[Federal Register: August 2, 2007 (Volume 72, Number 148)]
[Rules and Regulations]
[Page 42469-42626]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr02au07-17]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 410 and 416
Medicare Program; Revised Payment System Policies for Services
Furnished in Ambulatory Surgical Centers (ASCs) Beginning in CY 2008;
Final Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 410 and 416
[CMS-1517-F]
RIN 0938-AO73
Medicare Program; Revised Payment System Policies for Services
Furnished in Ambulatory Surgical Centers (ASCs) Beginning in CY 2008
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule revises the Medicare ambulatory surgical
center (ASC) payment system to implement certain related provisions of
the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (MMA). This final rule establishes the ASC list of covered
surgical procedures, identifies covered ancillary services under the
revised ASC payment system, and sets forth the amounts and factors that
will be used to determine the ASC payment rates for calendar year (CY)
2008. The changes to the ASC payment system and ratesetting methodology
in this final rule are applicable to services furnished on or after
January 1, 2008.
DATES: Effective Date: This final rule is effective on January 1, 2008.
FOR FURTHER INFORMATION, CONTACT: Alberta Dwivedi, (410) 786-0378. Dana
Burley, (410) 786-0378.
SUPPLEMENTARY INFORMATION:
Electronic Access
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Alphabetical List of Acronyms Appearing in This Final Rule
AHA American Hospital Association
AMA American Medical Association
APC Ambulatory payment classification
ASC Ambulatory surgical center
BESS [Medicare] Part B Extract Summary System
CAH Critical access hospital
CBSA Core-Based Statistical Area
CMS Centers for Medicare & Medicaid Services
CPI-U Consumer Price Index for All Urban Consumers
CPT [Physicians'] Current Procedural Terminology, Fourth Edition,
2007, copyrighted by the American Medical Association. CPT[supreg]
is a trademark of the American Medical Association.
CY Calendar year
DRA Deficit Reduction Act of 2005, Public Law 109-171
FY Federal fiscal year
GAO Government Accountability Office
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
HQA Hospital Quality Alliance
IOL Intraocular lens
IPPS [Hospital] Inpatient prospective payment system
MAC Medicare administrative contractor
MedPAC Medicare Payment Advisory Commission
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Public Law 108-173
MPFS Medicare Physician Fee Schedule
MSA Metropolitan Statistical Area
NTIOL New technology intraocular lens
OCE Outpatient Code Editor
OMB Office of Management and Budget
OPPS [Hospital] Outpatient prospective payment system
PM Program memorandum
PPAC Practicing Physicians Advisory Council
PPS Prospective payment system
PRA Paperwork Reduction Act of 1995
RFA Regulatory Flexibility Act
RVU Relative value unit
To assist readers in referencing sections contained in this
document, we are providing the following table of contents:
Table of Contents
I. Background
A. Legislative and Regulatory History
B. ASC Payment Method
C. Provisions of Public Law 108-173 (MMA)
D. Issuance of Proposed Rule
E. Changes to the ASC List for CY 2007
II. Revisions to the ASC Payment System Effective January 1, 2008
A. General
B. Factors Considered in the Development of the Revised ASC
Payment System
C. Rulemaking for the Revised ASC Payment System in CY 2008
III. Covered Surgical Procedures Paid in ASCs On or After January 1,
2008
A. Payable Procedures
1. Definition of Surgical Procedure
2. Procedures Excluded From Payment Under the Revised ASC
Payment System
a. Significant Safety Risk
b. Overnight Stay
B. Treatment of Unlisted Procedure Codes and Procedures That Are
Not Paid Separately Under the OPPS
C. Treatment of Office-Based Procedures
D. Specific Surgical Procedures Excluded From Payment Under the
Revised ASC Payment System
IV. Ratesetting Methodology for the Revised ASC Payment System
A. Overview of Current ASC Payment System
B. ASC Relative Payment Weights Based on APC Groups and Relative
Payment Weights Established Under the OPPS
C. Packaging Policy
1. General Policy
2. Policies for Specific Items and Services
a. Radiology Services
b. Brachytherapy Sources
c. Drugs and Biologicals
d. Implantable Devices With Pass-Through Status Under the OPPS
e. Implantable Devices Without Pass-Through Status Under the
OPPS
D. Payment for Corneal Tissue Under the Revised ASC Payment
System
E. Payment for Office-Based Procedures
F. Payment Policies for Multiple and Interrupted Procedures
1. Multiple Procedure Discounting Policy
2. Interrupted Procedure Policies
G. Geographic Adjustment
H. Adjustment for Inflation
I. Beneficiary Coinsurance
J. Phase-In of Full Implementation of Payment Rates Calculated
Under the Revised ASC Payment System Methodology
V. Calculation of ASC Conversion Factor and ASC Payment Rates for CY
2008
A. Overview
B. Budget Neutrality Requirement
C. Calculation of the ASC Payment Rates for CY 2008
1. Proposed Method for Calculation of the ASC Payment Rates for
CY 2008 in the August 2006 Proposed Rule
a. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurnace) Under the Current ASC Payment System in the August 2006
Proposed Rule
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Proposed Revised ASC Payment System in the
August 2006 Proposed Rule
c. Calculation of the Proposed CY 2008 Budget Neutrality
Adjustment in the August 2006 Proposed Rule
d. Application of the Budget Neutrality Adjustment To Determine
the Proposed CY 2008 ASC Conversion Factor in the August 2006
Proposed Rule
e. Calculation of the Proposed CY 2008 ASC Payment Rates Under
the Revised ASC Payment System in the August 2006 Proposed Rule
f. Calculation of the Proposed CY 2008 ASC Payment Rates Under
the Transition in the August 2006 Proposed Rule
2. Alternative Option for Calculating the Proposed Budget
Neutrality Adjustment in the August 2006 Proposed Rule
a. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance)
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Under the Existing ASC Payment System in the August 2006 Proposed
Rule
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Proposed Revised ASC Payment System in the
August 2006 Proposed Rule
c. Calculation of the Proposed CY 2008 Budget Neutrality
Adjustment in the August 2006 Proposed Rule
d. Discussion of the Alternative Calculation of the Budget
Neutrality Adjustment
3. Calculation of the Estimated CY 2008 Budget Neutrality
Adjustment According to the Final Policy
4. Final Calculation of the Estimated ASC Payment Rates for CY
2008
a. Estimated CY 2008 Medicare Program Payments (Excluding
Beneficiary Coinsurance) Under the Existing ASC Payment System
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Revised ASC Payment System
c. Calculation of the Final Estimated CY 2008 Budget Neutrality
Adjustment
d. Calculation of the Final Estimated CY 2008 ASC Payment Rates
D. Calculation of the ASC Payment Rates for CY 2009 and Future
Years
1. Updating the ASC Relative Payment Weights
2. Updating the ASC Conversion Factor
E. Annual Updates
VI. Information in Addenda Related to the Revised CY 2008 ASC
Payment System
VII. ASC Regulatory Changes
A. Regulatory Changes That Were Finalized in the CY 2007 OPPS/
ASC Final Rule With Comment Period
B. Regulatory Changes Included in This Final Rule
VIII. Files Available to the Public Via the Internet
IX. Collection of Information Requirements
X. Regulatory Impact Analysis
A. Overall Impact
1. Executive Order 12866
2. Regulatory Flexibility Act
3. Small Rural Hospitals
4. Unfunded Mandates
5. Federalism
B. Effects of the Revisions to the ASC Payment System for CY
2008
1. Alternatives Considered
2. Limitations of Our Analysis
3. Estimated Effects of This Final Rule on ASCs
4. Estimated Effects of This Final Rule on Beneficiaries
5. Conclusion
6. Accounting Statement
C. Executive Order 12866
Regulation Text
Addendum AA.--Illustrative ASC Covered Surgical Procedures for CY
2008 (Including Surgical Procedures for Which Payment Is Packaged)
Addendum BB.--Illustrative ASC Covered Ancillary Services Integral
to Covered Surgical Procedures for CY 2008 (Including Ancillary
Services for Which Payment Is Packaged)
Addendum DD1.--Illustrative ASC Payment Indicators
I. Background
A. Legislative and Regulatory History
Section 1832(a)(2)(F)(i) of the Social Security Act (the Act)
provides that benefits under the Medicare Supplementary Medical
Insurance program (Part B) include payment for facility services
furnished in connection with surgical procedures specified by the
Secretary that are performed in an ambulatory surgical center (ASC). To
participate in the Medicare program as an ASC, a facility must meet the
standards specified in section 1832(a)(2)(F)(i) of the Act, which are
implemented in 42 CFR Part 416, Subpart B and Subpart C of our
regulations. The regulations at 42 CFR 416, Subpart B set forth general
conditions and requirements for ASCs, and the regulations at Subpart C
provide specific conditions for coverage for ASCs.
The ASC services benefit was enacted by Congress through the
Omnibus Reconciliation Act of 1980 (Pub. L. 96-499). For a detailed
discussion of the legislative history related to ASCs, we refer readers
to the June 12, 1998 proposed rule (63 FR 32291).
Section 1833(i)(1)(A) of the Act requires the Secretary to specify
surgical procedures that, although appropriately performed in an
inpatient hospital setting, also can be performed safely on an
ambulatory basis in an ASC, critical access hospital (CAH), or a
hospital outpatient department (HOPD). The report accompanying the
legislation explained that Congress intended procedures currently
performed on an ambulatory basis in a physician's office that do not
generally require the more elaborate facilities of an ASC not be
included in the list of ASC covered procedures (H.R. Rep. No. 96-1167,
at 390-91, reprinted in 1980 U.S.C.C.A.N. 5526, 5753-54). In a final
rule published on August 5, 1982, in the Federal Register (47 FR
34082), we established regulations that included criteria for
specifying which surgical procedures were to be included for purposes
of implementing the ASC facility benefit. Medicare only allows payment
to ASCs for procedures that are specified on the ASC list.
Section 626(b) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, repealed the requirement
formerly found in section 1833(i)(2)(A) of the Act that the Secretary
conduct a survey of ASC costs for purposes of updating ASC payment
rates and, instead, requires the Secretary to implement a revised ASC
payment system, to be effective not later than January 1, 2008. Section
5103 of the Deficit Reduction Act of 2005 (DRA), Public Law 109-171,
amended section 1833(i)(2) of the Act by adding a new subparagraph (E)
to place a limitation on payments for surgical procedures in ASCs.
Section 1833(i)(2) of the Act provides that if the standard overhead
amount under section 1833(i)(2)(A) of the Act for a facility service
for such procedure, without application of any geographic adjustment,
exceeds the Medicare payment amount under the hospital outpatient
prospective payment system (OPPS) for the service for that year,
without application of any geographic adjustment, the Secretary shall
substitute the OPPS payment amount for the ASC standard overhead
amount. This provision applies to surgical procedures furnished in ASCs
on or after January 1, 2007, and before the effective date of the
revised ASC payment system implemented in this final rule.
In the November 24, 2006 final rule with comment period for the CY
2007 OPPS and ASC payment systems (71 FR 67960), we addressed the
changes in payment to ASCs mandated by section 5103 of Public Law 109-
171 and finalized Sec. 416.1(a)(5) of the regulations to implement
this provision. (Hereinafter, the November 24, 2006 final rule with
comment period is referred to as the CY 2007 OPPS/ASC final rule with
comment period.) We also addressed additions to and deletions from the
ASC list of covered surgical procedures that were implemented on
January 1, 2007. In addition, we made changes in the process to review
payment adjustments for insertion of new technology intraocular lenses
(NTIOLs) under section 1833(i)(2)(A)(iii) of the Act.
Section 416.65(a) of the regulations specifies general standards
for procedures on the ASC list. ASC procedures are those surgical and
other medical procedures that are--
Commonly performed on an inpatient basis but may be safely
performed in an ASC;
Not of a type that are commonly performed or that may be
safely performed in physicians' offices;
Limited to procedures requiring a dedicated operating room
or suite and generally requiring a postoperative recovery room or
short-term (not overnight) convalescent room; and
Not otherwise excluded from Medicare coverage.
Specific standards in Sec. 416.65(b) limit covered ASC procedures
to those that do not generally exceed 90 minutes operating time and a
total of 4 hours recovery or convalescent time. If
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anesthesia is required, the anesthesia must be local or regional
anesthesia, or general anesthesia of not more than 90 minutes duration.
Section 416.65(b)(3) of the regulations excludes from the ASC list
procedures that generally result in extensive blood loss, that require
major or prolonged invasion of body cavities, that directly involve
major blood vessels, or that are generally emergency or life-
threatening in nature.
A detailed history of published changes to the ASC list and ASC
payment rates can be found in the June 12, 1998 proposed rule (63 FR
32291). Subsequently, in accordance with Sec. 416.65(c), we published
updates of the ASC list in the Federal Register on March 28, 2003 (68
FR 15268), May 4, 2005 (70 FR 23690), and in the CY 2007 OPPS/ASC final
rule with comment period (71 FR 67960).
During years when we have not updated the ASC list in the Federal
Register, we have revised the list to be consistent with annual
calendar year changes to the Healthcare Common Procedure Coding System
(HCPCS) and Current Procedural Terminology (CPT) codes. These annual
coding updates have been implemented through program instructions to
the carriers that process ASC claims. (We note that Medicare Part B
carriers are transitioning to Medicare Administrative Contractors
(MACs) through 2011, as described in a final rule with comment period
published in the Federal Register on November 24, 2006 (71 FR 68229).)
We last issued program instructions to update the list only to conform
to CPT and HCPCS coding changes on December 20, 2006, via Transmittal
1134, Change Request 5211. This transmittal can be found on the CMS Web
site at: http://www.cms.hhs.gov/Transmittals/).
B. ASC Payment Method
On August 23, 2006, we proposed in the Federal Register (71 FR
49635) a revised payment system for ASCs to be implemented effective
January 1, 2008, in accordance with section 626(b) of Public Law 108-
173, including revisions to the ratesetting methodology and the
applicable ASC regulations to incorporate the requirements and payments
for ASC services under the revised ASC payment system. We also proposed
a new ``exclusionary'' approach for revising the ASC list of covered
surgical procedures beginning CY 2008. We proposed to evaluate surgical
procedures to identify those that could pose a significant safety risk
or that would be expected to require an overnight stay when performed
in ASCs, and that would, therefore, be excluded from Medicare payment
under the revised ASC payment system. Using that exclusionary method,
we developed a list of surgical procedures that we believed were safe
for Medicare beneficiaries in ASCs and that were appropriate for
Medicare payment. We proposed to adopt an exclusionary approach for
identifying surgical procedures that were appropriate for payment under
the revised ASC payment system, and the result of that process was a
proposed list of surgical procedures for which separate payment would
be made. We refer to that list of payable procedures hereinafter as the
ASC ``list of covered surgical procedures.''
There are two primary elements in the total cost of performing a
surgical procedure: (a) The cost of the physician's professional
services to perform the procedure; and (b) the cost of items and
services furnished by the facility where the procedure is performed
(for example, surgical supplies, equipment, and nursing services).
Payment for the first element is made under the Medicare Physician Fee
Schedule (MPFS). The August 2006 OPPS/ASC proposed rule addressed the
second element, payment for the cost of items and services furnished by
the facility.
Under the current ASC payment system, the ASC payment rate is a
standard overhead amount established on the basis of our estimate of a
fee that takes into account the costs incurred by ASCs generally in
providing facility services in connection with performing a specific
procedure. The report of the Conference Committee accompanying section
934 of the Omnibus Reconciliation Act of 1980 states that this overhead
amount is expected to be calculated on a prospective basis using sample
survey data and similar techniques to establish reasonable estimated
overhead allowances, which take into account volume (within reasonable
limits), for each of the listed procedures (H.R. Rept. No. 96-1479, at
134-35 (1980)).
As stated earlier, to establish those reasonable estimated
allowances for services furnished prior to implementation of the
revised ASC payment system, section 626(b)(1) of Public Law 108-73
amended section 1833(i)(2)(A)(i) of the Act that required us to take
into account the audited costs incurred by ASCs to perform a procedure
in accordance with a survey. Further, beginning January 1, 2007, and
prior to implementation of a revised ASC payment system, in accordance
with section 5103 of Pub. L. 109-171, no ASC standard overhead amount
may be greater than the OPPS payment rate for a given service for that
year. Except for screening colonoscopies and flexible sigmoidoscopies,
payment for ASC services is subject to the usual Medicare Part B
deductible and coinsurance requirements, and the amounts paid by
Medicare must be 80 percent of the standard overhead amount. As
required by section 1834(d) of the Act and implemented in regulations
at 42 CFR 410.152(i), the amount paid by Medicare must be 75 percent of
the fee schedule payment amount for screening colonoscopies and
flexible sigmoidoscopies.
Section 1833(i)(1) of the Act requires us to specify, in
consultation with appropriate medical organizations, surgical
procedures that are appropriately performed on an inpatient basis in a
hospital but that can be safely performed in an ASC, a CAH, or an HOPD
and to review and update the list of ASC procedures at least every 2
years.
Section 141(b) of the Social Security Act Amendments of 1994,
Public Law 103-432, requires us to establish a process for reviewing
the appropriateness of the payment amount provided under section
1833(i)(2)(A)(iii) of the Act for intraocular lenses (IOLs) that belong
to a class of NTIOLs. That process was the subject of a separate final
rule entitled ``Adjustment in Payment Amounts for New Technology
Intraocular Lenses Furnished by Ambulatory Surgical Centers,''
published on June 16, 1999, in the Federal Register (64 FR 32198). We
proposed changes to the NTIOL request for review process in the CY 2007
OPPS/ASC proposed rule published in the Federal Register on August 23,
2006 (71 FR 49631 through 49635) and finalized changes to that process
in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68175
through 68181).
C. Provisions of Public Law 108-173 (MMA)
Section 626(a) of Public Law 108-173 (MMA) amended section
1833(i)(2)(C) of the Act, which requires the Secretary to update ASC
payment rates using the Consumer Price Index for All Urban Consumers
(CPI-U) (U.S. city average) if the Secretary has not otherwise updated
the amounts under the revised ASC payment system. As amended by Pub. L.
108-173, section 1833(i)(2)(C) of the Act requires that, if the
Secretary is required to apply the CPI-U increase, the CPI-U percentage
increase is to be applied on a fiscal year (FY) basis beginning with FY
1986 through FY 2005 and on a
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calendar year (CY) basis beginning with CY 2006.
Section 626(a) of Public Law 108-173 further amended section
1833(i)(2)(C) of the Act to require us in FY 2004, beginning April 1,
2004, to increase the ASC payment rates using the CPI-U as estimated
for the 12-month period ending March 31, 2003, minus 3.0 percentage
points. Section 626(a) of Public Law 108-173 also requires that the
CPI-U adjustment factor equal zero percent in FY 2005, the last quarter
of CY 2005, and each calendar year from CY 2006 through CY 2009.
Section 626(b) of Public Law 108-173 repealed the requirement that
CMS conduct a survey of ASC costs upon which to base a standard
overhead payment amount for surgical services performed in ASCs, and
added section 1833(i)(2)(D) of the Act. Section 1833(i)(2)(D)(iii) of
the Act requires us to implement by no earlier than January 1, 2006,
and not later than January 1, 2008, a revised ASC payment system. The
revised payment system under section 1833(i)(2)(D)(i) of the Act is to
take into account the recommendations contained in a Report to Congress
that the Government Accountability Office (GAO) was required to submit
by January 1, 2005. Section 1833(i)(2)(D)(ii) of the Act requires that
the revised ASC payment system be designed to result in the same
aggregate amount of expenditures for surgical services furnished in
ASCs the year the system is implemented as would be made if the new
system did not apply as estimated by the Secretary. This requirement is
to take into account the limitation in ASC expenditures resulting from
implementation of section 5103 of Public Law 109-171 beginning January
1, 2007, as we described in sections XVII.A.1. and XVII.E. of the
preamble to the CY 2007 OPPS/ASC final rule with comment period (71 FR
68165 and 68174, respectively).
Section 1833(i)(2)(D)(iv) of the Act exempts the classification
system, relative weights, payment amounts, and geographic adjustment
factor (if any) under the revised ASC payment system from
administrative and judicial review.
Section 626(c) of Public Law 108-173 added a conforming amendment
to section 1833(a)(1) of the Act, which provides that the amounts paid
under the revised ASC payment system shall equal 80 percent of the
lesser of the actual charge for the services or the payment amount that
we determine under the revised ASC payment system.
D. Issuance of Proposed Rule
As stated earlier, in the August 23, 2006 Federal Register (71 FR
49635), we proposed to implement revisions to the ASC payment system so
that the revised system is first effective on January 1, 2008.
In addition, we set forth an analysis of the impact that the
proposed revised ASC payment system would have on affected entities and
Medicare beneficiaries.
We received over 8,900 pieces of correspondence in response to our
August 23, 2006 proposal for the revised ASC payment system, which
included some comments recommending various changes to how CMS pays for
ASC services and processes ASC claims that we did not propose in the
August 23, 2006 Federal Register. While we read those comments with
interest, we generally do not address them, nor have we made any
changes in this final rule based on them. We summarize the numerous
comments and recommendations that are pertinent to what we proposed,
and we respond to them in the appropriate sections of this final rule.
E. Changes to the ASC List for CY 2007
As part of the CY 2007 OPPS/ASC final rule with comment period, we
finalized additions to and deletions from the ASC list of covered
surgical procedures, effective January 1, 2007 (71 FR 68166). We did
not change the criteria for adding or deleting items from the ASC list
effective January 1, 2007. However, in the August 2006 proposed rule
(71 FR 49628), we discussed changes to the criteria in the context of
developing the proposed revised ASC payment system to be effective
January 1, 2008. The changes to the criteria that we proposed resulted
in the proposed addition for CY 2008 of many procedures that do not
meet the current criteria for addition to the list.
II. Revisions to the ASC Payment System Effective January 1, 2008
A. General
As we discussed earlier, generally, there are two primary elements
in the total cost of performing a surgical procedure: (a) The cost of
the physician's professional services for performing the procedure; and
(b) the cost of services furnished by the facility where the procedure
is performed (for example, surgical supplies, equipment, nursing
services, and overhead). The former is covered by the MPFS. The latter
is covered by a Medicare benefit enacted in 1980 that authorized
payment of a fee to ASCs for services furnished in connection with
performing certain surgical procedures.
Section 1833(i)(1) of the Act requires us to specify surgical
procedures that are appropriately and safely performed on an ambulatory
basis in an ASC. Moreover, we are required to review and update the
list of these procedures not less often than every 2 years, in
consultation with appropriate trade and professional associations. The
ASC list of covered surgical procedures was limited in 1982 to
approximately 100 procedures. Currently, the list consists of more than
2,500 CPT codes encompassing a cross-section of surgical services,
although 150 of these codes account for more than 90 percent of the
approximately 4.5 million procedures paid for each year under the ASC
Part B benefit. Eye, pain management, and gastrointestinal endoscopic
procedures are the highest volume ASC surgeries performed under the
present ASC payment system.
In CY 2007, Medicare only allows payment to ASCs for procedures on
the ASC list of covered surgical procedures. Except for screening
colonoscopy services, payment for ASC facility services is subject to
the usual Medicare Part B deductible and coinsurance requirements, and
the amounts paid by Medicare must be 80 percent of the standard
overhead amount. As discussed earlier, under section 626(b) of Public
Law 108-173, Congress mandated implementation of a revised payment
system for ASC surgical services by no later than January 1, 2008.
Public Law 108-173 set forth several requirements for the revised
payment system, but did not amend those provisions of the statute
pertaining to the ASC list.
As we proposed in the August 2006 proposed rule (71 FR 49635), in
this final rule, we address two components of the ASC payment system
that will go into effect January 1, 2008. First, we are establishing
the ASC list of covered surgical procedures for which an ASC may
receive Medicare payment for facility services under the revised ASC
payment system, as well as those covered ancillary services that may be
separately paid if they are provided integral to a covered surgical
procedure. Second, we are specifying the method we will use to set
payment rates for ASC services furnished in association with covered
surgical procedures. In this final rule, we also specify the regulatory
changes that we are making to 42 CFR Parts 410 and 416 to incorporate
the rules governing ASC payments that will be applicable beginning in
CY 2008.
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B. Factors Considered in the Development of the Revised ASC Payment
System
On August 2, 2005, we convened a listening session teleconference
on revising the Medicare ASC payment system. Over 450 callers
participated, including ASC staff, physicians, and representatives of
industry trade associations. The listening session provided an
opportunity for participants to identify the issues and concerns that
they wanted us to address as we developed the revised ASC payment
system.
Callers encouraged us to foster beneficiary access to ASCs by
creating incentives for physicians to use ASCs. The issues raised by
participants included suggestions to expand or eliminate altogether the
ASC list, recommendations to model payment on the OPPS, and concerns
about how we would propose to treat the geographic wage index
adjustment and the annual ASC payment rate update. Several callers also
raised concerns about ensuring adequate payment for supplies, ancillary
services, and implantable devices under the revised payment system, as
well as developing a process to allow special payment for new
technology.
We also met with representatives of the ASC industry over the past
several years to discuss options for ratesetting other than conducting
a survey, to discuss timely updates to the ASC list, and to listen to
industry concerns related to the implementation of a revised payment
system. We appreciate the thoughtful suggestions that were presented.
We considered the concerns and issues brought to our attention, the
proposals for revising the ASC list of covered surgical procedures, and
the suggested methods by which we could set ASC payment rates in
developing the policies in this final rule.
In the August 23, 2006 Federal Register (71 FR 49506), we proposed
the policies for the revised ASC payment system to be effective
beginning in CY 2008. In response to those proposed policies, we
received over 8,900 pieces of correspondence from the public that we
are addressing in this final rule.
Subsequent to publication of the August 2006 proposed rule for the
revised ASC payment system, the GAO published the statutorily mandated
report entitled, ``Medicare: Payment for Ambulatory Surgical Centers
Should Be Based on the Hospital Outpatient Payment System'' (GAO-07-86)
on November 30, 2006. We considered the report's methodology, findings,
and recommendations in the development of this CY 2008 final rule for
the revised ASC payment system. The GAO methodology, results, and
recommendations are summarized below.
The GAO was directed to conduct a study comparing the relative
costs of procedures furnished in ASCs to those furnished in HOPDs paid
under the OPPS, including examining the accuracy of the ambulatory
payment classifications (APC) with respect to surgical procedures
furnished in ASCs. Section 626(d) of Pub. L. 108-173 indicated that the
report should include recommendations on the following matters:
1. Appropriateness of using groups of covered services and relative
weights established for the OPPS as the basis of payment for ASCs.
2. If the OPPS relative weights are appropriate for this purpose,
whether the ASC payments should be based on a uniform percentage of the
payment rates or weights under the OPPS, or should vary, or the weights
should be revised based on specific procedures or types of services.
3. Whether a geographic adjustment should be used for ASC payment
and, if so, the labor and nonlabor shares of such payment.
To compare the relative costs of procedures performed in ASCs and
HOPDs, the GAO first compiled information on ASCs' costs and the
surgical procedures performed. It conducted a survey of 600 randomly
selected ASCs from the universe of all ASCs to obtain their CY 2004
cost and procedure data. The GAO received 397 responses from facilities
and, through data reliability testing, determined that data from 290
responding facilities were sufficiently reliable and geographically
representative of ASCs. Furthermore, to compare the delivery of
surgical procedures and their relative costs between ASC and HOPD
settings, the GAO analyzed OPPS claims data from CY 2003. It also
interviewed officials at CMS, representatives from ASC industry
organizations and physician specialty societies, and representatives
from nine ASCs.
In order to allocate ASCs' total costs among the individual
procedures they performed, the GAO developed a specific methodology to
allocate the portion of an ASC's costs accounted for by each procedure.
It constructed a relative weight scale for Medicare's covered ASC
procedures that captured the general variation in resources associated
with performing different procedures. Primarily, it used data that CMS
collects for the purpose of setting the practice expense component of
physician payment rates, supplemented by information from specialty
societies and physicians who work for CMS for those procedures for
which CMS had no data on the resources used.
To calculate per-procedure costs based upon data gathered through
its survey of ASCs, the GAO deducted costs that Medicare considers
unallowable, that is, advertising and entertainment costs. In addition,
it also removed costs for services that Medicare pays for separately,
such as physician and nonphysician practitioner services. The remaining
facility costs were then divided into direct and indirect costs. The
GAO defined direct costs as those associated with the clinical staff,
equipment, and supplies utilized during the procedure. Indirect costs
included all remaining costs. Next, to allocate each facility's direct
costs across the procedures it performed, the GAO applied its relative
weight scale. It allocated indirect costs equally across all procedures
performed by the facility. For each procedure performed by a responding
ASC facility, it summed the allocated direct and indirect costs to
determine a total cost for the procedure. To obtain a per-procedure
cost across all ASCs, the GAO arrayed the calculated costs for all ASCs
performing that procedure and identified the median cost.
To compare per-procedure costs for ASCs and HOPDs, the GAO obtained
the list of OPPS APCs and their assigned procedures, along with the
OPPS median cost of each procedure and its related APC group. It then
calculated a ratio between each procedure's ASC median cost as
determined by the survey and the median cost of the procedure's
corresponding APC group under the OPPS, referred to as the ASC-to-APC
cost ratio. It calculated a corresponding ratio between each ASC
procedure's median cost under the OPPS and the median cost of the
procedure's APC group using CMS data, referred to as the OPPS-to-APC
cost ratio. In order to evaluate the difference in procedure costs
between the two settings, the GAO compared the ASC-to-APC cost ratio to
the OPPS-to-APC cost ratio. Next, to assess how well the relative costs
of procedures in the OPPS, defined by their assignment to APC groups,
reflect the relative costs of procedures in the ASC setting, it
evaluated the distribution of both the ASC-to-APC cost ratios and the
OPPS-to-APC cost ratios.
The GAO also analyzed Medicare claims data for the top 20
procedures with the highest Medicare ASC claims volume in CY 2004 to
examine the delivery of additional services with
[[Page 42475]]
surgical procedures in ASCs and HOPDs. Last, to calculate the
percentage of labor-related costs among the responding ASCs, for each
ASC, the GAO divided total labor costs by total costs and then
determined the range of the percentage of labor-related costs among all
of the ASCs between the 25th and the 75th percentile, as well as the
mean and median percentage of labor-related costs.
Based on its extensive analyses, the GAO determined that the APC
groups in the OPPS accurately reflect the relative costs of the
procedures performed in ASCs. GAO's analysis of the cost ratios showed
that the ASC-to-APC cost ratios were more tightly distributed around
their median cost ratio than were the OPPS-to-APC cost ratios. These
patterns demonstrated that the APC groups reflect the relative costs of
procedures performed by ASCs and, therefore, that the APC groups could
be used as the basis for an ASC payment system. The GAO determined, in
fact, that there was less variation in the ASC setting between
individual procedures' costs and the costs of their assigned APC groups
than there is in the HOPD setting. It concluded that, as a group, the
costs of procedures performed in ASCs have a relatively consistent
relationship with the costs of the APC groups to which they would be
assigned under the OPPS. The GAO's analysis also found that procedures
in the ASC setting had substantially lower costs than those same
procedures in the HOPD. While ASC costs for individual procedures
varied, in general, the median costs for procedures were lower in ASCs,
relative to the median costs of their APC groups, than the median costs
for the same procedures in the HOPD setting. The median cost ratio
among all ASC procedures was 0.39 (0.84 when weighted by Medicare
volume based on CY 2004 claims), whereas the median cost ratio among
all OPPS procedures was 1.04.
The GAO found many similarities in the additional items and
services provided by ASCs and HOPDs for the top 20 ASC procedures.
However, of these additional items and services, few resulted in
additional payment in one setting but not the other. HOPDs were paid
for some of the related services separately, while in the ASC setting,
other Part B suppliers billed Medicare and received payment for many of
the related services.
Finally, in its analysis of labor-related costs, the GAO determined
that the mean labor-related proportion of costs was 50 percent. The
range of the labor-related costs for the middle 50 percent of
responding ASCs was 43 percent to 57 percent of total costs.
Based on its findings from the study, the GAO recommended that CMS
implement a payment system for procedures performed in ASCs based on
the OPPS, taking into account the lower relative costs of procedures
performed in ASCs compared to HOPDs in determining ASC payment rates.
Comment: A number of commenters noted that, by the close of the
public comment period for the August 2006 proposed rule for the revised
ASC payment system, the GAO had not yet provided recommendations
regarding ASC payment in a report to Congress that it was required to
submit by January 1, 2005. Some commenters recommended that, although
CMS was directed to take into account these recommendations in
implementing the revised ASC payment system, should the GAO's
recommendations be provided before publication of the final rule
establishing the policies of the revised ASC payment system, CMS should
not take them into consideration, given the public's inability to
provide input to CMS during the comment period regarding the GAO's
methodology, findings, and recommendations. Other commenters
recommended that, if the GAO Report was forthcoming shortly, CMS should
provide another opportunity for public comment prior to finalizing the
policies of the revised ASC payment system in order to allow the public
to provide CMS with their perspectives on those recommendations.
Response: As described earlier, the GAO published its report (GAO-
07-86) on November 30, 2006. In accordance with section
1833(i)(2)(D)(i) of the Act, we did take into account the
recommendations made in the GAO Report in developing the final policies
for the revised ASC payment system. The GAO's findings and
recommendations are summarized above, and its specific recommendations
are further discussed in the particular sections of this final rule
that address the related topics. We appreciate the public's interest in
providing us with detailed input regarding the revised ASC payment
system from a variety of perspectives. In regard to the commenters'
recommendation for a second opportunity for public comment prior to
finalizing the policies of the revised ASC payment system after the GAO
Report was published, we note that the GAO's recommendations are in
complete accord with our August 2006 proposal for the revised ASC
payment system. Therefore, we are not providing another opportunity for
public comment prior to finalizing the policies of the revised ASC
payment system, because the proposed revised system is fully consistent
with the recommendations of the GAO Report and we already provided a
90-day comment period regarding our proposal for CY 2008. We believe
that the comment period for the August 2006 proposed rule provided the
public with ample opportunity to comment on the policies that were
recommended by the GAO. The considerable operational changes required
to implement the revised ASC payment system necessitate significant
lead time that would not be possible if we were to provide another
comment period prior to finalizing the policies. We also believe that
our consideration of the recent GAO study, as well as other available
information regarding HOPD and ASC costs and payments, in addition to
our prior discussions with stakeholders and the many public comments on
the proposed rule, provide us with the necessary breadth and depth of
information and viewpoints to finalize our payment policies for the
revised ASC payment system in this final rule.
At its December 2006 meeting, the Practicing Physicians Advisory
Council (PPAC) made two recommendations to CMS regarding the final rule
for the revised ASC payment system. First, the PPAC recommended that
CMS establish a process to consult with national medical specialty
societies and the ASC community to develop and adopt a systematic and
adaptable means of fairly reimbursing ASCs for all safe and appropriate
services, allowing for changes in technology and current day practice.
Second, the PPAC recommended that CMS apply any payment policies
uniformly to both ASCs and HOPDs, as appropriate.
We have considered the GAO Report, in addition to the
recommendations of the PPAC, all public comments received on the
proposed rule, and other concerns and issues brought to our attention
by interested parties over the past several years, in developing this
final rule for the CY 2008 revised ASC payment system. Specific
policies are discussed, comments summarized and responses provided, and
policies finalized in subsequent sections of this final rule.
C. Rulemaking for the Revised ASC Payment System in CY 2008
In response to comments submitted timely regarding the proposals
set forth in the proposed rule for the revised ASC payment system
published on August 23, 2006, this final rule establishes the final
policies and regulations of the
[[Page 42476]]
revised ASC payment system for initial implementation in CY 2008. All
tables included in this final rule listing HCPCS codes subject to
pertinent final policies of the revised ASC payment system, as well as
estimated payment rates, are illustrative only, based on CY 2007 HCPCS
codes and final CY 2007 OPPS and MPFS information, with application of
the most current update estimates for CY 2008. The information in the
Addenda to this final rule is also only illustrative, to provide
examples of the results of applying the final policies of the revised
ASC payment system, based on the most recent information available for
CY 2007. As further discussed in sections V.E. and VI. of this final
rule, we will propose the CY 2008 relative payment weights, payment
amounts, specific HCPCS codes to which the final policies of the
revised ASC payment system would apply, and other pertinent ratesetting
information for the CY 2008 revised ASC payment system in the proposed
OPPS/ASC rule to update the payment systems for CY 2008 to be issued in
mid-summer of CY 2007. We will then publish final relative payment
weights, payment amounts, specific CY 2008 HCPCS codes to which the
final policies will apply, and other pertinent ratesetting information
for the CY 2008 revised ASC payment system in the final OPPS/ASC rule
to update the payment systems for CY 2008. The ASC payment system
treatment of new CY 2008 HCPCS codes published in the CY 2008 OPPS/ASC
final rule will provide interim determinations, open to public comment
on that final rule, and we will respond to comments about those
determinations in the OPPS/ASC final rule for CY 2009.
III. Covered Surgical Procedures Paid in ASCs On or After January 1,
2008
A. Payable Procedures
In its March 2004 Report to the Congress, the Medicare Payment
Advisory Commission (MedPAC) recommended replacing the current
``inclusive'' list of procedures, which are the only surgical
procedures for which Medicare allows payment to an ASC, with an
``exclusionary'' list. That is, rather than limiting payment to ASCs to
a list of procedures that CMS specifies, Medicare would allow payment
to ASCs for any surgical procedure except those that CMS explicitly
excludes from payment. MedPAC further recommended that clinical safety
standards and the need for an overnight stay be the only criteria for
excluding a procedure from eligibility for Medicare ASC payment. MedPAC
suggested that some of the criteria, such as site-of-service volume and
time limits, which we have used in the past to identify procedures for
the ASC list of covered surgical procedures, are probably no longer
clinically relevant.
In the August 2006 proposed rule for the revised ASC payment
system, we noted that we had given careful consideration to MedPAC's
recommendations and participated in considerable discussion and
consultation with members of ASC trade associations and physicians, who
represent a variety of surgical specialties, regarding the criteria
that we would use to identify procedures for payment under the revised
ASC payment system. We agreed that adoption of a policy similar to that
recommended by MedPAC would serve both to protect beneficiary safety
and increase beneficiary access to procedures in appropriate clinical
settings, recognizing the ASC industry's interest in obtaining Medicare
payment for a much wider spectrum of services than is now allowed.
Therefore, in the August 2006 proposed rule (71 FR 49636), we proposed
that, under the revised ASC payment system for services furnished on or
after January 1, 2008, Medicare would allow payment to ASCs for any
surgical procedure performed in an ASC, except those surgical
procedures that we determine are not payable under the ASC benefit.
Further, we proposed to establish beneficiary safety and the
expected need for an overnight stay as the principal clinical
considerations and decisive factors in determining whether ASC payment
would be allowed for a particular surgical procedure. As discussed in
section XVIII.B.2. of the preamble of the proposed rule, we also
proposed to exclude from separate payment under the revised ASC payment
system those surgical procedures that are on the OPPS inpatient list,
that are not eligible for separate payment under the OPPS, and that are
CPT surgical unlisted procedure codes.
We discuss below the criteria that we proposed as the basis for
identifying procedures that would pose a significant safety risk to a
Medicare beneficiary when performed in an ASC, or procedures following
which we would expect a Medicare beneficiary to require overnight care.
1. Definition of Surgical Procedure
In order to delineate the scope of procedures that constitute
``outpatient surgical procedures'' in the August 2006 proposed rule, we
first proposed to clarify what we considered to be a ``surgical''
procedure. Under the existing ASC payment system, we define a surgical
procedure as any procedure described within the range of Category I CPT
codes that the CPT Editorial Panel of the American Medical Association
(AMA) defines as ``surgery'' (CPT codes 10000 through 69999). Under the
revised payment system, we proposed to continue to define surgery using
that standard. The CPT Editorial Panel is responsible for maintaining
the CPT nomenclature, with authority to revise, update, or modify the
CPT codes. A larger body of CPT advisors, the CPT Advisory Committee,
supports the work of the CPT Editorial Panel. Members of the CPT
Editorial Panel include individuals nominated by physician and hospital
associations and insurers, providing for diverse specialty input.
In addition, in the August 2006 proposed rule for the revised ASC
payment system, we proposed to include within the scope of surgical
procedures payable in an ASC those procedures that are described by
Level II HCPCS codes or by Category III CPT codes that directly
crosswalk to or are clinically similar to procedures in the CPT
surgical range. We proposed to include all three types of codes in our
definition of surgical procedures because they all may be eligible for
separate payment under the OPPS and, to the extent it is reasonable to
do so, we proposed that the revised ASC payment system parallel the
OPPS in its policies.
In the August 2006 proposed rule, we provided an example of a Level
II HCPCS code that we believe represents a procedure that could be
safely and appropriately performed in an ASC, specifically HCPCS code
G0297 (Insertion of single chamber pacing cardioverter-defibrillator
pulse generator). We developed this Level II HCPCS code for use in the
OPPS because CPT code 33240 (Insertion of single or dual chamber pacing
cardioverter-defibrillator pulse generator), which describes the
surgical insertion of a cardioverter-defibrillator pulse generator,
does not distinguish insertion of a single chamber cardioverter-
defibrillator generator from insertion of a dual chamber cardioverter-
defibrillator generator. Under the OPPS, we were concerned that
different facility resources could be required for the insertion of
these two types of cardioverter-defibrillator pulse generators, so we
developed Level II HCPCS codes to permit HOPDs to more accurately
report the resources required when these surgical procedures are
performed. In instances such as this, when a Level II HCPCS code is
[[Page 42477]]
established as a substitute for a CPT surgical procedure code which
does not adequately describe, from a facility perspective, the nature
of a surgical service, we proposed to allow payment for the Level II
HCPCS code under the proposed revised ASC payment system. We proposed
not to allow ASC payment for Level II HCPCS codes or Category III CPT
codes that describe services that fall outside the scope of, that is,
that do not correspond to, surgical procedures described by CPT codes
10000 through 69999.
We recognized in the proposed rule that continuing to use this
definition of surgery would exclude from ASC payment certain invasive,
``surgery-like'' procedures, such as cardiac catheterization or certain
radiation treatment services which are assigned codes outside the CPT
surgical range. However, we believed that continuing to rely on the CPT
definition of surgery would be administratively straightforward,
logically related to the categorization of services by physician
experts who both establish the codes and perform the procedures, and
consistent with our proposal to allow ASC payment for all outpatient
surgical procedures. Given the number of other changes that we expected
to implement as part of the revised payment system, along with the
significant expansion of ASC covered surgical procedures that we
proposed, we explained that we believed it would be prudent at the
outset to continue to define surgery as it is defined by the CPT code
set, which is used to report services for payment under both the MPFS
and the OPPS. During the development of the August 2006 proposed rule,
we reviewed thousands of CPT codes in the surgical range (CPT codes
10000 through 69999), and we proposed to not exclude from payment over
750 surgical procedures previously excluded, in addition to providing
ASC payment for the more than 2,500 CPT codes on the CY 2007 ASC list
of covered surgical procedures.
However, we are cognizant of the dynamic nature of ambulatory
surgery, which has resulted in a dramatic shift of services from the
inpatient setting to the outpatient setting over the past two decades.
Therefore, in the proposed rule, we solicited comments regarding other
services that are invasive and ``surgery-like,'' which could safely and
appropriately be performed in an ASC, and which require the resources
typical of an ASC, even though the procedures are described by codes
that fall outside the range of CPT surgical codes. In particular, we
were interested in considering commenters' views regarding what
constitutes a ``surgical'' procedure.
We received many public comments about our August 2006 proposal to
define the surgical procedures for which we would make payment to ASCs
as those falling within the surgical code range specified by the CPT
Editorial Panel.
Comment: While, in general, hospital associations and device
manufacturers supported the proposal to maintain the definition of a
surgical procedure used under the existing ASC payment system, many ASC
industry representatives provided a broad range of suggestions about
how the definition should be expanded. Some of the commenters requested
that CMS place no limit on the procedures that would be payable in ASCs
because there is no such limit on Medicare payments to HOPDs. Other
commenters suggested a more limited expansion of procedures eligible
for payment under the revised ASC payment system. These commenters
specifically recommended that CMS expand its definition of a surgical
procedure to include:
(a) Medical procedures that are invasive and require general
anesthesia or that are specifically designated as intraoperative
procedures;
(b) X-ray, fluoroscopy, and ultrasound procedures that require
insertion of a needle, catheter, tube, or probe via a natural orifice
or through the skin;
(c) Radiology procedures integral to performance of nonradiologic
procedures, performed either during or immediately following the
surgical procedure; and
(d) Level II HCPCS and Category III CPT codes that describe
procedures that crosswalk directly or are clinically similar to those
listed in suggestions (a) through (c) above.
Response: We have given consideration to the many recommendations
of the commenters. In general, we continue to believe it is appropriate
to provide payments to ASCs for the resources associated with
performing those services that are surgical procedures as defined by
the CPT Editorial Panel. From the Panel's broad experience in regularly
addressing the complex issues associated with new and emerging health
care technologies, as well as the difficulties encountered with
obsolete procedures, we believe its members are well-positioned to
maintain and refine the existing coding taxonomy, which defines certain
procedures as surgery, to appropriately reflect medical practice in an
evolving health care delivery system. In addition, we believe that our
proposal to pay for surgical procedures in ASCs that are reported by
Level II HCPCS and Category III CPT codes that directly crosswalk or
are clinically similar to procedures in the surgical range of CPT codes
that are payable in ASCs is consistent with our definition of surgery
according to the CPT surgical code range, while providing ASC payment
for some procedures that have not yet been categorized by the CPT
Editorial Panel or for which Medicare recognizes alternative HCPCS
codes for payment.
Although we are not changing our definition of surgery as suggested
by commenters, we did review procedures that are coded by specific
Level II HCPCS or Category III CPT codes that were identified by
commenters as surgical procedures that should be payable in ASCs. We
assessed those procedures using the same final criteria discussed in
section III.A.2. of this final rule that we used to evaluate all
surgical procedures for their safety or the expected need for an
overnight stay in making decisions about their exclusion from ASC
payment. As we proposed, we also evaluated the codes in the context of
whether they directly crosswalk or are clinically similar to procedures
in the CPT surgical range that we have determined do not pose a
significant safety risk or for which an overnight stay is not expected
when performed in ASCs. As a result of that review, 14 additional Level
II HCPCS codes and 15 Category III CPT codes beyond those we proposed
for CY 2008 payment will be payable as covered surgical procedures when
performed in ASCs beginning in CY 2008.
Furthermore, as discussed in section IV. of this final rule,
although we are not expanding our definition of surgical procedures, we
will provide separate ASC payment for a number of covered ancillary
services when they are furnished on the same day as a covered surgical
procedure and are integral to the performance of that procedure in the
ASC setting. Those services include certain radiology procedures, such
as some fluoroscopy and ultrasound services, that some commenters
recommended we define as surgical procedures for addition to the ASC
list of covered surgical procedures.
Comment: Several commenters expressed concern regarding CMS'
proposed exclusion from ASC payment of all procedures described within
the range of Category I CPT codes defined as ``radiology'' in
accordance with the CPT Editorial Panel designation. The commenters
asserted that regulations regarding the Federal physician self-referral
prohibition (section 1877 of the Act) exclude interventional and
[[Page 42478]]
intraoperative radiology services from the definition of ``radiology''
services subject to the law's self-referral prohibition, and that CMS
should, therefore, treat those services as surgical services that are
eligible for payment as covered surgical procedures under the revised
ASC payment system. They believed that interventional radiology and
intraoperative radiology services that require insertion of a needle,
catheter, tube, probe, or similar device are appropriately considered
surgical in nature for purposes of ASC payment.
Response: The commenters' statements with respect to the treatment
of interventional radiology procedures under the physician self-
referral regulations seem overly broad. The physician self-referral
regulations provide that the following services (which may include
some, but not all, interventional radiology procedures) are not
``radiology and certain other imaging services'' for purposes of
section 1877 of the Act: (i) X-ray, fluoroscopy, or ultrasound
procedures that require the insertion of a needle, catheter, tube, or
probe through the skin or into a body orifice; and (ii) radiology
procedures that are integral to the performance of a nonradiological
medical procedure and performed either during the nonradiological
medical procedure or immediately following the nonradiological medical
procedure when necessary to confirm placement of an item inserted
during the nonradiological medical procedure. We do not believe that
Medicare's exclusion of specific services from the definition of
``radiology and certain other imaging services'' for purposes of the
physician self-referral prohibition should result in such services
being considered ``surgical services'' for purposes of the revised ASC
payment system.
Further, as we explain above, we believe that the characterization
of procedures as surgery for purposes of their performance in ASCs is
best left to the expertise of the CPT Editorial Panel. We do not
believe that services designated as radiology services by the CPT
Editorial Panel are appropriately classified as covered surgical
procedures in ASCs, facilities that specialize in the delivery of
ambulatory surgical services. However, as discussed further in section
IV.C.2. of this final rule, we do believe that it is appropriate to
provide separate ASC payment for certain ancillary services that are
integral to the covered surgical procedures. Thus, we will provide
separate payment to ASCs under the revised payment system for radiology
services that are integral to the performance of an ASC covered
surgical procedure when that radiology procedure is one of those for
which separate payment is made under the OPPS. That is, separate
payment will be made for covered ancillary radiology services integral
to covered surgical procedures that are provided in the ASC immediately
before, during, or immediately following the surgical procedure.
After consideration of the public comments we received, we are
finalizing our proposal to define surgery as those procedures described
by CPT codes within the surgical range of 10000 through 69999, without
modification. In addition, we are including within our definition of a
covered surgical procedure payable in the ASC setting those Level II
HCPCS codes or Category III CPT codes that directly crosswalk or are
clinically similar to procedures in the CPT surgical range that we have
determined do not pose a significant safety risk, that we would not
expect to require an overnight stay when performed in ASCs, and that
are separately paid under the OPPS. An illustrative list of covered
surgical procedures under the revised ASC payment system, including
Category I and Category III CPT codes and Level II HCPCS codes, can be
found in Addendum AA to this final rule. An illustrative list of
radiology services and other covered ancillary services that are
eligible for separate ASC payment when provided integral to an ASC
covered surgical procedure on the same day is located in Addendum BB to
this final rule.
2. Procedures Excluded From Payment Under the Revised ASC Payment
System
As stated above, in the August 2006 proposed rule for the revised
ASC payment system, we proposed to allow payment to ASCs for all
procedures described by CPT codes within the surgical range of 10000
through 69999, or by Level II HCPCS codes or Category III CPT codes
that directly crosswalk or are clinically similar to procedures in the
CPT surgical range, that do not pose a significant safety risk to
Medicare beneficiaries and that are not expected to require an
overnight stay. Having established what we consider to be a ``surgical
procedure,'' we next considered criteria that would enable us to
identify procedures that could pose a significant safety risk when
performed in an ASC or that we expect would require an overnight stay
within the bounds of prevailing medical practice. We discuss in the
next section how we proposed to identify procedures that could pose a
significant safety risk.
a. Significant Safety Risk
First, we proposed to exclude from ASC payment any procedure that
is included on the current OPPS inpatient list, that is, those
procedures designated as requiring inpatient care under Sec.
419.22(n). (See Addendum E to the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68385 through 68398).) The procedures included on
that list are typically performed in the hospital inpatient setting due
to the nature of the procedure, the need for at least 24 hours of
postoperative recovery time or monitoring before the patient can be
safely discharged, or the underlying physical condition of the patient.
We believed that any procedure for which we did not allow payment in
the hospital outpatient setting due to safety concerns would not be
safe to perform in an ASC.
Second, we proposed to exclude from ASC payment procedures that the
CY 2005 Part B Extract Summary System (BESS) data indicated were
performed 80 percent or more of the time in the hospital inpatient
setting, even if those procedures were not included on the OPPS
inpatient list. We selected an 80-percent threshold because we believed
that an 80-percent level of inpatient performance was a fair indicator
that a procedure is most appropriately performed on an inpatient basis
and, as such, would pose a significant safety risk for Medicare
beneficiaries if performed in an ASC. We believed that procedures with
inpatient utilization frequencies above the proposed threshold were
complex and were likely to require a longer and more intensive level of
care postoperatively than what is provided in a typical ASC. We also
believed that performing these procedures in an ASC, where immediate
access to the full resources of an acute care hospital is not the norm,
would pose a significant safety risk for beneficiaries.
Third, we proposed to retain some of the specific criteria for
evaluating safety risks that are listed in Sec. 416.65(b)(3) of our
existing regulations. Procedures that involve major blood vessels,
major or prolonged invasion of body cavities, extensive blood loss, or
are emergent or life-threatening in nature could, by definition, pose a
significant safety risk. Therefore, we proposed to exclude from ASC
payment surgical procedures that may be expected to involve any of
these characteristics, based on evaluation by our medical advisors. We
noted that most of the procedures that our medical advisors identified
as involving any of the characteristics listed in Sec. 416.65(b)(3)
also require overnight or
[[Page 42479]]
inpatient stays, reinforcing our belief that they should be excluded
from ASC payment.
Finally, we proposed not to continue applying under the proposed
revised system the current time-based, prescriptive criteria at
Sec. Sec. 416.65(b)(1) and (b)(2), which exclude from the ASC list
procedures that exceed 90 minutes of operating time or 4 hours of
recovery time or 90 minutes of anesthesia. We believed these criteria
were no longer clinically appropriate for purposes of defining a
significant safety risk for surgical procedures.
We indicated that, in light of the proposed changes for evaluating
procedures to identify those that pose a significant safety risk for
beneficiaries when performed in ASCs, we believed that it would not be
appropriate to apply the existing standard at Sec. 416.65(a)(1), which
states that covered surgical procedures are those that are commonly
performed on an inpatient basis but may be safely performed in an ASC,
because this standard is no longer relevant to prevailing medical
practice in the realm of ambulatory or outpatient surgery. Similarly,
we believed that it would not be appropriate to continue applying the
existing standard at Sec. 416.65(a)(2), which states that procedures
performed in an ASC are not of a type that are commonly performed, or
that may be performed, in a physician's office. This standard did not
seem relevant within the context of the proposal only to exclude from
ASC payment under the revised payment system those surgical procedures
that pose a safety risk or are expected to require an overnight stay.
We would expect the types of surgical procedures that are commonly
performed or that may be performed in a physician's office to pose no
significant safety risk and to require no overnight stay.
We proposed to add new Subpart F to 42 CFR Part 416 to reflect
coverage, scope, and payment for ASC services under the revised payment
system. Included in the changes would be new Sec. 416.166 to reflect
the changes that we proposed to our current policy for evaluating and
identifying those procedures that would pose a significant safety risk
for beneficiaries and would be excluded from our list of ASC covered
surgical procedures beginning January 1, 2008. To set the provisions
that are applicable to our existing ASC payment system apart from those
that would apply to the revised ASC payment system, as we proposed, in
the CY 2007 OPPS/ASC final rule with comment period, we revised the
section headings of Subparts D and E of Part 416 to clearly denote the
provisions that govern covered surgical procedures furnished before
January 1, 2008. We also added Sec. Sec. 416.76 and 416.121 to clearly
denote the effective dates of Subparts D and E (71 FR 68226).
Comment: Commenters provided many recommendations regarding the
proposed criteria for evaluating which procedures should be excluded
from the ASC list of covered surgical procedures that varied greatly.
At one end of the spectrum, some commenters recommended that CMS only
exclude from ASC payment those procedures that are included on the
``inpatient list'' used under the OPPS. They believed that all
procedures not on the OPPS inpatient list are safe for performance in
ASCs and that, by the specification of their payable status under the
OPPS, they do not require an overnight stay.
Some commenters suggested that CMS create the ASC exclusionary list
by individually reviewing surgical procedures based upon data that
demonstrate the risks, complications, and overall safety of a given
procedure, rather than attempting to specifically apply the standards
of the proposed criteria. They believed that health outcomes databases,
including the National Surgical Quality Improvement Project and patient
and device registries, could provide further information to refine an
initial safety assessment based on the proposed criteria when certain
procedures were identified as needing further consideration and
evaluation. The commenters recommended this flexible and specific
approach to allow for full consideration of the surgical aspects of
each procedure, in order to make an appropriate determination regarding
its safety for ASC performance. The commenters believed CMS could work
with surgical professional associations and external surgical experts
to facilitate a smooth and efficient clinical review process.
In contrast, other commenters recommended that CMS implement more
stringent review criteria than our criteria under the existing payment
system for evaluating which procedures are unsafe for performance in
ASCs. They believed that beneficiary safety could be better protected
if CMS would adopt review criteria that would exclude more procedures
from ASC performance than those criteria currently in place, while
maintaining the existing limitations on operating and recovery room
times.
Response: We believe that both ends of the spectrum of public
comments are inconsistent with our goal of only excluding those
procedures from ASC payment that are unsafe for performance in ASCs or
are expected to require an overnight stay. We agree with the
perspective of most commenters that procedures on the OPPS inpatient
list should also be excluded from ASC payment. However, while we
strongly disagree with the contention by some commenters that all
procedures performed in HOPDs are appropriate for performance in ASCs,
we also believe that instituting criteria that are more restrictive
than those currently in place would be inappropriate, because we do not
have safety concerns regarding procedures that are already included on
the ASC list of covered surgical procedures.
Typically, HOPDs are able to provide much higher acuity care than
ASCs. ASCs have neither patient safety standards consistent with those
in place for hospitals, nor are they required to have the trained staff
and equipment needed to provide the breadth and intensity of care that
hospitals are required to maintain. According to current CMS standards,
hospitals must meet numerous documentation, infection prevention, and
patient assessment requirements that are not applied to ASCs.
Therefore, there are some procedures that we believe may be
appropriately provided in the HOPD setting that are unsafe for
performance in ASCs. Thus, we are not adopting a final policy to
exclude only those surgical procedures on the OPPS inpatient list from
ASC payment under the revised payment system.
Nonetheless, as stated in our August 2006 proposal and consistent
with MedPAC recommendations, we are committed to revising the ASC list
of covered surgical procedures so that it excludes only those surgical
procedures that pose significant safety risks to beneficiaries or that
are expected to require an overnight stay. We believe that adoption of
a policy similar to that recommended by MedPAC would serve both to
protect beneficiary safety and increase beneficiary access to surgical
procedures in appropriate clinical settings. We also believe that this
approach is most consistent with the PPAC's recommendation that we
provide payment under the revised ASC payment system for all safe and
appropriate services. Thus, we do not believe that it would be
appropriate to implement more restrictive criteria for evaluating
procedures for exclusion from ASC payment or even to maintain all of
the current criteria that we use under the existing payment system to
evaluate the appropriateness of including procedures on the ASC list.
We continue to believe the current limitations on operating room and
recovery room times for ASC procedures
[[Page 42480]]
are no longer clinically relevant to assessing the safety risk of
surgical procedures. Our comprehensive review of all surgical
procedures has convinced us that there are procedures in addition to
those included on the CY 2007 ASC list of covered surgical procedures
that may be safely performed in ASCs, and that increasing the number
and types of procedures for which Medicare provides ASC payment is
appropriate.
Regarding our proposed overall approach to evaluating procedures
for exclusion from the ASC list of covered surgical procedures, we
believe that our evaluation process is generally consistent with the
approach advised by some commenters that we apply the proposed criteria
as part of an initial safety assessment, and then conduct procedure-
specific analyses of possible risks and complications of individual
procedures based on available data. In preparing the proposal for the
revised ASC payment system, we reviewed each surgical procedure that is
separately payable under the OPPS and not already on the CY 2007 ASC
list and with inpatient utilization of less than 80 percent against the
proposed safety and overnight stay criteria and identified a subset of
procedures for further assessment if we had concerns about their
potential safety risk. We then used all of the information available to
us to arrive at a preliminary determination regarding each procedure's
suitability for payment in the ASC setting. These preliminary
determinations constituted our proposed treatment of the procedures
under the revised ASC payment system, and the status of the codes was
open to public comment in the August 2006 proposed rule. We received
detailed information and recommendations from many commenters,
including hospitals, ASCs, device manufacturers, and physician
specialty organizations, as well as physician experts, regarding the
proposed treatment of many surgical procedure codes. Summaries of these
comments and our responses follow later in this section of this final
rule.
Comment: A number of commenters expressed concerns about the safety
implications of a greatly expanded list of surgical procedures to be
performed in ASCs. They advocated implementation of specific additional
measures for tightening and strengthening the criteria we proposed to
use to evaluate the potential for beneficiary risk associated with
surgical procedures. Included in the commenters' numerous
recommendations were the following comments:
(1) Make no changes to the current criteria until the ASC
Conditions for Coverage are revised to ensure that patient protections
comparable to those in place in hospitals are in place in ASCs.
(2) Apply the existing and proposed criterion to exclude procedures
from the ASC list that involve major blood vessels, by adopting a
specific list of blood vessels that CMS defines as major blood vessels,
in order to provide more certainty about which procedures would be
excluded. Some commenters recommended that CMS adopt the definition of
a major blood vessel advanced in a medical textbook, Essentials of
Anatomy & Physiology, 6th Edition, by Seeley, Stephens and Tate. For
procedures that involve blood vessels defined by Seeley, et al., as
major, but that are already being performed safely in ASCs (for
example, CPT code 36870, Thrombectomy, percutaneous, arteriovenous
fistula, autogenous or nonautogenous graft (includes mechanical
thrombus extraction and intra-graft thrombolysis)), the commenters
suggested that CMS retain them as ASC covered surgical procedures,
thereby allowing their continued payment when performed in ASCs.
(3) Apply the existing and proposed criterion to exclude from ASC
payment those procedures requiring major or prolonged invasion of body
cavities, by defining ``prolonged'' invasion as referring to any
procedure in which the patient is under anesthesia for 90 minutes or
longer, and expand the definition of body cavity to include major blood
vessels.
(4) Exclude from ASC payment procedures that commonly require
systemic thrombolytic therapy. Some commenters recommended that CMS
exclude procedures that involve blood vessels that, if occluded, would
require inpatient lytic therapy, while other commenters recommended
more generally that CMS exclude procedures that may result in a
patient's need for lytic therapy. Lytic or inpatient thrombolytic
therapy as used in this context both refer to systemic thrombolytic
therapy.
(5) Disallow procedures that require puncturing of the femoral
vessels for access. Some commenters recommended that this exclusion be
for procedures accessing either the femoral artery or the femoral vein,
while other commenters would have limited the exclusion to only those
procedures requiring femoral arterial access.
(6) Implement a quantitative measure (greater than or equal to 15
percent of total blood volume) to define the existing and proposed
criterion to exclude from the list procedures that generally result in
extensive blood loss.
(7) Use a 50-percent inpatient threshold for excluding procedures
from the ASC list instead of the proposed 80-percent threshold. While
some commenters recommended lowering the proposed threshold for
exclusion of procedures from the ASC list from 80 percent to 50
percent, several other commenters suggested that CMS should not apply a
specific numerical threshold of inpatient utilization at all to its
evaluation of procedure safety. They noted that this could have the
unintended effect of automatically excluding some procedures from ASC
payment simply because of limited data indicating their performance
slightly more than 80 percent of the time in the inpatient setting,
while data for clinically similar codes reflected inpatient performance
slightly less than the 80-percent threshold. Instead, these commenters
recommended that we evaluate each surgical procedure with respect to
the other proposed criteria, based on the clinical characteristics of
the procedure itself. The group of commenters recommending
establishment of a lower threshold of 50 percent believed that this
modified standard would better enable us to identify procedures that
are typically clinically complex and have a higher risk of
complications and extensive postoperative care. They suggested that
setting the threshold at 50 percent would ensure that procedures
performed the majority of time in the inpatient setting would be
excluded from ASC payment.
(8) Require that patients be assessed for comorbidities and
anesthesia risk using the American Society of Anesthesiologists' tool,
and those patients who are high risk, such as patients over age 85 or
with morbid obesity, should be required to go to hospital settings for
surgical procedures.
(9) Identify and implement outcome and process measures to assess
aspects of quality across care settings, including ASCs. To develop
those measures, some commenters suggested that CMS work closely with
the Hospital Quality Alliance (HQA) and the Ambulatory Quality Alliance
(AQA) (formerly both organizations were known as the AQA). The HQA has
already begun to include the measures of care used in the Surgical Care
Improvement Project, and some commenters believed that the goal of
preventing complications in the care of surgical patients provides an
appropriate starting point for determining the correct measures for
assessing important aspects of the safety
[[Page 42481]]
and quality of all types of ambulatory surgery.
Response: We appreciate the commenters' concerns regarding
beneficiary safety and gave consideration to each of the individual
recommendations listed above. We respond to each of these individually
as follows:
(1) Maintain the current procedure review criteria until after the
ASC Conditions for Coverage are revised.
We do not believe that postponing revisions to our review criteria
until after the ASC Conditions for Coverage are revised is warranted.
We cannot predict when those revisions will be issued, and we are
confident that the criteria we will use to evaluate procedures for
exclusion from the list of covered surgical procedures under the
revised ASC payment system are appropriate and serve to protect
beneficiary safety in the current environment.
(2) Specifically adopt a defined list of ``major blood vessels.''
As we stated earlier, we believe it is important to maintain
flexibility in our review of procedures for safe performance in the ASC
setting, consistent with our past practice regarding this criterion. As
noted by commenters requesting a specific definition of this criterion,
there are some procedures already on the ASC list that are being safely
performed in ASCs and that involve vessels that would be defined as
major according to the recommendations of some commenters. We do not
agree with these commenters that it would be logical or clinically
consistent for us to adopt a specific definition of major blood vessels
to evaluate procedures for exclusion from ASC payment, yet still
continue to provide ASC payment for procedures that would otherwise be
excluded, except for their history of safe performance in ASCs. We
believe the involvement of major blood vessels is best considered in
the context of the clinical characteristics of individual procedures,
as recommended by other commenters, and see no need to adopt a defined
list of major blood vessels.
(3) Define prolonged invasion of a body cavity as any procedure in
which the patient is under anesthesia for 90 minutes or longer, and
expand the definition of body cavity to include major blood vessels.
We do not believe that considering major blood vessels to be
included in the definition of a body cavity is clinically sensible,
based on the general medical understanding of the terms. In addition,
we already have a separate safety review criterion regarding major
blood vessels, and we believe that evaluation of the safety of
procedures involving major blood vessels will continue to be
appropriately assessed using that criterion. We also do not believe
that prolonged invasion should be defined as anesthesia for 90 minutes
or longer. There are surgical procedures that require more than 90
minutes that do not invade a major body cavity at all, and maintaining
that time-based restriction would be contrary to the recommendations of
MedPAC and current clinical practice. We believe the criterion
regarding major or prolonged invasion of body cavities is most
appropriately evaluated through a flexible review approach, consistent
with our past practice, in which we consider the criterion and its
relationship to each specific surgical procedure. Therefore, we are not
expanding the current criterion regarding invasion of a body cavity to
include the length of time the beneficiary will be under anesthesia or
to incorporate major blood vessels.
(4) Exclude from ASC payment procedures that commonly require
systemic thrombolytic therapy.
We agree with the commenters that systemic thrombolytic therapy is
unsafe for performance in ASCs. Systemic thrombolytic therapy involves
significant clinical risks and is not an appropriate procedure for
initiation in ASCs if its use is anticipated. We have historically
considered in our clinical evaluation of the safety of procedures for
performance in ASCs the likely need for systemic thrombolytic therapy
in association with a surgical procedure, but we have never previously
made that an explicit safety review criterion. We agree with the
commenters that it should be a specific criterion for evaluation of
procedure safety. Therefore, we are making it explicit that the final
criteria used to evaluate the safety of procedures for performance in
ASCs at Sec. 416.166(c)(5) include the criterion that covered surgical
procedures may not be of a type where systemic thrombolytic therapy
would commonly be required.
(5) Exclude procedures that require use of the femoral vessels for
access.
We do not agree with some commenters' position that excluding all
procedures that involve the femoral vessels is reasonable or necessary
to ensure the patient safety of surgical procedures performed in ASCs.
Other commenters stated that there are instances in which the
performance of procedures may require use of femoral vessels due to the
beneficiary's particular physical condition. For example, a beneficiary
who has experienced prolonged exposure to vascular sclerosing agents
(such as chemotherapy) or has been on hemodialysis for many years may
not have upper body peripheral blood vessels that are adequate even to
support the basic intravenous access required during any surgical
procedure performed under general anesthesia. In such a case, the
surgeon may need to use the femoral vein just to provide routine
intravenous access during surgery. In other cases, the use of the
femoral vessels may be required for certain surgical procedures. For
instance, the femoral blood vessels may be accessed to create an
arteriovenous fistula for hemodialysis using a graft, as described by
CPT code 36825 (Creation of arteriovenous fistula by other than direct
arteriovenous anastomosis (separate procedure); autogenous graft) or
CPT code 36830 (Creation of arteriovenous fistula by other than direct
arteriovenous anastomosis (separate procedure); nonautogenous graft
(e.g., biological collagen, thermoplastic graft)). Both of these
procedures that may directly involve the femoral vessels have been on
the list of covered ASC procedures since before July 2000, and we have
no concerns about their safe performance in ASCs. We do not believe
that it makes clinical sense to prohibit use of the femoral vessels in
ASC procedures, knowing that they may be needed in any number of
situations and that femoral access has been safely achieved in ASCs for
years. We believe that our process for clinical review of individual
procedures, during which our medical advisors consider the specific
performance characteristics of a particular surgical procedure, is the
most appropriate method for ensuring that procedures that pose a
significant safety risk are excluded from ASC payment. As evidenced by
the history of safe performance in ASCs of some procedures that utilize
femoral access, we agree with the commenters who believe that it is the
specific surgical procedure, rather than the method of vascular access,
that must be fully evaluated to assess a procedure's safety in ASCs.
(6) Adopt a quantitative definition of ``extensive blood loss.''
We do not believe that the recommendation by some commenters that
we revise the criteria used to evaluate procedures for exclusion from
the ASC list by quantifying extensive blood loss is necessary or
advisable. The existing and proposed criterion related to blood loss
requires exclusion of procedures that ``generally result in extensive
blood loss'' (42 CFR 416.65(b)(3)(i) and 42 CFR 416.166(c)(1),
[[Page 42482]]
respectively), and we have historically evaluated this criterion in
considering surgical procedures for ASC payment. We do not believe that
identifying a specific amount of blood loss that is considered by some
to be ``extensive'' would improve our clinical review regarding
procedural safety. For most surgical procedures, specific estimates of
expected blood loss are not available, and we do not believe that a
discussion of whether or not a procedure generally results in a loss of
14 percent versus 16 percent of a beneficiary's blood volume would be
clinically meaningful and contribute to our ability to evaluate a
surgical procedure's potential for safe performance in ASCs.
(7) Adopt a 50-percent inpatient utilization threshold for
exclusion of procedures from the ASC list.
We reexamined our proposal to exclude all procedures from ASC
payment that are performed in the inpatient setting 80 percent or more
of the time. Although the recommendations of some commenters advocated
using a lower threshold to exclude more procedures from ASC payment, we
confirmed that using any relatively arbitrary threshold resulted in
unintended inconsistencies in the treatment of clinically similar
procedures. There were several instances in which one procedure in a
clinical family would be excluded from ASC payment based on its
inpatient utilization of just slightly over 80 percent, whereas our
clinical review of other members of the family indicated that those
procedures were safe for performance in ASCs, with inpatient
utilization of slightly less than 80 percent. For example, we proposed
to exclude CPT codes 33207 (Insertion or replacement of permanent
pacemaker with transvenous electrode(s); ventricular) and 33208
(Insertion or replacement of permanent pacemaker with transvenous
electrode(s); atrial and ventricular) from ASC payment under the
revised payment system because the inpatient utilization for those
procedures was higher than 80 percent and, therefore, we did not
specifically review the procedures to assess their clinical safety or
need for an overnight stay before proposing to exclude them. We did not
propose to exclude CPT code 33206 (Insertion or replacement of
permanent pacemaker with transvenous electrode(s); atrial), the other
procedure in the same family of codes as CPT codes 33207 and 33208,
because the inpatient utilization for that procedure was somewhat lower
than 80 percent, and our clinical review, based on the other safety and
overnight stay criteria proposed for the revised ASC payment system,
led to our belief that it was appropriate for performance in ASCs. When
we performed a clinical review of CPT codes 33207 and 33208 in order to
respond to public comments, we determined that CPT codes 33207 and
33208 do not pose a significant risk to beneficiary safety and are not
expected to require an overnight stay, so they are appropriate for
performance in ASCs, along with CPT code 33206. Therefore, we have
removed both CPT codes 33207 and 33208 from the list of excluded
procedures for the revised ASC payment system. We are also, as
proposed, not excluding CPT code 33206 from eligibility for ASC
payment. This more flexible approach, without application of a specific
inpatient utilization threshold, allows us to treat the individual
members of the same family of procedures consistently as a clinically
coherent group, while considering them in the context of our final
safety and overnight stay criteria for the revised ASC payment system.
We also identified a number of surgical procedures with high
Medicare inpatient utilization because, most of the time, the
procedures are performed with other surgical procedures for
beneficiaries who are hospital inpatients. Thus, although the data
reflect high inpatient utilization, the procedures themselves are not
unsafe for ASC performance, nor do they typically require an overnight
stay. Specifically, commenters argued that the high inpatient
utilization of CPT code 64447 (Injection, anesthetic agent; femoral
nerve, single) was due to its frequent use during inpatient surgical
procedures, whereas the injection may also be performed safely in ASCs
on its own as an ambulatory pain management intervention. They believed
that using the inpatient utilization as the basis for the exclusion of
this procedure from ASC payment was unfair because we should evaluate
the procedure itself specifically based upon its clinical
characteristics, rather than based upon utilization data which could be
misleading with respect to the procedure's potential for safe
performance in the ASC setting. Our clinical review of CPT code 64447,
in response to comments, convinced us that it would clearly not pose a
significant safety risk or be expected to require an overnight stay
when performed in ASCs and should not be excluded from the list of
covered surgical procedures under the revised ASC payment system.
Therefore, we concluded that, in the cases of CPT codes 33207,
33208, and 64447, the utilization data alone could not be relied upon
to support a decision to exclude these procedures from ASC payment and,
as evidenced by our proposed list of excluded procedures, there were
many procedures paid under the OPPS that were not performed more than
80 percent of the time on an inpatient basis but that were proposed for
exclusion from ASC payment because of their safety risk or expected
need for an overnight stay. Therefore, for this final rule, we
evaluated each of the procedures that we had proposed for exclusion
from ASC payment based on inpatient utilization of 80 percent or more
and made separate determinations about the safety and need for an
overnight stay for each of those procedures using all available
information, as we did for all other procedures in the surgical range
of the CPT code set.
Thus, while we proposed an 80-percent inpatient utilization
threshold as one criterion for excluding surgical procedures from ASC
payment, we now believe that we will reach more appropriate, clinically
consistent decisions regarding procedures for exclusion from ASC
payment by not adopting any specific numerical threshold for inpatient
utilization that would automatically exclude surgical procedures from
ASC payment. Rather than institute a definite threshold for inpatient
utilization, we will examine all the clinical information regarding a
surgical procedure, including its inpatient utilization, to determine
whether or not a procedure would pose a significant risk to beneficiary
safety or would be expected to require an overnight stay if performed
in an ASC. We will not make final our proposal to exclude procedures
from the ASC list of covered surgical procedures based solely on their
inpatient utilization of 80 percent or more.
(8) Require beneficiary assessment of individual surgical risk and
do not permit high risk patients to receive ASC services.
We do not believe that it would be appropriate to accept the
commenters' recommendation that patients with certain specified
demographic characteristics or comorbidities be automatically excluded
from being considered for surgery within an ASC. The recommendation
would require ASCs to deny services to individual beneficiaries who are
found, based on an appraisal through a specific assessment tool, to
have a high level of risk. Section 416.2 defines an ASC as providing
surgical services to patients not requiring hospitalization. Thus, ASCs
must ensure that each patient is assessed for relevant risk factors by
the physician prior to performing the
[[Page 42483]]
surgical procedure, in order to screen out patients who are likely to
require hospitalization in connection with the planned procedure. We
require physicians to make these assessments as a part of their
decisions regarding where to perform a surgical procedure for specific
Medicare beneficiaries, prior to referring them to facilities for those
surgical procedures. The ASC Conditions for Coverage specifically state
in Sec. 416.42(a) that ``a physician must examine the patient
immediately before surgery to evaluate the risk of anesthesia and of
the procedure to be performed.'' In addition, we protect Medicare
beneficiary safety through our process of excluding procedures from ASC
payment that pose a significant safety risk for the typical Medicare
patient. In summary, we do not believe that it is necessary or
appropriate for CMS to mandate that ASCs use a specific assessment tool
in conducting these required beneficiary assessments.
(9) Identify and implement outcome and process measures in ASCs to
assess quality of care.
We will take into consideration for future action the
recommendation by some commenters that we identify and implement
outcome and process measures to assess aspects of quality of care
across settings, including ASCs, taking into consideration our final
policy for the CY 2009 OPPS that will require hospitals to meet quality
reporting standards to receive the full OPPS update (71 FR 68189). We
agree that this could be an appropriate next step and is consistent
with CMS'' policies being implemented in other beneficiary care
settings. In fact, section 109(b) of the Medicare Improvements and
Extension Act under Division B of the Tax Relief and Health Care Act of
2006, Public Law 109-432, enacted on December 20, 2006, specifies that
the Secretary may require that in order to receive the full annual
payment update, ASCs must report data on selected measures of quality.
The provisions for ASC services are to apply in a manner similar to
which they apply to hospital outpatient services, effective January 1,
2009.
After considering the public comments received, we are finalizing
our proposal, with modification, to exclude from ASC payment all
surgical procedures that could pose a significant safety risk to
Medicare beneficiaries or are expected to require an overnight stay.
The criteria to be used to identify procedures that could pose a
significant safety risk when performed in an ASC include those surgical
procedures that: generally result in extensive blood loss; require
major or prolonged invasion of body cavities; directly involve major
blood vessels; are emergent or life-threatening in nature; commonly
require systemic thrombolytic therapy; are designated as requiring
inpatient care under Sec. 419.22(n); can only be reported using a CPT
unlisted surgical procedure code (see section III.B. of this final rule
for further discussion); or are otherwise excluded under Sec. 411.15.
We are not adopting the specific 80-percent inpatient utilization
threshold that we proposed for exclusion of surgical procedures from
ASC payment. The final revised policy regarding covered surgical
procedures is set forth in Sec. 416.166 of this final rule, effective
January 1, 2008.
b. Overnight Stay
A longstanding criterion for determining which procedures are
appropriate for inclusion on the ASC list of covered surgical
procedures has been that the procedures on the list do not require an
extended recovery time. Section 416.65(a)(3) of the regulations
provides that ASC procedures ``[a]re limited to those requiring a
dedicated operating room (or suite), and generally requiring a
postoperative recovery room or short-term (not overnight) convalescent
room.'' Under Sec. 416.65(b)(1)(ii), we have historically considered
procedures that require more than 4 hours of recovery or convalescent
time to be inappropriately performed in the ASC.
We have heard many differing opinions of what constitutes an
``overnight'' stay, ranging from ``more than 24 hours'' to time spent
in recovery after sunset. After deliberation and consideration of
several options, in the August 2006 proposed rule for the revised ASC
payment system, we proposed to exclude from ASC payment any procedure
for which prevailing medical practice dictates that the beneficiary
would typically be expected to require active medical monitoring and
care at midnight following the procedure (hereinafter ``overnight
stay''). During the development of the August 2006 proposed rule, our
clinical staff evaluated each surgical procedure using available claims
and physician pricing data, as well as their clinical judgment, to
determine which procedures would be expected to require monitoring at
midnight of the day on which the surgical procedure was performed.
We proposed to use midnight as the defining measure of an overnight
stay for several reasons. First, a patient's location at midnight is a
generally accepted standard for determining his or her status as a
hospital inpatient or skilled nursing facility patient and as such, it
seems reasonable to apply the same standard in the ASC setting. Second,
overnight care is not within the scope of ASC services for which
Medicare makes payment. The expectation is that surgical procedures
performed in an ASC are ambulatory in nature; that is, patients
undergoing a procedure in an ASC will recover from anesthesia and
return home on the same day that they report to the ASC for a scheduled
procedure. Finally, the expected need for monitoring at midnight is a
straightforward and easily understood defining measure of ``overnight
stay.'' We proposed to add the requirement that procedures will
typically not be expected to require active medical monitoring and care
at midnight following the procedure to proposed new Sec.
416.166(c)(5).
Comment: Some commenters recommended that CMS use ``less than 24
hours'' as the definition of an overnight stay. Several of the
commenters stated that the same 24-hour postoperative recovery standard
that applies in HOPDs should apply in ASCs. One commenter stated that
CMS' definition of overnight stay related to survey and certification
for ASCs is a planned stay of over 24 hours and, that conversely, when
the ``length of stay is less than 24 hours, it is not considered an
overnight stay.'' Further, several commenters noted that a number of
States allow ASCs to perform procedures that require stays of up to 23
or 24 hours.
One commenter group argued that the terms ``ambulatory'' and
``outpatient'' surgery describe the same kind of care, and that the
same 24-hour postoperative recovery standard should apply in both ASC
and HOPD settings. Some commenters suggested that, if CMS allowed all
procedures that are performed in HOPDs to be performed in ASCs, no
specific definition of overnight stay would be required because any
procedure paid under the OPPS would be presumed to require no overnight
stay and that the same assumption should be applied to ASCs.
A number of other commenters agreed with our proposal that
procedures requiring an overnight stay should not be performed in an
ASC and specifically endorsed our definition of overnight stay. They
also believed that the proposed definition is consistent with other
accepted definitions and standards of the term.
Several commenters believed that our proposal, if adopted, would
require ASCs performing and billing covered surgical procedures to
transfer patients to other facilities if the recovery of
[[Page 42484]]
individual patients extended beyond midnight on the day of the
procedure, in order to receive payment under the revised ASC payment
system. Other commenters expressed concern that procedures performed
later in the day in ASCs would be treated differently for purposes of
ASC payment than those procedures that were performed in the morning,
in terms of allowing for adequate recovery time.
Response: We want to clarify our proposal to use the expected need
for medical monitoring at midnight following the performance of a
procedure as a consideration in determining whether a surgical
procedure should be excluded from ASC payment. Our proposal does not
affect the distinct care ASCs may provide in individual cases at
various times of the day, nor does it alter the ASC payment for covered
surgical procedures and covered ancillary services. As we explained in
the August 2006 proposed rule, we proposed to exclude surgical
procedures from ASC payment only based on their expected need for an
overnight stay or the risk they pose to beneficiary safety. We
identified the need for medical monitoring at midnight as a clinical
measure that was meaningful to our clinical staff and advisors in their
assessment, on a procedure-by-procedure basis, of the expected
postoperative needs of the typical Medicare beneficiary, in order to
determine whether a procedure was likely to require an overnight stay.
We agree with some commenters that the criteria currently in place
under the existing ASC payment system that limit covered surgical
services to those that do not generally exceed a total of 90 minutes
operating time and a total of 4 hours of recovery or convalescent time
are both outdated and inconsistent with the proposed policy to base
exclusion on the need for an overnight stay. We also agree with the
commenters who recognized that the proposed revised measure to
facilitate identification of those procedures requiring an overnight
stay is considerably less restrictive than the current criteria and, at
the same time, the use of midnight as a reference point is clinically
meaningful and adequate to ensure beneficiary safety.
As stated above, a beneficiary's location at midnight is a
generally accepted standard for determining his or her status as a
hospital inpatient or skilled nursing facility patient and, as such, it
seems reasonable to apply the same standard in the ASC setting. Second,
as defined at Sec. 416.2, ASC means ``any distinct entity that
operates exclusively for the purpose of providing surgical services to
patients not requiring hospitalization.'' Thus, ASCs are not certified
by Medicare to provide overnight care, and there is longstanding policy
to exclude from coverage in ASCs those surgical procedures that require
overnight stays, as evidenced by our existing criterion at Sec.
416.65(b)(1)(ii) that requires CMS to limit covered surgical procedures
to those that do not generally exceed a total of 4 hours of recovery
time following surgery. The expectation is that a beneficiary
undergoing a procedure in an ASC will recover from anesthesia and
return home on the same day that he or she reported to the ASC for a
scheduled procedure. This expectation is inconsistent with a 24-hour
postoperative recovery period as recommended by some commenters.
The commenters' comparisons of ASCs to HOPDs are not persuasive for
many reasons. Most importantly among these is the fact that HOPDs,
unlike ASCs, have medical and nursing staff on duty 24 hours a day and
all of the resources of the hospital to support the care requirements
of beneficiaries in that setting.
After consideration of the public comments we received, we continue
to believe that it is appropriate to exclude from ASC payment any
procedure for which standard medical practice dictates that the
beneficiary would typically be expected to require active medical
monitoring and care at midnight following the procedure. Therefore, we
are finalizing, with editorial modification to include this requirement
in the general standards for covered surgical procedures at Sec.
416.166(b), our proposal to exclude these surgical procedures from ASC
payment.
B. Treatment of Unlisted Procedure Codes and Procedures That Are Not
Paid Separately Under the OPPS
Unlisted procedure CPT codes are used to report services and
procedures that are not accurately described by any other, more
specific CPT codes. An example of an unlisted CPT code is 33999
(Unlisted procedure, cardiac surgery). Within the surgical range of CPT
codes, there are 91 such codes. None of the unlisted CPT codes in the
surgical range is on the current ASC list of covered surgical
procedures. Under the OPPS, we assign unlisted CPT codes to the lowest
weighted APC in the relevant clinical group, regardless of the median
cost for the unlisted procedure code, and we do not include the highly
variable claims-based cost information for unlisted services in
calculating APC median costs for purposes of establishing APC relative
payment weights. Payment for procedures reported by unlisted CPT codes
is made only at the discretion of the contractor under the MPFS.
Because of concerns about the potential for safety risks when
procedures that may only be reported with unlisted procedure CPT codes
are performed, in the August 2006 proposed rule for the revised ASC
payment system, we proposed to continue excluding CPT unlisted surgical
procedure codes from ASC payment. For example, when CPT code 33999 is
reported on a claim, we know only that some kind of cardiac surgery was
performed. We have no other information about the procedure, and we
have no way of knowing whether the procedure involved major blood
vessels, major or prolonged invasion of body cavities, or extensive
blood loss, or was emergent or life-threatening in nature.
Prior to our evaluation of surgical procedure codes for their
safety risk, we decided to propose that we would not make separate
payment under the revised ASC payment system for CPT codes in the
surgical range whose payments are packaged under the OPPS. Packaged CPT
codes under the OPPS are identified by status indicator ``N'' in
Addendum B of the CY 2007 OPPS/ASC final rule with comment period (71
FR 68283 through 68384), and their OPPS payment is provided through
payment for other separately payable services. We made this proposal
for two reasons. First, we would not be able to establish an ASC
payment rate for packaged surgical procedures using the same method we
proposed for all other ASC procedures because packaged surgical codes
have no relative payment weights under the OPPS upon which to base an
ASC payment rate. Second, ASCs, just like hospitals, would receive
payment for these packaged surgical procedures because their costs
would already be included in the APC relative payment weights upon
which the ASC payment rates would be based.
Comment: A few commenters recommended that CMS not exclude all
unlisted CPT codes from ASC payment as proposed. Some commenters
believed that, because Medicare makes facility payments for unlisted
CPT codes under the OPPS, CMS should provide the same treatment in
ASCs. Other commenters suggested that, for groups of related CPT codes
in which all codes but the related unlisted code are provided payment
in ASCs, CMS should also include the unlisted code on the ASC list of
covered surgical procedures. For example, all of the specific CPT codes
in the surgical hysteroscopy
[[Page 42485]]
subsection of CPT (CPT codes 58558 through 58578) are currently on the
ASC list. One commenter contended that because CMS had already
determined that all of those specific hysteroscopy procedures are safe
for performance in ASCs, the related unlisted hysteroscopy procedure
(CPT code 58579, Unlisted hysteroscopy procedure, uterus) should also
be deemed to pose no significant safety risk or require an overnight
stay.
Response: We appreciate the commenters' examples of unlisted codes
in families where all of the other procedures in the CPT subsection are
not excluded from ASC payment, in support of their recommendation that
the related unlisted procedure code should be treated comparably.
However, the fact remains that we do not know what specific procedure
would be represented by an unlisted code. Our charge requires us to
evaluate each surgical procedure for potential safety risk and the
expected need for overnight monitoring and to exclude such procedures
from ASC payment. It is not possible to evaluate procedures that would
be reported by unlisted CPT codes according to these criteria.
We continue to believe that because our final policy under the
revised ASC payment system excludes from ASC payment those procedures
that pose a significant safety risk in ASCs or would be expected to
require an overnight stay, it would not be appropriate to provide ASC
payment for unlisted CPT codes in the surgical range, even if payment
may be provided under the OPPS. As discussed earlier, ASCs do not
possess the breadth and intensity of services that hospitals must
maintain to care for patients of higher acuity, and we would have no
way of knowing what specific procedures reported by unlisted CPT codes
were provided to patients, in order to ensure that they are safe for
ASC performance. Therefore, we are finalizing in Sec. 416.166(c)(7)
our proposal, without modification, to exclude from ASC payment under
the revised ASC payment system all procedures reported by unlisted
surgical procedure codes.
Comment: A few commenters expressed concern that payments for
certain surgical services that are packaged under the OPPS are
frequently paid through the OPPS payments for more comprehensive
services that we had proposed to define as nonsurgical because they are
not classified by CPT within the surgical range of codes. Therefore,
these packaged surgical services would not be paid under the revised
ASC payment system. They pointed out that when ASCs perform these
packaged surgical services as part of providing a more comprehensive
nonsurgical service, the ASC would receive no payment for the surgical
service. To illustrate the problem, commenters provided examples of the
surgical codes that typically receive packaged payment under the OPPS
through payment for radiology services. The minor packaged surgical
procedures included numerous injection and catheter placement
procedures in the surgical range of CPT codes that generally accompany
radiology services for purposes of injecting contrast or facilitating
another nonsurgical intervention. These commenters recommended that CMS
expand the definition of surgical procedures to include invasive
radiology services that have a surgical component, including those
radiology procedures that are performed in association with a surgical
procedure proposed for packaged payment under the revised ASC payment
system, to enable ASCs to receive payment for the comprehensive
service, including both the radiology service and the minor surgical
procedure. Alternatively, several other commenters supported our
proposal to package payment under the revised ASC payment system for
the minor surgical procedures for which payment is also packaged under
the OPPS, rather than paying for them separately.
Response: We continue to believe that packaging payment for those
surgical services that are packaged under the OPPS is appropriate under
the revised ASC payment system. This policy is aligned with the
recommendation of the PPAC to apply payment policies uniformly in the
ASC and HOPD settings. It also maintains comparable payment bundles
under the OPPS and the revised ASC payment system for these services,
consistent with the recommendation of MedPAC to maintain consistent
payment bundles under both payment systems.
Packaged surgical services are minor procedures and are usually
reported with a more comprehensive procedure that may itself be
nonsurgical and, therefore, excluded from payment under the revised ASC
payment system. See section III.A.1. of this final rule for a further
discussion of the definition of surgical procedure under the revised
ASC payment system. We believe that payment for these minor surgical
procedures would be appropriately packaged into payment for
comprehensive surgical procedures that are separately paid in the ASC
setting, when those minor surgical procedures are provided in support
of the comprehensive surgical procedures. In the circumstances referred
to by the commenters, the minor surgical procedures are performed in
support of comprehensive nonsurgical services and payment for the minor
surgical procedures is packaged into payment for the nonsurgical
services under the OPPS. Although the packaged procedures are surgical
according to our definition for the revised ASC payment system, we do
not believe it is reasonable or appropriate to assign a different
packaging status for these procedures under the revised ASC payment
system than is assigned under the OPPS. The minor surgical procedures
are not separately paid in the OPPS and, thus, are not eligible for
separate payment under the revised ASC payment system. In addition, if
the procedures are only performed in conjunction with major services
not payable in ASCs, Medicare also will make no packaged payment for
these minor surgical procedures. As we discuss further in section
III.A. of this final rule, Medicare pays ASCs for the performance of
ambulatory surgical procedures, not for providing nonsurgical services.
We do not agree that we should define surgical procedures under the
revised ASC payment system to include other types of services, such as
radiology services, just because they are provided in association with
a minor surgical procedure in the CPT surgical range of codes. Instead,
we continue to believe that the other types of services, including
radiology services, are not appropriate for performance in ASCs unless
they are integral to covered surgical procedures. We see no rationale
for considering comprehensive radiology services to be integral to the
minor surgical procedures.
After considering all public comments received, we are finalizing,
without modification, our proposal to provide packaged payment under
the revised ASC payment system for all surgical procedures packaged
under the OPPS for the same calendar year. Therefore, we will exclude
these surgical procedures from separate payment in the ASC setting
under the revised payment system, and they will not be included on the
ASC list of covered surgical procedures. We believe that this approach
will provide appropriate packaged payment for minor surgical procedures
provided in association with significant ASC covered surgical
procedures. When these minor surgical procedures are performed in
support of comprehensive nonsurgical procedures, they are not
appropriate for ASC payment because the more comprehensive service is
not a surgical
[[Page 42486]]
procedure paid under the revised ASC payment system. HCPCS codes for
surgical procedures for which payment will be packaged under the
revised ASC payment system are identified in Addendum AA to this final
rule with payment indicator ``N1'' (Packaged service/item; no separate
payment made).
C. Treatment of Office-Based Procedures
According to the general standard in Sec. 416.65(a)(2) of the
existing regulations, procedures that ``are commonly performed, or that
may be safely performed, in physicians' offices'' are excluded from the
ASC list of covered surgical procedures. We did not propose to continue
to apply this provision under the revised ASC payment system. Rather,
in the August 2006 proposed rule for the revised ASC payment system, we
proposed to allow ASC payment for surgical procedures that are commonly
and safely performed in the office setting. We reasoned that the types
of procedures performed in physicians' offices would neither pose a
significant safety risk nor require an overnight stay when performed in
an ASC. However, we expressed concerns that allowing payment for
office-based procedures under the ASC benefit could create an incentive
for physicians inappropriately to convert their offices into ASCs or to
move all their office surgery to an ASC.
To address this concern, we proposed to limit payment for office-
based procedures to neutralize any such incentive (see section IV.E. of
this final rule). We also proposed in new Sec. 416.171(d) to set forth
rules governing the payment of office-based procedures in ASCs. We
specifically invited comment regarding the effect on the Medicare
program, and on practice patterns for ambulatory surgery generally, of
our proposal to allow ASC payment for office-based procedures that
historically have been excluded from the ASC list of covered surgical
procedures.
As we discussed in the August 2006 proposed rule, we proposed to
limit payment for office-based procedures in ASCs in an attempt to
mitigate potentially inappropriate migration of services from the
physician office setting to the ASC. Alternatively, we acknowledged
that we could entirely exclude office-based procedures or procedures
that require relatively inexpensive resources to perform from the ASC
list of covered surgical procedures.
Comment: Many commenters supported our proposal to not exclude from
ASC payment those procedures that are performed most of the time in the
physician's office setting. Numerous commenters requested that the
payment rate for those procedures be set at a percentage of the OPPS
amount, applying the same payment methodology under the revised ASC
payment system as for all other surgical procedures not excluded from
ASC payment. The commenters believed that the proposed treatment of
office-based procedures is unfair because, when any of those procedures
would be performed in the ASC setting, that facility site would be
necessary due to an individual beneficiary's need for the higher acuity
care setting. Therefore, the commenters concluded that the same level
of payment, in relationship to OPPS payment for those procedures,
should be made for office-based procedures as for other covered ASC
procedures that are not office-based. Furthermore, commenters contended
that there would be very little change in surgical practice patterns
under the revised ASC payment system, and that procedures currently
performed predominantly in physicians' offices would not move to ASC
settings as a result of our proposal to provide payment for those
procedures in ASCs.
Response: We appreciate the commenters' support for our proposal to
not exclude office-based surgical procedures from ASC payment under the
revised ASC payment system. Based on both our final definition of
surgical procedures and our final safety and overnight stay criteria to
be used in evaluating procedures for exclusion from ASC payment, we see
no reason to exclude surgical procedures that are currently commonly
performed in physicians' offices from payment under the revised ASC
payment system. We believe there are a variety of reasons that may
contribute to the choice of a particular care setting for the treatment
of an individual beneficiary, including the patient's surgical risk,
the geographic location of the beneficiary and physician, individual
physician practice patterns and preferences, the availability of
specialty ASCs, and others. We do not believe that individuals
receiving surgical procedures in ASCs routinely require care that is of
such greater acuity than care provided in the office-based setting that
the facility resources are significantly and systematically increased
when those procedures that are primarily office-based are performed
occasionally in ASCs. While it may be true that some more acute cases
are treated in ASCs rather than in physicians' offices, we continue to
believe that the structure of payments should not provide a financial
incentive for treatment in the ASC facility setting. Furthermore, this
policy is consistent with the averaging principle that is common to all
prospective payment systems; payment is based on the resources that are
required to treat the typical case, and payment for the treatment of a
specific Medicare beneficiary may, therefore, be higher than the costs
of treating less severe cases but lower than the costs of treating more
acute cases.
We believe that including these office-based procedures on the ASC
list of covered surgical procedures will ensure Medicare beneficiary
access to these services in the most appropriate ambulatory or
outpatient setting. Our final payment policy for these procedures,
along with public comments and our responses, is discussed in section
IV.E. of this final rule, and the related payment rules are set forth
in Sec. 416.171(d).
After considering the public comments received, we are finalizing
our proposal, without modification, to provide payment under the
revised ASC payment system for surgical procedures that are currently
performed predominantly in physicians' offices and that may be safety
performed in ASCs, without requiring an overnight stay.
D. Specific Surgical Procedures Excluded From Payment under the Revised
ASC Payment System
In Tables 44 and 45 of the August 2006 proposed rule (71 FR 49640
through 49646), we listed the HCPCS codes and short descriptors for
surgical procedures that, in addition to those that comprised the OPPS
inpatient list in Addendum E to the August 2006 proposed rule, we
proposed to exclude from ASC payment on or after January 1, 2008,
because they pose a significant safety risk or are expected to require
an overnight stay. Table 44 included those surgical procedures proposed
for exclusion from payment because at least 80 percent of Medicare
cases are performed on an inpatient basis, while Table 45 listed those
surgical procedures proposed for exclusion from payment because they
require an overnight stay. In section III.A.2. of this final rule, we
discuss our final rationale for excluding surgical procedures from ASC
payment. We note that because our final policy, as discussed above, for
the revised ASC payment system does not automatically exclude from
payment those procedures for which at least 80 percent of Medicare
cases are performed on an inpatient basis, all procedures listed in
Table 44 of the August 2006
[[Page 42487]]
proposed rule were reviewed again for this final rule as described
below, in the context of our final exclusionary patient safety and
overnight stay criteria.
For many of the procedures listed in Table 45 of the August 2006
proposed rule, several disqualifying criteria could be applicable, such
as ``requires inpatient stay'' or ``could potentially cause extensive
blood loss'' or ``is emergent in nature.'' Rather than list multiple
disqualifying criteria for individual codes in Table 45 of the August
2006 proposed rule, we defaulted to the one characteristic that is
common to all of the codes listed. That is, we believed that, at a
minimum, prevailing medical practice would dictate the provision of
overnight care following each of the procedures listed in Table 45 of
the August 2006 proposed rule. We acknowledged that we had to exercise
a degree of clinical judgment in identifying those procedures that we
proposed to exclude from ASC payment. Therefore, we solicited comments
on the appropriateness of excluding the procedures in Table 45 from
payment under the revised payment system. We requested that commenters
who disagreed with a specific procedure's proposed exclusion from
payment submit clinical evidence that demonstrates that the criteria we
proposed in proposed new Sec. 416.166 of the regulations are not
factors when the procedure is performed in the majority of cases. We
asked that commenters also provide data to support any assertion that
the preponderance of Medicare beneficiaries upon whom the procedure is
performed would not be expected to require overnight care or monitoring
following the surgery. We noted in the proposed rule that simply
asserting that the procedure could be safely performed in an ASC,
without providing corroborative evidence and data, would not furnish us
with sufficient information upon which to make an informed decision.
Comment: Several commenters requested that, if CMS decided not to
adopt less than 24 hours as its definition of an overnight stay, CMS
should revise the list of proposed excluded procedures that were
included in Table 45 of the August 2006 proposed rule on the basis of
their overnight stay requirement. The commenters disagreed with CMS'
determinations that all of those procedures required at least active
medical monitoring at midnight following the procedure. Many commenters
provided specific recommendations regarding surgical services that they
believed should not be excluded from payment under the revised ASC
payment system. In addition, several commenters identified a number of
procedures not on the OPPS inpatient list that CMS proposed to exclude
from ASC payment but that were not displayed in Table 44 or Table 45 of
the proposed rule and for which CMS provided no rationale for their
exclusion.
Response: In response to these procedure-specific comments and to
those comments that reflected the belief that all procedures not on the
OPPS inpatient list should be payable under the revised ASC payment
system, we reviewed a subset of all of the surgical procedures that we
proposed to exclude from payment under the revised ASC payment system,
identified as described below. This included reassessing the treatment
of those codes that were proposed to be excluded but were inadvertently
left out of Table 44 or Table 45 in the August 2006 proposed rule. To
conduct this comprehensive review, we identified all codes within the
surgical range of CPT codes that met all of the following criteria: (1)
Not proposed for the CY 2008 list of ASC covered surgical procedures
(Addendum BB to the August 2006 proposed rule); (2) not included on the
CY 2007 OPPS inpatient list; (3) not packaged under the OPPS; (4) not
CPT unlisted surgical procedure codes; and (5) recognized for separate
payment under the OPPS. Elimination of all CPT codes not meeting these
criteria yielded about 750 procedures designated for a second review by
our medical advisors, in order to finalize their treatment under the CY
2008 revised ASC payment system.
Our clinical staff evaluated each of those procedures using all
available claims and physician pricing data, as well as their clinical
judgment and the public comments, to determine which procedures would
be expected to require monitoring at midnight of the day on which the
surgical procedure was performed or that otherwise would pose a
significant safety risk to the typical Medicare beneficiary. Table 2
below, which provides an illustrative list of all surgical procedures
excluded from ASC payment under the revised ASC payment system,
reflects the final outcome of that comprehensive review process. In
all, we are not excluding 17 of the procedures that we had initially
proposed for exclusion from payment under the revised ASC payment
system. The procedures for which we made a different final
determination than our proposal regarding the appropriateness of their
performance in ASCs include procedures from virtually all specialty
areas within the surgical range, from dermatology to gastroenterology
to ophthalmology. In addition, we reviewed all Category III CPT codes
and Level II HCPCS codes in the context of the public comments and our
final policy for the revised ASC payment system and concluded that 29
of these codes, in addition to those HCPCS codes on the CY 2007 ASC
list of covered procedures, are appropriate for performance in ASCs
under the revised payment system.
Comment: A number of commenters requested that CMS exclude
additional procedures from the ASC list of covered surgical procedures.
Specifically, several commenters requested that CMS exclude the
procedures listed in Table 1 below, because they believed that they
pose significant safety risks to beneficiaries when performed in ASCs.
They stated that all of the procedures listed in Table 1 would violate
at least one of the proposed procedure review criteria by involving
major blood vessels or prolonged invasion of body cavities. Further,
one commenter suggested that some of the procedures (as listed, CPT
codes 35473 through 37650) should be excluded, because they involve
femoral access and could require thrombolytic therapy.
Table 1.--Specific Procedures That Commenters Requested Be Excluded From
ASC Payment
------------------------------------------------------------------------
HCPCS code Short descriptor
------------------------------------------------------------------------
21215............................ Lower jaw bone graft.
32002............................ Treatment of collapsed lung.
33206............................ Insertion of heart pacemaker.
33214............................ Upgrade of pacemaker system.
33215............................ Reposition pacing-defib lead.
33216............................ Insert lead pace-defib, one.
33217............................ Insert lead pace-defib, dual.
33218............................ Repair lead pace-defib, once.
33220............................ Repair lead pace-defib, dual.
33222............................ Revise pocket, pacemaker.
33223............................ Revise pocket, pacing-defib.
33224............................ Insert pacing lead & connect.
33225............................ L ventric pacing lead add-on.
33226............................ Reposition L ventric lead.
33234............................ Removal of pacemaker system.
35473............................ Repair arterial blockage.
35474............................ Repair arterial blockage.
35475............................ Repair arterial blockage (non-
dialysis).
35476............................ Repair venous blockage (non-
dialysis).
35492............................ Artherectomy, perc.
35761............................ Exploration of artery/vein.
37205............................ Transcath IV stent, perc.
37206............................ Transcath IV stent/perc addl.
37250............................ IV U.S. first vessel add-on.
37251............................ IV U.S. each add vessel add-on.
37650............................ Revision of major vein.
40700............................ Repair cleft lip/nasal.
40701............................ Repair cleft lip/nasal.
42200............................ Reconstruct cleft palate.
42205............................ Reconstruct cleft palate.
42210............................ Reconstruct cleft palate.
[[Page 42488]]
42215............................ Reconstruct cleft palate.
42220............................ Reconstruct cleft palate.
G0297............................ Insrt 1 chamb dfib pulse generator.
------------------------------------------------------------------------
Response: We appreciate the commenters' concerns and conducted a
comprehensive review of each of the procedures presented. We agree with
the commenters that the procedures reported by CPT codes 35475
(Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk
or braches, each vessel); 37205 (Transcatheter placement of an
intravascular stent(s), (except coronary, carotid, and vertebral
vessel), percutaneous; initial vessel); and 37206 (Transcatheter
placement of an intravascular stent(s), (except coronary, carotid, and
vertebral vessel), each additional vessel) should be excluded from the
ASC list of covered surgical procedures because they could pose a
significant safety risk to beneficiaries in ASCs. We did not include
CPT code 35475 in our proposed list of covered surgical procedures
under the revised ASC payment system because we, like the commenters,
believe that it poses a safety risk for beneficiaries if performed in
ASCs. Although we did propose to add CPT codes 37205 and 37206 to the
ASC list for CY 2007, we did not finalize that proposal for CY 2007 in
response to comments and continue to agree with commenters that those
procedures would likely require an overnight stay.
