on nine other

cardiovascular procedures.

The RUC agreed with the Society of

Cardiovascular and Interventional

Radiology that there are anomalies in

the current work RVUs for CPT codes

36215, 36218, 36245, and 36248, all of

which are codes for placing a catheter

in an artery. The RUC recommended an

adjustment in the current work RVUs

for CPT codes 36215 and 36245 to make

them equal and recommended a change

in the global period for CPT codes

36218 and 36248 to maintain

consistency within this family. The RUC

adopted the increase recommended by

the general and vascular surgeons for

CPT code 36830 (Creation of

arteriovenous fistula by other than

direct arteriovenous anastomosis

(separate procedure); nonautogenous

graft). For the remainder of the codes in

this group, the RUC did not believe the

commenters presented sufficient

evidence to support an increase and

recommended that the current work

RVUs be maintained.

HCFA Decision: We have accepted all

of the RUC recommendations for the

cardiothoracic and vascular surgery

codes.

13. Pathology and Laboratory

Procedures

Commenters identified numerous

pathology and laboratory procedure

codes as being overvalued.

The review of pathology and

laboratory procedures primarily focused

on the codes that commenters identified

as overvalued. In response to the

comments, the College of American

Pathologists provided recommendations

to the RUC to maintain or increase the

RVUs for these codes. Based on survey

results, comparisons to the final
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20029

Harvard study results, comparisons to

key reference services, and analysis of

Medicare claims data, the RUC believed

that the College of American

Pathologists provided compelling

evidence for maintaining the current

work RVUs of these procedures and, for

CPT code 86327

(Immunoelectrophoresis assay), for

increasing the work RVUs from their

current level.

Comment: The American Society of

Hematology provided recommendations

to the RUC on the following five codes:

CPT

code Descriptor

36520 Therapeutic apheresis (plasma and/

or cell exchange).

38230 Bone marrow harvesting for transplantation.

85390 Fibrinolysins or coagulopathy

screen, interpretation and report.

86077 Blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report.

86079 Blood bank physician services; authorization for deviation from

standard blood banking procedures (e.g., use of outdated blood,

transfusion of Rh incompatible

units), with written report.

RUC Evaluation/Recommendation:

Based on survey results and

comparisons to key reference services,

the RUC recommended increasing the

work RVUs of all five codes; however,

in two instances the RUC did not

believe that the specialty society had

provided enough evidence to support

adopting the increase that the specialty

society recommended.

Comment: The Medical Oncology

Association of Southern California, Inc.

requested increased work RVUs for CPT

code 85095 (Bone marrow, aspiration

only) and CPT code 85102 (Bone

marrow biopsy; needle or trocar).

RUC Evaluation/Recommendation:

Since the Medical Oncology Association

of Southern California, Inc. presented

no evidence to support the comment,

the RUC recommended maintaining the

current work RVUs of these codes.

HCFA Decision: We have accepted all

but two of the RUC recommendations

for the pathology and laboratory

procedures codes: CPT code 85390

(Fibrinolysins screen).

The current work RVUs are 0.37. We

received conflicting comments on this

code. One commenter recommended

that the work RVUs be reduced on the

basis that a fibrinolysin screen requires

less time and expertise than the

interpretation of CPT code 71021 (Chest

x-ray), which is assigned 0.22 work

RVUs with a Harvard study time of 5

minutes. Another commenter requested

an increase to 1.19 work RVUs. The

commenter compared this service to

CPT code 88331 (Pathology consult in

surgery), which has 1.19 work RVUs

and a Harvard time of 20 to 24 minutes.

The RUC noted that this procedure has

never been surveyed and the current

work RVUs were established by HCFA.

The RUC agreed that the physician work

of furnishing this service has changed

during the past few years. The clinical

problems presented by patients are more

complex, the tests are more technical,

and the physician is required to perform

more tests. However, the RUC did not

believe that these changes warranted an

increase to 1.20 work RVUs. Instead, the

RUC believed that the service is

comparable in physician work to the

key reference service CPT code 88305

(Tissue exam by pathologist), which has

0.75 work RVUs. Therefore, the RUC

recommended 0.75 work RVUs.

Clinical laboratory tests are covered

by the Medicare program and paid for

under the clinical laboratory fee

schedule; performance of the test itself

does not require the services of a

physician and does not have physician

work associated with it. However, we

have recognized that there are a limited

number of clinical laboratory codes for

which it is almost always necessary for

the laboratory physician to furnish an

interpretation, and we have assigned

0.37 work RVUs to these interpretations.

We are not persuaded that the work has

changed over time. The vignette used to

survey this code appeared to represent

service well beyond interpretation of a

single test and seemed to describe a

typical consultation. CPT code 80502

(Lab pathology consultation) describes

the surveyed vignette and is valued at

1.33 work RVUs, which is similar to the

1.20 work RVUs from the RUC survey.

Therefore, we have retained the current

0.37 work RVUs for CPT code 85390.

CPT code 86327

(Immunoelectrophoresis assay).

The current work RVUs are 0.37.

Pathology interpretation of laboratory

tests was originally valued at 0.37 work

RVUs. (See comment for CPT code

85390 above.) We are not persuaded that

the work has changed over time. The

vignette used to survey this code

appeared to represent service well

beyond interpretation of a single test

and seemed to describe a typical

consultation. CPT code 80502 (Lab

pathology consultation) describes the

surveyed vignette and is valued at 1.33

work RVUs, which is similar to the 1.20

work RVUs from the RUC survey.

14. Psychiatry

The American Psychiatric Association

and the American Academy of Child

and Adolescent Psychiatry submitted

comments on psychiatric services. Both

societies commented that the current

physician fee schedule has not

preserved the original work-value

relationships developed by Harvard. It

was their view that if the relative value

of the code for 45 minutes of

psychotherapy (CPT code 90844) is

changed, all other values in the

psychiatric section of CPT should be

changed to preserve the original

relationship with the psychotherapy

code. The societies contended that our

failure to maintain the relative

relationships among the psychiatric

codes that were surveyed by Harvard

has resulted in the undervaluation of all

psychiatric services.

The American Psychiatric Association

made five other specific comments:

• Psychotherapy service CPT codes

90842, 90843, and 90844 represent three

bundled services (continuing medical

evaluation, medication management,

and psychotherapy).

• Psychotherapy codes that are time

dependent, especially CPT code 90844,

have inappropriately low work RVUs as

a result of undervaluing of time as a

dimension of work.

• The nature of psychotherapy

services has become more intensive

since the development of the existing

work RVUs.

• The preservice and postservice

work for psychiatric services is

undervalued.

• CPT code 90844 is inappropriately

linked to CPT code 99204 (Office or

other outpatient visit for the evaluation

and management of a new patient). The

American Psychiatric Association

argued in its comments that CPT code

90844 requires that the physician spend

45 to 50 minutes of face-to-face time

with a patient. In contrast, CPT code

99204 can routinely last less than 45

minutes.

Based on a combined survey of 250

physicians, clinical psychologists, and

nurses, the American Psychiatric

Association presented recommendations

for 18 psychiatric codes. The American

Psychiatric Association, in its comments

and during its presentation to the RUC,

presented the following evidence to

support increasing the work RVUs of the

psychiatric codes:

• Patient type and mix have changed

dramatically during the past 5 years.

The American Psychiatric Association

reported that before 1990, for the most

part, ‘‘stable’’ patients were seen in an

office outpatient setting. Patients that
20030 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

were considered unstable, and

otherwise hard to manage, were treated

as inpatients, allowing the physician to

coordinate with the hospital staff, if

necessary. In the past, patients tended to

seek treatment earlier and physicians

were able to make referrals to

psychiatrists earlier. The onset of

managed care has increased the

likelihood that many patients are

referred to nonphysician mental health

providers, which has translated into

psychiatrists treating only the severely

ill patient.

• Decreasing inpatient hospital

admission has resulted in increased

patient morbidity. Again, the American

Psychiatric Association noted that

shifting insurance industry patterns

have played a significant role in this

trend. Although many insurance

policies offer mental health coverage,

the coverage is often very restrictive. For

example, most policies have strict limits

on the number of inpatient hospital

days. Many managed care policies have

shifted away from long-term

psychotherapy in favor of short

intermittent treatment therapies.

• Since many more patients are seen

on an outpatient basis, there is an

increasing amount of coordination of

care with other providers. The

American Psychiatric Association noted

that the time spent dealing with

coordination of care issues has resulted

in an increase of physician preservice

and postservice work.

• During the past 5 years, new, highly

sophisticated neuroleptic and

antidepressant medications have been

introduced. The American Psychiatric

Association noted that, because of the

advances in psychopharmacology, a

greater number of individual

psychotherapy patients will likely

utilize these medications than was the

case 5 years ago. The greater reliance on

these medications has increased the

complexity of the medical decision

making during an individual

psychotherapy visit. Many of these new

drugs require constant monitoring, such

as weekly blood monitoring in the case

of Clorazil. The failure to monitor these

drugs appropriately could result in

adverse side effects and possibly death.

• The psychotherapy codes have

specific times incorporated into the CPT

descriptor that do not accurately reflect

the current practice of psychiatry. The

American Psychiatric Association noted

that the practice of psychiatry has

changed significantly since the

psychotherapy codes were surveyed

during the Harvard study; therefore, the

current RVUs should be increased to

reflect this change.

The RUC reviewed 18 services in the

psychiatry section of CPT. For 13 of

those services, the RUC recommended

no change from the current work RVUs.

For the other five services, the RUC

believed that the five points cited by the

American Psychiatric Association

provide a compelling argument for

increasing the work RVUs from their

current levels. The RUC also concluded

that the survey vignettes that the

specialty society used describe the

‘‘typical patient’’ in 1995. In two

instances, a commenter recommended

lowering the current work RVUs of

psychiatric services. In both instances,

the RUC concluded that the specialty

society provided compelling evidence

for maintaining the current work RVUs

for those codes.

HCFA Decision: We agree with the

RUC recommendations not to change

the current work RVUs for 13

psychiatric services. We disagree with

the RUC that there is compelling

evidence to increase the work RVUs of

the remaining 5 psychiatric services

(CPT codes 90801, 90843, 90844, 90853,

and 90855). As a result, we will

maintain the current work RVUs for all

18 psychiatric services. The 1996 work

RVUs are slightly higher than the 1995

work RVUs because, effective January 1,

1996, we bundled the work RVUs for

CPT codes 90825 and 90887 across CPT

codes 90801, 90820, 90835, 90842

through 90847, and 90853 through

90857.

15. Other Medical and Therapeutic

Services

Comment: We received isolated

comments regarding purportedly

overvalued miscellaneous diagnostic

and therapeutic procedures such as

biofeedback, esophageal motility

studies, pulmonary testing, and

intralesional chemotherapy.

RUC Evaluation/Recommendation:

Based on recommendations from the

National Association of Medical

Directors of Respiratory Care, the

American Thoracic Society, the

American College of Chest Physicians,

the Joint Council of Allergy, Asthma

and Immunology, and the American

Academy of Electrodiagnostic Medicine,

the RUC recommended maintaining the

current work RVUs of most of the

procedures that were identified by

commenters. These recommendations

were based on survey results,

comparisons to final Harvard study

results, comparisons to key reference

services, and analysis of Medicare

claims data.

Comment: The American Academy of

Neurology submitted a comment on CPT

code 95951 (Monitoring for

identification and lateralization of

cerebral seizure focus by attached

electrodes; combined

electroencephalographic (EEG) and

video recording and interpretation, each

24 hours) recommending an increase in

work RVUs from 3.80 to 6.75.

RUC Evaluation/Recommendation:

The requested work RVUs were

amended to 6.00 based on results of the

survey by the American Academy of

Neurology. The RUC held the view that

the survey results provided sufficient

evidence to warrant increasing the work

RVUs for the procedure. This

recommendation was based on a survey

of 60 neurologists, comparisons to final

Harvard study results, and comparisons

to key reference services.

Comment: The Medical Oncology

Association of Southern California, Inc.

submitted work RVU recommendations

for the following CPT codes:

CPT

code Descriptor

96440 Chemotherapy administration into

pleural cavity, requiring and including thoracentesis.

96445 Chemotherapy administration into

peritoneal cavity, requiring and including peritoneocentesis.

96450 Chemotherapy administration into

CNS (e.g., intrathecal), requiring

and including lumbar puncture.

RUC Evaluation/Recommendation:

The RUC recommended maintaining the

current work RVUs for these three

chemotherapy codes. These

recommendations were based on the

fact that the RUC had recently reviewed

one of the procedures and the fact that

Medicare Part B data showed that the

other chemotherapy procedures are

infrequently performed.

HCFA Decision: We have accepted all

but one of the RUC recommendations

for other medical and therapeutic

services: CPT code 90911 (Anorectal

biofeedback).

The current work RVUs are 2.15. A

commenter recommended a reduction to

0.93 work RVUs since this procedure

lacks the intensity of CPT code 90937

(Hemodialysis, repeated evaluation) or

CPT code 90801 (Psychiatric interview).

CPT code 46606 (Anoscopy and biopsy)

requires less time but presents a greater

risk than CPT code 90911. The RUC

recommended retaining the current

work RVUs since the procedure is

lengthy, taking a minimum of 30

minutes but typically lasting 45 to 60

minutes. The RUC’s view was that the

procedure is more intense and requires

more work than CPT code 46606. The

RUC considers that this procedure is
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20031

similar in its intensity to CPT code

90801.

In our assessment, the RUC

recommendation is too high. Other

biofeedback procedures are valued at

0.89 work RVUs. This procedure

involves little physician work and is

similar to other biofeedback procedures;

therefore, we have assigned 0.89 work

RVUs.

16. Speech/Language/Hearing

Comment: The American SpeechLanguage-Hearing Association and the

American Academy of Audiology

submitted comments on the following

CPT codes:

CPT

code Descriptor

92506 Speech & hearing evaluation.

92507 Speech/hearing therapy.

92508 Speech/hearing therapy.

92541 Spontaneous nystagmus test.

92542 Positional nystagmus test

92544 Optokinetic nystagmus test.

92545 Oscillating tracking test.

92546 Sinusoidal rotational test.

92585 Auditory evoked potential.

In general, these commenters

expressed concern regarding our

payment policies for audiologists and

speech pathologists. These

organizations stated that the current

practice expense component does not

accurately reflect the technical work

that is involved in performing the

services. In addition, the American

Academy of Audiology noted that the

current physician fee schedule includes

zero work RVUs for audiology services,

even though the Harvard study included

physician work RVUs for these codes.

The American Speech-LanguageHearing Association and the American

Academy of Otolaryngology—Head and

Neck Surgery, Inc. had originally

wanted to survey these services;

however, they have now requested that

the codes be withdrawn from further

consideration.

RUC Evaluation/Recommendation: A

majority of these codes have been

revised for CPT 1996, and the RUC

submitted work RVU recommendations

to us in May 1995. The distinction

between physician work RVUs and

work recognized as practice expenses

such as the labor component of

audiology services is addressed in

section II.C.5. of this notice. Because

interim work RVUs, which are subject to

public comment, were established in

January 1996, and final work RVUs will

be established for 1997, we are not

considering these codes in the 5-year

review.

Comment: Commenters stated that

CPT code 92512 (Nasal function studies

(e.g., rhinomanometry)) is similar to

CPT code 94060 (Bronchospasm

evaluation: spirometry as in 94010,

before and after bronchodilator (aerosol

or parenteral) or exercise), with 0.31

work RVUs.

RUC Evaluation/Recommendation:

The RUC noted that nasal function

studies are performed to evaluate the

normal or abnormal function of the

nose. Rhinomanometry is a nasal

function study that measures the flow

and pressure of air through the nose. It

enables the physician to assess the

degree of obstruction, if any, that may

be present in the nasal passages.

Anterior rhinomanometry measures air

flow in the front of the nasal cavity and

is performed by inserting flexible air

tubes into each nostril. The tubes are

connected to a device that measures the

amount and pressure of air that flows

through them as the patient breathes.

The physician records measurements of

air flow and, from these, calculates the

degree of obstruction. CPT code 94060

is a distinctly different test, which uses

spirometry to measure exhaled gas and

record the time of collection. CPT code

94060 is less intense and requires less

physician time than CPT code 92512.

Therefore, the RUC recommended that

the current work RVUs be maintained.

HCFA Decision: We have accepted all

of the RUC recommendations for the

speech, language, and hearing codes.

C. Other Comments

1. Evaluation and Management Services

We received numerous comments

requesting review of evaluation and

management services. Most of the

comments focused on office visits,

hospital visits, and consultations. The

commenters offered three major reasons

for requesting that the work RVUs for

these evaluation and management

services be reviewed:

• The physician work involved in

these services has increased since the

initial Harvard study of RVUs was

conducted. As a mechanism to control

costs over the past 10 years, there has

been increased pressure to treat patients

in the office rather than the hospital or

emergency room. Patients are being

discharged from the hospital sooner. As

a result, the typical patient seen in the

office and in the hospital is more

complex than the patient seen in the

mid-1980’s. Also, the preservice and

postservice work has changed due to the

following factors:

+ Increased documentation

requirements.

+ Time and effort required for

obtaining or providing authorizations

for tests and referrals.

+ Higher patient expectations and an

increasingly well informed patient

population.

+ Increased coordination with other

health professionals and family

members.

+ Increased patient education

regarding issues such as fall prevention

and adverse drug reactions.

• Evaluation and management

services are undervalued relative to

most other procedures. The highest

level evaluation and management

services require a ‘‘comprehensive

examination’’ and ‘‘medical decision

making of high complexity,’’ yet the

assigned work RVUs for these services

are lower than for procedures that

involve less time, less mental effort and

judgment, and less technical skill and

physical effort. An analysis of

intraservice work per unit time

(intensity) by one commenter found that

the intensity of 96 percent of the

services paid under the physician fee

schedule exceeded the existing intensity

of evaluation and management services.

The existing intensities were calculated

by dividing the work RVUs by the

typical time of the CPT codes for

evaluation and management services.

• The current CPT codes for

evaluation and management services

were never directly surveyed or studied

in the Harvard RVU study. The Harvard

study conducted its survey from 1986

through 1988; the new CPT codes were

published in 1992. At the time of the

Harvard surveys, evaluation and

management services were not defined

based on the level of history,

examination, and medical decision

making. A crosswalk from the old CPT

codes to the new CPT codes was used

to establish work RVUs. Also, the

preservice and postservice work was not

directly surveyed, nor was postservice

work defined.

We forwarded these comments to the

RUC. The RUC agreed with the

commenters that an in-depth review of

the work involved in office and hospital

visits and consultations was warranted.

We also referred comments suggesting

that the work RVUs for nursing facility

visits and home visits should be

reviewed.

After reviewing selected evaluation

and management services, the RUC

found the evidence compelling to

recommend increasing the work RVUs

for office visits, subsequent hospital

visits, and consultations. The RUC made

an interim recommendation not to

change the work RVUs for the home

visits. In developing its
20032 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

recommendations, the RUC focused

principally on the work involved in the

evaluation and management services,

how the work has changed over time,

and how the work is related to the work

of other evaluation and management

services and non-evaluation and

management services. The RUC

recommended work RVUs for 39 of the

98 evaluation and management services

for which we have assigned work RVUs.

When there was not a recommendation,

the RUC took the position that the work

RVUs did not need to be changed.

As we evaluated the RUC

recommendations, we noted several

inconsistencies:

• The recommendations significantly

alter the existing relationships among

all the evaluation and management

services without providing compelling

evidence that the existing rank order is

incorrect.

• The complexity of the service, as

described by the level of history,

examination, and decision making, did

not directly correspond to the

recommended work RVUs.

• The survey data were flawed;

however, the RUC used the postservice

work times that it acknowledges are

overstated in its formula to calculate

intraservice work intensity. The formula

actually calculates something that is

more accurately described as total work

intensity, that is, total work divided by

total time.

• Many of the arguments to increase

the RVUs are based on the assumptions

that the CPT codes do not adequately

describe the service and that the current

CPT codes for evaluation and

management services were not used in

the Harvard surveys.

We believe that maintaining the

relationships among the evaluation and

management services is important.

Therefore, we have examined all 98

evaluation and management services for

which we have assigned work RVUs. In

assigning work RVUs, we considered

the level of complexity of each service

and valued the service as described by

the CPT code. As the American

Academy of Family Physicians noted in

its original 5-year review comments,

‘‘valuing a service which requires more

effort and more time at a lower level

than a ‘simple’ procedure is inconsistent

with the concept of a resource-based

relative value scale.’’ We believe that

this rationale applies within the family

of evaluation and management services.

We took the survey data into general

consideration but also investigated other

objective data sources such as the AMA

Socioeconomic Monitoring Survey from

1988 and 1994.