With regard to the remaining procedures, three of them,
specifically CPT codes 33222 (Revision or relocation of skin pocket for
pacemaker); 33223 (Revision of skin pocket for single or dual chamber
pacing cardioverter-defibrillator); and 37650 (Ligation of femoral
vein), are on the current ASC list of covered surgical procedures and
have been safely performed in ASCs for some time. We do not believe
that they represent a significant safety risk or are likely to require
an overnight stay.
We did not propose to exclude any of the remaining procedures in
Table 1 from the list of procedures for which ASCs may receive payment
under the revised payment system because, based on our clinical review,
we did not find that the procedures would be expected to require an
overnight stay or pose a significant risk to beneficiary safety when
performed in ASCs. Our review for this final rule, in consideration of
the comments, did not alter our final opinion on the appropriate
treatment of these other codes.
Therefore, we are finalizing our proposal, with modification,
regarding specific surgical procedures that are excluded from ASC
payment under the revised ASC payment system. Table 2 provides an
illustrative list of CPT codes that are payable under the OPPS but that
are excluded from the ASC list of covered surgical procedures. This
illustrative list does not include those procedures that are on the
OPPS inpatient list, packaged under the OPPS, or only reportable by CPT
unlisted surgical procedure codes. All of the procedures listed in
Table 2 are excluded from the list of covered surgical procedures for
which Medicare will provide ASC payment under the revised ASC payment
system because we believe, based on our review of each procedure's
clinical characteristics, utilization data reflected in physician
claims, and prevailing medical practice as reflected in the valuation
of the services by the AMA/Specialty Society Relative Value Scale
Update Committee (RUC), and consideration of the judgment of our
medical advisors and all public comments to the proposed rule, that
these surgical procedures pose a significant risk to beneficiary safety
or are expected to require an overnight stay.
In this final rule, we are finalizing the addition of 793 new
surgical procedures to the ASC list of covered surgical procedures for
CY 2008, while we are excluding those procedures listed in Table 2 from
ASC payment for CY 2008. This list will be updated for the CY 2008
revised ASC payment system through the CY 2008 OPPS/ASC annual
rulemaking cycle.
Table 2.--Illustrative List of Surgical Procedures Payable Under the
OPPS (Not on the OPPS Inpatient List, Not Packaged Under the OPPS and
Not Designated as CPT Unlisted Codes) That Are Excluded From ASC Payment
Because They Pose a Significant Safety Risk or Are Expected to Require
an Overnight Stay
------------------------------------------------------------------------
HCPCS code Short descriptor
------------------------------------------------------------------------
15170............................ Acell graft trunk/arms/legs.
15171............................ Acell graft t/arm/leg add-on.
15175............................ Acellular graft, f/n/hf/g.
15176............................ Acell graft, f/n/hf/g add-on.
19260............................ Removal of chest wall lesion.
19307............................ Mast, mod rad.
20100............................ Explore wound, neck.
20101............................ Explore wound, chest.
20102............................ Explore wound, abdomen.
21049............................ Excis uppr jaw cyst w/repair.
21175............................ Reconstruct orbit/forehead.
21195............................ Reconst lwr jaw w/o fixation.
21261............................ Revise eye sockets.
21263............................ Revise eye sockets.
21408............................ Treat eye socket fracture.
21470............................ Treat lower jaw fracture.
21742............................ Repair stern/nuss w/o scope.
21743............................ Repair sternum/nuss w/scope.
22100............................ Remove part of neck vertebra.
22101............................ Remove part, thorax vertebra.
22222............................ Revision of thorax spine.
22526............................ Idet, single level.
22527............................ Idet, 1 or more levels.
22612............................ Lumbar spine fusion.
22614............................ Spine fusion, extra segment.
22851............................ Apply spine prosth device.
23470............................ Reconstruct shoulder joint.
24150............................ Extensive humerus surgery.
24151............................ Extensive humerus surgery.
24935............................ Revision of amputation.
25170............................ Extensive forearm surgery.
26037............................ Decompress fingers/hand.
27216............................ Treat pelvic ring fracture.
27235............................ Treat thigh fracture.
27412............................ Autochondrocyte implant knee.
27415............................ Osteochondral knee allograft.
27446............................ Revision of knee joint.
27475............................ Surgery to stop leg growth.
27524............................ Treat kneecap fracture.
28360............................ Reconstruct cleft foot.
29866............................ Autgrft implnt, knee w/scope.
29867............................ Allgrft implnt, knee w/scope.
29868............................ Meniscal trnspl, knee w/scpe.
31292............................ Nasal/sinus endoscopy, surg.
31293............................ Nasal/sinus endoscopy, surg.
31294............................ Nasal/sinus endoscopy, surg.
31600............................ Incision of windpipe.
31601............................ Incision of windpipe.
31610............................ Incision of windpipe.
31785............................ Remove windpipe lesion.
32005............................ Treat lung lining chemically.
32020............................ Insertion of chest tube.
32201............................ Drain, percut, lung lesion.
32601............................ Thoracoscopy, diagnostic.
32602............................ Thoracoscopy, diagnostic.
32603............................ Thoracoscopy, diagnostic.
32604............................ Thoracoscopy, diagnostic.
32605............................ Thoracoscopy, diagnostic.
32606............................ Thoracoscopy, diagnostic.
32998............................ Perq rf ablate tx, pul tumor.
33244............................ Remove eltrd, transven.
34101............................ Removal of artery clot.
34111............................ Removal of arm artery clot.
34201............................ Removal of artery clot.
34203............................ Removal of leg artery clot.
[[Page 42489]]
34421............................ Removal of vein clot.
34471............................ Removal of vein clot.
34490............................ Removal of vein clot.
34501............................ Repair valve, femoral vein.
34510............................ Transposition of vein valve.
34520............................ Cross-over vein graft.
34530............................ Leg vein fusion.
35011............................ Repair defect of artery.
35180............................ Repair blood vessel lesion.
35184............................ Repair blood vessel lesion.
35190............................ Repair blood vessel lesion.
35201............................ Repair blood vessel lesion.
35206............................ Repair blood vessel lesion.
35226............................ Repair blood vessel lesion.
35231............................ Repair blood vessel lesion.
35236............................ Repair blood vessel lesion.
35256............................ Repair blood vessel lesion.
35261............................ Repair blood vessel lesion.
35266............................ Repair blood vessel lesion.
35286............................ Repair blood vessel lesion.
35321............................ Rechanneling of artery.
35458............................ Repair arterial blockage.
35459............................ Repair arterial blockage.
35460............................ Repair venous blockage.
35470............................ Repair arterial blockage.
35471............................ Repair arterial blockage.
35472............................ Repair arterial blockage.
35475............................ Repair arterial blockage.
35484............................ Atherectomy, open.
35485............................ Atherectomy, open.
35490............................ Atherectomy, percutaneous.
35491............................ Atherectomy, percutaneous.
35493............................ Atherectomy, percutaneous.
35494............................ Atherectomy, percutaneous.
35495............................ Atherectomy, percutaneous.
35500............................ Harvest vein for bypass.
35685............................ Bypass graft patency/patch.
35686............................ Bypass graft/av fist patency.
35860............................ Explore limb vessels.
35879............................ Revise graft w/vein.
35881............................ Revise graft w/vein.
35883............................ Revise graft w/nonauto graft.
35884............................ Revise graft w/vein.
35903............................ Excision, graft, extremity.
36838............................ Dist revas ligation, hemo.
37183............................ Remove hepatic shunt (tips).
37195............................ Thrombolytic therapy, stroke.
37201............................ Transcatheter therapy infuse.
37202............................ Transcatheter therapy infuse.
37204............................ Transcatheter occlusion.
37205............................ Transcath iv stent, precut.
37206............................ Transcath iv stent/perc addl.
37207............................ Transcath iv stent, open.
37208............................ Transcath iv stent/open addl.
37209............................ Change iv cath at thromb tx.
37210............................ Embolization uterine fibroid.
37565............................ Ligation of neck vein.
37600............................ Ligation of neck artery.
37605............................ Ligation of neck artery.
37606............................ Ligation of neck artery.
37615............................ Ligation of neck artery.
37620............................ Revision of major vein.
38120............................ Laparoscopy, splenectomy.
38240............................ Bone marrow/stem transplant.
38720............................ Removal of lymph nodes, neck.
39400............................ Visualization of chest.
42225............................ Reconstruct cleft palate.
42227............................ Lengthening of palate.
42842............................ Extensive surgery of throat.
42844............................ Extensive surgery of throat.
43020............................ Incision of esophagus.
43130............................ Removal of esophagus pouch.
43280............................ Laparoscopy, fundoplasty.
43510............................ Surgical opening of stomach.
43647............................ Lap impl electrode, antrum.
43648............................ Lap revise/remv eltrd antrum.
43651............................ Laparoscopy, vagus nerve
43652............................ Laparoscopy, vagus nerve.
43752............................ Nasal/orogastric w/stent.
43830............................ Place gastrostomy tube.
43831............................ Place gastrostomy tube.
44180............................ Lap, enterolysis.
44186............................ Lap, jejunostomy.
44206............................ Lap part colectomy w/stoma.
44207............................ Lcolectomy/coloproctostomy.
44208............................ Lcolectomy/coloproctostomy.
44213............................ Lap, mobil splenic fl add-on.
44500............................ Intro, gastrointestinal tube.
44901............................ Drain app abscess, precut.
44970............................ Laparoscopy, appendectomy.
45541............................ Correct rectal prolapse.
47011............................ Percut drain, liver lesion.
47370............................ Laparo ablate liver tumor rf.
47371............................ Laparo ablate liver cryosurg.
47490............................ Incision of gallbladder.
48511............................ Drain pancreatic pseudocyst.
49021............................ Drain abdominal abscess.
49041............................ Drain, percut, abdom abscess.
49061............................ Drain, percut, retroper absc.
49200............................ Removal of abdominal lesion.
49323............................ Laparo drain lymphocele.
49324............................ Lap insertion perm ip cath.
49325............................ Lap revision perm ip cath.
49326............................ Lap w/omentopexy add-on.
49435............................ Insert subq exten to ip cath.
49436............................ Embedded ip cath exit-site.
49491............................ Rpr hern preemie reduce.
49492............................ Rpr ing hern premie, blocked.
50020............................ Renal abscess, open drain.
50021............................ Renal abscess, percut drain.
50080............................ Removal of kidney stone.
50081............................ Removal of kidney stone.
50541............................ Laparo ablate renal cyst.
50542............................ Laparo ablate renal mass.
50543............................ Laparo partial nephrectomy.
50544............................ Laparoscopy, pyeloplasty.
50945............................ Laparoscopy, ureterolithotomy.
51990............................ Laparo urethral suspension.
53500............................ Urethrlys, transvag w/ scope.
57106............................ Remove vagina wall, partial.
57107............................ Remove vagina tissue, part.
57109............................ Vaginectomy partial w/nodes.
57120............................ Closure of vagina.
57282............................ Colpopexy, extraperitoneal.
57283............................ Colpopexy, intraperitoneal.
57284............................ Repair paravaginal defect.
57292............................ Construct vagina with graft.
57295............................ Change vaginal graft.
57310............................ Repair urethrovaginal lesion.
57330............................ Repair bladder-vagina lesion.
57335............................ Repair vagina.
57425............................ Laparoscopy, surg, colpopexy.
57555............................ Remove cervix/repair vagina.
58260............................ Vaginal hysterectomy.
58262............................ Vag hyst including t/o.
58263............................ Vag hyst w/t/o & vag repair.
58270............................ Vag hyst w/enterocele repair.
58290............................ Vag hyst complex.
58291............................ Vag hyst incl t/o, complex.
58292............................ Vag hyst t/o & repair, compl.
58294............................ Vag hyst w/enterocele, compl.
58541............................ Lsh, uterus 250 g or less.
58542............................ Lsh w/t/o ut 250 g or less.
58543............................ Lsh uterus above 250 g.
58544............................ Lsh w/t/o uterus above 250 g.
58553............................ Laparo-vag hyst, complex.
58554............................ Laparo-vag hyst w/t/o, compl.
58770............................ Create new tubal opening.
58823............................ Drain pelvic abscess, precut.
58920............................ Partial removal of ovary(s).
58925............................ Removal of ovarian cyst(s).
59030............................ Fetal scalp blood sample.
59074............................ Fetal fluid drainage w/us.
59409............................ Obstetrical care.
59612............................ Vbac delivery only.
60210............................ Partial thyroid excision.
60212............................ Partial thyroid excision.
60220............................ Partial removal of thyroid.
60225............................ Partial removal of thyroid.
60240............................ Removal of thyroid.
60252............................ Removal of thyroid.
60260............................ Repeat thyroid surgery.
60500............................ Explore parathyroid glands.
60502............................ Re-explore parathyroids.
60512............................ Autotransplant parathyroid.
60520............................ Removal of thymus gland.
61623............................ Endovasc tempory vessel occl.
61626............................ Transcath occlusion, non-cns.
61720............................ Incise skull/brain surgery.
62000............................ Treat skull fracture.
62160............................ Neuroendoscopy add-on.
62351............................ Implant spinal canal cath.
63001............................ Removal of spinal lamina.
63003............................ Removal of spinal lamina.
63005............................ Removal of spinal lamina.
63011............................ Removal of spinal lamina.
63012............................ Removal of spinal lamina.
[[Page 42490]]
63015............................ Removal of spinal lamina.
63016............................ Removal of spinal lamina.
63017............................ Removal of spinal lamina.
63020............................ Neck spine disk surgery.
63030............................ Low back disk surgery.
63035............................ Spinal disk surgery add-on.
63040............................ Laminotomy, single cervical.
63042............................ Laminotomy, single lumbar.
63045............................ Removal of spinal lamina.
63046............................ Removal of spinal lamina.
63047............................ Removal of spinal lamina.
63048............................ Remove spinal lamina add-on.
63055............................ Decompress spinal cord.
63056............................ Decompress spinal cord.
63057............................ Decompress spine cord add-on.
63064............................ Decompress spinal cord.
63066............................ Decompress spine cord add-on.
63075............................ Neck spine disk surgery.
63741............................ Install spinal shunt.
64448............................ Nblock inj fem, cont inf.
64449............................ Nblock inj, lumbar plexus.
64804............................ Remove sympathetic nerves.
64910............................ Nerve repair w/allograft.
64911............................ Neurorraphy w/vein autograft.
69725............................ Release facial nerve.
69955............................ Release facial nerve.
69960............................ Release inner ear canal.
------------------------------------------------------------------------
IV. Ratesetting Methodology for the Revised ASC Payment System
A. Overview of Current ASC Payment System
Section 1833(i)(1) of the Act requires us to specify, in
consultation with appropriate medical organizations, surgical
procedures that are appropriately performed on an inpatient basis in a
hospital but that also can be safely performed in an ASC and to review
and update the list of procedures paid under the ASC payment system at
least every 2 years.
Under the existing ASC payment system, the ASC payment rate is a
standard overhead amount established on the basis of our estimate of a
fee that takes into account the costs incurred by ASCs generally in
providing facility services in connection with performing a specific
procedure. We refer readers to section I.B. of this final rule for
further history regarding the establishment of standard overhead
amounts for ASC payment. The standard overhead amounts under the
existing ASC payment system for procedures on the ASC list of covered
surgical procedures were last rebased in 1990 using data collected in a
1986 survey of ASC costs. The process and methodology that we used to
establish the payment system are explained in the February 8, 1990
Federal Register (55 FR 4526).
The existing ASC payment system consists of 9 standard overhead
amounts ranging from $333 to $1,339, based on the data collected in the
1986 survey of ASC costs. An ASC payment group currently consists of
all the procedures assigned to a particular standard overhead amount.
ASC payment groups are heterogeneous in terms of clinical
characteristics, cutting across all body systems and types of surgery.
Medicare pays a $150 allowance for IOLs that are inserted during or
subsequent to cataract surgery and an additional $50 for IOLs that are
included in active NTIOL classes. Medicare also makes separate payment
for implantable prosthetic devices and implantable durable medical
equipment (DME) that are surgically inserted at an ASC under the
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) fee schedule. Payment for all other facility services that are
directly related to performing a surgical procedure is packaged into
the prospectively determined ASC payment for the covered surgical
procedure.
Section 5103 of Public Law 109-171 requires us to substitute the
OPPS payment amount for the ASC standard overhead amount for surgical
procedures performed in an ASC on or after January 1, 2007, but prior
to the revised ASC payment system, when the ASC standard overhead
amount exceeds the OPPS payment amount for the procedure in that year.
In Addendum AA to the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68243 through 68283), we identify the HCPCS codes on the CY 2007
ASC list for which the CY 2007 ASC payments are capped at the OPPS
payment amounts in accordance with the provisions of section 5103 of
Public Law 109-171, based on a comparison of the final CY 2007 OPPS
payment rates and the ASC standard overhead amounts that are effective
in CY 2007.
Except for screening flexible sigmoidoscopy and screening
colonoscopy services, payment for ASC services is subject to the usual
Medicare Part B deductible and coinsurance requirements and the amounts
paid by Medicare must be 80 percent of the standard fee. As required by
section 1834(d) of the Act, the coinsurance for screening flexible
sigmoidoscopies and colonoscopies is 25 percent and the amounts paid by
Medicare must be 75 percent of the standard fee.
Medicare currently accounts for geographic wage variations when
calculating individual ASC payments by applying the relevant inpatient
prospective payment system (IPPS) wage index values and localities that
were established under the IPPS prior to implementation of the new Core
Based Statistical Areas (CBSAs) issued by the Office of Management and
Budget (OMB) in June 2003 to 34.45 percent of the national ASC standard
overhead amount. The 1986 ASC survey data are the basis for attributing
34.45 percent of ASC facility costs to labor costs.
Section 1833(i)(2)(C) of the Act requires the Secretary to update
ASC payment rates using the CPI-U (U.S. city average) (CPI-U) if the
Secretary has not otherwise updated the amounts under the revised ASC
payment system. As amended by Public Law 108-173, section 1833(i)(2)(C)
of the Act provides that if the Secretary is required to apply the CPI-
U increase, the CPI-U percentage increase is to be applied on a fiscal
year basis beginning with FY 1986 through FY 2005 and on a calendar
year basis beginning with 2006. Public Law 108-173 further amended
section 1833(i)(2)(C) of the Act to require us in FY 2004, beginning
April 1, 2004, to increase ASC payment rates using the CPI-U as
estimated for the 12-month period ending March 31, 2003, minus 3.0
percentage points. Public Law 108-173 also requires that the CPI-U
adjustment factor equal zero percent in FY 2005, the last quarter of CY
2005, and each of CYs 2006 through 2009.
Section 141(b) of the Social Security Act Amendments of 1994,
Public Law 103-432, requires us to establish a process for considering
requests for review of the appropriateness of the payment amount
provided under section 1833(i)(2)(A)(iii) of the Act for IOLs to ensure
that the ASC payment for the insertion procedure is reasonable and
related to the cost of acquiring a lens that belongs to a class of
NTIOLs. In the CY 2007 OPPS/ASC proposed rule that was published August
23, 2006 (71 FR 49631 through 49635), we proposed changes to the
process for recognizing IOLs as belonging to a new NTIOL class. In the
subsequent CY 2007 OPPS/ASC final rule with comment period (71 FR 68175
through 68181), we finalized the proposed changes to that process,
beginning with requests for review for establishing new NTIOL classes
for CY 2008 payment.
The revised ASC payment system that we are finalizing in this rule
will implement requirements set forth in section 626 of Public Law 108-
173. The
[[Page 42491]]
revised payment system mandated by section 626(d) of Public Law 108-173
requires us to take into account recommendations in a report to
Congress prepared by the GAO. As mentioned earlier, that report (GAO-
07-86) was published on November 30, 2006. Its methodology, findings,
and recommendations are summarized in section II.B. of this final rule.
Specific ASC payment system issues considered in the GAO Report are
discussed in the individual sections below under the related topic
areas.
B. ASC Relative Payment Weights Based on APC Groups and Relative
Payment Weights Established Under the OPPS
As we stated in the August 2006 proposed rule for the revised ASC
payment system (71 FR 49647), we considered several strategies and
methodologies for setting ASC payment rates under a revised payment
system. These options included requiring ASCs to submit modified cost
reports as a basis for establishing ASC costs, expanding the number and
payment range of the current ASC payment groups, basing payments to
ASCs on the relative weights for surgical services established under
the MPFS, basing payments to ASCs on the relative weights for surgical
services established under the Medicare OPPS, as suggested in Public
Law 108-173, or basing payments to ASCs on a flat percentage of the
payment for the same services established under the OPPS, as advocated
by representatives of several ASC associations.
After reviewing the advantages and disadvantages of each of these
approaches, in the August 2006 proposed rule we proposed, within the
parameters of section 626 of Public Law 108-173, to use the APC groups
and the relative payment weights for surgical procedures established
under the OPPS as the basis of the payment groups and the relative
payment weights for surgical procedures performed in ASCs. These
payment weights would be multiplied by an ASC conversion factor in
order to calculate the ASC payment rates. Several factors persuaded us
to advance this proposal over the other approaches that we considered.
First, in section 626(d) of Public Law 108-173, the Congress
explicitly targets the OPPS for consideration by the GAO in its study
of ASC payments. We believe it is reasonable to assume that Congress,
by so doing, was highlighting the relative payment weights under the
OPPS as a theoretical model for ASC relative payment weights under the
revised payment system.
Second, the ASC benefit provides payment for services associated
with performing surgical procedures. The OPPS has equipped us with
nearly a decade of experience in developing and refining a relative
payment system for all services furnished in connection with outpatient
surgical procedures.
Third, Public Law 108-173 applies, for the first time, a budget
neutrality requirement to the ASC benefit. That is, in the year the
revised system is implemented, the system is to be designed to result
in the same aggregate amount of expenditures that would be made if the
revised payment system were not implemented. Because the OPPS is also a
prospective payment system for facility services that is subject to
budget neutrality requirements, it provides useful parallels for a
ratesetting methodology based on relative facility payment weights for
surgical services under the revised ASC payment system.
Fourth, in our analysis of the APC groups to which surgical
procedures are assigned for payment under the OPPS, we found that, of
the 150 highest volume surgical procedures furnished in HOPDs, more
than half (80) are also among the 150 highest volume procedures
performed in ASCs.
Finally, the ASC industry in numerous meetings with us over the
past several years has frequently voiced its preference for a payment
system that parallels the OPPS for the sake of promoting transparency
across sites of service in the arena of outpatient surgery and to
streamline and modernize how CMS sets payments and determines what is
payable under the ASC benefit.
We explained in the August 2006 proposed rule that the OPPS payment
rates are based on relative payment weights, which are updated annually
based on the most recent year of hospital outpatient claims data and
hospitals' latest Medicare cost reports. APCs to which surgical
procedures are assigned are generally homogeneous both in terms of
clinical characteristics and resource requirements. The APCs have been
continually refined over the past 6 years through the work of the
Advisory Panel on Ambulatory Payment Classification Groups (APC Panel)
and as a result of comments received during the OPPS annual rulemaking
cycles.
Moreover, we believed that the APC groups had matured with respect
to their clinical and resource homogeneity, and the relativity in
resource utilization among APCs containing surgical procedures had
stabilized. Thus, we concluded in the proposed rule that the APC groups
and their relative weights were reasonable and appropriate models for
grouping outpatient surgical procedures and determining the relativity
of the ASC payment weights under the revised payment system. For
example, whether performed in an HOPD or in an ASC, we believed the
time and facility resources required to perform a routine laparoscopic
hernia repair described by CPT code 49650 (Laparoscopy, surgical;
repair initial inguinal hernia), with a CY 2007 OPPS relative payment
weight of 43.5488, were approximately 5 times higher than those
required to perform a diagnostic colonoscopy described by CPT code
45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic,
with or without collection of specimen(s) by brushing or washing, with
or without colon decompression (separate procedure)), with a CY 2007
OPPS relative payment weight of 8.7686. Thus, we believed that the
relative payment weights established under the OPPS for procedures
performed in the hospital outpatient setting reasonably reflected the
relative facility resources required for such procedures and did so
with sufficient coherence to be applicable to other ambulatory sites of
service. Taking all these factors into account, we proposed to use the
APCs as a ``grouper'' and the APC relative payment weights as the basis
for ASC relative payment weights and for calculating ASC payment rates
under the revised payment system. Accordingly, we proposed to establish
provisions in proposed new Subpart F, Sec. Sec. 416.167 and 416.171,
to reflect these proposed changes for calculating the ASC payment rates
beginning January 1, 2008.
As further discussed in section II.B. of this final rule, on
November 30, 2006, the GAO published the report mandated by section
626(d) of Public Law 108-173 (GAO-07-86), where it determined that the
APC groups of the OPPS accurately reflect the relative costs of
procedures performed in ASCs. It concluded that the APC groups in the
OPPS reflect the relative costs of surgical procedures performed in
ASCs in the same way that they reflect the relative costs of the same
procedures when they are performed in HOPDs. Therefore, the GAO
recommended that the APC groups could be applied to procedures
performed in ASCs, and the OPPS could be used as the basis for an ASC
payment system, thereby eliminating the need for ASC surveys and
providing for an annual revision of the ASC payment groups. At its
December 2006 meeting, the PPAC recommended that CMS apply any payment
policies uniformly to both
[[Page 42492]]
ASCs and HOPDs as appropriate, confirming its belief that the OPPS and
the revised ASC payment system could be closely linked.
We received a number of comments on our proposal to use the OPPS
relative payment weights as the basis for establishing relative payment
weights under the revised ASC payment system. A summary of the comments
and our responses follow.
Comment: Many commenters agreed that using the OPPS APCs as a
``grouper'' and the APC relative payment weights to establish ASC
payment rates for surgical procedures paid under the revised ASC
payment system is appropriate because a significant number of surgical
procedures furnished in the hospital outpatient setting are also
performed in ASCs. Some commenters argued that because ASCs provide
many similar procedures that are also performed in HOPDs and often
utilize the same equipment, supplies, and clinical labor in performing
these procedures, the relative costs of performing the procedures
should be similar, if not identical, in both settings. Moreover, the
commenters generally agreed that creating an ASC payment system that
parallels the OPPS would promote transparency across sites of service
in the area of outpatient surgery and would also promote greater
alignment and coordination between the OPPS and the revised ASC payment
system, including providing for the annual updating of payment weights
in the ASC payment system.
Some commenters requested that CMS apply different conversion
factors to the OPPS relative payment weights for specific types of
procedures to calculate their ASC payment rates, because they suggested
that the OPPS relativity was not correct for some services provided in
single specialty ASCs (for example, gastroenterology and pain
management procedures). They believed that the OPPS APC weights, based
on all hospital services rather than just surgical services, may be
flawed and that additional analyses of relative hospital and ASC costs
are needed. They recommended that CMS develop firm data on the
differences between hospital outpatient and ASC costs and the magnitude
of those differences for numerous services before finalizing
significant changes in ASC payments for procedures. One commenter
specifically discussed a study commissioned by MedPAC in which RAND
found that no single outpatient surgical setting, ASCs or HOPDs, had
consistently higher rates of patient characteristics that would be
expected to increase facility costs. Analyses by another commenter
found that among a subset of gastrointestinal (GI) procedures, the
majority of surgical CPT codes describing those procedures received
OPPS payments that were less than hospitals' median costs for the
individual procedures.
Response: We appreciate the commenters' general support for basing
the revised ASC payment system relative weights on the OPPS APC groups
and their relative weights. As discussed in detail in section II.B. of
this final rule, in its November 2006 report on ASC payment, the GAO
found that the APC groups in the OPPS accurately reflect the relative
costs of procedures performed in ASCs. The GAO analyses also
demonstrated that there is less variation in the ASC setting between
individual procedures' costs and the costs of their assigned APC groups
than there is in the HOPD setting, and that when compared to the median
cost of the same APC group, procedures performed in ASCs had
substantially lower costs than those same procedures performed in
HOPDs.
The GAO findings were based upon data for all procedures performed
in ASCs in CY 2004, as reported by those ASCs responding to the GAO
survey. In view of the GAO's confirmation that the APC groups
accurately reflect the relative costs of these procedures performed in
ASCs in the same way that they reflect the relative costs of the same
procedures when they are performed in HOPDs, substantiating a key
assumption underlying our proposal for the revised ASC payment system,
we do not believe there is a compelling rationale for using different
ASC conversion factors to develop payment rates for various procedures
under the revised ASC payment system. Applying more than one ASC
conversion factor to different procedures would imply that we believe
the OPPS APC payment weight relativity is not applicable to the ASC
setting, contrary to our proposal and the GAO study results. APCs
currently serve as a ``grouper'' for the OPPS and, as such, the payment
for any given procedure under the OPPS does not specifically reflect
the cost of that procedure in any one facility. Instead, the APC
relative payment weights under the OPPS are developed based on the
median cost of all single claims for all procedures assigned to each
APC. Prospectively established APC payment rates provide an averaging
effect on OPPS payments for individual services. With the significant
expansion of covered surgical procedures eligible for ASC payment that
we are finalizing in this final rule for the revised ASC payment system
as discussed in section III. of this final rule, in many cases where
one service in an APC is an ASC procedure, most of the other procedures
assigned to the same APC will also be paid in the ASC setting. Thus,
under the revised payment system, ASCs generally will have the
potential to provide a mix of individual services assigned to those
APCs that is similar to the mix of OPPS procedures attributable to
certain APCs and, in many cases, all of the procedures assigned to
certain APCs under the OPPS will also be ASC covered surgical
procedures. We believe this uniform approach under the revised ASC
payment system is fully consistent with the recommendation of the PPAC
that we apply payment policies consistently to both ASCs and HOPDs, as
appropriate. It also generally treats procedures performed in ASCs
consistently for purposes of developing ASC payment rates under the
revised ASC payment system, in accordance with the PPAC recommendation
that we adopt a systematic and adaptable means of fairly reimbursing
ASCs for their services.
While information provided by the commenters clearly demonstrated
that some specific groups of procedures would experience a significant
decrease in payment under the revised ASC payment system as compared
with the existing payment structure, we are not convinced that the
information we received contradicts the premise of our proposal and the
GAO findings that the relativity of costs observed in HOPDs could
appropriately be used as the basis for the relative payment weights in
the revised ASC payment system. We also continue to see no clinical
basis that would support the differential relativity of costs for
various procedures performed in the ASC or HOPD settings.
While applying a single conversion factor to the OPPS relative
weights may result in decreases to ASC payments for some services
commonly provided in single specialty ASCs, we also believe that this
approach should result in facilities receiving more appropriate
payments for ASC services in general, where those payments more
accurately reflect the facility resources required for their
performance. As discussed further in section IV.J. of this final rule,
our final policy of a 4-year transition to phase in the revised ASC
payment system should mitigate the potential disruption in care that
could be associated with significant increases or decreases in payments
for specific surgical procedures under the revised payment system.
Individual ASCs will have a longer period of time to evaluate and
potentially modify the breadth of
[[Page 42493]]
surgical procedures they provide based on the expanded list of covered
surgical procedures and the final policies of the revised ASC payment
system. Further, our final ASC policies for payment of device=intensive
procedures and covered ancillary services that more closely align the
ASC and OPPS systems may moderate the magnitude of differences between
current ASC payments and those under the revised payment system for
individual surgical procedures. We do not believe that it would be
appropriate to modulate changes in payment under the revised system by
differentially adjusting the payment weights or the conversion factor
for various types of services because, consistent with the GAO
recommendation, we believe the OPPS relative payment weights upon which
the revised ASC payment system is based appropriately reflect the
relativity in ASC resource costs associated with different surgical
procedures. We believe that the final payment policies for the revised
payment system result in appropriate and equitable payments, and thus,
we see no rationale for applying adjustments that are counter to the
principles of a prospective payment system.
After considering the public comments received, we are finalizing
our proposal, without modification, to establish the relative payment
weights under the revised ASC payment system for most covered surgical
procedures based on their OPPS APC relative payment weights for the
same calendar year, with application of a single ASC conversion factor
to determine the national unadjusted ASC payment rates, as set forth in
Sec. Sec. 416.167 and 416.171. Several exceptions to this general
policy are discussed elsewhere in this final rule, specifically in
sections IV.C. and IV.E. of this preamble.
C. Packaging Policy
1. General Policy
Payment for a surgical procedure under both the current OPPS and
ASC payment systems represents payment for a package of various items
and services, all of which are directly related and required in order
to perform the procedure. In both systems, we package into a single
facility payment the payment for a bundle of direct and indirect costs
incurred by the facility to perform the surgical procedure. These costs
include, but are not limited to, use of the facility, including an
operating suite or procedure room and recovery room; nursing,
technician, and related services; administrative, recordkeeping, and
housekeeping items and services; medical and surgical supplies and
equipment; surgical dressings; and materials for anesthesia.
CMS currently applies different rules under the ASC payment system
and the OPPS for determining whether payment for other items and
services directly related to a surgical procedure is packaged into the
facility payment for the associated surgical procedure or paid for
separately. These other items and services include drugs, biologicals,
contrast agents, implantable devices, and diagnostic services such as
imaging. Currently, CMS packages payment for the costs for all drugs,
biologicals, and diagnostic services, including imaging, into the ASC
standard overhead amount for the surgical procedure with which these
items and services are associated. Under the OPPS, CMS pays separately
for some of these items and services, in addition to paying for the
surgical procedure.
ASCs currently receive separate payment for prosthetic implants and
implantable DME, as well as additional payment for NTIOLs. Laboratory
services, physicians' services, and x-ray or diagnostic procedures may
also be paid separately under other Medicare Part B fee schedules.
Conversely, under the OPPS, payment for prosthetic implants and
implantable DME is packaged into the OPPS payment for the surgical
procedure performed to insert the implants. Payments for IOLs,
anesthesia materials, and implantable surgical supplies, such as
stents, mesh, guidewires, pins, and catheters, are packaged into the
associated surgical procedure payment under both the OPPS and the ASC
payment system.
In developing the August 2006 proposed rule for the revised ASC
payment system, we considered several packaging options. First, we
considered making no change to the current policy regarding items and
services for which payment is packaged into the ASC payment. That is,
we would continue under the revised ASC payment system to package into
the ASC payment all services listed at existing Sec. 416.61(a). In
addition, we would continue to pay separately, sometimes under other
fee schedules, for items and services such as: NTIOLs; prosthetic
implants and implantable DME surgically inserted at an ASC (DMEPOS fee
schedule); laboratory services (Clinical Diagnostic Laboratory Fee
Schedule); physician services (MPFS); and x-ray or diagnostic
procedures other than those directly related to performance of the
surgical procedure (MPFS).
We also considered proposing to apply the OPPS packaging rules to
the ASC payment system and to pay under the revised ASC payment system
the same way we pay under the OPPS for items and services directly
related to a surgical procedure. If we adopted this option, payment for
certain imaging procedures, drugs, biologicals, and contrast agents
directly related to performing a covered surgical procedure would not
be packaged into the ASC payment for the procedure but would, instead,
be paid separately. Conversely, payment for most surgically implanted
devices and implantable DME would be packaged.
Each of the preceding two options has characteristics that are
inconsistent with a fundamental principle of a prospective payment
system, which is to base payment on large bundles of items and services
so as to promote the efficient provision of services. To preserve as
much as possible the elements of a prospective payment system within
the revised ASC payment system, in the August 2006 proposed rule for
the revised ASC payment system, we proposed a third option (71 FR
49648). That is, we proposed to continue the current policy of
packaging payment for all direct and indirect costs incurred by the
facility to perform a covered surgical procedure into the ASC payment
for the procedure. This would include payment for all drugs,
biologicals, contrast agents, anesthesia materials, and imaging
services, as well as the other items and services that were proposed
for packaging into the ASC surgical procedure payment as listed in
proposed Sec. 416.164(a). Proposed Sec. 416.164(a) addressed the
services for which payment was proposed to be included in the ASC
payment for the covered surgical procedures, and proposed Sec.
416.164(b) addressed those services that were proposed not to be
included in the ASC payment for the covered surgical procedures.
In addition, we proposed to cease making separate payment for
implantable prosthetic devices and implantable DME inserted surgically
in an ASC. Instead, under the revised payment system, we proposed to
package payment for implantable prosthetic devices and implantable DME
when they are surgically inserted into the ASC payment for the
associated covered surgical procedure, as we do under the OPPS.
However, we proposed to continue excluding from ASC payment for
covered surgical procedures the other services addressed in Sec.
416.164(b). That is, payment for items and services for which payment
is currently made under other Part B fee schedules, with the exception
of implantable prosthetic devices and implantable DME, would
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not be included in the ASC payment for the surgical procedure. Payment
for items and services, such as physicians' professional services;
laboratory, x-ray or diagnostic procedures (other than those directly
related to performance of the surgical procedure); nonimplantable
prosthetic devices; ambulance services; leg, arm, back and neck braces;
artificial limbs; and DME for use in the patient's home would not be
included in the ASC payment for the covered surgical procedure.
We proposed this third option for a number of reasons. First, in
the August 2006 proposed rule, we explained that this approach to
packaging is most consistent with the principles of a prospective
payment system. Second, we noted that we believe that ASCs generally
treat a less complex and severely ill patient case-mix and, as a
result, we believe that ASCs are less likely to provide, on a regular
basis, many of the separately paid items and services that patients
might receive more consistently in a hospital outpatient setting. Thus,
in the August 2006 proposed rule, we concluded that we did not believe
there is a need to pay for these services separately in ASCs, because
that would unbundle some items and services that are currently packaged
into the ASC facility services payment under the existing payment
system, reduce incentives for cost-efficient delivery of services in
ASCs, and increase the complexity of the revised ASC payment system.
Moreover, after analysis of OPPS claims for surgical procedures, we
were unable to identify ancillary items and services that are
repeatedly and consistently reported separately in association with
specific ambulatory surgical procedures. Rather, the OPPS claims for
surgical procedures were of two types: one group showed a broad range
of items and services that were provided on the same day that a
surgical procedure was performed in the HOPD, only some of which were
likely to be directly related to the surgical procedure; the second
group of claims revealed that many surgical procedures are only
infrequently associated with ancillary items and services paid
separately under the OPPS.
We sought comments in the August 2006 proposed rule (71 FR 49648)
from ASC clinical and administrative staff, and from physicians who
perform surgeries in ASCs, regarding nonsurgical ancillary services or
items that are directly related to a surgical procedure that would be
paid separately under the OPPS but that would be packaged under our
proposal for the revised ASC payment system. We specifically requested
that commenters provide data to indicate the frequency with which
specific items and services are typically furnished in association with
given procedures, the reasons why one patient might require the
additional items and services whereas another patient would not, and
the costs of those items and services relative to the other costs
incurred to perform the associated surgery.
At its December 2006 meeting, the PPAC recommended that CMS apply
any payment policies uniformly to ASCs under the revised ASC payment
system and HOPDs under the OPPS. In the GAO Report (GAO-07-86)
published on November 30, 2006, based upon its study of the 20 most
frequently performed ASC procedures in CY 2004, the GAO found that many
additional services were billed with surgical procedures in both the
ASC and HOPD settings, but few resulted in an additional payment in one
setting but not the other. In general, HOPDs were paid separately for
some of the related additional services they billed with the procedures
and, in the ASC setting, other Part B suppliers usually billed Medicare
for those services and received payment for them. Multiple surgical
procedures performed in one session were typically paid separately in
both settings, occurring in similar proportions of cases and subject to
the same 50-percent reduction policy for the procedure with the lower
payment rate. Laboratory services were paid under the OPPS according to
the Clinical Diagnostic Laboratory Fee Schedule (CLFS) rates and were
billed by another Medicare Part B supplier when provided in the context
of a surgical procedure performed in an ASC. Similarly, some radiology
services were paid separately under the OPPS, but when those radiology
services were performed with procedures provided in the ASC setting,
those services generally were furnished and billed by another Part B
supplier. Anesthesia services in both settings were usually billed by
another Part B supplier. While individual drugs were billed under the
OPPS for most procedures, the GAO found that none of those individual
drugs were separately payable in the HOPD setting, just as their
payment was packaged in ASCs. Thus, the GAO concluded that there were
many similarities in the additional services billed in the ASC or HOPD
settings with the top 20 ASC procedures. Furthermore, the GAO found
that, in the context of the existing ASC payment system, CMS generally
made separate payment for similar additional services in both settings,
although sometimes to other Part B suppliers than to the ASCs
themselves.
We also note that we proposed, consistent with section 141(b) of
the Social Security Act Amendments of 1994, Public Law 103-432, to
continue to provide adjustment to payment amounts for NTIOLs under the
revised ASC payment system as set forth in Subpart G that we finalized
in the CY 2007 OPPS/ASC final rule with comment period.
We received numerous comments on our proposed packaging policies
for the revised ASC payment system. The commenters submitted many
suggestions regarding the various approaches that they believed CMS
should follow when finalizing the packaging policies for certain items
and services under the revised ASC payment system. A summary of the
comments and our responses follow.
Comment: In general, many of the commenters agreed with CMS'
proposal to continue to package under the revised ASC payment system
payment for various items and services that are currently packaged
under the OPPS and the existing ASC payment system. They recommended
that CMS adopt its proposal to provide packaged payment for the costs
of many items and services that are directly related to the provision
of surgical procedures, such as facility overhead, operating and
recovery room use, nursing and technician services, administrative and
housekeeping items and services, appliances and equipment, materials
for anesthesia, IOLs, surgical dressings, supplies, splints, and casts.
They acknowledged that the statute requires that payment to ASCs for
IOLs (other than NTIOLs which receive a supplemental payment) must be
packaged into the ASC payment for IOL insertion procedures. In
addition, the commenters agreed that CMS should continue to exclude
from payment as part of the ASC payment for covered surgical procedures
some items and services that are paid under other Part B fee schedules,
specifically the professional services of physicians and nonphysician
practitioners paid under the MFPS and laboratory services paid under
the CLFS. Further, the commenters agreed that CMS should continue to
provide additional payment for NTIOLs.
The commenters who supported continued packaging of the items and
services described above generally provided those recommendations in
the context of their broader recommendation to apply the same packaging
policies under the revised ASC payment system as under the
[[Page 42495]]
OPPS, because the proposed payment rates under the revised ASC payment
system were based upon the OPPS payment groups. They argued that
parallel packaging policies were most consistent with promoting
transparency between the two systems and minimizing any payment
incentives to shift sites of service for various procedures. They also
believed that this approach is the most appropriate, given the proposal
to base the rates in the revised ASC payment system on the OPPS
relative payment weights, with application of a single conversion
factor. The commenters asserted that consistent packaging policies
would ensure that some payment was made for the costs of all items and
services used by facilities in performing surgical procedures, and that
there was no duplicate payment for these items under either the OPPS or
the revised ASC payment system.
MedPAC supported the proposal to expand the ASC payment bundles in
the revised payment system by packaging payment for implantable
prosthetics and DME, but recommended that CMS make the payment bundles
under the revised ASC payment system and the OPPS even more compatible
by expanding the payment bundles in the OPPS. MedPAC noted that
different bundling policies under the two payment systems may lead to
different relative payment amounts in each setting, even if the base
payment rates share the same relative values in both settings.
Response: We appreciate the commenters' support for continuing to
package payment under the revised ASC payment system for those items
and services that also receive packaged payment under the OPPS. The
commenters' recommendations are consistent with the PPAC recommendation
that we apply payment policies uniformly across the two systems. We
note that any changes to the OPPS payment bundles are outside the scope
of this final rule for the revised ASC payment system. Such changes
would have to be proposed and finalized through the OPPS annual
rulemaking cycle, and we will keep MedPAC's recommendations in mind for
future OPPS updates.
As set forth in final Sec. 416.163, payment is made under the
revised ASC payment system for ASC services furnished in connection
with covered surgical procedures. As set forth in revised Sec. 416.2,
ASC services include both facility services, which are defined as items
and services that are furnished in connection with a covered surgical
procedure performed in an ASC and for which payment is packaged into
the ASC payment for the covered surgical procedure, and covered
ancillary services, which are defined as those items and services that
are integral to a covered surgical procedure and for which separate
payment may be made under the revised ASC payment system.
After considering all public comments received, we are finalizing,
with modification, our proposal to provide packaged payment for ASC
facility services into the ASC payment for covered surgical procedures
under the revised ASC payment system. That is, we will continue to
identify as within the scope of ASC facility services for which payment
is packaged into the payment for covered surgical procedures as set
forth in final Sec. 416.164(a) the following: nursing, technician, and
related services; use of the facility where the surgical procedures are
performed; laboratory testing performed under a Clinical Laboratory
Improvement Amendments of 1988 (CLIA) certificate of waiver; drugs and
biologicals for which separate payment is not allowed under the OPPS;
medical and surgical supplies not on pass-through status under the
OPPS; equipment; surgical dressings; implanted prosthetic devices and
related accessories and supplies not on pass-through status under the
OPPS, including IOLs; implanted DME and related accessories and
supplies not on pass-through status under the OPPS; splints and casts
and related devices; radiology services for which separate payment is
not allowed under the OPPS and other diagnostic tests or interpretive
services that are integral to a surgical procedure; administrative,
recordkeeping, and housekeeping items and services; materials,
including supplies and equipment for the administration and monitoring
of anesthesia; and supervision of the services of an anesthetist by the
operating surgeon. Under the revised ASC payment system, the above
items and services fall within the scope of ASC facility services, and
we will package payment for them into the ASC payment for the covered
surgical procedure in order to promote efficient use of resources. We
will continue to provide a payment adjustment for insertion of an IOL
approved as belonging to a class of NTIOLs, for the 5-year period of
time established for that class, as set forth in Subpart G and new
Sec. 416.172(g) for the revised ASC payment system.
As a modification to our proposal, under the final policy of the
revised ASC payment system, covered ancillary services that are
integral to a covered ASC surgical procedure will be allowed separate
payment. These covered ancillary services, which are outside of the
scope of ASC facility services defined at Sec. 416.2 and described at
new Sec. 416.164(a) for which payment is packaged into the ASC payment
for covered surgical procedures, are defined at Sec. 416.2 and
described at new Sec. 416.164(b) as follows: brachytherapy sources;
certain implantable items that have pass-through status under the OPPS;
certain items and services that we designate as contractor-priced
(payment rate is determined by the Medicare contractor) including, but
not limited to, the procurement of corneal tissue; certain drugs and
biologicals for which separate payment is allowed under the OPPS; and
certain radiology services for which separate payment is allowed under
the OPPS. Public comments on the proposed rule and our responses
regarding these specific items and services are discussed later in this
section.
We will consider to be outside the scope of ASC services, as set
forth in Sec. 416.164(c), the following items and services, including,
but not limited to: physicians' services (including surgical procedures
and all preoperative and postoperative services that are performed by a
physician); anesthetists' services; radiology services (other than
those integral to performance of a covered surgical procedure);
diagnostic procedures (other than those directly related to performance
of a covered surgical procedure); ambulance services; leg, arm, back,
and neck braces other than those that serve the function of a cast or
splint; artificial limbs; and nonimplantable prosthetic devices and
DME.
2. Policies for Specific Items and Services
Although in the August 2006 proposed rule we proposed to package
payment for a broad array of items and services under the revised ASC
payment system into the ASC payment for a covered surgical procedure as
described earlier in this section, we solicited and received many
public comments regarding our proposed treatment of those items or
services that are directly related to a surgical procedure and that
would be paid separately under the OPPS but that were proposed for
packaging under the revised ASC payment system. We address those
specific comments and provide our responses below.
Comment: A number of commenters indicated that, if the goal of the
revised ASC payment system is to create a payment system that is based
on OPPS relative weights and payment rates, then the packaging policy
for ASCs should be
[[Page 42496]]
based on the same inclusions as those found under the OPPS. They
suggested that following the OPPS payment policies under the revised
ASC payment system would promote parity in payments between HOPDs and
ASCs and, thereby, eliminate inappropriate incentives to base care
decisions on payment considerations. Specifically, a number of
commenters were concerned about payment differences that could arise
between HOPDs and ASCs when services outside the CPT surgical range
were provided in an ASC in conjunction with a covered surgical
procedure on the ASC list. They noted that when HOPDs provide some of
these services and items, they generally receive separate payment for
them.
Response: Because we received numerous comments on various issues
related to the proposed packaging of payment for specific items and
services under the revised ASC payment system where the proposed
packaging policy differs from the OPPS payment policy, we address them
separately in the following sections:
a. Radiology Services
Under the existing ASC payment system, we define a surgical
procedure as any procedure described within the range of Category I CPT
codes that the AMA defines as ``surgery'' (CPT codes 10000-69999). In
the August 2006 proposed rule, we indicated that we would continue this
standard (71 FR 49636). Because the HCPCS codes that describe radiology
services are outside of the CPT surgical range, payment for radiology
services that are directly related to surgical procedures has been
packaged into the ASC payment for the covered surgical procedure under
the existing ASC payment system. The current regulatory definition of
an ASC does not allow the ASC and another entity to mix functions and
operations in a common space during concurrent or overlapping hours of
operation. That is, the two facilities must be separated by time
(different hours of operation) or the other entity may operate in the
ASC's space when the ASC is not operating in that space. Historically,
we have made an exception to this rule when there is a need for imaging
services during the course of a covered surgical procedure in progress
in an ASC under the existing ASC payment system. In that case, an
Independent Diagnostic Testing Facility (IDTF) sharing the space with
the ASC (normally at a different time) may conduct the required
radiology service outside of its normal business hours, as needed, and
receive Medicare payment for those services. Specifically, under the
existing ASC payment system if an ASC enrolls in the Medicare program
as an IDTF and bills as that supplier when furnishing a radiology
service that is reasonable and necessary and directly related to and
furnished in conjunction with a covered surgical procedure, the IDTF
may bill and receive payment under the MPFS for imaging and guidance
services, even though they are being provided during the ASC's
designated hours.
The GAO Report on ASC payment released on November 30, 2006
confirmed that separate payment is commonly made to another Part B
supplier for these radiology services provided in association with
surgical procedures in ASCs. Currently, radiology services provided in
association with surgical procedures paid under the OPPS are either
packaged or paid separately through an OPPS facility payment. We
received a number of comments regarding our proposal to package payment
for radiology services into payment for their associated surgical
procedures under the revised ASC payment system. A summary of the
comments and our responses follow.
Comment: Numerous commenters opposed CMS' proposed policy of
packaging payment for radiology services directly related to a surgical
procedure into the ASC payment for the associated covered surgical
procedure. Some commenters requested that CMS continue to follow the
existing practice regarding separate payment for radiology services
provided in association with surgical procedures under the current ASC
payment system. That is, they recommended that CMS permit continued
separate payments for such radiology services to IDTFs if the ASCs are
enrolled as IDTFs and bill for the services as that type of supplier.
On the other hand, other commenters believed that ASC enrollment as an
IDTF supplier was unnecessarily administratively burdensome for those
ASCs that only are providing radiology services necessary for the safe
provision of surgical procedures. These commenters requested that CMS
adopt the OPPS payment policy for radiology services under the revised
ASC payment system, which either provides separate payment or packages
their payment into the OPPS payment for the surgical procedure
associated with the radiology services. They indicated that following
the OPPS payment policy under the revised ASC payment system would
promote parity in payments between HOPDs and ASCs, especially because
the relative payment weights used in both payment systems were linked.
In contrast, MedPAC recommended that CMS address the potentially
inconsistent payment policies by creating larger payment bundles under
the OPPS, consistent with CMS' proposal to package payment for
radiology services directly related to a surgical procedure under the
revised ASC payment system.
Response: We believe that appropriate radiology services may be
necessary for the safe performance of covered surgical procedures that
are provided to Medicare beneficiaries in ASCs, and we realize that
under the current system, payments for many of these services are made
to other Part B suppliers even though the radiology services are
integral to the surgical procedures provided by ASCs. We have come to
believe that the most prudent method for providing accurate payment for
the ancillary radiology services that are integral to, and required for
the successful performance of, covered surgical procedures is to
provide separate payment for certain radiology services under our final
policy for the revised ASC payment system. Payment for the costs of
radiology services that are separately paid under the OPPS is not
included in the OPPS payment weights upon which the revised ASC payment
system is based so, under our proposal, ASCs may not have received the
most appropriate payment for the costs of these associated radiology
services. We will, therefore, provide separate payment to ASCs for
certain ancillary radiology services when they are integral to the
performance of a covered surgical procedure billed by the ASC on the
same day, provided that separate payment for the radiology service
would be made under the OPPS.
We specify that a radiology service is integral to the performance
of a covered surgical procedure if it is required for the successful
performance of the surgery and is performed in the ASC immediately
preceding, during, or immediately following the covered surgical
procedure. Based on our analysis of the OPPS data, we believe that, in
most cases, a radiology service that is separately payable under the
OPPS that is performed in the ASC on the same day as a covered surgical
procedure will be provided integral to a covered surgical procedure,
and the ASC will be able to receive separate payment for the service as
a covered ancillary service. The separate ASC payments for these
radiology services will be made at the lower of: (1) The amount
calculated according to the standard methodology of the revised ASC
payment system; or (2) the MPFS nonfacility practice expense amount for
the service (specifically, for the
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technical component (TC) if the service's HCPCS code is assigned a TC
under the MPFS). This is similar to our final payment policy for
covered office-based surgical procedures added to the ASC list in CY
2008 or later years. Payment for the costs of the facility resources
associated with the radiology service would have been made to IDTFs
under the existing ASC payment system at the MPFS nonfacility practice
expense amount. Therefore, we believe the revised payment system
beginning January 1, 2008, will both ensure appropriate and equitable
payment for covered ancillary radiology services integral to covered
surgical procedures and not provide a payment incentive for migration
of services from physicians' offices or IDTFs to ASCs.
This final policy will not encourage the proliferation of ASCs
enrolling as IDTF suppliers, a practice which could lead to even
greater future increases in the volume of diagnostic imaging services
than those recently observed for such services to Medicare
beneficiaries. CMS defines an IDTF in Sec. 410.33 as an entity
independent of a hospital or physician's office in which diagnostic
tests are performed by licensed or certified nonphysician personnel
under appropriate physician supervision. ASCs are distinct entities
that operate exclusively for the purpose of providing surgical services
to patients not requiring hospitalization (Sec. 416.2). As discussed
earlier, an ASC that is also enrolled as an IDTF must maintain
separate, exclusive hours of operation from those of the IDTF, and
there may be no overlap in the hours of operation of the two entities.
In order to bill for diagnostic tests, the IDTF must be enrolled as
such with Medicare and meet specific requirements regarding its
structure, ownership and, operation as set forth in Sec. 410.33. As
stated in Sec. 416.49, an ASC is responsible for obtaining radiologic
services from a Medicare approved facility to meet the needs of its
patients and, as confirmed by the GAO in its report released on
November 30, 2006, many ASCs currently provide those radiology services
in association with covered surgical procedures through other Part B
suppliers, specifically IDTFs.
Under the revised payment system, there is no incentive for ASCs
that provide only those radiology services that are integral to the
performance of covered surgical procedures to also enroll as IDTFs. In
contrast to current policy, under the revised system, payment will be
made to the ASC for radiology services that are furnished integral to a
covered surgical procedure. Payment will no longer be permitted to
IDTFs for covered ancillary radiology services furnished integral to
covered surgical procedures in ASCs. Because ASCs are distinct entities
that operate exclusively to provide ambulatory surgical services, we
would not expect that IDTFs sharing space with ASCs would be billing
for any services for a patient receiving those services in an ASC on
the date of a covered surgical procedure because all such services
would be integral to the surgical procedure.
Under the final policy, only the ASC can receive payment for the
facility resources required to provide the ancillary radiology
services. IDTFs would not be able to bill for radiology services
integral to the performance of a covered surgical procedure, an
existing practice which commenters claimed is unnecessarily
administratively burdensome because it requires ASCs that are only
providing radiology services related to the safe performance of
surgical procedures also to enroll as IDTF suppliers under Medicare. As
of January 1, 2008, we are no longer permitting the exception that has
allowed billing by IDTFs for required radiology services provided in
ASCs during the course of covered ASC surgical procedures. We are also
not allowing any other suppliers to bill for the technical component of
radiology services provided in ASCs that are integral to the
performance of an ASC covered surgical procedure. Only ASCs will
receive separate payment for the technical component of those radiology
services that are separately payable under the OPPS to ensure that no
duplicate payment is made. This policy will ensure that packaged or
separate payment is made to ASCs for all radiology services integral to
the performance of covered surgical procedures, thereby providing
appropriate payment to ASCs for those radiology services that are
essential to the delivery of safe, high quality surgical care.
In summary, under the revised ASC payment system, we are adopting
the OPPS payment status for radiology services and will pay separately,
at the lower of the amount developed according to the standard
methodology of the revised ASC payment system or the MPFS nonfacility
practice expense amount, for ancillary radiology services designated as
separately payable under the OPPS when those radiology services are
integral to the performance of a covered surgical procedure provided on
the same day and billed by the ASC. Similarly, we will package payment
for those services that are designated as packaged under the OPPS into
the payment for the covered surgical procedure. The separate national,
unadjusted ASC payment for a covered ancillary radiology service would
be based either upon the OPPS payment weight for the APC group of the
radiology service, with application of the uniform ASC conversion
factor, or upon the MPFS nonfacility practice expense relative value
units (RVUs) for the service. Payment under the revised ASC payment
system for these covered ancillary radiology services would be subject
to geographic adjustment, like payment for covered surgical procedures.
IDTFs would no longer be able to receive payment for ancillary
radiology services that are integral to the performance of a covered
surgical procedure for which the ASC is billing Medicare. This policy
is consistent with the PPAC's request for uniform payment policies
across the OPPS and the revised ASC payment system and is responsive to
MedPAC's concern about creating different payment bundles for ASCs and
HOPDs. Because the packaging status of radiology services under the
revised ASC payment system will parallel their treatment under the
OPPS, any changes to the packaging of radiology services under the OPPS
that would alter the OPPS payment bundles would also occur under the
revised ASC payment system. Therefore, we believe that this approach is
fully consistent with the recommendations of MedPAC and the PPAC in
applying payment policies consistently to both ASCs and HOPDs.
Radiology services include all Category I CPT codes in the
radiology range established by CPT, from 70000 to 79999, and Category
III CPT codes and Level II HCPCS codes that describe radiology services
that crosswalk or are clinically similar to procedures in the radiology
range established by CPT. This revised ASC payment system policy for
each calendar year will apply to all radiology services that are
separately payable under the OPPS in that same calendar year. An
illustrative listing that includes all radiology services that are
separately payable under the CY 2007 OPPS, which will be proposed for
updating and then finalized in the CY 2008 OPPS/ASC proposed and final
rules, respectively, can be found in Addendum BB to this final rule.
Covered ancillary radiology services are assigned to payment indicator
``Z2'' (Radiology service paid separately when provided integral to a
surgical procedure on ASC list; payment based on OPPS relative payment
weight) or ``Z3'' (Radiology service paid separately when provided
integral to a
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surgical procedure on ASC list; payment based on MPFS nonfacility PE
RVUs). ASC payment rates for these radiology services will be
determined according to the standard methodology of the revised ASC
payment system as discussed further in section V. of this final rule,
or according to the MPFS nonfacility practice expense amount, whichever
payment amount is lower. This final policy is set forth in Sec. Sec.
416.171(d) and 416.167(b)(3).
After consideration of all public comments received, we are
finalizing a policy to provide separate payment under the revised ASC
payment system for those ancillary radiology services separately paid
under the OPPS that are integral to the performance of covered surgical
procedures for which the ASC bills Medicare. This final policy
contrasts with our proposal which would have provided packaged payment
for all ancillary radiology services. Instead, under the revised ASC
payment system, we will provide separate payment for those ancillary
radiology services that are separately paid under the OPPS when they
are provided on the same day as, and integral to, the performance of a
covered surgical procedure in an ASC. Payment for ancillary radiology
services that are packaged under the OPPS will be packaged under the
revised ASC payment system, and these services are identified in
Addendum BB to this final rule with payment indicator ``N1'' (Packaged
service/item; no separate payment made).
Separately paid radiology services are considered to be covered
ancillary services. ASC payment for these radiology services will not
be subject to the 4-year transition (see section IV.J. of this final
rule) because the services have never received separate payment under
the existing ASC payment system. The 4-year transition applies only to
those services that receive separate payment under the existing CY 2007
ASC payment system. We also are revising proposed Sec. 416.164(a) and
(b) to reflect this final policy.
b. Brachytherapy Sources
As we stated in the August 2006 proposed rule, under the existing
ASC payment system, a single payment is made to an ASC for all facility
services furnished by the ASC in connection with a covered surgical
procedure. However, a number of services and related items covered
under Medicare may be furnished in an ASC, where these items and
services are not considered to be facility services and, therefore, are
not paid through the ASC payment for the covered surgical procedure.
These items and related services may be covered and paid to other Part
B suppliers, such as physicians. Such is sometimes the case with
payment for brachytherapy sources implanted in ASCs, where the needles
and catheters to implant the sources are implanted during surgical
procedures that are on the ASC list. Under the existing ASC payment
system, while payment is not made for brachytherapy sources to ASCs,
these sources may be separately paid at contractor-priced rates by
Medicare contractors under the MPFS to physicians who may also be
billing the CPT codes for application of the brachytherapy sources in
ASCs. Contractor-priced rates are those payment rates for certain items
or services that are individually established by each Medicare
contractor for payment of claims submitted to them. Brachytherapy
source application codes, which are included in the radiology section
of the CPT code book, are not on the existing ASC list because they do
not fall within the CPT surgical range and, therefore, are not defined
as surgery for purposes of ASC payment. While we did not explicitly
discuss payment for brachytherapy sources in the August 2006 proposed
rule, we received a number of comments regarding payment for
brachytherapy sources under the revised ASC payment system. A summary
of the comments and our responses follow.
Comment: Several commenters suggested that CMS pay separately for
brachytherapy sources under the revised ASC payment system when they
are implanted in ASCs. Other commenters recommended that CMS continue
to pay separately under the MPFS for brachytherapy sources provided in
ASCs. The commenters requested that CMS allow separate payment for
brachytherapy sources to facilitate the treatment of cancer patients
who have brachytherapy sources implanted in ASCs. As an example, they
described a closely related sequence of procedures performed in the ASC
setting for the brachytherapy treatment of patients with prostate
cancer, including the placement of needles and catheters, reported with
a CPT code on the ASC list; the application of brachytherapy sources,
reported with a CPT code not on the ASC list; and the provision of
numerous brachytherapy sources, reported with specific Level II HCPCS
codes in the OPPS setting. The commenters noted that it would be
appropriate to implant brachytherapy sources in ASCs for the treatment
of prostate cancer, because the surgical procedure to insert the
required needles and catheters is currently on the ASC list and, in the
case of prostate cancer in particular, patients must have the sources
implanted in the same session where the needles or catheters are
placed. The commenters pointed out that each of these related items and
services is separately paid under the OPPS, so the base OPPS payment
weights for the surgical needle and catheter placement procedures do
not provide payment for the brachytherapy source application or the
sources themselves. They noted that all of these individual procedures
and items are required to provide the full brachytherapy treatment.
Response: Based on the comments received and our review of the
issue, we have concluded that the most appropriate policy under the
revised ASC payment system is to provide separate payment to ASCs for
the brachytherapy sources as covered ancillary services implanted in
conjunction with covered surgical procedures billed by ASCs. Further,
as evidenced by our decisions regarding payment for other covered
ancillary services under the CY 2008 revised ASC payment system, our
intention is to maintain consistent payment and packaging policies
across HOPD and ASC settings for covered ancillary services that are
integral to covered surgical procedures performed in ASCs. Therefore,
consistent with our policy to pay separately for some drugs,
biologicals, and radiology services as covered ancillary services, we
also believe that adopting a payment policy consistent with the OPPS
for payment of brachytherapy sources is reasonable and appropriate to
ensure that the comprehensive brachytherapy service can be provided by
ASCs. The application of the brachytherapy sources is integrally
related to the surgical procedures for insertion of brachytherapy
needles and catheters, which are appropriate for performance in ASCs.
There is a statutory requirement that the OPPS establish separate
payment groups for brachytherapy sources related to their number,
radioisotope, and radioactive intensity, as well as for stranded and
non-stranded sources as of July 1, 2007, OPPS procedure payments do not
include payment for brachytherapy sources. We agree with both MedPAC
and the PPAC that consistent payment bundles between the two payment
systems are desirable. Therefore, under the revised ASC payment system,
we will pay ASCs separately for brachytherapy sources when they are
provided in association with a surgical
[[Page 42499]]
procedure not excluded from ASC payment and billed by the ASC on the
same day. The ASC brachytherapy source payment rate for a given
calendar year will be the same as the OPPS payment rate for that year
or, if specific OPPS prospective payment rates are unavailable, ASC
payments for brachytherapy sources will be contractor-priced. The ASC
brachytherapy source payment rate will be established at its OPPS
payment rate, without application of the ASC budget neutrality
adjustment factor to the OPPS conversion factor. In addition,
consistent with the payment of brachytherapy sources under the OPPS,
the ASC payment rates for brachytherapy sources will not be adjusted
for geographic wage differences. Because brachytherapy sources are
implantable devices with relatively fixed costs for which we would not
expect efficiencies that would permit ASCs to acquire them at lower
costs than HOPDs, we believe it is most appropriate to pay for the
brachytherapy sources at the same rates as the OPPS if possible. A list
of brachytherapy sources recognized under the CY 2007 OPPS, for which
payment according to the statute is made at charges reduced to cost
under the CY 2007 OPPS, is included in Table 3 below, as well as in
Addendum BB to this final rule, specifically those codes assigned to
payment indicator ``H7'' (Brachytherapy source paid separately when
provided integral to a surgical procedure on ASC list; payment
contractor-priced).
An updated list will be proposed and finalized for CY 2008 in the
CY 2008 OPPS/ASC proposed and final rules, respectively, as will the CY
2008 OPPS payment rates for brachytherapy sources. We also may
establish new brachytherapy source HCPCS codes, revise the existing
HCPCS codes, or both, for separate payment on a quarterly basis under
the revised ASC payment system, as we currently do under the OPPS, in
order to keep the two payment systems aligned. In addition, we note
that the CPT codes for the application of brachytherapy sources are
radiology services in the radiology range of Category I CPT codes, so
they would also be separately paid in ASCs under the revised ASC
payment system if provided in association with a covered surgical
procedure, as described in section IV.C.2.a. of this final rule.
Table 3.--Brachytherapy Sources Paid Separately Under the CY 2007 OPPS
as of April 1, 2007
------------------------------------------------------------------------
HCPCS code Long descriptor
------------------------------------------------------------------------
A9527........................... Iodine I-125, sodium iodide solution,
therapeutic, per millicurie.
C1716........................... Brachytherapy source, Gold-198, per
source.
C1717........................... Brachytherapy source, High Dose Rate
Iridium-192, per source.
C1718........................... Brachytherapy source, Iodine-125, per
source.
C1719........................... Brachytherapy source, Non-High Dose
Rate Iridium-192, per source.
C1720........................... Brachytherapy source, Palladium-103,
per source.
C2616........................... Brachytherapy source, Yttrium-90, per
source.
C2633........................... Brachytherapy source, Cesium-131, per
source.
C2634........................... Brachytherapy source, High Activity,
Iodine-125, greater than 1.01 mCi
(NIST), per source.
C2635........................... Brachytherapy source, High Activity,
Palladium-103, greater than 2.2 mCi
(NIST), per source.
C2636........................... Brachytherapy linear source, Palladium-
103, per 1MM.
C2637........................... Brachytherapy source, Ytterbium-169,
per source.
------------------------------------------------------------------------
After consideration of all public comments received, we are
finalizing a policy to provide separate payment under the revised ASC
payment system for ancillary brachytherapy sources implanted in
association with the performance of a covered surgical procedure that
is billed by the ASC to Medicare. Under our proposal, no payment would
have been made to ASCs for the implantation of brachytherapy sources in
conjunction with covered surgical procedures, although payment could
have been made to other Part B suppliers. Under this final policy, ASC
payment for brachytherapy sources as covered ancillary services in a
calendar year will be made at the OPPS rates for that same year, or if
OPPS rates are unavailable, ASC payment will be made at contractor-
priced rates. Payment rates for brachytherapy sources will not be
developed through application of the uniform ASC conversion factor, and
they will not be subject to the geographic adjustment. Accordingly, we
are revising proposed Sec. 416.164(a) and (b) to reflect this final
policy.
We would also caution that we expect ASCs to follow all Federal,
State, and local safety requirements regarding the proper handling and
disposal of these radioactive substances. ASCs that cannot comply with
those guidelines should not provide brachytherapy services. ASC
policies for the proper handling and disposal of brachytherapy sources
also should include accommodations for the appropriate disposal of
sources that were not implanted.
c. Drugs and Biologicals
In the August 2006 proposed rule, we indicated that under the
existing ASC payment system, payment for all drugs and biologicals
(whether packaged or separately payable under the OPPS) is packaged
into the ASC payment for the covered surgical procedure. We proposed to
continue that policy under the revised ASC payment system. Under the
OPPS, CMS pays separately for all pass-through drugs and biologicals,
while nonpass-through drugs and biologicals are either packaged or paid
separately under the OPPS, depending on whether or not their cost is
equal to or less than $55 per day or exceeds $55 per day, respectively,
for CY 2007. We received a number of comments on our proposal to
package payment for all drugs and biologicals into the payment for
their associated surgical procedures under the revised ASC payment
system. A summary of the comments and our responses follow.
Comment: While the commenters generally agreed with CMS' proposal
to package payment for inexpensive drugs into the ASC payment for the
covered surgical procedure under the revised ASC payment system
consistent with current practice, many commenters objected to CMS'
proposed packaging of payment for expensive drugs and biologicals and
urged CMS to pay separately for them. Moreover, several commenters
requested that CMS adopt the OPPS payment policies for both pass-
through and nonpass-through drugs and biologicals under the revised ASC
payment system. They indicated that following the OPPS payment policies
under the revised ASC payment system would promote parity in
[[Page 42500]]
payments between HOPDs and ASCs and, thereby, eliminate inappropriate
incentives to base care decisions on payment considerations.
Specifically, a number of commenters were concerned about payment
differences that could arise between HOPDs and ASCs when items were
provided in an ASC in conjunction with a covered surgical procedure on
the ASC list. They noted that when HOPDs provide pass-through and many
nonpass-through drugs and biologicals, they generally receive separate
payment for these items; therefore, the base OPPS payment rates contain
no payment for these drugs and biologicals.
Several commenters expressed particular concern regarding CMS'
proposal to package payment for expensive biologicals into the
associated surgical procedure's ASC payment. These commenters cited
surgical procedures for the application of skin substitutes, newly
proposed as additions for ASC payment in CY 2008, as examples of
relatively inexpensive surgical procedures that require the use of
costly biologicals, for which separate payment is made under the OPPS.
They argued that the additions of the procedures to the ASC list would
not provide meaningful access to those services in ASCs, given that the
relatively low procedure payments proposed for the revised ASC payment
system included no payment for those necessary biologicals. The
commenters further added that not paying separately for expensive drugs
and biologicals in ASCs could result in a shift of services from ASCs
to HOPDs or physicians' offices, where they are separately paid, even
though ASCs could be the most appropriate clinical setting for care.
Some commenters suggested that CMS select specific drugs and
biologicals for separate payment under the revised ASC payment system
based on specific criteria such as their cost, required use, or
association with specific surgical procedures not excluded from ASC
payment.
Response: After considering all the comments related to payment for
drugs and biologicals, we agree with the commenters that the revised
ASC payment system should provide separate payment for relatively
costly drugs and biologicals that are integral to covered surgical
procedures that are billed by ASCs and whose payments are not packaged
into the base OPPS payment rates. Therefore, effective January 1, 2008,
we will pay separately for all OPPS pass-through and nonpass-through
drugs and biologicals that are separately paid under the OPPS, when
they are provided in association with a covered surgical procedure that
is billed by the ASC to Medicare.
Based on the November 30, 2006 GAO Report on ASC payment, we
recognize that historically common ASC procedures generally used drugs
that are packaged under the OPPS, but we believe that the significant
expansion of the procedures eligible for payment under the revised ASC
payment system, in addition to evolving surgical practice, may
necessitate the use of different drugs and biologicals in ASCs in the
future. To ensure appropriate access to all surgical procedures that
are safe for performance in ASCs, we believe it is prudent under the
revised ASC payment system to provide separate payment in the ASC
setting for drugs and biologicals that are integral to covered surgical
procedures for which the ASC is billing, when the costs of those drugs
and biologicals were not included in developing the base procedure
payment weights under the OPPS. We do not believe it would be
appropriate to select only a subset of these drugs and biologicals that
are separately payable under the OPPS because we do not see a clear
rationale for doing so.
We specify that a drug or biological is integral to the performance
of a covered surgical procedure if it is required for the successful
performance of the surgery and is provided in the ASC immediately
preceding, during, or immediately following the covered surgical
procedure. Based on our analysis of OPPS data, we believe that, in most
cases, a drug or biological that is separately payable under the OPPS
that is provided in an ASC on the same day as a covered surgical
procedure will be provided as integral to the covered surgical
procedure, and the ASC will be able to receive separate payment for the
drug or biological as a covered ancillary service.
The payments for separately payable drugs and biologicals under the
revised ASC payment system for a calendar year will be equal to the
payment rates developed according to the payment methodology used in
the OPPS for that same year, without the application of the ASC budget
neutrality adjustment to the OPPS conversion factor. Because OPPS
payment for separately paid drugs and biologicals is provided at the
average hospital acquisition cost and is not based upon the application
of the OPPS conversion factor to relative payment weights, we believe
the OPPS rates should also reflect the typical acquisition cost of
these products in the ASC facility setting as well. The OPPS currently
relies on the average sales price (ASP) methodology to establish
payment rates for many separately paid drugs and biologicals, and ASP
data are based upon manufacturers' reports of all drug sales, including
those to different types of facilities and physicians' offices. The ASP
methodology is also utilized to establish the physician's office
payment for drugs and biologicals. Therefore, we believe that aligning
the ASC payment methodology with the OPPS payment for these covered
ancillary services is a consistent and logical approach to setting
their ASC payment rates, and we will not apply the ASC budget
neutrality adjustment to establish the ASC payment rates. Comparable to
their treatment under the OPPS, the ASC payment for separately paid
drugs and biologicals will also not be subject to the geographic wage
adjustment. In addition, ASC payment for drugs and biologicals that are
not separately payable under the OPPS will be packaged into the
payments for the covered surgical procedures with which they are
administered, consistent with the current OPPS payment methodology.
As noted above, under the CY 2007 OPPS, payment for separately
payable nonpass-through drugs and biologicals is made according to the
ASP methodology, and is generally equal to the ASP plus 6 percent in CY
2007, the same as the physician's office payment. Payment for pass-
through drugs and biologicals is set at the rate under the Competitive
Acquisition Program (CAP) for Part B drugs or, if the drug is not
included in the CAP, at the rate established by the ASP methodology and
generally equal to the ASP plus 6 percent. A list of the drugs and
biologicals that are separately paid under the CY 2007 OPPS, along with
their payment rates as of April 1, 2007, is included in Addendum BB to
this final rule, specifically those codes assigned to payment indicator
``K2'' (Drugs and biologicals paid separately when provided integral to
a surgical procedure on ASC list; payment based on OPPS rate). Drugs
and biologicals for which payment is packaged under the CY 2007 OPPS
are also listed in Addendum BB, where they are assigned to payment
indicator ``N1'' (Packaged service/item; no separate payment made).
The CY 2008 payment status and payment rates for drugs and
biologicals will be proposed and finalized in the CY 2008 OPPS/ASC
proposed and final rules, respectively. We also may establish new HCPCS
codes for separately payable drugs and plan to update payment rates for
drugs and biologicals based on new ASP information on a quarterly basis
under
[[Page 42501]]
the revised ASC payment system, as we currently do under the OPPS, in
order to keep the two payment systems aligned. This final policy is
consistent with the recommendation of the PPAC and the comments of
MedPAC to align the payment bundles under the OPPS and ASC payment
systems.
In summary, after consideration of all public comments received, we
are finalizing a policy to provide separate payment under the revised
ASC payment system for drugs and biologicals that are separately paid
under the OPPS, when those items are integral to the performance of a
covered surgical procedure for which the ASC is billing. We proposed to
provide packaged payment for all drugs and biologicals under the
revised ASC payment system through the ASC payment for the covered
surgical procedure. In contrast, this final policy will provide
separate payment for those drugs and biologicals that are separately
paid under the OPPS, when those items are provided on the same day as
and integral to the performance of a covered surgical procedure in an
ASC. Separate ASC payment for these drugs and biologicals will be made
at the OPPS payment rate for the same calendar quarter. ASC payment for
those drugs and biologicals that are integral to the performance of a
covered surgical procedure and whose payment is packaged under the OPPS
will receive packaged payment under the revised ASC payment system.
Payment rates for drugs and biologicals will not be developed through
application of the uniform ASC conversion factor, and they will not be
subject to the geographic adjustment. We also are revising proposed
Sec. 416.164(a) and (b) to reflect this final policy.
d. Implantable Devices With Pass-Through Status Under the OPPS
In the August 2006 proposal for the revised ASC payment system, we
proposed to pay for all implantable devices as part of the ASC payment
for the covered surgical procedure, thereby packaging payment for all
devices except for the additional ASC adjustment for NTIOLs. Under this
proposal, payment for devices included in those device categories with
pass-through status under the OPPS would also be packaged. In contrast,
pass-through status under the OPPS provides payment for a device
included in the pass-through device category on a claim-specific basis
at the hospital's charges reduced to cost. That is, fiscal
intermediaries apply the hospital's overall cost-to-charge ratio from
the hospital's last submitted cost report to the submitted charges on
the claim and pay the resulting amount on a claim-specific basis. A
device offset amount is applied, if appropriate, to take into
consideration the predecessor device payment already packaged into the
OPPS payment for the associated implantation procedure, in order to
ensure no duplicate payment. The predecessor device is the device that
would have been used in the procedure if the pass-through device had
not been implanted and for which the historical cost is packaged into
the payment for the implantation procedure.
Under the existing ASC payment system, payment for OPPS designated
pass-through devices is either packaged into the ASC payment for the
covered surgical procedure or, if the device is implantable DME or an
implantable prosthetic, separately paid under the DMEPOS fee schedule,
independent from the ASC payment for the associated surgical procedure.
We received many comments regarding our proposal to package payment for
devices with OPPS pass-through status into payment for their associated
surgical procedures under the revised ASC payment system. A summary of
the comments and our responses follow.
Comment: Many commenters encouraged us to expand the OPPS pass-
through program to the revised ASC payment system, to provide separate
payment for those devices whose payments, in whole or in part, were not
packaged into the base OPPS payment weights upon which the revised ASC
payment system would be based. These commenters questioned how ASCs
would be paid appropriately for devices that are paid separately under
the OPPS as pass-through devices at the hospital's charges reduced to
cost by the hospital's overall cost-to-charge ratio. The commenters did
not believe it would be appropriate to provide payment for devices with
pass-through status under the OPPS packaged into the ASC payment for
the associated surgical procedure, when there are either no costs
associated with those devices packaged into the base OPPS procedure
payment weights or inadequate costs associated only with predecessor
devices packaged into the base OPPS weights.
The commenters added that many of the OPPS designated pass-through
devices that are implanted in ASCs are expensive, and their cost would
not be adequately reflected in the ASC payment for the covered surgical
procedure. They believed that the proposed policy would result in
little access to these new technologies in the ASC setting, despite the
fact that the associated surgical procedures for their implantation are
appropriate for ASC payment. They pointed out that only devices that
demonstrate significant clinical improvement are provided pass-through
status under the OPPS; hence, Medicare beneficiaries would be unable to
receive the most clinically beneficial procedures in ASCs.
Several commenters requested that CMS not provide ASC payments for
many surgical procedures that use implantable devices, generally for
patient safety reasons, whether pass-through devices are used or not.
Response: While the OPPS pass-through program is a statutory
requirement of the OPPS under section 1833(t)(6) of the Act and,
therefore, not specifically applicable to the revised ASC payment
system, we agree with commenters that similar device payment policies
for these devices under the OPPS and the revised ASC payment system are
most appropriate to ensure access to procedures implanting these
clinically beneficial devices in ASCs. Specifically in the case of OPPS
pass-through devices, the costs of the devices are not fully packaged
into the OPPS payment weights upon which the revised ASC payment system
is based because the devices are separately paid under the OPPS. We
agree with commenters that if payments to ASCs for the associated
surgical implantation procedures are inadequate to cover the costs of
these beneficial devices, then ASCs will not offer the procedures
implanting these devices and beneficiary access to these effective
devices will thereby be limited to other sites for the services.
When we examined the three device categories that currently have
pass-through status under the CY 2007 OPPS, specifically C1820
(Generator, neurostimulator (implantable), with rechargeable battery
and charging system), C1821 (Interspinous process distraction device
(implantable)), and L8690 (Auditory osseointegrated device, includes
all internal and external components), we noted that the surgical
procedures associated with both C1820 and L8690 are currently payable
in the ASC setting. We continue to believe that the procedures
associated with these pass-through device categories are safe for ASC
performance and, as such, the procedures will be paid under the revised
ASC payment system. We remind the public that the list of device
categories with pass-through status under the OPPS is updated
quarterly, with the addition of new pass-through device categories, if
applicable, and that the dates for the expiration of pass-through
payment for device categories
[[Page 42502]]
are proposed and finalized during the OPPS annual rulemaking cycle.
Only device categories C1821 and L8690 will continue with pass-through
status under the CY 2008 OPPS, but there may be additional device
categories established in the future that will have pass-through status
during all or a portion of that calendar year. Under the OPPS, claim-
specific device pass-through payment is calculated based on the device
charge reduced to cost by application of the overall hospital cost-to-
charge ratio and, if applicable, the resulting device cost is further
subject to a payment reduction (device offset) that is equivalent to
the device cost for predecessor devices already included in the APC
median cost for the associated surgical procedure. This ensures that
the OPPS does not provide duplicate payment for any portion of an
implanted device with pass-through status. Of the three device
categories currently with pass-through status under the OPPS, only one
device category (C1820) has an associated device offset due to the
costs of the predecessor nonrechargeable implantable neurostimulators
already packaged into the base APC payment weights for neurostimulator
implantation procedures.
Commenters have persuaded us that, under the revised ASC payment
system, it is appropriate to provide separate payment for devices that
are included in device categories with pass-through status under the
OPPS. A list of the OPPS pass-through device categories as of April 1,
2007 is provided in Table 4 below, and their HCPCS codes are also
included in Addendum BB to this final rule, where they are assigned to
payment indicator ``J7'' (OPPS pass-through device paid separately when
provided integral to a surgical procedure on ASC list; payment
contractor-priced). Implantable devices that received packaged payment
because they do not have OPPS pass-through status are also listed in
Addendum BB to this final rule, where they are assigned to payment
indicator ``N1'' (Packaged service/item; no separate payment made).
Table 4.--Active OPPS Pass-Through Device Categories Under the CY 2007
OPPS as of April 1, 2007
------------------------------------------------------------------------
HCPCS code Long descriptor
------------------------------------------------------------------------
C1820........................... Generator, neurostimulator
(implantable), with rechargeable
battery and charging system.
C1821........................... Interspinous process distraction
device (implantable).
L8690........................... Auditory osseointegrated device,
includes all internal and external
components.
------------------------------------------------------------------------
It is not possible to pay for these devices using the specific OPPS
payment methodology, because cost-to-charge ratios are not available
for ASCs to convert ASC charges to cost in order to establish a claim-
specific device payment. Because these devices are new technology and
the number of device categories with pass-through status under the OPPS
has been limited over the past several years, we believe that
contractor-priced rates are the most appropriate payment methodology
for these devices under the revised ASC payment system since there
would be little or no OPPS claims data available to establish
prospective payment rates for these devices. Therefore, we will pay
ASCs separately for devices with pass-through status under the OPPS in
that same quarter of the calendar year at contractor-priced rates when
they are implanted in ASCs during a covered surgical procedure that is
billed by the ASC. As under the OPPS, ASC payment for these devices
would not be subject to the geographic wage adjustment, nor would the
uniform ASC conversion factor be applied because there is no OPPS
payment weight available for these devices and there is little clinical
labor associated with the device acquisition by the ASC. The associated
nondevice facility resources for the device implantation procedures
would be paid through an ASC surgical procedure service payment based
upon the payment weight for the nondevice portion of the related OPPS
APC payment weight, as described further below with respect to ASC
payment for implantable devices without pass-through status under the
OPPS. This policy, similar to the device offset policy under the OPPS,
would ensure no duplicate device payment by removing, if applicable,
the costs of related predecessor devices packaged into the base
procedure's OPPS payment weight. Under this policy, we will pay
separately in ASCs for new devices that result in significant clinical
improvement, consistent with the pass-through policy under the OPPS.
This similar treatment of devices included in device categories with
OPPS pass-through status under both the OPPS and revised ASC payment
systems will help to ensure that beneficiaries have access to the
devices in both settings. We believe this approach is fully consistent
with the recommendation of the PPAC to apply payment policies uniformly
to both ASCs and HOPDs, and with the comments of MedPAC in support of
comparable payment bundles in the two systems.
As we have stated earlier in this final rule, we are firmly
committed to ensuring that outpatient procedures are not limited to
certain sites of service and that all surgical procedures that can
safely be performed in ASCs and that are not expected to require an
overnight stay are on the ASC list of covered surgical procedures so
that Medicare beneficiaries have full access to surgical services in
all appropriate settings. We believe that paying separately for those
devices that are included in device categories with pass-through status
under the OPPS and that are implanted during ASC covered surgical
procedures under the revised ASC payment system will promote efficient
resource use and ensure appropriate access to care.
After considering all public comments received, we are finalizing a
policy to provide separate payment under the revised ASC payment system
for ancillary devices included in device categories with pass-through
status under the OPPS in the same quarter of the same calendar year
that the devices are implanted during a covered surgical procedure that
is billed by the ASC. In contrast with our proposal which would have
provided packaged payment for these devices, but consistent with their
separate payment under the OPPS, this specific subset of implantable
devices will receive separate payment under the revised ASC payment
system as covered ancillary services. ASC payment will be made for the
devices at contractor-priced rates and will not be subject to
geographic wage adjustment, and payment for the associated surgical
procedures will be made according to our standard methodology for the
revised ASC payment system, based on only the service (nondevice)
portion of the procedure's OPPS relative payment weight. Accordingly,
we are revising proposed Sec. 416.164(a) and (b) to reflect this final
policy.
[[Page 42503]]
e. Implantable Devices Without Pass-Through Status Under the OPPS
Historically, separate payment for implantable DME and prosthetics
provided in association with procedures on the ASC list of covered
surgical procedures has been made to ASCs on the basis of the DMEPOS
fee schedule. Payment for other devices that are not implantable DME or
prosthetics, including some nonpass-through devices under the OPPS, has
historically been made as part of the ASC payment for the covered
surgical procedure because such items have been considered to be
supplies.
In the August 2006 proposed rule for the revised ASC payment
system, we proposed to pay for nonpass-through devices as part of the
ASC payment that would be based on the OPPS relative payment weight of
the associated surgical procedure, thereby packaging payment for all
nonpass-through devices, consistent with their treatment under the
OPPS. We also proposed to apply an ASC budget neutrality adjustment of
62 percent to the OPPS conversion factor to calculate the ASC payment
rates for all covered surgical services, regardless of the specific
nature of the surgical procedures. Therefore, payment for surgical
procedures with high device costs, referred to as device-intensive
procedures, would be calculated like payment for all other surgical
procedures not excluded from ASC payment under the revised payment
system. We received many comments on our proposed payment policy for
devices without pass-through status under the OPPS. A summary of the
comments and our responses follow.
Comment: Many commenters objected to the packaging of payment for
all devices as proposed, principally on the basis that, where the
device cost exceeds 62 percent of the APC payment rate, the ASC would
not be paid enough to cover the cost of the device, let alone the other
service costs of the implantation procedure. Some commenters suggested
that CMS continue to pay separately for devices for which it currently
pays separately under the DMEPOS fee schedule and provide payment
through the ASC payment for only the nondevice portion of the
implantation procedure. They recommended that CMS apply the ASC
conversion factor only to the nondevice portion of the APC payment
weight to calculate the ASC service payment for the implantation
procedure. Other commenters believed that CMS should not apply the ASC
conversion factor to the device portion of the APC payment, but instead
should pass the OPPS payment amount for the device through to the ASC
payment system directly because ASCs would be unable to obtain the
devices at lower cost than HOPDs. They argued that ASCs would see no
efficiencies regarding the fixed device costs, so it would be
inappropriate to apply the ASC conversion factor to develop this
portion of the ASC procedure payment. These commenters suggested that
CMS could then apply the ASC conversion factor to the nondevice portion
of the APC payment to develop a service payment, and sum the two
partial payments (for the device and the service) to calculate the full
ASC payment for these device-intensive procedures under the revised ASC
payment system. They concluded that, in this manner, the OPPS and the
revised ASC payment system would be aligned, because both systems would
provide packaged payment for devices without OPPS pass-through status.
Several commenters requested that CMS not provide ASC payments for
many procedures that use devices and that are currently paid under the
OPPS, generally for patient safety reasons.
Response: For purposes of the revised ASC payment system, we are
defining device-intensive procedures as all those ASC covered surgical
procedures in CY 2008 that are assigned to device-dependent APCs under
the OPPS, where the APC device cost is greater than 50 percent of the
median APC cost. There are 40 such procedures that fall into this group
based on their CY 2007 APC assignments, 25 of which are on the CY 2007
ASC list and 15 of which will be newly recognized for ASC payment
beginning in CY 2008. They are listed in Tables 5 and 6, respectively,
below. These procedures are also identified in Addendum AA to this
final rule.
Specific payment policies have been applied to device-dependent
APCs under the OPPS over the past several years (71 FR 68063 through
68070). There are about 194 OPPS device-dependent procedures,
specifically those procedures that are assigned to the 42 OPPS device-
dependent APCs under the CY 2007 OPPS, and 89 of these device-dependent
procedures are also paid in ASCs in CY 2007. However, only 25 of those
89 procedures are assigned to APCs that have device costs that exceed
50 percent of the APC median costs and would be subject to the payment
policy applied to device-intensive procedures under the revised ASC
payment system. Thus, as noted above, based on current data, there are
40 device-intensive surgical procedures for which ASC payment will be
made in CY 2008. ASC payments for these 40 device-intensive procedures
will be made according to the policy described for device-intensive ASC
procedures based on their assignments to 19 of the 42 device-dependent
APCs under the OPPS for CY 2007.
We do not agree with the commenters who believe that many device-
intensive procedures are unsafe for performance in ASCs because most of
these device-intensive procedures have been on the ASC list of covered
surgical procedures for several years and no safety concerns have
arisen. In the context of developing this final rule, we have once
again reviewed the clinical characteristics of all of these device-
intensive procedures based on the public comments and our final
policies regarding surgical procedures for exclusion from ASC payment,
as discussed in section III.A.2. of this final rule. We continue to
believe that many device-intensive procedures are appropriate for
performance in ASCs under the final policies of the revised ASC payment
system.
We also are persuaded that it would be inappropriate to continue to
provide separate payment for some implantable prosthetics and DME under
the DMEPOS fee schedule by maintaining the practice of the existing ASC
payment system. Payment for these devices is already packaged into the
base OPPS payment weights, and separate payment for devices under the
ASC payment system could essentially pay twice for the device. Separate
payment for devices under the revised ASC payment system would also be
contrary to MedPAC's support for our proposal to increase the size of
the ASC payment bundles and to create comparable payable bundles under
the OPPS and the revised ASC payment system. Most importantly, separate
payment for certain devices would not provide the incentives for
efficiency that would occur through packaging device payment into
payment for the associated surgical implantation procedure, because
increased packaging through larger payment bundles would encourage ASCs
to provide surgical services as cost-effectively as possible. In
addition, there are some expensive implantable devices, such as ICDs,
which are not currently paid under the DMEPOS fee schedule, but for
which we will provide payment for their associated surgical
implantation procedures in ASCs beginning in CY 2008. If the separate
DMEPOS payment methodology were to be continued, ASCs would be
significantly underpaid for such procedures because the device would
not be separately paid if it were neither implantable DME nor an
implantable prosthetic device. The
[[Page 42504]]
commenters who recommended continued separate payment for some devices
under the DMEPOS fee schedule provided no suggestions for developing
the appropriate ASC payment for expensive implantable devices that are
neither implantable DME nor implantable prosthetics.
We agree with the commenters who are concerned that our standard
methodology for the revised ASC payment system that applies a uniform
ASC conversion factor to the OPPS relative payment weights could
provide inadequate payment for device-intensive procedures under the
revised ASC payment system. The estimated budget neutrality adjustment
for the revised ASC payment system was 62 percent of the OPPS
conversion factor in the proposed rule, and it is currently 67 percent
as discussed in section V. of this final rule (the final CY 2008 ASC
budget neutrality adjustment will be proposed and finalized through the
CY 2008 OPPS/ASC rulemaking cycle). Because of the expected magnitude
of the difference between the estimated ASC procedure payments,
calculated by application of the ASC conversion factor to the OPPS
payment weights under the revised ASC payment system, and the OPPS
payment rates for those same procedures, we are particularly concerned
that under the revised ASC payment system device-intensive procedures
would be underpaid if we paid for them as proposed.
We would not expect that ASCs' device costs for expensive devices
would differ significantly from the device costs of HOPDs because we do
not believe that ASCs would realize more substantial efficiencies in
their acquisition of devices in comparison with HOPDs. On the other
hand, we believe that ASCs would experience significant efficiencies in
comparison with HOPDs when performing the implantation procedures
themselves, consistent with the findings of the GAO Report regarding
the lower cost of procedures in ASCs in comparison with HOPDs. These
lower ASC costs may be attributable to a variety of factors, including
lower facility overhead costs due to ASCs' limited operating hours,
lack of emergency departments, specialization of ASCs contributing to
efficient delivery of services, and the characteristics of different
patient populations treated in ASCs versus HOPDs. Therefore, we believe
it would be most appropriate under the revised ASC payment system to
apply a modified payment methodology to this group of device-intensive
services. Accordingly, in developing the ASC payment rates under the
revised payment system for device-intensive procedures, we will
calculate the device portion of the ASC procedure payment separately
from the service portion, in order to provide special consideration for
the packaged device costs that are unlikely to vary significantly
across different facility settings.
Our final payment methodology for device-intensive procedures under
the revised ASC payment system is as follows. We will apply the OPPS
device offset percentage to the OPPS national unadjusted payment to
acquire the device cost included in the OPPS payment rate for a device-
intensive ASC covered surgical procedure, which we will then set as
equal to the device portion of the national unadjusted ASC payment rate
for the procedure. The device offset percentage, which is used under
the OPPS to remove the predecessor device cost from the device pass-
through payment when a pass-through device is paid at charges reduced
to cost, so that the pass-through payment for the device only
represents the incremental payment for the new device over the payment
for predecessor devices already packaged into the APC payment is our
best estimate of the amount of device cost included in an APC payment
under the OPPS. We believe that use of the OPPS device offset
percentage is appropriate to establish the device amount of payment
when device-intensive procedures are furnished in an ASC under the
revised ASC payment system. The OPPS device offset percentage is
calculated for each OPPS device-dependent APC based upon the most
recent year of hospital outpatient claims data available and represents
the relative amount of device payment that we believe exists in the
total APC payment. The device offset percentage is also applied to
reduce the APC payment when a typically expensive device is provided to
the hospital without cost or with full credit for the device being
replaced and, therefore, the hospital incurs no device cost for
implanting the replacement device. For more background on the
calculation and use of the device offset percentage, we refer readers
to the CY 2007 OPPS/ASC final rule with comment period (71 FR 68077
through 68079).
We will then calculate the service portion of the ASC payment for
device-intensive procedures by applying the uniform ASC conversion
factor as specified in new Sec. 416.171 to the service (nondevice)
portion of the OPPS relative payment weight for the device-intensive
procedure. Finally, we will sum the ASC device portion and ASC service
portion to establish the full payment for the device-intensive
procedure under the revised ASC payment system.
Tables 5 and 6 include the most current device-intensive procedures
that would be subject to this modified payment methodology under the
revised ASC payment system. The device-intensive procedure lists for
the CY 2008 revised ASC payment system will be proposed and finalized
in conjunction with the OPPS treatment of these procedures in the CY
2008 OPPS/ASC proposed and final rules, respectively. The device-
intensive procedures in Tables 5 and 6 are listed in Addendum AA to
this final rule, where they are assigned to payment indicators ``H8''
(Device-intensive procedure on ASC list in CY 2007; paid at adjusted
rate) and ``J8'' (Device-intensive procedure added to ASC list in CY
2008 or later; paid at adjusted rate), respectively.
Table 5.--Illustrative List of Device-Intensive Procedures on the CY 2007 ASC List Subject to the Modified
Payment Methodology Under the Revised ASC Payment System Beginning in CY 2008
----------------------------------------------------------------------------------------------------------------
CY 2007 device-
HCPCS code Short descriptor CY 2007 OPPS dependent APC
APC offset percent
----------------------------------------------------------------------------------------------------------------
33212.................................... Insertion of pulse generator..... 0090 74.74
33213.................................... Insertion of pulse generator..... 0654 77.35
36566.................................... Insert tunneled cv cath.......... 0625 57.56
53445.................................... Insert uro/ves nck sphincter..... 0386 61.16
53447.................................... Remove/replace ur sphincter...... 0386 61.16
54401.................................... Insert self-contd prosthesis..... 0386 61.16
54405.................................... Insert multi-comp penis pros..... 0386 61.16
54410.................................... Remove/replace penis prosth...... 0386 61.16
[[Page 42505]]
54416.................................... Remv/repl penis contain pros..... 0386 61.16
55873.................................... Cryoablate prostate.............. 0674 53.78
61885.................................... Insrt/redo neurostim 1 array..... 0039 78.85
61886.................................... Implant neurostim arrays......... 0315 83.19
62361.................................... Implant spine infusion pump...... 0227 80.27
62362.................................... Implant spine infusion pump...... 0227 80.27
63650.................................... Implant neuroelectrodes.......... 0040 54.06
63685.................................... Insrt/redo spine n generator..... 0222 77.65
64553.................................... Implant neuroelectrodes.......... 0225 79.04
64561.................................... Implant neuroelectrodes.......... 0040 54.06
64573.................................... Implant neuroelectrodes.......... 0225 79.04
64575.................................... Implant neuroelectrodes.......... 0061 60.06
64577.................................... Implant neuroelectrodes.......... 0061 60.06
64580.................................... Implant neuroelectrodes.......... 0061 60.06
64581.................................... Implant neuroelectrodes.......... 0061 60.06
64590.................................... Insrt/redo pn/gastr stimul....... 0222 77.65
69930.................................... Implant cochlear device.......... 0259 84.61
----------------------------------------------------------------------------------------------------------------
Table 6.--Illustrative List of Device-Intensive Procedures New to the CY 2008 ASC List Subject to the Modified
Payment Methodology Under the Revised ASC Payment System Beginning in CY 2008
----------------------------------------------------------------------------------------------------------------
CY 2007 device-
HCPCS code Short descriptor CY 2007 OPPS dependent APC
APC offset percent
----------------------------------------------------------------------------------------------------------------
33206.................................... Insertion of heart pacemaker..... 0089 77.11
33207.................................... Insertion of heart pacemaker..... 0089 77.11
33208.................................... Insertion of heart pacemaker..... 0655 76.59
33214.................................... Upgrade of pacemaker system...... 0655 76.59
33224.................................... Insert pacing lead & connect..... 0418 87.32
33225.................................... Lventric pacing lead add-on...... 0418 87.32
33282.................................... Implant pat-active ht record..... 0680 76.40
63655.................................... Implant neuroelectrodes.......... 0061 60.06
64555.................................... Implant neuroelectrodes.......... 0040 54.06
64560.................................... Implant neuroelectrodes.......... 0040 54.06
64565.................................... Implant neuroelectrodes.......... 0040 54.06
G0297.................................... Insert single chamber/cd......... 0107 90.44
G0298.................................... Insert dual chamber/cd........... 0107 90.44
G0299.................................... Inser/repos single icd+leads..... 0108 89.40
G0300.................................... Insert reposit lead dual+gen..... 0108 89.40
----------------------------------------------------------------------------------------------------------------
Table 7 provides an example of how we will calculate the ASC
payment for a device-intensive procedure. We use the example of
insertion of a cochlear implant, CPT code 69930 (Cochlear device
implantation, with or without mastoidectomy), that is included in Table
5 above. For purposes of this illustration, we are using the CY 2007
OPPS/ASC final rule with comment period device offset percentage and
payment rate for APC 0259 (Level VI ENT Procedures), the APC to which
CPT code 69930 is assigned under the CY 2007 OPPS. We also assume that
the ASC budget neutrality adjustment remains at 0.67 under both the
first transition year and full implementation scenarios, yielding an
ASC conversion factor of $42.543 based on our current estimate of the
CY 2008 OPPS conversion factor. The example includes the estimated ASC
payment in the first year of the 4-year transition and the estimated
payment under full implementation of the revised ASC payment system.
Table 7.--Example of Calculation of ASC Payment for a Device-Intensive Covered Surgical Procedure According to
the Modified Payment Methodology of the Revised ASC Payment System
----------------------------------------------------------------------------------------------------------------
Full implementation of revised
First year of 4-year transition system
----------------------------------------------------------------------------------------------------------------
OPPS CY 2007 national unadjusted payment $25,499.72 $25,499.72
rate...................................
OPPS CY 2007 device offset percent...... 84.61% 84.61%
OPPS/ASC device portion................. $21,575.31 $21,575.31
($25,499.72 x 0.8461) ($25,499.72 x 0.8461)
OPPS service portion.................... $3,924.41 $3,924.41
[[Page 42506]]
OPPS relative payment weight 61.8047 61.8047
attributable to service (OPPS service ($3,924.41/63.497) ($3,924.41/63.497)
portion divided by estimated CY 2008
OPPS conversion factor)................
ASC service portion (OPPS relative $2,629.36 $2,629.36
payment weight for service portion (61.8047 x $42.543) (61.8047 x $42.543)
multiplied by estimated CY 2008 ASC
conversion factor).....................
CY 2007 ASC payment (without device $995 N/A
payment)...............................
ASC service payment (see following $1,403.59 $2,629.36
paragraph)............................. (0.25 x $2,629.36) + (0.75 x $995)
Estimated CY 2008 ASC total payment (sum $22,978.90 $24,204.67
of service payment and device payment). ($1,403.59 + $21,575.31) ($2,629.36 + $21,575.31)
----------------------------------------------------------------------------------------------------------------
As discussed further in section IV.J. of this final rule and as
shown in the example above, we will apply the transitional blend only
to the service portion of the ASC procedure payment. Consistent with
their treatment under the OPPS, we will apply the ASC geographic wage
adjustment to payment for device-intensive procedures under the revised
ASC payment system.
Comment: Several commenters encouraged CMS to pay the same amount
and apply the same payment policies regarding implantable devices in
both ASCs and HOPDs. In particular, they recommended that ASCs be paid
100 percent of the portion of the OPPS procedure payment that is
device-related, when ASCs perform device-intensive procedures.
Response: We agree with commenters that providing the same device
payment amount for expensive devices under the revised ASC payment
system as under the OPPS is appropriate, and our final payment
methodology accomplishes that. As we discuss above, we will
specifically calculate the amount of OPPS device payment in APCs that
contain devices for which the device cost exceeds 50 percent of the APC
median cost. We will then add the OPPS device payment amount to the ASC
service payment for each device-intensive procedure that is a covered
ASC surgical procedure, in order to determine the total payment for the
device-intensive procedure when it is performed in an ASC.
We also agree that the same payment policies that exist with regard
to payment for costly devices under the OPPS should also apply to
payment for devices implanted in ASCs. In particular, under the OPPS,
beginning on January 1, 2007, when a device is replaced without cost to
the hospital or with full credit for the cost of the device being
replaced, CMS reduces the APC payment to the hospital by the amount
that we estimate represents the cost of the device. The application of
this same policy to ASC payment for certain device-intensive procedures
is fully consistent with the comments that CMS should pay ASCs for
expensive devices in the same manner that they are paid under the OPPS,
and with the recommendation of the PPAC that CMS should apply payment
policies uniformly under the OPPS and revised ASC payment systems.
Therefore, in accordance with the OPPS policy implemented in CY 2007,
beginning in CY 2008, we will reduce the amount of payment made to ASCs
for device-intensive procedures assigned to certain OPPS APCs in those
cases in which the necessary device is furnished without cost to the
ASC or the beneficiary, or with a full credit for the cost of the
device being replaced. We will provide the same amount of payment
reduction that would apply under the OPPS for performance of those
procedures under the same circumstances. Specifically, when an ASC
performs a procedure that is listed in Table 8 below and the case
involves implantation of a no cost or full credit device listed in
Table 9, the ASC must report the HCPCS ``FB'' modifier on the line with
the covered surgical procedure code to indicate that a major
implantable device in Table 9 was furnished without cost. We expect
that this scenario will occur most often in cases in which there is a
recall, field action, or other activity that results in the ASC
receiving a device from a device manufacturer, for which the facility
has no obligation to pay. In these cases, this policy is necessary to
be consistent with section 1862(a)(2) of the Act, which excludes from
Medicare coverage items and services for which neither the beneficiary
nor anyone on the beneficiary's behalf has an obligation to pay. This
reduction policy is consistent with the modified payment methodology
for device-intensive procedures under the revised ASC payment system
that would generally provide the same device-related payment amount in
HOPD and ASC settings, both in those cases where the facility bears the
cost of the device and those situations where it does not. Tables 8 and
9 list those specific procedures and implantable devices to which the
reduction policy applies under the CY 2007 OPPS. The list of device-
dependent APCs and their associated procedures and implantable devices
to which this policy will apply in CY 2008 will be proposed and
finalized in the CY 2008 OPPS/ASC proposed and final rules,
respectively. See the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68071 through 68077) for further discussion of this policy.