If, as the commenters have suggested,

the patients are more complex and the

postservice work has increased, we

should expect to see a change in the

number of patient care hours a

physician works or in the number of

patient visits per week or a change in

the level of visit billed. However, data

from the AMA Socioeconomic

Monitoring Survey as published in

Physician Marketplace Statistics 1989

and 1994, reveal that the median

number of hours a physician works in

patient care (51) and the median

number of patient visits per week (101)

have not changed between 1988 and

1994. The AMA definition of hours in

patient care includes activities that we

consider to be postservice work. Using

these data along with Medicare

frequency data and the total service

times provided in the RUC

recommendations (RUC RVUs/RUC

intensities), we calculated that the

minimum number of hours in patient

care necessary to perform 101 visits per

week is 78.5. This discrepancy suggests

that the RUC recommendations

overestimate the total times by

approximately 50 percent.

In reviewing our claims data, we have

seen a slight increase in the average

number of work RVUs billed within

each group of evaluation and

management services. For each family of

evaluation and management services,

we calculated the quarterly average

work RVUs since the beginning of the

physician fee schedule. The average

work RVUs for the family of office/

outpatient visit for an established

patient (CPT codes 99211 through

99215), have increased from 0.60 to

0.62, a 3.33 percent increase from 1992

to 1995. This increase may reflect the

increasing complexity of the Medicare

patient or other factors.

National Ambulatory Medical Care

Survey data from 1989 and 1993 reveal

that the mean face-to-face time for all

office visits has increased 13.6 percent.

In 1989, the mean time was 16.2

minutes and in 1993 it was 18.4

minutes. Although the change is

statistically significant, we question its

clinical significance. The data

demonstrate, however, that between

1989 and 1993 there has been a shift

toward office visits with longer face-toface times.

We approached review of the work

RVUs for the evaluation and

management services with three basic

assumptions that were integral to the

Harvard study and the 1992 work RVU

refinement:

• All services within a family of

evaluation and management services

(that is, office visits) have the same

intraservice work intensity.

• The intraservice work times in the

CPT code descriptors are correct.

• The preservice and postservice

work intensity is a fixed percentage of

the intraservice work intensity.

The RUC recommendations do not

preserve these basic assumptions except

for using the CPT times as an accurate

measure of intraservice work times.

Despite claiming that it maintained

constant intensities within a family, the

intensities the RUC calculated are not

always consistent. For example, the

RUC intensities for CPT codes 99231

through 99233 range from 0.018 to

0.021. It is also unclear whether the

RUC calculated preservice and

postservice work intensities. If we

assume a fixed intraservice work

intensity within a family of evaluation

and management codes, the RUC

recommendations actually assign higher

amounts of preservice and postservice

work to the lower level codes within an

evaluation and management family.

The commenters claim that Harvard

did not survey the current evaluation

and management codes is technically

correct but very misleading. In fact, the

current codes were carefully developed

to support the clinical vignettes used in,

and the results of, the Harvard surveys.

An extraordinary amount of work by

Harvard, HCFA, the Physician Payment

Review Commission, the CPT Editorial

Panel, and the specialty societies went

into the formulation and testing of the

codes. We will continue to value

services based on the CPT descriptions.

If physicians believe that the definitions

do not correctly describe the service as

furnished in today’s health care sector,

they should discuss revising the

definitions with the CPT Editorial

Panel.

In assigning work RVUs to these

services, we defined preservice work as

preparing to see the patient, reviewing

records, and communicating with other

professionals, as appropriate. We

defined postservice work as including

all coordination of care, documentation,

and telephone calls with the patient,

family members, or other health

professionals associated with the

delivery of care to the patient until the

next face-to-face evaluation and

management service is furnished

(excluding separately billable services

such as care plan oversight, CPT code

99375). The RUC used these definitions

in its survey of evaluation and

management services. Unlike the RUC

and other commenters, we consider the

time and effort required for obtaining

and providing authorizations for tests

and referrals to be a practice expense
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20033

issue because most of the work is done

by a physician’s staff rather than the

physicians themselves.

We agree with the commenters that

the intensities of evaluation and

management services should be

increased to bring them closer to the

intensities of procedural services on the

physician fee schedule. Therefore, we

propose to increase the intensities of the

intraservice work, which is that portion

of total work furnished either face-toface with the patient in the office or on

the floor or unit for inpatient services.

We also agree with the commenters that

postservice work has increased over

time. We propose to increase the fixed

percentage of intraservice work that

represents preservice and postservice

work. To determine the appropriate

amounts to increase these intensities,

we have chosen CPT code 99291

(Critical care, first hour) as our anchor

because we believe that it is the most

intense evaluation and management

service. We accepted the RUC

recommendation of 4.00 work RVUs for

this service.

If we assume that CPT code 99291 is

the most intense service, we do not

want the work RVUs for the other

evaluation and management services to

exceed 4.00. Under the current work

RVUs, we have an established

relationship between CPT code 99291

and CPT code 99213 (Level-three

established patient office visit). CPT

code 99213 represents a service with 15

minutes of face-to-face time. CPT code

99291 represents an hour of service. We

believe that four times the value for CPT

code 99213 plus the work RVUs for

ventilation management (1.22) and the

interpretation of a single view chest

x-ray (0.18) should be about equivalent

to the work RVUs for critical care. We

selected ventilation management and

interpretation of a chest x-ray because

they are the commonly performed items

in critical care that are bundled into the

critical care work RVUs. Given this

relationship, we used an iterative

process and determined that, for most

evaluation and management services, if

we increased the intraservice work

intensity by 10 percent and the fixed

percentage of intraservice work (to

capture preservice and postservice

work) by 25 percent, we would increase

the work RVUs for evaluation and

management services in a manner that

would be consistent with the RUC

recommendations while maintaining the

existing relationships of the evaluation

and management families.

We followed a straightforward

methodology in revising the work RVUs.

For each code in the following classes:

office, new patient; office, established

patient; initial hospital care; subsequent

hospital care; office consultation; initial

inpatient consultation; and follow-up

inpatient consultation, we calculated

the revised intensity by adjusting the

intensities developed in 1992 and

described in our November 25, 1992

final notice for the 1993 physician fee

schedule (57 FR 55949 through 55951).

Those intensities were originally based

upon results of the Harvard study and

adjusted to maintain linearity in 1992

based on comments received on the

1991 physician fee schedule final rule

(56 FR 59502).

The revised intraservice work

intensities that have resulted from our

5-year review of evaluation and

management services are summarized in

the following table.

Code/class

1995 intraservice intensity1997 intraservice intensity

Office visits, new

patient ................ 0.028 0.031

Office visits, established patient ..... 0.028 0.031

Initial hospital visits 0.028 0.031

Subsequent hospital visits ........... 0.028 0.031

Office consultations 0.028 0.031

Initial inpatient consultations ........... 0.022 0.024

Follow-up inpatient

consultations ...... 0.028 0.031

Preservice and postservice work is

expressed as a percentage of the

intraservice work. The following table

summarizes the revised preservice and

postservice work as percentage of

intraservice work for the evaluation and

management codes.

Code/class

1995

mean percentage

1997

mean percentage

Office visits, new

patient ................ 35.0 43.8

Code/class

1995

mean percentage

1997

mean percentage

Office visits, established patient ..... 35.1 43.8

Initial hospital visits 30.3 37.9

Subsequent hospital visits ........... 12.5 37.9

Office consultations 34.5 38.5

Initial inpatient consultations ........... 34.5 37.9

Follow-up inpatient

consultations ...... 34.9 37.9

To calculate the new work RVUs for

the above classes of evaluation and

management services as part of the 5-

year review, we used the above

intraservice work intensities and

preservice and postservice work

percentages in addition to the CPT

times. The intraservice work intensity

was multiplied by the typical time of

the codes as listed in CPT to determine

the new intraservice work values. The

preservice and postservice work

percentage of this value was added to

the intraservice work value to calculate

the final work RVUs for the codes. The

formula is total work RVUs =

(intraservice work intensity) × (CPT

time) × (1 + pre/post percentage of

intraservice work).

Table 2, ‘‘Evaluation and Management

Codes; Five-Year Review—Proposed

Relative Value Units,’’ lists all of the

evaluation and management services

and their 1995 and proposed new work

RVUs. For each code, we have also

provided a measure of complexity. This

is a numeric representation of the level

of history, examination, and medical

decision making associated with the

service. These three components of the

evaluation and management service are

considered the key components in

selecting a level of evaluation and

management service. For each of the 3

elements, the maximum score is 4;

therefore, the most complex service has

a score of 12. If the CPT code descriptor

does not define the typical level of

history, examination, and decision

making complexity, as with CPT code

99291 (Critical care, first hour), no score

for that code may be computed.

BILLING CODE 4120–01–P
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Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20035

BILLING CODE 4210–01–C
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CPT codes 99201 through 99215

(Office visits).

We disagree with the RUC’ contention

that the established patient visits are

more undervalued than the new patient

visits. We also disagree with the RUC

recommendations that assign higher

work RVUs to established patient visits

than new patient visits of the same

duration and same level of complexity,

for example, the recommended work

RVUs for CPT codes 99201 and 99212.

Both codes describe 10 minute office

visits of equal complexity. However, the

RUC has recommended work RVUs for

the established patient visit that are 28

percent greater than the recommended

work RVUs for the new patient visit.

Historically, there has been a consensus

in the physician community (confirmed

by the Harvard resource-based relative

value study) that new patients involve

more physician work than established

patients. It was for this reason that the

CPT Editorial Panel created separate

codes for new and established patients.

Finally, we do not agree that the work

RVUs for CPT code 99211 (Level-one

established patient office visit) should

change as the RUC has recommended.

Because this service, by definition, does

not require the presence of a physician,

we are maintaining the 1995 work

RVUs.

We adjusted the intraservice work

intensity of CPT code 99213 to equal the

intensities of the other office visit codes.

Rounding due to past budget neutrality

adjustments had caused the slight

variation in the intraservice work

intensities. To account for the

possibility that these services were

originally undervalued, we increased

the intraservice work intensity by 10

percent. Because the package of

postservice work, as defined earlier, was

not explicitly surveyed by Harvard and

we believe that the amount of

postservice work has increased since

these codes were originally assigned

RVUs, we increased the preservice and

postservice work percentage of

intraservice work for all office visit

codes (except for CPT code 99211) by 25

percent.

Using the adjusted work intensities

and the times included in the CPT

descriptors for the codes, we calculated

new work RVUs for all office visits. The

new work RVUs are on average 17.1

percent greater than the 1995 work

RVUs for CPT codes 99201 through

99215.

CPT codes 99221 through 99239

(Hospital visits).

The RUC assumed that there has been

no change in initial hospital visits (CPT

codes 99221 through 99223) since the

original Harvard study. In fact, the RUC

did not survey these services to

determine whether its assumption was

true. Neither did the RUC suggest that

these codes were originally undervalued

like other evaluation and management

services. The RUC recommended no

change in the work RVUs for these

codes despite the comments that all

evaluation and management services

were undervalued relative to procedural

services. Our view is that if the office

visits were undervalued, so were the

initial hospital visits. We approached

review of these codes in the same

manner as we did the office visit codes.

The RUC recommended that the work

RVUs for subsequent hospital visits and

follow-up inpatient consultations

should be equivalent because the time

and complexity of the lowest, middle,

and highest levels of subsequent

hospital care and follow-up inpatient

consultations are very similar. We agree

that they are similar; however, they are

not identical. Therefore, we have

reviewed each group of services on its

own merit.

Because the RUC recommended no

change in the work RVUs for initial

hospital visits and significant increases

in the work RVUs for subsequent

hospital visits, the rank order of these

two groups of evaluation and

management services is distorted. We

do not agree, as the RUC recommended,

that subsequent hospital visits typically

require more work than initial hospital

visits. The work RVUs recommended for

CPT code 99232 (Level-two subsequent

hospital visit with a typical time of 25

minutes and a complexity score of 7.0)

are 23 percent greater than the

recommended work RVUs for CPT code

99221 (Level-one initial hospital visit

with a typical time of 30 minutes and

a complexity score of 8.5). If we chose

to accept the RUC, we would be

allowing a shorter, less complex service

to be valued higher than a longer, more

complex service. This assignment of

work RVUs corrupts the integrity of a

resource-based relative value system.

We reestablished a fixed intraservice

work intensity for initial hospital visits

at 0.028. (There was minimal variation

across the three levels due to the past

budget neutrality adjustments.) This

intensity is the same as the intensity for

subsequent hospital visits (CPT codes

99231 through 99233). As with the

office visits, we increased the

intraservice work intensity by 10

percent for both initial and subsequent

hospital visits to account for an original

undervaluing of the services.

Following the change in the

intraservice work intensities, we

increased the preservice and postservice

work percentage of intraservice work for

the subsequent hospital visits to equal

that of inpatient consultations. We then

increased this percentage for all initial

and subsequent hospital visit codes by

25 percent. Using the adjusted work

intensities and the times included in the

CPT descriptors for the codes, we

calculated new work RVUs for all initial

and subsequent hospital visits. The new

work RVUs are on average 20 percent

greater than the 1995 work RVUs for

CPT codes 99221 through 99233.

After making these adjustments to the

initial hospital visit codes, we equated

CPT code 99238 (Hospital discharge day

management, 30 minutes or less) to CPT

code 99221 (Level-one initial hospital

visit) when assigning new work RVUs.

The 1995 work RVUs for CPT codes

99238 and 99221 are equal. We have

decided to maintain this relationship

because there is no evidence to suggest

that altering it is appropriate. We did

not change the work RVUs for CPT code

99239 (Hospital discharge day

management, more than 30 minutes)

because the code was new in calendar

year 1996. Therefore, there has been no

change over time in the service

described by this code. Not revising the

work RVUs for CPT code 99239 also

places it just below CPT code 99222, a

similar service of slightly greater

duration.

CPT codes 99217 through 99220

(Observation care services).

The RUC did not make any

recommendations regarding observation

care services. As part of our effort to

examine the whole group of evaluation

and management services to maintain

existing relationships, we reviewed

these codes.

In reviewing the work RVUs for CPT

code 99217 (Observation care

discharge), we noted that this code is

relatively equivalent to CPT code 99238

(Hospital discharge day management).

To reflect this relationship, we assigned

work RVUs to this code equal to the

work RVUs assigned to CPT code 99221,

a 17.3 percent increase in work RVUs.

The initial observation care services

for new or established patients (CPT

codes 99218 through 99220) match the

services described by the initial hospital

visits codes in the level of complexity.

Because both sets of codes can only be

billed once per date of service and

patients in observation status are

virtually identical to inpatients, we have

made the work RVUs for CPT codes

99218 through 99220 equivalent to the

work RVUs assigned to CPT codes

99221 through 99223, thereby

increasing the work RVUs by an average

of 21.6 percent.

CPT codes 99241 through 99275

(Consultations).
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The RUC concluded that the work

RVUs for office consultations and

inpatient consultations should be

‘‘equivalent at all levels of service

except the highest. This preserves the

same relationship that exists in the

current RVUs for these services.’’ We

disagree with the RUC that inpatient

and office consultations should be

equally valued. The 1995 work RVUs for

these two families are not equivalent.

The Harvard data demonstrated that

inpatient consultations are more total

work than office consultations, except at

the lowest level of service. We believe

that these services are not equivalent

because the intraservice times are

different and the associated postservice

work is different (it is greater for

inpatient consultations). However, we

acknowledge that the level of

complexity of the five levels of services

for both inpatient and office

consultations are the same.

CPT codes 99241 through 99245

(Office or other outpatient

consultations).

The work associated with office

consultations is more comparable to the

work of office visits than to inpatient

consultations. Therefore, we

standardized the intraservice work

intensities to make them equivalent to

the 1995 intraservice work intensities of

office and hospital visits (0.028). We

also adjusted the preservice and

postservice work percentage of

intraservice work to equal the 1995

percentage for office visits, a slight

increase from 34.5 percent to 35

percent.

After these initial adjustments were

made, we increased the intraservice

work intensities by 10 percent to reflect

our belief that the codes may have been

originally undervalued. To account for

the previously defined package of

postservice work, we increased the

preservice and postservice work

percentage of intraservice work by 10

percent. We did not increase the

postservice work percentage by 25

percent as we did with the office visits

because we do not believe that the

postservice work associated with an

office consultation is as great as for an

office visit. The postservice work for an

office visit includes the ongoing

management of the patient until the

next face-to-face visit. The postservice

work for a consultation involves writing

a report for the referring physician

without the expectation, in the typical

case, that the patient will return to the

consulting physician, nor is the

consulting physician responsible for any

ongoing management of the patient. If

the consultation results in a decision to

perform surgery, any postservice

management of the patient is included

in the global surgical package.

CPT codes 99251 through 99255

(Initial inpatient consultations).

We standardized the intraservice

work intensities to eliminate the minor

variation that resulted from the annual

budget neutrality adjustments to the

RVUs. Based on the Harvard study, the

intraservice work intensity is less than

that of the office consultations.

As we did with hospital visits, we

increased the intraservice work

intensities by 10 percent and the

preservice and postservice work

percentage of intraservice work by 25

percent. These increases reflect the

belief that the services were initially

undervalued and that the postservice

work, now clearly defined, is greater

due to changes over time. Postservice

work associated with an inpatient

consultation is greater than that for an

office consultation because of the

amount of work performed off-the-floor

by the consulting physician, such as

checking on laboratory results and

reviewing x-rays. The new work RVUs

are, on average, 17.5 percent greater

than the 1995 work RVUs assigned to

initial inpatient consultations.

CPT codes 99261 through 99263

(Follow-up inpatient consultations).

We disagree with the RUC that these

codes should have the same work RVUs

as their corresponding level of the

subsequent hospital visit codes because

the intraservice times are different and

consultations and visits are not

equivalent services. We agree that the

intraservice work intensities and the

preservice and postservice work

percentages of intraservice work are

probably the same for follow-up

consultations and subsequent hospital

visits. Therefore, we adjusted the

preservice and postservice work

percentage of intraservice work to match

the 1995 percentage of the subsequent

hospital visits, a decrease from 34.5

percent to 30.3 percent.

Using the same rationale as for the

initial inpatient consultations, we

increased the intraservice work

intensities by 10 percent and the

preservice and postservice work

percentages of intraservice work by 25

percent. The new work RVUs for these

services are about 14 percent higher

than the 1995 work RVUs assigned to

these codes.

CPT codes 99271 through 99275

(Confirmatory consultations).

We have decided not to change the

work RVUs assigned to these codes.

There is less work associated with a

confirmatory consultation than a new

patient office visit because the patient

arrives with a preliminary diagnosis and

the consulting physician is expected to

provide an opinion or advice only. Not

adjusting the work RVUs alters the

existing relationships that these codes

have with the rest of the evaluation and

management services, but we believe

that this change is appropriate.

CPT codes 99281 through 99285

(Emergency department services).

We disagree with the RUC’s

recommendation to maintain the 1995

work RVUs for emergency department

services. The RUC did not consider the

emergency room physicians’ survey of

CPT codes 99284 and 99285 adequate to

support change. In our view, this survey

was no less adequate than some surveys

on which the RUC based its

recommendations to increase the work

RVUs of other evaluation and

management codes. For consistency and

equity, if other visit codes are being

reviewed because of a belief that

evaluation and management services

were originally undervalued, emergency

department services should also be

reviewed.

Given that we have assigned

increased work RVUs to other

evaluation and management services

with complexities comparable to those

of the emergency room services, we

believe that we should make

comparable changes to CPT codes 99281

through 99285. We do not have work

intensities or CPT times for these codes,

thus, we have assigned work RVUs to

these services that maintain their

proportional relationship with the work

RVUs assigned to CPT code 99255, the

non-critical care evaluation and

management code with the highest work

RVUs. The resulting work RVUs reflect

an average 16.6 percent increase from

the 1995 work RVUs for emergency

department services.

CPT codes 99291 through 99297

(Critical care services).

We have accepted the RUC

recommendations for CPT codes 99291

and 99292. Because the work RVUs for

CPT codes 99293 through 99297 are

based on the work RVUs of CPT codes

99291 and 99292, we have adjusted the

work RVUs for these neonatal intensive

care services. Using the formula

articulated in the December 2, 1993

final rule for the 1994 physician fee

schedule (58 FR 63675), CPT code

99295 is equivalent to 4 hours of critical

care, CPT code 99296 is equivalent to 2

hours of critical care, and CPT code

99297 is equivalent to 1 hour of critical

care. Therefore, the new work RVUs for

CPT code 99295 (16.00) are calculated

as follows: the work RVUs of CPT code

99291 (4.00) plus six times CPT code

99292 (6×2.00). The new work RVUs for

CPT code 99296 (8.00) equal the work
20038 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

RVUs of CPT code 99291 (4.00) plus two

times CPT code 99292 (2×2.00). The

new work RVUs for CPT code 99297

(4.00) equal the work RVUs of CPT code

99291 (4.00).

CPT codes 99301 through 99313

(Nursing facility services).