When the ``FB'' modifier is reported with a procedure code that is
listed in Table 8, the contractor will reduce the ASC payment for the
procedure by the amount of payment that CMS attributed to the device
when the ASC payment rate was calculated. The reduction of ASC payment
in this circumstance is necessary to pay appropriately for the covered
surgical procedure being furnished by the ASC.
[[Page 42507]]
Table 8.--Illustrative List of Adjustments to Payments for ASC Covered Surgical Procedures in CY 2008 in Cases
of Devices Reported Without Cost or for Which Full Credit Is Received
----------------------------------------------------------------------------------------------------------------
CY 2007 OPPS CY 2007 OPPS
HCPCS code Short descriptor APC APC group title offset percent
----------------------------------------------------------------------------------------------------------------
61885..................... Insrt/redo neurostim 1 0039 Level I Implantation of 78.85
array. Neurostimulator.
63650..................... Implant neuroelectrodes.. 0040 Percutaneous Implantation 54.06
64555..................... Implant neuroelectrodes.. of Neurostimulator
64560..................... Implant neuroelectrodes.. Electrodes, Excluding
64561..................... Implant neuroelectrodes.. Cranial Nerve.
64565..................... Implant neuroelectrodes..
63655..................... Implant neuroelectrodes.. 0061 Laminectomy or Incision 60.06
64575..................... Implant neuroelectrodes.. for Implantation of
64577..................... Implant neuroelectrodes.. Neurostimulator
64580..................... Implant neuroelectrodes.. Electrodes, Excluding
64581..................... Implant neuroelectrodes.. Cranial Nerve.
33206..................... Insertion of heart 089 Insertion/Replacement of 77.11
33207..................... pacemaker. Permanent Pacemaker and
Insertion of heart Electrodes.
pacemaker..
33212..................... Insertion of pulse 0090 Insertion/Replacement of 74.74
generator. Pacemaker Pulse
Generator.
33210..................... Insertion of heart 0106 Insertion/Replacement/ 41.88
33211..................... electrode. Repair of Pacemaker and/
33216..................... Insertion of heart or Electrodes.
33217..................... electrode..
Insert lead pace-defib,
one..
Insert lead pace-defib,
dual..
G0297..................... Insert single chamber/cd. 0107 Insertion of Cardioverter- 90.44
G0298..................... Insert dual chamber/cd... Defibrillator.
G0299..................... Inser/repos single 0108 Insertion/Replacement/ 89.40
G0300..................... icd+leads. Repair of Cardioverter-
Insert reposit lead Defibrillator Leads.
dual+gen..
63685..................... Insrt/redo spine n 0222 Implantation of 77.65
64590..................... generator. Neurological Device.
Insrt/redo perph n
generator..
64553..................... Implant neuroelectrodes.. 0225 Implantation of 79.04
64573..................... Implant neuroelectrodes.. Neurostimulator
Electrodes, Cranial
Nerve.
62361..................... Implant spine infusion 0227 Implantation of Drug 80.27
62362..................... pump. Infusion Device.
Implant spine infusion
pump..
69930..................... Implant cochlear device.. 0259 Level VI ENT Procedures.. 84.61
61886..................... Implant neurostim arrays. 0315 Level II Implantation of 83.19
Neurostimulator.
53440..................... Male sling procedure..... 0385 Level I Prosthetic 46.86
53444..................... Insert tandem cuff....... Urological Procedures.
54400..................... Insert semi-rigid
prosthesis..
53445..................... Insert uro/ves nck 0386 Level II Prosthetic 61.16
53447..................... sphincter. Urological Procedures.
54401..................... Remove/replace ur
54405..................... sphincter..
54410..................... Insert self-contd
54416..................... prosthesis..
Insert multi-comp penis
pros..
Remove/replace penis
prosth..
Remv/repl penis contain
pros..
33224..................... Insert pacing lead & 0418 Insertion of Left 87.32
33225..................... connect. Ventricular Pacing Elect.
L ventric pacing lead add-
on..
33213..................... Insertion of pulse 0654 Insertion/Replacement of 77.35
generator. a permanent dual chamber
pacemaker.
33214..................... Upgrade of pacemaker 0655 Insertion/Replacement/ 76.59
33208..................... system. Conversion of a
Insertion of heart permanent dual chamber
pacemaker.. pacemaker.
33282..................... Implant pat-active ht 0680 Insertion of Patient 76.40
record. Activated Event
Recorders.
----------------------------------------------------------------------------------------------------------------
Table 9.--Illustrative List of Devices for Which the ``FB'' Modifier
Must Be Reported With the Procedure Code When Furnished Without Cost or
for Which Full Credit Is Received
------------------------------------------------------------------------
Device Short descriptor
------------------------------------------------------------------------
C1721.................................. AICD, dual chamber.
C1722.................................. AICD, single chamber.
C1764.................................. Event recorder, cardiac.
C1767.................................. Generator, neurostim, imp.
C1771.................................. Rep dev, urinary, w/sling.
C1772.................................. Infusion pump, programmable.
C1776.................................. Joint device (implantable.
C1777.................................. Lead, AICD, endo single coil.
C1778.................................. Lead, neurostimulator.
C1779.................................. Lead, pmkr, transvenous VDD.
C1785.................................. Pmkr, dual, rate-resp.
C1786.................................. Pmkr, single, rate-resp.
C1813.................................. Prosthesis, penile, inflatab.
C1815.................................. Pros, urinary sph, imp.
C1820.................................. Generator, neuro rechg bat sys.
C1882.................................. AICD, other than sing/dual.
C1891.................................. Infusion pump, non-prog, perm.
C1895.................................. Lead, AICD, endo dual coil.
C1896.................................. Lead, AICD, non sing/dual.
C1897.................................. Lead, neurostim, test kit.
C1898.................................. Lead, pmkr, other than trans.
C1899.................................. Lead, pmkr/AICD combination.
[[Page 42508]]
C1900.................................. Lead coronary venous.
C2619.................................. Pmkr, dual, non rate-resp.
C2620.................................. Pmkr, single, non rate-resp.
C2621.................................. Pmkr, other than sing/dual.
C2622.................................. Prosthesis, penile, non-inf.
C2626.................................. Infusion pump, non-prog, temp.
C2631.................................. Rep dev, urinary, w/o sling.
L8614.................................. Cochlear device/system.
------------------------------------------------------------------------
After considering all public comments received, while we are
finalizing our proposed policy to package payment under the revised ASC
payment system for all implantable devices without pass-through status
under the OPPS into the ASC payment for the associated surgical
implantation procedure, we are adopting a modified methodology to
calculate the payment rates for device-intensive procedures under the
revised ASC payment system. We proposed to pay for these devices and
their associated implantation procedures according to the standard
revised ASC payment system methodology, with application of the uniform
ASC conversion factor to the applicable OPPS payment weight for the
procedure. However, our final payment policy will apply a modified
payment methodology to develop the ASC payment rates for device-
intensive covered surgical procedures, in order to provide the same
payment amount to ASCs for the implantable devices as is made under the
OPPS. This methodology will apply to ASC covered surgical procedures
that are assigned to device-dependent APCs under the OPPS for the same
calendar year, where those APCs have a device cost of greater than 50
percent of the APC cost (device offset percentage greater than 50).
While lists of device-intensive procedures under the revised ASC
payment system to which this policy would apply based on their CY 2007
OPPS status are included in Tables 5 and 6 of this final rule, the list
of ASC procedures subject to this modified payment methodology will be
proposed and finalized in the CY 2008 OPPS/ASC proposed and final
rules, respectively.
We will also reduce the ASC procedure payment for certain device-
intensive procedures when the necessary device is furnished to the ASC
or the beneficiary at no cost or when a full credit for the device
being replaced is provided to the ASC, by the same amount as the OPPS
payment reduction for the same calendar year because neither the HOPD
nor the ASC incur a device cost for the replaced device in such
situations. Accordingly, we are adding new Sec. 416.179 to reflect
this payment reduction policy.
D. Payment for Corneal Tissue Under the Revised ASC Payment System
In a memorandum dated May 21, 1992, CMS (known at the time as the
Health Care Financing Administration or ``HCFA'') notified Regional
Administrators that carriers could pay corneal tissue acquisition costs
when HCPCS code V2785 (Processing, preserving and transporting corneal
tissue) is reported with corneal transplant procedures performed in an
ASC. The memorandum indicated that payment for corneal tissue
acquisition costs is subject to the usual coinsurance and deductible
requirements, and could be paid as an add-on to either the ASC payment
or the physician's fee for corneal transplant surgery performed at an
ASC. In the June 12, 1998 proposed rule to revise the ASC ratesetting
methodology and payment rates, we proposed to package the costs
incurred by an ASC to procure corneal tissue into the payment for the
associated corneal transplant procedure, rather than continue making
separate payment for those costs (63 FR 32312 and 32313). We also
proposed to package corneal tissue acquisition costs into the APC
payment for corneal transplant procedures in the September 8, 1998
proposed rule to implement the OPPS (63 FR 47760).
We received numerous comments from physicians, eye banks, and
health care associations opposing both proposals. In the April 7, 2000
final rule with comment period, which implemented the OPPS, we
summarized the comments that we received in response to the September
8, 1998 proposal, and we determined that we would not implement our
proposal to package payment under the OPPS for corneal tissue
acquisition costs but would, instead, make separate payment based on
hospitals' reasonable costs to procure corneal tissue (65 FR 18448 and
18449). Because we never made final the changes in the ASC payment
rates and ratesetting methodology that we proposed in the June 12, 1998
Federal Register, the policy issued in the June 1992 memorandum remains
in effect, which allows carriers (now MACs) to make separate payment
for the costs incurred to procure corneal tissue for transplant at an
ASC.
In the August 2006 proposed rule to revise the ASC ratesetting
methodology and payment rates beginning in CY 2008, we proposed to
continue to pay ASCs separately, based on their invoiced costs, for the
procurement of corneal tissue (71 FR 49648). We had no evidence to
suggest that costs incurred to procure corneal tissue are any less
variable now than they were in 1992, in 1998, or in 2000. We noted
that, if we were to package payment for the procurement of corneal
tissue into the APC payment for corneal transplant procedures, we
believed the resulting payment rate would overpay those facilities that
are able to acquire corneal tissue at little or no cost through
philanthropic organizations and underpay those facilities that must pay
for corneal tissue processing, testing, preservation, and
transportation costs. We further proposed in the August 2006 proposed
rule to exclude, through proposed new Sec. 416.164(b), the costs of
procurement of corneal tissue furnished in an ASC on or after January
1, 2008 from the scope of ASC facility services.
We invited comments and submission of data that supported or
challenged this proposal to continue paying ASCs separately for corneal
tissue on an acquisition cost basis.
Comment: Several commenters agreed with our proposal to continue to
pay separately for the acquisition costs of corneal tissue under the
revised ASC payment system, rather than package payment for corneal
tissue costs into the payment for the associated corneal transplant
procedure. The commenters indicated that this proposed methodology is
consistent with the way physicians and HOPDs are currently paid for
corneal tissue procurement. They believed that this policy of paying
separately for the procurement of corneal tissue has been, and
continues to be, the most appropriate payment policy for these services
provided in ASC settings, because of the continuing significant
variability in the costs of corneal tissue procurement. The commenters
further reiterated that packaging these costs should not be considered,
because such an option would result in overpayments to certain
facilities that have been able to acquire corneal tissue at little or
no cost through philanthropic organizations and would undoubtedly
result in underpayments to other facilities that paid for the corneal
tissue processing, testing, preservation, and transportation costs.
Response: After consideration of the public comments we received,
we are finalizing our proposed CY 2008 ASC corneal tissue procurement
payment policy, with modification to clarify that
[[Page 42509]]
corneal tissue is a covered ancillary service within the scope of ASC
services, but not within the scope of ASC facility services. Corneal
tissue procurement will be included in the scope of ASC services as a
covered ancillary service when it is integral to the performance of an
ASC covered surgical procedure, but its payment will not be packaged
into the ASC payment for the associated covered surgical procedure.
Specifically, under the revised ASC payment system, we will continue to
pay ASCs separately, based on their invoiced costs, for the acquisition
costs of corneal tissue for transplant in an ASC. The HCPCS code for
corneal tissue processing, V2785, is listed in Addendum BB to this
final rule, where it is assigned to payment indicator ``F4'' (Corneal
tissue processing; paid at reasonable cost). Accordingly, we are
reflecting this final policy in revised proposed Sec. Sec.
416.164(b)(3) and 416.171(b).
E. Payment for Office-Based Procedures
Since the inception of the ASC benefit, procedures that are
commonly performed or that can be safely performed in a physician's
office have generally been excluded from the ASC list of covered
surgical procedures. We refer to these procedures as ``office-based''
in this preamble discussion. Over the past 15 years, physicians and ASC
associations have urged CMS to add office-based procedures to the ASC
list of covered surgical procedures or to retain on the ASC list
procedures that were originally performed most commonly in an
institutional setting, but that have subsequently moved to an office
setting as surgical techniques and technology have advanced.
Representatives of the ASC industry have argued that although, for most
patients, the office is an appropriate setting for most high volume
office procedures, there are some patients for whom an ASC or another
more resource-intensive setting is required. The physician may decide
that a facility setting is necessary for individual patients for
various clinical reasons, such as the need for more nursing staff, a
sterile operating room, or a piece of equipment not typically available
in the office setting. CPT code 52000 (Cystourethroscopy (separate
procedure)) is a prime example of a high volume procedure that is
performed more than 80 percent of the time in an office setting, but
for which a small number of patients require resources usually
available only in an ASC or a hospital. Representatives of the ASC
industry have contended that unless we made an exception to the
criteria that historically governed which procedures comprised the ASC
list and allowed an office-based procedure to remain on the ASC list,
as we have done with CPT code 52000, the hospital would be the only
facility setting available as an alternative to the office setting. ASC
industry commenters asserted in the past that this limitation was
burdensome both to physicians and to beneficiaries and could, in some
cases, limit beneficiary access to needed surgery.
We generally interpret ``office-based'' or ``commonly performed in
a physician's office'' to mean a surgical procedure that the most
recent BESS data available indicate is performed more than 50 percent
of the time in the physician's office setting. In the August 2006
proposed rule for the revised ASC payment system and as discussed in
section III.A.2. of this final rule, we proposed to expand the ASC list
of covered surgical procedures to allow payment for all surgical
procedures, except those procedures that pose a significant safety risk
or would be expected to require an overnight stay. Because office-based
surgical procedures typically do not pose a significant safety risk and
do not require an overnight stay, we proposed not to exclude them from
ASC payment under the revised ASC payment system. However, we were
concerned that allowing payment to ASCs for office-based procedures
based on OPPS relative payment weights could have a significant impact
on Medicare program costs. Approximately two-thirds of the additional
procedures which we proposed not to exclude from ASC payment beginning
in CY 2008 are office-based, that is, they are performed in the
physician's office more than 50 percent of the time. The practice
expense payment for many of these procedures under the MPFS, when they
are performed in the physician's office, would be lower than the
payment for the same procedures under the OPPS or under the standard
methodology of the revised ASC payment system as proposed. Therefore,
we indicated that the proposed ASC payment rates based on the OPPS
relative payment weights could result in a significant program cost if
these high volume procedures were to shift from the office-based
setting to the ASC setting.
One reason why we were concerned about the possibility of a sizable
shift of office-based procedures to ASCs is the impact that such a
shift might have on ASC payments in light of the statutory requirements
that the revised ASC payment system be designed to result in the same
aggregate amount of expenditures that would be made if the revised
payment system were not implemented. In the August 2006 proposed rule,
we explained that, depending on the methodology for determining the
requisite budget neutrality adjustment (71 FR 49657), an influx of
high-volume, relatively low cost office-based surgical procedures into
the ASC setting under the revised payment system could lower the
payment amounts for other procedures made to ASCs due to the
constraints of budget neutrality. In other words, we might have had to
scale the ASC conversion factor downward in order for estimated
aggregate expenditures under the revised system to not exceed what they
would have been if the revised payment system were not implemented.
Payment for procedures with relatively high payments would have to be
reduced in order to offset increased aggregate costs resulting from an
influx of relatively low cost, high volume office-based procedures
shifting to ASCs. (See section V. of this final rule for a detailed
discussion of our proposed and final policies regarding calculation of
an ASC conversion factor.)
In the August 2006 proposed rule, we explained that we are
committed to refining Medicare payment systems wherever possible to
prevent payment incentives from inappropriately driving decisions about
where to perform a surgical procedure, when those decisions should
properly be based on clinical considerations. Towards that end, we
proposed to cap payment for office-based surgical procedures for which
ASC payment would be newly allowed under the revised payment system as
of January 1, 2008, at the lesser of the MPFS nonfacility practice
expense amount or the ASC rate developed according to the standard
methodology of the revised ASC payment system. We also proposed to
exempt procedures that are on the ASC list as of January 1, 2007, and
that meet our criterion for designation as office-based, from the
payment limitation proposed for office-based procedures for which ASC
payment would be allowed for the first time beginning January 1, 2008.
Accordingly, we proposed to incorporate in proposed new Sec.
416.171(e) the payment basis for these office-based procedures
beginning January 1, 2008.
When we started to identify the codes that we would propose to
classify as office-based surgical procedures beginning in CY 2008, we
encountered some anomalous cases that required further refinement of
our office-based criterion beyond strict application of a
[[Page 42510]]
50-percent utilization threshold. For example, we identified some CPT
codes that met the 50-percent office utilization threshold but for
which a nonfacility practice expense amount had not been developed
under the MPFS. We proposed to classify as office-based any surgical
codes that our physicians' claims data indicated are performed more
than 50 percent of the time in an office setting, even if the codes
currently lack a nonfacility practice expense value under the MPFS. We
further proposed to cap payment for these procedures, as appropriate,
once a nonfacility practice expense amount is established. Until that
time, we proposed to calculate payment for these office-based surgical
CPT codes using the methodology we proposed for other surgical
procedures under the revised ASC payment system. Similarly, until a
national nonfacility practice expense amount is established for office-
based surgical CPT codes that are contractor-priced (that is, carriers
typically determine the payment for a procedure for which there is no
calculated national payment) under the MPFS, we proposed to calculate
the ASC payment using the same methodology that we proposed for
surgical procedures that are not office-based. Application of the cap
to codes designated as office-based would be updated through rulemaking
as part of the annual OPPS/ASC payment update.
In applying the 50-percent threshold, we discovered some apparent
contradictions in the BESS data that required us to further refine our
definition of office-based procedures. For example, we noted instances
in which seemingly similar procedures had inconsistent site-of-service
utilization data. The BESS data showed high levels of office
utilization for some complex procedures that we expected to be
performed relatively infrequently in an office setting, whereas simpler
but related procedures showed lower levels of office utilization.
Therefore, we undertook another, more detailed level of review and
identified groups of surgical CPT codes related to procedures that are
performed 50 percent or more of the time in the office setting to
determine if there was a logical correlation between procedure
complexity within a group of related procedures and the frequency with
which those procedures were performed in the office setting. For
example, according to CPT coding, the following three codes are
related:
13120, Repair, complex, scalp arms and/or legs; 1.1 cm to
2.5 cm.
13121, Repair, complex, scalp arms and/or legs; 2.6 cm to
7.5 cm.
13122, Repair, complex, scalp arms and/or legs; each
additional 5 cm or less.
As is often the case for groups of related codes in the CPT coding
system, the first of these codes is the least complex clinically and,
in this example, the complexity of the procedure increases in
proportion to the increase in the size of the area to be repaired. If
utilization data indicated that CPT code 13122 was performed in the
office 67 percent of the time in CY 2005, we would expect to find that
both CPT codes 13120 and 13121 were also performed in the physician's
office more than 50 percent of the time during that year. Because the
most complex procedure was provided in the office most of the time,
logically, it would seem that the less complex procedures would also
have been performed frequently in that site of service. However, the
BESS data showed that this was not always the case.
Although our expectation was that the less complex procedures
within a group of related procedure codes would typically be performed
most often in the office and the more complex procedures less often in
the office, there were instances in which the less complex procedures
within the code group were billed more commonly in an ASC or HOPD,
while the more complex procedures within the code group were billed
more frequently in the office setting. Therefore, we believed it was
prudent to consider the clinical characteristics and utilization data
of related CPT codes in determining the codes to be proposed as office-
based, to supplement our consideration of data specific to the codes
under review.
In our analysis of the BESS site-of-service data, we also took into
consideration the volume of cases represented in the data. There were a
few instances in which we initially identified a procedure as office-
based because the data indicated that 100 percent of the cases were
performed in the physician's office. However, closer inspection
revealed that there was only one case reported for the procedure with a
physician's office as the site of service. We were concerned about
using such a low volume of procedure claims as the basis for
identifying a procedure as office-based. Therefore, we also believed it
was wise to consider the volume of claims for procedures in the context
of our assessment of their utilization data, to determine those codes
to propose as office-based for the revised ASC payment system.
Because of the occasional unevenness and inconsistency of the data
associated with some of the codes we initially classified as office-
based, we conducted a code-by-code analysis to buttress inconclusive
data with the clinical judgment of our medical advisors. As a result,
in our proposed rule, there were some procedures that met the 50-
percent office performance threshold when evaluated in isolation from
other closely related codes, but that we did not propose to designate
as office-based after more specific review.
In the August 2006 proposed rule for the revised ASC payment
system, we proposed to assess each year, based on the most recent
available BESS and other data available to us and detailed clinical
review, whether there are additional procedures that we would propose
to newly classify as office-based, beginning in the update year. We
would solicit comments on the proposed classification of additional
codes as office-based as part of the annual OPPS/ASC rulemaking cycle.
In addition, we proposed that once we identify a procedure as office-
based, that classification could not change in future updates of the
ASC payment system. We reasoned that once a procedure becomes safe
enough to be performed in more than 50 percent of cases in the office
setting, it would be improbable for it to revert to an institutional
setting.
To summarize, the list of codes that we proposed as office-based
took into account the most recent available volume and utilization data
for each individual procedure code and/or, if appropriate, the clinical
characteristics, utilization, and volume of related codes. We proposed
to apply the office-based designation only to procedures that would no
longer be excluded from ASC payment beginning in CY 2008 or later
years. Moreover, we proposed to exempt all procedures on the CY 2007
ASC list from application of the office-based classification. We
believed that the resulting list accurately reflected Medicare practice
patterns and was clinically coherent. The procedures that we proposed
to designate as subject to the office-based payment limit were
identified in Addendum BB to the proposed rule (71 FR 49845 through
49948). Those procedures for which the CY 2008 payment would be based
on the MPFS nonfacility practice expense RVUs according to our analysis
for the August 2006 proposed rule were flagged in Addendum BB to that
rule. The ASC relative payment weights shown for procedures in Addendum
BB to the proposed rule that would be capped by the MPFS nonfacility
practice expense RVUs were adjusted to reflect the capped payment
amounts. We reminded readers in the August 2006 proposed rule that the
ASC payment rates in
[[Page 42511]]
Addendum BB to that rule were based on the proposed CY 2007 OPPS
relative payment weights and the proposed CY 2007 MPFS nonfacility
practice expense RVUs. Similarly, the information in Addenda AA and BB
to this final rule is also only illustrative, meaning that the Addenda
provide examples of the results of applying the final policies of the
revised ASC payment system, based on the final information available
for CY 2007 and projected CY 2008 updates. As further discussed in
sections V.E. and VI. of this final rule, we will propose the CY 2008
relative payment weights, payment amounts, specific HCPCS codes to
which the final policies of the revised ASC payment system would apply,
and other pertinent ratesetting information for the CY 2008 revised ASC
payment system in the proposed OPPS/ASC rule to update the payment
systems for CY 2008 to be issued in mid-summer of CY 2007. We will then
publish final relative payment weights, payment amounts, specific CY
2008 HCPCS codes to which the final policies will apply, and other
pertinent ratesetting information for the CY 2008 revised ASC payment
system in the final OPPS/ASC rule to update the payment systems for CY
2008.
Comment: Several commenters suggested that instituting a cap on
payment for office-based surgical procedures would result in payment
levels that would make it economically infeasible for many ASCs to
perform certain surgical procedures, forcing patients who could be
treated safely and more cost effectively in an ASC to go to an HOPD for
surgery. Other commenters suggested that there is no empirical evidence
that payment of office-based procedures in ASCs would lead to
overutilization of ASCs or result in physicians converting their
offices into ASCs. The commenters pointed out that, in historical cases
where CMS has made exceptions to allow ASC payment for procedures
primarily performed in the office, there have not been significant
shifts in the sites of service for these procedures. Several commenters
suggested that imposing a cap on payment for these procedures would be
tantamount to a penalty and an affirmative policy intended to
discourage these procedures from performance in the ASC setting. The
commenters strongly recommended that the best policy would be to allow
physicians to select the site of service they believe is the most
clinically appropriate for their patients, especially because sicker
patients may require the additional infrastructure and safeguards of an
ASC or a HOPD. Other commenters pointed out that CMS' proposal for the
revised ASC payment system depends on the use of the relative payment
weights for the OPPS that CMS argued in the proposed rule would be
expected to reasonably reflect the relativity of ASC resources for
surgical procedures. They stated that CMS has no evidence to suggest
that the OPPS relativity of payment weights for office-based procedures
does not reflect the relative resource use for the performance of these
procedures in ASCs and, therefore, application of a payment limitation
for these procedures is unwarranted.
The commenters also expressed concern that the establishment of a
payment cap for office-based procedures would be problematic and
detrimental to CMS' desire to create a setting-neutral payment system.
The commenters recommended that CMS exclude this provision from the
final rule and pay all procedures using a single ASC conversion factor
applied to the applicable OPPS relative payment weight. Several
commenters suggested that CMS could follow trends in the sites of
service for office-based procedures, and should CMS find significant
and unwarranted migration of certain procedures to ASCs, implement the
proposed policy at a later date.
Response: We acknowledge the commenters' concerns regarding our
proposal to cap payments for office-based surgical procedures performed
in ASCs. Nevertheless, we continue to believe that capping the payment
for office-based surgical procedures performed in ASCs would be the
best approach to eliminating differential payment as a factor in site-
of-service decisions regarding minor surgical procedures. The combined
ASC and physician payment exceeds the single payment the physician
would receive for services performed in the office, even with the
application of the proposed payment limitation for office-based
procedures. Therefore, we are concerned that allowing payment for
office-based procedures under the ASC benefit may create an incentive
for physicians inappropriately to convert their offices into ASCs or to
move all their office surgery to an ASC. As discussed further in
section V. of this final rule, the final policy for the budget
neutrality adjustment for the revised ASC payment system which would
cap payment for office-based surgical procedures as we proposed takes
into account the expected migration of 15 percent of the current office
utilization of office-based procedures that will be newly paid in CY
2008 under the revised ASC payment system over the first 4 years of the
revised payment system. As commenters observed, a setting-neutral
payment system is most consistent with the principle that physicians
should be free to make site-of-service decisions on the basis of
clinical and quality of care considerations alone. We strongly agree
that the health of the patient should be the primary consideration. The
proposed cap significantly reduces the payment differential that would
otherwise exist when office-based surgical procedures are performed in
ASCs and is, thus, more consistent with the principle of site-neutral
payment.
After consideration of the public comments we received, we are
finalizing our proposal under Sec. 416.167(b)(3) and Sec. 416.171(d),
without modification, to cap payment for office-based surgical
procedures for which ASC payment would first be allowed under the
revised payment system beginning in January 1, 2008, or later years at
the lesser of the MPFS nonfacility practice expense amount or the ASC
rate developed according to the standard methodology of the revised ASC
payment system. For those office-based procedures for which there is no
available MPFS nonfacility practice expense amount, we will implement
the cap, as appropriate, once a MPFS nonfacility practice expense
amount is available. Until that time, those procedures that are office-
based but for which there is no available MPFS nonfacility practice
expense amount available for the comparison will be paid using the
standard methodology for calculating ASC payment under the revised ASC
payment system.
The procedures that we are finalizing as office-based for CY 2008
are identified in Addendum AA to this final rule, assigned to payment
indicators of ``P2'' (Office-based surgical procedure added to ASC list
in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on
OPPS relative payment weight); ``P3'' (Office-based surgical procedure
added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs;
payment based on MPFS nonfacility PE RVUs); and ``R2'' (Office-based
surgical procedure added to ASC list in CY 2008 or later without MPFS
nonfacility PE RVUs; payment based on OPPS relative payment weight).
These payment indicators identify the office-based procedures'
estimated payment status under the CY 2008 revised ASC payment system,
based on the final CY 2007 information for the OPPS and the MPFS as
discussed above, and their illustrative CY 2008 relative payment
weights and payment rates reflect
[[Page 42512]]
application of the capped payment amounts for those procedures with a
payment status indicator of ``P3.'' We note that the actual proposed
and final ASC relative payment weights and payment amounts for CY 2008
will be proposed and finalized through the CY 2008 OPPS/ASC proposed
and final rules, respectively. We will continue to monitor the
appropriateness of the payment cap for office-based surgical procedures
performed in ASCs and explore other opportunities to promote site-
neutral payments as we gain experience under the revised ASC payment
system.
Comment: Several commenters expressed concern about the ``50-
percent rule'' we proposed to use to designate which procedures would
be considered office-based. One commenter indicated that if a procedure
is performed in an office 50 percent of the time, that means half the
time the physician has determined that the office is not the
appropriate setting for specific patients. Commenters further indicated
that clinical circumstances dictate the site of service and not the
physician's personal preference, as suggested by the policy proposed
for the revised payment system. One commenter stated that surgeons
often perform a procedure in the office when anesthesia is not required
and perform the same procedure in an ASC when anesthesia is required
due to the complexity of individual patient factors.
The commenters offered several suggestions for modifying the
specific proposal for designating procedures as office-based. In
particular, one commenter requested that there be a reasonable, fair,
and efficient mechanism for removing a procedure from the office-based
list if the typical site of service for a procedure does change for a
legitimate clinical reason. Other commenters recommended that CMS
consider raising the threshold above 50 percent to a number that shows
the clear majority of cases are performed in the physician's office or
allow an exemption to the cap for procedures that are performed in ASCs
because of the need for anesthesia. Another commenter suggested that
CMS could implement this policy through the use of a modifier that
indicates the surgeon selected the ASC over the physician's office as
the site of service because of the necessity of anesthesia or patient
factors, whereupon the payment limitation would not be applied.
Response: As indicated in our proposed rule, office-based
procedures are surgical procedures that the most recent BESS data
available indicate are performed more than 50 percent of the time in
the physician's office setting. We believe our ``50-percent rule''
proposed policy is the best option at this point in time. It is our
current practice to consider procedures that are performed more than 50
percent of the time in the physician's office setting as office-based
procedures, and we will continue to monitor whether the 50-percent
threshold is appropriate for this categorization. These office-based
procedures, as categorized through application of the ``50-percent
rule,'' are typically procedures that have transitioned from low volume
in the office setting and high volume in the facility setting to higher
volume in the office setting and lower volume in the facility setting.
The 50-percent threshold marks the point in that transition at which a
procedure comes to be performed more often in the office. Typically,
procedures that come to be performed more frequently in offices than in
the facility setting remain primarily office-based once that transition
has taken place. Therefore, we continue to believe that the 50-percent
threshold is an appropriate, objective measure for determining which
procedures ought to be considered office-based. Moreover, a rigorous
review of procedures that met the aforementioned threshold took into
account the most recent available volume and utilization data for each
individual procedure code and, if appropriate, the utilization and
volume of related codes. In addition, we conducted a code-by-code
analysis to bolster inconclusive data with the clinical judgment of our
medical advisors.
We will continue to assess each year, based on the most recent
available BESS and other data available to us, whether there are
additional procedures that we would propose to classify as office-
based. However, we note that we proposed that once we identify a
procedure as office-based, that classification would not change in
future updates of the ASC payment system, except in cases of new codes,
where those initial determinations are temporary, as explained further
in section V.E. of this final rule. As we have explained above, once a
procedure becomes safe enough to be performed in more than 50 percent
of cases in the office setting, it is unlikely to revert to a facility
setting.
The vast majority of procedures designated as office-based under
the revised ASC payment system would require only either local
anesthesia or at most moderate or ``conscious'' sedation, that is,
sedation to achieve a medically controlled state of depressed
consciousness while maintaining the patient's airway, protective
reflexes, and ability to respond to stimulation or verbal commands. The
use of general anesthesia for the performance of these office-based
procedures would be expected to be highly unusual. In those cases where
local anesthesia or ``conscious'' sedation are the typical types of
anesthesia used in the performance of certain procedures, the
procedure's MPFS nonfacility practice expense amount would have already
been valued to include payment for the anesthesia typically used, so
appropriate payment would be provided in the ASC setting if the
procedure were subject to the office-based payment limitation. However,
even when general anesthesia may be required because of uncommon
patient-specific considerations, basing a surgical procedure's
prospective payment rate on the typical case when anesthesia is not
required and the procedure can be performed safely in the office is
consistent with the averaging principle that is the basis for all our
prospective payment systems, including the revised ASC payment system.
Therefore, after considering all comments received, we are
finalizing our proposal, without modification, to identify office-based
surgical procedures for the revised ASC payment system as those
surgical procedures no longer excluded from ASC payment beginning in CY
2008 or later years that are performed more than 50 percent of the time
in physicians' offices, taking into account the most recent available
volume and utilization data for each individual procedure code and/or,
if appropriate, the clinical characteristics, utilization, and volume
of related codes. We will annually assess whether there are additional
procedures that we would propose to classify as office-based as part of
the annual OPPS/ASC rulemaking cycle. With the exception of new codes
for which our determinations would remain preliminary until there are
adequate physicians' claims data available to assess their predominant
sites of service as discussed further in section V.E. of this final
rule, the classification of a procedure as office-based would not
change in future updates of the ASC payment system. Those procedures
whose office-based designation for CY 2008 is temporary because they
are new codes for which there is not yet adequate physicians' claims
data are flagged with an asterisk (*) in Addendum AA to this final
rule.
Comment: One commenter indicated that code CPT 64555 (Percutaneous
implantation of neurostimulator electrodes; peripheral nerve (excludes
[[Page 42513]]
sacral nerve)), should not be designated as an office-based procedure
under the revised ASC payment system because not all of the procedures
described by the code can be done in the physician's office. The
commenter further stated that payment accuracy should be included as a
goal of any new payment system, to avoid site-of-service decisions that
are based on financial factors rather than clinical appropriateness.
The commenter reasoned that the proposed payment method for procedures
similarly identified as office-based would inappropriately impact site-
of-service decisions, because it would not be possible to provide the
procedures in the ASC setting.
Another commenter suggested that CPT code 15340 (Tissue cultured
allogeneic skin substitute, first 25 sq cm or less) be removed from the
proposed list of office-based procedures so as to ensure appropriate
payment for the procedure in the ASC setting and thereby provide
Medicare beneficiaries with increased access to the procedure. The
commenter noted that this CPT code was new for CY 2006 and, therefore,
there were no CY 2005 utilization data available for our review. They
also explained that the predecessor CPT code was not performed in the
physician's office more than 50 percent of the time, and they did not
believe this new code would be determined to be office-based based on
the 50-percent threshold when CY 2006 data were available.
Response: We have identified CPT code 64555, newly proposed for ASC
payment beginning in CY 2008, as a device-intensive procedure that is
clinically similar to other CPT codes for implantation of
neuroelectrodes that are not office-based procedures, although some of
the other procedures are ASC covered surgical procedures prior to
January 2008. The code is assigned to APC 0040 (Percutaneous
Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve)
under the CY 2007 OPPS, where other neurostimatulor electrode
implantation procedures reside. Therefore, we believe it is most
appropriate to remove CPT code 64555 from the list of office-based
procedures under the revised ASC payment system, so that it will be
paid in the ASC setting according to the modified payment methodology
we are adopting for device-intensive procedures. We refer readers to
section IV.C.2.e. of this final rule for a detailed discussion of our
proposed and final policies regarding ASC payment for procedures with
significant device costs. In addition, we note that, while we had also
proposed an office-based designation for CPT code 64565 (Percutaneous
implantation of neurostimulator electrodes; neuromuscular) beginning
with its initial ASC payment in CY 2008, under the OPPS this code is
assigned to the same clinical APC as CPT code 64555, which it resembles
from both clinical and facility resource perspectives. Therefore, we
will also remove CPT code 64565 from the list of office-based
procedures for the CY 2008 revised ASC payment system. Following the
removal of these two codes from the list of office-based procedures,
there are no ASC covered surgical procedures that are both device-
intensive and office-based for the CY 2008 revised ASC payment system.
With respect to CPT code 15340, as the commenter pointed out, we
have no utilization data from CY 2005 available for this procedure to
review in developing this final rule. We note that we did not propose
to designate the CPT add-on code for an additional area of application,
15341 (Tissue cultured allogeneic skin substitute, each additional 25
sq cm) as office-based under the revised ASC payment system. The
proposed ASC treatment of CPT code 15340 was a temporary designation
for the new code, subject to change in response to public comments and
our examination of utilization data when available. At this time, we
have decided to remove this CPT code from the office-based list
because, after further review, we believe it is not likely to be
performed more than 50 percent of the time in the physician's office
setting. However, we will continue to evaluate the appropriateness of
this action as new data become available and will annually reassess
whether this code, or other procedures newly paid in ASCs in CY 2008 or
later years that are not already designated as office-based or for
which that classification is temporary, should be proposed as office-
based for ASC payment, in the context of each year's OPPS/ASC annual
update. We note, specifically, that our treatment of CPT code 15340 in
this CY 2008 ASC final rule is not a final determination for CY 2008,
because we expect to have CY 2006 utilization data available for the CY
2008 OPPS/ASC proposed rule, where we may propose that additional codes
be classified as office-based for the CY 2008 revised ASC payment
system.
After considering all public comments received, we are finalizing
our proposal, with modification, of the office-based list of covered
surgical procedures under the CY 2008 revised ASC payment system. At
this point, we are removing CPT codes 64555, 64565, and 15340 from the
office-based list for the CY 2008 revised ASC payment system. As new
data become available, we may propose that additional HCPCS codes newly
paid in ASCs in CY 2008 be classified as office-based in the CY 2008
OPPS/ASC proposed rule, and the final CY 2008 ASC list of covered
office-based surgical procedures will be published in the CY 2008 OPPS/
ASC final rule.
F. Payment Policies for Multiple and Interrupted Procedures
1. Multiple Procedure Discounting Policy
In the August 2006 proposed rule for the revised ASC payment
system, we proposed to mirror the OPPS policy for discounting when a
beneficiary has more than one surgical procedure performed on the same
day at an ASC facility (71 FR 49651). The current policy for multiple
procedure discounting in the ASC, as specified in Sec.
416.120(c)(2)(ii) of our regulations, is based on a simple count of
procedures performed on the same day. The most costly procedure is paid
the full amount and all other procedures are discounted by half.
Under the OPPS, certain surgical procedures are not subject to the
discounting policy. Generally, the procedures that are exempted are
those performed to implant costly devices. They are not discounted even
when performed in association with other surgical procedures because
the cost of the implantable device does not change; therefore, resource
savings due to efficiencies would be minimal.
Until now, there has been no reason to exempt any procedure from
the multiple procedure discounting policy in ASCs because separate
payments have been made for implantable devices. Although the ASC
payment for the procedure may have been discounted, the cost of the
device was paid outside of that rate and was unaffected by the multiple
procedure discount methodology.
Under the revised ASC payment system in the August 2006 proposed
rule, we proposed to package payment for implantable devices into the
procedure payment made to the ASC, as under the OPPS. Because we are
trying wherever possible to implement parallel payment policies across
both systems, we proposed to adopt the OPPS discounting policy that is
applied to surgical procedures so that the costs of performing multiple
procedures for the implantation of costly devices are taken into
account. Thus, payment for the
[[Page 42514]]
same set of multiple procedures under the OPPS and the ASC payment
system would be made using similar packaging and payment rules.
For the revised ASC payment system, we proposed in Table 46 of the
August 2006 proposed rule (71 FR 49652) a listing of the covered
surgical procedures that would be exempt from multiple procedure
discounting based on CY 2007 OPPS proposed procedure-specific
discounting designations (71 FR 49652 through 49654). These exempt
procedures were those surgical procedures proposed for ASC payment in
CY 2008 that were also proposed for assignment to a status indicator
other than ``T'' under the CY 2007 OPPS, indicating that a multiple
surgical procedure reduction would not apply. We proposed to update
this list annually in the OPPS/ASC proposed and final rules, and
solicited comments on the list.
We also proposed to incorporate our proposed policy on multiple
procedure discounting in proposed new Sec. 416.172(e).
Comment: Several commenters supported our proposal to apply the
multiple procedure discounting policy of the OPPS to procedures
provided under the revised ASC payment system. The commenters noted
that this policy would ensure that payments for ASC covered surgical
procedures with high fixed costs are not discounted, and that the full
costs of procedures to implant expensive devices are taken into account
when these device-intensive procedures are performed in conjunction
with other surgical procedures. The commenters also suggested that
adopting the OPPS multiple procedure discounting policy would provide
parity in payments to both HOPDs and ASCs, as well as minimize any
payment incentive to shift services between the two settings because of
different policies. They believed that this consistency would result in
appropriate and parallel policies for payment of multiple surgical
procedures performed in a single operative session in both of these
delivery settings where outpatient surgery is commonly performed.
Response: We appreciate the commenters' support for the proposed
ASC multiple procedure discounting policy. Specifically, when more than
one covered surgical procedure is provided by an ASC in a single
operative session to a Medicare beneficiary, the procedure with the
highest ASC payment rate would be paid 100 percent of the ASC payment
amount, and ASC payments for any other surgical procedures not
expressly exempt from the discounting policy would be reduced by half.
Certain ASC covered surgical procedures with relatively high fixed
costs would be specifically exempt from the ASC multiple procedure
discounting policy, consistent with the current OPPS multiple procedure
discounting policy for those surgical procedures assigned to a status
indicator other than ``T'' under the OPPS. We agree with the
commenters' general reasoning and further believe that adopting an ASC
policy that parallels the OPPS discounting policy would assist in
timely and coordinated updates to the multiple procedure discounting
status of services payable under both payment systems.
Comment: Several commenters indicated that CMS inappropriately
included only one of three similar CPT codes for the placement of
breast brachytherapy catheters (specifically CPT code 19298 (Placement
of radiotherapy after loading brachytherapy catheters (multiple tube
and button type) into the breast for interstitial radioelement
application following (at the time of or subsequent to) partial
mastectomy, includes imaging guidance)) on the list of procedures
proposed for exemption from multiple procedure discounting, which was
provided as Table 46 in the CY 2008 ASC proposed rule (and which has
been updated as Table 10 below based on the CY 2007 OPPS final
procedure-specific discounting designations). These commenters
explained that the general surgical approach and devices required to
perform CPT code 19298 are similar to those used to provide CPT code
19296 (Placement of radiotherapy after loading balloon catheter into
the breast for interstitial radioelement application following partial
mastectomy, includes imaging guidance; on date separate from partial
mastectomy) and CPT code 19297 (Placement of radiotherapy after loading
balloon catheter into the breast for interstitial radioelement
application following partial mastectomy, includes imaging guidance;
concurrent with partial mastectomy). Moreover, the commenters believed
that, because all three CPT codes are assigned to status indicator
``S'' under the OPPS, indicating that multiple procedure discounting
does not apply to payment for their performance in the hospital
outpatient setting, all of these codes should also be exempt from
multiple procedure discounting under the revised ASC payment system.
Response: While CPT code 19298 is assigned to status indicator
``S'' under the CY 2007 OPPS, CPT codes 19296 and 19297 are assigned to
status indicator ``T'' under the OPPS effective January 1, 2007. As
discussed in the CY 2007 OPPS final rule with comment period (71 FR
68028), CPT codes 19296 and 19297 were reassigned from New Technology
APCs to a clinical APC effective January 1, 2007. Along with their APC
reassignments, CPT codes 19296 and 19297 were also reassigned from
status indicator ``S'' to ``T'' effective January 1, 2007. During the
CY 2007 OPPS rulemaking cycle, in considering the public comments and
finalizing the new assignments of CPT codes 19296 and 19297 to a
clinical APC with status indicator ``T,'' the implications of the
multiple procedure reduction to payment for CPT codes 19296 and 19297
in various clinical scenarios were taken into consideration. Therefore,
consistent with our proposed multiple procedure discounting policy for
the revised ASC payment system, these two procedures were not included
on the proposed list of procedures for exemption from multiple
procedure discounting under the revised ASC payment system. Their OPPS
payment status of ``T'' implies that the multiple procedure payment
reduction would be appropriate, and the possibility of a 50-percent
payment reduction has already specifically been evaluated with respect
to the hospital outpatient resources required to perform the
procedures. However, because CPT code 19298 is assigned to status
indicator ``S'' under the CY 2007 OPPS, where it remains in its
original New Technology APC while additional hospital cost data are
being collected, we believe that CPT code 19298 would be appropriately
exempted from multiple procedure discounting in both the ASC and HOPD
settings, consistent with our overall proposal for discounting under
the revised ASC payment system.
After considering the public comments we received, we are
finalizing our proposed payment policy for multiple surgical procedure
discounting under the revised ASC payment system under Sec. 416.172(e)
with only editorial modification. We will mirror the OPPS payment
policy for discounting when a beneficiary has more than one covered
surgical procedure performed in a single operative session in an ASC in
CY 2008, by exempting those surgical procedures on the ASC list of
covered surgical procedures that are assigned to a status indicator
other than ``T'' under the CY 2008 OPPS from multiple procedure
discounting under the revised ASC payment system. The discounting
policy of the revised ASC payment system, like
[[Page 42515]]
the policy of the existing ASC payment system, will apply the multiple
procedure reduction if the same procedure is performed bilaterally,
consistent with the general discounting policy of the OPPS for payment
of surgical procedures that are performed bilaterally. A procedure
performed bilaterally in one operative session would be paid at 150
percent of the single procedure payment under the revised ASC payment
system. The multiple procedure discounting policy will only apply to
ASC payment for covered surgical procedures. ASC payment for covered
ancillary services, as discussed further in section IV.C.2. of this
final rule, will not be subject to the multiple procedure discount.
The specific multiple procedure discounting policy that applies to
each ASC covered surgical procedure is identified in Addendum AA to
this final rule. Table 10 provides an illustrative summary list of the
CY 2007 HCPCS codes on the ASC list of covered surgical procedures for
CY 2008, and their respective APCs as of January 1, 2007 under the
OPPS, which will be exempt from multiple procedure discounting in ASCs
effective January 1, 2008, if no changes are made to their OPPS
discounting designation for CY 2008. We will update this list annually
in the OPPS/ASC proposed and final rulemaking process, which includes
the solicitation of public comments. The CY 2008 list of exemptions
will be proposed and finalized for the CY 2008 revised ASC payment
system through the OPPS/ASC rulemaking cycle for CY 2008.
Table 10.--Illustrative List of Procedures Exempt From Multiple
Procedure Discounting Under the Revised ASC Payment System in CY 2008
------------------------------------------------------------------------
HCPCS code Short descriptor APC
------------------------------------------------------------------------
11980........................ Implant hormone pellet(s)....... 0340
11981........................ Insert drug implant device...... 0340
11982........................ Remove drug implant device...... 0340
11983........................ Remove/insert drug implant...... 0340
15852........................ Dressing change not for burn.... 0340
15860........................ Test for blood flow in graft.... 0340
19295........................ Place breast clip, percut....... 0657
19298........................ Place breast rad tube/caths..... 1524
20665........................ Removal of fixation device...... 0340
20975........................ Electrical bone stimulation..... 0340
20979........................ Us bone stimulation............. 0340
29010........................ Application of body cast........ 0426
29015........................ Application of body cast........ 0426
29020........................ Application of body cast........ 0058
29025........................ Application of body cast........ 0058
29035........................ Application of body cast........ 0426
29040........................ Application of body cast........ 0058
29044........................ Application of body cast........ 0426
29049........................ Application of figure eight..... 0058
29055........................ Application of shoulder cast.... 0426
29058........................ Application of shoulder cast.... 0058
29065........................ Application of long arm cast.... 0426
29075........................ Application of forearm cast..... 0426
29085........................ Apply hand/wrist cast........... 0058
29086........................ Apply finger cast............... 0058
29105........................ Apply long arm splint........... 0058
29125........................ Apply forearm splint............ 0058
29126........................ Apply forearm splint............ 0058
29130........................ Application of finger splint.... 0058
29131........................ Application of finger splint.... 0058
29200........................ Strapping of chest.............. 0058
29220........................ Strapping of low back........... 0058
29240........................ Strapping of shoulder........... 0058
29260........................ Strapping of elbow or wrist..... 0058
29280........................ Strapping of hand or finger..... 0058
29305........................ Application of hip cast......... 0426
29325........................ Application of hip casts........ 0426
29345........................ Application of long leg cast.... 0426
29355........................ Application of long leg cast.... 0426
29358........................ Apply long leg cast brace....... 0426
29365........................ Application of long leg cast.... 0426
29405........................ Apply short leg cast............ 0426
29425........................ Apply short leg cast............ 0426
29435........................ Apply short leg cast............ 0426
29440........................ Addition of walker to cast...... 0058
29445........................ Apply rigid leg cast............ 0426
29450........................ Application of leg cast......... 0058
29505........................ Application, long leg splint.... 0058
29515........................ Application lower leg splint.... 0058
29520........................ Strapping of hip................ 0058
29530........................ Strapping of knee............... 0058
29540........................ Strapping of ankle and/or ft.... 0058
29550........................ Strapping of toes............... 0058
29580........................ Application of paste boot....... 0058
29590........................ Application of foot splint...... 0058
29700........................ Removal/revision of cast........ 0058
29705........................ Removal/revision of cast........ 0058
29710........................ Removal/revision of cast........ 0426
29715........................ Removal/revision of cast........ 0058
29720........................ Repair of body cast............. 0058
29730........................ Windowing of cast............... 0058
29740........................ Wedging of cast................. 0058
29750........................ Wedging of clubfoot cast........ 0058
30300........................ Remove nasal foreign body....... 0340
31500........................ Insert emergency airway......... 0094
31620........................ Endobronchial us add-on......... 0670
33282........................ Implant pat-active ht record.... 0680
36002........................ Pseudoaneurysm injection trt.... 0267
36430........................ Blood transfusion service....... 0110
36440........................ Bl push transfuse, 2 yr or < .... 0110
36450........................ Bl exchange/transfuse, nb....... 0110
36511........................ Apheresis wbc................... 0111
36512........................ Apheresis rbc................... 0111
36513........................ Apheresis platelets............. 0111
36514........................ Apheresis plasma................ 0111
36515........................ Apheresis, adsorp/reinfuse...... 0112
36516........................ Apheresis, selective............ 0112
36522........................ Photopheresis................... 0112
36598........................ Inj w/fluor, eval cv device..... 0340
37250........................ Iv us first vessel add-on....... 0416
37251........................ Iv us each add vessel add-on.... 0416
38205........................ Harvest allogenic stem cells.... 0111
38206........................ Harvest auto stem cells......... 0111
38230........................ Bone marrow collection.......... 0123
38241........................ Bone marrow/stem transplant..... 0123
38242........................ Lymphocyte infuse transplant.... 0111
40804........................ Removal, foreign body, mouth.... 0340
42809........................ Remove pharynx foreign body..... 0340
46600........................ Diagnostic anoscopy............. 0340
51701........................ Insert bladder catheter......... 0340
51702........................ Insert temp bladder cath........ 0340
51798........................ Us urine capacity measure....... 0340
53440........................ Male sling procedure............ 0385
53444........................ Insert tandem cuff.............. 0385
53445........................ Insert uro/ves nck sphincter.... 0386
53447........................ Remove/replace ur sphincter..... 0386
[[Page 42516]]
54400........................ Insert semi-rigid prosthesis.... 0385
54401........................ Insert self-contd prosthesis.... 0386
54405........................ Insert multi-comp penis pros.... 0386
54410........................ Remove/replace penis prosth..... 0386
54416........................ Remv/repl penis contain pros.... 0386
61795........................ Brain surgery using computer.... 0302
61885........................ Insrt/redo neurostim 1 array.... 0039
62252........................ Csf shunt reprogram............. 0691
62367........................ Analyze spine infusion pump..... 0691
62368........................ Analyze spine infusion pump..... 0691
63650........................ Implant neuroelectrodes......... 0040
63655........................ Implant neuroelectrodes......... 0061
64553........................ Implant neuroelectrodes......... 0225
64555........................ Implant neuroelectrodes......... 0040
64560........................ Implant neuroelectrodes......... 0040
64561........................ Implant neuroelectrodes......... 0040
64565........................ Implant neuroelectrodes......... 0040
64573........................ Implant neuroelectrodes......... 0225
64575........................ Implant neuroelectrodes......... 0061
64577........................ Implant neuroelectrodes......... 0061
64580........................ Implant neuroelectrodes......... 0061
64581........................ Implant neuroelectrodes......... 0061
65205........................ Remove foreign body from eye.... 0698
65210........................ Remove foreign body from eye.... 0698
65220........................ Remove foreign body from eye.... 0698
65222........................ Remove foreign body from eye.... 0698
65430........................ Corneal smear................... 0698
65450........................ Treatment of corneal lesion..... 0231
67500........................ Inject/treat eye socket......... 0231
67820........................ Revise eyelashes................ 0698
67938........................ Remove eyelid foreign body...... 0698
68040........................ Treatment of eyelid lesions..... 0698
68200........................ Treat eyelid by injection....... 0230
68760........................ Close tear duct opening......... 0231
68761........................ Close tear duct opening......... 0231
68801........................ Dilate tear duct opening........ 0698
68810........................ Probe nasolacrimal duct......... 0231
68840........................ Explore/irrigate tear ducts..... 0698
69200........................ Clear outer ear canal........... 0340
69210........................ Remove impacted ear wax......... 0340
C9725........................ Place endorectal app............ 1507
C9726........................ Rxt breast appl place/remov..... 1508
C9727........................ Insert palate implants.......... 1510
G0104........................ CA screen; flexi sigmoidscope... 0159
------------------------------------------------------------------------
2. Interrupted Procedure Policies
When a procedure requiring anesthesia is discontinued after the
beneficiary is prepared for the procedure and taken to the room where
it is to be performed, but before the administration of anesthesia,
ASCs currently report modifier 73 (Discontinued outpatient procedure
prior to anesthesia administration) appended to the discontinued
procedure and receive 50 percent of the ASC payment for the planned
surgical procedure. We believe that ASCs, like hospital outpatient
facilities, realize significant savings when procedures for which
anesthesia is to be used are discontinued prior to their initiation but
after the beneficiary is taken to the procedure room. We believe that
savings are recognized for the costs associated with a variety of
facility resources, including treatment/operating room time, single use
devices, drugs, equipment, supplies, and recovery room time. When a
procedure is interrupted after its initiation or the administration of
anesthesia, ASCs currently report these cases using modifier 74
(Discontinued outpatient procedure after anesthesia administration)
appended to the interrupted procedure, and the full ASC payment for the
covered surgical procedure is made. Similar to hospital outpatient
procedures that are discontinued after the administration of anesthesia
or the initiation of the procedure, in cases where modifier 74 is
reported by ASCs, we believe that the facility costs incurred for these
discontinued procedures that were initiated to some degree are
generally as significant to the ASC as those for a completed procedure,
including resources for patient preparation, operating room use, and
recovery room care. In the August 2006 proposed rule, we proposed no
change to the existing ASC payment policy for procedures reported with
modifier 73 or 74 under the revised ASC payment system, and note that
the policy under the existing ASC payment system is the same as the
OPPS policy in these circumstances.
Under the existing ASC payment system, ASCs do not report modifier
52 (Reduced services) for interrupted procedures, because most
interrupted covered surgical procedures paid in ASCs would be
appropriately reported with modifier 73 or 74 because they generally
require anesthesia. Modifier 52 is appended to a service under the OPPS
to signify that a service that did not require anesthesia was partially
reduced or discontinued at the physician's discretion. Modifier 52 is
reported under the OPPS for a variety of types of interrupted services,
such as radiology services, and we believe that there are considerable
resource savings to the facility under the circumstances where it is
reported. Therefore, under the OPPS, we apply a 50 percent reduction to
the facility payment for interrupted procedures and services reported
with modifier 52.
The PPAC recommended that we apply payment policies consistently
under the revised ASC payment system and the OPPS. We received a number
of public comments recommending consistency of payment policies between
the two payment systems. Although not discussed in our proposed rule
for the revised ASC payment system, we received comments on the
application of the current interrupted procedure policies to the
revised ASC payment system and respond to these comments below.
Comment: Many commenters recommended that we establish consistent
payment policies under the OPPS and the revised ASC payment system,
because the hospital and ASC facilities provide many of the same
services to similar patients. In particular, several commenters
compared current payment policies that were similar between the
existing ASC payment system and the OPPS, including the payment policy
that reduces the payment for interrupted procedures reported with
modifier 73 by 50 percent in both payment systems.
Response: We agree with commenters that consistent policies between
the revised ASC payment system and the OPPS are desirable whenever
possible, because the revised ASC payment system will be based upon the
OPPS relative payment weights. We also note that, with the significant
expansion of procedures eligible for ASC payment under the revised ASC
payment system, it is possible that some of the additional procedures
payable in the ASC setting beginning in CY 2008 may not always require
anesthesia. In addition, as further discussed in section IV.C.2. of
this final rule, we will be providing separate payment for some
ancillary radiology services that are integral to the performance of
covered surgical procedures under the revised ASC payment system.
Therefore, we believe that the revised ASC payment system should also
allow ASCs to report interrupted services not requiring anesthesia with
modifier 52, consistent with the OPPS reporting of these services.
Because we expect ASCs to utilize fewer facility resources in such
situations, similar to ASC procedures where modifier 73 is reported and
to
[[Page 42517]]
HOPDs where modifier 73 or 52 is reported, we believe that it is
appropriate to provide the same payment reduction of 50 percent under
the revised ASC payment system as under the OPPS when modifier 52 is
reported.
After considering the public comments received, we are clarifying
here the payment policies for interrupted procedures in ASCs. First,
procedures requiring anesthesia that are terminated after the patient
has been prepared for surgery and taken to the operating room but
before the administration of anesthesia will be reported with modifier
73, and the ASC payment for the covered surgical procedure will be
reduced by 50 percent. Second, procedures and services not requiring
anesthesia that are partially reduced or discontinued at the
physician's discretion will be reported with modifier 52, and the ASC
payment for the covered surgical procedure or covered ancillary service
will be reduced by 50 percent. Third, procedures requiring anesthesia
that are terminated after the administration of anesthesia or the
initiation of the procedure will be reported with modifier 74, and the
full ASC payment for the covered surgical procedure will be provided.
We are adding new Sec. 416.172(f) to reflect this final policy.
G. Geographic Adjustment
Currently, Medicare adjusts 34.45 percent of the national ASC
payment rates using wage index values and localities that were
established under the hospital IPPS prior to implementation of the new
CBSAs issued by OMB in June 2003. Medicare currently adjusts 60 percent
of national OPPS payment rates by the IPPS wage index value assigned to
hospitals using the June 2003 OMB definitions for geographical
statistical areas and wage adjustments required under Public Law 108-
173.
Since 1990, ASC payments have been adjusted for regional wage
variations using the IPPS wage index values. As we discussed in the
August 2006 proposed rule, we believe that standardization continues to
be appropriate in recognition of widely varying labor market costs tied
to geographic localities. We also explained in the proposed rule that
we believe it is advisable to maintain consistency in locality
designations between ASCs and hospitals and acknowledge parity of labor
costs between ASCs and HOPDs that are competing for staff in the same
locality. Therefore, we proposed to apply to ASCs the IPPS pre-
reclassification wage index values associated with the June 2003 OMB
geographic localities, as recognized under the IPPS and OPPS, to adjust
national ASC payment rates for geographic wage differences under the
revised payment system.
Although we had not collected new data to identify whether the
current labor-related share is correct, the results of a 1994 survey of
ASC costs generally supported the current 34.45-percent labor
adjustment factor, and we had received no complaints from the ASC
community, prior to our proposal, about our continued use of the 34.45/
65.55 ratio of labor to nonlabor costs for purposes of adjusting
payments for regional wage differences. Moreover, in the proposed rule,
we stated our belief that it is reasonable to expect ASCs to have a
lower labor adjustment factor than that of hospitals. For example, most
OPPS HOPDs are staffed 24 hours per day to provide emergency department
services and observation care, and these patterns of operation could
lead to relatively higher labor costs for hospital services overall.
Therefore, we proposed to continue using 34.45 percent as the labor
adjustment factor for regional wage differences under the revised ASC
payment system, beginning in CY 2008. We proposed to establish rules
governing this proposal in new Sec. 416.172(c).
Subsequent to the publication of the August 2006 proposed rule for
the revised ASC payment system, the GAO issued the report, ``Medicare:
Payment for Ambulatory Surgical Centers Should Be Based on the Hospital
Outpatient Payment System,'' (GAO-07-86), which is discussed in further
detail in section II.B. of this final rule. In this report, the GAO
determined that based upon the 2004 ASC cost data from a geographically
representative group of ASCs received in response to its ASC survey,
the mean labor-related proportion of ASC costs was 50 percent.
Comment: Several commenters agreed with CMS' proposal to use the
IPPS pre-reclassification wage index values associated with the June
2003 OMB geographic localities. However, many commenters indicated that
the current 34.45-percent labor factor is based on old data and is too
low, leading to their recommendation that the 60-percent OPPS labor
factor would be more appropriate. Some commenters explained that it was
difficult to assess the appropriateness of CMS' proposal in the absence
of the GAO Report on the ASC payment system that was directed to
address whether a geographic adjustment should be provided for payment
of procedures furnished in ASCs and, if so, the labor and nonlabor
shares of ASC payment. Other commenters recommended that CMS collect
more recent data on the costs of delivering services in the ASC setting
or suggested that ASCs be asked to submit cost reports to inform the
development of an appropriate, contemporary labor factor reflecting
current ASC costs.
Response: For the reasons stated in the proposed rule and
reiterated above, we agree with the commenters that we should use the
IPPS pre-reclassification wage index values associated with the June
2003 OMB geographic localities. While we share the concerns of
commenters about the age of the survey data used for the current 34.45-
percent labor factor, we disagree that it would be appropriate to use
the same 60-percent labor factor used under the OPPS. The commenters
who indicated a preference for the OPPS labor factor did not address
the fact that most OPPS HOPDs are staffed 24 hours per day to provide
emergency department services and observation care. Other than their
request for parity with the OPPS labor adjustment, they provided no
specific data to support the appropriateness of a 60-percent labor
factor based on current ASC costs for performing procedures.
However, we agree with commenters that the 34.45 labor-related
share that we proposed for the revised payment system is likely too low
to accurately reflect the current proportion of ASCs' labor costs. The
data used to develop the 34.45 labor-related share are 20 years old,
and 1994 ASC survey cost data, which have never been used for ASC
payment, showed a slightly higher labor-related share of 37.66 percent
that we believe was likely reflective of a generally increasing
proportion of ASC labor costs. ASCs and HOPDs operate in some of the
same communities, using similar clinical staff to perform certain
procedures, and ASC staff wages may be comparable to those of hospital
staff. However, we have no data to indicate that ASCs and HOPDs have
equivalent ratios of labor to nonlabor costs, on average, for all the
services each type of facility provides. As discussed above, because
ASCs only provide a subset of surgical procedures compared with the
wide variety of OPPS services that we expect could be, overall,
relatively more labor-intensive than ambulatory surgical procedures
specifically, we believe that the most appropriate ASC labor-related
share would be lower than the 60 percent used to adjust HOPD payment.
The GAO Report determined, on the basis of the 2004 ASC cost data
received from a geographically representative group of ASCs in response
to its ASC survey, that the mean labor-related
[[Page 42518]]
proportion of costs was 50 percent. In addition, the GAO found that the
range of the labor-related costs for the middle 50 percent of ASCs
responding to the survey was relatively narrow, at 43 percent to 57
percent of total costs.
Therefore, in response to comments about the age of the historical
data used for the existing and proposed revised ASC payment system
labor factor, in addition to consideration of the GAO's determination
based on the most recent ASC survey findings, we reviewed the labor-
related share indicated by the 1994 ASC survey cost data and assessed
the clinical labor required to provide both ASC and OPPS services, in
the context of the full facility resource costs associated with those
services. Based on all of those considerations, we believe that it is
not necessary to collect additional ASC cost data in order to determine
the appropriate labor-related factor for use under the revised ASC
payment system and that a 50-percent labor factor for the revised ASC
payment system is most appropriate. Fifty percent is significantly
higher than the current labor-related share (34.45 percent) that we
proposed to maintain but is also lower than the OPPS labor-related
share of 60 percent, a differential we believe is appropriate given the
broader range of labor-intensive services provided in the HOPD setting.
A 50-percent labor-related share is fully consistent with the GAO
findings that we believe provide a more accurate representation of the
present-day labor-related proportion of ASC costs than the data upon
which we currently rely. In the future, if we believe that the
collection of additional ASC cost data is important to providing
appropriate payment to ASCs and such an activity is administratively
feasible, we may consider gathering such information from ASCs.
After considering the public comments received, we are finalizing
our proposal to apply to ASC payments under the revised ASC payment
system the IPPS pre-reclassification wage index values associated with
the June 2003 OMB geographic localities, as recognized under the IPPS
and OPPS, in order to adjust national ASC payment rates for geographic
wage differences under the revised payment system. However, rather than
adopting 34.45 percent as the labor adjustment factor as we proposed,
we are adopting 50 percent as the labor-related proportion under the
revised ASC payment system. The geographic adjustment policy of the
revised ASC payment system is set forth in Sec. 416.172(c).
H. Adjustment for Inflation
As noted above, section 1833(i)(2)(C)(iv) of the Act, as amended by
section 626(a) of Public Law 108-173, requires the adjustment of ASC
payment amounts for inflation for FY 2005, the last quarter of CY 2005,
and each of CYs 2006 through 2009 to equal zero percent. Otherwise,
section 1833(i)(2)(C)(i) of the Act provides that ASC payment amounts
are to be adjusted by the percentage increase in the CPI-U during years
when the ASC payment amounts are not updated.
Although we are only required to increase the ASC payment rates by
the percentage increase in the CPI-U during years in which we have not
updated the ASC payment amounts, we proposed to update the ASC
conversion factor annually using the CPI-U. For CY 2008 and CY 2009,
the statute requires a zero percent CPI-U increase for ASC services.
Beginning in CY 2010, in the August 2006 proposed rule for the revised
ASC payment system, we proposed to update the ASC conversion factor by
the percentage increase in the CPI-U (U.S. city average) as estimated
for the 12-month period ending with the midpoint of the year involved.
Accordingly, we proposed to establish rules in proposed new Sec. Sec.
416.171 and 416.172 to reflect our proposed policy for applying an
inflation adjustment under the proposed revised payment system
beginning January 1, 2008. (These sections of the proposed regulations
also included our proposed policies for calculating a conversion factor
and standardizing labor-related costs, respectively, under the proposed
revised payment system.)
Comment: A number of commenters recommended that CMS use the
hospital market basket as an update for inflation in the revised ASC
payment system. The commenters generally indicated that the hospital
market basket more appropriately reflects inflation in the costs of
providing surgical services. These commenters pointed out that the CPI-
U is a measure of consumer inflation rather than health care provider
inflation, and that the hospital market basket was specifically
designed to measure the cost of hospital inflation. They concluded that
the hospital market basket is, thus, a better proxy for the
inflationary pressures faced by ASCs. One commenter presented data
indicating that the cost of operating an ASC rose by an average of 13.4
percent between 2003 and 2005 and that, during that same period, the
CPI-U fell 36 percent short of meeting these increased costs.
Some commenters expressed concern that the use of two different
factors to update payments for ASCs and HOPDs would further increase
the discrepancies between payments in the two settings. They further
suggested that alignment with hospital updates and policies in general
would achieve parity and transparency in the market and ensure that
facility decisions are made based upon what is best for the patient.
Other commenters suggested that CMS develop another method that would
more closely approximate the rising cost of operating an ASC if the
proposal to base the annual update of the ASC conversion factor on the
CPI-U is finalized.
Response: As we explained in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68003), the OPPS conversion factor is updated
annually using the hospital inpatient market basket percentage
increase. The statute specifically required us to take into account the
recommendations of a GAO Report studying the appropriateness of
aligning a revised ASC payment system with the payment rates and
relative weights established under the OPPS. However, the statute gives
the Secretary broad authority in designing the specific features of the
revised system. In particular, the statute gives the Secretary
considerable discretion in determining an appropriate update mechanism
for the revised ASC payment system. Section 1833(i)(2)(C)(i) of the Act
requires that the Secretary update the payment amounts established
under the revised system ``by the percentage increase in the Consumer
Price Index for all urban consumers,'' but only if the Secretary has
not otherwise ``updated amounts established'' under the revised system
for that year. The statute, therefore, does not mandate the adoption of
any particular update mechanism, but it does establish the CPI-U as the
default update mechanism in the absence of any other update. In
addition, section 1833(i)(2)(C)(iv) of the Act mandates a zero CPI-U
adjustment in CY 2008 and CY 2009 for ASCs, the first 2 years under the
revised payment system, suggesting that maintaining continuity in the
update mechanism under the revised system may be appropriate.
Therefore, we proposed, under the revised system beginning in CY 2010,
to apply the CPI-U adjustment to update the ASC conversion factor for
inflation on an annual basis. While we understand the arguments of
commenters in favor of adopting the hospital market basket as the
update mechanism under the revised ASC
[[Continued on page 42519]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 42519-42568]] Medicare Program; Revised Payment System Policies for Services
Furnished in Ambulatory Surgical Centers (ASCs) Beginning in CY 2008
[[Continued from page 42518]]
[[Page 42519]]
payment system, we continue to believe that it is appropriate to adopt
the default update mechanism designated by Congress for the revised
system.
Therefore, we are finalizing our proposal, beginning in CY 2010, to
update the conversion factor by the percentage increase in the CPI-U
(U.S. city average) as estimated for the 12-month period ending with
the midpoint of the year involved. At the same time, we recognize that
we continue to have flexibility under the statute to employ a different
update mechanism under the revised ASC payment system. As one example,
we do not intend for the revised ASC payment system to result in
additional Medicare expenditures over time. We will be monitoring this
issue closely in the coming years. Consequently, we will reconsider the
ASC update if expenditures increase inappropriately in future years.
Therefore, after consideration of all public comments received, we
are finalizing our proposal under Sec. 416.171(a)(2), without
modification, to apply the CPI-U to update the ASC conversion factor
for inflation on an annual basis under the revised ASC payment system.
I. Beneficiary Coinsurance
Payment for ASC services is subject to the Medicare Part B
deductible and coinsurance requirements. Currently, Medicare pays
participating ASCs 80 percent of a prospectively determined standard
overhead amount, adjusted for regional wage variations for ASC covered
surgical procedures, except for screening colonoscopies. The
beneficiary deductible and coinsurance make up the other 20 percent of
payment for ASC services, except for screening colonoscopies for which
there is no deductible and for which the coinsurance is equal to 25
percent. Section 1834(d) of the Act requires this higher coinsurance
for screening colonoscopies and screening flexible sigmoidoscopies.
However, only screening colonoscopies are on the CY 2007 ASC list of
covered surgical procedures. In addition, effective January 1, 2007, a
deductible is no longer applied for colorectal cancer screening tests,
including screening flexible sigmoidoscopy and screening colonoscopy
procedures performed in ASCs or other settings, as specified in section
1833(b)(8) of the Act (as added by section 5113 of Public Law 109-171).
Section 626(c) of Public Law 108-173 amended section 1833(a)(1) of
the Act to provide that, beginning with the implementation date of the
revised payment system, the Medicare program payment to ASCs shall
equal 80 percent of the lesser of the actual charge for the services or
the payment amount that we determine under the revised payment system
for the services. This amendment, however, did not affect section
1834(d) of the Act. Therefore, we proposed to make this change and to
continue to maintain the beneficiary deductible and coinsurance at 20
percent under the revised ASC payment system, except for screening
colonoscopies and screening flexible sigmoidoscopies (which are both
ASC covered surgical procedures in CY 2008) for which the statute
requires 25 percent beneficiary coinsurance. In the August 2006
proposed rule for the revised ASC payment system, we proposed to
reflect the 20 percent beneficiary coinsurance in proposed new
Sec. Sec. 416.172(b) and (d); however, the proposed regulation text
did not address the statutory requirement of 25 percent coinsurance for
screening flexible sigmoidoscopies and screening colonoscopies.
Consistent with the provisions of section 1834(d) of the Act, we
implemented the 25 percent coinsurance requirement for screening
colonoscopies (screening flexible sigmoidoscopies are not on the CY
2007 ASC list of covered surgical procedures) in ASCs, effective
January 1, 2007, as finalized in Sec. 410.152(i) and discussed in the
preamble to the CY 2007 OPPS/ASC final rule with comment period (71 FR
68174).
Comment: Many commenters supported our proposal to continue to
apply the 20 percent coinsurance provision to payment for covered
surgical procedures performed in ASCs and paid under the revised ASC
payment system.
Response: We appreciate the comments. The statute requires Medicare
to pay 80 percent of the lesser of the actual charge for the service or
the amount we determine under the revised payment system, other than
for screening colonoscopy and screening flexible sigmoidoscopy
procedures. Beneficiary coinsurance will remain at 20 percent for ASC
services under the revised ASC payment system, except for screening
flexible sigmoidoscopy and screening colonoscopy procedures. The
coinsurance for screening colonoscopies and screening flexible
sigmoidoscopies will be 25 percent, as required by section 1834(d) of
the Act, with no deductible for those services under the revised ASC
payment system. This requirement is reflected in our regulations at
Sec. Sec. 416.172(b) and (d).
J. Phase-In of Full Implementation of Payment Rates Calculated Under
the Revised ASC Payment System Methodology
We discussed in section XXVII.D. of the preamble to the August 2006
proposed rule for the revised ASC payment system (71 FR 49690 through
49695), our analysis of the impact that the revised ASC payment system
and estimated payment rates for implementation in CY 2008 could have on
certain ASCs that specialize in or perform high volumes of procedures
for which payment under the new system would decrease. We wanted to
ensure that the revised payment system does not cause a sudden,
unwarranted migration of services from ASCs to other ambulatory
settings, or the reverse; that ASCs would have an opportunity to
balance their Medicare case[pi]mix between procedures whose rates
decrease and procedures whose rates increase; and that beneficiaries
and their physicians would continue to have a robust choice of sites
where important preventive and other surgical services are paid under
Medicare.
In the August 2006 proposed rule, we proposed to implement the
revised ASC payment system in CY 2008 using transitional payment rates
that would be based upon a 50/50 blend of the CY 2007 ASC payment rate
for a procedure on the CY 2007 ASC list of covered surgical procedures
and the final payment rate for that same procedure calculated under the
revised payment system methodology described in the proposed rule and
reflected in proposed new Sec. 416.171(c). We further proposed that,
in CY 2009, we would fully implement the ASC payment rates calculated
under the proposed payment methodology, discontinuing the blended
transitional payment rates for services furnished beginning January 1,
2009. This was proposed in new Sec. 416.171(d).
Comment: Several commenters expressed concern that the proposed 2-
year transition period would threaten the viability of many ASCs. The
commenters indicated that given the size of the payment cuts
contemplated under the proposed rule for certain procedures and
specialties, especially gastrointestinal, pain management, and
ophthalmology services, 1 year would not provide adequate time for ASCs
to adjust to the changes and that a 4-year phase-in would allow a more
gradual and less disruptive transition to the new payment system. Many
commenters urged CMS to implement policies to further address the
decrease in payments for procedures whose rates would fall
significantly during a
[[Page 42520]]
transition to the new payment system. One commenter suggested that CMS
hold harmless procedures that were on the ASC list of covered surgical
procedures prior to CY 2008 to prevent significant changes in payments
during the transition. Some commenters expressed concern that if CMS
revises both the payment system and the geographic localities used for
wage adjustment at the same time, providers in certain areas could
experience dramatic shifts in payment as a result of the cumulative
effect of the wage index and other policy changes that were described
in the proposed rule. These commenters encouraged CMS to consider the
cumulative effects of the wage index and other policy changes on
payments to ASCs under the revised ASC payment system and develop a
transitional approach that protects providers from significant
reductions in payment.
A number of commenters supported the proposed 2-year phase-in of
the ASC payment rates based on the final methodology of the revised ASC
payment system. The commenters generally believed that the transition
period as proposed would provide sufficient notice and time for ASCs to
adapt to the revised payment system.
Some commenters stated that the proposed transition does not
appropriately address payment for device-intensive procedures that
implant devices that are paid separately according to the DMEPOS fee
schedule under the existing payment system during the transitional year
of CY 2008. Some of these commenters urged CMS to devise a strategy
that would accelerate full implementation of payment for device-
intensive procedures according to the proposed methodology for the
revised ASC payment system. Alternatively, other commenters suggested
that CMS develop a final transitional policy that does not exclude the
payments for implanted devices now paid separately under the DMEPOS fee
schedule in calculating the CY 2007 ASC payment contributions to the
blended payment rates for device-intensive procedures for CY 2008.
Response: After consideration of all of these public comments, we
agree with the majority of the commenters who indicated that a 2-year
transition may provide some ASCs with insufficient time to adapt to the
revised payment system. During the transition to the revised system, we
believe it is important to maintain appropriate Medicare beneficiary
access to ASC services. In addition, we do not believe that the
transition should be asymmetrical, meaning that procedures with
decreasing payments under the revised payment system should be
transitioned differently from those with increasing payments. We also
do not believe that the transition should lead to increases or
decreases in overall Medicare ASC expenditures.
Therefore, in order to provide additional time for ASCs to adapt to
the revised payment system and to facilitate Medicare beneficiary
access to ambulatory surgical procedures at those ASCs that may not
adjust as quickly as others to the revised payment system, we are
extending the transition from our proposed 2 years to 4 years for all
services on the CY 2007 ASC list of covered surgical procedures, as
reflected in Sec. 416.171(c). We believe a transition period of 4
years, comparable to transition periods provided under other payment
systems (for example, the recent practice expense changes to the MPFS)
and as suggested in comments concerning this issue, will provide a
reasonable and balanced approach to implementation that addresses two
important objectives, in particular offering sufficient notice and time
for ASCs to adapt to the revised payment system and providing more
accurate and appropriate ASC payments for covered surgical procedures.
The contribution of CY 2007 ASC payment rates to the blended
transitional rates will decrease by 25 percentage point increments each
year of transitional payment, until CY 2011, when we will fully
implement the ASC payment rates calculated under the final methodology
of the revised payment system. Procedures new to ASC payment for CY
2008 or later calendar years will receive payments determined according
to the final methodology of the revised ASC payment system, as
reflected in Sec. 416.171(a), without the need for a transition. ASC
covered surgical procedures listed in Addendum AA to this final rule
that are subject to the transition are assigned to payment indicators
``A2'' (Surgical procedure on ASC list in CY 2007; payment based on
OPPS relative payment weight) and ``H8'' (Device-intensive procedure on
ASC list in CY 2007; paid at adjusted rate). ASC covered surgical
procedures listed in Addendum AA to this final rule that are not
subject to the transition are assigned to payment indicators ``G2''
(Non office-based surgical procedure added to ASC list in CY 2008 or
later; payment based on OPPS relative payment weight); ``J8'' (Device-
intensive procedure added to ASC list in CY 2008 or later; paid at
adjusted rate); ``P2'' (Office-based surgical procedure added to ASC
list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based
on OPPS relative payment weight); ``P3'' (Office-based surgical
procedure added to ASC list in CY 2008 or later with MPFS nonfacility
PE RVUs; payment based on MPFS nonfacility PE RVUs); and ``R2''
(Office-based surgical procedure added to ASC list in CY 2008 or later
without MPFS nonfacility PE RVUs; payment based on OPPS relative
payment weight).
In addition, we agree with commenters who indicated that an
adjustment should be made during the transition period for certain
procedures that implant devices that are separately payable under the
existing ASC payment system. For device-intensive procedures utilizing
separately payable devices of significant cost, ideally, we would
adjust the CY 2007 base rates for the procedures to appropriately
reflect the fact that associated devices may have been separately paid
to ASCs in CY 2007 under the DMEPOS fee schedule, but beginning in CY
2008 implantable device payment will be packaged into the ASC payment
for the covered surgical procedure under the revised ASC payment
system. This would require associating the current separately provided
implantable device payments with specific covered surgical procedures,
in order to determine an appropriate CY 2007 base payment rate for the
transition for each procedure. However, due to the challenges in making
these associations, including the common historical practice of payment
at contractor-priced rates for some implantable devices that have been
reported only under Level II HCPCS unlisted codes under the existing
payment system, we cannot accurately allocate those device payments to
covered surgical procedures using the ASC data.
Under the final methodology of the revised ASC payment system for
calculating payment for procedures with significant device costs as
discussed in section IV.C.2.e. of this final rule, for device-intensive
procedures on the CY 2007 ASC list of covered surgical procedures, we
will separately determine both the device payment and service payment
portions of the total ASC payment under the revised payment system. We
will apply the ASC conversion factor only to the specially calculated
OPPS relative payment weight for the service portion, while providing
the same packaged payment for the device portion as would be made under
the OPPS. That is, we will determine the payment amount attributable to
the device, as currently determined under the OPPS, and
[[Page 42521]]
combine that payment amount with the adjusted ASC service payment,
resulting in a total ``bundled'' ASC payment for the device-intensive
procedure under the revised ASC payment system.
Consistent with that approach, we also will apply our transition
policy differentially to those portions of the total ASC payment. While
we will not subject the device payment portion of the total ASC payment
for the procedure under the revised ASC payment system to the
transition policy, we will transition the service payment portion of
the total ASC payment for the procedure over the 4-year phase-in
period. Device-intensive procedures that are new to the ASC list of
covered surgical procedures for CY 2008 or later years will be exempted
from any transition period and will be paid at the fully implemented
revised ASC payment system rates beginning in CY 2008 or the applicable
update year, just like all other new ASC surgical procedures. During
each of the transition years, when the CY 2007 ASC payment rate for a
device-intensive procedure that did not previously include packaged ASC
payment for the implantable device itself is blended with the payment
developed under the methodology of the revised ASC payment system that
would otherwise package the device payment, the full device payment
amount will be paid to ASCs in the transition year, with blended
payment determined only for the service portion of the ASC payment, for
which a corresponding CY 2007 ASC payment rate exists. This methodology
achieves an appropriate payment for costly, implantable devices,
because it recognizes that, in general, the device costs are similar
for ASCs and HOPDs. This specific transition approach for device-
intensive procedures ensures that ASCs receive appropriate packaged
payment for implantable devices during the transition years, even
though payment for such devices is generally not included in their base
CY 2007 ASC payment rates under the existing ASC payment system.
A full discussion of the calculation of the payment rates for these
device-intensive procedures can be found in section IV.C.2.e. of this
final rule, in the context of establishing payment weights for device-
intensive procedures under the revised ASC payment system. Tables 5 and
6 above are illustrative of the device-intensive procedures likely to
be subject to this special transitional policy for device-intensive
procedures under the revised ASC payment system, pending updating of
their OPPS status in CY 2008 and future years.
After considering the public comments received, we are finalizing a
policy to phase in implementation of the payment rates calculated under
the revised ASC payment system over 4 years. For CYs 2008, 2009, and
2010, payment will be made for each procedure on the CY 2007 ASC list
of covered surgical procedures based on a 25/75, 50/50, and 75/25
blend, respectively, of the CY 2007 payment rate for the procedure and
the payment rate for that procedure calculated under the standard
revised payment system methodology set forth in Sec. 416.171(a).
Procedures that are newly approved for ASC payment in CY 2008 or later
years are not subject to the transition policy. In CY 2011, we will
fully implement the ASC payment rates calculated under the standard
payment methodology of the revised ASC payment system. This final
transition policy is set forth in Sec. 416.171(c).
The service payment portion of the total ASC payment for device-
intensive procedures that are on the ASC list of covered surgical
procedures in CY 2007 will be subject to the transition. The service
payment portion calculated under the fully implemented revised ASC
payment system methodology will be blended with the ASC payment for the
procedure under the existing payment system. In contrast, the device
payment portion of the total ASC payment for these procedures, where
the device would generally have been paid separately according to the
DMEPOS fee schedule under the existing ASC payment system, will not be
subject to the transition. Rather, the contribution of the device
payment portion to the total ASC payment during the transitional years
will be calculated according to the methodology of the fully
implemented revised ASC payment system. During the years of phase-in of
the revised ASC payment system, the device payment portion will be
summed with the blended service payment portion (that is, the 25/75,
50/50, or 75/25 blend, as appropriate) to establish the total ASC
payment for these device-intensive procedures for each year of the
transition. Device-intensive procedures new to the ASC list of covered
surgical procedures for CY 2008 or later years will be paid the fully
implemented revised payment system rates.
V. Calculation of ASC Conversion Factor and ASC Payment Rates for CY
2008
A. Overview
As discussed in section IV.B. of this final rule, in the August
2006 proposed rule, we proposed to base ASC relative payment weights
and payment rates under the revised ASC payment system on APC groups
and relative payment weights established under the OPPS. We also
proposed to set the ASC relative payment weight for certain office-
based surgical procedures so that the national ASC payment rate does
not exceed the MPFS unadjusted nonfacility practice expense amount. We
explained that the proposed ASC payment weights would be multiplied by
an ASC conversion factor to calculate the ASC payment rates. In the
August 2006 proposed rule, our estimate for the CY 2008 budget neutral
ASC conversion factor was $39.688. In this final rule, we estimate that
the ASC conversion factor for CY 2008 will be approximately $42.543.
This new estimate of the ASC conversion factor differs from the
estimate in the August 2006 proposed rule for a number of reasons,
including: (1) Use of the final OPPS relative payment weights for CY
2007; (2) use of the final MPFS nonfacility practice expense payment
amounts for CY 2007; (3) use of updated utilization data for the full
year of CY 2005; (4) a 4-year instead of 2-year transition to the
revised payment system rates, with a modified transition for device-
intensive procedures; (5) more recent estimates of the hospital market
basket update and the MPFS conversion factor update for CY 2008; and
(6) adoption of the with-migration approach to calculation of the
budget neutrality adjustment using different time periods for the
assumed migration of procedures from physicians' offices and HOPDs to
ASCs under the revised ASC payment system. Specific details regarding
our final methodology for estimating the revised ASC payment system
conversion factor are discussed later in this section.
We are not able to provide the final CY 2008 ASC conversion factor
in this final rule for the revised ASC payment system because the final
conversion factor will be based on the final OPPS relative payment
weights for CY 2008, the final MPFS nonfacility practice expense
payment amounts for CY 2008, and updated and complete CY 2006
utilization data, all of which are unavailable at this time but will be
available for the CY 2008 OPPS/ASC final rule. Therefore, in this final
rule, we are finalizing the methodology for calculating the ASC
conversion factor for the revised ASC payment system. When the
necessary data are available, they will be used in the methodology
described in this final rule, and we will provide the final CY 2008 ASC
conversion factor and ASC relative
[[Page 42522]]
payment weights and rates in the CY 2008 OPPS/ASC final rule.
B. Budget Neutrality Requirement
Section 626(b) of Public Law 108-173 amended section 1833(i)(2) of
the Act by adding subparagraph (D) to require that in the year the
revised ASC system is implemented:
``* * * [S]uch system shall be designed to result in the same
aggregate amount of expenditures for such services as would be made if
this subparagraph did not apply, as estimated by the Secretary. * * *''
As discussed in the August 2006 proposed rule for the revised ASC
payment system, the ASC conversion factor is calculated so that
estimated total Medicare payments under the revised ASC payment system
would be budget neutral to estimated total Medicare payments under the
current ASC payment system as required by the statute. That is,
application of the ASC conversion factor would be designed to result in
aggregate expenditures under the revised ASC payment system in CY 2008
equal to aggregate expenditures that would have occurred in CY 2008 in
the absence of the revised system, taking into consideration the cap on
payments in CY 2007 as required under section 5103 of Public Law 109-
171, which we discuss further in section IV.A. of this final rule.
We note that, in the August 2006 proposed rule (71 FR 49656), we
considered the term ``expenditures'' in the context of section 626(b)
of the Public Law 108-173 budget neutrality requirement to mean
expenditures from the Medicare Part B Trust Fund. We did not consider
expenditures to include beneficiary coinsurance and copayments.
C. Calculation of the ASC Payment Rates for CY 2008
1. Proposed Method for Calculation of the ASC Payment Rates for CY
2008 in the August 2006 Proposed Rule
In the August 2006 proposed rule, we proposed to calculate the ASC
payment rates for CY 2008 as follows:
a. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Current ASC Payment System in the August 2006
Proposed Rule
Step 1: To estimate the aggregate amount of expenditures that would
be made in CY 2008 under the current ASC payment system, we first
multiplied the estimated CY 2008 ASC volume for each HCPCS code on the
CY 2007 ASC list of covered surgical procedures by the estimated CY
2008 ASC payment rate for the HCPCS code under the existing ASC system,
and then subtracted beneficiary coinsurance. In the August 2006
proposed rule, the estimated CY 2008 ASC payment rates were based on
the proposed CY 2007 ASC payment rates, which were listed in Addendum
AA to the rule, taking into account the OPPS cap on ASC services at the
OPPS rate as required by section 5103 of Public Law 109-171 and
reflecting the zero percent CY 2008 update for ASC services mandated by
section 1833(i)(2)(C)(iv) of the Act. Although we did not specify in
the August 2006 proposed rule that we did so, we also estimated the
amount the Medicare program would pay in CY 2008 for implantable
prosthetic devices and implantable DME for which ASCs currently receive
separate payment under the DMEPOS fee schedule. We then summed the
estimated DMEPOS fee schedule total amount and all of the estimated
procedure payment amounts for services on the CY 2007 ASC list of
covered surgical procedures to estimate the aggregate amount of
expenditures that would be made in CY 2008 under the policies of the
current ASC payment system.
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Proposed Revised ASC Payment System in the
August 2006 Proposed Rule
Step 2: To estimate the aggregate amount of expenditures that would
be made in CY 2008, we used estimated CY 2008 OPPS payment amounts
instead of estimated CY 2008 ASC payment amounts under the current
system, and we multiplied the estimated CY 2008 ASC volume for each
HCPCS code on the CY 2007 ASC list of covered surgical procedures by
the estimated CY 2008 OPPS payment rate for the HCPCS code, and then
subtracted beneficiary coinsurance. We summed the results for all
services on that ASC list of covered surgical procedures.
c. Calculation of the Proposed CY 2008 Budget Neutrality Adjustment in
the August 2006 Proposed Rule
Step 3: To calculate the proposed CY 2008 ASC budget neutrality
adjustment, we divided the total expenditures calculated in Step 1 by
the total expenditures calculated in Step 2. We calibrated this
estimate of the budget neutrality adjustment to take into account that,
in CY 2008, the payment rate for procedures on the CY 2007 ASC list of
covered surgical procedures was proposed to be 50 percent of the CY
2007 ASC payment amount and 50 percent of the CY 2008 ASC payment rate
calculated according to the proposed revised payment system methodology
without the transition. The result of these calculations was a budget
neutrality adjustment of 0.62.
d. Application of the Budget Neutrality Adjustment To Determine the
Proposed CY 2008 ASC Conversion Factor in the August 2006 Proposed Rule
Step 4: To determine the proposed CY 2008 ASC conversion factor, we
multiplied the estimated CY 2008 OPPS conversion factor by the result
of Step 3. The proposed estimated CY 2008 OPPS conversion factor was
$64.013. Multiplying the estimated CY 2008 OPPS conversion factor by
the 0.62 budget neutrality adjustment yielded our proposed CY 2008 ASC
conversion factor of $39.688.
e. Calculation of the Proposed CY 2008 ASC Payment Rates Under the
Revised ASC Payment System in the August 2006 Proposed Rule
Step 5: To determine the proposed national ASC payment rates for
covered surgical procedures under the revised payment system (including
beneficiary coinsurance), we multiplied the ASC conversion factor from
Step 4 by the ASC relative payment weight.
The proposed ASC relative payment weights for covered surgical
procedures were based on the relative payment weights for the APC
groups established under the OPPS as described in section IV.B. of this
final rule. However, as further discussed in section IV.E. of this
final rule, the ASC relative payment weights for certain office-based
surgical procedures were set so that the national ASC payment rate did
not exceed the MPFS unadjusted nonfacility practice expense amount.
f. Calculation of the Proposed CY 2008 ASC Payment Rates Under the
Transition in the August 2006 Proposed Rule
Step 6: We proposed to fully implement the revised ASC payment
rates through a 2-year transition to 100 percent implementation of the
revised ASC payment rates for procedures included on the CY 2007 ASC
list of covered surgical procedures. In the first year of the
transition, the payment rate would be based on 50 percent of the final
CY 2007 ASC payment rate under the existing ASC payment system and 50
percent of the final CY 2008 ASC payment rate calculated under the
proposed revised payment methodology. The CY 2008 payment for
procedures not on the CY 2007 ASC list of covered surgical procedures,
but for which we proposed to make payment
[[Page 42523]]
under the revised payment system beginning in CY 2008, would be made at
the fully implemented revised ASC payment rates.
2. Alternative Option for Calculating the Proposed Budget Neutrality
Adjustment in the August 2006 Proposed Rule
In the August 2006 proposed rule, we presented an alternative
approach to calculating the budget neutrality adjustment under the
revised ASC payment system, which would take into account the effects
of migration of procedures across ASCs, physicians' offices, and HOPDs
that might be attributable to the revised ASC payment system (71 FR
49657 through 49658). In the following discussion, the phrase ``new ASC
procedure'' refers to a surgical procedure not on the CY 2007 ASC list
of covered surgical procedures but for which we proposed to make
payment under the revised ASC payment system beginning in CY 2008.
Under this alternative, we assumed that 25 percent of the HOPD
utilization for new ASC procedures would migrate to ASCs, and we also
assumed that 15 percent of the physician's office utilization for new
ASC procedures would migrate to ASCs in the first year of the revised
ASC payment system. In the August 2006 proposed rule, we also noted our
belief that our assumptions of 25 percent and 15 percent migration from
HOPDs and physicians' offices to ASCs, respectively, were reasonable,
given the general utilization relationships between those settings for
services on the CY 2007 ASC list of covered surgical procedures.
Services on the ASC list of covered surgical procedures that are
predominantly performed in ASC and HOPD settings are, on average,
performed 30 percent of the time in the ASC setting. Furthermore,
services on the existing ASC list of covered surgical procedures that
are mainly performed in ASC and physician's office settings are, on
average, performed 17 percent of the time in the ASC setting. We
assumed that new ASC procedures would migrate at slightly lower rates
in the first year of the revised ASC payment system, yielding our
migration assumptions to ASCs of 25 percent for the HOPD services and
15 percent for the physician's office services.
We also assumed that the net impact of migration of services on the
existing CY 2007 ASC list of covered surgical procedures would be
negligible. We noted that payment rates for the current highest volume
ASC procedures would generally decrease under the proposed revised ASC
payment system, and the lower volume ASC procedures would experience
significant payment increases. We believed it was reasonable to assume
that some of the higher volume services would migrate from ASCs to
other settings, and some of the current lower volume procedures would
migrate to the ASC setting as a result of the payment changes.
In order to calculate the budget neutrality adjustment under this
alternative option in the August 2006 proposed rule, first we estimated
expenditures that would occur if we did not revise the ASC payment
system. We estimated CY 2008 expenditures if the ASC payment rates were
not revised and the ASC list of covered surgical procedures was not
expanded, as described below.
a. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Existing ASC Payment System in the August 2006
Proposed Rule
Step 1: Migration from HOPDs to ASCs was valued using estimated CY
2008 OPPS payment rates.
(a) We multiplied the estimated CY 2008 HOPD utilization for each
new ASC procedure by 0.25, consistent with our assumption that 25
percent of the HOPD utilization for new ASC procedures would migrate to
the ASC.
(b) For each new ASC procedure, we multiplied the results of Step
1(a) by the estimated CY 2008 OPPS payment rate for the procedure, and
then subtracted beneficiary coinsurance for the procedure.
(c) We summed the results of Step 1(b) across all new ASC
procedures.
Step 2: Migration of procedures from physicians' offices to ASCs
was valued using estimated CY 2008 MPFS physician in-office payment
rates. ``Physician in-office payment rate'' was equal to the MPFS
nonfacility practice expense RVUs multiplied by the estimated CY 2008
MPFS conversion factor.
(a) To estimate the payment associated with our assumption that 15
percent of the physicians' office utilization for new ASC procedures
would migrate to the ASC, we multiplied the projected CY 2008
physicians' office utilization for each new ASC procedure by 0.15.
(b) For each new ASC procedure, we multiplied the results of Step
2(a) by the estimated CY 2008 physician in-office payment rate for the
procedure, and then subtracted beneficiary coinsurance for the
procedure.
(c) We summed the results of Step 2(b) across all new ASC
procedures.
Step 3: CY 2007 ASC services valued using the estimated CY 2008 ASC
payment rates under the current ASC system.
This is described under Step 1 in the Estimated Payments under the
Current ASC Payment System section, specifically section V.C.1.a.
above.
Step 4: The results of Steps 1-3 were summed.
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Proposed Revised ASC Payment System in the
August 2006 Proposed Rule
Step 5: HOPD migration was valued using estimated CY 2008 OPPS
payment rates.
This step is the same as Step 1 in section V.C.2.a. above.
Step 6: We identified new ASC procedures that were office-based (as
discussed in section III.C. of this final rule).
Step 7: Migration of new ASC office-based procedures from
physicians' offices to ASCs was valued based on estimated CY 2008 OPPS
payment rates capped at the estimated CY 2008 physician in-office
payment rates, if appropriate.
(a) For each new ASC procedure determined to be office-based, we
multiplied the results of Step 2(a) from section V.C.2.a. above by the
lesser of--
(1) The estimated CY 2008 OPPS payment rate for the procedure; or
(2) The estimated CY 2008 physician in-office payment rate for the
procedure, and then subtracted beneficiary coinsurance for the
procedure. (As noted in subsequent discussion in section V.C.3. of this
final rule, we applied this adjustment for the capped office-based
procedures after publication of the proposed rule and posted the
results on our Web site.)
(b) The results of Step 7(a) were summed across all new ASC
procedures considered to be office-based.
Step 8: Migration of new ASC procedures that were not determined to
be office-based from physicians' offices to ASCs was valued using the
estimated CY 2008 OPPS rates.
(a) For each new ASC procedure not considered to be office-based,
we multiplied the results of Step 2(a) from section V.C.2.a. above by
the estimated CY 2008 OPPS rate for the procedure, and then subtracted
beneficiary coinsurance for the procedure.
(b) The results of Step 8(a) were summed across all new ASC
procedures not considered to be office-based.
Step 9: Migration of new ASC procedures from physicians' offices to
ASCs was valued using the estimated CY 2008 MPFS physician out-of-
office payment rates. ``Physician out-of-office
[[Page 42524]]
payment rate'' was equal to the facility practice expense RVUs
multiplied by the estimated CY 2008 MPFS conversion factor.
(a) For each new ASC procedure, we multiplied the results of Step
2(a) from section V.C.2.a. above by the estimated CY 2008 physician
out-of-office payment rate for the procedure, and then subtracted
beneficiary coinsurance for the procedure.
(b) The results of Step 9(a) were summed across all new ASC
procedures.
Step 10: Current ASC services were valued using the estimated CY
2008 OPPS payment rates.
This is described under Step 2 in section V.C.1.b. above.
Step 11: The results of Steps 5 and 7-10 were summed.
c. Calculation of the Proposed CY 2008 Budget Neutrality Adjustment in
the August 2006 Proposed Rule
Step 12: The result of Step 4 was divided by the result of Step 11.
Step 13: The calculation of the budget neutrality adjustment in
Step 12 was calibrated in a number of ways. The application of the cap
at the estimated CY 2008 MPFS nonfacility practice expense amount that
occurred in Step 7 was dependent on the ASC conversion factor. The ASC
budget neutrality adjustment resulting from Step 12 was calibrated to
take into account the effects of the physician's office payment cap on
the ASC conversion factor. The ASC budget neutrality calculation was
also calibrated to take into account the fact that the additional
physician out-of-office payments under the revised ASC payment system
calculated in Step 9 must be fully offset by the budget neutrality
adjustment to ASC services under the revised payment system.
Furthermore, the budget neutrality calculation was calibrated to take
into account the CY 2008 transitional payment rates for procedures on
the CY 2007 ASC list of covered surgical procedures.
As reported in the August 2006 proposed rule (71 FR 49658), the
budget neutrality adjustment calculated using this alternative option
that incorporated CMS' migration assumptions was 0.62, indicating that
under the migration assumptions described above there was no
difference, rounded to the nearest hundredth, between our proposed
budget neutrality adjustment without migration (0.62) and the
alternative budget neutrality adjustment with migration (0.62).
d. Discussion of the Alternative Calculation of the Budget Neutrality
Adjustment
We chose to propose calculation of the budget neutrality adjustment
based on the CY 2007 final ASC list of covered surgical procedures and
the most recent available ASC utilization data because we believed this
was the most appropriate approach to estimating expenditures to result
in a budget neutral payment system in CY 2008. We believed that the
data available to us did not enable us to precisely estimate the net
potential migration of services between the ASC, outpatient hospital,
and physician's office settings that might result from implementation
of the revised ASC payment system. Moreover, basing our estimate of
expenditures on current ASC utilization without including migration
from other sites of service was consistent with how we estimate
expenditures for purposes of establishing budget neutrality in other
Medicare payment systems. However, we recognized, that significant
service migration would not generally be expected to occur under these
other payment systems and acknowledged that the potential for migration
could be significantly greater under the revised ASC payment system,
with a possible effect on Medicare expenditures. Our recognition of the
uniqueness of the revised ASC payment system was the reason we
presented the alternative with-migration budget neutrality adjustment
calculation in the August 2006 proposed rule, so commenters would have
the opportunity to fully examine this model, in addition to the
traditional without-migration methodology that we proposed to use.
Given that the revised ASC payment system includes a significant
expansion of procedures for which ASC payment would be allowed, in
addition to the expected service mix changes that result from the
changes in payment incentives that accompany the introduction of any
revised payment system, we expected that some commenters might believe
that it would be more appropriate to estimate the ASC budget neutrality
adjustment taking into account the potential migration of services
between the ASC, hospital outpatient, and physician's office settings,
consistent with the alternative with-migration model discussed in the
August 2006 proposed rule. In that proposed rule, we explained that we
would welcome data supporting the use of specific migration assumptions
in the calculation of the ASC budget neutrality adjustment. We
described the budget neutrality calculation under the alternative
approach based on our best estimate of the potential migration of
services between the different settings, hoping to facilitate and
stimulate comment on migration that could occur and specifically to
encourage the submission of pertinent quantitative evidence of service
migration resulting from changes in payment rates. We welcomed data on
all of the migration assumptions presented in the proposed rule
discussion of the alternative approach. We noted that there was no
difference between our proposed budget neutrality calculation without
migration (0.62) and the alternative budget neutrality adjustment with
migration (0.62), when rounded to the nearest hundredth.
Comment: Many commenters recommended different interpretations of
section 626(b) of Public Law 108-173. The commenters believed that CMS'
interpretation of the law's requirement that CMS ensure the budget
neutrality of the revised system was overly restrictive and that
consequently, the proposed budget neutrality factor was not adequate to
make fair ASC payments. According to the commenters' interpretations of
the law, they believed that CMS has the clear legal authority to make
assumptions regarding the migration of procedures between different
sites of service, and that expenditures for all services covered by the
ASC payment system, including beneficiary coinsurance, should be
considered in the calculation of budget neutrality. Most of the
commenters recommended that CMS include projected case migration across
ASC, HOPD, and physician's office settings in its budget neutrality
model and use total expenditures across all Medicare Part B sites of
service, rather than limit the base solely to estimated CY 2008
aggregate expenditures under the ASC payment system. Several commenters
supported the use of the alternative option for calculating budget
neutrality that incorporated the case migration assumptions as they
were presented in the August 2006 proposed rule, with the stipulation
that several technical corrections to fully account for the Medicare
expenditures for all procedures that were assumed to migrate to the ASC
would be made and that the resulting conversion factor would be 64.6
percent. Most other commenters believed that case migration would
certainly be one result of implementation of the revised ASC payment
system, and that CMS' budget neutrality adjustment model should include
recognition of those changes in sites of service and the related
Medicare expenditures. They recommended that
[[Page 42525]]
CMS use a model like the alternative option for calculating budget
neutrality presented in the August 2006 proposed rule and discussed
above in this final rule, but that the specific assumptions CMS used
should be revised as indicated in their comments.
Response: As discussed in the August 2006 proposed rule, we were
interested in comments from the public about our interpretation of
budget neutrality and our proposed methodology for developing the
budget neutrality adjustment factor for the revised ASC payment system.
We will fully address each of the specific technical corrections (for
example, that we account for differences in beneficiary coinsurance
amounts in HOPD and ASC settings) and migration assumption
modifications that were recommended by commenters in section V.C.3. of
this final rule. At the more general level, we noted the strong
preference among commenters for CMS to use the alternative, with-
migration methodology that would take into account the effects of
assumed migration of cases across ambulatory sites of service that
could result from the payment changes associated with the revised ASC
payment system. The August 2006 proposal reflected our belief that
adoption of the without-migration model was more appropriate than the
alternative with-migration model that was also discussed. In the
proposal, we explained that basing our estimate of expenditures on
current utilization without including migration from other sites of
services was consistent with how we estimate expenditures for purposes
of maintaining budget neutrality in other Medicare payment systems. We
realized that the influx of newly covered procedures was unique to our
proposal for the revised ASC payment system, but because the budget
neutrality adjustment that resulted from both models in the August 2006
proposed rule was the same and data to determine estimates of potential
case migration were limited, we adopted the without-migration model in
our proposal, consistent with our previous modeling to ensure that our
payment systems are budget neutral.