In 1992, these codes were evaluated

by a multispecialty refinement panel

after commenters had requested that we

assign work RVUs for nursing facility

services that were more commensurate

with the work RVUs assigned to the

hospital visit codes. The commenters

believed that nursing facility visits were

most similar to hospital visits in time,

intensity, and complexity. In general,

the refinement panel agreed with the

commenters. Therefore, we need to

revise the work RVUs assigned to CPT

codes 99301 through 99313 because we

have revised the work RVUs for the

initial and subsequent hospital visits. In

order to maintain the relationship that

the refinement panel created, we are

assigning new work RVUs to the nursing

facility services using the CPT times and

the revised intensities for initial and

subsequent hospital visits (intraservice

intensity = 0.031 and the pre/post fixed

percentage of intraservice work = 37.9

percent). Because the 1995 work RVUs

resulted from a refinement panel, they

do not consistently represent the above

relationship. The proposed work RVUs

use the intensities for initial and

subsequent hospital visits for all the

nursing facility codes. As a result, some

of the proposed work RVUs are lower

than the current work RVUs.

CPT codes 99341 through 99353

(Home services).

Our view is that the current

relationship between the work RVUs for

home visits and office visits should be

maintained. The May 1992 refinement

panel equated the home codes to office

visit codes. Our position is that a home

visit takes longer to furnish than a

service with a similar content (level of

history, examination, and medical

decision making) in an office setting,

thus, the home visits are equated with

office visits of greater length. Therefore,

we assigned new work RVUs to the

home visit codes using the following

relationships with the new work RVUs

for office visits:

New patients:

CPT code 99341=CPT code 99203;

CPT code 99342=CPT code 99204;

CPT code 99343=CPT code 99205.

Established patients:

CPT code 99351=CPT code 99213;

CPT code 99352=CPT code 99214;

CPT code 99353=CPT code 99215.

Because the 1995 work RVUs resulted

from a refinement panel, the above

relationships are not perfectly

represented by the 1995 work RVUs.

Therefore, in assigning new work RVUs

with the above-described relationship,

we have decreased the work RVUs for

CPT codes 99351 and 99352.

CPT codes 99321 through 99333

(Domiciliary, rest home (e.g., boarding

home), or custodial care services).

The source of the 1995 work RVUs is

HCFA. We assumed that these services

require less work than home visits

because of the availability of personal

assistant services. We have taken the

average of the relative proportion of the

1995 work RVUs for these codes to the

1995 work RVUs of the home visit

codes; on that basis, the domiciliary

codes represent two-thirds of the work

of the home visits. We are maintaining

the existing relationship in the fee

schedule. We calculated the new work

RVUs for CPT codes 99321 through

99333 by multiplying the work RVUs for

CPT codes 99341 through 99353 by

0.667. Specifically, the relationship

between the two families is the

following:

CPT code 99321=(0.667) CPT code

99341

CPT code 99322=(0.667) CPT code

99342

CPT code 99323=(0.667) CPT code

99343

CPT code 99331=(0.667) CPT code

99351

CPT code 99332=(0.667) CPT code

99352

CPT code 99333=(0.667) CPT code

99353

CPT codes 99354 through 99357

(Prolonged physician service with direct

(face-to-face) patient contact).

We did not receive any RUC

recommendations for these services.

However, the 1995 work RVUs for these

codes are based on the work RVUs of

three other evaluation and management

codes. This relationship was established

in the December 8, 1994 final rule for

the 1995 physician fee schedule (59 FR

63437 through 63440). To maintain this

relationship, we have recalculated the

work RVUs for CPT codes 99354

through 99357 using the new work

RVUs for CPT codes 99215, 99221, and

99222. The work RVUs for CPT codes

99354 and 99355 are equal to the work

RVUs assigned to CPT code 99215. The

work RVUs for CPT codes 99356 and

99357 are equal to the average of the

work RVUs of CPT codes 99221 and

99222.

We understand that some physicians

do not associate the use of prolonged

service codes with potential increases in

postservice work. Because the work

RVUs for these prolonged service codes

are based on other evaluation and

management services, the use of a

prolonged service code increases the

potential amount of postservice work

associated with the service being

furnished to the Medicare beneficiary.

The prolonged service codes describe

additional face-to-face time but CPT

codes 99215, 99221, and 99222 include

postservice time. By establishing a clear

relationship among these codes, a

prolonged face-to-face service may very

well have increased postservice work.

We believe that the use of these codes

adequately describes the total service.

CPT code 99375 (Care plan oversight).

Because the current 1.73 work RVUs

resulted from a 1995 refinement panel,

we do not see any need to adjust the

work RVUs further.

CPT codes 99381 through 99412

(Preventive medicine services).

The work RVUs assigned to these

codes were added to the Medicare

physician fee schedule in 1995. Because

these codes were recently valued, we do

not believe that we need to review the

work RVUs for them. The intraservice

work intensities and the preservice and

postservice work have not changed

since 1994 when the work RVUs were

assigned. Because we are not adjusting

the work RVUs, we are changing the

rank order of the evaluation and

management services. We believe that

the new rank order better reflects the

relative complexities of the office visits

for a sick patient and for a healthy

patient. For example, a preventive

medicine visit for a 65-year old patient

(CPT code 99397) has work RVUs

assigned to it that are between a levelfour and level-five office visit for an

established, sick patient (CPT codes

99214 and 99215). In fact, the work

RVUs are only 3 percent less than the

new RVUs assigned to CPT code 99215.

CPT codes 99431 through 99440

(Newborn care).

The work RVUs for these services

resulted from a multispecialty

refinement panel convened in the

summer of 1994. The work RVUs for

CPT code 99435 were assigned last

summer. We do not believe that we

need to revise these codes since the

work RVUs were recently assigned.

Ophthalmology Codes

We referred comments to the RUC

requesting review of the ophthalmology

codes for eye visits. The comments

compared the work RVUs for these

codes to the work RVUs for office visits.

The RUC agreed that a permanent link

should be established between the

ophthalmological eye examination

codes and evaluation and management

services. The RUC recommended that
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the following relationship be

established for assigning work RVUs to

the ophthalmological codes:

• CPT code 92002 (Ophthalmological

services: medical examination and

evaluation with initiation of diagnostic

and treatment program; intermediate,

new patient) should have the same work

RVUs as CPT code 99202 (Level-two

office/outpatient visit, new patient).

• CPT code 92004 (Ophthalmological

services: medical examination and

evaluation, with initiation of diagnostic

and treatment program; comprehensive,

new patient, one or more visits) should

have the same work RVUs as CPT code

99203 (Level-three office/outpatient

visit, new patient).

• CPT code 92012 (Ophthalmological

services: medical examination and

evaluation with initiation of diagnostic

and treatment program; intermediate,

established patient) should have the

same work RVUs as CPT code 99213

(Level-three office/outpatient visit,

established patient).

• CPT code 92014 (Ophthalmological

services: medical examination and

evaluation with initiation of diagnostic

and treatment program; comprehensive,

established patient, one or more visits)

should have the same work RVUs as

CPT code 99214 (Level-four office/

outpatient visit, established patient).

We agree with the relationships in the

RUC recommendation. However,

because the work RVUs that we

assigned to CPT codes 99202, 99203,

99213, and 99214 are different from the

RUC-recommended work RVUs for

these codes, the work RVUs that we

have assigned to the ophthalmological

codes are different from the RUC

recommendation. We have assigned the

following work RVUs:

CPT code

1995

work

RVUs

New

work

RVUs

92002 ................................ 1.01 0.88

92004 ................................ 1.61 1.34

92012 ................................ 0.82 0.67

92014 ................................ 1.06 1.10

These work RVUs represent a reduction

from the current work RVUs for eye

examinations, except for the slight

increase in work RVUs for CPT code

92014.

2. Review of Studies by Abt Associates,

Inc.

The RUC evaluated the methodologies

used by Abt Associates, Inc. before

considering the actual recommended

work RVUs. The RUC concluded that

the Abt studies for orthopaedics and

otolaryngology produced correct rankordering of codes within the respective

specialties, but that an additional study

would need to be conducted to produce

compelling evidence that the proposed

work RVUs were correct. The RUC did

not reach any conclusions about the Abt

study commissioned by the American

Society of Anesthesiologists but

indicated that the specialty was still

entitled to demonstrate the validity of

the study’s methodology through the

normal RUC update process.

Following the RUC review, the

American Academy of Orthopaedic

Surgeons, with our concurrence,

withdrew its Abt study from

consideration and developed a list of 83

codes for which it conducted a survey

and submitted individual

recommendations. The American

Academy of Otolaryngology—Head and

Neck Surgery, Inc. provided detailed

comments on about 100 codes, in

addition to submitting an Abt study.

The American Academy of

Otolaryngology—Head and Neck

Surgery, Inc. evaluated the work of the

individually identified codes and made

recommendations for work RVUs. The

American Society of Anesthesiologists

conducted further research to validate

its Abt study and presented the results.

3. Pediatrics

Section 124 of the Social Security Act

Amendments of 1994 (Public Law 103–

432), enacted on October 31, 1994,

requires the development of RVUs for

the full range of pediatric services. As

we noted in our December 8, 1994 final

rule, we believe that the work RVUs for

the full range of pediatric services are

essentially complete (59 FR 63454). We

proposed to use the 5-year review

process to determine whether there are

significant variations in the resources

used in furnishing similar services to

children and adults.

The comments submitted by the

American Academy of Pediatrics

responded to our question in the

December 8, 1994 final rule of whether

the work involved in treating pediatric

patients is different from that involved

in treating adult patients (59 FR 63454).

The American Academy of Pediatrics

requested that new codes be added to

the CPT to describe different age

categories of patients, and that work

RVUs be assigned to these codes

reflecting the differences in work for

patients of different ages. Following

adoption of new or revised CPT codes

for pediatric services, the RUC will

recommend work RVUs.

If, after reviewing the RUC

recommendations, we choose to assign

work RVUs for these new codes, we will

do so in a future annual physician fee

schedule update.

4. Anesthesia

Comment: The American Society of

Anesthesiologists submitted the report

of a study conducted by Abt Associates,

Inc. covering all the current CPT codes

for anesthesia services. Abt conducted

the study to assess the work of

anesthesia services in a way that does

not rely on the current anesthesia

conversion factor.

We base Medicare payments for

anesthesia services on allowable base

and time units. We have developed a

uniform relative value guide in which

the base unit per anesthesia code is

largely based on the American Society

of Anesthesiologists’ relative value

guide. We published the anesthesia

codes and their imputed work RVUs in

our December 8, 1994 final rule (59 FR

63456 through 63459) for the 1995

physician fee schedule and in the

January 3, 1995 correction notice (60 FR

48 through 49). Anesthesiologists report

the actual anesthesia time for each

procedure on the claim, and the carrier

converts the time to time units. The

carriers then multiply the sum of base

and time units by the anesthesia

conversion factor.

Although the relative values for each

service are not based on the Harvard

study, we used the Harvard study to

determine the anesthesia conversion

factor established under the physician

fee schedule in 1992. As with other

specialties, Harvard first conducted a

survey of anesthesiologists of the work

involved in a number of anesthesia

services, including two procedures

performed by anesthesiologists subject

to the conventional RVU payment

methodology instead of the base and

time unit payment methodology. These

are CPT code 93503 (Insertion and

placement of flow directed catheter

(e.g., Swan-Ganz) for monitoring

purposes) and CPT code 62279

(Injection of diagnostic or therapeutic

anesthetic or antispasmodic substance

(including narcotics); epidural, lumbar

or caudal, continuous). Two evaluation

and management services were also

included. Then, Harvard selected crossspecialty links and placed the

anesthesia services on the common

scale with other specialties. Our use of

these results produced a 42 percent

reduction in the work RVUs for

anesthesia, which was a 29 percent

reduction in the anesthesia conversion

factor.

The American Society of

Anesthesiologists’ comments claimed

that the Harvard cross-specialty process

produced flawed results, and this is the

reason for the Abt study. The study

involved Abt convening a
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multidisciplinary panel of 12

physicians. The panel accepted as

correct the average anesthesia times for

15 surgical procedures selected for indepth study. The panel separated the

anesthesia time for each service into five

components: preservice work,

induction, procedure, emergence, and

postservice work. The sum of the times

for induction, procedure, and

emergence were, in almost all cases,

equal to the intraservice times we

supplied.

For each component of these

reference services, the panel rated the

intensity (defined as the intraservice

work per unit time (IWPUT)) of the

work effort. The panel selected four key

procedures, listed in the table below, as

the fundamental levels of intensity for

use in this comparison, with the unit of

time being 1 minute:

CPT code Descriptor Intensity

(IWPUT)

99204 ...... Office or other outpatient visit for the evaluation and management of a new patient ...................................................... 0.027

62279 ...... Injection of diagnostic or therapeutic anesthetic or antispasmodic substance (including narcotics); epidural, lumbar or

caudal, continuous.

0.044

99291 ...... Critical care, evaluation and management of the unstable or critically injured patient, requiring the constant attendance of the physician; first hour.0.061

33405 ...... Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft .......................... 0.090

The panel then multiplied the

intensity values by the time for each

component to produce recommended

work RVUs on the same scale as other

services in the Medicare payment

schedule. The 15 studied services

represent 45.6 percent of total Medicare

payments for anesthesia services.

For illustrative purposes, the panel

presented an example for CPT code

00350 (Anesthesia for procedures on

major vessels of neck; not otherwise

specified) from the Abt study. The

surgical CPT code is 35301

(Thromboendarterectomy, with or

without patch graft; carotid, vertebral,

subclavian, by neck incision).

CPT Code 00350 (Anesthesia for

procedures on major vessels of neck; not

otherwise specified).

Period

Time

(minutes)

Intensity

(IWPUT) Work

Preanesthesia 20 @ 0.027 = 0.54

Induction .......... 25 @ 0.061 = 1.53

Procedure ........ 120 @ 0.044 = 5.28

Emergence ...... 20 @ 0.061 = 1.22

Postanesthesia 20 @ 0.027 = 0.54

Total Work .......... .............. = 9.11

The panel followed the same process for

each of the 15 procedures. The panel

performed a regression analysis to

extrapolate from these 15 procedures to

the other anesthesia services in CPT.

Based on the results of the panel’s

study, the American Society of

Anesthesiologists recommended that the

work RVUs for all anesthesia services be

increased by 40 percent through an

increase of approximately 27 percent in

the anesthesia conversion factor.

RUC Evaluation/Recommendation:

The RUC’s evaluation of the American

Society of Anesthesiologists’ comment

focused initially on the methodology

employed by Abt, particularly the use of

assigned intensity levels rather than

measures of physician work. The RUC

suggested to the American Society of

Anesthesiologists that, because many

anesthesiologists have experience in

other specialties, a study could be

conducted of anesthesiologists who are

board-certified in more than one

specialty. In this study, physicians

could assess the work involved in

reference services compared to the work

involved in both anesthesia and

nonanesthesia services. This study

could validate the approach of assigning

intensity levels to the discrete time

periods.

The RUC also expressed concern

about the particular levels of intensity

selected, especially the use of the

IWPUT of CPT code 99204 (Office or

other outpatient visit for the evaluation

and management of a new patient) as

the lowest value for any anesthesia

work, which is used for the period when

the surgeon is performing the operation.

The RUC noted that the regression

analysis used to expand the study from

the 15 services directly studied to the

250 anesthesia codes in the CPT

appeared to work well.

In response to the RUC’s request, the

American Society of Anesthesiologists

conducted a RUC-like survey of

anesthesiologists who are board

certified in more than one specialty.

This survey, however, produced even

higher work RVUs (median survey

values were on average 30 percent

higher) than the physician panel

produced. The American Society of

Anesthesiologists also reconvened the

multidisciplinary panel to review the

survey results and to discuss the levels

of intensity assigned to the codes. The

panel used the survey results to refine

its previous estimates, but did not adopt

the survey results as a substitute for its

previous approach. The panel also

confirmed its view that the intensity

levels selected are correct.

The RUC asked for an additional

explanation of the intensity levels

selected, particularly the use of 0.027,

the IWPUT for evaluation and

management services, as the reference

service for that period of time when the

surgeon is performing the procedure

and the patient is anesthetized. The

American Society of Anesthesiologists’

advisor explained that during this

period the anesthesiologist is

continuously monitoring the patient,

integrating the anesthesia care with

what the surgeon is doing, integrating

data, making decisions, and doing

whatever has to be done for the patient.

The panel considered this to be

equivalent to face-to-face evaluation and

management services.

The RUC concluded that, although

this period of time clearly involved two

of the components of physician work,

time and stress (because of the risk of

harm to the patient), this part of each

procedure does not involve the same

mental effort, judgment, technical skill,

and physical effort as an evaluation and

management encounter.

Following this review, the American

Society of Anesthesiologists made some

adjustments to its recommendations by

reducing the IWPUT for the period of

time considered to be equivalent to

evaluation and management services

from 0.027 to 0.025. It also shortened

the number of minutes to which the two

highest intensity levels were assigned.

Based on the review, the RUC did not

find the anesthesia study sufficiently

compelling to justify a recommendation

changing the work RVUs. The RUC

concluded that the method used was a

reasonable estimate of the rank order of

the procedures. The RUC was

concerned, however, that the actual

magnitudes were not validated and

therefore could not be directly

compared to other specialties.
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20041

The RUC agreed to reconsider this

issue at its February 1996 meeting and

allowed Abt Associates to make an

additional presentation. The RUC has

not transmitted to us the results of its

recommendation made at that meeting.

Since we have not yet received the final

recommendation, we will maintain the

current base unit values and the current

1996 national conversion factor of

$15.28 per unit.

5. Codes Without Work Relative Value

Units

Comment: Two specialty societies

objected to certain codes having zero

work RVUs. The American

Psychological Association believed we

should adopt the 1993 RUC work RVU

recommendations for CPT codes 90830

(a code which was deleted and replaced

by CPT code 96100 (Psychological

testing) in 1996), 95880 (Cerebral

aphasia testing), 95881 (Cerebral

developmental test), 95882 (Cognitive

function testing), and 95883

(Neuropsychological testing). Those

work RVU recommendations were in

the 2.00 to 2.20 range. Also, the

American Academy of Audiology

believed that work RVUs of greater than

zero should be assigned to certain

audiology function tests that now have

zero work RVUs.

Essentially, the organizations

contended that our view that only the

work of a physician, such as a doctor of

medicine or a doctor of osteopathy,

should qualify for work RVUs, is

erroneous. They contended that

everything that is included within the

definition of a physician service under

section 1848(j)(3) of the Act has work

that is done by a ‘‘physician’’ and

should therefore have physician work

RVUs.

Response: We disagree. Section 1848

of the Act defined physician services to

delineate which services would be paid

under the physician fee schedule. The

Congress intended that more than the

professional services of doctors of

medicine and doctors of osteopathy,

that is, physicians as defined in section

1861(r) of the Act, be included for

payment under the physician fee

schedule.

We currently believe, however, that

under section 1848 of the Act, only the

work of physicians, as defined in

section 1861(r) of the Act, their

‘‘incident to’’ employees, and

independently practicing occupational

and physical therapists qualify for

payment through the work RVUs.

Every service for which payment is

made under the physician fee schedule

requires the expenditure of work

resources by some entity. X-ray

technicians ‘‘work’’ to produce the

technical component of a diagnostic

chest x-ray. Radiology technicians

‘‘work’’ to produce the technical

component of radiation therapy.

However, the Congress did not intend

that every expenditure of ‘‘work’’ under

the fee schedule be paid through the

physician work RVUs. In section

1848(c)(1)(B) of the Act, the term

‘‘practice expense component’’ is

defined to clearly include the wages of

personnel who perform or create

physician fee schedule services. Their

labor is reimbursed through the practice

expense component rather than the

physician work component. Practice

expense RVUs are currently chargebased, but, in 1998, they will be

resource-based and there will be an

opportunity for appropriate adjustments

to these practice expense RVUs.

6. Codes Referred to the Physicians’

Current Procedural Terminology

Editorial Panel

For CPT 1997, the AMA placed a

moratorium on specialty requests for

coding changes in order to prevent a

large number of new codes from being

implemented at the same time as the

changes in the physician fee schedule

due to the 5-year review. The only

coding change requests being

considered are those for new

technologies that cannot currently be

reported with other codes in CPT and

those for codes that are not on the

physician fee schedule (for example,

clinical laboratory services). The RUC

and the CPT Editorial Panel had also

anticipated, however, that a small

percentage of the issues included in the

5-year review would require review by

CPT before they could be considered by

the RUC, because it appeared likely that

some comments on misvalued codes

would actually be due to the codes’

nomenclature.

After reviewing the comments

referred for inclusion in the 5-year

review, the RUC identified 25 issues

that it recommended be considered by

CPT before further review by the RUC.

The RUC requested the specialty

societies to submit proposals to CPT in

time for any coding changes to be

reviewed by the RUC and reflected in

CPT 1997 and the 1997 physician fee

schedule, simultaneous with the other

changes due to the 5-year review. We

discuss these issues in Table 3, ‘‘Codes

Referred to the Physicians’ Current

Procedural Terminology Editorial

Panel,’’ which follows.

In addition to issues requiring further

review by CPT, four issues were

addressed in 5-year review comments

that had already been addressed by the

CPT Editorial Panel and the RUC as part

of the updates for CPT 1996. We also

discuss these issues in Table 3.