We agree with commenters that the flexibility to include migration
assumptions in our calculation of budget neutrality for the revised ASC
payment system is provided by the statute. Furthermore, our review of
the extensive comments on the August 2006 proposed rule led to our
conclusion in this final rule that the significant expansion of ASC
covered surgical procedures proposed as part of the revised system is
not only a unique aspect of the revised ASC payment system, but that
its effects on ASC expenditures may be substantial. An influx of new
covered services has not been a factor in developing the budget
neutrality adjustment factors for our other prospective payment
systems. The scope of services in other payment systems does not change
significantly from one year to the next, as does the ASC scope of
services between CYs 2007 and 2008 in the context of our final policies
for the revised ASC payment system, as discussed in sections III. and
IV. of this final rule.
In view of our belief that the revised ASC payment system is unique
because of the significant expansion of covered surgical procedures and
covered ancillary services to be paid under the revised ASC payment
system, we conclude that including estimates of case migration of the
new procedures, as well as the existing ASC covered surgical
procedures, is the most accurate method for developing the budget
neutrality adjustment in this case. After reviewing all of the public
comments and reexamining the available data, we believe that there is
sufficient evidence to indicate that adoption of a with-migration
methodology for calculating the budget neutrality adjustment for the
revised ASC payment system is appropriate. Thus, we have determined
that it would be prudent, and more accurate, to adopt a with-migration
budget neutrality estimation methodology, in order to take into account
the effects of the migration of procedures between ASCs, physicians'
offices, and HOPDs that might be attributable to the revised ASC
payment system. While the budget neutrality estimation methodology that
takes into account migration increases the complexity associated with
establishing the budget neutrality adjustment, we believe that its
application provides us with the most reasonable approach to
establishing payment rates under the revised ASC payment system in
order to assist in ensuring continued access to current ASC procedures
and expanded access to new surgical procedures for Medicare
beneficiaries in ASCs.
Although we are convinced that the with-migration model is more
appropriate for calculating the final budget neutrality adjustment
factor for the revised ASC payment system, we calculated the budget
neutrality adjustment for this final rule using both with-migration and
without-migration models, as we had for the August 2006 proposed rule.
However, in contrast to the results of our work for that proposed rule,
where application of either model resulted in the same adjustment
factor, the budget neutrality factors that resulted from application of
the two methods for this final rule were different. The adjustment
factor that resulted from application of our proposed model that did
not consider migration was 0.64, while the with-migration model
resulted in a 0.67 budget neutrality adjustment factor. For a full
discussion of the calculation of the final budget neutrality adjustment
factor, we refer readers to section V.C.3. of this final rule.
Comment: Several commenters agreed with the use of a blended rate
for CY 2008 to calculate budget neutrality for the revised ASC payment
system, based on the proposal for a 2-year transition to the fully
implemented revised payment system. They believed this use of
discretion was an appropriate interpretation of the legislation and
produced the most reasonable result. They believed that, because the
proposed CY 2008 rates were a 50/50 blend of the CY 2007 ASC rate and
the estimated CY 2008 ASC rate calculated according to the methodology
of the proposed revised ASC payment system, the ASC payment system
would have increased expenditures in CY 2009 unless migration patterns
differed from the assumptions discussed in the proposed rule regarding
the alternative calculation of the budget neutrality adjustment. These
commenters concluded that the increased expenditures that would result
from our adoption of their recommendation to utilize a modification of
the alternative calculation of the proposed budget neutrality
adjustment were expected, appropriate, and consistent with the budget
neutrality provision of section 626(b) of Public Law 108-173 for the
revised ASC payment system.
Response: We agree with commenters that the migration assumptions
influence the relationship between estimated expenditures under the
current ASC system and the revised ASC payment system over time. As
noted elsewhere in sections IV.J. and V.C.4 of this final rule, we have
extended the transition period for payment of services on the CY 2007
ASC list of covered surgical procedures and have also modified our
migration assumptions to reflect migration over a more extended time
period than was reflected in our discussion of the alternative option
for calculating the budget neutrality adjustment in the August 2006
proposed rule. As described in section X. of this final rule, we
estimate that, over time, the expenditures under the revised ASC system
using our final migration assumptions would be slightly less than
[[Page 42526]]
the expenditures that would occur if we did not revise the system.
3. Calculation of the Estimated CY 2008 Budget Neutrality Adjustment
According to the Final Policy
In the August 2006 proposed rule, and as discussed earlier in this
section of the final rule, we described two methodologies for
determining the budget neutrality adjustment under the revised ASC
payment system that could then be used to establish the ASC conversion
factor for CY 2008 (71 FR 49656 through 49658). We proposed that, under
the standard methodology of the revised ASC payment system, the ASC
conversion factor would be multiplied by the ASC payment weight for
each covered surgical procedure to determine the procedure's CY 2008
ASC payment rate. As discussed in detail in section IV.C. of this final
rule, our final policy will also provide separate payment for covered
ancillary services under the revised ASC payment system. While the
payment rates for separately payable drugs and biologicals,
brachytherapy sources, corneal tissue acquisition, and implantable
devices with OPPS pass-through status that are covered ancillary
services, along with the device portion of ASC payment for device-
intensive covered surgical procedures, will be determined without
application of the ASC conversion factor, the final standard
methodology of the revised ASC payment system will apply the ASC
conversion factor to ASC payment weights to calculate the fully
implemented payment rates for covered surgical procedures and covered
ancillary radiology services. We received a number of general and
specific comments on our proposal for calculating the CY 2008 ASC
payment rates under the revised ASC payment system.
Comment: There was general agreement among the commenters that, in
the absence of cost data for surgical procedures performed in ASCs,
CMS' proposal to base the revised ASC payment system on the OPPS APC
groups and their relative payment weights was sound policy that could
reasonably be expected to result in accurate ASC payments for most
procedures. Further, the commenters generally agreed that ASC facility
costs are lower than the HOPD costs for providing the same surgical
services. The commenters gave specific examples of the reasons why
higher costs are incurred by hospitals, including the requirement that
HOPDs satisfy quality and safety standards that are not applied to
ASCs; the fact that hospitals' resources are available 24 hours a day,
7 days a week; Emergency Medical Treatment and Labor Act of 1986-
related (EMTALA-related) requirements; treatment of a more acutely ill
population with greater comorbidities; and higher uncompensated care
rates. Moreover, those commenters cited MedPAC's findings reported in
2003 and 2004 that hospitals probably incur higher costs than ASCs for
providing similar procedures, because HOPDs are subject to additional
regulatory requirements which are likely to increase their overhead
costs, and HOPDs also treat patients who are more medically complex.
Beyond these points, the commenters diverged on their opinions
about the accuracy and appropriateness of the proposed conversion
factor, as discussed in detail below.
Response: We appreciate the commenters' general support of our
proposal to base payment under the revised ASC payment system on the
OPPS relative payment weights and the APC groups. These comments were
consistent with the recommendation of the GAO (GAO-07-86) that CMS
should implement a payment system for procedures performed in ASCs
based on the OPPS, taking into account the lower relative costs of
procedures performed in ASCs compared to HOPDs. For further discussion
of this subject, as well as a summary of additional public comments and
our responses, we refer readers to section IV.B. of this final rule.
Comment: Several commenters specifically recommended that CMS adopt
75 percent as the multiplier to the OPPS conversion factor, so that
payment rates under the revised ASC payment system would be 75 percent
of the OPPS rates. They cited legislation that was introduced in the
U.S. Senate in 2003 in which payments to ASCs were to have been
provided at 75 percent of the OPPS rates. The proponents of that
proposed legislation believed that, by using a 75 percent factor to
reduce OPPS rates in order to provide payment for ASCs to perform
procedures, Medicare would save 25 cents for every dollar spent for
procedures performed in the ASC setting instead of the HOPD.
Several commenters also believed that, because ASC rates have been
frozen since 2003 while OPPS rates have been increased annually for
inflation, an unfair differential in payments between the two payment
systems has grown over the past several years. These commenters argued
that by calculating budget neutrality for the revised ASC payment
system using the static ASC rates in comparison with annually updated
OPPS rates, CMS proposed an inappropriately low budget neutrality
adjustment factor. They were convinced that, if CMS had implemented the
revised ASC payment system immediately after Congress passed Public Law
108-173 in 2003, before the differential between the payment rates for
the two systems increased due to the continued freeze on ASC rates, the
budget neutrality adjustment for the revised payment system would have
been close to 85 percent, rather than 62 percent as CMS proposed for
the revised payment system to be implemented in CY 2008. Other
commenters, noting that Congress gave CMS the authority to implement
the revised payment system between CY 2006 and CY 2008, expressed their
belief that, had CMS implemented the revised ASC payment system in an
earlier year, the budget neutrality adjustment would have been at least
8 percent higher than the 62 percent that was proposed.
Response: We see no rationale for estimating the budget neutrality
adjustment by comparing existing ASC payment system rates with OPPS
rates from an earlier calendar year, prior to implementation of the
revised ASC payment system. Congress provided CMS with the latitude to
implement the revised ASC payment system beginning on or after January
1, 2006, and not later than January 1, 2008. We believe that the
statute provides direction that the revised ASC payment system is to be
budget neutral in its design in order to result in the same aggregate
expenditures for services as would be made if the provisions of the
revised ASC payment system did not apply, that the ASC conversion
factor is not to be updated before CY 2010, and that implementation of
the revised system by January 1, 2008 is timely. There is no evidence
that Congress intended for CMS to attempt to maintain the relationship
between OPPS payment rates and ASC payments that existed at the time of
enactment of Public Law 108-173 (CY 2003) in the development of the
revised ASC payment system. We also see no rationale for adopting an
arbitrary multiplier, such as 75 percent of OPPS payment rates, that is
not founded on explicit consideration of budget neutrality as required
by the statute.
We received many public comments in response to our proposed budget
neutrality adjustment factor. A number of commenters included seven
specific recommendations, three of which were related to the migration
assumptions discussed as an alternative option for calculating the
budget neutrality adjustment in the proposed rule. The
[[Page 42527]]
other four were technical in nature and related to our proposed budget
neutrality model. A summary of the comments and our responses follow,
beginning with the four recommended technical modifications to our
proposed methodology, followed by the three migration assumption
recommendations.
Comment: One of the recommended technical modifications was that,
instead of basing ASC payments on CY 2007 rates for all procedures on
the CY 2007 ASC list of covered surgical procedures, CMS should use the
payment amounts that would be made in CY 2008 in the absence of the
revised payment system for those ASC procedures whose payments are
capped in CY 2007 due to section 5103 of Public Law 109-171. The
commenters believed that using the lower CY 2007 rates for ASC
procedures capped by section 5103 of Public Law 109-171 was an unfair
representation of estimated ASC payments under the existing payment
system in CY 2008. Their rationale was that, if the revised ASC system
were not implemented in CY 2008, the payments for those services under
the policy of the existing ASC payment system would increase in CY
2008, consistent with the overall projected increase in OPPS rates of 4
percent. The commenters expected that incorporation of this adjustment
would result in a 0.11 percentage point increase to the budget
neutrality adjustment.
Response: We do not agree that the ASC rates for these specific
services would necessarily increase consistent with an overall increase
in OPPS rates for CY 2008. Through the annual update of the OPPS, while
the aggregate spending is generally projected to increase in the
update, the specific payments for individual services may rise or fall
from year to year based on a variety of factors, including APC
recalibration. Because the ASC procedures that are capped at the OPPS
rates in CY 2007 are a small subset of all OPPS services, we are unable
to project that their rates would be subject to a 4 percent increase,
or indeed any increase, as suggested by the commenters. In addition, we
believe that Congress intended for the revised ASC payment system rates
and budget neutrality to be related to the estimated aggregate
expenditures for ASC services based on ASC payment rates from the year
prior to implementation of the revised system. Congress mandated that
the revised ASC system be budget neutral and be implemented by CY 2008.
It also set ASC updates to zero percent for the calendar years through
2009. We believe all of those actions, in combination, provide clear
indication that Congress did not intend for estimates of aggregate
expenditures under the existing ASC payment system to take into account
updated ASC payment rates for CY 2008. The limitations on ASC payments
prior to implementation of the revised ASC payment system, specifically
both section 626 of Public Law 108-173 that specifies that ASC rates
would not be updated before CY 2010 and, further, the limit on ASC
payment at the lesser of the OPPS or ASC rate, as required in section
5103 of Public Law 109-171 that extends until implementation of the
revised ASC payment system, provide clear evidence that the CY 2007 ASC
rates for covered procedures are to be used in developing the budget
neutrality adjustment for the revised payment system. We continue to
believe, for the purposes of this final rule, that the most appropriate
course for calculation of the budget neutrality adjustment, consistent
with our proposal, is to estimate that the CY 2008 rates for the ASC
procedures subject to the cap set forth in section 5103 of Public Law
109-171 in CY 2007 will be the same as their CY 2007 rates.
Comment: Some commenters stated that, in CMS' calculation of
estimated ASC payments under the existing ASC payment system for
comparison to payments under the proposed methodology for the revised
ASC payment system, CMS did not include payments for the costs of
implantable prosthetic devices that are currently separately paid to
ASCs under the DMEPOS fee schedule. The commenters recommended that CMS
include the amount paid to ASCs to cover the costs of separately
payable implantable prosthetics and DME under the DMEPOS fee schedule
to avoid understating Medicare's current full cost related to the
surgical implantation procedures. The commenters believed that
inclusion of those payments would increase the budget neutrality
adjustment by 0.41 percentage points.
Response: We agree with the commenters that the payments to ASCs
for the implantable prosthetic devices and DME should be included in
estimating total ASC payments for CY 2008 under the policies of the
existing ASC payment system. In fact, we did include those payments in
our proposed budget neutrality adjustment calculation, but we failed to
explicitly state that in our explanation in the August 2006 proposed
rule. Therefore, the effect of including those payments was reflected
in the budget neutrality adjustment that we proposed. We have also
included these payments in our calculation of the budget neutrality
adjustment for this final rule.
Comment: Several commenters believed that, although CMS accounted
for the 20 percent beneficiary coinsurance in ASCs by discounting by 20
percent all of the payment rates used to estimate the CY 2008 payments
under the existing ASC system and under the proposed methodology of the
revised ASC payment system, CMS did not appropriately account for
beneficiary coinsurance associated with the new ASC office-based
procedures for which payment was proposed to be limited to the MPFS
unadjusted nonfacility practice expense amount. They believed that CMS
should apply the 20 percent discount to those procedures because that
approach would more accurately and consistently reflect the Medicare
program costs, and they concluded that this change would increase the
budget neutrality adjustment by 0.43 percentage points.
Response: While we did not apply this discount to payment rates for
the capped office-based procedures newly proposed for ASC payment in CY
2008 in our calculation of the proposed budget neutrality adjustment,
we agree with this recommendation. Recognizing those lower costs to the
Medicare program, consistent with our calculation of program costs
under the existing ASC payment system and the standard methodology of
the revised ASC payment system, would be more accurate. Soon after
publication of the August 2006 proposed rule, we discovered this
oversight, made the appropriate adjustments to the data, and posted the
revised data on our Web site (http://www.cms.hhs.gov/ASCPayment).
Comment: Commenters noted that CMS did not account for the variable
copayment amounts associated with procedures under the OPPS for
purposes of establishing the budget neutrality adjustment under the
revised ASC payment system. The beneficiary copayment under the OPPS
varies from 20 to 40 percent of the payment rate, depending on the
procedure, whereas the coinsurance under the ASC payment system is 20
percent for all procedures. The commenters believed that as a result of
not considering the sometimes much higher copayments under the OPPS,
CMS artificially inflated Medicare's estimated payments under the
proposed methodology of the revised ASC payment system. They believed
that accurately accounting for the OPPS copayments would increase the
budget neutrality adjustment by 1.04 percentage points.
Response: We agree with the commenters regarding this
[[Page 42528]]
recommendation. We did not apply the variable OPPS copayment amounts in
the model that was proposed. However, soon after publication of the
August 2006 proposed rule, we discovered this oversight, made the
appropriate adjustments to the data, and posted the revised data on our
Web site (http://www.cms.hhs.gov/ASCPayment).
After considering the first four technical recommendations of many
commenters and making the two technical adjustments as described above,
the resulting increase in the proposed budget neutrality adjustment was
approximately 2.6 percentage points. We have applied these same two
technical adjustments in our calculation of the budget neutrality
adjustment for this final rule. In addition, we made another technical
change in this final rule by taking the multiple procedure discount
into account in our estimates of ASC, OPPS, and MPFS expenditures both
before and after implementation of the revised ASC payment system. We
factored the multiple procedure discount into our estimates of ASC,
OPPS, and MPFS spending under the existing and revised ASC payment
systems. We assumed that the pattern of multiple surgical procedures
furnished in ASCs and physicians' offices would be similar to the
pattern in HOPDs. Based on claims data indicating the prevalence of
multiple procedures in HOPDs, we estimated the percentage of discounted
units to total units for each procedure and then reduced the volume for
those procedures prior to estimating expenditures in each year. We
incorporated this reduction into our estimates of Medicare expenditures
under the ASC, OPPS, and MPFS payment systems both before and after
implementation of the revised ASC payment system. We had not factored
the multiple procedure discount into the August 2006 proposed rule
estimates.
The final three recommendations by commenters that were related to
the migration assumptions used in the alternative option for
calculating the budget neutrality adjustment presented in the August
2006 proposed rule are discussed below.
Comment: Many commenters believed that the alternative method for
calculating the budget neutrality adjustment that CMS discussed in the
August 2006 proposed rule described a preferable and superior method
for developing the budget neutrality adjustment for the revised ASC
payment system. They believed that developing and applying some
assumptions to account for the migration of services and their payment
across Medicare Part B sites of care would be the most appropriate
method for ensuring budget neutrality. However, they recommended that
CMS revise some of the assumptions regarding migration that were
described in that proposed rule.
The first of their recommendations in this regard was that CMS use
a much lower migration assumption of 2 percent for new ASC procedures
migrating from physicians' offices to ASCs. They were convinced that
CMS' assumption in the proposed rule that 15 percent of the current
office utilization of new ASC procedures would migrate to ASCs was far
greater than would be possible. They stated that ASCs do not have the
capacity to absorb that level of services. Furthermore, they explained
that ASCs have found that, once physicians acquire the equipment and
resources to provide a procedure in their offices, they prefer to
perform it there. The commenters believed that physicians only
typically perform procedures in an ASC or HOPD setting when there is a
particular patient need that requires the facility setting. They argued
that by allowing the new ASC procedures to receive payment in ASCs, CMS
would realize savings because cases could be moved from the office to
an ASC instead of to the more costly HOPD setting when the physician
determines that relocation of the service is preferable for a
particular beneficiary.
Furthermore, the commenters stated that ASCs would not only be
overwhelmed by the volume of cases CMS assumed would migrate to that
setting, but that ASCs would not welcome the influx of low paying,
minor procedures that could generally be performed in physicians'
offices over the more complex, higher paying procedures that ASCs are
accustomed to providing in the more efficient and intensive facility
setting. The commenters believed that adjusting the assumption for
migration of new ASC procedures from physicians' offices to ASCs to 2
percent of the cases would be more appropriate and would result in a
3.11 percentage point increase in the budget neutrality adjustment.
In addition, the commenters believed that CMS did not accurately
adjust for the likely negative migration of cases involving procedures
paid under the existing ASC payment system out of ASCs and into more
costly HOPDs under the proposal for the revised payment system. They
developed a model that they believed would more correctly predict the
migration of procedures out of ASCs and into HOPDs based on the
magnitude of the procedure's proposed payment rate decrease. In that
model, the commenters assumed that for every 10 percent decrease in a
procedure's ASC payment rate from the existing to the revised payment
system, 1.5 percent of the ASC volume would migrate to HOPDs. They
believed that CMS' application of this adjustment would result in a
0.51 percentage point decrease to the budget neutrality adjustment.
They also recommended that CMS account for the positive migration
of existing ASC covered procedures from HOPDs to ASCs by assuming that
for every 10 percent increase in a procedure's ASC payment rate under
the proposal for the revised ASC payment system, 1.5 percent of the
HOPD volume would migrate to ASCs, up to a maximum of 25 percent of the
procedure's current HOPD volume. Furthermore, commenters suggested that
ASC capacity would limit movement of these procedures to no more than
25 percent of each procedure's existing ASC volume. The commenters
believed that, although ASCs have significant excess capacity, as
confirmed by a CY 2006 industry study that showed that only about one
quarter of ASCs were operating above 60 percent operating room
capacity, they could not absorb more than 25 percent of the HOPD volume
for all ASC procedures for which payment was expected to increase under
the proposed revised payment system. They explained that application of
their assumption would result in a 5.57 percentage point increase in
the budget neutrality adjustment.
Response: We appreciate the extensive comments we received
regarding the appropriate migration assumptions to be applied in
determining the budget neutrality adjustment for the revised ASC
payment system. While commenters provided a number of suggestions
regarding migration assumptions for both the procedures on the CY 2007
ASC list of covered surgical procedures and new ASC procedures, they
did not provide data supporting all of the specific assumptions
regarding the relationship between expected service migration and
changes in payment rates that they recommended we adopt along with
their other migration assumptions. However, as stated above, we are
adopting a with-migration model for calculation of the final budget
neutrality adjustment factor because we believe that it is more
accurate than the without-migration model that we proposed that does
not consider the migration of new procedures across sites of service,
but we did not adopt the assumptions recommended by some commenters.
[[Page 42529]]
The CMS Office of the Actuary (OACT) developed the assumptions
utilized in the final budget neutrality model. With respect to current
ASC covered surgical procedures paid under the existing ASC payment
system, we did not accept the recommendation by commenters that we
should assume that negative migration, that is, movement of existing
ASC covered procedures out of ASCs and into the higher cost HOPD
setting, would have an effect on our budget neutrality adjustment that
is not equal to the effect of positive migration of cases from other
settings into ASCs. Rather, in this final rule, after reviewing
information provided by commenters and reevaluating current site-of-
service utilization patterns for exiting and new ASC procedures, we are
assuming that the effect on budget neutrality due to movement of cases
involving existing ASC procedures out of ASCs will be balanced by
movement of additional cases involving existing ASC procedures into
ASCs. We believe that it is reasonable to assume that the payment
increases for many currently low volume ASC procedures will result in
higher ASC volumes for those procedures under the revised ASC payment
system. Moreover, we believe that this anticipated positive migration
of those procedures will balance the estimated negative migration of
the high volume ASC procedures for which payment will decrease. Our
actuaries project that the net budgetary effect of migration into and
out of ASCs for procedures currently on the ASC list of covered
surgical procedures will be negligible.
Consistent with our assumption for the alternative budget
neutrality adjustment model discussed in the August 2006 proposed rule,
under the final methodology for the revised ASC payment system, we
assume that 25 percent of the current HOPD volume of new ASC procedures
would ultimately migrate from HOPDs to ASCs. However, taking into
consideration the final, longer 4-year transition period to the fully
implemented payment weights of the revised ASC payment system and the
final modifications to several aspects of the proposed payment policy
as discussed in this preamble, for this final rule, we assume that the
25 percent case migration would occur more gradually, over the first 2
years of the transition, instead of all in the first year. We believe
the migration would occur over the first 2 years of the 4-year
transition, as the ASC industry adapts to the revised ASC payment
system and the significant expansion of covered surgical procedures
described in this final rule. We agree with commenters that the level
of migration in a single year, as discussed in our presentation of the
with-migration budget neutrality adjustment model in the August 2006
proposed rule, would be difficult for ASCs to accommodate in a single
year, but we believe, based on current ASC and HOPD utilization and ASC
industry information, that the 25 percent case migration over 2 years
is most likely.
We believe that our assumption of 25 percent migration of current
HOPD volume for new ASC procedures is reasonable, given the general
utilization relationships between ASCs and HOPDs for services as
discussed in section V.C.2. above. We also note that commenters
generally did not disagree with our proposed HOPD migration assumption
for the new ASC procedures. As discussed in the August 2006 proposed
rule (71 FR 49657), services on the ASC list of covered surgical
procedures that are predominantly performed in ASC and HOPD settings
are, on average, performed 30 percent of the time in the ASC setting.
Thus, for calculation of the budget neutrality adjustment according to
the final policy of this final rule, we assume that new ASC procedures
would migrate at the slightly slower rate of 25 percent over the first
2 years of the 4-year transition, reflecting their movement toward the
general 30-percent site-of-service utilization pattern currently
observed for ASC covered surgical procedures as ASCs transition to the
revised ASC payment system.
Our assumed 25 percent migration of new ASC procedures from HOPDs
to ASCs differs considerably from the commenters' recommended positive
migration assumptions, because the commenters' model included all
current ASC procedures and applied a formula linking the magnitude of
ASC payment changes under the revised ASC payment system to the
expected volume of migration. Given that the commenters based their
estimate for this assumption on existing ASC procedures, they used 25
percent of current HOPD volume as the upper limit for migration from
HOPDs to ASCs, the same assumption we used for the migration of new ASC
procedures in CY 2008. However, because they believed that ASC capacity
would ultimately limit procedure movement, they also limited the
movement to 25 percent of the existing ASC volume for those procedures.
Our actuaries determined migration assumptions separately for existing
ASC covered procedures and new ASC procedures. As mentioned earlier,
the net effect of migration of existing procedures into and out of ASCs
is assumed to be negligible. For the new ASC procedures, it is assumed
that 25 percent of the current HOPD volume will migrate to ASCs during
the first 2 years of the revised ASC payment system.
The commenters assumed some negative migration of existing ASC
covered procedures from ASCs to HOPDs in response to price changes
under the revised ASC payment system, based on a relationship between a
procedure's decrease in ASC payment and its volume of migration.
However, as discussed above, we also believe that we have adequately
accounted for the expected migration of procedures currently covered in
ASCs from the ASC to the HOPD setting under the revised ASC payment
system.
Finally, the commenters' recommendation that we assume much less
migration from physicians' offices to ASCs for new ASC procedures due
to ASC capacity limitations led us to reconsider our earlier assumption
articulated in the August 2006 proposed rule for the alternative model
to calculate the budget neutrality adjustment. Thus, for this final
rule, although the actuaries' assumption is that 15 percent of the
physicians' office volume of new ASC procedures may eventually be
expected to move into ASCs, they did take into consideration the
commenters' argument that such a level of migration could not be fully
accommodated by ASCs in CY 2008. Therefore, in our final policy we
assume that the migration of these currently office-based cases would
occur more gradually, with an additional one quarter of the total
migration occurring in each year of the full 4-year transition period.
Thus, we expect that only 3.75 percent of the office utilization of new
ASC procedures would migrate to ASCs in CY 2008, followed by an
additional quarter of new cases in each subsequent year, reaching the
full 15 percent by the end of the transition period to the fully
implemented revised ASC payment rates. Given the current 17 percent ASC
utilization of procedures that are predominantly performed in
physicians' offices and ASCs that are on the existing ASC list of
covered surgical procedures, we see no reason to assume that only 2
percent of the current office volume for new ASC procedures would
migrate to ASCs, as suggested by some commenters. Instead, we believe
the eventual utilization data for those procedures would most likely
resemble the site-of-service utilization for procedures predominantly
performed in ASC and physician's office settings that are currently
paid in ASCs. Our
[[Page 42530]]
assumption of 15 percent is slightly lower than the current pattern of
17 percent ASC utilization, consistent with our expectation that
migration of the broad array of new ASC procedures would result in
slightly lower ASC utilization in 4 years than the currently observed
pattern for procedures on the CY 2007 ASC list of covered surgical
procedures that are predominantly performed in physicians' offices and
ASCs.
In addition, in the context of developing the budget neutrality
adjustment for the revised ASC payment system under the with-migration
model, the actuaries took into consideration the final payment policies
of the revised ASC payment system. These include the final changes to
the payment rate calculations for device-intensive procedures, as well
as the separate payment for covered ancillary services. While specific
current and projected ASC utilization of covered ancillary services is
difficult to estimate, in establishing the final budget neutrality
adjustment, the actuaries took into account the findings of the GAO
that payment for many of these ancillary services is currently provided
to other Medicare Part B suppliers under the existing ASC payment
system, and that most drugs and biologicals utilized with current ASC
procedures do not receive separate payment under the OPPS.
In summary, since our discussion of the alternative model for
calculating the budget neutrality adjustment presented in the August
2006 proposed rule for the revised ASC payment system, the actuaries
have continued to refine the assumptions and estimates related to the
with-migration budget neutrality model to take into account policy
decisions made in this final rule, additional research, information
from industry experts, and public comments. Application of our final
revised migration assumptions, along with changes to the OPPS rates,
MPFS rates, and updated utilization data, as well as the final payment
policies for the revised ASC payment system, taken together result in
an estimated budget neutrality adjustment of 0.67. The estimated budget
neutrality adjustment of 0.67 in this July 2007 final rule for the
revised ASC payment system is based on the CY 2007 OPPS relative
payment weights, with an estimated update factor for CY 2008, the CY
2007 MPFS PE RVUs trended forward to CY 2008, and CY 2005 utilization
data projected forward to CY 2008. It is important to note that the
budget neutrality estimate in this final rule is illustrative only. The
CY 2008 ASC budget neutrality adjustment will be proposed in the CY
2008 OPPS/ASC proposed rule based on the methodology for calculating
budget neutrality established in this final rule and incorporating the
proposed CY 2008 OPPS relative payment weights, the proposed CY 2008
MPFS PE RVUs, and CY 2006 utilization information projected forward to
CY 2008. The final CY 2008 ASC budget neutrality adjustment will be
established in the CY 2008 OPPS/ASC final rule with comment period. The
final CY 2008 ASC budget neutrality factor will be calculated in that
rule in accord with the methodology for calculating budget neutrality
established in this July 2007 final rule and based on the final CY 2008
OPPS relative payment weights, the final CY 2008 MPFS PE RVUs, and
updated CY 2006 utilization data projected forward to CY 2008.
4. Final Calculation of the Estimated ASC Payment Rates for CY 2008
The following is a step-by-step illustration of the final budget
neutrality adjustment calculation.
a. Estimated CY 2008 Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Existing ASC Payment System
Step 1: Migration from HOPDs to ASCs is valued using estimated CY
2008 OPPS payment rates.
(a) We multiply the estimated CY 2008 HOPD utilization for each new
ASC procedure by 0.125, consistent with our assumption that 25 percent
of the HOPD utilization for new ASC procedures will migrate to the ASC
over the first 2 years of the revised ASC payment system, only half of
which would be in CY 2008. In estimating HOPD utilization for CY 2008,
we take into account the impact of the multiple procedure discount (as
discussed in more detail in section V.C.3. of this final rule).
(b) For each new ASC procedure, we multiply the results of Step
1(a) by the estimated CY 2008 OPPS payment rate for the procedure, and
then subtract beneficiary coinsurance for the procedure.
(c) We sum the results of Step 1(b) across all new ASC procedures.
Step 2: Migration of procedures from physicians' offices to ASCs is
valued using estimated CY 2008 physician in-office payment rates.
``Physician in-office payment rate'' is equal to the MPFS nonfacility
practice expense RVUs multiplied by the estimated CY 2008 MPFS
conversion factor.
(a) We multiply the estimated physician office utilization for CY
2008 for each new ASC procedure by 0.0375, consistent with our
assumption that 15 percent of the physician's office utilization for
new ASC procedures will migrate to the ASC over the full 4-year
transition period.
(b) For each new ASC procedure, we multiply the results of Step
2(a) by the estimated CY 2008 physician in-office payment rate for the
procedure, and then subtract beneficiary coinsurance for the procedure.
(c) We sum the results of Step 2(b) across all new ASC procedures.
Step 3: CY 2007 ASC services are valued using the estimated CY 2008
ASC payment rates under the current ASC system.
To estimate the aggregate expenditures that would be made in CY
2008 under the existing ASC payment system:
(a) We multiply the estimated CY 2008 ASC utilization for each
HCPCS code on the CY 2007 ASC list by the estimated CY 2008 ASC payment
rate for the HCPCS code under the existing ASC payment system, and then
subtract beneficiary coinsurance for the procedure. The estimated CY
2008 ASC payment rates are based on the CY 2007 ASC payment rates,
which were listed in Addendum AA to the CY 2007 OPPS/ASC final rule
with comment period and take into account the OPPS cap on payment for
ASC services as required by section 5103 of Public Law 109-171 and
reflect the zero percent CY 2008 update for ASC services mandated by
section 1833(i)(2)(C) of the Act. In estimating ASC utilization for CY
2008, we take into account the impact of the multiple procedure
discount (as discussed in section V.C.3. of this final rule).
(b) We estimate the amount the Medicare program would pay in CY
2008 for implantable prosthetic devices and implantable DME for which
ASCs currently receive separate payment under the DMEPOS fee schedule.
(c) We sum the results of Steps 3(a) and 3(b) to estimate the
aggregate amount of expenditures that would be made in CY 2008 for
current covered surgical procedures under the existing ASC payment
system.
Step 4: Sum the results of Steps 1-3.
b. Estimated Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Revised ASC Payment System
Step 5: HOPD migration is valued using estimated CY 2008 OPPS
payment rates.
This step is the same as Step 1, above.
Step 6: We identify new ASC procedures that are office-based (as
discussed in section III.C. of this final rule).
[[Page 42531]]
Step 7: Migration of new ASC office-based procedures from
physicians' offices to ASCs is valued based on estimated CY 2008 OPPS
payment rates capped at the estimated CY 2008 physician in-office
payment rates, if appropriate.
(a) For each new ASC procedure determined to be office-based, we
multiply the results of Step 2(a) above by the lesser of--
(1) The estimated CY 2008 OPPS rate for the procedure; or
(2) The estimated CY 2008 physician in-office payment rate for the
procedure, and then subtract beneficiary coinsurance for the procedure.
(b) The results of Step 7(a) are summed across all new ASC
procedures considered to be office-based.
Step 8: Migration of new ASC procedures not determined to be
office-based from physicians' offices to ASCs is valued using the
estimated CY 2008 OPPS rates.
(a) For each new ASC procedure not considered to be office-based,
we multiply the results of Step 2(a) above by the estimated CY 2008
OPPS rate for the procedure, and then subtract beneficiary coinsurance
for the procedure.
(b) The results of Step 8(a) are summed across all new ASC
procedures not considered to be office-based.
Step 9: Migration of new ASC procedures from physicians' offices to
ASCs is valued using the estimated CY 2008 MPFS physician out-of-office
payment rate. ``Physician out-of-office payment rate'' is equal to the
facility practice expense RVUs multiplied by the estimated CY 2008 MFPS
conversion factor.
(a) For each new ASC procedure, we multiply the results of Step
2(a) from above by the estimated CY 2008 physician out-of-office
payment rate for the procedure, and then subtract beneficiary
coinsurance for the procedure.
(b) The results of Step 9(a) are summed across all new ASC
procedures.
Step 10: Current ASC services are valued using the estimated CY
2008 OPPS payment rates.
To estimate the aggregate amount of expenditures that would be made
in CY 2008, we use estimated CY 2008 OPPS payment amounts instead of
estimated CY 2008 ASC payment amounts under the current system, and we
multiply the estimated CY 2008 ASC volume for each HCPCS code on the CY
2007 ASC list by the estimated CY 2008 OPPS payment rate for the HCPCS
code, and then subtract beneficiary coinsurance for the procedure. We
sum the results over all services on that ASC list.
Step 11: The results of Steps 5 and 7-10 are summed.
c. Calculation of the Final Estimated CY 2008 Budget Neutrality
Adjustment
Step 12: The result of Step 4 is divided by the result of Step 11.
Step 13: The application of the cap at the estimated CY 2008
physician in-office payment rates that occurs in Step 7 is dependent on
the ASC conversion factor. The ASC budget neutrality adjustment
resulting from Step 12 is calibrated to take into account the
interactive nature of the ASC conversion factor and the physician's
office payment cap. The ASC budget neutrality calculation is also
calibrated to take into account the fact that the additional physician
out-of-office payment rates under the revised ASC payment system
calculated in Step 9 must be fully offset by the budget neutrality
adjustment to ASC services under the revised payment system.
Furthermore, the budget neutrality calculation is calibrated to take
into account the CY 2008 transitional payment rates for procedures on
the CY 2007 ASC list of covered surgical procedures.
d. Calculation of the Final Estimated CY 2008 ASC Payment Rates
As described earlier, the application of the methodology to the
data available for this final rule results in an estimated budget
neutrality adjustment of 0.67. The CY 2008 budget neutrality adjustment
for the revised ASC payment system, based on the methodology outlined
above, will be proposed in the CY 2008 OPPS/ASC proposed rule and
finalized in the CY 2008 OPPS/ASC final rule with comment period, based
on the methodology for calculating budget neutrality established in
this July 2007 final rule.
After developing the estimated CY 2008 budget neutrality adjustment
of 0.67 according to the policies established in this final rule, in
order to determine the estimated CY 2008 ASC conversion factor we
multiply the estimated CY 2008 OPPS conversion factor by the budget
neutrality adjustment. At this time, our estimate of the CY 2008 OPPS
conversion factor is $63.497. Multiplying the estimated CY 2008 OPPS
conversion factor by the 0.67 budget neutrality adjustment yields our
estimated CY 2008 ASC conversion factor of $42.543 for this final rule.
To determine the fully implemented ASC payment rates for this final
rule, including beneficiary coinsurance, according to the final payment
methodology that applies to covered surgical procedures and covered
ancillary radiology services under the revised ASC payment system, we
multiply the ASC conversion factor by the ASC relative payment weight
for each procedure or service. As further discussed in sections IV.C.
and IV.E. of this final rule, the ASC relative payment weights for
certain office-based surgical procedures and covered ancillary
radiology services are set so that the national unadjusted ASC payment
rate does not exceed the MPFS unadjusted nonfacility practice expense
amount. In addition, as discussed in section IV.C of this final rule,
the ASC relative payment weights for device-intensive covered surgical
procedures are set according to a modified payment methodology to
ensure the same device payment under the revised ASC payment system as
under the OPPS. We then calculate the estimated CY 2008 payment rate
for procedures on the CY 2007 ASC list of covered surgical procedures
using a blend of 75 percent of the final CY 2007 ASC payment rate and
25 percent of the estimated revised ASC payment rate developed
according to methodology of the revised ASC payment system, applying
the special transition treatment to device-intensive procedures as
discussed in section IV.J. of this final rule. See Addenda AA and BB to
this final rule for the illustrative estimated CY 2008 ASC payment
weights and payment rates for covered surgical procedures and covered
ancillary services that are expected to be paid separately under the CY
2008 revised ASC payment system.
D. Calculation of the ASC Payment Rates for CY 2009 and Future Years
1. Updating the ASC Relative Payment Weights
In the August 2006 proposed rule, we proposed to update the ASC
relative payment weights each year using the national OPPS relative
payment weights for that calendar year, as well as the practice expense
payment amounts under the MPFS schedule for that calendar year because
some covered office-based surgical procedures and covered ancillary
services will be paid according to MPFS amounts if those are less than
the rates calculated under the standard methodology of the revised ASC
payment system. We further proposed to uniformly scale the ASC relative
payment weights for each update year so that estimated aggregate
expenditures using updated ASC relative payment weights would be the
same as estimated aggregate expenditures using the current year ASC
[[Page 42532]]
relative payment weights. That is, we proposed to make the relative
payment weights budget neutral to ensure that changes in the relative
payment weights from year to year would not cause the estimated amount
of expenditures to ASCs to increase or decrease as a function of those
changes. For example, we proposed to uniformly scale the ASC relative
payment weights for CY 2009 so that estimated expenditures for CY 2009
using the updated CY 2009 ASC relative payment weights would be the
same as they would be using the CY 2008 ASC relative payment weights.
Similarly, we proposed to uniformly scale the ASC relative payment
weights for CY 2010 so that estimated expenditures for CY 2010 using
the updated CY 2010 ASC relative payment weights would be the same as
they would be using the CY 2009 ASC relative payment weights.
We proposed to scale the relative payment weights annually because
we believed that the purpose of using relative payment weights as part
of the ratesetting methodology under the proposed revised ASC payment
system was only to establish appropriate relativity among surgical
procedures paid in ASCs. Changes in weights should not, in and of
themselves, change aggregate payment levels under a prospective payment
system. Scaling the relative payment weights each year would also serve
as a buffer to protect ASCs from sudden changes that could occur under
the OPPS. For example, by making the relative payment weights budget
neutral under the revised ASC payment system, the ASC relative weights
would not drop were there to be a sudden upsurge in costs associated
with outpatient hospital emergency or clinic visits relative to
outpatient hospital surgical costs. Moreover, making the ASC relative
weights budget neutral would shield the ASC payment system from the
inadvertent impact of unrelated aggregate changes in OPPS expenditures.
We proposed to continue this methodology to update the revised ASC
payment system in future years.
Comment: Several commenters supported the proposal to annually
update ASC relative payment weights using the national OPPS payment
weights for the corresponding year; conversely, some commenters also
expressed concern regarding our proposed policy of rescaling ASC
relative weights. They were concerned that annual rescaling would cause
divergence of the relative weights between the OPPS and the revised ASC
payment system for individual procedures.
Response: We appreciate commenters' support for annually updating
ASC relative payment weights in coordination with the OPPS update,
consistent with the proposed relationship between the two payment
systems. We believe this process would provide more appropriate
payments for surgical services under the revised ASC payment system
that would reflect ongoing changes in the facility costs associated
with different surgical procedures. We also acknowledge commenters'
concerns about our proposed policy of rescaling ASC relative weights.
However, we note that rescaling the relative payment weights in the ASC
payment system would not cause divergence in the relativity of the
weights of various services under the two payment systems. Rescaling of
the weights would equally increase or decrease the relative payment
weights of services under the revised ASC payment system in comparison
to the relative weights of the same services under the OPPS, but only
to the extent necessary to ensure that changes in the relative weights
do not, in and of themselves, change aggregate payments to ASCs.
Rescaling of relative weights or the application of a budget
neutrality adjustment is a common feature of Medicare payment systems,
designed to ensure that the estimated aggregate payments under a
payment system for an upcoming year would be neither greater than nor
less than the aggregate payments that would be made in the prior year,
taking into consideration any changes or recalibrations for the
upcoming year. For example, in CY 2006, as required by section
1833(t)(9)(B) of the Act, we scaled relative weights under the OPPS by
applying a budget neutrality adjustment to ensure that changes due to
APC reclassification and recalibration changes, wage index changes, and
other adjustments were made in a manner that ensured that estimated
aggregate OPPS payments for CY 2006 would not exceed aggregate payments
for CY 2005 (70 FR 68542). We continue to believe that this principle
should apply as well in the revised ASC payment system. We note that
while we do not currently have a provider-level dataset of ASC
utilization that accurately identifies unique ASCs and their geographic
information that would allow us to compare changes in geographic
adjustment over time for budget neutrality purposes, we intend to take
these changes into account in maintaining budget neutrality for the
revised ASC payment system as soon as our provider-level ASC data
permit.
In addition to considerations that are common to many payment
systems, there is another reason for adopting annual rescaling of the
relative weights in the revised ASC payment system. Because we are
finalizing our proposal to generally employ the relative payment
weights developed under the OPPS in the revised ASC payment system as
discussed earlier in section IV.B. of this final rule, aggregate
payments to ASCs could, in the absence of rescaling, be affected by
changes in the cost structure of HOPDs that ought to be relevant only
under the OPPS. We provided an example of such a scenario in the August
2006 proposed rule. A sudden increase in the costs of hospital
outpatient emergency or clinic visits due, for instance, to an increase
in the volume of cases, would have the effect of increasing the weights
for these services relative to the weights for surgical procedures in
the hospital outpatient setting. In the absence of rescaling, this
change in the relative weights under the OPPS would result in a
decrease in the relative weights for surgical procedures under the ASC
payment system and, therefore, a decrease in aggregate ASC payments for
these same procedures. Because ASCs principally receive payment for
surgical procedures, aggregate payments to ASCs could decline; ASCs
would receive lower payments for surgical procedures without realizing
the benefits of the higher payments provided to HOPDs for emergency or
clinic visits. As we explained in the August 2006 proposed rule (71 FR
49657), we believe that changes in relative weights each year under the
OPPS should not, in and of themselves, cause aggregate payments under
the revised ASC payment system to increase or decrease. In fact,
scaling the relative weights each year under the revised ASC payment
system would serve as a buffer to protect ASCs from sudden changes that
could occur under the OPPS.
Rescaling of relative payment weights in a budget neutral manner
under the revised ASC payment system would thus shield the ASC payment
system from the inadvertent impact of unrelated aggregate changes in
OPPS expenditures. It is important to note that the specific adjustment
factor applied in the scaling process could be positive or negative in
any particular year. Annual scaling would prevent both sudden decreases
in aggregate payments to ASCs and sudden windfall payments due solely
to changes in HOPD costs for nonsurgical services. In the example given
above, the scaling adjustment would be positive, that is, scaling would
increase the relative weights of all surgical procedures under the ASC
payment system in order to maintain aggregate ASC payments for the
[[Page 42533]]
procedures at the same level, in the absence of other factors affecting
the relative payment weights of hospital outpatient emergency or clinic
visits and surgical procedures under the OPPS.
After considering the public comments we received, we are
finalizing our proposal, without modification, to update the ASC
relative payment weights in the revised ASC payment system each year
using the national OPPS relative payment weights for that same calendar
year and to uniformly scale the ASC relative payment weights for each
update year to make them budget neutral. For example, holding ASC
utilization and the mix of services constant, for CY 2009, we will
compare the total weight using the CY 2008 ASC relative payment weights
under the 75/25 blend (of the CY 2007 payment rate and the revised
payment rate) with the total weight using CY 2009 relative payment
weights under the 50/50 blend (of the CY 2007 payment rate and the
revised payment rate), taking into account the changes in the OPPS
relative payment weights between CY 2008 and CY 2009. We will use the
ratio of CY 2008 to CY 2009 total weight to scale the ASC relative
payment weights for CY 2009. Scaling of ASC relative payment weights
would apply to covered surgical procedures and covered ancillary
radiology services whose payment rates are related to OPPS relative
payment weights. Scaling would not apply in the case of ASC payment for
other separately payable covered ancillary services that have a
predetermined national payment amount (that is, their national payment
amounts are not based on OPPS relative payment weights) such as drugs
and biologicals that are separately paid under the OPPS. Any service
with a predetermined national payment amount would be included in the
budget neutrality comparison, but scaling of the relative payment
weights would not apply to those services that have a predetermined
payment amount. The ASC payment weights for those services without
predetermined national payment amounts (that is, their national payment
amounts would be based on OPPS relative payment weights if a payment
limitation did not apply) would be scaled to eliminate any difference
in the total payment weight between the current year and the update
year.
2. Updating the ASC Conversion Factor
Section 1833(i)(2)(C) of the Act requires that, if the Secretary
has not updated the ASC payment amounts in a calendar year after CY
2009, the payment amounts shall be increased by the percentage increase
in the CPI-U as estimated by the Secretary for the 12-month period
ending with the midpoint of the year involved. Therefore, in the August
2006 proposed rule for the revised ASC payment system we proposed to
update the ASC conversion factor using the CPI-U in order to adjust ASC
payment rates for inflation.
We received a number of comments regarding our proposal to use the
CPI-U to adjust payments to ASCs for inflation, and these comments and
our responses are discussed in section IV.H. of this final rule, which
addresses the adjustment for inflation under the revised ASC payment
system. We did not receive any public comments regarding our proposal
to adjust ASC payments for inflation by applying the inflation
adjustment to the conversion factor under the revised ASC payment
system.
As explained in section IV.H. of this final rule, after
consideration of the public comments we received, we are finalizing our
proposal under Sec. Sec. 416.171(a) and (b), without modification, to
apply the CPI-U to adjust payments to ASCs for inflation. We will
implement the annual update through an adjustment to the conversion
factor under the revised ASC payment system, beginning in CY 2010 when
the statutory requirement for a zero update no longer applies.
E. Annual Updates
Currently, under the existing ASC payment system, we update the ASC
list of covered surgical procedures every 2 years through the notice
and comment regulation process. We make additions to and deletions from
the ASC list of covered surgical procedures based on clinical judgment
and data that are available regarding utilization of care settings. We
last published an updated list of the ASC covered surgical procedures
in the CY 2007 OPPS/ASC final rule with comment period (71 FR 67960).
Under the revised ASC payment system, which will be implemented
effective January 1, 2008, we proposed in the August 2006 proposed rule
to update on an annual calendar year basis the ASC conversion factor,
the relative payment weights and APC assignments, the ASC payment
rates, and the list of procedures for which Medicare would not make
payment of an ASC payment rate. To the extent possible under the rules
and policies of the revised ASC payment system, we proposed to maintain
consistency between the OPPS and the ASC payment system in the way we
treat new and revised HCPCS and CPT codes for payment under the ASC
payment system. We also proposed to invite comment as part of the
annual update cycle to determine if there are procedures that we
exclude from payment in the ASC setting that merit reconsideration as a
result of changes in clinical practice or innovations in technology.
We proposed to update the ASC list of covered surgical procedures
and payment system as part of the annual proposed and final rulemaking
cycle updating the hospital OPPS. We believed that including the ASC
update as part of the OPPS rulemaking cycle would ensure that updates
of the ASC payment rates and the list of covered surgical procedures
for which Medicare makes payment to ASCs would be issued in a regular,
predictable, and timely manner. Moreover, the ASC payment system would
be updated concurrent with changes in the APC groups and the OPPS
inpatient list, making it easier to predict changes in payment for
particular services from year to year.
In the August 2006 proposed rule for the revised ASC payment
system, we proposed to issue a final rule in the first part of CY 2007
in which we would respond to comments submitted timely regarding the
proposals set forth in that proposed rule and make final the policy and
regulations for the revised ASC payment system for implementation
effective January 1, 2008. We also proposed to include the CY 2008 ASC
payment rates for surgical procedures payable in an ASC as part of the
proposed and final rules for the CY 2008 OPPS update.
In addition, in the August 2006 proposed rule we proposed to
evaluate each year all new HCPCS codes that describe surgical
procedures to make preliminary determinations regarding whether or not
they should be payable in the ASC setting and, if so, whether they are
office-based procedures. In the absence of claims data that would
indicate where procedures described by new codes are being performed
and identify the facility resources required to perform them, we
proposed to use other available information, including our clinical
advisors' judgment, predecessor CPT and Level II HCPCS codes,
information submitted by representatives of specialty societies and
professional associations, and information submitted by commenters
during the public comment period following publication of the final
rule with comment period in the Federal Register. We would publish in
the annual OPPS/ASC payment update final rule those interim
determinations for
[[Page 42534]]
the new codes to be active January 1 of the update year. The ASC
payment system treatment of those procedures would be open to comment
on that final rule, and we would respond to comments about our interim
determinations in the final rule for the following year, just as we
currently respond to comments about our APC assignments for new codes
in the OPPS final rule for the following year. After our review of
public comments and in the absence of physicians' claims data, if our
determination regarding a new code was that it should reside on the ASC
list of covered surgical procedures as an office-based procedure
subject to the payment limitation, this determination would remain
preliminary until we were able to consider more recent volume and
utilization data for each individual procedure code and/or, if
appropriate, the clinical characteristics, utilization, and volume of
related codes. Using that information, if we confirmed our
determination that the new code was appropriately assigned to an
office-based payment indicator, it would then be permanently assigned
to the list of office-based procedures subject to the payment
limitation.
Accordingly, we proposed to reflect this annual rulemaking and
publication of revised payment methodologies and payment rates in new
Sec. 416.173 in proposed new Subpart F.
Comment: Several commenters recommended that CMS continue to
consider the input of interested parties submitting comments regarding
the assignment of HCPCS codes to appropriate APCs, additions to and
deletions from the ASC list of covered surgical procedures, and
creation of payment mechanisms to account for new technology.
Response: As stated in our August 2006 proposal for the annual
update process, we intend to invite comments from interested parties as
part of the consolidated annual update cycle for updating the hospital
OPPS and revised ASC payment system. As always, the OPPS treatment,
including APC assignments, of all HCPCS codes would be open to comment,
and we proposed also to invite comment regarding whether there are
procedures that we exclude from payment in the ASC setting that merit
reconsideration as a result of changes in clinical practice or
innovations in technology. This approach is consistent with the
recommendation of the PPAC that we utilize a process for the revised
ASC payment system to obtain input from national medical specialty
societies and the ASC community in order to provide payment to ASCs for
all safe and appropriate procedures and to allow for changes in
technology and evolution in medical practice. Annual updating will
provide for the adaptable methodology that the PPAC recommends for the
revised ASC payment system.
Comment: Some commenters supported our proposal for the annual
updates, indicating that the proposed alignment of annual updates to
the revised ASC payment system with the OPPS updates is appropriate and
allows the industry to review and contemplate the changes in both
payment systems simultaneously.
Response: We appreciate the commenters' support and continue to
believe that including the ASC update as part of the OPPS rulemaking
cycle would ensure that updates of the ASC payment rates and the list
of surgical procedures for which Medicare pays ASCs would be issued in
a regular, predictable, and timely manner. Moreover, the ASC payment
system would be updated concurrent with changes in the APC groups and
the OPPS inpatient list, making it easier to predict changes in payment
for particular services from year to year. We believe this approach is
especially appropriate, given the final policy of the revised ASC
payment system as discussed further in section IV.B. of this final
rule, to use the APC groups and relative payment weights for surgical
procedures established under the OPPS as the basis of the payment
groups and the relative payment weights for surgical procedures paid in
ASCs beginning in CY 2008. The annually updated OPPS device offset
percents will be used to establish ASC payment rates for device-
intensive procedures. In addition, according to the final policies
established in this final rule, the OPPS relative payment weights and
rates will be used as the basis for the payment of most covered
ancillary services under the revised ASC payment system, so coordinated
annual updating of the OPPS and the revised ASC payment system is
particularly important.
Comment: A number of commenters indicated that many ASCs were
interested in submitting bills to Medicare using the same claim form
that is used by HOPDs, the CMS UB-92 (soon to be the UB-04), so that
CMS would have additional information available for the annual ASC
update under the revised ASC payment system. The commenters stated that
the CMS-1500 billing form currently used by most Medicare Part B
providers and suppliers, including ASCs, limits the amount of
information that ASCs can report on claims. The commenters expressed
concern that, as a result of having to use the CMS-1500, the true costs
incurred by ASCs to provide services are not available to CMS and that,
consequently, CMS cannot include actual ASC costs in its analyses to
develop and update the revised payment system. They recommended that
ASCs be allowed to report to CMS the same level of detail about the
services they provide as do HOPDs. Further, the commenters stated that
it would be less burdensome than the current Medicare billing policy
because ASCs already use the UB-92 to submit bills to commercial
payors. Thus, they concluded that allowing ASCs to use the UB-92 for
Medicare Part B billing would be advantageous for both CMS and ASCs,
because ASCs could provide more detailed cost information to CMS and
this change would reduce the administrative burden on ASCs that
currently are maintaining billing capabilities for both the CMS-1500
and UB-92 formats.
Response: For future ASC update years, we will explore the
feasibility of adopting the ASC billing change recommended by
commenters, but this is not a change that we can make by January 2008.
We understand the commenters' concerns in this regard and investigated
the possibility of implementing this recommendation as part of the
revised payment system, effective January 2008. A policy change that
requires ASCs to use a different billing format would have to
incorporate adequate time for CMS and ASCs to make the necessary
systems changes and for CMS to provide training for contractors and
ASCs prior to implementing the new format. Although we will continue to
explore this recommendation, not only is there insufficient time to
make systems changes and provide training before implementation of the
revised ASC payment system, but CMS is in the midst of a comprehensive
reorganization of its contracting functions, making adoption of any
significant billing change at this time even more challenging. During
the next few years, Medicare Part A and B claims will be processed by
reconfigured contracting entities, and we believe that allowing ASCs to
bill using the same format as HOPDs should be explored as part of that
larger contractor reform. We plan to pursue the feasibility of this
option and to coordinate any possible change to ASC billing
requirements with CMS' overall contracting transition. We welcome
additional information from the public regarding recommendations for
ASC billing
[[Page 42535]]
modifications or improvements that we should consider once the revised
payment system is implemented. We note that, under our final annual
update methodology for the revised ASC payment system, we would not
require ASC information beyond that currently available to us through
the CMS-1500 in order to annually update the ASC payment system.
After consideration of the public comments we received, we are
finalizing our proposal as reflected in Sec. 416.173, without
modification, to annually update the ASC conversion factor, the
relative payment weights and OPPS APC assignments of covered surgical
procedures paid in ASCs, the ASC payment rates, and the list of
surgical procedures for which Medicare would not make payment to ASCs
as part of the annual proposed and final rulemaking cycle updating the
hospital OPPS. In addition, we will annually update the list of covered
ancillary services and their ASC payment rates. We also are finalizing
our proposal, without modification, to evaluate each year all new HCPCS
codes that describe surgical procedures to make preliminary
determinations regarding whether they should be payable in the ASC
setting and, if so, whether they are office-based procedures. The ASC
treatment of these procedures would be open to comment in the final
rule, and we would provide responses in the final rule for the
following calendar year. Designations of new surgical procedure codes
as office-based would remain preliminary until there are adequate
physicians' claims data to assess their predominant sites of services,
whereupon if we confirm their office-based nature, the codes would be
permanently assigned to the list of office-based procedures subject to
the ASC payment limitation.
VI. Information in Addenda Related to the Revised CY 2008 ASC Payment
System
We include addenda to the preamble of proposed and final rules
updating the ASC payment system to present national ASC unadjusted
payment rates, by HCPCS code, and other factors that affect
ratesetting. For example, in Addendum BB to the August 2006 proposed
rule for the revised ASC payment system, we listed the HCPCS codes of
surgical procedures for which we proposed to allow payment to ASCs in
CY 2008, the short descriptors for those codes, and whether or not the
code was proposed to be newly added to the list of covered surgical
procedures. We also indicated for each HCPCS code: (1) Whether or not
we proposed to designate it as office-based; (2) whether or not we
proposed to cap it at the MPFS nonfacility practice expense rate; (3)
the estimated proposed CY 2008 ASC relative payment weight; (4) the
estimated proposed CY 2008 full payment and coinsurance amounts; and
(5) the estimated proposed CY 2008 transitional payment and coinsurance
amounts using a 50/50 blend of the current and proposed new rates.
Addendum CC to the August 2006 proposed rule listed the specific subset
of HCPCS codes and their short descriptors for procedures proposed for
payment limitation at the MPFS nonfacility practice expense amount
under the revised ASC payment system.
We will continue to use addenda to summarize, as part of the annual
proposed and final OPPS/ASC rules updating both payment systems, the
annual update of the relative payment weights of ASC covered surgical
procedures, the national unadjusted ASC payment amounts for those
procedures, the procedures designated as office-based that are subject
to payment limitation at the MPFS nonfacility practice expense amount,
and other pertinent information that bears on the determination of the
payment status and payment rates for services under the revised ASC
payment system for the update year. We will also summarize in the
addenda the covered ancillary services that will be separately paid
under the revised ASC payment system if they are integral to the
performance of a covered surgical procedure, including their updated
relative payment weights as appropriate, the national unadjusted ASC
payment amounts for those services, and other pertinent information.
Although we are including addenda to this final rule, we emphasize
that the information presented in these addenda is intended solely to
demonstrate the payment rates that result from application of the
revised ASC payment system methodology that we are finalizing in this
final rule based on the most current data available. We caution readers
that the illustrative relative payment weights, national payment
amounts, and other information shown in the addenda to this final rule
are neither the proposed nor final ASC rates for the CY 2008 revised
ASC payment system. The information in the addenda to this final rule
exemplifies the results of applying the revised ASC payment system
methodology implemented in this final rule to the final or most
recently updated CY 2007 OPPS information, with application of the
estimated CY 2008 OPPS update, including the CY 2007 APC groupings and
relative payment weights, the CY 2007 second quarter OPPS payment rates
for drugs and biologicals, the CY 2007 OPPS payment methodology for
brachytherapy sources, the specification of surgical procedures as
subject to OPPS multiple procedure discounting, the designation of
surgical procedures as inpatient only under the OPPS, the
identification of surgical procedures for which payment is packaged
under the OPPS rather than separately paid, and the CY 2007 OPPS
device-dependent APCs and their respective device offset percents. The
information is also based on the most recently available Part B
utilization data derived from the full year of CY 2005 ASC and
physicians' claims, and the CY 2008 estimated transitional nonfacility
practice expense payment amounts for the CY 2008 MPFS, with application
of the projected CY 2008 MPFS update.
We reiterate that the information in the addenda to this final rule
does not represent the rates that we will be proposing for
implementation in CY 2008 under the revised ASC payment system, but
merely serves to illustrate application of the final ratesetting
methodology under the revised ASC payment system. All information
included in Addendum AA and Addendum BB to this final rule is subject
to change in the annual cycle of notice and comment rulemaking to
update the OPPS/ASC payment rates for CY 2008, with the exception of
the office-based designation of procedures whose designation is not
marked as temporary. We note that we have also included in Addenda AA
and BB to this final rule HCPCS codes for those surgical procedures,
radiology services, implantable devices, and drugs and biologicals
whose payment is packaged under the OPPS and which, therefore, would
not be eligible for separate ASC payment as covered surgical procedures
or covered ancillary services, in order to facilitate review of the ASC
payment policies for these groups of services. Payment to ASCs under
the revised ASC payment system for these services would also be
packaged. We will propose the relative payment weights, payments rates,
and other pertinent ratesetting information for the CY 2008 revised ASC
payment system in the OPPS/ASC proposed rule to update both payment
systems for CY 2008. This proposed rule will be issued in mid-summer of
CY 2007. The relative payment weights and payment rates and other
pertinent ratesetting information proposed for the revised ASC payment
system in CY 2008 will be based on proposed CY 2008 OPPS payment
weights and APC groups, proposed CY
[[Page 42536]]
2008 MPFS nonfacility practice expense payment amounts, CY 2007 second
quarter OPPS payment rates for drugs and biologicals as established
based on the ASP information for that quarter, and the most recent Part
B utilization data available to us from CY 2006 claims.
CMS will publish final relative payment weights and final payment
rates and other pertinent ratesetting information for the CY 2008
revised ASC payment system in the final OPPS/ASC rule that updates both
payment systems for CY 2008.
Changes in CY 2008 payments for physicians' services under the
MPFS, in first quarter CY 2008 prices for drugs and biologicals based
on the most recent available ASP data, and in CY 2008 HCPCS codes and
pricing of OPPS services that may occur and that would affect the CY
2008 revised ASC payment system between publication of the CY 2008
OPPS/ASC final rule and release of the January 2008 OPPS PRICER and the
ASC payment files will be reflected in updated addenda that we will
post on the CMS Web site.
We have created Addendum DD1 to this final rule to define ASC
payment indicators that we will use in Addenda AA and BB to provide
payment information regarding covered surgical procedures and covered
ancillary services, respectively, under the revised ASC payment system.
Analogous to the OPPS payment status indicators that we publish in
Addendum D1 as part of the annual OPPS rulemaking cycle, the ASC
payment indicators in Addendum DD1 are intended to capture policy-
relevant characteristics of HCPCS codes that may receive packaged or
separate payment in ASCs, including their ASC payment status prior to
CY 2008; their designation as device-intensive; their designation as
office-based and the corresponding ASC payment methodology; and their
classification as a separately payable radiology service, brachytherapy
source, OPPS pass-through device, corneal tissue acquisition service,
drug or biological, or NTIOL.
VII. ASC Regulatory Changes
In the August 23, 2006 proposed rule, we proposed to modify
applicable ASC regulations under 42 CFR Parts 410, 414, and 416 to
incorporate the requirements and conditions for payments for ASC
facility services under the revised payment system that was proposed
for implementation beginning January 1, 2008.
A. Regulatory Changes That Were Finalized in the CY 2007 OPPS/ASC Final
Rule With Comment Period
In the August 23, 2006 proposed rule (71 FR 49631), we proposed the
following regulatory changes which we finalized in the CY 2007 OPPS/ASC
final rule with comment period (71 FR 68174).
We proposed to revise the current regulations at Part 416,
Subparts D and E, to ensure that the rules governing the current ASC
payment system are clearly distinguishable from those that would apply
to the revised system beginning January 1, 2008.
We proposed to revise Subparts D and E to Part 416 to
reflect the rules governing the ASC payment system prior to January 1,
2008.
We proposed to redesignate existing Subpart F as Subpart G
under Part 416 to codify the rules governing the ASC payment adjustment
for NTIOLs (71 FR 49631).
We proposed several technical changes to Part 416 (71 FR
49659).
We proposed to revise existing Sec. 416.1 (Basis and
scope) to remove the obsolete reference to ``a hospital outpatient
department,'' and to add provisions of section 5103 of Public Law 109-
171 and applicable provisions of Public Law 108-173.
We proposed to revise existing Sec. 416.65 (Covered
surgical procedures) to modify the introductory text to clearly denote
the section's application to covered surgical procedures furnished
before January 1, 2008. In addition, we proposed to remove the obsolete
cross-reference in paragraph (a)(4) to Sec. 405.310 and replace it
with the correct cross-reference to Sec. 411.15.
We proposed to revise Sec. 416.125 (ASC facility services
payment rate) to incorporate the limitation on payment imposed by
section 5103 of Public Law 109-171.
We proposed to revise Sec. 488.1 (Definitions) to add
ambulatory surgical centers to the definition of a supplier in
conformance with section 1861(d) of the Act.
We proposed to add new Sec. 416.76 and new Sec. 416.121
to Subparts D and E, respectively, to clearly state that the provisions
of Subparts D and E apply to services furnished before January 1, 2008.
The bases for these proposed regulatory changes were discussed in
detail throughout the preamble of the August 23, 2006 proposed rule. We
did not receive any public comments on these proposed revisions. In the
CY 2007 OPPS/ASC final rule with comment period, we made these
provisions final as proposed, without modification (71 FR 68174).
B. Regulatory Changes Included in This Final Rule
In the August 23, 2006 proposed rule (71 FR 49699), we proposed to
add a new Subpart F to Part 416 entitled ``Subpart--Coverage, Scope of
ASC Facility Services, and Prospective Payment System for Facility
Services Furnished On or After January 1, 2008,'' which would include
the following new sections:
Sec. 416.160 Basis and scope.
Sec. 416.161 Applicability.
Sec. 416.163 General rules.
Sec. 416.164 Scope of ASC facility services.
Sec. 416.166 Covered surgical procedures.
Sec. 416.167 Basis of payment.
Sec. 416.171 Calculation of prospective payment rates for ASC
services.
Sec. 416.172 Adjustments to national payment rates.
Sec. 416.173 Publication of revised payment methodologies and payment
rates.
Sec. 416.178 Limitations on administrative and judicial review.
We also proposed a technical change to 42 CFR Part 414 to conform
with changes we were proposing under Part 416, new Subpart F (71 FR
49659), and we likewise proposed to revise Sec. 410.152(i) to make it
consistent with provisions of the revised ASC payment system. The
numerous public comments that we received regarding the revised ASC
payment system we proposed to implement January 1, 2008, are addressed
in detail throughout the preamble of this final rule.
As a result of our review of the public comments, in this final
rule, we have made a number of modifications to our proposals for the
revised ASC payment system. These modifications, which are also
discussed in detail in other sections of this final rule, have
necessitated corresponding changes in the regulations that we proposed
for the revised ASC payment system. The following is a summary of
changes to 42 CFR 410 and 416 that reflect those modifications, which
we are finalizing in this final rule.
We added a new paragraph (i)(2) under Sec. 410.152 to
specify the amount of payment the Medicare program makes for ASC
services beginning January 1, 2008.
We decided not to finalize the proposed revision of Sec.
414.22(b)(5)(i)(B) in this final rule.
In Sec. 416.2, we revised the definitions of ``ASC
services,'' ``Covered surgical procedures,'' and ``Facility
[[Page 42537]]
services,'' and we added a definition of ``Covered ancillary
services.''
We added new Subpart F, as proposed, but modified the
title to read ``Coverage, Scope of ASC Services, and Prospective
Payment System for ASC Services Furnished on or after January 1,
2008.'' We also modified certain proposed sections under Subpart F and
added other provisions as outlined below.
We revised the section headings of Sec. Sec. 416.161 and
416.164 to read ``Applicability of this subpart'' and ``Scope of ASC
services,'' respectively.
We also revised the section heading of Sec. 416.171 to read
``Determination of payment rates for ASC services.'' In addition, we
added new Sec. 416.179 with a new section heading.
We added Sec. 416.160(a)(4), which addresses payment
rules for screening flexible sigmoidoscopy and screening colonoscopy
services. Also, we reordered the paragraphs of Sec. 416.160.
We revised Sec. 416.160(b) to conform the text with the
changes to the definitions in Sec. 416.2.
We made a technical change to Sec. Sec. 416.163(b) and
(c) to specify that payment for anesthetists' services is made in
accordance with 42 CFR part 414, in addition to editorial changes to
Sec. 416.163(a) to reference ASC services rather than ASC facility
services.
We revised Sec. 416.164(a), ``Included facility
services,'' and we renamed and revised Sec. 416.164(b) as ``Covered
ancillary services,'' to reflect the policy regarding the packaging of
services which is made final in section IV.C. of this final rule.
Proposed Sec. 416.164(b) becomes final Sec. 416.164(c), ``Excluded
services,'' where we revised anesthetists' services, which are paid
under 42 CFR part 414 and where we changed x-ray procedures to
radiology services and separated diagnostic procedures and radiology
services into separate items. Also, ``Excluded services'' no longer
includes costs incurred to procure corneal tissue.
In Sec. 416.166(c), ``General exclusions,'' we deleted
the phrase ``other medical procedures'' from the introductory sentence
to conform with the definition of the type of procedures covered under
the ASC benefit as discussed in section III. of this final rule. We
moved the criterion proposed as paragraph (c)(5) (regarding the
expected requirement for active medical monitoring and care at midnight
following the procedure) to Sec. 416.166(b) as an element of the
``General standards.'' We also added the following as new criteria for
exclusion of a procedure from coverage when performed in an ASC: (1)
Commonly require systemic thrombolytic therapy; (2) are designated as
requiring inpatient care under Sec. 419.22(n); and (3) can only be
reported using a CPT unlisted surgical procedure code.
We made technical and editorial changes to Sec.
416.167(a) and (b) to reference payment for ASC services and covered
ancillary services.
We revised Sec. 416.171 to reflect the modifications that
we are making final in this final rule regarding separate payment for
certain covered ancillary services and the extension of transitional
payment rates from 1 to 3 years, as discussed in section IV. J. of this
final rule.
We revised Sec. 416.172 as follows: (1) Made minor
changes to paragraphs (a), (b), (d), and (e) to reference ASC services
and to clarify that the comparison for purposes of assessing the lesser
of the actual charge or the prospective rate is to the geographically
adjusted payment rate; and (2) revised paragraph (c) to exclude
application of a geographic adjustment to payment rates for certain
drugs, devices, and brachytherapy sources, as discussed in section IV.
C. of this final rule. In addition, we added new paragraph (f) to
reflect the payment adjustment when ASC services are interrupted due to
circumstances that threaten the well-being of the beneficiary. We also
added new paragraph (g) to reflect the payment adjustment for the
insertion of NTIOLs.
We made editorial changes to Sec. 416.173 and Sec.
416.178.
We added new Sec. 416.179, ``Payment and coinsurance
reduction for devices replaced without cost or when full credit is
received,'' as discussed in section IV.C. of this final rule.
VIII. Files Available to the Public Via the Internet
Addenda AA, BB, and DD1 to this final rule provide various data
pertaining to the CY 2008 ASC list of covered procedures and the
covered ancillary services that will be separately paid to ASCs
beginning in CY 2008 when provided by an ASC as integral to a covered
surgical procedure on the same day as the procedure. All relative
payment weights and payment rates are illustrative only, demonstrating
the payment rates that result from application of the revised ASC
payment system methodology that we are finalizing in this final rule
based on the most current data available. They exemplify the results of
applying the revised ASC payment system methodology implemented in this
final rule to the final or most recently updated CY 2007 OPPS
information as updated by the currently estimated CY 2008 OPPS update
factor and to the CY 2008 estimated transitional nonfacility practice
expense amounts for the CY 2008 MPFS, with application of the projected
CY 2008 MPFS update.
As further discussed in section VI. of this final rule, Addendum
DD1 defines the payment indicators that are used in Addenda AA and BB
of this final rule, while Addenda AA and BB provide payment information
regarding covered surgical procedures and covered ancillary services
under the revised ASC payment system.
These addenda, as well as the final rule preamble tables and other
supporting data files, are included on the CMS Web site at: http://www.cms.hhs.gov/ASCPayment/
in a format that can easily be downloaded
and manipulated. Proposed and final ASC relative weights and payment
rates for CY 2008 will be published in the proposed and final CY 2008
OPPS/ASC rules, respectively, and related data files will be included
on the CMS Web site as noted above. The OPPS data files are available
to the public on the CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS, and the MPFS data files are located at: http://
http://www.cms.hhs.gov/PhysicianFeeSched.
We are not including as addenda to this final rule reprints of the
final FY 2007 IPPS wage indexes that were included in a notice
published in the Federal Register on October 11, 2006 (71 FR 59886).
Rather, we are providing a link on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN
to all of the final FY 2007 IPPS
wage index related tables. The final CY 2008 ASC payment system will
utilize the FY 2008 IPPS wage index related tables that will be
proposed and finalized in the FY 2008 IPPS rulemaking cycle, and we
will provide a link on the CMS Web site to those proposed and final
wage index related tables in the CY 2008 OPPS/ASC proposed and final
rules, respectively. For additional assistance, contact Gift Tee, (410)
786-0378.
IX. Collection of Information Requirements
This document does not impose any 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. 35).
[[Page 42538]]
X. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this final rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-
354), section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
1. Executive Order 12866
Executive Order 12866 (as amended by Executive Order 13258, which
merely reassigns responsibility of duties) directs agencies to assess
all costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
We estimate that the revised ASC payment system and the expanded
ASC list of covered surgical procedures that we are implementing in CY
2008 will have no net effect on Medicare expenditures compared to the
level of Medicare expenditures that would have occurred in CY 2008 in
the absence of the revised payment system. A more detailed discussion
of the effects of the changes to the ASC list of covered surgical
procedures and the effects of the revisions to the ASC payment system
in CY 2008 is provided in section X.B. below.
While we estimate that there will be no net change in Medicare
expenditures in CY 2008 as a result of the revised ASC payment system,
we estimate that the revised system will result in savings of $240
million over 5 years due to migration of new ASC covered surgical
procedures from HOPDs and physicians' offices to ASCs over time. In
addition, we note there will be a total increase in Medicare payments
to ASCs for CY 2008 of approximately $270 million compared to Medicare
expenditures that would have occurred in CY 2008 in the absence of the
revised payment system. These additional payments to ASCs of
approximately $270 million in CY 2008 will be fully offset by savings
from reduced Medicare spending in HOPDs and physicians' offices on
services that migrate from these settings to ASCs in CY 2008 (as
discussed in detail in section V.C. of this final rule). Therefore,
this final rule is an economically significant rule under Executive
Order 12866 and a major rule under 5 U.S.C. 804(2).
2. Regulatory Flexibility Act
The RFA requires agencies to determine whether a rule would have a
significant economic impact on a substantial number of small entities.
For purposes of the RFA, small entities include small businesses,
nonprofit organizations, and small governmental jurisdictions. Most
hospitals and most other providers and suppliers are small entities,
either by nonprofit status or by having revenues of $9 million to $31.5
million in any 1 year (65 FR 69432).
For purposes of the RFA, we have determined that approximately 73
percent of ASCs would be considered small businesses according to the
Small Business Administration (SBA) size standards. Individuals and
States are not included in the definition of a small entity. We
anticipate that this final rule will have a significant impact on a
substantial number of small entities.
3. Small Rural Hospitals
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital with fewer than 100 beds that is located outside
of a Metropolitan Statistical Area (MSA). The Secretary certifies that
this final rule will not have a significant impact on the operations of
a substantial number of small rural hospitals.
4. Unfunded Mandates
Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.
104-4) also requires that agencies assess anticipated costs and
benefits before issuing any rule whose mandates require spending in any
1 year of $100 million in 1995 dollars, updated annually for inflation.
That threshold level is currently approximately $120 million. This
final rule will not mandate any requirements for State, local, or
tribal government, nor will it affect private sector costs.
5. Federalism
Executive Order 13132 establishes certain requirements that an
agency must meet when it publishes any rule (proposed or final) that
imposes substantial direct costs on State and local governments,
preempts State law, or otherwise has Federalism implications.
We have examined this final rule in accordance with Executive Order
13132, Federalism, and have determined that it would not have an impact
on the rights, roles, and responsibilities of State, local or tribal
governments. The changes related to payments to ASCs in CY 2008 will
not affect payments to government hospitals.
B. Effects of Revisions to the ASC Payment System for CY 2008
In CY 2008, we are implementing a revised Medicare ASC payment
system that could have a far-reaching effect on the provision of
outpatient surgical services for a number of years to come. First, we
are greatly expanding the list of procedures that will be eligible for
payment under the revised ASC payment system. Second, we are moving
from a limited fee schedule based on nine disparate payment groups to a
payment system incorporating relative payment weights for groups of
procedures with similar clinical and resource characteristics, based on
the APCs that are key elements of the OPPS.
Implementation by January 1, 2008 of a revised ASC payment system
designed to result in budget neutrality is mandated by section 626 of
Public Law 108-173. To set ASC payment rates for CY 2008 under the
revised payment system, we are multiplying ASC relative payment weights
for surgical procedures by an ASC conversion factor that we calculate
to result in the same amount of aggregate Medicare expenditures for
those services in CY 2008 as we estimate would have been made if the
revised payment system were not implemented.
The effects of the expanded numbers and types of procedures for
which an ASC payment may be made and other policy changes that affect
the revised payment system, combined with significant changes in
payment rates for covered surgical procedures, will vary across ASCs,
depending on whether or not the ASC limits its services to those in a
particular surgical specialty area, the volume of specific services
provided by the ASC, the extent to which ASCs will offer different
services, and the percentage of its patients that are Medicare
beneficiaries.
In this July 2007 final rule for the revised ASC payment system, we
have estimated the CY 2008 ASC payment rates, budget neutrality factor,
and impacts using the CY 2007 OPPS relative payment weights with an
estimated update factor for CY 2008, the CY 2007 MPFS PE RVUs trended
forward to CY 2008, and CY 2005
[[Page 42539]]
utilization data projected forward to CY 2008. We emphasize that the
impact estimates in this final rule are illustrative only. The CY 2008
ASC payment rates and budget neutrality factor will be proposed in the
CY 2008 OPPS/ASC proposed rule based on the methodology for calculating
budget neutrality established in this final rule and incorporating the
proposed CY 2008 OPPS relative payment weights, the proposed CY 2008
MPFS PE RVUs, and CY 2006 utilization information projected forward to
CY 2008. The final CY 2008 ASC payment rates and budget neutrality
factor will be established in the CY 2008 OPPS/ASC final rule with
comment period, in accordance with the methodology for calculating
budget neutrality established in this final rule and based on the final
CY 2008 OPPS payment weights, the final CY 2008 MPFS RVUs, and updated
CY 2006 utilization data projected forward to CY 2008.
As discussed fully in section V.C. of this final rule, our final
methodology for calculating the budget neutrality factor considers not
only the effects of the new payment rates to be implemented under the
revised payment system, but also the estimated net effect of migration
of new ASC procedures across ambulatory care settings. The methodology
for calculating the budget neutrality adjustment factor finalized in
this rule assumes that over the first 2 years of the revised payment
system, approximately 25 percent of the HOPD volume of new ASC
procedures would migrate from the HOPD service setting to ASCs, and
that over the 4-year transition period, approximately 15 percent of the
physicians' office volume of new ASC procedures would migrate to ASCs.
We estimate that the revised ASC payment system established in this
final rule will result in neither savings nor costs to the Medicare
program in CY 2008. That is, because it is designed to be budget
neutral, in CY 2008, the revised ASC payment system will neither
increase nor decrease expenditures under Part B of Medicare. We further
estimate that beneficiaries will save approximately $20 million under
the revised ASC payment system in CY 2008, because ASC payment rates
will, in most cases, be lower than OPPS payment rates for the same
services and, because, except for screening flexible sigmoidoscopy and
screening colonoscopy procedures, beneficiary coinsurance for ASC
services is 20 percent rather than 20 to 40 percent as is the case
under the OPPS. (The only possible instance in which an ASC coinsurance
amount could exceed the OPPS copayment amount would be when the
coinsurance amount for a procedure under the revised ASC payment system
exceeds the hospital inpatient deductible. Section 1833(t)(8)(C)(i) of
the Act provides that the copayment amount for a procedure paid under
the OPPS cannot exceed the inpatient deductible established for the
year in which the procedure is performed, but there is no such
requirement related to the ASC coinsurance amount.) Beneficiary
coinsurance for services migrating from physicians' offices to ASCs may
decrease or increase under the revised ASC payment system, depending on
the particular service and whether the Medicare payment to the
physician for providing that service in his or her office is higher or
lower than the sum of the Medicare payment to the ASC for providing the
facility portion of that service and the Medicare payment to the
physician for providing that service in a facility (nonoffice) setting.
As noted previously, the net effect of the revised ASC payment system
on beneficiary coinsurance, taking into account the migration of
services from HOPDs and physicians' offices, is estimated to be $20
million in beneficiary savings in CY 2008.
1. Alternatives Considered
We are issuing this final rule to meet a statutory requirement to
implement, no later than January 1, 2008, a revised payment system for
ASCs. We are implementing the revised ASC payment system through
rulemaking in the Federal Register. Through the August 2006 proposed
rule, we have afforded interested parties an opportunity to comment on
revisions we proposed to make to the policies and rules for identifying
surgical procedures that would be excluded from payment in ASCs, to the
ASC ratesetting methodology and payment policies, and to the
regulations for the revised ASC payment system.
Throughout the preamble of this final rule, we discuss the various
options we considered as we developed policies to redesign the ASC
payment system in broad terms, and specific policies, such as those
affecting payment for covered ancillary services integral to covered
surgical procedures, the definition of a covered surgical procedure,
criteria for identifying procedures that are not safely or
appropriately performed in an ASC, and the payment methodology for
device-intensive procedures, among others.
Although we proposed to phase in the new ASC payment rates under
the revised payment system over a 2-year period, we are finalizing a
policy to phase in the ASC payment rates under the revised payment
system over a 4-year period. As we discuss in section X.B.3. of this
final rule, we believe that allowing a longer transition period is
appropriate in light of the adverse financial impact that some ASCs
could potentially experience if they perform a high volume of
procedures whose rates would decrease significantly under the revised
payment system. We believe the 4-year transition will give ASCs time to
reconfigure their mix of services and make other needed adjustments so
they can focus on achieving more efficient delivery of a broader range
of surgical procedures.
2. Limitations of Our Analysis
Presented here are the projected effects of the policy and
statutory changes that will be effective for CY 2008 on aggregate ASC
utilization and Medicare payments. One limitation of this analysis is
that we could only infer the effects of the revised payment system on
different types of ASCs, for example, single or multispecialty, high or
low volume, and urban or nonurban ASCs, based on an overall comparison
of procedure volumes and facility payments between the current and the
revised payment system. At this time, we do not have a provider-level
dataset of CY 2005 ASC utilization that accurately identifies unique
ASCs and their geographic information that would allow us to compare
estimated payments and geographic adjustment among classes of ASCs
based on a provider-level analysis.
A second limitation is our lack of information on ASC resource use.
ASCs are not required to file Medicare cost reports and, therefore, we
do not have cost information to evaluate whether or not the payments
for ASC services coincide with the resources required by ASCs to
provide those services.
A third limitation is our inability to predict changes in service
mix between CY 2005 and CY 2008. The aggregated impact tables below are
based upon a methodology that assumes no changes in service-mix with
respect to the CY 2005 ASC data used for this final rule. We believe
that the net effect on Medicare expenditures of changes in service-mix
for current ASC covered surgical procedures will be negligible, in the
aggregate. Such changes may have differential effects across surgical
specialty procedure groups as ASCs adjust to the revised payment
system. However, we are unable to accurately project such changes at a
disaggregated level. Clearly, individual ASCs will experience changes
in payment that
[[Page 42540]]
differ from the aggregated estimated changes presented in the tables
below.
Because we do not have experience with ASC payment under the
revised payment system, we have relied on comments and information from
stakeholders in response to our August 2006 proposed rule for the
revised ASC payment system to mitigate the limitations in the data
available to us for analysis of the impact of the changes on specific
procedures, on classes of specialty ASCs, and on beneficiaries.
3. Estimated Effect of This Final Rule on ASCs
Some ASCs are multispecialty facilities that perform the gamut of
surgical procedures, from excision of lesions to hernia repair to
cataract extraction; others focus on a single specialty and perform
only a limited range of surgical procedures, such as eye procedures,
gastrointestinal procedures, or orthopedic surgery. The combined effect
on an individual ASC of the CY 2008 revised payment system and the
expanded ASC list of covered surgical procedures will depend on a
number of factors, including, but not limited to, the mix of services
the ASC provides, the volume of specific services provided by the ASC,
the percentage of its patients who are Medicare beneficiaries, and the
extent to which an ASC will choose to provide different services under
the revised payment system. The following discussion presents two
tables that provide estimates of the impact of the revised ASC payment
system on Medicare payments to ASCs for current ASC services, assuming
the same mix of services as offered by ASCs in our CY 2005 claims data.
The first table depicts aggregate percent change in payment by surgical
specialty group and the other compares payment for procedures estimated
to receive the most payment in CY 2008 under the current payment
system.
In section IV.J. of this final rule, we finalize our policy of a
transition of 4 years for the revised payment rates, rather than the
proposed 2-year transition, where payments will generally be made using
a blend of the rates based on the CY 2007 ASC payment rate and the
revised ASC payment rate. In comparing estimated payment rates for CY
2008 under the existing system with the estimated payment rates for CY
2008 under the revised system, we noted the negative effect the
estimated proposed payment rates would have on Medicare payments to
ASCs for certain surgical procedures that currently are performed
frequently in ASCs. We were concerned about the impact of the revised
payment rates on ASCs that specialize in a limited number of surgical
procedures for which payment would decrease under the revised system
and wanted to encourage ASCs to continue to provide access to the high
volume procedures that are currently performed there because, in all
likelihood, the ASC has become an extremely efficient setting for those
procedures, such as cataract extractions and colonoscopies. Moreover,
we believe that a positive outcome of the revised ASC payment system
could be to expand beneficiary and physician choice in selection of an
appropriate site for ambulatory surgical services, as a consequence of
the expansion of surgical procedures for which Medicare will make an
ASC payment and the revised rates that will pay more appropriately for
those services. We believe a 4-year transition will give ASCs
additional time to reconfigure their mix of surgical services and make
other needed adjustments so that they can focus on achieving more
efficient delivery of a broader range of surgical procedures.
In CY 2008, we will pay ASCs using a 75/25 blend, in which payment
will be calculated by adding 75 percent of the CY 2007 ASC rate for a
surgical procedure on the CY 2007 ASC list of covered surgical
procedures and 25 percent of the revised CY 2008 ASC rate for the same
procedure. For CYs 2009 and 2010, the blend will be transitioned first
to 50/50 and then to a 25/75 blend of the CY 2007 ASC rate and the
revised ASC payment rate. Beginning in CY 2011, payments will be made
to ASCs for covered surgical procedures on the CY 2007 ASC list at the
fully implemented revised ASC payment rates. Procedures that were not
included on the ASC list of covered surgical procedures in CY 2007 will
not be paid at the transitional rates for CYs 2008 through 2010 because
they have no CY 2007 ASC payment rate. Those procedures will be paid at
the fully implemented ASC rate, beginning in CY 2008.
Table 11 shows the impact of the revised payment system at the
surgical specialty group level. We have aggregated the surgical HCPCS
codes by specialty group and estimated the effect on aggregated payment
for surgical specialty groups, considering separately the CY 2008
transitional rate and the fully implemented revised payment rate. The
groups are sorted for display in descending order by estimated Medicare
program payment to ASCs for CY 2008 in the absence of the revised ASC
payment system. The following is an explanation of the information
presented in Table 11:
Column 1--Surgical Specialty Group indicates the surgical
specialties into which ASC procedures are grouped. We used the CPT code
range definitions and added the related Level II HCPCS codes and
Category III CPT codes, as appropriate, to account for all surgical
procedures to which the Medicare program payments are attributed.
Column 2--Estimated CY 2008 ASC Payments in the absence of
the revised ASC payment system were calculated by multiplying the CY
2007 ASC payment rate by CY 2008 ASC utilization (which is based on CY
2005 ASC utilization multiplied by a factor of 1.305 to take into
account expected volume growth with volume adjustment, as appropriate,
for the multiple procedure discount). The resulting amount was then
multiplied by 0.8 to estimate the Medicare program's share of the total
payments to the ASC. The payment amounts are expressed in millions of
dollars.
Column 3--Estimated CY 2008 Percent Change with Transition
(75/25 Blend) is the aggregate percentage increase or decrease in
Medicare program payment to ASCs for each surgical specialty group that
is attributable to changes in the ASC payment rates for CY 2008 under
the 75/25 blend of the CY 2007 ASC payment rate and the revised ASC
payment rate.
Column 4--Estimated CY 2008 Percent Change without
Transition (Fully Implemented) is the aggregate percentage increase or
decrease in Medicare program payment to ASCs for each surgical
specialty group that is attributable to changes in the ASC payment
rates for CY 2008 if there were no transition period to the revised
payment rates. The percentages appearing in column 4 are presented as a
comparison for the transition policy in column 3 and do not depict the
impact of the fully implemented proposal in CY 2011.
Table 11 reflects the changes for ASCs at the surgical specialty
level and shows that for all but gastrointestinal procedures, if an ASC
offers the same mix of services in CY 2008 that is reflected in our
national CY 2005 claims data, Medicare payments to the ASC for services
in that surgical specialty area would be estimated to increase under
the revised payment system. If the revised payment system were fully
implemented in CY 2008, we would expect all but gastrointestinal
procedures and nervous system procedures to receive greater Medicare
payment. In addition to the impacts on
[[Page 42541]]
Medicare payments for current ASC procedures shown in Table 11, it is
important to note that overall CY 2008 payments to ASCs are estimated
to increase by about $270 million as a result of the revised payment
system. This increased spending in ASCs is projected to be fully offset
by savings from reduced spending in HOPDs and physicians' offices due
to service migration.
Table 11.--Estimated CY 2008 Impact of the Revised ASC Payment System on Estimated Aggregate CY 2008 Medicare
Program Payments Under the 75/25 Transition Blend and Without a Transition, by Surgical Specialty Group
----------------------------------------------------------------------------------------------------------------
Estimated CY
Estimated CY Estimated CY 2008 percent
2008 ASC 2008 percent change without
Surgical specialty group payments (in change with transition
millions) transition (75/ (fully
25 blend) implemented)
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
Eye and ocular adnexa........................................... $1,365 1 5
Digestive system................................................ 721 -4 -15
Nervous system.................................................. 274 2 -5
Musculoskeletal system.......................................... 167 24 97
Integumentary system............................................ 85 4 15
Genitourinary system............................................ 76 10 38
Respiratory system.............................................. 23 16 65
Cardiovascular system........................................... 8 25 95
Auditory system................................................. 4 30 85
Hemic and lymphatic systems..................................... 2 28 110
Other systems................................................... 0.1 19 75
----------------------------------------------------------------------------------------------------------------
Table 12 below shows the estimated impact of the revised payment
system on aggregate ASC payments for selected procedures during the
first year of implementation (CY 2008) with and without the
transitional blended rate. The table displays 30 of the procedures
receiving the highest estimated CY 2008 ASC payments under the existing
Medicare payment system. The HCPCS codes are sorted in descending order
by estimated CY 2008 ASC program payments in the absence of the revised
ASC payment system.
Column 1--HCPCS code.
Column 2--Short Descriptor of the HCPCS code.
Column 3--Estimated CY 2008 ASC Payments in the absence of
the revised payment system were calculated by multiplying the CY 2007
ASC payment rate by CY 2008 ASC utilization (which is based on CY 2005
ASC utilization multiplied by a factor of 1.305 to take into account
expected volume growth with volume adjustment, as appropriate, for the
multiple procedure discount). The resulting amount was then multiplied
by 0.8 to estimate the Medicare program's share of the total payments
to the ASC. The payment amounts are expressed in millions of dollars.
Column 4--CY 2008 Percent Change with Transition (75/25
Blend) reflects the percent differences between the estimated ASC
payment rates for CY 2008 under the current system and the estimated
payment rates for CY 2008 under the revised system, incorporating a 75/
25 blend of the estimated ASC payment using the CY 2007 ASC payment
rate and the revised ASC payment rate.
Column 5--CY 2008 Percent Change without Transition (Fully
Implemented) reflects the percent differences between the estimated ASC
payment rates for CY 2008 under the current system and the estimated
payment rates for CY 2008 under the revised payment system if there
were no transition period to the revised payment rates. The percentages
appearing in column 5 are presented as a comparison for the transition
policy in column 4 and do not depict the impact of the fully
implemented proposal in CY 2011.
Table 12.--Estimated CY 2008 Impact of Revised ASC Payment System on Aggregate Payments for Procedures With the
Highest Estimated CY 2008 Payments Under the Current System
----------------------------------------------------------------------------------------------------------------
Estimated CY
2008 percent
Estimated CY Estimated CY changes
HCPCS code Short descriptor 2008 ASC 2008 percent without
payments (in change (75/25 transition
millions) blend) (fully
implemented)
(1) (2)............................. (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
66984......................... Cataract surg w/iol, 1 stage.... $1,112 1 3
45378......................... Diagnostic colonoscopy.......... 153 -4 -16
43239......................... Upper GI endoscopy, biopsy...... 148 -5 -21
45380......................... Colonoscopy and biopsy.......... 114 -4 -16
66821......................... After cataract laser surgery.... 102 -8 -31
45385......................... Lesion removal colonoscopy...... 96 -4 -16
62311......................... Inject spine l/s (cd)........... 81 -5 -19
45384......................... Lesion remove colonoscopy....... 44 -4 -16
[[Page 42542]]
64483......................... Inj foramen epidural l/s........ 44 -5 -19
G0121......................... Colon ca scrn not hi rsk ind.... 37 -6 -25
15823......................... Revision of upper eyelid........ 35 -4 -17
66982......................... Cataract surgery, complex....... 33 1 3
64476......................... Inj paravertebral l/s add-on.... 29 -7 -27
G0105......................... Colorectal scrn; hi risk ind.... 27 -6 -25
43235......................... Uppr gi endoscopy, diagnosis.... 25 2 6
52000......................... Cystoscopy...................... 24 -4 -17
64475......................... Inj paravertebral l/s........... 24 -5 -19
67904......................... Repair eyelid defect............ 22 4 16
64721......................... Carpal tunnel surgery........... 17 18 70
29881......................... Knee arthroscopy/surgery........ 16 23 93
43248......................... Uppr gi endoscopy/guide wire.... 15 -5 -21
62310......................... Inject spine c/t................ 14 -5 -19
29880......................... Knee arthroscopy/surgery........ 11 23 93
64484......................... Inj foramen epidural add-on..... 11 -5 -19
28285......................... Repair of hammertoe............. 10 18 70
67038......................... Strip retinal membrane.......... 10 31 122
29848......................... Wrist endoscopy/surgery......... 9 -2 -9
64623......................... Destr paravertebral n add-on.... 9 -5 -19
45383......................... Lesion removal colonoscopy...... 9 -4 -16
26055......................... Incise finger tendon sheath..... 9 14 54
----------------------------------------------------------------------------------------------------------------
Over time, we believe that the current ASC payment system has
served as an incentive to ASCs to focus on providing procedures for
which they determine Medicare payments are adequate to support the
ASC's continued operation. We would expect that, under the existing
payment system, the ASC payment rates for many of the most frequently
performed procedures in ASCs are similar to the OPPS payment rates for
the same procedures. Conversely, we would expect that procedures with
existing ASC payment rates that are substantially lower than the OPPS
rates would be performed less often in ASCs. We believe the revised ASC
payment system represents a major stride towards encouraging greater
efficiency in ASCs and promoting a significant increase in the breadth
of surgical procedures performed in ASCs, because it more appropriately
distributes payments across the entire spectrum of covered surgical
procedures, based on a coherent system of relative payment weights that
are related to the clinical and facility resource characteristics of
those procedures.
Table 12 identifies a number of ASC procedures receiving the
highest estimated CY 2008 payments under the current system and shows
that most of them will experience payment decreases in CY 2008 under
the revised ASC payment system. This contrasts with the estimated
aggregate payment increases at the surgical specialty group level
displayed in Table 11. In fact, Table 11 shows only one surgical
specialty group of procedures for which the payments are expected to
see a small decrease in the first year under the revised ASC payment
system, and only two groups for which a decrease would be expected if
there were no transition period to the revised payment rates. The
increased payments at the full group level are due to the moderating
effect of the payment increases for the less frequently performed
procedures within the surgical specialty group. The exception to this
is the surgical specialty group of eye and ocular adnexa where the
aggregate increase in CY 2008 is driven by a small increase in payment
for the highest volume procedure (CPT code 66984, Extracapsular
cataract removal with insertion of intraocular lens prosthesis (one
stage procedures), manual or mechanical technique (e.g., irrigation and
aspiration or phacoemulsification)).
As a result of the redistribution of payments across the expanded
breadth of surgical procedures for which Medicare will provide an ASC
payment, we believe that ASCs may change the mix of services they
provide over the next several years. The revised ASC payment system
should encourage ASCs to expand their service mix beyond the handful of
the highest paying procedures which comprise the majority of ASC
utilization under the existing ASC payment system. For example,
although cystoscopy (CPT code 52000), the highest volume ASC
genitourinary procedure, is expected to experience a 4 percent payment
rate decrease in CY 2008, overall payment to ASCs for the group of
genitourinary procedures currently performed in ASCs is expected to
increase by 10 percent. Although a urology specialty ASC may currently
perform far more cystoscopy procedures than any other genitourinary
procedure, we believe that under the revised ASC payment system, the
ASC has the opportunity to adapt to the payment decrease for its most
frequently performed procedures by offering an increased breadth of
procedures, still within the clinical specialty area, and receive
payments that are adequate to support continued operations. Similarly,
payments for all of the highest volume pain management injection
procedures are expected to decrease in CY 2008, although payments for
nervous system procedures overall
[[Page 42543]]
are expected to increase. However, if there were no transition for CY
2008, payments would also decrease slightly for the nervous system
surgical specialty group.
For those procedures that will be paid a significantly lower amount
under the revised payment system than they are currently paid, we
believe that their current payment rates, which are closer to the OPPS
payment rates than other ASC procedures, are likely to be generous
relative to ASC costs, so ASCs would in all likelihood continue
performing those procedures under the revised payment system. We also
note that the majority of the most frequently performed ASC procedures
specifically studied by the GAO, as described in the section II.B. of
this final rule for the revised ASC payment system, appear in Table 12
with estimated payment decreases under the revised ASC payment system.
The GAO concluded that, for these procedures, the OPPS APC groups
accurately reflect the relative costs of procedures performed at ASCs
and that ASCs have substantially lower costs.
Generally, the payment changes for individual surgical procedures
are relatively small in the first year under the transition to the
revised payment system. As displayed in Table 12, a 1 percent increase
in payment for the most common cataract surgery, CPT code 66984, is
expected and mirrors the effect of the revised payment system on
payment for the eye and ocular adnexa surgical specialty group (Table
11), even though payment for another relatively high volume eye
procedure, 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)), is expected to
decrease by 8 percent.
For some procedures the estimated payment amounts in CY 2008 under
the revised ASC payment system are much higher than the CY 2007 rates
currently paid to ASCs. For example, payment for CPT code 67038
(Vitrectomy, mechanical, pars plana approach; with epiretinal membrane
stripping) increases by 31 percent compared to estimated CY 2008
payments under the current system. Similarly, the estimated CY 2008 ASC
payment for CPT code 29880 (Arthroscopy, knee, surgical; with
meniscetomy (medial and lateral, including any meniscal shaving))
increases by 23 percent. For these two procedures and the other
procedures with estimated payment increases greater than 10 percent,
the increases are due to the comparatively higher OPPS rates which,
when adjusted by the ASC budget neutrality factor and blended with the
CY 2007 ASC payment amounts, generate CY 2008 ASC payment rates that
are substantially above the current CY 2007 ASC payment rates.
We estimate that payments for most of the highest volume
colonoscopy and upper gastrointestinal endoscopy procedures will
decrease under the revised payment system. In fact, payment decreases
also are expected for the gastrointestinal surgical specialty group
overall. We believe that decreased payments for so many of the
gastrointestinal procedures are because current ASC payment rates are
close to the OPPS rates. Procedures with current payment rates that are
nearly as high as their OPPS rates are affected more negatively under
the revised payment system than procedures for which ASC rates have
historically been much lower than the comparable OPPS rates. The
payment decreases expected in the first year under the revised ASC
payment system for some of the high volume gastrointestinal procedures
are not large (all less than 7 percent). We believe that ASCs can
generally continue to cover their costs for these procedures, and that
ASCs specializing in providing those services will be able to adapt
their business practices and case-mix to manage declines for individual
procedures.
In CY 2008, we also are adding hundreds of surgical procedures to
the already extensive list of procedures for which Medicare allows
payment to ASCs, creating new opportunities for ASCs to expand their
range of covered surgical procedures. For the first time, ASCs will be
paid separately for covered ancillary services that are integral to
covered surgical procedures, including certain radiology procedures,
costly drugs and biologicals, devices with pass-through status under
the OPPS, and brachytherapy sources. While separately paid radiology
services will be paid based on their ASC relative payment weight
calculated according to the standard ratesetting methodology of the
revised ASC payment system or to the MPFS nonfacility practice expense
amount, whichever is lower, the other items newly eligible for separate
payment in ASCs will be paid comparably to their OPPS rates because we
would not expect ASCs to experience efficiencies in providing them.
Lastly, this final rule establishes a specific payment methodology for
device-intensive procedures that provides the same packaged payment for
the device as under the OPPS, while providing a reduced service payment
that is subject to the 4-year transition if the device-intensive
procedure is on the CY 2007 ASC list of covered surgical procedures.
This final methodology should allow ASCs to continue to expand their
provision of device-intensive services and to begin performing new
device-intensive ASC procedures.
4. Estimated Effects of This Final Rule on Beneficiaries
We estimate that the changes for CY 2008 will be positive for
beneficiaries in at least two respects. Except for screening
colonoscopy and flexible sigmoidoscopy procedures, the ASC coinsurance
rate for all procedures is 20 percent. This contrasts with procedures
performed in HOPDs where the beneficiary is responsible for copayments
that range from 20 percent to 40 percent. In addition, ASC payment
rates under the revised payment system are lower than payment rates for
the same procedures under the OPPS, so the beneficiary coinsurance
amount under the ASC payment system almost always will be less than the
OPPS copayment amount for the same services. (The only exceptions will
be when the ASC coinsurance amount exceeds the inpatient deductible.
The statute requires that copayment amounts under the OPPS not exceed
the inpatient deductible.) Beneficiary coinsurance for services
migrating from physicians' offices to ASCs may decrease or increase
under the revised ASC payment system, depending on the particular
service and the relative payment amounts for that service in the
physician's office compared with the ASC. As noted previously, the net
effect of the revised ASC payment system on beneficiary coinsurance,
taking into account the migration of services from HOPDs and
physicians' offices, is estimated to be $20 million in beneficiary
savings in CY 2008.
In addition to the lower out-of-pocket expenses, we believe that
beneficiaries also will have access to more services in ASCs as a
result of the addition of 793 surgical procedures to the ASC list of
covered surgical services eligible for Medicare payment. We expect that
ASCs will provide a broader range of surgical services under the
revised payment system and that beneficiaries will benefit from having
access to a greater variety of surgical procedures in ASCs.
5. Conclusion
The changes to the ASC payment system for CY 2008 will affect each
of the more than 4,600 ASCs currently approved for participation in the
Medicare program. The effect on an
[[Page 42544]]
individual ASC will depend on the ASC's mix of patients, the proportion
of the ASC's patients that are Medicare beneficiaries, the degree to
which the payments for the procedures offered by the ASC are changed
under the revised payment system, and the degree to which the ASC
chooses to provide a different set of procedures. The revised ASC
payment system is designed to result in the same aggregate amount of
Medicare expenditures in CY 2008 that would be made in the absence of
the revised ASC payment system. As mentioned previously, we estimate
that the revised ASC payment system and the expanded ASC list of
covered surgical procedures that we are implementing in CY 2008 will
have no net effect on Medicare expenditures compared to the level of
Medicare expenditures that would have occurred in CY 2008 in the
absence of the revised payment system. However, there will be a total
increase in Medicare payments to ASCs for CY 2008 of approximately $270
million as a result of the revised ASC payment system, which will be
fully offset by savings from reduced Medicare spending in HOPDs and
physicians' offices on services that migrate from these settings to
ASCs (as discussed in detail in section V.C. of this final rule).
Furthermore, we estimate that the revised ASC payment system will
result in Medicare savings of $240 million over 5 years due to
migration of new ASC services from HOPDs and physicians' offices to
ASCs over time. We anticipate that this final rule will have a
significant economic impact on a substantial number of small entities.
6. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf
), in Table 13 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the implementation of the CY 2008 revised
ASC payment system, based on the provisions of this final rule. As
explained above, we estimate that Medicare payments to ASCs in CY 2008
will be about $270 million higher than they would otherwise be in the
absence of the revised ASC payment system. This $270 million in
additional payments to ASCs in CY 2008 will be fully offset by savings
from reduced spending in HOPDs and physicians' offices on services that
migrate from these settings to ASCs. This table provides our best
estimate of Medicare payments to providers and suppliers as a result of
the CY 2008 revised ASC payment system, as presented in this final
rule. All expenditures are classified as transfers.
Table 13.--Accounting Statement: Classification of Estimated
Expenditures From CY 2007 to CY 2008 as a Result of the CY 2008 Revised
ASC Payment System
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $0 Million.
From Whom to Whom......................... Federal Government to
Medicare Providers and
Suppliers.
Annualized Monetized Transfer............. $0 Million.
From Whom to Whom......................... Premium Payments from
Beneficiaries to Federal
Government.
-----------------------------
Total................................. $0 Million.
------------------------------------------------------------------------
C. Executive Order 12866
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the OMB.
List of Subjects
42 CFR Part 410
Health facilities, Health professions, Laboratories, Medicare,
Rural areas, X-rays.
42 CFR Part 416
Health facilities, Kidney diseases, Medicare, Reporting and
recordkeeping requirements.
0
For reasons stated in the preamble of this final rule, the Centers for
Medicare & Medicaid Services is amending 42 CFR Chapter IV as set forth
below:
PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
0
1. The authority citation for part 410 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
0
2. Section 410.152 is amended by adding a new paragraph (i)(2) to read
as follows:
Sec. 410.152 Amounts of payment.
* * * * *
(i) * * *
(2) For ASC services furnished on or after January 1, 2008, in
connection with the covered surgical procedures specified in Sec.
416.166 of this subchapter, except as provided in paragraphs (i)(2)(i)
and (i)(2)(ii) of this section, Medicare Part B pays the lesser of 80
percent of the actual charge or 80 percent of the prospective payment
amount, geographically adjusted, if applicable, as determined under
Subpart F of Part 416 of this subchapter. Part B coinsurance is 20
percent of the actual charge or 20 percent of the prospective payment
amount, geographically adjusted, if applicable.
(i) If the limitation described in Sec. 416.167(b)(3) of this
subchapter applies, Medicare pays 80 percent of the amount determined
under Subpart B of Part 414 of this subchapter and Part B coinsurance
is 20 percent of the applicable payment amount.
(ii) Medicare Part B pays 75 percent of the applicable payment
amount for screening flexible sigmoidoscopies and screening
colonoscopies, and Part B coinsurance is 25 percent of the applicable
payment amount.
* * * * *
PART 416--AMBULATORY SURGICAL SERVICES
0
3. The authority citation for part 416 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
0
4. Section 416.2 is amended by--
0
a. Revising the definition of ``ASC services.''
0
b. Adding a definition of ``Covered ancillary services'' in
alphabetical order.
0
c. Revising the definition of ``Covered surgical procedures.''
0
d. Revising the definition of ``Facility services.''
The revisions and addition read as follows:
Sec. 416.2 Definitions.
* * * * *
ASC services means, for the period before January 1, 2008, facility
services that are furnished in an ASC, and beginning January 1, 2008,
means the combined facility services and covered ancillary services
that are furnished in an ASC in connection with covered surgical
procedures.
Covered ancillary services means items and services that are
integral to a covered surgical procedure performed in an ASC as
provided in Sec. 416.164(b), for which payment may be made under Sec.
416.171 in addition to the payment for the facility services.
Covered surgical procedures means those surgical procedures
furnished before January 1, 2008, that meet the criteria specified in
Sec. 416.65 and those surgical procedures furnished on or after
January 1, 2008, that meet the criteria specified in Sec. 416.166.
[[Page 42545]]
Facility services means for the period before January 1, 2008,
services that are furnished in connection with covered surgical
procedures performed in an ASC, and beginning January 1, 2008, means
services that are furnished in connection with covered surgical
procedures performed in an ASC as provided in Sec. 416.164(a) for
which payment is included in the ASC payment established under Sec.
416.171 for the covered surgical procedure.
0
5. A new Subpart F is added to read as follows:
Subpart F--Coverage, Scope of ASC Services, and Prospective Payment
System for ASC Services Furnished on or After January 1, 2008
Sec.
416.160 Basis and scope
416.161 Applicability of this subpart
416.163 General rules
416.164 Scope of ASC services
416.166 Covered surgical procedures
416.167 Basis of payment
416.171 Determination of payment rates for ASC services
416.172 Adjustments to national payment rates
416.173 Publication of revised payment methodologies and payment
rates
416.178 Limitations on administrative and judicial review
416.179 Payment and coinsurance reduction for devices replaced
without cost or when full credit is received
Subpart F--Coverage, Scope of ASC Services, and Prospective Payment
System for ASC Services Furnished on or After January 1, 2008
Sec. 416.160 Basis and scope.
(a) Statutory basis. (1) Section 1833(i)(2)(D) of the Act requires
the Secretary to implement a revised payment system for payment of
surgical services furnished in ASCs. The statute requires that, in the
year such system is implemented, the system shall be designed to result
in the same amount of aggregate expenditures for such services as would
be made if there was no requirement for a revised payment system. The
revised payment system shall be implemented no earlier than January 1,
2006, and no later than January 1, 2008. There shall be no
administrative or judicial review under section 1869 of the Act,
section 1878 of the Act, or otherwise of the classification system, the
relative weights, payment amounts, and the geographic adjustment
factor, if any, of the revised payment system.
(2) Section 1833(a)(1)(G) of the Act provides that, beginning with
the implementation date of a revised payment system for ASC facility
services furnished in connection with a surgical procedure pursuant to
section 1833(i)(1)(A) of the Act, the amount paid shall be 80 percent
of the lesser of the actual charge for such services or the amount
determined by the Secretary under the revised payment system.
(3) Section 1833(i)(1)(A) of the Act requires the Secretary to
specify the surgical procedures that can be performed safely on an
ambulatory basis in an ASC.
(4) Section 1834(d) of the Act specifies that, when screening
colonoscopies or screening flexible sigmoidoscopies are performed in an
ASC or hospital outpatient department, payment shall be based on the
lesser of the amount under the fee schedule that would apply to such
services if they were performed in a hospital outpatient department in
an area or the amount under the fee schedule that would apply to such
services if they were performed in an ambulatory surgical center in the
same area. Section 1834(d) of the Act further specifies that the
coinsurance for screening flexible sigmoidoscopy and screening
colonoscopy procedures is 25 percent of the payment amount. Section
1834(d) of the Act also specifies that, in the case of screening
flexible sigmoidoscopy and screening colonoscopy services, their
payment amounts must not exceed the payment rates established for the
related diagnostic services. Section 1833(b)(8) of the Act specifies
that the Part B deductible shall not apply with respect to colorectal
screening tests as described in section 1861(pp)(1) of the Act, which
include screening colonoscopies and screening flexible sigmoidoscopies.
(b) Scope. This subpart sets forth--
(1) The scope of ASC services and the criteria for determining the
covered surgical procedures for which Medicare provides payment for the
associated facility services and covered ancillary services;
(2) The basis of payment for facility services and for covered
ancillary services furnished in an ASC in connection with a covered
surgical procedure;
(3) The methodologies by which Medicare determines payment amounts
for ASC services.
Sec. 416.161 Applicability of this subpart.
The provisions of this subpart apply to ASC services furnished on
or after January 1, 2008.
Sec. 416.163 General rules.
(a) Payment is made under this subpart for ASC services specified
in Sec. Sec. 416.164(a) and (b) furnished to Medicare beneficiaries by
a participating ASC in connection with covered surgical procedures as
determined by the Secretary in accordance with Sec. 416.166.
(b) Payment for physicians' services and payment for anesthetists'
services are made in accordance with Part 414 of this subchapter.
(c) Payment for items and services other than physicians' and
anesthetists' services, as specified in Sec. 416.164(c), is made in
accordance with Sec. 410.152 of this subchapter.
Sec. 416.164 Scope of ASC services.
(a) Included facility services. ASC services for which payment is
packaged into the ASC payment for a covered surgical procedure under
Sec. 416.166 include, but are not limited to--
(1) Nursing, technician, and related services;
(2) Use of the facility where the surgical procedures are
performed;
(3) Any laboratory testing performed under a Clinical Laboratory
Improvement Amendments of 1988 (CLIA) certificate of waiver;
(4) Drugs and biologicals for which separate payment is not allowed
under the hospital outpatient prospective payment system (OPPS);
(5) Medical and surgical supplies not on pass-through status under
Subpart G of Part 419 of this subchapter;
(6) Equipment;
(7) Surgical dressings;
(8) Implanted prosthetic devices, including intraocular lenses
(IOLs), and related accessories and supplies not on pass-through status
under Subpart G of Part 419 of this subchapter;
(9) Implanted DME and related accessories and supplies not on pass-
through status under Subpart G of Part 419 of this subchapter;
(10) Splints and casts and related devices;
(11) Radiology services for which separate payment is not allowed
under the OPPS, and other diagnostic tests or interpretive services
that are integral to a surgical procedure;
(12) Administrative, recordkeeping and housekeeping items and
services;
(13) Materials, including supplies and equipment for the
administration and monitoring of anesthesia; and
(14) Supervision of the services of an anesthetist by the operating
surgeon.
(b) Covered ancillary services. Ancillary items and services that
are integral to a covered surgical procedure, as defined in Sec.
416.166, and for which separate payment is allowed include:
(1) Brachytherapy sources;
(2) Certain implantable items that have pass-through status under
the OPPS;
(3) Certain items and services that CMS designates as contractor-
priced,
[[Page 42546]]
including, but not limited to, the procurement of corneal tissue;
(4) Certain drugs and biologicals for which separate payment is
allowed under the OPPS;
(5) Certain radiology services for which separate payment is
allowed under the OPPS.
(c) Excluded services. ASC services do not include items and
services outside the scope of ASC services for which payment may be
made under Part 414 of this subchapter in accordance with Sec.
410.152, including, but not limited to--
(1) Physicians' services (including surgical procedures and all
preoperative and postoperative services that are performed by a
physician);
(2) Anesthetists' services;
(3) Radiology services (other than those integral to performance of
a covered surgical procedure);
(4) Diagnostic procedures (other than those directly related to
performance of a covered surgical procedure);
(5) Ambulance services;
(6) Leg, arm, back, and neck braces other than those that serve the
function of a cast or splint;
(7) Artificial limbs;
(8) Nonimplantable prosthetic devices and DME.
Sec. 416.166 Covered surgical procedures.
(a) Covered surgical procedures. Effective for services furnished
on or after January 1, 2008, covered surgical procedures are those
procedures that meet the general standards described in paragraph (b)
of this section (whether commonly furnished in an ASC or a physician's
office) and are not excluded under paragraph (c) of this section.
(b) General standards. Subject to the exclusions in paragraph (c)
of this section, covered surgical procedures are surgical procedures
specified by the Secretary and published in the Federal Register that
are separately paid under the OPPS, that would not be expected to pose
a significant safety risk to a Medicare beneficiary when performed in
an ASC, and for which standard medical practice dictates that the
beneficiary would not typically be expected to require active medical
monitoring and care at midnight following the procedure.
(c) General exclusions. Notwithstanding paragraph (b) of this
section, covered surgical procedures do not include those surgical
procedures that--
(1) Generally result in extensive blood loss;
(2) Require major or prolonged invasion of body cavities;
(3) Directly involve major blood vessels;
(4) Are generally emergent or life-threatening in nature;
(5) Commonly require systemic thrombolytic therapy;
(6) Are designated as requiring inpatient care under Sec.
419.22(n) of this subchapter;
(7) Can only be reported using a CPT unlisted surgical procedure
code; or
(8) Are otherwise excluded under Sec. 411.15 of this subchapter.
Sec. 416.167 Basis of payment.
(a) Unit of payment. Under the ASC payment system, prospectively
determined amounts are paid for ASC services furnished to Medicare
beneficiaries in connection with covered surgical procedures. Covered
surgical procedures and covered ancillary services are identified by
codes established under the Healthcare Common Procedure Coding System
(HCPCS). The unadjusted national payment rate is determined according
to the methodology described in Sec. 416.171. The manner in which the
Medicare payment amount and the beneficiary coinsurance amount for each
ASC service is determined is described in Sec. 416.172.
(b) Ambulatory payment classification (APC) groups and payment
weights.
(1) ASC covered surgical procedures are classified using the APC
groups described in Sec. 419.31 of this subchapter.
(2) For purposes of calculating ASC national payment rates under
the methodology described in Sec. 416.171, except as specified in
paragraph (b)(3) of this section, an ASC relative payment weight is
determined based on the APC relative payment weight for each covered
surgical procedure and covered ancillary service that has an applicable
APC relative payment weight described in Sec. 419.31 of this
subchapter.
(3) Notwithstanding paragraph (b)(2) of this section, the relative
payment weights for services paid in accordance with Sec. 416.171(d)
are determined so that the national ASC payment rate does not exceed
the unadjusted nonfacility practice expense amount paid under the
Medicare physician fee schedule for such procedures under Subpart B of
Part 414 of this subchapter.
Sec. 416.171 Determination of payment rates for ASC services.
(a) Standard methodology. The standard methodology for determining
the national unadjusted payment rate for ASC services is to calculate
the product of the applicable conversion factor and the relative
payment weight established under Sec. 416.167(b), unless otherwise
indicated in this section.
(1) Conversion factor for CY 2008. CMS calculates a conversion
factor so that payment for ASC services furnished in CY 2008 would
result in the same aggregate amount of expenditures as would be made if
the provisions in this Subpart F did not apply, as estimated by CMS.
(2) Conversion factor for CY 2009 and subsequent calendar years.
The conversion factor for a calendar year is equal to the conversion
factor calculated for the previous year, updated as follows:
(i) For CY 2009, the update is equal to zero percent.
(ii) For CY 2010 and subsequent calendar years, the update is the
Consumer Price Index for All Urban Consumers (U.S. city average) as
estimated by the Secretary for the 12-month period ending with the
midpoint of the year involved.
(b) Exception. The national ASC payment rates for the following
items and services are not determined in accordance with paragraph (a)
of this section but are paid an amount derived from the payment rate
for the equivalent item or service set under the payment system
established in Part 419 of this subchapter as updated annually in the
Federal Register. If a payment rate is not available, the following
items and services are designated as contractor-priced:
(1) Covered ancillary services specified in Sec. 416.164(b), with
the exception of radiology services as provided in Sec. 416.164(b)(5);
(2) Device-intensive procedures assigned to device-dependent APCs
under the OPPS with device costs greater than 50 percent of the APC
cost;
(3) Procedures using certain separately paid implantable devices
that are approved for transitional pass-through payment in accordance
with Sec. 419.66 of this subchapter.
(c) Transitional payment rates. (1) ASC payment rates for CY 2008
are a transitional blend of 75 percent of the CY 2007 ASC payment rate
for a covered surgical procedure on the CY 2007 ASC list of surgical
procedures and 25 percent of the payment rate for the procedure
calculated under the methodology described in paragraph (a) of this
section.
(2) ASC payment rates for CY 2009 are a transitional blend of 50
percent of the CY 2007 ASC payment rate for a covered surgical
procedure on the CY 2007 ASC list of surgical procedures and 50 percent
of the payment rate for the procedure calculated under the methodology
described in paragraph (a) of this section.
(3) ASC payment rates for CY 2010 are a transitional blend of 25
percent of the CY 2007 ASC payment rate for a
[[Page 42547]]
covered surgical procedure on the CY 2007 ASC list of surgical
procedures and 75 percent of the payment rate for the procedure
calculated under the methodology described in paragraph (a) of this
section.
(4) The national ASC payment rate for CY 2011 and subsequent
calendar years for a covered surgical procedure designated in
accordance with Sec. 416.166 is the payment rates for the procedure
calculated under the methodology described in paragraph (a) of this
section.
(5) Covered ancillary services described in Sec. 416.164(b) and
surgical procedures identified as covered when performed in an ASC
under Sec. 416.166 for the first time beginning on or after January 1,
2008, are not subject to the transitional payment rates applicable in
CYs 2008 through 2010 for ASC facility services.
(d) Limitation on payment rates for office-based surgical
procedures and covered ancillary radiology services. Notwithstanding
the provisions of paragraph (a) of this section, for any covered
surgical procedure under Sec. 416.166 that CMS determines is commonly
performed in physicians' offices or for any covered ancillary radiology
service, the national unadjusted ASC payment rates for these procedures
and services will be the lesser of the amount determined under
paragraph (a) of this section or the amount calculated at the
nonfacility practice expense relative value units under Sec.
414.22(b)(5)(i)(B) of this subchapter multiplied by the conversion
factor described in Sec. 414.20(a)(3) of this subchapter.
(e) Budget neutrality. (1) For CY 2008, CMS establishes the
conversion factor to result in budget neutrality as estimated by CMS in
accordance with paragraph (a)(1) of this section.
(2) For CY 2009 and subsequent calendar years, CMS adjusts the ASC
relative payment weights under Sec. 416.167(b)(2) as needed so that
any updates and adjustments made under Sec. 419.50(a) of this
subchapter are budget neutral as estimated by CMS.
Sec. 416.172 Adjustments to national payment rates.
(a) General rule. Contractors adjust the payment rates established
for ASC services to determine Medicare program payment and beneficiary
coinsurance amounts in accordance with paragraphs (b) through (g) of
this section.
(b) Lesser of actual charge or geographically adjusted payment
rate. Payments to ASCs equal 80 percent of the lesser of--
(1) The actual charge for the service; or
(2) The geographically adjusted payment rate determined under this
subpart.
(c) Geographic adjustment.--(1) General rule. Except as provided in
paragraph (c)(2) of this section, the national ASC payment rates
established under Sec. 416.171 for covered surgical procedures are
adjusted for variations in ASC labor costs across geographic areas
using wage index values, labor and nonlabor percentages, and localities
specified by the Secretary.
(2) Exception. The geographic adjustment is not applied to the
payment rates set for drugs, biologicals, devices with OPPS
transitional pass-through payment status, and brachytherapy sources.
(d) Deductibles and coinsurance. Part B deductible and coinsurance
amounts apply as specified in Sec. Sec. 410.152(a) and (i)(2) of this
subchapter.
(e) Payment reductions for multiple surgical procedures.--(1)
General rule. Except as provided in paragraph (e)(2) of this section,
when more than one covered surgical procedure for which payment is made
under the ASC payment system is performed during an operative session,
the Medicare program payment amount and the beneficiary coinsurance
amount are based on--
(i) 100 percent of the applicable ASC payment amount for the
procedure with the highest national unadjusted ASC payment rate; and
(ii) 50 percent of the applicable ASC payment amount for all other
covered surgical procedures.
(2) Exception: Procedures not subject to multiple procedure
discounting. CMS may apply any policies or procedures used with respect
to multiple procedures under the prospective payment system for
hospital outpatient department services under Part 419 of this
subchapter as may be consistent with the equitable and efficient
administration of this part.
(f) Interrupted procedures. When a covered surgical procedure or
covered ancillary service is terminated prior to completion due to
extenuating circumstances or circumstances that threaten the well-being
of the patient, the Medicare program payment amount and the beneficiary
coinsurance amount are based on one of the following--
(1) The full program and beneficiary coinsurance amounts if the
procedure for which anesthesia is planned is discontinued after the
induction of anesthesia or after the procedure is started;
(2) One-half of the full program and beneficiary coinsurance
amounts if the procedure for which anesthesia is planned is
discontinued after the patient is prepared for surgery and taken to the
room where the procedure is to be performed but before the anesthesia
is induced; or
(3) One-half of the full program and beneficiary coinsurance
amounts if a covered surgical procedure or covered ancillary service
for which anesthesia is not planned is discontinued after the patient
is prepared and taken to the room where the service is to be provided.
(g) Payment adjustment for new technology intraocular lenses
(NTIOLs). A payment adjustment will be made for insertion of an IOL
approved as belonging to a class of NTIOLs as defined in Subpart G.
Sec. 416.173 Publication of revised payment methodologies and payment
rates.
CMS publishes annually, through notice and comment rulemaking in
the Federal Register, the payment methodologies and payment rates for
ASC services and designates the covered surgical procedures and covered
ancillary services for which CMS will make an ASC payment and other
revisions as appropriate.
Sec. 416.178 Limitations on administrative and judicial review.
There is no administrative or judicial review under section 1869 of
the Act, section 1878 of the Act, or otherwise of the following:
(a) The classification system;
(b) Relative weights;
(c) Payment amounts; and
(d) Geographic adjustment factors.
Sec. 416.179 Payment and coinsurance reduction for devices replaced
without cost or when full credit is received.
(a) General rule. CMS reduces the amount of payment for a covered
surgical procedure for which CMS determines that a significant portion
of the payment is attributable to the cost of an implanted device not
on pass-through status under Subpart G of Part 419 of this subchapter
when one of the following situations occur:
(1) The device is replaced without cost to the ASC or the
beneficiary; or
(2) The ASC receives full credit for the cost of a replaced device.
(b) Amount of reduction to the ASC payment for the covered surgical
procedure. The amount of the reduction to the ASC payment made under
paragraph (a) of this section is calculated in the same manner as the
device payment reduction that would be applied to the ASC payment for
the covered surgical procedure in order to remove predecessor device
costs so that
[[Page 42548]]
the ASC payment amount for a device with pass-through status under
Sec. 419.66 of this subchapter represents the full cost of the device,
and no packaged device payment is provided through the ASC payment for
the covered surgical procedure.
(c) Amount of beneficiary coinsurance. The beneficiary coinsurance
is calculated based on the ASC payment for the covered surgical
procedure after application of the reduction under paragraph (b) of
this section.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: April 24, 2007.
Leslie Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: May 31, 2007.
Michael O. Leavitt,
Secretary.
[[Page 42549]]
--------------------
Note: The Medicare program payment is 80 percent of the total payment
amount and beneficiary coinsurance is 20 percent of the total payment
amount, except for screening flexible sigmoidoscopies and screening
colonoscopies for which the program payment is 75 percent and the
beneficiary coinsurance is 25 percent.
* Refers to codes designated as ``office-based'', whose designation as
office-based is temporary because we have insufficient claims data. We
will reconsider this designation when new claims data become available.
[[Page 42549]]
Addendum AA.--Illustrative ASC Covered Surgical Procedures for CY 2008
[Including surgical procedures for which payment is packaged]
----------------------------------------------------------------------------------------------------------------
Estimated
Subject to Estimated Estimated CY 2008
Short multiple Payment CY 2007 ASC fully CY 2008 first
HCPCS code descriptor procedure indicator payment implemented fully transition
discounting rate payment implemented year
weight payment payment
----------------------------------------------------------------------------------------------------------------
0016T........ Thermotx Y............ R2........... ........... 3.9333 $167.33 $167.33
choroids vasc
lesion.
0017T........ Photocoagulat Y............ R2........... ........... 3.9333 $167.33 $167.33
macular drusen.
0027T........ Endoscopic Y............ G2........... ........... 17.8499 $759.39 $759.39
epidural lysis.
0031T........ Speculoscopy... ............. N1........... ........... ........... ........... ...........
0032T........ Speculoscopy w/ ............. N1........... ........... ........... ........... ...........
direct sample.
0046T........ Cath lavage, Y............ R2........... ........... 15.1024 $642.50 $642.50
mammary
duct(s).
0047T........ Cath lavage, Y............ R2........... ........... 15.1024 $642.50 $642.50
mammary
duct(s).
0062T........ Rep intradisc Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
annulus;1 lev.
0063T........ Rep intradisc Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
annulus;>1lev.
0084T........ Temp prostate Y............ G2........... ........... 2.1393 $91.01 $91.01
urethral stent.
0099T \*\.... Implant corneal Y............ R2........... ........... 15.2259 $647.76 $647.76
ring.
0100T........ Prosth retina Y............ G2........... ........... 37.4290 $1,592.34 $1,592.34
receive&gen.
0101T........ Extracorp Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
shockwv tx,hi
enrg.
0102T........ Extracorp Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
shockwv
tx,anesth.
0123T........ Scleral Y............ G2........... ........... 22.9970 $978.36 $978.36
fistulization.
0124T \*\.... Conjunctival Y............ R2........... ........... 6.0673 $258.12 $258.12
drug placement.
0133T........ Esophageal Y............ G2........... ........... 25.7552 $1,095.70 $1,095.70
implant injexn.
0176T........ Aqu canal dilat Y............ A2........... $1,339.00 37.8967 $1,612.24 $1,407.31
w/o retent.
0177T........ Aqu canal dilat Y............ A2........... $1,339.00 37.8967 $1,612.24 $1,407.31
w retent.
10021........ Fna w/o image.. Y............ P2........... ........... 1.0995 $46.78 $46.78
10022........ Fna w/image.... Y............ G2........... ........... 2.0738 $88.23 $88.23
10040........ Acne surgery... Y............ P2........... ........... 0.4760 $20.25 $20.25
10060........ Drainage of Y............ P3........... ........... 1.0944 $46.56 $46.56
skin abscess.
10061........ Drainage of Y............ P2........... ........... 1.4392 $61.23 $61.23
skin abscess.
10080........ Drainage of Y............ P2........... ........... 1.4392 $61.23 $61.23
pilonidal cyst.
10081........ Drainage of Y............ P3........... ........... 3.0339 $129.07 $129.07
pilonidal cyst.
10120........ Remove foreign Y............ P2........... ........... 1.4392 $61.23 $61.23
body.
10121........ Remove foreign Y............ A2........... $446.00 15.1024 $642.50 $495.13
body.
10140........ Drainage of Y............ P3........... ........... 1.6174 $68.81 $68.81
hematoma/fluid.
10160........ Puncture Y............ P2........... ........... 1.0259 $43.64 $43.64
drainage of
lesion.
10180........ Complex Y............ A2........... $446.00 17.5086 $744.87 $520.72
drainage,
wound.
11000........ Debride Y............ P3........... ........... 0.5312 $22.60 $22.60
infected skin.
11001........ Debride Y............ P3........... ........... 0.1850 $7.87 $7.87
infected skin
add-on.
11010........ Debride skin, Y............ A2........... $251.52 4.0919 $174.08 $232.16
fx.
11011........ Debride skin/ Y............ A2........... $251.52 4.0919 $174.08 $232.16
muscle, fx.
11012........ Debride skin/ Y............ A2........... $251.52 4.0919 $174.08 $232.16
muscle/bone,
fx.
11040........ Debride skin, Y............ P3........... ........... 0.4828 $20.54 $20.54
partial.
11041........ Debride skin, Y............ P3........... ........... 0.5632 $23.96 $23.96
full.
11042........ Debride skin/ Y............ A2........... $164.42 2.6749 $113.80 $151.77
tissue.
11043........ Debride tissue/ Y............ A2........... $164.42 2.6749 $113.80 $151.77
muscle.
11044........ Debride tissue/ Y............ A2........... $423.10 6.8832 $292.83 $390.53
muscle/bone.
11055........ Trim skin Y............ P3........... ........... 0.5552 $23.62 $23.62
lesion.
11056........ Trim skin Y............ P3........... ........... 0.6116 $26.02 $26.02
lesions, 2 to
4.
11057........ Trim skin Y............ P3........... ........... 0.7000 $29.78 $29.78
lesions, over
4.
11100........ Biopsy, skin Y............ P2........... ........... 1.0259 $43.64 $43.64
lesion.
11101........ Biopsy, skin Y............ P3........... ........... 0.2978 $12.67 $12.67
add-on.
11200........ Removal of skin Y............ P3........... ........... 0.9174 $39.03 $39.03
tags.
11201........ Remove skin Y............ P3........... ........... 0.1288 $5.48 $5.48
tags add-on.
11300........ Shave skin Y............ P2........... ........... 0.8432 $35.87 $35.87
lesion.
11301........ Shave skin Y............ P2........... ........... 0.8432 $35.87 $35.87
lesion.
11302........ Shave skin Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion.
11303........ Shave skin Y............ P3........... ........... 1.4484 $61.62 $61.62
lesion.
11305........ Shave skin Y............ P3........... ........... 0.7726 $32.87 $32.87
lesion.
11306........ Shave skin Y............ P3........... ........... 1.0140 $43.14 $43.14
lesion.
11307........ Shave skin Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion.
11308........ Shave skin Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion.
11310........ Shave skin Y............ P3........... ........... 1.0058 $42.79 $42.79
lesion.
11311........ Shave skin Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion.
11312........ Shave skin Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion.
11313........ Shave skin Y............ P3........... ........... 1.6094 $68.47 $68.47
lesion.
11400........ Exc tr-ext Y............ P3........... ........... 1.5530 $66.07 $66.07
b9+marg 0.5
< cm.
11401........ Exc tr-ext Y............ P3........... ........... 1.6980 $72.24 $72.24
b9+marg 0.6-1
cm.
11402........ Exc tr-ext Y............ P3........... ........... 1.8508 $78.74 $78.74
b9+marg 1.1-2
cm.
[[Page 42550]]
11403........ Exc tr-ext Y............ P3........... ........... 1.9876 $84.56 $84.56
b9+marg 2.1-3
cm.
11404........ Exc tr-ext Y............ A2........... $333.00 15.1024 $642.50 $410.38
b9+marg 3.1-4
cm.
11406........ Exc tr-ext Y............ A2........... $446.00 15.1024 $642.50 $495.13
b9+marg > 4.0
cm.
11420........ Exc h-f-nk-sp Y............ P3........... ........... 1.4484 $61.62 $61.62
b9+marg 0.5< .
11421........ Exc h-f-nk-sp Y............ P3........... ........... 1.7220 $73.26 $73.26
b9+marg 0.6-1.
11422........ Exc h-f-nk-sp Y............ P3........... ........... 1.8750 $79.77 $79.77
b9+marg 1.1-2.
11423........ Exc h-f-nk-sp Y............ P3........... ........... 2.1085 $89.70 $89.70
b9+marg 2.1-3.
11424........ Exc h-f-nk-sp Y............ A2........... $446.00 15.1024 $642.50 $495.13
b9+marg 3.1-4.
11426........ Exc h-f-nk-sp Y............ A2........... $446.00 20.0656 $853.65 $547.91
b9+marg > 4 cm.
11440........ Exc face-mm Y............ P3........... ........... 1.6898 $71.89 $71.89
b9+marg 0.5 <
cm.
11441........ Exc face-mm Y............ P3........... ........... 1.8993 $80.80 $80.80
b9+marg 0.6-1
cm.
11442........ Exc face-mm Y............ P3........... ........... 2.0763 $88.33 $88.33
b9+marg 1.1-2
cm.
11443........ Exc face-mm Y............ P3........... ........... 2.3256 $98.94 $98.94
b9+marg 2.1-3
cm.
11444........ Exc face-mm Y............ A2........... $333.00 6.8083 $289.65 $322.16
b9+marg 3.1-4
cm.
11446........ Exc face-mm Y............ A2........... $446.00 20.0656 $853.65 $547.91
b9+marg > 4 cm.
11450........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11451........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11462........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11463........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11470........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11471........ Removal, sweat Y............ A2........... $446.00 20.0656 $853.65 $547.91
gland lesion.
11600........ Exc tr-ext Y............ P3........... ........... 2.1646 $92.09 $92.09
mlg+marg 0.5 <
cm.
11601........ Exc tr-ext Y............ P3........... ........... 2.4787 $105.45 $105.45
mlg+marg 0.6-1
cm.
11602........ Exc tr-ext Y............ P3........... ........... 2.6879 $114.35 $114.35
mlg+marg 1.1-2
cm.
11603........ Exc tr-ext Y............ P3........... ........... 2.8729 $122.22 $122.22
mlg+marg 2.1-3
cm.
11604........ Exc tr-ext Y............ A2........... $418.49 6.8083 $289.65 $386.28
mlg+marg 3.1-4
cm.
11606........ Exc tr-ext Y............ A2........... $446.00 15.1024 $642.50 $495.13
mlg+marg > 4
cm.
11620........ Exc h-f-nk-sp Y............ P3........... ........... 2.1888 $93.12 $93.12
mlg+marg 0.5.
11621........ Exc h-f-nk-sp Y............ P3........... ........... 2.4947 $106.13 $106.13
mlg+marg 0.6-1.
11622........ Exc h-f-nk-sp Y............ P3........... ........... 2.7683 $117.77 $117.77
mlg+marg 1.1-2.
11623........ Exc h-f-nk-sp Y............ P3........... ........... 3.0017 $127.70 $127.70
mlg+marg 2.1-3.
11624........ Exc h-f-nk-sp Y............ A2........... $446.00 15.1024 $642.50 $495.13
mlg+marg 3.1-4.
11626........ Exc h-f-nk-sp Y............ A2........... $446.00 20.0656 $853.65 $547.91
mlg+mar > 4 cm.
11640........ Exc face-mm Y............ P3........... ........... 2.2934 $97.57 $97.57
malig+marg
0.5< .
11641........ Exc face-mm Y............ P3........... ........... 2.6796 $114.00 $114.00
malig+marg 0.6-
1.
11642........ Exc face-mm Y............ P3........... ........... 2.9937 $127.36 $127.36
malig+marg 1.1-
2.
11643........ Exc face-mm Y............ P3........... ........... 3.2511 $138.31 $138.31
malig+marg 2.1-
3.
11644........ Exc face-mm Y............ A2........... $446.00 15.1024 $642.50 $495.13
malig+marg 3.1-
4.
11646........ Exc face-mm Y............ A2........... $446.00 20.0656 $853.65 $547.91
mlg+marg > 4
cm.
11719........ Trim nail(s)... Y............ P3........... ........... 0.2494 $10.61 $10.61
11720........ Debride nail, 1- Y............ P3........... ........... 0.3218 $13.69 $13.69
5.
11721........ Debride nail, 6 Y............ P3........... ........... 0.4024 $17.12 $17.12
or more.
11730........ Removal of nail Y............ P3........... ........... 0.9576 $40.74 $40.74
plate.
11732........ Remove nail Y............ P3........... ........... 0.4024 $17.12 $17.12
plate, add-on.
11740........ Drain blood Y............ P3........... ........... 0.5392 $22.94 $22.94
from under
nail.
11750........ Removal of nail Y............ P3........... ........... 2.0763 $88.33 $88.33
bed.
11752........ Remove nail bed/ Y............ P3........... ........... 2.8729 $122.22 $122.22
finger tip.
11755........ Biopsy, nail Y............ P3........... ........... 1.4566 $61.97 $61.97
unit.
11760........ Repair of nail Y............ G2........... ........... 1.4843 $63.15 $63.15
bed.
11762........ Reconstruction Y............ P2........... ........... 1.4843 $63.15 $63.15
of nail bed.
11765........ Excision of Y............ P2........... ........... 1.6241 $69.09 $69.09
nail fold, toe.
11770........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
pilonidal
lesion.
11771........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
pilonidal
lesion.
11772........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
pilonidal
lesion.
11900........ Injection into Y............ P3........... ........... 0.6358 $27.05 $27.05
skin lesions.
11901........ Added skin Y............ P3........... ........... 0.6760 $28.76 $28.76
lesions
injection.
11920........ Correct skin Y............ P2........... ........... 1.4843 $63.15 $63.15
color defects.
11921........ Correct skin Y............ P2........... ........... 1.4843 $63.15 $63.15
color defects.
11922........ Correct skin Y............ P3........... ........... 0.8368 $35.60 $35.60
color defects.
11950........ Therapy for Y............ P3........... ........... 0.8048 $34.24 $34.24
contour
defects.
11951........ Therapy for Y............ P3........... ........... 1.0784 $45.88 $45.88
contour
defects.
11952........ Therapy for Y............ P3........... ........... 1.4484 $61.62 $61.62
contour
defects.
11954........ Therapy for Y............ P2........... ........... 1.4843 $63.15 $63.15
contour
defects.
[[Page 42551]]
11960........ Insert tissue Y............ A2........... $446.00 21.4302 $911.71 $562.43
expander(s).
11970........ Replace tissue Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
expander.
11971........ Remove tissue Y............ A2........... $333.00 20.0656 $853.65 $463.16
expander(s).
11976........ Removal of Y............ P3........... ........... 1.3760 $58.54 $58.54
contraceptive
cap.
11980........ Implant hormone N............ P2........... ........... 0.6102 $25.96 $25.96
pellet(s).
11981........ Insert drug N............ P2........... ........... 0.6102 $25.96 $25.96
implant device.
11982........ Remove drug N............ P2........... ........... 0.6102 $25.96 $25.96
implant device.
11983........ Remove/insert N............ P2........... ........... 0.6102 $25.96 $25.96
drug implant.
12001........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12002........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12004........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12005........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12006........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12007........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12011........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12013........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12014........ Repair Y............ P2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12015........ Repair Y............ G2........... ........... 1.4843 $63.15 $63.15
superficial
wound(s).
12016........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12017........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12018........ Repair Y............ A2........... $91.24 1.4843 $63.15 $84.22
superficial
wound(s).
12020........ Closure of Y............ A2........... $91.24 1.4843 $63.15 $84.22
split wound.
12021........ Closure of Y............ A2........... $91.24 1.4843 $63.15 $84.22
split wound.
12031........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12032........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12034........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12035........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12036........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12037........ Layer closure Y............ A2........... $323.28 5.2594 $223.75 $298.40
of wound(s).
12041........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12042........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12044........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12045........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12046........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12047........ Layer closure Y............ A2........... $323.28 5.2594 $223.75 $298.40
of wound(s).
12051........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12052........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12053........ Layer closure Y............ P2........... ........... 1.4843 $63.15 $63.15
of wound(s).
12054........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12055........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12056........ Layer closure Y............ A2........... $91.24 1.4843 $63.15 $84.22
of wound(s).
12057........ Layer closure Y............ A2........... $323.28 5.2594 $223.75 $298.40
of wound(s).
13100........ Repair of wound Y............ A2........... $323.28 5.2594 $223.75 $298.40
or lesion.
13101........ Repair of wound Y............ A2........... $323.28 5.2594 $223.75 $298.40
or lesion.
13102........ Repair wound/ Y............ A2........... $91.24 1.4843 $63.15 $84.22
lesion add-on.
13120........ Repair of wound Y............ A2........... $91.24 1.4843 $63.15 $84.22
or lesion.
13121........ Repair of wound Y............ A2........... $91.24 1.4843 $63.15 $84.22
or lesion.
13122........ Repair wound/ Y............ A2........... $91.24 1.4843 $63.15 $84.22
lesion add-on.
13131........ Repair of wound Y............ A2........... $91.24 1.4843 $63.15 $84.22
or lesion.
13132........ Repair of wound Y............ A2........... $91.24 1.4843 $63.15 $84.22
or lesion.
13133........ Repair wound/ Y............ A2........... $91.24 1.4843 $63.15 $84.22
lesion add-on.
13150........ Repair of wound Y............ A2........... $323.28 5.2594 $223.75 $298.40
or lesion.
13151........ Repair of wound Y............ A2........... $323.28 5.2594 $223.75 $298.40
or lesion.
13152........ Repair of wound Y............ A2........... $323.28 5.2594 $223.75 $298.40
or lesion.
13153........ Repair wound/ Y............ A2........... $91.24 1.4843 $63.15 $84.22
lesion add-on.
13160........ Late closure of Y............ A2........... $446.00 21.4302 $911.71 $562.43
wound.
14000........ Skin tissue Y............ A2........... $446.00 14.0346 $597.07 $483.77
rearrangement.
14001........ Skin tissue Y............ A2........... $510.00 21.4302 $911.71 $610.43
rearrangement.
14020........ Skin tissue Y............ A2........... $510.00 14.0346 $597.07 $531.77
rearrangement.
14021........ Skin tissue Y............ A2........... $510.00 14.0346 $597.07 $531.77
rearrangement.
14040........ Skin tissue Y............ A2........... $446.00 14.0346 $597.07 $483.77
rearrangement.
14041........ Skin tissue Y............ A2........... $510.00 14.0346 $597.07 $531.77
rearrangement.
14060........ Skin tissue Y............ A2........... $510.00 14.0346 $597.07 $531.77
rearrangement.
[[Page 42552]]
14061........ Skin tissue Y............ A2........... $510.00 14.0346 $597.07 $531.77
rearrangement.
14300........ Skin tissue Y............ A2........... $630.00 21.4302 $911.71 $700.43
rearrangement.
14350........ Skin tissue Y............ A2........... $510.00 21.4302 $911.71 $610.43
rearrangement.
15002........ Wnd prep, ch/ Y............ A2........... $323.28 5.2594 $223.75 $298.40
inf, trk/arm/
lg.
15003........ Wnd prep, ch/ Y............ A2........... $323.28 5.2594 $223.75 $298.40
inf addl 100
cm.
15004........ Wnd prep ch/ Y............ A2........... $323.28 5.2594 $223.75 $298.40
inf, f/n/hf/g.
15005........ Wnd prep, f/n/ Y............ A2........... $323.28 5.2594 $223.75 $298.40
hf/g, addl cm.
15040........ Harvest Y............ A2........... $91.24 1.4843 $63.15 $84.22
cultured skin
graft.
15050........ Skin pinch Y............ A2........... $323.28 5.2594 $223.75 $298.40
graft.
15100........ Skin splt grft, Y............ A2........... $446.00 21.4302 $911.71 $562.43
trnk/arm/leg.
15101........ Skin splt grft Y............ A2........... $510.00 21.4302 $911.71 $610.43
t/a/l, add-on.
15110........ Epidrm autogrft Y............ A2........... $446.00 21.4302 $911.71 $562.43
trnk/arm/leg.
15111........ Epidrm autogrft Y............ A2........... $333.00 21.4302 $911.71 $477.68
t/a/l add-on.
15115........ Epidrm a-grft Y............ A2........... $446.00 21.4302 $911.71 $562.43
face/nck/hf/g.
15116........ Epidrm a-grft f/ Y............ A2........... $333.00 21.4302 $911.71 $477.68
n/hf/g addl.
15120........ Skn splt a-grft Y............ A2........... $446.00 21.4302 $911.71 $562.43
fac/nck/hf/g.
15121........ Skn splt a-grft Y............ A2........... $510.00 21.4302 $911.71 $610.43
f/n/hf/g add.
15130........ Derm autograft, Y............ A2........... $446.00 21.4302 $911.71 $562.43
trnk/arm/leg.
15131........ Derm autograft Y............ A2........... $333.00 21.4302 $911.71 $477.68
t/a/l add-on.
15135........ Derm autograft Y............ A2........... $446.00 21.4302 $911.71 $562.43
face/nck/hf/g.
15136........ Derm autograft, Y............ A2........... $333.00 21.4302 $911.71 $477.68
f/n/hf/g add.
15150........ Cult epiderm Y............ A2........... $446.00 21.4302 $911.71 $562.43
grft t/arm/leg.
15151........ Cult epiderm Y............ A2........... $333.00 21.4302 $911.71 $477.68
grft t/a/l
addl.
15152........ Cult epiderm Y............ A2........... $333.00 21.4302 $911.71 $477.68
graft t/a/l +%.
15155........ Cult epiderm Y............ A2........... $446.00 21.4302 $911.71 $562.43
graft, f/n/hf/
g.
15156........ Cult epidrm Y............ A2........... $333.00 21.4302 $911.71 $477.68
grft f/n/hfg
add.
15157........ Cult epiderm Y............ A2........... $333.00 21.4302 $911.71 $477.68
grft f/n/hfg
+%.
15200........ Skin full Y............ A2........... $510.00 14.0346 $597.07 $531.77
graft, trunk.
15201........ Skin full graft Y............ A2........... $323.28 5.2594 $223.75 $298.40
trunk add-on.
15220........ Skin full graft Y............ A2........... $446.00 14.0346 $597.07 $483.77
sclp/arm/leg.
15221........ Skin full graft Y............ A2........... $323.28 5.2594 $223.75 $298.40
add-on.
15240........ Skin full grft Y............ A2........... $510.00 14.0346 $597.07 $531.77
face/genit/hf.
15241........ Skin full graft Y............ A2........... $323.28 5.2594 $223.75 $298.40
add-on.
15260........ Skin full graft Y............ A2........... $446.00 14.0346 $597.07 $483.77
een & lips.
15261........ Skin full graft Y............ A2........... $323.28 5.2594 $223.75 $298.40
add-on.
15300........ Apply Y............ A2........... $323.28 5.2594 $223.75 $298.40
skinallogrft,
t/arm/lg.
15301........ Apply Y............ A2........... $323.28 5.2594 $223.75 $298.40
sknallogrft t/
a/l addl.
15320........ Apply skin Y............ A2........... $323.28 5.2594 $223.75 $298.40
allogrft f/n/
hf/g.
15321........ Aply Y............ A2........... $323.28 5.2594 $223.75 $298.40
sknallogrft f/
n/hfg add.
15330........ Aply acell Y............ A2........... $323.28 5.2594 $223.75 $298.40
alogrft t/arm/
leg.
15331........ Aply acell grft Y............ A2........... $323.28 5.2594 $223.75 $298.40
t/a/l add-on.
15335........ Apply acell Y............ A2........... $323.28 5.2594 $223.75 $298.40
graft, f/n/hf/
g.
15336........ Aply acell grft Y............ A2........... $323.28 5.2594 $223.75 $298.40
f/n/hf/g add.
15340........ Apply cult skin Y............ P3........... ........... 3.1385 $133.52 $133.52
substitute.
15341........ Apply cult skin Y............ G2........... ........... 5.2594 $223.75 $223.75
sub add-on.
15360........ Apply cult derm Y............ G2........... ........... 5.2594 $223.75 $223.75
sub, t/a/l.
15361........ Aply cult derm Y............ G2........... ........... 5.2594 $223.75 $223.75
sub t/a/l add.
15365........ Apply cult derm Y............ G2........... ........... 5.2594 $223.75 $223.75
sub f/n/hf/g.
15366........ Apply cult derm Y............ G2........... ........... 5.2594 $223.75 $223.75
f/hf/g add.
15400........ Apply skin Y............ A2........... $323.28 5.2594 $223.75 $298.40
xenograft, t/a/
l.
15401........ Apply skn Y............ A2........... $323.28 5.2594 $223.75 $298.40
xenogrft t/a/l
add.
15420........ Apply skin Y............ A2........... $323.28 5.2594 $223.75 $298.40
xgraft, f/n/hf/
g.
15421........ Apply skn xgrft Y............ A2........... $323.28 5.2594 $223.75 $298.40
f/n/hf/g add.
15430........ Apply acellular Y............ A2........... $323.28 5.2594 $223.75 $298.40
xenograft.
15431........ Apply acellular Y............ A2........... $323.28 5.2594 $223.75 $298.40
xgraft add.
15570........ Form skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
pedicle flap.
15572........ Form skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
pedicle flap.
15574........ Form skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
pedicle flap.
15576........ Form skin Y............ A2........... $510.00 14.0346 $597.07 $531.77
pedicle flap.
15600........ Skin graft..... Y............ A2........... $510.00 21.4302 $911.71 $610.43
15610........ Skin graft..... Y............ A2........... $510.00 21.4302 $911.71 $610.43
15620........ Skin graft..... Y............ A2........... $630.00 21.4302 $911.71 $700.43
15630........ Skin graft..... Y............ A2........... $510.00 21.4302 $911.71 $610.43
[[Page 42553]]
15650........ Transfer skin Y............ A2........... $717.00 21.4302 $911.71 $765.68
pedicle flap.
15731........ Forehead flap w/ Y............ A2........... $510.00 14.0346 $597.07 $531.77
vasc pedicle.
15732........ Muscle-skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
graft, head/
neck.
15734........ Muscle-skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
graft, trunk.
15736........ Muscle-skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
graft, arm.
15738........ Muscle-skin Y............ A2........... $510.00 21.4302 $911.71 $610.43
graft, leg.
15740........ Island pedicle Y............ A2........... $446.00 14.0346 $597.07 $483.77
flap graft.
15750........ Neurovascular Y............ A2........... $446.00 21.4302 $911.71 $562.43
pedicle graft.
15760........ Composite skin Y............ A2........... $446.00 21.4302 $911.71 $562.43
graft.
15770........ Derma-fat- Y............ A2........... $510.00 21.4302 $911.71 $610.43
fascia graft.
15775........ Hair transplant Y............ A2........... $323.28 5.2594 $223.75 $298.40
punch grafts.
15776........ Hair transplant Y............ A2........... $323.28 5.2594 $223.75 $298.40
punch grafts.
15780........ Abrasion Y............ P3........... ........... 9.3992 $399.87 $399.87
treatment of
skin.
15781........ Abrasion Y............ P2........... ........... 4.0919 $174.08 $174.08
treatment of
skin.
15782........ Abrasion Y............ P2........... ........... 4.0919 $174.08 $174.08
treatment of
skin.
15783........ Abrasion Y............ P2........... ........... 2.6749 $113.80 $113.80
treatment of
skin.
15786........ Abrasion, Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion, single.
15787........ Abrasion, Y............ P3........... ........... 0.7726 $32.87 $32.87
lesions, add-
on.
15788........ Chemical peel, Y............ P2........... ........... 0.8432 $35.87 $35.87
face, epiderm.
15789........ Chemical peel, Y............ P2........... ........... 1.6241 $69.09 $69.09
face, dermal.
15792........ Chemical peel, Y............ P2........... ........... 1.0918 $46.45 $46.45
nonfacial.
15793........ Chemical peel, Y............ P2........... ........... 0.8432 $35.87 $35.87
nonfacial.
15819........ Plastic Y............ G2........... ........... 5.2594 $223.75 $223.75
surgery, neck.
15820........ Revision of Y............ A2........... $510.00 21.4302 $911.71 $610.43
lower eyelid.
15821........ Revision of Y............ A2........... $510.00 21.4302 $911.71 $610.43
lower eyelid.
15822........ Revision of Y............ A2........... $510.00 21.4302 $911.71 $610.43
upper eyelid.
15823........ Revision of Y............ A2........... $717.00 14.0346 $597.07 $687.02
upper eyelid.
15824........ Removal of Y............ A2........... $510.00 21.4302 $911.71 $610.43
forehead
wrinkles.
15825........ Removal of neck Y............ A2........... $510.00 21.4302 $911.71 $610.43
wrinkles.
15826........ Removal of brow Y............ A2........... $510.00 21.4302 $911.71 $610.43
wrinkles.
15828........ Removal of face Y............ A2........... $510.00 21.4302 $911.71 $610.43
wrinkles.
15829........ Removal of skin Y............ A2........... $717.00 21.4302 $911.71 $765.68
wrinkles.
15830........ Exc skin abd... Y............ A2........... $510.00 20.0656 $853.65 $595.91
15832........ Excise Y............ A2........... $510.00 20.0656 $853.65 $595.91
excessive skin
tissue.
15833........ Excise Y............ A2........... $510.00 20.0656 $853.65 $595.91
excessive skin
tissue.
15834........ Excise Y............ A2........... $510.00 20.0656 $853.65 $595.91
excessive skin
tissue.
15835........ Excise Y............ A2........... $323.28 5.2594 $223.75 $298.40
excessive skin
tissue.
15836........ Excise Y............ A2........... $510.00 15.1024 $642.50 $543.13
excessive skin
tissue.
15837........ Excise Y............ G2........... ........... 15.1024 $642.50 $642.50
excessive skin
tissue.
15838........ Excise Y............ G2........... ........... 15.1024 $642.50 $642.50
excessive skin
tissue.
15839........ Excise Y............ A2........... $510.00 15.1024 $642.50 $543.13
excessive skin
tissue.
15840........ Graft for face Y............ A2........... $630.00 21.4302 $911.71 $700.43
nerve palsy.
15841........ Graft for face Y............ A2........... $630.00 21.4302 $911.71 $700.43
nerve palsy.
15842........ Flap for face Y............ G2........... ........... 14.0346 $597.07 $597.07
nerve palsy.
15845........ Skin and muscle Y............ A2........... $630.00 21.4302 $911.71 $700.43
repair, face.
15847........ Exc skin abd Y............ A2........... $510.00 20.0656 $853.65 $595.91
add-on.
15850........ Removal of Y............ G2........... ........... 2.6749 $113.80 $113.80
sutures.
15851........ Removal of Y............ P3........... ........... 1.2070 $51.35 $51.35
sutures.
15852........ Dressing change N............ G2........... ........... 0.6102 $25.96 $25.96
not for burn.
15860........ Test for blood N............ G2........... ........... 0.6102 $25.96 $25.96
flow in graft.
15876........ Suction Y............ A2........... $510.00 21.4302 $911.71 $610.43
assisted
lipectomy.
15877........ Suction Y............ A2........... $510.00 21.4302 $911.71 $610.43
assisted
lipectomy.
15878........ Suction Y............ A2........... $510.00 14.0346 $597.07 $531.77
assisted
lipectomy.
15879........ Suction Y............ A2........... $510.00 21.4302 $911.71 $610.43
assisted
lipectomy.
15920........ Removal of tail Y............ A2........... $251.52 4.0919 $174.08 $232.16
bone ulcer.
15922........ Removal of tail Y............ A2........... $630.00 21.4302 $911.71 $700.43
bone ulcer.
15931........ Remove sacrum Y............ A2........... $510.00 20.0656 $853.65 $595.91
pressure sore.
15933........ Remove sacrum Y............ A2........... $510.00 20.0656 $853.65 $595.91
pressure sore.
15934........ Remove sacrum Y............ A2........... $510.00 21.4302 $911.71 $610.43
pressure sore.
15935........ Remove sacrum Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15936........ Remove sacrum Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15937........ Remove sacrum Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15940........ Remove hip Y............ A2........... $510.00 20.0656 $853.65 $595.91
pressure sore.
[[Page 42554]]
15941........ Remove hip Y............ A2........... $510.00 20.0656 $853.65 $595.91
pressure sore.
15944........ Remove hip Y............ A2........... $510.00 21.4302 $911.71 $610.43
pressure sore.
15945........ Remove hip Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15946........ Remove hip Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15950........ Remove thigh Y............ A2........... $510.00 20.0656 $853.65 $595.91
pressure sore.
15951........ Remove thigh Y............ A2........... $630.00 20.0656 $853.65 $685.91
pressure sore.
15952........ Remove thigh Y............ A2........... $510.00 21.4302 $911.71 $610.43
pressure sore.
15953........ Remove thigh Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
15956........ Remove thigh Y............ A2........... $510.00 21.4302 $911.71 $610.43
pressure sore.
15958........ Remove thigh Y............ A2........... $630.00 21.4302 $911.71 $700.43
pressure sore.
16000........ Initial Y............ P3........... ........... 0.6438 $27.39 $27.39
treatment of
burn(s).
16020........ Dress/debrid p- Y............ P3........... ........... 0.9656 $41.08 $41.08
thick burn, s.
16025........ Dress/debrid p- Y............ A2........... $67.11 1.0918 $46.45 $61.95
thick burn, m.
16030........ Dress/debrid p- Y............ A2........... $99.83 1.6241 $69.09 $92.15
thick burn, l.
16035........ Incision of Y............ G2........... ........... 2.6749 $113.80 $113.80
burn scab,
initi.
17000........ Destruct Y............ P2........... ........... 0.4760 $20.25 $20.25
premalg lesion.
17003........ Destruct Y............ P3........... ........... 0.0886 $3.77 $3.77
premalg les, 2-
14.
17004........ Destroy premlg Y............ P3........... ........... 1.8993 $80.80 $80.80
lesions 15+.
17106........ Destruction of Y............ P2........... ........... 2.5665 $109.19 $109.19
skin lesions.
17107........ Destruction of Y............ P2........... ........... 2.5665 $109.19 $109.19
skin lesions.
17108........ Destruction of Y............ P2........... ........... 2.5665 $109.19 $109.19
skin lesions.
17110........ Destruct b9 Y............ P2........... ........... 0.8432 $35.87 $35.87
lesion, 1-14.
17111........ Destruct Y............ P2........... ........... 1.0918 $46.45 $46.45
lesion, 15 or
more.
17250........ Chemical Y............ P3........... ........... 1.0220 $43.48 $43.48
cautery,
tissue.
17260........ Destruction of Y............ P3........... ........... 1.0944 $46.56 $46.56
skin lesions.
17261........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17262........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17263........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17264........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17266........ Destruction of Y............ P3........... ........... 2.4382 $103.73 $103.73
skin lesions.
17270........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17271........ Destruction of Y............ P2........... ........... 1.0918 $46.45 $46.45
skin lesions.
17272........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17273........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17274........ Destruction of Y............ P3........... ........... 2.5026 $106.47 $106.47
skin lesions.
17276........ Destruction of Y............ P2........... ........... 2.6749 $113.80 $113.80
skin lesions.
17280........ Destruction of Y............ P3........... ........... 1.6014 $68.13 $68.13
skin lesions.
17281........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17282........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17283........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17284........ Destruction of Y............ P2........... ........... 2.6749 $113.80 $113.80
skin lesions.
17286........ Destruction of Y............ P2........... ........... 1.6241 $69.09 $69.09
skin lesions.
17311........ Mohs, 1 stage, Y............ P2........... ........... 3.7292 $158.65 $158.65
h/n/hf/g.
17312........ Mohs addl stage Y............ P2........... ........... 3.7292 $158.65 $158.65
17313........ Mohs, 1 stage, Y............ P2........... ........... 3.7292 $158.65 $158.65
t/a/l.
17314........ Mohs, addl Y............ P2........... ........... 3.7292 $158.65 $158.65
stage, t/a/l.
17315........ Mohs surg, addl Y............ P3........... ........... 0.9254 $39.37 $39.37
block.
17340........ Cryotherapy of Y............ P3........... ........... 0.2816 $11.98 $11.98
skin.
17360........ Skin peel Y............ P2........... ........... 1.0918 $46.45 $46.45
therapy.
17380........ Hair removal by Y............ R2........... ........... 1.0918 $46.45 $46.45
electrolysis.
19000........ Drainage of Y............ P3........... ........... 1.5290 $65.05 $65.05
breast lesion.
19001........ Drain breast Y............ P3........... ........... 0.1932 $8.22 $8.22
lesion add-on.
19020........ Incision of Y............ A2........... $446.00 17.5086 $744.87 $520.72
breast lesion.
19030........ Injection for ............. N1........... ........... ........... ........... ...........
breast x-ray.
19100........ Bx breast Y............ A2........... $240.00 3.9045 $166.11 $221.53
percut w/o
image.
19101........ Biopsy of Y............ A2........... $446.00 19.2788 $820.18 $539.55
breast, open.
19102........ Bx breast Y............ A2........... $240.00 3.9045 $166.11 $221.53
percut w/image.
19103........ Bx breast Y............ A2........... $395.77 6.4387 $273.92 $365.31
percut w/
device.
19105........ Cryosurg ablate Y............ G2........... ........... 28.0166 $1,191.91 $1,191.91
fa, each.
19110........ Nipple Y............ A2........... $446.00 19.2788 $820.18 $539.55
exploration.
19112........ Excise breast Y............ A2........... $510.00 19.2788 $820.18 $587.55
duct fistula.
19120........ Removal of Y............ A2........... $510.00 19.2788 $820.18 $587.55
breast lesion.
19125........ Excision, Y............ A2........... $510.00 19.2788 $820.18 $587.55
breast lesion.
[[Page 42555]]
19126........ Excision, addl Y............ A2........... $510.00 19.2788 $820.18 $587.55
breast lesion.
19290........ Place needle ............. N1........... $333.00 ........... ........... ...........
wire, breast.
19291........ Place needle ............. N1........... $333.00 ........... ........... ...........
wire, breast.
19295........ Place breast N............ A2........... $106.76 1.7369 $73.89 $98.54
clip, percut.
19296........ Place po breast Y............ A2........... $1,339.00 51.2269 $2,179.35 $1,549.09
cath for rad.
19297........ Place breast Y............ A2........... $1,339.00 51.2269 $2,179.35 $1,549.09
cath for rad.
19298........ Place breast N............ A2........... $1,339.00 52.8730 $2,249.38 $1,566.60
rad tube/caths.
19300........ Removal of Y............ A2........... $630.00 19.2788 $820.18 $677.55
breast tissue.
19301........ Partical Y............ A2........... $510.00 19.2788 $820.18 $587.55
mastectomy.
19302........ P-mastectomy w/ Y............ A2........... $995.00 36.9988 $1,574.04 $1,139.76
ln removal.
19303........ Mast, simple, Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
complete.
19304........ Mast, subq..... Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
19316........ Suspension of Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
breast.
19318........ Reduction of Y............ A2........... $630.00 36.9988 $1,574.04 $866.01
large breast.
19324........ Enlarge breast. Y............ A2........... $630.00 36.9988 $1,574.04 $866.01
19325........ Enlarge breast Y............ A2........... $1,339.00 51.2269 $2,179.35 $1,549.09
with implant.
19328........ Removal of Y............ A2........... $333.00 28.0166 $1,191.91 $547.73
breast implant.
19330........ Removal of Y............ A2........... $333.00 28.0166 $1,191.91 $547.73
implant
material.
19340........ Immediate Y............ A2........... $446.00 37.8692 $1,611.07 $737.27
breast
prosthesis.
19342........ Delayed breast Y............ A2........... $510.00 51.2269 $2,179.35 $927.34
prosthesis.
19350........ Breast Y............ A2........... $630.00 19.2788 $820.18 $677.55
reconstruction.
19355........ Correct Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
inverted
nipple(s).
19357........ Breast Y............ A2........... $717.00 51.2269 $2,179.35 $1,082.59
reconstruction.
19366........ Breast Y............ A2........... $717.00 28.0166 $1,191.91 $835.73
reconstruction.
19370........ Surgery of Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
breast capsule.
19371........ Removal of Y............ A2........... $630.00 28.0166 $1,191.91 $770.48
breast capsule.
19380........ Revise breast Y............ A2........... $717.00 37.8692 $1,611.07 $940.52
reconstruction.
19396........ Design custom Y............ G2........... ........... 28.0166 $1,191.91 $1,191.91
breast implant.
20000........ Incision of Y............ P2........... ........... 1.4392 $61.23 $61.23
abscess.
20005........ Incision of Y............ A2........... $446.00 20.8706 $887.90 $556.48
deep abscess.
20103........ Explore wound, Y............ G2........... ........... 4.2212 $179.58 $179.58
extremity.
20150........ Excise Y............ G2........... ........... 41.0893 $1,748.06 $1,748.06
epiphyseal bar.
20200........ Muscle biopsy.. Y............ A2........... $446.00 15.1024 $642.50 $495.13
20205........ Deep muscle Y............ A2........... $510.00 15.1024 $642.50 $543.13
biopsy.
20206........ Needle biopsy, Y............ A2........... $240.00 3.9045 $166.11 $221.53
muscle.
20220........ Bone biopsy, Y............ A2........... $251.52 4.0919 $174.08 $232.16
trocar/needle.
20225........ Bone biopsy, Y............ A2........... $418.49 6.8083 $289.65 $386.28
trocar/needle.
20240........ Bone biopsy, Y............ A2........... $446.00 20.0656 $853.65 $547.91
excisional.
20245........ Bone biopsy, Y............ A2........... $510.00 20.0656 $853.65 $595.91
excisional.
20250........ Open bone Y............ A2........... $510.00 20.8706 $887.90 $604.48
biopsy.
20251........ Open bone Y............ A2........... $510.00 20.8706 $887.90 $604.48
biopsy.
20500........ Injection of Y............ P3........... ........... 1.4162 $60.25 $60.25
sinus tract.
20501........ Inject sinus ............. N1........... ........... ........... ........... ...........
tract for x-
ray.
20520........ Removal of Y............ P3........... ........... 2.2131 $94.15 $94.15
foreign body.
20525........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
foreign body.
20526........ Ther injection, Y............ P3........... ........... 0.7162 $30.47 $30.47
carp tunnel.
20550........ Inj tendon Y............ P3........... ........... 0.5392 $22.94 $22.94
sheath/
ligament.
20551........ Inj tendon Y............ P3........... ........... 0.5312 $22.60 $22.60
origin/
insertion.
20552........ Inj trigger Y............ P3........... ........... 0.5230 $22.25 $22.25
point, 1/2
muscl.
20553........ Inject trigger Y............ P3........... ........... 0.5874 $24.99 $24.99
points, =/> 3.
20600........ Drain/inject, Y............ P3........... ........... 0.5312 $22.60 $22.60
joint/bursa.
20605........ Drain/inject, Y............ P3........... ........... 0.6036 $25.68 $25.68
joint/bursa.
20610........ Drain/inject, Y............ P3........... ........... 0.8128 $34.58 $34.58
joint/bursa.
20612........ Aspirate/inj Y............ P3........... ........... 0.5714 $24.31 $24.31
ganglion cyst.
20615........ Treatment of Y............ P2........... ........... 2.0687 $88.01 $88.01
bone cyst.
20650........ Insert and Y............ A2........... $510.00 20.8706 $887.90 $604.48
remove bone
pin.
20662........ Application of Y............ R2........... ........... 20.8706 $887.90 $887.90
pelvis brace.
20663........ Application of Y............ R2........... ........... 20.8706 $887.90 $887.90
thigh brace.
20665........ Removal of N............ G2........... ........... 0.6102 $25.96 $25.96
fixation
device.
20670........ Removal of Y............ A2........... $333.00 15.1024 $642.50 $410.38
support
implant.
20680........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
support
implant.
20690........ Apply bone Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
fixation
device.
20692........ Apply bone Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
fixation
device.
[[Page 42556]]
20693........ Adjust bone Y............ A2........... $510.00 20.8706 $887.90 $604.48
fixation
device.
20694........ Remove bone Y............ A2........... $333.00 20.8706 $887.90 $471.73
fixation
device.
20822........ Replantation Y............ G2........... ........... 25.8758 $1,100.83 $1,100.83
digit,
complete.
20900........ Removal of bone Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
for graft.
20902........ Removal of bone Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
for graft.
20910........ Remove Y............ A2........... $510.00 21.4302 $911.71 $610.43
cartilage for
graft.
20912........ Remove Y............ A2........... $510.00 21.4302 $911.71 $610.43
cartilage for
graft.
20920........ Removal of Y............ A2........... $630.00 14.0346 $597.07 $621.77
fascia for
graft.
20922........ Removal of Y............ A2........... $510.00 21.4302 $911.71 $610.43
fascia for
graft.
20924........ Removal of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
tendon for
graft.
20926........ Removal of Y............ A2........... $630.00 14.0346 $597.07 $621.77
tissue for
graft.
20950........ Fluid pressure, Y............ G2........... ........... 1.4392 $61.23 $61.23
muscle.
20972........ Bone/skin Y............ G2........... ........... 40.8559 $1,738.13 $1,738.13
graft,
metatarsal.
20973........ Bone/skin Y............ R2........... ........... 40.8559 $1,738.13 $1,738.13
graft, great
toe.
20975........ Electrical bone N............ A2........... $37.51 0.6102 $25.96 $34.62
stimulation.
20979........ Us bone N............ P3........... ........... 0.5552 $23.62 $23.62
stimulation.
20982........ Ablate, bone Y............ G2........... ........... 41.0893 $1,748.06 $1,748.06
tumor(s) perq.
21010........ Incision of jaw Y............ A2........... $446.00 23.3299 $992.52 $582.63
joint.
21015........ Resection of Y............ A2........... $510.00 16.4266 $698.84 $557.21
facial tumor.
21025........ Excision of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
bone, lower
jaw.
21026........ Excision of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
facial bone(s).
21029........ Contour of face Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
bone lesion.
21030........ Excise max/ Y............ P3........... ........... 5.4479 $231.77 $231.77
zygoma b9
tumor.
21031........ Remove Y............ P3........... ........... 4.4823 $190.69 $190.69
exostosis,
mandible.
21032........ Remove Y............ P3........... ........... 4.5869 $195.14 $195.14
exostosis,
maxilla.
21034........ Excise max/ Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
zygoma mlg
tumor.
21040........ Excise mandible Y............ A2........... $446.00 23.3299 $992.52 $582.63
lesion.
21044........ Removal of jaw Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
bone lesion.
21046........ Remove mandible Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
cyst complex.
21047........ Excise lwr jaw Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
cyst w/repair.
21048........ Remove maxilla Y............ R2........... ........... 38.1991 $1,625.10 $1,625.10
cyst complex.
21050........ Removal of jaw Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
joint.
21060........ Remove jaw Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
joint
cartilage.
21070........ Remove coronoid Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
process.
21076........ Prepare face/ Y............ P3........... ........... 8.1760 $347.83 $347.83
oral
prosthesis.
21077........ Prepare face/ Y............ P3........... ........... 20.1504 $857.26 $857.26
oral
prosthesis.
21079........ Prepare face/ Y............ P3........... ........... 14.2437 $605.97 $605.97
oral
prosthesis.
21080........ Prepare face/ Y............ P3........... ........... 16.3280 $694.64 $694.64
oral
prosthesis.
21081........ Prepare face/ Y............ P3........... ........... 14.9437 $635.75 $635.75
oral
prosthesis.
21082........ Prepare face/ Y............ P3........... ........... 13.8253 $588.17 $588.17
oral
prosthesis.
21083........ Prepare face/ Y............ P3........... ........... 13.5113 $574.81 $574.81
oral
prosthesis.
21084........ Prepare face/ Y............ P3........... ........... 15.6117 $664.17 $664.17
oral
prosthesis.
21085........ Prepare face/ Y............ P3........... ........... 6.1079 $259.85 $259.85
oral
prosthesis.
21086........ Prepare face/ Y............ P3........... ........... 14.7587 $627.88 $627.88
oral
prosthesis.
21087........ Prepare face/ Y............ P3........... ........... 14.6621 $623.77 $623.77
oral
prosthesis.
21088........ Prepare face/ Y............ R2........... ........... 38.1991 $1,625.10 $1,625.10
oral
prosthesis.
21100........ Maxillofacial Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
fixation.
21110........ Interdental Y............ P2........... ........... 7.5511 $321.25 $321.25
fixation.
21116........ Injection, jaw ............. N1........... ........... ........... ........... ...........
joint x-ray.
21120........ Reconstruction Y............ A2........... $995.00 23.3299 $992.52 $994.38
of chin.
21121........ Reconstruction Y............ A2........... $995.00 23.3299 $992.52 $994.38
of chin.
21122........ Reconstruction Y............ A2........... $995.00 23.3299 $992.52 $994.38
of chin.
21123........ Reconstruction Y............ A2........... $995.00 23.3299 $992.52 $994.38
of chin.
21125........ Augmentation, Y............ A2........... $995.00 23.3299 $992.52 $994.38
lower jaw bone.
21127........ Augmentation, Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
lower jaw bone.
21137........ Reduction of Y............ G2........... ........... 23.3299 $992.52 $992.52
forehead.
21138........ Reduction of Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
forehead.
21139........ Reduction of Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
forehead.
21150........ Reconstruct Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
midface,
lefort.
21181........ Contour cranial Y............ A2........... $995.00 23.3299 $992.52 $994.38
bone lesion.
21198........ Reconstr lwr Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
jaw segment.
21199........ Reconstr lwr Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
jaw w/advance.
21206........ Reconstruct Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
upper jaw bone.
[[Page 42557]]
21208........ Augmentation of Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
facial bones.
21209........ Reduction of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
facial bones.
21210........ Face bone graft Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
21215........ Lower jaw bone Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
graft.
21230........ Rib cartilage Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
graft.
21235........ Ear cartilage Y............ A2........... $995.00 23.3299 $992.52 $994.38
graft.
21240........ Reconstruction Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
of jaw joint.
21242........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of jaw joint.
21243........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of jaw joint.
21244........ Reconstruction Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of lower jaw.
21245........ Reconstruction Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of jaw.
21246........ Reconstruction Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of jaw.
21248........ Reconstruction Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of jaw.
21249........ Reconstruction Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of jaw.
21260........ Revise eye Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
sockets.
21267........ Revise eye Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
sockets.
21270........ Augmentation, Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
cheek bone.
21275........ Revision, Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
orbitofacial
bones.
21280........ Revision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
eyelid.
21282........ Revision of Y............ A2........... $717.00 16.4266 $698.84 $712.46
eyelid.
21295........ Revision of jaw Y............ A2........... $333.00 7.5511 $321.25 $330.06
muscle/bone.
21296........ Revision of jaw Y............ A2........... $333.00 23.3299 $992.52 $497.88
muscle/bone.
21310........ Treatment of Y............ A2........... $150.72 2.4520 $104.32 $139.12
nose fracture.
21315........ Treatment of Y............ A2........... $150.72 2.4520 $104.32 $139.12
nose fracture.
21320........ Treatment of Y............ A2........... $446.00 7.5511 $321.25 $414.81
nose fracture.
21325........ Treatment of Y............ A2........... $630.00 23.3299 $992.52 $720.63
nose fracture.
21330........ Treatment of Y............ A2........... $717.00 23.3299 $992.52 $785.88
nose fracture.
21335........ Treatment of Y............ A2........... $995.00 23.3299 $992.52 $994.38
nose fracture.
21336........ Treat nasal Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
septal
fracture.
21337........ Treat nasal Y............ A2........... $446.00 16.4266 $698.84 $509.21
septal
fracture.
21338........ Treat Y............ A2........... $630.00 23.3299 $992.52 $720.63
nasoethmoid
fracture.
21339........ Treat Y............ A2........... $717.00 23.3299 $992.52 $785.88
nasoethmoid
fracture.
21340........ Treatment of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
nose fracture.
21345........ Treat nose/jaw Y............ A2........... $995.00 23.3299 $992.52 $994.38
fracture.
21355........ Treat cheek Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
bone fracture.
21356........ Treat cheek Y............ A2........... $510.00 23.3299 $992.52 $630.63
bone fracture.
21390........ Treat eye Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
socket
fracture.
21400........ Treat eye Y............ A2........... $446.00 7.5511 $321.25 $414.81
socket
fracture.
21401........ Treat eye Y............ A2........... $510.00 16.4266 $698.84 $557.21
socket
fracture.
21406........ Treat eye Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
socket
fracture.
21407........ Treat eye Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
socket
fracture.
21421........ Treat mouth Y............ A2........... $630.00 23.3299 $992.52 $720.63
roof fracture.
21440........ Treat dental Y............ P3........... ........... 7.0012 $297.85 $297.85
ridge fracture.
21445........ Treat dental Y............ A2........... $630.00 23.3299 $992.52 $720.63
ridge fracture.
21450........ Treat lower jaw Y............ A2........... $150.72 2.4520 $104.32 $139.12
fracture.
21451........ Treat lower jaw Y............ A2........... $464.15 7.5511 $321.25 $428.43
fracture.
21452........ Treat lower jaw Y............ A2........... $446.00 16.4266 $698.84 $509.21
fracture.
21453........ Treat lower jaw Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
fracture.
21454........ Treat lower jaw Y............ A2........... $717.00 23.3299 $992.52 $785.88
fracture.
21461........ Treat lower jaw Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
fracture.
21462........ Treat lower jaw Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
fracture.
21465........ Treat lower jaw Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
fracture.
21480........ Reset Y............ A2........... $150.72 2.4520 $104.32 $139.12
dislocated jaw.
21485........ Reset Y............ A2........... $446.00 16.4266 $698.84 $509.21
dislocated jaw.
21490........ Repair Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
dislocated jaw.
21495........ Treat hyoid Y............ G2........... ........... 16.4266 $698.84 $698.84
bone fracture.
21497........ Interdental Y............ A2........... $446.00 16.4266 $698.84 $509.21
wiring.
21501........ Drain neck/ Y............ A2........... $446.00 17.5086 $744.87 $520.72
chest lesion.
21502........ Drain chest Y............ A2........... $446.00 20.8706 $887.90 $556.48
lesion.
21550........ Biopsy of neck/ Y............ G2........... ........... 6.8083 $289.65 $289.65
chest.
21555........ Remove lesion, Y............ A2........... $446.00 20.0656 $853.65 $547.91
neck/chest.
21556........ Remove lesion, Y............ A2........... $446.00 20.0656 $853.65 $547.91
neck/chest.
21557........ Remove tumor, Y............ G2........... ........... 20.0656 $853.65 $853.65
neck/chest.
[[Page 42558]]
21600........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of rib.
21610........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of rib.
21685........ Hyoid myotomy & Y............ G2........... ........... 7.5511 $321.25 $321.25
suspension.
21700........ Revision of Y............ A2........... $446.00 20.8706 $887.90 $556.48
neck muscle.
21720........ Revision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
neck muscle.
21725........ Revision of Y............ A2........... $88.46 1.4392 $61.23 $81.65
neck muscle.
21800........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
rib fracture.
21805........ Treatment of Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
rib fracture.
21820........ Treat sternum Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
21920........ Biopsy soft Y............ P3........... ........... 3.0983 $131.81 $131.81
tissue of back.
21925........ Biopsy soft Y............ A2........... $446.00 20.0656 $853.65 $547.91
tissue of back.
21930........ Remove lesion, Y............ A2........... $446.00 20.0656 $853.65 $547.91
back or flank.
21935........ Remove tumor, Y............ A2........... $510.00 20.0656 $853.65 $595.91
back.
22102........ Remove part, Y............ G2........... ........... 44.1489 $1,878.23 $1,878.23
lumbar
vertebra.
22103........ Remove extra Y............ G2........... ........... 44.1489 $1,878.23 $1,878.23
spine segment.
22305........ Treat spine Y............ A2........... $103.62 1.6857 $71.71 $95.64
process
fracture.
22310........ Treat spine Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
22315........ Treat spine Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
22505........ Manipulation of Y............ A2........... $446.00 14.5947 $620.90 $489.73
spine.
22520........ Percut Y............ A2........... $1,339.00 25.1296 $1,069.09 $1,271.52
vertebroplasty
thor.
22521........ Percut Y............ A2........... $1,339.00 25.1296 $1,069.09 $1,271.52
vertebroplasty
lumb.
22522........ Percut Y............ A2........... $1,339.00 25.1296 $1,069.09 $1,271.52
vertebroplasty
add-on.
22523........ Percut Y............ G2........... ........... 66.5800 $2,832.51 $2,832.51
kyphoplasty,
thor.
22524........ Percut Y............ G2........... ........... 66.5800 $2,832.51 $2,832.51
kyphoplasty,
lumbar.
22525........ Percut Y............ G2........... ........... 66.5800 $2,832.51 $2,832.51
kyphoplasty,
add-on.
22900........ Remove Y............ A2........... $630.00 20.0656 $853.65 $685.91
abdominal wall
lesion.
23000........ Removal of Y............ A2........... $446.00 15.1024 $642.50 $495.13
calcium
deposits.
23020........ Release Y............ A2........... $446.00 41.0893 $1,748.06 $771.52
shoulder joint.
23030........ Drain shoulder Y............ A2........... $333.00 17.5086 $744.87 $435.97
lesion.
23031........ Drain shoulder Y............ A2........... $510.00 17.5086 $744.87 $568.72
bursa.
23035........ Drain shoulder Y............ A2........... $510.00 20.8706 $887.90 $604.48
bone lesion.
23040........ Exploratory Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
shoulder
surgery.
23044........ Exploratory Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
shoulder
surgery.
23065........ Biopsy shoulder Y............ P3........... ........... 2.1888 $93.12 $93.12
tissues.
23066........ Biopsy shoulder Y............ A2........... $446.00 20.0656 $853.65 $547.91
tissues.
23075........ Removal of Y............ A2........... $446.00 15.1024 $642.50 $495.13
shoulder
lesion.
23076........ Removal of Y............ A2........... $446.00 20.0656 $853.65 $547.91
shoulder
lesion.
23077........ Remove tumor of Y............ A2........... $510.00 20.0656 $853.65 $595.91
shoulder.
23100........ Biopsy of Y............ A2........... $446.00 20.8706 $887.90 $556.48
shoulder joint.
23101........ Shoulder joint Y............ A2........... $995.00 25.1296 $1,069.09 $1,013.52
surgery.
23105........ Remove shoulder Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
23106........ Incision of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
collarbone
joint.
23107........ Explore treat Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
shoulder joint.
23120........ Partial Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
removal,
collar bone.
23125........ Removal of Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
collar bone.
23130........ Remove shoulder Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
bone, part.
23140........ Removal of bone Y............ A2........... $630.00 20.8706 $887.90 $694.48
lesion.
23145........ Removal of bone Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
lesion.
23146........ Removal of bone Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
lesion.
23150........ Removal of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
humerus lesion.
23155........ Removal of Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
humerus lesion.
23156........ Removal of Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
humerus lesion.
23170........ Remove collar Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone lesion.
23172........ Remove shoulder Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
blade lesion.
23174........ Remove humerus Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
lesion.
23180........ Remove collar Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
bone lesion.
23182........ Remove shoulder Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
blade lesion.
23184........ Remove humerus Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
lesion.
23190........ Partial removal Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
of scapula.
23195........ Removal of head Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
of humerus.
23330........ Remove shoulder Y............ A2........... $333.00 6.8083 $289.65 $322.16
foreign body.
23331........ Remove shoulder Y............ A2........... $333.00 20.0656 $853.65 $463.16
foreign body.
23350........ Injection for ............. N1........... ........... ........... ........... ...........
shoulder x-ray.
[[Page 42559]]
23395........ Muscle Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
transfer,shoul
der/arm.
23397........ Muscle Y............ A2........... $995.00 66.5800 $2,832.51 $1,454.38
transfers.
23400........ Fixation of Y............ A2........... $995.00 25.1296 $1,069.09 $1,013.52
shoulder blade.
23405........ Incision of Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tendon &
muscle.
23406........ Incise Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tendon(s) &
muscle(s).
23410........ Repair rotator Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
cuff, acute.
23412........ Repair rotator Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
cuff, chronic.
23415........ Release of Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
shoulder
ligament.
23420........ Repair of Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
shoulder.
23430........ Repair biceps Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
tendon.
23440........ Remove/ Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
transplant
tendon.
23450........ Repair shoulder Y............ A2........... $717.00 66.5800 $2,832.51 $1,245.88
capsule.
23455........ Repair shoulder Y............ A2........... $995.00 66.5800 $2,832.51 $1,454.38
capsule.
23460........ Repair shoulder Y............ A2........... $717.00 66.5800 $2,832.51 $1,245.88
capsule.
23462........ Repair shoulder Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
capsule.
23465........ Repair shoulder Y............ A2........... $717.00 66.5800 $2,832.51 $1,245.88
capsule.
23466........ Repair shoulder Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
capsule.
23480........ Revision of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
collar bone.
23485........ Revision of Y............ A2........... $995.00 66.5800 $2,832.51 $1,454.38
collar bone.
23490........ Reinforce Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
clavicle.
23491........ Reinforce Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
shoulder bones.
23500........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
23505........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
23515........ Treat clavicle Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
23520........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
23525........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
23530........ Treat clavicle Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
23532........ Treat clavicle Y............ A2........... $630.00 25.5264 $1,085.97 $743.99
dislocation.
23540........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
23545........ Treat clavicle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
23550........ Treat clavicle Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
23552........ Treat clavicle Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
dislocation.
23570........ Treat shoulder Y............ A2........... $103.62 1.6857 $71.71 $95.64
blade fx.
23575........ Treat shoulder Y............ A2........... $103.62 1.6857 $71.71 $95.64
blade fx.
23585........ Treat scapula Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
23600........ Treat humerus Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture.
23605........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
23615........ Treat humerus Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
23616........ Treat humerus Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
23620........ Treat humerus Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture.
23625........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
23630........ Treat humerus Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
fracture.
23650........ Treat shoulder Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
23655........ Treat shoulder Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
23660........ Treat shoulder Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
23665........ Treat Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation/
fracture.
23670........ Treat Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
dislocation/
fracture.
23675........ Treat Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation/
fracture.
23680........ Treat Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation/
fracture.
23700........ Fixation of Y............ A2........... $333.00 14.5947 $620.90 $404.98
shoulder.
23800........ Fusion of Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
shoulder joint.
23802........ Fusion of Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
shoulder joint.
23921........ Amputation Y............ A2........... $323.28 5.2594 $223.75 $298.40
follow-up
surgery.
23930........ Drainage of arm Y............ A2........... $333.00 17.5086 $744.87 $435.97
lesion.
23931........ Drainage of arm Y............ A2........... $446.00 17.5086 $744.87 $520.72
bursa.
23935........ Drain arm/elbow Y............ A2........... $446.00 20.8706 $887.90 $556.48
bone lesion.
24000........ Exploratory Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
elbow surgery.
24006........ Release elbow Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint.
24065........ Biopsy arm/ Y............ P3........... ........... 2.9695 $126.33 $126.33
elbow soft
tissue.
24066........ Biopsy arm/ Y............ A2........... $446.00 15.1024 $642.50 $495.13
elbow soft
tissue.
24075........ Remove arm/ Y............ A2........... $446.00 15.1024 $642.50 $495.13
elbow lesion.
24076........ Remove arm/ Y............ A2........... $446.00 20.0656 $853.65 $547.91
elbow lesion.
24077........ Remove tumor of Y............ A2........... $510.00 20.0656 $853.65 $595.91
arm/elbow.
[[Page 42560]]
24100........ Biopsy elbow Y............ A2........... $333.00 20.8706 $887.90 $471.73
joint lining.
24101........ Explore/treat Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
elbow joint.
24102........ Remove elbow Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
24105........ Removal of Y............ A2........... $510.00 20.8706 $887.90 $604.48
elbow bursa.
24110........ Remove humerus Y............ A2........... $446.00 20.8706 $887.90 $556.48
lesion.
24115........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
bone lesion.
24116........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
bone lesion.
24120........ Remove elbow Y............ A2........... $510.00 20.8706 $887.90 $604.48
lesion.
24125........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
bone lesion.
24126........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
bone lesion.
24130........ Removal of head Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
of radius.
24134........ Removal of arm Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone lesion.
24136........ Remove radius Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone lesion.
24138........ Remove elbow Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone lesion.
24140........ Partial removal Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
of arm bone.
24145........ Partial removal Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
of radius.
24147........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of elbow.
24149........ Radical Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
resection of
elbow.
24152........ Extensive Y............ G2........... ........... 41.0893 $1,748.06 $1,748.06
radius surgery.
24153........ Extensive Y............ G2........... ........... 66.5800 $2,832.51 $2,832.51
radius surgery.
24155........ Removal of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
elbow joint.
24160........ Remove elbow Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
joint implant.
24164........ Remove radius Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
head implant.
24200........ Removal of arm Y............ P3........... ........... 2.4867 $105.79 $105.79
foreign body.
24201........ Removal of arm Y............ A2........... $446.00 15.1024 $642.50 $495.13
foreign body.
24220........ Injection for ............. N1........... ........... ........... ........... ...........
elbow x-ray.
24300........ Manipulate Y............ G2........... ........... 14.5947 $620.90 $620.90
elbow w/anesth.
24301........ Muscle/tendon Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
transfer.
24305........ Arm tendon Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
lengthening.
24310........ Revision of arm Y............ A2........... $510.00 20.8706 $887.90 $604.48
tendon.
24320........ Repair of arm Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
tendon.
24330........ Revision of arm Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
muscles.
24331........ Revision of arm Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
muscles.
24332........ Tenolysis, Y............ G2........... ........... 20.8706 $887.90 $887.90
triceps.
24340........ Repair of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
biceps tendon.
24341........ Repair arm Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
tendon/muscle.
24342........ Repair of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
ruptured
tendon.
24343........ Repr elbow lat Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
ligmnt w/tiss.
24344........ Reconstruct Y............ G2........... ........... 66.5800 $2,832.51 $2,832.51
elbow lat
ligmnt.
24345........ Repr elbw med Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
ligmnt w/tissu.
24346........ Reconstruct Y............ G2........... ........... 41.0893 $1,748.06 $1,748.06
elbow med
ligmnt.
24350........ Repair of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tennis elbow.
24351........ Repair of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tennis elbow.
24352........ Repair of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tennis elbow.
24354........ Repair of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tennis elbow.
24356........ Revision of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tennis elbow.
24360........ Reconstruct Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
elbow joint.
24361........ Reconstruct Y............ A2........... $717.00 107.1942 $4,560.36 $1,677.84
elbow joint.
24362........ Reconstruct Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
elbow joint.
24363........ Replace elbow Y............ A2........... $995.00 107.1942 $4,560.36 $1,886.34
joint.
24365........ Reconstruct Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
head of radius.
24366........ Reconstruct Y............ A2........... $717.00 107.1942 $4,560.36 $1,677.84
head of radius.
24400........ Revision of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
humerus.
24410........ Revision of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
humerus.
24420........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
humerus.
24430........ Repair of Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
humerus.
24435........ Repair humerus Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
with graft.
24470........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
elbow joint.
24495........ Decompression Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of forearm.
24498........ Reinforce Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
humerus.
24500........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24505........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24515........ Treat humerus Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
[[Page 42561]]
24516........ Treat humerus Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
24530........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24535........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24538........ Treat humerus Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
24545........ Treat humerus Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
24546........ Treat humerus Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
fracture.
24560........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24565........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24566........ Treat humerus Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
24575........ Treat humerus Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
24576........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24577........ Treat humerus Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24579........ Treat humerus Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
24582........ Treat humerus Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
24586........ Treat elbow Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
24587........ Treat elbow Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
fracture.
24600........ Treat elbow Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
24605........ Treat elbow Y............ A2........... $446.00 14.5947 $620.90 $489.73
dislocation.
24615........ Treat elbow Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
dislocation.
24620........ Treat elbow Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24635........ Treat elbow Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
24640........ Treat elbow Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
24650........ Treat radius Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture.
24655........ Treat radius Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24665........ Treat radius Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
fracture.
24666........ Treat radius Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
24670........ Treat ulnar Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24675........ Treat ulnar Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
24685........ Treat ulnar Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
24800........ Fusion of elbow Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
joint.
24802........ Fusion/graft of Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
elbow joint.
24925........ Amputation Y............ A2........... $510.00 20.8706 $887.90 $604.48
follow-up
surgery.
25000........ Incision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
tendon sheath.
25001........ Incise flexor Y............ G2........... ........... 20.8706 $887.90 $887.90
carpi radialis.
25020........ Decompress Y............ A2........... $510.00 20.8706 $887.90 $604.48
forearm 1
space.
25023........ Decompress Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm 1
space.
25024........ Decompress Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm 2
spaces.
25025........ Decompress Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm 2
spaces.
25028........ Drainage of Y............ A2........... $333.00 20.8706 $887.90 $471.73
forearm lesion.
25031........ Drainage of Y............ A2........... $446.00 20.8706 $887.90 $556.48
forearm bursa.
25035........ Treat forearm Y............ A2........... $446.00 20.8706 $887.90 $556.48
bone lesion.
25040........ Explore/treat Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
wrist joint.
25065........ Biopsy forearm Y............ P3........... ........... 3.0259 $128.73 $128.73
soft tissues.
25066........ Biopsy forearm Y............ A2........... $446.00 20.0656 $853.65 $547.91
soft tissues.
25075........ Removal forearm Y............ A2........... $446.00 15.1024 $642.50 $495.13
lesion subcu.
25076........ Removal forearm Y............ A2........... $510.00 20.0656 $853.65 $595.91
lesion deep.
25077........ Remove tumor, Y............ A2........... $510.00 20.0656 $853.65 $595.91
forearm/wrist.
25085........ Incision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
wrist capsule.
25100........ Biopsy of wrist Y............ A2........... $446.00 20.8706 $887.90 $556.48
joint.
25101........ Explore/treat Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
wrist joint.
25105........ Remove wrist Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
25107........ Remove wrist Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
joint
cartilage.
25109........ Excise tendon Y............ G2........... ........... 20.8706 $887.90 $887.90
forearm/wrist.
25110........ Remove wrist Y............ A2........... $510.00 20.8706 $887.90 $604.48
tendon lesion.
25111........ Remove wrist Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendon lesion.
25112........ Reremove wrist Y............ A2........... $630.00 16.1540 $687.24 $644.31
tendon lesion.
25115........ Remove wrist/ Y............ A2........... $630.00 20.8706 $887.90 $694.48
forearm lesion.
25116........ Remove wrist/ Y............ A2........... $630.00 20.8706 $887.90 $694.48
forearm lesion.
25118........ Excise wrist Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tendon sheath.
25119........ Partial removal Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
of ulna.
25120........ Removal of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm lesion.
25125........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm lesion.
25126........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm lesion.
[[Page 42562]]
25130........ Removal of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
wrist lesion.
25135........ Remove & graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
wrist lesion.
25136........ Remove & graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
wrist lesion.
25145........ Remove forearm Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone lesion.
25150........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of ulna.
25151........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of radius.
25210........ Removal of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
wrist bone.
25215........ Removal of Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
wrist bones.
25230........ Partial removal Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
of radius.
25240........ Partial removal Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
of ulna.
25246........ Injection for ............. N1........... ........... ........... ........... ...........
wrist x-ray.
25248........ Remove forearm Y............ A2........... $446.00 20.8706 $887.90 $556.48
foreign body.
25250........ Removal of Y............ A2........... $333.00 25.1296 $1,069.09 $517.02
wrist
prosthesis.
25251........ Removal of Y............ A2........... $333.00 25.1296 $1,069.09 $517.02
wrist
prosthesis.
25259........ Manipulate Y............ G2........... ........... 1.6857 $71.71 $71.71
wrist w/
anesthes.
25260........ Repair forearm Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
tendon/muscle.
25263........ Repair forearm Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tendon/muscle.
25265........ Repair forearm Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendon/muscle.
25270........ Repair forearm Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
tendon/muscle.
25272........ Repair forearm Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendon/muscle.
25274........ Repair forearm Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
tendon/muscle.
25275........ Repair forearm Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
tendon sheath.
25280........ Revise wrist/ Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
forearm tendon.
25290........ Incise wrist/ Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
forearm tendon.
25295........ Release wrist/ Y............ A2........... $510.00 20.8706 $887.90 $604.48
forearm tendon.
25300........ Fusion of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendons at
wrist.
25301........ Fusion of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendons at
wrist.
25310........ Transplant Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
forearm tendon.
25312........ Transplant Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
forearm tendon.
25315........ Revise palsy Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
hand tendon(s).
25316........ Revise palsy Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
hand tendon(s).
25320........ Repair/revise Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
wrist joint.
25332........ Revise wrist Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
joint.
25335........ Realignment of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
hand.
25337........ Reconstruct Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
ulna/
radioulnar.
25350........ Revision of Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
radius.
25355........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
radius.
25360........ Revision of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
ulna.
25365........ Revise radius & Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
ulna.
25370........ Revise radius Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
or ulna.
25375........ Revise radius & Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
ulna.
25390........ Shorten radius Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
or ulna.
25391........ Lengthen radius Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
or ulna.
25392........ Shorten radius Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
& ulna.
25393........ Lengthen radius Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
& ulna.
25394........ Repair carpal Y............ G2........... ........... 16.1540 $687.24 $687.24
bone, shorten.
25400........ Repair radius Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
or ulna.
25405........ Repair/graft Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
radius or ulna.
25415........ Repair radius & Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
ulna.
25420........ Repair/graft Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
radius & ulna.
25425........ Repair/graft Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
radius or ulna.
25426........ Repair/graft Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
radius & ulna.
25430........ Vasc graft into Y............ G2........... ........... 25.8758 $1,100.83 $1,100.83
carpal bone.
25431........ Repair nonunion Y............ G2........... ........... 25.8758 $1,100.83 $1,100.83
carpal bone.
25440........ Repair/graft Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
wrist bone.
25441........ Reconstruct Y............ A2........... $717.00 107.1942 $4,560.36 $1,677.84
wrist joint.
25442........ Reconstruct Y............ A2........... $717.00 107.1942 $4,560.36 $1,677.84
wrist joint.
25443........ Reconstruct Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
wrist joint.
25444........ Reconstruct Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
wrist joint.
25445........ Reconstruct Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
wrist joint.
25446........ Wrist Y............ A2........... $995.00 107.1942 $4,560.36 $1,886.34
replacement.
25447........ Repair wrist Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
joint(s).
25449........ Remove wrist Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
joint implant.
[[Page 42563]]
25450........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
wrist joint.
25455........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
wrist joint.
25490........ Reinforce Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
radius.
25491........ Reinforce ulna. Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
25492........ Reinforce Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
radius and
ulna.
25500........ Treat fracture Y............ P2........... ........... 1.6857 $71.71 $71.71
of radius.
25505........ Treat fracture Y............ A2........... $103.62 1.6857 $71.71 $95.64
of radius.
25515........ Treat fracture Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
of radius.
25520........ Treat fracture Y............ A2........... $103.62 1.6857 $71.71 $95.64
of radius.
25525........ Treat fracture Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
of radius.
25526........ Treat fracture Y............ A2........... $717.00 37.5382 $1,596.99 $937.00
of radius.
25530........ Treat fracture Y............ P2........... ........... 1.6857 $71.71 $71.71
of ulna.
25535........ Treat fracture Y............ A2........... $103.62 1.6857 $71.71 $95.64
of ulna.
25545........ Treat fracture Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
of ulna.
25560........ Treat fracture Y............ P2........... ........... 1.6857 $71.71 $71.71
radius & ulna.
25565........ Treat fracture Y............ A2........... $103.62 1.6857 $71.71 $95.64
radius & ulna.
25574........ Treat fracture Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
radius & ulna.
25575........ Treat fracture Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
radius/ulna.
25600........ Treat fracture Y............ P2........... ........... 1.6857 $71.71 $71.71
radius/ulna.
25605........ Treat fracture Y............ A2........... $103.62 1.6857 $71.71 $95.64
radius/ulna.
25606........ Treat fx distal Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
radial.
25607........ Treat fx rad Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
extra-articul.
25608........ Treat fx rad Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
intra-articul.
25609........ Treat fx radial Y............ A2........... $717.00 57.2172 $2,434.19 $1,146.30
3+ frag.
25622........ Treat wrist Y............ P2........... ........... 1.6857 $71.71 $71.71
bone fracture.
25624........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
bone fracture.
25628........ Treat wrist Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
bone fracture.
25630........ Treat wrist Y............ P2........... ........... 1.6857 $71.71 $71.71
bone fracture.
25635........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
bone fracture.
25645........ Treat wrist Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
bone fracture.
25650........ Treat wrist Y............ P2........... ........... 1.6857 $71.71 $71.71
bone fracture.
25651........ Pin ulnar Y............ G2........... ........... 25.5264 $1,085.97 $1,085.97
styloid
fracture.
25652........ Treat fracture Y............ G2........... ........... 37.5382 $1,596.99 $1,596.99
ulnar styloid.
25660........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
25670........ Treat wrist Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
dislocation.
25671........ Pin radioulnar Y............ A2........... $333.00 25.5264 $1,085.97 $521.24
dislocation.
25675........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
25676........ Treat wrist Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
25680........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
25685........ Treat wrist Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
fracture.
25690........ Treat wrist Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
25695........ Treat wrist Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
25800........ Fusion of wrist Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
joint.
25805........ Fusion/graft of Y............ A2........... $717.00 41.0893 $1,748.06 $974.77
wrist joint.
25810........ Fusion/graft of Y............ A2........... $717.00 66.5800 $2,832.51 $1,245.88
wrist joint.
25820........ Fusion of hand Y............ A2........... $630.00 16.1540 $687.24 $644.31
bones.
25825........ Fuse hand bones Y............ A2........... $717.00 25.8758 $1,100.83 $812.96
with graft.
25830........ Fusion, Y............ A2........... $717.00 66.5800 $2,832.51 $1,245.88
radioulnar jnt/
ulna.
25907........ Amputation Y............ A2........... $510.00 20.8706 $887.90 $604.48
follow-up
surgery.
25922........ Amputate hand Y............ A2........... $510.00 20.8706 $887.90 $604.48
at wrist.
25929........ Amputation Y............ A2........... $510.00 14.0346 $597.07 $531.77
follow-up
surgery.
26010........ Drainage of Y............ P2........... ........... 1.4392 $61.23 $61.23
finger abscess.
26011........ Drainage of Y............ A2........... $333.00 11.1535 $474.50 $368.38
finger abscess.
26020........ Drain hand Y............ A2........... $446.00 16.1540 $687.24 $506.31
tendon sheath.
26025........ Drainage of Y............ A2........... $333.00 16.1540 $687.24 $421.56
palm bursa.
26030........ Drainage of Y............ A2........... $446.00 16.1540 $687.24 $506.31
palm bursa(s).
26034........ Treat hand bone Y............ A2........... $446.00 16.1540 $687.24 $506.31
lesion.
26035........ Decompress Y............ G2........... ........... 16.1540 $687.24 $687.24
fingers/hand.
26040........ Release palm Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
contracture.
26045........ Release palm Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
contracture.
26055........ Incise finger Y............ A2........... $446.00 16.1540 $687.24 $506.31
tendon sheath.
26060........ Incision of Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger tendon.
26070........ Explore/treat Y............ A2........... $446.00 16.1540 $687.24 $506.31
hand joint.
[[Page 42564]]
26075........ Explore/treat Y............ A2........... $630.00 16.1540 $687.24 $644.31
finger joint.
26080........ Explore/treat Y............ A2........... $630.00 16.1540 $687.24 $644.31
finger joint.
26100........ Biopsy hand Y............ A2........... $446.00 16.1540 $687.24 $506.31
joint lining.
26105........ Biopsy finger Y............ A2........... $333.00 16.1540 $687.24 $421.56
joint lining.
26110........ Biopsy finger Y............ A2........... $333.00 16.1540 $687.24 $421.56
joint lining.
26115........ Removal hand Y............ A2........... $446.00 20.0656 $853.65 $547.91
lesion subcut.
26116........ Removal hand Y............ A2........... $446.00 20.0656 $853.65 $547.91
lesion, deep.
26117........ Remove tumor, Y............ A2........... $510.00 20.0656 $853.65 $595.91
hand/finger.
26121........ Release palm Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
contracture.
26123........ Release palm Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
contracture.
26125........ Release palm Y............ A2........... $630.00 16.1540 $687.24 $644.31
contracture.
26130........ Remove wrist Y............ A2........... $510.00 16.1540 $687.24 $554.31
joint lining.
26135........ Revise finger Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
joint, each.
26140........ Revise finger Y............ A2........... $446.00 16.1540 $687.24 $506.31
joint, each.
26145........ Tendon Y............ A2........... $510.00 16.1540 $687.24 $554.31
excision, palm/
finger.
26160........ Remove tendon Y............ A2........... $510.00 16.1540 $687.24 $554.31
sheath lesion.
26170........ Removal of palm Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendon, each.
26180........ Removal of Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger tendon.
26185........ Remove finger Y............ A2........... $630.00 16.1540 $687.24 $644.31
bone.
26200........ Remove hand Y............ A2........... $446.00 16.1540 $687.24 $506.31
bone lesion.
26205........ Remove/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
bone lesion.
26210........ Removal of Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger lesion.
26215........ Remove/graft Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger lesion.
26230........ Partial removal Y............ A2........... $992.95 16.1540 $687.24 $916.52
of hand bone.
26235........ Partial Y............ A2........... $510.00 16.1540 $687.24 $554.31
removal,
finger bone.
26236........ Partial Y............ A2........... $510.00 16.1540 $687.24 $554.31
removal,
finger bone.
26250........ Extensive hand Y............ A2........... $510.00 16.1540 $687.24 $554.31
surgery.
26255........ Extensive hand Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
surgery.
26260........ Extensive Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger surgery.
26261........ Extensive Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger surgery.
26262........ Partial removal Y............ A2........... $446.00 16.1540 $687.24 $506.31
of finger.
26320........ Removal of Y............ A2........... $446.00 15.1024 $642.50 $495.13
implant from
hand.
26340........ Manipulate Y............ G2........... ........... 1.6857 $71.71 $71.71
finger w/
anesth.
26350........ Repair finger/ Y............ A2........... $333.00 25.8758 $1,100.83 $524.96
hand tendon.
26352........ Repair/graft Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26356........ Repair finger/ Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26357........ Repair finger/ Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26358........ Repair/graft Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26370........ Repair finger/ Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26372........ Repair/graft Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand tendon.
26373........ Repair finger/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand tendon.
26390........ Revise hand/ Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger tendon.
26392........ Repair/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand tendon.
26410........ Repair hand Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendon.
26412........ Repair/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand tendon.
26415........ Excision, hand/ Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger tendon.
26416........ Graft hand or Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger tendon.
26418........ Repair finger Y............ A2........... $630.00 16.1540 $687.24 $644.31
tendon.
26420........ Repair/graft Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger tendon.
26426........ Repair finger/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand tendon.
26428........ Repair/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger tendon.
26432........ Repair finger Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendon.
26433........ Repair finger Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendon.
26434........ Repair/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger tendon.
26437........ Realignment of Y............ A2........... $510.00 16.1540 $687.24 $554.31
tendons.
26440........ Release palm/ Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger tendon.
26442........ Release palm & Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger tendon.
26445........ Release hand/ Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger tendon.
26449........ Release forearm/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand tendon.
26450........ Incision of Y............ A2........... $510.00 16.1540 $687.24 $554.31
palm tendon.
26455........ Incision of Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger tendon.
26460........ Incise hand/ Y............ A2........... $510.00 16.1540 $687.24 $554.31
finger tendon.
26471........ Fusion of Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger tendons.
[[Page 42565]]
26474........ Fusion of Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger tendons.
26476........ Tendon Y............ A2........... $333.00 16.1540 $687.24 $421.56
lengthening.
26477........ Tendon Y............ A2........... $333.00 16.1540 $687.24 $421.56
shortening.
26478........ Lengthening of Y............ A2........... $333.00 16.1540 $687.24 $421.56
hand tendon.
26479........ Shortening of Y............ A2........... $333.00 16.1540 $687.24 $421.56
hand tendon.
26480........ Transplant hand Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
tendon.
26483........ Transplant/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
graft hand
tendon.
26485........ Transplant palm Y............ A2........... $446.00 25.8758 $1,100.83 $609.71
tendon.
26489........ Transplant/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
graft palm
tendon.
26490........ Revise thumb Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
tendon.
26492........ Tendon transfer Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
with graft.
26494........ Hand tendon/ Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
muscle
transfer.
26496........ Revise thumb Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
tendon.
26497........ Finger tendon Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
transfer.
26498........ Finger tendon Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
transfer.
26499........ Revision of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger.
26500........ Hand tendon Y............ A2........... $630.00 16.1540 $687.24 $644.31
reconstruction.
26502........ Hand tendon Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
reconstruction.
26508........ Release thumb Y............ A2........... $510.00 16.1540 $687.24 $554.31
contracture.
26510........ Thumb tendon Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
transfer.
26516........ Fusion of Y............ A2........... $333.00 25.8758 $1,100.83 $524.96
knuckle joint.
26517........ Fusion of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
knuckle joints.
26518........ Fusion of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
knuckle joints.
26520........ Release knuckle Y............ A2........... $510.00 16.1540 $687.24 $554.31
contracture.
26525........ Release finger Y............ A2........... $510.00 16.1540 $687.24 $554.31
contracture.
26530........ Revise knuckle Y............ A2........... $510.00 33.4505 $1,423.08 $738.27
joint.
26531........ Revise knuckle Y............ A2........... $995.00 47.4378 $2,018.15 $1,250.79
with implant.
26535........ Revise finger Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
joint.
26536........ Revise/implant Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
finger joint.
26540........ Repair hand Y............ A2........... $630.00 16.1540 $687.24 $644.31
joint.
26541........ Repair hand Y............ A2........... $995.00 25.8758 $1,100.83 $1,021.46
joint with
graft.
26542........ Repair hand Y............ A2........... $630.00 16.1540 $687.24 $644.31
joint with
graft.
26545........ Reconstruct Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger joint.
26546........ Repair nonunion Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
hand.
26548........ Reconstruct Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger joint.
26550........ Construct thumb Y............ A2........... $446.00 25.8758 $1,100.83 $609.71
replacement.
26555........ Positional Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
change of
finger.
26560........ Repair of web Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger.
26561........ Repair of web Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger.
26562........ Repair of web Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger.