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The American Academy of Pediatrics

submitted a public comment requesting

that 480 CPT codes each be divided into

several codes for different age categories

and about 20 new codes be added for

pediatric services that are not currently

described in CPT. To address these

issues, a Pediatrics Committee,

comprised of RUC members and two

members of the CPT Editorial Panel,

was formed. This committee has made

several recommendations to the

American Academy of Pediatrics about

how to handle the issues raised in its

comments.

The RUC referred 65 codes to the CPT

Editorial Panel to be considered for

coding changes before further review by

the RUC. These codes are included in

the Addendum, ‘‘Codes Subject to

Comment.’’

7. Potentially Overvalued Services

Comment/RUC Evaluation/

Recommendation: Because specialty

societies would be likely to identify the

most important undervalued services

during the public comment period for

the December 8, 1994 final rule (59 FR

63410), several groups, including the

Physician Payment Review

Commission, underscored the need to

identify potentially overvalued services.

The RUC and HCFA performed four

complementary analyses to identify

potentially misvalued services, based

primarily on recent Medicare claims

data. These analyses are discussed

below.

HCFA provided data on IWPUT and

other characteristics of services to

carrier medical directors to use in a

systematic analysis to identify

misvalued services. As a result of this

review, HCFA referred 300 potentially

misvalued codes to the RUC. Those

codes are included in Table 1 of this

notice.

The RUC analyzed trends in the

frequency and site-of-service for

services furnished between 1992 and

1994. It identified services for which the

frequency increased by an average of

more than 25 percent per year, the

percentage of times the service was

furnished in an inpatient setting

decreased by more than 5 percent per

year, and there were more than 1,000

Medicare claims for the service in 1992

and 1994.

The RUC believed that the

combination of a high rate of increase in

annual frequency combined with a shift

from inpatient to outpatient site-ofservice could be an indicator that the

services were becoming more commonly

furnished and that the work involved

each time the service was performed

may be less than the current work RVUs

imply.

The RUC also conducted an analysis

of IWPUT, although the analysis

differed somewhat from the HCFA

analysis. The RUC divided the codes

into clinical groupings and calculated

the mean IWPUT for each group. The

RUC identified individual services as

being potentially overvalued if they had

an IWPUT more than 3 standard

deviations above the mean for the

group.

Finally, the RUC identified a number

of codes for which the final Harvard

work RVUs are significantly lower than

the 1995 Medicare work RVUs. This

relationship suggested that the Medicare

work RVUs are too high.

After eliminating from these three

categories those codes that were already

included in the 5-year review because of

the comment process, the RUC asked us

if 33 of these potentially overvalued

codes could be included in the 5-year

review. Since the codes were not

identified until June 1995, the RUC also

asked if it could take more time, if

necessary, to complete review of these

codes. We agreed to add the codes and

to allow more time for review. We have

noted these 33 codes in Table 1 of this

notice.

The RUC disseminated the list to all

the specialty societies on its Advisory

Committee and, as with the codes

identified through the comment process,

asked them to indicate whether they

wished to be involved in developing the

primary recommendation to the RUC for

each code. The RUC asked the specialty

societies that responded affirmatively to

take one of the following four actions:

• Recommend lower work RVUs for

the code.

• Demonstrate, if the code was

identified by the RUC’s analysis of the

Harvard data, that it is appropriate that

the service have a higher IWPUT than

other clinically related codes or that the

current Medicare work RVUs are more

appropriate than the Harvard work

RVUs.

• Demonstrate, if the code was

identified by the AMA trends analysis,

that the service work has not decreased

over time.

• Show why the code was identified

for review in error.

The full RUC, not one of the RUC

workgroups, conducted the primary

review of most of these services. For 10

of the 33 codes, the specialty societies

recommended that the work RVUs be

reduced, and the RUC concurred with

these recommendations. Five of them

were found to have been identified in

error because of problems in the

Medicare Part B data or because

previous coding changes were

responsible for the trend changes. The

RUC reviewed an additional 17 services

and recommended that the current work

RVUs be maintained. We did not receive

RUC recommendations for the 6

remaining codes. One code, CPT code

67210, was sent to the CPT Editorial

Panel for clarification. The RUC has not

completed its consideration of the other

5 codes.

HCFA Decision: We agree with all but

one of the RUC recommendations. For

CPT codes 28010, 33970, 67210, 77420,

77425, and 77430, we are proposing to

maintain the current work RVUs

because we have no RUC

recommendations or additional

evidence to assist us in revising the

values.

CPT code 37201 (Transcatheter

therapy, infusion for thrombolysis other

than coronary).

The current work RVUs are 7.25. The

RUC agreed with the Society for

Cardiovascular and Interventional

Radiology that the frequency of claims

for this code is growing because

thrombolytic infusion is an effective

therapy for thrombosed arteries and

grafts, allowing physicians to save

patient limbs. The service is still a

relatively new technology and the RUC

believed that it is appropriately valued.

Unlike CPT code 34111 (Removal of

arm artery clot), a similar open

procedure with a 90-day global period,

CPT code 37201 is billed with an

evaluation and management code and a

supervision and interpretation code.

Therefore, we believe that the work

RVUs for CPT code 37201 should

approximate the work RVUs for CPT

code 34111 (7.18) minus the work RVUs

for a level-two subsequent hospital visit

(0.88) and the work RVUs for the

radiological supervision and

interpretation, CPT code 75894 (1.31).

We are proposing 5.00 work RVUs for

CPT code 37201.

D. Other Issues

1. Budget Neutrality

In conjunction with our review of

proposed changes to the work RVUs, we

reexamined our method for making the

required budget neutrality adjustments.

Past adjustments were made across-theboard, either on all RVUs or, beginning

in 1996, on the conversion factors.

Because this is a 5-year review of work

RVUs, we believe the budget neutrality

adjustment should be made only on the

work RVUs.

Many services on the physician fee

schedule have no work RVUs assigned

to them. Services with no work RVUs

were not subject to this 5-year review.
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If we made the budget neutrality

adjustment either on all RVUs or on the

conversion factors, those services would

be negatively affected by a process that

did not consider those codes. Other

services that would be adversely

affected by an across-the-board

approach to budget neutrality are those

with a practice expense percentage of

total RVUs that is greater than the

average practice expense percentage for

the physician fee schedule.

Next year we will propose new

resource-based RVUs to capture the

practice expenses associated with each

CPT and alphanumeric HCPCS code on

the physician fee schedule. We expect

to make a budget neutrality adjustment

as a result of this change. At that time,

we plan to make the adjustment across

the practice expense RVUs. Making the

budget neutrality adjustment only

across the type of RVUs affected

maintains the integrity of the different

pools for work, practice expense, and

malpractice expense.

Therefore, we propose a budget

neutrality adjustment resulting from the

5-year review of work RVUs on work

RVUs only. This proposal is consistent

with the Physician Payment Review

Commission’s recommendation in its

1996 Annual Report to Congress that

‘‘Implementation of any changes to

work relative values as a result of the

current five-year review should be

budget neutral with respect to work

values and should not affect practice

expense and malpractice expense

relative values.’’

Based on our proposed work RVUs,

the necessary budget neutrality

adjustment across the work RVUs is a

decrease of 7.63 percent. This

percentage is subject to change

depending on refinements made in

response to the comments. Because this

adjustment would be on only the work

RVUs, it does not directly correspond to

the impact on payments. The total

impact of this adjustment will also be

somewhat mitigated by the anticipated

updates to the conversion factors for

1997. For a discussion of the impact on

Medicare payments, refer to section V.B.

To make the adjustment, we plan to

rescale across the work RVUs. However,

in recognition that changing RVUs

causes some administrative burdens for

other payers, we will consider

developing a new budget neutrality

adjuster that will be applied only to the

work RVUs if we receive comments

requesting that we do so. In this case,

the payment formula would be

calculated as follows: [(work RVU)

(work adjuster) (work geographic

practice cost index) + (practice expense

RVU) (practice expense geographic

practice cost index) + (malpractice RVU)

(malpractice geographic practice cost

index)] × conversion factor. From year

to year this new adjuster would reflect

the cumulative adjustment needed to

maintain work budget neutrality.

We will continue to make any budget

neutrality adjustment due to policy

changes on the conversion factors and

not on the RVUs. Under our proposal,

only adjustments resulting from RVU

changes will be made on the appropriate

pool of RVUs (for example, work,

practice expense, or malpractice

expense).

2. Calculation of Practice Expense and

Malpractice Expense Relative Value

Units

As we noted in our December 8, 1994

final rule, practice expense and

malpractice expense RVUs were not

subject to comment and will not be

recalculated as a part of the 5-year

review of work RVUs (59 FR 63454).

Section 1848(c)(2) of the Act requires

that the practice expense and

malpractice expense RVUs be calculated

based upon 1991 allowed charges and

practice expense and malpractice

expense shares for the specialties that

furnish the services. When we

calculated the practice expense and

malpractice expense RVUs, we aged

1989 actual charges forward to

approximate 1991 actual charges, and

we used the specialty practice shares

from the AMA’s Socioeconomic Survey

of practice expenses by specialty.

In addition, as we mentioned in our

December 8, 1995 final rule, we are

presently developing a methodology for

a resource-based system for practice

expense RVUs for each physician

service (60 FR 63169). We expect to

publish a proposed rule in the spring of

1997 and will implement the resourcebased practice expense RVUs beginning

January 1, 1998.

3. Impact of Work Relative Value Unit

Changes for Evaluation and

Management Services on Work Relative

Value Units for Global Surgical Services

In the November 25, 1992 final notice

for the 1993 physician fee schedule, we

increased the RVUs for some evaluation

and management services. At the time,

we stated, ‘‘Because we have not

increased the RVUs for the lower level

codes, we do not believe it would be

necessary or appropriate to revise the

work RVUs of any surgical procedures

resulting from our refinement of the

evaluation and management services.’’

(57 FR 55951) We based this decision on

evidence from the Harvard study that

indicates that the evaluation and

management services included in the

global surgical packages are typically

comparable to lower level visits.

Based on data from the 5-year review

of work RVUs, we are proposing to

increase most of the work RVUs for

evaluation and management services,

including those for lower level

established patient visits. Our reasons

for increasing these work RVUs suggest

that making corresponding across-theboard increases to the work RVUs for all

global surgical packages may be

inappropriate. To the extent that

evaluation and management services

have been undervalued relative to

procedural services, it can be inferred

that we should not increase the

procedural services simply because we

increased the work RVUs for the

evaluation and management services. In

many cases the work RVUs for global

services have been reviewed, either as

part of the 5-year review or for new and

revised codes, and significant

aberrations of the work in the

postoperative office visits have not been

obvious. The assumption that work

RVUs for evaluation and management

services are directly related to global

surgical services has not been validated.