26565........ Correct Y............ A2........... $717.00 25.8758 $1,100.83 $812.96
metacarpal
flaw.
26567........ Correct finger Y............ A2........... $717.00 25.8758 $1,100.83 $812.96
deformity.
26568........ Lengthen Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
metacarpal/
finger.
26580........ Repair hand Y............ A2........... $717.00 16.1540 $687.24 $709.56
deformity.
26587........ Reconstruct Y............ A2........... $717.00 16.1540 $687.24 $709.56
extra finger.
26590........ Repair finger Y............ A2........... $717.00 16.1540 $687.24 $709.56
deformity.
26591........ Repair muscles Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
of hand.
26593........ Release muscles Y............ A2........... $510.00 16.1540 $687.24 $554.31
of hand.
26596........ Excision Y............ A2........... $446.00 16.1540 $687.24 $506.31
constricting
tissue.
26600........ Treat Y............ P2........... ........... 1.6857 $71.71 $71.71
metacarpal
fracture.
26605........ Treat Y............ A2........... $103.62 1.6857 $71.71 $95.64
metacarpal
fracture.
26607........ Treat Y............ A2........... $103.62 1.6857 $71.71 $95.64
metacarpal
fracture.
26608........ Treat Y............ A2........... $630.00 25.5264 $1,085.97 $743.99
metacarpal
fracture.
26615........ Treat Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
metacarpal
fracture.
26641........ Treat thumb Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
26645........ Treat thumb Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
26650........ Treat thumb Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
26665........ Treat thumb Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
fracture.
26670........ Treat hand Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
26675........ Treat hand Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
26676........ Pin hand Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
26685........ Treat hand Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
26686........ Treat hand Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
dislocation.
[[Page 42566]]
26700........ Treat knuckle Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
26705........ Treat knuckle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
26706........ Pin knuckle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
26715........ Treat knuckle Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
dislocation.
26720........ Treat finger Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
26725........ Treat finger Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
26727........ Treat finger Y............ A2........... $995.00 25.5264 $1,085.97 $1,017.74
fracture, each.
26735........ Treat finger Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
fracture, each.
26740........ Treat finger Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
26742........ Treat finger Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture, each.
26746........ Treat finger Y............ A2........... $717.00 37.5382 $1,596.99 $937.00
fracture, each.
26750........ Treat finger Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
26755........ Treat finger Y............ G2........... ........... 1.6857 $71.71 $71.71
fracture, each.
26756........ Pin finger Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture, each.
26765........ Treat finger Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
fracture, each.
26770........ Treat finger Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
26775........ Treat finger Y............ G2........... ........... 14.5947 $620.90 $620.90
dislocation.
26776........ Pin finger Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
26785........ Treat finger Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
26820........ Thumb fusion Y............ A2........... $717.00 25.8758 $1,100.83 $812.96
with graft.
26841........ Fusion of thumb Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
26842........ Thumb fusion Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
with graft.
26843........ Fusion of hand Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
joint.
26844........ Fusion/graft of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
hand joint.
26850........ Fusion of Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
knuckle.
26852........ Fusion of Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
knuckle with
graft.
26860........ Fusion of Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
finger joint.
26861........ Fusion of Y............ A2........... $446.00 25.8758 $1,100.83 $609.71
finger jnt,
add-on.
26862........ Fusion/graft of Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
finger joint.
26863........ Fuse/graft Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
added joint.
26910........ Amputate Y............ A2........... $510.00 25.8758 $1,100.83 $657.71
metacarpal
bone.
26951........ Amputation of Y............ A2........... $446.00 16.1540 $687.24 $506.31
finger/thumb.
26952........ Amputation of Y............ A2........... $630.00 16.1540 $687.24 $644.31
finger/thumb.
26990........ Drainage of Y............ A2........... $333.00 20.8706 $887.90 $471.73
pelvis lesion.
26991........ Drainage of Y............ A2........... $333.00 20.8706 $887.90 $471.73
pelvis bursa.
27000........ Incision of hip Y............ A2........... $446.00 20.8706 $887.90 $556.48
tendon.
27001........ Incision of hip Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendon.
27003........ Incision of hip Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendon.
27033........ Exploration of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
hip joint.
27035........ Denervation of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
hip joint.
27040........ Biopsy of soft Y............ A2........... $333.00 6.8083 $289.65 $322.16
tissues.
27041........ Biopsy of soft Y............ A2........... $418.49 6.8083 $289.65 $386.28
tissues.
27047........ Remove hip/ Y............ A2........... $446.00 20.0656 $853.65 $547.91
pelvis lesion.
27048........ Remove hip/ Y............ A2........... $510.00 20.0656 $853.65 $595.91
pelvis lesion.
27049........ Remove tumor, Y............ A2........... $510.00 20.0656 $853.65 $595.91
hip/pelvis.
27050........ Biopsy of Y............ A2........... $510.00 20.8706 $887.90 $604.48
sacroiliac
joint.
27052........ Biopsy of hip Y............ A2........... $510.00 20.8706 $887.90 $604.48
joint.
27060........ Removal of Y............ A2........... $717.00 20.8706 $887.90 $759.73
ischial bursa.
27062........ Remove femur Y............ A2........... $717.00 20.8706 $887.90 $759.73
lesion/bursa.
27065........ Removal of hip Y............ A2........... $717.00 20.8706 $887.90 $759.73
bone lesion.
27066........ Removal of hip Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
bone lesion.
27067........ Remove/graft Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
hip bone
lesion.
27080........ Removal of tail Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
bone.
27086........ Remove hip Y............ A2........... $333.00 6.8083 $289.65 $322.16
foreign body.
27087........ Remove hip Y............ A2........... $510.00 20.8706 $887.90 $604.48
foreign body.
27093........ Injection for ............. N1........... ........... ........... ........... ...........
hip x-ray.
27095........ Injection for ............. N1........... ........... ........... ........... ...........
hip x-ray.
27097........ Revision of hip Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
tendon.
27098........ Transfer tendon Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
to pelvis.
27100........ Transfer of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
abdominal
muscle.
27105........ Transfer of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
spinal muscle.
27110........ Transfer of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
iliopsoas
muscle.
27111........ Transfer of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
iliopsoas
muscle.
[[Page 42567]]
27193........ Treat pelvic Y............ A2........... $103.62 1.6857 $71.71 $95.64
ring fracture.
27194........ Treat pelvic Y............ A2........... $446.00 14.5947 $620.90 $489.73
ring fracture.
27200........ Treat tail bone Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture.
27202........ Treat tail bone Y............ A2........... $446.00 37.5382 $1,596.99 $733.75
fracture.
27220........ Treat hip Y............ G2........... ........... 1.6857 $71.71 $71.71
socket
fracture.
27230........ Treat thigh Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27238........ Treat thigh Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27246........ Treat thigh Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27250........ Treat hip Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27252........ Treat hip Y............ A2........... $446.00 14.5947 $620.90 $489.73
dislocation.
27256........ Treat hip Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
27257........ Treat hip Y............ A2........... $510.00 14.5947 $620.90 $537.73
dislocation.
27265........ Treat hip Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27266........ Treat hip Y............ A2........... $446.00 14.5947 $620.90 $489.73
dislocation.
27275........ Manipulation of Y............ A2........... $446.00 14.5947 $620.90 $489.73
hip joint.
27301........ Drain thigh/ Y............ A2........... $510.00 17.5086 $744.87 $568.72
knee lesion.
27305........ Incise thigh Y............ A2........... $446.00 20.8706 $887.90 $556.48
tendon &
fascia.
27306........ Incision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
thigh tendon.
27307........ Incision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
thigh tendons.
27310........ Exploration of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
knee joint.
27323........ Biopsy, thigh Y............ A2........... $333.00 6.8083 $289.65 $322.16
soft tissues.
27324........ Biopsy, thigh Y............ A2........... $333.00 20.0656 $853.65 $463.16
soft tissues.
27325........ Neurectomy, Y............ A2........... $446.00 17.8499 $759.39 $524.35
hamstring.
27326........ Neurectomy, Y............ A2........... $446.00 17.8499 $759.39 $524.35
popliteal.
27327........ Removal of Y............ A2........... $446.00 20.0656 $853.65 $547.91
thigh lesion.
27328........ Removal of Y............ A2........... $510.00 20.0656 $853.65 $595.91
thigh lesion.
27329........ Remove tumor, Y............ A2........... $630.00 20.0656 $853.65 $685.91
thigh/knee.
27330........ Biopsy, knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
27331........ Explore/treat Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
knee joint.
27332........ Removal of knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
cartilage.
27333........ Removal of knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
cartilage.
27334........ Remove knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
27335........ Remove knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
27340........ Removal of Y............ A2........... $510.00 20.8706 $887.90 $604.48
kneecap bursa.
27345........ Removal of knee Y............ A2........... $630.00 20.8706 $887.90 $694.48
cyst.
27347........ Remove knee Y............ A2........... $630.00 20.8706 $887.90 $694.48
cyst.
27350........ Removal of Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
kneecap.
27355........ Remove femur Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
lesion.
27356........ Remove femur Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
lesion/graft.
27357........ Remove femur Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
lesion/graft.
27358........ Remove femur Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
lesion/
fixation.
27360........ Partial Y............ A2........... $717.00 25.1296 $1,069.09 $805.02
removal, leg
bone(s).
27370........ Injection for ............. N1........... ........... ........... ........... ...........
knee x-ray.
27372........ Removal of Y............ A2........... $995.00 20.0656 $853.65 $959.66
foreign body.
27380........ Repair of Y............ A2........... $333.00 20.8706 $887.90 $471.73
kneecap tendon.
27381........ Repair/graft Y............ A2........... $510.00 20.8706 $887.90 $604.48
kneecap tendon.
27385........ Repair of thigh Y............ A2........... $510.00 20.8706 $887.90 $604.48
muscle.
27386........ Repair/graft of Y............ A2........... $510.00 20.8706 $887.90 $604.48
thigh muscle.
27390........ Incision of Y............ A2........... $333.00 20.8706 $887.90 $471.73
thigh tendon.
27391........ Incision of Y............ A2........... $446.00 20.8706 $887.90 $556.48
thigh tendons.
27392........ Incision of Y............ A2........... $510.00 20.8706 $887.90 $604.48
thigh tendons.
27393........ Lengthening of Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
thigh tendon.
27394........ Lengthening of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
thigh tendons.
27395........ Lengthening of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
thigh tendons.
27396........ Transplant of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
thigh tendon.
27397........ Transplants of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
thigh tendons.
27400........ Revise thigh Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
muscles/
tendons.
27403........ Repair of knee Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
cartilage.
27405........ Repair of knee Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
ligament.
27407........ Repair of knee Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
ligament.
27409........ Repair of knee Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
ligaments.
27418........ Repair Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
degenerated
kneecap.
27420........ Revision of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
unstable
kneecap.
[[Continued on page 42569]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 42569-42618]] Medicare Program; Revised Payment System Policies for Services
Furnished in Ambulatory Surgical Centers (ASCs) Beginning in CY 2008
[[Continued from page 42568]]
[[Page 42568]]
27422........ Revision of Y............ A2........... $995.00 41.0893 $1,748.06 $1,183.27
unstable
kneecap.
27424........ Revision/ Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
removal of
kneecap.
27425........ Lat retinacular Y............ A2........... $995.00 25.1296 $1,069.09 $1,013.52
release open.
27427........ Reconstruction, Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
knee.
27428........ Reconstruction, Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
knee.
27429........ Reconstruction, Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
knee.
27430........ Revision of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
thigh muscles.
27435........ Incision of Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
knee joint.
27437........ Revise kneecap. Y............ A2........... $630.00 33.4505 $1,423.08 $828.27
27438........ Revise kneecap Y............ A2........... $717.00 47.4378 $2,018.15 $1,042.29
with implant.
27440........ Revision of Y............ G2........... ........... 33.4505 $1,423.08 $1,423.08
knee joint.
27441........ Revision of Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
knee joint.
27442........ Revision of Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
knee joint.
27443........ Revision of Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
knee joint.
27446........ Revision of Y............ G2........... ........... 205.6815 $8,750.31 $8,750.31
knee joint.
27496........ Decompression Y............ A2........... $717.00 20.8706 $887.90 $759.73
of thigh/knee.
27497........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of thigh/knee.
27498........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of thigh/knee.
27499........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of thigh/knee.
27500........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27501........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27502........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27503........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27508........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27509........ Treatment of Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
thigh fracture.
27510........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
thigh fracture.
27516........ Treat thigh fx Y............ A2........... $103.62 1.6857 $71.71 $95.64
growth plate.
27517........ Treat thigh fx Y............ A2........... $103.62 1.6857 $71.71 $95.64
growth plate.
27520........ Treat kneecap Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27530........ Treat knee Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27532........ Treat knee Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27538........ Treat knee Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture(s).
27550........ Treat knee Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27552........ Treat knee Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
27560........ Treat kneecap Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27562........ Treat kneecap Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
27566........ Treat kneecap Y............ A2........... $446.00 37.5382 $1,596.99 $733.75
dislocation.
27570........ Fixation of Y............ A2........... $333.00 14.5947 $620.90 $404.98
knee joint.
27594........ Amputation Y............ A2........... $510.00 20.8706 $887.90 $604.48
follow-up
surgery.
27600........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of lower leg.
27601........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of lower leg.
27602........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of lower leg.
27603........ Drain lower leg Y............ A2........... $446.00 17.5086 $744.87 $520.72
lesion.
27604........ Drain lower leg Y............ A2........... $446.00 20.8706 $887.90 $556.48
bursa.
27605........ Incision of Y............ A2........... $333.00 20.4263 $869.00 $467.00
achilles
tendon.
27606........ Incision of Y............ A2........... $333.00 20.8706 $887.90 $471.73
achilles
tendon.
27607........ Treat lower leg Y............ A2........... $446.00 20.8706 $887.90 $556.48
bone lesion.
27610........ Explore/treat Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
ankle joint.
27612........ Exploration of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
ankle joint.
27613........ Biopsy lower Y............ P3........... ........... 2.8569 $121.54 $121.54
leg soft
tissue.
27614........ Biopsy lower Y............ A2........... $446.00 20.0656 $853.65 $547.91
leg soft
tissue.
27615........ Remove tumor, Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
lower leg.
27618........ Remove lower Y............ A2........... $446.00 15.1024 $642.50 $495.13
leg lesion.
27619........ Remove lower Y............ A2........... $510.00 20.0656 $853.65 $595.91
leg lesion.
27620........ Explore/treat Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
ankle joint.
27625........ Remove ankle Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
27626........ Remove ankle Y............ A2........... $630.00 25.1296 $1,069.09 $739.77
joint lining.
27630........ Removal of Y............ A2........... $510.00 20.8706 $887.90 $604.48
tendon lesion.
27635........ Remove lower Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
leg bone
lesion.
27637........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
leg bone
lesion.
27638........ Remove/graft Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
leg bone
lesion.
27640........ Partial removal Y............ A2........... $446.00 41.0893 $1,748.06 $771.52
of tibia.
27641........ Partial removal Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
of fibula.
[[Page 42569]]
27647........ Extensive ankle/ Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
heel surgery.
27648........ Injection for ............. N1........... ........... ........... ........... ...........
ankle x-ray.
27650........ Repair achilles Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
tendon.
27652........ Repair/graft Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
achilles
tendon.
27654........ Repair of Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
achilles
tendon.
27656........ Repair leg Y............ A2........... $446.00 20.8706 $887.90 $556.48
fascia defect.
27658........ Repair of leg Y............ A2........... $333.00 20.8706 $887.90 $471.73
tendon, each.
27659........ Repair of leg Y............ A2........... $446.00 20.8706 $887.90 $556.48
tendon, each.
27664........ Repair of leg Y............ A2........... $446.00 20.8706 $887.90 $556.48
tendon, each.
27665........ Repair of leg Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tendon, each.
27675........ Repair lower Y............ A2........... $446.00 20.8706 $887.90 $556.48
leg tendons.
27676........ Repair lower Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
leg tendons.
27680........ Release of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
lower leg
tendon.
27681........ Release of Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
lower leg
tendons.
27685........ Revision of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
lower leg
tendon.
27686........ Revise lower Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
leg tendons.
27687........ Revision of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
calf tendon.
27690........ Revise lower Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
leg tendon.
27691........ Revise lower Y............ A2........... $630.00 41.0893 $1,748.06 $909.52
leg tendon.
27692........ Revise Y............ A2........... $510.00 41.0893 $1,748.06 $819.52
additional leg
tendon.
27695........ Repair of ankle Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
ligament.
27696........ Repair of ankle Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
ligaments.
27698........ Repair of ankle Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
ligament.
27700........ Revision of Y............ A2........... $717.00 33.4505 $1,423.08 $893.52
ankle joint.
27704........ Removal of Y............ A2........... $446.00 20.8706 $887.90 $556.48
ankle implant.
27705........ Incision of Y............ A2........... $446.00 41.0893 $1,748.06 $771.52
tibia.
27707........ Incision of Y............ A2........... $446.00 20.8706 $887.90 $556.48
fibula.
27709........ Incision of Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
tibia & fibula.
27730........ Repair of tibia Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
epiphysis.
27732........ Repair of Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
fibula
epiphysis.
27734........ Repair lower Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
leg epiphyses.
27740........ Repair of leg Y............ A2........... $446.00 25.1296 $1,069.09 $601.77
epiphyses.
27742........ Repair of leg Y............ A2........... $446.00 41.0893 $1,748.06 $771.52
epiphyses.
27745........ Reinforce tibia Y............ A2........... $510.00 66.5800 $2,832.51 $1,090.63
27750........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
tibia fracture.
27752........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
tibia fracture.
27756........ Treatment of Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
tibia fracture.
27758........ Treatment of Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
tibia fracture.
27759........ Treatment of Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
tibia fracture.
27760........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27762........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27766........ Treatment of Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
ankle fracture.
27780........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
fibula
fracture.
27781........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
fibula
fracture.
27784........ Treatment of Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fibula
fracture.
27786........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27788........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27792........ Treatment of Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
ankle fracture.
27808........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27810........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27814........ Treatment of Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
ankle fracture.
27816........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27818........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
27822........ Treatment of Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
ankle fracture.
27823........ Treatment of Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
ankle fracture.
27824........ Treat lower leg Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27825........ Treat lower leg Y............ A2........... $103.62 1.6857 $71.71 $95.64
fracture.
27826........ Treat lower leg Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
27827........ Treat lower leg Y............ A2........... $510.00 57.2172 $2,434.19 $991.05
fracture.
27828........ Treat lower leg Y............ A2........... $630.00 57.2172 $2,434.19 $1,081.05
fracture.
27829........ Treat lower leg Y............ A2........... $446.00 37.5382 $1,596.99 $733.75
joint.
27830........ Treat lower leg Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27831........ Treat lower leg Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
[[Page 42570]]
27832........ Treat lower leg Y............ A2........... $446.00 37.5382 $1,596.99 $733.75
dislocation.
27840........ Treat ankle Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
27842........ Treat ankle Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
27846........ Treat ankle Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
27848........ Treat ankle Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
27860........ Fixation of Y............ A2........... $333.00 14.5947 $620.90 $404.98
ankle joint.
27870........ Fusion of ankle Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
joint, open.
27871........ Fusion of Y............ A2........... $630.00 66.5800 $2,832.51 $1,180.63
tibiofibular
joint.
27884........ Amputation Y............ A2........... $510.00 20.8706 $887.90 $604.48
follow-up
surgery.
27889........ Amputation of Y............ A2........... $510.00 25.1296 $1,069.09 $649.77
foot at ankle.
27892........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of leg.
27893........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of leg.
27894........ Decompression Y............ A2........... $510.00 20.8706 $887.90 $604.48
of leg.
28001........ Drainage of Y............ P3........... ........... 2.8327 $120.51 $120.51
bursa of foot.
28002........ Treatment of Y............ A2........... $510.00 20.8706 $887.90 $604.48
foot infection.
28003........ Treatment of Y............ A2........... $510.00 20.8706 $887.90 $604.48
foot infection.
28005........ Treat foot bone Y............ A2........... $510.00 20.4263 $869.00 $599.75
lesion.
28008........ Incision of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot fascia.
28010........ Incision of toe Y............ P3........... ........... 2.1164 $90.04 $90.04
tendon.
28011........ Incision of toe Y............ A2........... $510.00 20.4263 $869.00 $599.75
tendons.
28020........ Exploration of Y............ A2........... $446.00 20.4263 $869.00 $551.75
foot joint.
28022........ Exploration of Y............ A2........... $446.00 20.4263 $869.00 $551.75
foot joint.
28024........ Exploration of Y............ A2........... $446.00 20.4263 $869.00 $551.75
toe joint.
28035........ Decompression Y............ A2........... $630.00 17.8499 $759.39 $662.35
of tibia nerve.
28043........ Excision of Y............ A2........... $446.00 20.0656 $853.65 $547.91
foot lesion.
28045........ Excision of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot lesion.
28046........ Resection of Y............ A2........... $510.00 20.4263 $869.00 $599.75
tumor, foot.
28050........ Biopsy of foot Y............ A2........... $446.00 20.4263 $869.00 $551.75
joint lining.
28052........ Biopsy of foot Y............ A2........... $446.00 20.4263 $869.00 $551.75
joint lining.
28054........ Biopsy of toe Y............ A2........... $446.00 20.4263 $869.00 $551.75
joint lining.
28055........ Neurectomy, Y............ A2........... $630.00 17.8499 $759.39 $662.35
foot.
28060........ Partial Y............ A2........... $446.00 20.4263 $869.00 $551.75
removal, foot
fascia.
28062........ Removal of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
fascia.
28070........ Removal of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
joint lining.
28072........ Removal of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
joint lining.
28080........ Removal of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
lesion.
28086........ Excise foot Y............ A2........... $446.00 20.4263 $869.00 $551.75
tendon sheath.
28088........ Excise foot Y............ A2........... $446.00 20.4263 $869.00 $551.75
tendon sheath.
28090........ Removal of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
lesion.
28092........ Removal of toe Y............ A2........... $510.00 20.4263 $869.00 $599.75
lesions.
28100........ Removal of Y............ A2........... $446.00 20.4263 $869.00 $551.75
ankle/heel
lesion.
28102........ Remove/graft Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot lesion.
28103........ Remove/graft Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot lesion.
28104........ Removal of foot Y............ A2........... $446.00 20.4263 $869.00 $551.75
lesion.
28106........ Remove/graft Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot lesion.
28107........ Remove/graft Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot lesion.
28108........ Removal of toe Y............ A2........... $446.00 20.4263 $869.00 $551.75
lesions.
28110........ Part removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal.
28111........ Part removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal.
28112........ Part removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal.
28113........ Part removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal.
28114........ Removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal
heads.
28116........ Revision of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot.
28118........ Removal of heel Y............ A2........... $630.00 20.4263 $869.00 $689.75
bone.
28119........ Removal of heel Y............ A2........... $630.00 20.4263 $869.00 $689.75
spur.
28120........ Part removal of Y............ A2........... $995.00 20.4263 $869.00 $963.50
ankle/heel.
28122........ Partial removal Y............ A2........... $510.00 20.4263 $869.00 $599.75
of foot bone.
28124........ Partial removal Y............ P3........... ........... 4.7639 $202.67 $202.67
of toe.
28126........ Partial removal Y............ A2........... $510.00 20.4263 $869.00 $599.75
of toe.
28130........ Removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
ankle bone.
28140........ Removal of Y............ A2........... $510.00 20.4263 $869.00 $599.75
metatarsal.
28150........ Removal of toe. Y............ A2........... $510.00 20.4263 $869.00 $599.75
28153........ Partial removal Y............ A2........... $510.00 20.4263 $869.00 $599.75
of toe.
[[Page 42571]]
28160........ Partial removal Y............ A2........... $510.00 20.4263 $869.00 $599.75
of toe.
28171........ Extensive foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
surgery.
28173........ Extensive foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
surgery.
28175........ Extensive foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
surgery.
28190........ Removal of foot Y............ P3........... ........... 2.9855 $127.01 $127.01
foreign body.
28192........ Removal of foot Y............ A2........... $446.00 15.1024 $642.50 $495.13
foreign body.
28193........ Removal of foot Y............ A2........... $418.49 6.8083 $289.65 $386.28
foreign body.
28200........ Repair of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
tendon.
28202........ Repair/graft of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot tendon.
28208........ Repair of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
tendon.
28210........ Repair/graft of Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot tendon.
28220........ Release of foot Y............ P3........... ........... 4.4823 $190.69 $190.69
tendon.
28222........ Release of foot Y............ A2........... $333.00 20.4263 $869.00 $467.00
tendons.
28225........ Release of foot Y............ A2........... $333.00 20.4263 $869.00 $467.00
tendon.
28226........ Release of foot Y............ A2........... $333.00 20.4263 $869.00 $467.00
tendons.
28230........ Incision of Y............ P3........... ........... 4.4341 $188.64 $188.64
foot tendon(s).
28232........ Incision of toe Y............ P3........... ........... 4.2329 $180.08 $180.08
tendon.
28234........ Incision of Y............ A2........... $446.00 20.4263 $869.00 $551.75
foot tendon.
28238........ Revision of Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
foot tendon.
28240........ Release of big Y............ A2........... $446.00 20.4263 $869.00 $551.75
toe.
28250........ Revision of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot fascia.
28260........ Release of Y............ A2........... $510.00 20.4263 $869.00 $599.75
midfoot joint.
28261........ Revision of Y............ A2........... $510.00 20.4263 $869.00 $599.75
foot tendon.
28262........ Revision of Y............ A2........... $630.00 20.4263 $869.00 $689.75
foot and ankle.
28264........ Release of Y............ A2........... $333.00 40.8559 $1,738.13 $684.28
midfoot joint.
28270........ Release of foot Y............ A2........... $510.00 20.4263 $869.00 $599.75
contracture.
28272........ Release of toe Y............ P3........... ........... 4.0559 $172.55 $172.55
joint, each.
28280........ Fusion of toes. Y............ A2........... $446.00 20.4263 $869.00 $551.75
28285........ Repair of Y............ A2........... $510.00 20.4263 $869.00 $599.75
hammertoe.
28286........ Repair of Y............ A2........... $630.00 20.4263 $869.00 $689.75
hammertoe.
28288........ Partial removal Y............ A2........... $510.00 20.4263 $869.00 $599.75
of foot bone.
28289........ Repair hallux Y............ A2........... $510.00 20.4263 $869.00 $599.75
rigidus.
28290........ Correction of Y............ A2........... $446.00 28.2349 $1,201.20 $634.80
bunion.
28292........ Correction of Y............ A2........... $446.00 28.2349 $1,201.20 $634.80
bunion.
28293........ Correction of Y............ A2........... $510.00 28.2349 $1,201.20 $682.80
bunion.
28294........ Correction of Y............ A2........... $510.00 28.2349 $1,201.20 $682.80
bunion.
28296........ Correction of Y............ A2........... $510.00 28.2349 $1,201.20 $682.80
bunion.
28297........ Correction of Y............ A2........... $510.00 28.2349 $1,201.20 $682.80
bunion.
28298........ Correction of Y............ A2........... $510.00 28.2349 $1,201.20 $682.80
bunion.
28299........ Correction of Y............ A2........... $717.00 28.2349 $1,201.20 $838.05
bunion.
28300........ Incision of Y............ A2........... $446.00 40.8559 $1,738.13 $769.03
heel bone.
28302........ Incision of Y............ A2........... $446.00 20.4263 $869.00 $551.75
ankle bone.
28304........ Incision of Y............ A2........... $446.00 40.8559 $1,738.13 $769.03
midfoot bones.
28305........ Incise/graft Y............ A2........... $510.00 40.8559 $1,738.13 $817.03
midfoot bones.
28306........ Incision of Y............ A2........... $630.00 20.4263 $869.00 $689.75
metatarsal.
28307........ Incision of Y............ A2........... $630.00 20.4263 $869.00 $689.75
metatarsal.
28308........ Incision of Y............ A2........... $446.00 20.4263 $869.00 $551.75
metatarsal.
28309........ Incision of Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
metatarsals.
28310........ Revision of big Y............ A2........... $510.00 20.4263 $869.00 $599.75
toe.
28312........ Revision of toe Y............ A2........... $510.00 20.4263 $869.00 $599.75
28313........ Repair Y............ A2........... $446.00 20.4263 $869.00 $551.75
deformity of
toe.
28315........ Removal of Y............ A2........... $630.00 20.4263 $869.00 $689.75
sesamoid bone.
28320........ Repair of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28322........ Repair of Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
metatarsals.
28340........ Resect enlarged Y............ A2........... $630.00 20.4263 $869.00 $689.75
toe tissue.
28341........ Resect enlarged Y............ A2........... $630.00 20.4263 $869.00 $689.75
toe.
28344........ Repair extra Y............ A2........... $630.00 20.4263 $869.00 $689.75
toe(s).
28345........ Repair webbed Y............ A2........... $630.00 20.4263 $869.00 $689.75
toe(s).
28400........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
heel fracture.
28405........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
heel fracture.
28406........ Treatment of Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
heel fracture.
28415........ Treat heel Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
28420........ Treat/graft Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
heel fracture.
[[Page 42572]]
28430........ Treatment of Y............ P2........... ........... 1.6857 $71.71 $71.71
ankle fracture.
28435........ Treatment of Y............ A2........... $103.62 1.6857 $71.71 $95.64
ankle fracture.
28436........ Treatment of Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
ankle fracture.
28445........ Treat ankle Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
28450........ Treat midfoot Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
28455........ Treat midfoot Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture, each.
28456........ Treat midfoot Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
28465........ Treat midfoot Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture, each.
28470........ Treat Y............ P2........... ........... 1.6857 $71.71 $71.71
metatarsal
fracture.
28475........ Treat Y............ P2........... ........... 1.6857 $71.71 $71.71
metatarsal
fracture.
28476........ Treat Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
metatarsal
fracture.
28485........ Treat Y............ A2........... $630.00 37.5382 $1,596.99 $871.75
metatarsal
fracture.
28490........ Treat big toe Y............ P3........... ........... 1.6579 $70.53 $70.53
fracture.
28495........ Treat big toe Y............ P2........... ........... 1.6857 $71.71 $71.71
fracture.
28496........ Treat big toe Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
fracture.
28505........ Treat big toe Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
28510........ Treatment of Y............ P3........... ........... 1.2956 $55.12 $55.12
toe fracture.
28515........ Treatment of Y............ P3........... ........... 1.6658 $70.87 $70.87
toe fracture.
28525........ Treat toe Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
fracture.
28530........ Treat sesamoid Y............ P3........... ........... 1.2392 $52.72 $52.72
bone fracture.
28531........ Treat sesamoid Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
bone fracture.
28540........ Treat foot Y............ P2........... ........... 1.6857 $71.71 $71.71
dislocation.
28545........ Treat foot Y............ A2........... $333.00 25.5264 $1,085.97 $521.24
dislocation.
28546........ Treat foot Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
28555........ Repair foot Y............ A2........... $446.00 37.5382 $1,596.99 $733.75
dislocation.
28570........ Treat foot Y............ P2........... ........... 1.6857 $71.71 $71.71
dislocation.
28575........ Treat foot Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
28576........ Treat foot Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
dislocation.
28585........ Repair foot Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
28600........ Treat foot Y............ P2........... ........... 1.6857 $71.71 $71.71
dislocation.
28605........ Treat foot Y............ A2........... $103.62 1.6857 $71.71 $95.64
dislocation.
28606........ Treat foot Y............ A2........... $446.00 25.5264 $1,085.97 $605.99
dislocation.
28615........ Repair foot Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
28630........ Treat toe Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
28635........ Treat toe Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
28636........ Treat toe Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
dislocation.
28645........ Repair toe Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
28660........ Treat toe Y............ G2........... ........... 1.6857 $71.71 $71.71
dislocation.
28665........ Treat toe Y............ A2........... $333.00 14.5947 $620.90 $404.98
dislocation.
28666........ Treat toe Y............ A2........... $510.00 25.5264 $1,085.97 $653.99
dislocation.
28675........ Repair of toe Y............ A2........... $510.00 37.5382 $1,596.99 $781.75
dislocation.
28705........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28715........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28725........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28730........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28735........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28737........ Revision of Y............ A2........... $717.00 40.8559 $1,738.13 $972.28
foot bones.
28740........ Fusion of foot Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
bones.
28750........ Fusion of big Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
toe joint.
28755........ Fusion of big Y............ A2........... $630.00 20.4263 $869.00 $689.75
toe joint.
28760........ Fusion of big Y............ A2........... $630.00 40.8559 $1,738.13 $907.03
toe joint.
28810........ Amputation toe Y............ A2........... $446.00 20.4263 $869.00 $551.75
& metatarsal.
28820........ Amputation of Y............ A2........... $446.00 20.4263 $869.00 $551.75
toe.
28825........ Partial Y............ A2........... $446.00 20.4263 $869.00 $551.75
amputation of
toe.
28890........ High energy Y............ G2........... ........... 25.1296 $1,069.09 $1,069.09
eswt, plantar
f.
29000........ Application of N............ G2........... ........... 1.0607 $45.13 $45.13
body cast.
29010........ Application of N............ P2........... ........... 2.2777 $96.90 $96.90
body cast.
29015........ Application of N............ P2........... ........... 2.2777 $96.90 $96.90
body cast.
29020........ Application of N............ G2........... ........... 1.0607 $45.13 $45.13
body cast.
29025........ Application of N............ P2........... ........... 1.0607 $45.13 $45.13
body cast.
29035........ Application of N............ G2........... ........... 2.2777 $96.90 $96.90
body cast.
29040........ Application of N............ G2........... ........... 1.0607 $45.13 $45.13
body cast.
29044........ Application of N............ P2........... ........... 2.2777 $96.90 $96.90
body cast.
[[Page 42573]]
29046........ Application of N............ G2........... ........... 2.2777 $96.90 $96.90
body cast.
29049........ Application of N............ P3........... ........... 0.9736 $41.42 $41.42
figure eight.
29055........ Application of N............ P2........... ........... 2.2777 $96.90 $96.90
shoulder cast.
29058........ Application of N............ P2........... ........... 1.0607 $45.13 $45.13
shoulder cast.
29065........ Application of N............ P3........... ........... 1.0462 $44.51 $44.51
long arm cast.
29075........ Application of N............ P3........... ........... 0.9978 $42.45 $42.45
forearm cast.
29085........ Apply hand/ N............ P3........... ........... 1.0220 $43.48 $43.48
wrist cast.
29086........ Apply finger N............ P3........... ........... 0.8048 $34.24 $34.24
cast.
29105........ Apply long arm N............ P3........... ........... 0.9334 $39.71 $39.71
splint.
29125........ Apply forearm N............ P3........... ........... 0.7966 $33.89 $33.89
splint.
29126........ Apply forearm N............ P3........... ........... 0.8932 $38.00 $38.00
splint.
29130........ Application of N............ P3........... ........... 0.3622 $15.41 $15.41
finger splint.
29131........ Application of N............ P3........... ........... 0.5472 $23.28 $23.28
finger splint.
29200........ Strapping of N............ P3........... ........... 0.5312 $22.60 $22.60
chest.
29220........ Strapping of N............ P3........... ........... 0.5312 $22.60 $22.60
low back.
29240........ Strapping of N............ P3........... ........... 0.6116 $26.02 $26.02
shoulder.
29260........ Strapping of N............ P3........... ........... 0.5632 $23.96 $23.96
elbow or wrist.
29280........ Strapping of N............ P3........... ........... 0.5874 $24.99 $24.99
hand or finger.
29305........ Application of N............ G2........... ........... 2.2777 $96.90 $96.90
hip cast.
29325........ Application of N............ G2........... ........... 2.2777 $96.90 $96.90
hip casts.
29345........ Application of N............ P3........... ........... 1.3760 $58.54 $58.54
long leg cast.
29355........ Application of N............ P3........... ........... 1.3438 $57.17 $57.17
long leg cast.
29358........ Apply long leg N............ P3........... ........... 1.6496 $70.18 $70.18
cast brace.
29365........ Application of N............ P3........... ........... 1.3036 $55.46 $55.46
long leg cast.
29405........ Apply short leg N............ P3........... ........... 0.9736 $41.42 $41.42
cast.
29425........ Apply short leg N............ P3........... ........... 0.9898 $42.11 $42.11
cast.
29435........ Apply short leg N............ P3........... ........... 1.2392 $52.72 $52.72
cast.
29440........ Addition of N............ P3........... ........... 0.5230 $22.25 $22.25
walker to cast.
29445........ Apply rigid leg N............ P3........... ........... 1.3760 $58.54 $58.54
cast.
29450........ Application of N............ P2........... ........... 1.0607 $45.13 $45.13
leg cast.
29505........ Application, N............ G2........... ........... 1.0607 $45.13 $45.13
long leg
splint.
29515........ Application N............ G2........... ........... 1.0607 $45.13 $45.13
lower leg
splint.
29520........ Strapping of N............ P3........... ........... 0.6116 $26.02 $26.02
hip.
29530........ Strapping of N............ P3........... ........... 0.5714 $24.31 $24.31
knee.
29540........ Strapping of N............ P3........... ........... 0.3862 $16.43 $16.43
ankle and/or
ft.
29550........ Strapping of N............ P3........... ........... 0.4024 $17.12 $17.12
toes.
29580........ Application of N............ P3........... ........... 0.5552 $23.62 $23.62
paste boot.
29590........ Application of N............ P3........... ........... 0.4506 $19.17 $19.17
foot splint.
29700........ Removal/ N............ P3........... ........... 0.7484 $31.84 $31.84
revision of
cast.
29705........ Removal/ N............ P3........... ........... 0.6438 $27.39 $27.39
revision of
cast.
29710........ Removal/ N............ P3........... ........... 1.1990 $51.01 $51.01
revision of
cast.
29715........ Removal/ N............ P3........... ........... 0.9254 $39.37 $39.37
revision of
cast.
29720........ Repair of body N............ P3........... ........... 0.9254 $39.37 $39.37
cast.
29730........ Windowing of N............ P3........... ........... 0.6276 $26.70 $26.70
cast.
29740........ Wedging of cast N............ P3........... ........... 0.8852 $37.66 $37.66
29750........ Wedging of N............ P3........... ........... 0.7966 $33.89 $33.89
clubfoot cast.
29800........ Jaw arthroscopy/ Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
surgery.
29804........ Jaw arthroscopy/ Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
surgery.
29805........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy,
dx.
29806........ Shoulder Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29807........ Shoulder Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29819........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29820........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29821........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29822........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29823........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29824........ Shoulder Y............ A2........... $717.00 28.6245 $1,217.77 $842.19
arthroscopy/
surgery.
29825........ Shoulder Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29826........ Shoulder Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29827........ Arthroscop Y............ A2........... $717.00 45.5027 $1,935.82 $1,021.71
rotator cuff
repr.
29830........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy.
29834........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29835........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
[[Page 42574]]
29836........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29837........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29838........ Elbow Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29840........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy.
29843........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29844........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29845........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29846........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29847........ Wrist Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29848........ Wrist endoscopy/ Y............ A2........... $1,339.00 28.6245 $1,217.77 $1,308.69
surgery.
29850........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29851........ Knee Y............ A2........... $630.00 45.5027 $1,935.82 $956.46
arthroscopy/
surgery.
29855........ Tibial Y............ A2........... $630.00 45.5027 $1,935.82 $956.46
arthroscopy/
surgery.
29856........ Tibial Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29860........ Hip Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy,
dx.
29861........ Hip arthroscopy/ Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
surgery.
29862........ Hip arthroscopy/ Y............ A2........... $1,339.00 45.5027 $1,935.82 $1,488.21
surgery.
29863........ Hip arthroscopy/ Y............ A2........... $630.00 45.5027 $1,935.82 $956.46
surgery.
29870........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy,
dx.
29871........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
drainage.
29873........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29874........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29875........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29876........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29877........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29879........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29880........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29881........ Knee Y............ A2........... $630.00 28.6245 $1,217.77 $776.94
arthroscopy/
surgery.
29882........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29883........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29884........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29885........ Knee Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29886........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29887........ Knee Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29888........ Knee Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29889........ Knee Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29891........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29892........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29893........ Scope, plantar Y............ A2........... $1,255.56 20.4263 $869.00 $1,158.92
fasciotomy.
29894........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29895........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29897........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29898........ Ankle Y............ A2........... $510.00 28.6245 $1,217.77 $686.94
arthroscopy/
surgery.
29899........ Ankle Y............ A2........... $510.00 45.5027 $1,935.82 $866.46
arthroscopy/
surgery.
29900........ Mcp joint Y............ A2........... $510.00 16.1540 $687.24 $554.31
arthroscopy,
dx.
29901........ Mcp joint Y............ A2........... $510.00 16.1540 $687.24 $554.31
arthroscopy,
surg.
29902........ Mcp joint Y............ A2........... $510.00 16.1540 $687.24 $554.31
arthroscopy,
surg.
30000........ Drainage of Y............ P2........... ........... 2.4520 $104.32 $104.32
nose lesion.
30020........ Drainage of Y............ P2........... ........... 2.4520 $104.32 $104.32
nose lesion.
30100........ Intranasal Y............ P3........... ........... 1.7625 $74.98 $74.98
biopsy.
30110........ Removal of nose Y............ P3........... ........... 2.7683 $117.77 $117.77
polyp(s).
30115........ Removal of nose Y............ A2........... $446.00 16.4266 $698.84 $509.21
polyp(s).
30117........ Removal of Y............ A2........... $510.00 16.4266 $698.84 $557.21
intranasal
lesion.
30118........ Removal of Y............ A2........... $510.00 23.3299 $992.52 $630.63
intranasal
lesion.
30120........ Revision of Y............ A2........... $333.00 16.4266 $698.84 $424.46
nose.
30124........ Removal of nose Y............ R2........... ........... 7.5511 $321.25 $321.25
lesion.
30125........ Removal of nose Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
lesion.
30130........ Excise inferior Y............ A2........... $510.00 16.4266 $698.84 $557.21
turbinate.
30140........ Resect inferior Y............ A2........... $446.00 23.3299 $992.52 $582.63
turbinate.
30150........ Partial removal Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
of nose.
30160........ Removal of nose Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
30200........ Injection Y............ P3........... ........... 1.4082 $59.91 $59.91
treatment of
nose.
30210........ Nasal sinus Y............ P3........... ........... 1.7784 $75.66 $75.66
therapy.
[[Page 42575]]
30220........ Insert nasal Y............ A2........... $464.15 7.5511 $321.25 $428.43
septal button.
30300........ Remove nasal N............ P2........... ........... 0.6102 $25.96 $25.96
foreign body.
30310........ Remove nasal Y............ A2........... $333.00 16.4266 $698.84 $424.46
foreign body.
30320........ Remove nasal Y............ A2........... $446.00 16.4266 $698.84 $509.21
foreign body.
30400........ Reconstruction Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
of nose.
30410........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of nose.
30420........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of nose.
30430........ Revision of Y............ A2........... $510.00 23.3299 $992.52 $630.63
nose.
30435........ Revision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
nose.
30450........ Revision of Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
nose.
30460........ Revision of Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
nose.
30462........ Revision of Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
nose.
30465........ Repair nasal Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
stenosis.
30520........ Repair of nasal Y............ A2........... $630.00 23.3299 $992.52 $720.63
septum.
30540........ Repair nasal Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
defect.
30545........ Repair nasal Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
defect.
30560........ Release of Y............ A2........... $150.72 2.4520 $104.32 $139.12
nasal
adhesions.
30580........ Repair upper Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
jaw fistula.
30600........ Repair mouth/ Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
nose fistula.
30620........ Intranasal Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
reconstruction.
30630........ Repair nasal Y............ A2........... $995.00 23.3299 $992.52 $994.38
septum defect.
30801........ Ablate inf Y............ A2........... $333.00 7.5511 $321.25 $330.06
turbinate,
superf.
30802........ Cauterization, Y............ A2........... $333.00 7.5511 $321.25 $330.06
inner nose.
30901........ Control of Y............ P3........... ........... 1.0300 $43.82 $43.82
nosebleed.
30903........ Control of Y............ A2........... $72.48 1.1791 $50.16 $66.90
nosebleed.
30905........ Control of Y............ A2........... $72.48 1.1791 $50.16 $66.90
nosebleed.
30906........ Repeat control Y............ A2........... $72.48 1.1791 $50.16 $66.90
of nosebleed.
30915........ Ligation, nasal Y............ A2........... $446.00 24.8809 $1,058.51 $599.13
sinus artery.
30920........ Ligation, upper Y............ A2........... $510.00 24.8809 $1,058.51 $647.13
jaw artery.
30930........ Ther fx, nasal Y............ A2........... $630.00 16.4266 $698.84 $647.21
inf turbinate.
31000........ Irrigation, Y............ P3........... ........... 2.3499 $99.97 $99.97
maxillary
sinus.
31002........ Irrigation, Y............ R2........... ........... 7.5511 $321.25 $321.25
sphenoid sinus.
31020........ Exploration, Y............ A2........... $446.00 23.3299 $992.52 $582.63
maxillary
sinus.
31030........ Exploration, Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
maxillary
sinus.
31032........ Explore sinus, Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
remove polyps.
31040........ Exploration Y............ R2........... ........... 23.3299 $992.52 $992.52
behind upper
jaw.
31050........ Exploration, Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
sphenoid sinus.
31051........ Sphenoid sinus Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
surgery.
31070........ Exploration of Y............ A2........... $446.00 23.3299 $992.52 $582.63
frontal sinus.
31075........ Exploration of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31080........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31081........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31084........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31085........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31086........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31087........ Removal of Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
frontal sinus.
31090........ Exploration of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
sinuses.
31200........ Removal of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
ethmoid sinus.
31201........ Removal of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ethmoid sinus.
31205........ Removal of Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
ethmoid sinus.
31231........ Nasal Y............ P2........... ........... 1.4054 $59.79 $59.79
endoscopy, dx.
31233........ Nasal/sinus Y............ A2........... $86.39 1.4054 $59.79 $79.74
endoscopy, dx.
31235........ Nasal/sinus Y............ A2........... $333.00 14.7928 $629.33 $407.08
endoscopy, dx.
31237........ Nasal/sinus Y............ A2........... $446.00 14.7928 $629.33 $491.83
endoscopy,
surg.
31238........ Nasal/sinus Y............ A2........... $333.00 14.7928 $629.33 $407.08
endoscopy,
surg.
31239........ Nasal/sinus Y............ A2........... $630.00 21.9512 $933.87 $705.97
endoscopy,
surg.
31240........ Nasal/sinus Y............ A2........... $446.00 14.7928 $629.33 $491.83
endoscopy,
surg.
31254........ Revision of Y............ A2........... $510.00 21.9512 $933.87 $615.97
ethmoid sinus.
31255........ Removal of Y............ A2........... $717.00 21.9512 $933.87 $771.22
ethmoid sinus.
31256........ Exploration Y............ A2........... $510.00 21.9512 $933.87 $615.97
maxillary
sinus.
31267........ Endoscopy, Y............ A2........... $510.00 21.9512 $933.87 $615.97
maxillary
sinus.
31276........ Sinus Y............ A2........... $510.00 21.9512 $933.87 $615.97
endoscopy,
surgical.
31287........ Nasal/sinus Y............ A2........... $510.00 21.9512 $933.87 $615.97
endoscopy,
surg.
[[Page 42576]]
31288........ Nasal/sinus Y............ A2........... $510.00 21.9512 $933.87 $615.97
endoscopy,
surg.
31300........ Removal of Y............ A2........... $717.00 23.3299 $992.52 $785.88
larynx lesion.
31320........ Diagnostic Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
incision,
larynx.
31400........ Revision of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
larynx.
31420........ Removal of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
epiglottis.
31500........ Insert N............ G2........... ........... 2.4233 $103.09 $103.09
emergency
airway.
31502........ Change of Y............ G2........... ........... 2.3587 $100.35 $100.35
windpipe
airway.
31505........ Diagnostic Y............ P2........... ........... 0.7698 $32.75 $32.75
laryngoscopy.
31510........ Laryngoscopy Y............ A2........... $446.00 14.7928 $629.33 $491.83
with biopsy.
31511........ Remove foreign Y............ A2........... $86.39 1.4054 $59.79 $79.74
body, larynx.
31512........ Removal of Y............ A2........... $446.00 14.7928 $629.33 $491.83
larynx lesion.
31513........ Injection into Y............ A2........... $86.39 1.4054 $59.79 $79.74
vocal cord.
31515........ Laryngoscopy Y............ A2........... $333.00 14.7928 $629.33 $407.08
for aspiration.
31520........ Dx Y............ G2........... ........... 1.4054 $59.79 $59.79
laryngoscopy,
newborn.
31525........ Dx laryngoscopy Y............ A2........... $333.00 14.7928 $629.33 $407.08
excl nb.
31526........ Dx laryngoscopy Y............ A2........... $446.00 21.9512 $933.87 $567.97
w/oper scope.
31527........ Laryngoscopy Y............ A2........... $333.00 21.9512 $933.87 $483.22
for treatment.
31528........ Laryngoscopy Y............ A2........... $446.00 14.7928 $629.33 $491.83
and dilation.
31529........ Laryngoscopy Y............ A2........... $446.00 14.7928 $629.33 $491.83
and dilation.
31530........ Laryngoscopy w/ Y............ A2........... $446.00 21.9512 $933.87 $567.97
fb removal.
31531........ Laryngoscopy w/ Y............ A2........... $510.00 21.9512 $933.87 $615.97
fb & op scope.
31535........ Laryngoscopy w/ Y............ A2........... $446.00 21.9512 $933.87 $567.97
biopsy.
31536........ Laryngoscopy w/ Y............ A2........... $510.00 21.9512 $933.87 $615.97
bx & op scope.
31540........ Laryngoscopy w/ Y............ A2........... $510.00 21.9512 $933.87 $615.97
exc of tumor.
31541........ Larynscop w/ Y............ A2........... $630.00 21.9512 $933.87 $705.97
tumr exc +
scope.
31545........ Remove vc Y............ A2........... $630.00 21.9512 $933.87 $705.97
lesion w/scope.
31546........ Remove vc Y............ A2........... $630.00 21.9512 $933.87 $705.97
lesion scope/
graft.
31560........ Laryngoscop w/ Y............ A2........... $717.00 21.9512 $933.87 $771.22
arytenoidectom.
31561........ Larynscop, Y............ A2........... $717.00 21.9512 $933.87 $771.22
remve cart +
scop.
31570........ Laryngoscope w/ Y............ A2........... $446.00 14.7928 $629.33 $491.83
vc inj.
31571........ Laryngoscop w/ Y............ A2........... $446.00 21.9512 $933.87 $567.97
vc inj + scope.
31575........ Diagnostic Y............ P3........... ........... 1.4002 $59.57 $59.57
laryngoscopy.
31576........ Laryngoscopy Y............ A2........... $446.00 21.9512 $933.87 $567.97
with biopsy.
31577........ Remove foreign Y............ A2........... $236.42 3.8463 $163.63 $218.22
body, larynx.
31578........ Removal of Y............ A2........... $446.00 21.9512 $933.87 $567.97
larynx lesion.
31579........ Diagnostic Y............ P3........... ........... 2.5833 $109.90 $109.90
laryngoscopy.
31580........ Revision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
larynx.
31582........ Revision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
larynx.
31588........ Revision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
larynx.
31590........ Reinnervate Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
larynx.
31595........ Larynx nerve Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
surgery.
31603........ Incision of Y............ A2........... $333.00 7.5511 $321.25 $330.06
windpipe.
31605........ Incision of Y............ G2........... ........... 7.5511 $321.25 $321.25
windpipe.
31611........ Surgery/speech Y............ A2........... $510.00 23.3299 $992.52 $630.63
prosthesis.
31612........ Puncture/clear Y............ A2........... $333.00 23.3299 $992.52 $497.88
windpipe.
31613........ Repair windpipe Y............ A2........... $446.00 23.3299 $992.52 $582.63
opening.
31614........ Repair windpipe Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
opening.
31615........ Visualization Y............ A2........... $333.00 9.5228 $405.13 $351.03
of windpipe.
31620........ Endobronchial N............ A2........... $333.00 32.2854 $1,373.52 $593.13
us add-on.
31622........ Dx bronchoscope/ Y............ A2........... $333.00 9.5228 $405.13 $351.03
wash.
31623........ Dx bronchoscope/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
brush.
31624........ Dx bronchoscope/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
lavage.
31625........ Bronchoscopy w/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
biopsy(s).
31628........ Bronchoscopy/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
lung bx, each.
31629........ Bronchoscopy/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
needle bx,
each.
31630........ Bronchoscopy Y............ A2........... $446.00 22.0099 $936.37 $568.59
dilate/fx repr.
31631........ Bronchoscopy, Y............ A2........... $446.00 22.0099 $936.37 $568.59
dilate w/stent.
31632........ Bronchoscopy/ Y............ G2........... ........... 9.5228 $405.13 $405.13
lung bx, add'l.
31633........ Bronchoscopy/ Y............ G2........... ........... 9.5228 $405.13 $405.13
needle bx
add'l.
31635........ Bronchoscopy w/ Y............ A2........... $446.00 9.5228 $405.13 $435.78
fb removal.
31636........ Bronchoscopy, Y............ A2........... $446.00 22.0099 $936.37 $568.59
bronch stents.
31637........ Bronchoscopy, Y............ A2........... $333.00 9.5228 $405.13 $351.03
stent add-on.
31638........ Bronchoscopy, Y............ A2........... $446.00 22.0099 $936.37 $568.59
revise stent.
[[Page 42577]]
31640........ Bronchoscopy w/ Y............ A2........... $446.00 22.0099 $936.37 $568.59
tumor excise.
31641........ Bronchoscopy, Y............ A2........... $446.00 22.0099 $936.37 $568.59
treat blockage.
31643........ Diag Y............ A2........... $446.00 9.5228 $405.13 $435.78
bronchoscope/
catheter.
31645........ Bronchoscopy, Y............ A2........... $333.00 9.5228 $405.13 $351.03
clear airways.
31646........ Bronchoscopy, Y............ A2........... $333.00 9.5228 $405.13 $351.03
reclear airway.
31656........ Bronchoscopy, Y............ A2........... $333.00 9.5228 $405.13 $351.03
inj for x-ray.
31715........ Injection for ............. N1........... ........... ........... ........... ...........
bronchus x-ray.
31717........ Bronchial brush Y............ A2........... $236.42 3.8463 $163.63 $218.22
biopsy.
31720........ Clearance of Y............ A2........... $47.32 0.7698 $32.75 $43.68
airways.
31730........ Intro, windpipe Y............ A2........... $236.42 3.8463 $163.63 $218.22
wire/tube.
31750........ Repair of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
windpipe.
31755........ Repair of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
windpipe.
31820........ Closure of Y............ A2........... $333.00 16.4266 $698.84 $424.46
windpipe
lesion.
31825........ Repair of Y............ A2........... $446.00 23.3299 $992.52 $582.63
windpipe
defect.
31830........ Revise windpipe Y............ A2........... $446.00 23.3299 $992.52 $582.63
scar.
32000........ Drainage of Y............ A2........... $222.78 3.6244 $154.19 $205.63
chest.
32002........ Treatment of Y............ G2........... ........... 3.6244 $154.19 $154.19
collapsed lung.
32019........ Insert pleural Y............ G2........... ........... 29.5416 $1,256.79 $1,256.79
catheter.
32400........ Needle biopsy Y............ A2........... $333.00 6.1384 $261.15 $315.04
chest lining.
32405........ Biopsy, lung or Y............ A2........... $333.00 6.1384 $261.15 $315.04
mediastinum.
32420........ Puncture/clear Y............ A2........... $222.78 3.6244 $154.19 $205.63
lung.
32960........ Therapeutic Y............ G2........... ........... 3.6244 $154.19 $154.19
pneumothorax.
33010........ Drainage of Y............ A2........... $222.78 3.6244 $154.19 $205.63
heart sac.
33011........ Repeat drainage Y............ A2........... $222.78 3.6244 $154.19 $205.63
of heart sac.
33206........ Insertion of Y............ J8........... ........... 170.6370 $7,259.41 $7,259.41
heart
pacemaker.
33207........ Insertion of Y............ J8........... ........... 170.6370 $7,259.41 $7,259.41
heart
pacemaker.
33208........ Insertion of Y............ J8........... ........... 210.2184 $8,943.32 $8,943.32
heart
pacemaker.
33210........ Insertion of Y............ G2........... ........... 58.8594 $2,504.06 $2,504.06
heart
electrode.
33211........ Insertion of Y............ G2........... ........... 58.8594 $2,504.06 $2,504.06
heart
electrode.
33212........ Insertion of Y............ H8........... $510.00 134.4886 $5,721.55 $5,311.76
pulse
generator.
33213........ Insertion of Y............ H8........... $510.00 155.7342 $6,625.40 $6,192.90
pulse
generator.
33214........ Upgrade of Y............ J8........... ........... 210.2184 $8,943.32 $8,943.32
pacemaker
system.
33215........ Reposition Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
pacing-defib
lead.
33216........ Insert lead Y............ G2........... ........... 58.8594 $2,504.06 $2,504.06
pace-defib,
one.
33217........ Insert lead Y............ G2........... ........... 58.8594 $2,504.06 $2,504.06
pace-defib,
dual.
33218........ Repair lead Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
pace-defib,
one.
33220........ Repair lead Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
pace-defib,
dual.
33222........ Revise pocket, Y............ A2........... $446.00 21.4302 $911.71 $562.43
pacemaker.
33223........ Revise pocket, Y............ A2........... $446.00 21.4302 $911.71 $562.43
pacing-defib.
33224........ Insert pacing Y............ J8........... ........... 439.4366 $18,694.95 $18,694.95
lead & connect.
33225........ Lventric pacing Y............ J8........... ........... 439.4366 $18,694.95 $18,694.95
lead add-on.
33226........ Reposition 1 Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
ventric lead.
33233........ Removal of Y............ A2........... $446.00 25.6142 $1,089.70 $606.93
pacemaker
system.
33234........ Removal of Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
pacemaker
system.
33235........ Removal Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
pacemaker
electrode.
33241........ Remove pulse Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
generator.
33282........ Implant pat- N............ J8........... ........... 99.9215 $4,250.96 $4,250.96
active ht
record.
33284........ Remove pat- Y............ G2........... ........... 10.9918 $467.62 $467.62
active ht
record.
33508........ Endoscopic vein ............. N1........... ........... ........... ........... ...........
harvest.
35188........ Repair blood Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
vessel lesion.
35207........ Repair blood Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
vessel lesion.
35473........ Repair arterial Y............ G2........... ........... 42.9360 $1,826.63 $1,826.63
blockage.
35474........ Repair arterial Y............ G2........... ........... 42.9360 $1,826.63 $1,826.63
blockage.
35476........ Repair venous Y............ G2........... ........... 42.9360 $1,826.63 $1,826.63
blockage.
35492........ Atherectomy, Y............ G2........... ........... 42.9360 $1,826.63 $1,826.63
percutaneous.
35572........ Harvest ............. N1........... ........... ........... ........... ...........
femoropoplitea
l vein.
35761........ Exploration of Y............ G2........... ........... 29.2133 $1,242.82 $1,242.82
artery/vein.
35875........ Removal of clot Y............ A2........... $1,339.00 37.7391 $1,605.53 $1,405.63
in graft.
35876........ Removal of clot Y............ A2........... $1,339.00 37.7391 $1,605.53 $1,405.63
in graft.
36000........ Place needle in ............. N1........... ........... ........... ........... ...........
vein.
36002........ Pseudoaneurysm N............ G2........... ........... 2.4606 $104.68 $104.68
injection trt.
36005........ Injection ext ............. N1........... ........... ........... ........... ...........
venography.
36010........ Place catheter ............. N1........... ........... ........... ........... ...........
in vein.
[[Page 42578]]
36011........ Place catheter ............. N1........... ........... ........... ........... ...........
in vein.
36012........ Place catheter ............. N1........... ........... ........... ........... ...........
in vein.
36013........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36014........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36015........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36100........ Establish ............. N1........... ........... ........... ........... ...........
access to
artery.
36120........ Establish ............. N1........... ........... ........... ........... ...........
access to
artery.
36140........ Establish ............. N1........... ........... ........... ........... ...........
access to
artery.
36145........ Artery to vein ............. N1........... ........... ........... ........... ...........
shunt.
36160........ Establish ............. N1........... ........... ........... ........... ...........
access to
aorta.
36200........ Place catheter ............. N1........... ........... ........... ........... ...........
in aorta.
36215........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36216........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36217........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36218........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36245........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36246........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36247........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36248........ Place catheter ............. N1........... ........... ........... ........... ...........
in artery.
36260........ Insertion of Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
infusion pump.
36261........ Revision of Y............ A2........... $446.00 28.5032 $1,212.61 $637.65
infusion pump.
36262........ Removal of Y............ A2........... $333.00 22.6665 $964.30 $490.83
infusion pump.
36400........ Bl draw < 3 yrs ............. N1........... ........... ........... ........... ...........
fem/jugular.
36405........ Bl draw < 3 yrs ............. N1........... ........... ........... ........... ...........
scalp vein.
36406........ Bl draw < 3 yrs ............. N1........... ........... ........... ........... ...........
other vein.
36410........ Non-routine bl ............. N1........... ........... ........... ........... ...........
draw >3 yrs.
36416........ Capillary blood ............. N1........... ........... ........... ........... ...........
draw.
36420........ Vein access Y............ G2........... ........... 0.1999 $8.50 $8.50
cutdown < 1 yr.
36425........ Vein access Y............ R2........... ........... 0.1999 $8.50 $8.50
cutdown >1 yr.
36430........ Blood N............ P3........... ........... 0.7806 $33.21 $33.21
transfusion
service.
36440........ Bl push N............ R2........... ........... 3.4584 $147.13 $147.13
transfuse, 2
yr or < .
36450........ Bl exchange/ N............ R2........... ........... 3.4584 $147.13 $147.13
transfuse, nb.
36468........ Injection(s), Y............ R2........... ........... 1.0798 $45.94 $45.94
spider veins.
36469........ Injection(s), Y............ G2........... ........... 1.0798 $45.94 $45.94
spider veins.
36470........ Injection Y............ P2........... ........... 1.0798 $45.94 $45.94
therapy of
vein.
36471........ Injection Y............ P2........... ........... 1.0798 $45.94 $45.94
therapy of
veins.
36475........ Endovenous rf, Y............ A2........... $1,339.00 34.7288 $1,477.47 $1,373.62
1st vein.
36476........ Endovenous rf, Y............ A2........... $1,339.00 34.7288 $1,477.47 $1,373.62
vein add-on.
36478........ Endovenous Y............ A2........... $1,339.00 24.8809 $1,058.51 $1,268.88
laser, 1st
vein.
36479........ Endovenous Y............ A2........... $1,339.00 24.8809 $1,058.51 $1,268.88
laser vein
addon.
36481........ Insertion of ............. N1........... ........... ........... ........... ...........
catheter, vein.
36500........ Insertion of ............. N1........... ........... ........... ........... ...........
catheter, vein.
36510........ Insertion of ............. N1........... ........... ........... ........... ...........
catheter, vein.
36511........ Apheresis wbc.. N............ G2........... ........... 11.7134 $498.32 $498.32
36512........ Apheresis rbc.. N............ G2........... ........... 11.7134 $498.32 $498.32
36513........ Apheresis N............ G2........... ........... 11.7134 $498.32 $498.32
platelets.
36514........ Apheresis N............ G2........... ........... 11.7134 $498.32 $498.32
plasma.
36515........ Apheresis, N............ G2........... ........... 30.2231 $1,285.78 $1,285.78
adsorp/
reinfuse.
36516........ Apheresis, N............ G2........... ........... 30.2231 $1,285.78 $1,285.78
selective.
36522........ Photopheresis.. N............ G2........... ........... 30.2231 $1,285.78 $1,285.78
36540........ Collect blood ............. N1........... ........... ........... ........... ...........
venous device.
36550........ Declot vascular Y............ P3........... ........... 0.2816 $11.98 $11.98
device.
36555........ Insert non- Y............ A2........... $333.00 8.7846 $373.72 $343.18
tunnel cv cath.
36556........ Insert non- Y............ A2........... $333.00 8.7846 $373.72 $343.18
tunnel cv cath.
36557........ Insert tunneled Y............ A2........... $446.00 22.6665 $964.30 $575.58
cv cath.
36558........ Insert tunneled Y............ A2........... $446.00 22.6665 $964.30 $575.58
cv cath.
36560........ Insert tunneled Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
cv cath.
36561........ Insert tunneled Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
cv cath.
36563........ Insert tunneled Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
cv cath.
36565........ Insert tunneled Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
cv cath.
36566........ Insert tunneled Y............ H8........... $510.00 107.1217 $4,557.28 $3,809.60
cv cath.
36568........ Insert picc Y............ A2........... $333.00 8.7846 $373.72 $343.18
cath.
36569........ Insert picc Y............ A2........... $333.00 8.7846 $373.72 $343.18
cath.
[[Page 42579]]
36570........ Insert picvad Y............ A2........... $510.00 22.6665 $964.30 $623.58
cath.
36571........ Insert picvad Y............ A2........... $510.00 22.6665 $964.30 $623.58
cath.
36575........ Repair tunneled Y............ A2........... $446.00 8.7846 $373.72 $427.93
cv cath.
36576........ Repair tunneled Y............ A2........... $446.00 8.7846 $373.72 $427.93
cv cath.
36578........ Replace Y............ A2........... $446.00 22.6665 $964.30 $575.58
tunneled cv
cath.
36580........ Replace cvad Y............ A2........... $333.00 8.7846 $373.72 $343.18
cath.
36581........ Replace Y............ A2........... $446.00 22.6665 $964.30 $575.58
tunneled cv
cath.
36582........ Replace Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
tunneled cv
cath.
36583........ Replace Y............ A2........... $510.00 28.5032 $1,212.61 $685.65
tunneled cv
cath.
36584........ Replace picc Y............ A2........... $333.00 8.7846 $373.72 $343.18
cath.
36585........ Replace picvad Y............ A2........... $510.00 22.6665 $964.30 $623.58
cath.
36589........ Removal Y............ A2........... $333.00 8.7846 $373.72 $343.18
tunneled cv
cath.
36590........ Removal Y............ A2........... $333.00 8.7846 $373.72 $343.18
tunneled cv
cath.
36595........ Mech remov Y............ G2........... ........... 22.6665 $964.30 $964.30
tunneled cv
cath.
36596........ Mech remov Y............ G2........... ........... 8.7846 $373.72 $373.72
tunneled cv
cath.
36597........ Reposition Y............ G2........... ........... 8.7846 $373.72 $373.72
venous
catheter.
36598 \*\.... Inj w/fluor, N............ P2........... ........... 0.6102 $25.96 $25.96
eval cv device.
36600........ Withdrawal of ............. N1........... ........... ........... ........... ...........
arterial blood.
36620........ Insertion ............. N1........... ........... ........... ........... ...........
catheter,
artery.
36625........ Insertion ............. N1........... ........... ........... ........... ...........
catheter,
artery.
36640........ Insertion Y............ A2........... $333.00 28.5032 $1,212.61 $552.90
catheter,
artery.
36680........ Insert needle, Y............ G2........... ........... 1.0995 $46.78 $46.78
bone cavity.
36800........ Insertion of Y............ A2........... $510.00 29.2133 $1,242.82 $693.21
cannula.
36810........ Insertion of Y............ A2........... $510.00 29.2133 $1,242.82 $693.21
cannula.
36815........ Insertion of Y............ A2........... $510.00 29.2133 $1,242.82 $693.21
cannula.
36818........ Av fuse, uppr Y............ A2........... $510.00 37.7391 $1,605.53 $783.88
arm, cephalic.
36819........ Av fuse, uppr Y............ A2........... $510.00 37.7391 $1,605.53 $783.88
arm, basilic.
36820........ Av fusion/ Y............ A2........... $510.00 37.7391 $1,605.53 $783.88
forearm vein.
36821........ Av fusion Y............ A2........... $510.00 37.7391 $1,605.53 $783.88
direct any
site.
36825........ Artery-vein Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
autograft.
36830........ Artery-vein Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
nonautograft.
36831........ Open thrombect Y............ A2........... $1,339.00 37.7391 $1,605.53 $1,405.63
av fistula.
36832........ Av fistula Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
revision, open.
36833........ Av fistula Y............ A2........... $630.00 37.7391 $1,605.53 $873.88
revision.
36834........ Repair A-V Y............ A2........... $510.00 37.7391 $1,605.53 $783.88
aneurysm.
36835........ Artery to vein Y............ A2........... $630.00 29.2133 $1,242.82 $783.21
shunt.
36860........ External Y............ A2........... $127.40 2.0726 $88.17 $117.59
cannula
declotting.
36861........ Cannula Y............ A2........... $510.00 29.2133 $1,242.82 $693.21
declotting.
36870........ Percut Y............ A2........... $1,339.00 32.3818 $1,377.62 $1,348.66
thrombect av
fistula.
37184........ Prim art mech Y............ G2........... ........... 37.7391 $1,605.53 $1,605.53
thrombectomy.
37185........ Prim art m- Y............ G2........... ........... 37.7391 $1,605.53 $1,605.53
thrombect add-
on.
37186........ Sec art m- Y............ G2........... ........... 37.7391 $1,605.53 $1,605.53
thrombect add-
on.
37187........ Venous mech Y............ G2........... ........... 37.7391 $1,605.53 $1,605.53
thrombectomy.
37188........ Venous m- Y............ G2........... ........... 37.7391 $1,605.53 $1,605.53
thrombectomy
add-on.
37200........ Transcatheter Y............ G2........... ........... 6.1384 $261.15 $261.15
biopsy.
37203........ Transcatheter Y............ G2........... ........... 16.2375 $690.79 $690.79
retrieval.
37250........ Iv us first N............ G2........... ........... 32.5472 $1,384.66 $1,384.66
vessel add-on.
37251........ Iv us each add N............ G2........... ........... 32.5472 $1,384.66 $1,384.66
vessel add-on.
37500........ Endoscopy Y............ A2........... $510.00 34.7288 $1,477.47 $751.87
ligate perf
veins.
37607........ Ligation of a-v Y............ A2........... $510.00 24.8809 $1,058.51 $647.13
fistula.
37609........ Temporal artery Y............ A2........... $446.00 15.1024 $642.50 $495.13
procedure.
37650........ Revision of Y............ A2........... $446.00 24.8809 $1,058.51 $599.13
major vein.
37700........ Revise leg vein Y............ A2........... $446.00 34.7288 $1,477.47 $703.87
37718........ Ligate/strip Y............ A2........... $510.00 34.7288 $1,477.47 $751.87
short leg vein.
37722........ Ligate/strip Y............ A2........... $510.00 34.7288 $1,477.47 $751.87
long leg vein.
37735........ Removal of leg Y............ A2........... $510.00 34.7288 $1,477.47 $751.87
veins/lesion.
37760........ Ligation, leg Y............ A2........... $510.00 24.8809 $1,058.51 $647.13
veins, open.
37765........ Phleb veins - Y............ R2........... ........... 24.8809 $1,058.51 $1,058.51
extrem - to 20.
37766........ Phleb veins - Y............ R2........... ........... 24.8809 $1,058.51 $1,058.51
extrem 20+.
37780........ Revision of leg Y............ A2........... $510.00 24.8809 $1,058.51 $647.13
vein.
37785........ Ligate/divide/ Y............ A2........... $510.00 24.8809 $1,058.51 $647.13
excise vein.
37790........ Penile venous Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
occlusion.
38200........ Injection for ............. N1........... ........... ........... ........... ...........
spleen x-ray.
[[Page 42580]]
38204........ Bl donor search ............. N1........... ........... ........... ........... ...........
management.
38205........ Harvest N............ G2........... ........... 11.7134 $498.32 $498.32
allogenic stem
cells.
38206........ Harvest auto N............ G2........... ........... 11.7134 $498.32 $498.32
stem cells.
38220........ Bone marrow Y............ P2........... ........... 2.4011 $102.15 $102.15
aspiration.
38221........ Bone marrow Y............ P2........... ........... 2.4011 $102.15 $102.15
biopsy.
38230........ Bone marrow N............ G2........... ........... 20.3582 $866.10 $866.10
collection.
38241........ Bone marrow/ N............ G2........... ........... 20.3582 $866.10 $866.10
stem
transplant.
38242........ Lymphocyte N............ R2........... ........... 11.7134 $498.32 $498.32
infuse
transplant.
38300........ Drainage, lymph Y............ A2........... $333.00 11.1535 $474.50 $368.38
node lesion.
38305........ Drainage, lymph Y............ A2........... $446.00 17.5086 $744.87 $520.72
node lesion.
38308........ Incision of Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph channels.
38500........ Biopsy/removal, Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38505........ Needle biopsy, Y............ A2........... $240.00 3.9045 $166.11 $221.53
lymph nodes.
38510........ Biopsy/removal, Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38520........ Biopsy/removal, Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38525........ Biopsy/removal, Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38530........ Biopsy/removal, Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38542........ Explore deep Y............ A2........... $446.00 37.7224 $1,604.82 $735.71
node(s), neck.
38550........ Removal, neck/ Y............ A2........... $510.00 21.2621 $904.55 $608.64
armpit lesion.
38555........ Removal, neck/ Y............ A2........... $630.00 21.2621 $904.55 $698.64
armpit lesion.
38570........ Laparoscopy, Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
lymph node
biop.
38571........ Laparoscopy, Y............ A2........... $1,339.00 70.5066 $2,999.56 $1,754.14
lymphadenectom
y.
38572........ Laparoscopy, Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
lymphadenectom
y.
38700........ Removal of Y............ G2........... ........... 21.2621 $904.55 $904.55
lymph nodes,
neck.
38740........ Remove armpit Y............ A2........... $446.00 37.7224 $1,604.82 $735.71
lymph nodes.
38745........ Remove armpit Y............ A2........... $630.00 37.7224 $1,604.82 $873.71
lymph nodes.
38760........ Remove groin Y............ A2........... $446.00 21.2621 $904.55 $560.64
lymph nodes.
38790........ Inject for ............. N1........... ........... ........... ........... ...........
lymphatic x-
ray.
38792........ Identify ............. N1........... ........... ........... ........... ...........
sentinel node.
38794........ Access thoracic ............. N1........... ........... ........... ........... ...........
lymph duct.
40490........ Biopsy of lip.. Y............ P3........... ........... 1.4968 $63.68 $63.68
40500........ Partial Y............ A2........... $446.00 16.4266 $698.84 $509.21
excision of
lip.
40510........ Partial Y............ A2........... $446.00 23.3299 $992.52 $582.63
excision of
lip.
40520........ Partial Y............ A2........... $446.00 16.4266 $698.84 $509.21
excision of
lip.
40525........ Reconstruct lip Y............ A2........... $446.00 23.3299 $992.52 $582.63
with flap.
40527........ Reconstruct lip Y............ A2........... $446.00 23.3299 $992.52 $582.63
with flap.
40530........ Partial removal Y............ A2........... $446.00 23.3299 $992.52 $582.63
of lip.
40650........ Repair lip..... Y............ A2........... $464.15 7.5511 $321.25 $428.43
40652........ Repair lip..... Y............ A2........... $464.15 7.5511 $321.25 $428.43
40654........ Repair lip..... Y............ A2........... $464.15 7.5511 $321.25 $428.43
40700........ Repair cleft Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
lip/nasal.
40701........ Repair cleft Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
lip/nasal.
40702........ Repair cleft Y............ R2........... ........... 38.1991 $1,625.10 $1,625.10
lip/nasal.
40720........ Repair cleft Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
lip/nasal.
40761........ Repair cleft Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
lip/nasal.
40800........ Drainage of Y............ P2........... ........... 1.4392 $61.23 $61.23
mouth lesion.
40801........ Drainage of Y............ A2........... $446.00 7.5511 $321.25 $414.81
mouth lesion.
40804........ Removal, N............ P2........... ........... 0.6102 $25.96 $25.96
foreign body,
mouth.
40805........ Removal, Y............ P3........... ........... 3.8385 $163.30 $163.30
foreign body,
mouth.
40806........ Incision of lip Y............ P3........... ........... 1.6898 $71.89 $71.89
fold.
40808........ Biopsy of mouth Y............ P2........... ........... 2.4520 $104.32 $104.32
lesion.
40810........ Excision of Y............ P3........... ........... 2.5913 $110.24 $110.24
mouth lesion.
40812........ Excise/repair Y............ P3........... ........... 3.3155 $141.05 $141.05
mouth lesion.
40814........ Excise/repair Y............ A2........... $446.00 16.4266 $698.84 $509.21
mouth lesion.
40816........ Excision of Y............ A2........... $446.00 23.3299 $992.52 $582.63
mouth lesion.
40818........ Excise oral Y............ A2........... $150.72 2.4520 $104.32 $139.12
mucosa for
graft.
40819........ Excise lip or Y............ A2........... $333.00 7.5511 $321.25 $330.06
cheek fold.
40820........ Treatment of Y............ P3........... ........... 3.6455 $155.09 $155.09
mouth lesion.
40830........ Repair mouth Y............ G2........... ........... 2.4520 $104.32 $104.32
laceration.
40831........ Repair mouth Y............ A2........... $333.00 7.5511 $321.25 $330.06
laceration.
40840........ Reconstruction Y............ A2........... $446.00 23.3299 $992.52 $582.63
of mouth.
40842........ Reconstruction Y............ A2........... $510.00 23.3299 $992.52 $630.63
of mouth.
40843........ Reconstruction Y............ A2........... $510.00 23.3299 $992.52 $630.63
of mouth.
[[Page 42581]]
40844........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of mouth.
40845........ Reconstruction Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
of mouth.
41000........ Drainage of Y............ P3........... ........... 1.9394 $82.51 $82.51
mouth lesion.
41005........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
mouth lesion.
41006........ Drainage of Y............ A2........... $333.00 23.3299 $992.52 $497.88
mouth lesion.
41007........ Drainage of Y............ A2........... $333.00 16.4266 $698.84 $424.46
mouth lesion.
41008........ Drainage of Y............ A2........... $333.00 16.4266 $698.84 $424.46
mouth lesion.
41009........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
mouth lesion.
41010........ Incision of Y............ A2........... $333.00 7.5511 $321.25 $330.06
tongue fold.
41015........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
mouth lesion.
41016........ Drainage of Y............ A2........... $333.00 7.5511 $321.25 $330.06
mouth lesion.
41017........ Drainage of Y............ A2........... $333.00 7.5511 $321.25 $330.06
mouth lesion.
41018........ Drainage of Y............ A2........... $333.00 7.5511 $321.25 $330.06
mouth lesion.
41100........ Biopsy of Y............ P3........... ........... 2.0118 $85.59 $85.59
tongue.
41105........ Biopsy of Y............ P3........... ........... 1.9634 $83.53 $83.53
tongue.
41108........ Biopsy of floor Y............ P3........... ........... 1.7947 $76.35 $76.35
of mouth.
41110........ Excision of Y............ P3........... ........... 2.5913 $110.24 $110.24
tongue lesion.
41112........ Excision of Y............ A2........... $446.00 16.4266 $698.84 $509.21
tongue lesion.
41113........ Excision of Y............ A2........... $446.00 16.4266 $698.84 $509.21
tongue lesion.
41114........ Excision of Y............ A2........... $446.00 23.3299 $992.52 $582.63
tongue lesion.
41115........ Excision of Y............ P3........... ........... 3.0339 $129.07 $129.07
tongue fold.
41116........ Excision of Y............ A2........... $333.00 16.4266 $698.84 $424.46
mouth lesion.
41120........ Partial removal Y............ A2........... $717.00 23.3299 $992.52 $785.88
of tongue.
41250........ Repair tongue Y............ A2........... $150.72 2.4520 $104.32 $139.12
laceration.
41251........ Repair tongue Y............ A2........... $150.72 2.4520 $104.32 $139.12
laceration.
41252........ Repair tongue Y............ A2........... $446.00 7.5511 $321.25 $414.81
laceration.
41500........ Fixation of Y............ A2........... $333.00 23.3299 $992.52 $497.88
tongue.
41510........ Tongue to lip Y............ A2........... $333.00 16.4266 $698.84 $424.46
surgery.
41520........ Reconstruction, Y............ A2........... $446.00 7.5511 $321.25 $414.81
tongue fold.
41800........ Drainage of gum Y............ A2........... $88.46 1.4392 $61.23 $81.65
lesion.
41805........ Removal of Y............ P3........... ........... 2.9695 $126.33 $126.33
foreign body,
gum.
41806........ Removal of Y............ P3........... ........... 3.8145 $162.28 $162.28
foreign body,
jawbone.
41820........ Excision, gum, Y............ R2........... ........... 7.5511 $321.25 $321.25
each quadrant.
41821........ Excision of gum Y............ G2........... ........... 7.5511 $321.25 $321.25
flap.
41822........ Excision of gum Y............ P3........... ........... 3.4363 $146.19 $146.19
lesion.
41823........ Excision of gum Y............ P3........... ........... 4.8525 $206.44 $206.44
lesion.
41825........ Excision of gum Y............ P3........... ........... 2.6879 $114.35 $114.35
lesion.
41826........ Excision of gum Y............ P3........... ........... 3.0339 $129.07 $129.07
lesion.
41827........ Excision of gum Y............ A2........... $446.00 23.3299 $992.52 $582.63
lesion.
41828........ Excision of gum Y............ P3........... ........... 3.1867 $135.57 $135.57
lesion.
41830........ Removal of gum Y............ P3........... ........... 4.4261 $188.30 $188.30
tissue.
41850........ Treatment of Y............ R2........... ........... 16.4266 $698.84 $698.84
gum lesion.
41870........ Gum graft...... Y............ G2........... ........... 23.3299 $992.52 $992.52
41872........ Repair gum..... Y............ P3........... ........... 4.3939 $186.93 $186.93
41874........ Repair tooth Y............ P3........... ........... 4.2651 $181.45 $181.45
socket.
42000........ Drainage mouth Y............ A2........... $150.72 2.4520 $104.32 $139.12
roof lesion.
42100........ Biopsy roof of Y............ P3........... ........... 1.7220 $73.26 $73.26
mouth.
42104........ Excision Y............ P3........... ........... 2.3980 $102.02 $102.02
lesion, mouth
roof.
42106........ Excision Y............ P3........... ........... 3.0741 $130.78 $130.78
lesion, mouth
roof.
42107........ Excision Y............ A2........... $446.00 23.3299 $992.52 $582.63
lesion, mouth
roof.
42120........ Remove palate/ Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
lesion.
42140........ Excision of Y............ A2........... $446.00 7.5511 $321.25 $414.81
uvula.
42145........ Repair palate, Y............ A2........... $717.00 23.3299 $992.52 $785.88
pharynx/uvula.
42160........ Treatment mouth Y............ P3........... ........... 3.1707 $134.89 $134.89
roof lesion.
42180........ Repair palate.. Y............ A2........... $150.72 2.4520 $104.32 $139.12
42182........ Repair palate.. Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
42200........ Reconstruct Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
cleft palate.
42205........ Reconstruct Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
cleft palate.
42210........ Reconstruct Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
cleft palate.
42215........ Reconstruct Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
cleft palate.
42220........ Reconstruct Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
cleft palate.
42226........ Lengthening of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
palate.
42235........ Repair palate.. Y............ A2........... $717.00 16.4266 $698.84 $712.46
[[Page 42582]]
42260........ Repair nose to Y............ A2........... $630.00 23.3299 $992.52 $720.63
lip fistula.
42280........ Preparation, Y............ P3........... ........... 1.6898 $71.89 $71.89
palate mold.
42281........ Insertion, Y............ G2........... ........... 16.4266 $698.84 $698.84
palate
prosthesis.
42300........ Drainage of Y............ A2........... $333.00 16.4266 $698.84 $424.46
salivary gland.
42305........ Drainage of Y............ A2........... $446.00 16.4266 $698.84 $509.21
salivary gland.
42310........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
salivary gland.
42320........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
salivary gland.
42330........ Removal of Y............ P3........... ........... 2.5511 $108.53 $108.53
salivary stone.
42335........ Removal of Y............ P3........... ........... 4.1685 $177.34 $177.34
salivary stone.
42340........ Removal of Y............ A2........... $446.00 16.4266 $698.84 $509.21
salivary stone.
42400........ Biopsy of Y............ P3........... ........... 1.4244 $60.60 $60.60
salivary gland.
42405........ Biopsy of Y............ A2........... $446.00 16.4266 $698.84 $509.21
salivary gland.
42408........ Excision of Y............ A2........... $510.00 16.4266 $698.84 $557.21
salivary cyst.
42409........ Drainage of Y............ A2........... $510.00 16.4266 $698.84 $557.21
salivary cyst.
42410........ Excise parotid Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
gland/lesion.
42415........ Excise parotid Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
gland/lesion.
42420........ Excise parotid Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
gland/lesion.
42425........ Excise parotid Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
gland/lesion.
42440........ Excise Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
submaxillary
gland.
42450........ Excise Y............ A2........... $446.00 23.3299 $992.52 $582.63
sublingual
gland.
42500........ Repair salivary Y............ A2........... $510.00 23.3299 $992.52 $630.63
duct.
42505........ Repair salivary Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
duct.
42507........ Parotid duct Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
diversion.
42508........ Parotid duct Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
diversion.
42509........ Parotid duct Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
diversion.
42510........ Parotid duct Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
diversion.
42550........ Injection for ............. N1........... ........... ........... ........... ...........
salivary x-ray.
42600........ Closure of Y............ A2........... $333.00 16.4266 $698.84 $424.46
salivary
fistula.
42650........ Dilation of Y............ P3........... ........... 0.9254 $39.37 $39.37
salivary duct.
42660........ Dilation of Y............ P3........... ........... 1.1186 $47.59 $47.59
salivary duct.
42665........ Ligation of Y............ A2........... $995.00 23.3299 $992.52 $994.38
salivary duct.
42700........ Drainage of Y............ A2........... $150.72 2.4520 $104.32 $139.12
tonsil abscess.
42720........ Drainage of Y............ A2........... $333.00 16.4266 $698.84 $424.46
throat abscess.
42725........ Drainage of Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
throat abscess.
42800........ Biopsy of Y............ P3........... ........... 1.7947 $76.35 $76.35
throat.
42802........ Biopsy of Y............ A2........... $333.00 16.4266 $698.84 $424.46
throat.
42804........ Biopsy of upper Y............ A2........... $333.00 16.4266 $698.84 $424.46
nose/throat.
42806........ Biopsy of upper Y............ A2........... $446.00 23.3299 $992.52 $582.63
nose/throat.
42808........ Excise pharynx Y............ A2........... $446.00 16.4266 $698.84 $509.21
lesion.
42809........ Remove pharynx N............ G2........... ........... 0.6102 $25.96 $25.96
foreign body.
42810........ Excision of Y............ A2........... $510.00 23.3299 $992.52 $630.63
neck cyst.
42815........ Excision of Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
neck cyst.
42820........ Remove tonsils Y............ A2........... $510.00 22.1165 $940.90 $617.73
and adenoids.
42821........ Remove tonsils Y............ A2........... $717.00 22.1165 $940.90 $772.98
and adenoids.
42825........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
tonsils.
42826........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
tonsils.
42830........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
adenoids.
42831........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
adenoids.
42835........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
adenoids.
42836........ Removal of Y............ A2........... $630.00 22.1165 $940.90 $707.73
adenoids.
42860........ Excision of Y............ A2........... $510.00 22.1165 $940.90 $617.73
tonsil tags.
42870........ Excision of Y............ A2........... $510.00 22.1165 $940.90 $617.73
lingual tonsil.
42890........ Partial removal Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
of pharynx.
42892........ Revision of Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
pharyngeal
walls.
42900........ Repair throat Y............ A2........... $333.00 7.5511 $321.25 $330.06
wound.
42950........ Reconstruction Y............ A2........... $446.00 23.3299 $992.52 $582.63
of throat.
42955........ Surgical Y............ A2........... $446.00 23.3299 $992.52 $582.63
opening of
throat.
42960........ Control throat Y............ A2........... $72.48 1.1791 $50.16 $66.90
bleeding.
42962........ Control throat Y............ A2........... $446.00 38.1991 $1,625.10 $740.78
bleeding.
42970........ Control nose/ Y............ R2........... ........... 1.1791 $50.16 $50.16
throat
bleeding.
42972........ Control nose/ Y............ A2........... $510.00 16.4266 $698.84 $557.21
throat
bleeding.
43030........ Throat muscle Y............ G2........... ........... 16.4266 $698.84 $698.84
surgery.
43200........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy.
[[Page 42583]]
43201........ Esoph scope w/ Y............ A2........... $333.00 8.3175 $353.85 $338.21
submucous inj.
43202........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy,
biopsy.
43204........ Esoph scope w/ Y............ A2........... $333.00 8.3175 $353.85 $338.21
sclerosis inj.
43205........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy/
ligation.
43215........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy.
43216........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy/
lesion.
43217........ Esophagus Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy.
43219........ Esophagus Y............ A2........... $333.00 22.9475 $976.26 $493.82
endoscopy.
43220........ Esoph Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy,
dilation.
43226........ Esoph Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy,
dilation.
43227........ Esoph Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy,
repair.
43228........ Esoph Y............ A2........... $446.00 25.7552 $1,095.70 $608.43
endoscopy,
ablation.
43231........ Esoph endoscopy Y............ A2........... $446.00 8.3175 $353.85 $422.96
w/us exam.
43232........ Esoph endoscopy Y............ A2........... $446.00 8.3175 $353.85 $422.96
w/us fn bx.
43234........ Upper GI Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy,
exam.
43235........ Uppr gi Y............ A2........... $333.00 8.3175 $353.85 $338.21
endoscopy,
diagnosis.
43236........ Uppr gi scope w/ Y............ A2........... $446.00 8.3175 $353.85 $422.96
submuc inj.
43237........ Endoscopic us Y............ A2........... $446.00 8.3175 $353.85 $422.96
exam, esoph.
43238........ Uppr gi Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy w/us
fn bx.
43239........ Upper GI Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy,
biopsy.
43240........ Esoph endoscope Y............ A2........... $446.00 8.3175 $353.85 $422.96
w/drain cyst.
43241........ Upper GI Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy with
tube.
43242........ Uppr gi Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy w/us
fn bx.
43243........ Upper gi Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy &
inject.
43244........ Upper GI Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy/
ligation.
43245........ Uppr gi scope Y............ A2........... $446.00 8.3175 $353.85 $422.96
dilate strictr.
43246........ Place Y............ A2........... $446.00 8.3175 $353.85 $422.96
gastrostomy
tube.
43247........ Operative upper Y............ A2........... $446.00 8.3175 $353.85 $422.96
GI endoscopy.
43248........ Uppr gi Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy/
guide wire.
43249........ Esoph Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy,
dilation.
43250........ Upper GI Y............ A2........... $446.00 8.3175 $353.85 $422.96
endoscopy/
tumor.
43251........ Operative upper Y............ A2........... $446.00 8.3175 $353.85 $422.96
GI endoscopy.
43255........ Operative upper Y............ A2........... $446.00 8.3175 $353.85 $422.96
GI endoscopy.
43256........ Uppr gi Y............ A2........... $510.00 22.9475 $976.26 $626.57
endoscopy w/
stent.
43257........ Uppr gi scope w/ Y............ A2........... $510.00 25.7552 $1,095.70 $656.43
thrml txmnt.
43258........ Operative upper Y............ A2........... $510.00 8.3175 $353.85 $470.96
GI endoscopy.
43259........ Endoscopic Y............ A2........... $510.00 8.3175 $353.85 $470.96
ultrasound
exam.
43260........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43261........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43262........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43263........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43264........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43265........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43267........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43268........ Endo Y............ A2........... $446.00 22.9475 $976.26 $578.57
cholangiopancr
eatograph.
43269........ Endo Y............ A2........... $446.00 22.9475 $976.26 $578.57
cholangiopancr
eatograph.
43271........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43272........ Endo Y............ A2........... $446.00 19.8381 $843.97 $545.49
cholangiopancr
eatograph.
43450........ Dilate Y............ A2........... $333.00 5.4566 $232.14 $307.79
esophagus.
43453........ Dilate Y............ A2........... $333.00 5.4566 $232.14 $307.79
esophagus.
43456........ Dilate Y............ A2........... $335.41 5.4566 $232.14 $309.59
esophagus.
43458........ Dilate Y............ A2........... $335.41 5.4566 $232.14 $309.59
esophagus.
43600........ Biopsy of Y............ A2........... $333.00 8.3175 $353.85 $338.21
stomach.
43653........ Laparoscopy, Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
gastrostomy.
43750........ Place Y............ A2........... $446.00 8.3175 $353.85 $422.96
gastrostomy
tube.
43760........ Change Y............ A2........... $144.98 2.3587 $100.35 $133.82
gastrostomy
tube.
43761........ Reposition Y............ A2........... $333.00 7.4800 $318.22 $329.31
gastrostomy
tube.
43870........ Repair stomach Y............ A2........... $333.00 8.3175 $353.85 $338.21
opening.
43886........ Revise gastric Y............ G2........... ........... 5.2594 $223.75 $223.75
port, open.
43887........ Remove gastric Y............ G2........... ........... 5.2594 $223.75 $223.75
port, open.
43888........ Change gastric Y............ G2........... ........... 14.0346 $597.07 $597.07
port, open.
44100........ Biopsy of bowel Y............ A2........... $333.00 8.3175 $353.85 $338.21
44312........ Revision of Y............ A2........... $333.00 21.4302 $911.71 $477.68
ileostomy.
[[Page 42584]]
44340........ Revision of Y............ A2........... $510.00 21.4302 $911.71 $610.43
colostomy.
44360........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44361........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy/
biopsy.
44363........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44364........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44365........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44366........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44369........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44370........ Small bowel Y............ A2........... $1,339.00 22.9475 $976.26 $1,248.32
endoscopy/
stent.
44372........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44373........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44376........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44377........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy/
biopsy.
44378........ Small bowel Y............ A2........... $446.00 9.4946 $403.93 $435.48
endoscopy.
44379........ Sbowel Y............ A2........... $1,339.00 22.9475 $976.26 $1,248.32
endoscope w/
stent.
44380........ Small bowel Y............ A2........... $333.00 9.4946 $403.93 $350.73
endoscopy.
44382........ Small bowel Y............ A2........... $333.00 9.4946 $403.93 $350.73
endoscopy.
44383........ Ileoscopy w/ Y............ A2........... $1,339.00 22.9475 $976.26 $1,248.32
stent.
44385........ Endoscopy of Y............ A2........... $333.00 8.7686 $373.04 $343.01
bowel pouch.
44386........ Endoscopy, Y............ A2........... $333.00 8.7686 $373.04 $343.01
bowel pouch/
biop.
44388........ Colonoscopy.... Y............ A2........... $333.00 8.7686 $373.04 $343.01
44389........ Colonoscopy Y............ A2........... $333.00 8.7686 $373.04 $343.01
with biopsy.
44390........ Colonoscopy for Y............ A2........... $333.00 8.7686 $373.04 $343.01
foreign body.
44391........ Colonoscopy for Y............ A2........... $333.00 8.7686 $373.04 $343.01
bleeding.
44392........ Colonoscopy & Y............ A2........... $333.00 8.7686 $373.04 $343.01
polypectomy.
44393........ Colonoscopy, Y............ A2........... $333.00 8.7686 $373.04 $343.01
lesion removal.
44394........ Colonoscopy w/ Y............ A2........... $333.00 8.7686 $373.04 $343.01
snare.
44397........ Colonoscopy w/ Y............ A2........... $333.00 22.9475 $976.26 $493.82
stent.
44701........ Intraop colon ............. N1........... ........... ........... ........... ...........
lavage add-on.
45000........ Drainage of Y............ A2........... $312.07 5.0770 $215.99 $288.05
pelvic abscess.
45005........ Drainage of Y............ A2........... $446.00 12.7389 $541.95 $469.99
rectal abscess.
45020........ Drainage of Y............ A2........... $446.00 12.7389 $541.95 $469.99
rectal abscess.
45100........ Biopsy of Y............ A2........... $333.00 22.2682 $947.36 $486.59
rectum.
45108........ Removal of Y............ A2........... $446.00 22.2682 $947.36 $571.34
anorectal
lesion.
45150........ Excision of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal
stricture.
45160........ Excision of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal lesion.
45170........ Excision of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal lesion.
45190........ Destruction, Y............ A2........... $1,339.00 22.2682 $947.36 $1,241.09
rectal tumor.
45300........ Proctosigmoidos Y............ P3........... ........... 1.3922 $59.23 $59.23
copy dx.
45303........ Proctosigmoidos Y............ P2........... ........... 8.5477 $363.64 $363.64
copy dilate.
45305........ Proctosigmoidos Y............ A2........... $333.00 8.5477 $363.64 $340.66
copy w/bx.
45307........ Proctosigmoidos Y............ A2........... $333.00 20.6375 $877.98 $469.25
copy fb.
45308........ Proctosigmoidos Y............ A2........... $333.00 8.5477 $363.64 $340.66
copy removal.
45309........ Proctosigmoidos Y............ A2........... $333.00 8.5477 $363.64 $340.66
copy removal.
45315........ Proctosigmoidos Y............ A2........... $333.00 8.5477 $363.64 $340.66
copy removal.
45317........ Proctosigmoidos Y............ A2........... $333.00 8.5477 $363.64 $340.66
copy bleed.
45320........ Proctosigmoidos Y............ A2........... $333.00 20.6375 $877.98 $469.25
copy ablate.
45321........ Proctosigmoidos Y............ A2........... $333.00 20.6375 $877.98 $469.25
copy volvul.
45327........ Proctosigmoidos Y............ A2........... $333.00 22.9475 $976.26 $493.82
copy w/stent.
45330........ Diagnostic Y............ P3........... ........... 1.9152 $81.48 $81.48
sigmoidoscopy.
45331........ Sigmoidoscopy Y............ A2........... $299.24 4.8683 $207.11 $276.21
and biopsy.
45332........ Sigmoidoscopy w/ Y............ A2........... $299.24 4.8683 $207.11 $276.21
fb removal.
45333........ Sigmoidoscopy & Y............ A2........... $333.00 8.5477 $363.64 $340.66
polypectomy.
45334........ Sigmoidoscopy Y............ A2........... $333.00 8.5477 $363.64 $340.66
for bleeding.
45335........ Sigmoidoscopy w/ Y............ A2........... $299.24 4.8683 $207.11 $276.21
submuc inj.
45337........ Sigmoidoscopy & Y............ A2........... $299.24 4.8683 $207.11 $276.21
decompress.
45338........ Sigmoidoscopy w/ Y............ A2........... $333.00 8.5477 $363.64 $340.66
tumr remove.
45339........ Sigmoidoscopy w/ Y............ A2........... $333.00 8.5477 $363.64 $340.66
ablate tumr.
45340........ Sig w/balloon Y............ A2........... $333.00 8.5477 $363.64 $340.66
dilation.
45341........ Sigmoidoscopy w/ Y............ A2........... $333.00 8.5477 $363.64 $340.66
ultrasound.
45342........ Sigmoidoscopy w/ Y............ A2........... $333.00 8.5477 $363.64 $340.66
us guide bx.
45345........ Sigmoidoscopy w/ Y............ A2........... $333.00 22.9475 $976.26 $493.82
stent.
45355........ Surgical Y............ A2........... $333.00 8.7686 $373.04 $343.01
colonoscopy.
[[Page 42585]]
45378........ Diagnostic Y............ A2........... $446.00 8.7686 $373.04 $427.76
colonoscopy.
45379........ Colonoscopy w/ Y............ A2........... $446.00 8.7686 $373.04 $427.76
fb removal.
45380........ Colonoscopy and Y............ A2........... $446.00 8.7686 $373.04 $427.76
biopsy.
45381........ Colonoscopy, Y............ A2........... $446.00 8.7686 $373.04 $427.76
submucous inj.
45382........ Colonoscopy/ Y............ A2........... $446.00 8.7686 $373.04 $427.76
control
bleeding.
45383........ Lesion removal Y............ A2........... $446.00 8.7686 $373.04 $427.76
colonoscopy.
45384........ Lesion remove Y............ A2........... $446.00 8.7686 $373.04 $427.76
colonoscopy.
45385........ Lesion removal Y............ A2........... $446.00 8.7686 $373.04 $427.76
colonoscopy.
45386........ Colonoscopy Y............ A2........... $446.00 8.7686 $373.04 $427.76
dilate
stricture.
45387........ Colonoscopy w/ Y............ A2........... $333.00 22.9475 $976.26 $493.82
stent.
45391........ Colonoscopy w/ Y............ A2........... $446.00 8.7686 $373.04 $427.76
endoscope us.
45392........ Colonoscopy w/ Y............ A2........... $446.00 8.7686 $373.04 $427.76
endoscopic fnb.
45500........ Repair of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectum.
45505........ Repair of Y............ A2........... $446.00 29.6189 $1,260.08 $649.52
rectum.
45520........ Treatment of Y............ P2........... ........... 1.0798 $45.94 $45.94
rectal
prolapse.
45560........ Repair of Y............ A2........... $446.00 29.6189 $1,260.08 $649.52
rectocele.
45900........ Reduction of Y............ A2........... $312.07 5.0770 $215.99 $288.05
rectal
prolapse.
45905........ Dilation of Y............ A2........... $333.00 22.2682 $947.36 $486.59
anal sphincter.
45910........ Dilation of Y............ A2........... $333.00 22.2682 $947.36 $486.59
rectal
narrowing.
45915........ Remove rectal Y............ A2........... $312.07 5.0770 $215.99 $288.05
obstruction.
45990........ Surg dx exam, Y............ A2........... $312.07 5.0770 $215.99 $288.05
anorectal.
46020........ Placement of Y............ A2........... $510.00 22.2682 $947.36 $619.34
seton.
46030........ Removal of Y............ A2........... $312.07 5.0770 $215.99 $288.05
rectal marker.
46040........ Incision of Y............ A2........... $510.00 22.2682 $947.36 $619.34
rectal abscess.
46045........ Incision of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal abscess.
46050........ Incision of Y............ A2........... $312.07 5.0770 $215.99 $288.05
anal abscess.
46060........ Incision of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal abscess.
46070........ Incision of Y............ G2........... ........... 12.7389 $541.95 $541.95
anal septum.
46080........ Incision of Y............ A2........... $510.00 22.2682 $947.36 $619.34
anal sphincter.
46083........ Incise external Y............ P3........... ........... 1.9554 $83.19 $83.19
hemorrhoid.
46200........ Removal of anal Y............ A2........... $446.00 22.2682 $947.36 $571.34
fissure.
46210........ Removal of anal Y............ A2........... $446.00 22.2682 $947.36 $571.34
crypt.
46211........ Removal of anal Y............ A2........... $446.00 22.2682 $947.36 $571.34
crypts.
46220........ Removal of anal Y............ A2........... $333.00 22.2682 $947.36 $486.59
tag.
46221........ Ligation of Y............ P3........... ........... 2.5591 $108.87 $108.87
hemorrhoid(s).
46230........ Removal of anal Y............ A2........... $333.00 22.2682 $947.36 $486.59
tags.
46250........ Hemorrhoidectom Y............ A2........... $510.00 22.2682 $947.36 $619.34
y.
46255........ Hemorrhoidectom Y............ A2........... $510.00 22.2682 $947.36 $619.34
y.
46257........ Remove Y............ A2........... $510.00 22.2682 $947.36 $619.34
hemorrhoids &
fissure.
46258........ Remove Y............ A2........... $510.00 22.2682 $947.36 $619.34
hemorrhoids &
fistula.
46260........ Hemorrhoidectom Y............ A2........... $510.00 22.2682 $947.36 $619.34
y.
46261........ Remove Y............ A2........... $630.00 22.2682 $947.36 $709.34
hemorrhoids &
fissure.
46262........ Remove Y............ A2........... $630.00 22.2682 $947.36 $709.34
hemorrhoids &
fistula.
46270........ Removal of anal Y............ A2........... $510.00 22.2682 $947.36 $619.34
fistula.
46275........ Removal of anal Y............ A2........... $510.00 22.2682 $947.36 $619.34
fistula.
46280........ Removal of anal Y............ A2........... $630.00 22.2682 $947.36 $709.34
fistula.
46285........ Removal of anal Y............ A2........... $333.00 22.2682 $947.36 $486.59
fistula.
46288........ Repair anal Y............ A2........... $630.00 22.2682 $947.36 $709.34
fistula.
46320........ Removal of Y............ P3........... ........... 1.8186 $77.37 $77.37
hemorrhoid
clot.
46500........ Injection into Y............ P3........... ........... 2.2934 $97.57 $97.57
hemorrhoid(s).
46505........ Chemodenervatio Y............ G2........... ........... 5.0770 $215.99 $215.99
n anal musc.
46600........ Diagnostic N............ P2........... ........... 0.6102 $25.96 $25.96
anoscopy.
46604........ Anoscopy and Y............ P2........... ........... 8.5477 $363.64 $363.64
dilation.
46606........ Anoscopy and Y............ P3........... ........... 3.0821 $131.12 $131.12
biopsy.
46608........ Anoscopy, Y............ A2........... $333.00 8.5477 $363.64 $340.66
remove for
body.
46610........ Anoscopy, Y............ A2........... $333.00 20.6375 $877.98 $469.25
remove lesion.
46611........ Anoscopy....... Y............ A2........... $333.00 8.5477 $363.64 $340.66
46612........ Anoscopy, Y............ A2........... $333.00 20.6375 $877.98 $469.25
remove lesions.
46614........ Anoscopy, Y............ P3........... ........... 1.9634 $83.53 $83.53
control
bleeding.
46615........ Anoscopy....... Y............ A2........... $446.00 20.6375 $877.98 $554.00
46700........ Repair of anal Y............ A2........... $510.00 22.2682 $947.36 $619.34
stricture.
46706........ Repr of anal Y............ A2........... $333.00 29.6189 $1,260.08 $564.77
fistula w/glue.
46750........ Repair of anal Y............ A2........... $510.00 37.8991 $1,612.34 $785.59
sphincter.
[[Page 42586]]
46753........ Reconstruction Y............ A2........... $510.00 22.2682 $947.36 $619.34
of anus.
46754........ Removal of Y............ A2........... $446.00 22.2682 $947.36 $571.34
suture from
anus.
46760........ Repair of anal Y............ A2........... $446.00 37.8991 $1,612.34 $737.59
sphincter.
46761........ Repair of anal Y............ A2........... $510.00 37.8991 $1,612.34 $785.59
sphincter.
46762........ Implant Y............ A2........... $995.00 37.8991 $1,612.34 $1,149.34
artificial
sphincter.
46900........ Destruction, Y............ P3........... ........... 2.4947 $106.13 $106.13
anal lesion(s).
46910........ Destruction, Y............ P3........... ........... 2.7281 $116.06 $116.06
anal lesion(s).
46916........ Cryosurgery, Y............ P2........... ........... 1.0918 $46.45 $46.45
anal lesion(s).
46917........ Laser surgery, Y............ A2........... $333.00 20.4276 $869.05 $467.01
anal lesions.
46922........ Excision of Y............ A2........... $333.00 20.4276 $869.05 $467.01
anal lesion(s).
46924........ Destruction, Y............ A2........... $333.00 20.4276 $869.05 $467.01
anal lesion(s).
46934........ Destruction of Y............ P3........... ........... 4.2087 $179.05 $179.05
hemorrhoids.
46935........ Destruction of Y............ P3........... ........... 2.8729 $122.22 $122.22
hemorrhoids.
46936........ Destruction of Y............ P3........... ........... 4.4341 $188.64 $188.64
hemorrhoids.
46937........ Cryotherapy of Y............ A2........... $446.00 22.2682 $947.36 $571.34
rectal lesion.
46938........ Cryotherapy of Y............ A2........... $446.00 29.6189 $1,260.08 $649.52
rectal lesion.
46940........ Treatment of Y............ P3........... ........... 1.9394 $82.51 $82.51
anal fissure.
46942........ Treatment of Y............ P3........... ........... 1.8588 $79.08 $79.08
anal fissure.
46945........ Ligation of Y............ P3........... ........... 3.2511 $138.31 $138.31
hemorrhoids.
46946........ Ligation of Y............ A2........... $333.00 12.7389 $541.95 $385.24
hemorrhoids.
46947........ Hemorrhoidopexy Y............ A2........... $995.00 29.6189 $1,260.08 $1,061.27
by stapling.
47000........ Needle biopsy Y............ A2........... $333.00 6.1384 $261.15 $315.04
of liver.
47001........ Needle biopsy, ............. N1........... ........... ........... ........... ...........
liver add-on.
47382........ Percut ablate Y............ G2........... ........... 37.3604 $1,589.42 $1,589.42
liver rf.
47500........ Injection for ............. N1........... ........... ........... ........... ...........
liver x-rays.
47505........ Injection for ............. N1........... ........... ........... ........... ...........
liver x-rays.
47510........ Insert Y............ A2........... $446.00 20.2682 $862.27 $550.07
catheter, bile
duct.
47511........ Insert bile Y............ A2........... $1,245.85 20.2682 $862.27 $1,149.96
duct drain.
47525........ Change bile Y............ A2........... $333.00 11.6575 $495.95 $373.74
duct catheter.
47530........ Revise/reinsert Y............ A2........... $333.00 11.6575 $495.95 $373.74
bile tube.
47552........ Biliary Y............ A2........... $446.00 20.2682 $862.27 $550.07
endoscopy thru
skin.
47553........ Biliary Y............ A2........... $510.00 20.2682 $862.27 $598.07
endoscopy thru
skin.
47554........ Biliary Y............ A2........... $510.00 20.2682 $862.27 $598.07
endoscopy thru
skin.
47555........ Biliary Y............ A2........... $510.00 20.2682 $862.27 $598.07
endoscopy thru
skin.
47556........ Biliary Y............ A2........... $1,245.85 20.2682 $862.27 $1,149.96
endoscopy thru
skin.
47560........ Laparoscopy w/ Y............ A2........... $510.00 32.1241 $1,366.66 $724.17
cholangio.
47561........ Laparo w/ Y............ A2........... $510.00 32.1241 $1,366.66 $724.17
cholangio/
biopsy.
47562........ Laparoscopic Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
cholecystectom
y.
47563........ Laparo Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
cholecystectom
y/graph.
47564........ Laparo Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
cholecystectom
y/explr.
47630........ Remove bile Y............ A2........... $510.00 20.2682 $862.27 $598.07
duct stone.
48102........ Needle biopsy, Y............ A2........... $333.00 6.1384 $261.15 $315.04
pancreas.
49080........ Puncture, Y............ A2........... $222.78 3.6244 $154.19 $205.63
peritoneal
cavity.
49081........ Removal of Y............ A2........... $222.78 3.6244 $154.19 $205.63
abdominal
fluid.
49180........ Biopsy, Y............ A2........... $333.00 6.1384 $261.15 $315.04
abdominal mass.
49250........ Excision of Y............ A2........... $630.00 22.0832 $939.49 $707.37
umbilicus.
49320........ Diag laparo Y............ A2........... $510.00 32.1241 $1,366.66 $724.17
separate proc.
49321........ Laparoscopy, Y............ A2........... $630.00 32.1241 $1,366.66 $814.17
biopsy.
49322........ Laparoscopy, Y............ A2........... $630.00 32.1241 $1,366.66 $814.17
aspiration.
49400........ Air injection ............. N1........... ........... ........... ........... ...........
into abdomen.
49402........ Remove foreign Y............ A2........... $446.00 22.0832 $939.49 $569.37
body, adbomen.
49419........ Insrt abdom Y............ A2........... $333.00 29.2133 $1,242.82 $560.46
cath for
chemotx.
49420........ Insert abdom Y............ A2........... $333.00 29.5416 $1,256.79 $563.95
drain, temp.
49421........ Insert abdom Y............ A2........... $333.00 29.5416 $1,256.79 $563.95
drain, perm.
49422........ Remove perm Y............ A2........... $333.00 25.6142 $1,089.70 $522.18
cannula/
catheter.
49423........ Exchange Y............ G2........... ........... 11.6575 $495.95 $495.95
drainage
catheter.
49424........ Assess cyst, ............. N1........... ........... ........... ........... ...........
contrast
inject.
49426........ Revise abdomen- Y............ A2........... $446.00 22.0832 $939.49 $569.37
venous shunt.
49427........ Injection, ............. N1........... ........... ........... ........... ...........
abdominal
shunt.
49429........ Removal of Y............ G2........... ........... 25.6142 $1,089.70 $1,089.70
shunt.
49495........ Rpr ing hernia Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
baby, reduc.
49496........ Rpr ing hernia Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
baby, blocked.
49500........ Rpr ing hernia, Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
init, reduce.
[[Page 42587]]
49501........ Rpr ing hernia, Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
init blocked.
49505........ Prp i/hern init Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
reduc > 5 yr.
49507........ Prp i/hern init Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
block > 5 yr.
49520........ Rerepair ing Y............ A2........... $995.00 29.2182 $1,243.03 $1,057.01
hernia, reduce.
49521........ Rerepair ing Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
hernia,
blocked.
49525........ Repair ing Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
hernia,
sliding.
49540........ Repair lumbar Y............ A2........... $446.00 29.2182 $1,243.03 $645.26
hernia.
49550........ Rpr rem hernia, Y............ A2........... $717.00 29.2182 $1,243.03 $848.51
init, reduce.
49553........ Rpr fem hernia, Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
init blocked.
49555........ Rerepair fem Y............ A2........... $717.00 29.2182 $1,243.03 $848.51
hernia, reduce.
49557........ Rerepair fem Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
hernia,
blocked.
49560........ Rpr ventral Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
hern init,
reduc.
49561........ Rpr ventral Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
hern init,
block.
49565........ Rerepair ventrl Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
hern, reduce.
49566........ Rerepair ventrl Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
hern, block.
49568........ Hernia repair w/ Y............ A2........... $995.00 29.2182 $1,243.03 $1,057.01
mesh.
49570........ Rpr epigastric Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
hern, reduce.
49572........ Rpr epigastric Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
hern, blocked.
49580........ Rpr umbil hern, Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
reduc < 5 yr.
49582........ Rpr umbil hern, Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
block < 5 yr.
49585........ Rpr umbil hern, Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
reduc > 5 yr.
49587........ Rpr umbil hern, Y............ A2........... $1,339.00 29.2182 $1,243.03 $1,315.01
block > 5 yr.
49590........ Repair Y............ A2........... $510.00 29.2182 $1,243.03 $693.26
spigelian
hernia.
49600........ Repair Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
umbilical
lesion.
49650........ Laparo hernia Y............ A2........... $630.00 43.5488 $1,852.70 $935.68
repair initial.
49651........ Laparo hernia Y............ A2........... $995.00 43.5488 $1,852.70 $1,209.43
repair recur.
50200........ Biopsy of Y............ A2........... $333.00 6.1384 $261.15 $315.04
kidney.
50382........ Change ureter Y............ G2........... ........... 19.2251 $817.89 $817.89
stent, percut.
50384........ Remove ureter Y............ G2........... ........... 19.2251 $817.89 $817.89
stent, percut.
50387........ Change ext/int Y............ G2........... ........... 7.4800 $318.22 $318.22
ureter stent.
50389........ Remove renal Y............ G2........... ........... 3.4079 $144.98 $144.98
tube w/fluoro.
50390........ Drainage of Y............ A2........... $333.00 6.1384 $261.15 $315.04
kidney lesion.
50391........ Instll rx agnt Y............ P2........... ........... 1.0887 $46.32 $46.32
into rnal tub.
50392........ Insert kidney Y............ A2........... $333.00 19.2251 $817.89 $454.22
drain.
50393........ Insert ureteral Y............ A2........... $333.00 19.2251 $817.89 $454.22
tube.
50394........ Injection for ............. N1........... ........... ........... ........... ...........
kidney x-ray.
50395........ Create passage Y............ A2........... $333.00 19.2251 $817.89 $454.22
to kidney.
50396........ Measure kidney Y............ A2........... $131.50 2.1393 $91.01 $121.38
pressure.
50398........ Change kidney Y............ A2........... $333.00 7.4800 $318.22 $329.31
tube.
50551........ Kidney Y............ A2........... $333.00 6.4951 $276.32 $318.83
endoscopy.
50553........ Kidney Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy.
50555........ Kidney Y............ A2........... $333.00 6.4951 $276.32 $318.83
endoscopy &
biopsy.
50557........ Kidney Y............ A2........... $333.00 23.8700 $1,015.50 $503.63
endoscopy &
treatment.
50561........ Kidney Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
treatment.
50562........ Renal scope w/ Y............ G2........... ........... 6.4951 $276.32 $276.32
tumor resect.
50570........ Kidney Y............ G2........... ........... 6.4951 $276.32 $276.32
endoscopy.
50572........ Kidney Y............ G2........... ........... 6.4951 $276.32 $276.32
endoscopy.
50574........ Kidney Y............ G2........... ........... 6.4951 $276.32 $276.32
endoscopy &
biopsy.
50575........ Kidney Y............ G2........... ........... 34.9261 $1,485.86 $1,485.86
endoscopy.
50576........ Kidney Y............ G2........... ........... 19.2251 $817.89 $817.89
endoscopy &
treatment.
50590........ Fragmenting of Y............ G2........... ........... 43.5398 $1,852.31 $1,852.31
kidney stone.
50592........ Perc rf ablate Y............ G2........... ........... 37.3604 $1,589.42 $1,589.42
renal tumor.
50684........ Injection for ............. N1........... ........... ........... ........... ...........
ureter x-ray.
50686........ Measure ureter Y............ P2........... ........... 1.0887 $46.32 $46.32
pressure.
50688........ Change of Y............ A2........... $333.00 7.4800 $318.22 $329.31
ureter tube/
stent.
50690........ Injection for ............. N1........... ........... ........... ........... ...........
ureter x-ray.
50947........ Laparo new Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
ureter/bladder.
50948........ Laparo new Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
ureter/bladder.
50951........ Endoscopy of Y............ A2........... $333.00 6.4951 $276.32 $318.83
ureter.
50953........ Endoscopy of Y............ A2........... $333.00 6.4951 $276.32 $318.83
ureter.
50955........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
biopsy.
50957........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
treatment.
50961........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
treatment.
[[Page 42588]]
50970........ Ureter Y............ A2........... $333.00 6.4951 $276.32 $318.83
endoscopy.
50972........ Ureter Y............ A2........... $333.00 6.4951 $276.32 $318.83
endoscopy &
catheter.
50974........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
biopsy.
50976........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
treatment.
50980........ Ureter Y............ A2........... $333.00 19.2251 $817.89 $454.22
endoscopy &
treatment.
51000........ Drainage of Y............ P3........... ........... 1.1588 $49.30 $49.30
bladder.
51005........ Drainage of Y............ P2........... ........... 1.0887 $46.32 $46.32
bladder.
51010........ Drainage of Y............ A2........... $333.00 18.1679 $772.92 $442.98
bladder.
51020........ Incise & treat Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
bladder.
51030........ Incise & treat Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
bladder.
51040........ Incise & drain Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
bladder.
51045........ Incise bladder/ Y............ A2........... $399.24 6.4951 $276.32 $368.51
drain ureter.
51050........ Removal of Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
bladder stone.
51065........ Remove ureter Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
calculus.
51080........ Drainage of Y............ A2........... $333.00 17.5086 $744.87 $435.97
bladder
abscess.
51500........ Removal of Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
bladder cyst.
51520........ Removal of Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
bladder lesion.
51600........ Injection for ............. N1........... ........... ........... ........... ...........
bladder x-ray.
51605........ Preparation for ............. N1........... ........... ........... ........... ...........
bladder xray.
51610........ Injection for ............. N1........... ........... ........... ........... ...........
bladder x-ray.
51700........ Irrigation of Y............ P3........... ........... 1.2554 $53.41 $53.41
bladder.
51701........ Insert bladder N............ P2........... ........... 0.6102 $25.96 $25.96
catheter.
51702........ Insert temp N............ P2........... ........... 0.6102 $25.96 $25.96
bladder cath.
51703........ Insert bladder Y............ P2........... ........... 1.0887 $46.32 $46.32
cath, complex.
51705........ Change of Y............ P3........... ........... 1.7302 $73.61 $73.61
bladder tube.
51710........ Change of Y............ A2........... $333.00 7.4800 $318.22 $329.31
bladder tube.
51715........ Endoscopic Y............ A2........... $510.00 29.0253 $1,234.82 $691.21
injection/
implant.
51720........ Treatment of Y............ P3........... ........... 1.3600 $57.86 $57.86
bladder lesion.
51725........ Simple Y............ P2........... ........... 2.1393 $91.01 $91.01
cystometrogram.
51726........ Complex Y............ A2........... $209.48 3.4079 $144.98 $193.36
cystometrogram.
51736........ Urine flow Y............ P3........... ........... 0.4264 $18.14 $18.14
measurement.
51741........ Electro- Y............ P3........... ........... 0.4990 $21.23 $21.23
uroflowmetry,
first.
51772........ Urethra Y............ A2........... $131.50 2.1393 $91.01 $121.38
pressure
profile.
51784........ Anal/urinary Y............ P2........... ........... 1.0887 $46.32 $46.32
muscle study.
51785........ Anal/urinary Y............ A2........... $66.92 1.0887 $46.32 $61.77
muscle study.
51792........ Urinary reflex Y............ P2........... ........... 1.0887 $46.32 $46.32
study.
51795........ Urine voiding Y............ P2........... ........... 2.1393 $91.01 $91.01
pressure study.
51797........ Intraabdominal Y............ P2........... ........... 2.1393 $91.01 $91.01
pressure test.
51798........ Us urine N............ P3........... ........... 0.3702 $15.75 $15.75
capacity
measure.
51880........ Repair of Y............ A2........... $333.00 23.8700 $1,015.50 $503.63
bladder
opening.
51992........ Laparo sling Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
operation.
52000........ Cystoscopy..... Y............ A2........... $333.00 6.4951 $276.32 $318.83
52001........ Cystoscopy, Y............ A2........... $399.24 6.4951 $276.32 $368.51
removal of
clots.
52005........ Cystoscopy & Y............ A2........... $446.00 19.2251 $817.89 $538.97
ureter
catheter.
52007........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
biopsy.
52010........ Cystoscopy & Y............ A2........... $399.24 6.4951 $276.32 $368.51
duct catheter.
52204........ Cystoscopy w/ Y............ A2........... $446.00 19.2251 $817.89 $538.97
biopsy(s).
52214........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52224........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52234........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52235........ Cystoscopy and Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
treatment.
52240........ Cystoscopy and Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
treatment.
52250........ Cystoscopy and Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
radiotracer.
52260........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52265........ Cystoscopy and Y............ P2........... ........... 6.4951 $276.32 $276.32
treatment.
52270........ Cystoscopy & Y............ A2........... $446.00 19.2251 $817.89 $538.97
revise urethra.
52275........ Cystoscopy & Y............ A2........... $446.00 19.2251 $817.89 $538.97
revise urethra.
52276........ Cystoscopy and Y............ A2........... $510.00 19.2251 $817.89 $586.97
treatment.
52277........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52281........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52282........ Cystoscopy, Y............ A2........... $1,339.00 34.9261 $1,485.86 $1,375.72
implant stent.
52283........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52285........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
[[Page 42589]]
52290........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52300........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52301........ Cystoscopy and Y............ A2........... $510.00 19.2251 $817.89 $586.97
treatment.
52305........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52310........ Cystoscopy and Y............ A2........... $399.24 6.4951 $276.32 $368.51
treatment.
52315........ Cystoscopy and Y............ A2........... $446.00 19.2251 $817.89 $538.97
treatment.
52317........ Remove bladder Y............ A2........... $333.00 23.8700 $1,015.50 $503.63
stone.
52318........ Remove bladder Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
stone.
52320........ Cystoscopy and Y............ A2........... $717.00 23.8700 $1,015.50 $791.63
treatment.
52325........ Cystoscopy, Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
stone removal.
52327........ Cystoscopy, Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
inject
material.
52330........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52332........ Cystoscopy and Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
treatment.
52334........ Create passage Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
to kidney.
52341........ Cysto w/ureter Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
stricture tx.
52342........ Cysto w/up Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
stricture tx.
52343........ Cysto w/renal Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
stricture tx.
52344........ Cysto/uretero, Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
stricture tx.
52345........ Cysto/uretero w/ Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
up stricture.
52346........ Cystouretero w/ Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
renal strict.
52351........ Cystouretero & Y............ A2........... $510.00 19.2251 $817.89 $586.97
or pyeloscope.
52352........ Cystouretero w/ Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
stone remove.
52353........ Cystouretero w/ Y............ A2........... $630.00 34.9261 $1,485.86 $843.97
lithotripsy.
52354........ Cystouretero w/ Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
biopsy.
52355........ Cystouretero w/ Y............ A2........... $630.00 23.8700 $1,015.50 $726.38
excise tumor.
52400........ Cystouretero w/ Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
congen repr.
52402........ Cystourethro Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
cut ejacul
duct.
52450........ Incision of Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
prostate.
52500........ Revision of Y............ A2........... $510.00 23.8700 $1,015.50 $636.38
bladder neck.
52510........ Dilation Y............ A2........... $510.00 19.2251 $817.89 $586.97
prostatic
urethra.
52601........ Prostatectomy Y............ A2........... $630.00 34.9261 $1,485.86 $843.97
(TURP).
52606........ Control postop Y............ A2........... $333.00 23.8700 $1,015.50 $503.63
bleeding.
52612........ Prostatectomy, Y............ A2........... $446.00 34.9261 $1,485.86 $705.97
first stage.
52614........ Prostatectomy, Y............ A2........... $333.00 34.9261 $1,485.86 $621.22
second stage.
52620........ Remove residual Y............ A2........... $333.00 34.9261 $1,485.86 $621.22
prostate.
52630........ Remove prostate Y............ A2........... $446.00 34.9261 $1,485.86 $705.97
regrowth.
52640........ Relieve bladder Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
contracture.
52647........ Laser surgery Y............ A2........... $1,339.00 43.1004 $1,833.62 $1,462.66
of prostate.
52648........ Laser surgery Y............ A2........... $1,339.00 43.1004 $1,833.62 $1,462.66
of prostate.
52700........ Drainage of Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
prostate
abscess.
53000........ Incision of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53010........ Incision of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53020........ Incision of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53025........ Incision of Y............ R2........... ........... 18.3960 $782.62 $782.62
urethra.
53040........ Drainage of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra
abscess.
53060........ Drainage of Y............ P3........... ........... 1.6416 $69.84 $69.84
urethra
abscess.
53080........ Drainage of Y............ A2........... $510.00 18.3960 $782.62 $578.16
urinary
leakage.
53085........ Drainage of Y............ G2........... ........... 18.3960 $782.62 $782.62
urinary
leakage.
53200........ Biopsy of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53210........ Removal of Y............ A2........... $717.00 29.0253 $1,234.82 $846.46
urethra.
53215........ Removal of Y............ A2........... $717.00 18.3960 $782.62 $733.41
urethra.
53220........ Treatment of Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra lesion.
53230........ Removal of Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra lesion.
53235........ Removal of Y............ A2........... $510.00 18.3960 $782.62 $578.16
urethra lesion.
53240........ Surgery for Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra pouch.
53250........ Removal of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra gland.
53260........ Treatment of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra lesion.
53265........ Treatment of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra lesion.
53270........ Removal of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra gland.
53275........ Repair of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra defect.
53400........ Revise urethra, Y............ A2........... $510.00 29.0253 $1,234.82 $691.21
stage 1.
53405........ Revise urethra, Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
stage 2.
53410........ Reconstruction Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
of urethra.
[[Page 42590]]
53420........ Reconstruct Y............ A2........... $510.00 29.0253 $1,234.82 $691.21
urethra, stage
1.
53425........ Reconstruct Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra, stage
2.
53430........ Reconstruction Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
of urethra.
53431........ Reconstruct Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra/
bladder.
53440........ Male sling N............ A2........... $446.00 79.2092 $3,369.80 $1,176.95
procedure.
53442........ Remove/revise Y............ A2........... $333.00 29.0253 $1,234.82 $558.46
male sling.
53444........ Insert tandem N............ A2........... $446.00 79.2092 $3,369.80 $1,176.95
cuff.
53445........ Insert uro/ves N............ H8........... $333.00 178.7754 $7,605.64 $6,152.75
nck sphincter.
53446........ Remove uro Y............ A2........... $333.00 29.0253 $1,234.82 $558.46
sphincter.
53447........ Remove/replace N............ H8........... $333.00 178.7754 $7,605.64 $6,152.75
ur sphincter.
53449........ Repair uro Y............ A2........... $333.00 29.0253 $1,234.82 $558.46
sphincter.
53450........ Revision of Y............ A2........... $333.00 29.0253 $1,234.82 $558.46
urethra.
53460........ Revision of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53502........ Repair of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra injury.
53505........ Repair of Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra injury.
53510........ Repair of Y............ A2........... $446.00 18.3960 $782.62 $530.16
urethra injury.
53515........ Repair of Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra injury.
53520........ Repair of Y............ A2........... $446.00 29.0253 $1,234.82 $643.21
urethra defect.
53600........ Dilate urethra Y............ P3........... ........... 0.9254 $39.37 $39.37
stricture.
53601........ Dilate urethra Y............ P3........... ........... 1.0702 $45.53 $45.53
stricture.
53605........ Dilate urethra Y............ A2........... $446.00 19.2251 $817.89 $538.97
stricture.
53620........ Dilate urethra Y............ P3........... ........... 1.4888 $63.34 $63.34
stricture.
53621........ Dilate urethra Y............ P3........... ........... 1.5692 $66.76 $66.76
stricture.
53660........ Dilation of Y............ P3........... ........... 1.0542 $44.85 $44.85
urethra.
53661........ Dilation of Y............ P3........... ........... 1.0462 $44.51 $44.51
urethra.
53665........ Dilation of Y............ A2........... $333.00 18.3960 $782.62 $445.41
urethra.
53850........ Prostatic Y............ P2........... ........... 41.1375 $1,750.11 $1,750.11
microwave
thermotx.
53852........ Prostatic rf Y............ P2........... ........... 41.1375 $1,750.11 $1,750.11
thermotx.
53853........ Prostatic water Y............ P2........... ........... 23.8700 $1,015.50 $1,015.50
thermother.
54000........ Slitting of Y............ A2........... $446.00 18.3960 $782.62 $530.16
prepuce.
54001........ Slitting of Y............ A2........... $446.00 18.3960 $782.62 $530.16
prepuce.
54015........ Drain penis Y............ A2........... $630.00 17.5086 $744.87 $658.72
lesion.
54050........ Destruction, Y............ P2........... ........... 1.0918 $46.45 $46.45
penis
lesion(s).
54055........ Destruction, Y............ P3........... ........... 1.4404 $61.28 $61.28
penis
lesion(s).
54056........ Cryosurgery, Y............ P2........... ........... 0.8432 $35.87 $35.87
penis
lesion(s).
54057........ Laser surg, Y............ A2........... $333.00 17.4423 $742.05 $435.26
penis
lesion(s).
54060........ Excision of Y............ A2........... $333.00 17.4423 $742.05 $435.26
penis
lesion(s).
54065........ Destruction, Y............ A2........... $333.00 20.4276 $869.05 $467.01
penis
lesion(s).
54100........ Biopsy of penis Y............ A2........... $333.00 15.1024 $642.50 $410.38
54105........ Biopsy of penis Y............ A2........... $333.00 20.0656 $853.65 $463.16
54110........ Treatment of Y............ A2........... $446.00 32.9873 $1,403.38 $685.35
penis lesion.
54111........ Treat penis Y............ A2........... $446.00 32.9873 $1,403.38 $685.35
lesion, graft.
54112........ Treat penis Y............ A2........... $446.00 32.9873 $1,403.38 $685.35
lesion, graft.
54115........ Treatment of Y............ A2........... $333.00 17.5086 $744.87 $435.97
penis lesion.
54120........ Partial removal Y............ A2........... $446.00 32.9873 $1,403.38 $685.35
of penis.
54150........ Circumcision w/ Y............ A2........... $333.00 20.5513 $874.31 $468.33
regionl block.
54160........ Circumcision, Y............ A2........... $446.00 20.5513 $874.31 $553.08
neonate.
54161........ Circum 28 days Y............ A2........... $446.00 20.5513 $874.31 $553.08
or older.
54162........ Lysis penil Y............ A2........... $446.00 20.5513 $874.31 $553.08
circumic
lesion.
54163........ Repair of Y............ A2........... $446.00 20.5513 $874.31 $553.08
circumcision.
54164........ Frenulotomy of Y............ A2........... $446.00 20.5513 $874.31 $553.08
penis.
54200........ Treatment of Y............ P3........... ........... 1.5370 $65.39 $65.39
penis lesion.
54205........ Treatment of Y............ A2........... $630.00 32.9873 $1,403.38 $823.35
penis lesion.
54220........ Treatment of Y............ A2........... $131.50 2.1393 $91.01 $121.38
penis lesion.
54230........ Prepare penis ............. N1........... ........... ........... ........... ...........
study.
54231........ Dynamic Y............ P3........... ........... 1.3036 $55.46 $55.46
cavernosometry.
54235........ Penile Y............ P3........... ........... 0.9496 $40.40 $40.40
injection.
54240........ Penis study.... Y............ P3........... ........... 0.6518 $27.73 $27.73
54250........ Penis study.... Y............ P3........... ........... 0.2254 $9.59 $9.59
54300........ Revision of Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
penis.
54304........ Revision of Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
penis.
54308........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54312........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
[[Page 42591]]
54316........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54318........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54322........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54324........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54326........ Reconstruction Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
of urethra.
54328........ Revise penis/ Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
urethra.
54340........ Secondary Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
urethral
surgery.
54344........ Secondary Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
urethral
surgery.
54348........ Secondary Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
urethral
surgery.
54352........ Reconstruct Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
urethra/penis.
54360........ Penis plastic Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
surgery.
54380........ Repair penis... Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
54385........ Repair penis... Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
54400........ Insert semi- N............ A2........... $510.00 79.2092 $3,369.80 $1,224.95
rigid
prosthesis.
54401........ Insert self- N............ H8........... $510.00 178.7754 $7,605.64 $6,285.50
contd
prosthesis.
54405........ Insert multi- N............ H8........... $510.00 178.7754 $7,605.64 $6,285.50
comp penis
pros.
54406........ Remove muti- Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
comp penis
pros.
54408........ Repair multi- Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
comp penis
pros.
54410........ Remove/replace N............ H8........... $510.00 178.7754 $7,605.64 $6,285.50
penis prosth.
54415........ Remove self- Y............ A2........... $510.00 32.9873 $1,403.38 $733.35
contd penis
pros.
54416........ Remv/repl penis N............ H8........... $510.00 178.7754 $7,605.64 $6,285.50
contain pros.
54420........ Revision of Y............ A2........... $630.00 32.9873 $1,403.38 $823.35
penis.
54435........ Revision of Y............ A2........... $630.00 32.9873 $1,403.38 $823.35
penis.
54440........ Repair of penis Y............ A2........... $630.00 32.9873 $1,403.38 $823.35
54450........ Preputial Y............ A2........... $209.48 3.4079 $144.98 $193.36
stretching.
54500........ Biopsy of Y............ A2........... $333.00 10.2655 $436.73 $358.93
testis.
54505........ Biopsy of Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
testis.
54512........ Excise lesion Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
testis.
54520........ Removal of Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
testis.
54522........ Orchiectomy, Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
partial.
54530........ Removal of Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
testis.
54550........ Exploration for Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
testis.
54560........ Exploration for Y............ G2........... ........... 23.5310 $1,001.08 $1,001.08
testis.
54600........ Reduce testis Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
torsion.
54620........ Suspension of Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
testis.
54640........ Suspension of Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
testis.
54660........ Revision of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
testis.
54670........ Repair testis Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
injury.
54680........ Relocation of Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
testis(es).
54690........ Laparoscopy, Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
orchiectomy.
54692........ Laparoscopy, Y............ G2........... ........... 70.5066 $2,999.56 $2,999.56
orchiopexy.
54700........ Drainage of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
scrotum.
54800........ Biopsy of Y............ A2........... $127.16 2.0687 $88.01 $117.37
epididymis.
54830........ Remove Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
epididymis
lesion.
54840........ Remove Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
epididymis
lesion.
54860........ Removal of Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
epididymis.
54861........ Removal of Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
epididymis.
54865........ Explore Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
epididymis.
54900........ Fusion of Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
spermatic
ducts.
54901........ Fusion of Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
spermatic
ducts.
55000........ Drainage of Y............ P3........... ........... 1.5772 $67.10 $67.10
hydrocele.
55040........ Removal of Y............ A2........... $510.00 29.2182 $1,243.03 $693.26
hydrocele.
55041........ Removal of Y............ A2........... $717.00 29.2182 $1,243.03 $848.51
hydroceles.
55060........ Repair of Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
hydrocele.
55100........ Drainage of Y............ A2........... $333.00 11.1535 $474.50 $368.38
scrotum
abscess.
55110........ Explore scrotum Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
55120........ Removal of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
scrotum lesion.
55150........ Removal of Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
scrotum.
55175........ Revision of Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
scrotum.
55180........ Revision of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
scrotum.
55200........ Incision of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
sperm duct.
55250........ Removal of Y............ A2........... $446.00 23.5310 $1,001.08 $584.77
sperm duct(s).
55300........ Prepare, sperm ............. N1........... ........... ........... ........... ...........
duct x-ray.
[[Page 42592]]
55400........ Repair of sperm Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
duct.
55450........ Ligation of Y............ P3........... ........... 5.2227 $222.19 $222.19
sperm duct.
55500........ Removal of Y............ A2........... $510.00 23.5310 $1,001.08 $632.77
hydrocele.
55520........ Removal of Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
sperm cord
lesion.
55530........ Revise Y............ A2........... $630.00 23.5310 $1,001.08 $722.77
spermatic cord
veins.
55535........ Revise Y............ A2........... $630.00 29.2182 $1,243.03 $783.26
spermatic cord
veins.
55540........ Revise hernia & Y............ A2........... $717.00 29.2182 $1,243.03 $848.51
sperm veins.
55550........ Laparo ligate Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
spermatic vein.
55600........ Incise sperm Y............ R2........... ........... 23.5310 $1,001.08 $1,001.08
duct pouch.
55680........ Remove sperm Y............ A2........... $333.00 23.5310 $1,001.08 $500.02
pouch lesion.
55700........ Biopsy of Y............ A2........... $345.83 5.6262 $239.36 $319.21
prostate.
55705........ Biopsy of Y............ A2........... $345.83 5.6262 $239.36 $319.21
prostate.
55720........ Drainage of Y............ A2........... $333.00 23.8700 $1,015.50 $503.63
prostate
abscess.
55725........ Drainage of Y............ A2........... $446.00 23.8700 $1,015.50 $588.38
prostate
abscess.
55860........ Surgical Y............ G2........... ........... 18.1679 $772.92 $772.92
exposure,
prostate.
55870........ Electroejaculat Y............ P3........... ........... 1.6094 $68.47 $68.47
ion.
55873........ Cryoablate Y............ H8........... $1,339.00 137.5639 $5,852.38 $5,252.74
prostate.
55875........ Transperi Y............ A2........... $1,339.00 34.9261 $1,485.86 $1,375.72
needle place,
pros.
55876 \*\.... Place rt device/ Y............ P3........... ........... 1.6416 $69.84 $69.84
marker, pros.
56405........ I & D of vulva/ Y............ P3........... ........... 1.0058 $42.79 $42.79
perineum.
56420........ Drainage of Y............ P2........... ........... 1.2900 $54.88 $54.88
gland abscess.
56440........ Surgery for Y............ A2........... $446.00 20.5081 $872.48 $552.62
vulva lesion.
56441........ Lysis of labial Y............ A2........... $333.00 14.8489 $631.72 $407.68
lesion(s).
56442........ Hymenotomy..... Y............ A2........... $333.00 14.8489 $631.72 $407.68
56501........ Destroy, vulva Y............ P3........... ........... 1.3680 $58.20 $58.20
lesions, sim.
56515........ Destroy vulva Y............ A2........... $510.00 20.4276 $869.05 $599.76
lesion/s compl.
56605........ Biopsy of vulva/ Y............ P3........... ........... 0.7966 $33.89 $33.89
perineum.
56606........ Biopsy of vulva/ Y............ P3........... ........... 0.3460 $14.72 $14.72
perineum.
56620........ Partial removal Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
of vulva.
56625........ Complete Y............ A2........... $995.00 28.5095 $1,212.88 $1,049.47
removal of
vulva.
56700........ Partial removal Y............ A2........... $333.00 20.5081 $872.48 $467.87
of hymen.
56740........ Remove vagina Y............ A2........... $510.00 20.5081 $872.48 $600.62
gland lesion.
56800........ Repair of Y............ A2........... $510.00 20.5081 $872.48 $600.62
vagina.
56805........ Repair clitoris Y............ G2........... ........... 14.8489 $631.72 $631.72
56810........ Repair of Y............ A2........... $717.00 20.5081 $872.48 $755.87
perineum.
56820........ Exam of vulva w/ Y............ P3........... ........... 1.0058 $42.79 $42.79
scope.
56821........ Exam/biopsy of Y............ P3........... ........... 1.3116 $55.80 $55.80
vulva w/scope.
57000........ Exploration of Y............ A2........... $333.00 14.8489 $631.72 $407.68
vagina.
57010........ Drainage of Y............ A2........... $446.00 14.8489 $631.72 $492.43
pelvic abscess.
57020........ Drainage of Y............ A2........... $409.33 6.6592 $283.30 $377.82
pelvic fluid.
57022........ I & d vaginal Y............ G2........... ........... 11.1535 $474.50 $474.50
hematoma, pp.
57023........ I & d vag Y............ A2........... $333.00 17.5086 $744.87 $435.97
hematoma, non-
ob.
57061........ Destroy vag Y............ P3........... ........... 1.2634 $53.75 $53.75
lesions,
simple.
57065........ Destroy vag Y............ A2........... $333.00 20.5081 $872.48 $467.87
lesions,
complex.
57100........ Biopsy of Y............ P3........... ........... 0.8048 $34.24 $34.24
vagina.
57105........ Biopsy of Y............ A2........... $446.00 20.5081 $872.48 $552.62
vagina.
57130........ Remove vagina Y............ A2........... $446.00 20.5081 $872.48 $552.62
lesion.
57135........ Remove vagina Y............ A2........... $446.00 20.5081 $872.48 $552.62
lesion.
57150........ Treat vagina Y............ P2........... ........... 0.1468 $6.25 $6.25
infection.
57155........ Insert uteri Y............ A2........... $409.33 6.6592 $283.30 $377.82
tandems/ovoids.
57160........ Insert pessary/ Y............ P3........... ........... 0.8208 $34.92 $34.92
other device.
57170........ Fitting of Y............ P2........... ........... 0.1468 $6.25 $6.25
diaphragm/cap.
57180........ Treat vaginal Y............ A2........... $178.05 2.8966 $123.23 $164.35
bleeding.
57200........ Repair of Y............ A2........... $333.00 20.5081 $872.48 $467.87
vagina.
57210........ Repair vagina/ Y............ A2........... $446.00 20.5081 $872.48 $552.62
perineum.
57220........ Revision of Y............ A2........... $510.00 42.9896 $1,828.91 $839.73
urethra.
57230........ Repair of Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
urethral
lesion.
57240........ Repair bladder Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
& vagina.
57250........ Repair rectum & Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
vagina.
57260........ Repair of Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
vagina.
57265........ Extensive Y............ A2........... $995.00 42.9896 $1,828.91 $1,203.48
repair of
vagina.
57267........ Insert mesh/ Y............ A2........... $995.00 28.5095 $1,212.88 $1,049.47
pelvic flr
addon.
57268........ Repair of bowel Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
bulge.
[[Page 42593]]
57287........ Revise/remove Y............ G2........... ........... 28.5095 $1,212.88 $1,212.88
sling repair.
57288........ Repair bladder Y............ A2........... $717.00 42.9896 $1,828.91 $994.98
defect.
57289........ Repair bladder Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
& vagina.
57291........ Construction of Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
vagina.
57300........ Repair rectum- Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
vagina fistula.
57320........ Repair bladder- Y............ G2........... ........... 28.5095 $1,212.88 $1,212.88
vagina lesion.
57400........ Dilation of Y............ A2........... $446.00 20.5081 $872.48 $552.62
vagina.
57410........ Pelvic Y............ A2........... $446.00 14.8489 $631.72 $492.43
examination.
57415........ Remove vaginal Y............ A2........... $446.00 20.5081 $872.48 $552.62
foreign body.
57420........ Exam of vagina Y............ P3........... ........... 1.0380 $44.16 $44.16
w/scope.
57421........ Exam/biopsy of Y............ P3........... ........... 1.3842 $58.89 $58.89
vag w/scope.
57452........ Exam of cervix Y............ P3........... ........... 0.9818 $41.77 $41.77
w/scope.
57454........ Bx/curett of Y............ P3........... ........... 1.2232 $52.04 $52.04
cervix w/scope.
57455........ Biopsy of Y............ P3........... ........... 1.2876 $54.78 $54.78
cervix w/scope.
57456........ Endocerv Y............ P3........... ........... 1.2474 $53.07 $53.07
curettage w/
scope.
57460........ Bx of cervix w/ Y............ P3........... ........... 4.0639 $172.89 $172.89
scope, leep.
57461........ Conz of cervix Y............ P3........... ........... 4.2811 $182.13 $182.13
w/scope, leep.
57500........ Biopsy of Y............ P3........... ........... 1.8186 $77.37 $77.37
cervix.
57505........ Endocervical Y............ P3........... ........... 1.1104 $47.24 $47.24
curettage.
57510........ Cauterization Y............ P3........... ........... 1.1508 $48.96 $48.96
of cervix.
57511........ Cryocautery of Y............ P2........... ........... 1.2900 $54.88 $54.88
cervix.
57513........ Laser surgery Y............ A2........... $446.00 14.8489 $631.72 $492.43
of cervix.
57520........ Conization of Y............ A2........... $446.00 20.5081 $872.48 $552.62
cervix.
57522........ Conization of Y............ A2........... $446.00 28.5095 $1,212.88 $637.72
cervix.
57530........ Removal of Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
cervix.
57550........ Removal of Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
residual
cervix.
57556........ Remove cervix, Y............ A2........... $717.00 42.9896 $1,828.91 $994.98
repair bowel.
57558........ D&c of cervical Y............ A2........... $510.00 17.7499 $755.13 $571.28
stump.
57700........ Revision of Y............ A2........... $333.00 20.5081 $872.48 $467.87
cervix.
57720........ Revision of Y............ A2........... $510.00 20.5081 $872.48 $600.62
cervix.
57800........ Dilation of Y............ P3........... ........... 0.5874 $24.99 $24.99
cervical canal.
58100........ Biopsy of Y............ P3........... ........... 0.9818 $41.77 $41.77
uterus lining.
58110 \*\.... Bx done w/ Y............ P3........... ........... 0.3782 $16.09 $16.09
colposcopy add-
on.
58120........ Dilation and Y............ A2........... $446.00 17.7499 $755.13 $523.28
curettage.
58145........ Myomectomy vag Y............ A2........... $717.00 28.5095 $1,212.88 $840.97
method.
58301........ Remove Y............ P3........... ........... 0.9496 $40.40 $40.40
intrauterine
device.
58321........ Artificial Y............ P3........... ........... 0.8450 $35.95 $35.95
insemination.
58322........ Artificial Y............ P3........... ........... 0.9012 $38.34 $38.34
insemination.
58323........ Sperm washing.. Y............ P3........... ........... 0.2736 $11.64 $11.64
58340........ Catheter for ............. N1........... ........... ........... ........... ...........
hysterography.
58345........ Reopen Y............ R2........... ........... 14.8489 $631.72 $631.72
fallopian tube.
58346........ Insert heyman Y............ A2........... $446.00 14.8489 $631.72 $492.43
uteri capsule.
58350........ Reopen Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
fallopian tube.
58353........ Endometr Y............ A2........... $995.00 28.5095 $1,212.88 $1,049.47
ablate,
thermal.
58356........ Endometrial Y............ P3........... ........... 41.9827 $1,786.07 $1,786.07
cryoablation.
58545........ Laparoscopic Y............ A2........... $1,339.00 32.1241 $1,366.66 $1,345.92
myomectomy.
58546........ Laparo- Y............ A2........... $1,339.00 43.5488 $1,852.70 $1,467.43
myomectomy,
complex.
58550........ Laparo-asst vag Y............ A2........... $1,339.00 70.5066 $2,999.56 $1,754.14
hysterectomy.
58552........ Laparo-vag hyst Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
incl t/o.
58555........ Hysteroscopy, Y............ A2........... $333.00 21.3586 $908.66 $476.92
dx, sep proc.
58558........ Hysteroscopy, Y............ A2........... $510.00 21.3586 $908.66 $609.67
biopsy.
58559........ Hysteroscopy, Y............ A2........... $446.00 21.3586 $908.66 $561.67
lysis.
58560........ Hysteroscopy, Y............ A2........... $510.00 34.0155 $1,447.12 $744.28
resect septum.
58561........ Hysteroscopy, Y............ A2........... $510.00 34.0155 $1,447.12 $744.28
remove myoma.
58562........ Hysteroscopy, Y............ A2........... $510.00 21.3586 $908.66 $609.67
remove fb.
58563........ Hysteroscopy, Y............ A2........... $1,339.00 34.0155 $1,447.12 $1,366.03
ablation.
58565........ Hysteroscopy, Y............ A2........... $1,339.00 42.9896 $1,828.91 $1,461.48
sterilization.
58600........ Division of Y............ G2........... ........... 28.5095 $1,212.88 $1,212.88
fallopian tube.
58615........ Occlude Y............ G2........... ........... 20.5081 $872.48 $872.48
fallopian
tube(s).
58660........ Laparoscopy, Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
lysis.
58661........ Laparoscopy, Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
remove adnexa.
58662........ Laparoscopy, Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
excise lesions.
58670........ Laparoscopy, Y............ A2........... $510.00 43.5488 $1,852.70 $845.68
tubal cautery.
[[Page 42594]]
58671........ Laparoscopy, Y............ A2........... $510.00 43.5488 $1,852.70 $845.68
tubal block.
58672........ Laparoscopy, Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
fimbrioplasty.
58673........ Laparoscopy, Y............ A2........... $717.00 43.5488 $1,852.70 $1,000.93
salpingostomy.
58800........ Drainage of Y............ A2........... $510.00 14.8489 $631.72 $540.43
ovarian
cyst(s).
58820........ Drain ovary Y............ A2........... $510.00 28.5095 $1,212.88 $685.72
abscess, open.
58900........ Biopsy of Y............ A2........... $510.00 14.8489 $631.72 $540.43
ovary(s).
58970........ Retrieval of Y............ A2........... $245.92 4.0007 $170.20 $226.99
oocyte.
58974........ Transfer of Y............ A2........... $245.92 4.0007 $170.20 $226.99
embryo.
58976........ Transfer of Y............ A2........... $245.92 4.0007 $170.20 $226.99
embryo.
59000........ Amniocentesis, Y............ P2........... ........... 1.4222 $60.50 $60.50
diagnostic.
59001........ Amniocentesis, Y............ R2........... ........... 6.6592 $283.30 $283.30
therapeutic.
59012........ Fetal cord Y............ G2........... ........... 1.4222 $60.50 $60.50
puncture,
prenatal.
59015........ Chorion biopsy. Y............ P3........... ........... 1.1910 $50.67 $50.67
59020........ Fetal contract Y............ P3........... ........... 0.5632 $23.96 $23.96
stress test.
59025........ Fetal non- Y............ P3........... ........... 0.2816 $11.98 $11.98
stress test.
59070........ Transabdom Y............ G2........... ........... 1.4222 $60.50 $60.50
amnioinfus w/
us.
59072........ Umbilical cord Y............ G2........... ........... 1.4222 $60.50 $60.50
occlud w/us.
59076........ Fetal shunt Y............ G2........... ........... 1.4222 $60.50 $60.50
placement, w/
us.
59100........ Remove uterus Y............ R2........... ........... 28.5095 $1,212.88 $1,212.88
lesion.
59150........ Treat ectopic Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
pregnancy.
59151........ Treat ectopic Y............ G2........... ........... 43.5488 $1,852.70 $1,852.70
pregnancy.
59160........ D& c after Y............ A2........... $510.00 17.7499 $755.13 $571.28
delivery.
59200........ Insert cervical Y............ P3........... ........... 0.8530 $36.29 $36.29
dilator.
59300........ Episiotomy or Y............ P3........... ........... 1.7542 $74.63 $74.63
vaginal repair.
59320........ Revision of Y............ A2........... $333.00 20.5081 $872.48 $467.87
cervix.
59412........ Antepartum Y............ G2........... ........... 2.3864 $101.52 $101.52
manipulation.
59414........ Deliver Y............ G2........... ........... 14.8489 $631.72 $631.72
placenta.
59812........ Treatment of Y............ A2........... $717.00 18.5201 $787.90 $734.73
miscarriage.
59820........ Care of Y............ A2........... $717.00 18.5201 $787.90 $734.73
miscarriage.
59821........ Treatment of Y............ A2........... $717.00 18.5201 $787.90 $734.73
miscarriage.
59840........ Abortion....... Y............ A2........... $717.00 16.9328 $720.37 $717.84
59841........ Abortion....... Y............ A2........... $717.00 16.9328 $720.37 $717.84
59866........ Abortion (mpr). Y............ G2........... ........... 1.4222 $60.50 $60.50
59870........ Evacuate mole Y............ A2........... $717.00 18.5201 $787.90 $734.73
of uterus.
59871........ Remove cerclage Y............ A2........... $717.00 20.5081 $872.48 $755.87
suture.
60000........ Drain thyroid/ Y............ A2........... $333.00 7.5511 $321.25 $330.06
tongue cyst.
60001........ Aspirate/inject Y............ P3........... ........... 1.3116 $55.80 $55.80
thyriod cyst.
60100........ Biopsy of Y............ P3........... ........... 1.0462 $44.51 $44.51
thyroid.
60200........ Remove thyroid Y............ A2........... $446.00 37.7224 $1,604.82 $735.71
lesion.
60280........ Remove thyroid Y............ A2........... $630.00 37.7224 $1,604.82 $873.71
duct lesion.
60281........ Remove thyroid Y............ A2........... $630.00 37.7224 $1,604.82 $873.71
duct lesion.
61000........ Remove cranial Y............ R2........... ........... 2.9907 $127.23 $127.23
cavity fluid.
61001........ Remove cranial Y............ R2........... ........... 2.9907 $127.23 $127.23
cavity fluid.
61020........ Remove brain Y............ A2........... $183.83 2.9907 $127.23 $169.68
cavity fluid.
61026........ Injection into Y............ A2........... $183.83 2.9907 $127.23 $169.68
brain canal.
61050........ Remove brain Y............ A2........... $183.83 2.9907 $127.23 $169.68
canal fluid.
61055........ Injection into Y............ A2........... $183.83 2.9907 $127.23 $169.68
brain canal.
61070........ Brain canal Y............ A2........... $183.83 2.9907 $127.23 $169.68
shunt
procedure.
61215........ Insert brain- Y............ A2........... $510.00 47.0342 $2,000.98 $882.75
fluid device.
61330........ Decompress eye Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
socket.
61334........ Explore orbit/ Y............ G2........... ........... 38.1991 $1,625.10 $1,625.10
remove object.
61790........ Treat Y............ A2........... $510.00 17.8499 $759.39 $572.35
trigeminal
nerve.
61791........ Treat Y............ A2........... $351.92 5.7253 $243.57 $324.83
trigeminal
tract.
61795........ Brain surgery N............ A2........... $302.04 4.9138 $209.05 $278.79
using computer.
61880........ Revise/remove Y............ G2........... ........... 17.8334 $758.69 $758.69
neuroelectrode.
61885........ Insrt/redo N............ H8........... $446.00 260.1530 $11,067.69 $10,137.66
neurostim 1
array.
61886........ Implant Y............ H8........... $510.00 342.4747 $14,569.90 $13,649.39
neurostim
arrays.
61888........ Revise/remove Y............ A2........... $333.00 35.5702 $1,513.26 $628.07
neuroreceiver.
62194........ Replace/ Y............ A2........... $333.00 11.6575 $495.95 $373.74
irrigate
catheter.
62225........ Replace/ Y............ A2........... $333.00 11.6575 $495.95 $373.74
irrigate
catheter.
62230........ Replace/revise Y............ A2........... $446.00 47.0342 $2,000.98 $834.75
brain shunt.
62252........ Csf shunt N............ P3........... ........... 1.0462 $44.51 $44.51
reprogram.
62263........ Epidural lysis Y............ A2........... $333.00 12.1702 $517.76 $379.19
mult sessions.
[[Page 42595]]
62264........ Epidural lysis Y............ A2........... $333.00 12.1702 $517.76 $379.19
on single day.
62268........ Drain spinal Y............ A2........... $183.83 2.9907 $127.23 $169.68
cord cyst.
62269........ Needle biopsy, Y............ A2........... $333.00 6.1384 $261.15 $315.04
spinal cord.
62270........ Spinal fluid Y............ A2........... $139.00 2.2614 $96.21 $128.30
tap,
diagnostic.
62272........ Drain cerebro Y............ A2........... $139.00 2.2614 $96.21 $128.30
spinal fluid.
62273........ Inject epidural Y............ A2........... $333.00 5.7253 $243.57 $310.64
patch.
62280........ Treat spinal Y............ A2........... $333.00 6.3603 $270.59 $317.40
cord lesion.
62281........ Treat spinal Y............ A2........... $333.00 6.3603 $270.59 $317.40
cord lesion.
62282........ Treat spinal Y............ A2........... $333.00 6.3603 $270.59 $317.40
canal lesion.
62284........ Injection for ............. N1........... ........... ........... ........... ...........
myelogram.
62287........ Percutaneous Y............ A2........... $1,339.00 33.1520 $1,410.39 $1,356.85
diskectomy.
62290........ Inject for ............. N1........... ........... ........... ........... ...........
spine disk x-
ray.
62291........ Inject for ............. N1........... ........... ........... ........... ...........
spine disk x-
ray.
62292........ Injection into Y............ G2........... ........... 2.9907 $127.23 $127.23
disk lesion.
62294........ Injection into Y............ A2........... $183.83 2.9907 $127.23 $169.68
spinal artery.
62310........ Inject spine c/ Y............ A2........... $333.00 6.3603 $270.59 $317.40
t.
62311........ Inject spine l/ Y............ A2........... $333.00 6.3603 $270.59 $317.40
s (cd).
62318........ Inject spine w/ Y............ A2........... $333.00 6.3603 $270.59 $317.40
cath, c/t.
62319........ Inject spine w/ Y............ A2........... $333.00 6.3603 $270.59 $317.40
cath l/s (cd).
62350........ Implant spinal Y............ A2........... $446.00 30.8394 $1,312.00 $662.50
canal cath.
62355........ Remove spinal Y............ A2........... $446.00 12.1702 $517.76 $463.94
canal catheter.
62360........ Insert spine Y............ A2........... $446.00 112.6322 $4,791.71 $1,532.43
infusion
device.
62361........ Implant spine Y............ H8........... $446.00 243.3568 $10,353.13 $9,589.69
infusion pump.
62362........ Implant spine Y............ H8........... $446.00 243.3568 $10,353.13 $9,589.69
infusion pump.
62365........ Remove spine Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
infusion
device.
62367........ Analyze spine N............ P3........... ........... 0.4104 $17.46 $17.46
infusion pump.
62368........ Analyze spine N............ P3........... ........... 0.5150 $21.91 $21.91
infusion pump.
63600........ Remove spinal Y............ A2........... $446.00 17.8499 $759.39 $524.35
cord lesion.
63610........ Stimulation of Y............ A2........... $333.00 17.8499 $759.39 $439.60
spinal cord.
63615........ Remove lesion Y............ R2........... ........... 17.8499 $759.39 $759.39
of spinal cord.
63650........ Implant N............ H8........... $446.00 71.6329 $3,047.48 $2,552.76
neuroelectrode
s.
63655........ Implant N............ J8........... ........... 109.1028 $4,641.56 $4,641.56
neuroelectrode
s.
63660........ Revise/remove Y............ A2........... $333.00 17.8334 $758.69 $439.42
neuroelectrode.
63685........ Insrt/redo Y............ H8........... $446.00 251.0862 $10,681.96 $9,721.25
spine n
generator.
63688........ Revise/remove Y............ A2........... $333.00 35.5702 $1,513.26 $628.07
neuroreceiver.
63744........ Revision of Y............ A2........... $510.00 39.2633 $1,670.38 $800.10
spinal shunt.
63746........ Removal of Y............ A2........... $446.00 10.9918 $467.62 $451.41
spinal shunt.
64400........ Nblock inj, Y............ P3........... ........... 1.3198 $56.15 $56.15
trigeminal.
64402........ Nblock inj, Y............ P3........... ........... 1.2312 $52.38 $52.38
facial.
64405........ Nblock inj, Y............ P3........... ........... 1.0542 $44.85 $44.85
occipital.
64408........ Nblock inj, Y............ P3........... ........... 1.2232 $52.04 $52.04
vagus.
64410........ Nblock inj, Y............ A2........... $333.00 5.7253 $243.57 $310.64
phrenic.
64412........ Nblock inj, Y............ P3........... ........... 1.8830 $80.11 $80.11
spinal
accessor.
64413........ Nblock inj, Y............ P3........... ........... 1.2554 $53.41 $53.41
cervical
plexus.
64415........ Nblock inj, Y............ A2........... $139.00 2.2614 $96.21 $128.30
brachial
plexus.
64416........ Nblock cont Y............ G2........... ........... 2.2614 $96.21 $96.21
infuse, b plex.
64417........ Nblock inj, Y............ A2........... $139.00 2.2614 $96.21 $128.30
axillary.
64418........ Nblock inj, Y............ P3........... ........... 1.8026 $76.69 $76.69
suprascapular.
64420........ Nblock inj, Y............ A2........... $139.00 2.2614 $96.21 $128.30
intercost, sng.
64421........ Nblock inj, Y............ A2........... $333.00 5.7253 $243.57 $310.64
intercost, mlt.
64425........ Nblock inj, Y............ P3........... ........... 1.1990 $51.01 $51.01
ilio-ing/
hypogi.
64430........ Nblock inj, Y............ A2........... $139.00 2.2614 $96.21 $128.30
pudendal.
64435........ Nblock inj, Y............ P3........... ........... 1.8026 $76.69 $76.69
paracervical.
64445........ Nblock inj, Y............ P3........... ........... 1.7382 $73.95 $73.95
sciatic, sng.
64446........ Nblk inj, Y............ G2........... ........... 5.7253 $243.57 $243.57
sciatic, cont
inf.
64447........ Nblock inj fem, Y............ G2........... ........... 2.2614 $96.21 $96.21
single.
64450........ Nblock, other Y............ P3........... ........... 1.0140 $43.14 $43.14
peripheral.
64470........ Inj Y............ A2........... $333.00 6.3603 $270.59 $317.40
paravertebral
c/t.
64472........ Inj Y............ A2........... $333.00 5.7253 $243.57 $310.64
paravertebral
c/t add-on.
64475........ Inj Y............ A2........... $333.00 6.3603 $270.59 $317.40
paravertebral
l/s.
64476........ Inj Y............ A2........... $333.00 5.7253 $243.57 $310.64
paravertebral
l/s add-on.
64479........ Inj foramen Y............ A2........... $333.00 6.3603 $270.59 $317.40
epidural c/t.
64480........ Inj foramen Y............ A2........... $333.00 6.3603 $270.59 $317.40
epidural add-
on.
[[Page 42596]]
64483........ Inj foramen Y............ A2........... $333.00 6.3603 $270.59 $317.40
epidural l/s.
64484........ Inj foramen Y............ A2........... $333.00 6.3603 $270.59 $317.40
epidural add-
on.
64505........ Nblock, Y............ P3........... ........... 0.9416 $40.06 $40.06
spenopalatine
gangl.
64508........ Nblock, carotid Y............ P3........... ........... 2.0922 $89.01 $89.01
sinus s/p.
64510........ Nblock, Y............ A2........... $333.00 6.3603 $270.59 $317.40
stellate
ganglion.
64517........ Nblock inj, Y............ A2........... $139.00 2.2614 $96.21 $128.30
hypogas plxs.
64520........ Nblock, lumbar/ Y............ A2........... $333.00 6.3603 $270.59 $317.40
thoracic.
64530........ Nblock inj, Y............ A2........... $333.00 6.3603 $270.59 $317.40
celiac pelus.
64553........ Implant N............ H8........... $333.00 307.2433 $13,071.05 $11,841.79
neuroelectrode
s.
64555........ Implant N............ J8........... ........... 71.6329 $3,047.48 $3,047.48
neuroelectrode
s.
64560........ Implant N............ J8........... ........... 71.6329 $3,047.48 $3,047.48
neuroelectrode
s.
64561........ Implant N............ H8........... $510.00 71.6329 $3,047.48 $2,600.76
neuroelectrode
s.
64565........ Implant N............ J8........... ........... 71.6329 $3,047.48 $3,047.48
neuroelectrode
s.
64573........ Implant N............ H8........... $333.00 307.2433 $13,071.05 $11,841.79
neuroelectrode
s.
64575........ Implant N............ H8........... $333.00 109.1028 $4,641.56 $3,818.33
neuroelectrode
s.
64577........ Implant N............ H8........... $333.00 109.1028 $4,641.56 $3,818.33
neuroelectrode
s.
64580........ Implant N............ H8........... $333.00 109.1028 $4,641.56 $3,818.33
neuroelectrode
s.
64581........ Implant N............ H8........... $510.00 109.1028 $4,641.56 $3,951.08
neuroelectrode
s.
64585........ Revise/remove Y............ A2........... $333.00 17.8334 $758.69 $439.42
neuroelectrode.
64590........ Insrt/redo pn/ Y............ H8........... $446.00 251.0862 $10,681.96 $9,721.25
gastr stimul.
64595........ Revise/rmv pn/ Y............ A2........... $333.00 35.5702 $1,513.26 $628.07
gastr stimul.
64600........ Injection Y............ A2........... $333.00 12.1702 $517.76 $379.19
treatment of
nerve.
64605........ Injection Y............ A2........... $333.00 12.1702 $517.76 $379.19
treatment of
nerve.
64610........ Injection Y............ A2........... $333.00 12.1702 $517.76 $379.19
treatment of
nerve.
64612........ Destroy nerve, Y............ P3........... ........... 1.6579 $70.53 $70.53
face muscle.
64613........ Destroy nerve, Y............ P3........... ........... 1.7302 $73.61 $73.61
neck muscle.
64614........ Destroy nerve, Y............ P3........... ........... 1.9474 $82.85 $82.85
extrem musc.
64620........ Injection Y............ A2........... $333.00 12.1702 $517.76 $379.19
treatment of
nerve.
64622........ Destr Y............ A2........... $333.00 12.1702 $517.76 $379.19
paravertebrl
nerve l/s.
64623........ Destr Y............ A2........... $333.00 6.3603 $270.59 $317.40
paravertebral
n add-on.
64626........ Destr Y............ A2........... $333.00 12.1702 $517.76 $379.19
paravertebrl
nerve c/t.
64627........ Destr Y............ A2........... $333.00 6.3603 $270.59 $317.40
paravertebral
n add-on.
64630........ Injection Y............ A2........... $351.92 5.7253 $243.57 $324.83
treatment of
nerve.
64640........ Injection Y............ P3........... ........... 2.6716 $113.66 $113.66
treatment of
nerve.
64650........ Chemodenerv Y............ G2........... ........... 2.2614 $96.21 $96.21
eccrine glands.
64653........ Chemodenerv Y............ G2........... ........... 2.2614 $96.21 $96.21
eccrine glands.
64680........ Injection Y............ A2........... $390.95 6.3603 $270.59 $360.86
treatment of
nerve.
64681........ Injection Y............ A2........... $446.00 12.1702 $517.76 $463.94
treatment of
nerve.
64702........ Revise finger/ Y............ A2........... $333.00 17.8499 $759.39 $439.60
toe nerve.
64704........ Revise hand/ Y............ A2........... $333.00 17.8499 $759.39 $439.60
foot nerve.
64708........ Revise arm/leg Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve.
64712........ Revision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
sciatic nerve.
64713........ Revision of arm Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve(s).
64714........ Revise low back Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve(s).
64716........ Revision of Y............ A2........... $510.00 17.8499 $759.39 $572.35
cranial nerve.
64718........ Revise ulnar Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve at elbow.
64719........ Revise ulnar Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve at wrist.
64721........ Carpal tunnel Y............ A2........... $446.00 17.8499 $759.39 $524.35
surgery.
64722........ Relieve Y............ A2........... $333.00 17.8499 $759.39 $439.60
pressure on
nerve(s).
64726........ Release foot/ Y............ A2........... $333.00 17.8499 $759.39 $439.60
toe nerve.
64727........ Internal nerve Y............ A2........... $333.00 17.8499 $759.39 $439.60
revision.
64732........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
brow nerve.
64734........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
cheek nerve.
64736........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
chin nerve.
64738........ Incision of jaw Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve.
64740........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
tongue nerve.
64742........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
facial nerve.
64744........ Incise nerve, Y............ A2........... $446.00 17.8499 $759.39 $524.35
back of head.
64746........ Incise Y............ A2........... $446.00 17.8499 $759.39 $524.35
diaphragm
nerve.
64761........ Incision of Y............ G2........... ........... 17.8499 $759.39 $759.39
pelvis nerve.
64763........ Incise hip/ Y............ G2........... ........... 17.8499 $759.39 $759.39
thigh nerve.
64766........ Incise hip/ Y............ G2........... ........... 33.1520 $1,410.39 $1,410.39
thigh nerve.
64771........ Sever cranial Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve.
[[Page 42597]]
64772........ Incision of Y............ A2........... $446.00 17.8499 $759.39 $524.35
spinal nerve.
64774........ Remove skin Y............ A2........... $446.00 17.8499 $759.39 $524.35
nerve lesion.
64776........ Remove digit Y............ A2........... $510.00 17.8499 $759.39 $572.35
nerve lesion.
64778........ Digit nerve Y............ A2........... $446.00 17.8499 $759.39 $524.35
surgery add-on.
64782........ Remove limb Y............ A2........... $510.00 17.8499 $759.39 $572.35
nerve lesion.
64783........ Limb nerve Y............ A2........... $446.00 17.8499 $759.39 $524.35
surgery add-on.
64784........ Remove nerve Y............ A2........... $510.00 17.8499 $759.39 $572.35
lesion.
64786........ Remove sciatic Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
nerve lesion.
64787........ Implant nerve Y............ A2........... $446.00 17.8499 $759.39 $524.35
end.
64788........ Remove skin Y............ A2........... $510.00 17.8499 $759.39 $572.35
nerve lesion.
64790........ Removal of Y............ A2........... $510.00 17.8499 $759.39 $572.35
nerve lesion.
64792........ Removal of Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
nerve lesion.
64795........ Biopsy of nerve Y............ A2........... $446.00 17.8499 $759.39 $524.35
64802........ Remove Y............ A2........... $446.00 17.8499 $759.39 $524.35
sympathetic
nerves.
64820........ Remove Y............ G2........... ........... 17.8499 $759.39 $759.39
sympathetic
nerves.
64821........ Remove Y............ A2........... $630.00 25.8758 $1,100.83 $747.71
sympathetic
nerves.
64822........ Remove Y............ G2........... ........... 25.8758 $1,100.83 $1,100.83
sympathetic
nerves.
64823........ Remove Y............ G2........... ........... 25.8758 $1,100.83 $1,100.83
sympathetic
nerves.
64831........ Repair of digit Y............ A2........... $630.00 33.1520 $1,410.39 $825.10
nerve.
64832........ Repair nerve Y............ A2........... $333.00 33.1520 $1,410.39 $602.35
add-on.
64834........ Repair of hand Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
or foot nerve.
64835........ Repair of hand Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
or foot nerve.
64836........ Repair of hand Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
or foot nerve.
64837........ Repair nerve Y............ A2........... $333.00 33.1520 $1,410.39 $602.35
add-on.
64840........ Repair of leg Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
nerve.
64856........ Repair/ Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
transpose
nerve.
64857........ Repair arm/leg Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
nerve.
64858........ Repair sciatic Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
nerve.
64859........ Nerve surgery.. Y............ A2........... $333.00 33.1520 $1,410.39 $602.35
64861........ Repair of arm Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
nerves.
64862........ Repair of low Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
back nerves.
64864........ Repair of Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
facial nerve.
64865........ Repair of Y............ A2........... $630.00 33.1520 $1,410.39 $825.10
facial nerve.
64870........ Fusion of Y............ A2........... $630.00 33.1520 $1,410.39 $825.10
facial/other
nerve.
64872........ Subsequent Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
repair of
nerve.
64874........ Repair & revise Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
nerve add-on.
64876........ Repair nerve/ Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
shorten bone.
64885........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
head or neck.
64886........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
head or neck.
64890........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
hand or foot.
64891........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
hand or foot.
64892........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
arm or leg.
64893........ Nerve graft, Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
arm or leg.
64895........ Nerve graft, Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
hand or foot.
64896........ Nerve graft, Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
hand or foot.
64897........ Nerve graft, Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
arm or leg.
64898........ Nerve graft, Y............ A2........... $510.00 33.1520 $1,410.39 $735.10
arm or leg.
64901........ Nerve graft add- Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
on.
64902........ Nerve graft add- Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
on.
64905........ Nerve pedicle Y............ A2........... $446.00 33.1520 $1,410.39 $687.10
transfer.
64907........ Nerve pedicle Y............ A2........... $333.00 33.1520 $1,410.39 $602.35
transfer.
65091........ Revise eye..... Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
65093........ Revise eye with Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
implant.
65101........ Removal of eye. Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
65103........ Remove eye/ Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
insert implant.
65105........ Remove eye/ Y............ A2........... $630.00 35.2292 $1,498.76 $847.19
attach implant.
65110........ Removal of eye. Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
65112........ Remove eye/ Y............ A2........... $995.00 35.2292 $1,498.76 $1,120.94
revise socket.
65114........ Remove eye/ Y............ A2........... $995.00 35.2292 $1,498.76 $1,120.94
revise socket.
65125........ Revise ocular Y............ G2........... ........... 17.1243 $728.52 $728.52
implant.
65130........ Insert ocular Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
implant.
65135........ Insert ocular Y............ A2........... $446.00 25.2550 $1,074.42 $603.11
implant.
65140........ Attach ocular Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
implant.
[[Page 42598]]
65150........ Revise ocular Y............ A2........... $446.00 25.2550 $1,074.42 $603.11
implant.
65155........ Reinsert ocular Y............ A2........... $510.00 35.2292 $1,498.76 $757.19
implant.
65175........ Removal of Y............ A2........... $333.00 17.1243 $728.52 $431.88
ocular implant.
65205........ Remove foreign N............ P3........... ........... 0.4990 $21.23 $21.23
body from eye.
65210........ Remove foreign N............ P3........... ........... 0.6196 $26.36 $26.36
body from eye.
65220........ Remove foreign N............ G2........... ........... 1.1607 $49.38 $49.38
body from eye.
65222........ Remove foreign N............ P3........... ........... 0.6840 $29.10 $29.10
body from eye.
65235........ Remove foreign Y............ A2........... $446.00 15.2259 $647.76 $496.44
body from eye.
65260........ Remove foreign Y............ A2........... $510.00 16.5239 $702.98 $558.25
body from eye.
65265........ Remove foreign Y............ A2........... $630.00 27.6020 $1,174.27 $766.07
body from eye.
65270........ Repair of eye Y............ A2........... $446.00 17.1243 $728.52 $516.63
wound.
65272........ Repair of eye Y............ A2........... $446.00 22.9970 $978.36 $579.09
wound.
65275........ Repair of eye Y............ A2........... $630.00 22.9970 $978.36 $717.09
wound.
65280........ Repair of eye Y............ A2........... $630.00 16.5239 $702.98 $648.25
wound.
65285........ Repair of eye Y............ A2........... $630.00 37.4290 $1,592.34 $870.59
wound.
65286........ Repair of eye Y............ P2........... ........... 6.0673 $258.12 $258.12
wound.
65290........ Repair of eye Y............ A2........... $510.00 21.2801 $905.32 $608.83
socket wound.
65400........ Removal of eye Y............ A2........... $333.00 15.2259 $647.76 $411.69
lesion.
65410........ Biopsy of Y............ A2........... $446.00 15.2259 $647.76 $496.44
cornea.
65420........ Removal of eye Y............ A2........... $446.00 15.2259 $647.76 $496.44
lesion.
65426........ Removal of eye Y............ A2........... $717.00 22.9970 $978.36 $782.34
lesion.
65430........ Corneal smear.. N............ P3........... ........... 0.9736 $41.42 $41.42
65435........ Curette/treat Y............ P3........... ........... 0.7564 $32.18 $32.18
cornea.
65436........ Curette/treat Y............ G2........... ........... 15.2259 $647.76 $647.76
cornea.
65450........ Treatment of N............ G2........... ........... 2.1451 $91.26 $91.26
corneal lesion.
65600........ Revision of Y............ P3........... ........... 3.8707 $164.67 $164.67
cornea.
65710........ Corneal Y............ A2........... $995.00 38.2707 $1,628.15 $1,153.29
transplant.
65730........ Corneal Y............ A2........... $995.00 38.2707 $1,628.15 $1,153.29
transplant.
65750........ Corneal Y............ A2........... $995.00 38.2707 $1,628.15 $1,153.29
transplant.
65755........ Corneal Y............ A2........... $995.00 38.2707 $1,628.15 $1,153.29
transplant.
65770........ Revise cornea Y............ A2........... $995.00 51.9894 $2,211.78 $1,299.20
with implant.
65772........ Correction of Y............ A2........... $630.00 15.2259 $647.76 $634.44
astigmatism.
65775........ Correction of Y............ A2........... $630.00 15.2259 $647.76 $634.44
astigmatism.
65780........ Ocular reconst, Y............ A2........... $717.00 38.2707 $1,628.15 $944.79
transplant.
65781........ Ocular reconst, Y............ A2........... $717.00 38.2707 $1,628.15 $944.79
transplant.
65782........ Ocular reconst, Y............ A2........... $717.00 38.2707 $1,628.15 $944.79
transplant.
65800........ Drainage of eye Y............ A2........... $333.00 15.2259 $647.76 $411.69
65805........ Drainage of eye Y............ A2........... $333.00 15.2259 $647.76 $411.69
65810........ Drainage of eye Y............ A2........... $510.00 22.9970 $978.36 $627.09
65815........ Drainage of eye Y............ A2........... $446.00 22.9970 $978.36 $579.09
65820........ Relieve inner Y............ A2........... $333.00 6.0673 $258.12 $314.28
eye pressure.
65850........ Incision of eye Y............ A2........... $630.00 22.9970 $978.36 $717.09
65855........ Laser surgery Y............ P3........... ........... 3.1947 $135.91 $135.91
of eye.
65860........ Incise inner Y............ P3........... ........... 2.9855 $127.01 $127.01
eye adhesions.
65865........ Incise inner Y............ A2........... $333.00 15.2259 $647.76 $411.69
eye adhesions.
65870........ Incise inner Y............ A2........... $630.00 22.9970 $978.36 $717.09
eye adhesions.
65875........ Incise inner Y............ A2........... $630.00 22.9970 $978.36 $717.09
eye adhesions.
65880........ Incise inner Y............ A2........... $630.00 15.2259 $647.76 $634.44
eye adhesions.
65900........ Remove eye Y............ A2........... $717.00 15.2259 $647.76 $699.69
lesion.
65920........ Remove implant Y............ A2........... $995.00 22.9970 $978.36 $990.84
of eye.
65930........ Remove blood Y............ A2........... $717.00 22.9970 $978.36 $782.34
clot from eye.
66020........ Injection Y............ A2........... $333.00 15.2259 $647.76 $411.69
treatment of
eye.
66030........ Injection Y............ A2........... $333.00 6.0673 $258.12 $314.28
treatment of
eye.
66130........ Remove eye Y............ A2........... $995.00 22.9970 $978.36 $990.84
lesion.
66150........ Glaucoma Y............ A2........... $630.00 22.9970 $978.36 $717.09
surgery.
66155........ Glaucoma Y............ A2........... $630.00 22.9970 $978.36 $717.09
surgery.
66160........ Glaucoma Y............ A2........... $446.00 22.9970 $978.36 $579.09
surgery.
66165........ Glaucoma Y............ A2........... $630.00 22.9970 $978.36 $717.09
surgery.
66170........ Glaucoma Y............ A2........... $630.00 22.9970 $978.36 $717.09
surgery.
66172........ Incision of eye Y............ A2........... $630.00 22.9970 $978.36 $717.09
66180........ Implant eye Y............ A2........... $717.00 37.8967 $1,612.24 $940.81
shunt.
66185........ Revise eye Y............ A2........... $446.00 37.8967 $1,612.24 $737.56
shunt.
66220........ Repair eye Y............ A2........... $510.00 37.4290 $1,592.34 $780.59
lesion.
[[Page 42599]]
66225........ Repair/graft Y............ A2........... $630.00 37.8967 $1,612.24 $875.56
eye lesion.
66250........ Follow-up Y............ A2........... $446.00 15.2259 $647.76 $496.44
surgery of eye.
66500........ Incision of Y............ A2........... $333.00 6.0673 $258.12 $314.28
iris.
66505........ Incision of Y............ A2........... $333.00 6.0673 $258.12 $314.28
iris.
66600........ Remove iris and Y............ A2........... $510.00 22.9970 $978.36 $627.09
lesion.
66605........ Removal of iris Y............ A2........... $510.00 22.9970 $978.36 $627.09
66625........ Removal of iris Y............ A2........... $372.94 6.0673 $258.12 $344.24
66630........ Removal of iris Y............ A2........... $510.00 22.9970 $978.36 $627.09
66635........ Removal of iris Y............ A2........... $510.00 22.9970 $978.36 $627.09
66680........ Repair iris & Y............ A2........... $510.00 22.9970 $978.36 $627.09
ciliary body.
66682........ Repair iris & Y............ A2........... $446.00 22.9970 $978.36 $579.09
ciliary body.
66700........ Destruction, Y............ A2........... $446.00 15.2259 $647.76 $496.44
ciliary body.
66710........ Ciliary Y............ A2........... $446.00 15.2259 $647.76 $496.44
transsleral
therapy.
66711........ Ciliary Y............ A2........... $446.00 15.2259 $647.76 $496.44
endoscopic
ablation.
66720........ Destruction, Y............ A2........... $446.00 15.2259 $647.76 $496.44
ciliary body.
66740........ Destruction, Y............ A2........... $446.00 22.9970 $978.36 $579.09
ciliary body.
66761........ Revision of Y............ P3........... ........... 4.3375 $184.53 $184.53
iris.
66762........ Revision of Y............ P3........... ........... 4.4019 $187.27 $187.27
iris.
66770........ Removal of Y............ P3........... ........... 4.7639 $202.67 $202.67
inner eye
lesion.
66820........ Incision, Y............ G2........... ........... 6.0673 $258.12 $258.12
secondary
cataract.
66821........ After cataract Y............ A2........... $312.50 5.0839 $216.28 $288.45
laser surgery.
66825........ Reposition Y............ A2........... $630.00 22.9970 $978.36 $717.09
intraocular
lens.
66830........ Removal of lens Y............ A2........... $372.94 6.0673 $258.12 $344.24
lesion.
66840........ Removal of lens Y............ A2........... $630.00 14.8702 $632.62 $630.66
material.
66850........ Removal of lens Y............ A2........... $995.00 29.2281 $1,243.45 $1,057.11
material.
66852........ Removal of lens Y............ A2........... $630.00 29.2281 $1,243.45 $783.36
material.
66920........ Extraction of Y............ A2........... $630.00 29.2281 $1,243.45 $783.36
lens.
66930........ Extraction of Y............ A2........... $717.00 29.2281 $1,243.45 $848.61
lens.
66940........ Extraction of Y............ A2........... $717.00 14.8702 $632.62 $695.91
lens.
66982........ Cataract Y............ A2........... $973.00 23.6313 $1,005.35 $981.09
surgery,
complex.
66983........ Cataract surg w/ Y............ A2........... $973.00 23.6313 $1,005.35 $981.09
iol, 1 stage.
66984........ Cataract surg w/ Y............ A2........... $973.00 23.6313 $1,005.35 $981.09
iol, 1 stage.
66985........ Insert lens Y............ A2........... $826.00 23.6313 $1,005.35 $870.84
prosthesis.
66986........ Exchange lens Y............ A2........... $826.00 23.6313 $1,005.35 $870.84
prosthesis.
66990........ Ophthalmic ............. N1........... ........... ........... ........... ...........
endoscope add-
on.
67005........ Partial removal Y............ A2........... $630.00 27.6020 $1,174.27 $766.07
of eye fluid.
67010........ Partial removal Y............ A2........... $630.00 27.6020 $1,174.27 $766.07
of eye fluid.
67015........ Release of eye Y............ A2........... $333.00 27.6020 $1,174.27 $543.32
fluid.
67025........ Replace eye Y............ A2........... $333.00 27.6020 $1,174.27 $543.32
fluid.
67027........ Implant eye Y............ A2........... $630.00 37.4290 $1,592.34 $870.59
drug system.
67028........ Injection eye Y............ P3........... ........... 1.9876 $84.56 $84.56
drug.
67030........ Incise inner Y............ A2........... $333.00 16.5239 $702.98 $425.50
eye strands.
67031........ Laser surgery, Y............ A2........... $312.50 5.0839 $216.28 $288.45
eye strands.
67036........ Removal of Y............ A2........... $630.00 37.4290 $1,592.34 $870.59
inner eye
fluid.
67038........ Strip retinal Y............ A2........... $717.00 37.4290 $1,592.34 $935.84
membrane.
67039........ Laser treatment Y............ A2........... $995.00 37.4290 $1,592.34 $1,144.34
of retina.
67040........ Laser treatment Y............ A2........... $995.00 37.4290 $1,592.34 $1,144.34
of retina.
67101........ Repair detached Y............ P3........... ........... 7.2104 $306.75 $306.75
retina.
67105........ Repair detached Y............ P2........... ........... 5.0841 $216.29 $216.29
retina.
67107........ Repair detached Y............ A2........... $717.00 37.4290 $1,592.34 $935.84
retina.
67108........ Repair detached Y............ A2........... $995.00 37.4290 $1,592.34 $1,144.34
retina.
67110........ Repair detached Y............ P3........... ........... 7.8462 $333.80 $333.80
retina.
67112........ Rerepair Y............ A2........... $995.00 37.4290 $1,592.34 $1,144.34
detached
retina.
67115........ Release Y............ A2........... $446.00 16.5239 $702.98 $510.25
encircling
material.
67120........ Remove eye Y............ A2........... $446.00 16.5239 $702.98 $510.25
implant
material.
67121........ Remove eye Y............ A2........... $446.00 27.6020 $1,174.27 $628.07
implant
material.
67141........ Treatment of Y............ A2........... $241.77 3.9333 $167.33 $223.16
retina.
67145........ Treatment of Y............ P3........... ........... 4.5387 $193.09 $193.09
retina.
67208........ Treatment of Y............ P3........... ........... 4.8283 $205.41 $205.41
retinal lesion.
67210........ Treatment of Y............ P2........... ........... 5.0841 $216.29 $216.29
retinal lesion.
67218........ Treatment of Y............ A2........... $717.00 16.5239 $702.98 $713.50
retinal lesion.
67220........ Treatment of Y............ P2........... ........... 3.9333 $167.33 $167.33
choroid lesion.
67221........ Ocular Y............ P3........... ........... 2.9695 $126.33 $126.33
photodynamic
ther.
[[Page 42600]]
67225........ Eye Y............ P3........... ........... 0.2012 $8.56 $8.56
photodynamic
ther add-on.
67227........ Treatment of Y............ A2........... $333.00 27.6020 $1,174.27 $543.32
retinal lesion.
67228........ Treatment of Y............ P2........... ........... 5.0841 $216.29 $216.29
retinal lesion.
67250........ Reinforce eye Y............ A2........... $510.00 17.1243 $728.52 $564.63
wall.
67255........ Reinforce/graft Y............ A2........... $510.00 27.6020 $1,174.27 $676.07
eye wall.
67311........ Revise eye Y............ A2........... $510.00 21.2801 $905.32 $608.83
muscle.
67312........ Revise two eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscles.
67314........ Revise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscle.
67316........ Revise two eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscles.
67318........ Revise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscle(s).
67320........ Revise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscle(s) add-
on.
67331........ Eye surgery Y............ A2........... $630.00 21.2801 $905.32 $698.83
follow-up add-
on.
67332........ Rerevise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscles add-on.
67334........ Revise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscle w/
suture.
67335........ Eye suture Y............ A2........... $630.00 21.2801 $905.32 $698.83
during surgery.
67340........ Revise eye Y............ A2........... $630.00 21.2801 $905.32 $698.83
muscle add-on.
67343........ Release eye Y............ A2........... $995.00 21.2801 $905.32 $972.58
tissue.
67345........ Destroy nerve Y............ P3........... ........... 1.9634 $83.53 $83.53
of eye muscle.
67346........ Biopsy, eye Y............ A2........... $333.00 14.3845 $611.96 $402.74
muscle.
67400........ Explore/biopsy Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
eye socket.
67405........ Explore/drain Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
eye socket.
67412........ Explore/treat Y............ A2........... $717.00 25.2550 $1,074.42 $806.36
eye socket.
67413........ Explore/treat Y............ A2........... $717.00 25.2550 $1,074.42 $806.36
eye socket.
67414........ Explr/ Y............ G2........... ........... 35.2292 $1,498.76 $1,498.76
decompress eye
socket.
67415........ Aspiration, Y............ A2........... $333.00 17.1243 $728.52 $431.88
orbital
contents.
67420........ Explore/treat Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
eye socket.
67430........ Explore/treat Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
eye socket.
67440........ Explore/drain Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
eye socket.
67445........ Explr/ Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
decompress eye
socket.
67450........ Explore/biopsy Y............ A2........... $717.00 35.2292 $1,498.76 $912.44
eye socket.
67500........ Inject/treat N............ G2........... ........... 2.1451 $91.26 $91.26
eye socket.
67505........ Inject/treat Y............ G2........... ........... 2.8954 $123.18 $123.18
eye socket.
67515........ Inject/treat Y............ P3........... ........... 0.5714 $24.31 $24.31
eye socket.
67550........ Insert eye Y............ A2........... $630.00 35.2292 $1,498.76 $847.19
socket implant.
67560........ Revise eye Y............ A2........... $446.00 25.2550 $1,074.42 $603.11
socket implant.
67570........ Decompress Y............ A2........... $630.00 35.2292 $1,498.76 $847.19
optic nerve.
67700........ Drainage of Y............ P2........... ........... 2.8954 $123.18 $123.18
eyelid abscess.
67710........ Incision of Y............ P3........... ........... 3.6777 $156.46 $156.46
eyelid.
67715........ Incision of Y............ A2........... $333.00 17.1243 $728.52 $431.88
eyelid fold.
67800........ Remove eyelid Y............ P3........... ........... 1.2312 $52.38 $52.38
lesion.
67801........ Remove eyelid Y............ P3........... ........... 1.4888 $63.34 $63.34
lesions.
67805........ Remove eyelid Y............ P3........... ........... 1.9232 $81.82 $81.82
lesions.
67808........ Remove eyelid Y............ A2........... $446.00 17.1243 $728.52 $516.63
lesion(s).
67810........ Biopsy of Y............ P2........... ........... 2.8954 $123.18 $123.18
eyelid.
67820........ Revise N............ P3........... ........... 0.4264 $18.14 $18.14
eyelashes.
67825........ Revise Y............ P3........... ........... 1.2794 $54.43 $54.43
eyelashes.
67830........ Revise Y............ A2........... $446.00 7.2819 $309.79 $411.95
eyelashes.
67835........ Revise Y............ A2........... $446.00 17.1243 $728.52 $516.63
eyelashes.
67840........ Remove eyelid Y............ P3........... ........... 3.8063 $161.93 $161.93
lesion.
67850........ Treat eyelid Y............ P3........... ........... 2.6879 $114.35 $114.35
lesion.
67875........ Closure of Y............ G2........... ........... 7.2819 $309.79 $309.79
eyelid by
suture.
67880........ Revision of Y............ A2........... $510.00 15.2259 $647.76 $544.44
eyelid.
67882........ Revision of Y............ A2........... $510.00 17.1243 $728.52 $564.63
eyelid.
67900........ Repair brow Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67901........ Repair eyelid Y............ A2........... $717.00 17.1243 $728.52 $719.88
defect.
67902........ Repair eyelid Y............ A2........... $717.00 17.1243 $728.52 $719.88
defect.
67903........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67904........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67906........ Repair eyelid Y............ A2........... $717.00 17.1243 $728.52 $719.88
defect.
67908........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67909........ Revise eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67911........ Revise eyelid Y............ A2........... $510.00 17.1243 $728.52 $564.63
defect.
67912........ Correction Y............ A2........... $510.00 17.1243 $728.52 $564.63
eyelid w/
implant.
[[Page 42601]]
67914........ Repair eyelid Y............ A2........... $510.00 17.1243 $728.52 $564.63
defect.
67915........ Repair eyelid Y............ P3........... ........... 4.2329 $180.08 $180.08
defect.
67916........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67917........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67921........ Repair eyelid Y............ A2........... $510.00 17.1243 $728.52 $564.63
defect.
67922........ Repair eyelid Y............ P3........... ........... 4.1685 $177.34 $177.34
defect.
67923........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67924........ Repair eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
defect.
67930........ Repair eyelid Y............ P3........... ........... 4.1121 $174.94 $174.94
wound.
67935........ Repair eyelid Y............ A2........... $446.00 17.1243 $728.52 $516.63
wound.
67938........ Remove eyelid N............ P2........... ........... 1.1607 $49.38 $49.38
foreign body.
67950........ Revision of Y............ A2........... $446.00 17.1243 $728.52 $516.63
eyelid.
67961........ Revision of Y............ A2........... $510.00 17.1243 $728.52 $564.63
eyelid.
67966........ Revision of Y............ A2........... $510.00 17.1243 $728.52 $564.63
eyelid.
67971........ Reconstruction Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
of eyelid.
67973........ Reconstruction Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
of eyelid.
67974........ Reconstruction Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
of eyelid.
67975........ Reconstruction Y............ A2........... $510.00 17.1243 $728.52 $564.63
of eyelid.
68020........ Incise/drain Y............ P3........... ........... 1.0864 $46.22 $46.22
eyelid lining.
68040........ Treatment of N............ P3........... ........... 0.5392 $22.94 $22.94
eyelid lesions.
68100........ Biopsy of Y............ P3........... ........... 2.2775 $96.89 $96.89
eyelid lining.
68110........ Remove eyelid Y............ P3........... ........... 2.9131 $123.93 $123.93
lining lesion.
68115........ Remove eyelid Y............ A2........... $446.00 17.1243 $728.52 $516.63
lining lesion.
68130........ Remove eyelid Y............ A2........... $446.00 15.2259 $647.76 $496.44
lining lesion.
68135........ Remove eyelid Y............ P3........... ........... 1.3922 $59.23 $59.23
lining lesion.
68200........ Treat eyelid by N............ P3........... ........... 0.4024 $17.12 $17.12
injection.
68320........ Revise/graft Y............ A2........... $630.00 17.1243 $728.52 $654.63
eyelid lining.
68325........ Revise/graft Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
eyelid lining.
68326........ Revise/graft Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
eyelid lining.
68328........ Revise/graft Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
eyelid lining.
68330........ Revise eyelid Y............ A2........... $630.00 22.9970 $978.36 $717.09
lining.
68335........ Revise/graft Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
eyelid lining.
68340........ Separate eyelid Y............ A2........... $630.00 17.1243 $728.52 $654.63
adhesions.
68360........ Revise eyelid Y............ A2........... $446.00 22.9970 $978.36 $579.09
lining.
68362........ Revise eyelid Y............ A2........... $446.00 22.9970 $978.36 $579.09
lining.
68371........ Harvest eye Y............ A2........... $446.00 15.2259 $647.76 $496.44
tissue,
alograft.
68400........ Incise/drain Y............ P2........... ........... 2.8954 $123.18 $123.18
tear gland.
68420........ Incise/drain Y............ P3........... ........... 4.3777 $186.24 $186.24
tear sac.
68440........ Incise tear Y............ P3........... ........... 1.3520 $57.52 $57.52
duct opening.
68500........ Removal of tear Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
gland.
68505........ Partial Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
removal, tear
gland.
68510........ Biopsy of tear Y............ A2........... $333.00 17.1243 $728.52 $431.88
gland.
68520........ Removal of tear Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
sac.
68525........ Biopsy of tear Y............ A2........... $333.00 17.1243 $728.52 $431.88
sac.
68530........ Clearance of Y............ P3........... ........... 5.5929 $237.94 $237.94
tear duct.
68540........ Remove tear Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
gland lesion.
68550........ Remove tear Y............ A2........... $510.00 25.2550 $1,074.42 $651.11
gland lesion.
68700........ Repair tear Y............ A2........... $446.00 25.2550 $1,074.42 $603.11
ducts.
68705........ Revise tear Y............ P2........... ........... 2.8954 $123.18 $123.18
duct opening.
68720........ Create tear sac Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
drain.
68745........ Create tear Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
duct drain.
68750........ Create tear Y............ A2........... $630.00 25.2550 $1,074.42 $741.11
duct drain.
68760........ Close tear duct N............ P2........... ........... 2.1451 $91.26 $91.26
opening.
68761........ Close tear duct N............ P3........... ........... 1.6658 $70.87 $70.87
opening.
68770........ Close tear Y............ A2........... $630.00 17.1243 $728.52 $654.63
system fistula.
68801........ Dilate tear N............ P2........... ........... 1.1607 $49.38 $49.38
duct opening.
68810........ Probe N............ A2........... $131.86 2.1451 $91.26 $121.71
nasolacrimal
duct.
68811........ Probe Y............ A2........... $446.00 17.1243 $728.52 $516.63
nasolacrimal
duct.
68815........ Probe Y............ A2........... $446.00 17.1243 $728.52 $516.63
nasolacrimal
duct.
68840........ Explore/ N............ P2........... ........... 1.1607 $49.38 $49.38
irrigate tear
ducts.
68850........ Injection for ............. N1........... ........... ........... ........... ...........
tear sac x-ray.
69000........ Drain external Y............ P2........... ........... 1.4392 $61.23 $61.23
ear lesion.
69005........ Drain external Y............ P3........... ........... 2.2934 $97.57 $97.57
ear lesion.
[[Page 42602]]
69020........ Drain outer ear Y............ P2........... ........... 1.4392 $61.23 $61.23
canal lesion.
69100........ Biopsy of Y............ P3........... ........... 1.4404 $61.28 $61.28
external ear.
69105........ Biopsy of Y............ P3........... ........... 1.9474 $82.85 $82.85
external ear
canal.
69110........ Remove external Y............ A2........... $333.00 15.1024 $642.50 $410.38
ear, partial.
69120........ Removal of Y............ A2........... $446.00 23.3299 $992.52 $582.63
external ear.
69140........ Remove ear Y............ A2........... $446.00 23.3299 $992.52 $582.63
canal
lesion(s).
69145........ Remove ear Y............ A2........... $446.00 15.1024 $642.50 $495.13
canal
lesion(s).
69150........ Extensive ear Y............ A2........... $464.15 7.5511 $321.25 $428.43
canal surgery.
69200........ Clear outer ear N............ P2........... ........... 0.6102 $25.96 $25.96
canal.
69205........ Clear outer ear Y............ A2........... $333.00 20.0656 $853.65 $463.16
canal.
69210........ Remove impacted N............ P3........... ........... 0.4748 $20.20 $20.20
ear wax.
69220........ Clean out Y............ P2........... ........... 0.8432 $35.87 $35.87
mastoid cavity.
69222........ Clean out Y............ P3........... ........... 3.0339 $129.07 $129.07
mastoid cavity.
69300........ Revise external Y............ A2........... $510.00 23.3299 $992.52 $630.63
ear.
69310........ Rebuild outer Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
ear canal.
69320........ Rebuild outer Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear canal.
69400........ Inflate middle Y............ P3........... ........... 1.9152 $81.48 $81.48
ear canal.
69401........ Inflate middle Y............ P3........... ........... 1.0944 $46.56 $46.56
ear canal.
69405........ Catheterize Y............ P3........... ........... 2.7842 $118.45 $118.45
middle ear
canal.
69420........ Incision of Y............ P2........... ........... 2.4520 $104.32 $104.32
eardrum.
69421........ Incision of Y............ A2........... $510.00 16.4266 $698.84 $557.21
eardrum.
69424........ Remove Y............ P3........... ........... 1.7542 $74.63 $74.63
ventilating
tube.
69433........ Create eardrum Y............ P3........... ........... 2.4787 $105.45 $105.45
opening.
69436........ Create eardrum Y............ A2........... $510.00 16.4266 $698.84 $557.21
opening.
69440........ Exploration of Y............ A2........... $510.00 23.3299 $992.52 $630.63
middle ear.
69450........ Eardrum Y............ A2........... $333.00 38.1991 $1,625.10 $656.03
revision.
69501........ Mastoidectomy.. Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
69502........ Mastoidectomy.. Y............ A2........... $995.00 23.3299 $992.52 $994.38
69505........ Remove mastoid Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
structures.
69511........ Extensive Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
mastoid
surgery.
69530........ Extensive Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
mastoid
surgery.
69540........ Remove ear Y............ P3........... ........... 2.9615 $125.99 $125.99
lesion.
69550........ Remove ear Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
lesion.
69552........ Remove ear Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
lesion.
69601........ Mastoid surgery Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
revision.
69602........ Mastoid surgery Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
revision.
69603........ Mastoid surgery Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
revision.
69604........ Mastoid surgery Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
revision.
69605........ Mastoid surgery Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
revision.
69610........ Repair of Y............ P3........... ........... 4.0477 $172.20 $172.20
eardrum.
69620........ Repair of Y............ A2........... $446.00 23.3299 $992.52 $582.63
eardrum.
69631........ Repair eardrum Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
structures.
69632........ Rebuild eardrum Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
structures.
69633........ Rebuild eardrum Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
structures.
69635........ Repair eardrum Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
structures.
69636........ Rebuild eardrum Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
structures.
69637........ Rebuild eardrum Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
structures.
69641........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69642........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69643........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69644........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69645........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69646........ Revise middle Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69650........ Release middle Y............ A2........... $995.00 23.3299 $992.52 $994.38
ear bone.
69660........ Revise middle Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear bone.
69661........ Revise middle Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear bone.
69662........ Revise middle Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear bone.
69666........ Repair middle Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
ear structures.
69667........ Repair middle Y............ A2........... $630.00 38.1991 $1,625.10 $878.78
ear structures.
69670........ Remove mastoid Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
air cells.
69676........ Remove middle Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
ear nerve.
69700........ Close mastoid Y............ A2........... $510.00 38.1991 $1,625.10 $788.78
fistula.
69711........ Remove/repair Y............ A2........... $333.00 38.1991 $1,625.10 $656.03
hearing aid.
[[Page 42603]]
69714........ Implant temple Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
bone w/stimul.
69715........ Temple bne Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
implnt w/
stimulat.
69717........ Temple bone Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
implant
revision.
69718........ Revise temple Y............ A2........... $1,339.00 38.1991 $1,625.10 $1,410.53
bone implant.
69720........ Release facial Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
nerve.
69740........ Repair facial Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
nerve.
69745........ Repair facial Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
nerve.
69801........ Incise inner Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear.
69802........ Incise inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear.
69805........ Explore inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear.
69806........ Explore inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear.
69820........ Establish inner Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear window.
69840........ Revise inner Y............ A2........... $717.00 38.1991 $1,625.10 $944.03
ear window.
69905........ Remove inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear.
69910........ Remove inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear & mastoid.
69915........ Incise inner Y............ A2........... $995.00 38.1991 $1,625.10 $1,152.53
ear nerve.
69930........ Implant Y............ H8........... $995.00 587.7216 $25,003.44 $23,712.58
cochlear
device.
69990........ Microsurgery ............. N1........... ........... ........... ........... ...........
add-on.
C9716........ Radiofrequency Y............ G2........... ........... 29.6189 $1,260.08 $1,260.08
energy to anu.
C9724........ EPS gast cardia Y............ G2........... ........... 25.7552 $1,095.70 $1,095.70
plic.
C9725........ Place N............ G2........... ........... 8.9477 $380.66 $380.66
endorectal app.
C9726........ Rxt breast appl N............ G2........... ........... 10.5746 $449.88 $449.88
place/remov.
C9727........ Insert palate N............ G2........... ........... 13.8283 $588.30 $588.30
implants.
G0104........ CA screen;flexi N............ P3........... ........... 1.9152 $81.48 $81.48
sigmoidscope.
G0105........ Colorectal Y............ A2........... $446.00 7.8492 $333.93 $417.98
scrn; hi risk
ind.
G0121........ Colon ca scrn Y............ A2........... $446.00 7.8492 $333.93 $417.98
not hi rsk ind.
G0127........ Trim nail(s)... Y............ P3........... ........... 0.2494 $10.61 $10.61
G0186........ Dstry eye Y............ R2........... ........... 3.9333 $167.33 $167.33
lesn,fdr vssl
tech.
G0247........ Routine Y............ P3........... ........... 0.4828 $20.54 $20.54
footcare pt w
lops.
G0259........ Inject for ............. N1........... ........... ........... ........... ...........
sacroiliac
joint.
G0260........ Inj for Y............ A2........... $333.00 5.7253 $243.57 $310.64
sacroiliac jt
anesth.
G0268........ Removal of N............ P3........... ........... 0.4990 $21.23 $21.23
impacted wax
md.
G0269........ Occlusive ............. N1........... ........... ........... ........... ...........
device in vein
art.
G0289........ Arthro, loose ............. N1........... ........... ........... ........... ...........
body + chondro.
G0297........ Insert single Y............ J8........... ........... 440.1206 $18,724.05 $18,724.05
chamber/cd.
G0298........ Insert dual Y............ J8........... ........... 440.1206 $18,724.05 $18,724.05
chamber/cd.
G0299........ Inser/repos Y............ J8........... ........... 546.9370 $23,268.34 $23,268.34
single
icd+leads.
G0300........ Insert reposit Y............ J8........... ........... 546.9370 $23,268.34 $23,268.34
lead dual+gen.
G0364........ Bone marrow Y............ P3........... ........... 0.1208 $5.14 $5.14
aspirate &
biopsy.
G0392........ AV fistula or Y............ A2........... $1,339.00 42.9360 $1,826.63 $1,460.91
graft arterial.
G0393........ AV fistula or Y............ A2........... $1,339.00 42.9360 $1,826.63 $1,460.91
graft venous.
----------------------------------------------------------------------------------------------------------------
Note: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20
percent of the total payment amount, except for screening flexible sigmoidoscopies and screening colonoscopies
for which the program payment is 75 percent and the beneficiary coinsurance is 25 percent.
* Refers to codes designated as ``office-based,'' whose designation as office-based is temporary because we have
insufficient claims data. We will reconsider this designation when new claims data become available.
[[Page 42603]]
[[Page 42604]]
--------------------
Note: The Medicare program payment is 80 percent of the total payment
amount and beneficiary coinsurance is 20 percent of the total payment
amount, except for screening flexible sigmoidoscopies and screening
colonoscopies for which the program payment is 75 percent and the
beneficiary coinsurance is 25 percent.
[[Page 42604]]
Addendum BB.--Illustrative ASC Covered Ancillary Services Integral to
Covered Surgical Procedures for CY 2008 (Including Ancillary Services
for Which Payment is Packaged)
------------------------------------------------------------------------
Estimated
Short Payment CY 2008 Estimated
HCPCS code descriptor indicator payment CY 2008
weights payment
------------------------------------------------------------------------
0028T......... Dexa body N1........... ........... ...........
composition
study.
0042T......... Ct perfusion w/ N1........... ........... ...........
contrast, cbf.
0054T......... Bone surgery Z2........... 4.9138 $209.05
using computer.
0055T......... Bone surgery Z2........... 4.9138 $209.05
using computer.
0056T......... Bone surgery Z2........... 4.9138 $209.05
using computer.
0067T......... Ct Z2........... 4.8405 $205.93
colonography;d
x.
0071T......... U/s leiomyomata Z2........... 28.5095 $1,212.88
ablate < 200.
0072T......... U/s leiomyomata Z2........... 42.9896 $1,828.91
ablate >200.
0073T......... Delivery, comp Z2........... 5.4731 $232.84
imrt.
0126T......... Chd risk imt N1........... ........... ...........
study.
0144T......... CT heart wo Z2........... 4.1265 $175.55
dye; qual calc.
0145T......... CT heart w/wo Z2........... 4.9832 $212.00
dye funct.
0146T......... CCTA w/wo dye.. Z2........... 4.9832 $212.00
0147T......... CCTA w/wo, quan Z2........... 4.9832 $212.00
calcium.
0148T......... CCTA w/wo, Z2........... 6.5012 $276.58
strxr.
0149T......... CCTA w/wo, Z2........... 6.5012 $276.58
strxr quan
calc.
0150T......... CCTA w/wo, Z2........... 4.1265 $175.55
disease strxr.
0151T......... CT heart funct Z2........... 1.5379 $65.43
add-on.
0159T......... Cad breast mri. N1........... ........... ...........
0174T......... Cad cxr with N1........... ........... ...........
interp.
0175T......... Cad cxr remote. N1........... ........... ...........
70010......... Contrast x-ray Z2........... 2.5544 $108.67
of brain.
70015......... Contrast x-ray Z3........... 1.4806 $62.99
of brain.
70030......... X-ray eye for Z3........... 0.3782 $16.09
foreign body.
70100......... X-ray exam of Z3........... 0.4346 $18.49
jaw.
70110......... X-ray exam of Z3........... 0.5230 $22.25
jaw.
70120......... X-ray exam of Z3........... 0.4990 $21.23
mastoids.
70130......... X-ray exam of Z2........... 0.7093 $30.18
mastoids.
70134......... X-ray exam of Z3........... 0.6036 $25.68
middle ear.
70140......... X-ray exam of Z3........... 0.4346 $18.49
facial bones.
70150......... X-ray exam of Z3........... 0.6116 $26.02
facial bones.
70160......... X-ray exam of Z3........... 0.4506 $19.17
nasal bones.
70170......... X-ray exam of Z2........... 2.9586 $125.87
tear duct.
70190......... X-ray exam of Z3........... 0.4990 $21.23
eye sockets.
70200......... X-ray exam of Z3........... 0.6116 $26.02
eye sockets.
70210......... X-ray exam of Z3........... 0.4506 $19.17
sinuses.
70220......... X-ray exam of Z3........... 0.5632 $23.96
sinuses.
70240......... X-ray exam, Z3........... 0.3862 $16.43
pituitary
saddle.
70250......... X-ray exam of Z3........... 0.4908 $20.88
skull.
70260......... X-ray exam of Z3........... 0.6518 $27.73
skull.
70300......... X-ray exam of Z3........... 0.1932 $8.22
teeth.
70310......... X-ray exam of Z3........... 0.4828 $20.54
teeth.
70320......... Full mouth x- Z2........... 0.6550 $27.87
ray of teeth.
70328......... X-ray exam of Z3........... 0.4104 $17.46
jaw joint.
70330......... X-ray exam of Z3........... 0.6920 $29.44
jaw joints.
70332......... X-ray exam of Z3........... 1.3520 $57.52
jaw joint.
70336......... Magnetic image, Z2........... 4.5523 $193.67
jaw joint.
70350......... X-ray head for Z3........... 0.2576 $10.96
orthodontia.
70355......... Panoramic x-ray Z3........... 0.3218 $13.69
of jaws.
70360......... X-ray exam of Z3........... 0.3622 $15.41
neck.
70370......... Throat x-ray & Z3........... 1.1346 $48.27
fluoroscopy.
70371......... Speech Z2........... 1.2908 $54.91
evaluation,
complex.
70373......... Contrast x-ray Z3........... 1.3036 $55.46
of larynx.
70380......... X-ray exam of Z3........... 0.5714 $24.31
salivary gland.
70390......... X-ray exam of Z3........... 1.5612 $66.42
salivary duct.
70450......... Ct head/brain w/ Z2........... 3.0908 $131.49
o dye.
70460......... Ct head/brain w/ Z2........... 4.0825 $173.68
dye.
70470......... Ct head/brain w/ Z2........... 4.8405 $205.93
o & w/dye.
70480......... Ct orbit/ear/ Z2........... 3.0908 $131.49
fossa w/o dye.
70481......... Ct orbit/ear/ Z2........... 4.0825 $173.68
fossa w/dye.
70482......... Ct orbit/ear/ Z2........... 4.8405 $205.93
fossa w/o & w/
dye.
70486......... Ct Z2........... 3.0908 $131.49
maxillofacial
w/o dye.
70487......... Ct Z2........... 4.0825 $173.68
maxillofacial
w/dye.