We also revised the work RVUs for

the evaluation and management services

in recognition of the increase in

preservice and postservice work. Many

of the items included in preservice and

postservice work are not of equal

magnitude when considering

preoperative and postoperative visits.

We believe that the preservice and

postservice work associated with

postoperative visits has not changed.

The arguments about increased case

management, telephone calls, and

documentation that supported changes

for evaluation and management services

may not hold true for visits in a global

surgical period where many elements

may be duplicative. For example, the

documentation requirements are much

lower for a surgical follow-up visit than

for an established patient office visit

because individual claims subject to

audit are not being submitted. The visits

also all fall within a defined time limit

(that is, 0, 10, or 90 days). Regular office

visits are not so predictable, increasing

the time that the postservice work may

cover.

When we originally valued most of

the global surgical packages, we did not

use a discreet building block approach.

We acknowledged the need to

incorporate evaluation and management

equivalents but did not use specific

evaluation and management services as

described by CPT. For all these reasons,

we believe that the global surgical

packages should be valued solely on

their own merit rather than in
20046 Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices

connection with the evaluation and

management services.

We did not receive comments that

suggested we make changes to the work

RVUs assigned to CPT codes with global

periods to reflect changes in the work

RVUs for the evaluation and

management services. We did receive

comments to review many procedure

codes because of changes in technology,

work, skill, etc. Unlike the comments

regarding the need to review the

evaluation and management services,

the comments on surgical codes did not

discuss any change in the postservice

work associated with the postoperative

visits. Additionally, the RUC did not

express an opinion on this issue.

Given a lack of evidence that the

preservice and postservice work

associated with surgical procedures has

changed, we are not adjusting the work

RVUs of services with a global period.

We have no plans to adjust the global

surgical packages as a result of our

increases to the evaluation and

management services. If the physician

community, through the RUC, makes a

recommendation to us on this issue, we

will consider reviewing our current

policy. However, until we receive

compelling evidence to make

adjustments to the global surgical

packages, we will make no across-theboard adjustments outside of our regular

review of work RVUs.

4. Future Review

Since the physician fee schedule was

implemented in 1992 we have

undertaken significant annual revisions

to the work RVUs for large numbers of

codes, and with the publication of a

final rule later this year we will have

completed the first 5-year review. We

believe that through these extensive

efforts the work RVUs are now largely

correct. We believe that a significant

case would need to be made to change

the work RVUs for the overwhelming

bulk of procedures.

For the future, we are considering

periodic review of the physician fee

schedule as necessary. However, there

are several categories of codes and

issues for which we have tentative plans

to review prior to the next 5-year

review: Services that typically require

reporting more than one code to

describe the service correctly; the

relationship of physician work between

analogous open and closed procedures;

radiation oncology; and rank order

anomalies within families.

5. Nature and Format of Comments on

Work Relative Value Units

We will accept comments on the

proposed work RVUs for the codes

identified in the Addendum of this

notice. We will also accept comments

on the anesthesia codes. Comments

should discuss how the work associated

with a given CPT/HCPCS code is

analogous to the work in other services

or discuss the rationale for disagreeing

with the RUC recommendation. We are

especially interested in information or

arguments that were not presented in

earlier comments.

III. Collection of Information

Requirements

This document does not impose

information collection and

recordkeeping requirements.

Consequently, it need not be reviewed

by the Office of Management and

Budget under the authority of the

Paperwork Reduction Act of 1995 (44

U.S.C. 3501 et seq.).

IV. Response to Comments

Because of the large number of items

of correspondence we normally receive

on Federal Register documents

published for comment, 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, if we proceed with

a subsequent document, we will

respond to the comments in the

preamble to that document.

V. Regulatory Impact Analysis

A. Regulatory Flexibility Act

Consistent with the Regulatory

Flexibility Act (5 U.S.C. 601 through

612), we prepare a regulatory flexibility

analysis unless the Secretary certifies

that a rule would not have a significant

economic impact on a substantial

number of small entities. For purposes

of the Regulatory Flexibility Act, all

physicians are considered to be small

entities.

Although the changes included in this

proposed notice are not expected to

have a significant economic impact on

a substantial number of small entities,

we are preparing a voluntary regulatory

flexibility analysis. The provisions of

this proposed notice would have

varying effects on the distribution of

Medicare physician payments across

specialties. We anticipate that virtually

all of the approximately 500,000

physicians who furnish covered services

to Medicare beneficiaries would be

affected by one or more provisions of

this notice. In addition, physicians who

are paid by private insurers for nonMedicare services would be affected to

the extent that they are paid by private

insurers that choose to use the RVUs.

However, with few exceptions, we

expect that the impact on individual

medical practitioners would be limited.

B. Effects on Physician Payments

1. Impact Estimation Methodology

Physician fee schedule impacts were

estimated by comparing predicted

physician payments under a

continuation of the current work RVUs

to the estimated payments under the

proposed work RVUs resulting from the

5-year review. The impact analysis does

not incorporate assumptions about

volume and intensity responses.

2. Overall Fee Schedule Impact

Because the proposed work RVUs

cause an increase in total estimated

payments under the physician fee

schedule, we must reduce payments in

order to maintain budget neutrality as

required by section 1848(c)(2)(B)(ii)(II)

of the Act. As we discussed in section

II.D.1. of this notice, we are proposing

to make the budget neutrality

adjustment on the physician work

component on the physician fee

schedule. In the discussion below of

differential impacts by specialty, we

have incorporated this projected

downward adjustment of 7.63 percent.

3. Specialty Level Effect

Table 4, ‘‘Five-Year Review Impact on

Medicare Payments by Specialty,’’

shows the estimated percentage change

in Medicare physician payment from

the current work RVUs to the proposed

work RVUs by specialty. The specialties

are ranked according to the impact of

the work RVU change on Medicare

payments. The magnitude of the impact

depends on the mix of services the

specialty provides. In general, because

of the proposed changes to the

evaluation and management services,

those specialties that account for more

visits and fewer procedures are

expected to experience larger increases

in Medicare payments than

procedurally oriented specialties,

including surgical specialties.

Because the budget neutrality

adjustment reduces payments for

services with work RVUs which did not

experience any change as a result of the

5-year review, specialties that primarily

perform these services will experience a

negative impact. For example, although

the one code that chiropractors can bill

under Medicare, HCPCS code A2000,

was unchanged, chiropractors are

expected to experience a 4.4 percent

decrease in Medicare payments. This

decrease is less than the budget

neutrality adjustment of 7.63 percent

because only 60 percent of payments for
Federal Register / Vol. 61, No. 87 / Friday, May 3, 1996 / Notices 20047

HCPCS code A2000 are attributable to

the work RVUs. The rest of the

payments are attributable to the practice

expense and malpractice expense RVUs

which were unaffected by the budget

neutrality adjustment. The total impact

of the budget neutrality adjustment will

be somewhat mitigated by the

anticipated updates to the conversion

factors for 1997.

TABLE 4.—FIVE-YEAR REVIEW IMPACT

ON MEDICARE PAYMENTS BY SPECIALTY

Specialty

Impact of

work

RVU

change

(percent)

Family Practice ............................. 4.6

Internal Medicine .......................... 4.2

Hematology Oncology .................. 3.9

Emergency Medicine .................... 3.7

Pulmonary ..................................... 3.6

General Practice ........................... 3.5

Rheumatology ............................... 3.4

All Other Physicians ..................... 2.9

Neurology ...................................... 2.6

Obstetrics/Gynecology .................. 2.0

Clinics ........................................... 1.2

Cardiology ..................................... 1.1

Otolaryngology .............................. 0.9

Vascular Surgery .......................... 0.5

Gastroenterology .......................... 0.2

Neurosurgery ................................ 0.2

Nephrology .................................... ¥0.4

General Surgery ........................... ¥0.8

Orthopedic Surgery ....................... ¥1.5

Suppliers ....................................... ¥1.6

Urology .......................................... ¥1.6

Oral Surgery ................................. ¥1.8

Thoracic Surgery .......................... ¥1.8

Plastic Surgery .............................. ¥2.0

Psychiatry ..................................... ¥2.2

Cardiac Surgery ............................ ¥2.4

Radiology ...................................... ¥2.6

Podiatry ......................................... ¥2.6

TABLE 4.—FIVE-YEAR REVIEW IMPACT

ON MEDICARE PAYMENTS BY SPECIALTY—Continued

Specialty

Impact of

work

RVU

change

(percent)

Radiation Oncology ...................... ¥3.1

Ophthalmology .............................. ¥3.8

Nonphysician Practitioners ........... ¥4.1

Pathology ...................................... ¥4.2

Optometrist ................................... ¥4.5

Chiropractor .................................. ¥4.6

Anesthesiology .............................. ¥4.7

Dermatology .................................. ¥6.2

All Physician Specialties ............... 0.0

C. Rural Hospital Impact Statement

Section 1102(b) of the Act requires the

Secretary to prepare a regulatory impact

analysis if a rule 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 603 of the Regulatory

Flexibility Act. For purposes of section

1102(b) of the Act, we define a small

rural hospital as a hospital that is

located outside of a Metropolitan

Statistical Area and has fewer than 50

beds.

This proposed notice would have

little direct effect on payments to rural

hospitals since this notice would change

only payments made to physicians and

certain other practitioners under Part B

of the Medicare program and would not

change payments to hospitals under Part

A. We do not believe the changes would

have a major, indirect effect on rural

hospitals.

Therefore, we are not preparing an

analysis for section 1102(b) of the Act

since we have determined, and the

Secretary certifies, that this notice

would not have a significant impact on

the operations of a substantial number

of small rural hospitals.

In accordance with the provisions of

Executive Order 12866, this notice was

reviewed by the Office of Management

and Budget.

Authority: Section 1848(c) of the Social

Security Act (42 U.S.C. 1395w–4(c)).

(Catalog of Federal Domestic Assistance

Program No. 93.774, Medicare—

Supplementary Medical Insurance Program)

Dated: April 26, 1996.

Bruce C. Vladeck,

Administrator, Health Care Financing

Administration.

Dated: April 26, 1996.

Donna E. Shalala,

Secretary.

Addendum—Codes Subject to Comment

This addendum lists the codes

reviewed during the 5-year review. This

addendum includes the following

information:

• CPT/HCPCS (HCFA Common

Procedure Coding System) code. This is

the CPT or alphanumeric HCPCS code

for a service.

• Modifier. A modifier -26 is shown if

the work RVUs represent the

professional component of the service.

• Description. This is an abbreviated

version of the narrative description of

the code.

• Proposed work RVUs. This column

contains the proposed RVUs for

physician work. The work RVUs shown

have not been adjusted for budget

neutrality.

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[FR Doc. 96–10902 Filed 5–2–96; 8:45 am]

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