70488......... Ct Z2........... 4.8405 $205.93
maxillofacial
w/o & w/dye.
[[Page 42605]]
70490......... Ct soft tissue Z2........... 3.0908 $131.49
neck w/o dye.
70491......... Ct soft tissue Z2........... 4.0825 $173.68
neck w/dye.
70492......... Ct sft tsue nck Z2........... 4.8405 $205.93
w/o & w/dye.
70496......... Ct angiography, Z2........... 4.8552 $206.55
head.
70498......... Ct angiography, Z2........... 4.8552 $206.55
neck.
70540......... Mri orbit/face/ Z2........... 5.6745 $241.41
neck w/o dye.
70542......... Mri orbit/face/ Z2........... 6.1231 $260.50
neck w/dye.
70543......... Mri orbt/fac/ Z2........... 8.1155 $345.26
nck w/o & w/
dye.
70544......... Mr angiography Z2........... 5.6745 $241.41
head w/o dye.
70545......... Mr angiography Z2........... 6.1231 $260.50
head w/dye.
70546......... Mr angiograph Z2........... 8.1155 $345.26
head w/o & w/
dye.
70547......... Mr angiography Z2........... 5.6745 $241.41
neck w/o dye.
70548......... Mr angiography Z2........... 6.1231 $260.50
neck w/dye.
70549......... Mr angiograph Z2........... 8.1155 $345.26
neck w/o & w/
dye.
70551......... Mri brain w/o Z2........... 5.6745 $241.41
dye.
70552......... Mri brain w/dye Z2........... 6.1231 $260.50
70553......... Mri brain w/o & Z2........... 8.1155 $345.26
w/dye.
70554......... Fmri brain by Z2........... 5.6745 $241.41
tech.
70555......... Fmri brain by Z2........... 5.6745 $241.41
phys/psych.
70557......... Mri brain w/o Z2........... 5.6745 $241.41
dye.
70558......... Mri brain w/dye Z2........... 6.1231 $260.50
70559......... Mri brain w/o & Z2........... 8.1155 $345.26
w/dye.
71010......... Chest x-ray.... Z3........... 0.3300 $14.04
71015......... Chest x-ray.... Z3........... 0.4024 $17.12
71020......... Chest x-ray.... Z3........... 0.4426 $18.83
71021......... Chest x-ray.... Z3........... 0.5392 $22.94
71022......... Chest x-ray.... Z3........... 0.6036 $25.68
71023......... Chest x-ray and Z3........... 0.8690 $36.97
fluoroscopy.
71030......... Chest x-ray.... Z3........... 0.6276 $26.70
71034......... Chest x-ray and Z2........... 1.2908 $54.91
fluoroscopy.
71035......... Chest x-ray.... Z3........... 0.4828 $20.54
71040......... Contrast x-ray Z3........... 1.3278 $56.49
of bronchi.
71060......... Contrast x-ray Z2........... 1.6956 $72.14
of bronchi.
71090......... X-ray & Z2........... 1.2908 $54.91
pacemaker
insertion.
71100......... X-ray exam of Z3........... 0.4426 $18.83
ribs.
71101......... X-ray exam of Z3........... 0.5230 $22.25
ribs/chest.
71110......... X-ray exam of Z3........... 0.5794 $24.65
ribs.
71111......... X-ray exam of Z3........... 0.7322 $31.15
ribs/chest.
71120......... X-ray exam of Z3........... 0.4748 $20.20
breastbone.
71130......... X-ray exam of Z3........... 0.5472 $23.28
breastbone.
71250......... Ct thorax w/o Z2........... 3.0908 $131.49
dye.
71260......... Ct thorax w/dye Z2........... 4.0825 $173.68
71270......... Ct thorax w/o & Z2........... 4.8405 $205.93
w/dye.
71275......... Ct angiography, Z2........... 4.8552 $206.55
chest.
71550......... Mri chest w/o Z2........... 5.6745 $241.41
dye.
71551......... Mri chest w/dye Z2........... 6.1231 $260.50
71552......... Mri chest w/o & Z2........... 8.1155 $345.26
w/dye.
72010......... X-ray exam of Z2........... 0.7093 $30.18
spine.
72020......... X-ray exam of Z3........... 0.3218 $13.69
spine.
72040......... X-ray exam of Z3........... 0.5150 $21.91
neck spine.
72050......... X-ray exam of Z3........... 0.7322 $31.15
neck spine.
72052......... X-ray exam of Z3........... 0.9416 $40.06
neck spine.
72069......... X-ray exam of Z3........... 0.4586 $19.51
trunk spine.
72070......... X-ray exam of Z3........... 0.4748 $20.20
thoracic spine.
72072......... X-ray exam of Z3........... 0.5552 $23.62
thoracic spine.
72074......... X-ray exam of Z3........... 0.7000 $29.78
thoracic spine.
72080......... X-ray exam of Z3........... 0.5070 $21.57
trunk spine.
72090......... X-ray exam of Z3........... 0.6196 $26.36
trunk spine.
72100......... X-ray exam of Z3........... 0.5552 $23.62
lower spine.
72110......... X-ray exam of Z3........... 0.7644 $32.52
lower spine.
72114......... X-ray exam of Z3........... 1.0380 $44.16
lower spine.
72120......... X-ray exam of Z3........... 0.7484 $31.84
lower spine.
72125......... Ct neck spine w/ Z2........... 3.0908 $131.49
o dye.
72126......... Ct neck spine w/ Z2........... 4.0825 $173.68
dye.
[[Page 42606]]
72127......... Ct neck spine w/ Z2........... 4.8405 $205.93
o & w/dye.
72128......... Ct chest spine Z2........... 3.0908 $131.49
w/o dye.
72129......... Ct chest spine Z2........... 4.0825 $173.68
w/dye.
72130......... Ct chest spine Z2........... 4.8405 $205.93
w/o & w/dye.
72131......... Ct lumbar spine Z2........... 3.0908 $131.49
w/o dye.
72132......... Ct lumbar spine Z2........... 4.0825 $173.68
w/dye.
72133......... Ct lumbar spine Z2........... 4.8405 $205.93
w/o & w/dye.
72141......... Mri neck spine Z2........... 5.6745 $241.41
w/o dye.
72142......... Mri neck spine Z2........... 6.1231 $260.50
w/dye.
72146......... Mri chest spine Z2........... 5.6745 $241.41
w/o dye.
72147......... Mri chest spine Z2........... 6.1231 $260.50
w/dye.
72148......... Mri lumbar Z2........... 5.6745 $241.41
spine w/o dye.
72149......... Mri lumbar Z2........... 6.1231 $260.50
spine w/dye.
72156......... Mri neck spine Z2........... 8.1155 $345.26
w/o & w/dye.
72157......... Mri chest spine Z2........... 8.1155 $345.26
w/o & w/dye.
72158......... Mri lumbar Z2........... 8.1155 $345.26
spine w/o & w/
dye.
72170......... X-ray exam of Z3........... 0.3782 $16.09
pelvis.
72190......... X-ray exam of Z3........... 0.5714 $24.31
pelvis.
72191......... Ct angiograph Z2........... 4.8552 $206.55
pelv w/o & w/
dye.
72192......... Ct pelvis w/o Z2........... 3.0908 $131.49
dye.
72193......... Ct pelvis w/dye Z2........... 4.0825 $173.68
72194......... Ct pelvis w/o & Z2........... 4.8405 $205.93
w/dye.
72195......... Mri pelvis w/o Z2........... 5.6745 $241.41
dye.
72196......... Mri pelvis w/ Z2........... 6.1231 $260.50
dye.
72197......... Mri pelvis w/o Z2........... 8.1155 $345.26
& w/dye.
72200......... X-ray exam Z3........... 0.4184 $17.80
sacroiliac
joints.
72202......... X-ray exam Z3........... 0.5070 $21.57
sacroiliac
joints.
72220......... X-ray exam of Z3........... 0.4264 $18.14
tailbone.
72240......... Contrast x-ray Z2........... 2.5544 $108.67
of neck spine.
72255......... Contrast x-ray, Z3........... 2.5026 $106.47
thorax spine.
72265......... Contrast x-ray, Z3........... 2.4867 $105.79
lower spine.
72270......... Contrast x-ray, Z2........... 2.5544 $108.67
spine.
72275......... Epidurography.. Z3........... 1.4404 $61.28
72285......... X-ray c/t spine Z3........... 3.8145 $162.28
disk.
72291......... Perq Z2........... 2.5544 $108.67
vertebroplasty
, fluor.
72292......... Perq Z2........... 2.5544 $108.67
vertebroplasty
, ct.
72295......... X-ray of lower Z3........... 3.6213 $154.06
spine disk.
73000......... X-ray exam of Z3........... 0.4024 $17.12
collar bone.
73010......... X-ray exam of Z3........... 0.4184 $17.80
shoulder blade.
73020......... X-ray exam of Z3........... 0.3460 $14.72
shoulder.
73030......... X-ray exam of Z3........... 0.4264 $18.14
shoulder.
73040......... Contrast x-ray Z3........... 1.6256 $69.16
of shoulder.
73050......... X-ray exam of Z3........... 0.5230 $22.25
shoulders.
73060......... X-ray exam of Z3........... 0.4264 $18.14
humerus.
73070......... X-ray exam of Z3........... 0.4024 $17.12
elbow.
73080......... X-ray exam of Z3........... 0.4990 $21.23
elbow.
73085......... Contrast x-ray Z3........... 1.4806 $62.99
of elbow.
73090......... X-ray exam of Z3........... 0.4024 $17.12
forearm.
73092......... X-ray exam of Z3........... 0.4024 $17.12
arm, infant.
73100......... X-ray exam of Z3........... 0.4104 $17.46
wrist.
73110......... X-ray exam of Z3........... 0.4908 $20.88
wrist.
73115......... Contrast x-ray Z3........... 1.4806 $62.99
of wrist.
73120......... X-ray exam of Z3........... 0.3944 $16.78
hand.
73130......... X-ray exam of Z3........... 0.4426 $18.83
hand.
73140......... X-ray exam of Z3........... 0.4184 $17.80
finger(s).
73200......... Ct upper Z2........... 3.0908 $131.49
extremity w/o
dye.
73201......... Ct upper Z2........... 4.0825 $173.68
extremity w/
dye.
73202......... Ct uppr Z2........... 4.8405 $205.93
extremity w/o
& w/dye.
73206......... Ct angio upr Z2........... 4.8552 $206.55
extrm w/o & w/
dye.
73218......... Mri upper Z2........... 5.6745 $241.41
extremity w/o
dye.
73219......... Mri upper Z2........... 6.1231 $260.50
extremity w/
dye.
73220......... Mri uppr Z2........... 8.1155 $345.26
extremity w/o
& w/dye.
73221......... Mri joint upr Z2........... 5.6745 $241.41
extrem w/o dye.
73222......... Mri joint upr Z2........... 6.1231 $260.50
extrem w/dye.
[[Page 42607]]
73223......... Mri joint upr Z2........... 8.1155 $345.26
extr w/o & w/
dye.
73500......... X-ray exam of Z3........... 0.3540 $15.06
hip.
73510......... X-ray exam of Z3........... 0.5070 $21.57
hip.
73520......... X-ray exam of Z3........... 0.5392 $22.94
hips.
73525......... Contrast x-ray Z3........... 1.4726 $62.65
of hip.
73530......... X-ray exam of Z2........... 1.2224 $52.00
hip.
73540......... X-ray exam of Z3........... 0.5150 $21.91
pelvis & hips.
73542......... X-ray exam, Z3........... 1.2312 $52.38
sacroiliac
joint.
73550......... X-ray exam of Z3........... 0.4184 $17.80
thigh.
73560......... X-ray exam of Z3........... 0.4184 $17.80
knee, 1 or 2.
73562......... X-ray exam of Z3........... 0.4908 $20.88
knee, 3.
73564......... X-ray exam, Z3........... 0.5552 $23.62
knee, 4 or
more.
73565......... X-ray exam of Z3........... 0.4264 $18.14
knees.
73580......... Contrast x-ray Z3........... 1.9152 $81.48
of knee joint.
73590......... X-ray exam of Z3........... 0.3944 $16.78
lower leg.
73592......... X-ray exam of Z3........... 0.4104 $17.46
leg, infant.
73600......... X-ray exam of Z3........... 0.3944 $16.78
ankle.
73610......... X-ray exam of Z3........... 0.4506 $19.17
ankle.
73615......... Contrast x-ray Z3........... 1.5128 $64.36
of ankle.
73620......... X-ray exam of Z3........... 0.3944 $16.78
foot.
73630......... X-ray exam of Z3........... 0.4426 $18.83
foot.
73650......... X-ray exam of Z3........... 0.3862 $16.43
heel.
73660......... X-ray exam of Z3........... 0.4024 $17.12
toe(s).
73700......... Ct lower Z2........... 3.0908 $131.49
extremity w/o
dye.
73701......... Ct lower Z2........... 4.0825 $173.68
extremity w/
dye.
73702......... Ct lwr Z2........... 4.8405 $205.93
extremity w/o
& w/dye.
73706......... Ct angio lwr Z2........... 4.8552 $206.55
extr w/o & w/
dye.
73718......... Mri lower Z2........... 5.6745 $241.41
extremity w/o
dye.
73719......... Mri lower Z2........... 6.1231 $260.50
extremity w/
dye.
73720......... Mri lwr Z2........... 8.1155 $345.26
extremity w/o
& w/dye.
73721......... Mri jnt of lwr Z2........... 5.6745 $241.41
extre w/o dye.
73722......... Mri joint of Z2........... 6.1231 $260.50
lwr extr w/dye.
73723......... Mri joint lwr Z2........... 8.1155 $345.26
extr w/o & w/
dye.
74000......... X-ray exam of Z3........... 0.3622 $15.41
abdomen.
74010......... X-ray exam of Z3........... 0.5070 $21.57
abdomen.
74020......... X-ray exam of Z3........... 0.5150 $21.91
abdomen.
74022......... X-ray exam Z3........... 0.6196 $26.36
series,
abdomen.
74150......... Ct abdomen w/o Z2........... 3.0908 $131.49
dye.
74160......... Ct abdomen w/ Z2........... 4.0825 $173.68
dye.
74170......... Ct abdomen w/o Z2........... 4.8405 $205.93
& w/dye.
74175......... Ct angio abdom Z2........... 4.8552 $206.55
w/o & w/dye.
74181......... Mri abdomen w/o Z2........... 5.6745 $241.41
dye.
74182......... Mri abdomen w/ Z2........... 6.1231 $260.50
dye.
74183......... Mri abdomen w/o Z2........... 8.1155 $345.26
& w/dye.
74190......... X-ray exam of Z2........... 2.9586 $125.87
peritoneum.
74210......... Contrst x-ray Z3........... 1.1024 $46.90
exam of throat.
74220......... Contrast x-ray, Z3........... 1.1830 $50.33
esophagus.
74230......... Cine/vid x-ray, Z3........... 1.1990 $51.01
throat/esoph.
74235......... Remove Z2........... 1.0974 $46.69
esophagus
obstruction.
74240......... X-ray exam, Z3........... 1.3680 $58.20
upper gi tract.
74241......... X-ray exam, Z2........... 1.4294 $60.81
upper gi tract.
74245......... X-ray exam, Z2........... 2.2176 $94.34
upper gi tract.
74246......... Contrst x-ray Z2........... 1.4294 $60.81
uppr gi tract.
74247......... Contrst x-ray Z2........... 1.4294 $60.81
uppr gi tract.
74249......... Contrst x-ray Z2........... 2.2176 $94.34
uppr gi tract.
74250......... X-ray exam of Z3........... 1.4082 $59.91
small bowel.
74251......... X-ray exam of Z2........... 2.2176 $94.34
small bowel.
74260......... X-ray exam of Z2........... 1.4294 $60.81
small bowel.
74270......... Contrast x-ray Z2........... 1.4294 $60.81
exam of colon.
74280......... Contrast x-ray Z2........... 2.2176 $94.34
exam of colon.
74283......... Contrast x-ray Z2........... 1.4294 $60.81
exam of colon.
74290......... Contrast x-ray, Z3........... 0.8450 $35.95
gallbladder.
74291......... Contrast x- Z3........... 0.7726 $32.87
rays,
gallbladder.
74300......... X-ray bile Z2........... 1.6956 $72.14
ducts/pancreas.
[[Page 42608]]
74301......... X-rays at Z2........... 1.6956 $72.14
surgery add-on.
74305......... X-ray bile Z2........... 1.6956 $72.14
ducts/pancreas.
74320......... Contrast x-ray Z3........... 2.0039 $85.25
of bile ducts.
74327......... X-ray bile Z3........... 1.7462 $74.29
stone removal.
74328......... X-ray bile duct N1........... ........... ...........
endoscopy.
74329......... X-ray for N1........... ........... ...........
pancreas
endoscopy.
74330......... X-ray bile/panc N1........... ........... ...........
endoscopy.
74340......... X-ray guide for Z2........... 1.2908 $54.91
GI tube.
74350......... X-ray guide, Z2........... 1.6956 $72.14
stomach tube.
74355......... X-ray guide, Z2........... 1.6956 $ 72.14
intestinal
tube.
74360......... X-ray guide, GI Z2........... 1.0974 $46.69
dilation.
74363......... X-ray, bile Z2........... 3.6392 $154.82
duct dilation.
74400......... Contrst x-ray, Z3........... 1.6094 $68.47
urinary tract.
74410......... Contrst x-ray, Z3........... 1.7625 $74.98
urinary tract.
74415......... Contrst x-ray, Z3........... 2.0440 $86.96
urinary tract.
74420......... Contrst x-ray, Z2........... 2.4159 $102.78
urinary tract.
74425......... Contrst x-ray, Z2........... 2.4159 $102.78
urinary tract.
74430......... Contrast x-ray, Z3........... 1.1346 $48.27
bladder.
74440......... X-ray, male Z3........... 1.2634 $53.75
genital tract.
74445......... X-ray exam of Z2........... 2.4159 $102.78
penis.
74450......... X-ray, urethra/ Z2........... 2.4159 $102.78
bladder.
74455......... X-ray, urethra/ Z3........... 1.4324 $60.94
bladder.
74470......... X-ray exam of Z2........... 1.6956 $72.14
kidney lesion.
74475......... X-ray control, Z3........... 2.3738 $100.99
cath insert.
74480......... X-ray control, Z3........... 2.3738 $100.99
cath insert.
74485......... X-ray guide, GU Z3........... 2.0683 $87.99
dilation.
74710......... X-ray Z3........... 0.6276 $26.70
measurement of
pelvis.
74740......... X-ray, female Z3........... 1.1508 $48.96
genital tract.
74742......... X-ray, Z2........... 2.9586 $125.87
fallopian tube.
74775......... X-ray exam of Z2........... 2.4159 $102.78
perineum.
75552......... Heart mri for Z2........... 5.6745 $241.41
morph w/o dye.
75553......... Heart mri for Z2........... 6.1231 $260.50
morph w/dye.
75554......... Cardiac MRI/ Z2........... 5.6745 $241.41
function.
75555......... Cardiac MRI/ Z2........... 5.6745 $241.41
limited study.
75600......... Contrast x-ray Z3........... 7.5404 $320.79
exam of aorta.
75605......... Contrast x-ray Z3........... 6.2929 $267.72
exam of aorta.
75625......... Contrast x-ray Z3........... 6.2125 $264.30
exam of aorta.
75630......... X-ray aorta, Z3........... 6.4941 $276.28
leg arteries.
75635......... Ct angio Z2........... 4.8552 $206.55
abdominal
arteries.
75650......... Artery x-rays, Z3........... 6.2125 $264.30
head & neck.
75658......... Artery x-rays, Z3........... 6.3815 $271.49
arm.
75660......... Artery x-rays, Z2........... 6.2463 $265.74
head & neck.
75662......... Artery x-rays, Z3........... 6.7840 $288.61
head & neck.
75665......... Artery x-rays, Z3........... 6.4699 $275.25
head & neck.
75671......... Artery x-rays, Z3........... 6.7920 $288.95
head & neck.
75676......... Artery x-rays, Z3........... 6.3815 $271.49
neck.
75680......... Artery x-rays, Z3........... 6.5987 $280.73
neck.
75685......... Artery x-rays, Z3........... 6.3736 $271.15
spine.
75705......... Artery x-rays, Z2........... 6.2463 $265.74
spine.
75710......... Artery x-rays, Z3........... 6.4619 $274.91
arm/leg.
75716......... Artery x-rays, Z3........... 6.7920 $288.95
arms/legs.
75722......... Artery x-rays, Z3........... 6.4055 $272.51
kidney.
75724......... Artery x-rays, Z3........... 6.8242 $290.32
kidneys.
75726......... Artery x-rays, Z3........... 6.3413 $269.78
abdomen.
75731......... Artery x-rays, Z3........... 6.4055 $272.51
adrenal gland.
75733......... Artery x-rays, Z2........... 6.2463 $265.74
adrenals.
75736......... Artery x-rays, Z3........... 6.3975 $272.17
pelvis.
75741......... Artery x-rays, Z3........... 6.0999 $259.51
lung.
75743......... Artery x-rays, Z3........... 6.1963 $263.61
lungs.
75746......... Artery x-rays, Z3........... 6.2607 $266.35
lung.
75756......... Artery x-rays, Z3........... 6.5828 $280.05
chest.
75774......... Artery x-ray, Z3........... 6.0033 $255.40
each vessel.
75790......... Visualize A-V Z3........... 1.5210 $64.71
shunt.
75801......... Lymph vessel x- Z2........... 2.9586 $125.87
ray, arm/leg.
[[Page 42609]]
75803......... Lymph vessel x- Z2........... 2.9586 $125.87
ray, arms/legs.
75805......... Lymph vessel x- Z2........... 2.9586 $125.87
ray, trunk.
75807......... Lymph vessel x- Z2........... 2.9586 $125.87
ray, trunk.
75809......... Nonvascular Z3........... 1.0864 $46.22
shunt, x-ray.
75810......... Vein x-ray, Z2........... 9.5061 $404.42
spleen/liver.
75820......... Vein x-ray, arm/ Z3........... 1.4484 $61.62
leg.
75822......... Vein x-ray, Z3........... 1.6738 $71.21
arms/legs.
75825......... Vein x-ray, Z3........... 6.0515 $257.45
trunk.
75827......... Vein x-ray, Z3........... 6.0677 $258.14
chest.
75831......... Vein x-ray, Z3........... 6.0999 $259.51
kidney.
75833......... Vein x-ray, Z3........... 6.3009 $268.06
kidneys.
75840......... Vein x-ray, Z3........... 6.1723 $262.59
adrenal gland.
75842......... Vein x-ray, Z3........... 6.2769 $267.04
adrenal glands.
75860......... Vein x-ray, Z3........... 6.2285 $264.98
neck.
75870......... Vein x-ray, Z3........... 6.1641 $262.24
skull.
75872......... Vein x-ray, Z3........... 6.4459 $274.23
skull.
75880......... Vein x-ray, eye Z3........... 1.4484 $61.62
socket.
75885......... Vein x-ray, Z3........... 6.0837 $258.82
liver.
75887......... Vein x-ray, Z3........... 6.1561 $261.90
liver.
75889......... Vein x-ray, Z3........... 6.0837 $258.82
liver.
75891......... Vein x-ray, Z3........... 6.0837 $258.82
liver.
75893......... Venous sampling N1........... ........... ...........
by catheter.
75894......... X-rays, Z2........... 8.3906 $356.96
transcath
therapy.
75896......... X-rays, Z2........... 8.3906 $356.96
transcath
therapy.
75898......... Follow-up Z2........... 1.6956 $72.14
angiography.
75901......... Remove cva Z2........... 1.6956 $72.14
device
obstruct.
75902......... Remove cva Z3........... 1.1024 $46.90
lumen obstruct.
75940......... X-ray Z2........... 8.3906 $356.96
placement,
vein filter.
75945......... Intravascular Z2........... 2.4606 $104.68
us.
75946......... Intravascular Z2........... 1.5607 $66.40
us add-on.
75960......... Transcath iv Z2........... 6.2463 $265.74
stent rs&i.
75961......... Retrieval, Z3........... 5.4399 $231.43
broken
catheter.
75962......... Repair arterial Z2........... 6.2463 $265.74
blockage.
75964......... Repair artery Z3........... 4.2571 $181.11
blockage, each.
75966......... Repair arterial Z2........... 6.2463 $265.74
blockage.
75968......... Repair artery Z3........... 4.2731 $181.79
blockage, each.
75970......... Vascular biopsy Z2........... 6.2463 $265.74
75978......... Repair venous Z2........... 6.2463 $265.74
blockage.
75980......... Contrast xray Z2........... 3.6392 $154.82
exam bile duct.
75982......... Contrast xray Z2........... 3.6392 $154.82
exam bile duct.
75984......... Xray control Z3........... 1.5692 $66.76
catheter
change.
75989......... Abscess N1........... ........... ...........
drainage under
x-ray.
75992......... Atherectomy, x- Z2........... 6.2463 $265.74
ray exam.
75993......... Atherectomy, x- Z2........... 6.2463 $265.74
ray exam.
75994......... Atherectomy, x- Z2........... 6.2463 $265.74
ray exam.
75995......... Atherectomy, x- Z2........... 6.2463 $265.74
ray exam.
75996......... Atherectomy, x- Z2........... 6.2463 $265.74
ray exam.
76000......... Fluoroscope Z2........... 1.2908 $54.91
examination.
76001......... Fluoroscope N1........... ........... ...........
exam,
extensive.
76010......... X-ray, nose to Z3........... 0.3944 $16.78
rectum.
76080......... X-ray exam of Z3........... 0.7644 $32.52
fistula.
76098......... X-ray exam, Z3........... 0.2736 $11.64
breast
specimen.
76100......... X-ray exam of Z2........... 1.2224 $52.00
body section.
76101......... Complex body Z2........... 1.6956 $72.14
section x-ray.
76102......... Complex body Z2........... 2.9586 $125.87
section x-rays.
76120......... Cine/video x- Z3........... 1.1024 $46.90
rays.
76125......... Cine/video x- Z2........... 0.7093 $30.18
rays add-on.
76150......... X-ray exam, dry Z3........... 0.4346 $18.49
process.
76350......... Special x-ray N1........... ........... ...........
contrast study.
76376......... 3d render w/o Z2........... 0.6102 $25.96
postprocess.
76377......... 3d rendering w/ Z2........... 1.5379 $65.43
postprocess.
76380......... CAT scan follow- Z2........... 1.5379 $65.43
up study.
76496......... Fluoroscopic Z2........... 1.2908 $54.91
procedure.
76497......... Ct procedure... Z2........... 1.5379 $65.43
[[Page 42610]]
76498......... Mri procedure.. Z2........... 4.5523 $193.67
76499......... Radiographic Z2........... 0.7093 $30.18
procedure.
76506......... Echo exam of Z2........... 0.9923 $42.22
head.
76510......... Ophth us, b & Z2........... 1.5607 $66.40
quant a.
76511......... Ophth us, quant Z3........... 1.2312 $52.38
a only.
76512......... Ophth us, b w/ Z3........... 1.0702 $45.53
non-quant a.
76513......... Echo exam of Z3........... 1.1426 $48.61
eye, water
bath.
76514......... Echo exam of Z3........... 0.0644 $2.74
eye, thickness.
76516......... Echo exam of Z3........... 0.8852 $37.66
eye.
76519......... Echo exam of Z3........... 0.9736 $41.42
eye.
76529......... Echo exam of Z3........... 0.8450 $35.95
eye.
76536......... Us exam of head Z3........... 1.5290 $65.05
and neck.
76604......... Us exam, chest. Z2........... 0.9923 $42.22
76645......... Us exam, Z2........... 0.9923 $42.22
breast(s).
76700......... Us exam, abdom, Z2........... 1.5607 $66.40
complete.
76705......... Echo exam of Z3........... 1.3922 $59.23
abdomen.
76770......... Us exam abdo Z2........... 1.5607 $66.40
back wall,
comp.
76775......... Us exam abdo Z3........... 1.4002 $59.57
back wall, lim.
76776......... Us exam k Z2........... 1.5607 $66.40
transpl w/
doppler.
76800......... Us exam, spinal Z3........... 1.3680 $58.20
canal.
76801......... Ob us < 14 wks, Z2........... 1.5607 $66.40
single fetus.
76802......... Ob us < 14 wks, Z3........... 0.7000 $29.78
add'l fetus.
76805......... Ob us >/= 14 Z2........... 1.5607 $66.40
wks, sngl
fetus.
76810......... Ob us >/= 14 Z3........... 0.9576 $40.74
wks, addl
fetus.
76811......... Ob us, Z3........... 2.4060 $102.36
detailed, sngl
fetus.
76812......... Ob us, Z2........... 0.9923 $42.22
detailed, addl
fetus.
76813......... Ob us nuchal Z3........... 1.3922 $59.23
meas, 1 gest.
76814......... Ob us nuchal Z3........... 0.6760 $28.76
meas, add-on.
76815......... Ob us, limited, Z2........... 0.9923 $42.22
fetus(s).
76816......... Ob us, follow- Z2........... 0.9923 $42.22
up, per fetus.
76817......... Transvaginal Z2........... 0.9923 $42.22
us, obstetric.
76818......... Fetal biophys Z3........... 1.3922 $59.23
profile w/nst.
76819......... Fetal biophys Z3........... 1.1990 $51.01
profil w/o nst.
76820......... Umbilical Z3........... 0.8128 $34.58
artery echo.
76821......... Middle cerebral Z3........... 1.3036 $55.46
artery echo.
76825......... Echo exam of Z2........... 1.5973 $67.95
fetal heart.
76826......... Echo exam of Z3........... 1.2794 $54.43
fetal heart.
76827......... Echo exam of Z3........... 1.0462 $44.51
fetal heart.
76828......... Echo exam of Z3........... 0.6358 $27.05
fetal heart.
76830......... Transvaginal Z2........... 1.5607 $66.40
us, non-ob.
76831......... Echo exam, Z3........... 1.6094 $68.47
uterus.
76856......... Us exam, Z2........... 1.5607 $66.40
pelvic,
complete.
76857......... Us exam, Z2........... 0.9923 $42.22
pelvic,
limited.
76870......... Us exam, Z2........... 1.5607 $66.40
scrotum.
76872......... Us, transrectal Z2........... 1.5607 $66.40
76873......... Echograp trans Z2........... 1.5607 $66.40
r, pros study.
76880......... Us exam, Z2........... 1.5607 $66.40
extremity.
76885......... Us exam infant Z2........... 0.9923 $42.22
hips, dynamic.
76886......... Us exam infant Z2........... 0.9923 $42.22
hips, static.
76930......... Echo guide, Z2........... 1.1882 $50.55
cardiocentesis.
76932......... Echo guide for Z2........... 2.1012 $89.39
heart biopsy.
76936......... Echo guide for Z2........... 2.1012 $89.39
artery repair.
76937......... Us guide, N1........... ........... ...........
vascular
access.
76940......... Us guide, Z2........... 1.1882 $50.55
tissue
ablation.
76941......... Echo guide for Z2........... 1.1882 $50.55
transfusion.
76942......... Echo guide for Z2........... 1.1882 $50.55
biopsy.
76945......... Echo guide, Z2........... 1.1882 $50.55
villus
sampling.
76946......... Echo guide for Z3........... 0.7404 $31.50
amniocentesis.
76948......... Echo guide, ova Z3........... 0.7404 $31.50
aspiration.
76950......... Echo guidance Z3........... 0.9416 $40.06
radiotherapy.
76965......... Echo guidance Z2........... 2.1012 $89.39
radiotherapy.
76970......... Ultrasound exam Z2........... 0.9923 $42.22
follow-up.
76975......... GI endoscopic Z2........... 1.5607 $66.40
ultrasound.
76977......... Us bone density Z3........... 0.3702 $15.75
measure.
[[Page 42611]]
76998......... Us guide, Z2........... 1.5607 $66.40
intraop.
76999......... Echo Z2........... 0.9923 $42.22
examination
procedure.
77001......... Fluoroguide for N1........... ........... ...........
vein device.
77002......... Needle N1........... ........... ...........
localization
by xray.
77003......... Fluoroguide for N1........... ........... ...........
spine inject.
77011......... Ct scan for Z2........... 4.0825 $173.68
localization.
77012......... Ct scan for Z3........... 4.0559 $172.55
needle biopsy.
77013......... Ct guide for Z2........... 4.8405 $205.93
tissue
ablation.
77014......... Ct scan for Z2........... 1.5379 $65.43
therapy guide.
77021......... Mr guidance for Z2........... 4.5523 $193.67
needle place.
77022......... Mri for tissue Z2........... 4.5523 $193.67
ablation.
77031......... Stereotact Z2........... 2.9586 $125.87
guide for brst
bx.
77032......... Guidance for Z3........... 0.6840 $29.10
needle, breast.
77053......... X-ray of Z3........... 1.2554 $53.41
mammary duct.
77054......... X-ray of Z2........... 1.6956 $72.14
mammary ducts.
77071......... X-ray stress Z3........... 0.3782 $16.09
view.
77072......... X-rays for bone Z3........... 0.2736 $11.64
age.
77073......... X-rays, bone Z3........... 0.5312 $22.60
length studies.
77074......... X-rays, bone Z3........... 0.8852 $37.66
survey,
limited.
77075......... X-rays, bone Z2........... 1.2224 $52.00
survey
complete.
77076......... X-rays, bone Z2........... 0.7093 $30.18
survey, infant.
77077......... Joint survey, Z3........... 0.6598 $28.07
single view.
77078......... Ct bone Z2........... 1.1755 $50.01
density, axial.
77079......... Ct bone Z3........... 1.4566 $61.97
density,
peripheral.
77080......... Dxa bone Z2........... 1.1755 $50.01
density, axial.
77081......... Dxa bone Z2........... 0.5497 $23.39
density/
peripheral.
77082......... Dxa bone Z3........... 0.4426 $18.83
density, vert
fx.
77083......... Radiographic Z3........... 0.4264 $18.14
absorptiometry.
77084......... Magnetic image, Z2........... 4.5523 $193.67
bone marrow.
77280......... Sbrt management Z2........... 1.5735 $66.94
77285......... Set radiation Z2........... 3.9723 $168.99
therapy field.
77290......... Set radiation Z2........... 3.9723 $168.99
therapy field.
77295......... Set radiation Z3........... 13.6401 $580.29
therapy field.
77299......... Radiation Z2........... 1.5735 $66.94
therapy
planning.
77300......... Radiation Z3........... 0.9334 $39.71
therapy dose
plan.
77301......... Radiotherapy Z2........... 13.8081 $587.44
dose plan,
imrt.
77305......... Teletx isodose Z3........... 1.0140 $43.14
plan simple.
77310......... Teletx isodose Z3........... 1.3036 $55.46
plan intermed.
77315......... Teletx isodose Z3........... 1.7060 $72.58
plan complex.
77321......... Special teletx Z3........... 2.1085 $89.70
port plan.
77326......... Brachytx Z2........... 1.5735 $66.94
isodose calc
simp.
77327......... Brachytx Z3........... 2.8649 $121.88
isodose calc
interm.
77328......... Brachytx Z3........... 3.8305 $162.96
isodose plan
compl.
77331......... Special Z3........... 0.4104 $17.46
radiation
dosimetry.
77332......... Radiation Z3........... 1.0944 $46.56
treatment
aid(s).
77333......... Radiation Z3........... 0.8610 $36.63
treatment
aid(s).
77334......... Radiation Z3........... 2.2453 $95.52
treatment
aid(s).
77336......... Radiation Z2........... 1.5735 $66.94
physics
consult.
77370......... Radiation Z2........... 1.5735 $66.94
physics
consult.
77371......... Srs, Z3........... 24.3429 $1,035.62
multisource.
77399......... External Z2........... 1.5735 $66.94
radiation
dosimetry.
77401......... Radiation Z3........... 0.9094 $38.69
treatment
delivery.
77402......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77403......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77404......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77406......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77407......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77408......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77409......... Radiation Z2........... 1.4826 $63.07
treatment
delivery.
77411......... Radiation Z2........... 2.2295 $94.85
treatment
delivery.
77412......... Radiation Z2........... 2.2295 $94.85
treatment
delivery.
77413......... Radiation Z2........... 2.2295 $94.85
treatment
delivery.
77414......... Radiation Z2........... 2.2295 $94.85
treatment
delivery.
77416......... Radiation Z2........... 2.2295 $94.85
treatment
delivery.
[[Page 42612]]
77417......... Radiology port Z3........... 0.3782 $16.09
film(s).
77418......... Radiation tx Z2........... 5.4731 $232.84
delivery, imrt.
77421......... Stereoscopic x- Z2........... 1.0974 $46.69
ray guidance.
77422......... Neutron beam Z2........... 2.2295 $94.85
tx, simple.
77423......... Neutron beam Z2........... 2.2295 $94.85
tx, complex.
77435......... Sbrt management N1........... ........... ...........
77470......... Special Z3........... 4.9813 $211.92
radiation
treatment.
77520......... Proton trmt, Z2........... 18.8926 $803.75
simple w/o
comp.
77522......... Proton trmt, Z2........... 18.8926 $803.75
simple w/comp.
77523......... Proton trmt, Z2........... 22.6031 $961.60
intermediate.
77525......... Proton Z2........... 22.6031 $961.60
treatment,
complex.
77600......... Hyperthermia Z2........... 3.3461 $142.35
treatment.
77605......... Hyperthermia Z2........... 3.3461 $142.35
treatment.
77610......... Hyperthermia Z2........... 3.3461 $142.35
treatment.
77615......... Hyperthermia Z2........... 3.3461 $142.35
treatment.
77620......... Hyperthermia Z2........... 3.3461 $142.35
treatment.
77750......... Infuse Z3........... 1.7140 $72.92
radioactive
materials.
77761......... Apply intrcav Z3........... 3.0419 $129.41
radiat simple.
77762......... Apply intrcav Z3........... 3.7741 $160.56
radiat interm.
77763......... Apply intrcav Z3........... 4.8283 $205.41
radiat compl.
77776......... Apply interstit Z3........... 3.2109 $136.60
radiat simpl.
77777......... Apply interstit Z3........... 3.8707 $164.67
radiat inter.
77778......... Apply interstit Z3........... 5.1261 $218.08
radiat compl.
77781......... High intensity Z3........... 9.7854 $416.30
brachytherapy.
77782......... High intensity Z2........... 12.8473 $546.56
brachytherapy.
77783......... High intensity Z2........... 12.8473 $546.56
brachytherapy.
77784......... High intensity Z2........... 12.8473 $546.56
brachytherapy.
77789......... Apply surface Z3........... 0.8530 $36.29
radiation.
77790......... Radiation N1........... ........... ...........
handling.
77799......... Radium/ Z2........... 4.8569 $206.63
radioisotope
therapy.
78000......... Thyroid, single Z3........... 1.0622 $45.19
uptake.
78001......... Thyroid, Z3........... 1.3520 $57.52
multiple
uptakes.
78003......... Thyroid Z3........... 1.0622 $45.19
suppress/
stimul.
78006......... Thyroid imaging Z2........... 2.3432 $99.69
with uptake.
78007......... Thyroid image, Z3........... 2.1085 $89.70
mult uptakes.
78010......... Thyroid imaging Z3........... 2.2692 $96.54
78011......... Thyroid imaging Z2........... 2.3432 $99.69
with flow.
78015......... Thyroid met Z3........... 3.0097 $128.04
imaging.
78016......... Thyroid met Z2........... 3.9934 $169.89
imaging/
studies.
78018......... Thyroid met Z2........... 3.9934 $169.89
imaging, body.
78020......... Thyroid met Z3........... 1.1346 $48.27
uptake.
78070......... Parathyroid Z2........... 2.7146 $115.49
nuclear
imaging.
78075......... Adrenal nuclear Z2........... 2.7146 $115.49
imaging.
78099......... Endocrine Z2........... 2.3432 $99.69
nuclear
procedure.
78102......... Bone marrow Z3........... 2.3336 $99.28
imaging, ltd.
78103......... Bone marrow Z3........... 3.2431 $137.97
imaging, mult.
78104......... Bone marrow Z2........... 3.9073 $166.23
imaging, body.
78110......... Plasma volume, Z3........... 1.1830 $50.33
single.
78111......... Plasma volume, Z3........... 1.8266 $77.71
multiple.
78120......... Red cell mass, Z3........... 1.4566 $61.97
single.
78121......... Red cell mass, Z3........... 1.9634 $83.53
multiple.
78122......... Blood volume... Z3........... 2.6394 $112.29
78130......... Red cell Z3........... 2.4060 $102.36
survival study.
78135......... Red cell Z2........... 3.7562 $159.80
survival
kinetics.
78140......... Red cell Z3........... 2.5913 $110.24
sequestration.
78185......... Spleen imaging. Z3........... 2.8808 $122.56
78190......... Platelet Z2........... 2.0057 $85.33
survival,
kinetics.
78191......... Platelet Z2........... 2.0057 $85.33
survival.
78195......... Lymph system Z2........... 3.9073 $166.23
imaging.
78199......... Blood/lymph Z2........... 3.9073 $166.23
nuclear exam.
78201......... Liver imaging.. Z3........... 2.7039 $115.03
78202......... Liver imaging Z3........... 3.1385 $133.52
with flow.
78205......... Liver imaging Z3........... 4.2811 $182.13
(3D).
78206......... Liver image Z2........... 4.3774 $186.23
(3d) with flow.
[[Page 42613]]
78215......... Liver and Z3........... 2.9453 $125.30
spleen imaging.
78216......... Liver & spleen Z3........... 2.3980 $102.02
image/flow.
78220......... Liver function Z3........... 2.5833 $109.90
study.
78223......... Hepatobiliary Z2........... 4.3774 $186.23
imaging.
78230......... Salivary gland Z3........... 2.3980 $102.02
imaging.
78231......... Serial salivary Z3........... 2.2775 $96.89
imaging.
78232......... Salivary gland Z3........... 2.4143 $102.71
function exam.
78258......... Esophageal Z3........... 3.2995 $140.37
motility study.
78261......... Gastric mucosa Z2........... 3.6526 $155.39
imaging.
78262......... Gastroesophagea Z2........... 3.6526 $155.39
l reflux exam.
78264......... Gastric Z2........... 3.6526 $155.39
emptying study.
78270......... Vit B-12 Z3........... 1.3278 $56.49
absorption
exam.
78271......... Vit B-12 absrp Z3........... 1.3760 $58.54
exam, int fac.
78272......... Vit B-12 Z3........... 1.6898 $71.89
absorp,
combined.
78278......... Acute GI blood Z2........... 3.6526 $155.39
loss imaging.
78282......... GI protein loss Z2........... 3.6526 $155.39
exam.
78290......... Meckel's divert Z2........... 3.6526 $155.39
exam.
78291......... Leveen/shunt Z3........... 3.4765 $147.90
patency exam.
78299......... GI nuclear Z2........... 3.6526 $155.39
procedure.
78300......... Bone imaging, Z3........... 2.5106 $106.81
limited area.
78305......... Bone imaging, Z3........... 3.4443 $146.53
multiple areas.
78306......... Bone imaging, Z3........... 3.9029 $166.04
whole body.
78315......... Bone imaging, 3 Z2........... 3.9174 $166.66
phase.
78320......... Bone imaging Z2........... 3.9174 $166.66
(3D).
78399......... Musculoskeletal Z2........... 3.9174 $166.66
nuclear exam.
78414......... Non-imaging Z2........... 4.1265 $175.55
heart function.
78428......... Cardiac shunt Z3........... 2.8729 $122.22
imaging.
78445......... Vascular flow Z2........... 2.4204 $102.97
imaging.
78456......... Acute venous Z2........... 2.4204 $102.97
thrombus image.
78457......... Venous Z2........... 2.4204 $102.97
thrombosis
imaging.
78458......... Ven thrombosis Z2........... 2.4204 $102.97
images, bilat.
78459......... Heart muscle Z2........... 11.8963 $506.10
imaging (PET).
78460......... Heart muscle Z3........... 2.6235 $111.61
blood, single.
78461......... Heart muscle Z3........... 3.2673 $139.00
blood,
multiple.
78464......... Heart image Z2........... 4.1265 $175.55
(3d), single.
78465......... Heart image Z2........... 6.5012 $276.58
(3d), multiple.
78466......... Heart infarct Z3........... 2.7039 $115.03
image.
78468......... Heart infarct Z3........... 3.7099 $157.83
image (ef).
78469......... Heart infarct Z2........... 4.1265 $175.55
image (3D).
78472......... Gated heart, Z2........... 4.1265 $175.55
planar, single.
78473......... Gated heart, Z2........... 4.9832 $212.00
multiple.
78478......... Heart wall Z3........... 0.8530 $36.29
motion add-on.
78480......... Heart function Z3........... 0.8530 $36.29
add-on.
78481......... Heart first Z3........... 3.9431 $167.75
pass, single.
78483......... Heart first Z2........... 4.9832 $212.00
pass, multiple.
78491......... Heart image Z2........... 11.8963 $506.10
(pet), single.
78492......... Heart image Z2........... 11.8963 $506.10
(pet),
multiple.
78494......... Heart image, Z2........... 4.1265 $175.55
spect.
78496......... Heart first Z2........... 1.5054 $64.04
pass add-on.
78499......... Cardiovascular Z2........... 4.1265 $175.55
nuclear exam.
78580......... Lung perfusion Z2........... 3.1802 $135.30
imaging.
78584......... Lung V/Q image Z3........... 2.2775 $96.89
single breath.
78585......... Lung V/Q Z2........... 5.0975 $216.86
imaging.
78586......... Aerosol lung Z3........... 2.5670 $109.21
image, single.
78587......... Aerosol lung Z3........... 3.1305 $133.18
image,
multiple.
78588......... Perfusion lung Z3........... 4.4261 $188.30
image.
78591......... Vent image, 1 Z3........... 2.6637 $113.32
breath, 1 proj.
78593......... Vent image, 1 Z3........... 3.1465 $133.86
proj, gas.
78594......... Vent image, Z2........... 3.1802 $135.30
mult proj, gas.
78596......... Lung Z2........... 5.0975 $216.86
differential
function.
78599......... Respiratory Z2........... 3.1802 $135.30
nuclear exam.
78600......... Brain imaging, Z3........... 3.8627 $164.33
ltd static.
78601......... Brain imaging, Z3........... 3.3315 $141.73
ltd w/flow.
78605......... Brain imaging, Z3........... 3.1063 $132.15
complete.
[[Page 42614]]
78606......... Brain imaging, Z2........... 4.6418 $197.48
compl w/flow.
78607......... Brain imaging Z2........... 4.6418 $197.48
(3D).
78608......... Brain imaging Z2........... 13.9166 $592.05
(PET).
78610......... Brain flow Z3........... 2.2855 $97.23
imaging only.
78615......... Cerebral Z3........... 3.5327 $150.29
vascular flow
image.
78630......... Cerebrospinal Z2........... 3.4923 $148.57
fluid scan.
78635......... CSF Z2........... 3.4923 $148.57
ventriculograp
hy.
78645......... CSF shunt Z2........... 3.4923 $148.57
evaluation.
78647......... Cerebrospinal Z2........... 3.4923 $148.57
fluid scan.
78650......... CSF leakage Z2........... 3.4923 $148.57
imaging.
78660......... Nuclear exam of Z3........... 2.4143 $102.71
tear flow.
78699......... Nervous system Z2........... 4.6418 $197.48
nuclear exam.
78700......... Kidney imaging, Z3........... 2.8891 $122.91
morphol.
78701......... Kidney imaging Z3........... 3.4041 $144.82
with flow.
78707......... Kflow/funct Z2........... 3.4209 $145.54
image w/o drug.
78708......... Kflow/funct Z3........... 2.9373 $124.96
image w/drug.
78709......... Kflow/funct Z2........... 4.0378 $171.78
image,
multiple.
78710......... Kidney imaging Z2........... 3.4209 $145.54
(3D).
78725......... Kidney function Z2........... 1.3754 $58.51
study.
78730......... Urinary bladder Z2........... 0.6102 $25.96
retention.
78740......... Ureteral reflux Z3........... 2.8649 $121.88
study.
78761......... Testicular Z3........... 3.0499 $129.75
imaging w/flow.
78799......... Genitourinary Z2........... 3.4209 $145.54
nuclear exam.
78800......... Tumor imaging, Z3........... 2.9293 $124.62
limited area.
78801......... Tumor imaging, Z3........... 3.9271 $167.07
mult areas.
78802......... Tumor imaging, Z2........... 3.9934 $169.89
whole body.
78803......... Tumor imaging Z2........... 3.9934 $169.89
(3D).
78804......... Tumor imaging, Z2........... 5.9245 $252.05
whole body.
78805......... Abscess Z3........... 2.8729 $122.22
imaging, ltd
area.
78806......... Abscess Z2........... 3.9934 $169.89
imaging, whole
body.
78807......... Nuclear Z2........... 3.9934 $169.89
localization/
abscess.
78811......... Tumor imaging Z2........... 13.9166 $592.05
(pet), limited.
78812......... Tumor image Z2........... 13.9166 $592.05
(pet)/skul-
thigh.
78813......... Tumor image Z2........... 13.9166 $592.05
(pet) full
body.
78814......... Tumor image pet/ Z2........... 15.4552 $657.51
ct, limited.
78815......... Tumorimage pet/ Z2........... 15.4552 $657.51
ct skul-thigh.
78816......... Tumor image pet/ Z2........... 15.4552 $657.51
ct full body.
78890......... Nuclear N1........... ........... ...........
medicine data
proc.
78891......... Nuclear med N1........... ........... ...........
data proc.
78999......... Nuclear Z2........... 1.3754 $58.51
diagnostic
exam.
79005......... Nuclear rx, Z3........... 1.5370 $65.39
oral admin.
79101......... Nuclear rx, iv Z3........... 1.6094 $68.47
admin.
79200......... Nuclear rx, Z3........... 1.6738 $71.21
intracav admin.
79300......... Nuclr rx, Z2........... 3.1779 $135.20
interstit
colloid.
79403......... Hematopoietic Z3........... 2.5591 $108.87
nuclear tx.
79440......... Nuclear rx, Z3........... 1.4968 $63.68
intra-
articular.
79445......... Nuclear rx, Z2........... 3.1779 $135.20
intra-arterial.
79999......... Nuclear Z2........... 3.1779 $135.20
medicine
therapy.
90371......... Hep b ig, im... K2........... ........... $133.69
90375......... Rabies ig, im/ K2........... ........... $65.44
sc.
90376......... Rabies ig, heat K2........... ........... $70.06
treated.
90396......... Varicella- K2........... ........... $122.74
zoster ig, im.
90585......... Bcg vaccine, K2........... ........... $113.63
precut.
90675......... Rabies vaccine, K2........... ........... $146.91
im.
90676......... Rabies vaccine, K2........... ........... $119.86
id.
90708......... Measles-rubella K2........... ........... $45.53
vaccine, sc.
90720......... Dtp/hib K2........... ........... $58.70
vaccine, im.
90727......... Plague vaccine, K2........... ........... $7.13
im.
90733......... Meningococcal K2........... ........... $89.43
vaccine, sc.
90734......... Meningococcal K2........... ........... $82.00
vaccine, im.
90735......... Encephalitis K2........... ........... $99.11
vaccine, sc.
A4218......... Sterile saline N1........... ........... ...........
or water.
A4220......... Infusion pump N1........... ........... ...........
refill kit.
A4248......... Chlorhexidine N1........... ........... ...........
antisept.
[[Page 42615]]
A4262......... Temporary tear N1........... ........... ...........
duct plug.
A4263......... Permanent tear N1........... ........... ...........
duct plug.
A4270......... Disposable N1........... ........... ...........
endoscope
sheath.
A4300......... Cath impl vasc N1........... ........... ...........
access portal.
A4301......... Implantable N1........... ........... ...........
access syst
perc.
A4305......... Drug delivery N1........... ........... ...........
system [gE]50
ML.
A4306......... Drug delivery N1........... ........... ...........
system [lE]50
ml.
A9527......... Iodine I-125 H7........... ........... ...........
sodium iodide.
A9698......... Non-rad N1........... ........... ...........
contrast
materialNOC.
C1713......... Anchor/screw bn/ N1........... ........... ...........
bn,tis/bn.
C1714......... Cath, trans N1........... ........... ...........
atherectomy,
dir.
C1715......... Brachytherapy N1........... ........... ...........
needle.
C1716......... Brachytx H7........... ........... ...........
source, Gold
198.
C1717......... Brachytx H7........... ........... ...........
source, HDR Ir-
192.
C1718......... Brachytx H7........... ........... ...........
source, Iodine
125.
C1719......... Brachytx sour, H7........... ........... ...........
Non-HDR Ir-192.
C1720......... Brachytx sour, H7........... ........... ...........
Palladium 103.
C1721......... AICD, dual N1........... ........... ...........
chamber.
C1722......... AICD, single N1........... ........... ...........
chamber.
C1724......... Cath, trans N1........... ........... ...........
atherec,
rotation.
C1725......... Cath, N1........... ........... ...........
translumin non-
laser.
C1726......... Cath, bal dil, N1........... ........... ...........
non-vascular.
C1727......... Cath, bal tis N1........... ........... ...........
dis, non-vas.
C1728......... Cath, brachytx N1........... ........... ...........
seed adm.
C1729......... Cath, drainage. N1........... ........... ...........
C1730......... Cath, EP, 19 or N1........... ........... ...........
few elect.
C1731......... Cath, EP, 20 or N1........... ........... ...........
more elec.
C1732......... Cath, EP, diag/ N1........... ........... ...........
abl, 3D/vect.
C1733......... Cath, EP, othr N1........... ........... ...........
than cool-tip.
C1750......... Cath, N1........... ........... ...........
hemodialysis,
long-term.
C1751......... Cath, inf, per/ N1........... ........... ...........
cent/midline.
C1752......... Cath, N1........... ........... ...........
hemodialysis,
short-term.
C1753......... Cath, intravas N1........... ........... ...........
ultrasound.
C1754......... Catheter, N1........... ........... ...........
intradiscal.
C1755......... Catheter, N1........... ........... ...........
intraspinal.
C1756......... Cath, pacing, N1........... ........... ...........
transesoph.
C1757......... Cath, N1........... ........... ...........
thrombectomy/
embolect.
C1758......... Catheter, N1........... ........... ...........
ureteral.
C1759......... Cath, intra N1........... ........... ...........
echocardiograp
hy.
C1760......... Closure dev, N1........... ........... ...........
vasc.
C1762......... Conn tiss, N1........... ........... ...........
human (inc
fascia).
C1763......... Conn tiss, non- N1........... ........... ...........
human.
C1764......... Event recorder, N1........... ........... ...........
cardiac.
C1765......... Adhesion N1........... ........... ...........
barrier.
C1766......... Intro/sheath, N1........... ........... ...........
strble, non-
peel.
C1767......... Generator, N1........... ........... ...........
neuro non-
recharg.
C1768......... Graft, vascular N1........... ........... ...........
C1769......... Guide wire..... N1........... ........... ...........
C1770......... Imaging coil, N1........... ........... ...........
MR, insertable.
C1771......... Rep dev, N1........... ........... ...........
urinary, w/
sling.
C1772......... Infusion pump, N1........... ........... ...........
programmable.
C1773......... Ret dev, N1........... ........... ...........
insertable.
C1776......... Joint device N1........... ........... ...........
(implantable).
C1777......... Lead, AICD, N1........... ........... ...........
endo single
coil.
C1778......... Lead, N1........... ........... ...........
neurostimulato
r.
C1779......... Lead, pmkr, N1........... ........... ...........
transvenous
VDD.
C1780......... Lens, N1........... ........... ...........
intraocular
(new tech).
C1781......... Mesh N1........... ........... ...........
(implantable).
C1782......... Morcellator.... N1........... ........... ...........
C1783......... Ocular imp, N1........... ........... ...........
aqueous drain
de.
C1784......... Ocular dev, N1........... ........... ...........
intraop, det
ret.
C1785......... Pmkr, dual, N1........... ........... ...........
rate-resp.
C1786......... Pmkr, single, N1........... ........... ...........
rate-resp.
C1787......... Patient progr, N1........... ........... ...........
neurostim.
[[Continued on page 42619]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 42619-42626]] Medicare Program; Revised Payment System Policies for Services
Furnished in Ambulatory Surgical Centers (ASCs) Beginning in CY 2008
[[Continued from page 42618]]
[[Page 42616]]
C1788......... Port, N1........... ........... ...........
indwelling,
imp.
C1789......... Prosthesis, N1........... ........... ...........
breast, imp.
C1813......... Prosthesis, N1........... ........... ...........
penile,
inflatab.
C1814......... Retinal tamp, N1........... ........... ...........
silicone oil.
C1815......... Pros, urinary N1........... ........... ...........
sph, imp.
C1816......... Receiver/ N1........... ........... ...........
transmitter,
neuro.
C1817......... Septal defect N1........... ........... ...........
imp sys.
C1818......... Integrated N1........... ........... ...........
keratoprosthes
is.
C1819......... Tissue N1........... ........... ...........
localization-
excision.
C1820......... Generator neuro J7........... ........... ...........
rechg bat sy.
C1821......... Interspinous J7........... ........... ...........
implant.
C1874......... Stent, coated/ N1........... ........... ...........
cov w/del sys.
C1875......... Stent, coated/ N1........... ........... ...........
cov w/o del sy.
C1876......... Stent, non-coa/ N1........... ........... ...........
non-cov w/del.
C1877......... Stent, non-coat/ N1........... ........... ...........
cov w/o del.
C1878......... Matrl for vocal N1........... ........... ...........
cord.
C1879......... Tissue marker, N1........... ........... ...........
implantable.
C1880......... Vena cava N1........... ........... ...........
filter.
C1881......... Dialysis access N1........... ........... ...........
system.
C1882......... AICD, other N1........... ........... ...........
than sing/dual.
C1883......... Adapt/ext, N1........... ........... ...........
pacing/neuro
lead.
C1884......... Embolization N1........... ........... ...........
Protect syst.
C1885......... Cath, N1........... ........... ...........
translumin
angio laser.
C1887......... Catheter, N1........... ........... ...........
guiding.
C1888......... Endovas non- N1........... ........... ...........
cardiac abl
cath.
C1891......... Infusion pump, N1........... ........... ...........
non-prog, perm.
C1892......... Intro/sheath, N1........... ........... ...........
fixed, peel-
away.
C1893......... Intro/sheath, N1........... ........... ...........
fixed, non-
peel.
C1894......... Intro/sheath, N1........... ........... ...........
non-laser.
C1895......... Lead, AICD, N1........... ........... ...........
endo dual coil.
C1896......... Lead, AICD, non N1........... ........... ...........
sing/dual.
C1897......... Lead, neurostim N1........... ........... ...........
test kit.
C1898......... Lead, pmkr, N1........... ........... ...........
other than
trans.
C1899......... Lead, pmkr/AICD N1........... ........... ...........
combination.
C1900......... Lead, coronary N1........... ........... ...........
venous.
C2614......... Probe, perc N1........... ........... ...........
lumb disc.
C2615......... Sealant, N1........... ........... ...........
pulmonary,
liquid.
C2616......... Brachytx H7........... ........... ...........
source,
Yttrium-90.
C2617......... Stent, non-cor, N1........... ........... ...........
tem w/o del.
C2618......... Probe, N1........... ........... ...........
cryoablation.
C2619......... Pmkr, dual, non N1........... ........... ...........
rate-resp.
C2620......... Pmkr, single, N1........... ........... ...........
non rate-resp.
C2621......... Pmkr, other N1........... ........... ...........
than sing/dual.
C2622......... Prosthesis, N1........... ........... ...........
penile, non-
inf.
C2625......... Stent, non-cor, N1........... ........... ...........
tem w/del sy.
C2626......... Infusion pump, N1........... ........... ...........
non-prog, temp.
C2627......... Cath, N1........... ........... ...........
suprapubic/
cystoscopic.
C2628......... Catheter, N1........... ........... ...........
occlusion.
C2629......... Intro/sheath, N1........... ........... ...........
laser.
C2630......... Cath, EP, cool- N1........... ........... ...........
tip.
C2631......... Rep dev, N1........... ........... ...........
urinary, w/o
sling.
C2633......... Brachytx H7........... ........... ...........
source, Cesium-
131.
C2634......... Brachytx H7........... ........... ...........
source, HA, I-
125.
C2635......... Brachytx H7........... ........... ...........
source, HA, P-
103.
C2636......... Brachytx linear H7........... ........... ...........
source, P-103.
C2637......... Brachytx, H7........... ........... ...........
Ytterbium-169.
C8900......... MRA w/cont, abd Z2........... 6.1231 $260.50
C8901......... MRA w/o cont, Z2........... 5.6745 $241.41
abd.
C8902......... MRA w/o fol w/ Z2........... 8.1155 $345.26
cont, abd.
C8903......... MRI w/cont, Z2........... 6.1231 $260.50
breast, uni.
C8904......... MRI w/o cont, Z2........... 5.6745 $241.41
breast, uni.
C8905......... MRI w/o fol w/ Z2........... 8.1155 $345.26
cont, brst, un.
C8906......... MRI w/cont, Z2........... 6.1231 $260.50
breast, bi.
C8907......... MRI w/o cont, Z2........... 5.6745 $241.41
breast, bi.
[[Page 42617]]
C8908......... MRI w/o fol w/ Z2........... 8.1155 $345.26
cont, breast,.
C8909......... MRA w/cont, Z2........... 6.1231 $260.50
chest.
C8910......... MRA w/o cont, Z2........... 5.6745 $241.41
chest.
C8911......... MRA w/o fol w/ Z2........... 8.1155 $345.26
cont, chest.
C8912......... MRA w/cont, lwr Z2........... 6.1231 $260.50
ext.
C8913......... MRA w/o cont, Z2........... 5.6745 $241.41
lwr ext.
C8914......... MRA w/o fol w/ Z2........... 8.1155 $345.26
cont, lwr ext.
C8918......... MRA w/cont, Z2........... 6.1231 $260.50
pelvis.
C8919......... MRA w/o cont, Z2........... 5.6745 $241.41
pelvis.
C8920......... MRA w/o fol w/ Z2........... 8.1155 $345.26
cont, pelvis.
C9003......... Palivizumab, K2........... ........... $684.43
per 50 mg.
C9113......... Inj N1........... ........... ...........
pantoprazole
sodium, via.
C9121......... Injection, K2........... ........... $18.04
argatroban.
C9232......... Injection, K2........... ........... $455.03
idursulfase.
C9233......... Injection, K2........... ........... $2,030.92
ranibizumab.
C9234......... Inj, K2........... ........... $127.20
alglucosidase
alfa.
C9235......... Injection, K2........... ........... $84.80
panitumumab.
C9350......... Porous collagen K2........... ........... $485.91
tube per cm.
C9351......... Acellular derm K2........... ........... $41.59
tissue percm2.
C9399......... Unclassified K7........... ........... ...........
drugs or
biolog.
E0616......... Cardiac event N1........... ........... ...........
recorder.
E0749......... Elec osteogen N1........... ........... ...........
stim implanted.
E0782......... Non-programble N1........... ........... ...........
infusion pump.
E0783......... Programmable N1........... ........... ...........
infusion pump.
E0785......... Replacement N1........... ........... ...........
impl pump
cathet.
E0786......... Implantable N1........... ........... ...........
pump
replacement.
G0130......... Single energy x- Z3........... 0.5150 $21.91
ray study.
G0173......... Linear acc Z2........... 63.3759 $2,696.20
stereo radsur
com.
G0251......... Linear acc Z2........... 20.3224 $864.58
based stero
radio.
G0288......... Recon, CTA for Z2........... 3.2393 $137.81
surg plan.
G0339......... Robot lin- Z2........... 63.3759 $2,696.20
radsurg com,
first.
G0340......... Robt lin- Z2........... 43.0297 $1,830.61
radsurg fractx
2-5.
J0120......... Tetracyclin N1........... ........... ...........
injection.
J0128......... Abarelix K2........... ........... $68.62
injection.
J0129......... Abatacept K2........... ........... $18.69
injection.
J0130......... Abciximab K2........... ........... $413.16
injection.
J0132......... Acetylcysteine K2........... ........... $1.95
injection.
J0133......... Acyclovir N1........... ........... ...........
injection.
J0135......... Adalimumab K2........... ........... $319.03
injection.
J0150......... Injection K2........... ........... $22.86
adenosine 6 MG.
J0152......... Adenosine K2........... ........... $69.16
injection.
J0170......... Adrenalin N1........... ........... ...........
epinephrin
inject.
J0180......... Agalsidase beta K2........... ........... $127.20
injection.
J0190......... Inj biperiden K2........... ........... $88.15
lactate/5 mg.
J0200......... Alatrofloxacin N1........... ........... ...........
mesylate.
J0205......... Alglucerase K2........... ........... $39.22
injection.
J0207......... Amifostine..... K2........... ........... $480.64
J0210......... Methyldopate K2........... ........... $10.11
hcl injection.
J0215......... Alefacept...... K2........... ........... $26.07
J0256......... Alpha 1 K2........... ........... $3.28
proteinase
inhibitor.
J0278......... Amikacin N1........... ........... ...........
sulfate
injection.
J0280......... Aminophyllin N1........... ........... ...........
250 MG inj.
J0282......... Amiodarone HCl. N1........... ........... ...........
J0285......... Amphotericin B. N1........... ........... ...........
J0287......... Amphotericin b K2........... ........... $10.38
lipid complex.
J0288......... Ampho b K2........... ........... $12.00
cholesteryl
sulfate.
J0289......... Amphotericin b K2........... ........... $17.24
liposome inj.
J0290......... Ampicillin 500 N1........... ........... ...........
MG inj.
J0295......... Ampicillin N1........... ........... ...........
sodium per 1.5
gm.
J0300......... Amobarbital 125 N1........... ........... ...........
MG inj.
J0330......... Succinycholine N1........... ........... ...........
chloride inj.
J0348......... Anadulafungin K2........... ........... $1.91
injection.
J0350......... Injection K2........... ........... $2,693.80
anistreplase
30 u.
J0360......... Hydralazine hcl N1........... ........... ...........
injection.
[[Page 42618]]
J0364......... Apomorphine K2........... ........... $2.99
hydrochloride.
J0365......... Aprotonin, K2........... ........... $2.52
10,000 kiu.
J0380......... Inj metaraminol K2........... ........... $15.67
bitartrate.
J0390......... Chloroquine N1........... ........... ...........
injection.
J0395......... Arbutamine HCl K2........... ........... $182.40
injection.
J0456......... Azithromycin... N1........... ........... ...........
J0460......... Atropine N1........... ........... ...........
sulfate
injection.
J0470......... Dimecaprol N1........... ........... ...........
injection.
J0475......... Baclofen 10 MG K2........... ........... $197.04
injection.
J0476......... Baclofen K2........... ........... $71.59
intrathecal
trial.
J0480......... Basiliximab.... K2........... ........... $1,359.97
J0500......... Dicyclomine N1........... ........... ...........
injection.
J0515......... Inj benztropine N1........... ........... ...........
mesylate.
J0520......... Bethanechol N1........... ........... ...........
chloride
inject.
J0530......... Penicillin g N1........... ........... ...........
benzathine inj.
J0540......... Penicillin g N1........... ........... ...........
benzathine inj.
J0550......... Penicillin g N1........... ........... ...........
benzathine inj.
J0560......... Penicillin g N1........... ........... ...........
benzathine inj.
J0570......... Penicillin g N1........... ........... ...........
benzathine inj.
J0580......... Penicillin g N1........... ........... ...........
benzathine inj.
J0583......... Bivalirudin.... K2........... ........... $1.74
J0585......... Botulinum toxin K2........... ........... $5.10
a per unit.
J0587......... Botulinum toxin K2........... ........... $8.37
type B.
J0592......... Buprenorphine N1........... ........... ...........
hydrochloride.
J0594......... Busulfan K2........... ........... $8.89
injection.
J0595......... Butorphanol N1........... ........... ...........
tartrate 1 mg.
J0600......... Edetate calcium K2........... ........... $40.19
disodium inj.
J0610......... Calcium N1........... ........... ...........
gluconate
injection.
J0620......... Calcium glycer N1........... ........... ...........
& lact/10 ML.
J0630......... Calcitonin N1........... ........... ...........
salmon
injection.
J0636......... Inj calcitriol N1........... ........... ...........
per 0.1 mcg.
J0637......... Caspofungin K2........... ........... $30.35
acetate.
J0640......... Leucovorin N1........... ........... ...........
calcium
injection.
J0670......... Inj mepivacaine N1........... ........... ...........
HCL/10 ml.
J0690......... Cefazolin N1........... ........... ...........
sodium
injection.
J0692......... Cefepime HCl N1........... ........... ...........
for injection.
J0694......... Cefoxitin N1........... ........... ...........
sodium
injection.
J0696......... Ceftriaxone N1........... ........... ...........
sodium
injection.
J0697......... Sterile N1........... ........... ...........
cefuroxime
injection.
J0698......... Cefotaxime N1........... ........... ...........
sodium
injection.
J0702......... Betamethasone N1........... ........... ...........
acet&sod phosp.
J0704......... Betamethasone N1........... ........... ...........
sod phosp/4 MG.
J0706......... Caffeine K2........... ........... $3.36
citrate
injection.
J0710......... Cephapirin N1........... ........... ...........
sodium
injection.
J0713......... Inj ceftazidime N1........... ........... ...........
per 500 mg.
J0715......... Ceftizoxime N1........... ........... ...........
sodium/500 MG.
J0720......... Chloramphenicol N1........... ........... ...........
sodium injec.
J0725......... Chorionic N1........... ........... ...........
gonadotropin/
1000u.
J0735......... Clonidine K2........... ........... $63.46
hydrochloride.
J0740......... Cidofovir K2........... ........... $761.81
injection.
J0743......... Cilastatin N1........... ........... ...........
sodium
injection.
J0744......... Ciprofloxacin N1........... ........... ...........
iv.
J0745......... Inj codeine N1........... ........... ...........
phosphate /30
MG.
J0760......... Colchicine N1........... ........... ...........
injection.
J0770......... Colistimethate N1........... ........... ...........
sodium inj.
J0780......... Prochlorperazin N1........... ........... ...........
e injection.
J0795......... Corticorelin K2........... ........... $4.31
ovine
triflutal.
J0800......... Corticotropin K2........... ........... $127.73
injection.
J0835......... Inj cosyntropin K2........... ........... $63.85
per 0.25 MG.
J0850......... Cytomegalovirus K2........... ........... $868.05
imm IV /vial.
J0878......... Daptomycin K2........... ........... $0.33
injection.
J0881......... Darbepoetin K2........... ........... $3.14
alfa, non-esrd.
J0885......... Epoetin alfa, K2........... ........... $9.45
non-esrd.
J0894......... Decitabine K2........... ........... $26.48
injection.
[[Page 42619]]
J0895......... Deferoxamine K2........... ........... $14.52
mesylate inj.
J0900......... Testosterone N1........... ........... ...........
enanthate inj.
J0945......... Brompheniramine N1........... ........... ...........
maleate inj.
J0970......... Estradiol N1........... ........... ...........
valerate
injection.
J1000......... Depo-estradiol N1........... ........... ...........
cypionate inj.
J1020......... Methylprednisol N1........... ........... ...........
one 20 MG inj.
J1030......... Methylprednisol N1........... ........... ...........
one 40 MG inj.
J1040......... Methylprednisol N1........... ........... ...........
one 80 MG inj.
J1051......... Medroxyprogeste N1........... ........... ...........
rone inj.
J1060......... Testosterone N1........... ........... ...........
cypionate 1 ML.
J1070......... Testosterone N1........... ........... ...........
cypionat 100
MG.
J1080......... Testosterone N1........... ........... ...........
cypionat 200
MG.
J1094......... Inj N1........... ........... ...........
dexamethasone
acetate.
J1100......... Dexamethasone N1........... ........... ...........
sodium phos.
J1110......... Inj N1........... ........... ...........
dihydroergotam
ine mesylt.
J1120......... Acetazolamid N1........... ........... ...........
sodium
injectio.
J1160......... Digoxin N1........... ........... ...........
injection.
J1162......... Digoxin immune K2........... ........... $516.35
fab (ovine).
J1165......... Phenytoin N1........... ........... ...........
sodium
injection.
J1170......... Hydromorphone N1........... ........... ...........
injection.
J1180......... Dyphylline N1........... ........... ...........
injection.
J1190......... Dexrazoxane HCl K2........... ........... $174.07
injection.
J1200......... Diphenhydramine N1........... ........... ...........
hcl injectio.
J1205......... Chlorothiazide K2........... ........... $123.84
sodium inj.
J1212......... Dimethyl N1........... ........... ...........
sulfoxide 50%
50 ML.
J1230......... Methadone N1........... ........... ...........
injection.
J1240......... Dimenhydrinate N1........... ........... ...........
injection.
J1245......... Dipyridamole N1........... ........... ...........
injection.
J1250......... Inj dobutamine N1........... ........... ...........
HCL/250 mg.
J1260......... Dolasetron K2........... ........... $6.11
mesylate.
J1265......... Dopamine N1........... ........... ...........
injection.
J1270......... Injection, N1........... ........... ...........
doxercalcifero
l.
J1320......... Amitriptyline N1........... ........... ...........
injection.
J1324......... Enfuvirtide K2........... ........... $22.91
injection.
J1325......... Epoprostenol N1........... ........... ...........
injection.
J1327......... Eptifibatide K2........... ........... $16.05
injection.
J1330......... Ergonovine K2........... ........... $4.00
maleate
injection.
J1335......... Ertapenem N1........... ........... ...........
injection.
J1364......... Erythro N1........... ........... ...........
lactobionate /
500 MG.
J1380......... Estradiol N1........... ........... ...........
valerate 10 MG
inj.
J1390......... Estradiol N1........... ........... ...........
valerate 20 MG
inj.
J1410......... Inj estrogen K2........... ........... $60.90
conjugate 25
MG.
J1430......... Ethanolamine K2........... ........... $79.01
oleate 100 mg.
J1435......... Injection N1........... ........... ...........
estrone per 1
MG.
J1436......... Etidronate K2........... ........... $71.41
disodium inj.
J1438......... Etanercept K2........... ........... $161.55
injection.
J1440......... Filgrastim 300 K2........... ........... $189.47
mcg injection.
J1441......... Filgrastim 480 K2........... ........... $300.58
mcg injection.
J1450......... Fluconazole.... N1........... ........... ...........
J1451......... Fomepizole, 15 K2........... ........... $12.39
mg.
J1452......... Intraocular K2........... ........... $237.50
Fomivirsen na.
J1455......... Foscarnet K2........... ........... $10.20
sodium
injection.
J1457......... Gallium nitrate N1........... ........... ...........
injection.
J1458......... Galsulfase K2........... ........... $299.92
injection.
J1460......... Gamma globulin K2........... ........... $11.42
1 CC inj.
J1562......... Immune globulin K2........... ........... $12.72
subcutaneous.
J1565......... RSV-ivig....... K2........... ........... $16.18
J1566......... Immune K2........... ........... $25.72
globulin,
powder.
J1567......... Immune K2........... ........... $30.57
globulin,
liquid.
J1570......... Ganciclovir N1........... ........... ...........
sodium
injection.
J1580......... Garamycin N1........... ........... ...........
gentamicin inj.
J1590......... Gatifloxacin N1........... ........... ...........
injection.
J1595......... Injection N1........... ........... ...........
glatiramer
acetate.
J1600......... Gold sodium N1........... ........... ...........
thiomaleate
inj.
[[Page 42620]]
J1610......... Glucagon K2........... ........... $66.27
hydrochloride/
1 MG.
J1620......... Gonadorelin K2........... ........... $180.30
hydroch/ 100
mcg.
J1626......... Granisetron HCl K2........... ........... $7.50
injection.
J1630......... Haloperidol N1........... ........... ...........
injection.
J1631......... Haloperidol N1........... ........... ...........
decanoate inj.
J1640......... Hemin, 1 mg.... K2........... ........... $6.80
J1642......... Inj heparin N1........... ........... ...........
sodium per 10
u.
J1644......... Inj heparin N1........... ........... ...........
sodium per
1000u.
J1645......... Dalteparin N1........... ........... ...........
sodium.
J1650......... Inj enoxaparin N1........... ........... ...........
sodium.
J1652......... Fondaparinux N1........... ........... ...........
sodium.
J1655......... Tinzaparin K2........... ........... $2.45
sodium
injection.
J1670......... Tetanus immune K2........... ........... $97.26
globulin inj.
J1700......... Hydrocortisone N1........... ........... ...........
acetate inj.
J1710......... Hydrocortisone N1........... ........... ...........
sodium ph inj.
J1720......... Hydrocortisone N1........... ........... ...........
sodium succ i.
J1730......... Diazoxide K2........... ........... $114.32
injection.
J1740......... Ibandronate K2........... ........... $138.71
sodium
injection.
J1742......... Ibutilide K2........... ........... $266.92
fumarate
injection.
J1745......... Infliximab K2........... ........... $53.76
injection.
J1751......... Iron dextran K2........... ........... $11.72
165 injection.
J1752......... Iron dextran K2........... ........... $10.42
267 injection.
J1756......... Iron sucrose K2........... ........... $0.37
injection.
J1785......... Injection K2........... ........... $3.92
imiglucerase /
unit.
J1790......... Droperidol N1........... ........... ...........
injection.
J1800......... Propranolol N1........... ........... ...........
injection.
J1815......... Insulin N1........... ........... ...........
injection.
J1817......... Insulin for N1........... ........... ...........
insulin pump
use.
J1830......... Interferon beta- K2........... ........... $84.92
1b /.25 MG.
J1835......... Itraconazole K2........... ........... $38.41
injection.
J1840......... Kanamycin N1........... ........... ...........
sulfate 500 MG
inj.
J1850......... Kanamycin N1........... ........... ...........
sulfate 75 MG
inj.
J1885......... Ketorolac N1........... ........... ...........
tromethamine
inj.
J1890......... Cephalothin N1........... ........... ...........
sodium
injection.
J1931......... Laronidase K2........... ........... $23.87
injection.
J1940......... Furosemide N1........... ........... ...........
injection.
J1945......... Lepirudin...... K2........... ........... $154.89
J1950......... Leuprolide K2........... ........... $433.92
acetate /3.75
MG.
J1956......... Levofloxacin N1........... ........... ...........
injection.
J1960......... Levorphanol N1........... ........... ...........
tartrate inj.
J1980......... Hyoscyamine N1........... ........... ...........
sulfate inj.
J1990......... Chlordiazepoxid N1........... ........... ...........
e injection.
J2001......... Lidocaine N1........... ........... ...........
injection.
J2010......... Lincomycin N1........... ........... ...........
injection.
J2020......... Linezolid K2........... ........... $25.17
injection.
J2060......... Lorazepam N1........... ........... ...........
injection.
J2150......... Mannitol N1........... ........... ...........
injection.
J2170......... Mecasermin K2........... ........... $11.93
injection.
J2175......... Meperidine N1........... ........... ...........
hydrochl /100
MG.
J2180......... Meperidine/ N1........... ........... ...........
promethazine
inj.
J2185......... Meropenem...... K2........... ........... $3.71
J2210......... Methylergonovin N1........... ........... ...........
maleate inj.
J2248......... Micafungin K2........... ........... $1.71
sodium
injection.
J2250......... Inj midazolam N1........... ........... ...........
hydrochloride.
J2260......... Inj milrinone N1........... ........... ...........
lactate/5 MG.
J2270......... Morphine N1........... ........... ...........
sulfate
injection.
J2271......... Morphine so4 N1........... ........... ...........
injection 100
mg.
J2275......... Morphine N1........... ........... ...........
sulfate
injection.
J2278......... Ziconotide K2........... ........... $6.52
injection.
J2280......... Inj, N1........... ........... ...........
moxifloxacin
100 mg.
J2300......... Inj nalbuphine N1........... ........... ...........
hydrochloride.
J2310......... Inj naloxone N1........... ........... ...........
hydrochloride.
J2315......... Naltrexone, K2........... ........... $1.90
depot form.
J2320......... Nandrolone N1........... ........... ...........
decanoate 50
MG.
[[Page 42621]]
J2321......... Nandrolone N1........... ........... ...........
decanoate 100
MG.
J2322......... Nandrolone N1........... ........... ...........
decanoate 200
MG.
J2325......... Nesiritide K2........... ........... $31.66
injection.
J2353......... Octreotide K2........... ........... $96.77
injection,
depot.
J2354......... Octreotide inj, N1........... ........... ...........
non-depot.
J2355......... Oprelvekin K2........... ........... $247.31
injection.
J2357......... Omalizumab K2........... ........... $16.95
injection.
J2360......... Orphenadrine N1........... ........... ...........
injection.
J2370......... Phenylephrine N1........... ........... ...........
hcl injection.
J2400......... Chloroprocaine N1........... ........... ...........
hcl injection.
J2405......... Ondansetron hcl K2........... ........... $3.40
injection.
J2410......... Oxymorphone hcl N1........... ........... ...........
injection.
J2425......... Palifermin K2........... ........... $11.43
injection.
J2430......... Pamidronate K2........... ........... $30.78
disodium/30 MG.
J2440......... Papaverin hcl N1........... ........... ...........
injection.
J2460......... Oxytetracycline N1........... ........... ...........
injection.
J2469......... Palonosetron K2........... ........... $16.00
HCl.
J2501......... Paricalcitol... N1........... ........... ...........
J2503......... Pegaptanib K2........... ........... $1,054.70
sodium
injection.
J2504......... Pegademase K2........... ........... $177.83
bovine, 25 iu.
J2505......... Injection, K2........... ........... $2,163.33
pegfilgrastim
6mg.
J2510......... Penicillin g N1........... ........... ...........
procaine inj.
J2513......... Pentastarch 10% N1........... ........... ...........
solution.
J2515......... Pentobarbital N1........... ........... ...........
sodium inj.
J2540......... Penicillin g N1........... ........... ...........
potassium inj.
J2543......... Piperacillin/ N1........... ........... ...........
tazobactam.
J2550......... Promethazine N1........... ........... ...........
hcl injection.
J2560......... Phenobarbital N1........... ........... ...........
sodium inj.
J2590......... Oxytocin N1........... ........... ...........
injection.
J2597......... Inj N1........... ........... ...........
desmopressin
acetate.
J2650......... Prednisolone N1........... ........... ...........
acetate inj.
J2670......... Totazoline hcl N1........... ........... ...........
injection.
J2675......... Inj N1........... ........... ...........
progesterone
per 50 MG.
J2680......... Fluphenazine N1........... ........... ...........
decanoate 25
MG.
J2690......... Procainamide N1........... ........... ...........
hcl injection.
J2700......... Oxacillin N1........... ........... ...........
sodium
injection.
J2710......... Neostigmine N1........... ........... ...........
methylslfte
inj.
J2720......... Inj protamine N1........... ........... ...........
sulfate/10 MG.
J2725......... Inj protirelin N1........... ........... ...........
per 250 mcg.
J2730......... Pralidoxime N1........... ........... ...........
chloride inj.
J2760......... Phentolaine N1........... ........... ...........
mesylate inj.
J2765......... Metoclopramide N1........... ........... ...........
hcl injection.
J2770......... Quinupristin/ K2........... ........... $117.81
dalfopristin.
J2780......... Ranitidine N1........... ........... ...........
hydrochloride
inj.
J2783......... Rasburicase.... K2........... ........... $132.53
J2788......... Rho d immune K2........... ........... $26.66
globulin 50
mcg.
J2790......... Rho d immune K2........... ........... $81.48
globulin inj.
J2792......... Rho(D) immune K2........... ........... $15.91
globulin h, sd.
J2794......... Risperidone, K2........... ........... $4.85
long acting.
J2795......... Ropivacaine HCl N1........... ........... ...........
injection.
J2800......... Methocarbamol N1........... ........... ...........
injection.
J2805......... Sincalide N1........... ........... ...........
injection.
J2810......... Inj N1........... ........... ...........
theophylline
per 40 MG.
J2820......... Sargramostim K2........... ........... $25.31
injection.
J2850......... Inj secretin K2........... ........... $20.31
synthetic
human.
J2910......... Aurothioglucose N1........... ........... ...........
injection.
J2916......... Na ferric N1........... ........... ...........
gluconate
complex.
J2920......... Methylprednisol N1........... ........... ...........
one injection.
J2930......... Methylprednisol N1........... ........... ...........
one injection.
J2940......... Somatrem K2........... ........... $168.90
injection.
J2941......... Somatropin K2........... ........... $47.19
injection.
J2950......... Promazine hcl N1........... ........... ...........
injection.
J2993......... Reteplase K2........... ........... $899.51
injection.
J2995......... Inj K2........... ........... $129.75
streptokinase /
250000 IU.
[[Page 42622]]
J2997......... Alteplase K2........... ........... $32.79
recombinant.
J3000......... Streptomycin N1........... ........... ...........
injection.
J3010......... Fentanyl N1........... ........... ...........
citrate
injeciton.
J3030......... Sumatriptan K2........... ........... $59.38
succinate / 6
MG.
J3070......... Pentazocine N1........... ........... ...........
injection.
J3100......... Tenecteplase K2........... ........... $2,043.40
injection.
J3105......... Terbutaline N1........... ........... ...........
sulfate inj.
J3120......... Testosterone N1........... ........... ...........
enanthate inj.
J3130......... Testosterone N1........... ........... ...........
enanthate inj.
J3140......... Testosterone N1........... ........... ...........
suspension inj.
J3150......... Testosterone N1........... ........... ...........
propionate inj.
J3230......... Chlorpromazine N1........... ........... ...........
hcl injection.
J3240......... Thyrotropin K2........... ........... $765.38
injection.
J3243......... Tigecycline K2........... ........... $0.91
injection.
J3246......... Tirofiban HCl.. K2........... ........... $7.73
J3250......... Trimethobenzami N1........... ........... ...........
de hcl inj.
J3260......... Tobramycin N1........... ........... ...........
sulfate
injection.
J3265......... Injection N1........... ........... ...........
torsemide 10
mg/ml.
J3280......... Thiethylperazin N1........... ........... ...........
e maleate inj.
J3285......... Treprostinil K2........... ........... $55.89
injection.
J3301......... Triamcinolone N1........... ........... ...........
acetonide inj.
J3302......... Triamcinolone N1........... ........... ...........
diacetate inj.
J3303......... Triamcinolone N1........... ........... ...........
hexacetonl inj.
J3305......... Inj K2........... ........... $145.26
trimetrexate
glucoronate.
J3310......... Perphenazine N1........... ........... ...........
injection.
J3315......... Triptorelin K2........... ........... $155.44
pamoate.
J3320......... Spectinomycn di- K2........... ........... $30.08
hcl inj.
J3350......... Urea injection. K2........... ........... $74.16
J3355......... Urofollitropin, K2........... ........... $50.70
75 iu.
J3360......... Diazepam N1........... ........... ...........
injection.
J3364......... Urokinase 5000 N1........... ........... ...........
IU injection.
J3365......... Urokinase K2........... ........... $457.73
250,000 IU inj.
J3370......... Vancomycin hcl N1........... ........... ...........
injection.
J3396......... Verteporfin K2........... ........... $8.92
injection.
J3400......... Triflupromazine N1........... ........... ...........
hcl inj.
J3410......... Hydroxyzine hcl N1........... ........... ...........
injection.
J3411......... Thiamine hcl N1........... ........... ...........
100 mg.
J3415......... Pyridoxine hcl N1........... ........... ...........
100 mg.
J3420......... Vitamin b12 N1........... ........... ...........
injection.
J3430......... Vitamin k N1........... ........... ...........
phytonadione
inj.
J3465......... Injection, K2........... ........... $4.99
voriconazole.
J3470......... Hyaluronidase N1........... ........... ...........
injection.
J3471......... Ovine, up to N1........... ........... ...........
999 USP units.
J3472......... Ovine, 1000 USP K2........... ........... $135.04
units.
J3473......... Hyaluronidase K2........... ........... $0.40
recombinant.
J3475......... Inj magnesium N1........... ........... ...........
sulfate.
J3480......... Inj potassium N1........... ........... ...........
chloride.
J3485......... Zidovudine..... N1........... ........... ...........
J3486......... Ziprasidone N1........... ........... ...........
mesylate.
J3487......... Zoledronic acid K2........... ........... $206.04
J3490......... Drugs N1........... ........... ...........
unclassified
injection.
J3530......... Nasal vaccine N1........... ........... ...........
inhalation.
J3590......... Unclassified N1........... ........... ...........
biologics.
J7030......... Normal saline N1........... ........... ...........
solution infus.
J7040......... Normal saline N1........... ........... ...........
solution infus.
J7042......... 5% dextrose/ N1........... ........... ...........
normal saline.
J7050......... Normal saline N1........... ........... ...........
solution infus.
J7060......... 5% dextrose/ N1........... ........... ...........
water.
J7070......... D5w infusion... N1........... ........... ...........
J7100......... Dextran 40 N1........... ........... ...........
infusion.
J7110......... Dextran 75 N1........... ........... ...........
infusion.
J7120......... Ringers lactate N1........... ........... ...........
infusion.
J7130......... Hypertonic N1........... ........... ...........
saline
solution.
J7187......... Inj K2........... ........... $0.88
Vonwillebrand
factor IU.
[[Page 42623]]
J7189......... Factor viia.... K2........... ........... $1.12
J7190......... Factor viii.... K2........... ........... $0.70
J7191......... Factor VIII K2........... ........... $0.75
(porcine).
J7192......... Factor viii K2........... ........... $1.07
recombinant.
J7193......... Factor IX non- K2........... ........... $0.89
recombinant.
J7194......... Factor ix K2........... ........... $0.75
complex.
J7195......... Factor IX K2........... ........... $0.99
recombinant.
J7197......... Antithrombin K2........... ........... $1.64
iii injection.
J7198......... Anti-inhibitor. K2........... ........... $1.36
J7308......... Aminolevulinic K2........... ........... $105.43
acid hcl top.
J7310......... Ganciclovir K2........... ........... $4,752.26
long act
implant.
J7311......... Fluocinolone K2........... ........... $19,345.00
acetonide
implt.
J7340......... Metabolic K2........... ........... $28.78
active D/E
tissue.
J7341......... Non-human, K2........... ........... $1.82
metabolic
tissue.
J7342......... Metabolically K2........... ........... $31.66
active tissue.
J7343......... Nonmetabolic K2........... ........... $18.30
act d/e tissue.
J7344......... Nonmetabolic K2........... ........... $89.21
active tissue.
J7345......... Non-human, non- K2........... ........... $36.10
metab tissue.
J7346......... Injectable K2........... ........... $735.38
human tissue.
J7500......... Azathioprine N1........... ........... ...........
oral 50 mg.
J7501......... Azathioprine K2........... ........... $48.44
parenteral.
J7502......... Cyclosporine K2........... ........... $3.60
oral 100 mg.
J7504......... Lymphocyte K2........... ........... $317.18
immune
globulin.
J7505......... Monoclonal K2........... ........... $895.15
antibodies.
J7506......... Prednisone oral N1........... ........... ...........
J7507......... Tacrolimus oral K2........... ........... $3.66
per 1 MG.
J7509......... Methylprednisol N1........... ........... ...........
one oral.
J7510......... Prednisolone N1........... ........... ...........
oral per 5 mg.
J7511......... Antithymocyte K2........... ........... $327.75
globuln rabbit.
J7513......... Daclizumab, K2........... ........... $299.86
parenteral.
J7515......... Cyclosporine N1........... ........... ...........
oral 25 mg.
J7516......... Cyclosporin N1........... ........... ...........
parenteral 250
mg.
J7517......... Mycophenolate K2........... ........... $2.62
mofetil oral.
J7518......... Mycophenolic K2........... ........... $2.27
acid.
J7520......... Sirolimus, oral K2........... ........... $7.22
J7525......... Tacrolimus K2........... ........... $140.44
injection.
J7599......... Immunosuppressi N1........... ........... ...........
ve drug noc.
J7674......... Methacholine N1........... ........... ...........
chloride, neb.
J7799......... Non-inhalation N1........... ........... ...........
drug for DME.
J8501......... Oral aprepitant K2........... ........... $5.07
J8510......... Oral busulfan.. K2........... ........... $2.14
J8520......... Capecitabine, K2........... ........... $3.97
oral, 150 mg.
J8530......... Cyclophosphamid N1........... ........... ...........
e oral 25 MG.
J8540......... Oral N1........... ........... ...........
dexamethasone.
J8560......... Etoposide oral K2........... ........... $29.60
50 MG.
J8597......... Antiemetic drug N1........... ........... ...........
oral NOS.
J8600......... Melphalan oral N1........... ........... ...........
2 MG.
J8610......... Methotrexate N1........... ........... ...........
oral 2.5 MG.
J8650......... Nabilone oral.. K2........... ........... $16.96
J8700......... Temozolomide... K2........... ........... $7.41
J9000......... Doxorubic hcl K2........... ........... $6.31
10 MG vl chemo.
J9001......... Doxorubicin hcl K2........... ........... $389.48
liposome inj.
J9010......... Alemtuzumab K2........... ........... $541.20
injection.
J9015......... Aldesleukin/ K2........... ........... $762.98
single use
vial.
J9017......... Arsenic K2........... ........... $34.17
trioxide.
J9020......... Asparaginase K2........... ........... $54.72
injection.
J9025......... Azacitidine K2........... ........... $4.30
injection.
J9027......... Clofarabine K2........... ........... $116.75
injection.
J9031......... Bcg live K2........... ........... $110.67
intravesical
vac.
J9035......... Bevacizumab K2........... ........... $57.53
injection.
J9040......... Bleomycin K2........... ........... $35.85
sulfate
injection.
J9041......... Bortezomib K2........... ........... $32.68
injection.
J9045......... Carboplatin K2........... ........... $8.46
injection.
J9050......... Carmus bischl K2........... ........... $139.84
nitro inj.
[[Page 42624]]
J9055......... Cetuximab K2........... ........... $49.81
injection.
J9060......... Cisplatin 10 MG N1........... ........... ...........
injection.
J9065......... Inj cladribine K2........... ........... $36.12
per 1 MG.
J9070......... Cyclophosphamid N1........... ........... ...........
e 100 MG inj.
J9093......... Cyclophosphamid K2........... ........... $1.99
e lyophilized.
J9098......... Cytarabine K2........... ........... $395.04
liposome.
J9100......... Cytarabine hcl N1........... ........... ...........
100 MG inj.
J9120......... Dactinomycin K2........... ........... $493.43
actinomycin d.
J9130......... Dacarbazine 100 K2........... ........... $5.25
mg inj.
J9150......... Daunorubicin... K2........... ........... $20.47
J9151......... Daunorubicin K2........... ........... $55.92
citrate
liposom.
J9160......... Denileukin K2........... ........... $1,406.59
diftitox, 300
mcg.
J9165......... Diethylstilbest N1........... ........... ...........
rol injection.
J9170......... Docetaxel...... K2........... ........... $306.81
J9175......... Elliotts b N1........... ........... ...........
solution per
ml.
J9178......... Inj, epirubicin K2........... ........... $21.21
hcl, 2 mg.
J9181......... Etoposide 10 MG N1........... ........... ...........
inj.
J9185......... Fludarabine K2........... ........... $236.44
phosphate inj.
J9190......... Fluorouracil N1........... ........... ...........
injection.
J9200......... Floxuridine K2........... ........... $51.31
injection.
J9201......... Gemcitabine HCl K2........... ........... $125.16
J9202......... Goserelin K2........... ........... $198.68
acetate
implant.
J9206......... Irinotecan K2........... ........... $126.00
injection.
J9208......... Ifosfomide K2........... ........... $46.59
injection.
J9209......... Mesna injection K2........... ........... $8.97
J9211......... Idarubicin hcl K2........... ........... $304.61
injection.
J9212......... Interferon K2........... ........... $4.65
alfacon-1.
J9213......... Interferon alfa- K2........... ........... $37.89
2a inj.
J9214......... Interferon alfa- K2........... ........... $13.88
2b inj.
J9215......... Interferon alfa- K2........... ........... $9.12
n3 inj.
J9216......... Interferon K2........... ........... $289.87
gamma 1-b inj.
J9217......... Leuprolide K2........... ........... $229.50
acetate
suspnsion.
J9218......... Leuprolide K2........... ........... $8.88
acetate
injeciton.
J9219......... Leuprolide K2........... ........... $1,713.12
acetate
implant.
J9225......... Histrelin K2........... ........... $1,460.77
implant.
J9230......... Mechlorethamine K2........... ........... $141.61
hcl inj.
J9245......... Inj melphalan K2........... ........... $1,284.12
hydrochl 50 MG.
J9250......... Methotrexate N1........... ........... ...........
sodium inj.
J9261......... Nelarabine K2........... ........... $83.33
injection.
J9263......... Oxaliplatin.... K2........... ........... $8.97
J9264......... Paclitaxel K2........... ........... $8.73
protein bound.
J9265......... Paclitaxel K2........... ........... $12.59
injection.
J9266......... Pegaspargase/ K2........... ........... $1,683.49
singl dose
vial.
J9268......... Pentostatin K2........... ........... $1,934.91
injection.
J9270......... Plicamycin K2........... ........... $172.41
(mithramycin)
inj.
J9280......... Mitomycin 5 MG K2........... ........... $16.13
inj.
J9293......... Mitoxantrone K2........... ........... $168.23
hydrochl / 5
MG.
J9300......... Gemtuzumab K2........... ........... $2,356.98
ozogamicin.
J9305......... Pemetrexed K2........... ........... $43.79
injection.
J9310......... Rituximab K2........... ........... $496.22
cancer
treatment.
J9320......... Streptozocin K2........... ........... $153.73
injection.
J9340......... Thiotepa K2........... ........... $40.70
injection.
J9350......... Topotecan...... K2........... ........... $830.74
J9355......... Trastuzumab.... K2........... ........... $57.87
J9357......... Valrubicin, 200 K2........... ........... $77.96
mg.
J9360......... Vinblastine N1........... ........... ...........
sulfate inj.
J9370......... Vincristine N1........... ........... ...........
sulfate 1 MG
inj.
J9390......... Vinorelbine K2........... ........... $20.07
tartrate/10 mg.
J9395......... Injection, K2........... ........... $80.56
Fulvestrant.
J9600......... Porfimer sodium K2........... ........... $2,563.31
J9999......... Chemotherapy N1........... ........... ...........
drug.
L8600......... Implant breast N1........... ........... ...........
silicone/eq.
L8603......... Collagen imp N1........... ........... ...........
urinary 2.5 ml.
L8606......... Synthetic N1........... ........... ...........
implnt urinary
1ml.
[[Page 42625]]
L8609......... Artificial N1........... ........... ...........
cornea.
L8610......... Ocular implant. N1........... ........... ...........
L8612......... Aqueous shunt N1........... ........... ...........
prosthesis.
L8613......... Ossicular N1........... ........... ...........
implant.
L8614......... Cochlear device N1........... ........... ...........
L8630......... Metacarpophalan N1........... ........... ...........
geal implant.
L8631......... MCP joint repl N1........... ........... ...........
2 pc or more.
L8641......... Metatarsal N1........... ........... ...........
joint implant.
L8642......... Hallux implant. N1........... ........... ...........
L8658......... Interphalangeal N1........... ........... ...........
joint spacer.
L8659......... Interphalangeal N1........... ........... ...........
joint repl.
L8670......... Vascular graft, N1........... ........... ...........
synthetic.
L8682......... Implt neurostim N1........... ........... ...........
radiofq rec.
L8690......... Aud osseo dev, J7........... ........... ...........
int/ext comp.
L8699......... Prosthetic N1........... ........... ...........
implant NOS.
Q0163......... Diphenhydramine N1........... ........... ...........
HCl 50mg.
Q0164......... Prochlorperazin N1........... ........... ...........
e maleate 5mg.
Q0166......... Granisetron HCl K2........... ........... $44.87
1 mg oral.
Q0167......... Dronabinol 2.5 N1........... ........... ...........
mg oral.
Q0169......... Promethazine N1........... ........... ...........
HCl 12.5 mg
oral.
Q0171......... Chlorpromazine N1........... ........... ...........
HCl 10 mg oral.
Q0173......... Trimethobenzami N1........... ........... ...........
de HCl 250 mg.
Q0174......... Thiethylperazin N1........... ........... ...........
e maleate 10
mg.
Q0175......... Perphenazine 4 N1........... ........... ...........
mg oral.
Q0177......... Hydroxyzine N1........... ........... ...........
pamoate 25 mg.
Q0179......... Ondansetron HCl K2........... ........... $36.55
8 mg oral.
Q0180......... Dolasetron K2........... ........... $47.52
mesylate oral.
Q0515......... Sermorelin K2........... ........... $1.75
acetate
injection.
Q1003......... Ntiol category L6........... ........... $50.00
3.
Q2004......... Bladder calculi N1........... ........... ...........
irrig sol.
Q2009......... Fosphenytoin, K2........... ........... $5.66
50 mg.
Q2017......... Teniposide, 50 K2........... ........... $264.09
mg.
Q3025......... IM inj K2........... ........... $114.57
interferon
beta 1-a.
Q4079......... Natalizumab K2........... ........... $7.52
injection.
Q4083......... Hyalgan/supartz K2........... ........... $104.85
inj per dose.
Q4084......... Synvisc inj per K2........... ........... $186.66
dose.
Q4085......... Euflexxa inj K2........... ........... $115.16
per dose.
Q4086......... Orthovisc inj K2........... ........... $198.34
per dose.
Q9945......... LOCM [lE]149 mg/ K2........... ........... $0.42
ml iodine, 1
ml.
Q9946......... LOCM 150-199 mg/ K2........... ........... $1.95
ml iodine,1 ml.
Q9947......... LOCM 200-249 mg/ K2........... ........... $1.33
ml iodine,1 ml.
Q9948......... LOCM 250-299 mg/ K2........... ........... $0.36
ml iodine,1 ml.
Q9949......... LOCM 300-349 mg/ K2........... ........... $0.37
ml iodine,1 ml.
Q9950......... LOCM 350-399 mg/ K2........... ........... $0.22
ml iodine,1 ml.
Q9951......... LOCM [gE] 400 K2........... ........... $0.22
mg/ml iodine,1
ml.
Q9952......... Inj Gad-base MR K2........... ........... $2.82
contrast,1 ml.
Q9953......... Inj Fe-based MR K2........... ........... $30.41
contrast,1 ml.
Q9954......... Oral MR K2........... ........... $8.82
contrast, 100
ml.
Q9955......... Inj perflexane K2........... ........... $12.96
lip micros, ml.
Q9956......... Inj K2........... ........... $49.61
octafluoroprop
ane mic, ml.
Q9957......... Inj perflutren K2........... ........... $61.55
lip micros, ml.
Q9958......... HOCM [lE]149 mg/ N1........... ........... ...........
ml iodine, 1ml.
Q9959......... HOCM 150-199 mg/ N1........... ........... ...........
ml iodine, 1ml.
Q9960......... HOCM 200-249 mg/ N1........... ........... ...........
ml iodine, 1
ml.
Q9961......... HOCM 250-299 mg/ N1........... ........... ...........
ml iodine, 1ml.
Q9962......... HOCM 300-349 mg/ N1........... ........... ...........
ml iodine, 1
ml.
Q9963......... HOCM 350-399 mg/ N1........... ........... ...........
ml iodine, 1ml.
Q9964......... HOCM[gE] 400 mg/ N1........... ........... ...........
ml iodine, 1
ml.
V2630......... Anter chamber N1........... ........... ...........
intraocul lens.
V2631......... Iris support N1........... ........... ...........
intraoclr lens.
V2632......... Post chmbr N1........... ........... ...........
intraocular
lens.
V2785......... Corneal tissue F4........... ........... ...........
processing.
[[Page 42626]]
V2790......... Amniotic N1........... ........... ...........
membrane.
------------------------------------------------------------------------
Note: The Medicare program payment is 80 percent of the total payment
amount and beneficiary coinsurance is 20 percent of the total payment
amount, except for screening flexible sigmoidoscopies and screening
colonoscopies for which the program payment is 75 percent and the
beneficiary coinsurance is 25 percent.
[[Page 42626]]
Addendum DD1.--Illustrative ASC Payment Indicators
------------------------------------------------------------------------
Indicator Payment indicator definition
------------------------------------------------------------------------
A2.................... Surgical procedure on ASC list in CY 2007;
payment based on OPPS relative payment weight.
F4.................... Corneal tissue acquisition; paid at reasonable
cost.
G2.................... Non office-based surgical procedure added to ASC
list in CY 2008 or later; payment based on OPPS
relative payment weight.
H7.................... Brachytherapy source paid separately when
provided integral to a surgical procedure on
ASC list; payment contractor-priced.
H8.................... Device-intensive procedure on ASC list in CY
2007; paid at adjusted rate.
J7.................... OPPS pass-through device paid separately when
provided integral to a surgical procedure on
ASC list; payment contractor-priced.
J8.................... Device-intensive procedure added to ASC list in
CY 2008 or later; paid at adjusted rate.
K2.................... Drugs and biologicals paid separately when
provided integral to a surgical procedure on
ASC list; payment based on OPPS rate.
K7.................... Unclassified drugs and biologicals; payment
contractor-priced.
L6.................... New Technology Intraocular Lens (NTIOL); special
payment.
N1.................... Packaged procedure/item; no separate payment
made.
P2.................... Office-based surgical procedure added to ASC
list in CY 2008 or later with MPFS nonfacility
PE RVUs; payment based on OPPS relative payment
weight.
P3.................... Office-based surgical procedure added to ASC
list in CY 2008 or later with MPFS nonfacility
PE RVUs; payment based on MPFS nonfacility PE
RVUs.
R2.................... Office-based surgical procedure added to ASC
list in CY 2008 or later without MPFS
nonfacility PE RVUs; payment based on OPPS
relative payment weight.
Z2.................... Radiology service paid separately when provided
integral to a surgical procedure on ASC list;
payment based on OPPS relative payment weight.
Z3.................... Radiology service paid separately when provided
integral to a surgical procedure on ASC list;
payment based on MPFS nonfacility PE RVUs.
------------------------------------------------------------------------
[FR Doc. 07-3490 Filed 7-16-07; 4:00 pm]
BILLING CODE 4120-01-P